Impact of the AAP Guideline on Management of Brief Resolved Unexplained Events.

OBJECTIVES: In May 2016, the American Academy of Pediatrics published a clinical practice guideline (CPG) defining apparent life-threatening events (ALTEs) as brief resolved unexplained events (BRUEs) and recommending risk-based management. We analyzed the association of CPG publication on admission rate, diagnostic testing, treatment, cost, length of stay (LOS), and revisits in patients with BRUE. METHODS: Using the Pediatric Health Information Systems database, we studied patients discharged from the hospital with a diagnosis of ALTE/BRUE from January 2012 to December 2019. We grouped encounters into 2 time cohorts on the basis of discharge date: preguideline (January 2012-January 2016) and postguideline (July 2016-December 2019). We used interrupted time series to test if the CPG publication was associated with level change and change in slope for each metric. RESULTS: The study included 27 941 hospitalizations for ALTE/BRUE from 36 hospitals. There was an early decrease in 12 diagnostic tests that the CPG strongly recommended against. There was a positive change in the use of electrocardiogram (+3.5%, P < .001), which is recommended by CPG. There was a significant reduction in admissions (-13.7%, P < .001), utilization of medications (-8.3%, P < .001), cost (-$1146.8, P < .001), and LOS (-0.2 days, P < .001), without a change in the revisit rates. In the postguideline period, there were an estimated 2678 admissions avoided out of 12 508 encounters. CONCLUSIONS: Publication of the American Academy of Pediatrics BRUE CPG was associated with substantial reductions in testing, utilization of medications, admission rates, cost, and LOS, without a change in the revisit rates.

Preparing for a Career in Pediatric Hospital Medicine: A Needs Assessment and Recommendations for Individualized Curricula.

OBJECTIVES: The individualized curriculum within residency programs allows residents to tailor their elective time toward future career goals and interests. Our objective was to identify experiences and activities that would foster resident interest and enhance preparation for a career in pediatric hospital medicine (PHM). METHODS: Electronic surveys were distributed to pediatric hospitalists, PHM fellowship directors, and graduating PHM fellows. These stakeholders were asked to identify key experiences for residents to explore before entering fellowship or practice. Descriptive statistics and thematic analysis were performed on survey responses. RESULTS: Forty-six percent of PHM fellows (16 of 35), 42% of pediatric hospitalists (149 of 356), and 58% of fellowship program directors (35 of 60) completed the survey. All 3 groups identified complex care as the most important clinical experience to gain in residency. Other highly valued clinical experiences included pain management, surgical comanagement, and palliative care. Lumbar puncture, electrocardiograph interpretation, and airway management were identified as essential procedural skills. Nonclinical experiences that were deemed important included quality improvement, development of teaching skills, and research methodology. All groups agreed that these recommendations should be supplemented with effective mentorship. CONCLUSIONS: Identification of key clinical experiences, nonclinical activities, and mentorship for residents interested in PHM may assist with tailoring the individualized curriculum to personal career goals. Incorporating these suggested experiences can improve preparedness of residents entering PHM.

Improving Discharge Outcomes by Using a Standardized Risk Assessment and Intervention Tool Facilitated by Advanced Pediatric Providers.

OBJECTIVES: Pediatric discharge from the inpatient setting is a complex, error-prone process. In this study, we evaluated the outcomes of using a standardized process for hospital discharge of pediatric patients. METHODS: A 1-year pre- and postintervention pilot study was designed to improve discharge transition of care. The bundle intervention, facilitated by advanced practice providers, included risk identification and intervention. Process and outcome metrics included patient satisfaction measures on the discharge domain (overall discharge, speed of discharge process, whether they felt ready for discharge), use of handouts, scheduling of follow-up appointments, and postdischarge phone call. RESULTS: Significant improvements were found in all aspects of patient satisfaction, including speed of the discharge process and instructions for discharge, discharge readiness, and the overall discharge process. Length of stay decreased significantly after intervention. The checklist identified ∼4% of discharges without a correct primary care physician. Significant differences were found for scheduled primary care appointment before discharge and patients receiving handouts. The bundle identified risks that may complicate transition of care in approximately half of the patients. Phone communication occurred with almost half of the patients after discharge. CONCLUSIONS: Integration of an evidence-based discharge checklist can improve processes, increase delivery of patient education, and improve patient and family perceptions of the discharge process. Involvement of key stakeholders, use of evidence-based interventions with local adaptation, and use of a consistent provider responsible for implementation can improve transitions of care.

Current Practices and Perspectives on Peer Observation and Feedback: A National Survey.

OBJECTIVE: Peer observation and feedback (POF) is the direct observation of an activity performed by a colleague followed by feedback with the goal of improved performance and professional development. Although well described in the education literature, the use of POF as a tool for development beyond teaching skills has not been explored. We aimed to characterize the practice of POF among pediatric hospitalists to explore the perceived benefits and barriers and to identify preferences regarding POF. METHODS: We developed a 14-item cross-sectional survey regarding divisional expectations, personal practice, perceived benefits and barriers, and preferences related to POF. We refined the survey based on expert feedback, cognitive interviews, and pilot testing, distributing the final survey to pediatric hospitalists at 12 institutions across the United States. RESULTS: Of 357 eligible participants, 198 (56%) responded, with 115 (58%) practicing in a freestanding children's hospital. Although 61% had participated in POF, less than one half (42%) reported divisional POF expectation. The most common perceived benefits of POF were identifying areas for improvement (94%) and learning about colleagues' teaching and clinical styles (94%). The greatest perceived barriers were time (51%) and discomfort with receiving feedback from peers (38%), although participation within a POF program reduced perceived barriers. Most (76%) desired formal POF programs focused on improving teaching skills (85%), clinical management (83%), and family-centered rounds (82%). CONCLUSIONS: Although the majority of faculty desired POF, developing a supportive environment and feasible program is challenging. This study provides considerations for improving and designing POF programs.

Measuring Harm in Hospitalized Children via a Trigger Tool.

BACKGROUND: The 1999 report To Err Is Human published by the Institute of Medicine estimated that between 44,000 and 98,000 deaths occur each year in US hospitals due to medical errors. However, processes to detect medically induced harm remain inaccurate and inconsistent. Hospitalized pediatric patients are at high risk for adverse events, with published rates ranging between 1% and 11% of all hospitalizations. OBJECTIVE: The study aimed to use the Global Assessment of Pediatric Patient Safety (GAPPS) tool to detect adverse events in a pediatric inpatient setting of an academic medical center children's hospital and compare to internal incident reporting methods. METHODS: Nurse reviewers used the GAPPS tool during a retrospective chart review of 100 patients discharged from the children's hospital. Among the total 100 cases, 20 adverse events were discovered with the tool. Adverse events were validated by physician reviewers, and the severity of harm and preventability were assigned. The number of adverse events was then compared to internal incident reporting for the same time frame. RESULTS: The detection rate is 4.87% within 411 patient-days. In contrast, the hospital had only 1.22% incident reports. CONCLUSIONS: The GAPPS tool can detect four times more adverse events than the hospital incident reporting system. The results are likely to be replicated for other children's hospitals to increase identification of adverse events and harm to patients.

Bullous Henoch-Schönlein purpura in children.

Henoch-Schönlein purpura (HSP) is a systemic vasculitis that is common in the pediatric population and often presents with the classical triad of palpable purpura, arthralgia, and abdominal pain. We describe a case of HSP in a 14-year-old adolescent girl who presented with atypical features of painful hemorrhagic bullae. The patient was treated with high-dose steroids, dapsone, and supportive therapy with remarkable improvement.

Obesity hypoventilation syndrome in a 12-year-old child requiring therapeutic phlebotomy: case report and review of the literature.

The childhood obesity epidemic involves unusual and underrecognized complications associated with this clinical and public health problem. Obesity hypoventilation syndrome (OHS) is defined as the triad of obesity, daytime hypoventilation, and sleep-disordered breathing in the absence of an alternative neuromuscular, mechanical or metabolic explanation for hypoventilation. We herewith report a 12-year-old boy who was diagnosed with OHS. The patient improved with phlebotomy and bi-level positive airway pressure. To the best of our knowledge, this is the first reported case of secondary polycythemia due to OHS requiring therapeutic phlebotomy.

A case of Nocardia transvalensis pneumonia in a 19-year-old cystic fibrosis patient.

Nocardia species is rarely encountered in cystic fibrosis (CF) patients. Its isolation usually implies colonization. Of all other Nocardia species, Nocardia transvalensis is very unusual and is clinically distinguishable because of its resistance to aminoglycosides, a standard antinocardial therapy. We report a case of N. transvalensis pulmonary infection in a CF patient.

Endocarditis with ruptured sinus of Valsalva aneurysm caused by nonvaccine Streptococcus pneumoniae serotype 21.

Sinus of Valsalva aneurysm is a rare, catastrophic complication of endocarditis. We report an unusual case of ruptured sinus of Valsalva aneurysm associated with endocarditis that was caused by Streptococcus pneumoniae serotype 21. The patient, a 12-year-old girl, underwent surgical repair of the aneurysm and was given intravenous antibiotics for 6 weeks. She was doing well at the 6-week follow-up visit. This case is unusual because of the patient's young age at presentation, the absence of predisposing factors, and the isolation of a nonvaccine serotype 21, which revealed the epidemiologic changes of invasive pneumococcal disease. To our knowledge, this is the first reported case of endocarditis caused by this S. pneumoniae serotype.

Significance of screening electrocardiogram before the initiation of amitriptyline therapy in children with functional abdominal pain.

Amitriptyline (AMT) is commonly used in the management of children with irritable bowel syndrome. AMT is pro-arrhythmogenic and increases the risk of sudden cardiac death. However, there is not enough data regarding the cardiac toxicity in therapeutic doses of AMT in children and the need for screening electrocardiogram (EKG). Errors in computer EKG interpretation are not uncommon. In a risk-prevention study, the authors sought to identify the true incidence of prolonged corrected QT (QTc) interval and other arrhythmias in children with irritable bowel syndrome before the initiation of AMT. Out of the 760 EKGs screened, 3 EKGs demonstrated a true prolonged QTc after the careful manual reading by a pediatric cardiologist and they were not picked by computer-generated reading. The authors conclude that screening EKG should always be performed on children before initiating AMT therapy. Also, the computer-generated EKG needs to be verified by a pediatric cardiologist to avoid serious misinterpretations.