Improving CarE for Community Acquired Pneumonia 1 (ICE-CAP2) (ICE-CAP2)

National Institute of Allergy and Infectious Diseases (NIAID), University of Pittsburgh Medical Center

Children with pneumonia presenting to the emergency department at Monroe Carell Jr. Children's Hospital at Vanderbilt or Children's Hospital of Pittsburgh will be potentially eligible for study. During intervention periods, providers caring for enrolled children will be presented with a detailed decision support strategy that emphasizes management in accordance with national guideline recommendations. The anticipated study duration is 24 months and, as this study does not include direct contact with enrolled subjects, there is no anticipated follow up.

Pneumonia is the most common serious infection in childhood. In the United States (US), pneumonia accounts for 1-4% of all emergency department (ED) visits in children (3-28 per 1,000 US children per year) and ranks among the top 3 reasons for pediatric hospitalization with >100,000 hospitalizations per year (15-22 per 100,000 US children per year). Pneumonia also accounts for more days of antibiotic use in US children's hospitals than any other condition. Emergency care for childhood pneumonia, including hospitalization rates, varies widely across the nation. A study examining hospital admission rates at 35 US children's hospitals from 2009-12 showed marked differences in severity-adjusted pneumonia hospital admission rates (median 31%; range 19-69%). Provider preferences and inaccurate risk perceptions contribute to these differences in hospitalization rates. Within the Intermountain Healthcare System in Utah, Dean et al. exposed large differences in admission rates (range 38-79%) among 18 individual ED providers providing care for >2,000 adults with pneumonia. Differences were not explained by patient characteristics or illness severity and higher rates of hospitalization did not reduce hospital readmissions or mortality. In another multicenter study of 472 adults with pneumonia at <4% risk of 30-day mortality estimated using objective severity scores, providers overestimated the risk of mortality in 5% of outpatients (range across institutions 0-12%) and 41% of inpatients (range across institutions 36-48%). These studies suggest that risk perceptions are often inaccurate, and potentially lead to unnecessary or prolonged hospitalizations and intensive therapies. Similar studies have not been performed in children because no valid prognostic tools exist to reliably predict pediatric pneumonia severity.

We will conduct a randomized controlled trial comparing our prognostic tool (intervention arm) to usual care (control arm) over a period of 24 months. Randomization will occur at the patient level. Allocation to intervention or control will be based on medical record number (even vs. odd) or similar strategy and will be assigned automatically once a provider confirms the diagnosis of pneumonia. Importantly, all standard of care treatment options will be available and decision-making will not be restricted in any way in either group.

The prognostic decision support application will be provided to those randomized to the intervention arm. Due to the nature of the intervention, blinding of treating providers will not be possible. All children will receive usual care and all treatment decisions will be made by the clinical providers and will not be restricted or altered in any way.

No experimental decision support will be provided to those randomized to the control arm. All children will receive usual care and treatment will not be restricted or altered in any way by the study.

For enrolled subjects assigned to the decision support arm, providers will receive prognostic information derived using our previously validated and best performing model. The decision support application will automatically calculate predicted risk for moderate (intensive care) and severe (respiratory failure or shock) outcomes using the parameters derived from the prognostic tool's regression equation. Outcome probabilities will be integrated into the decision support application and displayed within the EHR.

Number of participants who were disposed to the appropriate site of care according to the following definitions: Discharged to home (No subsequent hospitalization within 24h); Inpatient ward (Hospital length of stay (LOS) ≥ 24h OR hospital LOS < 24h but objective criteria for admission present (eg, need for supplemental oxygen)) AND no subsequent transfer to ICU within 24h; or ICU (ICU LOS ≥ 24h OR ICU LOS < 24h but objective criteria for ICU admission present (eg, respiratory failure))

This secondary outcome reports the total number of participants who were discharged from the ED, admitted to the inpatient ward, and admitted to the ICU.

This secondary outcome reports the number of participants who presented to the ED for care within 72 hours of the index discharge.

This secondary outcome reports the number of participants who presented to the ED for care within 7 days of the index discharge.

This secondary outcome reports the number of participants who were readmitted to the hospital for pneumonia-related illness within 72 hours of the index discharge.

This secondary outcome reports the number of participants who were readmitted to the hospital for pneumonia-related illness within 7 days of the index discharge.

Inclusion Criteria: Six months to <18 years of age Radiographic evidence of pneumonia in ED Provider-confirmed diagnosis of pneumonia Exclusion Criteria: Children with tracheostomy, cystic fibrosis, immunosuppression Inter-hospital transfers Hospitalization within preceding 7 days Previously enrolled within preceding 28 days Provider preference for any reason