Prediction of Pediatric Critical Care Resource Utilization for Disaster Triage*

Abstract

Objectives: Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use. Design: Retrospective cohort study. Setting: Seattle Children's Hospital. Patients: PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206). Interventions: None. Measurements and Main Results: We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R 2 (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay. Conclusions: A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.

Allocation of intensive care resources during an infectious disease outbreak: a rapid review to inform practice

“…Additionally, our review is focused on an adult critical care setting as pediatric populations use different types of triage criteria. Resource allocation and triage in pediatric groups has been explored elsewhere [122,123]. Regardless of the operating characteristics, healthcare systems need to decide which triage protocol to enact if the demand of critical care resources exceeds supply to ensure a standardized and ethically sound approach to allocating health resources.…”

Finding the Right Ethical Framework for PICU Resource Allocation During a Pandemic*

“…We developed and validated such a tool using data derived from the Virtual PICU System database and demonstrated that its use would result in improved population survival compared with random allocation, employing a virtual pandemic modeled after the 1918-1919 Spanish influenza outbreak (6, 7); but the tool was novel and unfamiliar to the general population of pediatric intensivists. Hence, the publication by Killien et al (8) in this issue of Pediatric Critical Care Medicine using a variation of the 12-hour Pediatric Logistic Organ Dysfunction (PELOD)-2 score ( 9) is a welcome addition to these efforts. That score, when added to selected additional, readily accessible variables, strongly predicted use and duration of PICU resources, particularly mechanical ventilators, with an area under the receiver operating characteristic curve greater than 0.900.…”

“…Indeed, when only children not intubated at the time of the score's calculation were considered, the discriminatory power of the score was much reduced. Additional considerations, including the score's derivation from data from a single center, and the exclusion of children with primary cardiac diagnoses and neonates, further limit the generalizable predictive strength of the proposed score, as noted by the authors (8).…”

“…PELOD-2 is familiar to most pediatric intensivists. Furthermore, considering that hospitals will need to rapidly score all patients in need of scarce resources, training someone to score using PELOD-2, even with the variations proposed by Killien et al (8), is feasible. Employing the same scoring method across the country satisfies the justice argument that every pediatric patient, from Alaska to Florida and from California to Maine, will be scored the same way.…”

“…Employing the same scoring method across the country satisfies the justice argument that every pediatric patient, from Alaska to Florida and from California to Maine, will be scored the same way. Although uniform use of the version of PELOD-2 proposed by Killien et al (8) will not eliminate all variation from resource allocation strategies, finding any common ground in resource triage schemes represents an important first step.…”