Hospital pediatrics

BACKGROUND AND OBJECTIVES There is widespread unwarranted antibiotic use and large individual provider variation in antibiotic use in NICUs. Vignette-based research methodology offers a unique method of studying variation in individual provider decisions. The objective with this study was to use a vignette-based survey to identify specific areas of provider antibiotic use variation in newborns being evaluated for early onset sepsis. METHODS This study was undertaken as part of a statewide multicenter neonatal antibiotic stewardship quality improvement project led by a perinatal quality improvement collaborative. A web-based vignette survey was administered to identify variation in decisions to start and discontinue antibiotics in cases of early onset sepsis. RESULTS The largest variation was noted in 3 of the 6 vignette cases. These cases highlighted variation in (1) decisions to start antibiotics in a case describing a well-appearing newborn with risk factors and an elevated C-reactive protein, (2) decisions to start antibiotics in the case of a newborn with risk factors plus mild respiratory signs at birth, and (3) decisions to stop antibiotics in the case of the newborn with a history of sepsis risk factors and mild clinical respiratory signs that resolved after 72 hours. CONCLUSIONS Clinical vignette assessment identified specific areas of variation in individual provider antibiotic use decisions in cases of suspected early onset sepsis. Vignettes are a valuable method of describing individual provider variation and highlighting antibiotic stewardship improvement opportunities in NICUs.

Kurlen S. E. Payton

David Wirtschafter

Mihoko V. Bennett

William E. Benitz

Henry C. Lee

Alexandria Kristensen-Cabrera

Courtney C. Nisbet

Jeffrey Gould

Colin Parker

Paul J. Sharek

Hospital Pediatrics

Vignettes Identify Variation in Antibiotic Use for Suspected Early Onset Sepsis

BACKGROUND AND OBJECTIVES: Children with neurologic and neuromuscular complex chronic conditions (NNCCCs) undergo various procedures to optimize their health. We assessed the prevalence, characteristics, and risk of postoperative pneumonia (PoP) across surgery types, hospitals, and comorbidities in children with NNCCC. METHODS: This study is a retrospective analysis of 63 732 inpatient surgical encounters (2016–2020) in 45 freestanding children’s hospitals for patients of any age with NNCCCs in the Pediatric Health Information System database. NNCCCs were distinguished with International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes using Feudtner’s system. PoP within 7 days of surgery was identified with International Classification of Diseases, 10th Revision, Clinical Modification codes with antibiotic exposure (coded documentation of antibiotics being given). PoP likelihood was assessed by type of procedure across hospitals and by clinical characteristics using Rao–Scott χ2 tests and estimating equations. RESULTS: The prevalence of 7-day PoP was 1.1% (n = 688), with significant variation (P &amp;lt; .001) across hospitals (range: 0.4% to 3.0%). The highest PoP rates were found for bone marrow transplant (12.5%), solid organ transplantation (8.1%), and cardiothoracic surgery (4.5%); the lowest PoP rates included craniofacial/plastic (0.8%) and neurology (0.3%). Patients with ≥4 coexisting chronic conditions had the highest likelihood of acquiring PoP (odds ratio 10.69 [95% confidence interval 6.62–17.25]). CONCLUSIONS: PoP in children with NNCCCs varied significantly across hospitals and types of surgery. Further investigation is needed to assess how to ameliorate the risk of PoP in children with NNCCCs, especially those with multimorbidity.

Alexander J. Strzalkowski

Patrice Melvin

Sangeeta Mauskar

Isabel Stringfellow

Jay G. Berry

Postoperative Pneumonia Risk in Children With Neurologic and Neuromuscular Disorders

神经和神经肌肉疾病患儿术后肺炎风险

Rebekah Conroy

Hosp Pediatr

An Unhealthy Rumination

不健康的沉思

ABSTRACT Objective: To describe the implementation of nirsevimab for the prevention of respiratory syncytial virus (RSV)-associated lower respiratory tract disease in a pediatric hospital, focusing on strategies to ensure equitable access and address logistical challenges. Additionally, we aimed to identify predictors of nirsevimab deferral among eligible infants. Patients and Methods: Our hospital implemented a universal immunization campaign to all eligible infants, including those discharged from the newborn nursery, intermediate care nursery (ICN), and neonatal intensive care unit (NICU). We identified key drivers and barriers, formed a multidisciplinary team, and applied a systematic approach for integration of nirsevimab orders into existing workflows. We developed and disseminated educational resources for staff and caregivers. After the implementation, we conducted univariate and multivariate analyses to identify predictors of nirsevimab deferral to evaluate implementation success and possible gaps. Results: Despite challenges, we offered nirsevimab to 99% of eligible infants prior to discharge from the newborn nursery, ICN, and NICU with 71% receiving the immunization. On multivariate analysis, independent predictors of nirsevimab deferral included preferred language of English, deferral of hepatitis B vaccine, discharge from the newborn nursery, and public insurance. Conclusions: Our implementation strategy ensured equitable access to nirsevimab for newborns, with both our high uptake and acceptance rate underscoring the effectiveness of our approach. Key strategies for success included early stakeholder engagement, multidisciplinary collaboration, and proactive logistical planning. Our approach serves as a model for other institutions to offer nirsevimab prior to hospital discharge and highlights the importance of addressing both clinical and socioeconomic barriers.

Lauren Puckett

Lauren E. Kushner

Laura Bio

Sean Cornell

Matthew Wood

Hayden T. Schwenk

Successful Implementation of Nirsevimab and Factors Influencing Uptake in Neonatal Care

尼塞韦单抗在新生儿护理中的成功实施及其影响因素

BACKGROUND AND OBJECTIVES: The AAP’s Clinical Practice Guidelines (CPG) for febrile infants provides recommendations in evaluating well-appearing febrile infants aged 8–60 days at risk for invasive bacterial infections (IBIs; ie, bacteremia and bacterial meningitis). However, guidance remains limited for the infants excluded from (ie, ineligible for) the CPG. The objectives are to estimate the proportion of well-appearing CPG-ineligible febrile infants and to examine CPG performance in detecting IBIs for CPG-ineligible febrile infants. METHODS: We performed a secondary analysis of single-site data collected for a prior study from 2011 to 2018. Infants were included if they were 8–60 days and well-appearing. We stratified IBI risk using age and CPG inflammatory marker thresholds for temperature, absolute neutrophil count, and C-reactive protein. We conducted analyses on CPG-ineligible infants and CPG-eligible infants. We estimated the areas under the receiver operating characteristics curve, sensitivity, and specificity of both approaches in detecting IBIs. RESULTS: Of 648 infants, 22% did not meet CPG eligibility. Sensitivities for both analyses were 100% with specificities for CPG-ineligible and eligible of 38.1% (95% CI, 30–47) and 38.2% (95% CI, 33.9–42.6), respectively. CONCLUSIONS: Strict adherence to the CPG may result in a substantial proportion of ineligible infants. Findings suggest that CPG-based approaches can maintain high sensitivities for all febrile infants, including CPG-ineligible infants. Future studies should examine the contribution of specific conditions (eg, preterm birth) to IBI risk.

Melissa J. Knudson

Jeffrey P. Yaeger

Performance of AAP CPG for Ineligible Well-Appearing Febrile Infants Aged 8–60 Days

8-60天不符合AAP指南标准的外观正常发热婴儿的表现

OBJECTIVE To determine the prevalence of invasive and noninvasive mechanical ventilation (IMV and NIV) for children who die in the hospital, to assess for change over time, and to determine the association between mode(s) of ventilation and hospital resource utilization. METHODS Multicenter retrospective cohort of 37 children’s hospitals in the United States participating in Pediatric Health Information Systems Database. Included 41 091 hospitalizations for patients 0 to 21 years who died in hospital January 2010 to December 2019. Univariate and multivariate logistic regression examined IMV and NIV use clustered by hospital, adjusting for demographic and clinical characteristics. χ2, Kruskal-Wallis tests and multivariable regression models measured associations between mode of ventilation and resource utilization. RESULTS Over the decade, the percentage exposed to any IMV remained unchanged (∼88.5%), whereas any NIV increased 7.1% (18.8% to 25.9%), with wide interhospital variability in NIV use. Exposure to both IMV + NIV increased 6.0% (16.8% to 22.8%). Compared with only IMV, only NIV had lower odds of ICU admission and death, shorter ICU length of stay (LOS), similar hospital LOS, and lower costs. Both IMV + NIV had higher odds of ICU admission, longer duration of IMV, lower likelihood of ICU death, longer ICU and hospital LOS, and higher costs than IMV alone. CONCLUSIONS For children who died in the hospital in the past decade, use of NIV has increased without a reciprocal decrease in IMV, because of an increase in exposure to both IMV + NIV, a combination associated with high hospital resource utilization.

Deirdre F. Puccetti

Steven J. Staffa

Jeffrey P. Burns

Mechanical Ventilation for Children Approaching End of Life: A PHIS Study, 2010–2019

儿童临终阶段的机械通气：PHIS研究，2010-2019年

Heller et al1 successfully developed and implemented a night curriculum that significantly enhanced the educational experience for residents during night rotations. By employing best practices in change management and curriculum design, the authors provided a model for creating and sustaining effective educational programs. This guide synthesizes their approach into actionable steps, offering a framework for those looking to innovate or improve their educational offerings.Projects typically start with identifying an opportunity for improvement, as Heller et al did with resident night education. The authors appropriately used Kern's 6-step approach for curriculum development2 beginning with a needs assessment. This included analyzing night rotation evaluations, engaging in discussions with residents and program leaders, reviewing national trends in the literature, and identifying gaps in the residency curriculum. This thorough process confirmed that night rotation presented a significant opportunity for improvement and that the project was a priority for stakeholders. Ideally, this exploration culminates in the formulation of a global aim, conveying a compelling vision for change. Although the authors did not specify their global aim in the manuscript, we can infer from their stated goal of a "curricular frameshift" built directly from residents' needs that it centered around providing these learners with an excellent educational experience during night rotations.Explore potential opportunities for improvement broadly, ensuring stakeholder agreement on the project's priority in the context of competing needs.For curriculum design and implementation projects, use a structured development framework such as Kern's 6-step approach.2Formulate a global aim that conveys a compelling vision for change.Identifying and engaging stakeholders is crucial in exploring improvement opportunities. Heller et al involved residents, hospitalists, the night rotation director, and residency program leadership early in the process, forming a diverse project leadership team. Including residency program leadership led to the identification of a related opportunity for improvement: absence of a Residents as Teachers (RaT) curriculum, despite its growing popularity among graduate medical education programs.3 Through discussion with stakeholders and literature review, the authors confirmed buy-in for including the RaT curriculum during night rotations. Recognizing that stakeholder needs might evolve, they remained open to revisiting and expanding the group as the project progressed. In the future, medical students might also be included as key stakeholders in RaT initiatives.Identify and engage stakeholders early.Form a project leadership team with representatives from all stakeholder groups.Remain flexible, revisiting and expanding the stakeholder group as the project evolves.Although stakeholders agreed on the global aim of optimizing resident night education, they likely had varying ideas about what success would look like. To operationalize success, Heller et al translated their global aim into clear, measurable objectives through iterative discussions with stakeholders. They systematically developed evaluation processes that represented levels 1–4 of the Kirkpatrick framework,4 which allowed for data-driven curriculum adjustments to meet stakeholders' diverse needs. The authors operationalized participation, engagement, learner satisfaction (Kirkpatrick level 1), and perceived change in knowledge (level 2). Additionally, the authors conducted qualitative reviews of narrative comments to explore the impact of the RaT curriculum on behavior (level 3) and institutional outcomes (level 4). This iterative process likely included confirming proposed success metrics aligned with stakeholder definitions of success. For instance, that a goal of 90% of night residents participating in at least 1 RaT activity during their night rotation by the end of the academic year aligned with residency leaders' definition of RaT program success.Collaborate with stakeholders to define specific success metrics that align with their goals.Develop clear, measurable indicators of success.Implement a robust evaluation using framework like Kirkpatrick's model4 to assess the project's efficacy at multiple levels.Confirm proposed success metrics align with stakeholder definition of success.According to diffusion of innovations theory, the rate of innovation adoption can be predicted by individuals' perception of 5 characteristics: relative advantage, compatibility, simplicity, trialability, and observability.5 The curriculum designed by Heller et al was clearly "adoptable." It offered a clear advantage through incorporation of best practices in adult education including self-directed learning, experiential learning, peer education, and reflective practice. The activities were additionally compatible with existing framework, simple to implement and maintain, triable, and observable.Ensure the new program offers clear advantages.Enlist team members with education expertise when implementing educational programs.Choose activities that are relevant, engaging, time-efficient, compatible with existing processes, and simple to implement and maintain.Change is difficult, and most people resist when it feels forced. The authors retained the option of board review questions when introducing new educational activities, including the exclusive offering of the RaT curriculum. They acknowledged that exploring the reasons why a minority of residents chose not to engage with the new curriculum, using methods such as focus groups and interviews, could provide valuable insights for further curriculum improvement.Introduce changes gradually, allowing for coexistence of old and new activities.Engage nonparticipants in ongoing program improvement efforts.Educational program development projects offer numerous opportunities for scholarly work, including comprehensive manuscripts describing curriculum development, educational innovation reports focusing on a novel aspect of the curriculum (eg, RaT curriculum implementation during night rotations), quality improvement projects describing the impact of various interventions over time (eg, increased resident participation in experiential learning activities at night), novel educational materials (eg, phone triage), and qualitative studies delving deeper into participants' experiences (eg, residents' experience as educators). Early consideration of scholarship is crucial because scholarly products often require institutional review board evaluation and more robust outcomes data than what is typically collected for program improvement. Involving experts in study design and data analysis early in the process increases the likelihood of successful scholarship.Although those embarking on educational program development should consider the potential for scholarship during the planning process, the decision to pursue it—and to what extent—is complex. Opting not to pursue scholarship after careful consideration is a valid choice. Factors to consider include the project's novelty, applicability in other settings, and practical considerations such as time, resources, and competing priorities. Heller et al's initial decision not to plan for scholarship, given the urgent need for night rotation improvement compounded by the unforeseen and unprecedented challenges of learning during the pandemic, was valid.Consider the potential scholarly outcomes early.Involve team members with expertise in study design and analysis.Acknowledge the conscious decision not to pursue specific scholarly work is valid.Ideally, one would decide on scholarship, involve those with expertise in study design and data analysis, and draft the manuscript in the initial stages of project planning. However, the Heller et al manuscript exemplifies that scholarship is possible even if not initially planned. After noting high engagement with the RaT curriculum, the authors explored the resident experience through a secondary analysis of narrative comments, providing deeper insights into the curriculum's success while acknowledging methodological limitations.Remain open to scholarship.Explore unexpected findings through secondary analysis.Acknowledge the limitations of secondary analyses and use findings to guide future research.Developing or revamping an educational program is a complex and rewarding endeavor. By applying best practices in change management and curriculum design, educators can create programs that are engaging, sustainable, and impactful. The night curriculum developed by Heller et al offers valuable lessons and strategies that can be adapted to a wide range of educational contexts.

Marta King

Annie Suydam

Developing Educational Programs: Insights From a Night Curriculum Initiative

发展教育项目：夜校课程计划的启示

BACKGROUND: Implementation of a successful night curriculum has been a historical barrier to education during night rotations. Residents are tasked with teaching students and peers at night, often with little educational material to support this. To address the need for engaging night curriculum for pediatric residents, we aimed to (1) develop and implement a night curriculum with an emphasis on residents as teachers (RaTs) and (2) explore residents’ experience with the RaT curriculum through a secondary qualitative analysis of reflections. METHODS: After a needs assessment, we developed and implemented a night curriculum consisting of both facilitated and independent learning activities. Each resident was expected to complete 3 out of the offered 5 to 7 learning activities during their month-long night rotation. One independent activity featured RaT topics, including clinical teaching, mentoring, or hidden curriculum. Participation was tracked via reflection submissions, which were inductively coded using Dedoose. RESULTS: A total of 90% (180/199) of resident rotations completed new curriculum requirements, with 45% (90/199) completing more than the required 3 activities. A total of 76% (151/199) chose to participate in the RaT activity as part of their night educational requirements. A total of 52 reflection responses were collected, 38 individual and 14 team responses. Responses highlighted themes including growing as educators, fostering interprofessional relationships, and developing careers. CONCLUSIONS: High participation in the novel curriculum reveals the potential of virtual RaT activities to improve night education for residents. Participant reflections suggest high engagement in RaT and emphasize the andragogical value of key topics.

Kayla Heller

Jonathan Ermer

Angela Etzenhouser

Nik Schuetz

Emily A. Hurley

Teaching Residents at Night: Exploration of a Novel Curriculum

夜间住院医师教学：新型课程的探索

Suzanne N. Ramazani

Tina Sosa

Conrad Gleber

Lauren G. Solan

Paul R. Burchard

Steven Bondi

Evaluating Opportunities for Critical Care Billing on a Pediatric Hospital Medicine Service

评估儿科医院医学服务中的重症监护计费机会

ISSN	2154-1663, 2154-1671
h-index	35

涉及主题	医学内科学生物心理学病理儿科精神科外科政治学法学数学护理部统计化学家庭医学经济急诊医学生物化学遗传学计算机科学社会学经济增长医疗保健免疫学
出版信息	出版商: American Academy of Pediatrics，出版周期: ，期刊类型: journal，开源期刊: 否
基本数据	创刊年份: 2012，原创研究文献占比: 0.00%，自引率:N.A.， Gold OA占比: 0.00%

Hospital pediatrics

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Vignettes Identify Variation in Antibiotic Use for Suspected Early Onset Sepsis

Postoperative Pneumonia Risk in Children With Neurologic and Neuromuscular Disorders

An Unhealthy Rumination

Successful Implementation of Nirsevimab and Factors Influencing Uptake in Neonatal Care

Performance of AAP CPG for Ineligible Well-Appearing Febrile Infants Aged 8–60 Days

Mechanical Ventilation for Children Approaching End of Life: A PHIS Study, 2010–2019

Developing Educational Programs: Insights From a Night Curriculum Initiative

Teaching Residents at Night: Exploration of a Novel Curriculum

Performance of AAP CPG for Ineligible Well-Appearing Febrile Infants Aged 8–60 Days

Evaluating Opportunities for Critical Care Billing on a Pediatric Hospital Medicine Service