Paul D. Hain

Prospective Multicenter Study of the Viral Etiology of Bronchiolitis in the Emergency Department

Abstract Objectives:  To determine the viral etiology of bronchiolitis and clinical characteristics of children age < 2 years presenting to the emergency department (ED) with bronchiolitis. Methods:  The authors conducted a 14‐center prospective cohort study during 2005–2006 of ED patients age < 2 years with bronchiolitis. The study was conducted in 10 states as part of the Emergency Medicine Network. Researchers collected nasopharyngeal aspirates and conducted structured interviews, medical record reviews, and 2‐week follow‐up telephone calls. Samples were tested using reverse transcription polymerase chain reaction for respiratory syncytial virus (RSV), rhinovirus (RV), human metapneumovirus (hMPV), and influenza viruses (Flu). Results:  Testing of 277 samples revealed 176 (64%) positive for RSV, 44 (16%) for RV, 26 (9%) for hMPV, 17 (6%) for Flu A, and none for Flu B. When children were categorized as RSV only, RV only, RV and RSV, and all others (hMPV, Flu, no identified virus), children with RV only were more likely to be African American (19, 62, 14, and 40%, respectively; p < 0.001) and have a history of wheezing (23, 52, 21, and 15%, respectively; p = 0.01). In multivariate models, children with RV were more likely to receive corticosteroids (odds ratio [OR] 3.5; 95% confidence interval [CI] = 1.5 to 8.15). The duration of illness may be shorter for children with RV (Days 8, 3, 6, and 8; p = 0.07). Conclusions:  In this multicenter study, RSV was the most frequent cause of bronchiolitis (64%). RV was present in 16%, and these children have a distinct profile in terms of demographics, medical history, and ED treatment.

Preventability of Early Readmissions at a Children’s Hospital

OBJECTIVE: To determine whether pediatric readmissions within 15 days of discharge were considered preventable. METHODS: Retrospective chart review of 200 randomly selected readmissions (8% of all readmissions) occurring within 15 days of discharge from a freestanding children’s hospital between January 1, 2007, and December 31, 2008. The degree of preventability was assessed independently for each case by 4 pediatricians using a 5-point Likert scale and was correlated with chronic conditions and reason for index admission with 3M’s Clinical Risk Groups and All Patient-Refined Diagnostic-Related Groups, respectively. RESULTS: The rate of 15-day readmissions considered more likely preventable by the discharging hospital was 20.0% (1.7% of total admissions, 95% confidence interval 14.8%–26.4%). Reviewers failed to reach initial consensus in 62.5% of cases, although final consensus was achieved after the panel reviewed cases together. Consensus ratings served as the standard for the remainder of the study. Readmissions in children with malignancies were considered less preventable than those in children with other chronic illnesses (5.8% vs 25.8%, P = .003). Readmissions following surgical admissions were considered more likely preventable than those following medical admissions (38.9% vs 15.9%, P = .002). Central venous catheter infections and ventricular shunt malfunctions accounted for 8.5% of all readmissions reviewed. CONCLUSIONS: Although initial consensus about which readmissions were more likely preventable was difficult to achieve, the overall rate of preventable pediatric 15-day readmissions was low. Pediatric readmissions are unlikely to serve as a highly productive focus for cost savings or quality measurement.

Accuracy of Administrative Billing Codes to Detect Urinary Tract Infection Hospitalizations

BACKGROUND: Hospital billing data are frequently used for quality measures and research, but the accuracy of the use of discharge codes to identify urinary tract infections (UTIs) is unknown. OBJECTIVE: To determine the accuracy of International Classification of Diseases, 9th revision (ICD-9) discharge codes to identify children hospitalized with UTIs. METHODS: This multicenter study conducted in 5 childrens hospitals included children aged 3 days to 18 years who had been admitted to the hospital, undergone a urinalysis or urine culture, and discharged from the hospital. Data were obtained from the pediatric health information system database and medical record review. With the use of 2 gold-standard methods, the positive predictive value (PPV) was calculated for individual and combined UTI codes and for common UTI identification strategies. PPV was measured for all groupings for which the UTI code was the principal discharge diagnosis. RESULTS: There were 833 patients in the study. The PPV was 50.3% with the use of the gold standard of laboratory-confirmed UTIs but increased to 85% with provider confirmation. Restriction of the study cohort to patients with a principle diagnosis of UTI improved the PPV for laboratory-confirmed UTI (61.2%) and provider-confirmed UTI (93.2%), as well as the ability to benchmark performance. Other common identification strategies did not markedly affect the PPV. CONCLUSIONS: ICD-9 codes can be used to identify patients with UTIs but are most accurate when UTI is the principal discharge diagnosis. The identification strategies reported in this study can be used to improve the accuracy and applicability of benchmarking measures.

Epidemiology of 15-Day Readmissions to a Children's Hospital

OBJECTIVE: To describe the population of pediatric patients readmitted to a childrens hospital within 15 days of discharge. PATIENTS AND METHODS: Medical records were reviewed to identify characteristics of patients and their hospitalizations for all children hospitalized during calendar years 2007–2008 who were readmitted up to and including 15 days after a previous discharge. RESULTS: Of 30 188 total hospital admissions during the study period, 2546 (8.4%) were followed by a readmission within 15 days of discharge. The age groups with the greatest number of readmissions were infants (aged 31–364 days, 20.8% of readmissions) and patients aged >10 years (31.3% of readmissions). Most readmitted patients (78.0%) had an underlying chronic illness, and patients with malignancies were most likely to be readmitted, followed by newborns and patients with neurologic conditions. Patients with malignancies also experienced the greatest number of readmissions per patient (4.1). Most patients who were readmitted had only 1 readmission (71.5%), but the small subset of patients with 3 or more readmissions accounted for 43.7% of all 15-day readmissions. Disease recurrence and natural course of the original diagnosis were the most common reasons for readmission (44.9%), followed by planned readmissions (20.6%) and readmissions for a new, unrelated illness (7.7%). CONCLUSIONS: This report is the first description of the epidemiology of all 15-day pediatric readmissions at a childrens hospital. The results of this study serve as a basis for additional analysis to determine the extent to which readmissions in the pediatric population may or may not be preventable.

Establishing Benchmarks for the Hospitalized Care of Children With Asthma, Bronchiolitis, and Pneumonia

BACKGROUND AND OBJECTIVES: Asthma, pneumonia, and bronchiolitis are the leading causes of admission for pediatric patients; however, the lack of accepted benchmarks is a barrier to quality improvement efforts. Using data from children hospitalized with asthma, bronchiolitis, or pneumonia, the goals of this study were to: (1) measure the 2012 performance of freestanding children’s hospitals using clinical quality indicators; and (2) construct achievable benchmarks of care (ABCs) for the clinical quality indicators. METHODS: This study was a cross-sectional trial using the Pediatric Health Information System database. Patient inclusions varied according to diagnosis: asthma (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 493.0–493.92) from 2 to 18 years of age; bronchiolitis (ICD-9-CM codes 466.11 and 466.19) from 2 months to 2 years of age; and pneumonia (ICD-9-CM codes 480–486, 487.0) from 2 months to 18 years of age. ABC methods use the best-performing hospitals that comprise at least 10% of the total population to compute the benchmark. RESULTS: Encounters from 42 hospitals included: asthma, 22 186; bronchiolitis, 14 882; and pneumonia, 12 983. Asthma ABCs include: chest radiograph utilization, 24.5%; antibiotic administration, 6.6%; and ipratropium bromide use >2 days, 0%. Bronchiolitis ABCs include: chest radiograph utilization, 32.4%; viral testing, 0.6%; antibiotic administration, 18.5%; bronchodilator use >2 days, 11.4%; and steroid use, 6.4%. Pneumonia ABCs include: complete blood cell count utilization, 28.8%; viral testing, 1.5%; initial narrow-spectrum antibiotic use, 60.7%; erythrocyte sedimentation rate, 3.5%; and C-reactive protein, 0.1%. CONCLUSIONS: We report achievable benchmarks for inpatient care for asthma, bronchiolitis, and pneumonia. The establishment of national benchmarks will drive improvement at individual hospitals.

Reducing the Blood Culture Contamination Rate in a Pediatric Emergency Department and Subsequent Cost Savings

BACKGROUND AND OBJECTIVE: Blood culture contamination in the pediatric population remains a significant quality and safety issue because false-positive blood cultures lead to unnecessary use of resources and testing. In addition, few studies describe interventions to reduce peripheral blood culture contamination rates in this population. We hypothesized that the introduction of a standardized sterile collection process would reduce the pediatric emergency department’s peripheral blood culture contamination rate and unnecessary use of resources. METHODS: A sterile blood culture collection process was designed by analyzing current practice and identifying areas in which sterile technique could be introduced. To spread the new technique, a web-based educational model was developed and disseminated. Subsequently, all nursing staff members were expected to perform peripheral blood cultures by using the modified sterile technique. RESULTS: The peripheral blood culture contamination rate was reduced from 3.9% during the baseline period to 1.6% during the intervention period (P < .0001), with yearly estimated savings of ∼

Community Household Income and Resource Utilization for Common Inpatient Pediatric Conditions

250 000 in hospital charges. CONCLUSIONS: Subsequent to our intervention, there was a significant reduction of the peripheral blood culture contamination rate as well as considerable cost savings to the institution. When performed in a standardized fashion by using sterile technique, blood culture collection with low contamination rates can be performed via the insertion of an intravenous catheter.

Children's Hospitals with Shorter Lengths of Stay Do Not Have Higher Readmission Rates

BACKGROUND AND OBJECTIVE: Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI). METHODS: Retrospective national cohort from 32 freestanding children’s hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups. RESULTS: From 116 636 hospitalizations, 4 of 5 conditions had differences at the hospitalization and at the patient level, with lowest-income groups having higher costs. The individual hospitalization level cost differences ranged from

Differences in designations of observation care in US freestanding children's hospitals: Are they virtual or real?

187 (4.1%) to

Pediatric Observation Status: Are We Overlooking a Growing Population in Children's Hospitals?

404 (6.4%). Patient-level cost differences ranged from