Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. e1068-e1073 (doi:10.1542/10.1542/peds.2007-2898)
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ARTICLE

Reducing Inappropriate Hospital Use on a General Pediatric Inpatient Unit

Sanjay Mahant, MDa,b,c,d, Rishita Peterson, MNe, Maggie Campbell, BScNe, Daune L. MacGregor, MDa,f and Jeremy N. Friedman, MB, ChBa,b,c,d

a Department of Pediatrics and Divisions of
b Paediatric Medicine and
f Neurology
c Pediatric Outcomes Research Team, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
d Child Health and Evaluative Sciences, Research Institute
e Quality and Risk Management, Hospital for Sick Children, Toronto, Ontario, Canada

OBJECTIVE. Studies have documented high rates of inappropriate hospital use in children. We assessed the effectiveness of an audit-and-feedback intervention at reducing inappropriate hospital days on a general pediatric inpatient unit.

METHODS. A prospective observational study, using a before-and-after design, was conducted at a tertiary care pediatric hospital in Canada between March 2005 and August 2006. The appropriateness of all hospital days for all admissions was evaluated by a nurse trained in using a utilization review tool. This tool classifies hospital days as "qualified" or "nonqualified" on the basis of the nature of the inpatient services that are used. Reasons for nonqualified days were classified. The intervention consisted of (1) weekly feedback to attending physicians of which patients were nonqualified and (2) dissemination of summary reports to attending physicians. Comparisons were made between the preintervention (March 2005 to August 2005) and intervention (March 2006 to August 2006) phases.

RESULTS. The intervention was associated with a significantly lower risk of inappropriate hospital days. Of the 7246 hospital days in the 6-month intervention phase, 2413 (33%) were nonqualified versus 3859 (47%) of 8228 hospital days in the 6-month preintervention phase. A total of 7.35 hospital days would have to be reviewed, combined with weekly feedback, to prevent 1 nonqualified hospital day. The 48-hour readmission rate in the intervention phase and preintervention phase was 1.0% and 1.6%, respectively. The proportion of nonqualified days to total hospital days that were attributable to "finishing intravenous antibiotics," "awaiting tests," "providing nutrition," "observation only," "tapering treatment," and "teaching" decreased significantly, whereas the "lack of an alternate level of care" increased significantly.

CONCLUSIONS. An audit-and-feedback intervention directed at attending physicians was associated with a lower risk of inappropriate hospital days without an increase in the readmission rate. The utilization review tool also identified processes that impact on inappropriate hospital days.

Key Words: hospital use • hospitalization appropriateness • health services research • audit and feedback, quality improvement

Abbreviations: MCAP—Medical Care Appropriateness Protocol • RR—relative risk • CI—confidence interval

Accepted Oct 18, 2007.


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