Hospitalist Co-management of Pediatric Orthopaedic Surgical Patients at a Community Hospital.

PURPOSE: The benefits of hospitalist co-management of pediatric surgical patients include bettering patient safety, decreasing negative patient outcomes, providing comprehensive medical care, and establishing a dedicated resource to patients for postoperative care. The purpose of this study was to characterize the nature of patients co-managed by a pediatric hospitalist. The authors hypothesize that hospitalist co-management is safe and efficacious in pediatric orthopaedic surgical patients who are admitted to a community hospital. METHODS: A retrospective review was performed of all pediatric orthopaedic surgical patients admitted to a community hospital who were co-managed by a pediatric hospitalist. Indications for hospitalization included pain control, antibiotic infusion, and need for neurovascular monitoring. Parameters of postoperative care and co-management were assessed, including presence of complications, medication introduction or adjustment by the hospitalist, follow-up adherence, and readmission/complication rates after discharge. RESULTS: Thirty-two patients were assessed with an average age of 8.8 years. Twenty-five percent of patients had an associated comorbidity, including asthma, attention deficit disorder, and/or autism. The pediatric hospitalist added pain medication to the original postoperative orders placed by the orthopaedics team in 44 percent of patients (14 of the 32) either for breakthrough pain or better long-term coverage. Additionally, 25 percent of patients had pain medication adjusted from the original dosing and schedule. The hospitalist team contacted the surgeon about the four patients (12.5 percent). In three of the cases, the surgeon was contacted to discuss pain medication, and one patient woke up agitated from anesthesia, necessitating a visit from the surgeon on the pediatrics floor. The length of stay was one day for all patients. The hospitalists rounded on and discharged patients the subsequent morning. All patients were given a follow-up appointment and schedule by the hospitalist team, and every patient followed up accordingly within ten days of discharge. No complications or hospital readmissions occurred within thirty days of discharge. CONCLUSION: Hospitalist co-management of pediatric orthopaedic surgical patients in a community hospital allows for better medical comorbidity and medication management. Hospitalists can provide closer observation during the inpatient stay and help streamline communication between providers and patients while allowing the surgeon the ability to be more mobile. Co-management is safe and efficacious in pediatric orthopaedic surgical patients who are admitted to a community hospital.

Hospital-associated venous thromboembolism in children: incidence and clinical characteristics.

OBJECTIVE: To determine incidence and clinical characteristics of hospital-associated venous thromboembolism (VTE) in pediatric patients. STUDY DESIGN: A retrospective analysis of patients with hospital-associated VTE at the Johns Hopkins Hospital from 1994 to 2009 was performed. Clinical characteristics of patients aged 21 years and younger who developed VTE symptoms after 2 days of hospitalization or <90 days after hospital discharge were examined. International Classification of Diseases, Ninth Revision codes were used to categorize patients with complex chronic medical conditions and trauma. RESULTS: There were 270 episodes of hospital-associated VTE in 90,485 admissions (rate 30 per 10,000 admissions). Young adults (18-21 years) and adolescents (14-17 years) had significantly increased rates of VTE compared with children (2-9 years) (incidence rate ratio [IRR] 7.7, 95% CI 5.1-12.0; IRR 4.3, 95% CI 2.7-6.8, respectively). A central venous catheter (CVC) was present in 50% of patients, and a surgical procedure was performed in 45% of patients before VTE diagnosis. For patients without a CVC, trauma was the most common admitting diagnosis. CVC-related VTE was diagnosed most frequently in infants (<1 year old) and in patients with malignancy. Renal and cardiac diseases were associated with the highest rates of VTE (51 and 48 per 10,000, respectively). Rates were significantly higher among those with ≥ 4 medical conditions compared with those with 1 medical condition (IRR 4.0, 95% CI 1.4-8.9). CONCLUSION: Older age and multiple medical conditions were associated with increased rates of hospital-associated VTE. These data can contribute to the design of future clinical trials to prevent hospital-associated VTE in high-risk children.

A retrospective identification of gastroesophageal reflux disease as a new risk factor for surgical site infection in cerebral palsy patients after spine surgery.

BACKGROUND: Neuromuscular scoliosis is a known risk factor for surgical site infection (SSI) after spinal fusion, with reported infection rates as high as 11.2%. Although risk factors such as antibiotic timing have been previously addressed, our objective was to identify intrinsic risk factors for SSI in cerebral palsy (CP) patients with neuromuscular scoliosis. We hypothesized that CP patients who develop SSI after spine fusion would have a risk profile similar to those who develop nosocomial infection. METHODS: We retrospectively analyzed records from patients with CP who developed infections after spinal fusion from January 1998 until July 2008, who were identified by our Infection Control Officer using National Nosocomial Infection Surveillance System criteria (N = 34). Demographically and procedurally matched controls without infection were identified from our spine database (N = 37). We compared these groups for gastroesophageal reflux disease (GERD), use of gastric acid inhibitors, presence of preoperative decubitus ulcer, previous infection, and postoperative ventilation. Multivariable logistic regression was then performed to assess the relative contributions of the predictors to "deep infection" and "any infection." RESULTS: Of 30 evaluable infected patients, 70% had incisional SSI. Although many of the infections were polymicrobial, the most common pathogens identified were Gram-negative bacilli. Many significant predictors were identified by univariable logistic regression for any infection and deep infection. Multivariable logistic regression found a significant effect only for GERD (odds ratio, 6.4; 95% confidence interval, 1.9-21.3; P = 0.002) for any infection, whereas the effect of therapy with gastric acid inhibitors did not reach statistical significance (odds ratio, 6.1 [95% confidence interval, 0.84-44.6]; P = 0.07). No significant interaction between the 2 factors was detected. Among our controls and infected patients altogether, 46.3% had GERD. CONCLUSIONS: We show that GERD increases the risk for infection in CP patients after spine fusion. Prospective multicenter studies are necessary to further validate the predictive value of this risk factor.