Pediatric Discharges Research Articles

A framework of pediatric hospital discharge care informed by legislation, research, and practice.

To our knowledge, no widely used pediatric standards for hospital discharge care exist, despite nearly 10 000 pediatric discharges per day in the United States. This lack of standards undermines the quality of pediatric hospital discharge, hinders quality-improvement efforts, and adversely affects the health and well-being of children and their families after they leave the hospital. In this article, we first review guidance regarding the discharge process for adult patients, including federal law within the Social Security Act that outlines standards for hospital discharge; a variety of toolkits that aim to improve discharge care; and the research evidence that supports the discharge process. We then outline a framework within which to organize the diverse activities that constitute discharge care to be executed throughout the hospitalization of a child from admission to the actual discharge. In the framework, we describe processes to (1) initiate pediatric discharge care, (2) develop discharge care plans, (3) monitor discharge progress, and (4) finalize discharge. We contextualize these processes with a clinical case of a child undergoing hospital discharge. Use of this narrative review will help pediatric health care professionals (eg, nurses, social workers, and physicians) move forward to better understand what works and what does not during hospital discharge for children, while steadily improving their quality of care and health outcomes.

Ethnic Disparities among Pediatric Tonsillectomy Patients

Objectives: Study ethnic disparities in rates of complications in inpatient pediatric tonsillectomy patients. Methods: Study Design: Retrospective cohort study. Setting: USA pediatric discharge samples from 2003, 2006, and 2009 calendar years. Method: This study examined inpatient admissions for pediatric tonsillectomy in 2003, 2006, and 2009 using the Kids’ Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Outcomes were analyzed for racial disparities. Pearson chi-squared was used to analyze categorical data and linear regression for continuous variables. Logistical regression and multivariate linear regression models were created to assess for confounding and to create odds ratios. Results: The estimated population of inpatient pediatric patients who underwent tonsillectomy was 82,222. Forty-two percent were female. The ethnic breakdown was: 52% white, 20% black, 19% Hispanic, 2% Asian, 6% other. The mean length of stay was 2.3 days and the complication rate was 18%. The postoperative bleed rate was 13% and 2% required a blood transfusion. Black children had longer hospital stays (3.0 days vs 2.1 days, P < .01), more respiratory complications (31% vs 21%, P < .01), higher postoperative intubation rates (7% vs 2%, P < .01), and needed more blood transfusion (3.6% vs 1.7%, P < .01). White children were more likely to have postoperative bleeding (17% vs 9%, P < .01). Approximately 0.06% of patients died with no ethnic predilection. Conclusions: Ethnic disparities exist among pediatric inpatient tonsillectomy patients. Further research to understand the etiology of these differences is necessary.

National Trends in Pediatric Basilar Skull Fractures

Objectives: (1) Identify the current public health burden of pediatric temporal bone fractures. (2) Determine if the introduction of bicycle helmet and child safety seat laws has resulted in a change in national patterns. Methods: The 2000 and 2009 Kids’ Inpatient Databases were used to gather data on a sample of all pediatric discharges in the United States during the years 2000 and 2009. Children diagnosed with basilar skull fractures were identified by corresponding ICD-9 codes. Database analyses generated national estimates of summary statistics and comparison of trends over the 9-year period. Results: The estimated prevalence of pediatric skull base fractures requiring hospitalization in the United States has remained essentially stable with 9641 (95% confidence interval [CI]: 8782, 10,501) admissions in 2000 and 10,581 (95% CI: 9532, 11,630) in 2009. Likewise, the mean age is unchanged from 10.02 (95% CI: 9.66, 10.38) years to 9.76 (95% CI: 9.44, 10.07). The proportion of female patients is the same (33%) (95% CI: 0.031, 0.34) and (95% CI: 0.0.32, 0.35) respectively. Total charges increased from $25,900,000 (95% CI: $22,200,000, $29,600,000) to $60,300,000 (95% CI: $53,100,000, $67,600,000) with a mean charge per admission increasing from $28,958 (95% CI: $26,302, $31,615) in 2000 to $57,596 (95% CI: $53,134, $62,058) in 2009. The mean length of stay remained stable at 6.04 (95% CI: 5.60, 6.48) to 5.31 (95% CI: 5.00, 5.62) hospital days. Conclusions: The public health impact of pediatric skull base fractures continues to be substantial. Despite the institution of bicycle helmet and child safety seat laws, national trends demonstrate a stable prevalence of hospital admissions, age at admission, sex distribution, and mean hospital stays with an increasing economic burden over the past decade.

IMPACT OF HOSPITAL PHARMACISTS ON THE PAEDIATRIC DISCHARGE PROCESS

AimTo evaluate the discharge planning process undertaken by hospital pharmacists in a paediatric hospital and to identify areas for improvement in the discharge planning process.MethodAccurate and timely medicines information at...

Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge.

Discharging patients from hospital is a complex multidisciplinary process that can lead to non-compliance and medication-related problems. To evaluate risks of discontinuity of pharmaceutical care at paediatric hospital discharge and assess potential improvement strategies, using two complementary methods: a prospective risk analysis and a spontaneous incident reporting system. Geneva University hospitals and community pharmacies. A multidisciplinary team analysed the paediatric medication discharge process applying the failure modes (FM), effects, and criticality analysis (FMECA), using ibuprofen, morphine, valganciclovir as model drugs. Over 46 months, incidents with discharge prescriptions, reported by community pharmacists, were classified according to FMECA's FM. FM, criticality indexes (CI), incidents. Twenty-four FM were identified. The highest criticality scores were given for prescribing the wrong dosage [mean criticality index (CI = 205)], early treatment discontinuation by the patient (CI = 195), and continuation of contraindicated treatment by the general practitioner (CI = 191). Implementation of eight improvement strategies covering the eight most critical FM led to a 64 % reduction in criticality scores (CI 496 vs 1,392). Improvement of the computerized-physician-order-entry system was the single most effective strategy (CI 843 vs 1,392). Only 52 incidents were spontaneously reported (17 for paediatric patients). Paediatric problems most frequently reported (lack of information, 35 %; delay in drug supply, 18 %) were consistent with the highest frequencies scored by FMECA. Spontaneous incident reporting leads to high levels of under-reporting, but highlighted similar problems at paediatric hospital discharge to FMECA. Using FMECA allowed estimations of criticalities at each step and the potential impact of safety improvement strategies. Proactive and reactive methods proved complementary and would help to set up effective targeted improvement strategies to improve medication process at paediatric hospital discharge.

Lower rates of EMR use in rural hospitals represent a previously unexplored child health disparity.

Rural hospitals face significant barriers to adoption of advanced-stage electronic medical records (EMRs), which may translate to an unexplored disparity for children in rural hospitals. Our objective was to determine whether children hospitalized in rural settings are less likely to be cared for using advanced-stage EMRs. We merged the 2009 Healthcare Cost and Utilization Project Kids Inpatient Dataset with the 2009 Healthcare Information and Management Systems Society database. Logistic regression determined the independent relationship between receiving care in a rural hospital and advanced-stage EMRs. A total of 430 055 (9.3%) of the 4 605 454 pediatric discharges were rural. Logistic regression analysis determined that even when an extensive list of various patient and hospital characteristics are accounted for, rurality continues to be a strong predictor of a child's care without advanced-stage EMRs (odds ratio 0.3; 95% confidence interval, 0.2-0.5). Children hospitalized in a rural hospital are less than half as likely to be treated using advanced-stage EMRs. A focus of government and hospital policies to expand the use of EMRs among rural hospitals may reduce this child health care disparity.

Pediatric inpatient hospital resource use for congenital heart defects.

Congenital heart defects (CHDs) occur in approximately 8 per 1000 live births. Improvements in detection and treatment have increased survival. Few national estimates of the healthcare costs for infants, children and adolescents with CHDs are available. We estimated hospital costs for hospitalizations using pediatric (0-20 years) hospital discharge data from the 2009 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) for hospitalizations with CHD diagnoses. Estimates were up-weighted to be nationally representative. Mean costs were compared by demographic factors and presence of critical CHDs (CCHDs). Up-weighting of the KID generated an estimated 4,461,615 pediatric hospitalizations nationwide, excluding normal newborn births. The 163,980 (3.7%) pediatric hospitalizations with CHDs accounted for approximately $5.6 billion in hospital costs, representing 15.1% of costs for all pediatric hospitalizations in 2009. Approximately 17% of CHD hospitalizations had a CCHD, but it varied by age: approximately 14% of hospitalizations of infants, 30% of hospitalizations of patients aged 1 to 10 years, and 25% of hospitalizations of patients aged 11 to 20 years. Mean costs of CHD hospitalizations were higher in infancy ($36,601) than at older ages and were higher for hospitalizations with a CCHD diagnosis ($52,899). Hospitalizations with CCHDs accounted for 26.7% of all costs for CHD hospitalizations, with hypoplastic left heart syndrome, coarctation of the aorta, and tetralogy of Fallot having the highest total costs. Hospitalizations for children with CHDs have disproportionately high hospital costs compared with other pediatric hospitalizations, and the 17% of hospitalizations with CCHD diagnoses accounted for 27% of CHD hospital costs.

ABSTRACT 996

Background and aims: Night time discharges are associated increased readmission morbidity and mortality. In last decade there has been increased stress on existing resources, stretching the limits during winter months. Aims: We review paediatric intensive care discharge practice with respect to the time of day. Methods: A single centre retrospective review of prospectively collected data. We compared three cohorts, 2003-05 cohort, 2006-09 and 2010-12 cohort. Night is defined between 00 -06 hours, office hours are between 08:00 - 17:00 hours, and out-of-hours (OOH) are between 17:01 and 07:59 hours. Results: Over ten year period (January2003-December2012) there were total 11,016 discharges. There is 11% increase in patient episodes in 3rd episode compared to 1st episode. (3085 Vs. 3452). 78% patients were discharged during office hours, 4% were discharged at night. Peak discharge time during year 2003-05 was mid afternoon. In cohort 2010-12 there is plateaued phase of discharges continued till late evening with missing mid afternoon peak. There is 25% increase in patients discharged during mid-night (147 Vs. 117).FigureConclusions: Total patient workload has increased over last ten years, however there is disproportionate increase in out-of-hours and night discharges. Surprisingly, office time discharges have remained same.

Examining interrater reliability and validity of a paediatric cardiopulmonary physiotherapy discharge tool.

To determine the interrater reliability (IRR) of the individual items in the Paediatric Cardiopulmonary Physiotherapy (CPT) Discharge Tool. This tool identifies six critical items that physiotherapists should consider when determining a paediatric patient's readiness for discharge from CPT after upper-abdominal, cardiac, or thoracic surgery: oxygen saturation, mobility, secretion retention, discharge planning, auscultation, and signs of respiratory distress. A total of 33 paediatric patients (ages 2 to <19 years) who received at least 1 day of CPT following cardiac, thoracic, or upper-abdominal surgery were independently assessed using the Paediatric CPT Discharge Tool by two designated assessors, who assessed each patient within 4 hours of each other. Kappa analysis showed the following levels of interrater agreement for the six items of the Paediatric CPT Discharge Tool: Oxygen Saturation, excellent (κ=0.80); Mobility, substantial (κ=0.62); Secretion Clearance, moderate (κ=0.39); Discharge Planning, fair (κ=0.37); and Auscultation and Respiratory Distress, poor (κ=0.24 and κ=-0.08, respectively). Several of the items in the Paediatric CPT Discharge Tool demonstrate good IRR. The discharge tool is ready for further psychometric testing, specifically validity testing.

Increased Utilization of Pediatric Specialty Care

To examine inpatient utilization of pediatric cancer specialty centers (PCSCs) by pediatric oncology patients. We performed a retrospective (1999 to 2010) population-based analysis of oncology hospitalizations for pediatric patients aged 0 through 18 years using the California Office of Statewide Health Planning and Development database. Logistic regression examined hospitalization at 29 PCSCs and variables of age, sex, tumor type, payer, race, income, and distance to admission site. Analysis of 103,961 pediatric oncology discharges revealed that 93% occurred at PCSCs. These sites experienced a 20% increase in pediatric oncology discharges, conversely non-PCSCs exhibited a 70% decrease (P<0.0001). Multivariate analyses revealed increased utilization with young age (odds ratio [OR], 4.58; 95% CI, 3.88-5.42), African American (OR, 1.26; 95% CI, 1.11-1.43), and middle income (OR, 1.36; 95% CI, 1.29-1.45). Decreased utilization was seen for females (OR, 0.88; 95% CI, 0.84-0.93) and Hispanics (OR, 0.72; 95% CI, 0.68-0.77). Payer and proximity were not significantly associated with change in utilization. Tumor types less likely to utilize a PCSC included germ cell, solid, and central nervous system tumors. Adolescents were >3 times less likely to be treated at a PCSC. Inpatient pediatric oncology care in California has become increasingly regionalized with the vast majority of patients accessing PCSCs. However, variability in hospitalizations of adolescent patients and children not treated in PCSCs deserve further evaluation.

DI-049 Pharmacist’s interventions to improve drug supply and parentsí knowledge at paediatric hospital discharge

BackgroundDischarging paediatric patients from hospital is a complex process that can lead to non-compliance and medicines-related problems. Crucial issues are drug supply in community pharmacies and patients’ knowledge of treatments....

Paediatric discharges against medical advice at a tertiary health centre in Bayelsa State, Nigeria

Introduction : Paediatric discharges against medical advice (DAMA) are common hospital experiences which limit appropriate and comprehensive treatment as a result of abrupt termination of physician care. The fact remains that the children who are the major culprits of this practice are not legally able to participate in this decision making process which may negatively affect their health. Objectives : This present study was carried out with the aim of identifying the DAMA prevalence, the socio-cultural characteristics and reason(s) for DAMA among the paediatric patients admitted into the Niger Delta University Teaching Hospital, Bayelsa. Methods : Case notes of all children who had been discharged against medical advice over a 2 year period(1st of June 2011 to 31st of May 2013) were retrospectively reviewed and analysed. Results : One hundred and fortyone children out of a total of 1872 children admitted into the paediatric wards had been discharged against medical advice, giving a DAMA prevalence rate of 7.5%. Out of 120 children whose case notes were retrieved and analysed, there were69(57.5%) males and 51 (42.5%) females with a male: female ratio of 1.4:1. Neonatal septicaemia (32.6%), birth asphyxia (27.9%) and prematurity (14.0%) were the major diagnosis in neonates while respiratory tract infections (18.2%), severe malaria (15.6%) and septicaemia (14.3%) were the commonest diagnosis in older children who were DAMA. Discharges against medical advice occurred commonly in the first week of admission (69.0%) and among infants (58.0%). Majority of the patients were from low and middle social classes (85.8%) with 30% of the children belonging to families with 4 or more children. The commonest reasons for DAMA were financial constraints (36.7%), lack of clinical improvement (7.5%) and inconvenience of child’s admission (7.5%). Only 27% of the children’s clinical condition had been noted to have improved before DAMA and fathers were the signatories to the discharge documents in 68% of cases. Conclusions: Discharges against medical advice remain a serious public health problem with infants being the most vulnerable. Government provision of free child health services, improving access to health facilities through creation of better road network, better patient- physician relationship, child advocacy and female empowerment would help to ameliorate this problem. Keywords : Discharges against medical advice, child care, advocacy, Nigeria.

Age at presentation of common pediatric surgical conditions: Reexamining dogma

PurposeThe commonly cited ages at presentation of many pediatric conditions have been based largely on single center or outdated epidemiologic evidence. Thus, we sought to examine the ages at presentation of common pediatric surgical conditions using cases from large national databases. MethodsA retrospective analysis was performed on Healthcare Cost and Utilization Project databases from 1988 to 2009. Pediatric discharges were selected using matched ICD9 diagnosis and procedure codes for malrotation, intussusception, hypertrophic pyloric stenosis (HPS), incarcerated inguinal hernia (IH), and Hirschsprung disease (HD). Descriptive statistics were computed. ResultsA total of 63,750 discharges were identified, comprising 2744 cases of malrotation, 5831 of intussusception, 36,499 of HPS, 8564 of IH, and 10,112 of HD. About 58.2% of malrotation cases presented before age 1. Moreover, 92.8% of HPS presented between 3 and 10weeks. For intussusception, 50.3% and 91.4% presented prior to ages 1 and 4years, respectively. Also, 55.8% of IHD cases presented before their first birthday. For HD, 6.5% of cases presented within the neonatal period and 45.9% prior to age 1year. ConclusionOur findings support generally cited presenting ages for HPS and intussusception. However, the ages at presentation for HD, malrotation, and IH differ from commonly cited texts.

Impact of Audit and Feedback and Pay-for-Performance Interventions on Pediatric Hospitalist Discharge Communication With Primary Care Providers

The study team sought to improve hospitalist communication with primary care providers (PCPs) at discharge through interventions consisting of (a) audit and feedback and (b) inclusion of a discharge communication measure in the incentive compensation for pediatric hospitalists. The setting was a 16-physician pediatric hospitalist group within a tertiary pediatric hospital. Discharge summaries were selected randomly for documentation of communication with PCPs. At baseline, 57% of charts had documented communication with PCPs, increasing to 84% during the audit and feedback period. Following the addition of a financial incentive, documentation of communication with PCPs increased to 93% and was sustained during the combined intervention period. The number of physicians meeting the study's performance goal increased from 1 to 14 by the end of the study period. A financial incentive coupled with an audit and feedback tool was effective at modifying physician behavior, achieving focused, measurable quality improvement gains.

Using quality improvement to optimise paediatric discharge efficiency

BackgroundBed capacity management is a critical issue facing hospital administrators, and inefficient discharges impact patient flow throughout the hospital. National recommendations include a focus on providing care that is timely...

Pediatric Discharge Content: A Multisite Assessment of Physician Preferences and Experiences

Professional medical societies endorse prompt, consistent discharge communication to primary care providers (PCPs) on discharge. However, evidence is limited about what clinical elements to communicate. Our main goal was to identify and compare the clinical elements considered by PCPs and pediatric hospitalists to be essential to communicate to PCPs within 2 days of pediatric hospital discharge. A secondary goal was to describe experiences of the PCPs and pediatric hospitalists regarding sending and receiving discharge information. A survey of physician preferences and experiences regarding discharge communication was sent to 320 PCPs who refer patients to 16 hospitals, with an analogous survey sent to 147 hospitalists. Descriptive statistics were calculated, and χ² analyses were performed. A total of 201 PCPs (63%) and 71 hospitalists (48%) responded to the survey. Seven clinical elements were reported as essential by >75% of both PCPs and hospitalists: dates of admission and discharge; discharge diagnoses; brief hospital course; discharge medications; immunizations given during hospitalization; pending laboratory or test results; and follow-up appointments. PCPs reported reliably receiving discharge communication significantly less often than hospitalists reported sending it (71.8% vs 85.1%; P < .01), and PCPs considered this communication to be complete significantly less often than hospitalists did (64.9% vs 79.1%; P < .01). We identified 7 core clinical elements that PCPs and hospitalists consider essential in discharge communication. Consistently and promptly communicating at least these core elements after discharge may enhance PCP satisfaction and patient-level outcomes. Reported rates of transmission and receipt of this information were suboptimal and should be targeted for improvement.

Pediatric hospital discharge interventions to reduce subsequent utilization: A systematic review

Reducing avoidable readmission and posthospitalization emergency department (ED) utilization has become a focus of quality-of-care measures and initiatives. For pediatric patients, no systematic efforts have assessed the evidence for interventions to reduce these events. We sought to synthesize existing evidence on pediatric discharge practices and interventions to reduce hospital readmission and posthospitalization ED utilization. PubMed and the Cumulative Index to Nursing and Allied Health Literature. Studies available in English involving pediatric inpatient discharge interventions with at least 1 outcome of interest were included. We utilized a modified Cochrane Good Practice data extraction tool and assessed study quality with the Downs and Black tool. Our search identified a total of 1296 studies, 14 of which met full inclusion criteria. All included studies examined multifaceted discharge interventions initiated in the inpatient setting. Overall, 2 studies demonstrated statistically significant reductions in both readmissions and subsequent ED visits, 4 studies demonstrated statistically significant reductions in either readmissions or ED visits, and 2 studies found statistically significant increases in subsequent utilization. Several studies were not sufficiently powered to detect changes in either subsequent utilization outcome measure. Interventions that demonstrated reductions in subsequent utilization targeted children with specific chronic conditions, providing enhanced inpatient feedback and education reinforced with postdischarge support. Interventions seeking to reduce subsequent utilization should identify an individual or team to assume responsibility for the inpatient-to-outpatient transition and offer ongoing support to the family via telephone or home visitation following discharge.

Characteristics of hospitals with lowest costs in management of pediatric appendicitis

BackgroundA primary determinant of value in treating appendicitis is inpatient cost. The purpose of this study was to identify hospital-level factors that drive costs associated with the treatment of appendicitis. MethodsCost-to-charge ratios from the 2009 Kids' Inpatient Database gave average all-payer costs by hospital for uncomplicated appendicitis (without peritonitis, ICD-9-CM 540.9) and complicated appendicitis (generalized peritonitis, 540.0; peritoneal abscess, 540.1). The 10% of hospitals with the lowest costs were defined as low cost; the remaining 90% were defined non-low cost. Bivariate and multivariate analyses compared hospital characteristics between the two groups. ResultsThreshold cost dividing low cost from non-low cost for uncomplicated appendicitis was $4626; for complicated appendicitis, it was $6,026. For both conditions teaching status, lower percentage of pediatric discharges, and fewer registered nurses (RN) per 1000 adjusted patient-days predicted a hospital to be low cost. A cost benefit for medium and large hospitals and higher inpatient volume was found only for uncomplicated appendicitis. Regional effects were noted. ConclusionsThe findings show the high-cost structure of hospitals that care for high volumes of children, emphasizing the need to constrain cost. There is some benefit of economies of scale, and careful attention to the numbers of nursing personnel.

Factors Associated With High Resource Utilization in Pediatric Skin and Soft Tissue Infection Hospitalizations

To describe factors associated with prolonged lengths of stay (LOS) and increased charges for pediatric skin and soft tissue infection (SSTI) hospitalizations. This study was a cross-sectional analysis of pediatric SSTI hospital discharges in 2009 within the Healthcare Cost and Utilization Project Kids' Inpatient Database. Outcomes were prolonged LOS (>75th percentile) and increased hospital charges (>75th percentile). Multivariate logistic regression controlling for patient and hospital level factors was conducted for 2009 data to assess associations among variables. The 75th percentile for LOS was 3 days. Infants had higher odds of prolonged LOS than other age groups (<1 year: 1; 1-4 years: 0.70 [95% confidence interval (CI): 0.64-0.76]; 5-12 years: 0.69 [95% CI: 0.63-0.76]; 13-18 years: 1.01 [95% CI: 0.91-1.10]), as did all minority groups compared with white subjects (black subjects: 1.23 [95% CI: 1.09-1.38]; Hispanic subjects: 1.33 [95% CI: 1.20-1.47]; and other races: 1.30 [95% CI: 1.12-1.50]). Public payers compared with private payers (odds ratio: 1.17 [95% CI: 1.10-1.26]) also had increased odds of prolonged LOS. The 75th percentile for charges was $14 317. The adolescent-aged category had higher odds of charges >75th percentile compared with the age category <1 year (odds ratio: 1.54 [95% CI: 1.36-1.74]). All racial/ethnic minorities had higher odds of charges >75th percentile compared with white subjects (black subjects: 1.38 [95% CI: 1.17-1.62]; Hispanic subjects: 1.90 [95% CI: 1.59-2.26]; and other races: 1.26 [95% CI: 1.06-1.50]). Vulnerable populations, including infants, racial/ethnic minorities, and publicly insured children, had higher odds of increased resource utilization during hospitalizations for SSTIs. The findings of this study provide potential targets for future preventive and public health interventions.

Pediatric Emergency Department Discharge Failure: A Systemic Review of Risk Factors and Interventions

Pediatric emergency department (ED) discharge failure, defined as ED return within 72 hours or more, poor compliance or comprehension, carries significant clinical implications such as unfinished treatments, progression of illness. Therefore, identifying risk factors for pediatric ED discharge failure would serve to design better interventions to improve patient care. This systemic review aimed at identifying risk factors and interventions trying to reduce discharge failure.