Mark Shen, MD, FHM

Pediatric Readmissions Vary Significantly across Children’s Hospitals

Clinical question: What are the characteristics of readmissions to children’s hospitals?

Background: Thirty-day readmissions in adult Medicare beneficiaries are common and thought to represent potential for significant improvements in the quality of care. Penalties will be levied upon hospitals with excessively high readmission rates in adults. The stage is set for a translation of this practice to pediatric readmissions. However, the characteristics of readmissions to children’s hospitals are not well-defined.

Study design: Retrospective review.

Setting: National Association of Children’s Hospitals and Related Institutions (NACHRI) Case Mix data set.

Synopsis: Of 568,845 readmissions examined across 72 children’s hospitals, the 30-day readmission rate was 6.5%. Readmission rates varied by many factors: age, chronic conditions, insurance type, race/ethnicity, length of stay, number of annual hospital admissions, and hospital type. Rates varied significantly across hospitals, even after adjustment for age and chronic conditions. Anemia or neutropenia, ventricular shunt procedures, and sickle cell crisis had the highest unadjusted, 30-day, condition-specific readmission rates.

This study is notable for its large sample size but limited by the administrative data, which might, for example, underestimate readmissions that went to another hospital. Additionally, the majority of children in the U.S. are hospitalized outside of children’s hospitals, which are overrepresented in this study.

However, this study paints a clear picture of the differences between adult readmissions and pediatric readmissions—rates are lower than in elderly adults, and the top three conditions are distinctly different. Anemia or neutropenia likely are due to effects of chemotherapy; ventricular shunt readmissions often reflect surgery-related issues; and sickle cell disease is a lifelong, chronic condition. The significant variation between hospitals after case-mix adjustment offers an opportunity for further investigation and improvement.

Bottom line: Pediatric readmissions differ from adult readmissions and vary significantly across children’s hospitals.

Citation: Berry JG, Toomey SL, Zaslavsky AM, et al. Pediatric readmission prevalence and variability across hospitals. JAMA. 2013;309(4):372-380.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Pediatric Readmissions Vary Significantly across Children’s Hospitals

Clinical question: What are the characteristics of readmissions to children’s hospitals?

Background: Thirty-day readmissions in adult Medicare beneficiaries are common and thought to represent potential for significant improvements in the quality of care. Penalties will be levied upon hospitals with excessively high readmission rates in adults. The stage is set for a translation of this practice to pediatric readmissions. However, the characteristics of readmissions to children’s hospitals are not well-defined.

Study design: Retrospective review.

Setting: National Association of Children’s Hospitals and Related Institutions (NACHRI) Case Mix data set.

Synopsis: Of 568,845 readmissions examined across 72 children’s hospitals, the 30-day readmission rate was 6.5%. Readmission rates varied by many factors: age, chronic conditions, insurance type, race/ethnicity, length of stay, number of annual hospital admissions, and hospital type. Rates varied significantly across hospitals, even after adjustment for age and chronic conditions. Anemia or neutropenia, ventricular shunt procedures, and sickle cell crisis had the highest unadjusted, 30-day, condition-specific readmission rates.

This study is notable for its large sample size but limited by the administrative data, which might, for example, underestimate readmissions that went to another hospital. Additionally, the majority of children in the U.S. are hospitalized outside of children’s hospitals, which are overrepresented in this study.

However, this study paints a clear picture of the differences between adult readmissions and pediatric readmissions—rates are lower than in elderly adults, and the top three conditions are distinctly different. Anemia or neutropenia likely are due to effects of chemotherapy; ventricular shunt readmissions often reflect surgery-related issues; and sickle cell disease is a lifelong, chronic condition. The significant variation between hospitals after case-mix adjustment offers an opportunity for further investigation and improvement.

Bottom line: Pediatric readmissions differ from adult readmissions and vary significantly across children’s hospitals.

Citation: Berry JG, Toomey SL, Zaslavsky AM, et al. Pediatric readmission prevalence and variability across hospitals. JAMA. 2013;309(4):372-380.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Pediatric Readmissions Vary Significantly across Children’s Hospitals

Clinical question: What are the characteristics of readmissions to children’s hospitals?

Background: Thirty-day readmissions in adult Medicare beneficiaries are common and thought to represent potential for significant improvements in the quality of care. Penalties will be levied upon hospitals with excessively high readmission rates in adults. The stage is set for a translation of this practice to pediatric readmissions. However, the characteristics of readmissions to children’s hospitals are not well-defined.

Study design: Retrospective review.

Setting: National Association of Children’s Hospitals and Related Institutions (NACHRI) Case Mix data set.

Synopsis: Of 568,845 readmissions examined across 72 children’s hospitals, the 30-day readmission rate was 6.5%. Readmission rates varied by many factors: age, chronic conditions, insurance type, race/ethnicity, length of stay, number of annual hospital admissions, and hospital type. Rates varied significantly across hospitals, even after adjustment for age and chronic conditions. Anemia or neutropenia, ventricular shunt procedures, and sickle cell crisis had the highest unadjusted, 30-day, condition-specific readmission rates.

This study is notable for its large sample size but limited by the administrative data, which might, for example, underestimate readmissions that went to another hospital. Additionally, the majority of children in the U.S. are hospitalized outside of children’s hospitals, which are overrepresented in this study.

However, this study paints a clear picture of the differences between adult readmissions and pediatric readmissions—rates are lower than in elderly adults, and the top three conditions are distinctly different. Anemia or neutropenia likely are due to effects of chemotherapy; ventricular shunt readmissions often reflect surgery-related issues; and sickle cell disease is a lifelong, chronic condition. The significant variation between hospitals after case-mix adjustment offers an opportunity for further investigation and improvement.

Bottom line: Pediatric readmissions differ from adult readmissions and vary significantly across children’s hospitals.

Citation: Berry JG, Toomey SL, Zaslavsky AM, et al. Pediatric readmission prevalence and variability across hospitals. JAMA. 2013;309(4):372-380.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What are the long-term outcomes of pediatric pleural empyema?

Background: Hospitalizations for complicated pneumonia have increased in recent years. In the U.S., early intervention—commonly video-assisted thorascopic surgery (VATS)—has become popular. Although short-term outcomes appear cost-effective with this approach, long-term comparative-effectiveness outcomes are not entirely clear.

Study design: Prospective observational study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a two-year period, 82 patients were enrolled and available for at least one follow-up visit in a 12-month period. Chest drain was used in 62% of children; fibrinolytics were used in 78% of those cases. All patients received antibiotics. Six patients (7%) were readmitted in the first month, with three patients requiring a chest drain. At 12 months, four patients (5%) had mildly abnormal spirometric or radiographic abnormalities but were asymptomatic with normal quality-of-life scores.

This prospective observational study is notable for the relatively conservative approach (antibiotics alone or chest drainage, without VATS) employed in all subjects. The results provide a comprehensive summary of outcomes at 12 months in this population. Unfortunately, comparative-effectiveness data for VATS are not available in a generalizable form. Nevertheless, this single-center snapshot suggests that long-term outcomes are good with a conservative approach.

Given these findings, and the low likelihood that significant advantages of VATS will be demonstrated in the absence of a large multicenter trial, better understanding of parental preferences will become critical to making the right decision for each patient.

Bottom line: Conservative management of pediatric pleural empyema yields good long-term outcomes.

Citation: Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study. Arch Pediatr Adolesc Med. 2012;166(11):999-1004.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What are the long-term outcomes of pediatric pleural empyema?

Background: Hospitalizations for complicated pneumonia have increased in recent years. In the U.S., early intervention—commonly video-assisted thorascopic surgery (VATS)—has become popular. Although short-term outcomes appear cost-effective with this approach, long-term comparative-effectiveness outcomes are not entirely clear.

Study design: Prospective observational study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a two-year period, 82 patients were enrolled and available for at least one follow-up visit in a 12-month period. Chest drain was used in 62% of children; fibrinolytics were used in 78% of those cases. All patients received antibiotics. Six patients (7%) were readmitted in the first month, with three patients requiring a chest drain. At 12 months, four patients (5%) had mildly abnormal spirometric or radiographic abnormalities but were asymptomatic with normal quality-of-life scores.

This prospective observational study is notable for the relatively conservative approach (antibiotics alone or chest drainage, without VATS) employed in all subjects. The results provide a comprehensive summary of outcomes at 12 months in this population. Unfortunately, comparative-effectiveness data for VATS are not available in a generalizable form. Nevertheless, this single-center snapshot suggests that long-term outcomes are good with a conservative approach.

Given these findings, and the low likelihood that significant advantages of VATS will be demonstrated in the absence of a large multicenter trial, better understanding of parental preferences will become critical to making the right decision for each patient.

Bottom line: Conservative management of pediatric pleural empyema yields good long-term outcomes.

Citation: Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study. Arch Pediatr Adolesc Med. 2012;166(11):999-1004.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What are the long-term outcomes of pediatric pleural empyema?

Background: Hospitalizations for complicated pneumonia have increased in recent years. In the U.S., early intervention—commonly video-assisted thorascopic surgery (VATS)—has become popular. Although short-term outcomes appear cost-effective with this approach, long-term comparative-effectiveness outcomes are not entirely clear.

Study design: Prospective observational study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a two-year period, 82 patients were enrolled and available for at least one follow-up visit in a 12-month period. Chest drain was used in 62% of children; fibrinolytics were used in 78% of those cases. All patients received antibiotics. Six patients (7%) were readmitted in the first month, with three patients requiring a chest drain. At 12 months, four patients (5%) had mildly abnormal spirometric or radiographic abnormalities but were asymptomatic with normal quality-of-life scores.

This prospective observational study is notable for the relatively conservative approach (antibiotics alone or chest drainage, without VATS) employed in all subjects. The results provide a comprehensive summary of outcomes at 12 months in this population. Unfortunately, comparative-effectiveness data for VATS are not available in a generalizable form. Nevertheless, this single-center snapshot suggests that long-term outcomes are good with a conservative approach.

Given these findings, and the low likelihood that significant advantages of VATS will be demonstrated in the absence of a large multicenter trial, better understanding of parental preferences will become critical to making the right decision for each patient.

Bottom line: Conservative management of pediatric pleural empyema yields good long-term outcomes.

Citation: Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study. Arch Pediatr Adolesc Med. 2012;166(11):999-1004.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of a clinical practice guideline for hospitalized children with community-acquired pneumonia (CAP) on antibiotic selection?

Background: CAP is one of the most common reasons for hospitalizations in children. Broad-spectrum antibiotics frequently are prescribed for presumed bacterial pneumonia in children. Recent guidelines for CAP in children have emphasized that ampicillin is an appropriate empiric inpatient treatment option.

Study design: Retrospective review.

Setting: Tertiary referral children’s hospital.

Synopsis: Patients older than two months old with acute, uncomplicated CAP and without significant secondary illness were identified in the 12-month periods preceding and following the implementation of a clinical practice guideline (CPG) that recommended empiric treatment with ampicillin upon admission, and amoxicillin upon discharge.

A total of 1,033 patients were identified, 530 pre-CPG and 503 post-CPG, and the groups were similar. After the CPG, there was a significant increase in empiric ampicillin use (13% to 63%) and concomitant decrease in ceftriaxone use (72% to 21%). Rates of outpatient narrow-spectrum antibiotic prescribing increased as well, and the rate of treatment failure was similar between the groups.

Complex regression analysis was used to analyze the impact of a concomitant antibiotic stewardship program (ASP), implemented three months prior to the initiation of the CPG and demonstrating a separate and additive effect of both initiatives. Thus, changes in antibiotic prescribing were multifactorial over this time period.

The outcomes remain impressive in the context of two increasingly popular QI efforts—CPGs and ASPs. This study represents a meaningful contribution toward demonstration of outcomes-based quality improvement (QI).

Bottom line: In the context of a CPG, antibiotic spectrum may be safely narrowed in pediatric CAP.

Citation: Newman RE, Hedican EB, Herigon JC, Williams DD, Williams AR, Newland JG. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597-604.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the impact of a clinical practice guideline for hospitalized children with community-acquired pneumonia (CAP) on antibiotic selection?

Background: CAP is one of the most common reasons for hospitalizations in children. Broad-spectrum antibiotics frequently are prescribed for presumed bacterial pneumonia in children. Recent guidelines for CAP in children have emphasized that ampicillin is an appropriate empiric inpatient treatment option.

Study design: Retrospective review.

Setting: Tertiary referral children’s hospital.

Synopsis: Patients older than two months old with acute, uncomplicated CAP and without significant secondary illness were identified in the 12-month periods preceding and following the implementation of a clinical practice guideline (CPG) that recommended empiric treatment with ampicillin upon admission, and amoxicillin upon discharge.

A total of 1,033 patients were identified, 530 pre-CPG and 503 post-CPG, and the groups were similar. After the CPG, there was a significant increase in empiric ampicillin use (13% to 63%) and concomitant decrease in ceftriaxone use (72% to 21%). Rates of outpatient narrow-spectrum antibiotic prescribing increased as well, and the rate of treatment failure was similar between the groups.

Complex regression analysis was used to analyze the impact of a concomitant antibiotic stewardship program (ASP), implemented three months prior to the initiation of the CPG and demonstrating a separate and additive effect of both initiatives. Thus, changes in antibiotic prescribing were multifactorial over this time period.

The outcomes remain impressive in the context of two increasingly popular QI efforts—CPGs and ASPs. This study represents a meaningful contribution toward demonstration of outcomes-based quality improvement (QI).

Bottom line: In the context of a CPG, antibiotic spectrum may be safely narrowed in pediatric CAP.

Citation: Newman RE, Hedican EB, Herigon JC, Williams DD, Williams AR, Newland JG. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597-604.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the impact of a clinical practice guideline for hospitalized children with community-acquired pneumonia (CAP) on antibiotic selection?

Background: CAP is one of the most common reasons for hospitalizations in children. Broad-spectrum antibiotics frequently are prescribed for presumed bacterial pneumonia in children. Recent guidelines for CAP in children have emphasized that ampicillin is an appropriate empiric inpatient treatment option.

Study design: Retrospective review.

Setting: Tertiary referral children’s hospital.

Synopsis: Patients older than two months old with acute, uncomplicated CAP and without significant secondary illness were identified in the 12-month periods preceding and following the implementation of a clinical practice guideline (CPG) that recommended empiric treatment with ampicillin upon admission, and amoxicillin upon discharge.

A total of 1,033 patients were identified, 530 pre-CPG and 503 post-CPG, and the groups were similar. After the CPG, there was a significant increase in empiric ampicillin use (13% to 63%) and concomitant decrease in ceftriaxone use (72% to 21%). Rates of outpatient narrow-spectrum antibiotic prescribing increased as well, and the rate of treatment failure was similar between the groups.

Complex regression analysis was used to analyze the impact of a concomitant antibiotic stewardship program (ASP), implemented three months prior to the initiation of the CPG and demonstrating a separate and additive effect of both initiatives. Thus, changes in antibiotic prescribing were multifactorial over this time period.

The outcomes remain impressive in the context of two increasingly popular QI efforts—CPGs and ASPs. This study represents a meaningful contribution toward demonstration of outcomes-based quality improvement (QI).

Bottom line: In the context of a CPG, antibiotic spectrum may be safely narrowed in pediatric CAP.

Citation: Newman RE, Hedican EB, Herigon JC, Williams DD, Williams AR, Newland JG. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597-604.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

I am decidedly anti-politics. The entire process seems fatally flawed. The vast majority of the public votes based on one or two emotional interests, such as religion or personal finances. The candidates’ responses are calculated, based on the millions of dollars they receive from competing interest groups and evidence-based analysis of what will garner the most votes. So for me at this time of year, watching debates and TV coverage of primaries is akin to watching an MTV reality show—lots of drama, little substance.

But there is one election (of sorts) this year that gives me hope: Our input has been solicited by the Strategic Planning (STP) Committee to help sort through the issue of certification in pediatric hospital medicine. What is potentially at stake here is how we define ourselves as a field. At one end is the traditional, three-year fellowship with certification as a subspecialty. At the other end is no change, or the status quo. In between are myriad options, each with unique pros and cons. It is all summarized at the STP blog (http://stpcommittee.blogspot.com), which allows for input.

This is a unique opportunity, as pediatric HM is at a crossroads. The STP Committee states that this solicitation of public comment is different from processes that other fields (pediatric emergency medicine, child abuse, adult hospital medicine) have used, and it will allow for more engagement of the pediatric hospitalist community at large. I agree. And I heartily endorse an open forum for this process.

What happens after this is somewhat less clear, but it involves synthesis of all of the input and presentation to the Joint Council of Pediatric Hospital Medicine (JCPHM). In addition, the American Pediatric Association (APA), the American Academy of Pediatrics (AAP), and SHM representatives will solicit feedback from their leadership and membership. A minor drawback of this process is the fact that the JCPHM remains a somewhat mythical body to date, as it has not been publicly defined to my knowledge. But this will be the body that makes the final decision.

The Candidates

OK, enough of the sausage-making (“laws are like sausages: It is best not to see them being made”) and on to the actual candidates. I suppose we should begin with the “incumbent”—the status quo. I will not rehash the pros and cons that have been meticulously laid out by the STP Committee on the website. But I will add that this candidate has the benefit of being well-known and is the least complicated option. Unfortunately, it’s also the least sexy option, which I’m told is actually a factor in elections. Given the number of alternatives that the committee has laid out, I’m not going with this one, simply because there has to be a better one out there.

I also immediately discount the option on the other end of the spectrum: a full three-year fellowship (the current standard for subspecialists). We’re all familiar with the details of this option, but the year of research is, on average, a bigger waste of time than college calculus. I remember a lot of fellows who didn’t care about research; they were sleeping next to me in the clinical research classes, ones that I was taking in my spare time. They completed projects to get through the fellowship, and that was it for “research” in their careers. Now, I can’t exclude the fact that they learned something from those projects, but the American Board of Pediatrics (ABP) clearly states that the “rationale for including a requirement for participation in scholarly activity flows from the belief that the principal goal of fellowship training should be the development of future academic pediatricians.”1 Practice in a community hospital is quite different from that of an academic pediatrician.

(This is not to say that we do not need a pipeline of future academic leaders, an absolute necessity for our young field. However, if we are to decide certification options for everyone, I think we should focus on a set of minimum requirements and have additional options, or tracks, for academicians. Thus, I would reframe the debate to focus on what every hospitalist needs.)

What is really needed to train effective pediatric hospitalists? I think we begin by acknowledging that additional clinical training is a priority for several reasons:

• Pediatric residents are receiving less and less inpatient training;
• Our patients are increasingly complex; and
• The hospital is a unique and complicated system within which to practice.

I was trained in the good ol’ days, before duty hours, and I was still pretty dumb when I started as an attending. While I don’t think it’s difficult for new grads to learn on the job, once you pay someone a full salary and give them billing as a full-fledged attending, you lose a lot of leeway—on both sides—to structure their education.

Some standard of quality and safety training should be included in this minimum requirement. One byproduct of the quality movement in medicine is that we now clearly understand that hospitals are complex systems with many moving parts. Interacting in that system, and providing safe and effective care within those confines, requires a certain set of knowledge, attitudes, and skills—particularly if we are to be leaders in hospital practice. It is no longer sufficient to be just a hospital-based doctor with no extramural involvement in improving the system. Strategically, this would be of value to both hospital administrators and academic institutions, our primary funding streams.

The Endorsement

So I vote for some set of minimum requirements. And I think that has to be the focus of our initial discussion. Once those are decided, the immediate next issue should be whether this is implemented as a fellowship or through focused practice. Here, I lean towards the former, as I think that a fellowship allows us to better control the quality of that training. The final issue is which option to choose, but I think that becomes a formality once minimum requirements are decided; in many instances, there may be more than one option that works.

So do your part, and contribute to the discussion. But don’t just pick an option. Describe what you think hospitalists of tomorrow need when they start their careers. And enjoy this refreshing process, one without the irrationalities of politics and something that we can all buy into for the future of pediatric HM.

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

Reference

1. American Board of Pediatrics. Training requirements for subspecialty certification. American Board of Pediatrics website. Available at: https://www.abp.org/abpwebsite/publicat/trainingrequirements.pdf. Accessed May 1, 2012.

I am decidedly anti-politics. The entire process seems fatally flawed. The vast majority of the public votes based on one or two emotional interests, such as religion or personal finances. The candidates’ responses are calculated, based on the millions of dollars they receive from competing interest groups and evidence-based analysis of what will garner the most votes. So for me at this time of year, watching debates and TV coverage of primaries is akin to watching an MTV reality show—lots of drama, little substance.

But there is one election (of sorts) this year that gives me hope: Our input has been solicited by the Strategic Planning (STP) Committee to help sort through the issue of certification in pediatric hospital medicine. What is potentially at stake here is how we define ourselves as a field. At one end is the traditional, three-year fellowship with certification as a subspecialty. At the other end is no change, or the status quo. In between are myriad options, each with unique pros and cons. It is all summarized at the STP blog (http://stpcommittee.blogspot.com), which allows for input.

This is a unique opportunity, as pediatric HM is at a crossroads. The STP Committee states that this solicitation of public comment is different from processes that other fields (pediatric emergency medicine, child abuse, adult hospital medicine) have used, and it will allow for more engagement of the pediatric hospitalist community at large. I agree. And I heartily endorse an open forum for this process.

What happens after this is somewhat less clear, but it involves synthesis of all of the input and presentation to the Joint Council of Pediatric Hospital Medicine (JCPHM). In addition, the American Pediatric Association (APA), the American Academy of Pediatrics (AAP), and SHM representatives will solicit feedback from their leadership and membership. A minor drawback of this process is the fact that the JCPHM remains a somewhat mythical body to date, as it has not been publicly defined to my knowledge. But this will be the body that makes the final decision.

The Candidates

OK, enough of the sausage-making (“laws are like sausages: It is best not to see them being made”) and on to the actual candidates. I suppose we should begin with the “incumbent”—the status quo. I will not rehash the pros and cons that have been meticulously laid out by the STP Committee on the website. But I will add that this candidate has the benefit of being well-known and is the least complicated option. Unfortunately, it’s also the least sexy option, which I’m told is actually a factor in elections. Given the number of alternatives that the committee has laid out, I’m not going with this one, simply because there has to be a better one out there.

I also immediately discount the option on the other end of the spectrum: a full three-year fellowship (the current standard for subspecialists). We’re all familiar with the details of this option, but the year of research is, on average, a bigger waste of time than college calculus. I remember a lot of fellows who didn’t care about research; they were sleeping next to me in the clinical research classes, ones that I was taking in my spare time. They completed projects to get through the fellowship, and that was it for “research” in their careers. Now, I can’t exclude the fact that they learned something from those projects, but the American Board of Pediatrics (ABP) clearly states that the “rationale for including a requirement for participation in scholarly activity flows from the belief that the principal goal of fellowship training should be the development of future academic pediatricians.”1 Practice in a community hospital is quite different from that of an academic pediatrician.

(This is not to say that we do not need a pipeline of future academic leaders, an absolute necessity for our young field. However, if we are to decide certification options for everyone, I think we should focus on a set of minimum requirements and have additional options, or tracks, for academicians. Thus, I would reframe the debate to focus on what every hospitalist needs.)

What is really needed to train effective pediatric hospitalists? I think we begin by acknowledging that additional clinical training is a priority for several reasons:

• Pediatric residents are receiving less and less inpatient training;
• Our patients are increasingly complex; and
• The hospital is a unique and complicated system within which to practice.

I was trained in the good ol’ days, before duty hours, and I was still pretty dumb when I started as an attending. While I don’t think it’s difficult for new grads to learn on the job, once you pay someone a full salary and give them billing as a full-fledged attending, you lose a lot of leeway—on both sides—to structure their education.

Some standard of quality and safety training should be included in this minimum requirement. One byproduct of the quality movement in medicine is that we now clearly understand that hospitals are complex systems with many moving parts. Interacting in that system, and providing safe and effective care within those confines, requires a certain set of knowledge, attitudes, and skills—particularly if we are to be leaders in hospital practice. It is no longer sufficient to be just a hospital-based doctor with no extramural involvement in improving the system. Strategically, this would be of value to both hospital administrators and academic institutions, our primary funding streams.

The Endorsement

So I vote for some set of minimum requirements. And I think that has to be the focus of our initial discussion. Once those are decided, the immediate next issue should be whether this is implemented as a fellowship or through focused practice. Here, I lean towards the former, as I think that a fellowship allows us to better control the quality of that training. The final issue is which option to choose, but I think that becomes a formality once minimum requirements are decided; in many instances, there may be more than one option that works.

So do your part, and contribute to the discussion. But don’t just pick an option. Describe what you think hospitalists of tomorrow need when they start their careers. And enjoy this refreshing process, one without the irrationalities of politics and something that we can all buy into for the future of pediatric HM.

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

Reference

1. American Board of Pediatrics. Training requirements for subspecialty certification. American Board of Pediatrics website. Available at: https://www.abp.org/abpwebsite/publicat/trainingrequirements.pdf. Accessed May 1, 2012.

I am decidedly anti-politics. The entire process seems fatally flawed. The vast majority of the public votes based on one or two emotional interests, such as religion or personal finances. The candidates’ responses are calculated, based on the millions of dollars they receive from competing interest groups and evidence-based analysis of what will garner the most votes. So for me at this time of year, watching debates and TV coverage of primaries is akin to watching an MTV reality show—lots of drama, little substance.

But there is one election (of sorts) this year that gives me hope: Our input has been solicited by the Strategic Planning (STP) Committee to help sort through the issue of certification in pediatric hospital medicine. What is potentially at stake here is how we define ourselves as a field. At one end is the traditional, three-year fellowship with certification as a subspecialty. At the other end is no change, or the status quo. In between are myriad options, each with unique pros and cons. It is all summarized at the STP blog (http://stpcommittee.blogspot.com), which allows for input.

This is a unique opportunity, as pediatric HM is at a crossroads. The STP Committee states that this solicitation of public comment is different from processes that other fields (pediatric emergency medicine, child abuse, adult hospital medicine) have used, and it will allow for more engagement of the pediatric hospitalist community at large. I agree. And I heartily endorse an open forum for this process.

What happens after this is somewhat less clear, but it involves synthesis of all of the input and presentation to the Joint Council of Pediatric Hospital Medicine (JCPHM). In addition, the American Pediatric Association (APA), the American Academy of Pediatrics (AAP), and SHM representatives will solicit feedback from their leadership and membership. A minor drawback of this process is the fact that the JCPHM remains a somewhat mythical body to date, as it has not been publicly defined to my knowledge. But this will be the body that makes the final decision.

The Candidates

OK, enough of the sausage-making (“laws are like sausages: It is best not to see them being made”) and on to the actual candidates. I suppose we should begin with the “incumbent”—the status quo. I will not rehash the pros and cons that have been meticulously laid out by the STP Committee on the website. But I will add that this candidate has the benefit of being well-known and is the least complicated option. Unfortunately, it’s also the least sexy option, which I’m told is actually a factor in elections. Given the number of alternatives that the committee has laid out, I’m not going with this one, simply because there has to be a better one out there.

I also immediately discount the option on the other end of the spectrum: a full three-year fellowship (the current standard for subspecialists). We’re all familiar with the details of this option, but the year of research is, on average, a bigger waste of time than college calculus. I remember a lot of fellows who didn’t care about research; they were sleeping next to me in the clinical research classes, ones that I was taking in my spare time. They completed projects to get through the fellowship, and that was it for “research” in their careers. Now, I can’t exclude the fact that they learned something from those projects, but the American Board of Pediatrics (ABP) clearly states that the “rationale for including a requirement for participation in scholarly activity flows from the belief that the principal goal of fellowship training should be the development of future academic pediatricians.”1 Practice in a community hospital is quite different from that of an academic pediatrician.

(This is not to say that we do not need a pipeline of future academic leaders, an absolute necessity for our young field. However, if we are to decide certification options for everyone, I think we should focus on a set of minimum requirements and have additional options, or tracks, for academicians. Thus, I would reframe the debate to focus on what every hospitalist needs.)

What is really needed to train effective pediatric hospitalists? I think we begin by acknowledging that additional clinical training is a priority for several reasons:

• Pediatric residents are receiving less and less inpatient training;
• Our patients are increasingly complex; and
• The hospital is a unique and complicated system within which to practice.

I was trained in the good ol’ days, before duty hours, and I was still pretty dumb when I started as an attending. While I don’t think it’s difficult for new grads to learn on the job, once you pay someone a full salary and give them billing as a full-fledged attending, you lose a lot of leeway—on both sides—to structure their education.

Some standard of quality and safety training should be included in this minimum requirement. One byproduct of the quality movement in medicine is that we now clearly understand that hospitals are complex systems with many moving parts. Interacting in that system, and providing safe and effective care within those confines, requires a certain set of knowledge, attitudes, and skills—particularly if we are to be leaders in hospital practice. It is no longer sufficient to be just a hospital-based doctor with no extramural involvement in improving the system. Strategically, this would be of value to both hospital administrators and academic institutions, our primary funding streams.

The Endorsement

So I vote for some set of minimum requirements. And I think that has to be the focus of our initial discussion. Once those are decided, the immediate next issue should be whether this is implemented as a fellowship or through focused practice. Here, I lean towards the former, as I think that a fellowship allows us to better control the quality of that training. The final issue is which option to choose, but I think that becomes a formality once minimum requirements are decided; in many instances, there may be more than one option that works.

So do your part, and contribute to the discussion. But don’t just pick an option. Describe what you think hospitalists of tomorrow need when they start their careers. And enjoy this refreshing process, one without the irrationalities of politics and something that we can all buy into for the future of pediatric HM.

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

Reference

1. American Board of Pediatrics. Training requirements for subspecialty certification. American Board of Pediatrics website. Available at: https://www.abp.org/abpwebsite/publicat/trainingrequirements.pdf. Accessed May 1, 2012.

Clinical question: Does intravenous volume expansion during diarrheal illness mitigate the nephrotoxic effects of hemolytic uremic syndrome (HUS)?

Background: HUS often results in significant morbidity, particularly when oligoanuria is also present. Shiga-toxin-producing bacteria, notoriously Escherichia coli O157:H7 in the context of a diarrheal illness, are the most common cause, and worldwide outbreaks have been increasingly described. One prior report suggests that early IV fluid administration results in improved outcomes.

Study design: Prospective cohort study.

Setting: Eleven pediatric hospitals in the U.S. and Scotland.

Synopsis: Fifty children with diarrhea-associated HUS were enrolled and received clinical care at the discretion of the local provider, independent of the study. A family questionnaire (to define initial illness) and chart review were subsequently performed. Oligoanuria, defined as a urine output of less than 0.5 mL/kg/hr for at least one calendar day after HUS onset, was present in 34 (68%) patients. Oligoanuric and nonoligoanuric patients were similar at baseline; however, there was a significant association between less fluid administration in the first four days of illness and oligoanuria. Specifically, lack of IV fluids portended a 1.6 times higher likelihood of oligoanuria (95% confidence interval, 1.1-2.4; P=0.02).

The authors also suggest a dose-response relationship to their findings, which potentially strengthens their findings. However, the practical applicability of these findings appears limited. Many of the patients who did not receive IV fluids early on were also not admitted to a hospital, likely signifying mild illness without notable dehydration. Replicability of the benefits of early volume expansion in HUS will depend on the ability to accurately identify patients with Shiga-toxin-producing diarrheal illnesses at presentation. If this is feasible, it would be interesting to examine the details of oral hydration as well, particularly in those who are not dehydrated enough to require hospitalization.

Bottom line: Early IV fluids might be nephroprotective in diarrhea-associated HUS.

Citation: Hickey CA, Beattie J, Cowieson J, et al. Early volume expansion during diarrhea and relative nephroprotection during subsequent hemolytic uremic syndrome. Arch Pediatr Adolesc Med. 2011;165:884-889.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Does intravenous volume expansion during diarrheal illness mitigate the nephrotoxic effects of hemolytic uremic syndrome (HUS)?

Background: HUS often results in significant morbidity, particularly when oligoanuria is also present. Shiga-toxin-producing bacteria, notoriously Escherichia coli O157:H7 in the context of a diarrheal illness, are the most common cause, and worldwide outbreaks have been increasingly described. One prior report suggests that early IV fluid administration results in improved outcomes.

Study design: Prospective cohort study.

Setting: Eleven pediatric hospitals in the U.S. and Scotland.

Synopsis: Fifty children with diarrhea-associated HUS were enrolled and received clinical care at the discretion of the local provider, independent of the study. A family questionnaire (to define initial illness) and chart review were subsequently performed. Oligoanuria, defined as a urine output of less than 0.5 mL/kg/hr for at least one calendar day after HUS onset, was present in 34 (68%) patients. Oligoanuric and nonoligoanuric patients were similar at baseline; however, there was a significant association between less fluid administration in the first four days of illness and oligoanuria. Specifically, lack of IV fluids portended a 1.6 times higher likelihood of oligoanuria (95% confidence interval, 1.1-2.4; P=0.02).

The authors also suggest a dose-response relationship to their findings, which potentially strengthens their findings. However, the practical applicability of these findings appears limited. Many of the patients who did not receive IV fluids early on were also not admitted to a hospital, likely signifying mild illness without notable dehydration. Replicability of the benefits of early volume expansion in HUS will depend on the ability to accurately identify patients with Shiga-toxin-producing diarrheal illnesses at presentation. If this is feasible, it would be interesting to examine the details of oral hydration as well, particularly in those who are not dehydrated enough to require hospitalization.

Bottom line: Early IV fluids might be nephroprotective in diarrhea-associated HUS.

Citation: Hickey CA, Beattie J, Cowieson J, et al. Early volume expansion during diarrhea and relative nephroprotection during subsequent hemolytic uremic syndrome. Arch Pediatr Adolesc Med. 2011;165:884-889.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Does intravenous volume expansion during diarrheal illness mitigate the nephrotoxic effects of hemolytic uremic syndrome (HUS)?

Background: HUS often results in significant morbidity, particularly when oligoanuria is also present. Shiga-toxin-producing bacteria, notoriously Escherichia coli O157:H7 in the context of a diarrheal illness, are the most common cause, and worldwide outbreaks have been increasingly described. One prior report suggests that early IV fluid administration results in improved outcomes.

Study design: Prospective cohort study.

Setting: Eleven pediatric hospitals in the U.S. and Scotland.

Synopsis: Fifty children with diarrhea-associated HUS were enrolled and received clinical care at the discretion of the local provider, independent of the study. A family questionnaire (to define initial illness) and chart review were subsequently performed. Oligoanuria, defined as a urine output of less than 0.5 mL/kg/hr for at least one calendar day after HUS onset, was present in 34 (68%) patients. Oligoanuric and nonoligoanuric patients were similar at baseline; however, there was a significant association between less fluid administration in the first four days of illness and oligoanuria. Specifically, lack of IV fluids portended a 1.6 times higher likelihood of oligoanuria (95% confidence interval, 1.1-2.4; P=0.02).

The authors also suggest a dose-response relationship to their findings, which potentially strengthens their findings. However, the practical applicability of these findings appears limited. Many of the patients who did not receive IV fluids early on were also not admitted to a hospital, likely signifying mild illness without notable dehydration. Replicability of the benefits of early volume expansion in HUS will depend on the ability to accurately identify patients with Shiga-toxin-producing diarrheal illnesses at presentation. If this is feasible, it would be interesting to examine the details of oral hydration as well, particularly in those who are not dehydrated enough to require hospitalization.

Bottom line: Early IV fluids might be nephroprotective in diarrhea-associated HUS.

Citation: Hickey CA, Beattie J, Cowieson J, et al. Early volume expansion during diarrhea and relative nephroprotection during subsequent hemolytic uremic syndrome. Arch Pediatr Adolesc Med. 2011;165:884-889.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is oral trimethoprim-sulfamethoxazole (TMP-SMX) a therapeutic option for the treatment of acute osteomyelitis in children?

Background: With the recent increase in methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis in children, both clindamycin and vancomycin have become common first-line options for treatment. MRSA’s resistance to clindamycin and the potential for the development of resistance to vancomycin are significant concerns with both of these approaches. The efficacy of TMP-SMX in acute osteomyelitis is unknown, despite almost uniform susceptibility of MRSA to TMP-SMX and excellent oral bioavailability.

Study design: Retrospective chart review.

Setting: Tertiary-care children’s hospital.

Synopsis: Twenty patients with acute osteomyelitis who had received TMP-SMX and had documented follow-up were identified from 1998 to 2009. All patients were presumed to have staphylococcal disease either confirmed via positive culture (eight patients) or history and/or initial response to antistaphylococcal antibiotics. Fifteen of the patients initially received vancomycin or clindamycin for a median of 4.5 days before then receiving TMP-SMX. Nineteen patients received TMP-SMX primarily via the oral route. The median duration of total antibiotic therapy was 40 days. At the end of therapy, all patients were effectively treated with complete resolution of symptoms. Eight patients did experience mild adverse events to TMP-SMX and were switched to an alternative antibiotic.

The study demonstrates that oral TMP-SMX is a potential therapeutic option for staphylococcal acute osteomyelitis in children. Although theoretical concerns regarding efficacy have limited its use in severe staphylococcal infections, resistance patterns will increasingly necessitate consideration of palatable alternatives to vancomycin and clindamycin. This retrospective nature of this report, the lack of long-term follow-up beyond the completion of therapy, and the high rate of antibiotic-switching due to adverse events are limitations that preclude immediate and widespread uptake of this antibiotic regimen.

Bottom line: Oral TMP-SMX is a potentially effective option for acute staphylococcal osteomyelitis.

Citation: Messina AF, Namtu K, Guild M, Dumois JA, Berman DM. Trimethoprim-sulfamethoxazole therapy for children with acute osteomyelitis. Pediatr Infect Dis J. 2011;30:1019-1021.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is oral trimethoprim-sulfamethoxazole (TMP-SMX) a therapeutic option for the treatment of acute osteomyelitis in children?

Background: With the recent increase in methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis in children, both clindamycin and vancomycin have become common first-line options for treatment. MRSA’s resistance to clindamycin and the potential for the development of resistance to vancomycin are significant concerns with both of these approaches. The efficacy of TMP-SMX in acute osteomyelitis is unknown, despite almost uniform susceptibility of MRSA to TMP-SMX and excellent oral bioavailability.

Study design: Retrospective chart review.

Setting: Tertiary-care children’s hospital.

Synopsis: Twenty patients with acute osteomyelitis who had received TMP-SMX and had documented follow-up were identified from 1998 to 2009. All patients were presumed to have staphylococcal disease either confirmed via positive culture (eight patients) or history and/or initial response to antistaphylococcal antibiotics. Fifteen of the patients initially received vancomycin or clindamycin for a median of 4.5 days before then receiving TMP-SMX. Nineteen patients received TMP-SMX primarily via the oral route. The median duration of total antibiotic therapy was 40 days. At the end of therapy, all patients were effectively treated with complete resolution of symptoms. Eight patients did experience mild adverse events to TMP-SMX and were switched to an alternative antibiotic.

The study demonstrates that oral TMP-SMX is a potential therapeutic option for staphylococcal acute osteomyelitis in children. Although theoretical concerns regarding efficacy have limited its use in severe staphylococcal infections, resistance patterns will increasingly necessitate consideration of palatable alternatives to vancomycin and clindamycin. This retrospective nature of this report, the lack of long-term follow-up beyond the completion of therapy, and the high rate of antibiotic-switching due to adverse events are limitations that preclude immediate and widespread uptake of this antibiotic regimen.

Bottom line: Oral TMP-SMX is a potentially effective option for acute staphylococcal osteomyelitis.

Citation: Messina AF, Namtu K, Guild M, Dumois JA, Berman DM. Trimethoprim-sulfamethoxazole therapy for children with acute osteomyelitis. Pediatr Infect Dis J. 2011;30:1019-1021.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is oral trimethoprim-sulfamethoxazole (TMP-SMX) a therapeutic option for the treatment of acute osteomyelitis in children?

Background: With the recent increase in methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis in children, both clindamycin and vancomycin have become common first-line options for treatment. MRSA’s resistance to clindamycin and the potential for the development of resistance to vancomycin are significant concerns with both of these approaches. The efficacy of TMP-SMX in acute osteomyelitis is unknown, despite almost uniform susceptibility of MRSA to TMP-SMX and excellent oral bioavailability.

Study design: Retrospective chart review.

Setting: Tertiary-care children’s hospital.

Synopsis: Twenty patients with acute osteomyelitis who had received TMP-SMX and had documented follow-up were identified from 1998 to 2009. All patients were presumed to have staphylococcal disease either confirmed via positive culture (eight patients) or history and/or initial response to antistaphylococcal antibiotics. Fifteen of the patients initially received vancomycin or clindamycin for a median of 4.5 days before then receiving TMP-SMX. Nineteen patients received TMP-SMX primarily via the oral route. The median duration of total antibiotic therapy was 40 days. At the end of therapy, all patients were effectively treated with complete resolution of symptoms. Eight patients did experience mild adverse events to TMP-SMX and were switched to an alternative antibiotic.

The study demonstrates that oral TMP-SMX is a potential therapeutic option for staphylococcal acute osteomyelitis in children. Although theoretical concerns regarding efficacy have limited its use in severe staphylococcal infections, resistance patterns will increasingly necessitate consideration of palatable alternatives to vancomycin and clindamycin. This retrospective nature of this report, the lack of long-term follow-up beyond the completion of therapy, and the high rate of antibiotic-switching due to adverse events are limitations that preclude immediate and widespread uptake of this antibiotic regimen.

Bottom line: Oral TMP-SMX is a potentially effective option for acute staphylococcal osteomyelitis.

Citation: Messina AF, Namtu K, Guild M, Dumois JA, Berman DM. Trimethoprim-sulfamethoxazole therapy for children with acute osteomyelitis. Pediatr Infect Dis J. 2011;30:1019-1021.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What are the rates of serious bacterial infection (SBI) in infants with bronchiolitis?

Background: Fever is common in young infants with viral bronchiolitis. Infants younger than 90 days of age with clinical bronchiolitis and fever often are evaluated according to established guidelines for fever without source. The extent to which this work-up is necessary remains unclear, as rates for bacteremia, urinary tract infections (UTIs), and meningitis have not been precisely defined in this population.

Study design: Systematic review of the literature.

Synopsis: After a Medline database search including the terms serious bacterial infection, bacteremia, meningitis, urinary tract infection, bronchiolitis, and respiratory syncytial virus (RSV), studies and bibliographies were screened for articles that allowed for a calculation of site- and age-specific rates of SBI. Studies based in ICUs and studies of pneumonia were excluded. Eleven studies were analyzed.

The prevalence rate for UTI was 3.3% based on a random effects meta-analysis. Study design and setting did not appear to influence this rate; however, the prevalence of UTI was higher in RSV-positive infants as opposed to infants with clinical bronchiolitis. Rates for bacteremia were very low, and there were no reported cases of meningitis.

This study provides useful information to guide clinical decision-making in the setting of a young, febrile infant presenting with bronchiolitis. Nonselective work-up for SBI appeared to be routine in the studies reviewed; the yield of work-up for bacteremia was extremely low (and zero for meningitis). Thus, investigations of blood and cerebrospinal fluid might be unnecessary in the uncomplicated patient.

Although it appears that UTIs do occur with reasonable frequency in this population, a primary limitation of the review is that the studies analyzed primarily used urine culture as a means of diagnosis without publication of urinalysis results. This increases the likelihood that UTI rates are overestimated in this population, as asymptomatic bacteriuria is a potential confounder.

Bottom line: Serious bacterial infection is rare in febrile young infants with bronchiolitis.

Citation: Ralston S, Hill V, Waters A. Occult serious bacterial infection in infants younger than 60 to 90 days with bronchiolitis: a systematic review. Arch Pediatr Adolesc Med. 2011;165(10):951-956.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What are the rates of serious bacterial infection (SBI) in infants with bronchiolitis?

Background: Fever is common in young infants with viral bronchiolitis. Infants younger than 90 days of age with clinical bronchiolitis and fever often are evaluated according to established guidelines for fever without source. The extent to which this work-up is necessary remains unclear, as rates for bacteremia, urinary tract infections (UTIs), and meningitis have not been precisely defined in this population.

Study design: Systematic review of the literature.

Synopsis: After a Medline database search including the terms serious bacterial infection, bacteremia, meningitis, urinary tract infection, bronchiolitis, and respiratory syncytial virus (RSV), studies and bibliographies were screened for articles that allowed for a calculation of site- and age-specific rates of SBI. Studies based in ICUs and studies of pneumonia were excluded. Eleven studies were analyzed.

The prevalence rate for UTI was 3.3% based on a random effects meta-analysis. Study design and setting did not appear to influence this rate; however, the prevalence of UTI was higher in RSV-positive infants as opposed to infants with clinical bronchiolitis. Rates for bacteremia were very low, and there were no reported cases of meningitis.

This study provides useful information to guide clinical decision-making in the setting of a young, febrile infant presenting with bronchiolitis. Nonselective work-up for SBI appeared to be routine in the studies reviewed; the yield of work-up for bacteremia was extremely low (and zero for meningitis). Thus, investigations of blood and cerebrospinal fluid might be unnecessary in the uncomplicated patient.

Although it appears that UTIs do occur with reasonable frequency in this population, a primary limitation of the review is that the studies analyzed primarily used urine culture as a means of diagnosis without publication of urinalysis results. This increases the likelihood that UTI rates are overestimated in this population, as asymptomatic bacteriuria is a potential confounder.

Bottom line: Serious bacterial infection is rare in febrile young infants with bronchiolitis.

Citation: Ralston S, Hill V, Waters A. Occult serious bacterial infection in infants younger than 60 to 90 days with bronchiolitis: a systematic review. Arch Pediatr Adolesc Med. 2011;165(10):951-956.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What are the rates of serious bacterial infection (SBI) in infants with bronchiolitis?

Background: Fever is common in young infants with viral bronchiolitis. Infants younger than 90 days of age with clinical bronchiolitis and fever often are evaluated according to established guidelines for fever without source. The extent to which this work-up is necessary remains unclear, as rates for bacteremia, urinary tract infections (UTIs), and meningitis have not been precisely defined in this population.

Study design: Systematic review of the literature.

Synopsis: After a Medline database search including the terms serious bacterial infection, bacteremia, meningitis, urinary tract infection, bronchiolitis, and respiratory syncytial virus (RSV), studies and bibliographies were screened for articles that allowed for a calculation of site- and age-specific rates of SBI. Studies based in ICUs and studies of pneumonia were excluded. Eleven studies were analyzed.

The prevalence rate for UTI was 3.3% based on a random effects meta-analysis. Study design and setting did not appear to influence this rate; however, the prevalence of UTI was higher in RSV-positive infants as opposed to infants with clinical bronchiolitis. Rates for bacteremia were very low, and there were no reported cases of meningitis.

This study provides useful information to guide clinical decision-making in the setting of a young, febrile infant presenting with bronchiolitis. Nonselective work-up for SBI appeared to be routine in the studies reviewed; the yield of work-up for bacteremia was extremely low (and zero for meningitis). Thus, investigations of blood and cerebrospinal fluid might be unnecessary in the uncomplicated patient.

Although it appears that UTIs do occur with reasonable frequency in this population, a primary limitation of the review is that the studies analyzed primarily used urine culture as a means of diagnosis without publication of urinalysis results. This increases the likelihood that UTI rates are overestimated in this population, as asymptomatic bacteriuria is a potential confounder.

Bottom line: Serious bacterial infection is rare in febrile young infants with bronchiolitis.

Citation: Ralston S, Hill V, Waters A. Occult serious bacterial infection in infants younger than 60 to 90 days with bronchiolitis: a systematic review. Arch Pediatr Adolesc Med. 2011;165(10):951-956.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the epidemiology of 15-day readmissions to a children’s hospital?

Background: Readmissions are a common event in the adult population. Given the national focus on accountable care across the continuum, the Centers for Medicare & Medicaid Services (CMS) has devoted increasing attention to readmissions as a reportable quality metric in certain conditions and a target for improvement. Recommendations for pediatric patients are currently not available, primarily due to limited evidence.

Study design: Retrospective chart review.

Setting: Tertiary-care children’s hospital.

Synopsis: Of the 30,188 admissions over a two-year period, 2,546 (8.4%) resulted in readmission within 15 days. There were a total of 1,435 individual patients who were readmitted, for an average readmission rate of 1.8 per patient. Oncology patients represented the most likely group of patients to be readmitted (13.9%) and had the most number of readmissions per patient (4.1). Children with acute infectious disease, newborns, and patients with neurologic diseases represented 11.4%, 11.1%, and 10% of the readmitted patients, respectively.

Children with short-bowel syndrome and biliary atresia had a high number of readmissions per patient: 3.9 and 3.8, respectively. The majority of readmissions were unplanned (79.4%) and occurred in patients with an underlying chronic condition (78%). Readmissions 7 days from discharge accounted for 59.5% of the total, with the remaining 40.5% occurring between eight and 15 days of discharge.

This study provides one of the more comprehensive pictures of readmissions to a children’s hospital. Although the data are limited by an inability to account for readmissions to and from other facilities, they nonetheless clearly differentiate pediatric readmissions from those in an adult population.

Bottom line: Pediatric readmissions are quantitatively and qualitatively different from adult readmissions.

Citation: Gay JC, Hain PD, Grantham JA, Saville BR. Epidemiology of 15-day readmissions to a children’s hospital. Pediatrics. 2011;127:e1-e8.

Clinical question: What is the epidemiology of 15-day readmissions to a children’s hospital?

Background: Readmissions are a common event in the adult population. Given the national focus on accountable care across the continuum, the Centers for Medicare & Medicaid Services (CMS) has devoted increasing attention to readmissions as a reportable quality metric in certain conditions and a target for improvement. Recommendations for pediatric patients are currently not available, primarily due to limited evidence.

Study design: Retrospective chart review.

Setting: Tertiary-care children’s hospital.

Synopsis: Of the 30,188 admissions over a two-year period, 2,546 (8.4%) resulted in readmission within 15 days. There were a total of 1,435 individual patients who were readmitted, for an average readmission rate of 1.8 per patient. Oncology patients represented the most likely group of patients to be readmitted (13.9%) and had the most number of readmissions per patient (4.1). Children with acute infectious disease, newborns, and patients with neurologic diseases represented 11.4%, 11.1%, and 10% of the readmitted patients, respectively.

Children with short-bowel syndrome and biliary atresia had a high number of readmissions per patient: 3.9 and 3.8, respectively. The majority of readmissions were unplanned (79.4%) and occurred in patients with an underlying chronic condition (78%). Readmissions 7 days from discharge accounted for 59.5% of the total, with the remaining 40.5% occurring between eight and 15 days of discharge.

This study provides one of the more comprehensive pictures of readmissions to a children’s hospital. Although the data are limited by an inability to account for readmissions to and from other facilities, they nonetheless clearly differentiate pediatric readmissions from those in an adult population.

Bottom line: Pediatric readmissions are quantitatively and qualitatively different from adult readmissions.

Citation: Gay JC, Hain PD, Grantham JA, Saville BR. Epidemiology of 15-day readmissions to a children’s hospital. Pediatrics. 2011;127:e1-e8.

Clinical question: What is the epidemiology of 15-day readmissions to a children’s hospital?

Background: Readmissions are a common event in the adult population. Given the national focus on accountable care across the continuum, the Centers for Medicare & Medicaid Services (CMS) has devoted increasing attention to readmissions as a reportable quality metric in certain conditions and a target for improvement. Recommendations for pediatric patients are currently not available, primarily due to limited evidence.

Study design: Retrospective chart review.

Setting: Tertiary-care children’s hospital.

Synopsis: Of the 30,188 admissions over a two-year period, 2,546 (8.4%) resulted in readmission within 15 days. There were a total of 1,435 individual patients who were readmitted, for an average readmission rate of 1.8 per patient. Oncology patients represented the most likely group of patients to be readmitted (13.9%) and had the most number of readmissions per patient (4.1). Children with acute infectious disease, newborns, and patients with neurologic diseases represented 11.4%, 11.1%, and 10% of the readmitted patients, respectively.

Children with short-bowel syndrome and biliary atresia had a high number of readmissions per patient: 3.9 and 3.8, respectively. The majority of readmissions were unplanned (79.4%) and occurred in patients with an underlying chronic condition (78%). Readmissions 7 days from discharge accounted for 59.5% of the total, with the remaining 40.5% occurring between eight and 15 days of discharge.

This study provides one of the more comprehensive pictures of readmissions to a children’s hospital. Although the data are limited by an inability to account for readmissions to and from other facilities, they nonetheless clearly differentiate pediatric readmissions from those in an adult population.

Bottom line: Pediatric readmissions are quantitatively and qualitatively different from adult readmissions.

Citation: Gay JC, Hain PD, Grantham JA, Saville BR. Epidemiology of 15-day readmissions to a children’s hospital. Pediatrics. 2011;127:e1-e8.

I sincerely appreciate the responses to my review of an article (“Incidence Rates of Kernicterus Remain Unchanged,” The Hospitalist, October 2011, p. 12) that raised questions regarding a “resurgence” of kernicterus in the 1990s. Kernicterus is a devastating illness, and family members bear an unquestionable burden from this disease. Because phototherapy appears to limit the burden of disease, evidence-based guidelines for appropriate treatment of hyperbilirubinemia are paramount to decreasing the incidence of kernicterus. True rates of kernicterus have been difficult to calculate for a variety of reasons, yet we must get a handle on “who” gets kernicterus if we are to appropriately decide which infants receive phototherapy. Thus, I would strongly agree that using the California database is a limitation of the study reviewed.

The mission of the monthly “Pediatric HM” literature review is to regularly summarize articles that might be of interest in the field of pediatric HM. The letters to the editor we received highlight a critical need to delve deeper into the epidemiology of kernicterus, a journey that must begin with accurate reporting of this disease. We appreciate the opportunity to raise awareness of family-centered concerns surrounding the interpretation and analysis of scientific evidence.

As a final note, Mr. Spencer Brown’s letter states that “nearly half of all babies born (44,000 out of every 100,000) have hyperbilirubinemia” based on an incidence of 0.44 per 100,000 mentioned in my review. I would clarify that 0.44 per 100,000 is a rate of kernicterus and is not a percentage. Thus, 0.44 out of 100,000 children (or 4.4 per million) will develop kernicterus, not 44,000 per 100,000.

Mark Shen, MD, FHM, director of hospital medicine, Dell Children’s Medical Center, Austin, Texas, pediatric physician editor, The Hospitalist

I sincerely appreciate the responses to my review of an article (“Incidence Rates of Kernicterus Remain Unchanged,” The Hospitalist, October 2011, p. 12) that raised questions regarding a “resurgence” of kernicterus in the 1990s. Kernicterus is a devastating illness, and family members bear an unquestionable burden from this disease. Because phototherapy appears to limit the burden of disease, evidence-based guidelines for appropriate treatment of hyperbilirubinemia are paramount to decreasing the incidence of kernicterus. True rates of kernicterus have been difficult to calculate for a variety of reasons, yet we must get a handle on “who” gets kernicterus if we are to appropriately decide which infants receive phototherapy. Thus, I would strongly agree that using the California database is a limitation of the study reviewed.

The mission of the monthly “Pediatric HM” literature review is to regularly summarize articles that might be of interest in the field of pediatric HM. The letters to the editor we received highlight a critical need to delve deeper into the epidemiology of kernicterus, a journey that must begin with accurate reporting of this disease. We appreciate the opportunity to raise awareness of family-centered concerns surrounding the interpretation and analysis of scientific evidence.

As a final note, Mr. Spencer Brown’s letter states that “nearly half of all babies born (44,000 out of every 100,000) have hyperbilirubinemia” based on an incidence of 0.44 per 100,000 mentioned in my review. I would clarify that 0.44 per 100,000 is a rate of kernicterus and is not a percentage. Thus, 0.44 out of 100,000 children (or 4.4 per million) will develop kernicterus, not 44,000 per 100,000.

Mark Shen, MD, FHM, director of hospital medicine, Dell Children’s Medical Center, Austin, Texas, pediatric physician editor, The Hospitalist

I sincerely appreciate the responses to my review of an article (“Incidence Rates of Kernicterus Remain Unchanged,” The Hospitalist, October 2011, p. 12) that raised questions regarding a “resurgence” of kernicterus in the 1990s. Kernicterus is a devastating illness, and family members bear an unquestionable burden from this disease. Because phototherapy appears to limit the burden of disease, evidence-based guidelines for appropriate treatment of hyperbilirubinemia are paramount to decreasing the incidence of kernicterus. True rates of kernicterus have been difficult to calculate for a variety of reasons, yet we must get a handle on “who” gets kernicterus if we are to appropriately decide which infants receive phototherapy. Thus, I would strongly agree that using the California database is a limitation of the study reviewed.

The mission of the monthly “Pediatric HM” literature review is to regularly summarize articles that might be of interest in the field of pediatric HM. The letters to the editor we received highlight a critical need to delve deeper into the epidemiology of kernicterus, a journey that must begin with accurate reporting of this disease. We appreciate the opportunity to raise awareness of family-centered concerns surrounding the interpretation and analysis of scientific evidence.

As a final note, Mr. Spencer Brown’s letter states that “nearly half of all babies born (44,000 out of every 100,000) have hyperbilirubinemia” based on an incidence of 0.44 per 100,000 mentioned in my review. I would clarify that 0.44 per 100,000 is a rate of kernicterus and is not a percentage. Thus, 0.44 out of 100,000 children (or 4.4 per million) will develop kernicterus, not 44,000 per 100,000.

Mark Shen, MD, FHM, director of hospital medicine, Dell Children’s Medical Center, Austin, Texas, pediatric physician editor, The Hospitalist