<p><strong>BACKGROUND: </strong> Surveillance for surgical site infections (SSIs) after ambulatory surgery in children requires a detailed manual chart review to assess criteria defined by the National Health and Safety Network (NHSN). Electronic health records (EHRs) impose an inefficient search process where infection preventionists must manually review every postsurgical encounter (&lt; 30 days). Using text mining and business intelligence software, we developed an information foraging application, the SSI Workbench, to visually present which postsurgical encounters included SSI-related terms and synonyms, antibiotic, and culture orders.</p>

<p><strong>OBJECTIVE: </strong> This article compares the Workbench and EHR on four dimensions: (1) effectiveness, (2) efficiency, (3) workload, and (4) usability.</p>

<p><strong>METHODS: </strong> Comparative usability test of Workbench and EHR. Objective test metrics are time per case, encounters reviewed per case, time per encounter, and retrieval of information meeting NHSN definitions. Subjective measures are cognitive load using the National Aeronautics and Space Administration (NASA) Task Load Index (NASA TLX), and a questionnaire on system usability and utility.</p>

<p><strong>RESULTS: </strong> Eight infection preventionists participated in the test. There was no difference in effectiveness as subjects retrieved information from all cases, using both systems, to meet the NHSN criteria. There was no difference in efficiency in time per case between the Workbench and EHR (8.58 vs. 7.39 minutes,  = 0.36). However, with the Workbench subjects opened fewer encounters per case (3.0 vs. 7.5,  = 0.002), spent more time per encounter (2.23 vs. 0.92 minutes,  = 0.002), rated the Workbench lower in cognitive load (NASA TLX, 24 vs. 33,  = 0.02), and significantly higher in measures of usability.</p>

<p><strong>CONCLUSION: </strong> Compared with the EHR, the Workbench was more usable, short, and reduced cognitive load. In overall efficiency, the Workbench did not save time, but demonstrated a shift from between-encounter foraging to within-encounter foraging and was rated as significantly more efficient. Our results suggest that infection surveillance can be better supported by systems applying information foraging theory.</p>

<p><strong>Objective: </strong>The objective was to prospectively derive and validate a prediction rule for detecting cases warranting investigation for surgical site infections (SSI) after ambulatory surgery.</p>

<p><strong>Methods: </strong>We analysed electronic health record (EHR) data for children who underwent ambulatory surgery at one of 4 ambulatory surgical facilities. Using regularized logistic regression and random forests, we derived SSI prediction rules using 30 months of data (derivation set) and evaluated performance with data from the subsequent 10 months (validation set). Models were developed both with and without data extracted from free text. We also evaluated the presence of an antibiotic prescription within 60 days after surgery as an independent indicator of SSI evidence. Our goal was to exceed 80% sensitivity and 10% positive predictive value (PPV).</p>

<p><strong>Results: </strong>We identified 234 surgeries with evidence of SSI among the 7910 surgeries available for analysis. We derived and validated an optimal prediction rule that included free text data using a random forest model (sensitivity = 0.9, PPV = 0.28). Presence of an antibiotic prescription had poor sensitivity (0.65) when applied to the derivation data but performed better when applied to the validation data (sensitivity = 0.84, PPV = 0.28).</p>

<p><strong>Conclusions: </strong>EHR data can facilitate SSI surveillance with adequate sensitivity and PPV.</p>

<p><strong>OBJECTIVE: </strong>To examine the effect of ambulatory health care processes on asthma hospitalizations.</p>

<p><strong>METHODS: </strong>A retrospective cohort study using electronic health records was completed. Patients aged 2-18&nbsp;years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations.</p>

<p><strong>RESULTS: </strong>5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2&nbsp;years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09-1.78).</p>

<p><strong>CONCLUSIONS: </strong>In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.</p>

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Palivizumab can reduce hospitalizations due to respiratory syncytial virus (RSV), but many eligible infants fail to receive the full 5-dose series. The efficacy of clinical decision support (CDS) in fostering palivizumab receipt has not been studied. We sought a comprehensive solution for identifying eligible patients and addressing barriers to palivizumab administration.</p>

<p><strong>METHODS: </strong>We developed workflow and CDS tools targeting patient identification and palivizumab administration. We randomized 10 practices to receive palivizumab-focused CDS and 10 to receive comprehensive CDS for premature infants in a 3-year longitudinal cluster-randomized trial with 2 baseline and 1 intervention RSV seasons.</p>

<p><strong>RESULTS: </strong>There were 356 children eligible to receive palivizumab, with 194 in the palivizumab-focused group and 162 in the comprehensive CDS group. The proportion of doses administered to children in the palivizumab-focused intervention group increased from 68.4% and 65.5% in the two baseline seasons to 84.7% in the intervention season. In the comprehensive intervention group, proportions of doses administered declined during the baseline seasons (from 71.9% to 62.4%) with partial recovery to 67.9% during the intervention season. The palivizumab-focused group improved by 19.2 percentage points in the intervention season compared to the prior baseline season (p &lt; 0.001), while the comprehensive intervention group only improved 5.5 percentage points (p = 0.288). The difference in change between study groups was significant (p = 0.05).</p>

<p><strong>CONCLUSIONS: </strong>Workflow and CDS tools integrated in an EHR may increase the administration of palivizumab. The support focused on palivizumab, rather than comprehensive intervention, was more effective at improving palivizumab administration.</p>

<p><strong>OBJECTIVE: </strong>Pediatric health care workers (HCWs) are at particular risk for pertussis exposure, infection, and subsequent disease transmission to susceptible patients. This cross-sectional study describes the epidemiology of occupational exposures to pertussis and identifies factors that may inform interventions to promote effective implementation of infection prevention and control (IPC) guidelines.</p>

<p><strong>METHODS: </strong>We abstracted data from occupational health (OH) and IPC records for pertussis cases that resulted in an exposure investigation in a large quaternary pediatric care network, January 1, 2002 to July 18, 2011. We calculated the frequency of occupational exposures and measured associated characteristics. To assess the frequency of potential missed exposures, we reviewed electronic health record (EHR) data identifying laboratory-confirmed pertussis cases not documented in OH or IPC records.</p>

<p><strong>RESULTS: </strong>A total of 1193 confirmed HCW pertussis exposures were associated with 219 index cases during the study period. Of these, 38.8% were infants &lt;6 months old and 7 were HCWs. Most (77.5%) of exposures occurred in the emergency department or an ambulatory site; 27.0% of exposures occurred after documented initiation of IPC precautions. We identified 450 laboratory-confirmed pertussis cases through EHR review, of which 49.8% (N = 224) had no OH or IPC investigation. The majority of uninvestigated cases (77.2%) were from ambulatory sites.</p>

<p><strong>CONCLUSIONS: </strong>Occupational exposures to pertussis occur frequently in pediatric health care settings despite appropriate IPC guidelines. Interventions are needed to ensure consistent implementation of IPC practices and timely identification and reporting of pertussis index cases to prevent HCW exposures and potential transmission to patients.</p>

<p><strong>OBJECTIVE: </strong>To assess the utility of imputing race/ethnicity using U.S. Census race/ethnicity, residential address, and surname information compared to standard missing data methods in a pediatric cohort.</p>

<p><strong>DATA SOURCES/STUDY SETTING: </strong>Electronic health record data from 30 pediatric practices with known race/ethnicity.</p>

<p><strong>STUDY DESIGN: </strong>In a simulation experiment, we constructed dichotomous and continuous outcomes with pre-specified associations with known race/ethnicity. Bias was introduced by nonrandomly setting race/ethnicity to missing. We compared typical methods for handling missing race/ethnicity (multiple imputation alone with clinical factors, complete case analysis, indicator variables) to multiple imputation incorporating surname and address information.</p>

<p><strong>PRINCIPAL FINDINGS: </strong>Imputation using U.S. Census information reduced bias for both continuous and dichotomous outcomes.</p>

<p><strong>CONCLUSIONS: </strong>The new method reduces bias when race/ethnicity is partially, nonrandomly missing.</p>