Published in the August 2011 issue of Today’s Hospitalist
AS A HOSPITALIST, wouldn’t it be nice to get a heads up that one of your patients is going downhill fast? You’d have a chance to intervene before a rapid response team or code blue was called.
A study published in the pediatric literature last year H may have described just such an early warning system. Researchers found that a pediatric early warning score (PEWS) can alert clinicians to "clinical deterioration" hours before an emergency happens.
The article, which appeared in the April 1, 2010, issue of Pediatrics (http://bit.ly/jIk5CF), indicated that the scoring system, which is based on a combination of behavioral, cardiovascular and respiratory indicators, helps health care providers "alter plans of care in response to changing patient status."
John A. Pope, MD, MPH, physician director for pediatric services for the Scottsdale Healthcare Hospitals in Arizona, discussed the paper at a pediatric update at this year’s Society of Hospital Medicine annual meeting. He said that the article, which was written by staff at Children’s Hospitals and Clinics of Minnesota in Minneapolis, showed that the PEWS system was successfully used in a children’s hospital, but that it could also be very helpful in community hospitals.
"We all would appreciate knowing earlier if one of our patients is going to have a problem so that interventions can occur when patients can respond better," Dr. Pope said. He added that researchers found that in 85.5% of the cases they reviewed, the system detected clinical deterioration as early as 12 hours before a rapid response team or code blue was called.
"That gives us a good amount of time to make some interventions before a patient decompensates," Dr. Pope said, "rather than waiting until the event occurs and our intervention can’t be quite as good."
Dr. Pope and two other pediatric hospitalists reviewed six other recent articles in the pediatric hospital medicine literature. Here’s a look at those studies, which explored issues from how to dull pain in newborns who need needle sticks to strategies to reduce antibiotic use.
1. Lactobacillus and abdominal pain
A group of Italian researchers examined one of the most common complaints of school-age children “chronic abdominal pain “that can present as functional abdominal pain and irritable bowel syndrome.
Because there aren’t any effective treatments outside of "reassurance and pain management," Dr. Pope said, these children "often end up on our services. They can take up a lot of our energy and time, but to their detriment, they often get multiple workups. They get a lot of blood drawn, they go to the ED, they are hospitalized and they often end up on narcotics. Some good studies on these kids are welcome."
A small Italian study published in the Nov. 15, 2010, issue of Pediatrics (http://bit.ly/iGwwaz) concluded that children ages 5 through 14 (an average age of 6) with IBS who were given Lactobacillus rhamnosus GG (LGG) had "significantly reduced frequency and severity of abdominal pain" compared to children given a placebo.
Dr. Pope noted that while the children who received LGG did better, "both groups had a good result," especially as perceived by parents. In addition, the improvement persisted for weeks after the medications were stopped.
While the authors concluded that "LGG is superior to placebo and effect persisted," Dr. Pope said the study also demonstrates the power of placebo. "Overall, this is great information for treating these patients," he explained. "Anything we can do that can improve their function, improve their parents’ perception of pain, and reduce hospitalization, ED visits, and use of narcotics is good news. Hopefully, there will be more studies like this."
2. Oral sucrose and newborn pain
Dr. Pope said that a small British study examining pain in newborns wouldn’t necessarily change his current use of oral sucrose as an analgesic drug for procedural pain in newborns. But most physicians want to know how much pain newborn infants feel when they have procedures done in the hospital, ranging from blood draws and IV insertion to circumcision.
"Sometimes I see that oral sucrose works, but I wonder," Dr. Pope said. "The problem is having a reliable, objective way of measuring pain."
The study, which appeared in the Oct. 9, 2010, issue of The Lancet (http://bit.ly/mUcCQb), attempted to find a more quantitative way of measuring pain. During a single heel lance given to healthy newborns less than eight days old for routine lab tests, researchers looked at two measures: nociceptive brain activity as captured by electroencephalography (EEG), and spinal nociceptive reflexes as recorded by electromyography (EMG).
The researchers, who were at University College Hospital in London, found that babies who received oral sucrose before the heel lance appeared on video to experience less pain than those who received sterile water. (They grimaced or furrowed their brows less than other infants.) But neither group experienced any change in their sensory pain circuits in the brain or spinal cord as measured by the EEG and EMG.
As a result, researchers concluded that "oral sucrose does not significantly affect activity in neonatal brain or spinal cord nociceptive circuits, and therefore might not be an effective analgesic drug."
Dr. Pope said that because the study was so small and short, it didn’t necessarily change his attitudes toward using sucrose. "I think I would still use it," he explained, "but this study puts us a step ahead in more objectively measuring newborn pain. It also sets us up for some future studies."
3. Watching low-risk febrile young infants: at home or in the hospital?
Another important study was small and observational, but it found that hospitalizing very young infants (29 to 60 days old) who have fevers but no other risks to rule out a serious bacterial infection may not be a good idea. Researchers at Kosair Children’s Hospital in Louisville, Ky., found that hospitalization not only results in "high charges and potentially preventable complications," but is often "contrary to the wishes of most parents."
The study, which was published in the March 2010 issue of Pediatric Emergency Care (http://bit.ly/lNShpf ), looked at infants treated with IV antibiotics. Researchers found that 29% (17 of 58 infants) developed a complication in the hospital. Problems included an IV catheter infiltrate, a contaminated blood or spinal fluid culture, a test performed on the wrong patient, and an averted drug error or readmission after discharge. The mean length of stay for these children was 49 hours; the mean hospital charge was $6,202.
In presenting the paper, Kris P. Rehm, MD, director of hospital medicine at Vanderbilt University’s Monroe H Carell Jr. Children’s Hospital in Nashville, Tenn., said the paper raised another important concern for pediatric hospitalists: Few of the children saw a primary care physician on follow-up, even though they were instructed to do so within 48 hours of discharge.
Dr. Rehm said that it is "debatable" just how significant the complications were. Nonetheless, she noted, the study gives physicians something to think about, particularly because "parents consistently preferred discharge to admission."
4. Lumbar punctures for seizure patients
Children who present with their first complex febrile seizure “the most common form of childhood seizure ” may not need a lumbar puncture to determine if they have acute bacterial meningitis.
Although the association between seizures and meningitis is well known, researchers have found that "in the absence of other signs and symptoms," few patients who experience a single complex febrile seizure have acute bacterial meningitis. The study was published in the July 1, 2010, issue of Pediatrics (http://bit.ly/lFeqOg).
Dr. Rehm said that the research appears to show that a lumbar puncture should probably be reserved for patients "when clinical suspicion is quite high." One limitation of the article, she added, was that the children studied had very high vaccination rates, so it’s unclear if the results would apply in a community where immunizations are not as widespread.
5. UTIs and antibiotics
Does a longer course of antibiotics improve treatment of children with UTIs? A large retrospective review of 12,000 children under six months of age found that there is no difference in readmission rates when children receive a short-term course of IV antibiotics (three days or less) or a long-term course (four or more days).
Brian Alverson, MD, head of the pediatric hospitalist program at Rhode Island Hospital/Hasbro Children’s Hospital of Providence, said that his take on the data is that treating very young infants for a shorter period of time in the hospital and then sending them home on an oral antibiotic seems to be appropriate.
"This is the largest and most thorough study to date to consider length of IV therapy for infants under one month of age," Dr. Alverson said. "Overall, children with prolonged IV therapy actually had a higher bounceback rate than those with a shorter duration."
Another interesting finding of the article, which was published in the Aug. 1, 2010, issue of Pediatrics (http://bit.ly/ixyIPI), was that hospitals showed "quite a bit of variation" in their practice. Some gave long courses of antibiotics to nearly 90% of these infants, while others gave long courses only rarely.
6. Controlling overuse of vancomycin
Another study described an antimicrobial stewardship program at the Alfred I. DuPont Hospital for Children in Wilmington, Del., that decreased vancomycin prescription errors without increasing the use of other antibiotics.
The article, which appeared in the August 2010 issue of Pediatric Infectious Disease Journal (http://bit.ly/mHaL1F), explained that the hospital had been dealing with increasing rates of vancomycin-resistant S. aureus and enterococcal infections. The stewardship program made use of a computerized physician order entry system to alert pharmacists when vancomycin prescriptions were written.
After discussing the appropriateness, dose and frequency of vancomycin with pediatric infectious disease physicians, program personnel found that 28% of vancomycin orders did not meet the institution’s guidelines. The hospital now requires approval from infectious disease physicians to continue vancomycin for more than two doses.
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.