To determine the proportion of US children hospitalized for a primary mental health condition who are discharged to postacute care (PAC); whether PAC discharge is associated with demographic, ...clinical, and hospital characteristics; and whether PAC use varies by state.
Retrospective cohort study of a nationally representative sample of US acute care hospitalizations for children ages 2-20 years with a primary mental health diagnosis, using the 2009 and 2012 Kids' Inpatient Databases. Discharge to PAC was used as a proxy for transfer to an inpatient mental health facility. We derived adjusted logistic regression models to assess the association of patient and hospital characteristics with discharge to PAC.
In 2012, 14.7% of hospitalized children (n = 248 359) had a primary mental health diagnosis. Among these, 72% (n = 178 214) had bipolar disorder, depression, or psychosis, of whom 4.9% (n = 8696) were discharged to PAC. The strongest predictors of PAC discharge were homicidal ideation (aOR, 24.9; 96% CI, 4.1-150.4), suicide and self-injury (aOR, 15.1; 95% CI, 11.7-19.4), and substance abuse–related medical illness (aOR, 5.0; 95% CI, 4.5-5.6). PAC use varied widely by state, ranging from 2.2% to 36.3%.
The majority of children hospitalized primarily for a mood disorder or psychosis were not discharged to PAC, and safety-related conditions were the primary drivers of the relatively few PAC discharges. There was substantial state-to-state variation. Target areas for quality improvement include improving access to PAC for children hospitalized for mood disorders or psychosis and equitable allocation of appropriate PAC resources across states.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
OBJECTIVE
To inform resource allocation toward a continuum of care for youth at risk of suicide, we examined unplanned 30‐day readmissions after pediatric hospitalization for either suicide ideation ...(SI) or suicide attempt (SA).
METHODS
We conducted a retrospective cohort study of a nationally representative sample of 133,516 hospitalizations for SI or SA among 6‐ to 17‐year‐olds to determine prevalence, risk factors, and characteristics of 30‐day readmissions using the 2013 and 2014 Nationwide Readmissions Dataset (NRD). Risk factors for readmission were modeled using logistic regression.
RESULTS
We identified 95,354 hospitalizations for SI and 38,162 hospitalizations for SA. Readmission rates within 30 days were 8.5% for SI and SA hospitalizations. Among 30‐day readmissions, more than one‐third (34.1%) occurred within seven days. Among patients with any 30‐day readmission, 11% had more than one readmission within 30 days. The strongest risk factors for readmission were SI or SA hospitalization in the 30 days preceding the index SI/SA hospitalization (adjusted odds ratio AOR: 3.14, 95% CI: 2.73‐3.61) and hospitalization for other indications in the previous 30 days (AOR: 3.18, 95% CI: 2.67‐3.78). Among readmissions, 94.5% were for a psychiatric condition and 63.4% had a diagnosis of SI or SA.
CONCLUSIONS
Quality improvement interventions to reduce unplanned 30‐day readmissions among children hospitalized for SI or SA should focus on children with a recent prior hospitalization and should be targeted to the first week following hospital discharge.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
BACKGROUND
Many hospitals are considering contacting hospitalized patients soon after discharge to help with issues that arise.
OBJECTIVES
To (1) describe the prevalence of contact‐identified ...postdischarge issues (PDI) and (2) assess characteristics of children with the highest likelihood of having a PDI.
DESIGN, SETTING, AND PATIENTS
A retrospective analysis of hospital‐initiated follow‐up contact for 12,986 children discharged from January 2012 to July 2015 from 4 US children's hospitals. Contact was made within 14 days of discharge by hospital staff via telephone call, text message, or e‐mail. Standardized questions were asked about issues with medications, appointments, and other PDIs. For each hospital, patient characteristics were compared with the likelihood of PDI by using logistic regression.
RESULTS
Median (interquartile range) age of children at admission was 4.0 years (0‐11); 59.9% were non‐Hispanic white, and 51.0% used Medicaid. The most common reasons for admission were bronchiolitis (6.3%), pneumonia (6.2%), asthma (5.1%), and seizure (4.9%). Twenty‐five percent of hospitalized children (n = 3263) reported a PDI at contact (hospital range: 16.0%‐62.8%). Most (76.3%) PDIs were related to follow‐up appointments (eg, difficulty getting one); 20.8% of PDIs were related to medications (eg, problems filling a prescription). Patient characteristics associated with the likelihood of PDI varied across hospitals. Older age (age 10‐18 years vs <1 year) was significantly (P < .001) associated with an increased likelihood of PDI in 3 of 4 hospitals.
CONCLUSIONS
PDIs were identified often through hospital‐initiated follow‐up contact. Most PDIs were related to appointments. Hospitals caring for children may find this information useful as they strive to optimize their processes for follow‐up contact after discharge.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
OBJECTIVE
Mental health conditions (MHCs) are prevalent among hospitalized children and could influence the success of hospital discharge. We assessed the relationship between MHCs and 30‐day ...readmissions.
METHODS
This retrospective, cross‐sectional study of the 2013 Nationwide Readmissions Database included 512,997 hospitalizations of patients ages 3 to 21 years for the 10 medical and 10 procedure conditions with the highest number of 30‐day readmissions. MHCs were identified by using the International Classification of Diseases, 9th Revision‐Clinical Modification codes. We derived logistic regression models to measure the associations between MHC and 30‐day, all‐cause, unplanned readmissions, adjusting for demographic, clinical, and hospital characteristics.
RESULTS
An MHC was present in 17.5% of medical and 13.1% of procedure index hospitalizations. Readmission rates were 17.0% and 6.2% for medical and procedure hospitalizations, respectively. In the multivariable analysis, compared with hospitalizations with no MHC, hospitalizations with MHCs had higher odds of readmission for medical admissions (adjusted odds ratio AOR, 1.23; 95% confidence interval CI, 1.19‐1.26 and procedure admissions (AOR, 1.24; 95% CI, 1.15‐1.33). Three types of MHCs were associated with higher odds of readmission for both medical and procedure hospitalizations: depression (medical AOR, 1.57; 95% CI, 1.49‐1.66; procedure AOR, 1.39; 95% CI, 1.17‐1.65), substance abuse (medical AOR, 1.24; 95% CI, 1.18‐1.30; procedure AOR, 1.26; 95% CI, 1.11‐1.43), and multiple MHCs (medical AOR, 1.43; 95% CI, 1.37‐1.50; procedure AOR, 1.26; 95% CI, 1.11‐1.44).
CONCLUSIONS
MHCs are associated with a higher likelihood of hospital readmission in children admitted for medical conditions and procedures. Understanding the influence of MHCs on readmissions could guide strategic planning to reduce unplanned readmissions for children with cooccurring physical and mental health conditions.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Suicide ideation (SI) and suicide attempts (SAs) have been reported as increasing among US children over the last decade. We examined trends in emergency and inpatient encounters for SI and SA at US ...children's hospitals from 2008 to 2015.
We used retrospective analysis of administrative billing data from the Pediatric Health Information System database.
There were 115 856 SI and SA encounters during the study period. Annual percentage of all visits for SI and SA almost doubled, increasing from 0.66% in 2008 to 1.82% in 2015 (average annual increase 0.16 percentage points 95% confidence intervals (CIs) 0.15 to 0.17). Significant increases were noted in all age groups but were higher in adolescents 15 to 17 years old (average annual increase 0.27 percentage points 95% CI 0.23 to 0.30) and adolescents 12 to 14 years old (average annual increase 0.25 percentage points 95% CI 0.21 to 0.27). Increases were noted in girls (average annual increase 0.14 percentage points 95% CI 0.13 to 0.15) and boys (average annual increase 0.10 percentage points 95% CI 0.09 to 0.11), but were higher for girls. Seasonal variation was also observed, with the lowest percentage of cases occurring during the summer and the highest during spring and fall.
Encounters for SI and SA at US children's hospitals increased steadily from 2008 to 2015 and accounted for an increasing percentage of all hospital encounters. Increases were noted across all age groups, with consistent seasonal patterns that persisted over the study period. The growing impact of pediatric mental health disorders has important implications for children's hospitals and health care delivery systems.
OBJECTIVE:To describe the use of an emergency department (ED)-based injury surveillance model to determine the incidence and mechanisms of nonfatal injuries among children living in Cabrini Green, a ...poor urban community.
METHODS:Using ED records and census data, population-based injury rates were determined for a retrospective cohort of children, 0 to 14 years old, (N = 3908) with nonfatal injuries resulting in ED treatment between January 1994 and December 1998.
RESULTS:There were 1950 nonfatal injuries during the 5-year study period (annual injury incidence of 998/10,000). Age-specific rates (per 10,000 per year) were 899 among 0- to 4-year olds, 616 among 5- to 9-year olds, and 435 among 10- to 14-year olds. Sixty-three percent were male. The most common injury mechanisms were falls (339/10,000 per year), being struck by/against an object (201/10,000 per year), and being cut/pierced by an object (87/10,000 per year). Falls from a building window (2/10,000 per year) were infrequent. The incidence of housefire-related burns was 1.5/10,000 per year. Intentional injuries included alleged child abuse, 43/10,000 per year, and assaults, 30/10,000 per year. The assault rate among 10- to 14-year-old males was 100/10,000 per year. One hundred thirty-four children were admitted to the hospital (average annual rate of 69/10,000). The most frequent admission diagnoses were falls (22/10,000) among 0- to 9-year olds and assaults (13/10,000) among 10- to 14-year olds.
CONCLUSION:An ED-based injury surveillance system can provide an efficient and useful way to determine injury incidence in a defined urban community. The data suggest that rates of violence-related injuries were high, while rates of window falls and housefires were low. These data have allowed targeted injury prevention efforts in Cabrini Green, and future surveillance will allow the evaluation of injury prevention activities.
IntroductionAntibiotics are time-critical in the management of sepsis. When infectious organisms are unknown, patients are treated with empiric antibiotics to include coverage for gram-negative ...organisms, such as antipseudomonal cephalosporins and penicillins. However, in observational studies, some antipseudomonal cephalosporins (eg, cefepime) are associated with neurologic dysfunction while the most common antipseudomonal penicillin (piperacillin–tazobactam) is associated with acute kidney injury (AKI). No randomised control trials have compared these regimens. This manuscript describes the protocol and analysis plan for a trial designed to compare the effects of antipseudomonal cephalosporins and antipseudomonal penicillins among acutely ill patients receiving empiric antibiotics.Methods and analysisThe Antibiotic Choice On ReNal outcomes trial is a prospective, single-centre, non-blinded randomised trial being conducted at Vanderbilt University Medical Center. The trial will enrol 2500 acutely ill adults receiving gram-negative coverage for treatment of infection. Eligible patients are randomised 1:1 to receive cefepime or piperacillin–tazobactam on first order entry of a broad-spectrum antibiotic covering gram-negative organisms. The primary outcome is the highest stage of AKI and death occurring between enrolment and 14 days after enrolment. This will be compared between patients randomised to cefepime and randomised to piperacillin–tazobactam using an unadjusted proportional odds regression model. The secondary outcomes are major adverse kidney events through day 14 and number of days alive and free of delirium and coma in 14 days after enrolment. Enrolment began on 10 November 2021 and is expected to be completed in December 2022.Ethics and disseminationThe trial was approved by the Vanderbilt University Medical Center institutional review board (IRB#210591) with a waiver of informed consent. Results will be submitted to a peer-reviewed journal and presented at scientific conferences.Trial registration numberNCT05094154.
Co-located bridge clinics aim to facilitate a timely transition to outpatient care for inpatients with opioid use disorder (OUD); however, their effect on hospital length of stay (LOS) and ...postdischarge outcomes remains unclear.
To evaluate the effect of a co-located bridge clinic on hospital LOS among inpatients with OUD.
This parallel-group randomized clinical trial recruited 335 adult inpatients with OUD seen by an addiction consultation service and without an existing outpatient clinician to provide medication for OUD (MOUD) between November 25, 2019, and September 28, 2021, at a tertiary care hospital affiliated with a large academic medical center and its bridge clinic.
The bridge clinic included enhanced case management before and after hospital discharge, MOUD prescription, and referral to a co-located bridge clinic. Usual care included MOUD prescription and referrals to community health care professionals who provided MOUD.
The primary outcome was the index admission LOS. Secondary outcomes, assessed at 16 weeks, were linkage to health care professionals who provided MOUD, MOUD refills, same-center emergency department (ED) and hospital use, recurrent opioid use, quality of life (measured by the Schwartz Outcome Scale-10), overdose, mortality, and cost. Analysis was performed on an intent-to-treat basis.
Of 335 participants recruited (167 randomized to the bridge clinic and 168 to usual care), the median age was 38.0 years (IQR, 31.9-45.7 years), and 194 (57.9%) were male. The median LOS did not differ between arms (adjusted odds ratio AOR, 0.94 95% CI, 0.65-1.37; P = .74). At the 16-week follow-up, participants referred to the bridge clinic had fewer hospital-free days (AOR, 0.54 95% CI, 0.32-0.92), more readmissions (AOR, 2.17 95% CI, 1.25-3.76), and higher care costs (AOR, 2.25 95% CI, 1.51-3.35), with no differences in ED visits (AOR, 1.15 95% CI, 0.68-1.94) or deaths (AOR, 0.48 95% CI, 0.08-2.72) compared with those receiving usual care. Follow-up calls were completed for 88 participants (26.3%). Participants referred to the bridge clinic were more likely to receive linkage to health care professionals who provided MOUD (AOR, 2.37 95% CI, 1.32-4.26) and have more MOUD refills (AOR, 6.17 95% CI, 3.69-10.30) and less likely to experience an overdose (AOR, 0.11 95% CI, 0.03-0.41).
This randomized clinical trial found that among inpatients with OUD, bridge clinic referrals did not improve hospital LOS. Referrals may improve outpatient metrics but with higher resource use and expenditure. Bending the cost curve may require broader community and regional partnerships.
ClinicalTrials.gov Identifier: NCT04084392.
BACKGROUND
Recovery from respiratory illness (RI), a common reason for hospitalization, can be protracted for some children because of high illness severity or underlying medical complexity.
...OBJECTIVE
We assessed which children hospitalized with RI are the most likely to use post‐acute facility care (PAC) for recovery.
METHODS
Retrospective analysis of 609,800 hospitalizations for patients in 43 US children's hospitals between 2010‐2015 for RI, identified with the Agency for Healthcare Research and Quality Clinical Classification System. Discharge to PAC was identified using Centers for Medicare & Medicaid Services Discharge Status Codes. We compared patient characteristics by PAC use with generalized estimating equations.
RESULTS
There were 2660 (0.4%) RI hospitalizations resulting in PAC transfer (n = 2660, 0.4%). Discharges to PAC had greater percentages of technology assistance (83.2% vs 15.1%), neuromuscular chronic condition (57.5% vs 8.9%), and mechanical ventilation (52.7% vs 9.1%), P < 0.001 for all. The highest likelihood of PAC use occurred with ≥11 vs no chronic conditions (odds ratio OR 11.7 95% CI, 8.0‐17.2), ≥9 vs no therapeutic medication classes (OR 4.8 95% CI, 1.8‐13.0), and existing tracheostomy (OR 3.0, 95% confidence interval CI, 2.6‐3.5). Median (interquartile range IQR) acute‐care length of stay (LOS) for children most likely to use PAC was 19 (8‐56) days; LOS remained long (median 13 6‐41 days) for children with the same attributes (n = 9448) not transferred to PAC.
CONCLUSIONS
Children with RI who are most likely to use PAC have a high prevalence of multiple chronic conditions, multiple medications, and medical technology. Future investigations should assess the supply of PAC against the demand of hospitalized children with RI who might need it.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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