A Quality Improvement Intervention Bundle to Reduce 30-Day Pediatric Readmissions.

INTRODUCTION: Pediatric hospital readmissions can represent gaps in care quality between discharge and follow-up, including social factors not typically addressed by hospitals. This study aimed to reduce the 30-day pediatric readmission rate on 2 general pediatric services through an intervention to enhance care spanning the hospital stay, discharge, and follow-up process. METHODS: A multidisciplinary team developed an intervention bundle based on a needs assessment and evidence-based models of transitional care. The intervention included pre-discharge planning with a transition coordinator, screening and intervention for adverse social determinants of health (SDH), medication reconciliation after discharge, communication with the primary care provider, access to a hospital-based transition clinic, and access to a 24-hour direct telephone line staffed by hospital attending pediatricians. These were implemented sequentially from October 2013 to February 2017. The primary outcome was the readmission rate within 30 days of index discharge. The length of stay was a balancing measure. RESULTS: During the intervention, the included services discharged 4,853 children. The pre-implementation readmission rate of 10.3% declined to 7.4% and remained stable during a 4-month post-intervention observation period. Among 1,394 families screened for adverse SDH, 48% reported and received assistance with ≥ 1 concern. The length of stay increased from 4.10 days in 2013 to 4.30 days in 2017. CONCLUSIONS: An intervention bundle, including SDH, was associated with a sustained reduction in readmission rates to 2 general pediatric services. Transitional care that addresses multiple domains of family need during a child's health crisis can help reduce pediatric readmissions.

Patient- and Visit-Level Variables Associated With Late Arrival to Pediatric Clinic Appointments.

We conducted a cross-sectional study to evaluate timeliness of patient arrival at a pediatric multispecialty clinic. Bivariate and ordered logistic regression analyses were conducted to determine the odds of late arrival by specified patient- and visit-level characteristics. A total of 64 856 visits were available for analysis, of which 6513 (10.0%) were late arrivals. The odds of late arrival were higher for patients who spoke English (odds ratio [OR] = 1.34, P < .001) compared with those who spoke Spanish, had Medicaid (OR = 1.54, P < .001) or no insurance (OR = 1.49, P < .001) compared with those with insurance other than Medicaid, and were late to their previous visit (OR = 2.46, P < .001). Visit-level variables associated with late arrival included appointment time earlier in the day (i.e. 8-10 am, OR = 2.77, P < .001 compared with 4-6 pm), earlier in the week (i.e. on Mondays, OR = 1.21, P < .001 compared with Wednesdays), and for certain subspecialty clinics ( P < .001). Numerous variables are significantly associated with late arrival for pediatric clinic appointments.

ß-adrenergic receptor mediation of stress-induced reinstatement of extinguished cocaine-induced conditioned place preference in mice: roles for ß1 and ß2 adrenergic receptors.

Stress can trigger the relapse of drug use in recovering cocaine addicts and reinstatement in rodent models through mechanisms that may involve norepinephrine release and ß-adrenergic receptor activation. The present study examined the role of ß-adrenergic receptor subtypes in the stressor-induced reinstatement of extinguished cocaine-induced (15 mg/kg i.p.) conditioned place preference in mice. Forced swim (6 min at 22°C) stress or activation of central noradrenergic neurotransmission by administration of the selective α(2) adrenergic receptor antagonist 2-[(4,5-dihydro-1H-imidazol-2-yl)methyl]-2,3-dihydro-1-methyl-1H-isoindole (BRL-44,408) (10 mg/kg i.p.) induced reinstatement in wild-type, but not ß- adrenergic receptor-deficient Adrb1/Adrb2 double-knockout, mice. In contrast, cocaine administration (15 mg/kg i.p.) resulted in reinstatement in both wild-type and ß-adrenergic receptor knockout mice. Stress-induced reinstatement probably involved ß(2) adrenergic receptors. The ß(2) adrenergic receptor antagonist -(isopropylamino)-1-[(7-methyl-4-indanyl)oxy]butan-2-ol (ICI-118,551) (1 or 2 mg/kg i.p.) blocked reinstatement by forced swim or BRL-44,408, whereas administration of the nonselective ß-adrenergic receptor agonist isoproterenol (2 or 4 mg/kg i.p.) or the ß(2) adrenergic receptor-selective agonist clenbuterol (2 or 4 mg/kg i.p.) induced reinstatement. Forced swim-induced, but not BRL-44,408-induced, reinstatement was also blocked by a high (20 mg/kg) but not low (10 mg/kg) dose of the ß(1) adrenergic receptor antagonist betaxolol, and isoproterenol-induced reinstatement was blocked by pretreatment with either ICI-118,551 or betaxolol, suggesting a potential cooperative role for ß(1) and ß(2) adrenergic receptors in stress-induced reinstatement. Overall, these findings suggest that targeting ß-adrenergic receptors may represent a promising pharmacotherapeutic strategy for preventing drug relapse, particularly in cocaine addicts whose drug use is stress related.