<p><strong>Background: </strong>Deimplementation, the systematic elimination of low-value practices, has emerged as an important focus within implementation science. Bronchiolitis is the leading cause of infant hospitalization. Among stable inpatients with bronchiolitis who do not require supplemental oxygen, continuous pulse oximetry monitoring is recognized as an overused, low-value practice in pediatric hospital medicine. There is strong scientific evidence and practice guideline support for limiting pulse oximetry monitoring of stable children with bronchiolitis who do not require supplemental oxygen, yet the practice remains common. This study aims to (1) characterize the extent of this overuse in hospitals located in the USA and Canada, (2) identify barriers and facilitators of successful deimplementation of continuous pulse oximetry monitoring in bronchiolitis, and (3) develop consensus strategies for large-scale deimplementation. In addition to identifying feasible strategies for deimplementation, this study will test the feasibility of data collection approaches to be employed in a large-scale deimplementation trial.</p>

<p><strong>Methods: </strong>This multicenter study will be performed in approximately 38 hospitals in the Pediatric Research in Inpatient Settings Network. In Aim 1, we will determine the rate of overuse within each hospital by performing repeated cross-sectional observational sampling of continuous pulse oximetry monitoring of stable bronchiolitis patients age 8 weeks through 23 months who do not require supplemental oxygen. In Aim 2, we will use the Consolidated Framework for Implementation Research (CFIR) as a framework for semi-structured interviews with key stakeholders (physician, nurse, respiratory therapist, administrator, and parent) at the highest- and lowest-overuse hospitals to understand barriers and facilitators of continuous pulse oximetry monitoring deimplementation. In Aim 3, we will use a theory-based causal model to match the identified barriers and facilitators to potential strategies for deimplementation. Candidate strategies will be discussed with a panel of stakeholders from hospitals with high rates of overuse to assess feasibility and acceptability. A questionnaire ranking strategies based on feasibility, acceptability, and impact will be administered to a broader group of stakeholders to arrive at consensus about promising strategies for large-scale deimplementation to be tested in a subsequent trial.</p>

<p><strong>Discussion: </strong>Effective strategies for deimplementing continuous pulse oximetry monitoring of stable patients with bronchiolitis have not been well characterized. The findings of this study will provide further understanding of factors that facilitate deimplementation in pediatric hospital settings and provide pilot and feasibility data to inform a trial of large-scale deimplementation of this overused practice.</p>

<p><strong>Trial registration: </strong>Not applicable. This study does not meet the World Health Organization definition of a clinical trial.</p>

<p><strong>OBJECTIVE: </strong>The aim of this study was to identify emergency department (ED) heart rate (HR) values that identify children at elevated risk of ED revisit with admission.</p>

<p><strong>METHODS: </strong>We performed a retrospective cohort study of patients 0 to 18 years old discharged from a tertiary-care pediatric ED from January 2013 to December 2014. We created percentile curves for the last recorded HR for age using data from calendar year 2013 and used receiver operating characteristic (ROC) curves to characterize the performance of the percentiles for predicting ED revisit with admission within 72 hours. In a held-out validation data set (calendar year 2014 data), we evaluated test characteristics of last-recorded HR-for-age cut points identified as promising on the ROC curves, as well as those identifying the highest 5% and 1% of last recorded HRs for age.</p>

<p><strong>RESULTS: </strong>We evaluated 183,433 eligible ED visits. Last recorded HR for age had poor discrimination for predicting revisit with admission (area under the curve, 0.61; 95% confidence interval, 0.58-0.63). No promising cut points were identified on the ROC curves. Cut points identifying the highest 5% and 1% of last recorded HRs for age showed low sensitivity (10.1% and 2.5%) with numbers needed to evaluate of 62 and 50, respectively, to potentially prevent 1 revisit with admission.</p>

<p><strong>CONCLUSIONS: </strong>Last recorded ED HR discriminates poorly between children who are and are not at risk of revisit with admission in a pediatric ED. The use of single-parameter HR in isolation as an automated trigger for mandatory reevaluation prior to discharge may not improve revisit outcomes.</p>

<p>Alarm fatigue has been linked to patient morbidity and mortality in hospitals due to delayed or absent responses to monitor alarms. We sought to describe alarm rates at 5 freestanding children's hospitals during a single day and the types of alarms and proportions of patients monitored by using a point-prevalence, cross-sectional study design. We collected audible alarms on all inpatient units and calculated overall alarm rates and rates by alarm type per monitored patient per day. We found a total of 147,213 alarms during the study period, with 3-fold variation in alarm rates across hospitals among similar unit types. Across hospitals, onequarter of monitored beds were responsible for 71%, 61%, and 63% of alarms in medical-surgical, neonatal intensive care, and pediatric intensive care units, respectively. Future work focused on addressing nonactionable alarms in patients with the highest alarm counts may decrease alarm rates.</p>

<p><strong>OBJECTIVE: </strong>To estimate differences in the length of stay (LOS) and costs for comparable pediatric patients with and without venous thromboembolism (VTE), catheter-associated urinary tract infection (CAUTI), and pressure ulcer (PU).</p>

<p><strong>METHODS: </strong>We identified at-risk children 1 to 17 years old with inpatient discharges in the Nationwide Inpatient Sample. We used a high dimensional propensity score matching method to adjust for case-mix at the patient level then estimated differences in the LOS and costs for comparable pediatric patients with and without VTE, CAUTI, and PU.</p>

<p><strong>RESULTS: </strong>Incidence rates were 32 (VTE), 130 (CAUTI), and 3 (PU) per 10 000 at-risk patient discharges. Patients with VTE had an increased 8.1 inpatient days (95% confidence interval [CI]: 3.9 to 12.3) and excess average costs of $27 686 (95% CI: $11 137 to $44 235) compared with matched controls. Patients with CAUTI had an increased 2.4 inpatient days (95% CI: 1.2 to 3.6) and excess average costs of $7200 (95% CI: $2224 to $12 176). No statistical differences were found between patients with and without PU.</p>

<p><strong>CONCLUSIONS: </strong>The significantly extended LOS highlights the substantial morbidity associated with these potentially preventable events. Hospitals seeking to develop programs targeting VTE and CAUTI should consider the improved turnover of beds made available by each event prevented.</p>

<p><strong>OBJECTIVE: </strong>To develop and validate heart and respiratory rate percentile curves for hospitalized children and compare their vital sign distributions to textbook reference ranges and pediatric early warning score (EWS) parameters.</p>

<p><strong>METHODS: </strong>For this cross-sectional study, we used 6 months of nurse-documented heart and respiratory rates from the electronic records of 14,014 children on general medical and surgical wards at 2 tertiary-care children's hospitals. We developed percentile curves using generalized additive models for location, scale, and shape with 67% of the patients and validated the curves with the remaining 33%. We then determined the proportion of observations that deviated from textbook reference ranges and EWS parameters.</p>

<p><strong>RESULTS: </strong>We used 116,383 heart rate and 116,383 respiratory rate values to develop and validate the percentile curves. Up to 54% of heart rate observations and up to 40% of respiratory rate observations in our sample were outside textbook reference ranges. Up to 38% of heart rate observations and up to 30% of respiratory rate observations in our sample would have resulted in increased EWSs.</p>

<p><strong>CONCLUSIONS: </strong>A high proportion of vital signs among hospitalized children would be considered out of range according to existing reference ranges and pediatric EWSs. The percentiles we derived may serve as useful references for clinicians and could be used to inform the development of evidence-based vital sign parameters for physiologic monitor alarms, inpatient electronic health record vital sign alerts, medical emergency team calling criteria, and EWSs.</p>

<p><strong>OBJECTIVES: </strong>Medical emergency teams (METs) can reduce adverse events in hospitalized children. We aimed to model the financial costs and benefits of operating an MET and determine the annual reduction in critical deterioration (CD) events required to offset MET costs.</p>

<p><strong>METHODS: </strong>We performed a single-center cohort study between July 1, 2007 and March 31, 2012 to determine the cost of CD events (unplanned transfers to the ICU with mechanical ventilation or vasopressors in the 12 hours after transfer) as compared with transfers to the ICU without CD. We then performed a cost-benefit analysis evaluating varying MET compositions and staffing models (freestanding or concurrent responsibilities) on the annual reduction in CD events needed to offset MET costs.</p>

<p><strong>RESULTS: </strong>Patients who had CD cost $99,773 (95% confidence interval, $69,431 to $130,116; P &lt; .001) more during their post-event hospital stay than transfers to the ICU that did not meet CD criteria. Annual MET operating costs ranged from $287,145 for a nurse and respiratory therapist team with concurrent responsibilities to $2,358,112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost $350,698 per year, equivalent to a reduction of 3.5 CD events.</p>

<p><strong>CONCLUSIONS: </strong>CD is expensive. The costs of operating a MET can plausibly be recouped with a modest reduction in CD events. Hospitals reimbursed with bundled payments could achieve real financial savings by reducing CD with an MET.</p>

<p><strong>OBJECTIVES: </strong>To compare the prevalence, resource utilization, and mortality for pediatric severe sepsis identified using two established identification strategies.</p>

<p><strong>DESIGN: </strong>Observational cohort study from 2004 to 2012.</p>

<p><strong>SETTING: </strong>Forty-four pediatric hospitals contributing data to the Pediatric Health Information Systems database.</p>

<p><strong>PATIENTS: </strong>Children 18 years old or younger.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>We identified patients with severe sepsis or septic shock by using two International Classification of Diseases, 9th edition, Clinical Modification-based coding strategies: 1) combinations of International Classification of Diseases, 9th edition, Clinical Modification codes for infection plus organ dysfunction (combination code cohort); 2) International Classification of Diseases, 9th edition, Clinical Modification codes for severe sepsis and septic shock (sepsis code cohort). Outcomes included prevalence of severe sepsis, as well as hospital and ICU length of stay, and mortality. Outcomes were compared between the two cohorts examining aggregate differences over the study period and trends over time. The combination code cohort identified 176,124 hospitalizations (3.1% of all hospitalizations), whereas the sepsis code cohort identified 25,236 hospitalizations (0.45%), a seven-fold difference. Between 2004 and 2012, the prevalence of sepsis increased from 3.7% to 4.4% using the combination code cohort and from 0.4% to 0.7% using the sepsis code cohort (p &lt; 0.001 for trend in each cohort). Length of stay (hospital and ICU) and costs decreased in both cohorts over the study period (p &lt; 0.001). Overall, hospital mortality was higher in the sepsis code cohort than the combination code cohort (21.2% [95% CI, 20.7-21.8] vs 8.2% [95% CI, 8.0-8.3]). Over the 9-year study period, there was an absolute reduction in mortality of 10.9% (p &lt; 0.001) in the sepsis code cohort and 3.8% (p &lt; 0.001) in the combination code cohort.</p>

<p><strong>CONCLUSIONS: </strong>Prevalence of pediatric severe sepsis increased in the studied U.S. children's hospitals over the past 9 years, whereas resource utilization and mortality decreased. Epidemiologic estimates of pediatric severe sepsis varied up to seven-fold depending on the strategy used for case ascertainment.</p>