Showing posts with label hospital. Show all posts
Showing posts with label hospital. Show all posts

Thursday, October 16, 2014

Off-Hours Admission to Pediatric Intensive Care and Mortality

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our October issue. To learn more about Dr. Schulte, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by Philip Dean via Flickr
Timing counts, especially for critically ill children admitted to pediatric intensive care units (ICUs). The time of day and day of the week are important, as is the kind of illness encountered, the staffing numbers and experience levels of the ICU. All are factors that can shape a child's outcome and determine whether he or she survives to go home.

New research published this month in Pediatrics (doi: 10.1542/peds.2014-1071) found off-hour admissions were associated with a decreased risk of mortality, but morning admissions were associated with an increased likelihood of death. The study was based on a retrospective cohort, assembled using information from a database containing data from 234,192 admissions to 99 hospitals between January 2009 and September 2012. The study ICUs represent about 30 percent of the pediatric ICUs in the United States. The team at Wake Forest University in North Carolina, headed by Dr. Michael McCrory, used a primary outcome of ICU death and defined off-hour admissions as any occurring after 7 p.m. and weekends as Saturday and Sunday.

Other factors associated with an increased risk of mortality included neonatal and infant ages, trauma admission and transfer admissions from inpatient locations or other ICUs. The authors said additional work is needed to evaluate why the morning time period was associated with the peak morality in this study.

This study is important because it adds information about factors associated with leaving the pediatric ICU to go home. So what should this article tell you as a general pediatrician or as a sub-specialist who might have a patient admitted to the ICU? And if you’re practicing in an ICU, what should you tell the referring physician or patient’s parents?

If you’re the referring physician, perhaps you ought to ask about the 24/7 coverage of the ICU and how it is staffed. Does your patient admitted to the ICU have specific issues or parameters or labs that are especially important to monitor no matter what time of day it is? If you’re the ICU physician, has your unit done any monitoring to know temporal patterns of mortality among patients?

This Pediatrics article presents evidence that physicians, no matter what their practice area, need to understand more about the content of care their patients receive day or night in an inpatient setting—in this study, one that focuses on critical care.

Wednesday, October 1, 2014

Healthcare-Associated Infections in Critically Ill Children

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our October issue. To learn more about Dr. Schulte, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by daveynin via Flickr
Nosocomial infections have been bad news since the days of Ignaz Philipp Semmelweis who proved that washing hands drastically reduced the incidence of puerperal fever in mid-19th-century hospitals.

He has modern day counterparts in the infection control practitioners and hospital epidemiologists who combat healthcare-associated infections (HAIs) in US hospitals. There’s some good news about HAIs among children who got care in neonatal ICUs (NICUs) and pediatric ICUs (PICUs) documented in the October issue of Pediatrics (doi: 10.1542/peds.2014-0613).

A cohort study done with data reported to the US Centers for Disease Control and Prevention found the incidence rates of central-line associated blood infections and ventilator-associated pneumonia declined during a 5-year period between 2007 and 2012. The study examined data from 173 NICUs and 64 PICUs. Infections associated with central lines in NICUs declined from 4.9 to 1.5 per 1,000 central-line days and from 4.7 to 1.0 per 1,000 central line days in PICUs. Rates of pneumonia declined in NICUs from 1.6 to 0.6 per 1,000 ventilator days and in PICUs from 1.9 to 0.7 per 1,000 ventilator days. Rates of urinary tract infections associated with catheters did not change significantly in PICUs.

The team of investigators, led by Dr. Stephen Patrick at Vanderbilt University, used a time-series design to evaluate the changes in HAIs among hospitalized neonates and children. The investigators estimated the reduction in infections associated with central lines saved $131 million. The physicians and researchers who are the intellectual descendants of Semmelweis have done important work.  

Tuesday, September 23, 2014

Location, Location, Location: Single Family Room Versus Open Bay NICUs

By: Lewis First, MD, MS; Editor-in-Chief 
Photo by Bob J. Galindo via Flickr

More and more NICUs are considering renovations or redesign to favor single family room intensive care versus open bay traditional units. While they certainly assure more privacy for a family, do they also improve medical and neurodevelopmental outcomes?

Lester et al. (doi:10.1542/ peds.2013-4252) report on a longitudinal, prospective quasi-experimental cohort study involving a conversion of one NICU from open bay to single family rooms comparing medical and neurodevelopmental outcomes of infants weighing fewer than 1,500 grams at discharge.

The results are quite impressive in showing the advantages of single family rooms in terms of the outcomes measured. Just why these results might be associated with single family versus open bay rooms awaits your own evaluation of the space we have given this article in our journal.

How important do you think a single family room is for your hospitalized infants or children? Do you agree with the findings in this study? Share with us your thoughts on space planning by leaving a comment below, sharing an eLetter, or posting on Facebook or Twitter.

Thursday, August 28, 2014

Benchmarks to Strive for in Caring for Children with Asthma, Bronchiolitis & Pneumonia

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Hey Paul Studios via Flickr
Pediatrics, along with other journals, has published studies on the variability of tests ordered, treatments used, and length of stay for a number of common pediatric illnesses. In fact, hospitalists use variability studies to help them identify care pathways to improve quality and reduce costs of care. But is there an ideal set of benchmarks we should strive for in creating our care pathways?

Parikh et al. (doi: 10.1542/peds.2014-1052) believe there are, as a result of their performing a cross-sectional study of data obtained from the Pediatric Health Information System (PHIS) to identify common benchmarks used at the top 10 percent of performing hospitals to note how often images, lab and viral studies, types of antibiotics and frequency of usage could be or should be utilized for inpatient care of asthma, bronchiolitis, and pneumonia.

And speaking of benchmarks, Ralston et al. (doi: 10.1542/peds.2014-1036) add to the discussion with release of their systematic review article of quality improvement studies on ways to reduce unnecessary tests and treatments for children hospitalized with bronchiolitis and provide some additional benchmarks for you to consider.

After reading these studies, you will want to reflect on your own patients or those cared for by your local hospitalists to see whether the benchmarks recommended in these two studies are being adhered to or not when children present with asthma, bronchiolitis, or pneumonia. Benchmark this article for further reference – you’ll likely need it as we move away from volume-based to value-based quality care.

Friday, August 15, 2014

Variation in Pediatric Emergency Department Admissions Rates

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our September issue. To learn more about Dr. Schulte and her work in general pediatrics and preventive medicine, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by Dana Beveridge via Flickr
To admit or not to admit is the question in the pediatric emergency room. Some children are deposited into the waiting line at the ER because there’s no primary care provider available. Others roll in with the siren blaring and an escort of paramedics. Which children go home and which stay to be admitted varies greatly according to new research published in the September issue of Pediatrics.

Four researchers at Boston Children’s Hospital led by Dr. Florence Bourgeois (doi: 10.1542/peds.2014-1278) looked at data for a 3-year period ending in 2012, examining variation in admissions to tertiary pediatric hospitals. Using data from the Pediatric Hospital Information System, an administrative database containing information about pediatric admissions and visits, the researchers focused on seven common diagnoses that could be serious, resulting in admissions approximately 10 percent of the time: asthma, cellulitis, bronchiolitis, pneumonia, kidney infections, seizures and concussions.

Wide variations in admissions were found for concussion (between 5 and72 percent), pneumonia (19 to 69 percent) and bronchiolitis (19 to 65 percent). Such differences might be related to the patient population, practice patterns of physicians and availability of care in other settings.

Understanding the variation in care is an important part of providing the best care for children. Such research is also important in understanding factors associated with admissions, which is a more expensive form of care. In 2006, the median daily cost for a pediatric admission was estimated to be $3,000.

How do the admission rates reported in this study compare to those at your hospital? Leave a comment, or join in the discussion over on our journal's website, Facebook or Twitter.

Related Reading:

Wednesday, June 25, 2014

Readmissions for Pneumonia: Coughing Up Some Troublesome Data

By: Lewis First, MD, MS

While we recognize that children with pneumonia do find themselves on occasion as inpatients, how often do these same children require readmission and for what reasons?

Photo by the US CDC
Neuman et al. (doi: 10.1542/ peds. 2014-0331) addressed these questions using a retrospective cohort of children hospitalized at 43 hospitals between 2008 and 2011 to better understand patient and hospital characteristics and the costs associated with readmission. As it turns out, readmissions play more of a role in overall hospitalizations for pneumonia than you may have expected. Just why that is, and what might we do differently to reduce the readmission rate form the crux of a good discussion by the authors.

Take a deep breath and read this interesting study to become more aware of what you might do to reduce readmissions rates for pneumonia.

Related Reading:

Monday, January 27, 2014

Hospitalizations for Firearm Injuries: How Frequent Are They?

With so much being reported nowadays about the dangers of unsecured firearms being used near or by children and teenagers, one wonders just how common non-life threatening injuries are.

Photo by Bobjgalindo via Wikimedia Commons
Leventhal et al. (doi: 10.1542/peds.2013-1809) decided to study the national frequency of firearm-related hospitalizations in children and teens under 20 years of age categorized by cause and
demographics from a national inpatient database. Injuries were labeled from diagnostic codes in the database as due to assault, suicide attempt, unintentional or undetermined with incidences then calculated accordingly and risk ratios used to compare the various incidences. The authors categorize the etiology not just by cause, but also by gender, age and race/ethnicity.

The results are troubling and worth paying attention to in regard to prevention strategies you might help champion for our own patients, your community, state, or as the AAP is doing—from a national perspective. If you ever needed the ammunition to do something about firearm injuries in children, this article may be exactly what you need to take aim at preventing these tragic injuries from occurring.

Friday, January 24, 2014

No One Benefits from Delays

Deputy Editor Dr. Alex Kemper offers a preview of a Quality Report being early released this week from our February issue:

There is no doubt that scheduling of a limited resource, like a treatment room, is difficult. Procedures are inherently variable and difficult to predict. However, that does not mean that improving efficiency is impossible.

Photo by stevendepolo via Flickr
Dr. Tomer and colleagues (doi: 10.1542/peds.2013-2316) at the Children’s Hospital of Montefiore share with us their experience in improving time management of a pediatric endoscopy suite. There are important and generalizable lessons in their quality report relating to understanding patient flow. Remarkably, they were able to decrease the total average delays each day by more than one hour. What could an extra hour mean for your own facility’s limited resources? For your patients?

I would be interested to hear your thoughts about improving patient flow. Share your comment on this blog (below), or speak your mind on Facebook or Twitter. Or if you’d rather, visit our website to submit an eLetter response to the authors.

Tuesday, December 31, 2013

Isotonic or Hypotonic Maintenance IV Fluids?: A Meta-analysis Tells All

Photo by abbamouse via Flickr
It seems like the standard of care for decades has been to resuscitate with isotonic fluids but keep hydrated at maintenance using hypotonic fluids—at least until Wang et al. (doi: 10.1542/peds.2013-2041) sent us their meta-analysis on the safety of isotonic versus hypotonic IV fluids based on 10 published randomized controlled trials that met study criteria. The results will likely surprise you—so go with the flow of information aggregated in this study and find out more!

Related Reading:

Thursday, December 12, 2013

Does 24/7 In-Hospital Intensivist Coverage Help or Hurt Housestaff Education?

With a focus on improving safety in patient care, it seems as though more and more children’s hospitals have been moving toward a system of 24/7 in-house attending coverage with hospitalists, neonatologists, and intensivists.

Photo by isafmedia via Flickr
While we await the studies that show us this staffing model results in safer, higher quality, lower cost care with better outcomes, Rehder et al. (doi: 10.1542/peds.2013-1990) opted to look at the effect of this staffing on pediatric housestaff education. Using a survey of pediatric intensivists, fellows and residents, researchers assessed the role of in-house coverage on training and education as perceived by these three stakeholder groups.

With more than 1,300 responses from 147 institutions, the results of this survey raised a number of issues focused around the balance between housestaff supervision and their autonomy. To help interpret the findings in this study, Dr. Ellen Burnham, an intensivist (doi: 10.1542/peds.2013-3493), offers some commentary on the topic as well.

Does having 24/7 intensivist coverage prepare a house officer for independent practice (which is the goal of residency training)? You’ll have to read this article on a call night and decide.

Thursday, November 7, 2013

Pediatric Palliative Care Programs in the US: Updates from a National Survey

There is a growing effort to bring palliative care programs into children’s hospitals around the country—especially over the past 10 years. Unfortunately, we have not taken inventory of the nature of these programs, how busy they are, and how they are staffed or funded.

Fortunately, Feudtner et al. (doi: peds.10.1542/2013-1286) have surveyed the 226 children’s hospitals that in 2012 were members of the National Association of Children’s Hospitals and Related Institutions, now called the Children’s Hospital Association. Palliative care programs appear to be increasing in number on a yearly basis and are largely dependent on hospital funding.

This study can be of use to you whether you have a pediatric palliative care program or are thinking of starting one. Reading this article will certainly ease any discomfort you may have had about making sure palliative care is an important part of the care services your children’s hospital or facility should be providing, optimally. While there is no family-satisfaction data in this study, one cannot imagine the importance such a program plays in helping a child and family cope with a serious and often painful illness.

Thursday, October 10, 2013

Why Quality Improvement?

Quality Reports Editor Dr. Alex Kemper offers a preview of a Quality Report being early released this week from our November issue: 

Photo by Stethoscopes via Wikimedia Commons
Imagine if there was a new medication that could reduce the risk of bacteremia in children with cancer by 50 percent? It would be great, and we would be willing to pay a lot for it. I bet it would also get a lot of media attention.

Well, I am happy to share the quality-improvement project by Dr. Rinke and colleagues (doi: 10.1542/peds. 2013-0302), who show how a well-designed, thoughtful quality-improvement project can drop the rate of CLABSIs and associated bacteremia in half.

This is exactly why there is so much emphasis on QI and why we at Pediatrics have developed the Quality Reports section. I would encourage those of you who have improved care to share your work with us. Leave us a comment below or submit an eLetter.

Related Reading:

Friday, September 20, 2013

Checklists for Delivery-Room Quality Improvement

Quality Reports Editor Dr. Alex Kemper offers a preview of a Quality Report being early released this week from our October issue: 

I am a big believer in the power of checklists.  DeMauro et al. (doi: 10.1542/peds.2013-0686) share with us the development and implementation of their checklist to improve delivery room care for very preterm infants. I suspect that there are many birthing centers that could easily adopt their approach, including the critical evaluation and continuous improvement of the checklist and its use. So, go ahead and check it out –  and let me know what your experience is.