Accuracy of hospital administrative data in reporting central line-associated bloodstream infections in newborns.

OBJECTIVES: Central line-associated bloodstream infections (CLABSIs) are a significant source of morbidity and mortality in the NICU. In 2010, Medicaid was mandated not to pay hospitals for treatment of CLABSI; however, the source of CLABSI data for this policy was not specified. Our objective was to evaluate the accuracy of hospital administrative data compared with CLABSI confirmed by an infection control service. METHODS: We evaluated hospital administrative and infection control data for newborns admitted consecutively from January 1, 2008, to December 31, 2010. Clinical and demographic data were collected through chart review. We compared cases of CLABSI identified by administrative data (International Classification of Diseases, Ninth Revision, Clinical Modification 999.31) with infection control data that use national criteria from the Centers for Disease Control and Prevention as the gold standard. To ascertain the nature possible deficiencies in the administrative data, each patient's medical record was searched to determine if clinical phrases that commonly refer to CLABSI appeared. RESULTS: Of 2920 infants admitted to the NICU during our study period, 52 were identified as having a CLABSI: 42 by infection control data only, 7 through hospital administrative data only, and 3 appearing in both. Against the gold standard, hospital administrative data were 6.7% sensitive and 99.7% specific, with a positive predictive value of 30.0% and a negative predictive value of 98.6%. Only 48% of medical records indicated a CLABSI. CONCLUSIONS: Our findings from a major children's hospital NICU indicate that International Classification of Diseases, Ninth Revision, Clinical Modification code 993.31 is presently not accurate and cannot be used reliably to compare CLABSI rates in NICUs.

Comparison of Administrative Data Versus Infection Control Data in Identifying Central Line-Associated Bloodstream Infections in Children's Hospitals.

OBJECTIVE: As of July 2012, the Centers for Medicare and Medicaid Services prohibited state Medicaid programs from paying for medical care related to certain provider-preventable conditions. The most prevalent provider-preventable condition in pediatrics is central line-associated bloodstream infections (CLABSIs), which cause significant morbidity and mortality. The objective of this study was to compare the uses of administrative data and infection control data in measuring CLABSIs. METHODS: Retrospective chart reviews were performed in 3 children's hospitals to compare CLABSIs identified according to administrative data diagnostic coding versus infections identified by hospital infection control departments. Clinical criteria from the Centers for Disease Control and Prevention and reported to the National Healthcare Safety Network were used. RESULTS: A total of 166 CLABSIs were identified in 35 698 discharges in the 3 children's hospitals in 2010. Using the Centers for Disease Control and Prevention criteria as the standard, administrative data had 34.78% sensitivity and 99.92% specificity. The positive predictive value was 63.16% whereas the negative predictive value was 99.75%. CONCLUSIONS: Administrative data and National Healthcare Safety Network criteria identify discordant numbers of CLABSIs.

Evaluation of the agency for healthcare research and quality pediatric quality indicators.

OBJECTIVES: Pediatric quality indicators were developed in 2006 by the Agency for Healthcare Research and Quality to identify potentially preventable complications in hospitalized children. Our objectives for this study were to (1) apply these algorithms to an aggregate children's hospital's discharge abstract database, (2) establish rates for each of the pediatric quality indicator events in the children's hospitals, (3) use direct chart review to investigate the accuracy of the pediatric quality indicators, (4) calculate the number of complications that were already present on admission and, therefore, not attributable to the specific hospitalization, and (5) evaluate preventability and calculate positive predictive value for each of the indicators. In addition, we wanted to use the data to set priorities for ongoing clinical investigation. METHODS: The Agency for Healthcare Research and Quality pediatric quality indicator algorithms were applied to 76 children's hospital's discharge abstract data (1794675 discharges) from 2003 to 2005. Rates were calculated for 11 of the pediatric quality indicators from all 3 years of discharge data: accidental puncture or laceration, decubitus ulcer, foreign body left in during a procedure, iatrogenic pneumothorax in neonates at risk, iatrogenic pneumothorax in nonneonates, postoperative hemorrhage or hematoma, postoperative respiratory failure, postoperative sepsis, postoperative wound dehiscence, selected infections caused by medical care, and transfusion reaction. Subsequently, clinicians from 28 children's hospitals reviewed 1703 charts in which complications had been identified. They answered questions as to correctness of secondary diagnoses that were associated with the indicator, whether a complication was already present on admission, and whether that complication was preventable, nonpreventable, or uncertain. RESULTS: Across 3 years of data the rates of pediatric quality indicators ranged from a low of 0.01/1000 discharges for transfusion reaction to a high of 35/1000 for postoperative respiratory failure, with a median value of 1.85/1000 for the 11 pediatric quality indicators. Indicators were often already present on admission and ranged from 43% for infection caused by medical care to 0% for iatrogenic pneumothorax in neonates, with a median value of 16.9%. Positive predictive value for the subset of pediatric quality indicators occurring after admission was highest for decubitus ulcer (51%) and infection caused by medical care (40%). Because of the very large numbers of cases identified and its low preventability, the indicator postoperative respiratory failure is particularly problematic. The initial definition includes all children on ventilators postoperatively for >4 days with few exclusions. Being on a ventilator for 4 days would be a normal occurrence for many children with extensive surgery; therefore, the majority of the time does not indicate a complication and makes the indicator inappropriate. CONCLUSIONS: A subset of pediatric quality indicators derived from administrative data are reasonable screening tools to help hospitals prioritize chart review and subsequent improvement projects. However, in their present form, true preventability of these complications is relatively low; therefore, the indicators are not useful for public hospital comparison. Identifying which complications are present on admission versus those that occur within the hospitalization will be essential, along with adequate risk adjustment, for any valid comparison between institutions. Infection caused by medical care and decubitus ulcers are clinically important indicators once the present-on-admission status is determined. These complications cause significant morbidity in hospitalized children, and research has shown a high level of preventability. The pediatric quality indicator software can help children's hospitals objectively review their cases and target improvement activities appropriately. The postoperative-respiratory-failure indicator does not represent a complication in the majority of cases and, therefore, should not be included for hospital screening or public comparison. Chart review should become part of the development process for quality indicators to avoid inappropriate conclusions that misdirect quality-improvement resources.

Implementing pediatric growth charts into an electronic health record system.

Electronic health record (EHR) systems are increasingly being adopted in pediatric practices; however, requirements for integrated growth charts are poorly described and are not standardized in current systems. The authors integrated growth chart functionality into an EHR system being developed and installed in a multispecialty pediatric clinic in an academic medical center. During a three-year observation period, rates of electronically documented values for weight, stature, and head circumference increased from fewer than ten total per weekday, up to 488 weight values, 293 stature values, and 74 head circumference values (p<0.001 for each measure). By the end of the observation period, users accessed the growth charts an average 175 times per weekday, compared to 127 patient visits per weekday to the sites that most closely monitored pediatric growth. Because EHR systems and integrated growth charts can manipulate data, perform calculations, and adapt to user preferences and patient characteristics, users may expect greater functionality from electronic growth charts than from paper-based growth charts.

Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for children's hospitals.

OBJECTIVES: Patient safety indicators (PSIs) were developed by the Agency for Healthcare Research and Quality. Our objectives were (1) to apply these algorithms to the National Association of Children's Hospitals and Related Institutions (NACHRI) Aggregate Case Mix Comparative Database for 1999-2002, (2) to establish mean rates for each of the PSI events in children's hospitals, (3) to investigate the inadequacies of PSIs in relation to pediatric diagnoses, and (4) to express the data in such a way that children's hospitals could use the PSIs determined to be appropriate for pediatric use for comparison with their own data. In addition, we wanted to use the data to set priorities for ongoing clinical investigations and to propose interventions if the indicators demonstrated preventable errors. METHODS: The Agency for Healthcare Research and Quality PSI algorithms (version 2.1, revision 1) were applied to children's hospital administrative data (1.92 million discharges) from the NACHRI Aggregate Case Mix Comparative Database for 1999-2002. Rates were measured for the following events: complications of anesthesia, death in low-mortality diagnosis-related groups (DRGs), decubitus ulcer, failure to rescue (ie, death resulting from a complication, rather than the primary diagnosis), foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care (ie, infections related to surgery or device placement), postoperative hemorrhage or hematoma, postoperative pulmonary embolism or venous thrombosis, postoperative wound dehiscence, and accidental puncture/laceration. RESULTS: Across the 4 years of data, the mean risk-adjusted rates of PSI events ranged from 0.01% (0.1 event per 1000 discharges) for a foreign body left in during a procedure to 14.0% (140 events per 1000 discharges) for failure to rescue. Review of International Classification of Diseases, Ninth Revision, Clinical Modification codes associated with each PSI category showed that the failure to rescue and death in low-mortality DRG indicators involved very complex cases and did not predict preventable events in the majority of cases. The PSI for infection attributable to medical care appeared to be accurate the majority of the time. Incident risk-adjusted rates of infections attributable to medical care averaged 0.35% (3.5 events per 1000 discharges) and varied up to fivefold from the lowest rate to the highest rate. The highest rates were up to 1.8 times the average. CONCLUSIONS: PSIs derived from administrative data are indicators of patient safety concerns and can be relevant as screening tools for children's hospitals; however, cases identified by these indicators do not always represent preventable events. Some, such as a foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care, decubitus ulcer, and venous thrombosis, seem to be appropriate for pediatric care and may be directly amenable to system changes. Evidence-based practices regarding those particular indicators that have been reported in the adult literature need to be investigated in the pediatric population. In their present form, 2 of the indicators, namely, failure to rescue and death in low-mortality DRGs, are inaccurate for the pediatric population, do not represent preventable errors in the majority of pediatric cases, and should not be used to estimate quality of care or preventable deaths in children's hospitals. The PSIs can assist institutions in prioritizing chart review-based investigations; if clusters of validated events emerge in reviews, then improvement activities can be initiated. Large aggregate databases, such as the NACHRI Case Mix Database, can help establish mean rates of potential pediatric events, giving children's hospitals a context within which to examine their own data.

Clinical redesign using all patient refined diagnosis related groups.

OBJECTIVE: Clinical redesign of processes in hospitals that care for children has been limited by a paucity of severity-adjusted indicators that are sensitive enough to identify areas of concern. This is especially true of hospitals that analyze pediatric patient care using standard Centers for Medicare and Medicaid Services (CMS) diagnosis-related groups (DRGs). The objectives of this study were to determine whether 1) utilization of all-patient refined (APR)-DRG severity-adjusted indicators (length of stay, cost per case, readmission rate) from the National Association of Children's Hospitals and Related Institutions (NACHRI) database could identify areas for improvement at University of Michigan Mott Children's Hospital (UMMCH) and 2) hospital staff could use the information to implement successful clinical redesign. METHODS: The APR-DRG Classification System (version 20) was used with the NACHRI Case Mix Comparative Database by severity level comparison from 1999 to 2002. Indicators include average length of stay (ALOS), case mix index, cost per case, and readmission rate for low acuity asthma (APR-DRG 141.1). UMMCH cases of 141.1 (n = 511) were compared with NACHRI 141.1 (n = 64,312). Although not part of the standard report, mortality rates were calculated by NACHRI for UMMCH and an aggregate of NACHRI member children's hospitals. RESULTS: Data from 1999 revealed that in noncomplicated asthma cases (level 1 severity), the UMMCH ALOS versus NACHRI ALOS was slightly longer (UMMCH 2.16 days vs NACHRI 2.14 days), and the cost per case was higher (UMMCH $2824 vs NACHRI 2738 dollars), whereas levels 2, 3, and 4 cases (moderate, major, and extreme severity) indicated the ALOS and cost per case were lower than the national aggregate. This showed that the APR-DRG system was sensitive enough to distinguish variances of care within a diagnosis according to severity level. After analysis of internal data and meeting with clinicians to review the indicators, 3 separate clinical processes were targeted: 1) correct documentation of comorbidities and complications, 2) standardized preprinted orders were created with the involvement of the pediatric pulmonologists, and 3) standardized automatic education for parents was started on the first day of admission. Yearly data were reviewed and appropriate adjustments made in the education of both residents and staff. In 2002, the UMMCH ALOS dropped to 1.75 +/- .08 days from 2.16 +/- .09. In 2002, the NACHRI ALOS was 2.00 days +/- 0.01 versus the UMMCH ALOS of 1.75 days +/- 0.0845, indicating that the UMMCH ALOS dropped significantly lower than the NACHRI aggregate database over the 3-year period. Cost per case of UMMCH compared with NACHRI after the 3 years indicated that UMMCH increased 12%, whereas the NACHRI aggregate increased 18%. These data show that length of stay and cost per case relative to the national database improved after clinical redesign. Improvements have been sustained throughout the 3-year period. Readmission rates ranged from 2.97% to 0.80% and were less than the national cohort by the third year. There were no mortalities in the UMMCH inpatient asthma program. This demonstrates that clinicians believed that the data from the APR-DRG acuity-adjusted system was useful and that they were then able to apply classical clinical redesign strategies to improve cost-effectiveness and quality that was sustained over 3 years. CONCLUSIONS: Severity-adjusted indicators were useful for identifying areas appropriate for clinical redesign and contributed to the improvement in cost-effective patient care without a detriment in quality indicators. This method of using a large comparative database, having measures of severity, and using internal analysis is generalizable for pediatric hospitals and can contribute to ongoing attempts to improve cost-effectiveness and quality in medical care.

Improved growth in young children with severe chronic renal insufficiency who use specified nutritional therapy.

Growth in children with chronic renal failure caused by polyuric, salt-wasting diseases may be hampered if ongoing sodium and water losses are not corrected. Twenty-four children were treated with polyuric chronic renal insufficiency (CRI; creatinine clearance <65 ml/min per 1.73 m(2)) with low-caloric-density, high-volume, sodium-supplemented feedings. Subsequent growth was compared with that of children in two control groups: a national historic population control from the US Renal Data System database (n = 42), and a literature control (n = 12). Members of the three groups were 81 to 96% white, and 58 to 70% were boys. Obstructive uropathy and dysplasia were the cause of CRI in 92% of the treatment group, 75% of the literature control group, and 30% of the population control group. Treatment effect was assessed in a multivariate, retrospective analysis of the height standard deviation score (SDS), simultaneously controlling for the severity of disease by renal replacement therapy, primary cause of CRI, and initial height SDS. The change in SDS (Delta SDS) for height by regression analysis at 1 yr was significantly greater by +1.37 in the treatment group versus the population control (P = 0.017). The 2-yr height Delta SDS by regression analysis adjusted for creatinine clearance was significantly greater by +1.83 in the treatment group versus the literature control (P = 0.003). Nutritional support with sodium and water supplementation can maintain or improve the growth of children with polyuric, salt-wasting CRI. This inexpensive intervention may delay the need for renal replacement therapy, growth hormone treatment, or both in many of these children and may be used in any clinical setting.