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Al-Harbi S. Impact of Rapid Response Teams on Pediatric Care: An Interrupted Time Series Analysis of Unplanned PICU Admissions and Cardiac Arrests. Healthcare (Basel) 2024; 12:518. [PMID: 38470629 PMCID: PMC10931051 DOI: 10.3390/healthcare12050518] [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: 12/28/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024] Open
Abstract
Pediatric rapid response teams (RRTs) are expected to significantly lower pediatric mortality in healthcare settings. This study evaluates RRTs' effectiveness in decreasing cardiac arrests and unexpected Pediatric Intensive Care Unit (PICU) admissions. A quasi-experimental study (2014-2017) at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, involved 3261 pediatric inpatients, split into pre-intervention (1604) and post-intervention (1657) groups. Baseline pediatric warning scores and monthly data on admissions, transfers, arrests, and mortality were analyzed pre- and post-intervention. Statistical methods including bootstrapping, segmented regression, and a Zero-Inflation Poisson model were employed to ensure a comprehensive evaluation of the intervention's impact. RRT was activated 471 times, primarily for respiratory distress (29.30%), sepsis (22.30%), clinical anxiety (13.80%), and hematological abnormalities (6.7%). Family concerns triggered 0.1% of activations. Post-RRT implementation, unplanned PICU admissions significantly reduced (RR = 0.552, 95% CI 0.485-0.628, p < 0.0001), and non-ICU cardiac arrests were eliminated (RR = 0). Patient care improvement was notable, with a -9.61 coefficient for PICU admissions (95% CI: -12.65 to -6.57, p < 0.001) and a -1.641 coefficient for non-ICU cardiac arrests (95% CI: -2.22 to -1.06, p < 0.001). Sensitivity analysis showed mixed results for PICU admissions, while zero-inflation Poisson analysis confirmed a reduction in non-ICU arrests. The deployment of pediatric RRTs is associated with fewer unexpected PICU admissions and non-ICU cardiopulmonary arrests, indicating improved PICU management. Further research using robust scientific methods is necessary to conclusively determine RRTs' clinical benefits.
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Affiliation(s)
- Samah Al-Harbi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Department of Pediatrics, King Abdulaziz University Hospital, Jeddah 22252, Saudi Arabia
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Olfat M, Hosseinzadeh R, Sharifzadeh M, Hassani SA, Goudarzi M, Mohammadpour M. Infant Intensive Care Unit: Is it Time to Change? Indian J Pediatr 2024:10.1007/s12098-024-05032-1. [PMID: 38358405 DOI: 10.1007/s12098-024-05032-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES To assess the effect of the Infant intensive care unit (InICU), a specialized unit for critically ill infants established in 2016 in authors' hospital, on infant mortality and compare the outcome with the current Pediatric intensive care units (PICU). METHODS In this retrospective cross-sectional study, two groups were defined; the first included expired patients aged 1 mo to 2 y admitted to PICU before the establishment of the InICU (the PICU group). The second included age-matched expired patients admitted to the InICU (the InICU group). Data were recorded using a questionnaire. RESULTS The authors found that the age, sex, underlying diseases, the leading cause of admission to the ICU, time of death, hospital and ICU length of stay, and the pediatric index of mortality 2 (PIM 2) score were same between the two groups. The incidence of mortality in the PICU group was 10.66 in 1000 person-month. This value was 6.37 for the InICU group (P-value <0.001). The relative risk of mortality of patients admitted to the PICU group compared to the InICU group was 1.67 (P-value <0.001). CONCLUSIONS Establishment of age specific InICU for infants may be beneficial in reducing infant mortality.
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Affiliation(s)
- Mehrnaz Olfat
- Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
- Division of Pediatric Intensive Care, Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | | | - Meisam Sharifzadeh
- Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
- Division of Pediatric Intensive Care, Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Abbas Hassani
- Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
- Division of Pediatric Intensive Care, Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Goudarzi
- Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
- Department of Anesthesiology, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Mohammadpour
- Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran.
- Division of Pediatric Intensive Care, Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
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Liang H, Carey KA, Jani P, Gilbert ER, Afshar M, Sanchez-Pinto LN, Churpek MM, Mayampurath A. Association between mortality and critical events within 48 hours of transfer to the pediatric intensive care unit. Front Pediatr 2023; 11:1284672. [PMID: 38188917 PMCID: PMC10768058 DOI: 10.3389/fped.2023.1284672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction Critical deterioration in hospitalized children, defined as ward to pediatric intensive care unit (PICU) transfer followed by mechanical ventilation (MV) or vasoactive infusion (VI) within 12 h, has been used as a primary metric to evaluate the effectiveness of clinical interventions or quality improvement initiatives. We explore the association between critical events (CEs), i.e., MV or VI events, within the first 48 h of PICU transfer from the ward or emergency department (ED) and in-hospital mortality. Methods We conducted a retrospective study of a cohort of PICU transfers from the ward or the ED at two tertiary-care academic hospitals. We determined the association between mortality and occurrence of CEs within 48 h of PICU transfer after adjusting for age, gender, hospital, and prior comorbidities. Results Experiencing a CE within 48 h of PICU transfer was associated with an increased risk of mortality [OR 12.40 (95% CI: 8.12-19.23, P < 0.05)]. The increased risk of mortality was highest in the first 12 h [OR 11.32 (95% CI: 7.51-17.15, P < 0.05)] but persisted in the 12-48 h time interval [OR 2.84 (95% CI: 1.40-5.22, P < 0.05)]. Varying levels of risk were observed when considering ED or ward transfers only, when considering different age groups, and when considering individual 12-h time intervals. Discussion We demonstrate that occurrence of a CE within 48 h of PICU transfer was associated with mortality after adjusting for confounders. Studies focusing on the impact of quality improvement efforts may benefit from using CEs within 48 h of PICU transfer as an additional evaluation metric, provided these events could have been influenced by the initiative.
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Affiliation(s)
- Huan Liang
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
| | - Kyle A. Carey
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Priti Jani
- Department of Pediatrics, University of Chicago, Chicago, IL, United States
| | - Emily R. Gilbert
- Department of Medicine, Loyola University Medical Center, Maywood, IL, United States
| | - Majid Afshar
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - L. Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Matthew M. Churpek
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Anoop Mayampurath
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
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Simpson MD, Watson CJ, Whitledge JD, Monuteaux MC, Burns MM. Intensive Care Interventions Among Children With Toxicologic Exposures to Cardiovascular Medications. Pediatr Crit Care Med 2023; 24:893-900. [PMID: 37133321 DOI: 10.1097/pcc.0000000000003274] [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: 05/04/2023]
Abstract
OBJECTIVES Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications. DESIGN Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022. SETTING International multicenter research network of 40 sites. PATIENTS Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied. CONCLUSIONS PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition.
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Affiliation(s)
- Michael D Simpson
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - C James Watson
- Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - James D Whitledge
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Risk Factors for Longer Pediatric Intensive Care Unit Length of Stay Among Children Who Required Escalation of Care Within 24 Hours of Admission. Pediatr Emerg Care 2022; 38:678-685. [PMID: 35138768 DOI: 10.1097/pec.0000000000002636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Children who require early escalation of care (EOC) to the pediatric intensive care unit (PICU) after floor admission have higher mortality and increased hospital length of stay (LOS) as compared with direct emergency department (ED) admissions. This study was designed to identify subgroups of patients within this cohort (EOC to PICU within 24 hours of hospital admission) who have worse outcomes (actual PICU LOS [aLOS] > predicted PICU LOS [pLOS]). METHODS This was a retrospective single-center cohort study. Patients who required EOC to PICU from January 2015 to December 2019 within 24 hours of admission were included. Postoperative patients, missing cause of EOC, and mortality were excluded. Predicted LOS was calculated based on Pediatric Risk of Mortality scores. Patients with aLOS > pLOS (group A) were compared with patients with aLOS ≤ pLOS (group B). Multivariable logistic regression was performed to adjust for confounders. RESULTS Of 587 patients transferred to PICU after hospital admission during the study period, 286 patients met the study criteria (group A, n = 69; group B, n = 217). The 2 groups were similar in age, race, the severity of illness, and ED vitals and therapies. A higher proportion of patients in group B had EOC ≤ 6 hours of admission (51.1% vs 36.2%, P = 0.03), and a higher proportion in group A required Mechanical ventilation (56% vs 34%, P = 0.01). On multivariable regression, patients who required EOC to PICU after 6 hours after admission (adjusted odds ratio, 2.27; 95% confidence interval [CI] 1.2, 4.0), p,<0.01) and patients admitted to the floor from referral hospitals (adjusted odds ratio, 1.8; 95% confidence interval, 1.0-3.2), P = 0.04) had higher risk of greater than PLOS. CONCLUSIONS Among patients who required EOC to PICU, risk factors associated with aLOS > pLOS were patients who required EOC to PICU longer than 6 hours after admission to the hospital and patients admitted to the floor as a transfer from referral hospitals.
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Kamzan AD, Tsoi S, Arslanian T, Sim MS, Romero T, Newcomer CA. Admission Source Is Associated With the Risk of Rapid Response Team Activation in a Children's Hospital. Acad Pediatr 2022; 22:1477-1481. [PMID: 35858662 DOI: 10.1016/j.acap.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 06/16/2022] [Accepted: 06/19/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate source of admission to a children's hospital as a predictor of rapid response team (RRT) activation, both in the first 48 hours of admission and over the entire hospitalization. METHODS Retrospective cohort study of all patients admitted to the pediatric ward between March 1, 2013 and December 31, 2015. Source of admission was categorized as from the emergency department, transfer from another hospital facility, admission following a planned surgery, direct admission planned in advance, or unplanned direct admission. Information was collected including whether or not the patient had a RRT activation and survival to discharge. A Fisher's exact test was used to assess the association between source of admission and risk of rapid response. RESULTS Of 8083 admissions included in the study, 194 had at least one RRT event. The odds of having an RRT was significantly associated with source of admission (P < .001). Using admission from the emergency department as a reference group, planned elective admissions (odds ratio [OR] 0.27; P < .001) and admissions following planned surgery (OR 0.07; P < .001) were significantly associated with reduced odds of having at least one RRT activation during the admission. Planned elective admissions also demonstrated reduced odds of RRT in the first 48 hours of hospitalization (OR 0.14; P = .002). Source of admission was also associated with survival to discharge (P < .05). CONCLUSION Source of admission is associated with likelihood of RRT activation as well as with survival to discharge and should be considered by providers when assessing inpatient risk of decompensation.
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Affiliation(s)
- Audrey D Kamzan
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif.
| | - Stephanie Tsoi
- UCSF Department of Pediatrics (S Tsoi), San Francisco, Calif
| | - Talin Arslanian
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif
| | - Myung Shin Sim
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of General Internal Medicine and Health Services Research (MS Sim, T Romero), Los Angeles, Calif
| | - Tahmineh Romero
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of General Internal Medicine and Health Services Research (MS Sim, T Romero), Los Angeles, Calif
| | - Charles A Newcomer
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif
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Taylor KL, Frndova H, Szadkowski L, Joffe AR, Parshuram CS. Risk factors for unplanned paediatric intensive care unit admission after anaesthesia—an international multicentre study. Paediatr Child Health 2022; 27:333-339. [DOI: 10.1093/pch/pxac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Unplanned intensive care unit (ICU) admissions are associated with near-miss events, morbidity, and mortality. We describe the rate, resource utilization, and outcomes of paediatric patients urgently admitted directly to ICU post-anaesthesia compared to other sources of unplanned ICU admissions.
Methods
We performed a secondary analysis of data from specialist paediatric hospitals in 7 countries. Patients urgently admitted to the ICU post-anaesthesia were combined and matched with 1 to 3 unique controls from unplanned ICU admissions from other locations by age and hospital. Demographic, clinical, and outcome variables were compared using the Wilcoxon rank-sum test for continuous variables and chi-square or Fisher’s exact test for categorical variables. The effect of admission sources on binary outcomes was estimated using univariable conditional logistic regression models with stratification by matched set of anaesthesia and non-anaesthesia admission sources.
Results
Most admissions were <1 year of age and for respiratory reasons. Admissions post-anaesthesia were shorter, occurred later in the day, and were more likely to be mechanically ventilated. Admissions post-anaesthesia were less likely to have had a previous ICU admission (4.8% compared to 11%, P=0.032) or PIM ‘high-risk diagnosis’ (9.5% versus 17.2%, P=0.035) but there was no difference in the number of subsequent ICU admissions. There was no difference in the PIM severity of illness score and no mortality difference between the groups.
Conclusions
Young children and respiratory indications dominated unplanned ICU admissions post-anaesthesia, which was more likely later in the day and with mechanical ventilation.
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Affiliation(s)
- Katherine L Taylor
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Anesthesia, University of Toronto , Toronto, Ontario , Canada
| | - Helena Frndova
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Leah Szadkowski
- University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Ari R Joffe
- Division of Critical Care Medicine, Department of Pediatrics, University of Alberta , Edmonton, Alberta , Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Critical Care Medicine, Department of Paediatrics, University of Toronto , Toronto, Ontario , Canada
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Mehta SD, Muthu N, Yehya N, Galligan M, Porter E, McGowan N, Papili K, Favatella D, Liu H, Griffis H, Bonafide CP, Sutton RM. Leveraging EHR Data to Evaluate the Association of Late Recognition of Deterioration With Outcomes. Hosp Pediatr 2022; 12:447-460. [PMID: 35470399 DOI: 10.1542/hpeds.2021-006363] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Emergency transfers (ETs), deterioration events with late recognition requiring ICU interventions within 1 hour of transfer, are associated with adverse outcomes. We leveraged electronic health record (EHR) data to assess the association between ETs and outcomes. We also evaluated the association between intervention timing (urgency) and outcomes. METHODS We conducted a propensity-score-matched study of hospitalized children requiring ICU transfer between 2015 and 2019 at a single institution. The primary exposure was ET, automatically classified using Epic Clarity Data stored in our enterprise data warehouse endotracheal tube in lines/drains/airway flowsheet, vasopressor in medication administration record, and/or ≥60 ml/kg intravenous fluids in intake/output flowsheets recorded within 1 hour of transfer. Urgent intervention was defined as interventions within 12 hours of transfer. RESULTS Of 2037 index transfers, 129 (6.3%) met ET criteria. In the propensity-score-matched cohort (127 ET, 374 matched controls), ET was associated with higher in-hospital mortality (13% vs 6.1%; odds ratio, 2.47; 95% confidence interval [95% CI], 1.24-4.9, P = .01), longer ICU length of stay (subdistribution hazard ratio of ICU discharge 0.74; 95% CI, 0.61-0.91, P < .01), and longer posttransfer length of stay (SHR of hospital discharge 0.71; 95% CI, 0.56-0.90, P < .01). Increased intervention urgency was associated with increased mortality risk: 4.1% no intervention, 6.4% urgent intervention, and 10% emergent intervention. CONCLUSIONS An EHR measure of deterioration with late recognition is associated with increased mortality and length of stay. Mortality risk increased with intervention urgency. Leveraging EHR automation facilitates generalizability, multicenter collaboratives, and metric consistency.
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Affiliation(s)
- Sanjiv D Mehta
- aDepartments of Anesthesiology and Critical Care Medicine
| | | | - Nadir Yehya
- aDepartments of Anesthesiology and Critical Care Medicine
- dDepartment of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Ezra Porter
- eCenter for Healthcare Quality and Analytics
| | | | - Kelly Papili
- aDepartments of Anesthesiology and Critical Care Medicine
| | - Dana Favatella
- gCritical Care Center for Evidence and Outcomes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hongyan Liu
- hBiomedical and Health Informatics, Data Science and Biostatistics Unit
| | - Heather Griffis
- hBiomedical and Health Informatics, Data Science and Biostatistics Unit
| | | | - Robert M Sutton
- aDepartments of Anesthesiology and Critical Care Medicine
- dDepartment of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Schleisman AS, Potthoff M, Schjodt K. Modification of a children's hospital pediatric early warning score (EWS): An evaluation of inter-rater reliability, nurses' critical thinking and perceptions of the tool. J Pediatr Nurs 2022; 63:90-95. [PMID: 34702596 DOI: 10.1016/j.pedn.2021.09.023] [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: 04/26/2021] [Revised: 08/02/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
Pediatric early warning scores (EWS) have been utilized to assist the identification of children at risk for clinically decompensating, experiencing a cardiac or respiratory arrest, or requiring a transfer to a higher level of care. Although their use is widespread, little consistency exists between tools and research evaluating the effectiveness of these tools is lacking. This quasi-experimental project evaluated twenty-five medical-surgical staff nurses' use and perceptions as well as the inter-rater reliability of a newly modified pediatric EWS tool at a free standing, academic Midwestern pediatric hospital. The tool was modified utilizing existing literature and an interdisciplinary team's expertise. Five fictionalized patients, presented in case studies, were developed and nurses were asked to score these patients using the newly modified tool with rationale. Inter-rater reliability was assessed utilizing Fleiss' Kappa and qualitative questionnaire data was analyzed for emerging themes. Overall, Fleiss' Kappa showed that there was moderate agreement between the nurses' judgments and scoring, with scores primarily differing due to the difficulty level of each case study. Nurses' responses to a questionnaire indicated differing levels of comfort identifying and managing children that present with mid-range total scores as opposed to those who scored in the lower or higher ranges. This project's findings highlight nurses' concerns that an objective tool may not accurately describe a subjective assessment. The results of this project indicated that use of this tool, with some modifications to address nursing concerns, may help to identify clinically decompensating pediatric patients being treated on medical-surgical units.
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Affiliation(s)
- Adrienne S Schleisman
- Creighton University, Children's Hospital & Medical Center, Omaha, NE 68124, United States of America.
| | - Meghan Potthoff
- Creighton University, 2500 California Plaza, Omaha, NE 68178, United States of America.
| | - Katharine Schjodt
- Children's Hospital & Medical Center, 8200 Dodge Street, Omaha, NE 68114, United States of America.
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10
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Tripathi S, Kim M. Outcome Differences Between Direct Admissions to the PICU From ED and Escalations From Floor. Hosp Pediatr 2021; 11:1237-1249. [PMID: 34625489 DOI: 10.1542/hpeds.2020-005769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare the outcomes (mortality and ICU length of stay) of patients with direct admissions to the PICU from the emergency department [ED]) versus as an escalation of care from the floor. METHODS A retrospective cohort study with a secondary analysis of registry data. Patient demographics and outcome variables collected from January 1, 2015, to December 31, 2019, were obtained from the Virtual Pediatric Systems database. Patients with a source of admission other than the hospital's ED or pediatric floor were excluded. Multivariable regression analysis controlling for age groups, sex, race, diagnostic categories, and severity of illness (Pediatric Index of Mortality III), with clustering for sites, was performed. RESULTS A total of 209 695 patients from 121 sites were included in the analysis. A total of 154 716 (73.7%) were admitted directly from the ED, and 54 979 were admitted (26.2%) as an escalation of care from the floor. Two groups differed in age and race distribution, medical complexity, diagnostic categories, and severity of illness. After controlling for measured confounders, patients with floor escalations had higher mortality (2.78% vs 1.95%; P < .001), with an odds ratio of 1.71 (95% CI 1.5 to 1.9) and longer PICU length of stay (4.9 vs 3.6 days; P < .001). The rates of most of the common ICU procedures and their durations were also significantly higher in patients with an escalation of care. CONCLUSIONS Compared with direct admissions to the PICU from the ED, patients who were initially triaged to the pediatric floor and then require escalation to the PICU have worse outcomes. Further research is needed to explore the potential causes of this difference.
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Affiliation(s)
- Sandeep Tripathi
- PICU, Children's Hospital of Illinois, OSF Saint Francis Medical Center, Peoria, Illinois
| | - Minchul Kim
- Center for Outcomes Research and Department of Internal Medicine, College of Medicine at Peoria, University of Illinois, Peoria, Illinois
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11
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Gawronski O, Ferro F, Cecchetti C, Ciofi Degli Atti M, Dall'Oglio I, Tiozzo E, Raponi M. Adherence to the bedside paediatric early warning system (BedsidePEWS) in a pediatric tertiary care hospital. BMC Health Serv Res 2021; 21:852. [PMID: 34419038 PMCID: PMC8380378 DOI: 10.1186/s12913-021-06809-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 07/22/2021] [Indexed: 12/03/2022] Open
Abstract
Background The aim of this study is to describe the adherence to the Bedside Pediatric Early Warning System (BedsidePEWS) escalation protocol in children admitted to hospital wards in a large tertiary care children’s hospital in Italy. Methods This is a retrospective observational chart review. Data on the frequency and accuracy of BedsidePEWS score calculations, escalation of patient observations, monitoring and medical reviews were recorded. Two research nurses performed weekly visits to the hospital wards to collect data on BedsidePEWS scores, medical reviews, type of monitoring and vital signs recorded. Data were described through means or medians according to the distribution. Inferences were calculated either with Chi-square, Student’s t test or Wilcoxon-Mann–Whitney test, as appropriate (P < 0.05 considered as significant). Results A total of 522 Vital Signs (VS) and score calculations [BedsidePEWS documentation events, (DE)] on 177 patient clinical records were observed from 13 hospital inpatient wards. Frequency of BedsidePEWS DE occurred < 3 times per day in 33 % of the observations. Adherence to the BedsidePEWS documentation frequency according to the hospital protocol was observed in 54 % of all patients; in children with chronic health conditions (CHC) it was significantly lower than children admitted for acute medical conditions (47 % vs. 69 %, P = 0.006). The BedsidePEWS score was correctly calculated and documented in 84 % of the BedsidePEWS DE. Patients in a 0–2 BedsidePEWS score range were all reviewed at least once a day by a physician. Only 50 % of the patients in the 5–6 score range were reviewed within 4 h and 42 % of the patients with a score ≥ 7 within 2 h. Conclusions Escalation of patient observations, monitoring and medical reviews matching the BedsidePEWS is still suboptimal. Children with CHC are at higher risk of lower compliance. Impact of adherence to predefined response algorithms on patient outcomes should be further explored.
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Affiliation(s)
- Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, 00165, Rome, Italy.
| | - Federico Ferro
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, 00165, Rome, Italy
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, 00165, Rome, Italy
| | - Marta Ciofi Degli Atti
- Clinical Epidemiology Unit, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, 00165, Rome, Italy
| | - Immacolata Dall'Oglio
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, 00165, Rome, Italy
| | - Emanuela Tiozzo
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, 00165, Rome, Italy
| | - Massimiliano Raponi
- Medical Directorate, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, 00165, Rome, Italy
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12
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DeSanti RL, Al-Subu AM, Cowan EA, Kamps NN, Lasarev MR, Schmidt J, Kory PD. Point-of-Care Lung Ultrasound to Diagnose the Etiology of Acute Respiratory Failure at Admission to the PICU. Pediatr Crit Care Med 2021; 22:722-732. [PMID: 33739956 DOI: 10.1097/pcc.0000000000002716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Determine the sensitivity and specificity of point-of-care lung ultrasound in identifying the etiology of acute respiratory failure at admission to the PICU. DESIGN Prospective observational study. SETTING Tertiary PICU. PATIENTS Children older than 37 weeks gestational age and less than or equal to 18 years old admitted to the PICU with acute respiratory failure from December 2018 to February 2020. INTERVENTION Point-of-care lung ultrasound performed within 14 hours of admission to the PICU by physicians blinded to patient history and clinical course. Two physicians, blinded to all clinical information, independently interpreted the point-of-care lung ultrasound and then established a consensus diagnosis (ultrasound diagnosis). The ultrasound diagnosis was compared with an independent, standardized review of the medical record following hospital discharge (final diagnosis). MEASUREMENTS AND RESULTS Eighty-eight patients were enrolled in the study. Forty-eight patients had a final diagnosis of bronchiolitis/viral pneumonitis (55%), 29 had pneumonia (33%), 10 had status asthmaticus (11%), and one was excluded because of an inability to differentiate the final diagnosis. Point-of-care lung ultrasound correctly identified the etiology of acute respiratory failure in 56% of patients (49/87; 95% CI, 46-66%). It identified bronchiolitis/viral pneumonitis with 44% sensitivity (95% CI, 0.31-0.58) and 74% specificity (95% CI, 0.59-0.85), pneumonia with 76% sensitivity (95% CI, 0.58-0.88) and 67% specificity (95% CI 0.54-0.78), and status asthmaticus with 60% sensitivity (95% CI, 0.31-0.83) and 88% specificity (95% CI, 0.79-0.94). CONCLUSIONS In contrast to literature demonstrating high utility differentiating the cause of acute respiratory failure in adults, blinded point-of-care lung ultrasound demonstrates moderate sensitivity and specificity in identifying the etiology of pediatric acute respiratory failure at admission to the PICU among children with bronchiolitis, pneumonia, and status asthmaticus.
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Affiliation(s)
- Ryan L DeSanti
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Awni M Al-Subu
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Eileen A Cowan
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Nicole N Kamps
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael R Lasarev
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jessica Schmidt
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Pierre D Kory
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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13
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Psychological Outcomes in Fathers of Critically Ill Children in the Pediatric Intensive Care Unit: A Systematic Review. J Clin Psychol Med Settings 2021; 29:249-261. [PMID: 34272639 DOI: 10.1007/s10880-021-09800-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 10/20/2022]
Abstract
Systematically review evidence of psychological distress in fathers of children admitted to the pediatric intensive care unit (PICU). Two reviewers independently reviewed 24 published articles that studied fathers during and closely following a PICU admission. Results are presented for psychological outcomes of stress, PTSD, anxiety and depression, family functioning, and other forms of distress. Potential moderators of distress are also presented. Although methodological variance and inconsistent findings make it difficult to draw definitive conclusions, mothers and fathers appear to experience similar levels of distress and psychiatric symptoms during and after a PICU admission. Fathers' distress may be characterized by feelings of helplessness and often manifests after discharge, later than for mothers. More research is needed to understand gender differences in the expression of parental distress during and after a PICU admission as this will serve to inform interventions designed to improve family functioning.
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14
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Nadeau N, Monuteaux MC, Tripathi J, Stack AM, Perron C, Neuman MI. Does Timing Matter?: Timing and Outcomes Among Early Unplanned PICU Transfers. Hosp Pediatr 2021; 11:896-901. [PMID: 34234009 DOI: 10.1542/hpeds.2020-004978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Many institutions track early ICU transfers (transfer from an inpatient floor to an ICU within 24 hours of admission) as a marker of quality of emergency department (ED) care. There are limited data evaluating whether patient characteristics or clinical outcomes differ on the basis of timing of ICU transfer within this 24-hour window. METHODS We conducted a retrospective cohort study examining all patients ≤21 years old admitted to an inpatient pediatric floor from the ED and subsequently transferred to an ICU within 24 hours of hospitalization. Patient characteristics and clinical outcomes were compared on the basis of timing (0-6 hours, 6-12 hours, 12-24 hours) of ICU transfer. Outcomes assessed included receipt of critical intervention, timing of intervention with respect to transfer, type of intervention received, hospital and ICU length of stay, and mortality at 72 hours and during hospitalization. RESULTS A total of 841 patients were transferred to an ICU within 24 hours from admission to a pediatric ward from the ED; 266 patients (32%) transferred within 6 hours of admission, 269 patients (32%) transferred between 6 and 12 hours, and 306 patients (36%) transferred between 12 and 24 hours. Patient characteristics did not materially differ on the basis of timing of ICU transfer, nor did clinical outcomes. CONCLUSIONS Among children transferred to an ICU within 24 hours of hospitalization, patient characteristics and clinical outcomes did not materially differ based on the timing of transfer relative to admission from the ED.
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Affiliation(s)
| | - Michael C Monuteaux
- Department of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jaya Tripathi
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne M Stack
- Department of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Catherine Perron
- Department of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark I Neuman
- Department of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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15
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Reisi M, Keivanfar M, Mostofizadeh N, Madihi Y, Esmaeilian Y, Hashemi E. Correlation between Stable Hyperglycemia and Mortality in Children Admitted to the Pediatric Intensive Care Unit of Imam Hossein Hospital. Adv Biomed Res 2021; 10:2. [PMID: 33959559 PMCID: PMC8095254 DOI: 10.4103/abr.abr_31_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/07/2020] [Accepted: 04/22/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Stress-induced hyperglycemia is an important issue among pediatrics admitted in the pediatric intensive care unit (PICU). Former studies have declared that hyperglycemia has a high prevalence rate and could increase the risks of mortality among pediatrics. Here, we aimed to investigate the prevalence rate of hyperglycemia and its effects on mortality among pediatrics in the PICU of the hospital. Materials and Methods: This cross-sectional study was performed in 2018–2019 on 88 patients admitted in PICU. Data regarding blood sugar (BS) and other clinical and laboratory parameters were collected. Hyperglycemia was accounted for as BS of >126 mg/dl. Hyperglycemia was divided into: mild (126 <BS <150), moderate (150 <BS <200) and severe (BS >200). The pediatric risk of mortality (PRISM) score was also calculated for each patient during the first 24 h. Results: Thirty patients (34.1%) had persistent hyperglycemia and 58 patients (65.9%) had normal glycemic indexes. Eleven patients (12.5%) had mild, 9 patients (10.2%) had moderate, and 10 patients (11.4%) had severe hyperglycemia. The prevalence of mortality was 5.7% among hyperglycemic patients and 6.8% among normal glycemic pediatrics. There were no statistically significant differences regarding mortality rate (P = 0.499). The mean PRISM score for normal glycemic patients was 7.03 ± 5.18 and for patients with hyperglycemia was 7.36 ± 6.37. Conclusion: Hyperglycemia has no significant effects on mortality and PRISM score of pediatrics in PICU, despite of the previous studies. The frequency of hyperglycemia was also 5.7% among the patients admitted in PICU.
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Affiliation(s)
- Mohsen Reisi
- Department of Pediatric Pulmonology, Emam Hossein Children Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Keivanfar
- Department of Pediatric Pulmonology, Emam Hossein Children Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Neda Mostofizadeh
- Department of Pediatric Endocrinology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yahya Madihi
- Department of Pediatric Nephrology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yousof Esmaeilian
- Department of Pediatric Pulmonology, Emam Hossein Children Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elham Hashemi
- Department of Pediatric Endocrinology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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16
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Tripathi S, Meixsell LJ, Astle M, Kim M, Kapileshwar Y, Hassan N. A Longer Route to the PICU Can Lead to a Longer Stay in the PICU: A Single-Center Retrospective Cohort Study. J Intensive Care Med 2020; 37:60-67. [PMID: 33131382 DOI: 10.1177/0885066620969102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Admission to the pediatric ICU versus general pediatric floor for patients is a significant triage decision for emergency department physicians. Escalation of care within 24 hours of hospital admission is considered as a quality metric for pediatric E.R. There exists, however, a lack of data to show that such escalation leads to a poor outcome. METHODS A retrospective cohort study was conducted to compare outcomes of patients who required escalation of care within 24 hours of hospital admission to the pediatric ICU (cases) from 01/01 2015 to 02/28 2019 with those who were directly admitted from emergency department to the PICU (controls). A total of 327 cases were compared to 931 controls. Univariate and multivariable regression analysis was done to compare the length of stay and mortality data. RESULTS Patients who required escalation of care were significantly younger (median age 1.9 years compared to 4.6 years for controls) and had lower severity of illness score (PIM 3). Cases had a much higher proportion of respiratory diagnosis. ICU length of stay, hospital length of stay and the direct cost was significantly higher for cases compared to controls. This difference persisted for all age groups and respiratory diagnosis. The cost of care, however, was only different for 1-5 years and >5 years age groups. The difference in ICU length of stay (Δ11.1%) and hospital length of stay (Δ7.8%) persisted on multivariate regression analysis after controlling for age, sex, PIM3 score, and diagnostic variables. There was no difference in mortality on the univariate or multivariate analysis between the 2 groups. CONCLUSIONS Patients who required escalation of care within 24 hours of hospital admissions have more prolonged ICU and hospital stay and potentially increased cost of care. This measure should be considered while making patient disposition decisions in the emergency department.
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Affiliation(s)
- Sandeep Tripathi
- Division of Critical Care, Department of Pediatrics, 17120University of Illinois College of Medicine, Peoria, IL, USA
| | | | - Michele Astle
- Department of Quality and Safety, 14407OSF Saint Francis Medical Centre, Peoria, IL, USA
| | - Minchul Kim
- Center for Outcomes Research, Department of Internal Medicine, 17120University of Illinois College of Medicine, Peoria, IL, USA
| | - Yamini Kapileshwar
- Division of Critical Care, Department of Pediatrics, 17120University of Illinois College of Medicine, Peoria, IL, USA
| | - Nabil Hassan
- Division of Critical Care, Department of Pediatrics, 17120University of Illinois College of Medicine, Peoria, IL, USA
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17
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Nadeau N, Monuteaux MC, Tripathi J, Stack AM, Perron C, Neuman MI. Pediatric ICU Transfers Within 24 Hours of Admission From the Emergency Department: Rate of Transfer, Outcomes, and Clinical Characteristics. Hosp Pediatr 2020; 9:393-397. [PMID: 31023788 DOI: 10.1542/hpeds.2018-0235] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is a paucity of data describing pediatric patients transferred to an ICU within 24 hours of hospital admission from the emergency department (ED). METHODS We conducted a retrospective cohort study of patients ≤21 years old transferred from an inpatient floor to an ICU within 24 hours of ED disposition from 2007 to 2016 in a tertiary children's hospital. Patients transferred to an ICU after planned operative procedures were excluded. Rate of transfer, clinical course, and baseline demographic and/or clinical characteristics of these patients are described. RESULTS The study cohort consisted of 841 children, representing 1% of 82 397 non-ICU ED admissions over the 10-year period. Median age was 5.1 years, 43% had ≥1 complex chronic condition, and 47% were hospitalized within the previous year (27% in the ICU). The majority of transfers were for respiratory conditions (65%) and cardiovascular compromise (18%). Median time from hospitalization to ICU transfer was 9.1 hours (interquartile range 5.1-14.9 hours). Thirty-eight percent of transfers received 1 or more critical interventions within 72 hours of hospitalization, most commonly positive pressure ventilation (29%) and vasoactive infusion (9%). Median time to intervention from hospitalization was 13.6 hours (interquartile range 7.5-21.6 hours), 0.8% of children died within 72 hours of hospitalization, and 2.4% died overall. CONCLUSIONS In this single pediatric academic center, 1% of hospitalized children were transferred to an ICU within 24 hours of ED disposition. One-third of patients received a critical intervention, and 2.4% died. Although most ED dispositions are appropriate, future efforts to identify patients at the highest risk of deterioration are warranted.
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Affiliation(s)
- Nicole Nadeau
- Division of Pediatric Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jaya Tripathi
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Anne M Stack
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Catherine Perron
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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18
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Rongali S, Rose AJ, McManus DD, Bajracharya AS, Kapoor A, Granillo E, Yu H. Learning Latent Space Representations to Predict Patient Outcomes: Model Development and Validation. J Med Internet Res 2020; 22:e16374. [PMID: 32202503 PMCID: PMC7136840 DOI: 10.2196/16374] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/27/2020] [Accepted: 02/14/2020] [Indexed: 12/13/2022] Open
Abstract
Background Scalable and accurate health outcome prediction using electronic health record (EHR) data has gained much attention in research recently. Previous machine learning models mostly ignore relations between different types of clinical data (ie, laboratory components, International Classification of Diseases codes, and medications). Objective This study aimed to model such relations and build predictive models using the EHR data from intensive care units. We developed innovative neural network models and compared them with the widely used logistic regression model and other state-of-the-art neural network models to predict the patient’s mortality using their longitudinal EHR data. Methods We built a set of neural network models that we collectively called as long short-term memory (LSTM) outcome prediction using comprehensive feature relations or in short, CLOUT. Our CLOUT models use a correlational neural network model to identify a latent space representation between different types of discrete clinical features during a patient’s encounter and integrate the latent representation into an LSTM-based predictive model framework. In addition, we designed an ablation experiment to identify risk factors from our CLOUT models. Using physicians’ input as the gold standard, we compared the risk factors identified by both CLOUT and logistic regression models. Results Experiments on the Medical Information Mart for Intensive Care-III dataset (selected patient population: 7537) show that CLOUT (area under the receiver operating characteristic curve=0.89) has surpassed logistic regression (0.82) and other baseline NN models (<0.86). In addition, physicians’ agreement with the CLOUT-derived risk factor rankings was statistically significantly higher than the agreement with the logistic regression model. Conclusions Our results support the applicability of CLOUT for real-world clinical use in identifying patients at high risk of mortality.
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Affiliation(s)
- Subendhu Rongali
- College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, United States
| | - Adam J Rose
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, United States
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Adarsha S Bajracharya
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States.,Meyers Primary Care Institute, Worcester, MA, United States
| | - Edgard Granillo
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Hong Yu
- College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, United States.,Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States.,Department of Computer Science, University of Massachusetts Lowell, Lowell, MA, United States.,Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, MA, United States
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19
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Miranda JDOF, Camargo CLD, Nascimento Sobrinho CL, Portela DS, Pinho PDS, Oliveira TDL. FACTORS ASSOCIATED WITH THE CLINICAL DETERIORATION RECOGNIZED BY AN EARLY WARNING PEDIATRIC SCORE. TEXTO & CONTEXTO ENFERMAGEM 2020. [DOI: 10.1590/1980-265x-tce-2018-0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To identify the factors associated with clinical deterioration recognized by a Pediatric Early Warning Score. Method: A cross-sectional study conducted in a tertiary pediatric public hospital with 271 children aged from zero to ten, hospitalized between May and October 2015. For the identification of the children with and without signs of clinical deterioration, the translated, adapted and validated version of the Brighton Pediatric Early Warning Score was applied to the Brazilian context. Logistic regression analysis and prevalence ratio (PR) were used to measure the association between the variables studied. A 95% Confidence Interval (CI) and p value were adopted as a measure of statistical significance to identify potential associated factors. Results: The factors associated with the clinical deterioration of the children studied were age ≤ 2 years old (p=0.000), hospitalization in the emergency unit (p=0.000), comorbidity (p=0.020) and clinical diagnosis of respiratory disease (p=0.000). Conclusion: Children ≤ 2 years old, with comorbidity, diagnosed with respiratory disease and hospitalized in the emergency unit showed an increased likelihood of clinical deterioration. The identification of factors associated with clinical deterioration may alert and direct the health team to children more susceptible to this phenomenon.
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Affiliation(s)
| | | | | | | | | | - Thaiane de Lima Oliveira
- Universidade Estadual de Feira de Santana, Brasil; Hospital Estadual da Criança da Bahia, Brasil
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20
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Jensen CS, Kirkegaard H, Aagaard H, Olesen HV. Clinical profile of children experiencing in-hospital clinical deterioration requiring transfer to a higher level of care. J Child Health Care 2019; 23:522-533. [PMID: 30124066 DOI: 10.1177/1367493518794400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Few studies have described the various reasons for unplanned transfer to a higher level of care due to clinical deterioration and the clinical profile of those paediatric patients. However, an understanding of the nature of illness is important to patient safety. This study aimed to describe the frequency and clinical characteristics of children who experience unplanned transfer to a higher level of care due to clinical deterioration. A retrospective, descriptive registry study design was used. Of the 92 paediatric patients included, 69% (n = 64) was male. The median age was 2.1 years (interquartile range 0.4-6.9) with 33% being infants under 1 year. The highest number (61.3%) of transfers occurred between 8 and 16 hours. In the 24 hours leading up to a transfer due to clinical deterioration, 15 patients had no vital parameters documented, and 77 patients had least one vital parameter measured. Physiological abnormalities were present in 19 (37.7%) of the 77 patients where vital parameters were documented. This study provides essential baseline data to inform further research to improve care and treatment for critically ill children in paediatric wards. This study's findings suggest reporting of vital parameters is incomplete and infrequent.
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Affiliation(s)
- Claus Sixtus Jensen
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.,Department of Paediatrics and Adolescent Medicine, Herlev Gentofte Hospital, Herlev, Denmark
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Hanne Aagaard
- Lovisenberg Diaconal University College, Oslo, Norway.,Section for Nursing, Department of Public Health, Aarhus University, Aarhus N, Denmark
| | - Hanne Vebert Olesen
- Department of Child and Adolescent Health, Aarhus University Hospital, Aarhus N, Denmark
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21
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Williams V, Jaiswal N, Chauhan A, Pradhan P, Jayashree M, Singh M. Time of Pediatric Intensive Care Unit Admission and Mortality: A Systematic Review and Meta-Analysis. J Pediatr Intensive Care 2019; 9:1-11. [PMID: 31984150 DOI: 10.1055/s-0039-3399581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/03/2019] [Indexed: 01/21/2023] Open
Abstract
The aim of this study was to determine the association between the time of admission (day, night, and/or weekends) and mortality among critically ill children admitted to a pediatric intensive care unit (PICU). Electronic databases that were searched include PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Ovid, and Cochrane Library since inception till June 15, 2018. The article included observational studies reporting inhospital mortality and the time of admission to PICU limited to patients aged younger than 18 years. Meta-analysis was performed by a frequentist approach with both fixed and random effect models. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was used to evaluate the quality of evidence. Ten studies met our inclusion criteria. Five studies comparing weekday with weekend admissions showed better odds of survival on weekdays (odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.60-0.99). Pooled data of four studies showed that odds of mortality were similar between day and night admissions (OR: 0.93; 95% CI: 0.77-1.13). Similarly, three studies comparing admission during off-hours versus regular hours did not show better odds of survival during regular hours (OR: 0.77; 95% CI: 0.57-1.05). Heterogeneity was significant due to variable sample sizes and time period. Inconsistency in adjusting for confounders across the included studies precluded us from analyzing the adjusted risk of mortality. Weekday admissions to PICU were associated with lesser odds of mortality. No significant differences in the odds of mortality were found between admissions during day versus night or between admission during regular hours and that during off-hours. However, the evidence is of low quality and requires larger prospective studies.
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Affiliation(s)
- Vijai Williams
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Nishant Jaiswal
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India.,Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Anil Chauhan
- Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Pranita Pradhan
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Muralidharan Jayashree
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Meenu Singh
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India.,Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
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22
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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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23
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Sick, But Not Sick Enough? Pediatr Crit Care Med 2019; 20:685-686. [PMID: 31274799 DOI: 10.1097/pcc.0000000000001991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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A Retrospective Case-Control Study to Identify Predictors of Unplanned Admission to Pediatric Intensive Care Within 24 Hours of Hospitalization. Pediatr Crit Care Med 2019; 20:e293-e300. [PMID: 31149966 DOI: 10.1097/pcc.0000000000001977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To identify the clinical findings available at the time of hospitalization from the emergency department that are associated with deterioration within 24 hours. DESIGN A retrospective case-control study. SETTING A pediatric hospital in Ottawa, ON, Canada. PATIENTS Children less than 18 years old who were hospitalized via the emergency department between January 1, 2008, and December 31, 2012. Cases (n = 98) had an unplanned admission to the PICU or unexpected death on the hospital ward within 24 hours of hospitalization and controls (n = 196) did not. INTERVENTIONS None. MAIN RESULTS Ninety-eight children (53% boys; mean age 63.2 mo) required early unplanned admission to the PICU. Multivariable conditional logistic regression resulted in a model with five predictors reaching statistical significance: higher triage acuity score (odds ratio, 4.1; 95% CI, 1.7-10.2), tachypnea in the emergency department (odds ratio, 4.6; 95% CI, 1.8-11.8), tachycardia in the emergency department (odds ratio, 2.6; 95% CI, 1.1-6.5), PICU consultation in the emergency department (odds ratio, 8.0; 95% CI, 1.1-57.7), and admission to a ward not typical for age and/or diagnosis (odds ratio, 4.5; 95% CI, 1.7-11.6). CONCLUSIONS We have identified risk factors that should be included as potential predictor variables in future large, prospective studies to derive and validate a weighted scoring system to identify hospitalized children at high risk of early clinical deterioration.
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25
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Flaherty BF, Schroeder AR. Early, Unanticipated PICU Transfers: Is There a Need for Improvement? Hosp Pediatr 2019; 9:402-404. [PMID: 31023787 DOI: 10.1542/hpeds.2019-0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Brian F Flaherty
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah; and
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
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26
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Wang BC, Pei T, Lin CB, Guo R, Elashoff D, Lin JA, Pineda C. Clinical characteristics and outcomes associated with nasal intermittent mandatory ventilation in acute pediatric respiratory failure. World J Crit Care Med 2018; 7:46-51. [PMID: 30211019 PMCID: PMC6134265 DOI: 10.5492/wjccm.v7.i4.46] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 07/25/2018] [Accepted: 08/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To characterize the clinical course and outcomes of nasal intermittent mandatory ventilation (NIMV) use in acute pediatric respiratory failure.
METHODS We identified all patients treated with NIMV in the pediatric intensive care unit (PICU) or inpatient general pediatrics between January 2013 and December 2015 at two academic centers. Patients who utilized NIMV with other modes of noninvasive ventilation during the same admission were included. Data included demographics, vital signs on admission and prior to initiation of NIMV, pediatric risk of mortality III (PRISM-III) scores, complications, respiratory support characteristics, PICU and hospital length of stays, duration of respiratory support, and complications. Patients who did not require escalation to mechanical ventilation were defined as NIMV responders; those who required escalation to mechanical ventilation (MV) were defined as NIMV non-responders. NIMV responders were compared to NIMV non-responders.
RESULTS Forty-two patients met study criteria. Six (14%) failed treatment and required MV. The majority of the patients (74%) had a primary diagnosis of bronchiolitis. The median age of these 42 patients was 4 mo (range 0.5-28.1 mo, IQR 7, P = 0.69). No significant difference was measured in other baseline demographics and vitals on initiation of NIMV; these included age, temperature, respiratory rate, O2 saturation, heart rate, systolic blood pressure, diastolic blood pressure, and PRISM-III scores. The duration of NIMV was shorter in the NIMV non-responder vs NIMV responder group (6.5 h vs 65 h, P < 0.0005). Otherwise, NIMV failure was not associated with significant differences in PICU length of stay (LOS), hospital LOS, or total duration of respiratory support. No patients had aspiration pneumonia, pneumothorax, or skin breakdown.
CONCLUSION Most of our patients responded to NIMV. NIMV failure is not associated with differences in hospital LOS, PICU LOS, or duration of respiratory support.
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Affiliation(s)
- Billy C Wang
- Department of Pediatrics, Division of Critical Care Medicine, Loma Linda University Children’s Hospital, Loma Linda, CA 92354, United States
| | - Theodore Pei
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
| | - Cheryl B Lin
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
| | - Rong Guo
- Department of Medicine, Biostatistics Core, UCLA David Geffen School of Medicine, Los Angeles, CA 90024, United States
| | - David Elashoff
- Department of Medicine, Biostatistics Core, UCLA David Geffen School of Medicine, Los Angeles, CA 90024, United States
| | - James A Lin
- Department of Pediatrics, Mattel Children’s Hospital at UCLA, Los Angeles, CA 90095, United States
| | - Carol Pineda
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
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27
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Levkovich BJ, Bingham G, Jones D, Kirkpatrick CM, Cooper DJJ, Dooley MJ. Understanding how medications contribute to clinical deterioration and are used in rapid response systems: A comprehensive scoping review. Aust Crit Care 2018; 32:256-272. [PMID: 30005938 DOI: 10.1016/j.aucc.2018.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In hospitals, rapid response systems (RRSs) identify patients who deteriorate and provide critical care at their bedsides to stabilise and escalate care. Medications, including oral and parenteral pharmaceutical preparations, are the most common intervention for hospitalised patients and the most common cause of harm. This connection between clinical deterioration and medication safety is poorly understood. OBJECTIVES To inform improvements in prevention and management of clinical deterioration, this review aimed to examine how medications contributed to clinical deterioration and how medications were used in RRSs. REVIEW METHODS A scoping review was undertaken of medication data reported in studies of clinical deterioration or RRSs in diverse hospital settings between 2005 and 2017. Bibliographic database searches used permutations of "rapid response system," "medical emergency team," and keyword searching with medication-related terms. Independent selection, quality assessment, and data extraction informed mapping against four medication themes: causes of deterioration, predictors of deterioration, RRS use, and management. RESULTS Thirty articles were reviewed. Quality was low: limited by small samples, observational, single-centre designs and few primary medication-related outcomes. Adverse drug reactions and potentially preventable medication errors, involving sedatives, analgesics, and cardiovascular agents, contributed to clinical deterioration. While sparsely reported, outcomes included death and escalation of care. In children, administration of antibiotics or nebulised medications appeared to predict subsequent deterioration. Cardiovascular medications, sedatives, and analgesics commonly were used to manage deterioration but further detail was lacking. Despite reported potential for patient harm, evaluation of medication management systems was limited. CONCLUSIONS Medications contributed to potentially preventable clinical deterioration, with considerable harm, and were common interventions for its management. When assessing deteriorating patients or caring for patients who require escalation to critical care, clinicians should consider medication errors and adverse reactions. Studies with more specific medication-related, patient-centred end points could reduce medication-related deterioration and refine RRS medication use and management.
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Affiliation(s)
- Bianca J Levkovich
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia.
| | - Gordon Bingham
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Daryl Jones
- Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia.
| | - Carl M Kirkpatrick
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.
| | - D J Jamie Cooper
- Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Michael J Dooley
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia.
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Ye S, Zhang Y, Zhang C, Xu D. Are platelet volume indices related to mortality in hospitalized children on mechanical ventilation? J Int Med Res 2018; 46:1197-1208. [PMID: 29322854 PMCID: PMC5972253 DOI: 10.1177/0300060517737211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives To investigate platelet volume indices and in-hospital mortality in children on mechanical ventilation. Methods This retrospective study included children aged <16 years on mechanical ventilation, and compared parameters, measured on admission, between survivors and non-survivors. Dynamic platelet volume indices over the first 7 days were visualized. Independent risk factors of mortality were identified using multivariate logistic regression analysis. Results Out of 2 319 children aged 28 days–3 years, serum albumin (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.85, 0.96), bilirubin (OR 1.01, 95% CI 1.0, 1.77), and lactic acid (OR 1.22, 95% CI 1.05, 1.38) levels were associated with mortality. Out of 2 415 children aged > 3 years, procalcitonin (OR 1.01, 95% CI 1.0, 1.01) and lactic acid (OR 1.22, 95% CI 1.09, 1.35) were associated with mortality. Platelet volume indices on admission were not independently associated with mortality in either group. Mean platelet volume (MPV) and platelet distribution width (PDW) showed different trends in non-survivors versus survivors over 1 week in both age groups. Conclusions Platelet volume indices may be associated with mortality in critically ill children receiving mechanical ventilation.
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Affiliation(s)
- Sheng Ye
- 1 Pediatric Intensive Care Unit, 37066 The Children's Hospital, Zhejiang University School of Medicine , Hangzhou, China
| | - Yanyi Zhang
- 2 Psychological Department, 37066 The Children's Hospital, Zhejiang University School of Medicine , Hangzhou, China
| | - Chenmei Zhang
- 1 Pediatric Intensive Care Unit, 37066 The Children's Hospital, Zhejiang University School of Medicine , Hangzhou, China
| | - Dan Xu
- 1 Pediatric Intensive Care Unit, 37066 The Children's Hospital, Zhejiang University School of Medicine , Hangzhou, China
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29
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Krmpotic K, Van den Bruel A, Lobos AT. A Modified Delphi Study to Identify Factors Associated With Clinical Deterioration in Hospitalized Children. Hosp Pediatr 2017; 6:616-625. [PMID: 27686826 DOI: 10.1542/hpeds.2016-0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Hospitalized children who are admitted to the inpatient ward can deteriorate and require unplanned transfer to the PICU. Studies designed to validate early warning scoring systems have focused mainly on abnormalities in vital signs in patients admitted to the inpatient ward. The objective of this study was to determine the patient and system factors that experienced clinicians think are associated with progression to critical illness in hospitalized children. METHODS We conducted a modified Delphi study with 3 iterations, administered electronically. The expert panel consisted of 11 physician and nonphysician health care providers from hospitals in Canada and the United States. RESULTS Consensus was reached that 21 of the 57 factors presented are associated with clinical deterioration in hospitalized children. The final list of variables includes patient characteristics, signs and symptoms in the emergency department, emergency department management, and system factors. CONCLUSIONS We generated a list of variables that can be used in future prospective studies to determine if they are predictors of clinical deterioration on the inpatient ward.
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Affiliation(s)
- Kristina Krmpotic
- Department of Pediatrics, Janeway Children's Health and Rehabilitation Centre, St. John's, Canada; Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada;
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Anna-Theresa Lobos
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada; and Faculty of Medicine, University of Ottawa, Ottawa, Canada
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Increased Mortality and Length of Stay Associated With Medical Emergency Team Review in Hospitalized Pediatric Patients: A Retrospective Cohort Study. Pediatr Crit Care Med 2017; 18:571-579. [PMID: 28445242 DOI: 10.1097/pcc.0000000000001164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Rapid response systems using medical emergency teams reduce hospital wide cardiorespiratory arrest and mortality. While rapid response systems improve hospital-wide outcomes, children receiving medical emergency team review may still be at increased risk for morbidity and mortality. The study purpose was to compare the length of stay and mortality rate in children receiving a medical emergency team review with those of other hospitalized children. DESIGN Retrospective cohort study. SETTING Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. PATIENTS Cohort of 42,308 pediatric admissions to the general inpatient ward. INTERVENTIONS Data over 7 years were obtained from a prospectively maintained rapid response systems database. MEASUREMENTS AND MAIN RESULTS From the cohort, 995 (2.35%) of the admissions had one and 276 (0.65%) had multiple medical emergency team activations. When compared with patients without, children having one or multiple medical emergency team reviews had 13.34 (95% CI, 5.33-33.2) and 50.10 (95% CI, 19.86-126.39) times the odds of death, respectively. Patients experiencing a medical emergency team review stayed in hospital 1.59 times (95% CI, 1.39-1.82) longer, whereas those with multiple medical emergency team reviews stayed 2.44 times (95% CI, 1.85-3.20) longer. The associations remained significant after controlling for important confounders and excluding elective admissions from the analyses. Most repeat medical emergency team reviews occurred within a day of the initial review or involved patients with multiple comorbidities. CONCLUSIONS Our study suggests that pediatric patients reviewed by the medical emergency team are at significantly higher risk of mortality and longer length of stay than general ward inpatients. As well, patients with multiple medical emergency team reviews were at particularly high risk compared with patients with one medical emergency team review. Patients who experience medical emergency team reviews should be recognized as a high-risk group, and future studies should consider how to decrease morbidity and mortality. Based on our findings, we suggest that these patients be followed for 24-48 hours after any medical emergency team activation.
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Abstract
OBJECTIVES Little is known about the ongoing mortality risk and healthcare utilization among U.S. children after discharge from a hospitalization involving ICU care. We sought to understand risks for hospital readmission and trends in mortality during the year following ICU discharge. DESIGN Retrospective observational cohort study. SETTING This study was performed using administrative claims data from 2006-2013 obtained from the Truven Health Analytics MarketScan Database. SUBJECTS We included all children in the dataset admitted to a U.S. ICU less than or equal to 18 years old. INTERVENTIONS The primary outcome was nonelective readmission in the year following discharge. Risk of rehospitalization was determined using a Cox proportional hazards model. MEASUREMENTS AND MAIN RESULTS We identified 109,130 children with at least one ICU admission in the dataset. Over three quarters of the index ICU admissions (78.6%) had an ICU length of stay less than or equal to 3 days, and the overall index hospitalization mortality rate was 1.4%. In multivariate analysis, risk of nonelective readmission for children without cancer was higher with longer index ICU admission length of stay, younger age, and several chronic and acute conditions. By the end of the 1-year observation period, 36.0% of children with an index ICU length of stay greater than or equal to 14 days had been readmitted, compared with only 13.9% of children who had an index ICU length of stay equals to 1 day. Mortality in the year after ICU discharge was low overall (106 deaths per 10,000 person-years of observation) but was high among children with an initial index ICU admission length of stay greater than or equal to 14 days (599 deaths per 10,000 person-years). CONCLUSIONS Readmission after ICU care is common. Further research is needed to investigate the potentially modifiable factors affecting likelihood of readmissions after discharge from the ICU. Although late mortality was relatively uncommon overall, it was 10-fold higher in the year after ICU discharge than in the general U.S. pediatric population.
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Chapman SM, Wray J, Oulton K, Peters MJ. Systematic review of paediatric track and trigger systems for hospitalised children. Resuscitation 2016; 109:87-109. [DOI: 10.1016/j.resuscitation.2016.07.230] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/18/2016] [Accepted: 07/18/2016] [Indexed: 11/24/2022]
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Reese J, Deakyne SJ, Blanchard A, Bajaj L. Rate of preventable early unplanned intensive care unit transfer for direct admissions and emergency department admissions. Hosp Pediatr 2015; 5:27-34. [PMID: 25554756 DOI: 10.1542/hpeds.2013-0102] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Appropriate patient placement at the time of admission to avoid unplanned transfers to the ICU and codes outside of the ICU is an important safety goal for many institutions. The objective of this study was to determine if the overall rate of unplanned ICU transfers within 12 hours of admission to the inpatient medical/surgical unit was higher for direct admissions compared with emergency department (ED) admissions. METHODS This was a retrospective cohort study of all unplanned ICU transfers within 12 hours of admission to an inpatient unit at a tertiary care children's hospital from January 2010 to December 2012. Proportions of preventable unplanned transfers from the ED and from direct admission were calculated and compared. RESULTS Over the study period, there were a total of 46,998 admissions; 279 unplanned ICU transfers occurred during the study period of which 101 (36%) were preventable. Preventable unplanned transfers from each portal of entry were calculated and compared with the total number of admissions from those portals. The portals of entry evaluated included admissions from our internal ED versus all outside facility transfers. The rates of early unplanned transfer (per 1000 admissions) by portal of entry were 3.50 for direct admissions and 3.18 for ED. There was no difference between direct admissions and ED admissions resulting in preventable unplanned transfers to the ICU (P=.64). CONCLUSIONS Rates of unplanned ICU transfers within 12 hours of admission to an inpatient unit are not higher for direct admissions compared with ED admissions. Further studies are required to determine clinical risk factors associated with unplanned ICU transfer after admission, thus allowing for more accurate initial patient placement.
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Affiliation(s)
| | - Sara J Deakyne
- Research Informatics, Children's Hospital Colorado, Aurora, Colorado; and
| | - Ashley Blanchard
- New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York
| | - Lalit Bajaj
- Emergency Medicine, Department of Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
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Pediatric Early Warning Score and unplanned readmission to the pediatric intensive care unit. J Crit Care 2015; 30:1090-5. [PMID: 26235654 DOI: 10.1016/j.jcrc.2015.06.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/16/2015] [Accepted: 06/20/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Early unplanned Pediatric Intensive Care Unit (PICU) readmission is associated with greater length of stay and mortality. No tools exist to identify children at risk for PICU readmission. The Pediatric Early Warning Score (PEWS) currently identify children at risk for deterioration on the ward. Our primary objective was to evaluate the ability of PEWS to identify children at risk for unplanned PICU readmission. METHODS A single-center case-control study of 189 children (38 cases and 151 age-matched controls) 18years or younger transferred from the PICU to the pediatric ward from January 1, 2010-March 30, 2013, at an urban tertiary care children's hospital was conducted. RESULTS Thirty-eight cases had unplanned PICU readmission within 48hours of transfer to pediatric ward, whereas 151 controls were not readmitted. The PEWS assigned prior to PICU discharge and first PEWS assigned on the ward were collected for cases and controls. Each 1-point increase in the PEWS score significantly increased risk of PICU readmission (odds ratios [95% confidence intervals], 1.6 [1.12-2.27; P = .009] and 1.89 [1.33-2.69; P < .001], respectively). Discrimination ability of PEWS for PICU readmission improved when chronic diagnoses were included. CONCLUSIONS Higher PEWS scores were associated with increased risk of unplanned PICU readmission. However, cutoff scores are not sensitive or specific enough to be clinically useful. Adding chronic disease variables may improve the clinical utility of cutoff PEWS scores.
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