Pediatric Intensive Care Unit Transfer Research Articles

Risk Factors Associated with Intensive Care Admission in Children with Severe Acute Respiratory Syndrome Coronavirus 2-Related Multisystem Inflammatory Syndrome (MIS-C) in Latin America: A Multicenter Observational Study of the REKAMLATINA Network.

Background: Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 varies widely in its presentation and severity, with low mortality in high-income countries. In this study in 16 Latin American countries, we sought to characterize patients with MIS-C in the pediatric intensive care unit (PICU) compared with those hospitalized on the general wards and analyze the factors associated with severity, outcomes, and treatment received. Study Design: An observational ambispective cohort study was conducted including children 1 month to 18 years old in 84 hospitals from the REKAMLATINA network from January 2020 to June 2022. Results: A total of 1239 children with MIS-C were included. The median age was 6.5 years (IQR 2.5-10.1). Eighty-four percent (1043/1239) were previously healthy. Forty-eight percent (590/1239) were admitted to the PICU. These patients had more myocardial dysfunction (20% vs 4%; P < 0.01) with no difference in the frequency of coronary abnormalities (P = 0.77) when compared to general ward subjects. Of the children in the PICU, 83.4% (494/589) required vasoactive drugs, and 43.4% (256/589) invasive mechanical ventilation, due to respiratory failure and pneumonia (57% vs 32%; P = 0.01). On multivariate analysis, the factors associated with the need for PICU transfer were age over 6 years (aOR 1.76 95% CI 1.25-2.49), shock (aOR 7.06 95% CI 5.14-9.80), seizures (aOR 2.44 95% CI 1.14-5.36), thrombocytopenia (aOR 2.43 95% CI 1.77-3.34), elevated C-reactive protein (aOR 1.89 95% CI 1.29-2.79), and chest x-ray abnormalities (aOR 2.29 95% CI 1.67-3.13). The overall mortality was 4.8%. Conclusions: Children with MIS-C who have the highest risk of being admitted to a PICU in Latin American countries are those over age six, with shock, seizures, a more robust inflammatory response, and chest x-ray abnormalities. The mortality rate is five times greater when compared with high-income countries, despite a high proportion of patients receiving adequate treatment.

Association between mortality and critical events within 48 hours of transfer to the pediatric intensive care unit.

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. 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. 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. 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.

Associating a standardized reporting tool for chest radiographs with clinical complications in pediatric acute chest syndrome.

Acute chest syndrome (ACS) is an important cause of morbidity in sickle cell disease (SCD). A standardized tool for reporting chest radiographs in pediatric SCD patients did not previously exist. To analyze the interobserver agreement among pediatric radiologists' interpretations for pediatric ACS chest radiographs utilizing a standardized reporting tool. We also explored the association of radiographic findings with ACS complications. This was a retrospective cohort study of pediatric ACS admissions from a single institution in 2019. ICD-10 codes identified 127 ACS admissions. Two radiologists independently interpreted the chest radiographs utilizing a standardized reporting tool, a third radiologist adjudicated discrepancies, and κ analysis assessed interobserver agreement. Clinical outcomes were correlated with chest radiograph findings utilizing Pearsons' χ2 , ttests, and Mann-Whitney U tests. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was moderate to near-perfect across variables, with κ analysis showing near-perfect agreement for opacity reported in the right upper lobe (0.84), substantial agreement for right lower lobe (0.63), and vertebral bony changes (0.72), with moderate agreement for all other reported variables. On the initial chest radiograph, an opacity located in the left lower lobe (LLL) correlated with pediatricintensive care unit transfer (p = .03). Pleural effusion on the initial chest radiograph had a 3.98 OR (95% CI: 1.35-11.74) of requiring blood products and a 10.67 OR (95%CI: 3.62-31.39) for noninvasive ventilation. The standardized reporting tool showed moderate to near-perfect agreement between radiologists. LLL opacity, and pleural effusion were associated with increased risk of ACS complications.

Transferring critical pediatric patients from emergency department to intensive care: A quality improvement initiative

BackgroundTransfer of care, moving hospitalized patients between care areas, is a critical point of vulnerability for healthcare organizations. Patient information handoff is an essential activity occurring frequently in hospital environments. Poor communication has been linked with adverse events and poor patient outcomes. This evidence-based quality project aimed to enhance the handoff process between the Emergency Department (ED) and Pediatric Intensive Care Unit (PICU) by standardizing transfer of care steps. This was accomplished through customizing a reporting tool to contain all the information the receiving department deemed necessary for safe patient care. MethodsA customized situation, background, assessment, recommendation (SBAR) form handoff tool was developed for ED to PICU transfers. This SBAR tool included information that PICU nurses identified as critical to transfer of care. Nurse perceptions were surveyed pre- and post-implementation. Patient safety event reports were tracked to evaluate events related to transfer of care before and after the practice change. FindingsAn increased number of PICU nurses agreed the customized handoff tool was complete and organized. Additionally, more nurses agreed that handoff gave all information needed to safely care for critically ill patients transferred from the ED. Lastly, bedside patient checks increased, and patient safety events related to transfer of care decreased. DiscussionThis project demonstrated that implementation of a standardized transfer of care process coupled with a customized handoff tool increased PICU nurse perceptions that handoff was organized, and all information needed to safely care for critically ill patients was conveyed. Application to practiceTransfer of care processes between the ED and PICU should be standardized. The use of customized tools may improve information exchange between nurses and ensure that all vital patient information is communicated.

Prognostic factors of sepsis in children with acute leukemia admitted to the pediatric intensive care unit.

To analyze the prognostic factors of sepsis in children with acute leukemia admitted to the pediatric intensive care unit (PICU) and to compare the efficacy of different scoring systems for predicting the outcome of children. Patients with an acute leukemia diagnosis admitted to a tertiary care university hospital PICU due to sepsis during chemotherapy between May 2015 and August 2022 were retrospectively analyzed through an electronic medical record system. During this period, 693 children with acute leukemia initially diagnosed were admitted to the center, and 155 (22.3%) of them were transferred to PICU due to deterioration of the disease during treatment. Total 109 (70.3%) patients were transferred to PICU due to sepsis. Here, 17 patients was excluded (prior treatment from another hospital; referring from other hospitals; discontinued treatment; incomplete medical record). Of the 92 patients studied, the mortality rate was 35.9%. Multivariate analysis revealed that remission status, lactate level, invasive mechanical ventilation (IMV), and inotropic support within 48hours after PICU transfer were independent risk factors for PICU mortality. The pediatric sequential organ failure assessment (PSOFA) score had the greatest predictive validity for hospital mortality (area under the receiver operating characteristic curve [AUROC]: 0.83, 95% confidence intervals [CI]: 0.74-0.92), followed by the pediatric early warning score (PEWS) (0.82, 0.73-0.91) and pediatric critical illness score (PCIS) (0.79, 0.69-0.88). The mortality rate among children with acute leukemia complicated with sepsis is high after being transferred to the PICU. Various scoring systems can be used to monitor the clinical status of patients, identify sepsis early, detect critical illness, and determine the optimal time for transfer to the PICU for supportive treatment, thereby improving the prognosis of these patients.

1065: IMPROVING THE TIME OF PICU PATIENT TRANSFER ORDERS TO THE GENERAL WARD

Introduction: Delays in patient transfer orders from the pediatric intensive care unit (PICU) to the general ward may cause holdups for new admissions. Thus, improving the PICU transfer flow will increase planned and unplanned admission capacity. Therefore, we aimed to increase Picu transfer orders to 50% before noon and 70% by 2 pm over six months. Methods: We used tableau software to monitor the PICU transfer orders and focused on the percentage of transfer orders before noon and 2 pm. Utilizing a PICU transfer process map, we recognized different areas for improvement. The team implemented a systematic approach for changes. The on-call PICU attending during sign-out identifies the patients ready or almost ready for transfer. The PICU Charge nurse gets the list and starts the bed request process. A list of the possible patient transfers is provided to the PICU Assistant to be sent to the Hospitalist admitting team. Multidisciplinary morning huddle changed to start earlier and limited to 15 minutes. Pre rounding and Rounding process were re-arranged to start earlier and finish sooner. From November to April, a third attending was added to the team to help decrease interruptions during the rounding time. Results: Our PICU’s baseline percentage of patient transfer orders before noon was 33.5 % and, before 2 pm, 44%. However, we observed an upper trend of transfer orders during the implemented changes. By the end of the six months, our noon transfer orders increased to 50% and 75% by 2 pm. Conclusions: Improving the patient transfer flow to Acute Care optimizes planned admissions readiness and the availability for unplanned admissions to the PICU. As a secondary benefit, the number of patients declines decreases.

Validation of a modified bedside Pediatric Early Warning System score for detection of clinical deterioration in hospitalized pediatric oncology patients: A prospective cohort study.

Hospitalized pediatric oncology patients are at risk of severe clinical deterioration. Yet Pediatric Early Warning System (PEWS) scores have not been prospectively validated in these patients. We aimed to determine the predictive performance of the modified BedsidePEWS score for unplanned pediatric intensive care unit (PICU) admission and cardiopulmonary resuscitation (CPR) in this patient population. We performed a prospective cohort study in an 80-bed pediatric oncology hospital in the Netherlands, where care has been nationally centralized. All hospitalized pediatric oncology patients aged 0-18years were eligible for inclusion. A Cox proportional hazard model was estimated to study the association between BedsidePEWS score and unplanned PICU admissions or CPR. The predictive performance of the model was internally validated by bootstrapping. A total of 1137 patients were included. During the study, 103 patients experienced 127 unplanned PICU admissions and three CPRs. The hazard ratio for unplanned PICU admission or CPR was 1.65 (95% confidence interval [CI]: 1.59-1.72) for each point increase in the modified BedsidePEWS score. The discriminative ability was moderate (D-index close to 0 and a C-index of 0.83 [95% CI: 0.79-0.90]). Positive and negative predictive values of modified BedsidePEWS score at the widely used cutoff of 8, at which escalation of care is required, were 1.4% and 99.9%, respectively. The modified BedsidePEWS score is significantly associated with requirement of PICU transfer or CPR. In pediatric oncology patients, this PEWS score may aid in clinical decision-making for timing of PICU transfer.

Unplanned Intensive Care Unit Admission Following Cleft Palate Repair by Head and Neck Surgeons.

To examine the incidence of pediatric intensive care unit (PICU) admission following primary repair of cleft palate by otolaryngologist-head and neck surgeons at 2 tertiary centers. To identify potential diagnoses associated with admission or unanticipated PICU transfer. Multi-institutional case series with chart review. Two tertiary pediatric medical centers. Children who underwent primary repair of cleft palate at 2 cleft centers over a 10-year period were identified. Charts were reviewed for demographics, comorbidities, and whether PICU admission was required. From 2009 to 2019, 464 patients underwent primary repair of a cleft palate by 1 of 6 otolaryngologist-head and neck surgeons with subspecialty training in cleft surgery; 459 patients had sufficient postoperative documentation and 443 children met inclusion criteria. The incidence of PICU admission was 9.3% (41/443), with 33 (7.4%) planned admissions and 8 (1.8%) unexpected PICU transfers. Syndromic conditions were associated with both planned and unanticipated PICU admissions. The incidence of unanticipated postoperative PICU admission following cleft palate repair by otolaryngologist-head and neck surgeons was low. Risk stratification by surgeons with expertise in airway management may inform decisions regarding postoperative disposition of patients with medical or airway complexity who are undergoing cleft palate repair.

Comparison of a Teaching and Nonteaching Service at a Children's Hospital in the Community.

The impact of trainees on inpatient patient care is incompletely understood. This study sought to discern the impact of trainees on patient outcomes and costs at a children's hospital in the community. We hypothesized that there would be no differences in patient outcomes and costs on an inpatient teaching service compared to a nonteaching service. As a secondary goal, we analyzed trainee evaluations. The authors conducted a cohort study of patients hospitalized from October 1, 2016 to September 30, 2017 on an acute care unit in a children's hospital in the community. Using t test or Fisher exact test, the authors compared patient outcomes between teaching and nonteaching services including, length of stay, discharge times, readmission rates, rapid response team (RRT) calls, pediatric intensive care unit (PICU) transfers, hospital transfers, and costs. During the study period, there were 1066 patients admitted and discharged from the teaching service and 1038 from the nonteaching service. There were no statistically significant differences in patient demographics or patient complexity. Similarly, there were no differences in length of stay, discharge times, readmission rates, RRT calls, PICU transfers, hospital transfers or patient costs between services. Trainee evaluations of the inpatient experience were overwhelmingly positive. In a children's hospital in the community, there were no significant differences in patient outcomes and costs on a teaching service compared to a nonteaching service. Furthermore, trainee evaluations suggested a favorable learning experience, illustrating the feasibility of incorporating trainees into inpatient care in a nontraditional learner setting.

Critically Ill Children in a Swiss Pediatric Emergency Department With an Interdisciplinary Approach: A Prospective Cohort Study.

Objective: Delivery of prompt and adequate care for critically ill and injured children presenting to the pediatric emergency department (PED) is paramount for optimal outcomes. Knowledge of the local epidemiology, patient profile, and presentation modes are key for organizational planning, staff education strategy, and optimal care in a PED. Our aim was to analyze the profile of critically ill and injured children admitted to a tertiary, non-academic Swiss PED, to investigate potential risk factors associated with admission to the pediatric intensive care unit (PICU), and the outcomes mortality and PICU admission.Methods: Prospective cohort study of critically ill and injured children presenting to the PED over a two-year period (2018–2019). Inclusion criteria were Australasian triage scale category (ATS) 1, trauma team activation (TTA), medical emergency response (MER) activation, additional critical care consult, and transfer to an outside hospital.Results: Of 42,579 visits during the two-year period, 347 presentations matched the inclusion criteria (0.81%). Leading presentations were central nervous system (CNS) disorders (26.2%), trauma (25.1%), and respiratory emergencies (24.2%). 288 out of 347 cases (83%) arrived during the day or evening with an even distribution over the days of the week. 128 out of 347 (37%) arrived unexpectedly as walk-ins. 233 (67.15%) were ATS category 1. 51% of the cohort was admitted to PICU. Australasian triage scale category 1 was significantly more common in this group (p = 0.0001). Infants with respiratory disease had an increased risk of PICU transfer compared to other age groups (OR 4.18 [95%CI 2.46, 7.09] p = 0.0001), and this age group presented mainly as walk-in (p = 0.0001). Pediatric intensive care unit admissions had a longer hospital stay (4 [2, 8] days vs. 2 [1, 4] days, p = 0.0001) compared to other patients. 0.045% of all PED patients had to be transferred out. Three deaths (0.86%) occurred in the PED, 10 patients died in the PICU (2.9%).Conclusions: High acuity presentations in the PED were rare, more likely to be young with CNS disorders, trauma and respiratory diseases. A significant proportion were unexpected walk-in presentations, mainly during day and evening shifts. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED.

SNAP: Supportive noninvasive ventilation for acute chest syndrome prevention in children with sickle cell disease.

Acute chest syndrome (ACS) is a leading cause of morbidity and mortality among children with sickle cell disease (SCD). Preventing hypoxemia by optimizing lung aeration during sleep remains a challenge. To explore safety, feasibility, and tolerability of noninvasive, bi-level positive airway pressure ventilation (BiPAP) as preventative, supportive care for hospitalized, medically stable children with SCD on a general pediatric inpatient unit. Retrospective chart review of patients ≤22years of age with SCD admitted to the general pediatric inpatient unit from February 1, 2017 to March 1, 2020 for whom BiPAP was recommended as supportive care. Hospitalizations were excluded if patients were admitted to the pediatric intensive care unit (PICU), required BiPAP for respiratory failure, or used BiPAP at home for obstructive sleep apnea. Twenty-three patients had 53 hospitalizations in which BiPAP was recommended. Fifty-two (98%) hospitalizations included acute SCD pain. Indications for BiPAP included prior ACS (94%), chest or back pain (79%), and/or oxygen desaturation (66%). On 17 occasions, patients already had mild to moderate ACS but were stable when BiPAP was recommended. BiPAP was used successfully during 75% of hospitalizations for a median of two nights. There were no adverse effects associated with BiPAP. PICU transfer for respiratory support occurred during three hospitalizations. In 26 hospitalizations of children at risk for ACS who tolerated BiPAP, 23 (88%) did not develop ACS. BiPAP is safe, feasible, and well tolerated as supportive care for hospitalized children with SCD. Next steps include an intervention trial to further assess the efficacy of BiPAP on ACS prevention.

Current practices and policies regarding the use of high-flow nasal cannula on general pediatric inpatient wards in Canada.

High-flow nasal cannula (HFNC) oxygen therapy has become a common treatment for respiratory conditions in children. To our knowledge, no study has described practice patterns for HFNC on pediatric inpatient wards in Canada. The aim of this study was to survey current practices and policies regarding the use of HFNC on the ward in children's hospitals in Canada. We conducted a web-based survey of Pediatric Hospital Medicine section chiefs in major tertiary care hospitals in Canada. The primary outcome was the proportion of hospitals that use HFNC on the general pediatric ward. Secondary outcomes included indications for HFNC, initial and maximum flow rates, maximum FiO2, method of nutrition delivery while on HFNC, level of nursing and respiratory therapist care required, criteria for pediatric intensive care unit transfer, and subjective successes and challenges of implementing a ward-based HFNC policy. The section chief survey response rate was 100% (15/15). Eight centres (53%) allowed the use of HFNC outside of an intensive care setting. Six centres initiated HFNC on the ward, while two centres only accepted patients after HFNC had been initiated in an intensive care setting. Other practices and policies varied considerably from centre to centre. Our study reveals that approximately half of tertiary children's hospitals in Canada currently use HFNC on the ward and utilize a range of practices and policies. Other centres are considering implementation. Further research is needed to inform best practices for HFNC therapy, support stewardship of health care resources, and promote safe patient care.

P0157 / #2124: IDENTIFYING THE RIGHT SOLUTION FOR THE RIGHT PROBLEM: THE CRITICALLY-ILL PEDIATRIC HEMATOLOGY-ONCOLOGY PATIENT

Aims & Objectives: To describe the clinical characteristics, epidemiology, management and outcome of unplanned transfers to the Pediatric Intensive Care Unit (PICU) from the Pediatric Hematology-Oncology Inpatient Unit (PHOIU). Methods: Retrospective descriptive study in a tertiary hospital including 34 non-elective PICU transfers from the PHOIU in 2019. Results: 20 patients (60% boys, mean age 7.7 years) required 34 PICU unplanned transfers (41.5% of the total PICU admissions from the PHOIU). 80% had malignancies, acute lymphoblastic leukemia being the most frequent (25%) and 55% had undergone a hematopoietic stem cell transplant. The majority were hospitalized for diagnosis confirmation (55%) or treatment initiation (40%). The median stay before PICU admission was 34.7 days. The median delay since the deterioration event to the intensivist’s evaluation and PICU transfer was 3.8 and 5.6 hours respectively. The median PICU stay was 4.4 days. During the first 24 hours of PICU stay, non-invasive ventilation was required in 11.5% of the episodes, invasive ventilation in 14.7% and vasoactive drugs in 17.6%. Upon admission, neutropenia was present in 47.1%, neurologic impairment in 20.1%, systemic inflammatory response syndrome in 38.2% and multiorgan failure in 35.3%. The most frequent diagnoses were sepsis/septic shock (35.6%), pneumonia (11.7%) and catheter-related bacteraemia (5.9%). Mortality rate was 15% during PICU stay. Conclusions: Morbimortality in pediatric hematology-oncology patients requiring an unplanned PICU admission is high. We decided to implement EVAT, an early warning system specific to the pediatric hematology-oncology patient for early detection and management of clinical deterioration in behalf of improving healthcare quality and survival.

Accuracy and Monitoring of Pediatric Early Warning Score (PEWS) Scores Prior to Emergent Pediatric Intensive Care Unit (ICU) Transfer: Retrospective Analysis.

BackgroundCurrent approaches to early detection of clinical deterioration in children have relied on intermittent track-and-trigger warning scores such as the Pediatric Early Warning Score (PEWS) that rely on periodic assessment and vital sign entry. There are limited data on the utility of these scores prior to events of decompensation leading to pediatric intensive care unit (PICU) transfer.ObjectiveThe purpose of our study was to determine the accuracy of recorded PEWS scores, assess clinical reasons for transfer, and describe the monitoring practices prior to PICU transfer involving acute decompensation.MethodsWe conducted a retrospective cohort study of patients ≤21 years of age transferred emergently from the acute care pediatric floor to the PICU due to clinical deterioration over an 8-year period. Clinical charts were abstracted to (1) determine the clinical reason for transfer, (2) quantify the frequency of physiological monitoring prior to transfer, and (3) assess the timing and accuracy of the PEWS scores 24 hours prior to transfer.ResultsDuring the 8-year period, 72 children and adolescents had an emergent PICU transfer due to clinical deterioration, most often due to acute respiratory distress. Only 35% (25/72) of the sample was on continuous telemetry or pulse oximetry monitoring prior to the transfer event, and 47% (34/72) had at least one incorrectly documented PEWS score in the 24 hours prior to the event, with a score underreporting the actual severity of illness.ConclusionsThis analysis provides support for the routine assessment of clinical deterioration and advocates for more research focused on the use and utility of continuous cardiorespiratory monitoring for patients at risk for emergent transfer.

21: Trends in Vital Signs Predict Critical Deterioration in Pediatric Intensive Care Unit Transfers

Mayampurath, Anoop1; Zhang, Xindi2; Eusuff, Jaser2; Sanchez-Pinto, L. Nelson3; Carey, Kyle1; Jani, Priti4; Churpek, Matthew5 Author Information

Improving the Safety of an Emergency Department-Based Direct Admission Process at a Children's Hospital.

Direct admission refers to admitting a patient to a unit avoiding usual entry points such as the emergency department. Inappropriate placement of direct admissions can result in rapid response activations, codes and unanticipated pediatric intensive care unit (PICU) transfers, which correlate with higher mortality and longer lengths of stay. The objective of the project was to improve the safety of the direct admission process as evidenced by decreasing the transfer of direct admission patients to the PICU within 6 hours. Utilizing the model for improvement, a multidisciplinary team was assembled to improve our screening process and reduce unanticipated direct admission-to-PICU transfers within 6 hours of arrival. Our emergency department-based direct admission process includes screening vital signs (temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry) and a Pediatric Early Warning Score. Five Plan-Do-Study-Act cycles focused on role definition, improved documentation, referring facility and family awareness, improved visual management within the ED, and education of partner EMS and transport providers. The primary outcome was PICU transfer within 6 hours of direct admission arrival. Compliance with full screening was a process measure and number of direct admissions a balancing measure. Statistical process control charts and run charts were used to follow the measures. The total number of direct admissions from January 2014 to the end of data collection, June 2018, was 3070 patients. Screening protocol compliance improved from 56% to over 80% for the entire hospital. Unanticipated direct admission-to-PICU transfers decreased from a baseline of 1 every 98 patients to a special cause of 1 in 1126 patients. By utilizing QI methodology our team was able to implement and sustain a direct admission process that was more consistent, easier to document and improved the safety of our patients. Our study demonstrates that screening direct admissions reliably and consistently can decrease the rate of unanticipated transfer to a higher level of care.

RESPIRATORY THERAPIST-DRIVEN HIGH FLOW NASAL CANNULA PATHWAY AND PICU ADMISSION RATES FOR PEDIATRIC PATIENTS WITH ACUTE BRONCHIOLITIS: A RETROSPECTIVE STUDY

SESSION TITLE: Respiratory Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The purpose of this study is to evaluate the effect of a newly implemented Respiratory Therapist (RT) driven “weight-based” (WB) high flow nasal cannula (HFNC) pathway on Pediatric Intensive Care Unit (PICU) admission rates of acute bronchiolitis patients in the pediatric acute care unit. METHODS: This study was approved by the UCSF Benioff Children’s Hospital Oakland Institutional Review Board. Data was retrospectively extracted via electronic medical records from January 2018 for the non-weight based pathway (non-WB) and January 2019 weight-based pathway (WB). The non-WB group pathway allowed RTs to adjust the HFNC to a maximum flow of 8 L/min and up to 50% FiO2. If a patient’s condition worsened, this would prompt a PICU consult and transfer, in order to provide an escalation of care. The reconfigured 2019 WB pathway, implemented in December 2018, allowed RTs to provide a higher level of care on the pediatric acute care unit by administering higher flow rates via a weight based approach in terms of liters per minute delivered. Patients weighing under 5 kg could receive flows up to 8 L/min, 5-10 kg patients could receive flows up to 10 L/min, 10-15 kg patients could receive flows up to 12 L/min, and 15 kg patients could receive flows up to 15 L/min. Non-WB group was compared to WB using the following outcome variables: PICU admission rate, hospital length of stay (LOS), and hours spent on HFNC. RESULTS: There was a total of 78 patients diagnosed with acute bronchiolitis (non-WB n=28; WB n=50). There was a significantly higher PICU admission rate for non-WB versus WB (57.1% versus 32%, P= 0.027, Eta=0.25). Mean hours spent on HFNC was lower in WB compared to non-WB (65.2 ± 38.6 versus 83.7 ± 43.8, p=0.05). Hospital LOS also reduced in WB to 5.8 ± 2.9 from 6.7 ± 3.8 non-WB, p=0.23). CONCLUSIONS: In this preliminary study, there was a significant reduction in PICU admission rate and hours spent on HFNC using the WB pathway. We believe this study will help pave the way for further exploration and implementation of RT driven pathways to be conducted in other facilities. Further research on cost-saving analysis for patients who are on RT driven pathways is needed. CLINICAL IMPLICATIONS: An RT Driven Weight Based High Flow Nasal Cannula pathway in pediatric acute care units may reduce PICU admissions for acute bronchiolitis patients. Further prospective analysis is required to confirm recommendations. DISCLOSURES: Stock market shareholder relationship with ABT, ABBV, AZN, BMY, DOW,JNJ, LLY,PFE Please note: $1-$1000 Added 06/09/2020 by Abdullah Alismail, source=Web Response, value=only Quar.Div when applied No relevant relationships by Noha Daher, source=Web Response No relevant relationships by Alex Golchehreh, source=Web Response No relevant relationships by David Lopez, source=Web Response No relevant relationships by MICHAEL TERRY, source=Web Response

Abnormal Vital Signs Predict Critical Deterioration in Hospitalized Pediatric Hematology-Oncology and Post-hematopoietic Cell Transplant Patients.

Introduction: Hospitalized pediatric hematology-oncology and post-hematopoietic cell transplant (HCT) patients have frequent deterioration requiring Pediatric Intensive Care Unit (PICU) care. Critical deterioration (CD), defined as unplanned PICU transfer requiring life-sustaining interventions within 12 h, is a pragmatic metric to evaluate emergency response systems (ERS) in pediatrics, however, it has not been investigated in these patients. The goal of this study was to evaluate if CD is an appropriate metric to assess effectiveness of ERS in pediatric hematology-oncology and post-HCT patients and if it is preceded by an actionable period of vital sign changes.Methods: A retrospective review of all unplanned PICU transfers and floor cardiopulmonary arrests in a dedicated pediatric hematology-oncology hospital between August 2014 and July 2016. Vital signs and physical exam findings 48 h prior to events were converted to Pediatric Early Warning System-Like Scores (PEWS-LS) using cardiovascular, respiratory, and neurologic criteria.Results: There were 220 deterioration events, with 107 (48.6%) meeting criteria for CD, representing a rate of 2.98 per 1,000-inpatient-days. Using the first event per hospitalization (n = 184), patients with CD had higher mortality (17.4 vs. 7.6%, p = 0.045), fewer median ICU-free-days (21 vs. 24, p = 0.011), ventilator-free-days (25 vs. 28, p < 0.001), and vasoactive-free-days (27 vs. 28, p < 0.001). Using vital sign data 48 h prior to deterioration events, those with CD had higher PEWS-LS on PICU admission (p < 0.001), spent more time with elevated PEWS-LS prior to PICU transfer (p = 0.008 to 0.023) and had a longer time from first abnormal PEWS-LS (p = 0.007 to 0.043). Significant difference between the two groups was observed as early as 4 h prior to the event (p = 0.047).Conclusion: Hospitalized pediatric hematology-oncology and post-HCT patients have frequent deterioration resulting in a high mortality. In these patients, CD is over 13 times more common than floor cardiopulmonary arrests and associated with higher mortality and fewer event-free days, making it a useful metric in these patients. CD is preceded by a long duration of abnormal vital signs, making it potentially preventable through earlier recognition.

Effects of transitional nursing mode on the occurrence of post-PICU syndrome

Objective To explore the value of transitional nursing mode in nursing care of children with Pediatric Intensive Care Unit (PICU) post syndrome. Methods From August 2014 to January 2017, 170 cases of children transferred from PICU in this hospital were selected as research objects.According to the random number table method, the patients were divided into the control group (basic care) and the experimental group (transitional care), 85 cases of each group.The negative mood improvement, adverse events and incidence of post-PICU syndrome were observed in the two groups. Results The incidence of adverse events, return to PICU, post-PICU syndrome and psychological disorder syndrome in the experimental group were significantly lower than those in the control group, and the differences were statistically significant(P<0.05). After intervention, the Self-rating Anxiery Scale (SAS) and Self-rating Depression Scale(SDS)scores of the experimental group were significantly lower than those of the control group, and the differences were statistically significant(P<0.05). The total satisfaction score of the experimental group was higher than that of the control group, and the difference was statistically significant(P<0.05). Conclusions The implementation of transitional nursing intervention during PICU transfer can effectively improve the psychological state of children, reduce the risk of adverse events and post-PICU syndrome, and contribute to better recovery of children. Key words: Transition period nursing mode; Post PICU syndrome; Mentality

Cost-benefit analysis of implementing a pediatric early warning system at a pediatric oncology hospital in a low-middle income country.

Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in low-income and middle-income countries (LMICs). Pediatric early warning systems (PEWS) assist with the early identification of deterioration. To the authors' knowledge, no studies to date have evaluated the cost-benefit of PEWS in LMICs. A PEWS was implemented at the National Pediatric Oncology Unit (Unidad Nacional de Oncologia Pediatrica [UNOP]), a pediatric oncology hospital in Guatemala, resulting in a reduction in unplanned pediatric intensive care unit (PICU) transfers. Variable costs of maintaining the PICU and hospital floor were calculated for the year prior to and after the implementation of PEWS using administrative data. PEWS implementation costs were tabulated. The number of PICU inpatient days averted due to reduced unplanned PICU transfers after implementation was calculated, adjusting for changes in hospital inpatient days. Savings per inpatient day from unplanned PICU transfers were calculated. All costs were adjusted for inflation. There were 457 fewer PICU inpatient days due to unplanned transfers noted the year after implementation of PEWS, adjusting for changes in hospital volume. The variable costs of an unplanned PICU transfer versus a bed on the hospital floor was $806 per day. The total cost of implementing PEWS at UNOP was $13,644 ($7 per admission). Through reductions in variable PICU costs, UNOP saved a net $173 per admission ($354,514 annual net savings) after implementation of PEWS. The cost savings were sustained in a series of more conservative 1-way sensitivity analyses. Implementation of PEWS at UNOP resulted in an incremental savings due to a reduction in the number of unplanned PICU transfers. The results of the current study demonstrate that hospital investment in PEWS can improve the quality of pediatric cancer care, optimize PICU use, and reduce costs.