Intermediate care to intensive care triage: A quality improvement project to reduce mortality

Hager, David N.; Chandrashekar, Pranav; Bradsher, Robert W.; Abdel-Halim, Ali; Chatterjee, Souvik; Sawyer, Melinda; Brower, Roy G.

doi:10.1016/j.jcrc.2017.08.002

Cited by 8 publications

(7 citation statements)

References 69 publications

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“…35 Our data also suggest that there may be further scope of improvement in the assessment of deteriorating patients on the pediatric floor. Modalities such as structured assessment and communication algorithms to identify deteriorating patients on the floor have been shown to impact their outcomes 36 and offer an additional avenue for intervention.…”

Section: Discussionmentioning

confidence: 99%

Outcome Differences Between Direct Admissions to the PICU From ED and Escalations From Floor

Tripathi

Kim

2021

Hospital Pediatrics

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OBJECTIVES To compare the outcomes (mortality and ICU length of stay) of patients with direct admissions to the PICU from the emergency department [ED]) versus as an escalation of care from the floor. METHODS A retrospective cohort study with a secondary analysis of registry data. Patient demographics and outcome variables collected from January 1, 2015, to December 31, 2019, were obtained from the Virtual Pediatric Systems database. Patients with a source of admission other than the hospital’s ED or pediatric floor were excluded. Multivariable regression analysis controlling for age groups, sex, race, diagnostic categories, and severity of illness (Pediatric Index of Mortality III), with clustering for sites, was performed. RESULTS A total of 209 695 patients from 121 sites were included in the analysis. A total of 154 716 (73.7%) were admitted directly from the ED, and 54 979 were admitted (26.2%) as an escalation of care from the floor. Two groups differed in age and race distribution, medical complexity, diagnostic categories, and severity of illness. After controlling for measured confounders, patients with floor escalations had higher mortality (2.78% vs 1.95%; P < .001), with an odds ratio of 1.71 (95% CI 1.5 to 1.9) and longer PICU length of stay (4.9 vs 3.6 days; P < .001). The rates of most of the common ICU procedures and their durations were also significantly higher in patients with an escalation of care. CONCLUSIONS Compared with direct admissions to the PICU from the ED, patients who were initially triaged to the pediatric floor and then require escalation to the PICU have worse outcomes. Further research is needed to explore the potential causes of this difference.

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Section: Discussionmentioning

confidence: 99%

Outcome Differences Between Direct Admissions to the PICU From ED and Escalations From Floor

Tripathi

Kim

2021

Hospital Pediatrics

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“…ED clinicians are often tasked the challenge of triaging the ‘borderline’ patients, whose needs are higher than a general floor but do not clearly need ICU care 1. The process of identifying patients at risk for deterioration can be difficult and determining where to admit a patient from the ED can be complex and multifactorial.…”

Section: Introductionmentioning

confidence: 99%

Reduction of early inpatient transfers and rapid response team calls after implementation of an emergency department intake huddle process

et al. 2020

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Patients admitted to the hospital and requiring a subsequent transfer to a higher level of care have increased morbidity, mortality and length of stay compared with patients who do not require a transfer during their hospital stay. We identified that a high number of patients admitted to our intermediate care (IMC) unit required a rapid response team (RRT) call and an early (<24 hours) transfer to the intensive care unit (ICU). A quality improvement project was initiated with the goal to reduce subsequent early transfers to the ICU and RRT calls. We started by focusing on IMC patients, implementing acuity-based nursing assignments and standardised daily nursing rounds in the IMC aiming to reduce early patient transfers to the ICU. Then, we expanded to all patients admitted to a hospital medical unit from the emergency department (ED), targeting patients with gastrointestinal (GI) bleed and sepsis who were at a higher risk for early transfer to the ICU. We then created an ED intake huddle process that over time was refined to target patients with SIRS criteria with an elevated serum lactic acid level greater than 2.0 mmol/L or a GI bleed with a haematocrit value less than 24%. These interventions resulted in an 10.8 percentage points (31.7% (225/710) to 20.9% (369/1764)) decrease in the early transfers to the ICU for all hospital medicine patients admitted to the hospital from the ED. Mean RRT calls/day decreased by 17%, from 3.0 mean calls/day preintervention to 2.5 mean calls/day postintervention. These quality improvement initiatives have sustained successful outcomes for over 6 years due to integrating enhanced team communication as organisational cultural norm that has become the standard.

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“…30 Indeed, several studies addressing different aspects of intermediate care have used the APACHE II to characterize studied populations. 11,12,14,15,31 –34 However, only 1 study assessed performance of the model. In that study, the APACHE II exhibited excellent discrimination (AUROC = 0.85), but substantially overestimated mortality (SMR = 0.44).…”

Section: Discussionmentioning

confidence: 99%

Performance of Critical Care Outcome Prediction Models in an Intermediate Care Unit

Brusca

Simpson

Sahetya

et al. 2019

J Intensive Care Med

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Background: Intermediate care units (IMCUs) are heterogeneous in design and operation, which makes comparative effectiveness studies challenging. A generalizable outcome prediction model could improve such comparisons. However, little is known about the performance of critical care outcome prediction models in the intermediate care setting. The purpose of this study is to evaluate the performance of the Acute Physiology and Chronic Health Evaluation version II (APACHE II), Simplified Acute Physiology Score version II (SAPS II) and version 3 (SAPS 3), and Mortality Probability Model version III (MPM0III) in patients admitted to a well-characterized IMCU. Materials and Methods: In the IMCU of an academic medical center (July to December 2012), the discrimination and calibration of each outcome prediction model were evaluated using the area under the receiver–operating characteristic and Hosmer-Lemeshow goodness-of-fit test, respectively. Standardized mortality ratios (SMRs) were also calculated. Results: The cohort included data from 628 unique IMCU admissions with an inpatient mortality rate of 8.3%. All models exhibited good discrimination, but only the SAPS II and MPM0III were well calibrated. While the APACHE II and SAPS 3 both markedly overestimated mortality, the SMR for the SAPS II and MPM0III were 0.91 and 0.91, respectively. Conclusions: The SAPS II and MPM0III exhibited good discrimination and calibration, with slight overestimation of mortality. Each model should be further evaluated in multicenter studies of patients in the intermediate care setting.

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Intermediate care to intensive care triage: A quality improvement project to reduce mortality

Cited by 8 publications

References 69 publications

Outcome Differences Between Direct Admissions to the PICU From ED and Escalations From Floor

Outcome Differences Between Direct Admissions to the PICU From ED and Escalations From Floor

Reduction of early inpatient transfers and rapid response team calls after implementation of an emergency department intake huddle process

Performance of Critical Care Outcome Prediction Models in an Intermediate Care Unit

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