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Illness Severity of Children Admitted to the PICU from Referring Emergency Departments Jacqueline M

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Illness Severity of Children Admitted to the PICU from Referring Emergency Departments Jacqueline M RESEARCH ARTICLE Illness Severity of Children Admitted to the PICU From Referring Emergency Departments Jacqueline M. Evans, MD, PhD, Parul Dayal, MS, Douglas L. Hallam, BS, JoAnne E. Natale, MD, PhD, Pranav Kodali, Hadley S. Sauers-Ford, MPH, James P. Marcin, MD, MPH ABSTRACT OBJECTIVES: To compare patient factors and outcomes among children admitted to PICUs from referring versus children’s hospital emergency departments (EDs). METHODS: Pediatric patients (,19 years old) admitted to PICUs from referring and children’s hospital EDs from July 1, 2011 to June 30, 2013. We compared demographic and clinical factors, including severity of illness as measured by a recalibrated Pediatric Index of Mortality, version 2 score. RESULTS: Of 80 045 children from 109 PICUs, 35.6% were admitted from referring EDs and 64.4% were admitted from children’s hospital EDs. Children from referring EDs had higher illness severity (Pediatric Index of Mortality, version 2–predicted risk of mortality, 3.1% vs 2.2%, P , .001), were more likely to be mechanically ventilated within their first hour in the PICU (28.4% vs 23.4%, P , .001), and had higher observed mortality (3.3% vs 2.1%, P , .001). Once adjusted for illness severity and other confounders in a multivariable logistic regression model, there was no difference in the odds of mortality between children from referring and children’s hospital EDs (odds ratio: 0.90; 95% confidence interval: 0.79 to 1.02, P 5 .09) CONCLUSIONS: Children transferred to PICUs from referring EDs had higher illness severity on arrival compared with children admitted from children’s hospital EDs. Variations in patient selection for transfer or pretransfer treatment at referring EDs may contribute to the greater illness severity of transferred children. Referring hospitals may benefit from leveraging existing resources to improve patient stabilization before transfer. www.hospitalpediatrics.org DOI:https://doi.org/10.1542/hpeds.2017-0201 Copyright © 2018 by the American Academy of Pediatrics Address correspondence to James P. Marcin, MD, MPH, Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd, Sacramento, CA 95817. E-mail: [email protected] HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671). FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. Dr Evans conceptualized and designed the study and drafted the initial manuscript; Ms Dayal conducted the data analyses, reviewed, Department of Pediatrics, and revised the manuscript; Mr Hallam designed the data collection instruments; Dr Natale conceptualized and designed the study and University of California critically reviewed the manuscript; Mr Kodali conducted the initial data collection and analysis; Ms Sauers-Ford critically reviewed Davis Children’s Hospital, and revised the manuscript; Dr Marcin conceptualized and designed the study, supervised the data analysis, and critically reviewed Sacramento, California and revised the manuscript; and all authors approved the final manuscript as submitted. HOSPITAL PEDIATRICS Volume 8, Issue 7, July 2018 1 Downloaded from www.aappublications.org/news by guest on September 25, 2021 In 2012, 8.8 million US infants, children, and METHODS PIM2 score and the PIM2-predicted risk of adolescents were evaluated and treated in Data Source and Patient Data mortality (ROM).18 1 an emergency department (ED). The This was a retrospective cohort study Risk Adjustment majority of these children received care in using data from the VPS database (http:// EDs within general or community hospitals www.myvps.org). This Web-based registry The ROM predicted by the PIM2 score was that treat both adults and children but do includes data from 109 US PICUs in free used to compare severity of illness between not have PICUs.2,3 Thus, community EDs cohorts. The PIM2 score is estimated by standing and nonfree-standing children’s need to transfer critically ill patients using patient-level clinical variables that are hospitals and contains .600 000 needing higher levels of care to PICUs collected at the time of admission to a PICU. admission records to date. The database located within children’shospitals.On The original model includes the following contains granular patient-specificdata average, community EDs (ie, “referring” 10 covariates: (1) systolic blood pressure; obtained from chart abstraction including EDs) are hampered by lower “pediatric (2) pupillary reaction to bright light; (3) demographic, physiologic, and laboratory readiness”4 as compared with EDs in ratio of fraction inspired oxygen and partial information, as well as the validated children’s hospitals, including but not pressure oxygen in arterial blood; (4) base pediatric illness severity score, PIM2. limited to exposure to relatively smaller excess in arterial or capillary blood; (5) VPS data elements are collected volumes of pediatric patients,5 deficiencies need for mechanical ventilation during the prospectively and deidentified by in pediatric-specific training of staff and first hour in the ICU; (6) whether admission participating PICUs. VPS data have been providers,6 variable access to pediatric was elective; (7) whether patient was in used extensively for quality improvement subspecialists,2,7 insufficient mechanisms recovery from surgery or another purposes, benchmarking, and outcomes for identifying high-risk pediatric procedure; (8) whether the patient was research.17 In this study, VPS data from a patients,8,9 inadequate resuscitation and admitted after cardiopulmonary bypass; (9) 2-year period were used to compare stabilization,1,10,11 limited pediatric-specific whether the patient presented with selected demographic and clinical characteristics resources and equipment,2,5 and a lack of high-risk diagnoses including, cardiac adherence to published pediatric-specific of pediatric patients admitted to PICUs arrest preceding ICU admission, severe ’ guidelines.12 from referring and childrenshospital combined immune deficiency, leukemia or EDs. fi Deviations from published pediatric lymphoma after rst induction, spontaneous emergency medicine guidelines in The original data set included all cerebral hemorrhage, cardiomyopathy or referring EDs2,13 are likely to exert a nonscheduled PICU admissions of children myocarditis, hypoplastic left heart , substantive impact on the outcomes of 19 years of age from July 1, 2011, to June syndrome, HIV, liver failure, and pediatric patients who require transfer 30, 2013. Patients with a physical length of neurodegenerative disorders; and , and admission to a children’shospital stay of 2 hours and patients who came to (10) whether the patient presented with PICU. Existing evidence suggests that the PICU from either an operating room or a selected low-risk diagnoses including children admitted to PICUs from referring cardiac catheterization laboratory were asthma, bronchiolitis, croup, obstructive 18 hospital EDs are sicker, more likely to be excluded, as were children admitted to the sleep apnea, and diabetic ketoacidosis. intubated, and have poorer outcomes than PICU from a pediatric ward or from a PICU The designation of high- and low-risk children admitted to PICUs from EDs in another children’s hospital. The primary diagnoses was created within the VPS located within the same hospital14–16; variable of interest was the source of PICU database. All other covariates for the PIM2 however, previous comparisons have been admission, dichotomized into referring estimation model were also available in the focusedonsinglediagnoses16 or involved hospital EDs and children’s hospital EDs. database. much smaller numbers of patients and Referring hospital EDs were defined as In this study, we recalibrated the PICUs.15 In this study, we used a large, general and community EDs that provide coefficients of the original PIM2 estimation national cohort of PICU admissions care to both adults and children and are model on our population. The reference collected by the Virtual PICU Performance located within a hospital that does not have population for the original model was System (VPS) database and a validated a PICU. Children’s hospital EDs are EDs 20 787 children from Australia, New Zealand, physiologic adjustment tool, the Pediatric located within children’s hospitals that also and the United Kingdom from 1997 to 1999.18 Index of Mortality, version 2 (PIM2) scoring have a PICU. Other variables in our study In comparison, our study included system, to generate a more robust included demographics including age, sex, 80 045 children admitted to PICUs located in comparison of demographic race, and clinical variables including the the United States. Because our study was characteristics and clinical factors, use of mechanical ventilation during the focused on patients transferred from including severity of illness and risk- first hour in the PICU, whether a trauma referring EDs, we excluded children adjusted mortality between children activation was associated with the ICU admitted to the PICU on an elective basis, admitted to PICUs from referring EDs and encounter (trauma activation, yes or no), children admitted after surgery, and those EDs located within children’s hospitals that primary diagnosis, PICU mortality, and the admitted after cardiopulmonary bypass. have a PICU. severity of illness as measured by the These
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