Comparison of Empiric Antibiotics for Acute Osteomyelitis in Children.

OBJECTIVES: Broad-spectrum antibiotics are commonly used for the empiric treatment of acute hematogenous osteomyelitis and often target methicillin-resistant Staphylococcus aureus (MRSA) with medication-associated risk and unknown treatment benefit. We aimed to compare clinical outcomes among patients with osteomyelitis who did and did not receive initial antibiotics used to target MRSA. METHODS: A retrospective cohort study of 974 hospitalized children 2 to 18 years old using the Pediatric Health Information System database, augmented with clinical data. Rates of hospital readmission, repeat MRI and 72-hour improvement in inflammatory markers were compared between treatment groups. RESULTS: Repeat MRI within 7 and 180 days was more frequent among patients who received initial MRSA coverage versus methicillin-sensitive S aureus (MSSA)-only coverage (8.6% vs 4.1% within 7 days [P = .02] and 12% vs 5.8% within 180 days [P < .01], respectively). Ninety- and 180-day hospital readmission rates were similar between coverage groups (9.0% vs 8.7% [P = .87] and 10.9% vs 11.2% [P = .92], respectively). Patients with MRSA- and MSSA-only coverage had similar rates of 72-hour improvement in C-reactive protein values, but patients with MRSA coverage had a lower rate of 72-hour white blood cell count normalization compared with patients with MSSA-only coverage (4.2% vs 16.4%; P = .02). CONCLUSIONS: In this study of children hospitalized with acute hematogenous osteomyelitis, early antibiotic treatment used to target MRSA was associated with a higher rate of repeat MRI compared with early antibiotic treatment used to target MSSA but not MRSA. Hospital readmission rates were similar for both treatment groups.

Identifying Pediatric Severe Sepsis and Septic Shock: Accuracy of Diagnosis Codes.

OBJECTIVES: To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. STUDY DESIGN: Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. RESULTS: A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008). CONCLUSIONS: Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction.

Delay discounting by depressed and non-depressed adolescent smokers and non-smokers.

BACKGROUND: Both delay discounting and depression are risk factors for cigarette smoking during adolescence. However, very little research has explored associations between these variables in adolescent smokers and non-smokers. METHODS: Eighty adolescents were recruited based on depression status (depressed and non-depressed) and smoking status (smokers and non-smokers) to form four groups (n=20 per group). All participants completed a computerized monetary delay discounting task and a measure of depression. RESULTS: Delay discounting and depression were significantly correlated. Also, smokers (both depressed and non-depressed) and depressed non-smokers all discounted significantly more than non-smokers who were not depressed. Depressed non-smokers and both groups of smokers did not differ in rate of delay discounting. CONCLUSIONS: Adolescent non-smokers who are depressed discount similarly to adolescents who smoke and more than non-smokers who are not depressed. Future research should explore the unique versus shared roles of delay discounting and depression as risk factors for smoking during adolescence.

Pediatric hospitalist perceptions of the impact of duty hour changes on education and patient care.

OBJECTIVE: The goal of this study was to measure the impact of the new 2011 Accreditation Council for Graduate Medical Education duty hour standards (DHS) on education, patient care, and overall satisfaction as perceived by pediatric hospitalist faculty. METHODS: We undertook a nonrandomized but controlled study of 23 pediatric hospitalist faculty members during a trial of the new DHS in 2011. During the intervention (January), residents piloted schedules that complied with the new DHS, and in the control period (February), resident schedules complied with previous DHS. Daily surveys solicited faculty perceptions of the amount and quality of teaching provided, time with patients, quality of patient care, and overall faculty satisfaction. Faculty were also surveyed on their years of experience as a hospitalist and clinical teaching activity. Multiple logistic regression analysis with generalized estimating equations was used to examine outcome associations after adjusting for census and accounting for multiple attending reports. RESULTS: Census volumes were higher in the control group. During the intervention, faculty were less likely to rate their quality of teaching (odds ratio [OR]: 0.40 [95% confidence interval (CI): 0.18-0.88]) and overall satisfaction with the shift (OR: 0.23 [95% CI: 0.08-0.66]) as good/excellent compared with controls. During the intervention, more years of experience as a hospitalist were associated with rating quality of patient care provided as good/excellent (OR: 1.77 [95% CI: 1.23-2.54]). CONCLUSIONS: Faculty were less likely to rate their quality of teaching and overall satisfaction as good/excellent during a trial of the 2011 DHS. In addition, more experienced faculty were more likely to rate the quality of care highly.

Antithrombin concentrate use in children: a multicenter cohort study.

OBJECTIVE: To describe the off-label use of antithrombin concentrate in tertiary care pediatric hospitals across the US. STUDY DESIGN: This is a retrospective, multicenter, cohort study of 4210 admissions of children younger than 18 years of age who received antithrombin concentrate between 2002 and 2011 within the Pediatric Health Information System administrative database. An on-label admission was defined as an admission with an International Classification of Diseases diagnostic code for a primary hypercoagulable state; admissions without this code were classified as off-label. RESULTS: During the 10-year study period, off-label use of antithrombin concentrate increased 5-fold. Overall, 97% of study subjects received antithrombin off-label. Neonates younger than 30 days of age comprised the largest age group (45.7%) of use; 87% of patients had at least one complex chronic condition, with congenital heart/lung defects being the most prevalent primary diagnosis (36.3%). Extracorporeal membrane oxygenation was the most common procedure associated with antithrombin use (43.7%). CONCLUSIONS: The off-label use of antithrombin concentrate is increasing rapidly, particularly in critically ill children receiving extracorporeal membrane oxygenation, with few parallel studies to substantiate its safety or efficacy. Further preclinical and controlled clinical studies are critical to expanding our knowledge of this drug. In the meantime, antithrombin concentrate should be used judiciously by clinicians and following guidelines instated by hospitals.

Rapid implementation of evidence-based guidelines for imaging after first urinary tract infection.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics published a new guideline for management of first urinary tract infection (UTI) in children aged 2 to 24 months in September 2011. The imaging evaluation changed from the previous guideline to recommend voiding cystourethrogram (VCUG) only for patients with an abnormal renal and bladder ultrasound (RBUS). The objective was to decrease the proportion of guideline-eligible children with a normal RBUS who underwent VCUG from median of 92% for patients treated as inpatients and 100% for patients treated in the emergency department to 5% in both settings. METHODS: This was a quality improvement implementation study in a large academic medical center. Key drivers included: appropriate guideline knowledge, timely identification of guideline eligible patients, and effective communication with the community-based primary care provider. A multidisciplinary team developed and tested interventions. Impact was assessed with annotated run charts. Statistical comparisons were made with χ(2) analysis and Fisher's exact test. RESULTS: The proportion of children with first UTI and normal RBUS who underwent VCUG decreased from a median of 92% to 0% within 1 month of initiating the project among those hospitalized and from 100% to 40% within 4 months among those diagnosed in the emergency department. Rates have been sustained for 12 months and 8 months, respectively. Interventions using the electronic medical record and ordering system were most impactful. CONCLUSIONS: Rapid adoption of evidence-based UTI care across multiple settings is achievable. Practice change occurred faster and to a greater magnitude in the inpatient setting compared with the outpatient setting.

Improved documentation and care planning with an asthma-specific history and physical.

OBJECTIVE: The objective was to determine the effect of an electronic asthma-specific inpatient history and physical (H&P) template on documented history and improvements in care plans. METHODS: This was a before-after comparison of history and care plan documentation following implementation of a new H&P template. The template was implemented in May 2011. A retrospective review of the electronic health record was completed for 304 consecutive patients (2-16 years of age) admitted for asthma June to September 2010 and 242 admitted June to September 2011. Elements reviewed included asthma severity classification, utilization history (previous oral steroids, emergency visits, hospitalizations, intensive care admissions, and intubations), and environmental history (exposure to cockroaches, rodents, and mold). Assessed changes in care plans included social work or asthma-related subspecialty consult and change in controller medications. Patients from 2011 were compared with those from 2010 by using ttest and chi2 statistics with adjustment for confounders by use of logistic regression. Interrupted time-series analyses assessed variability in documentation over time. RESULTS: In 2011, the new H&P template was used in 74% of encounters. Compared with patients seen preimplementation, documentation in those seen after implementation was more likely to include severity classification (71% vs 44%; P < .0001), complete utilization history (73% vs 12%; P < .0001), and environmental history (66% v. 2%; P < .0001). Documentation became more consistent over time. Changes in care planning were also more common after implementation (63% vs 49%; P = .0006). CONCLUSIONS: A structured H&P template for asthma led to more complete and less variable documentation of important history and likely led to enhancements in care plans.