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

Abstract

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...

Risks and Benefits of Adenotonsillectomy in Children With Cerebral Palsy With Obstructive Sleep Apnea: A Systematic Review

“…Interestingly, Theilhaber et al found that the majority of severe adverse events occurred within 2 hours of surgery 21 and suggested that children with CP could be monitored in the PACU for 2 hours following AT and ICU admission could be reserved for children who develop severe adverse events during that period. A previous study has shown that implementing a “gray zone,” where complex children were monitored in the PACU for 2 to 5 hours before transfer to the appropriate level of care, reduced the number of unplanned ICU admissions 39 . Children with CP with an otherwise uneventful postoperative course could be safely transferred to the ward, provided that rapid ICU response was available.…”

“…A previous study has shown that implementing a "gray zone," where complex children were monitored in the PACU for 2 to 5 hours before transfer to the appropriate level of care, reduced the number of unplanned ICU admissions. 39 Children with CP with an otherwise uneventful postoperative course could be safely transferred to the ward, provided that rapid ICU response was available. This graduated approach to postoperative disposition planning is intriguing, particularly as resources and bed availabilities are increasingly constrained but dedicated prospective studies and quality improvement initiatives will be required.…”

Incidence and Risk Factors Associated with Respiratory Compromise in Planned PICU Admissions Following Tonsillectomy

“…Surgeons are required to balance the need to avoid unnecessary costly PICU admission with the desire to prevent adverse respiratory events requiring urgent escalation of care, which are associated with a worse prognosis. 5,6 Suggested criteria for PICU admission include “very severe” OSA (defined as AHI ≥ 30/hour), complex medical history predisposing the patient to airway obstruction, age<2 years, intraoperative respiratory complications requiring treatment, and desaturations in the immediate post-operative period. 1,4,7,8…”

Risk factors associated with unplanned ICU admissions following paediatric surgery: A systematic review

“…At-risk patients who only require closer monitoring and simple therapies rather than invasive organ support could be managed in this setting for a certain period of time and would obviate the need for ICU care. [17] …”

“…At-risk patients who only require closer monitoring and simple therapies rather than invasive organ support could be managed in this setting for a certain period of time and would obviate the need for ICU care. [17] Patients who required unplanned ICU admission postoperatively were found to need respiratory support in the form of supplemental oxygen or mechanical ventilation. [12,13] This is in keeping with the fact that the reason for ICU admission was commonly respiratory related.…”