BACKGROUND: Late recognition of in-hospital deterioration is a source of preventable harm. Emergency transfers (ET), when hospitalized patients require intensive care unit (ICU) interventions within 1 h of ICU transfer, are a proximal measure of late recognition associated with increased mortality and length of stay (LOS).

OBJECTIVE: To apply diagnostic process improvement frameworks to identify missed opportunities for improvement in diagnosis (MOID) in ETs and evaluate their association with outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS: A single-center retrospective cohort study of ETs, January 2015 to June 2019. ET criteria include intubation, vasopressor initiation, or 60 mL/kg fluid resuscitation 1 h before to 1 h after ICU transfer. The primary exposure was the presence of MOID, determined using SaferDx. Cases were screened by an ICU and non-ICU physician. Final determinations were made by an interdisciplinary group. Diagnostic process improvement opportunities were identified.

MAIN OUTCOME AND MEASURES: Primary outcomes were in-hospital mortality and posttransfer LOS, analyzed by multivariable regression adjusting for age, service, deterioration category, and pretransfer LOS.

RESULTS: MOID was identified in 37 of 129 ETs (29%, 95% confidence interval [CI] 21%-37%). Cases with MOID differed in originating service, but not demographically. Recognizing the urgency of an identified condition was the most common diagnostic process opportunity. ET cases with MOID had higher odds of mortality (odds ratio 5.5; 95% CI 1.5-20.6; p = .01) and longer posttransfer LOS (rate ratio 1.7; 95% CI 1.1-2.6; p = .02).

CONCLUSION: MOID are common in ETs and are associated with increased mortality risk and posttransfer LOS. Diagnostic improvement strategies should be leveraged to support earlier recognition of clinical deterioration.

IMPORTANCE: Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.

OBJECTIVES: To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.

EXPOSURES: Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.

MAIN OUTCOMES AND MEASURES: The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.

RESULTS: We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001).

CONCLUSIONS AND RELEVANCE: In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

BACKGROUND AND OBJECTIVES: Consumer home monitors (CHM), which measure vital signs, are popular products marketed to detect airway obstruction and arrhythmia. Yet, they lack evidence of infant death prevention, demonstrate suboptimal accuracy, and may result in false alarms that prompt unnecessary acute care visits. To better understand the hospital utilization and costs of CHM, we characterized emergency department (ED) and hospital encounters associated with CHM use at a children's hospital.

METHODS: We used structured query language to search the free text of all ED and admission notes between January 2013 and December 2019 to identify clinical documentation discussing CHM use. Two physicians independently reviewed the presence of CHM use and categorized encounter characteristics.

RESULTS: Evidence of CHM use contributed to the presentation of 36 encounters in a sample of over 300 000 encounters, with nearly half occurring in 2019. The leading discharge diagnoses were viral infection (13, 36%), gastroesophageal reflux (8, 22%) and false positive alarm (6, 17%). Median encounter duration was 20 hours (interquartile range: 3 hours to 2 days; max 10.5 days) and median cost of encounters was $2188 (interquartile range: $255 to $7632; max $84 928).

CONCLUSIONS: Although the annual rate of CHM-related encounters was low and did not indicate a major public health burden, for individual families who present to the ED or hospital for concerns related to CHMs, there may be important adverse financial and emotional consequences.

OBJECTIVE: Evaluate the positive predictive value of International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes in identifying young children diagnosed with physical abuse.

METHODS: We extracted 230 charts of children <24 months of age who had any emergency department, inpatient, or ambulatory care encounters between Oct 1, 2015 and Sept 30, 2020 coded using ICD-10-CM codes suggestive of physical abuse. Electronic health records were reviewed to determine if physical abuse was considered during the medical encounter and assess the level of diagnostic certainty for physical abuse. Positive predictive value of each ICD-10-CM code was assessed.

RESULTS: Of 230 charts with ICD-10 codes concerning for physical abuse, 209 (91%) had documentation that a diagnosis of physical abuse was considered during an encounter. The majority of cases, 138 (60%), were rated as definitely or likely abuse, 36 cases (16%) were indeterminate, and 35 (15%) were likely or definitely accidental injury. Other forms of suspected maltreatment were discussed in 16 (7%) charts and 5 (2%) had no documented concerns for child maltreatment. The positive predictive values of the specific ICD-10 codes for encounters rated as definitely or likely abuse varied considerably, ranging from 0.89 (0.80-0.99) for T74.12 "Adult and child abuse, neglect, and other maltreatment, confirmed" to 0.24 (95% CI: 0.06-0.42) for Z04.72 "Encounter for examination and observation following alleged child physical abuse."

CONCLUSIONS: ICD-10-CM codes identify young children who experience physical abuse, but certain codes have a higher positive predictive value than others.

Background: Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described.

Objective: To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning.

Methods: We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework.

Results: Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process.

Conclusions: This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.

<p><strong>OBJECTIVES: </strong>Diagnostic excellence is an important domain of healthcare quality. Delays in diagnosis have been described in 20-30% of children with abusive injuries. Despite the well characterized epidemiology, improvement strategies remain elusive. We sought to assess the applicability of diagnostic improvement instruments to cases of non-accidental trauma and to identify potential opportunities for system improvement in child physical abuse diagnosis.</p>

<p><strong>METHODS: </strong>We purposefully sampled 10 cases identified as having potential for system level interventions and in which the child had prior outpatient encounters to review. Experts in pediatrics, child abuse, and diagnostic improvement independently reviewed each case and completed SaferDx, a validated instrument used to evaluate the diagnostic process. Cases were subsequently discussed to map potential opportunities for improving the diagnostic process to the DEER Taxonomy, which classifies opportunities by type and phase of the diagnostic process.</p>

<p><strong>RESULTS: </strong>The most frequent improvement opportunities identified by the SaferDx were in recognition of potential alarm symptoms and in expanding differential diagnosis (5 of 10 cases). The most frequent DEER taxonomy process opportunities were in history taking (8 of 10) and hypothesis generation (7 of 10). Discussion elicited additional opportunities in reconsideration of provisional diagnoses, understanding biopsychosocial risk, and addressing information scatter within the electronic health record (EHR).</p>

<p><strong>CONCLUSIONS: </strong>Applying a diagnostic excellence framework facilitated identification of systems opportunities to improve recognition of child abuse including integration of EHR information to support recognition of alarm symptoms, collaboration to support vulnerable families, and communication about diagnostic reasoning.</p>

<p>Guidelines discourage continuous pulse oximetry monitoring of hospitalized infants with bronchiolitis who are not receiving supplemental oxygen. Excess monitoring is theorized to contribute to increased alarm burden, but this burden has not been quantified. We evaluated admissions of 201 children (aged 0-24 months) with bronchiolitis. We categorized time ≥60 minutes following discontinuation of supplemental oxygen as "continuously monitored (guideline-discordant)," "intermittently measured (guideline-concordant)," or "unable to classify." Across 4402 classifiable hours, 77% (11,101) of alarms occurred during periods of guideline-discordant monitoring. Patients experienced a median of 35 alarms (interquartile range [IQR], 10-81) during guideline-discordant, continuously monitored time, representing a rate of 6.7 alarms per hour (IQR, 2.1-12.3). In comparison, the median hourly alarm rate during periods of guideline-concordant intermittent measurement was 0.5 alarms per hour (IQR, 0.1-0.8). Reducing guideline-discordant monitoring in bronchiolitis patients would reduce nurse alarm burden.</p>

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Continuous pulse oximetry (oxygen saturation [Spo]) monitoring in hospitalized children with bronchiolitis not requiring supplemental oxygen is discouraged by national guidelines, but determining monitoring status accurately requires in-person observation. Our objective was to determine if electronic health record (EHR) data can accurately estimate the extent of actual Spo monitoring use in bronchiolitis.</p>

<p><strong>METHODS: </strong>This repeated cross-sectional study included infants aged 8 weeks through 23 months hospitalized with bronchiolitis. In the validation phase at 3 children's hospitals, we calculated the test characteristics of the Spo monitor data streamed into the EHR each minute when monitoring was active compared with in-person observation of Spo monitoring use. In the application phase at 1 children's hospital, we identified periods when supplemental oxygen was administered using EHR flowsheet documentation and calculated the duration of Spo monitoring that occurred in the absence of supplemental oxygen.</p>

<p><strong>RESULTS: </strong>Among 668 infants at 3 hospitals (validation phase), EHR-integrated Spo data from the same minute as in-person observation had a sensitivity of 90%, specificity of 98%, positive predictive value of 88%, and negative predictive value of 98% for actual Spo monitoring use. Using EHR-integrated data in a sample of 317 infants at 1 hospital (application phase), infants were monitored in the absence of oxygen supplementation for a median 4.1 hours (interquartile range 1.4-9.4 hours). Those who received supplemental oxygen experienced a median 5.6 hours (interquartile range 3.0-10.6 hours) of monitoring after oxygen was stopped.</p>

<p><strong>CONCLUSIONS: </strong>EHR-integrated monitor data are a valid measure of actual Spo monitoring use that may help hospitals more efficiently identify opportunities to deimplement guideline-inconsistent use.</p>

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Physiologic monitor alarms occur at high rates in children's hospitals; ≤1% are actionable. The burden of alarms has implications for patient safety and is challenging to measure directly. Nurse workload, measured by using a version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX) validated among nurses, is a useful indicator of work burden that has been associated with patient outcomes. A recent study revealed that 5-point increases in the NASA-TLX score were associated with a 22% increased risk in missed nursing care. Our objective was to measure the relationship between alarm count and nurse workload by using the NASA-TLX.</p>

<p><strong>METHODS: </strong>We conducted a repeated cross-sectional study of pediatric nurses in a tertiary care children's hospital to measure the association between NASA-TLX workload evaluations (using the nurse-validated scale) and alarm count in the 2 hours preceding NASA-TLX administration. Using a multivariable mixed-effects regression accounting for nurse-level clustering, we modeled the adjusted association of alarm count with workload.</p>

<p><strong>RESULTS: </strong>The NASA-TLX score was assessed in 26 nurses during 394 nursing shifts over a 2-month period. In adjusted regression models, experiencing &gt;40 alarms in the preceding 2 hours was associated with a 5.5 point increase (95% confidence interval 5.2 to 5.7; &lt; .001) in subjective workload.</p>

<p><strong>CONCLUSION: </strong>Alarm count in the preceding 2 hours is associated with a significant increase in subjective nurse workload that exceeds the threshold associated with increased risk of missed nursing care and potential patient harm.</p>