Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both

Geneslaw, Andrew; Jia, Haomiao; Lucas, Adam R.; Agus, Michael S. D.; Edwards, Jeffrey D.

doi:10.1016/j.jcrc.2017.05.028

Cited by 18 publications

(17 citation statements)

References 23 publications

(21 reference statements)

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“…Moreover, a separate analysis has demonstrated that some of the differences observed in subgroups may represent chance variation 5 . Third, the Pediatric Airway Management Project trial reported a higher ICU mortality rate than most pediatric ICUs currently report; however, 75% of the patients in the trial were in cardiac arrest prior to ICU admission, and the overall survival rates of these patients were similar to those reported in recently published trials of therapeutic hypothermia in this population 24–27 . Our study suggests that the apparent gain in sensitivity with the proposed ICU‐free days outcome measure might be limited to pediatric populations with high mortality.…”

Section: Limitationssupporting

confidence: 77%

ICU‐free days as a more sensitive primary outcome for clinical trials in critically ill pediatric patients

et al. 2021

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Background Our objective was to assess the association between intensive care unit (ICU)‐free days and patient outcomes in pediatric prehospital care and to evaluate whether ICU‐free days is a more sensitive outcome measure for emergency medical services research in this population. Methods This study used data from a previous pediatric prehospital trial. The original study enrolled patients ≤12 years of age and compared bag‐valve‐mask‐ventilation (BVM) versus endotracheal intubation (ETI) during prehospital resuscitation. For the current study, we defined ICU‐free days as 30 minus the number of days in the ICU (range, 0–30 days) and assigned 0 ICU‐free days for death within 30 days. We compared ICU‐free days between the original study treatment groups (BVM vs ETI) and with the original trial outcomes of survival to hospital discharge and Pediatric Cerebral Performance Category (PCPC). Results Median ICU‐free days for the BVM group (n = 404) versus ETI group (n = 416) was not statistically different: 0 ICU‐free days (interquartile range, 0–10) versus 0 (0–0), P = 0.219. Median ICU‐free days were greater for BVM group in 3 subgroups: foreign body aspiration 30 (0–30) versus 0 (0–21), P = 0.028; child maltreatment 0 (0–14.2) versus 0 (0‐0), P = 0.004; and respiratory arrest 25 (1–29) versus 7.5 (0–27.7), P = 0.015. In the original trial, neither survival nor PCPC demonstrated differences in all 3 subgroups—survival was greater with BVM for child maltreatment and respiratory arrest and favorable PCPC was greater with BVM for foreign body aspiration. Overall, in the current study, patients with more ICU‐free days also had greater survival to hospital discharge and more favorable PCPC scores. Conclusions This initial study of the association between ICU‐free days and patient outcomes during prehospital pediatric resuscitation appears to support the use of ICU‐free days as a clinical endpoint in this population. ICU‐free days may be more sensitive than either mortality or PCPC alone while capturing aspects of both measures.

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Section: Limitationssupporting

confidence: 77%

ICU‐free days as a more sensitive primary outcome for clinical trials in critically ill pediatric patients

et al. 2021

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“…While some studies have suggested improved efficiency of care through utilization of IMCUs, others have shown that standard ICU markers of quality are not improved. [33][34][35] Due to this controversy, as well as a variable return on investment, IMCUs are not feasible in all hospital settings. Furthermore, similar to the PICU, the potential exists to over-utilize this level of care with the same resultant risk of lack of bed availability during times of need.…”

Section: Discussionmentioning

confidence: 99%

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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“…19(p10) Previous research found no association between having an intermediate care, or step-down, unit and most measures of PICU efficiency (eg, length of stay, readmissions). 20 However, little has been reported on the overall experiences of PICU health care providers or families working in such a unit. We found support for a distinct space with proximity to a traditional PICU focusing on the care required by PCCPs.…”

Section: Theme 2: Designation Of a Primary Intensivistmentioning

confidence: 99%

Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study

Kobussen

Hansen

Brockman

et al. 2020

Critical Care Nurse

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Background Children with complex chronic conditions present unique challenges to the pediatric intensive care unit, including prolonged length of stay, complex medical regimens, and complicated family dynamics. Objectives To examine perspectives of pediatric intensive care unit health care providers regarding pediatric patients with complex chronic conditions, and to explore potential opportunities to improve these patients’ care. Methods A prospective mixed-methods sequential explanatory study was conducted in a tertiary medical-surgical pediatric intensive care unit using surveys performed with REDCap (Research Electronic Data Capture) followed by semistructured interviews. Results The survey response rate was 70.6% (77 of 109). Perspectives of health care providers did not vary with duration of work experience. Ten semistructured interviews were conducted. Eight overarching themes emerged from the interviews: (1) the desire for increased formal education specific to pediatric complex chronic care patients; (2) designation of a primary intensivist; (3) modifying delivery of care to include a discrete location for care provision; (4) establishing daily, short-term, and long-term goals; (5) monitoring and documenting care milestones; (6) strengthening patient and family communications with the health care team; (7) optimizing discharge coordination and planning; and (8) integrating families into care responsibilities. Conclusions Pediatric intensive care unit health care providers’ perspectives of pediatric patients with complex chronic conditions indicated opportunities to refine the care provided by establishing daily goals, coordinating discharge planning, and creating occasions for close communication between patients, families, and providers.

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Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both

Cited by 18 publications

References 23 publications

ICU‐free days as a more sensitive primary outcome for clinical trials in critically ill pediatric patients

ICU‐free days as a more sensitive primary outcome for clinical trials in critically ill pediatric patients

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

Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study

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