Impact of Longitudinal Coaching on Pediatric Residents' Professional Identity Formation: A Multi-Institution Qualitative Study

OBJECTIVE

Coaching has emerged in medical education as a strategy for trainees' development and has been endorsed by the Coalition for Physician Accountability and the American Medical Association. However, there is a lack of literature on how coaching impacts residents' professional identity formation (PIF). The purpose of this study was to explore how longitudinal clinical coaching impacted the professional identity of residency graduates.

METHODS

In July to November 2020, we conducted an Institutional Review Board-approved qualitative study with semistructured interviews of residency graduates from 2 pediatric programs who participated in a longitudinal coaching program. We inductively analyzed the transcripts using thematic analysis, guided by the sensitizing principles of PIF. We did a member check to enhance trustworthiness.

RESULTS

We interviewed 34 residency graduates from 2 institutions and identified 4 themes on how coaches influenced residency graduates' PIF by 1) the presence of a trusting relationship; 2) creating trust and sense of belonging through longitudinal encounters, supportive reflection, and formative feedback; 3) integrating clinical skill, career interests, and work-life integration; and 4) reflecting on their own personal and professional identities. Residency graduates highlighted coaching strategies that coaches, coaching programs, and residents themselves can take to promote resident PIF during residency.

CONCLUSIONS

Residency coaches have the potential to influence residents' PIF through their longitudinal relationship grounded in trust. Coaching strategies can be used to enhance resident clinical and professional development during residency training.

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.

The Effects of Coaching Pediatric Residents on Faculty Coaches' Relationships, Learning, and Professional Identity Formation

PURPOSE

Coaching programs have been implemented in medical education to improve skill development and feedback for trainees. As more faculty take on coaching roles, it is critical to understand how being a coach affects faculty as well as trainees. This study examined the effects of coaching residents on faculty members' relationships, learning, and professional identity formation (PIF), as they move through intersecting communities across landscapes of practice.

METHOD

From July 2020 to January 2021, the authors conducted a mixed-methods study of current and former coaches at 2 institutions with longitudinal pediatric resident coaching programs. They used a concurrent triangulation design in which qualitative and quantitative data were collected simultaneously and integrated during data analysis. A survey explored the impact of coaching on faculty members' learning, relationships, and PIF, and semistructured interviews further examined coaches' experiences. The interview transcripts were analyzed inductively guided by the sensitizing principles of PIF and landscapes of practice.

RESULTS

Of 43 eligible coaches, 32 (74%) completed the survey, and 18 completed interviews. Four themes emerged from the interviews. (1) Coaches' relationships supported belonging in multiple communities. (2) Coaching enabled multidimensional learning. (3) Relationships served as mechanisms of learning for coaches. (4) Coaches' relationships and learning catalyzed PIF. Furthermore, there was a significant difference in the effects of coaching on career growth by faculty rank ( P = .02). Coaches' strengthened PIF increased a sense of purpose, meaning, and professional fulfillment, and inspired new career directions. Survey data further supported these findings.

CONCLUSIONS

Being a coach deepened faculty members' professional identities through their varied relationships, multidimensional learning, and sense of belonging in intersecting communities. This study introduces a framework to understand the factors mediating coaches' PIF and highlights how investing in coaching leads to important benefits for coaches.

"The curriculum brings equity to the forefront": Pediatric residents' perspectives and experiences in a longitudinal EDI curriculum

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements include training in caring for diverse populations and understanding social determinants of health. Our large pediatric residency program implemented a longitudinal equity, diversity and inclusion (EDI) curriculum.

OBJECTIVE

To explore pediatric residents' perspectives and experiences in our longitudinal EDI curriculum.

METHODS

We applied the holistic framework by Haji et al. to characterize the effect of our EDI curriculum. We conducted 4 focus groups from November 2019 to September 2020 with trained facilitators using a structured question guide. We approached all eligible senior residents (n = 87) via email to participate. Project members coded written notes and transcripts and analyzed data using inductive thematic analysis.

RESULTS

26 pediatric senior residents participated either in person (n = 13) or online (n = 13). Themes emerged from domains of knowledge, attitudes and behavioral change. These included having: (1) increased knowledge surrounding EDI issues, (2) a framework and language to better engage in EDI efforts and (3) increased confidence interrupting bias and microaggressions. Additional themes demonstrated: an increased need for EDI education at the institutional level, the unique experiences of Black, Indigenous, People of Color (BIPOC) trainees, and systemic barriers to equitable care.

CONCLUSION

A longitudinal EDI curriculum has the potential to influence individual trainees, their work, and perceptions of the broader institutions in which they operate. Residents recognized and valued the curriculum and felt driven to use this knowledge to ensure that institutional policies and practices led to equitable clinical care.

Association of Tolerance of Uncertainty With Outcomes in a Quality Improvement Collaborative

BACKGROUND

Tolerance of uncertainty may influence how physicians and other providers practice and make clinical decisions. We hypothesized that increased tolerance of uncertainty would be associated with an increased uptake of a quality improvement (QI) intervention.

METHODS

We examined tolerance of uncertainty using the Physicians' Reactions to Uncertainty Scale in the context of a national QI project in the Value in Inpatient Pediatrics network. The QI project aimed to increase exclusive isotonic fluid use and decrease laboratory draws. Exposure to the intervention was measured by using the stepped wedge design with sequential implementation across a diverse group of US hospitals. Multivariable analysis was conducted by using exposure to the intervention and tolerance of uncertainty as independent variables and exclusive isotonic fluid use or laboratory testing as the dependent variable.

RESULTS

Of 106 participating hospitals, 97 contributed valid responses, with an overall mean reported tolerance of uncertainty of 3.39 (95% confidence interval: 3.27-3.50), with lower numbers on the 6-point scale indicating greater tolerance of uncertainty. Exposure to the QI intervention was significantly associated with exclusive isotonic fluid use (P <.001). Lower tolerance of uncertainty at baseline was associated with lower baseline isotonic fluid use and greater uptake of the use of isotonic fluids but not reduction in laboratory testing.

CONCLUSIONS

Contrary to our hypothesis, lower tolerance of uncertainty was associated with greater uptake of the QI intervention for the outcome of isotonic fluids. This initial association warrants further study to evaluate how tolerance of uncertainty plays a role in quality improvement science.

Description of a novel curriculum on equity, diversity and inclusion for pediatric residents

BACKGROUND

Accreditation standards in medical education require curricular elements dedicated to understanding diversity and addressing inequities in health care. The development and implementation of culturally effective care curricula are crucial to improving health care outcomes, yet these curricular elements are currently limited in residency training.

METHODS

A needs assessment of 125 pediatric residents was conducted that revealed minimal prior culturally effective care instruction. To address identified needs, an integrated, longitudinal equity, diversity and inclusion (EDI) curriculum was designed and implemented at a single institution using Kern's Framework. This consisted of approximately 25 h of instruction including monthly didactics and sessions which addressed (1) EDI definitions and history and (2) microaggressions. A mixed methods evaluation was used to assess the curricular elements with quantitative summary of resident session scores and a qualitative component using in-depth content analysis of resident evaluations. Thematic analysis was used to code qualitative responses and identify common attitudes and perceptions about the curricular content.

RESULTS

109/125 (87.2%) residents completed the needs assessment. Over one year, 323 resident evaluations were collected for curricular sessions. Average overall quality rating for sessions was 4.7 (scale 1-5), and 85% of comments included positive feedback. Key themes included lecture topic relevance, adequate time to cover the content, need for screening tools and patient resources, importance of patient case examples to supplement instruction, and novel/ "eye opening" content. In addition, several broader institutional impacts of the curriculum were noted such as recognizing the need for comprehensive support for residents of color, corresponding EDI faculty training, and a resident reporting system to identify learning climate issues.

CONCLUSIONS

The implementation of a comprehensive resident EDI curriculum was feasible earning positive evaluations in its first year, with requests for additional content. It has also spurred multiple institution-wide ripple effects. Suggestions for improvement included more case-based learning, skills practice, and simulation. Future steps include expansion of this EDI curriculum to faculty and examining its impact in resident of color affinity groups. Given ACGME requirements to improve training addressing equity and social determinants of health, this curriculum development process serves as a possible template for other training programs.

Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients: A Stepped-Wedge, Cluster Randomized Clinical Trial

IMPORTANCE

Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients.

OBJECTIVE

To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020.

INTERVENTIONS

Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards.

MAIN OUTCOMES AND MEASURES

Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models.

RESULTS

A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF.

CONCLUSIONS AND RELEVANCE

In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03924674.

Grounded in Justice: An Equity Framework for Chief Residents

The 2019-2020 academic year was unprecedented, with navigating the COVID-19 pandemic and meaningfully engaging with the causes and consequences of long-standing racism and social injustice in the United States. In this article, the authors, all former chief residents, reflect on how they carried out their role during this last year using an approach that was grounded in equity and justice. They describe a framework based on their experiences, including setting the tone and culture of the residency program; providing medical education, teaching, and feedback; advocating for resident well-being and inclusion; participating in quality improvement and hospital policymaking; and partnering for institutional change. They end with a call to action to reconceptualize the role of the chief resident to include the genuine work of diversity, equity, and inclusion to ensure a more equitable future.

Height of fever and invasive bacterial infection

OBJECTIVE

We aimed to evaluate the association of height of fever with invasive bacterial infection (IBI) among febrile infants <=60 days of age.

METHODS

In a secondary analysis of a multicentre case-control study of non-ill-appearing febrile infants <=60 days of age, we compared the maximum temperature (at home or in the emergency department) for infants with and without IBI. We then computed interval likelihood ratios (iLRs) for the diagnosis of IBI at each half-degree Celsius interval.

RESULTS

The median temperature was higher for infants with IBI (38.8°C; IQR 38.4-39.2) compared with those without IBI (38.4°C; IQR 38.2-38.9) (p<0.001). Temperatures 39°C-39.4°C and 39.5°C-39.9°C were associated with a higher likelihood of IBI (iLR 2.49 and 3.40, respectively), although 30.4% of febrile infants with IBI had maximum temperatures <38.5°C.

CONCLUSIONS

Although IBI is more likely with higher temperatures, height of fever alone should not be used for risk stratification of febrile infants.

Characteristics of Afebrile Infants ≤60 Days of Age With Invasive Bacterial Infections

OBJECTIVES

To describe the characteristics and outcomes of afebrile infants ≤60 days old with invasive bacterial infection (IBI).

METHODS

We conducted a secondary analysis of a cross-sectional study of infants ≤60 days old with IBI presenting to the emergency departments (EDs) of 11 children's hospitals from 2011 to 2016. We classified infants as afebrile if there was absence of a temperature ≥38°C at home, at the referring clinic, or in the ED. Bacteremia and bacterial meningitis were defined as pathogenic bacterial growth from a blood and/or cerebrospinal fluid culture.

RESULTS

Of 440 infants with IBI, 78 (18%) were afebrile. Among afebrile infants, 62 (79%) had bacteremia without meningitis and 16 (20%) had bacterial meningitis (10 with concomitant bacteremia). Five infants (6%) died, all with bacteremia. The most common pathogens were Streptococcus agalactiae (35%), Escherichia coli (16%), and Staphylococcus aureus (16%). Sixty infants (77%) had an abnormal triage vital sign (temperature <36°C, heart rate ≥181 beats per minute, or respiratory rate ≥66 breaths per minute) or a physical examination abnormality (ill appearance, full or depressed fontanelle, increased work of breathing, or signs of focal infection). Forty-three infants (55%) had ≥1 of the following laboratory abnormalities: white blood cell count <5000 or >15 000 cells per μL, absolute band count >1500 cells per μl, or positive urinalysis. Presence of an abnormal vital sign, examination finding, or laboratory test result had a sensitivity of 91% (95% confidence interval 82%-96%) for IBI.

CONCLUSIONS

Most afebrile young infants with an IBI had vital sign, examination, or laboratory abnormalities. Future studies should evaluate the predictive ability of these criteria in afebrile infants undergoing evaluation for IBI.

Febrile Infants ≤60 Days Old With Positive Urinalysis Results and Invasive Bacterial Infections

OBJECTIVES

We aimed to describe the clinical and laboratory characteristics of febrile infants ≤60 days old with positive urinalysis results and invasive bacterial infections (IBI).

METHODS

We performed a planned secondary analysis of a retrospective cohort study of febrile infants ≤60 days old with IBI who presented to 11 emergency departments from July 1, 2011, to June 30, 2016. For this subanalysis, we included infants with IBI and positive urinalysis results. We analyzed the sensitivity of high-risk past medical history (PMH) (prematurity, chronic medical condition, or recent antimicrobial receipt), ill appearance, and/or abnormal white blood cell (WBC) count (<5000 or >15 000 cells/μL) for identification of IBI.

RESULTS

Of 148 febrile infants with positive urinalysis results and IBI, 134 (90.5%) had bacteremia without meningitis and 14 (9.5%) had bacterial meningitis (11 with concomitant bacteremia). Thirty-five infants (23.6%) with positive urinalysis results and IBI did not have urinary tract infections. The presence of high-risk PMH, ill appearance, and/or abnormal WBC count had a sensitivity of 53.4% (95% confidence interval: 45.0-61.6) for identification of IBI. Of the 14 infants with positive urinalysis results and concomitant bacterial meningitis, 7 were 29 to 60 days old. Six of these 7 infants were ill-appearing or had an abnormal WBC count. The other infant had bacteremia with cerebrospinal fluid pleocytosis after antimicrobial pretreatment and was treated for meningitis.

CONCLUSIONS

The sensitivity of high-risk PMH, ill appearance, and/or abnormal WBC count is suboptimal for identifying febrile infants with positive urinalysis results at low risk for IBI. Most infants with positive urinalysis results and bacterial meningitis are ≤28 days old, ill-appearing, or have an abnormal WBC count.

A Qualitative Evaluation of a Clinical Faculty Mentorship Program Using a Realist Evaluation Approach

OBJECTIVE

Clinically focused faculty (full-time clinical faculty and clinician educators) comprise an increasing proportion of academic faculty, yet they underutilize mentorship nationally. The aims of this study were to test and refine a program theory for an institutional mentorship program for junior clinically focused faculty and to understand the facilitators and barriers of sustained participation.

METHODS

We conducted a qualitative study using a realist evaluation approach. Between July and December 2017, we performed in-depth semistructured interviews of 2 participant groups from a junior faculty mentorship program at our institution: 1) those who attended more than two thirds of the program sessions; and 2) those who only attended 1 session. We used inductive thematic analysis to identify key context and program mechanisms that led to meaningful outcomes for faculty mentorship.

RESULTS

We interviewed 23 junior faculty representing 15 pediatric specialties. We identified 4 contextual themes (past personal experience, current competing priorities, institutional culture, and gaps in support and resources), 3 mechanisms (connecting with faculty, sharing ideas and strategies, and self-reflecting), and 3 outcomes (sense of community, acquired tools and skills, and broadened perspectives), which we organized into a programmatic theory representing the program's impact on participants. Themes that emerged were consistent between both groups.

CONCLUSIONS

A mentorship program that provided junior faculty with opportunities to connect, share ideas and strategies, and self-reflect led to improvement in meaningful outcomes for clinically focused faculty. Our program theory provides a basis for institutions seeking to build a mentorship program targeted towards this increasing proportion of junior faculty.

Parenteral Antibiotic Therapy Duration in Young Infants With Bacteremic Urinary Tract Infections

OBJECTIVES

To determine the association between parenteral antibiotic duration and outcomes in infants ≤60 days old with bacteremic urinary tract infection (UTI).

METHODS

This multicenter retrospective cohort study included infants ≤60 days old who had concomitant growth of a pathogen in blood and urine cultures at 11 children's hospitals between 2011 and 2016. Short-course parenteral antibiotic duration was defined as ≤7 days, and long-course parenteral antibiotic duration was defined as >7 days. Propensity scores, calculated using patient characteristics, were used to determine the likelihood of receiving long-course parenteral antibiotics. We conducted inverse probability weighting to achieve covariate balance and applied marginal structural models to the weighted population to examine the association between parenteral antibiotic duration and outcomes (30-day UTI recurrence, 30-day all-cause reutilization, and length of stay).

RESULTS

Among 115 infants with bacteremic UTI, 58 (50%) infants received short-course parenteral antibiotics. Infants who received long-course parenteral antibiotics were more likely to be ill appearing and have growth of a non-Escherichia coli organism. There was no difference in adjusted 30-day UTI recurrence between the long- and short-course groups (adjusted risk difference: 3%; 95% confidence interval: -5.8 to 12.7) or 30-day all-cause reutilization (risk difference: 3%; 95% confidence interval: -14.5 to 20.6).

CONCLUSIONS

Young infants with bacteremic UTI who received ≤7 days of parenteral antibiotics did not have more frequent recurrent UTIs or hospital reutilization compared with infants who received long-course therapy. Short-course parenteral therapy with early conversion to oral antibiotics may be considered in this population.

A Prediction Model to Identify Febrile Infants ≤60 Days at Low Risk of Invasive Bacterial Infection

OBJECTIVES

To derive and internally validate a prediction model for the identification of febrile infants ≤60 days old at low probability of invasive bacterial infection (IBI).

METHODS

We conducted a case-control study of febrile infants ≤60 days old who presented to the emergency departments of 11 hospitals between July 1, 2011 and June 30, 2016. Infants with IBI, defined by growth of a pathogen in blood (bacteremia) and/or cerebrospinal fluid (bacterial meningitis), were matched by hospital and date of visit to 2 control patients without IBI. Ill-appearing infants and those with complex chronic conditions were excluded. Predictors of IBI were identified with multiple logistic regression and internally validated with 10-fold cross-validation, and an IBI score was calculated.

RESULTS

We included 181 infants with IBI (155 [85.6%] with bacteremia without meningitis and 26 [14.4%] with bacterial meningitis) and 362 control patients. Twenty-three infants with IBI (12.7%) and 138 control patients (38.1%) had fever by history only. Four predictors of IBI were identified (area under the curve 0.83 [95% confidence interval (CI): 0.79-0.86]) and incorporated into an IBI score: age <21 days (1 point), highest temperature recorded in the emergency department 38.0-38.4°C (2 points) or ≥38.5°C (4 points), absolute neutrophil count ≥5185 cells per μL (2 points), and abnormal urinalysis results (3 points). The sensitivity and specificity of a score ≥2 were 98.8% (95% CI: 95.7%-99.9%) and 31.3% (95% CI: 26.3%-36.6%), respectively. All 26 infants with meningitis had scores ≥2.

CONCLUSIONS

Infants ≤60 days old with fever by history only, a normal urinalysis result, and an absolute neutrophil count <5185 cells per μL have a low probability of IBI.

Factors Associated with Adverse Outcomes among Febrile Young Infants with Invasive Bacterial Infections

OBJECTIVE

To determine factors associated with adverse outcomes among febrile young infants with invasive bacterial infections (IBIs) (ie, bacteremia and/or bacterial meningitis).

STUDY DESIGN

Multicenter, retrospective cohort study (July 2011-June 2016) of febrile infants ≤60 days of age with pathogenic bacterial growth in blood and/or cerebrospinal fluid. Subjects were identified by query of local microbiology laboratory and/or electronic medical record systems, and clinical data were extracted by medical record review. Mixed-effect logistic regression was employed to determine clinical factors associated with 30-day adverse outcomes, which were defined as death, neurologic sequelae, mechanical ventilation, or vasoactive medication receipt.

RESULTS

Three hundred fifty infants met inclusion criteria; 279 (79.7%) with bacteremia without meningitis and 71 (20.3%) with bacterial meningitis. Forty-two (12.0%) infants had a 30-day adverse outcome: 29 of 71 (40.8%) with bacterial meningitis vs 13 of 279 (4.7%) with bacteremia without meningitis (36.2% difference, 95% CI 25.1%-48.0%; P < .001). On adjusted analysis, bacterial meningitis (aOR 16.3, 95% CI 6.5-41.0; P < .001), prematurity (aOR 7.1, 95% CI 2.6-19.7; P < .001), and ill appearance (aOR 3.8, 95% CI 1.6-9.1; P = .002) were associated with adverse outcomes. Among infants who were born at term, not ill appearing, and had bacteremia without meningitis, only 2 of 184 (1.1%) had adverse outcomes, and there were no deaths.

CONCLUSIONS

Among febrile infants ≤60 days old with IBI, prematurity, ill appearance, and bacterial meningitis (vs bacteremia without meningitis) were associated with adverse outcomes. These factors can inform clinical decision-making for febrile young infants with IBI.

Risk Stratification of Febrile Infants ≤60 Days Old Without Routine Lumbar Puncture

: media-1vid110.1542/5840460609001PEDS-VA_2018-1879Video Abstract OBJECTIVES: To evaluate the Rochester and modified Philadelphia criteria for the risk stratification of febrile infants with invasive bacterial infection (IBI) who do not appear ill without routine cerebrospinal fluid (CSF) testing.

METHODS

We performed a case-control study of febrile infants ≤60 days old presenting to 1 of 9 emergency departments from 2011 to 2016. For each infant with IBI (defined as a blood [bacteremia] and/or CSF [bacterial meningitis] culture with growth of a pathogen), controls without IBI were matched by site and date of visit. Infants were excluded if they appeared ill or had a complex chronic condition or if data for any component of the Rochester or modified Philadelphia criteria were missing.

RESULTS

Overall, 135 infants with IBI (118 [87.4%] with bacteremia without meningitis and 17 [12.6%] with bacterial meningitis) and 249 controls were included. The sensitivity of the modified Philadelphia criteria was higher than that of the Rochester criteria (91.9% vs 81.5%; P = .01), but the specificity was lower (34.5% vs 59.8%; P < .001). Among 67 infants >28 days old with IBI, the sensitivity of both criteria was 83.6%; none of the 11 low-risk infants had bacterial meningitis. Of 68 infants ≤28 days old with IBI, 14 (20.6%) were low risk per the Rochester criteria, and 2 had meningitis.

CONCLUSIONS

The modified Philadelphia criteria had high sensitivity for IBI without routine CSF testing, and all infants >28 days old with bacterial meningitis were classified as high risk. Because some infants with bacteremia were classified as low risk, infants discharged from the emergency department without CSF testing require close follow-up.

Time to Pathogen Detection for Non-ill Versus Ill-Appearing Infants ≤60 Days Old With Bacteremia and Meningitis

OBJECTIVES

We sought to determine the time to pathogen detection in blood and cerebrospinal fluid (CSF) for infants ≤60 days old with bacteremia and/or bacterial meningitis and to explore whether time to pathogen detection differed for non-ill-appearing and ill-appearing infants.

METHODS

We included infants ≤60 days old with bacteremia and/or bacterial meningitis evaluated in the emergency departments of 10 children's hospitals between July 1, 2011, and June 30, 2016. The microbiology laboratories at each site were queried to identify infants in whom a bacterial pathogen was isolated from blood and/or CSF. Medical records were then reviewed to confirm the presence of a pathogen and to extract demographic characteristics, clinical appearance, and the time to pathogen detection.

RESULTS

Among 360 infants with bacteremia, 316 (87.8%) pathogens were detected within 24 hours and 343 (95.3%) within 36 hours. A lower proportion of non-ill-appearing infants with bacteremia had a pathogen detected on blood culture within 24 hours compared with ill-appearing infants (85.0% vs 92.9%, respectively; P = .03). Among 62 infants with bacterial meningitis, 55 (88.7%) pathogens were detected within 24 hours and 59 (95.2%) were detected within 36 hours, with no difference based on ill appearance.

CONCLUSIONS

Among infants ≤60 days old with bacteremia and/or bacterial meningitis, pathogens were commonly identified from blood or CSF within 24 and 36 hours. However, clinicians must weigh the potential for missed bacteremia in non-ill-appearing infants discharged within 24 hours against the overall low prevalence of infection.

Outcomes of a Clinical Pathway to Standardize Use of Maintenance Intravenous Fluids

OBJECTIVES

Improper use of maintenance intravenous fluids (IVFs) may cause serious hospital-acquired harm. We created an evidence-based clinical pathway to guide providers on the indications for IVF, its preferred composition, and appropriate clinical monitoring.

METHODS

Pathway implementation was supported by the creation of an electronic order set (PowerPlan) and hospital-wide education. Outcomes were measured among pathway-eligible patients for the years before (July 1, 2014-June 30, 2015) and after (July 1, 2015-June 30, 2016) implementation. An interrupted time series analysis was used to evaluate monthly trends related to IVF use, including the following: median duration, proportions of isotonic and hypotonic IVF, adherence to monitoring recommendations, incidence of associated severe dysnatremia, potassium-containing IVF use in the emergency department, and costs.

RESULTS

There were 11 602 pathway-eligible encounters (10 287 patients) across the study. Median IVF infusion hours did not change. Isotonic maintenance IVF use increased significantly from 9.3% to 50.6%, whereas the use of any hypotonic fluid decreased from 94.2% to 56.6%. There were significant increases in daily weight measurement and recommended serum sodium testing. Cases of dysnatremia increased from 2 to 4 among pathway-eligible patients and were mostly associated with hypotonic IVF use. Patients in the emergency department had a significant increase in the number of potassium-containing IVF bags (52.9% to 75.3%). Total hospitalization and laboratory test costs did not change significantly.

CONCLUSIONS

This is the first report of outcomes of a clinical pathway to standardize IVF use. Implementation was feasible in both medical and surgical units, with sustained improvements for 1 year. Future improvement work includes increasing PowerPlan use and developing clinical assessment tools.