Background Standard methods for obtaining data may delay quality improvement (QI) interventions including for bronchiolitis, a common cause of childhood hospitalization. Objective To describe the use of a dashboard in the context of a multifaceted QI intervention aimed at reducing the use of chest radiographs, bronchodilators, antibiotics, steroids, and viral testing in patients with bronchiolitis. Methods This QI initiative took place at Children's Minnesota, a large, not-for-profit children's health care organization. A multidisciplinary bronchiolitis workgroup developed a local clinical guideline and order-set. Delays in obtaining baseline data prompted a pediatric hospitalist and information technology specialist to modify a vendor's dashboard to display data related to bronchiolitis guideline metrics. Patients 2 months to 2 years old with a bronchiolitis emergency department (ED)/inpatient encounter in the period October 1, 2014 to April 30, 2018 were included. The primary outcome was a functioning dashboard; a process measure was the percentage of ED clinician logins. Outcome measures included the percent use of guideline metrics (e.g., bronchodilators) displayed on statistical process control charts (ED vs. inpatient). Balancing measures included length of stay, charge ratios, and hospital revisits. Results A workgroup (formed October 2015) implemented a bronchiolitis order-set and guideline (February 2016) followed by a bronchiolitis dashboard (August 2016) consolidating disparate data sources loaded within 2 to 4 days of discharge. In total, 35% of ED clinicians logged in. Leaders used the dashboard to target and track interventions such as a bronchodilator order alert. There were improvements in most outcome metrics; however, timing did not suggest direct dashboard impact. ED balancing measures were lower after implementation. Conclusion We described use of a dashboard to support a multifaceted QI initiative for bronchiolitis. Leaders used the dashboard for targeted interventions but the dashboard did not directly impact the observed improvements. Future studies should assess reasons for low individual dashboard use.

A B S T R A C T BACKGROUND AND OBJECTIVES:Skin and soft tissue infections (SSTIs) are an increasingly common cause of pediatric hospital visits among infants. The optimal evaluation strategy for younger infants with SSTI is unknown because there is little information about outcomes including risks of concomitant bacterial infections and treatment failure. This study was designed to determine rates of concomitant invasive bacterial infection and hospital revisits for treatment failure as well as factors associated with treatment failure in infants presenting with SSTI. METHODS:Retrospective study of patients #90 days of age who received care from the 22 emergency departments and hospitals in the Intermountain Healthcare system from July 1, 2004 to December 31, 2011, with a primary discharge diagnosis of SSTI. Concomitant bacterial infections were defined as urinary tract infection (UTI; culture-confirmed) or invasive bacterial infection (IBI; culture-confirmed bacteremia and/or meningitis). Treatment failure was defined as any unplanned change in care at hospital revisit within 14 days of discharge. RESULTS:The study included 172 infants; 29 (17%) were febrile, and 91 (53%) had $1 sterile site culture performed. One case of bacteremia in a febrile infant was identified giving an overall proportion with UTI/IBI of 0.58% (95% confidence interval 0.01%-3.2%). Sixteen infants (9.3%; 95% confidence interval 5.4%-14.7%) returned for treatment failure. Perianal location (P 5 .03) and private insurance status (P 5 .01) were associated with more treatment failures compared with other locations or payer types. No patients returned for missed UTI/IBI. CONCLUSIONS:Concomitant bacterial infections were rare in infants with SSTI, with none identified in afebrile infants. Treatment failure of SSTI leading to hospital revisit was common.

In children with NI, GER, and dysphagia: fundoplication and GJ feeding have similar RRH outcomes. Either intervention can reduce future aspiration risk; the choice can reflect non-RRH-related complication risks, caregiver preference, and clinician recommendation.

Background: There are no recent descriptions of measles hospitalizations and complications in US children despite outbreaks within the past decade—including 2 in Minnesota (2011 and 2017). The objective of our study was to describe complications, hospital management and resource utilization for children hospitalized for measles at a US children’s hospital. Methods: Retrospective case series of children (0–18 years of age) hospitalized for measles (observation/inpatient diagnosis code for measles) at Children’s Minnesota, January 1, 2011, to September 1, 2017. Descriptive statistics were performed. Results: Thirty-three patients were included (7 from 2011 and 21 from 2017 outbreaks). Median age was 27 months (range, 6–95 months), 94% were Black or African American (73% Somali ethnicity), 88% had medical assistance and 91% were unvaccinated to measles. Poor feeding was a primary reason for admission (97%); additional complications included otitis media (42%), pneumonia (30%), tracheitis (6%) and keratitis (3%). Additional testing was common [chest radiographs (70%), blood cultures (64%), nonmeasles viral testing (42%)]. Seventy-three percent received antibiotics, 30% required oxygen and 21% received vitamin A. Median length of stay was 3.7 days (range, 1.1–26.2 days); 1 patient was readmitted. Median direct cost in 2017 was $5291 (interquartile range : $3907–$7519), and estimated total cost to the hospital for the 2017 outbreak was $1.3 million. Conclusions: Clinicians should be aware of measles complications and treatment. Public and private health efforts should continue to focus on immunization, given significant implications of measles infections for patients and healthcare systems. Future studies may assess complications of measles across the United States as individual outbreaks often occur in specific populations, making generalization of results challenging.

For children hospitalized with SSSS, lower use of diagnostic tests was not associated with changes in outcomes. Hospitals with high diagnostic test use may be able to reduce testing without adversely affecting patient outcomes.

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Vitamin A reduces measles morbidity/mortality and and is recommended for management. We studied 142 patients hospitalized at US Children’s hospitals for measles between January 1, 2004, and March 31, 2019, and found only 47 (33%) received vitamin A. Patients with complex chronic conditions were less likely to be treated. This study highlights a concerning gap between recommendations and practice for hospital management of measles.

A B S T R A C TOBJECTIVES: To describe variation in empirical antibiotic selection in infants ,60 days old who are hospitalized with skin and soft-tissue infections (SSTIs) and to determine associations with outcomes, including length of stay (LOS), 30-day returns (emergency department revisit or readmission), and standardized cost. METHODS:Using the Pediatric Health Information System, we conducted a retrospective study of infants hospitalized with SSTI from 2009 to 2014. We analyzed empirical antibiotic selection in the first 2 days of hospitalization and categorized antibiotics as those typically administered for (1) staphylococcal infection, (2) neonatal sepsis, or (3) combination therapy (staphylococcal infection and neonatal sepsis). We examined the association of antibiotic selection and outcomes using generalized linear mixed-effects models. RESULTS:A total of 1319 infants across 36 hospitals were included; the median age was 30 days (interquartile range [IQR]: 17-42 days). We observed substantial variation in empirical antibiotic choice, with 134 unique combinations observed before categorization. The most frequently used antibiotics included staphylococcal therapy (50.0% [IQR: 39.2-58.1]) and combination therapy (45.4% [IQR: 36.0-56.0]). Returns occurred in 9.2% of infants. Compared with administration of staphylococcal antibiotics, use of combination therapy was associated with increased LOS (adjusted rate ratio: 1.35; 95% confidence interval: 1.17-1.53) and cost (adjusted rate ratio: 1.39; 95% confidence interval: 1.21-1.58), but not with 30-day returns.CONCLUSIONS: Infants who are hospitalized with SSTI experience wide variation in empirical antibiotic selection. Combination therapy was associated with increased LOS and cost, with no difference in returns. Our findings reveal the need to identify treatment strategies that can be used to optimize resource use for infants with SSTI.