Adult survivors of pediatric illness: the impact on pediatric hospitals

Pediatric to Adult Care Transition in the Hospital Context (PATCH) Tool: A Novel Tool to Assess Pediatric Institutional Guidelines for Inpatient Care of Adults

OBJECTIVE

The growing number of adults with childhood onset chronic conditions (COCC) is reflected in the increase of adult-aged admissions to pediatric institutions. Despite national bodies advising pediatric institutions to have a pediatric to adult health care transition (HCT) policy, little guidance is available on if or how to include inpatient care. We sought to create a framework-based Pediatric to Adult Transitional Care in the Hospital Context (PATCH) tool to assess how inpatient care of adults is addressed in pediatric institutional guidelines or policies (hereafter guidelines) as a first step towards informing future PATCH guideline development.

METHODS

We used convenience and snowball sampling to obtain 11 pediatric institutional guidelines. Combining the GotTransition core elements with Coller et al's inpatient transition conceptual model through iterative consensus building, we developed the PATCH tool. Interrater reliability was assessed by using mean percent agreement among raters. A three-phase content validity process utilizing existing guidelines refined the finalized tool.

RESULTS

The PATCH tool included 42 items within nine domains. There was a high degree of agreeability among reviewers, and qualitative analysis revealed no missing items. Twenty-five (59%) of our 42 PATCH tool items were present in at least one of the reviewed guidelines, with age being present in all.

CONCLUSIONS

We developed the PATCH tool as a guide for pediatric institutions regarding the care of adolescent and adult patients. The PATCH tool, embedded in multidisciplinary stakeholder discussion and patient- and system-specific knowledge, may help institutions incorporate HCT into processes for adolescent and adult patients with COCCs.

Age has an independent association with total cost of care in adults admitted to pediatric hospitals

Previous studies in adults admitted to pediatric hospitals primarily investigated associations between complex chronic condition characteristics and patient outcomes. Our study explored the association of age with length of stay (LOS) and total cost in these adults, accounting for other patient factors. Using the Pediatric Health Information System, we included 1,215,736 patient encounters from 2021 to 2022. Unadjusted and adjusted analyses were performed using bivariable and multivariable log-linear regression. There was a significant positive association between age and total cost, with adults 18-20 years having 13% higher total cost (95% confidence interval [CI]: 12%-15%), 21-25 years with 25% higher total cost (95% CI: 22%-29%), and 25-99 years having 72% higher total cost (95% CI: 66%-79%) than 1-17 years. Our findings suggest expanding upon the existing status quo to identify the most appropriate environment to care for this unique and growing population, especially given the anticipated reduction in pediatric beds and subspecialty expertise.

Indications and practice of home invasive mechanical ventilation in children

BACKGROUND

Developments and technological advances in neonatal and pediatric intensive care units have led to a prolonged life expectancy of pediatric patients with chronic respiratory failure. Therefore, the number of hemodynamically stable pediatric patients with chronic respiratory failure who need mechanical ventilator assistance throughout the day has significantly increased.

AIMS

Numerous conditions, including parenchymal lung diseases, airway disorders, neuromotor disorders, or respiratory defects, can lead to chronic respiratory failure. For individuals who cannot tolerate non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV) is the only suitable choice. Due to increasing need, mechanical ventilator technology is continuously evolving.

RESULTS

As a result of this process, home-type mechanical ventilators have been produced for patients requiring long-term IMV. Patients with chronic respiratory failure can be safely monitored at home with these ventilators.

DISCUSSION

Home follow-up of these patients has many benefits such as an increase in general quality of life and a positive contribution to their emotional and cognitive development.

CONCLUSION

In this compilation, indications for home-based IMV, features of home invasive mechanical ventilators (HMVs), patient monitoring, and the detailed advantages of using IMV at home will be elucidated.

Disparities in pediatric hospital use during transition to adult healthcare for young adults with childhood-onset chronic conditions

BACKGROUND

Young adults (YA) with childhood-onset chronic conditions-particularly YA with cystic fibrosis (CF), congenital heart disease (CHD), and sickle cell disease (SCD)-continue to have pediatric hospital admissions. Factors associated with this continued pediatric hospital use remain underexplored.

OBJECTIVE

To determine if pediatric hospital use by YA differed (1) across condition and (2) within each condition by sociodemographic factors.

METHODS

Conducted a cross-sectional analysis of admissions for YA 22-35 years with CF, CHD, and SCD from 2016 to 2020 in the National Inpatient Sample. Admissions for YA with CF, CHD, and SCD were identified by international classification of diseases, 10th revision-clinical modification diagnosis codes. To determine if conditions or sociodemographic factors were associated with YA pediatric hospital use, we used multivariable logistic regression with separate models for the different objectives.

RESULTS

YA with SCD had lower odds of pediatric hospital use compared to YA with CF. Relationships between sociodemographic factors and pediatric hospital use varied. Black YA with both CF and CHD had lower odds of pediatric hospital use than white YA with CF and CHD. For YA with SCD, despite 17,810 (6.5%) having rural residence, zero (0) had pediatric hospital use; whereas YA with CF living in a rural area had greater odds of pediatric hospital use compared to urban residents.

CONCLUSION

YA with SCD used pediatric hospitals less than YA with either CF or CHD. Coupled with our findings that Black YA with CF and CHD had less pediatric hospital use, these data may reflect systematic racial differences within pediatric to adult healthcare transition programs.

Characteristics and Outcomes of Cardiac Arrest in Adult Patients Admitted to Pediatric Services: A Descriptive Analysis of the American Heart Association's Get With The Guidelines-Resuscitation Data

OBJECTIVES

Differences between adult and pediatric in-hospital cardiac arrest (IHCA) are well-described. Although most adults are cared for on adult services, pediatric services often admit adults, particularly those with chronic conditions. The objective of this study is to describe IHCA in adults admitted to pediatric services.

DESIGN

Retrospective cohort analysis from the American Heart Association's Get With The Guidelines-Resuscitation registry of a subpopulation of adults with IHCA while admitted to pediatric services. Multivariable logistic regression was used to evaluate adjusted survival outcomes and compare outcomes between age groups (18-21, 22-25, and ≥26 yr old).

SETTING

Hospitals contributing to the Get With The Guidelines-Resuscitation registry.

PATIENTS

Adult-aged patients (≥ 18 yr) with an index pulseless IHCA while admitted to a pediatric service from 2000 to 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 491 adult IHCAs were recorded on pediatric services at 17 sites, during the 19 years of review, and these events represented 0.1% of all adult IHCAs. In total, 221 cases met inclusion criteria with 139 events excluded due to an initial rhythm of bradycardia with poor perfusion. Median patient age was 22 years (interquartile range, 19-28 yr). Ninety-eight percent of patients had at least one pre-existing condition. Return of spontaneous circulation occurred in 63% of events and 30% of the patients survived to discharge. All age groups had similar rates of survival to discharge (range 26-37%; p = 0.37), and survival did not change over the study period (range 26-37%; p = 0.23 for adjusted survival to discharge).

CONCLUSIONS

In this cohort of adults with IHCA while admitted to a pediatric service, we failed to find an association between survival outcomes and age. Additional research is needed to better understand resuscitation in this population.

In-Hospital Cardiac Arrest in Adult Patients Admitted to a Quaternary Children's Center

OBJECTIVE

This study aimed to describe baseline and event characteristics and outcomes for adult patients who experience in-hospital cardiac arrest (IHCA) in a quaternary children's hospital and compare IHCA outcomes in younger (18-24 years) versus older (≥25 years) adults. We hypothesized that the rate of survival to hospital discharge would be lower in the older adult group.

METHODS

We performed a retrospective single-center cohort study of inpatient areas of a quaternary children's center. Adult patients (≥18 years of age) with an index pulseless IHCA requiring at least 1 minute of cardiopulmonary resuscitation or defibrillation were included.

RESULTS

Thirty-three events met the inclusion criteria with a median patient age of 23.9 years (interquartile range, 20.2-33.3 years). Twenty-one (64%) patients had congenital heart disease, and 25 (76%) patients had comorbidities involving ≥2 organ systems. The most common prearrest interventions were invasive mechanical ventilation (76%) and vasoactive infusions (55%). Seventeen patients (52%) survived to hospital discharge.Survival to discharge was lower in patients 25 years or older compared with patients aged 18 to 24 years old (3 of 15 [20%] vs 14 of 18 [78%], respectively; P = 0.002).

CONCLUSIONS

The majority of adult patients with IHCA in our pediatric hospital had preexisting multisystem comorbidities, the most common of which was congenital heart disease. Overall survival to discharge after IHCA was 52%, similar to that reported for the general pediatric population. Survival to discharge was significantly lower in the subgroup of patients 25 years or older when compared with those between the ages of 18 and 24 years.

The increasing proportion of adult discharges at children's hospitals, 2004-2019

Significant medical advances now enable individuals with pediatric illnesses to survive into adulthood. Finding medical homes for these individuals often remains challenging. We utilized the Pediatric Health Information System to measure the variation in and growth of admissions to children's hospitals, stratified by age and payor from 2004 to 2019. We identified 8,097,081 patient encounters from 30 hospitals. Compared to children, adults discharged at children's hospitals are more likely to have a complex chronic condition, have a higher median cost, and have a longer median length of stay. Hospital-level adult discharges ranged from 1.9% to 10.1% (median 4.1%; interquartile range: 2.8%-5.4%). Significantly higher increases were seen in each adult age subgroup (18-20, 21-25, and >25 years old) compared to the pediatric age group (p < .001). The number of adults discharged from children's hospitals is increasing faster than children, impacting children's hospitals and the populations they serve.

Redesigning Care of Hospitalized Young Adults With Chronic Childhood-Onset Disease

Background

Young adults with chronic childhood-onset disease (CCOD) are routinely admitted to internal medicine hospitalist services, yet most lack transition preparation to adult care. Providers and patients feel the strain of admissions to adult services in part due to their medical and social complexity.

Methods

We performed a descriptive study of a care redesign project for young adults with CCOD hospitalized at a large, tertiary care academic hospital. We describe the process of implementation of the Med-Peds (MP) service line and characterize patients cared for by the service. We measured and analyzed patient demographics, process implementation, healthcare screening, and healthcare utilization data.

Results

During the 16 months of the study period, 254 patients were cared for by the MP service line, accounting for 385 hospitalizations. The most common CCODs were sickle cell disease (22.4%) and type 1 diabetes (14.6%). The majority (76%) of patients completed transition readiness assessment, and 38.6% completed social determinant of health (SDH) screening during their admission. Patients had high prevalence of SDH with 66.7% having an unmet social need. The average length of stay was 6.6 days and the average 30-day readmission rate was 20.0%.

Conclusions

There is opportunity to redesign the inpatient care of young adult patients with CCOD. The MP service line is a care model that can be integrated into existing hospital medicine teams with MP physicians. Hospitals should consider redesigning care for young adults with CCOD to meet the transitional and social needs unique to this patient population.

Adults Followed by Pediatric Subspecialists: A Growing Population in the Pediatric Emergency Department

BACKGROUND

Adults are being seen with increasing frequency in pediatric emergency departments (PEDs), but the drivers behind this increase are unknown. Our primary aim was to compare adults seen in the PED followed by pediatric subspecialists to those who are not.

METHODS

A retrospective study of patients 21 years or older presenting to the PED of a tertiary care children's hospital was performed from January 2011 through December 2018. Data included patient demographics, PED length of stay, disposition, and any subspecialty clinic encounters at the children's hospital in the prior year.

RESULTS

A total of 10,034 adult encounters were seen in the PED over the study period; 5852 (58.3%) adult PED encounters had preceding pediatric subspecialty clinic visit(s) within a year prior. Pediatric subspecialty adult PED encounters increased by 38.9%, compared with 10.6% for other adults (P = 0.01). Encounters for pediatric subspecialty adults were significantly longer and more likely to result in admission to the children's hospital. The most common pediatric subspecialists caring for adult patients seen in the PED were hematology/oncology (1655 encounters), neurology (1572 encounters), cardiology (1217 encounters), and gastroenterology (1173 encounters).

CONCLUSIONS

Pediatric subspecialty adults are presenting to the PED at a greater rate, and they require more time and resources compared with other presenting adults. As frontline providers, PEDs, physicians, and staff must be prepared to address this growing subset of patients driving the increase in adults presenting to the PED.

Therapie-Adhärenz bei Patient*innen mit Mukoviszidose im Erwachsenenalter

Hintergrund Um die Folgen der Progression von Mukoviszidose möglichst gering zu halten, benötigen Patient*innen ein Konzept für lebenslange medikamentöse Interventionen und intensive Physiotherapie, gepaart mit einer sehr hohen Therapie-Adhärenz. Durch die Erhöhung der durchschnittlichen Lebenswartung auf über 50 Jahre bei über der Hälfte der Betroffenen stehen medizinische Fachkräfte vor neuen Herausforderungen bei der Versorgung. Die nötigte Implementierung von Übergangsprogrammen für junge Erwachsene, aus den Kinderambulanzen heraus, sind jedoch noch immer nicht flächendeckend vollzogen. Niedrige Raten bei der Adhärenz verdeutlichen die problematische Situation.

Ziel Erfassung der Wahrnehmung von jungen Erwachsenen mit Mukoviszidose in Bezug auf Faktoren, die einen Einfluss auf ihre Therapie-Adhärenz haben.

Methode Das Erleben der Behandlungen sowie die Adhärenz beeinflussenden Faktoren wurden anhand von Leitfadeninterviews (n = 10) erhoben. Die Auswertung erfolgte mithilfe der inhaltlich strukturierenden Inhaltsanalyse nach Kuckartz.

Ergebnisse Es zeigt sich ein komplexes Gesamtbild von Einflussfaktoren, mit einem auffälligen Wechselverhalten zwischen Adhärenz und Non-Adhärenz zu medizinisch notwendigen Therapien. Aus Sicht der Befragten ist die partizipative Entscheidungsfindung der zentrale Ansatzpunkt zur Förderung der Adhärenz, Minderung des Wechselverhaltens und Stärkung der Bewältigung und Aufrechterhaltung von Selbstwirksamkeit.

Schlussfolgerung Die Ergebnisse geben Implikationen für die Ausbildung von Physiotherapeut*innen und Mediziner*innen bezüglich theoretischer Grundlagen zum Gesundheitsverhalten, zur Verhaltensänderung, Adhärenz und zu Entscheidungsprozessen von Patient*innen.

Priorities and Outcomes for Youth-Adult Transitions in Hospital Care: Perspectives of Inpatient Clinical Leaders at US Children's Hospitals

OBJECTIVES

Adults with chronic conditions originating in childhood experience ongoing hospitalizations; however, efforts to guide youth-adult transitions rarely address transitioning to adult-oriented inpatient care. Our objectives were to identify perceptions of clinical leaders on important and feasible inpatient transition activities and outcomes, including when, how, and for whom inpatient transition processes are needed.

METHODS

Clinical leaders at US children's hospitals were surveyed between January and July 2016. Questionnaires were used to assess 21 inpatient transition activities and 13 outcomes. Perceptions about feasible and important outcome measures and appropriate patients and settings for activities were summarized. Each transition activity was categorized into one of the Six Core Elements (policy, tracking, readiness, planning, transfer, or completion). Associations between perceived transition activity importance or feasibility, hospital characteristics, and transition activity performance were evaluated.

RESULTS

In total, 96 of 195 (49.2%) children's hospital leaders responded. The most important and feasible activities were identifying patients needing or overdue for transition, discussing transition timing with youth and/or families, and informing youth and/or families that future stays would be at an adult facility. Feasibility, but not importance, ratings were associated with current performance of transition activities. Inpatient transition activities were perceived to be important for children with medical and/or social complexity or high hospital use. Emergency department visits and patient experience during transition were top outcome measurement priorities.

CONCLUSIONS

Children's hospital clinical leaders rated inpatient youth-adult transition activities and outcome measures as important and feasible; however, feasibility may ultimately drive implementation. This work should be used to inform initial research and quality improvement priorities, although additional stakeholder perspectives are needed.

Risk Factors for the Development of Hospital-Associated Venous Thromboembolism in Adult Patients Admitted to a Children's Hospital

BACKGROUND AND OBJECTIVES

Hospital-associated venous thromboembolism (HA-VTE) is a leading cause of preventable in-hospital mortality in adults. Our objective was to describe HA-VTE and evaluate risk factors for its development in adults admitted to a children's hospital, which has not been previously studied. We also evaluated the performance of commonly used risk assessment tools for HA-VTE.

METHODS

A case-control study was performed at a freestanding children's hospital. Cases of HA-VTE in patients ≥18 years old (2013-2017) and age-matched controls were identified. We extracted patient and HA-VTE characteristics and HA-VTE risk factors on the basis of previous literature. Thrombosis risk assessment was performed retrospectively by using established prospective adult tools (Caprini and Padua scores).

RESULTS

Thirty-nine cases and 78 controls were identified. Upper extremities were the most common site of thrombosis (62%). Comorbid conditions were common (91.5%), and malignancy was more common among case patients than controls (P = .04). The presence of a central venous catheter (P < .01), longer length of stay (P < .01), ICU admission (P = .005), and previous admission within 30 days (P = .01) were more common among case patients when compared with controls. Median Caprini score was higher for case patients (P < .01), whereas median Padua score was similar between groups (P = .08).

CONCLUSIONS

HA-VTE in adults admitted to children's hospitals is an important consideration in a growing high-risk patient population. HA-VTE characteristics in our study were more similar to published data in pediatrics.

Changes in Clinical Markers During A Short-Term Transfer Program of Adult Cystic Fibrosis Patients from Pediatric to Adult Care

Background:

Transition from child-oriented to adult-oriented health care in Cystic Fibrosis (CF) has become more important over recent decades as the survival of people with this disease has increased. The transition process usually begins in adolescence, with full transfer completed in early adulthood.

Objective:

This study investigated the impact of a short-term transfer program on clinical markers in an adult CF cohort still being managed by pediatricians.

Methods:

Clinically relevant data from the year before (T-1), the time of Transfer (T) and the year after the transfer (T+1) were analysed retrospectively.

Results:

39 patients (median age 29.0 years; 64% male) were transferred between February and December 2016. Lung function had declined significantly in the year before transfer (in % predicted: Forced Expiratory Volume in 1 second (FEV), 62.8 vs. 57.7, p <0.05; Forced Vital Capacity (FVC), 79.9 vs. 71.1, p<0.05), but remained stable in the year after transfer (in % predicted: FEV: 56.3; FVC 68.2). BMI was stable over the whole observational period. There was no relevant change in chronic lung infection with P. aeruginosa, Methicillin-Resistant Staphylococcus aureus (MRSA) and Burkholderia sp. during the observation period. The number of patient contacts increased significantly in the year after versus the year before transfer (inpatient: 1.51 vs. 2.51, p<0.05; outpatient: 2.67 vs. 3.41, p<0.05).

Conclusions:

Our data show that, within the framework of a structured transfer process, it is possible to transfer a large number of adult CF patients, outside a classic transition program, from a pediatric to an adult CF center in a short period of time, without any relevant changes in clinical markers and, stability.

Resource Utilization Among Adult Congenital Heart Failure Admissions in Pediatric Hospitals

We sought to analyze the trends and resource utilization of adult congenital heart disease (ACHD)-related heart failure admissions at children's hospitals. Heart failure admissions in patients with ACHD continue to rise at both pediatric and adult care facilities. Data from the Pediatric Health Information Systems database (2005 to 2015) were used to identify patients (≥18 years) admitted with congenital heart disease (745.xx-747.xx) and principal diagnosis of heart failure (428.xx). High resource use (HRU) admissions were defined as those over the 90th percentile. There were 562 admissions (55.9% male) across 39 pediatric hospitals. ACHD-related heart failure admissions increased from 4.1% in 2006 to 6.3% in 2015 (p = 0.015). Median hospital charge for ACHD-related heart failure admissions was $59,055 [IQR $26,633 to $156,846]. Total charges increased with more complex anatomic category (p = 0.049). Though HRU admissions represented 10% of ACHD-related heart failure admissions, they accounted for >66% of the total charges. The median total hospital charges for HRU admissions were $1,018,656 [IQR $722,574 to $1,784,743], compared with $58,890 [IQR $26,456 to $145,890] for non-HRU admissions (p < 0.001). Inpatient mortality rate (26.3% vs 4.0%) and the presence of ≥2 comorbidities (68% vs 31%) were higher for HRU admissions (p < 0.001). On multivariable analysis, technology dependence (aOR: 4.4, p < 0.001) and renal comorbidities (aOR: 3.0, p = 0.04) were associated with HRU. In conclusion, heart failure-related ACHD admissions in pediatric hospitals are increasing. Compared with non-HRU, HRU admissions had higher inhospital mortality and greater comorbidities. Additional care strategies to reduce resource use among these patients and improve overall quality of care merits further study.

The Epidemiology of Transition into Adulthood of Rare Diseases Patients: Results from a Population-Based Registry

Background: Despite the fact that a considerable number of patients diagnosed with childhood-onset rare diseases (RD) survive into adulthood, limited information is available on the epidemiology of this phenomenon, which has a considerable impact both on patients' care and on the health services. This study describes the epidemiology of transition in a population of RD patients, using data from the Veneto Region Rare Diseases Registry (VRRDR), a web-based registry monitoring since 2002 a consistent number of RD in a defined area (4.9 million inhabitants). Methods: Longitudinal cohorts of patients born in the years 1988 to 1998 and enrolled in the VRRDR in their paediatric age were identified. Data referred to this group of patients, experiencing transition from paediatric to adult age during the years 2006⁻2016, are presented. Results: 2153 RD patients (44.1% females and 55.9% males) passed from childhood to adulthood in the study period, corresponding to a 3-fold increase from 2006 to 2016. The majority of these patients was affected by congenital anomalies (32.0%), by hematologic diseases (15.9%), eye disorders (12.1%) and neoplasms (7.9%). RD patients who experienced transition from paediatric age to adulthood represent the 9.2% of adult patients enrolled in the Registry at 31 December 2016. Conclusions: We described a subset of RD young adults experiencing transition into adulthood. The data reported can be considered as minimum values for estimating the size of this increasing population presenting specific transition needs. These figures are valuable for clinicians, patients and health planners. Public policy interventions are needed in order to promote dedicated care transition pathways in the broader framework of health policies devoted to RD.

Transitioning from General Pediatric to Adult-Oriented Inpatient Care: National Survey of US Children's Hospitals

BACKGROUND

Hospital charges and lengths of stay may be greater when adults with chronic conditions are admitted to children's hospitals. Despite multiple efforts to improve pediatric-adult healthcare transitions, little guidance exists for transitioning inpatient care.

OBJECTIVE

This study sought to characterize pediatricadult inpatient care transitions across general pediatric services at US children's hospitals.

DESIGN, SETTING AND PARTICIPANTS

National survey of inpatient general pediatric service leaders at US children's hospitals from January 2016 to July 2016.

MEASUREMENTS

Questionnaires assessed institutional characteristics, presence of inpatient transition initiatives (having specific process and/or leader), and 22 inpatient transition activities. Scales of highly correlated activities were created using exploratory factor analysis. Logistic regression identified associations between institutional characteristics, transition activities, and presence of an inpatient transition initiative.

RESULTS

Ninety-six of 195 children's hospitals responded (49.2% response rate). Transition initiatives were present at 38% of children's hospitals, more often when there were dual-trained internal medicine-pediatrics providers or outpatient transition processes. Specific activities were infrequent and varied widely from 2.1% (systems to track youth in transition) to 40.5% (addressing potential insurance problems). Institutions with initiatives more often consistently performed the majority of activities, including using checklists and creating patient-centered transition care plans. Of remaining activities, half involved transition planning, the essential step between readiness and transfer.

CONCLUSIONS

Relatively few inpatient general pediatric services at US children's hospitals have leaders or dedicated processes to shepherd transitions to adultoriented inpatient care. Across institutions, there is a wide variability in performance of activities to facilitate this transition. Feasible process and outcome measures are needed.

Pediatric tracheotomy: A comparison of outcomes and lengths of hospitalization between different indications

OBJECTIVES

To assess outcomes of pediatric tracheotomy and duration of associated hospital stay according to indications.

SUBJECTS AND METHODS

In this retrospective study, subjects were 142 consecutive pediatric patients (<18 years old) who underwent tracheotomy at a tertiary referral medical center, National Taiwan University Hospital, in 1997-2012. Age, sex, indications, pre-operative status (oxygen demand, number of repeated intubations), and post-operative status (duration of weaning, length of hospital stay, mortality) were analyzed.

RESULTS

The indications included craniofacial anomalies (n = 19, 13.4%), upper airway obstruction (n = 41, 28.9%), neurological deficit (n = 58, 40.8%), prolonged ventilation (n = 15, 10.6%), and trauma (n = 9, 6.3%). Ninety-one patients (64.1%) were successfully weaned off ventilation after tracheotomy (40% in the prolonged ventilation group). Total hospital stay and duration of ventilation before tracheotomy were longest in patients with craniofacial anomalies (150.9 ± 98.8 days, p = 0.004; 108.8 ± 88.2, p < 0.001). The early tracheotomy group had a shorter duration of post-tracheotomy mechanical ventilation support than the late tracheotomy group (14.4 ± 19.0, n = 49 vs. 34.9 ± 58.6, n = 80, p = 0.004). Decannulation was successful in 20 patients (14.1%), with the highest rate in the upper airway obstruction group (n = 14, 34.1%) and lowest in the prolonged ventilation group (none). Thirteen patients (9.2%) died during admission from causes unrelated to tracheotomy.

CONCLUSION

Outcomes of pediatric tracheotomy and duration of hospitalization depend on indications. Children with craniofacial anomalies had earlier tracheotomy age and longer mechanical ventilation before tracheotomy resulted in longer hospitalization. Earlier tracheotomy can shorten the duration of post-tracheotomy mechanical ventilation in several conditions.

Using Quality Improvement to Introduce and Standardize the National Early Warning Score (NEWS) for Adult Inpatients at a Children's Hospital

INTRODUCTION

The population of adults with childhood-onset chronic illness is growing across children's hospitals and constitutes a high risk population. National Early Warning Score (NEWS) is among the most recently validated adult early warning scores (EWSs) for early recognition of and response to clinical deterioration. Our aim was to implement and standardize NEWS scoring in 80% of patients age 21 and older admitted to a children's hospital.

METHODS

Our intervention was tested on a single unit of our children's hospital. The primary process measure was the percentage of NEWS documented within 1 hour of routine nursing assessments, and was tracked using a run chart. Improvement activities focused on effective training, key stakeholder buy-in, increased awareness, real-time mitigation of failures, accountability for adherence, and action-oriented response. We also tracked the distribution of NEWS values and medical emergency team calls.

RESULTS

The percentage of NEWS documented with routine nursing assessments for patients age 21 and over increased from 0% to 90% within 15 weeks and remained at 77% or greater for 17 weeks. Our distribution of NEWS values was similar to previously reported NEWS distribution.

CONCLUSIONS

A nurse-driven adult early warning system for inpatients age 21 and older at a children's hospital can be achieved through a standardized EWS assessment process, incorporation into the electronic health record, and charge nurse and key stakeholder oversight. Furthermore, implementation of an adult EWS being used at a pediatric institution and our distribution of NEWS values were comparable to distribution published from adult hospitals.

Inter-prefecture disparity in under-5 mortality: 115 year trend in Japan

BACKGROUND

Child poverty is a growing, serious issue in Japan, where various social disparities are increasing. Numerous reports have focused on the relationship between social inequity and health, but few studies have assessed how the overall magnitude of disparities in child health has changed in the course of drastic social and economic transitions from 1899 to more recent times. In this study, we assessed the trend of the under-5 mortality rate (U5MR) and its inter-prefecture disparity in Japan.

METHODS

This is a secondary analysis of Japan's vital statistics data from 1899 to 2014 (115 years), which covers a core period of modern Japan. We calculated the U5MR of each prefecture and its Theil index by year to assess the trend of inter-prefecture disparity in child health from 1899 to 2014.

RESULTS

The U5MR monotonically decreased from 238 per 1,000 births in 1899 to 3 in 2014. The Theil index of the U5MR increased in the post-war period, peaked in 1962 (0.027) and gradually reduced to <0.01 in the 1970s. In the 2000s, however, even though U5MR continued to decrease, the Theil index started to increase, and in 2014 (0.013) it exceeded that in 1970 and was more similar to that before World War II.

CONCLUSIONS

The disparities in child health appear to be widening, and may serve as a warning to today's society that increasing socioeconomic gradients may lead to rising health inequity among children. Further investigations into the causes, mechanisms, and possible interventions are needed.

On SHiPs and safety: a journey of safe patient handling in pediatrics

Nursing personnel have consistently been ranked among the top ten professions impacted by musculoskeletal injuries. Inpatient pediatric nurses witnessed an increase in injuries and upon discovering limited evidence applicable to pediatrics, conducted a research study to evaluate the effectiveness of a safe patient handling program. Surveys were distributed to assess risk and workplace safety perceptions. Post-implementation, surveys revealed a statistically significant (p>0.0001) increase in staff perception of workplace safety, reduction in risk perception for several nursing tasks, and reduction in injury related costs. As a result of this program, workplace safety was improved through education and equipment provision.

Comparison of emergency care delivered to children and young adults with complex chronic conditions between pediatric and general emergency departments

OBJECTIVES

Increasing attention is being paid to medically complex children and young adults, such as those with complex chronic conditions, because they are high consumers of inpatient hospital days and resources. However, little is known about where these children and young adults with complex chronic conditions seek emergency care and if the type of emergency department (ED) influences the likelihood of admission. The authors sought to generate nationwide estimates for ED use by children and young adults with complex chronic conditions and to evaluate if being of the age for transition to adult care significantly affects the site of care and likelihood of hospital admission.

METHODS

This was a cross-sectional study using discharge data from the 2008 Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality to evaluate visits to either pediatric or general EDs by pediatric-aged patients (17 years old or younger) and transition-aged patients (18 to 24 years old) with at least one complex chronic condition. The main outcome measures were hospital admission, ED charges for treat-and-release visits, and total charges for admitted patients.

RESULTS

In 2008, 69% of visits by pediatric-aged and 92% of visits by transition-aged patients with multiple complex chronic conditions occurred in general EDs. Not surprisingly, pediatric age was the strongest predictor of seeking care in a pediatric ED (odds ratio [OR] = 15.86; 95% confidence interval [CI] = 12.3 to 20.5). Technology dependence (OR = 1.56; 95% CI =1.2 to 2.0) and presence of multiple complex chronic conditions (OR = 1.39; 95% CI = 1.2 to 1.6) were also associated with higher odds of seeking care in a pediatric ED. When controlling for patient and hospital characteristics, type of ED was not a significant predictor of admission (p = 0.87) or total charges (p = 0.26) in either age group.

CONCLUSIONS

Overall, this study shows that, despite their complexity, the vast majority of children and young adults with multiple complex chronic conditions are cared for in general EDs. When controlling for patient and hospital characteristics, the admission rate and total charges for hospitalized patients did not differ between pediatric and general EDs. This result highlights the need for increased attention to the care that these medically complex children and young adults receive outside of pediatric-specialty centers. These results also emphasize that any future performance metrics developed to evaluate the quality of emergency care for children and young adults with complex chronic conditions must be applicable to both pediatric and general ED settings.

Hospice support and the transition to adult services and adulthood for young people with life-limiting conditions and their families: a qualitative study

BACKGROUND

Transition to adult services and adulthood is now a prospect for young people with life-limiting conditions requiring palliative care. Little is known about their transition experiences or how children's hospices can support a young adult population during/following transition.

AIMS

(1) To examine how young people with life-limiting conditions and their parents experience transition. (2) To identify families' and hospice staff's perceptions of family support needs during transition. (3) To identify the implications for children's hospices.

DESIGN

Qualitative study using in-depth, semi-structured interviews. Analysis used a grounded theory approach.

SETTING/PARTICIPANTS

A total of 39 participants recruited from one children's hospice in the United Kingdom.

RESULTS

Transition planning was absent or poorly coordinated; for most families, there were no equivalent adult health/social services. Consequently, it was a time of uncertainty and anxiety for families. Moving to a young adult unit was a positive experience for young people as the building/support model recognised their adult status. However, they had unmet needs for emotional support and accessing information/services to realise their aspirations. Parents had unmet emotional needs and were unclear of support available once their children reached adulthood. Staff identified training needs in relation to working with adults, providing emotional support and acting as an advocate/key worker.

CONCLUSIONS

Providing an appropriate building is only one aspect of developing support for young adults. A different model of support is needed, one which promotes young people's independence and provides emotional support while continuing to support parents and siblings. Hospices could play a role in transition support and coordination.

Pediatric to adult-care transitions in childhood-onset chronic disease: hospitalist perspectives

OBJECTIVE

Survey of adult-centered hospitalist perspectives on caring for adults with chronic diseases of childhood onset (CDoCO) to investigate comfort level and identify targets of future educational and policy intervention.

METHODS

We developed an on-line survey for adult-centered hospitalists based on a prior outpatient survey and introduced it to the Society of Hospital Medicine membership via e-mail. Consent was implied by completing the survey.

RESULTS

Of all respondents, 60% saw 5 or more adults with CDoCO over a 6-month period. Among internal medicine respondents, 40% did not feel comfortable caring for this population, with lack of familiarity with the literature, lack of training in CDoCO, coordinating with multiple specialists, and lack of training in adolescent development and behavior ranked as the most significant barriers to care.

CONCLUSION

The steadily growing population of adults with CDoCO and their high inpatient utilization have lead to increased care by adult-centered hospitalists, many of whom do not feel comfortable caring for them. Educational initiatives aimed at increasing medical knowledge base for common issues, training in adolescent development, increased care coordination, and access to address psychosocial issues would improve hospitalist comfort and patient care for this vulnerable population.

Hospital readmissions and repeat emergency department visits among children with medical complexity: an integrative review

Children with medical complexity (CMC) have chronic conditions, intense healthcare needs, and high healthcare utilization. Proposed changes in the healthcare environment initiated by the Affordable Care Act have led to efforts toward preventing hospital readmissions. The purpose of this integrative review is to explore the current empirical literature and examine how hospital readmissions and repeat emergency department visits have been studied among CMC. A computer database search and ancestry search were conducted, resulting in a sample of 26 studies. The results of the integrative review are presented along with gaps in the literature and implications for nursing practice and research.

Multi-institutional profile of adults admitted to pediatric intensive care units

IMPORTANCE

Growing numbers of persons with childhood-onset chronic illnesses are surviving to adulthood. Many use pediatric hospitals for their inpatient needs. To our knowledge, the prevalence and characteristics of adult pediatric intensive care unit patients have not been reported.

OBJECTIVES

To estimate the proportion of adults admitted to pediatric intensive care units (PICUs), characterize them, and compare them with older adolescents.

DESIGN

One-year cross-sectional analysis.

SETTING

Pediatric intensive care units in the United States that participated in the Virtual Pediatric Intensive Care Unit Systems.

PARTICIPANTS

Pediatric intensive care unit patients 15 years or older admitted in 2008.

MAIN OUTCOME MEASURES

We compared adults with adolescents across clinical characteristics and outcomes. Mixed-effects logistic regression was used to estimate the independent association of age with PICU mortality.

RESULTS

Seventy PICUs had 67 629 admissions; 1954 admissions (2.7%) were patients 19 years or older; and 9105 admissions (13.5%) were patients aged 15 to 18 years. The proportion of adults (≥19 years) varied considerably by PICU (range, 0%-9.2%). As age increased, the proportion of patients who had a complex chronic condition and planned or perioperative admissions increased; the proportion of trauma-related admissions decreased. Patients aged 21 to 29 years had a 2 times (95% CI, 1.3-3.2; P = .004) greater odds of PICU mortality compared with adolescent patients, after adjusting for Paediatric Index of Mortality score, sex, trauma, and having a complex chronic condition. Being 30 years or older was associated with a 3.5 (95% CI, 1.3-9.7; P = .01) greater odds of mortality.

CONCLUSIONS AND RELEVANCE

In this multi-institutional study, adults constituted a small but high-risk proportion of patients in some PICUs, suggesting that these PICUs should have plans and protocols specifically focused on this group.

Inpatient growth and resource use in 28 children's hospitals: a longitudinal, multi-institutional study

OBJECTIVE

To compare inpatient resource use trends for healthy children and children with chronic health conditions of varying degrees of medical complexity.

DESIGN

Retrospective cohort analysis.

SETTING

Twenty-eight US children's hospitals.

PATIENTS

A total of 1 526 051 unique patients hospitalized from January 1, 2004, through December 31, 2009, who were assigned to 1 of 5 chronic condition groups using 3M's Clinical Risk Group software.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Trends in the number of patients, hospitalizations, hospital days, and charges analyzed with linear regression.

RESULTS

Between 2004 and 2009, hospitals experienced a greater increase in the number of children hospitalized with vs without a chronic condition (19.2% vs 13.7% cumulative increase, P < .001). The greatest cumulative increase (32.5%) was attributable to children with a significant chronic condition affecting 2 or more body systems, who accounted for 19.2% (n = 63 203) of patients, 27.2% (n = 111 685) of hospital discharges, 48.9% (n = 1.1 million) of hospital days, and 53.2% ($9.2 billion) of hospital charges in 2009. These children had a higher percentage of Medicaid use (56.5% vs 49.7%; P < .001) compared with children without a chronic condition. Cerebral palsy (9179 [14.6%]) and asthma (13 708 [21.8%]) were the most common primary diagnosis and comorbidity, respectively, observed among these patients.

CONCLUSIONS

Patients with a chronic condition increasingly used more resources in a group of children's hospitals than patients without a chronic condition. The greatest growth was observed in hospitalized children with chronic conditions affecting 2 or more body systems. Children's hospitals must ensure that their inpatient care systems and payment structures are equipped to meet the protean needs of this important population of children.

Referral patterns and perceived barriers to adult congenital heart disease care: results of a survey of U.S. pediatric cardiologists

OBJECTIVES

This study sought to elucidate referral patterns and barriers to adult congenital heart disease (ACHD) care, as perceived by pediatric cardiologists (PCs).

BACKGROUND

Management guidelines recommend that care of adults with moderate/complex congenital heart disease be guided by clinicians trained in ACHD.

METHODS

A cross-sectional survey was distributed to randomly selected U.S. PCs.

RESULTS

Overall response rate was 48% (291 of 610); 88% (257 of 291) of respondents met inclusion criteria (outpatient care to patients >11 years of age). Participants were in practice for 18.2 ± 10.7 years; 70% were male, and 72% were affiliated with an academic institution; 79% stated that they provide care to adults (>18 years). The most commonly perceived patient characteristic prompting referral to ACHD care was adult comorbidities (83%). The most perceived barrier to ACHD care was emotional attachment of parents and patients to the PC (87% and 86%, respectively). Clinician attachment to the patient/family was indicated as a barrier by 70% of PCs and was more commonly identified by responders with an academic institutional affiliation (p = 0.001). A lack of qualified ACHD care providers was noted by 76% of PCs. Those affiliated with an academic institution were less likely to identify this barrier to ACHD care (p = 0.002).

CONCLUSIONS

Most PC respondents in the United States provide care to ACHD patients. Common triggers that prompt referral and perceived barriers to ACHD care were identified. These findings might assist ACHD programs in developing strategies to identify and retain patients, improve collaborative care, and address emotional needs during the transition and transfer process.

Resource use among adult congenital heart surgery admissions in pediatric hospitals: risk factors for high resource utilization and association with inpatient death

BACKGROUND

Pediatric hospitals frequently perform congenital heart surgery in adults with congenital heart disease. The impact of these admissions on pediatric hospital resources is unknown. Our goals were to examine resource use by adults undergoing congenital heart surgery in pediatric hospitals, explore the association between high resource use (HRU) and inpatient death, and identify HRU risk factors.

METHODS AND RESULTS

We obtained inpatient data from 42 pediatric hospitals from 2000 to 2008 and selected adult congenital heart (ACH) surgery admissions. We defined HRU admissions as those exceeding the 90th percentile for total hospital charges. We performed multivariable analyses using generalized estimating equations to identify risk factors for HRU. Of 97 563 congenital heart surgery admissions to pediatric hospitals, 3061 (3.1%) were adults, accounting for 2.2% of total hospital charges. The threshold for HRU was total hospital charges ≥$213 803. Although HRU admissions comprised 10% of admissions, they accounted for 34% of charges for all ACH surgery admissions. Mortality rate was 16% for HRU admissions and 0.7% for others (P<0.001). Multivariable analysis demonstrated higher case complexity: risk category 2 (adjusted odds ratio [AOR], 3.6; P=0.02), risk category 3 (AOR, 13.7; P<0.001), and risk category 4+ (AOR, 30.7; P<0.001) as compared with risk category 1; DiGeorge syndrome (AOR, 4.2; P=0.006); depression (AOR, 3.1; P<0.001); weekend admission (AOR, 2.6; P<0.001); and government insurance (AOR, 2.0; P<0.001) as risk factors for HRU.

CONCLUSIONS

High resource use ACH surgery admissions are associated with significantly greater mortality rates. ACH admissions with greater surgical complexity, government insurance, DiGeorge syndrome, weekend admission, and depression were more likely to result in HRU.

Adults with chronic health conditions originating in childhood: inpatient experience in children's hospitals

OBJECTIVE

To describe the rate of increase of the population of adults seeking care as inpatients in children's hospitals over time.

PATIENTS AND METHODS

We analyzed data from January 1, 1999, to December 31, 2008, from patients hospitalized at 30 academic children's hospitals, including growth rates according to age group (pediatric: aged <18 years; transitional: aged 18-21 years; or adult: aged >21 years) and disease.

RESULTS

There were 3 343 194 hospital discharges for 2 143 696 patients. Transitional patients represented 2.0%, and adults represented 0.8%, totaling 59 974 patients older than 18 years. The number of unique patients, admissions, patient-days, and charges increased in all age groups over the study period and are projected to continue to increase. Resource use was disproportionately higher in the older ages. The growth of transitional patients exceeded that of others, with 6.9% average annual increase in discharges, 7.6% in patient-days, and 15% in charges. Chronic conditions occurred in 87% of adults compared with 48% of pediatric patients. Compared with pediatric patients, the rates of increase of inpatient-days increased significantly for transitional age patients with cystic fibrosis, malignant neoplasms, and epilepsy, and for adults with cerebral palsy. Annual growth rates of charges increased for transitional and adult patients for all diagnoses except cystic fibrosis and sickle cell disease.

CONCLUSIONS

The population of adults with diseases originating in childhood who are hospitalized at children's hospitals is increasing, with varying disease-specific changes over time. Our findings underscore the need for proactive identification of strategies to care for adult survivors of pediatric diseases.

Early and long-term outcome after tracheostomy in children

BACKGROUND

  Tracheostomy has become an increasingly important issue for children discharged with primary or secondary respiratory problems. Despite the known advantages, considerable controversy remains regarding the appropriate indications, timing, and results of tracheostomy, in the context of home care. The aims of this study were to retrospectively evaluate our experience with tracheostomy and to consider problems related to this procedure, both in the hospital and after discharge.

METHODS

  We performed a retrospective chart review of all patients receiving new tracheostomies in our department, over a 5-year period.

RESULTS

  Thirty tracheostomies were performed in 30 patients over a 5-year period. The overall tracheostomy rate among ventilated patients was 3.4%. Most (90%) of the tracheostomies were placed after mechanical ventilation. Patients who were successfully decannulated spent significantly less time in intensive care, both before (P= 0.01) and after surgical tracheostomy procedure (P= 0.034) when compared to the patients discharged with tracheostomy, either with or without home ventilation. These patients also had shorter total intensive care admissions (P= 0.002) and shorter hospitalizations overall (P= 0.013). Successful decannulation was achieved in five patients (17%). The cumulative mortality rate was 17% in the pediatric intensive care unit, 20% within 30 days, and 41% within 1 year.

CONCLUSIONS

  Patients admitted with anatomic or functional airway problems had higher decannulation rates. Patients who were successfully decannulated also had significantly shorter PICU stays prior to tracheostomy. In patients with neurologic and muscular disease, or with chronic heart/lung disease, decannulation rates are very low, and these patients have a higher mortality risk after discharge.

Hospital utilization and characteristics of patients experiencing recurrent readmissions within children's hospitals

CONTEXT

Early hospital readmission is emerging as an indicator of care quality. Some children with chronic illnesses may be readmitted on a recurrent basis, but there are limited data describing their rehospitalization patterns and impact.

OBJECTIVES

To describe the inpatient resource utilization, clinical characteristics, and admission reasons of patients recurrently readmitted to children's hospitals.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort analysis of 317,643 patients (n = 579,504 admissions) admitted to 37 US children's hospitals in 2003 with follow-up through 2008.

MAIN OUTCOME MEASURE

Maximum number of readmissions experienced by each child within any 365-day interval during the 5-year follow-up period.

RESULTS

In the sample, 69,294 patients (21.8%) experienced at least 1 readmission within 365 days of a prior admission. Within a 365-day interval, 9237 patients (2.9%) experienced 4 or more readmissions; time between admissions was a median 37 days (interquartile range [IQR], 21-63). These patients accounted for 18.8% (109,155 admissions) of all admissions and 23.2% ($3.4 billion) of total inpatient charges for the study cohort during the entire follow-up period. Tests for trend indicated that as the number of readmissions increased from 0 to 4 or more, the prevalences increased for a complex chronic condition (from 22.3% [n = 55,382/248,349] to 89.0% [n = 8225/9237]; P < .001), technology assistance (from 5.3% [n = 13,163] to 52.6% [n = 4859]; P < .001), public insurance use (from 40.9% [n = 101,575] to 56.3% [n = 5202]; P < .001), and non-Hispanic black race (from 21.8% [n = 54,140] to 34.4% [n = 3181]; P < .001); and the prevalence decreased for readmissions associated with an ambulatory care-sensitive condition (from 23.1% [62,847/272,065] to 14.0% [15,282/109,155], P < .001). Of patients readmitted 4 or more times in a 365-day interval, 2633 (28.5%) were rehospitalized for a problem in the same organ system across all admissions during the interval.

CONCLUSIONS

Among a group of pediatric hospitals, 18.8% of admissions and 23.2% of inpatient charges were accounted for by the 2.9% of patients with frequent recurrent admissions. Many of these patients were rehospitalized recurrently for a problem in the same organ system.

Health care transitions among youth with disabilities or special health care needs: an ecological approach

This literature review of 46 articles uses the ecological model as a framework for organizing concepts and themes related to health care transition among youth with disabilities or special health care needs (SHCN). Transition involves interactions in immediate and distal environmental systems. Important interactions in immediate environments include those with family members, health care providers, and peers. Activities in distal systems include policies at the governmental and health system levels. The ecological model can help researchers and practitioners to design experimental interventions in multiple settings that ensure smooth transitions and support the well-being of youth with disabilities or SHCN.

Transition to adulthood: delays and unmet needs among adolescents and young adults with asthma

OBJECTIVE

To examine the effect of the transition to adulthood on financial and non-financial barriers to care in youth with asthma.

STUDY DESIGN

With National Health Interview Survey data from 2000 to 2005, we examined delays and unmet needs because of financial and non-financial barriers, evaluating the effect of adolescent (age, 12-17 years; n = 1539) versus young adult age (age, 18-24 years; N = 833), controlling for insurance, usual source of care, and sociodemographic characteristics. We also simulated the effects of providing public insurance to uninsured patients and a usual source of care to patients without one.

RESULTS

More young adults than adolescents encountered financial barriers resulting in delays (18.6% versus 8%, P < .05) and unmet needs (26.6% versus 11.4%, P < .05), although delays caused by non-financial barriers were similar (17.3% versus 14.9%, P = not significant). In logistic models young adults were more likely than adolescents to report delays (odds ratio [OR], 1.45; 95% CI, 1.02-2.08) and unmet needs (OR, 1.8; 95% CI, 1.29-2.52) caused by financial barriers.

CONCLUSIONS

Delays and unmet needs for care caused by financial reasons are significantly higher for young adults than they are for adolescents with asthma.

What Do We Really Know About the Transition to Adult-Centered Health Care? A Focus on Cerebral Palsy and Spina Bifida

OBJECTIVES

To address the lack of synthesis regarding the factors, processes, and outcomes specific to the transition from child-centered to adult-centered health care for people with cerebral palsy (CP) and spina bifida (SB); more specifically, to identify barriers, to outline key elements, to review empirical studies, and to make clinical and research recommendations.

DATA SOURCES

We searched Medline and CINAHL databases from 1990 to 2006 using the key words: transition, health care transition, pediatric health care, adult health care, health care access, health care use, chronic illness, special health care needs, and physical disability. The resulting studies were reviewed with a specific focus on clinical transition for persons with CP and SB, and were supplemented with key information from other diagnostic groups.

STUDY SELECTION

All studies meeting the inclusion criteria were included.

DATA EXTRACTION

Each article classified according to 5 criteria: methodology, diagnostic group, country of study, age group, and sample size.

DATA SYNTHESIS

We identified 149 articles: 54 discussion, 21 case series, 28 database or register, 25 qualitative, and 34 survey articles (some included multiple methods). We identified 5 key elements that support a positive transition to adult-centered health care: preparation, flexible timing, care coordination, transition clinic visits, and interested adult-centered health care providers. There was, however, limited empirical evidence to support the impact of these elements.

CONCLUSIONS

This review summarizes key factors that must be considered to support this critical clinical transition and sets the foundation for future research. It is time to apply prospective study designs to evaluate transition interventions and determine long-term health outcomes.

The population prevalence of children receiving invasive home ventilation in Utah

Children requiring home mechanical ventilation (HMV) represent a select group of technology-dependent patients. We evaluated the prevalence of children using invasive HMV in Utah from 1996 to 2004. Residents of Utah, 16 years old and less ventilated via a tracheostomy between 1996 and 2004 were identified. Children ventilated in 1996 and 2004 were compared. Data including demographic information, diagnosis leading to HMV, and age at initiation were compared between the two groups. The prevalence of HMV in 1996 was 5.0/100,000 (95% CI: 4.4-8.1) and 6.3/100,000 (95% CI: 4.7-8.4) in 2004. Median age at initiation was 6.5 months (IQR: 1.3, 24.0). Sixty-one percent (n = 47) were male, 84% (n = 65) lived in an urban county, and 86% (n = 66) had public insurance. The most frequent diagnostic category was abnormal ventilatory control (n = 36, 47%), followed by chronic lung disease (n = 19, 25%), airway abnormalities (n = 12, 16%), and neuromuscular weakness (n = 10, 13%). Thirteen patients died (17%). The median length of HMV was 39 months (IQR: 15, 102). Diagnostic categories, age at initiation of HMV, and sex did not differ significantly over the 8 years. The prevalence of children requiring HMV differed very little between 1996 and 2004. Moreover, the diagnoses for which children received this therapy remained constant.

La continuité de prise en charge lors de la transition des soins de l'enfant à l'adulte handicapé

Most children born with a chronic health condition or disability are expected to live more than 20 years. Health care is provided for these children in paediatric units until they are 18 years old, and the transition to the adult health care system is difficult because of poor collaboration between specialists and families who sometimes wonder if the adult specialist will be competent, although young disabled people need specialised follow-up. This report discusses U.S. and English models in the transition in health care. Coordination between paediatricians and adult services is necessary. The neuromuscular disorders clinic is cited as an example.

Augmentation Cystoplasty Rates at Children’s Hospitals in the United States: A Pediatric Health Information System Database Study

PURPOSE

We identified augmentation cystoplasty rates in children with spina bifida at children's hospitals enrolled in the Pediatric Health Information System database.

MATERIALS AND METHODS

The Pediatric Health Information System database tabulates demographic and diagnostic patient data from 35 children's hospital centers in the United States. Between October 1999 and September 2004 we extracted data on 0 to 19-year-old patients with International Classification of Diseases-9 diagnosis codes for spina bifida. The International Classification of Diseases-9 procedure code for augmentation cystoplasty was cross-referenced with these patients to determine the total number of patients with augmentation, total population augmentation rates and individual institution rates of bladder augmentation.

RESULTS

Staff at enrolled pediatric medical centers submitted inpatient data accounting for 9,059 beds servicing an aggregate metropolitan population of 82 million individuals. In the 5-year period 12,925 unique spina bifida patient encounters were identified, including 665 patients who underwent augmentation cystoplasty. The mean 5-year institutional number of augmentations performed in children with spina bifida was 20 (range 1 to 121) and the mean annual number of augmentations performed per institution was 4. The overall augmentation rate at 33 hospitals contributing data for the full years 2000 to 2003 was 5.4% (range 0.5% to 16.3%, p <0.0001). The male-to-female ratio of those who underwent augmentation was 1:1.2. Median length of stay in children with augmentation was 7 days (mean 9). The median age of children with augmentation was 10.4 years, that is 11.3 years in boys and 9.8 years in girls. The difference in mean age was statistically significant (p <0.003). At institutions where 10 or more augmentations were performed in 5 years (mean 27) mean patient age at operation was 10.1 years. This was significantly younger than the mean patient age of 12.3 years at hospitals where fewer than 10 augmentations (mean 5) were done in 5 years (p <0.05).

CONCLUSIONS

Clinical management for neurogenic bladder conditions has evolved to emphasize nonoperative management. Several studies suggest that aggressive early intervention improves bladder compliance and may protect renal function. However, results from the Pediatric Health Information System database demonstrate no change in augmentation rates during this time and they demonstrate significant interinstitutional variability. To our knowledge this represents the largest series of augmentation cystoplasty in children with spina bifida to date.

Young adults in children's hospitals: why are they there?

OBJECTIVE

To measure the pattern of admissions of young adults to a children's hospital.

DESIGN AND SETTING

Ten-year audit (1992-2001) of admissions of young adults aged 18 years and over to the Royal Children's Hospital (RCH), Melbourne, with a detailed chart review of the 2001 cohort to assess disease complexity and transition planning.

OUTCOME MEASURES

Number of admissions, disease complexity, transition planning.

RESULTS

There was a significant increase in the number of young adults admitted over 10 years, from 308 in 1992-1993 to 659 in 2000-2001. The greatest increase was in admissions to surgical units. There was significant variation in admission practices between units over time. Many young adults required multidisciplinary care: 57% had more than three medical/surgical units involved in their care, and 34% had two or more allied health units involved. Fifty-one per cent of surgical inpatients and 28% of medical inpatients had no documented plan for transition to adult care. Only 30% of medical and 17% of surgical inpatients in 2001 had been transferred to adult services by 2002.

CONCLUSIONS

Both disease complexity and failure of transition planning appear to have contributed to the increased admission of young adults to the RCH. While greater support of transition planning is needed, there are also concerns about the lack of appropriate services within the adult sector for young adults with complex, multidisciplinary healthcare needs.