To improve quality of care and patient safety, researchers are developing quality measures, analyzing medical injuries, and assessing the usefulness of diverse strategies to enhance care.
Researchers examine ways to improve the quality of pediatric critical care.
The Institute of Medicine's six aims for improving quality of care provide a useful framework to advance quality of care in pediatric intensive care. In this article, the authors discuss the relevance of the six aims, which are: safety, effectiveness, equity, timeliness, patient-centeredness, and efficiency.
Slonim and Pollack, Pediatr Crit Care Med 6(3):264-269, 2005 (AHRQ grant HS14009).
Potential medication dosing errors occur often during outpatient pediatric care.
According to these researchers, medication doses were incorrectly cited in about one in seven (15 percent) new prescriptions written during children's outpatient visits. Slightly more than half of these incorrect dosages involved potential overdoses. Young and medically complex children, who are most vulnerable to potentially serious adverse drug events, were most likely to be prescribed potential drug overdoses. These findings were based on an analysis of pharmacy data from three HMOs for 1,933 children.
McPhillips, Stille, Smith, et al., J Pediatr 147:761-767, 2005 (AHRQ grants HS10391 and HS11843; AHRQ contract 290-00-0015).
Real-time safety audits can detect a broad range of errors in neonatal intensive care units.
The researchers implemented a real-time audit system, including a 36-item patient safety checklist, in a 20-bed NICU in Vermont. The checklist included errors associated with delays in care, equipment failure, diagnostic lab and radiology exams, information transfer, and noncompliance with hospital policy. A research nurse used the checklist to perform safety audits during and after morning work rounds three times a week. The audits detected 338 errors during the 5-week study period, including unlabeled medication at the patient's bedside, missing or inappropriately placed ID bands, improper alarm settings on pulse oximeters, ineffective communication, and delays in care. Errors usually were detected at the patient's bedside, permitting immediate notification of clinical staff.
Ursprung, Gray, Edwards, et al., Qual Safety Health Care 14:284-289, 2005 (AHRQ grant HS11583).
Treatment recommendations published during physicians' residencies impact their future clinical practice.
Using clinical vignettes, researchers found that pediatricians recommended sepsis workups 82 percent of the time, and family physicians recommended them 68 percent of the time, for febrile infants less than 3 months of age. These recommendations were more common among pediatricians who completed residency from 1975 to 1980 and family physicians who completed residency from 1981 to 1987, when specialty-specific journals published recommendations for sepsis workups of febrile infants.
Cox, Smith, and Bartell, Eval Health Prof 28(3):328-348, 2005 (AHRQ grant HS13183).
Nurses have an important role in preventing medication errors in hospitalized children.
These researchers suggest several practical steps that nurses should take to improve pediatric medication safety in the hospital. Examples include: reporting medication errors, double-checking drugs prescribed for off-label use, confirming patient information, minimizing distractions during medication administration, communicating with parents and involving them in patient care, and many others.
Hughes and Edgerton, Am J Nurs 105(5):36-42, 2005 (AHRQ Publication No. 05-R052)* (Intramural).
National reports focus on health care quality and disparities.
AHRQ has released the 2005 national reports on health care quality and disparities. These reports, which are prepared by AHRQ annually, provide measures of quality and disparities for the U.S. population, including children and adolescents. The reports cover four key areas of health care—effectiveness, safety, timeliness, and patient centeredness—and present data on several clinical conditions, including cancer and respiratory diseases.
National Healthcare Quality Report (AHRQ Publication No. 06-0018):
Also: National Healthcare Disparities Report (AHRQ Publication No.
06-0017)* (Intramural).
Failure to report medical errors affecting children is a significant problem.
The majority of medical errors committed by doctors and nurses during the care of pediatric patients go unreported, according to this study. Fewer than half of the 140 randomly selected doctors and nurses surveyed for this study said that they had completed incident reports on the majority of errors that they committed. About one-third said they had reported less than 20 percent of their errors.
Taylor, Brownstein, Christakis, et al., Pediatrics 114(3):729-735, 2004 (AHRQ grant HS11590).
Experts examine quality improvement in children's health care.
This article describes challenges encountered by the Child Business Case Working Group in its attempt to make “a business case” for improving the quality of children's health care. AHRQ's Senior Advisor on Child Health and Quality Improvement is a member of the group. The group recommends creating a less fragmented system of financing and delivery of health care services, expanding the emphasis on clinical research, and educating the public concerning the importance of high quality health care for children.
Health Affairs 23(4):159-166, 2004 (AHRQ Publication No. 04-R062)* (Intramural).
Hospitalized children often experience adverse events.
Researchers used AHRQ's Patient Safety Indicators (PSIs) to focus on children under age 19 cared for in hospitals in 27 States in 2000. The data were from 5.7 million pediatric hospital discharge records. In total, the PSIs identified 51,615 patient safety events involving hospitalized children in 2000. The most common errors involved obstetric trauma, postoperative respiratory failure, and infections resulting from medical care. The errors were related to increased costs, extended hospital stays, and death for some patients.
Miller and Zhan, Pediatrics 113(6):1741-1746, 2004 (AHRQ Publication
No. 04-R047).* (Intramural).
Also: Suresh, Horbar, Plesk, et al., Pediatrics 113(6):1609-1618,
2004 (AHRQ grant HS11583).
Five IT innovations hold promise for improving pediatric patient safety.
Five emerging information technologies have great potential to improve patient safety for children: care provider order entry, guideline-based documentation of care, Internet-based disease management resources, teleconsultation, and electronic health records.
Johnson and Davison, Ambulatory Pediatr 4(1):64-72, 2004 (AHRQ grant
HS11868).
Also: Bakken, Cimino, and Hripcsak, Med Care 42(2 suppl):1149-1156, 2004
(AHRQ grant HS11806).
Research agenda focuses on pediatric outpatient safety.
At a May 2003 conference, participants developed a research agenda to promote safety in outpatient child and adolescent health care. Five themes were given special attention: communication lapses, technological solutions to safety problems, identification of safety as a priority, more effective approaches for improving safety, and establishment of priorities for improving pediatric patient safety.
Perrin and Bloom, Ambulatory Pediatr 4(1):43-46, 2003 (AHRQ grant HS13883).
Also: Miller, Pronovost, and Burstin, Ambulatory Pediatr 4(1):47-54, 2004 (AHRQ
Publication No. 04-R031) (Intramural).
Quality of care measures are lacking for many aspects of children's health care.
Based on recommendations stemming from a meeting of QI experts, the authors suggest that a minimum of four activities be identified as national priorities. They are: creating an information infrastructure for collection and use of data, building support for quality improvement in children's health care, improving the reliability and validity of existing measures, and developing the evidence base for measures development and quality improvement.
Dougherty and Simpson, Pediatrics 113(1):185-198, 2004 (AHRQ Publication
No. 04-R026)* (Intramural).
Also in the same journal: Beal, Co, and Dougherty, pp. 199-209; Kuhlthau,
Ferris, and Iezzoni, pp. 210-216; and Shaller, pp. 217-227.
Medical errors affect two to three of every 100 hospitalized children.
Researchers used HCUP data to calculate hospital-reported medical errors among non-newborn pediatric inpatients up to 18 years of age. Results show the national medical error rate in hospitalized children ranged from 1.81 to 2.96 per 100 discharges. The error rate increased from 1988 to 1991 but remained stable from 1991 to 1997.
Slonim, LaFleur, Ahmed, et al., Pediatrics 111(3):617-621, 2003 (AHRQ grant HS11022).
Researchers evaluated in-hospital safety problems.
Using hospital discharge data, researchers identified patient safety problems involving inpatient procedures. Rates of problems ranged from 0.2 (foreign body left during procedure) to 154.0 (birth trauma) problems per 10,000 discharge records. Miller, Elixhauser, Zhan, et al., Pediatrics 111:1358-1366, 2003 (AHRQ Publication No. 03-R042)* (Intramural).
Managed care organizational characteristics affect health care use for children with special needs.
The goal of this project was to examine the relationship between features of managed care organizations (MCOs) and children's health care use patterns. The study used telephone survey data collected from 2,223 parents of children with special health care needs, managed care organization administrator interview data, and data on health care claims. Results indicate that the child's age, sex, and condition were consistent variables related to health care use and charges.
Shenkman, Wu, Nackashi, and Sherman, Health Serv Res 38(6 Pt 1):1599-1624, 2003 (AHRQ grant HS09949).
Parent reports of pediatric primary care quality vary by race and ethnicity.
Researchers surveyed parents of elementary school students in a large California urban school district during the 1999-2000 school year. They found that Asian and Latino parents were less satisfied than black and white parents with their children's health care in terms of continuity of care, access to care, communication with the physician, and other important aspects of primary care.
Seid, Stevens, and Varni, Health Serv Res 38(4):1009-1031, 2003 (AHRQ grant HS10317).
Parents provide views of inpatient care quality.
Responding to the Pediatric Inpatient Survey, 6,030 parents of children treated for a medical condition at one of 38 hospitals rated their child's care, on average, as very good. They also reported problems associated with 27 percent of the survey's hospital process measures. They had the most problems with poor information to the child and coordination of care.
Co, Ferris, Marino, et al., Pediatrics 111(2):308-314, 2003 (AHRQ grant T32 HS00063).
Severity model uncovers source of errors at admission.
Using a nationally applicable model to control for severity of illness in the ED, investigators examined 11,664 hospital records to determine the factors associated with quality of pediatric care. Total errors were strongly associated with residents; there was no association with other care factors.
Murray M. Pollack, PI (AHRQ grant HS10238), Pediatric Emergency Care: Severity and Quality (Final Report, NTIS Accession No. PB2003-101524).**
AHRQ's evidence-based practice program reviews scientific evidence to improve quality of care.
Under this program, contracts are awarded to institutions in the United States and Canada to serve as evidence-based practice centers (EPCs). These centers review the scientific literature on assigned topics and produce evidence reports and assessments that can be used by public and private organizations as the basis for quality improvement tools and activities.
Visit the AHRQ Web site at www.ahrq.gov and select “Evidence-based Practice” to find evidence reports and summaries on topics relevant to children.
High-quality research in children's health care can only come from having a pool of talented researchers and a strong infrastructure to support analytic projects. AHRQ is committed to the development and support of health services researchers, particularly minority researchers and those who are new to the field.
Specially focused research is needed for children and adolescents.
This researcher proposes priorities for studies focused on child health care outcomes that take into account the special characteristics of childhood. These include developmental change, dependency on adults, differences in disease epidemiology from adults, and unique demographic characteristics.
Forrest, Med Care 42(4 Suppl):19-23, 2004 (AHRQ grant K02 HS00003).
AHRQ's KID database facilitates child health services research.
In August 2001, AHRQ unveiled the Kids' Inpatient Database (KID), the Nation's first all-children's hospital care research database. It was developed for use in making national and regional estimates of children's treatment, including surgery and other procedures, and for estimating treatment outcomes and hospital charges. The database includes information on the hospital care of children from birth through age 18, regardless of insurance status. The KID contains information on the inpatient stays of about 1.9 million children at over 2,500 hospitals across the country in 2000.
KID is a component of AHRQ's Healthcare Cost and Utilization Project (HCUP). For more information, go to the AHRQ Web site at www.ahrq.gov and click on “HCUP.” (Intramural)
New pediatric disaster preparedness resource now available.
Children have increased vulnerability to injury from catastrophic events because of their unique anatomic, physiologic, immunologic, and developmental characteristics. This new resource, which was prepared for AHRQ by the American Academy of Pediatrics, can assist in the development of local, State, regional, and Federal emergency response plans that recognize and address these differences. The resource is intended to increase awareness of the unique needs of children and encourage collaboration among pediatricians, State and local emergency response planners, health care systems, and others involved in planning and response efforts for natural disasters and terrorism.
Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians (AHRQ Publication Nos. 06-0056, full report, and 06-0048, summary).* Also available online at www.ahrq.gov/research/pedprep/resource.htm (Purchase order 05R000190).
Long-term outpatient use of central venous catheters in children with bone infections often results in complications.
Children who are diagnosed with acute hematogenous osteomyelitis (AHO), bone infection, usually receive several days of IV antibiotic treatment in the hospital, followed by placement of a central venous catheter in a vein that leads directly to the heart for 4 to 6 weeks of IV antibiotic therapy at home. In this study, 41 percent of children who received more than 2 weeks of IV treatment at home had one or more central venous catheter-associated complications. Many of these complications were serious enough to warrant a visit to the emergency department or readmission to the hospital. Twenty-three percent of the children had a catheter-related malfunction or displacement, 11 percent had a catheter-associated bloodstream infection, and 5 percent had a local skin infection at the site of catheter insertion.
Ruebner, Keren, Coffin, et al., Pediatrics 117(4):1210-1215, 2006 (AHRQ grant HS10399).
Children's use of motor vehicle restraints may be linked to parental use of seat belts and mother's psychological distress.
Researchers analyzed data on more than 6,200 children aged infant to 17 years and found that children whose mothers have emotional problems and/or don't use seat belts are less likely than other children to be restrained by car seats or seat belts themselves. Older children were especially likely to forgo seat belts if their mothers did. More than 35 percent of children were low users of restraints if their mothers also reported low use, compared with 6.1 percent of children whose mothers buckled-up every time or most of the time. Children were less likely to be restrained if their mother was older, black, or less educated or if they lived with a single parent, in a family of four or more members, in poverty, or in a rural area.
Witt, Fortuna, Wu, et al., Ambulatory Pediatr 6:145-151, 2006 (AHRQ grant T32 HS00063).
U.S. children use electronic media an average of more than 4 hours a day.
Researchers conducted a survey of parents during well-child office visits to assess children's media use and parental oversight and control of media use. Children in this study were using electronic media (e.g., TV, video games, and computers) an average of 4 hours a day, or twice the recommended limit of 2 hours. More than half of parents used some type of strategy to control and inform their children's use of electronic media. About 23 percent used a restrictive approach, and 22 percent used an instructive approach, while some parents used multiple approaches. Only 7 percent of parents allowed unlimited media use and engaged in no mediation strategy.
Barkin, Ip, Richardson, et al., Arch Pediatr Adolesc Med 160:395-401, 2006 (AHRQ grant HS10913).
Anthrax in children is difficult to detect and treat.
According to an AHRQ evidence report, difficulties in diagnosing anthrax in children may lead to dangerous delays in treatment for this often deadly infection. Symptoms of pediatric anthrax infection can be easily confused with those of more common illnesses. For example, the symptoms of inhalational anthrax are similar to those of influenza. Also, there is little evidence about the effectiveness in children of interventions currently recommended for adults.
Pediatric Anthrax: Implications for Bioterrorism Preparedness, Evidence Report/Technology Assessment No. 141 (AHRQ Publication No. 06-E013)* (contract 290-02-0017).
DNRs for terminally ill children may not be honored by public schools.
Researchers surveyed personnel from school districts in 81 U.S. cities about written policies or procedures for student DNRs and compared school policies with relevant State laws from all 50 States and the District of Columbia. Most (80 percent) of the school districts surveyed did not have policies for dealing with student DNRs. Also, 76 percent of those surveyed indicated they either would not honor student DNRs or were uncertain about whether they could honor them. Nineteen school districts reported that they honor student DNRs, but 13 of them have no laws to protect school personnel from civil or criminal liability for withholding CPR.
Kimberly, Forte, Carroll, and Feudtner, Am J Bioeth 5(1):59-65, 2005 (AHRQ grant HS00002).
Age is a better marker than height and weight for assessing the risk of air bag deployment.
The government requires warnings on motor vehicles that children aged 12 and younger can be seriously injured or killed by an air bag. However, this study found that the risk of serious air-bag-related injury may extend to age 14 when children are seated in the right front passenger seat in vehicles equipped with air bags. Researchers analyzed data for nearly 3,800 children aged 1 month to 18 years and found that children aged 15 to 18 years who were involved in frontal collisions were 81 percent less likely than younger children to be injured when an air bag deployed. Changes in body composition and bone mass associated with the onset of puberty (typically age 11 for girls and age 13 for boys) may play a role in susceptibility to injury from air bags, note the researchers.
Newgard and Lewis, Pediatrics 115(6):1579-1585, 2005 (AHRQ grant F32 HS00148).
Home routines in minority families may impede the development and future school success of children.
According to this study, black and Hispanic children younger than age 3 experience multiple disparities in home routines, safety measures, and educational practices/resources that could impede their healthy development and future school success. For example, minority parents were less likely than white parents to install stair gates or cabinet safety locks or to lower the temperature setting on hot water heaters to prevent scalding. Minority parents also were much less likely than white parents to read to their children daily, and they had fewer children's books in the home. The researchers suggest that pediatric providers should educate minority parents of young children about more effective home routines.
Flores, Tomany-Korman, and Olson, Arch Pediatr Adolesc Med 159:158-165, 2005 (AHRQ grant HS11305).
TV viewing and use of computers and video games may have negative effects for young children.
Children under 11 years of age currently spend more time watching videos and playing computer games than watching TV, according to this study. But, 30 percent of parents reported that their child had eaten breakfast or dinner in front of the TV in the preceding week, 26 percent said their child had a TV in his or her bedroom, and 22 percent of parents were concerned about the amount of TV that their child watched. TV viewing, video games, and computer use have been associated with problems ranging from obesity to attention deficits and aggressive behavior.
Christakis, Ebel, Rivara, and Zimmerman, J Pediatr 145:652-656, 2004 (AHRQ grant HS13302).
More frequent placements of foster children increase their reliance on the ER for outpatient care.
This analysis of Medicaid claims data and foster care administrative data found that 38 percent of children in foster care experienced two or more placement changes in 1995. Foster children of all ages showed increasing reliance on the ER for outpatient care services as the number of placements increased. These findings underscore the need for better health care management for foster children, particularly in the period after a placement change.
Rubin, Alessandrini, Feudtner, et al., Pediatrics 114(3), 2004; online at www.pediatrics.org (AHRQ grant K08 HS00002).
Health and access to care problems vary between street and shelter-based youths.
For this study, researchers interviewed 45 homeless youths aged 15 to 23 who visited a free clinic (clinic-based youths) or mobile medical vans in two street settings (street-based youths). Compared with clinic-based youths, street-based youths reported longer and more entrenched homelessness, more illness related to drug use, increased reliance on the ER for health care, and less use of emergency shelters. Street-based youths also tended to come from backgrounds of more poverty and disruption and to have traveled further from their hometowns.
Ensign and Bell, Qual Health Res 14(9):1239:1254, 2004 (AHRQ grant HS11414).
New video shows clinicians how to care for children exposed to chemicals used in bioterrorism.
This 27-minute training video provides a step-by-step demonstration of the decontamination process and instructs clinicians about the nuances of treating infants and children. A short clip from the video is online at www.ahrq.gov/browse/bioterbr.htm.
A free, single copy of the video, The Decontamination of Children, is available in DVD (AHRQ Product No. 05-0036-DVD)* or VHS (AHRQ Product No. 05-0036-VHS)* format (AHRQ contract 290-00-0020).
National advisory committee makes recommendations on preparedness for children.
The National Advisory Committee on Children and Terrorism recently issued recommendations for disaster planning affecting children. The recommendations address the particular vulnerabilities of children to terrorist attacks and disasters and represent a first step in improving planning that affects children. They focus on the following major areas: emergency and prehospital care, hospital care, terrorism preparedness, physical protection, decontamination, and the Strategic National Stockpile.
Markenson and Redlener, Biosecur Bioterror 2(4):301-319, 2004 (AHRQ grant HS13855).
Pediatricians will have an important role in the event of a bioterrorist attack.
Pediatricians need to participate in disaster planning to ensure that the unique health needs of children are addressed in the event of a bioterrorist attack. They also must be knowledgeable about the signs of possible exposure to a weapon of terror and understand the role of first-line responders to such attacks, including the chain of command and organization of resources that can be tapped.
Redlener and Markenson, Adv Pediatr 50:1-37, 2003 (AHRQ grant HS13855).
Pediatricians should encourage parents to read daily to their children.
According to this study of more than 2,000 parents of young children, only 52 percent of children aged 3 or younger are read to every day by a parent, and about 27 percent of children are read to three to six times per week. Children were about twice as likely to be read to each day if they were older (19 to 35 months) or their mother had more than a high school education, and they were 1.66 times more likely to be read to if a pediatric provider discussed with parents the importance of reading to children.
Kuo, Franke, Regalado, and Halfon, Pediatrics 113(6):1944-1951, 2004 (cofunded by AHRQ and HRSA, contract 240-97-0043).
Most children with short stature function within the normal range.
On average, children with short stature (2 to 3 deviations below the mean for height) score lower than their peers on tests of mental and physical functioning. However, few short children score outside the normal range, and there is no evidence that treatment of short stature improves function. Nevertheless, this review of the evidence indicates that growth hormone treatment may be warranted for children with severe short stature (4 to 5 standard deviations below the mean for height) to relieve everyday restrictions, such as being able to use school bathrooms or reach elevator buttons.
Wheeler, Bresnahan, Shephard, et al., Arch Pediatr Adolesc Med 158:236-243, 2004 (contract 290-97-0019).
Doctors vary in their management of young children with developmental delays.
More than half of the estimated 17 percent of U.S. children who have developmental delays are not diagnosed before they enter school. A survey of pediatricians and family physicians found substantial variations in how they manage delays (e.g., instruments used to measure development and timing of specialty referrals for children with suspected delays). Avoidant behavior (e.g., not looking at parents/grandparents) rather than disruptive behavior was associated with an increased probability of referral, perhaps because doctors recognized a potential autism spectrum disorder.
Sices, Feudtner, McLaughlin, et al., J Dev Behav Pediatr 24:409-417, 2004 (AHRQ grant K08 HS00002).
Family and community violence and risky behaviors affect millions of U.S. children.
Young people living in impoverished neighborhoods often are the victims of community violence, and sometimes they are the perpetrators. For example, an estimated 10 million U.S. children witness the punching, kicking, and beating of a parent, usually their mother, each year. A recent study of 258 abused mothers of children 18 months to 18 years found that these children had far more behavior problems, anxiety, depression, and withdrawal than other children. Sixty-nine percent of the children were Hispanic, and nearly half came from impoverished households.
McFarlane, Groff, O'Brien, and Watson, Pediatrics 112(3), 2003 online
at www.pediatrics.org (AHRQ grant HS11079).
Also: Howard, Kaljee, Rachuba, and Cross, Am J Health Behav 27(5):483-492,
2003.
Also: Rai, Stanton, Wu, et al., J Adolesc Health 35(2):108-118, 2003 (AHRQ
grant HS07392).
Health status measures must consider the effects of race, income, and other factors on children's health.
These researchers discuss the challenges inherent in designing health status measures for children that take into account the effects on health of race, ethnicity, income, and other socioeconomic factors.
Olson, Lara, and Frintner, Ambul Pediatr 4:377-386, 2004 (AHRQ grant HS12078, K08 HS00008).
Survey data can be obtained from Medicaid-insured families.
These authors describe the strategies they used to locate families and complete telephone and mail surveys with parents of Medicaid-insured children. The authors analyzed the proportion of completed interviews contributed by each strategy, stratified findings by five health plans, and reported labor and other costs per completed interview.
Jensvold, Lieu, Chi, et al., J Health Care Poor Underserved 14(1):17-22, 2003 (AHRQ grant HS09935).
Pediatric and adolescent outcomes research is described.
A systematic review of the literature (published from 1994 to 1999) on pediatric outcomes research was conducted. Reviewers report that the number of articles doubled in the 6-year period. They identify hospitals and primary care practices as the most common service sectors and note that the common clinical categories include neonatal conditions, asthma, psychosocial problems, and injuries.
Forrest, Shipman, Dougherty, et al., Pediatrics 111(1):171-178, 2003 (AHRQ Publication No. 03-R018)* (Intramural).
Study assesses parents' source and quality of advice.
Using a self-administered survey of 1,108 subjects, researchers determined sources and quality of medical advice and information used by parents. Half of the respondents reported using the Internet for medical information, 30 percent used it to obtain information about a specific acute or chronic medical illness, and 15 percent had communicated with a physician by E-mail. Respondents also rated physician advice by phone or visit and information obtained via the Internet as very good or excellent (76 and 47 percent, respectively).
Baraff, Wall, Lee, and Guzy, Clin Pediatr 42(6):557-560, 2003;
Also: Lee, Baraff, Guzy, et al., Arch Pediatr Adolesc Med 157:635-641, 2003;
Also: Lee, Baraff, Wall, et al., Clinical Pediatr 42(7):613-619, 2003
(AHRQ grant HS10604).
AHRQ Publication No. 07-P007
Current as of March 2007
Internet Citation:
Child Health Research Findings. Program Brief, AHRQ Publication No. 07-P007, March 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/childfind/
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