Objectives & Hypothesis
Children with home mechanical ventilation (HMV) require skilled care by trained caregivers, and their families feel the impacts of ubiquitous home nursing shortages. It is ...unknown which factors determine allocation; no standards for private duty nursing intensity exist. We sought to characterize provider experiences with and opinions on home nursing for children with HMV, hypothesizing providers would describe frequent home nursing gaps across clinical scenarios.
Methods
Purposeful and snowball sampling identified key informant clinical providers. Survey topics included hours of home nursing received across clinical and family scenarios. Close‐ended responses were analyzed using descriptive statistics and open‐ended questions coded with iterative modification for major theme agreement.
Results
A total of 59 respondents represented care of patients from 44 states; 49.2% physicians, 37.3% nurses, 10.2% respiratory therapists, and 3.4% case managers. Nearly all (97%) believed that families should receive more hours during initial home transition, yet less than half (47%) do. The majority (80.7%) thought the presence of other children in the home should influence nursing hours, yet only three (5.3%) reported other children have influence. Across hypothetical medical technology scenarios, providers consistently described children receiving fewer nursing hours than the providers' ideal practice. A third (31.7%) described discharging patients without any home nursing arranged.
Conclusions
This HMV provider sample highlights pervasive deficiency in home nursing provision with heterogenous interpretation of what constitutes ideal home care. Family and social contextual factors are infrequently considered in nursing allocations. Provider, community health, and family stakeholders must collaborate to generate national community practice standards for children with HMV.
Little is known about the use of chronic medications (CMs) in children. We assessed the prevalence of CM use in children and the association of clinical characteristics and health care resource use ...with the number of CMs used.
This is a retrospective study of children ages 1 to 18 years using Medicaid from 10 states in 2014 grouped by the annual number of CMs (0, 1, 2-4, 5-9, and ≥10 medications), which are defined as a dispensed ≥30-day prescription with ≥2 dispensed refills. Trends in clinical characteristics and health care use by number of CMs were evaluated with the Cochran-Armitage trend test.
Of 4 594 061 subjects, 18.8% used CMs. CM use was 44.4% in children with a complex chronic condition. Across all children, the most common CM therapeutic class was neurologic (28.9%). Among CM users, 48.8% used multiple CMs (40.3% used 2-4, 7.0% used 5-9, and 0.5% used ≥10). The diversity of medications increased with increasing number of CMs: for 1 CM, amphetamine stimulants were most common (29.0%), and for ≥10 CMs, antiepileptics were most common (7.1%). Of $2.3 billion total pharmacy spending, 59.3% was attributable to children dispensed multiple CMs. Increased CM use (0 to ≥10 medications) was associated with increased emergency department use (32.1% to 56.2%) and hospitalization (2.3% to 36.7%).
Nearly 1 in 5 children with Medicaid used CMs. Use of multiple CMs was common and correlated with increased health care use. Understanding CM use in children should be fundamentally important to health care systems when strategizing how to provide safe, evidence-based, and cost-effective pharmaceutical care to children.
Background
Carbon dioxide concentration trending is used in chronic management of children with invasive home mechanical ventilation (HMV) in clinical settings, but options for end‐tidal carbon ...dioxide (EtCO2) monitoring at home are limited. We hypothesized that a palm‐sized, portable endotracheal capnograph (PEC) that measures EtCO2 could be adapted for in‐home use in children with HMV.
Methods
We evaluated the internal consistency of the PEC by calculating an intraclass correlation coefficient of three back‐to‐back breaths by children (0–17 years) at baseline health in the clinic. Pearson's correlation was calculated for PEC EtCO2 values with concurrent mean values of in‐clinic EtCO2 and transcutaneous CO2 (TCM) capnometers. The Bland–Altman test determined their level of agreement. Qualitative interviews and surveys assessed usability and acceptability by family‐caregivers at home.
Results
CO2 values were collected in awake children in varied activity levels and positions (N = 30). The intraclass correlation coefficient for the PEC was 0.95 (p < 0.05). The correlation between the PEC and in‐clinic EtCO2 device was 0.85 with a mean difference of −3.8 mmHg and precision of ±1.1 mmHg. The correlation between the PEC and the clinic TCM device was 0.92 with a mean difference of 0.2 mmHg and precision of ±1.0. Family‐caregivers (N = 10) trialed the PEC at home; all were able to obtain measurements at home while children were awake and sometimes asleep.
Conclusions
A portable, noninvasive device for measuring EtCO2 was feasible and acceptable, with values that trend similarly to currently in‐practice, outpatient models. These devices may facilitate monitoring of EtCO2 at home in children with invasive HMV.
To describe the rate of increase of the population of adults seeking care as inpatients in children's hospitals over time.
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.
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.
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.
PDF
