The Academy of Pediatric Hospital Medicine Articles and Sciences Annual Awards Ceremony July 26, 2014 Orlando, FL Robert Dudas Karen Wilson
Disclosures Sadly, neither of us can disclose Hollywood contacts, significant sources of slightly unethical funding, or investments in highly profitable medically-oriented corporations. Bob is an editor for the Monthly Feature section of Pediatrics Karen is deputy editor of Hospital Pediatrics. We promise these affiliations had nothing to do with the large number of articles from those journals, or any subliminal messaging the AAP may or may not have inserted into the slides.
R3 Strategy Recent, relevant, and reputable… Wading through XXXX articles Reviewed articles from August 2013-July 2014 Pediatrics, Hospital Pediatrics, Academic Pediatrics, JAMAPeds, JAMA, NEJM, Journal of Pediatrics, Pediatric Infectious Disease, Journal of Hospital Medicine, Pediatric Emergency Care, and Chest PubMed searches on common pediatric hospital medicine topics: Bronchiolitis, asthma, pneumonia, IV fluid therapy, ALTE, GERD, osteomyelitis, chocolate, and hyperbilirubinemia Sought the counsel of leaders in hospital medicine Selected articles based on quality, general interest, and potential to impact pediatric hospital medicine practice
Choosing wisely, our categories… We loaded all of the article keywords in to a database and then used a modified Delphinium technique to identify emerging concepts for thematic saturation and used factor analysis to create our final categories. Actually, it was a proprietary methodology. We each read the abstracts of all potentially hospitalist-related articles and chose the ones we thought were most relevant.
Choosing wisely, our categories…cont. We each read all of the articles from this list, and scored from 1 (least relevant) to 3 (most relevant). These scores were summed. There were 9 articles that scored a 6, and 5 that scored a 5; these were included in our Top 10 (ish) These were placed in to categories with other high scoring articles on a similar topic, to add suspense.
Disclaimers All literature presented should be independently evaluated prior to changing practice. Just because we liked these articles doesn’t mean you will. We probably missed the most important pediatric hospital medicine article of the year…and we are very sorry.
The article most likely to help us Choose Wisely And the nominees are: 1. Adam Hersh, Brian Lee, Erin Hedican, et al. Linezolid Use in Hospitalized Children. Peds Inf. Dis. J. 2. Pranita Tamma, Alison Turnbull, Anthony Harris, et al. Less Is More: Combination Antibiotic Therapy for the Treatment of Gram-Negative Bacteremia in Pediatric Patients. JAMA Peds. 3. Choosing Wisely in Pediatric Hospital Medicine. Ricardo Quinonez, Matthew Garber, Alan Schroeder, and 13 of their friends. Journal of Hospital Medicine.
Article most likely to help us choose wisely 3/10/2014Footer Text
Relevance Someone, somewhere, said: “Pediatric Hospitalists: No one does nothing better than us” Waste accounts for at least 20% of healthcare expenditures in the US One way to reduce waste is to eliminate practices of unproven benefit. ABIM-F is partnering with medical societies to identify lists of 5 tests or therapies that physicians and patients should question. The Society for Hospital Medicine (SHM) joined the Choosing Wisely campaign and supported this study.
Design A diverse workgroup of 13 hospitalists was convened and charged with identifying the tests and therapies in pediatric hospital medicine that are most overused. The group was charged to maintain focus on overuse practices that had a strong basis in evidence, and were prevalent in practice. The group initially proposed candidate recommendations based on feedback from colleagues. Based on consensus the group reduced the list These were evaluated using: Exhaustive literature review on each Input from the Listserv
Results The group initially identified 20 tests and therapies: The list was narrowed to the top 11 by consensus A literature review was done on each to determine the strength of evidence A modified Delphi technique was used by the group to score the candidate tests/treatments over two rounds. The top 5 scoring tests/treatments were highlighted for publication.
The top 5 recommendations: Do not order chest radiographs in children with asthma or bronchiolitis Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. Do not use bronchodilators in children with bronchiolitis. Do not treat gastroesophageal reflux routinely in infants with acid suppression therapy Do not use continuous pulse oximetry in children with acute respiratory illness unless they are on supplemental O2.
Category: Best article about the diagnosis that shall not be named And the nominees are: 1. Alan Schroeder, Jonathan Mansbach, Michelle Stevenson, et al. Apnea in Children Hospitalized with Bronchiolitis. Pediatrics. 2. Kelly Flett, Kristin Breslin, Patricia Braun, and Simon Hambidge. Outpatient Course and Complications Associated with Home Oxygen Therapy for Mild Bronchiolitis. Pediatrics. 3. Kavita Parikh, Matthew Hall, and Stephen Teach. Bronchiolitis Management Before and After the AAP Guidelines. Pediatrics. * . * ** *
Best Article about * 3/10/2014Footer Text *
Importance In 2006, Guidelines were released to help standardize the treatment of bronchiolitis. They told us everything we were doing to treat bronchiolitis was wrong, and that we should just stand there, and give oxygen if needed. Skeptical about the uptake of this advice, a few intrepid researchers used the PHIS dataset to see if the guidelines were, in fact, followed, and if there was a decrease in the rate of use of non-evidence based care.
Design A retrospective analysis of Pediatric Health Information Systems (PHIS) administrative data from 41 children’s hospitals. Data used were from November 1, 2004 to March 31, 2012. Trends in diagnostic and treatment resource use were compared before and after publication of the guidelines Segmented time-series regression analyses were used. Included were children 1 month to 2 years of age with a primary discharge code for bronchiolitis Children with CCCs, mechanical ventilation, and LOS>10 days were excluded.
Results 130,262 patients were included Median age=4 months 58% male 59% government payor
Conclusions and Relevance The publication of the AAP’s 2006 guidelines on the treatment of bronchiolitis was associated with a reduction in diagnostic testing and medication use that was unsupported by evidence in this sample. Guidelines can, in fact, help to increase the likelihood of the delivery of evidence-based care.
Category: Best article in Medical Education And the nominees are: Amy Starmer, O’Toole J, Rosenbluth G et al: Development, Implementation, and Dissemination of the I-PASS Handoff Curriculum: A Multisite Educational Intervention to Improve Patient Handoffs. Brian Drolet, Whittle S, Khokhar M et al: Approval and Perceived Impact of Duty Hour Regulations: Survey of Pediatric Program Directors Amy Starmer, Sectish T, Simon D et al: Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle
Best Med Ed 3/10/2014Footer Text
IMPORTANCE OBJECTIVE To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow.
INTERVENTIONS Resident handoff bundle: consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. Pre-intervention: separate signouts-intern to intern SAR to SAR. No structured tool but rely upon a word based document with synopsis, plan and “to do” list Intervention 1: 2 hour training, SIGNOUT?, unified signout, designated space, periodic supervision Intervention 2: same as above plus-Name, sex, age, weight, medical record number, location, admission date, diagnosis, allergies, medications, intravenous access, code status, laboratories, vital signs, and problem list. It also contained structured fields entitled “Patient Summary”, “To Do List,” and “Contingency Planning” with free-text format
Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med. 2007;22(10):1470- 1474.
Prospective intervention study of patient admissions involving pediatric resident physicians from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children’s Hospital. Primary outcomes - rates of medical errors and preventable adverse events Secondary outcomes - omissions in the printed handoff document and resident time-motion activity Design and Outcomes
RESULTS A total of 1255 patient admissions (n = 642 preintervention; n = 613 postintervention) were reviewed for the presence of medical errors. Medical errors decreased from 33.8 per 100 admissions (95%CI, 27.3- 40.3) to 18.3 per 100 admissions (95%CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95%CI, 1.7-4.8) to 1.5 (95%CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention 8.3% (95%CI 7.1%-9.8%) vs 10.6%(95%CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95%CI, 14.5%- 52.2%vs 67.9%; 95%CI, 50.6%-85.2%; P = .03) and private location (50.0%;
How do interns/residents spend their time? Creating memes
CONCLUSIONS AND RELEVANCE Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.
Category: Best Nursery article
Category: Best Nursery article Cora Peterson, Ailes E, Riehle-Colarusso T et al: Late Detection of Critical Congenital Heart Disease Among US infants John Kelleher, Bhat R, Salas A et al: Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial David Chalmers, Wiedel C Siparsky G et al: Discovery of Hypospadias during Newborn Circumcision Should Not Preclude Completion of the Procedure
Best Nursery article 3/10/2014Footer Text
Importance Congenital heart defects affect approximately 1% of live births in the United States; 25% are considered critical congenital heart disease (CCHD) (defined as requiring surgery or catheterization at or before age 1 year) Screening for CCHD was added to the US Recommended Uniform Screening Panel for Newborns in 2011. Screening performed using pulse oximetry. Screening recommended within 24-48 hours of birth.
Study Objectives To estimate the proportion of US infants with clinically validated, nonsyndromic, screening-detectable CCHD whose condition was detected late (>3 days after birth). To investigate clinical and demographic factors associated with late detection.
Design Study Design: National Birth Defects Prevention Study (NBDPS). Ongoing, population-based, case-control study of >30 major birth defects. CCHD confirmed by echocardiography, catheterization, surgery, or autopsy. Setting Infants born from January 1, 1998, through December 31, 2007. Mothers lived in sampled states (Arkansas, California, Georgia, Iowa, Massachusetts, New Jersey, New York, North Carolina, Texas, Utah) at time of delivery. Outcome: Late CCHD detection. No evidence of diagnostic echocardiography prenatally or ≤3 days of birth.
Implications Estimated 30% of live-born infants with nonsyndromic CCHD in the NBDPS were diagnosed >3 days after birth. Varied substantially by CCHD type from 8% (pulmonary atresia) to 62% (coarctation of the aorta). Many infants with CCHD might benefit from screening through pulse oximetry before birth hospital discharge. Whether these infants are actually detected through screening is likely to vary by a number of factors, including CCHD type and the presence of extracardiac defects. Future studies of routine screening in practice might
Category: Best article about pneumonia Derek Williams, Hall M, Shah S et al: Narrow vs. Broad-spectrum Antimicrobial Therapy for Children Hospitalized with Pneumonia Rachael Ross, Hersh A, Kronman M, et al: Impact of Infectious Diseases Society of America/Pediatric Infectious Diseases Society Guidelines on Treatment of Community-Acquired Pneumonia in Hospitalized Children Queen Mary, Myers A, Hall M, et al: Comparative Effectiveness of Empiric Antibiotics for Community- Acquired Pneumonia
Best Pneumonia article 3/10/2014Footer Text
IMPORTANCE Broad-spectrum antibiotics are frequently used to empirically treat children hospitalized with community-acquired pneumonia despite recent national recommendations to use narrow-spectrum antibiotics. OBJECTIVE to compare the effectiveness of empiric therapy with narrow spectrum antibiotics with empiric therapy with broad-spectrum antibiotics in children hospitalized with uncomplicated CAP.
Outcomes Length of stay Readmission Duration of fever Duration of supplemental oxygen Standardized total costs
Conclusions and Relevance Compared with broad-spectrum agents, narrow- spectrum antibiotic coverage is associated with similar outcomes. Royalty are an untapped source of potential medical researchers.
Best article about chocolate Hanks AS, Just DR, Wansink B. Chocolate milk consequences: a pilot study evaluating the consequences of banning chocolate milk in school cafeterias. PLoS One. Gajendragadkar PR, Moualed DJ, Nicolson PL, et al. The survival time of chocolates on hospital wards: covert observational study. BMJ. Collodel G, Moretti E, Del Vecchio MT, et al. Effect of chocolate and Propolfenol on rabbit spermatogenesis and sperm quality following bacterial lipopolysaccharide treatment. Syst. Biol. Reprod. Med.
Best Article about Chocolate 3/10/2014Footer Text *
Methods Multicentre prospective covert observational study Setting: 4 wards at 3 hospitals Subjects: Boxes of Quality Street and Roses candy and those eating said candy Main outcome measure: median survival time of a chocolate
Kaplan-Meier survival curve
Chocolate consumption by role
Actual figures included in the manuscript
Limitations Lack of generalizability of chocolate consumption outside of the UK US chocolate consumption is likely to be faster
Conclusions The median survival time of a chocolate on the wards was 51 minutes. Frequency of chocolate delivery on the wards should be increased to account for demand, even in an era of cost-reduction. Chocolate box shrinkage should be vigorously fought . It is not good to be a chocolate in the hospital.
Category: Best article about Serious Bacterial Infections. Seriously. And the nominees are: Tara Greenhow, Hung Y, Herz A et al: The Changing Epidemiology of Serious Bacterial Infections in Young Infants James Laham, Breheny P, gardner B, et al: Procalcitonin to Predict Bacterial Coinfection in Infants With Acute Bronchiolitis Jamie Librizzi, McCulloh, R, Koehn K, et al: Appropriateness of Testing for Serious Bacterial Infection in Children Hospitalized With Bronchiolitis *
Best Article about Serious Bacterial Infections 3/10/2014Footer Text *
IMPORTANCE 200,000 annual hospitalizations for OBJECTIVE to evaluate provider practice patterns for evaluation of SBI in patients hospitalized with and to assess the association of SBI testing with LOS and ABX usage * * *
Design A retrospective chart review of hospitalized patients <24 months of age with a discharge diagnosis of from 2 separate study sites (Rhode Island and Missouri) during 2004 to 2008 Exclusions: lack discharge diagnosis of blitis or was initially admitted to ICU *
Results * SBI= CBC UA/UC BC CSF
Results * *
Conclusions and Relevance SBI is uncommon in children hospitalized for , and urinary tract infection is the most common diagnosis. In the evaluation of SBI in , providers more frequently obtain blood cultures than urinalysis and/or urine cultures. Evaluation for SBI is associated with increased antibiotic use (more than half of them) and increased LOS. …since we’re putting in an IV we might as well…. Remember 200,000 annual hospitalizations quickly adds up to lots of $$ * *
Best Commentary 3/10/2014Footer Text
Richard Smith Editor of the BMJ until 2004 • “The poor quality of much medical research is widely acknowledged, yet disturbingly the leaders of the medical profession seem only minimally concerned about the problem and make no apparent efforts to find a solution.” 3/10/2014Footer Text
"We need to get away from the notion, proven wrong on a daily basis, that peer review of any kind at any journal means that a work of science is correct. What it means is that a few (1-4) people read it over and didn't see any major problems. That's a very low bar in even the best of circumstances.“ Michael Eisen, a biologist at UC Berkeley, is a co-founder of the Public Library of Science
Category: Fluid Management And the nominees are: 1. Jinjing Wang, Erdi Xu, and Yanfeng Xiao. Isotonic versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis. Pediatrics 2. Francis Carandang, Andrew Anglemyer, Christopher Longhurst, et al. Association between Maintenance Fluid Tonicity and Hospital-Acquired Hyponatremia. J. Pediatr. 3. Ed Oakley, Meredith Borland, Jocelyn Neutze, and 9 other friends from the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Nasogastric hydration versus intravenous hydration for infants with Bronchiolitis: a Randomised Trial. Lancet.
Best article(s) in fluid management 3/10/2014Footer Text *
Importance Maintenance IV fluids maintain homeostasis when patients are unable to take in water, electrolytes, and energy. The Holliday and Segar method has traditionally been used to calculate fluid and electrolyte needs, but it may underestimate electrolyte needs for hospitalized children, especially those prone to SIADH There has been increasing concern about the potential for iatrogenic hyponatremia in patients receiving hypotonic IV fluids such as ¼ or ½ normal saline. This study is a meta-analysis of the most recent
Design Meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement Multiple databases and reference lists searched for relevant articles 2 authors independently screened all titles and abstracts Included: RCTs, hospitalized children 1 month-17 years, and comparing isotonic (NS or LR), to hypotonic (.45%/.3%/.18% NS) Primary outcome was NA<136 mmol/L Methodologic quality assessed with Cochrane risk-of-bias tool Relative risks, mean differences, and CIs were pooled A random-effects model was used Sensitivity analysis was done where biases were identified Heterogeneity was determined using I2 statistic The lower the I2 percent, the less variability between the studies that can’t be explained by chance Analyses done in RevMen 5.1
Results The risk of bias tool identified potential issues in all of the studies, which were addressed in subsequent sensitivity analyses where possible. Overall, the RR of hyponatremia with hypotonic fluids vs. isotonic fluids was 2.24 (95% CI 1.58-3.37; I2=14%). The RR of severe hyponatremia (Na<130 mmol/L) was 5.29; 95% CI 1.74-16.06; I2=0%. The fall in pNa was significantly greater in children receiving hypotonic IV fluids (3.49 mmol/L; 95% CI 5.63- 1.35; p<.001; I2=87%). There were no differences between the groups in hypernatremia (RR .73; 95% CI .22-2.48; I2=0%) These results held up with sensitivity analyses.
Conclusions and Relevance Isotonic fluids are less likely to cause hyponatremia than hypotonic fluids in hospitalized children. Isotonic fluids are not more likely to cause hypernatremia. However there were still methodological concerns with most of the included RCTs. Is there a better way?
Best article(s) in fluid management 3/10/2014Footer Text *
Importance Many children admitted with that diagnosis are unable to take in enough fluids by mouth to stay hydrated In many institutions, IV fluid hydration is the default. However IV fluid is a medication (see last article) and can have negative effects Naso-gastric hydration may be a more physiologic approach.
Design Multi-centre randomized trial of infants 2-12 months of age in Australia and New Zealand. Diagnosis of bronchiolitis Randomly allocated to receive NG or IV hydration Primary outcome was length of stay Secondary outcomes included rates of ICU admission, adverse events, and success of insertion. 750 infants would give 80% power to detect a difference of 10-14 hours in length of stay between groups at α=.05. Intention to treat T-tests, Kaplan-Meier curves, using Stata 11.1.
Conclusions and Relevance This was a nicely done RCT with sufficient power to detect differences. There were no differences in length of stay, ICU admission, or adverse events between the two groups NG insertion was more likely to be successful than IV insertion. Parents were equally satisfied. Consider NG hydration first!
Best Article. 3/10/2014Footer Text *
Alternatives to the handshake The familiar hand wave Right palm over the heart The bow The Namaste The wai gesture The salaam Interestingly, no mention of the fist bump or the high five
Best RCT about nebulized saline 1. Wu S, Baker C, Lang M, et al. Nebulized Hypertonic Saline for Bronchiolitis: A Randomized Clinical Trial. JAMA Peds. 2. Florin T, Shaw K, Kittick M, et al. Nebulized Hypertonic Saline for Bronchiolitis in the Emergency Room: A Randomized Clinical Trial. JAMA Peds. 3. Jonathan Jacobs, Megan Foster, Jim Wan, and Jay Pershad. 7% Saline in Bronchiolitis. Pediatrics.
Best RCT on nebulized saline 3/10/2014Footer Text *
Importance What could be more important that finding out if nebulized saline actually works?
Design Double-blind randomized clinical trial comparing 3% saline with .9% saline Recruited in the ED; treated in the ED and after admission Pre-dosed with albuterol 3 bronchiolitis seasons in 2 CA hospitals Age <24 months, no prior wheeze Outcome measures: Hospital admission rate Respiratory Assessment Change Score: 30 minutes post-treatment Respiratory Distress Assessment Instrument (RDAI) Respiratory parameters Length of stay
Analysis Intention to treat analysis Χ2 and t-tests used for bivariate comparisons Logistic and multivariate linear regression for treatment effects Controlling for demographic and clinical confounders Analyses done in SPSS
Results Hospital admission rates were 42.6% for NS vs. 28.9% for HS (p<.01); adjusted OR .49 (.28-.71). There were no differences in RDAI, RACS, or LOS No differences in study withdrawal or complications However there were significant differences by site Primarily Hispanic population
Best other RCT on nebulized saline 3/10/2014Footer Text *
Design Double-blind randomized clinical trial comparing 3% saline with .9% saline Recruited in the ED; treated in the ED After nasal suctioning and a trial of albuterol 2 bronchiolitis seasons in 1 PA hospital Age 2 months to <24 months, no prior wheeze Outcome measures: Hospital admission rate Respiratory Assessment Change Score: 1 hour post treatment Respiratory Distress Assessment Instrument (RDAI) Respiratory parameters Clinical parameters Parent perceptions
Analysis Intention to treat analysis Χ2 and t-tests used for bivariate comparisons Median differences analyzed using Mann-Whitney test. Analyses done in Stata v.12
Limitations Small sample size But there was a significant increase in RACS!
Take home points These were both well done RCTs using very similar methods in similar populations, that found divergent results. Editorial
Category: NUMBER 1 And the nominees are: Diana Averbuch, Nir-Paz R, Tenenbaum A et al. Factors Associated with Bacteremia in young Infants with Urinary Tract Infection RIVUR Trial Investigators: Antimicrobial Prophylaxis for Children with Vesicoureteral Reflux. Susanna Hernandez-Bou, Trenchs V, Alarcon, et al: Afebrile Very Young Infants With Urinary Tract Infection and the Risk for Bacteremia
Best article(s) about Urine 3/10/2014Footer Text *
Importance Children with febrile urinary tract infection commonly have vesicoureteral reflux (30-40%) The utility of antimicrobial prophylaxis to prevent recurrences in children with reflux remains controversial
Design 2 year, 19 site, randomized, double blind, placebo- controlled 2-71 months of age with grade I-IV vesicoureteral reflux Trimethoprim-sulfamethoxazole vs placebo OUTCOME(S): Primary: recurrence over 2 years Secondary: Renal scarring Failure of prophylaxis Antimicrobial resistance
Relevance/Importance Bactrim prophylaxis in children less than 6 years with VUR diagnosed after UTI is associated with a decrease in the risk of UTI recurrence Rates of renal scarring were the SAME in both groups
Final thoughts A special thanks to the authors and contributors who have been such great sports through this process. And huge thank you to our ‘people” Samantha and Kris for shepherding us through this process. And a big raspberry to the planning committee who coerced us into this