Bundled Care to Reduce Sepsis Mortality: The Improving Pediatric Sepsis Outcomes (IPSO) Collaborative.

OBJECTIVES: We sought to improve utilization of a sepsis care bundle and decrease 3- and 30- day sepsis-attributable mortality, as well as determine which care elements of a sepsis bundle are associated with improved outcomes. METHODS: Children's Hospital Association formed a QI collaborative to Improve Pediatric Sepsis Outcomes (IPSO) (January 2017-March 2020 analyzed here). IPSO Suspected Sepsis (ISS) patients were those without organ dysfunction where the provider "intended to treat" sepsis. IPSO Critical Sepsis (ICS) patients approximated those with septic shock. Process (bundle adherence), outcome (mortality), and balancing measures were quantified over time using statistical process control. An original bundle (recognition method, fluid bolus < 20 min, antibiotics < 60 min) was retrospectively compared with varying bundle time-points, including a modified evidence-based care bundle, (recognition method, fluid bolus < 60 min, antibiotics < 180 min). We compared outcomes using Pearson χ-square and Kruskal Wallis tests and adjusted analysis. RESULTS: Reported are 24 518 ISS and 12 821 ICS cases from 40 children's hospitals (January 2017-March 2020). Modified bundle compliance demonstrated special cause variation (40.1% to 45.8% in ISS; 52.3% to 57.4% in ICS). The ISS cohort's 30-day, sepsis-attributable mortality dropped from 1.4% to 0.9%, a 35.7% relative reduction over time (P < .001). In the ICS cohort, compliance with the original bundle was not associated with a decrease in 30-day sepsis-attributable mortality, whereas compliance with the modified bundle decreased mortality from 4.75% to 2.4% (P < .01). CONCLUSIONS: Timely treatment of pediatric sepsis is associated with reduced mortality. A time-liberalized care bundle was associated with greater mortality reductions.

Children's surgery verification and value-based care in pediatric surgery.

With the prevailing focus on increasing value in healthcare, understanding the different components of the value equation is of primary importance. Michael E. Porter's writings on the value agenda and the use of integrated practice units (IPUs) have provided easy correlation to adult disease entities with large populations sharing common pathways and providers in the diagnosis and care of these patients. In pediatric surgery, with smaller populations and larger numbers of rare or unique conditions and anatomic challenges, utilizing the concept of an IPU is more challenging. The literature has generally shown the improvements in quality of care through participation in various programs through the American College of Surgeons (ACS) such as trauma verification, or the National Surgical Quality Improvement Project (NSQIP), but that participation alone does not guarantee better outcomes. Use of these programs in conjunction with participation in quality collaboratives have tended to show favorable returns on investment for these programs. We seek to demonstrate how the Children's Surgery Verification (CSV) program provides pediatric surgeons an effective vehicle with which to engage the value agenda, evaluating and improving care over the care continuum in order to improve the function of children's hospitals as larger integrated units.

Utilizing big data from electronic health records in pediatric clinical care.

Big data has the capacity to transform both pediatric healthcare delivery and research, but its potential has yet to be fully realized. Curation of large multi-institutional datasets of high-quality data has allowed for significant advances in the timeliness of quality improvement efforts. Improved access to large datasets and computational power have also paved the way for the development of high-performing, data-driven decision support tools and precision medicine approaches. However, implementation of these approaches and tools into pediatric practice has been hindered by challenges in our ability to adequately capture the heterogeneity of the pediatric population as well as the nuanced complexities of pediatric diseases such as sepsis. Moreover, there are large gaps in knowledge and definitive evidence demonstrating the utility, usability, and effectiveness of these types of tools in pediatric practice, which presents significant challenges to provider willingness to leverage these solutions. The next wave of transformation for pediatric healthcare delivery and research through big data and sophisticated analytics will require focusing efforts on strategies to overcome cultural barriers to adoption and acceptance. IMPACT: Big data from EHRs can be used to drive improvement in pediatric clinical care. Clinical decision support, artificial intelligence, machine learning, and precision medicine can transform pediatric care using big data from the EHR. This article provides a review of barriers and enablers for the effective use of data analytics in pediatric clinical care using pediatric sepsis as a use case. The impact of this review is that it will inform influencers of pediatric care about the importance of current trends in data analytics and its use in improving outcomes of care through EHR-based strategies.

The evolving value of older biomarkers in the clinical diagnosis of pediatric sepsis.

Sepsis remains the leading cause of childhood mortality worldwide. The evolving definition of pediatric sepsis is extrapolated from adult studies. Although lacking formal validation in the pediatric population, this working definition has historically proven its clinical utility. Prompt identification of pediatric sepsis is challenging as clinical picture is often variable. Timely intervention is crucial for optimal outcome, thus biomarkers are utilized to aid in immediate, yet judicious, diagnosis of sepsis. Over time, their use in sepsis has expanded with discovery of newer biomarkers that include genomic bio-signatures. Despite recent scientific advances, there is no biomarker that can accurately diagnose sepsis. Furthermore, older biomarkers are readily available in most institutions while newer biomarkers are not. Hence, the latter's clinical value in pediatric sepsis remains theoretical. Albeit promising, scarce data on newer biomarkers have been extracted from research settings making their clinical value unclear. As interest in newer biomarkers continue to proliferate despite their ambiguous clinical use, the literature on older biomarkers in clinical settings continue to diminish. Thus, revisiting the evolving value of these earliest biomarkers in optimizing pediatric sepsis diagnosis is warranted. This review focuses on the four most readily available biomarkers to bedside clinicians in diagnosing pediatric sepsis. IMPACT: The definition of pediatric sepsis remains an extrapolation from adult studies. Older biomarkers that include C-reactive protein, procalcitonin, ferritin, and lactate are the most readily available biomarkers in most pediatric institutions to aid in the diagnosis of pediatric sepsis. Older biomarkers, although in varying levels of reliability, remain to be useful clinical adjuncts in the diagnosis of pediatric sepsis if used in the appropriate clinical context. C-reactive protein and procalcitonin are more sensitive and specific among these older biomarkers in diagnosing pediatric sepsis although evidence varies in different age groups and clinical scenarios.

Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis.

Purpose: Pediatric sepsis guidelines recommend rapid intravenous fluid (IVF) bolus administration rates (BAR). Recent sepsis studies suggest that rapid BAR may be associated with increased morbidity. We aimed to describe the association between emergency department (ED) IVF BAR and clinical outcomes in pediatric sepsis. Patients and Methods: Secondary post-hoc analysis of retrospective cohort data from 19 hospitals in the Pediatric Septic Shock Collaborative (PSSC) database. Patients with presumed septic shock were defined by severe sepsis/septic shock diagnostic codes, receipt of septic shock therapies, or floor-to-ICU transfers within 12 hours from ED admission for septic shock. Patients (2 months-21 years) with complete data on weight, antibiotic receipt, bolus timing, and bolus volumes were included. The primary outcome was 30-day mortality. Associations between BAR and mortality and secondary (intubation or non-invasive positive pressure ventilation = NIPPV) outcomes were assessed using unadjusted and adjusted logistic regression. Results: The PSSC database included 6731 patients; 3969 met inclusion and received a median ED volume of 40.2 mL/kg. Seventy-six (1.9%) patients died, 151 (3.8%) were intubated, and 235 (5.9%) had NIPPV administered. The median BAR was 25.7 mL/kg/hr. For each 20 mL/kg/hr increase in BAR, the adjusted odds ratio (aOR) for 30-day mortality [aOR = 1.11 (95% CI 1.01, 1.23)], intubation [aOR = 1.25 (95% CI 1.09, 1.44)], and NIPPV [aOR = 1.20 (95% CI 1.05, 1.38)] significantly increased. Conclusion: Faster ED IVF bolus administration rates in this pediatric sepsis database were associated with higher adjusted odds of death, intubation and NIPPV. Controlled trials are needed to determine if these associations are replicable.

Establishing national stakeholder priorities for quality improvement in pediatric trauma care: Consensus results using a modified Delphi process.

BACKGROUND: Quality improvement efforts within pediatric trauma centers (PTCs) are robust, but the majority of children do not receive initial postinjury care at PTCs. Disparities in access to quality trauma care remain, particularly for children who initially access the trauma system outside of a PTC. The purpose of this project was to identify unmet needs for injured children within the pediatric emergency care system and to determine national priorities for quality improvement across the continuum of pediatric trauma care. METHODS: A panel of delegates representing patients and families, prehospital providers, federal funding partners, nurses, and physicians was recruited from 10 national stakeholder organizations. Potential targets were identified using an initial stakeholder meeting followed by a free text response survey. Free text items were coded and condensed as themes and then ranked by the panel using a modified Delphi approach to determine consensus priorities. Items not achieving >35% prioritization on a given iteration were dropped from subsequent iterations. Consensus was defined as 75% of members designating an item as a top-four priority. RESULTS: Nineteen themes were identified as potential targets for QI initiatives. Four iterations of panel ranking were used to achieve consensus, with four priorities identified: (1) creation of a toolkit and standard provider training for pediatric trauma triage, shock recognition, and early recognition for need to transfer to higher level of care; (2) development of minimum standards for pediatric trauma resuscitation and stabilization capability in nonpediatric centers; (3) facilitating creation of local nursing and physician champions for pediatric trauma; and (4) development and dissemination of best-practice guidelines to improve imaging practices for injured children. CONCLUSION: System-level quality improvement priorities for pediatric trauma care should focus resources on developing and implementing minimum pediatric standards for injury care, frontline provider training, stabilization protocols, imaging guidelines, and local pediatric champions. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Pediatric Septic Shock Collaborative Improves Emergency Department Sepsis Care in Children.

OBJECTIVES: The pediatric emergency department (ED)-based Pediatric Septic Shock Collaborative (PSSC) aimed to improve mortality and key care processes among children with presumed septic shock. METHODS: This was a multicenter learning and improvement collaborative of 19 pediatric EDs from November 2013 to May 2016 with shared screening and patient identification recommendations, bundles of care, and educational materials. Process metrics included minutes to initial vital sign assessment and to first and third fluid bolus and antibiotic administration. Outcomes included 3- and 30-day all-cause in-hospital mortality, hospital and ICU lengths of stay, hours on increased ventilation (including new and increases from chronic baseline in invasive and noninvasive ventilation), and hours on vasoactive agent support. Analysis used statistical process control charts and included both the overall sample and an ICU subgroup. RESULTS: Process improvements were noted in timely vital sign assessment and receipt of antibiotics in the overall group. Timely first bolus and antibiotics improved in the ICU subgroup. There was a decrease in 30-day all-cause in-hospital mortality in the overall sample. CONCLUSIONS: A multicenter pediatric ED improvement collaborative showed improvement in key processes for early sepsis management and demonstrated that a bundled quality improvement-focused approach to sepsis management can be effective in improving care.

Ready for Children Part II: Increasing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting.

Objectives: Treating pediatric patients often invokes discomfort and anxiety among emergency medical service (EMS) personnel. As part of the process to improve pediatric care in the prehospital system, the Health Resources and Services Administration (HRSA) Emergency Services for Children (EMSC) Program implemented two prehospital performance measures -access to a designated pediatric care coordinator (PECC) and skill evaluation using pediatric equipment-along with a multi-year plan to aid states in achieving the measures. Baseline data from a survey conducted in 2017 showed that less than 25% of EMS agencies had access to PECC and 47% performed skills evaluation using pediatric equipment at least twice a year. To evaluate change over time, the survey was again conducted in 2020, and agencies that participated in both years are compared. Methods: A web-based survey was sent to EMS agency administrators in 58 states and territories from January to March 2020. Descriptive statistics, odds ratios, and 95% confidence intervals were conducted. Results: The response rate was 56%. A total of 5,221 agencies participated in both survey periods representing over 250,000 providers. The percentage of agencies reporting the presence of a PECC increased from 24% to 34% (p= <0.001). However, some agencies reported that they no longer had a PECC, while others reported having a PECC for the first time. Fifty percent (50%) of agencies conduct pediatric psychomotor skills evaluation at least twice/year, a 2% increase over time (p = 0.041); however, a third (34%) evaluate skills using pediatric equipment less than once a year. The presence of a PECC continues to be the variable associated with the highest odds (AOR 2.15, 95% CI 1.91-2.43) of conducting at least semiannual skills evaluation.Conclusions: There is an increase in the presence of pediatric care coordination and the frequency of pediatric psychomotor skills evaluation among national EMS agencies over time. Continued efforts to increase and sustain PECC presence should be an ongoing focus to improve pediatric readiness in the prehospital system.

Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes.

Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children's hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.

Evaluating Pediatric Sepsis Definitions Designed for Electronic Health Record Extraction and Multicenter Quality Improvement.

OBJECTIVES: To describe the Children's Hospital Association's Improving Pediatric Sepsis Outcomes sepsis definitions and the identified patients; evaluate the definition using a published framework for evaluating sepsis definitions. DESIGN: Observational cohort. SETTING: Multicenter quality improvement collaborative of 46 hospitals from January 2017 to December 2018, excluding neonatal ICUs. PATIENTS: Improving Pediatric Sepsis Outcomes Sepsis was defined by electronic health record evidence of suspected infection and sepsis treatment or organ dysfunction. A more severely ill subgroup, Improving Pediatric Sepsis Outcomes Critical Sepsis, was defined, approximating septic shock. INTERVENTIONS: Participating hospitals identified patients, extracted data, and transferred de-identified data to a central data warehouse. The definitions were evaluated across domains of reliability, content validity, construct validity, criterion validity, measurement burden, and timeliness. MEASUREMENTS AND MAIN RESULTS: Forty hospitals met data quality criteria across four electronic health record platforms. There were 23,976 cases of Improving Pediatric Sepsis Outcomes Sepsis, including 8,565 with Improving Pediatric Sepsis Outcomes Critical Sepsis. The median age was 5.9 years. There were 10,316 (43.0%) immunosuppressed or immunocompromised patients, 4,135 (20.3%) with central lines, and 2,352 (11.6%) chronically ventilated. Among Improving Pediatric Sepsis Outcomes Sepsis patients, 60.8% were admitted to intensive care, 26.4% had new positive-pressure ventilation, and 19.7% received vasopressors. Median hospital length of stay was 6.0 days (3.0-13.0 d). All-cause 30-day in-hospital mortality was 958 (4.0%) in Improving Pediatric Sepsis Outcomes Sepsis; 541 (6.3%) in Improving Pediatric Sepsis Outcomes Critical Sepsis. The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated strengths in content validity, convergent construct validity, and criterion validity; weakness in reliability. Improving Pediatric Sepsis Outcomes Sepsis definitions had significant initial measurement burden (median time from case completion to submission: 15 mo [interquartile range, 13-18 mo]); timeliness improved once data capture was established (median, 26 d; interquartile range, 23-56 d). CONCLUSIONS: The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated feasibility for large-scale data abstraction. The patients identified provide important information about children treated for sepsis. When operationalized, these definitions enabled multicenter identification and data aggregation, indicating practical utility for quality improvement.

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis.

BACKGROUND AND OBJECTIVES: International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS: We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). RESULTS: In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. CONCLUSIONS: The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

Machine learning-based prediction of acute severity in infants hospitalized for bronchiolitis: a multicenter prospective study.

We aimed to develop machine learning models to accurately predict bronchiolitis severity, and to compare their predictive performance with a conventional scoring (reference) model. In a 17-center prospective study of infants (aged < 1 year) hospitalized for bronchiolitis, by using routinely-available pre-hospitalization data as predictors, we developed four machine learning models: Lasso regression, elastic net regression, random forest, and gradient boosted decision tree. We compared their predictive performance-e.g., area-under-the-curve (AUC), sensitivity, specificity, and net benefit (decision curves)-using a cross-validation method, with that of the reference model. The outcomes were positive pressure ventilation use and intensive treatment (admission to intensive care unit and/or positive pressure ventilation use). Of 1,016 infants, 5.4% underwent positive pressure ventilation and 16.0% had intensive treatment. For the positive pressure ventilation outcome, machine learning models outperformed reference model (e.g., AUC 0.88 [95% CI 0.84-0.93] in gradient boosted decision tree vs 0.62 [95% CI 0.53-0.70] in reference model), with higher sensitivity (0.89 [95% CI 0.80-0.96] vs. 0.62 [95% CI 0.49-0.75]) and specificity (0.77 [95% CI 0.75-0.80] vs. 0.57 [95% CI 0.54-0.60]). The machine learning models also achieved a greater net benefit over ranges of clinical thresholds. Machine learning models consistently demonstrated a superior ability to predict acute severity and achieved greater net benefit.

Clinical Predictors for Abnormal Renal Bladder Ultrasound in Hospitalized Young Children With a First Febrile Urinary Tract Infection.

BACKGROUND: Physicians often obtain a routine renal bladder ultrasound (RBUS) for young children with a first febrile urinary tract infection (UTI). However, few children are diagnosed with serious anatomic anomalies, and opportunity may exist to take a focused approach to ultrasonography. We aimed to identify characteristics of the child, prenatal ultrasound (PNUS), and illness that could be used to predict an abnormal RBUS and measure the impact of RBUS on management. METHODS: We conducted a single-center prospective cohort study of hospitalized children 0 to 24 months of age with a first febrile UTI from October 1, 2016, to December 23, 2018. Independent variables included characteristics of the child, PNUS, and illness. The primary outcome, abnormal RBUS, was defined through consensus of a multidisciplinary team on the severity of ultrasound findings important to identify during a first UTI. RESULTS: A total of 211 children were included; the median age was 1.0 month (interquartile range 0-2), and 55% were uncircumcised boys. All mothers had a PNUS with 10% being abnormal. Escherichia coli was the pathogen in 85% of UTIs, 20% (n = 39 of 197) had bacteremia, and 7% required intensive care. Abnormal RBUS was found in 36% (n = 76 of 211) of children; of these, 47% (n = 36 of 76) had moderately severe findings and 53% (n = 40 of 76) had severe findings. No significant difference in clinical characteristics was seen among children with and without an abnormal RBUS. One child had Foley catheter placement, and 33% received voiding cystourethrograms, 15% antibiotic prophylaxis, and 16% subspecialty referrals. CONCLUSIONS: No clinical predictors were identified to support a focused approach to RBUS examinations. Future studies should investigate the optimal timing for RBUS.

Characterizing Avoidable Transfer Admissions in Infants Hospitalized for Bronchiolitis.

OBJECTIVES: The appropriateness of interfacility transfer admissions for bronchiolitis to pediatric centers is uncertain. We characterized avoidable transfer admissions for bronchiolitis. We hypothesized that a higher proportion of hospitalized infants transferred from a community emergency department (ED) or hospital (transfer admission) would be discharged within 48 hours with little or no intervention, compared with direct admissions from an enrolling ED (nontransfer admission). METHODS: We analyzed a 17-center, prospective infant cohort (age <1 year) hospitalized for bronchiolitis (2011-2014). An avoidable transfer admission (primary outcome) was hospitalization for <48 hours without an intervention for severe illness in which a pediatric specialist could be beneficial (oxygen, advanced airway management, life support). Parenteral fluids and routine medications were excluded. We compared admissions by patient, ED, inpatient, and transferring hospital characteristics to identify factors associated with avoidable transfer admissions. Multivariable logistic regression was used to identify predictors of avoidable transfer admission. RESULTS: Among 1007 infants, 558 (55%) were nontransfer admissions, 164 (16%) were transfer admissions, and 204 (20%) were referrals from clinics; 81 (8%) were missing referral type. Significantly fewer transferred infants were hospitalized for <48 hours with little or no intervention (40 of 164; 24% [95% confidence interval 18%-32%]) than nontransferred infants (199 of 558; 36% [95% confidence interval 32%-40%]; P = .007). Avoidable transfer admissions were more likely to be children of color, have nonprivate insurance, receive fewer ED interventions, and originate from small EDs. A multivariable model revealed that minority race and/or ethnicity, normal oxygenation, and small ED transfers increased odds of avoidable transfer admission. CONCLUSIONS: Although most transferred infants hospitalized for bronchiolitis required interventions for severe illness, 1 in 4 admissions were potentially avoidable.

Provider-Level and Hospital-Level Factors and Process Measures of Quality Care Delivered in Pediatric Emergency Departments.

OBJECTIVE: Differences in the quality of emergency department (ED) care are often attributed to nonclinical factors such as variations in the structure, systems, and processes of care. Few studies have examined these associations among children. We aimed to determine whether process measures of quality of care delivered to patients receiving care in children's hospital EDs were associated with physician-level or hospital-level factors. METHODS: We included children (<18 years old) who presented to any of the 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2011 and December 2011. We measured quality of care from medical record reviews using a previously validated implicit review instrument with a summary score ranging from 5 to 35, and examined associations between process measures of quality and physician- and hospital-level factors using a mixed-effects linear regression model adjusted for patient case-mix, with hospital site as a random effect. RESULTS: Among the 620 ED encounters reviewed, we did not find process measures of quality to be associated with any physician-level factors such as physician sex, years since medical school graduation, or physician training. We found, however, that process measures of quality were positively associated with delivery at freestanding children's hospitals (1.96 points higher in quality compared to nonfreestanding status, 95% confidence interval: 0.49, 3.43) and negatively associated with higher annual ED patient volume (-0.03 points per thousand patients, 95% confidence interval: -0.05, -0.01). CONCLUSION: Process measures of quality of care delivered to children were higher among patients treated at freestanding children's hospitals but lower among patients treated at higher volume EDs.

A National Approach to Pediatric Sepsis Surveillance.

Pediatric sepsis is a major public health concern, and robust surveillance tools are needed to characterize its incidence, outcomes, and trends. The increasing use of electronic health records (EHRs) in the United States creates an opportunity to conduct reliable, pragmatic, and generalizable population-level surveillance using routinely collected clinical data rather than administrative claims or resource-intensive chart review. In 2015, the US Centers for Disease Control and Prevention recruited sepsis investigators and representatives of key professional societies to develop an approach to adult sepsis surveillance using clinical data recorded in EHRs. This led to the creation of the adult sepsis event definition, which was used to estimate the national burden of sepsis in adults and has been adapted into a tool kit to facilitate widespread implementation by hospitals. In July 2018, the Centers for Disease Control and Prevention convened a new multidisciplinary pediatric working group to tailor an EHR-based national sepsis surveillance approach to infants and children. Here, we describe the challenges specific to pediatric sepsis surveillance, including evolving clinical definitions of sepsis, accommodation of age-dependent physiologic differences, identifying appropriate EHR markers of infection and organ dysfunction among infants and children, and the need to account for children with medical complexity and the growing regionalization of pediatric care. We propose a preliminary pediatric sepsis event surveillance definition and outline next steps for refining and validating these criteria so that they may be used to estimate the national burden of pediatric sepsis and support site-specific surveillance to complement ongoing initiatives to improve sepsis prevention, recognition, and treatment.

Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis.

BACKGROUND: Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments. METHODS: We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge. FINDINGS: Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70-49·96), the USA (8·20, 2·79-24·11), Canada (5·17, 1·61-16·67), and Australia and New Zealand (1·21, 0·36-4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16-1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01-1·18), chest retractions (1·88, 1·26-2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50). INTERPRETATION: Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis. FUNDING: None.

The Effect of a Primary Care Provider Incentive Program on Pediatric Emergency Medicine Visits.

OBJECTIVE: The aim of the study was to analyze the effect of a financial incentive program targeting primary care providers (PCPs) with the goal of decreasing emergency department (ED) utilization. METHODS: We performed a retrospective cohort analysis in a single health maintenance organization comparing ED visit/1000 member-months before and after the physician incentive program in 2009. We compared the median ED visit rate between physicians who did (PIP) and did not participate (non-PIP) from 2009 to 2012. We used 2008 data as a baseline study period to compare the ED visit rate between PIP and non-PIP providers to detect any inherent difference between the 2 groups. RESULTS: A total of 1376 PCPs were enrolled. A total of US $18,290,817 was spent in total on incentives. Overall, the median ED visit rate for all providers was statistically significantly lower during the study period (baseline period, study period: 56.36 ED visits/1000 member-months vs 45.82, respectively, P < 0.001). During the baseline period in our fully adjusted linear regression for degree, specialty, education, and board status, PIP versus non-PIP visits were not statistically significantly different (P = 0.17). During the study period in our fully adjusted model, we found that PIP had statistically significant fewer ED visits compared with non-PIP (P = 0.02). In a subgroup analysis of providers who did and did not receive an incentive payment, in the fully adjusted linear regression, providers who received any payment had statistically significant fewer ED visits/1000 member-months (P < 0.001). In addition, we found in the fully adjusted analysis that those providers who received at least 1 incentive payment for meeting after-hours criteria had statistically significantly fewer ED visits/1000 member-months (P < 0.001). CONCLUSIONS: A financial incentive program to provide PCPs with specific targets and goals to decrease pediatric ED utilization can decrease ED visits.

Discharging Asthma Patients on 3-Hour ß-Agonist Treatments: A Quality Improvement Project.

OBJECTIVES: Asthma exacerbations are a leading cause of hospitalization among children. Despite the existence of hospital protocols and national guidelines, little guidance is available regarding appropriate short-acting ß-agonist (SABA) frequency discharge criteria. Our aim was to reduce the median length of stay (LOS) for children hospitalized with asthma exacerbations by 4 hours by changing the discharge requirement SABA frequency. METHODS: Multiple plan-do-study-act cycles based on findings in our key driver diagram were used to decrease LOS. Our primary intervention was reducing the SABA administration frequency discharge requirement from every 4 hours to every 3 hours. After a feasibility pilot, this change was implemented throughout the hospital. Our intervention bundle included updating our evidence-based guidelines, electronic health record order sets and note templates, house-wide education, and a new process for respiratory therapists to notify physicians of discharge readiness. Our primary metric was LOS, with 3-, 7-, and 14-day same-cause emergency department (ED) revisits and hospital readmissions as balancing metrics. Statistical process control charts and nonparametric testing were performed for data analysis. RESULTS: Median hospital LOS was significantly lower in the postintervention period compared with the preintervention period (30.18 vs 36.14 hours respectively; P < .001). Statistical process control charts indicated special cause variation was achieved. No significant differences were observed in rates of ED revisits or hospital readmissions. CONCLUSIONS: Reducing the discharge requirement of SABA frequency from every 4 hours to every 3 hours resulted in a reduction in LOS, with no increase in ED recidivism or hospital readmission rates.

A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned.

BACKGROUND: Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis. METHODS: Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement. RESULTS: Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality. CONCLUSIONS: A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a "time zero" for measuring the timeliness of treatment.