Frequency and yield of blood cultures for observation patients with skin and soft tissue infections.

OBJECTIVES: 1) To measure frequency and yield of blood cultures obtained for observation status adult patients with skin and soft tissue infection (SSTI), 2) describe how often blood cultures were performed according to Infectious Diseases Society of America (IDSA) SSTI guideline indications, 3) identify proportion of patients meeting Center for Medicare Services (CMS) sepsis criteria. DESIGN: Retrospective cohort. SETTING: Tertiary academic center. PATIENTS: Consecutive adult observation status patients hospitalized with SSTI between July 2017 and July 2018. METHODS: We measured the proportion and results of blood cultures obtained among the study cohort and proportion of obtained cultures that satisfied IDSA indications. RESULTS: We identified 132 observation status patients with SSTI during the study period; 67 (50.8%) had blood cultures drawn. Only 14 (10.6%) patients met IDSA indications for culture; 51 (38.%) met Center for Medicare Services definition for sepsis. We identified two (3.0%) cases of bacteremia and two (3.0%) cases of skin bacteria contamination. In multivariable analysis, only temperature > 38 °C (OR 3.84, 95%CI 1.09-13.60) and white race (OR 2.71, 95%CI 1.21-6.20) were associated with blood culture obtainment; neither meeting IDSA SSTI guideline indications nor meeting CMS sepsis criteria was associated with culture. CONCLUSIONS: Among observation status patients with SSTI, over half had blood cultures drawn, though 10% satisfied guideline indications for culture. The proportion of cultures with bacterial growth was low and yielded as many skin contaminants as cases of bacteremia. Our study highlights the need for further quality improvement efforts to reduce unnecessary blood cultures in routine SSTI cases.

Pediatric Hospitalization Trends at Children's and General Hospitals, 2000-2019.

This study examines whether pediatric inpatient care has been redistributed from general hospitals into children's hospitals.

Healthcare Utilization and Spending for Constipation in Children With Versus Without Complex Chronic Conditions.

OBJECTIVES: The aim of the study was to examine the prevalence of diagnosis and treatment for constipation among children receiving Medicaid and to compare healthcare utilization and spending for constipation among children based on number of complex chronic conditions (CCCs). METHODS: Retrospective cohort study of 4.9 million children ages 1 to 17 years enrolled in Medicaid from 2009 to 2011 in 10 states in the Truven Marketscan Database. Constipation was identified using International Classification of Disease, 9th revision codes for constipation (564.0x), intestinal impaction (560.3x), or encopresis (307.7). Outpatient and inpatient utilization and spending for constipation were assessed. CCC status was identified using validated methodology. RESULTS: A total of 267,188 children (5.4%) were diagnosed with constipation. Total constipation spending was $79.5 million. Outpatient constipation spending was $66.8 million (84.1%) during 406,814 visits, mean spending $120/visit. Among children with constipation, 1363 (0.5%) received inpatient treatment, accounting for $12.2 million (15.4%) of constipation spending, mean spending $7815/hospitalization. Of children hospitalized for constipation, 552 (40.5%) did not have an outpatient visit for constipation before admission. Approximately 6.8% of children in the study had ≥1 CCC; these children accounted for 33.5% of total constipation spending, 70.3% of inpatient constipation spending, and 19.8% of emergency department constipation spending. Constipation prevalence was 11.0% for children with 1 CCC, 16.6% with 2 CCCs, and 27.1% with ≥3 CCCs. CONCLUSIONS: Although the majority of pediatric constipation treatment occurs in the outpatient setting, inpatient care accounts for a sizable percentage of spending. Children with CCCs have a higher prevalence of constipation and account for a disproportionate amount of constipation healthcare utilization and spending.

Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification.

BACKGROUND: Clinicians caring for patients seeking alcohol detoxification face many challenges, including lack of evidence-based guidelines for treatment and high recidivism rates. OBJECTIVES: To develop a standardized protocol for determining which alcohol dependent patients seeking detoxification need inpatient versus outpatient treatment, and to study the protocol's implementation. DESIGN: Review of best evidence by ad hoc task force and subsequent creation of standardized protocol. Prospective observational evaluation of initial protocol implementation. PARTICIPANTS: Patients presenting for alcohol detoxification. INTERVENTION: Development and implementation of a protocol for evaluation and treatment of patients requesting alcohol detoxification. MAIN MEASURES: Number of admissions per month with primary alcohol related diagnosis (DRG), 30-day readmission rate, and length of stay, all measured before and after protocol implementation. RESULTS: We identified one randomized clinical trial and three cohort studies to inform the choice of inpatient versus outpatient detoxification, along with one prior protocol in this population, and combined that data with clinical experience to create an institutional protocol. After implementation, the average number of alcohol related admissions was 15.9 per month, compared with 18.9 per month before implementation (p = 0.037). There was no difference in readmission rate or length of stay. CONCLUSIONS: Creation and utilization of a protocol led to standardization of care for patients requesting detoxification from alcohol. Initial evaluation of protocol implementation showed a decrease in number of admissions.

Pilot study of peripheral internal jugular venous catheters on a hospitalist-run medicine procedure service.

Providers caring for hospitalized patients with difficult intravenous access (DIVA) frequently use central venous catheters (CVCs). One potential alternative is a peripheral internal jugular (PIJ) catheter, which is less traumatic to place and has fewer lumens than a CVC. We describe the results of 2 years' experience from a pilot project of a medicine procedure service placing PIJ catheters in hospitalized patients with DIVA. We successfully placed 34/35 (97%) PIJ catheters in 32 patients with zero complications. Median duration of use was 2.5 days (range 0-53 days, IQR 1-5). Catheter failure rate within 7 days was 32.4%, though it varied across catheter types: 9.5% in 8-10 cm midline catheters versus 69.2% (p < .001) in 6 cm angiocatheter wire introducers or shorter peripheral intravenous catheters. Our results suggest that PIJ catheters may be an option to reduce the mechanical and infectious risks associated with CVCs in some hospitalized patients with DIVA.

Phlebotomy-free days in children hospitalized with common infections and their association with clinical outcomes.

BACKGROUND: Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure. OBJECTIVE: To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes. DESIGN, SETTINGS AND PARTICIPANTS: We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality. MAIN OUTCOME AND MEASURES: We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups. RESULTS: We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children.

Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections.

OBJECTIVE: The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes. DESIGN, SETTING AND PARTICIPANTS: We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database. MAIN OUTCOME AND MEASURES: We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions. RESULTS: We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 (95% confidence interval [CI]: 30.8-35.4) h versus broad-spectrum: 46.1 (95% CI: 44.1-48.2) h) and reduced costs [narrow-spectrum: $4570 ($3751-5568) versus broad-spectrum: $5699 ($5005-$6491)]. There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.

Unilateral Periorbital Swelling in a Pediatric Patient.

Infratemporal fossa (ITF) tumors are rare in children and may present with a variety of symptoms. Teratomas are neoplasms derived from the 3 germ layers and approximately 6% to 10% are within the head and neck. Our study discusses one of the first reported cases of teratoma in the ITF in a pediatric patient. A 3-year-old girl presents with 2 years of recurrent monthly left periorbital swelling accompanied by fevers, skin discoloration, and pain. Prior episodes were treated with antibiotics with incomplete resolution. Imaging revealed a cystic lesion centered in the ITF. She was taken for endoscopic endonasal biopsy of the lesion and had no complications. Pathology revealed a mature teratoma composed primarily of pancreatic tissue. Providers should consider masses such as teratoma in the differential for ITF tumors and periorbital edema unresponsive to typical treatment.

Changing patterns of routine laboratory testing over time at children's hospitals.

BACKGROUND: Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES: To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES: We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS: Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.

Differences in testing for drugs of abuse amongst racial and ethnic groups at children's hospitals.

OBJECTIVES: Racial and ethnic differences in drug testing have been described among adults and newborns. Less is known regarding testing patterns among children and adolescents. We sought to describe the association between race and ethnicity and drug testing at US children's hospitals. We hypothesized that non-Hispanic White children undergo drug testing less often than children from other groups. METHODS: We conducted a retrospective cohort study of emergency department (ED)-only encounters and hospitalizations for children diagnosed with a condition for which drug testing may be indicated (abuse or neglect, burns, malnutrition, head injury, vomiting, altered mental status or syncope, psychiatric, self-harm, and seizure) at 41 children's hospitals participating in the Pediatric Health Information System during 2018 and 2021. We compared drug testing rates among (non-Hispanic) Asian, (non-Hispanic) Black, Hispanic, and (non-Hispanic) White children overall, by condition and patient cohort (ED-only vs. hospitalized) and across hospitals. RESULTS: Among 920,755 encounters, 13.6% underwent drug testing. Black children were tested at significantly higher rates overall (adjusted odds ratio [aOR]: 1.18; 1.05-1.33) than White children. Black-White testing differences were observed in the hospitalized cohort (aOR: 1.42; 1.18-1.69) but not among ED-only encounters (aOR: 1.07; 0.92-1.26). Asian, Hispanic, and White children underwent testing at similar rates. Testing varied by diagnosis and across hospitals. CONCLUSIONS: Hospitalized Black children were more likely than White children to undergo drug testing at US children's hospitals, though this varied by diagnosis and hospital. Our results support efforts to better understand and address healthcare disparities, including the contributions of implicit bias and structural racism.

Essential Concepts for Reducing Bias in Observational Studies.

Randomized controlled trials (RCTs) are the gold standard study design for clinical research, as prospective randomization, at least in theory, balances any differences that can exist between groups (including any differences not measured as part of the study) and isolates the studied treatment effect. Any remaining imbalances after randomization are attributable to chance. However, there are many barriers to conducting RCTs within pediatric populations, including lower disease prevalence, high costs, inadequate funding, and additional regulatory requirements. Researchers thus frequently use observational study designs to address many research questions. Observational studies, whether prospective or retrospective, do not involve randomization and thus have more potential for bias when compared with RCTs because of imbalances that can exist between comparison groups. If these imbalances are associated with both the exposure of interest and the outcome, then failure to account for these imbalances may result in a biased conclusion. Understanding and addressing differences in sociodemographic and/or clinical characteristics within observational studies are thus necessary to reduce bias. Within this Method/ology submission we describe techniques to minimize bias by controlling for important measurable covariates within observational studies and discuss the challenges and opportunities in addressing specific variables.

Safety and predictors of the success of lumbar punctures performed by a medicine procedure service.

BACKGROUND: Medicine procedure services (MPS) increasingly perform bedside procedures, including lumbar punctures (LPs). Success rates and factors associated with LP success performed by MPS have not been well described. OBJECTIVE: We identified patients undergoing LP by an MPS September 2015 to December 2020. We identified demographic and clinical factors, including patient position, body mass index (BMI), use of ultrasound, and trainee participation. We performed multivariable analysis to identify factors associated with LP success and complications. MAIN OUTCOME AND MEASURES: We identified 1065 LPs among 844 patients. Trainees participated in 82.2%; ultrasound guidance was used in 76.7% of LPs. The overall success rate was 81.3% with 7.8% minor and 0.1% major complications. A minority of LPs were referred to radiology (15.2%) or were traumatic (11.1%). In multivariable analysis, BMI > 30 kg/m2 (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.21-0.48), prior spinal surgery (OR 0.50, 95% CI 0.26-0.87), and Black race (OR 0.62, 95% CI 0.41-0.95) were associated with decreased odds of successful LP; trainee participation (OR 2.49, 95% CI 1.51-4.12) was associated with increased odds. Ultrasound guidance (OR 0.53, 95% CI 0.31-0.89) was associated with lower odds of traumatic LP. RESULTS: In a large cohort of patients undergoing LP by an MPS, we identified high success and low complication rates. Trainee participation was associated with increased odds of success, while obesity, prior spinal surgery, and Black race were associated with decreased odds of success. Ultrasound guidance was associated with lower odds of a traumatic LP. Our data may help proceduralists in planning and assist in shared decision-making.

Variation in stool testing for children with acute gastrointestinal infections.

BACKGROUND AND OBJECTIVE: Children with gastrointestinal infections often require acute care.The objectives of this study were to describe variations in patterns of stool testing across children's hospitals and determine whether such variation was associated with utilization outcomes. DESIGN, SETTINGS AND PARTICIPANTS: We performed a multicenter, cross-sectional study using the Pediatric Health Information System (PHIS) database. We identified stool testing (multiplex polymerase chain reaction [PCR], stool culture, ova and parasite, Clostridioides difficile, and other individual stool bacterial or viral tests) in children diagnosed with acute gastrointestinal infections. MAIN OUTCOME AND MEASURES: We calculated the overall testing rates and hospital-level stool testing rates, stratified by setting (emergency department [ED]-only vs. hospitalized). We stratified individual hospitals into low, moderate, or high testing institutions. Generalized estimating equations were then used to examine the association of hospital testing groups and outcomes, specifically, length of stay (LOS), costs, and revisit rates. RESULTS: We identified 498,751 ED-only and 40,003 encounters for hospitalized children from 2016 to 2020. Compared to ED-only encounters, stool studies were obtained with increased frequency among encounters for hospitalized children (ED-only: 0.1%-2.3%; Hospitalized: 1.5%-13.8%, all p < 0.001). We observed substantial variation in stool testing rates across hospitals, particularly during encounters for hospitalized children (e.g., rates of multiplex PCRs ranged from 0% to 16.8% for ED-only and 0% to 65.0% for hospitalized). There were no statistically significant differences in outcomes among low, moderate, or high testing institutions in adjusted models. CONCLUSIONS: Children with acute gastrointestinal infections experience substantial variation in stool testing within and across hospitals, with no difference in utilization outcomes. These findings highlight the need for guidelines to address diagnostic stewardship.

A Pediatric Hospital Medicine Primer for Performing Research Using Administrative Data.

Provider- and claims-focused administrative databases are powerful tools for conducting health services research, and these studies often have good generalizability owing to diversity of hospitals from which samples are derived. In this research methods article, we describe administrative data and how available provider- and claims-focused administrative databases can be used to conduct health services research. We describe common observational study designs using administrative data and provide real-world examples. We highlight the strengths and weaknesses of studies conducted using administrative data and describe methodological considerations to reduce bias and improve the rigor of observational studies using administrative data. Finally, we provide guidance on the types of study questions suitable for observational study designs using administrative data.

Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures.

BACKGROUND: Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures. OBJECTIVES: (1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care. OUTCOME MEASURES: Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs. RESULTS: We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization. CONCLUSIONS: Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

Variation in bacterial pneumonia diagnoses and outcomes among children hospitalized with lower respiratory tract infections.

BACKGROUND: Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP). OBJECTIVES: We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes. DESIGN, SETTING AND PARTICIPANTS: This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals. MAIN OUTCOME AND METHODS: We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes. RESULTS: We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs. CONCLUSION: There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP.

Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes.

OBJECTIVES: To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization. METHODS: Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement. RESULTS: We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year. CONCLUSIONS: Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.

Implementation of an academic hospital medicine procedure service: 5-year experience.

OBJECTIVES: Procedural complications are a common source of adverse events in hospitals, especially where bedside procedures are often performed by trainees. Medical procedure services (MPS) have been established to improve procedural education, ensure patient safety, and provide additional revenue for services that are typically referred. Prior descriptions of MPS have reported outcomes over one to 2 years. We aim to describe the implementation and 5-year outcomes of a hospitalist-run MPS. METHODS: We identified all patients referred to our MPS for a procedure over the 5-year span between 2014 and 2018. We manually reviewed all charts for complications of paracentesis, thoracentesis, central venous catheterization, and lumbar punctures performed by the MPS in both inpatient and outpatient settings. Annual charges for these procedures were queried using Current Procedural Terminology (CPT) codes. RESULTS: We identified 3,634 MPS procedures. Of these, ultrasound guidance was used in 3224 (88.7%) and trainees performed 2701 (74%). Complications identified included pneumothorax (3.7%, n = 16) for thoracentesis, post-dural puncture headache (13.9%, n = 100) and bleeding (0.1%, n = 1) for lumbar puncture, ascites leak for diagnostic (1.6%, n = 8) and large volume (3.7%, n = 56) paracentesis, and bleeding (3.5%, n = 16) for central venous catheter placement. Prior to initiation of the MPS, total annual procedural charges were $90,437. After MPS implementation, charges increased to a mean of $787,352 annually in the last 4 years of the study period. CONCLUSIONS: Implementation of a hospitalist-run, academic MPS resulted in a large volume of procedures, high rate of trainee participation, low rates of complications, and significant increase in procedural charges over 5 years. Wider adoption of this model has the potential to further improve patient procedural care and trainee education.