The utility of imputed matched sets. Analyzing probabilistically linked databases in a low information setting.

OBJECTIVE: To compare results from high probability matched sets versus imputed matched sets across differing levels of linkage information. METHODS: A series of linkages with varying amounts of available information were performed on two simulated datasets derived from multiyear motor vehicle crash (MVC) and hospital databases, where true matches were known. Distributions of high probability and imputed matched sets were compared against the true match population for occupant age, MVC county, and MVC hour. Regression models were fit to simulated log hospital charges and hospitalization status. RESULTS: High probability and imputed matched sets were not significantly different from occupant age, MVC county, and MVC hour in high information settings (p > 0.999). In low information settings, high probability matched sets were significantly different from occupant age and MVC county (p < 0.002), but imputed matched sets were not (p > 0.493). High information settings saw no significant differences in inference of simulated log hospital charges and hospitalization status between the two methods. High probability and imputed matched sets were significantly different from the outcomes in low information settings; however, imputed matched sets were more robust. CONCLUSIONS: The level of information available to a linkage is an important consideration. High probability matched sets are suitable for high to moderate information settings and for situations involving case-specific analysis. Conversely, imputed matched sets are preferable for low information settings when conducting population-based analyses.

Development and impact of a computerized pediatric antiinfective decision support program.

OBJECTIVE: Computerized medical decision support tools have been shown to improve the quality of care and have been cited by the Institute of Medicine as one method to reduce pharmaceutical errors. We evaluated the impact of an antiinfective decision support tool in a pediatric intensive care unit (PICU). METHODS: We enhanced an existing adult antiinfective management tool by adding and changing medical logic to make it appropriate for pediatric patients. Process and outcomes measures were monitored prospectively during a 6-month control and a 6-month intervention period. Mandatory use of the decision support tool was initiated for all antiinfective orders in a 26-bed PICU during the intervention period. Clinician opinions of the decision support tool were surveyed via questionnaire. RESULTS: The rate of pharmacy interventions for erroneous drug doses declined by 59%. The rate of anti-infective subtherapeutic patient days decreased by 36%, and the rate of excessive-dose days declined by 28%. The number of orders placed per antiinfective course decreased 11.5%, and the robust estimate of the antiinfective costs per patient decreased 9%. The type of anti-infectives ordered and the number of antiinfective doses per patient remained similar, as did the rates of adverse drug events and antibiotic-bacterial susceptibility mismatches. The surveyed clinicians reported that use of the program improved their antiinfective agent choices as well as their awareness of impairments in renal function and reduced the likelihood of adverse drug events. CONCLUSIONS: Use of the pediatric antiinfective decision support tool in a PICU was considered beneficial to patient care by the clinicians and reduced the rates of erroneous drug orders, improved therapeutic dosage targets, and was associated with a decreased robust estimate of antiinfective costs per patient. antiinfective agents, decision support systems, drug therapy, medication errors, child, infant.

A population-based assessment of pediatric all-terrain vehicle injuries.

OBJECTIVE: To describe the types of injuries sustained by children who ride all-terrain vehicles (ATVs), to estimate the hospital charges associated with these injuries, and to determine adherence to existing rules and regulations governing ATV use. METHODS: Analysis of statewide hospital admissions (1992-1996) and emergency department (ED) visits (1996) in Utah. All patients who were younger than 16 years and had an external cause of injury code for ATV use were included. RESULTS: In 1996, 268 ED visits by children involved an ATV. Boys were twice as commonly injured as girls (male:female ratio: 2.1:1), and skin and orthopedic injuries were most frequent. The median ED charge was $368, and ED charges for these patients totaled $138 000. From 1992 to 1996, 130 children were hospitalized as a result of injuries sustained during ATV use, with median charges of $4240 per admission. Male to female ratio was 2.7:1, and the average age was 11.2 +/- 3.6 years. Mean injury severity score was 8.0 +/- 6.0, and median length of stay was 2 days (range: 0-43 days). Orthopedic injuries were most frequent, but 25% (n = 32) of children sustained head or spinal cord injury. Most children (94%) were discharged from the hospital, but 8 children died as a result of their injuries. Utah regulations prohibit children who are younger than 8 years from driving an ATV and advise against carrying passengers on ATVs. However, 25% (n = 15) of all injured children who were younger than 8 were driving the ATV when injured, and 15% (n = 60) of injured children were passengers on ATVs. Four of the 8 fatally injured children were younger than 8, and all were driving the ATV at the time of the crash. Finally, the estimated injury rate per 100 registered ATVs is significantly higher for children than for adults (3.41 vs 1.71). CONCLUSIONS: ATV use results in significant injuries to children. Efforts to educate parents regarding the risks of ATV use, proper supervision, and use of safety equipment are warranted. Manufacturers of ATVs should continue to improve the safety profile of these inherently unstable vehicles.

Probabilistic linkage of computerized ambulance and inpatient hospital discharge records: a potential tool for evaluation of emergency medical services.

STUDY OBJECTIVES: Emergency medical services (EMS) is an important part of the health care system. The effect of EMS on morbidity, mortality, and costs of illness is difficult to evaluate because hospital information is not available in out-of-hospital databases. We used probabilistic linkage to create such a database from ambulance and inpatient data and demonstrate the potential for linkage to facilitate evaluation of EMS responses resulting in hospital admission. METHODS: Statewide ambulance and inpatient hospital discharge records were available for 1994 through 1996. Ambulance records indicating admission to the emergency department or hospital (165,649 records) were linked to inpatient hospital records indicating emergency admission (146,292 records) by using probabilistic linkage. Out-of-hospital data (dispatch code, treatments rendered, and ages), linkage rates, and inpatient data (discharge status, charges, length of stay, and payer category) were analyzed. RESULTS: We linked 24,299 (14.7%) ambulance events to inpatient hospital discharges. If we had used exact linkage methods, we would have only linked 14,621 record pairs, a loss of nearly 40%. Linkage rates were relatively constant between years (approximately 15%) but differed by ambulance dispatch codes. Out-of-hospital dispatch codes with high linkage rates included breathing problems (22.6%), chest pain (21.5%), diabetic problems (16.9%), drowning incidents (14.9%), falls (19.2%), strokes (32.8%), and unconsciousness or fainting episodes (16.1%). Linkage to the hospital record provided access to hospital outcome data. Inpatient mortality was 6.8%. Survivors were discharged home (60.7%), transferred to other acute-care facilities (3.6%) or intermediate-care facilities (23.3%), or discharged with home health care provision (4.9%). The median length of stay was 3 days, and median charges were $6,620; total inpatient charges were $286,737,067. CONCLUSION: Probabilistic linkage enables ambulance and hospital discharge records to be linked together and potentially increases our ability to critically evaluate EMS by providing access to hospital-based outcomes. Such evaluation will be further improved by linking to ED, other outpatient, and other public health data sources.

A population-based study of crashes involving 16- and 17-year-old drivers: the potential benefit of graduated driver licensing restrictions.

OBJECTIVE: To evaluate the potential effectiveness of graduated driver licensing programs using population-based linked data for motor vehicle crashes (MVCs) that involved teenaged drivers (TDs). METHODS: Utah crash, inpatient hospital discharge, and emergency department databases were analyzed and probabilistically linked. We computed hospital charges and compared violations, contributing factors, seatbelt use, and passengers for TDs (16-17 years old) relative to adult drivers (18-59 years old). RESULTS: TDs comprised 5.8% of the study population, but were involved in 19.0% of MVCs. TD crashes resulted in $11 million in inpatient hospital charges and 158 fatalities. TD crashes were 1.70 times (95% confidence interval [CI]: 1.34, 2.04) less likely to result in fatal injury to drivers than were crashes that involved adult drivers, but TDs were 2.20 times (95% CI: 1.96, 2.47) more likely to receive citations. The following were findings of the study: 1) 11% of all TD crashes but 19% of fatal TD crashes occurred between 2200 and 0600 hours; 2) TDs used seatbelts less often than did adult drivers (79.1% vs 84.4%) and less often with passengers present (81.9% vs 75.0%; 3) TDs were 1.72 times (95% CI: 1.38, 2.14) more likely to be involved in crashes that resulted in seriously or fatally injured occupants when driving with passengers than when driving alone. CONCLUSIONS: TDs are overrepresented in MVCs. TD crashes have a higher fatality rate at night, and TDs wear seatbelts less often than do adult drivers. Passengers affect TD crash characteristics. Graduated driver licensing programs that target state-specific characteristics of TDs may decrease morbidity and mortality.

Usage of emergency medical services by children with special health care needs.

OBJECTIVE: To describe the usage of emergency medical services (EMS) by children with special health care needs (CSHCN). METHODS: All EMS runs and related hospital records for children aged 0-17 years in Utah in 1991-92 were linked. The CSHCN status was determined from ICD-9 diagnoses using three available definitions. The amounts of EMS usage were compared between CSHCN and other children. A pediatric intensive care practitioner determined CSHCN status by chart review for 915 children transported by EMS to a pediatric tertiary care hospital, and his classification was compared with the CSHCN status assigned by the three ICD-9-based definitions. RESULTS: The three definitions assigned CSHCN status for 2% to 24% of children using EMS. When compared with other children, CSHCN were more likely to be admitted to the hospital, more likely to use EMS for transfer between health care facilities, and more likely to receive prehospital procedures such as intravenous therapy. In the group of children whose charts were reviewed individually, one ICD-9-based definition most closely agreed to determination of CSHCN status by a pediatric intensive care practitioner. CONCLUSIONS: Children with special health care needs who use EMS are more likely to receive advanced life support service, to receive prehospital procedures, and to be transferred from one health care facility to another. There is need for a specific and measurable definition of CSHCN that can be applied to existing health data.

Distinctive emergency department usage for injury for workers' compensation cases in Utah in 1996.

To compare emergency department services paid by worker's compensation (WC) with services paid by other payers, a state database of 72,747 emergency department visits for injured adults (ages 21 to 54) in 1996 in Utah was analyzed. WC visits accounted for 21.6% (15,704) of all adult injury visits. The mean emergency department charge for WC visits was $282, and the admission rate was 17 per 1000 visits. The mean charge for other payers was $334, and the admission rate was 43 per 1000 visits. Differences were also found between these groups for Injury Severity Scores and diagnoses. In summary, WC emergency department usage was associated with less severe injuries than was emergency department usage for other payers in Utah in 1996.

The epidemiology of pediatric air medical transports in Utah.

OBJECTIVE: To describe the air-transported patients treated at Primary Children's Medical Center (PCMC), the sole pediatric tertiary care center in Utah and a referral center in the intermountain region. This study describes the patients who utilized the air medical transport system, the medical services provided in the prehospital setting, and the corresponding charges for transport and treatment. METHODS: Participants were air-transported patients aged 17 years and less who were treated at PCMC during the calendar years 1991-1992. The study population excluded patients who were transported to other medical facilities, and newborns. Data were abstracted retrospectively from the patients' medical and transport records. Data collected included demographic information, patient diagnoses, and treatments performed during transport. Financial data were supplied by the hospital. RESULTS: During the study period, 874 pediatric patients met the participant criteria. Helicopter and fixed-wing transports comprised 561 and 313, respectively, from nine states in the mountain and western regions. The majority (313, 56%) of the patients transported by helicopter were trauma patients, while the majority (195, 62%) of fixed-wing transports were for illness-related conditions. Scene transports accounted for 120 (21%) of helicopter transports. Children with special health care needs accounted for 171 (20%) of all transports. CONCLUSIONS: Injury severity scores indicate that, overall, air-transported patients were more severely injured than comparable ground-transported patients. However, it is apparent that some patients who were air-transported could have been transported by ground ambulance without detriment. medical services.

Critical pathways for postoperative care after simple congenital heart surgery.

OBJECTIVE: To evaluate the clinical, financial, and parent/patient satisfaction impact of critical pathways on the postoperative care of pediatric cardiothoracic patients with simple congenital heart lesions. STUDY DESIGN: Critical pathways were developed by pediatric intensive care nurses and implemented under the direction of pediatric cardiothoracic surgeons. PATIENTS AND METHODS: Critical pathways were used during a 12-month study on 46 postoperative patients with simple repair of atrial septal defect (ASD), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). Using the study criteria, a control group of 58 patients was chosen from 1993. Prospective and control group data collected included postoperative intubation time, total laboratory tests, arterial blood gas utilization, morphine utilization, time in the pediatric intensive care unit, total hospital stay, total hospital charges, total hospital cost, and complications. Variances from the critical pathway and satisfaction data were also recorded for study patients. RESULTS: Resource utilization was reduced after implementation of critical pathways. Significant reductions were seen in total hours in the pediatric intensive care unit, total number of laboratory tests, postoperative intubation times, arterial blood gas utilization, morphine utilization, length of hospitalization (ASD, 4.9 to 3.1 days; CoA, 5.2 to 3.2 days; and PDA, 4.1 to 1.4 days; all P < 0.05), total hospital charges (ASD, $16,633 to $13,627; CoA, $14,292 to $8319; and PDA, $8249 to $4216; all P < 0.05), and total hospital costs. There was no increase in respiratory complications or other complications. Patients and families were generally satisfied with their hospital experience, including analgesia and length of hospitalization. CONCLUSIONS: Implementation of critical pathways reduced resource utilization and costs after repair of three simple congenital heart lesions, without obvious complications or patient dissatisfaction.

Innovation in the assessment of nursing theory and its evaluation: a team approach.

In response to recent national changes in United Kingdom (UK) nurse education (e.g. devolution of assessment, moves to higher education, revision of the aims) and to local concerns (e.g. fairness to students, validity and reliability of written assessments, helping staff with less experience of assessment, student learning) an initiative has been developed at Southampton based on a team approach to marking and moderating. A five-stage evaluation was designed to accompany implementation of the initiative. The evaluation, carried out by a lecturer and an independent educational evaluator, involved both tutors/lecturers and students. Interviews, questionnaires and observation methods were used. Benefits of the initiative and of the particular model of evaluation included: increased knowledge and confidence in the validity and reliability of the marking and moderating process undertaken by tutor-teams; increased fairness to students; in-service tutor training related to student assessment; knowledge that assessment-promoted learning was taking place. A review of the total assessment programme was an unexpected outcome, including a review of the frequency and timing of assessments and of the written guidelines. The five-stage evaluation developed a feeling of involvement and heightened self-knowledge. Curricular understanding also increased; this helped to achieve the initiative as designed and intended. We recommend this model of evaluation; it promotes involvement of all concerned, students as well as staff, and generates valuable process-knowledge. It can be used in pre- and post-registration nurse education.

Nonradiographic assessment of enteral feeding tube position.

OBJECTIVE: To determine whether a clinical, nonradiographic criterion can be used to predict when the tip of a blindly placed feeding tube is in the small intestine. DESIGN: Prospective sample. SETTING: Pediatric intensive care unit at a tertiary care children's hospital. PATIENTS: Critically ill children requiring transpyloric feeding. INTERVENTIONS: The small bowel was intubated, using a blind, bedside transpyloric feeding tube placement protocol. The feeding tube was considered to be in the small bowel when <2 mL of a 10- mL aliquot of insufflated air could be aspirated from the feeding tube. This clinical criterion was confirmed with an abdominal radiograph. MEASUREMENTS AND MAIN RESULTS: Patient age ranged from 1 month to 19 yrs (median 6 months). Weight ranged from 2.2 to 60 kg (median 4.9). Median time to feeding tube placement was 10 mins (range 5 to 60). Eighty-nine percent of the patients were mechanically ventilated, while 28% of these patients were pharmacologically paralyzed. Seventy-five feeding tubes were inserted. There were no known complications. Ninety-nine (74/75) percent of the feeding tubes were positioned in the small bowel. The inability to aspirate insufflated air correctly predicted small bowel intubation with 99% certainty (Sequential Probability Ratio Test, p = .05 and power = .80). This test incorrectly predicted the position of only one feeding tube, the 26th, which was in the stomach. Of the 74 feeding tubes positioned in the small bowel, 13 feeding tubes were in the duodenum and 61 were in the jejunum. CONCLUSIONS: The inability to aspirate insufflated air confirms the transpyloric position of a feeding tube. Other clinical criteria did not successfully predict small bowel intubation. Use of this single test may obviate confirmatory abdominal radiographs in carefully selected patients and may lead to more cost-effective and timely initiation of enteral feedings.

Lack of validity of diagnosis-related group payment systems in an intensive care population.

Case mix based on diagnosis-related groups (DRGs) was studied over 3 years for duration of stay and mean charges for a pediatric intensive care unit (PICU) and a general ward (WARD) population. Case mix variation for 2403 PICU and 14,552 WARD patients was analyzed, and a subset of 856 PICU and 2222 WARD patients examined for variations in duration of stay and mean charges in nine DRGs. Whereas case mix by DRG was consistent over time for both groups, the PICU case mix differed consistently from WARD case mix (P less than 0.001). After adjustment for inflation and for differences in case mix, average stay for the PICU was 10.7 days, versus 6.1 for the WARD (P less than 0.025), with a mean charge of $7172 per PICU and $2946 per WARD patient (P less than 0.01). Furthermore, the case mix-adjusted differences in duration of stay and mean charge between the PICU and WARD populations increased over time. Pediatricians will need to address DRG-based reimbursement systems that place intensive care units, and their institutions, at a significant financial disadvantage.