Post-acute day and night non-invasive respiratory intervention use and outcome: A brief report.

OBJECTIVE: This study aimed to describe daytime and nighttime use and outcome of non-invasive respiratory intervention (NIRI) for infants born prematurely and for children with medical complexity (CMC) during a post-acute care hospital (PACH) admission. METHODS: Thirty-eight initial PACH admissions (October 2018 through September 2020) for premature infants (< 1 year; n = 19) and CMC (> 1 year; n = 19) requiring NIRI during the day and/or at night were retrospectively examined. Measures included: 1) daytime and nighttime NIRI use by type (supplemental oxygen therapy via low-flow nasal cannula or positive airway pressure [PAP] via high-flow nasal cannula, continuous positive airway pressure, or biphasic positive airway pressure at admission and discharge) and 2) daytime and nighttime NIRI outcome-reduction, increase, or no change from admission to discharge. RESULTS: For the total sample (n = 38), daytime vs nighttime NIRI use was significantly different (p < 0.001). At both admission and discharge, supplemental oxygen was the most common NIRI during the day, while PAP was most common at night. From admission to discharge, seven (18%) infants and children had a positive change (reduced NIRI) during the day, while nine (24%) had a positive change at night. At discharge, 11/38 (29%) infants and children required no daytime NIRI, while 4/38 (11%) required no day or night NIRI. CONCLUSION: NIRI use differs between day and night at PACH admission and discharge for CMC. Reductions in NIRI were achieved during the day and at night from PACH admission to discharge for both infants born prematurely and for children with varied congenital, neurological, or cardiac diagnoses.

Identification of prognostic factors in childhood T-cell acute lymphoblastic leukemia: Results from DFCI ALL Consortium Protocols 05-001 and 11-001.

BACKGROUND/OBJECTIVES: While outcomes for pediatric T-cell acute lymphoblastic leukemia (T-ALL) are favorable, there are few widely accepted prognostic factors, limiting the ability to risk stratify therapy. DESIGN/METHODS: Dana-Farber Cancer Institute (DFCI) Protocols 05-001 and 11-001 enrolled pediatric patients with newly diagnosed B- or T-ALL from 2005 to 2011 and from 2012 to 2015, respectively. Protocol therapy was nearly identical for patients with T-ALL (N = 123), who were all initially assigned to the high-risk arm. End-induction minimal residual disease (MRD) was assessed by reverse transcription polymerase chain reaction (RT-PCR) or next-generation sequencing (NGS), but was not used to modify postinduction therapy. Early T-cell precursor (ETP) status was determined by flow cytometry. Cases with sufficient diagnostic DNA were retrospectively evaluated by targeted NGS of known genetic drivers of T-ALL, including Notch, PI3K, and Ras pathway genes. RESULTS: The 5-year event-free survival (EFS) and overall survival (OS) for patients with T-ALL was 81% (95% CI, 73-87%) and 90% (95% CI, 83-94%), respectively. ETP phenotype was associated with failure to achieve complete remission, but not with inferior OS. Low end-induction MRD (<10-4 ) was associated with superior disease-free survival (DFS). Pathogenic mutations of the PI3K pathway were mutually exclusive of ETP phenotype and were associated with inferior 5-year DFS and OS. CONCLUSIONS: Together, our findings demonstrate that ETP phenotype, end-induction MRD, and PI3K pathway mutation status are prognostically relevant in pediatric T-ALL and should be considered for risk classification in future trials. DFCI Protocols 05-001 and 11-001 are registered at www.clinicaltrials.gov as NCT00165087 and NCT01574274, respectively.

Children dependent on respiratory support: A 10-year review from one pediatric postacute care hospital.

OBJECTIVE: Pediatric postacute care hospitals (PACH) provide long-term care for children with medical complexity including children dependent on respiratory support. Descriptions of PACH respiratory care populations and outcomes, however, remain under-reported. Our aim was to describe demographics, respiratory outcome, and longitudinal trend of children with respiratory support admitted to a single PACH in the United States. METHODS: Using electronic records from 2009 to 2018, data were examined for all children dependent on respiratory support. Children were identified for inclusion using respiratory level of care classifications (type of support) as outlined in hospital policy. Outcome was defined as change in level from first admission to final discharge. Number of admissions by level and year during the study timeframe were analyzed. RESULTS: There were 1423 admissions for 767 children requiring respiratory support during the study timeframe. Children with higher respiratory classification level (eg, mechanical ventilation) at initial admission had more admissions to PACH (P < .001) and longer length of stays (P < .001). From first admission to final discharge, there was a significant change (reduction) in respiratory level (z = -4.588, P < .001). An increase in the overall number of admissions for children with respiratory support during the study timeframe was noted, with the largest increase for children requiring the highest level of support. CONCLUSION: There has been a consistent increase in the number of children requiring respiratory support at admission to PACH. Reduction in respiratory support with postacute care occurs but children admitted with a higher level of support stay longer and experience multiple admissions.

Refining risk classification in childhood B acute lymphoblastic leukemia: results of DFCI ALL Consortium Protocol 05-001.

Dana-Farber Cancer Institute (DFCI) ALL Consortium Protocol 05-001 tested a new risk stratification system in children and adolescents with newly diagnosed acute lymphoblastic leukemia (ALL). At study entry, B-ALL patients were classified as standard risk (SR) or high risk (HR) based on age, white blood cell (WBC) count, and central nervous system status. After achieving complete remission (CR), patients with high end-induction minimal residual disease (MRD) (≥10-3 by polymerase chain reaction analysis of patient-specific antigen receptor rearrangements) and/or adverse cytogenetics (KMT2A rearrangement or hypodiploidy) were reclassified as very high risk (VHR) and received intensified therapy. IKZF1 deletion status was retrospectively evaluated by multiplex ligation-dependent probe amplification. Between 2005 and 2011, 678 Philadelphia chromosome-negative B-ALL patients aged 1 to 18 years enrolled; 651 achieved CR and 648 received a final risk group. Among all 678 patients, 5-year event-free survival (EFS) was 87% (95% confidence interval [CI], 84-89) and overall survival 93% (95% CI, 90-94). Five-year disease-free survival of SR patients (N = 407) was 94% (95% CI, 91-96), HR (N = 176) was 84% (95% CI, 77-88), and VHR (N = 65) was 79% (95% CI, 67-87). IKZF1 deletion was present in 62 of 385 (16%) assessed patients and was associated with inferior 5-year EFS (63%; 95% CI, 49%-74% vs 88%; 95% CI, 84%-91%; P < .001), and higher 5-year cumulative incidence of relapse, including among those with low MRD (24% vs 8%, P = .001). In multivariable analysis, age ≥15 years, WBC ≥50 × 109/L, IKZF1 deletion, and MRD ≥10-4 was each associated with inferior outcome. In conclusion, risk-stratified therapy on DFCI 05-001 resulted in favorable outcomes for B-ALL patients, including those with VHR features. IKZF1 deletion was an independent predictor of inferior outcome. This trial was registered at www.clinicaltrials.gov as #NCT00400946.

Admissions to Acute Care Within 30 and 90 Days of Discharge Home From a Pediatric Post-acute Care Hospital.

OBJECTIVES: Of all hospitalized children, those with medical complexity have the highest likelihood of hospital readmission. Post-acute hospital care could potentially help stabilize the health of these children. We examined the frequency of acute care hospital admissions after discharge home from a post-acute care hospital (PACH). METHODS: A retrospective cohort analysis of 448 children with medical complexity discharged from a PACH from January 1, 2010, to December 31, 2015, with the main outcomes of acute care hospital readmissions 0 to 30 and 31 to 90 days after discharge home from a PACH. Demographic and clinical characteristics were compared between children with and without acute care readmission and between the 2 readmission groups. RESULTS: Ninety-nine children (22%) had a readmission to the acute care hospital. Of these readmissions, 61 (62%) occurred between 0 and 30 days and 38 (38%) between 31 and 90 days after PACH discharge. A higher percentage of children readmitted had high medical severity (>3 systems involved or ventilator dependent) compared with children not readmitted (68% vs 31%, P = .04). No differences were found between children who were readmitted and those who were not by sex, race, payer, length of stay, or age at PACH discharge. Additionally, no differences were found between children readmitted within 30 days and children readmitted 31 to 90 days after PACH discharge. CONCLUSIONS: The majority of children discharged home from a PACH do not require an acute care hospitalization within the first 3 months. Children with greater medical severity are readmitted more often than others.

Construct validity of the pediatric evaluation of disability inventory computer adaptive test (PEDI-CAT) in children with medical complexity.

PURPOSE: To assess construct (convergent and divergent) validity of the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) in a sample of children with complex medical conditions. METHOD: Demographics, clinical information, PEDI-CAT normative score, and the Post-Acute Acuity Rating for Children (PAARC) level were collected for all post-acute hospital admissions (n = 110) from 1 April 2015 to 1 March 2016. Correlations between the PEDI-CAT Daily Activities, Mobility, and Social/Cognitive domain scores for the total sample and across three age groups (infant, preschool, and school-age) were calculated. Differences in mean PEDI-CAT scores for each domain across two groups, children with "Less Complexity," or "More Complexity" based on PAARC level were examined. RESULTS: All correlations for the total sample and age subgroups were statistically significant and trends across age groups were evident with the stronger associations between domains for the infant group. Significant differences were found between mean PEDI-CAT Daily Activities, Mobility, and Social/Cognitive normative scores across the two complexity groups with children in the "Less Complex" group having higher PEDI-CAT scores for all domains. CONCLUSION: This study provides evidence indicating the PEDI-CAT can be used with confidence in capturing and differentiating children's level of function in a post-acute care setting. Implications for Rehabilitation The PEDI-CAT is measure of function for children with a variety of conditions and can be used in any clinical setting. Convergent validity of the PEDI-CAT's Daily Activities, Mobility, and Social/Cognitive domains was significant and particularly strong for infants and young children with medical complexity. The PEDI-CAT was able to discriminate groups of children with differing levels of medical complexity admitted to a pediatric post-acute care hospital.

Responsiveness of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test in measuring functional outcomes for inpatient pediatric rehabilitation.

PURPOSE: Responsiveness of the PEDI-CAT Mobility, Daily Activities, and Social/Cognitive domains and Wheelchair subdomain was evaluated for youth admitted to a pediatric post-acute care hospital. METHODS: Inpatients ages 2-21 years, with a length of stay of ≥ 5 days and with both admission and discharge scores were included. The difference between mean admission and discharge PEDI-CAT scaled scores were analyzed using paired t-tests. Effect sizes, standard response means (SRMs), and minimal detectable change values were calculated. Score comparison between diagnostic subgroups (Traumatic Brain Injury, Neurological, Orthopedic, Medical) and age groups ( ≤ 5, > 5 but < 13, ≥ 13 years) were evaluated for the Mobility domain. RESULTS: Sample size differed by domain with 66 Mobility, 30 Daily Activities, 19 Social/Cognitive and 9 Wheelchair subdomain pairs. Significant differences were found for all domains when mean admission and discharge scaled scores were compared. Moderate to large effect sizes and SRMs were found for the Mobility and Daily Activities domains and Wheelchair subdomain. Small effect size but large SRM was found for the Social/Cognitive domain. The Mobility domain was also responsive to changes in all diagnostic and age groups. CONCLUSION: The PEDI-CAT was responsive to functional changes for youth discharged from an inpatient pediatric rehabilitation hospital.

Development and Initial Psychometric Evaluation of the Post-Acute Acuity Rating for Children.

The Post-Acute Acuity Rating for Children (PAARC) is the first known acuity rating intended to reflect medical severity based on age, reason for admission, diagnoses, dependence in activities of daily living, and technology reliance for children admitted to post-acute care rehabilitation hospitals. Content validity was tested using an expert panel scoring the Content Validity Index (CVI). Concurrent validity was examined using clinician's opinion of acuity at admission, the Complexity Index, and All Patient Refined Diagnosis Related Group (APR-DRG) codes. Predictive validity was examined with acute care readmission within 30 days. Interrater reliability was assessed using admission histories from closed cases. Content validity was established and concurrent validity was moderate to high with clinician opinion (rho = .76, p < .001), the Complexity Index (rho = .76, p < .001), and APR-DRGs (rho = .349, p = .001). Predictive validity was moderate (rho = .504, p = .005) and returns to acute care within 30 days. Interrater reliability was excellent (ICC = 0.97; 95% CI = 0.92-0.90, p < .001). Experts agreed that the PAARC's content is relevant, simple, and representative of the population. The PAARC measured well against indicators of medical complexity for pediatric outpatient care and medical record coding and was reliable between raters. This work supports proceeding with additional development and validity testing of the PAARC.

Intravenous pegylated asparaginase versus intramuscular native Escherichia coli L-asparaginase in newly diagnosed childhood acute lymphoblastic leukaemia (DFCI 05-001): a randomised, open-label phase 3 trial.

BACKGROUND: l-asparaginase is a universal component of treatment for childhood acute lymphoblastic leukaemia, and is usually administered intramuscularly. Pegylated Escherichia coli asparaginase (PEG-asparaginase) has a longer half-life and is potentially less immunogenic than the native Escherichia coli (E coli) preparation, and can be more feasibly administered intravenously. The aim of the Dana-Farber Cancer Institute Acute Lymphoblastic Leukaemia Consortium Protocol 05-001 (DFCI 05-001) was to compare the relative toxicity and efficacy of intravenous PEG-asparaginase and intramuscular native E colil-asparaginase in children with newly diagnosed acute lymphoblastic leukaemia. METHODS: DFCI 05-001 enrolled patients aged 1-18 years with newly diagnosed acute lymphoblastic leukaemia from 11 consortium sites in the USA and Canada. Patients were assigned to an initial risk group on the basis of their baseline characteristics and then underwent 32 days of induction therapy. Those who achieved complete remission after induction therapy were assigned to a final risk group and were eligible to participate in a randomised comparison of intravenous PEG-asparaginase (15 doses of 2500 IU/m(2) every 2 weeks) or intramuscular native E colil-asparaginase (30 doses of 25 000 IU/m(2) weekly), beginning at week 7 after study entry. Randomisation (1:1) was unmasked, and was done by a statistician-generated allocation sequence using a permuted blocks algorithm (block size of 4), stratified by final risk group. The primary endpoint of the randomised comparison was the overall frequency of asparaginase-related toxicities (defined as allergy, pancreatitis, and thrombotic or bleeding complications). Predefined secondary endpoints were disease-free survival, serum asparaginase activity, and quality of life during therapy as assessed by PedsQL surveys. All analyses were done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00400946. FINDINGS: Between April 22, 2005, and Feb 12, 2010, 551 eligible patients were enrolled. 526 patients achieved complete remission after induction, of whom 463 were randomly assigned to receive intramuscular native E colil-asparaginase (n=231) or intravenous PEG-asparaginase (n=232). The two treatment groups did not differ significantly in the overall frequency of asparaginase-related toxicities (65 [28%] of 232 patients in the intravenous PEG-asparaginase group vs 59 [26%] of 231 patients in the intramuscular native E colil-asparaginase group, p=0·60), or in the individual frequency of allergy (p=0·36), pancreatitis (p=0·55), or thrombotic or bleeding complications (p=0·26). Median follow-up was 6·0 years (IQR 5·0-7·1). 5-year disease-free survival was 90% (95% CI 86-94) for patients assigned to intravenous PEG-asparaginase and 89% (85-93) for those assigned to intramuscular native E colil-asparaginase (p=0·58). The median nadir serum asparaginase activity was significantly higher in patients who received intravenous PEG-asparaginase than in those who received intramuscular native E colil-asparaginase. Significantly more anxiety was reported by both patients and parent-proxy in the intramuscular native E colil-asparaginase group than in the intravenous PEG-asparaginase group. Scores for other domains were similar between the groups. The most common grade 3 or worse adverse events were bacterial or fungal infections (47 [20%] of 232 in the intravenous PEG-asparaginase group vs 51 [22%] of 231 patients in the intramuscular E colil-asparaginase group) and asparaginase-related allergic reactions (14 [6%] vs 6 [3%]). INTERPRETATION: Intravenous PEG-asparaginase was not more toxic than, was similarly efficacious to, and was associated with decreased anxiety compared with intramuscular native E colil-asparaginase, supporting its use as the front-line asparaginase preparation in children with newly diagnosed acute lymphoblastic leukaemia. FUNDING: National Cancer Institute and Enzon Pharmaceuticals.

Pediatric Post-Acute Hospital Care: Striving for Identity and Value.

The landscape of hospital care for children is changing. Hospital clinicians are challenged to provide high-quality care to 2 increasingly complex groups of children: (1) healthy children admitted for high-severity acute illnesses or injury and (2) children admitted with lifelong, and often disabling, chronic conditions. Hospitalizations for both of these groups are becoming more prevalent, lengthy, and costly. In many situations, these children need weeks, or sometimes months, to recover from their illness or injury, with a sustained intensity of daily caregiving needs throughout their recovery period. Pediatric post-acute hospital care is a little-known and underused option in pediatric health care that could substantially help these children stabilize in a less restrictive and less costly environment than acute care hospitals can provide. In this commentary, we (1) propose the need and place for pediatric post-acute care hospitals along the continuum of care, (2) discuss the characteristics of children currently cared for in pediatric post-acute care hospitals, (3) suggest research opportunities and challenges, and (4) present issues related to the cost and value of pediatric post-acute care hospitals.

Neonatal abstinence outcomes in post-acute care: A brief report.

PURPOSE: To describe characteristics and care outcomes in a pediatric post-acute rehabilitation hospital for infants with Neonatal Abstinence Syndrome (NAS). METHODS: Demographic and clinical data were combined for 43 infants accounting for 46 admissions over a two-year period with a diagnosis of NAS and a goal of weaning from treatment medications. RESULTS: Mean age at admission for the total sample was 21 days. One hundred percent of the infants were weaned from treatment medications at discharge and all infants were discharged to a home setting. Mean length of stay in post-acute care was 24 days (SD = 12.80; range = 4-70 days) while the mean cost of admissions was $27,904. Ninety-one percent had a public payer. Post-acute care clinical outcomes were excellent. CONCLUSION: Post-acute care for infants with NAS could be an effective way to free NICU beds and reduce hospital costs for this population of infants.

Unplanned readmissions to acute care from a pediatric postacute care hospital: incidence, clinical reasons, and predictive factors.

OBJECTIVE: To identify the incidence, clinical reasons, and predictive factors for unplanned readmissions to acute care from a pediatric postacute care hospital. METHODS: A retrospective cohort analysis of all discharges between October 1, 2011, and September 30, 2013 (n=298), in 1 pediatric postacute care hospital was conducted. Descriptive statistics were used to summarize the incidence and assess the clinical reasons for all readmissions to an acute care hospital. Logistic regression was used to identify predictive factors of any unplanned readmission to an acute care hospital. RESULTS: Thirty percent of all postacute care hospital discharges were unplanned readmissions to an acute care hospital. The primary clinical reasons for unplanned readmissions to acute care were respiratory decompensation (54%) and infection (20%). Requiring invasive mechanical ventilation, being <1 year of age, and having a postacute care length of stay<30 days were the 3 predictive factors. CONCLUSIONS: This is the first study to examine readmission to acute care from a postacute care hospital and to identify age, length of stay, and dependence on mechanical ventilation as predictive factors. Understanding which children are likely to require an unplanned readmission may allow providers to develop strategies to minimize this occurrence.

Pediatric post-acute care hospital transitions: an evaluation of current practice.

OBJECTIVES: After discharge from an acute care hospital, some children require ongoing care at a post-acute care hospital. Care transitions occur at both admission to the post-acute care hospital and again at discharge to the home/community. Our objective was to report the current practices used during the admission to and discharge from 7 pediatric post-acute care hospitals in the United States. METHODS: Participants from 7 pediatric post-acute care hospitals completed a survey and rated the frequency of use of 20 practices to prepare and support children and their families during both admission to the hospital and at time of discharge to the home/community. For consistency with existing literature, practices were grouped into 4 previously reported categories: assessment, communication, education, and logistics. Descriptive statistics were used to report the frequency of use within practices and between hospitals. RESULTS: Only 2 of 10 admission practices and 3 of 10 discharge practices were reportedly "always" used by all hospitals. Assessment and communication practices were reported to be more frequently used (57%-100% of the time) than education and logistic procedures. Between hospitals, only the reported frequency of use of the discharge practices was statistically significantly different (P = .03). CONCLUSIONS: Variability exists in transition practices among 7 post-acute care pediatric hospitals. This report is the first known to detail the frequency of use of admission and discharge practices for pediatric post-acute care hospitals in the United States.

Hospital length of stay, discharge disposition, and reimbursement by clinical program group in pediatric post-acute rehabilitation.

OBJECTIVE: To describe hospital length of stay (LOS), discharge disposition, and reimbursement by clinical group for children admitted to pediatric post-acute rehabilitation. METHODS: Demographic and financial information for all admissions (n=382) for calendar years 2010 and 2011 were combined. Clinical groups (Active Rehabilitation, Medically Complex, Ventilator Dependent, Neonates) were delineated and compared by LOS, discharge disposition, and per diem and per admission reimbursement, as well as by age, gender, admission number, and payer using descriptives, chi-square, or analysis of variance. LOS, discharge disposition, and reimbursement were also examined by payer and/or admission number. RESULTS: Clinical groups differed by LOS (p=0.008), discharge disposition (p < 0.001), age (p < 0.001), admission number (p < 0.001), and payer (p < 0.001). Although per diem reimbursement was not statistically significant between groups, total admission reimbursement was highest for the Ventilator group due to a significantly longer LOS (mean=57.78 days, SD=56.33, p=0.008). LOS nor discharge disposition was significantly different if the payer was public or private. Children were more likely discharged home from a first admission (r=0.321, p < 0.001) than a subsequent admission, and private payers had a significantly greater (p< 0.001) mean daily reimbursement rate. CONCLUSION: Hospital LOS, discharge disposition, and reimbursement vary by clinical group in pediatric post-acute rehabilitation.

Measuring physical function in children with airway support: a pilot study using computer adaptive testing.

OBJECTIVE: To assess the responsiveness, examine the scoring range and determine the efficiency of a multidimensional computer adaptive testing version of the Pediatric Evaluation of Disability Inventory (PEDI-MCAT) for children admitted to inpatient pulmonary rehabilitation. METHODS: The PEDI-MCAT was completed by clinician report for 30 infants and children. Mean self-care and mobility admission scores were compared with discharge scores for the total group and two diagnostic sub-groups (prematurity and congenital/neurological conditions). The scoring range of the mobility and self-care scales was examined to determine placement of the scores along the overall PEDI-MCAT scale. Efficiency was determined using an internal clock and average number of items required for score generation. RESULTS: Mean changes for the total group and both sub-groups were significant for both self-care and mobility, except for the prematurity group's mobility scores. Effect sizes were small-to-moderate. Scores for both groups were at the low end of the scoring ranges. Average time to complete the PEDI-MCAT was 1.57 minutes. Average number of items administered was nine for self-care and 11 for mobility. CONCLUSION: The PEDI-MCAT was responsive to change in physical function, although only low-ability items were needed. The PEDI-MCAT can potentially minimize clinician burden in inpatient settings.

Intravenous PEG-asparaginase during remission induction in children and adolescents with newly diagnosed acute lymphoblastic leukemia.

Over the past several decades, L-asparaginase, an important component of therapy for acute lymphoblastic leukemia (ALL), has typically been administered intramuscularly rather than intravenously in North America because of concerns regarding anaphylaxis. We evaluated the feasibility of giving polyethylene glycosylated (PEG)-asparaginase, the polyethylene glycol conjugate of Escherichia coli L-asparaginase, by intravenous infusion in children with ALL. Between 2005 and 2007, 197 patients (age, 1-17 years) were enrolled on Dana-Farber Cancer Institute ALL Consortium Protocol 05-01 and received a single dose of intravenous PEG-asparaginase (2500 IU/m(2)) over 1 hour during remission induction. Serum asparaginase activity more than 0.1 IU/mL was detected in 95%, 88%, and 7% of patients at 11, 18, and 25 days after dosing, respectively. Toxicities included allergy (1.5%), venous thrombosis (2%), and pancreatitis (4.6%). We conclude that intravenous administration of PEG-asparaginase is tolerable in children with ALL, and potentially therapeutic enzyme activity is maintained for at least 2 weeks after a single dose in most patients. This trial was registered at www.clinicaltrials.gov as #NCT00400946.

Predictors of clinical outcomes and hospital resource use of children after tracheotomy.

OBJECTIVES: The objectives are to describe health outcomes and hospital resource use of children after tracheotomy and identify patient characteristics that correlate with outcomes and hospital resource use. PATIENTS AND METHODS: A retrospective analysis of 917 children aged 0 to 18 years undergoing tracheotomy from 36 children's hospitals in 2002 with follow-up through 2007. Children were identified from ICD-9-CM tracheotomy procedure codes. Comorbid conditions (neurologic impairment [NI], chronic lung disease, upper airway anomaly, prematurity, and trauma) were identified with ICD-9-CM diagnostic codes. Patient characteristics were compared with in-hospital mortality, decannulation, and hospital resource use by using generalized estimating equations. RESULTS: Forty-eight percent of children were

Development and evaluation of a minimum data set for children with airway support for transfers between acute and post-acute care.

OBJECTIVE: To generate consensus on the reasons why children with airway support transfer between acute and post-acute care; develop a minimum data set to transmit between care settings; and examine transfer reports to determine the frequency of data set content. STUDY DESIGN: Two consensus development meetings were conducted of acute and post-acute care professionals to identify reasons for transfer and develop the minimum data set. A content analysis was used to generate the frequency of inclusion of minimum data set elements in the narrative reports of 15 acute to post-acute and 15 post-acute to acute transfer summaries. The observed frequencies were compared with the expected frequencies (95%), as were frequencies between the two groups. RESULTS: Advanced diagnostic assessment and unexpected changes in medical, surgical and mental health conditions were the primary reasons for transfer from post-acute to acute care. For transfers in both directions, 20 of the 34 data elements were present in <75% of the cases and were statistically different than the pre-set 95% standard. No statistical difference in the occurrence of data elements between transfer directions existed. CONCLUSION: A minimum data set has the potential to reduce redundancy, improve safety and optimize care co-ordination between facilities for children with airway support.

Bronchoscopy findings in children and young adults with tracheostomy due to congenital anomalies and neurological impairment.

The aim of this study was to examine bronchoscopy findings for children and young adults with long-term tracheostomies due to congenital anomalies and neurological impairment and identify characteristics associated with abnormal bronchoscopic findings. We conducted a retrospective study of 128 bronchoscopy cases (81 children) at a pediatric rehabilitation center. Thirty-eight cases (30%) had normal findings and 14 children (17% of all children) were decannulated following bronchoscopy. Ninety cases (70% of cases) had abnormal findings (e.g. granulomas, airway inflammation, fixed obstruction). An acute indication for bronchoscopy was the strongest predictor of an abnormal finding, while age (younger) and diagnosis (multiple congenital anomalies (MCA)) also were associated with abnormalities. For a subsample of children undergoing bronchoscopy for routine surveillance (n= 90), underlying diagnosis (MCA) was the strongest predictor of an abnormal finding, while younger age contributed slightly. These findings add to the limited literature describing bronchoscopic findings in children and youth with tracheostomies due to congenital anomalies or neurological impairment. These findings may be useful for rehabilitation clinicians in determining care needs for children with long-term tracheostomy.