Methods of Mortality Risk Adjustment in the NICU: A 20-Year Review
ABSTRACT Improving the quality of care delivered in NICUs relies on the ability to partition variation associated with patient characteristics from those attributed to processes of care delivery through risk adjustment. Multiple methods of mortality risk adjustment have been proposed for NICU populations. We review existing literature pertaining to mortality risk adjustment in the NICU.
PubMed and Scopus were searched to identify unique methods of mortality risk adjustment in the NICU and their trends in citation since original publication. Additional online searches were performed to identify organizational and government agency means of mortality risk adjustment for patients in the NICU.
Among 10 unique neonatal mortality risk adjustment scores identified by this review, there are >3 dozen different measurement components. No score includes >28 components; no score contains <6. Scores differ substantively in their intended purposes, component parameters and intensity of data collection. The Clinical Risk Index for Babies (CRIB) has been referenced most frequently in other research articles (447 citations), while the National Institutes of Child Health and Human Development "calculator" has the greatest rate of citations per year since initial publication (37). The scores are notably inconsistent in their approaches to timing of data collection and inclusion of comorbidity indicators.
Rigorous means of risk adjustment in the NICU are essential to enhancing the quality of care delivered to neonates, by facilitating more meaningful comparisons in quality improvement. Building on the first 20 years of neonatal mortality risk adjustment will ultimately allow researchers and quality improvement teams to apply measures that facilitate cross-institutional comparisons thoroughly and fairly.
- Pediatric Critical Care Medicine 09/2013; 14(7):718-9. DOI:10.1097/PCC.0b013e3182a1251b · 2.34 Impact Factor
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ABSTRACT: Background. Hospital-acquired bloodstream infection (HA-BSI) is associated with substantial morbidity, mortality, and healthcare costs in all patient populations. Young children have been shown to have a high rate of healthcare-associated infections compared with the adult population. We aimed to quantify the excess mortality and length of stay in pediatric patients from HA-BSI. Methods. We analyzed data collected retrospectively from a probabilistically linked national database of pediatric (aged 1 month–18 years) in-patients with a microbiologically confirmed HA-BSI in England between January and March 2009. A time-dependent Cox regression model was fit to determine the presence of any effect. Furthermore, a multistate model, adjusted for the time to onset of HA-BSI, was used to compare outcomes in patients with HA-BSI to those without HA-BSI. We further adjusted for patients' characteristics as recorded in hospital admission data. Results. The dataset comprised 333 605 patients, with 214 cases of HA-BSI. After adjustment for time to HA-BSI and comorbidities, the hazard for discharge (dead or alive) from hospital for patients with HA-BSI was 0.9 times (95% confidence interval [CI], .8–1.1) that of noninfected patients. Excess length of stay associated with all-cause HA-BSI was 1.6 days (95% CI, .2–3.0), although this duration varied by pathogen. Patients with HA-BSI had a 3.6 (95% CI, 1.3–10.4) times higher hazard for in-hospital death than noninfected patients. Conclusions. Hospital-acquired bloodstream infection increased the length of stay and mortality of pediatric inpatients. The results of this study provide an evidence base to judge the health and economic impact of programs to prevent and control HA-BSI in children. Key words. length of stay; multistate model; pediatric. Hospital-acquired bloodstream infection (HA-BSI) is associ-ated with substantial morbidity, mortality, and healthcare costs in all patient populations [1–4]. However, young children and older adults have been shown to have higher rates of healthcare-associated infections (HCAI) than the ge-neral population [5–7]. In a recent national point prevalence survey in the UK, the highest prevalence of HCAI (8.2%; 95% CI, 6.6–10.0) was found in children aged between 1 month and 2 years, compared with an overall prevalence of 6.4% (95% CI, 4.6–8.7) , with HA-BSI diagnosed in 15% of pediatric HCAI cases. Thus, HA-BSI is an important issue in children in particular. Furthermore, pediatric HCAI is a Europe-wide and global problem. An HCAI point prev-alence survey conducted by the European Centre for Disease Prevention and Control found HCAI diagnosed in 15.7% of patients on pediatric intensive care units (ICUs) and 1.8% on general paediatric units . Amongst others, studies from the United States of America, Brazil, Kenya, and Tunisia have similarly highlighted the impact of HA-BSI in children [9–12].06/2014; DOI:10.1093/jpids/piu073
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ABSTRACT: Pain management and sedation is a priority in neonatal intensive care units. A study was designed with the aim of determining current clinical practice as regards sedation and analgesia in neonatal intensive care units in Spain, as well as to identify factors associated with the use of sedative and analgesic drugs. A multicenter, observational, longitudinal and prospective study. Thirty neonatal units participated and included 468 neonates. Of these, 198 (42,3%) received sedatives or analgesics. A total of 19 different drugs were used during the study period, and the most used was fentanyl. Only fentanyl, midazolam, morphine and paracetamol were used in at least 20% of the neonates who received sedatives and/or analgesics. In infusions, 14 different drug prescriptions were used, with the most frequent being fentanyl and the combination of fentanyl and midazolam. The variables associated with receiving sedation and/or analgesia were, to have required invasive ventilation (P<.001; OR=23.79), a CRIB score >3 (P=.023; OR=2.26), the existence of pain evaluation guides in the unit (P<.001; OR=3.82), and a pain leader (P=.034; OR=2.35). Almost half of the neonates admitted to intensive care units receive sedatives or analgesics. There is significant variation between Spanish neonatal units as regards sedation and analgesia prescribing. Our results provide evidence on the "state of the art", and could serve as the basis of preparing clinical practice guidelines at a national level. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.Anales de Pediatría 05/2015; 83(2). DOI:10.1016/j.anpedi.2015.03.017 · 0.83 Impact Factor