title: Implementation and impact of a consensus diagnostic and management algorithm for complicated pneumonia in children.
abstract: BACKGROUND
  Variable treatment exists for children with bacterial pneumonia complications such as pleural effusion and empyema. Subspecialists at an urban academic tertiary children's hospital created a literature-based diagnosis and management algorithm for complicated pneumonia in children. We proposed that algorithm implementation would reduce use of computed tomography (CT) for diagnosis of pleural infection, thereby decreasing radiation exposure, without increased adverse outcomes.
  
  
  METHODS
  A cross-sectional study was undertaken in children (3 months to 20 years old) with principal or secondary diagnosis codes for empyema and/or pleural effusion in conjunction with bacterial pneumonia. Study cohorts consisted of subjects admitted 15 months before (cohort 1, n = 83) and after (cohort 2, n = 87) algorithm implementation. Data were collected using clinical and financial data systems. Imaging studies and procedures were identified using Current Procedural Terminology codes. Statistical analysis included χ test, linear and ordinal regression, and analysis of variance.
  
  
  RESULTS
  Age (P = 0.56), sex (P = 0.30), diagnoses (P = 0.12), and severity level (P = 0.84) were similar between cohorts. There was a significant decrease in CT use in cohort 2 (cohort 1, 60% vs cohort 2, 17.2%; P = 0.001) and reduction in readmission rate (7.7% vs 0%; P = 0.01) and video-assisted thoracoscopic surgery procedures (44.6% vs 28.7; P = 0.03), without concomitant increases in vancomycin use (34.9% vs 34.5%; P = 0.95) or hospital length of stay (6.4 vs 7.6 days; P = 0.4). Among patients who received video-assisted thoracoscopic surgery drainage (n = 57), there were no significant differences between cohorts in median time from admission to video-assisted thoracoscopic surgery (2 days; P = 0.29) or median duration of chest tube drainage (3 vs 4 days; P = 0.10). There was a statistically nonsignificant trend for higher rate of pathogen identification in cohort 2 (cohort 1, 33% vs cohort 2, 54.1%; P = 0.12); Streptococcus pneumonia was the most commonly identified pathogen in both cohorts (37.5% vs 27%; P = 0.23).
  
  
  CONCLUSIONS
  Implementation of an institutional complicated pneumonia management algorithm reduced CT scan use/radiation exposure, VATS procedures, and readmission rate in children with a diagnosis of pleural infection, without associated increases in length of stay or vancomycin use. This algorithm provides the framework for future prospective quality improvement studies in pediatric patients with complicated pneumonia.
authors.affiliation: Division of Pediatric Pulmonary Medicine, Children's National Medical Center, Washington, DC 20010, USA. dpillai@cnmc.org
authors.forename: Dinesh
authors.initials: D
authors.lastname: Pillai
authors.forename: Xiaoyan
authors.initials: X
authors.lastname: Song
authors.forename: William
authors.initials: W
authors.lastname: Pastor
authors.forename: Mary
authors.initials: M
authors.lastname: Ottolini
authors.forename: David
authors.initials: D
authors.lastname: Powell
authors.forename: Bernhard L
authors.initials: BL
authors.lastname: Wiedermann
authors.forename: Roberta L
authors.initials: RL
authors.lastname: DeBiasi
mesh_terms: D000293:Adolescent; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D032921:Consensus; D004636:Emergency Service, Hospital; D006801:Humans; D007223:Infant; D010045:Outpatients; D010351:Patient Discharge; D011014:Pneumonia / Q000175:diagnosis* / Q000628:therapy*; D055815:Young Adult