Implementation and Clinical Impact of an Immunocompromised Infectious Diseases Service at a Large Academic Pediatric Hospital
Alexander S Plattner, Madeline M Cullity, Andrew B JanowskiAbstract
Background
Hospitalized children with medical complexity (CMC) have a greater need for specialized medical teams in order to receive optimal care. One subspecialty that has evolved in recent years is Immunocompromised Infectious Diseases (ICID). Immunocompromised (IC) patients often have very complex medical histories and clinical courses requiring frequent hospitalizations, along with an increased risk of rare, unusual, and opportunistic infections. Therefore, it is critical to have a subset of providers who are experts in evaluating these patients to provide specialized care and continuity in their treatment courses. While there is an increased demand for subspecialization in ICID, there is a paucity of data regarding the clinical impact of this subspecialty. Thus, we aimed to better characterize the impact of a newly formed ICID group through the following objectives: 1) Quantify the growth of the ICID service through consult volume and type, 2) Assess involvement in patients receiving either solid organ or stem cell transplantation, 3) Determine impact on antibiotic usage by units that frequently utilize the ICID service.
Design/Methods
A retrospective review was performed using data from the electronic medical record at St. Louis Children’s Hospital, a large tertiary academic children’s hospital, to perform a pre-post analysis around the introduction of the ICID service in July 2019. The service includes a single full-time equivalent advanced practice provider and a subset of ~6 physicians whose clinical time is dedicated to ICID. The pre-intervention period included data from 2015-2019 and the post-intervention period included data from 2019-2023. A pre-existing database of patients receiving solid organ or stem cell transplantation was available for review of infectious diseases involvement.
Results
Over the first four years of implementation (2019-2023), total annual consults doubled from 203 to 429. After normalizing for hospital volume, there was a similar increase from 2.2 consults per 1,000 patient days to 3.9 consults per 1,000 patient days. This increased demand of consultation came from multiple clinical services with the greatest absolute number of consults from the hematology/oncology service. The percent of patients receiving hematopoietic stem cell transplantation (HSCT) with an ICID consult within 30 days of their transplant increased from 27.5% in the pre-implementation years to 51.9% (P < 0.001). Implementation of the ICID service was also associated with improved HSCT one year survival when analyzing all-cause (P = 0.023) and infection-attributable mortality (P = 0.046). In the post-intervention time-frame, a decrease in usage of broad-spectrum antimicrobials was observed, with a significant decrease meropenem usage in the hematology/oncology, pediatric intensive care, and cardiac intensive care units (all P ≤ 0.033).
Conclusions
Implementation of an ICID service led to increased engagement in the care of IC patients. Additional effects were observed in patient outcomes and antibiotic utilization. Our data provides deeper insights into the impact of an ICID service and how it contributes to the optimization of care in a complex patient population. Future multi-centered studies are needed to validate the effects of ICID care on the outcomes of IC individuals.