PICU Readmission Research Articles

New Morbidities During Critical Illness and Associated Risk of ICU Readmission: Virtual Pediatric Systems Cohort, 2017-2020.

To describe change in Functional Status Scale (FSS) associated with critical illness and assess associated development of new morbidities with PICU readmission. Retrospective, cross-sectional cohort study using the Virtual Pediatric Systems (VPS; Los Angeles, CA) database. One hundred twenty-six U.S. PICUs participating in VPS. Children younger than 21 years old admitted 2017-2020 and followed to December 2022. None. Among 40,654 patients, 86.2% were classified as having good function or mild dysfunction before illness. Most patients did not have a change in their FSS category during hospitalization. Survival with new morbidity occurred most in children with baseline good/mild dysfunction (8.7%). Hospital mortality increased across categories of baseline dysfunction. Of 39,701 survivors, 14.2% were readmitted within 1 year. Median time to readmission was 159 days. In multivariable, mixed-effects Cox modeling, time to readmission was most associated with discharge functional status (hazard ratio [HR], 5.3 [95% CI, 4.6-6.1] for those with very severe dysfunction), and associated with lower hazard in those who survived with new morbidity (HR, 0.7 [95% CI, 0.6-0.7]). Development of new morbidities occurs commonly in pediatric critical illness, but we failed to find an association with greater hazard of PICU readmission. Instead, patient functional status is associated with hazard of PICU readmission.

Frequency, Characteristics, and Outcomes of Patients Requiring Early PICU Readmission.

Readmission to the PICU is associated with worse outcomes, but factors associated with PICU readmission within the same hospitalization remain unclear. We sought to describe the prevalence of, and identify factors associated with, early PICU readmission. We performed a retrospective analysis of PICU admissions for patients aged 0 to 26 years in 48 tertiary care children's hospitals between January 1, 2016 and December 31, 2019 in the Pediatric Health Information System. We defined early readmission as return to the PICU within 2 calendar days of floor transfer during the same hospitalization. Generalized linear mixed models were used to analyze associations between patient and clinical variables, including complex chronic conditions (CCC) and early PICU readmission. The results included 389 219 PICU admissions; early PICU readmission rate was 2.5%. Factors with highest odds of early PICU readmission were CCC, with ≥4 CCCs (reference: no CCC[s]) as highest odds of readmission (adjusted odds ratio [95% confidence interval]: 4.2 [3.8-4.5]), parenteral nutrition (2.3 [2.1-2.4]), and ventriculoperitoneal shunt (1.9 [1.7-2.2]). Factors with decreased odds of PICU readmission included extracorporeal membrane oxygenation (0.4 [0.3-0.6]) and cardiopulmonary resuscitation (0.8 [0.7-0.9]). Patients with early PICU readmissions had longer overall length of stay (geometric mean [geometric SD]: 18.2 [0.9] vs 5.0 [1.1] days, P < .001) and increased odds of mortality (1.7 [1.5-1.9]). Although early PICU readmissions within the same hospitalization are uncommon, they are associated with significantly worse clinical outcomes. Patients with medical complexity and technology dependence are especially vulnerable.

A Novel Comprehensive Algorithm for Evaluation of PICU Patients With New Fever or Instability.

There is variation in microbiology testing among PICU patients with fever offering opportunities to reduce avoidable testing and treatment. Our objective is to describe the development and assess the impact of a novel comprehensive testing algorithm to support judicious testing practices and expanded diagnostic differentials for PICU patients with new fever or instability. A mixed-methods quality improvement study. Single-center academic PICU and pediatric cardiac ICU. Admitted PICU patients and physicians. A multidisciplinary team developed a clinical decision-support algorithm. We evaluated blood, endotracheal, and urine cultures, urinalyses, and broad-spectrum antibiotic use per 1,000 ICU patient-days using statistical process control charts and incident rate ratios (IRRs) and assessed clinical outcomes 24 months pre- and 18 months postimplementation. We surveyed physicians weekly for 12 months postimplementation. Blood cultures declined by 17% (IRR, 0.83; 95% CI, 0.77-0.89), endotracheal cultures by 26% (IRR, 0.74; 95% CI, 0.63-0.86), and urine cultures by 36% (IRR, 0.64; 95% CI, 0.56-0.73). There was an anticipated rise in urinalysis testing by 23% (IRR, 1.23; 95% CI, 1.14-1.33). Despite higher acuity and fewer brief hospitalizations, mortality, hospital, and PICU readmissions were stable, and PICU length of stay declined. Of the 108 physician surveys, 46 replied (43%), and 39 (85%) recently used the algorithm; 0 reported patient safety concerns, two (4%) provided constructive feedback, and 28 (61%) reported the algorithm improved patient care. A comprehensive fever algorithm was associated with reductions in blood, endotracheal, and urine cultures and anticipated increase in urinalyses. We detected no patient harm, and physicians reported improved patient care.

Child Opportunity Index and Emergent PICU Readmissions: A Retrospective, Cross-Sectional Study of 43 U.S. Hospitals.

To examine the association between a validated composite measure of neighborhood factors, the Child Opportunity Index (COI), and emergent PICU readmission during the year following discharge for survivors of pediatric critical illness. Retrospective cross-sectional study. Forty-three U.S. children's hospitals contributing to the Pediatric Health Information System administrative dataset. Children (< 18 yr) with at least one emergent PICU admission in 2018-2019 who survived an index admission. None. Of 78,839 patients, 26% resided in very low COI neighborhoods, 21% in low COI, 19% in moderate COI, 17% in high COI, and 17% in very high COI neighborhoods, and 12.6% had an emergent PICU readmission within 1 year. After adjusting for patient-level demographic and clinical factors, residence in neighborhoods with moderate, low, and very low COI was associated with increased odds of emergent 1-year PICU readmission relative to patients in very high COI neighborhoods. Lower COI levels were associated with readmission in diabetic ketoacidosis and asthma. We failed to find an association between COI and emergent PICU readmission in patients with an index PICU admission diagnosis of respiratory conditions, sepsis, or trauma. Children living in neighborhoods with lower child opportunity had an increased risk of emergent 1-year readmission to the PICU, particularly children with chronic conditions such as asthma and diabetes. Assessing the neighborhood context to which children return following critical illness may inform community-level initiatives to foster recovery and reduce the risk of adverse outcomes.

Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU.

To decrease length of high-flow nasal cannula (HFNC), PICU, and hospital length of stay (LOS). Quality improvement project. A quaternary academic PICU. Patients with bronchiolitis less than 24 months old. After initial implementation of a respiratory therapist (RT)-driven HFNC protocol (Plan-Do-Study-Act [PDSA] 1) in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. Duration of HFNC was used as the primary outcome measure. PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use, and 7-day PICU and hospital readmission rates were used as balancing measures. A total of 1,310 patients were included in this study. Patients in PDSA 2, PDSA 3 and 4 groups were older compared with pre-intervention and PDSA 1 (median of 9 and 10 mo compared with 8 mo; p = 0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2, and 1.5 days after PDSA 3 and 4. Hospital LOS decreased from 5.7 to 4.5 days after PDSA 1, 3.1 days after PDSA 2, and 2.7 days after PDSA 3 and 4. The use of noninvasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at the end of the project. The 7-day PICU and hospital readmission rates did not increase after implementation. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. Modifications to an existing RT-driven HFNC protocol and standardization of discharge criteria led to an improvement in outcomes for patients admitted to the PICU with bronchiolitis without an increase in adverse events.

Pediatric Delirium and All-Cause PICU Readmissions Within 1 Year.

Delirium in critically ill children is associated with increased in-hospital morbidity and mortality. Little is known about the lingering effects of pediatric delirium in survivors after hospital discharge. The primary objective of this study was to determine whether children with delirium would have a higher likelihood of all-cause PICU readmission within 1 calendar year, when compared with children without delirium. Retrospective cohort study. Tertiary care, mixed PICU at an urban academic medical center. Index admissions included all children admitted between September 2014 and August 2015. For each index admission, any readmission occurring within 1 year after PICU discharge was captured. Every child was screened for delirium daily throughout the PICU stay. Among 1,145 index patients, 166 children (14.5%) were readmitted at least once. Bivariate analyses compared patients readmitted within 1 year of discharge with those not readmitted: complex chronic conditions (CCCs), increased severity of illness, longer PICU length of stay, need for mechanical ventilation, age less than 6 months, and a diagnosis of delirium were all associated with subsequent readmission. A multivariable logistic regression model was constructed to describe adjusted odds ratios for readmission. The primary exposure variable was number of delirium days. After controlling for confounders, critically ill children who experienced greater than 2 delirium days on index admission were more than twice as likely to be readmitted (adjusted odds ratio, 2.2; CI, 1.1-4.4; p = 0.023). A dose-response relationship was demonstrated as children with longer duration of delirium had increased odds of readmission. In this cohort, delirium duration was an independent risk factor for readmission in critically ill children. Future research is needed to determine if decreasing prevalence of delirium during hospitalization can decrease need for PICU readmission.

Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated With Pediatric Intensive Care Use for Acute Respiratory Failure Requiring Mechanical Ventilation.

Poverty, racial bias, and disparities are linked to adverse health outcomes for children in the United States. The social vulnerability and child opportunity indices are composite measures of the social, economic, education, health, and environmental qualities that affect human health for every U.S. census tract. Composite measures of social vulnerability and child opportunity were compared for neighborhood hot spots, where PICU admissions for acute respiratory failure requiring invasive mechanical ventilation were at the 90th percentile or greater per 1,000 children, versus non-hot spots. Population-based ecological study. Two urban free-standing children's hospital PICUs consisting of a 36-bed quaternary academic and a 56-bed tertiary community center, in Atlanta, GA. Mechanically ventilated children who were 17 years of age or younger with a geocodable Georgia residential address admitted to a PICU for at least 1 day. None. Residential addresses were geocoded and spatially joined to census tracts. Composite measures of social vulnerability and childhood opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots versus non-hot spots. There were 340 of 3,514 children (9.7%) who lived within a hot spot. Hot spots were associated with a higher (worse) composite social vulnerability index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a lower (worse) composite childhood opportunity index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower childhood opportunity were not associated with readmission rates but were associated with longer total median duration of hospital days per 1,000 children in a census tract. Social determinants of health identified by geospatial analyses are associated with acute respiratory failure requiring invasive mechanical ventilation in critically ill children. Interventions addressing the neighborhood social vulnerability and child opportunity are needed to decrease disparities in intensive care admissions for acute respiratory failure requiring mechanical ventilation.

Reducing PICU-to-Floor Time-to-Transfer Decision in Critically Ill Bronchiolitis Patients using Quality Improvement Methodology.

Specific criteria for de-escalation from the PICU are often not included in viral bronchiolitis institutional pathways. Variability of transfer preferences can prolong PICU length of stay. We aimed to decrease the time from reaching floor-appropriate heated high flow nasal cannula (HHF) settings to the transfer decision by 20% through standardizing PICU-to-floor transfer assessment in a PICU bronchiolitis cohort. We included PICU bronchiolitis admissions from October 2019 to April 2020, who were 6-months to 2-years-old with no comorbidities nor intubation during their encounter. Our intervention bundle included introduction of transfer criteria and standardization of transfer-readiness assessment. The primary outcome was time from reaching floor-appropriate HHF settings [8 L per minutes (Lpm)] to placement of the transfer order ("time-to-transfer decision"). The secondary outcome was PICU length of stay. The main process measure was the proportion of patients transferred on ≥6 Lpm HHF. Balancing measures included Rapid Response Team activation and unplanned PICU readmission. We assessed admissions meeting inclusion criteria from December, 2018-March, 2019 for the preintervention baseline. Special cause variation indicated improvement in our primary outcome and process measures. Comparison of baseline to postintervention revealed a reduction in median time-to-transfer decision (14.4-7.8 hours; P < 0.001) and increase in children transferred on ≥6 Lpm (51%-72%; P < 0.001). We observed no change in PICU length of stay or balancing measures. Standardizing de-escalation criteria and transfer-readiness assessment reduced the time-to-transfer decision out of the PICU and increased the proportion transferred on ≥6 Lpm HHF for children with viral bronchiolitis without increasing PICU readmissions.

The characteristics of patients requiring readmission to an Australian forensic psychiatric intensive care unit

IntroductionPsychiatric intensive care units (or PICU’s) emerged to manage high acuity patients outside the justice system. Studies have sought to better understand characteristics of those admitted to forensic or civilian PICU’s. Few, in contrast, have explored the frequency and contributors to readmission. The following study was conducted on Apsley unit, a Forensic PICU based in Melbourne, Australia, and seeks to understand the differences which would allow early identification of patients likely to require readmission and the provision of targeted interventions.ObjectivesExamine rates of and contributors to forensic PICU readmission over a 6-month period.MethodsA retrospective audit was conducted to collect clinical, problem behaviour (and strategies to manage), forensic history and demographic information for consecutively admitted patients to an 8-bed forensic PICU between March-September 2019.ResultsData analysis is ongoing. Interim analysis found that 96 patients were admitted during the 6-month study period: 74 (77.1%) had a single admission; 22 (22.9%) required readmission. Almost all were admitted from prison (96.9%), most had a psychosis diagnosis (80.2%) and substance abuse history (96.9%), and many had a personality disorder (24.0%) and history of adolescent antisocial behaviour (46.5%). Patients requiring readmission were significantly more likely to have been previously under compulsory mental health treatment (95.5% vs 75.3%, p=.039) and have a Positive Behaviour Support Plan developed during admission (85.7% vs 54.8%, p=.010).ConclusionsInterim analysis highlighted the multicomplexity for forensic PICU patients alongside the occurrence of problem behaviour during admission and history of compulsory treatment as indicators of increased risk for re-admission.

O033 / #1238: PAEDIATRIC CARDIAC CRITICAL CARE IN A MIDDLE INCOME COUNTRY: EMERGENCY AND ELECTIVE PICU ADMISSIONS

Aims & Objectives: There is a paucity of data on paediatric cardiac critical care (PCCC) patients in South Africa. This study describes PCCC patients profiles and outcomes in a tertiary PICU. Methods: A 12-month prospective review of consecutive PICU admissions. Results: A total of 472 PCCC PICU admissions included (34.6% of the total annual PICU population). Of the PCCC admissions, 58% (n=274) were elective cardiac surgery, 7.8% (n=37) post elective general surgery and 34% (n=161) unplanned emergency admissions. Indications for emergency admission included: shock (28%), respiratory failure (22%), cyanosis (18%), decompensated cardiac failure (18%), post cardiac arrest (8%) and life-threatening arrhythmias (3%). Comparing elective admissions with emergency admissions: median age of admission was 24 v. 5 months (p<0.0001); length of PICU stay 3 v. 6 days (p<0.0001); length of ventilation 1 v. 2 days (p=0.13), length of inotrope use 1 v. 2 days (p=0.08); and median maximum inotrope score 1 v. 9 (p=0.46). Eighty-one patients (19.8%) needed PICU readmissions. Complications in the elective group v. the emergency group included failed extubation 5.7% v. 13% (p=0.006), infection on admission 20.6% v. 45.0% (p<0.0001), CLABSI 3.8% v. 17.4% (p<0.0001), AKI 17.4% v. 32.9% (p=0.001), liver impairment 3.5% v. 19.3% (p<0.0001), neurological sequelae 1.9% v. 14.9% (p<0.0001) and PICU readmission 10.3% v. 30.4% (p<0.0001). In both groups 4.1% suffered a cardiac arrest during PICU stay (p<0.0001). PICU mortality for the elective v. emergency admission group was 1.6% v. 12.4% (p<0.0001) and standardised mortality 0.25 v. 0.80. Conclusions: Unplanned emergency PCCC admissions have a higher morbidity and mortality in our setting.

P0611 / #1112: ANTIMICROBIAL STEWARDSHIP AND PROCALCITONIN TESTING TO OPTIMIZE SEPSIS CARE IN CRITICALLY ILL PEDIATRIC PATIENTS

Aims & Objectives: We aim to prospectively evaluate an antimicrobial stewardship program (ASP) and Procalcitonin (PCT) testing on septic pediatric intensive care (PICU) patients. Methods: We performed a 30-week baseline collection (Phase 1), and a 30-week evaluation (Phase 2) of ASP and PCT in PICU patients with suspected or confirmed sepsis (inclusion criteria: temperature >38.0 or <36.0 and requiring IV antibiotic). The primary endpoint was in-hospital mortality; secondary endpoints included antimicrobial adequacy, ASP interventions and acceptance, LOS, re-admissions and economic indices, etc. Segmented logistic and linear regression analyses were performed for associations. Results: Each phase had 40 children, mean age of 3.9 (1.8) years; 56.3% male; PRISM III mean was 3.3 and 7.0 (CI:±2.66,p=0.0068) in each phase, respectively. From 104 antibiotic prescriptions, 91 (88%) were guideline-concordant; 103 ASP recommendations were made in 60 assessments, with 83% full acceptance rate; in 12% of patients antimicrobials were not indicated, in 6% narrower spectrum was suggested. PCT was measured at least once in 95% of patients: in 24% initial PCT values were <0.25 ng/mL (stopping rule) while in 71% were >1 ng/mL (continuation rule). Only 1 patient died (phase 1), mortality 1.2%. In phase 2 the mean ICU LOS was shorter (-6.58 days; 95% CI, -14.51, 1.36, p=0.10) and PICU readmissions decreased (12 vs. 4; p=0.048); costs were lower (-$5,830) and QALYs were higher (0.192 vs 0.188). Conclusions: ASP and PCT testing were effectively implemented, well accepted and helpful, albeit mortality did not differ. Implementation was cost effective with fewer re-admissions and resulted in higher quality-adjusted life years.

Is Unplanned PICU Readmission a Proper Quality Indicator? A Systematic Review and Meta-analysis.

Unplanned PICU readmissions within 48 hours of discharge (to home or a different hospital setting) are considered a quality metric of critical care. We sought to determine identifiable risk factors associated with early unplanned PICU readmissions. A comprehensive search of Medline, Embase, the Cochrane Database of Systematic Reviews, and Scopus was conducted from each database's inception to July 16, 2018. Observational studies of early unplanned PICU readmissions (<48 hours) in children (<18 years of age) published in any language were included. Two reviewers selected and appraised studies independently and abstracted data. A meta-analysis was performed by using the random-effects model. We included 11 observational studies in which 128 974 children (mean age: 5 years) were evaluated. The presence of complex chronic diseases (odds ratio 2.42; 95% confidence interval 1.06 to 5.55; I 2 79.90%) and moderate to severe disability (odds ratio 2.85; 95% confidence interval 2.40 to 3.40; I 2 11.20%) had the highest odds of early unplanned PICU readmission. Other significant risk factors included an unplanned index admission, initial admission to a general medical ward, spring season, respiratory diagnoses, and longer initial PICU stay. Readmission was less likely after trauma- and surgery-related index admissions, after direct admission from home, or during the summer season. Modifiable risk factors, such as evening or weekend discharge, revealed no statistically significant association. Included studies were retrospective, which limited our ability to account for all potential confounders and establish causality. Many risk factors for early unplanned PICU readmission are not modifiable, which brings into question the usefulness of this quality measure.

Unplanned PICU Readmission in a Middle-Income Country: Who Is at Risk and What Is the Outcome?

To study the rate of unplanned PICU readmission, determine the risk factors and its impact on mortality. A single-center retrospective cross-sectional study. Tertiary referral PICU in Johor, Malaysia. All children admitted to the PICU over 8 years were included. Patients readmitted into PICU after the first PICU discharge during the hospitalization period were categorized into "early" (within 48 hr) and "late" (after 48 hr), and factors linked to the readmissions were identified. The mortality rate was determined and compared between no, early, and late readmission. None. There were 2,834 patients in the study with 70 early and 113 late readmissions. Therefore, the rate of early and late PICU readmission was 2.5% (95% CI, 1.9-3.0%) and 3.9% (95% CI, 3.2-4.7%), respectively. The median length of stay of the second PICU admission for early and late readmissions was 2.7 days (interquartile range, 1.1-7.0 d) and 3.2 days (interquartile range, 1.2-7.5 d), respectively. The majority of early and late readmissions had a similar diagnosis with their first PICU admission. Multivariable multinomial logistic regression revealed a Pediatric Index Mortality 2 score of greater than or equal to 15, chronic cardiovascular condition, and oxygen supplement upon discharge as independent risk factors for early PICU readmission. Meanwhile, an infant of less than 1 year old, having cardiovascular, other congenital and genetic chronic conditions and being discharged between 8 AM and 5 PM was an independent risk factor for late readmission. There was no significant difference in the mortality rate of early (12.9%), late (13.3%), and no readmission (10.7%). Despite the lack of resources and expertise in lower- and middle-income countries, the rate and factors for PICU readmission are similar to those in high-income countries. However, PICU readmission has no statistically significant association with mortality.

Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus

Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish “late-rescues” (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), “PICU readmissions” (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5–18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5–8] vs. 5 [IQR:3–6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1–1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61–0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.

Variability of Care in Infants with Severe Bronchiolitis: Less-Invasive Respiratory Management Leads to Similar Outcomes

To compare the management of children with severe bronchiolitis requiring intensive care (based on duration of ventilatory support and duration of pediatric intensive care unit [PICU] stay) in 2 countries with differing pediatric transport and PICU organizations. This was a prospective observational care study in 2 PICUs of tertiary care university hospitals, 1 in France and 1 in Canada. All children with bronchiolitis who required admission to the PICU between November 1, 2013, and March 31, 2014, were included. A total of 194 children were included. Baseline characteristics and illness severity were similar at the 2 sites. There was a significant difference between centers in the use of invasive ventilation (3% in France vs 26% in Canada; P < .0001). The number of investigations performed from admission to emergency department presentation and during the PICU stay was significantly higher in Canada for both chest radiographs and blood tests (P < .001). The use of antibiotics was significantly higher in Canada both before (60% vs 28%; P < .001) and during (72% vs 33%; P < .0001) the PICU stay. The duration of ventilatory support, median length of stay, and rate of PICU readmission were similar in the 2 centers. Important differences in the management of children with severe bronchiolitis were observed during both prehospital transport and PICU treatment. Less invasive management resulted in similar outcomes with in fewer complications.

PICU Readmissions: Not Just Output but Patient Throughput*

PICU Readmissions: Not Just Output but Patient Throughput*

Description of PICU Unplanned Readmission.

ICU readmission within 48 hours of discharge is associated with increased mortality. The objectives of this study were to describe the frequency of, factors associated with, and outcomes associated with unplanned PICU readmission. A retrospective case-control study was performed. We evaluated 13 candidate risk factors and report patient outcomes following readmission. Subgroup analyses were performed for patients discharged from the cardiac PICU and medical-surgical PICU. The study was undertaken at the Hospital for Sick Children, Department of Critical Care Medicine. Eligible patients were discharged from the PICU to an inpatient ward between December 2006 and January 2013. Case patients were readmitted to the PICU within 48 hours of discharge. There were 10,422 eligible patient discharges; 264 (2.5%) were readmitted within 48 hours. In the univariable analysis, unplanned readmission was associated with PICU patient admissions of younger age, lower weight, greater duration of PICU stay, greater cumulative stay in PICU in the past 2 years, higher Pediatric Logistic Organ Dysfunction score on PICU discharge, discharge outside goal discharge time (06:00-11:59 hr), use of extracorporeal organ support during ICU stay, greater Bedside Pediatric Early Warning Score, at discharge and discharge from the cardiac PICU. In the multivariable analysis, the factors most significantly associated with unplanned PICU readmission were length of stay more than 48 hours, greater cumulative length of PICU stay in the past 2 years, discharge from cardiac PICU, and higher Pediatric Logistic Organ Dysfunction and Bedside Pediatric Early Warning Scores on index discharge. Mortality was 1.8 times (p = 0.03) higher in patients with an unplanned PICU readmission compared with patients during their index PICU admission. The only potentially modifiable factors we found associated with PICU readmission within 48 hours of discharge were discharge time of day and the Pediatric Logistic Organ Dysfunction and Bedside Pediatric Early Warning Scores at the time of PICU discharge.

Routine Medical Emergency Team Assessments of Patients Discharged From the PICU: Description of a Medical Emergency Team Follow-Up Program.

This study describes one follow-up program in the Ontario Rapid-Response System project consisting of routine medical emergency team visits of patients discharged from the PICU consisting of two planned visits within 48 hours following discharge. Study purpose was to describe interventions provided and the patient characteristics associated with medical emergency team utilization. Retrospective cohort study. Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. Discharged pediatric patients from PICU. Data over 41 months were obtained from a prospectively maintained rapid-response system database. Major medical emergency team support was defined as an early unplanned visit, intervention, or readmission during the follow-up period. Interrupted time-series analysis comparing the 2 years preceding rapid-response system implementation with the subsequent 4 years demonstrated a statistically significant immediate change in PICU readmission rate (-5.5%, p = 0.0001). There were 1,805 patients followed after PICU discharge. During the 48-hour planned follow-up period, 4% of patients received an unplanned medical emergency team visit and 13% received an active intervention. Analysis of the first medical emergency team visit identified that 10% received major medical emergency team support. After the initial visit, 6% of patients received major medical emergency team support with predictive characteristics being an unplanned first visit (odds ratio, 3.7; 95% CI, 1.6-8.5) or an intervention during the first visit (odds ratio, 3.5; 95% CI, 2.1-5.8). Multiple diseased organs were associated with major medical emergency team support after the initial visit for recent surgical patients (odds ratio, 3.0 vs 1.2; p = 0.03). Routine medical emergency team visits following PICU discharge reduced the risk of early readmission. Our results suggest that one in seven patients in the follow-up program receive major medical emergency team support. We suggest a follow-up program with at least one routine medical emergency team visit within the first 24 hours of discharge with a second planned visit reserved for complex postsurgical patients.

Frequency, Risk Factors, and Outcomes of Early Unplanned Readmissions to PICUs*

To determine the rate of unplanned PICU readmissions, examine the characteristics of index admissions associated with readmission, and compare outcomes of readmissions versus index admissions. Retrospective cohort analysis. Ninety North American PICUs that participated in the Virtual Pediatric Intensive Care Unit Systems. One hundred five thousand four hundred thirty-seven admissions between July 2009 and March 2011. None. Unplanned PICU readmission within 48 hours of index discharge was the primary outcome. Summary statistics, bivariate analyses, and mixed-effects logistic regression model with random effects for each hospital were performed.There were 1,161 readmissions (1.2%). The readmission rate varied among PICUs (0-3.3%), and acute respiratory (56%), infectious (35%), neurological (28%), and cardiovascular (20%) diagnoses were often present on readmission. Readmission risk increased in patients with two or more complex chronic conditions (adjusted odds ratio, 1.72; p < 0.001), unscheduled index admission (adjusted odds ratio, 1.37; p < 0.001), and transfer to an intermediate unit (adjusted odds ratio, 1.29; p = 0.004, compared with ward). Trauma patients had a decreased risk of readmission (adjusted odds ratio, 0.67; p = 0.003). Gender, race, insurance, age more than 6 months, perioperative status, and nighttime transfer were not associated with readmission. Compared with index admissions, readmissions had longer median PICU length of stay (3.1 vs 1.7 d, p < 0.001) and higher mortality (4% vs 2.5%, p = 0.002). Unplanned PICU readmissions were relatively uncommon, but were associated with worse outcomes. Several patient and admission characteristics were associated with readmission. These data help identify high-risk patient groups and inform risk-adjustment for standardized readmission rates.

Unscheduled Readmissions to the PICU

To determine the rate of, and potential risk factors for, unscheduled PICU readmission and assess for variability among PICUs within the United States. This retrospective cohort study used 2005-2008 data from 73 PICUs in the Virtual PICU Systems database. Early (within 48 hr of PICU discharge) and late (later than 48 hr) unscheduled readmission rates were calculated. Hierarchical logistic regression, with a random intercept for site, was used to identify factors independently associated with early readmission. Significant random effects identified sites with an outlying risk of readmission, adjusting for patient and admission characteristics. For 117,923 children meeting inclusion criteria, the unscheduled readmission rate was 3.7% with 38% (1.4%) occurring early. Half of early readmissions had the same primary diagnosis as the first admission. Patients with late readmissions had a higher mortality (6.6% vs 3.3%, p < 0.001) and longer median total PICU length of stay (11 d vs 6 d, p < 0.0001) than those with early readmission. Patient characteristics strongly associated with increased risk of early readmission included the following: age < 6 months, acute respiratory and renal disease, and several underlying chronic conditions such as liver disease, bone marrow transplant, airway stenosis, and abnormal antidiuretic hormone balances. An initial PICU admission that was unscheduled, originated from the general floor, or with a discharge time between 4 PM and 8 AM was associated with higher risk of readmission. A quarter of sites were identified as potential high (16%) or low (8%) outliers. The rate of unscheduled PICU readmission was low but associated with worse outcomes. Patient and admission/discharge characteristics associated with increased risk of readmissions could be used to target high-risk populations or modifiable factors to improve outcome. Variation of risk among centers suggests room for improvement.