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Background and Objective: Clinical pathways translate best evidence into the local context of a care setting through structured, multidisciplinary care plans. Little is known about clinical pathway programs in pediatric settings. The purpose of this study was to determine the prevalence of clinical pathway programs and describe similarities and differences., Methods: We performed a cross-sectional web survey to assess the existence of a clinical pathway program, number, type, and creation or revision of clinical pathways, and its characteristics in the 111 hospitals of the Pediatric Research in Inpatient Settings network., Results: Eighty-one hospitals responded to the survey (73% response rate). Most hospitals had a clinical pathway program (63%, n = 50 of 80) that was hospital-wide (70%, n = 35 of 50). Freestanding children's (48%, n = 39 of 81), academic (60%, n = 43 of 72), teaching hospitals (96%, n = 78 of 81) made up the largest proportion of survey respondents. There was no funding for nearly half of the programs (n = 21 of 46, 46%). Over a quarter of survey respondents reported no data collected to assess pathway utilization and/or care outcomes (n = 19 of 71, 27%)., Conclusions: Greater than half of respondents confirmed existence of a program. Freestanding, academic teaching hospitals accounted for the most responses. However, nearly half of surveyed programs were unfunded, and many are unable to measure their pathway outcomes or demonstrate improvement in care. Survey respondents were enthusiastic about participating in a national collaborative on pediatric clinical pathways., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: Dr Bakel is a coprimary investigator on a Pfizer Global Bridges grant, and the Colorado Department of Public Health and Environment supports 20% of her salary; and the other authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Background and Objectives: Croup and bronchiolitis are common reasons for hospitalization in children, and the role of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on utilization outcomes for these conditions is not well understood. To compare health care utilization including the rates of hospitalization, readmission, length of stay, and ICU admission for croup and bronchiolitis in children with and without evidence of concurrent SARS-CoV-2 infection over the pandemic period., Methods: This retrospective cohort study used inpatient and outpatient electronic health record data from PEDSnet institutions to examine health services use for children aged 30 days to 14 years with SARS-CoV-2 infection and diagnosed with croup or bronchiolitis. The time frame (March 2020-May 2022) was divided into predelta, delta, and omicron variant periods. Multivariable mixed effects logistic and log gamma regression models were used to calculate adjusted odds ratios for factors linked to utilization outcomes for children with versus without SARS-CoV-2 infections. Disease burden was described by variant time period., Results: Across all time periods, among subjects with croup and bronchiolitis, 9.65% of croup patients and 3.92% of bronchiolitis patients were SARS-CoV-2-positive. The omicron variant period had the highest number of SARS-CoV-2 cases for both croup and bronchiolitis. After controlling for patient-level variables and hospital variability, we found no statistically significant differences in utilization outcomes comparing children with and without SARS-CoV-2., Conclusions: Pediatric patients with croup and bronchiolitis and positive SARS-CoV-2 polymerase chain reaction testing did not exhibit a significant increase in hospital and ICU admissions, which may have implications for future staffing models and public health recommendations., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: Dr Rao reports previous grant support from GSK and Biofire. Dr Bakel reports current grant support from Pfizer. Dr Jhaveri is a consultant for AstraZeneca, Seqirus, and Dynavax; receives an editorial stipend from Elsevier and the Pediatric Infectious Diseases Society; and receives royalties from Up To Date/Wolters Kluwer. The other authors have indicated they have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Background and Objectives: Pediatric sepsis quality improvement in emergency departments has been well described and associated with improved survival. Acute care (non-ICU inpatient) units differ in important ways, and optimal approaches to improving sepsis processes and outcomes in this setting are not yet known. Our objective was to increase the proportion of acute care sepsis cases in our health system with initial antibiotic order-to-administration time ≤60 minutes by 20% from a baseline of 43% to 52% by December 2020., Methods: Employing the Model for Improvement with broad stakeholder engagement, we developed and implemented interventions aimed at effective intervention for sepsis cases on acute care units. We analyzed process and outcome metrics over time using statistical process control charts. We used descriptive statistics to explore differences in antibiotic order-to-administration time and inform ongoing improvement., Results: We cared for 187 patients with sepsis over the course of our initiative. The proportion within our goal antibiotic order-to-administration time rose from 43% to 64% with evidence of special cause variation after our interventions. Of all patients, 66% experienced ICU transfer and 4% died., Conclusions: We successfully decreased antibiotic order-to-administration time. We also introduced a novel model for sepsis response systems that integrates interventions designed for the complexities of acute care settings. We demonstrated impactful local improvements in the acute care setting where quality improvement reports and success have previously been limited., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Objectives: Recent evidence suggests that measuring the procalcitonin level may improve identification of low-risk febrile infants who may not need intervention. We describe outcomes after the implementation of a febrile infant clinical pathway recommending measurement of the procalcitonin level for risk stratification., Methods: In this single-center retrospective pre-post intervention study of febrile infants aged 29 to 60 days, we used interrupted time series analyses to evaluate outcomes of lumbar puncture (LP), antibiotic administration, hospital admission, and emergency department (ED) length of stay (LOS). A multivariable logistic regression was used to evaluate the odds of LP., Results: Data were analyzed between January 2017 and December 2019 and included 740 participants. Procalcitonin use increased post-pathway implementation (PI). The proportion of low-risk infants receiving an LP decreased significantly post-PI ( P = .001). In the adjusted interrupted time series analysis, there was no immediate level change (shift) post-PI for LP (0.98 [95% confidence interval (CI): 0.49-1.97]), antibiotics (1.17 [95% CI: 0.56-2.43]), admission (1.07 [95% CI: 0.59-1.96]), or ED LOS (1.08 [95% CI: 0.92-1.28]), and there was no slope change post-PI versus pre-PI for any measure (LP: 1.01 [95% CI: 0.94-1.08]; antibiotics: 1.00 [95% CI: 0.93-1.08]; admission: 1.03 [95% CI: 0.97-1.09]; ED LOS: 1.01 [95% CI: 0.99-1.02]). More patients were considered high risk, and fewer had incomplete laboratory test results post-PI ( P < .001). There were no missed serious bacterial infections. A normal procalcitonin level significantly decreased the odds of LP ( P < .001)., Conclusions: Clinicians quickly adopted procalcitonin testing. Resource use for low-risk infants decreased; however, there was no change to resource use for the overall population because more infants underwent laboratory evaluation and were classified as high risk post-PI., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: The American Academy of Pediatrics published bronchiolitis clinical practice guidelines in 2014 recommending against the routine use of bronchodilators, chest radiographs, or respiratory viral testing in children with a clinical diagnosis of bronchiolitis. Our aim in this project was to align care with the American Academy of Pediatrics clinical practice guidelines by decreasing the overuse of these interventions., Methods: This study included patients who were admitted to a non-ICU setting with a primary or secondary diagnosis of bronchiolitis. The team used a multidisciplinary kickoff event to understand the problem and develop interventions, including sharing provider-specific data and asking providers to sign a pledge to reduce use. We used a novel, real-time data dashboard to collect and analyze data., Results: Special cause variation on control charts indicated improvement for all outcomes for inpatients during the intervention season. Pre- and postanalyses in which we compared baseline to intervention values for all admitted patients and patients who were discharged from the emergency department or urgent care revealed a significant reduction in the ordering of chest radiographs (from 22.7% to 13.6%; P ≤ .001), respiratory viral testing (from 12.5% to 9.8%; P = .001), and bronchodilators (from 17.5% to 10.3%; P = .001) without changes in balancing measures (eg, hospital readmission within 7 days [1.7% (preanalysis) and 1.0% (postanalysis); P = .21]) for bronchiolitis., Conclusions: This multidisciplinary improvement initiative resulted in a significant reduction in use for bronchiolitis care at our institution. Our approach, which included a novel, real-time data dashboard and interventions such as individual providers pledging to reduce use, may have the potential to reduce overuse in other settings and diseases., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background and Objectives: Guideline recommendations for the same clinical condition may vary. The purpose of this study was to determine the degree of agreement among comparable asthma and bronchiolitis treatment recommendations from guidelines., Methods: National and international guidelines were searched by using guideline databases (eg, National Guidelines Clearinghouse: December 16-17, 2014, and January 9, 2015). Guideline recommendations were categorized as (1) recommend, (2) optionally recommend, (3) abstain from recommending, (4) recommend against a treatment, and (5) not addressed by the guideline. The degree of agreement between recommendations was evaluated by using an unweighted and weighted κ score. Pairwise comparisons of the guidelines were evaluated similarly., Results: There were 7 guidelines for asthma and 4 guidelines for bronchiolitis. For asthma, there were 166 recommendation topics, with 69 recommendation topics given in ≥2 guidelines. For bronchiolitis, there were 46 recommendation topics, with 21 recommendation topics provided in ≥2 guidelines. The overall κ for asthma was 0.03, both unweighted (95% confidence interval [CI]: -0.01 to 0.07) and weighted (95% CI: -0.01 to 0.10); for bronchiolitis, it was 0.32 unweighted (95% CI: 0.16 to 0.52) and 0.15 weighted (95% CI: -0.01 to 0.5)., Conclusions: Less agreement was found in national and international guidelines for asthma than for bronchiolitis. Additional studies are needed to determine if differences are based on patient preferences and values and economic considerations or if other recommendation-level, guideline-level, and condition-level factors are driving these differences., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Context: Half of children experience wheezing by age 6 years, and optimal strategies for preventing severe exacerbations are not well defined., Objective: Synthesize the evidence of the effects of daily inhaled corticosteroids (ICS), intermittent ICS, and montelukast in preventing severe exacerbations among preschool children with recurrent wheeze., Data Sources: Medline (1946, 2/25/15), Embase (1947, 2/25/15), CENTRAL., Study Selection: Studies were included based on design (randomized controlled trials), population (children ≤6 years with asthma or recurrent wheeze), intervention and comparison (daily ICS vs placebo, intermittent ICS vs placebo, daily ICS vs intermittent ICS, ICS vs montelukast), and outcome (exacerbations necessitating systemic steroids)., Data Extraction: Completed by 2 independent reviewers., Results: Twenty-two studies (N = 4550) were included. Fifteen studies (N = 3278) compared daily ICS with placebo and showed reduced exacerbations with daily medium-dose ICS (risk ratio [RR] 0.70; 95% confidence interval [CI], 0.61-0.79; NNT = 9). Subgroup analysis of children with persistent asthma showed reduced exacerbations with daily ICS compared with placebo (8 studies, N = 2505; RR 0.56; 95% CI, 0.46-0.70; NNT = 11) and daily ICS compared with montelukast (1 study, N = 202; RR 0.59; 95% CI, 0.38-0.92). Subgroup analysis of children with intermittent asthma or viral-triggered wheezing showed reduced exacerbations with preemptive high-dose intermittent ICS compared with placebo (5 studies, N = 422; RR 0.65; 95% CI, 0.51-0.81; NNT = 6)., Limitations: More studies are needed that directly compare these strategies., Conclusions: There is strong evidence to support daily ICS for preventing exacerbations in preschool children with recurrent wheeze, specifically in children with persistent asthma. For preschool children with intermittent asthma or viral-triggered wheezing, there is strong evidence to support intermittent ICS for preventing exacerbations., (Copyright © 2016 by the American Academy of Pediatrics.)

Background and Objectives: Respiratory illnesses are the leading cause of pediatric hospitalizations in the United States, and a major focus of efforts to improve quality of care. Understanding factors associated with poor outcomes will allow better targeting of interventions for improving care. The objective of this study was to identify patient and hospital factors associated with prolonged length of stay (LOS) or complications during pediatric hospitalizations for asthma or lower respiratory infection (LRI)., Methods: Cross-sectional study of hospitalizations of patients <18 years with asthma or LRI (bronchiolitis, influenza, or pneumonia) by using the nationally representative 2012 Kids Inpatient Database. We used multivariable logistic regression models to identify factors associated with prolonged LOS (>90th percentile) or complications (noninvasive ventilation, mechanical ventilation, or death)., Results: For asthma hospitalizations(n = 85 320), risks for both prolonged LOS and complications were increased with each year of age (adjusted odds ratio [AOR] 1.06, 95% confidence interval [CI] 1.05-1.07; AOR 1.05, 95% CI 1.03-1.07, respectively for each outcome) and in children with chronic conditions (AOR 4.87, 95% CI 4.15-5.70; AOR 21.20, 95% CI 15.20-29.57, respectively). For LRI hospitalizations (n = 204 950), risks for prolonged LOS and complications were decreased with each year of age (AOR 0.98, 95% CI 0.97-0.98; AOR 0.95, 95% CI 0.94-0.96, respectively) and increased in children with chronic conditions (AOR 9.86, 95% CI 9.03-10.76; AOR 56.22, 95% CI 46.60-67.82, respectively). Risks for prolonged LOS for asthma were increased in large hospitals (AOR 1.67, 95% CI 1.32-2.11) and urban-teaching hospitals (AOR 1.62, 95% CI 1.33-1.97)., Conclusions: Older children with asthma, younger children with LRI, children with chronic conditions, and those hospitalized in large urban-teaching hospitals are more vulnerable to prolonged LOS and complications. Future research and policy efforts should evaluate and support interventions to improve outcomes for these high-risk groups (eg, hospital-based care coordination for children with chronic conditions)., (Copyright © 2015 by the American Academy of Pediatrics.)

Background: The problem list is a meaningful use incentivized criterion, and >80% of patients should have 1 problem entered as structured data., Objective: The aim of the present study was to use a series of interventions to increase the use of the problem list for inpatients to >80% as measured by at least 1 hospital problem at discharge., Methods: This study was a quasi-experimental time series quality improvement trial. The primary outcome was 80% of medical and psychiatric inpatients with a problem added to the problem list before discharge. Control charts of percentage (p charts) of medical and psychiatric patients with an inpatient problem list at discharge were constructed with three-σ control limits. Control limits were revised after evidence of improvement. The charts were annotated with interventions, including increasing awareness, focused education, and timely feedback in the form of performance graphs e-mailed to providers., Results: For medical inpatients, use rose from 31% to 97% at its peak in April 2011 and continues to maintain above the goal of 80%. In psychiatry, problem list use rose from 2% initially to an average of 72% after the interventions., Conclusions: Significant gains were made with inpatient problem list usage by the medical and psychiatric teams. Our goal ascribed by meaningful use for >80% of inpatients to have a problem at discharge was met after initiation of our series of interventions., (Copyright © 2014 by the American Academy of Pediatrics.)