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“Doctor, this patient is sick” From the ward to the PICU John Tsukahara MD “Doctor, this patient is sick” From the ward to the PICU John Tsukahara MD Pediatric ICU California Pacific Medical Center

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

“Doctor, this patient is sick. ” Important concepts 1. Recognize critically ill or deteriorating “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.

Ward patients are sicker and more complicated than they used to be Ward patients are sicker and more complicated than they used to be

Procedures are just as difficult as they used to be Procedures are just as difficult as they used to be

Pediatric ward nurses work hard. Pediatric ward nurses work hard.

Pediatric residents have less experience with critically ill patients Pediatric residents have less experience with critically ill patients

The line between the pediatric ward and the Pediatric ICU is not precise. The line between the pediatric ward and the Pediatric ICU is not precise.

Subtle changes in patients can be difficult to detect and difficult to articulate Subtle changes in patients can be difficult to detect and difficult to articulate

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

The pediatric hospitalist is key The pediatric hospitalist is key

From ward to PICU: the typical process • The ward team rounds in the 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

“Doctor, this patient is sick. ” Important concepts 1. Recognize critically ill or deteriorating “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.

PICU outcome: Does it make a difference where the patient came from? • Odetola. PICU outcome: Does it make a difference where the patient came from? • Odetola. FO. Do outcomes vary according to the source of admission to the pediatric intensive care unit? Ped. Crit. Care. Med. 2008 Jan; 9(1): 20 • University of Michigan, Ann Arbor • Tertiary care university children’s hospital. • 16 bed med-surg PICU and 15 bed cardiac PICU • 6 years, 8, 897 patients

PICU outcome: Does it make a difference where the patient came from? • PRISM 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? Ped. Crit. Care. Med. 2008 Jan; 9(1): 20

PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): 20 ED Un-adjusted PICU Mortality Mean PRISM III score Adjusted mortality risk OR Pediatric Transport, Ward non PICU

PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): 20 ED Un-adjusted PICU Mortality Mean PRISM III score Adjusted mortality risk OR 2. 2% Pediatric Transport, Ward non PICU

PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): 20 ED Un-adjusted PICU Mortality Mean PRISM III score Adjusted mortality risk OR 3. 7% 2. 2% Pediatric Transport, Ward non PICU

PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): 20 ED Un-adjusted PICU Mortality Mean PRISM III score Adjusted mortality risk OR 3. 7% 2. 2% Pediatric Transport, Ward non PICU 6. 7%

PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): 20 ED Un-adjusted PICU Mortality Mean PRISM III score Adjusted mortality risk OR 3. 7% 2. 2% Pediatric Transport, Ward non PICU 9. 8% 6. 7%

PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): 20 ED Un-adjusted PICU Mortality Mean PRISM III score Adjusted mortality risk OR Pediatric Transport, Ward non PICU 3. 7% 2. 2% 9. 8% 6. 7% 4. 9 4. 7 7. 2 7. 1

PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): PICU admission source and outcome: Odetola FO. Ped. Crit. Care. Med. 2008 Jan; 9(1): 20 ED Un-adjusted PICU Mortality Mean PRISM III score Adjusted mortality risk OR Pediatric Transport, Ward non PICU 3. 7% 2. 2% 9. 8% 6. 7% 4. 9 4. 7 7. 2 7. 1 1 0. 51 1. 65 0. 80

 • Why are pediatric patients transferred to the PICU from the ward sicker • 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?

The adult experience • Escarce JJ, Admission source to the medical intensive care unit The adult experience • Escarce JJ, Admission source to the medical intensive care unit predicts hospital death independent of APACHE II score. JAMA 1990; 264(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.

The adult experience • Goldhill D, Outcome of intensive care patients in a group The adult experience • Goldhill D, Outcome of intensive care patients in a group of British intensive care units. CCM 1998; 26(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…”

Pediatric rapid response teams • Brilli RJ, et al, Implementation of a medical emergency 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. 2007; 8(3): 236 • 50% of MET (Medical Emergency Team) calls resulted in transfer to the Pediatric ICU.

Pediatric rapid response teams • Sharek PJ, et al, Effect of a rapid response Pediatric rapid response teams • Sharek PJ, et al, Effect of a rapid response team on hospitalwide mortality and code rates outside the ICU in a Children’s Hospital. JAMA. 2007 Nov 21; 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.

Pediatric rapid response teams • North Carolina Children’s Hospital (Chapel Hill, NC) • Tina Pediatric rapid response teams • North Carolina Children’s 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. ”

What is happening in the PICU after transfer? • Is the PICU staff managing 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?

What is happening on the ward? • Are deteriorating patients unrecognized? • Prior to 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?

Do sick ward patients go unrecognized? • Tume L. , The deterioration of children Do sick ward patients go unrecognized? • Tume L. , The deterioration of children in ward areas in a specialist children’s hospital. 2007; 12(1): 12 • Most patients had significantly abnormal physiologic measures in the 24 hours prior to emergent transfer to the PICU

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

Pediatric rapid response teams • Also, “Medical Response Team” or “Medical Emergency Team” • 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

Pediatric rapid response teams • • Alters normal chain of command An open system 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

Pediatric rapid response teams • • Tibballs J. Arch. Dis. Child 2005. 90(11): 1148 Pediatric rapid response teams • • Tibballs J. Arch. Dis. Child 2005. 90(11): 1148 Brilli RJ. Ped. Crit. Care. Med 2007. 8(3): 236 Sharek PJ. JAMA 2007. 298(19): 2267 Hunt EA. Arch. Ped. Adol. Med 2008. 162(2): 117 • Fewer respiratory arrests • Fewer cardiac arrests • Improved hospital survival

DEW line DEW line

DEW line DEW line

Pediatric Early Warning Score: PEWS • A systematic method of identifying early physiologic deterioration. 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

Pediatric Early Warning Score: PEWS • • Multiple scoring systems have been developed Some 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.

Pediatric Early Warning Systems • Akre M. Sensitivity of the Pediatric Early Warning Score Pediatric Early Warning Systems • Akre M. Sensitivity of the Pediatric Early Warning Score to Identify Patient Deterioration. Pediatrics 2010. 125(4): e 763 • Children’s 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

Akre M. Sensitivity of the Pediatric Early Warning Score to Identify Patient Deterioration. Pediatrics. Akre M. Sensitivity of the Pediatric Early Warning Score to Identify Patient Deterioration. Pediatrics. 2010 Apr; 125(4): e 763

Pediatric Early Warning Systems • The overwhelming majority of the patients had elevated PEWS 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. 2010 Apr; 125(4): e 763

You’ve missed dinner and are headed to the ED to see another patient. A You’ve 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. ”

A nurse comes to you and says, “The baby’s blood glucose is low. ” A nurse comes to you and says, “The baby’s blood glucose is low. ”

Pediatric Early Warning Systems • “The definitive way to get doctors’ attention and convince 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. JAdv. Nurs. 2005; 52(5): 473)

Pediatric Early Warning Systems: the UK • “Why Children Die—a pilot study” – Confidential Pediatric Early Warning Systems: the UK • “Why Children Die—a 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 illness—an early warning score. ”

“Doctor, this patient is sick. ” Important concepts 1. Recognize critically ill or deteriorating “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.

PICU outcome: Does it make a difference where the patient came from? ED Un-adjusted PICU outcome: Does it make a difference where the patient came from? ED Un-adjusted PICU Mortality Mean PRISM III score Adjusted mortality risk OR Pediatric Transport, Ward non PICU 3. 7% 2. 2% 9. 8% 6. 7% 4. 9 4. 7 7. 2 7. 1 1 0. 51 1. 65 0. 80

Why do equally ill patients transferred to the PICU from the ward do worse Why do equally ill patients transferred to the PICU from the ward do worse than patients transferred from the ED or the OR?

Early intervention makes a difference. Early intervention makes a difference.

Sepsis and septic shock Sepsis and septic shock

Pediatric asthma Asthma mortality in children has dropped in the last few years. (CDC 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…”

“Doctor, this patient is sick. ” Important concepts 1. Recognize critically ill or deteriorating “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.

Careful transfer to the PICU • • Detailed communication Written summary Critical lines and 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

“Doctor, this patient is sick. ” Concepts/Recommendations for Hospitalists 1. Recognize critically ill or “Doctor, this patient is sick. ” Concepts/Recommendations for Hospitalists 1. Recognize critically ill or deteriorating patients early. • • • Pediatric Rapid Response Team Pediatric Early Warning System Staff education 2. Manage critically ill patients aggressively before they are transferred to the Pediatric ICU. • • Begin aggressive treatment before transfer Transfer expediently and safely

What about patients transported to the PICU from outlying hospitals? • Gregory CJ. Comparison 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. 2008; 121: e 906 • 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.