When Should a Child Be in the Hospital?

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PEDIATRICS

FOR THE CLINICIAN

540 PEDIATRICS Vol. 57 No. 4 April 1976

When

Should

a Child

Be in the

Hospital?

A. Frederick North, Jr., M.D.

University of Pittsburgh School of Medicine and Graduate School of’Public Health, Pittsburgh, Pennsylvania

With

the

advent of more active and widespread

utilization review activities, spurred federally by

Professional Standards Review Organization1

(PSRO) legislation

and

locally by various types of

quality

assurance programs, physicians who care

for children are increasingly concerned with

setting norms, criteria, and standards for judging

the necessity for admission to hospital and the

duration of hospital care.2 Most of the current

approaches to devising utilization standards

attempt to identify for each common diagnostic

category a standard for length of stay based either

on statistical analyses of current hospitalization

practices3’4 or upon normative values based on a

consensus of expert opinion.3 Criteria for

admis-sion may also be derived for each diagnosis.2’57

Committees of the American Academy of

Pediat-rics and of state and local medical and pediatric

societies are currently devoting a great deal of

effort to formulating admission and length of stay

standards for a variety of diagnoses which are

associated

with

hospitalization

of children.

The approach to formulating utilization

stan-dards using separate diagnostic categories may

prove not to be well suited to children. As is

shown in Tables I and II, a large number of

diagnostic categories must be dealt with, and

many of the diagnostic categories are so broad

that admission and length of stay standards would

be impossible to derive except for much smaller

subsets. Table I shows the 25 most common

diagnoses of children admitted to approximately 1,200 hospitals which reported data to the

Profes-sional Activities Survey (PAS) in 1970.2 The

diagnostic categories used in this analysis group

several separate ICDA diagnostic codes together.

The ten most frequent diagnostic categories

include 50% of the admissions, 24 diagnostic

categories account for 66% of the admissions, and

50 diagnostic categories for 80% of the

admis-sions. More recent 1972 data from the PAS’#{176}

revealed a pattern similar to that for the 1970

PAS data, but also pointed out that the most

frequent specific diagnoses vary tremendously

between individual hospitals and between large

general hospitals, small general hospitals, and

children’s hospitals. Table II shows the 25 most

common diagnostic categories for patients

admit-ted to Children’s Hospital of Pittsburgh. In these

data, for which the three-digit ICDA code is used

for classification and the patient mix is that of a

referral center rather than of community

hospi-tals, the top 10 diagnoses account for 25% of the

admissions, 25 diagnoses account for 39% of the

admissions, and 50 diagnoses for only 53% of the

admissions. Using either approach to coding, and

assuming some subcategories will have to be

created in either case, the time and effort

required to derive standards for even the

diag-noses which account for 60% to 80% of children’s stays in hospital would be immense.

A generic approach to standards for hospital

(Received March 20; revision accepted for publication July 15, 1975.)

ADDRESS FOR REPRINTS: Graduate School of Public

Health, 223 Parran Hall, Pittsburgh, Pennsylvania 15261.

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TABLE I

THE Twsry-FrvE MOST COMMON DIAGNOSES OF PERSONS 0 TO 19 YEARS OF AGE ADMITTED TO PAS

HOSPITALS, 1970#{176}

Rank

PAS

Code Diagnostic Category

%of AdmLs-sions %of Hospital Days

1 1 11 Hypertrophy of tonsils and

adenoids

18.9 6.2

2 106 Pneumonia 4.6 6.8

3 104 Acute upper respiratory infection except staphylo-coccal

4.2 3.9

4 202 Laceration, open wound,

superficial injury,

contu-sion, foreign body

4.0 3.3

5 190 Signs, symptoms, and

ill-defined conditions

4.0 3.6

6 1 Intestinal infectious disease 3.7 3.6

7 122 Inguinal hernia 2.9 1.8

8 119 Acute appendicitis 2.8 2.5

9 200 Intracranial injury 2.4 2.0

10 107 Bronchitis, acute 2.3 2.5

1 1 134 Disease of bladder and ure-thra except cystitis

2.0 1.4

12 195 Fracture, upper extremity 2.0 1.5

13 84 Otitis media 1.8 1.0

14 197 Fracture of lower extremity except upper end of

femur

1.5 4.1

15 1 14 Disease of teeth and jaws 1.5 0.6

16 77 Strabismus 1.4 0.6

17 108 Bronchitis, chronic and

un-specified

1.3 1.4

18 125 Disease of intestine and 1.2 1.4 peritoneum except

ap-pendix, hernia, and anal

disease

19 191 Fracture of skull and face bones

1.2 1.3

20 174 Skin disease other than infective and pilonidal cyst

1.1 1.1

21 136 Disease of male genitalia except prostate

1.1 0.7

22 188 Congenital anomalies of musculoskeletal system

1.0 1.3

23 187 Congenital anomalies of

genito-urinary system

1.0 1.1

24 205 Adverse effect of medicinal agent

1.0 0.7

25 67 Lymphadenitis except acute

1.0 0.9

#{176}Obstetrical deliveries and newborn infants

62.1 53.6

are excluded.

PEDIATRICS

FOR THE CLINICIAN

541

utilization by children may be more precise and

also more feasible. The rationale and method of

application of such standards is based on the

following considerations.

The need to hospitalize a child is dependent

upon the special services which the child requires

rather than upon the diagnosis. It is true that

children with certain diagnoses, such as acute

appendicitis, always require these services, but

for the vast majority of diagnoses the necessity for

hospitalization will depend on the specific

services which are needed and the degree to

which these services might be made available in

the home or in other alternative settings.

CRITERIA FOR ADMISSION

Children who need the following services

require hospitalization:

(

1) General anesthesia: Any surgery or

manipu-lation requiring general anesthesia should be

performed in a hospital. Safe general anesthesia

requires the intensive observation and access to

special equipment and facilities that can be

provided only in a hospital (or in special surgical

facilities closely related-geographically and

functionally-to a hospital).

(2) Intensive observation and monitoring:

Chil-dren with conditions in which a sudden change in

status is likely to cause a need for immediate

treatment, or children with undiagnosed

symp-toms or signs suggestive of such conditions,

require continuing observation and monitoring.

When conditions are appropriate, parents may be

able to provide such monitoring in the home in

many situations (e.g., following toxic ingestions or

head trauma). Hospitalization will be necessary

when the necessary observations are beyond the

capability of the home, when the home is too

distant in travel time from a suitable source of

treatment, or when the probability and severity of

risk is high.

(3)

Intravenous and other parenteral treatment:

While brief intramuscular or intravenous therapy

may be given in ambulatory settings, children

requiring prolonged or frequently repeated

parenteral therapy generally deserve

hospitaliza-hon.

(4) Re,spiratonj treatment involving oxygen, tents, respirators, or similar equipment: Only in certain instances requiring prolonged daily thera-py (e.g., cystic fibrosis) is such therapy practical in other-than-hospital settings.

(5) Special therapeutic modalities requiring frequent application of special nursing or

tech-nical skills: Tube feeding, constant irrigation of

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TABLE II

THE TWENTY-FIVE MOST COMMON DIAGNOSES AT THE

CHILDREN’S HOSPITAL OF PITTSBURGH, 1973

ICDA

Code Diagnostic Category#{176} Rank 2 % of AdmLs-sions 5.3 5.0 % of Hospital Days 1.5 4-9

542 HOSPITALIZATION CRITERIA

550 Inguinal hernia

746 Congenital anomalies of the heart

3 500 Hypertrophy of tonsils and adenoids

2.7 1.1

4 493 Asthma 2.5 2.0

5 373 Strabismus 2.3 0.2

6 755 Other congenital anomalies

of limbs

1.7 2.1

7 997 Complications peculiar to

certain surgical proce-dures

1.4 3.3

8 780 Certain symptoms refer-able to nervous system

and special senses

1.3 1.5

of circulatory system

1.3 1.6

10 752 Congenital anomalies of genital organs

1.2 0.4

11 735 Curvature of spine 1.2 2.7

12 756 Other congenital anomalies of musculoskeletal system

1.2 2.4

13 754 Club foot 1.2 1.6

14 729 Other diseases of joints 1.2 2.0

of upper alimentary tract

1.1 2.2

16 749 Cleft lip and cleft palate 1.1 2.2

17 250 Diabetes mellitus 1.0 0.5

18 599 Other diseases of urinary tract

1.0 0.3

19 998 Other complications of stir-gical procedures

0.9 1.2

20 381 Otitis media 0.9 0.4

21 751 Other congenital anomalies of digestive system

0.9 7.7

22 733 Other diseases of muscle, tendon, fascia

0.9 0.7

23 009 Diarrheal disease 0.8 1.6

24 738 Other deformities 0.8 1.2

25 731 Synovitis, bursitis, and

ten-osynovitis

0.8 0.7

#{176}AlIforms of pneumonia if combined wo uld rank 19th.

wounds or of organs such as the bladder, topical

therapy of extensive burns, and a variety of

similar procedures will most often require skills

and equipment only available in a hospital (or

highly specialized extended care facility).

(

6) Removal from dangerous home situations:

Children with suspected lead poisoning or

sus-pected child abuse or neglect must be

immediate-ly removed from their home environment. While

nonhospital institutional or foster parent care is

theoretically just as efficacious as hospitalization in such circumstances, in reality it is not available to medical personnel in crisis situations, nor is it as likely to be acceptable to parents.

(

7) Observation under controlled environmental situatiori: This is occasionally necessary for the diagnosis and management of such conditions as

eczema, asthma, or failure to thrive syndromes or

for special studies in certain metabolic conditions

(

e.g., balance studies) and in certain behavorial syndromes. While settings other than hospitals

might

be appropriate in many such instances,

they are not actually available as practical

alternatives.

(8) Suicidal attcmpt or threat: Such situations

are relatively uncommon in childhood, but the

involved child must be protected until more

complete investigation reveals the extent of real

danger.

(9) To establish maternal-infant attachment in the neonatal period: Most newborn infants require none of the above services after the first few hours

of life. But the importance of mother-infant

interaction during this period demands that the

infant remain in the hospital with the

post-partum mother. Also, infants who have been

separated from their mother at birth because of a

need for neonatal intensive care, may require an

extension of hospitalization beyond that required

for any of the above services during which time

the mother-infant attachment can be established

(

perhaps requiring a “rooming-in” arrangement

for the mother).

CRITERIA FOR DISCHARGE

Children should remain in a hospital only as

long as they require one or more of the above

services. The requirement for services, not

complete recovery from the condition that caused

the need for such services, should be the criterion

for discharge. While some compromises are no

doubt necessary for the convenience of parents

and physicians, prolonging hospitalization until

“sutures can be removed,” “casts or dressings can

be

changed,” or “x-rays have cleared” cannot

routinely be justified. Hospitals present constant hazards to children (e.g., medication errors, falls, psychological isolation) and prolonging hospitali-zation prolongs these risks as well as imposing a very high cost.

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PEDIATRICS Vol. 57 No. 4 April 1976 543

APPLICATION OF CRITERIA

Certification for admission4 would consist of a

simple statement of the reason that one or more of

these services was necessary for the care of the

child, and an estimate of the duration of such

need. Concurrent review would be provided by

scanning of medical orders-whenever none of the

above services were in effect the patient would be

presumed to be ready for discharge and the

physician so notified. Each additional day of stay

would have to be justified by notes and orders.

Retrospective review would be based on the same

standards, but would rarely be necessary if

concurrent review were in effect.

Such generic standards appear to be much

easier to derive and no more difficult to apply

than standards based on individual diagnoses.

They do not require an “admitting diagnosis,”

which is so often a convenient fiction in the case

of diagnostic problems. They are immediately

applicable to all patients, not just those with

certain categories of diagnoses. They recognize

the wide variation in duration of need for services

which occurs among children with the same

diagnostic label. Using similar explicit but generic criteria, Duff et al.8 found high interobserver

reliability in judgments on the necessity for

admission and duration of hospital stay. Without explicit criteria, Lovejoy et al.9 found much lower mterobserver reliability.

Like standards based on diagnosis, these

generic standards do not preclude unnecessary

medical or surgical treatments based on

misdiag-nosis, overzealousness, or overly cautious

moni-toring in the absence of real risk. They would, for

example, do nothing to reduce the number of

tonsillectomies. Their application would,

how-ever, ensure that children in a hospital were

actually receiving services-necessary or unneces-saiy-that appropriately require hospitalization.

It is hoped that PSROs and hospital utilization

committees will review these suggested generic

standards and will substitute them for the much

more cumbersome standards based on diagnosis.

REFERENCES

1. Dale MG: PSRO: A primer. JAMA 229:157, 1974. 2. Task Force on Guidelines of Care: PSRO’s and norms of

care. JAMA, 229:166, 1974.

3. Douebedian A: Medical Care Appraisal-Quality and Utilization: A Guide to Medical Care Administra-tion. New York. American Public Health Associa-tion, 1969, Vol 2, pp 17-26.

4. Commission on Professional and Hospital Activities: Length of Stay in PAS Hospitals, United States, 1970. Ann Arbor, Michigan, The Commission,

1971.

5. Jacobs CM: Procedure for Retrospective Patient Care Audit in Hospitals. Chicago, Joint Commission on Accreditation of Hospitals, 1973.

6. American Hospital Association: Quality Assurance Programs for Medical Care in the Hospital. Chicago, American Hospital Association, 1975. 7. McClain JO, Riedel DC: Screening for utilization

review: On the use of explicit criteria and

non-physicians in case selection. Am J Public Health

63:247, 1973.

8. Duff RS, Cook CD, Wanerk GR, et a!: Use of utilization review to assess the quality of pediatric inpatient care. Pediatrics 49:169, 1972.

9. Lovejoy HI, Carper, JM, Janeway CA, Kosa J: Unneces-saiy and preventable hospitalizations: Report of an

internal audit. J Pediatr 78:868, 1971.

Echocardiography:

Its Role

in the Severely

Ill Infant

Robert Solinger, M.D., Francisco EIbI, M.D., and Kareem Minhas, M.D.

From the Department of Pediatrics, Division of Cardiology, University of Louisville School of Medicine, Louisville, Kentucky

Nearly every cardiac malformation is within

the scope of modern surgical technique either for

correction or for significant palliation. In spite of

this, congenital cardiac anomalies continue to be

a major cause of death in infancy.

During the first few days of life, cyanosis,

dyspnea, and murmurs are sometimes seen in

infants with normal hearts. At the same time, as a

result of the newborn physiology, the history,

physical examination, electrocardiogram, and

plain chest X-ray film obtained in patients with

(Received April 28; revision accepted for publication August

7, 1975.)

ADDRESS FOR REPRINTS: (R.S.) Department of Pediat-nc-s (Cardiology), University of Louisville School of

Medi-cine, Norton-Children’s Hospital, 200 East Chestnut Street, Louisville, Kentucky 40202.

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1976;57;540

Pediatrics

A. Frederick North, Jr.