The Scope and Trends of Pediatric Hospitalizations in Texas, 2004-2010

Elevated Rates of Restraint and Seclusion in Child and Adolescent Psychiatric Inpatients in China and Their Associated Factors

To investigate the rate of restraint and seclusion (R&S) use in child and adolescent psychiatric inpatients in China and to examine factors associated with use of these interventions. As part of an official national survey, 41 provincial tertiary psychiatric hospitals in China were selected. Data from 196 youth inpatients discharged from these hospitals from March 19 to 31, 2019 were retrieved and analyzed. (1) The overall rate of R&S was 29.1% (N = 57) and the rate of restraint was 28.6% (N = 56), and seclusion was 11.7% (N = 23) respectively. (2) Compared to patients who did not require R&S, those who required R&S were more likely to have been hospitalized on an involuntary basis, more likely to present with either manic symptoms or aggressive behavior as primary reason for admission, had more frequent aggressive behaviors during hospitalization, and had a significantly longer length of stay. (3) A logistic regression showed that aggressive behaviors during hospitalization was significantly associated with the use of R&S (OR = 21.277, p < 0.001), along with three other factors: manic symptoms as a reason for admission, involuntary admission and a lower GAF score at admission (all p < 0.01). The rate of R&S is dramatically higher in child and adolescent psychiatric hospitalizations in China compared to other regions. Targeted training of staff, development of precise operational guidelines for appropriate use of R&S, and strict oversight are urgently needed to minimize the inappropriate use of R&S in child and adolescent patients.

Utilizing a Behavioral Health Bundle to Improve Patient and Clinician Safety for Hospitalized Children

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Due to limited psychiatric hospital availability, increasing numbers of pediatric patients with behavioral health (BH) needs are hospitalized in medical units in the US Patients and staff are at increased risk for safety events like self-harm or aggression. Our study aimed to decrease safety events by 25% over a year among hospitalized children with BH diagnoses by implementing an intervention bundle.

Readmissions Following Hospitalization for Infection in Children With or Without Medical Complexity

OBJECTIVE

To describe the prevalence and characteristics of infection-related readmissions in children and to identify opportunities for readmission reduction and estimate associated cost savings.

STUDY DESIGN

Retrospective analysis of 380,067 nationally representative index hospitalizations for children using the 2014 Nationwide Readmissions Database. We compared 30-day, all-cause unplanned readmissions and costs across 22 infection categories. We used the Inpatient Essentials database to measure hospital-level readmission rates and to establish readmission benchmarks for individual infections. We then estimated the number of readmissions avoided and costs saved if hospitals achieved the 10th percentile of hospitals' readmission rates (ie, readmission benchmark). All analyses were stratified by the presence/absence of a complex chronic condition (CCC).

RESULTS

The overall 30-day readmission rate was 4.9%. Readmission rates varied substantially across infections and by presence/absence of a CCC (CCC: range, 0%-21.6%; no CCC: range, 1.5%-8.6%). Approximately 42.6% of readmissions (n = 3,576) for children with a CCC and 54.7% of readmissions (n = 5,507) for children without a CCC could have been potentially avoided if hospitals achieved infection-specific benchmark readmission rates, which could result in an estimated savings of $70.8 million and $44.5 million, respectively. Bronchiolitis, pneumonia, and upper respiratory tract infections were among infections with the greatest number of potentially avoidable readmissions and cost savings for children with and without a CCC.

CONCLUSION

Readmissions following hospitalizations for infection in children vary significantly by infection type. To improve hospital resource use for infections, future preventative measures may prioritize children with complex chronic conditions and those with specific diagnoses (eg, respiratory illnesses).

A cross-sectional study on the characteristics and factors associated with the clinical course of child and adolescent patients hospitalized in a public child and adolescent psychiatric unit of Chile

Introduction

Patients of the Short-stay Child and Adolescent Unit of the Del Salvador Psychiatric Hospital (Valparaíso, Chile) exhibit different clinical and social characteristics compared to literature reports of other national centers, although published data are scarce.

Objectives

To describe the operation of the Unit, the socio-familial and clinical characteristics of its patients and analyze factors associated with their clinical evolution.

Methods

We performed a cross-sectional study to describe the patients hospitalized over a three-year period. Variables were registered in an anonymized database. Clinical evolution was evaluated over the year following hospital discharge.

Results

The Unit's model of care can be described as involving biomedical, psychodynamic, and ecological components. We included 98 patients, of which 70.4% were male, and the average age was 11.5 ± 2.3 years. 82.6% were of low socioeconomic status, and 35.7% did not attend school; 98.9% presented family dysfunction, and 91.8% of parents had a history of psychopathology. The most frequent reason for admission was the risk of harm to self or others. The most frequent discharge diagnoses were behavioral, depressive, and personality development disorders. The average length of stay was 41.8 ± 31.1 days. The most commonly used pharmacological agents were antipsychotics and mood stabilizers. Regarding clinical evolution in the first year post-discharge, 47% were evaluated as positive, 27% regular, and 26% unsatisfactory. The factor associated with an unsatisfactory clinical course was having had in-patient antidepressants. Re-admission during the first year post-discharge was associated with comorbid substance use disorder. Treatment noncompliance was associated with a history of behavioral disorder at hospital discharge and having parents with a history of suicide or consummated suicide.

Conclusions

The patient profile is one of low socioeconomic status, severe psychopathology, maladaptive behavior, family dysfunction, and parental psychopathology. Substance use disorder is also associated with readmission.

Effect of Patient Care Coordination on Hospital Encounters and Related Costs

Given high costs of hospital encounters, providers have increasingly turned to patient-centered health care programs to improve cost-effectiveness and population health for patients with high needs. Yet, evidence is mixed about program effectiveness. This pre-post comparative analysis assessed whether the number of hospital encounters and related costs decreased for patients who received care coordination services funded through Texas's 1115(a) Medicaid waiver incentive-based payment model, under which providers created new programs to improve care quality, population health, and cost-effectiveness. This study compared hospital records for patients who were frequent emergency department users at 4 urban safety net hospitals in Texas and state data for hospital encounters for the calendar years 2013 through 2015. The study included 9061 patients who frequently used emergency departments: 4117 patients who received waiver-funded care coordination services at 2 hospitals and 4944 patients who received usual care at 2 comparison hospitals. Regression models compared changes in patients' hospital use and length of stay for the 2 groups. Patients receiving waiver-funded care coordination had a 19% lower probability of hospitalization after receiving care coordination relative to patients who received usual care, for a mean savings of approximately $1500 per year per patient. Receiving care coordination was not associated with a change in length of stay. Care coordination developed by hospitals to meet the needs of their most vulnerable patients can reduce their use of hospital resources through better preventive care. These findings bolster the business case for care coordination, which may help ensure service continuation.

Improving Influenza Testing and Treatment in Hospitalized Children

OBJECTIVES

National guidelines recommend influenza testing for children hospitalized with influenza-like illness (ILI) during influenza season and treatment of those with confirmed influenza. Using quality improvement methods, we sought to increase influenza testing and treatment of children admitted to our hospital medicine service with ILI from 65% to 90% during the 2014-2015 influenza season.

METHODS

We targeted several key drivers using multiple plan-do-study-act cycles. Interventions included awareness modules, biweekly flyers, and failure tracking. ILI admissions (fever plus respiratory symptoms) were reviewed weekly once surveillance data revealed elevated influenza activity. Appropriate testing and treatment of ILI was defined as influenza testing and/or treatment within 24 hours of admission unless a known cause other than influenza was present. We used statistical process control charts to track progress using established quality improvement methods. Appropriate testing and treatment was also assessed in the 2016-2017 influenza season by using similar methods, although no new interventions were introduced.

RESULTS

For the 2014-2015 season, appropriate testing and treatment increased from a baseline mean of 65% to 91% within 3 months. For the 2016-2017 season, appropriate testing and treatment remained at a mean of 80% throughout the influenza season.

CONCLUSIONS

Appropriate influenza testing and treatment increased to 90% in children with ILI during the 2014-2015 season. Improvements were sustained in a subsequent influenza season. Our initiative improved recognition of influenza and likely increased treatment opportunities. Future work should be focused on wider implementation and further reducing variation.

High antibiotic prescription rates in hospitalized children with human metapneumovirus infection in comparison to RSV infection emphasize the value of point-of-care diagnostics

BACKGROUND

Respiratory infections are the main causes for hospitalization in children and a common reason for the initiation of antibiotic treatment. Rapid antigen detection tests and point-of-care mPCR-based assays provide a fast detection of viral pathogens. Nonetheless, the prescription rate of antibiotics for respiratory infections is exceedingly high. In particular, human metapneumovirus (hMPV) infections frequently cause antibiotic treatment.

METHODS

Children hospitalized in our clinic with an acute respiratory infection between January 2008 and January 2013 were included in the present study. Data of 3799 children were analyzed retrospectively for clinical symptoms, laboratory findings, and antibiotic and inhalation treatment. We performed an in-house m-RT-PCR-ELISA method for pathogen detection.

RESULTS

Pathogen detection was possible in 2464 patients. In 6.3%, hMPV and, in 24.0%, RSV were detected. Patients positively tested for hMPV received inhalation therapy in 62.9%; patients positive for RSV in 73.8%. Patients positive for hMPV were treated with antibiotics in 62.3%. Patients with RSV infection received antibiotic treatment in 44.4%; all others in 43.5%. Notably, a positive result in RSV-RADT was associated with reduced number of antibiotic treatment.

CONCLUSION

hMPV infections inherit a two times higher probability of antibiotic treatment. There was no significant difference in laboratory findings or body temperature between hMPV infection and infections caused by other pathogens. Clinical symptoms seem not to differ from those in RSV illness. Nonetheless, RSV infections triggered significantly lower antibiotic prescription rates. A considerate application of a POC-mPCR for patients with RSV-like symptoms and age of 1 year and older with a negative RSV-RADT might lead to higher detection rates of hMPV and a reduction in prescription of antibiotics.

Predictors of Oophorectomy in Girls Hospitalized in Texas With Ovarian Torsion

OBJECTIVES

Inconsistent results have been reported by authors of studies of the management of pediatric patients with ovarian torsion (OT). Our objective was to identify predictors of oophorectomy in girls hospitalized throughout Texas with OT.

METHODS

The Texas Public Use Data File (years 2013-2014) was queried for the records of girls under the age of 18 years who had a principal or secondary discharge diagnosis of OT (International Classification of Diseases, Ninth Revision, Clinical Modification code 620.5). Adjusted odds ratios were estimated from a logistic regression model by using Firth's bias-reducing penalized likelihood. Variables for inclusion in the final model were identified by using a directed acyclic graph.

RESULTS

A sample of 158 girls was identified with an overall risk of oophorectomy during the hospital stay of 41.1% (65 out of 158). After adjusting for the patient's age, health insurance status, and the presence of an ovarian cyst, girls who were treated at a nonteaching hospital were more than twice as likely to undergo oophorectomy than girls who were treated at a teaching hospital (odds ratio = 2.22; 95% confidence interval: 1.05-4.69).

CONCLUSIONS

Our analysis of a statewide database revealed that girls with OT who presented at nonteaching hospitals were significantly more likely to undergo oophorectomy compared with girls who presented at teaching hospitals.

Psychiatric Boarding in the Pediatric Inpatient Medical Setting: A Retrospective Analysis

BACKGROUND AND OBJECTIVES

Psychiatric concerns are a common presenting problem for pediatric providers across many settings, particularly on inpatient medical services. The volume of youth requiring intensive psychiatric treatment outnumbers the availability of psychiatric placements, and as a result many youth must board on pediatric medical units while awaiting placement. As the phenomenon of boarding in the inpatient pediatric setting increases, it is important to understand trends in boarding volume and characteristics of pediatric psychiatric boarders (PBs) and understand the supports they receive while boarding.

METHODS

A retrospective chart review of patients admitted as PBs to a medical inpatient unit at a large northeastern US pediatric hospital during 2013.

RESULTS

Four hundred thirty-seven PBs were admitted to the medical service from January to December 2013, representing a more than 50% increase from PB admissions in 2011 and 2012. Most PBs were admitted for suicidal attempt and/or ideation. Average length of boarding was 3.11 ± 3.34 days. PBs received a wide range of mental health supports throughout their admissions. PBs demonstrated modest but statistically significant clinical improvements over the course of their stay, with only a small proportion demonstrating clinical deterioration.

CONCLUSIONS

Psychiatric boarding presents many challenges for families, providers, and the health care system, and PBs have complex psychiatric histories and needs. However, boarding may offer a valuable opportunity for psychiatric intervention and stabilization among psychiatrically vulnerable youth.