Streptococcal pneumonia meningitis as an initial presentation of X-linked agammaglobulinemia: A case report and discussion.

X-linked agammaglobulinemia (XLA) is a primary immunodeficiency caused by mutations in the gene for Bruton's tyrosine kinase (Btk), with affected males most commonly presenting with recurrent bacterial infections during the first few years of life. Here we present a 17-month-old male with a chief complaint of worsening rash and fever, whose history of streptococcal pneumonia meningitis at 5 months of age prompted suspicion for an underlying immunodeficiency and subsequent diagnosis of XLA. Bacterial meningitis is a rare initial presentation of XLA, and therefore physicians may easily overlook any underlying immunodeficiency. Prompt workup for immunodeficiency should be initiated in any vaccinated patient with a history of pneumococcal meningitis outside of the newborn period. Further discussion surrounding the various presentations of XLA, their related clinical manifestations and laboratory findings, and the importance of thorough chart review may encourage earlier diagnosis and initiation of treatment of this disease.

Improving Efficiency of Primary Care Provider Communication for Uncomplicated Admissions.

BACKGROUND: Communication between inpatient pediatric hospital medicine (HM) and primary care providers (PCPs) is important for quality care. As provider workload increases, it is important to focus on a means to improve communication efficiency. Our goal was to increase the percentage of HM admissions using 1-way communication from 0% to 35% over a 16-month period. METHODS: HM providers and PCPs collaborated to identify 12 admission diagnoses for which 1-way communication could be used. Using quality improvement methods, we studied the implementation of "Leave a Message" (LAM) calls for 1-way communication and providing PCPs with the option to place a return call. Control charts were used to track LAM call use and balancing measures of PCP return phone calls, additional PCP communications, and 7-day readmissions over time. RESULTS: A total of 778 LAM calls were placed by HM providers over 16 months. The percentage of LAM calls out of all PCP calls placed ranged from 0% to 35% during this time, increasing significantly during winter months and before the coronavirus disease 2019 pandemic. Only 0.4% (n = 3) of LAM calls were returned by PCPs. Estimated PCP return phone calls were reduced by 11.1 calls per week. CONCLUSIONS: We created a system for 1-way telephone communication between HM providers and PCPs for common, simple admissions and reduced the need for PCP return phone calls. The low percentage of LAM calls returned by PCPs may suggest that 1-way communication is adequate for most simple admissions.

Community Pediatric Hospitalist Workload: Results from a National Survey.

As a newly recognized subspecialty, understanding programmatic models for pediatric hospital medicine (PHM) programs is vital to lay the groundwork for a sustainable field. Although variability has been described within university-based PHM programs, there remains no national benchmark for community-based PHM programs. In this report, we describe the workload, clinical services, employment, and perception of sustainability of 70 community-based PHM programs in 29 states through a survey of community site leaders. The median hours for a full-time hospitalist was 1,882 hours/year with those employed by community hospitals working 8% more hours/year and viewing appropriate morning pediatric census as 20% higher than those employed by university institutions. Forty-three out of 70 (63%) site leaders perceived their programs as sustainable, with no significant difference by employer structure. Future studies should further explore root causes for workload discrepancies between community and academic employed programs along with establishing potential standards for PHM program development.

Efficacy and Safety of Pediatric Critical Care Physician Telemedicine Involvement in Rapid Response Team and Code Response in a Satellite Facility.

OBJECTIVES: Satellite inpatient facilities of larger children's hospitals often do not have on-site intensivist support. In-house rapid response teams and code teams may be difficult to operationalize in such facilities. We developed a system using telemedicine to provide pediatric intensivist involvement in rapid response team and code teams at the satellite facility of our children's hospital. Herein, we compare this model with our in-person model at our main campus. DESIGN: Cross-sectional. SETTING: A tertiary pediatric center and its satellite facility. PATIENTS: Patients admitted to the satellite facility. INTERVENTIONS: Implementation of a rapid response team and code team model at a satellite facility using telemedicine to provide intensivist support. MEASUREMENTS AND MAIN RESULTS: We evaluated the success of the telemedicine model through three a priori outcomes: 1) reliability: involvement of intensivist on telemedicine rapid response teams and codes, 2) efficiency: time from rapid response team and code call until intensivist response, and 3) outcomes: disposition of telemedicine rapid response team or code calls. We compared each metric from our telemedicine model with our established main campus model. MAIN RESULTS: Critical care was involved in satellite campus rapid response team activations reliably (94.6% of the time). The process was efficient (median response time 7 min; mean 8.44 min) and effective (54.5 % patients transferred to PICU, similar to the 45-55% monthly rate at main campus). For code activations, the critical care telemedicine response rate was 100% (6/6), with a fast response time (median 1.5 min). We found no additional risk to patients, with no patients transferred from the satellite campus requiring a rapid escalation of care defined as initiation of vasoactive support, greater than 60 mL/kg in fluid resuscitation, or endotracheal intubation. CONCLUSIONS: Telemedicine can provide reliable, timely, and effective critical care involvement in rapid response team and Code Teams at satellite facilities.

Development and Evaluation of High-Value Pediatrics: A High-Value Care Pediatric Resident Curriculum.

Low-value health care is pervasive in the United States, and clinicians need to be trained to be stewards of health care resources. Despite a mandate by the Accreditation Council for Graduate Medical Education to educate trainee physicians on cost awareness, only 10% of pediatric residency programs have a high-value care (HVC) curriculum. To meet this need, we set out to develop and evaluate the impact of High-Value Pediatrics, an open-access HVC curriculum. High-Value Pediatrics is a 3-part curriculum that includes 4 standardized didactics, monthly interactive morning reports, and an embedded HVC improvement project. Curriculum evaluation through an anonymous, voluntary survey revealed an improvement in the self-reported knowledge of health care costs, charges, reimbursement, and value (P < .05). Qualitative results revealed self-reported behavior changes, and HVC improvement projects resulted in higher-value patient care. The implementation of High-Value Pediatrics is feasible and reveals improved knowledge and attitudes about HVC. HVC improvement projects augmented curricular knowledge gains and revealed behavior changes. It is imperative that formal high-value education be taught to every pediatric trainee to lead the culture change that is necessary to turn the tide against low-value health care. In addition, simultaneous work on faculty education and attention to the hidden curriculum of low-value care is needed for sustained and long-term improvements.

Pediatric Hospitalist Workload and Sustainability in University-Based Programs: Results from a National Interview-Based Survey.

Wide variability exists in the clinical workload of pediatric hospitalists without an accepted standard for benchmarking purposes. By using data obtained from interviews of pediatric hospital medicine (PHM) program leaders, we describe the clinical workload of university-based programs and report on the program sustainability perceived by PHM program leaders. The median clinical hours reported for a full-time pediatric hospitalist were 1800 hours per year, with a median of 15 weekends worked per year. Furthermore, program leaders reported an ideal number of clinical hours as 1700 hours per year. Half of the interviewed program leaders perceived their current models as unsustainable. Programs perceived as unsustainable were more likely than those perceived as sustainable to require a higher number of weekends worked per year or to be university employed. Further research should focus on establishing benchmarks for the workloads of pediatric hospitalists and on evaluating factors that can affect sustainability.

Increasing PCP and Hospital Medicine Physician Verbal Communication During Hospital Admissions.

OBJECTIVES: During hospital admission, communication between primary care physicians (PCPs) and hospital medicine (HM) physicians provides an opportunity for collaboration. Two-way communication facilitates collaboration by allowing the receiver to ask and respond to questions. At our institution, most HM-to-PCP communication occurred by telephone call after discharge. Our specific aim was to increase the percentage of patients for whom a telephone conversation occurred between HM and PCPs during hospital admission from 40% to >80%. METHODS: An improvement team that included PCPs and HM physicians redesigned the process for communication with PCPs to emphasize collaboration during hospitalization. Interventions were used to target key drivers of information transparency, PCP and HM provider buy-in, the value of early call initiation, process standardization, accommodating provider availability, and preoccupation with failure. We used improvement-science methods and run charts to measure our progress and attain our goal. RESULTS: The median weekly percentage of patients with a phone call completed during hospitalization increased from 40% to 85% at the satellite campus and 40% to 80% at the main campus. In addition to the standardized use of a telephone operator system to route calls and follow-up on unplaced calls, critical interventions included feedback on PCP call preferences to providers and the provider script for calls. CONCLUSIONS: PCPs and HM physicians applied quality-improvement methodology to ensure reliable HM-PCP communication during hospital admission. Interventions to facilitate communication between providers and learners (who may otherwise have limited interaction), such as the scripting of phone calls and feedback from PCPs to HM physicians, were important for success.

Using Simulation to Develop Care Models for Rapid Response and Code Teams at a Satellite Facility.

BACKGROUND: Our institution recently completed an expansion of an acute care inpatient unit within a satellite hospital that does not include an on-site ICU or PICU. Because of expected increases in volume and acuity, new care models for Rapid Response Teams (RRTs) and Code Blue Teams were necessary. OBJECTIVES: Using simulation-based training, our objectives were to define the optimal roles and responsibilities for team members (including ICU physicians via telemedicine), refine the staffing of RRTs and code Teams, and identify latent safety threats (LSTs) before opening the expanded inpatient unit. METHODS: The laboratory-based intervention consisted of 8 scenarios anticipated to occur at the new campus, with each simulation followed by an iterative debriefing process and a 30-minute safety talk delivered within 4-hour interprofessional sessions. In situ sessions were delivered after construction and before patients were admitted. RESULTS: A total of 175 clinicians completed a 4-hour course in 17 sessions. Over 60 clinicians participated during 2 in situ sessions before the opening of the unit. Eleven team-level knowledge deficits, 19 LSTs, and 25 system-level issues were identified, which directly informed changes and refinements in care models at the bedside and via telemedicine consultation. CONCLUSIONS: Simulation-based training can assist in developing staffing models, refining the RRT and code processes, and identify LSTs in a new pediatric acute care unit. This training model could be used as a template for other facilities looking to expand pediatric acute care at outlying smaller, more resource-limited facilities to evaluate new teams and environments before patient exposure.

Educational Added Value Unit: Development and Testing of a Measure for Educational Activities.

OBJECTIVES: University-based hospitalists educate health care professionals as an expectation, often lacking time and support for these activities. The purpose of this study was to (1) develop a tracking tool to record educational activities, (2) demonstrate its applicability and ease of completion for faculty members in different divisions, and (3) compare educational efforts of individuals from different professional pathways and divisions by using the educational added value unit (EAVU). METHODS: Educational activities were selected and ranked according to preparation effort, presentation time, and impact to calculate the EAVU. Faculty participants from 5 divisions at 1 institution (hospital medicine, general and community pediatrics, emergency medicine, behavior medicine and clinical psychology, and biostatistics and epidemiology) completed the retrospective, self-report tracking tool. RESULTS: A total of 62% (74 of 119) of invited faculty members participated. All faculty earned some EAVUs; however, there was a wide distribution range. The median EAVU varied by division (hospital medicine [21.7], general and community pediatrics [20.6], emergency medicine [26.1], behavior medicine and clinical psychology [18.3], and biostatistics and epidemiology [8.2]). Faculty on the educator pathway had a higher median EAVU compared with clinical or research pathways. CONCLUSIONS: The EAVU tracking tool holds promise as a mechanism to track educational activities of different faculty pathways. EAVU collection could be of particular benefit to hospitalists, who often perform unsupported teaching activities. Additional studies are needed to determine how to apply a similar process in different institutions and to determine how EAVUs could be used for additional support for teaching, curriculum development, and educational scholarship.

Hospital-Level Factors Associated with Pediatric Emergency Department Return Visits.

BACKGROUND: Return visits (RVs) and RVs with admission (RVAs) are commonly used emergency department quality measures. Visit- and patient-level factors, including several social determinants of health, have been associated with RV rates, but hospital-specific factors have not been studied. OBJECTIVE: To identify what hospital-level factors correspond with high RV and RVA rates. SETTING: Multicenter mixed-methods study of hospital characteristics associated with RV and RVA rates. DATA SOURCE: Pediatric Health Information System with survey of emergency department directors. MEASUREMENTS: Adjusted return rates were calculated with generalized linear mixed-effects models. Hospitals were categorized by adjusted RV and RVA rates for analysis. RESULTS: Twenty-four hospitals accounted for 1,456,377 patient visits with an overall adjusted RV rate of 3.7% and RVA rate of 0.7%. Hospitals with the highest RV rates served populations that were more likely to have government insurance and lower median household incomes and less likely to carry commercial insurance. Hospitals in the highest RV rate outlier group had lower pediatric emergency medicine specialist staffing, calculated as full-time equivalents per 10,000 patient visits: median (interquartile range) of 1.9 (1.5-2.1) versus 2.9 (2.2-3.6). There were no differences in hospital population characteristics or staffing by RVA groups. CONCLUSION: RV rates were associated with population social determinants of health and inversely related to staffing. Hospital-level variation may indicate population-level economic factors outside the control of the hospital and unrelated to quality of care.

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.

Decreasing Duration of Antibiotic Prescribing for Uncomplicated Skin and Soft Tissue Infections.

BACKGROUND AND OBJECTIVE: Short courses of antibiotics are often indicated for uncomplicated skin and soft tissue infections (uSSTIs). Our objective was to decrease duration of antibiotics prescribed in children hospitalized for uSSTIs by using quality improvement (QI) methods. METHODS: QI methods were used to decrease duration of antibiotics prescribed upon hospital discharge for uSSTIs. We sought to accomplish this goal by increasing outpatient prescriptions for short courses of therapy (≤7 days). Key drivers included awareness of evidence among physicians, changing the culture of prescribing, buy-in from prescribers, and monitoring of prescribing. Physician education, modification of antibiotic order sets for discharge prescriptions, and continual identification and mitigation of therapy plans, were key interventions implemented by using plan-do-study-act cycles. A run chart assessed the impact of the interventions over time. RESULTS: We identified 641 index admissions for uSSTIs over a 23-month period for patients aged >90 days to 18 years. The proportion of children discharged with short courses of antibiotics increased from a baseline median of 23% to 74%, which was sustained for 6 months. Differences in the proportion of children admitted for treatment failure or recurrence before and after project initiation were not significant. CONCLUSIONS: Using QI methodology, we decreased duration of antibiotics prescribed in children hospitalized for uSSTIs by increasing prescriptions for short courses of antibiotics. Modification of electronic order sets for discharge prescriptions allowed for sustained improvement in prescribing practices. Our findings support the use of shorter outpatient antibiotic courses in most children with uSSTIs, and suggest criteria for complicated SSTIs.

Prevalence and predictors of return visits to pediatric emergency departments.

OBJECTIVE: To determine the rate of return visits to pediatric emergency departments (EDs) and identify patient- and visit-level factors associated with return visits and hospitalization upon return. DESIGN AND SETTING: Retrospective cohort study of visits to 23 pediatric EDs in 2012 using data from the Pediatric Health Information System. PARTICIPANTS: Patients <18 years old discharged following an ED visit. MEASURES: The primary outcomes were the rate of return visits within 72 hours of discharge from the ED and of return visits within 72 hours resulting in hospitalization. RESULTS: 1,415,721 of the 1,610,201 ED visits to study hospitals resulted in discharge. Of the discharges, 47,294 patients (3.3%) had a return visit. Of these revisits, 9295 (19.7%) resulted in hospitalization. In multivariate analyses, the odds of having a revisit were higher for patients with a chronic condition (odds ratio [OR]: 1.91, 95% confidence interval [CI]: 1.86-1.96), higher severity scores (OR: 1.42, 95% CI: 1.40-1.45), and age <1 year (OR: 1.32, 95% CI: 1.22-1.42). The odds of hospitalization on return were higher for patients with higher severity (OR: 3.42, 95% CI: 3.23-3.62), chronic conditions (OR: 2.92, 95% CI: 2.75-3.10), age <1 year (1.7-2.5 times the odds of other age groups), overnight arrival (OR: 1.84, 95% CI: 1.71-1.97), and private insurance (OR: 1.47, 95% CI: 1.39-1.56). Sickle cell disease and cancer patients had the highest rates of return at 10.7% and 7.3%, respectively. CONCLUSIONS: Multiple patient- and visit-level factors are associated with revisits. These factors may provide insight in how to optimize care and decrease avoidable ED utilization.

Survey of academic pediatric hospitalist programs in the US: organizational, administrative, and financial factors.

BACKGROUND: Many pediatric academic centers have hospital medicine programs. Anecdotal data suggest that variability exists in program structure. OBJECTIVE: To provide a description of the organizational, administrative, and financial structures of academic pediatric hospital medicine (PHM). METHODS: This online survey focused on the organizational, administrative, and financial aspects of academic PHM programs, which were defined as hospitalist programs at US institutions associated with accredited pediatric residency program (n = 246) and identified using the Accreditation Council for Graduate Medical Education (ACGME) Fellowship and Residency Electronic Interactive Database. PHM directors and/or residency directors were targeted by both mail and the American Academy of Pediatrics Section on Hospital Medicine LISTSERV. RESULTS: The overall response rate was 48.8% (120/246). 81.7% (98/120) of hospitals reported having an academic PHM program, and 9.1% (2/22) of hospitals without a program reported plans to start a program in the next 3 years. Over a quarter of programs provide coverage at multiple sites. Variability was identified in many program factors, including hospitalist workload and in-house coverage provided. Respondents reported planning increased in-house hospitalist coverage coinciding with the 2011 ACGME work-hour restrictions. Few programs reported having revenues greater than expenses (26% single site, 4% multiple site). CONCLUSIONS: PHM programs exist in the majority of academic centers, and there appears to be variability in many program factors. This study provides the most comprehensive data on academic PHM programs and can be used for benchmarking as well as program development.

Quality improvement project to reduce infiltration and extravasation events in a pediatric hospital.

A safety event response team at Cincinnati Children's Hospital Medical Center developed and tested improvement strategies to reduce peripheral intravenous (PIV) infiltration and extravasation injuries. Improvement activities included development of the touch-look-compare method for hourly PIV site assessment, staff education and mandatory demonstration of PIV site assessment, and performance monitoring and sharing of compliance results. We observed a significant reduction in the injury rate immediately following implementation of the interventions that corresponded with monitoring compliance in performing hourly assessments on patients with a PIV, but this was not sustained. The team is currently examining other strategies to reduce PIV injuries.

Perceptions of physician bedside handoff with nurse and family involvement.

OBJECTIVE: Physician-to-physician handoffs have been identified as a high-risk area of patient care. Few data exist to support any specific handoff process as being superior. We developed a handoff process entitled physician bedside handoff (PBH), which is unique for allowing all stakeholders, including the parents of patients, to be involved in the handoff at the bedside. Our goal was to compare stakeholder perceptions of PBH with traditional physician handoff and to learn which factors stakeholders believe are important for improving handoffs in general. METHODS: A convenience sample of 34 stakeholders (including attending physicians, residents, nurses, patient care attendants, patient parents, and medical students) participated in 1 of 3 group level assessments IGLAs), a participatory method in which valid data are generated regarding an issue of importance through an interactive and collaborative process. RESULTS: In comparing PBH and traditional handoffs, participants uniformly perceived that both processes have value and that neither is superior in all cases; individual circumstances and parental preference should dictate which is used. Participation of all stakeholders was identified as being essential in improving handoffs in general. Other themes included that handoffs should occur in both verbal and written formats, and that providers and learners, specifcally medical students and residents, should be comfortable with both types of handoffs. CONCLUSIONS: Participants identified that including all stakeholders is essential to improve handoffs, that PBH is not superior to traditional handoffs, and that both processes have value. Further research should be conducted to determine if including all stakeholders in the handoff process results in improved quality of care and safety.