A Multicenter Collaborative to Improve Care of Community Acquired Pneumonia in Hospitalized Children

Simultaneously implementing pathways for improving asthma, pneumonia, and bronchiolitis care for hospitalized children: Protocol for a hybrid effectiveness-implementation, cluster-randomized trial

BACKGROUND

Asthma, pneumonia, and bronchiolitis are the top causes of childhood hospitalization in the United States, leading to over 350,000 hospitalizations and ≈$2 billion in costs annually. The majority of these hospitalizations occur in general/community hospitals. Poor guideline adoption by clinicians contributes to poor health outcomes for children hospitalized with these illnesses, including longer recovery time/hospital stay, higher rates of intensive care unit transfer, and increased risk of hospital readmission. A prior single-center study at a children's hospital tested a multicondition clinical pathway intervention (simultaneous implementation of multiple pathways for multiple pediatric conditions) and demonstrated improved clinician guideline adherence and patient health outcomes. This intervention has not yet been studied in community hospitals, which face unique implementation barriers.

OBJECTIVE

To study the implementation and effectiveness of a multicondition pathway intervention for children hospitalized with asthma, pneumonia, or bronchiolitis in community hospitals.

METHODS

We will conduct a pragmatic, hybrid effectiveness-implementation, cluster-randomized trial in community hospitals around the United States (1:1 randomization to intervention vs. wait-list control). Our primary outcome will be the adoption of 2-3 evidence-based practices for each condition over a sustained period of 2 years. Secondary outcomes include hospital length of stay, ICU transfer, and readmission.

DISCUSSION

This hybrid trial will lead to a comprehensive understanding of how to pragmatically and sustainably implement a multicondition pathway intervention in community hospitals and an assessment of its effects. Enrollment began in July 2022 and is projected to be completed in September 2024. Primary analysis completion is anticipated in March 2025, with reporting of results following.

A National Quality Improvement Collaborative to Improve Antibiotic Use in Pediatric Infections

BACKGROUND

Nearly 25% of antibiotics prescribed to children are inappropriate or unnecessary, subjecting patients to avoidable adverse medication effects and cost.

METHODS

We conducted a quality improvement initiative across 118 hospitals participating in the American Academy of Pediatrics Value in Inpatient Pediatrics Network 2020 to 2022. We aimed to increase the proportion of children receiving appropriate: (1) empirical, (2) definitive, and (3) duration of antibiotic therapy for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections to ≥85% by Jan 1, 2022. Sites reviewed encounters of children >60 days old evaluated in the emergency department or hospital. Interventions included monthly audit with feedback, educational webinars, peer coaching, order sets, and a mobile app containing site-specific, antibiogram-based treatment recommendations. Sites submitted 18 months of baseline, 2-months washout, and 10 months intervention data. We performed interrupted time series (analyses for each measure.

RESULTS

Sites reviewed 43 916 encounters (30 799 preintervention, 13 117 post). Overall median [interquartile range] adherence to empirical, definitive, and duration of antibiotic therapy was 67% [65% to 70%]; 74% [72% to 75%] and 61% [58% to 65%], respectively at baseline and was 72% [71% to 72%]; 79% [79% to 80%] and 71% [69% to 73%], respectively, during the intervention period. Interrupted time series revealed a 13% (95% confidence interval: 1% to 26%) intercept change at intervention for empirical therapy and a 1.1% (95% confidence interval: 0.4% to 1.9%) monthly increase in adherence per month for antibiotic duration above baseline rates. Balancing measures of care escalation and revisit or readmission did not increase.

CONCLUSIONS

This multisite collaborative increased appropriate antibiotic use for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infection among diverse hospitals.

Asthma-community acquired pneumonia co-diagnosis in children: a scoping review

OBJECTIVE

This scoping review investigated the existing literature and identified the evidence gaps related to diagnosis and management in children aged 2-18 years presenting to hospitals with a co-diagnosis of asthma and community-acquired pneumonia.

DATA SOURCES

We designed a scoping review following Arksey and O'Malley's scoping review framework and PRISMA extension for a scoping review. We searched literature using five electronic databases: PubMed, CINAHL, Scopus, Web of Science, and Embase from 2003 to June 2023.

RESULTS

A total of 1599 abstracts with titles were screened and 12 abstracts were selected for full review. Separate guidelines including Modified Global Initiative for Asthma (GINA) guidelines; modified Integrated Management of Childhood Illness (IMCI) guidelines; and a consensus guideline developed by the Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) were used for diagnosing asthma and CAP individually. Chest X-rays were used in 83.3% (10/12) of studies to establish the co-diagnosis of asthma-CAP in children. Variations were observed in using different laboratory investigations across the studies. Infectious etiologies were detected in five (41.7%) studies. In 75% (9/12) of studies, children with asthma-CAP co-diagnosis were treated with antimicrobials, however, bacterial etiology was not reported in 44.4% (4/9) of the studies.

CONCLUSIONS

Our scoping review suggests that chest X-rays are commonly used to establish the co-diagnosis of asthma-CAP and antibiotics are often used without laboratory confirmation of a bacterial etiology. Clinical practice guidelines for the management of asthma and pneumonia in children who present with co-diagnosis may standardize clinical care and reduce variation.

Childhood Pneumonia in Low- and Middle-Income Countries: A Systematic Review of Prevalence, Risk Factors, and Healthcare-Seeking Behaviors

Childhood pneumonia is a major contributor to illness and death in children under the age of five globally. Despite advancements in medical science, the burden of pediatric community-acquired pneumonia (CAP) remains high, particularly in low- and middle-income countries. This systematic review aims to synthesize existing literature on the prevalence, risk factors, and healthcare-seeking behaviors associated with pediatric CAP to inform the development of targeted community-based interventions. An extensive search of various databases such as Medline, EMBASE, Web of Science, Cochrane, PubMed, PubMed Central, Helinet, SpringerLink, Google Scholar, and Biomed Central was performed, resulting in 65 potentially relevant studies. After a thorough evaluation process, 25 studies were selected for the final analysis. These selected studies offered valuable information on the epidemiology, risk factors, and healthcare-seeking behaviors associated with childhood pneumonia. The review revealed that environmental factors such as indoor air pollution, overcrowding, and exposure to tobacco smoke are significant risk factors for pediatric pneumonia. Additionally, socioeconomic factors, including poverty and a lack of access to clean water and sanitation, contribute to the vulnerability of children to this disease. Poor healthcare-seeking behaviors, driven by limited knowledge and awareness of pneumonia symptoms and treatment, further exacerbate the situation. The review also highlighted the critical role of vaccination, particularly against Haemophilus influenzae type b (Hib) and pneumococcus, in preventing pneumonia. However, gaps in vaccination coverage and challenges in accessing healthcare services remain barriers to effective pneumonia control. In light of these findings, the review recommends the implementation of community-based interventions that address the multifaceted determinants of pediatric pneumonia. These interventions should focus on improving environmental conditions, enhancing access to preventive measures such as vaccination, and promoting better healthcare-seeking behaviors through education and awareness campaigns. It is essential for healthcare providers, policymakers, and community members to collaborate in developing and implementing culturally appropriate and sustainable interventions. This cooperation aims to lessen the impact of pneumonia on children and their families.

Barriers and Facilitators of High-Efficiency Clinical Pathway Implementation in Community Hospitals

BACKGROUND

An intervention that involved simultaneously implementing clinical pathways for multiple conditions was tested at a tertiary children's hospital and it improved care quality. We are conducting a randomized trial to evaluate this multicondition pathway intervention in community hospitals. Our objectives in this qualitative study were to prospectively (1) identify implementation barriers and (2) map barriers to facilitators using an established implementation science framework.

METHODS

We recruited participants via site leaders from hospitals enrolled in the trial. We designed an interview guide using the Consolidated Framework for Implementation Research and conducted individual interviews. Analysis was done using constant comparative methods. Anticipated barriers were mapped to facilitators using the Capability, Opportunity, Motivation, Behavior Framework.

RESULTS

Participants from 12 hospitals across the United States were interviewed (n = 21). Major themes regarding the multicondition pathway intervention included clinician perceptions, potential benefits, anticipated barriers/challenges, potential facilitators, and necessary resources. We mapped barriers to additional facilitators using the Capability, Opportunity, Motivation, Behavior framework. To address limited time/bandwidth of clinicians, we will provide Maintenance of Certification credits. To address new staff and trainee turnover, we will provide easily accessible educational videos/resources. To address difficulties in changing practice across other hospital units, we will encourage emergency department engagement. To address parental concerns with deimplementation, we will provide guidance on parent counseling.

CONCLUSIONS

We identified several potential barriers and facilitators for implementation of a multicondition clinical pathway intervention in community hospitals. We also illustrate a prospective process for identifying implementation facilitators.

Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care

BACKGROUND AND OBJECTIVES

Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC).

METHODS

A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports.

RESULTS

The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs.

CONCLUSIONS

The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.

Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status

OBJECTIVE

To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities.

METHODS

Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA.

RESULTS

We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P = .01), have longer inpatient length of stay (31 vs 29 hours, P = .01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P = .02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures.

CONCLUSION

At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.

Comparing Patterns of Care for Febrile Infants at Community and University-Affiliated Hospitals

OBJECTIVES

Most children in the United States receive treatment in community hospitals, but descriptions of clinical practice patterns in pediatric care in this setting are lacking. Our objectives were to compare clinical practice patterns primarily between community and university-affiliated hospitals and secondarily by number of pediatric beds before and during participation in a national practice standardization project.

METHODS

We performed a retrospective secondary analysis on data from 126 hospitals that participated in the American Academy of Pediatrics' Value in Inpatient Pediatrics Reducing Excessive Variability in the Infant Sepsis Evaluation project, a national quality improvement project conducted to improve care for well-appearing febrile infants aged 7 to 60 days. Four use measures were compared by hospital type and by number of non-ICU pediatric beds.

RESULTS

There were no differences between community and university-affiliated hospitals in the odds of hospital admission, average length of stay, or odds of cerebrospinal fluid culture. The odds of chest radiograph at community hospitals were higher only during the baseline period. There were no differences by number of pediatric beds in odds of admission or average length of stay. For hospitals with ≤30 pediatric beds, the odds of chest radiograph were higher and the odds of cerebrospinal fluid culture were lower compared with hospitals >50 beds during both study periods.

CONCLUSIONS

In many key aspects, care for febrile infants does not differ between community and university-affiliated hospitals. Clinical practice may differ more by number of pediatric beds.

Variation in Pediatric Asthmonia Diagnosis and Outcomes among Hospitalized Children

RATIONALE

Although <5% of children hospitalized with an asthma exacerbation have pneumonia that can be radiographically confirmed, at some hospitals asthma-pneumonia co-diagnosis is so common that the term "asthmonia" is used to describe the phenomenon. High rates of asthmonia diagnosis may incur unwarranted healthcare costs and contribute to unnecessary antibiotic prescribing.

OBJECTIVE

To characterize hospital variation in rates of pediatric asthmonia diagnosis and analyze associations between hospitals' asthmonia diagnosis rates and clinical outcomes.

METHODS

We conducted a cross-sectional analysis of 274 hospitals contributing to the Premier Healthcare Database. Children and adolescents 2-17 years of age were included if they were hospitalized with an asthma exacerbation from 10/1/2015-6/30/2018. Asthmonia was defined as a discharge diagnosis of pneumonia in a patient with an asthma exacerbation. To compute hospital-level risk-standardized asthmonia rates, hierarchical generalized linear models with hospital random effects were estimated, adjusting for patient characteristics. The median odds ratio (MOR) was calculated to quantify the effect of hospital-level clustering on asthmonia diagnosis. Hospitals were stratified into quartiles based on risk-standardized asthmonia diagnosis rates to identify associated hospital characteristics. Generalized linear models, adjusting for hospital characteristics, were developed to compute associations between hospital risk-standardized rates and clinical outcomes.

RESULTS

Of 24606 asthma exacerbations, 19402 (78.9%) were diagnosed with asthma alone and 5204 (21.1%) received asthma-pneumonia co-diagnoses. The hospital median risk-adjusted asthmonia diagnosis rate was 20.9% (IQR:16.2-27.2%, range:8.4-55.9%). The MOR was 1.75 (95% CI:1.63-1.86). Compared to hospitals in the lowest quartile of asthma-pneumonia co-diagnosis, those in the highest quartile were more likely to be smaller, non-teaching, rural hospitals with minimal subspecialty support (all p<0.001). Hospitals with high rates of risk-standardized asthmonia diagnosis had greater antibiotic utilization, more prolonged lengths of stay, and higher costs, with no significant differences in risk of transfer or readmission.

CONCLUSIONS

Marked variation exists in rates of asthmonia diagnosis, and the hospital of admission is one of the strongest predictors of diagnosis. Efforts to reduce rates of unwarranted asthmonia diagnosis are needed, particularly at small, rural, non-teaching hospitals with minimal pediatric specialty support.

Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative

BACKGROUND

Community hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate changes in care quality in community hospitals after the end of the Pathways for Improving Paediatric Asthma Care (PIPA) national QI collaborative.

METHODS

We conducted a longitudinal cohort study during and after PIPA. PIPA included 45 community hospitals, of which 34 completed the 12-month collaborative and were invited for extended sustainability monitoring (total of 21-24 months from collaborative start). PIPA provided paediatric asthma pathways, educational materials/seminars, QI mentorship, monthly data reports, a mobile application and peer-to-peer learning opportunities. Access to pathways, educational materials and the mobile application remained during sustainability monitoring. Charts were reviewed for children aged 2-17 years old hospitalised with a primary diagnosis of asthma (maximum 20 monthly per hospital). Outcomes included measures of guideline adherence (early bronchodilator administration via metered-dose inhaler (MDI), secondhand smoke screening and referral to smoking cessation resources) and length of stay (LOS). We evaluated outcomes using multilevel regression models adjusted for patient mix, using an interrupted time-series approach.

RESULTS

We analysed 2159 hospitalisations from 23 hospitals (68% of eligible). Participating hospitals were structurally similar to those that dropped out but had more improvement in guideline adherence during the collaborative (29% vs 15%, p=0.02). The end of the collaborative was associated with a significant initial decrease in early MDI administration (81%-68%) (adjusted OR (aOR) 0.26 (95% CI 0.15 to 0.42)) and decreased rate of referral to smoking cessation resources (2.2% per month increase to 0.3% per month decrease) (aOR 0.86 (95% CI 0.75 to 0.98)) but no significant changes in LOS or secondhand smoke screening.

CONCLUSIONS

The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.

High prescribing rates of third-generation cephalosporins in children hospitalized with acute lower respiratory infections at a university hospital

OBJECTIVE

Antibiotics are frequently prescribed for the treatment of acute lower respiratory infections (ALRI) in children ≤5 years of age, even though viral aetiologies are the most common. The aim of this study was to describe antibiotic prescribing rates and patterns in children ≤5 years of age hospitalized with ALRI.

METHODS

A retrospective study was conducted involving patients aged 1 month to 5 years hospitalized with ALRI at a university hospital. Patient demographics, ALRI diagnosis, microbiological data, antibiotics prescribed, and treatment outcomes were recorded and analysed.

RESULTS

A total of 1283 patients were enrolled. Their median age was 1.6 years (interquartile range 0.8-2.8 years). Thirty-six percent had a co-morbidity. The diagnosis at discharge was viral ALRI in 81% and bacterial pneumonia in 19%. The mortality rate was 0.4%. The overall antibiotic prescribing rate was 46% (95% confidence interval 43-49%). Antibiotic prescribing rates were higher among children with co-morbidities (65% vs 35%, p < 0.001) and older children (57% for >2-5 years vs 39% for ≤2 years, p < 0.001). Parenteral third-generation cephalosporins were prescribed in up to 68% of all prescriptions.

CONCLUSIONS

Nearly-half of hospitalized children with ALRI were prescribed antibiotics. The majority of prescribed antibiotics were third-generation cephalosporins. An antimicrobial stewardship programme and antibiotic guidelines should be implemented to promote the judicious use of antibiotics.

Learning from Each Other: A Multisite Collaborative to Reduce Electrolyte Testing

Inpatient electrolyte testing rates vary significantly across pediatric hospitals. Despite evidence that unnecessary testing exists, providers still struggle with reducing electrolyte laboratory testing. We aimed to reduce serum electrolyte testing among pediatric inpatients by 20% across 5 sites within 6 months.

METHODS

A national quality improvement collaborative evaluated standardized interventions for reducing inpatient serum electrolyte testing at 5 large tertiary and quaternary children's hospitals. The outcome measure was the rate of electrolyte laboratory tests per 10 patient-days. The interventions were adapted from a previous single-site improvement project and included cost card reminders, automated laboratory plans via electronic medical record, structured rounds discussions, and continued education. The collaborative utilized weekly conference calls to discuss Plan, Do, Study, Act cycles, and barriers to implementation efforts.

RESULTS

The study included 17,149 patient-days across 5 hospitals. The baseline preintervention electrolyte laboratory testing rate mean was 4.82 laboratory tests per 10 patient-days. Postimplementation, special cause variation in testing rates shifted the mean to 4.19 laboratory tests per 10 patient-days, a 13% reduction. There was a wide variation in preintervention electrolyte testing rates and the effectiveness of interventions between the hospitals participating in the collaborative.

CONCLUSIONS

This multisite improvement collaborative was able to rapidly disseminate and implement value improvement interventions leading to a reduction in electrolyte testing; however, we did not meet our goal of 20% testing reduction across all sites. Quality improvement collaboratives must consider variation in context when adapting previously successful single-center interventions to a wide variety of sites.

Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study

BACKGROUND AND OBJECTIVES

Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve inpatient asthma care but mainly in studies at large, tertiary children's hospitals. It remains unclear if these effects are generalizable across diverse hospital settings. Our objective was to improve inpatient asthma care by implementing pathways in a diverse, national sample of hospitals.

METHODS

We used a learning collaborative model. Pathway implementation strategies included local champions, external facilitators and/or mentors, educational seminars, quality improvement methods, and audit and feedback. Outcomes included length of stay (LOS) (primary), early administration of metered-dose inhalers, screening for secondhand tobacco exposure and referral to cessation resources, and 7-day hospital readmissions or emergency revisits (balancing). Hospitals reviewed a sample of up to 20 charts per month of children ages 2 to 17 years who were admitted with a primary diagnosis of asthma (12 months before and 15 months after implementation). Analyses were done by using multilevel regression models with an interrupted time series approach, adjusting for patient characteristics.

RESULTS

Eighty-five hospitals enrolled (40 children's and 45 community); 68 (80%) completed the study (n = 12 013 admissions). Pathways were associated with increases in early administration of metered-dose inhalers (odds ratio: 1.18; 95% confidence interval [CI]: 1.14-1.22) and referral to smoking cessation resources (odds ratio: 1.93; 95% CI: 1.27-2.91) but no statistically significant changes in other outcomes, including LOS (rate ratio: 1.00; 95% CI: 0.96-1.06). Most hospitals (65%) improved in at least 1 outcome.

CONCLUSIONS

Pathways did not significantly impact LOS but did improve quality of asthma care for children in a diverse, national group of hospitals.

Identification of High-Yield Targets for Antimicrobial Stewardship Program Efforts Within a Nonfreestanding Children's Hospital

OBJECTIVES

Identify diagnoses with the highest likelihood of prompting antimicrobial stewardship program (ASP) recommendations and lowest probability of recommendation acceptance, investigate the impact of provider years in practice on recommendation receipt and acceptance, and simultaneously assess the influence of patient and provider-level variables associated with recommendations within a nonfreestanding children's hospital.

METHODS

Retrospective cohort study of antibiotic courses reviewed by the ASP staff from December 1, 2014 to November 30, 2016. Poisson regression was used to detect associations between diagnoses, provider years in practice, and the probability of recommendation receipt and acceptance. Multivariable logistic regression was used to simultaneously examine the influence of patient and provider-level characteristics on recommendation probability.

RESULTS

A total of 938 inpatient encounters and 1170 antibiotic courses were included. Diagnoses were associated with provider receipt (P < .001) and acceptance (P < .001) of recommendations, with ear, nose, and throat and/or sinopulmonary diagnoses most likely to prompt recommendations (56%; 95% confidence interval [CI], 48-64) and recommendations for neonatal and/or infant diagnoses accepted least often (67%; 95% CI, 58-76). No associations were initially found between provider experience and recommendation receipt or acceptance, although multivariable analysis revealed a trend between increasing years in practice and recommendation likelihood (P = .001). Vancomycin usage (64%; 95% CI, 56-72) and ear, nose, and throat and/or sinopulmonary diagnoses (56%; 95% CI, 47-65) had the highest probability of a recommendation. Sensitivity analyses revealed that use of diagnosis-related clinical practice guidelines decreased recommendations and increased acceptance rates, especially for the surgery diagnosis category.

CONCLUSIONS

High-yield targets for ASP activities at our nonfreestanding children's hospital were identified. Clinical practice guidelines have the potential to decrease ASP workload, and their development should be particularly encouraged for ASPs with limited resources.

Implementing pediatric inpatient asthma pathways

OBJECTIVE

Pathways are succinct, operational versions of evidence-based guidelines. Studies have demonstrated pathways improve quality of care for children hospitalized with asthma, but we have limited information on other key factors to guide hospital leaders and clinicians in pathway implementation efforts. Our objective was to evaluate the adoption, implementation, and reach of inpatient pediatric asthma pathways.

METHODS

This was a mixed-methods study of hospitals participating in a national collaborative to implement pathways. Data sources included electronic surveys of implementation leaders and staff, field observations, and chart review of children ages 2-17 years admitted with a primary diagnosis of asthma. Outcomes included adoption by hospitals, pathway implementation factors, and reach of pathways to children hospitalized with asthma. Quantitative data were analyzed using descriptive statistics and multivariable regression. Qualitative data were analyzed using thematic content analysis.

RESULTS

Eighty-five hospitals enrolled; 68 (80%) adopted/completed the collaborative. These 68 hospitals implemented pathways with overall high fidelity, implementing a median of 5 of 5 core pathway components (Interquartile Range [IQR] 4-5) in a median of 5 months (IQR 3-9). Implementation teams reported a median time cost of 78 h (IQR: 40-120) for implementation. Implementation leaders reported the values of pathway implementation included improvements in care, enhanced interdisciplinary collaboration, and access to educational resources. Leaders reported barriers in modifying electronic health records (EHRs), and only 63% of children had electronic pathway orders placed.

CONCLUSIONS

Hospitals implemented pathways with high fidelity. Barriers in modifying EHRs may have limited the reach of pathways to children hospitalized with asthma.

Quality and Safety of Pediatric Inpatient Care in Community Hospitals: A Scoping Review

BACKGROUND

Although the majority of children are hospitalized in nonchildren's hospitals, little is known about the quality and safety of pediatric care in community hospitals.

OBJECTIVE

The aim of this study was to conduct a scoping review and synthesize literature on the quality and safety of pediatric inpatient care in United States community hospitals.

METHODS

We performed a systematic literature search in October 2016 to identify pediatric studies that reported on safety, effectiveness, efficiency, timeliness, patient-centeredness, or equity set in general, nonuniversity, or nonchildren's hospitals. We extracted data on study design, patient descriptors, and quality outcomes and assessed the risk of bias using modified Newcastle-Ottawa Scales.

RESULTS

A total of 44 articles met the inclusion criteria. Study designs, patient populations, and quality outcome measures were heterogeneous; only three clinical domains, (1) perinatal regionalization, (2) telemedicine, and (3) imaging radiation, were explored in multiple studies with consistent directionality of results. A total of 30 studies were observational, and 22 studies compared community hospital quality outcomes with other hospital types. The remaining 14 studies reported testing of interventions; 12 showed improved quality of care postintervention. All studies reported an outcome addressing safety, effectiveness, or efficiency, whereas timeliness, patient-centeredness, and equity were infrequently addressed. Risk of bias was moderate or high for 72% of studies.

CONCLUSIONS

Literature on the inpatient care of children in community hospitals is limited, making it difficult to evaluate healthcare quality. Measures of timeliness, patient-centeredness, and equity are underrepresented. The field would benefit from more multicenter collaborations to facilitate the application of robust study designs and to enable a systematic assessment of individual interventions and community hospital quality outcomes.

Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis

BACKGROUND AND OBJECTIVES

To determine factors associated with cerebrospinal fluid (CSF) testing in febrile young infants with a positive urinalysis and assess the probability of delayed diagnosis of bacterial meningitis in infants treated for urinary tract infection (UTI) without CSF testing.

METHODS

We performed a retrospective cohort study using data from the Reducing Excessive Variability in Infant Sepsis Evaluation quality improvement project. A total of 20 570 well-appearing febrile infants 7 to 60 days old presenting to 124 hospitals from 2015 to 2017 were included. A mixed-effects logistic regression was conducted to determine factors associated with CSF testing. Delayed meningitis was defined as a new diagnosis of bacterial meningitis within 7 days of discharge.

RESULTS

Overall, 3572 infants had a positive urinalysis; 2511 (70.3%) underwent CSF testing. There was wide variation by site, with CSF testing rates ranging from 64% to 100% for infants 7 to 30 days old and 10% to 100% for infants 31 to 60 days old. Factors associated with CSF testing included: age 7 to 30 days (adjusted odds ratio [aOR]: 4.6; 95% confidence interval [CI]: 3.8-5.5), abnormal inflammatory markers (aOR: 2.2; 95% CI: 1.8-2.5), and site volume >300 febrile infants per year (aOR: 1.8; 95% CI: 1.2-2.6). Among 505 infants treated for UTI without CSF testing, there were 0 (95% CI: 0%-0.6%) cases of delayed meningitis.

CONCLUSIONS

There was wide variation in CSF testing in febrile infants with a positive urinalysis. Among infants treated for UTI without CSF testing (mostly 31 to 60-day-old infants), there were no cases of delayed meningitis within 7 days of discharge, suggesting that routine CSF testing of infants 31 to 60 days old with a positive urinalysis may not be necessary.

Pediatric Hospitalists Improving Patient Care Through Quality Improvement

This article reviews the industrial underpinnings of the quality improvement (QI) movement and describes how QI became integrated within the larger health care landscape, including hospital medicine. QI methodologies and a framework for using them are described. Key components that make up a successful QI clinical project are outlined, with a focus on the essential role of pediatric hospitalists and practical professional tips to be successful. QI training opportunities are reviewed with opportunities for hospitalists to get involved in QI on a national level. National QI networks are showcased, with multiple examples of advanced improvement projects that have significantly improved patient outcomes highlighted.

Accelerating Improvement in Children's Healthcare Through Quality Improvement Collaboratives: A Synthesis of Recent Efforts

Purpose of review

Quality improvement collaboratives can accelerate quality improvement and patient safety efforts. We reviewed major pediatric quality improvement collaboratives that have published results in the past five years and discussed common success factors and barriers encountered by these collaboratives.

Recent Findings

Many pediatric quality improvement collaboratives are active in neonatal, cystic fibrosis, congenital heart disease, hematology/oncoogy, chronic kidney disease, rheumatology, critical care, and general pediatric care.

Summary

Factors important to the success of these pediatric quality improvement collaboratives include data sharing and communication, trust among institutions, financial support, support from national organizations, use of a theoretical framework to guide collaboration, patient and family involvement, and incentives for participation at both the individual and institutional levels. Common barriers encountered by these collaboratives include insufficient funding or resources, legal concerns, difficulty coming to consensus on best practices and outcome measures, and overcoming cultural barriers to change. Learning from the successes and challenges encountered by these collaboratives will enable the pediatric healthcare quality improvement community to continue to evolve this approach to maximize benefits to children.

Best practices in implementing inpatient pediatric asthma pathways: a qualitative study

Objective: Clinical pathways (operational versions of practice guidelines) can improve guideline adherence and quality of care for children hospitalized with asthma. However, there is limited guidance on how to implement pathways successfully. Our objective was to identify potential best practices in pathway implementation.Methods: In a previous observational study, we identified higher and lower performing children's hospitals based on hospital-level changes in asthma patient length of stay after implementation of a pathway. In this qualitative study, we conducted semi-structured interviews with a purposive sample of healthcare providers involved in pathway implementation at these hospitals. We used constant comparative methods to develop a conceptual model of potential best practices in implementation.Results: Healthcare providers (n = 24) from 6 higher performing and 2 lower performing hospitals were interviewed about pathway implementation. We identified several practices that addressed barriers and promoted successful pathway implementation: (1) utilizing quality improvement (QI) methodology and a data-driven approach helped overcome inertia of current practice; (2) getting teams to commit to shared goals around asthma care helped overcome disagreements in the implementation process; (3) integrating pathways into the electronic medical record decreased some burdens of implementation; (4) leveraging multidisciplinary teams by developing protocols for nurses and/or respiratory therapists to titrate medications reduced variability in provider practice; and (5) engaging hospital leaders with pathway implementation teams helped secure crucial resources.Conclusions: We identified several potential best practices to support pathway implementation. Hospitals implementing pathways should consider applying these strategies to better ensure success in improving quality of asthma care for children.

The Impact of the Evolving Health Care System on Pediatric Emergency Care

This article discusses the implications of health care reform on the pediatric emergency department (ED). The author briefly discusses the health care costs and outcomes in the United States in comparison to other developed nations. The article discusses the impact of the Affordable Care Act and insurance expansion on the pediatric ED. Then the article addresses the impacts of the growing patient financial responsibility on ED use. There will be a discussion of the development of pediatric accountable care organizations and how payment mechanisms are evolving, and the challenges the pediatric ED may face in these new payment strategies.

Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project

Objective

Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project.

Materials and Methods

We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled "Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE)." The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics.

Results

Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5].

Discussion

We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects.

Conclusions

ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools' impact on medical decision making, clinical practice, and health outcomes.

Using Quality Improvement to Change Testing Practices for Community-acquired Pneumonia

BACKGROUND

National guidelines for pediatric community-acquired pneumonia (CAP) contain recommendations regarding diagnostic testing including chest radiographs (CXRs), complete blood counts (CBCs), and blood cultures. Local data indicated that our institution was not delivering care at standards outlined by these guidelines. This project aimed to decrease CXRs for children with CAP discharged from the emergency department (ED) by 10% and decrease CBCs and blood cultures for patients hospitalized with uncomplicated CAP by 20% within 1 year.

METHODS

This single-site quality improvement initiative targeted otherwise healthy children 3 months to 18 years who presented to the ED with uncomplicated CAP at a free-standing academic children's hospital. A quality improvement team performed a series of interventions including guideline implementation, data sharing, and annual education. Process measures included CXR, CBC, and blood culture rates. Balancing measures included the number of patients diagnosed with CAP, the frequency of antibiotic use, length of stay, and ED and hospital return rates. The team used statistical process control charts to plot measures.

RESULTS

There was special cause improvement with a desirable downward shift in testing that correlated with the project's interventions. The percentage of CXRs for discharged patients decreased from 79% to 57%. CBCs and blood cultures for hospitalized patients decreased from 30% to 19% and 24% to 14%, respectively. Balancing measures remained unchanged.

CONCLUSIONS

We used elements of quality improvement methodology to reduce testing for uncomplicated CAP without impacting the number of patients diagnosed with CAP, the frequency of antibiotic use, length of stay, and reutilization rates.

Facilitators of interdepartmental quality improvement: a mixed-methods analysis of a collaborative to improve pediatric community-acquired pneumonia management

BACKGROUND

Emergency medicine and paediatric hospital medicine physicians each provide a portion of the initial clinical care for the majority of hospitalised children in the USA. While these disciplines share goals to increase quality of care, there are scant data describing their collaboration. Our national, multihospital learning collaborative, which aimed to increase narrow-spectrum antibiotic prescribing for paediatric community-acquired pneumonia, provided an opportunity to examine factors influencing the success of quality improvement efforts across these two clinical departments.

OBJECTIVE

To identify barriers to and facilitators of interdepartmental quality improvement implementation, with a particular focus on increasing narrow-spectrum antibiotic use in the emergency department and inpatient settings for children hospitalised with pneumonia.

METHODS

We used a mixed-methods design, analysing interviews, written reports and quality measures. To describe hospital characteristics and quality measures, we calculated medians/IQRs for continuous variables, frequencies for categorical variables and Pearson correlation coefficients. We conducted in-depth, semistructured interviews by phone with collaborative site leaders; interviews were transcribed verbatim and, with progress reports, analysed using a general inductive approach.

RESULTS

47 US-based hospitals were included in this analysis. Qualitative analysis of 35 interview transcripts and 142 written reports yielded eight inter-related domains that facilitated successful interdepartmental quality improvement: (1) hospital leadership and support, (2) quality improvement champions, (3) evidence supporting the intervention, (4) national health system influences, (5) collaborative culture, (6) departments' structure and resources, (7) quality improvement implementation strategies and (8) interdepartmental relationships.

CONCLUSIONS

The conceptual framework presented here may be used to identify hospitals' strengths and potential barriers to successful implementation of quality improvement efforts across clinical departments.

Setting the Benchmark for the Ground and Air Medical Quality in Transport International Quality Improvement Collaborative

OBJECTIVE

Critical care transport (CCT) supports regionalization of medical care. Focus on the quality of CCT care prompted the development of the Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement collaborative database which tracks consensus quality metrics. The Institute of Medicine recommends benchmarking of comparative data to accelerate improvement. Herein, we report the strategies and rationale for GAMUT QI Collaborative benchmarking.

METHODS

The GAMUT database includes >350 programs internationally with >200,000 annual patient contacts. Evidence-based literature review performed in May 2016 and October 2017 identified benchmarking strategies were evaluated and summarized, specific to the GAMUT metrics. Statistical analyses include simple statistics and weighted expectation calculations for benchmark examples (Pearson chi-square with Bonferroni adjusted post-hoc z tests).

RESULTS

Evidence-based literature search yielded 70 articles, and 31 were selected for inclusion in our evidence table. 5 evidence-based benchmark strategies were considered: average (mean), average (median), adjusted benchmark (based on expected outcome), Achievable Benchmark of Care (ABC), and Delphi. ABC threshold establishes a higher target (90th percentile) forcing more programs to achieve higher performance.

CONCLUSION

Benchmarking is not well-suited for a single strategy and requires customized consideration based on each metric, though adjusted benchmark and ABC generally set higher performance benchmarks.

Categorization of National Pediatric Quality Measures

BACKGROUND AND OBJECTIVE

The number of quality measures has grown dramatically in recent years. This growth has outpaced research characterizing content and impact of these metrics. Our study aimed to identify and classify nationally promoted quality metrics applicable to children, both by type and by content, and to analyze the representation of common pediatric issues among available measures.

METHODS

We identified nationally applicable quality measure collections from organizational databases or clearinghouses, federal Web sites, and key informant interviews and then screened each measure for pediatric applicability. We classified measures as structure, process, or outcome using a Donabedian framework. Additionally, we classified process measures as targeting underuse, overuse, or misuse of health services. We then classified measures by content area and compared disease-specific metrics to frequency of diagnoses observed among children.

RESULTS

A total of 386 identified measures were relevant to pediatric patients; exclusion of duplicates left 257 unique measures. The majority of pediatric measures were process measures (59%), most of which target underuse of health services (77%). Among disease-specific measures, those related to depression and asthma were the most common, reflecting the prevalence and importance of these conditions in pediatrics. Conditions such as respiratory infection and otitis media had fewer associated measures despite their prevalence. Other notable pediatric issues lacking associated measures included care of medically complex children and injuries.

CONCLUSIONS

Pediatric quality measures are predominated by process measures targeting underuse of health care services. The content represented among these measures is broad, although there remain important gaps.