Pediatrics AEP

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 have

recognized 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 Evaluation

Protocol (AEP), developed during the past decade

by 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. In

several trials conducted by researchers at the

Received for publication Jun 10, 1988; accepted Sep 2, 1988.

Reprint requests to (J.D.R.) 720 Harrison Aye, Suite 1102,

Boston, MA 02118.PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by theAmerican Academy of Pediatrics.

Health Care Review Unit and elsewhere, its validity

and reliability have been confirmed. The AEP is

now a major instrument used by hospitals, HMOs,

peer review organizations, Medicaid agencies, andprivate insurers to screen cases concurrently for

physician advisor review and to profile retrospec-

tively provider practice patterns.’1’The AEP was designed originally to apply only

to adult patients hospitalized in medical and sur-

gical services in acute care institutions. We thought

that different criteria might be needed to monitor

pediatric, 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 of

the design and testing of this instrument are de-scribed, in particular, the modifications to the orig-

inal criteria to tailor them to the special problems

encountered in the hospitalization of children.

METHOD

The first step in evolving the pediatric AEP was

the application of the standard (adult) AEP criteria

to children. It had already been determined through

our 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 “overrides”in AEP parlance) because no criteria were satis-

fled.’ In addition, groups that were using AEP sinceits inception had reported back to us that they tried

applying adult criteria to the pediatric inpatients

and found them useful. We, therefore, enlisted thehelp of the Quality Assurance Unit of Children’sHospital 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 nurse

reviewers 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 these

pediatric patients. The deficiencies in the AEP

adult 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 found

among adult inpatients. Based on this new set ofcriteria, a new pediatric AEP instruction manual

for 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 as

young as 2 years of age, but it was confirmed withsubsequent use that the instrument may be used

with even younger infants. (2) Hematocrit <30%as an admission criterion represents a child in

potential trouble, usually with leukemia or its treat-ment. (3) Need for lumbar puncture was added, to

allow for those locales where such a procedure isimpractical on an outpatient basis. (4) Special pe-diatrics situations, often a combination of medicaland social problems, were added to the admissioncriteria: failure of (or history of noncompliancewith) outpatient therapy, documented or suspected

child abuse, or need for special observation (as infailure to thrive). (5) For day of care criteria, appli-

cable to any day during a hospital stay other thanthe days of admission and discharge, additions weremade to allow inpatient performance of gastroin-testinal endoscopy and traction for major orthope-

dics problems.

Two nurse reviewers who were already trained in

AEP application then used the new criteria andinstructions to assess a set of 1200 pediatrics rec-ords at New England Medical Center Hospital,Boston. They provided documentation regardingapplicability of the criteria and adequacy of thewording of the criteria and the instruction manual.Where indicated, additional wording changes to the

criteria and instructions for their application weremade by Health Care Review Unit researchers with

the assistance of clinical consultants.The third step in the development process in-

volved field trials. A small trial addressed the ques-

tion: Does the Pediatric AEP work as well forcommunity hospitals as it does in academic centers

and teaching hospitals. For this preliminary trial,50 records from each of two community hospitals

were reviewed independently by a physician and a

nurse reviewer. No additional problems were foundinvolving the instrument or the instructions. How-

ever, a much larger trial was necessary both toensure the generalizability of this finding and to

establish a baseline appropriateness level with

which to compare subsequent pediatric applica-

tions.To that end, the Eastern Massachusetts Profes-

sional Services Review Organization (EMPSRO)

agreed to assist us, after review of the Pediatric

AEP criteria by EMPSRO member pediatriciansindicated that the criteria had sufficient validity to

warrant a large field trial. EMPSRO then helpedorganize field testing in 24 hospitals in the greater

Boston area and 2 hospitals in western Massachu-

setts. In each hospital, 100% of all Medicaid pa-

tients aged 2 to 15 years discharged during a 6-month period in 1983 (February to July or March

to August) were sampled, a total of 793 patients.After receiving training in use of the pediatric AEPfrom Health Care Review Unit staff, EMPSRO

nurse reviewers applied the pediatric AEP to thetime of admission and to the day before discharge.For admissions lasting only 1 day, no day of care

criteria were applicable. When an admission or daywas found to be inappropriate at the acute hospitallevel, the reviewer identified the probable cause of

inappropriateness with the assistance of the AEPReasons List (see Appendix 2). To assess reliability,143 patients from 3 of the study hospitals wererereviewed by a second nurse reviewer.

RESULTS

In the reliability study, 93.7 and 88.4% agreement

was found among reviewers in terms of appropri-

ateness decisions regarding admissions and days ofcare, respectively. The K statistic was applied todetermine the extent to which this agreement dif-fered from the agreement occurring by randomchance.’2 A K of 0.68 (P < .0001) for admissions and0.46 (P < .0001) for days indicated that agreementwas not due to chance alone and was sufficiently

great for the pediatric AEP to be used as either a

screening instrument in use review of individual




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 period

reviewed. The total study sample consisted of 793patient admissions and 648 days of care (ie, there

were 145 one-day stays). Mean length of stay was

4.6 days, with a range of 1 to 49 days. Mean age

was 7.5 years; 55% were male.By objective criteria, 10.5% ofpatient admissions

were judged inappropriate, with a range of 2.4% to24.1% among the 12 hospitals at which there had

been at least 25 admissions. For day of care, theobjective inappropriateness rate was 13.3% among

the 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 of

care. As had been the case in the development ofthe Adult Medical/Surgical AEP, when we analyzedthe use of overrides, we found only a few situations

that 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 Pediatric

AEP rather than creating totally new ones. In themain, though, the differences between objective

conclusions and those made through the use of

overrides reflected incorrect use of the override

option. 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 requiring

outpatient 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 possible

to be scheduled on an outpatient basis” to indicatewhy the patient was hospitalized despite not havinga need for acute hospitalization. It was therefore

judged that the data from the use of objective

criteria alone provide the most accurate picture ofpatterns of inappropriateness.

The inappropriate admission rate was 9.8% for

boys 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 was

statistically significant at the P < .05 level. Among

the 10 most frequent discharge diagnoses, the rangeof inappropriateness was 0% to 19.2%, with pneu-monia, gastroenteritis, and cellulitis and abscess

associated with the largest rates of inappropriate-

ness. If the hospital stay included a procedure, the

child’s 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 to

5 years and 12 to 15 years (11.3% vs 12.2% and

16.8%). The 10 most common diagnoses had 0% to

19% inappropriate penultimate inpatient days, with

pneumonia, acute appendicitis, concussion, and

fracture of radius and ulna all greater than 14%. Atthe end of a child’s hospital stay, those who had a

procedure 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 an

outpatient. Similarly, inappropriate days of carewere most commonly attributed to the lack of needfor continuing institutional care.

COMMENT

The extensive experience gained in the designand 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 had

had evaluating pediatrics hospitalizations using theadult criteria. Thus, the pediatric AEP grew out of

an already validated and reliable instrument to

which necessary and appropriate adjustments weremade.

The trial application of this version proceededalong lines similar to those involved in the original

adult 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 the

override option, wherein a reason for inappropriate-ness was used as a justification for hospitalization

instead of an explanation of the reason for the

hospitalization despite its being medically inappro-priate. With sufficient further training, AEP users

both in the United States and abroad have found

that this most common of errors in applicationgradually disappears, although not always totally.Thus, it is best to prohibit use of the override option

unless the reviewer has demonstrated proper use

through formal reliability tests or is required toconsult a physician advisor to obtain approval for

use of the override.

It was not surprising to find inappropriatenessrates for children’s hospitalizations appreciably less

than those for adults. The difference probably re-sults from the presence of built-in care givers at

home for almost all children, whereas many adults,



ARTICLES 245

especially the elderly, are inconveniently solitary in

this regard. Yet, at least in this initial trial, the

reasons for inappropriate admissions and days of

care seem to echo those chosen to explain inappro-priate hospitalization of adults. Children, too, are

admitted 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 the

University of Wisconsin Hospitals and Clinics, de-

scribed a pediatrics adaptation of the adult AEP

that included several of the changes we made.’3 The

proportion ofinappropriate days found, 21.4%, can-not be compared directly with our results for anumber of reasons: the age range of Kemper’s 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 that

day 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, a

deviation from AEP procedure; and patients insome special units that were evaluated in our study

were not considered in hers. It would be useful to

apply our pediatric AEP to the 6-month to 15-year-

old population described by Kemper, with both

admission and day of care criteria, to see what rate

of inappropriate use would result. Our expectationwould be to find inappropriateness rates closer towhat we described in our trials.

IMPLICATIONS

With children as with adults, medical resources

can be put to better, more effective use withoutsacrificing health. Indeed, the extremely technical

facilities of today’s acute care hospitals should be

more 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 disorientation

2. 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 part

5. Persistent fever (�37.8#{176}C [100#{176}F] orally or�38.3#{176}C [�101#{176}F] rectally) for more than 10 days

6. Active bleeding7. Wound dehiscence or evisceration

8. Severe electrolyte/acid base abnormality (any ofthe following values):a. Na <123 mEqjL,

Na >156 mEqJL

b. K <2.5 mEqJL,K >5.6 mEqjL

c. CO2 combining power (unless chronically ab-

normal) <20 mEciJL,CO2 combining power (unless chronically ab-normal) >36 mEqjL

d. Arterial pH <7.30, arterial pH >7.45

9. Hematocrit <30%10. Pulse rate greater or less than the following ranges

(optimally a sleeping pulse for <12 years old):

6 months-2 years minus 1 day of age, 80-100/mm;2-6 years of age 70-200/mm;7-11 years of age, 60-180/mm;

�12 years of age, 50-140/mm

11. BP values outside following ranges:

6 months-2 years minus 1 day of age, 70-100/40-

85 mm Hg;2-6 years of age, 75-125/40-90 mm Hg7-11 years of age, 80-130/45-90 mm Hg-�

�12 years of age, 90-200/60-120 mmHg

12. Need for lumbar puncture, where this procedure is

not done routinely on an outpatient basis

13. Any of the following conditions not responding to

outpatient (including emergency room) manage-ment:

a. Seizuresb. Cardiac arrhythmiac. Bronchial asthma or croupd. Dehydratione. Encopresis (for cleanout)f. Other physiologic problem

14. Special pediatric problems

a. Child abuseb. Noncompliance with necessary therapeutic reg-

imen

c. Need for special observation or close monitoring

of behavior, including calorie intake in cases offailure to thrive

B. Intensity of Service1. Surgery or procedure scheduled within 24 hours

necessitatinga. General or regional anesthesia orb. Use of equipment, facilities, or procedure avail-

able only in a hospital2. Treatment in an intensive care unit3. Vital sign monitoring every 2 hours or more often

(may include telemetry or bedside cardiac monitor)4. IV medications and/or fluid replacement (does not

include tube feedings)5. Chemotherapeutic agents that require continuous

observation for life-threatening toxic reaction




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 day

2. Procedure scheduled in operating room the next

day, necessitating preoperative consultation or

evaluation3. 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 in

record)12. Postoperative day for any procedure described in

numbers 1 or 3 to 8 aboveB. Nursing/Life Support Services

1. Respiratory care-intermittent or continuous res-

pirator use and/or inhalation therapy (with chestphysical therapy, intermittent positive pressure

breathing) 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 30

minutes for at least 4 hours4. IM and/or subcutaneous injections at least twice

daily

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 doctor’s ordersC. Patient Condition

A. (Being reviewed the day before for the day of care)

1. Inability to void or move bowels, not attributable

to neurologic disorder-usually a postoperative

problemBeing reviewed within 2 days before the day of

care2. Transfusion due to blood loss3. Ventricular fibrillation or ECG evidence of acute

ischemia, as stated in progress note or in ECG

report

4. Fever at least 38.30C (1010F) rectally (at least

37.8#{176}C[100#{176}F]orally), if patient was admitted for

reason other than fever

5. Coma-unresponsiveness for at least 1 hour

6. Acute confusional state, including withdrawal from

drugs and alcohol

7. Acute hematologic disorders-significant neutro-

penia, anemia, thrombocytopenia, leukocytosis, er-

ythrocytosis, or thrombocytosis-yielding signs or

symptoms

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 outpatient

basis

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 an

outpatient basis)4. Patient needs institutional care, but at a level less

than an acute care hospital-general (unspecified)5. Patient needs care in a chronic disease hospital6. Patient needs care in a skilled nursing facility

7. Patient needs care in a nonskilled nursing facility

8. Premature admission (eg, on Friday for a proce-dure scheduled for the following Monday)

9. Other-specifyFor Inappropriate Day of CareA. For patients who need continued hospital stay for

medical reasons20. Problem in hospital scheduling of operative pro-

cedure

21. Problem in hospital scheduling of tests or nonop-

erative procedure22. Premature admission

23. Patient “bumped” because of operating room prob-lems

24. 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 physician

d. 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 patient’s home carec. Patient/family rejection of available space at

appropriate alternate facilityd. Other-specify

3. Environmental responsibilities

a. Patient from unhealthy environment-patientkept until environment becomes acceptable or

alternative facility foundb. Patient is convalescing from an illness, and it is

anticipated 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: N

EngI J Med. 1986;315:1259-12663. 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 don’t 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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