Triage of Intermediate-Care Patients in Pediatric Hospitals

Abstract

BACKGROUND: Hospitalized children have a wide range of acuity and risk of decompensation. The objective of this study was to determine where pediatric patients are triaged when they present to pediatric hospitals needing intense monitoring and nursing care, but do not require invasive monitoring or technology. METHODS: We completed a telephone survey of pediatric hospitals in the United States with at least 2 non-neonatal pediatric wards and at least 50 acute inpatient beds. The survey consisted of a brief scripted portrayal of 6 hypothetical patients who may be admitted to a hospital's general floor, ICU, or an intermediate care unit (IMCU). The scenarios included severe asthma, bronchiolitis, croup, diabetic ketoacidosis, and patients dependent on home ventilation via noninvasive interface or tracheostomy. The hospital bed coordinator or emergency department charge nurse was asked where each hypothetical patient would be admitted in their hospital. RESULTS: A total192 hospitals met inclusion criteria and 164 hospitals (85%) responded. For all of the scenarios, most of the institutions triaged them to the PICU. Twenty-eight (17%) of the responding institutions triaged at least 1 of the patient scenarios to an IMCU. The presence of an IMCU decreased triage to the ICU for all scenarios when comparing hospitals with and without an IMCU (P < .001). CONCLUSIONS: Inpatient triage practices among pediatric hospitals vary widely for patients who require intense nursing or frequent monitoring due to specific acute illnesses or respiratory technologies. Institutions that have an IMCU available are less likely to send these patients to the ICU.

Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both

“…A recent survey suggested that pediatric hospitals vary widely in their use of IMCUs, but that having an IMCU provides an alternative location to the PICU to care for patients needing intense monitoring and nursing care[16]. PICU patients discharged to IMCUs have tended to be “long-stay” patients[17] and had greater odds of early unplanned PICU readmission[18].…”

“…Fourth, treating all patients with a primary cardiac diagnosis admitted from or discharged to an “IMCU/telemetry unit” as having moved from/to a telemetry unit may have introduced misclassification error, because some cardiac patients might have been admitted from or discharged to IMCUs. Finally, while large, our sample of institutions may not be representative of North American pediatric hospitals in general—a recent survey reported a lower proportion (17%) of hospitals with an IMCU[16]. …”

Characteristics and Outcomes of Critical Illness in Children With Feeding and Respiratory Technology Dependence

“…Little is known about the critical care course of technology-dependent children. While some technology-dependent children are routinely triaged to the pediatric ICU regardless of their reason for admission due to resource constraints on the general care wards, others are admitted with significant critical illness (7).…”

Resource Utilization in Children who Receive a Pediatric Intensive Care Unit Consult in the Emergency Department: A Retrospective Cohort Study

“…Although there are published guidelines surrounding Pediatric Intensive Care Unit (PICU) admission criteria, 1 practices vary based on institutional resource availability and individual clinician judgement and preferences. 2 Children who imminently need a critical care intervention have an obvious indication for PICU admission, but many others may be considered based on their risk of deterioration and need for close monitoring or a high frequency of noncritical care interventions. [1][2][3][4][5] PICU physicians must consider many clinical and system factors when determining patient disposition following a consult in the Emergency Department (ED).…”