Validating the Physician Documentation Quality Instrument for Intensive Care Unit-Ward Transfer Notes.

Background: Physician communication failures during transfers of patients from the intensive care unit (ICU) to the general ward are common and can lead to adverse events. Efforts to improve written handoffs during these transfers are increasingly prominent, but no instruments have been developed to assess the quality of physician ICU-ward transfer notes. Objective: To collect validity evidence for the modified nine-item Physician Documentation Quality Instrument (mPDQI-9) for assessing ICU-ward transfer note usefulness across several hospitals. Methods: Twenty-four physician raters independently used the mPDQI-9 to grade 12 notes collected from three academic hospitals. A priori, we excluded the "up-to-date" and "accurate" domains, because these could not be assessed without giving the rater access to the complete patient chart. Assessments therefore used the domains "thorough," "useful," "organized," "comprehensible," "succinct," "synthesized," and "consistent." Raters scored each domain on a Likert scale ranging from 1 (low) to 5 (high). The total mPDQI-9 was the sum of these domain scores. The primary outcome was the raters' perceived clinical utility of the notes, and the primary measures of interest were criterion validity (Spearman's ρ) and interrater reliability (intraclass correlation [ICC]). Results: Mean mPDQI-9 scores by note ranged from 19 (SD = 5.5) to 30 (SD = 4.2). Mean note ratings did not systematically differ by rater expertise (for interaction, P = 0.15). The proportion of raters perceiving each note as independently sufficient for patient care (the primary outcome) ranged from 33% to 100% across the set of notes. We found a moderately positive correlation between mPDQI-9 ratings and raters' overall assessments of each note's clinical utility (ρ = 0.48, P < 0.001). Interrater reliability was strong; the overall ICC was 0.89 (95% confidence interval [CI], 0.80-0.85), and ICCs were similar among reviewer groups. Finally, Cronbach's α was 0.87 (95% CI, 0.84-0.89), indicating good internal consistency. Conclusions: We report moderate validity evidence for the mPDQI-9 to assess the usefulness of ICU-ward transfer notes written by internal medicine residents.

Staphylococcus aureus Bacteremia in Pediatric Patients: Uncovering a Rural Health Challenge.

Background: Staphylococcus aureus bacteremia poses significant risk for morbidity and mortality. This may be exacerbated in rural populations facing unique health challenges. Methods: To investigate factors influencing S. aureus bacteremia outcomes, we conducted a retrospective cohort study of children admitted to St. Louis Children's Hospital (SLCH) from 2011 to 2019. Exposures included rurality (defined by the Rural-Urban Continuum Code), Area Deprivation Index, and outside hospital (OSH) admission before SLCH admission. The primary outcome was treatment failure, a composite of 90-day all-cause mortality and hospital readmission. Results: Of 251 patients, 69 (27%) were from rural areas; 28 (11%) were initially admitted to an OSH. Treatment failure occurred in 39 (16%) patients. Patients from rural areas were more likely to be infected with methicillin-resistant S. aureus (45%) vs urban children (29%; P = .02). Children initially admitted to an OSH, vs those presenting directly to SLCH, were more likely to require intensive care unit-level (ICU) care (57% vs 29%; P = .002), have an endovascular source of infection (32% vs 12%; P = .004), have a longer duration of illness before hospital presentation (4.1 vs 3.0 days; P = .04), and have delayed initiation of targeted antibiotic therapy (3.9 vs 2.6 days; P = .01). Multivariable analysis revealed rural residence (adjusted odds ratio [aOR], 2.3; 95% CI, 1.1-5.0), comorbidities (aOR, 2.9; 95% CI, 1.3-6.2), and ICU admission (aOR, 3.9; 95% CI, 1.9-8.3) as predictors of treatment failure. Conclusions: Children from rural areas face barriers to specialized health care. These challenges may contribute to severe illness and worse outcomes among children with S. aureus bacteremia.

Healthcare worker perceptions surrounding Staphylococcus aureus transmission and prevention practices in the neonatal intensive care unit.

OBJECTIVE: To understand healthcare worker (HCW) perceptions surrounding Staphylococcus aureus transmission and prevention in the neonatal intensive care unit (NICU). DESIGN: Qualitative case study with focus groups. SETTING: A level IV, 150-bed NICU at a Midwestern academic medical center that conducts active surveillance and decolonization of S. aureus-positive patients. PARTICIPANTS: NICU HCWs, including bedside nurses, nurse managers, therapy services personnel, pediatric nurse practitioners, clinical fellows, and attending neonatologists. METHODS: Semistructured focus group interviews, assembled by occupation, were conducted by 2 study team members. Interviews were video recorded and transcribed. Deductive coding and thematic analyses were performed using NVivo software. RESULTS: In total, 38 HCWs participated in 10 focus groups (1-12 participants each), lasting 40-90 minutes. Four main themes emerged: (1) Methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) are inconsistently described as high risk. (2) Infection prevention interventions are burdensome. (3) Multiple sources of transmission are recognized. (4) opportunities exist to advance infection prevention. HCWs perceived MSSA to be less clinically relevant than MRSA. Participants expressed a desire to see published data supporting infection prevention interventions, including contact precautions, environmental cleaning, and patient decolonization. These practices were identified to be considerable burdens. HCWs perceived families to be the main source of S. aureus in the NICU, and they suggested opportunities for families to play a larger role in infection prevention. CONCLUSIONS: These data highlight opportunities for HCW and parental education, research, and reevaluating interventions aimed at improving infection prevention efforts to reduce the burden of S. aureus in NICU settings.

Understanding antibiotic prophylaxis prescribing in pediatric surgical specialties.

BACKGROUND: Overuse of antibiotics has caused secondary poor outcomes and has led to a current rate of antibiotic resistant infections that constitutes a public health crisis. In pediatric surgical specialties, children continue to receive unnecessary antibiotics. OBJECTIVE: To understand the factors that contribute to pediatric surgeons' decisions regarding the use of perioperative antibiotic prophylaxis. METHODS: Focus groups included pediatric proceduralists/surgeons from the following specialties: interventional cardiology, otolaryngology, orthopedic surgery, cardiothoracic surgery, and general surgery. RESULTS: A total of 23 surgeons with a median of 9 years of experience (range, 0.5-29 years) participated in the focus groups that lasted 30-90 minutes each. Five themes emerged influencing beliefs about antibiotic prescribing practices: (1) reliance on previous experience and early education, (2) balancing antibiotic use with risk of infection, (3) uncertainty about the state of the scientific evidence, (4) understanding importance of communication and team collaboration, and (5) a prevalence of hospital-level concerns. CONCLUSIONS: Surgeons describe a complex set of factors that impact their antibiotic prescribing in pediatric surgical cases. They reported initial, but not ongoing, training and a use of individual weight of risk and benefit as a major dictator of prescribing practices. Antimicrobial stewardship programs should work with surgeons to develop acceptable implementation strategies to optimize antibiotic prescribing.