Elsevier

Journal of Critical Care

Volume 30, Issue 5, October 2015, Pages 1090-1095
Journal of Critical Care

Clinical Potpourri
Pediatric Early Warning Score and unplanned readmission to the pediatric intensive care unit,☆☆,,★★,☆☆☆,☆☆☆☆

https://doi.org/10.1016/j.jcrc.2015.06.019Get rights and content

Abstract

Background and Objectives

Early unplanned Pediatric Intensive Care Unit (PICU) readmission is associated with greater length of stay and mortality. No tools exist to identify children at risk for PICU readmission. The Pediatric Early Warning Score (PEWS) currently identify children at risk for deterioration on the ward. Our primary objective was to evaluate the ability of PEWS to identify children at risk for unplanned PICU readmission.

Methods

A single-center case-control study of 189 children (38 cases and 151 age-matched controls) 18 years or younger transferred from the PICU to the pediatric ward from January 1, 2010-March 30, 2013, at an urban tertiary care children's hospital was conducted.

Results

Thirty-eight cases had unplanned PICU readmission within 48 hours of transfer to pediatric ward, whereas 151 controls were not readmitted. The PEWS assigned prior to PICU discharge and first PEWS assigned on the ward were collected for cases and controls. Each 1-point increase in the PEWS score significantly increased risk of PICU readmission (odds ratios [95% confidence intervals], 1.6 [1.12-2.27; P = .009] and 1.89 [1.33-2.69; P < .001], respectively). Discrimination ability of PEWS for PICU readmission improved when chronic diagnoses were included.

Conclusions

Higher PEWS scores were associated with increased risk of unplanned PICU readmission. However, cutoff scores are not sensitive or specific enough to be clinically useful. Adding chronic disease variables may improve the clinical utility of cutoff PEWS scores.

Introduction

Patients discharged from the pediatric intensive care unit (PICU) to the pediatric ward are at higher risk for clinical deterioration and/or life-threatening events than other ward patients [1], [2]. A patient's readiness for PICU discharge is determined by a number of different factors, most importantly clinical evaluation by experienced PICU physicians and nurses. Despite best efforts, the incidence of code blue events or urgent need for PICU readmission within 48 hours of PICU discharge remains unacceptably high, with a national average of 2% to 8% [3], [4], [5]. Because unplanned PICU readmission has been associated with increased length of PICU stay and higher mortality compared with nonreadmitted patients [5], [6], a tool to identify this at-risk population would be of great clinical utility. Identifying patients at high risk for PICU readmission will allow the ward team to monitor these patients more closely, as well as enable PICU physicians to make more informed decisions when evaluating a patient's readiness for PICU discharge. Although scoring systems to identify risk of clinical deterioration exist [7], none have been used in the evaluation of children prior to PICU discharge.

Pediatric Early Warning Score (PEWS) tools were developed to screen children for risk of clinical deterioration on the pediatric ward [8], [9], [10]. The PEWS tools provide a systematic method of measuring severity of illness that is easily understood and communicated between different members of the medical team. Although many PEWS scoring systems exist, Children's Hospital Los Angeles (CHLA) uses a modified version of the validated Brighton PEWS score [11]. A PEWS-based clinical management algorithm recommends escalating levels of monitoring and intervention based on increasing PEWS scores. Although it has been well described that the PEWS tool has identified increased risk of clinically significant deterioration on the pediatric ward [12], [13], [14], the relationship between PEWS and unplanned PICU readmission has not been previously established.

The primary objective of this study was to evaluate the association between PEWS assigned at PICU discharge and first PEWS on the pediatric ward with early unplanned PICU readmission. This will allow us to modify our institutional PEWS scoring system, if necessary, and inform future multicenter validation of PEWS as a tool to identify risk of PICU readmission. The secondary objective was to identify a cutoff score that could be used clinically at PICU discharge to identify low-risk vs high-risk populations. We hypothesized that higher PEWS at PICU discharge and first PEWS on the pediatric ward would be positively associated with early unplanned PICU readmission, defined as PICU readmission within 48 hours of transfer to the pediatric ward. A third objective was to determine if the predictive model would be improved by the addition of complex chronic conditions. We hypothesized that the utility of the PEWS to predict early unplanned PICU readmission would be improved with the addition of complex chronic conditions.

Section snippets

Study design

After approval by the hospital's institutional review board, we conducted a single-center case-control study to evaluate the association between PEWS at PICU discharge and first PEWS on the pediatric ward with risk of early unplanned PICU readmission at a tertiary care, academic, free-standing children's hospital.

The Brighton-based PEWS tool used at CHLA has 4 components (Fig. 1). These include evaluation of a child's behavior (playful, irritable, lethargic), cardiovascular system (abnormal

Results

Fifty-seven potential case patients were screened. Nineteen of the 57 were excluded: 3 were discharged home prior to PICU readmission, 7 were planned postoperative readmissions, 3 were transferred to the CTICU due to bed space issues, and 6 had previous PICU readmissions within the study period. This left 38 cases and 151 age-matched controls. Median age and weight, and sex were similar for cases and controls (Table 1). Technology-dependent diagnoses, except for presence of gastrostomy tube,

Discussion

This study demonstrates a positive association between PEWS score assigned at PICU discharge and first PEWS on the pediatric ward with early unplanned PICU readmission. Both PEWS at PICU discharge and first PEWS on the pediatric ward were higher in children readmitted to the PICU within 48 hours compared with children who were not readmitted. Each 1-point increase in PEWS score was associated with a minimum 60% increase in risk of unplanned PICU readmission. These findings suggest that PEWS

Conclusion

Regardless of the clinical expertise of PICU providers, an optimally functioning PICU will experience early unplanned readmissions. Therefore, proactive identification of high-risk patients is essential. Pediatric Early Warning Score prior to PICU discharge and first PEWS on the pediatric ward may help raise awareness of children at risk for early unplanned PICU readmission. Although currently, cutoff PEWS scores are of limited clinical use, adding chronic disease variables to PEWS criteria may

Acknowledgments

The authors are grateful for the contribution of PEWS committee members at CHLA for the development and refinement of our modified PEWS score and for providing their expertise to study investigators throughout this project. PEWS committee members include Barry Markovitz, MD, MPH; Kathleen Ostrom, MD; Ronen Zipkin, MD; Rica Morzov, RN; Kay Gilmore, RN; Margaret Frankel, RN, and Kathy Derlighter, RCP.

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Funding source: No funding was secured for this study.

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Financial disclosures: All authors have no financial relationships relevant to this article to disclose.

Conflicts of interest: Sarah Rubin is a KL2 Scholar awarded under the KL2 Mentoring Research Career Development Award (National Center for Advancing Translational Science, National Institutes of Health) through Southern California Clinical and Translational Science Institute at the University of Southern California, Keck School of Medicine. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health. Other authors have no conflicts of interest to disclose.

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What's known on this subject: Early unplanned pediatric intensive care unit (PICU) readmission is associated with greater length of PICU stay and mortality. Currently, there is no tool to identify this at-risk population.

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What this study adds: We demonstrated a positive association between Pediatric Early Warning Score (PEWS) assigned at PICU discharge and first PEWS on the pediatric ward with early unplanned PICU readmission. Previously, PEWS scores were validated to screen children for risk of clinical deterioration on the pediatric ward.

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Contributor's statement: Dr Mandell coordinated data collection, contributed to analyses, drafted the initial manuscript, reviewed and revised the manuscript, and approved the final draft as submitted. Dr Bynum conceptualized the idea, coordinated data collection, contributed to the initial analyses, reviewed the manuscript, and approved the final draft as submitted. Dr Marshall assisted with study design, provided PEWS expertise, and conducted critical review of the manuscript. She has approved the final draft of the manuscript as submitted. Dr Bart assisted with the coordination of the data collection, reviewed the manuscript, and approved the final draft as submitted. Dr Gold assisted with study design and critical review of the manuscript and approved the final draft as submitted. Dr Rubin coordinated and contributed to data collection, performed the analyses, reviewed and revised the manuscript, and approved the final draft as submitted.

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Current affiliation: Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115.

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