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Mao A, Niu X. Subtle respiratory distress during the postoperative transition period in children with congenital heart disease. Minerva Med 2024; 115:240-243. [PMID: 37166209 DOI: 10.23736/s0026-4806.23.08609-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Aifang Mao
- Department of Pediatric Cardio-Vascular Surgery, Anhui Provincial Children's Hospital, Hefei, China -
| | - Xiaomei Niu
- Department of Pediatric Cardio-Vascular Surgery, Anhui Provincial Children's Hospital, Hefei, China
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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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AlZaher RA, Murabi I, Enazi J, Antar M, Kolobe E, Delafuente S, Awani M. Implementation of nursing-led follow-up service for patients newly discharged from paediatric intensive care units: quality improvement initiative. BMJ Open Qual 2023; 12:bmjoq-2022-002148. [PMID: 37001907 PMCID: PMC10069594 DOI: 10.1136/bmjoq-2022-002148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundHuman resource shortages are a global challenge in the healthcare system and create barriers in providing timely follow-up visits for paediatric patients discharged recently from the intensive care unit (ICU). Relying on experienced intensive care nurses to provide follow-up services for patients post paediatric ICU (PICU) transfer has been proven a cost-effective and safe practice. This study aimed to achieve no delays in initiating follow-up visits and to assess the safety of implementing a nurse-led follow-up service.MethodsPlan–Do–Study–Act cycle was used targeting to achieve no delay in initiating follow-up visits and to maintain the safety of the patients. This cycle resulted in the implementation of a nurse-led follow-up service, which is under the provision of a paediatric rapid response team (RRT). Fifteen PICU nurses were trained in their new roles and responsibilities. Service databases were established to track and trend the frequency of visits, service safety measures and clinical deterioration.ResultsAfter the implementation of the nurse-led follow-up service, we achieved no delays in initiating the follow-up visits. 45% (n=487) of patients received a nurse-led follow-up visit service. Safety measures demonstrated 0.21% (n=1) recorded events of RRT activations during the follow-up service. RRT activation within 48 hours from service discharge was 1.2% (n=6), and readmission to PICU within 48 hours was 0.8% (n=4). No cardiopulmonary arrest event was recorded for patients under the nurse-led follow-up service during the service, postservice discharge or postreadmission to PICU.ConclusionsImplementing nursing-led service has been shown to be safe, efficient and provides patients with timely visits post-PICU discharge.
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Affiliation(s)
- Ruqiah Ali AlZaher
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Iris Murabi
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Jaber Enazi
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pediatric department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohannad Antar
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- Pediatric department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Efraim Kolobe
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Mona Awani
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
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Chong SL, Goh MSL, Ong GYK, Acworth J, Sultana R, Yao SHW, Ng KC, Scholefield B, Aickin R, Maconochie I, Atkins D, Couto TB, Guerguerian AM, Kleinman M, Kloeck D, Nadkarni V, Nuthall G, Reis A, Rodriguez-Nunez A, Schexnayder S, Tijssen J, Van de Voorde P, Morley P. Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis. Resusc Plus 2022; 11:100262. [PMID: 35801231 PMCID: PMC9253845 DOI: 10.1016/j.resplu.2022.100262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 11/17/2022] Open
Abstract
Aim We conducted a systematic review and meta-analysis to answer the question: Does the implementation of Paediatric Early Warning Systems (PEWS) in the hospital setting reduce mortality, cardiopulmonary arrests, unplanned codes and critical deterioration events among children, as compared to usual care without PEWS? Methods We conducted a comprehensive search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Web of Science. We included studies published between January 2006 and April 2022 on children <18 years old performed in inpatient units and emergency departments, and compared patient populations with PEWS to those without PEWS. We excluded studies without a comparator, case control studies, systematic reviews, and studies published in non-English languages. We employed a random effects meta-analysis and synthesised the risk and rate ratios from individual studies. We used the Scottish Intercollegiate Guidelines Network (SIGN) to appraise the risk of bias. Results Among 911 articles screened, 15 were included for descriptive analysis. Fourteen of the 15 studies were pre- versus post-implementation studies and one was a multi-centre cluster randomised controlled trial (RCT). Among 10 studies (580,604 hospital admissions) analysed for mortality, we found an increased risk (pooled RR 1.18, 95% CI 1.01–1.38, p = 0.036) in the group without PEWS compared to the group with PEWS. The sensitivity analysis performed without the RCT (436,065 hospital admissions) showed a non-significant relationship (pooled RR 1.17, 95% CI 0.98–1.40, p = 0.087). Among four studies (168,544 hospital admissions) analysed for unplanned code events, there was an increased risk in the group without PEWS (pooled RR 1.73, 95%CI 1.01–2.96, p = 0.046) There were no differences in the rate of cardiopulmonary arrests or critical deterioration events between groups. Our findings were limited by potential confounders and imprecision among included studies. Conclusions Healthcare systems that implemented PEWS were associated with reduced mortality and code rates. We recognise that these gains vary depending on resource availability and efferent response systems. PROSPERO registration: CRD42021269579.
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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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Discharge and Readmission to the Pediatric Cardiac ICU in Pediatric Patients With Durable Ventricular Assist Devices. Pediatr Crit Care Med 2020; 21:e810-e818. [PMID: 32769703 DOI: 10.1097/pcc.0000000000002456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Pediatric patients implanted with a durable ventricular assist device are initially managed in the pediatric cardiac ICU but are eligible for discharge to the ward. Our objectives were to characterize discharge and readmission of ventricular assist device patients to the pediatric cardiac ICU, identify risk factors for readmission, and determine whether discharge or readmission is associated with mortality. DESIGN Retrospective study. SETTING Stollery Children's Hospital. PATIENTS Patients implanted with a durable ventricular assist device at less than 18 years old between 2005 and 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 44 patients who underwent ventricular assist device implantation at a median age of 3.7 years (interquartile range, 0.6-9.0 yr), with the most common etiology being noncongenital heart disease (76.7%). Median time of total ventricular assist device support was 110.0 days (interquartile range, 42.3-212.3 d) with the median index pediatric cardiac ICU stay being 34.0 days (interquartile range, 19.8-81.0 d). Thirty patients (68.0%) were discharged to the ward with 18 (60.0%) having at least one readmission. The median time to first readmission was 18.0 days (interquartile range, 14.8-109.8 d) with a median of two readmissions per patient (interquartile range, 1.0-3.0). The most common reason for readmission was pump thrombosis (30.4%), followed by neurologic dysfunction (23.9%). There were no statistically significant pre- or post-implant factors associated with readmission, and readmission was not associated with mortality (p = 0.600). Univariate Kaplan-Meier survival analysis indicated that use of pre-implant extracorporeal membrane oxygenation, post-implant continuous renal replacement therapy, as well as failure to be discharged from the index pediatric cardiac ICU stay were associated with mortality. CONCLUSIONS Readmissions to the pediatric cardiac ICU occurred in 60.0% of pediatric patients on durable ventricular assist devices with the first readmission occurring within a month of discharge from the index pediatric cardiac ICU stay. While readmission was not associated with mortality, lack of discharge from index pediatric cardiac ICU stay was likely due to a worse pre-implant clinical status.
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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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Chapman SM, Maconochie IK. Early warning scores in paediatrics: an overview. Arch Dis Child 2019; 104:395-399. [PMID: 30413488 DOI: 10.1136/archdischild-2018-314807] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 01/05/2023]
Abstract
Paediatric Early Warning Scores (PEWS)are used in hospitalised patients to detect physiological deterioration and is being used increasingly throughout healthcare systems with a limited evidence based. There are two versions in general use that can lead to a clinical response, either by triggering an action or by reaching a 'threshold' when graduated responses may occur depending on the value of the score. Most evidence has come from research based on paediatric inpatients in specialist children's hospitals, although the range of research is expanding, taking into account other clinical areas such as paediatric intensive care unit, emergency department and the prehospital setting. Currrently, it is uncertain whether a unified system does deliver benefits in terms of outcomes or financial savings, but it may inform and improve patient communication. PEWS may be an additional tool in context of a patient's specific condition, and future work will include its validation for different conditions, different clinical settings, patient populations and organisational structure. The incorporation of PEWS within the electronic health records may form a keystone of the safe system framework and allow the development of consistent PEWS system to standardise practice.
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Affiliation(s)
- Susan M Chapman
- International and Private Patients Division, Great Ormond Street Hospital, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Ian K Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, London, UK.,Imperial College, London, UK
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