Pandemic influenza and acute care centers: taking care of sick patients in a nonhospital setting.

The ongoing spread of H5N1 avian influenza in Southeast Asia has raised concern about a worldwide influenza pandemic and has made clear the need to plan in advance for such an event. The federal government has stressed the importance of planning and, in particular, has asked hospitals and public health agencies to develop plans to care for patients outside of traditional healthcare settings. These alternative or acute care centers (ACCs) would be opened when hospitals, emergency departments (EDs), and clinics are overwhelmed by an influenza pandemic. The University of Michigan Hospital System (UMHS), a large tertiary care center in southeast Michigan, has been developing a model for offsite care of patients during an influenza pandemic. This article summarizes our planning efforts and the lessons learned from 2 functional exercises over the past 3 years.

Clinical redesign using all patient refined diagnosis related groups.

OBJECTIVE: Clinical redesign of processes in hospitals that care for children has been limited by a paucity of severity-adjusted indicators that are sensitive enough to identify areas of concern. This is especially true of hospitals that analyze pediatric patient care using standard Centers for Medicare and Medicaid Services (CMS) diagnosis-related groups (DRGs). The objectives of this study were to determine whether 1) utilization of all-patient refined (APR)-DRG severity-adjusted indicators (length of stay, cost per case, readmission rate) from the National Association of Children's Hospitals and Related Institutions (NACHRI) database could identify areas for improvement at University of Michigan Mott Children's Hospital (UMMCH) and 2) hospital staff could use the information to implement successful clinical redesign. METHODS: The APR-DRG Classification System (version 20) was used with the NACHRI Case Mix Comparative Database by severity level comparison from 1999 to 2002. Indicators include average length of stay (ALOS), case mix index, cost per case, and readmission rate for low acuity asthma (APR-DRG 141.1). UMMCH cases of 141.1 (n = 511) were compared with NACHRI 141.1 (n = 64,312). Although not part of the standard report, mortality rates were calculated by NACHRI for UMMCH and an aggregate of NACHRI member children's hospitals. RESULTS: Data from 1999 revealed that in noncomplicated asthma cases (level 1 severity), the UMMCH ALOS versus NACHRI ALOS was slightly longer (UMMCH 2.16 days vs NACHRI 2.14 days), and the cost per case was higher (UMMCH $2824 vs NACHRI 2738 dollars), whereas levels 2, 3, and 4 cases (moderate, major, and extreme severity) indicated the ALOS and cost per case were lower than the national aggregate. This showed that the APR-DRG system was sensitive enough to distinguish variances of care within a diagnosis according to severity level. After analysis of internal data and meeting with clinicians to review the indicators, 3 separate clinical processes were targeted: 1) correct documentation of comorbidities and complications, 2) standardized preprinted orders were created with the involvement of the pediatric pulmonologists, and 3) standardized automatic education for parents was started on the first day of admission. Yearly data were reviewed and appropriate adjustments made in the education of both residents and staff. In 2002, the UMMCH ALOS dropped to 1.75 +/- .08 days from 2.16 +/- .09. In 2002, the NACHRI ALOS was 2.00 days +/- 0.01 versus the UMMCH ALOS of 1.75 days +/- 0.0845, indicating that the UMMCH ALOS dropped significantly lower than the NACHRI aggregate database over the 3-year period. Cost per case of UMMCH compared with NACHRI after the 3 years indicated that UMMCH increased 12%, whereas the NACHRI aggregate increased 18%. These data show that length of stay and cost per case relative to the national database improved after clinical redesign. Improvements have been sustained throughout the 3-year period. Readmission rates ranged from 2.97% to 0.80% and were less than the national cohort by the third year. There were no mortalities in the UMMCH inpatient asthma program. This demonstrates that clinicians believed that the data from the APR-DRG acuity-adjusted system was useful and that they were then able to apply classical clinical redesign strategies to improve cost-effectiveness and quality that was sustained over 3 years. CONCLUSIONS: Severity-adjusted indicators were useful for identifying areas appropriate for clinical redesign and contributed to the improvement in cost-effective patient care without a detriment in quality indicators. This method of using a large comparative database, having measures of severity, and using internal analysis is generalizable for pediatric hospitals and can contribute to ongoing attempts to improve cost-effectiveness and quality in medical care.

Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit.

OBJECTIVE: Unplanned extubation (UEX) is a potentially serious complication of mechanical ventilation. Limited information is available regarding factors that contribute to UEXs and subsequent reintubation of children. We monitored UEXs in our pediatric intensive care unit (PICU) for a 5-year period to assess the incidence and patient conditions associated with UEX and to evaluate whether targeted interventions were associated with a reduced rate of UEXs. METHODS: Over a 5-year period, demographic and clinical information was collected prospectively on all patients who required an artificial airway while admitted to the PICU. Additional information was collected for patients who experienced an UEX. Educational sessions and care management protocols were developed, implemented, and modified according to issues identified via the monitoring program. RESULTS: From a total of 2192 patients who required 13 630 airway days (AWD), 141 (6%) patients experienced 164 UEXs. The overall rate of UEX for the study period was 1.2 UEXs per 100 AWD, and this rate decreased from 1.5 in the first year to 0.8 in the last year. UEXs were more common in children who were younger than 5 years (1.6 vs 0.6 UEX per 100 AWD) compared with older children. The UEX children experienced significantly longer length of mechanical ventilation (6 vs 3 days) and longer length of PICU stay (8 vs 4 days) compared with non-UEX children. Forty-six percent of the UEXs occurred in patients who were weaning from mechanical ventilation, and 22% of those patients required reintubation. CONCLUSIONS: We conclude that UEX in pediatric patients is associated with longer length of mechanical ventilation and length of stay in the PICU. A continuous quality improvement monitoring and educational program that identified high-risk patients for UEX (younger patients) and patients who were at low risk for subsequent reintubation (weaning patients) contributed to a reduction of these potentially adverse events.