The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits.

OBJECTIVE: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.

Hospital Observation Status and Readmission Rates.

BACKGROUND: In several states, payers penalize hospitals when an inpatient readmission follows an inpatient stay. Observation stays are typically excluded from readmission calculations. Previous studies suggest inconsistent use of observation designations across hospitals. We sought to describe variation in observation stays and examine the impact of inclusion of observation stays on readmission metrics. METHODS: We conducted a retrospective cohort study of hospitalizations at 50 hospitals contributing to the Pediatric Health Information System database from January 1, 2018, to December 31, 2018. We examined prevalence of observation use across hospitals and described changes to inpatient readmission rates with higher observation use. We described 30-day inpatient-only readmission rates and ranked hospitals against peer institutions. Finally, we included observation encounters into the calculation of readmission rates and evaluated hospitals' change in readmission ranking. RESULTS: Most hospitals (n = 44; 88%) used observation status, with high variation in use across hospitals (0%-53%). Readmission rate after index inpatient stay (6.8%) was higher than readmission after an index observation stay (4.4%), and higher observation use by hospital was associated with higher inpatient-only readmission rates. When compared with peers, hospital readmission rank changed with observation inclusion (60% moving at least 1 quintile). CONCLUSIONS: The use of observation status is variable among children's hospitals. Hospitals that more liberally apply observation status perform worse on the current inpatient-to-inpatient readmission metric, and inclusion of observation stays in the calculation of readmission rates significantly affected hospital performance compared with peer institutions. Consideration should be given to include all admission types for readmission rate calculation.

10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System.

BACKGROUND: In 2014, Children's National Health System's executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting. METHODS: Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting. RESULTS: Children's National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as "other" decreased from a baseline of 6% to 2%. CONCLUSIONS: Children's National Health System's focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.

Hospital readmission in children with complex chronic conditions discharged from subacute care.

OBJECTIVES: Children with complex chronic conditions (CCC) are responsible for a disproportionate number of hospital readmissions. This study sought to determine 30-day hospital readmission rates in children with CCC discharged from a rehabilitation and transitional care hospital and to identify factors associated with increased risk of readmission. METHODS: We conducted a retrospective cohort study identifying children with CCC discharged over an 18-month period from a subacute care facility staffed by hospitalists from a freestanding children's hospital. The primary outcome measure was readmission to the referring acute care hospital within 30 days of the subacute discharge. RESULTS: Of the 272 discharged patients meeting inclusion criteria as children with at least 1 CCC, 19% had at least 1 readmission within 30 days of discharge. On univariate analysis, readmission was associated with the number of home medications (P = .001), underlying chronic respiratory illness (P < .001), home apnea or pulse oximetry monitor use (P = .02), tracheostomy and/or ventilator dependence (P = .003), length of stay (P = .04), and number of follow-up appointments (P = .02). On multivariate analysis, the number of discharge medications was associated with increased odds of readmission (odds ratio: 1.11 [95% confidence interval: 1.03-1.20]; P = .01). Receiver operating curve analysis identified a cutoff of 8 medications as most associated with readmission; in patients discharged with ≥8 medications, the hospital readmission rate was 29%. CONCLUSIONS: This is the first known study that investigated hospital readmission rates in children with CCC discharged from a subacute facility and specifically identified the number of discharge medications as a significant risk factor for readmission.

Do we need this blood culture?

OBJECTIVES: This study describes blood culture collection rates, results, and microbiology laboratory charges for 4 leading pediatric inpatient diagnoses (asthma, bronchiolitis, pneumonia, and skin and soft tissue infection [SSTI]) in low-risk patients. METHODS: This retrospective cohort study was conducted at an urban, academic, quaternary children's hospital. The study period was from January 1, 2011, to December 31, 2011. Inclusion criteria were as follows: 6 months to 18 years of age and primary diagnosis of asthma (International Classification of Diseases, Ninth Revision [ICD-9] codes 493.91-493.92), bronchiolitis (ICD-9 codes 466.11 and 466.19), SSTI (ICD-9 codes 680.00-686.99), or pneumonia (community-acquired pneumonia; ICD-9 codes 481.00-486.00). Patients with complex chronic conditions were excluded. Data were collected via administrative billing data and chart review. Descriptive statistics were performed; χ(2) tests were used for categorical variables, and nonparametric tests were used for continuous variables because of non-normal distributions. RESULTS: Administrative data review included 5159 encounters, with 1629 (32%) inpatient encounters and 3530 (68%) emergency department/outpatient encounters. Twenty-one percent (n = 343) of inpatient encounters had blood cultures performed, whereas 3% (n = 111) of emergency department/outpatient encounters had blood culture testing performed. Inpatient blood culture utilization varied according to diagnosis: asthma, 4%; bronchiolitis, 15%; pneumonia, 36%; and SSTI, 46%. Charts were reviewed for all 343 inpatients with blood culture testing. Results of all the blood cultures obtained for asthma and bronchiolitis admissions were negative, with 98% and 99% negative or false-positive (contaminant) for SSTI and community-acquired pneumonia, respectively. The approximate financial impact of blood culture utilization (according to gross microbiology laboratory charges) approximated $100 000 over the year for all 4 diagnoses. CONCLUSIONS: There was a high rate of negative or false-positive blood culture results for these common inpatient diagnoses. In addition, there was a low rate of clinically significant true-positive (pathogenic) culture results. These results identify points of potential blood culture overutilization.

Pediatric early warning score at time of emergency department disposition is associated with level of care.

OBJECTIVE: The objective of this study was to determine the association between the Pediatric Early Warning Score (PEWS) at time of emergency department (ED) disposition and level of care. METHODS: We conducted a prospective observational study with a convenience sample of patients aged 0 to 21 years in the ED of an urban, tertiary care children's hospital between November 2010 and July 2011. Pediatric Early Warning Score data were obtained at time of ED disposition, and the disposition decision was collected from the electronic medical record. Multinomial logistic regression was used to determine the association between PEWS and disposition. RESULTS: The sample of 383 patients included 239 (62%) who were discharged, 126 (33%) admitted to acute care, and 18 (5%) admitted to intensive care. Assigned scores ranged from 0 to 9. Adjusting for triage level, a 1-point increase in PEWS increased the odds of acute care admission 48% relative to the odds of discharge (odds ratio, 1.48; 95% confidence interval, 1.25-1.76) and increased the odds of intensive care admission 41% relative to the odds of acute care admission (odds ratio, 1.41; 95% confidence interval, 1.13-1.76). Pediatric Early Warning Score of 1 or more had maximum discriminant ability for admission, and PEWS of 3 or greater had maximum discriminant ability for intensive care. Area under the receiver operator characteristic curve was 0.68 to detect need for admission for the entire sample and 0.80 among the 97 patients with respiratory complaints. CONCLUSIONS: Pediatric Early Warning Score is associated with the level of care at ED disposition but does not provide adequate sensitivity and specificity to be used in isolation. Performance characteristics are better for patients with respiratory complaints.

The Impact of a Parent Brochure on Perceptions of Their Child's Hospitalization.

BACKGROUND AND OBJECTIVE: The primary purpose of family-centered rounds (FCR) is to improve communication and family satisfaction with care. However, hospital satisfaction surveys continue to identify parental concerns about communication with the medical team. The goal of this study was to evaluate the impact of a new "Division of Hospital Medicine" brochure on parent (ie, caregiver) identification of physician names, understanding of FCR, and overall satisfaction with the hospitalist team. METHODS A prospective cohort study with historical controls compared parent responses on anonymous, self-administered predischarge surveys, before and after brochure implementation. A trifold brochure to explain physician roles, identify names of the attending and intern, and describe the purpose of FCR was provided to parents on admission. It included a photo card of hospitalist attending physicians and explanations of the role of a hospitalist and FCR. The brochure was available in English and Spanish. RESULTS The overall response rate was 83% (183 of 220). The intervention group of parents identified physician names more accurately and felt more comfortable in FCR, but there was no significant difference in satisfaction. There were no difference between the control and intervention groups in relation to language, inpatient transfer, or length of stay, but the preintervention group did include more patients never before hospitalized. CONCLUSIONS An informational brochure is a simple tool to improve physician identification and caregiver comfort with FCR. However, further research should explore other factors contributing to family satisfaction during hospitalization and the use of electronic media to provide the same information to families.