Disparities in Management of Acute Gastroenteritis in Hospitalized Children.

BACKGROUND AND OBJECTIVES: Acute gastroenteritis (AGE) is a common health care problem accounting for up to 200 000 pediatric hospitalizations annually. Previous studies show disparities in the management of children from different ethnic backgrounds presenting to the emergency department with AGE. Our aim was to evaluate whether differences in medical management also exist between Hispanic and non-Hispanic children hospitalized with AGE. METHODS: We performed a single-center retrospective study of children aged 2 months to 12 years admitted to the pediatric hospital medicine service from January 2016 to December 2020 with a diagnosis of (1) acute gastroenteritis or (2) dehydration with feeding intolerance, vomiting, and/or diarrhea. Differences in clinical pathway use, diagnostic studies performed, and medical interventions ordered were compared between Hispanic and non-Hispanic patients. RESULTS: Of 512 admissions, 54.9% were male, 51.6% were Hispanic, and 59.2% were on Medicaid. There was no difference between Hispanic and non-Hispanic patients in reported nausea or vomiting at admission, pathway use, or laboratory testing including stool studies. However, after adjusting for covariates, Hispanic patients had more ultrasound scans performed (odds ratio 1.65, 95% confidence interval 1.04-2.64) and fewer orders for antiemetics (odds ratio 0.53, 95% CI 0.29-0.95) than non-Hispanic patients. CONCLUSIONS: Although there were no differences in many aspects of AGE management between Hispanic and non-Hispanic patients, there was still variability in ultrasound scans performed and antiemetics ordered, despite similarities in reported abdominal pain, nausea, and vomiting. Prospective and/or qualitative studies may be needed to clarify underlying reasons for these differences.

Assessing Parental Discharge Readiness by Using the Ticket to Home Survey Tool.

OBJECTIVES: Ticket to Home (TTH), a survey tool designed to assess parental comprehension of their child's hospitalization and postdischarge care needs, allows providers to address knowledge gaps before discharge. Our goal was to evaluate the impact of TTH on parents' retention of discharge teaching. METHODS: In this pilot study, we enrolled a convenience sample of families admitted to pediatric hospital medicine and randomly assigned families on the basis of team assignment. The intervention group received TTH before discharge. The control group received usual care (without TTH survey tool). Both groups were sent a survey 24 to 72 hours postdischarge to assess parental understanding of discharge teaching. A senior-level provider also completed a survey; responses were compared with evaluate parent level of understanding. Descriptive statistics and logistic regression were used for analysis. RESULTS: Although 495 parents consented to participate, only 100 completed the necessary surveys (41 intervention and 59 control). Both groups showed high parent-provider concordance regarding reason for admission (92.7% intervention versus 86.4% control; P = .33). The intervention group had significantly higher concordance for return precautions (90.2% vs 58.2%; P < .001), which remained significant when controlling for covariates (odds ratio 6.24, 95% confidence interval 1.78-21.93). Most parents in the intervention group felt sharing TTH responses with their medical team was beneficial (95.0%). CONCLUSIONS: Parents who received TTH before discharge were more likely to accurately recall return precautions and valued sharing TTH results with the team. Given that response bias may have affected pilot results, additional studies in which researchers use larger samples with more diverse patient populations is required.

True Versus False Bacteremia in Infants and Children Less Than 3 Years of Age.

OBJECTIVE: The objective of this study was to examine patient history as well as clinical and laboratory features associated with true bacteremia versus false bacteremia in previously healthy febrile children ages 0 to 36 months in the era of polyvalent conjugate pneumococcal immunization. METHODS: Using retrospective chart review, we examined history, physical examination, and laboratory characteristics associated with true and false bacteremia. We included subjects under 3 years old, with a positive blood culture obtained in the emergency department or clinic from July 2011 to July 2013, and fever defined as a temperature of greater than or equal to 100.4°F by history or examination. We excluded those with a previously known underlying disease process that could increase the risk for positive blood culture, for example, immunodeficiency, cancer, cystic fibrosis, or significant skin disorders such as severe eczema, as well as patients with any indwelling central line, shunt, or other implanted device, or recent hospitalization for a febrile illness. RESULTS: Thirty subjects (24%) had true bacteremia, and 97 (76%) had false bacteremia. In the multivariable logistic regression analysis, exposure to sick contacts (odds ratio, 0.1; 95% confidence interval, 0.01-0.6; P = 0.01) and increased hours to positive blood culture (odds ratio, 0.8; 95% confidence interval, 0.8-0.9; P < 0.001) remained significant factors associated with false bacteremia. Age, maximum reported temperature, and reported days of fever were not associated with true bacteremia. CONCLUSIONS: We found that previously healthy children with true bacteremia are more likely to grow bacteria faster on blood culture and lack exposure to sick contacts than children with false bacteremia.

Low Infection-Related Re-Admission Rates in a Retrospective of 4725 Children with Appendicitis Using a Clinical Pathway in a Tertiary Care Pediatric Center.

BACKGROUND: Standardization of antibiotic management of appendicitis in tertiary care pediatric centers has been associated with improved outcomes. Rady Children's Hospital-San Diego implemented an appendicitis clinical pathway in 2005. We evaluated infection-related re-admission risk factors since 2010, when an electronic medical record was established, with the aim to optimize the clinical pathway. METHODS: Between January 2010 and August 2015, 4725 children with a diagnosis of appendicitis were evaluated for demographic data, pathology diagnoses, culture results, and inpatient and oral step-down antibiotic therapy regimens. From children originally admitted for appendicitis, those who were re-admitted with infection were compared with those who were not re-admitted for infection. The populations were controlled by severity of infection using a pathology-defined appendicitis severity scale: Grade 0, no appendicitis; grade 1, simple acute appendicitis with gross and microscopic evidence of inflammation, but no perforation; grade 2, gangrenous/necrotizing/micro-perforated appendicitis with subserosal or serosal exudate, but no frank or visually appreciated perforation; and grade 3, frank perforation. RESULTS: Of 4725 children (total population, TP) admitted with a diagnosis of appendicitis, only 199 (4.2%) were re-admitted, with 125 of these admissions for infection (2.65% of the TP). Age, race/ethnicity, language preference, and body mass index were not found to correlate with re-admission for infection. Length of stay significantly differed between the no infection-related re-admission population and infection-related re-admission population (3.02 vs. 4.03 d, p < 0.001). There was a trend toward higher infection-re-admission rates as the pathology grade increased (odds ratio grade 1 vs. grade 3 = 2.28, 95% confidence interval 1.03, 5.03). CONCLUSIONS: Infection-related re-admission rates for children on the clinical pathway in our institution were infrequent. The greater association of all-cause and infection-related re-admission rates with pathology grade suggest that defining appendicitis by pathology and clinical severity may provide an evidence-based scoring system to support clinical observation in the use and duration of antibiotic therapy.