An Innovative Framework to Improve Efficiency of Interhospital Transfer of Children in Respiratory Failure.

RATIONALE: High mortality and resource use burden are associated with hospitalization of critically ill children transferred from level II pediatric intensive care units (PICUs) to level I PICUs for escalated care. Guidelines urge transfer of the most severely ill children to level I PICUs without specification of either the criteria or the best timing of transfer to achieve good outcomes. OBJECTIVES: To identify factors associated with transfer, develop a modeling framework that uses those factors to determine thresholds to guide transfer decisions, and test these thresholds against actual patient transfer data to determine if delay in transfer could be reduced. METHODS: A multistep approach was adopted, with initial identification of factors associated with transfer status using data from a prior case-control study conducted with children with respiratory failure admitted to six level II PICUs between January 1, 1997, and December 31, 2007. To identify when to transfer a patient, thresholds for transfer were created using generalized estimating equations and discrete event simulation. The transfer policies were then tested against actual transfer data. MEASUREMENTS AND MAIN RESULTS: Multivariate logistic regression revealed that the absolute difference of a patient's pediatric logistic organ dysfunction score from the admission value, high-frequency oscillatory ventilation use, antibiotic use, and blood transfusions were all significantly associated with transfer status. The resulting threshold policies led to average transfer delay reduction ranging from 0.5 to 2.3 days in the testing dataset. CONCLUSIONS: Current transfer guidelines are devoid of criteria to identify critically ill children who might benefit from transfer and when the best time to transfer might be. In this study, we used innovative methods to create thresholds of transfer that might reduce delay in transfer.

Review of the acuity scoring systems for the pediatric intensive care unit and their use in quality improvement.

Acuity scoring systems quantitate the severity of clinical conditions and stratify patients according to presenting patient condition. In the pediatric intensive care unit, the complexity and number of clinical scoring systems are increasing as their applications for clinicians, health services researches, and quality improvement broaden. This article is a review of acuity scoring systems for the pediatric intensive care unit, including examples of scoring systems available, the methods used in assessing these tools, the ways in which these systems are used, and the utility of acuity scoring systems in accurate benchmarking. It is anticipated that with increasing health care costs and competition and increased focus on medical error reduction and quality improvement, the demands for risk-adjusted outcomes and institutional benchmarking will increase; therefore, as clinicians, academicians, and administrators, it is imperative that we be knowledgeable of the methods and applications of these acuity scoring systems to ensure their quality and appropriate use.

Effect of training and strict guidelines on the reliability of risk adjustment systems in paediatric intensive care.

OBJECTIVE: Many risk-adjustment systems have significant interobserver variability in everyday clinical practice. This can be partly corrected by strict guidelines and training. These issues have not been well studied in the paediatric setting. We assessed the reliability of two widely used paediatric scoring systems, the Paediatric Risk of Mortality (PRISM) and Paediatric Index of Mortality (PIM), before and after a special training program. DESIGN: Prospective observational multi-centred cohort study. INTERVENTION: Twenty-seven physicians from five paediatric intensive care units (PICUs) assessed severity of illness in 20 selected patients using PRISM and PIM scores before and after a special training program. Physicians were divided according to level of PICU experience: intensivists (>3 years experience, n=12), fellows (6-30 months experience, n=6) and residents (<6 months experience, n=9). Intraclass correlation was used to compare scoring reliability before and after training. MEASUREMENTS AND RESULTS: Wide variability in PRISM and PIM scoring was observed before training (intraclass correlation for PRISM scores 0.24-0.73, intraclass correlation for PIM scores 0.16-0.33). Training and implementation of guidelines led to significant increases in interobserver agreement (intraclass correlation 0.74-0.86 for PRISM and 0.88-0.95 for PIM scores), although some variability remained. CONCLUSION: Our results show that the reliability of PRISM and PIM risk adjustment systems in daily clinical practice is much lower than expected. Training and guidelines can significantly increase interobserver agreement. These factors should be taken into account when using these systems for benchmarking, or to compare quality of care between different PICUs.

Tratado de medicina y terapia intensiva / Textbook of critical care

Reanimación cardiopulmonar-cerebral del recién nacido. Traslado prehospitalario de adultos. Programa de traslado médico neonatal y pediátrico. Reanimación en situaciones de emergencia aguda con algoritmos clínico, y con líquidos coloidales y cristaloideos. Alimentación enteral. Diagnóstico y tratamiento del envenenamiento. Aspectos médicos y legales de la muerte cerebral. Reclutamiento, desarrollo y retención de las enfermeras de terapia intensiva

Tratado de medicina y terapia intensiva / Textbook of critical care

Reanimación cardiopulmonar-cerebral del recién nacido. Traslado prehospitalario de adultos. Programa de traslado médico neonatal y pediátrico. Reanimación en situaciones de emergencia aguda con algoritmos clínico, y con líquidos coloidales y cristaloideos. Alimentación enteral. Diagnóstico y tratamiento del envenenamiento. Aspectos médicos y legales de la muerte cerebral. Reclutamiento, desarrollo y retención de las enfermeras de terapia intensiva