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
Two single-site studies also evaluated quality and safety outcomes associated with the use of radiographic imaging for pediatric appendicitis in a community hospital.40,42 For example, York et al. demonstrated that, compared with nonimaged patients, patients who underwent diagnostic imaging for appendicitis experienced a significant time delay from initial evaluation to surgery and incurred significantly higher hospital charges, whereas there were no significant differences in intraoperative findings, antibiotic requirements, and surgical complications between the groups.42
Interventional Studies
Neonatal Medicine
We identified six studies that evaluated interventions to improve healthcare quality for neonates in community hospitals; two involved telemedicine.43-48 Hall et al. described “Telenursery,” a program linking regional perinatal centers with a large academic neonatal practice through real-time teleconferencing, in addition to providing weekly educational conferences.45 After its implementation, there was an increase in the state-recommended delivery of very low birth weight infants at the regional perinatal center from 24% to 33% (P < .05); clinical outcomes were not discussed. In a similar study, Sable et al. found that a videoconferencing system for cardiologists from an academic center to guide care in a community setting provided diagnostic services more quickly (28 minutes vs 12 hours) and had high diagnostic accuracy.47 The remaining four studies evaluated heterogeneous interventions such as a maternal education program to reduce shaking injuries to infants or implementation of evidence-based order sets to reduce early onset group B streptococcal disease in neonates.43,44,46,48 Five of the six neonatal studies demonstrated improved quality outcomes after intervention.43-47
Pediatric Medicine
Seven studies evaluated QI interventions for children at community hospitals,49-55 three of which described interventions to improve quality of management of respiratory diseases.49,51,53 Dayal et al. evaluated the implementation of respiratory illness order sets and an asthma pathway, demonstrating a 41% reduction in asthma hospitalization cost per patient (P < .05), reduced bronchodilator use for all respiratory illnesses, and no change in readmission rates.49 Similarly, Nkoy et al. evaluated an asthma “Evidence-Based Care Practice Model” implemented at seven community hospitals and demonstrated a nonsignificant reduction in readmissions (P = .12), as well as lower hospitalization costs (P = .05).53 Using QI methods, Kuhlmann et al. demonstrated improved compliance from 43% to 97% with the Asthma Home Management Plan of Care measure.51 The remaining four studies evaluated heterogeneous interventions, including telemedicine critical care consultations, use of I-PASS, and consolidation of pediatric care onto one hospital unit.50,52,54,55 Six of the seven pediatric studies (86%) demonstrated improved inpatient quality outcomes after intervention,49,51-55 but only one study was multisite.53
Surgery
We identified only one study evaluating a surgical intervention aimed at improving the quality of pediatric care.56 Kelley-Quon evaluated the impact of a community hospital partnering with an Academic Medical Pediatric Trauma Center to become a Level II Pediatric Trauma Center (PTC). After achieving Level II PTC designation, they reported that children treated at the community hospital had reduced rates of CT use, transfers, and in-hospital mortality (from 81% to 51%, 8.5% to 2.5%, and 2% to 0.4%, respectively, P < .05 for all) compared to those treated predesignation.
