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Zoham MH, Mohammadpour M, Yaghmaie B, Hadizadeh A, Eskandarizadeh Z, Beigi EH. Validity of Pediatric Early Warning Score in Predicting Unplanned Pediatric Intensive Care Unit Readmission. J Pediatr Intensive Care 2023; 12:312-318. [PMID: 37970145 PMCID: PMC10631837 DOI: 10.1055/s-0041-1735297] [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: 02/13/2021] [Accepted: 07/15/2021] [Indexed: 10/20/2022] Open
Abstract
Despite the fact that unscheduled readmission to pediatric intensive care units (PICUs) has significant adverse consequences, there is a need for a predictive tool appropriate for use in the clinical setting. The aim of this study was to assess the ability of the modified Brighton pediatric early warning score (PEWS) to identify children at high risk for early unplanned readmission. In this retrospective cohort study, all patients aged 1 month to 18 years of age discharged from PICUs of two tertiary children's hospitals during the study interval were enrolled. Apart from demographic data, the association between PEWS and early readmission, defined as readmission within 48 hours of discharge, was analyzed by multivariable logistic regression. From 416 patients, 27 patients had early PICU readmission. Patients who experienced readmission were significantly younger than the controls. (≤12 months, 70.4 vs. 39.1%, p = 0.001) Patients who were admitted from the emergency room (66.7 and 33.3% for emergency department (ED) and floor, respectively, p = 0.012) had higher risk of early unplanned readmission. PEWS at discharge was significantly higher in patients who experienced readmission (3.07 vs. 0.8, p < 0.001). A cut-off PEWS of 2, with sensitivity 85.2% and specificity 78.1%, determined the risk of unplanned readmission. Each 1-point increase in the PEWS at discharge significantly increases the risk of readmission (odds ratio [OR] = 3.58, 95% confidence interval [CI]: [2.42-5.31], p < 0.001). PEWS can be utilized as a useful predictive tool regarding predicting unscheduled readmission in PICU. Further large-scale studies are needed to determine its benefits in clinical practice.
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Affiliation(s)
- Mojdeh Habibi Zoham
- Division of Pediatric Intensive Care, Bahrami Children Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Mohammadpour
- Division of Pediatric Intensive Care, Children's Medical Center Hospital (Center of Excellence), Tehran University of Medical Sciences, Tehran, Iran
| | - Bahareh Yaghmaie
- Division of Pediatric Intensive Care, Children's Medical Center Hospital (Center of Excellence), Tehran University of Medical Sciences, Tehran, Iran
| | - Amere Hadizadeh
- Division of Pediatric Intensive Care, Bahrami Children Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Eskandarizadeh
- Division of Pediatric Intensive Care, Bahrami Children Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Effat H. Beigi
- Division of Pediatric Intensive Care, Bahrami Children Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Edwards JD, Wocial LD, Madrigal VN, Moon MM, Ramey-Hunt C, Walter JK, Baird JD, Leland BD. Continuity Strategies for Long-Stay PICU Patients: Consensus Statements From the Lucile Packard Foundation PICU Continuity Panel. Pediatr Crit Care Med 2023; 24:849-861. [PMID: 38415714 PMCID: PMC10540754 DOI: 10.1097/pcc.0000000000003308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
OBJECTIVES To develop consensus statements on continuity strategies using primary intensivists, primary nurses, and recurring multidisciplinary team meetings for long-stay patients (LSPs) in PICUs. PARTICIPANTS The multidisciplinary Lucile Packard Foundation PICU Continuity Panel comprising parents of children who had prolonged PICU stays and experts in several specialties/professions that care for children with medical complexity in and out of PICUs. DESIGN/METHODS We used modified RAND Delphi methodology, with a comprehensive literature review, Delphi surveys, and a conference, to reach consensus. The literature review resulted in a synthesized bibliography, which was provided to panelists. We used an iterative process to generate draft statements following panelists' completion of four online surveys with open-ended questions on implementing and sustaining continuity strategies. Panelists were anonymous when they voted on revised draft statements. Agreement of 80% constituted consensus. At a 3-day virtual conference, we discussed, revised, and re-voted on statements not reaching or barely reaching consensus. We used Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of the evidence and rate the statements' strength. The Panel also generated outcome, process, and balancing metrics to evaluate continuity strategies. RESULTS The Panel endorsed 17 consensus statements in five focus areas of continuity strategies (Eligibility Criteria, Initiation, Standard Responsibilities, Resources Needed to Implement, Resources Needed to Sustain). The quality of evidence of the statements was low to very low, highlighting the limited evidence and the importance of panelists' experiences/expertise. The strength of the statements was conditional. An extensive list of potential evaluation metrics was generated. CONCLUSIONS These expert/parent-developed consensus statements provide PICUs with novel summaries on how to operationalize, implement, and sustain continuity strategies for LSP, a rapidly growing, vulnerable, resource-intensive population in PICUs.
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Affiliation(s)
- Jeffrey D Edwards
- Section of Critical Care, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY
| | - Lucia D Wocial
- John J. Lynch, MD Center for Ethics, MedStar Washington Hospital Center, Washington, DC
- Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN
| | - Vanessa N Madrigal
- Division of Critical Care Medicine, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
- Pediatric Ethics Program, Children's National Medical Center, Washington, DC
| | - Michelle M Moon
- Palliative Care and Symptom Management, Swedish Health Systems, Issaquah, Washington, DC
| | - Cheryl Ramey-Hunt
- Integrated Care Management, Case Management, and Social Work, Indiana University Health and Riley Hospital for Children, Indianapolis, IN
| | - Jennifer K Walter
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Pediatric Advanced Care Team, Justin Michael Ingerman Center for Palliative Care, The Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Pediatric Clinical Effectiveness and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer D Baird
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, CA
| | - Brian D Leland
- Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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Sharp EA, Wang L, Hall M, Berry JG, Forster CS. Frequency, Characteristics, and Outcomes of Patients Requiring Early PICU Readmission. Hosp Pediatr 2023; 13:678-688. [PMID: 37476936 PMCID: PMC10375031 DOI: 10.1542/hpeds.2022-007100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVES Readmission to the PICU is associated with worse outcomes, but factors associated with PICU readmission within the same hospitalization remain unclear. We sought to describe the prevalence of, and identify factors associated with, early PICU readmission. METHODS We performed a retrospective analysis of PICU admissions for patients aged 0 to 26 years in 48 tertiary care children's hospitals between January 1, 2016 and December 31, 2019 in the Pediatric Health Information System. We defined early readmission as return to the PICU within 2 calendar days of floor transfer during the same hospitalization. Generalized linear mixed models were used to analyze associations between patient and clinical variables, including complex chronic conditions (CCC) and early PICU readmission. RESULTS The results included 389 219 PICU admissions; early PICU readmission rate was 2.5%. Factors with highest odds of early PICU readmission were CCC, with ≥4 CCCs (reference: no CCC[s]) as highest odds of readmission (adjusted odds ratio [95% confidence interval]: 4.2 [3.8-4.5]), parenteral nutrition (2.3 [2.1-2.4]), and ventriculoperitoneal shunt (1.9 [1.7-2.2]). Factors with decreased odds of PICU readmission included extracorporeal membrane oxygenation (0.4 [0.3-0.6]) and cardiopulmonary resuscitation (0.8 [0.7-0.9]). Patients with early PICU readmissions had longer overall length of stay (geometric mean [geometric SD]: 18.2 [0.9] vs 5.0 [1.1] days, P < .001) and increased odds of mortality (1.7 [1.5-1.9]). CONCLUSIONS Although early PICU readmissions within the same hospitalization are uncommon, they are associated with significantly worse clinical outcomes. Patients with medical complexity and technology dependence are especially vulnerable.
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Affiliation(s)
- Eleanor A. Sharp
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Li Wang
- Clinical and Translational Science Institute, Office of Clinical Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Jay G. Berry
- Complex Care, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Catherine S. Forster
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Zhu JL, Xu XM, Yin HY, Wei JR, Lyu J. Development and validation of a nomogram for predicting hospitalization longer than 14 days in pediatric patients with ventricular septal defect-a study based on the PIC database. Front Physiol 2023; 14:1182719. [PMID: 37469560 PMCID: PMC10352838 DOI: 10.3389/fphys.2023.1182719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/30/2023] [Indexed: 07/21/2023] Open
Abstract
Background: Ventricular septal defect is a common congenital heart disease. As the disease progresses, the likelihood of lung infection and heart failure increases, leading to prolonged hospital stays and an increased likelihood of complications such as nosocomial infections. We aimed to develop a nomogram for predicting hospital stays over 14 days in pediatric patients with ventricular septal defect and to evaluate the predictive power of the nomogram. We hope that nomogram can provide clinicians with more information to identify high-risk groups as soon as possible and give early treatment to reduce hospital stay and complications. Methods: The population of this study was pediatric patients with ventricular septal defect, and data were obtained from the Pediatric Intensive Care Database. The resulting event was a hospital stay longer than 14 days. Variables with a variance inflation factor (VIF) greater than 5 were excluded. Variables were selected using the least absolute shrinkage and selection operator (Lasso), and the selected variables were incorporated into logistic regression to construct a nomogram. The performance of the nomogram was assessed by using the area under the receiver operating characteristic curve (AUC), Decision Curve Analysis (DCA) and calibration curve. Finally, the importance of variables in the model is calculated based on the XGboost method. Results: A total of 705 patients with ventricular septal defect were included in the study. After screening with VIF and Lasso, the variables finally included in the statistical analysis include: Brain Natriuretic Peptide, bicarbonate, fibrinogen, urea, alanine aminotransferase, blood oxygen saturation, systolic blood pressure, respiratory rate, heart rate. The AUC values of nomogram in the training cohort and validation cohort were 0.812 and 0.736, respectively. The results of the calibration curve and DCA also indicated that the nomogram had good performance and good clinical application value. Conclusion: The nomogram established by BNP, bicarbonate, fibrinogen, urea, alanine aminotransferase, blood oxygen saturation, systolic blood pressure, respiratory rate, heart rate has good predictive performance and clinical applicability. The nomogram can effectively identify specific populations at risk for adverse outcomes.
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Affiliation(s)
- Jia-Liang Zhu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiao-Mei Xu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hai-Yan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jian-Rui Wei
- Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
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Daoust D, Dodin P, Sy E, Lau V, Roumeliotis N. Prevalence and Readmission Rates of Discharge Directly Home From the PICU: A Systematic Review. Pediatr Crit Care Med 2023; 24:62-71. [PMID: 36594800 DOI: 10.1097/pcc.0000000000003114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Critically ill patients are increasingly being discharged directly home from PICU as opposed to discharged home, via the ward. The objective was to assess the prevalence, safety, and satisfaction of discharge directly home from PICUs. DATA SOURCES We searched PubMed, Medline, EMBASE, PsycINFO, and CINAHL for studies published between January 1991 and June 2021. STUDY SELECTION We included observational or randomized studies, of children up to 18 years old, that reported on the prevalence, safety, or satisfaction of discharge directly home from the PICU, compared with the ward. Safety outcomes included readmission, unplanned visits to hospital, and any adverse events. We excluded case series, reviews, and studies discharging patients to other facilities. DATA EXTRACTION Two independent reviewers evaluated 88 full-text articles; five studies met eligibility (362,868 patients). Only one study had discharge directly home as a primary outcome. DATA SYNTHESIS Prevalence of discharge directly to home from the PICU ranged from less than 1% to 23% (random effects proportion 7.7 [95% CI, 1.3-18.6]). Readmissions to the PICU (only safety outcome) were significantly lower in the discharge directly home group compared with the ward group, in two of three studies (p < 0.0001). No studies reported on patient or family satisfaction. CONCLUSIONS The prevalence of discharge directly home from the PICU ranges from 1% to 23%. PICU readmission rates do not appear to increase after discharge directly home. Caution is needed in the interpretation of the results, given the significant heterogeneity of the included studies. Further high-quality studies are needed to evaluate the safety of discharge directly home from the PICU and support families in this transition.
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Affiliation(s)
- Daphne Daoust
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Philippe Dodin
- Medical Librarian, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, QC, Canada
| | - Eric Sy
- Department of Medicine, College of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Vincent Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nadia Roumeliotis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
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Roumeliotis N, Hassine CH, Ducruet T, Lacroix J. Discharge Directly Home From the PICU: A Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:e9-e19. [PMID: 36053070 DOI: 10.1097/pcc.0000000000003061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Healthcare constraints with decreasing bed availability cause strain in acute care units, and patients are more frequently being discharged directly home. Our objective was to describe the population, predictors, and explore PICU readmission rates of patients discharged directly home from PICU, compared with those discharge to the hospital ward, then home. DESIGN An observational cohort study. SETTING Children admitted to the PICU of CHU Sainte-Justine, between January 2014 and 2020. PATIENTS Patients less than 18 years old, who survived their PICU stay, and were discharged directly home or to an inpatient ward. Patients discharged directly home were compared with patients discharged to the ward using descriptive statistics. Logistic regression was used to identify factors associated with home discharge. Propensity scores were used to compare PICU readmission rates in patients discharged directly home to those discharged to the ward. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 5,531 admissions included, 594 (10.7%) were discharged directly home from the PICU. Patients who were more severe ill (odds ratio [OR], 0.93; 95% CI, 0.90-0.97), had invasive ventilation (OR, 0.70; 95% CI, 0.53-0.92), or had vasoactive agents (OR, 0.70; 95% CI, 0.53-0.92) were less likely to be discharged directly home. Diagnoses associated with discharge directly home were acute intoxication, postoperative ear-nose-throat care, and shock states. There was no difference in the rate of readmission to PICU at 2 (relative risk [RR], 0.20 [95% CI, 0.02-1.71]) and 28 days (RR, 1.20 [95% CI, 0.61-3.36]) between propensity matched patients discharged to the ward for 2 or less days, compared with those discharged directly home. CONCLUSION Discharge directly home from the PICU is increasing locally. The population includes less severely ill patients with rapidly resolving diagnoses. Rates of PICU readmission between patients discharged directly home from the PICU versus to ward are similar, but safety of the practice requires ongoing evaluation.
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Affiliation(s)
- Nadia Roumeliotis
- Division of Critical care Medicine, Department of Pediatrics CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montréal, QC, Canada
| | - Chatila Hadj Hassine
- Division of Critical care Medicine, Department of Pediatrics CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Thierry Ducruet
- Unité de Recherche Clinique Appliqué (URCA), Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Jacques Lacroix
- Division of Critical care Medicine, Department of Pediatrics CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montréal, QC, Canada
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Abstract
OBJECTIVES Delirium in critically ill children is associated with increased in-hospital morbidity and mortality. Little is known about the lingering effects of pediatric delirium in survivors after hospital discharge. The primary objective of this study was to determine whether children with delirium would have a higher likelihood of all-cause PICU readmission within 1 calendar year, when compared with children without delirium. DESIGN Retrospective cohort study. SETTING Tertiary care, mixed PICU at an urban academic medical center. PATIENTS Index admissions included all children admitted between September 2014 and August 2015. For each index admission, any readmission occurring within 1 year after PICU discharge was captured. INTERVENTION Every child was screened for delirium daily throughout the PICU stay. MEASUREMENTS AND MAIN RESULTS Among 1,145 index patients, 166 children (14.5%) were readmitted at least once. Bivariate analyses compared patients readmitted within 1 year of discharge with those not readmitted: complex chronic conditions (CCCs), increased severity of illness, longer PICU length of stay, need for mechanical ventilation, age less than 6 months, and a diagnosis of delirium were all associated with subsequent readmission. A multivariable logistic regression model was constructed to describe adjusted odds ratios for readmission. The primary exposure variable was number of delirium days. After controlling for confounders, critically ill children who experienced greater than 2 delirium days on index admission were more than twice as likely to be readmitted (adjusted odds ratio, 2.2; CI, 1.1-4.4; p = 0.023). A dose-response relationship was demonstrated as children with longer duration of delirium had increased odds of readmission. CONCLUSIONS In this cohort, delirium duration was an independent risk factor for readmission in critically ill children. Future research is needed to determine if decreasing prevalence of delirium during hospitalization can decrease need for PICU readmission.
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Affiliation(s)
| | - Elizabeth A Mauer
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Linda M Gerber
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
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Jaberi E, Kassai B, Berard A, Grenet G, Nguyen KA. Drug-related risk of hospital readmission in children with chronic diseases, a systematic review. Therapie 2022:S0040-5957(22)00164-0. [PMID: 36192191 DOI: 10.1016/j.therap.2022.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/01/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Drug-related problems (DRPs) are one of the leading causes of hospital readmissions. Children with chronic diseases are more likely to experience DRPs than adults. The burden and characteristics of drug-related readmissions at and after hospital discharge in children remain unclear. OBJECTIVE We aimed to summarize the impact of DRPs at and after hospital discharge on the risk of readmissions in children with chronic diseases. METHODS We conducted a systematic review searching PubMed from inception until January 2022. Study selection criteria were studies assessing the impact of different factors at discharge and after discharge on the risk of hospital readmissions in children with chronic diseases, reporting an assessment of DRPs. DRP could be the only risk factor assessed or one among others. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Exposure (ROBINS-E) tool. We summarized the qualitative impact of the reported DRPs on hospital readmission as conclusive (significant association) or inconclusive. RESULTS Of the 4734 studies initially identified, 13 met inclusion criteria. Eleven studies were retrospective, using electronic health records. The studies assessed the impact of DRPs at or after discharge according to the type of medication (in 6 studies), number of medication (in 5 studies) and medication nonadherence (in 2 studies). From the 44 reported associations between DRPs and the risk of readmission 26 (59% [95% CI, 43%-73%]) were conclusive, of which 81% increased the risk and 19% decreased the risk, and 17 (39% [95% CI, 24%-55%]) were inconclusive. CONCLUSION The impact of DRPs on hospital readmissions in children with chronic diseases displayed conflicting results, estimated associations having potentially a serious risk of bias. We need more evidence with a lower risk of bias.
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Patel AK, Gai J, Trujillo-Rivera E, Faruqe F, Kim D, Bost JE, Pollack MM. National Intravenous Acetaminophen Use in Pediatric Inpatients From 2011–2016. J Pediatr Pharmacol Ther 2022; 27:358-365. [DOI: 10.5863/1551-6776-27.4.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
To 1) determine current intravenous (IV) acetaminophen use in pediatric inpatients; and 2) determine the association between opioid medication duration when used with or without IV acetaminophen.
METHODS
A retrospective analysis of pediatric inpatients exposed to IV acetaminophen from January 2011 to June 2016, using the national database Health Facts.
RESULTS
Eighteen thousand one hundred ninety-seven (2.0%) of 893,293 pediatric inpatients received IV acetaminophen for a median of 14 doses per patient (IQR, 8–56). A greater proportion of IV acetaminophen patients were admitted to the intensive care unit (ICU) (14.8% vs 5.1%, p < 0.0001), received positive pressure ventilation (2.0% vs 1.5%, p < 0.0001), had a higher hospital mortality rate (0.9% vs 0.3%, p < 0.0001), and were operative (35.5% vs 12.8%, p < 0.001) than those not receiving IV acetaminophen. The most common operations associated with IV acetaminophen use were musculoskeletal and digestive system operations. Prescription of IV acetaminophen increased over time, both in prescription rates and number of per patient doses. Of the 18,197 patients prescribed IV acetaminophen, 16,241 (89.2%) also were prescribed opioids during their hospitalization. A multivariate analysis revealed patients prescribed both IV acetaminophen and opioids had a 54.8% increase in opioid duration as compared with patients who received opioids alone.
CONCLUSIONS
This is the first study to assess IV acetaminophen prescription practices for pediatric inpatients. Intravenous acetaminophen prescription was greater in the non-operative pediatric inpatient population than operative patients. Intravenous acetaminophen prescription was associated with an increase in opioid duration as compared with patients who received opioids alone, suggesting that it is commonly used to supplement opioids for pain relief.
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Affiliation(s)
- Anita K. Patel
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Jiaxiang Gai
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Eduardo Trujillo-Rivera
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Farhana Faruqe
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
| | - Dongkyu Kim
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - James E. Bost
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Murray M. Pollack
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
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Abstract
OBJECTIVES To describe the demographic, clinical, outcome, and cost differences between children with high-frequency PICU admission and those without. DESIGN Retrospective, cross-sectional cohort study. SETTING United States. PATIENTS Children less than or equal to 18 years old admitted to PICUs participating in the Pediatric Health Information System database in 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We assessed survivors of PICU admissions for repeat PICU admissions within a year of their index visit. Children with greater than or equal to 3 PICU admissions within a year were classified as high-frequency PICU utilization (HFPICU). We compared demographic, clinical, outcome, and cost characteristics between children with HFPICU and those with only an index or two admissions per year (nHFPICU). Of 95,465 children who survived an index admission, 5,880 (6.2%) met HFPICU criteria. HFPICU patients were more frequently younger, technology dependent, and publicly insured. HFPICU patients had longer lengths of stay and were more frequently discharged to a rehabilitation facility or with home nursing services. HFPICU patients accounted for 24.8% of annual hospital utilization costs among patients requiring PICU admission. Time to readmission for children with HFPICU was 58% sooner (95% CI, 56-59%) than in those with nHFPICU with two admissions using an accelerated failure time model. Among demographic and clinical factors that were associated with development of HFPICU status calculated from a multivariable analysis, the greatest effect size was for time to first readmission within 82 days. CONCLUSIONS Children identified as having HFPICU account for 6.2% of children surviving an index ICU admission. They are a high-risk patient population with increased medical resource utilization during index and subsequent ICU admissions. Patients readmitted within 82 days of discharge should be considered at higher risk of HFPICU status. Further research, including validation and exploration of interventions that may be of use in this patient population, are necessary.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, MN
| | - Manzilat Akande
- Division of Pediatric Critical Care, Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, OK
| | - Denise M Goodman
- Division of Pediatric Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Maddux AB, Mourani PM, Miller K, Carpenter TC, LaVelle J, Pyle LL, Watson RS, Bennett TD. Identifying Long-Term Morbidities and Health Trajectories After Prolonged Mechanical Ventilation in Children Using State All Payer Claims Data. Pediatr Crit Care Med 2022; 23:e189-e198. [PMID: 35250002 PMCID: PMC9058185 DOI: 10.1097/pcc.0000000000002909] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify postdischarge outcome phenotypes and risk factors for poor outcomes using insurance claims data. DESIGN Retrospective cohort study. SETTING Single quaternary center. PATIENTS Children without preexisting tracheostomy who required greater than or equal to 3 days of invasive mechanical ventilation, survived the hospitalization, and had postdischarge insurance eligibility in Colorado's All Payer Claims Database. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used unsupervised machine learning to identify functional outcome phenotypes based on claims data representative of postdischarge morbidities. We assessed health trajectory by comparing change in the number of insurance claims between quarters 1 and 4 of the postdischarge year. Regression analyses identified variables associated with unfavorable outcomes. The 381 subjects had median age 3.3 years (interquartile range, 0.9-12 yr), and 147 (39%) had a complex chronic condition. Primary diagnoses were respiratory (41%), injury (23%), and neurologic (11%). We identified three phenotypes: lower morbidity (n = 300), higher morbidity (n = 62), and 1-year nonsurvivors (n = 19). Complex chronic conditions most strongly predicted the nonsurvivor phenotype. Longer PICU stays and tracheostomy placement most strongly predicted the higher morbidity phenotype. Patients with high but improving postdischarge resource use were differentiated by high illness severity and long PICU stays. Patients with persistently high or increasing resource use were differentiated by complex chronic conditions and tracheostomy placement. CONCLUSIONS New morbidities are common after prolonged mechanical ventilation. Identifying phenotypes at high risk of postdischarge morbidity may facilitate prognostic enrichment in clinical trials.
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Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s, Little Rock, AR
| | - Kristen Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Todd C. Carpenter
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | | | - Laura L. Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Department of Biostatistics and Informatics, Colorado School of Public Health, Children’s Hospital Colorado, Aurora, CO
| | - R. Scott Watson
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington School of Medicine and Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Tellen D. Bennett
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
- Department of Pediatrics, Section of Informatics and Data Science, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
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Bond DM, Ampt A, Festa M, Teo A, Nassar N, Schell D. Factors associated with admission of children to an intensive care unit and readmission to hospital within 28 days of discharge: A population-based study. J Paediatr Child Health 2022; 58:579-587. [PMID: 34704639 DOI: 10.1111/jpc.15766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 09/12/2021] [Accepted: 09/20/2021] [Indexed: 11/28/2022]
Abstract
AIM Hospital readmissions within 28 days are an important performance measurement of quality and safety of health care. The aims of this study were to examine the rates, trends and characteristics of paediatric intensive care unit admissions, and factors associated with readmissions to hospital within 28 days of discharge. METHODS This retrospective, population-based record linkage study included all children ≥28 days and <16 years old admitted to an intensive care unit (ICU) in a New South Wales (NSW) public hospital from 2004 to 2013. Data were sourced from the NSW Admitted Patients Data Collection and the NSW Registry of Births, Deaths and Marriages, Death Registration. RESULTS We identified 21 200 ICU admissions involving 17 130 children. Admissions increased by 24% over the study period with the greatest increase attributed to respiratory and musculoskeletal conditions. A higher proportion of children were <5 years, male, lived in major cities, were publicly insured and had chronic conditions. The median length of ICU stay was 42 h and overall hospital stay was 7 days. There were 905 deaths, two-thirds during the index admission with the leading causes being injuries, cancer and infections. Twenty-three per cent of ICU admissions were readmitted to hospital within 28 days of discharge. Associated independent factors were younger age, longer index hospital stay and emergency index admission. Children with chronic conditions of cancer and genitourinary disorders were more likely to be readmitted. CONCLUSIONS Identification of complex chronic conditions, consideration of long-term health planning and interventions intended to reduce readmission is warranted in order to reduce the burden to families and the health-care system.
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Affiliation(s)
- Diana M Bond
- Child Population Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Amanda Ampt
- Child Population Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Arthur Teo
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Natasha Nassar
- Child Population Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David Schell
- Kids Critical Care Research, Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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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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15
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Alali H, Antar M, AlShehri A, AlHamouieh O, Al-Surimi K, Kazzaz Y. Improving physician handover documentation process for patient transfer from paediatric intensive care unit to general ward. BMJ Open Qual 2021; 9:bmjoq-2020-001020. [PMID: 33384337 PMCID: PMC7780523 DOI: 10.1136/bmjoq-2020-001020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 11/17/2020] [Accepted: 11/22/2020] [Indexed: 11/04/2022] Open
Abstract
Background Inadequate handover communication is responsible for many adverse events during the transfer of care, which can be attributed to many factors, including incomplete documentation or lack of standardised documentation process. The quality improvement project aimed to standardise the handover documentation process during patient transfer from paediatric intensive care unit (PICU) to the general paediatric ward. Methods Data analysis revealed lack of proper handover documentation with the omission of vital information when transferring patients from PICU to general ward. The quality improvement team assessed the current handover documentation practice using a brainstorming technique during multiple meetings. The team evaluated the process for possible causes of incomplete handover documentation, framed the existing challenges, and proposed improvement interventions, including a standardised handover form and conducting education sessions for the new proposed process. The main quality measures included physician’s compliance with handover documentation elements, physician’s satisfaction and PICU emergency readmission rate within 48 hours. Results Physician compliance to handover documentation improved from 29.5% to 95.5% before and after implanting the improvement interventions, respectively. The level of physician satisfaction with the quality of communicated information during the handover process improved from 47.5% to 84%, and the PICU emergency readmission rate declined from 3.8% to zero after all improvement interventions were implanted. Conclusion Implementation of standardised handover form is essential to improve physician compliance for clear handover documentation and to avoid data omission during the patient transfer process. Documented handover in patient’s medical record has positive impact on physician satisfaction when managing patients recently discharged from PICU.
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Affiliation(s)
- Hamza Alali
- Pediatrics, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia .,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohannad Antar
- Pediatrics, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ali AlShehri
- Pediatrics, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ousaima AlHamouieh
- Quality and Patient Safety, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Khaled Al-Surimi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yasser Kazzaz
- Pediatrics, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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16
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Mitchell HK, Reddy A, Perry MA, Gathers CA, Fowler JC, Yehya N. Racial, ethnic, and socioeconomic disparities in paediatric critical care in the USA. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:739-750. [PMID: 34370979 DOI: 10.1016/s2352-4642(21)00161-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/17/2022]
Abstract
In an era of tremendous medical advancements, it is important to characterise and address inequities in the provision of health care and in outcomes. There is a large body of evidence describing such disparities by race or ethnicity and socioeconomic position in critically ill adults; however, this important issue has received less attention in children and adolescents (aged ≤21 years). This Review presents a summary of the available evidence on disparities in outcomes in paediatric critical illness in the USA as a result of racism and socioeconomic privilege. The majority of evidence of racial and socioeconomic disparities in paediatric critical care originates from the USA and is retrospective, with only one prospective intervention-based study. Although there is mixed evidence of disparities by race or ethnicity and socioeconomic position in general paediatric intensive care unit admissions and outcomes in the USA, there are striking trends within some disease processes. Notably, there is evidence of disparities in management and outcomes for out-of-hospital cardiac arrest, asthma, severe trauma, sepsis, and oncology, and in families' perceptions of care. Furthermore, there is clear evidence that critical care research is limited by under-enrolment of participants from minority race or ethnicity groups. We advocate for rigorous research standards and increases in the recruitment and enrolment of a diverse range of participants in paediatric critical care research to better understand the disparities observed, including the effects of racism and poverty. A clearer understanding of when, where, and how such disparities affect patients will better enable the development of effective strategies to inform practice, interventions, and policy.
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Affiliation(s)
- Hannah K Mitchell
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Anireddy Reddy
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, PA, USA
| | - Mallory A Perry
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cody-Aaron Gathers
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jessica C Fowler
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, PA, USA
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17
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Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective. CHILDREN-BASEL 2021; 8:children8040254. [PMID: 33805106 PMCID: PMC8064072 DOI: 10.3390/children8040254] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/17/2021] [Accepted: 03/20/2021] [Indexed: 12/14/2022]
Abstract
Advances in medical and surgical care for children in the pediatric intensive care unit (PICU) have led to vast reductions in mortality, but survivors often leave with newly acquired or worsened morbidity. Emerging evidence reveals that survivors of pediatric critical illness may experience a constellation of physical, emotional, cognitive, and social impairments, collectively known as the “post-intensive care syndrome in pediatrics” (PICs-P). The spectrum of PICs-P manifestations within each domain are heterogeneous. This is attributed to the wide age and developmental diversity of children admitted to PICUs and the high prevalence of chronic complex conditions. PICs-P recovery follows variable trajectories based on numerous patient, family, and environmental factors. Those who improve tend to do so within less than a year of discharge. A small proportion, however, may actually worsen over time. There are many gaps in our current understanding of PICs-P. A unified approach to screening, preventing, and treating PICs-P-related morbidity has been hindered by disparate research methodology. Initiatives are underway to harmonize clinical and research priorities, validate new and existing epidemiologic and patient-specific tools for the prediction or monitoring of outcomes, and define research priorities for investigators interested in long-term outcomes.
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18
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Abstract
Supplemental Digital Content is available in the text. To determine the costs and hospital resource use from all PICU patients readmitted with a PICU stay within 12 months of hospital index discharge.
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19
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Prutsky GJ, Padhya D, Ahmed AT, Almasri J, Farah WH, Prokop LJ, Murad MH, Alsawas M. Is Unplanned PICU Readmission a Proper Quality Indicator? A Systematic Review and Meta-analysis. Hosp Pediatr 2021; 11:167-174. [PMID: 33504562 DOI: 10.1542/hpeds.2020-0192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
CONTEXT Unplanned PICU readmissions within 48 hours of discharge (to home or a different hospital setting) are considered a quality metric of critical care. OBJECTIVE We sought to determine identifiable risk factors associated with early unplanned PICU readmissions. DATA SOURCES A comprehensive search of Medline, Embase, the Cochrane Database of Systematic Reviews, and Scopus was conducted from each database's inception to July 16, 2018. STUDY SELECTION Observational studies of early unplanned PICU readmissions (<48 hours) in children (<18 years of age) published in any language were included. DATA EXTRACTION Two reviewers selected and appraised studies independently and abstracted data. A meta-analysis was performed by using the random-effects model. RESULTS We included 11 observational studies in which 128 974 children (mean age: 5 years) were evaluated. The presence of complex chronic diseases (odds ratio 2.42; 95% confidence interval 1.06 to 5.55; I 2 79.90%) and moderate to severe disability (odds ratio 2.85; 95% confidence interval 2.40 to 3.40; I 2 11.20%) had the highest odds of early unplanned PICU readmission. Other significant risk factors included an unplanned index admission, initial admission to a general medical ward, spring season, respiratory diagnoses, and longer initial PICU stay. Readmission was less likely after trauma- and surgery-related index admissions, after direct admission from home, or during the summer season. Modifiable risk factors, such as evening or weekend discharge, revealed no statistically significant association. Included studies were retrospective, which limited our ability to account for all potential confounders and establish causality. CONCLUSIONS Many risk factors for early unplanned PICU readmission are not modifiable, which brings into question the usefulness of this quality measure.
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Affiliation(s)
- Gabriela J Prutsky
- Department of Pediatrics, Mayo Clinic Health System, Mankato, Minnesota; .,Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Dipti Padhya
- Pediatric Critical Care, Department of Pediatrics, Cedar-Sinai Hospital, Los Angeles, California
| | - Ahmed T Ahmed
- Depression Center, Department of Psychiatry and Psychology
| | - Jehad Almasri
- Internal Medicine, Piedmont Athens Regional Health System, Athens, Georgia; and
| | - Wigdan H Farah
- Internal Medicine, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- Evidence-Based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, and
| | - Mouaz Alsawas
- Evidence-Based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, and
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20
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Murphy Salem S, Graham RJ. Chronic Illness in Pediatric Critical Care. Front Pediatr 2021; 9:686206. [PMID: 34055702 PMCID: PMC8160444 DOI: 10.3389/fped.2021.686206] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
Abstract
Children and Youth with Special Healthcare Needs (CYSHCN), children with medical complexity (CMC), and children with chronic, critical illness (CCI) represent pediatric populations with varying degrees of medical dependance and vulnerability. These populations are heterogeneous in underlying conditions, congenital and acquired, as well as intensity of baseline medical needs. In times of intercurrent illness or perioperative management, these patients often require acute care services in the pediatric intensive care (PICU) setting. This review describes epidemiologic trends in chronic illness in the PICU setting, differentiates these populations from those without significant baseline medical requirements, reviews models of care designed to address the intersection of acute and chronic illness, and posits considerations for future roles of PICU providers to optimize the care and outcomes of these children and their families.
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Affiliation(s)
- Sinead Murphy Salem
- Department of Anesthesiology, Boston Children's Hospital, Critical Care and Pain Medicine and Harvard Medical School, Boston, MA, United States
| | - Robert J Graham
- Department of Anesthesiology, Boston Children's Hospital, Critical Care and Pain Medicine and Harvard Medical School, Boston, MA, United States
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21
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Unplanned PICU Readmission in a Middle-Income Country: Who Is at Risk and What Is the Outcome? Pediatr Crit Care Med 2020; 21:e959-e966. [PMID: 32590834 DOI: 10.1097/pcc.0000000000002406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To study the rate of unplanned PICU readmission, determine the risk factors and its impact on mortality. DESIGN A single-center retrospective cross-sectional study. SETTING Tertiary referral PICU in Johor, Malaysia. PATIENTS All children admitted to the PICU over 8 years were included. Patients readmitted into PICU after the first PICU discharge during the hospitalization period were categorized into "early" (within 48 hr) and "late" (after 48 hr), and factors linked to the readmissions were identified. The mortality rate was determined and compared between no, early, and late readmission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 2,834 patients in the study with 70 early and 113 late readmissions. Therefore, the rate of early and late PICU readmission was 2.5% (95% CI, 1.9-3.0%) and 3.9% (95% CI, 3.2-4.7%), respectively. The median length of stay of the second PICU admission for early and late readmissions was 2.7 days (interquartile range, 1.1-7.0 d) and 3.2 days (interquartile range, 1.2-7.5 d), respectively. The majority of early and late readmissions had a similar diagnosis with their first PICU admission. Multivariable multinomial logistic regression revealed a Pediatric Index Mortality 2 score of greater than or equal to 15, chronic cardiovascular condition, and oxygen supplement upon discharge as independent risk factors for early PICU readmission. Meanwhile, an infant of less than 1 year old, having cardiovascular, other congenital and genetic chronic conditions and being discharged between 8 AM and 5 PM was an independent risk factor for late readmission. There was no significant difference in the mortality rate of early (12.9%), late (13.3%), and no readmission (10.7%). CONCLUSIONS Despite the lack of resources and expertise in lower- and middle-income countries, the rate and factors for PICU readmission are similar to those in high-income countries. However, PICU readmission has no statistically significant association with mortality.
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23
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Azar R, Doucet S, Horsman AR, Charlton P, Luke A, Nagel DA, Hyndman N, Montelpare WJ. A concept analysis of children with complex health conditions: implications for research and practice. BMC Pediatr 2020; 20:251. [PMID: 32456672 PMCID: PMC7248453 DOI: 10.1186/s12887-020-02161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 05/20/2020] [Indexed: 11/10/2022] Open
Abstract
Background This concept analysis aimed to clarify the meaning of “children with complex health conditions” and endorse a definition to inform future research, policy, and practice. Methods Using Walker and Avant’s (2011)‘s approach, we refined the search strategy with input from our team, including family representatives. We reviewed the published and grey literature. We also interviewed 84 health, social, and educational stakeholders involved in the care of children with complex health conditions about their use/understanding of the concept. Results We provided model, borderline, related, and contrary cases for clarification purposes. We identified defining attributes that nuance the concept: (1) conditions and needs’ breadth; (2) uniqueness of each child/condition; (3) varying extent of severity over time; 4) developmental age; and (5) uniqueness of each family/context. Antecedents were chronic physical, mental, developmental, and/or behavioural condition(s). There were individual, family, and system consequences, including fragmented services. Conclusions Building on previous definitions, we proposed an iteration that acknowledges the conditions’ changing trajectories as involving one or more chronic condition(s), regardless of type(s), whose trajectories can change over time, requiring services across sectors/settings, oftentimes resulting in a lower quality of life. A strength of this paper is the integration of the stakeholders’/family’s voices into the development of the definition.
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Affiliation(s)
- Rima Azar
- Psychobiology of Stress and Health Lab, Psychology Department, Mount Allison University, 49A York Street, Sackville, NB, E4L 1C7, Canada. .,NaviCare/SoinsNavi, Sackville, Canada.
| | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, PO Box 5050, Saint John, NB, E2L 4L5, Canada
| | - Amanda Rose Horsman
- Interdisciplinary Studies, School of Graduate Studies, University of New Brunswick, 100 Tucker Park Rd, Box 5050, Saint John, NB, E2L 4L5, Canada
| | - Patricia Charlton
- Faculty of Nursing, University of Prince Edward Island, 550 University Avenue, Charlottetown, Prince Edward Island, C1A 4P3, Canada
| | - Alison Luke
- Department of Nursing and Health Sciences, University of New Brunswick, PO Box 5050, Saint John, NB, E2L 4L5, Canada
| | - Daniel A Nagel
- Department of Nursing and Health Sciences, University of New Brunswick, PO Box 5050, Saint John, NB, E2L 4L5, Canada
| | - Nicky Hyndman
- Veterans Affairs Canada, PO Box 7700, Charlottetown, PE, C1A 8M9, Canada
| | - William J Montelpare
- Faculty of Science, University of Prince Edward Island, 550 University Avenue, Charlottetown, Prince Edward Island, C1A 4P3, Canada
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Dalesio NM, Lester LC, Barone B, Deanehan JK, Fackler JC. Real-Time Emergency Airway Consultation via Telemedicine: Instituting the Pediatric Airway Response Team Board! Anesth Analg 2020; 130:1097-1102. [PMID: 31904634 DOI: 10.1213/ane.0000000000004635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Nicholas M Dalesio
- From the Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine
| | - Laeben C Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ben Barone
- Department of Engineering, Johns Hopkins University, Baltimore, Maryland
| | - J Kate Deanehan
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James C Fackler
- From the Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine
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Konishi U, Hatachi T, Ikebe R, Inata Y, Takemori K, Takeuchi M. Incidence and risk factors for readmission to a paediatric intensive care unit. Nurs Crit Care 2019; 25:149-155. [PMID: 31576633 DOI: 10.1111/nicc.12471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 07/03/2019] [Accepted: 08/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Unscheduled readmission to a paediatric intensive care unit can lead to unfavourable patient outcomes. Therefore, determining the incidence and risk factors is important. Previous studies on such readmissions have only focused on the first 48 hours after discharge and described the relative risk factors as unmodifiable. AIM To identify the incidence and risk factors of unscheduled readmission to a paediatric intensive care unit within 7 days of discharge. DESIGN This was a retrospective observational study. METHODS Our study population comprised consecutive patients admitted to the paediatric intensive care unit of our tertiary hospital in Japan in 2012 to 2016. We determined the incidence of unscheduled readmission to the unit within 7 days of discharge and identified potential risk factors using multivariable logistic regression analysis. RESULTS Among the 2432 admissions (1472 patients), 60 admissions (2.5%, 44 patients) were followed by ≥1 unscheduled readmission. The median time to readmission was 3.5 days. The most common causes for readmission were respiratory issues and cardiovascular symptoms. The significant risk factors for readmission within 7 days of discharge were unscheduled initial admission (odds ratio [OR]: 3.02; 95% confidence interval [CI:] 1.45-6.31), admission from a general ward (OR: 5.13; 95% CI: 1.75-15.0), and withdrawal syndrome during the initial stay (OR: 3.95; 95% CI: 1.53-10.2). CONCLUSIONS The incidence of unscheduled readmission within 7 days was not high (2.5%), and one of the three identified risk factors for readmissions (withdrawal syndrome) is potentially modifiable. RELEVANCE TO CLINICAL PRACTICE Appropriate treatment of withdrawal syndrome may reduce readmissions and improve patient outcomes. Although unscheduled initial admission and admission from general ward are not modifiable risk factors, careful discharge judgement and follow up after discharge from paediatric intensive care units for high-risk patients may be beneficial.
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Affiliation(s)
- Umi Konishi
- Registered Nurse, Department of Nursing, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Takeshi Hatachi
- Physician, Department of Intensive Care Medicine, Osaka Womens and Children's Hospital 840 Murodocho, Osaka, Japan
| | - Ryo Ikebe
- Registered Nurse, Department of Nursing, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yu Inata
- Physician, Department of Intensive Care Medicine, Osaka Womens and Children's Hospital 840 Murodocho, Osaka, Japan
| | - Kazumi Takemori
- Registered Nurse, Department of Nursing, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Muneyuki Takeuchi
- Physician, Department of Intensive Care Medicine, Osaka Womens and Children's Hospital 840 Murodocho, Osaka, Japan
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Abstract
OBJECTIVES To identify modifiable factors leading to unplanned readmission and characterize differences in adjusted unplanned readmission rates across hospitals. DESIGN Retrospective cohort study using prospectively collected clinical registry data SETTING:: Pediatric Cardiac Critical Care Consortium clinical registry. PATIENTS Patients admitted to a pediatric cardiac ICU at Pediatric Cardiac Critical Care Consortium hospitals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We examined pediatric cardiac ICU encounters in the Pediatric Cardiac Critical Care Consortium registry from October 2013 to March 2016. The primary outcomes were early (< 48 hr from pediatric cardiac ICU transfer) and late (2-7 d) unplanned readmission. Generalized logit models identified independent predictors of unplanned readmission. We then calculated observed-to-expected ratios of unplanned readmission and identified higher-than or lower-than-expected unplanned readmission rates for those with an observed-to-expected ratios greater than or less than 1, respectively, and a 95% CI that did not cross 1. Of 11,301 pediatric cardiac ICU encounters (16 hospitals), 62% were surgical, and 18% were neonates. There were 175 (1.6%) early unplanned readmission, and 300 (2.7%) late unplanned readmission, most commonly for respiratory (31%), or cardiac (28%) indications. In multivariable analysis, unique modifiable factors were associated with unplanned readmission. Although shorter time between discontinuation of vasoactive infusions and pediatric cardiac ICU transfer was associated with early unplanned readmission, nighttime discharge was independently associated with a greater likelihood of late unplanned readmission. Two hospitals had lower-than-expected unplanned readmission in both the early and late categories, whereas two other hospitals were higher-than-expected in both. CONCLUSIONS This analysis demonstrated time from discontinuation of critical care therapies to pediatric cardiac ICU transfer as a significant, modifiable predictor of unplanned readmission. We identified two hospitals with lower-than-expected adjusted rates of both early and late unplanned readmission, suggesting that their systems are well designed to prevent unplanned readmission. This offers the possibility of disseminating best practices to other hospitals through collaborative learning.
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ICU Readmission Is a More Complex Metric Than We First Imagined. Crit Care Med 2019; 46:2064-2067. [PMID: 30444819 DOI: 10.1097/ccm.0000000000003480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McKelvie BL, Lobos AT, Chan J, Momoli F, McNally JD. High Rate of Medical Emergency Team Activation in Children with Tracheostomy. J Pediatr Intensive Care 2019; 9:27-33. [PMID: 31984154 DOI: 10.1055/s-0039-1695733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022] Open
Abstract
Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.
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Affiliation(s)
- Brianna L McKelvie
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, Western University, Children's Hospital-London Health Sciences Centre, London, Ontario, Canada
| | - Anna-Theresa Lobos
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jason Chan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - James Dayre McNally
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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da Silva PSL, Fonseca MCM. Which children account for repeated admissions within 1 year in a Brazilian pediatric intensive care unit? JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2018.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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da Silva PSL, Fonseca MCM. Which children account for repeated admissions within 1 year in a Brazilian pediatric intensive care unit? J Pediatr (Rio J) 2019; 95:559-566. [PMID: 29856945 DOI: 10.1016/j.jped.2018.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/27/2018] [Accepted: 04/27/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE While studies have focused on early readmissions or readmissions during the same hospitalization in a pediatric intensive care unit, little is known about the children with recurrent admissions. We sought to assess the characteristics of patients readmitted within 1 year in a Brazilian pediatric intensive care unit. METHODS This was a retrospective study carried out in a tertiary pediatric intensive care unit. The outcome was the maximum number of readmissions experienced by each child within any 365-day interval during a 5-year follow-up period. RESULTS Of the 758 total eligible admissions, 75 patients (9.8%) were readmissions. Those patients accounted for 33% of all pediatric intensive care unit bed care days. Median time to readmission was 73 days for all readmissions. Logistic regression showed that complex chronic conditions (odds ratio 1.07), severe to moderate cognitive disability (odds ratio 1.08), and use of technology assistance (odds ratio 1.17) were associated with readmissions. Multiple admissions had a significantly prolonged duration of mechanical ventilation (8 vs. 6 days), longer length of pediatric intensive care unit (7 vs 4 days) and hospital stays (20 vs 9 days), and higher mortality rate (21.3% vs 5.1%) compared with index admissions. CONCLUSION The rate of pediatric intensive care unit readmissions within 1 year was low; however, it was associated with a relevant number of bed care days and worse outcomes. A 30-day index of readmission may be inadequate to mirror the burden of pediatric intensive care unit readmissions. Patients with complex chronic conditions, poor functional status or technology assistance are at higher risk for readmissions. Future studies should address the impact of qualitative interventions on healthcare and recurrent admissions.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Hospital do Servidor Público Municipal, Departamento de Pediatria, Unidade de Terapia Intensiva Pediátrica, São Paulo, SP, Brazil.
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Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance. Pediatr Crit Care Med 2019; 20:847-887. [PMID: 31483379 DOI: 10.1097/pcc.0000000000001963] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. DESIGN A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. METHODS The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. RESULTS The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. CONCLUSIONS This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.
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Unplanned PICU Readmissions: A Representation of Care Gaps Within the Community. Crit Care Med 2019; 45:1409-1410. [PMID: 28708681 DOI: 10.1097/ccm.0000000000002468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Readmissions: Accepting Those That Cannot Be Prevented, Courage to Prevent Those That Can Be, and the Wisdom to Know the Difference. Crit Care Med 2019; 45:378-379. [PMID: 28098642 DOI: 10.1097/ccm.0000000000002108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naoum NK, Chua ME, Ming JM, Santos JD, Saunders MA, Lopes RI, Koyle MA, Farhat WA. Return to emergency department after pediatric urology procedures. J Pediatr Urol 2019; 15:42.e1-42.e6. [PMID: 30527684 DOI: 10.1016/j.jpurol.2018.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Unplanned postoperative return visits to the emergency department (ED) and readmission represent a quality bench outcome and pose a considerable cost burden to health-care systems. OBJECTIVE The aim of this study is to evaluate ED return visits after pediatric urology procedures in a tertiary care children's hospital, trying to identify potential causes. This may constitute a platform for future improvement areas. MATERIALS AND METHODS A Quality Board-approved retrospective study was performed identifying all urologic cases completed between October 2012 and September 2015. Baseline demographics, American Society of Anesthesia class, operating surgeon, type of admission, type and duration of surgical procedure, and type of anesthesia given were evaluated. Patients who returned to the ED within 30 days of the surgery date were identified. The ED records were reviewed for time of return, etiology for visit, and management received. Univariate and subsequent multivariate logistic regression statistical analyses were performed to identify variables associated with ED return. Odds ratio (OR) and 95% confidence intervals (95% CIs) were generated to determine the significance of relationships. RESULTS Total of 4125 cases was identified. Median age was 32.9 months, with 85.1% of them being male. 349 (8.5%) cases returned to the ED within 30 days of the surgery. The majority of the returned patients, 295 (84.5%), managed conservatively with medications or reassurance, whereas 54 (15.5%) required readmission, and of those readmitted, 15 (4.3%) cases needed further surgical interventions, mainly urinary tract drainage procedures. Multivariate logistic regression analysis identified that the age, residence, admission type, inguinoscrotal surgery, and duration of surgical procedure were significantly associated with ED return (Table). The most common reason for the ED visit was UTI in 17.2%, followed by stent and catheter issues in 14.3%, wound-related in 14.3%, and bleeding in 11.7%. DISCUSSION Pediatric literature show varying rates of ED return ranging from 2.4% to 2.6% after urologic procedures. Our return to ED rate exceeds that found in US studies, which can perhaps be attributed to the differences between the Canadian and US health-care systems. As found with other studies, age, inpatient admission, procedure type, and increased operative time were related to ED returns, possibly because of the difficulty of young children expressing themselves and the presumed complex nature of longer operations that mostly need inpatient admission. The most common reason for ED return in this study as in others was presumptive UTI. A known limitation of this study is its retrospective nature, along with the possible missed visits of patients who presented to outside hospitals. CONCLUSION We present an account of the status of ED return visits after pediatric urology procedures in our institute. The majority of ED returns can be managed conservatively and are probably preventable.
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Affiliation(s)
- N K Naoum
- Division of Urology, The Hospital for Sick Children-Toronto, Canada.
| | - M E Chua
- Division of Urology, The Hospital for Sick Children-Toronto, Canada
| | - J M Ming
- Division of Urology, The Hospital for Sick Children-Toronto, Canada
| | - J D Santos
- Division of Urology, The Hospital for Sick Children-Toronto, Canada
| | - M A Saunders
- Division of Urology, The Hospital for Sick Children-Toronto, Canada
| | - R I Lopes
- Division of Urology, The Hospital for Sick Children-Toronto, Canada
| | - M A Koyle
- Division of Urology, The Hospital for Sick Children-Toronto, Canada
| | - W A Farhat
- Division of Urology, The Hospital for Sick Children-Toronto, Canada
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Ishihara T, Tanaka H. Causes of death in critically ill paediatric patients in Japan: a retrospective multicentre cohort study. BMJ Paediatr Open 2019; 3:e000499. [PMID: 31531406 PMCID: PMC6720739 DOI: 10.1136/bmjpo-2019-000499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/06/2019] [Accepted: 07/12/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The primary objective is to clarify the clinical profiles of paediatric patients who died in intensive care units (ICUs) or paediatric intensive care units (PICUs), and the secondary objective is to ascertain the demographic differences between patients who died with and without chronic conditions. METHODS In this retrospective multicentre cohort study, we collected data on paediatric death from the Japanese Registry of Pediatric Acute Care (JaRPAC) database. We included patients who were ≤16 years of age and had died in either a PICU or an ICU of a participating hospital between April 2014 and March 2017. The causes of death were compared between patients with and without chronic conditions. RESULTS Twenty-three hospitals participated, and 6199 paediatric patients who were registered in the JaRPAC database were included. During the study period, 126 (2.1%) patients died (children without chronic illness, n=33; children with chronic illness, n=93). Twenty-five paediatric patients died due to an extrinsic disease, and there was a significant difference in extrinsic diseases between the two groups (children without chronic illness, 15 (45%); children with chronic illness, 10 (11%); p<0.01). Cardiovascular disease was the most common chronic condition (27/83, 29%). Eighty-three patients (85%) in the chronic group died due to an intrinsic disease, primarily congenital heart disease (14/93, 15%), followed by sepsis (13/93, 14%). CONCLUSIONS The majority of deaths were in children with a chronic condition. The major causes of death in children without a chronic illness were due to intrinsic factors such as cardiovascular and neuromuscular diseases, and the proportion of deaths due to extrinsic causes was higher in children without chronic illness.
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Affiliation(s)
- Tadashi Ishihara
- Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
| | - Hiroshi Tanaka
- Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
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Lystad RP, Bierbaum M, Curtis K, Braithwaite J, Mitchell R. Unwarranted clinical variation in the care of children and young people hospitalised for injury: a population-based cohort study. Injury 2018; 49:1781-1786. [PMID: 30017178 DOI: 10.1016/j.injury.2018.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/29/2018] [Accepted: 07/09/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Injury is a leading cause of death and disability among children and young people. Recovery may be negatively affected by unwarranted clinical variation such as representation to an emergency department (ED), readmission to a hospital, and mortality. The aim of this study was to examine unwarranted clinical variation across providers of care of children and young people who were hospitalised for injury in New South Wales (NSW). MATERIALS AND METHODS Retrospective population-based cohort study using linked ED, hospital, and mortality data of all children and young people aged ≤25 years who were injured and hospitalised during 1 January 2010-30 June 2014 in NSW. Unwarranted clinical variation across providers was examined using three indicators. That is, for each hospital that treated ≥100 cases per year, risk standardised ratios were calculated with 95% and 99.8% confidence limits using the number of observed and expected events of (1) representations to ED within 72 h, (2) unplanned readmissions to hospital within 28 days, and (3) all-cause mortality within 30 days. RESULTS There were 189,990 injury-related hospitalisations of children and young people. Of these, 4.4% represented to an ED, 8.7% were readmitted to hospital, and 0.2% died. Of the 45 public hospitals that treated ≥100 cases per year, higher than expected rates of ED representations, hospital readmissions, and mortality were observed in eleven, six, and two hospitals, respectively. CONCLUSION The rates of ED representations, hospital readmissions, and mortality among children and young people hospitalised for injury in NSW were similar to the rates reported in other countries. However, unwarranted clinical variation across public hospitals was observed for all three indicators. These findings suggest that by improving routine follow-up support services post-discharge for children and young people and their families, it may be possible to reduce unwarranted clinical variation and improve health outcomes.
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Affiliation(s)
- Reidar P Lystad
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
| | - Mia Bierbaum
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Kate Curtis
- Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Herbst LA, Desai S, Benscoter D, Jerardi K, Meier KA, Statile AM, White CM. Going back to the ward-transitioning care back to the ward team. Transl Pediatr 2018; 7:314-325. [PMID: 30460184 PMCID: PMC6212378 DOI: 10.21037/tp.2018.08.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Transition of care from the intensive care unit (ICU) to the ward is usually an indication of the patient's improving clinical status, but is also a time when patients are particularly vulnerable. The transition between care teams poses a higher risk of medical error, which can be mitigated by safe and complete patient handoff and medication reconciliation. ICU readmissions are associated with increased mortality as well as ICU and hospital length of stay (LOS); however tools to accurately predict ICU readmission risk are limited. While there are many mechanisms in place to carefully identify patients appropriate for transfer to the ward, the optimal timing of transfer can be affected by ICU strain, limited resources such as ICU beds, and overall hospital capacity and flow leading to suboptimal transfer times or delays in transfer. The patient and family perspectives should also be considered when planning for transfer from the ICU to the ward. During times of transition, families will meet a new care team, experience uncertainty of future care plans, and adjust to a different daily routine which can lead to increased stress and anxiety. Additionally, a subset of patients, such as those with new technology, require additional multidisciplinary support, education and care coordination which can contribute to longer hospital LOS if not addressed proactively early in the hospitalization while the patient remains in the ICU. In this review article, we describe key components of the transfer from ICU to the ward, discuss current strategies to optimize timing of patient transfers, explore strategies to partner with patients and families during the transfer process, highlight patient populations where additional considerations are needed, and identify future areas of exploration which could improve the care transition from the ICU to the ward.
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Affiliation(s)
- Lori A Herbst
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA.,Geriatrics & Palliative Care Division, Department of Family & Community Medicine, UC College of Medicine, Cincinnati, OH, USA
| | - Sanyukta Desai
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Dan Benscoter
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Karen Jerardi
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Katie A Meier
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Christine M White
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
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Nielsen KR, Aronés Rojas R, Tantaleán da Fieno J, Huicho L, Roberts JS, Zunt J. Emergency department risk factors for serious clinical deterioration in a paediatric hospital in Peru. J Paediatr Child Health 2018; 54:866-871. [PMID: 29582497 DOI: 10.1111/jpc.13904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 11/30/2022]
Abstract
AIM Identification of critically ill children upon presentation to the emergency department (ED) is challenging, especially when resources are limited. The objective of this study was to identify ED risk factors associated with serious clinical deterioration (SCD) during hospitalisation in a resource-limited setting. METHODS A retrospective case-control study of children less than 18 years of age presenting to the ED in a large, freestanding children's hospital in Peru was performed. Cases had SCD during the first 7 days of hospitalisation whereas controls did not. Information collected during initial ED evaluation was used to identify risk factors for SCD. RESULTS A total of 120 cases and 974 controls were included. In univariate analysis, young age, residence outside Lima, evaluation at another facility prior to ED presentation, congenital malformations, abnormal neurologic baseline, co-morbidities and a prior paediatric intensive care unit admission were associated with SCD. In multivariate analysis, age < 12 months, residence outside Lima and evaluation at another facility prior to ED presentation remained associated with SCD. In addition, comatose neurological status, hypoxaemia, tachycardia, tachypnoea and temperature were also associated with SCD. CONCLUSIONS Many risk factors for SCD during hospitalisation can be identified upon presentation to the ED. Using these factors to adjust monitoring during and after the ED stay has the potential to decrease SCD events. Further studies are needed to determine whether this holds true in other resource-limited settings.
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Affiliation(s)
- Katie R Nielsen
- Department of Pediatrics Critical Care Medicine, University of Washington, Seattle, Washington, United States.,Department of Global Health, University of Washington, Seattle, Washington, United States
| | - Rubén Aronés Rojas
- Departments of Emergency, National Institute of Child Health, Lima, Peru
| | - José Tantaleán da Fieno
- Departments of Critical Care, National Institute of Child Health, Lima, Peru.,National University Federico Villareal, Lima, Peru
| | - Luis Huicho
- Research Center for Maternal and Child Health, Research Center for Integral and Sustainable Development, Cayetano Heredia University, Lima, Peru.,School of Medicine, National University of San Marcos, Lima, Peru
| | - Joan S Roberts
- Department of Pediatrics Critical Care Medicine, University of Washington, Seattle, Washington, United States
| | - Joseph Zunt
- Department of Global Health, University of Washington, Seattle, Washington, United States
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Kalzén H, Larsson B, Eksborg S, Lindberg L, Edberg KE, Frostell C. Survival after PICU admission: The impact of multiple admissions and complex chronic conditions. PLoS One 2018; 13:e0193294. [PMID: 29621235 PMCID: PMC5886395 DOI: 10.1371/journal.pone.0193294] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 02/08/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Factors predicting survival over time after pediatric intensive care unit (PICU) admissions are not fully understood. The primary aim of the current study was to investigate whether multiple admissions (MADM) compared to single PICU admissions (SADM) were associated with poor survival over time after being admitted to PICU facilities. Our secondary aim was to investigate if the presence of a complex chronic condition (CCC) would further impair prognosis. DESIGN A closed cohort of all children up to 16 years of age admitted to the three PICUs in Sweden between 2008 and 2010 was prospectively collected and followed until 2012, providing survival data for at least one but up to four years of follow-up. SETTING Three Swedish tertiary referral centers for pediatric intensive care and extracorporeal membrane oxygenation (ECMO) care were used. PATIENTS In total, 3,688 Swedish children with 5,019 PICU admissions were included. INTERVENTIONS No interventions were conducted. MEASUREMENTS An extensive data set was recorded, including up to four-year survival information following first PICU admission. The patients were assigned to seven admission diagnostic groups, which were then divided into SADM or MADM groups. The difference in survival over time and mortality rates (MR) and mortality rate ratios (MRR) were calculated. SADM and MADM groups with and without an existing CCC were formed. The difference in survival over time between groups was calculated. MAIN RESULTS A highly significant difference in survival over time was noted between SADM and MADM patients (p<0.0001), which was intensified by the presence of a CCC. MADM patients with a CCC had the worst outcome, while SADM patients without a CCC had the best outcome. MADM patients with no CCC demonstrated decreased survival over time compared to SADM patients with a CCC. Survival over time was statistically worsened for patients with MADM compared to SADM for the following admission diagnostic groups: Cardiovascular, Gastrointestinal/Renal, Respiratory, Neurological, and Miscellaneous. The mortality rate (deaths/patient year of follow-up) during the time of follow-up was 0.023 for SADM and 0.062 for MADM patients. The mortality rate ratio (MRR) between these groups was 2.69. CONCLUSION Compared to single admissions, multiple admissions to PICU were associated with a significant decrease in survival over time in some but not all diagnostic groups. Regarding our secondary aim, we found that when the presence of a CCC is factored into the survival analysis, survival over time is further impaired.
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Affiliation(s)
- Håkan Kalzén
- Department of Paediatric Anaesthesia, Intensive Care and ECMO services, Astrid Lindgren Children's Hospital, Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden
| | - Björn Larsson
- Department of Paediatric Anaesthesia, Intensive Care and ECMO services, Astrid Lindgren Children's Hospital, Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden
| | - Staffan Eksborg
- Childhood Cancer Research Unit Q6:05, Department of Women's and Children's Health, Karolinska Institutet, Astrid Lindgren Children's Hospital, Karolinska University Hospital (Solna), Stockholm, Sweden
| | - Lars Lindberg
- Department of Anaesthesia and Intensive Care, Children’s Hospital, Paediatric Intensive Care Unit, University Hospital of Lund, Lund, Sweden
| | - Karl Erik Edberg
- Department of Paediatric Intensive Care, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Claes Frostell
- Department of Anaesthesia and Intensive Care at Danderyd Hospital, Karolinska Institutet at Danderyd Hospital (KIDS), Stockholm, Sweden
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Shapiro MC, Henderson CM, Hutton N, Boss RD. Defining Pediatric Chronic Critical Illness for Clinical Care, Research, and Policy. Hosp Pediatr 2017; 7:236-244. [PMID: 28351944 DOI: 10.1542/hpeds.2016-0107] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronically critically ill pediatric patients represent an emerging population in NICUs and PICUs. Chronic critical illness has been recognized and defined in the adult population, but the same attention has not been systematically applied to pediatrics. This article reviews what is currently known about pediatric chronic critical illness, highlighting the unique aspects of chronic critical illness in infants and children, including specific considerations of prognosis, outcomes, and decision-making. We propose a definition that incorporates NICU versus PICU stays, recurrent ICU admissions, dependence on life-sustaining technology, multiorgan dysfunction, underlying medical complexity, and the developmental implications of congenital versus acquired conditions. We propose a research agenda, highlighting existing knowledge gaps and targeting areas of improvement in clinical care, research, and policy.
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Affiliation(s)
- Miriam C Shapiro
- Johns Hopkins University School of Medicine, Baltimore, Maryland; .,Johns Hopkins Children's Center, Baltimore, Maryland.,Berman Institute of Bioethics, Baltimore, Maryland
| | - Carrie M Henderson
- University of Mississippi Medical Center, Jackson, Mississippi; and.,Center for Bioethics and Medical Humanities, Jackson, Mississippi
| | - Nancy Hutton
- Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Children's Center, Baltimore, Maryland
| | - Renee D Boss
- Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Children's Center, Baltimore, Maryland.,Berman Institute of Bioethics, Baltimore, Maryland
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Abstract
OBJECTIVES To determine the occurrence rate of unplanned readmissions to PICUs within 1 year and examine risk factors associated with repeated readmission. DESIGN Retrospective cohort analysis. SETTING Seventy-six North American PICUs that participated in the Virtual Pediatric Systems, LLC (VPS, LLC, Los Angeles, CA). PATIENTS Ninety-three thousand three hundred seventy-nine PICU patients discharged between 2009 and 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Index admissions and unplanned readmissions were characterized and their outcomes compared. Time-to-event analyses were performed to examine factors associated with readmission within 1 year. Eleven percent (10,233) of patients had 15,625 unplanned readmissions within 1 year to the same PICU; 3.4% had two or more readmissions. Readmissions had significantly higher PICU mortality and longer PICU length of stay, compared with index admissions (4.0% vs 2.5% and 2.5 vs 1.6 d; all p < 0.001). Median time to readmission was 30 days for all readmissions, 3.5 days for readmissions during the same hospitalization, and 66 days for different hospitalizations. Having more complex chronic conditions was associated with earlier readmission (adjusted hazard ratio, 2.9 for one complex chronic condition; hazard ratio, 4.8 for two complex chronic conditions; hazard ratio, 9.6 for three or more complex chronic conditions; all p < 0.001 compared no complex chronic condition). Most specific complex chronic condition conferred a greater risk of readmission, and some had considerably higher risk than others. CONCLUSIONS Unplanned readmissions occurred in a sizable minority of PICU patients. Patients with complex chronic conditions and particular conditions were at much higher risk for readmission.
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Kroeger AR, Morrison J, Smith AH. Predicting unplanned readmissions to a pediatric cardiac intensive care unit using predischarge Pediatric Early Warning Scores. CONGENIT HEART DIS 2017; 13:98-104. [PMID: 28762646 DOI: 10.1111/chd.12525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/10/2017] [Accepted: 07/17/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Unplanned readmission to the pediatric cardiac intensive care unit (CICU) is associated with significant morbidity and mortality. The Pediatric Early Warning Score (PEWS) predicts ward patients at risk for decompensation but has not been previously reported to identify at-risk patients with cardiac disease prior to ward transfer. This study aimed to determine whether PEWS prior to transfer may serve as a predictor of unplanned readmission to the CICU. DESIGN All patients discharged from a tertiary children's hospital CICU from September 2012 through August 2015 were included for analysis. PEWS assessment was performed following transfer to the cardiac ward, and starting in January 2014, PEWS scores were also assigned by bedside CICU nurse prior to transfer from the CICU. Scores exceeding a predetermined threshold prompted further stability assessment by provider team prior to transfer. RESULTS Among 1320 discharges of 1082 patients during the study period, there were 130 unplanned readmissions during their hospitalization. Following implementation of pretransfer PEWS scoring, there was no significant reduction in unplanned readmission frequency (10.2% vs 9.2%, P = .39). A secondary analysis of PEWS scores revealed cardiac scoring as a strong discriminator of those likely to experience an unplanned readmission, independent of other significant clinical predictors of readmission (OR 1.78, 95% CI 1.17-2.71, P = .007). The resultant multivariate model was a good predictor of unplanned readmission (AUC 0.77, 95% CI 0.71-0.83, P < .001). CONCLUSION While implementation of a pretransfer PEWS assessment did not reduce the frequency of unplanned readmissions in this small single-center cohort, a multivariate model including pretransfer elements of an early warning scoring system, along with other patient characteristics serves as a good discriminator of patients likely to experience an unplanned readmission following CICU discharge. Further prospective investigation is needed to define objective measures of pretransfer discharge readiness to potentially reduce the likelihood of unplanned readmissions.
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Affiliation(s)
- Ashley R Kroeger
- Department of Pediatrics, Section of Critical Care Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | | | - Andrew H Smith
- Department of Pediatrics, Section of Critical Care Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
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Geneslaw AS, Jia H, Lucas AR, Agus MSD, Edwards JD. Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both. J Crit Care 2017; 41:268-274. [PMID: 28601043 DOI: 10.1016/j.jcrc.2017.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 04/24/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To examine how intermediate care units (IMCUs) are used in relation to pediatric intensive care units (PICUs), characterize PICU patients that utilize IMCUs, and estimate the impact of IMCUs on PICU metrics. MATERIALS & METHODS Retrospective study of PICU patients discharged from 108 hospitals from 2009 to 2011. Patients admitted from or discharged to IMCUs were characterized. We explored the relationships between having an IMCU and several PICU metrics: physical length-of-stay (LOS), medical LOS, discharge wait time, admission severity of illness, unplanned PICU admissions from wards, and early PICU readmissions. RESULTS Thirty-three percent of sites had an IMCU. After adjusting for known confounders, there was no association between having an IMCU and PICU LOS, mean severity of illness of PICU patients admitted from general wards, or proportion of PICU readmissions or unplanned ward admissions. At sites with an IMCU, patients waited 3.1h longer for transfer from the PICU once medically cleared (p<0.001). CONCLUSIONS There was no association between having an IMCU and most measures of PICU efficiency. At hospitals with an IMCU, patients spent more time in the PICU once they were cleared for discharge. Other ways that IMCUs might affect PICU efficiency or particular patient populations should be investigated.
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Affiliation(s)
- Andrew S Geneslaw
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital, 3959 Broadway, New York, NY 10032, United States.
| | - Haomiao Jia
- School of Nursing, Columbia University, 617 West 168th Street, New York, NY 10032, United States.
| | - Adam R Lucas
- Department of Statistics, University of California, 367 Evans Hall, Berkeley, CA 94720, United States.
| | - Michael S D Agus
- Division of Medicine Critical Care, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
| | - Jeffrey D Edwards
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital, 3959 Broadway, New York, NY 10032, United States.
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Verlaat CW, Visser IH, Wubben N, Hazelzet JA, Lemson J, van Waardenburg D, van der Heide D, van Dam NA, Jansen NJ, van Heerde M, van der Starre C, van Asperen R, Kneyber M, van Woensel JB, van den Boogaard M, van der Hoeven J. Factors Associated With Mortality in Low-Risk Pediatric Critical Care Patients in The Netherlands. Pediatr Crit Care Med 2017; 18:e155-e161. [PMID: 28178075 DOI: 10.1097/pcc.0000000000001086] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine differences between survivors and nonsurvivors and factors associated with mortality in pediatric intensive care patients with low risk of mortality. DESIGN Retrospective cohort study. SETTING Patients were selected from a national database including all admissions to the PICUs in The Netherlands between 2006 and 2012. PATIENTS Patients less than 18 years old admitted to the PICU with a predicted mortality risk lower than 1% according to either the recalibrated Pediatric Risk of Mortality or the Pediatric Index of Mortality 2 were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 16,874 low-risk admissions were included of which 86 patients (0.5%) died. Nonsurvivors had more unplanned admissions (74.4% vs 38.5%; p < 0.001), had more complex chronic conditions (76.7% vs 58.8%; p = 0.001), were more often mechanically ventilated (88.1% vs 34.9%; p < 0.001), and had a longer length of stay (median, 11 [interquartile range, 5-32] d vs median, 3 [interquartile range, 2-5] d; p < 0.001) when compared with survivors. Factors significantly associated with mortality were complex chronic conditions (odds ratio, 3.29; 95% CI, 1.97-5.50), unplanned admissions (odds ratio, 5.78; 95% CI, 3.40-9.81), and admissions in spring/summer (odds ratio, 1.67; 95% CI, 1.08-2.58). CONCLUSIONS Nonsurvivors in the PICU with a low predicted mortality risk have recognizable risk factors including complex chronic condition and unplanned admissions.
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Affiliation(s)
- Carin W Verlaat
- 1Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands. 2Dutch Pediatric Intensive Care Evaluation, Department of Pediatric Intensive Care, Erasmus Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands. 3Radboud University, Nijmegen, The Netherlands. 4Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands. 5Department of Pediatric Intensive Care, Academic Hospital Maastricht, The Netherlands. 6Faculty Board Member, PICE Registry, the Netherlands. 7Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, The Netherlands. 8Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands. 9Department of Pediatric Intensive Care, VU University Medical Center, Amsterdam, The Netherlands. 10Department of Neonatal and Pediatric Intensive Care, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands. 11Department of Pediatric Intensive Care, University Medical Center Groningen, Groningen, The Netherlands. 12Department of Pediatric Intensive Care, Academic Medical Center, Amsterdam, The Netherlands. This work was performed at the Department of Pediatric Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Coro MD, Spaeder MC, Penk JS, Levin AB, Futterman C. Unscheduled Pediatric Intensive Care Unit Admissions in Patients With Cardiovascular Disease: Clinical Features and Outcomes. World J Pediatr Congenit Heart Surg 2017; 7:454-9. [PMID: 27358300 DOI: 10.1177/2150135116648308] [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: 10/22/2015] [Accepted: 04/06/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND An unscheduled readmission to the intensive care unit (ICU) is associated with increased morbidity and mortality in children. There is a paucity of data examining the impact of unscheduled admissions on outcomes in children with specific disease processes such as cardiovascular disease. We investigated the impact of scheduled versus unscheduled ICU admission on clinical outcomes and differences in patient characteristics in children with cardiovascular disease. METHODS This was a retrospective analysis of contemporaneously collected clinical data using the Virtual PICU Systems database. All consecutive admissions at 102 participating pediatric ICUs in patients with cardiovascular disease were collected from October 2010 to September 2012. RESULTS There were 48,653 admissions included in the analysis (44% scheduled and 56% unscheduled). The median patient age was 31 months. Unscheduled admissions were associated with longer ICU length of stay and increased mortality (both P < .001). Adjusting for age, weight, and primary ICU admission diagnosis (cardiovascular vs noncardiovascular), patients with unscheduled admissions had an increased odds of mortality (odds ratio = 4.8, P < .001). CONCLUSIONS Unscheduled ICU admissions were associated with worse clinical outcomes including increased mortality. Efforts targeted at reducing unscheduled admissions in at-risk patients are warranted.
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Affiliation(s)
- Melinda D Coro
- Division of Critical Care Medicine, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Michael C Spaeder
- Division of Pediatric Critical Care, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jamie S Penk
- Division of Pediatric Cardiology, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Amanda B Levin
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
| | - Craig Futterman
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
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Edwards JD. Anticipatory Guidance on the Risks for Unfavorable Outcomes among Children with Medical Complexity. J Pediatr 2017; 180:247-250. [PMID: 28029344 PMCID: PMC5722216 DOI: 10.1016/j.jpeds.2016.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 09/06/2016] [Accepted: 10/05/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Jeffrey D Edwards
- Division of Pediatric Critical Care Medicine, Columbia University College of Physician and Surgeons, New York, NY.
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47
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Kaur H, Naessens JM, Hanson AC, Fryer K, Nemergut ME, Tripathi S. PROPER: Development of an Early Pediatric Intensive Care Unit Readmission Risk Prediction Tool. J Intensive Care Med 2016; 33:29-36. [PMID: 27601481 DOI: 10.1177/0885066616665806] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE No risk prediction model is currently available to measure patient's probability for readmission to the pediatric intensive care unit (PICU). This retrospective case-control study was designed to assess the applicability of an adult risk prediction score (Stability and Workload Index for Transfer [SWIFT]) and to create a pediatric version (PRediction Of PICU Early Readmissions [PROPER]). DESIGN Eighty-six unplanned early (<48 hours) PICU readmissions from January 07, 2007, to June 30, 2014, were compared with 170 random controls. Patient- and disease-specific data and PICU workload factors were compared across the 2 groups. Factors statistically significant on multivariate analysis were included in the creation of the risk prediction model. The SWIFT scores were calculated for cases and controls and compared for validation. RESULTS Readmitted patients were younger, weighed less, and were more likely to be admitted from the emergency department. There were no differences in gender, race, or admission Pediatric Index of Mortality scores. A higher proportion of patients in the readmission group had a Pediatric Cerebral Performance Category in the moderate to severe disability category. Cases and controls did not differ with respect to staff workload at discharge or discharge day of the week; there was a much higher proportion of patients on supplemental oxygen in the readmission group. Only 2 of 5 categories in the SWIFT model were significantly different, and although the median SWIFT score was significantly higher in the readmissions group, the model discriminated poorly between cases and controls (area under the curve: 0.613). A 7-category PROPER score was created based on a multiple logistic regression model. Sensitivity of this model (score ≥12) for the detection of readmission was 81% with a positive predictive value of 0.50. CONCLUSION We have created a preliminary model for predicting patients at risk of early readmissions to the PICU from the hospital floor. The SWIFT score is not applicable for predicting the risk for pediatric population.
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Affiliation(s)
- Harsheen Kaur
- 1 Department of Pediatric Critical Care, Mayo Clinic, Rochester, MN, USA
| | - James M Naessens
- 2 Department of Health Science Research, Mayo Clinic, Rochester, MN, USA
| | - Andrew C Hanson
- 2 Department of Health Science Research, Mayo Clinic, Rochester, MN, USA
| | - Karen Fryer
- 1 Department of Pediatric Critical Care, Mayo Clinic, Rochester, MN, USA
| | | | - Sandeep Tripathi
- 4 Pediatric Critical Care, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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Abstract
OBJECTIVES ICU readmission within 48 hours of discharge is associated with increased mortality. The objectives of this study were to describe the frequency of, factors associated with, and outcomes associated with unplanned PICU readmission. DESIGN A retrospective case-control study was performed. We evaluated 13 candidate risk factors and report patient outcomes following readmission. Subgroup analyses were performed for patients discharged from the cardiac PICU and medical-surgical PICU. SETTING The study was undertaken at the Hospital for Sick Children, Department of Critical Care Medicine. PATIENTS Eligible patients were discharged from the PICU to an inpatient ward between December 2006 and January 2013. Case patients were readmitted to the PICU within 48 hours of discharge. MEASUREMENTS AND MAIN RESULTS There were 10,422 eligible patient discharges; 264 (2.5%) were readmitted within 48 hours. In the univariable analysis, unplanned readmission was associated with PICU patient admissions of younger age, lower weight, greater duration of PICU stay, greater cumulative stay in PICU in the past 2 years, higher Pediatric Logistic Organ Dysfunction score on PICU discharge, discharge outside goal discharge time (06:00-11:59 hr), use of extracorporeal organ support during ICU stay, greater Bedside Pediatric Early Warning Score, at discharge and discharge from the cardiac PICU. In the multivariable analysis, the factors most significantly associated with unplanned PICU readmission were length of stay more than 48 hours, greater cumulative length of PICU stay in the past 2 years, discharge from cardiac PICU, and higher Pediatric Logistic Organ Dysfunction and Bedside Pediatric Early Warning Scores on index discharge. Mortality was 1.8 times (p = 0.03) higher in patients with an unplanned PICU readmission compared with patients during their index PICU admission. CONCLUSIONS The only potentially modifiable factors we found associated with PICU readmission within 48 hours of discharge were discharge time of day and the Pediatric Logistic Organ Dysfunction and Bedside Pediatric Early Warning Scores at the time of PICU discharge.
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Abstract
OBJECTIVES To investigate the association between the type of ICU and mortality for children treated at PICUs and adult ICUs. DESIGN This was a national multicenter cohort study. Data were collected from electronic critical care data management systems at 3 units and from national intensive care registries at 26 units. SETTING We assessed the incidence of admissions, length of stay at ICUs, main diagnoses, and mortality for children at ICUs. Units were categorized as PICUs or as adult ICUs located at university hospitals or at non-academic central hospitals. PATIENTS Children younger than 17 years of age treated at ICUs in Finland. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS There were 4,876 admissions from 2009 to 2010, and 98.9% of patients survived until unit discharge. The mean length of stay was 3.0 ± 7.4 days; 1,395 patients (35%) required mechanical ventilation at PICUs versus 167 (35%) at adult university hospital ICUs versus 79 (19%) at central hospital ICUs (p < 0.001). The odds for mortality in univariate regression analysis were emergency admission (odds ratio, 3.99; 95% CI, 1.82-8.76), cardiovascular (odds ratio, 7.84; 95% CI, 3.49-22.88), gastrointestinal (odds ratio, 5.37; 95% CI, 1.45-19.88), acute infections (odds ratio, 2.83; 95% CI, 1.23-6.48), hematologic/oncologic disease (odds ratio, 10.32; 95% CI, 3.14-33.86), and nonsurgical trauma (odds ratio, 3.53; 95% CI, 1.19-10.41). Treatment at adult ICUs had higher odds of mortality compared with PICUs (university hospital: odds ratio, 3.93; 95% CI, 1.85-8.35 and central hospital: odds ratio, 3.91; 95% CI, 1.69-9.05), adjusted for readmission less than 48 hours after discharge, emergency admission, mechanical ventilation, and diagnostic group. CONCLUSIONS Pediatric patients treated at PICUs showed lower mortality. Requirement of mechanical ventilation, emergency admission, and readmission less than 48 hours after discharge and cardiovascular, gastrointestinal, acute infections, hematologic/oncologic disease, and nonsurgical trauma were associated with higher risk of mortality.
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