PICU Resources Research Articles

Interfacility Referral Communication for PICU Transfer.

For patients requiring transfer to a higher level of care, excellent interfacility communication is essential. Our objective was to characterize verbal handoffs for urgent interfacility transfers of children to the PICU and compare these characteristics with known elements of high-quality intrahospital shift-to-shift handoffs. Mixed methods retrospective study of audio-recorded referral calls between referring clinicians and receiving PICU physicians for urgent interfacility PICU transfers. Academic tertiary referral PICU. Children 0-18 years old admitted to a single PICU following interfacility transfer over a 4-month period (October 2019 to January 2020). None. We reviewed interfacility referral phone calls for 49 patients. Referral calls between clinicians lasted a median of 9.7 minutes (interquartile range, 6.8-14.5 min). Most referring clinicians provided information on history (96%), physical examination (94%), test results (94%), and interventions (98%). Fewer clinicians provided assessments of illness severity (87%) or code status (19%). Seventy-seven percent of referring clinicians and 6% of receiving PICU physicians stated the working diagnosis. Only 9% of PICU physicians summarized information received. Interfacility handoffs usually involved: 1) indirect references to illness severity and diagnosis rather than explicit discussions, 2) justifications for PICU admission, 3) statements communicating and addressing uncertainty, and 4) statements indicating the referring hospital's reliance on PICU resources. Interfacility referral communication was similar to intrahospital shift-to-shift handoffs with some key differences: 1) use of contextual information for appropriate PICU triage, 2) difference in expertise between communicating clinicians, and 3) reliance of referring clinicians and PICU physicians on each other for accurate information and medical/transport guidance. Interfacility PICU referral communication shared characteristics with intrahospital shift-to-shift handoffs; however, communication did not adhere to known elements of high-quality handovers. Structured tools specific to PICU interfacility referral communication must be developed and investigated for effectiveness in improving communication and patient outcomes.

Pediatric Sepsis Phenotypes and Outcome: 5-Year Retrospective Cohort Study in a Single Center in India (2017-2022).

To describe mortality associated with different clinical phenotypes of sepsis in children. Retrospective study. PICU of a tertiary care center in India from 2017 to 2022. Six hundred twelve children (from 2 mo to 17 yr old) with a retrospectively applied diagnosis of sepsis using 2020 guidance. The main outcome was mortality associated with sepsis subtypes. Other analyses included assessment of risk factors, requirement for organ support, and PICU resources used by sepsis phenotype. Clinical data were recorded on a predesigned proforma. None. Of the 612 children identified, there were 382 (62%) with sepsis but no multiple organ failure (NoMOF), 48 (8%) with thrombocytopenia-associated MOF (TAMOF), 140 (23%) with MOF without thrombocytopenia, and 40 (6.5%) with sequential MOF (SMOF). Mortality was higher in the SMOF (20/40 [50%]), MOF (62/140 [44%]) and TAMOF (20/48 [42%]) groups, compared with NoMOF group (82/382 [21%] [ p < 0.001]). The requirement for organ support and PICU resources was higher in all phenotypes with MOF as compared with those without MOF. On multivariable analysis elevated lactate and having MOF were associated with greater odds of mortality. In this single-center experience of sepsis in India, we found that sepsis phenotypes having MOF were associated with mortality and the requirement of PICU resources. Prospective studies in different regions of the world will help identify a classification of pediatric sepsis that is more widely applicable.

Characteristics of Long-Stay Patients in a PICU and Healthcare Resource Utilization After Discharge.

To examine the characteristics of long-stay patients (LSPs) admitted to a PICU and to investigate discharge characteristics of medical complexity among discharged LSP. We performed a retrospective cohort study where clinical data were collected on all children admitted to our PICU between July 1, 2017, and January 1, 2020. A single-center study based at Erasmus MC Sophia Children's Hospital, a level III interdisciplinary PICU in The Netherlands, providing all pediatric and surgical subspecialties. LSP was defined as those admitted for at least 28 consecutive days. None. Length of PICU stay, diagnosis at admission, length of mechanical ventilation, need for extracorporeal membrane oxygenation, mortality, discharge location after PICU and hospital admission, medical technical support, medication use, and involvement of allied healthcare professionals after hospital discharge. LSP represented a small proportion of total PICU patients (108 patients; 3.2%) but consumed 33% of the total admission days, 47% of all days on extracorporeal membrane oxygenation, and 38% of all days on mechanical ventilation. After discharge, most LSP could be classified as children with medical complexity (CMC) (76%); all patients received discharge medications (median 5.5; range 2-19), most patients suffered from a chronic disease (89%), leaving the hospital with one or more technological devices (82%) and required allied healthcare professional involvement after discharge (93%). LSP consumes a considerable amount of resources in the PICU and its impact extends beyond the point of PICU discharge since the majority are CMC. This indicates complex care needs at home, high family needs, and a high burden on the healthcare system across hospital borders.

660: RECURRENT GUILLAIN-BARRE SYNDROME: CLINICAL PROFILE AND OUTCOME OF CHILDREN FROM A NORTH INDIAN PICU

Introduction: Guillian-Barre Syndrome (GBS) is an acute flaccid ascending paralysis, usually considered a monophasic illness. Recurrences do occur in an undefined group of patients. However, there is a dearth of literature on recurrent GBS, especially in the pediatric age group. We studied the subgroup of recurrent GBS in children and compared the clinical, neurological, treatment and outcomes of these children with non-recurrent GBS. We also compared different episodes of recurrent GBS. Methods: Patients’ case records were retrieved retrospectively from the electronic database and case record files. All children diagnosed with GBS admitted to PICU from 2010 to March 2022 were screened. Clinical profile, nerve conduction study, treatment and outcome details were recorded. Recurrent GBS cases, as defined by the National Institute of Neurological and Communicative Diseases and Strokes (NINCDS) criteria, were analyzed separately. The comparison was made between the first episode of recurrent GBS with non-recurrent GBS, and predictors of recurrence were identified. A comparison of course and outcome was also done between different episodes of GBS in recurrent cases. Results: 11(4.7%) out of 234 cases admitted to PICU between 2010 and March 2022 had recurrent GBS. Respiratory (p-0.015) and gastrointestinal illness (0.007) as preceding illnesses were predictors of recurrence. No difference was noted between the first episode of recurrent GBS and non-recurrent GBS. The first and second episodes of GBS in 11 recurrent cases were similar in course and outcome. Conclusions: Recurrent GBS is underreported but a known entity. Respiratory and gastrointestinal illness in first-episode predicted recurrence. We did not observe any difference between the 2 episodes of recurrent GBS. However, more data is required to find the features of recurrent GBS so that limited PICU resources can be used judiciously and intervention planned accordingly.

Association of Pathogen Type With Outcomes of Children Encountering Community-Acquired Pediatric Septic Shock.

To determine the association of pathogen type with mortality, functional status, and health-related quality of life (HRQL) among children at hospital discharge/1 month following hospitalization for septic shock. Secondary database analysis of a prospective, descriptive cohort investigation. Twelve academic PICUs in the United States. Critically ill children, 1 month to 18 years old, enrolled from 2013 to 2017. None. Association of clinical outcomes with pathogen type was assessed for all patients and separately for surviving patients enrolled in the primary Life After Pediatric Sepsis Evaluation (LAPSE) investigation. For this secondary analysis, we predicted that age would be associated with pathogen type and outcomes, and accordingly, it was incorporated as a confounding variable in primary analyses. Among 389 children enrolled with septic shock, at 1 month/hospital discharge, we observed no statistically significant differences in relation to pathogen types for the composite outcome mortality or substantial new functional morbidity: no causative organism identified (27% [28/103]), pure viral infections (26% [24/91]), pure bacterial/fungal infections (25% [31/125]), and bacterial/fungal+viral coinfections (33% [23/70]). Similarly, we observed no statistically significant differences in relation to pathogen types for the composite outcome, mortality, or persistent serious deterioration of HRQL: no causative organism identified (43% [44/103]), pure viral infections (33% [30/91]), pure bacterial/fungal infections (46% [57/125]), and bacterial/fungal+viral coinfections (43% [30/70]). However, we did identify statistically significant associations between pathogen type and the outcome ventilator-free days ( p = 0.0083) and PICU-free days (0.0238). This secondary analysis of the LAPSE database identified no statistically significant association of pathogen type with composite mortality and morbidity outcomes. However, pathogen type may be associated with PICU resources employed to treat sepsis organ dysfunction. Ultimately, pediatric septic shock was frequently associated with adverse patient-centered, clinically meaningful outcomes regardless of infectious disease pathogen type.

Epidemiology of Pediatric Critical Care Admissions in 43 United States Children’s Hospitals, 2014–2019*

To identify trends in the population of patients in PICUs over time. Cross-sectional, retrospective cohort study using the Pediatric Health Information System database. Forty-three U.S. children's hospitals. All patients admitted to Pediatric Health Information System-participating hospitals from January 2014 to December 2019. Individuals greater than 65 years old and normal newborns were excluded. None. PICU care occurred in 13.8% of all pediatric hospital encounters and increased over the study period from 13.3% to 14.3%. Resource intensity, based on average Hospitalization Resource Intensity Scores for Kids score, increased significantly across epochs (6.5 in 2014-2015 vs 6.9 in 2018-2019; p < 0.001), although this was not consistently manifested as additional procedural exposure. Geometric mean PICU cost per patient encounter was stable. The two most common disease categories in PICU patients were respiratory failure and cardiac and circulatory congenital anomalies. Of all PICU encounters, 35.5% involved mechanical ventilation, and 25.9% involved vasoactive infusions. Hospital-level variation in the percentage of days spent in the PICU ranged from 15.1% to 63.5% across the participating sites. Of the total hospital costs for patients admitted to the PICU, 41.7% of costs were accrued during the patients' PICU stay. The proportional use of PICU beds is increasing over time, although was variable across centers. Case-based resource use and complexity of pediatric patients are also increasing. Despite the higher use of PICU resources, the standardized costs of PICU care per patient encounter have remained stable. These data may help to inform current PICU resource allocation and future PICU capacity planning.

Prediction of Pediatric Critical Care Resource Utilization for Disaster Triage.

Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use. Retrospective cohort study. Seattle Children's Hospital. PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206). None. We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay. A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.

Risk of Mortality in Immunocompromised Children With Severe Sepsis and Septic Shock.

To assess the prevalence of immunocompromised diagnoses among children with severe sepsis and septic shock, and to determine the association between immunocompromised diagnoses and clinical outcomes after adjustment for demographics and illness severity. Retrospective multicenter cohort study. Eighty-three centers in the Virtual Pediatric Systems database. Children with severe sepsis or septic shock admitted to a participating PICU between January 1, 2012, and December 31, 2016. None. Across 83 centers, we identified 10,768 PICU admissions with an International Classification of Diseases, 9th Revision, Clinical Modification code for severe sepsis or septic shock; 3,021 of these patients (28%) had an immunocompromised diagnosis. To evaluate variation across centers and determine factors associated with PICU mortality, we used mixed-effect logistic regression models. Among patients without hematopoietic cell transplant, congenital immunodeficiency (adjusted odds ratio, 1.90; 95% CI, 1.24-2.92), multiple prior malignancies (adjusted odds ratio, 1.86; 95% CI, 1.15-2.99), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 3.09; 95% CI, 1.91-4.98) were associated with an increased odds of PICU mortality. Among patients with prior hematopoietic cell transplant, liquid malignancy (adjusted odds ratio, 3.15; 95% CI, 2.09-4.74), congenital immunodeficiency (adjusted odds ratio, 6.94; 95% CI, 3.84-12.53), multiple prior malignancies (adjusted odds ratio, 3.54; 95% CI, 1.80-6.95), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 2.79; 95% CI, 1.36-5.71) were associated with an increased odds of PICU mortality. PICU mortality varied significantly by center, and a higher mean number of sepsis patients per month in a center was associated with lower PICU mortality (adjusted odds ratio, 0.94; 95% CI, 0.90-0.98). PICU resource utilization varied by immunocompromised diagnosis and history of hematopoietic cell transplant, and among survivors immunocompromised patients have shorter median PICU length of stay compared with patients without immunocompromised diagnoses (p < 0.001). Immunocompromised diagnoses are present in 28% of children with severe sepsis or septic shock. Multiple prior malignancies, hemophagocytic lymphohistiocytosis, congenital immunodeficiency, and hematopoietic cell transplant are independently associated with an increased odds of PICU mortality in children with severe sepsis or septic shock. Significant variation exists in PICU mortality among centers despite adjustment for immunocompromised diagnoses, known risk factors for sepsis-related mortality, and center-level sepsis volume.

Critical Trio Exome Benefits In-Time Decision-Making for Pediatric Patients With Severe Illnesses.

Critical illnesses caused by undiagnosed genetic conditions are challenging in PICUs. Whole-exome sequencing is a powerful diagnostic tool but usually costly and often fail to arrive at a final diagnosis in a short period. We assessed the feasibility of our whole-exome sequencing as a tool to improve the efficacy of rare diseases diagnosis for pediatric patients with severe illness. Observational analysis. We employed a fast but standard whole-exome sequencing platform together with text mining-assisted variant prioritization in PICU setting over a 1-year period. A tertiary referral Children's Hospital in Taiwan. Critically ill PICU patients suspected of having a genetic disease and newborns who were suspected of having a serious genetic disease after newborn screening were enrolled. None. Around 50,000 to 100,000 variants were obtained for each of the 40 patients in 5 days after blood sampling. Eleven patients were immediately found be affected by previously reported mutations after searching mutation databases. Another seven patients had a diagnosis among the top five in a list ranked by text mining. As a whole, 21 patients (52.5%) obtained a diagnosis in 6.2 ± 1.1 working days (range, 4.3-9 d). Most of the diagnoses were first recognized in Taiwan. Specific medications were recommended for 10 patients (10/21, 47.6%), transplantation was advised for five, and hospice care was suggested for two patients. Overall, clinical management was altered in time for 81.0% of patients who had a molecular diagnosis. The current whole-exome sequencing algorithm, balanced in cost and speed, uncovers genetic conditions in infants and children in PICU, which helps their managements in time and promotes better utilization of PICU resources.

Study of PRISM III score as a predictor of mortality in PICU

Objectives: To determine the discriminative ability of PRISM III scoring system in predicting mortality in children admitted to PICU. Methods: Prospective observational study in all children 1 month to 12 years of age admitted to PICU during July2017 to June2018. Result: Out of 250 patients admitted in the PICU, 133 were male & 117 were female. In the age group of 1 month to 12 months, 30(22.22%) expired while in 12 months to 12 years,18(11.65%) expired. Due to respiratory system involvement, mortality was 24(16.43%), due to central nervous system 8(17.39%) and septicemia 12(46.15%) . At 12 hours of admission, 214 patients had PRISM score 0 to 4, out of which 14 expired. 17 patients had score of 5 to 9, out of which 15 expired.19 patients had score >10 having 100% mortality. PRISM 24 score was taken 12 hours after the 1st score. 216 patients had PRISM score between 0 to 4, out of which 14 expired. 8 patients had score of 5 to 9 & 26 patients had score >10, out of which all expired. Conclusion: Since mortality rises with increase in PRISM 3 score at the time of admission, PRISM III score can be taken as an indicator of the initial severity of illness. PRISM III can help in selecting sick children for PICU admission and optimum utilization of limited PICU resources.

Abstract P-544: PRE-OPERATIVE BIOELECTRICAL IMPEDANCE PREDICTS INTENSIVE CARE LENGTH OF STAY IN CHILDREN FOLLOWING CARDIAC SURGERY

Aims & Objectives: Following cardiac surgery for congenital heart disease (CHD), there are many factors known to influence paediatric intensive care unit length of stay (PICU-LOS). Objective pre-operative assessments may more accurately identify those children at risk of prolonged PICU stay and facilitate specific PICU management strategies, allowing for better utilisation of PICU resources. The aim was to investigate the predictive value of a pre-operative measures of bioelectrical impedance spectroscopy phase angle (BIS-PA) 200/50 in children admitted to PICU following cardiac surgery to predict PICU-LOS. Methods Children (0 – 16 years) with CHD undergoing cardiac surgery were prospectively enrolled at a single tertiary centre. BIS-PA measurements were collected at baseline (day before surgery). Fluid balance was recorded in the post-operative phase. Results BIS PA 200/50 measurements were obtained in 50 children. Moderate malnutrition height-for-age Z score ≤-2; 16% of children met this. Significant positive correlations: PICU-LOS and BIS PA 200/50 (n=50, r=0.46, p<0.001) and fluid balance on day 0 (n=50, r=0.46, p<0.001). There were significant correlations between BIS PA 200/50 and fluid balance on day 0 (n=50, r=-0.3, p=0.03) and height for age z score (n=50, r=-0.3, p=0.03). BIS PA 200/50 remained statistically associated with PICU-LOS when entered into a linear regression model (p=0.029). Conclusions In this study we were able to demonstrate a statistically significant relationship between BIS PA 200/50 and PICU-LOS of stay and positive fluid balance the day following surgery. A pre-operative objective estimate of risk may allow for earlier the identification and more targeted fluid management therapy during the post-operative period.

Pattern and outcome of severe childhood unintentional injuries from pediatric intensive care unit

Introduction: Childhood unintentional injuries (CUI) carry high morbidity and mortality. Little is known about epidemiology of CUI in PICU, their course and outcome. We report experience of CUI at our center.Methods: Retrospective review of medical records of children (1 mo- 16 years) admitted in PICU between Jan 2009- Dec 2014 with admitting diagnosis of unintentional injury was done. Data collected included age, gender, category and mechanism of injury, type of trauma, body region affected, place of injury, presentation, initial baseline laboratory workup, intervention done in the ER and PICU, length of stay and outcome. Results are presented as frequency/ percentages and mean ±SD.Results: A total 103 patients were admitted with the diagnosis of severe injury, 67% (69/103) were males and mean age was 90±55 months. Trauma was the major category (88%, 91/103) with road traffic accidents (RTA) comprising 37% (38/91) and fall 29% (30/91). 8 patients had poisoning, 91% (83/91) blunt trauma and 70% (64/91) had single body region involvement, isolated head being involved in 55% (50/94). 78% (81/103) of the injuries were witnessed. Coma was the main presentation in 36% (37/103) children, shock in 25% (26/103), respiratory problem in 22% (23/103), and, 67% were intubated in ER, CPR was done in 2 patient, 83.5% (86/103) patients needed mechanical ventilation, 77% (80/103) needed inotropic support and surgical intervention was done 64% of patients. PICU length of stay was 6±3 days and case fatality rate was 21% (22/103) compared to overall mortality rate of 12% during the same period.Conclusion: Severe injuries consume a lot of PICU resources and are associated with high mortality.

PICU Readmissions: Not Just Output but Patient Throughput*

PICU Readmissions: Not Just Output but Patient Throughput*

Pediatric Intensive Care in South Africa

To develop explicit criteria for patient admission in order to optimize utilization of PICU facilities in the face of increasing demand outstripping resources. Multidisciplinary PICU in a university-affiliated referral hospital in Cape Town, South Africa. Retrospective description of policy development and implementation All patients referred to the Paediatric Intensive Care Unit of the Red Cross War Memorial Children's Hospital. Development and application of admission policy. In consultation with clinicians at the hospital, principles for utilization of PICU resources were established and then translated into specific policies for prioritization of admission of particular groups of patients. The hospital team developed and implemented: criteria for intensive care admission; prioritization for certain categories of patients (including those scheduled for elective surgery); processes for refusing intensive care admission to other categories of patients; and processes to review implementation. These criteria and procedures were made explicit to clinicians, administrators, and managers and eventually agreed to by them. It was challenging to obtain "buy-in" from all potential stakeholders in the process and also to implement such policies under conditions of high stress. Development and implementation of explicit policies for utilization of PICU resources provide a "reasonable" process for fair and equitable utilization of scarce resources. The factors that have to be considered while developing these policies may extend beyond the priorities of individual patients. Implementation is still fraught with problems. Development of explicit admission policies that consider the needs of individual patients and also the longer term development of healthcare services may enable the retention of small but essential services.

Impact of ASA and Body Mass Index in Pediatric Tonsillectomy

Objective: To identify the impact of body mass index and ASA classification on complications, PICU stay and length of hospitalization following tonsillectomy. Method: Retrospective chart review of all tonsillectomies performed from July 2008 to December 2009 at a tertiary pediatric institution, including BMI, length of stay, length of intubation, ASA status, hemorrhage, and PICU stay. Results: A total of 677 patients were identified, with complete data in 607, 4.4% underweight, 49% normal, 45% overweight or obese. No significance difference between BMI categories for hospitalization, length of intubation or postoperative hemorrhage, or between ASA for hemorrhage or length of intubation. BMI normal to obese ( P = .0006) and overweight to obese patients ( P = .0253) showed significant difference in PICU stay. ASA classification showed significant difference in length of hospitalization in ASA 1 and 2 ( P &lt; .001), 2 and 3 ( P = .0002), and 1 and 3 ( P = .0002), and in PICU stay between ASA 1 and 3 ( P &lt; .0001), 1 and 2 ( P = .0095) and 2 and 3 ( P &lt; .0001). Conclusion: Overweight and obese patients are a significant percentage of patients undergoing tonsillectomies in this country. Patients with higher ASA status (2 and 3) show higher use of PICU resources and longer hospitalizations, and patients of overweight and obese categories require PICU care more often than patients with normal weight.

Experience of pediatric rapid response team in a tertiary care hospital in Pakistan

To report our experience before and after implementation of pediatric rapid response team (RRT) in pediatric wards of a tertiary care hospital in Pakistan. An audit of RRT activity from December 2007 to August 2008 was conducted and reviewed patient diagnoses at the time of call placement, interventions done and post-intervention clinical outcomes. Clinical Outcomes in the nine months before RRT implementation were compared with those in the first operational nine months after RRT. Eighty-three calls were generated during the post-intervention study period of 9-month (21 calls/1000 admissions). The median age of patients was 27 months; 37% calls were for infants. The majority of patients were under care of medical services (93% vs 7% under care of surgical services). Greater numbers of calls were made during 0800-1600 hours (45%). Respiratory issues were the most common reason for activation of RRT. Because of early interventions, majority (61%) of patients avoided unnecessary PICU stay and expenditure; only 17% required mechanical ventilation in PICU. The code rate per 1000 admissions decreased from 5.2 (pre-RRT) to 2.7 (post-RRT) (p=0.08; OR 1.88 (95%Cl 0.9-3.93). The mortality rate of patients admitted in PICU from wards decreased from 50% to 15% (p=0.25; OR 1.64 (95%Cl 0.63-4.29). Our experience with implementation of RRT was associated with reduction in cardiorespiratory arrest, mortality and saved a lot of PICU resource utilization. It is an excellent patient-safety initiative especially in resource-constrained countries by bringing PICU reflexes outside the PICU.

Comparison of Critically Ill and Injured Children Transferred From Referring Hospitals Versus In-House Admissions

The purpose of this work was to compare the outcomes, severity of illness, and resource use of patients transferred to PICUs from outside hospitals to patients admitted from within the same hospital. We conducted a secondary analysis of patients from the 20 US PICUs in the most recent Pediatric Intensive Care Unit Evaluations Software Recalibration Database on a total of 13,017 emergent PICU admissions between January 2001 and January 2006. Dependent variables were PICU resource use and risk-adjusted mortality. The main independent variable was the PICU admission source: patients transferred from referring emergency departments and inpatient wards versus in-house admissions from the same hospitals' emergency departments and inpatient ward. Patients admitted from referring emergency departments had higher use of vasoactive infusions (7.31% vs 5.23%) and mechanical ventilation (33.45% vs 23.6%) than same-hospital emergency department admissions. Compared with in-house ward admissions, patients transferred from referring inpatient wards had higher mechanical ventilation rates (45.05% vs 28.56%) and PICU lengths of stay (8.0 vs 6.7 days). On average, children admitted to a cohort of US PICUs from referring hospitals were more ill and required more intensive care resources than patients admitted to the same PICUs from within the institution. Hospital-level differences in PICU efficiency and severity of illness were highly variable. These data highlight the need for standardized PICU admission criteria to maximize hospital efficiency and suggest opportunities for earlier intervention and consultation by hospitals with PICU-level services to improve quality of care for critically ill children.

A National Survey of Pediatric Critical Care Resources in the United States

To characterize resources available for the care of critically ill and injured children in the United States. In January through May 2004, we conducted a cross-sectional survey of medical directors of intensive care facilities for children. Pediatric critical care medical directors from 257 of 337 eligible hospitals responded to the survey (response rate: 76%). The median number of beds was 12 (interquartile range: 8-17 beds), with a median of 58 admissions per PICU bed (interquartile range: 44-70 admissions per PICU bed) in 2003. The median numbers of admissions per PICU bed were not statistically different among PICUs of different sizes. Fewer than 6% of hospitals shared PICU space with space for critically ill adults. The smallest units (1-6 beds) had higher physician and nurse staffing ratios per PICU bed. Advanced therapeutic technology, particularly renal replacement and inhaled nitric oxide therapy, was significantly more likely to be available in larger PICUs (> or =7 beds). PICUs with the fewest beds had higher physician and nurse staffing ratios per PICU bed and lower resource capacity for high-intensity renal and respiratory therapy. The impact of PICU resource availability on referral patterns and outcomes of pediatric critical illnesses warrants additional study.

The Pediatric Risk of Mortality (PRISM) score and Injury Severity Score (ISS) for predicting resource utilization and outcome of intensive care in pediatric trauma

Mortality prediction in trauma is assessed using the Injury Severity Score (ISS) and Revised Trauma Score using Trauma Injury Severity Score (TRISS) methodology. The Pediatric Risk of Mortality (PRISM) score assesses mortality risk in critically ill children. We compared the ability of PRISM and ISS (using TRISS methodology) to predict resource utilization and outcome in pediatric trauma. Retrospective chart and database review. Pediatric intensive care unit (PICU). Consecutive admissions to a PICU over a 2-yr period. Demographic data including PICU resource utilization and outcome were recorded. Data were recorded on 1,052 admissions (31 deaths), including 125 pediatric trauma patients (11 deaths). Patients were stratified into low- and high-risk categories based on PRISM and ISS scores. Patients with PRISM scores <6 and ISS scores <10 were classified as low risk. While both low-risk PRISM and ISS scores readily identified survivors, PRISM was the more sensitive indicator of resource utilization. PRISM, however, performed less well in determining risk-adjusted mortality as compared with ISS. PRISM readily stratifies pediatric trauma patients for resource utilization. PRISM appears to underestimate mortality in pediatric trauma as compared with ISS using TRISS methodology.

EFFICIENCY OF PEDIATRIC INTENSIVE CARE: A COMPARATIVE ANALYSIS OF 8 PEDIATRIC ICUS

A national standard of ICU efficiency does not exist. This study objectively measures efficiency rates in 8 PICUs to determine if PICUs greatly differ in their efficiencies. Data included demographics, daily mortality risk (Dynamic Risk Index) and therapeutic interventions. Inefficient use of PICU resources was defined using daily mortality risks and a previously developed list of unique PICU resources; (a) low risk, monitored (LRM) pts had daily mortality risks of < 1% and did not use any unique PICU therapies and (b) potential early discharge (PED) pts did use unique resources or have mortality risks >1% during the early ICU stay but their last, consecutive PICU day were equivalent to LRM pts. Total, LRM and PED days of care were used to calculate efficiency rates. RESULTS. Data was collected on 1668 pts and 6962 days of care. LRM pts comprised from 16% to 58% of the PICU pts (p <.0001) and utilized between 5.4% and 34.5% of the days of care (p< .0001). PED pts comprised from 12% to 29% of the PICU pts (p < .0001) and their PED days comprised from 5.1% to 17.2%. Overall, the efficiency ratings ranged from .89 to .55. CONCLUSIONS. (1) Large differences in efficiency of PICU utilization exist. (2) The finding of significant over-utilization by PED patients is unique. (3) Efficiency rates over .80 are reasonable. Supported by MCH grant MCJ-11-527.