Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients

Landry, Elizabeth; Gabriel, Rodney A.; Beutler, Sascha S.; Dutton, Richard P.; Urman, Richard D.

doi:10.1177/0885066616661152

Cited by 13 publications

(31 citation statements)

References 23 publications

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“…In accordance with previous studies, we have demonstrated that children below 2 years of age are at a higher risk for severe complications . Similar findings related to other invasive procedures have also been reported in children in this age group . This could result from smaller pulmonary reserve related to a lower residual volume, increased airway resistance, and nearly exclusive diaphragmatic breathing.…”

Section: Discussionsupporting

confidence: 92%

“…4,20,21 Similar findings related to other invasive procedures have also been reported in children in this age group. 27,28 This could result from smaller pulmonary reserve related to a lower residual volume, increased airway resistance, and nearly exclusive diaphragmatic breathing. We did not see an association between prematurity and the occurrence of severe complications.…”

Section: Analysis Of Risk Factors For Complicationsmentioning

confidence: 99%

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Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center

Carlens

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et al. 2018

Pediatric Pulmonology

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Section: Discussionsupporting

confidence: 92%

Section: Analysis Of Risk Factors For Complicationsmentioning

confidence: 99%

Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center

Carlens

Fuge

Price

et al. 2018

Pediatric Pulmonology

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“…These patients were not obese and, in those who had preoperative polysomnogram, the degree of OSA was usually not severe. Although no true risk‐adjusted benchmark for UIAs is established in children, UIA rates have been described in the literature to range from 0.06% to 2.6% . Because the overall rate of UIA at our institution after T&A is 0.21%, these miscalculations represent the unpredictable nature of this population rather than poor preoperative planning.…”

Section: Discussionmentioning

confidence: 94%

“…Although no true risk-adjusted benchmark for UIAs is established in children, UIA rates have been described in the literature to range from 0.06% to 2.6%. [9][10][11] Because the overall rate of UIA at our institution after T&A is 0.21%, these miscalculations represent the unpredictable nature of this population rather than poor preoperative planning. In comparing patients utilizing ICU resources to those for whom resources were not necessary, our cohort demonstrated an association between resource need and young age, neurological/neuromuscular comorbidity, and gastrostomy tube status.…”

Section: Discussionmentioning

confidence: 99%

“…Selection of the appropriate postoperative location for the high‐risk T&A patient is critical because unanticipated intensive care unit admission (UIA) rate is a validated metric of patient safety due to its association with adverse events (AE) . Several studies have analyzed UIAs in postoperative pediatric patients and have identified airway procedures, higher American Society of Anesthesiologists Classification score, longer anesthesia time, multiple procedures, and infants less than 1 year of age as risk factors . Because high‐risk adenotonsillectomy patients routinely fall into this category, many practitioners admit these patients to a pediatric intensive care unit (PICU) for postoperative observation to avoid a UIA or other AE outside the ICU setting.…”

Section: Introductionmentioning

confidence: 99%

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Critical care resources utilized in high‐risk adenotonsillectomy patients

et al. 2018

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Objective Children at high risk for respiratory complication after adenotonsillectomy are often admitted to a pediatric intensive care unit (PICU) postoperatively. Although many patients receive care in such units, it is unknown how many utilize critical care resources. Methods A review was conducted to audit intensive care needs of postadenotonsillectomy patients admitted to the PICU at a tertiary, academic, pediatric hospital between July 2013, and March 2017. Demographic information, ICU indication, polysomnogram results, and comorbidities were collected. Patients were defined as needing ICU resources based on supplemental oxygen requirements greater than 2 L between 2 to 24 hours postoperatively, more than two desaturation events in a 2‐hour period, or more than hourly nursing intervention. Factors associated with utilization of ICU resources were assessed. Results One hundred and ten patients were admitted to the PICU after adenotonsillectomy. Median age was 4.2 years, median body mass index was 90.8 percentile, and median apnea hypopnea index (AHI) was 34.3. Twenty patients (18.2%) utilized ICU resources by criteria defined. Of these patients, 14 were known to need such resources by 2 hours postoperatively (70%, negative predictive value 93.8%). Neither AHI nor obesity status was correlated with need for resources; however, resource need was associated with young age, gastrostomy tube status, and neuromuscular disorders (P = 0.048, P = 0.002 and 0.013, respectively). Conclusion Most high‐risk adenotonsillectomy patients do not utilize critical care resources despite their increased perioperative risk. Patients with respiratory complications are frequently identifiable within the first 2 hours of surgery. Level of Evidence 4 Laryngoscope, 129:1229–1234, 2019

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Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach

et al. 2020

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Objective Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate‐risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. Study Design Quality improvement initiative. Methods Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level‐of‐care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2–5 hours in the post‐anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. Results In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. Conclusions Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate‐risk patients. This was a...

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Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients

Cited by 13 publications

References 23 publications

Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center

Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center

Critical care resources utilized in high‐risk adenotonsillectomy patients

Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach

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