Jerril W. Green

Volume-outcome relationships in pediatric intensive care units.

Context. Pediatric intensive care units (PICUs) have expanded nationally, yet few studies have examined the potential impact of regionalization and no study has demonstrated whether a relationship between patient volume and outcome exists in these units. Documentation of an inverse relationship between volume and outcome has important implications for regionalization of care. Objectives. This study examines relationships between the volume of patients and other unit characteristics on patient outcomes in PICUs. Specifically, we investigate whether an increase in patient volume improves mortality risk and reduces length of stay. Design and Setting. A prospective multicenter cohort design was used with 16 PICUs. All of the units participated in the Pediatric Critical Care Study Group. Participants. Data were collected on 11 106 consecutive admissions to the 16 units over a 12-month period beginning in January 1993. Main Outcome Measures. Risk-adjusted mortality and length of stay were examined in multivariate analyses. The multivariate models used the Pediatric Risk of Mortality score and other clinical measures as independent variables to risk-adjust for illness severity and case-mix differences. Results. The average patient volume across the 16 PICUs was 863 with a standard deviation of 341. We found significant effects of patient volume on both risk-adjusted mortality and patient length of stay. A 100-patient increase in PICU volume decreased risk-adjusted mortality (adjusted odds ratio: .95; 95% confidence interval: .91–.99), and reduced length of stay (incident rate ratio: .98; 95% confidence interval: .975–.985). Other PICU characteristics, such as fellowship training program, university hospital affiliation, number of PICU beds, and childrens hospital affiliation, had no effect on risk-adjusted mortality or patient length of stay. Conclusions. The volume of patients in PICUs is inversely related to risk-adjusted mortality and patient length of stay. A further understanding of this relationship is needed to develop effective regionalization and referral policies for critically ill children.

Variation in therapy and outcome for pediatric head trauma patients.

ObjectiveThis study was undertaken to examine variation in therapies and outcome for pediatric head trauma patients by patient characteristics and by pediatric intensive care unit. Specifically, the study was designed to examine severity of illness on admission to the pediatric intensive care unit, the therapies used during the pediatric intensive care unit stay, and patient outcomes. Data Sources and Setting Consecutive admissions from three pediatric intensive care units were recorded prospectively (n = 5,749). For this study, all patients with an admitting diagnosis of head trauma were included (n = 477). Data collection occurred during an 18-month period beginning in June 1996. All of the pediatric intensive care units were located in children’s hospitals, had residency and fellowship training programs, and were headed by a pediatric intensivist. MethodsAdmission severity was measured as the worst recorded physiological derangement during the period ≤6 hrs before pediatric intensive care unit admission. Therapies and resource use were based on the Therapeutic Intervention Scoring System with adaptations for pediatrics. The use of intracranial pressure monitoring was recorded on admission to the unit (within 1 hr) and at any time during the pediatric intensive care unit stay. Outcomes were measured at the time of pediatric intensive care unit discharge by the Pediatric Overall Performance Category scale. Risk factors for mortality were examined by using bivariate analyses with significant predictors as candidate variables in a logistic regression to predict expected mortality. Intracranial pressure monitoring and other therapies were added to the mortality prediction model to test for protective effects. Finally, race and insurance status were added to the model to test for differences in the quality of care. ResultsThe overall mortality rate for the entire sample was 7.8%. Mortality rates for children ≤1 yr old were significantly higher than for children >1 yr old (16.1% vs. 6.1%;p = .002). Comparisons by insurance status indicated that observed mortality rates were highest for self-paying patients. However, patient characteristics were not associated with use of therapies or standardized mortality rates after adjustment for patient severity. There was significant variation in the use of paralytic agents, seizure medications, induced hypothermia, and intracranial pressure monitoring on admission across the three pediatric intensive care units. In multivariate models, only the use of seizure medications was associated significantly with reduced mortality risk (odds ratio = 0.17; 95% confidence interval = 0.04–0.70;p = .014). ConclusionsTherapies and outcomes vary across pediatric intensive care units that care for children with head injuries. Increased use of seizure medications may be warranted based on data from this observational study. Large randomized controlled trials of seizure prophylaxis in children with head injury have not been conducted and are needed to confirm the findings presented here.

Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach

Problem Bloodstream infections associated with catheters were the most common nosocomial infections in one paediatric intensive care unit in 1994-7, with rates well above the national average. Design Clinical data were collected prospectively to assess the rates of infection from 1994 onwards. The high rates in 1994-7 led to the stepwise introduction of interventions over a five year period. At quarterly intervals, prospective data continued to be collected during this period and an additional three year follow-up period. Setting A 292 bed tertiary care childrens hospital. Key measures for improvement We aimed to reduce our infection rates to below the national mean rates for similar units by 2000 (a 25% reduction). Strategies for change A stepwise introduction of interventions designed to reduce infection rates, including maximal barrier precautions, transition to antibiotic impregnated central venous catheters, annual handwashing campaigns, and changing the skin disinfectant from povidone-iodine to chlorhexidine. Effects of change Significant decreases in rates of infection occurred over the intervention period. These were sustained over the three year follow-up. Annual rates decreased from 9.7/1000 days with a central venous catheter in 1997 to 3.0/1000 days in 2005, which translates to a relative risk reduction of 75% (95% confidence interval 35% to 126%), an absolute risk reduction of 6% (2% to 10%), and a number needed to treat of 16 (10 to 35). Lessons learnt A stepwise introduction of interventions leading to a greater than threefold reduction in nosocomial infections can be implemented successfully. This requires a multidisciplinary team, support from hospital leadership, ongoing data collection, shared data interpretation, and introduction of evidence based interventions.

Hospitalizations for critically ill children with traumatic brain injuries: A longitudinal analysis*

Objective:This study examines the incidence, utilization of procedures, and outcomes for critically ill children hospitalized with traumatic brain injury over the period 1988–1999 to describe the benefits of improved treatment. Design:Retrospective analysis of hospital discharges was conducted using data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample that approximates a 20% sample of U.S. acute care hospitals. Setting:Hospital inpatient stays from all types of U.S. community hospitals. Participants:The study sample included all children aged 0–21 with a primary or secondary ICD-9-CM diagnosis code for traumatic brain injury and a procedure code for either endotracheal intubation or mechanical ventilation. Interventions:None. Measurements and Main Results:Deaths occurring during hospitalization were used to calculate mortality rates. Use of intracranial pressure monitoring and surgical openings of the skull were investigated as markers for the aggressiveness of treatment. Patients were further classified by insurance status, household income, and hospital characteristics. Over the 12-yr study period, mortality rates decreased 8 percentage points whereas utilization of intracranial pressure monitoring increased by 11 percentage points. The trend toward more aggressive management of traumatic brain injury corresponded with improved hospital outcomes over time. Lack of insurance was associated with vastly worse outcomes. An estimated 6,437 children survived their traumatic brain injury hospitalization because of improved treatment, and 1,418 children died because of increased mortality risk associated with being uninsured. Improved treatment was valued at approximately

Variation in pediatric intensive care therapies and outcomes by race, gender, and insurance status*

17 billion, whereas acute care hospitalization costs increased by

Differential Lung Ventilation and Venovenous Extracorporeal Membrane Oxygenation for Traumatic Bronchopleural Fistula

1.5 billion (in constant 2000 dollars). Increased mortality in uninsured children was associated with a

Child health-related quality of life following neurocritical care for traumatic brain injury: an analysis of preference-weighted outcomes

3.76 billion loss in economic benefits. Conclusions:More aggressive management of pediatric traumatic brain injury appears to have contributed to reduced mortality rates over time and saved thousands of lives. Additional lives could be saved if mortality rates could be equalized between insured and uninsured children.

The Procoagulant and Anti-fibrinolytic state and the development of pediatric sepsis-induced persistent multiple organ failure

Context: The differential allocation of medical resources to adult patients according to characteristics such as race, gender, and insurance status raises the serious concern that such issues apply to critically ill children as well. Objective: This study examined whether medical resources and outcomes for children admitted to pediatric intensive care units differed according to race, gender, or insurance status. Design: An observational analysis was conducted with use of prospectively collected data from a multicenter cohort. Data were collected on 5,749 consecutive admissions for children from three pediatric intensive care units located in large urban children’s hospitals. Participants: Children aged ≤18 years admitted over an 18-month period beginning in June 1996 formed the study sample. Main Outcome Measures: Hospital mortality, length of hospital stay, and overall resource use were examined in relation to severity of illness. Standardized ratios were formed with generalized regression analyses that included the Pediatric Index of Mortality for risk adjustment. Results: After adjustment for differences in illness severity, standardized mortality ratios and overall resource use were similar with regard to race, gender, and insurance status, but uninsured children had significantly shorter lengths of stay in the pediatric intensive care unit. Uninsured children also had significantly greater physiologic derangement on admission (mortality probability, 8.1%; 95% confidence interval [CI], 6.2–10.0) than did publicly insured (3.6%; 95% CI, 3.2–4.0) and commercially insured patients (3.7%; 95% CI, 3.3–4.1). Consistent with greater physiologic derangement, hospital mortality was higher among uninsured children than insured children. Conclusions: Risk-adjusted mortality and resource use for critically ill children did not differ according to race, gender, or insurance status. Policies to expand health insurance to children appear more likely to affect physiologic derangement on admission rather than technical quality of care in the pediatric intensive care unit setting.

It's All About the Brain

A 16-year-old adolescent boy sustained traumatic bronchopleural fistula, refractory to conventional management, which was treated successfully with differential lung ventilation and extracorporeal membrane oxygenation support. This case highlights a novel approach for managing traumatic bronchopleural fistula in children.