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As hospitalized children become more medically complex, hospital-to-home care transitions will become increasingly challenging. During a quality improvement (QI) initiative, we developed an electronic tool to improve the quality of our hospital discharge process.
METHODS
Setting
This work was conducted at the Children’s Hospital Colorado as part of a national QI collaborative. The hospital’s EHR is Epic (Verona, Wisconsin). The project was approved as QI by the Children’s Hospital Organizational Research Risk and Quality Improvement Review Panel, precluding review from the Colorado Multiple Institutional Review Board.
Tool Design, Implementation, and Use
A team of clinicians, nurse–family educators, case managers, social workers, and informatics experts helped design the instrument between 2014 and 2015. In addition to the selected features (number of discharge medications, presence of home health, and language preference), we considered adding the number of consulting specialists but had previously improved our process for scheduling follow-up appointments. Diagnoses were not systematically or discretely documented to be reliably extracted in real time. We excluded known readmission predictor variables (such as length of stay [LOS] and prior hospitalizations) from the initial model to maintain emphasis on the modifiable discharge processes. Additional considerations, such as health literacy and social determinants, were not systematically measured to be operationally usable.
To generate the score, the clinical documentation of home-health orders categorizes children with home care. Each home-care equipment or service category is documented in separate flowsheet rows, allowing for identification of distinct categories (Table). Total parenteral nutrition, intravenous medications, and durable medical equipment and supplies are counted as home care. The number of discharge medications is approximated by inpatient medication orders and finalized as the number of discharge medication orders. The medications include new, historic, and as-needed medications (if included among discharge medication orders). 
The electronic score is displayed within the EHR’s Discharge Readiness Report8 and updates automatically as relevant data are entered. The tool displays the individual components and as a composite of 0-3 points. To register a point in each category, a patient needs to exceed (1) the dichotomous discharge medications criterion (ie, ≥6 medications), (2) the dichotomous home-health order criterion (ie, ≥1 home-care order), and (3) to possess documentation of a non-English speaking caregiver. The tool serves as a visual reminder of discharge planning needs during daily coordination rounds attended by clinicians, nursing managers, case managers, and social workers. Case managers use the home-care alert to verify the accuracy of home-care orders.
Evaluation of Predictive Utility for Readmission
We performed a retrospective cohort study on patients aged 0-21 years who were discharged between January 1, 2014 and December 30, 2015. This study was performed to determine the optimal cut points for the continuous variables (discharge medications and home-care orders) and to evaluate the predictive value of the composite score.
Unplanned readmission within 30 days was used as the primary outcome. The index hospitalization was randomly selected for patients with >1 admissions to avoid biasing the results with multiple hospitalizations from individual patients.
Patient characteristics were summarized using percentages for categorical variables and the median and interquartile range (IQR) for continuous variables. We examined bivariate associations for each of the tool’s predictor elements with readmission using Chi-square and Wilcoxon tests
The area under the ROC curve (AUC) was estimated to evaluate the performance of the composite score
RESULTS
Cohort Characteristics
Analysis was restricted to 
ROC analysis indicated that dichotomizing number of medications at ≥6 vs. <6 and home health at 0 vs. ≥1 categories maximized the sensitivity and specificity for predicting 30-day unplanned readmissions. In predictive logistic regression analysis, the odds of readmission was significantly higher in children with a composite score of 1 vs. 0 (odds ratio [OR], 1.7; 95% CI 1.5-2) and a score of ≥2 vs. 0 (OR, 4.2; 95% CI, 3.6-4.9). The c statistic for this model was 0.62, and the Brier score was 0.037. Internal validation of the predictive logistic regression model yielded identical results.
DISCUSSION
The instrument’s framework is relatively simple and should reduce barriers to implementation elsewhere. However, this tool was developed for one setting, and the design may require adjustment for other environments. Regional or institutional variation in home-health eligibility or clinical documentation may impact home-care and medication scores. The score may change at discharge if home-health or medication orders are modified late. The tool performs none of the following: measurement of regimen complexity, identification of high-risk medications, distinguishing of new versus preexisting medications/home care, nor measurement of health literacy, parent education, or psychosocial risk. Adding these features might enhance the model. Finally, readmission rates did not rise linearly with each added point. A more sophisticated scoring system (eg, differentially weighting each risk factor) may also improve the performance of the tool.
Despite these limitations, we have implemented a real-time electronic tool with practical potential to improve the discharge process but with low utility for distinguishing readmissions. Additional validation and research is needed to evaluate its impact on hospital discharge quality metrics and family reported outcome measures.
Disclosures
The authors have no relevant financial relationships to disclose.
Funding
This study was supported by an institutional Clinical and Operational Effectiveness and Patient Safety Small Grants Program
1. Holland DE, Conlon PM, Rohlik GM, Gillard KL, Messner PK, Mundy LM. Identifying hospitalized pediatric patients for early discharge planning: a feasibility study. J Pediatr Nurs. 2015;30(3):454-462. doi: 10.1016/j.pedn.2014.12.011. PubMed
2. Brittan M, Albright K, Cifuentes M, Jimenez-Zambrano A, Kempe A. Parent and provider perspectives on pediatric readmissions: what can we learn about readiness for discharge? Hosp Pediatr. 2015;5(11):559-565. doi: 10.1542/hpeds.2015-0034. PubMed
3. Brittan M FV, Martin S, Moss A, Keller D. Provider feedback: a potential method to reduce readmissions. Hosp Pediatr. 2016;6(11):684-688. PubMed
4. Berry JG, Hall DE, Kuo DZ, et al. Hospital utilization and characteristics of patients experiencing recurrent readmissions within children’s hospitals. JAMA 2011;305(7):682-690. doi: 10.1001/jama.2011.122. PubMed
5. Feudtner C, Levin JE, Srivastava R, et al. How well can hospital readmission be predicted in a cohort of hospitalized children? A retrospective, multicenter study. Pediatrics 2009;123(1):286-293. doi: 10.1542/peds.2007-3395. PubMed
6. Jurgens V, Spaeder MC, Pavuluri P, Waldman Z. Hospital readmission in children with complex chronic conditions discharged from subacute care. Hosp Pediatr. 2014;4(3):153-158. doi: 10.1542/hpeds.2013-0094. PubMed
7. Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med. 2010;5(5):276-282. doi: 10.1002/jhm.658. PubMed
8. Tyler A, Boyer A, Martin S, Neiman J, Bakel LA, Brittan M. Development of a discharge readiness report within the electronic health record-A discharge planning tool. J Hosp Med. 2014;9(8):533-539. doi: 10.1002/jhm.2212. PubMed
9. Youden WJ. Index for rating diagnostic tests. Cancer 1950;3(1):32-35. doi: 10.1002/1097-0142(1950)3:1<32::AID-CNCR2820030106>3.0.CO;2-3. PubMed
10. Steyerberg EW, Harrell FE, Jr., Borsboom GJ, Eijkemans MJ, Vergouwe Y, Habbema JD. Internal validation of predictive models: efficiency of some procedures for logistic regression analysis. J Clin Epidemiol. 2001;54(8):774-781. doi: 10.1016/S0895-4356(01)00341-9. PubMed
11. Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA 2011;306(15):1688-1698. doi: 10.1001/jama.2011.1515. PubMed
12. Pepe MS, Janes H, Longton G, Leisenring W, Newcomb P. Limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker. Am J Epidemiol. 2004;159(9):882-890. doi: 10.1093/aje/kwh101. PubMed
13. Coller RJ, Klitzner TS, Lerner CF, Chung PJ. Predictors of 30-day readmission and association with primary care follow-up plans. J Pediatr. 2013;163(4):1027-1033. doi: 10.1016/j.jpeds.2013.04.013. PubMed
14. Jovanovic M, Radovanovic S, Vukicevic M, Van Poucke S, Delibasic B. Building interpretable predictive models for pediatric hospital readmission using Tree-Lasso logistic regression. Artif Intell Med. 2016;72:12-21. doi: 10.1016/j.artmed.2016.07.003. PubMed
15. Naessens JM, Knoebel E, Johnson M, Branda M. ISQUA16-1722 predicting pediatric readmissions. Int J Qual Health Care. 2016;28(suppl_1):24-25. doi: 10.1093/intqhc/mzw104.34.
As hospitalized children become more medically complex, hospital-to-home care transitions will become increasingly challenging. During a quality improvement (QI) initiative, we developed an electronic tool to improve the quality of our hospital discharge process.
METHODS
Setting
This work was conducted at the Children’s Hospital Colorado as part of a national QI collaborative. The hospital’s EHR is Epic (Verona, Wisconsin). The project was approved as QI by the Children’s Hospital Organizational Research Risk and Quality Improvement Review Panel, precluding review from the Colorado Multiple Institutional Review Board.
Tool Design, Implementation, and Use
A team of clinicians, nurse–family educators, case managers, social workers, and informatics experts helped design the instrument between 2014 and 2015. In addition to the selected features (number of discharge medications, presence of home health, and language preference), we considered adding the number of consulting specialists but had previously improved our process for scheduling follow-up appointments. Diagnoses were not systematically or discretely documented to be reliably extracted in real time. We excluded known readmission predictor variables (such as length of stay [LOS] and prior hospitalizations) from the initial model to maintain emphasis on the modifiable discharge processes. Additional considerations, such as health literacy and social determinants, were not systematically measured to be operationally usable.
To generate the score, the clinical documentation of home-health orders categorizes children with home care. Each home-care equipment or service category is documented in separate flowsheet rows, allowing for identification of distinct categories (Table). Total parenteral nutrition, intravenous medications, and durable medical equipment and supplies are counted as home care. The number of discharge medications is approximated by inpatient medication orders and finalized as the number of discharge medication orders. The medications include new, historic, and as-needed medications (if included among discharge medication orders).
The electronic score is displayed within the EHR’s Discharge Readiness Report8 and updates automatically as relevant data are entered. The tool displays the individual components and as a composite of 0-3 points. To register a point in each category, a patient needs to exceed (1) the dichotomous discharge medications criterion (ie, ≥6 medications), (2) the dichotomous home-health order criterion (ie, ≥1 home-care order), and (3) to possess documentation of a non-English speaking caregiver. The tool serves as a visual reminder of discharge planning needs during daily coordination rounds attended by clinicians, nursing managers, case managers, and social workers. Case managers use the home-care alert to verify the accuracy of home-care orders.
Evaluation of Predictive Utility for Readmission
We performed a retrospective cohort study on patients aged 0-21 years who were discharged between January 1, 2014 and December 30, 2015. This study was performed to determine the optimal cut points for the continuous variables (discharge medications and home-care orders) and to evaluate the predictive value of the composite score.
Unplanned readmission within 30 days was used as the primary outcome. The index hospitalization was randomly selected for patients with >1 admissions to avoid biasing the results with multiple hospitalizations from individual patients.
Patient characteristics were summarized using percentages for categorical variables and the median and interquartile range (IQR) for continuous variables. We examined bivariate associations for each of the tool’s predictor elements with readmission using Chi-square and Wilcoxon tests
The area under the ROC curve (AUC) was estimated to evaluate the performance of the composite score
RESULTS
Cohort Characteristics
Analysis was restricted to
ROC analysis indicated that dichotomizing number of medications at ≥6 vs. <6 and home health at 0 vs. ≥1 categories maximized the sensitivity and specificity for predicting 30-day unplanned readmissions. In predictive logistic regression analysis, the odds of readmission was significantly higher in children with a composite score of 1 vs. 0 (odds ratio [OR], 1.7; 95% CI 1.5-2) and a score of ≥2 vs. 0 (OR, 4.2; 95% CI, 3.6-4.9). The c statistic for this model was 0.62, and the Brier score was 0.037. Internal validation of the predictive logistic regression model yielded identical results.
DISCUSSION
The instrument’s framework is relatively simple and should reduce barriers to implementation elsewhere. However, this tool was developed for one setting, and the design may require adjustment for other environments. Regional or institutional variation in home-health eligibility or clinical documentation may impact home-care and medication scores. The score may change at discharge if home-health or medication orders are modified late. The tool performs none of the following: measurement of regimen complexity, identification of high-risk medications, distinguishing of new versus preexisting medications/home care, nor measurement of health literacy, parent education, or psychosocial risk. Adding these features might enhance the model. Finally, readmission rates did not rise linearly with each added point. A more sophisticated scoring system (eg, differentially weighting each risk factor) may also improve the performance of the tool.
Despite these limitations, we have implemented a real-time electronic tool with practical potential to improve the discharge process but with low utility for distinguishing readmissions. Additional validation and research is needed to evaluate its impact on hospital discharge quality metrics and family reported outcome measures.
Disclosures
The authors have no relevant financial relationships to disclose.
Funding
This study was supported by an institutional Clinical and Operational Effectiveness and Patient Safety Small Grants Program
As hospitalized children become more medically complex, hospital-to-home care transitions will become increasingly challenging. During a quality improvement (QI) initiative, we developed an electronic tool to improve the quality of our hospital discharge process.
METHODS
Setting
This work was conducted at the Children’s Hospital Colorado as part of a national QI collaborative. The hospital’s EHR is Epic (Verona, Wisconsin). The project was approved as QI by the Children’s Hospital Organizational Research Risk and Quality Improvement Review Panel, precluding review from the Colorado Multiple Institutional Review Board.
Tool Design, Implementation, and Use
A team of clinicians, nurse–family educators, case managers, social workers, and informatics experts helped design the instrument between 2014 and 2015. In addition to the selected features (number of discharge medications, presence of home health, and language preference), we considered adding the number of consulting specialists but had previously improved our process for scheduling follow-up appointments. Diagnoses were not systematically or discretely documented to be reliably extracted in real time. We excluded known readmission predictor variables (such as length of stay [LOS] and prior hospitalizations) from the initial model to maintain emphasis on the modifiable discharge processes. Additional considerations, such as health literacy and social determinants, were not systematically measured to be operationally usable.
To generate the score, the clinical documentation of home-health orders categorizes children with home care. Each home-care equipment or service category is documented in separate flowsheet rows, allowing for identification of distinct categories (Table). Total parenteral nutrition, intravenous medications, and durable medical equipment and supplies are counted as home care. The number of discharge medications is approximated by inpatient medication orders and finalized as the number of discharge medication orders. The medications include new, historic, and as-needed medications (if included among discharge medication orders).
The electronic score is displayed within the EHR’s Discharge Readiness Report8 and updates automatically as relevant data are entered. The tool displays the individual components and as a composite of 0-3 points. To register a point in each category, a patient needs to exceed (1) the dichotomous discharge medications criterion (ie, ≥6 medications), (2) the dichotomous home-health order criterion (ie, ≥1 home-care order), and (3) to possess documentation of a non-English speaking caregiver. The tool serves as a visual reminder of discharge planning needs during daily coordination rounds attended by clinicians, nursing managers, case managers, and social workers. Case managers use the home-care alert to verify the accuracy of home-care orders.
Evaluation of Predictive Utility for Readmission
We performed a retrospective cohort study on patients aged 0-21 years who were discharged between January 1, 2014 and December 30, 2015. This study was performed to determine the optimal cut points for the continuous variables (discharge medications and home-care orders) and to evaluate the predictive value of the composite score.
Unplanned readmission within 30 days was used as the primary outcome. The index hospitalization was randomly selected for patients with >1 admissions to avoid biasing the results with multiple hospitalizations from individual patients.
Patient characteristics were summarized using percentages for categorical variables and the median and interquartile range (IQR) for continuous variables. We examined bivariate associations for each of the tool’s predictor elements with readmission using Chi-square and Wilcoxon tests
The area under the ROC curve (AUC) was estimated to evaluate the performance of the composite score
RESULTS
Cohort Characteristics
Analysis was restricted to
ROC analysis indicated that dichotomizing number of medications at ≥6 vs. <6 and home health at 0 vs. ≥1 categories maximized the sensitivity and specificity for predicting 30-day unplanned readmissions. In predictive logistic regression analysis, the odds of readmission was significantly higher in children with a composite score of 1 vs. 0 (odds ratio [OR], 1.7; 95% CI 1.5-2) and a score of ≥2 vs. 0 (OR, 4.2; 95% CI, 3.6-4.9). The c statistic for this model was 0.62, and the Brier score was 0.037. Internal validation of the predictive logistic regression model yielded identical results.
DISCUSSION
The instrument’s framework is relatively simple and should reduce barriers to implementation elsewhere. However, this tool was developed for one setting, and the design may require adjustment for other environments. Regional or institutional variation in home-health eligibility or clinical documentation may impact home-care and medication scores. The score may change at discharge if home-health or medication orders are modified late. The tool performs none of the following: measurement of regimen complexity, identification of high-risk medications, distinguishing of new versus preexisting medications/home care, nor measurement of health literacy, parent education, or psychosocial risk. Adding these features might enhance the model. Finally, readmission rates did not rise linearly with each added point. A more sophisticated scoring system (eg, differentially weighting each risk factor) may also improve the performance of the tool.
Despite these limitations, we have implemented a real-time electronic tool with practical potential to improve the discharge process but with low utility for distinguishing readmissions. Additional validation and research is needed to evaluate its impact on hospital discharge quality metrics and family reported outcome measures.
Disclosures
The authors have no relevant financial relationships to disclose.
Funding
This study was supported by an institutional Clinical and Operational Effectiveness and Patient Safety Small Grants Program
1. Holland DE, Conlon PM, Rohlik GM, Gillard KL, Messner PK, Mundy LM. Identifying hospitalized pediatric patients for early discharge planning: a feasibility study. J Pediatr Nurs. 2015;30(3):454-462. doi: 10.1016/j.pedn.2014.12.011. PubMed
2. Brittan M, Albright K, Cifuentes M, Jimenez-Zambrano A, Kempe A. Parent and provider perspectives on pediatric readmissions: what can we learn about readiness for discharge? Hosp Pediatr. 2015;5(11):559-565. doi: 10.1542/hpeds.2015-0034. PubMed
3. Brittan M FV, Martin S, Moss A, Keller D. Provider feedback: a potential method to reduce readmissions. Hosp Pediatr. 2016;6(11):684-688. PubMed
4. Berry JG, Hall DE, Kuo DZ, et al. Hospital utilization and characteristics of patients experiencing recurrent readmissions within children’s hospitals. JAMA 2011;305(7):682-690. doi: 10.1001/jama.2011.122. PubMed
5. Feudtner C, Levin JE, Srivastava R, et al. How well can hospital readmission be predicted in a cohort of hospitalized children? A retrospective, multicenter study. Pediatrics 2009;123(1):286-293. doi: 10.1542/peds.2007-3395. PubMed
6. Jurgens V, Spaeder MC, Pavuluri P, Waldman Z. Hospital readmission in children with complex chronic conditions discharged from subacute care. Hosp Pediatr. 2014;4(3):153-158. doi: 10.1542/hpeds.2013-0094. PubMed
7. Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med. 2010;5(5):276-282. doi: 10.1002/jhm.658. PubMed
8. Tyler A, Boyer A, Martin S, Neiman J, Bakel LA, Brittan M. Development of a discharge readiness report within the electronic health record-A discharge planning tool. J Hosp Med. 2014;9(8):533-539. doi: 10.1002/jhm.2212. PubMed
9. Youden WJ. Index for rating diagnostic tests. Cancer 1950;3(1):32-35. doi: 10.1002/1097-0142(1950)3:1<32::AID-CNCR2820030106>3.0.CO;2-3. PubMed
10. Steyerberg EW, Harrell FE, Jr., Borsboom GJ, Eijkemans MJ, Vergouwe Y, Habbema JD. Internal validation of predictive models: efficiency of some procedures for logistic regression analysis. J Clin Epidemiol. 2001;54(8):774-781. doi: 10.1016/S0895-4356(01)00341-9. PubMed
11. Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA 2011;306(15):1688-1698. doi: 10.1001/jama.2011.1515. PubMed
12. Pepe MS, Janes H, Longton G, Leisenring W, Newcomb P. Limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker. Am J Epidemiol. 2004;159(9):882-890. doi: 10.1093/aje/kwh101. PubMed
13. Coller RJ, Klitzner TS, Lerner CF, Chung PJ. Predictors of 30-day readmission and association with primary care follow-up plans. J Pediatr. 2013;163(4):1027-1033. doi: 10.1016/j.jpeds.2013.04.013. PubMed
14. Jovanovic M, Radovanovic S, Vukicevic M, Van Poucke S, Delibasic B. Building interpretable predictive models for pediatric hospital readmission using Tree-Lasso logistic regression. Artif Intell Med. 2016;72:12-21. doi: 10.1016/j.artmed.2016.07.003. PubMed
15. Naessens JM, Knoebel E, Johnson M, Branda M. ISQUA16-1722 predicting pediatric readmissions. Int J Qual Health Care. 2016;28(suppl_1):24-25. doi: 10.1093/intqhc/mzw104.34.
1. Holland DE, Conlon PM, Rohlik GM, Gillard KL, Messner PK, Mundy LM. Identifying hospitalized pediatric patients for early discharge planning: a feasibility study. J Pediatr Nurs. 2015;30(3):454-462. doi: 10.1016/j.pedn.2014.12.011. PubMed
2. Brittan M, Albright K, Cifuentes M, Jimenez-Zambrano A, Kempe A. Parent and provider perspectives on pediatric readmissions: what can we learn about readiness for discharge? Hosp Pediatr. 2015;5(11):559-565. doi: 10.1542/hpeds.2015-0034. PubMed
3. Brittan M FV, Martin S, Moss A, Keller D. Provider feedback: a potential method to reduce readmissions. Hosp Pediatr. 2016;6(11):684-688. PubMed
4. Berry JG, Hall DE, Kuo DZ, et al. Hospital utilization and characteristics of patients experiencing recurrent readmissions within children’s hospitals. JAMA 2011;305(7):682-690. doi: 10.1001/jama.2011.122. PubMed
5. Feudtner C, Levin JE, Srivastava R, et al. How well can hospital readmission be predicted in a cohort of hospitalized children? A retrospective, multicenter study. Pediatrics 2009;123(1):286-293. doi: 10.1542/peds.2007-3395. PubMed
6. Jurgens V, Spaeder MC, Pavuluri P, Waldman Z. Hospital readmission in children with complex chronic conditions discharged from subacute care. Hosp Pediatr. 2014;4(3):153-158. doi: 10.1542/hpeds.2013-0094. PubMed
7. Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med. 2010;5(5):276-282. doi: 10.1002/jhm.658. PubMed
8. Tyler A, Boyer A, Martin S, Neiman J, Bakel LA, Brittan M. Development of a discharge readiness report within the electronic health record-A discharge planning tool. J Hosp Med. 2014;9(8):533-539. doi: 10.1002/jhm.2212. PubMed
9. Youden WJ. Index for rating diagnostic tests. Cancer 1950;3(1):32-35. doi: 10.1002/1097-0142(1950)3:1<32::AID-CNCR2820030106>3.0.CO;2-3. PubMed
10. Steyerberg EW, Harrell FE, Jr., Borsboom GJ, Eijkemans MJ, Vergouwe Y, Habbema JD. Internal validation of predictive models: efficiency of some procedures for logistic regression analysis. J Clin Epidemiol. 2001;54(8):774-781. doi: 10.1016/S0895-4356(01)00341-9. PubMed
11. Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA 2011;306(15):1688-1698. doi: 10.1001/jama.2011.1515. PubMed
12. Pepe MS, Janes H, Longton G, Leisenring W, Newcomb P. Limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker. Am J Epidemiol. 2004;159(9):882-890. doi: 10.1093/aje/kwh101. PubMed
13. Coller RJ, Klitzner TS, Lerner CF, Chung PJ. Predictors of 30-day readmission and association with primary care follow-up plans. J Pediatr. 2013;163(4):1027-1033. doi: 10.1016/j.jpeds.2013.04.013. PubMed
14. Jovanovic M, Radovanovic S, Vukicevic M, Van Poucke S, Delibasic B. Building interpretable predictive models for pediatric hospital readmission using Tree-Lasso logistic regression. Artif Intell Med. 2016;72:12-21. doi: 10.1016/j.artmed.2016.07.003. PubMed
15. Naessens JM, Knoebel E, Johnson M, Branda M. ISQUA16-1722 predicting pediatric readmissions. Int J Qual Health Care. 2016;28(suppl_1):24-25. doi: 10.1093/intqhc/mzw104.34.
© 2018 Society of Hospital Medicine