When should a child be in the hospital? A.Frederick North, Jr, MD, revisited

Objectives. My objective was to revisit the issues and approaches raised in a seminal article published in Pediatrics in 1976 by A. Frederick Noah,Jr, entitled "When Should a Child Be in the Hospital?" Dr North proposed a set of nine criteria to guide the evaluation of appropriateness of admission to hospital. These were based on a core assertion that, "The need to hospitalize a child is dependent on the special services which the child requires rather than upon the diagnosis." This original work antedated more recent activities and publications in the area of appropriateness evaluation as applied to pediatrics (such as the Pediatric Appropriateness Evaluation Protocol), but is more context-specific than later works in the field. Methods. A review of the literature concerning temporal trends in hospital use for children in North America was undertaken. This was done to place some of the subsequent observations in a macrocontext of overall trends in hospital use. A review of the English language literature focusing on alternatives to hospitalization and contextual evolution affecting patterns of hospital care for children is presented. Factors influencing each of the nine admission criteria proposed by North are reviewed and discussed in turn. Results. Overall rates of hospitalization declined by 46% and 41% in the United States and Canada, respectively, during the 1971 to 1993 interval. The relative composition by diagnostic category in two specific pediatric hospital settings also evolved substantially during the 2 decades. Many of North's specific criteria required extensive revision or updating to match the contextual realities of the 1990s. Conclusions. Although important overall shifts have occurred in the absolute levels and relative composition of pediatric hospitalization, Dr North's core assertion, relating to the need for specific services driving the need for hospitalization, has largely stood the test of time.