re-admissions to inpatient paediatric pulmonary rehabilitation
TRANSCRIPT
PEDIATRIC REHABILITATION, 2002, VOL. 5, NO. 3, 133±139
Re-admissions to inpatient paediatricpulmonary rehabilitation
DOUGLAS G. CUSHMAN, HELENE M. DUMAS, STEPHEN M.HALEY, JANE E. O’BRIEN and VIRGINIA S. KHARASCH
Accepted for publication: August 2002
Keywords Hospital, re-admission, oxygen, ventilator
Summary
Objective: To describe re-admission rates, identify reasonsfor re-admission and examine characteristics of childrenrequiring re-admission to inpatient pulmonary rehabilitation.
Methodology: Retrospective record review of infants andtoddlers (less than three years of age) requiring oxygen orventilator support discharged from an inpatient paediatricpulmonary rehabilitation programme between 1992 and 1999.
Results: Forty-one initial admissions resulted in 45 re-admissions with a mean re-admission rate of 1.1 (SD ˆ 1.41)re-admissions per child. Children with re-admissions (n ˆ 22,54%) required signi®cantly more ventilator support( p ˆ 0:001) and nursing care ( p ˆ 0:001) and were transferredto acute care more frequently ( p ˆ 0:002) than children with-out re-admissions. One-half of the children re-admitted toinpatient pulmonary rehabilitation were re-admitted two ormore times.
Conclusions: Based on this cohort of children, dependenceon supplemental oxygen and/or mechanical ventilation andmedical complexity may be indicators that children willrequire re-admission to rehabilitation following a transferback to acute care. Further examination of re-admissionrates and reasons and children’s clinical characteristics may
have predictive value and provide practice improvementopportunities.
Introduction
Following hospitalization in a neonatal or paediatricintensive care unit, a percentage of infants and toddlersdependent on supplemental oxygen and/or mechanicalventilation are transferred to an inpatient pulmonaryrehabilitation programme. The two main objectives ofinpatient pulmonary rehabilitation programmes are towean children to the least invasive pulmonary interven-tion and to prepare the child and family for discharge tothe community [1±3]. The goals of transfer to an inpa-tient pulmonary rehabilitation programme also includeachievement of medical stability, facilitation of parent±child interaction, caregiver education, and developmen-tal intervention in an appropriately stimulating environ-ment at a lower ®nancial cost [1, 2, 4, 5].
It has been suggested that for the child who is venti-lator dependent, fewer total ventilator days and fewerunplanned hospital re-admissions are the result of a wellorganized inpatient programme with early dischargeplanning and coordinated care [5]. Burdens of a hospitalre-admission for the child and family may includeseparation from family, coping with the illness itself,and ®nancial concerns including loss of income andthe cost of the hospital admission [3, 4]. Children andtheir families face the possibility of a breakdown in theirestablished network of community service providers dueto the interruption in service. Unplanned re-admissionsto the acute care or rehabilitation hospital may cause astrain on inpatient sta� ng as the medical acuity of thesechildren is high [2, 6]. Though inpatient rehabilitationprogrammes potentially provide a lower cost alternativeto the intensive care setting, payers are faced with addi-tional cost due to a potentially lengthy hospitalization[3, 7].
Rates of hospital re-admission for infants and tod-dlers who are dependent on oxygen and/or mechanical
Pediatric Rehabilitatio n ISSN 1363±8491 print/ISSN 1464±5270 online # 2002 Taylor & Francis Ltdhttp://www.tandf.co.uk/journals
DOI: 10.1080/136384902100003933 5
Authors: Douglas G. Cushman (author for correspondence;e-mail: [email protected]), RN CCM, KindredHospital±Boston, 1515 Commonwealth Avenue, Brighton,MA 02135, USA; Helene M. Dumas, MS PT, Manager, TheResearch Center for Children with Special Health Care Needs,Franciscan Children’s Hospital and Rehabilitation Center, 30Warren Street, Boston, MA 02135, USA; Stephen M. Haley,PhD PT, Director, Center for Rehabilitation E� ectiveness,Sargent College of Health and Rehabilitation Sciences,Boston University, 635 Commonwealth Avenue, Boston,MA, USA; Jane E. O’Brien, MD, Medical Director,Franciscan Children’s Hospital and Rehabilitation Center,30 Warren Street, Boston, MA 02135, USA; Virginia S.Kharasch, MD, Medical Director, Pediatric PulmonaryRehabilitation Services, Franciscan Children’s Hospital andRehabilitation Center, 30 Warren Street, Boston, MA02135, Assistant Professor in Pulmonary Medicine,Children’s Hospital, Boston, MA, and Instructor inPediatrics at Harvard Medical School, Boston, MA, USA.
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ventilation are scarcely reported [3, 4]. Hospital re-admissions following surgery, acute respiratory illness,or medical complications, are often necessary to enablechildren to return to their baseline pulmonary statusor continue with their initial pulmonary rehabilitation[3, 4, 8].
Re-admission to acute care hospitals has been used asa measure of morbidity among very low birth weightinfants with chronic lung disease and in evaluating thee� ectiveness of a home care programme for childrendependent on ventilators [3, 9]. An examination ofchildren’s characteristics related to re-admission tohospital-based inpatient pulmonary rehabilitation pro-grammes and the di� erences between groups of childrenwho require and who do not require re-admission to therehabilitation hospital has not been studied. Within thisheterogeneous group of children with multiple medical,rehabilitative, and psychosocial needs [1, 2, 10] it is notknown what factors predispose children to a higher riskfor re-admission to an inpatient pulmonary rehabili-tation programme. Thus programmes are challengedin identifying and devising strategies to address factorsleading to hospital re-admission.
Understanding the characteristics of children who aredependent on pulmonary technology and at high riskfor re-admission to inpatient rehabilitation is importantfor medical management, discharge planning, and forsetting realistic expectations for children and theirfamilies, sta� , payers, and hospital administrators.Understanding and identifying factors related to hospi-tal re-admission may help to minimize the burden of re-admission on the child, family, hospital, community-based service providers, and payers by highlightingopportunities for clinical practice improvement. Thepurpose of this study was to describe re-admissionrates, identify reasons for re-admission, and examinecharacteristics of children re-admitted one or moretimes to inpatient pulmonary rehabilitation.
Methods
SUBJECTS
A total of 41 infants and toddlers (accounting for 41initial hospital admission±discharge episodes and 45 re-admissions) discharged from the inpatient paediatricpulmonary rehabilitation programme at FranciscanChildren’s Hospital and Rehabilitation Center (FCH),Boston, MA, from August 1992 through to January1999 met the inclusion criteria for this study. Primarydiagnoses for the 41 children in the study sampleincluded prematurity (n ˆ 16, 39%), multiple congenital
anomalies (n ˆ 16, 39%), and neurological conditions(n ˆ 9, 22%). Reasons for the initial admission to theinpatient pulmonary rehabilitation programmeincluded: bronchopulmonary dysplasia (n ˆ 14, 34%),respiratory illness (n ˆ 12, 29%), chronic/restrictivelung disease (n ˆ 6, 15%), pulmonary hypoplasia(n ˆ 4, 10%), respiratory dysfunction due to neurologicaetiology (n ˆ 4, 10%), and tracheo/subglottic stenosis(n ˆ 1, 2%).
Of the total sample, 63% were males. The mean ageat initial discharge from the inpatient pulmonary re-habilitation programme was 1.18 years (SD ˆ 0.83).Twenty-®ve (61%) of the children used a gastrostomytube, ten (24%) used a nasogastric tube, and six (15%)were oral feeders at discharge. Thirty children (73%)had a tracheostomy, 17 children (42%) required 24full ventilatory support, four children (10%) requiredpartial ventilation (one to 23 hours per day), and 20children (49%) required no oxygen or ventilator sup-port upon initial discharge from the inpatient pulmon-ary rehabilitation programme.
The mean length of stay for the initial admission±discharge episode in the inpatient paediatric pulmonaryrehabilitation programme was 21.25 weeks (SD ˆ 22.26weeks). Forty-six percent of the children were dis-charged home after their initial admission to the pul-monary rehabilitation programme and 46% weredischarged back to an acute care hospital. Medicaidwas the primary payer for 25 (61%) of the childrenand commercial insurance or health maintenanceorganization (HMO) was the primary payer for 14(34%) children (Table 1).
PROGRAMME
Franciscan Children’s Hospital and RehabilitationCenter (FCH), Boston, MA, o� ers an inpatientpaediatric pulmonary rehabilitation programme forchildren who have received medical and respiratorycare in a neonatal or paediatric intensive care unit atreferring acute care hospitals. Infants and toddlersadmitted to the programme are followed by an attend-ing paediatrician with the support of a multi-specialtymedical team that include: pulmonology, physicalmedicine and rehabilitation, genetics, orthopaedic sur-gery, neurology, otolaryngology , gastroenterology ,and/or cardiology. Nursing care is provided on a2±4:1 ratio. A specialized care plan is developed foreach child to include: physical therapy, occupationaltherapy, speech therapy, social services, audiology,and nutrition as needed. Professional team conferences
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to review the child’s progress in all areas are held on aweekly basis.
Inclusion criteria for this study included: the child
was under three years of age upon ®rst admission tothe inpatient pulmonary rehabilitation programme at
FCH; the child required oxygen or ventilator support
during all admissions to FCH; and re-admissions toFCH were within a two-year period following initial
discharge from the inpatient pulmonary rehabilitationprogramme at FCH. Re-admissions up to two years
from initial discharge were considered for this study
to demonstrate the chronicity of oxygen and/or venti-lator dependence. For consistent availability of clinical
data however, only re-admissions (planned orunplanned) of two weeks duration or longer were ex-
amined.
`Re-admission’ was de®ned for this study as a return
to the inpatient pulmonary rehabilitation unit following
discharge home or transfer to an acute care hospital.`Transfer’ was de®ned for this study as a planned or
unplanned discharge to another level of care (acutecare, intensive care) necessitated by a change in the
child’s clinical condition. `Discharge’ was de®ned for
this study as a transition to a de®nitive disposition forwhich there was active discharge planning.
PROCEDURE
For this study, a retrospective medical record reviewof infants and toddlers discharged from the inpatientpulmonary rehabilitation programme at FCH was per-formed. The Program Medical Director categorized thechildren by diagnosis. Ventilator hours per day at dis-charge from the pulmonary rehabilitation unit werecoded as none (zero hours per day), partial (one to 23hours per day), and full ventilation (24 hours per day).Nursing hours were assessed using an acuity tool devel-oped at Franciscan Children’s Hospital and used since1990. The acuity tool ranks the intensity of nursing careusing a point system, which is then extrapolated intonumber of nursing hours per day.
DATA ANALYSIS
Descriptive statistics were generated to reportfrequency data for the total sample (n ˆ 41) and twosubgroups (children without re-admissions, n ˆ 19, andchildren with at least one re-admission of two weeks orlonger, n ˆ 22). Independent t-tests and chi-squareanalysis were used to determine if there were di� erencesin identi®ed characteristics of the two subgroups of
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Re-admissions to inpatient paediatric pulmonary rehabilitation
Table 1 Descriptors of children upon initial discharge from the inpatient paediatric pulmonary rehabilitationprogramme
Total samplen ˆ 41
Children withno re-admissionsn ˆ 19 (46%)
Children withre-admissions(one or more)n ˆ 22 (54%)
Age at discharge (years)* 1.18 (0.83) 1.17 (0.65) 1.20 (0.98)Length of stay (weeks)* 21.25 (22.26) 25.61 (26.29) 17.48 (17.86)Nursing hours/day at discharge* 9.26 (2.37) 8.07 (1.31) 10.29 (2.61)Sex (% male) 26 (63%) 12 (63%) 14 (64%)Tracheostomy at discharge (% yes) 30 (73%) 13 (68%) 17 (77%)
Primary diagnosisPrematurityMultiple congenital anomaliesNeurological
16 (39%)16 (39%)9 (22%)
8 (42%)6 (32%)5 (26%)
8 (36%)10 (46%)4 (18%)
Ventilator hours/day at dischargeNonePartial (1±23 hours/day)Full (24 hours/day)
20 (49%)4 (10%)
17 (42%)
15 (79%)0 (0%)4 (21%)
5 (23%)4 (18%)
13 (59%)
Discharge dispositionHome/foster homeTransfer to another hospitalNursing homeDeath
19 (46%)19 (46%)2 (5%)1 (2%)
13 (68%)3 (16%)2 (11%)1 (5%)
6 (27%)16 (73%)0 (0%)0 (0%)
Payer sourceMedicaidCommercial insurance/HMOPrivate pay
25 (61%)14 (34%)2 (5%)
9 (47%)9 (47%)1 (5%)
16 (73%)5 (14%)1 (5%)
* Values are mean with standard deviation.
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children discharged from the inpatient rehabilitationprogramme. Descriptive frequencies were further used
to examine characteristics of children with one re-
admission (n ˆ 11) and children with two or more re-
admissions (n ˆ 11).
Results
RATES AND REASONS FOR RE-ADMISSION
Twenty two (54%) children were re-admitted one ormore times for a period of two weeks or longer for a
total of 45 re-admissions. The mean number of re-admissions per child for the total study group (n ˆ 41)
was 1.10 (SD ˆ 1.41). The mean number of re-admis-
sions for the group requiring re-admission (n ˆ 22) was
3.27 (SD ˆ 1.47). Eleven children had one re-admission.
A further 11 children had multiple re-admissions (twoor more). Four children had two re-admissions, a
further four children had three re-admissions, one
child had four re-admissions, and two children had
®ve re-admissions during the study period.
Eighteen (82%) of the 22 children requiring one or
more re-admissions experienced their ®rst re-admission
within one year of their initial discharge from the inpa-
tient pulmonary rehabilitation programme. One childwith ®ve re-admissions experienced all re-admissions
over an 18-month period and a second child with ®ve
re-admissions experienced all re-admissions over a two-
year period. The mean length of stay for all re-admis-
sions was 18.67 weeks (SD ˆ 21.31). The mean length
of stay for each re-admission was greatest for second re-admissions (27.42 weeks, SD ˆ 32.90).
Table 2 identi®es the reasons for re-admission to theinpatient pulmonary rehabilitation programme.
CHARACTERISTICS OF CHILDREN REQUIRING
RE-ADMISSION
Statistically signi®cant di� erences were foundbetween the group of children who did not require re-admission (n ˆ 19, 46%) and the group of children whorequired at least one re-admission to the inpatient pul-monary rehabilitation programme (n ˆ 22, 54%).Di� erences were found for ventilator hours per day atinitial discharge from the rehabilitation programme(p ˆ 0.001), nursing hours per day at initial dischargefrom the rehabilitation programme (p ˆ 0.001) and dis-charge disposition (p ˆ 0.002). In the group of childrenwho did not require re-admission (n ˆ 19, 46%), fourchildren (21%) required full ventilation and 15 children(79%) required no ventilation at discharge. For thissame group, the mean number of nursing hours perday at initial rehabilitation discharge was 8.07(SD ˆ 1.31). Sixty eight percent of the children withno re-admissions were discharged home.
For the group of children with re-admissions (n ˆ 22,54%), 13 (59%) were re-admitted to FCH one or moretimes (range one to ®ve) and were on full day (24 hours)ventilation. Four children (18%) required partial dayventilation (one to 23 hours per day) and ®ve children(23%) required no ventilator or oxygen support atinitial discharge from the inpatient rehabilitation pro-gramme. The mean number of nursing hours per day atinitial discharge was 9.26 (SD ˆ 2.37). Seventy threepercent of this group was transferred from the inpatientpulmonary rehabilitation programme to an acute carehospital concluding their initial admission.
Frequencies examining the clinical characteristics ofchildren re-admitted multiple times (two or more) arepresented in Table 3.
Discussion
The purpose of this study was to describe re-admis-sion rates, identify reasons for re-admission and ex-amine characteristics of children re-admitted one ormore times to inpatient pulmonary rehabilitation.
RATES AND REASONS FOR RE-ADMISSION
In addition to the demographic, clinical and pro-gramme characteristics of a patient population (age,diagnosis, level of care) many possible variables con-found the reporting and comparison of re-admission
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D. G. Cushman et al.
Table 2 Reasons for re-admission to the inpatient pulmonaryrehabilitation programme
Re-admissions from Acute Care Hospitals n (%)
" Planned transfer to an acute care hospital with aplanned re-admission to inpatient pulmonaryrehabilitation
10 (22%)
" Unplanned transfer to an acute care hospital with aplanned re-admission to inpatient pulmonaryrehabilitation
24 (53%)
" Unplanned re-admission from acute care hospitalafter an illness at home
4 (9%)
Re-admissions from Home
" Unplanned re-admission directly to inpatientpulmonary rehabilitation from home due to home/social and/or community service provision issues
1 (2%)
" Unplanned re-admission directly to inpatientpulmonary rehabilitation due to illness at home
6 (13%)
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rates. For example, de®nitions of terms such as trans-
fers, discharge, and re-admission; time from initial dis-charge to initial re-admission; and the clinical setting towhich the child is being re-admitted require explanationand consideration. Also, the method in which re-admission rates are calculated and presented may
vary. For example, rates have been presented as anaverage per child or per group of children [3, 4, 9].Re-admission rates have also been presented as the per-centage of a group of children who were discharged andre-admitted to a particular programme [3, 4, 9]. There is
limited published data available describing re-admissionrates for children who are chronically dependent onoxygen and/or mechanical ventilation, limiting thecomparability of results.
Two previous studies appear most comparable for theevaluation of re-admission rates described in our study.In one study of 89 children (mean age 11.3 years) fol-lowed through the University of Michigan Pediatric and
Adolescent Home Ventilator Program, 47% were re-admitted to the hospital and averaged 1.7 re-admissionsper year per child [4]. In a study evaluating the e� ec-tiveness of a home care programme, 68% of 22 children(age range 10 months to 16 years) dependent on venti-
lators were re-admitted to the hospital with the meannumber of re-admissions per child equalling 3.27 overthe study’s six and a half year period [9]. In our study,54% of 41 children were re-admitted one or more times
and the mean re-admission rate was 1.1 re-admissionsper child (n ˆ 41).
In a study by Canlas-Yamsuan et al. [9], di� erences inre-admission rates were found by diagnostic group andlengths of stay. Children with neurological disordershad a lower nonelective re-admission rate but lengthsof stay were longer than children with ventilator-dependence due to pulmonary disorders. Though themean length of stay for children in our sample contin-ued to decrease with subsequent admissions, there wasno signi®cant di� erence in length of stay between thepulmonary group and the neurological group for initialrehabilitation hospitalization.
Respiratory infection and scheduled surgery havebeen reported as the most common reasons for re-admission to the hospital from home for childrendependent on ventilators [4]. More speci®cally, cardiacissues and respiratory illnesses were reported as the pri-mary causes of re-hospitalization for infants under twoyears of age [3]. The results of our study were suppor-tive of these ®ndings.
CHARACTERISTICS OF CHILDREN REQUIRING
RE-ADMISSION
In our study, the group of children who required re-admission required a signi®cantly greater number ofventilator hours per day. The majority (59%) of thesechildren required full ventilatory support, indicating agreater severity of pulmonary impairment than thosechildren not requiring re-admission to the programme.Greater severity of lung disease poses a higher risk forcomplication and infection, and increases the likelihoodof re-admission to the hospital. This is in contrast to astudy by Furman et al. [3], where no di� erences werefound between infants re-hospitalized during their ®rstyear of life from those not requiring re-hospitalizationwith regard to severity of chronic lung disease. In thatstudy however, duration of neonatal stay and total hos-pital stay were signi®cantly associated with diseaseseverity.
Twenty seven percent of the children re-admitted tothe inpatient pulmonary rehabilitation programmewere re-admitted following discharge home. Childrenrequiring supplemental oxygen and/or mechanicalventilation at home pose a high risk for families andcommunity care providers. These children often requirein-home nursing care, which may be di� cult to consis-tently acquire. Lack of adequate home nursing placesthe child at risk for medical emergency and illness aswell as increased stress on family caregivers thus againincreasing the likelihood of hospital re-admission.
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Re-admissions to inpatient paediatric pulmonary rehabilitation
Table 3 Initial rehabilitation discharge descriptors of children withtwo or more re-admissions (n ˆ 11)
Age at discharge (years)* 1.87 (0.91)Length of stay (weeks)* 27.42 (32.90)Nursing hours/day at discharge* 8.98 (2.19)Sex (% male) 7 (64%)Tracheostomy at discharge (% yes) 10 (91%)
Primary diagnosisPrematurityMultiple congenital anomaliesNeurological
5 (46%)5 (46%)1 (9%)
Ventilator hours/day at dischargeNonePartial (1±23 hours/day)Full (24 hours/day)
5 (46%)1 (9%)5 (46%)
Discharge dispositionHome/foster homeTransfer to another hospitalNursing homeDeath
5 (46%)6 (55%)0 (0%)0 (0%)
Payer sourceMedicaidCommercial insurance/HMOPrivate pay
8 (73%)2 (18%)1 (9%)
* Values are mean with standard deviation.
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The group of children in our study requiring re-admission also required a greater number of nursinghours per day at the time of initial discharge from theinpatient pulmonary rehabilitation programme thanchildren who did not require re-admission. This levelof nursing care may be explained by the fact that themajority of these children (73%) were transferred to anacute care hospital for acute medical management dueto their high medical complexity and severe illness.When medically stable, children often return to com-plete their course of rehabilitation.
To our surprise, ®ve of the 11 (46%) children withmultiple (two or more) re-admissions did not requiremechanical ventilation at discharge from the inpatientrehabilitation programme. An equal percentage, how-ever, required full day ventilation. Also, to our surprise,children with multiple re-admissions required, on aver-age, fewer nursing hours per day at the time of initialhospital discharge than the total sample (n ˆ 41) and/orthe group of children with one or more re-admissions(n ˆ 22). These ®ndings therefore do not support ourprevious supposition that ventilator hours per day andnursing hours per day are an indication of disease sever-ity. This ®nding indicates that children may requiremultiple re-admissions despite clinically successful pre-sentations at initial discharge from inpatient pulmonaryrehabilitation. This ®nding may have implications fordischarge planners, payers, and community service pro-viders at the time of discharge when considering thelevel of services to be instituted in the community tomaintain a child’s health status at home.
In this study, all hospital re-admissions might nothave been captured. For example, admissions to anacute care facility for acute medical management with-out re-admission to the inpatient rehabilitation pro-gramme were not captured. There is also thepossibility that children may have been re-admitted toanother inpatient pulmonary rehabilitation programmeor remained in an acute care hospital if the inpatientpulmonary rehabilitation programme at FranciscanChildren’s Hospital was a signi®cant distance fromthe child’s home and the travel and distance were aburden to the child’s family. Factors such as familyrelocation, overseas residence, or change in medicalcoverage may have in¯uenced our capture rate.Additionally, we chose to report on re-admissions thatwere two weeks or longer to obtain consistent standar-dized clinical data from our programme.
Our study identi®ed that over half of the childrendischarged from our inpatient rehabilitation pro-gramme, during the study period, required anunplanned transfer to an acute setting due to an acute
medical management need. Contributing to this issue isthe fact that our inpatient pulmonary rehabilitationprogramme admits infants and toddlers who are highlymedically complex and technology-dependent . Thoughmany accommodations for safety and frequent evalua-tion of medically complex patients are made, multi-organ involvement and signi®cant technological sup-port increase the likelihood that these patients willrequire a return to the intensive care setting.
As technologic advances continue to improve theprognosis for this population of young children, wehave made changes in our own practice. For example,preparation of family/caregivers prior to a child’sadmission to the programme and prior to dischargefrom the programme to the community includes infor-mation about recidivism rates. In addition, knowing thereasons for re-admission to the hospital, the hospital’sCase Manager/Discharge Planner spends a considerableamount of time insuring that community service provi-ders are prepared to accept and maintain this child in acommunity (non-hospital ) setting using the most up-to-date technology. Lastly, as follow-up care is essential tothe success of a planned discharge, all children are dis-charged with a follow-up appointment to return to ouroutpatient clinic. At this visit, the child’s physical con-dition is evaluated as well as the adequacy of the dis-charge plan. Adjustments are made to the treatmentand discharge plans with the aim of preventing anotheradmission.
Ongoing careful monitoring of transfer and re-admission rates can be valuable as performanceindicators when analysing other programme com-ponents such as admission criteria, standards of care,infectious disease monitoring, and team communicationand consultation. As this is the ®rst description ofcharacteristics of children with and without re-admis-sions solely to inpatient pediatric pulmonary rehabili-tation, further examination may highlight additionalpractice improvement opportunities for inpatientclinical care provision.
Acknowledgements
This study was approved by the Institutional Review Board atFranciscan Children’s Hospital & Rehabilitation Center, Boston,MA, USA.
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