Clostridioides difficile Infection in Hospitalized Pediatric Patients: Comparisons of Epidemiology, Testing, and Treatment from 2013 to 2019.

OBJECTIVES: To compare the incidence, epidemiology, testing patterns, treatment, and outcomes of Clostridioides difficile infection (CDI) among hospitalized pediatric patients from 2013 to 2019. STUDY DESIGN: The Pediatric Health Information System database was queried for patient admissions (age 0-17 years) with International Classification of Diseases, 9th and 10th edition, codes for diagnoses of CDI with a billing code for a CDI-related antibiotic treatment. RESULTS: We identified 17 142 pediatric patients, representing 23 052 admissions, with CDI. The adjusted annual CDI incidence decreased over the study period from 7.09 cases per 10 000 patient-days (95% CI, 6.15-8.18) in 2013 to 4.89 cases per 10 000 patient-days (95% CI, 4.03-5.93) in 2019 (P < .001). C difficile-specific testing also decreased during the study period (P < .001). Chronic gastrointestinal conditions (36%) and malignancy (32%) were the most common comorbidities in CDI encounters. Oral metronidazole use decreased during the study period (P < .01) and oral vancomycin use increased (P < .001). CONCLUSIONS: Our study demonstrates a decrease in CDI incidence in hospitalized pediatric patients, a notable change from prior studies, although this may have been influenced by altered testing patterns. We found a high incidence of CDI in patients with cancer and gastrointestinal conditions: groups that warrant targeted evaluation of CDI prevention and treatment.

Impact of institutional routine surveillance endomyocardial biopsy frequency in the first year on rejection and graft survival in pediatric heart transplantation.

BACKGROUND: Routine surveillance biopsy (RSB) is performed to detect asymptomatic acute rejection (AR) after heart transplantation (HT). Variation in pediatric RSB across institutions is high. We examined center-based variation in RSB and its relationship to graft loss, AR, coronary artery vasculopathy (CAV), and cost of care during the first year post-HT. METHODS: We linked the Pediatric Health Information System (PHIS) and Scientific Registry of Transplant Recipients (SRTR, 2002-2016), including all primary-HT aged 0-21 years. We characterized centers by RSB frequency (defined as median biopsies performed among recipients aged ≥12 months without rejection in the first year). We adjusted for potential confounders and center effects with mixed-effects regression analysis. RESULTS: We analyzed 2867 patients at 29 centers. After adjusting for patient and center differences, increasing RSB frequency was associated with diagnosed AR (OR 1.15 p = 0.004), a trend toward treated AR (OR 1.09 p = 0.083), and higher hospital-based cost (US$390 315 vs. $313 248, p < 0.001) but no difference in graft survival (HR 1.00, p = 0.970) or CAV (SHR 1.04, p = 0.757) over median follow-up 3.9 years. Center RSB-frequency threshold of ≥2/year was associated with increased unadjusted rates of treated AR, but no association was found at thresholds greater than this. CONCLUSION: Center RSB frequency is positively associated with increased diagnosis of AR at 1 year post-HT. Graft survival and CAV appear similar at medium-term follow-up. We speculate that higher frequency RSB centers may have increased detection of clinically less important AR, though further study of the relationship between center RSB frequency and differences in treated AR is necessary.

Interhospital Variability in Perioperative Red Blood Cell Ordering Patterns in United States Pediatric Surgical Patients.

OBJECTIVE: To evaluate perioperative red blood cell (RBC) ordering and interhospital variability patterns in pediatric patients undergoing surgical interventions at US children's hospitals. STUDY DESIGN: This is a multicenter cross-sectional study of children aged <19 years admitted to 38 pediatric tertiary care hospitals participating in the Pediatric Health Information System in 2009-2014. Only cases performed at all represented hospitals were included in the study, to limit case mix variability. Orders for blood type and crossmatch were included when done on the day before or the day of the surgical procedure. The RBC transfusions included were those given on the day of or the day after surgery. The type and crossmatch-to-transfusion ratio (TCTR) was calculated for each surgical procedure. An adjusted model for interhospital variability was created to account for variation in patient population by age, sex, race/ethnicity, payer type, and presence/number of complex chronic conditions (CCCs) per patient. RESULTS: A total of 357 007 surgical interventions were identified across all participating hospitals. Blood type and crossmatch was performed 55 632 times, and 13 736 transfusions were provided, for a TCTR of 4:1. There was an association between increasing age and TCTR (R(2) = 0.43). Patients with multiple CCCs had lower TCTRs, with a stronger relationship (R(2) = 0.77). There was broad variability in adjusted TCTRs among hospitals (range, 2.5-25). CONCLUSIONS: The average TCTR in US children's hospitals was double that of adult surgical data, and was associated with wide interhospital variability. Age and the presence of CCCs markedly influenced this ratio. Studies to evaluate optimal preoperative RBC ordering and standardization of practices could potentially decrease unnecessary costs and wasted blood.

Assessing Structural Quality Elements of Pediatric Emergency Care.

BACKGROUND AND OBJECTIVE: Emergency departments must have appropriate resources and equipment available to meet the unique needs of children. We assessed the availability of stakeholder-endorsed quality structure performance measures for pediatric emergency department patients. METHODS: A survey of Child Health Corporation of America member hospitals was conducted. Six broad equipment groups were queried: general, monitoring, respiratory, vascular access, fracture-management, and specialized pediatric trays. Equipment availability was determined at the level of the individual item, 6 broad groups, and 44 equipment subgroups. The survey queried the availability of 8 protocol/procedure elements: method to identify age-based abnormal vital signs, patient-centered care advisory council, bronchiolitis evidence-based guideline, pediatric radiation dosing standards, suspected child abuse protocols, use of validated pediatric triage tool, and presence of nurse and physician pediatric coordinators. RESULTS: Fifty-two percent (22/42) of sites completed the survey. Forty-one percent reported availability of all 113 recommended equipment items. Every hospital reported complete availability of equipment in 77% of the subgroups. The most common missing items were adult-sized lumbar puncture needles, hypothermia thermometers, and various sizes of laryngeal mask airways. Regarding the protocol/procedure elements, a method to identify age-based abnormal vital signs, pediatric radiation dosing standard, and nurse and physician pediatric coordinators were present in 100%. Ninety-five percent used a validated triage tool and had suspected child abuse protocols. CONCLUSIONS: Presence of necessary pediatric emergency equipment is better in the surveyed hospitals than in prior reports. Most responding hospitals have important protocol/procedures in place. These data may provide benchmarks for optimal care.

Delayed repeat enemas are safe and cost-effective in the management of pediatric intussusception.

BACKGROUND/PURPOSE: The purpose of the study is to compare outcomes between delayed repeat enema (DRE) and immediate surgery (IS) in children with ileocolic intussusception who fail initial enema reduction. METHODS: Retrospective cohort study of children <6 years-of-age from 2008 to 2012 in the Pediatric Health Information System (PHIS) database. Outcomes measured were bowel resection, length of stay (LOS), and adjusted hospital costs (AHC). RESULTS: 4980 of 6889 (72.3%) children with intussusception were discharged without operation following a single successful enema. 1407 of 1909 (73.7%) remaining patients underwent IS while 502 (26.3%) had a DRE. Bowel resection was required in 372 of 1407 (26.4%) patients in IS group compared to 59 of 502 (11.8%) in the DRE group (p<0.001). The number of patients needed to treat by DRE to prevent a bowel resection was 7. In multivariable analysis, the IS patients had a 2.5 times greater likelihood of undergoing bowel resection than the DRE patients (adjusted odds ratio [OR] 2.50, 95% confidence interval [CI] 1.83-3.41, p<0.001). The DRE group had a mean LOS of 3.2 days (95% CI 2.9-3.6) and mean AHC of $9205 (95% CI $7673-$10,735). The IS group had a longer LOS (4.4days, 95% CI 4.0-4.8, p≤0.001) and higher AHC ($14,422, 95% CI $12,631-$16,214, p<0.001). CONCLUSION: Delayed repeat enemas for ileocolic intussusception increase the success of nonoperative reduction, decrease the rate of bowel resection and reduce mean hospital length of stay and costs.

Prevalence and predictors of return visits to pediatric emergency departments.

OBJECTIVE: To determine the rate of return visits to pediatric emergency departments (EDs) and identify patient- and visit-level factors associated with return visits and hospitalization upon return. DESIGN AND SETTING: Retrospective cohort study of visits to 23 pediatric EDs in 2012 using data from the Pediatric Health Information System. PARTICIPANTS: Patients <18 years old discharged following an ED visit. MEASURES: The primary outcomes were the rate of return visits within 72 hours of discharge from the ED and of return visits within 72 hours resulting in hospitalization. RESULTS: 1,415,721 of the 1,610,201 ED visits to study hospitals resulted in discharge. Of the discharges, 47,294 patients (3.3%) had a return visit. Of these revisits, 9295 (19.7%) resulted in hospitalization. In multivariate analyses, the odds of having a revisit were higher for patients with a chronic condition (odds ratio [OR]: 1.91, 95% confidence interval [CI]: 1.86-1.96), higher severity scores (OR: 1.42, 95% CI: 1.40-1.45), and age <1 year (OR: 1.32, 95% CI: 1.22-1.42). The odds of hospitalization on return were higher for patients with higher severity (OR: 3.42, 95% CI: 3.23-3.62), chronic conditions (OR: 2.92, 95% CI: 2.75-3.10), age <1 year (1.7-2.5 times the odds of other age groups), overnight arrival (OR: 1.84, 95% CI: 1.71-1.97), and private insurance (OR: 1.47, 95% CI: 1.39-1.56). Sickle cell disease and cancer patients had the highest rates of return at 10.7% and 7.3%, respectively. CONCLUSIONS: Multiple patient- and visit-level factors are associated with revisits. These factors may provide insight in how to optimize care and decrease avoidable ED utilization.

Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs.

OBJECTIVES: Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool. METHODS: A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events. RESULTS: Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients <28 weeks' gestation and <1500 g birth weight. Fifty-six percent of all adverse events were deemed preventable; 16% could have been identified earlier, and 6% could have been mitigated more effectively. Only 8% of adverse events were identified in existing hospital-based occurrence reports. The most common adverse events identified were nosocomial infections, catheter infiltrates, and abnormal cranial imaging. CONCLUSIONS: Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events.