Epidemiology and Severity of Illness of MIS-C and Kawasaki Disease During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) is a novel, severe condition following severe acute respiratory syndrome coronavirus 2 infection. Large epidemiologic studies comparing MIS-C to Kawasaki disease (KD) and evaluating the evolving epidemiology of MIS-C over time are lacking. We sought to understand the illness severity of MIS-C compared with KD and evaluate changes in MIS-C illness severity over time during the coronavirus disease 2019 pandemic compared with KD. METHODS: We included hospitalizations of children with MIS-C and KD from April 2020 to May 2022 from the Pediatric Health Information System administrative database. Our primary outcome measure was the presence of shock, defined as the use of vasoactive/inotropic cardiac support or extracorporeal membrane oxygenation. We examined the volume of MIS-C and KD hospitalizations and the proportion of hospitalizations with shock over time using 2-week intervals. We compared the proportion of hospitalizations with shock in MIS-C and KD patients over time using generalized estimating equations adjusting for hospital clustering and age, with time as a fixed effect. RESULTS: We identified 4868 hospitalizations for MIS-C and 2387 hospitalizations for KD. There was a higher proportion of hospitalizations with shock in MIS-C compared with KD (38.7% vs 5.1%). In our models with time as a fixed effect, we observed a significant decrease in the odds of shock over time in MIS-C patients (odds ratio 0.98, P < .001) but not in KD patients (odds ratio 1.00, P = .062). CONCLUSIONS: We provide further evidence that MIS-C is a distinct condition from KD. MIS-C was a source of lower morbidity as the pandemic progressed.

Identifying and Validating Pediatric Hospitalizations for MIS-C Through Administrative Data.

BACKGROUND: Individual children's hospitals care for a small number of patients with multisystem inflammatory syndrome in children (MIS-C). Administrative databases offer an opportunity to conduct generalizable research; however, identifying patients with MIS-C is challenging. METHODS: We developed and validated algorithms to identify MIS-C hospitalizations in administrative databases. We developed 10 approaches using diagnostic codes and medication billing data and applied them to the Pediatric Health Information System from January 2020 to August 2021. We reviewed medical records at 7 geographically diverse hospitals to compare potential cases of MIS-C identified by algorithms to each participating hospital's list of patients with MIS-C (used for public health reporting). RESULTS: The sites had 245 hospitalizations for MIS-C in 2020 and 358 additional MIS-C hospitalizations through August 2021. One algorithm for the identification of cases in 2020 had a sensitivity of 82%, a low false positive rate of 22%, and a positive predictive value (PPV) of 78%. For hospitalizations in 2021, the sensitivity of the MIS-C diagnosis code was 98% with 84% PPV. CONCLUSION: We developed high-sensitivity algorithms to use for epidemiologic research and high-PPV algorithms for comparative effectiveness research. Accurate algorithms to identify MIS-C hospitalizations can facilitate important research for understanding this novel entity as it evolves during new waves.

How Do Pediatric Hospital Medicine Fellowships Prepare Graduates as Educators? A Survey of Program Directors and Graduates in the United States.

Pediatric hospital medicine (PHM) is the newest recognized subspecialty in pediatrics within the United States. While fellowships in PHM have been available for several years, completion of a 2-year fellowship has become a requirement for subspecialty certification. Pediatric hospitalists provide substantial teaching to trainees, and therefore, PHM fellowships must include dedicated training around teaching and medical education. The purpose of this study was to determine how current PHM fellowships prepare graduates for their roles as medical educators. Two surveys were developed from the published PHM core competencies and Entrustable Professional Activities for pediatric subspecialties. One survey was disseminated to all active PHM program directors and the second was disseminated to all PHM fellowship graduates who completed training between 2012 and 2016. Items included those related to program structure and training/assessment in medical education. A total of 21 program directors (response rate = 58%) and 46 fellowship graduates (response rate = 46%) participated in the survey. All graduates (100%) reported teaching learners in their current setting. Many (67%) fellowship programs offered formal training in medical education, and this is greater than the 50% that was previously described. Direct observation (71%) was the most common method of assessment. Most graduates reported their fellowship provided optimal training in feedback and teaching during family centered rounds but suboptimal training in other skills such as curriculum development. The results of this study highlight areas for improvement in fellowship curriculum and assessment to better prepare fellows for their roles as educators.

Improving Efficiency of Pediatric Hospital Medicine Team Daily Workflow.

BACKGROUND AND OBJECTIVES: Workflow inefficiencies by medical teams caring for hospitalized patients may affect patient care and team experience. At our institution, complexity and clinical volume of the pediatric hospital medicine (HM) service have increased over time; however, efficient workflow expectations were lacking. We aimed to increase the percentage of HM teams meeting 3 efficiency criteria (70% nurses present for rounds, rounds completed by 11:30 am, and HM attending notes completed by 5 pm) from 28% to 80% within 1 year. METHODS: Improvement efforts targeted 5 HM teams at a large academic hospital. Our multidisciplinary team, including HM attending physicians, pediatric residents, and nurses, focused on several key drivers: shared expectations, enhanced physician and nursing buy-in and communication, streamlined rounding process, and data transparency. Interventions included (1) daily rounding expectations with prerounds huddle, (2) visible reminders, (3) complex care team scheduled rounds, (4) real-time nurse notification of rounds via electronic platform, (5) workflow redesign, (6) attending feedback and data transparency, and (7) resource attending implementation. Attending physicians entered efficiency data each day through a Research Electronic Data Capture survey. Annotated control charts were used to assess the impact of interventions over time. RESULTS: Through sequential interventions, the percentage of HM teams meeting all 3 efficiency criteria increased from 28% to 61%. Nursing presence on rounds improved, and rounds end time compliance remained high, whereas attending note completion time remained variable. CONCLUSIONS: Inpatient workflow for pediatric providers was improved by setting clear expectations and enhancing team communication; competing demands while on service contributed to difficulty in improving timely attending note completion.

Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships.

Pediatric Hospital Medicine (PHM) is an emerging field in pediatrics and one that has experienced immense growth and maturation in a short period of time. Evolution and rapid expansion of the field invigorated the goal of standardizing PHM fellowship curricula, which naturally aligned with the field's evolving pursuit of a defined identity and consideration of certification options. The national group of PHM fellowship program directors sought to establish curricular standards that would more accurately reflect the competencies needed to practice pediatric hospital medicine and meet future board certification needs. In this manuscript, we describe the method by which we reached consensus on a 2-year curricular framework for PHM fellowship programs, detail the current model for this framework, and provide examples of how this curricular framework may be applied to meet the needs of a variety of fellows and fellowship programs. The 2-year PHM fellowship curricular framework was developed over a number of years through an iterative process and with the input of PHM fellowship program directors (PDs), PHM fellowship graduates, PHM leaders, pediatric hospitalists practicing in a variety of clinical settings, and other educators outside the field. We have developed a curricular framework for PHM Fellowships that consists of 8 education units (defined as 4 weeks each) in 3 areas: clinical care, systems and scholarship, and individualized curriculum.

Assessment of readability, understandability, and completeness of pediatric hospital medicine discharge instructions.

The average American adult reads at an 8th-grade level. Discharge instructions written above this level might increase the risk of adverse outcomes for children as they transition from hospital to home. We conducted a cross-sectional study at a large urban academic children's hospital to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge. Two hundred charts for patients discharged from the hospital medicine service were randomly selected for review. Written discharge instructions were extracted and scored for readability (Fry Readability Scale [FRS]), understandability (Patient Education Materials Assessment Tool [PEMAT]), and completeness (5 criteria determined by consensus). Descriptive statistics enumerated the distribution of readability, understandability, and completeness of written discharge instructions. Of the patients included in the study, 51% were publicly insured. Median age was 3.1 years, and median length of stay was 2.0 days. The median readability score corresponded to a 10th-grade reading level (interquartile range, 8-12; range, 1-13). Median PEMAT score was 73% (interquartile range, 64%-82%; range, 45%-100%); 36% of instructions scored below 70%, correlating with suboptimal understandability. The diagnosis was described in only 33% of the instructions. Although explicit warning signs were listed in most instructions, 38% of the instructions did not include information on the person to contact if warning signs developed. Overall, the readability, understandability, and completeness of discharge instructions were subpar. Efforts to improve the content of discharge instructions may promote safe and effective transitions home. Journal of Hospital Medicine 2017;12:98-101.

Bacteraemic urinary tract infection: management and outcomes in young infants.

OBJECTIVES: To determine predictors of parenteral antibiotic duration and the association between parenteral treatment duration and relapses in infants <3 months with bacteraemic urinary tract infection (UTI). DESIGN: Multicentre retrospective cohort study. SETTING: Eleven healthcare institutions across the USA. PATIENTS: Infants <3 months of age with bacteraemic UTI, defined as the same pathogenic organism isolated from blood and urine. MAIN OUTCOME MEASURES: Duration of parenteral antibiotic therapy, relapsed UTI within 30 days. RESULTS: The mean (±SD) duration of parenteral antibiotics for the 251 included infants was 7.8 days (±4 days), with considerable variability between institutions (mean range 5.5-12 days). Independent predictors of the duration of parenteral antibiotic therapy included (coefficient, 95% CI): age (-0.2 days, -0.3 days to -0.08 days, for each week older), year treated (-0.2 days, -0.4 to -0.03 days for each subsequent calendar year), male gender (0.9 days, 0.01 to 1.8 days), a positive repeat blood culture during acute treatment (3.5 days, 1.2-5.9 days) and a non-Escherichia coli organism (2.2 days, 0.8-3.6 days). No infants had a relapsed bacteraemic UTI. Six infants (2.4%) had a relapsed UTI (without bacteraemia). The duration of parenteral antibiotics did not differ between infants with and without a relapse (8.2 vs 7.8 days, p=0.81). CONCLUSIONS: Parenteral antibiotic treatment duration in young infants with bacteraemic UTI was variable and only minimally explained by measurable patient factors. Relapses were rare and were not associated with treatment duration. Shorter parenteral courses may be appropriate in some infants.

Association of White Blood Cell Count and C-Reactive Protein with Outcomes in Children Hospitalized for Community-acquired Pneumonia.

We examined the association between baseline peripheral white blood cell count and C-reactive protein (CRP) values with outcomes among 153 children hospitalized with pneumonia. In multivariable analyses, CRP, but not white blood cell count, was significantly associated with both fever duration and hospital length of stay. For every 1mg/dL increase in CRP, length of stay increased by 1 hour.

Blood culture time to positivity in febrile infants with bacteremia.

IMPORTANCE: Blood cultures are often obtained as part of the evaluation of infants with fever and these infants are typically observed until their cultures are determined to have no growth. However, the time to positivity of blood culture results in this population is not known. OBJECTIVE: To determine the time to positivity of blood culture results in febrile infants admitted to a general inpatient unit. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, retrospective, cross-sectional evaluation of blood culture time to positivity. Data were collected by community and academic hospital systems associated with the Pediatric Research in Inpatient Settings Network. The study included febrile infants 90 days of age or younger with bacteremia and without surgical histories outside of an intensive care unit. EXPOSURES: Blood culture growing pathogenic bacteria. MAIN OUTCOMES AND MEASURES: Time to positivity and proportion of positive blood culture results that become positive more than 24 hours after placement in the analyzer. RESULTS: A total of 392 pathogenic blood cultures were included from 17 hospital systems across the United States. The mean (SD) time to positivity was 15.41 (8.30) hours. By 24 hours, 91% (95% CI, 88-93) had turned positive. By 36 and 48 hours, 96% (95% CI, 95-98) and 99% (95% CI, 97-100) had become positive, respectively. CONCLUSIONS AND RELEVANCE: Most pathogens in febrile, bacteremic infants 90 days of age or younger hospitalized on a general inpatient unit will be identified within 24 hours of collection. These data suggest that inpatient observation of febrile infants for more than 24 hours may be unnecessary in most infants.