Factors Associated with Acute Injurious Falls in Elderly Hospitalized Patients: A Multicenter Descriptive Study.

BACKGROUND: The Centers for Medicare & Medicaid Services Hospital-Acquired Conditions (CMS-HAC) links Medicare payments to health care quality. Experiencing a serious disability or death associated with a fall in a health care facility based on diagnosis codes has been identified as an opportunity for improvement. Multiple factors contribute to an inpatient fall, including medications that affect cognition in older adults. The primary aim of this study was to investigate the effect of the commonly prescribed classes of medications on the CMS-HAC falls and trauma definition in US hospitals in a large inpatient database from 2019 to 2021. METHODS: The authors analyzed data from 835 hospitals in the Vizient Clinical Data Base between January 1, 2019, and December 31, 2021, on patients ≥ 65 years of age with CMS-HAC patient falls and trauma codes. Using logistic regression and stepwise Poisson regression analysis, the authors identified demographic, clinical, and hospital-related variables associated with falls meeting the CMS-HAC definition. The top 20 prescribed drug classes in these patients were also identified. RESULTS: Among 11,064,024 patient encounters, 5,978 met the CMS-HAC definition of a serious fall. Patients who experienced a serious fall were significantly more likely to be > 79 years of age (p < 0.001, odds ratio [OR] 1.30, 95% confidence interval [CI] 1.23-1.37), have a history of prior falls (p < 0.001, OR 2.30, 95% CI 2.11-2.50), have a code for dementia (p < 0.001, OR 1.50, 95% CI 1.40-1.60), and have higher anticholinergic cognitive burden (ACB) scores (p < 0.001, OR 1.14, 95% CI 1.13-1.14). Specific medication classes associated with CMS-HAC falls were first-generation antihistamines (p < 0.00, OR 1.21, 95% CI 1.09-1.35), second-generation antihistamines (p ≤ 0.001, OR 1.15, 95% CI 1.13-1.19), and atypical antipsychotics (p < 0.001, OR 1.18, CI 1.13-1.29). CONCLUSION: Patients who experience a fall meeting the CMS-HAC fall definition are significantly more likely to have a prior history of falling, dementia, and a higher ACB score. Results from this study may inform future quality improvement work aimed at reducing injurious falls.

National Documentation and Coding Practices of Noncompliance: The Importance of Social Determinants of Health and the Stigma of African-American Bias.

Patient records serve many purposes, one of which includes monitoring the quality of care provided that they can be analyzed through coding and documentation. Z-codes can provide additional information beyond a specific clinical disorder that may still warrant treatment. Social Determinants of Health have specific Z-codes that may help clinicians address social factors that may contribute to patients' health care outcomes. However, there are Z-codes that specify patient noncompliance which has a pejorative connotation that may stigmatize patients and prevent clinicians from examining nonadherence from a social determinant of health perspective. A retrospective cross-sectional study was performed to examine the associations of patient and encounter characteristics with the coding of patient noncompliance. Included in the study were all patients >18 years of age who were admitted to hospitals participating in the Vizient Clinical Data Base (CDB) between January 1, 2019 and December 31, 2019. Almost 9 million US inpatients were included in the study. Of those, 6.3% had a noncompliance Z-code. Use of noncompliance Z-codes was associated with the following odds estimate ratio in decreasing order: the presence of a social determinant of health (odds ratio [OR], 4.817), African American race (OR, 2.010), Medicaid insurance (OR, 1.707), >3 chronic medical conditions (OR, 1.546), living in an economically distressed community (OR, 1.320), male gender (OR, 1.313), nonelective admission status (OR, 1.245), age <65 years (OR, 1.234). More than 1 in 15 patient hospitalizations had a noncompliance code. Factors associated with these codes are difficult, if not impossible, for patients to modify. Disproportionate representation of Africa-Americans among hospitalizations with noncompliance coding is concerning and urgently deserves further exploration to determine the degree to which it may be a product of clinician bias, especially if the term noncompliance prevents health care providers from looking into socioeconomic factors that may contribute to patient nonadherence.

Improving Mortality Through a Multihospital, Collaborative Quality Improvement Project.

Improving hospital mortality is a key focus of quality and safety efforts at both the local and national level. Structured interventions can assist organizations in determining whether interventional efforts have led to sustained improvement. The PARiHS framework (Promoting Action on Research Implementation in Health Services) can assist organizations in implementing research into practice. This study investigates the use of the PARiHS framework in implementing a multihospital quality improvement project aimed at improving observed-to-expected mortality as measured by Vizient's Clinical Data Base (CDB). Structured interventions during the study period included mortality reviews, clinical documentation improvement opportunities, educational webinars, training and support in the use of CDB to explore ongoing opportunities for mortality improvement and quarterly reports to each participating hospital's leadership team on their performance. Data were gathered from an improvement collaborative in the Upper Midwest, which comprised 34 hospitals, of which 17 participated in the intervention. Measurement occurred from Quarter 4 2016 through Quarter 3 2020 and consisted of a preintervention, intervention, and postintervention period. Although both participating and nonparticipating hospitals achieved a significant reduction in their mortality observed-to-expected ratio from the preintervention period through the postintervention period, the participating hospitals achieved a greater reduction in their observed-to-expected mortality ratio ( P < 0.0004). In addition, the participating hospitals achieved a relative 21% improvement in the mortality domain rank of the Vizient Quality & Accountability Study.

Use of Postdischarge Emergency Medical Services to Reduce Hospital Readmissions: Does It Work and Is It Economically Feasible?

A new model of community health delivery has utilized emergency medical services (EMS) to manage care transitions and provide chronic care services in patients' homes. The authors performed a retrospective, case-controlled analysis of a quality improvement project that examined whether an EMS home visit to recently discharged inpatients from the zip code where EMS provides services can reduce 30-day unscheduled ED visits and hospital readmissions. Additionally, the financial impact from the perspective of the community-based EMS provider and the community hospital from which patients were discharged was examined. A total of 53 patients and 53 controls were matched on the following variables: readmission risk score, age, sex, insurance status, and case management intervention. Patients who received the intervention had a 44% relative reduction of 30-day ED visits (17% vs 24.5%, P = 0.3381) and a 28.4% relative reduction in 30-day readmissions (18.9% vs 26.4%, P = 0.3532) but neither achieved statistical significance. The intervention cost to EMS was $1937; the intervention led to a $3626 profit for the hospital compared to a loss of $9915 for the control group. Use of local EMS providers may lead to enhanced health care and financial outcomes for community hospitals but the study was underpowered to make a definitive conclusion. However, the results may allow health systems to assess whether collaboration with local EMS providers can improve outcomes at a lower cost.

Improved physician consult response times in an academic Emergency Department after implementation of an institutional guideline.

BACKGROUND: Physician consultation in the Emergency Department (ED) can account for a significant portion of ED length of stay, which can lead to poor clinical outcomes. OBJECTIVE: The purpose of this study was to determine whether an institutional guideline could lead to a reduction in time between consult request and admission decision. This guideline codified a 90-min expected time interval to arrive and complete an admission disposition where the consulting and admitting service were the same in an academic ED with weekly audits and reports to departmental chairs and hospital administrators. METHODS: This was a study of consultation times of patients who presented to an academic ED 6 months before the adoption of an institutional guideline and 6 months after the adoption of the guideline. Data measurement in both periods included the length of time from ED consult order to admission disposition, time of ED discharge, number of ED consultations (single and multiple), ED admissions, and the hospital discharge time of admitted patients. RESULTS: Physician consult response time decreased from 121 min to 100 min (p < 0.0001), and patients left the ED 18 min earlier (p = 0.0221) after implementation of the consultation guideline despite more ED visits, consultations, and admissions in the post-implementation time period. Patients were discharged from the inpatient setting 50 min later (p < 0.0001) after implementation of the guideline. CONCLUSION: An institutional guideline codifying timely ED consultations led to a significant reduction in the time from ED consultation to admission disposition while also allowing patients to leave the ED earlier in a high-occupancy academic medical center. However, the discharge time of admitted hospital patients was later after implementation of the guideline.

Managing the morbidity associated with respiratory viral infections in children with congenital heart disease.

Children with congenital heart disease (CHD) are at risk for increased morbidity from viral lower respiratory tract infections because of anatomical cardiac lesions than can worsen an already compromised respiratory status. Respiratory syncytial virus (RSV) remains an important pathogen in contributing toward the morbidity in this population. Although the acute treatment of RSV largely remains supportive, the development of monoclonal antibodies, such as palivuzumab, has reduced the RSV-related hospitalization rate in children with CHD. This review highlights the specific cardiac complications of RSV infection, the acute treatment of bronchiolitis in patients with CHD, and the search for new therapies against RSV, including an effective vaccine, because of the high cost associated with immunoprophylaxis and its lack of reducing RSV-related mortality.

Superior mesenteric artery syndrome in intellectually disabled children.

OBJECTIVES: Superior mesenteric artery syndrome (SMAS) is a rare cause of small intestinal obstruction in pediatric patients. Children with intellectual disabilities are a challenging patient population in which to make this diagnosis. The goal of this study was to determine the frequency, presenting symptoms, and outcomes of SMAS in intellectually disabled and non-intellectually disabled children. METHODS: Retrospective chart review of pediatric patients with SMAS admitted to Penn State Hershey Children's Hospital between January 1999 and July 2010. RESULTS: Sixteen children with SMAS were identified. The majority were male (n = 9) and more than two thirds had an intellectual disability (n = 11). Presenting symptoms were similar between groups, but 78% (7/9) of intellectually disabled patients who had a gastrostomy tube presented with feeding intolerance. Although intellectually disabled patients had a higher number of comorbidities and the number of health care visits before diagnosis was higher, this did not reach statistical significance. There were also no significant differences in length of symptoms before diagnosis and amount of weight loss. However, the weight-for-age percentiles in intellectual disabled children were significantly lower in those without an intellectual disability (9.09 [20.31] vs 48 [20.19], respectively, P ≤ 0.001). Seventy-five percent of patients responded favorably to conservative treatment, but 36% (4/11) of intellectually disabled patients required multiple treatments before there was an improvement in their condition. CONCLUSIONS: Superior mesenteric artery syndrome was found more often in children with an intellectual disability. These data highlight the need to consider SMAS if there is difficulty tolerating gastrostomy tube feedings in patients with weight-for-age percentiles less than 5%.

Evaluating communication between pediatric primary care physicians and hospitalists.

To determine the preferences for and satisfaction with communication between pediatric primary care physicians (PCPs) and hospitalists, 2 surveys (PCP and hospitalist versions with matching questions) were developed. Overall, PCPs were less satisfied than hospitalists with communication (P < .01). The 2 provider types had differing opinions on responsibility for care after hospital discharge, with hospitalists more likely than PCPs to assign responsibility to the PCP for pending labs (65% vs 49%; P < .01), adverse events (85% vs 67%; P < .01), or status changes (85% vs 69%; P < .01). Whereas satisfaction with and preferences for patient-related communication differed between hospitalists and PCPs, the incongruent views on the responsibility for care after patient discharge have major implications for safety particularly if poor communication occurs at discharge. Successful transitions from the hospital to primary care require communication between hospitalists and PCPs to be consistent, timely, and informative with responsibility for care discussed at discharge.

Transmission of surfactant protein variants and haplotypes in children hospitalized with respiratory syncytial virus.

Severity of lung injury with respiratory syncytial virus (RSV) infection is variable and may be related to genetic variations. This preliminary report describes a prospective, family-based association study of children hospitalized secondary to RSV, aimed to determine whether intragenic and other haplotypes of surfactant proteins (SP)-A and SP-D are transmitted disproportionately from parents to offspring with RSV disease. Genomic DNA was genotyped for several SP-A and SP-D single nucleotide polymorphisms (SNPs). Transmission disequilibrium test analysis was used to determine transmission of variants and haplotypes from parents to affected offspring. Three hundred seventy-five individuals were studied, including 148 children with active RSV disease and one or both parents. The SP-A2 intragenic haplotype 1A was found to be protective (p = 0.013). The SP-D SNP DA160_A may possibly be an "at-risk" marker (p = 0.0058). Additional two- and three-marker haplotypes were associated with severe RSV disease, with two being protective (DA11_T/DA160_G and DA160_G/SP-A2 1A/SP-A1 6A). We conclude that there may be associations between SP-A and SP-D and RSV disease. Further study is required to determine whether these variants can be used to target a high-risk patient population in clinical trials aimed at reducing either the symptoms of acute infection or long-term pulmonary sequelae.

Palivizumab in congenital heart disease: should international guidelines be revised?

Palivizumab has reduced the incidence of respiratory syncytial virus hospitalization in infants and children with congenital heart disease by 45%. Although the mortality rate of children with congenital heart disease hospitalized with respiratory syncytial virus infection has declined from 37% to approximately 3% over the past 3 decades, palivizumab has not been shown to improve mortality. There has been considerable controversy over the cost-effectiveness of administering palivizumab according to international guidelines, including children with congenital heart disease. In particular, the number of children that need to be treated with palivizumab to prevent one respiratory syncytial virus hospitalization increases dramatically in children > 12 months of age. As a result, the authors recommend that countries re-examine their recommendations for providing palivizumab up to age 24 months in children with congenital heart disease.

Palivizumab prophylaxis to prevent respiratory syncytial virus mortality after pediatric bone marrow transplantation: a decision analysis model.

OBJECTIVE: Palivizumab, a monoclonal antibody against respiratory syncytial virus (RSV), has been demonstrated to be safe and effective in young children, but evidence is lacking as to whether palivizumab is effective in preventing RSV-induced morbidity and mortality in children who are immunosuppressed after bone marrow transplantation (BMT). As a randomized, double-blind, placebo-controlled trial is lacking, we chose to examine this issue with the use of decision analysis methodology. METHODS: A decision tree was designed to determine mortality from RSV-related lung disease in children who received palivizumab after BMT. Probabilities were derived by meta-analysis methodology on the basis of the available literature. Sensitivity analyses were performed across a broad range of biologically plausible probabilities to judge the robustness of the results of the model. RESULTS: The model revealed that there is a 10% increase in survival in BMT patients who receive palivizumab. The absolute survival rate increased from 83% to 92%. A practitioner would need to treat 12 children to save 1 post-BMT child from dying from RSV-related lung disease. CONCLUSIONS: Decision analysis modeling demonstrates a decrease in mortality in pediatric BMT patients with the addition of palivizumab to protect against RSV-related lung disease. A well-designed, randomized controlled trial is necessary.

Third-year medical students' evaluation of hospitalist and nonhospitalist faculty during the inpatient portion of their pediatrics clerkships.

BACKGROUND: Although the data on the impact of hospitalist programs on the inpatient education of medical students during their internal medicine clerkships are favorable, the data is limited on the inpatient educational experience of medical students during their pediatric clerkships. The purpose of this study was to compare the evaluations of hospitalist and nonhospitalist faculty of third-year medical students during their inpatient pediatrics rotations. METHODS: We performed a retrospective study of the evaluations of third-year medical student of hospitalist and nonhospitalist faculty during their inpatient pediatrics rotations at Penn State Children's Hospital from July 1999 through September 2000. Using a 4-point scale, students gave an overall evaluation and also rated the hospitalist and nonhospitalist faculty on effectiveness as teachers, effectiveness as pediatricians, and effectiveness as student advocates. Using the same 4-point scale, students rated the following aspects of the rotation: ward rounds, sick newborn care, well newborn care, outpatient clinics, private physician's office, noon conferences, and morning report. RESULTS: A total of 67 students rotated on the pediatric inpatient service during the study period; 35 students rotated with 2 hospitalists, and 32 students rotated with 8 nonhospitalists. All 67 students (100%) submitted an evaluation. The hospitalists received higher scores than nonhospitalists on effectiveness as teachers (3.87 vs. 2.91; P < 0.001), effectiveness as pediatricians (3.94 vs. 3.25; P < .001), effectiveness as student advocates (3.76 vs. 2.97; P < .001), and in the overall evaluation (3.93 vs. 3.06; P < .001). Ward rounds were rated as more beneficial when conducted by hospitalists then when conducted by nonhospitalists (3.15 vs. 2.58; P < .006). CONCLUSIONS: Hospitalists were perceived by third-year medical students as providing more effective teaching and more satisfying overall rotations than were nonhospitalists during the inpatient portion of the students' pediatric clerkships. Further studies that examine inpatient systems, particularly as they relate to the acquisition of knowledge and the development of effective communication skills in medical learners, are needed.

Palivizumab: a review of its use in the protection of high risk infants against respiratory syncytial virus (RSV).

Respiratory syncytial virus (RSV) is a leading cause of hospitalization in children less than 1 year of age and causes substantial morbidity. Although there is not currently a vaccine available to prevent RSV infection, prophylaxis with the humanized monoclonal antibody palivizumab has been shown to reduce the rate of RSV hospitalization in premature infants and those infants with chronic lung disease or congenital heart disease. Because palivizumab has not been shown to have a beneficial clinical effect on established RSV disease such as reducing the rate of mechanical ventilation and mortality in children afflicted with RSV, there has been considerable debate as to the cost-benefit ratio of administering palivizumab according to international guidelines. Palivizumab has demonstrated a favorable side-effect profile in clinical trials without the development of anti-palivizumab antibodies. Future studies are needed to determine whether palivizumab, or other more potent monoclonal antibodies which are currently undergoing clinical trials, will reduce the long-term sequelae of RSV infection such as the development of wheezing and asthma.

Amantadine penetration into cerebrospinal fluid of a child with influenza A encephalitis.

The use of amantadine has been advocated as treatment for influenza A encephalitis despite limited information regarding cerebrospinal fluid concentrations and the pathogenesis of encephalitis associated with influenza virus infections. We report a 2-year-old child with influenza A encephalitis treated with amantadine who achieved a potentially therapeutic concentration in cerebrospinal fluid. Despite this the child developed significant neurologic impairment.

Administration of the first dose of palivizumab immunoprophylaxis against respiratory syncytial virus in infants before hospital discharge: what is the evidence for its benefit?

BACKGROUND: Palivizumab is 1 of 2 agents used to prevent severe lower respiratory tract disease due to respiratory syncytial virus (RSV) infection. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend administering the first dose of RSV immunoprophylaxis to eligible infants before hospital discharge. Unfortunately, third-party payers frequently do not separately reimburse administration of this therapy to hospitalized infants. OBJECTIVE: Because palivizumab is commonly used to provide RSV immunoprophylaxis, we systematically reviewed all published data on this drug to determine whether the evidence supports the recommendation of administering the first dose before hospital discharge. METHODS: MEDLINE was searched for all articles published in English from January 1, 1996, to October 31, 2003, using the search terms palivizumab and Synagis, and the following data were extracted onto a standardized form: author(s), year of publication, study design, patient population, sample size, criteria used for administration of RSV prophylaxis, location of palivizumab prophylaxis (inpatient or outpatient), parental satisfaction with administration of prophylaxis, incidence of RSV infection, and hospitalization rates for RSV. All selected publications were reviewed to determine whether they reported differences in the incidence of RSV infection or hospitalization in patients who received palivizumab before discharge compared with those who received it after discharge. Only those publications that specifically documented administration of the first dose of palivizumab before hospital discharge were included in the final analysis. RESULTS: Six of the 166 studies reviewed met the selection criteria. Although all 6 studies reported reduced RSV hospitalization rates with palivizumab prophylaxis, no study directly compared inpatient and outpatient administration with regard to parental satisfaction or rates of RSV infection or hospitalization. Furthermore, based on the data in these studies, it was not possible to detect any differences in parental satisfaction or rates of RSV infection or hospitalization between the 2 locations of administration. CONCLUSIONS: Based on our literature review, there is no evidence to support the recommendation that palivizumab be administered before hospital discharge in every infant who meets the criteria for RSV immunoprophylaxis. Eligible infants may be given the initial dose of RSV prophylaxis as outpatients, reducing the cost to institutions that currently provide palivizumab before hospital discharge.