Shorter hospital stays possible for children with pneumonia
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Key takeaways:
- Most stays for pneumonia were significantly longer than the time it took to reach clinical stability.
- Children discharged with unstable parameters were not more likely to return to the ED or be readmitted.
Assessing children hospitalized with community-acquired pneumonia for certain objective measures of clinical stability could help shorten their stays, according to a study published in Pediatrics.
“Pediatric community-acquired pneumonia (CAP) is incredibly common and one of the top reasons for pediatric hospitalizations,” Madeline R. Field, MD, a pediatric emergency medicine physician and researcher at Children’s Hospital Wisconsin, told Healio. “However, objective markers of clinical stability and readiness for discharge are not standardized in pediatric patients with community-acquired pneumonia.”
As a result, practice is widely variable, “which has implications for many issues, including quality of care, judicious use of health care resources, and quality of life for children and families,” Field said.
“While measures of clinical stability have been widely studied in adults with pneumonia, there are few pediatric data on this topic,” she said.
Field and colleagues conducted a prospective cohort study of children aged 3 to 18 years hospitalized with suspected CAP.
“We analyzed routinely collected patient vital signs data, including temperature, heart rate, respiratory rate, oxygen saturation and use of supplemental oxygen both on admission and when recorded every 4 hours while admitted to the hospital,” Field said.
They defined clinical stability as reaching a temperature between 36°C and 37.9°C, having a respiratory rate and heart rate below the 99th percentile for their age, and over 90% oxygen saturation without the administration of supplemental oxygen.
“Using these criteria, we defined time to clinical stability,” Field said. “We then compared these with hospital length of stay and illness severity, evaluated whether patients discharged with unstable parameters were more likely to be readmitted, and lastly, evaluated what clinical factors were associated with reaching early clinical stability within the first 24 hours of hospitalization.”
In a cohort of 571 children, 32.7% had at least one abnormal parameter at discharge, but none had three or more abnormal discharge parameters. The researchers found that 93% of infants were stable across all four parameters at discharge compared with 49% of 12- to 18-year-olds.
The median time to clinical stability for each parameter was less than 24 hours, with factors such as a younger age, absence of vomiting, diffusely decreased breath sounds and normal capillary refill associated with earlier time to clinical stability, Field and colleagues reported. They also noted that children who did not reach stability were not more likely to revisit after discharge.
Field said that most of the results were what they expected.
“We expected that patients hospitalized with community-acquired pneumonia stay in the hospital longer than necessary, and we suspect that this likely is due to the lack of objective markers of discharge readiness,” Field said. “As we expected, length of stay was significantly longer than the time it took to reach clinical stability. While there are other factors contributing to length of stay, our data suggest that children would be discharged back home sooner if clinical stability parameters were introduced into discharge readiness planning.”
One finding was surprising, according to Field: that children discharged with unstable parameters did not appear to be more likely to return to the ED or be readmitted.
“The objective parameters used in this study are routinely collected variables and therefore would be easy to incorporate into decision-making,” Field said. “Using clinical stability parameters can ideally facilitate earlier, yet safe, discharges and target patients who might be at risk of longer lengths of stays, [such as] those who are admitted for IV fluids.”
In older children, using temperature and oxygenation alone may be sufficient to determine readiness for discharge, she said.
“This work now needs to be validated in additional populations,” Field said. “In addition, in order to truly shorten hospital length of stay, we need to understand the factors outside of our objective vital sign parameters contributing to length of stay, [such as] tolerating oral intake, transportation, and rounding time, among others. Finally, we would need to study how to best implement and operationalize time to clinical stability parameters into clinical workflows.”
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