Evelyn M. Kuhn

Hospital Characteristics and Mortality Rates

The Health Care Financing Administration (HCFA) publishes hospital mortality rates each year. We undertook a study to identify characteristics of hospitals associated with variations in these rates. To do so, we obtained data on 3100 hospitals from the 1986 HCFA mortality study and the American Hospital Associations 1986 annual survey of hospitals. The mortality rates were adjusted for each hospitals case mix and other characteristics of its patients. The mortality rate for all hospitalizations was 116 per 1000 patients. Adjusted mortality rates were significantly higher for for-profit hospitals (121 per 1000) and public hospitals (120 per 1000) than for private not-for-profit hospitals (114 per 1000; P less than 0.0001 for both comparisons). Osteopathic hospitals also had an adjusted mortality rate that was significantly higher than average (129 per 1000; P less than 0.0001). Private teaching hospitals had a significantly lower adjusted mortality rate (108 per 1000) than private nonteaching hospitals (116 per 1000; P less than 0.0001). Adjusted mortality rates were also compared for hospitals in the upper and lower fourths of the sample in terms of certain hospital characteristics. The mortality rates were 112 and 121 per 1000 for the hospitals in the upper and lower fourths, respectively, in terms of the percentage of physicians who were board-certified specialists (P less than 0.0001), 112 and 120 per 1000 for occupancy rate (P less than 0.0001), 113 and 120 per 1000 for payroll expenses per hospital bed (P less than 0.0001), and 113 and 119 per 1000 for the percentage of nurses who were registered (P less than 0.0001).

Hospitalization Costs Associated with Homelessness in New York City

BACKGROUND Homelessness is believed to be a cause of health problems and high medical costs, but data supporting this association have been difficult to obtain. We compared lengths of stay and reasons for hospital admission among homeless and other low-income persons in New York City to estimate the hospitalization costs associated with homelessness. METHODS We obtained hospital-discharge data on 18,864 admissions of homeless adults to New York Citys public general hospitals (excluding admissions for childbirth) and 383,986 nonmaternity admissions of other low-income adults to all general hospitals in New York City during 1992 and 1993. The differences in length of stay were adjusted for diagnosis-related group, principal diagnosis, selected coexisting illnesses, and demographic characteristics. RESULTS Of the admissions of homeless people, 51.5 percent were for treatment of substance abuse or mental illness, as compared with 22.8 percent for the other low-income patients, and another 19.7 percent of the admissions of homeless people were for trauma, respiratory disorders, skin disorders, and infectious diseases (excluding the acquired immunodeficiency syndrome [AIDS]), many of which are potentially preventable medical conditions. For the homeless, 80.6 percent of the admissions involved either a principal or a secondary diagnosis of substance abuse or mental illness -- roughly twice the rates for the other patients. The homeless patients stayed 4.1 days, or 36 percent, longer per admission on average than the other patients, even after adjustments were made for differences in the rates of substance abuse and mental illness and other clinical and demographic characteristics. The costs of the additional days per discharge averaged

Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis

4,094 for psychiatric patients,

Age and gender patterns in motor vehicle crash injuries: importance of type of crash and occupant role

3,370 for patients with AIDS, and

Quality of life and functional outcome after pediatric trauma

2,414 for all types of patients. CONCLUSIONS Homelessness is associated with substantial excess costs per hospital stay in New York City. Decisions to fund housing and supportive services for the homeless should take into account the potential of these services to reduce the high costs of hospitalization in this population.

The relationship of hospital characteristics and the results of peer review in six large states

Background. Ambulance crashes have become an increasing source of public concern. Emergency medical services directors have little data to develop ambulance operation and risk management policies. Objective. To describe fatal ambulance crash characteristics, identifying those that differentiate emergency and nonemergency use crashes. Methods. This was a retrospective analysis of all fatal ambulance crashes on U.S. public roadways reported to the Fatality Analysis Reporting System (FARS) database from 1987 to 1997. Main outcome measures were 42 variables describing crash demographics, crash configuration, vehicle description, crash severity, and ambulance operator and vehicle occupant attributes. Results. Three hundred thirty-nine ambulance crashes caused 405 fatalities and 838 injuries. These crashes occurred more often between noon and 6 PM (39%), on improved (99%), straight (86%), dry roads (69%) during clear weather (77%), while going straight (80%), through an intersection (53%), and striking (81%) another vehicle (80%) at an angle (56%). Most crashes (202/339) and fatalities (233/405) occurred during emergency use. These crashes occurred significantly more often at intersections (p < 0.001), at an angle (p < 0.001), with another vehicle (p < 0.001). Most crashes resulted in one fatality, not in the ambulance. Thirty pedestrians and one bicyclist comprised 9% of all fatalities. In the ambulance, most serious and fatal injuries occurred in the rear (OR 2.7 vs front) and to improperly restrained occupants (OR 2.5 vs restrained). Sixteen percent of ambulance operators were cited; 41% had poor driving records. Conclusions. Most crashes and fatalities occurred during emergency use and at intersections. The greater burden of injury fell upon persons not in the ambulance. Rear compartment occupants were more likely to be injured than those in the front. Crash and injury reduction programs should address improved intersection control, screening to identify high-risk drivers, appropriate restraint use, and design modifications to the rear compartment of the ambulance.

Protecting Fragile Skin: Nursing Interventions to Decrease Development of Pressure Ulcers in Pediatric Intensive Care

To evaluate the interaction of gender, age, type of crash, and occupant role in motor vehicle crash injuries leading to hospitalization, we analyzed 1997 Wisconsin hospital discharge data for patients with primary E-code diagnoses of motor vehicle injuries. The overall ratio of males to females (M/F ratio) hospitalized for motor vehicle crash injuries was 1.33 (95% confidence interval (CI): 1.26-1.41). The M/F ratio varied by type of crash and differed for passengers and drivers. For injuries sustained in collisions between vehicles, the M/F ratio was 0.96 (95% CI: 0.87-1.05); in loss of control accidents the M/F ratio was 1.95 (95% CI: 1.76-2.17). Within each type of crash, the M/F ratio for drivers was similar to that for the entire type; the M/F ratio for passengers was about half of the type total. Expressed as rates of hospitalization per 100,000 people in the general population, hospitalizations of drivers in collisions with another motor vehicle increased steeply in males, but not in females, beginning at about age 70. For drivers in loss of control crashes, male rates exceeded female rates in all age groups, with peaks in the groups 15-24 and 85-89. For passengers, injury rates from collisions with other motor vehicles were greater for females, especially in the elderly, and injury rates from loss of control crashes were similar for both genders, with peaks at 15-24 and 85-94. The higher fatality of men in loss of control motor vehicle crashes, compared to women, suggests an important area for further investigation.

The relationship of hospital ownership and teaching status to 30-and 180-day adjusted mortality rates

BACKGROUND Injury is the leading cause of preventable morbidity and functional limitation in children. Long-term sequelae are measured best by the degree of impairment after recovery from the acute traumatic event. The specific aim of this study was to determine the quality of life and functional status of moderately to severely injured pediatric trauma patients at hospital discharge and at 1, 6, and 12 months postinjury. METHODS We conducted a prospective longitudinal study of children aged 1 to 18 years with blunt injury and Injury Severity Score >/= 9, excluding head and spinal cord injury. Children were evaluated at hospital discharge and at 1, 6, and 12 months postinjury, using the Child Health Questionnaire (CHQ), the Functional Independence Measure, and the Impact on Family Scale. Baseline and 1- and 6-month data analyses are reported. RESULTS One hundred sixty-two children were enrolled in the study, and 156 had completed 6-month data entry. The mean age was 9.3 +/- 5.3 years, and the mean Injury Severity Score was 14 +/- 7.4. The most common cause of injury was motor vehicular-related (43%). Fifty-eight (37%) had multisystem injuries. Femur fracture represented the most common injury (54.8%). Families experienced economic, social, and personal strain, as measured by the Impact on Family scale. There was a significant improvement in CHQ and Functional Independence Measure scores between baseline and 1 month and between 1 month and 6 months postinjury. However, at 6 months, physical scores remained lower than age-matched norms. CONCLUSION Injury in children results in a significant burden on families. Although children demonstrate a rapid recovery of function and quality of life after blunt injury, physical function remains lower than age-matched norms at 6 months postinjury. It is unclear whether this represents a plateau in recovery or whether further improvements can be expected over longer time intervals.

Pre‐transplant identification of risk factors that adversely affect length of stay and charges for renal transplantation

To determine which characteristics of hospitals may be related to a higher quality of care, the association of hospital characteristics with the outcomes of medical record review by state Peer Review Organizations (PROs) was studied. The two data sources were: 1) the AHA 1986 Annual Survey of Hospitals and 2) reviews completed between July 1987 through June 1988 from six large PROs. For each hospital the percentage of cases that failed physician review (the confirmed problem rate) was computed. Hospital characteristics evaluated included financial status, ownership, medical training, technological sophistication, and size. The following characteristics were significantly associated with a lower confirmed problem rate: a higher occupancy rate, greater payroll expenses per bed, a higher proportion of physicians who were board-certified specialists, greater technological sophistication, a higher number of beds, a higher proportion of nurses who were registered, and membership in the Council of Teaching Hospitals. Public hospitals had higher problems rates than private not-for-profit hospitals. All characteristics significantly related to higher confirmed problem rates were also related to higher adjusted mortality rates in a previous study of 3,100 U.S. hospitals. The results suggest that hospital resources, including financial status, training of medical personnel, and availability of sophisticated equipment, are related to the quality of care provided by the hospital.

Assessing providers of coronary revascularization: a method for peer review organizations.

BACKGROUND The reported incidence of pressure ulcers in critically ill infants and children is 18% to 27%. Patients at risk for pressure ulcers and nursing interventions to prevent the development of the ulcers have not been established. OBJECTIVES To determine the incidence of pressure ulcers in critically ill children, to compare the characteristics of patients in whom pressure ulcers do and do not develop, and to identify prevention strategies associated with less frequent development of pressure ulcers. METHODS Characteristics of 5346 patients in pediatric intensive care units in whom pressure ulcers did and did not develop were compared. Multiple logistic regression was used to determine which prevention strategies were associated with less frequent development of pressure ulcers. RESULTS The overall incidence of pressure ulcers was 10.2%. Patients at greatest risk were those who were more than 2 years old; who were in the intensive care unit 4 days or longer; or who required mechanical ventilation, noninvasive ventilation, or extracorporeal membrane oxygenation. Strategies associated with less frequent development of pressure ulcers included use of specialty beds, egg crates, foam overlays, gel pads, dry-weave diapers, urinary catheters, disposable under-pads, body lotion, nutrition consultations, change in body position every 2 to 4 hours, blanket rolls, foam wedges, pillows, and draw sheets. CONCLUSIONS The overall incidence of pressure ulcers among critically ill infants and children is greater than 10%. Nursing interventions play an important role in the prevention of pressure ulcers.