Community-acquired pneumonia in the post 13-valent pneumococcal conjugate vaccine era.

PURPOSE OF REVIEW: This review covers the outpatient management of pediatric community-acquired pneumonia (CAP), discussing the changing microbiology of CAP since the introduction of the 13-valent pneumococcal conjugate vaccine in 2010, and providing an overview of national guideline recommendations for diagnostic evaluation and treatment. RECENT FINDINGS: Rates of invasive pneumococcal disease and pneumococcal antibiotic resistance have plummeted since widespread 13-valent pneumococcal conjugate vaccine immunization. Viruses remain the most common cause of CAP in young children; children over age 5 years have increased rates of Mycoplasma pneumoniae. A recent national guideline offers recommendations for office-based diagnostic evaluation and treatment of pediatric CAP. SUMMARY: This review offers a discussion of the above findings with practical recommendations for the office-based practitioner in the evaluation and treatment of an infant (>3 months) or child with suspected CAP.

Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study.

OBJECTIVES: This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs. METHODS: A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate. RESULTS: Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively). CONCLUSIONS: Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.

Clinical guideline highlights for the hospitalist: Evaluation and management of well-appearing febrile infants 8 to 60 days old.

GUIDELINE TITLE: Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old RELEASE DATE: August 1, 2021 PRIOR VERSION(S): n/a DEVELOPER: American Academy of Pediatrics FUNDING SOURCE: American Academy of Pediatrics TARGET POPULATION: Well-appearing, otherwise healthy infants with fever, ages 8 to 60 days, excluding those with prematurity (<37 wk gestation), focal bacterial infections except acute otitis media, high suspicion for herpes simplex virus (vesicles), clinical bronchiolitis.

Long peripheral catheters in children: A scoping review.

BACKGROUND AND OBJECTIVES: Long peripheral catheters (LPCs) are emerging vascular access devices used for short-medium term vascular access needs. Literature in adults suggests LPCs have longer dwell-times than peripheral intravenous catheters (PIVs) and lower rates of serious complications than peripherally inserted central catheters (PICCs). The role of LPCs in children is less established. The objective of this scoping review is to describe and synthesize the existing literature on the effectiveness and safety of LPCs in children. METHODS: This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Searches were done in MEDLINE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection, Scopus, CINAHL (Ebsco), and Google Scholar most recently on February 22, 2022. Studies were included if published in English on or after 2000 and included patients <18 years of age. RESULTS: Twenty-one studies were included. The body of literature is variable in quality, measurements, and reported outcomes. Median dwell-time ranged from 5 to 14 days. The rate of completion of therapy ranged from 20% to 86%. Dislodgement, occlusion, and infiltration were the most common complications reported (0%-31%). Venous thromboembolism rates ranged from 0% to 13%. The rate of catheter-related bloodstream infection was 0% in 9 of 10 studies. Less than 50% of studies reported comparative outcomes. CONCLUSION: LPCs show promising outcomes in select populations, with longer dwell-time than PIVs and possibly lower rates of serious complications than PICCs. However, more research is needed to clarify the optimal use of LPCs in pediatrics.

Gender Distribution in Pediatric Hospital Medicine Leadership.

Pediatric Hospital Medicine (PHM), a field early in its development and with a robust pipeline of women, is in a unique position to lead the way in gender equity. We describe the proportion of women in divisional and fellowship leadership positions at university-based PHM programs (n = 142). When compared with the PHM field at large, women appear to be underrepresented as PHM division/program leaders (70% vs 55%; P< .001) but not as fellowship directors (70% vs 66%; P > .05). Women appear proportionally represented in associate/assistant leadership roles when compared with the distribution of the PHM field at large. Tracking these trends overtime is essential to advancing the field.

Clinical Guideline Highlights for the Hospitalist: Maintenance Intravenous Fluids in Infants and Children.

GUIDELINE TITLE: 2018 American Academy of Pediatrics (AAP) Clinical Practice Guideline: Maintenance Intravenous Fluids in Children RELEASE DATE: November 26, 2018 PRIOR VERSION: Not Applicable DEVELOPER: Multidisciplinary subcommittee of experts assembled by the AAP FUNDING SOURCE: AAP TARGET POPULATION: Patients 28 days to 18 years of age requiring maintenance intravenous fluids (IVFs).

Quality Improvement Feature Series Article 1: Introduction to Quality Improvement.

Quality improvement methods offer a rigorous approach to designing and disseminating improvement efforts. This report is the first in a series to introduce QI methodology, effective data display, and considerations in the review of QI manuscripts.

Pediatric Hospitalist Workload and Sustainability in University-Based Programs: Results from a National Interview-Based Survey.

Wide variability exists in the clinical workload of pediatric hospitalists without an accepted standard for benchmarking purposes. By using data obtained from interviews of pediatric hospital medicine (PHM) program leaders, we describe the clinical workload of university-based programs and report on the program sustainability perceived by PHM program leaders. The median clinical hours reported for a full-time pediatric hospitalist were 1800 hours per year, with a median of 15 weekends worked per year. Furthermore, program leaders reported an ideal number of clinical hours as 1700 hours per year. Half of the interviewed program leaders perceived their current models as unsustainable. Programs perceived as unsustainable were more likely than those perceived as sustainable to require a higher number of weekends worked per year or to be university employed. Further research should focus on establishing benchmarks for the workloads of pediatric hospitalists and on evaluating factors that can affect sustainability.

Quality Improvement Feature Series Article 2: Displaying and Analyzing Quality Improvement Data.

In this second article in the quality improvement (QI) methods series, we discuss how data are best displayed and analyzed in QI projects while focusing on some similarities with and differences from traditional clinical research. We demonstrate why displaying data over time on a run or control chart is superior to using pre-post analysis for QI studies. We introduce several types of statistical process control charts for data commonly collected during QI programs and provide guidance on how to use the proper chart. Last, we present solutions to several common data challenges in QI projects.

Development of a Surveillance System for Pediatric Hospital-Acquired Venous Thromboembolism.

BACKGROUND: Pediatric hospital-acquired (HA) venous thromboembolism (VTE) is a vexing problem with improvement efforts hampered by lack of robust surveillance methods to establish accurate rates of HA-VTE. METHODS: At a freestanding children's hospital, a multidisciplinary team worked to develop a comprehensive surveillance strategy for HA-VTE. Starting with diagnosis codes, we implemented complementary detection methods, including clinical and radiology data, to develop a robust surveillance system. HA-VTE events were tracked by using descriptive statistics and a statistical process control chart. Detection methods were evaluated via retrospective application of each method to every identified HA-VTE. Initial detection method was tracked. RESULTS: A total of 68 HA-VTE events were identified and the median number of events per 1000 patient days increased from 0.18 to 0.34. No single detection method would have identified all events. Each detection method initially identified HA-VTE events. CONCLUSIONS: Implementation of multiple detection methods has optimized timely detection of HA-VTE. This allows the establishment of a reliable baseline rate, enabling quality improvement efforts to address HA-VTE.

Feasibility of Episode-Based Bundled Payment for a Pediatric Surgical Condition: Posterior Spinal Fusion.

INTRODUCTION: Episode-based bundled payment (EBBP) is an alternative model of health-care payment that aims to align providers' and hospitals' incentives toward delivery of more coordinated, higher quality, and lower cost care. EBBP programs have been studied for numerous adult conditions over the past decade, yet there have been no studies exploring the use of EBBP in pediatric conditions. METHODS: This article explores the feasibility of EBBP for a relatively common, costly, pediatric surgical procedure: spinal fusion for adolescent idiopathic scoliosis. We begin with a review of successful EBBP programs in the United States. We then apply American College of Surgeons criteria for bundled payment episode selection to identify benefits and challenges of using EBBP for this condition. RESULTS: We identify several features of pediatric spinal fusion that make it an attractive EBBP target: high variability in costs with multiple distinct targets for cost reduction, high variability in quality across hospitals, and proven methods for improvement via application of standardized, evidence based pathways. We find that challenges to EBBP may arise due to the relatively low incidence of the procedure, which limits overall savings to the health-care community. CONCLUSIONS: Our results suggest that spinal fusion for adolescent idiopathic scoliosis is an attractive pediatric target for EBBP, with potential benefits to patients, providers, health systems, and payers if limitations in procedure volume and administrative expense are overcome. The framework presented may also be useful for analyzing feasibility of EBBP for other pediatric conditions.

Quality Initiative to Introduce Pediatric Venous Thromboembolism Risk Assessment for Orthopedic and Surgery Patients.

BACKGROUND AND OBJECTIVES: Pediatric hospital-acquired venous thromboembolism (VTE) is costly, has high morbidity, and is often preventable. The objective of this quality-improvement effort was to increase the percentage of general surgery and orthopedic patients ≥10 years of age screened for VTE risk from 0% to 80%. METHODS: At a freestanding children's hospital, 2 teams worked to implement VTE risk screening for postoperative inpatients. The general surgery team used residents and nurse practitioners to perform screening whereas the orthopedic team initially used bedside nursing staff. Both groups employed multiple small tests of change. Shared key interventions included refinement of a screening tool, provider education, mitigation of failures, and embedding the risk assessment task into staff workflow. The primary outcome measure, the percentage of eligible patients with a completed VTE risk assessment, was plotted on run charts. Secondary outcome measures for screened patients included the level of risk, the use of appropriate prophylaxis, and VTE events. RESULTS: Median weekly percentage of general surgery patients screened for VTE risk increased from 0% to 86% within 12 months, and median weekly percentage of orthopedic patients screened for VTE risk increased from 0% to 46% within 8 months. Among screened patients, the majority were at low or moderate risk for VTE and received prophylaxis in accordance with or beyond guideline recommendations. No screened patients developed VTE. CONCLUSIONS: Quality-improvement methods were used to implement a VTE risk screening process for postoperative patients. Using providers as screeners, as opposed to bedside nurses, led to a greater percentage of patients screened.

RNA interference using boranophosphate siRNAs: structure-activity relationships.

In RNA interference (RNAi), short double-stranded RNA (known as siRNA) inhibits expression from homologous genes. Clinical or pre-clinical use of siRNAs is likely to require stabilizing modifications because of the prevalence of intracellular and extracellular nucleases. In order to examine the effect of modification on siRNA efficacy and stability, we developed a new method for synthesizing stereoregular boranophosphate siRNAs. This work demonstrates that boranophosphate siRNAs are consistently more effective than siRNAs with the widely used phosphorothioate modification. Furthermore, boranophosphate siRNAs are frequently more active than native siRNA if the center of the antisense strand is not modified. Boranophosphate modification also increases siRNA potency. The finding that boranophosphate siRNAs are at least ten times more nuclease resistant than unmodified siRNAs may explain some of the positive effects of boranophosphate modification. The biochemical properties of boranophosphate siRNAs make them promising candidates for an RNAi-based therapeutic.

Implementation of Postoperative Respiratory Care for Pediatric Orthopedic Patients.

BACKGROUND AND OBJECTIVES: At our institution, one-fifth of pediatric patients undergoing hip and spine surgery require prolonged oxygen supplementation, most likely due to postoperative atelectasis. Using quality improvement methodology, we aimed to implement an innovative postoperative respiratory care algorithm for hip and spine surgery patients, with a global aim of improving respiratory outcomes. METHODS: A multidisciplinary team developed a care algorithm that relied on an activated respiratory therapist (RT) and engagement of patients and families. The algorithm was implemented via multiple rapid tests of change. Process measures representing the beginning and end of the care algorithm were plotted on standard run charts. We evaluated the association of algorithm implementation with a primary outcome of prolonged (>10 hours) oxygen supplementation via a quasi-experimental design using Fisher's exact and t tests. RESULTS: The team successfully implemented the algorithm, with a reliability to process of 80%. Key interventions included education of RTs, a daily huddle, and implementation of automated orders. Among all hip and spine patients, algorithm implementation was associated with a small, non-statistically significant decrease in prolonged oxygen use (21% to 16%). Among patients with underlying chronic conditions, there was a significant decrease in prolonged oxygen use from 22% to 6% after algorithm implementation (P = .04). CONCLUSIONS: We implemented an innovative respiratory care algorithm in hip and spine surgery patients by empowering RTs and engaging families to participate in care. We found that this approach was associated with decreased prolonged oxygen use in patients with chronic underlying conditions.