Giulio De Marco 1, Andrea Lo Vecchio 1, Antonietta Giannattasio 1,
Cristina Morciano 2, Alfredo Guarino 1.
1 Department of Pediatrics, University Federico II of Naples, Naples,
Italy
2 Istituto Superiore di Sanità, Rome, Italy
We read with interest the recent paper by Mahant and colleagues on
the reduction of inappropriate hospital stay 1. The authors applied the
Medical Care Appropriateness Protocol (MCAP) to monitor the incidence of
inappropriate hospital days, and by a weekly feedback to physicians were
able to reduce the incidence of inappropriate days of hospitalization from
47% down to 33% 1.
Inappropriate stay in hospital is an extraordinarily frequent phenomenon,
and the incidence reported in Toronto confirms very similar data
(approximately 50% of inappropriate hospital stay) obtained in Italian
pediatric wards 2. However, the issue of appropriateness is even more
important when referred to hospital admissions, and is a major problem
during the influenza season, when referral to hospitals may overload
hospitals capacities.
Inappropriate admissions are associated with unnecessary treatments and
procedures, increased risk for nosocomial infections, familial discomfort,
and major direct and societal costs. Guideline implementation is a well
recognized tool for optimizing clinical practice 3, but optimal tools for
implementation are not clear. The Italian Ministry of Health has produced
evidence-based guidelines for the management of influenza-like illness
(ILI) which include indications to hospital admissions. Based on that
document, we previously performed a case-controlled trial of guidelines
implementation and observed a reduction in the total number of admissions
for ILI, and a substantial cut, by approximately a half, of all
inappropriate admissions 4. In our implementation trial, specific
guidelines proved to be very effective because they were tailored for ILI
in children, and were implemented locally. The intervention of
implementation consisted in a 3 hours training course to physisicans
working in emergency, including critical discussion on guideline and
procedures to comply with. Such a simple and effective approach is a good
candidate for reduction of inappropriate admission for children with ILI.
An updated version of the Italian guidelines for influenza management has
been now released 5 , but the major point is how to increase compliance
in various local conditions and on a large scale. Training courses, audits
and educational outreach visits are being considered with the aim of
reducing unnecessary medical interventions, including unjustified drug
prescription and inappropriate hospital admissions.
References
1. Mahant S, Peterson R, Campbell M, MacGregor DL, Friedman JN.
Reducing inappropriate hospital use on a general pediatric inpatient unit.
Pediatrics. 2008;121(5):e1068-e1073.
2. Bianco A, Pileggi C, Trani F, Angelillo IF. Appropriateness of
admissions and days of stay in pediatric wards in Italy. Pediatrics.
2003;112(1 pt 1): 124-128.
3. Merritt TA, Palmer D, Bergman DA, Shiono P. Clinical practice
guidelines in pediatric and newborn medicine: implications for their use
in practice. Pediatrics. 1997;99(1):100-114.
4. De Marco G, Mangani S, Correra A, Di Caro S, Tarallo L, De
Franciscis A, Jefferson T, Guarino A. Reduction of inappropriate hospital
admissions of children with influenza-like illness through the
implementation of specific guidelines: a case-controlled study.
Pediatrics. 2005; 116(4):e506-e511.
5. SNLG. La gestione della syndrome influenzale. Available at:
www.snlg-iss.it/cms/files/LG_Influenza_2008*.pdf. Accessed July 10, 2008.
Conflict of Interest:
None declared
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