The Future of Inpatient Community Hospital Care: Is There One?

Community hospital inpatient pediatric programs face a variety of challenges including financial instability, variable censuses, difficulty maintaining qualified staff, and a lack of focus for the hospital. With the addition of new payment models, such as bundled payments and global budgets, along with a global pandemic, the future of community hospital pediatric inpatient care is uncertain at best. In this article we summarize the challenges, opportunities, and potential solutions to maintaining high-quality care for hospitalized children in community hospitals.

A Hospital-Based Initiative to Reduce Postdischarge Sudden Unexpected Infant Deaths.

BACKGROUND AND OBJECTIVES: Sudden unexpected infant deaths (SUID) most often occur because infants are placed in unsafe sleep environments. Although authors of previous literature have demonstrated that parents who receive comprehensive safe sleep education increase knowledge and intention to place children in safe sleep environments, no studies have demonstrated improved outcomes. We describe the development of a hospital-based newborn SUID risk reduction quality improvement project and its effectiveness in reducing subsequent SUIDs in a community using linked outcome data from local Child Fatality Review Teams. METHODS: Qualitative and quantitative evaluation of a long-term iterative performance improvement intervention for a nursery-based comprehensive safe sleep program in a community teaching hospital. Key themes and exemplary comments were noted. The rate of infant deaths per 1000 births was the primary quantitative outcome. The rate is calculated quarterly and monitored with control charts by using Child Fatality Review data about infant sleep deaths. RESULTS: The average death rate fell from 1.08 infants per 1000 births preintervention to 0.48 infants per 1000 births after complete intervention, and the average number of deaths between deliveries increased from 1 in every 584 deliveries (upper control limit: 3371) to 1 in every 1420 deliveries (upper control limit: 8198). Qualitative observation of nursery providers revealed 3 themes, including routine inclusion of sleep safety information, dissemination of safety information by all staff, and personal commitment to success. CONCLUSIONS: A comprehensive sleep safety culture change can be effectively integrated into a nursery setting over time by using feedback from Child Fatality Review and performance improvement methodology. Repeated messaging and education by the entire nursery staff has the potential to play a role in reducing sleep-related deaths in infants born at their hospital.

Changes in Asthma Maintenance Therapy Prescribing Patterns Following the 2006 Long-acting ß-Agonist FDA Drug Warning.

PURPOSE: The US Food and Drug Administration issued a boxed warning on all products containing a long-acting ß-agonist (LABA) in March 2006, after the findings from a trial suggested an increased risk for death in patients treated with salmeterol monotherapy. Almost nothing is known about the impact of this warning on LABA prescribing patterns or on clinicians' approaches to asthma maintenance therapy. METHODS: A cohort of asthmatic adults on LABA therapy was retrospectively identified from a Baltimore-area Medicaid data warehouse. Pharmacy claims were used for determining the utilization rates of all asthma maintenance medications. Rates from the 6-month period before the warning (September 1, 2005, to February 28, 2006) were compared with rates from a similar 6-month period 1 year afterward (September 1, 2006, to February 28, 2007). The demographic characteristics of patients who continued LABA use were compared with those of discontinuers. In LABA discontinuers, utilization of alternative maintenance drugs was assessed. FINDINGS: In this cohort of 455 asthmatic patients, LABAs were prescribed only in combination with inhaled corticosteroids. Following the warning, 53% of patients discontinued LABA use, and the mean number of LABA prescription fills per patient decreased from 2.6 to 1.8 (P < 0.0001). Concurrently, the use of inhaled corticosteroids increased from 0.3 to 0.8 fills per patient (P < 0.0001). LABA continuers were younger (P = 0.0005), more likely to be black (P = 0.0079), and more consistent with LABA fills prewarning (P < 0.0001). Of the 243 LABA discontinuers, 155 were placed on no alternative maintenance therapy. IMPLICATIONS: The management of asthma changed significantly after the LABA warning. The use of LABAs combined with inhaled corticosteroids plummeted, while the use of inhaled corticosteroid monotherapy increased. More than half of patients who discontinued LABAs were not placed on alternative maintenance therapy.

Improving infant sleep safety through a comprehensive hospital-based program.

We evaluated a comprehensive hospital-based infant safe sleep education program on parental education and safe sleep behaviors in the home using a cross-sectional survey of new parents at hospital discharge (HD) and 4-month follow-up (F/U). Knowledge and practices of infant safe sleep were compared to the National Infant Sleep Position Study benchmark. There were 1092 HD and 490 F/U surveys. Supine sleep knowledge was 99.8% at HD; 94.8% of families planned to always use this position. At F/U, 97.3% retained supine knowledge, and 84.9% maintained this position exclusively (P < .01). Knowledge of crib as safest surface was 99.8% at HD and 99.5% F/U. Use in the parents' room fell to 91.9% (HD) and 68.2% (F/U). Compared to the National Infant Sleep Position Study, the F/U group was more likely to use supine positioning and a bassinette or crib. Reinforcing the infant sleep safety message through intensive hospital-based education improves parental compliance with sudden infant death syndrome risk reduction guidelines.

Advocacy and child neglect.

Pediatricians have a unique opportunity to intervene in the lives of children to identify and to prevent neglect. While it remains important to care for individual patients affected by neglect, the ecological model of child neglect requires intervention at the parent, family, community, and societal levels. Pediatricians can improve the outcomes for children by advocating for policies and interventions at each level. Effective advocacy principally requires the willingness to tackle broader issues beyond individual clinical care. Working with local, state, and national organizations, pediatricians can contribute a unified voice to promote evidence-based policies and programs that improve the well-being of children.

Variability of the institutional review board process within a national research network.

OBJECTIVE: To determine the variability of the institutional review board (IRB) process for a minimal risk multicenter study. METHODS: Participants included 24 Continuity Research Network (CORNET) sites of the Academic Pediatric Association that participated in a cross-sectional study. Each site obtained individual institutional IRB approval. An anonymous questionnaire went to site investigators about the IRB process at their institution. RESULTS: Twenty-two of 24 sites (92%) responded. Preparation time ranged from 1 to 20 hours, mean of 7.1 hours. Individuals submitting ≤3 IRB applications/year required more time for completion than those submitting >3/year (P < .05). Thirteen of 22 (59%) study sites received approval with "exempt" status, and 6 (27%) approved as "expedited" studies. CONCLUSIONS: IRB experiences were highly variable across study sites. These findings indicate that multicenter research projects should anticipate barriers to timely study implementation. Improved IRB standardization or centralization for multicenter clinical studies would facilitate this type of practice-based clinical research.

Effect of focused debriefing on team communication skills.

BACKGROUND AND OBJECTIVE: Community hospitals often lack tertiary care support such as pediatric intensivists and anesthesiologists. Resuscitation of critically ill and injured children in community hospitals requires a well-coordinated team effort, because good team performance improves quality of care. The lack of subspecialty support makes team coordination and communication more imperative yet much more challenging. This study sought to determine if the addition of a defined focused post-mock code debriefing session improved communication skills among team members in a community pediatric emergency department. METHODS: Twenty-two volunteer members of the pediatric emergency and respiratory therapy departments at Medstar Franklin Square Medical Center took part in monthly simulated resuscitations for 3 consecutive months. After each simulation, participants answered an 18-item survey on observed communication among their team members. Members then participated in a 30-minute debriefing session in which they reflected on their own communication skills. A video taping of the resuscitation was later scored by one of the investigators by using a rubric designed by the investigators. Descriptive statistics were calculated for both the participant survey and the team communication indicator scores. Paired-sample Wilcoxon signed rank test examined the difference in the scores between each of 3 sessions. RESULTS: The mean scores by investigator-scored video recordings of the teams' mock resuscitation by session showed overall team communication improved between sessions 1 and 3 for all communication areas (P = .03), with significant improvement in 4 of 9 communication areas by the third session. All team members improved communication skills as well, with the greatest improvement by the clinical multifunctional technicians. CONCLUSIONS: Communication skills improve with the addition of focused debriefing sessions after mock codes as perceived by participants during debriefing sessions and evidenced by investigator-scored video recordings of resuscitations.

Newborn adiposity by body mass index predicts childhood overweight.

OBJECTIVE: To evaluate the association between adiposity at birth and in infancy with overweight at age 5 years. This study hypothesizes that adiposity at birth as approximated by body mass index (BMI) predicts childhood fatness. METHODS: Anthropomorphic data from birth to 5 years were used to calculate BMI percentiles. Multiple logistic regression assessed the association between BMI percentile > or =85% at 2 weeks and BMI percentile > or =85% at 6, 12, 36, and 60 months. RESULTS: Elevated BMI at age 2 weeks > or =85th percentile was associated with significant increases in risk of overweight at 6, 12, 36, and 60 months of age. Infants with a BMI at age 2 weeks > or =85th percentile had an adjusted odds ratio of 3.42 (95% confidence interval [CI] = 1.79, 6.50) and an adjusted risk ratio of 2.12 (95% CI = 1.71, 2.61) of being overweight at 60 months of age. CONCLUSIONS: Adiposity at birth as approximated by BMI is a significant predictor of overweight at 5 years.

Gender disparity in women's health training at a family medicine residency program.

BACKGROUND AND OBJECTIVES: Women's health services are an important part of the practice of family medicine. Anecdotally, family medicine residents' training experience in certain aspects of women's health differs based on the trainees' gender. METHODS: We conducted 5-year retrospective evaluation of acute and preventive women's health encounters at one site. Total number of visits, type of visits, and visits by resident year were compared between male and female residents. We also compared mean women's health in-service examination training scores, by year of training, for male and female residents. RESULTS: Male residents cared for a total 13% of the 3,415 women's health visits while female residents performed 59.5% of the visits; the remainder of visits were to faculty and other practitioners. Female resident physicians cared for 86% of all preventive and 91% of all acute women's health visits performed by residents. Female residents also had a significantly higher mean number of women's health visits per resident than did male residents (63 versus 20). Female residents' mean score of 56.8 (95% CI=51.1--62.0) on the women's health section of the in-service exam was significantly higher than male residents' mean score of 41.7 (95% CI=34.9--48.5). CONCLUSIONS: This study demonstrates discrepancies by gender in the exposure of family medicine residents to women's health cases and their knowledge about women's health.

Does quality of primary care vary by level of training in pediatric resident continuity practices?

OBJECTIVE: The aim of this study was to compare parental perception of quality of care provided by first- versus third-year pediatric residents who served as their children's primary care providers. METHODS: The Parents' Perception of Primary Care (P3C) survey was administered to all parents who identified a pediatric resident as a primary care provider at 19 Continuity Research Network (CORNET) sites. Parent survey scores were compared between those identifying first-year pediatric residents (PL-1) versus third-year pediatric residents (PL-3) as care providers by using t tests and linear regression modeling, as well as item-specific chi-square analysis and logistic regression. RESULTS: Comparing the responses of the 347 parents who identified a PL-3 resident and the 360 parents who identified a PL-1 resident as their child's primary care provider, those who identified a PL-3 resident rated their childrens overall care higher, with a mean score of 79.2 (95% confidence interval [95% CI] 77.5-80.8) as compared to 75.9 (95% CI 74.4-77.3); P < .05. This disparity was primarily due to differences in the longitudinal continuity domain. Comparisons of the other domains of communication, comprehensiveness, access, contextual knowledge, and coordination showed no statistically significant differences between the 2 groups. Parents rated PL-3 residents as having greater knowledge in behavioral counseling and coordination with schools than PL-1 residents. CONCLUSIONS: Parents rated residents at both training levels very highly for the quality of care provided. PL-3 residents had higher longitudinal continuity scores and were perceived to have greater knowledge about behavioral counseling and coordination of care with schools. Further research will need to elucidate strategies to improve earlier resident acquisition of coordination and behavior management skills.

Spanish-speaking patients perceive high quality care in resident continuity practices: a CORNET study.

Prior research has demonstrated that limited English proficiency in Hispanic patients is associated with adverse health outcomes. The authors sought to compare the perception of primary care in resident practices between Spanish-speaking and English-speaking parents using a previously validated tool, the Parents' Perception of Primary Care. Using survey results from 19 CORNET sites nationwide, they compared mean scores for each primary care domain and the full scale between the groups using Student's t test. Multiple linear regression models compared outcomes controlling for demographic variables. Of the 2122 analyzable surveys, 490 (23%) were completed in Spanish and 1632 (77%) in English. The mean scores for each domain and the total scale were not statistically different between the 2 groups. After adjustment, Spanish-speaking parents rated communication significantly higher. Resident clinics may use systems to provide high quality care to Spanish-speaking patients, which may help other sites improve care.