Strain in the Pediatric Intensive Care Unit and its Association with Patient Outcomes

Abstract

Objective: To characterize measures of pediatric intensive care unit (PICU) strain and test for associations between strain and patient outcomes. We hypothesized that periods of increased strain would be associated with increased odds of experiencing a post-ICU floor escalation event. Design: Retrospective cohort study. Setting: Quaternary care children's hospital PICU. Study Population: PICU admissions (2014-2023). Interventions: None. Measurements and Main Results: We measured PICU strain metrics daily including percent occupancy, percent turnover, and acuity. Percent occupancy and turnover were higher during annual peak viral season versus non-peak season (percent occupancy: median 84.4 [interquartile range (IQR) 72.9, 91.7] versus 68.8 [IQR 56.3, 82.1], P < .001; percent turnover: median 25.0 [IQR 20.0, 31.3] versus 21.9 [IQR 15.6, 28.1], P < .001). Acuity metrics did not differ during these periods. In patients admitted for respiratory or neurologic illness, we used multivariable logistic regression to test for associations between strain metrics on the day of transfer and odds of a floor escalation event defined as an unplanned PICU readmission or rapid response or code blue activation within 48 h of transfer. Of 12 832 patient transfers, 429 (3.3%) experienced a floor escalation event. After controlling for patient and clinical characteristics, percent occupancy and turnover were independently associated with an increase in floor escalation events. This risk was not linear for occupancy: above 87.5% (95% confidence interval (CI): 80.4, 94.6%), per 5% increase in occupancy patients experienced more floor escalation events (odds ratio [OR] 1.29 [95% CI: 1.07, 1.57]). For every 5% increase in turnover, patients experienced more floor escalation events (OR 1.06 [95% CI: 1.01, 1.12]). Conclusions: Occupancy and turnover characterized recognized periods of PICU strain. High occupancy and turnover were associated with more floor escalation events. Multicenter studies are needed to evaluate the generalizability of these findings across other PICUs.

Keywords

intensive care unit pediatric intensive care critical care resource utilization outcomes pediatrics

Get full access to this article

View all access options for this article.

References

Campbell

. The benefits of designing a stratification system for New York city pediatric intensive care units for use in regional surge capacity planning and management. J Community Health. 2010;35(4):337–347.

Cushing

Bucholz

Chien

Rauch

Michelson

. Availability of pediatric inpatient services in the United States. Pediatrics. 2021;148(1).

Kanter

Cooper

. Mass critical care: pediatric considerations in extending and rationing care in public health emergencies. Disaster Med Public Health Prep. 2009;3(Suppl 2):S166–S171.

Markovitz

. Pediatric critical care surge capacity. J Trauma. 2009;67(2 Suppl):S140–S142.

Anesi

Kerlin

. The impact of resource limitations on care delivery and outcomes: routine variation, the coronavirus disease 2019 pandemic, and persistent shortage. Curr Opin Crit Care. 2021;27(5):513–519.

Halpern

. ICU Capacity strain and the quality and allocation of critical care. Curr Opin Crit Care. 2011;17(6):648–657.

Rewa

Stelfox

Ingolfsson

, et al. Indicators of intensive care unit capacity strain: a systematic review. Crit Care. 2018;22(1):86.

Bagshaw

Wang

Zygun

, et al. Association between strained capacity and mortality among patients admitted to intensive care: a path-analysis modeling strategy. J Crit Care. 2018;43:81–87.

Pilcher

Hensman

Bihari

, et al. Measuring the impact of ICU strain on mortality, after-hours discharge, discharge delay, interhospital transfer, and readmission in Australia with the activity index. Crit Care Med. 2023;51(12):1623–1637.

10.

Wagner

Gabler

Ratcliffe

Brown

Strom

Halpern

. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447–455.

11.

Weissman

Gabler

Brown

Halpern

. Intensive care unit capacity strain and adherence to prophylaxis guidelines. J Crit Care. 2015;30(6):1303–1309.

12.

Weissman

Rothschild

Bendavid

, et al. Hospital workload and adverse events. Med Care. 2007;45(5):448–455.

13.

Duggal

Mathews

. Impact of ICU strain on outcomes. Curr Opin Crit Care. 2022;28(6):667–673.

14.

Rubinson

. Intensive care unit strain and mortality risk among critically ill patients with COVID-19-there is no “me” in COVID. JAMA Netw Open. 2021;4(1):e2035041.

15.

Wilcox

Rowan

Harrison

Doidge

. Does unprecedented ICU capacity strain, as experienced during the COVID-19 pandemic, impact patient outcome? Crit Care Med. 2022;50(6):e548–ee56.

16.

Chan

Rodean

Richardson

, et al. Pediatric critical care resource use by children with medical complexity. J Pediatr. 2016;177:197–203.e1.

17.

Edwards

Goodman

. The child with severe chronic illness in the ICU: a concise review. Crit Care Med. 2022;50(5):848–859.

18.

Horak

Griffin

Brown

, et al. Growth and changing characteristics of pediatric intensive care 2001-2016. Crit Care Med. 2019;47(8):1135–1142.

19.

Murphy Salem

Graham

. Chronic illness in pediatric critical care. Front Pediatr. 2021;9:686206.

20.

Killien

Keller

Watson

Hartman

. Epidemiology of intensive care admissions for children in the US from 2001 to 2019. JAMA Pediatr. 2023;177(5):506–515.

21.

Pollack

Patel

Ruttimann

. PRISM III: an updated pediatric risk of mortality score. Crit Care Med. 1996;24(5):743–752.

22.

Feltz

Miller

. An asymptotic test for the equality of coefficients of variation from k populations. Stat Med. 1996;15(6):647-6458.

23.

Candidate Critical Care Quality Indicators. Society of Critical Care Medicine Quality Indicators Committee: 1995. Society of Critical Care Medicine; 1995.

24.

Christiansen

Moller

Nielsen

Christensen

. The Danish intensive care database. Clin Epidemiol. 2016;8:525–530.

25.

Mandell

Bynum

Marshall

Bart

Gold

Rubin

. Pediatric Early Warning Score and unplanned readmission to the pediatric intensive care unit. J Crit Care. 2015;30(5):1090–1095.

26.

Gao

, et al. Evaluation of ICUs and weight of quality control indicators: an exploratory study based on Chinese ICU quality data from 2015 to 2020. Front Med. 2023;17(4):675–684.

27.

Muggeo

. Estimating regression models with unknown break-points. Stat Med. 2003;22(19):3055–3071.

28.

Czaja

Hosokawa

Henderson

. Unscheduled readmissions to the PICU: epidemiology, risk factors, and variation among centers. Pediatr Crit Care Med. 2013;14(6):571–579.

29.

Kotsakis

Stevens

Frndova

, et al. Description of PICU unplanned readmission. Pediatr Crit Care Med. 2016;17(6):558–562.

30.

Odetola

Clark

Dechert

Shanley

. Going back for more: an evaluation of clinical outcomes and characteristics of readmissions to a pediatric intensive care unit. Pediatr Crit Care Med. 2007;8(4):343–347; CEU quiz 57.

31.

Wunsch

Wagner

Herlim

Chong

Kramer

Halpern

. ICU Occupancy and mechanical ventilator use in the United States. Crit Care Med. 2013;41(12):2712–2719.

32.

Fieldston

Ragavan

Jayaraman

Metlay

Pati

. Traditional measures of hospital utilization may not accurately reflect dynamic patient demand: findings from a children's hospital. Hosp Pediatr. 2012;2(1):10–18.

33.

Fieldston

Hall

Sills

, et al. Children's hospitals do not acutely respond to high occupancy. Pediatrics. 2010;125(5):974–981.

34.

Epstein

Dexter

. A predictive model for patient census and ventilator requirements at individual hospitals during the coronavirus disease 2019 (COVID-19) pandemic: a preliminary technical report. Cureus. 2020;12(6):e8501.

35.

Nguyen

Turk

McWilliams

. Forecasting COVID-19 hospital census: a multivariate time-series model based on local infection incidence. JMIR Public Health Surveill. 2021;7(8):e28195.

36.

Hosein

Roberts

Turin

Zygun

Ghali

Stelfox

. A meta-analysis to derive literature-based benchmarks for readmission and hospital mortality after patient discharge from intensive care. Crit Care. 2014;18(6):715.

37.

Pleacher

Bratton

. Pediatric intensive care unit bounce-backs: are we evaluating them? Pediatr Crit Care Med. 2007;8(4):401–402.

38.

Scanlon

Mistry

Jeffries

. Determining pediatric intensive care unit quality indicators for measuring pediatric intensive care unit safety. Pediatr Crit Care Med. 2007;8(2 Suppl):S3–S10.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

3.61 MB