Section on Hospital Medicine Program

Presentations following on page 2 2 Abstract Presentations 1) Pediatric Hospital Medicine Abstract Research Award Winner: The SOHM annual abstract award recognizes outstanding research presented during the SOHM academic and scientific program at the Academy's National Conference & Exhibition (NCE). Perceptions of Timeliness and Content of Discharge Communication Differ Between Hospitalists and Primary Care Providers: Results from the Value in Inpatient Pediatrics Transitions of Care Collaborative JoAnna K. Leyenaar, MD, MPH, Department of Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Boston, MA, David Cooperberg, MD, Pediatrics, Drexel University College of Medicine/ St. Christopher's Hospital for Children, Philadelphia, PA, Caroline E. Rassbach, MD, Pediatrics, Stanford University, Palo Alto, CA, Leah A. Mallory, MD, Pediatrics, Tufts University School of Medicine/ Maine Medical Center, Portland, ME and Daniel T. Coghlin, MD, FAAP, Pediatrics, The Warren Alpert Medical School of Brown University/ Hasbro Children's Hospital, Providence, RI Purpose: Effective communication between hospitalists and primary care providers (PCPs) at the time of discharge is essential in the transition of patients from the inpatient to outpatient setting. Our objective was to assess the content and timeliness of discharge communication from a national sample of pediatric hospital medicine programs. Methods: A survey querying current and desired discharge communication was sent to 320 PCPs who refer patients to 16 hospitals participating in the Value in Inpatient Pediatrics Transitions of Care Collaborative. An analogous survey was sent to 147 hospital medicine program directors (PDs) listed in the AAP SOHM database. Descriptive statistics were calculated and chi-square tests performed to identify differences between physician groups. Subgroup analysis was conducted to assess for differences in discharge communication patterns between freestanding children's hospitals, community hospitals and children's hospitals within adult centers. Results: Responses were received from 201 PCPs and 71 PDs, representing response rates of 62% and 48% respectively. Among PDs, 85% reported reliably sending discharge communication within two days of discharge, with 79% reporting that all necessary details were consistently transmitted. Among PCPs, 72% reported reliably receiving discharge communication within two days of discharge, with 65% reporting that the communication contained all necessary details. These between-group differences are statistically significant (p < 0.01). In comparing the content PCPs consider essential with that reported as consistently received within two days of discharge, significant gaps were found. The largest gaps included: immunizations given during inpatient stay (reported as essential by 83% and consistently received by 36% of PCPs); pending investigations (essential to 78% and received by 45% of PCPs) and discharge medications (essential to 97% and received by 72% of PCPs). Conclusion: The results of this multi-center study suggest that perceptions of PCPs and PDs regarding the timeliness and content of discharge communication differ significantly. Although the majority of PCPs report receiving communication within two days of discharge, the content may be sub-optimal. It will be important to assess for perceived improvements in discharge communication following implementation of the next phase of this quality improvement initiative. 2) Bedside Moderate Sedation by Non-Anesthesiologist Dramatically Improves the Success Rate of Peripherally-Inserted Central Catheter (PICC) Lines in Pediatric Patients Diana Bottari, DO, Kim Wittmayer, APN and Kent T. Nelson, MD, Pediatrics, Advocate Hope Children's Hospital, Oak Lawn, IL Purpose: The ability to obtain and maintain reliable intravenous access is an essential but sometimes elusive goal in pediatric inpatient medicine. Peripheral inserted catheters (PICC) have long been established as reliable and safe for pediatric patients and area ideal for children requiring several days or weeks of IV infusion therapy. Bedside PICC placement has had less than ideal success in the pediatric world as compared to adults who have had documented success in the high 90%s. Barriers encountered during PICC line insertion include vessel caliber, age of the patient, and the inability for patients to cooperate and remain still for the procedure. Sedation administered by an experienced clinician provides motionless or near motionless state, decrease anxiety, and amnesia increasing the likelihood of success during PICC placement while minimizing possible adverse events. An extensive literature search showed no studies pertaining to success rate of pediatric bedside ultrasound guided PICC placement with or without sedation. Methods: At a large Midwestern Children's Hospital, bedside PICC insertion traditionally occurred without sedation under ultrasound guidance by specially trained vascular assist device (VAD) nurses with annual success rate of 77% (2008), 75% (2009), and 77% (2010). In May 2010, a dedicated Pediatric Sedation Service was established with the goal to reduce pain and anxiety as much as possible during a wide range of procedures including PICC line insertion. Each candidate for sedation had a full history and physical performed by the board-certified pediatrician on the Sedation Service documenting not only the suitability of the patient for sedation but also American Society of Anesthesiology status (ASA), airway documentation, and NPO status. Results: Between January 1, 2011 and December 31, 2011, 189 bedside PICC lines were attempted. Of these, 79 were attempted with sedation provided by the Sedation Service and 110 were attempted without sedation. The success rate was 94% with sedation versus 75% without. One episode of laryngospasm occurred without adverse outcome; no other adverse events reported. Conclusion: Our outcomes demonstrate that sedation can be delivered safely and positively impact the pediatric PICC insertion success rate. The average cost of each bedside PICC insertion is $1,300 while the average cost of a PICC insertion by interventional radiology (IR) is $2,600. Neither of these prices includes the cost of the interventionist, anesthesiologist, or the sedationist. Not only is there an immediate cost savings, but also a savings in avoidable days. If bedside failure occurs, the patient has to wait one to several 3 days to have the PICC attempted by IR, increasing the burden on the patient, family, and hospital. It is clear that with the addition of a board-certified and experienced pediatrician providing sedation for bedside PICC placement success is overwhelmingly increased and costs decreased. 3) Use of a Standardized Respiratory Scoring System and a Threshold Score Prior to Intervention Decreases Unnecessary Bronchodilator Usage in Bronchiolitis Michelle Marks, DO, Rita Pappas, Matthew Garber, MD, Michele Lossius, MD, FAAP, Shawn Ralston, MD, FAAP and A. Steve Narang, MD, FAAP, (1)Pediatric Hospital Medicine, Cleveland Clinic Children's Hospital, Cleveland, OH, (2)Palmetto Health University of South Carolina, (3)Pediatrics, University of Florida, Gainesville, FL, (4)University of Texas Health Science Center San Antonio, San Antonio, TX, (5)Cardon Children's Medical Center Purpose: Use of a standardized respiratory scoring system and a threshold score prior to intervention will decrease unnecessary bronchodilator usage in bronchiolitis across diverse clinical settings. Methods: Five hospitalist groups incorporated the WARM (wheeze, air exchange, respiratory rate, muscle use) respiratory score into their bronchiolitis protocols, but the individual protocols varied. Data were retrospectively collected on all children less than 24 months of age with a primary diagnosis of acute viral bronchiolitis admitted to observation or inpatient status from 2007 to 2010. Patients admitted to intensive care or who had chronic lung diseases, asthma, chromosomal abnormalities, congenital heart disease or neurological diseases were excluded. Bronchodilator utilization was measured by the overall percentage of patients who received any dose of bronchodilator and the total number of bronchodilator doses used during the year. Data were analyzed on the hospital level using repeated measures mixed models with year treated as a continuous variable from 1 to 4; correlation within hospital over time was modeled with an autoregressive correlation structure. All tests were two-tailed and performed at a significance level of 0.05 using SAS 9.2 software (SAS Institute, Cary, NC). Results: Over the intervention period from 2007-2010, there was a significant decrease in the percentage of patients who received bronchodilators over all 5 institutions, an average of 8% per year (P=0.004). There was a significant decrease in the number of bronchodilator doses given during the intervention period, reported as the mean number of bronchodilator doses per patient, which decreased by an average of 1 per year (P=0.036). The average length of stay and readmission rate did not change significantly at any of the 5 institutions over the intervention period. Conclusion: Use of a standardized respiratory scoring system and a threshold score prior to intervention decreases unnecessary bronchodilator usage in bronchiolitis across diverse clinical settings without increasing length of stay or readmission rate. 4) Maintaining Sedation Proficiency and Quality Improvement of Pediatric Hospitalist Sedation Providers Mythili Srinivasan, MD, PhD, Pediatrics, Washington University School of Medicine, St. Louis, MO and Douglas Carlson, MD, Pediatrics, Washington University/St. Louis Children's Hospital, St. Louis, MO Purpose: Procedural sedation (PS) is a core competency for pediatric hospitalists (PH), but there is little sedation training during pediatric residency. Our goal was to develop strategies to maintain competency by identifying knowledge gaps and developing measures to improve proficiency and quality within our sedation program. Methods: A web-based anonymous survey was developed consisting of multiple choice questions and case-based scenarios to query the knowledge base of PH regarding two commonly used PS agents, ketamine and nitrous oxide (N2O). Results: The survey was sent to 49 PH at St. Louis Children's Hospital. All responded, 86% completed the survey. 85% of PH had performed >20 ketamine sedations; 48% >20 N2O sedations. 100% and 88% of PH correctly identified the sedative properties of ketamine and N2O, respectively. 88% and 55% identified their analgesic properties, respectively. We queried PH on contraindications for ketamine and N2O (Tables 1&2). We categorized PH as experienced (>50 ketamine/N2O sedations) or less experienced (<50 ketamine/N2O sedations). Table 1: Identification of ketamine contraindications Less experienced PH (n=20) % Experienced PH (n =20) % Increased intracranial pressure 95 95