Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit

Abstract

Background: Late recognition of in-hospital deterioration is a source of preventable harm. Emergency transfers (ET), when hospitalized patients require intensive care unit (ICU) interventions within 1 h of ICU transfer, are a proximal measure of late recognition associated with increased mortality and length of stay (LOS).Objective: To apply diagnostic process improvement frameworks to identify missed opportunities for improvement in diagnosis (MOID) in ETs and evaluate their association with outcomes.Design, Settings, and Participants: A single-center retrospective cohort study of ETs, January 2015 to June 2019. ET criteria include intubation, vasopressor initiation, or ≥60 mL/kg fluid resuscitation 1 h before to 1 h after ICU transfer. The primary exposure was the presence of MOID, determined using SaferDx. Cases were screened by an ICU and non-ICU physician. Final determinations were made by an interdisciplinary group. Diagnostic process improvement opportunities were identified.Main Outcome and Measures: Primary outcomes were in-hospital mortality and posttransfer LOS, analyzed by multivariable regression adjusting for age, service, deterioration category, and pretransfer LOS.Results: MOID was identified in 37 of 129 ETs (29%, 95% confidence interval [CI] 21%-37%). Cases with MOID differed in originating service, but not demographically. Recognizing the urgency of an identified condition was the most common diagnostic process opportunity. ET cases with MOID had higher odds of mortality (odds ratio 5.5; 95% CI 1.5−20.6; p = .01) and longer posttransfer LOS (rate ratio 1.7; 95% CI 1.1-2.6; p = .02). Conclusion: MOID are common in ETs and are associated with increased mortality risk and posttransfer LOS. Diagnostic improvement strategies should be leveraged to support earlier recognition of clinical deterioration.

Implementation of a critical care outreach team in a children’s hospital

“…Indeed, in a recent study at our institution, we used a diagnostic improvement framework to analyze emergency transfers (ETs) to the PICU—escalation events in which patients require initiation of inotropes, intubation, and/or 60 cc/kg of intravenous fluid boluses within 1 hour of transfer from a ward to an ICU. 11 , 12 , 13 We demonstrated that diagnostic errors were common among ETs and thus may contribute to both delayed recognition of deterioration and adverse patient outcomes associated with this delay. 1 , 13 …”

“… 11 , 12 , 13 We demonstrated that diagnostic errors were common among ETs and thus may contribute to both delayed recognition of deterioration and adverse patient outcomes associated with this delay. 1 , 13 …”

Clinical progress note: Diagnostic error in hospital medicine

“…5 Lastly, a single-center retrospective study of pediatric patients who experienced emergent transfer to the intensive care unit, a proximal measure for late recognition of clinical deterioration, found that 29% had missed opportunities for improvement in diagnosis. 6 Not surprisingly, these patients had higher mortality rates and longer posttransfer lengths of stay.…”