A National Quality Improvement Collaborative to Improve Antibiotic Use in Pediatric Infections.

BACKGROUND: Nearly 25% of antibiotics prescribed to children are inappropriate or unnecessary, subjecting patients to avoidable adverse medication effects and cost. METHODS: We conducted a quality improvement initiative across 118 hospitals participating in the American Academy of Pediatrics Value in Inpatient Pediatrics Network 2020 to 2022. We aimed to increase the proportion of children receiving appropriate: (1) empirical, (2) definitive, and (3) duration of antibiotic therapy for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections to ≥85% by Jan 1, 2022. Sites reviewed encounters of children >60 days old evaluated in the emergency department or hospital. Interventions included monthly audit with feedback, educational webinars, peer coaching, order sets, and a mobile app containing site-specific, antibiogram-based treatment recommendations. Sites submitted 18 months of baseline, 2-months washout, and 10 months intervention data. We performed interrupted time series (analyses for each measure. RESULTS: Sites reviewed 43 916 encounters (30 799 preintervention, 13 117 post). Overall median [interquartile range] adherence to empirical, definitive, and duration of antibiotic therapy was 67% [65% to 70%]; 74% [72% to 75%] and 61% [58% to 65%], respectively at baseline and was 72% [71% to 72%]; 79% [79% to 80%] and 71% [69% to 73%], respectively, during the intervention period. Interrupted time series revealed a 13% (95% confidence interval: 1% to 26%) intercept change at intervention for empirical therapy and a 1.1% (95% confidence interval: 0.4% to 1.9%) monthly increase in adherence per month for antibiotic duration above baseline rates. Balancing measures of care escalation and revisit or readmission did not increase. CONCLUSIONS: This multisite collaborative increased appropriate antibiotic use for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infection among diverse hospitals.

Documentation of Trauma-Informed Care Elements for Young People Hospitalized After Assault Trauma.

INTRODUCTION: Violent traumatic injury, including firearm violence, can adversely impact individual and community health. Trauma-informed care (TIC) can promote resilience and prevent future violence in patients who have experienced trauma. However, few protocols exist to facilitate implementation of TIC for patients who survive traumatic injury. The purpose of the study is to characterize documentation of TIC practices and identify opportunities for intervention in a single academic quaternary care center. METHODS: This study is a retrospective chart review analyzing the documentation of trauma-informed elements in the electronic medical record of a random sample of youth patients (ages 12-23) admitted for assault trauma to the pediatric (n = 50) and adult trauma (n = 200) services between 2016 and mid-2021. Descriptive statistics were used to summarize patient demographics, hospitalization characteristics, and documentation of trauma-informed elements. Chi-square analyses were performed to compare pediatric and adult trauma services. RESULTS: Among pediatric and adult assault trauma patients, 36.0% and 80.5% were hospitalized for firearm injury, respectively. More patients admitted to the pediatric trauma service (96%) had at least one trauma-informed element documented than patients admitted to the adult service (82.5%). Social workers were the most likely clinicians to document a trauma-informed element. Pain assessment and social support were most frequently documented. Safety assessments for suicidal ideation, retaliatory violence, and access to a firearm were rarely documented. CONCLUSIONS: Results highlight opportunities to develop trauma-informed interventions for youth admitted for assault trauma. Standardized TIC documentation could be used to assess risk of violent reinjury and mitigate sequelae of trauma.

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.

Training Hospital Personnel in Trauma-Informed Care: Assessing an Interprofessional Workshop With Patients as Teachers.

OBJECTIVE: Trauma-informed care (TIC) and violence intervention programs (VIPs) facilitate psychosocial healing and reduce injury recidivism for children and families affected by community violence. To integrate a VIP into 2 Level 1 Pediatric Trauma Centers, an educational initiative was developed and co-taught by pediatricians and former patients. The primary aim was to increase provider-driven patient referrals to the VIP. A secondary aim was to improve all participants' comfort levels in 5 areas of TIC. METHODS: Referrals to the VIP from 2014 to 2018 were tracked and analyzed. A curriculum based on Five Points of TIC was developed and offered to interprofessional groups of hospital employees. Pediatricians and former patients recovering from violent injury facilitated the workshops. Twenty-two workshops were attended by 318 providers and hospital staff members from 2015 to 2018. Pre- and postworkshop surveys asked participants to rate their comfort levels with 5 areas of TIC. RESULTS: Provider-driven patient identification increased from 34.8% to 86.8% over the study period. For the entire cohort, participants' self-assessment of comfort levels with TIC improved by 21% (P < .001), with medical students' scores improving the most (24%). Residents were less likely to complete the workshop than fellows or attendings (P = .03). CONCLUSIONS: This novel curriculum was associated with a change in practice patterns, as well as a closer relationship between the VIP and pediatric hospital systems. All professional groups experienced an improvement in comfort levels with the Five Points of TIC. Future study on information retention and other patient care-related outcomes is needed.

Vector competence of New Zealand mosquitoes for selected arboviruses.

New Zealand (NZ) historically has been free of arboviral activity with the exception of Whataroa virus (Togaviridae: Alphavirus), which is established in bird populations and is transmitted by local mosquitoes. This naive situation is threatened by global warming, invasive mosquitoes, and tourism. To determine the threat of selected medically important arboviruses to NZ, vector competence assays were conducted using field collected endemic and introduced mosquito species. Four alphaviruses (Togaviridae): Barmah Forest virus, Chikungunya virus, Ross River virus, and Sindbis virus, and five flaviviruses (Flaviviridae): Dengue virus 2, Japanese encephalitis virus, Murray Valley encephalitis virus, West Nile virus, and Yellow fever virus were evaluated. Results indicate some NZ mosquito species are highly competent vectors of selected arboviruses, particularly alphaviruses, and may pose a threat were one of these arboviruses introduced at a time when the vector was prevalent and the climatic conditions favorable for virus transmission.