Influence of Geographic Access on Surgical Center Readmissions After Index Congenital Heart Surgery.

OBJECTIVE: To assess the impact of geographic access to surgical center on readmission risk and burden in children after congenital heart surgery. STUDY DESIGN: Children <6 years old at discharge after congenital heart surgery (Risk Adjustment for Congenital Heart Surgery-1 score 2-6) were identified using Pediatric Health Information System data (46 hospitals, 2004-2015). Residential distance from the surgery center, calculated using ZIP code centroids, was categorized as <15, 15-29, 30-59, 60-119, and ≥120 miles. Rurality was defined using rural-urban commuting area codes. Geographic risk factors for unplanned readmissions to the surgical center and associated burden (total hospital length of stay [LOS], costs, and complications) were analyzed using multivariable regression. RESULTS: Among 59 696 eligible children, 19 355 (32%) had ≥1 unplanned readmission. The median LOS was 9 days (IQR 22) across the entire cohort. In those readmitted, median total costs were $31 559 (IQR $90 176). Distance from the center was inversely related but rurality was positively related to readmission risk. Among those readmitted, increased distance was associated with longer LOS, more complications, and greater costs. Compared with urban patients, highly rural patients were more likely to have an unplanned readmission but had fewer average readmission days. CONCLUSIONS: Geographic measures of access differentially affect readmission to the surgery center. Increased distance from the center was associated with fewer unplanned readmissions but more complications. Among those readmitted, the most isolated patients had the greatest readmission costs. Understanding the contribution of geographic access will aid in developing strategies to improve care delivery to this population.

Scaling up child development centres in Bangladesh.

BACKGROUND: Child Development Centres (CDCs) have been established within government medical college tertiary hospitals across Bangladesh. Services entail a parent-professional partnership in a child and family friendly environment with a focus on assessment, diagnosis, and management of a range of neurodevelopmental disorders in children and adolescents 0-16 years of age. Services are provided by a multidisciplinary team of professionals (child health physician, child psychologist, and developmental therapist) who emphasize quality of services over the numbers of children seen. METHODS: In 2008, Dhaka Shishu (Children's) Hospital was given the mandate by the government to conceptualize, train, and monitor CDCs nationwide. Here, we describe the rationale and processes for the establishment of the national network of CDCs and discuss lessons learned on scaling up early childhood development services in a low resource setting. RESULTS: Fifteen CDCs were established in major government hospitals across Bangladesh and have recorded 208,866 patient visits. The majority (79%) of children were from the lowest and middle-income families, and about one third (30%) were < 2 years of age at first presentation. Two thirds of children seen in follow-up demonstrated improvements in functional skills since their first visit, 77% in their adaptive behaviour (i.e., activities of daily living) and 70% in cognitive functions. CONCLUSIONS: CDCs are expanding coverage for child neurodevelopment services across Bangladesh through a tiered system of home-based screening, community- and clinic-based functional assessment, and CDC-based diagnosis, support, and referral. Vulnerable populations-the lowest income groups and younger children-comprised the majority of patients, among whom there is high unmet need for psychological services that is being met for the first time. Innovative human resource development, including a 3-month training for the multidisciplinary teams, enabled wide coverage for assessment and diagnosis of a range of neurodevelopmental problems. Demand for services is growing, especially among non-government and private hospitals.

Availability of a pediatric trauma center in a disaster surge decreases triage time of the pediatric surge population: a population kinetics model.

BACKGROUND: The concept of disaster surge has arisen in recent years to describe the phenomenon of severely increased demands on healthcare systems resulting from catastrophic mass casualty events (MCEs) such as natural disasters and terrorist attacks. The major challenge in dealing with a disaster surge is the efficient triage and utilization of the healthcare resources appropriate to the magnitude and character of the affected population in terms of its demographics and the types of injuries that have been sustained. RESULTS: In this paper a deterministic population kinetics model is used to predict the effect of the availability of a pediatric trauma center (PTC) upon the response to an arbitrary disaster surge as a function of the rates of pediatric patients' admission to adult and pediatric centers and the corresponding discharge rates of these centers. We find that adding a hypothetical pediatric trauma center to the response documented in an historical example (the Israeli Defense Forces field hospital that responded to the Haiti earthquake of 2010) would have allowed for a significant increase in the overall rate of admission of the pediatric surge cohort. This would have reduced the time to treatment in this example by approximately half. The time needed to completely treat all children affected by the disaster would have decreased by slightly more than a third, with the caveat that the PTC would have to have been approximately as fast as the adult center in discharging its patients. Lastly, if disaster death rates from other events reported in the literature are included in the model, availability of a PTC would result in a relative mortality risk reduction of 37%. CONCLUSIONS: Our model provides a mathematical justification for aggressive inclusion of PTCs in planning for disasters by public health agencies.

[Medical and surgical health care for congenital heart disease: a panoramic vision of the reality in Mexico. Inquiry 2009]. / Atención médico-quirúrgica de las cardiopatías congénitas: una visión panorámica de la realidad en México. Encuesta 2009.

INTRODUCTION: The only way to characterize the Mexican problem related to congenital heart disease care is promoting the creation of a national database for registering the organization, resources, and related activities. MATERIAL AND METHODS: The Health Secretary of Mexico adopted a Spanish registration model to design a survey for obtaining a national Mexican reference in congenital heart disease. This survey was distributed to all directors of medical and/or surgical health care centers for congenital heart disease in Mexico. This communication presents the results obtained in relation to organization, resources and activities performed during the last year 2009. RESULTS: From the 22 health care centers which answered the survey 10 were reference centers (45%) and 12 were assistant centers (55%). All of them are provided with cardiologic auxiliary diagnostic methods. Except one, all centers have at least one bidimentional echocardiography apparatus. There is a general deficit between material and human resources detected in our study. Therapeutic actions for congenital heart disease (70% surgical and 30% therapeutical interventionism) show a clear centralization tendency for this kind of health care in Mexico City, Monterrey and finally Guadalajara. CONCLUSIONS: Due to the participation of almost all cardiac health centers in Mexico, our study provides an important information related to organization, resources, and medical and/or surgical activities for congenital heart disease. The data presented not only show Mexican reality, but allows us to identify better the national problematic for establishing priorities and propose solution alternatives.

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals.

BACKGROUND: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. METHODS: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. RESULTS: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. CONCLUSION: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Geographical maldistribution of pediatric medical resources in Seattle-King County.

OBJECTIVE: Seattle-King County (SKC) Washington is at risk for regional disasters, especially earthquakes. Of 1.8 million residents, >400,000 (22%) are children, a proportion similar to that of the population of the State of Washington (24%) and of the United States (24%). The county's large area of 2,134 square miles (5,527 km2) is connected through major transportation routes that cross numerous waterways; sub-county zones may become isolated in the wake of a major earthquake. Therefore, each of SKC's three subcounty emergency response zones must have ample pediatric medical response capabilities. To date, total quantities and distribution of crucial hospital resources (available in SKC) to manage pediatric victims of a medical disaster are unknown. This study assessed whether geographical distribution of hospital pediatric resources corresponds to the pediatric population distribution in SKC. METHODS: Surveys were delivered electronically to all eight acute care hospitals in SKC that admit pediatric patients. Quantities and categories of pediatric resources, including inpatient treatment space, staff, and equipment, were queried and verified via site visits. RESULTS: Within the seven responding hospitals of eight queried, the following were identified: 477 formal pediatric bed spaces (pediatric intensive care unit, neo-natal intensive care unit, general wards, and emergency department), 43 informal pediatric bed spaces (operating room and post-anesthesia care unit), 1,217 pediatric nurses, 554 pediatric physicians, and 252 infant/pediatric-adaptable ventilators. The City of Seattle emergency response zone contains 82.1% of bed spaces, 83.5% of nurses, and 95.8% of physicians, yet only 22.8% of all SKC children live in that zone. CONCLUSIONS: The majority of hospital pediatric resources are located in the SKC sub-region with the fewest children. These resources are potentially inaccessible and unable to be redistributed by ground transportation in the event of a significant regional disaster. Future planning for pediatric care in the event of a medical disaster in SKC must address this vulnerability.

Pandemic influenza planning: addressing the needs of children.

Children represent one quarter of the US population. Because of its enormous size and special needs, it is critically important to address this population group in pandemic influenza planning. Here we describe the ways in which children are vulnerable in a pandemic, provide an overview of existing plans, summarize the resources available, and, given our experience with influenza A(H1N1), outline the evolving lessons we have learned with respect to planning for a severe influenza pandemic. We focus on a number of issues affecting children-vaccinations, medication availability, hospital capacity, and mental health concerns-and emphasize strategies that will protect children from exposure to the influenza virus, including infection control practices and activities in schools and child care programs.

The Global Initiative for Children's Surgery: Optimal Resources for Improving Care.

BACKGROUND: The Lancet Commission on Global Surgery reported that 5 billion people lack access to safe, affordable surgical care. The majority of these people live in low-resource settings, where up to 50% of the population is children. The Disease Control Priorities (Debas HTP, Donkor A, Gawande DT, Jamison ME, Kruk, and Mock CN, editors. Essential Surgery. Disease Control Priorities. Third Edition, vol 1. Essential Surgery. Washington, DC: World Bank; 2015) on surgery included guidelines for the improvement of access to surgical care; however, these lack detail for children's surgery. AIM: To produce guidance for low- and middle-income countries (LMICs) on the resources required for children's surgery at each level of hospital care. METHODS: The Global Initiative for Children's Surgery (GICS) held an inaugural meeting at the Royal College of Surgeons in London in May 2016, with 52 surgical providers from 21 countries, including 27 providers from 18 LMICs. Delegates engaged in working groups over 2 days to prioritize needs and solutions for optimizing children's surgical care; these were categorized into infrastructure, service delivery, training, and research. At a second GICS meeting in Washington in October 2016, 94 surgical care providers, half from LMICs, defined the optimal resources required at primary, secondary, tertiary, and national referral level through a series of working group engagements. RESULTS: Consensus solutions for optimizing children's surgical care included the following: · Establishing standards and integrating them into national surgical plans.. · Each country should have at least one children's hospital.. · Designate, facilitate, and support regional training hubs covering all. · children's surgical specialties.. · Establish regional research support centers.. An "Optimal Resources" document was produced detailing the facilities and resources required at each level of care. CONCLUSION: The Optimal Resources document has been produced by surgical providers from LMICs who have the greatest insight into the needs and priorities in their population. The document will be refined further through online GICS Working Groups and the World Health Organization for broad application to ensure all children have timely access to safe surgical care.

Leaps and bounds.

The nation's children's hospitals are in the midst of a building boom, moving into dazzling new spaces, adding an array of amenities and boosting research.

Communities with and without children's hospitals: Where do the sickest children receive care?

The author's purpose in this study was to examine whether children's hospitals treat more resource-intense children within their communities than do general acute-care hospitals in the same communities, and then to examine which general acute-care hospitals in communities without children's hospitals fill the role of caring for very sick children. In large communities without children's hospitals, at least one general hospital is likely to treat resource-intense children. Healthcare managers in community hospitals need to be prepared to meet the healthcare needs of resource-intense children, which includes having the appropriate specialized staff and technology to care for the sickest children.

Do pediatric hospitalizations have a unique geography?

BACKGROUND: In the U.S. small-area health services research studies are often based on the hospital service areas (HSAs) defined by the Dartmouth Atlas of Healthcare project. These areas are based on the geographic origins of Medicare Part A hospital patients, the great majority of whom are seniors. It is reasonable to question whether the geographic system so defined is appropriate for health services research for all ages, particularly for children, who have a very different system of healthcare financing and provision in the U.S. METHODS: This article assesses the need for a unique system of HSAs to support pediatric small-area analyses. It is a cross-sectional analysis of California hospital discharges for two age groups - non-newborns 0-17 years old, and seniors. The measure of interest was index of localization, which is the percentage of HSA residents hospitalized in their home HSA. Indices were computed separately for each age group, and index agreement was assessed for 219 of the state's HSAs. We examined the effect of local pediatric inpatient volume and pediatric inpatient resources on the divergence of the age group indices. We also created a new system of HSAs based solely on pediatric patient origins, and visually compared maps of the traditional and the new system. RESULTS: The mean localization index for pediatric discharges was 20 percentage points lower than for Medicare cases, indicating a poorer fit of the traditional geographic system for children. The volume of pediatric cases did not appear to be associated with the magnitude of index divergence between the two age groups. Pediatric medical and surgical case subgroups gave very similar results, and both groups differed substantially from seniors. Location of children's hospitals and local pediatric bed supply were associated with Medicare-pediatric divergence. There was little visual correspondence between the maps of traditional and pediatric-specific HSAs. CONCLUSION: Children and seniors have significantly different geographic patterns of hospitalization in California. Medicare-based HSAs may not be appropriate for all age groups and service types throughout the U.S.

Especificidades contextuais do cuidado de enfermagem à criança em condição crônica hospitalizada / Contextual specificities of nursing care to hospitalized children with chronic condition

Objetivou-se compreender as especificidades contextuais do cuidado de enfermagem à criança em condição crônica hospitalizada. Foi utilizada a abordagem qualitativa apoiando-se nos referenciais teórico e metodológico, respectivamente, o Pensamento Complexo e a Grounded Theory. Os dados foram coletados entre julho e novembro de 2012 por meio da entrevista semiestruturada. Participaram do estudo 18 sujeitos organizados em três grupos amostrais: enfermeiros, técnicos de enfermagem e familiares. A categoria Revelando especificidades contextuais que influenciam o cuidado de enfermagem à criança em condição crônica hospitalizada e suas respectivas subcategorias apresentam os significados do cuidado de enfermagem, aspectos relacionados à hospitalização da criança em condição crônica e as percepções dos participantes acerca do contexto de cuidado. Conclui-se que as relações de cuidado e a hospitalização da criança em condição crônica configuram-se como fenômenos complexos, solicitando do enfermeiro e de sua equipe a valorização do contexto e a articulação de múltiplos saberes e práticas.

This study aimed to understand the contextual specificities of nursing care givento the hospitalized children with chronic conditions. The qualitative approach was usedbased on the theoretical and methodological frameworks, respectively, the Complex Thought and the Grounded Theory. Data were collected from July to November 2012 through semi-structured interviews. The study included 18 subjects arrangedin three sample groups: nurses, nursing technicians and family. The category Revealing contextual specificities that influence nursing care given to hospitalized children with chronic conditionsand its subcategories present the meanings of nursing care, aspects about the hospitalization of children with chronic conditions and perceptions of participants about the care context. We concluded that the care relationships and the hospitalization of children with chronic condition are characterized as complex phenomena, requiring from the nurse and the nursing team the appreciation of the context and articulation of multiple knowledge and practices.

Access to pediatric trauma care in the United States.

OBJECTIVES: To catalog trauma center resources and estimate access to age-specific trauma care for children younger than 15 years in the United States. DESIGN: Cross-sectional study collating information from national, state, and local trauma systems authorities to create a catalog of verified pediatric trauma centers (PTCs) and self-designated "candidate" trauma centers. Access-to-care calculations were estimated using all US block groups and prior validated methods. SETTING: United States. PATIENTS: Children in the US younger than 15 years. MAIN OUTCOME MEASURES: The PTC statuses of hospitals in the United States. Percentages of pediatric populations (by state and population density) having access (by ground or air) within 60 minutes to a PTC. RESULTS: A total of 170 verified PTCs were identified in 41 states (including the District of Columbia). An estimated 71.5% of pediatric patients were within 60 minutes of a verified PTC by air or ground transport, 43% if ground transportation only was considered. An estimated 17.4 million children did not have access to a PTC within 60 minutes. Access ranged from 22.9% of the population in the most rural areas of the United States to 93.5% in the most urban. The addition of 24 candidate centers increased coverage to 77.4% of the pediatric population being within 60 minutes of a PTC. CONCLUSIONS: Current pediatric trauma resources vary greatly by state and population density, with many children, particularly in rural areas, underserved. A thorough standardized catalog of verified PTCs is necessary to accurately assess pediatric trauma needs now and to optimize future trauma system planning for children.

Pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care.

BACKGROUND: Federal planners have suggested that one strategy to accommodate disaster surges of 500 inpatients per million population would involve altering standards of care. No data are available indicating the extent of alterations necessary to meet disaster surge targets. OBJECTIVE: Our goal was to, in a Monte Carlo simulation study, determine the probability that specified numbers of children could be accommodated for PICU and non-ICU hospital care in a disaster by a set of strategies involving altered standards of care. METHODS: Simulated daily vacancies at each hospital in New York City were generated as the difference between peak capacity and daily occupancy (generated randomly from a normal distribution on the basis of empirical data for each hospital). Simulations were repeated 1000 times. Capacity for new patients was explored for normal standards of care, for expansion of capacity by a discretionary 20% increase in vacancies by altering admission and discharge criteria, and for more strictly reduced standards of care to double or quadruple admissions for each vacancy. Resources were considered to reliably serve specified numbers of patients if that number could be accommodated with a probability of 90%. RESULTS: Providing normal standards of care, hospitals in New York City would reliably accommodate 250 children per million age-specific population. Hypothetical strict reductions in standards of care would reliably permit hospital care of 500 children per million, even if the disaster reduced hospital resources by 40%. On the basis of historical experience that as many as 30% of disaster casualties may be critically ill or injured, existing pediatric intensive care beds will typically be insufficient, even with modified standards of care. CONCLUSIONS: Extending resources by hypothetical alterations of standards of care would usually satisfy targets for hospital surge capacity, but ICU capacity would remain inadequate for large disasters.