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Willer RJ, Brady PW, Tyler AN, Treasure JD, Coon ER. Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis. JAMA Netw Open 2024; 7:e242722. [PMID: 38497961 PMCID: PMC10949097 DOI: 10.1001/jamanetworkopen.2024.2722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/24/2024] [Indexed: 03/19/2024] Open
Abstract
Importance Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown. Objective To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission. Design, Setting, and Participants This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024. Exposure Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey. Main Outcomes and Measures Proportion of patients with bronchiolitis admitted to the ICU. Results A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups. Conclusions and Relevance Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.
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Affiliation(s)
- Robert J. Willer
- Department of Pediatrics, Division of Pediatric Hospital Medicine, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City
| | - Patrick W. Brady
- University of Cincinnati College of Medicine, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Amy N. Tyler
- The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus
| | - Jennifer D. Treasure
- University of Cincinnati College of Medicine, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Eric R. Coon
- Department of Pediatrics, Division of Pediatric Hospital Medicine, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City
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2
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Ghirardo S, Ullmann N, Zago A, Ghezzi M, Minute M, Madini B, D'Auria E, Basile C, Castelletti F, Chironi F, Capodiferro A, Andrenacci B, Risso FM, Aversa S, Dotta L, Coretti A, Vittucci AC, Badolato R, Amaddeo A, Barbi E, Cutrera R. Increased bronchiolitis burden and severity after the pandemic: a national multicentric study. Ital J Pediatr 2024; 50:25. [PMID: 38350986 PMCID: PMC10865582 DOI: 10.1186/s13052-024-01602-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/28/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND The coronavirus 2019 (COVID-19) related containment measures led to the disruption of all virus distribution. Bronchiolitis-related hospitalizations shrank during 2020-2021, rebounding to pre-pandemic numbers the following year. This study aims to describe the trend in bronchiolitis-related hospitalization this year, focusing on severity and viral epidemiology. METHODS We conducted a retrospective investigation collecting clinical records data from all infants hospitalized for bronchiolitis during winter (1st September-31th March) from September 2018 to March 2023 in six Italian hospitals. No trial registration was necessary according to authorization no.9/2014 of the Italian law. RESULTS Nine hundred fifty-three infants were hospitalized for bronchiolitis this last winter, 563 in 2021-2022, 34 in 2020-2021, 395 in 2019-2020 and 483 in 2018-2019. The mean length of stay was significantly longer this year compared to all previous years (mean 7.2 ± 6 days in 2022-2023), compared to 5.7 ± 4 in 2021-2022, 5.3 ± 4 in 2020-2021, 6.4 ± 5 in 2019-2020 and 5.5 ± 4 in 2018-2019 (p < 0.001), respectively. More patients required mechanical ventilation this winter 38 (4%), compared to 6 (1%) in 2021-2022, 0 in 2020-2021, 11 (2%) in 2019-2020 and 6 (1%) in 2018-2019 (p < 0.05), respectively. High-flow nasal cannula and non-invasive respiratory supports were statistically more common last winter (p = 0.001 or less). RSV prevalence and distribution did not differ this winter, but coinfections were more prevalent 307 (42%), 138 (31%) in 2021-2022, 1 (33%) in 2020-2021, 68 (23%) in 2019-2020, 61 (28%) in 2018-2019 (p = 0.001). CONCLUSIONS This study shows a growth of nearly 70% in hospitalisations for bronchiolitis, and an increase in invasive respiratory support and coinfections, suggesting a more severe disease course this winter compared to the last five years.
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Affiliation(s)
- Sergio Ghirardo
- Department of Medicine, Surgery and Health Sciences, University of Trieste, via dell'Istria 65/1, Trieste, Italy.
| | - Nicola Ullmann
- Pediatric Pulmonology and Cystic Fibrosis Unit, Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandro Zago
- Department of Medicine, Surgery and Health Sciences, University of Trieste, via dell'Istria 65/1, Trieste, Italy
| | - Michele Ghezzi
- Department of Pediatrics, Buzzi Children's Hospital, Milan, Italy
| | - Marta Minute
- Ospedale Regionale Ca Foncello Treviso, Treviso, Italy
| | - Barbara Madini
- S.C. Pediatria Pneumoinfettivologia Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Enza D'Auria
- Department of Pediatrics, Buzzi Children's Hospital, Milan, Italy
| | - Cecilia Basile
- Department of Pediatrics, Buzzi Children's Hospital, Milan, Italy
| | | | - Federica Chironi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, 20122, Italy
| | - Agata Capodiferro
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, 20122, Italy
| | - Beatrice Andrenacci
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Francesco Maria Risso
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili, Brescia, Italy
| | - Salvatore Aversa
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili, Brescia, Italy
| | - Laura Dotta
- Department of Pediatrics and "A. Nocivelli" Institute for Molecular Medicine, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Antonella Coretti
- Pediatric Pulmonology and Cystic Fibrosis Unit, Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Chiara Vittucci
- Pediatric Pulmonology and Cystic Fibrosis Unit, Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Raffaele Badolato
- Department of Pediatrics and "A. Nocivelli" Institute for Molecular Medicine, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Alessandro Amaddeo
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, 34137, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, via dell'Istria 65/1, Trieste, Italy
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, 34137, Italy
| | - Renato Cutrera
- Pediatric Pulmonology and Cystic Fibrosis Unit, Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Franklin D, Schibler A. Rising Intensive Care Costs in Bronchiolitis Infants-Is Nasal High Flow the Culprit? Pediatr Crit Care Med 2022; 23:218-222. [PMID: 35238842 DOI: 10.1097/pcc.0000000000002900] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Donna Franklin
- Gold Coast University Hospital, Children's Emergency and Critical Care Research, Southport, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, VIC, Australia
- Wesley Medical Research, St Andrew's War Memorial Hospital, Brisbane, QLD, Australia
| | - Andreas Schibler
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, VIC, Australia
- Wesley Medical Research, St Andrew's War Memorial Hospital, Brisbane, QLD, Australia
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4
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Ghirardo S, Cozzi G, Tonin G, Risso FM, Dotta L, Zago A, Lupia D, Cogo P, Ullmann N, Coretti A, Badolato R, Amaddeo A, Barbi E, Cutrera R. Increased use of high-flow nasal cannulas after the pandemic in bronchiolitis: a more severe disease or a changed physician's attitude? Eur J Pediatr 2022; 181:3931-3936. [PMID: 36083314 PMCID: PMC9458479 DOI: 10.1007/s00431-022-04601-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/08/2022] [Accepted: 08/24/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED After the SARS-CoV-2 pandemic, we noticed a marked increase in high-flow nasal cannula use for bronchiolitis. This study aims to report the percentage of children treated with high-flow nasal cannula (HFNC) in various seasons. The secondary outcomes were admissions for bronchiolitis, virological results, hospital burden, and NICU/PICU need. We conducted a retrospective study in four Italian hospitals, examining the medical records of all infants (< 12 months) hospitalized for bronchiolitis in the last four winter seasons (1 September-31 March 2018-2022). In the 2021-2022 winter season, 66% of admitted children received HFNC versus 23%, 38%, and 35% in the previous 3 years. A total of 876 patients were hospitalized in the study periods. In 2021-2022, 300 infants were hospitalized for bronchiolitis, 22 in 2020-2021, 259 in 2019-2020, and 295 in 2018-2019. The percentage of patients needing intensive care varied from 28.7% to 18%, 22%, and 15% in each of the four considered periods (p < 0.05). Seventy-seven percent of children received oxygen in the 2021-2022 winter; vs 50%, 63%, and 55% (p < 0.01) in the previous 3 years. NIV/CPAP was used in 23%, 9%, 16%, and 12%, respectively. In 2021-2020, 2% of patients were intubated; 0 in 2020-2021, 3% in 2019-2020, and 1% in 2018-2019. CONCLUSION This study shows a marked increase in respiratory support and intensive care admissions this last winter. While these severity indexes were all driven by medical choices, more reliable indexes such as intubation rate and length of stay did not change. Therefore, we suggest that there is a more aggressive treatment attitude rather than a more severe disease. WHAT IS KNOWN • COVID-19 pandemic deeply impacted bronchiolitis epidemiology, reducing hospitalizations to onetenth. In the 2021-2022 winter, bronchiolitis resurged to pre-pandemic numbers in Europe. WHAT IS NEW • Bronchiolitis hospitalization rose much faster in the 2021-2022 winter period, peaking at a higher level. Respiratory supports and high-flow nasal cannula increased significantly compared to the pre-pandemic era.
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Affiliation(s)
- Sergio Ghirardo
- Unit of Pediatrics, Department of Medicine, University Hospital S. Maria della Misericordia, Viale San Daniele 27, Udine, Italy.
| | - Giorgio Cozzi
- grid.418712.90000 0004 1760 7415Institute for Maternal and Child Health - IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Giovanna Tonin
- grid.5390.f0000 0001 2113 062XDepartment of Medicine, DAME, University of Udine, Udine, Italy
| | - Francesco Maria Risso
- grid.412725.7Neonatal Intensive Care Unit, Children’s Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Laura Dotta
- grid.7637.50000000417571846Department of Pediatrics, Università di Brescia, Istituto di Medicina Molecolare Angelo Nocivelli”, ASST Spedali Civili, Brescia, Italy
| | - Alessandro Zago
- grid.5133.40000 0001 1941 4308University of Trieste, Trieste, Italy
| | - Daniela Lupia
- grid.414125.70000 0001 0727 6809Pediatric Pulmonology & Respiratory Intermediate Care Unit, Clinical, Management and Technology Innovation Research Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Paola Cogo
- grid.411492.bUnit of Pediatrics, Department of Medicine, University Hospital S. Maria della Misericordia, Viale San Daniele 27, Udine, Italy ,grid.5390.f0000 0001 2113 062XDepartment of Medicine, DAME, University of Udine, Udine, Italy
| | - Nicola Ullmann
- grid.414125.70000 0001 0727 6809Pediatric Pulmonology & Respiratory Intermediate Care Unit, Clinical, Management and Technology Innovation Research Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Antonella Coretti
- grid.414125.70000 0001 0727 6809Pediatric Pulmonology & Respiratory Intermediate Care Unit, Clinical, Management and Technology Innovation Research Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Raffaele Badolato
- grid.7637.50000000417571846Department of Pediatrics, Università di Brescia, Istituto di Medicina Molecolare Angelo Nocivelli”, ASST Spedali Civili, Brescia, Italy
| | - Alessandro Amaddeo
- grid.418712.90000 0004 1760 7415Institute for Maternal and Child Health - IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Egidio Barbi
- grid.418712.90000 0004 1760 7415Institute for Maternal and Child Health - IRCCS “Burlo Garofolo”, Trieste, Italy ,grid.5133.40000 0001 1941 4308University of Trieste, Trieste, Italy
| | - Renato Cutrera
- grid.414125.70000 0001 0727 6809Pediatric Pulmonology & Respiratory Intermediate Care Unit, Clinical, Management and Technology Innovation Research Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
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Willer RJ, Coon ER, Harrison WN, Ralston SL. Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals. JAMA Netw Open 2021; 4:e2129920. [PMID: 34698848 PMCID: PMC8548950 DOI: 10.1001/jamanetworkopen.2021.29920] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined. OBJECTIVE To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019. EXPOSURE Hospitalization for bronchiolitis. MAIN OUTCOMES AND MEASURES Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost. RESULTS A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity. CONCLUSIONS AND RELEVANCE This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.
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Affiliation(s)
- Robert J. Willer
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City
| | - Eric R. Coon
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City
| | - Wade N. Harrison
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill
| | - Shawn L. Ralston
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Washington, Seattle
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Willer RJ, Johnson MD, Cipriano FA, Stone BL, Nkoy FL, Chaulk DC, Knochel ML, Kawai CK, Neiswender KL, Coon ER. Implementation of a Weight-Based High-Flow Nasal Cannula Protocol for Children With Bronchiolitis. Hosp Pediatr 2021; 11:891-895. [PMID: 34234010 DOI: 10.1542/hpeds.2021-005814] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine if the implementation of a weight-based high-flow nasal cannula (HFNC) protocol for infants with bronchiolitis was associated with improved outcomes, including decreased ICU use. METHODS We implemented a weight-based HFNC protocol across a tertiary care children's hospital and 2 community hospitals that admit pediatric patients on HFNC. We included all patients who were <2 years old and had a discharge diagnosis of bronchiolitis or viral pneumonia during the preimplementation (November 2013 to April 2018) and postimplementation (November 2018 to April 2020) respiratory seasons. Data were analyzed by using an interrupted time series approach. The primary outcome measure was the proportion of patients treated in the ICU. Patients with a complex chronic condition were excluded. RESULTS Implementation of the weight-based HFNC protocol was associated with an immediate absolute decrease in ICU use of 4.0%. We also observed a 6.2% per year decrease in the slope of ICU admissions pre- versus postintervention. This was associated with an immediate reduction in median cost per bronchiolitis encounter of $661, a 2.3% immediate absolute reduction in the proportion of patients who received noninvasive ventilation, and a 3.4% immediate absolute reduction in the proportion of patients who received HFNC. CONCLUSIONS A multicenter, weight-based HFNC protocol was associated with decreased ICU use and noninvasive ventilation use. In hospitals where HFNC is used in non-ICU units, weight-based approaches may lead to improved resource use.
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Affiliation(s)
- Robert J Willer
- School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Michael D Johnson
- School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Frank A Cipriano
- School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Bryan L Stone
- School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Flory L Nkoy
- School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - David C Chaulk
- School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Miguel L Knochel
- School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | | | | | - Eric R Coon
- School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
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Flaherty BF, Schroeder AR. Early, Unanticipated PICU Transfers: Is There a Need for Improvement? Hosp Pediatr 2019; 9:402-404. [PMID: 31023787 DOI: 10.1542/hpeds.2019-0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Brian F Flaherty
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah; and
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
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