Publications by authors named "Shabnam Jain"

33 Publications

Quality Initiative to Reduce High-Flow Nasal Cannula Duration and Length of Stay in Bronchiolitis.

Hosp Pediatr 2021 Apr 22;11(4):309-318. Epub 2021 Mar 22.

Department of Pediatrics, Emory University School of Medicine Atlanta, Georgia; and.

Objectives: High-flow nasal cannula (HFNC) use in bronchiolitis may prolong length of stay (LOS) if weaned more slowly than medically indicated. We aimed to reduce HFNC length of treatment (LOT) and inpatient LOS by 12 hours in 0- to 18-month-old patients with bronchiolitis on the pediatric hospital medicine service.

Methods: After identifying key drivers of slow weaning, we recruited a multidisciplinary "Wean Team" to provide education and influence provider weaning practices. We then implemented a respiratory therapist-driven weaning protocol with supportive sociotechnical interventions (huddles, standardized orders, simplification of protocol) to reduce LOT and LOS and promote sustainability.

Results: In total, 283 patients were included: 105 during the baseline period and 178 during the intervention period. LOT and LOS control charts revealed special cause variation at the start of the intervention period; mean LOT decreased from 48.2 to 31.2 hours and mean LOS decreased from 84.3 to 60.9 hours. LOT and LOS were less variable in the intervention period compared with the baseline period. There was no increase in PICU transfers or 72-hour return or readmission rates.

Conclusions: We reduced HFNC LOT by 17 hours and LOS by 23 hours for patients with bronchiolitis via multidisciplinary collaboration, education, and a respiratory therapist-driven weaning protocol with supportive interventions. Future steps will focus on more judicious application of HFNC in bronchiolitis.
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http://dx.doi.org/10.1542/hpeds.2020-005306DOI Listing
April 2021

Asymptomatic bacteriuria prevalence.

J Pediatr 2020 07;222:253-257

Stanford University School of Medicine, Stanford, California.

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http://dx.doi.org/10.1016/j.jpeds.2020.04.022DOI Listing
July 2020

Improving Bronchiolitis Care in Outpatient Settings Across a Health Care System.

Pediatr Emerg Care 2019 Nov;35(11):791-798

From the Children's Healthcare of Atlanta.

Objective: This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives.

Methods: We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts.

Results: For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change.

Conclusion: A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.
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http://dx.doi.org/10.1097/PEC.0000000000001966DOI Listing
November 2019

Ruptured Thoracic and Abdominal Gastrointestinal Duplication Cysts Presenting With Failure to Thrive.

Pediatr Emerg Care 2018 Jul;34(7):e128-e130

Gastrointestinal duplication cysts are rare congenital malformations, with esophageal and gastric duplication cysts being among the rarest. We report an 8-week-old female who presented to the emergency department with failure to thrive and was subsequently found to have multiple gastric and esophageal duplication cysts that had ruptured intrathoracically and intra-abdominally. We describe the diagnosis and management of this patient who underwent successful resection of 4 gastrointestinal duplication cysts. This report emphasizes the unexpected, and sometimes relatively benign, presentations of gastrointestinal duplication cysts. To our knowledge, this is the first reported occurrence of multiple duplication cysts that independently ruptured thoracically and abdominally.
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http://dx.doi.org/10.1097/PEC.0000000000001532DOI Listing
July 2018

Should We Believe the Urinalysis?

Authors:
Shabnam Jain

Pediatrics 2017 03;139(3)

Emory University

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http://dx.doi.org/10.1542/peds.2016-3814BDOI Listing
March 2017

Quality Improvement in Concussion Care: Influence of Guideline-Based Education.

J Pediatr 2017 05 21;184:26-31. Epub 2017 Feb 21.

Department of Neurosurgery, Children's Healthcare of Atlanta, Atlanta, GA.

Objective: To evaluate the potential impact of a concussion management education program on community-practicing pediatricians.

Study Design: We prospectively surveyed 210 pediatricians before and 18 months after participation in an evidence-based, concussion education program. Pediatricians were part of a network of 38 clinically integrated practices in metro-Atlanta. Participation was mandatory for at least 1 pediatrician in each practice. We assessed pediatricians' self-reported concussion knowledge, use of guidelines, and comfort level, as well as self-reported referral patterns for computed tomography (CT) and/or emergency department (ED) evaluation of children who sustained concussion.

Results: Based on responses from 120 pediatricians participating in the 2 surveys and intervention (response rate, 57.1%), the program had significant positive effects from pre- to postintervention on knowledge of concussions (-0.26 to 0.56 on -3 to +1 scale; P < .001), guideline use (0.73-.06 on 0-6 scale; P < .01), and comfort level in managing concussions (3.76-4.16 on 1-5 scale; P < .01). Posteducation, pediatricians were significantly less likely to self-report referral for CT (1.64-1.07; P < .001) and CT/ED (4.73-3.97; P < .01), but not ED referral alone (3.07-3.09; P = ns).

Conclusions: Adoption of a multifaceted, evidence-based, education program translated into a positive modification of self-reported practice behavior for youth concussion case management. Given the surging demand for community-based youth concussion care, this program can serve as a model for improving the quality of pediatric concussion management.
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http://dx.doi.org/10.1016/j.jpeds.2017.01.045DOI Listing
May 2017

Risk of Skin and Soft Tissue Infections among Children Found to be MRSA USA300 Carriers.

West J Emerg Med 2017 Feb 27;18(2):201-212. Epub 2017 Jan 27.

Emory University, Department of Pathology, Atlanta, Georgia.

Introduction: The purpose of this study was to examine community-associated methicillin resistant (CA-MRSA) carriage and infections and determine risk factors associated specifically with MRSA USA300.

Methods: We conducted a case control study in a pediatric emergency department. Nasal and axillary swabs were collected, and participants were interviewed for risk factors. The primary outcome was the proportion of carriers among those presenting with and without a skin and soft tissue infection (SSTI). We further categorized carriers into MRSA USA300 carriers or non-MRSA USA300 carriers.

Results: We found the MRSA USA300 carriage rate was higher in children less than two years of age, those with an SSTI, children with recent antibiotic use, and those with a family history of SSTI. MRSA USA300 carriers were also more likely to have lower income compared to non-MRSA USA300 carriers and no carriers. Rates of Panton-Valentine leukocidin (PVL) genes were higher in MRSA carriage isolates with an SSTI, compared to MRSA carriage isolates of patients without an SSTI. There was an association between MRSA USA300 carriage and presence of PVL in those diagnosed with an abscess.

Conclusion: Children younger than two years were at highest risk for MRSA USA300 carriage. Lower income, recent antibiotic use, and previous or family history of SSTI were risk factors for MRSA USA300 carriage. There is a high association between MRSA USA300 nasal/axillary carriage and presence of PVL in those with abscesses.
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http://dx.doi.org/10.5811/westjem.2016.10.30483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5305125PMC
February 2017

Emergency Department Return Visits Resulting in Admission: Do They Reflect Quality of Care?

Am J Med Qual 2016 11 9;31(6):541-551. Epub 2015 Jul 9.

Emory University, Atlanta, GA.

Prior studies have suggested that emergency department (ED) return visits resulting in admission may be a more robust quality indicator than all 72-hour returns. The objective was to evaluate factors that contribute to admission within 72 hours of ED discharge. Each return visit resulting in admission was independently reviewed by 3 physicians. Analysis was by descriptive statistics. Of 45 071 ED discharges, 4.1% returned within 72 hours; 0.96% returned for related reasons and were admitted to wards (91.2%), intensive care units (6.5%), or operating rooms (1.2%). Management was acceptable in 92.6%, suboptimal in 7.4%. Admissions were illness (94.9%), patient (1.6%), and physician related (3.5%). Almost all admissions within 72 hours after ED discharge are illness related, including all intensive care unit admissions and the majority of operating room admissions. Deficiencies in ED care are rarely the reason for admission on return. ED return visits resulting in admission may not be reflective of ED quality of care.
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http://dx.doi.org/10.1177/1062860615594879DOI Listing
November 2016

Rotavirus vaccination rate disparities seen among infants with acute gastroenteritis in Georgia.

Ethn Health 2017 12 14;22(6):585-595. Epub 2016 Oct 14.

a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA.

Objective: Rotavirus (RV) is one of the most common diarrheal diseases affecting children less than 5 years of age. RV vaccines have greatly reduced this burden in the United States. The purpose of this study was to determine possible disparities and socio-economic differences in RV vaccination rates.

Design: Children with acute gastroenteritis were enrolled. Stool was tested for presence of rotavirus using an enzyme immunoassay kit. Vaccination records were abstracted from the state immunization registry and healthcare providers to examine complete and incomplete vaccination status. Cases were identified as children receiving a complete RV dose series and controls were identified as children with incomplete RV doses. A logistic regression model was used to determine disparities seen amongst children with incomplete vaccination status.

Results: Racial differences between Black and white infants for RV vaccination rates were not significant when controlling for covariates (OR 1.15, 95% CI 0.74-1.78); however ethnicity (p-value .0230), age at onset of illness (p-value .0004), birth year (p-value < .0001), and DTaP vaccination status (p-value < .0001) were all significant in determining vaccination status for children.

Conclusions: Racial disparities and socio-economic differences are not determinants in rotavirus vaccination rates; however, age and ethnicity have an effect on RV vaccine status.
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http://dx.doi.org/10.1080/13557858.2016.1244744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314174PMC
December 2017

Improving Discharge Instructions in a Pediatric Emergency Department: Impact of a Quality Initiative.

Pediatr Emerg Care 2017 Jan;33(1):10-13

From the *Emory University School of Medicine; †Children's Healthcare of Atlanta, Atlanta, GA.

Background: Effective communication between physician and patient is essential to optimize care after discharge from the emergency department (ED). Written discharge care instructions (DCI) complement verbal instructions and have been shown to improve communication and patient management. In 2012, Centers for Medicare and Medicaid Services proposed a quality measure (OP-19) that assesses compliance with key elements considered essential for high-quality written DCI.

Objective: To evaluate the impact of a QI intervention on improving quality of written DCI in a pediatric emergency department (PED).

Methods: A QI initiative was conducted at a tertiary PED with greater than 60,000 annual visits. Based on Centers for Medicare and Medicaid Services OP-19 measure and group consensus, 8 elements were defined a priori as requisites for good quality DCI. These elements are:Providers reviewed a random sample of DCI of patients. Proportion of DCI that had each element documented was compared between preintervention phase (PRE) and postintervention phase (POST).

Results: Three hundred twenty-nine DCI (PRE) and 1434 DCI (POST) were reviewed. The POST DCI showed statistically significant improvement for each of the 8 elements. The bundle measure (proportion containing all 8 elements) increased from 23% (PRE) to 79% (POST) (P < 0.001).

Conclusions: The ED DCI improved in all 8 elements after a QI intervention. A detailed DCI at ED discharge enhances the patient's ability to comply with postdischarge treatment plan. Further studies are needed to evaluate the impact of improving DCI on ED return rates and other outcomes.
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http://dx.doi.org/10.1097/PEC.0000000000000816DOI Listing
January 2017

Sustained Effectiveness of Monovalent and Pentavalent Rotavirus Vaccines in Children.

J Pediatr 2016 05 28;172:116-120.e1. Epub 2016 Feb 28.

Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA.

Objective: Using case-control methodology, we measured the vaccine effectiveness (VE) of the 2-dose monovalent rotavirus vaccine (RV1) and 3-dose pentavalent rotavirus vaccine (RV5) series given in infancy against rotavirus disease resulting in hospital emergency department or inpatient care.

Study Design: Children were eligible for enrollment if they presented to any 1 of 3 hospitals in Atlanta, Georgia with diarrhea ≤10 days duration during January-June 2013 and were born after RV1 introduction. Stool samples were tested for rotavirus by enzyme immunoassay and immunization records were obtained from providers and the state electronic immunization information system. Case-subjects (children testing rotavirus antigen-positive) were compared with children testing rotavirus antigen-negative.

Results: Overall, 98 rotavirus-case subjects and 175 rotavirus-negative controls were enrolled. Genotype G12P[8] predominated (n = 87, 89%). The VE of 2 RV1 doses was 84% (95% CI 38, 96) among children aged 8-23 months and 82% (95% CI 41, 95) among children aged ≥24 months. For the same age groups, the VE of 3 RV5 doses was 80% (95% CI 27, 95) and 87% (95% CI 22, 98), respectively.

Conclusions: Under routine use, the RV1 and RV5 series were both effective against moderate-to-severe rotavirus disease during a G12P[8] season, and both vaccines demonstrated sustained protection beyond the first 2 years of life.
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http://dx.doi.org/10.1016/j.jpeds.2016.01.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5040162PMC
May 2016

Association between mixed rotavirus vaccination types of infants and rotavirus acute gastroenteritis.

Vaccine 2015 Oct 29;33(42):5670-5677. Epub 2015 Aug 29.

Emory University, Department of Pathology and Laboratory Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA.

Introduction: Rotavirus remains the leading cause of severe diarrhea in children under 5 years worldwide. In the US, Rotarix (RV1) and RotaTeq (RV5), have been associated with reductions in and severity of rotavirus disease. Studies have evaluated the impact of RV1 or RV5 but little is known about the impact of incomplete or mixed vaccination upon vaccine effectiveness.

Methods: Case control study to examine association of combined RV1 and RV5 and rotavirus acute gastroenteritis, factoring severity of diarrheal disease. Children born after March 1, 2009 with acute gastroenteritis from three pediatric hospitals in Atlanta, Georgia were approached for enrollment. Survey was administered, stool specimen was collected, and vaccination records were obtained.

Results: 891 of 1127 children with acute gastroenteritis were enrolled. Stool specimens were collected from 708 for rotavirus testing; 215 stool samples tested positively for rotavirus. Children >12 months of age were more likely to have rotavirus. Children categorized with Vesikari score of >11 were almost twice as likely to be rotavirus positive. Prior rotavirus vaccination decreased the mean Vesikari score, p<0.0001. Children with complete single type vaccination were protected against rotavirus (OR 0.21, 95% CI: 0.14-0.31, p<0.0001).

Conclusion: Complete rotavirus vaccination with a single vaccine type resulted in protection against rotavirus diarrhea and decrease in severity of rotavirus gastroenteritis. Incomplete rotavirus vaccination either with a single vaccine or mixed vaccination types also provided some protection.
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http://dx.doi.org/10.1016/j.vaccine.2015.08.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444377PMC
October 2015

Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency.

Pediatrics 2015 Sep 10;136(3):e670-9. Epub 2015 Aug 10.

Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Background And Objectives: Variability in practice patterns and resource use in the emergency department (ED) can affect costs without affecting outcomes. ED quality measures have not included resource use in relation to ED outcomes and efficiency. Our objectives were to develop a tool for comprehensive physician feedback on practice patterns relative to peers and to study its impact on resource use, quality, and efficiency.

Methods: We evaluated condition-specific resource use (laboratory tests; imaging; antibiotics, intravenous fluids, and ondansetron; admission) by physicians at 2 tertiary pediatric EDs for 4 common conditions (fever, head injury, respiratory illness, gastroenteritis). Resources used, ED length of stay (efficiency measure), and 72-hour return to ED (return rate [RR]) (balancing measure) were reported on scorecards with boxplots showing physicians their practice relative to peers. Quarterly scorecards were distributed for baseline (preintervention, July 2009-August 2010) and postintervention (September 2010-December 2011). Preintervention, postintervention, and trend analyses were performed.

Results: In 51 450 patient visits (24 834 preintervention, 26 616 postintervention) seen by 96 physicians, we observed reduced postintervention use of abdominal and pelvic and head computed tomography scans, chest radiographs, intravenous antibiotics, and ondansetron (P < .01 for all). Hospital admissions decreased from 7.4% to 6.7% (P = .002), length of stay from 112 to 108 minutes (P < .001), and RR from 2.2% to 2.0%. Trends for use of laboratory tests and intravenous antibiotics showed significant reduction (P < .001 and P < .05, respectively); admission trends increased, and trends for use of computed tomography scans and plain abdominal radiographs showed no change.

Conclusions: Physician feedback on practice patterns relative to peers results in reduction in resource use for several common ED conditions without adversely affecting ED efficiency or quality of care.
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http://dx.doi.org/10.1542/peds.2014-2363DOI Listing
September 2015

Decline in Pneumococcal Nasopharyngeal Carriage of Vaccine Serotypes After the Introduction of the 13-Valent Pneumococcal Conjugate Vaccine in Children in Atlanta, Georgia.

Pediatr Infect Dis J 2015 Nov;34(11):1168-74

From the *Emory University School of Medicine, Atlanta, Georgia; †Children's Healthcare of Atlanta, Atlanta, Georgia; ‡Women and Children's Hospital of Buffalo, University at Buffalo, The State University of New York, Buffalo, New York; §Georgia Emerging Infections Program, Atlanta, Georgia; ¶Veterans Affairs Medical Center, Atlanta, Georgia; and ‖Division of Bacterial Diseases, Respiratory Diseases Branch, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia. Ankita P. Desai, MD is currently at the Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio.

Background: Streptococcus pneumoniae (SP) serotype distribution among nasopharyngeal (NP) carriage isolates changed significantly after the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). We evaluated the impact on NP carriage and invasive disease of SP after the introduction of the 13-valent PCV (PCV13) in March 2010.

Methods: NP swabs were collected from children 6-59 months of age in an emergency department from July 2010 to June 2013. After broth enrichment, samples were cultured for SP and isolates were serotyped. Clinical and immunization records were reviewed. Findings during 6 sequential 6-month study periods were compared. Surveillance isolates of invasive disease isolates were reviewed.

Results: A total of 2048 children were enrolled, and 656 (32%) were SP carriers. Mean age of carriers was 27 months, 54% were males. Carriage was higher among day-care attendees (P < 0.01) and children with respiratory tract illnesses (P < 0.5) and otitis media (P < 0.01). Commonly carried serotypes included 35B (15.2%), 15B/C (14.2%), 19A (9.6%), 11A (8%), 23B (5.6%), 6C (5.3%), 21 (5%), and 15A (5%); 13.9% were PCV13 serotypes. The proportion of children with SP carriage remained stable but the serotype distribution changed during the study period. Among carriers, PCV13 serotypes declined from 29% (36/124) to 3% (3/99; P < 0.0001), predominantly because of decline of serotype 19A from 25.8% (32/124) to 3% (3/99; P < 0.0001); non-PCV13 serotypes (excluding 6C) increased from 68.4% (78/114) to 97% (95/98; P < 0.0001); serotype 35B significantly increased from 8.9% (11/124) to 25.3% (25/99; P < 0.05). Nonsusceptibility to ceftriaxone declined from 22.6% (28/124) to 0% (0/99; P < 0.0001), with a similar decline in penicillin nonsusceptibility.

Conclusions: Introduction of PCV13 for universal infant use was associated with significant reductions in nasopharyngeal carriage of PCV13 serotypes and resistant strains. Carriage of non-PCV13 serotypes increased modestly, particularly serotype 35B. Further investigation is warranted to determine whether nonvaccine pneumococcal serotypes carried in the nasopharynx are associated with significant replacement disease.
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http://dx.doi.org/10.1097/INF.0000000000000849DOI Listing
November 2015

Variation in pediatric emergency department care of sickle cell disease and fever.

Acad Emerg Med 2015 Apr 16;22(4):423-30. Epub 2015 Mar 16.

The Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.

Objectives: The objective was to study the variation in pediatric emergency department (PED) practice patterns for evaluation and management of children with sickle cell disease (SCD) and fever in U.S. children's hospitals.

Methods: A cross-sectional study of visits by children 3 months to 18 years of age with SCD and fever evaluated in 36 U.S. children's hospital PEDs within the 2010 Pediatric Health Information System database. The main outcome measures were the proportions of SCD visits that received evaluation (laboratory testing and chest radiographs [CXRs]) and treatment (parenteral administration of antibiotics) and were admitted for fever.

Results: Of the 4,853 PED visits for SCD and fever, 91.7% had complete blood counts (CBCs), 93.8% had reticulocyte counts, 93% had blood cultures obtained, 68.5% had CXRs, and 91.7% received antibiotics. Most (81.4%) patients received the recommended National Heart, Lung and Blood Institute evaluation (CBC, reticulocyte count, and blood culture) and treatment (parenteral antibiotics). In multivariate regression modeling controlling for hospital- and patient-level effects, age groups ≥1 to <5 years (odds ratio [OR] = 0.32, 95% confidence interval [CI] = 0.25 to 0.40) and ≥5 to <13 years (OR = 0.40, 95% CI = 0.32 to 0.50), and those visits that did not have CXRs had lower odds of hospital admission. After adjusting for age, payor status, receipt of laboratory testing, antibiotics, and CXRs, admission rates varied by sevenfold across U.S. children's hospitals (p < 0.001).

Conclusions: Standardization of practice exists across children's hospitals regarding obtaining laboratory studies and administering antibiotics for patients with SCD and fever. However, admission rates vary significantly. Evaluating the causes and consequences of such significant variation needs further exploration to improve the quality of care for patients with SCD.
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http://dx.doi.org/10.1111/acem.12626DOI Listing
April 2015

Management of febrile neonates in US pediatric emergency departments.

Pediatrics 2014 Feb 27;133(2):187-95. Epub 2014 Jan 27.

Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia;

Background: Blood, urine, and cerebrospinal fluid cultures and admission for antibiotics are considered standard management of febrile neonates (0-28 days). We examined variation in adherence to these recommendations across US pediatric emergency departments (PEDs) and incidence of serious infections (SIs) in febrile neonates.

Methods: Cross-sectional study of neonates with a diagnosis of fever evaluated in 36 PEDs in the 2010 Pediatric Health Information System database. We analyzed performance of recommended management (laboratory testing, antibiotic use, admission to hospital), 48-hour return visits to PED, and diagnoses of SI.

Results: Of 2253 neonates meeting study criteria, 369 (16.4%) were evaluated and discharged from the PED; 1884 (83.6%) were admitted. Recommended management occurred in 1497 of 2253 (66.4%; 95% confidence interval, 64.5-68.4) febrile neonates. There was more than twofold variation across the 36 PEDs in adherence to recommended management, recommended testing, and recommended treatment of febrile neonates. There was significant variation in testing and treatment between admitted and discharged neonates (P < .001). A total of 269 in 2253 (11.9%) neonates had SI, of whom 223 (82.9%; 95% confidence interval, 77.9-86.9) received recommended management.

Conclusions: There was wide variation across US PEDs in adherence to recommended management of febrile neonates. One in 6 febrile neonates was discharged from the PED; discharged patients were less likely to receive testing or antibiotic therapy than admitted patients. A majority of neonates with SI received recommended evaluation and management. High rates of SI in admitted patients but low return rates for missed infections in discharged patients suggest a need for additional studies to understand variation from the current recommendations.
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http://dx.doi.org/10.1542/peds.2013-1820DOI Listing
February 2014

Effectiveness of monovalent and pentavalent rotavirus vaccine.

Pediatrics 2013 Jul 17;132(1):e25-33. Epub 2013 Jun 17.

Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Objective: Previous US evaluations have not assessed monovalent rotavirus vaccine (RV1, a G1P[8] human rotavirus strain) effectiveness, because of its later introduction (2008). Using case-control methodology, we measured the vaccine effectiveness (VE) of the 2-dose RV1 and 3-dose pentavalent vaccine (RV5) series against rotavirus disease resulting in hospital emergency department or inpatient care.

Methods: Children were eligible for enrollment if they presented to 1 of 5 hospitals (3 in Georgia, 2 in Connecticut) with diarrhea of ≤10 days' duration during January through June 2010 or 2011, and were born after RV1 introduction. Stools were collected; immunization records were obtained from providers and state electronic immunization information system (IIS). Case-subjects (children testing rotavirus antigen-positive) were compared with 2 control groups: children testing rotavirus negative and children selected from IIS.

Results: Overall, 165 rotavirus-case subjects and 428 rotavirus-negative controls were enrolled. Using the rotavirus-negative controls, RV1 VE was 91% (95% confidence interval [CI] 80 to 95) and RV5 VE was 92% (CI 75 to 97) among children aged ≥8 months. The RV1 VE against G2P[4] disease was high (94%, CI 78 to 98), as was that against G1P[8] disease (89%, CI 70 to 96). RV1 effectiveness was sustained among children aged 12 through 23 months (VE 91%; CI 75 to 96). VE point estimates using IIS controls were similar to those using rotavirus-negative controls.

Conclusions: RV1 and RV5 were both highly effective against severe rotavirus disease. RV1 conferred sustained protection during the first 2 years of life and demonstrated high effectiveness against G2P[4] (heterotypic) disease.
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http://dx.doi.org/10.1542/peds.2012-3804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4074617PMC
July 2013

Methicillin-resistant Staphylococcus aureus colonization among pediatric health care workers from different outpatient settings.

Am J Infect Control 2013 Sep 20;41(9):841-3. Epub 2013 Feb 20.

Department of Pediatrics, Morehouse School of Medicine, Atlanta, GA 30310, USA.

Staphylococcus aureus colonization rates in pediatric health care workers from different types of outpatient settings were determined from December 2008 through May 2010. Colonization rates for Staphylococcus aureus and, specifically, methicillin-resistant Staphylococcus aureus (MRSA) rates were similar to the rates that have been reported for the general population. The predominant MRSA pulsed-field gel electrophoresis type associated with colonization in these health care workers is not MRSA USA300.
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http://dx.doi.org/10.1016/j.ajic.2012.11.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3759650PMC
September 2013

Physician performance assessment using a composite quality index.

Stat Med 2013 Jul 26;32(15):2661-80. Epub 2012 Dec 26.

H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA.

Assessing physician performance is important for the purposes of measuring and improving quality of service and reducing healthcare delivery costs. In recent years, physician performance scorecards have been used to provide feedback on individual measures; however, one key challenge is how to develop a composite quality index that combines multiple measures for overall physician performance evaluation. A controversy arises over establishing appropriate weights to combine indicators in multiple dimensions, and cannot be easily resolved. In this study, we proposed a generic unsupervised learning approach to develop a single composite index for physician performance assessment by using non-negative principal component analysis. We developed a new algorithm named iterative quadratic programming to solve the numerical issue in the non-negative principal component analysis approach. We conducted real case studies to demonstrate the performance of the proposed method. We provided interpretations from both statistical and clinical perspectives to evaluate the developed composite ranking score in practice. In addition, we implemented the root cause assessment techniques to explain physician performance for improvement purposes.
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http://dx.doi.org/10.1002/sim.5710DOI Listing
July 2013

Pneumococcal carriage and invasive disease in children before introduction of the 13-valent conjugate vaccine: comparison with the era before 7-valent conjugate vaccine.

Pediatr Infect Dis J 2013 Feb;32(2):e45-53

Emory University School of Medicine, Atlanta, GA, USA.

Background: Nasopharyngeal (NP) carriage and invasive pneumococcal disease (IPD) attributable to serotypes in the 7-valent pneumococcal conjugate vaccine (PCV7) declined dramatically after vaccine introduction, whereas non-PCV7 serotypes increased modestly. Characteristics of pneumococcal carriage and IPD among children in Atlanta, GA, were compared during 2 time periods: before PCV7 introduction and before 13-valent PCV (PCV13) introduction.

Methods: NP swabs from 231 and 451 children 6-59 months old receiving outpatient medical care were obtained in 1995 and 2009, respectively. A total of 202 and 47 IPD cases were identified in children younger than 5 years of age in 1995 and in 2008 to 2009, respectively, through active, population-based surveillance in Atlanta. Isolates were serotyped, sequence-typed (ST) and tested for antimicrobial susceptibility.

Results: Forty percent (93/231) of children in 1995 and 31% (139/451) in 2009 were colonized with Streptococcus pneumoniae; 60% and 0.7% were PCV7 serotypes, respectively. In 1995, PCV7 serotypes accounted for 83% and 19A accounted for 5% of IPD compared with no PCV7 serotypes and 19A accounting for 49% of IPD in 2009 (P < 0.001). In 2009, PCV13 serotypes accounted for 22% of carriage (mostly 19A) and 60% of invasive isolates (P < 0.001). ST320 accounted for 66% and 52% of 19A carriage and IPD isolates in 2009, respectively; all ST320 isolates were multidrug-resistant. No ST320 NP or IPD isolates were identified before PCV7.

Conclusions: Serotype distribution among NP and IPD isolates in Atlanta has shifted to non-PCV7 serotypes; 19A was the leading serotype for both. The multidrug-resistant ST320 strain was responsible for two-thirds of 19A carriage isolates and half of IPD isolates. The predominance of serotype 19A in carriage and IPD among children in Atlanta highlights the potential direct and indirect benefits anticipated by implementation of PCV13 in the community.
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http://dx.doi.org/10.1097/INF.0b013e3182788fddDOI Listing
February 2013

Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency department.

Pediatr Emerg Care 2012 Oct;28(10):1013-6

Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30329, USA.

Objective: To describe the management of afebrile neonatal skin and soft tissue infections (SSTIs) in the pediatric emergency department (PED).

Methods: This is a retrospective cohort study of all patients aged 0 to 28 days seen in the PED for SSTIs from 2004 to 2010. The SSTIs were identified from the International Classification of Diseases, Ninth Revision codes of pustulosis, cellulitis, and abscess. Records were reviewed to determine the absence of fever; anatomical location; cultures of blood, urine, and cerebrospinal fluid; antibiotic usage; and return visits. Data were analyzed to compare admitted versus discharged patients with SSTI subtypes.

Results: Of the 136 neonates identified, 104 met inclusion criteria. Afebrile SSTIs included 8 pustulosis, 45 cellulitis, and 51 abscesses. Blood cultures were obtained in 13% of pustulosis, 96% of cellulitis, and 69% of abscesses. No serious bacterial infection was noted. Three blood cultures grew contaminants. Parenteral antibiotics for neonates with pustulosis, cellulitis, and abscesses were given in 13%, 87%, and 59%, respectively. Admission rates for neonates with pustulosis, cellulitis, and abscesses were 13%, 84%, and 55%, respectively. Cases of cellulitis were more likely to have blood cultures drawn (odds ratio [OR], 13.7; 95% confidence interval [CI], 3.03-62.3), receive intravenous antibiotics (OR, 5.87; 95% CI, 2.16-15.0), and be admitted to the hospital (OR, 5.62; 95% CI, 2.16-14.6) as compared with the other SSTI subtypes.

Conclusions: None of the neonates who had cultures drawn had serious bacterial infection. The SSTI subtype correlated with the extent of evaluation and dispositions. The findings of this study will help with management strategies for afebrile neonates with SSTIs in the PED.
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http://dx.doi.org/10.1097/PEC.0b013e31826caaacDOI Listing
October 2012

Empiric treatment of sexually transmitted infections in a pediatric Emergency Department: are we making the right decisions?

Am J Emerg Med 2012 Oct 12;30(8):1588-90. Epub 2011 Dec 12.

Department of Pediatrics, Division of Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30329, USA.

Objective: Limited recommendations address empiric versus delayed treatment of pediatric patients for sexually transmitted infections (STIs). This study investigates how frequently empiric STI treatment correlated with subsequent positive test results in an urban, high-risk pediatric emergency department (PED).

Methods: A retrospective chart review was performed on patients 18 years and younger who presented to an urban PED and had testing for Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT).

Results: The positivity rate for STI among the 198 patients who met inclusion criteria was 28%. In 130 patients (66%), providers' management decision regarding use of empiric antibiotics correlated with subsequent test results. 45 patients (23%) received unnecessary antibiotics. Of the 23 patients (12%) who were positive for STI, but did not receive treatment, 43% (10) had difficulties with followup.

Conclusions: Providers in high-risk pediatric populations with unreliable patient follow-up should consider having a low threshold for empiric treatment. Development of clinical decision rules and/or strategies to improve patient follow-up may help optimize empiric STI treatment decisions in the PED.
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http://dx.doi.org/10.1016/j.ajem.2011.09.028DOI Listing
October 2012

Haemophilus influenzae type b carriage among young children in metropolitan Atlanta in the context of vaccine shortage and booster dose deferral.

Clin Vaccine Immunol 2011 Dec 19;18(12):2178-80. Epub 2011 Oct 19.

Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, Atlanta, Georgia 30329, USA.

Short-term deferral of the Haemophilus influenzae type b (Hib) vaccine booster dose during a recent U.S. Hib vaccine shortage did not result in widespread Hib carriage in Atlanta, as the Hib carriage rate was found to be 0.3% (1/342). Hib colonization was significantly more common among males and day care attendees.
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http://dx.doi.org/10.1128/CVI.05254-11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3232693PMC
December 2011

sodC-based real-time PCR for detection of Neisseria meningitidis.

PLoS One 2011 May 5;6(5):e19361. Epub 2011 May 5.

Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.

Real-time PCR (rt-PCR) is a widely used molecular method for detection of Neisseria meningitidis (Nm). Several rt-PCR assays for Nm target the capsule transport gene, ctrA. However, over 16% of meningococcal carriage isolates lack ctrA, rendering this target gene ineffective at identification of this sub-population of meningococcal isolates. The Cu-Zn superoxide dismutase gene, sodC, is found in Nm but not in other Neisseria species. To better identify Nm, regardless of capsule genotype or expression status, a sodC-based TaqMan rt-PCR assay was developed and validated. Standard curves revealed an average lower limit of detection of 73 genomes per reaction at cycle threshold (C(t)) value of 35, with 100% average reaction efficiency and an average R(2) of 0.9925. 99.7% (624/626) of Nm isolates tested were sodC-positive, with a range of average C(t) values from 13.0 to 29.5. The mean sodC C(t) value of these Nm isolates was 17.6±2.2 (±SD). Of the 626 Nm tested, 178 were nongroupable (NG) ctrA-negative Nm isolates, and 98.9% (176/178) of these were detected by sodC rt-PCR. The assay was 100% specific, with all 244 non-Nm isolates testing negative. Of 157 clinical specimens tested, sodC detected 25/157 Nm or 4 additional specimens compared to ctrA and 24 more than culture. Among 582 carriage specimens, sodC detected Nm in 1 more than ctrA and in 4 more than culture. This sodC rt-PCR assay is a highly sensitive and specific method for detection of Nm, especially in carriage studies where many meningococcal isolates lack capsule genes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0019361PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088665PMC
May 2011

Physician practice variation in the pediatric emergency department and its impact on resource use and quality of care.

Pediatr Emerg Care 2010 Dec;26(12):902-8

Department of Pediatrics, Emory University, Atlanta, GA, USA.

Objective: To evaluate variation in case-mix adjusted resource use among pediatric emergency department (ED) physicians and its correlation with ED length of stay (LOS) and return rates.

Methods: Resource use patterns at 2 EDs for 36 academic physicians (163,669 patients at ED1) and 45 private physicians (289,199 patients at ED2) from 2003 to 2006 were abstracted for common laboratory tests, imaging studies, intravenous therapy (fluids/antibiotics), LOS and 72-hour return rate for discharged patients, and hospital admissions for all patients. Case-mix adjustment was based on triage acuity, diagnostic category, demographics, and temporal measures.

Outcome Measures: (1) adjusted overall resource use for ED1 and ED2 physicians and (2) observed-to-expected ratios for ED1 physicians.

Results: Case-mix adjusted hospital admission rates among physicians varied nearly 3-fold (6.3%-18%) for ED1 and 8-fold (2.5%-19.4%) for ED2. Intravenous therapy use varied 2-fold (4.9%-10.4%) at ED1 and 3-fold (3.6%-11.4%) at ED2. Emergency department 2 physicians had an almost 2-fold (10.9%-20.6%) variation in imaging use. Variation in head computed tomography use was 2-fold (1.1%-2.5%) at ED1 and 5-fold (0.9%-4.8%) at ED2. Physicians had longer than expected LOS if they had higher than expected use of laboratory tests (r, 0.41; 95% confidence interval [CI], 0.09-0.65; P < 0.05) and imaging (r, 0.48; 95% CI, 0.17-0.69; P < 0.01). Return rate was not significantly correlated with resource use in any category. Physicians with higher than expected use of laboratory tests had higher than expected use of imaging (r, 0.62; 95% CI, 0.36-0.78; P < 0.001), head computed tomography (r, 0.49; 95% CI, 0.19-0.70; P < 0.01), and intravenous therapy (r, 0.51; 95% CI, 0.20-0.71; P < 0.01).

Conclusions: Significant variation exists in physician use of common ED resources. Higher resource use was associated with increased LOS but did not reduce return to ED. Practice variation such as this may represent an opportunity to improve health care quality and decrease costs.
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http://dx.doi.org/10.1097/PEC.0b013e3181fe9108DOI Listing
December 2010

Quality initiatives in the emergency department.

Curr Opin Pediatr 2010 Jun;22(3):262-7

Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.

Purpose Of Review: To report on recent advances in quality initiatives in emergency departments (EDs), with a special focus on applicability to pediatric EDs (PED) RECENT FINDINGS: Although healthcare quality improvement has made great strides in the last couple of decades, quality improvement efforts in pediatrics have lagged behind. Over the last decade, as quality initiatives have matured in adult hospitals, there has been a downstream effect on general EDs, as system-wide clinical guidelines are usually initiated through the ED--such efforts are being reported in the literature. There is significant overlap in quality improvement efforts in adult and pediatric EDs. In this article, we review the recent relevant articles, with particular emphasis on pediatrics where appropriate.

Summary: There is an opportunity in pediatric emergency medicine to reduce practice variability, decrease cost and improve efficiency of care. There is an urgent need to report the successes and failures of these initiatives, so we can develop benchmarks and optimize services provided in the PED.
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http://dx.doi.org/10.1097/MOP.0b013e3283396fe1DOI Listing
June 2010

Making the case to improve quality and reduce costs in pediatric health care.

Pediatr Clin North Am 2009 Aug;56(4):731-43

National Outcomes Center and Children's Hospital of Wisconsin, 9000 W. Wisconsin Avenue, MS-950, Milwaukee, WI 53226, USA.

This article makes a case for the urgent need to improve health care quality and reduce costs. It provides an overview of the importance of the quality movement and the definition of quality, including the concept of clinical and operational quality. Some national drivers for quality improvement as well as drivers of escalating health care costs are discussed, along with the urgency of reducing health care costs. The link between quality and cost is reviewed using the concept of value in health care, which combines quality and cost in the same equation. The article ends with a discussion of future directions of the quality movement, including emerging concepts, such as risk-adjustment, shared responsibility for quality, measuring quality at the individual provider level, and evolving legal implications of the quality movement, as well as the concept of a shared savings model.
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http://dx.doi.org/10.1016/j.pcl.2009.05.013DOI Listing
August 2009

Pediatric quality. Preface.

Pediatr Clin North Am 2009 Aug;56(4):xxi-xxiii

Levine Children's Hospital at Carolinas Medical Center, Department of Pediatrics, PO Box 32861, Charlotte, NC 28232, USA.

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http://dx.doi.org/10.1016/j.pcl.2009.05.020DOI Listing
August 2009