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Background and Objective: Treatment of postoperative pain for children with severe neurologic impairment (SNI) is challenging. We describe the type, number of classes, and duration of postoperative pain medications for procedures common among children with SNI, as well as the variability across children's hospitals in pain management with an emphasis on opioid prescribing., Methods: This retrospective cohort study included children with SNI ages 0-21 years old who underwent common procedures between January 1, 2019 and December 31, 2019 within 49 children's hospitals in the Pediatric Health Information System. We defined SNI using previously described high-intensity neurologic impairment diagnosis codes and identified six common procedures which included fracture treatment, tracheostomy, spinal fusion, ventriculoperitoneal shunt placement (VP shunt), colostomy, or heart valve repair. Medication classes included benzodiazepines, opioids, and other nonopioid pain medications. Acetaminophen and nonsteroidal anti-inflammatory drugs were excluded from analysis. All findings were summarized using bivariate statistics., Results: A total of 7184 children with SNI underwent a procedure of interest. The median number of classes of pain medications administered varied by procedure (e.g., VP shunt: 0 (interquartile range [IQR] 0-1); tracheostomy: 3 (IQR 2-4)). Across all procedures, opioids and benzodiazepines were the most commonly prescribed pain medications (48.8% and 38.7%, respectively). We observed significant variability in the percentage of postoperative days with opioids across hospitals by procedure (all p < .001)., Conclusion: There is substantial variability in the postoperative delivery of pain medications for children with SNI. A standardized approach may decrease the variability in postoperative pain control and enhance care for children with SNI., (© 2024 Society of Hospital Medicine.)

Objective: The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes., Design, Setting and Participants: We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database., Main Outcome and Measures: We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions., Results: We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 [95% confidence interval; CI]: 30.8-35.4] h vs. broad-spectrum: 46.1 [95% CI: 44.1-48.2] h) and reduced costs (narrow-spectrum: $4570 [$3751-5568] versus broad-spectrum: $5699 [$5005-$6491]). There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities., (© 2024 Society of Hospital Medicine.)

Background: Despite nationally endorsed treatment guidelines and stewardship programs, variation and deviation from evidence-based antibiotic prescribing occur, contributing to inappropriate use and medication-related adverse events. Measures of antibiotic prescribing variability can aid in quantifying this problem but are not adequate., Objective: The objective of this study is to develop a standardized metric to quantify antibiotic prescribing variability (diversity) within and across children's hospitals, and to examine its association with outcomes., Methods: We performed a cross-sectional study of empiric antibiotic exposure among children hospitalized during 2017-2019 with one of 15 common pediatric infections using the Pediatric Health Information System database. Encounters for children with complex chronic conditions, transfers in, and birth hospitalizations were excluded. Using the Shannon-Weiner entropy index, we quantified antibiotic diversity for each infection type using the d-measure of diversity. Generalized linear mixed-effects models were used to examine the association between hospital-level antibiotic diversity and risk-adjusted length of stay and costs., Results: A total of 79,515 hospitalizations for common pediatric infections were included. Antibiotic diversity varied within and across hospitals. Infections with low mean antibiotic diversity included appendicitis (mean diversity [mDiv] = 4.9, SD = 2.5) and deep neck space infections (mDiv = 5.9, SD = 1.9). Infections with high mean antibiotic diversity included pneumonia (mDiv = 23.4, SD = 5.6) and septicemia/bacteremia (mDiv = 28.5, SD = 12.1). There was no statistically significant association between hospital-level antibiotic diversity and risk-adjusted LOS or costs., Conclusions: We developed and applied a novel metric to quantify diversity in antibiotic prescribing that permits comparisons across hospitals and can be leveraged to identify high-priority areas for local and national stewardship interventions., (© 2024 Society of Hospital Medicine.)

Background: Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time., Objectives: To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes., Design, Settings, and Participants: We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database., Main Outcomes and Measures: We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A >2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index., Results: Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all 10 years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction., (© 2024 Society of Hospital Medicine.)

Background: Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure., Objective: To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes., Design, Settings and Participants: We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality., Main Outcome and Measures: We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups., Results: We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children., (© 2024 Society of Hospital Medicine.)

Background and Objective: Children with gastrointestinal infections often require acute care.The objectives of this study were to describe variations in patterns of stool testing across children's hospitals and determine whether such variation was associated with utilization outcomes., Design, Settings and Participants: We performed a multicenter, cross-sectional study using the Pediatric Health Information System (PHIS) database. We identified stool testing (multiplex polymerase chain reaction [PCR], stool culture, ova and parasite, Clostridioides difficile, and other individual stool bacterial or viral tests) in children diagnosed with acute gastrointestinal infections., Main Outcome and Measures: We calculated the overall testing rates and hospital-level stool testing rates, stratified by setting (emergency department [ED]-only vs. hospitalized). We stratified individual hospitals into low, moderate, or high testing institutions. Generalized estimating equations were then used to examine the association of hospital testing groups and outcomes, specifically, length of stay (LOS), costs, and revisit rates., Results: We identified 498,751 ED-only and 40,003 encounters for hospitalized children from 2016 to 2020. Compared to ED-only encounters, stool studies were obtained with increased frequency among encounters for hospitalized children (ED-only: 0.1%-2.3%; Hospitalized: 1.5%-13.8%, all p < 0.001). We observed substantial variation in stool testing rates across hospitals, particularly during encounters for hospitalized children (e.g., rates of multiplex PCRs ranged from 0% to 16.8% for ED-only and 0% to 65.0% for hospitalized). There were no statistically significant differences in outcomes among low, moderate, or high testing institutions in adjusted models., Conclusions: Children with acute gastrointestinal infections experience substantial variation in stool testing within and across hospitals, with no difference in utilization outcomes. These findings highlight the need for guidelines to address diagnostic stewardship., (© 2023 Society of Hospital Medicine.)

Background: Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP)., Objectives: We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes., Design, Setting and Participants: This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals., Main Outcome and Methods: We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes., Results: We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs., Conclusion: There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP., (© 2022 Society of Hospital Medicine.)

Background: Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures., Objectives: (1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals., Design, Setting, and Participants: Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care., Outcome Measures: Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs., Results: We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization., Conclusions: Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable., (© 2022 Society of Hospital Medicine.)

Rigorous evidence for antibiotic management of pediatric complicated pneumonia is lacking, likely contributing to variation in empiric antibiotic(s). Using the Pediatric Health Information System database, we sought to describe use and clinical outcomes of children hospitalized with complicated pneumonia who received empiric antibiotic regimens with and without methicillin-resistant Staphylococcus aureus (MRSA) coverage. We evaluated empiric antibiotic selection on Day 0-1, grouping based on use of an antibiotic with or without MRSA coverage. We used generalized linear mixed effects models to examine the association of MRSA coverage and outcomes. Across 46 children's hospitals, 71.5% of children (N = 1279) received an empiric antibiotic regimen with MRSA coverage. In adjusted analyses, length of stay, need for repeat pleural drainage procedures, 7-day emergency department revisits and 7-day readmissions were similar between groups. Future prospective studies examining the need for MRSA coverage may assist in refining national treatment guidelines for complicated pneumonia in children., (© 2022 Society of Hospital Medicine.)

Background/objective: This study aims to comprehensively examine racial and ethnic differences in pediatric unintentional injuries requiring hospitalization by age across injury mechanisms., Study Design: This was a retrospective, nationally representative cross-sectional analysis of discharge data within the 2016 Kids' Inpatient Database for 98,611 children ≤19 years with unintentional injuries resulting in hospitalization. Injury categories included passengers and pedestrians injured in a motor vehicle crash, falls, drownings, burns, firearms, drug and nondrug poisonings, suffocations, and other injuries. Relative risk (RR) for injuries requiring hospitalization were calculated for children of Black, Hispanic, and Other races and ethnicities compared with White children, and then RR were further stratified by age. Excessive hospitalizations were calculated as the absolute number of hospitalizations for each race and ethnicity group that would have been avoided if each group had the same rate as White children., Results: Black children were significantly more likely to be hospitalized compared with White children for all injury mechanisms except falls, and in nearly all age groups with the greatest RR for firearm injuries (RR 9.8 [95% confidence interval: 9.5-10.2]). Differences were associated with 6263 excessive hospitalizations among all racial and ethnic minority children compared with White children., Conclusions: Racial and ethnic minority children represent populations at persistent disproportionate risk for injuries resulting in hospitalization; risk that varies in important ways by injury mechanism and children's age. These findings suggest the importance of the environmental and societal exposures that may drive these differences, but other factors, such as provider bias, may also contribute., (© 2022 Society of Hospital Medicine.)

Background: Controversy exists regarding the optimal antibiotic regimen for use in hospitalized children with staphylococcal scalded skin syndrome (SSSS). Various regimens may confer toxin suppression and/or additional coverage for methicillin-susceptible Staphylococcus aureus (MSSA) or methicillin-resistant S aureus (MRSA)., Objectives: To describe antibiotic regimens in hospitalized children with SSSS and examine the association between antistaphylococcal antibiotic regimens and patient outcomes., Design/methods: Retrospective cohort study of children hospitalized with SSSS using the Pediatric Health Information System database (2011-2016). Children who received clindamycin monotherapy, clindamycin plus MSSA coverage (eg, nafcillin), or clindamycin plus MRSA coverage (eg, vancomycin) were included. The primary outcome was hospital length of stay (LOS); secondary outcomes were treatment failure and cost. Generalized linear mixed-effects models were used to compare outcomes among antibiotic groups., Results: Of 1,259 children included, 828 children received the most common antistaphylococcal antibiotic regimens: clindamycin monotherapy (47%), clindamycin plus MSSA coverage (33%), and clindamycin plus MRSA coverage (20%). Children receiving clindamycin plus MRSA coverage had higher illness severity (44%) compared with clindamycin monotherapy (28%) and clindamycin plus MSSA (32%) (P =.001). In adjusted analyses, LOS and treatment failure did not differ among the 3 regimens (P =.42 and P =.26, respectively). Cost was significantly lower for children receiving clindamycin monotherapy and highest in those receiving clindamycin plus MRSA coverage (mean, $4,839 vs $5,348, respectively; P <.001)., Conclusions: In children with SSSS, the addition of MSSA or MRSA coverage to clindamycin monotherapy was associated with increased cost and no incremental difference in clinical outcomes.

Objective: To describe the prevalence and characteristics of infection-related readmissions in children and to identify opportunities for readmission reduction and estimate associated cost savings., Study Design: Retrospective analysis of 380,067 nationally representative index hospitalizations for children using the 2014 Nationwide Readmissions Database. We compared 30-day, all-cause unplanned readmissions and costs across 22 infection categories. We used the Inpatient Essentials database to measure hospital-level readmission rates and to establish readmission benchmarks for individual infections. We then estimated the number of readmissions avoided and costs saved if hospitals achieved the 10th percentile of hospitals' readmission rates (ie, readmission benchmark). All analyses were stratified by the presence/absence of a complex chronic condition (CCC)., Results: The overall 30-day readmission rate was 4.9%. Readmission rates varied substantially across infections and by presence/absence of a CCC (CCC: range, 0%-21.6%; no CCC: range, 1.5%-8.6%). Approximately 42.6% of readmissions (n = 3,576) for children with a CCC and 54.7% of readmissions (n = 5,507) for children without a CCC could have been potentially avoided if hospitals achieved infection-specific benchmark readmission rates, which could result in an estimated savings of $70.8 million and $44.5 million, respectively. Bronchiolitis, pneumonia, and upper respiratory tract infections were among infections with the greatest number of potentially avoidable readmissions and cost savings for children with and without a CCC., Conclusion: Readmissions following hospitalizations for infection in children vary significantly by infection type. To improve hospital resource use for infections, future preventative measures may prioritize children with complex chronic conditions and those with specific diagnoses (eg, respiratory illnesses).

Background/objective: Pediatric patients hospitalized with bacterial infections often receive intravenous (IV) antibiotics. Early transition to enteral antibiotics can reduce hospital duration, cost, and complications. We aimed to identify opportunities to transition from IV to enteral antibiotics, describe variation of transition among hospitals, and evaluate feasibility of novel stewardship metrics., Methods: This multisite retrospective cohort study used the Pediatric Health Information System to identify pediatric patients hospitalized with pneumonia, neck infection, orbital infection, urinary tract infection (UTI), osteomyelitis, septic arthritis, or skin and soft tissue infection (SSTI) between 2017 and 2018. Opportunity days were defined as days on which patients received both IV antibiotics and enteral medications, suggesting enteral tolerance. Percent opportunity was defined as opportunity days divided by days on any antibiotics. Both outcomes excluded IV antibiotics that have no alternative oral formulation. We evaluated outcomes per infection and antibiotic and assessed across-hospital variation., Results: We identified 88,522 aggregate opportunity days in 100,103 hospitalizations. On 57% of the antibiotic days, there was an opportunity to switch patients to enteral therapy, with greatest opportunity days in SSTI, neck infection, and pneumonia encounters, and with clindamycin, ceftriaxone, and ampicillin-sulbactam. Percent opportunity varied by infection (73% in septic arthritis to 40% in pneumonia). There was significant across-hospital variation in percent opportunity for all infections., Conclusion: This multicenter study demonstrated the potential opportunity to transition from IV to enteral therapy in over half of antibiotic days. Opportunity varied by infection, antibiotic, and hospital. Across-hospital variation demonstrated likely missed opportunities for earlier transition and the need to define optimal transition times. Stewardship efforts promoting earlier transition for highly bioavailable antibiotics could reduce healthcare utilization and promote high-value care. We identified feasible stewardship metrics.

Background: Worse outcomes among adults presenting for/receiving care on weekends (ie, "the weekend effect") have been observed for many diseases. However, little is known about the overall impact of the weekend effect in hospitalized children., Objective: o determine the association between weekend admission and length of stay (LOS) and between weekend discharge and 30-day all-cause readmission., Methods: We conducted a retrospective, cross-sectional study of children hospitalized between October 1, 2014 and September 30, 2015 using the Pediatric Health Information System. Birth hospitalizations and planned procedures were excluded. We used generalized linear mixed modeling to assess the independent association between weekend admission and LOS and weekend discharge and readmission risk., Results: Among 390,745 hospitalizations across 43 hospitals, the median LOS was 41 hours (interquartile range [IQR] 24-71) and the 30-day readmission rate was 8.2% (IQR 7.2-9.4). We observed no association between weekend admission and LOS (adjusted LOS [95% CI: weekend 63.70 [61.01-66.52] hours vs weekday 63.40 [60.73-66.19] hours, P = .112). Weekend discharge was associated with slightly increased odds of readmission compared with weekday discharge (adjusted probability of readmission [95% CI]: weekend 0.13 [0.12-0.13] versus weekday 0.11 [0.11-0.12], P < .001) but was variable among individual hospitals. Patient characteristics (ie, number of chronic conditions) were more strongly associated with LOS and readmission risk than weekend admission or discharge., Conclusions: Patient-level factors (ie, clinical and demographic characteristics) are more indicative of longer LOS and readmission risk than weekend admissions or discharges. The overall impact of the weekend effect across children's hospitals was minimal., (© 2018 Society of Hospital Medicine.)