1
Doctor, this patient is sick From the ward to
the PICU

• John Tsukahara MD
• Pediatric ICU
• California Pacific Medical Center

2

• I have no relevant financial relationships that
  might create any personal conflicts of interest.

3
Doctor, this patient is sick. Important
concepts

1. Recognize critically ill or deteriorating
   patients early.
2. Manage critically ill patients aggressively
   before they are transferred to the Pediatric ICU.

4
Ward patients are sicker and more complicated
than they used to be
5
Procedures are just as difficult as they used to
be
6

• Pediatric ward nurses work hard.

7
Pediatric residents have less experience with
critically ill patients
8
The line between the pediatric ward and the
Pediatric ICU is not precise.
9
Subtle changes in patients can be difficult to
detect and difficult to articulate
10

• The decision to transfer a patient from the ward
  to the PICU can be difficult.

11
The pediatric hospitalist is key
12
From ward to PICU the typical process

• The ward team rounds in the morning, evaluates
  the patients and develops plans for the day
• During the day, a child has an acute event or
  deteriorates.
• The bedside nurse is concerned
• The nurse alerts the resident
• The resident evaluates the patient and speaks
  with the hospitalist
• The hospitalist evaluates the patient and decides
  that the child should go to the PICU
• The hospitalist contacts the PICU and speaks with
  the fellow or pediatric intensivist
• The PICU staff checks staffing and bed
  availablity
• The PICU accepts the patient
• The child is transferred from the ward to the
  PICU

13
Doctor, this patient is sick. Important
concepts

1. Recognize critically ill or deteriorating
   patients early.
2. Manage critically ill patients aggressively
   before they are transferred to the Pediatric ICU.

14
PICU outcome Does it make a difference where the
patient came from?

• OdetolaFO. Do outcomes vary according to the
  source of admission to the pediatric intensive
  care unit? PedCritCareMed. 2008Jan9(1)20
• University of Michigan, Ann Arbor
• Tertiary care university childrens hospital.
• 16 bed med-surg PICU and 15 bed cardiac PICU
• 6 years, 8,897 patients

15
PICU outcome Does it make a difference where the
patient came from?

• PRISM III Pediatric Risk of Mortality score
• A prognostic scoring system derived from 17
  physiologic variables measured in the first 12
  hours of PICU hospitalization
• Vital signs
• Laboratory results
• Neurologic signs
• Diagnoses
• Well-validated measure of severity of illness

Odetola, FO, et. al. Do outcomes vary according
to the source of admission to the pediatric
intensive care unit? PedCritCareMed.
2008Jan9(1)20
16
PICU admission source and outcome
Odetola FO. PedCritCareMed. 2008Jan9(1)20
ED OR Pediatric Ward Transport, non PICU
Un-adjusted PICU Mortality
Mean PRISM III score
Adjusted mortality risk
17
PICU admission source and outcome
Odetola FO. PedCritCareMed. 2008Jan9(1)20
ED OR Pediatric Ward Transport, non PICU
Un-adjusted PICU Mortality 2.2
Mean PRISM III score
Adjusted mortality risk
18
PICU admission source and outcome
Odetola FO. PedCritCareMed. 2008Jan9(1)20
ED OR Pediatric Ward Transport, non PICU
Un-adjusted PICU Mortality 3.7 2.2
Mean PRISM III score
Adjusted mortality risk
19
PICU admission source and outcome
Odetola FO. PedCritCareMed. 2008Jan9(1)20
ED OR Pediatric Ward Transport, non PICU
Un-adjusted PICU Mortality 3.7 2.2 6.7
Mean PRISM III score
Adjusted mortality risk
20
PICU admission source and outcome
Odetola FO. PedCritCareMed. 2008Jan9(1)20
ED OR Pediatric Ward Transport, non PICU
Un-adjusted PICU Mortality 3.7 2.2 9.8 6.7
Mean PRISM III score
Adjusted mortality risk
21
PICU admission source and outcome
Odetola FO. PedCritCareMed. 2008Jan9(1)20
ED OR Pediatric Ward Transport, non PICU
Un-adjusted PICU Mortality 3.7 2.2 9.8 6.7
Mean PRISM III score 4.9 4.7 7.2 7.1
Adjusted mortality risk
22
PICU admission source and outcome
Odetola FO. PedCritCareMed. 2008Jan9(1)20
ED OR Pediatric Ward Transport, non PICU
Un-adjusted PICU Mortality 3.7 2.2 9.8 6.7
Mean PRISM III score 4.9 4.7 7.2 7.1
Adjusted mortality risk 1 0.51 1.65 0.80
23

• Why are pediatric patients transferred to the
  PICU from the ward sicker than ED or OR
  admissions?
• Why is their mortality higher, even corrected for
  how sick they are?
• Is the same phenomenon seen in adults?

24
The adult experience

• Escarce JJ, Admission source to the medical
  intensive care unit predicts hospital death
  independent of APACHE II score. JAMA
  1990264(18)2389.
• APACHE Acute Physiology and Chronic Health
  Evaluation Score
• an independent association between the MICU
  admission source and the risk of death.
• Actual mortality rate was significantly higher
  than predicted for patients transferred to the
  MICU from the hospital ward.

25
The adult experience

• Goldhill D, Outcome of intensive care patients in
  a group of British intensive care units. CCM
  199826(8)1337.
• 15 adult ICUs, 12,762 admissions
• Patients admitted from wards had a higher
  mortality than patients from the operating
  room/recovery or the emergency department.
• Early identification of patients at risk

26
Pediatric rapid response teams

• Brilli RJ, et al, Implementation of a medical
  emergency team in a large pediatric teaching
  hospital prevents respiratory and cardiopulmonary
  arrests outside the intensive care unit. PCCM.
  20078(3)236
• 50 of MET (Medical Emergency Team) calls
  resulted in transfer to the Pediatric ICU.

27
Pediatric rapid response teams

• Sharek PJ, et al, Effect of a rapid response team
  on hospital-wide mortality and code rates outside
  the ICU in a Childrens Hospital. JAMA. 2007
  Nov21 298(19)2267
• 57 of RRT calls resulted in transfer to the
  PICU, plus an additional 10 of the calls leading
  to transfer to the intermediate care unit.

28
Pediatric rapid response teams

• North Carolina Childrens Hospital (Chapel Hill,
  NC)
• Tina Schade Willis MD In cases where family
  concern was the reason for calling the Rapid
  Response Team, 70 percent of the pediatric
  patients were transferred to the ICU.

29
What is happening in the PICU after transfer?

• Is the PICU staff managing ward transfer patients
  differently than patients from the OR or the ED?

30
What is happening on the ward?

• Are deteriorating patients unrecognized?
• Prior to transfer to the PICU, are patients from
  the ward managed differently than those from the
  OR or the ED?

31
Do sick ward patients go unrecognized?

• Tume L., The deterioration of children in ward
  areas in a specialist childrens hospital.
  200712(1)12
• Most patients had significantly abnormal
  physiologic measures in the 24 hours prior to
  emergent transfer to the PICU

32

• In retrospective reviews, cardiopulmonary arrest
  is seldom sudden and unpredictable.
• Generally preceded by up to several hours of
  signs and symptoms predicting clinical
  deterioration.

33
Pediatric rapid response teams

• Also, Medical Response Team or Medical
  Emergency Team
• A multidisciplinary team of ICU-trained personnel
• Rapidly available for evaluation of patients
  outside the ICU who develop signs or symptoms of
  clinical deterioration

34
Pediatric rapid response teams

• Alters normal chain of command
• An open system
• No false alarms
• A large fraction of the calls results in transfer
  to the Pediatric ICU

35
Pediatric rapid response teams

• Tibballs J. ArchDisChild 2005. 90(11)1148
• Brilli RJ. PedCritCareMed 2007. 8(3)236
• Sharek PJ. JAMA 2007. 298(19)2267
• Hunt EA. ArchPedAdolMed 2008. 162(2)117
• Fewer respiratory arrests
• Fewer cardiac arrests
• Improved hospital survival

36
DEW line
37
DEW line
38
Pediatric Early Warning Score PEWS

• A systematic method of identifying early
  physiologic deterioration.
• Vital signs, objective observations
• Earlier recognition and earlier intervention for
  deteriorating patients
• Improved outcome

39
Pediatric Early Warning Score PEWS

• Multiple scoring systems have been developed
• Some require as many as 20 items to score
• Popular in Canada and England
• Retrospective reviews reveal unrecognized
  physiologic deterioration is common prior to
  acute events.

40
Pediatric Early Warning Systems

• Akre M. Sensitivity of the Pediatric Early
  Warning Score to Identify Patient Deterioration.
  Pediatrics 2010.125(4)e763
• Childrens Hospitals and Clinics of Minnesota
• 325 beds
• Retrospective review of 170 Rapid Response Team
  events and 16 Code Blue Events on the pediatric
  ward
• Calculation of PEWS scores
• Critical PEWS 4

41
(No Transcript)
42
Akre M. Sensitivity of the Pediatric Early
Warning Score to Identify Patient Deterioration.
Pediatrics.2010Apr125(4)e763
43
Pediatric Early Warning Systems

• The overwhelming majority of the patients had
  elevated PEWS scores for hours prior to an
  emergency call.
• The results of this study clearly demonstrate a
  prolonged period of patient change, affording the
  opportunity for consultation and intervention
  before a level of decompensation that requires an
  RRT or code blue event.

Akre M. Pediatrics.2010Apr125(4)e763
44

• Youve missed dinner and are headed to the ED to
  see another patient. A bedside nurse comes to you
  and says, Doctor, this patient is sick.

45

• A nurse comes to you and says, The babys blood
  glucose is low.

46
Pediatric Early Warning Systems

• The definitive way to get doctors attention and
  convince them to review patients is by presenting
  quantifiable evidence of deterioration.
• Quantifiable changes enable them to make
  judgments about how ill patients are and to
  prioritize care in terms of assessment and
  treatment.
• (Andrews T. Packaging a grounded theory of how
  to report physiological deterioration
  effectively. JAdvNurs.200552(5)473)

47
Pediatric Early Warning Systems the UK

• Why Children Diea pilot study
• Confidential Enquiry into Maternal and Child
  Health (2008)
• For paediatric care in hospital we recommend a
  standardised and rational monitoring system with
  imbedded early warning systems for children
  developing critical illnessan early warning
  score.

48
Doctor, this patient is sick. Important
concepts

1. Recognize critically ill or deteriorating
   patients early.
2. Manage critically ill patients aggressively
   before they are transferred to the Pediatric ICU.

49
PICU outcome Does it make a difference where the
patient came from?
ED OR Pediatric Ward Transport, non PICU
Un-adjusted PICU Mortality 3.7 2.2 9.8 6.7
Mean PRISM III score 4.9 4.7 7.2 7.1
Adjusted mortality risk 1 0.51 1.65 0.80
50
Why do equally ill patients transferred to the
PICU from the ward do worse than patients
transferred from the ED or the OR?
51
Early intervention makes a difference.
52
Sepsis and septic shock
53
Pediatric asthma

• Asthma mortality in children has dropped in the
  last few years. (CDC 2006)

However, a high percentage of deaths have
resulted from under-recognition of asthma
severity and undertreatment
54
Doctor, this patient is sick. Important
concepts

1. Recognize critically ill or deteriorating
   patients early.
2. Manage critically ill patients aggressively
   before they are transferred to the Pediatric ICU.

55
Careful transfer to the PICU

• Detailed communication
• Written summary
• Critical lines and tubes secured
• Sick patients should be accompanied by a
  physician, even if it is just down the hall

56
Doctor, this patient is sick.
Concepts/Recommendations for Hospitalists

• Recognize critically ill or deteriorating
  patients early.
• Pediatric Rapid Response Team
• Pediatric Early Warning System
• Staff education
• Manage critically ill patients aggressively
  before they are transferred to the Pediatric ICU.
• Begin aggressive treatment before transfer
• Transfer expediently and safely

57
What about patients transported to the PICU from
outlying hospitals?

• Gregory CJ. Comparison of Critically Ill and
  Injured Children Transferred From Referring
  Hospitals Versus In-House Admissions. Pediatrics.
  2008121e906
• They tend to be sicker than patients transferred
  into the PICU from in-house sources.
• They have higher PRISM scores, greater
  utilization of PICU resources, and longer lengths
  of stay.