Effect of Viral Illness on Procalcitonin as a Predictor of Bacterial Infection in Febrile Infants.

OBJECTIVE: The impact of confirmed viral infections (CVI) on procalcitonin (PCT) levels in febrile infants aged 8-60 days with a bacterial illness (BI) is unknown. The objectives of the study were to (1) examine the association of CVI with PCT levels in patients with/without a concurrent BI, defined as bacteremia, meningitis, or urinary tract infection, and (2) assess PCT as a predictor of BI in infants with a concurrent CVI. METHODS: In this single-center, retrospective cohort study, we examined febrile infants aged 8-60 days presenting between January 1, 2018 and December 31, 2020. PCT levels were compared between groups, according to results of bacterial cultures and viral tests, using the Wilcoxon rank test. The prediction ability of PCT to detect BI with/without concurrent CVI was assessed by using area under the curve from logistic regression. RESULTS: Patients included: 404 BI-/CVI+, 73 BI+/CVI-, 48 BI+/CVI+, and 138 BI-/CVI-. Median PCT level in the BI+/CVI+ group was significantly lower when compared to BI+/CVI- (0.36 ng/mL vs 0.89 ng/mL), but significantly higher than the BI-/CVI- group (0.36 ng/mL vs 0.1 ng/mL). The presence of a CVI reduced the sensitivity of PCT in BI detection (68% vs 44%), with minimal impact specificity (93% vs 96%). CONCLUSIONS: In previously healthy febrile infants 8-60 days old, the presence of a CVI reduces the sensitivity of PCT BI detection without impacting its specificity. The impact of a CVI on PCT levels in febrile infants has implications for how this marker of infection should be considered when assessing risk of BI in infants.

Factors Correlated With Successful Pediatric Post-Discharge Phone Call Attempt and Connection.

OBJECTIVES: Postdischarge phone calls can identify discharge errors and gather information following hospital-to-home transitions. This study used the multisite Project IMPACT (Improving Pediatric Patient Centered Care Transitions) dataset to identify factors associated with postdischarge phone call attempt and connectivity. METHODS: This study included 0- to 18-year-old patients discharged from 4 sites between January 2014 and December 2017. We compared demographic and clinical factors between postdischarge call attempt and no-attempt and connectivity and no-connectivity subgroups and used mixed model logistic regression to identify significant independent predictors of call attempt and connectivity. RESULTS: Postdischarge calls were attempted for 5528 of 7725 (71.6%) discharges with successful connection for 3801 of 5528 (68.8%) calls. Connection rates varied significantly among sites (52% to 79%, P < .001). Age less than 30 days (P = .03; P = .01) and age 1 to 6 years (P = .04; P = .04) were independent positive predictors for both call attempt and connectivity, whereas English as preferred language (P < .001) and the chronic noncomplex clinical risk group (P = .02) were independent positive predictors for call attempt and connectivity, respectively. In contrast, readmission within 3 days (P = .004) and federal or state payor (P = .02) were negative independent predictors for call attempt and call connectivity, respectively. CONCLUSIONS: This study suggests that targeted interventions may improve postdischarge call attempt rates, such as investment in a reliable call model or improvement in interpreter use, and connectivity, such as enhanced population-based communication.

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls.

Postdischarge phone calls (PDPCs) are recommended to identify and mitigate postdischarge issues such as missed follow-up appointments, medication errors, and failure to activate contingency plans. A current state assessment showed variability in documenting PDPC content and postdischarge issue mitigation. Therefore, the primary aim was to improve the postdischarge issue mitigation documentation rate from 65% to 100% over 16 months. Methods: An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation. Results: The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged. Conclusions: Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Late-Career Pediatric Hospitalists: Programmatic Accommodations and Supports.

BACKGROUND: As the number of late-career pediatric hospitalists increases, issues regarding aging and retirement will require more attention. Long shifts and overnight clinical responsibilities may be challenging for older physicians. Our study objectives include investigation of the current state of practice regarding work hours, night call responsibilities, productivity requirements, coronavirus disease 2019 (COVID-19) exposure modifications, and division chief knowledge about retirement supports for late-career pediatric hospitalists. METHODS: This cross-sectional study used a web survey, distributed in spring of 2020 on the American Academy of Pediatrics, Section on Hospital Medicine, Division Chief listserv. The questionnaire asked about (1) program demographics, (2) overnight call responsibilities, (3) clinical schedules, (4) modifications for COVID-19, and (5) retirement benefits and supports. Data were analyzed by using descriptive statistics and the Fisher exact test. RESULTS: The 47 responding programs employ 982 hospitalists in 728 full-time equivalent positions. Division chiefs estimated 117 (12%) individuals were aged 50 to 64 years and 16 (1.6%) were 65 years or older. Most programs (91%) had at least 1 member 50 to 64 years of age; 13 programs (28%) had a member aged 65 or older. Larger programs were more likely to allow older physicians to opt out of some night call responsibilities. Most programs made some accommodations for COVID-19 exposure. Other than financial counseling and academic benefits, most programs did not provide retirement counseling or other supports for retiring physicians. CONCLUSION: Although limited by a low response rate, we found most programs had older faculty. Substantial variation exists in how programs make accommodations and offer support for older members.

Association of Psychiatric Comorbidities With Treatment and Outcomes in Pediatric Migraines.

BACKGROUND AND OBJECTIVES: Migraine headache is a common disorder in pediatrics, sometimes leading to hospital admission. Psychiatric comorbidities are prevalent in adults with migraine headache, but there is limited evidence in the pediatric population. This study aimed to examine the prevalence of psychiatric comorbidity in children hospitalized for migraine headache and assess the association of this comorbid state on treatment interventions and outcomes. METHODS: This multicenter, retrospective cohort study examined data from the Pediatric Health Information System. Subjects included patients aged 6 to 18 hospitalized for migraine headache between 2010 and 2018, excluding those with complex chronic conditions. Associations of psychiatric comorbidity with treatments, length of stay (LOS), cost, and 30-day readmissions were assessed using the Fisher-exact, Wilcoxon-rank-sum test, and adjusted linear or logistic regression models. RESULTS: The total 21 436 subjects included 6796 (32%) with psychiatric comorbidity, with prevalence highest for anxiety (2415; 11.2%), depression (1433; 6.7%), and attention-deficit/hyperactivity disorder (1411; 6.5%). Patients with psychiatric comorbidity were significantly more likely (P < .001) to receive dihydroergotamine (61% vs 54%), topiramate (23% vs 18%), and valproate (38% vs 34%), and have longer mean LOS (2.6 vs 2.0 days), higher average costs ($8749 vs $7040), and higher 30-day readmission (21% vs 17%). CONCLUSIONS: Of children hospitalized for migraine headache, 32% have comorbid psychiatric disorders associated with increased use of medications, longer LOS, and increased cost of hospitalization and readmission. Prospective studies are recommended to identify optimal multidisciplinary care models for children with migraine headaches and psychiatric comorbidities in the inpatient setting.

Factorial Analysis Quantifies the Effects of Pediatric Discharge Bundle on Hospital Readmission.

BACKGROUND AND OBJECTIVES: Factorial design of a natural experiment was used to quantify the benefit of individual and combined bundle elements from a 4-element discharge transition bundle (checklist, teach-back, handoff to outpatient providers, and postdischarge phone call) on 30-day readmission rates (RRs). METHODS: A 24 factorial design matrix of 4 bundle element combinations was developed by using patient data (N = 7725) collected from January 2014 to December 2017 from 4 hospitals. Patients were classified into 3 clinical risk groups (CRGs): no chronic disease (CRG1), single chronic condition (CRG2), and complex chronic condition (CRG3). Estimated main effects of each bundle element and their interactions were evaluated by using Study-It software. Because of variation in subgroup size, important effects from the factorial analysis were determined by using weighted effect estimates. RESULTS: RR in CRG1 was 3.5% (n = 4003), 4.1% in CRG2 (n = 1936), and 17.6% in CRG3 (n = 1786). Across the 3 CRGs, the number of subjects in the factorial groupings ranged from 16 to 674. The single most effective element in reducing RR was the checklist in CRG1 and CRG2 (reducing RR by 1.3% and 3.0%) and teach-back in CRG3 (by 4.7%) The combination of teach-back plus a checklist had the greatest effect on reducing RR in CRG3 by 5.3%. CONCLUSIONS: The effect of bundle elements varied across risk groups, indicating that transition needs may vary on the basis of population. The combined use of teach-back plus a checklist had the greatest impact on reducing RR for medically complex patients.

The Pediatric Hospital Medicine Core Competencies: 2020 Revision.

BACKGROUND: The Pediatric Hospital Medicine (PHM) Core Competencies define the expertise required of practitioners and provide a framework for educational activities. Since initial publication in 2010, the scope of practice for pediatric hospitalists has evolved in clinical, research, administrative, and educational arenas. OBJECTIVE: To describe the methodology utilized in the revision of The PHM Core Competencies to ensure a product reflective of current roles and expectations for pediatric hospitalists across all training pathways and practice settings. METHODS: The Society of Hospital Medicine (SHM) Pediatrics Special Interest Group supported the initiation of the revision. A diverse group of editors and authors was engaged from among members of SHM, the American Academy of Pediatrics and the Academic Pediatrics Association. Editorial roles were expanded to represent all practice settings. More than 80 individuals contributed, representing both university and community sites, and all US geographic regions. Editors conducted a two-part needs assessment; a survey related to content was distributed to the PHM community and content from recent conferences and PHM related publications was reviewed. The final compendium consists of 4 sections and 66 chapters, including 12 new chapters and 36 chapters with substantial changes. Individual chapters and the entire compendium underwent rigorous internal and external review. CONCLUSION: The PHM Core Competencies: 2020 Revision reflects the work of a broad spectrum of PHM practitioners responding to the practice and educational changes in PHM over the past decade. The compendium can inform education, training, and career development for pediatric hospitalists practicing now and in coming years.

Parents Support Teach-back, Demonstration, and a Postdischarge Phone Call to Augment Discharge Education.

OBJECTIVES: To identify caregiver preferences for discharge education components, content, and techniques. METHODS: Before discharge education, a 9-question structured interview was performed with caregivers of children from 2 populations admitted to the hospital medicine service: patients with asthma (age 2-17 years) or children who were not dependent on technology (age <2 years). McNemar's tests were used to evaluate for significant differences between response options. Open coding was used for theme development to interpret qualitative responses about information caregivers wished to receive before leaving the hospital. RESULTS: The interview was administered to 100 caregivers. More than 90% of caregivers believed that instruction regarding follow-up appointments, medications, and reasons to call the pediatrician or return to the emergency department were important aspects of discharge education. Caregivers also identified a desire for education on their child's condition, care at home, and illness prevention. Most caregivers reported that teach-back, early discharge education, and a postdischarge phone call would be beneficial. Caregivers varied in their preferences for written, verbal, and video instruction, whereas live demonstration was rated almost universally as an effective method by 97% of caregivers (P < .0001). CONCLUSIONS: In our study, we provide insight into caregivers' perspectives on the content, timing, and style of education needed to promote a safe transition of care from the hospital to the home. These findings add caregiver support to the expert consensus in Project Improving Pediatric Patient-Centered Care Transitions and elucidate additional themes to aid in further study and optimization of discharge education.

Project IMPACT Pilot Report: Feasibility of Implementing a Hospital-to-Home Transition Bundle.

BACKGROUND AND OBJECTIVES: To improve hospital to home transitions, a 4-element pediatric patient-centered transition bundle was developed, including: a transition readiness checklist; predischarge teach-back education; timely and complete written handoff to the primary care provider; and a postdischarge phone call. The objective of this study was to demonstrate the feasibility of bundle implementation and report initial outcomes at 4 pilot sites. Outcome measures included postdischarge caregiver ability to teach-back key home management information and 30-day reuse rates. METHODS: A multisite, observational time series using multiple planned sequential interventions to implement bundle components with non-technology-supported and technology-supported patients. Data were collected via electronic health record reviews and during postdischarge phone calls. Statistical process control charts were used to assess outcomes. RESULTS: Four pilot sites implemented the bundle between January 2014 and May 2015 for 2601 patients, of whom 1394 had postdischarge telephone encounters. Improvement was noted in the implementation of all bundle elements with the transitions readiness checklist posing the greatest feasibility challenge. Phone contact connection rates were 69%. Caregiver ability to teach-back essential home management information postdischarge improved from 18% to 82%. No improvement was noted in reuse rates, which differed dramatically between technology-supported and non-technology-supported patients. CONCLUSIONS: A pediatric care transition bundle was successfully tested and implemented, as demonstrated by improvement in all process measures, as well as caregiver home management skills. Important considerations for successful implementation and evaluation of the discharge bundle include the role of local context, electronic health record integration, and subgroup analysis for technology-supported patients.

A quality improvement initiative to achieve high nursing presence during patient- and family-centered rounds.

OBJECTIVES: The objectives of this study were to: (1) identify local barriers to nursing presence on patient- and family-centered rounds (PFCR); and (2) increase nursing attendance during PFCR. METHODS: An electronic survey needs assessment was administered to nursing staff on a single acute medical care unit to identify local barriers to nursing presence on PFCR. Daily tracking of nursing presence on rounds was then performed over a 7-month period. During this time period, 2 Plan-Do-Study Act cycles were conducted. The first intervention was a workshop for nurses about PFCR. The second intervention was the development of a strategy to contact nurses by using a hands-free communication device so that nurses were notified when rounds were starting on their patients. To evaluate the impact of our interventions, a p-chart was generated for the outcome of average daily nursing attendance (%) on PFCR per week over the 7-month period. RESULTS: Two barriers identified on the survey were: (1) nurses were uncertain if physicians valued their input during PFCR; and (2) nurses were unsure when the physician team would be conducting rounds on their patients. On the p-chart, the average percentage of nursing attendance before interventions was 47%. After the nursing workshop, no change in the mean nursing attendance on PFCR was noted. After initiation of the hands-free contact strategy, nursing attendance on PFCR rose to 80%. CONCLUSIONS: A nursing contact strategy using a hands-free device led to a sustained increase in nursing attendance during PFCR.

Clues that aid in the diagnosis of nonaccidental trauma presenting as an apparent life-threatening event.

BACKGROUND: Apparent life-threatening events (ALTEs) can encompass many different diagnoses. Nonaccidental trauma (NAT) is one potential serious diagnosis. OBJECTIVE: (1) To identify key elements in the history and physical exam in infants presenting with an ALTE that aid in the subsequent diagnosis of NAT; and (2) to evaluate the role of diagnostic studies in these infants in confirming the diagnosis of NAT. DESIGN/METHODS: A retrospective chart review analysis, over a 2-year period, of infants with an ALTE was performed. From this group, all children with a discharge diagnosis of child physical abuse, shaken infant syndrome, or NAT were included in the study. RESULTS: 4 patients were found to be victims of NAT based on their clinical histories and physical examinations. Although confirmatory, ophthalmologic exams, skeletal surveys, and head CT scans had a lower sensitivity for NAT. CONCLUSIONS: NAT should be considered when an infant is admitted for evaluation of an ALTE.