Elsevier

Journal of Critical Care

Volume 62, April 2021, Pages 145-150
Journal of Critical Care

The impact of eligibility for primary attendings and nurses on PICU length of stay

https://doi.org/10.1016/j.jcrc.2020.12.006Get rights and content

Highlights

  • First multi-institutional retrospective cohort study of primary attendings and nurses.

  • Primary nurses for long-stay PICU patients was more common than primary attendings.

  • The use of primary nurses was associated with shorter PICU lengths of stay (LOS).

  • Primary attendings correlated with shorter LOS when utilized for more patients.

  • Orders to limit or withdrawal interventions correlated with use of primary attendings.

Abstract

Purpose

To examine whether primary attendings and/or nurses impact pediatric intensive care unit (PICU) length of stay (LOS) in long-stay patients (LSP).

Materials and methods

Retrospective observational cross-sectional study from 2012 to 2016 of 29,170 LSP (LOS ≥ 10 days) admitted to 64 PICUs that participated in the Virtual Pediatric Systems, LLC. Generalized linear mixed models were used to examine the association between being eligible for primary practices and LOS. Secondary outcomes of proportions of limitations and withdrawal of aggressive, life-sustaining interventions were also explored.

Results

After controlling for several factors, being eligible for primary nurses and for primary attendings and nurses were associated with significantly lower mean LOS (8.9% and 9.7% lower, respectively), compared to not being eligible for any primary practice. Being eligible for primary attendings was associated with significantly higher mean LOS (9.6% higher). When the primary attendings were used for larger proportions of LSP, the practice was associated with significantly lower mean LOS. Limitations and withdrawal of aggressive interventions were more common in LSPs cared for in PICUs that utilized primary attendings.

Conclusions

The findings of lower LOS in LSP who were eligible for primary practices should induce more rigorous research on the impact of these primary practices.

Introduction

Increasing numbers of children are surviving critical illness or are living with profound chronic illness, but many can only do so because of the care they receive during prolonged admissions in pediatric intensive care units (PICUs) [1,2]. These long-stay patients (LSPs), varyingly described as having PICU lengths of stay (LOS) >8, 10, 14, or 28 days [[3], [4], [5], [6]], have a substantial impact on PICU bed availability. LSPs can account for <5% of PICU admissions but utilize up to 60% of total admission days [[6], [7], [8]], straining costly ICU resources and potentially delaying admissions of other critically ill children and elective surgeries. Unfortunately, the transitory way PICU care is provided likely contributes to prolonged LOS. Specifically, intensivists commonly change weekly and nurses work in shifts, so information about LSPs can be ineffectively passed along, clinical goals and approaches for LSPs can vary among providers, and important decisions for LSPs can be delayed [[9], [10], [11], [12], [13], [14], [15], [16], [17]].

Some institutions use continuity strategies to address the needs of LSPs and their families and the shortcomings of transitory PICU care. These patient−/family-centered strategies seek to facilitate continuity of care, enhance information dissemination, and expedite decision-making. Strategies include 1) having one intensivist serve as a consistent physician-presence for the LSP/family and PICU team throughout the child's PICU stay (ie, primary attendings) and despite changes in the “service” intensivists who orchestrate day-to-day management and 2) having a small team of PICU nurses provide all/most of the bedside care to the LSP (ie, primary nursing).

Single-site studies of these strategies have demonstrated potentially promising results in decreasing the LOS of LSPs [[18], [19], [20], [21]]. However, the impact of these strategies has not been studied in a multi-institutional cohort. Therefore, we used data from the Virtual Pediatric Systems, LLC (VPS, Los Angeles, CA) to explore if there is an association between the use of these strategies and PICU LOS.

Section snippets

Data source and hospitals

We performed a retrospective, observational cross-sectional study of LSPs admitted between 2012 and 2016 from 119 North American PICUs that participated in VPS. VPS contains encounter-level information entered by VPS-trained persons at the individual units. Annual certification of data definitions, routine interrater reliability testing, and automated and manual data cleaning queries ensure data validity and quality. We defined LSPs as having LOS ≥ 10 days. This threshold is consistent with

Results

One hundred nineteen units submitted data on 50,395 LSPs admitted between 2012 and 2016. Twenty-five (21%) units did not answer the primary practices questions; 30 (25%) units had data on fewer than 100 LSPs. No remaining units were excluded for not reporting secondary diagnoses. After these exclusions, 29,170 (58%) LSPs from 64 (54%) units remained and compromised our study cohort. About half (33) of the included units reported not having primary attending or nurses. Twelve (19%) units

Discussion

Some institutions utilize primary attendings and primary nurses to mitigate the short-comings of transitory PICU care and better meet the needs of LSPs and their families. This study is the first to investigate the potential impact of these primary practices in a large multi-institutional cohort. We found that about half of the PICUs utilized these practices and that the use of primary nurses was more common than primary attendings. Among patients with PICU stays >10 days, being cared for in a

Conclusions

The future of PICUs is likely intertwined with the growing population of children with medical complexity, who not uncommonly require prolonged stays for their acute-on-chronic illnesses and post-operative needs. The needs of these LSPs are different than patients with short stays. In order to meet these patients' needs while still appreciating the necessity of patient throughput, PICU providers will likely need to increasingly adapt the way they practice. Studies such as this one suggest

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations of Interest

None.

Acknowledgements

We thank VPS, LLC for providing the data and support for this study, especially Nancy Brundage, Chloe Gordon, and Dr. Tom Rice. No endorsement or editorial restriction of the interpretation of these data or opinions of the authors have been implied or stated by VPS.

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