Characteristics associated with pediatric inpatient death.

OBJECTIVE: The primary objective of this study was to obtain a broad understanding of inpatient deaths across academic children's hospitals. METHODS: A nonconcurrent cohort study of children hospitalized in 37 academic children's hospitals in 2005 was performed. The primary outcome was death. Patient characteristics including age, gender, race, diagnostic grouping, and insurance status and epidemiological measures including standardized mortality rate and standardized mortality ratios (SMRs) were used. RESULTS: A total of 427 615 patients were discharged during the study period, of whom 4529 (1.1%) died. Neonates had the highest mortality rate (4.03%; odds ratio: 8.66; P < .001), followed by patients >18 years of age (1.4%; odds ratio: 2.86; P < .001). The SMRs ranged from 0.46 (all patient-refined, diagnosis-related group 663, other anemias and disorders of blood) to 30.0 (all patient-refined, diagnosis-related group 383, cellulitis and other bacterial skin infections). When deaths were compared according to institution, there was considerable variability in both the number of children who died and the SMRs at those institutions. CONCLUSIONS: Patient characteristics, such as age, severity, and diagnosis, were all substantive factors associated with the death of children. Opportunities to improve the environment of care by reducing variability within and between hospitals may improve mortality rates for hospitalized children.

Blood transfusions in children: a multi-institutional analysis of practices and complications.

BACKGROUND: Blood product transfusions are a valuable health-care resource. Guidelines for transfusion exist, but variability in their application, particularly in children, remains. The risk factors that threaten transfusion safety are well established, but because their occurrence in children is rare, single-institution studies have limited utility in determining the rates of occurrence. An epidemiologic approach that investigates blood transfusions in hospitalized children may help improve our understanding of transfused blood products in this vulnerable population. STUDY DESIGN AND METHODS: This was a nonconcurrent cohort study of pediatric patients not more than 18 years of age hospitalized from 2001 to 2003 at 35 academic children's hospitals that are members of the Pediatric Health Information System (PHIS). RESULTS: A total of 51,720 (4.8%) pediatric patients received blood product transfusions during the study period. Red blood cells (n = 44,632) and platelets (n = 14,274) were the two most frequently transfused products. The rate of transfusions was highest among children with neutropenia, agranulocytosis, and sickle cell crisis. Asian and American Indian patients had important differences in the rate of blood transfusions and their complications. Resource use in terms of length of stay and costs were higher in patients who received transfusion. Of those patients who received transfusions, 492 (0.95%) experienced a complication from the administered blood product. This accounted for a rate of complications of 10.7 per 1,000 units transfused. CONCLUSIONS: The administration of blood products to children is a common practice in academic children's hospitals. Complications associated with these transfused products are rare.

Leadership and management training of pediatric intensivists: how do we gain our skills?

BACKGROUND: Intensivists manage a diverse team of health care professionals. For decades, business literature has recognized the value of leadership and management skills, yet this is relatively unexplored in critical care. OBJECTIVE: Investigate the status of intensivists' preparation for the clinical leadership and management roles that they will assume after medical training. DESIGN: Authoritative business leadership literature was reviewed to identify attributes of successful leadership and management relevant to critical care. A survey was designed to assess the process by which intensivists learn these attributes and to assess their perceived level of preparedness (20 items). Each survey item received a preparedness score structured as a Likert scale (1=not prepared, 5=very prepared), representing the averaged response to each item. In addition, an inadequate preparedness percentage was created representing the percentage of respondents answering "not at all prepared" and "hardly prepared" on the Likert-scaled items. SETTING: Pediatric Critical Care Medicine Board Review Course, Washington, DC, 2004. SUBJECTS: Physician course participants (n=259). INTERVENTION: Survey administration. MEASUREMENTS AND MAIN RESULTS: The response rate was 61% (n = 159). The majority of respondents (69%) had completed fellowship training (median, 1 yr posttraining). Modeling the behavior of other physicians was the dominant technique for leadership and management skill acquisition (86%). The respondents were taught these skills by a variety of sources (attendings, 92%; other fellows, 42%; nurses, 37%; teachers, 20%; residents, 14%). Most (82%) thought that leadership and management training was important or very important, yet only 47% had received any formal training (40% fellowship, 36% residency, 21% medical school, 16% masters, 30% other). Overall, respondents felt only "somewhat prepared" for the 20 leadership and management items surveyed (mean+/- sd of preparedness score, 2.8+/- 0.2). Respondents were least prepared to manage conflict within a team, manage conflict with other groups, and manage stress effectively (preparedness scores of 2.5, 2.4, and 2.6 and inadequate preparedness percentages of 19.5%, 15.7%, and 18.9%, respectively). Respondents were most prepared to "set high standards" (preparedness score=3.3). Of the respondents feeling at least somewhat prepared, only 33% credited medical training as preparing them. CONCLUSIONS: Although leadership and management training was perceived as important to this sample of pediatric generally young intensivists, most feel inadequately prepared for critical aspects of these responsibilities, most notably, stress and conflict management. These findings provide an opportunity for specific curriculum development in leadership and management for those believing these skills should be further refined.