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Children - General


Most of the nationally endorsed indicators were developed for adult patients. It remains to be seen if these indicators can be used with children. This section lists those indicators that do clearly apply to children. The indicators in this section apply to Kosair Children's Hospital and to newborns at Norton Hospital and Norton Suburban Hospital. Indicators that apply to intensive care of newborns are listed in the section Neonatal ICU Care and infection control indicators for children are listed in the section Infection Control - Children. Kosair Children’s Hospital performs complex open heart procedures on patients of all ages with congenital heart defects (shown here under Pediatric heart surgeries). Other open heart and interventional cardiology procedures on adults are performed at Norton Audubon Hospital, Norton Hospital and Norton Brownsboro Hospital, and are listed in the section Heart Procedures. Norton Healthcare performance represents the performance of all the hospitals combined.

Children's asthma care - percent of pediatric asthma inpatients
TJC computes CAC accountability composite rate from 3 CAC measures (cac1a, cac2a, cac3).  Elements include cac1a, cac2a, cac3. Accountability measures have been integrated into the information reported on Quality Check. However, the categorization of the measures into accountability and non-accountability measures will not affect individual measure information reported on Quality Check.(JC) CAC accountability measures' composite high         95.1 95.1   95.5
Number of pediatric patients aged 2 through 17 years with asthma as the reason for hospitalization per 100, who received eligible reliever medications during hospitalization. Relievers make airways bigger and result in easier breathing. Includes inpatients aged 2 through 17 years who were discharged with a principal diagnosis of asthma. Excludes children that have documented contraindications to the reliever, children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay > 120 days.(JC) given relievers, age 2-17 high         99.7 99.7   100.0
Number of pediatric patients aged 2 through 4 years with asthma as the reason for hospitalization per 100, who received eligible reliever medications. Relievers make airways bigger and result in easier breathing. Includes inpatients aged 2 through 4 years who were discharged with a principal diagnosis of asthma. Excludes children that have documented contraindications to the reliever, children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay > 120 days.(JC) given relievers, age 2-4 high         100.0Quality Ribbon 100.0Quality Ribbon   100.0
Number of pediatric patients aged 5 through 12 years with asthma as the reason for hospitalization per 100, who received eligible reliever medications. Relievers make airways bigger and result in easier breathing. Includes inpatients aged 5 through 12 years who were discharged with a principal diagnosis of asthma. Excludes children that have documented contraindications to the reliever, children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay > 120 days.(JC) given relievers, age 5-12 high         99.5 99.5   100.0
Number of pediatric patients aged 13 through 17 years with asthma as the reason for hospitalization per 100, who received eligible reliever medications. Relievers make the airways bigger and result in easier breathing. Includes inpatients aged 13 through 17 years who were discharged with a principal diagnosis of asthma. Excludes children that have documented contraindications to the reliever, children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay > 120 days.(JC) given relievers, age 13-17 high         100.0Quality Ribbon 100.0Quality Ribbon   99.9
Number of pediatric patients aged 2 through 17 years with asthma as the reason for hospitalization per 100, who received eligible systemic corticosteroid medications during hospitalization. Corticosteroids help control inflammation by stopping airways from reacting to whatever triggers the asthmatic episode. Includes inpatients aged 2 through 17 years who were discharged with a principal diagnosis of asthma. Excludes children that have documented contraindications to the corticosteroids, children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay more than 120 days.(JC) given systemic corticosteroids, age 2-17 high         99.9 99.8   99.7
Number of pediatric patients aged 2 through 4 years with asthma as the reason for hospitalization per 100, who received eligible corticosteroids. Corticosteroids help control inflammation by stopping airways from reacting to whatever triggers the asthmatic episode. Includes inpatients aged 2 through 4 years who were discharged with a principal diagnosis of asthma. Excludes children that have documented contraindications to the corticosteroids, children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay more than 120 days.(JC) given systemic corticosteroids, age 2-4 high         100.1 100.0Quality Ribbon   99.7
Number of pediatric patients aged 4 through 12 years with asthma as the reason for hospitalization per 100, who received eligible corticosteroids. Corticosteroids help control inflammation by stopping airways from reacting to whatever triggers the asthmatic episode. Includes inpatients aged 5 through 12 years who were discharged with a principal diagnosis of asthma. Excludes children that have documented contraindications to the corticosteroids, children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay more than 120 days.(JC) given systemic corticosteroids, age 5-12 high         99.7 99.7   99.7
Number of pediatric patients aged 13 through 17 years with asthma as the reason for hospitalization per 100, who received eligible corticosteroids. Corticosteroids help control inflammation by stopping airways from reacting to whatever triggers the asthmatic episode. Includes inpatients aged 13 through 17 years who were discharged with a principal diagnosis of asthma. Excludes children that have documented contraindications to the corticosteroids, children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay more than 120 days.(JC) given systemic corticosteroids, age 13-17 high         100.1 100.0Quality Ribbon   99.7
Number of pediatric patients aged 2 through 17 years with asthma as the reason for hospitalization per 100, who received (or whose caregiver received) a written home management plan of care (HMPC). The HMPC must address all of the following: arrangements for follow-up care, environmental control and control of other asthma triggers, method and timing of rescue actions, use of controllers, and use of relievers. Includes inpatients aged 2 through 17 years who were discharged with a principal diagnosis of asthma. Excludes children that are not discharged home (AMA, transfer, etc), children involved in asthma research, children with obstructive asthma (493.2x), children with length of stay more than 120 days.(JC) given complete home management plan of care, age 2-17 high         87.3 85.8   88.3
Pediatric heart surgeries volume
Number of pediatric heart surgery procedures per year. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients less than 18 years old with (1) a congenital heart disease procedure or (2) a non-specific heart surgery with a diagnosis of congenital heart disease or (3) procedures to repair congenital heart defect, (4) diagnosis of congenital heart disease. Excludes certain single cardiac procedures without bypass.(AHRQ PDI 7) # of procedures (AHRQ definition) high         234 234   100
Pediatric heart surgeries - 4 years of data
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 1 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 1.(NQF) % patients who survive, risk level 1 high         98.4 98.4    
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 2 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 2.(NQF) % patients who survive, risk level 2 high         97.9 97.9    
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 3 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 3.(NQF) % patients who survive, risk level 3 high         93.6 93.6    
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 4 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 4.(NQF) % patients who survive, risk level 4 high         91.5 91.5    
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 5 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 5.(NQF) % patients who survive, risk level 5 high         70.2 70.2    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 1 per 4 years. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 1.(NQF) # of procedures, risk level 1 high         341 341    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 2 per 4 years. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 2.(NQF) # of procedures, risk level 2 high         325 325    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 3 per 4 years. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 3.(NQF) # of procedures, risk level 3 high         79 79    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 4 per 4 years. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 4.(NQF) # of procedures, risk level 4 high         163 163    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 5 per 4 years. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 5.(NQF) # of procedures, risk level 5 high         41 41    
Pediatric heart surgeries - 1 year of data
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 1 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 1.(NQF) % patients who survive, risk level 1 high         98.9 98.9    
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 2 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 2.(NQF) % patients who survive, risk level 2 high         99.1 99.1    
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 3 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 3.(NQF) % patients who survive, risk level 3 high         96.1 96.1    
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 4 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 4.(NQF) % patients who survive, risk level 4 high         88.9 88.9    
Number of pediatric heart surgery patients in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 5 per 100, who were discharged alive and survived more than 30 days past their surgery date. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 5.(NQF) % patients who survive, risk level 5 high         # #    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 1 per year. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 1.(NQF) # of procedures, risk level 1 high         108 108    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 2 per year. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 2.(NQF) # of procedures, risk level 2 high         99 99    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 3 per year. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 3.(NQF) # of procedures, risk level 3 high         26 26    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 4 per year. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 4.(NQF) # of procedures, risk level 4 high         46 46    
Number of pediatric heart surgery procedures in STS-EACTS (European Association for Cardio-Thoracic Surgery) Category 5 per year. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients with a congenital cardiac surgical procedure performed with or without cardiopulmonary bypass. Excludes procedures for which the STS-EACTS Category is not category 5.(NQF) # of procedures, risk level 5 high         12 12    
Immunization - percent of newborns with
Hepatitis B vaccines given to all newborns prior to discharge Included in the numerator are newborns receiving a hepatitis B vaccine (CPT 90744 or 90471 or ICD-9 code V05.3) prior to discharge. All newborns are included in the denominator. Newborns less than 39 weeks and less than 2000 grams and discharged before one month of age are excluded. Newborns transferred back to sending hospital are excluded.(NQF) hepatitis B vaccine given prior to discharge high     94 100 77 95 77 61
Patient safety
Number of pediatric patients who had a length of stay of at least 5 days per 100 who developed a pressure ulcer (bed sore) while in the hospital. Excludes patients with diseases of the skin, subcutaneous tissue and breast, hemiplegia, paraplegia, quadriplegia, obstetrical patients, neonates, and patients admitted from a long-term care facility.(AHRQ PDI 2) % ped inpats developing in-hosp pressure ulcer (AHRQ) low         0Quality Ribbon 0Quality Ribbon    
Number of medical and surgical pediatric patients with a foreign body accidentally left in during procedure. Includes medical and surgical discharges defined by specific DRGs. Excludes patients with a principal diagnosis of foreign body accidentally left in during a procedure.(AHRQ PDI 3) # ped surgeries when foreign body unintentionally left low         0Quality Ribbon 0Quality Ribbon    
Number of medical and surgical neonatal patients per 100 with pneumothorax caused by medical care. Pneumothorax is the abnormal presence of air in the area containing the lungs. Neonates have birth weight between 501and 2500 grams (1.1-5.5 lbs). Includes medical and surgical neonatal discharges defined by specific DRGs. Excludes patients with iatrogenic pneumothorax as a principal diagnosis, patients with a diagnosis of chest trauma, patients with a thoracic or cardiac surgery, patients with lung or pleural biopsy, patients with pleural effusion, patients under 500 grams or over 2500 grams birth weight, normal newborns, and obstetrical patients, patients for cardiac procedure.(AHRQ PDI 4) % neonates w/ pneumothorax resulting from medical care low     0Quality Ribbon 0.27 0Quality Ribbon 0.07    
Number of medical and surgical non-neonatal pediatric patients per 100 with pneumothorax caused by medical care. Pneumothorax is the abnormal presence of air in the area containing the lungs. Non-neonates have a birth weight of more than 2500 grams (5.5 lbs). Includes medical and surgical discharges defined by specific DRGs. Excludes patients with iatrogenic pneumothorax as a principal diagnosis, patients with a diagnosis of chest trauma, patients with a thoracic or cardiac surgery/procedure, patients with lung or pleural biopsy, patients with pleural effusion, patients with birth weight under 2500 grams, normal newborns, and obstetrical patients.(AHRQ PDI 5) % ped pats w/ pneumothorax resulting from medical care low         0Quality Ribbon 0Quality Ribbon   0.02
Number of pediatric surgery patients per 100 with a postoperative hemorrhage (surgical site bleeding) or hematoma (abnormal collection of blood). Includes inpatients discharged with a surgical DRG and an operating room procedure, or coagulopathies to high risk group. Excludes patients with principal diagnosis of postoperative hemorrhage or postoperative hematoma, patients whose only OR procedure is postoperative control of hemorrhage or drainage of hematoma, patients where a procedure for control of hemorrhage or drainage of hematoma occurs before the first OR procedure, and obstetrical patients.(AHRQ PDI 8) % pediatric surgeries w/ postoperative bleeding low         0.10 0.10   0.23
Number of elective pediatric surgery patients per 100 with postoperative respiratory failure. Respiratory failure occurs when the body is unable to rid itself of carbon dioxide and cannot provide adequate oxygen to the body?s cells. Includes inpatients with an admit type of elective, and discharged with a surgical DRG. Excludes patients with a principal diagnosis of acute respiratory failure, patients where tracheostomy is the only OR procedure, patients where a tracheostomy procedure occurs before the first OR procedure, patients with respiratory or circulatory disease, neonates less than 500 grams, and OB patients.(AHRQ PDI 9) % ped surgeries w/ postoperative respiratory failure low         0.12 0.12   0.93
Number of abdominopelvic pediatric surgery patients per 100 with reclosure of postoperative disruption of abdominal wall. This indicator identifies patients who have had abdominal or pelvic surgery and then experience a rupture of the surgical wound. Excludes patients where a reclosure of postoperative disruption of abdominal wall occurs before or on the same day as the first abdominopelvic surgery procedure, patients with a length of stay less than 2 days, neonates less than 500 grams, and OB patients.(AHRQ PDI 11) % ped abdominal surgeries w/ postop wound dehiscence low         0.25 0.25   0.11
Number of pediatric inpatients with blood transfusion who had a blood transfusion reaction. Blood transfusion is the process of transferring blood or blood-based products from one person into the circulatory system of another person. Excludes neonates and patients with principal diagnosis of blood transfusion reaction.(AHRQ PDI 13) # ped inpats with a blood transfusion reaction low         0Quality Ribbon 0Quality Ribbon    
Number of newborns who died in the hospital. Excludes neonates with a birth weight less than 500 grams(1 lb. 2 oz.).(AHRQ NQI 02) % neonates who die low     0.4 0.2 0.2 0.2   0.3
Newborns - percent of babies with
Infants born under 3 lb. 5 oz. whose first temperature was taken within one hour of admission to NICU All NICU admissions with a birth weight of 501-1500g. Outborn infants that had been home prior to admission are excluded, as well as outborn infants admitted more than 28 days after birth.(NQF) very low birth weight, admit temp taken w/in 1 hr of NICU admit high       99 100 99    
Infants born under 3 lb. 5 oz. whose first temperature was below 36 degrees Celsius (96.8 degrees F). Included population: All NICU admissions with a birth weight of 501-1500g whose first temperature was measured with one hour of admission to NICU.(NQF) very low birth weight w/ NICU admit, first temp < 36 degrees low       4.3 2.8 3.1    
Infants born 11-18 weeks early who received an eye exam for ROP (a disease of the eye that can cause loss of vision in infants born early). Included population: infants aged 22 to 29 weeks gestation hospitalized at the postnatal age at which a retinal exam is recommended by the American Academy of Pediatrics. Outborn infants that had been home prior to admission are excluded, as well as outborn infants admitted more than 28 days after birth.(NQF) premature birth, receiving ROP retinal exam high       100Quality Ribbon 99 99    
Infants born 11-18 weeks early who were treated with surfactant (a drug given to help prevent the collapse of air sacs in the lungs) within 2hrs of birth Included population: infants born at 22 to 29 weeks gestation treated with surfactant at any time. Outborn infants that had been home prior to admission are excluded, as well as outborn infants admitted more than 28 days after birth.(NQF) premature birth, given surfactant w/in 2hrs of birth high       75 78 77    
Miscellaneous
Is this hospital a level III or equivalent NICU (infants under 1500g delivered at appropriate site)? Level III subspecialty NICUs have the personnel and equipment to care for infants <1500 grams.(NQF) Is hospital level III or equal NICU (babies <1500g delivered site appropriate)? high     yes yes yes yes    
Indication of whether the hospital is in a national database for pediatric and congenital heart surgery or not. By committing to collecting outcomes (e.g., complications, mortality) data for a national database, hospitals are committing to improving the quality of care that their cardiac surgery patients receive.(NQF) Is the hospital in a national pediatric congenital heart surgery database? high         yes      

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