Lung Ultrasonography: A Viable Alternative to Chest Radiography in Children with Suspected Pneumonia?

OBJECTIVE: To determine the interrater reliability (IRR) of lung ultrasonography (LUS) and chest radiography (CXR) and evaluate the accuracy of LUS compared with CXR for detecting pediatric pneumonia compared with chest computed tomography (CT) scan. STUDY DESIGN: This was a prospective cohort study of children aged 3 months to 18 years with a CXR and LUS performed between May 1, 2012, and January 31, 2014 with or without a clinical diagnosis of pneumonia. Four pediatric radiologists blinded to clinical information reported findings for the CXR and LUS images. IRR was estimated for 50 LUS and CXR images. The main outcome was the finding from CT ordered clinically or the probability of the CT finding for patients clinically requiring CT. Two radiologists reviewed CT scans to determine an overall finding. Latent class analysis was used to evaluate the sensitivity and specificity for findings (eg, consolidation) for LUS and CXR compared with CT. RESULTS: Of the 132 patients in the cohort, 36 (27%) had CT performed for a clinical reason. Pneumonia was clinically documented in 47 patients (36%). The IRR for lung consolidation was 0.55 (95% CI, 0.40-0.70) for LUS and 0.36 (95% CI, 0.21-0.51) for CXR. The sensitivity for detecting consolidation, interstitial disease, and pleural effusion was statistically similar for LUS and CXR compared with CT; however, specificity was higher for CXR. The negative predictive value was similar for CXR and LUS. CONCLUSIONS: LUS has a sufficiently high IRR for detection of consolidation. Compared with CT, LUS and CXR have similar sensitivity, but CXR is more specific for findings indicating pneumonia.

The Parent Role in Advocating for a Deteriorating Child: A Qualitative Study.

BACKGROUND AND OBJECTIVES: Families of children with medical complexity are experts on their child's baseline behavior and temperament and may recognize changes in their hospitalized child's health before clinicians. Our objective was to develop a comprehensive understanding of how families identify and communicate their child's deteriorating health with the hospital-based health care team. METHODS: In this qualitative study, our multidisciplinary team recruited family members of hospitalized children with neurologic impairment. Interviews, conducted in the hospital, were audio recorded, deidentified, and transcribed. By using inductive thematic analysis, each transcript was independently coded by 3 or 4 team members. Members met regularly to reach consensus on coding decisions. Patterns observed were organized into themes and subthemes. RESULTS: Participants included 28 family members of 26 hospitalized children 9 months to 17 years of age. Children had a mean of 9 hospitalizations in the previous 3 years. Analysis resulted in 6 themes. First, families often reported their child "writes his own book," meaning the child's illness narrative rarely conformed to textbooks. Second, families developed informal, learned pathways to navigate the inpatient system. Third, families stressed the importance of advocacy. Fourth, families self-identified as "not your typical parents" and discussed how they learned their roles as part of the care team. Fifth, medical culture often did not support partnership. Finally, families noted they are often "running on empty" from stress, fear, and lack of sleep. CONCLUSIONS: Families of children with medical complexity employ mature, experience-based pathways to identify deteriorating health. Existing communication structures in the hospital are poorly equipped to incorporate families' expertise.

Guideline Adoption for Community-Acquired Pneumonia in the Outpatient Setting.

BACKGROUND: The Pediatric Infectious Diseases Society and Infectious Diseases Society of America national childhood community-acquired pneumonia (CAP) guideline encouraged the standard evaluation and treatment of children who were managed as outpatients. Our objectives were to (1) increase adherence to guideline-recommended diagnostics and antibiotic treatment of CAP at 5 pediatric primary care practices (PPCPs) by using quality-improvement methods and (2) evaluate the association between guideline adherence and unscheduled follow-up visits. METHODS: Immunocompetent children >3 months of age with no complex chronic conditions and who were diagnosed with CAP were eligible for inclusion in this stepped-wedge study. Interventions were focused on education, knowledge of colleagues' prescribing practices, and feedback sessions. Statistical process control charts were used to assess changes in recommendations and antibiotic treatment. Unscheduled follow-up visits were compared across time by using generalized estimating equations that were clustered by PPCP. RESULTS: CAP was diagnosed in 1906 children. Guideline recommended therapy and pulse oximetry use increased from a mean baseline of 24.9% to a mean of 68.0% and from 4.3% to 85.0%, respectively, over the study period. Among children >5 years of age, but not among those who were younger, the receipt of guideline recommended antibiotics, as compared with nonguideline therapy, was associated with the increased likelihood of unscheduled follow-up (adjusted odds ratio, 2.12; 95% confidence interval: 1.31-3.43). Chest radiographs and complete blood cell counts were rarely performed at baseline. CONCLUSIONS: Recommendations for limited use of chest radiographs and complete blood cell counts and standardized antibiotic therapy in children is supported at PPCPs. However, the guideline may need to include macrolide monotherapy as appropriate antibiotic therapy for older children.

Local Pharmacy Partnership to Prevent Pediatric Asthma Reutilization in a Satellite Hospital.

OBJECTIVES: In our previous work, providing medications in-hand at discharge was a key strategy to reduce asthma reutilization (readmissions and emergency revisits) among children in a large, urban county. We sought to spread this work to our satellite hospital in an adjacent county. A key initial barrier was the lack of an outpatient pharmacy on site, so we sought to determine if a partnership with community pharmacies could improve the percentage of patients with medications in-hand at discharge, thus decreasing reutilization. METHODS: A multidisciplinary team partnered with community pharmacies. Using rapid-cycle improvement methods, the team aimed to reduce asthma reutilization by providing medications in-hand at discharge. Run charts were used to display the proportion of patients with asthma discharged with medications in-hand and to track 90-day reutilization rates. RESULTS: During the intervention period, the median percentage of patients with asthma who received medications in-hand increased from 0% to 82%. A key intervention was the expansion of the medication in-hand program to all patients. Additional changes included expanding team to evening stakeholders, narrowing the number of community partners, and building electronic tools to support key processes. The mean percentage of patients with asthma discharged from the satellite who had a readmission or emergency department revisit within 90 days of their index admission decreased from 18% to 11%. CONCLUSIONS: Impacting population-level asthma outcomes requires partnerships between community resources and health providers. When hospital resources are limited, community pharmacies are a potential partner, and providing access to medications in-hand at hospital discharge can reduce asthma reutilization.

Intravenous Versus Oral Antibiotics for Postdischarge Treatment of Complicated Pneumonia.

BACKGROUND AND OBJECTIVES: Postdischarge treatment of complicated pneumonia includes antibiotics administered intravenously via a peripherally inserted central venous catheter (PICC) or orally. Antibiotics administered via PICC, although effective, may result in serious complications. We compared the effectiveness and treatment-related complications of postdischarge antibiotics delivered by these 2 routes. METHODS: This multicenter retrospective cohort study included children ≥2 months and <18 years discharged with complicated pneumonia between 2009 and 2012. The main exposure was the route of postdischarge antibiotic administration, classified as PICC or oral. The primary outcome was treatment failure. Secondary outcomes included PICC complications, adverse drug reactions, other related revisits, and a composite of all 4 outcomes, termed "all related revisits." RESULTS: Among 2123 children, 281 (13.2%) received antibiotics via PICC. Treatment failure rates were 3.2% among PICC and 2.6% among oral antibiotic recipients and were not significantly different between the groups in across-hospital-matched analysis (matched odds ratio [OR], 1.26; 95% confidence interval [CI], 0.54 to 2.94). PICC complications occurred in 7.1%. Adverse drug reactions occurred in 0.6% of children; PICC antibiotic recipients had greater odds of adverse drug reaction in across hospital matched analysis (matched OR, 19.1; 95% CI, 4.2 to 87.3). The high rate of PICC complications and differences in adverse drug reactions contributed to higher odds of the composite outcome of all related revisits among PICC antibiotic recipients (matched OR, 4.71; 95% CI, 2.97 to 7.46). CONCLUSIONS: Treatment failure rates between PICC and oral antibiotics did not differ. Children with complicated pneumonia should preferentially receive oral antibiotics at discharge when effective oral options are available.