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Shen BH, Dobie AC, Shusterman SL, Duzgol M, Homer-Bouthiette C, Kearney LE, Newman J, Pang B, Shankar DA, Zhang J, Gillmeyer KR, Bosch NA, Law AC. Variation in Triage to Pediatric vs Adult ICUs Among Adolescents and Young Adults With Asthma Exacerbations. CHEST CRITICAL CARE 2024; 2:100088. [PMID: 39364391 PMCID: PMC11449464 DOI: 10.1016/j.chstcc.2024.100088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
BACKGROUND More than 90,000 children and adults in the United States are hospitalized with an asthma exacerbation annually, and between 5% and 34% of these hospitalizations include admission to an ICU. It is unclear how adolescent and young adults with severe asthma exacerbations are triaged in the inpatient setting between PICUs and adult ICUs. Using a large multicenter US cohort, we characterized how hospitals triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs. RESEARCH QUESTION How do hospitals across the United States triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs? STUDY DESIGN AND METHODS This was a retrospective cohort study carried out from 2016 through 2022 using the enhanced-claims PINC AI database. Participants were patients aged 12 to 26 years who were hospitalized with an asthma exacerbation and admitted to a PICU or adult ICU. We used nested hierarchical multivariable regression models to quantify changes in the intraclass correlation coefficient (ICC; a measure of variation in triage decisions attributable to hospital of admission after accounting for covariables). RESULTS Analyses included 3,946 admissions from 93 hospitals. Stratified by age, the percent of patients admitted to PICUs dropped by 26.9% between 17 and 18 years of age. In the nested models, the ICC showed a large decrease going from the empty model (28.7%) to the age-adjusted model (4.5%), but was similar between the age-adjusted and fully adjusted model (3.4%). INTERPRETATION Our results showed that among adolescents and young adults with asthma exacerbations, age of 18 years or younger was a strong determinant of PICU triage. Further research is needed to understand differences in asthma care and outcomes between PICUs and adult ICUs, as well as how intermediate care units affect triage decision-making from wards and the ED.
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Affiliation(s)
- Burton H Shen
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Aaron C Dobie
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Sara L Shusterman
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Mine Duzgol
- Pediatric Infectious Disease, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | | | - Lauren E Kearney
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Julia Newman
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Brandon Pang
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Divya A Shankar
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Jingzhou Zhang
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Kari R Gillmeyer
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Nicholas A Bosch
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Anica C Law
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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Lampin ME, Duhamel A, Béhal H, Leteurtre S, Leclerc F, Recher M. Patient Characteristics and Severity Trajectories in a Pediatric Intermediate Care Unit. Indian J Pediatr 2023:10.1007/s12098-023-04902-4. [PMID: 37971648 DOI: 10.1007/s12098-023-04902-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES To describe the characteristics of patients admitted to Pediatric Intermediate Care Units (PImCU) and to assess their illness severity trajectories. METHODS This prospective, observational, multicentre cohort study was conducted in seven French PImCUs between September 2012 and January 2014. All consecutive patients aged under 18 were included. The severity of illness was evaluated through the Paediatric Advanced Warning Score (PAWS), measured every 8 h for each patient. A latent class mixed model was used to identify severity trajectory classes. RESULTS A total of 2868 patients were included. The median [interquartile range] age was 29 [5-103] mo and the median length of stay was 1 [1-3] d. The primary indication for admission was respiratory (44%). Almost 3% of the patients were subsequently transferred to a pediatric intensive care unit. Three severity trajectory classes were identified. In one class, comprising the largest proportion of patients, the PAWS was low on admission and did not change markedly over time. In this class, patients were older and had a shorter length of stay. The other two classes were characterized by a higher PAWS on admission and rapid or slow improvement. These patients were more severely ill, mostly due to respiratory failure. CONCLUSIONS A large proportion of patients had a stable profile and no signs of severity which suggests that the stay in PImCU was not indicated but a part of these patients have remained stable perhaps because of the advanced monitoring and intensive nursing in these units. CLINICAL TRIAL REGISTRATION The study was registered with ClinicalTrials.gov Protocol, Identifier: NCT02304341, ClinicalTrials.gov .
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Affiliation(s)
- Marie E Lampin
- Pediatric Critical Care Unit, University Hospital of Lille, Lille, F-59000, France.
- University of Lille, University Hospital of Lille, ULR 2694 - METRICS: Assessment of Health Technologies and Medical Practices, Lille, F-59000, France.
| | - Alain Duhamel
- University of Lille, University Hospital of Lille, ULR 2694 - METRICS: Assessment of Health Technologies and Medical Practices, Lille, F-59000, France
| | - Hélène Béhal
- University of Lille, University Hospital of Lille, ULR 2694 - METRICS: Assessment of Health Technologies and Medical Practices, Lille, F-59000, France
| | - Stephane Leteurtre
- Pediatric Critical Care Unit, University Hospital of Lille, Lille, F-59000, France
- University of Lille, University Hospital of Lille, ULR 2694 - METRICS: Assessment of Health Technologies and Medical Practices, Lille, F-59000, France
| | - Francis Leclerc
- Pediatric Critical Care Unit, University Hospital of Lille, Lille, F-59000, France
| | - Morgan Recher
- Pediatric Critical Care Unit, University Hospital of Lille, Lille, F-59000, France
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Boerman GH, Haspels HN, de Hoog M, Joosten KF. Characteristics of Long-Stay Patients in a PICU and Healthcare Resource Utilization After Discharge. Crit Care Explor 2023; 5:e0971. [PMID: 37644970 PMCID: PMC10461958 DOI: 10.1097/cce.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES To examine the characteristics of long-stay patients (LSPs) admitted to a PICU and to investigate discharge characteristics of medical complexity among discharged LSP. DESIGN We performed a retrospective cohort study where clinical data were collected on all children admitted to our PICU between July 1, 2017, and January 1, 2020. SETTING A single-center study based at Erasmus MC Sophia Children's Hospital, a level III interdisciplinary PICU in The Netherlands, providing all pediatric and surgical subspecialties. PATIENTS LSP was defined as those admitted for at least 28 consecutive days. INTERVENTIONS None. MEASUREMENTS Length of PICU stay, diagnosis at admission, length of mechanical ventilation, need for extracorporeal membrane oxygenation, mortality, discharge location after PICU and hospital admission, medical technical support, medication use, and involvement of allied healthcare professionals after hospital discharge. MAIN RESULTS LSP represented a small proportion of total PICU patients (108 patients; 3.2%) but consumed 33% of the total admission days, 47% of all days on extracorporeal membrane oxygenation, and 38% of all days on mechanical ventilation. After discharge, most LSP could be classified as children with medical complexity (CMC) (76%); all patients received discharge medications (median 5.5; range 2-19), most patients suffered from a chronic disease (89%), leaving the hospital with one or more technological devices (82%) and required allied healthcare professional involvement after discharge (93%). CONCLUSIONS LSP consumes a considerable amount of resources in the PICU and its impact extends beyond the point of PICU discharge since the majority are CMC. This indicates complex care needs at home, high family needs, and a high burden on the healthcare system across hospital borders.
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Affiliation(s)
- Gerharda H Boerman
- Division of Pediatric Intensive Care, Department of Neonatology and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Heleen N Haspels
- Division of Pediatric Intensive Care, Department of Neonatology and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Pediatric Intensive Care Unit, Amsterdam Reproduction, and Development, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Transitional Care Unit Consortium, The Netherlands
| | - Matthijs de Hoog
- Division of Pediatric Intensive Care, Department of Neonatology and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Transitional Care Unit Consortium, The Netherlands
| | - Koen F Joosten
- Division of Pediatric Intensive Care, Department of Neonatology and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Transitional Care Unit Consortium, The Netherlands
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4
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Mysore MR, Ranjit S. Organizing and Leading a Multidisciplinary PICU. Indian J Pediatr 2023; 90:251-260. [PMID: 36680728 DOI: 10.1007/s12098-022-04427-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 11/13/2022] [Indexed: 01/22/2023]
Abstract
Pediatric critical care units (PICUs) have come a long way over the past four decades. They continue to be clinical areas that are resource-intensive. PICUs require a team of highly engaged and well-trained professionals working together to change the trajectory of critical illness. Consequently, it requires strong physician and nursing leadership to lead the team of dedicated individuals to perform at the highest level. A dyad of a PICU Medical Director and a PICU Nursing Director is a good construct for administrative leadership. Several options of models exist-open versus closed or a hybrid model. A 24 × 7 coverage of the PICU with skilled personnel is important to provide timely care but is not always possible due to personnel constraints. Indian PICUs have also evolved and made significant strides in their governance and coverage models. Policies and standard operating procedures (SOPs) govern the care that is delivered and may need to be updated regularly. The NABH reviews these as part of their accreditation process. A multidisciplinary committee structure to review aspects of PICU function and outcomes on a regular basis is vital. Certain guiding principles should determine the philosophy of the PICU, and the leaders in the PICU need to model behavior in keeping with these principles. PICU outcomes should be measured and tracked; a root-cause analysis should be triggered when appropriate; and interventions should be made using the PDSA (plan-do-study-act) cycle of process improvement when outcomes fall short of expectations. Adverse events should ideally be disclosed, but this represents a challenge in the current environment. Indian PICUs continue to evolve rapidly, and establishing a database for comparative analysis of outcomes is a natural next step.
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Affiliation(s)
- Mohan Ram Mysore
- Pediatric Critical Care, Boys Town National Research Hospital, 14000 Hospital Rd, Boys Town, NE, 68010, USA.
| | - Suchitra Ranjit
- Pediatric ICU, Apollo Children's Hospital, Chennai, Tamil Nadu, 600006, India
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Stoesslein S, Gramm JD, Bender HU, Müller P, Rabenhorst D, Borasio GD, Führer M. "More life and more days"-patient and care characteristics in a specialized acute pediatric palliative care inpatient unit. Eur J Pediatr 2023; 182:1847-1855. [PMID: 36795188 PMCID: PMC10167193 DOI: 10.1007/s00431-023-04813-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/30/2022] [Accepted: 01/06/2023] [Indexed: 02/17/2023]
Abstract
UNLABELLED Only a few acute hospital inpatient units dedicated to pediatric palliative care (PPC) patients exist today. Clinical data on the patients and care provided at specialized acute PPC inpatient units (PPCUs) are scarce. This study aims at describing patient and care characteristics on our PPCU to learn about the complexity and relevance of inpatient PPC. A retrospective chart analysis was performed on the 8-bed PPCU of the Center for Pediatric Palliative Care of the Munich University Hospital, including demographic, clinical, and treatment characteristics (487 consecutive cases; 201 individual patients; 2016-2020). Data were analyzed descriptively; the chi-square test was used for comparisons. Patients' age (1-35.5 years, median: 4.8 years) and length of stay (1-186 days, median 11 days) varied widely. Thirty-eight percent of patients were admitted repeatedly (range 2-20 times). Most patients suffered from neurological diseases (38%) or congenital abnormalities (34%); oncological diseases were rare (7%). Patients' predominant acute symptoms were dyspnea (61%), pain (54%), and gastrointestinal symptoms (46%). Twenty percent of patients suffered from > 6 acute symptoms, 30% had respiratory support incl. invasive ventilation, 71% had a feeding tube, and 40% had full resuscitation code. In 78% of cases, patients were discharged home; 11% died on the unit. CONCLUSION This study shows the heterogeneity, high symptom burden, and medical complexity of the patients on the PPCU. The high dependency on life-sustaining medical technology points to the parallelism of life-prolonging and palliative treatments that is typical for PPC. Specialized PPCUs need to offer care at the intermediate care level in order to respond to the needs of patients and families. WHAT IS KNOWN • Pediatric patients in outpatient PPC or hospices present with a variety of clinical syndromes and different levels of complexity and care intensity. • There are many children with life-limiting conditions (LLC) in hospitals, but specialized PPC hospital units for these patients are rare and poorly described. WHAT IS NEW • Patients on a specialized PPC hospital unit show a high symptom burden and a high level of medical complexity, including dependency on medical technology and frequent full resuscitation code. • The PPC unit is mainly a place for pain and symptom management as well as crisis intervention, and needs to be able to offer treatment at the intermediate care level.
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Affiliation(s)
- Sophie Stoesslein
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Julia D Gramm
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Hans-Ulrich Bender
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.,Pediatric Palliative Care, Department of Pediatrics, Bern University Hospital, Bern, Switzerland
| | - Petra Müller
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Dorothee Rabenhorst
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.
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Boggs S, de Caen G, Lobos AT, Plint AC, Krmpotic K. Resource Utilization in Children who Receive a Pediatric Intensive Care Unit Consult in the Emergency Department: A Retrospective Cohort Study. J Intensive Care Med 2022; 38:106-113. [PMID: 35795966 DOI: 10.1177/08850666221109176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To describe the characteristics, critical care resource requirements, and outcomes of children who were hospitalized after a Pediatric Intensive Care Unit (PICU) consult in the Emergency Department (ED). METHODS In this single-centre retrospective cohort study, we conducted chart reviews for children (<18 years) hospitalized following a PICU consult in the ED to examine patient characteristics, timing of consult, ED length of stay, Medical Emergency Team (MET) utilization, PICU nursing workload, and critical care interventions for children who were and were not admitted to the PICU. RESULTS During the one-year study period, 247 PICU consults were performed in the ED resulting in 161 (65.2%) direct admissions to PICU and 1 indirect PICU admission via the ward. Of 105 children with complex chronic conditions, 73 (69.5%) were admitted to PICU, including 32 (91.4%) of 35 children with chronic home ventilatory needs, only 2 (6.2%) of whom received a critical care intervention beyond respiratory support. Within 24 h of hospitalization, 112 (69.1%) of 162 PICU admissions received a critical care-specific intervention. Of 86 (34.8%) ward admissions, 16 (18.6%) were reviewed by the MET. Children admitted to the ward had a significantly longer post-consult ED length of stay than children admitted to PICU (median 428 min vs. 130 min; p <0.0001). CONCLUSIONS Over two-thirds of children admitted to PICU from the ED required early critical care interventions, with the remainder potentially benefitting from closer monitoring or a higher frequency of non-critical care interventions than can be reasonably provided on general inpatient wards. More research is needed to evaluate critical care and hospital resource utilization when children are triaged to the ward following a PICU consult in the ED.
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Affiliation(s)
- Samantha Boggs
- Division of Pediatric Critical Care, 27338CHEO, Ottawa, Canada.,274065CHEO Research Institute, Ottawa, Canada
| | | | - Anna-Theresa Lobos
- Division of Pediatric Critical Care, 27338CHEO, Ottawa, Canada.,274065CHEO Research Institute, Ottawa, Canada.,Department of Pediatrics, 6363University of Ottawa, Ottawa, Canada
| | - Amy C Plint
- 274065CHEO Research Institute, Ottawa, Canada.,Department of Pediatrics, 6363University of Ottawa, Ottawa, Canada.,Division of Emergency Medicine, 27338CHEO, Ottawa, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Canada
| | - Kristina Krmpotic
- Department of Pediatric Critical Care, 3682IWK Health, Halifax, Canada.,Department of Critical Care, 3688Dalhousie University, Halifax Canada
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Taylor KL, Frndova H, Szadkowski L, Joffe AR, Parshuram CS. Risk factors for unplanned paediatric intensive care unit admission after anaesthesia—an international multicentre study. Paediatr Child Health 2022; 27:333-339. [DOI: 10.1093/pch/pxac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Unplanned intensive care unit (ICU) admissions are associated with near-miss events, morbidity, and mortality. We describe the rate, resource utilization, and outcomes of paediatric patients urgently admitted directly to ICU post-anaesthesia compared to other sources of unplanned ICU admissions.
Methods
We performed a secondary analysis of data from specialist paediatric hospitals in 7 countries. Patients urgently admitted to the ICU post-anaesthesia were combined and matched with 1 to 3 unique controls from unplanned ICU admissions from other locations by age and hospital. Demographic, clinical, and outcome variables were compared using the Wilcoxon rank-sum test for continuous variables and chi-square or Fisher’s exact test for categorical variables. The effect of admission sources on binary outcomes was estimated using univariable conditional logistic regression models with stratification by matched set of anaesthesia and non-anaesthesia admission sources.
Results
Most admissions were <1 year of age and for respiratory reasons. Admissions post-anaesthesia were shorter, occurred later in the day, and were more likely to be mechanically ventilated. Admissions post-anaesthesia were less likely to have had a previous ICU admission (4.8% compared to 11%, P=0.032) or PIM ‘high-risk diagnosis’ (9.5% versus 17.2%, P=0.035) but there was no difference in the number of subsequent ICU admissions. There was no difference in the PIM severity of illness score and no mortality difference between the groups.
Conclusions
Young children and respiratory indications dominated unplanned ICU admissions post-anaesthesia, which was more likely later in the day and with mechanical ventilation.
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Affiliation(s)
- Katherine L Taylor
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Anesthesia, University of Toronto , Toronto, Ontario , Canada
| | - Helena Frndova
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Leah Szadkowski
- University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Ari R Joffe
- Division of Critical Care Medicine, Department of Pediatrics, University of Alberta , Edmonton, Alberta , Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Critical Care Medicine, Department of Paediatrics, University of Toronto , Toronto, Ontario , Canada
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Ettinger NA, Hill VL, Russ CM, Rakoczy KJ, Fallat ME, Wright TN, Choong K, Agus MSD, Hsu B, Mack E, Day S, Lowrie L, Siegel L, Srinivasan V, Gadepalli S, Hirshberg EL, Kissoon N, October T, Tamburro RF, Rotta A, Tellez S, Rauch DA, Ernst K, Vinocur C, Lam VT, Romito B, Hanson N, Gigli KH, Mauro M, Leonard MS, Alexander SN, Davidoff A, Besner GE, Browne M, Downard CD, Gow KW, Islam S, Saunders Walsh D, Williams RF, Thorne V. Guidance for Structuring a Pediatric Intermediate Care Unit. Pediatrics 2022; 149:186777. [PMID: 35490284 DOI: 10.1542/peds.2022-057009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.
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Affiliation(s)
- Nicholas A Ettinger
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Vanessa L Hill
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine/The Children's Hospital of San Antonio, San Antonio, Texas
| | - Christiana M Russ
- Intermediate Care Program.,Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine J Rakoczy
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Tuft's Children's Hospital, Boston, Massachusetts
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Karen Choong
- Division of Critical Care, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Michael S D Agus
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Benson Hsu
- Division of Critical Care, Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
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Boss RD, Henderson CM, Weiss EM, Falck A, Madrigal V, Shapiro MC, Williams EP, Donohue PK. The Changing Landscape in Pediatric Hospitals: A Multicenter Study of How Pediatric Chronic Critical Illness Impacts NICU Throughput. Am J Perinatol 2022; 39:646-651. [PMID: 33075841 DOI: 10.1055/s-0040-1718572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Pediatric inpatient bed availability is increasingly constrained by the prolonged hospitalizations of children with medical complexity. The sickest of these patients are chronic critically ill and often have protracted intensive care unit (ICU) stays. Numbers and characteristics of infants with chronic critical illness are unclear, which undermines resource planning in ICU's and general pediatric wards. The goal of this study was to describe infants with chronic critical illness at six academic institutions in the United States. STUDY DESIGN Infants admitted to six academic medical centers were screened for chronic, critical illness based on a combination of prolonged and repeated hospitalizations, use of medical technology, and chronic multiorgan involvement. Data regarding patient and hospitalization characteristics were collected. RESULTS Just over one-third (34.8%) of pediatric inpatients across the six centers who met eligibility criteria for chronic critical illness were <12 months of age. Almost all these infants received medical technology (97.8%) and had multiorgan involvement (94.8%). Eighty-six percent (115/134) had spent time in an ICU during the current hospitalization; 31% were currently in a neonatal ICU, 34% in a pediatric ICU, and 17% in a cardiac ICU. Among infants who had been previously discharged home (n = 55), most had been discharged with medical technology (78.2%) and nearly all were still using that technology during the current readmission. Additional technologies were commonly added during the current hospitalization. CONCLUSION Advanced strategies are needed to plan for hospital resource allocation for infants with chronic critical illness. These infants' prolonged hospitalizations begin in the neonatal ICU but often transition to other ICUs and general inpatient wards. They are commonly discharged with medical technology which is rarely weaned but often escalated during subsequent hospitalizations. Identification and tracking of these infants, beginning in the neonatal ICU, will help hospitals anticipate and strategize for inpatient bed management. KEY POINTS · 35% of inpatients with chronic critical illness are infants.. · Nearly 90% of these infants spend some time in an intensive care unit.. · 78% are discharged with medical technology..
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Affiliation(s)
- Renee D Boss
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Berman Institute of Bioethics, Baltimore, Maryland
| | - Carrie M Henderson
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
- Center for Bioethics and Medical Humanities, Jackson, Mississippi
| | - Elliott M Weiss
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington
| | - Alison Falck
- Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa Madrigal
- Department of Pediatrics, Children's National Medical Center, Washington, Dist. of Columbia
| | - Miriam C Shapiro
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | | | - Pamela K Donohue
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Population and Families, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Abstract
OBJECTIVES Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs. DATA SOURCES English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed. STUDY SELECTION Original articles, review articles, and commentaries were considered. DATA EXTRACTION Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review. DATA SYNTHESIS Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured. CONCLUSIONS The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.
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Bhat MA, Soto-Campos G, Scanlon MC. Relationship between Pediatric ICU Length of Stay and 24-Hour-Unplanned Readmission Rate. Health Serv Res 2022; 57:598-602. [PMID: 35149985 DOI: 10.1111/1475-6773.13952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/25/2022] [Accepted: 02/01/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the relationship between Pediatric Intensive Care Unit (PICU) Severity-Adjusted Length of Stay (LOS) and 24-hour-unplanned readmission rate. DATA SOURCE 10-year cohort from 2009-2018 from the Virtual Pediatric Systems (VPS, LLC) database. STUDY DESIGN In this retrospective study, Standardized Length of Stay Ratio was computed for each Pediatric Intensive Care Unit as the ratio of the sum of actual Length of Stay divided by the predicted Length Of Stay for each Pediatric Intensive Care Unit using VPS predictive length of stay model. Correlation between Standardized Length of Stay Ratios and 24-hour-unplanned readmission rates were computed using Pearson's correlation coefficient. PRINCIPAL FINDINGS There was practically no relationship between Standardized Length of Stay Ratio and 24-hour readmission rate (R2 = 0.05). DATA COLLECTION/EXTRACTION METHODS Not Applicable CONCLUSIONS: Severity-Adjusted Length of Stay has no relationship with 24-hour- unplanned readmission rate. These findings suggest that the relationship between PICU severity adjusted LOS and 24-hour- unplanned readmission rate should not be used as a balancing quality measure.
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Affiliation(s)
- Moodakare Ashwini Bhat
- Department of Pediatrics, Medical College of Wisconsin 9000 W Wisconsin Avenue, P O Box 1997, Milwaukee, WI
| | | | - Matthew C Scanlon
- Department of Pediatrics, Medical College of Wisconsin 9000 W Wisconsin Avenue, P O Box 1997, Milwaukee, WI
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12
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Pozzi N, Cogo P, Moretti C, Biban P, Fedeli T, Orfeo L, Gitto E, Mosca F. The care of critically ill infants and toddlers in neonatal intensive care units across Italy and Europe: our proposal for healthcare organization. Eur J Pediatr 2022; 181:1385-1393. [PMID: 35088115 PMCID: PMC8794634 DOI: 10.1007/s00431-021-04349-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/02/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022]
Abstract
UNLABELLED Numerous studies have shown that critically ill infants and toddlers admitted to paediatric intensive care units (PICUs) have a lower mortality than those admitted to adult ICUs. In 2014, there were only 23 registered PICUs in Italy, most of which were located in the north. For this reason, in Italy and elsewhere in Europe, some neonatal ICUs (NICUs) have begun managing critically ill infants and toddlers. Our proposal for healthcare organization is to establish "extended NICUs" in areas where paediatric intensive care beds are lacking. While some countries have opted for a strict division between neonatal and paediatric intensive care units, the model of "extended NICUs" has already been set up in Italy and in Europe. In this instance, the management of critically ill infants and toddlers undoubtedly falls upon neonatologists, who, however, must gain specific knowledge and technical skills in paediatric critical care medicine (PCCM). Postgraduate residencies in paediatrics need to include periods of specific training in neonatology and PCCM. The Italian Society of Neonatology's Early Childhood Intensive Care Study Group is supporting certified training courses for its members involving both theory and practice. CONCLUSION Scientific societies should promote awareness of the issues involved in the intensive management of infants and toddlers in NICUs and the training of all health workers involved. These societies include the Italian Society of Neonatology, the European Society of Paediatric and Neonatal Intensive Care, and the Union of European Neonatal and Perinatal Societies. They should also act in concert with the governmental institutional bodies to establish the standards for the "extended NICUs." WHAT IS KNOWN • The mortality of critically ill infants and toddlers admitted to PICUs is lower than that for those admitted to adult ICUs. • In Italy, there are only a handful of PICUs, located mainly in the north. WHAT IS NEW • Critically ill infants and small toddlers can be managed in "extended NICUs" in areas with a lack of paediatric intensive care beds. • "Extended NICUs" is our proposal for healthcare organization to compensate for the paucity of paediatric intensive care beds, but neonatologists must be trained to provide them with specific knowledge and technical skills in PCCM.
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Affiliation(s)
- Nicola Pozzi
- Neonatal Intensive Care Unit, Department of Maternal and Child Health, San Pio Hospital, Via dell'Angelo 1, Benevento, 83013, Italy.
| | - Paola Cogo
- Department of Medicine (DAME), Division of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, P.zzale S. Maria della Misericordia, 15, Udine, 33100 Italy
| | - Corrado Moretti
- Emeritus Consultant in Paediatrics, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Paolo Biban
- Department of Neonatal and Paediatric Critical Care, Verona University Hospital, Verona, Italy
| | - Tiziana Fedeli
- Neonatal Intensive Care Unit, Fondazione Monza e Brianza per il Bambino e la sua Mamma and Azienda Socio Sanitaria Territoriale-Monza, Monza, Italy
| | - Luigi Orfeo
- Neonatal Intensive Care Unit, San Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
| | - Eloisa Gitto
- Neonatal and Paediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi, ” University of Messina, Via Consolare Valeria, 1, Messina, 98125 Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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13
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Kobussen TA, Hansen G, Brockman RJ, Holt TR. Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study. Crit Care Nurse 2021; 40:e10-e17. [PMID: 33000135 DOI: 10.4037/ccn2020710] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Children with complex chronic conditions present unique challenges to the pediatric intensive care unit, including prolonged length of stay, complex medical regimens, and complicated family dynamics. OBJECTIVES To examine perspectives of pediatric intensive care unit health care providers regarding pediatric patients with complex chronic conditions, and to explore potential opportunities to improve these patients' care. METHODS A prospective mixed-methods sequential explanatory study was conducted in a tertiary medical-surgical pediatric intensive care unit using surveys performed with REDCap (Research Electronic Data Capture) followed by semistructured interviews. RESULTS The survey response rate was 70.6% (77 of 109). Perspectives of health care providers did not vary with duration of work experience. Ten semistructured interviews were conducted. Eight overarching themes emerged from the interviews: (1) the desire for increased formal education specific to pediatric complex chronic care patients; (2) designation of a primary intensivist; (3) modifying delivery of care to include a discrete location for care provision; (4) establishing daily, short-term, and long-term goals; (5) monitoring and documenting care milestones; (6) strengthening patient and family communications with the health care team; (7) optimizing discharge coordination and planning; and (8) integrating families into care responsibilities. CONCLUSIONS Pediatric intensive care unit health care providers' perspectives of pediatric patients with complex chronic conditions indicated opportunities to refine the care provided by establishing daily goals, coordinating discharge planning, and creating occasions for close communication between patients, families, and providers.
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Affiliation(s)
- Taylor A Kobussen
- Taylor A. Kobussen is a pediatric resident, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gregory Hansen
- Gregory Hansen is a pediatric intensive care physician, Department of Pediatrics, University of Saskatchewan
| | - Rebecca J Brockman
- Rebecca J. Brockman is a pediatric intensive care and transport nurse and nurse educator, Department of Pediatrics, University of Saskatchewan
| | - Tanya R Holt
- Tanya R. Holt is Director of the pediatric intensive care unit, Department of Pediatrics, University of Saskatchewan
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14
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Cho H, Wendelberger B, Gausche‐Hill M, Wang HE, Hansen M, Bosson N, Lewis RJ. ICU-free days as a more sensitive primary outcome for clinical trials in critically ill pediatric patients. J Am Coll Emerg Physicians Open 2021; 2:e12479. [PMID: 34263247 PMCID: PMC8262607 DOI: 10.1002/emp2.12479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 05/06/2021] [Accepted: 05/24/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Our objective was to assess the association between intensive care unit (ICU)-free days and patient outcomes in pediatric prehospital care and to evaluate whether ICU-free days is a more sensitive outcome measure for emergency medical services research in this population. METHODS This study used data from a previous pediatric prehospital trial. The original study enrolled patients ≤12 years of age and compared bag-valve-mask-ventilation (BVM) versus endotracheal intubation (ETI) during prehospital resuscitation. For the current study, we defined ICU-free days as 30 minus the number of days in the ICU (range, 0-30 days) and assigned 0 ICU-free days for death within 30 days. We compared ICU-free days between the original study treatment groups (BVM vs ETI) and with the original trial outcomes of survival to hospital discharge and Pediatric Cerebral Performance Category (PCPC). RESULTS Median ICU-free days for the BVM group (n = 404) versus ETI group (n = 416) was not statistically different: 0 ICU-free days (interquartile range, 0-10) versus 0 (0-0), P = 0.219. Median ICU-free days were greater for BVM group in 3 subgroups: foreign body aspiration 30 (0-30) versus 0 (0-21), P = 0.028; child maltreatment 0 (0-14.2) versus 0 (0-0), P = 0.004; and respiratory arrest 25 (1-29) versus 7.5 (0-27.7), P = 0.015. In the original trial, neither survival nor PCPC demonstrated differences in all 3 subgroups-survival was greater with BVM for child maltreatment and respiratory arrest and favorable PCPC was greater with BVM for foreign body aspiration. Overall, in the current study, patients with more ICU-free days also had greater survival to hospital discharge and more favorable PCPC scores. CONCLUSIONS This initial study of the association between ICU-free days and patient outcomes during prehospital pediatric resuscitation appears to support the use of ICU-free days as a clinical endpoint in this population. ICU-free days may be more sensitive than either mortality or PCPC alone while capturing aspects of both measures.
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Affiliation(s)
- Hanjin Cho
- Department of Emergency MedicineCollege of MedicineKorea UniversitySeoulKorea
| | | | - Marianne Gausche‐Hill
- Los Angeles County Emergency Medical Services AgencySanta Fe SpringsCaliforniaUSA
- Department of Emergency MedicineHarbor‐UCLA Medical CenterTorranceCaliforniaUSA
- Departments of PediatricsHarbor‐UCLA Medical CenterTorranceCaliforniaUSA
- Department of Emergency MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Henry E Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Matthew Hansen
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOregonUSA
| | - Nichole Bosson
- Los Angeles County Emergency Medical Services AgencySanta Fe SpringsCaliforniaUSA
- Department of Emergency MedicineHarbor‐UCLA Medical CenterTorranceCaliforniaUSA
- Department of Emergency MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Roger J. Lewis
- Berry Consultants, LLCAustinTexasUSA
- Department of Emergency MedicineHarbor‐UCLA Medical CenterTorranceCaliforniaUSA
- Department of Emergency MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
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15
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Cheng DR, Hui C, Langrish K, Beck CE. Anticipating Pediatric Patient Transfers From Intermediate to Intensive Care. Hosp Pediatr 2021; 10:347-352. [PMID: 32220935 DOI: 10.1542/hpeds.2019-0260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To explore characteristics of patients who were admitted to the intermediate care (IC) unit at a tertiary academic institution. In particular, we sought to compare the characteristics of IC patients who were transferred with the characteristics of those who were not transferred to PICU care and evaluate predictors of patient transfer. METHODS Data were collected on all admitted IC patients between July 2016 and June 2018. Patients whose index IC admission was from the PICU were excluded. Data collected included demographics and physiologic characteristics: heart rate, respiratory rate, temperature, oxygen therapy, as well as Bedside Pediatric Early Warning System (BPEWS) score. RESULTS In this time period, 427 eligible patient visits occurred, with 66 patients (15.46%) being transferred to the PICU. Patients were commonly transferred early in their IC course (1.41 days into admission [0.66-3.87]); transferred patients had higher median admission BPEWS scores (7 [4.25-9] vs 5 [3-7]; P < .01). In the univariate analysis, no individual physiologic characteristic was predictive for transfer. In the multivariate analysis, BPEWS (P < .001) and need for any form of respiratory support (P = .04) were significant predictive factors for transfer (R 2 = 0.56). CONCLUSIONS The need for close monitoring of physiologic parameters remains paramount, especially in the first 48 hours of admission, in predicting the need for transfer from the IC to PICU. The need for any form of respiratory support is predictive of transfer. Situational awareness and assessment including BPEWS score is of critical importance.
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Affiliation(s)
- Daryl R Cheng
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; .,Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Carlton, Victoria, Australia; and
| | | | - Kate Langrish
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
| | - Carolyn E Beck
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics.,Pediatric Outcomes Research Team and
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16
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Lavin JM, Sawardekar A, Sohn L, Jones RC, Fusilero L, Iafelice ME, Molenda L. Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach. Laryngoscope 2020; 131 Suppl 1:S1-S10. [PMID: 32438522 DOI: 10.1002/lary.28760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/16/2020] [Accepted: 04/30/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. STUDY DESIGN Quality improvement initiative. METHODS Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. RESULTS In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. CONCLUSIONS Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. LEVEL OF EVIDENCE N/A Laryngoscope, 131:S1-S10, 2021.
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Affiliation(s)
- Jennifer M Lavin
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Amod Sawardekar
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Lisa Sohn
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Roderick C Jones
- Department of Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Laurely Fusilero
- Center for Excellence, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Mary E Iafelice
- Department of Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Laura Molenda
- Department of Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
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17
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Sfriso F, Biban P, Paglietti MG, Giuntini L, Rufini E, Mondardini MC, Zaglia F, Cutrera R, De Zan F, Amigoni A. Distribution and characteristics of Italian paediatric intermediate care units in Italy: A national survey. Acta Paediatr 2020; 109:1062-1063. [PMID: 31730257 DOI: 10.1111/apa.15091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Francesca Sfriso
- Department of Woman's and Child's Health University Hospital of Padova Padova Italy
| | - Paolo Biban
- Department of Neonatal and Paediatric Critical Care University Hospital of Verona Verona Italy
| | | | | | | | | | | | | | - Francesca De Zan
- Department of Woman's and Child's Health University Hospital of Padova Padova Italy
| | - Angela Amigoni
- Department of Woman's and Child's Health University Hospital of Padova Padova Italy
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18
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Agulnik A, Nadkarni A, Mora Robles LN, Soberanis Vasquez DJ, Mack R, Antillon-Klussmann F, Rodriguez-Galindo C. Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource-limited hospitals. Pediatr Blood Cancer 2018; 65:e27076. [PMID: 29637687 DOI: 10.1002/pbc.27076] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/12/2018] [Accepted: 03/12/2018] [Indexed: 12/25/2022]
Abstract
Pediatric oncology patients hospitalized in resource-limited settings are at high risk for clinical deterioration resulting in mortality. Intermediate care units (IMCUs) provide a cost-effective alternative to pediatric intensive care units (PICUs). Inappropriate IMCU triage, however, can lead to poor outcomes and suboptimal resource utilization. In this study, we sought to characterize patients with clinical deterioration requiring unplanned transfer to the IMCU in a resource-limited pediatric oncology hospital. Patients requiring subsequent early PICU transfer had longer PICU length of stay. PEWS results prior to IMCU transfer were higher in patients requiring early PICU transfer, suggesting PEWS can aid in triage between IMCU and PICU care.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Division of Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Anisha Nadkarni
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland, USA
| | | | | | - Ricardo Mack
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Federico Antillon-Klussmann
- Hematology/Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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