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Kamzan AD, Tsoi S, Arslanian T, Sim MS, Romero T, Newcomer CA. Admission Source Is Associated With the Risk of Rapid Response Team Activation in a Children's Hospital. Acad Pediatr 2022; 22:1477-1481. [PMID: 35858662 DOI: 10.1016/j.acap.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 06/16/2022] [Accepted: 06/19/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate source of admission to a children's hospital as a predictor of rapid response team (RRT) activation, both in the first 48 hours of admission and over the entire hospitalization. METHODS Retrospective cohort study of all patients admitted to the pediatric ward between March 1, 2013 and December 31, 2015. Source of admission was categorized as from the emergency department, transfer from another hospital facility, admission following a planned surgery, direct admission planned in advance, or unplanned direct admission. Information was collected including whether or not the patient had a RRT activation and survival to discharge. A Fisher's exact test was used to assess the association between source of admission and risk of rapid response. RESULTS Of 8083 admissions included in the study, 194 had at least one RRT event. The odds of having an RRT was significantly associated with source of admission (P < .001). Using admission from the emergency department as a reference group, planned elective admissions (odds ratio [OR] 0.27; P < .001) and admissions following planned surgery (OR 0.07; P < .001) were significantly associated with reduced odds of having at least one RRT activation during the admission. Planned elective admissions also demonstrated reduced odds of RRT in the first 48 hours of hospitalization (OR 0.14; P = .002). Source of admission was also associated with survival to discharge (P < .05). CONCLUSION Source of admission is associated with likelihood of RRT activation as well as with survival to discharge and should be considered by providers when assessing inpatient risk of decompensation.
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Affiliation(s)
- Audrey D Kamzan
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif.
| | - Stephanie Tsoi
- UCSF Department of Pediatrics (S Tsoi), San Francisco, Calif
| | - Talin Arslanian
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif
| | - Myung Shin Sim
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of General Internal Medicine and Health Services Research (MS Sim, T Romero), Los Angeles, Calif
| | - Tahmineh Romero
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of General Internal Medicine and Health Services Research (MS Sim, T Romero), Los Angeles, Calif
| | - Charles A Newcomer
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif
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Hoffman OL, Romano J, Kleinman ME. Emergency Medical Response for Non-Hospitalized Person Events in a Children's Hospital. Pediatrics 2022; 12:e2021006268. [PMID: 35288738 DOI: 10.1542/hpeds.2021-006268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Hospital-based code blue (CB) teams are designed for hospitalized patients (HP) with unanticipated medical emergencies outside of an ICU. At our freestanding pediatric institution, the same team responds to CB calls involving nonhospitalized persons (NHP) throughout the hospital campus. We hypothesized there are significant differences between the characteristics of NHP and HP requiring emergency medical response, and most responses for NHP do not require advanced critical care. METHODS We analyzed a retrospective cohort of CB responses at our large, urban, academic children's medical center from January to December 2017. We evaluated the demographic and clinical characteristics of these HP compared with NHP events. RESULTS There were 168 CB activations during the study, of which 135 (80.4%) were for NHP. Ninety-one (67.4%) of the NHP responses involved adults (age >18 years) compared with 6 (18.2%) of the HP. Triggers for CB team activation for NHP were most frequently syncope (42.2%), seizure (10.3%), or fall (9.6%) compared with seizure (30.3%), hypoxia (27.3%), or anaphylaxis (12.1%) for HP. Critical interventions such as bag-mask ventilation and cardiopulmonary resuscitation were infrequently performed for either cohort. CONCLUSIONS CB activations in our pediatric institution more often involve NHP than HP. NHP responses are more likely to involve adults and infrequently require advanced interventions. Use of a pediatric CB team for NHP events may be an unnecessary use of pediatric critical care resources. Future studies are warranted to evaluate the most effective team composition, training, and response system for NHP in a freestanding children's hospital.
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Affiliation(s)
- Olivia L Hoffman
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jane Romano
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Monica E Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts
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Lawson NR, Acorda D, Guffey D, Bracken J, Bavare A, Checchia P, Afonso NS. Association of Social Determinants of Health With Rapid Response Events: A Retrospective Cohort Trial in a Large Pediatric Academic Hospital System. Front Pediatr 2022; 10:853691. [PMID: 35515353 PMCID: PMC9070691 DOI: 10.3389/fped.2022.853691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Social determinants of health (SDH) are known to impact hospital and intensive care unit (ICU) outcomes. Little is known about the association between SDH and pediatric rapid response (RR) events and understanding this impact will help guide future interventions aimed to eliminate health disparities in the inpatient setting. OBJECTIVES The primary objective of this study is to describe the association between SDH and RR utilization (number of RR events, time to RR event, shift of event and caller). The secondary objective is to determine if SDH can predict hospital length of stay (LOS), ICU transfer, critical deterioration (CD), and mortality. METHODS A retrospective cohort study was conducted. We reviewed all RR events from 2016 to 2019 at a large, academic, pediatric hospital system including a level 1 trauma center and two satellite community campuses. All hospitalized patients up to age 25 who had a RR event during their index hospitalization were included. Exposure variables included age, gender, race/ethnicity, language, income, insurance status, chronic disease status, and repeat RR event. The primary outcome variables were hospital LOS, ICU transfer, CD, and mortality. The odds of mortality, CD events and ICU transfer were assessed using unadjusted and multivariable logistic regression. Associations with hospital LOS were assessed with unadjusted and multivariable quantile regression. RESULTS Four thousand five hundred and sixty-eight RR events occurred from 3,690 unique admissions and 3301 unique patients, and the cohort was reduced to the index admission. The cohort was largely representative of the population served by the hospital system and varied according to race and ethnicity. There was no variation by race/ethnicity in the number of RR events or the shift in which RR events occurred. Attending physicians initiated RR calls more for event for non-Hispanic patients of mixed or other race (31.6% of events), and fellows and residents were more likely to be the callers for Hispanic patients (29.7% of events, p = 0.002). Families who are non-English speaking are also less likely to activate the RR system (12% of total RR events, p = 0.048). LOS was longest for patients speaking languages other than Spanish or English and CD was more common in patients with government insurance. In adjusted logistic regression, Hispanic patients had 2.5 times the odds of mortality (95% CI: 1.43-4.53, p = 0.002) compared with non-Hispanic white patients. CONCLUSION Disparities exist in access to and within the inpatient management of pediatric patients. Our results suggest that interventions to address disparities should focus on Hispanic patients and non-English speaking patients to improve inpatient health equity. More research is needed to understand and address the mortality outcomes in Hispanic children compared to other groups.
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Affiliation(s)
- Nikki R Lawson
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | | | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, United States
| | - Julie Bracken
- Texas Children's Hospital, Houston, TX, United States
| | - Aarti Bavare
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Paul Checchia
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Natasha S Afonso
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Houston, TX, United States
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Diurnal Variation in Medical Emergency Team Calls at a Tertiary Care Children's Hospital. Pediatr Qual Saf 2020; 5:e341. [PMID: 32984741 PMCID: PMC7480995 DOI: 10.1097/pq9.0000000000000341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/07/2020] [Indexed: 11/25/2022] Open
Abstract
Medical emergency teams (METs) bring critical care expertise to the bedsides of hospital ward patients who may be deteriorating. Diurnal variation in MET activation rates may identify inconsistencies in the detection of patients needing intervention. We aimed to determine whether such variation exists at our tertiary care children's hospital. Methods In this retrospective cohort study, we collected data including date and time of MET and disposition following MET for all inpatients at Cincinnati Children's Hospital Medical Center with a MET call between January 2008 and May 2014. The analysis compared the MET rate between days and nights, weekdays and weekends, and before and after nursing shift change. Results The number of METs per hour varied throughout the day. More METs were called during the day than at night (0.7 calls/shift ± 0.95 vs 0.6 ± 0.9, P < 0.001). There were also more METs per day on weekdays than weekends (1.4 ± 1 calls/d vs 1.2 ± 1, P < 0.001). Daytime METs were more likely to lead to transfer to the intensive care unit or operating room than those called at night (61.9% vs. 52.9%, P < 0.001). MET activation rates did not differ significantly in the 2 hours before nursing shift change compared to the 2 hours after. Conclusions At our large tertiary care children's hospital, there are both diurnal variations and variations across weekdays versus weekends in the MET activation rate. This difference may indicate variations in our ability to detect deteriorating patients on the wards and be further studied.
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Lambert V, Matthews A, MacDonell R, Fitzsimons J. Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review. BMJ Open 2017; 7:e014497. [PMID: 28289051 PMCID: PMC5353324 DOI: 10.1136/bmjopen-2016-014497] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To systematically review the available evidence on paediatric early warning systems (PEWS) for use in acute paediatric healthcare settings for the detection of, and timely response to, clinical deterioration in children. METHOD The electronic databases PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). 2 review authors independently completed the screening and selection process, the quality appraisal of the retrieved evidence and data extraction; with a third reviewer resolving any discrepancies, as required. Results were narratively synthesised. RESULTS From a total screening of 2742 papers, 90 papers, of varied designs, were identified as eligible for inclusion in the review. Findings revealed that PEWS are extensively used internationally in paediatric inpatient hospital settings. However, robust empirical evidence on which PEWS is most effective was limited. The studies examined did however highlight some evidence of positive directional trends in improving clinical and process-based outcomes for clinically deteriorating children. Favourable outcomes were also identified for enhanced multidisciplinary team work, communication and confidence in recognising, reporting and making decisions about child clinical deterioration. CONCLUSIONS Despite many studies reporting on the complexity and multifaceted nature of PEWS, no evidence was sourced which examined PEWS as a complex healthcare intervention. Future research needs to investigate PEWS as a complex multifaceted sociotechnical system that is embedded in a wider safety culture influenced by many organisational and human factors. PEWS should be embraced as a part of a larger multifaceted safety framework that will develop and grow over time with strong governance and leadership, targeted training, ongoing support and continuous improvement.
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Affiliation(s)
- Veronica Lambert
- School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - Anne Matthews
- School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - Rachel MacDonell
- HSE Clinical Programmes, Office of Nursing & Midwifery Services Directorate, Health Service Executive
| | - John Fitzsimons
- Our Lady of Lourdes Hospital Drogheda & Quality Improvement Division Health Service Executive
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Humphreys S, Totapally BR. Rapid Response Team Calls and Unplanned Transfers to the Pediatric Intensive Care Unit in a Pediatric Hospital. Am J Crit Care 2016; 25:e9-13. [PMID: 26724305 DOI: 10.4037/ajcc2016329] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Variability in disposition of children according to the time of rapid response calls is unknown. OBJECTIVE To evaluate times and disposition of rapid response alerts and outcomes for children transferred from acute care to intensive care. METHODS Deidentified data on demographics, time and disposition of the child after activation of a rapid response, time of transfer to intensive care, and patient outcomes were reviewed retrospectively. Data for rapid-response patients on time of activation of the response and unplanned transfers to the intensive care unit were compared with data on other patients admitted to the unit. RESULTS Of 542 rapid responses activated, 321 (59.2%) were called during the daytime. Out of all rapid response activations, 323 children (59.6%) were transferred to intensive care, 164 (30.3%) remained on the general unit, and 19 (3.5%) required resuscitation. More children were transferred to intensive care after rapid response alerts (P = .048) during the daytime (66%) than at night (59%). During the same period, 1313 patients were transferred to intensive care from acute care units. Age, sex, risk of mortality, length of stay, and mortality rate did not differ according to the time of transfer. Mortality among unplanned transfers (3.8%) was significantly higher (P < .001) than among other intensive care patients (1.4%). CONCLUSION Only 25% of transfers from acute care units to the intensive care unit occurred after activation of a rapid response team. Most rapid responses were called during daytime hours. Mortality was significantly higher among unplanned transfers from acute care than among other intensive care admissions.
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Affiliation(s)
- Stacey Humphreys
- Stacey Humphreys is a pediatric intensivist, Division of Critical Care Medicine, Palmetto Health Children’s Hospital, Columbia, South Carolina. Balagangadhar R. Totapally is medical director of the pediatric intensive care unit, Division of Critical Care Medicine, Miami Children’s Hospital, and a clinical professor of pediatrics, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Balagangadhar R. Totapally
- Stacey Humphreys is a pediatric intensivist, Division of Critical Care Medicine, Palmetto Health Children’s Hospital, Columbia, South Carolina. Balagangadhar R. Totapally is medical director of the pediatric intensive care unit, Division of Critical Care Medicine, Miami Children’s Hospital, and a clinical professor of pediatrics, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
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Bonafide CP, Holmes JH, Nadkarni VM, Lin R, Landis JR, Keren R. Development of a score to predict clinical deterioration in hospitalized children. J Hosp Med 2012; 7:345-9. [PMID: 22489072 DOI: 10.1002/jhm.971] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 08/02/2011] [Accepted: 08/13/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Identification of the characteristics that put hospitalized children at high risk of deterioration may help to target patients whose physiologic status should be intensively monitored for signs of deterioration, and reduce unnecessary monitoring in patients at very low risk. Previous studies have evaluated vital sign-based early warning scores to detect deterioration that has already begun. OBJECTIVE To develop a predictive score for deterioration using non-vital sign patient characteristics in order to risk-stratify hospitalized children before signs of deterioration are detectable. DESIGN Case-control study. SETTING A 460-bed children's hospital. PATIENTS Cases (n = 141) were children who deteriorated while receiving care on non-intensive care unit (non-ICU) inpatient units. Controls (n = 423) were randomly selected. MEASUREMENTS The exposures were complex chronic conditions, other patient characteristics, and laboratory studies. The outcome was clinical deterioration, defined as cardiopulmonary arrest, acute respiratory compromise, or urgent ICU transfer. RESULTS The 7-item score included age <1 year, epilepsy, congenital/genetic conditions, history of transplant, enteral tube, hemoglobin <10 g/dL, and blood culture drawn in the preceding 72 hours. We grouped the patients into risk strata based on their scores. The very low-risk group's probability of deterioration was less than half of baseline risk. The high-risk group's probability of deterioration was more than 80-fold higher than the baseline risk. CONCLUSIONS We identified a set of characteristics associated with clinical deterioration in children. Used in combination as a score, these characteristics may be useful in triaging the intensity of monitoring and surveillance for deterioration that children receive while hospitalized on non-ICU units.
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Affiliation(s)
- Christopher P Bonafide
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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