I am so pleased to serve as guest editor for this issue of Pediatric Annals! I must admit that I was a bit confused initially as to how my perspective as a pediatric hospitalist would be valuable to general pediatricians. After a few discussions with the Editor-in-Chief Dr. Joseph R. Hageman, however, I realized that this issue could serve as a bridge between what happens with patients outside the hospital and what happens inside the hospital.
As general pediatricians are managing more and more conditions that have traditionally required hospitalization, patients who are admitted tend to be sicker and have more complex conditions than ever before. Despite this, there are still quite a few conditions for which patients will present to their primary pediatrician prior to being admitted to the hospital. It can be disheartening when a patient requires hospital admission even though you have provided excellent care. It can be downright frustrating when that same patient returns for outpatient follow-up after hospitalization, and you have not received any communication from the hospital physicians about inpatient treatment. Even though pediatric hospitalists strive to provide excellent communication with patients, families, and primary care physicians, it is clear from recent studies that there continue to be challenges around the communication of discharge information.1 My hope is that this issue can help improve that communication—even just a little bit.
Pediatric hospitalists are a diverse group of physicians, from many different training backgrounds and practicing in a variety of different locations, but the care we deliver tends to be evidence based and centered on adherence to published clinical practice guidelines (when available).2 Much of the care provided by pediatric hospitalists is rooted in the philosophy of the “Choosing Wisely” campaign. The American Board of Internal Medicine Foundation and Consumer Reports developed this campaign to encourage physicians and patients to question the need for tests or treatments that may be unnecessary and may even place the patient at risk of harm.3 The fact that pediatric hospital medicine has its own list of “Choosing Wisely” practices speaks to the importance we as hospitalists place on the delivery of evidence-based, cost-conscious care. The articles in this issue, all written by hospital-based pediatricians, are wonderful illustrations of pediatric hospitalists' desire to provide such care.
In the first article, “Less is More: Evidence-Based Management of Bronchiolitis,” Drs. Elisa Hampton and Erika Abramson provide an overview of the most recent evidence surrounding the care of children with bronchiolitis. Many of the latest studies on bronchiolitis in children are centered on recommendations from the 2014 clinical practice guideline4 on the diagnosis, management, and prevention of bronchiolitis. Certain recommendations in the guideline are very different from the previously published 2006 guidelines,5 and this has caused many hospitalists to change their practice in caring for these children. Two of the biggest changes are related to the use of bronchodilators and continuous pulse oximetry, neither of which is routinely recommended in the 2014 guideline4 for all children with bronchiolitis. They do a great job explaining why sometimes it appears the doctors “do nothing” during a child's hospitalization for bronchiolitis.
In the second article, “Back to the Basics: Community-Acquired Pneumonia in Children,” Dr. Kathleen Boyd provides an equally compelling case for “less is more.” As with bronchiolitis, a recently published guideline6 provides recommendations for best practices in treating these children. Many pediatric hospitalists changed their practice upon learning that narrow-spectrum antibiotics are the recommended first-line treatment for uncomplicated pneumonia in fully immunized children. It is also nice to feel comfortable treating such a common problem with an antibiotic like amoxicillin that is well-tolerated, relatively inexpensive, and that tastes good.
Next, in the article, “The Cost of Hospital Admission: Brief Resolved Unexplained Events,” Dr. Justin Triemstra looks at clinical practice guidelines through the lens of health care costs. The recommendations in the 2016 clinical practice guideline “Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants”7 are oriented much more toward watchful waiting for infants considered to be at lower risk of having a repeat event or a serious underlying disorder. This approach may be considered controversial by some, but the recommendations are based on solid research and are designed to save patients unnecessary tests, procedures, and even hospitalizations. In an era of health care reform designed to decrease costs, this topic is particularly timely.
Finally, in the last article, “Pediatric Cellulitis: A Red-Hot Concern,” Dr. Andrew Shriner and I discuss the diagnosis and treatment of cellulitis in pediatric patients. Skin and soft tissue infections are an increasingly common reason for pediatric office and emergency department visits, but the best treatment for pediatric patients with cellulitis remains a work in progress. Practice guidelines published by the Infectious Disease Society of America in 20148 recommend empiric treatment with the least broad-spectrum antibiotic for the least amount of time necessary, but recent research has shown that this is not always being done for our patients. It is clear that pediatric patients will benefit from more research and education around this topic.
My sincere hope is that this issue is both informative and illustrative. The hospital can sometimes seem like a “black box” where patients go and have things done—or have “nothing” done—particularly if communication between pediatric hospitalists and their patients' primary care physicians is lacking. In these comprehensive articles, the authors have hopefully shed some light on why pediatric hospitalists make some of the decisions we do. I am grateful, and thank them for their tremendous efforts. I would also like to thank Dr. Hageman for always keeping me in mind and for inviting me to be the guest editor. Happy reading!
- Solan LG, Sherman SN, DeBlasio D, Simmons JM. Communication challenges: a qualitative look at the relationship between pediatric hospitalists and primary care providers. Acad Pediatr. 2016;16(5):453–459. doi: . doi:10.1016/j.acap.2016.03.003 [CrossRef]
- Parikh K, Hall M, Teach SJ. Bronchiolitis management before and after the AAP guidelines. Pediatrics. 2014;133(1):e1–7. doi: . doi:10.1542/peds.2013-2005 [CrossRef]
- Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307:1801–1802. doi: . doi:10.1001/jama.2012.476 [CrossRef]
- Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474–1502. doi: . doi:10.1542/peds.2014-2742 [CrossRef]
- American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118(4):1774–1793. doi:10.1542/peds.2006-2223 [CrossRef]
- Bradley JS, Byinton CL, Shah SS, et al. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Disease Society of America. Clin Infect Dis. 2011;53(7):617–630. doi: . doi:10.1093/cid/cir625 [CrossRef]
- Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Pediatrics. 2016;137(5). [Epub ahead of print]. doi:10.1542/peds.2016-0591 [CrossRef].
- Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10–52. doi: . doi:10.1093/cid/ciu296 [CrossRef]