Pediatrics 1989 Kreger 242 7

1989;84;242PediatricsBernard E. Kreger and Joseph D. Restuccia

ProtocolAssessing the Need to Hospitalize Children: Pediatric Appropriateness Evaluation

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242 HOSPITALIZATION EVALUATION

Assessing the Need to Hospitalize Children:Pediatric Appropriateness Evaluation Protocol

Bernard E. Kreger, MD, MPH, and Joseph D. Restuccia, DPH

From the Health Care Research Unit, Section of General Internal Medicine, UniversityHospital, and the Evans Memorial Department of Clinical Research, Boston UniversitySchool of Medicine, Boston, Massachusetts

ABSTRACT. Rapidly increasing hospital costs have ne-cessitated use review of hospitalized patients to improvethe appropriateness (medical necessity) of hospital use.The development and testing of the Pediatric Appropri-ateness Evaluation Protocol, an objective, criteria-basedinstrument intended to assist physicians and use review-ers in making decisions regarding appropriateness ofpediatric hospital admissions and days of care, are de-scribed. Pediatrics 1989;84:242-247; hospital use, pediat-nc appropriateness evaluation protocol.

ABBREVIATIONS. AEP, Appropriateness Evaluation Protocol;EMPSRO, Eastern Massachusetts Professional Services ReviewOrganization.

For many years, those who provide, administer,and pay for health care in the United States haverecognized the need for a valid and reliable methodof assessing the use of hospital beds. Criteria basedon diagnoses have proven burdensome, both be-cause of their sheer number and because of medicaladvances that result in frequent changes in pre-ferred treatment modalities for particular diag-noses. Instead, the Appropriateness EvaluationProtocol (AEP), developed during the past decadeby the Boston University Health Care ResearchUnit, has met the demands of the health care sys-tern in providing useful, objective generic criteriafor assessing the appropriateness (medical neces-sity) of hospitalization in an acute care facility. Inseveral trials conducted by researchers at the

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Health Care Review Unit and elsewhere, its validityand reliability have been confirmed. The AEP isnow a major instrument used by hospitals, HMOs,peer review organizations, Medicaid agencies, andprivate insurers to screen cases concurrently forphysician advisor review and to profile retrospec-tively provider practice patterns.1

The AEP was designed originally to apply onlyto adult patients hospitalized in medical and sur-gical services in acute care institutions. We thoughtthat different criteria might be needed to monitorpediatric, obstetric, and psychiatric inpatient care,as well as various sorts oflong-term or chronic care,including rehabilitation services. Medicaid, lookingfor a method to evaluate pediatric care, providedthe primary impetus for the development of a pe-diatric AEP. In this article, the iterative process ofthe design and testing of this instrument are de-scribed, in particular, the modifications to the orig-inal criteria to tailor them to the special problemsencountered in the hospitalization of children.

METHOD

The first step in evolving the pediatric AEP wasthe application of the standard (adult) AEP criteriato children. It had already been determined throughour validation studies that approximately 95% oftruly appropriate use of acute beds by adults wouldbe identified by these AEP criteria: thus, only ap-proximately 5% of these truly appropriate caseswould require special mention (called overridesin AEP parlance) because no criteria were satis-fled. In addition, groups that were using AEP sinceits inception had reported back to us that they triedapplying adult criteria to the pediatric inpatientsand found them useful. We, therefore, enlisted thehelp of the Quality Assurance Unit of ChildrensHospital Medical Center, Boston, for a formal test

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PEDIATRICS Vol. 84 No. 2 August 1989 243

of applicability as the first step in the developmentof the Pediatric AEP.

An independent review of 50 medical records ofrecently discharged patients was done by two nursereviewers trained in AEP and experienced in pedi-atric care. Besides applying the adult AEP criteria,the nurses provided detailed documentation of de-ficiencies in the application of the criteria to thesepediatric patients. The deficiencies in the AEPadult instrument identified through this reviewwere codified and discussed with pediatricians fromboth Massachusetts and elsewhere. Exact phra-seology for new criteria and modifications of exist-ing criteria were arrived at by consensus. Thechanges to existing criteria consisted primarily ofdifferent physiologic values indicative of a suffi-ciently severe illness in a child to warrant hospital-ization. The new criteria consisted of special pedi-atrics clinical situations not commonly foundamong adult inpatients. Based on this new set ofcriteria, a new pediatric AEP instruction manualfor reviewers was created.

The following changes characterize the pediatricsversion of the AEP (Appendix 1): (1) The instru-ment applies to children 6 months of age and older,with physiologic measurements taken at admissionsuch as BP, pulse, and various laboratory test re-sults being stratified according to subgroup of age.(Originally, the instrument included children asyoung as 2 years of age, but it was confirmed withsubsequent use that the instrument may be usedwith even younger infants. (2) Hematocrit


patients or as an instrument to assess accuratelyrates of appropriateness among groups of patients,as was the case in this study.

Of the 26 hospitals in the field trial, 14 had fewerthan 25 sample patients during the 6-month periodreviewed. The total study sample consisted of 793patient admissions and 648 days of care (ie, therewere 145 one-day stays). Mean length of stay was4.6 days, with a range of 1 to 49 days. Mean agewas 7.5 years; 55% were male.

By objective criteria, 10.5% ofpatient admissionswere judged inappropriate, with a range of 2.4% to24.1% among the 12 hospitals at which there hadbeen at least 25 admissions. For day of care, theobjective inappropriateness rate was 13.3% amongthe same hospitals, ranging from 3.5% to 24.7%.The application of override options resulted in re-duction of these rates to 5.8% (0% to 17.1%) foradmissions and 9.4% (0% to 22.5%) for days ofcare. As had been the case in the development ofthe Adult Medical/Surgical AEP, when we analyzedthe use of overrides, we found only a few situationsthat were considered suitable to warrant additionsto objective criteria. These additions were accom-plished by expanding definitions of existing admis-sion criteria in posttrial versions of the PediatricAEP rather than creating totally new ones. In themain, though, the differences between objectiveconclusions and those made through the use ofoverrides reflected incorrect use of the overrideoption. The misuse often occurred because of theconfusion of relatively inexperienced reviewers be-tween reasons for inappropriate hospitalization andmedical need for hospitalization: for example, usingan override to conclude that a patient requiringoutpatient services that could not be scheduledconveniently was appropriately hospitalized ratherthan using the reason, Patient admitted for diag-nosis and/or treatment because it was not possibleto be scheduled on an outpatient basis to indicatewhy the patient was hospitalized despite not havinga need for acute hospitalization. It was thereforejudged that the data from the use of objectivecriteria alone provide the most accurate picture ofpatterns of inappropriateness.

The inappropriate admission rate was 9.8% forboys and 10.8% for girls. It was smallest for ages 6to 11 compared with 2 to 5 and 12 to 15 (8.6% vs11.2% and 12.3%). None of these differences wasstatistically significant at the P < .05 level. Amongthe 10 most frequent discharge diagnoses, the rangeof inappropriateness was 0% to 19.2%, with pneu-monia, gastroenteritis, and cellulitis and abscessassociated with the largest rates of inappropriate-ness. If the hospital stay included a procedure, thechilds admission was significantly less likely to be

considered inappropriate (6.6% vs 12.8%, P =.0055).

For day of care, objective inappropriateness rateswere less for girls than for boys (11.4% vs 14.5%)and least for ages 6 to 11 years compared with 2 to5 years and 12 to 15 years (11.3% vs 12.2% and16.8%). The 10 most common diagnoses had 0% to19% inappropriate penultimate inpatient days, withpneumonia, acute appendicitis, concussion, andfracture of radius and ulna all greater than 14%. Atthe end of a childs hospital stay, those who had aprocedure were more likely to be inappropriatelythere (15.2% vs 10.2%), but not significantly so.

Finally, the reason cited most frequently for in-appropriate admission was that the patient requiredno institutional care and could be treated as anoutpatient. Similarly, inappropriate days of carewere most commonly attributed to the lack of needfor continuing institutional care.

COMMENTThe extensive experience gained in the design

and implementation of the Adult Medical/SurgicalAEP tended to facilitate the development of thepediatric version. The process was made especiallyeasy because of the success some AEP users hadhad evaluating pediatrics hospitalizations using theadult criteria. Thus, the pediatric AEP grew out ofan already validated and reliable instrument towhich necessary and appropriate adjustments weremade.

The trial application of this version proceededalong lines similar to those involved in the originaladult version and encountered similar problems.Namely, the EMPSRO reviewers, who were rela-tively inexperienced in using the AEP in general,made reviewing errors mainly by misuse of theoverride option, wherein a reason for inappropriate-ness was used as a justification for hospitalizationinstead of an explanation of the reason for thehospitalization despite its being medically inappro-priate. With sufficient further training, AEP usersboth in the United States and abroad have foundthat this most common of errors in applicationgradually disappears, although not always totally.Thus, it is best to prohibit use of the override optionunless the reviewer has demonstrated proper usethrough formal reliability tests or is required toconsult a physician advisor to obtain approval foruse of the override.

It was not surprising to find inappropriatenessrates for childrens hospitalizations appreciably lessthan those for adults. The difference probably re-sults from the presence of built-in care givers athome for almost all children, whereas many adults,


ARTICLES 245

especially the elderly, are inconveniently solitary inthis regard. Yet, at least in this initial trial, thereasons for inappropriate admissions and days ofcare seem to echo those chosen to explain inappro-priate hospitalization of adults. Children, too, areadmitted to receive diagnostic and/or therapeuticattention at a level easily achieved as outpatients;and children ready medically for discharge arenevertheless kept in the hospital.

Finally, in an interesting report, Kemper, of theUniversity of Wisconsin Hospitals and Clinics, de-scribed a pediatrics adaptation of the adult AEPthat included several of the changes we made.3 Theproportion ofinappropriate days found, 21.4%, can-not be compared directly with our results for anumber of reasons: the age range of Kempers pop-ulation extended beyond that in our patient samplein both directions (2 days to 18 years of age);Kemper reviewed the day of discharge, whereas thatday was omitted from analysis in the AEP; for 1-day stays, Kemper seemed to have applied day ofcare criteria to the time of admission, again, adeviation from AEP procedure; and patients insome special units that were evaluated in our studywere not considered in hers. It would be useful toapply our pediatric AEP to the 6-month to 15-year-old population described by Kemper, with bothadmission and day of care criteria, to see what rateof inappropriate use would result. Our expectationwould be to find inappropriateness rates closer towhat we described in our trials.

IMPLICATIONSWith children as with adults, medical resources

can be put to better, more effective use withoutsacrificing health. Indeed, the extremely technicalfacilities of todays acute care hospitals should bemore successfully used when they and their person-nel can concentrate on the care of those who reallyneed them, undiluted by the presence of even 10%or 15% of patients who are inappropriately there.The pediatric AEP should help identify areas forimprovement not only for individual institutionsbut for the pediatric hospital system as a whole.

APPENDIX 1: PEDIATRIC APPROPRIATENESSEVALUATION PROTOCOL (AEP) ADMISSIONCRITERIA

A. Severity of Illness Criteria1. Sudden onset of unconsciousness (coma or unre-

sponsiveness) or disorientation2. Acute or progressive sensory, motor, circulatory,

or respiratory embarrassment sufficient to inca-pacitate the patient (inability to move, feed,breathe, urinate, etc)

3. Acute loss of sight or hearing4. Acute loss of ability to move body part5. Persistent fever (37.8#{176}C [100#{176}F] orally or

38.3#{176}C [101#{176}F] rectally) for more than 10 days6. Active bleeding7. Wound dehiscence or evisceration8. Severe electrolyte/acid base abnormality (any of

the following values):a. Na 156 mEqJLb. K 5.6 mEqjLc. CO2 combining power (unless chronically ab-

normal) 36 mEqjL

d. Arterial pH 7.459. Hematocrit


6. IM antibiotics at least every 8 hours7. Intermittent or continuous respirator use at least

every 8 hours

PEDIATRIC AEP DAY OF CARE CRITERIA

B. Medical Services1. Procedure in operating room that day2. Procedure scheduled in operating room the next

day, necessitating preoperative consultation orevaluation

3. Cardiac catheterization that day4. Angiography that day5. Biopsy of internal organ that day6. Thoracentesis or paracentesis that day7. Invasive CNS diagnostic procedure that day (eg,

lumbar puncture, cysternal tap, ventricular tap,pneumoencephalography)

8. Gastrointestinal endoscopy that day9. Any test requiring strict dietary control for the

duration of the diet10. New or experimental treatment requiring frequent

dose adjustments with direct medical supervision11. Close medical monitoring by a doctor at least three

times daily (observations must be documented inrecord)

12. Postoperative day for any procedure described innumbers 1 or 3 to 8 above

B. Nursing/Life Support Services1. Respiratory care-intermittent or continuous res-

pirator use and/or inhalation therapy (with chestphysical therapy, intermittent positive pressurebreathing) at least three times daily, isoetharinehydrochloride (Bronkosol) with oxygen, Oxyhoods,oxygen tents

2. Parenteral therapy-intermittent or continuousIV fluid with any supplementation (electrolytes,protein, medications)

3. Continuous vital sign monitoring, at least every 30minutes for at least 4 hours

4. IM and/or subcutaneous injections at least twicedaily

5. Intake and/or output measurement6. Major surgical wound and drainage care (eg, chest

tubes, t tubes, Hemovacs, Penrose drains)7. Traction for fractures, dislocations, or congenital

deformities8. Close medical monitoring by nurse at least three

times daily with doctors ordersC. Patient ConditionA. (Being reviewed the day before for the day of care)

1. Inability to void or move bowels, not attributableto neurologic disorder-usually a postoperativeproblemBeing reviewed within 2 days before the day ofcare

2. Transfusion due to blood loss3. Ventricular fibrillation or ECG evidence of acute

ischemia, as stated in progress note or in ECGreport

4. Fever at least 38.30C (1010F) rectally (at least37.8#{176}C[100#{176}F]orally), if patient was admitted forreason other than fever

5. Coma-unresponsiveness for at least 1 hour6. Acute confusional state, including withdrawal from

drugs and alcohol7. Acute hematologic disorders-significant neutro-

penia, anemia, thrombocytopenia, leukocytosis, er-ythrocytosis, or thrombocytosis-yielding signs orsymptoms

8. Progressive acute neurologic difficulties

APPENDIX 2: REASONS LIST

For Inappropriate Admission1. Any needed diagnosis and/or treatment that can

be done on an outpatient basis2. Patient admitted for diagnostic testing and/or

treatment because patient lives too great a distancefrom a hospital for it to be done on an outpatientbasis

3. Patient admitted for diagnosis and/or treatmentbecause it was not possible to be scheduled on anoutpatient basis (although, aside from scheduling,testing and treatment could have been done on anoutpatient basis)

4. Patient needs institutional care, but at a level lessthan an acute care hospital-general (unspecified)

5. Patient needs care in a chronic disease hospital6. Patient needs care in a skilled nursing facility7. Patient needs care in a nonskilled nursing facility8. Premature admission (eg, on Friday for a proce-

dure scheduled for the following Monday)9. Other-specify

For Inappropriate Day of CareA. For patients who need continued hospital stay for

medical reasons20. Problem in hospital scheduling of operative pro-

cedure21. Problem in hospital scheduling of tests or nonop-

erative procedure22. Premature admission23. Patient bumped because of operating room prob-

lems24. Delay due to 40-hour week problem (ie, proce-

dures not done on weekend)25. Delay in receiving results of diagnostic test or

consultation needed to direct further evaluation/treatment

29. Other-specifyB. For patients who do not need continued hospital stay

for medical reasons1. Hospital or physician responsibility

a. Failure to write discharge ordersb. Failure to initiate timely hospital discharge

planningc. Overly conservative medical management of pa-

tient by physiciand. No documented plan for active treatment of

evaluation of patient


ARTICLES 247

e. Other-specify2. Patient or family responsibility

a. Lack of family for home careb. Family unprepared for patients home carec. Patient/family rejection of available space at

appropriate alternate facilityd. Other-specify

3. Environmental responsibilitiesa. Patient from unhealthy environment-patient

kept until environment becomes acceptable oralternative facility found

b. Patient is convalescing from an illness, and it isanticipated that his/her stay in an alternativefacility would be less than 72 hours

c. Unavailability of alternative facilityd. Unavailability of alternative nonfacility-based

treatment (eg, home health care)e. Other-specify

REFERENCES

1. Gertman PM, Restuccia JD. The appropriateness evaluationprotocol: a technique for assessing unnecessary days ofhospital care. Med Care. 1981;19:855-870

2. Siu AL, Sonnenberg FA, Manning WG, et al. Inappropriateuse of hospitals in a randomized trial of health plans: NEngI J Med. 1986;315:1259-1266

3. Strumwasser I, Paranjpe NV. Estimate of non-acute hospi-talization: a comparative analysis of the appropriateness

evaluation protocol and the standardized medreview instru-ment. Final Report, Health Care Financing Administrationgrant 18-C-98582/5-01 and 02. Detroit, MI, September 1987

4. Rishpon 5, Lubacsh 5, Epstein LM. Reliability of a methodof determining the necessity for hospital days in Israel. MedCare. 1986;24:279-282

5. Wakefield DG, Pfaller MA, Hammons GT, et al. Use of theappropriateness evaluation protocol for estimating incre-mental costs associated with nosocomial infections. MedCare. 1987;25:481-488

6. Restuccia JD, Payne SMC, Lenhart GM, et al. Assessingthe appropriateness of hospital utilization to improve effi-ciency and competitive position. Health Care Manage Rev.1987;13:17-27

7. Restuccia JD, Kreger BE, Gertman PM, et al. The appro-priateness of hospital use in Massachusetts. Health CareFinan Rev. 1986;8:47-53

8. Restuccia JD, Gertman PM, Dayno SJ, et al. A comparativeanalysis of appropriateness of hospital use. Health Aff.1984;3:130-138

9. Studnicki J, Stevens CE. The impact of a cybernetic controlsystem on inappropriate admissions. Quality Rev Bull.1984;304-311

10. Payne SMC. Identifying and managing inappropriate hos-pital utilization. Health Serv Res. 1987;22:709-769

11. Restuccia JD, Payne SMC, Welge CH, et al. Reducinginappropriate use of inpatient medical/surgical and pediat-nc services. Report on Health Care Financing Administra-tion contract 18-C-98317/1-02. Boston, MA: Health CareResearch Unit, Boston University Medical Center, March1986

12. Cohen JA. A coefficient of agreement for nominal scales.Educ Psychol Measure. 1960;20:37-46

13. Kemper KJ. Medical inappropriate use in a pediatric popu-lation. N Engl J Med. 1988;318:1033-1037

ENDURING FAMILIES AT RISK

A divorce-prone society is producing its first generation of young adults, menand women so anxious about attachment and love that their ability to createenduring families is imperiled.

Submitted by Student

From Wallerstein JS. Children after divorce: wounds that dont heal. The New York Times; Jan 22,1989.


1989;84;242PediatricsBernard E. Kreger and Joseph D. Restuccia

ProtocolAssessing the Need to Hospitalize Children: Pediatric Appropriateness Evaluation

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