BACKGROUND AND OBJECTIVE: Children with medical complexity have unique needs when facilitating transitions from hospital to home. Defining readiness for discharge is challenging, and preparation requires coordination of family, education, equipment, and medications. Our multidisciplinary team aimed to increase the percentage of medically complex hospital medicine patients discharged within 2 hours of meeting medical discharge goals from 50% to 80%. METHODS: We used quality improvement methods to identify key drivers and inform interventions. Medical discharge goals were defined on admission for each patient. Interventions included implementation of a complex care inpatient team with electronic admission order set, weekly care coordination rounds, needs assessment tool, and medication pathway. The primary measure, percentage of patients discharged within 2 hours of meeting medical discharge goals, was followed on a run chart. The secondary measures, pre- and post-intervention length of stay and 30-day readmission rate, were compared by using Wilcoxon rank-sum and χ2 tests, respectively. RESULTS: The percentage of medically complex patients discharged within 2 hours of meeting medical discharge goals improved from 50% to 88% over 17 months and sustained for 6 months. In preintervention–postintervention comparison, median length of stay did not change (3.1 days [interquartile range, 1.8–7.0] vs 2.9 days [interquartile range, 1.7–6.1]; P = .67) and 30-day readmission rate was not impacted (30.7% vs 26.4%; P = .51). CONCLUSIONS: Efficient discharge for medically complex patients requires support of a multidisciplinary team to proactively address discharge needs, ensuring patients are ready for discharge when medical goals are met.

Purpose Surgical procedures, such as medial hamstring lengthening (MHL) and femoral derotational osteotomy (FDO), can improve the gait of children with cerebral palsy (CP); however, substantial variation exists in the factors that influence the decision to perform surgery. The purpose of this study was to use expert surgeon opinion through a Delphi technique to establish consensus for indications in ambulatory children with CP. Methods A 15-member panel, all established experts with at least nine years’ experience in the surgical management of children with CP, was created (mean of 20.81 years’ experience). All panel members also had expertise of the use of movement analysis for the assessment of gait disorders in children with CP. The group initially focused on two of the most commonly performed procedures, MHL and FDO, in an attempt to gain consensus (> 80%). This was obtained through a standardized, iterative Delphi process. Results For MHL, a total of 59 questions were surveyed: 41 indication questions and 18 outcome questions, for which there was consensus on ten indication questions and seven outcomes. For FDO, a total of 55 questions were surveyed: 43 indication questions and 12 outcome questions, for which there was consensus on 29 indication questions and eight outcomes. Conclusion This study is the first to use an expert panel to identify best-practice indications for common surgical procedures of children with CP. The results from this study will allow for more informed evaluation of practice and form the basis for future improvement efforts to standardize surgical recommendations internationally. Level of Evidence Level IV

Kawasaki disease (KD) is an acute, self-limited vasculitis of mediumsized arteries that leads to coronary artery aneurysms in approximately 25% of untreated patients. Timely treatment with intravenous immunoglobulin (IVIG) has decreased this risk to 3% to 5%. Incomplete KD is a risk factor for delayed diagnosis and treatment, thus increasing the risk for coronary artery abnormalities (CAAs). The American Heart Association (AHA) guideline provides a diagnostic algorithm for suspected cases of incomplete KD, which has retrospectively been shown to hasten treatment. 1,2 There remains a subset of children, particularly infants younger than 6 months and adolescents, in whom the diagnosis is exceedingly challenging. Once the diagnosis is made, the treatment of complete and incomplete KD is identical. Intravenous immunoglobulin and acetylsalicylic acid are the hallmarks of therapy. The use of adjunctive agents and strategies for treatment of IVIG-resistant disease remains controversial. 1

Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children 1 -3 and often requires prolonged and costly treatment. 1, 3 -6 A recent large study from Spain revealed that children with osteomyelitis were hospitalized for an average of 13.5 days, that 20% required surgery, and that 2.3% developed longterm sequelae, such as leg-length discrepancy. 3 Early transition to oral therapy has been shown to be an effective and less costly approach compared with prolonged parenteral therapy. 5 -13 Despite efforts at our institution to reduce costs through early transition to oral therapy, 14 our inpatient costs remained high. In preliminary discussions among specialties involved in caring for children with AHO at our institution, substantial variation in practices from 1 patient to another was identified. We hypothesized that standardizing our practice in all areas would lead to an overall cost reduction and improved care. on behalf of the AHO Care Algorithm Team BACKGROUND AND OBJECTIVES: Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children. Quality improvement (QI) methods have been used to successfully improve care and decrease costs through standardization for numerous conditions, including pediatric AHO. We embarked on a QI initiative to standardize our approach to the inpatient management of AHO, with a global aim of reducing inpatient costs. METHODS:We used existing literature and local consensus to develop a care algorithm for the inpatient management of AHO. We used the Model for Improvement as the framework for the project, which included process mapping, failure mode analysis, and key driver identification. We engaged with institutional providers to achieve at least 80% consensus regarding specific key drivers and tested various interventions to support uptake of the care algorithm. RESULTS:Fifty-seven patients were included. There were 31 patients in the preintervention cohort and 26 in the postintervention cohort, of whom 19 were managed per the algorithm. Mean inpatient charges decreased from $45 718 in the preintervention cohort to $32 895 in the postintervention cohort; length of stay did not change. Adherence to recommended empirical antimicrobial agents trended upward. CONCLUSIONS: A simple and low-cost QI project was used to safely decrease the cost of inpatient care for pediatric AHO at a tertiary care children's hospital. A robust local consensus process proved to be a key component in the uptake of standardization. abstract To cite: Robinette ED, Brower L, Schaffzin JK, et al. Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis.