Quality and Safety of Pediatric Inpatient Care in Community Hospitals: A Scoping Review
BACKGROUND: Although the majority of children are hospitalized in nonchildren's hospitals, little is known about the quality and safety of pediatric care in community hospitals.
OBJECTIVE: The aim of this study was to conduct a scoping review and synthesize literature on the quality and safety of pediatric inpatient care in United States community hospitals.
METHODS: We performed a systematic literature search in October 2016 to identify pediatric studies that reported on safety, effectiveness, efficiency, timeliness, patient-centeredness, or equity set in general, nonuniversity, or nonchildren’s hospitals. We extracted data on study design, patient descriptors, and quality outcomes and assessed the risk of bias using modified Newcastle-Ottawa Scales.
RESULTS: A total of 44 articles met the inclusion criteria. Study designs, patient populations, and quality outcome measures were heterogeneous; only three clinical domains, (1) perinatal regionalization, (2) telemedicine, and (3) imaging radiation, were explored in multiple studies with consistent directionality of results. A total of 30 studies were observational, and 22 studies compared community hospital quality outcomes with other hospital types. The remaining 14 studies reported testing of interventions; 12 showed improved quality of care postintervention. All studies reported an outcome addressing safety, effectiveness, or efficiency, whereas timeliness, patient-centeredness, and equity were infrequently addressed. Risk of bias was moderate or high for 72% of studies.
CONCLUSIONS: Literature on the inpatient care of children in community hospitals is limited, making it difficult to evaluate healthcare quality. Measures of timeliness, patient-centeredness, and equity are underrepresented. The field would benefit from more multicenter collaborations to facilitate the application of robust study designs and to enable a systematic assessment of individual interventions and community hospital quality outcomes.
© 2019 Society of Hospital Medicine
Pediatric Medicine
Nine multisite studies explored the quality and safety of pediatric medical care across hospital types.21-23,25-30 Of these, four were conducted using the Kids’ Inpatient Database (KID)28-30 or the National Inpatient Sample (NIS),27 two were conducted using other national databases,21,25 and two were conducted using electronic medical record data.22,26 All of the KID and NIS studies examined hospital charges, either alone or in conjunction with mortality. Two of these studies found no differences in risk-adjusted hospital charges between children’s hospitals and community hospitals (for burn injuries),28,29 whereas two found that hospitalization at community hospitals was associated with lower risk-adjusted charges (for asthma and sepsis).27,30 The remaining five studies evaluated diverse quality outcomes such as medication errors, therapeutic drug monitoring, practice guideline compliance, antibiotic prescribing, or hospital-to-home transition summary scores.21-23,25,26
Three single-site studies examined quality outcomes for pediatric medical patients, including mortality, outcome ratings for dehydration, and measures of peripherally inserted central catheter (PICC) safety and effectiveness.24,31,32 For example, Frank et al. evaluated safety of care in one community hospital pediatric intensive care unit (PICU) compared with a tertiary hospital using the Pediatric Risk of Mortality (PRISM) score.24 They reported that the observed number of deaths in their community PICU did not differ significantly from the number of deaths predicted in a tertiary center (23 vs 33, respectively, P > .2).
Surgery
Three multisite studies examined quality outcomes among children with surgical conditions, including surgical complications, readmission, and hospital charges.34,35,37 For example, Kelley-Quon et al. examined outcomes following surgery in infants with hypertrophic pyloric stenosis and found that infants who received their surgery at community hospitals had twice the odds of a surgical complication compared with those at children’s hospitals (P = .027).34 They also examined how the risk of appendiceal perforation differed by hospital type, finding that black children who received their surgery at children’s hospitals had twice the odds of appendiceal perforation compared with those who received care at community hospitals.35
In addition, two studies evaluated quality and safety outcomes for pediatric surgical care in a single community hospital.33,36 For example, Beaty et al. prospectively evaluated the incidence of missed injuries in hospitalized pediatric trauma patients, reporting that the incidence of missed injury was 33% when admission evaluation was performed by a trauma surgeon alone compared to 11% when performed by a pediatric doctor or a trauma surgeon and a pediatric doctor together (P < .001).33
Radiology
Three multisite studies examined quality and safety outcomes associated with radiographic imaging in community hospitals, including radiation dosing and frequency of preoperative imaging modalities and accuracy.38,39,41 For instance, Marin et al. found substantial variation in radiation dose across hospital types, with children’s hospitals delivering lower median radiation doses than academic and community hospitals.39 Similarly, Saito et al. demonstrated increased use of radiating modalities when evaluation was performed at community hospitals, with four times higher odds of computed tomography (CT) and five times lower odds of ultrasound use compared to a children’s hospital.41
