Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

OBJECTIVES: To describe how in-depth analysis of adverse events can reveal underlying causes. METHODS: Triggers for adverse events were developed using the hospital's computerised medical record (naloxone for opiate-related oversedation and administration of a glucose bolus while on insulin for insulin-related hypoglycaemia). Triggers were identified daily. Based on information from the medical record and interviews, a subject expert determined if an adverse drug event had occurred and then conducted a real-time analysis to identify event characteristics. Expert groups, consisting of frontline staff and specialist physicians, examined event characteristics and determined the apparent cause. RESULTS: 30 insulin-related hypoglycaemia events and 34 opiate-related oversedation events were identified by the triggers over 16 and 21 months, respectively. In the opinion of the experts, patients receiving continuous-infusion insulin and those receiving dextrose only via parenteral nutrition were at increased risk for insulin-related hypoglycaemia. Lack of standardisation in insulin-dosing decisions and variation regarding when and how much to adjust insulin doses in response to changing glucose levels were identified as common causes of the adverse events. Opiate-related oversedation events often occurred within 48 h of surgery. Variation in pain management in the operating room and post-anaesthesia care unit was identified by the experts as potential causes. Variations in practice, multiple services writing orders, multidrug regimens and variations in interpretation of patient assessments were also noted as potential contributing causes. CONCLUSIONS: Identification of adverse drug events through an automated trigger system, supplemented by in-depth analysis, can help identify targets for intervention and improvement.

Inpatient care for uncomplicated bronchiolitis: comparison with Milliman and Robertson guidelines.

CONTEXT: Bronchiolitis is the most common lower respiratory tract infection in infancy. A recent Centers for Disease Control and Prevention report confirmed that hospitalization rates for bronchiolitis have increased 2.4-fold from 1980 to 1996. Controversies exist about optimal treatment plans. Milliman and Robertson recommend ambulatory care management; in case of hospitalization, the recommended length of stay is 1 day. OBJECTIVES: To relate actual practice variation for infants admitted with uncomplicated bronchiolitis to Milliman and Robertson's recommendations. DESIGN: Prospective observational study. SETTING: General care wards of 8 pediatric hospitals of the Child Health Accountability Initiative during the winter of 1998-1999. PATIENTS: First-time admissions for uncomplicated bronchiolitis in patients not previously diagnosed as having asthma and who were younger than 1 year. MAIN OUTCOME MEASURES: Respiratory rate, monitored interventions, attainment of discharge criteria goals, and length of stay. RESULTS: Eight hundred forty-six patients were included in the final analysis: 85.7% were younger than 6 months, 48.5% were nonwhite, and 64.1% were Medicaid recipients or self-pay. On admission to the hospital, 18.3% of the infants had respiratory rates higher than higher than 80 breaths per minute, 53.8% received supplemental oxygen therapy, and 52.6% received intravenous fluids. These proportions decreased to 1.9%, 33.8%, and 20.3%, respectively, 1 day after admission, and to 0.7%, 20.1%, and 8.6%, respectively, 2 days after admission. The average length of stay was 2.8 days (SD, 2.3 days). CONCLUSIONS: Milliman and Robertson's recommendations do not correspond to practice patterns observed at the hospitals participating in this study; no hospital met the Milliman and Robertson recommended 1-day goal length of stay. Administration of monitored intervention persisted past the second day of hospitalization.

Predictors of cost of liver transplantation in children: a single center study.

OBJECTIVE: Efforts to decrease the cost of orthotopic liver transplantation (OLT) must address the impact of specific interventions on clinical outcome. We hypothesized that an intervention designed to decrease the length of hospitalization would reduce costs without jeopardizing clinical outcome. We further sought to identify predictors of length of stay and cost for hospitalization after liver transplantation. METHODS: The study group included 47 children who underwent OLT from September 1996 to April 1999, and the control group included 36 children who underwent OLT from March 1994 to August 1996. The intervention was a transition to home program in which patients were discharged to a family living center when they met established clinical criteria and their families met predefined educational goals. We analyzed patients who survived 3 months after OLT. RESULTS: For the intervention group, the mean length of stay, total costs, and surgical costs were 29%, 36%, and 34% lower, respectively. Organ type, height z score, race, hepatic artery thrombosis, early allograft rejection, and participation in the transition to home program predicted length of stay and total costs. CONCLUSION: An early discharge program based on defined criteria can be used to decrease length of stay and cost after OLT without jeopardizing clinical outcome.

Effect of treatment with prostaglandin E1 and N-acetylcysteine on pediatric liver transplant recipients: a single-center study.

Prostaglandin E1 (PGE1) and N-acetylcysteine (NAC) have been used as single agents to decrease reperfusion injury and improve outcome after solid-organ transplantation (Tx). We hypothesized that combined treatment with NAC and PGE1 would be safe and reduce reperfusion injury. We therefore carried out a pilot study to assess the safety of this drug combination and gain information regarding the efficacy of treating pediatric liver transplant recipients with NAC and PGE1. The pilot study took the form of an open-label study incorporating 25 pediatric liver transplant recipients (12 children in the treatment group and 13 children as controls). NAC (70 mg/kg) was given intravenously over 1 h following reperfusion and then every 12 h for 6 days. PGE1 (0.4 mg/kg/h) was given as a continuous intravenous infusion for 6 days, starting after the first NAC dose. The primary outcome was the safety of combined treatment with NAC and PGE1. Patient survival, graft survival, allograft rejection within the first 90 days after Tx, peak post-transplant serum alanine aminotransferase (ALT) concentration, post-transplant length of hospitalization, and post-operative complications were secondary outcomes. Post-operative complications occurred at similar rates in both control and treated groups. No complications or adverse events occurred in the treated group as a result of study drugs. The 3-month patient survival rate was 100% for both groups. For the group treated with NAC and PGE1, peak serum ALT was lower and median length of stay was shorter but the differences did not reach statistical significance. The proportion of patients with allograft rejection was not significantly different between the two groups. However, rejection was more severe in the control group than in the treated group. In summary, infusions of NAC and PGE1 were safely administered to pediatric liver transplant recipients. However, a randomized controlled study is needed to determine the efficacy of treatment with NAC and PGE1.

Sustaining the implementation of an evidence-based guideline for bronchiolitis.

OBJECTIVE: To describe the changes occurring over a 3-year period after implementation of an evidence-based clinical practice guideline for the care of infants with bronchiolitis. DESIGN: Before and after study. SETTING: Children's Hospital Medical Center, Cincinnati, Ohio. PATIENTS: Infants 1 year or younger admitted to the hospital with a first-time episode of typical bronchiolitis. INTERVENTION: The guideline was implemented January 15, 1997. Data on all patients discharged from the hospital with bronchiolitis, from January 15 through March 27, in 1997, 1998, and 1999, were stratified by year and compared with data on similar patients discharged from the hospital in the same periods in the years 1993 through 1996. MAIN OUTCOME MEASURES: Patient volumes, length of stay for admissions, and use of specific laboratory and therapeutic resources ancillary to bed occupancy. RESULTS: After implementation of the guideline, admissions decreased 30% and mean length of stay decreased 17% (P<.001). Nasopharyngeal washings for respiratory syncytial virus were obtained in 52% fewer patients (P<.001); 14% fewer chest x-ray films were ordered (P<.001). There were significant reductions in the use of all respiratory therapies, with a 17% decrease in the use of at least 1 beta(2)-agonist inhalation therapy (P<.001). In addition, 28% fewer repeated inhalations were administered (P<.001); mean costs for all resources ancillary to bed occupancy fell 41% (P<.001); and mean costs for respiratory care services fell 72% (P<.001). CONCLUSIONS: An evidence-based clinical practice guideline for the care of patients encountered in major pediatric care facility has been successfully sustained beyond the initial year of its introduction to practitioners in southwest Ohio.

Differential markers for regionalization.

OBJECTIVE: To examine the site of delivery for very low birth weight (VLBW) infants and infants with major congenital malformations (MCM) within an established system of perinatal regionalization. STUDY DESIGN: A retrospective study of site of delivery for VLBW infants and infants born with MCM (tracheoesophageal fistula/esophageal atresia, diaphragmatic hernia, or gastroschisis/omphalocele) from 1990 through 1995 in Ohio. RESULTS: A total of 59.8% of VLBW infants and 36.1% of MCM infants were born in a level III hospital. There was a significant trend toward a decrease in VLBW infants (p < 0.01) and an increase in MCM infants (p < 0.05) born in a level III hospital between 1990 and 1995. There were significant regional variations among the six perinatal regions in Ohio in the proportion of both VLBW and MCM infants born in a tertiary center. CONCLUSION: Using the traditional marker of VLBW to assess regionalization in one state, we found significant variation in site of delivery among the perinatal regions and over the time course of the study. The delivery of infants with MCM at level III centers may be an alternative measure of regionalization.

Prenatal care and infant emergency department use.

OBJECTIVE: To determine the relationship between mothers' use of prenatal care and pediatric emergency department (ED) use by their infants in the first 3 months of life. METHODS: This is a retrospective, cohort-control study of well, full-term infants who use a children's hospital ED. Using logistic regression, the likelihood of an emergency visit in the first 3 months of life was compared between infants of women with fewer than two prenatal visits and infants of women with two or more prenatal visits. Covariates were maternal age, race, substance abuse history, parity, infant birth weight, insurance status, and distance from the ED. RESULTS: The odds of an ED visit before age 3 months by infants of mothers with less than two prenatal visits was 29% lower than the comparison group. ED use was increased by proximity, Medicaid or no health insurance and younger maternal age. Seventy percent (70%) of visits by both cohorts were classified as unjustified. The odds of making an unjustified ED visit were increased by younger maternal age and proximity to the emergency department. CONCLUSIONS: Women with poor prenatal care are less likely to seek ED care for their young infants. Although suboptimal prenatal care is associated with negative health outcomes, it is not known whether fewer infant ED visits are similarly deleterious.

Evaluation of an evidence-based guideline for bronchiolitis.

OBJECTIVE: To describe the effect of implementing an evidence-based clinical practice guideline for the inpatient care of infants with bronchiolitis at the Children's Hospital Medical Center in Cincinnati, Ohio. METHODOLOGY: A multidisciplinary team generated the guideline for infants < or = 1 year old who were admitted to the hospital with a first-time episode of typical bronchiolitis. The guideline was implemented January 15, 1997, and data on all patients admitted with bronchiolitis from that date through March 27, 1997, were compared with data on similar patients admitted in the same periods in the years 1993 through 1996. Data were extracted from hospital charts and clinical and financial databases. They included LOS and use and costs of resources ancillary to bed occupancy. RESULTS: After implementation of the guideline, admissions decreased 29% and mean LOS decreased 17%. Nasopharyngeal washings for respiratory syncytial virus were obtained in 52% fewer patients. Twenty percent fewer chest radiographs were ordered. There were significant reductions in the use of all respiratory therapies, with a 30% decrease in the use of at least 1 beta-agonist inhalation therapy. In addition, 51% fewer repeated inhalations were administered. Mean costs for all resources ancillary to bed occupancy decreased 37%. Mean costs for respiratory care services decreased 77%. CONCLUSIONS: An evidence-based clinical practice guideline for managing bronchiolitis was highly successful in modifying care during its first year of implementation.guideline, bronchiolitis, evidence-based medicine, pediatrics, outcome research.

Health system factors contributing to breastfeeding success.

OBJECTIVE: To identify and characterize health care system factors that contribute to successful breastfeeding in the early postpartum period. STUDY DESIGN: A prospective 8-week cohort study of 522 women at five area hospitals who had a vaginal delivery of a healthy, full-term single child and who intended to breastfeed. Mothers and infants had free access to each other for breastfeeding during the hospital stay. Data were obtained through chart review and surveys. In-person postpartum interviews in the hospital and 4- and 8-week telephone interviews were used to determine participants' perceptions of breastfeeding support by hospital personnel, home visit nurses, and family and friends. The hospital in-person interview with each mother was conducted before discharge to confirm maternal interest and intent to breastfeed. Questions were asked regarding breastfeeding information and support provided by medical and nursing personnel. Mothers were asked to rate the quality of information, as well as the degree of support they received for breastfeeding. Mothers also were asked to rate their hospital breastfeeding experience. A second interview was conducted by telephone 4 weeks after birth. The focus of this interview was to ascertain the rating of their breastfeeding experience, the quality of their interactions with health care professionals, and whether supplemental formula was being provided to the infant. If supplemental formula was being provided, the mothers were asked to quantify the volume and frequency of supplementation. A final telephone interview was conducted when the infants were 8 weeks of age. This interview determined the continuance or cessation of breastfeeding and information about formula supplementation, as in the 4-week interview. Mothers were given a journal and asked to note all telephone calls, clinic visits, and home nurse visits that related to breastfeeding issues and concerns. Demographic data examined included maternal age, marital status, highest level of education reached, race, employment, insurance coverage, and length of stay in the hospital. Pregnancy characteristics included prenatal care, parity, and gravity. Infant characteristics included gestational age and birth weight. Other factors examined included maternal rating of the support received from the infant's father for the decision to breastfeed, the time the infant spent in the mother's hospital room, and whether the infant was breastfed in the delivery room. RESULTS: The women were mostly white (90%), educated (82% had some college education), married, older (mean maternal age of 29.3 years), and insured (92% commercial). The primary outcome of interest was success at breastfeeding. Success was determined based on each mother's initial estimate of the planned duration of breastfeeding. Of the participants, 76% breastfed successfully for at least as long as they had initially planned. Seventeen percent of the mothers had stopped breastfeeding at the time of the 4-week interview, and 29% had stopped by the 8-week interview. Of the infants' fathers, 97% were reported by the mothers to be supportive of the decision to breastfeed. Once discharged, 98% of mothers expected to have help with the household chores. Eighty percent rated their hospital breastfeeding experience as good or very good. However, only 56% rated hospital breastfeeding support as good or very good, and only 44% spoke with a lactation consultant while in the hospital. Of those who spoke with the lactation consultant, 85% felt more confident afterward. Hospital nurses talked with 82% of women, and 97% of these found this helpful. Seventy-four percent reported receiving a home nursing visit after discharge, and of these, 82% found it helpful. Successful mothers were significantly more likely to report that the visiting nurse watched them breastfeed and asked how it was going. Mothers were more likely to call or visit family and friends with concerns about breastfeeding than

Safety of early discharge for Medicaid newborns.

CONTEXT: Neonates are being discharged from the hospital more rapidly, but the risks associated with this practice, especially for low-income populations, are unclear. OBJECTIVE: To determine the impact of decreasing postnatal length of stay on rehospitalization rates in the immediate postdischarge period for Medicaid neonates. DESIGN AND SETTING: Retrospective, population-based cohort study using Ohio Medicaid claims data linked to vital statistics files from July 1, 1991, to June 15, 1995. PARTICIPANTS: A total of 102 678 full-term neonates born to mothers receiving Medicaid for at least 30 days after birth. MAIN OUTCOME MEASURES: Rehospitalization rates within 7 and 14 days of discharge, postdischarge health care use, and regional variations in length of stay and rehospitalization. RESULTS: The proportion of neonates who were discharged following a short stay (less than 1 day after vaginal delivery, less than 2 days after cesarean birth) increased 185%, from 21% to 59.8% (P<.001) and the mean (SD) length of stay decreased 27%, from 2.2 (1.0) to 1.6 (0.9) days (P<.001), over the course of the study. The proportion of neonates who received a primary care visit within 14 days of birth increased 117% (P = .001). Rehospitalization rates within 7 and 14 days of discharge decreased by 23%, from 1.3% to 1.0% (P=.01), and by 19%, from 2.1% to 1.7% (P=.03), respectively. Short stay across the 6 regions of the state varied significantly over time (P<.001). Factors significantly associated with increased likelihood of rehospitalization within both 7 and 14 days of discharge were white race, shorter gestation, primiparity, earlier year of birth, lower 5-minute Apgar score, vaginal delivery, married mother, and region of the state. CONCLUSION: Our data suggest that reductions in length of stay for full-term Medicaid newborns in Ohio have not resulted in an increase in rehospitalization rates in the immediate postnatal period.

Management of sore throats in children: a cost-effectiveness analysis.

OBJECTIVE: To perform a cost-effectiveness analysis of treatment management strategies for children older than 3 years who present with signs or symptoms of pharyngitis. DESIGN: Decision model with 7 strategies, including neither testing for streptococcus nor treating with antibiotics; treating empirically with penicillin V; basing treatment on results of a throat culture (Culture); and basing treatment on results of enzyme immunoassay or optical immunoassay rapid tests, performed alone or in combination with throat cultures. In these 7 strategies, all tests are performed in a local reference laboratory. In a sensitivity analysis, we examined the cost-effectiveness of 4 strategies involving office-based testing. We obtained data on event probabilities and test characteristics from our hospital's clinical laboratory and the literature; costs for the analysis were based on resource use. RESULTS: At a baseline prevalence of 20.8% for streptococcal pharyngitis, the Culture strategy was the least expensive and most effective, with an average cost of $6.85 per patient. The outcome was sensitive to the prevalence of streptococcal pharyngitis, the rheumatic fever attack rate, the cost of the enzyme immunoassay test, and the cost of culturing and reporting culture results. The Culture strategy was also preferred if amoxicillin was substituted for oral penicillin. For office-based testing, Culture was the least costly strategy, but treatment based on results of the optical immunoassay test alone had an incremental cost-effectiveness ratio of $1.6 million per additional life saved. CONCLUSION: In a setting with adherent patients, children with sore throats should generally get throat cultures in lieu of rapid streptococcus antigen tests.

Outcomes and resource utilization for newborns with major congenital malformations: the initial NICU admission.

HYPOTHESIS: Newborns with major congenital malformations (MCM) have contributed to a significant proportion of resource utilization in a regional referral neonatal intensive care unit (NICU). SETTING: The Children's Hospital Medical Center NICU, Cincinnati, OH. SUBJECTS: Newborns with and without MCM admitted from August 1, 1993 through July 31, 1994. Total patients studied were 572; 147 with and 385 without MCM. No intervention was performed in this observational study. STATISTICS: Statistics were t test, chi-squared, and rank sum analysis. RESULTS: MCM accounted for 27.6% of NICU referrals, 32.4% of total NICU days, and 39.6% of NICU costs. Both median cost per patient and length of stay were significantly (p < 0.01) higher for patients with MCM than those without MCM. Surgery was more frequent in MCM than non-MCM cases. Thirty-three percent of the newborns with MCM received ongoing medical support at discharge. CONCLUSION: Patients with MCM remain as one of the largest and costliest groups hospitalized in a referral NICU.

An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost.

BACKGROUND/PURPOSE: In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS: A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS: Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION: An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care.

Standards of laboratory practice: theophylline and caffeine monitoring. National Academy of Clinical Biochemistry.

Theophylline is used in the treatment of asthma and chronic obstructive pulmonary disease. The use of theophylline has declined with the advent of potent steroid inhalants. Because of the therapeutic index of this drug, monitoring of theophylline concentrations in plasma is essential. Monitoring should be done on trough specimens after steady-state has been reached. Non-steady-state concentrations may be indicated in selected situations. Caffeine is used to treat apnea of the newborn because of its low toxicity. Monitoring is often by clinical effect. Monitoring of serum concentrations should be performed in cases where there is no clinical response or if there is suspected toxicity.

Physician variations and the ancillary costs of neonatal intensive care.

OBJECTIVE: To determine to what degree attending physicians contribute to cost variations in the care of ventilator-dependent newborns. DATA SOURCES: Clinical data were merged with hospital financial data describing daily ancillary care costs during the first two weeks of life for 132 extremely low-birthweight newborns. In addition, each patient's chart was reviewed and illness severity graded using both SNAP and CRIB scores. STUDY DESIGN: This was a retrospective cohort of infants with birth weights of less than 1,001 grams and respiratory distress syndrome requiring mechanical ventilation in the first day of life. From birth up to two weeks of life, each received care directed by only one of 11 faculty neonatologists in a single university hospital. Data were analyzed stratified by these physicians. t-Test, ANOVA, and chi-square were used to assess bivariate data. For continuous data, log linear regressions were used. PRINCIPAL FINDINGS: After controlling for illness severity, when stratified by physicians, there were significant variances in the costs of ancillary resources for the study infants (p < .0001). Twenty-nine percent of the variance was attributable to whether or not the hospital day included the use of a ventilator. Physician identity explained only 5.6 percent (p < .0001). CONCLUSIONS: Physician identity was significant but explained less than 6 percent of the total variance in ancillary costs. Whether or not a ventilator was used during care was far more important. We conclude that for very sick babies during the first two weeks of care, reducing variations in ancillary services utilization among neonatologists will yield only modest savings.

Use of hospital-based services in the first three months of life: impact of an early discharge program.

OBJECTIVE: To assess the effect of an early discharge program on the use of hospital-based health care services in the first 3 months of life. DESIGN: Retrospective cohort study. SETTING: Metropolitan university hospital and a children's hospital. PATIENTS: Term infants cared for in a single term nursery, before and after implementation of an early discharge program. INTERVENTION: Early discharge program. METHODS: Linking of the birth hospital and the children's hospital records and chart review. OUTCOME MEASURES: Pattern of emergency department visits and rehospitalizations in the first 3 months of life. RESULTS: The early discharge group had a shorter stay, 32 +/- 21 hours (mean +/- SD) than the control group (48 +/- 22 hours). There was no effect of early discharge on mean age at rehospitalization, rehospitalization rate, or reason for rehospitalization. Twenty-eight percent of infants in both study and control groups had at least one emergency department visit by 3 months of age. There was no difference between study and control groups in mean age or frequency of emergency department visits. Maternal age and race had a significant effect on the odds of visiting the emergency department. For any maternal age, nonwhite mothers were more likely to visit the emergency department. CONCLUSIONS: Early discharge of newborn infants to inner city parents can be accomplished without increasing hospital-based resource use in the first 3 months of life provided coordinated postdischarge care and home visiting services are available.

The influence of day of life in predicting the inpatient costs for providing care to very low birth weight infants.

The purpose of this study was to test, refine, and extend a statistical model that adjusts neonatal intensive care costs for a very low birth weight infant's day of life and birth weight category. Subjects were 62 infants with birth weights below 1,501 g who were born and cared for in a university hospital until discharged home alive. Subjects were stratified into 250-g birth weight categories. Clinical and actual daily room and ancillary-resource costs for each day of care of each infant were tabulated. Data were analyzed by using a nonlinear regression procedure specifying two separate for modeling. The modeling was performed with data sets that both included and excluded room costs. The former set of data were used for generating a model applicable for comparing interhospital performances and the latter for comparing interphysician performances. The results confirm the existence of a strong statistical relationship between an infant's day of life and both total hospital costs and the isolated costs for ancillary-resource alone (P < 0.0001). A refined series of statistical models have been generated that are applicable to the assessment of either interhospital or interphysician costs associated with providing inpatient care to very low birth weight infants.

Use of health care services by inner-city infants in an early discharge program.

OBJECTIVE: To assess the use of health care services by inner-city infants enrolled in an early discharge program who received care in tertiary care children's hospital primary care clinic. DESIGN: Retrospective cohort study. SETTING: Large, metropolitan university hospital and a children's hospital. PATIENTS: Term infants cared for in a single full-term nursery, before and after implementation of a coordinated early discharge program, who received primary care at the children's hospital. INTERVENTION: The coordinated Early Discharge Program was characterized by in-hospital visits by hospital-based coordinating nurses, home visits by nurses from a home nursing agency, and communication with physicians for necessary adjustments in postdischarge care. METHODS: After linking birth hospital records and the children's hospital medical records, a retrospective chart review was performed to obtain maternal demographic information and birth hospital length of stay, as well as the infants' attendance at primary care clinic, immunizations, emergency department visits, and rehospitalization. MAIN OUTCOME MEASURES: Number of primary care visits in the first 3 months of life, completion of one series of immunizations by 3 months of life, and number of emergency department visits and rehospitalization during the first 3 months of life. RESULTS: The early discharge group (n = 253) had a significantly shorter birth hospital length of stay (35 +/- 24 hours, mean +/- SD) when compared with the control group (n = 212) (52 +/- 14 hours). The early discharge group was also younger than the control group at the first primary care visit, with significantly more infants visiting the primary care clinic in the first month of life. There was also a significant difference between the groups in the mean number of emergency department visits (early discharge = .61 visits/patient, control = .79 visits/patient) and the proportion of patients with no emergency department visits during the first 3 months of life (early discharge = 57%, control = 43%). There was no difference between the two groups in the proportion of infants completing one series of immunizations or in the number of infants rehospitalized during the study period. CONCLUSIONS: Coordinated early discharge with home nursing visits for inner-city infants may result in earlier use of primary care services. Furthermore, there is a significant decrease in use of the emergency department during the first 3 months of life, and no increase in rehospitalization.

Optimal gentamicin therapy in preterm neonates includes loading doses and early monitoring.

Recent studies have suggested the inadequacy of an initial gentamicin 2.5 mg/kg standard dose in neonates and the need for a loading dose. The purpose of this prospective, randomized study was to compare initial peak and initial trough serum gentamicin concentrations (SGC) in neonates after a standard dose (2.5 mg/kg) or a loading dose (4 mg/kg) on the first day of life. A secondary objective of the study was to evaluate the use of two SGC drawn after the first dose in designing individualized dosage regimens, despite the many changes in gentamicin disposition that occur over the first week of life. Forty infants admitted to the NICU were randomized to receive either 2.5 or 4 mg/kg gentamicin. Individual gentamicin pharmacokinetic parameters were determined after the first dose. Initial peak SGC were > 5 mcg/ml in only 6% of neonates receiving 2.5 mg/kg, versus 94% of neonates receiving 4 mg/kg. The initial trough after the first dose was < 2 mcg/ml in 100% of patients receiving 2.5 mg/kg and only 39% of patients receiving 4 mg/kg. Using two SGC after the first dose successfully predicted steady state peaks in 13/16 infants and steady state troughs in 14/16 infants. Thus, standard treatment of 2.5 mg/kg gentamicin yields initial peak serum gentamicin concentrations < 5 mcg/ml in neonates while a 4 mg/kg gentamicin loading dose, combined with pharmacokinetic monitoring after the first dose, optimizes gentamicin therapy in neonates.