J. Mitchell Harris

Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts

OBJECTIVE: Despite the magnitude of the problem of catheter-associated bloodstream infections (CA-BSIs) in children, relatively little research has been performed to identify effective strategies to reduce these complications. In this study, we aimed to develop and evaluate effective catheter-care practices to reduce pediatric CA-BSIs. STUDY DESIGN AND METHODS: Our study was a multi-institutional, interrupted time-series design with historical control data and was conducted in 29 PICUs across the United States. Two central venous catheter–care practice bundles comprised our intervention: the insertion bundle of pediatric-tailored care elements derived from adult efforts and the maintenance bundle derived from the Centers for Disease Control and Prevention recommendations and expert pediatric clinician consensus. The bundles were deployed with quality-improvement teaching and methods to support their adoption by teams at the participating PICUs. The main outcome measures were the rate of CA-BSIs from January 2004 to September 2007 and compliance with each element of the insertion and maintenance bundles from October 2006 to September 2007. RESULTS: Average CA-BSI rates were reduced by 43% across 29 PICUs (5.4 vs 3.1 CA-BSIs per 1000 central-line-days; P < .0001). By September 2007, insertion-bundle compliance was 84% and maintenance-bundle compliance was 82%. Hierarchical regression modeling showed that the only significant predictor of an observed decrease in infection rates was the collective use of the insertion and maintenance bundles, as demonstrated by the relative rate (RR) and confidence intervals (CIs) (RR: 0.57 [95% CI: 0.45–0.74]; P < .0001). We used comparable modeling to assess the relative importance of the insertion versus maintenance bundles; the results showed that the only significant predictor of an infection-rate decrease was maintenance-bundle compliance (RR: 0.41 [95% CI: 0.20–0.85]; P = .017). CONCLUSIONS: In contrast with adult ICU care, maximizing insertion-bundle compliance alone cannot help PICUs to eliminate CA-BSIs. The main drivers for additional reductions in pediatric CA-BSI rates are issues that surround daily maintenance care for central lines, as defined in our maintenance bundle. Additional research is needed to define the optimal maintenance bundle that will facilitate elimination of CA-BSIs for children.

Relevance of the agency for healthcare research and quality patient safety indicators for children's hospitals

Objectives. Patient safety indicators (PSIs) were developed by the Agency for Healthcare Research and Quality. Our objectives were (1) to apply these algorithms to the National Association of Childrens Hospitals and Related Institutions (NACHRI) Aggregate Case Mix Comparative Database for 1999–2002, (2) to establish mean rates for each of the PSI events in childrens hospitals, (3) to investigate the inadequacies of PSIs in relation to pediatric diagnoses, and (4) to express the data in such a way that childrens hospitals could use the PSIs determined to be appropriate for pediatric use for comparison with their own data. In addition, we wanted to use the data to set priorities for ongoing clinical investigations and to propose interventions if the indicators demonstrated preventable errors. Methods. The Agency for Healthcare Research and Quality PSI algorithms (version 2.1, revision 1) were applied to childrens hospital administrative data (1.92 million discharges) from the NACHRI Aggregate Case Mix Comparative Database for 1999–2002. Rates were measured for the following events: complications of anesthesia, death in low-mortality diagnosis-related groups (DRGs), decubitus ulcer, failure to rescue (ie, death resulting from a complication, rather than the primary diagnosis), foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care (ie, infections related to surgery or device placement), postoperative hemorrhage or hematoma, postoperative pulmonary embolism or venous thrombosis, postoperative wound dehiscence, and accidental puncture/laceration. Results. Across the 4 years of data, the mean risk-adjusted rates of PSI events ranged from 0.01% (0.1 event per 1000 discharges) for a foreign body left in during a procedure to 14.0% (140 events per 1000 discharges) for failure to rescue. Review of International Classification of Diseases, Ninth Revision, Clinical Modification codes associated with each PSI category showed that the failure to rescue and death in low-mortality DRG indicators involved very complex cases and did not predict preventable events in the majority of cases. The PSI for infection attributable to medical care appeared to be accurate the majority of the time. Incident risk-adjusted rates of infections attributable to medical care averaged 0.35% (3.5 events per 1000 discharges) and varied up to fivefold from the lowest rate to the highest rate. The highest rates were up to 1.8 times the average. Conclusions. PSIs derived from administrative data are indicators of patient safety concerns and can be relevant as screening tools for childrens hospitals; however, cases identified by these indicators do not always represent preventable events. Some, such as a foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care, decubitus ulcer, and venous thrombosis, seem to be appropriate for pediatric care and may be directly amenable to system changes. Evidence-based practices regarding those particular indicators that have been reported in the adult literature need to be investigated in the pediatric population. In their present form, 2 of the indicators, namely, failure to rescue and death in low-mortality DRGs, are inaccurate for the pediatric population, do not represent preventable errors in the majority of pediatric cases, and should not be used to estimate quality of care or preventable deaths in childrens hospitals. The PSIs can assist institutions in prioritizing chart review-based investigations; if clusters of validated events emerge in reviews, then improvement activities can be initiated. Large aggregate databases, such as the NACHRI Case Mix Database, can help establish mean rates of potential pediatric events, giving childrens hospitals a context within which to examine their own data.

Diarrhea-Associated Hospitalizations Among US Children Over 2 Rotavirus Seasons After Vaccine Introduction

OBJECTIVE: After implementation of rotavirus vaccination in 2006, large decreases in rates of severe diarrhea among US children occurred in 2007–2008. We ascertained whether these decreases were sustained in 2008–2009. METHODS: We examined hospital discharge data from a national network of pediatric hospitals and compared all-cause diarrhea-related and rotavirus-specific hospitalizations in 3 prevaccine rotavirus seasons (2003–2006) with those in 2 postvaccine seasons (2007–2008 and 2008–2009) among children <5 years of age. We defined rotavirus seasons using data from a national laboratory surveillance network. RESULTS: At 62 consistently reporting hospitals, a median of 15 645 diarrhea-related hospitalizations (range: 14 881–16 884 hospitalizations) occurred each rotavirus season among children <5 years of age in 2003–2006. Compared with this median, all-cause diarrhea-related hospitalizations decreased by 50% (n = 7760) in 2007–2008 and by 29% (n = 11 039) in 2008–2009. In 2007–2008, reductions of 47% to 55% were seen for all age groups, including vaccine-ineligible children ≥2 years of age (48%). In 2008–2009, these reductions decreased in magnitude, especially among children ≥2 years of age (17%). Decreases in 2007–2008 and 2008–2009 were similar in the Northeast and West, but decreases were smaller in 2008–2009, compared with 2007–2008, in the Midwest and South. CONCLUSIONS: Compared with prevaccine seasons, decreases in diarrhea- and rotavirus-associated hospitalizations seen in 2007–2008 were sustained in 2008–2009 but were somewhat smaller. Given the variability in diarrhea-related hospitalization trends over the 2 postvaccine seasons according to age group and region, continued surveillance is required for full assessment of the impact of rotavirus vaccination.

Evaluation of the agency for healthcare research and quality pediatric quality indicators.

OBJECTIVES. Pediatric quality indicators were developed in 2006 by the Agency for Healthcare Research and Quality to identify potentially preventable complications in hospitalized children. Our objectives for this study were to (1) apply these algorithms to an aggregate childrens hospitals discharge abstract database, (2) establish rates for each of the pediatric quality indicator events in the childrens hospitals, (3) use direct chart review to investigate the accuracy of the pediatric quality indicators, (4) calculate the number of complications that were already present on admission and, therefore, not attributable to the specific hospitalization, and (5) evaluate preventability and calculate positive predictive value for each of the indicators. In addition, we wanted to use the data to set priorities for ongoing clinical investigation. METHODS. The Agency for Healthcare Research and Quality pediatric quality indicator algorithms were applied to 76 childrens hospitals discharge abstract data (1794675 discharges) from 2003 to 2005. Rates were calculated for 11 of the pediatric quality indicators from all 3 years of discharge data: accidental puncture or laceration, decubitus ulcer, foreign body left in during a procedure, iatrogenic pneumothorax in neonates at risk, iatrogenic pneumothorax in nonneonates, postoperative hemorrhage or hematoma, postoperative respiratory failure, postoperative sepsis, postoperative wound dehiscence, selected infections caused by medical care, and transfusion reaction. Subsequently, clinicians from 28 childrens hospitals reviewed 1703 charts in which complications had been identified. They answered questions as to correctness of secondary diagnoses that were associated with the indicator, whether a complication was already present on admission, and whether that complication was preventable, nonpreventable, or uncertain. RESULTS. Across 3 years of data the rates of pediatric quality indicators ranged from a low of 0.01/1000 discharges for transfusion reaction to a high of 35/1000 for postoperative respiratory failure, with a median value of 1.85/1000 for the 11 pediatric quality indicators. Indicators were often already present on admission and ranged from 43% for infection caused by medical care to 0% for iatrogenic pneumothorax in neonates, with a median value of 16.9%. Positive predictive value for the subset of pediatric quality indicators occurring after admission was highest for decubitus ulcer (51%) and infection caused by medical care (40%). Because of the very large numbers of cases identified and its low preventability, the indicator postoperative respiratory failure is particularly problematic. The initial definition includes all children on ventilators postoperatively for >4 days with few exclusions. Being on a ventilator for 4 days would be a normal occurrence for many children with extensive surgery; therefore, the majority of the time does not indicate a complication and makes the indicator inappropriate. CONCLUSIONS. A subset of pediatric quality indicators derived from administrative data are reasonable screening tools to help hospitals prioritize chart review and subsequent improvement projects. However, in their present form, true preventability of these complications is relatively low; therefore, the indicators are not useful for public hospital comparison. Identifying which complications are present on admission versus those that occur within the hospitalization will be essential, along with adequate risk adjustment, for any valid comparison between institutions. Infection caused by medical care and decubitus ulcers are clinically important indicators once the present-on-admission status is determined. These complications cause significant morbidity in hospitalized children, and research has shown a high level of preventability. The pediatric quality indicator software can help childrens hospitals objectively review their cases and target improvement activities appropriately. The postoperative-respiratory-failure indicator does not represent a complication in the majority of cases and, therefore, should not be included for hospital screening or public comparison. Chart review should become part of the development process for quality indicators to avoid inappropriate conclusions that misdirect quality-improvement resources.

Epidemiology of central line-associated bloodstream infections in the pediatric intensive care unit

OBJECTIVE Describe central line-associated bloodstream infection (CLA-BSI) epidemiology in pediatric intensive care units (PICUs). DESIGN Descriptive study (29 PICUs); cohort study (18 PICUs). SETTING PICUs in a national improvement collaborative. PATIENTS/PARTICIPANTS Patients admitted October 2006 to December 2007 with 1 or more central lines. METHODS CLA-BSIs were prospectively identified using the National Healthcare Safety Network definition and then readjudicated using the revised 2008 definition. Risk factors for CLA-BSI were examined using age-adjusted, time-varying Cox proportional hazards models. RESULTS In the descriptive study, the CLA-BSI incidence was 3.1/1,000 central line-days; readjudication with the revised definition resulted in a 17% decrease. In the cohort study, the readjudicated incidence was 2.0/1,000 central line-days. Ninety-nine percent of patients were CLA-BSI-free through day 7, after which the daily risk of CLA-BSI doubled to 0.27% per day. Compared with patients with respiratory diagnoses (most prevalent category), CLA-BSI risk was higher in patients with gastrointestinal diagnoses (hazard ratio [HR], 2.7 [95% confidence interval {CI}, 1.43-5.16]; P < .002 ) and oncologic diagnoses (HR, 2.6 [CI, 1.06-6.45]; P = .037). Among all patients, including those with more than 1 central line, CLA-BSI risk was lower among patients with a central line inserted in the jugular vein (HR, 0.43 [CI, 0.30-0.95]; [P < .03). CONCLUSIONS The 2008 CLA-BSI definition change decreased the measured incidence. The daily CLA-BSI risk was very low in patients during the first 7 days of catheterization but doubled thereafter. The risk of CLA-BSI was lower in patients with lines inserted in the jugular vein and higher in patients with gastrointestinal and oncologic diagnoses. These patients are target populations for additional study and intervention.

Targeted chart review of pediatric patient safety events identified by the agency for healthcare research and quality's patient safety indicators methodology

Objectives: We reviewed potential patient safety events identified with Agency for Healthcare Research and Qualitys Patient Safety Indicator (PSI) Software to characterize clinical events associated with potential patient safety events and to identify clinical opportunities for care improvement. Methods: Agency for Healthcare Research and Qualitys PSI algorithms (version 2.1, revision 1) were applied to the National Association of Childrens Hospitals and Related Institutions Case Mix Database, and clinicians at 14 hospitals retrospectively reviewed 1151 events from 1132 patient charts identified as having potential patient safety events. Standard questions were asked for each PSI, and preventability of events was assessed. Results: Infection due to medical care was the most commonly confirmed potentially preventable patient safety event using the PSI software. Pediatric-specific findings were identified for PSIs related to decubitus ulcers, foreign bodies associated with procedures, and procedure-associated thrombosis. The primary diagnosis identified by medical coders agreed with clinician evaluation 92.2% of the time. The chart review confirmed previous work done with administrative data; the indicators complications of anesthesia, death in low-mortality diagnosis-related groups, and failure to rescue were inaccurate in the pediatric population. Significant variation in preventability was identified for the 11 PSIs. Conclusions: Clinician chart reviews to verify pediatric patient safety events suggest that 8 of 11 PSIs are useful for quality improvement in pediatric patients but are inadequate for public comparison of hospital performance. Infection caused by medical care was the most commonly preventable patient safety event. Targeted chart reviews using PSI software are a useful way to guide hospitals in prioritizing their patient safety efforts based on hospital-specific data about patient injury.

Characteristics of Youth Presenting for Weight Management: Retrospective National Data from the POWER Study Group.

BACKGROUND There are no existing multisite national data on obese youth presenting for pediatric weight management. The primary aim was to describe BMI status and comorbidities among youth with obesity presenting for pediatric weight management (PWM) at programs within the Pediatric Obesity Weight Evaluation Registry (POWER). METHODS Data were collected from 2009-2010 among 6737 obese patients ages 2-17. Patients were classified in three groups by BMI (kg/m(2)) cutoffs and percent of the 95th percentile for BMI: (1) obesity; (2) severe obesity class 2; and (3) severe obesity class 3. Weighted percentages are presented for baseline laboratory tests, blood pressure, and demographics. Generalized logistic regression with clustering was used to examine the relationships between BMI status and comorbidities. RESULTS Study youth were 11.6 ± 3.4 years of age, 56% female, 31% black, 17% Hispanic, and 53% publicly insured. Twenty-five percent of patients had obesity (n = 1674), 34% (2337) had severe obesity class 2, and 41% (2726) had severe obesity class 3. Logistic regression revealed that males (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.0), blacks (OR, 1.7; 95% CI, 1.5-2.0), age <6 years (OR, 2.0; 95% CI, 1.5-2.6), and public insurance (OR, 1.8; 95% CI, 1.5-2.0) had a higher odds of severe obesity class 3. Severe obesity class 3 was associated with higher odds of laboratory abnormalities for hemoglobin A1c (OR, 1.7; 95% CI, 1.3-2.2), alanine aminotransferase ≥40 U/L (OR, 1.9; 95% CI, 1.3-2.6), and elevated systolic blood pressure (OR, 2.5; 95% CI, 2.0-3.0). CONCLUSIONS Youth with obesity need earlier access to PWM given that they are presenting when they have severe obesity with significant comorbidities.

Children’s Hospital Characteristics and Readmission Metrics

BACKGROUND AND OBJECTIVE: Like their adult counterparts, pediatric hospitals are increasingly at risk for financial penalties based on readmissions. Limited information is available on how the composition of a hospital’s patient population affects performance on this metric and hence affects reimbursement for hospitals providing pediatric care. We sought to determine whether applying different readmission metrics differentially affects hospital performance based on the characteristics of patients a hospital serves. METHODS: We performed a cross-sectional analysis of 64 children’s hospitals from the Children’s Hospital Association Case Mix Comparative Database 2012 and 2013. We calculated 30-day observed-to-expected readmission ratios by using both all-cause (AC) and Potentially Preventable Readmissions (PPR) metrics. We examined the association between observed-to-expected rates and hospital characteristics by using multivariable linear regression. RESULTS: We examined a total of 1 416 716 hospitalizations. The mean AC 30-day readmission rate was 11.3% (range 4.3%–19.6%); the mean PPR rate was 4.9% (range 2.9%–6.9%). The average 30-day AC observed-to-expected ratio was 0.96 (range 0.63–1.23), compared with 0.95 (range 0.65–1.23) for PPR; 59% of hospitals performed better than expected on both measures. Hospitals with higher volumes, lower percentages of infants, and higher percentage of patients with low income performed worse than expected on PPR. CONCLUSIONS: High-volume hospitals, those that serve fewer infants, and those with a high percentage of patients from low-income neighborhoods have higher than expected PPR rates and are at higher risk of reimbursement penalties.

Comparison of Administrative Data Versus Infection Control Data in Identifying Central Line–Associated Bloodstream Infections in Children’s Hospitals

OBJECTIVE As of July 2012, the Centers for Medicare and Medicaid Services prohibited state Medicaid programs from paying for medical care related to certain provider-preventable conditions. The most prevalent provider-preventable condition in pediatrics is central line-associated bloodstream infections (CLABSIs), which cause significant morbidity and mortality. The objective of this study was to compare the uses of administrative data and infection control data in measuring CLABSIs. METHODS Retrospective chart reviews were performed in 3 childrens hospitals to compare CLABSIs identified according to administrative data diagnostic coding versus infections identified by hospital infection control departments. Clinical criteria from the Centers for Disease Control and Prevention and reported to the National Healthcare Safety Network were used. RESULTS A total of 166 CLABSIs were identified in 35 698 discharges in the 3 childrens hospitals in 2010. Using the Centers for Disease Control and Prevention criteria as the standard, administrative data had 34.78% sensitivity and 99.92% specificity. The positive predictive value was 63.16% whereas the negative predictive value was 99.75%. CONCLUSIONS Administrative data and National Healthcare Safety Network criteria identify discordant numbers of CLABSIs.

Limitations in the agency for healthcare research and quality pediatric quality indicators result in flawed call for national benchmarks

To the Editor .— In their recent article in Pediatrics Electronic Pages , “Charges and Lengths of Stay Attributable to Adverse Patient-Care Events Using Pediatric-Specific Quality Indicators: A Multicenter Study of Freestanding Childrens Hospitals,” Kronman et al1 reported charge and length-of-stay data associated with a positive screen using the Agency for Healthcare Research and Quality (AHRQ) pediatric quality indicators (PDIs). We commend them on their work further defining the impact of hospital-associated adverse events. However, we are concerned about their conclusions calling for national standards and benchmarks using the AHRQ PDIs. Specifically, our article in the same issue of …