Comparison of Clinical Risk Factors Among Pediatric Patients With Single Admission, Multiple Admissions (Without Any 7-Day Readmissions), and 7-Day Readmission.

BACKGROUND AND OBJECTIVE: Readmissions have received increasing attention. The goal of this study was to identify demographic and clinical factors associated with hospital utilization and 7-day readmissions. METHODS: This retrospective case-control study of inpatient and observation encounters was conducted at a freestanding children's hospital. Over a 1-year period, patients were categorized into 3 groups: patients with a single admission, patients with multiple admissions without any 7-day readmissions, and patients with at least one 7-day readmission. Factors associated with risk of future hospital utilization were determined, and post hoc testing was performed to compare groups. RESULTS: Patients with a single admission had statistically significant lower numbers of medications at admission and discharge, lower rates of home health care at admission and discharge, and fewer diagnosis codes during index admission than patients with multiple admissions. There were no statistically significant differences among patients with multiple admissions between those with and without 7-day readmissions. CONCLUSIONS: This study found that patients with multiple admissions were similar regardless of whether they had any 7-day readmissions. Because patients with multiple admissions seemed to represent a single high-risk group, it is possible that many readmissions represent a consequence of medical complexity rather than a failure of care. Further studies are necessary to determine if providing targeted interventions to high-risk patients will lower their future hospital utilization.

Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock.

BACKGROUND: The Institute of Medicine has called for the development of clinical guidelines and practice parameters to develop "best practice" and potentially improve patient outcome. OBJECTIVE: To provide American College of Critical Care Medicine clinical guidelines for hemodynamic support of neonates and children with septic shock. SETTING: Individual members of the Society of Critical Care Medicine with special interest in neonatal and pediatric septic shock were identified from literature review and general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (1998-2001). METHODS: The MEDLINE literature database was searched with the following age-specific keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, and extracorporeal membrane oxygenation. More than 30 experts graded literature and drafted specific recommendations by using a modified Delphi method. More than 30 more experts then reviewed the compiled recommendations. The task-force chairman modified the document until <10% of experts disagreed with the recommendations. RESULTS: Only four randomized controlled trials in children with septic shock could be identified. None of these randomized trials led to a change in practice. Clinical practice has been based, for the most part, on physiologic experiments, case series, and cohort studies. Despite relatively low American College of Critical Care Medicine-graded evidence in the pediatric literature, outcomes in children have improved from 97% mortality in the 1960s to 60% in the 1980s and 9% mortality in 1999. U.S. hospital survival was three-fold better in children compared with adults (9% vs. 27% mortality) in 1999. Shock pathophysiology and response to therapies is age specific. For example, cardiac failure is a predominant cause of death in neonates and children, but vascular failure is a predominant cause of death in adults. Inotropes, vasodilators (children), inhaled nitric oxide (neonates), and extracorporeal membrane oxygenation can be more important contributors to survival in the pediatric populations, whereas vasopressors can be more important contributors to adult survival. CONCLUSION: American College of Critical Care Medicine adult guidelines for hemodynamic support of septic shock have little application to the management of pediatric or neonatal septic shock. Studies are required to determine whether American College of Critical Care Medicine guidelines for hemodynamic support of pediatric and neonatal septic shock will be implemented and associated with improved outcome.

[Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock]. / Parâmetros de prática clínica para suporte hemodinâmico a pacientes pediátricos e neonatais em choque séptico.

BACKGROUND: The Institute of Medicine has called for the development of clinical guidelines and practice parameters to develop "best practice" and potentially improve patient outcome. OBJECTIVE: To provide American College of Critical Care Medicine clinical guidelines for hemodynamic support of neonates and children with septic shock. SETTING: Individual members of the Society of Critical Care Medicine with special interest in neonatal and pediatric septic shock were identified from literature review and general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (1998-2001). METHODS: The Medline literature database was searched with the following age specific keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, and extracorporeal membrane oxygenation. More than 30 experts graded literature and drafted specific recommendations by using a modified Delphi method. More than 30 more experts then reviewed the compiled recommendations. The task force chairman modified the document until <10% of experts disagreed with the recommendations. RESULTS: Only four randomized controlled trials in children with septic shock could be identified. None of these randomized trials led to a change in practice. Clinical practice has been based, for the most part, on physiologic experiments, case series, and cohort studies. Despite relatively low American College of Critical Care Medicine-graded evidence in the pediatric literature, outcomes in children have improved from 97% mortality in the 1960s to 60% in the 1980s and 9% mortality in 1999. U.S. hospital survival was three fold better in children compared with adults (9% vs. 27% mortality) in 1999. Shock pathophysiology and response to therapies is age specific. For example, cardiac failure is a predominant cause of death in neonates and children, but vascular failure is a predominant cause of death in adults. Inotropes, vasodilators (children), inhaled nitric oxide (neonates), and extracorporeal membrane oxygenation can be more important contributors to survival in the pediatric populations, whereas vasopressors can be more important contributors to adult survival. CONCLUSION: American College of Critical Care Medicine adult guide lines for hemodynamic support of septic shock have little application to the management of pediatric or neonatal septic shock. Studies are required to determine whether American College of Critical Care Medicine guidelines for hemodynamic support of pediatric and neonatal septic shock will be implemented and associated with improved outcome.