Pediatric Hospital Medicine 2013

NEW ORLEANS – How did dehydration, an order for a peripherally inserted central catheter line, and the bright lights of the ward add up to a full-thickness burn on an infant?

The simple answer is a flashlight.

The more telling response is that the PICC line wasn’t needed in the first place – much less the 20 minutes spent trying to isolate a vein with a flashlight. The infant rebounded with intravenous fluids and by simply advancing feeding volumes, Dr. Alan R. Schroeder said at the Pediatric Hospital Medicine 2013 meeting.

"When we think about patient safety and errors, we spend an awful lot of time talking about how could we better optimize the PICC line process, but we don’t spend as much time on whether this PICC line was even necessary," he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Patrice Wendling/IMNG Medical Media

Indeed, physicians are quite good at responding when asked to do more. A recent study of ambulatory health care utilization shows that six of nine quality indicators of underuse improved between 1999 and 2009, whereas only two of eleven overuse indicators got better (JAMA Intern. Med. 2013;173:142-8).

Still, the unnecessary care movement is picking up steam in recent years, insists Dr. Schroeder of the department of pediatrics, Santa Clara Valley Medical Center, San Jose, Calif.

Three medical meetings, including the Preventing Overdiagnosis Conference, were organized this year specifically on medical overutilization, with at least one article devoted each month to the topic in JAMA Internal Medicine.

The Image Wisely initiative has garnered 18,621 pledges to lower the amount of radiation used, while the Choosing Wisely campaign, challenging medical societies to identify five things physicians and patients should question, is bearing fruit.

The pediatric committee of the Society of Hospital Medicine was the first pediatric subspecialty group to respond to the challenge, with a panel of experts, including Schroeder, recently publishing the top five recommendations for pediatric hospital medicine (J. Hosp. Med. 2013 [doi:10.1002/jhm.2064]).

" ‘Less is more’ is almost becoming a trend," Dr. Schroeder said.

Widely publicized public health mistakes in adult medicine, like near-universal prostate-specific antigen testing in men and hormone therapy for menopausal women, coupled with a financially stressed health care system, have helped move the needle. But several barriers to safely doing less still remain, he observed.

Time pressures, malpractice concerns, and pressure from families and colleagues all push physicians to increase healthcare utilization. The case of 12-year-old Rory Staunton, who died last year from potentially preventable septic shock after being released from the emergency department, has prompted new measures nationwide to spot sepsis earlier and a slew of stories in the New York Times and other publications.

The response was quite different, however, when two other adolescents, Jenny Olenick and Ben Ellis, died during or within hours of routine wisdom teeth extraction, a procedure that has been suggested as unnecessary 60% of the time, Dr. Schroeder said.

"They were killed by health care," he said. "This is a commission error, yet this has had scant media coverage. This is the type of case that should really, really upset you."

He went on to say that the omission/commission philosophy has its roots in medical education school.

"A lot of you are doing noble jobs trying to change that, but traditionally we are taught from day one not to miss a diagnosis," he said. "You have to generate these very, very broad differential diagnoses. We don’t want to be the guy that misses a diagnosis on day one and someone else comes in and makes a diagnosis on day two."

Money as motive

Another powerful barrier to safely doing less is the financial motive. Some of the best work in this area was the 2009 watershed essay by surgeon Atul Gawande showing that the strong entrepreneurial spirit in McAllen, Texas, doubled Medicare spending, compared with nearby El Paso, without improving outcomes, Dr. Schroeder observed. Recent research also refuted the widely endorsed belief that PSA screening improves outcomes by picking up more cancers than diagnosing based on symptoms. It was a hard-fought battle with high financial stakes, with some 30 million men undergoing PSA testing each year at a cost of $3 billion.

"There’s not a billboard outside my hospital saying ‘Come see Dr. Schroeder because today he will do less for you,’ " he said. "I wish there were one, but it’s not going to bring patients in or help the hospital’s bottom line."

Dr. Schroeder called for financing reform to disconnect reimbursement from utilization by compensating physicians for how they do their job, not what they do. There was also a pitch for comparative-effectiveness research to confirm that existing therapies are of benefit and if not, should not be reimbursed. As role models, he cited an unfunded, randomized controlled study presented at the meeting on nebulized hypertonic saline, and a voluntary quality improvement collaborative of pediatric hospitalists that cut bronchodilator use by 46% among inpatients with bronchiolitis (J. Hosp. Med. 2013;8:25-30). Not surprising, one of the top five new recommendations for pediatric hospital medicine is: "Do not use bronchodilators in children with bronchiolitis."

Talk about ‘less’

Dr. Schroeder urged the audience of some 1,000 pediatric hospitalists to introduce "safely doing less" into the patient-safety dialogue. Clinicians should always remind their patients and trainees of unanticipated harms. Instead of saying, "It’s a straightforward procedure," try saying, "There isn’t a procedure out there that can’t make someone worse or cause harm."

When there’s an adverse event at your institution, he advised clinicians not to just focus on the details of the incident, but also on the necessity of the interventions that led up to the incident. This strategy was conspicuous in its absence during the recent meningitis outbreak from contaminated steroid injections for back and neuropathic pain, that prompted 749 cases of fungal infection, 63 deaths, and a massive, multistate investigation.

"Everyone wanted to know how this could have happened; where was the regulation behind the compounding pharmacy, which is a worthy question," he said. "But it took weeks before it came out that these epidural steroid injections aren’t evidence based, although they sure make a lot of money."

Finally, he suggested the audience redefine the term "conservative" care from its current definition of test and treat to watch and wait.

During a discussion immediately following the lecture, however, attendee and pediatric hospitalist Lynn Campbell, who is with Dell Children’s Medical Center of Central Texas, in Austin, pointed out that, unlike primary care providers or ED physicians, hospitalists come into the game midstream and thus don’t have the same trust level established with families when trying to take away unnecessary tests or therapies.

Dr. Schroeder said many families don’t want more therapies, like antibiotics, and just want to take their child home, but added, "There are no easy answers."

Dr. Schroeder reported having no financial disclosures.

[email protected]

NEW ORLEANS – How did dehydration, an order for a peripherally inserted central catheter line, and the bright lights of the ward add up to a full-thickness burn on an infant?

The simple answer is a flashlight.

The more telling response is that the PICC line wasn’t needed in the first place – much less the 20 minutes spent trying to isolate a vein with a flashlight. The infant rebounded with intravenous fluids and by simply advancing feeding volumes, Dr. Alan R. Schroeder said at the Pediatric Hospital Medicine 2013 meeting.

"When we think about patient safety and errors, we spend an awful lot of time talking about how could we better optimize the PICC line process, but we don’t spend as much time on whether this PICC line was even necessary," he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Patrice Wendling/IMNG Medical Media

Indeed, physicians are quite good at responding when asked to do more. A recent study of ambulatory health care utilization shows that six of nine quality indicators of underuse improved between 1999 and 2009, whereas only two of eleven overuse indicators got better (JAMA Intern. Med. 2013;173:142-8).

Still, the unnecessary care movement is picking up steam in recent years, insists Dr. Schroeder of the department of pediatrics, Santa Clara Valley Medical Center, San Jose, Calif.

Three medical meetings, including the Preventing Overdiagnosis Conference, were organized this year specifically on medical overutilization, with at least one article devoted each month to the topic in JAMA Internal Medicine.

The Image Wisely initiative has garnered 18,621 pledges to lower the amount of radiation used, while the Choosing Wisely campaign, challenging medical societies to identify five things physicians and patients should question, is bearing fruit.

The pediatric committee of the Society of Hospital Medicine was the first pediatric subspecialty group to respond to the challenge, with a panel of experts, including Schroeder, recently publishing the top five recommendations for pediatric hospital medicine (J. Hosp. Med. 2013 [doi:10.1002/jhm.2064]).

" ‘Less is more’ is almost becoming a trend," Dr. Schroeder said.

Widely publicized public health mistakes in adult medicine, like near-universal prostate-specific antigen testing in men and hormone therapy for menopausal women, coupled with a financially stressed health care system, have helped move the needle. But several barriers to safely doing less still remain, he observed.

Time pressures, malpractice concerns, and pressure from families and colleagues all push physicians to increase healthcare utilization. The case of 12-year-old Rory Staunton, who died last year from potentially preventable septic shock after being released from the emergency department, has prompted new measures nationwide to spot sepsis earlier and a slew of stories in the New York Times and other publications.

The response was quite different, however, when two other adolescents, Jenny Olenick and Ben Ellis, died during or within hours of routine wisdom teeth extraction, a procedure that has been suggested as unnecessary 60% of the time, Dr. Schroeder said.

"They were killed by health care," he said. "This is a commission error, yet this has had scant media coverage. This is the type of case that should really, really upset you."

He went on to say that the omission/commission philosophy has its roots in medical education school.

"A lot of you are doing noble jobs trying to change that, but traditionally we are taught from day one not to miss a diagnosis," he said. "You have to generate these very, very broad differential diagnoses. We don’t want to be the guy that misses a diagnosis on day one and someone else comes in and makes a diagnosis on day two."

Money as motive

Another powerful barrier to safely doing less is the financial motive. Some of the best work in this area was the 2009 watershed essay by surgeon Atul Gawande showing that the strong entrepreneurial spirit in McAllen, Texas, doubled Medicare spending, compared with nearby El Paso, without improving outcomes, Dr. Schroeder observed. Recent research also refuted the widely endorsed belief that PSA screening improves outcomes by picking up more cancers than diagnosing based on symptoms. It was a hard-fought battle with high financial stakes, with some 30 million men undergoing PSA testing each year at a cost of $3 billion.

"There’s not a billboard outside my hospital saying ‘Come see Dr. Schroeder because today he will do less for you,’ " he said. "I wish there were one, but it’s not going to bring patients in or help the hospital’s bottom line."

Dr. Schroeder called for financing reform to disconnect reimbursement from utilization by compensating physicians for how they do their job, not what they do. There was also a pitch for comparative-effectiveness research to confirm that existing therapies are of benefit and if not, should not be reimbursed. As role models, he cited an unfunded, randomized controlled study presented at the meeting on nebulized hypertonic saline, and a voluntary quality improvement collaborative of pediatric hospitalists that cut bronchodilator use by 46% among inpatients with bronchiolitis (J. Hosp. Med. 2013;8:25-30). Not surprising, one of the top five new recommendations for pediatric hospital medicine is: "Do not use bronchodilators in children with bronchiolitis."

Talk about ‘less’

Dr. Schroeder urged the audience of some 1,000 pediatric hospitalists to introduce "safely doing less" into the patient-safety dialogue. Clinicians should always remind their patients and trainees of unanticipated harms. Instead of saying, "It’s a straightforward procedure," try saying, "There isn’t a procedure out there that can’t make someone worse or cause harm."

When there’s an adverse event at your institution, he advised clinicians not to just focus on the details of the incident, but also on the necessity of the interventions that led up to the incident. This strategy was conspicuous in its absence during the recent meningitis outbreak from contaminated steroid injections for back and neuropathic pain, that prompted 749 cases of fungal infection, 63 deaths, and a massive, multistate investigation.

"Everyone wanted to know how this could have happened; where was the regulation behind the compounding pharmacy, which is a worthy question," he said. "But it took weeks before it came out that these epidural steroid injections aren’t evidence based, although they sure make a lot of money."

Finally, he suggested the audience redefine the term "conservative" care from its current definition of test and treat to watch and wait.

During a discussion immediately following the lecture, however, attendee and pediatric hospitalist Lynn Campbell, who is with Dell Children’s Medical Center of Central Texas, in Austin, pointed out that, unlike primary care providers or ED physicians, hospitalists come into the game midstream and thus don’t have the same trust level established with families when trying to take away unnecessary tests or therapies.

Dr. Schroeder said many families don’t want more therapies, like antibiotics, and just want to take their child home, but added, "There are no easy answers."

Dr. Schroeder reported having no financial disclosures.

[email protected]

NEW ORLEANS – How did dehydration, an order for a peripherally inserted central catheter line, and the bright lights of the ward add up to a full-thickness burn on an infant?

The simple answer is a flashlight.

The more telling response is that the PICC line wasn’t needed in the first place – much less the 20 minutes spent trying to isolate a vein with a flashlight. The infant rebounded with intravenous fluids and by simply advancing feeding volumes, Dr. Alan R. Schroeder said at the Pediatric Hospital Medicine 2013 meeting.

"When we think about patient safety and errors, we spend an awful lot of time talking about how could we better optimize the PICC line process, but we don’t spend as much time on whether this PICC line was even necessary," he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Patrice Wendling/IMNG Medical Media

Indeed, physicians are quite good at responding when asked to do more. A recent study of ambulatory health care utilization shows that six of nine quality indicators of underuse improved between 1999 and 2009, whereas only two of eleven overuse indicators got better (JAMA Intern. Med. 2013;173:142-8).

Still, the unnecessary care movement is picking up steam in recent years, insists Dr. Schroeder of the department of pediatrics, Santa Clara Valley Medical Center, San Jose, Calif.

Three medical meetings, including the Preventing Overdiagnosis Conference, were organized this year specifically on medical overutilization, with at least one article devoted each month to the topic in JAMA Internal Medicine.

The Image Wisely initiative has garnered 18,621 pledges to lower the amount of radiation used, while the Choosing Wisely campaign, challenging medical societies to identify five things physicians and patients should question, is bearing fruit.

The pediatric committee of the Society of Hospital Medicine was the first pediatric subspecialty group to respond to the challenge, with a panel of experts, including Schroeder, recently publishing the top five recommendations for pediatric hospital medicine (J. Hosp. Med. 2013 [doi:10.1002/jhm.2064]).

" ‘Less is more’ is almost becoming a trend," Dr. Schroeder said.

Widely publicized public health mistakes in adult medicine, like near-universal prostate-specific antigen testing in men and hormone therapy for menopausal women, coupled with a financially stressed health care system, have helped move the needle. But several barriers to safely doing less still remain, he observed.

Time pressures, malpractice concerns, and pressure from families and colleagues all push physicians to increase healthcare utilization. The case of 12-year-old Rory Staunton, who died last year from potentially preventable septic shock after being released from the emergency department, has prompted new measures nationwide to spot sepsis earlier and a slew of stories in the New York Times and other publications.

The response was quite different, however, when two other adolescents, Jenny Olenick and Ben Ellis, died during or within hours of routine wisdom teeth extraction, a procedure that has been suggested as unnecessary 60% of the time, Dr. Schroeder said.

"They were killed by health care," he said. "This is a commission error, yet this has had scant media coverage. This is the type of case that should really, really upset you."

He went on to say that the omission/commission philosophy has its roots in medical education school.

"A lot of you are doing noble jobs trying to change that, but traditionally we are taught from day one not to miss a diagnosis," he said. "You have to generate these very, very broad differential diagnoses. We don’t want to be the guy that misses a diagnosis on day one and someone else comes in and makes a diagnosis on day two."

Money as motive

Another powerful barrier to safely doing less is the financial motive. Some of the best work in this area was the 2009 watershed essay by surgeon Atul Gawande showing that the strong entrepreneurial spirit in McAllen, Texas, doubled Medicare spending, compared with nearby El Paso, without improving outcomes, Dr. Schroeder observed. Recent research also refuted the widely endorsed belief that PSA screening improves outcomes by picking up more cancers than diagnosing based on symptoms. It was a hard-fought battle with high financial stakes, with some 30 million men undergoing PSA testing each year at a cost of $3 billion.

"There’s not a billboard outside my hospital saying ‘Come see Dr. Schroeder because today he will do less for you,’ " he said. "I wish there were one, but it’s not going to bring patients in or help the hospital’s bottom line."

Dr. Schroeder called for financing reform to disconnect reimbursement from utilization by compensating physicians for how they do their job, not what they do. There was also a pitch for comparative-effectiveness research to confirm that existing therapies are of benefit and if not, should not be reimbursed. As role models, he cited an unfunded, randomized controlled study presented at the meeting on nebulized hypertonic saline, and a voluntary quality improvement collaborative of pediatric hospitalists that cut bronchodilator use by 46% among inpatients with bronchiolitis (J. Hosp. Med. 2013;8:25-30). Not surprising, one of the top five new recommendations for pediatric hospital medicine is: "Do not use bronchodilators in children with bronchiolitis."

Talk about ‘less’

Dr. Schroeder urged the audience of some 1,000 pediatric hospitalists to introduce "safely doing less" into the patient-safety dialogue. Clinicians should always remind their patients and trainees of unanticipated harms. Instead of saying, "It’s a straightforward procedure," try saying, "There isn’t a procedure out there that can’t make someone worse or cause harm."

When there’s an adverse event at your institution, he advised clinicians not to just focus on the details of the incident, but also on the necessity of the interventions that led up to the incident. This strategy was conspicuous in its absence during the recent meningitis outbreak from contaminated steroid injections for back and neuropathic pain, that prompted 749 cases of fungal infection, 63 deaths, and a massive, multistate investigation.

"Everyone wanted to know how this could have happened; where was the regulation behind the compounding pharmacy, which is a worthy question," he said. "But it took weeks before it came out that these epidural steroid injections aren’t evidence based, although they sure make a lot of money."

Finally, he suggested the audience redefine the term "conservative" care from its current definition of test and treat to watch and wait.

During a discussion immediately following the lecture, however, attendee and pediatric hospitalist Lynn Campbell, who is with Dell Children’s Medical Center of Central Texas, in Austin, pointed out that, unlike primary care providers or ED physicians, hospitalists come into the game midstream and thus don’t have the same trust level established with families when trying to take away unnecessary tests or therapies.

Dr. Schroeder said many families don’t want more therapies, like antibiotics, and just want to take their child home, but added, "There are no easy answers."

Dr. Schroeder reported having no financial disclosures.

[email protected]

Molecular and imaging tests have increased the identification of pediatric osteomyelitis, but there are still plenty of challenges and conundrums in the management of these cases.

Part of the problem is that not all children fit the diagnosis of acute uncomplicated osteomyelitis, and fall into a "data-free zone," suggests Dr. Russell McCulloh, an infectious disease specialist with Children’s Mercy Hospital in Kansas City, Mo. Acute hematogenous osteomyelitis (AHOM) accounts for 1% of pediatric hospitalizations, although most studies don’t address complicated osteomyelitis, culture-negative cases, neonates, surgical interventions, cases with hardware in place, and colonization outside of the long bone, the most usual site for osteomyelitis.

"It’s easy, I think, to look at the abstracts and inadvertently extrapolate the data to patients we just don’t have the data on," he said during a pediatric osteomyelitis roundtable at Pediatric Hospital Medicine 2013 in New Orleans.

In the absence of a consensus on how to manage complicated or culture-negative patients, a surprising number of groups are turning to medium-course therapy. Data have shown that if a peripherally inserted central catheter (PICC) line is in place for 2 weeks or less, there are far fewer complications than if it’s in place for 4-6 weeks. This has led some groups to take the approach of giving intravenous antibiotics for 2 weeks and then transitioning to oral antibiotics if the patient is doing well, observed Dr. Samir S. Shah, director of hospital medicine at Cincinnati Children’s Hospital Medical Center.

"Again, there’s no great data on whether that’s a good strategy or not, but some folks feel that it mitigates some of the challenges with doing a more prolonged course of IV therapy, with their nervousness of transitioning to oral therapy in the process," he said.

The data are fairly clear, however, that oral antibiotics are effective in treating acute, uncomplicated osteomyelitis, and that early transition to oral antibiotics demonstrates similar success to that of long-term IV therapy, said copresenter Dr. Joanna Thomson, a fellow in hospital medicine at Cincinnati Children’s.

One of the best analyses on this issue is a systematic review of 12 studies showing similar 6-month cure rates among children, aged 3 months to 16 years, with AHOM given IV antibiotics for less than 7 days or for 1 week or longer (95.2% vs. 98.8%) (BMC Infect. Dis. 2002;2:16).

Six-month treatment failure rates also were similar between prolonged IV antibiotics and early transition to oral therapy in one of the largest studies of pediatric osteomyelitis, a retrospective cohort study of about 2,000 children carefully screened to exclude all but the most straightforward cases (Pediatrics 2009;123:636-42), she said.

An audience member questioned whether orthopedic surgical involvement tips the diagnostic scales from simple to complicated osteomyelitis, to which Dr. Shah replied that complicated cases typically involve additional problems such as thrombosis, pulmonary septic emboli, metastatic dissemination of infection, or prolonged bacteremia. Another attendee also suggested that cancer should be on clinicians’ radar in patients failing to respond, noting that she had two recent cases including a 5-year-old with neuroblastoma and extensive metastases.

The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America (IDSA) have partnered to create new pediatric guidelines for the diagnosis and management of AHOM. At present, they are considering a possible recommendation that, if approved, would call for early transition to oral antibiotics, said Dr. Shah, a member of the guideline committee.

Clindamycin is a good choice for empiric coverage of Staphylococcus aureus for acute osteomyelitis in stable patients, if the local susceptibility patterns allow, said copresenter Dr. Amanda C. Schondelmeyer, also a hospital medicine fellow at Cincinnati Children’s. Vancomycin should be considered for empiric coverage of S. aureus in patients with bacteremia or abnormal vital signs, while beta-lactam antibiotics can be added for coverage of Kingella kingae in patients under age 3 with septic arthritis.

Current IDSA guidelines recommend IV vancomycin for children with acute hematogenous methicillin-resistant S. aureus (MRSA) osteomyelitis or septic arthritis. If the patient is stable without ongoing bacteremia or intravascular infection, clindamycin can be used as empiric therapy, if the clindamycin resistance rate is low, for example, less than 10%.

A quick show of hands revealed that while most attendees knew the clindamycin susceptibility pattern for MRSA at their institution, only a handful knew if it exceeded 10%.

An informal survey of the overflow crowd also indicated no clear consensus on what factors are most important in transitioning patients to oral antibiotics. A normalized C-reactive protein (CRP), afebrile state, and at least 48 hours of IV antibiotics were suggested, but some attendees commented that it was rare for CRP values to normalize within 2-3 days of initiating therapy and expressed uncertainty about the optimal CRP threshold to use.

A recent single-center, retrospective study reported using a CRP lower than 2.0-3.0 mg/L and evidence of clinical response for oral step-down therapy among 194 children with culture-positive, acute bacterial osteomyelitis or acute bacterial arthritis. This combination strategy, in place at Rady Children’s Hospital in San Diego for more than a decade, yielded only one microbiologic failure and a long-term success rate with early transition to oral antibiotics that was similar to outcomes for long-term IV courses (Pediatrics 2012;130:e821-8).

A smaller prospective study in 44 children with AHOM reported that CRP values peaked 2 days after admission and normalized within a week of initiating therapy and transitioning to oral antibiotics within 4 days (Pediatrics 1994;93:59-62).

Regardless of the antibiotic plan, follow-up after discharge is key, said copresenter Dr. Lauren G. Solan, a hospital medicine fellow at Cincinnati Children’s. Hospitalists should ensure that the primary care physician is comfortable with the discharge plan and consider follow-up with an infectious disease specialist, particularly in children sent home on IV therapy. Catheter-associated complications requiring attention occur in about 30% of children with PICC lines at home, with malfunction or displacement reported in nearly one-fourth of those receiving more than 2 weeks of IV therapy, she observed. Notably, just five audience members acknowledged requesting an orthopedic follow-up, even in cases involving surgical procedures.

The presenters reported having no financial disclosures.

[email protected]

Molecular and imaging tests have increased the identification of pediatric osteomyelitis, but there are still plenty of challenges and conundrums in the management of these cases.

Part of the problem is that not all children fit the diagnosis of acute uncomplicated osteomyelitis, and fall into a "data-free zone," suggests Dr. Russell McCulloh, an infectious disease specialist with Children’s Mercy Hospital in Kansas City, Mo. Acute hematogenous osteomyelitis (AHOM) accounts for 1% of pediatric hospitalizations, although most studies don’t address complicated osteomyelitis, culture-negative cases, neonates, surgical interventions, cases with hardware in place, and colonization outside of the long bone, the most usual site for osteomyelitis.

"It’s easy, I think, to look at the abstracts and inadvertently extrapolate the data to patients we just don’t have the data on," he said during a pediatric osteomyelitis roundtable at Pediatric Hospital Medicine 2013 in New Orleans.

In the absence of a consensus on how to manage complicated or culture-negative patients, a surprising number of groups are turning to medium-course therapy. Data have shown that if a peripherally inserted central catheter (PICC) line is in place for 2 weeks or less, there are far fewer complications than if it’s in place for 4-6 weeks. This has led some groups to take the approach of giving intravenous antibiotics for 2 weeks and then transitioning to oral antibiotics if the patient is doing well, observed Dr. Samir S. Shah, director of hospital medicine at Cincinnati Children’s Hospital Medical Center.

"Again, there’s no great data on whether that’s a good strategy or not, but some folks feel that it mitigates some of the challenges with doing a more prolonged course of IV therapy, with their nervousness of transitioning to oral therapy in the process," he said.

The data are fairly clear, however, that oral antibiotics are effective in treating acute, uncomplicated osteomyelitis, and that early transition to oral antibiotics demonstrates similar success to that of long-term IV therapy, said copresenter Dr. Joanna Thomson, a fellow in hospital medicine at Cincinnati Children’s.

One of the best analyses on this issue is a systematic review of 12 studies showing similar 6-month cure rates among children, aged 3 months to 16 years, with AHOM given IV antibiotics for less than 7 days or for 1 week or longer (95.2% vs. 98.8%) (BMC Infect. Dis. 2002;2:16).

Six-month treatment failure rates also were similar between prolonged IV antibiotics and early transition to oral therapy in one of the largest studies of pediatric osteomyelitis, a retrospective cohort study of about 2,000 children carefully screened to exclude all but the most straightforward cases (Pediatrics 2009;123:636-42), she said.

An audience member questioned whether orthopedic surgical involvement tips the diagnostic scales from simple to complicated osteomyelitis, to which Dr. Shah replied that complicated cases typically involve additional problems such as thrombosis, pulmonary septic emboli, metastatic dissemination of infection, or prolonged bacteremia. Another attendee also suggested that cancer should be on clinicians’ radar in patients failing to respond, noting that she had two recent cases including a 5-year-old with neuroblastoma and extensive metastases.

The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America (IDSA) have partnered to create new pediatric guidelines for the diagnosis and management of AHOM. At present, they are considering a possible recommendation that, if approved, would call for early transition to oral antibiotics, said Dr. Shah, a member of the guideline committee.

Clindamycin is a good choice for empiric coverage of Staphylococcus aureus for acute osteomyelitis in stable patients, if the local susceptibility patterns allow, said copresenter Dr. Amanda C. Schondelmeyer, also a hospital medicine fellow at Cincinnati Children’s. Vancomycin should be considered for empiric coverage of S. aureus in patients with bacteremia or abnormal vital signs, while beta-lactam antibiotics can be added for coverage of Kingella kingae in patients under age 3 with septic arthritis.

Current IDSA guidelines recommend IV vancomycin for children with acute hematogenous methicillin-resistant S. aureus (MRSA) osteomyelitis or septic arthritis. If the patient is stable without ongoing bacteremia or intravascular infection, clindamycin can be used as empiric therapy, if the clindamycin resistance rate is low, for example, less than 10%.

A quick show of hands revealed that while most attendees knew the clindamycin susceptibility pattern for MRSA at their institution, only a handful knew if it exceeded 10%.

An informal survey of the overflow crowd also indicated no clear consensus on what factors are most important in transitioning patients to oral antibiotics. A normalized C-reactive protein (CRP), afebrile state, and at least 48 hours of IV antibiotics were suggested, but some attendees commented that it was rare for CRP values to normalize within 2-3 days of initiating therapy and expressed uncertainty about the optimal CRP threshold to use.

A recent single-center, retrospective study reported using a CRP lower than 2.0-3.0 mg/L and evidence of clinical response for oral step-down therapy among 194 children with culture-positive, acute bacterial osteomyelitis or acute bacterial arthritis. This combination strategy, in place at Rady Children’s Hospital in San Diego for more than a decade, yielded only one microbiologic failure and a long-term success rate with early transition to oral antibiotics that was similar to outcomes for long-term IV courses (Pediatrics 2012;130:e821-8).

A smaller prospective study in 44 children with AHOM reported that CRP values peaked 2 days after admission and normalized within a week of initiating therapy and transitioning to oral antibiotics within 4 days (Pediatrics 1994;93:59-62).

Regardless of the antibiotic plan, follow-up after discharge is key, said copresenter Dr. Lauren G. Solan, a hospital medicine fellow at Cincinnati Children’s. Hospitalists should ensure that the primary care physician is comfortable with the discharge plan and consider follow-up with an infectious disease specialist, particularly in children sent home on IV therapy. Catheter-associated complications requiring attention occur in about 30% of children with PICC lines at home, with malfunction or displacement reported in nearly one-fourth of those receiving more than 2 weeks of IV therapy, she observed. Notably, just five audience members acknowledged requesting an orthopedic follow-up, even in cases involving surgical procedures.

The presenters reported having no financial disclosures.

[email protected]

Molecular and imaging tests have increased the identification of pediatric osteomyelitis, but there are still plenty of challenges and conundrums in the management of these cases.

Part of the problem is that not all children fit the diagnosis of acute uncomplicated osteomyelitis, and fall into a "data-free zone," suggests Dr. Russell McCulloh, an infectious disease specialist with Children’s Mercy Hospital in Kansas City, Mo. Acute hematogenous osteomyelitis (AHOM) accounts for 1% of pediatric hospitalizations, although most studies don’t address complicated osteomyelitis, culture-negative cases, neonates, surgical interventions, cases with hardware in place, and colonization outside of the long bone, the most usual site for osteomyelitis.

"It’s easy, I think, to look at the abstracts and inadvertently extrapolate the data to patients we just don’t have the data on," he said during a pediatric osteomyelitis roundtable at Pediatric Hospital Medicine 2013 in New Orleans.

In the absence of a consensus on how to manage complicated or culture-negative patients, a surprising number of groups are turning to medium-course therapy. Data have shown that if a peripherally inserted central catheter (PICC) line is in place for 2 weeks or less, there are far fewer complications than if it’s in place for 4-6 weeks. This has led some groups to take the approach of giving intravenous antibiotics for 2 weeks and then transitioning to oral antibiotics if the patient is doing well, observed Dr. Samir S. Shah, director of hospital medicine at Cincinnati Children’s Hospital Medical Center.

"Again, there’s no great data on whether that’s a good strategy or not, but some folks feel that it mitigates some of the challenges with doing a more prolonged course of IV therapy, with their nervousness of transitioning to oral therapy in the process," he said.

The data are fairly clear, however, that oral antibiotics are effective in treating acute, uncomplicated osteomyelitis, and that early transition to oral antibiotics demonstrates similar success to that of long-term IV therapy, said copresenter Dr. Joanna Thomson, a fellow in hospital medicine at Cincinnati Children’s.

One of the best analyses on this issue is a systematic review of 12 studies showing similar 6-month cure rates among children, aged 3 months to 16 years, with AHOM given IV antibiotics for less than 7 days or for 1 week or longer (95.2% vs. 98.8%) (BMC Infect. Dis. 2002;2:16).

Six-month treatment failure rates also were similar between prolonged IV antibiotics and early transition to oral therapy in one of the largest studies of pediatric osteomyelitis, a retrospective cohort study of about 2,000 children carefully screened to exclude all but the most straightforward cases (Pediatrics 2009;123:636-42), she said.

An audience member questioned whether orthopedic surgical involvement tips the diagnostic scales from simple to complicated osteomyelitis, to which Dr. Shah replied that complicated cases typically involve additional problems such as thrombosis, pulmonary septic emboli, metastatic dissemination of infection, or prolonged bacteremia. Another attendee also suggested that cancer should be on clinicians’ radar in patients failing to respond, noting that she had two recent cases including a 5-year-old with neuroblastoma and extensive metastases.

The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America (IDSA) have partnered to create new pediatric guidelines for the diagnosis and management of AHOM. At present, they are considering a possible recommendation that, if approved, would call for early transition to oral antibiotics, said Dr. Shah, a member of the guideline committee.

Clindamycin is a good choice for empiric coverage of Staphylococcus aureus for acute osteomyelitis in stable patients, if the local susceptibility patterns allow, said copresenter Dr. Amanda C. Schondelmeyer, also a hospital medicine fellow at Cincinnati Children’s. Vancomycin should be considered for empiric coverage of S. aureus in patients with bacteremia or abnormal vital signs, while beta-lactam antibiotics can be added for coverage of Kingella kingae in patients under age 3 with septic arthritis.

Current IDSA guidelines recommend IV vancomycin for children with acute hematogenous methicillin-resistant S. aureus (MRSA) osteomyelitis or septic arthritis. If the patient is stable without ongoing bacteremia or intravascular infection, clindamycin can be used as empiric therapy, if the clindamycin resistance rate is low, for example, less than 10%.

A quick show of hands revealed that while most attendees knew the clindamycin susceptibility pattern for MRSA at their institution, only a handful knew if it exceeded 10%.

An informal survey of the overflow crowd also indicated no clear consensus on what factors are most important in transitioning patients to oral antibiotics. A normalized C-reactive protein (CRP), afebrile state, and at least 48 hours of IV antibiotics were suggested, but some attendees commented that it was rare for CRP values to normalize within 2-3 days of initiating therapy and expressed uncertainty about the optimal CRP threshold to use.

A recent single-center, retrospective study reported using a CRP lower than 2.0-3.0 mg/L and evidence of clinical response for oral step-down therapy among 194 children with culture-positive, acute bacterial osteomyelitis or acute bacterial arthritis. This combination strategy, in place at Rady Children’s Hospital in San Diego for more than a decade, yielded only one microbiologic failure and a long-term success rate with early transition to oral antibiotics that was similar to outcomes for long-term IV courses (Pediatrics 2012;130:e821-8).

A smaller prospective study in 44 children with AHOM reported that CRP values peaked 2 days after admission and normalized within a week of initiating therapy and transitioning to oral antibiotics within 4 days (Pediatrics 1994;93:59-62).

Regardless of the antibiotic plan, follow-up after discharge is key, said copresenter Dr. Lauren G. Solan, a hospital medicine fellow at Cincinnati Children’s. Hospitalists should ensure that the primary care physician is comfortable with the discharge plan and consider follow-up with an infectious disease specialist, particularly in children sent home on IV therapy. Catheter-associated complications requiring attention occur in about 30% of children with PICC lines at home, with malfunction or displacement reported in nearly one-fourth of those receiving more than 2 weeks of IV therapy, she observed. Notably, just five audience members acknowledged requesting an orthopedic follow-up, even in cases involving surgical procedures.

The presenters reported having no financial disclosures.

[email protected]

NEW ORLEANS – Hypertonic saline alone does not affect length of stay among infants hospitalized for bronchiolitis, according to preliminary results of an ongoing randomized, prospective U.S. trial.

Among 127 evaluable patients, the median length of stay was 2.2 days with hypertonic saline and 2.0 days with normal saline (P = .65).

Infants in one still-blinded group were significantly younger (3.3 vs. 4.4 months), but hospital stay did not differ between groups, even when adjusted for age.

"Preliminary results suggest little utility for the routine use of hypertonic saline in treating infants hospitalized with bronchiolitis," Dr. Alyssa Silver said at Pediatric Hospital Medicine 2013.

However, she added, the results do show that 3% hypertonic saline without adjunctive bronchodilators is safe for infants, including those with a history of prior wheeze, even in a population with a high endemic prevalence of asthma.

Patrice Wendling/IMNG Medical Media

A theoretical risk of bronchospasm has been identified in patients with cystic fibrosis at much higher concentrations and quantities.

This is the first prospective, randomized, double-blind, controlled clinical trial of nebulized hypertonic saline conducted in the United States.

Several studies have been conducted outside the United States, but adjuvant bronchodilators were used in all but one, patients with a history of wheeze were excluded, and they had long lengths of stay that make the data difficult to generalize to the United States, said Dr. Silver, a pediatric hospitalist with the Children’s Hospital at Montefiore in New York.

Dr. Shawn Ralston, cochair of the American Academy of Pediatrics subcommittee on diagnosis and management of bronchiolitis, which is revising the 2006 AAP clinical practice guidelines for bronchiolitis,said in an interview that a clearer picture of the utility of hypertonic saline is beginning to emerge. All of the studies where hypertonic saline is used in the ED or short-stay units show no utility, and the only inpatient studies that show benefit seem to be in settings where there is longer length of stay. Further, Montefiore has a very short length of stay, which is typical of U.S. hospitals.

"I think what we’re learning about hypertonic saline as the studies come in is that any treatment effect, if there does prove to be one, will be seen over several days," said Dr. Ralston, chief of the pediatrics section, Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

"From a guidelines standpoint, it is very important for us to keep up with the emerging data, and we are unlikely to be able to recommend the use of hypertonic saline given what has been published or presented within the last year. That said, I would actually welcome studies of outpatient use of hypertonic saline, as I think that is where the real utility may lie, based on my review of the literature in preparation for the guideline."

The current study included 156 infants, less than 12 months of age, admitted with a diagnosis of bronchiolitis from November 2011 through January 2013 and randomized by the pharmacy to 4 mL of hypertonic saline or 4 mL of normal saline every 4 hours until discharge.

The readmission rate was identical at 6.3% in both study groups (P = 1.0), Dr. Silver reported. Also similar were clinically important adverse events, including readmission (four events in each group) and worsening respiratory status (six events in each group; both P = 1.0).

A subgroup analysis showed no difference in length of stay among patients treated with hypertonic saline vs. normal saline who were positive for respiratory syncytial virus (2.5 vs. 2.0 days; P = .35), had a history of previous wheeze (1.8 vs. 2.0 days; P = .58), or had a history of prematurity (3.5 vs. 2.5 days; P = .11).

The study was limited by the single-center design and the inability to randomize all patients within 12 hours of admission. Despite the lack of funding, however, the study captured 80% of bronchiolitis admissions among infants during the study period, Dr. Silver noted.

"These findings cast significant doubt on the utility of nebulized 3% hypertonic saline for the routine treatment of infants hospitalized with bronchiolitis," she said in an interview. "Unfortunately, the mainstay of routine inpatient treatment remains supportive care."

Future directions include enrolling patients directly from the emergency department with a minimum severity score for study entry, use of higher concentrations of sodium chloride, and possibly an outpatient study.

Dr. Silver reported having no relevant financial disclosures.

[email protected]

NEW ORLEANS – Hypertonic saline alone does not affect length of stay among infants hospitalized for bronchiolitis, according to preliminary results of an ongoing randomized, prospective U.S. trial.

Among 127 evaluable patients, the median length of stay was 2.2 days with hypertonic saline and 2.0 days with normal saline (P = .65).

Infants in one still-blinded group were significantly younger (3.3 vs. 4.4 months), but hospital stay did not differ between groups, even when adjusted for age.

"Preliminary results suggest little utility for the routine use of hypertonic saline in treating infants hospitalized with bronchiolitis," Dr. Alyssa Silver said at Pediatric Hospital Medicine 2013.

However, she added, the results do show that 3% hypertonic saline without adjunctive bronchodilators is safe for infants, including those with a history of prior wheeze, even in a population with a high endemic prevalence of asthma.

Patrice Wendling/IMNG Medical Media

A theoretical risk of bronchospasm has been identified in patients with cystic fibrosis at much higher concentrations and quantities.

This is the first prospective, randomized, double-blind, controlled clinical trial of nebulized hypertonic saline conducted in the United States.

Several studies have been conducted outside the United States, but adjuvant bronchodilators were used in all but one, patients with a history of wheeze were excluded, and they had long lengths of stay that make the data difficult to generalize to the United States, said Dr. Silver, a pediatric hospitalist with the Children’s Hospital at Montefiore in New York.

Dr. Shawn Ralston, cochair of the American Academy of Pediatrics subcommittee on diagnosis and management of bronchiolitis, which is revising the 2006 AAP clinical practice guidelines for bronchiolitis,said in an interview that a clearer picture of the utility of hypertonic saline is beginning to emerge. All of the studies where hypertonic saline is used in the ED or short-stay units show no utility, and the only inpatient studies that show benefit seem to be in settings where there is longer length of stay. Further, Montefiore has a very short length of stay, which is typical of U.S. hospitals.

"I think what we’re learning about hypertonic saline as the studies come in is that any treatment effect, if there does prove to be one, will be seen over several days," said Dr. Ralston, chief of the pediatrics section, Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

"From a guidelines standpoint, it is very important for us to keep up with the emerging data, and we are unlikely to be able to recommend the use of hypertonic saline given what has been published or presented within the last year. That said, I would actually welcome studies of outpatient use of hypertonic saline, as I think that is where the real utility may lie, based on my review of the literature in preparation for the guideline."

The current study included 156 infants, less than 12 months of age, admitted with a diagnosis of bronchiolitis from November 2011 through January 2013 and randomized by the pharmacy to 4 mL of hypertonic saline or 4 mL of normal saline every 4 hours until discharge.

The readmission rate was identical at 6.3% in both study groups (P = 1.0), Dr. Silver reported. Also similar were clinically important adverse events, including readmission (four events in each group) and worsening respiratory status (six events in each group; both P = 1.0).

A subgroup analysis showed no difference in length of stay among patients treated with hypertonic saline vs. normal saline who were positive for respiratory syncytial virus (2.5 vs. 2.0 days; P = .35), had a history of previous wheeze (1.8 vs. 2.0 days; P = .58), or had a history of prematurity (3.5 vs. 2.5 days; P = .11).

The study was limited by the single-center design and the inability to randomize all patients within 12 hours of admission. Despite the lack of funding, however, the study captured 80% of bronchiolitis admissions among infants during the study period, Dr. Silver noted.

"These findings cast significant doubt on the utility of nebulized 3% hypertonic saline for the routine treatment of infants hospitalized with bronchiolitis," she said in an interview. "Unfortunately, the mainstay of routine inpatient treatment remains supportive care."

Future directions include enrolling patients directly from the emergency department with a minimum severity score for study entry, use of higher concentrations of sodium chloride, and possibly an outpatient study.

Dr. Silver reported having no relevant financial disclosures.

[email protected]

NEW ORLEANS – Hypertonic saline alone does not affect length of stay among infants hospitalized for bronchiolitis, according to preliminary results of an ongoing randomized, prospective U.S. trial.

Among 127 evaluable patients, the median length of stay was 2.2 days with hypertonic saline and 2.0 days with normal saline (P = .65).

Infants in one still-blinded group were significantly younger (3.3 vs. 4.4 months), but hospital stay did not differ between groups, even when adjusted for age.

"Preliminary results suggest little utility for the routine use of hypertonic saline in treating infants hospitalized with bronchiolitis," Dr. Alyssa Silver said at Pediatric Hospital Medicine 2013.

However, she added, the results do show that 3% hypertonic saline without adjunctive bronchodilators is safe for infants, including those with a history of prior wheeze, even in a population with a high endemic prevalence of asthma.

Patrice Wendling/IMNG Medical Media

A theoretical risk of bronchospasm has been identified in patients with cystic fibrosis at much higher concentrations and quantities.

This is the first prospective, randomized, double-blind, controlled clinical trial of nebulized hypertonic saline conducted in the United States.

Several studies have been conducted outside the United States, but adjuvant bronchodilators were used in all but one, patients with a history of wheeze were excluded, and they had long lengths of stay that make the data difficult to generalize to the United States, said Dr. Silver, a pediatric hospitalist with the Children’s Hospital at Montefiore in New York.

Dr. Shawn Ralston, cochair of the American Academy of Pediatrics subcommittee on diagnosis and management of bronchiolitis, which is revising the 2006 AAP clinical practice guidelines for bronchiolitis,said in an interview that a clearer picture of the utility of hypertonic saline is beginning to emerge. All of the studies where hypertonic saline is used in the ED or short-stay units show no utility, and the only inpatient studies that show benefit seem to be in settings where there is longer length of stay. Further, Montefiore has a very short length of stay, which is typical of U.S. hospitals.

"I think what we’re learning about hypertonic saline as the studies come in is that any treatment effect, if there does prove to be one, will be seen over several days," said Dr. Ralston, chief of the pediatrics section, Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

"From a guidelines standpoint, it is very important for us to keep up with the emerging data, and we are unlikely to be able to recommend the use of hypertonic saline given what has been published or presented within the last year. That said, I would actually welcome studies of outpatient use of hypertonic saline, as I think that is where the real utility may lie, based on my review of the literature in preparation for the guideline."

The current study included 156 infants, less than 12 months of age, admitted with a diagnosis of bronchiolitis from November 2011 through January 2013 and randomized by the pharmacy to 4 mL of hypertonic saline or 4 mL of normal saline every 4 hours until discharge.

The readmission rate was identical at 6.3% in both study groups (P = 1.0), Dr. Silver reported. Also similar were clinically important adverse events, including readmission (four events in each group) and worsening respiratory status (six events in each group; both P = 1.0).

A subgroup analysis showed no difference in length of stay among patients treated with hypertonic saline vs. normal saline who were positive for respiratory syncytial virus (2.5 vs. 2.0 days; P = .35), had a history of previous wheeze (1.8 vs. 2.0 days; P = .58), or had a history of prematurity (3.5 vs. 2.5 days; P = .11).

The study was limited by the single-center design and the inability to randomize all patients within 12 hours of admission. Despite the lack of funding, however, the study captured 80% of bronchiolitis admissions among infants during the study period, Dr. Silver noted.

"These findings cast significant doubt on the utility of nebulized 3% hypertonic saline for the routine treatment of infants hospitalized with bronchiolitis," she said in an interview. "Unfortunately, the mainstay of routine inpatient treatment remains supportive care."

Future directions include enrolling patients directly from the emergency department with a minimum severity score for study entry, use of higher concentrations of sodium chloride, and possibly an outpatient study.

Dr. Silver reported having no relevant financial disclosures.

[email protected]

Washington University School of Medicine in St. Louis has led the charge for pediatric hospitalist sedation, offering a panel of experts who shared their insights on nitrous oxide sedation in a wide-ranging, hands-on session at Pediatric Hospital Medicine 2013. Some highlights of that session were:

Patrice Wendling/IMNG Medical Media

• Administer 50%-70% nitrous oxide (N₂O) based on the need for minimal, moderate, or deep sedation. Consider N₂O alone for procedures such as joint injections or voiding cystourethrograms.

• Augment N₂O with 0.15-0.3 mg/kg of oxycodone (maximum dose of 10 mg) to achieve deeper sedation and greater analgesia for more painful procedures such as abscess incision and drainage, burn debridement, and postoperative dressing change. To maximize the analgesic effect of the opioid, wait for its effect to peak at 60 minutes before administering N₂O.

• The peak effect of N₂O is usually seen within 2-3 minutes, so plan to perform the most painful portion of the procedure at least 2 minutes after the start of 70% N₂O. Titrate to 50% after about 5 minutes of 70% N₂O, with a total duration of N₂O not to exceed 15 minutes.

• Be alert for signs of emesis during sedation such as pallor, sweating, and elevation in heart rate, and position the patients appropriately so they do not aspirate, if there is emesis.

• The hospitalists’ only duty is to perform the sedation, but monitoring should be performed by qualified personnel according to American Academy of Pediatrics, American Society of Anesthesiologists, and local institutional guidelines. At St. Louis Children’s Hospital, a trained sedation nurse is present during and after sedation. Rescue equipment including continuous positive airway pressure (CPAP) bag, and suction and airway supplies should be readily available, if needed.

John Twombly/St. Louis Children's Hospital

• Administer 100% oxygen for 2-3 minutes after turning off the N₂O to prevent diffusion hypoxia and improve scavenging of exhaled N₂O and, thus, reduce the environmental N₂O exposure to sedation providers, nursing staff, and family members.

• Ensure that scavenging systems and proper airflow parameters are in place for rooms that use N₂O to reduce N₂O exposure. Use passive air monitoring badges to measure exposure and avoid exposing pregnant health care workers and family members by using good delivery techniques.

• Contraindications to N₂O sedation include, but are not limited to patients with any trapped air in a body cavity, such as those with bowel obstruction, recent tympanoplasty, or recent intraocular surgery; patients with elevated intracranial pressure; and those with a deficiency in vitamin B₁₂ or the enzyme 5, 10 methylenetetrahydrofolate reductase. Caution should be used in sickle cell patients, although gastroesophageal reflux disease is not a contraindication.

It has been noted that there have been reports of infertility, blood dyscrasias, and neurologic deficits with chronic exposure to nitrous oxide exposure. However, N₂O has been used safely in dental offices and OR suites for several decades.

The Washington University team included Dr. Mythili Srinivasan, Dr. Jon Chiles, Dr. Mike Turmelle, and Dr. Yasmeen Daud.

Washington University School of Medicine in St. Louis has led the charge for pediatric hospitalist sedation, offering a panel of experts who shared their insights on nitrous oxide sedation in a wide-ranging, hands-on session at Pediatric Hospital Medicine 2013. Some highlights of that session were:

Patrice Wendling/IMNG Medical Media

• Administer 50%-70% nitrous oxide (N₂O) based on the need for minimal, moderate, or deep sedation. Consider N₂O alone for procedures such as joint injections or voiding cystourethrograms.

• Augment N₂O with 0.15-0.3 mg/kg of oxycodone (maximum dose of 10 mg) to achieve deeper sedation and greater analgesia for more painful procedures such as abscess incision and drainage, burn debridement, and postoperative dressing change. To maximize the analgesic effect of the opioid, wait for its effect to peak at 60 minutes before administering N₂O.

• The peak effect of N₂O is usually seen within 2-3 minutes, so plan to perform the most painful portion of the procedure at least 2 minutes after the start of 70% N₂O. Titrate to 50% after about 5 minutes of 70% N₂O, with a total duration of N₂O not to exceed 15 minutes.

• Be alert for signs of emesis during sedation such as pallor, sweating, and elevation in heart rate, and position the patients appropriately so they do not aspirate, if there is emesis.

• The hospitalists’ only duty is to perform the sedation, but monitoring should be performed by qualified personnel according to American Academy of Pediatrics, American Society of Anesthesiologists, and local institutional guidelines. At St. Louis Children’s Hospital, a trained sedation nurse is present during and after sedation. Rescue equipment including continuous positive airway pressure (CPAP) bag, and suction and airway supplies should be readily available, if needed.

John Twombly/St. Louis Children's Hospital

• Administer 100% oxygen for 2-3 minutes after turning off the N₂O to prevent diffusion hypoxia and improve scavenging of exhaled N₂O and, thus, reduce the environmental N₂O exposure to sedation providers, nursing staff, and family members.

• Ensure that scavenging systems and proper airflow parameters are in place for rooms that use N₂O to reduce N₂O exposure. Use passive air monitoring badges to measure exposure and avoid exposing pregnant health care workers and family members by using good delivery techniques.

• Contraindications to N₂O sedation include, but are not limited to patients with any trapped air in a body cavity, such as those with bowel obstruction, recent tympanoplasty, or recent intraocular surgery; patients with elevated intracranial pressure; and those with a deficiency in vitamin B₁₂ or the enzyme 5, 10 methylenetetrahydrofolate reductase. Caution should be used in sickle cell patients, although gastroesophageal reflux disease is not a contraindication.

It has been noted that there have been reports of infertility, blood dyscrasias, and neurologic deficits with chronic exposure to nitrous oxide exposure. However, N₂O has been used safely in dental offices and OR suites for several decades.

The Washington University team included Dr. Mythili Srinivasan, Dr. Jon Chiles, Dr. Mike Turmelle, and Dr. Yasmeen Daud.

Washington University School of Medicine in St. Louis has led the charge for pediatric hospitalist sedation, offering a panel of experts who shared their insights on nitrous oxide sedation in a wide-ranging, hands-on session at Pediatric Hospital Medicine 2013. Some highlights of that session were:

Patrice Wendling/IMNG Medical Media

• Administer 50%-70% nitrous oxide (N₂O) based on the need for minimal, moderate, or deep sedation. Consider N₂O alone for procedures such as joint injections or voiding cystourethrograms.

• Augment N₂O with 0.15-0.3 mg/kg of oxycodone (maximum dose of 10 mg) to achieve deeper sedation and greater analgesia for more painful procedures such as abscess incision and drainage, burn debridement, and postoperative dressing change. To maximize the analgesic effect of the opioid, wait for its effect to peak at 60 minutes before administering N₂O.

• The peak effect of N₂O is usually seen within 2-3 minutes, so plan to perform the most painful portion of the procedure at least 2 minutes after the start of 70% N₂O. Titrate to 50% after about 5 minutes of 70% N₂O, with a total duration of N₂O not to exceed 15 minutes.

• Be alert for signs of emesis during sedation such as pallor, sweating, and elevation in heart rate, and position the patients appropriately so they do not aspirate, if there is emesis.

• The hospitalists’ only duty is to perform the sedation, but monitoring should be performed by qualified personnel according to American Academy of Pediatrics, American Society of Anesthesiologists, and local institutional guidelines. At St. Louis Children’s Hospital, a trained sedation nurse is present during and after sedation. Rescue equipment including continuous positive airway pressure (CPAP) bag, and suction and airway supplies should be readily available, if needed.

John Twombly/St. Louis Children's Hospital

• Administer 100% oxygen for 2-3 minutes after turning off the N₂O to prevent diffusion hypoxia and improve scavenging of exhaled N₂O and, thus, reduce the environmental N₂O exposure to sedation providers, nursing staff, and family members.

• Ensure that scavenging systems and proper airflow parameters are in place for rooms that use N₂O to reduce N₂O exposure. Use passive air monitoring badges to measure exposure and avoid exposing pregnant health care workers and family members by using good delivery techniques.

• Contraindications to N₂O sedation include, but are not limited to patients with any trapped air in a body cavity, such as those with bowel obstruction, recent tympanoplasty, or recent intraocular surgery; patients with elevated intracranial pressure; and those with a deficiency in vitamin B₁₂ or the enzyme 5, 10 methylenetetrahydrofolate reductase. Caution should be used in sickle cell patients, although gastroesophageal reflux disease is not a contraindication.

It has been noted that there have been reports of infertility, blood dyscrasias, and neurologic deficits with chronic exposure to nitrous oxide exposure. However, N₂O has been used safely in dental offices and OR suites for several decades.

The Washington University team included Dr. Mythili Srinivasan, Dr. Jon Chiles, Dr. Mike Turmelle, and Dr. Yasmeen Daud.

NEW ORLEANS – The process for creating a new pediatric hospital medicine subspecialty continues to move forward, but concerns are being raised that a PHM fellowship may not meet the needs of community hospitalists and could cut off the pipeline of potential talent.

A recent medical school graduate put a very real and poignant face to those concerns during a panel session at the Pediatric Hospital Medicine 2013 meeting, where experts spent the better part of an hour clarifying and updating the subspecialty process. With $500,000 in medical school debts at more than 6% interest for himself and his physician spouse, the fellowship is not an option.

"I see (the fellowship) as a potential risk for our subspecialty to join the other subspecialties as being one that is in shortage in rural areas and unattractive to a large portion of our workforce," he said.

Ultimately, the goal of the PHM fellowship track is to provide the best patient care for hospitalized children and to move the field forward, panel members stressed. In April 2013, national PHM leaders convened to review multiple sources of data and debate options, before overwhelmingly agreeing that the practice of pediatric hospital medicine requires postresidency training (16 for, 1 against, 1 abstain) and that a 2-year accredited fellowship would be the best option (16 for, 2 abstain).

"I see (the fellowship) as a potential risk for our subspecialty to join the other subspecialties as being one that is in shortage in rural areas and unattractive to a large portion of our workforce..."

An audience member said the new fellowship is a good idea and will be particularly beneficial to pediatric hospitalists in the community setting both for patient trust and peer recognition. She went on to say, however, that the skill set for community pediatric hospitalists is unique in terms of the breadth of knowledge and services they provide and that a strong working relationship will be needed with hospitalists in the university setting, where the fellowship programs will be based, to ensure that community hospitalists get the skill sets they need.

Panelist Dr. Rebecca Blankenburg of Stanford (Calif.) University, said the issue has been a "huge area of conversation" for the group and "what we realized, certainly in fellowship, people have different training goals and training needs. But in all fellowships, we should have very strong community partnerships and so the university programs are really exploring that."

Dr. Blankenburg said the group would welcome input on community hospitalists’ skill sets and that a subgroup is also looking at how those skills should look in residency as well as in fellowship training.

Having worked in both the community and university setting, panelist Dr. Mary Ottolini, vice chair of medical education, Children’s National Medical Center, Washington, D.C., said PHM certification will offer enrichment to both groups.

"The more we can have our training programs bridge these two types of hospital medicine settings, it is just going to strengthen pediatric hospital medicine as a whole," she said.

Panelist Daniel Rauch, associate director of pediatrics at Elmhurst Hospital Center, Queens, N.Y., said there was strong feeling that a 3-year fellowship would be more appropriate for hospitalists to be prepared for work in the community setting. Ultimately, though, they had to balance this with workforce issues and people’s willingness to endure more training after residency.

A 2-year program is not the current standard for fellowships at the American Board of Pediatrics, so the ABP may not accept the group’s petition to create the new subspecialty. Even if it does, it will take awhile. The process for petitioning the ABP for subspecialty status typically takes 6 years, and it could be another 1-2 years once a certifying examination has been implemented before the Accreditation Council for Graduate Medical Education begins the fellowship program accreditation process.

Pediatric hospitalists who are currently in practice or in a currently nonaccredited fellowship will be "grandfathered" in and will be able to sit for the exam the first three test dates, if they meet experiential standards, according to the panel, led by Dr. Jeffrey Simmons, director of pediatric hospital medicine fellowship, Cincinnati Children’s Hospital and Medical Center.

The test will be given every other year, so there will be 4 years from the first test for non–fellowship-trained individuals to be eligible to take the exam. This process allows everyone currently practicing PHM and, most future pediatric hospitalists for at least the next 7-8 years, the ability to sit for the exam, according to the panel.

An audience member expressed concern about meeting the standards for certification, and asked whether the group had considered offering 6 months intensive training in specific areas such as pediatric sedation or pediatric lines for early career hospitalists like himself, whose nearest academic center is 150 miles away and who can’t take 2 years off the job for a fellowship.

Audience member Dr. Gail McGuinness, ABP executive vice president, said that experts in hospital medicine joined the ABP in setting the minimal criteria to sit for the boards.

"The goal with early certification is really to be inclusive and not prevent people from gaining certification, recognizing the training in the future is going to be somewhat different from the training, or lack of training, that those of you who are practicing the subspecialty now have," she said.

That said, Dr. McGuiness observed that "a new certificate has to say something to the public that everyone who holds that certificate has had the same experiences and same standardized training" and suggested that individuals who feel they have deficits in procedural areas need to address those deficits.

Once the fellowship accreditation process goes online, then only ACGME-approved fellowships will be able to have their graduates sit for the exam. Hospitalists who take the PHM subspecialty board, however, do not need to maintain board certification in general pediatrics once PHM certification is attained.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The panel reported having no financial disclosures.

[email protected]

NEW ORLEANS – The process for creating a new pediatric hospital medicine subspecialty continues to move forward, but concerns are being raised that a PHM fellowship may not meet the needs of community hospitalists and could cut off the pipeline of potential talent.

A recent medical school graduate put a very real and poignant face to those concerns during a panel session at the Pediatric Hospital Medicine 2013 meeting, where experts spent the better part of an hour clarifying and updating the subspecialty process. With $500,000 in medical school debts at more than 6% interest for himself and his physician spouse, the fellowship is not an option.

"I see (the fellowship) as a potential risk for our subspecialty to join the other subspecialties as being one that is in shortage in rural areas and unattractive to a large portion of our workforce," he said.

Ultimately, the goal of the PHM fellowship track is to provide the best patient care for hospitalized children and to move the field forward, panel members stressed. In April 2013, national PHM leaders convened to review multiple sources of data and debate options, before overwhelmingly agreeing that the practice of pediatric hospital medicine requires postresidency training (16 for, 1 against, 1 abstain) and that a 2-year accredited fellowship would be the best option (16 for, 2 abstain).

"I see (the fellowship) as a potential risk for our subspecialty to join the other subspecialties as being one that is in shortage in rural areas and unattractive to a large portion of our workforce..."

An audience member said the new fellowship is a good idea and will be particularly beneficial to pediatric hospitalists in the community setting both for patient trust and peer recognition. She went on to say, however, that the skill set for community pediatric hospitalists is unique in terms of the breadth of knowledge and services they provide and that a strong working relationship will be needed with hospitalists in the university setting, where the fellowship programs will be based, to ensure that community hospitalists get the skill sets they need.

Panelist Dr. Rebecca Blankenburg of Stanford (Calif.) University, said the issue has been a "huge area of conversation" for the group and "what we realized, certainly in fellowship, people have different training goals and training needs. But in all fellowships, we should have very strong community partnerships and so the university programs are really exploring that."

Dr. Blankenburg said the group would welcome input on community hospitalists’ skill sets and that a subgroup is also looking at how those skills should look in residency as well as in fellowship training.

Having worked in both the community and university setting, panelist Dr. Mary Ottolini, vice chair of medical education, Children’s National Medical Center, Washington, D.C., said PHM certification will offer enrichment to both groups.

"The more we can have our training programs bridge these two types of hospital medicine settings, it is just going to strengthen pediatric hospital medicine as a whole," she said.

Panelist Daniel Rauch, associate director of pediatrics at Elmhurst Hospital Center, Queens, N.Y., said there was strong feeling that a 3-year fellowship would be more appropriate for hospitalists to be prepared for work in the community setting. Ultimately, though, they had to balance this with workforce issues and people’s willingness to endure more training after residency.

A 2-year program is not the current standard for fellowships at the American Board of Pediatrics, so the ABP may not accept the group’s petition to create the new subspecialty. Even if it does, it will take awhile. The process for petitioning the ABP for subspecialty status typically takes 6 years, and it could be another 1-2 years once a certifying examination has been implemented before the Accreditation Council for Graduate Medical Education begins the fellowship program accreditation process.

Pediatric hospitalists who are currently in practice or in a currently nonaccredited fellowship will be "grandfathered" in and will be able to sit for the exam the first three test dates, if they meet experiential standards, according to the panel, led by Dr. Jeffrey Simmons, director of pediatric hospital medicine fellowship, Cincinnati Children’s Hospital and Medical Center.

The test will be given every other year, so there will be 4 years from the first test for non–fellowship-trained individuals to be eligible to take the exam. This process allows everyone currently practicing PHM and, most future pediatric hospitalists for at least the next 7-8 years, the ability to sit for the exam, according to the panel.

An audience member expressed concern about meeting the standards for certification, and asked whether the group had considered offering 6 months intensive training in specific areas such as pediatric sedation or pediatric lines for early career hospitalists like himself, whose nearest academic center is 150 miles away and who can’t take 2 years off the job for a fellowship.

Audience member Dr. Gail McGuinness, ABP executive vice president, said that experts in hospital medicine joined the ABP in setting the minimal criteria to sit for the boards.

"The goal with early certification is really to be inclusive and not prevent people from gaining certification, recognizing the training in the future is going to be somewhat different from the training, or lack of training, that those of you who are practicing the subspecialty now have," she said.

That said, Dr. McGuiness observed that "a new certificate has to say something to the public that everyone who holds that certificate has had the same experiences and same standardized training" and suggested that individuals who feel they have deficits in procedural areas need to address those deficits.

Once the fellowship accreditation process goes online, then only ACGME-approved fellowships will be able to have their graduates sit for the exam. Hospitalists who take the PHM subspecialty board, however, do not need to maintain board certification in general pediatrics once PHM certification is attained.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The panel reported having no financial disclosures.

[email protected]

NEW ORLEANS – The process for creating a new pediatric hospital medicine subspecialty continues to move forward, but concerns are being raised that a PHM fellowship may not meet the needs of community hospitalists and could cut off the pipeline of potential talent.

A recent medical school graduate put a very real and poignant face to those concerns during a panel session at the Pediatric Hospital Medicine 2013 meeting, where experts spent the better part of an hour clarifying and updating the subspecialty process. With $500,000 in medical school debts at more than 6% interest for himself and his physician spouse, the fellowship is not an option.

"I see (the fellowship) as a potential risk for our subspecialty to join the other subspecialties as being one that is in shortage in rural areas and unattractive to a large portion of our workforce," he said.

Ultimately, the goal of the PHM fellowship track is to provide the best patient care for hospitalized children and to move the field forward, panel members stressed. In April 2013, national PHM leaders convened to review multiple sources of data and debate options, before overwhelmingly agreeing that the practice of pediatric hospital medicine requires postresidency training (16 for, 1 against, 1 abstain) and that a 2-year accredited fellowship would be the best option (16 for, 2 abstain).

"I see (the fellowship) as a potential risk for our subspecialty to join the other subspecialties as being one that is in shortage in rural areas and unattractive to a large portion of our workforce..."

An audience member said the new fellowship is a good idea and will be particularly beneficial to pediatric hospitalists in the community setting both for patient trust and peer recognition. She went on to say, however, that the skill set for community pediatric hospitalists is unique in terms of the breadth of knowledge and services they provide and that a strong working relationship will be needed with hospitalists in the university setting, where the fellowship programs will be based, to ensure that community hospitalists get the skill sets they need.

Panelist Dr. Rebecca Blankenburg of Stanford (Calif.) University, said the issue has been a "huge area of conversation" for the group and "what we realized, certainly in fellowship, people have different training goals and training needs. But in all fellowships, we should have very strong community partnerships and so the university programs are really exploring that."

Dr. Blankenburg said the group would welcome input on community hospitalists’ skill sets and that a subgroup is also looking at how those skills should look in residency as well as in fellowship training.

Having worked in both the community and university setting, panelist Dr. Mary Ottolini, vice chair of medical education, Children’s National Medical Center, Washington, D.C., said PHM certification will offer enrichment to both groups.

"The more we can have our training programs bridge these two types of hospital medicine settings, it is just going to strengthen pediatric hospital medicine as a whole," she said.

Panelist Daniel Rauch, associate director of pediatrics at Elmhurst Hospital Center, Queens, N.Y., said there was strong feeling that a 3-year fellowship would be more appropriate for hospitalists to be prepared for work in the community setting. Ultimately, though, they had to balance this with workforce issues and people’s willingness to endure more training after residency.

A 2-year program is not the current standard for fellowships at the American Board of Pediatrics, so the ABP may not accept the group’s petition to create the new subspecialty. Even if it does, it will take awhile. The process for petitioning the ABP for subspecialty status typically takes 6 years, and it could be another 1-2 years once a certifying examination has been implemented before the Accreditation Council for Graduate Medical Education begins the fellowship program accreditation process.

Pediatric hospitalists who are currently in practice or in a currently nonaccredited fellowship will be "grandfathered" in and will be able to sit for the exam the first three test dates, if they meet experiential standards, according to the panel, led by Dr. Jeffrey Simmons, director of pediatric hospital medicine fellowship, Cincinnati Children’s Hospital and Medical Center.

The test will be given every other year, so there will be 4 years from the first test for non–fellowship-trained individuals to be eligible to take the exam. This process allows everyone currently practicing PHM and, most future pediatric hospitalists for at least the next 7-8 years, the ability to sit for the exam, according to the panel.

An audience member expressed concern about meeting the standards for certification, and asked whether the group had considered offering 6 months intensive training in specific areas such as pediatric sedation or pediatric lines for early career hospitalists like himself, whose nearest academic center is 150 miles away and who can’t take 2 years off the job for a fellowship.

Audience member Dr. Gail McGuinness, ABP executive vice president, said that experts in hospital medicine joined the ABP in setting the minimal criteria to sit for the boards.

"The goal with early certification is really to be inclusive and not prevent people from gaining certification, recognizing the training in the future is going to be somewhat different from the training, or lack of training, that those of you who are practicing the subspecialty now have," she said.

That said, Dr. McGuiness observed that "a new certificate has to say something to the public that everyone who holds that certificate has had the same experiences and same standardized training" and suggested that individuals who feel they have deficits in procedural areas need to address those deficits.

Once the fellowship accreditation process goes online, then only ACGME-approved fellowships will be able to have their graduates sit for the exam. Hospitalists who take the PHM subspecialty board, however, do not need to maintain board certification in general pediatrics once PHM certification is attained.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The panel reported having no financial disclosures.

[email protected]

NEW ORLEANS – Hospitalist comanagement of pediatric neurosurgical cases significantly shortens hospital length of stay without increasing readmissions or complications, according to a retrospective analysis of 526 patients.

The mean LOS fell from 8.6 days to 5.6 days and median LOS from 4 days to 3 days after the transition to hospitalist comanagement. Both differences were significant.

Comanagement also had a great impact on the variability of LOS, as demonstrated by a reduction in the standard deviation from 20.0 to 7.2, observed Dr. Catherine Sullivan, with Connecticut Children’s Medical Center in Hartford.

"It looked like our greatest effect was on the variability of the outliers," she said at Pediatric Hospital Medicine 2013.

Patrice Wendling/IMNG Medical Media

Ten patients stayed for more than 50 days before hospitalist comanagement was implemented, whereas none did in the time after.

One extreme outlier stayed for about 400 days prior to comanagement, and likely explains the large discrepancy between the mean and median LOS, Dr. Sullivan explained.

The chart review involved 347 neurosurgical patients cared for in the 2 years prior to hospitalist comanagement and 179 patients cared for in the year after the launch of the program in March 2011. Children with routine ventriculoperitoneal shunt revision or those hospitalized for brief neurologic observations were excluded.

Two staff neurosurgeons provided education to hospitalists and pediatric residents prior to implementation.

Hospitalists provided care in the areas of nutrition, pulmonary clearance, pain management, rehabilitation, and discharge planning. Areas where hospitalists could write orders without running them by the neurosurgeon were hashed out in a departmental meeting at the attending level. A monthly hospitalist meeting was also dedicated to the project.

"We did really focus on that communication piece," Dr. Sullivan said. "I think that’s probably a challenge between many medical and surgical teams. It was a change in culture, and it has improved relationships between the two divisions."

About 80% of pediatric neurosurgical cases have been hospitalist-comanaged since the project began. The LOS reduction was maintained across neurosurgeons.

Despite the shorter stay, no differences have been observed in rates of complications or readmissions, Dr. Sullivan said.

The study sparked a lively debate, with audience members lauding the relevancy of the study, but also questioning whether the involvement of pediatric residents or other factors might have impacted LOS.

Dr. Sullivan acknowledged this was hard to tease out since the pediatric residents also began to follow these patients, and had done so "only peripherally" in the past.

"So whether the pediatric residents impacted the length of stay as much as, or more than, the hospitalists, is really not clear," she said.

Other attendees suggested performing subgroup analyses or a case-mix adjustment to strengthen the results, or applying a winsoring technique to address the statistical outliers.

"Because the data were so striking, one of the first things we did was to have our people go back and make sure we weren’t having an increase in readmissions, and, in fact, we weren’t," Dr. Sullivan remarked at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

An informal poll was performed, however, with only favorable responses received from both neurosurgeons regarding the areas of communication, management, and perceived provider and family satisfaction, she said.

The hospital is looking at expanding the project to include other surgical subspecialties such as orthopedics, urology, ENT, craniofacial, and ophthalmology, particularly for cases with high co-medical morbidities such as spinal fusion or Pierre Robin malformation sequences, Dr. Sullivan said.

Cost analyses are also ongoing, and the hospital is debating whether to have hospitalists meet with patients upon admission rather than after surgery. However, "it creates a staffing challenge of who is going to cover that visit," Dr. Sullivan said

Session comoderator and pediatric hospitalist Dr. Jack Percelay, with E.L.M.O. Pediatrics in New York, encouraged Dr. Sullivan and her colleagues to publish the data, observing that "it really struck a chord."

Dr. Sullivan and her coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Hospitalist comanagement of pediatric neurosurgical cases significantly shortens hospital length of stay without increasing readmissions or complications, according to a retrospective analysis of 526 patients.

The mean LOS fell from 8.6 days to 5.6 days and median LOS from 4 days to 3 days after the transition to hospitalist comanagement. Both differences were significant.

Comanagement also had a great impact on the variability of LOS, as demonstrated by a reduction in the standard deviation from 20.0 to 7.2, observed Dr. Catherine Sullivan, with Connecticut Children’s Medical Center in Hartford.

"It looked like our greatest effect was on the variability of the outliers," she said at Pediatric Hospital Medicine 2013.

Patrice Wendling/IMNG Medical Media

Ten patients stayed for more than 50 days before hospitalist comanagement was implemented, whereas none did in the time after.

One extreme outlier stayed for about 400 days prior to comanagement, and likely explains the large discrepancy between the mean and median LOS, Dr. Sullivan explained.

The chart review involved 347 neurosurgical patients cared for in the 2 years prior to hospitalist comanagement and 179 patients cared for in the year after the launch of the program in March 2011. Children with routine ventriculoperitoneal shunt revision or those hospitalized for brief neurologic observations were excluded.

Two staff neurosurgeons provided education to hospitalists and pediatric residents prior to implementation.

Hospitalists provided care in the areas of nutrition, pulmonary clearance, pain management, rehabilitation, and discharge planning. Areas where hospitalists could write orders without running them by the neurosurgeon were hashed out in a departmental meeting at the attending level. A monthly hospitalist meeting was also dedicated to the project.

"We did really focus on that communication piece," Dr. Sullivan said. "I think that’s probably a challenge between many medical and surgical teams. It was a change in culture, and it has improved relationships between the two divisions."

About 80% of pediatric neurosurgical cases have been hospitalist-comanaged since the project began. The LOS reduction was maintained across neurosurgeons.

Despite the shorter stay, no differences have been observed in rates of complications or readmissions, Dr. Sullivan said.

The study sparked a lively debate, with audience members lauding the relevancy of the study, but also questioning whether the involvement of pediatric residents or other factors might have impacted LOS.

Dr. Sullivan acknowledged this was hard to tease out since the pediatric residents also began to follow these patients, and had done so "only peripherally" in the past.

"So whether the pediatric residents impacted the length of stay as much as, or more than, the hospitalists, is really not clear," she said.

Other attendees suggested performing subgroup analyses or a case-mix adjustment to strengthen the results, or applying a winsoring technique to address the statistical outliers.

"Because the data were so striking, one of the first things we did was to have our people go back and make sure we weren’t having an increase in readmissions, and, in fact, we weren’t," Dr. Sullivan remarked at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

An informal poll was performed, however, with only favorable responses received from both neurosurgeons regarding the areas of communication, management, and perceived provider and family satisfaction, she said.

The hospital is looking at expanding the project to include other surgical subspecialties such as orthopedics, urology, ENT, craniofacial, and ophthalmology, particularly for cases with high co-medical morbidities such as spinal fusion or Pierre Robin malformation sequences, Dr. Sullivan said.

Cost analyses are also ongoing, and the hospital is debating whether to have hospitalists meet with patients upon admission rather than after surgery. However, "it creates a staffing challenge of who is going to cover that visit," Dr. Sullivan said

Session comoderator and pediatric hospitalist Dr. Jack Percelay, with E.L.M.O. Pediatrics in New York, encouraged Dr. Sullivan and her colleagues to publish the data, observing that "it really struck a chord."

Dr. Sullivan and her coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Hospitalist comanagement of pediatric neurosurgical cases significantly shortens hospital length of stay without increasing readmissions or complications, according to a retrospective analysis of 526 patients.

The mean LOS fell from 8.6 days to 5.6 days and median LOS from 4 days to 3 days after the transition to hospitalist comanagement. Both differences were significant.

Comanagement also had a great impact on the variability of LOS, as demonstrated by a reduction in the standard deviation from 20.0 to 7.2, observed Dr. Catherine Sullivan, with Connecticut Children’s Medical Center in Hartford.

"It looked like our greatest effect was on the variability of the outliers," she said at Pediatric Hospital Medicine 2013.

Patrice Wendling/IMNG Medical Media

Ten patients stayed for more than 50 days before hospitalist comanagement was implemented, whereas none did in the time after.

One extreme outlier stayed for about 400 days prior to comanagement, and likely explains the large discrepancy between the mean and median LOS, Dr. Sullivan explained.

The chart review involved 347 neurosurgical patients cared for in the 2 years prior to hospitalist comanagement and 179 patients cared for in the year after the launch of the program in March 2011. Children with routine ventriculoperitoneal shunt revision or those hospitalized for brief neurologic observations were excluded.

Two staff neurosurgeons provided education to hospitalists and pediatric residents prior to implementation.

Hospitalists provided care in the areas of nutrition, pulmonary clearance, pain management, rehabilitation, and discharge planning. Areas where hospitalists could write orders without running them by the neurosurgeon were hashed out in a departmental meeting at the attending level. A monthly hospitalist meeting was also dedicated to the project.

"We did really focus on that communication piece," Dr. Sullivan said. "I think that’s probably a challenge between many medical and surgical teams. It was a change in culture, and it has improved relationships between the two divisions."

About 80% of pediatric neurosurgical cases have been hospitalist-comanaged since the project began. The LOS reduction was maintained across neurosurgeons.

Despite the shorter stay, no differences have been observed in rates of complications or readmissions, Dr. Sullivan said.

The study sparked a lively debate, with audience members lauding the relevancy of the study, but also questioning whether the involvement of pediatric residents or other factors might have impacted LOS.

Dr. Sullivan acknowledged this was hard to tease out since the pediatric residents also began to follow these patients, and had done so "only peripherally" in the past.

"So whether the pediatric residents impacted the length of stay as much as, or more than, the hospitalists, is really not clear," she said.

Other attendees suggested performing subgroup analyses or a case-mix adjustment to strengthen the results, or applying a winsoring technique to address the statistical outliers.

"Because the data were so striking, one of the first things we did was to have our people go back and make sure we weren’t having an increase in readmissions, and, in fact, we weren’t," Dr. Sullivan remarked at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

An informal poll was performed, however, with only favorable responses received from both neurosurgeons regarding the areas of communication, management, and perceived provider and family satisfaction, she said.

The hospital is looking at expanding the project to include other surgical subspecialties such as orthopedics, urology, ENT, craniofacial, and ophthalmology, particularly for cases with high co-medical morbidities such as spinal fusion or Pierre Robin malformation sequences, Dr. Sullivan said.

Cost analyses are also ongoing, and the hospital is debating whether to have hospitalists meet with patients upon admission rather than after surgery. However, "it creates a staffing challenge of who is going to cover that visit," Dr. Sullivan said

Session comoderator and pediatric hospitalist Dr. Jack Percelay, with E.L.M.O. Pediatrics in New York, encouraged Dr. Sullivan and her colleagues to publish the data, observing that "it really struck a chord."

Dr. Sullivan and her coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Inpatient staffing in the wake of tighter residency work hours, avoiding premature diagnostic closure, and hospitalist perceptions of resident effects on quality of care and costs were tackled in a trio of oral abstracts presented at Pediatric Hospital Medicine 2013.

Work-rules effects

A Web-based survey of 152 pediatric residency programs in the United States revealed marked variation in how programs have responded after the Accreditation Council for Graduate Medical Education mandated new residency work hour restrictions in July 2011.

Patrice Wendling/IMNG Medical Media

The most common changes were the addition of a resident night-float system and an increase in the number of attending physicians present at night, primarily in the form of pediatric hospitalists and pediatric intensivists, said Dr. Jennifer Oshimura, with Indiana University, Riley Hospital for Children, Indianapolis.

The number of programs using a night-float system increased from 43% to 71% after the new residency work hours, while the number of programs utilizing resident admission caps increased only slightly, from 12% to 15%.

In all, 23% of programs increased night in-house attending coverage following the work-hour restrictions.

Of these, 63% of programs increased their night-time attending coverage by adding pediatric hospitalists, 37% added pediatric intensivists, and 26% added neonatologists, Dr. Oshimura said.

Overall, the number of programs with pediatric hospitalist attendings in-house 24/7 rose from 16% to 20%, with 41% of programs planning to add this kind of coverage within the next 5 years.

Finally, only 12% of residency programs had no in-house attending coverage at night of any kind. This compares with 22% of programs in a previous study conducted by the group in 2010, before the work hour restrictions were in place, she noted.

The anonymous survey was sent to 198 pediatric residency training programs in the United States. The response rate was 77% (152/198), representing 7,828 pediatric residents or 79% of all pediatric residents in the United States.

The programs varied "drastically" in terms of size (average, 51.5 residents; range, 6-168) and average daily patient census per ward intern during the daytime (7.4 patients; range, 2-30), Dr. Oshimura remarked.

Premature closure

Results of a randomized trial show that simulated patient encounters can be used to help teach residents to avoid premature closure, or the tendency to accept a diagnosis before it is fully verified. The phenomenon prevents consideration of alternative diagnoses and is a common source of error in the care of inpatients.

"Premature closure can be summarized with the axiom: ‘When the diagnosis is made, the thinking stops,’ " Dr. Lauren Nassetta said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Patrice Wendling/IMNG Medical Media

Dr. Nassetta and her colleagues at the University of Alabama at Birmingham randomly assigned 61 residents on inpatient pediatrics rotations to receive a text page with a brief description of a patient that contained either an incorrect diagnosis (stem A) or a symptom (stem B). The remainder of the case was carefully scripted and presented identically. Each of the 36 teams received 2 cases, and the cases were paired such that residents who received stem A for case 1 received stem B for case 2, and vice versa.

The cases involved common pediatric presentations for unusual reasons, such as a 14-month-old who presents with wheezing, secondary to congestive heart failure. For this case, the incorrect diagnosis was given as asthma.

The residents had 10 minutes to evaluate (history, physical exam, laboratory, and radiology) and treat simulated patients. High-fidelity mannequins were used to provide responses to the residents, while investigators played the role of nurse and family member.

Residents obtained significantly more elements in the evaluation when they received the symptom stem versus the incorrect diagnosis stem (63% vs. 55%; P less than .05), Dr. Nassetta said.

Residents given the symptom stem made the correct diagnosis 86% of the time, compared with only 69% of the time when given the incorrect diagnosis. The difference did not reach statistical significance at the group level (P = .16), but was significant on an individual participant level.

Still, the finding resulted in a relative risk of 2.2, "meaning that having the incorrect diagnosis made it twice as likely to miss the correct diagnosis," she said.

When data from individual participants were used in a multivariable logistic regression model, the adjusted odds ratio was 14.9 for making a correct diagnosis with the symptom stem vs. the incorrect diagnosis. The model adjusted for a variety of variables, including prior simulation time, case difficulty, level of training, program type, and confidence in independent care of patients.

Other predictors of making a correct diagnosis were obtaining a patient history (adjusted OR, 1.35) and obtaining an exam, labs, and radiology (aOR, 1.47).

"It’s obvious that residents lack insight into the causes of premature closure, but this does set us up for some opportunities for education," Dr. Nassetta said. "We can use simulated cases to demonstrate diagnostic error, discuss premature closure, and strategies for avoiding it."

Strategies she employs with residents include stressing the importance of the history and physical exam, having residents ask what doesn’t fit the diagnosis they have in mind, encouraging them to come up with one alternative diagnosis for every patient they see, and having residents describe rather than diagnose the patient at the time of handoff.

Are residents perceived as pricey?

Most pediatric hospitalists surveyed think residents increase the quality of care, but do so at increased cost to the hospital, according to a 15-item, anonymous, electronic survey of 127 pediatric hospitalists at 113 institutions.

Overall, 60% of respondents thought residents increase the quality of care, 23% said they have no impact, and 17% thought they actually decrease quality, said Dr. David P. Johnson, of Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn.

Subgroup analyses showed that 71% of hospitalists who always work with residents thought residents improve the quality of care, whereas only 43% of those who sometimes do, and 53% who never do felt the same (P less than .05).

Hospitalists affiliated with academic hospitals were also significantly more likely to say residents improve quality than were those at community hospitals (65% vs. 38%), he said.

Patrice Wendling/IMNG Medical Media

In all, 72% of respondents said residents increase hospital costs, while 23% said they had no impact and 6% said they decrease costs.

In subgroup analyses, however, the perception that residents increase costs was similar no matter how much respondents worked with residents (71%, 71%, 73%; always, sometimes, never) or what their affiliation was (69% academic, 83% community), Dr. Johnson said.

One of the most intriguing findings from the survey was that 78% of hospitalists deny having any formal training in resource utilization, yet 91% think they provide cost-effective care, and 81% feel they are qualified to teach it, Dr. Johnson said.

"A gap exists between what we think we know and the training that we received," he said. "I don’t think that’s necessarily a bad thing, but it’s something we need to be cognizant of, both as we are taking care of our patients and teaching our residents."

Dr. Johnson hypothesized that informal training, reading, and being at the right place at the right time might explain some of the hospitalists’ confidence in the absence of formal training, but that experience may also matter.

Hospitalists with more than 10 years of experience were significantly more likely to say they had the knowledge to provide cost-effective care, compared with those with 6-10 years of experience or 5 years or less (100% vs. 91% vs. 85%; P less than .05). A similar, but nonsignificant, trend was present when respondents were asked whether they were qualified to teach cost-effective care (93% vs. 77% vs. 75%).

At baseline, 31% of respondents had been in practice for more than 10 years, 28% for 6-10 years, and 41% for 0-5 years. The majority had an academic affiliation (81%); 55% always worked with residents, 33% sometimes, and 12% never.

Dr. Oshimura, Dr. Nassetta, and Dr. Johnson reported having no financial disclosures.

[email protected]

NEW ORLEANS – Inpatient staffing in the wake of tighter residency work hours, avoiding premature diagnostic closure, and hospitalist perceptions of resident effects on quality of care and costs were tackled in a trio of oral abstracts presented at Pediatric Hospital Medicine 2013.

Work-rules effects

A Web-based survey of 152 pediatric residency programs in the United States revealed marked variation in how programs have responded after the Accreditation Council for Graduate Medical Education mandated new residency work hour restrictions in July 2011.

Patrice Wendling/IMNG Medical Media

The most common changes were the addition of a resident night-float system and an increase in the number of attending physicians present at night, primarily in the form of pediatric hospitalists and pediatric intensivists, said Dr. Jennifer Oshimura, with Indiana University, Riley Hospital for Children, Indianapolis.

The number of programs using a night-float system increased from 43% to 71% after the new residency work hours, while the number of programs utilizing resident admission caps increased only slightly, from 12% to 15%.

In all, 23% of programs increased night in-house attending coverage following the work-hour restrictions.

Of these, 63% of programs increased their night-time attending coverage by adding pediatric hospitalists, 37% added pediatric intensivists, and 26% added neonatologists, Dr. Oshimura said.

Overall, the number of programs with pediatric hospitalist attendings in-house 24/7 rose from 16% to 20%, with 41% of programs planning to add this kind of coverage within the next 5 years.

Finally, only 12% of residency programs had no in-house attending coverage at night of any kind. This compares with 22% of programs in a previous study conducted by the group in 2010, before the work hour restrictions were in place, she noted.

The anonymous survey was sent to 198 pediatric residency training programs in the United States. The response rate was 77% (152/198), representing 7,828 pediatric residents or 79% of all pediatric residents in the United States.

The programs varied "drastically" in terms of size (average, 51.5 residents; range, 6-168) and average daily patient census per ward intern during the daytime (7.4 patients; range, 2-30), Dr. Oshimura remarked.

Premature closure

Results of a randomized trial show that simulated patient encounters can be used to help teach residents to avoid premature closure, or the tendency to accept a diagnosis before it is fully verified. The phenomenon prevents consideration of alternative diagnoses and is a common source of error in the care of inpatients.

"Premature closure can be summarized with the axiom: ‘When the diagnosis is made, the thinking stops,’ " Dr. Lauren Nassetta said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Patrice Wendling/IMNG Medical Media

Dr. Nassetta and her colleagues at the University of Alabama at Birmingham randomly assigned 61 residents on inpatient pediatrics rotations to receive a text page with a brief description of a patient that contained either an incorrect diagnosis (stem A) or a symptom (stem B). The remainder of the case was carefully scripted and presented identically. Each of the 36 teams received 2 cases, and the cases were paired such that residents who received stem A for case 1 received stem B for case 2, and vice versa.

The cases involved common pediatric presentations for unusual reasons, such as a 14-month-old who presents with wheezing, secondary to congestive heart failure. For this case, the incorrect diagnosis was given as asthma.

The residents had 10 minutes to evaluate (history, physical exam, laboratory, and radiology) and treat simulated patients. High-fidelity mannequins were used to provide responses to the residents, while investigators played the role of nurse and family member.

Residents obtained significantly more elements in the evaluation when they received the symptom stem versus the incorrect diagnosis stem (63% vs. 55%; P less than .05), Dr. Nassetta said.

Residents given the symptom stem made the correct diagnosis 86% of the time, compared with only 69% of the time when given the incorrect diagnosis. The difference did not reach statistical significance at the group level (P = .16), but was significant on an individual participant level.

Still, the finding resulted in a relative risk of 2.2, "meaning that having the incorrect diagnosis made it twice as likely to miss the correct diagnosis," she said.

When data from individual participants were used in a multivariable logistic regression model, the adjusted odds ratio was 14.9 for making a correct diagnosis with the symptom stem vs. the incorrect diagnosis. The model adjusted for a variety of variables, including prior simulation time, case difficulty, level of training, program type, and confidence in independent care of patients.

Other predictors of making a correct diagnosis were obtaining a patient history (adjusted OR, 1.35) and obtaining an exam, labs, and radiology (aOR, 1.47).

"It’s obvious that residents lack insight into the causes of premature closure, but this does set us up for some opportunities for education," Dr. Nassetta said. "We can use simulated cases to demonstrate diagnostic error, discuss premature closure, and strategies for avoiding it."

Strategies she employs with residents include stressing the importance of the history and physical exam, having residents ask what doesn’t fit the diagnosis they have in mind, encouraging them to come up with one alternative diagnosis for every patient they see, and having residents describe rather than diagnose the patient at the time of handoff.

Are residents perceived as pricey?

Most pediatric hospitalists surveyed think residents increase the quality of care, but do so at increased cost to the hospital, according to a 15-item, anonymous, electronic survey of 127 pediatric hospitalists at 113 institutions.

Overall, 60% of respondents thought residents increase the quality of care, 23% said they have no impact, and 17% thought they actually decrease quality, said Dr. David P. Johnson, of Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn.

Subgroup analyses showed that 71% of hospitalists who always work with residents thought residents improve the quality of care, whereas only 43% of those who sometimes do, and 53% who never do felt the same (P less than .05).

Hospitalists affiliated with academic hospitals were also significantly more likely to say residents improve quality than were those at community hospitals (65% vs. 38%), he said.

Patrice Wendling/IMNG Medical Media

In all, 72% of respondents said residents increase hospital costs, while 23% said they had no impact and 6% said they decrease costs.

In subgroup analyses, however, the perception that residents increase costs was similar no matter how much respondents worked with residents (71%, 71%, 73%; always, sometimes, never) or what their affiliation was (69% academic, 83% community), Dr. Johnson said.

One of the most intriguing findings from the survey was that 78% of hospitalists deny having any formal training in resource utilization, yet 91% think they provide cost-effective care, and 81% feel they are qualified to teach it, Dr. Johnson said.

"A gap exists between what we think we know and the training that we received," he said. "I don’t think that’s necessarily a bad thing, but it’s something we need to be cognizant of, both as we are taking care of our patients and teaching our residents."

Dr. Johnson hypothesized that informal training, reading, and being at the right place at the right time might explain some of the hospitalists’ confidence in the absence of formal training, but that experience may also matter.

Hospitalists with more than 10 years of experience were significantly more likely to say they had the knowledge to provide cost-effective care, compared with those with 6-10 years of experience or 5 years or less (100% vs. 91% vs. 85%; P less than .05). A similar, but nonsignificant, trend was present when respondents were asked whether they were qualified to teach cost-effective care (93% vs. 77% vs. 75%).

At baseline, 31% of respondents had been in practice for more than 10 years, 28% for 6-10 years, and 41% for 0-5 years. The majority had an academic affiliation (81%); 55% always worked with residents, 33% sometimes, and 12% never.

Dr. Oshimura, Dr. Nassetta, and Dr. Johnson reported having no financial disclosures.

[email protected]

NEW ORLEANS – Inpatient staffing in the wake of tighter residency work hours, avoiding premature diagnostic closure, and hospitalist perceptions of resident effects on quality of care and costs were tackled in a trio of oral abstracts presented at Pediatric Hospital Medicine 2013.

Work-rules effects

A Web-based survey of 152 pediatric residency programs in the United States revealed marked variation in how programs have responded after the Accreditation Council for Graduate Medical Education mandated new residency work hour restrictions in July 2011.

Patrice Wendling/IMNG Medical Media

The most common changes were the addition of a resident night-float system and an increase in the number of attending physicians present at night, primarily in the form of pediatric hospitalists and pediatric intensivists, said Dr. Jennifer Oshimura, with Indiana University, Riley Hospital for Children, Indianapolis.

The number of programs using a night-float system increased from 43% to 71% after the new residency work hours, while the number of programs utilizing resident admission caps increased only slightly, from 12% to 15%.

In all, 23% of programs increased night in-house attending coverage following the work-hour restrictions.

Of these, 63% of programs increased their night-time attending coverage by adding pediatric hospitalists, 37% added pediatric intensivists, and 26% added neonatologists, Dr. Oshimura said.

Overall, the number of programs with pediatric hospitalist attendings in-house 24/7 rose from 16% to 20%, with 41% of programs planning to add this kind of coverage within the next 5 years.

Finally, only 12% of residency programs had no in-house attending coverage at night of any kind. This compares with 22% of programs in a previous study conducted by the group in 2010, before the work hour restrictions were in place, she noted.

The anonymous survey was sent to 198 pediatric residency training programs in the United States. The response rate was 77% (152/198), representing 7,828 pediatric residents or 79% of all pediatric residents in the United States.

The programs varied "drastically" in terms of size (average, 51.5 residents; range, 6-168) and average daily patient census per ward intern during the daytime (7.4 patients; range, 2-30), Dr. Oshimura remarked.

Premature closure

Results of a randomized trial show that simulated patient encounters can be used to help teach residents to avoid premature closure, or the tendency to accept a diagnosis before it is fully verified. The phenomenon prevents consideration of alternative diagnoses and is a common source of error in the care of inpatients.

"Premature closure can be summarized with the axiom: ‘When the diagnosis is made, the thinking stops,’ " Dr. Lauren Nassetta said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Patrice Wendling/IMNG Medical Media

Dr. Nassetta and her colleagues at the University of Alabama at Birmingham randomly assigned 61 residents on inpatient pediatrics rotations to receive a text page with a brief description of a patient that contained either an incorrect diagnosis (stem A) or a symptom (stem B). The remainder of the case was carefully scripted and presented identically. Each of the 36 teams received 2 cases, and the cases were paired such that residents who received stem A for case 1 received stem B for case 2, and vice versa.

The cases involved common pediatric presentations for unusual reasons, such as a 14-month-old who presents with wheezing, secondary to congestive heart failure. For this case, the incorrect diagnosis was given as asthma.

The residents had 10 minutes to evaluate (history, physical exam, laboratory, and radiology) and treat simulated patients. High-fidelity mannequins were used to provide responses to the residents, while investigators played the role of nurse and family member.

Residents obtained significantly more elements in the evaluation when they received the symptom stem versus the incorrect diagnosis stem (63% vs. 55%; P less than .05), Dr. Nassetta said.

Residents given the symptom stem made the correct diagnosis 86% of the time, compared with only 69% of the time when given the incorrect diagnosis. The difference did not reach statistical significance at the group level (P = .16), but was significant on an individual participant level.

Still, the finding resulted in a relative risk of 2.2, "meaning that having the incorrect diagnosis made it twice as likely to miss the correct diagnosis," she said.

When data from individual participants were used in a multivariable logistic regression model, the adjusted odds ratio was 14.9 for making a correct diagnosis with the symptom stem vs. the incorrect diagnosis. The model adjusted for a variety of variables, including prior simulation time, case difficulty, level of training, program type, and confidence in independent care of patients.

Other predictors of making a correct diagnosis were obtaining a patient history (adjusted OR, 1.35) and obtaining an exam, labs, and radiology (aOR, 1.47).

"It’s obvious that residents lack insight into the causes of premature closure, but this does set us up for some opportunities for education," Dr. Nassetta said. "We can use simulated cases to demonstrate diagnostic error, discuss premature closure, and strategies for avoiding it."

Strategies she employs with residents include stressing the importance of the history and physical exam, having residents ask what doesn’t fit the diagnosis they have in mind, encouraging them to come up with one alternative diagnosis for every patient they see, and having residents describe rather than diagnose the patient at the time of handoff.

Are residents perceived as pricey?

Most pediatric hospitalists surveyed think residents increase the quality of care, but do so at increased cost to the hospital, according to a 15-item, anonymous, electronic survey of 127 pediatric hospitalists at 113 institutions.

Overall, 60% of respondents thought residents increase the quality of care, 23% said they have no impact, and 17% thought they actually decrease quality, said Dr. David P. Johnson, of Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn.

Subgroup analyses showed that 71% of hospitalists who always work with residents thought residents improve the quality of care, whereas only 43% of those who sometimes do, and 53% who never do felt the same (P less than .05).

Hospitalists affiliated with academic hospitals were also significantly more likely to say residents improve quality than were those at community hospitals (65% vs. 38%), he said.

Patrice Wendling/IMNG Medical Media

In all, 72% of respondents said residents increase hospital costs, while 23% said they had no impact and 6% said they decrease costs.

In subgroup analyses, however, the perception that residents increase costs was similar no matter how much respondents worked with residents (71%, 71%, 73%; always, sometimes, never) or what their affiliation was (69% academic, 83% community), Dr. Johnson said.

One of the most intriguing findings from the survey was that 78% of hospitalists deny having any formal training in resource utilization, yet 91% think they provide cost-effective care, and 81% feel they are qualified to teach it, Dr. Johnson said.

"A gap exists between what we think we know and the training that we received," he said. "I don’t think that’s necessarily a bad thing, but it’s something we need to be cognizant of, both as we are taking care of our patients and teaching our residents."

Dr. Johnson hypothesized that informal training, reading, and being at the right place at the right time might explain some of the hospitalists’ confidence in the absence of formal training, but that experience may also matter.

Hospitalists with more than 10 years of experience were significantly more likely to say they had the knowledge to provide cost-effective care, compared with those with 6-10 years of experience or 5 years or less (100% vs. 91% vs. 85%; P less than .05). A similar, but nonsignificant, trend was present when respondents were asked whether they were qualified to teach cost-effective care (93% vs. 77% vs. 75%).

At baseline, 31% of respondents had been in practice for more than 10 years, 28% for 6-10 years, and 41% for 0-5 years. The majority had an academic affiliation (81%); 55% always worked with residents, 33% sometimes, and 12% never.

Dr. Oshimura, Dr. Nassetta, and Dr. Johnson reported having no financial disclosures.

[email protected]

NEW ORLEANS – Monitoring blood cultures for more than 24 hours may be unnecessary to rule out bacteremia in febrile, nontoxic infants, a new study suggests.

Among 393 blood cultures drawn at 17 institutions, 9.7% turned positive after 24 hours, compared with 3.8% after 36 hours and 1.8% after 48 hours, Dr. Eric Biondi said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

"Our data demonstrate that about 90% of blood cultures from febrile infants are going to turn positive by 24 hours when they are positive, and more than 95% are going to turn positive by 36 hours," said Dr. Biondi of the University of Rochester (N.Y.) Medical Center.

Using the Pediatric Research in Inpatient Settings (PRIS) Network, the investigators performed a retrospective chart review of 393 positive blood cultures drawn between January 2009 and January 2013 from infants less than 91 days old admitted for fever and treated as pathogenic. Their average age was 39 days and 51% were male.

Samples drawn from infants who had central lines, a surgical history, or were admitted to the ICU in less than 5 hours after the culture were excluded.

Overall Escherichia coli was the most common pathogen (41%), although there was significant variability of species between sites when compared with the reference site in Minnesota (P = .04), Dr. Biondi said. E. coli was the most common at 12 of the 17 sites, while group B streptococcus was the most common at 5.

The median time to positivity did not vary dramatically between species or sites, reaching a median of 13 hours for E. coli (range 12-15 hours) and 11 hours for group B strep (range 9-12 hours).

Based on the generally accepted premise that 2% of febrile infants will have bacteremia, the number needed to treat would be 515 infants for one blood culture to turn positive in more than 24 hours, Dr. Biondi said. That number increases to 1,315 infants after 36 hours and to 6,250 infants after 48 hours.

"You have to think about this in context," he remarked. "Even though about 10% of samples will turn positive after 24 hours, we’re talking about a group that includes only 2% of infants in the first place."

Although ruling out sepsis in febrile infants is one of the most common tasks hospitalists do, the inpatient observational period varies widely from 24 to as much as 72 hours. Dr. Biondi called for a prospective study to develop a national approach, but said that the current data are strong enough to guide clinicians now. The samples were all analyzed with an automated detection system and the PRIS Network is geographically diverse.

"If you’ve got a well-appearing kid staring at you and you’re just waiting for your blood culture, I’m hoping we can use these data to say, ‘We’re probably safe to send this one home,’ "he said.

Dr. Shawn Ralston, session comoderator and chief of the pediatrics section at Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., said that she trained in the era of the 72-hour rule-out and described the self-funded, multicenter study as a tremendous undertaking that provides clinically important data hospitalists can use in the management of febrile infants.

"This contributes to patient-centered decision making with the number-needed-to-treat analysis, and I think it’s awesome," she said.

Dr. Biondi said in an interview that he and his colleagues are in the early stages of designing a prospective feasibility study at three sites that would provide more detailed information on positive, as well as negative, cultures and provide pilot data that could be used for a national study with the PRIS Network.

"We hope, in the end, that these data will lead to a cultural shift in the way we ‘rule out sepsis,’ which will allow us to treat kids with fewer doses of antibiotics and get them home with their families, where they belong," he said.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Biondi and his coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Monitoring blood cultures for more than 24 hours may be unnecessary to rule out bacteremia in febrile, nontoxic infants, a new study suggests.

Among 393 blood cultures drawn at 17 institutions, 9.7% turned positive after 24 hours, compared with 3.8% after 36 hours and 1.8% after 48 hours, Dr. Eric Biondi said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

"Our data demonstrate that about 90% of blood cultures from febrile infants are going to turn positive by 24 hours when they are positive, and more than 95% are going to turn positive by 36 hours," said Dr. Biondi of the University of Rochester (N.Y.) Medical Center.

Using the Pediatric Research in Inpatient Settings (PRIS) Network, the investigators performed a retrospective chart review of 393 positive blood cultures drawn between January 2009 and January 2013 from infants less than 91 days old admitted for fever and treated as pathogenic. Their average age was 39 days and 51% were male.

Samples drawn from infants who had central lines, a surgical history, or were admitted to the ICU in less than 5 hours after the culture were excluded.

Overall Escherichia coli was the most common pathogen (41%), although there was significant variability of species between sites when compared with the reference site in Minnesota (P = .04), Dr. Biondi said. E. coli was the most common at 12 of the 17 sites, while group B streptococcus was the most common at 5.

The median time to positivity did not vary dramatically between species or sites, reaching a median of 13 hours for E. coli (range 12-15 hours) and 11 hours for group B strep (range 9-12 hours).

Based on the generally accepted premise that 2% of febrile infants will have bacteremia, the number needed to treat would be 515 infants for one blood culture to turn positive in more than 24 hours, Dr. Biondi said. That number increases to 1,315 infants after 36 hours and to 6,250 infants after 48 hours.

"You have to think about this in context," he remarked. "Even though about 10% of samples will turn positive after 24 hours, we’re talking about a group that includes only 2% of infants in the first place."

Although ruling out sepsis in febrile infants is one of the most common tasks hospitalists do, the inpatient observational period varies widely from 24 to as much as 72 hours. Dr. Biondi called for a prospective study to develop a national approach, but said that the current data are strong enough to guide clinicians now. The samples were all analyzed with an automated detection system and the PRIS Network is geographically diverse.

"If you’ve got a well-appearing kid staring at you and you’re just waiting for your blood culture, I’m hoping we can use these data to say, ‘We’re probably safe to send this one home,’ "he said.

Dr. Shawn Ralston, session comoderator and chief of the pediatrics section at Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., said that she trained in the era of the 72-hour rule-out and described the self-funded, multicenter study as a tremendous undertaking that provides clinically important data hospitalists can use in the management of febrile infants.

"This contributes to patient-centered decision making with the number-needed-to-treat analysis, and I think it’s awesome," she said.

Dr. Biondi said in an interview that he and his colleagues are in the early stages of designing a prospective feasibility study at three sites that would provide more detailed information on positive, as well as negative, cultures and provide pilot data that could be used for a national study with the PRIS Network.

"We hope, in the end, that these data will lead to a cultural shift in the way we ‘rule out sepsis,’ which will allow us to treat kids with fewer doses of antibiotics and get them home with their families, where they belong," he said.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Biondi and his coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Monitoring blood cultures for more than 24 hours may be unnecessary to rule out bacteremia in febrile, nontoxic infants, a new study suggests.

Among 393 blood cultures drawn at 17 institutions, 9.7% turned positive after 24 hours, compared with 3.8% after 36 hours and 1.8% after 48 hours, Dr. Eric Biondi said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

"Our data demonstrate that about 90% of blood cultures from febrile infants are going to turn positive by 24 hours when they are positive, and more than 95% are going to turn positive by 36 hours," said Dr. Biondi of the University of Rochester (N.Y.) Medical Center.

Using the Pediatric Research in Inpatient Settings (PRIS) Network, the investigators performed a retrospective chart review of 393 positive blood cultures drawn between January 2009 and January 2013 from infants less than 91 days old admitted for fever and treated as pathogenic. Their average age was 39 days and 51% were male.

Samples drawn from infants who had central lines, a surgical history, or were admitted to the ICU in less than 5 hours after the culture were excluded.

Overall Escherichia coli was the most common pathogen (41%), although there was significant variability of species between sites when compared with the reference site in Minnesota (P = .04), Dr. Biondi said. E. coli was the most common at 12 of the 17 sites, while group B streptococcus was the most common at 5.

The median time to positivity did not vary dramatically between species or sites, reaching a median of 13 hours for E. coli (range 12-15 hours) and 11 hours for group B strep (range 9-12 hours).

Based on the generally accepted premise that 2% of febrile infants will have bacteremia, the number needed to treat would be 515 infants for one blood culture to turn positive in more than 24 hours, Dr. Biondi said. That number increases to 1,315 infants after 36 hours and to 6,250 infants after 48 hours.

"You have to think about this in context," he remarked. "Even though about 10% of samples will turn positive after 24 hours, we’re talking about a group that includes only 2% of infants in the first place."

Although ruling out sepsis in febrile infants is one of the most common tasks hospitalists do, the inpatient observational period varies widely from 24 to as much as 72 hours. Dr. Biondi called for a prospective study to develop a national approach, but said that the current data are strong enough to guide clinicians now. The samples were all analyzed with an automated detection system and the PRIS Network is geographically diverse.

"If you’ve got a well-appearing kid staring at you and you’re just waiting for your blood culture, I’m hoping we can use these data to say, ‘We’re probably safe to send this one home,’ "he said.

Dr. Shawn Ralston, session comoderator and chief of the pediatrics section at Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., said that she trained in the era of the 72-hour rule-out and described the self-funded, multicenter study as a tremendous undertaking that provides clinically important data hospitalists can use in the management of febrile infants.

"This contributes to patient-centered decision making with the number-needed-to-treat analysis, and I think it’s awesome," she said.

Dr. Biondi said in an interview that he and his colleagues are in the early stages of designing a prospective feasibility study at three sites that would provide more detailed information on positive, as well as negative, cultures and provide pilot data that could be used for a national study with the PRIS Network.

"We hope, in the end, that these data will lead to a cultural shift in the way we ‘rule out sepsis,’ which will allow us to treat kids with fewer doses of antibiotics and get them home with their families, where they belong," he said.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Biondi and his coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Pediatric hospitalists were able to safely and effectively deliver nitrous oxide and ketamine sedation to children of all ages in a review of more than 8,000 sedations.

The procedure completion rates were more than 99%.

No patient experienced a major complication defined as death, need for CPR, unplanned intubations, suspected aspirations, or emergency anesthesia consultations. Two unplanned admissions occurred each for nitrous oxide and ketamine, putting the overall rate of major complications at 0.05%.

"This is comparable to the rates by other providers such as pediatric ED physicians or pediatric intensivists in other studies," Dr. Mythili Srinivasan said at Pediatric Hospital Medicine 2013.

Although several studies have illustrated the safe use of ketamine and nitrous oxide for procedural sedation by ED physicians and intensivists, this is the first study to demonstrate the safe and effective use of these agents by pediatric hospitalists.

"This is important to show since there are barriers in many institutions for pediatric hospitalists to provide deep sedation," she said. "These barriers result in procedures, such as incision and drainage of abscesses, being performed in the operating room by anesthesiologists, which not only raises costs significantly, but also exposes patients to the unnecessary risks of general anesthesia."

The retrospective study was based on the hospitalist sedation program at St. Louis Children’s Hospital, which consists of 50 pediatric hospitalists who provide procedural sedation at multiple settings in the hospital including the emergency department, ambulatory procedure center, and pediatric acute wound service. A variety of sedation agents are used depending on the hospitalist’s training and sedation credentialing.

Dr. Srinivasan analyzed all 8,870 sedations performed by pediatric hospitalists using ketamine and nitrous oxide in the hospital’s quality improvement database from February 2007 to February 2013. Of these, 5,339 involved ketamine (60%) and 3,531 nitrous oxide.

Almost all sedations were deep se­dations, with either inhaled 70% nitrous oxide or IV ketamine, usually after pre-medication with a high dose of oxycodone,
said Dr. Srinivasan of Washington University in St. Louis.

Sedation was used in a wide age range of children (6 months through 18 years), with about 72% of children between 1 and 12 years. Almost half of ketamine sedations and more than three-fourths of nitrous oxide sedations were performed in the pediatric acute wound clinic.

Abscess incision and drainage was the most common procedure requiring sedation, followed by other wound debridement/laceration repair, fracture reduction/casting, and radiologic imaging.

Only 0.12% of sedations were not completed due to inadequate sedation, Dr. Srinivasan said at the meeting, cosponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. The desired sedation level was not achieved in 1.71% of sedations.

The overall rate of respiratory events was 2.15% for ketamine and 0.91% for nitrous oxide, with airway obstruction reported in 0.97% and 0.57% of patients, respectively. To put this in perspective, a large, pooled analysis involving 8,282 pediatric ketamine sedations by ED physicians reported an airway and respiratory event rate of 3.9% (Ann. Emerg. Med. 2009;54:158-68.e1-4), she said.

Overall rates for airway interventions were low for both ketamine and nitrous oxide including airway repositioning (4% and 1%, respectively), blow-by oxygen/oxygen by nasal cannula/flow mask (2.3%, 0.33%), and mask ventilation or continuous positive airway pressure (0.43%, 0.08%).

During a discussion of the study, an attendee questioned the generalizability of the results noting that the St. Louis group probably does more pediatric sedations than any other hospitalist group in the United States. It was also noted that the hospital has an extensive training program for pediatric hospitalist sedation (J. Hosp. Med. 2012;7:335-9).

Dr. Srinivasan said a collaborative relationship with anesthesia is important, and that clinicians who don’t do many sedations can find it difficult to judge which patients to sedate.

"I think the most important thing is to judge when you should be sedating and when you should be sending them over to anesthesia, and I think that knowledge comes with experience from sedating more and more children," she said.

As pediatric hospitalists take on more and more sedations, however, they may find this collaborative relationship has its limits. When asked whether hospitalists get reimbursed differently for sedations than anesthesiologists, Dr. Srinivasan said deep sedations by pediatric hospitalists are billed as deep sedations, but likely generate less income than those performed by anesthesiologists.

"We were generating the same income when we were doing our propofol sedations, and so that’s how we had a conflict; they really wanted that revenue back," she added, to a round of laughter.

Dr. Srinivasan reported having no relevant financial disclosures.

*This story was updated August 26, 2013.

[email protected]

NEW ORLEANS – Pediatric hospitalists were able to safely and effectively deliver nitrous oxide and ketamine sedation to children of all ages in a review of more than 8,000 sedations.

The procedure completion rates were more than 99%.

No patient experienced a major complication defined as death, need for CPR, unplanned intubations, suspected aspirations, or emergency anesthesia consultations. Two unplanned admissions occurred each for nitrous oxide and ketamine, putting the overall rate of major complications at 0.05%.

"This is comparable to the rates by other providers such as pediatric ED physicians or pediatric intensivists in other studies," Dr. Mythili Srinivasan said at Pediatric Hospital Medicine 2013.

Although several studies have illustrated the safe use of ketamine and nitrous oxide for procedural sedation by ED physicians and intensivists, this is the first study to demonstrate the safe and effective use of these agents by pediatric hospitalists.

"This is important to show since there are barriers in many institutions for pediatric hospitalists to provide deep sedation," she said. "These barriers result in procedures, such as incision and drainage of abscesses, being performed in the operating room by anesthesiologists, which not only raises costs significantly, but also exposes patients to the unnecessary risks of general anesthesia."

The retrospective study was based on the hospitalist sedation program at St. Louis Children’s Hospital, which consists of 50 pediatric hospitalists who provide procedural sedation at multiple settings in the hospital including the emergency department, ambulatory procedure center, and pediatric acute wound service. A variety of sedation agents are used depending on the hospitalist’s training and sedation credentialing.

Dr. Srinivasan analyzed all 8,870 sedations performed by pediatric hospitalists using ketamine and nitrous oxide in the hospital’s quality improvement database from February 2007 to February 2013. Of these, 5,339 involved ketamine (60%) and 3,531 nitrous oxide.

Almost all sedations were deep se­dations, with either inhaled 70% nitrous oxide or IV ketamine, usually after pre-medication with a high dose of oxycodone,
said Dr. Srinivasan of Washington University in St. Louis.

Sedation was used in a wide age range of children (6 months through 18 years), with about 72% of children between 1 and 12 years. Almost half of ketamine sedations and more than three-fourths of nitrous oxide sedations were performed in the pediatric acute wound clinic.

Abscess incision and drainage was the most common procedure requiring sedation, followed by other wound debridement/laceration repair, fracture reduction/casting, and radiologic imaging.

Only 0.12% of sedations were not completed due to inadequate sedation, Dr. Srinivasan said at the meeting, cosponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. The desired sedation level was not achieved in 1.71% of sedations.

The overall rate of respiratory events was 2.15% for ketamine and 0.91% for nitrous oxide, with airway obstruction reported in 0.97% and 0.57% of patients, respectively. To put this in perspective, a large, pooled analysis involving 8,282 pediatric ketamine sedations by ED physicians reported an airway and respiratory event rate of 3.9% (Ann. Emerg. Med. 2009;54:158-68.e1-4), she said.

Overall rates for airway interventions were low for both ketamine and nitrous oxide including airway repositioning (4% and 1%, respectively), blow-by oxygen/oxygen by nasal cannula/flow mask (2.3%, 0.33%), and mask ventilation or continuous positive airway pressure (0.43%, 0.08%).

During a discussion of the study, an attendee questioned the generalizability of the results noting that the St. Louis group probably does more pediatric sedations than any other hospitalist group in the United States. It was also noted that the hospital has an extensive training program for pediatric hospitalist sedation (J. Hosp. Med. 2012;7:335-9).

Dr. Srinivasan said a collaborative relationship with anesthesia is important, and that clinicians who don’t do many sedations can find it difficult to judge which patients to sedate.

"I think the most important thing is to judge when you should be sedating and when you should be sending them over to anesthesia, and I think that knowledge comes with experience from sedating more and more children," she said.

As pediatric hospitalists take on more and more sedations, however, they may find this collaborative relationship has its limits. When asked whether hospitalists get reimbursed differently for sedations than anesthesiologists, Dr. Srinivasan said deep sedations by pediatric hospitalists are billed as deep sedations, but likely generate less income than those performed by anesthesiologists.

"We were generating the same income when we were doing our propofol sedations, and so that’s how we had a conflict; they really wanted that revenue back," she added, to a round of laughter.

Dr. Srinivasan reported having no relevant financial disclosures.

*This story was updated August 26, 2013.

[email protected]

NEW ORLEANS – Pediatric hospitalists were able to safely and effectively deliver nitrous oxide and ketamine sedation to children of all ages in a review of more than 8,000 sedations.

The procedure completion rates were more than 99%.

No patient experienced a major complication defined as death, need for CPR, unplanned intubations, suspected aspirations, or emergency anesthesia consultations. Two unplanned admissions occurred each for nitrous oxide and ketamine, putting the overall rate of major complications at 0.05%.

"This is comparable to the rates by other providers such as pediatric ED physicians or pediatric intensivists in other studies," Dr. Mythili Srinivasan said at Pediatric Hospital Medicine 2013.

Although several studies have illustrated the safe use of ketamine and nitrous oxide for procedural sedation by ED physicians and intensivists, this is the first study to demonstrate the safe and effective use of these agents by pediatric hospitalists.

"This is important to show since there are barriers in many institutions for pediatric hospitalists to provide deep sedation," she said. "These barriers result in procedures, such as incision and drainage of abscesses, being performed in the operating room by anesthesiologists, which not only raises costs significantly, but also exposes patients to the unnecessary risks of general anesthesia."

The retrospective study was based on the hospitalist sedation program at St. Louis Children’s Hospital, which consists of 50 pediatric hospitalists who provide procedural sedation at multiple settings in the hospital including the emergency department, ambulatory procedure center, and pediatric acute wound service. A variety of sedation agents are used depending on the hospitalist’s training and sedation credentialing.

Dr. Srinivasan analyzed all 8,870 sedations performed by pediatric hospitalists using ketamine and nitrous oxide in the hospital’s quality improvement database from February 2007 to February 2013. Of these, 5,339 involved ketamine (60%) and 3,531 nitrous oxide.

Almost all sedations were deep se­dations, with either inhaled 70% nitrous oxide or IV ketamine, usually after pre-medication with a high dose of oxycodone,
said Dr. Srinivasan of Washington University in St. Louis.

Sedation was used in a wide age range of children (6 months through 18 years), with about 72% of children between 1 and 12 years. Almost half of ketamine sedations and more than three-fourths of nitrous oxide sedations were performed in the pediatric acute wound clinic.

Abscess incision and drainage was the most common procedure requiring sedation, followed by other wound debridement/laceration repair, fracture reduction/casting, and radiologic imaging.

Only 0.12% of sedations were not completed due to inadequate sedation, Dr. Srinivasan said at the meeting, cosponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. The desired sedation level was not achieved in 1.71% of sedations.

The overall rate of respiratory events was 2.15% for ketamine and 0.91% for nitrous oxide, with airway obstruction reported in 0.97% and 0.57% of patients, respectively. To put this in perspective, a large, pooled analysis involving 8,282 pediatric ketamine sedations by ED physicians reported an airway and respiratory event rate of 3.9% (Ann. Emerg. Med. 2009;54:158-68.e1-4), she said.

Overall rates for airway interventions were low for both ketamine and nitrous oxide including airway repositioning (4% and 1%, respectively), blow-by oxygen/oxygen by nasal cannula/flow mask (2.3%, 0.33%), and mask ventilation or continuous positive airway pressure (0.43%, 0.08%).

During a discussion of the study, an attendee questioned the generalizability of the results noting that the St. Louis group probably does more pediatric sedations than any other hospitalist group in the United States. It was also noted that the hospital has an extensive training program for pediatric hospitalist sedation (J. Hosp. Med. 2012;7:335-9).

Dr. Srinivasan said a collaborative relationship with anesthesia is important, and that clinicians who don’t do many sedations can find it difficult to judge which patients to sedate.

"I think the most important thing is to judge when you should be sedating and when you should be sending them over to anesthesia, and I think that knowledge comes with experience from sedating more and more children," she said.

As pediatric hospitalists take on more and more sedations, however, they may find this collaborative relationship has its limits. When asked whether hospitalists get reimbursed differently for sedations than anesthesiologists, Dr. Srinivasan said deep sedations by pediatric hospitalists are billed as deep sedations, but likely generate less income than those performed by anesthesiologists.

"We were generating the same income when we were doing our propofol sedations, and so that’s how we had a conflict; they really wanted that revenue back," she added, to a round of laughter.

Dr. Srinivasan reported having no relevant financial disclosures.

*This story was updated August 26, 2013.

[email protected]

NEW ORLEANS – The 3M Potentially Preventable Readmissions algorithm is not ready for prime time as a tool to assess preventable pediatric readmissions, preliminary data from an analysis of 1.7 million admissions suggests.

The analysis found that only about 20% of all pediatric readmissions are potentially preventable, whereas the PPR algorithm put that number at about 40%, Dr. James Gay said at the Pediatric Hospital Medicine 2013 meeting.

The results are concerning because the PPR algorithm has been used by several state Medicaid programs as the basis for levying financial penalties on hospitals with high readmission rates, including some children’s hospitals.

"We’re not at the point where children’s hospitals should be penalized by any system that’s judging readmission preventable, because we just don’t have the tools for that to be fair," he said. "I’m hoping 3M will use this [data] to apply overlays to their algorithm – socioeconomic overlays, preventability scoring factors – but this will take a lot more work to decide what’s really preventable or not."

Patrice Wendling/IMNG Medical Media

The 3M algorithm was designed for use in patients of all ages and uses administrative data to identify "potentially preventable" readmissions based on the relationship between All Patient Refined Diagnosis Related Groups (APR-DRGs) of the index admission and readmissions. It is thought to have a potential advantage over an "all-cause" approach because it has many predefined exclusions such as APR-DRGs for chemotherapy and cystic fibrosis.

The problem is the algorithm may not be sensitive to pediatric readmissions, which differ from those in adults in diagnoses, rates, and preventability, said Dr. Gay, with the Monroe Carell Jr. Children’s Hospital at Vanderbilt, in Nashville.

The investigators analyzed data from 1,719,617 hospitalizations for 1,496,470 patients admitted at 58 Children’s Hospital Association hospitals from 2009 to 2011. They compared the PPR algorithm readmission rates with all-cause readmission rates at 7, 15, and 30 days, determined which diagnoses accounted for the largest volume and cost of readmission by both methods, and accessed the financial impact of the readmissions.

At 7, 15, and 30 days, the PPR algorithm readmission rates were 2.5%, 4.1%, and 6.3% or almost exactly half of the all-cause readmission rates of 5%, 8.7%, and 13.3%, respectively, Dr. Gay said.

The same was true for the total number of PPR admissions at 11,898, 19,724, and 30,226, respectively, versus all-cause readmissions of 28,755, 49,982, and 76,245, respectively.

For each time period, the overall percentage of potentially preventable readmissions with the PPR algorithm hovered around 40%, with very little variability, Dr. Gay said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

"This runs somewhat contrary to the common notion that a readmission is more likely to be preventable the earlier it occurs after discharge, but the PPR system does not pick up on that," he observed.

Notably, the PPR algorithm considered at least 80% of readmissions preventable for six APR-DRGs: sickle cell crisis (81%), asthma (81%), bronchiolitis (83%), ventricular shunt procedures (86%), connective tissue disorders (87%), and appendectomy (100%).

"Parenthetically, there are a number of pediatricians that might argue about 80% of bronchiolitis readmissions being preventable," he quipped.

Finally, the total annual cost for admissions in the study was $11.6 billion, of which $1.7 billion (14.7%) was related to all-cause readmissions and $533 million (4.6%) to PPR algorithm readmissions.

If the data are extrapolated, the estimated nationwide annual cost for pediatric hospitalizations is $33.6 billion, with a potential savings of $1.5 billion per year (4.6%) if all PPR readmissions could be prevented. Based on a crude back-of-the-envelope calculation, the $1.5 billion pales in comparison to the $25 billion projected to be saved annually in preventable Medicare readmissions, Dr. Gay observed.

"The financial yield in preventing PPR readmissions in pediatric populations is relatively small, and efforts should continue to assure the highest-quality inpatient care and discharge planning," he said.

"Further research is needed to validate the applicability and appropriateness of PPR inclusions and exclusions in pediatric populations before it can be recommended for such consequential purposes as financial penalties to children’s hospitals."

During a discussion of the findings, an attendee asked whether this type of research was worth burning up so many bright minds, given that the data have repeatedly shown that pediatric readmission rates are so low. Dr. Gay responded, saying that, quite frankly, the work is necessary to avoid financial penalties and to drive home the point that quality improvement measures focused on pediatric readmissions are "bogus."

In a statement responding to Dr. Gay’s analysis, 3M Health Information Systems’ senior vice president of clinical and economic research, Richard Averill, said, "In payment applications, the number of PPRs for each provider is compared on a risk-adjusted basis to identify those providers with an ‘excess’ number of readmissions that are potentially preventable. Any payment adjustment for readmission is based only on the extent of excess readmissions.

"If all providers had the same PPR rate, no provider would have any excess PPRs and there would be no payment adjustment for readmission. Unfortunately, Dr. Gay’s comments omit any mention of how PPRs are actually being used and that they are not intended to provide a direct measure of the number of preventable readmissions."

Mr. Averill noted that Dr. Gay’s analysis observes that "half of readmissions detected by an ‘all-cause’ method would not be considered potentially preventable using PPRs. An examination of excess PPR rates across children’s hospitals can be an important quality improvement tool," he said.

In a separate interview, Dr. Shawn Ralston, chief of the pediatrics section, Dartmouth-Hitchcock Medical Center, Lebanon, N.H., agreed with Dr. Gay and said there are more pressing issues in pediatric clinical quality that deserve attention.

"I want meaningful quality measures developed by people with pediatric expertise and not things extrapolated from adult patients," Dr. Ralston added.

Dr. Gay reported serving as the medical consultant to the Children’s Hospital Association.

[email protected]

NEW ORLEANS – The 3M Potentially Preventable Readmissions algorithm is not ready for prime time as a tool to assess preventable pediatric readmissions, preliminary data from an analysis of 1.7 million admissions suggests.

The analysis found that only about 20% of all pediatric readmissions are potentially preventable, whereas the PPR algorithm put that number at about 40%, Dr. James Gay said at the Pediatric Hospital Medicine 2013 meeting.

The results are concerning because the PPR algorithm has been used by several state Medicaid programs as the basis for levying financial penalties on hospitals with high readmission rates, including some children’s hospitals.

"We’re not at the point where children’s hospitals should be penalized by any system that’s judging readmission preventable, because we just don’t have the tools for that to be fair," he said. "I’m hoping 3M will use this [data] to apply overlays to their algorithm – socioeconomic overlays, preventability scoring factors – but this will take a lot more work to decide what’s really preventable or not."

Patrice Wendling/IMNG Medical Media

The 3M algorithm was designed for use in patients of all ages and uses administrative data to identify "potentially preventable" readmissions based on the relationship between All Patient Refined Diagnosis Related Groups (APR-DRGs) of the index admission and readmissions. It is thought to have a potential advantage over an "all-cause" approach because it has many predefined exclusions such as APR-DRGs for chemotherapy and cystic fibrosis.

The problem is the algorithm may not be sensitive to pediatric readmissions, which differ from those in adults in diagnoses, rates, and preventability, said Dr. Gay, with the Monroe Carell Jr. Children’s Hospital at Vanderbilt, in Nashville.

The investigators analyzed data from 1,719,617 hospitalizations for 1,496,470 patients admitted at 58 Children’s Hospital Association hospitals from 2009 to 2011. They compared the PPR algorithm readmission rates with all-cause readmission rates at 7, 15, and 30 days, determined which diagnoses accounted for the largest volume and cost of readmission by both methods, and accessed the financial impact of the readmissions.

At 7, 15, and 30 days, the PPR algorithm readmission rates were 2.5%, 4.1%, and 6.3% or almost exactly half of the all-cause readmission rates of 5%, 8.7%, and 13.3%, respectively, Dr. Gay said.

The same was true for the total number of PPR admissions at 11,898, 19,724, and 30,226, respectively, versus all-cause readmissions of 28,755, 49,982, and 76,245, respectively.

For each time period, the overall percentage of potentially preventable readmissions with the PPR algorithm hovered around 40%, with very little variability, Dr. Gay said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

"This runs somewhat contrary to the common notion that a readmission is more likely to be preventable the earlier it occurs after discharge, but the PPR system does not pick up on that," he observed.

Notably, the PPR algorithm considered at least 80% of readmissions preventable for six APR-DRGs: sickle cell crisis (81%), asthma (81%), bronchiolitis (83%), ventricular shunt procedures (86%), connective tissue disorders (87%), and appendectomy (100%).

"Parenthetically, there are a number of pediatricians that might argue about 80% of bronchiolitis readmissions being preventable," he quipped.

Finally, the total annual cost for admissions in the study was $11.6 billion, of which $1.7 billion (14.7%) was related to all-cause readmissions and $533 million (4.6%) to PPR algorithm readmissions.

If the data are extrapolated, the estimated nationwide annual cost for pediatric hospitalizations is $33.6 billion, with a potential savings of $1.5 billion per year (4.6%) if all PPR readmissions could be prevented. Based on a crude back-of-the-envelope calculation, the $1.5 billion pales in comparison to the $25 billion projected to be saved annually in preventable Medicare readmissions, Dr. Gay observed.

"The financial yield in preventing PPR readmissions in pediatric populations is relatively small, and efforts should continue to assure the highest-quality inpatient care and discharge planning," he said.

"Further research is needed to validate the applicability and appropriateness of PPR inclusions and exclusions in pediatric populations before it can be recommended for such consequential purposes as financial penalties to children’s hospitals."

During a discussion of the findings, an attendee asked whether this type of research was worth burning up so many bright minds, given that the data have repeatedly shown that pediatric readmission rates are so low. Dr. Gay responded, saying that, quite frankly, the work is necessary to avoid financial penalties and to drive home the point that quality improvement measures focused on pediatric readmissions are "bogus."

In a statement responding to Dr. Gay’s analysis, 3M Health Information Systems’ senior vice president of clinical and economic research, Richard Averill, said, "In payment applications, the number of PPRs for each provider is compared on a risk-adjusted basis to identify those providers with an ‘excess’ number of readmissions that are potentially preventable. Any payment adjustment for readmission is based only on the extent of excess readmissions.

"If all providers had the same PPR rate, no provider would have any excess PPRs and there would be no payment adjustment for readmission. Unfortunately, Dr. Gay’s comments omit any mention of how PPRs are actually being used and that they are not intended to provide a direct measure of the number of preventable readmissions."

Mr. Averill noted that Dr. Gay’s analysis observes that "half of readmissions detected by an ‘all-cause’ method would not be considered potentially preventable using PPRs. An examination of excess PPR rates across children’s hospitals can be an important quality improvement tool," he said.

In a separate interview, Dr. Shawn Ralston, chief of the pediatrics section, Dartmouth-Hitchcock Medical Center, Lebanon, N.H., agreed with Dr. Gay and said there are more pressing issues in pediatric clinical quality that deserve attention.

"I want meaningful quality measures developed by people with pediatric expertise and not things extrapolated from adult patients," Dr. Ralston added.

Dr. Gay reported serving as the medical consultant to the Children’s Hospital Association.

[email protected]

NEW ORLEANS – The 3M Potentially Preventable Readmissions algorithm is not ready for prime time as a tool to assess preventable pediatric readmissions, preliminary data from an analysis of 1.7 million admissions suggests.

The analysis found that only about 20% of all pediatric readmissions are potentially preventable, whereas the PPR algorithm put that number at about 40%, Dr. James Gay said at the Pediatric Hospital Medicine 2013 meeting.

The results are concerning because the PPR algorithm has been used by several state Medicaid programs as the basis for levying financial penalties on hospitals with high readmission rates, including some children’s hospitals.

"We’re not at the point where children’s hospitals should be penalized by any system that’s judging readmission preventable, because we just don’t have the tools for that to be fair," he said. "I’m hoping 3M will use this [data] to apply overlays to their algorithm – socioeconomic overlays, preventability scoring factors – but this will take a lot more work to decide what’s really preventable or not."

Patrice Wendling/IMNG Medical Media

The 3M algorithm was designed for use in patients of all ages and uses administrative data to identify "potentially preventable" readmissions based on the relationship between All Patient Refined Diagnosis Related Groups (APR-DRGs) of the index admission and readmissions. It is thought to have a potential advantage over an "all-cause" approach because it has many predefined exclusions such as APR-DRGs for chemotherapy and cystic fibrosis.

The problem is the algorithm may not be sensitive to pediatric readmissions, which differ from those in adults in diagnoses, rates, and preventability, said Dr. Gay, with the Monroe Carell Jr. Children’s Hospital at Vanderbilt, in Nashville.

The investigators analyzed data from 1,719,617 hospitalizations for 1,496,470 patients admitted at 58 Children’s Hospital Association hospitals from 2009 to 2011. They compared the PPR algorithm readmission rates with all-cause readmission rates at 7, 15, and 30 days, determined which diagnoses accounted for the largest volume and cost of readmission by both methods, and accessed the financial impact of the readmissions.

At 7, 15, and 30 days, the PPR algorithm readmission rates were 2.5%, 4.1%, and 6.3% or almost exactly half of the all-cause readmission rates of 5%, 8.7%, and 13.3%, respectively, Dr. Gay said.

The same was true for the total number of PPR admissions at 11,898, 19,724, and 30,226, respectively, versus all-cause readmissions of 28,755, 49,982, and 76,245, respectively.

For each time period, the overall percentage of potentially preventable readmissions with the PPR algorithm hovered around 40%, with very little variability, Dr. Gay said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

"This runs somewhat contrary to the common notion that a readmission is more likely to be preventable the earlier it occurs after discharge, but the PPR system does not pick up on that," he observed.

Notably, the PPR algorithm considered at least 80% of readmissions preventable for six APR-DRGs: sickle cell crisis (81%), asthma (81%), bronchiolitis (83%), ventricular shunt procedures (86%), connective tissue disorders (87%), and appendectomy (100%).

"Parenthetically, there are a number of pediatricians that might argue about 80% of bronchiolitis readmissions being preventable," he quipped.

Finally, the total annual cost for admissions in the study was $11.6 billion, of which $1.7 billion (14.7%) was related to all-cause readmissions and $533 million (4.6%) to PPR algorithm readmissions.

If the data are extrapolated, the estimated nationwide annual cost for pediatric hospitalizations is $33.6 billion, with a potential savings of $1.5 billion per year (4.6%) if all PPR readmissions could be prevented. Based on a crude back-of-the-envelope calculation, the $1.5 billion pales in comparison to the $25 billion projected to be saved annually in preventable Medicare readmissions, Dr. Gay observed.

"The financial yield in preventing PPR readmissions in pediatric populations is relatively small, and efforts should continue to assure the highest-quality inpatient care and discharge planning," he said.

"Further research is needed to validate the applicability and appropriateness of PPR inclusions and exclusions in pediatric populations before it can be recommended for such consequential purposes as financial penalties to children’s hospitals."

During a discussion of the findings, an attendee asked whether this type of research was worth burning up so many bright minds, given that the data have repeatedly shown that pediatric readmission rates are so low. Dr. Gay responded, saying that, quite frankly, the work is necessary to avoid financial penalties and to drive home the point that quality improvement measures focused on pediatric readmissions are "bogus."

In a statement responding to Dr. Gay’s analysis, 3M Health Information Systems’ senior vice president of clinical and economic research, Richard Averill, said, "In payment applications, the number of PPRs for each provider is compared on a risk-adjusted basis to identify those providers with an ‘excess’ number of readmissions that are potentially preventable. Any payment adjustment for readmission is based only on the extent of excess readmissions.

"If all providers had the same PPR rate, no provider would have any excess PPRs and there would be no payment adjustment for readmission. Unfortunately, Dr. Gay’s comments omit any mention of how PPRs are actually being used and that they are not intended to provide a direct measure of the number of preventable readmissions."

Mr. Averill noted that Dr. Gay’s analysis observes that "half of readmissions detected by an ‘all-cause’ method would not be considered potentially preventable using PPRs. An examination of excess PPR rates across children’s hospitals can be an important quality improvement tool," he said.

In a separate interview, Dr. Shawn Ralston, chief of the pediatrics section, Dartmouth-Hitchcock Medical Center, Lebanon, N.H., agreed with Dr. Gay and said there are more pressing issues in pediatric clinical quality that deserve attention.

"I want meaningful quality measures developed by people with pediatric expertise and not things extrapolated from adult patients," Dr. Ralston added.

Dr. Gay reported serving as the medical consultant to the Children’s Hospital Association.

[email protected]