Antibiotic Prescribing Patterns Across the Continuum of Care for Children Hospitalized With Community-Acquired Pneumonia.

OBJECTIVES: The aim of this study was to describe the variation in antibiotic prescribing practices for uncomplicated community-acquired pneumonia across the continuum of care for hospitalized pediatric patients to better inform future efforts at standardizing antibiotic therapy throughout a single hospitalization. METHODS: This is a retrospective cohort study involving 4 hospitals caring for children aged 3 months to 18 years, hospitalized between January 1, 2011, and December 31, 2012, with diagnosis of uncomplicated pneumonia and without complex chronic medical conditions.Data collected include antibiotics prescribed before hospitalization, at the emergency department (ED) encounter, during hospitalization, and at hospital discharge. RESULTS: Six hundred nine children met inclusion criteria, with a mean age of 5.3 years and median length of stay of 2 days. Emergency department providers prescribed narrow-spectrum therapy 27% of the time, whereas discharging providers prescribed narrow-spectrum therapy 56% of the time. Third- and fourth-generation cephalosporins were less often prescribed in the preadmission setting and at discharge but were more often prescribed in the ED and inpatient setting. There was an association between inpatient prescription of broad-spectrum antibiotics when a blood culture was obtained, when broad-spectrum antibiotics were prescribed in the ED, and with increasing length of stay. CONCLUSION: Broad-spectrum antibiotic therapy for community-acquired pneumonia, especially third- and fourth-generation cephalosporins, often originates in the ED. When initiated in this setting, it is likely to be continued in the inpatient setting.

Diagnosis and treatment of Mycoplasma pneumoniae in children.

Mycoplasma pneumoniae is a common cause of community-acquired respiratory tract infections and accounts for up to 40% of cases of pneumonia in children over age 5. This article seeks to provide a general overview of the current recommended management of Mycoplasma pneumoniae infection in children.

Interobserver reliability of attending physicians and bedside nurses when using an inpatient paediatric respiratory score.

AIMS AND OBJECTIVES: This study aimed to determine the interobserver reliability between bedside nurses and attending physicians for a paediatric respiratory score as part of an asthma Integrated Care Pathway implementation. BACKGROUND: An Integrated Care Pathway is one approach to improving quality of care for children hospitalised with asthma. Prior to implementation of the integrated care pathway, it was necessary to train nursing staff on the use of a respiratory assessment tool and to evaluate the interobserver reliability use of this tool. DESIGN: Prospective study using a convenience sample of children hospitalised for a respiratory illness in an academic medical centre. METHODS: The respiratory assessment used was the Paediatric Asthma Score. Bedside nurse-attending physician (27 different RNs and three attending paediatric hospitalists) pairs performed 71 simultaneous patient assessments on 20 patients. Intraclass correlation coefficient and kappa statistics were used to assess interobserver reliability. RESULTS: The overall intraclass correlation coefficient was nearly perfect where κ = 0·95, 95% CI (0·92, 0·97) and overall kappa for reliability based on clinically relevant score breakpoints was also high with κ = 0·82, 95% CI (0·75, 0·90). The majority of subgroup analyses revealed substantial to almost perfect agreement across a variety of diagnoses, age ranges, and individual score components. CONCLUSIONS: Bedside nurses, with support and training from attending physicians, can perform respiratory assessments that agree almost perfectly with those of attending physicians. RELEVANCE TO CLINICAL PRACTICE: The use of an Integrated Care Pathway allows for optimal interprofessional collaboration between bedside nurses and attending physicians.

Improving Guideline-Concordant Care for Febrile Infants Through a Quality Improvement Initiative.

OBJECTIVES: We aimed to examine the impact of a quality improvement (QI) collaborative on adherence to specific recommendations within the American Academy of Pediatrics' Clinical Practice Guideline (CPG) for well-appearing febrile infants aged 8 to 60 days. METHODS: Concurrent with CPG release in August 2021, we initiated a QI collaborative involving 103 general and children's hospitals across the United States and Canada. We developed a multifaceted intervention bundle to improve adherence to CPG recommendations for 4 primary measures and 4 secondary measures, while tracking 5 balancing measures. Primary measures focused on guideline recommendations where deimplementation strategies were indicated. We analyzed data using statistical process control (SPC) with baseline and project enrollment from November 2020 to October 2021 and the intervention from November 2021 to October 2022. RESULTS: Within the final analysis, there were 17 708 infants included. SPC demonstrated improvement across primary and secondary measures. Specifically, the primary measures of appropriately not obtaining cerebrospinal fluid in qualifying infants and appropriately not administering antibiotics had the highest adherence at the end of the collaborative (92.4% and 90.0% respectively). Secondary measures on parent engagement for emergency department discharge of infants 22 to 28 days and oral antibiotics for infants 29 to 60 days with positive urinalyses demonstrated the greatest changes with collaborative-wide improvements of 16.0% and 20.4% respectively. Balancing measures showed no change in missed invasive bacterial infections. CONCLUSIONS: A QI collaborative with a multifaceted intervention bundle was associated with improvements in adherence to several recommendations from the AAP CPG for febrile infants.

Prevalence of Invasive Bacterial Infections in Well-Appearing, Febrile Infants.

BACKGROUND AND OBJECTIVES: Data on invasive bacterial infection (IBI), defined as bacteremia and/or bacterial meningitis, in febrile infants aged <60 days old primarily derive from smaller, dated studies conducted at large, university-affiliated medical centers. Our objective with the current study was to determine current prevalence and epidemiology of IBI from a contemporary, national cohort of well-appearing, febrile infants at university-affiliated and community-based hospitals. PATIENTS AND METHODS: Retrospective review of well-appearing, febrile infants aged 7 to 60 days was performed across 31 community-based and 44 university-affiliated centers from September 2015 to December 2017. Blood and cerebrospinal fluid bacterial culture results were reviewed and categorized by using a priori criteria for pathogenic organisms. Prevalence estimates and subgroup comparisons were made by using descriptive statistics. RESULTS: A total of 10 618 febrile infants met inclusion criteria; cerebrospinal fluid and blood cultures were tested from 6747 and 10 581 infants, respectively. Overall, meningitis prevalence was 0.4% (95% confidence interval [CI]: 0.2-0.5); bacteremia prevalence was 2.4% (95% CI: 2.1-2.7). Neonates aged 7 to 30 days had significantly higher prevalence of bacteremia, as compared with infants in the second month of life. IBI prevalence did not differ between community-based and university-affiliated hospitals (2.7% [95% CI: 2.3-3.1] vs 2.1% [95% CI: 1.7-2.6]). Escherichia coli and Streptococcus agalactiae were the most commonly identified organisms. CONCLUSIONS: This contemporary study of well-appearing, febrile infants supports previous epidemiological estimates of IBI prevalence and suggests that the prevalence of IBI may be similar among community-based and university-affiliated hospitals. These results can be used to aid future clinical guidelines and prediction tool development.

Comparing Patterns of Care for Febrile Infants at Community and University-Affiliated Hospitals.

OBJECTIVES: Most children in the United States receive treatment in community hospitals, but descriptions of clinical practice patterns in pediatric care in this setting are lacking. Our objectives were to compare clinical practice patterns primarily between community and university-affiliated hospitals and secondarily by number of pediatric beds before and during participation in a national practice standardization project. METHODS: We performed a retrospective secondary analysis on data from 126 hospitals that participated in the American Academy of Pediatrics' Value in Inpatient Pediatrics Reducing Excessive Variability in the Infant Sepsis Evaluation project, a national quality improvement project conducted to improve care for well-appearing febrile infants aged 7 to 60 days. Four use measures were compared by hospital type and by number of non-ICU pediatric beds. RESULTS: There were no differences between community and university-affiliated hospitals in the odds of hospital admission, average length of stay, or odds of cerebrospinal fluid culture. The odds of chest radiograph at community hospitals were higher only during the baseline period. There were no differences by number of pediatric beds in odds of admission or average length of stay. For hospitals with ≤30 pediatric beds, the odds of chest radiograph were higher and the odds of cerebrospinal fluid culture were lower compared with hospitals >50 beds during both study periods. CONCLUSIONS: In many key aspects, care for febrile infants does not differ between community and university-affiliated hospitals. Clinical practice may differ more by number of pediatric beds.

Things We Do for No Reason™ : Lumbar Punctures in Low-Risk Febrile Infants with Bronchiolitis.

Inspired by the ABIM Foundation's Choosing Wisely® campaign, the "Things We Do for No Reason™ " (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative.

Health care providers' adherence to guidelines declines over time, and feasible strategies for sustaining adherence have not yet been identified. We assessed the long-term feasibility of various strategies for sustaining guideline adherence and described factors influencing their use. We conducted a cross-sectional survey (N = 104) of physician leaders who participated in a national collaborative to improve care of infants with suspected sepsis. Data were collected on long-term use of strategies to promote guideline adherence (use, perceived effectiveness, and barriers to use). Sixty (58%) participants from diverse hospital settings responded. There were significant declines in use of quality improvement and educational strategies, largely driven by lack of time or staff resources and competing priorities. Electronic strategies (eg, order sets) and hospital policies or guidelines were feasible to continue long-term after the collaborative ended and were perceived as effective. Clinicians and healthcare leaders should consider prioritizing these strategies in their efforts to improve care and outcomes for children in hospital settings.

Are Caregivers Who Respond to the Child HCAHPS Survey Reflective of All Hospitalized Pediatric Patients?

OBJECTIVES: The Child Hospital Consumer Assessment of Healthcare Providers and Systems (C-HCAHPS) survey was developed to measure satisfaction levels of pediatric inpatients' caregivers. Studies in adults have revealed that certain demographic groups (people of color or who are multiracial and people with public insurance) respond to surveys at decreased rates, contributing to nonresponse bias. Our primary goal was to determine if results from the C-HCAHPS survey accurately reflect the intended population or reveal evidence of nonresponse bias. Our secondary goal was to examine whether demographic or clinical factors were associated with increased satisfaction levels. METHODS: This was a retrospective cohort study of responses (n = 421) to the C-HCAHPS survey of patients admitted to a tertiary-care pediatric hospital between March 2016 and March 2017. Respondent demographic information was compared with that of all hospital admissions over the same time frame. Satisfaction was defined as "top-box" scores for questions on overall rating and willingness to recommend the hospital. RESULTS: Caregivers returning surveys were more likely to be white, non-Hispanic, and privately insured (P < .001). Caregivers with the shortest emergency department wait times were more likely to assign top-box scores for global rating (P = .025). We found no differences in satisfaction between race and/or ethnicity, length of stay, insurance payer, or total cost. CONCLUSIONS: Caregivers who identified with underrepresented minority groups and those without private insurance were less likely to return surveys. Among the surveys received, short emergency department wait time and older age were the only factors measured that were associated with higher satisfaction. Efforts to increase patient satisfaction on the basis of satisfaction scores may exacerbate existing disparities in health care.

Point Prevalence of Children Hospitalized With Chronic Critical Illness in the General Inpatient Units.

OBJECTIVES: Children with medical complexity (CMC) have high rates of mortality and morbidity, prolonged lengths of stay, and use a disproportionately high amount of health care expenditures. A subset of children with CMC have chronic critical illness requiring even higher levels of clinical support and resource use. We aimed to describe the point prevalence of children hospitalized in general inpatient care units with pediatric chronic critical illness (PCCI). METHODS: Point prevalence analysis across 6 pediatric tertiary medical centers in the United States on a "snapshot day" (May 17, 2017). On the day of sampling, a number of demographic, historical, and clinical descriptors were collected. A previously published definition of PCCI was used to establish inclusion criteria. RESULTS: The point prevalence of patients with PCCI in general inpatient care units was 41% (232 out of 571). Of these, 91% (212 out of 232) had been admitted more than once in the previous 12 months, 50% (117 out of 232) had a readmission within 30 days of a previous admission, and 20% (46 out of 232) were oncology patients. Only 1 had a designated complex care team, and there were no attending physicians designated primarily for medically complex children. CONCLUSIONS: Children with chronic critical illness, a subset of CMC, may make up a substantial proportion of pediatric patients hospitalized in general inpatient care units. There is a critical need to understand how to better care for this medically fragile population. In our data, it is suggested that resources should be allocated for PCCI in nonintensive care clinical areas.

Facilitators of interdepartmental quality improvement: a mixed-methods analysis of a collaborative to improve pediatric community-acquired pneumonia management.

BACKGROUND: Emergency medicine and paediatric hospital medicine physicians each provide a portion of the initial clinical care for the majority of hospitalised children in the USA. While these disciplines share goals to increase quality of care, there are scant data describing their collaboration. Our national, multihospital learning collaborative, which aimed to increase narrow-spectrum antibiotic prescribing for paediatric community-acquired pneumonia, provided an opportunity to examine factors influencing the success of quality improvement efforts across these two clinical departments. OBJECTIVE: To identify barriers to and facilitators of interdepartmental quality improvement implementation, with a particular focus on increasing narrow-spectrum antibiotic use in the emergency department and inpatient settings for children hospitalised with pneumonia. METHODS: We used a mixed-methods design, analysing interviews, written reports and quality measures. To describe hospital characteristics and quality measures, we calculated medians/IQRs for continuous variables, frequencies for categorical variables and Pearson correlation coefficients. We conducted in-depth, semistructured interviews by phone with collaborative site leaders; interviews were transcribed verbatim and, with progress reports, analysed using a general inductive approach. RESULTS: 47 US-based hospitals were included in this analysis. Qualitative analysis of 35 interview transcripts and 142 written reports yielded eight inter-related domains that facilitated successful interdepartmental quality improvement: (1) hospital leadership and support, (2) quality improvement champions, (3) evidence supporting the intervention, (4) national health system influences, (5) collaborative culture, (6) departments' structure and resources, (7) quality improvement implementation strategies and (8) interdepartmental relationships. CONCLUSIONS: The conceptual framework presented here may be used to identify hospitals' strengths and potential barriers to successful implementation of quality improvement efforts across clinical departments.

Prevalence of Bacteremia and Bacterial Meningitis in Febrile Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis.

Importance: Febrile neonates (persons in the first month of life) are believed to be at higher risk for bacteremia or bacterial meningitis than infants in their second month of life. However, the true prevalence is unclear. Objective: To determine modern rates of bacteremia and bacterial meningitis in febrile neonates and infants in the second month of life presenting to an ambulatory setting. Data Sources: A comprehensive, no-limit search was conducted in PubMed using previously published search terms in February 2015 and repeated in September 2016. Study Selection: Abstracts and full texts were reviewed independently by several investigators. Studies were included if data regarding blood cultures or cerebrospinal fluid cultures from consecutive febrile infants in an ambulatory setting could be extrapolated within the age groups. To limit the analysis to the period after the availability of the Haemophilus influenzae type b vaccination, studies that collected data before 1990 were excluded. Data Extraction and Synthesis: Data were extracted in accordance with the Meta-analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines via independent abstraction by several investigators. The Newcastle-Ottawa Scale was used to assess bias. Main Outcomes and Measures: The primary outcomes were prevalence rates of bacteremia and bacterial meningitis in febrile neonates and infants in the second month of life. In neonates, prevalence rates were also estimated in the era of group B Streptococcus intrapartum antibiotic prophylaxis (after 1996). Results: In total, 7264 abstracts were screened, resulting in 188 full-text manuscripts reviewed, with 12 meeting inclusion criteria (with 15 713 culture results). For febrile neonates, the prevalence of bacteremia was 2.9% (95% CI, 2.3%-3.7%; I2 = 50%; n = 5145) and the prevalence of bacterial meningitis was 1.2% (95% CI, 0.8%-1.9%; I2 = 27%; n = 3288). In neonates in the era after group B Streptococcus prophylaxis, the prevalence of bacteremia was 3.0% (95% CI, 2.3%-3.9%; I2 = 6%; n = 2055) and the prevalence of meningitis was 1.0% (95% CI, 0.4%-2.1%; I2 = 28%; n = 1739). For febrile infants in the second month of life, the prevalence of bacteremia was 1.6% (95% CI, 0.9%-2.7%; I2 = 78%; n = 4778) and the prevalence of meningitis was 0.4% (95% CI, 0.2%-1.0%; I2 = 33%; n = 2502). Conclusions and Relevance: These findings suggest that febrile neonates have approximately twice the rate of bacteremia and meningitis as febrile infants in their second month of life.

Negative Urinalyses in Febrile Infants Age 7 to 60 Days Treated for Urinary Tract Infection.

The role of the urinalysis (UA) in the management of young, febrile infants is controversial. To assess how frequently infants are treated for urinary tract infection (UTI) despite having normal UA values and to compare the characteristics of infants treated for UTI who have positive versus negative UAs, we reviewed 20,570 wellappearing febrile infants 7-60 days of age evaluated at 124 hospitals in the United States who were included in a national quality improvement project. Of 19,922 infants without bacteremia and meningitis, 2,407 (12.1%) were treated for UTI, of whom 2,298 (95.5%) had an initial UA performed. UAs were negative in 337/2,298 (14.7%) treated subjects. The proportion of infants treated for UTI with negative UAs ranged from 0%-35% across hospitals. UA-negative subjects were more likely to have respiratory symptoms and less likely to have abnormal inflammatory markers than UA+ subjects, indicating that they are mounting less of an inflammatory response to their underlying illness and/or might have contaminated specimens or asymptomatic bacteriuria.

Reducing Variability in the Infant Sepsis Evaluation (REVISE): A National Quality Initiative.

BACKGROUND: Substantial variability exists in the care of febrile, well-appearing infants. We aimed to assess the impact of a national quality initiative on appropriate hospitalization and length of stay (LOS) in this population. METHODS: The initiative, entitled Reducing Variability in the Infant Sepsis Evaluation (REVISE), was designed to standardize care for well-appearing infants ages 7 to 60 days evaluated for fever without an obvious source. Twelve months of baseline and 12 months of implementation data were collected from emergency departments and inpatient units. Ill-appearing infants and those with comorbid conditions were excluded. Participating sites received change tools, run charts, a mobile application, live webinars, coaching, and a LISTSERV. Analyses were performed via statistical process control charts and interrupted time series regression. The 2 outcome measures were the percentage of hospitalized infants who were evaluated and hospitalized appropriately and the percentage of hospitalized infants who were discharged with an appropriate LOS. RESULTS: In total, 124 hospitals from 38 states provided data on 20 570 infants. The median site improvement in percentages of infants who were evaluated and hospitalized appropriately and in those with appropriate LOS was 5.3% (interquartile range = -2.5% to 13.7%) and 15.5% (interquartile range = 2.9 to 31.3), respectively. Special cause variation toward the target was identified for both measures. There was no change in delayed treatment or missed bacterial infections (slope difference 0.1; 95% confidence interval, -8.3 to 9.1). CONCLUSIONS: Reducing Variability in the Infant Sepsis Evaluation noted improvement in key aspects of febrile infant management. Similar projects may be used to improve care in other clinical conditions.

Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis.

BACKGROUND AND OBJECTIVES: To determine factors associated with cerebrospinal fluid (CSF) testing in febrile young infants with a positive urinalysis and assess the probability of delayed diagnosis of bacterial meningitis in infants treated for urinary tract infection (UTI) without CSF testing. METHODS: We performed a retrospective cohort study using data from the Reducing Excessive Variability in Infant Sepsis Evaluation quality improvement project. A total of 20 570 well-appearing febrile infants 7 to 60 days old presenting to 124 hospitals from 2015 to 2017 were included. A mixed-effects logistic regression was conducted to determine factors associated with CSF testing. Delayed meningitis was defined as a new diagnosis of bacterial meningitis within 7 days of discharge. RESULTS: Overall, 3572 infants had a positive urinalysis; 2511 (70.3%) underwent CSF testing. There was wide variation by site, with CSF testing rates ranging from 64% to 100% for infants 7 to 30 days old and 10% to 100% for infants 31 to 60 days old. Factors associated with CSF testing included: age 7 to 30 days (adjusted odds ratio [aOR]: 4.6; 95% confidence interval [CI]: 3.8-5.5), abnormal inflammatory markers (aOR: 2.2; 95% CI: 1.8-2.5), and site volume >300 febrile infants per year (aOR: 1.8; 95% CI: 1.2-2.6). Among 505 infants treated for UTI without CSF testing, there were 0 (95% CI: 0%-0.6%) cases of delayed meningitis. CONCLUSIONS: There was wide variation in CSF testing in febrile infants with a positive urinalysis. Among infants treated for UTI without CSF testing (mostly 31 to 60-day-old infants), there were no cases of delayed meningitis within 7 days of discharge, suggesting that routine CSF testing of infants 31 to 60 days old with a positive urinalysis may not be necessary.

Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods.

BACKGROUND AND OBJECTIVES: Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS: We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS: The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS: Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.

Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project.

Objective: Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project. Materials and Methods: We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled "Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE)." The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics. Results: Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5]. Discussion: We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects. Conclusions: ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools' impact on medical decision making, clinical practice, and health outcomes.

A Multicenter Collaborative to Improve Care of Community Acquired Pneumonia in Hospitalized Children.

BACKGROUND AND OBJECTIVES: The Value in Inpatient Pediatrics Network sponsored the Improving Care in Community Acquired Pneumonia collaborative with the goal of increasing evidence-based management of children hospitalized with community acquired pneumonia (CAP). Project aims included: increasing use of narrow-spectrum antibiotics, decreasing use of macrolides, and decreasing concurrent treatment of pneumonia and asthma. METHODS: Data were collected through chart review across emergency department (ED), inpatient, and discharge settings. Sites reviewed up to 20 charts in each of 6 3-month cycles. Analysis of means with 3-σ control limits was the primary method of assessment for change. The expert panel developed project measures, goals, and interventions. A change package of evidence-based tools to promote judicious use of antibiotics and raise awareness of asthma and pneumonia codiagnosis was disseminated through webinars. Peer coaching and periodic benchmarking were used to motivate change. RESULTS: Fifty-three hospitals enrolled and 48 (91%) completed the 1-year project (July 2014-June 2015). A total of 3802 charts were reviewed for the project; 1842 during baseline cycles and 1960 during postintervention cycles. The median before and after use of narrow-spectrum antibiotics in the collaborative increased by 67% in the ED, 43% in the inpatient setting, and 25% at discharge. Median before and after use of macrolides decreased by 22% in the ED and 27% in the inpatient setting. A decrease in asthma and CAP codiagnosis was noted, but the change was not sustained. CONCLUSIONS: Low-cost strategies, including collaborative sharing, peer benchmarking, and coaching, increased judicious use of antibiotics in a diverse range of hospitals for pediatric CAP.