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

PURPOSE: 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.

The Head Control Scale: Responsiveness and Concurrent Validity With the Alberta Infant Motor Scale.

PURPOSE: The purpose of this study was to investigate the Head Control Scale's (HCS's) responsiveness and concurrent validity with the Alberta Infant Motor Scale (AIMS). METHODS: The HCS and the AIMS were administered to 50 infants and young children. Thirty children were reevaluated at hospital discharge or at 18 months of age. RESULTS: A statistically significant positive change was noted in mean score from the initial HCS assessment to the second assessment for total score and all position scores. Concurrent validity between HCS and AIMS total scores was excellent. CONCLUSION: Responsiveness to changes in head control and concurrent validity with the AIMS were established, supporting HCS use in clinical practice.

Point-of-Care Ultrasound in Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) have significant chronic health conditions that involve congenital or acquired multisystem disease associated with medical fragility, functional limitations, dependence on technology, and high health care utilization. The objective of this study was to describe the indications, applications, and point-of-care ultrasound (POCUS) findings in this population. METHODS: A descriptive study of POCUS scans performed for clinical purposes in CMC admitted to a single pediatric postacute care hospital. All children for whom a POCUS was requested by a medical team provider were eligible for inclusion. RESULTS: One hundred and four POCUS evaluations were performed for 33 patients. Diagnostic groups for the 33 patients included multiple congenital anomalies (41%), neurologic or neuromuscular (31%), prematurity (25%) and cardiac (3%). Lung, cardiac, and diaphragmatic ultrasound accounted for 57% of POCUS requested. POCUS was abnormal in 82% of diaphragmatic, 73% of lung, and 11% of cardiac ultrasounds. Twenty-three percent of POCUS studies were requested to answer a specific clinical question, 56% for follow-up information, and 21% for baseline evaluation. CONCLUSIONS: Lung, diaphragmatic, and cardiac ultrasound were the most prevalent POCUS studies requested in a postacute care hospital. POCUS may offer an expanded role in such patients and settings by answering clinical questions and by providing baseline and follow-up information.

National survey of health services provided by pediatric post-acute care facilities in the US.

PURPOSE: The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff. METHODS: An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery. RESULTS: Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%). CONCLUSION: PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.

Inter- and Intra-rater Reliability of the Head Control Scale: Brief Report.

PURPOSE: To examine inter-rater and intra-rater reliability of the Head Control Scale (HCS). METHODS: Introduction of the HCS to eight physical therapists in a pediatric post-acute hospital was followed by use in a repeated-measures design across two trials to establish reliability of the raters. Therapists scored the HCS twice within 4 weeks, using videos of infants at both 2 and 6 months of age, one infant described as typically developing and one with atypical development. RESULTS: For the HCS overall score, reliability was excellent with an inter-rater reliability intraclass correlation coefficient ((ICC) (3,1) = 0.97 (95% confidence interval, 0.899-0.998) and intra-rater reliability ICC (3,1) range = 0.815-1.0. HCS position scores between and within raters ranged from slight to substantial agreement. CONCLUSION: In this small study of inter- and intra-rater reliability, HCS overall score demonstrated excellent reliability for all raters however, HCS position scores demonstrated some variability, especially for the prone position.

Scoping Review of Judgment-Based Measures of Ambulation with Assistive Devices for Children and Youth.

AIM: To identify available judgment-based measures of ambulation with assistive devices for the purpose of examining item content and responses to aid in the expansion of the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) Mobility Domain. METHODS: PubMed and CINAHL databases were used to identify measures meeting the following criteria: 1) applicable for children/youth; 2) self-report, proxy-report, or interview administration; and 3) assistive device (walker, cane, crutches, gait trainer) use specified or considered with responses. Population, administration, respondent(s), items, and responses were compiled. Item content was categorized and response scales grouped by type. RESULTS: Fifteen measures met inclusion criteria. Measures included child and proxy-report. Item categories included Surfaces, Steps/Stairs, Dual Tasks, Negotiation of Environment, Distance, and Time. Only two measures distinguished between device type within items. One measure specified gait trainers. "Difficulty" and "Assistance" were the most frequently used response scales. CONCLUSIONS: Available measures have content examining device use; however, none of the measures are comprehensive, devices are not consistently specified, and responses are imprecise. Items with well-defined responses for measuring a child's ambulation with an assistive device are needed for clinical practice, research, and program evaluation.

A content validity evaluation of the PEDI-CAT Speedy Mobility domain.

Objective: To evaluate the content validity of the PEDI-CAT Speedy Mobility domain through analysis of item and content area exposure, score range and scoring precision.Methods: Retrospective analysis of 3,364 items from assessments (n = 301) completed from 2013 to 2017. Content validity was appraised through analysis of item and content area exposure (item, content area, response frequency), score range (floor and ceiling effect) and scoring precision (person fit, score reliability, item information function).Results: Sixty-five of the 75 general mobility items from the PEDI-CAT Mobility domain item bank were exposed. "Stands up from the middle of the floor" (68%) was the most frequently exposed non-mandatory item. Almost half (49%) of all items were from the Basic Mobility and Transfers content area. Scaled scores ranged from 26.77 to 69.40 with a floor (scores ≤27; n = 51, 17%) but no ceiling effect. Person fit statistics were acceptable for 238 (79%), suggesting limited outliers. Score reliability was sufficient with 68% of scores above threshold (>0.9). Item information function plot indicated less discriminating items at the lower end of the score range.Conclusion: Content is adequately and reliably measuring the intended construct, but additional items at the lower end of the scale could improve score precision.

Detecting Ventilator-Induced Diaphragmatic Dysfunction Using Point-of-Care Ultrasound in Children With Long-term Mechanical Ventilation.

Long-term mechanical ventilation (MV) is defined as the use of MV for more than 6 hours per day for at least 3 weeks. Children requiring long-term MV include those with neuromuscular disease, central dysregulation, or lung dysfunction. Such children with medical complexity may be at risk for ventilator-induced diaphragmatic dysfunction. Ventilator-induced diaphragmatic dysfunction has been described in adult patients requiring acute MV with ultrasound (US). At this time, diaphragmatic US has not been evaluated in the pediatric post-acute care setting or incorporated into weaning strategies. We present 24 cases of children requiring long-term MV who underwent diaphragmatic US examinations to evaluate for ventilator-induced diaphragmatic dysfunction.

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.

Development and Validation of Equations to Link Pediatric Evaluation of Disability Inventory (PEDI) Functional Skills Scores to PEDI-Computer Adaptive Test Scores for Youth with Cerebral Palsy.

Aim: The Pediatric Evaluation of Disability Inventory (PEDI) was revised to the PEDI-Computer Adaptive Test (PEDI-CAT). The PEDI has been used for over two decades to track function in youth, so it is important that follow-up data are not lost with this transition. The purpose of this study was to develop and validate equations for linking PEDI scores to PEDI-CAT scores.Methods: Caregivers of 101 youth 6.1 to 19.8 years of age with cerebral palsy (CP) and classified at Gross Motor Classification System (GMFCS) Levels I-V completed the PEDI and PEDI-CAT. Scaled score data from this sample were used to develop and validate linking equations using least squares regression and bootstrap cross-validation techniques. Next, equations were tested in an independent sample of 35 children with developmental disabilities.Results: The equations to predict PEDI-CAT scores exhibited excellent model fit. PEDI Self-care, Mobility, and Social Function explained 92%, 84%, and 85% of the variation in PEDI-CAT Daily Activities, Mobility, and Social/Cognitive domains, respectively. No differences were detected between actual and predicted PEDI-CAT scores across all domains and by GMFCS level for the equation development sample and for an equation validation independent sample.Conclusions: The model fit was excellent; however, equations should be used cautiously when evaluating changes in function for individual children with ceiling level PEDI scores. Valid score prediction equations for youth with CP will assist with transitioning from the PEDI to the PEDI-CAT.

A Tablet-Based Interactive Movement Tool for Pediatric Rehabilitation: Development and Preliminary Usability Evaluation.

BACKGROUND: Motivating interactive tools may increase adherence to repetitive practice for children with disabilities, but many virtual reality and active video gaming systems are too challenging for children with significant needs. OBJECTIVE: The objective of this study was to develop and conduct a usability evaluation of the Fun, Interactive Therapy Board (FITBoard), a movement toy bridging digital and physical interactions for children with disabilities. METHODS: The FITBoard is a tablet app involving games controlled by hand, head, or foot touch of configurable, wired surfaces. Usability evaluation involved a cognitive walkthrough and think-aloud processes. Participants verbalized aloud while completing a series of 26 task actions involved in selecting a game and configuring the FITBoard to achieve the therapeutic goal. Therapists then responded to questions about usability perceptions. Unsuccessful actions were categorized as goal or action failures. Qualitative content analysis supported understanding of usability problems. RESULTS: Participants included 5 pediatric physical therapists and 2 occupational therapists from 2 clinical sites. Goal failure was experienced by all participants in 2 tasks, and action failure was experienced by all participants in 2 tasks. For 14 additional tasks, 1 or more patients experienced goal or action failure, with an overall failure rate of 69% (18 of 26 tasks). Content analysis revealed 4 main categories: hardware usability, software usability, facilitators of therapy goals, and improvement suggestions. CONCLUSIONS: FITBoard hardware and software changes are needed to address goal and action failures to rectify identified usability issues. Results highlight potential FITBoard applications to address therapeutic goals and outline important practical considerations for product use by therapists. Subsequent research will evaluate therapist, parent, and child perspectives on FITBoard clinical utility when integrated within regular therapy interventions.

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.

Use of Post-Acute Facility Care in Children Hospitalized With Acute Respiratory Illness.

BACKGROUND: Recovery from respiratory illness (RI), a common reason for hospitalization, can be protracted for some children because of high illness severity or underlying medical complexity. OBJECTIVE: We assessed which children hospitalized with RI are the most likely to use post-acute facility care (PAC) for recovery. METHODS: Retrospective analysis of 609,800 hospitalizations for patients in 43 US children's hospitals between 2010- 2015 for RI, identified with the Agency for Healthcare Research and Quality Clinical Classification System. Discharge to PAC was identified using Centers for Medicare & Medicaid Services Discharge Status Codes. We compared patient characteristics by PAC use with generalized estimating equations. RESULTS: There were 2660 (0.4%) RI hospitalizations resulting in PAC transfer (n = 2660, 0.4%). Discharges to PAC had greater percentages of technology assistance (83.2% vs 15.1%), neuromuscular chronic condition (57.5% vs 8.9%), and mechanical ventilation (52.7% vs 9.1%), 𝑃 < 0.001 for all. The highest likelihood of PAC use occurred with ≥11 vs no chronic conditions (odds ratio [OR] 11.7 [95% CI, 8.0- 17.2]), ≥9 vs no therapeutic medication classes (OR 4.8 [95% CI, 1.8-13.0]), and existing tracheostomy (OR 3.0, 95% confidence interval [CI], 2.6-3.5). Median (interquartile range [IQR]) acute-care length of stay (LOS) for children most likely to use PAC was 19 (8-56) days; LOS remained long (median 13 [6-41] days) for children with the same attributes (n = 9448) not transferred to PAC. CONCLUSIONS: Children with RI who are most likely to use PAC have a high prevalence of multiple chronic conditions, multiple medications, and medical technology. Future investigations should assess the supply of PAC against the demand of hospitalized children with RI who might need it.

Physical Therapy Dosing: Frequency and Type of Intervention in Pediatric Postacute Hospital Care.

PURPOSE: To examine differences in physical therapy dosing frequency recommendations based on children's characteristics and to describe types of intervention recommended at postacute hospital admission. METHODS: Demographic and clinical information, recommended physical therapy intervention frequency, and intervention types were collected for all admissions from April 1, 2015, to March 1, 2016. Differences across 2 groups, children with recommendations for "less" (≤3x/wk) or "more" (≥4x/wk) frequent therapy, were examined. Types of interventions recommended were described and the measure of association between frequency and type was determined. RESULTS: Older children, those with higher admission functional scores, and children with less dependence on medical technology were recommended for "more." Therapeutic exercise was the most common intervention recommended. Greater physical therapy frequency was associated with Functional Training and Motor Function Training. CONCLUSION: Children's age, functional level, and technology dependence influence dosing recommendations. Interventions focused on function are associated with greater physical therapy frequency.

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.

Child to nurse communication in paediatric post-acute hospital care: evaluation of the VerbalCare tablet application.

VerbalCare is a mobile software platform for hospital patients and nursing staff to communicate in real-time. The purposes of this study were to (1) identify and evaluate icons for the VerbalCare tablet application and (2) examine use and satisfaction with this tablet application in a paediatric post-acute hospital. Hospital nursing staff were surveyed to identify the most common reasons children use the "nursing call bell". Icons for the VerbalCare tablet application were developed to match the identified call bell requests and be understood by children. Through structured interview, three children provided feedback on the icons. Following staff training, the system was implemented for five patients (8-18 years). Data on frequency of use, types and timing of requests were collected via the internal software. Satisfaction surveys were completed at discharge. The VerbalCare application was used most frequently to communicate the need to use the bathroom (24%) and the need to get something (21%). Request frequency was consistent across morning, afternoon and evening and the tablet was used 40% of available days. These results indicate that children in a paediatric post-acute care hospital were able to use a tablet application for communicating with their nurse and reported satisfaction with the experience. Implications for Rehabilitation The VerbalCare tablet application was developed to allow patients to convey specific messages to nursing staff who are not in the patient's room. Children of varying ages were able to use the VerbalCare tablet application to communicate varying messages to hospital nursing staff and were satisfied with its use.

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.