Excess risk of severe acute illness in children with chronic health conditions.

Abstract

We estimated the relative risk (RR) of an unscheduled pediatric intensive care unit (ICU) admission as a marker for severe acute illness in children with chronic health conditions, compared with previously healthy children. Potentially preventable events that lead to acute illness were identified to develop preventive strategies. Children with chronic conditions were defined as those who have a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. RR was estimated from admissions and regional population data. Potentially preventable events that lead to ICU admission of chronically ill children were identified retrospectively from hospital records. Children with chronic health conditions had an RR of 3.3 for an unscheduled ICU admission related to their chronic condition, compared with previously healthy individuals (95% confidence interval [CI] = 2.5-4.2). The risk of severe acute illness in the small subgroup that received technology-assisted care was much greater (RR = 373; 95% CI = 330-422) than for the large group of chronically ill patients who did not require technology-assisted care (RR = 2.3; 95% CI = 1.7-3.0), each expressed relative to previously healthy children. Acute illness related to chronic health conditions accounted for 45% of 251 unscheduled ICU admissions during the 1-year study. Thirty-two percent of admissions that were related to chronic conditions were judged to have been potentially preventable. Preventable events were more common for those who did not require technology-assisted care, occurring in 38% of admissions, compared with those who received technology-assisted care, for whom 19% of admissions involved a preventable event. Fifty-six percent of potentially preventable events involved the physical or social environment and decisions made by the family, whereas 64% could be attributed to health care system factors. Children with chronic health conditions account for a substantial share of severe acute illness in a region. Because their underlying conditions have already been identified, problems may be anticipated. The small number of children who receive technology-assisted care each have such a high risk of severe and unavoidable acute illness that individualized emergency care plans are justified. For the remainder of children with chronic conditions, investigation of health system strategies to improve families' ability to anticipate, minimize, or prevent related acute illness is warranted.