Hospital Pediatrics
Issue No. 2 2008
Featured Stories:
• Community Acquired Pneumonia:
A Common Problem with No Common Ground
One Hospital’s Algorithm
• Improving the Value of Healthcare:
The Role of the Hospitalist
You are the Hospitalist:
A 14 year old boy with prolonged fever,
back ulcer and pulmonary nodules
Hospital Pediatrics
Our Vision
The Section on Hospital
Medicine of the American
Academy of Pediatrics is
dedicated to the health
of all children in the
hospital setting through
advocacy, education and
service—incorporating
the core principles of
safety, effectiveness,
timeliness, efficiency, and
equitability in familycentered health care.
Our Mission
Advocacy
inside this issue...
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Letter from the chair of SOHM
Letter from the Editor
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The Section is dedicated
to being a leader in
Pediatric Hospital
Medicine — advocating
for the health and safety
of hospitalized children.
Education
The Section is dedicated to
being a leader in educating
health care providers,
patients and families.
Service
The Section is dedicated to
being a leader in identifying
the professional needs of
Pediatric Hospitalists.
Hospitalist Service Children’s Medical Center Dallas and
Children’s Medical Center Legacy at Plano Dallas, TX
Practice Profile — Susan Wu, MD, FAAP, Editor
Case: 14 Year Old Boy with Prolonged Fever, Back Ulcer and
Pulmonary Nodules
You are the Hospitalist — Lisa Zaoutis, MD, FAAP, Editor
Policy Statements and Reports
For Your Information
Community Acquired Pneumonia:
A common problem with no common ground
Hospitalists On-line — Jennifer Maniscalco, MD, FAAP, Editor
Clinical Guideline for Community Acquired Pneumonia
On the Ward — Julie Lipps Kim, MD, FAAP, Editor
Improving Value of Health Care Delivery in Pediatrics:
The Role of the Pediatric Hospitalist
Quality and Safety — Mark Shen, MD, FAAP, Editor
Complex Care — Mary Rocha, MD, MPH, FAAP, Editor
James O’Callaghan, MD, FAAP, Editor
2 | American Academy of Pediatrics
Quality, it’s not just for Hospitals
Publication of this news
journal is supported by
Mead Johnson Nutritionals.
Making the Rounds
Collaborative Developments in Complex Care
Billing and Coding Corner
Grant Recipients talk about the NICHQ Forum
What We’ve Learned
Family - Centered Care
Special Report
Child Life Specialists Join the Section on Hospital Medicine
New Membership Category
What’s New?
Subcommittee Updates
Matthew Garber, MD, FAAP
Thank You for the Opportunity
SOHM Activities
SOHM Executive
Committee
2007-2008
Letter from the Chair of SOHM
Making the Rounds
Laura Mirkinson, MD, FAAP
Laura Mirkinson, MD, FAAP
Chairperson
laura.mirkinson@gmail.com
laura.mirkinson@gmail.com
Jannifer Daru, MD, FAAP
jadaru@gmail.com
G
reetings to everyone and
welcome to summer! I always
know its summer when the
discussions about enterovirus start to
circulate—it’s that time of year. I have a
new perspective being at a rehabilitation
hospital. The summer tends to be quite
a busy time, oddly enough. We get
the referrals for children recovering
from summer injuries, encephalitis,
and elective surgeries. I used to think
summer was the slow season!
By now you are aware of the results of
our recent elections. The new incoming
member to the Executive Committee
is Dr Mathew Garber. This means that
we are losing a member of our EC—Dr
Michael Ruhlen. Mike was one of the
founding members of the SOHM back in
1999 when a small group of physicians
(of the current EC only Jack Perceley,
Mike Ruhlen and I remain) met in San
Francisco to form the interest group that
eventually morphed into the Section
on Hospital Medicine. I know I speak
for the entire EC when I say that we
will sorely miss Mike’s insight, critical
thinking and thoughtful approach to
solving problems. His contributions to
the Section have been invaluable and
have helped SOHM become the strong
and vibrant section that it is today.
Since my last message to the Section,
Child Life Professionals have been
approved as Affiliate Members of the
SOHM. Also, after much hard work, our
subcommittee on Palliative Care moved
on to become a new separate provisional
section within the AAP. My kudos to Drs
Maggie Hood and Marcia Levetown and
others for their success in achieving
section status so quickly. Their success
is well-deserved and I am certain the
section will become an important
contributor to the AAP as a whole.
Like many of you, I attended the July
Pediatric Hospital Medicine meeting
in Denver. Last year, I had the job of
overseeing the entire meeting. This
year, I got to relax, listen, and meet
more people. The joint sponsorship of
the AAP, SHM and APA has produced a
fantastic educational and professional
opportunity—every year it just gets
better. See you in 2009!
Laura Mirkinson
Yong Han, MD, FAAP
yshan@texaschildrenshospital.org
Timothy Hartzog, MD, FAAP
thartzog@mac.com
Daniel Rauch, MD, FAAP
daniel.rauch@med.nyu.edu
Michael Ruhlen, MD, FAAP
michael.ruhlen.md@promedica.org
Jack Percelay, MD, MPH, FAAP
Immediate Past Chairperson
jpercelaymd@yahoo.com
Julia Aquino, MD
Section on Residents Representative
Committee On
Hospital Care
2007-2008
Jerrold Eichner, MD, FAAP
Chairperson
jerrold.eichner@gfclinic.com
Members
Jamie Calabrese MD, FAAP
Patricia Lye MD, FAAP
Sanford Melzer MD, MBA, FAAP
Anthony Pearson-Shaver MD,
MHSA, FAAP
Section Member
Laura Mirkinson MD, FAAP
Section on Hospital Medicine
O
Thank You
Michael Ruhlen, MD, FAAP
n behalf
of the Executive
Committee of the Section on
Hospital Medicine we extend our grateful appreciation and
profound thanks to Michael Ruhlen, MD, for his years of dedication, vision,
leadership, good humor and, above all, friendship since the inception of the
Section in 1999. We will miss his clear thinking, gentle manner, and common
sense. Mike has established a great precedent for service to the Section for all
those who will follow him. He has shown through leadership and example the
richness and opportunities of pediatric hospitalist medicine.
Mike, I speak for all of your colleagues in wishing you the very best of luck in all things.
Laura J. Mirkinson, MD, FAAP
Consultants
Kurt Heiss, MD, FAAP
Section on Surgery
Jack Percelay, MD, MPH, FAAP
The Joint Commission Hospital
Professional and Technical
Advisory Committee
Liaisons
Chris Brown MS, CCLS
Child Life Council (CLC)
Lynne Lostocco
National Association of Children’s
Hospitals and Related Institutions
(NACHRI)
Barbara Meeks, RN, MSN, MBA
American Hospital Association (AHA)
Hospital Pediatrics | 3
News Journal
Editorial Board
Editor-in-Chief
Jennifer Daru, MD, FAAP
jadaru@gmail.com
General Editor
Sheldon Berkowitz, MD, FAAP
LETTER FROM THE EDITOR
Quality, it’s not just
for Hospitals
Jennifer Daru, MD, FAAP
Sheldon.Berkowitz@childrensmn.org
jadaru@gmail.com
Column Editors
talked about “Quality: Special
Considerations in Pediatric Hospitals”
during the July Pediatric Hospital
Medicine Conference in Denver. When
you are giving a lecture on something,
you always try to think of a catch-what
will interest people so they don’t think
you are boring and leave? So, I spent a
lot of time thinking about what “quality”
means. If I told my friend she had a
“quality haircut,” she probably wouldn’t
appreciate it. In fact if I told her she
went to a “quality hospital,” she probably
wouldn’t be sure if that was good or
not. But as physicians and hospitalists,
quality seems to be taking on greater and
greater meaning. As of July 1st, we were
charged with enhancing and ensuring
the quality and safety of our central
lines. We are now reporting on quality
measures for asthma and ventilator
associated pneumonias.
Billing and Coding Corner
James O’Callaghan, MD, FAAP
James.ocallaghan@seattlechildrens.org
Community Hospital Medicine
John Pope, MD, MPH, FAAP
jpope@phoenixchildrens.com
Complex Care
Mary Rocha, MD, MPH, FAAP
mr039001@bcm.edu
Critical Care Update
Linda Snelling, MD, FAAP
Linda_Snelling@brown.edu
Hospitalists On-Line
Jennifer Maniscalco, MD, FAAP
JManisca@cnmc.org
Neonatal Medicine
Ursula Kneissl, MD, FAAP
I
In this edition, and indeed with every
edition, of Hospital Pediatrics, we hope
to help you ensure the quality of your
practice. This issue we have several
articles that focus on pneumonia
(see “On the Wards” for one group’s
algorithm for care; “You are the
Hospitalist” for a case with rash and
pulmonary infiltrates and “Hospitalistson-line” for a review of the literature on
community acquired pneumonia).
Our other pieces strive to bring
something new to your practice (new
codes in “Billing and Coding Corner,”
new initiatives in our “Quality and
Safety” piece). Feel free to write in,
provide us feedback or disagree (or
agree!) with our authors.
There’s Plenty More to Say!
Jennifer Daru
ukneissl@crhc.org
On The Ward
Julie Lipps Kim, MD, FAAP
jlipps@stanford.edu
Politics and Ethics
OPEN
Practice Profile
Susan Wu, MD, FAAP
suwu@chla.usc.edu
Quality and Safety (NEW)
Mark Shen, MD, FAAP
mshen@seton.org
You Are the Hospitalist
Lisa Zaoutis, MD, FAAP
zaoutisl@email.chop.edu
Section Chairperson
Laura Mirkinson, MD, FAAP
laura.mirkinson@gmail.com
Staff Manager
Niccole Alexander, MPP
nalexander@aap.org
Division Coordinator
Ruth Podjasek, BGS
rpodjasek@aap.org
4 | American Academy of Pediatrics
WANTED: GENERAL EDITOR
After years of dedicated service to Hospital Pediatrics, Dr Sheldon Berkowitz
has stepped down as General Editor. At this time the Section is looking for
candidates to fill his position on the News Journal Editorial Board.
The General Editor is responsible for outlining objectives and requirements
for column editors, actively recruiting writers from a wide variety of
professional backgrounds, ensuring that articles meet Hospital Pediatrics
standards and guidelines, and brainstorming with other members of the
Editorial Board on future News Journal issues and projects.
Applicants must be a member of the Section on Hospital Medicine and have
demonstrated writing experience (editorial experience a plus).
For more information on the position please contact:
Jennifer Daru, MD, FAAP
Hospital Pediatrics Editor-in-Chief
jadaru@gmail.com
PRACTICE PROFILE — Susan Wu, MD, FAAP, Editor
Hospitalist Service
Children’s Medical Center Dallas and
Children’s Medical Center Legacy at Plano
Dallas, TX
Editors Note:
Interview with Vineeta Mittal, MD, FAAP,
Assistant Professor of General Pediatrics,
Division of General Pediatrics, UT
Southwestern Medical School, Children’s
Medical Center Dallas; conducted by Susan
Wu, MD, Assistant Professor of Clinical
Pediatrics, Division of General Pediatrics,
Childrens Hospital Los Angeles and
University of Southern California
Program History and Overview
The Hospitalist Service at Children’s
Medical Center Dallas was founded
six years ago and has grown rapidly
since then. Like many other hospitalist
programs, the service was established
in response to clinical service needs
resulting from new ACGME rule limiting
house staff work hours. The hospitalists
cover four floors of the 411 bed
Children’s Medical Center Dallas and in
August of 2008 will begin covering some
of the beds at the newly opened 72 bed
Children’s Medical Center Legacy in
Plano.
Ward Coverage
The general pediatrics ward is staffed by
Hospitalist Service teams and Teaching
Service teams. The number of teams
on each service varies depending on
census and season, but in general at
any given time there are 4-5 Hospitalist
Teams and 1-3 Teaching Teams. The
Teaching Service Team includes a senior
pediatric resident, up to three pediatric
interns, a sub-intern, up to three medical
students, and rotating interns from other
specialties (psychiatry, ER, anesthesia,
family practice). The Hospitalist Service
Team includes family practice residents
and sometimes nurse practitioner
students. The Teaching Service Teams
are capped at 18 patients, and the
Hospitalist Service teams are capped at
12. Additional patients above the caps
are then distributed to subspecialtybased teams.
Coverage at Children’s Medical Center
Legacy will begin with 12 beds when
the program opens in August 2008
with plans for expansion. Starting out
there will be one FTE staffing this
unit 24 hours a day. Unlike the staff
at Children’s Medical Center Dallas,
faculty at Legacy will perform consults,
co-management of subspecialty patients
and evaluation of pediatric patients in
the emergency department.
depending on interest and seniority.
Staffing for the Teaching Teams is also
supplemented by non-hospitalist faculty
in the Division of General Pediatrics.
Moonlighters also help to fill out the
Hospitalist Team shift schedule.
Asthma Short Stay Unit
Staffing
The Hospitalist Teams are staffed by
in-house attendings 24 hours a day with
day and night shifts. During the daytime
there are usually 4 hospitalists on
service, while at night time 2 hospitalists
cover. Daytime shifts start at 7 am and
end at 5 pm; nighttime shifts are from
5 pm to 7 am. One FTE generally works
The Hospitalist Service also staffs a
12-bed Asthma Short Stay Unit 24
hours per day without house staff. This
unit consists predominantly of patients
with asthma but occasionally includes
other respiratory illnesses such as
bronchiolitis. Continuous nebulizations
can be administered in this unit.
Clinical Scholars Program
PRACTICE PROFILE: IN BRIEF
Program Name
Hospitalist Service, General
Pediatrics Division
Location
Children’s Medical Center Dallas,
Children’s Medical Center Legacy
in Plano
Academic Affiliation
University of Texas Southwestern
Medical School
Areas Covered
Inpatient general pediatrics ward,
asthma short stay unit
FTEs
Currently 13, actively recruiting
Unique Aspects
Family Centered Rounds,
Asthma Short Stay Unit,
Clinical Scholar Program
14-16 shifts per month. The Teaching
Teams have house staff covering at
night with attending staff on home pager
call. Attendings on the Teaching Teams
work 14 days in a row and then work
an additional 5 shifts on the Hospitalist
Service during the second half of
the month. Each hospitalist spends
some months on the Teaching Teams
and some on the Hospitalist Teams,
Academic activities of the Hospitalist
group are strongly supported by the UT
Southwestern Department of Pediatrics
and the Division of General Pediatrics.
Most hospitalists are hired by UT
Southwestern at the Assistant Professor
level. Significant research support and
opportunities for intramural grants are
available. The division sponsors weekly
research conferences, which includes
topics such as journal club, how to write
grants, how to create a poster, and how
to write a case report. UT Southwestern
also operates a clinical research scholar
program, which provides the opportunity
for faculty to develop the skills to run
a clinical research program, while
obtaining a Masters degree in Clinical
Science.
Teaching Activities
In addition to ward attending
responsibilities, the Hospitalist Team
is very active in medical student and
resident education. The hospitalists run
a weekly conference discussing all of
the cases on the Hospitalist Teams that
week. They also participate in facilitating
senior morning reports and medical
student conferences.
Continued on page 9
Hospital Pediatrics | 5
You are the Hospitalist — Lisa Zaoutis, MD, FAAP, Editor
Case: 14 Year Old Boy with Prolonged
Fever, Back Ulcer and Pulmonary Nodules
Javier Lasa, MD, Pediatric Resident, LASAJ@email.chop.edu
Pamela Mazzeo, MD, Pediatric Resident
Lisa Zaoutis, MD, FAAP, Section Chief, Inpatient Services, zaoutisl@email.chop.edu
The Children’s Hospital of Philadelphia, Philadelphia, PA
Y
ou are the pediatric hospitalist
taking admissions on a late
summer day when you accept
a 14-year-old male with a 3-week
history of nightly fevers and a painless
lesion on his right upper back. After
obtaining a history from the Emergency
Department (ED) staff, the patient, and
his family, you learn that he initially
presented to his primary medical doctor
(PMD) 2 weeks earlier with complaints
of nightly fevers and the presence of
a right upper back lesion that was
noticed the day prior to the onset of
fevers. The back lesion was initially a
“small spot” on his right upper back
that progressed to a small abscess with
surrounding erythema. It remained
non-tender, but then spontaneously
began to drain serous fluid before
becoming a small ulcer. Culture of the
fluid by his PMD revealed methicillinsensitive Staphylococcus aureus which
was also sensitive to trimethoprimsulfamethoxazole (TMP-SMZ). After
completing a 10-day course of TMP-SMZ
with no improvement in the ulcer or
nightly fevers, the patient was referred to
the ED by his PMD.
The boy reports that his fevers were
associated with chills, myalgias and
lethargy. Other complaints include
intermittent abdominal pain, nausea,
decreased appetite, “swollen glands” in
his neck, and a 6-kilogram weight loss
since the onset of his illness. He denies
trauma, joint pain, cough, dyspnea,
emesis, diarrhea, recent travel or
possible tuberculosis exposures.
His past medical, surgical and family
history are noncontributory. The patient
lives in a wooded area with no pets
although several friends owned dogs, cats
and a rabbit (with which he had minimal
contact). He has occasionally pulled
ticks off of himself over the preceding
months but denies any rash with a red
ring or target appearance. Aside from
the recent course of TMP-SMZ, he takes
6 | American Academy of Pediatrics
no medications and denies any allergies.
He has no history of travel outside of the
United States nor contact with persons
at risk for tuberculosis (TB).
His vital signs on arrival include a
temperature of 39.8°C (102°F) orally,
heart rate 96 beats/min, blood pressure
110/65 mm Hg, respiratory rate 16
breaths/minute, and oxygen saturation
99% while on room air. The young
man is awake, alert, comfortable,
and well nourished with a nontoxic
appearance. He has a 2-cm nontender
ulcer with raised erythematous edge
and mild crusting on the right upper
back (see figures 1 and 2). On palpation
of the head and neck region, you
discover bilateral scattered nontender,
nonerythematous, mobile nodes in the
anterior and posterior cervical chains
(1-2 cm each), and one similar but larger
Figure 2: Close-up view of right upper back
lesion seen in figure 1.
Figure 1: Right upper back lesion of 14-yearold boy with 3 weeks of fever.
node in the left supraclavicular area (3.5
cm). Nodes are also palpable in the right
axilla (1 cm) and left inguinal region. His
lungs, heart, abdominal, genitourinary,
and neurologic examinations are normal
and there are no joint deformities.
Laboratory work from the ED reveals a
normal complete blood count and basic
serum chemistry panel as well as normal
serum levels of liver enzymes, lactate
dehydrogenase and uric acid. You send
cultures from blood, urine, and sputum
(acid-fast bacilli and bacterial) samples
which all return negative. In addition,
serologies and/or polymerase chain
reaction (PCR) analysis for Epstein-Barr
virus (EBV), cytomegalovirus (CMV),
human immunodeficiency virus (HIV),
Borrelia burgdorferi (Lyme), Bartonella
henselae (cat scratch), Histoplasmosis
capsulatum, and blastomyces are
all negative. A serum angiotensinconverting enzyme (ACE) level is also
within normal limits. A chest radiograph
is normal; however, a chest CT scan
reveals approximately 10 bilateral
intrapulmonary nodules varying from
2-12 mm in size as well as bilateral hilar
lymphadenopathy showing questionable
calcification.
The boy continues to spike fevers
twice daily, and on hospital day 4
you choose one of the following
tests which proves to be diagnostic.
A. Punch biopsy of right upper back
ulcer and excisional biopsy of the
supraclavicular node with pathologic
analysis and bacteriologic culture
B. Skin testing for tuberculosis via
purified protein derivative Mantoux
testing
C.Bone marrow aspirate and biopsy
D.Serologic indirect fluorescent
antibody testing for human monocytic
ehrlichiosis (HME) and for human
granulocytic anaplasmosis (HGA)
See page 8 for answer.
FOR YOUR INFORMATION
Policy Statements and Reports
Febrile Seizures: Clinical
Practice Guideline for the
Long-term Management
of the Child With Simple
Febrile Seizures
Febrile seizures are the most common
seizure disorder in childhood, affecting
2% to 5% of children between the
ages of 6 and 60 months. Simple
febrile seizures are defined as brief
(<15-minute) generalized seizures that
occur once during a 24-hour period
in a febrile child who does not have
an intracranial infection, metabolic
disturbance, or history of afebrile
seizures. This guideline (a revision of the
1999 American Academy of Pediatrics
practice parameter [now termed clinical
practice guideline] “The Long-term
Treatment of the Child With Simple
Febrile Seizures”) addresses the risks
and benefits of both continuous and
intermittent anticonvulsant therapy
as well as the use of antipyretics in
children with simple febrile seizures.
It is designed to assist pediatricians by
providing an analytic framework for
decisions regarding possible therapeutic
interventions in this patient population.
It is not intended to replace clinical
judgment or to establish a protocol for
all patients with this disorder. Rarely will
these guidelines be the only approach to
this problem.
the policy of the American Academy
of Pediatrics that graduate medical
education is a public good and is an
essential part of maintaining a highquality physician workforce. The
American Academy of Pediatrics
advocates for lifelong learning across
the continuum of medical education.
This policy statement focuses on the
financing of one component of this
continuum, namely residency education.
The statement calls on federal and state
governments to continue their support
of residency education and advocates
for stable means of funding such as the
establishment of an all-payer graduate
medical education trust fund. It further
proposes a portable authorization
system that would allocate graduate
medical education funds for direct
medical education costs to accredited
residency programs on the basis of the
selection of the program by qualified
student or residents. This system allows
the funding to follow the residents to
their program. Recognizing the critical
workforce needs of many pediatric
medical subspecialties, pediatric
surgical specialties, and other pediatric
specialty disciplines, this statement
maintains that subspecialty fellowship
training and general pediatrics research
fellowship training should receive
adequate support from the graduate
medical education financing system,
including funding from the National
Institutes of Health and other federal
agencies, as appropriate. Furthermore,
residency education that is provided in
freestanding children’s hospitals should
receive a level of support equivalent to
that of other teaching hospitals. The
financing of graduate medical education
is an important and effective tool to
ensure that the future pediatrician
workforce can provide optimal heath
care for infants, children, adolescents,
and young adults.
Committee on Pediatric Workforce
Published in Pediatrics in April 2008
http://aappolicy.aappublications.org/cgi/
content/full/pediatrics;121/4/855
Steering Committee on Quality
Improvement and Management,
Subcommittee on Febrile Seizures
Published in Pediatrics in June 2008
http://aappolicy.aappublications.org/cgi/
content/full/pediatrics;121/6/1281
Financing Graduate Medical
Education to Meet the Needs
of Children and the Future
Pediatrician Workforce
This policy statement articulates the
positions of the American Academy
of Pediatrics on graduate medical
education and the associated costs
and funding mechanisms. It reaffirms
Hospital Pediatrics | 7
Case: 14 Year Old Boy with Prolonged Fever and Back Ulcer, continued from page 6
Answer: A
On hospital day 4, this patient
undergoes both biopsies. Francisella
tularensis grows from both biopsy sites
and is confirmed by PCR testing, which
confirms the diagnosis of tularemia.
Introduction
Tularemia is an uncommon zoonotic
infection caused by the highly
infectious Gram-negative pleomorphic
bacillus Francisella tularensis.
Worldwide, more than 100 species
of animals, birds, amphibians, and
arthropods host F. tularensis. Many
animals and arthropods may carry the
organism; however, ticks (especially
Dermatocentor and Amblyomma
species) during summer months and
rabbits during winter months are the
most common vectors implicated in
cases of human infection. In addition,
domestic cats are increasingly
recognized as associated with human
tularemia. There are no recorded cases
of human-to-human transmission,
although laboratory workers are at
significant risk of the inhalational form
of the disease.
With approximately 120 cases per year
in the United States (all states except
Hawaii), only 28% of cases occur in
children aged 1 to 14 years of age.
Cases of tularemia are most commonly
reported in Arkansas, Tennessee, Texas,
Oklahoma, Kansas, Utah and Missouri.
Clinical Features
Clinical infection occurs via
inhalation, intradermal inoculation,
or oral ingestion of pathogens in
the environment. Several clinical
presentations have been described and
each form of the disease reflects the
mode of transmission: ulceroglandular,
glandular, oculoglandular,
oropharyngeal, pneumonic, and
typhoidal. The clinical presentation of
the boy presented above fits the most
common ulceroglandular form (accounts
for 80% of cases) in which a slow
healing ulcer is associated with inflamed
regional lymph nodes. The likely mode
of inoculation of the boy was through
the bite of an infected tick to his right
upper back. This case also demonstrates
more common unifying symptoms found
with tularemia with the presence of
fever, chills, myalgias, fatigue and skin
lesions. Rare manifestations include
8 | American Academy of Pediatrics
osteomyelitis, pericarditis, peritonitis,
endocarditis, and nervous system
abnormalities, including meningitis,
abscesses and optic neuritis.
Diagnostic Studies
Due to its relative infrequency and
non-specific presenting symptoms,
there is often considerable delay in
diagnosis and in initiation of effective
therapy. Routine blood culture results
are usually negative for tularemia.
Successful cultivation requires medium
that contains cysteine for growth such
as the tissue cultures used in this case.
Cultivation in the laboratory poses a
hazard for workers; thus, laboratory
personnel should be advised prior
to receipt of tissue samples about
potential tularemia cases to ensure
safe handling techniques. Additional
means of diagnosis include PCR, direct
fluorescent antibody or seroconversion
(at 2-7 weeks after exposure).
with typical SLE cutaneous lesions, and
he did not meet other criteria for the
disease.
Oncologic processes would be important
diagnostic considerations. Leukemia
and lymphoma are the childhood
cancers of particular concern based
on the patient’s lymphadenopathy and
systemic symptoms, and though bone
marrow aspirate and biopsy might
have helped establish a diagnosis, a
negative biopsy would not necessarily
exclude lymphoma. On the other hand,
the excisional tissue biopsy of the
entire enlarged supraclavicular lymph
node would likely provide important
histological information.
The presence of the ulcer on this
patient’s back made an infectious
process a strong possibility, and after
your initial laboratory evaluations,
several possible pathogens remained
Figure 3. Fever curve during hospitalization.
Differential Diagnosis
The salient characteristics of this boy’s
presentation included his systemic
symptoms (fever, weight loss, fatigue,
myalgias, nausea), his back ulcer,
and his lymphadenopathy (with an
apparent predominance in the region
of the ulcer). The differential diagnosis
would include oncologic, infectious, and
inflammatory infectious etiologies.
Based on the testing done previously,
some of the more common causes of
fever and lymphadenopathy could be
excluded: EBV and CMV mononucleosis,
HIV, cat scratch disease, Lyme disease,
and histoplasmosis and blastomyces
were ruled out on the basis of negative
titers and PCRs. Sarcoidosis is
unlikely in the context of a normal
ACE level, and though systemic lupus
erythematosus (SLE) could have
accounted for some of this patient’s
symptoms, his ulcer was not consistent
on the differential. This patient
had no history of tuberculosis (TB)
exposure and no cough, but given his
chest CT findings of bilateral hilar
lymphadenopathy and the possibility
of tuberculous lymphadenitis (scrofula)
or cutaneous TB, placing a PPD would
have been a most reasonable test
in his work-up. Ehrlichial disease
(HGA and HME) can cause systemic
symptoms, rash, and lymphadenopathy,
and it can be transmitted by ticks;
however, its characteristic rash is
usually macular, maculopaplar, or
petechial. Herpes simplex virus (HSV)
or varicella zoster virus (VZV) would
be unlikely to present with a single
cutaneous lesion, and though cutaneous
leishmaniasis can present with fever,
adenopathy, and a single ulcer, this
patient has no history of travel to
an endemic area. Ulceroglandular
tularemia, however, could account for
his systemic symptoms, his regional
lymphadenopathy, and his skin lesion.
With these considerations for the
differential diagnosis, the combination
of punch biopsy of the back ulcer
and excisional biopsy of the left
supraclavicular lymph node would be
the best choice for establishing the
diagnosis by providing both histologic
and bacteriologic information.
Treatment
Medical management of tularemia
often includes using targeted antimicrobials with symptomatic and
supportive care for accompanying
conditions. F. tularensis is naturally
resistant to penicillins and firstgeneration cephalosporins. Intravenous
gentamicin is the most effective
treatment in pediatric populations,
though fluoroquinolones may offer
similar efficacy with fewer toxicities.
Outcome
This patient defervesced promptly
on intravenous gentamicin (see
figure 3) and was discharged with
a percutaneously inserted central
catheter (PICC) to complete a 14-day
course of treatment. With no direct
exposure to an infected mammal, the
most likely route of infection for this
patient in a tick-endemic area would be
from an unrecognized tick bite to his
upper back.
Hospitalist Service, Children’s Medical Center Dallas and Children’s
Medical Center Legacy at Plano, Dallas, TX, continued from page 5
Family Centered Rounds
Family Centered Rounds has been
conducted every day on one of the
hospitalist-lead Teaching Teams since
July 2007. Participating in these bedside
rounds are the attending hospitalist,
residents and medical students, bedside
nurse, pharmacist, nutritionist, and
discharge planner. The Family Centered
Rounds faculty is actively involved
in setting up a website with resource
on Family Centered Rounds, and
conducting evaluation research studies of
the program.
Other Activities
Hospitalists at Children’s Medical
Center Dallas are involved in many
hospital administrative committees.
They take the lead in the Inpatient
Throughput committee and the
Family Centered Rounds steering
committee. In addition, several
hospitalists have been instrumental in
the implementation of the electronic
medical record system. Other groups
the hospitalists are involved in include
the Infection Control Committee,
Medical Advisory Committee, and
Patient Safety Committee. Within the
Division of General Pediatrics, there
are subcommittees as well. The Billing
Committee includes two medical billers
and three hospitalists, and creates
individual reports on billing activities
for each faculty members. The Quality
Improvement Committee evaluates
readmissions, ICU admissions/transfers,
and conducts Morbidity and Mortality
Review for the group. The Division offers
an incentive plan in addition to the basic
salary, based on certain measures. A
few members of the hospitalist group
also have outpatient responsibilities,
including one member that participates
in the Adolescent Medicine clinic and
one with infectious disease background
who works in the HIV clinic.
For more information,
contact Dr Vineeta Mittal,
Vineeta.Mittal@childrens.com
Interested in having your hospitalist
group featured in Practice Profile?
Email Susan Wu, MD, FAAP
at suwu@chla.usc.edu.
References:
Farlow J, Wagner DM, Dukerich M, Stanley M, Chu
M, Kubota K. Francisella tularensis in the United
States. Emerg Infect Dis. Dec 2005;11(12):1835-41.
Ellis J, Oyston PC, Green M, Titball RW. Tularemia.
Clin Microbiol Rev. Oct 2002;15(4):631-46.
Cunha BA. Tularemia. In: Tickborne Infectious
Diseases: Diagnosis and Management. Marcel
Dekker Inc., New York. 2000:251-68.
2008 Course on Neonatal and
Pediatric Critical Care
Transport Medicine
Interested in submitting a case for You
Are The Hospitalist? Contact Lisa Zaoutis,
MD, FAAP at zaoutisl@email.chop.edu
SPONSORED BY THE AAP SECTION ON TRANSPORT MEDICINE
WRITERS or
WANTED!!
October 12-14, 2008
Boston, Massachusetts
What’s up with you?
What’s going on in your hospital or in
your city? A conference or workshop?
An intriguing case? A new perspective,
procedure or protocol?
Come on, share!
If you have an idea for an article that
might interest your colleagues across
the continent, let us know because we’re
looking for new contributors to
Hospital Pediatrics!
Contact Jennifer Daru, Editor-in-Chief,
at jadaru@gmail.com.
held in conjunction with the AAP
National Conference & Exhibition
• Special mini-S.T.A.B.L.E. session
• Administrative and clinical tracks that include breakout
sessions on developing a communications center, newborn
case reviews, blue babies—just to name a few
• An exhibit area dedicated to transport medicine vendors
• And so much more!
Watch the Section on Transport
Medicine website at:
www.aap.org/sections/transmed
for more information.
Hospital Pediatrics | 9
HOSPITALISTS ON-LINE — Jennifer Maniscalco, MD, FAAP, Editor
Community Acquired Pneumonia:
A common problem with no common ground
Ricardo Quinonez, MD, FAAP, Faculty Inpatient Service, quinonez@bcm.edu
Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
P
neumonia is the most common
infectious cause of hospitalization
in children under five. The
World Health Organization (WHO)
estimates that there are 150.7 million
pediatric cases per year, resulting in
nearly 20 million hospitalizations.1
The costs to patients, families, and the
healthcare system are staggering if you
take into account “sick” days, missed
work, and the cost of both inpatient
and outpatient treatment.2 However,
despite being such a common diagnosis,
the evaluation and management of
community acquired pneumonia (CAP)
remains variable and based on local or
personal practice rather than available
evidence. Furthermore, the available
evidence does not answer all of the
relevant questions. This article will
review the literature with regards to
3 main components of the evaluation
and treatment of CAP: chest radiograph
(CXR), blood culture, and antibiotic
management, particularly in the
inpatient setting.
CXR is considered by many to be the
best diagnostic tool available for CAP.
However, the utility of the CXR in
the evaluation of CAP has not been
consistently demonstrated in the
available literature. A study published
in Lancet in 19983 measured the effect
of a CXR on clinical outcomes of
522 children who met the WHO case
definition for pneumonia.4 The children
were randomized into two groups—
one group had CXRs as part of the
evaluation, and the other group did not.
Management decisions were made based
on clinical data alone for those patients
in whom a radiograph was not obtained,
and based on all available data including
CXR for those in whom it was obtained.
The primary clinical outcome was
time to recovery, defined as resolution
of symptoms and determined by
structured phone interviews with
caregivers. Secondary outcomes
included final diagnosis, antibiotic and
other management, and subsequent use
10 | American Academy of Pediatrics
of health facilities (“bounce-backs”).
Time to recovery was similar in both
groups and subsequent use of health
facilities was the same. The children in
whom radiographs were obtained were
prescribed antibiotics more often while
the ones in the non-radiograph group
were given the final diagnosis of viral
pneumonia or bronchiolitis more often.3
Other studies have looked at the utility
of CXR for identifying the etiology of
pneumonia. Virkki et al. evaluated
laboratory and radiographic findings in
254 patients with CAP. An infectious
etiology was found in 85% of patients.
While they found that 71% of children
with alveolar infiltrates had bacterial
etiologies, half of the patients with
interstitial infiltrates also had bacterial
infections.5 Esposito el al. looked at
whether clinical, laboratory, or CXR
findings could differentiate pneumonia
caused by “typical pathogens” such as
Streptococcus pneumonia or “atypical
pathogens” such as Mycoplasma
pneumonia. Although their study
showed a major contribution of atypical
pathogens in children with CAP, they
failed to find any significant radiographic
differences between typical and atypical
pneumonia.6 These studies indicate
that radiographic findings in CAP do
not reliably delineate the etiology of the
infection, potentially minimizing the
impact of CXR results on management
decisions.
There is also little evidence to support
the practice of obtaining a blood culture
in patients with CAP. The Community
Acquired Pneumonia Guideline Team at
Cincinnati Children’s Hospital Medical
Center does not recommend obtaining
blood cultures on a routine basis for
CAP in the associated evidence-based
care guideline.7 This recommendation
is based on the fact that, even before
universal pneumoccocal vaccination, the
yield for blood cultures in the evaluation
of CAP in an outpatient setting was
around 2%.8
Recent data in adults has shown that the
rate of false positive blood cultures in
CAP is similar to or exceeds that of true
positives. More importantly, the true
positives infrequently led to changes in
therapy, and when therapy was changed,
the decision was rarely based on
detection of resistant organisms.9,10 Even
if you were to take only pneumococcal
pneumonias as your starting point,
the rate of positive blood cultures is
around 5%.1 If you think these odds are
favorable, consider that only about 40%
of kids hospitalized with CAP have been
shown to have S. pneumoniae as the
cause of their disease.11 Suddenly that
5% drops again to approximately 2% for
all children hospitalized with CAP.
The treatment of CAP in the inpatient
setting remains variable and often
lacking in evidence. Furthermore, as
opposed to other common pediatric
entities such as urinary tract infection
and otitis media, there are no AAP
practice guidelines for management of
CAP. The Cincinnati CAP Guideline
Team recommends high-dose amoxicillin
for children under 5 and a macrolide for
those over 5 years of age for outpatient
treatment of CAP, but they do not
make recommendations for inpatient
management.7 Many institutions use
2nd or 3rd generation cephalosporins,
instead of ampicillin, as first-line
therapy for children hospitalized with
CAP. The use of cephalosporins for the
inpatient management of pneumonia
is likely driven by concerns about the
increasing resistance of pneumococcus
to penicillin. Nationally, 15-35% of S.
pneumoniae causing CAP are resistant
to penicillin in all age groups.12 However,
the clinical relevance of this resistance
has not been shown. As a matter of fact,
the available evidence argues against
any clinical significance of streptococcal
resistance to penicillin and may actually
show a relative advantage to using
penicillin.
In adults, a prospective multi-national
study showed that the use of penicillin
or cefotaxime in discordant therapy
of pneumococcal bacteremia did
not increase mortality. Not so with
cefuroxime (a commonly used 2nd
generation cephalosporin), which
increased mortality by as much as
30%.13 More recent data demonstrated a
slight increase in adult mortality when
S. pneumoniae is penicillin resistant,
but showed that this mortality was
not influenced by the initial use of
amoxicillin. This study and others
suggest that outcomes in pneumococcal
disease are less likely related to therapy
or drug resistance and more likely
related to host factors or severity of
disease at presentation.14, 15 In children
with pneumonia, pneumococcal
resistance to antibiotics has not been
shown to affect outcomes in at least one
multi-center retrospective study.16
To date, there is no study that has
shown any clinical advantage of IV
cephalosporins over IV ampicillin
in children hospitalized with CAP.
When taking into account the costs of
transitioning children from hospital
to home, the clear advantage goes to
ampicillin. Its oral equivalent costs less
than $10 for a 10-day supply, whereas
10-day supply of an oral 2nd or 3rd
generation cephalosporin costs over
$80.17
Several studies have shown the
emergent and significant role of
atypical pathogens as the cause of
CAP even in children as young as 2
years of age.5, 11 One of these found
no significant differences between the
various treatment regiments for typical
infections, but clinical treatment failures
were frequent when children with
atypical pneumonias where not treated
with macrolides.5 These results suggest
that lowering the age threshold for
empiric treatment of atypical pathogens
may be a sound strategy.
Community acquired pneumonia
remains a significant challenge for
pediatricians. The absence of a true
“gold standard” diagnostic modality has
led to many unproven and unsupported
strategies in the evaluation and
treatment of this common inpatient
entity. Techniques currently available
for etiologic work-up of CAP, such as
PCR or serology, are often cumbersome,
time-consuming, and more useful
in a research setting than in clinical
practice. However, enough data exists to
support the creation of evidence-based
national guidelines. Such an effort could
standardize diagnostic and treatment
modalities in a cost-effective manner.
However, as is often pointed out, clinical
guidelines are just that—guidelines.
Evidence-based medicine by its very
nature ignores the “human” side of
medicine. A chest radiograph may not
always affect outcomes in pneumonia,
but its utility may be one beyond the
scope of clinical outcomes. Discussions
with parents and caregivers are always
more effective when accompanied by
visual aids. And until better tests are
available, a chest radiograph will still
remain the main diagnostic tool in our
armamentarium for the evaluation of
CAP, no matter whether the evidence
supports its use or not. Treatment
however is not bound by such concerns.
Adherence to the evidence when it
comes to treatment of CAP can reduce
costs and reserve wider spectrum
antibiotics for conditions in which they
are truly indicated.
References
1. Barson J (2008), Epidemiology, pathogenesis,
and etiology of pneumonia in children.
Retrieved May 28, 2008. from UpToDate Inc,
Web site: http://www.uptodate.com/online/
content/topic.do?topicKey=pedi_id/16558&selec
tedTitle=1~150&source=search_result
2. Shoham Y, Dagan R, Givon-Lavi N, Liss Z,
Shagan T, Zamir O, Greenberg D. Communityacquired pneumonia in children: quantifying
the burden on patients and their families
including decrease in quality of life. Pediatrics
2005;115(5):1213-9
3. Swingler GH, Hussey GD, Zwarenstein M.,
Randomised controlled trial of clinical outcome
after chest radiograph in ambulatory acute
lower-respiratory infection in children. Lancet
1998;351(9100):404-8.
4. World Health Organization. The management
of acute respiratory infections in children.
Practical Guidelines for outpatient care. Geneva:
WHO, 1995.
5. Virkki R, Juven T, Rikalainen H, Svedström
E, Mertsola J, Ruuskanen O. Differentiation
of bacterial and viral pneumonia in children.
Thorax 2002;57(5):438-41.
6. Esposito S, Bosis S, Cavagna R, Faelli N, Begliatti
E, Marchisio P, Blasi F, Bianchi C, Principi N.
Characteristics of Streptococcus pneumoniae
and atypical bacterial infections in children
2-5 years of age with community-acquired
pneumonia. Clin Infect Dis 2002;35(11):134552. Epub 2002 Nov 13.
7. Community Acquired Pneumonia Guideline
Team, Cincinnati Children’s Hospital Medical
Center: Evidence-based care guideline for
medical management of Community Acquired
Pneumonia in children 60 days to 17 years of
age, http://www.cincinnatichildrens.org/svc/
alpha/h/health-policy/ev-based/pneumonia.htm,
Guideline 14, pages 1-16, December 22, 2005.
Accessed June 13, 2008.
8. Hickey RW, Bowman MJ, Smith GA. Utility of
blood cultures in pediatric patients found to
have pneumonia in the emergency department.
Ann Emerg Med 1996;27(6):721-5.
9. Corbo J, Friedman B, Bijur P, Gallagher EJ.
Limited usefulness of initial blood cultures in
community acquired pneumonia. Emerg Med J
2004;21(4):446-8.
10.Ramanujam P, Rathlev NK . Blood cultures do
not change management in hospitalized patients
with community-acquired pneumonia. Acad
Emerg Med 2006;13(7):740-5. Epub 2006 Jun 9.
11.Michelow IC, Olsen K, Lozano J, Rollins NK,
Duffy LB, Ziegler T, Kauppila J, Leinonen M,
McCracken GH Jr. Epidemiology and clinical
characteristics of community-acquired
pneumonia in hospitalized children. Pediatrics
2004;113(4):701-7
12.Gordon KA, Biedenbach DJ, Jones RN.
Comparison of Streptococcus pneumonia
and Haemophilous influenza susceptibilities
from community-acquired pneumonia: five
year results for the SENTRY Antimicrobial
Surveillance Program. Diagn Microbiol Infect
Dis 2003;46(4): 285-9.
13.Yu VL, Chiou CC, Feldman C, Ortqvist A, Rello
J, Morris AJ, Baddour LM, Luna CM, Snydman
DR, Ip M, Ko WC, Chedid MB, Andremont A,
Klugman KP. International Pneumococcal Study
Group. An international prospective study of
pneumococcal bacteremia: correlation with
in vitro resistance, antibiotics administered,
and clinical outcome. Clin Infect Dis
2003;37(2):230-7.
14.Falcó V, Almirante B, Jordano Q, Calonge L, del
Valle O, Pigrau C, Planes AM, Gavaldà J, Pahissa
A. Influence of penicillin resistance on outcome
in adult patients with invasive pneumococcal
pneumonia: is penicillin useful against
intermediately resistant strains? J Antimicrob
Chemother 2004;54(2):481-8.
15.SR, McGee L, Jackson D, Chiou CC, Feldman
C, Morris AJ, Ortqvist A, Rello J, Luna CM,
Baddour LM, Ip M, Yu VL, Klugman KP.
International Pneumococcal Study Group.
Association of serotypes of Streptococcus
pneumoniae with disease severity and outcome
in adults: an international study. Clin Infect Dis
2007;45(1):46-51.
16.Tan TQ, Mason EO Jr, Barson WJ, Wald ER,
Schutze GE, Bradley JS, Arditi M, Givner
LB, Yogev R, Kim KS, Kaplan SL. Clinical
characteristics and outcome of children with
pneumonia attributable to penicillin-susceptible
and penicillin-nonsusceptible Streptococcus
pneumoniae. Pediatrics 1998;102(6):1369-75.
17.Cefuroxim Axetil and Amoxil, Retrieved May
29, 2008, from drugstore.com, Web site: http://
www.drugstore.com/pharmacy/prices/drugprice.
asp?ndc=63304096404&trx=1Z5006, http://
www.drugstore.com/pharmacy/prices/drugprice.
asp?ndc=00029600923&trx=1Z5006
Did a topic or conversation on the SOHM
Listserv spark your interest? If so, please
contact Jennifer Maniscalco, MD, MPH,
FAAP at jmaniscalcomd@gmail.com to
learn how to contribute to this column.
Hospital Pediatrics | 11
ON THE WARD — Julie Lipps Kim, MD, FAAP, Editor
Clinical Guideline for Community
Acquired Pneumonia
Kishore Vellody, MD, FAAP, Assistant Professor of Pediatrics
Children’s Hospital of Pittsburgh, Pittsburgh, PA
Editors Note:
Clinical guidelines are increasingly
recognized as a means to ensure quality of
care, to standardize care at an institution, to
educate young clinicians and to streamline
the movement into computerized order
entry on the inpatient wards. Common
diagnoses do not always lend themselves
to a straightforward clinical guideline.
Dr Vellody and his team at Children’s
Hospital of Pittsburg have developed a
Clinical Guideline for community acquired
pneumonia, a diagnosis for which
multiple management strategies exist. The
abbreviated guideline presented in this
article is for your review. Complete versions
are available upon request.
Purpose
Based on the most current and best
scientific information, the following
guidelines are intended to help
practitioners at all levels of experience
refine their knowledge and select
among the options for evaluation and
management of community acquired
pneumonia.
Inclusions
These guidelines are intended primarily
for use in children 60 days through 17
years of age with signs, symptoms, or
other findings suggesting a diagnosis
of uncomplicated pneumonia acquired
by exposure to organisms in the
community.
Exclusions
The guidelines do not address
considerations needed to manage all
children. See algorithm for exclusions.
Etiology
The etiology of community-acquired
pneumonia has proven difficult to
clearly describe. Direct culture of
infected lung tissue requires invasive
techniques, and blood cultures are
positive in only 10% or less of children
with bacterial disease.20 In spite of these
problems some consistent trends and
conclusions can be derived from the
literature and these are summarized
below.19,25,47,49,51
12 | American Academy of Pediatrics
Table 1: Respiratory rates
Age
Approximate normal
Respiratory Rates
(breaths/min)
WHO Tachypnea
threshold
(breaths/min)
2-12 months
25-40
50
1-5 years
20-30
40
> 5 years
15-25
30
• Streptococcus pneumoniae is the
most commonly identified bacterial
cause of pneumonia in all age
groups. The rates of pneumococcal
pneumonia are declining with
introduction of the PCV7 vaccine.2,10
• Viruses are identified most often in
children < 5 years of age. Respiratory
syncytial virus (RSV) and human
metapneumovirus are the most
common viral etiologies in those < 3
years of age.
• Mycoplasma pneumoniae and
Chlamydia pneumoniae are more
common in school-age children.26
These organisms may be becoming
increasingly prevalent in preschool
children.15
Clinical Assessments
• Pneumonia is suggested by the child’s
signs and symptoms. Important
historical data include the age
of the child, season of the year,
travel history, sick contacts, and
immunization status – particularly
Hib, PCV7 (Prevnar), and influenza
vaccinations.32 On physical exams,
signs of respiratory distress including
tachypnea, retractions, nasal flaring,
grunting, cough, crackles, wheeze,
and decreased breath sounds are
possible predictors of pneumonia
in children. The predictive value of
these signs is strongest when the
child is febrile, cyanotic, or when
more than one of these signs of
breathing dysfunction is present.33
The absence of fever is reported to
have a negative predictive value of up
to 97% for children under 17 years of
age when temperature has not been
modified by antipyretics.52
• It is recommended that practitioners
use the World Health Organization
(WHO) age specific criteria for
tachypnea. (Table 1).
• Respiratory rates are best determined
over a full 60-second period or
by adding together two separate
30 second counts.40 Tachypnea
may not be present in a child with
pronounced retractions or other signs
of increased work of breathing (WHO
1999[E]).
• A small proportion of patients under
five years of age may present without
classical findings of pneumonia.3
Pneumonia also may present as
abdominal or chest pain, vomiting, or
headache.23,32,37
• A normal pulse oximetry reading
does not rule out pneumonia.44
Radiologic Assessments
• The routine use of radiographs in
the diagnosis of pneumonia as well
as to distinguish bacterial disease
from viral disease is not supported by
evidence.1,7,25,48
• It is recommended that chest
radiographs be considered in
• children less than 5 years of
age with high fevers and high
white blood cell (WBC) counts of
uncertain source with a negative
urinalysis3
• when clinical findings are
ambiguous
• when a complication such as a
pleural effusion is suspected
• when pneumonia is prolonged and
unresponsive to antimicrobials
• children who are admitted for
pneumonia
• children with a prior history of
pneumonia1,3,8,43,46
Laboratory Assessments
Routine laboratory tests are not
necessary when uncomplicated CAP is
suspected.
• A WBC count and differential should
be considered when adjunctive
information is judged necessary
to help decide whether to use
antibiotics during management.3,46
The likelihood of a bacterial cause
generally increases as WBC counts
increase above 15,000-20,000/mm3
and, especially when associated with
fevers higher than 39oC (102oF),
3,20,22,39
but these relationships
have not been documented in all
studies.38,51
• A sputum Gram stain and culture
on high quality specimens (<10
squamous epithelial cells and >25
WBC’s per low powered field4) should
be considered when managing older
children and adolescents with more
severe disease. Pleural cultures are
also considered particularly valuable
prior to starting antibiotics when
managing a child with an effusion.
• Blood cultures are not recommended
as routine studies for outpatients
(likelihood of positive culture is
less than 3%).20 Blood cultures are
recommended for inpatients with
more severe forms of pneumonia and
patients under 3 months of age. 20
• Neither cultures, PCR, nor serologic
testing for specific pathogens
such as viruses, M. pneumoniae,
or C. pneumoniae are routinely
recommended.4,21,42
• C reactive protein (CRP), erythrocyte
sedimentation rate (ESR), and
other measures of acute phase
reactants are not specific enough to
recommend as routine studies.27,38
• PPD and other skin testing are always
considered appropriate for children
with a history of exposure.
• When historical, physical,
radiologic, or laboratory findings
are inconsistent, additional studies
should be considered to evaluate for
alternative or coincident conditions,
such as foreign body aspiration or
immunodeficiency.
Treatment Recommendations
• High dose amoxicillin or amoxicillin/
clavulanate (80-90 mg/kg/day based
on amoxicillin component) for 10
days should be used to treat children
60 days to 5 years of age when a
bacterial cause for CAP is likely. S.
Suspected pneumonia for healthy children 60 days through 17 years of age
Immediate exclusions
“septic” or critically ill children;
cardiac or pulmonary disorders (CHD, CF, etc);
immunocompromised states (chemotherapy, organ transplant, or primary immunodeficiency);
airway abnormalities;
other chronic illness
Fever (rectal or oral temperature
>38.3°C) AND/OR
Resp rate >50
2-12 months old
Resp rate >40
1-5 years old
Resp rate >30
>5 years old
Is respiratory rate above threshold for age when counted for 60 seconds?
OR
Are there signs of increased work of breathing such as retractions, nasal flaring, grunting, or use of accessory muscles?
OR
Are there abnormal findings (crackles, rhonchi, decreased sounds, dullness) other than stridor?
OR
Is the patient’s pulse oximetry abnormal (saturations on room air of 90% or lower)?
YES
NO
May have pneumonia or other
respiratory disorder
Pneumonia less
likely
Are there clinical or historical data that
still make pneumonia likely?
Proceed to
pneumonia workup
(see page 2)
pneumoniae is the most commonly
identified bacterial organism for
outpatient children in this age range.5
However, non typeable H. influenzae
may be causative as well. 16.7% to
35% of S. pneumoniae isolates from
patients with community acquired
respiratory tract infections (all
ages) in the U.S. are resistant to
penicillins.16 Fifty-seven percent
of S. pneumoniae isolates from
blood/CSF specimens cultured at
Children’s Hospiital of Pittsburgh
in 2006 were nonsusceptible
to penicillin, including both
intermediate and resistant strains.
Resistance of S. pneumoniae to
penicillin (including amoxicillin)
is mediated through alterations
in the penicillin-binding proteins.
Using high doses of amoxicillin
saturates the penicillin-binding
proteins and is therefore considered
a reasonable antibiotic option.35
EXIT
NO
YES
20.1% of S. pneumoniae isolates
from the CDC core surveillance in
2005 were resistant to erythromycin,
while 15% were resistant to TMP/
SMX.10 An organism resistant to
penicillin is often resistant also
to erythromycin. Erythromycin
resistance generally suggests
resistance to all macrolides.9,12 For
children with allergies to penicillin, a
macrolide, cephalosporin or second
generation fluoroquinolone with
anti-pneumococcal activity may be
considered.14,24
• Practitioners should consider the use
of a macrolide when treating CAP in
a child greater than 5 years of age.
Macrolides usually provide effective
coverage for M. pneumoniae and C.
pneumoniae, the organisms most
likely to cause CAP as children grow
older. A macrolide will concurrently
Continued on page 14
Hospital Pediatrics | 13
Clinical Guideline for Community Acquired Pneumonia, continued from page 13
provide coverage for penicillin
sensitive S. pneumoniae, the most
common bacterial cause of CAP in all
age groups.24 Treatment duration is 7
to 10 days, although a five-day course
of azithromycin may be used.18,24,51
Proceed to
pneumonia workup
•
•
Inpatient Management Considerations
• Specific admission criteria include ill
appearance, dehydration, hypoxemia,
respiratory distress, inability to
tolerate oral liquids, failed outpatient
treatment, or social concerns that
would limit proper treatment or
follow-up.
• ICU evaluation should be obtained
for severe respiratory distress, vital
sign instability, sepsis, persistent
hypoxemia despite supplemental
oxygen delivery, or requirement for
positive pressure ventilation
• Pneumonia complicated by effusion
or empyema may require chest
tube placement and consultation
with the surgical or intervention
radiology service. Infectious Diseases
or Pulmonary consultations are
recommended in the management of
complicated pneumonias.
• Discharge criteria include:
a. adequate oral intake
b. antibiotic therapies can be
continued at home
c. family has participated in
discharge planning and
understands and agrees with
prescribed therapies and follow-up
plans
d. home is appropriate for continuing
care
e. follow-up physician is identified
and agrees with the discharge
plans with follow up within 24-72
hours.
• Follow-up x-rays in otherwise
healthy children are not indicated
as consolidation may persist
radiographically for up to 4 weeks.13
References
1. Alario, A. J., P. L. McCarthy, R. Markowitz, P.
Kornguth, N. Rosenfield, and J. M. Leventhal.
1987. Usefulness of chest radiographs in
children with acute lower respiratory tract
disease. The Journal of pediatrics 111:187-193.
2. Albrich, W. C., W. Baughman, B. Schmotzer, and
M. M. Farley. 2007. Changing characteristics of
invasive pneumococcal disease in Metropolitan
Atlanta, Georgia, after introduction of a 7-valent
pneumococcal conjugate vaccine. Clin Infect Dis
44:1569-1576.
3. Bachur, R., H. Perry, and M. B. Harper. 1999.
Occult pneumonias: empiric chest radiographs
in febrile children with leukocytosis. Annals of
emergency medicine 33:166-173.
14 | American Academy of Pediatrics
Is a chest x-ray needed?
evidence of complicated pneumonia (i.e.
effusion/abscess/pneumatocele)
uncertain diagnosis of pneumonia
YES
NO
NO
UNCERTAIN
Obtain chest x-ray
Do you still
believe
pneumonia is
likely?
NO
Do you believe pneumonia is
bacterial?
Is x-ray consistent
with pneumonia?
YES
NO
Do focal findings suggest bacterial
disease?
• lobar consolidation
• round pneumonia
• effusion
• pneumatocele
YES
EXIT
NO
Manage
as viral
•
•
•
•
•
•
•
•
•
Manage
as viral
YES
•
•
•
YES
•
•
Consider
CBC with diff
blood culture
sputum culture/gram
stain
chest x-ray or CT if
complicated disease
PPD
Initiate antimicrobial therapy with
High dose amoxicillin or cefuroxime/ceftriaxone for children
Consider adding macrolide for atypical pneumonia in school
age children
Alternatives based on first line drugs, allergies or patient and
practitioner preference.
Consider admission on antimicrobial therapy for
ill appearance
dehydration or inability to tolerate oral liquids
hypoxemia
respiratory distress
failed outpatient treatment
social concerns that would preclude treatment or follow-up
Guideline developed by Respiratory committee, Review coordinated by Andrew Nowalk, MD., and Kishore Vellody, MD.
4. Bartlett, J. G., R. F. Breiman, L. A. Mandell,
and T. M. File, Jr. 1998. Communityacquired pneumonia in adults: guidelines for
management. The Infectious Diseases Society of
America. Clin Infect Dis 26:811-838.
5. Bartlett, J. G., and L. M. Mundy. 1995.
Community-acquired pneumonia. The New
England journal of medicine 333:1618-1624.
6. Berman, S., E. A. Simoes, and C. Lanata. 1991.
Respiratory rate and pneumonia in infancy.
Archives of disease in childhood 66:81-84.
7. Bettenay, F. A., J. F. de Campo, and D. B.
McCrossin. 1988. Differentiating bacterial
from viral pneumonias in children. Pediatric
radiology 18:453-454.
8. Bushyhead, J. B., R. W. Wood, R. K. Tompkins,
B. W. Wolcott, and P. Diehr. 1983. The effect
of chest radiographs on the management and
clinical course of patients with acute cough.
Medical care 21:661-673.
9. Campbell, G. D., Jr., and R. Silberman. 1998.
Drug-resistant Streptococcus pneumoniae. Clin
Infect Dis 26:1188-1195.
10.CDC 2007, posting date. Active Bacterial Core
Surveillance. [Online.]
11.Chumpa, A., R. G. Bachur, and M. B. Harper.
1999. Bacteremia-associated pneumococcal
pneumonia and the benefit of initial parenteral
antimicrobial therapy. The Pediatric infectious
disease journal 18:1081-1085.
12.Doern, G. V., A. Brueggemann, H. P. Holley,
Jr., and A. M. Rauch. 1996. Antimicrobial
resistance of Streptococcus pneumoniae
recovered from outpatients in the United States
during the winter months of 1994 to 1995:
results of a 30-center national surveillance
study. Antimicrobial agents and chemotherapy
40:1208-1213.
13.Donnelly, L. F. 1999. Maximizing the usefulness
of imaging in children with community-acquired
pneumonia. Ajr 172:505-512.
14.Dudas, V., A. Hopefl, R. Jacobs, and B. J.
Guglielmo. 2000. Antimicrobial selection
for hospitalized patients with presumed
community-acquired pneumonia: a survey of
nonteaching US community hospitals. The
Annals of pharmacotherapy 34:446-452.
15.Esposito, S., S. Bosis, R. Cavagna, N. Faelli,
E. Begliatti, P. Marchisio, F. Blasi, C. Bianchi,
and N. Principi. 2002. Characteristics of
Streptococcus pneumoniae and atypical
bacterial infections in children 2-5 years of age
with community-acquired pneumonia. Clin
Infect Dis 35:1345-1352.
16.Gordon, K. A., D. J. Biedenbach, and R. N.
Jones. 2003. Comparison of Streptococcus
pneumoniae and Haemophilus influenzae
susceptibilities from community-acquired
respiratory tract infections and hospitalized
patients with pneumonia: five-year results
for the SENTRY Antimicrobial Surveillance
Program. Diagnostic microbiology and infectious
disease 46:285-289.
17.Hardie, W., R. Bokulic, V. F. Garcia, S. F. Reising,
and C. D. Christie. 1996. Pneumococcal pleural
empyemas in children. Clin Infect Dis 22:10571063.
18.Harris, J. A., A. Kolokathis, M. Campbell, G. H.
Cassell, and M. R. Hammerschlag. 1998. Safety
and efficacy of azithromycin in the treatment
of community-acquired pneumonia in children.
The Pediatric infectious disease journal 17:865871.
19.Heiskanen-Kosma, T., M. Korppi, C. Jokinen, S.
Kurki, L. Heiskanen, H. Juvonen, S. Kallinen,
M. Sten, A. Tarkiainen, P. R. Ronnberg, M.
Kleemola, P. H. Makela, and M. Leinonen. 1998.
Etiology of childhood pneumonia: serologic
results of a prospective, population-based study.
The Pediatric infectious disease journal 17:986991.
20.Hickey, R. W., M. J. Bowman, and G. A. Smith.
1996. Utility of blood cultures in pediatric
patients found to have pneumonia in the
emergency department. Annals of emergency
medicine 27:721-725.
21.Honda, J., T. Yano, M. Kusaba, J. Yonemitsu,
H. Kitajima, M. Masuoka, K. Hamada, and K.
Oizumi. 2000. Clinical use of capillary PCR to
diagnose Mycoplasma pneumonia. Journal of
clinical microbiology 38:1382-1384.
22.Jadavji, T., B. Law, M. H. Lebel, W. A. Kennedy,
R. Gold, and E. E. Wang. 1997. A practical guide
for the diagnosis and treatment of pediatric
pneumonia. Cmaj 156:S703-711.
23.Jona, J. Z., and R. P. Belin. 1976. Basilar
pneumonia simulating acute appendicitis in
children. Arch Surg 111:552-553.
24.Klein, J. O. 1997. History of macrolide use in
pediatrics. The Pediatric infectious disease
journal 16:427-431.
25.Korppi, M., T. Heiskanen-Kosma, E. Jalonen,
P. Saikku, M. Leinonen, P. Halonen, and P. H.
Makela. 1993. Aetiology of community-acquired
pneumonia in children treated in hospital.
European journal of pediatrics 152:24-30.
26.Korppi, M., T. Heiskanen-Kosma, and M.
Kleemola. 2004. Incidence of communityacquired pneumonia in children caused by
Mycoplasma pneumoniae: serological results of a
prospective, population-based study in primary
health care. Respirology (Carlton, Vic 9:109114.
27.Korppi, M., T. Heiskanen-Kosma, and M.
Leinonen. 1997. White blood cells, C-reactive
protein and erythrocyte sedimentation rate
in pneumococcal pneumonia in children. Eur
Respir J 10:1125-1129.
28.Kuppermann, N., D. E. Bank, E. A. Walton, M.
O. Senac, Jr., and I. McCaslin. 1997. Risks for
bacteremia and urinary tract infections in young
febrile children with bronchiolitis. Archives of
pediatrics & adolescent medicine 151:12071214.
29.Laundy, M., E. Ajayi-Obe, K. Hawrami, C.
Aitken, J. Breuer, and R. Booy. 2003. Influenza
A community-acquired pneumonia in East
London infants and young children. The
Pediatric infectious disease journal 22:S223227.
30.Leventhal, J. M. 1982. Clinical predictors
of pneumonia as a guide to ordering chest
roentgenograms. Clinical pediatrics 21:730-734.
31.Lichenstein, R., A. H. Suggs, and J. Campbell.
2003. Pediatric pneumonia. Emergency
medicine clinics of North America 21:437-451.
32.Mahabee-Gittens, E. M., J. Grupp-Phelan, A. S.
Brody, L. F. Donnelly, S. E. Bracey, E. M. Duma,
M. L. Mallory, and G. B. Slap. 2005. Identifying
children with pneumonia in the emergency
department. Clinical pediatrics 44:427-435.
33.Margolis, P., and A. Gadomski. 1998. The
rational clinical examination. Does this infant
have pneumonia? Jama 279:308-313.
34.Morley, C. J., A. J. Thornton, M. A. Fowler, T. J.
Cole, and P. H. Hewson. 1990. Respiratory rate
and severity of illness in babies under 6 months
old. Archives of disease in childhood 65:834837.
35.Pallares, R., J. Linares, M. Vadillo, C. Cabellos,
F. Manresa, P. F. Viladrich, R. Martin, and F.
Gudiol. 1995. Resistance to penicillin and
cephalosporin and mortality from severe
pneumococcal pneumonia in Barcelona, Spain.
The New England journal of medicine 333:474480.
36.Piglansky, L., E. Leibovitz, S. Raiz, D.
Greenberg, J. Press, A. Leiberman, and R.
Dagan. 2003. Bacteriologic and clinical efficacy
of high dose amoxicillin for therapy of acute
otitis media in children. The Pediatric infectious
disease journal 22:405-413.
37.Ravichandran, D., and D. M. Burge. 1996.
Pneumonia presenting with acute abdominal
pain in children. The British journal of surgery
83:1707-1708.
38.Ruuskanen, O., and J. Mertsola. 1999.
Childhood community-acquired pneumonia.
Seminars in respiratory infections 14:163-172.
39.Shuttleworth, D. B., and E. Charney. 1971.
Leukocyte count in childhood pneumonia.
American journal of diseases of children (1960)
122:393-396.
40.Simoes, E. A., R. Roark, S. Berman, L. L.
Esler, and J. Murphy. 1991. Respiratory rate:
measurement of variability over time and
accuracy at different counting periods. Archives
of disease in childhood 66:1199-1203.
41.Singhi, S., A. Dhawan, S. Kataria, and B. N.
Walia. 1994. Validity of clinical signs for the
identification of pneumonia in children. Annals
of tropical paediatrics 14:53-58.
42.Skerrett, S. J. 1999. Diagnostic testing for
community-acquired pneumonia. Clinics in
chest medicine 20:531-548.
43.Swingler, G. H., G. D. Hussey, and M.
Zwarenstein. 1998. Randomised controlled trial
of clinical outcome after chest radiograph in
ambulatory acute lower-respiratory infection in
children. Lancet 351:404-408.
44.Tanen, D. A., and D. R. Trocinski. 2002. The
use of pulse oximetry to exclude pneumonia in
children. The American journal of emergency
medicine 20:521-523.
45.Taylor, J. A., M. Del Beccaro, S. Done, and W.
Winters. 1995. Establishing clinically relevant
standards for tachypnea in febrile children
younger than 2 years. Archives of pediatrics &
adolescent medicine 149:283-287.
46.Tew, J., L. Calenoff, and B. S. Berlin. 1977.
Bacterial or nonbacterial pneumonia: accuracy
of radiographic diagnosis. Radiology 124:607612.
47.Turner, R. B., A. E. Lande, P. Chase, N. Hilton,
and D. Weinberg. 1987. Pneumonia in pediatric
outpatients: cause and clinical manifestations.
The Journal of pediatrics 111:194-200.
48.Virkki, R., T. Juven, H. Rikalainen, E.
Svedstrom, J. Mertsola, and O. Ruuskanen.
2002. Differentiation of bacterial and viral
pneumonia in children. Thorax 57:438-441.
49.Vuori, E., H. Peltola, M. J. Kallio, M. Leinonen,
and K. Hedman. 1998. Etiology of pneumonia
and other common childhood infections
requiring hospitalization and parenteral
antimicrobial therapy. SE-TU Study Group. Clin
Infect Dis 27:566-572.
50.Williams, J. V., P. A. Harris, S. J. Tollefson, L.
L. Halburnt-Rush, J. M. Pingsterhaus, K. M.
Edwards, P. F. Wright, and J. E. Crowe, Jr. 2004.
Human metapneumovirus and lower respiratory
tract disease in otherwise healthy infants and
children. The New England journal of medicine
350:443-450.
51.Wubbel, L., L. Muniz, A. Ahmed, M. Trujillo, C.
Carubelli, C. McCoig, T. Abramo, M. Leinonen,
and G. H. McCracken, Jr. 1999. Etiology and
treatment of community-acquired pneumonia
in ambulatory children. The Pediatric infectious
disease journal 18:98-104.
52.Zukin, D. D., J. R. Hoffman, R. H. Cleveland, D.
C. Kushner, and T. E. Herman. 1986. Correlation
of pulmonary signs and symptoms with chest
radiographs in the pediatric age group. Annals of
emergency medicine 15:792-796.
Would you like to contribute to
On the Ward? Contact Julie Lipps
Kim at jlipps@stanford.edu.
Hospital Pediatrics | 15
QUALITY AND SAFETY — Mark Shen, MD, FAAP, Editor
Improving Value of Health Care
Delivery in Pediatrics:
The Role of the Pediatric Hospitalist
Anuj Steve Narang, MD, FAAP, Pediatric Hospitalists of Louisiana, LLC, snarang@pcaofbr.com
Our Lady of the Lake Regional Medical Center, Children’s Hospital, Baton Rouge, LA
Editors Note:
Welcome to the new Quality and Safety
column of Hospital Pediatrics. In this article,
Dr Narang has provided us insightful
perspective on the issue of value, an
important yet underappreciated topic in
health care. As hospitalists, we are perfectly
poised to analyze and/or provide some of
the most costly, and perhaps variable, care
in our field. Building on this report, this
column seeks to provide a forum for the
promotion and discussion of quality and
safety issues in pediatric hospital medicine.
If you are interested in submitting an article,
particularly if you have an illustrative case
or project from your institution, please
contact mshen@seton.org.
Introduction:
“Quality problems are everywhere,
affecting many patients. Between the
health care we have and the care we
could have lies not just a gap, but a
chasm”1 It is this ‘Quality Chasm’ that
formed the basis for the Institute of
Medicine (IOM) report released in March
2001 which focuses on developing a
new health system for the 21st century.
The report is emphatic: “Trying harder
will not work. Changing systems of
care will.”1 The Center for Medicaid
and Medicare has used its influence
as the administrator of Medicare to
influence quality and performance
improvement measurements in adult
health care. The past decade has
seen significant improvement in adult
health care quality measurement,
with the development of specific
JCAHO measures and targeted pay for
performance initiatives for hospitals.
Unfortunately, with no similar federal
influence in pediatric medicine, the
“quality chasm” between adult and
child health care has widened. This
chasm is growing larger, despite the
320 billion dollars spent annually for
children’s health care through Medicaid
and SCHIP.2 Moreover, with almost
every state recently facing yearly cuts
in their Medicaid programs because
of fiscal pressures, it is clear that they
cannot continue to waste resources
16 | American Academy of Pediatrics
by paying for poor quality care that is
clearly ineffective and unnecessary.
Unfortunately, little if any of the
resources are invested in improving
quality of pediatric inpatients. Of the 18
private health insurance plans’ quality
and pay for performance programs
identified by Leapfrog: only 17 percent
developed pediatric specific inpatient
measures.2 Only 5 of 40 controlled
trials of quality improvement efforts for
children published between 1980 and
1998 addressed inpatient problems.
The Pediatric Hospitalists of Louisiana is
a hospitalist group whose primary goal
is to meet this challenge of decreasing
the quality chasm by approaching the
management of pediatric inpatient
disease with a combination of evidencebased reviews, health information
technology, and data driven performance
measures. This group contracts with
Our Lady of the Lake Regional Medical
Center (OLOL) in Baton Rouge, LA,
to provide inpatient care at OLOL
Children’s Center. The hospitalist
pediatric service (HPS) admitted over
3000 children in 2006 with access to
approximately 50 inpatient beds, a 16
bed PICU, and a 24 hour pediatric ER
with 30,000 annual visits. At the onset
of the establishment of HPS, there was
a clear acknowledgement of the lack
of evidence-based pediatric care in the
Southeast Louisiana region, noting the
wide variation of management of even
the most common inpatient pediatric
conditions. This wide variation of
care often leads to a wide variation
of outcomes—technical, operational,
and financial. With greater than 80%
of their patients’ healthcare costs paid
by the LA Medicaid program, HPS
recognized that such variation in care
could have a significant negative impact
on the return on investment of the LA
Medicaid program. With this context,
HPS identified the 10 most common
pediatric inpatient diagnoses admitted
to OLOL this decade, and focused on
developing a library of clinical pathways
and flowcharts. The goals have been
clear: 1) improve technical quality of
care; 2) reduce cost of care; and 3)
improve operational efficiency of care.
In order to demonstrate the impact
of this system on specific operational,
financial, and technical benchmarks,
HPS has begun to develop a dashboard
of data on several common pediatric
inpatient diagnoses.
One example of the impact of
standardization of processes has
been on the inpatient management of
bronchiolitis. Before the institution of
a clinical pathway to guide clinicians,
the management of bronchiolitis was
often guided by individual practices,
rather than established evidence based
guidelines. This practice led to wide
variation in management strategies
and poor utilization of resources. In
response, HPS developed a clinical
pathway based on analysis of various
published evidence based studies
that examined the impact of steroid,
chest x-rays, RSV testing, chest
physiotherapy, and bronchodilators
on the management of bronchiolitis.
HPS then focused on implementing
a pathway that identified 2 aspects
of inpatient care that required more
consistency: (1) decreased utilization
of bronchodilators, and (2) decreased
utilization of steroids. The strategy to
improve these processes focuses on
utilization of computerized order sets,
implementation of a respiratory therapy
(RT) protocol, and education of nurses
and respiratory therapists. This clinical
pathway for bronchiolitis was adopted
by the HPS group and implemented in
November 2006.
Evaluation of the impact of a
standardized process for bronchiolitis
on outcome measures focused on
comparing the HPS group of patients
from 2006 (prior to adoption of a clinical
pathway) to the HPS group of patients
from 2008 (1st quarter data). It should
be noted that even though the HPS
physicians were required to utilize the
bronchiolitis pathway when managing
their patients, often these patients were
initially seen in the Pediatric Emergency
Room, where individual physician
practices often dictated management
strategy. Process measures that were
analyzed included: (1)% of patients who
received ≥ 1 bronchodilator treatment
and (2) % of patients who received ≥ 1
dose of a steroid. Outcome measures
included (1) length of stay (LOS) and
(2) variable direct cost/encounter.
Hospital costs are categorized as
variable direct, fixed direct and indirect
costs. The total cost of a patient care
encounter is defined as variable direct
plus fixed direct plus indirect cost.
Hospital overhead is defined as the sum
of fixed and indirect costs. Variable
direct costs are those that vary with
patient activity, such as laboratory
tests, medications, surgical supplies,
and nursing expenses.5 The 2008 HPS
data currently shows a decrease in
utilization of bronchodilators by 40%
and a 50% decrease in utilization of
steroids as compared to the 2006 data,
leading to a 16% decrease in LOS and
13% decrease in variable direct cost.
Readmit rate within 72 hours for the
2008 HPS group was 0.01% compared
to 2.96% for the 2006 HPS group. There
was no documented mortality in either
group of patients and no PICU admission
for any of the readmits. This is just
the impact of a standardized process
within a pediatric hospitalist group.
When comparing the 2008 HPS patient
data with data from patients cared for
in 2006 by a group of non-hospitalists
(comprised of over 30 individual
physicians managing their own patients
based on individualized processes), the
impact of the standardized process was
even greater. The 2008 HPS providers
utilized 60% less bronchodilators and
70% less steroids than their 2006 nonhospitalists colleagues, leading to a 23%
decrease in LOS and 20% decrease in
variable direct cost. The readmit rate
within 72 hours for the 2008 HPS group
was 0.01% compared to 2.88% for the
2006 non-hospitalist group. There was
no documented mortality in either group
of patients and no PICU admissions for
any of the readmits.
In this retrospective study in a
community hospital in Southeast
Louisiana, we have clearly demonstrated
that the utilization of a standardized
process can lead to high value outcomes
in the management of a common
pediatric diagnosis. The group that
utilized an evidenced-based clinical
pathway to help deliver its care clearly
achieved superior outcomes when
evaluating resource utilization, length of
stay and cost data. In terms of analyzing
morbidity associated with higher value
outcomes, initial data actually indicates
a decrease in readmission rates by the
2008 HPS group and no increase in
mortality or readmissions to the PICU.
We hope to use this study as a platform
for a national discussion on how
pediatricians can lead the discussion
on how to improve health care
outcomes for our patients. In their
book, Redefining Health Care, Michael
Porter and Elizabeth Teisberg argue
that “the way to transform health care
is to realign competition with value
for patients. Value in health care is
the health outcome per dollar of cost
expended. If all system participants
have to compete on value, value will
improve dramatically.”3 For example,
in Southeast Louisiana, patients and
other payers of quality should have
access to data that compares providers
in the management of a variety of
pediatric diagnoses. There should be
a real competition for value based
on results, and those providers that
demonstrate the best value based
outcomes should be rewarded. Imagine
a pediatric health care delivery system
where participants are incentivized to
deliver high value care for bronchiolitis,
asthma, gastroenteritis, osteomyelitis,
and so on. The U.S. health care system
has no choice but to be reorganized, and
those groups that position themselves
strategically by utilizing information
technology, transparent databases, and
innovative 3rd party payer systems are
the ones that will succeed.
The field of Pediatrics can be a model
for the U.S. Health Care system if our
leaders take careful strategic steps on
how to move forward. The solution
is complex as it will take cooperation
at many levels. Moreover, though this
study focuses on only on the inpatient
aspect of disease management, we need
to recognize that true competition for
health care value has to occur across
“the full cycle of care.”3 This idea is
echoed by Donald Berwick, CEO of IHI,
in his discussion of the “Triple Aim,”
where he suggests that reorganization of
our health care system has to focus on
improving all three of these areas: (1)
The health of a defined population, (2)
The experience of care by people in this
population, and (3) the cost per capita of
providing care for this population.4 For
example, using the Triple Aim model,
we would re-examine the management
of bronchiolitis in our community, and
partner with the essential stakeholders
to develop a system where all providers
including hospitalists, outpatient
pediatricians, and ER physicians are
incentivized to deliver the highest
value outcome for the patient with
bronchiolitis (use of standardized
process in all settings that reduce
utilization of unnecessary resources,
including reducing emergency room
visits and hospital admissions).
This study is only the first of many
we hope that will begin to explore the
concept of value based competition in
pediatrics. We cannot afford to waste
more resources on processes that are
clearly unsafe, ineffective, inefficient,
and inequitable. We hope that our
leaders in pediatrics will see that one
of the first steps towards this goal
is to develop a national database of
transparent value-based process and
outcome measures. This will take an
extraordinary effort requiring levels of
cooperation that are unprecedented in
our fragmented health care system. As
we urge our national leaders to make
this happen, the reality is that all of us
can begin at a local level to define and
measure quality. We certainly aren’t
waiting in Southeast Louisiana. We
cannot afford to.
References
1. Public Health Communication. Committee on
Quality of Health Care in America, Institute
of Medicine Washington D.C. USA: National
Academies Press: Public Health Communication;
2001.
2. Duchon L, Smith V. National Association of
Children’s Hospitals. Quality Performance
Measurement in Medicaid and SCHIP: Result
of a 2006 National Survey of State Officials.
Lansing, Mich: Health Management Associates;
August 2006.
3. Porter M, Teisberg E O. Redefining Health Care:
Creating Value Based Competition On Results.
Harvard Business School Press. 2006.
4. Berwick D. Technical Brief. Best Health Care
Results for Populations: The Triple Aim.
Institute for Health Care Improvement. 2007.
5. Finkler S, Ward D. Cost Accounting for
Health Care Organizations. Jones and Bartlett
Publishers. 2001: 28-29.
Hospital Pediatrics | 17
Complex Care — Mary Rocha, MD, MPH, FAAP, Editor
Collaborative Developments in Complex Care
Rishi Agrawal, MD, MPH, FAAP 1,2, ragrawal@childrensmemorial.org
Allison Ballantine, MD, FAAP 3,4, BALLANTINE@email.chop.edu
Raj Srivastava, MD, FRCP(C), MPH, FAAP 5-7, raj.srivastava@hsc.utah.edu
Jay G. Berry, MD, MPH, FAAP 8,9, jay.berry@childrens.harvard.edu
1.
Division of Hospital-Based Medicine,
Department of Pediatrics, Northwestern
University Feinberg School of Medicine,
Chicago, IL
2. Children’s Memorial Hospital, Chicago, IL
3. Division of General Pediatrics, Department of
Pediatrics, University of Pennsylvania School
of Medicine, Philadelphia, PA.
4. Children’s Hospital of Philadelphia,
Philadelphia, PA.
5. Division of Inpatient Medicine, Department of
Pediatrics, University of Utah Health Sciences
Center, Salt Lake City, UT
6. Primary Children’s Medical Center,
Intermountain Healthcare Inc, Salt Lake City,
UT
7.Institute for Healthcare Delivery Research,
Intermountain Healthcare Inc, Salt Lake City,
UT
8. Division of General Pediatrics, Department of
Pediatrics, Harvard University Medical School,
Children’s Hospital Boston, Boston, MA
9. Children’s Hospital Boston, Boston, MA.
I
t has been an eventful year for
medical providers of medicallycomplex children (MCC). MCC are a
subset of children with special health
care needs (CSHCN) or children and
youth with special health care needs
(CYSHCN). CSHCN are defined as
“having or being at risk for having
a chronic physical, developmental,
behavioral or emotional condition that
requires health and related services of
a type or amount beyond that required
by children generally.”1 Per surveys
of the US pediatric population 12% to
18% of children meet this definition for
CSHCN.2,3 There is no single agreed
upon definition for MCC and the
literature also refers to this group as
medically fragile, or medically complex
and fragile. One characterization of
MCC states that “a small and growing
subset of CSHCN are medically fragile
with complex chronic conditions
that involve several organ systems
and require multiple specialists,
technological supports, and community
services.” 4
In late 2007, the AAP Section
on Hospital Medicine (SOHM)
established a new Subcommittee on
Complex Care. Next, in the spring, an
international group of complex care
18 | American Academy of Pediatrics
providers convened to develop quality
improvement (QI) initiatives for MCC.
The following month, the Pediatric
Academic Societies (PAS) Conference
served as a venue for a record nine
platforms and posters on complex care
issues. The momentum is building. It is
an opportune time to collaborate with
other providers focused on the care of
MCC.
SOHM Complex Care Subcommittee
In October 2007, the SOHM Executive
Committee approved the formation of
a Complex Care Subcommittee. The
Subcommittee actively communicates
via an electronic listserv® on various
topics including systems organization,
patient care, collaboration with other
providers, medical education, and
research ideas. Four areas of interest
to the Subcommittee are being
spearheaded as follows:
• Current State of Inpatient Complex
Care: Rishi Agrawal, MD, MPH, FAAP,
ragrawal@childrensmemorial.org
• Coordination with Outpatient
Providers: Annique Hogan, MD, FAAP,
HOGAN@email.chop.edu
• Clinical Pathway Development:
Noeme Adame, MD, FAAP, adamen@uthscsa.ed
• Educational Resource Development:
Tamara Simon, MD, MPH, FAAP,
Tamara.simon@hsc.utah.edu
If you are interested in participating
in any of these projects, please e-mail
the appropriate coordinator. If another
aspect of complex care interests you,
feel free to use the Subcommittee to
organize a collaborative effort.
To join the Complex Care listserv®
or to get more information about the
Subcommittee, email the chair, Allison
Ballantine, MD, FAAP, at BALLANTINE@
email.chop.edu.
CHCA Quality Improvement Meeting
for Medically-Complex Children
In April 2008, the Child Health
Corporation of America (CHCA)
and Children’s Hospital Boston cosponsored a meeting to discuss quality
improvement (QI) for MCC. CHCA
represents 42 freestanding children’s
hospitals that have an agreement to
share de-identified inpatient admission
data on all of their patients. Meeting
participation was also open to providers
at non-CHCA affiliated hospitals. Along
with CHCA staff, Jay Berry, MD, MPH,
FAAP, and Kathy Jenkins, MD, MPH,
FAAP, of Children’s Hospital Boston
were also instrumental in organizing the
meeting.
Healthcare providers from programs
in Boston, Chicago, Little Rock,
Milwaukee, Philadelphia, Salt Lake City,
and Toronto discussed experiences with
both inpatient and outpatient programs
for MCC and an agenda of collaborative
QI efforts. The group brainstormed
quality measures for the care of both
inpatient and outpatient MCC within
the framework of “Six Aims for QI” put
forth by the Institute of Medicine. The
Six Aims are as follows: Safe, Effective,
Patient-Centered, Timely, Efficient, and
Equitable. One subgroup is actively
working on defining the population
of MCC, while several others are
developing ideas raised at the meeting
into specific quality measures.
Among participants there was a
consensus that ongoing collaborative
QI efforts for MCC should be more
inclusive of all medical professionals
interested in complex pediatric care.
The working group plans to use the
SOHM Complex Care Subcommittee’s
listserv® to communicate about future
activities, and to reconvene at future
national pediatric meetings (such
as AAP, PAS and PHM) to encourage
broader participation. If you are
interested in learning more about
this collaborative QI effort, please
contact Jay Berry, MD, MPH, FAAP at
jay.berry@childrens.harvard.edu.
PAS Meeting 2008
Several pieces of original research
on complex care were presented
at the April 2008 PAS meeting.
While two posters described specific
programs,5,6 others examined trends
in hospitalizations of MCC,7 inpatient
resource use for MCC following
tracheotomy,8 and infection control
identification for children with CSF
shunts.9 A poster and platform session
presentation addressed fundoplication in
children with neurological impairment
and GERD.10,11 Another platform session
presented the results of the Pediatric
Research in Inpatient Settings (PRIS)
Survey questions on complex care.12
A final platform session focused on
identification of presenting conditions
of children who are hospitalized at both
children’s and non-children’s hospitals,
and presented data on MCC in both
settings.13
Presented Abstracts may be viewed
online at http://www.abstracts2view.
com/pas/index.php.
Discussions are ongoing regarding
applying for a new Complex Care special
interest group (SIG) via the Academic
Pediatric Association. This Complex
Care SIG would span both outpatient
and inpatient care of MCC in order to
promote academic activity regarding
MCC.
Future Directions
The events of the past year are laying
a framework for ongoing collaborative
efforts in clinical care, research,
education, and advocacy for MCC. There
may be other important efforts in place
that are not mentioned in this update.
If you have an interest in this area (or
know someone who does), there are
many opportunities to get involved and
collaborate in this rapidly-emerging
field. We encourage broad participation
from all medical professionals and allied
health professionals with an interest
in MCC. We welcome those who focus
on inpatient care, outpatient care, or
both. Please feel free to contact any of
the leaders listed above to receive more
information.
1):117-123.
3. Van Dyck PC, Kogan MD, McPherson MG,
Weissman GR, Newacheck PW. Prevelence and
characteristics of children with special health
care needs. Arch Pediatr Adolesc Med. 2004;
158(9):884-890.
4. Gordon JB, Colby HH, Bartelt T, Jablonski DD,
Krauthoefer ML, Havens P. A Tertiaty CarePrimary Care Partnership Model for Medically
Complex and Fragile Children and Youth with
Special Health Care Needs. Arch Pediatr Adolesc
Med. 2007; 161(10):937-944.
5. Agrawal RK, Shah PK, Polk DH, Coddington
WJ, Pell-Doyle CJ, Rath KV. Economics and
Utilization of a Hospitalist Medicine Group
Providing Medically Complex Inpatient and
General Pediatric Consultation Services
[abstract]. Presented May 3, 2008 at PAS
Conference, Honolulu, Hawaii. PAS Publication
3782.12.
6. Bekmezian A, Chung PJ, Yazdani S. Staff-Only
Pediatric Hospitalist Care of Medically Complex
Subspecialty Patients in a Major Teaching
Hospital [abstract]. Presented May 3, 2008
at PAS Conference, Honolulu, Hawaii. PAS
Publication 3782.5
7. Burns KH, Casey PH, Bird TM, Robbins JM,
Fussell JJ, Reading Meyer JA. Increasing
Prevalence of Hospitalizations of Medically
Complex Children [abstract]. Presented May 3,
2008 at PAS Conference, Honolulu, Hawaii. PAS
Publication 3782.16.
8. Berry JG, Graham R, Graham D. Inpatient
Health Services Utilization and Outcomes for
Children Following Tracheotomy [abstract].
Presented May 5, 2008 at PAS Conference,
Honolulu, Hawaii. PAS Publication 5826.8
9. Albert JE, Simon TD, Hall M, Kestle J, Jeffries
HE. Improved Identification of Pediatric
Neurosurgical Procedure Infections [abstract].
Presented May 3, 2008 at PAS Conference,
Honolulu, Hawaii. PAS Publication 3792.6
10. Srivastava R, Berry J, O’Gorman M, Downey J,
Dean JM, Hall M. Does Fundoplication Prevent
Reflux Related Hospitalizations in Children with
Neurological Impairment? [abstract]. Presented
May 3, 2008 at PAS Conference, Honolulu,
Hawaii. PAS Publication 3785.26.
11. Lemoine T, Downey J, O’Gorman M, et al.
Indications and Outcomes of Fundoplication
to Treat Gastroesophageal Reflux Disease
in Children with Neurological Impairment
[abstract]. Presented May 4, 2008 at PAS
Conference, Honolulu, Hawaii. PAS Publication
4055.1.
12. Ballantine A, Feudtner C. Inpatient Care of
Children with Complex Medical Conditions: A
Study from the Pediatric Research in Inpatient
Settings (PRIS) Network [abstract]. Presented
May 6, 2008 at PAS Conference, Honolulu,
Hawaii. PAS Publication 6725.2.
13. Michael Mundorff, Raj Srivastava, Chris
Maloney, Ed Clark, Carolyn Reynolds, Karen
Valentine, Brent James. Identifying and
Prioritizing Pediatric Conditions for Quality
Improvement [abstract]. Presented May 6, 2008
at PAS Conference, Honolulu, Hawaii. PAS
Publication 6725.7Interested in submitting an
article on Complex Care?
Contact Mary Rocha, MD, MPH at mr039001@
bcm.edu
ENDNOTES
1. McPherson M, Arango P, Fox H, et al. A new
definition of children with special health care
needs. Pediatrics. 1998;102(1, pt 1):137-140.
2. Newacheck PW, Strickland B, Shonkoff JP, et al.
An epidemiologic profile of children with special
health care needs. Pediatrics. 1998;102(1, pt
THIRD ANNUAL SYMPOSIUM
Frontiers in
Pediatric
Hospital
Medicine
Thursday and Friday
September 11-12, 2008
Grand Hyatt San Francisco
345 Stockton Street
San Francisco, CA
Presented by the
California Pacific Medical Center
For details & registration, visit
http://www.cpmc.org/advanced/pediatrics
/news/Ped_07HospSymp.html
A Sutter Health Affiliate
S AV E
T H E
D AT E
Pediatric
Hospital
Medicine
2 0 0 9
July 23 - 26, 2009
Tampa Marriott
Waterside Hotel and Marina
Tampa, FL
Interested in submitting an article on
Complex Care? Contact Mary Rocha, MD,
MPH, FAAP at mr039001@bcm.edu.
Hospital Pediatrics | 19
Billing and Coding Corner — James O’Callaghan, MD, FAAP, Editor
Q:
A:
I have heard that there is a new code for use with hospitalized
newborns, CPT 99477. When should I use this code?
CPT 99477 is a new code
for use beginning in January
2008. Since many pediatric
hospitalist programs may care for
newborns as part of their job, it is
important to learn and understand the
use of this new code. CPT 2008 states
that the definition of code 99477 is:
Initial hospital care, per day, for
the evaluation and management
of the neonate, 28 days of
age of less, who requires
intensive observation, frequent
interventions, and other intensive
care services
This new code is intended to fill the gap
between CPT codes 99221-99223 (initial
hospital care codes of the neonate NOT
requiring intensive observation, frequent
interventions, and other intensive
care services) and CPT 99295 (initial
inpatient neonatal critical care, per day,
for the evaluation and management of
a critically ill neonate, 28 days of age
or less). This code is intended to be
used with infants that require intensive
services but not critical care services.
It may be best to think of initial hospital
care codes for newborns along a
continuum:
99431: the normal newborn
99221-99223: the ill newborn
99477: the newborn requiring
intensive services
99295: the critically ill newborn
Let’s use the example of a 2.5kg infant
born vaginally at 36 weeks gestation
to a mother with unknown Group B
streptococcus status. If the mother
had developed fever during delivery,
the infant was mildly symptomatic, a
CBC and blood culture were ordered
and antibiotics were started, then CPT
code 99222 would be used. If instead
the infant was grunting and tachypneic,
required supplemental oxygen and
admission to a NICU or special care
nursery for intensive monitoring and
further sepsis evaluation, then the
new CPT code 99477 would be used.
If the infant was in shock, or required
intubation or pressor support, then CPT
20 | American Academy of Pediatrics
code 99295 would be used.
It is important to remember that
CPT 99477 is a bundled code. The
included/bundled services are the
same as those included in the initial
neonatal critical care code CPT 99295.
These services include, but are not
limited to: monitoring, pulse oximetry,
CPAP, peripheral/central/umbilical
catheterization, IVF administration,
lumbar puncture and bladder
catheterization.
Remember also that CPT 99477 is only
an initial hospital care code. Subsequent
hospital days requiring intensive care
should be reported with CPT 99298 to
CPT 99300. These subsequent intensive
care codes are based on current infant
weight:
99298:
99299:
99300:
subsequent intensive
care, per day, for infants
< 1500 grams
subsequent intensive
care, per day, for infants
1501-2500 grams
subsequent intensive
care, per day, for infants
2501-5000 grams
Of note, once the infant’s weight is
>5000 grams, then use the subsequent
hospital care codes CPT 99231-99233. If
the infant became unstable or critically
ill, then use code 99296, subsequent
inpatient neonatal critical care,
regardless of weight.
Since this code is new, it may take some
time for payers to recognize the code
and reimburse your work. Remember,
just because you code correctly,
this does not mean that you will be
reimbursed. However, this should not
discourage you from correctly using this
new code when appropriate.
Have a coding conundrum?
Contact James O’Callaghan, MD,
FAAP at jjocallaghan@aap.net
with your question.
Resources for Members
Pediatric Hospitalist Programs of
North America – Newly Updated
The Pediatric Hospitalist Programs of North America
resource can be used by individuals and programs to
network as well as by members to seek out contacts
and job opportunities in a location of interest. Visit
the SOHM web site at www.aaphospmed.org for more
information.
Neonatal/Pediatric Transport Team
Database – Newly Updated
The Neonatal/Pediatric Transport Team Database is a
resource for professionals who are interested in reviewing
transport programs across the country. Visit the Section on
Transport Medicine web site at www.aap.org/sections/transmed
for additional information.
WHAT WE LEARNED
Grant Recipients talk about the NICHQ Forum
Anu Subramony, MD, MBA, FAAP, as3353@columbia.edu
Assistant Director, General Pediatrics Inpatient Service, Morgan Stanley Children’s Hospital of New York
Jack Percelay, MD, MPH, FAAP, jpercelaymd@yahoo.com
E.L.M.O. Pediatrics
An Asthma Success Story
I
he National Initiative for Health
Care Quality 7th Annual Forum
“Excellence through Innovation”
showcased significant innovation in
quality improvement efforts. NICHQ
(pronounced nitch-cue) is “an actionoriented organization dedicated to
improving the quality of health care
provided to children.” Its four part
improvement agenda is:
1) prevention of childhood obesity
2) promoting evidence based, family
centered care for children with
chronic conditions
3) purging harm from children’s health
care
4) promoting equity in care and
outcomes for all children
Given the obvious overlapping interests
between NICHQ’s goals and our goals as
hospitalists, it’s clear that we hospitalists
are key players in achieving goals 2, 3,
and 4 on the inpatient setting, and have
responsibilities with obesity as well.
NICHQ is similar to the Institute for
Healthcare Improvement run by Don
Berwick, champion of the 100,000 lives
and 5 Million lives campaigns. IHI has a
pediatric node that has done wonderful
work (with the support of many
pediatric organizations) extrapolating
adult oriented materials to pediatrics for
projects such as rapid response teams,
catheter related blood stream infections,
and ventilator associated pneumonia,
but NICHQ is unique with its exclusive
focus on pediatrics.
What’s striking about the three day
NICHQ meeting of 700+ pediatric
quality improvement experts and
enthusiasts is the limited pediatric
hospitalist presence. As NICHQ CEO
Charlie Homer noted in his keynote
speech at the 2007 Pediatric Hospital
Medicine Meeting in Salt Lake City,
we share the same goals. Yet there
were only a handful of hospitalists
in the audience. True, some of the
themes are replicated in hospitalist
meetings, including PDSA cycles,
reliability science, and hand-off
standardization, but it’s mostly
doctors who are present at the typical
PAS, AAP, or SHM meetings. What’s
unique about NICHQ is the multidisciplinary approach encouraged by the
different professionals, interests, and
international perspectives represented.
For us as hospitalists to make a
difference, we need to collaborate and
expand our horizons. NICHQ is one
way for us to do this. After attending
this meeting, the benefits are clear,
and it’s obvious why the AAP SOHM
is encouraging more active hospitalist
participation in NICHQ by offering $500
scholarships to this meeting. Next year’s
meeting is March 10-12 in Dallas. Please
think about going, or sending someone
from your program. It’s particularly
important to get community hospitalists
to attend this meeting, since most of the
representatives come from children’s
hospitals. Stay tuned to the listserv®
for announcements about next year’s
scholarship program.
To find out what you missed in Miami
(what happens in South Beach, stays in
South Beach), go to www.NICHQ.org. In
fact, you can access handouts from the
2008 meeting by going to the NICHQ
website, and navigating to the 7th
Annual Forum Section and clicking on
the meeting materials tab. (It’s free, so
keep it quiet.) The take home message is
really to encourage greater collaboration
between hospitalists and NICHQ. A
partial listing of relevant inpatient
topics includes: quality improvement
fundamentals (full day workshop),
expanding parent/provider partnership
to improve quality and safety (full day
workshop), a practical approach to
purging harm from pediatric healthcare
(full day workshop), pediatric nursing
workshop strategic planning, hot topics
in the 5 Million Lives campaigns, asthma
guidelines, nurses take the quality lead,
transforming academic hospitals, timely
treatment and recognition of shock, and
standardization of patient hand-offs.
Mamta Reddy, Director of
SOBRAP, Pat Wanieweski,
Asthma Coordinator for New
York State Department of Health,
and Humayun J. Chaudhry, the
Commissioner of Health Services
of Suffolk County Department
of Health Services, held an
educational session revolving
around the care of asthma at a
local and state level. Dr Reddy
reviewed the new guidelines and
discussed the efforts of the South
Bronx Asthma Partnership which
provides provider education
and medical and non-medical
asthma management for inner
city patients and families in
New York City. Pat Wanieweski
described collaborative efforts
to reduce the burden of asthma
in New York City by forming
improvement teams to organically
spread innovations in asthma care
through primary care practices,
community health centers, school
based clinics, day cares, hospitals,
and emergency departments.
Dr Chaudhry showed how a
Medicaid demonstration project
was able to reduce ER visits and
hospitalizations by more than
60%, by identifying high resource
utilization patients, focusing on
teaching these patients home
management skills and utilizing
public health nurse visits. See
page 27 for all SOHM grant
opportunities.
Hospital Pediatrics | 21
Special report
Family-Centered Care…
Jugglers Needed! How hospitalists can create balance between patient
care, education and work during family-centered rounds.
Nicole Paradise Black, MD, FAAP, Assistant Professor of Pediatrics,
Associate Director, Pediatric Residency Program, blacknm@peds.ufl.edu
University of Florida College of Medicine, Shands Children’s Hospital at UF, Gainesville, FL
Shelley Wells Collins, MD, FAAP, Assistant Professor of Pediatrics, swcgator@peds.ufl.edu
University of Florida College of Medicine, The Congenital Heart Center, Shands Children’s Hospital at UF, Gainesville, FL
Erik W. Black, MA, Doctoral Fellow and Candidate, Educational Technology, erikwblack@gmail.com
University of Florida College of Education, School of Teaching and Learning, Gainesville, FL
Introduction
A growing body of research exists to
support the positive impact that familycentered care (FCC) creates for patients,
patients’ families, physicians-in-training
and practicing physicians.1-3 Familycentered rounds (FCR) is a subset of
family-centered care in an inpatient
setting and described by Sisterhen
et al. as facilitating an interface
between patients, families and medical
professionals and allowing for the
development of a unified plan of care.4
Equally as important, in the academic
setting FCR constitutes an opportunity
for both teaching and assessing medical
students and residents in the context of
real-life situations.
This article focuses on education
and FCR. It reviews the theory of
contextualized learning, describes what
can be learned and assessed during
FCR, and provides practitioners with
recommendations for maintaining a
balance between education, work and
patient care on rounds.
Contextualized learning theory
FCR is an example of a pedagogic
strategy used in a contextualized
learning environment. The notion
of contextualized learning suggests
that knowledge is most effectively
acquired when it is framed within
the context in which it will be used.
Koohang and Harman state that
contextualized learning and teaching
situations permit theoretical learning
and proficiency development through
direct participation in real-life learning
environments. Students are able to
integrate “propositional knowledge”
with “experiential knowledge”, thereby
“[linking] theory to action.” This type of
“deep learning” fosters the development
22 | American Academy of Pediatrics
of higher order or critical thinking
skills.5
According to Fullan, learning in context
is effective because it is targeted,
situational, and social; promoting
shared and collective knowledge and
engendering commitments. Learning
in context also creates situations that
specifically promote lifelong learning,
including opportunities to learn from
others, the selective retention of good
ideas and best practices, and monitoring
of performance.6
Medical school clerkships and residency
are historically rooted in contextualized
learning, so the trend towards workroom
conference rounds and away from
rounds with the patient stands in
contrast to precedent. Fortunately, the
FCC movement is bringing us back to
the bedside.
What can be learned?
FCR is an experience that is full
of teachable moments. Modeling
behaviors is one of the more obvious
ones. Examples include demonstrating
effective communication while
navigating a difficult situation or
engaging a scared or reluctant patient.
Physical exam findings provide
concrete and memorable learning
experiences. Even situations that are
not handled correctly (e.g., giving
medical information in an inappropriate
manner) can serve as an educational
opportunity. These teachable moments
simply cannot occur in a conference
room without the presence of the
patient and/or their family.
Furthermore, the concept of presenting
in front of patients and families on FCR
can serve as a motivator to improve
medical knowledge and communication
skills. Paradise Black et al. found that
medical students reported spending
more time understanding their patients’
medical issues in order to be better
prepared for FCR and adequately
present the information to the patients
and families.3 One student stated that,
“Communicating with the families in
layman’s terms also forced me to truly
understand the problems and our plan;
in order to communicate it in the most
basic way.” Another student noted that:
I feel encouraged to be completely
prepared for rounds in order to show
parents that the individuals who are
taking care of their child are informed
and educated. This motivated me to do
as much research as possible into the
disease process taking place.
Finally, teaching in the family-centered
environment is not instructivist or from
the top down. Anyone in the room—
patient, family, nurse, staff, medical
student, or physician—-can contribute
and provide teaching points. In order to
foster this concept, it may behoove the
attending to set the tone of the learning
environment by thinking of his or her
role as that of the “lead learner” rather
than an all-knowing disseminator of
knowledge.6
What can be assessed?
Not only is FCR important for teaching,
it is an effective venue for assessment.
The Accreditation Council of Graduate
Medical Education (ACGME) mandates
that pediatric residents provide
culturally effective, developmentally
and age-appropriate, and effective
family-centered care.7 In addition
to these requirements, a variety of
assessment ‘tools’ have been identified
by the ACGME for outcomes assessment
determination. Some of these tools (e.g.
checklist evaluation of live performance)
easily lend themselves to the FCR
experience.8 Swing advocates for
multiple administrations of qualitative
assessments, stating: “Ongoing
implementation of snapshot methods
of assessment involving observation or
interaction focused on specific aspects
of resident performance will be more
helpful”.9 Given these specifics, FCR
is an ideal method for the repeated
qualitative assessment of ACGME
competencies, potentially eliminating
some of the logistical issues associated
with evaluation as presently practiced.10
Balance Between Patient
Care and Education
The challenge of balancing patient
care and promoting educational
opportunities during FCR is not a new
problem. Families need and deserve
the opportunity to be involved in
the discussion of the care of their
children. It is easy to underestimate
the impact physicians have upon the
experience a family has while their
child is in the hospital. Families are
frightened, frequently navigating the
hospital system for the first time. FCR
allows the medical team to advocate for
their patients and families on a more
personal level and in a highly involved
way. Having a sick child is the worst
nightmare most people could ever
imagine—knowing that there is a team
caring for them and feeling involved as a
member of that team gives the families a
sense of control, a sense of calm. It goes
a long way towards providing peace of
mind.
On the educational side residents
have increasing workloads and
decreasing work hours, making each
minute spent in the hospital valuable.
While it is true that every patient
presents an opportunity to learn, it
is impractical to spend 15 minutes
discussing each patient on the service.
Naturally, organized rounds present
more time for teaching, while, at the
same time, addressing the needs of
the patient and families. Here are a
few recommendations to help mediate
resident education and patient care
needs in order to conduct efficient FCR.
1. Prioritize the patients so the
residents know which patients will
be presented first. For example,
see all the discharges first or the
sickest patients first and then the
discharges. Each attending should
decide what works for him or her,
and then be consistent.
2. Do your “homework”. Review
vital signs and laboratory data
prior to rounds and then just have
the presenter touch on what was
abnormal.
3. Ask nursing to enlist the families’
involvement in rounds. Be sure to
have a consistent time for rounds
and share that with nursing and the
families.
4. Have residents and medical students
give problem-directed presentations.
5. Make expectations about roles clear
(written and verbal format) at the
beginning of the rotation and review
as needed. For example, as you enter
the room, the process can be akin
to running a code blue. “Medical
student Mark you’ll be writing the
orders, intern Isabel you’ll conduct
introductions…”
6.In order to preserve the autonomy
of the senior residents as they run
rounds, have them observe how you
conduct FCR. Adopt the philosophy
that you are partners in the lead
learner role and spend time with
them outside of rounds to ensure
they understand how to conduct
FCR. Then, let them do it.
7. Set an expectation for the residents
and students that a plan has already
been formulated by them.
8. Establish teaching goals for rounds.
Choose patients on your service
about which you can make specific
teaching points and spend more time
on those patients during rounds.
Or, as Dr. Glen Tamura suggested
at the FCR panel discussion at the
APA SIG on FCC in Hawaii 2008,
make a habit of providing two quick
teaching points on each patient.
9. Examine the patient while the
resident is presenting the data.
10.Bring charts on rounds and identify
someone as a scribe for orders.
11.Check yourself—if parents or
patients require a more prolonged
discussion reassure them that you
will return. Include the resident
when you return to talk with the
family.
12.Watch the clock. No one is listening
to you if rounds last too long.
13.Enlist the senior resident to keep
you moving.
Whether you have 5 or 35 patients on
your service, keeping rounds moving
while ensuring that the residents are
learning and the patients and parents
feel attended to is an art. It takes
practice and persistence. Don’t let the
groaning in the background deter you.
The more you do it, the more smoothly
it will go.
References
1. Muething, S, Kotagal, UR, Schoettker, PJ,
Gonzalez del Rey, J, DeWitt, TG. Familycentered bedside rounds: A new approach to
patient care and teaching. Pediatrics. 2007;
119: 829-832
2. Latta, LC, Dick, R, Parry, C, Tamura GS.
Parental responses to involvement in rounds on
a pediatric inpatient unit at a teaching hospital:
a qualitative study. Acad Med. 2008; 83:292-7
3. Paradise Black, NM, Kelly, MN, Black, EW,
DiPietro, MK, Novak, MA. Understanding the
educational impact of family-centered rounds
on medical student education using reflective
assessments. Unpublished manuscript, 2008
4. Sisterhen, LL, Blaszak, RT, Woods, MB, Smith,
CE. Defining family-centered rounds. Teach
Learn Med. 2007; 19: 319-322
5.Koohang, A, Harman, K. Learning Objects:
Theory, Praxis, Issues and Trends. Santa Rosa,
CA: Informing Science Press; 2007
6. Fullan, M. Principals as leaders in a culture of
change. Educational Leadership. 2002; 59: 1620
7. Accreditation Council for Graduate Medical
Education. Program Requirements for
Residency Education in Pediatrics. Available
at: www.acgme.org/acWebsite/downloads/RRC_
progReq/320pr106.pdf. Accessed February 27,
2008
8. Accreditation Council for Graduate Medical
Education, American Board of Medical
Specialties. Toolbox of Assessment Methods.
Available at: www.acgme.org/Outcome/assess/
Toolbox.pdf. Accessed February 28, 2008
9. Swing, SR. Assessing the ACGME general
competencies: general considerations and
assessment methods. Acad Emerg Med. 2003; 9:
1278-88
10.Heard, JK, Allen, RM, Clardy, J. Assessing the
needs of residency program directors to meet
the ACGME general competencies. Acad Med.
2002; 77: 750
Interested in submitting an article on
Family Centered Care? Please contact
Jennifer Maniscalco, MD, MPH, FAAP
at jmaniscalcomd@gmail.com.
Section On
Hospital
Medicine
Review current pediatric hospitalist
resources. Find out what other programs
are doing.
Visit the SOHM Web site.
http://www.aaphospmed.org
And join the SOHM LISTSERV®. E-mail
Niccole Alexander at nalexander@aap.org
Hospital Pediatrics | 23
NEW MEMBERSHIP CATEGORY
Child Life Specialists Join the
Section on Hospital Medicine
Chris Brown, MS, CCLS, Director, Child Life and Family Centered Care
Dell Children’s Medical Center, Austin, TX
Child Life Council Liaison to the AAP Committee on Hospital Care
O
n May 15th, 2008 the Advisory
Committee to the Board on
Membership (ACBOM) approved
a bylaw referendum to allow Certified
Child Life Specialists (CCLS) to join
the Society on Hospital Medicine
(SOHM) as affiliate members. This
gesture reflects the important and
successful working partnership between
physicians and CCLS’s in hospital
settings. The inclusion of Child Life
programs in pediatric settings has
become widely accepted and advocated
by the American Academy of Pediatrics
(AAP)1 and other organizations such as
the National Association of Children’s
Hospitals and Related Institutions
(NACHRI)2 and The Joint Commission.3
Child Life programs strive to promote
optimum development of children,
adolescents, and families, to maintain
normal living patterns, and to minimize
psychological trauma.4 Child Life
professionals are specially trained in
child development and the effects of
illness, injury, disability, and healthcare
or hospitalization on the child and
family. Utilizing therapeutic play
techniques, relationship building,
communication skills, educational
interventions, and emotional support,
the CCLS seeks to provide a normalizing
and supportive experience for children
and families so as to enhance effective
coping and understanding.
The CCLS works collaboratively
with physicians and other healthcare
professionals to positively influence care
that strives to be psychosocially sound,
developmentally appropriate and familycentered. Interdisciplinary collaboration
is fundamental to the quality of pediatric
health care delivery, including physicians
at every level of their training and
clinical practice working side by side
with CCLS’s. This partnership has proven
effective in facilitating pain management,
enhancing compliance with treatment
protocols, and promoting family-centered
care. In addition, physicians report that
24 | American Academy of Pediatrics
their job is often made easier with the
assistance of CCLS’s, for example, to
provide developmentally appropriate
explanations and support the child and/
or family during procedures. According
to Dr Mark Shen, Lead Hospitalist at
Dell Children’s Medical Center in Austin,
TX, “Child Life has been invaluable in
my practice for those daily situations
where I’ve planned a test or intervention
but lack both the time and training
to adequately prepare the child, and
family, for the event. I have also found
that child life specialists are in a better
position to evaluate the emotional and
developmental well-being of children
with their ability to remove many of
the intimidating ‘layers’ of the hospital
environment. And, frankly, they simply
create happier places for kids, which
always reminds me of why I love being a
pediatrician.”
diagnoses, medical procedures,
treatment regimens, or side effects
such as hair loss).
3. Teaching and facilitating “positioning
for procedures” to enable safe and
effective medical care (see figure 1).
4. Accompanying the healthcare
team during medical procedures by
providing distraction (also known
as alternative focus techniques)
and other coping techniques during
procedures, thus maximizing
the child’s cooperation and often
minimizing or precluding the use of
sedation.
5. Supporting family members during
anesthesia induction, resuscitation,
bereavement, or other challenging
events.
6. Educating medical students or new
residents regarding psychosocially
sound, family-centered care.
Specific ways a Certified Child Life
Specialist can support care by medical
staff include:
References
1. Conducting informal and formal
developmental assessments (such as
the Denver Development Screening
Tool).
2. Assisting in the physician or
other provider’s age-appropriate
communication with patients and/
or family members (e.g., explaining
1. American Academy of Pediatrics, Committee
on Hospital Care. (2006) Child life services.
Pediatrics 118:11757-1763.
2. National Association of Children’s Hospitals
and Related Institutions. (1996) Pediatric
Excellence in Health Delivery Systems.
3. Joint Commission. (2008) Management of
human resources. Comprehensive Accreditation
Manual for Hospitals. Chicago, IL: Joint
Commission.
4. Child Life Council (1995). Child life position
statement. Rockville, MD: Child Life Council.
Child Life Specialists Now Eligible
for Section Membership!!
The AAP now accepts Child Life Specialists as Affiliate Members into
the Section on Hospital Medicine. The other approved Affiliate Member
categories for Section membership are Nurse Practitioners and Physician
Assistants.
Child Life Specialists are experts in child development, who promote
effective coping through play, preparation, education, and self-expression
activities (Child Life Council). For information on membership please
visit the Academy web site at www.aap.org.
SUBCOMMITTEE UPDATES
What’s New?
NEW!!
Subcommittee
on Research
Karen Wilson, MD, FAAP
Chairperson
Karen_wilson@urmc.rochester.edu
We are very excited to announce
the formation of the Research
Subcommittee for the SOHM! The
purpose of the subcommittee is to
further the research agenda of the
pediatric hospitalist community, and
support pediatric hospitalist research
nationally. We met informally at the
PAS in Hawaii. Some of our initial
ideas include doing a needs assessment
of the PHM community to see what
support our colleagues need, working
with PRIS to increase its capacity and
infrastructure, and creating workshops
on using the large national inpatient
datasets. We also have a listserv for
members. The subcommittee is open
to anyone interested in pediatric
hospitalist research. If you would like
to join us, we will be meeting at the
Pediatric Hospital Meeting meeting in
Denver, or you can email Karen Wilson,
chair, at Karen_wilson@urmc.rochester.
edu.
PLEASE NOTE: We are planning a
workshop organized by Lisa Simpson
at the Cincinnati Children’s Hospital
Medical Center on HCUP inpatient
datasets in conjunction with an existing
1.5 day workshop on HCUP data in
general. If you have any questions about
the workshop, contact Karen Wilson at
Karen_wilson@urmc.rochester.edu or
585-273-1679.
Interested in working with the
new Subcommittee on Research?
Contact Karen Wilson, MD, FAAP at
Karen_wilson@urmc.rochester.edu.
Subcommittee
on Complex Care
Allison Ballantine, MD, FAAP
ballantine@email.chop.edu
It has been another busy season for the
Complex Care Subcommittee. For a full
update on the broad issues of complex
care, please see Rishi Agrawal’s column
on developments in Complex Care in
this issue. In terms of activities specific
to the subcommittee, we launched
our listserv® and have seen many
interesting discussions around clinical
and administrative issues. We also have
witnessed an enthusiastic populating
of the SOHM Library with educational
materials relating to complex care. We
are looking forward to the hospitalist
meeting in Denver where we will have a
round table discussion exploring issues
relating to inpatient services caring for
medically complex patients.
Interested in Complex Care
or related areas? Want more
information about the plans and
workings of this subcommittee?
Write Allison Ballantine, MD, FAAP
at ballantine@email.chop.edu to
get involved!
Section on
Hospital Medicine
Subcommittee
Chairpersons
Billing & Coding
Yong Han, MD, FAAP Chair
yshan@texaschildrenshospital.org
Community Hospitalists
Beth Robbins, MD, FAAP Chair
erobbins@aahs.org
Complex Care
Allison Ballantine, MD, FAAP
Chair
ballantine@email.chop.edu
Critical Care
Ben Alexander, MD, FAAP
Co-Chair
balexander@wakemed.org
Kimberly Boland, MD, FAAP
Co-Chair
k.boland@louisville.edu
Early Careerists &
Pediatric Residents
Julia Aquino, MD, FAAP Chair
jaquino3@jhmi.edu
Family-Centered Care
Geeta Singhal, MD, FAAP
Co-Chair
gsinghal@bcm.edu
Ted Sigrest, MD, FAAP Co-Chair
tsigrest@pol.net
Subcommittee on
Community Hospitalists
Beth Robbins, MD, FAAP
Medical Informatics &
Technology
David Price, MD, FAAP Chair
dtprice0599@gmail.com
Chairperson
erobbins@aahs.org
Palliative Care
Maggie Hood, MD, FAAP Chair
Jack Percelay, MD, MPH, FAAP
maggie.hood@multicare.org
Exec Comm Liaison
jpercelaymd@yahoo.com
The Subcommittee on Community
Hospitalists recently hosted two
conference call meetings for members
to meet each other and to begin
discussions about goals and projects for
the committee. Work was begun on a
mission statement for the group. The
need to express the value of our work
was discussed and ways to partner with
existing networks and projects that
are examining such issues. Short term
goals are 1) fostering communication
Research
Karen Wilson, MD, FAAP Chair
karen_wilson@urmc.rochester.edu
Web Master
Liborio LaRussa, MD, FAAP
lee@larussafamily.com
LISTSERV® Moderator
Kevin Powell, MD, PhD, FAAP
kpowell@pol.net
Continued on page 27
Hospital Pediatrics | 25
THANK YOU FOR THE OPPORTUNITY
Matthew Garber, MD, FAAP
Matthew Garber, MD, FAAP
Matthew.Garber@PalmettoHealth.org
I
am honored and excited to have been
elected to the AAP SOHM Executive
Committee.
I grew up in Florida, majored in Russian
language and literature at Dartmouth
College, got my MD from the University
of South Florida, and completed my
Pediatric residency at the University
of South Carolina in Columbia. After
residency, I joined the Children’s Clinic
in the upstate of SC, a traditional
practice with rotating hospital duties.
Some of us aren’t designed for well
visits, and three years later I became
an academic hospitalist at Greenville
Memorial Hospital.
At Greenville, the director of inpatient
pediatrics introduced me to the then
Provisional AAP Section on Hospital
Care. I became active on the listserv®,
joined many hospital committees,
and got involved in many “systems”
issues, but the die was cast after that
first meeting in San Antonio, Pediatric
Hospitalists in Academic Settings.
The most enthusiastic, intellectually
curious group of people ever assembled,
dedicated to the acquisition of
knowledge and the health of children.
I still have the attendee list with brief
job descriptions next to several of the
names (you may not remember what
you were doing five years ago, but I do).
The list substantiates Jack Percelay’s
aphorism, “if you’ve seen one hospitalist
program, you’ve seen one.”
Last year I returned to Columbia, lured
by the academic opportunities with the
school of medicine, my older but still
unparalleled attendings from residency,
and the promise of a new freestanding
Children’s Hospital. This position affords
me more time to work on hospitalist
issues and serve on committees like
this one and the subcommittee for
Family Centered Care. Unfortunately
for section members, I also have time
to subject them to even more prolific
listserv contributions.
26 | American Academy of Pediatrics
Every PHM meeting has been a
great success, and I have a strong
kinship with the rapidly evolving
pediatric hospitalist community. My
current position combines aspects
of an academic medical center
and a community hospital, giving
me a somewhat unique and broad
perspective. Collaboration and flexibility
have served me well in hospital
medicine and should help me contribute
to the work of the section. I have strong
interests in evidence based medicine,
medical education, and family centered
care, and will advocate for these
principles as well as for the children
and hospitalists the committee serves.
Issues the committee will face are
standardization and cost effectiveness of
care, original research, post-residency
training, career satisfaction and
longevity, and recruitment. One key
issue which I would like to address is
the tension between standardization
of care and clinician autonomy. I will
strive to continue the excellent work
which has been done, and build on it,
trying to keep in mind the community
hospitalist, the academician, the
resident interested in hospital medicine,
and, of course, the children. Thanks for
electing me to your committee.
Available Now!
PREP® Pediatric Hospital
Medicine Study Kit
N
ew from the American Academy
of Pediatrics trusted Pediatrics
Review and Education Program
(PREP®), the Pediatric Hospital Medicine
Study Kit is a collection of questions,
critiques and articles published in the
pertinent 2006-2008 editions of PREP
Self-Assessment.
This indispensable and affordable
study kit is a great way to enhance the
knowledge and skills needed to provide
excellent patient care and prepare for
Maintenance of Certification™ (MOC).
The PREP® Pediatric Hospital Medicine
Study Kit contains:
• 213 PREP Self-Assessment questions from
2006-2008 focusing on Hospital Medicine
related topics
• Up to 24 AMA PRA Category 1 Credit(s)™
• Answer Key
• Spiral bound book format
For more information contact Monique
Evelyn at mevelyn@aap.org
or call 1-847-434-4728.
The American Academy of
Pediatrics (AAP) is accredited
by the Accreditation Council for
Continuing Medical Education
(ACCME) to provide continuing
medical education for physicians.
The AAP designates this
educational activity for a
maximum of 24 AMA PRA
Category 1 Credit(s) ™.
Physicians should only claim
credit commensurate with the
extent of their participation in
the activity.
Subcommittee Updates, continued from page 25
within the group by distributing contact
information and 2) reaching out to other
SOHM members on the website and at
the annual meeting in Denver this July.
Any members interested in
working with the committee should
contact Beth Robbins, MD, FAAP at
erobbins@aahs.org. Any members
interested in contributing to the
Community Hospitalists column
of the SOHM news journal should
contact John Pope, MD, MPH, FAAP
at jpope@phoenixchildrens.com.
Subcommittee on
Palliative Care
Maggie Hood, MD, FAAP
Margaret.hood@orhs.org
Glad tidings!! After much effort, hard
work and perseverance on the behalf of
many individuals committed to Pediatric
Palliative Care, we are happy to
announce that provisional status of the
American Academy of Pediatrics Section
on Pediatric Hospice and Palliative
Medicine (SPHPM) was granted in May
2008. At the present time, the details
of AAP staff assignments are pending.
Membership application, activities and
goals will be forthcoming.
The SPHPM Steering Committee is very
excited to have the educational and
advocacy expertise of the AAP as the
development of the Section unfolds,
and will work with interested members
to ensure their needs are addressed.
One of the most critical elements
at this very moment is the subject
of board certification for Palliative
Care. In 2007, the American Board of
Medical Specialties assumed the role of
certification for Hospice and Palliative
Medicine. Ten certifying boards are
participating in this, including the
American Board of Pediatrics.
Application for the first certifying board
has closed. The next certifying exams
will be held in 2010 and 2012. After that,
one must have completed a fellowship
in Palliative Care to qualify for board
certification. As of now, there are three
fellowships in Pediatric Hospice and
Palliative Medicine. This is a crucial factor
since the field of Palliative Care is calling
for more qualified providers to educate
and provide expertise to a growing
number of patients and families. Please
be proactive in evaluating your interest,
practice experience in Palliative Care and
consider applying for certification.
The SOHM Subcommittee on Palliative
Care will be retired and folded into
the new Section as of July 30, 2008. I
would like to thank the members of this
Subcommittee for the commitment and
interest in moving this field ahead. We
welcome your continued participation and
will keep you posted as the details unfold.
Should you have any questions, or if
you need more information about the
Provisional Section or certification,
please contact Maggie Hood, MD,
FAAP at Margaret.hood@orhs.org.
Section on Hospital Medicine Grant Opportunities
The Section funds a number of opportunities for SOHM members throughout the year. Stay tuned to the Section LISTSERV®
and SOHM web site at www.aaphospmed.org for details.
AAP Legislative Conference
Over 1,900 pediatricians and other interested individuals throughout the nation participate in the Academy’s annual legislative
conference. The conference planners instruct attendees on the overall state and federal legislative process, develop advocacy
skills, and introduce strategies and techniques for utilizing the media.
Travel Grant: All travel and meeting-related expenses as outlined in the Academy’s travel policy
(1 - last approved in August/September 2007)
Next Conference: March/April 2009
NICHQ Forum
The National Initiative for Children’s Healthcare Quality (NICHQ)
is an action-oriented organization dedicated solely to improving the quality
of health care provided to children. Founded in 1999, NICHQ’s mission is to
eliminate the gap between what is and what can be in health care for all children.
Travel Grant: $500 (up to 3 - last approved
in December/January 2008)
Next Conference: March 10-12, 2009
Pediatric Hospital Medicine Conference
The three leading organizations in Pediatric Hospital Medicine –
AAP, Academic Pediatric Association, and the Society of Hospital Medicine –
convene to discuss the latest in this growing field. The Section presents an
opportunity for Residents to attend the Conference by offering $500 travel grants.
Travel Grant: $500
(up to 3 - last approved in May/June 2008)
Next Conference: July 23-26, 2009
Hospital Pediatrics | 27
SOHM ACTIVITIES
Section on Hospital Medicine Program
Monday, October 13, 2008 · Boston, MA · AAP National Conference & Exhibition
Moderator
Daniel Rauch MD, FAAP
Education and Program Chairperson
8:00 am
Joint Session (H3018) – Section on
Hospital Medicine and Section on
Critical Care: Hospice and Palliative
Care for the Hospitalized Patient Caring
for children with life-threatening
illness: Can we do better?”
Joanne Wolfe, MD, FAAP
Palliative Care in the PICU
Lorry Frankel, MD, FAAP
Overcoming Barriers to Palliative
and Hospice Care
Margaret Hood, MD, FAAP
10:00 am
Poster Session and Presentation
of the Pediatric Hospital Medicine
Abstract Research Award
11:30 am
Break
11:45 am
Business Meeting and Lunch
Laura Mirkinson, MD, FAAP, Chairperson
12:30 pm
Community Hospital
“Hospitalist” Programs
Faculty: Scott Krugman, MD,
FAAP; Ken Roberts, MD, FAAP; and
Steve Narang, MD, FAAP
P osters for V iewing
• (718) Cost and Length of Stay for US
Children Hospitalized for Respiratory
Illness.
• (1058) Pediatric Hospitalist
Compensation and Productivity 2006-7.
• (691) Follow-Up Echocardiogram Rate
after Diagnosis of Kawasaki Disease.
• (984) Risk of Apnea in Bronchiolitis: A
Systematic Review.
• (500) Applying of Inpatient
Core Measures Before and After
Implementation of a Bronchiolitis Care
Path.
• (562) Infantile Kawasaki Disease
Refractory to Conventional Therapy: A
Case for Infliximab.
• (550) Putting in the Pediatric IV: Does
Confidence and Competence Make a
Difference?
• (883) Newborn Circumcision by
Hospitalists: A Three-Year Report
on Complications and Referrals for
Suspected Abnormalities.
• (166) Improvement of Quality and
Timeliness of Discharge Summaries.
• (69) A Pediatric Hospitalist Elective:
Training Hospitalist Leaders.
• (431) Back Pain and Braces? 14 Year-Old
with Eikenella Corrodens Discitis with
Contiguous Vertebral Osteomyelitis.
• (679) An Infant with Salmonella
Meningitis and Concurrent Influenza
Type B Infection.
• (556) An Uncommon Case of Neonatal
Cholestasis.
• (311) Pediatric Mock Codes: Improving
Resident Resuscitations.
• (630) A Survey of Health Care Providers
Regarding Family-Centered Rounding.
• (794) Langerhans Cell Histiocytosis: An
Unusual Mimic of Sexual Abuse.
• (611) Contribution of a Hospitalist
Lecture Series to the Medical Student
Inpatient Experience.
• (210) Family Centered Rounds:
Measuring the Impact.
• (322) Pulmonary Hypertension,
a Presentation of Arnold Chiari
Malformation Treated by Surgical
Decompression.
• (218) When Parents and Providers
Disagree on a Child’s Treatment.
• (603) Pic’m Study: Parental Influence in
Clinical Management.
• (103) Baclofen-Induced Psychosis.
• (368) A Limitation of Computerized
Records in Recognizing Critical Lab
Values: An Infant with Neutropenia.
2:00 pm
Break
2:15 pm
Inpatient Quality Improvement
Faculty: Mike Vossmeyer, MD, FAAP
3:45 pm
Break
4:00 pm
Primary Care for the Hospitalized Patient
Faculty: Sarah McBride, MD, FAAP
5:30 pm
Adjourn
28 | American Academy of Pediatrics
Non-Profit Org
U.S. Postage
PAID
Arlington Heights, IL
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