Computerized reminders to physicians in the emergency department: a web-based system to report late-arriving abnormal laboratory results. (57/831)

Inadequate follow-up for abnormal laboratory results is a frequent cause of medical errors, especially for those that arrive after the patient is discharged in an Emergency Department (ED) setting. We have developed and implemented a computerized reminder system called the Automated Late-Arriving Results Monitoring System (ALARMS) for the Emergency Department at Children's Hospital, Boston. ALARMS scans the hospital's laboratory and ED registration databases to generate an electronic daily log of all late-arriving abnormal results for ED patients, which can be obtained by authorized physicians through a web-based user interface inside the hospital's intranet. We believe, by using this automated data-driven rule-based reminder system, we can minimize the risk of errors resulting from late-arriving laboratory data without requiring substantial additional efforts from clinicians.  (+info)

Cerebrospinal fluid lactate and pyruvate concentrations and their ratio in children: age-related reference intervals. (58/831)

BACKGROUND: Lactate (L) and pyruvate (P) concentrations in cerebrospinal fluid (CSF) and the L/P ratio have diagnostic value in numerous primary and acquired disorders affecting the central nervous system, but age-related reference values are not available for children. METHODS: We analyzed CSF and blood lactate and pyruvate concentrations and their ratio in a 4-year retrospective survey of a children's hospital laboratory database. Reference intervals (10th-90th percentiles) were established from data on 197 hospitalized children. A recent regression modeling method was used to normalize and smooth values against age. The model equation of best fit was calculated for each variable. RESULTS: Slight age-related variations were shown by the model, with an increase in lactate, a decrease in pyruvate, and a resulting increase in the L/P ratio with increasing age. However, the SD did not vary with age. We defined the upper limit of the reference intervals as the 90th percentiles, which from birth to 186 months of age varied continuously from 1.78 to 1.88 mmol/L (6%), 148 to 139 micro mol/L (6%), and 16.9 to 19.2 (14%) for lactate, pyruvate, and the L/P ratio, respectively. At a threshold of 2 (in Z-score units), the sensitivity for a subgroup of inborn errors of metabolism (respiratory chain disorders) was 73%, 42%, and 31% for lactate, pyruvate, and the L/P ratio, respectively. CONCLUSIONS: In children, CSF lactate and pyruvate concentrations and their ratio appear to vary slightly with age. Average 90th percentile values of 1.8 mmol/L, 147 micro mol/L, and 17, respectively, could be used in infants up to 24 months of age. In older children, age-adjusted reference intervals should be used, especially when values are close to the 90th percentile.  (+info)

Effect of weather on attendance with injury at a paediatric emergency department. (59/831)

OBJECTIVES: To ascertain whether the weather affects the attendance rate of children with injuries at a paediatric accident and emergency department. METHODS: The maximum daily temperature and weather conditions (rain/cloud/sun) were noted over a three month period in spring/summer 2002, together with the number of children attending with new injuries or trauma. RESULTS: There was a direct association between trauma attendance and clement weather with higher attendances on dry and sunny days. There was a less obvious association between maximum daily temperature and attendance. CONCLUSIONS: These findings confirm the anecdotal belief that warm sunny weather results in a higher attendance of paediatric injuries.  (+info)

Variability in surgical caseload and access to intensive care services. (60/831)

BACKGROUND: Variability in the demand for any service is a significant barrier to efficient distribution of limited resources. In health care, demand is often highly variable and access may be limited when peaks cannot be accommodated in a downsized care delivery system. Intensive care units may frequently present bottlenecks to patient flow, and saturation of these services limits a hospital's responsiveness to new emergencies. METHODS: Over a 1-yr period, information was collected prospectively on all requests for admission to the intensive care unit of a large, urban children's hospital. Data included the nature of each request, as well as each patient's final disposition. The daily variability of requests was then analyzed and related to the unit's ability to accommodate new admissions. RESULTS: Day-to-day demand for intensive care services was extremely variable. This variability was particularly high among patients undergoing scheduled surgical procedures, with variability of scheduled admissions exceeding that of emergencies. Peaks of demand were associated with diversion of patients both within the hospital (to off-service care sites) and to other institutions (ambulance diversions). Although emergency requests for admission outnumbered scheduled requests, diversion from the intensive care unit was better correlated with scheduled caseload (r = 0.542, P < 0.001) than with unscheduled volume (r = 0.255, P < 0.001). During the busiest periods, nearly 70% of all diversions were associated with variability in the scheduled caseload. CONCLUSIONS: Variability in scheduled surgical caseload represents a potentially reducible source of stress on intensive care units in hospitals and throughout the healthcare delivery system generally. When uncontrolled, variability limits access to care and impairs overall responsiveness to emergencies.  (+info)

Neonatal outcomes and quality of care in level II perinatal centers supported by a children's hospital-medical school level III program. (61/831)

OBJECTIVE: Eight Level II perinatal centers developed contracts with the children's hospital to provide consultative neonatal patient care, education, and administrative support. The purpose of the present study was to evaluate infant outcomes and quality of care during a 3-year period of the program, 1994 to 1996. STUDY DESIGN: Neonatal mortality rates were determined for the 18,703 live births. Quality of care was assessed for 30 infants who died at the Level II centers and 315 infants transferred to the children's hospital. RESULTS: The neonatal mortality rate was 2.2/1000 live births. Quality-of-care issues primarily involved 80 "drop-in" deliveries +info)

One year experience at the Emergency Unit of the Children's Hospital of Parma. (62/831)

The objective of the study was to analyse the activity of the Paediatric Emergency Unit (PEU) of the Children's Hospital in Parma, Italy, in the first year of its functioning. To this aim, the child's chronological age, place of origin (town or province), ethnic group, cause of consultation, time and date of admission, diagnosis and final destination were retrospectively collected from the clinical notes of all children who attended PEU from 1st. 10.1998 to 30th. 09.1999. During the period of this study 8,564 medical consultations (57% of users were male) were carried out by the Paediatricians on duty in the EU of The Children's Hospital. The average age of the patients was 3.9 +/- 3.5 years. Only 7% of patients passed through the General Emergency Department of the same Hospital. The peak period of consultations was found to be in February. The number of daily attendances progressively increased from Monday to Sunday according to a r of 0.59 (p<0.02) with a peak during the weekend. The most frequent causes for attendance concerned infections in the upper respiratory tract (36%), gastroenteritis (22%) and injuries (12%). Attendance, consultation and discharge procedures were covered at an average interval of 36.1 +/- 15.6 minutes (median 30 min.). Seventy per cent of the patients were discharged, 56.7% were males. Fourteen per cent of the rest were admitted for a short period of observation in the beds of the PEU and 16% in beds of specialised wards in the PD. Eighty per cent of admissions at the PEU lasted less than 48 hours. The analysis of the data collected at the PEU of our PD during the first year of its activity highlights the huge amount of work carried out by the Paediatricians on duty. To solve the abnormal admittance to a PEU, a complete reorganization of the Family Paediatricians network has to be hoped for. Special attention must also be addressed to the users of a PEU in order to reduce their attendance. To reach this target a continuous health education and information program for the general population and first-time parents has to be planned. Beyond these considerations, there is not doubt that a PEU requires a specific medical and nursing staff in order to prevent the service becoming ineffective.  (+info)

Length of stay, conditional length of stay, and prolonged stay in pediatric asthma. (63/831)

OBJECTIVE: To understand differences in length of stay for asthma patients between New York State and Pennsylvania across children's and general hospitals in order to better guide policy. DATA SOURCES/STUDY SETTING: All pediatric admissions for asthma in the states of Pennsylvania and New York using claims data obtained from each state for the years 1996-1998, n = 38,310. STUDY DESIGN: A retrospective cohort design to model length of stay (LOS), the probability of prolonged stay, conditional length of stay (CLOS or the LOS after stay is prolonged), and the probability of readmission, controlling for patient factors, state, location and hospital type. ANALYTIC METHODS: Logit models were used to estimate the probability of prolonged stay and readmission. The LOS and the CLOS were estimated with Cox regression. Model variables included comorbidities, income, race, distance from hospital, and insurance type. Prolonged stay was based on a Hollander-Proschan "New-Worse-Than-Used" test, corresponding to a three-day stay. PRINCIPAL FINDINGS: The LOS was longer in New York than Pennsylvania, and the probabilities of prolonged stay and readmission were much higher in New York than Pennsylvania. However, once an admission was prolonged, there were no differences in CLOS between states (when readmissions were not added to the LOS calculation). In both states, children's hospitals and general hospitals had similar adjusted LOS. CONCLUSIONS: Management of asthma appears more efficient in Pennsylvania than New York: Less severe patients are discharged faster in Pennsylvania than New York; once discharged, patients are less likely to be readmitted in Pennsylvania than New York. However, once a stay is prolonged, there is little difference between New York and Pennsylvania, suggesting medical care for severely ill patients is similar across states. Differences between children's and general hospitals were small as compared to differences between states. We conclude that policy initiatives in New York, and other states, should focus their efforts on improving the care provided to less severe patients in order to help reduce overall length of stay.  (+info)

Use of discharge abstract databases to differentiate among pediatric hospitals based on operative procedures: surgery in infants and young children in the state of Iowa. (64/831)

INTRODUCTION: A pediatric hospital may aim to show governmental agencies, charitable organizations, and philanthropic individuals how its clinical services differ from those of nonpediatric surgical facilities and of other pediatric hospitals. Yet, it is unknown how to use existing databases to quantify where infants and young children undergo surgery, and to use that information to differentiate among facilities. METHODS: Discharge abstracts were used to study inpatient and outpatient operative procedures performed between January and June 2001 in children 0-2 yr old at hospitals or hospital-affiliated outpatient surgery centers in Iowa. RESULTS: Of the 93 facilities performing at least one procedure, the 90 performing 15 or fewer different types of procedures provided surgical care for 80% of procedures. Among procedures performed at these 90 facilities, less than 0.15% were physiologically complex (more than seven American Society of Anesthesiologists' basic units). In contrast, at the larger and smaller pediatric hospitals, the percentages were 26% and 7%, respectively. These pediatric hospitals performed 181 and 73 different types of procedures, respectively; 64% of the physiologically complex procedures performed statewide were performed at the larger pediatric hospital. The smaller pediatric hospital was no more similar to the larger pediatric hospital in its relative volumes of each type of procedure than it was to the other 91 facilities. CONCLUSIONS: Statewide discharge abstract data can be used by a hospital to quantify how its surgical practice differs from that of other hospitals (e.g., to show that it provides a more diverse, comprehensive, and physiologically complex selection of procedures in younger patients).  (+info)