Society of Hospital Medicine (SHM)/ Ambulatory Pediatric Association/ American Academy of Pediatrics (AAP): Pediatric Hospital Medicine 2012

COVINGTON, KY. – Racemic epinephrine may be more effective in premature than in full-term infants who are hospitalized for bronchiolitis, a chart review suggests.

The positive response rate to inhaled racemic epinephrine was significantly higher at 54.3% among premature infants, compared with 28% among full-term infants (P = .003).

In contrast, there was no significant difference in documented positive response rates to albuterol (Proventil, Ventolin, Volmax, Vospire) among premature and full-term infants (43.4% vs. 38%; P = .18), Dr. Russell J. McCulloh reported in a poster at the Pediatric Hospital Medicine 2012 meeting.

He said that few studies have examined the effectiveness of commonly used bronchiolitis therapies in children with a history of premature birth, even though these children are commonly affected by bronchiolitis and are at higher risk of severe outcomes and prolonged stay.

The chart review included 1,222 infants with and without a history of premature birth who were admitted for bronchiolitis to two academic medical centers. Of these, 229 (19%) were premature.

At baseline, preemies were significantly older than full-term infants (6.6 months vs. 5.4 months) and less likely to have day care exposure (15.3% vs. 24%), but more likely to have a history of wheeze (18% vs. 14%).

Premature patients had a significantly longer mean length of stay of 3.8 days compared with 2.5 days among full-term infants, although this did not differ significantly based on systemic steroid use (31% vs. 27.6%; P = .3), noted Dr. McCulloh of the pediatrics division at Rhode Island Hospital, Providence.

Premature infants were significantly more likely than full-term infants to require an ICU stay (23% vs. 11%), and they trended toward more pneumonia diagnosed (9.3% vs. 6%) and IV hydration (63% vs. 58.4%).

Full-term infants had more fever documented (45% vs. 36%) and urinary tract infections diagnosed (2.4% vs. 0%).

In logistic regression analyses, premature birth was independently associated with improved responsiveness to epinephrine (odds ratio, 1.89), Dr. McCulloh reported at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. McCulloh reported having no conflicts of interest.

COVINGTON, KY. – Racemic epinephrine may be more effective in premature than in full-term infants who are hospitalized for bronchiolitis, a chart review suggests.

The positive response rate to inhaled racemic epinephrine was significantly higher at 54.3% among premature infants, compared with 28% among full-term infants (P = .003).

In contrast, there was no significant difference in documented positive response rates to albuterol (Proventil, Ventolin, Volmax, Vospire) among premature and full-term infants (43.4% vs. 38%; P = .18), Dr. Russell J. McCulloh reported in a poster at the Pediatric Hospital Medicine 2012 meeting.

He said that few studies have examined the effectiveness of commonly used bronchiolitis therapies in children with a history of premature birth, even though these children are commonly affected by bronchiolitis and are at higher risk of severe outcomes and prolonged stay.

The chart review included 1,222 infants with and without a history of premature birth who were admitted for bronchiolitis to two academic medical centers. Of these, 229 (19%) were premature.

At baseline, preemies were significantly older than full-term infants (6.6 months vs. 5.4 months) and less likely to have day care exposure (15.3% vs. 24%), but more likely to have a history of wheeze (18% vs. 14%).

Premature patients had a significantly longer mean length of stay of 3.8 days compared with 2.5 days among full-term infants, although this did not differ significantly based on systemic steroid use (31% vs. 27.6%; P = .3), noted Dr. McCulloh of the pediatrics division at Rhode Island Hospital, Providence.

Premature infants were significantly more likely than full-term infants to require an ICU stay (23% vs. 11%), and they trended toward more pneumonia diagnosed (9.3% vs. 6%) and IV hydration (63% vs. 58.4%).

Full-term infants had more fever documented (45% vs. 36%) and urinary tract infections diagnosed (2.4% vs. 0%).

In logistic regression analyses, premature birth was independently associated with improved responsiveness to epinephrine (odds ratio, 1.89), Dr. McCulloh reported at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. McCulloh reported having no conflicts of interest.

COVINGTON, KY. – Racemic epinephrine may be more effective in premature than in full-term infants who are hospitalized for bronchiolitis, a chart review suggests.

The positive response rate to inhaled racemic epinephrine was significantly higher at 54.3% among premature infants, compared with 28% among full-term infants (P = .003).

In contrast, there was no significant difference in documented positive response rates to albuterol (Proventil, Ventolin, Volmax, Vospire) among premature and full-term infants (43.4% vs. 38%; P = .18), Dr. Russell J. McCulloh reported in a poster at the Pediatric Hospital Medicine 2012 meeting.

He said that few studies have examined the effectiveness of commonly used bronchiolitis therapies in children with a history of premature birth, even though these children are commonly affected by bronchiolitis and are at higher risk of severe outcomes and prolonged stay.

The chart review included 1,222 infants with and without a history of premature birth who were admitted for bronchiolitis to two academic medical centers. Of these, 229 (19%) were premature.

At baseline, preemies were significantly older than full-term infants (6.6 months vs. 5.4 months) and less likely to have day care exposure (15.3% vs. 24%), but more likely to have a history of wheeze (18% vs. 14%).

Premature patients had a significantly longer mean length of stay of 3.8 days compared with 2.5 days among full-term infants, although this did not differ significantly based on systemic steroid use (31% vs. 27.6%; P = .3), noted Dr. McCulloh of the pediatrics division at Rhode Island Hospital, Providence.

Premature infants were significantly more likely than full-term infants to require an ICU stay (23% vs. 11%), and they trended toward more pneumonia diagnosed (9.3% vs. 6%) and IV hydration (63% vs. 58.4%).

Full-term infants had more fever documented (45% vs. 36%) and urinary tract infections diagnosed (2.4% vs. 0%).

In logistic regression analyses, premature birth was independently associated with improved responsiveness to epinephrine (odds ratio, 1.89), Dr. McCulloh reported at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. McCulloh reported having no conflicts of interest.

COVINGTON, KY. – Early electroencephalogram monitoring is playing an increasingly critical role in the recognition and management of status epilepticus, the most common neurologic emergency of childhood.

EEG is important for a definitive diagnosis of nonconvulsive status epilepticus (SE), particularly in children who have been in a convulsive state and in those with encephalopathy of unknown etiology or a seizure history, Dr. Rajit K. Basu of Cincinnati Children’s Hospital Medical Center said at the Pediatric Hospital Medicine 2012 meeting.

This view is formed in part by a recent study at his institution, in which video EEG monitoring revealed that more than one-third of children admitted for encephalopathy (35%) were in nonconvulsive status epilepticus. Almost all had convulsive seizures prior to presenting (92%) and more than half were being cared for on the floor (Pediatrics 2012;129:e748-55).

Similarly, an earlier study reported that up to 22% of children who had prolonged EEG monitoring after convulsive SE were found to be in nonconvulsive SE (Neurology 2010;74:636-42).

"These are the kids that I think really fall through the cracks for us – the ones that got a bunch of meds in the ER and are admitted to the floor for observation because they’re ‘sleepy’ or need to ‘wake up,’ " Dr. Basu said. "But you don’t know actually that they’ve recovered, and every minute that you let them go – every minute that you don’t know they’re in nonconvulsive status – is a problem."

He acknowledged that not every institution has the capacity for emergency EEG monitoring but said the idea is for clinicians to think about an EEG at 7 or 8 a.m. rather than 2 p.m.

The International League Against Epilepsy (ILAE) defined status epilepticus in 1993 as more than 30 minutes of continuous epileptic activity without complete recovery of consciousness, although more recent definitions have shortened the duration to 20, 15, or even 5 minutes of continuous seizure activity.

Essential to the management of SE is an understanding of the inciting disease and that seizures are neurotoxic, said Dr. Basu, lead for the hospital working group on management of refractory SE.

"Seizures are not a benign thing, even if you stop them," he said. "They’re a pre-status state. Your brain is on fire and that fire needs to be put out."

Multiple diagnostic algorithms for SE exist, including one by the ILAE that is expected to be revised soon, but most are center specific or user specific. The common thread, however, is that time matters, both for treatment response and outcomes.

Patrice Wendling/IMNG Medical Media

"If you don’t act quickly, the outcome on the backside is severe," Dr. Basu said. "Even if they don’t die, which some kids unfortunately do, there is an increased incidence of epilepsy syndrome and poor neurologic recovery."

Indeed, the Mayo Clinic reported (Epilepsia 2008;49:615-25) that seizures stopped in 100% of children with SE receiving an additional second-line therapy within less than 60 minutes of the first drug, compared with only 22% of those receiving additional second-line therapy later in the clinical course. (Patients were allowed two second-line therapies before third-line treatment.)

Children in that study’s refractory SE group were significantly less likely than those treated more aggressively to return to baseline neurological status and more likely to die during hospitalization (see graph), and they had a twofold higher risk of developing a new neurological deficit or epilepsy at 4-year follow-up. (Researchers defined the refractory group as "clinical or electrographic seizures lasting longer than 60 minutes despite treatment with at least one first-line AED and one second-line AED.")

"The point is that if you follow some kind of time algorithm and deliver meds early and aggressively, you can get ahead of this and may stop status from developing," Dr. Basu said.

A continuing challenge is predicting which child presenting with SE will progress to refractory SE and likely end up in the ICU on burst suppression. To this end, Cincinnati Children’s recently launched the PARSE (Pediatric Acute Refractory Status Epilepticus) Initiative to derive a predictive model that may actually trigger a change in the "tempo" of SE management, he said.

Until predictive modeling becomes a reality, in-hospital and at-home seizure plans are being created. The London-Innsbruck Colloquium on Acute Seizures and Status Epilepticus has penned several SE protocols, with a recent review (Curr. Opin. Neurol. 2011;24:165-70) detailing treatment advances since the first colloquium was held in 2007.

Hospitals are also developing at-home seizure plans that may be tailored to individual at-risk patients, featuring a red, yellow, and green light system similar to that used in at-home asthma action plans. Parents may understand the idea of giving rectal diazepam (Valium, Valrelease) at home, but such remote plans can help address questions such as when a second therapy should be delivered, the correct dosing of benzodiazepines, or when to come to the hospital, Dr. Basu said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. Basu reported no relevant conflicts of interest.

COVINGTON, KY. – Early electroencephalogram monitoring is playing an increasingly critical role in the recognition and management of status epilepticus, the most common neurologic emergency of childhood.

EEG is important for a definitive diagnosis of nonconvulsive status epilepticus (SE), particularly in children who have been in a convulsive state and in those with encephalopathy of unknown etiology or a seizure history, Dr. Rajit K. Basu of Cincinnati Children’s Hospital Medical Center said at the Pediatric Hospital Medicine 2012 meeting.

This view is formed in part by a recent study at his institution, in which video EEG monitoring revealed that more than one-third of children admitted for encephalopathy (35%) were in nonconvulsive status epilepticus. Almost all had convulsive seizures prior to presenting (92%) and more than half were being cared for on the floor (Pediatrics 2012;129:e748-55).

Similarly, an earlier study reported that up to 22% of children who had prolonged EEG monitoring after convulsive SE were found to be in nonconvulsive SE (Neurology 2010;74:636-42).

"These are the kids that I think really fall through the cracks for us – the ones that got a bunch of meds in the ER and are admitted to the floor for observation because they’re ‘sleepy’ or need to ‘wake up,’ " Dr. Basu said. "But you don’t know actually that they’ve recovered, and every minute that you let them go – every minute that you don’t know they’re in nonconvulsive status – is a problem."

He acknowledged that not every institution has the capacity for emergency EEG monitoring but said the idea is for clinicians to think about an EEG at 7 or 8 a.m. rather than 2 p.m.

The International League Against Epilepsy (ILAE) defined status epilepticus in 1993 as more than 30 minutes of continuous epileptic activity without complete recovery of consciousness, although more recent definitions have shortened the duration to 20, 15, or even 5 minutes of continuous seizure activity.

Essential to the management of SE is an understanding of the inciting disease and that seizures are neurotoxic, said Dr. Basu, lead for the hospital working group on management of refractory SE.

"Seizures are not a benign thing, even if you stop them," he said. "They’re a pre-status state. Your brain is on fire and that fire needs to be put out."

Multiple diagnostic algorithms for SE exist, including one by the ILAE that is expected to be revised soon, but most are center specific or user specific. The common thread, however, is that time matters, both for treatment response and outcomes.

Patrice Wendling/IMNG Medical Media

"If you don’t act quickly, the outcome on the backside is severe," Dr. Basu said. "Even if they don’t die, which some kids unfortunately do, there is an increased incidence of epilepsy syndrome and poor neurologic recovery."

Indeed, the Mayo Clinic reported (Epilepsia 2008;49:615-25) that seizures stopped in 100% of children with SE receiving an additional second-line therapy within less than 60 minutes of the first drug, compared with only 22% of those receiving additional second-line therapy later in the clinical course. (Patients were allowed two second-line therapies before third-line treatment.)

Children in that study’s refractory SE group were significantly less likely than those treated more aggressively to return to baseline neurological status and more likely to die during hospitalization (see graph), and they had a twofold higher risk of developing a new neurological deficit or epilepsy at 4-year follow-up. (Researchers defined the refractory group as "clinical or electrographic seizures lasting longer than 60 minutes despite treatment with at least one first-line AED and one second-line AED.")

"The point is that if you follow some kind of time algorithm and deliver meds early and aggressively, you can get ahead of this and may stop status from developing," Dr. Basu said.

A continuing challenge is predicting which child presenting with SE will progress to refractory SE and likely end up in the ICU on burst suppression. To this end, Cincinnati Children’s recently launched the PARSE (Pediatric Acute Refractory Status Epilepticus) Initiative to derive a predictive model that may actually trigger a change in the "tempo" of SE management, he said.

Until predictive modeling becomes a reality, in-hospital and at-home seizure plans are being created. The London-Innsbruck Colloquium on Acute Seizures and Status Epilepticus has penned several SE protocols, with a recent review (Curr. Opin. Neurol. 2011;24:165-70) detailing treatment advances since the first colloquium was held in 2007.

Hospitals are also developing at-home seizure plans that may be tailored to individual at-risk patients, featuring a red, yellow, and green light system similar to that used in at-home asthma action plans. Parents may understand the idea of giving rectal diazepam (Valium, Valrelease) at home, but such remote plans can help address questions such as when a second therapy should be delivered, the correct dosing of benzodiazepines, or when to come to the hospital, Dr. Basu said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. Basu reported no relevant conflicts of interest.

COVINGTON, KY. – Early electroencephalogram monitoring is playing an increasingly critical role in the recognition and management of status epilepticus, the most common neurologic emergency of childhood.

EEG is important for a definitive diagnosis of nonconvulsive status epilepticus (SE), particularly in children who have been in a convulsive state and in those with encephalopathy of unknown etiology or a seizure history, Dr. Rajit K. Basu of Cincinnati Children’s Hospital Medical Center said at the Pediatric Hospital Medicine 2012 meeting.

This view is formed in part by a recent study at his institution, in which video EEG monitoring revealed that more than one-third of children admitted for encephalopathy (35%) were in nonconvulsive status epilepticus. Almost all had convulsive seizures prior to presenting (92%) and more than half were being cared for on the floor (Pediatrics 2012;129:e748-55).

Similarly, an earlier study reported that up to 22% of children who had prolonged EEG monitoring after convulsive SE were found to be in nonconvulsive SE (Neurology 2010;74:636-42).

"These are the kids that I think really fall through the cracks for us – the ones that got a bunch of meds in the ER and are admitted to the floor for observation because they’re ‘sleepy’ or need to ‘wake up,’ " Dr. Basu said. "But you don’t know actually that they’ve recovered, and every minute that you let them go – every minute that you don’t know they’re in nonconvulsive status – is a problem."

He acknowledged that not every institution has the capacity for emergency EEG monitoring but said the idea is for clinicians to think about an EEG at 7 or 8 a.m. rather than 2 p.m.

The International League Against Epilepsy (ILAE) defined status epilepticus in 1993 as more than 30 minutes of continuous epileptic activity without complete recovery of consciousness, although more recent definitions have shortened the duration to 20, 15, or even 5 minutes of continuous seizure activity.

Essential to the management of SE is an understanding of the inciting disease and that seizures are neurotoxic, said Dr. Basu, lead for the hospital working group on management of refractory SE.

"Seizures are not a benign thing, even if you stop them," he said. "They’re a pre-status state. Your brain is on fire and that fire needs to be put out."

Multiple diagnostic algorithms for SE exist, including one by the ILAE that is expected to be revised soon, but most are center specific or user specific. The common thread, however, is that time matters, both for treatment response and outcomes.

Patrice Wendling/IMNG Medical Media

"If you don’t act quickly, the outcome on the backside is severe," Dr. Basu said. "Even if they don’t die, which some kids unfortunately do, there is an increased incidence of epilepsy syndrome and poor neurologic recovery."

Indeed, the Mayo Clinic reported (Epilepsia 2008;49:615-25) that seizures stopped in 100% of children with SE receiving an additional second-line therapy within less than 60 minutes of the first drug, compared with only 22% of those receiving additional second-line therapy later in the clinical course. (Patients were allowed two second-line therapies before third-line treatment.)

Children in that study’s refractory SE group were significantly less likely than those treated more aggressively to return to baseline neurological status and more likely to die during hospitalization (see graph), and they had a twofold higher risk of developing a new neurological deficit or epilepsy at 4-year follow-up. (Researchers defined the refractory group as "clinical or electrographic seizures lasting longer than 60 minutes despite treatment with at least one first-line AED and one second-line AED.")

"The point is that if you follow some kind of time algorithm and deliver meds early and aggressively, you can get ahead of this and may stop status from developing," Dr. Basu said.

A continuing challenge is predicting which child presenting with SE will progress to refractory SE and likely end up in the ICU on burst suppression. To this end, Cincinnati Children’s recently launched the PARSE (Pediatric Acute Refractory Status Epilepticus) Initiative to derive a predictive model that may actually trigger a change in the "tempo" of SE management, he said.

Until predictive modeling becomes a reality, in-hospital and at-home seizure plans are being created. The London-Innsbruck Colloquium on Acute Seizures and Status Epilepticus has penned several SE protocols, with a recent review (Curr. Opin. Neurol. 2011;24:165-70) detailing treatment advances since the first colloquium was held in 2007.

Hospitals are also developing at-home seizure plans that may be tailored to individual at-risk patients, featuring a red, yellow, and green light system similar to that used in at-home asthma action plans. Parents may understand the idea of giving rectal diazepam (Valium, Valrelease) at home, but such remote plans can help address questions such as when a second therapy should be delivered, the correct dosing of benzodiazepines, or when to come to the hospital, Dr. Basu said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. Basu reported no relevant conflicts of interest.

COVINGTON, KY. – A healthy 2-year-old is admitted for incision and drainage of a MRSA thigh abscess and is given intravenous clindamycin during a 1-day hospital stay before being discharged home with a prescription for oral clindamycin.

The child refuses to take the clindamycin at home, and is readmitted 3 days later with a new abscess on her arm that requires a 2-day hospital stay.

Was this readmission preventable?

Some attendees at the Pediatric Hospital Medicine 2012 meeting thought it was out of the hospital’s hands, while others suggested the hospital was at fault because clindamycin is such an unpalatable medication that an oral dose should have been given at the hospital, along with instructions for how to make it more palatable at home.

The scenario is part of the ongoing Vanderbilt Readmissions Project, which seeks to identify patient and hospitalization characteristics of 15-day readmissions in children, create a 5-point "preventability scale" for early pediatric readmissions that can be applied by multiple reviewers, and institute measures to decrease potentially preventable readmissions.

What the investigators have found so far is that, even after reviewing the same clinical information for 200 pediatric readmissions, a panel of four knowledgeable pediatricians gave exactly the same ratings in 37.5% of cases, Dr. James C. Gay said. There was 94% agreement on planned readmissions (47/50 cases), but only 19% agreement on unplanned readmissions (28/150).

"Further studies are needed to develop concrete rules for assessing preventability that can be applied reproducibly by multiple reviewers in multiple types of readmissions," he said.

The Vanderbilt findings have financial implications for hospitals, as the federal government has already taken to heart the issue of preventable readmissions following the sentinel article reporting that 19.6% of Medicare beneficiaries were readmitted within 30 days at a cost of $17.4 billion in 2004 (N. Engl. J. Med. 2009;360:1418-28). Many of these readmissions were thought to be avoidable by improvements in care and the discharge planning processes during the initial hospitalization.

The Affordable Care Act has also taken up the issue, and beginning Oct. 1, 2012, prospective payment system (PPS) hospitals will experience decreased Medicare payments for three index admissions – myocardial infarction, heart failure, and pneumonia – with "higher than expected" 30-day readmissions, coauthor Dr. Paul Hain explained at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The Centers for Medicare and Medicaid Services (CMS) will calculate hospitals’ actual readmissions, excluding planned readmissions and readmissions unrelated to the index admission, and then compare these to hospitals’ expected readmission rates. Hospitals with "higher than expected" rates will be required to pay back the payments they’ve received for readmissions deemed to be excessive.

Beginning in 2015, the CMS may expand the list of conditions to include chronic obstructive pulmonary disease and several cardiac and vascular surgical procedures, he said. Similar penalties are likely to befall children’s hospitals, as rules that start in Medicare trickle down to Medicaid in 3-5 years.

Part of the problem is that researchers have yet to identify what can reliably drive down adult or pediatric readmissions or even determine whether the readmission interval should be 3, 7, 15, 60, 90, 365, or 30 days, as the CMS uses.

"We looked at 30 days, and the noise that comes in is incredible," said Dr. Hain, now with Children’s Medical Center, Dallas. Ultimately, the researchers chose 15 days for their analyses because of the intuitively greater relationship to events in the index hospitalization.

Based on 4-year data from Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn., the 15-day readmission rate among non-newborns was 9.6% in 2007, 9.6% in 2008, 8.8% in 2009, and 8.9% in 2010; and among newborns, the rates were 2.5%, 3.2%, 2.5%, and 3.0%, respectively.

The first real global study of pediatric readmissions reported that 16.7% of patients between 2 and 18 years old at 38 U.S. children’s hospitals were readmitted within 365 days, and that readmissions were strongly associated with any complex chronic condition, female gender, older age, black race, public insurance coverage, longer length of stay during the initial admission, and number of previous admissions (Pediatrics 2009;123:286-93).

One year later, the same group reported that the likelihood of readmission among children aged 2-18 years actually increased as a states’ health system performance ranking improved (J. Pediatr. 2010;157:98-102.e1), observed Dr. Gay of the Children’s Hospital at Vanderbilt.

Similarly vexing results have been observed among adults. The Mayo Clinic in Rochester, Minn., recently reported that general medicine patients with a documented follow-up appointment were slightly more likely to have a hospital readmission, make an emergency department visit, or die within 180 days after discharge than those without an appointment (Arch. Intern. Med. 2010;170:955-60).

In the Vanderbilt cohort, the final expert consensus was that 40 early readmissions (20%) were more likely preventable (ratings 4 and 5). Nearly half of these were central venous catheter infections or ventriculo-peritoneal shunt malfunctions in children with serious chronic illnesses.

Extrapolating these results, about 1.7% of all hospital admissions would have a significant degree of preventability, Dr. Gay said. In absolute terms, about 250 admissions per year, or less than one admission per day, would be preventable at the Children’s Hospital at Vanderbilt.

"With 80% of readmissions planned or likely not preventable, it seems unreasonable to believe that pediatric readmissions are associated with substandard inpatient care, calling into question the validity of an all-cause readmission rate as a quality measure," he said. "If the responsibility for pediatric readmissions is placed on the hospital, then realistic benchmarks should be established."

Dr. Gay said more data is also needed from across the country, with some of that information trickling in from the recent Pediatric Academic Societies meeting. Various investigators reported that there was no relationship between length of stay and pediatric readmissions; 30-day readmission rates were low at 2%-8% in the top 10 APR-DRG (All Patient Refined Diagnosis Related Groups) hospitals; and significant variability exists in readmission rates across hospitals for 10 of the top 30 APR-DRG index admissions.

"This may be where we need to hone our efforts," Dr. Gay said. "If there’s variability, there may be a reason for that variability that we can have an impact on."

Dr. Gay reported funding support for medical consulting for the National Association of Children’s Hospitals and Related Institutions. Dr. Hain reported no conflicts of interest.

COVINGTON, KY. – A healthy 2-year-old is admitted for incision and drainage of a MRSA thigh abscess and is given intravenous clindamycin during a 1-day hospital stay before being discharged home with a prescription for oral clindamycin.

The child refuses to take the clindamycin at home, and is readmitted 3 days later with a new abscess on her arm that requires a 2-day hospital stay.

Was this readmission preventable?

Some attendees at the Pediatric Hospital Medicine 2012 meeting thought it was out of the hospital’s hands, while others suggested the hospital was at fault because clindamycin is such an unpalatable medication that an oral dose should have been given at the hospital, along with instructions for how to make it more palatable at home.

The scenario is part of the ongoing Vanderbilt Readmissions Project, which seeks to identify patient and hospitalization characteristics of 15-day readmissions in children, create a 5-point "preventability scale" for early pediatric readmissions that can be applied by multiple reviewers, and institute measures to decrease potentially preventable readmissions.

What the investigators have found so far is that, even after reviewing the same clinical information for 200 pediatric readmissions, a panel of four knowledgeable pediatricians gave exactly the same ratings in 37.5% of cases, Dr. James C. Gay said. There was 94% agreement on planned readmissions (47/50 cases), but only 19% agreement on unplanned readmissions (28/150).

"Further studies are needed to develop concrete rules for assessing preventability that can be applied reproducibly by multiple reviewers in multiple types of readmissions," he said.

The Vanderbilt findings have financial implications for hospitals, as the federal government has already taken to heart the issue of preventable readmissions following the sentinel article reporting that 19.6% of Medicare beneficiaries were readmitted within 30 days at a cost of $17.4 billion in 2004 (N. Engl. J. Med. 2009;360:1418-28). Many of these readmissions were thought to be avoidable by improvements in care and the discharge planning processes during the initial hospitalization.

The Affordable Care Act has also taken up the issue, and beginning Oct. 1, 2012, prospective payment system (PPS) hospitals will experience decreased Medicare payments for three index admissions – myocardial infarction, heart failure, and pneumonia – with "higher than expected" 30-day readmissions, coauthor Dr. Paul Hain explained at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The Centers for Medicare and Medicaid Services (CMS) will calculate hospitals’ actual readmissions, excluding planned readmissions and readmissions unrelated to the index admission, and then compare these to hospitals’ expected readmission rates. Hospitals with "higher than expected" rates will be required to pay back the payments they’ve received for readmissions deemed to be excessive.

Beginning in 2015, the CMS may expand the list of conditions to include chronic obstructive pulmonary disease and several cardiac and vascular surgical procedures, he said. Similar penalties are likely to befall children’s hospitals, as rules that start in Medicare trickle down to Medicaid in 3-5 years.

Part of the problem is that researchers have yet to identify what can reliably drive down adult or pediatric readmissions or even determine whether the readmission interval should be 3, 7, 15, 60, 90, 365, or 30 days, as the CMS uses.

"We looked at 30 days, and the noise that comes in is incredible," said Dr. Hain, now with Children’s Medical Center, Dallas. Ultimately, the researchers chose 15 days for their analyses because of the intuitively greater relationship to events in the index hospitalization.

Based on 4-year data from Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn., the 15-day readmission rate among non-newborns was 9.6% in 2007, 9.6% in 2008, 8.8% in 2009, and 8.9% in 2010; and among newborns, the rates were 2.5%, 3.2%, 2.5%, and 3.0%, respectively.

The first real global study of pediatric readmissions reported that 16.7% of patients between 2 and 18 years old at 38 U.S. children’s hospitals were readmitted within 365 days, and that readmissions were strongly associated with any complex chronic condition, female gender, older age, black race, public insurance coverage, longer length of stay during the initial admission, and number of previous admissions (Pediatrics 2009;123:286-93).

One year later, the same group reported that the likelihood of readmission among children aged 2-18 years actually increased as a states’ health system performance ranking improved (J. Pediatr. 2010;157:98-102.e1), observed Dr. Gay of the Children’s Hospital at Vanderbilt.

Similarly vexing results have been observed among adults. The Mayo Clinic in Rochester, Minn., recently reported that general medicine patients with a documented follow-up appointment were slightly more likely to have a hospital readmission, make an emergency department visit, or die within 180 days after discharge than those without an appointment (Arch. Intern. Med. 2010;170:955-60).

In the Vanderbilt cohort, the final expert consensus was that 40 early readmissions (20%) were more likely preventable (ratings 4 and 5). Nearly half of these were central venous catheter infections or ventriculo-peritoneal shunt malfunctions in children with serious chronic illnesses.

Extrapolating these results, about 1.7% of all hospital admissions would have a significant degree of preventability, Dr. Gay said. In absolute terms, about 250 admissions per year, or less than one admission per day, would be preventable at the Children’s Hospital at Vanderbilt.

"With 80% of readmissions planned or likely not preventable, it seems unreasonable to believe that pediatric readmissions are associated with substandard inpatient care, calling into question the validity of an all-cause readmission rate as a quality measure," he said. "If the responsibility for pediatric readmissions is placed on the hospital, then realistic benchmarks should be established."

Dr. Gay said more data is also needed from across the country, with some of that information trickling in from the recent Pediatric Academic Societies meeting. Various investigators reported that there was no relationship between length of stay and pediatric readmissions; 30-day readmission rates were low at 2%-8% in the top 10 APR-DRG (All Patient Refined Diagnosis Related Groups) hospitals; and significant variability exists in readmission rates across hospitals for 10 of the top 30 APR-DRG index admissions.

"This may be where we need to hone our efforts," Dr. Gay said. "If there’s variability, there may be a reason for that variability that we can have an impact on."

Dr. Gay reported funding support for medical consulting for the National Association of Children’s Hospitals and Related Institutions. Dr. Hain reported no conflicts of interest.

COVINGTON, KY. – A healthy 2-year-old is admitted for incision and drainage of a MRSA thigh abscess and is given intravenous clindamycin during a 1-day hospital stay before being discharged home with a prescription for oral clindamycin.

The child refuses to take the clindamycin at home, and is readmitted 3 days later with a new abscess on her arm that requires a 2-day hospital stay.

Was this readmission preventable?

Some attendees at the Pediatric Hospital Medicine 2012 meeting thought it was out of the hospital’s hands, while others suggested the hospital was at fault because clindamycin is such an unpalatable medication that an oral dose should have been given at the hospital, along with instructions for how to make it more palatable at home.

The scenario is part of the ongoing Vanderbilt Readmissions Project, which seeks to identify patient and hospitalization characteristics of 15-day readmissions in children, create a 5-point "preventability scale" for early pediatric readmissions that can be applied by multiple reviewers, and institute measures to decrease potentially preventable readmissions.

What the investigators have found so far is that, even after reviewing the same clinical information for 200 pediatric readmissions, a panel of four knowledgeable pediatricians gave exactly the same ratings in 37.5% of cases, Dr. James C. Gay said. There was 94% agreement on planned readmissions (47/50 cases), but only 19% agreement on unplanned readmissions (28/150).

"Further studies are needed to develop concrete rules for assessing preventability that can be applied reproducibly by multiple reviewers in multiple types of readmissions," he said.

The Vanderbilt findings have financial implications for hospitals, as the federal government has already taken to heart the issue of preventable readmissions following the sentinel article reporting that 19.6% of Medicare beneficiaries were readmitted within 30 days at a cost of $17.4 billion in 2004 (N. Engl. J. Med. 2009;360:1418-28). Many of these readmissions were thought to be avoidable by improvements in care and the discharge planning processes during the initial hospitalization.

The Affordable Care Act has also taken up the issue, and beginning Oct. 1, 2012, prospective payment system (PPS) hospitals will experience decreased Medicare payments for three index admissions – myocardial infarction, heart failure, and pneumonia – with "higher than expected" 30-day readmissions, coauthor Dr. Paul Hain explained at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The Centers for Medicare and Medicaid Services (CMS) will calculate hospitals’ actual readmissions, excluding planned readmissions and readmissions unrelated to the index admission, and then compare these to hospitals’ expected readmission rates. Hospitals with "higher than expected" rates will be required to pay back the payments they’ve received for readmissions deemed to be excessive.

Beginning in 2015, the CMS may expand the list of conditions to include chronic obstructive pulmonary disease and several cardiac and vascular surgical procedures, he said. Similar penalties are likely to befall children’s hospitals, as rules that start in Medicare trickle down to Medicaid in 3-5 years.

Part of the problem is that researchers have yet to identify what can reliably drive down adult or pediatric readmissions or even determine whether the readmission interval should be 3, 7, 15, 60, 90, 365, or 30 days, as the CMS uses.

"We looked at 30 days, and the noise that comes in is incredible," said Dr. Hain, now with Children’s Medical Center, Dallas. Ultimately, the researchers chose 15 days for their analyses because of the intuitively greater relationship to events in the index hospitalization.

Based on 4-year data from Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn., the 15-day readmission rate among non-newborns was 9.6% in 2007, 9.6% in 2008, 8.8% in 2009, and 8.9% in 2010; and among newborns, the rates were 2.5%, 3.2%, 2.5%, and 3.0%, respectively.

The first real global study of pediatric readmissions reported that 16.7% of patients between 2 and 18 years old at 38 U.S. children’s hospitals were readmitted within 365 days, and that readmissions were strongly associated with any complex chronic condition, female gender, older age, black race, public insurance coverage, longer length of stay during the initial admission, and number of previous admissions (Pediatrics 2009;123:286-93).

One year later, the same group reported that the likelihood of readmission among children aged 2-18 years actually increased as a states’ health system performance ranking improved (J. Pediatr. 2010;157:98-102.e1), observed Dr. Gay of the Children’s Hospital at Vanderbilt.

Similarly vexing results have been observed among adults. The Mayo Clinic in Rochester, Minn., recently reported that general medicine patients with a documented follow-up appointment were slightly more likely to have a hospital readmission, make an emergency department visit, or die within 180 days after discharge than those without an appointment (Arch. Intern. Med. 2010;170:955-60).

In the Vanderbilt cohort, the final expert consensus was that 40 early readmissions (20%) were more likely preventable (ratings 4 and 5). Nearly half of these were central venous catheter infections or ventriculo-peritoneal shunt malfunctions in children with serious chronic illnesses.

Extrapolating these results, about 1.7% of all hospital admissions would have a significant degree of preventability, Dr. Gay said. In absolute terms, about 250 admissions per year, or less than one admission per day, would be preventable at the Children’s Hospital at Vanderbilt.

"With 80% of readmissions planned or likely not preventable, it seems unreasonable to believe that pediatric readmissions are associated with substandard inpatient care, calling into question the validity of an all-cause readmission rate as a quality measure," he said. "If the responsibility for pediatric readmissions is placed on the hospital, then realistic benchmarks should be established."

Dr. Gay said more data is also needed from across the country, with some of that information trickling in from the recent Pediatric Academic Societies meeting. Various investigators reported that there was no relationship between length of stay and pediatric readmissions; 30-day readmission rates were low at 2%-8% in the top 10 APR-DRG (All Patient Refined Diagnosis Related Groups) hospitals; and significant variability exists in readmission rates across hospitals for 10 of the top 30 APR-DRG index admissions.

"This may be where we need to hone our efforts," Dr. Gay said. "If there’s variability, there may be a reason for that variability that we can have an impact on."

Dr. Gay reported funding support for medical consulting for the National Association of Children’s Hospitals and Related Institutions. Dr. Hain reported no conflicts of interest.

COVINGTON, KY. – Providers continue to rely on blood cultures to detect serious bacterial infections in children with bronchiolitis, even though urinary tract infections are the most common culprit, a chart review shows.

"Even though there is outstanding evidence in the literature that cultures are unnecessary in the vast majority of infants with clinical bronchiolitis, this practice is common, has a cost, and false-positive results can result in prolonged length of stay and exposure to antibiotics that is unnecessary," according to researcher Dr. Brian Alverson.

Dr. Alverson of Hasbro Children’s Hospital in Providence, R.I., said the chart review supports other studies that show that the rate of UTI positivity is approximately the same as reported rates of benign transient bacteriuria in infants. Indeed, the incidence of UTI in the analysis was only 2.9% among patients who underwent urine testing, and the rates of meningitis and bacteremia were zero.

The study comprised 652 children, aged 1-24 months, with a discharge diagnosis of bronchiolitis. Of those, 26% had a blood culture obtained and 18.4% had a urinalysis or urine culture. Of patients undergoing blood cultures, 55% also had a urinalysis or urine culture.

"People who are going to look for infections aren’t looking in the right place," the study’s lead author, Dr. Jamie Librizzi, said at Pediatric Hospital Medicine 2012.

The findings are noteworthy since children in the analysis were discharged during 2007-2008 – after the American Academy of Pediatrics bronchiolitis practice guidelines recommending that clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination.

The 2006 guidelines (Pediatrics 2006;118:1774-93) state that "the clinical utility of diagnostic testing in infants with suspected bronchiolitis is not well supported by evidence" and that "the occurrence of serious bacterial infections (SBIs) such as urinary tract infections (UTIs), sepsis, and meningitis is very low."

Despite the cohort being drawn from Hasbro Children’s Hospital and University of Missouri Children’s Hospital in Columbia, the misdirected testing could be explained by a knowledge gap and a wide variation in providers including residents, emergency department physicians, and referring community physicians, Dr. Librizzi said.

"Even though we know these guidelines are out there, the practices maybe still haven’t caught up to the evidence," she said. " ... It’s also hard when a kid comes in febrile, not looking great, to sit back and be assured that the numbers are really low for a concurrent infection."

"It’s a good reminder that we still have work to do educating our emergency departments," Dr. Paul Hain, now with Children’s Medical Center, Dallas, commented in a separate interview. "A lot of kids are seen in adult EDs, and folks who are not familiar with children are mostly scared of adult bacteremia and think that blood cultures are what they need, even though bronchiolitis is a special subset."

Children who were evaluated for an SBI received significantly more antibiotics and had significantly longer hospital stays, said Dr. Librizzi, formerly with Hasbro and now a hospitalist fellow at Children’s National Medical Center in Washington.

Length of stay (LOS) was 3.6 days for patients with blood cultures and 2.3 days for those without blood cultures, and 3.5 days for patients undergoing urine testing alone vs. 2.4 days for those without urine testing More than half (56.6%) of patients who underwent testing for an SBI received antibiotics, compared with 24% who did not.

Specifically, the percent of children receiving antibiotics was 17.5% among children with no urine testing (48/445); 48.6% for those with urine testing (51/105); 14% for those without blood cultures (58/411); and 51% for those with blood cultures (71/139), Dr. Librizzi said.

LOS for patients without an SBI who were on antibiotics was significantly longer than for patients off antibiotics (3.7 days vs. 2.5 days).

All of the children in the study were deemed to have bronchiolitis based on the note of the ED physician, or the ward’s physician for direct admissions. Their mean age was 5.6 months, 19% were premature infants, and 57% were male.

Patients were considered positive for a UTI if cultures grew more than 10,000 colony-forming U/mL of a single organism, or in the absence of culture results, if urinalysis was positive for leukocyte esterase and/or nitrites with evidence of pyuria (more than five white blood cells/high-power field).

Patients were considered bacteremic if blood cultures were positive for a pathogen not deemed a contaminant in more than one set, the authors reported in a poster at the meeting, sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The authors and Dr. Hain reported no conflicts of interest. Printing of the poster was funded by a Thrasher Research Fund Early Career Award.

COVINGTON, KY. – Providers continue to rely on blood cultures to detect serious bacterial infections in children with bronchiolitis, even though urinary tract infections are the most common culprit, a chart review shows.

"Even though there is outstanding evidence in the literature that cultures are unnecessary in the vast majority of infants with clinical bronchiolitis, this practice is common, has a cost, and false-positive results can result in prolonged length of stay and exposure to antibiotics that is unnecessary," according to researcher Dr. Brian Alverson.

Dr. Alverson of Hasbro Children’s Hospital in Providence, R.I., said the chart review supports other studies that show that the rate of UTI positivity is approximately the same as reported rates of benign transient bacteriuria in infants. Indeed, the incidence of UTI in the analysis was only 2.9% among patients who underwent urine testing, and the rates of meningitis and bacteremia were zero.

The study comprised 652 children, aged 1-24 months, with a discharge diagnosis of bronchiolitis. Of those, 26% had a blood culture obtained and 18.4% had a urinalysis or urine culture. Of patients undergoing blood cultures, 55% also had a urinalysis or urine culture.

"People who are going to look for infections aren’t looking in the right place," the study’s lead author, Dr. Jamie Librizzi, said at Pediatric Hospital Medicine 2012.

The findings are noteworthy since children in the analysis were discharged during 2007-2008 – after the American Academy of Pediatrics bronchiolitis practice guidelines recommending that clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination.

The 2006 guidelines (Pediatrics 2006;118:1774-93) state that "the clinical utility of diagnostic testing in infants with suspected bronchiolitis is not well supported by evidence" and that "the occurrence of serious bacterial infections (SBIs) such as urinary tract infections (UTIs), sepsis, and meningitis is very low."

Despite the cohort being drawn from Hasbro Children’s Hospital and University of Missouri Children’s Hospital in Columbia, the misdirected testing could be explained by a knowledge gap and a wide variation in providers including residents, emergency department physicians, and referring community physicians, Dr. Librizzi said.

"Even though we know these guidelines are out there, the practices maybe still haven’t caught up to the evidence," she said. " ... It’s also hard when a kid comes in febrile, not looking great, to sit back and be assured that the numbers are really low for a concurrent infection."

"It’s a good reminder that we still have work to do educating our emergency departments," Dr. Paul Hain, now with Children’s Medical Center, Dallas, commented in a separate interview. "A lot of kids are seen in adult EDs, and folks who are not familiar with children are mostly scared of adult bacteremia and think that blood cultures are what they need, even though bronchiolitis is a special subset."

Children who were evaluated for an SBI received significantly more antibiotics and had significantly longer hospital stays, said Dr. Librizzi, formerly with Hasbro and now a hospitalist fellow at Children’s National Medical Center in Washington.

Length of stay (LOS) was 3.6 days for patients with blood cultures and 2.3 days for those without blood cultures, and 3.5 days for patients undergoing urine testing alone vs. 2.4 days for those without urine testing More than half (56.6%) of patients who underwent testing for an SBI received antibiotics, compared with 24% who did not.

Specifically, the percent of children receiving antibiotics was 17.5% among children with no urine testing (48/445); 48.6% for those with urine testing (51/105); 14% for those without blood cultures (58/411); and 51% for those with blood cultures (71/139), Dr. Librizzi said.

LOS for patients without an SBI who were on antibiotics was significantly longer than for patients off antibiotics (3.7 days vs. 2.5 days).

All of the children in the study were deemed to have bronchiolitis based on the note of the ED physician, or the ward’s physician for direct admissions. Their mean age was 5.6 months, 19% were premature infants, and 57% were male.

Patients were considered positive for a UTI if cultures grew more than 10,000 colony-forming U/mL of a single organism, or in the absence of culture results, if urinalysis was positive for leukocyte esterase and/or nitrites with evidence of pyuria (more than five white blood cells/high-power field).

Patients were considered bacteremic if blood cultures were positive for a pathogen not deemed a contaminant in more than one set, the authors reported in a poster at the meeting, sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The authors and Dr. Hain reported no conflicts of interest. Printing of the poster was funded by a Thrasher Research Fund Early Career Award.

COVINGTON, KY. – Providers continue to rely on blood cultures to detect serious bacterial infections in children with bronchiolitis, even though urinary tract infections are the most common culprit, a chart review shows.

"Even though there is outstanding evidence in the literature that cultures are unnecessary in the vast majority of infants with clinical bronchiolitis, this practice is common, has a cost, and false-positive results can result in prolonged length of stay and exposure to antibiotics that is unnecessary," according to researcher Dr. Brian Alverson.

Dr. Alverson of Hasbro Children’s Hospital in Providence, R.I., said the chart review supports other studies that show that the rate of UTI positivity is approximately the same as reported rates of benign transient bacteriuria in infants. Indeed, the incidence of UTI in the analysis was only 2.9% among patients who underwent urine testing, and the rates of meningitis and bacteremia were zero.

The study comprised 652 children, aged 1-24 months, with a discharge diagnosis of bronchiolitis. Of those, 26% had a blood culture obtained and 18.4% had a urinalysis or urine culture. Of patients undergoing blood cultures, 55% also had a urinalysis or urine culture.

"People who are going to look for infections aren’t looking in the right place," the study’s lead author, Dr. Jamie Librizzi, said at Pediatric Hospital Medicine 2012.

The findings are noteworthy since children in the analysis were discharged during 2007-2008 – after the American Academy of Pediatrics bronchiolitis practice guidelines recommending that clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination.

The 2006 guidelines (Pediatrics 2006;118:1774-93) state that "the clinical utility of diagnostic testing in infants with suspected bronchiolitis is not well supported by evidence" and that "the occurrence of serious bacterial infections (SBIs) such as urinary tract infections (UTIs), sepsis, and meningitis is very low."

Despite the cohort being drawn from Hasbro Children’s Hospital and University of Missouri Children’s Hospital in Columbia, the misdirected testing could be explained by a knowledge gap and a wide variation in providers including residents, emergency department physicians, and referring community physicians, Dr. Librizzi said.

"Even though we know these guidelines are out there, the practices maybe still haven’t caught up to the evidence," she said. " ... It’s also hard when a kid comes in febrile, not looking great, to sit back and be assured that the numbers are really low for a concurrent infection."

"It’s a good reminder that we still have work to do educating our emergency departments," Dr. Paul Hain, now with Children’s Medical Center, Dallas, commented in a separate interview. "A lot of kids are seen in adult EDs, and folks who are not familiar with children are mostly scared of adult bacteremia and think that blood cultures are what they need, even though bronchiolitis is a special subset."

Children who were evaluated for an SBI received significantly more antibiotics and had significantly longer hospital stays, said Dr. Librizzi, formerly with Hasbro and now a hospitalist fellow at Children’s National Medical Center in Washington.

Length of stay (LOS) was 3.6 days for patients with blood cultures and 2.3 days for those without blood cultures, and 3.5 days for patients undergoing urine testing alone vs. 2.4 days for those without urine testing More than half (56.6%) of patients who underwent testing for an SBI received antibiotics, compared with 24% who did not.

Specifically, the percent of children receiving antibiotics was 17.5% among children with no urine testing (48/445); 48.6% for those with urine testing (51/105); 14% for those without blood cultures (58/411); and 51% for those with blood cultures (71/139), Dr. Librizzi said.

LOS for patients without an SBI who were on antibiotics was significantly longer than for patients off antibiotics (3.7 days vs. 2.5 days).

All of the children in the study were deemed to have bronchiolitis based on the note of the ED physician, or the ward’s physician for direct admissions. Their mean age was 5.6 months, 19% were premature infants, and 57% were male.

Patients were considered positive for a UTI if cultures grew more than 10,000 colony-forming U/mL of a single organism, or in the absence of culture results, if urinalysis was positive for leukocyte esterase and/or nitrites with evidence of pyuria (more than five white blood cells/high-power field).

Patients were considered bacteremic if blood cultures were positive for a pathogen not deemed a contaminant in more than one set, the authors reported in a poster at the meeting, sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The authors and Dr. Hain reported no conflicts of interest. Printing of the poster was funded by a Thrasher Research Fund Early Career Award.

COVINGTON, KY. – Basing an interpreter directly inside inpatient units shaved roughly 30 minutes off a nearly 1-hour delay in discharge times for patients from Spanish-speaking families at Childrens Hospital Los Angeles.

"We have a thousand discharges per month and 60%-70% require a translator, so it made a big difference," Dr. Ara Balkian, chief medical director of inpatient operations and associate chair of inpatient pediatrics, said at the Pediatric Hospital Medicine 2012 meeting.

Prior to the intervention, interpreters were centralized in a single office away from the units and were deployed as requests were submitted. In the fourth quarter of 2010, however, a Spanish-language interpreter was stationed on one of the medical-surgical floors for 4-6 hours per day during peak weekday discharge times to assist with discharge instructions.

Between the third quarters of 2009 and 2010, there was a statistically significant difference of 41 minutes in mean discharge times between English- and Spanish-speaking families, he said. The average time between the discharge order and the patient’s actually being discharged was 2 hours 25 minutes for English-speaking families and 3 hours 6 minutes for Spanish-speaking families.

During the intervention period, the difference decreased to 23 minutes in the fourth quarter of 2010 and to 27 minutes in the first quarter of 2011, and was no longer significant, he said.

As for why times lagged for Spanish-speaking families compared with English speakers, Dr. Balkian said the investigators hypothesize that many discharge components – such as instructions, or the interpretation of pharmacy directions – all require more time to convert to the parent’s or guardian’s primary language. The findings were based on the preferred language of the adults, even if the child spoke perfect English, Dr. Balkian explained.

He said it’s possible that interpreters were spending more time educating Spanish-speaking families, who according to previously published studies may have disparities in health literacy, compared with English speakers. In addition, the use of the unit-based interpreters during discharge and rounds identified more errors in the medication reconciliation and discharge instructions of Spanish-speaking patients. This may have been the result of miscommunication with non–Spanish-speaking providers while the components of the discharge were being prepared.

As fate would have it, funding for the project dried up and the interpreters were pulled off the units in the second quarter of 2011. Once again, the disparity in discharge times between Spanish speakers and English speakers increased significantly, this time to 48 minutes, Dr. Balkian said. The team also required more translators with increased hours on the units to meet the discharge demands in a consistent way.

Based on the results and longer response times resulting from the centralized interpreter office’s move to a location farther away from the inpatient units, funding has been restored and interpreters are again based in the units.

"Anecdotally, the nurses and interpreters do believe the discharge times have improved for Spanish-speaking patients," he said.

The investigators are currently collecting data on discharge times since the second quarter of 2011, and may expand the scope of their research to other non–English-speaking patients.

In a separate study presented at the meeting, interventions to improve awareness of, access to, and accountability for interpreter usage doubled the use of interpreters in a medical unit, compared with the rest of the hospital, to about three interpreter encounters per limited English-proficiency patient-day.

Interventions included staff education, inclusion of language needs in the emergency department admissions request, instructions in how to access face-to-face interpreter services, placement of interpreter phones in all rooms at all time, and providing for documentation of interpreter usage for attending notes.

Increased interpreter usage has been sustained, compared with other inpatient units, although multiple clinical encounters still occur without interpreters, reported Dr. Padmaja Pavuluri, a pediatric hospitalist at Children’s National Medical Center in Washington, D.C.

Dr. Balkian and Dr. Pavuluri reported having no relevant conflicts of interest.

COVINGTON, KY. – Basing an interpreter directly inside inpatient units shaved roughly 30 minutes off a nearly 1-hour delay in discharge times for patients from Spanish-speaking families at Childrens Hospital Los Angeles.

"We have a thousand discharges per month and 60%-70% require a translator, so it made a big difference," Dr. Ara Balkian, chief medical director of inpatient operations and associate chair of inpatient pediatrics, said at the Pediatric Hospital Medicine 2012 meeting.

Prior to the intervention, interpreters were centralized in a single office away from the units and were deployed as requests were submitted. In the fourth quarter of 2010, however, a Spanish-language interpreter was stationed on one of the medical-surgical floors for 4-6 hours per day during peak weekday discharge times to assist with discharge instructions.

Between the third quarters of 2009 and 2010, there was a statistically significant difference of 41 minutes in mean discharge times between English- and Spanish-speaking families, he said. The average time between the discharge order and the patient’s actually being discharged was 2 hours 25 minutes for English-speaking families and 3 hours 6 minutes for Spanish-speaking families.

During the intervention period, the difference decreased to 23 minutes in the fourth quarter of 2010 and to 27 minutes in the first quarter of 2011, and was no longer significant, he said.

As for why times lagged for Spanish-speaking families compared with English speakers, Dr. Balkian said the investigators hypothesize that many discharge components – such as instructions, or the interpretation of pharmacy directions – all require more time to convert to the parent’s or guardian’s primary language. The findings were based on the preferred language of the adults, even if the child spoke perfect English, Dr. Balkian explained.

He said it’s possible that interpreters were spending more time educating Spanish-speaking families, who according to previously published studies may have disparities in health literacy, compared with English speakers. In addition, the use of the unit-based interpreters during discharge and rounds identified more errors in the medication reconciliation and discharge instructions of Spanish-speaking patients. This may have been the result of miscommunication with non–Spanish-speaking providers while the components of the discharge were being prepared.

As fate would have it, funding for the project dried up and the interpreters were pulled off the units in the second quarter of 2011. Once again, the disparity in discharge times between Spanish speakers and English speakers increased significantly, this time to 48 minutes, Dr. Balkian said. The team also required more translators with increased hours on the units to meet the discharge demands in a consistent way.

Based on the results and longer response times resulting from the centralized interpreter office’s move to a location farther away from the inpatient units, funding has been restored and interpreters are again based in the units.

"Anecdotally, the nurses and interpreters do believe the discharge times have improved for Spanish-speaking patients," he said.

The investigators are currently collecting data on discharge times since the second quarter of 2011, and may expand the scope of their research to other non–English-speaking patients.

In a separate study presented at the meeting, interventions to improve awareness of, access to, and accountability for interpreter usage doubled the use of interpreters in a medical unit, compared with the rest of the hospital, to about three interpreter encounters per limited English-proficiency patient-day.

Interventions included staff education, inclusion of language needs in the emergency department admissions request, instructions in how to access face-to-face interpreter services, placement of interpreter phones in all rooms at all time, and providing for documentation of interpreter usage for attending notes.

Increased interpreter usage has been sustained, compared with other inpatient units, although multiple clinical encounters still occur without interpreters, reported Dr. Padmaja Pavuluri, a pediatric hospitalist at Children’s National Medical Center in Washington, D.C.

Dr. Balkian and Dr. Pavuluri reported having no relevant conflicts of interest.

COVINGTON, KY. – Basing an interpreter directly inside inpatient units shaved roughly 30 minutes off a nearly 1-hour delay in discharge times for patients from Spanish-speaking families at Childrens Hospital Los Angeles.

"We have a thousand discharges per month and 60%-70% require a translator, so it made a big difference," Dr. Ara Balkian, chief medical director of inpatient operations and associate chair of inpatient pediatrics, said at the Pediatric Hospital Medicine 2012 meeting.

Prior to the intervention, interpreters were centralized in a single office away from the units and were deployed as requests were submitted. In the fourth quarter of 2010, however, a Spanish-language interpreter was stationed on one of the medical-surgical floors for 4-6 hours per day during peak weekday discharge times to assist with discharge instructions.

Between the third quarters of 2009 and 2010, there was a statistically significant difference of 41 minutes in mean discharge times between English- and Spanish-speaking families, he said. The average time between the discharge order and the patient’s actually being discharged was 2 hours 25 minutes for English-speaking families and 3 hours 6 minutes for Spanish-speaking families.

During the intervention period, the difference decreased to 23 minutes in the fourth quarter of 2010 and to 27 minutes in the first quarter of 2011, and was no longer significant, he said.

As for why times lagged for Spanish-speaking families compared with English speakers, Dr. Balkian said the investigators hypothesize that many discharge components – such as instructions, or the interpretation of pharmacy directions – all require more time to convert to the parent’s or guardian’s primary language. The findings were based on the preferred language of the adults, even if the child spoke perfect English, Dr. Balkian explained.

He said it’s possible that interpreters were spending more time educating Spanish-speaking families, who according to previously published studies may have disparities in health literacy, compared with English speakers. In addition, the use of the unit-based interpreters during discharge and rounds identified more errors in the medication reconciliation and discharge instructions of Spanish-speaking patients. This may have been the result of miscommunication with non–Spanish-speaking providers while the components of the discharge were being prepared.

As fate would have it, funding for the project dried up and the interpreters were pulled off the units in the second quarter of 2011. Once again, the disparity in discharge times between Spanish speakers and English speakers increased significantly, this time to 48 minutes, Dr. Balkian said. The team also required more translators with increased hours on the units to meet the discharge demands in a consistent way.

Based on the results and longer response times resulting from the centralized interpreter office’s move to a location farther away from the inpatient units, funding has been restored and interpreters are again based in the units.

"Anecdotally, the nurses and interpreters do believe the discharge times have improved for Spanish-speaking patients," he said.

The investigators are currently collecting data on discharge times since the second quarter of 2011, and may expand the scope of their research to other non–English-speaking patients.

In a separate study presented at the meeting, interventions to improve awareness of, access to, and accountability for interpreter usage doubled the use of interpreters in a medical unit, compared with the rest of the hospital, to about three interpreter encounters per limited English-proficiency patient-day.

Interventions included staff education, inclusion of language needs in the emergency department admissions request, instructions in how to access face-to-face interpreter services, placement of interpreter phones in all rooms at all time, and providing for documentation of interpreter usage for attending notes.

Increased interpreter usage has been sustained, compared with other inpatient units, although multiple clinical encounters still occur without interpreters, reported Dr. Padmaja Pavuluri, a pediatric hospitalist at Children’s National Medical Center in Washington, D.C.

Dr. Balkian and Dr. Pavuluri reported having no relevant conflicts of interest.

Someone’s dropping the baton when it comes to pediatric discharge information, but just who that is appears to depend on what part of the relay team you’re on.

A full 85% of hospitalists said they reliably send discharge information and 79% said it contained all elements needed by the primary care physician.

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Only 72% of PCPs, however, said they got the information and only 65% felt it was complete.

"Perceptions of PCPs and hospitalists regarding the timeliness and content of discharge communication do differ significantly," Dr. JoAnna Leyenaar said at the recent Pediatric Hospital Medicine 2012.

Although the majority of the PCPs surveyed said they receive communication within 2 days of discharge, "the content may be suboptimal," she added.

Information about immunizations given during hospitalization proved particularly troublesome, with a "communication gap" of 47% existing between the 83% of PCPs who rated information about this clinical element as "essential" and the 36% who said they currently received it.

"We certainly know that avoidance of duplicate immunizations reduces unnecessary patient discomfort, costs, and adverse events, so the size of this gap was surprising and concerning," said Dr. Leyenaar, a pediatrician at Boston’s Tufts Medical Center. "When we asked hospitalists about what was essential, they agreed that immunizations were essential to report, which suggests that this gap is less related to differences in hospitalist and PCP perspectives and potentially more related to communication system issues."

Other clinical elements where the baton pass proved wonky were: pending lab or test results, with a gap of 30% (75% essential vs. 45% currently received), information on discharge medications, with a gap of 25% (96% vs. 72%), and suggested management plans, with a gap of about 22% (72% vs. 51%).

The survey was conducted by the Value in Inpatient Pediatrics (VIP) Network’s Transitions of Care Collaborative – part of the Quality Improvement Innovation Network of the American Academy of Pediatrics – among 201 PCPs and 71 pediatric hospitalist program directors. Most PCPs were pediatricians (91%), in private practice (63%), and practicing for more than 15 years (44%).

Dr. Leyenaar said the collaborative will be implementing and tracking a discharge communications bundle that contains essential elements to determine whether this can improve the timeliness and content of discharge communications.

It may do little, however, to change physician perceptions. A Kaiser Permanente physician in the audience said the perception in his practice was that docs weren’t receiving discharge faxes, but when they reconciled those complaints with network records they verified that 80% had actually received the fax.

Dr. Leyenaar reports no relevant conflicts of interest and a coauthor reports a medical education grant from Pfizer.

–Patrice Wendling (on Twitter @pwendl)

Someone’s dropping the baton when it comes to pediatric discharge information, but just who that is appears to depend on what part of the relay team you’re on.

A full 85% of hospitalists said they reliably send discharge information and 79% said it contained all elements needed by the primary care physician.

© william87 - Fotolia.com

Only 72% of PCPs, however, said they got the information and only 65% felt it was complete.

"Perceptions of PCPs and hospitalists regarding the timeliness and content of discharge communication do differ significantly," Dr. JoAnna Leyenaar said at the recent Pediatric Hospital Medicine 2012.

Although the majority of the PCPs surveyed said they receive communication within 2 days of discharge, "the content may be suboptimal," she added.

Information about immunizations given during hospitalization proved particularly troublesome, with a "communication gap" of 47% existing between the 83% of PCPs who rated information about this clinical element as "essential" and the 36% who said they currently received it.

"We certainly know that avoidance of duplicate immunizations reduces unnecessary patient discomfort, costs, and adverse events, so the size of this gap was surprising and concerning," said Dr. Leyenaar, a pediatrician at Boston’s Tufts Medical Center. "When we asked hospitalists about what was essential, they agreed that immunizations were essential to report, which suggests that this gap is less related to differences in hospitalist and PCP perspectives and potentially more related to communication system issues."

Other clinical elements where the baton pass proved wonky were: pending lab or test results, with a gap of 30% (75% essential vs. 45% currently received), information on discharge medications, with a gap of 25% (96% vs. 72%), and suggested management plans, with a gap of about 22% (72% vs. 51%).

The survey was conducted by the Value in Inpatient Pediatrics (VIP) Network’s Transitions of Care Collaborative – part of the Quality Improvement Innovation Network of the American Academy of Pediatrics – among 201 PCPs and 71 pediatric hospitalist program directors. Most PCPs were pediatricians (91%), in private practice (63%), and practicing for more than 15 years (44%).

Dr. Leyenaar said the collaborative will be implementing and tracking a discharge communications bundle that contains essential elements to determine whether this can improve the timeliness and content of discharge communications.

It may do little, however, to change physician perceptions. A Kaiser Permanente physician in the audience said the perception in his practice was that docs weren’t receiving discharge faxes, but when they reconciled those complaints with network records they verified that 80% had actually received the fax.

Dr. Leyenaar reports no relevant conflicts of interest and a coauthor reports a medical education grant from Pfizer.

–Patrice Wendling (on Twitter @pwendl)

Someone’s dropping the baton when it comes to pediatric discharge information, but just who that is appears to depend on what part of the relay team you’re on.

A full 85% of hospitalists said they reliably send discharge information and 79% said it contained all elements needed by the primary care physician.

© william87 - Fotolia.com

Only 72% of PCPs, however, said they got the information and only 65% felt it was complete.

"Perceptions of PCPs and hospitalists regarding the timeliness and content of discharge communication do differ significantly," Dr. JoAnna Leyenaar said at the recent Pediatric Hospital Medicine 2012.

Although the majority of the PCPs surveyed said they receive communication within 2 days of discharge, "the content may be suboptimal," she added.

Information about immunizations given during hospitalization proved particularly troublesome, with a "communication gap" of 47% existing between the 83% of PCPs who rated information about this clinical element as "essential" and the 36% who said they currently received it.

"We certainly know that avoidance of duplicate immunizations reduces unnecessary patient discomfort, costs, and adverse events, so the size of this gap was surprising and concerning," said Dr. Leyenaar, a pediatrician at Boston’s Tufts Medical Center. "When we asked hospitalists about what was essential, they agreed that immunizations were essential to report, which suggests that this gap is less related to differences in hospitalist and PCP perspectives and potentially more related to communication system issues."

Other clinical elements where the baton pass proved wonky were: pending lab or test results, with a gap of 30% (75% essential vs. 45% currently received), information on discharge medications, with a gap of 25% (96% vs. 72%), and suggested management plans, with a gap of about 22% (72% vs. 51%).

The survey was conducted by the Value in Inpatient Pediatrics (VIP) Network’s Transitions of Care Collaborative – part of the Quality Improvement Innovation Network of the American Academy of Pediatrics – among 201 PCPs and 71 pediatric hospitalist program directors. Most PCPs were pediatricians (91%), in private practice (63%), and practicing for more than 15 years (44%).

Dr. Leyenaar said the collaborative will be implementing and tracking a discharge communications bundle that contains essential elements to determine whether this can improve the timeliness and content of discharge communications.

It may do little, however, to change physician perceptions. A Kaiser Permanente physician in the audience said the perception in his practice was that docs weren’t receiving discharge faxes, but when they reconciled those complaints with network records they verified that 80% had actually received the fax.

Dr. Leyenaar reports no relevant conflicts of interest and a coauthor reports a medical education grant from Pfizer.

–Patrice Wendling (on Twitter @pwendl)

COVINGTON, KY. – A national pediatric nighttime curriculum is feasible and improves resident learning and confidence, data from a national field test have shown.

The Web- and case-based curriculum was created through a massive collaborative effort and fills a global need in the wake of the 2011 Accreditation Council for Graduate Medical Education resident work-hour restrictions. Those restrictions led to a substantial increase in nighttime rotations for interns and second- and third-year residents.

Despite this shift, only 30% of residency programs had a formal nighttime curriculum by November 2010.

Nighttime rotations bring a unique challenge of delivering resident education in "an environment where there isn’t the traditional morning report, noon conference, and postcall rounds," Dr. Rebecca Blankenburg said at Pediatric Hospital Medicine 2012.

Through a collaboration of the Academic Pediatric Association, American Academy of Pediatrics, Society of Hospital Medicine, and the Association of Pediatric Program Directors, educators nationally created 30 modules based on topics determined through a literature review, a needs assessment of residency program directors, and an expert consensus.

Each module contains one case geared toward interns and one case geared toward residents, a brief 15-minute PowerPoint presentation with and without voiceover, a 1- to 2-page topic summary, and five pre- and posttest questions, said Dr. Blankenburg, a hospitalist with Lucile Packard Children’s Hospital at Stanford (Calif.) University.

A preliminary pilot test was conducted at Stanford from February to June 2011, followed by the national field test of 10 modules from July to December 2011.

The top 10 topics, selected by informal focus groups of 124 program directors, were 60% medical and 40% communication. They covered shock, respiratory distress, fever, seizures, altered mental status, pain management, handoffs, triage on the wards, communication with patients and families, and autonomous decision making.

"The focus groups felt really strongly that at nighttime, we shouldn’t be teaching things that could be taught by a content expert during the day, but rather emphasizing those teachable moments at night," Dr. Blankenburg said.

In all, 89 pediatric and combined internal medicine–pediatric residency programs participated, representing 46% of all programs nationally and involving more than 2,000 learners. Prior to the study, 84% of participating programs had no nighttime curriculum.

Although program directors anticipated that the curriculum would be taught equally between self-study computer modules, resident-led modules, and faculty-led modules, in actuality, those percentages were 47%, 29%, and 20%, respectively, with the remaining 4% conducted via other means including Skype, she said.

During their nighttime rotation, 64% of residents completed at least six modules (average, 6.8).

"The curriculum was implemented in a variety of ways, which we felt was a potential limitation in that it was a more difficult study design, but it also makes it more practical in that we will be applying this broadly," Dr. Blankenburg said.

Residents responding to confidential online pre- and postcurriculum surveys believed that the curriculum significantly improved their nighttime learning (4.7 vs. 6.4 on a 10-point scale). Confidence also increased significantly for all 10 topics and all levels of learners, she said.

Among 493 respondents, pre- and postcurriculum knowledge scores increased significantly for first-year residents (6.11 vs. 7.24) and second-year residents (6.84 vs. 7.22), but not among those in their third year (7.16 vs. 7.31).

Though there were rich comments expressing a desire for residents or faculty to facilitate the sessions, an analysis of variance revealed no significant differences in attitudes, confidence, or knowledge across teaching methods, Dr. Blankenburg said.

Some residents described the curriculum as focused, quick, effective, and pertinent to night-shift concerns. Others suggested it could be improved by having higher levels of discussion for higher-level residents, using a facilitator, and adding more topics, questions, and cases to practice the knowledge learned in the sessions. The survey indicated that "77% of residents believed the modules were most geared towards interns," but that’s not necessarily a fatal flaw. " ‘[It’s] probably more helpful in terms of knowledge for earlier in residency. The formatting, however, helped with passing info along to my PGY1 counterpart,’ " Dr. Blankenburg quoted a third-year resident as saying.

Patrice Wendling/IMNG Medical Media

The collaborative is already at work improving the curriculum based on feedback and has funding to place version 2 of the curriculum on the interactive Web-based platform Moodle by Aug. 15, Dr. Blankenburg said. There are also plans to join forces in the coming year with educational and design students to make the curriculum more interactive.

"We’re really interested in the idea of a flipped classroom and how to have these be learning modules that residents can do on their own, perhaps, but really have applied learning activities that bring it to a higher level," she added.

Dr. Blankenburg reported having no relevant financial conflicts. The research was funded through an APPD grant and the 2012 APA Ray E. Helfer Award for Innovation in Medical Education

**This story was updated and a collaborator's name corrected on Aug. 3, 2012.

COVINGTON, KY. – A national pediatric nighttime curriculum is feasible and improves resident learning and confidence, data from a national field test have shown.

The Web- and case-based curriculum was created through a massive collaborative effort and fills a global need in the wake of the 2011 Accreditation Council for Graduate Medical Education resident work-hour restrictions. Those restrictions led to a substantial increase in nighttime rotations for interns and second- and third-year residents.

Despite this shift, only 30% of residency programs had a formal nighttime curriculum by November 2010.

Nighttime rotations bring a unique challenge of delivering resident education in "an environment where there isn’t the traditional morning report, noon conference, and postcall rounds," Dr. Rebecca Blankenburg said at Pediatric Hospital Medicine 2012.

Through a collaboration of the Academic Pediatric Association, American Academy of Pediatrics, Society of Hospital Medicine, and the Association of Pediatric Program Directors, educators nationally created 30 modules based on topics determined through a literature review, a needs assessment of residency program directors, and an expert consensus.

Each module contains one case geared toward interns and one case geared toward residents, a brief 15-minute PowerPoint presentation with and without voiceover, a 1- to 2-page topic summary, and five pre- and posttest questions, said Dr. Blankenburg, a hospitalist with Lucile Packard Children’s Hospital at Stanford (Calif.) University.

A preliminary pilot test was conducted at Stanford from February to June 2011, followed by the national field test of 10 modules from July to December 2011.

The top 10 topics, selected by informal focus groups of 124 program directors, were 60% medical and 40% communication. They covered shock, respiratory distress, fever, seizures, altered mental status, pain management, handoffs, triage on the wards, communication with patients and families, and autonomous decision making.

"The focus groups felt really strongly that at nighttime, we shouldn’t be teaching things that could be taught by a content expert during the day, but rather emphasizing those teachable moments at night," Dr. Blankenburg said.

In all, 89 pediatric and combined internal medicine–pediatric residency programs participated, representing 46% of all programs nationally and involving more than 2,000 learners. Prior to the study, 84% of participating programs had no nighttime curriculum.

Although program directors anticipated that the curriculum would be taught equally between self-study computer modules, resident-led modules, and faculty-led modules, in actuality, those percentages were 47%, 29%, and 20%, respectively, with the remaining 4% conducted via other means including Skype, she said.

During their nighttime rotation, 64% of residents completed at least six modules (average, 6.8).

"The curriculum was implemented in a variety of ways, which we felt was a potential limitation in that it was a more difficult study design, but it also makes it more practical in that we will be applying this broadly," Dr. Blankenburg said.

Residents responding to confidential online pre- and postcurriculum surveys believed that the curriculum significantly improved their nighttime learning (4.7 vs. 6.4 on a 10-point scale). Confidence also increased significantly for all 10 topics and all levels of learners, she said.

Among 493 respondents, pre- and postcurriculum knowledge scores increased significantly for first-year residents (6.11 vs. 7.24) and second-year residents (6.84 vs. 7.22), but not among those in their third year (7.16 vs. 7.31).

Though there were rich comments expressing a desire for residents or faculty to facilitate the sessions, an analysis of variance revealed no significant differences in attitudes, confidence, or knowledge across teaching methods, Dr. Blankenburg said.

Some residents described the curriculum as focused, quick, effective, and pertinent to night-shift concerns. Others suggested it could be improved by having higher levels of discussion for higher-level residents, using a facilitator, and adding more topics, questions, and cases to practice the knowledge learned in the sessions. The survey indicated that "77% of residents believed the modules were most geared towards interns," but that’s not necessarily a fatal flaw. " ‘[It’s] probably more helpful in terms of knowledge for earlier in residency. The formatting, however, helped with passing info along to my PGY1 counterpart,’ " Dr. Blankenburg quoted a third-year resident as saying.

Patrice Wendling/IMNG Medical Media

The collaborative is already at work improving the curriculum based on feedback and has funding to place version 2 of the curriculum on the interactive Web-based platform Moodle by Aug. 15, Dr. Blankenburg said. There are also plans to join forces in the coming year with educational and design students to make the curriculum more interactive.

"We’re really interested in the idea of a flipped classroom and how to have these be learning modules that residents can do on their own, perhaps, but really have applied learning activities that bring it to a higher level," she added.

Dr. Blankenburg reported having no relevant financial conflicts. The research was funded through an APPD grant and the 2012 APA Ray E. Helfer Award for Innovation in Medical Education

**This story was updated and a collaborator's name corrected on Aug. 3, 2012.

COVINGTON, KY. – A national pediatric nighttime curriculum is feasible and improves resident learning and confidence, data from a national field test have shown.

The Web- and case-based curriculum was created through a massive collaborative effort and fills a global need in the wake of the 2011 Accreditation Council for Graduate Medical Education resident work-hour restrictions. Those restrictions led to a substantial increase in nighttime rotations for interns and second- and third-year residents.

Despite this shift, only 30% of residency programs had a formal nighttime curriculum by November 2010.

Nighttime rotations bring a unique challenge of delivering resident education in "an environment where there isn’t the traditional morning report, noon conference, and postcall rounds," Dr. Rebecca Blankenburg said at Pediatric Hospital Medicine 2012.

Through a collaboration of the Academic Pediatric Association, American Academy of Pediatrics, Society of Hospital Medicine, and the Association of Pediatric Program Directors, educators nationally created 30 modules based on topics determined through a literature review, a needs assessment of residency program directors, and an expert consensus.

Each module contains one case geared toward interns and one case geared toward residents, a brief 15-minute PowerPoint presentation with and without voiceover, a 1- to 2-page topic summary, and five pre- and posttest questions, said Dr. Blankenburg, a hospitalist with Lucile Packard Children’s Hospital at Stanford (Calif.) University.

A preliminary pilot test was conducted at Stanford from February to June 2011, followed by the national field test of 10 modules from July to December 2011.

The top 10 topics, selected by informal focus groups of 124 program directors, were 60% medical and 40% communication. They covered shock, respiratory distress, fever, seizures, altered mental status, pain management, handoffs, triage on the wards, communication with patients and families, and autonomous decision making.

"The focus groups felt really strongly that at nighttime, we shouldn’t be teaching things that could be taught by a content expert during the day, but rather emphasizing those teachable moments at night," Dr. Blankenburg said.

In all, 89 pediatric and combined internal medicine–pediatric residency programs participated, representing 46% of all programs nationally and involving more than 2,000 learners. Prior to the study, 84% of participating programs had no nighttime curriculum.

Although program directors anticipated that the curriculum would be taught equally between self-study computer modules, resident-led modules, and faculty-led modules, in actuality, those percentages were 47%, 29%, and 20%, respectively, with the remaining 4% conducted via other means including Skype, she said.

During their nighttime rotation, 64% of residents completed at least six modules (average, 6.8).

"The curriculum was implemented in a variety of ways, which we felt was a potential limitation in that it was a more difficult study design, but it also makes it more practical in that we will be applying this broadly," Dr. Blankenburg said.

Residents responding to confidential online pre- and postcurriculum surveys believed that the curriculum significantly improved their nighttime learning (4.7 vs. 6.4 on a 10-point scale). Confidence also increased significantly for all 10 topics and all levels of learners, she said.

Among 493 respondents, pre- and postcurriculum knowledge scores increased significantly for first-year residents (6.11 vs. 7.24) and second-year residents (6.84 vs. 7.22), but not among those in their third year (7.16 vs. 7.31).

Though there were rich comments expressing a desire for residents or faculty to facilitate the sessions, an analysis of variance revealed no significant differences in attitudes, confidence, or knowledge across teaching methods, Dr. Blankenburg said.

Some residents described the curriculum as focused, quick, effective, and pertinent to night-shift concerns. Others suggested it could be improved by having higher levels of discussion for higher-level residents, using a facilitator, and adding more topics, questions, and cases to practice the knowledge learned in the sessions. The survey indicated that "77% of residents believed the modules were most geared towards interns," but that’s not necessarily a fatal flaw. " ‘[It’s] probably more helpful in terms of knowledge for earlier in residency. The formatting, however, helped with passing info along to my PGY1 counterpart,’ " Dr. Blankenburg quoted a third-year resident as saying.

Patrice Wendling/IMNG Medical Media

The collaborative is already at work improving the curriculum based on feedback and has funding to place version 2 of the curriculum on the interactive Web-based platform Moodle by Aug. 15, Dr. Blankenburg said. There are also plans to join forces in the coming year with educational and design students to make the curriculum more interactive.

"We’re really interested in the idea of a flipped classroom and how to have these be learning modules that residents can do on their own, perhaps, but really have applied learning activities that bring it to a higher level," she added.

Dr. Blankenburg reported having no relevant financial conflicts. The research was funded through an APPD grant and the 2012 APA Ray E. Helfer Award for Innovation in Medical Education

**This story was updated and a collaborator's name corrected on Aug. 3, 2012.

COVINGTON, KY. – A multifaceted intervention propelled probiotic prescriptions within 18 hours of admission from 1% to 100% among children admitted for acute gastroenteritis with diarrhea.

This was true regardless of their insurance status.

Moreover, the 100% prescribing rate was achieved within 6 weeks and has been sustained for 7 months, lead author Dr. Michelle Parker reported at Pediatric Hospital Medicine 2012.

Patrice Wendling/IMNG Medical Media

"It’s definitely become culture," she said during the poster presentation.

A multidisciplinary team of hospital medicine attending physicians, nurse representative, and a research assistant at Cincinnati Children’s Hospital identified six key drivers they felt would increase inpatient prescribing of Lactobacillus rhamnosus GG (LGG) at admission. They were identification of eligible patients; adequate staff knowledge; prescriber buy-in; available and appropriate administration of LGG; immediate response to failure of prescribing; and process standardization.

One of the biggest game changers was to incorporate LGG as a default order within the acute gastroenteritis electronic order set, with the appropriate dose and frequency preselected, Dr. Parker said. The default order did not just happen, without the physician being aware, as prescribing physicians still had to click, enter LGG, and save the indication for its use.

The second key element was monitoring the electronic medical records each weekday for children with acute gastroenteritis, aged 2 months to 18 years, who were not prescribed LGG, and e-mailing their care team.

"We engaged them in a dialogue, not told them they had to [prescribe]," said Dr. Parker, with Cincinnati Children’s division of hospital medicine. "That gave them a chance to prescribe it if that was their intention and it was just forgotten, and it was also a good chance to further the education."

Education included reviewing the evidence on LGG and appropriate prescribing with hospital medicine attending physicians, residents and medical students, brief monthly reminders to residents and a campaign to private pediatricians with admitting privileges that included electronic information and signage in key areas of the hospital.

Before the intervention, however, the hospital had published its own evidence-based guideline in 2007, recommending consideration of probiotics. A Cochrane review of 63 studies in 8,014 infants and young children had also been published, showing that probiotics were safe and had a clear benefit in reducing the duration of diarrhea, although the size of the effect varied between studies (Cochrane Database Syst. Rev. 2010 [doi:10.1002/14651858.CD003048.pub3]).

So why then did the hospital have a 1% preintervention prescribing rate?

Dr. Parker admits the 1% rate is "far less than ideal" but said other hospitals are likely in the same predicament because it’s very hard for people to put evidence and guidelines into practice.

"I think this is all around the country," she said. "There’s evidence that it takes 17 years of solid evidence to change practice, for it to become the expert recommendation."

The intervention also removed a logistic barrier, with the help of its pharmacy, which began supplying the community hospital inpatient unit with LGG, specifically adult Culturelle because it has the most evidence behind it, she said.

The labor-intensive identification and mitigation process was discontinued after the system stabilized and the focus of the initiative shifted more towards shared decision-making with families.

"Instead of saying you have to do this in all kids, we tell them it’s something they have to pay for out of pocket and that it’s a modest benefit of 24 hours of less stool," Dr. Parker said. "So, is that something you’re interested in doing?"

A separate analysis found that there was no difference in prescription fill rates based on insurance status. One explanation for this is that the pharmacy will dispense only the number of capsules prescribed, rather than having families pay for the entire bottle, which can cost between $17 and $30, she said.

The chart review excluded children with known or presumed bacterial gastroenteritis, major comorbid conditions, and former premature infants not yet 2 months corrected gestational age. Specific demographics on the cohort were not provided.

The authors acknowledged that the James M. Anderson Center for Health Systems Excellence in Cincinnati collaborated in the project.

COVINGTON, KY. – A multifaceted intervention propelled probiotic prescriptions within 18 hours of admission from 1% to 100% among children admitted for acute gastroenteritis with diarrhea.

This was true regardless of their insurance status.

Moreover, the 100% prescribing rate was achieved within 6 weeks and has been sustained for 7 months, lead author Dr. Michelle Parker reported at Pediatric Hospital Medicine 2012.

Patrice Wendling/IMNG Medical Media

"It’s definitely become culture," she said during the poster presentation.

A multidisciplinary team of hospital medicine attending physicians, nurse representative, and a research assistant at Cincinnati Children’s Hospital identified six key drivers they felt would increase inpatient prescribing of Lactobacillus rhamnosus GG (LGG) at admission. They were identification of eligible patients; adequate staff knowledge; prescriber buy-in; available and appropriate administration of LGG; immediate response to failure of prescribing; and process standardization.

One of the biggest game changers was to incorporate LGG as a default order within the acute gastroenteritis electronic order set, with the appropriate dose and frequency preselected, Dr. Parker said. The default order did not just happen, without the physician being aware, as prescribing physicians still had to click, enter LGG, and save the indication for its use.

The second key element was monitoring the electronic medical records each weekday for children with acute gastroenteritis, aged 2 months to 18 years, who were not prescribed LGG, and e-mailing their care team.

"We engaged them in a dialogue, not told them they had to [prescribe]," said Dr. Parker, with Cincinnati Children’s division of hospital medicine. "That gave them a chance to prescribe it if that was their intention and it was just forgotten, and it was also a good chance to further the education."

Education included reviewing the evidence on LGG and appropriate prescribing with hospital medicine attending physicians, residents and medical students, brief monthly reminders to residents and a campaign to private pediatricians with admitting privileges that included electronic information and signage in key areas of the hospital.

Before the intervention, however, the hospital had published its own evidence-based guideline in 2007, recommending consideration of probiotics. A Cochrane review of 63 studies in 8,014 infants and young children had also been published, showing that probiotics were safe and had a clear benefit in reducing the duration of diarrhea, although the size of the effect varied between studies (Cochrane Database Syst. Rev. 2010 [doi:10.1002/14651858.CD003048.pub3]).

So why then did the hospital have a 1% preintervention prescribing rate?

Dr. Parker admits the 1% rate is "far less than ideal" but said other hospitals are likely in the same predicament because it’s very hard for people to put evidence and guidelines into practice.

"I think this is all around the country," she said. "There’s evidence that it takes 17 years of solid evidence to change practice, for it to become the expert recommendation."

The intervention also removed a logistic barrier, with the help of its pharmacy, which began supplying the community hospital inpatient unit with LGG, specifically adult Culturelle because it has the most evidence behind it, she said.

The labor-intensive identification and mitigation process was discontinued after the system stabilized and the focus of the initiative shifted more towards shared decision-making with families.

"Instead of saying you have to do this in all kids, we tell them it’s something they have to pay for out of pocket and that it’s a modest benefit of 24 hours of less stool," Dr. Parker said. "So, is that something you’re interested in doing?"

A separate analysis found that there was no difference in prescription fill rates based on insurance status. One explanation for this is that the pharmacy will dispense only the number of capsules prescribed, rather than having families pay for the entire bottle, which can cost between $17 and $30, she said.

The chart review excluded children with known or presumed bacterial gastroenteritis, major comorbid conditions, and former premature infants not yet 2 months corrected gestational age. Specific demographics on the cohort were not provided.

The authors acknowledged that the James M. Anderson Center for Health Systems Excellence in Cincinnati collaborated in the project.

COVINGTON, KY. – A multifaceted intervention propelled probiotic prescriptions within 18 hours of admission from 1% to 100% among children admitted for acute gastroenteritis with diarrhea.

This was true regardless of their insurance status.

Moreover, the 100% prescribing rate was achieved within 6 weeks and has been sustained for 7 months, lead author Dr. Michelle Parker reported at Pediatric Hospital Medicine 2012.

Patrice Wendling/IMNG Medical Media

"It’s definitely become culture," she said during the poster presentation.

A multidisciplinary team of hospital medicine attending physicians, nurse representative, and a research assistant at Cincinnati Children’s Hospital identified six key drivers they felt would increase inpatient prescribing of Lactobacillus rhamnosus GG (LGG) at admission. They were identification of eligible patients; adequate staff knowledge; prescriber buy-in; available and appropriate administration of LGG; immediate response to failure of prescribing; and process standardization.

One of the biggest game changers was to incorporate LGG as a default order within the acute gastroenteritis electronic order set, with the appropriate dose and frequency preselected, Dr. Parker said. The default order did not just happen, without the physician being aware, as prescribing physicians still had to click, enter LGG, and save the indication for its use.

The second key element was monitoring the electronic medical records each weekday for children with acute gastroenteritis, aged 2 months to 18 years, who were not prescribed LGG, and e-mailing their care team.

"We engaged them in a dialogue, not told them they had to [prescribe]," said Dr. Parker, with Cincinnati Children’s division of hospital medicine. "That gave them a chance to prescribe it if that was their intention and it was just forgotten, and it was also a good chance to further the education."

Education included reviewing the evidence on LGG and appropriate prescribing with hospital medicine attending physicians, residents and medical students, brief monthly reminders to residents and a campaign to private pediatricians with admitting privileges that included electronic information and signage in key areas of the hospital.

Before the intervention, however, the hospital had published its own evidence-based guideline in 2007, recommending consideration of probiotics. A Cochrane review of 63 studies in 8,014 infants and young children had also been published, showing that probiotics were safe and had a clear benefit in reducing the duration of diarrhea, although the size of the effect varied between studies (Cochrane Database Syst. Rev. 2010 [doi:10.1002/14651858.CD003048.pub3]).

So why then did the hospital have a 1% preintervention prescribing rate?

Dr. Parker admits the 1% rate is "far less than ideal" but said other hospitals are likely in the same predicament because it’s very hard for people to put evidence and guidelines into practice.

"I think this is all around the country," she said. "There’s evidence that it takes 17 years of solid evidence to change practice, for it to become the expert recommendation."

The intervention also removed a logistic barrier, with the help of its pharmacy, which began supplying the community hospital inpatient unit with LGG, specifically adult Culturelle because it has the most evidence behind it, she said.

The labor-intensive identification and mitigation process was discontinued after the system stabilized and the focus of the initiative shifted more towards shared decision-making with families.

"Instead of saying you have to do this in all kids, we tell them it’s something they have to pay for out of pocket and that it’s a modest benefit of 24 hours of less stool," Dr. Parker said. "So, is that something you’re interested in doing?"

A separate analysis found that there was no difference in prescription fill rates based on insurance status. One explanation for this is that the pharmacy will dispense only the number of capsules prescribed, rather than having families pay for the entire bottle, which can cost between $17 and $30, she said.

The chart review excluded children with known or presumed bacterial gastroenteritis, major comorbid conditions, and former premature infants not yet 2 months corrected gestational age. Specific demographics on the cohort were not provided.

The authors acknowledged that the James M. Anderson Center for Health Systems Excellence in Cincinnati collaborated in the project.

COVINGTON, KY. – Evaluation and management of apparent life-threatening events should start with a clear, concise definition and an understanding of the risk for a serious underlying disorder, but so far this has proved elusive.

Despite a deluge of testing, nearly 50% of children leave the hospital with a diagnosis of idiopathic or gastroesophageal reflux, Dr. Joel Tieder said at the Pediatric Hospital Medicine 2012 meeting.

Patrice Wendling/IMNG Medical Media

National efforts by an expert panel of hospitalist researchers and policy makers are underway to standardize inpatient care for an apparent life-threatening event (ALTE), a condition that evokes high anxiety in parents and providers alike and is defined by a loose constellation of symptoms.

The rallying cry for many pediatric hospitalists proved to be the largest multicenter study of ALTE to date (J. Pediatr. 2008;152:629-35). This study identified the frequent use of nonindicated testing – including pH probes, chest x-rays, and EKGs – and inconsistent hospital outcomes among infants admitted with ALTE.

"People really coalesced around this idea that hospitalists should own this disorder and fix it," explained Dr. Tieder, who led the study and sits on the expert panel. "There was just too much variability around the diagnosis and management, and we felt that this might be the first disorder we could tackle with guidelines."

The panel, sponsored by the Society for Hospital Medicine, has summarized and submitted for publication the sparse science there is on ALTE in hopes of soliciting comment and consensus.

Redefinition in Action

The panel also took the ambitious and somewhat unorthodox step of holding workshops at the Pediatric Hospital Medicine 2012 meeting for attendees to pen their own definition of ALTE. The discourse was dynamic and at times deafening, and despite the agreed upon goal among an audience of pediatric hospitalists, consensus on the content was conspicuously absent, which speaks to the difficulty of the task. Common themes did emerge and will be folded into the ongoing dialogue, said Dr. Tieder of Seattle Children’s Hospital.

Currently, clinicians diagnose ALTE using the National Institutes of Health’s definition that was put forth in 1986: an episode in the first year of life that appears potentially life threatening to the observer and is characterized by some combination of color change, apnea, alteration in muscle tone, and choking or gagging.

The crux of the problem is that this definition does not distinguish ALTE as a constellation of symptoms vs. ALTE as a diagnosis, he said. The term is loosely applied when testing proves to be unfruitful, or it is kept as the diagnosis despite an identification of the underlying cause of the event.

The new definition should also make very clear that – despite previous misnomers such as "near-miss SIDS" or "aborted crib deaths" –an ALTE is very different from SIDS, Dr. Tieder said. The two conditions have different risk factors, and interventions to reduce SIDS (such as the "Back to Sleep" campaign) have not reduced ALTEs.

The broad subjective definition of ALTE, the low prevalence of underlying disease, and the anxiety induced by ALTE combine to make "a recipe for testing cascade," Dr. Tieder said. "These are beautiful, healthy-appearing infants, and yet we do all these potentially harmful things to them with little evidence that the results will improve their outcomes."

Patrice Wendling/IMNG Medical News

Importantly, the yield for routine diagnostic testing for ALTE is low. In one study of 243 consecutive infants who experienced an ALTE, only 17.7% of 3,776 tests ordered were positive; even worse, just 6% contributed to the diagnosis (Pediatrics 2005;115:885-93).

Common discharge diagnoses for ALTE – such as idiopathic gastroesophageal reflux, respiratory infections (8%-11%), and seizures (9-11%) – are largely self-limiting and nonrecurring. It’s with the less common causes that clinicians start seeing the problem with managing an ALTE, Dr. Tieder said. These include pertussis (0.05%-9%), cardiac arrhythmias (fewer than 1%), bacterial infection (0%-8%), metabolic disorder (1.5%), and – increasingly and especially in infants with recurrent ALTE – child maltreatment (fewer than 1%).

"You need to have a high index of suspicion for child maltreatment," he said. A recent study involving 563 children, average age 2.3 months, who presented to the emergency department following an ALTE found a mortality rate of 9% in victims of child abuse (Pediatr. Emerg. Care 2011;27:591-5).

An Unfunded Conundrum

Despite the potential risk for serious underlying conditions and death, research funding has been lacking. Again, the problem lies with ALTE’s being defined as a constellation of symptoms, not as a disease (which is how government typically allocates research dollars), Dr. Tieder explained.

"We’re really stuck without a research source," he said. In the conventional mechanism, government funders "might fund child maltreatment, but [ALTE represents] only a minority of these patients. So when they start to rank priorities in this current austere environment, ALTEs don’t have a lot of cachet."

Grasping the Risks

A better understanding of life-threatening risk in infants with an ALTE, however, could revolutionize the work-up of these infants, just as greater understanding of the risk of myocardial infarction has revolutionized the way adult hospitalists stage the evaluation and management of adults presenting with chest pain.

Based on the current evidence, the panel has concluded that certain features can be used to assess risk and guide diagnostic testing. Factors that may define lower-risk infants are age older than 2 months; a first ALTE; a previously healthy status on no medications; no social concerns; no family history of SIDS or ALTE; and an obstructive event (such as choking, gagging, breath holding, or having a vasovagal episode) that was secondary to emesis, coughing, or crying, Dr. Tieder said. Although this is not set in stone, the panel suggests that routine screening is not indicated in low-risk infants, he added.

Key elements for higher-risk infants are age younger than 2 months, especially with upper respiratory symptoms or exposure; more than one ALTE; a history of prematurity, central apnea, comorbid conditions, or medication use; pertussis exposure/risk; social concerns; family history of SIDS; or unexplained death with physical findings of bruising or bleeding, particularly in the mouth.

Groups that are most likely to benefit from hospital admission include high-risk infants, infants younger than 37 weeks post-conceptual age, those younger than 2 months of age in whom pertussis and respiratory syncytial virus testing is pending, or cases where maltreatment is a concern, he said.

A Gap Filled

No definite timeline has been established for the panel to complete its task, but hospitalists are uniquely qualified to define ALTE and to establish a national standard for inpatient care for ALTEs, according to panel member and pediatric hospitalist Dr. Jack Percelay, who holds the newly created pediatrics seat on the SHM board of directors.

Patrice Wendling/IMNG Medical Media

"It’s very multidisciplinary, so everybody looks at it from their own scope," he said in an interview. "The GI people look at it and say it’s got to be reflux; the neurology people say it looks like it’s going to be seizures. Or it could be trauma. We have that global view, so that’s why we’re the best people for it.

"I’m not sure that we want to be the experts, but no one else has really looked at it, so it was an opportunity for us. It was an orphan disease."

Dr. Tieder reported a relationship with Child Hospital Association, which provides grant support to the Pediatric Research in Inpatient Settings Network. Dr. Percelay reported no conflicts of interest.

COVINGTON, KY. – Evaluation and management of apparent life-threatening events should start with a clear, concise definition and an understanding of the risk for a serious underlying disorder, but so far this has proved elusive.

Despite a deluge of testing, nearly 50% of children leave the hospital with a diagnosis of idiopathic or gastroesophageal reflux, Dr. Joel Tieder said at the Pediatric Hospital Medicine 2012 meeting.

Patrice Wendling/IMNG Medical Media

National efforts by an expert panel of hospitalist researchers and policy makers are underway to standardize inpatient care for an apparent life-threatening event (ALTE), a condition that evokes high anxiety in parents and providers alike and is defined by a loose constellation of symptoms.

The rallying cry for many pediatric hospitalists proved to be the largest multicenter study of ALTE to date (J. Pediatr. 2008;152:629-35). This study identified the frequent use of nonindicated testing – including pH probes, chest x-rays, and EKGs – and inconsistent hospital outcomes among infants admitted with ALTE.

"People really coalesced around this idea that hospitalists should own this disorder and fix it," explained Dr. Tieder, who led the study and sits on the expert panel. "There was just too much variability around the diagnosis and management, and we felt that this might be the first disorder we could tackle with guidelines."

The panel, sponsored by the Society for Hospital Medicine, has summarized and submitted for publication the sparse science there is on ALTE in hopes of soliciting comment and consensus.

Redefinition in Action

The panel also took the ambitious and somewhat unorthodox step of holding workshops at the Pediatric Hospital Medicine 2012 meeting for attendees to pen their own definition of ALTE. The discourse was dynamic and at times deafening, and despite the agreed upon goal among an audience of pediatric hospitalists, consensus on the content was conspicuously absent, which speaks to the difficulty of the task. Common themes did emerge and will be folded into the ongoing dialogue, said Dr. Tieder of Seattle Children’s Hospital.

Currently, clinicians diagnose ALTE using the National Institutes of Health’s definition that was put forth in 1986: an episode in the first year of life that appears potentially life threatening to the observer and is characterized by some combination of color change, apnea, alteration in muscle tone, and choking or gagging.

The crux of the problem is that this definition does not distinguish ALTE as a constellation of symptoms vs. ALTE as a diagnosis, he said. The term is loosely applied when testing proves to be unfruitful, or it is kept as the diagnosis despite an identification of the underlying cause of the event.

The new definition should also make very clear that – despite previous misnomers such as "near-miss SIDS" or "aborted crib deaths" –an ALTE is very different from SIDS, Dr. Tieder said. The two conditions have different risk factors, and interventions to reduce SIDS (such as the "Back to Sleep" campaign) have not reduced ALTEs.

The broad subjective definition of ALTE, the low prevalence of underlying disease, and the anxiety induced by ALTE combine to make "a recipe for testing cascade," Dr. Tieder said. "These are beautiful, healthy-appearing infants, and yet we do all these potentially harmful things to them with little evidence that the results will improve their outcomes."

Patrice Wendling/IMNG Medical News

Importantly, the yield for routine diagnostic testing for ALTE is low. In one study of 243 consecutive infants who experienced an ALTE, only 17.7% of 3,776 tests ordered were positive; even worse, just 6% contributed to the diagnosis (Pediatrics 2005;115:885-93).

Common discharge diagnoses for ALTE – such as idiopathic gastroesophageal reflux, respiratory infections (8%-11%), and seizures (9-11%) – are largely self-limiting and nonrecurring. It’s with the less common causes that clinicians start seeing the problem with managing an ALTE, Dr. Tieder said. These include pertussis (0.05%-9%), cardiac arrhythmias (fewer than 1%), bacterial infection (0%-8%), metabolic disorder (1.5%), and – increasingly and especially in infants with recurrent ALTE – child maltreatment (fewer than 1%).

"You need to have a high index of suspicion for child maltreatment," he said. A recent study involving 563 children, average age 2.3 months, who presented to the emergency department following an ALTE found a mortality rate of 9% in victims of child abuse (Pediatr. Emerg. Care 2011;27:591-5).

An Unfunded Conundrum

Despite the potential risk for serious underlying conditions and death, research funding has been lacking. Again, the problem lies with ALTE’s being defined as a constellation of symptoms, not as a disease (which is how government typically allocates research dollars), Dr. Tieder explained.

"We’re really stuck without a research source," he said. In the conventional mechanism, government funders "might fund child maltreatment, but [ALTE represents] only a minority of these patients. So when they start to rank priorities in this current austere environment, ALTEs don’t have a lot of cachet."

Grasping the Risks

A better understanding of life-threatening risk in infants with an ALTE, however, could revolutionize the work-up of these infants, just as greater understanding of the risk of myocardial infarction has revolutionized the way adult hospitalists stage the evaluation and management of adults presenting with chest pain.

Based on the current evidence, the panel has concluded that certain features can be used to assess risk and guide diagnostic testing. Factors that may define lower-risk infants are age older than 2 months; a first ALTE; a previously healthy status on no medications; no social concerns; no family history of SIDS or ALTE; and an obstructive event (such as choking, gagging, breath holding, or having a vasovagal episode) that was secondary to emesis, coughing, or crying, Dr. Tieder said. Although this is not set in stone, the panel suggests that routine screening is not indicated in low-risk infants, he added.

Key elements for higher-risk infants are age younger than 2 months, especially with upper respiratory symptoms or exposure; more than one ALTE; a history of prematurity, central apnea, comorbid conditions, or medication use; pertussis exposure/risk; social concerns; family history of SIDS; or unexplained death with physical findings of bruising or bleeding, particularly in the mouth.

Groups that are most likely to benefit from hospital admission include high-risk infants, infants younger than 37 weeks post-conceptual age, those younger than 2 months of age in whom pertussis and respiratory syncytial virus testing is pending, or cases where maltreatment is a concern, he said.

A Gap Filled

No definite timeline has been established for the panel to complete its task, but hospitalists are uniquely qualified to define ALTE and to establish a national standard for inpatient care for ALTEs, according to panel member and pediatric hospitalist Dr. Jack Percelay, who holds the newly created pediatrics seat on the SHM board of directors.

Patrice Wendling/IMNG Medical Media

"It’s very multidisciplinary, so everybody looks at it from their own scope," he said in an interview. "The GI people look at it and say it’s got to be reflux; the neurology people say it looks like it’s going to be seizures. Or it could be trauma. We have that global view, so that’s why we’re the best people for it.

"I’m not sure that we want to be the experts, but no one else has really looked at it, so it was an opportunity for us. It was an orphan disease."

Dr. Tieder reported a relationship with Child Hospital Association, which provides grant support to the Pediatric Research in Inpatient Settings Network. Dr. Percelay reported no conflicts of interest.

COVINGTON, KY. – Evaluation and management of apparent life-threatening events should start with a clear, concise definition and an understanding of the risk for a serious underlying disorder, but so far this has proved elusive.

Despite a deluge of testing, nearly 50% of children leave the hospital with a diagnosis of idiopathic or gastroesophageal reflux, Dr. Joel Tieder said at the Pediatric Hospital Medicine 2012 meeting.

Patrice Wendling/IMNG Medical Media

National efforts by an expert panel of hospitalist researchers and policy makers are underway to standardize inpatient care for an apparent life-threatening event (ALTE), a condition that evokes high anxiety in parents and providers alike and is defined by a loose constellation of symptoms.

The rallying cry for many pediatric hospitalists proved to be the largest multicenter study of ALTE to date (J. Pediatr. 2008;152:629-35). This study identified the frequent use of nonindicated testing – including pH probes, chest x-rays, and EKGs – and inconsistent hospital outcomes among infants admitted with ALTE.

"People really coalesced around this idea that hospitalists should own this disorder and fix it," explained Dr. Tieder, who led the study and sits on the expert panel. "There was just too much variability around the diagnosis and management, and we felt that this might be the first disorder we could tackle with guidelines."

The panel, sponsored by the Society for Hospital Medicine, has summarized and submitted for publication the sparse science there is on ALTE in hopes of soliciting comment and consensus.

Redefinition in Action

The panel also took the ambitious and somewhat unorthodox step of holding workshops at the Pediatric Hospital Medicine 2012 meeting for attendees to pen their own definition of ALTE. The discourse was dynamic and at times deafening, and despite the agreed upon goal among an audience of pediatric hospitalists, consensus on the content was conspicuously absent, which speaks to the difficulty of the task. Common themes did emerge and will be folded into the ongoing dialogue, said Dr. Tieder of Seattle Children’s Hospital.

Currently, clinicians diagnose ALTE using the National Institutes of Health’s definition that was put forth in 1986: an episode in the first year of life that appears potentially life threatening to the observer and is characterized by some combination of color change, apnea, alteration in muscle tone, and choking or gagging.

The crux of the problem is that this definition does not distinguish ALTE as a constellation of symptoms vs. ALTE as a diagnosis, he said. The term is loosely applied when testing proves to be unfruitful, or it is kept as the diagnosis despite an identification of the underlying cause of the event.

The new definition should also make very clear that – despite previous misnomers such as "near-miss SIDS" or "aborted crib deaths" –an ALTE is very different from SIDS, Dr. Tieder said. The two conditions have different risk factors, and interventions to reduce SIDS (such as the "Back to Sleep" campaign) have not reduced ALTEs.

The broad subjective definition of ALTE, the low prevalence of underlying disease, and the anxiety induced by ALTE combine to make "a recipe for testing cascade," Dr. Tieder said. "These are beautiful, healthy-appearing infants, and yet we do all these potentially harmful things to them with little evidence that the results will improve their outcomes."

Patrice Wendling/IMNG Medical News

Importantly, the yield for routine diagnostic testing for ALTE is low. In one study of 243 consecutive infants who experienced an ALTE, only 17.7% of 3,776 tests ordered were positive; even worse, just 6% contributed to the diagnosis (Pediatrics 2005;115:885-93).

Common discharge diagnoses for ALTE – such as idiopathic gastroesophageal reflux, respiratory infections (8%-11%), and seizures (9-11%) – are largely self-limiting and nonrecurring. It’s with the less common causes that clinicians start seeing the problem with managing an ALTE, Dr. Tieder said. These include pertussis (0.05%-9%), cardiac arrhythmias (fewer than 1%), bacterial infection (0%-8%), metabolic disorder (1.5%), and – increasingly and especially in infants with recurrent ALTE – child maltreatment (fewer than 1%).

"You need to have a high index of suspicion for child maltreatment," he said. A recent study involving 563 children, average age 2.3 months, who presented to the emergency department following an ALTE found a mortality rate of 9% in victims of child abuse (Pediatr. Emerg. Care 2011;27:591-5).

An Unfunded Conundrum

Despite the potential risk for serious underlying conditions and death, research funding has been lacking. Again, the problem lies with ALTE’s being defined as a constellation of symptoms, not as a disease (which is how government typically allocates research dollars), Dr. Tieder explained.

"We’re really stuck without a research source," he said. In the conventional mechanism, government funders "might fund child maltreatment, but [ALTE represents] only a minority of these patients. So when they start to rank priorities in this current austere environment, ALTEs don’t have a lot of cachet."

Grasping the Risks

A better understanding of life-threatening risk in infants with an ALTE, however, could revolutionize the work-up of these infants, just as greater understanding of the risk of myocardial infarction has revolutionized the way adult hospitalists stage the evaluation and management of adults presenting with chest pain.

Based on the current evidence, the panel has concluded that certain features can be used to assess risk and guide diagnostic testing. Factors that may define lower-risk infants are age older than 2 months; a first ALTE; a previously healthy status on no medications; no social concerns; no family history of SIDS or ALTE; and an obstructive event (such as choking, gagging, breath holding, or having a vasovagal episode) that was secondary to emesis, coughing, or crying, Dr. Tieder said. Although this is not set in stone, the panel suggests that routine screening is not indicated in low-risk infants, he added.

Key elements for higher-risk infants are age younger than 2 months, especially with upper respiratory symptoms or exposure; more than one ALTE; a history of prematurity, central apnea, comorbid conditions, or medication use; pertussis exposure/risk; social concerns; family history of SIDS; or unexplained death with physical findings of bruising or bleeding, particularly in the mouth.

Groups that are most likely to benefit from hospital admission include high-risk infants, infants younger than 37 weeks post-conceptual age, those younger than 2 months of age in whom pertussis and respiratory syncytial virus testing is pending, or cases where maltreatment is a concern, he said.

A Gap Filled

No definite timeline has been established for the panel to complete its task, but hospitalists are uniquely qualified to define ALTE and to establish a national standard for inpatient care for ALTEs, according to panel member and pediatric hospitalist Dr. Jack Percelay, who holds the newly created pediatrics seat on the SHM board of directors.

Patrice Wendling/IMNG Medical Media

"It’s very multidisciplinary, so everybody looks at it from their own scope," he said in an interview. "The GI people look at it and say it’s got to be reflux; the neurology people say it looks like it’s going to be seizures. Or it could be trauma. We have that global view, so that’s why we’re the best people for it.

"I’m not sure that we want to be the experts, but no one else has really looked at it, so it was an opportunity for us. It was an orphan disease."

Dr. Tieder reported a relationship with Child Hospital Association, which provides grant support to the Pediatric Research in Inpatient Settings Network. Dr. Percelay reported no conflicts of interest.

COVINGTON, KY. – Peripheral blood culture contamination can be reduced by more than half with little to no cost and without a dreaded second venipuncture for the patient, new research shows.

The contamination rate at in the pediatric emergency department at Vanderbilt University Medical Center in Nashville, Tenn., fell 60% from 4% to 1.6% after an intervention that focused on establishing a sterile bedside field, staff education and using a single-site intravenous insertion, Dr. Paul Hain said at Pediatric Hospital Medicine 2012.

Patrice Wendling/IMNG Medical Media

The American Society of Microbiology currently recommends that contamination rates should not exceed 3% for the hospital setting.

Akron (Ohio) Children’s Hospital and Kansas City (Mo.) Children’s Hospital have both reported reducing false-positive blood culture rates from 9% to 2.8% and from 6.7% to 2.3%, respectively, but they did so by drawing culture specimens from a site separate from the inserted IV catheters, he explained.

The tipping point at Vanderbilt centered on a 7-week-old admitted with a diagnosis of apparent life-threatening event who, as a result of blood culture contamination, underwent an unnecessary lumbar puncture, received 2 days of unneeded antibiotics and antiviral therapy, spent 2 extra days in the hospital because of concerns for a serious bacterial infection and, ultimately, needed a plastic surgeon consult for an infiltration wound, he said.

A preintervention analysis revealed several opportunities during the process that could contribute to contamination. They were:

• The top of the culture bottle, clearly labeled as being nonsterile, was not sterilized with alcohol or chlorhexidine.

• Chlorhexidine solution was not allowed to completely dry on the skin prior to catheter insertion.

• The catheter site was palpated with a gloveless, nonsterile finger prior to insertion, but after cleansing.

• The blood sample was injected into a nonsterile container before injection into a sterile blood culture bottle or was placed on a nonsterile surface, bed, or sheets.

• The blood culture was drawn from peripheral intravenous catheter placed at the transferring hospital.

Based on these observations, lead author Dr. Randon T. Hall created a kit that included an IV catheter, transfer device, syringe, T-connector, clave, sterile tape and gloves, and an IV needle to help set up a sterile field.

A webinar was created to educate day and night shift nurses and the blood draw procedure was standardized, explained Dr. Hain, who recently became vice president and medical director for population health and network development at Children’s Medical Center, Dallas.

The procedure requires cleaning the top of the blood culture bottle with alcohol or chlorhexidine, placing extra tape on the side of the stand for later use in securing the IV, and having a holder ready the patient and position the sterile field kit for easy access.

The nurse dons sterile gloves, attaches the syringe to the T-connector and leaves it on the sterile field before cleansing the IV site thoroughly with a chlorhexidine swab, and creating a generous sterile area above and below the injection site, he said.

A tourniquet is then applied, the IV catheter placed, the blood drawn, and the sample put directly into a blood culture bottle. If working alone, the syringe has to be placed on the sterile glove field before securing the catheter, Dr. Hain said.

"It seems like this should have been the old procedure, I realize that, but it wasn’t," he added. "The old procedure was: If you learned how to draw blood in nursing school, good."

Contamination rates began falling within a month of the intervention began in July 2009, and hit a low of about 0.5% in early 2011 before reaching an average of 1.6% at the time of the analysis in December 2011.

From July 2009 to June 2010, there were 149 contaminations, costing the hospital $416,243, Dr. Hain said. That’s not counting the additional 53 calls made to families for repeat cultures, two needle sticks, one IV infiltrate and, on two occasions, police being sent to the home to retrieve a child when parents could not be reached by phone.

A 60% reduction in $417,000 yearly costs is $250,000 in approximate savings or $2,800/contamination. If one calculates the true cost, which current dogma places at approximately 50% of costs, then the true cost savings per year in the pediatric ED is $125,000, Dr. Hain said.

"This costs nothing to do, except Dr. Hall’s time," he said. "And the interesting part is that the [pediatric ED] collects only about 30% of our blood cultures, so we think there is the opportunity to double or triple our return on investment of zero dollars, if we can get this to spread to the rest of the hospital."

When asked by the audience how the intervention got buy-in from nurses, Dr. Hain said that Dr. Hall, who is now with Cincinnati Children’s Hospital Medical Center, acknowledged each month that the contamination rate remained below 4%, thanking each nurse for keeping children safe.

"It was much more of a positive thing, than if you drew a bad blood culture," he added.

Dr. Hall said in an interview that he’s discussed implementing the intervention into daily practice and potential savings with the executive board at Vanderbilt Children’s Hospital and the NICU educator and also has met with the current chief resident to continue surveillance and reporting to the ED.

Dr. Hall and Dr. Hain report no conflicts of interest. A coauthor disclosed research funding from CareFusion, bioMérieux and Affinium Pharmaceuticals.

COVINGTON, KY. – Peripheral blood culture contamination can be reduced by more than half with little to no cost and without a dreaded second venipuncture for the patient, new research shows.

The contamination rate at in the pediatric emergency department at Vanderbilt University Medical Center in Nashville, Tenn., fell 60% from 4% to 1.6% after an intervention that focused on establishing a sterile bedside field, staff education and using a single-site intravenous insertion, Dr. Paul Hain said at Pediatric Hospital Medicine 2012.

Patrice Wendling/IMNG Medical Media

The American Society of Microbiology currently recommends that contamination rates should not exceed 3% for the hospital setting.

Akron (Ohio) Children’s Hospital and Kansas City (Mo.) Children’s Hospital have both reported reducing false-positive blood culture rates from 9% to 2.8% and from 6.7% to 2.3%, respectively, but they did so by drawing culture specimens from a site separate from the inserted IV catheters, he explained.

The tipping point at Vanderbilt centered on a 7-week-old admitted with a diagnosis of apparent life-threatening event who, as a result of blood culture contamination, underwent an unnecessary lumbar puncture, received 2 days of unneeded antibiotics and antiviral therapy, spent 2 extra days in the hospital because of concerns for a serious bacterial infection and, ultimately, needed a plastic surgeon consult for an infiltration wound, he said.

A preintervention analysis revealed several opportunities during the process that could contribute to contamination. They were:

• The top of the culture bottle, clearly labeled as being nonsterile, was not sterilized with alcohol or chlorhexidine.

• Chlorhexidine solution was not allowed to completely dry on the skin prior to catheter insertion.

• The catheter site was palpated with a gloveless, nonsterile finger prior to insertion, but after cleansing.

• The blood sample was injected into a nonsterile container before injection into a sterile blood culture bottle or was placed on a nonsterile surface, bed, or sheets.

• The blood culture was drawn from peripheral intravenous catheter placed at the transferring hospital.

Based on these observations, lead author Dr. Randon T. Hall created a kit that included an IV catheter, transfer device, syringe, T-connector, clave, sterile tape and gloves, and an IV needle to help set up a sterile field.

A webinar was created to educate day and night shift nurses and the blood draw procedure was standardized, explained Dr. Hain, who recently became vice president and medical director for population health and network development at Children’s Medical Center, Dallas.

The procedure requires cleaning the top of the blood culture bottle with alcohol or chlorhexidine, placing extra tape on the side of the stand for later use in securing the IV, and having a holder ready the patient and position the sterile field kit for easy access.

The nurse dons sterile gloves, attaches the syringe to the T-connector and leaves it on the sterile field before cleansing the IV site thoroughly with a chlorhexidine swab, and creating a generous sterile area above and below the injection site, he said.

A tourniquet is then applied, the IV catheter placed, the blood drawn, and the sample put directly into a blood culture bottle. If working alone, the syringe has to be placed on the sterile glove field before securing the catheter, Dr. Hain said.

"It seems like this should have been the old procedure, I realize that, but it wasn’t," he added. "The old procedure was: If you learned how to draw blood in nursing school, good."

Contamination rates began falling within a month of the intervention began in July 2009, and hit a low of about 0.5% in early 2011 before reaching an average of 1.6% at the time of the analysis in December 2011.

From July 2009 to June 2010, there were 149 contaminations, costing the hospital $416,243, Dr. Hain said. That’s not counting the additional 53 calls made to families for repeat cultures, two needle sticks, one IV infiltrate and, on two occasions, police being sent to the home to retrieve a child when parents could not be reached by phone.

A 60% reduction in $417,000 yearly costs is $250,000 in approximate savings or $2,800/contamination. If one calculates the true cost, which current dogma places at approximately 50% of costs, then the true cost savings per year in the pediatric ED is $125,000, Dr. Hain said.

"This costs nothing to do, except Dr. Hall’s time," he said. "And the interesting part is that the [pediatric ED] collects only about 30% of our blood cultures, so we think there is the opportunity to double or triple our return on investment of zero dollars, if we can get this to spread to the rest of the hospital."

When asked by the audience how the intervention got buy-in from nurses, Dr. Hain said that Dr. Hall, who is now with Cincinnati Children’s Hospital Medical Center, acknowledged each month that the contamination rate remained below 4%, thanking each nurse for keeping children safe.

"It was much more of a positive thing, than if you drew a bad blood culture," he added.

Dr. Hall said in an interview that he’s discussed implementing the intervention into daily practice and potential savings with the executive board at Vanderbilt Children’s Hospital and the NICU educator and also has met with the current chief resident to continue surveillance and reporting to the ED.

Dr. Hall and Dr. Hain report no conflicts of interest. A coauthor disclosed research funding from CareFusion, bioMérieux and Affinium Pharmaceuticals.

COVINGTON, KY. – Peripheral blood culture contamination can be reduced by more than half with little to no cost and without a dreaded second venipuncture for the patient, new research shows.

The contamination rate at in the pediatric emergency department at Vanderbilt University Medical Center in Nashville, Tenn., fell 60% from 4% to 1.6% after an intervention that focused on establishing a sterile bedside field, staff education and using a single-site intravenous insertion, Dr. Paul Hain said at Pediatric Hospital Medicine 2012.

Patrice Wendling/IMNG Medical Media

The American Society of Microbiology currently recommends that contamination rates should not exceed 3% for the hospital setting.

Akron (Ohio) Children’s Hospital and Kansas City (Mo.) Children’s Hospital have both reported reducing false-positive blood culture rates from 9% to 2.8% and from 6.7% to 2.3%, respectively, but they did so by drawing culture specimens from a site separate from the inserted IV catheters, he explained.

The tipping point at Vanderbilt centered on a 7-week-old admitted with a diagnosis of apparent life-threatening event who, as a result of blood culture contamination, underwent an unnecessary lumbar puncture, received 2 days of unneeded antibiotics and antiviral therapy, spent 2 extra days in the hospital because of concerns for a serious bacterial infection and, ultimately, needed a plastic surgeon consult for an infiltration wound, he said.

A preintervention analysis revealed several opportunities during the process that could contribute to contamination. They were:

• The top of the culture bottle, clearly labeled as being nonsterile, was not sterilized with alcohol or chlorhexidine.

• Chlorhexidine solution was not allowed to completely dry on the skin prior to catheter insertion.

• The catheter site was palpated with a gloveless, nonsterile finger prior to insertion, but after cleansing.

• The blood sample was injected into a nonsterile container before injection into a sterile blood culture bottle or was placed on a nonsterile surface, bed, or sheets.

• The blood culture was drawn from peripheral intravenous catheter placed at the transferring hospital.

Based on these observations, lead author Dr. Randon T. Hall created a kit that included an IV catheter, transfer device, syringe, T-connector, clave, sterile tape and gloves, and an IV needle to help set up a sterile field.

A webinar was created to educate day and night shift nurses and the blood draw procedure was standardized, explained Dr. Hain, who recently became vice president and medical director for population health and network development at Children’s Medical Center, Dallas.

The procedure requires cleaning the top of the blood culture bottle with alcohol or chlorhexidine, placing extra tape on the side of the stand for later use in securing the IV, and having a holder ready the patient and position the sterile field kit for easy access.

The nurse dons sterile gloves, attaches the syringe to the T-connector and leaves it on the sterile field before cleansing the IV site thoroughly with a chlorhexidine swab, and creating a generous sterile area above and below the injection site, he said.

A tourniquet is then applied, the IV catheter placed, the blood drawn, and the sample put directly into a blood culture bottle. If working alone, the syringe has to be placed on the sterile glove field before securing the catheter, Dr. Hain said.

"It seems like this should have been the old procedure, I realize that, but it wasn’t," he added. "The old procedure was: If you learned how to draw blood in nursing school, good."

Contamination rates began falling within a month of the intervention began in July 2009, and hit a low of about 0.5% in early 2011 before reaching an average of 1.6% at the time of the analysis in December 2011.

From July 2009 to June 2010, there were 149 contaminations, costing the hospital $416,243, Dr. Hain said. That’s not counting the additional 53 calls made to families for repeat cultures, two needle sticks, one IV infiltrate and, on two occasions, police being sent to the home to retrieve a child when parents could not be reached by phone.

A 60% reduction in $417,000 yearly costs is $250,000 in approximate savings or $2,800/contamination. If one calculates the true cost, which current dogma places at approximately 50% of costs, then the true cost savings per year in the pediatric ED is $125,000, Dr. Hain said.

"This costs nothing to do, except Dr. Hall’s time," he said. "And the interesting part is that the [pediatric ED] collects only about 30% of our blood cultures, so we think there is the opportunity to double or triple our return on investment of zero dollars, if we can get this to spread to the rest of the hospital."

When asked by the audience how the intervention got buy-in from nurses, Dr. Hain said that Dr. Hall, who is now with Cincinnati Children’s Hospital Medical Center, acknowledged each month that the contamination rate remained below 4%, thanking each nurse for keeping children safe.

"It was much more of a positive thing, than if you drew a bad blood culture," he added.

Dr. Hall said in an interview that he’s discussed implementing the intervention into daily practice and potential savings with the executive board at Vanderbilt Children’s Hospital and the NICU educator and also has met with the current chief resident to continue surveillance and reporting to the ED.

Dr. Hall and Dr. Hain report no conflicts of interest. A coauthor disclosed research funding from CareFusion, bioMérieux and Affinium Pharmaceuticals.