Comparison of length of stay for asthma by hospital type.

OBJECTIVE: To determine whether length of stay (LOS) for asthma admissions at a local university-affiliated children's hospital (UACH) is similar to that of community hospitals within the same county. METHODS: A retrospective analysis was performed using computerized hospital abstract records from 1989 through 1994. The study population was children 1 to 18 years old whose first or only hospitalization for a primary diagnosis of asthma occurred during the study period at either the UACH or one of the 17 community hospitals in King County, WA, that admit pediatric patients (n = 2491). Transfers and patients with chronic obstructive asthma or secondary diagnoses such as cystic fibrosis were not included in the study. Asthma patients were compared by sociodemographic and health risk characteristics such as age, sex, insurance status, and a comorbidity severity score. Differences between the two hospital populations were tested by chi2 and t tests. The effect of hospitalization at the UACH or the community hospitals on LOS was determined using analysis of covariance after adjusting for the sociodemographic and health risk covariates. RESULTS: Sixty-two percent (62%) of the asthma patients in the study population were discharged from the UACH. Compared with patients discharged from the community hospitals, the UACH patients were significantly younger, more often male, used public insurance, and resided in areas with lower median household incomes. The severity of comorbidities was not different between the two hospital groups. Overall, adjusted mean LOS was not significantly longer at the UACH (2.1 days) than at the community hospitals (2.0 days); however, adjusted mean LOS for specific subgroups, most notably poor children and those with public insurance, was significantly longer at the UACH. CONCLUSION: LOS for first or only asthma hospitalizations during 1989 through 1994 at the UACH was similar to local community hospitals within the same county. Specific subgroups of children were hospitalized for a longer period at the UACH, but children with private insurance and from areas with higher median household incomes had similar LOS, and presumably costs, at the UACH and the community hospitals.

The safety of newborn early discharge. The Washington State experience.

CONTEXT: While early discharge of newborns following routine vaginal delivery has become common practice, its safety has not been firmly established. OBJECTIVE: To assess the risk for rehospitalization following newborn early discharge. DESIGN: Population-based, case-control study. SETTING: Washington State linked birth certificate and hospital discharge abstracts covering 310578 live births from 1991 through 1994. PATIENTS: Case patients were 2029 newborns rehospitalized in the first month of life. Control subjects were 8657 randomly selected newborns not rehospitalized and frequency matched to case patients on year of birth. Cesarean deliveries, multiple births, and births at less than 36 weeks' gestation were not included. MAIN OUTCOME MEASURE: Stratified analyses and logistic regression were performed to assess the risk for rehospitalization within a month of birth after early discharge (<30 hours after birth) compared with later discharge (30-78 hours after birth). RESULTS: Seventeen percent of newborns were discharged early. Newborns discharged early were more likely to be rehospitalized within 7 days (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.11-1.47), 14 days (OR, 1.16; 95% CI, 1.03-1.32), and 28 days (OR, 1.12; 95% CI, 1.00-1.25) of discharge than newborns sent home later. Subgroups at increased risk for rehospitalization following early discharge included newborns born to primigravidas (OR,1.25; 95% CI, 1.07-1.45), mothers younger than 18 years (OR, 1.22; 95% CI, 0.79-1.91), and mothers with premature rupture of membranes (OR, 1.41; 95% CI, 0.85-2.36). Early discharge was also associated with an increased risk of readmission for jaundice, dehydration, and sepsis. CONCLUSION: Newborns discharged home early (<30 hours after birth) are at increased risk for rehospitalization during the first month of life.

Pediatric home health care in King County, Washington.

BACKGROUND: Pediatric home health care is one of the fastest growing segments of our health care system. However, our knowledge of the extent and quality of the services provided in this field is generally limited. Despite this shortcoming, pediatric health care providers are increasingly expected to participate in the home health care of their patients. OBJECTIVE: To describe the agencies and services that constitute pediatric home health care in a large metropolitan setting. METHODS: During the summer of 1995, home health care agencies in King County, WA, were surveyed if they had provided any pediatric services within the preceding 6 months. The agencies were queried about their characteristics and services provided, as well as referral and reimbursement sources. Survey data were supplemented by interviews with agency and state health personnel. RESULTS: Fourteen (88%) of the 16 agencies providing pediatric home health care services completed the survey. Agencies were predominantly for-profit, free-standing, and in business fewer than 10 years. Although there were uniform licensing requirements for agencies, no pediatric-specific regulations existed. In addition, many agencies lacked internal methods to ensure the provision of quality pediatric care. Eighty percent of all pediatric home health care services were provided by only 5 agencies. For intermittent (acute) services, agencies served approximately 450 children per month. The average number of visits per child was two, with 40% receiving only one visit. Services included skilled nursing (60%), infusion (27%), and respiratory therapy (9%). Maintenance (chronic) home health care services, for 156 chronically ill children, were provided almost exclusively by skilled nursing for an average of 9 hours per patient per day. The majority of referrals to agencies (75%) originated from health care providers, although a small number came from insurance companies or individual families. Reimbursement for intermittent care services was divided among commercial insurance (35%), captitated contracts (35%), and Medicaid (20%). In contrast, 90% of reimbursement for the chronically ill was from Medicaid. CONCLUSIONS: In King County, WA, pediatric home health care is predominantly an unregulated, for-profit industry, with most agencies having little actual experience in pediatric home health care. In addition, the unique features of pediatric home health care necessitate both a greater understanding of this field and the consideration of more specific guidelines.

Efficacy of cough suppressants in children.

To test the hypothesis that codeine and dextromethorphan are effective in alleviating the symptoms of acute cough, we conducted a randomized, controlled trial. Eligible patients were children 18 months to 12 years of age, seen in private pediatric practices, with significant night cough of less than 14 days' duration. Study patients were randomly selected to receive codeine, dextromethorphan, or placebo at bedtime for 3 consecutive nights. Outcomes were assessed by the use of a parent questionnaire rating the severity of symptoms at the initiation of therapy, and after each night of the study. Every patient had a cough score (range 0 to 4) and composite symptom score (range 0 to 9) computed for each day of the study. One hundred forty-one doses of study medication were evaluated in 49 patients, including 13 children receiving placebo, 19 dextromethorphan, and 17 codeine. Mean cough and composite symptom scores decreased in each of the three treatment groups on each day of the study; there were no significant differences. Regression analysis, with reduction in cough score as the outcome of interest, showed that neither dextromethorphan nor codeine was significantly more effective than placebo (p = 0.41 and 0.70, respectively). Reduction in cough score was positively correlated with the severity of cough at the start of treatment (p = 0.007). Our data suggest that, in the doses used, neither codeine nor dextromethorphan is superior to placebo in treating night cough in children.

Measurement of gestational cocaine exposure: sensitivity of infants' hair, meconium, and urine.

We studied the sensitivity of testing the newborn infant's hair, meconium, and urine in detecting gestational cocaine exposure. The infants were born to 59 women who were interviewed to determine their use of cocaine during pregnancy and whose hair was analyzed for the presence of cocaine. Regression analysis was used to evaluate the relationship between cocaine in newborn hair and in maternal hair. Radioimmunoassay of infants' hair and gas chromatography-mass spectrometry of meconium were more sensitive than immunoassay of urine (p less than 0.02), which failed to identify 60% of cocaine-exposed infants. The quantity of benzoylecgonine in the newborn infant's hair correlated best with the proximal-segment maternal hair, representing the last 12 weeks of antepartum hair growth (R = less than R less than 0.83). Approximately half (52%) of the variation in infants' hair was explained by variation in the proximal maternal hair segment. Correlation (R = 0.77) and explained variation (59%) improved slightly when premature infants (n = 9) were excluded. We conclude that analysis of the newborn infant's hair by radioimmunoassay or of meconium by gas chromatography-mass spectrometry is more sensitive than analysis by immunoassay of urine, and can detect fetal cocaine exposure that occurred during the last two trimesters of pregnancy.

Ten-year study of pediatric drownings and near-drownings in King County, Washington: lessons in injury prevention.

The factors associated with submersion events among less than 20-year-old persons that occurred in King County from 1974 to 1983 were studied to focus prevention efforts. Near-drowning (n = 103) and drowning (n = 96) victims were identified from medical examiners' reports, paramedics' reports, and hospital discharge registers. Annual incidence was 5.5; the mortality rate was 2.6 per 100,000 children. Although preschool-aged children had the largest incidence (12.8), followed by older adolescents (4.9), adolescents had the largest case fatality rate, 77%. Lake and river victims had the largest incidence, mortality, and case fatality rate; swimming pools, the smallest case fatality rate (25%). A total of 89% of all victims had absent or no supervision; victims supervised by lifeguards had a 42% case fatality rate. Prior seizures were part of the history of 7.5% of all victims; 25% of fatal submersions by adolescents were associated with alcohol. Bathtub submersions were associated with child abuse in three of 16 preschool-aged children and epilepsy in four of five older children. Certain age groups and sites combined had the greatest incidence: preschool-aged children in swimming pools, infants in bathtubs, teenagers in lakes and rivers. Incidence decreased in public and semipublic pools coincident with fencing regulations. These findings suggest prevention strategies: extending fencing requirements to private pools, discouraging alcohol consumption during water sports, changing bathing practices of epileptics, and improving lifeguard efficacy.

Umbilical cord separation in the normal newborn.

During a 13-month period, 363 infants were followed up through the first six weeks to determine the effect of perinatal factors (birth weight, gestational age, type of delivery, and pregnancy and neonatal complications) on umbilical cord separation. Also, breast-feedings and umbilical cord care were studied. Except for cesarean section deliveries, study infants were similar to all infants (N = 1474) admitted to the same nursery during the study period. Cord separation occurred from days three to 45, with a mean of 13.9 days. Infants born by cesarean section were found to have an increased interval for cord separation when compared with infants born vaginally (mean +/- SD, 15.9 +/- 5.0 days vs 12.9 +/- 4.2 days). In this study, delays in separation of the umbilical cord beyond 3 weeks of age was not associated with an increased risk of infection.

Fever as a predictor of infection in burned children.

Although children with burns often develop fevers, we have found no reports characterizing the course and duration of these fevers. To evaluate the predictive value of fever as an indicator of infection in burned children, we reviewed the hospital charts of all 223 children admitted to a regional burn center in the years 1979 through 1982. The highest temperature reading for each 8-hour period of the child's hospitalization was recorded. The highest mean temperature in burned children occurred at 38 to 96 hours after the burn injury; the peak temperatures appeared at the same time, regardless of whether the child had an infection. All of the 23 children with infections (100%) and 145 of the 200 without infections (73%) had a recorded temperature reading of 38.2 degrees C or higher within 2 weeks after their burn injury. When children less than 4 years, or children with more than 20% total body surface area burns were considered alone, the presence of a temperature greater than 38.2 degrees C was not significant in differentiating those with infections. Fever is not a specific predictor of infection in burned children; in children less than 4 years of age and in children with more than 20% burns, fever has no predictive value for the presence of infection. The physical examination is a reliable source of information about wound infection, sepsis, or other childhood infections, and should be the primary tool used in making the diagnosis of infection in burned children.

Pediatric patients in a regional burn center.

Because scald burns are reported to be the leading cause of burn injuries to children, little is written about other etiologies of burn injury in the pediatric literature. To test the hypothesis that burns from other etiologies are more serious and require longer hospitalizations than scald burns, a retrospective chart review was undertaken. The charts of all patients less than 16 years of age who were admitted to Harborview Medical Center Burn Unit in the years 1979 to 1984 were reviewed. Four hundred sixty-four children were admitted to the regional burn center during that time. We found that children under four years of age are at greatest risk for being hospitalized for thermal injury, that the burn most commonly occurs inside the home between 6 PM and midnight, and that scalds are the most common etiology for thermal injuries in children (54%). However, 46% of the burns resulting in admission to our burn center were from etiologies other than scald injury. There was no significant correlation between etiology of the burns and length of hospital stay, rate of infection, or need for excision and grafting. Thermal injuries to children from any etiology are serious; pediatric health care providers should be aware that children may be burned in a variety of ways and should direct some of their well-child visit time to the topic of burn prevention in the home.

The status of research in ambulatory pediatrics.

To investigate the status of clinical research in ambulatory pediatrics and to characterize those environments that produce the most research activities and receive funding for research, a questionnaire survey was undertaken of all ambulatory pediatrics programs in the United States and Canada (N = 143). Our response rate was 68%. We found that divisions of ambulatory pediatrics that conduct clinical research have more faculty with formal research training, faculty with more time devoted to research endeavors, a designated research coordinator, research funding, and regular research seminars. Divisions of ambulatory pediatrics that have funding for research have more faculty with formal research training, fellows, a designated research coordinator, and regular research seminars. Funding for research is a more influential factor in producing clinical research than the number of faculty members in the division. The most frequently mentioned barrier to doing research was lack of time. Divisions of ambulatory pediatrics must continue to stress formal research training, faculty time set aside for research, and skills in grant writing if they hope to compete for academic recognition in the years ahead.

Multiple pulmonary complications in a patient with Stevens-Johnson syndrome.

Since first described in 1922, Stevens-Johnson syndrome has been associated frequently with pneumonia of many etiologies. This "mucosal respiratory syndrome," first reported by Stanyon and Warner in 1945, is associated with "early" pneumonia which resolves 2 to 3 weeks after onset of the rash. In our patient, pneumonia began 10 days after rash onset and was nearly resolved by day 20. The unique feature of this case was the onset of late pulmonary complications 25 days after the appearance of the exanthem, manifesting as acute noninfectious interstitial disease with superimposed airway obstruction.

Pediatric residents' attitudes and cognitive knowledge, and faculty ratings.

We compared pediatric residents' psychosocial attitude, personality, and in-training examination (American Board of Pediatrics) scores with faculty evaluations of the residents' clinical performance (clinical skills, medical knowledge, interpersonal skills and relationship with other staff) in inpatient, outpatient, and intensive care settings. We found no relationship between psychosocial attitudes and the in-training examination scores or among aggregate faculty ratings, attitudes, and examination scores, but faculty ratings grouped by setting yielded more discriminating results. On inpatient rotations, cognitive knowledge (as reflected by in-training examination scores) was positively correlated with faculty ratings. On intensive care and outpatient rotations, knowledge did not correlate with faculty ratings. Residents' attitudes favoring a psychosocial approach to medical practice were associated with positive evaluations on outpatient rotations but with negative evaluations on intensive care rotations. Psychosocial attitudes seemed to be determined by the social orientation of the resident's personality styles. Our results emphasize the importance of clinical setting to faculty rating and suggest that valued resident characteristics vary by setting. These findings have significant implications for both improving the clinical evaluation of residents and creating a better understanding of the interaction of personality, attitude, and cognitive variables in rated clinical performance.

Etiology of cervical lymphadenitis in children.

Thirty children under 17 years of age with cervical lymphadenopathy were evaluated. Lymphadenitis was attributed to Group A beta-hemolytic streptococci in 10 of the patients (33 percent), to Staphylococcus aureus in four and to infectious mononucleosis in four. Two patients had both infectious mononucleosis in Group A beta-hemolytic streptococci. One child was affected with Acinetobacter with calcoaceticus (mima) and another with mycobacteria. In eight children (27 percent), no etiologic agent could be found.

Public attitudes toward some changes in the division of labor in medicine.

This study examined public attitudes toward the delegation of medical tasks to nonphysician health workers. Data were obtained in household interviews of a probability sample of the adult residents of Cuyahoga County, Ohio (N = 808). The proportions of the sample giving approval to care from nonphysicians varied widely among the 18 tasks on which opinions were elicited. The results of the public survey were compared to those from an earlier national survey of physicians. Physicians' responses paralleled the responses of the lay public regarding most tasks. However, with respect to regular checkups on babies and prenatal checkups, markedly higher proportions of the physicians than the public were willing to delegate to nonphysicians. The analysis indicated that public attitudes toward task delegation in medical practice do not bear strong relationships to social status indicators, political self-designations, or preceived health status.

Postgraduate training in ambulatory pediatrics. Program evaluation.

Ambulatory pediatric, adolescent medicine, and child development fellowship programs listed in the Ambulatory Pediatric Association (APA) newsletter were surveyed to gather information about the programs for prospective fellows, to develop a descriptive summary, and to determine the extent to which programs adhere to APA guidelines. Number and types of positions offered, criteria for admission to programs, program educational objectives and activities, and career choice of graduates were examined for the 73 programs offering 132 fellowship positions in 1976 to 1977. In general, APA guidelines were followed. Programs emphasized patient care experience in contrast to health care administration, research, and teaching.

Work settings and job satisfaction: a study of primary care physicians and paramedical personnel.

This paper examines job satisfaction of primary care physicians and paramedical personnel in traditional office practices and in modern medical organizations. A series of two-way analyses of variance using work settings and occupational level as independent variables showed consistent effects of setting on job satisfaction. In modern organizational settings satisfaction with the work activity, with coworkers, and with income was lower than in traditional practices. Only with respect to income, were physicians, on the average, more satisfied than paramedical workers. The relationships between job satisfaction and the variety and complexity of work as well as ownership of work settings are analyzed and discussed.