Resource Utilization and Costs Associated with Approaches to Identify Infants with Early-Onset Sepsis.

Objective. To compare resource utilization and costs associated with 3 alternative screening approaches to identify early-onset sepsis (EOS) in infants born at ≥35 wk of gestational age, as recommended by the American Academy of Pediatrics (AAP) in 2018. Study Design. Decision tree-based cost analysis of the 3 AAP-recommended approaches: 1) categorical risk assessment (categorization by chorioamnionitis exposure status), 2) neonatal sepsis calculator (a multivariate prediction model based on perinatal risk factors), and 3) enhanced clinical observation (assessment based on serial clinical examinations). We evaluated resource utilization and direct costs (2022 US dollars) to the health system. Results. Categorical risk assessment led to the greatest neonatal intensive care unit usage (210 d per 1,000 live births) and antibiotic exposure (6.8%) compared with the neonatal sepsis calculator (112 d per 1,000 live births and 3.6%) and enhanced clinical observation (99 d per 1,000 live births and 3.1%). While the per-live birth hospital costs of the 3 approaches were similar-categorical risk assessment cost $1,360, the neonatal sepsis calculator cost $1,317, and enhanced clinical observation cost $1,310-the cost of infants receiving intervention under categorical risk assessment was approximately twice that of the other 2 strategies. Results were robust to variations in data parameters. Conclusion. The neonatal sepsis calculator and enhanced clinical observation approaches may be preferred to categorical risk assessment as they reduce the number of infants receiving intervention and thus antibiotic exposure and associated costs. All 3 approaches have similar costs over all live births, and prior literature has indicated similar health outcomes. Inclusion of downstream effects of antibiotic exposure in the neonatal period should be evaluated within a cost-effectiveness analysis. Highlights: Of the 3 approaches recommended by the American Academy of Pediatrics in 2018 to identify early-onset sepsis in infants born at ≥35 weeks, the categorical risk assessment approach leads to about twice as many infants receiving evaluation to rule out early-onset sepsis compared with the neonatal sepsis calculator and enhanced clinical observation approaches.While the hospital costs of the 3 approaches were similar over the entire population of live births, the neonatal sepsis calculator and enhanced clinical observation approaches reduce antibiotic exposure, neonatal intensive care unit admission, and hospital costs associated with interventions as part of the screening approach compared with the categorical risk assessment approach.

Implementing a triage tool to improve appropriateness of care for children coming to the emergency department in a small hospital in India.

BACKGROUND: In 2015, senior consultants at Sitaram Bhartia Institute of Science and Research saw several sick children in their outpatient clinics for which they had been seen in the emergency department the previous day. These children seemed to require admission but were sent home. This prompted us to review the paediatric care provided in our emergency department. METHODS: A multidisciplinary team was formed to run this improvement initiative. Review of literature suggested that establishing a triage system around a prevalidated triage tool would help us deliver more appropriate care. The South African Triage Scale was selected and adapted. INTERVENTIONS: With the aim of delivering appropriate care to at least 50% of children, a series of sequential interventions were tested using the improvement methodology of Plan-Do-Study-Act (PDSA) cycles, an approach recommended by the Institute for Healthcare Improvement. Learnings from the PDSA cycle of the previous intervention helped decide the subsequent change idea. The interventions included training in use of tool, increasing nurse staffing levels, using team huddles as feedback opportunities, introducing nurse reminders, reducing non-productive work, developing local leadership and training a restricted group of locum paediatricians. Qualitative and quantitative information was analysed to retain or reject change ideas. RESULTS: At baseline only 16%-17% of children were receiving appropriate care. The sequential changes resulted in a gradual improvement to a median of 63% of children receiving appropriate care by the end of 20 months. CONCLUSIONS: We succeeded in establishing a paediatric emergency triage system and culture in the given setting through a unique enriching experience. We worked on removing systemic barriers and facilitating change while facing several unexpected outcomes. A sustained iterative approach may be the best way to achieving significant improvement in difficult settings like ours.

Assessment of the Effects of Rituximab Monotherapy on Different Subsets of Circulating T-Regulatory Cells and Clinical Disease Severity in Severe Pemphigus Vulgaris.

BACKGROUND: Robust evidence for the efficacy of rituximab monotherapy in pemphigus is lacking. The effects of rituximab on T-regulatory cells (Tregs) in pemphigus have not been studied. OBJECTIVE: The primary objective was to assess the efficacy of rituximab monotherapy in severe pemphigus vulgaris. The secondary objectives were to assess whether counts of different subsets of Tregs in the peripheral blood correlate with baseline clinical severity and whether clinical response in severe pemphigus is associated with an alteration in the Treg count. METHODS: Eighteen eligible subjects with severe pemphigus vulgaris were recruited and were treated with 1 g of intravenous rituximab on days 0 and 15. Efficacy was assessed in terms of disease control, time to disease control, complete remission off therapy, and relapse. Flow cytometric analysis of CD4+CD25+FoxP3, IL-10-secreting Tr1, and TGF-ß secreting Th3 regulatory cells was performed. Clinical evaluation and flow cytometric analysis of Tregs was performed periodically until follow-up at 26 weeks. RESULTS: Rituximab monotherapy was able to induce complete remission in all but 5 (68.75%) patients and was well tolerated. No direct relationship between clinical severity and CD4+CD25+FoxP3 cell counts was found. There were inverse correlations between serially measured values of the cutaneous and mucosal Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and Th3 cell count. CONCLUSION: Rituximab is a safe and effective monotherapy option for severe pemphigus. As the immunological findings were somewhat different from those observed in other autoimmune conditions treated with rituximab, further studies are required to substantiate the findings of our study in pemphigus patients.