Frequency of and Risk Factors Associated With Hospital Readmission After Sepsis.

OBJECTIVES: Although children who survive sepsis are at risk for readmission, identification of patient-level variables associated with readmission has been limited by administrative datasets. We determined frequency and cause of readmission within 90 days of discharge and identified patient-level variables associated with readmission using a large, electronic health record-based registry. METHODS: This retrospective observational study included 3464 patients treated for sepsis or septic shock between January 2011 and December 2018 who survived to discharge at a single academic children's hospital. We determined frequency and cause of readmission through 90 days post-discharge and identified patient-level variables associated with readmission. Readmission was defined as inpatient treatment within 90 days post-discharge from a prior sepsis hospitalization. Outcomes were frequency of and reasons for 7-, 30-, and 90-day (primary) readmission. Patient variables were tested for independent associations with readmission using multivariable logistic regression. RESULTS: Following index sepsis hospitalization, frequency of readmission at 7, 30, and 90 days was 7% (95% confidence interval 6%-8%), 20% (18%-21%), and 33% (31%-34%). Variables independently associated with 90-day readmission were age ≤ 1 year, chronic comorbid conditions, lower hemoglobin and higher blood urea nitrogen at sepsis recognition, and persistently low white blood cell count ≤ 2 thous/µL. These variables explained only a small proportion of overall risk (pseudo-R2 range 0.05-0.13) and had moderate predictive validity (area under the receiver operating curve range 0.67-0.72) for readmission. CONCLUSIONS: Children who survive sepsis were frequently readmitted, most often for infections. Risk for readmission was only partly indicated by patient-level variables.

Improving Vancomycin Stewardship in Critically Ill Children.

BACKGROUND AND OBJECTIVES: Inappropriate vancomycin use is common in children's hospitals. We report a quality improvement (QI) intervention to reduce vancomycin use in our tertiary care PICU. METHODS: We retrospectively quantified the prevalence of infections caused by organisms requiring vancomycin therapy, including methicillin-resistant Staphylococcus aureus (MRSA), among patients with suspected bacterial infections. Guided by these data, we performed 3 QI interventions over a 3-year period, including (1) stakeholder education, (2) generation of a consensus-based guideline for empiric vancomycin use, and (3) implementation of this guideline through clinical decision support. Vancomycin use in days of therapy (DOT) per 1000 patient days was measured by using statistical process control charts. Balancing measures included frequency of bacteremia due to an organism requiring vancomycin not covered with empiric therapy, 30-day mortality, and cardiovascular, respiratory, and renal organ dysfunction. RESULTS: Among 1276 episodes of suspected bacterial infection, a total of 19 cases of bacteremia (1.5%) due to organisms requiring vancomycin therapy were identified, including 6 MRSA bacteremias (0.5%). During the 3-year QI project, overall vancomycin DOT per 1000 patient days in the PICU decreased from a baseline mean of 182 DOT per 1000 patient days to 109 DOT per 1000 patient days (a 40% reduction). All balancing measures were unchanged, and all cases of MRSA bacteremia were treated empirically with vancomycin. CONCLUSION: Our interventions reduced overall vancomycin use in the PICU without evidence of harm. Provider education and consensus building surrounding indications for empiric vancomycin use were key strategies.