Christopher G. Maloney, MD, PhD

Apparent life‐threatening events (ALTEs) are frightening for the parent/guardian and represent a challenge for the healthcare provider. ALTEs are defined as worrisome episodes of any combination of apnea, color change, change in muscle tone, choking or gagging.1 ALTEs account for 0.6% to 0.8% of emergency department (ED) visits for children <12 months old,2, 3 have an average length of stay (LOS) of 4.4 days and an average cost of $15,000 per hospitalization.4

Gastroesophageal reflux disease (GERD) is common in infancy11 and also is the most commonly (in 31%55% of ALTE cases) attributed cause of ALTE.2, 4, 5 It has been speculated that chemosensitivity to gastric acid results in laryngospasm, bronchospasm, and apnea. However, several small studies have failed to prove a causal link between reflux episodes and apnea.69 Furthermore, although consensus guidelines for GERD have been developed,14 the clinical use of testing for GERD remains highly variable. A study of infants discharged with an ALTE (n = 12,067) from 36 children's hospitals in the United States revealed extensive variability in the use of pH probes and upper gastrointestinal x‐ray series to diagnose GERD.4

The incidence of adverse outcomes associated with GERD after an ALTE remains unknown. It is also unknown whether an association exists between long‐term gastrointestinal (GI) outcomes and testing demonstrative of GERD or a diagnosis of GERD during hospitalization for ALTE. The primary objective of our study was to determine, in patients with an ALTE, the adverse outcomes associated with GERD (failure‐to‐thrive, aspiration pneumonia, and/or anti‐reflux surgery), the incidence of readmission for second ALTE, and death. Our secondary objective was to determine risk factors for adverse outcomes associated with GERD following an ALTE.

METHODS

Participants

Patients were included if a computer search of ED chief complaint or hospital discharge diagnoses found one or more of the following keywords (or corresponding International Classification of Diseases, Ninth Revision [ICD‐9] codes if applicable): ALTE, altered mental status, apnea, breath‐holding spell, choking, GERD, hypotonia, lethargy, other convulsions, other neurologic diagnosis, other respiratory diagnosis, pallor, seizures, sleep apnea, stiff, syncope, and unresponsiveness. These diagnoses were chosen as potential proxy diagnoses or codes for possible ALTE, as ALTE did not have a corresponding ICD‐9 code at the time of this study.

Detailed review of the medical record included infants who were <12 months old at admission with a history consistent with ALTE, defined as an episode frightening to the observer with any combination of apnea, color change, change in muscle tone, choking, or gagging. Infants were excluded from the study if they had a previously documented underlying medical condition to explain the ALTE (such as a known seizure disorder) or had a clearly apparent diagnosis upon initial history and physical examination (such as bronchiolitis diagnosed in the emergency department) that would explain the event. Patients with unstable vital signs (eg, hypotension), trauma clearly apparent on admission, documented medication dosing error, or febrile seizure were also excluded. A complete list of exclusion criteria is found in Figure 1.

Figure 1

All hospital admissions, ED visits, and Pediatric GI clinic notes were reviewed for adverse outcomes associated with GERD, second ALTE admission, and death. The follow‐up time period included the original enrollment period (January 1, 1999 through December 31, 2003) through August 31, 2009.

RESULTS

Eleven hundred forty‐eight infants with ALTE met inclusion criteria, from 187,903 patients meeting initial search criteria. Six hundred seventy‐one patients were excluded and 8 patients had missing charts. The study population of the 469‐patient cohort is shown in Figure 1.

Demographics are displayed in Table 1. The mean age was 65 days. One hundred three (22%) were premature. One hundred eighty‐nine patients (40%) had a primary discharge diagnosis of GERD; details of the diagnoses for the remaining patients are in Figure 1. Median length of follow‐up for the cohort was 7.8 years. The entire study period was 10.7 years.

Eighteen patients (3.8%) had an adverse outcome associated with GERD. Four (0.9%) had aspiration pneumonia, 9 (1.9%) had failure‐to‐thrive, and 7 (1.5%) had a Nissen fundoplication (no patients had a gastrojejunal tube placed). Five patients had a gastrostomy tube placed at the time of fundoplication. Two patients had more than 1 adverse GI outcome; 1 patient had aspiration pneumonia and another had failure‐to‐thrive prior to their Nissen fundoplications.

Fifty‐six patients (11.9%) were readmitted for a second ALTE. Median time from index ALTE to second ALTE admission was 16.5 days (interquartile range: Q1, 8Q3, 32). Two (0.4%) patients died. Both (occurring at 18 months and 5.5 years after the initial ALTE hospitalization) were related to the children first developing seizure disorders and severe developmental delay. Neither of the patients who died had an index discharge diagnoses of GERD.

There was no significance of the following variables in predicting adverse outcomes associated with GERD: age, prematurity, gender, previous event, testing positive for reflux, primary discharge diagnosis of GERD, or discharge on anti‐reflux medications (see Table 2). Patients with adverse outcomes associated with GERD had longer mean LOS on the index ALTE hospitalization (4.3 days vs 2.4 days; P = 0.03) and a higher rate of neurologic impairment diagnosed in follow‐up (16.7% vs 4.4%; P = 0.02) than patients without long‐term adverse GI outcomes. Patients with neurological impairment diagnosed in follow‐up were more likely to eventually develop an adverse outcome associated with GERD, compared to patients without neurological impairment (odds ratio 8.4; 95% confidence interval 1.1516.1).

DISCUSSION

Our study had 2 main findings. First, infants admitted for an ALTE had a low percentage (3.8%) of adverse outcomes associated with GERD. Review of the literature provides little context to interpret this percentage. One study reports 9 per 100,000 of the general population <18 years of age having anti‐reflux surgery.24 The percentage of adverse outcomes associated with GERD converted to a rate in our study would likely reflect the bias of our center serving as a referral population for Utah and 5 surrounding states. Furthermore, there may be an additional bias of ALTE being a potential indication for anti‐reflux surgery for some clinicians, as well as confounding additional diagnoses (such as later neurologic impairment which might independently increase risk of study outcomes).

The second main finding of our study is that the development of neurologic impairment was predictive of developing adverse GI outcomes. As previous studies have shown that neurological impairment cannot be predicted during the initial ALTE hospitalization,14 adverse outcomes associated with GERD are similarly not predictable with current clinical approaches. Furthermore, the exact nature of the relationship between neurologic impairment and ALTEs remains unclear. While previous studies have described the increased prevalence of adverse neurological outcomes (such as seizures, developmental delay) in children who have had an ALTE, it is unclear what the precipitating reason for ALTE is in these infants (seizure, central apnea, GERD, etc).14

There is ongoing debate in the literature surrounding the optimal diagnosis of GERD in infants with ALTE. Recent guidelines state that investigations aimed to prove GERD causing an ALTE should include pH probe or impedance monitor testing, in combination with a sleep study, and discourages a GERD diagnosis based on upper GI‐series alone.14 Given the low use of pH probe and impedance monitoring at our institution during the study period (86% of the patients who had GI‐related testing had an upper GI‐series), we did not attempt to find the sensitivity or specificity of the different GI testing modalities for GERD in the setting of ALTE. The high use of upper‐GI series is not unique to our institutionone large study examining practice variation from 12,067 ALTE admissions in 36 children's hospitals, with 36.9% of infants (n = 4453) having a primary discharge diagnosis of gastroesophageal reflux, revealed that only 8.9% (SD 28%) received an esophageal pH probe, while 25.6% (SD 43.6%) had an upper GI‐series or swallow study.4

Given the difficulties in assigning a GERD diagnosis for ALTE infants, we focused on the long‐term adverse outcomes associated with GERD for the entire ALTE infant cohort. The 3 adverse outcomes we chose deserve some mention. Aspiration pneumonia is generally due to either primary aspiration (from dysfunctional swallowing) or secondary aspiration (from GERD). Failure‐to‐thrive can be due to ongoing GERD. Anti‐reflux surgery is often performed for severe GERD. While we believe that a prospective study with better diagnostic evaluations for GERD and apnea (such as pH probe or impedance monitor in combination with a sleep study) might help elucidate the unclear relationship between reflux episodes and ALTE, the low percentage of adverse outcomes associated with GERD after ALTE may suggest that such a study would be difficult both in terms of sample size and an unnecessary use of resources.

We also found that a high percentage (11.9%) of all patients had readmission for a second ALTE. This was substantially higher than the 2.5% readmission rate for second ALTE reported in a previous study of short‐term follow‐up (30 days).4 The number of readmissions in our study might be higher due to our comprehensive follow‐up, both in length of time and number of additional EDs and hospitals captured. Unfortunately, the retrospective nature of our study makes it difficult to determine if any interventions (prescription of anti‐reflux medication, education on reflux precautions) impacted the rate of readmission, as compliance was not measurable. Further studies should address why patients return with recurrent ALTE.

Interestingly, several potential risk factors did not predict long‐term adverse GI outcomes. For example, prematurity, a discharge diagnosis of GERD, or prescription of an anti‐reflux medication, were not associated with adverse GI outcomes. These findings support the concept that a diagnosis of GERD, at least as is commonly applied, is not meaningful in the setting of an ALTE. We did find associations with longer length of stay (LOS), and with eventual development of neurological impairment. Longer LOS might be a proxy for other subtle predictors that could influence adverse outcomes, such as requiring additional diagnostic tests prolonging hospitalization, or continued ALTEs while inpatient. The neurologic outcomes of patients with ALTE have been previously published, and the strong correlation between neurologic impairment and GERD has been well described.14, 25

There are several strengths of this study. This is the first study, to our knowledge, to look at adverse outcomes associated with GERD following ALTE, despite GERD being the most commonly attributed cause. The use of Intermountain Healthcare's electronic medical record system allowed for comprehensive tracking, over an extensive follow‐up period (median of 7.8 years), across 20 hospitals and EDs which care for the vast majority of pediatric patients in Utah. Finally, this large cohort of ALTE patients used clinical data from medical records and not only administrative data.

There are limitations of this study. This is a retrospective cohort study. Some of our study outcomes may be a result of pathophysiology other than GERD and, conversely, GERD may be a result of other issues (neurologic impairment). The small sample size and low percentage of the study outcomes make it possible that we did not detect true risk factors. Patients were lost to follow‐up if they moved or presented to a hospital not within the Intermountain Healthcare system. This study has slightly different patient numbers from 3 previously published studies for different outcomes on this cohort, as exclusion criteria for the different cohorts were different.14, 26, 27 Six patients had only their electronic medical record reviewed because the paper chart was missing.

IMPLICATIONS

The results of this study extend previous work of various outcomes regarding well‐appearing infants following an ALTE.14, 26, 27 In these studies, 3.9% and 3% were ultimately diagnosed with epilepsy and developmental delay, respectively; 1.4% were diagnosed with abusive head trauma; and 0.6% required otolaryngologic surgical intervention. In these previous studies, there were few predictors of these outcomes, with testing demonstrating largely normal results during the index ALTE admission.

Our study helps clinicians place the outcomes of aspiration pneumonia, failure‐to‐thrive, and anti‐reflux surgery into the context of these other studies when discharging infants from the hospital after an ALTE. Collectively, these studies provide clinicians with the information that, in the setting of a well‐appearing infant, few diagnostic tests in their ALTE patients will yield a definitive diagnosis. Ultimately, close follow‐up with further investigations if symptoms recur will be an important part of diagnosing the etiology of the ALTE in these infants.

We found that well‐appearing infants with ALTE, regardless of attributed cause, are at low risk for adverse outcomes associated with GERD. Only the eventual development of neurologic impairment or an increased length of stay during index ALTE hospitalization was found to be predictive of these outcomes.

Apparent life‐threatening events (ALTEs) are frightening for the parent/guardian and represent a challenge for the healthcare provider. ALTEs are defined as worrisome episodes of any combination of apnea, color change, change in muscle tone, choking or gagging.1 ALTEs account for 0.6% to 0.8% of emergency department (ED) visits for children <12 months old,2, 3 have an average length of stay (LOS) of 4.4 days and an average cost of $15,000 per hospitalization.4

Gastroesophageal reflux disease (GERD) is common in infancy11 and also is the most commonly (in 31%55% of ALTE cases) attributed cause of ALTE.2, 4, 5 It has been speculated that chemosensitivity to gastric acid results in laryngospasm, bronchospasm, and apnea. However, several small studies have failed to prove a causal link between reflux episodes and apnea.69 Furthermore, although consensus guidelines for GERD have been developed,14 the clinical use of testing for GERD remains highly variable. A study of infants discharged with an ALTE (n = 12,067) from 36 children's hospitals in the United States revealed extensive variability in the use of pH probes and upper gastrointestinal x‐ray series to diagnose GERD.4

The incidence of adverse outcomes associated with GERD after an ALTE remains unknown. It is also unknown whether an association exists between long‐term gastrointestinal (GI) outcomes and testing demonstrative of GERD or a diagnosis of GERD during hospitalization for ALTE. The primary objective of our study was to determine, in patients with an ALTE, the adverse outcomes associated with GERD (failure‐to‐thrive, aspiration pneumonia, and/or anti‐reflux surgery), the incidence of readmission for second ALTE, and death. Our secondary objective was to determine risk factors for adverse outcomes associated with GERD following an ALTE.

METHODS

Participants

Patients were included if a computer search of ED chief complaint or hospital discharge diagnoses found one or more of the following keywords (or corresponding International Classification of Diseases, Ninth Revision [ICD‐9] codes if applicable): ALTE, altered mental status, apnea, breath‐holding spell, choking, GERD, hypotonia, lethargy, other convulsions, other neurologic diagnosis, other respiratory diagnosis, pallor, seizures, sleep apnea, stiff, syncope, and unresponsiveness. These diagnoses were chosen as potential proxy diagnoses or codes for possible ALTE, as ALTE did not have a corresponding ICD‐9 code at the time of this study.

Detailed review of the medical record included infants who were <12 months old at admission with a history consistent with ALTE, defined as an episode frightening to the observer with any combination of apnea, color change, change in muscle tone, choking, or gagging. Infants were excluded from the study if they had a previously documented underlying medical condition to explain the ALTE (such as a known seizure disorder) or had a clearly apparent diagnosis upon initial history and physical examination (such as bronchiolitis diagnosed in the emergency department) that would explain the event. Patients with unstable vital signs (eg, hypotension), trauma clearly apparent on admission, documented medication dosing error, or febrile seizure were also excluded. A complete list of exclusion criteria is found in Figure 1.

Figure 1

All hospital admissions, ED visits, and Pediatric GI clinic notes were reviewed for adverse outcomes associated with GERD, second ALTE admission, and death. The follow‐up time period included the original enrollment period (January 1, 1999 through December 31, 2003) through August 31, 2009.

RESULTS

Eleven hundred forty‐eight infants with ALTE met inclusion criteria, from 187,903 patients meeting initial search criteria. Six hundred seventy‐one patients were excluded and 8 patients had missing charts. The study population of the 469‐patient cohort is shown in Figure 1.

Demographics are displayed in Table 1. The mean age was 65 days. One hundred three (22%) were premature. One hundred eighty‐nine patients (40%) had a primary discharge diagnosis of GERD; details of the diagnoses for the remaining patients are in Figure 1. Median length of follow‐up for the cohort was 7.8 years. The entire study period was 10.7 years.

Eighteen patients (3.8%) had an adverse outcome associated with GERD. Four (0.9%) had aspiration pneumonia, 9 (1.9%) had failure‐to‐thrive, and 7 (1.5%) had a Nissen fundoplication (no patients had a gastrojejunal tube placed). Five patients had a gastrostomy tube placed at the time of fundoplication. Two patients had more than 1 adverse GI outcome; 1 patient had aspiration pneumonia and another had failure‐to‐thrive prior to their Nissen fundoplications.

Fifty‐six patients (11.9%) were readmitted for a second ALTE. Median time from index ALTE to second ALTE admission was 16.5 days (interquartile range: Q1, 8Q3, 32). Two (0.4%) patients died. Both (occurring at 18 months and 5.5 years after the initial ALTE hospitalization) were related to the children first developing seizure disorders and severe developmental delay. Neither of the patients who died had an index discharge diagnoses of GERD.

There was no significance of the following variables in predicting adverse outcomes associated with GERD: age, prematurity, gender, previous event, testing positive for reflux, primary discharge diagnosis of GERD, or discharge on anti‐reflux medications (see Table 2). Patients with adverse outcomes associated with GERD had longer mean LOS on the index ALTE hospitalization (4.3 days vs 2.4 days; P = 0.03) and a higher rate of neurologic impairment diagnosed in follow‐up (16.7% vs 4.4%; P = 0.02) than patients without long‐term adverse GI outcomes. Patients with neurological impairment diagnosed in follow‐up were more likely to eventually develop an adverse outcome associated with GERD, compared to patients without neurological impairment (odds ratio 8.4; 95% confidence interval 1.1516.1).

DISCUSSION

Our study had 2 main findings. First, infants admitted for an ALTE had a low percentage (3.8%) of adverse outcomes associated with GERD. Review of the literature provides little context to interpret this percentage. One study reports 9 per 100,000 of the general population <18 years of age having anti‐reflux surgery.24 The percentage of adverse outcomes associated with GERD converted to a rate in our study would likely reflect the bias of our center serving as a referral population for Utah and 5 surrounding states. Furthermore, there may be an additional bias of ALTE being a potential indication for anti‐reflux surgery for some clinicians, as well as confounding additional diagnoses (such as later neurologic impairment which might independently increase risk of study outcomes).

The second main finding of our study is that the development of neurologic impairment was predictive of developing adverse GI outcomes. As previous studies have shown that neurological impairment cannot be predicted during the initial ALTE hospitalization,14 adverse outcomes associated with GERD are similarly not predictable with current clinical approaches. Furthermore, the exact nature of the relationship between neurologic impairment and ALTEs remains unclear. While previous studies have described the increased prevalence of adverse neurological outcomes (such as seizures, developmental delay) in children who have had an ALTE, it is unclear what the precipitating reason for ALTE is in these infants (seizure, central apnea, GERD, etc).14

There is ongoing debate in the literature surrounding the optimal diagnosis of GERD in infants with ALTE. Recent guidelines state that investigations aimed to prove GERD causing an ALTE should include pH probe or impedance monitor testing, in combination with a sleep study, and discourages a GERD diagnosis based on upper GI‐series alone.14 Given the low use of pH probe and impedance monitoring at our institution during the study period (86% of the patients who had GI‐related testing had an upper GI‐series), we did not attempt to find the sensitivity or specificity of the different GI testing modalities for GERD in the setting of ALTE. The high use of upper‐GI series is not unique to our institutionone large study examining practice variation from 12,067 ALTE admissions in 36 children's hospitals, with 36.9% of infants (n = 4453) having a primary discharge diagnosis of gastroesophageal reflux, revealed that only 8.9% (SD 28%) received an esophageal pH probe, while 25.6% (SD 43.6%) had an upper GI‐series or swallow study.4

Given the difficulties in assigning a GERD diagnosis for ALTE infants, we focused on the long‐term adverse outcomes associated with GERD for the entire ALTE infant cohort. The 3 adverse outcomes we chose deserve some mention. Aspiration pneumonia is generally due to either primary aspiration (from dysfunctional swallowing) or secondary aspiration (from GERD). Failure‐to‐thrive can be due to ongoing GERD. Anti‐reflux surgery is often performed for severe GERD. While we believe that a prospective study with better diagnostic evaluations for GERD and apnea (such as pH probe or impedance monitor in combination with a sleep study) might help elucidate the unclear relationship between reflux episodes and ALTE, the low percentage of adverse outcomes associated with GERD after ALTE may suggest that such a study would be difficult both in terms of sample size and an unnecessary use of resources.

We also found that a high percentage (11.9%) of all patients had readmission for a second ALTE. This was substantially higher than the 2.5% readmission rate for second ALTE reported in a previous study of short‐term follow‐up (30 days).4 The number of readmissions in our study might be higher due to our comprehensive follow‐up, both in length of time and number of additional EDs and hospitals captured. Unfortunately, the retrospective nature of our study makes it difficult to determine if any interventions (prescription of anti‐reflux medication, education on reflux precautions) impacted the rate of readmission, as compliance was not measurable. Further studies should address why patients return with recurrent ALTE.

Interestingly, several potential risk factors did not predict long‐term adverse GI outcomes. For example, prematurity, a discharge diagnosis of GERD, or prescription of an anti‐reflux medication, were not associated with adverse GI outcomes. These findings support the concept that a diagnosis of GERD, at least as is commonly applied, is not meaningful in the setting of an ALTE. We did find associations with longer length of stay (LOS), and with eventual development of neurological impairment. Longer LOS might be a proxy for other subtle predictors that could influence adverse outcomes, such as requiring additional diagnostic tests prolonging hospitalization, or continued ALTEs while inpatient. The neurologic outcomes of patients with ALTE have been previously published, and the strong correlation between neurologic impairment and GERD has been well described.14, 25

There are several strengths of this study. This is the first study, to our knowledge, to look at adverse outcomes associated with GERD following ALTE, despite GERD being the most commonly attributed cause. The use of Intermountain Healthcare's electronic medical record system allowed for comprehensive tracking, over an extensive follow‐up period (median of 7.8 years), across 20 hospitals and EDs which care for the vast majority of pediatric patients in Utah. Finally, this large cohort of ALTE patients used clinical data from medical records and not only administrative data.

There are limitations of this study. This is a retrospective cohort study. Some of our study outcomes may be a result of pathophysiology other than GERD and, conversely, GERD may be a result of other issues (neurologic impairment). The small sample size and low percentage of the study outcomes make it possible that we did not detect true risk factors. Patients were lost to follow‐up if they moved or presented to a hospital not within the Intermountain Healthcare system. This study has slightly different patient numbers from 3 previously published studies for different outcomes on this cohort, as exclusion criteria for the different cohorts were different.14, 26, 27 Six patients had only their electronic medical record reviewed because the paper chart was missing.

IMPLICATIONS

The results of this study extend previous work of various outcomes regarding well‐appearing infants following an ALTE.14, 26, 27 In these studies, 3.9% and 3% were ultimately diagnosed with epilepsy and developmental delay, respectively; 1.4% were diagnosed with abusive head trauma; and 0.6% required otolaryngologic surgical intervention. In these previous studies, there were few predictors of these outcomes, with testing demonstrating largely normal results during the index ALTE admission.

Our study helps clinicians place the outcomes of aspiration pneumonia, failure‐to‐thrive, and anti‐reflux surgery into the context of these other studies when discharging infants from the hospital after an ALTE. Collectively, these studies provide clinicians with the information that, in the setting of a well‐appearing infant, few diagnostic tests in their ALTE patients will yield a definitive diagnosis. Ultimately, close follow‐up with further investigations if symptoms recur will be an important part of diagnosing the etiology of the ALTE in these infants.

We found that well‐appearing infants with ALTE, regardless of attributed cause, are at low risk for adverse outcomes associated with GERD. Only the eventual development of neurologic impairment or an increased length of stay during index ALTE hospitalization was found to be predictive of these outcomes.

Apparent life‐threatening events (ALTEs) are frightening for the parent/guardian and represent a challenge for the healthcare provider. ALTEs are defined as worrisome episodes of any combination of apnea, color change, change in muscle tone, choking or gagging.1 ALTEs account for 0.6% to 0.8% of emergency department (ED) visits for children <12 months old,2, 3 have an average length of stay (LOS) of 4.4 days and an average cost of $15,000 per hospitalization.4

Gastroesophageal reflux disease (GERD) is common in infancy11 and also is the most commonly (in 31%55% of ALTE cases) attributed cause of ALTE.2, 4, 5 It has been speculated that chemosensitivity to gastric acid results in laryngospasm, bronchospasm, and apnea. However, several small studies have failed to prove a causal link between reflux episodes and apnea.69 Furthermore, although consensus guidelines for GERD have been developed,14 the clinical use of testing for GERD remains highly variable. A study of infants discharged with an ALTE (n = 12,067) from 36 children's hospitals in the United States revealed extensive variability in the use of pH probes and upper gastrointestinal x‐ray series to diagnose GERD.4

The incidence of adverse outcomes associated with GERD after an ALTE remains unknown. It is also unknown whether an association exists between long‐term gastrointestinal (GI) outcomes and testing demonstrative of GERD or a diagnosis of GERD during hospitalization for ALTE. The primary objective of our study was to determine, in patients with an ALTE, the adverse outcomes associated with GERD (failure‐to‐thrive, aspiration pneumonia, and/or anti‐reflux surgery), the incidence of readmission for second ALTE, and death. Our secondary objective was to determine risk factors for adverse outcomes associated with GERD following an ALTE.

METHODS

Participants

Patients were included if a computer search of ED chief complaint or hospital discharge diagnoses found one or more of the following keywords (or corresponding International Classification of Diseases, Ninth Revision [ICD‐9] codes if applicable): ALTE, altered mental status, apnea, breath‐holding spell, choking, GERD, hypotonia, lethargy, other convulsions, other neurologic diagnosis, other respiratory diagnosis, pallor, seizures, sleep apnea, stiff, syncope, and unresponsiveness. These diagnoses were chosen as potential proxy diagnoses or codes for possible ALTE, as ALTE did not have a corresponding ICD‐9 code at the time of this study.

Detailed review of the medical record included infants who were <12 months old at admission with a history consistent with ALTE, defined as an episode frightening to the observer with any combination of apnea, color change, change in muscle tone, choking, or gagging. Infants were excluded from the study if they had a previously documented underlying medical condition to explain the ALTE (such as a known seizure disorder) or had a clearly apparent diagnosis upon initial history and physical examination (such as bronchiolitis diagnosed in the emergency department) that would explain the event. Patients with unstable vital signs (eg, hypotension), trauma clearly apparent on admission, documented medication dosing error, or febrile seizure were also excluded. A complete list of exclusion criteria is found in Figure 1.

Figure 1

All hospital admissions, ED visits, and Pediatric GI clinic notes were reviewed for adverse outcomes associated with GERD, second ALTE admission, and death. The follow‐up time period included the original enrollment period (January 1, 1999 through December 31, 2003) through August 31, 2009.

RESULTS

Eleven hundred forty‐eight infants with ALTE met inclusion criteria, from 187,903 patients meeting initial search criteria. Six hundred seventy‐one patients were excluded and 8 patients had missing charts. The study population of the 469‐patient cohort is shown in Figure 1.

Demographics are displayed in Table 1. The mean age was 65 days. One hundred three (22%) were premature. One hundred eighty‐nine patients (40%) had a primary discharge diagnosis of GERD; details of the diagnoses for the remaining patients are in Figure 1. Median length of follow‐up for the cohort was 7.8 years. The entire study period was 10.7 years.

Eighteen patients (3.8%) had an adverse outcome associated with GERD. Four (0.9%) had aspiration pneumonia, 9 (1.9%) had failure‐to‐thrive, and 7 (1.5%) had a Nissen fundoplication (no patients had a gastrojejunal tube placed). Five patients had a gastrostomy tube placed at the time of fundoplication. Two patients had more than 1 adverse GI outcome; 1 patient had aspiration pneumonia and another had failure‐to‐thrive prior to their Nissen fundoplications.

Fifty‐six patients (11.9%) were readmitted for a second ALTE. Median time from index ALTE to second ALTE admission was 16.5 days (interquartile range: Q1, 8Q3, 32). Two (0.4%) patients died. Both (occurring at 18 months and 5.5 years after the initial ALTE hospitalization) were related to the children first developing seizure disorders and severe developmental delay. Neither of the patients who died had an index discharge diagnoses of GERD.

There was no significance of the following variables in predicting adverse outcomes associated with GERD: age, prematurity, gender, previous event, testing positive for reflux, primary discharge diagnosis of GERD, or discharge on anti‐reflux medications (see Table 2). Patients with adverse outcomes associated with GERD had longer mean LOS on the index ALTE hospitalization (4.3 days vs 2.4 days; P = 0.03) and a higher rate of neurologic impairment diagnosed in follow‐up (16.7% vs 4.4%; P = 0.02) than patients without long‐term adverse GI outcomes. Patients with neurological impairment diagnosed in follow‐up were more likely to eventually develop an adverse outcome associated with GERD, compared to patients without neurological impairment (odds ratio 8.4; 95% confidence interval 1.1516.1).

DISCUSSION

Our study had 2 main findings. First, infants admitted for an ALTE had a low percentage (3.8%) of adverse outcomes associated with GERD. Review of the literature provides little context to interpret this percentage. One study reports 9 per 100,000 of the general population <18 years of age having anti‐reflux surgery.24 The percentage of adverse outcomes associated with GERD converted to a rate in our study would likely reflect the bias of our center serving as a referral population for Utah and 5 surrounding states. Furthermore, there may be an additional bias of ALTE being a potential indication for anti‐reflux surgery for some clinicians, as well as confounding additional diagnoses (such as later neurologic impairment which might independently increase risk of study outcomes).

The second main finding of our study is that the development of neurologic impairment was predictive of developing adverse GI outcomes. As previous studies have shown that neurological impairment cannot be predicted during the initial ALTE hospitalization,14 adverse outcomes associated with GERD are similarly not predictable with current clinical approaches. Furthermore, the exact nature of the relationship between neurologic impairment and ALTEs remains unclear. While previous studies have described the increased prevalence of adverse neurological outcomes (such as seizures, developmental delay) in children who have had an ALTE, it is unclear what the precipitating reason for ALTE is in these infants (seizure, central apnea, GERD, etc).14

There is ongoing debate in the literature surrounding the optimal diagnosis of GERD in infants with ALTE. Recent guidelines state that investigations aimed to prove GERD causing an ALTE should include pH probe or impedance monitor testing, in combination with a sleep study, and discourages a GERD diagnosis based on upper GI‐series alone.14 Given the low use of pH probe and impedance monitoring at our institution during the study period (86% of the patients who had GI‐related testing had an upper GI‐series), we did not attempt to find the sensitivity or specificity of the different GI testing modalities for GERD in the setting of ALTE. The high use of upper‐GI series is not unique to our institutionone large study examining practice variation from 12,067 ALTE admissions in 36 children's hospitals, with 36.9% of infants (n = 4453) having a primary discharge diagnosis of gastroesophageal reflux, revealed that only 8.9% (SD 28%) received an esophageal pH probe, while 25.6% (SD 43.6%) had an upper GI‐series or swallow study.4

Given the difficulties in assigning a GERD diagnosis for ALTE infants, we focused on the long‐term adverse outcomes associated with GERD for the entire ALTE infant cohort. The 3 adverse outcomes we chose deserve some mention. Aspiration pneumonia is generally due to either primary aspiration (from dysfunctional swallowing) or secondary aspiration (from GERD). Failure‐to‐thrive can be due to ongoing GERD. Anti‐reflux surgery is often performed for severe GERD. While we believe that a prospective study with better diagnostic evaluations for GERD and apnea (such as pH probe or impedance monitor in combination with a sleep study) might help elucidate the unclear relationship between reflux episodes and ALTE, the low percentage of adverse outcomes associated with GERD after ALTE may suggest that such a study would be difficult both in terms of sample size and an unnecessary use of resources.

We also found that a high percentage (11.9%) of all patients had readmission for a second ALTE. This was substantially higher than the 2.5% readmission rate for second ALTE reported in a previous study of short‐term follow‐up (30 days).4 The number of readmissions in our study might be higher due to our comprehensive follow‐up, both in length of time and number of additional EDs and hospitals captured. Unfortunately, the retrospective nature of our study makes it difficult to determine if any interventions (prescription of anti‐reflux medication, education on reflux precautions) impacted the rate of readmission, as compliance was not measurable. Further studies should address why patients return with recurrent ALTE.

Interestingly, several potential risk factors did not predict long‐term adverse GI outcomes. For example, prematurity, a discharge diagnosis of GERD, or prescription of an anti‐reflux medication, were not associated with adverse GI outcomes. These findings support the concept that a diagnosis of GERD, at least as is commonly applied, is not meaningful in the setting of an ALTE. We did find associations with longer length of stay (LOS), and with eventual development of neurological impairment. Longer LOS might be a proxy for other subtle predictors that could influence adverse outcomes, such as requiring additional diagnostic tests prolonging hospitalization, or continued ALTEs while inpatient. The neurologic outcomes of patients with ALTE have been previously published, and the strong correlation between neurologic impairment and GERD has been well described.14, 25

There are several strengths of this study. This is the first study, to our knowledge, to look at adverse outcomes associated with GERD following ALTE, despite GERD being the most commonly attributed cause. The use of Intermountain Healthcare's electronic medical record system allowed for comprehensive tracking, over an extensive follow‐up period (median of 7.8 years), across 20 hospitals and EDs which care for the vast majority of pediatric patients in Utah. Finally, this large cohort of ALTE patients used clinical data from medical records and not only administrative data.

There are limitations of this study. This is a retrospective cohort study. Some of our study outcomes may be a result of pathophysiology other than GERD and, conversely, GERD may be a result of other issues (neurologic impairment). The small sample size and low percentage of the study outcomes make it possible that we did not detect true risk factors. Patients were lost to follow‐up if they moved or presented to a hospital not within the Intermountain Healthcare system. This study has slightly different patient numbers from 3 previously published studies for different outcomes on this cohort, as exclusion criteria for the different cohorts were different.14, 26, 27 Six patients had only their electronic medical record reviewed because the paper chart was missing.

IMPLICATIONS

The results of this study extend previous work of various outcomes regarding well‐appearing infants following an ALTE.14, 26, 27 In these studies, 3.9% and 3% were ultimately diagnosed with epilepsy and developmental delay, respectively; 1.4% were diagnosed with abusive head trauma; and 0.6% required otolaryngologic surgical intervention. In these previous studies, there were few predictors of these outcomes, with testing demonstrating largely normal results during the index ALTE admission.

Our study helps clinicians place the outcomes of aspiration pneumonia, failure‐to‐thrive, and anti‐reflux surgery into the context of these other studies when discharging infants from the hospital after an ALTE. Collectively, these studies provide clinicians with the information that, in the setting of a well‐appearing infant, few diagnostic tests in their ALTE patients will yield a definitive diagnosis. Ultimately, close follow‐up with further investigations if symptoms recur will be an important part of diagnosing the etiology of the ALTE in these infants.

We found that well‐appearing infants with ALTE, regardless of attributed cause, are at low risk for adverse outcomes associated with GERD. Only the eventual development of neurologic impairment or an increased length of stay during index ALTE hospitalization was found to be predictive of these outcomes.

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.

The third‐year pediatric clerkship at the University of Utah School of Medicine has a relatively unique inpatient service, the Glasgow Service, which consists of an academic attending, a third‐year pediatric resident, and 4 third‐year medical students, but no interns. (This service was named in honor of Lowell Glasgow, chair of pediatrics, 1972‐82.) This structure was introduced in 1992 by the chair of pediatrics, Michael Simmons, the residency program director, Richard Molteni, and the clerkship director, Karen Hansen. These individuals desired to improve students' inpatient experience by providing greater responsibility for patient care. An additional motive was to increase the total number of patients followed by house staff without increasing the size of the residency program.

This inpatient service is a part of a 6‐week pediatric clerkship. All students perform the 3‐week inpatient portion of their clerkship at Primary Children's Medical Center, a tertiary‐care, freestanding children's hospital. (The students also spend 1 week each in a newborn nursery, an outpatient clinic, and a subspecialty setting). The academic attendings include generalists, hospitalists, and specialists who concurrently have other clinical responsibilities. The students take in‐house call every fourth night, supervised by senior residents who are not necessarily members of their service. All students share the same formal teaching activities, including morning report, a noon conference, and a student conference.

Patients are assigned to the ward services by a senior admitting resident. The admitting resident distributes patients among the services based on the complexity and acuity of the patients' conditions as well as the census on the various services. The senior resident supervising a particular service then assigns patients among the members of that service. Each third‐year medical student is expected to care for 2 or 3 patients at a time.

In addition to the intervention service, students also rotate on 2 similar traditional services. These services are traditional in the sense that they are composed of an academic attending, a community attending, a third‐year pediatric resident, 4 interns, and up to 2 fourth‐year and 2 third‐year medical students. Faculty preferences regarding service assignments were accommodated when possible. Therefore, some faculty attended only on one type of service, intervention or traditional, and others attended on both types. Because they have more members and because interns are capable of caring for more patients than are medical students, the traditional services cared for more patients than the intervention service. Although identical in composition, the 2 traditional services differ with each other in several ways. One service typically admits children 3 years old and younger, whereas the other admits children who are between 3 and 12 years old. The service that admits older children also admits most of the hematology‐oncology patients.

Although other authors have described similar inpatient clerkship structures, to our knowledge, none have evaluated them through a prospective randomized controlled trial.1, 2 The recent literature on ambulatory experiences during third‐year clerkships provided a methodological framework for this study. Collectively, such studies have evaluated outcomes with a variety of measures, including patient logs,35 evaluations,3, 4, 6, 7 examinations,37 surveys,3, 5, 7, 8 and career choices.4, 68 Additional outcomes, such as the effect of educational interventions on patient care, have been emphasized.9

In the light of this research, we conducted a prospective, randomized controlled trial to compare outcomes on the intervention service with those on the traditional services. We hypothesized that, compared with the traditional services, the intervention service would show:

• improved process measures in terms of increased number of patients admitted, number of key diagnoses encountered in the patients cared for, and range of ages of the patients admitted;

• similar or improved student performance, as measured by faculty and resident evaluations and a National Board of Medical Examiners (NBME) subject examination;

• increased student satisfaction, as assessed by an end‐of‐rotation questionnaire;

• increased interest in pediatric and, more broadly, primary care careers, as measured by subinternship and internship selections; and

• comparable or improved resource utilization in terms of length of stay and total charges.

METHODS

All students enrolled in the third‐year pediatric rotation during the 2001‐2003 academic years were individually randomized by the clerkship assistant to the intervention service or 1 of the 2 traditional services without respect to career preference. A 5:3 student randomization ratio was used to fulfill the requirement that 4 students be assigned to the intervention service during every 3‐week block. This permitted the service to have call every fourth night.

To evaluate the adequacy of the randomization process, we obtained baseline student characteristics on age, sex, and United States Medical Licensing Examination (USMLE) Step 1 score from the Dean of Student Affairs. The dean also reported the discipline each student enrolled in for the required fourth‐year subinternship(s) and matched in for internship. These data were reported anonymously and linked to the service to which the student was assigned. In this study, pediatrics, internal medicine, and family practice were all considered primary care, but preliminary or transitional internships were not.

RESULTS

Two hundred and three students enrolled in the third‐year pediatric clerkship during the study period, and all students completed the clerkship on their assigned services. One hundred and twenty‐eight were randomized to the intervention service and 75 to the traditional services. There were no statistically significant differences in median age, percentage of male students, or mean USMLE Step 1 score between the students randomized to the intervention service and those randomized to the traditional services (Table 1).

DISCUSSION

This study's objective was to evaluate a third‐year pediatric clerkship structure that focuses on students, using multiple outcome parameters. Utilizing a robust design, the results of this study have demonstrated that the intervention service is more successful than the traditional services in several outcomes. Students assigned to the intervention service were more satisfied and more likely to select pediatrics as a career. These improvements were accomplished while maintaining similar process measures, student performance, and resource utilization compared with those of the traditional services.

CONCLUSIONS

The intervention service is a structure for the pediatric inpatient rotation of third‐year medical students that, instead of dividing the faculty and supervising resident's attention between interns and students, focuses their attention on the students. Although it has been difficult to demonstrate improvements as a result of the educational interventions, we have shown several improvements in the evaluations of the students. Moreover, the pattern of increased student satisfaction and a tendency toward more student selecting careers in pediatrics are remarkable. This was accomplished with similar resource utilization. Therefore, this program merits being continued at our institution and possibly adopted at other medical schools. Further research is needed to determine which aspects of the intervention are responsible for its effects. Some components, such as focused time with students, may be applicable to traditional services.

The third‐year pediatric clerkship at the University of Utah School of Medicine has a relatively unique inpatient service, the Glasgow Service, which consists of an academic attending, a third‐year pediatric resident, and 4 third‐year medical students, but no interns. (This service was named in honor of Lowell Glasgow, chair of pediatrics, 1972‐82.) This structure was introduced in 1992 by the chair of pediatrics, Michael Simmons, the residency program director, Richard Molteni, and the clerkship director, Karen Hansen. These individuals desired to improve students' inpatient experience by providing greater responsibility for patient care. An additional motive was to increase the total number of patients followed by house staff without increasing the size of the residency program.

This inpatient service is a part of a 6‐week pediatric clerkship. All students perform the 3‐week inpatient portion of their clerkship at Primary Children's Medical Center, a tertiary‐care, freestanding children's hospital. (The students also spend 1 week each in a newborn nursery, an outpatient clinic, and a subspecialty setting). The academic attendings include generalists, hospitalists, and specialists who concurrently have other clinical responsibilities. The students take in‐house call every fourth night, supervised by senior residents who are not necessarily members of their service. All students share the same formal teaching activities, including morning report, a noon conference, and a student conference.

Patients are assigned to the ward services by a senior admitting resident. The admitting resident distributes patients among the services based on the complexity and acuity of the patients' conditions as well as the census on the various services. The senior resident supervising a particular service then assigns patients among the members of that service. Each third‐year medical student is expected to care for 2 or 3 patients at a time.

In addition to the intervention service, students also rotate on 2 similar traditional services. These services are traditional in the sense that they are composed of an academic attending, a community attending, a third‐year pediatric resident, 4 interns, and up to 2 fourth‐year and 2 third‐year medical students. Faculty preferences regarding service assignments were accommodated when possible. Therefore, some faculty attended only on one type of service, intervention or traditional, and others attended on both types. Because they have more members and because interns are capable of caring for more patients than are medical students, the traditional services cared for more patients than the intervention service. Although identical in composition, the 2 traditional services differ with each other in several ways. One service typically admits children 3 years old and younger, whereas the other admits children who are between 3 and 12 years old. The service that admits older children also admits most of the hematology‐oncology patients.

Although other authors have described similar inpatient clerkship structures, to our knowledge, none have evaluated them through a prospective randomized controlled trial.1, 2 The recent literature on ambulatory experiences during third‐year clerkships provided a methodological framework for this study. Collectively, such studies have evaluated outcomes with a variety of measures, including patient logs,35 evaluations,3, 4, 6, 7 examinations,37 surveys,3, 5, 7, 8 and career choices.4, 68 Additional outcomes, such as the effect of educational interventions on patient care, have been emphasized.9

In the light of this research, we conducted a prospective, randomized controlled trial to compare outcomes on the intervention service with those on the traditional services. We hypothesized that, compared with the traditional services, the intervention service would show:

• improved process measures in terms of increased number of patients admitted, number of key diagnoses encountered in the patients cared for, and range of ages of the patients admitted;

• similar or improved student performance, as measured by faculty and resident evaluations and a National Board of Medical Examiners (NBME) subject examination;

• increased student satisfaction, as assessed by an end‐of‐rotation questionnaire;

• increased interest in pediatric and, more broadly, primary care careers, as measured by subinternship and internship selections; and

• comparable or improved resource utilization in terms of length of stay and total charges.

METHODS

All students enrolled in the third‐year pediatric rotation during the 2001‐2003 academic years were individually randomized by the clerkship assistant to the intervention service or 1 of the 2 traditional services without respect to career preference. A 5:3 student randomization ratio was used to fulfill the requirement that 4 students be assigned to the intervention service during every 3‐week block. This permitted the service to have call every fourth night.

To evaluate the adequacy of the randomization process, we obtained baseline student characteristics on age, sex, and United States Medical Licensing Examination (USMLE) Step 1 score from the Dean of Student Affairs. The dean also reported the discipline each student enrolled in for the required fourth‐year subinternship(s) and matched in for internship. These data were reported anonymously and linked to the service to which the student was assigned. In this study, pediatrics, internal medicine, and family practice were all considered primary care, but preliminary or transitional internships were not.

RESULTS

Two hundred and three students enrolled in the third‐year pediatric clerkship during the study period, and all students completed the clerkship on their assigned services. One hundred and twenty‐eight were randomized to the intervention service and 75 to the traditional services. There were no statistically significant differences in median age, percentage of male students, or mean USMLE Step 1 score between the students randomized to the intervention service and those randomized to the traditional services (Table 1).

DISCUSSION

This study's objective was to evaluate a third‐year pediatric clerkship structure that focuses on students, using multiple outcome parameters. Utilizing a robust design, the results of this study have demonstrated that the intervention service is more successful than the traditional services in several outcomes. Students assigned to the intervention service were more satisfied and more likely to select pediatrics as a career. These improvements were accomplished while maintaining similar process measures, student performance, and resource utilization compared with those of the traditional services.

CONCLUSIONS

The intervention service is a structure for the pediatric inpatient rotation of third‐year medical students that, instead of dividing the faculty and supervising resident's attention between interns and students, focuses their attention on the students. Although it has been difficult to demonstrate improvements as a result of the educational interventions, we have shown several improvements in the evaluations of the students. Moreover, the pattern of increased student satisfaction and a tendency toward more student selecting careers in pediatrics are remarkable. This was accomplished with similar resource utilization. Therefore, this program merits being continued at our institution and possibly adopted at other medical schools. Further research is needed to determine which aspects of the intervention are responsible for its effects. Some components, such as focused time with students, may be applicable to traditional services.

The third‐year pediatric clerkship at the University of Utah School of Medicine has a relatively unique inpatient service, the Glasgow Service, which consists of an academic attending, a third‐year pediatric resident, and 4 third‐year medical students, but no interns. (This service was named in honor of Lowell Glasgow, chair of pediatrics, 1972‐82.) This structure was introduced in 1992 by the chair of pediatrics, Michael Simmons, the residency program director, Richard Molteni, and the clerkship director, Karen Hansen. These individuals desired to improve students' inpatient experience by providing greater responsibility for patient care. An additional motive was to increase the total number of patients followed by house staff without increasing the size of the residency program.

This inpatient service is a part of a 6‐week pediatric clerkship. All students perform the 3‐week inpatient portion of their clerkship at Primary Children's Medical Center, a tertiary‐care, freestanding children's hospital. (The students also spend 1 week each in a newborn nursery, an outpatient clinic, and a subspecialty setting). The academic attendings include generalists, hospitalists, and specialists who concurrently have other clinical responsibilities. The students take in‐house call every fourth night, supervised by senior residents who are not necessarily members of their service. All students share the same formal teaching activities, including morning report, a noon conference, and a student conference.

Patients are assigned to the ward services by a senior admitting resident. The admitting resident distributes patients among the services based on the complexity and acuity of the patients' conditions as well as the census on the various services. The senior resident supervising a particular service then assigns patients among the members of that service. Each third‐year medical student is expected to care for 2 or 3 patients at a time.

In addition to the intervention service, students also rotate on 2 similar traditional services. These services are traditional in the sense that they are composed of an academic attending, a community attending, a third‐year pediatric resident, 4 interns, and up to 2 fourth‐year and 2 third‐year medical students. Faculty preferences regarding service assignments were accommodated when possible. Therefore, some faculty attended only on one type of service, intervention or traditional, and others attended on both types. Because they have more members and because interns are capable of caring for more patients than are medical students, the traditional services cared for more patients than the intervention service. Although identical in composition, the 2 traditional services differ with each other in several ways. One service typically admits children 3 years old and younger, whereas the other admits children who are between 3 and 12 years old. The service that admits older children also admits most of the hematology‐oncology patients.

Although other authors have described similar inpatient clerkship structures, to our knowledge, none have evaluated them through a prospective randomized controlled trial.1, 2 The recent literature on ambulatory experiences during third‐year clerkships provided a methodological framework for this study. Collectively, such studies have evaluated outcomes with a variety of measures, including patient logs,35 evaluations,3, 4, 6, 7 examinations,37 surveys,3, 5, 7, 8 and career choices.4, 68 Additional outcomes, such as the effect of educational interventions on patient care, have been emphasized.9

In the light of this research, we conducted a prospective, randomized controlled trial to compare outcomes on the intervention service with those on the traditional services. We hypothesized that, compared with the traditional services, the intervention service would show:

• improved process measures in terms of increased number of patients admitted, number of key diagnoses encountered in the patients cared for, and range of ages of the patients admitted;

• similar or improved student performance, as measured by faculty and resident evaluations and a National Board of Medical Examiners (NBME) subject examination;

• increased student satisfaction, as assessed by an end‐of‐rotation questionnaire;

• increased interest in pediatric and, more broadly, primary care careers, as measured by subinternship and internship selections; and

• comparable or improved resource utilization in terms of length of stay and total charges.

METHODS

All students enrolled in the third‐year pediatric rotation during the 2001‐2003 academic years were individually randomized by the clerkship assistant to the intervention service or 1 of the 2 traditional services without respect to career preference. A 5:3 student randomization ratio was used to fulfill the requirement that 4 students be assigned to the intervention service during every 3‐week block. This permitted the service to have call every fourth night.

To evaluate the adequacy of the randomization process, we obtained baseline student characteristics on age, sex, and United States Medical Licensing Examination (USMLE) Step 1 score from the Dean of Student Affairs. The dean also reported the discipline each student enrolled in for the required fourth‐year subinternship(s) and matched in for internship. These data were reported anonymously and linked to the service to which the student was assigned. In this study, pediatrics, internal medicine, and family practice were all considered primary care, but preliminary or transitional internships were not.

RESULTS

Two hundred and three students enrolled in the third‐year pediatric clerkship during the study period, and all students completed the clerkship on their assigned services. One hundred and twenty‐eight were randomized to the intervention service and 75 to the traditional services. There were no statistically significant differences in median age, percentage of male students, or mean USMLE Step 1 score between the students randomized to the intervention service and those randomized to the traditional services (Table 1).

DISCUSSION

This study's objective was to evaluate a third‐year pediatric clerkship structure that focuses on students, using multiple outcome parameters. Utilizing a robust design, the results of this study have demonstrated that the intervention service is more successful than the traditional services in several outcomes. Students assigned to the intervention service were more satisfied and more likely to select pediatrics as a career. These improvements were accomplished while maintaining similar process measures, student performance, and resource utilization compared with those of the traditional services.

CONCLUSIONS

The intervention service is a structure for the pediatric inpatient rotation of third‐year medical students that, instead of dividing the faculty and supervising resident's attention between interns and students, focuses their attention on the students. Although it has been difficult to demonstrate improvements as a result of the educational interventions, we have shown several improvements in the evaluations of the students. Moreover, the pattern of increased student satisfaction and a tendency toward more student selecting careers in pediatrics are remarkable. This was accomplished with similar resource utilization. Therefore, this program merits being continued at our institution and possibly adopted at other medical schools. Further research is needed to determine which aspects of the intervention are responsible for its effects. Some components, such as focused time with students, may be applicable to traditional services.