Reducing Erythrocyte Sedimentation Rate Ordering: De-implementation and Diagnostic Stewardship.

OBJECTIVES: The Choosing Wisely campaign recommends against the routine use of erythrocyte sedimentation rate (ESR) for the assessment of acute undiagnosed inflammation or infection. We examined ESR and C-reactive protein (CRP) ordering practices at a large, freestanding children's hospital. We found that 80% of ESR orders were placed concurrently with a CRP order. We aimed to reduce the ESR testing rate by 20% within 6 months in both inpatient and emergency department (ED) settings. METHODS: Applying Lean process improvement principles, we interviewed stakeholders from multiple subspecialties and engaged the institutional laboratory stewardship committee to identify the root causes of ESR ordering and design interventions. We conducted provider education (November 2020) and employed clinical decision support through an order panel in the electronic health record (April 2021). The outcome measures were monthly ESR testing rate per 1000 patient days (inpatient) and per 1000 ED visits, analyzed using statistical process control charts. CRP testing rate was a balancing measure. RESULTS: After intervention implementation, the ESR testing rate decreased from 11.4 to 8.9 tests per 1000 inpatient patient days (22% decrease) and from 49.4 to 29.5 tests per 1000 ED visits (40% decrease). This change has been sustained for >1 year postintervention. Interventions were effective even during the coronavirus disease 2019 pandemic when there was a rise in baseline ED ESR ordering rate. CRP testing rates did not increase after the interventions. CONCLUSIONS: Education and clinical decision support were effective in reducing the ESR ordering rate in both inpatient and ED settings.

Race and Antibiotic Use for Children Hospitalized With Acute Respiratory Infections.

We sought to evaluate whether children hospitalized with acute respiratory infections experienced differences in antibiotic use by race and ethnicity. We found that likelihood of broad-spectrum antibiotic receipt differed across racial and ethnic groups. Future work should confirm this finding, evaluate causes, and ensure equitable antibiotic use.

Laying the Groundwork for a Fulfilling Career in Pediatric Infectious Diseases: The Transition From Fellowship to Faculty.

There are limited resources for guidance on the transition from fellowship into a new faculty role in pediatric infectious diseases. This review aims to address this gap and provides a framework for a successful transition that is composed of four essential pillars-(1) stepping into your role, (2) finding your niche, (3) building your network, and (4) self-care-all of which are supported by strong mentorship/sponsorship and continual realignment with one's personal mission statement. In addition to providing general principles and guidance, this review also outlines specific steps that a junior faculty member can take to expand their influence and build a successful, fulfilling career in pediatric infectious diseases.

Pediatric Infectious Diseases Milestones: A Step in the Right Direction to Evaluate Subspecialty Learners.

We share the work of the ACGME Pediatric Infectious Diseases Working Group in creating the Pediatric Infectious Diseases-Specific Milestones and discuss key considerations that lead to the reformation of competencies to better assess learners in Pediatric Infectious Diseases.

Opportunities for Diagnostic Improvement Among Pediatric Hospital Readmissions.

OBJECTIVES: Diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs), are known sources of harm in children but have not been well characterized in pediatric hospital medicine. Our objectives were to systematically identify and describe MOIDs among general pediatric patients who experienced hospital readmission, outline improvement opportunities, and explore factors associated with increased risk of MOID. PATIENTS AND METHODS: Our retrospective cohort study included unplanned readmissions within 15 days of discharge from a freestanding children's hospital (October 2018-September 2020). Health records from index admissions and readmissions were independently reviewed and discussed by practicing inpatient physicians to identify MOIDs using an established instrument, SaferDx. MOIDs were evaluated using a diagnostic-specific tool to identify improvement opportunities within the diagnostic process. RESULTS: MOIDs were identified in 22 (6.3%) of 348 readmissions. Opportunities for improvement included: delay in considering the correct diagnosis (n = 11, 50%) and failure to order needed test(s) (n = 10, 45%). Patients with MOIDs were older (median age: 3.8 [interquartile range 1.5-11.2] vs 1.0 [0.3-4.9] years) than patients without MOIDs but similar in sex, primary language, race, ethnicity, and insurance type. We did not identify conditions associated with higher risk of MOID. Lower respiratory tract infections accounted for 26% of admission diagnoses but only 1 (4.5%) case of MOID. CONCLUSIONS: Standardized review of pediatric readmissions identified MOIDs and opportunities for improvement within the diagnostic process, particularly in clinician decision-making. We identified conditions with low incidence of MOID. Further work is needed to better understand pediatric populations at highest risk for MOID.

Clinical pathways and diagnostic reasoning: A qualitative study of pediatric residents' and hospitalists' perceptions.

BACKGROUND: Clinical pathways are evidence-based guidelines adapted to local settings. They have been shown to improve patient outcomes and reduce resource utilization. However, it is unknown how physicians integrate clinical pathways into their clinical reasoning. METHODS: We conducted a single-center qualitative study involving one-on-one semi-structured interviews of pediatric residents and pediatric hospitalist attendings between August 2021 and March 2022. Interviews were audio-recorded and professionally transcribed. We utilized a qualitative descriptive framework to code data and identify themes. RESULTS: We interviewed 15 pediatric residents and 12 pediatric hospitalists. Thematic analysis of interview transcripts revealed four themes related to physician utilization of and experience with clinical pathways: (1) utility as a tool, (2) means of standardizing care, (3) reflection of institutional culture, and (4) element of the dynamic relationship with the clinician diagnostic process. These themes were generally common to both residents and attending physicians; however, some differences existed and are noted when they occurred. CONCLUSIONS: Clinical pathways are part of many clinicians' diagnostic processes. Pathways can standardize care, influence the diagnostic process, and express local institutional culture. Further research is required to ascertain the optimal clinical pathway design to augment and not inhibit the clinician's diagnostic process.

Diagnostic Stewardship: Appropriate Testing and Judicious Treatments.

Diagnostic stewardship encompasses the entire diagnosis-to-treatment paradigm in the intensive care unit (ICU). Initially born of the antimicrobial stewardship movement, contemporary diagnostic stewardship aims to promote timely and appropriate diagnostic testing that directly links to management decisions. In the stewardship framework, excessive diagnostic testing in low probability cases is discouraged due to its tendency to generate false-positive results, which have their own downstream consequences. Though the evidence basis for diagnostic stewardship initiatives in the ICU is nascent and largely limited to retrospective analyses, available literature generally suggests that these initiatives are safe, feasible, and associated with similar patient outcomes. As diagnostic testing of critically ill patients becomes increasingly sophisticated in the ensuing decade, a stewardship mindset will aid bedside clinicians in interpreting and incorporating new diagnostic strategies in the ICU.

The COVID trap: pediatric diagnostic errors in a pandemic world.

OBJECTIVES: The COVID-19 pandemic has introduced strains in the diagnostic process through uncertainty in diagnosis, changes to usual clinical processes, and introduction of a unique social context of altered health care delivery and fear of the medical environment. These challenges created a context ripe for diagnostic error involving both systems and cognitive factors. CASE PRESENTATION: We present a series of three pediatric cases presenting to care during the early phases of the COVID-19 pandemic that highlight the heightened potential for diagnostic errors in the pandemic context with particular focus on the interplay of systems and cognitive factors leading to delayed and missed diagnoses. These cases illustrate the particular power of availability bias, diagnostic momentum, and premature closure in the diagnostic process. CONCLUSIONS: Through integrated commentary and a fishbone analysis of the cognitive and systems factors at play, these three cases emphasize the specific influence of the COVID-19 pandemic on pediatric patients.

Acute Flaccid Myelitis: A Clinical Overview for 2019.

Acute flaccid myelitis (AFM) is characterized by flaccid paralysis of one or more limbs, often following a viral illness, with magnetic resonance imaging findings consistent with inflammation of the spinal cord gray matter. It is unclear whether all patients with AFM will have full recovery of neurologic function. Since 2014, there have been several clusters of AFM in the United States, with a 3-fold increase in reported AFM cases recorded in 2018 compared with the previous year. Epidemiological evidence supports a temporal association between respiratory enteroviral illness, particularly with enteroviruses D68 and A71, and clustering of AFM cases. However, causality has yet to be established. Treatment of AFM is primarily supportive. Adjunctive therapies such as intravenous immunoglobulin, corticosteroids, plasmapheresis, and fluoxetine have not been found to improve long-term outcomes. Further research is urgently needed to characterize and optimize management of this emerging, yet poorly understood, condition.

Central Nervous System Blastomycosis in Children: A Case Report and Review of the Literature.

We present a 7-year-old boy with chronic meningitis caused by Blastomyces dermatitidis. A review of the literature revealed 32 cases of central nervous system blastomycosis in children between 1983 and 2016, of which 18 represented parenchymal disease of the brain or spinal cord. Blastomycosis affecting the central nervous system is rare but should be considered in children with chronic meningitis.

Challenges in the management of giant intraductal breast papilloma.

The differential diagnosis of a large breast mass in a post-menopausal woman can include both benign and malignant etiologies. Although rare, diagnosis of giant intraductal papilloma must be considered in the differential. Furthermore, although benign, papillomas presenting as a large breast mass affecting the skin require extensive breast surgical treatment.

Neuropsychiatric aspects of primary progressive aphasia.

Few studies have reported neuropsychiatric symptoms (NPS) in primary progressive aphasia (PPA), a neurodegenerative disorder that primarily affects the left hemisphere. Depression is associated with left-sided stroke, but it remains unclear whether depression and other NPS are also associated with PPA. The authors compared the frequency of neuropsychiatric symptoms in 55 cases of PPA with 110 cognitively normal persons matched for age, sex, and education. Depression, apathy, agitation, anxiety, appetite change, and irritability are associated with PPA. Hallucinations, delusions, and night-time behavior were not associated with PPA.