Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity.

Importance: Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission. Objectives: To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care. Design, Setting, and Participants: Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity. Exposures: Live birth at GA of 34 weeks or more. Main Outcomes and Measures: Inborn NICU admission rate. Results: Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ρ = -0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman ρ = -0.21, P = .41). Conclusions and Relevance: Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

Cost Analysis and Policy Implications of a Pediatric Palliative Care Program.

CONTEXT: In 2010, California launched Partners for Children (PFC), a pediatric palliative care pilot program offering hospice-like services for children eligible for full-scope Medicaid delivered concurrently with curative care, regardless of the child's life expectancy. OBJECTIVES: We assessed the change from before PFC enrollment to the enrolled period in 1) health care costs per enrollee per month (PEPM), 2) costs by service type and diagnosis category, and 3) health care utilization (days of inpatient care and length of hospital stay). METHODS: A pre-post analysis compared enrollees' health care costs and utilization up to 24 months before enrollment with their costs during participation in the pilot, from January 2010 through December 2012. Analyses were conducted using paid Medicaid claims and program enrollment data. RESULTS: The average PEPM health care costs of program enrollees decreased by $3331 from before their participation in PFC to the enrolled period, driven by a reduction in inpatient costs of $4897 PEPM. PFC enrollees experienced a nearly 50% reduction in the average number of inpatient days per month, from 4.2 to 2.3. Average length of stay per hospitalization dropped from an average of 16.7 days before enrollment to 6.5 days while in the program. CONCLUSION: Through the provision of home-based therapeutic services, 24/7 access to medical advice, and enhanced, personally tailored care coordination, PFC demonstrated an effective way to reduce costs for children with life-limiting conditions by moving from costly inpatient care to more coordinated and less expensive outpatient care. PFC's home-based care strategy is a cost-effective model for pediatric palliative care elsewhere.

Neonatal intensive care unit antibiotic use.

BACKGROUND AND OBJECTIVES: Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay. METHODS: In a retrospective cohort study of 52,061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles. RESULTS: Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile. CONCLUSIONS: Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

Using telemedicine to improve the care delivered to sexually abused children in rural, underserved hospitals.

OBJECTIVE: We used live telemedicine consultations to assist remote providers in the examination of sexually assaulted children presenting to rural, underserved hospitals. We hypothesized that telemedicine would increase the ability of the rural provider to perform a complete and accurate sexual assault examination. PATIENTS AND METHODS: Child abuse experts from a university children's hospital provided 24/7 live telemedicine consultations to clinicians at 2 rural, underserved hospitals. Consultations consisted of videoconferencing to assist in the examination and interpretation of findings during live examinations. Consecutive female patients <18 years of age presenting to the 2 participating hospitals were included. We developed and used an instrument to assess the quality of care and the interventions provided via telemedicine as it related to patient history, physical examination, colposcopic and manual manipulation techniques, interpretation of findings, and treatment plans for victims of child sexual abuse. RESULTS: Data from 42 live telemedicine consultations were analyzed. The mean duration of the consultations was 71 minutes (range: 25-210 minutes). The consultations resulted in changes in interview methods (47%), the use of the multimethod examination technique (86%), and the use of adjunct techniques (40%). There were 9 acute sexual assault telemedicine consults that resulted in changes to the collection of forensic evidence (89%). Rankings of practitioners' skills and the telemedicine consult effectiveness were high, with the majority of cases scoring > or =5 on a 7-point Likert scale. CONCLUSIONS: The use of telemedicine to assist in the examination of sexually assaulted children presenting to underserved, rural communities results in significant changes in the methods of examination and evidence collection. It is possible that this model of care results in increased quality of care and appropriate forensic evidence collection.

The use of telemedicine to provide pediatric critical care consultations to pediatric trauma patients admitted to a remote trauma intensive care unit: a preliminary report.

OBJECTIVE: Injured pediatric patients in remote communities are often cared for at trauma centers that may be underserved with respect to pediatric specialty services. The objective of this study is to describe a pilot telemedicine project that allows a remote trauma center's adult intensive care unit to obtain nontrauma, nonsurgical-related pediatric critical care consultations for acutely injured children. DESIGN: Nonconcurrent cohort design. SETTING: A remote, level II trauma center's shock-trauma intensive care unit and a tertiary care children's hospital pediatric intensive care unit. PATIENTS: Analyses were conducted on cohorts of pediatric trauma patients (<16 yrs) consecutively admitted to the remote adult intensive care unit, including historical control patients and patients who received and did not receive telemedicine consultations. INTERVENTIONS: Telemedicine consultations were obtained at the discretion of the remote intensive care unit provider for nontrauma, nonsurgical medical issues. MEASUREMENTS AND RESULTS: The Injury Severity Score and Trauma and Injury Severity Score were used to assess severity of injury and predicted mortality rates, respectively, for the patient cohorts. Parental and provider satisfaction with the telemedicine consultations was also described. Thirty-nine consultations were conducted on 17 patients from the 97 pediatric patients admitted during the 2-yr study. Patients who received consultations were younger (5.5 yrs vs. 13.3 yrs, p <.01) and were more severely injured (mean Injury Severity Score = 18.3 vs. 14.7, p =.07). Severity-adjusted mortality rates were consistent with Trauma and Injury Severity Score expectations. Satisfaction surveys suggested a high level of provider and parental satisfaction. CONCLUSIONS: Our report of a trauma intensive care unit based pediatric critical care telemedicine program demonstrates that telemedicine consultations to a remote intensive care unit are feasible and suggests a high level of satisfaction among providers and parents.

Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California.

OBJECTIVE: To report a novel application of telemedicine and to assess the resulting quality and satisfaction of care. Study design An existing telemedicine program was evaluated through the use of a nonconcurrent cohort design. Cohorts of patients were compared by means of the Pediatric Risk of Mortality, version III (PRISM III), to adjust for severity of illness and assess risk-adjusted mortality rates. Satisfaction and quality of care surveys administered to the pediatric patient's parents and providers were also analyzed. RESULTS: Telemedicine consultations (n=70) were conducted on 47 patients during a 2-year period. Patients receiving telemedicine consultations were sicker than the average pediatric patient cared for in the adult intensive care unit (ICU) (n=180) and compared with historic control pediatric patients (n=116) (mean PRISM III score of 9.6 versus 7.7 and 7.5, respectively). PRISM III-standardized mortality ratios were consistent among the same cohorts of patients (0.24, 0.36, and 0.37, respectively). Overall satisfaction and perception of quality of care was high among parents and rural health care providers. CONCLUSIONS: This study demonstrates that a regional pediatric ICU-based telemedicine program providing live interactive consultations to a rural adult ICU can provide quality care that is considered highly satisfactory to a select group of critically ill pediatric patients.

Children with cancer, fever, and treatment-induced neutropenia: risk factors associated with illness requiring the administration of critical care therapies.

OBJECTIVES: To identify clinical and laboratory characteristics of pediatric patients with cancer, fever, and treatment-induced neutropenia, available at existing at initial presentation, that are independently associated with the development of illnesses requiring administration of critical care therapies. METHODS: We retrospectively collected historical, clinical, and laboratory data on initial presentation for all pediatric (younger than 18 years) cancer patients admitted for fever and treatment-induced neutropenia at our institution over a 5-year period. The outcome variable was the need for administration of a critical care therapy within 24 hours of admission. A multivariable analysis was performed and internally validated using bootstrap analysis. RESULTS: We identified 303 events in 143 patients, of which 36 (11.9%) received a critical care therapy. Higher temperature at presentation and capillary filling time (CFT) of >3 seconds retained significance in the multivariable analysis and were validated by the bootstrap analysis. The positive and negative predictive values of the presence of either temperature of > or =39.5 degrees C or CFT of >3 seconds were 35% and 91%, respectively. CONCLUSIONS: Pediatric patients with cancer, fever, and treatment-induced neutropenia who present with higher fever or prolonged CFT are at increased risk of developing life-threatening illnesses requiring administration of critical care therapies, independent of hematologic factors, type of cancer, or other physiologic signs of sepsis.

Using telemedicine to provide pediatric subspecialty care to children with special health care needs in an underserved rural community.

OBJECTIVE: For children with special health care needs (CSHCN) that live in rural, medically underserved communities, obtaining subspecialty care is a challenge. Telemedicine is a means of improving access to these children by addressing rural physician shortages and geographic barriers. This article reports a medical-needs assessment of parents/guardians with CSHCN and the status of a telemedicine program for CSHCN as well as the results of parent/guardian and local provider satisfaction with the telemedicine program. DESIGN: We report the results of a pretelemedicine medical-needs survey conducted in March 1999 by using a convenience sample of CSHCN living in a rural, medically underserved community located 90 miles north of the University of California Davis Children's Hospital (Davis, CA). In April 1999, a telemedicine program was initiated to provide consultations to CSHCN and has continued since. We also report the parent/guardian's perceptions of the appropriateness and quality of telemedicine consultations and the local provider's satisfaction with telemedicine consultations completed from April 1999 to April 2002. RESULTS: The pretelemedicine medical-needs assessment demonstrated several barriers in access to subspecialty care including traveling >1 hour for appointments (86% of parents/guardians), missing work for appointments (96% of working parents/guardians), and frequently relying on emergency department services and/or self-regulation of their child's medications. From April 1999 to April 2002, 130 telemedicine consultations were completed on 55 CSHCN. Overall, satisfaction was very high. All the parents/guardians rated satisfaction with telemedicine care as either "excellent" or "very good," and all but 2 of the rural providers' surveys reported satisfaction with telemedicine as "excellent" or "very good." The frequency of telemedicine consultations has increased with time. CONCLUSIONS: Pediatric subspecialty telemedicine consultations can be provided to CSHCN living in a rural, medically underserved community with high satisfaction among local providers and parents/guardians. Telemedicine should be considered as a means of facilitating care to CSHCN that, relative to the customary delivery of health care, is more accessible, family-centered, and coordinated among patients and their health care providers.

Financial benefits of a pediatric intensive care unit-based telemedicine program to a rural adult intensive care unit: impact of keeping acutely ill and injured children in their local community.

The objective of this research was to examine the fiscal impact of telemedicine consultations for acutely ill and injured children in a rural setting using pediatric intensive care unit (ICU) telemedicine. One hundred seventy-nine acutely ill and injured infants and children were cared for in the Mercy Redding ICU from April 2000 to April 2002. Data were gathered from these patients, including 47 patients who received 70 pediatric ICU telemedicine consultations during the same time period. Transport and hospital costs avoided were calculated for patients who received telemedicine consultations (Group 1) and for those not transferred due to the availability telemedicine consultations (Group 2), estimated to be one-half of the 179 patients (Group 2). The revenue generated in the rural ICU based on the ability to keep these patients was also determined. An estimated annual cost savings of $172,000 and $300,000 for transport and inpatient care was demonstrated for Group 1 and Group 2, respectively. Additionally, this program resulted in generating $186,000 and $279,000 of inpatient revenue annually for the two groups at the rural hospital. The cost of this program was approximately $120,000 per year. Given the substantial financial savings, support for underserved rural programs, and significant funds kept in the rural community, this may serve as a viable model for providing care to acutely ill and injured infants and children.

Continuous Infusion Ranitidine in Postoperative Pediatric Liver Transplant Patients: Effects on Intragastric pH, Gastrointestinal Bleeding and Metabolic Alkalosis.

The effects of ranitidine, an H(2)-receptor antagonist, on gastric pH, incidence of upper gastrointestinal hemorrhage and postoperative metabolic alkalosis were evaluated in 23 pediatric liver transplant recipients. Intragastric pH probes were inserted postoperatively and pH was monitored for 48 h. Ranitidine was infused for 48 h at 0.2 mg kg(minus sign1) h(minus sign1) (0.15 with renal impairment) and increased once by 0.05 mg kg(minus sign1) if the pH was less than 4.0 for 4 h. The pretreatment gastric pH was 2.1 plus minus 0.7; ranitidine infusion raised the pH to 6.8 plus minus 0.6 (p greater-than-or-equal 0.05). An intragastric pH > 4 was achieved in 64 plus minus 36 min, with a median ED(50) (50% of maximum response) of 0.24 mg kg(minus sign1). The pH was < 4 for 5.3 plus minus 4.8% of the time after the initial response. Loss of pH control occurred in three patients, two of whom had bacterial sepsis. The incidence of upper gastrointestinal bleeding and metabolic alkalosis was evaluated by comparing the study patients to age- and weight-matched historic controls from our center. Bleeding occurred in 1 of 23 (4%) study patients compared to 7 of 23 (30%) controls (p greater-than-or-equal 0.05). Metabolic alkalosis did not develop in the study patients at 24 or 48 h postoperatively (p greater-than-or-equal 0.05 versus controls). Whole blood cyclosporine levels and hepatocellular enzymes were similar in the two groups. We conclude that continuous intravenous infusion of ranitidine in the postoperative pediatric liver transplant recipient raises intragastric pH, decreases the incidence of upper gastrointestinal hemorrhage and prevents the development of metabolic alkalosis.