J Pediatr Intensive Care
DOI: 10.1055/s-0041-1740449
Original Article

A Single-Center Retrospective Evaluation of Unplanned Pediatric Critical Care Upgrades

1   Penn State College of Medicine, Hershey, Pennsylvania, United States
,
2   Department of Pediatrics, Division of General Pediatrics, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, United States
,
Theodore K. M. DeMartini
3   Department of Pediatrics, Division of Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, United States
,
Shouhao Zhou
4   Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States
5   Penn State Cancer Institute, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
,
3   Department of Pediatrics, Division of Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, United States
4   Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States
,
3   Department of Pediatrics, Division of Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, United States
› Author Affiliations
Funding The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), through grant UL1 TR002014. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Abstract

Background Inappropriate triage of critically ill pediatric patients can lead to poor outcomes and suboptimal resource utilization. This study aimed to determine and describe the demographic characteristics, diagnostic categories, and timing of unplanned upgrades to the pediatric intensive care unit (PICU) that required short (< 24 hours of care) and extended (≥ 24 hours of care) stays. In this article, we hypothesized that we will identify demographic characteristics, diagnostic categories, and frequent upgrade timing periods in both of these groups that may justify more optimal triage strategies.

Methods This was a single-institution retrospective study of unplanned PICU upgrades between 2012 and 2018. The cohort was divided into two groups (short and extended PICU stay). We reviewed the electronic health record and evaluated for: demographics, mortality scores, upgrade timing (7a-3p, 3p-11p, 11p-7a), lead-in time (time spent on clinical service before upgrade), patient origin, and diagnostic category.

Results Four hundred and ninety-eight patients' unplanned PICU upgrades were included. One hundred and nine patients (21.9%) required a short and 389 (78.1%) required an extended PICU stay. Lead-in time (mean, standard deviation) was significantly lower in the short group (0.65 ± 0.66 vs. 0.91 ± 0.82) (p = 0.0006). A higher proportion of short group patients (59, 46.1%) were upgraded during the 3p-11p shift (p = 0.0077).

Conclusion We found that approximately one-fifth of PICU upgrades required less than 24 hours of critical care services, were more likely to be transferred between 3p-11p, and had lower lead-in times. In institutions where ill pediatric patients can be admitted to either a PICU or a monitored step-down unit, this study highlights quality improvement opportunities, particularly in recognizing which pediatric patients truly need critical care.

Supplementary Material



Publication History

Received: 04 August 2021

Accepted: 04 November 2021

Article published online:
07 December 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Corno AF. Great challenges in pediatrics. Front Pediatr 2013; 1 (05) 5
  • 2 Gulla KM, Sachdev A. Illness severity and organ dysfunction scoring in pediatric intensive care unit. Indian J Crit Care Med 2016; 20 (01) 27-35
  • 3 Frankel LR, Hsu BS, Yeh TS. et al; Voting Panel. Criteria for critical care infants and children: PICU admission, discharge, and triage practice statement and levels of care guidance. Pediatr Crit Care Med 2019; 20 (09) 847-887
  • 4 Hsu BS, Hill V, Frankel LR. et al. Executive summary: criteria for critical care of infants and children: PICU admission, discharge, and triage practice statement and levels of care guidance. Pediatrics 2019; 144 (04) e20192433
  • 5 Miles AH, Spaeder MC, Stockwell DC. Unplanned ICU transfers from inpatient units: examining the prevalence and preventability of adverse events associated with ICU transfer in pediatrics. J Pediatr Intensive Care 2016; 5 (01) 21-27
  • 6 Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J Hosp Med 2011; 6 (02) 68-72
  • 7 Chang DW, Dacosta D, Shapiro MF. Priority levels in medical intensive care at an academic public hospital. JAMA Intern Med 2017; 177 (02) 280-281
  • 8 Agarwal S, Classen D, Larsen G. et al. Prevalence of adverse events in pediatric intensive care units in the United States. Pediatr Crit Care Med 2010; 11 (05) 568-578
  • 9 Marquet K, Claes N, De Troy E. et al. One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals. Crit Care Med 2015; 43 (05) 1053-1061
  • 10 Chang DW, Shapiro MF. Association between intensive care unit utilization during hospitalization and costs, use of invasive procedures, and mortality. JAMA Intern Med 2016; 176 (10) 1492-1499
  • 11 Fieldston ES, Li J, Terwiesch C. et al. Direct observation of bed utilization in the pediatric intensive care unit. J Hosp Med 2012; 7 (04) 318-324
  • 12 Agulnik A, Nadkarni A, Mora Robles LN. et al. Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource-limited hospitals. Pediatr Blood Cancer 2018; 65 (08) e27076
  • 13 Arespacochaga E, Combes JR. Appropriate use of medical resources. American Hospital Association's Physician Leadership Forum. Published online November 2013. Accessed November 24, 2021 at: http://www.ahaphysicianforum.org/files/pdf/appropusewhiteppr.pdf
  • 14 American Academy of Pediatrics Committee on Hospital Care and Section on Critical Care, Society of Critical Care Medicine Pediatric Section Admission Criteria Task Force. Guidelines for developing admission and discharge policies for the pediatric intensive care unit. American Academy of Pediatrics. Committee on Hospital Care and Section of Critical Care. Society of Critical Care Medicine. Pediatric Section Admission Criteria Task Force. Pediatrics 1999; 103 (4 Pt 1): 840-842
  • 15 Tyagi P, Tullu MS, Agrawal M. Comparison of Pediatric Risk of Mortality III, Pediatric Index of Mortality 2, and Pediatric Index of Mortality 3 in predicting mortality in a pediatric intensive care unit. J Pediatr Intensive Care 2018; 7 (04) 201-206
  • 16 van Keulen JG, Polderman KH, Gemke RJBJ. Reliability of PRISM and PIM scores in paediatric intensive care. Arch Dis Child 2005; 90 (02) 211-214
  • 17 Trubey R, Huang C, Lugg-Widger FV. et al. Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review. BMJ Open 2019; 9 (05) e022105
  • 18 Fitzsimons J, Pentony M. Paediatric early warning systems in 2019: what we know and what we've yet to learn. Curr Treat Options Pediatr 2019; 5 (04) 315-325
  • 19 Downey CL, Tahir W, Randell R, Brown JM, Jayne DG. Strengths and limitations of early warning scores: a systematic review and narrative synthesis. Int J Nurs Stud 2017; 76: 106-119
  • 20 Smith MEB, Chiovaro J, O'Neil M. et al. Early warning system scores: a systematic review. VA Evidence-based Synthesis Program Reports. 2013 . Project #05–255. Accessed November 24, 2021 at: https://www.ncbi.nlm.nih.gov/books/NBK259026/
  • 21 Finlay GD, Rothman MJ, Smith RA. Measuring the modified early warning score and the Rothman Index: advantages of utilizing the electronic medical record in an early warning system. J Hosp Med 2014; 9 (02) 116-119
  • 22 Chapman SM, Maconochie IK. Early warning scores in paediatrics: an overview. Arch Dis Child 2019; 104 (04) 395-399
  • 23 Murray JS, Williams LA, Pignataro S, Volpe D. An integrative review of pediatric early warning system scores. Pediatr Nurs 2015; 41 (04) 165-174
  • 24 Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children. J Crit Care 2006; 21 (03) 271-278
  • 25 Fenix JB, Gillespie CW, Levin A, Dean N. Comparison of pediatric early warning score to physician opinion for deteriorating patients. Hosp Pediatr 2015; 5 (09) 474-479
  • 26 Gold DL, Mihalov LK, Cohen DM. Evaluating the Pediatric Early Warning Score (PEWS) system for admitted patients in the pediatric emergency department. Acad Emerg Med 2014; 21 (11) 1249-1256