Subspecialty Consultation Research Articles

A70 SEVERE ENTERITIS AND IGA VASCULITIS IN A PEDIATRIC PATIENT WITH ULCERATIVE COLITIS ON VEDOLIZUMAB

Abstract Background Pediatric Ulcerative Colitis (UC) is often unsatisfactorily controlled using ‘conventional’ therapies, thus there has been increasing use of biologic therapies and small molecules to try and improve rates of clinical remission and mucosal healing. Consequently, pediatric gastroenterologists and generalists should be aware of the complications and side effects of these newer molecules. Vedolizumab (VDZ) is a fully humanised anti-integrin therapy that is thought to limit systemic side effects given its gut-specific mechanism. Aims Here we report the unique case of a 14-year-old male with UC on vedolizumab presenting with severe abdominal pain, GI bleeding, markedly elevated inflammatory markers and subsequent purpura. Methods N/A Results A diagnosis of IgA vasculitis (IgAV) was made after extensive imaging, endoscopy and subspecialty consultation. Clinical course was complicated but ultimately responded to high dose steroid treatment without cessation of VDZ. Conclusions This case illustrates a potentially independent pathway behind IgAV in a patient on a gut-selective therapy with UC. This is the first pediatric case of vasculitis in a patient with UC on VDZ. Funding Agencies None

Review of MIS-C Clinical Protocols and Diagnostic Pathways: Towards a Consensus Algorithm.

BackgroundThe emergence of multisystem inflammatory syndrome in children (MIS-C) during the severe acute respiratory syndrome coronavirus 2 pandemic led to the development of institutional clinical pathways based on expert opinion. We assessed North American paediatric centres’ adaptation to MIS-C and analysed the degree of agreement between algorithms on tiered clinical investigations.MethodsThis study evaluated MIS-C diagnostic algorithms from 50 tertiary centres developed between May 2020 and December 2021 in the United States and Canada obtained online and through colleagues in various institutions. Descriptive statistics were used to analyse results.ResultsAll clinical pathways used a tiered approach, and most required coronavirus disease 2019 polymerase chain reaction testing on presentation. Over one-quarter used a 24-hour fever to initiate investigations, and another quarter used 3 days. Basic biochemical workup was performed in all centres on presentation (complete blood count, inflammatory markers, hepatic, and renal functions). Specialized investigation was generally reserved for secondary testing (cardiac biomarkers, electrocardiogram and echo, and coagulation panel). Institutions were divided on several investigations for tier distribution, including urine studies, blood cultures, chest radiograph, and severe acute respiratory syndrome coronavirus 2 serology. Subspecialty consultations were reserved for second-line testing, including cardiology, infectious disease, and rheumatology. Finally, we propose a composite algorithm representative of the consulted pathways.ConclusionsFaced with an unprecedented clinical challenge, paediatric institutions responded swiftly with evaluation standardization, adapting to evolving knowledge. Most pathways agreed on initial basic screening tests followed by secondary workup including cardiac investigations. These protocols, developed during a high level of uncertainty, require comparative assessment on efficacy and superiority.

Vulvar granular cell tumour in a recently post-partum woman: a case report

Granular cell tumours (GCTs) are uncommon neuroectodermally derived tumours. Vulvar location is rare with 134 reported cases presenting as a non-specific vulvar mass. They are of low malignant potential and management is local excision. They have a high local recurrence rate if incompletely excised. The GCT diagnosis is often retrospective due to its rarity, its non-specific presenting symptoms and numerous differentials. Here we descibe the case of a 31-year-old woman presenting after an asymptomatic right labium majus mass was noted during a postnatal visit. This was imaged with magentic resonance imaging (MRI) and a biopsy was inconclusive. She was referred for subspecialty consultation at the Chris O’Brien Lifehouse. The lesion was five centimetres, overlying the pubis and inferolateral to the clitoris with no skin changes or epidermal attachment. Wide local excision was performed. Histopathology showed GCT features with no malignant characteristics, but positive margins. Despite positive margins, the decision was made to not complete re-excision and observe for recurrence. This was an unusual case in a young postpartum woman. It highlights the need for clinical suspicion of this tumour type during a postpartum examination and the need for nuanced decision making regarding re-excision based on individual patient needs despite recurrence risk.

Trauma transfers discharged from the emergency department-Is there a role for telemedicine?

As the only Level I trauma center in the state, our hospital has seen an increase in the number of traumas requiring transfer for a higher level of care, placing strain on an already strained health care system. Traumas that are transferred to our facility and subsequently discharged back home indicate a subset of patients who may not be appropriate to transfer. The aim of this study is to identify commonalities between patients who were transferred for a higher level of care but do not require inpatient status and to assess patients who may benefit from a telemedicine evaluation. A 2-year retrospective review of a prospective collected database of patients who were discharged from the ED following transfer to a Level I trauma center was conducted. Data included demographics, injuries, transferring facility, method of transport, activation criteria and level, additional imaging, consulting services, procedures, and disposition. A total of 2,350 patients were transferred. Of those, 27% (632/2,350) were discharged home directly from the trauma bay. Of those patients, 36% (230/632) required complex bedside intervention or subspecialty consultation prior to discharge including complex laceration repairs 53%, ophthalmology examination 24%, splinting 18%, and joint reduction 5%. Sixty-four percent (402/632) of patients did not require complex bedside procedures prior to discharge. One hundred twenty hospitals transferred patients to our center during this period. The top 10 transferring facilities accounted for 40% (948/2,350) of our transfer volume. Our study demonstrates that patients who are transferred to our facility and subsequently discharged have a common pattern of injuries; typically, isolated hand and face/ophthalmology. This is likely attributed to the lack of resources in rural facilities to evaluate and develop treatment plans for these injuries; however, only 36% of discharged patients required a bedside procedure. Excluding Level I traumas, head and spine injuries, and patients requiring complex bedside procedures, there was a 13% inappropriate rate of transfer (310/2,350). Development and implementation of a telemedicine system could potentially reduce the transfer and ED discharge rate, thereby improving efficiency and allowing for reallocation of resources as appropriate. Prognostic and Epidemiologic, Level III.

Use of telemedicine for initial outpatient subspecialist consultative visit: A national survey of general pediatricians and pediatric subspecialists

BackgroundEvidence-based strategies are needed to support appropriate use of telemedicine for initial outpatient subspecialty consultative visits. To inform such strategies we performed a survey of general pediatricians and pediatric subspecialists about use of telemedicine for patients newly referred for pediatric subspecialty care. MethodsWe developed and fielded an e-mail and postal survey of a national sample of 840 general pediatricians and 840 pediatric subspecialists in May and June 2020. ResultsOf 266 completed surveys (17% response rate), 204 (76%) thought telemedicine should be offered for some and 29 (11%) thought telemedicine should be offered for all initial subspecialist visits. Most respondents who indicated telemedicine should be offered for some initial consultations believed this decision should be made by subspecialty attendings (176/204, 86%). Respondents prioritized several data elements to inform this decision, including clinical information and family-based contextual information (e.g., barriers to in-person care, interest in telemedicine, potential communication barriers). Factors perceived to reduce appropriateness of telemedicine for subspecialty consultation included need for interpreter services and prior history of frequent no-shows. Responses from generalists and subspecialists rarely differed significantly. ConclusionsSurvey results suggest potential opportunities to support the appropriate use of telemedicine for initial outpatient pediatric subspecialty visits through structured transfer of specific clinical and contextual information at the time of referral and through strategies to mitigate perceived communication or engagement barriers. ImplicationPediatric physician beliefs about telemedicine for initial outpatient subspecialty consultative visits may inform future interventions to support appropriate telemedicine use. Level of evidenceSurvey of a national sample of clinicians.

83. ID Coaches Contribute to a Highly Effective Learning Experience for Third-Year Medical Students Rotating on the Infectious Diseases Consult Service

BackgroundEducation on infections in hospitalized patients, antimicrobial selection, and principles of antimicrobial stewardship are foundational to all clinicians. Incorporating early learners into Infectious Diseases (ID) consult services has the potential to build a strong fund of knowledge in these content domains, but also poses potential challenges. We evaluated the impact of a novel clinical rotation and supporting curriculum on third-year medical students rotating on the ID consult service for 2 weeks during their 12-week Internal Medicine clerkship at the University of California, San Diego.MethodsThird-year medical students who selected to rotate on the ID consult service were given an hour-long orientation about the service and common infectious syndromes. They were provided with a checklist of clinical skills to complete during the rotation. In addition to daily rounds and clinical care, ID Coaches (ID faculty and senior ID fellows) met with students weekly for 1-2 hours to review ID topics, practice oral presentations, and/or conduct physical exam finding rounds. We surveyed medical students to assess the effectiveness of the rotation.ResultsForty third-year medical students participated in the 2-week ID consult rotation between June 2020-May 2021; 31 (77%) completed the rotation evaluation. Seventy percent or more of students reported that the ID rotation facilitated their learning across 8 of 10 ID-content domains (Figure 1). More students reported that the ID Coach facilitated learning (71%) compared to the clinical skills checklist (42%). Students highlighted learning about antimicrobial selection, stewardship, and clinical reasoning on the rotation but reported that teaching was limited when the service census was high (Figure 2).Figure 1: Percent of Students Rating the ID Consult Rotation as Extremely or Very Effective in Facilitating Learning Across 10 Domains Figure 2: Students' Reflections on the Effectiveness of the ID Consult Rotation ConclusionThird-year medical students found that a 2-week rotation on the ID consult service was highly effective in teaching foundational ID content and general medicine skills. Incorporating early learners into a busy and complex subspecialty consult service can be facilitated through the use of supplemental curricular tools such as ID Coaches.Disclosures Darcy Wooten, MD, MS, Nothing to disclose

Annals for Hospitalists Inpatient Notes - Internal Medicine Bedside Procedure Services: Is the Juice Worth the Squeeze?

Web ExclusivesDecember 2021Annals for Hospitalists Inpatient Notes - Internal Medicine Bedside Procedure Services: Is the Juice Worth the Squeeze?Majid Shafiq, MD, MPH and Anirudh Nandan, MDMajid Shafiq, MD, MPHDepartment of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (M.S.)Search for more papers by this author and Anirudh Nandan, MDDepartment of Hospital-Based Specialists, Kaiser Permanente San Francisco, San Francisco, California (A.N.).Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-4191 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Faced with many competing demands and a finite amount of time, hospitalists have traditionally looked toward interventional radiology (IR) for common medical procedures. However, that approach has several inherent shortcomings. In some situations, patient transport to a dedicated IR suite may be undesirable (for example, because of tenuous clinical status or the need for isolation). Removal of a patient from their room may result in postponement of other important interventions (for example, subspecialty consultation or physical therapy). Waiting for IR sometimes leads to procedural delays resulting from scheduling or staffing constraints, especially during weekends and holidays. In addition, the increasingly ...

Challenges of Using Instant Communication Technology in the Emergency Department during the COVID-19 Pandemic: A Focus Group Study

A record outbreak of community-spread COVID-19 started on 10 May 2021, in Taiwan. In response to the COVID-19 pandemic, care facilities have adopted various protocols using instant communication technology (ICT) to provide remote yet timely healthcare while ensuring staff safety. The challenges of patient evaluation in the emergency department (ED) using ICT are seldom discussed in the literature. The objective of this study was to investigate the factors influencing the utility of ICT for patient assessment in emergency settings during the pandemic. The patient flow protocol and the ED layout were modified and regionalized into different areas according to the patient’s risk of COVID-19 infection. Nine iPads were stationed in different zones to aid in virtual patient assessment and communication between medical personnel. A focus group study was performed to assess and analyze the utility of the ICT module in the ED. Eight emergency physicians participated in the study. Of them, four (50%) had been directly involved in the development of the ICT module in the study hospital. Three main themes that influenced the application of the ICT module were identified: setting, hardware, and software. The setting theme included six factors: patient evaluation, subspecialty consultation, patient privacy and comfortableness, sanitation, cost, and patient acceptability. The hardware theme included six factors: internet connection, power, quality of image and voice, public or personal mode, portable or fixed mode, and maintenance. The software theme included six factors: platform choices, security, ICT accounts, interview modes, video/voice recording, and time limitation. Future studies should focus on quantifying module feasibility, user satisfaction, and protocol adjustment for different settings.

Abstract 11221: Counseling in the Time of COVID - Prenatal Diagnosis of Congenital Heart Disease During a Pandemic

Introduction: Comprehensive prenatal care of congenital heart disease (CHD) relies on a multi-disciplinary approach that includes timely prenatal counseling and individualized care plans for the pregnancy, delivery and neonatal period. With the COVID-19 pandemic our fetal therapy clinic (FTC) approach to patient care was altered to accommodate restrictions, including the use of telehealth visits. We investigated whether counseling and access to care for fetal patients with CHD was negatively impacted by COVID-19. Hypothesis: Fetuses with CHD would experience a delay in timing of diagnosis and referral; parents would receive a shorter counseling session during the COVID-19 pandemic. Methods: Retrospective chart review of all fetal cardiology patients seen in our multidisciplinary FTC both before (5/1/19-12/31-19) and during the COVID-19 pandemic (5/1/20-12/31/20). Data collected included gestational age (GA) at referral, GA at first fetal echo, use of telehealth, total time counseled, number of sub-specialty consults, and total number of fetal cardiology visits. Results: A comparable number of dyads were seen before and during the pandemic (Table 1). GA at initial diagnosis was similar, but GA at referral and first visit was earlier during the pandemic. Additionally, families seen during the pandemic had longer counselling across all disciplines with significant differences in pediatric cardiology and neonatology. There was no difference in total number of consults or access to care based on insurance. Conclusions: While prenatal counseling and referral to FTC is multifaceted, we demonstrated that COVID-19 and alterations in care delivery did not in fact lead to delays in referrals for patients across a large geographical catchment. Moreover, with telemedicine we were able to ensure our families continued to receive multidisciplinary care and families were able to spend more time with our care team developing comprehensive individualized plans.

Inpatient Subspecialty Consultations: A New Target for High-Value Pediatric Hospital Care?

Inpatient Subspecialty Consultations: A New Target for High-Value Pediatric Hospital Care?

The Role of Early Subspeciality Consultation in the Timing of Hemophagocytic Lymphohistiocytosis Diagnosis and Management.

The aim of this study was to investigate the relation between timing of subspeciality consult and hemophagocytic lymphohistiocytosis (HLH) consideration, immunosuppression initiation, and in-hospital mortality in patients with HLH. We conducted a medical records review study of patients 18 years or older with definite or probable HLH at Montefiore Medical Center between 2006 and 2019. Earlier subspeciality consultation (rheumatology, hematology, and infectious disease) was defined as consultation in less than or equal to 18 hours from time of admission. Demographic, clinical characteristics, and outcomes were compared between patients with early and later subspecialty consultation. A total of 28 patients were included. The median age was 40 years, and 61% of patients were male. Infection was identified as a cause of HLH in 13 patients (46%). Fifteen patients (54%) were classified as having an earlier subspeciality consultation with a median time (interquartile range) to HLH consideration of 1.0 day (0.3-4.2 days) compared with 7.9 days (3.1-9.9 days) for the later consultation group (p = 0.002). The median time (interquartile range) to immunosuppression initiation was 4.6 days (1.7-7.8 days) versus 10.9 days (5.1-13.4 days) (p = 0.01), respectively. Five patients (33%) had in-hospital deaths in the early consultation group compared with 7 patients (54%) in later consultation group (p = 0.27). Among the subset of patients who survived to discharge, the 90-day readmission rate was higher in the later consultation group (83% vs 30%, p = 0.12). In patients with HLH, earlier subspeciality consultation may play a role in earlier HLH consideration and treatment initiation.

Changes in the Management of Severe Orbital Infections Over Seventeen Years.

Periorbital and orbital cellulitis are common but serious infections in children. Management of these infections varies because of an absence of clinical guidelines, but it is unclear if management within institutions has changed over time. We compared the management and outcomes of children hospitalized with periorbital and orbital cellulitis in 2 eras. Data were extracted from records of children hospitalized at a tertiary care children's hospital with periorbital or orbital cellulitis from 2000 to 2005 and 2012 to 2016. Patient demographics, cross-sectional imaging, antibiotic and corticosteroid use, length of stay, and surgical rates were collected. Data from the eras were compared by using descriptive statistics, t tests, Mann-Whitney U tests, Fisher's exact tests, and χ2 tests. There were 318 children included, 143 from 2000 to 2005 and 175 from 2012 to 2016. Compared with the first era, in the second era there were increased rates of MRI (5% vs 11%, P = .04), although rates of computed tomography scan use remained unchanged (60% vs 65%); increased number (1 vs 3, P < .01) and spectrum of antibiotics; increased use of intranasal corticosteroids (3% vs 49%, P < .01); and subspecialty consultation (89% vs 99%, P = .01). There were no differences in length of stay, readmission, or surgical rates between eras. There has been considerable change in the management of hospitalized children with severe orbital infections at our institution, including the rates of MRI, number and spectrum of antibiotics used, use of adjunctive agents, and increased subspecialty involvement with no observed impact on clinical outcomes. Future research is needed to rationalize antimicrobial therapy and reduce low-value health care.

Healthcare spending and utilization for pediatric Irritable Bowel Syndrome in a commercially insured population.

Pediatric Irritable Bowel Syndrome (IBS) is common and can be associated with disabling gastrointestinal symptoms. Comprehensive data regarding utilization and cost of pediatric IBS are lacking. Our aim was to determine the annual all-cause spending and healthcare utilization in pediatric IBS. Cross-sectional cohort study using a national claims database of commercially insured individuals. 932,592 members, age 8-18years, were included. Members were selected based on PheWas codes and continuous enrollment in 2014. Linear and binomial regression models were used to calculate healthcare spending and compare comorbidities between IBS subjects and controls. 1215 members with claims for IBS (68.4% female) and 931,377 controls (55.7% female) were included. Mean age was 15.03±2.83 (median 16) years in the IBS group and 13.14±3.12 (median 13) years in controls. Mental health and chronic pain comorbidities were more prevalent in the IBS cohort. Healthcare spending: The mean annual all-cause incremental spending of members with IBS was $6,364.60 compared to controls when adjusting for age and gender. Healthcare utilization: Members with IBS had increased healthcare utilization including higher rates of inpatient, outpatient, and emergency room visits, and higher rates of health service utilization including medical care, radiology/laboratory services, surgery, anesthesia, mental health, and physical therapy. General pediatrics was more frequently consulted by controls. All subspecialty consultations, with the exception of dental medicine and endocrinology, were sought more frequently by IBS patients. Patients with IBS incur significant annual spending through increased healthcare utilization.

Minor head injury transfers: Trends and outcomes.

Children with traumatic head injury are often transferred from community Emergency Departments (ED) to a Pediatric Emergency Department (PED). The primary objective of this study was to describe the outcomes of minor head injury (MHI) transfers to a PED. The secondary objective was to report Computed Tomography (CT) utilization rates for MHI. We conducted a retrospective study of children aged ≤18years transferred to our PED for MHI from 2013 to 2018. Patients with Glasgow Coma Scale (GCS)<14, coagulopathies, history of brain mass/shunt and suspected non-accidental trauma were excluded. Data collected included demographics, interventions performed, and disposition. MHI risk stratification and clinically important traumatic brain injury (ciTBI) were defined per the Pediatric Emergency Care Applied Research Network (PECARN) head injury guidelines. Descriptive statistics were reported using general measures of frequency and central tendency. A total of 1078 children with MHI were analyzed based on eligibility criteria. The majority of patients were male (62%) and≥2years of age (69.3%). Subspecialist consultation (57.2%) and neuroimaging (27.4%) were the most commonly performed interventions in the PED. Only 14 children (1.3%) required neurosurgical intervention. One-third of the transferred patients required no additional work-up. Two-thirds of the patients (66.6%) were directly discharged from the PED. Though the total number of MHI transfers per year declined steadily during the study period (from 271/year to 119/year), CT head utilization remained relatively similar across the study years (60.3% to 70.8%). A higher proportion of children received CT in the ED when compared to the PED for low-risk (28.9% vs 15.8%) and intermediate-risk groups (42.8% vs 29.4%). The majority of pediatric MHI transfers are discharged home following a subspecialty consultation and/or neuroimaging. Despite guidelines and a low incidence of ciTBI, CT utilization remains high in the intermediate and low risk MHI groups, especially in the community settings. Targeted interventions are needed to reduce the potentially avoidable transfers and low-value performance of CT in children with MHI.

1125: Impact of Subspecialty Consults on Diagnosis in the Pediatric Intensive Care Unit

1125: Impact of Subspecialty Consults on Diagnosis in the Pediatric Intensive Care Unit

Optimizing Multidisciplinary Simulation in Medical School for Larger Groups: Role Assignment by Lottery and Guided Learning.

PurposeMedical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups.Patients and MethodsWe devised a low technology “Orchestra Leader’s” chart approach to prominently display students’ roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017–2019) with a range of 8 to 19 students per laboratory session.ResultsOur 2017–2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method.ConclusionWe designed a novel, “Orchestra Leader’s” chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.

The cases not seen: Patterns of emergency department visits and procedures in the era of COVID-19.

ObjectivePrior data suggest Emergency Department (ED) visits for many emergency conditions decreased during the initial COVID-19 surge. However, the pandemic's impact on the wide range of conditions seen in EDs, and the resources required for treating them, has been less studied. We sought to provide a comprehensive analysis of ED visits and associated resource utilization during the initial COVID-19 surge.MethodsWe performed a retrospective analysis from 5 hospitals in a large health system in Massachusetts, comparing ED encounters from 3/1/2020–4/30/2020 to identical weeks from the prior year. Data collected included demographics, ESI, diagnosis, consultations ordered, bedside procedures, and inpatient procedures within 48 h. We compared raw frequencies between time periods and calculated incidence rate ratios.ResultsED volumes decreased by 30.9% in 2020 compared to 2019. Average acuity of ED presentations increased, while most non-COVID-19 diagnoses decreased. The number and incidence rate of all non-critical care ED procedures decreased, while the occurrence of intubations and central lines increased. Most subspecialty consultations decreased, including to psychiatry, trauma surgery, and cardiology. Most non-elective procedures related to ED encounters also decreased, including craniotomies and appendectomies.ConclusionOur health system experienced decreases in nearly all non-COVID-19 conditions presenting to EDs during the initial phase of the pandemic, including those requiring specialty consultation and urgent inpatient procedures. Findings have implications for both public health and health system planning.

Influence of Telemedicine-first Intervention on Patient Visit Choice, Postvisit Care, and Patient Satisfaction in Gastroenterology

Influence of Telemedicine-first Intervention on Patient Visit Choice, Postvisit Care, and Patient Satisfaction in Gastroenterology

Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use.

Pediatric somatic symptom and related disorders (SSRDs) are common with high health care costs and use because of lack of standardized, evidence-based practice. Our hospital implemented a clinical pathway (CP) for SSRD evaluation and management. Our study objective was to evaluate health care cost and use associated with the organization's SSRD CP in the emergency department (ED) and inpatient settings hypothesizing lower cost and use in the CP group relative to controls. We conducted a retrospective analysis of costs and use before and after implementation of the SSRD CP. Data were collected from the hospital's electronic health record and the Pediatric Health Information System database. Participants included pediatric patients on the CP ("P" group) and control groups with an SSRD diagnosis and mental health consultation either the year before the CP ("C" group) or during the CP study period ("T" group). Primary outcomes included costs, length of stay, diagnostic testing, imaging, subspecialty consultation, and readmission rates. The ED P group had more lower-cost imaging, whereas the inpatient T group greater higher-cost imaging than other groups. The inpatient P group had significantly shorter length of stay, fewer subspecialty consults, and lower costs. There were no significant group differences in readmission rates. The CP reduced median total costs per patient encounter by $51 433 for the inpatient group and $6075 for the ED group. The CP group showed significant reductions in health care cost and use after implementation of a CP for SSRD care. In future work, researchers should explore patient and practitioner experience with the SSRD CP and long-term outcomes.

Relationship Between Clinical Factors and Duration of IV Antibiotic Treatment in Neonatal UTI.

To describe practice patterns of intravenous (IV) antibiotic treatment duration in term neonates ≤28 days old with a urinary tract infection (UTI). We performed a retrospective chart review of term neonates ≤28 days old hospitalized for UTI at 2 academic pediatric hospitals from 2012 to 2018. Neonates who were admitted to the PICU or with known preexisting renal and/or urologic anomalies or concomitant bacteremia were excluded. We examined clinical features, complications, and duration of IV antibiotic therapy. Univariate and multivariate analyses of long duration of IV antibiotics (>48 hours) were performed by using logistic regression. Of 310 neonates identified by diagnostic codes and chart review, 112 met criteria for inclusion. The median IV antibiotic duration was 49 hours (51% received IV antibiotics for >48 hours), and the median total antibiotic duration was 10 days. No demographic features or laboratory values correlated with IV antibiotic duration apart from age <7 days. The odds of long IV antibiotic duration increased if the neonate had a secondary diagnosis extending hospitalization (adjusted odds ratio [aOR] = 3.2; P = .002; 95% confidence interval [CI], 1.2-8.7), subspecialty consult (aOR = 4.79; P < .001; 95% CI, 1.87-12.3), or an abnormal renal ultrasound (aOR = 2.26; P = .02; 95% CI, 1.01-5.08). Only 1 neonate experienced treatment failure. Our study revealed the recent trend toward shorter IV antibiotic courses for healthy term neonates with UTI is inclusive of infants ≤28 days at these 2 sites. Few factors associated with neonates' initial clinical presentation appear to influence the length of IV antibiotic treatment.