Reid Farris

Pediatric severe sepsis in U.S. children's hospitals.

Objectives: To compare the prevalence, resource utilization, and mortality for pediatric severe sepsis identified using two established identification strategies. Design: Observational cohort study from 2004 to 2012. Setting: Forty-four pediatric hospitals contributing data to the Pediatric Health Information Systems database. Patients: Children 18 years old or younger. Measurements and Main Results: We identified patients with severe sepsis or septic shock by using two International Classification of Diseases, 9th edition, Clinical Modification–based coding strategies: 1) combinations of International Classification of Diseases, 9th edition, Clinical Modification codes for infection plus organ dysfunction (combination code cohort); 2) International Classification of Diseases, 9th edition, Clinical Modification codes for severe sepsis and septic shock (sepsis code cohort). Outcomes included prevalence of severe sepsis, as well as hospital and ICU length of stay, and mortality. Outcomes were compared between the two cohorts examining aggregate differences over the study period and trends over time. The combination code cohort identified 176,124 hospitalizations (3.1% of all hospitalizations), whereas the sepsis code cohort identified 25,236 hospitalizations (0.45%), a seven-fold difference. Between 2004 and 2012, the prevalence of sepsis increased from 3.7% to 4.4% using the combination code cohort and from 0.4% to 0.7% using the sepsis code cohort (p < 0.001 for trend in each cohort). Length of stay (hospital and ICU) and costs decreased in both cohorts over the study period (p < 0.001). Overall, hospital mortality was higher in the sepsis code cohort than the combination code cohort (21.2% [95% CI, 20.7–21.8] vs 8.2% [95% CI, 8.0–8.3]). Over the 9-year study period, there was an absolute reduction in mortality of 10.9% (p < 0.001) in the sepsis code cohort and 3.8% (p < 0.001) in the combination code cohort. Conclusions: Prevalence of pediatric severe sepsis increased in the studied U.S. children’s hospitals over the past 9 years, whereas resource utilization and mortality decreased. Epidemiologic estimates of pediatric severe sepsis varied up to seven-fold depending on the strategy used for case ascertainment.

Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia

Background: Substantial care variation occurs in a number of pediatric diseases. Methods: We evaluated the variability in healthcare resource utilization and its association with clinical outcomes among children, aged 1–18 years, hospitalized with community-acquired pneumonia (CAP). Each of 29 children’s hospitals contributing data to the Pediatric Hospital Information System was ranked based on the proportion of CAP patients receiving each of 8 diagnostic tests. Primary outcome variable was length of stay (LOS), revisit to the emergency department or readmission within 14 days of discharge. Results: Of 21,213 children hospitalized with nonsevere CAP, median age was 3 years (interquartile range: 1–6 years). Laboratory testing and antibiotic usage varied widely across hospitals; cephalosporins were the most commonly prescribed antibiotic. There were large differences in the processes of care by age categories. The median LOS was 2 days (interquartile range: 1–3 days) and differed across hospitals; 25% of hospitals had median LOS ≥ 3 days. Hospital-level variation occurred in 14-day emergency department visits and 14-day readmission, ranging from 0.9% to 4.9% and from 1.5% to 4.4%, respectively. Increased utilization of diagnostic testing was associated with longer hospital LOS (P = 0.036) but not with probability of 14-day readmission (Spearman &rgr; = 0.234; P = 0.225). There was an inverse correlation between LOS and 14-day revisit to the emergency department (&rgr; = −0.48; P = 0.013). Conclusions: Wide variability occurred in diagnostic testing for children hospitalized with CAP. Increased diagnostic testing was associated with a longer LOS. Earlier hospital discharge did not correlate with increased 14-day readmission. The precise interaction of increased use with longer LOS remains unclear.

Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial.

Objectives: To evaluate risk factors for poor functional outcome in 28-day survivors after an episode of severe sepsis. Design: Retrospective cohort study examining data from the Researching Severe Sepsis and Organ Dysfunction in Children: A Global Perspective trial (NCT00049764). Setting: One hundred and four pediatric centers in 18 countries. Subjects: Children with severe sepsis who required both vasoactive-inotropic infusions and mechanical ventilation and who survived to 28 days (n = 384). Interventions: None. Measurements and Main Results: Poor functional outcome was defined as a Pediatric Overall Performance Category score greater than or equal to 3 and an increase from baseline when measured 28 days after trial enrollment. Median Pediatric Overall Performance Category at enrollment was 1 (interquartile range, 1–2). Median Pediatric Overall Performance Category at 28 days was 2 (interquartile range, 1–4). Thirty-four percent of survivors had decline in their functional status at 28 days, and 18% were determined to have a “poor” functional outcome. Hispanic ethnicity was associated with poor functional outcome compared to the white referent group (risk ratio = 1.9; 95% CI: 1.0–3.0). Clinical factors associated with increased risk of poor outcome included CNS and intra-abdominal infection sources compared to the lung infection referent category (risk ratio = 3.3; 95% CI: 1.4–5.6 and 2.4; 95% CI: 1.0–4.5, respectively); a history of recent trauma (risk ratio = 3.9; 95% CI: 1.4–5.4); receipt of cardiopulmonary resuscitation prior to enrollment (risk ratio = 5.1; 95% CI: 2.9–5.7); and baseline Pediatric Risk of Mortality III score of 20–29 (risk ratio = 2.8; 95% CI: 1.2–5.2) and Pediatric Risk of Mortality III greater than or equal to 30 (risk ratio = 4.5; 95% CI: 1.6–8.0) compared to the referent group with Pediatric Risk of Mortality III scores of 0–9. Conclusions: In this sample of 28-day survivors of pediatric severe sepsis diminished functional status was common. This analysis provides evidence that particular patient characteristics and aspects of an individual’s clinical course are associated with poor functional outcome 28 days after onset of severe sepsis. These characteristics may provide opportunity for intervention in order to improve functional outcome in pediatric patients with severe sepsis. Decline in functional status 28 days after onset of severe sepsis is a frequent and potentially clinically meaningful event. Utilization of functional status as the primary outcome in future pediatric sepsis clinical trials should be considered.

Influenza Coinfection and Outcomes in Children With Complicated Pneumonia

OBJECTIVE To determine the impact of influenza coinfection on outcomes for children with complicated pneumonia. DESIGN Retrospective cohort study. SETTING Forty childrens hospitals that contribute data to the Pediatric Health Information System. PARTICIPANTS Children discharged from participating hospitals between January 1, 2004, and June 30, 2009, with complicated pneumonia requiring a pleural drainage procedure. MAIN EXPOSURE Influenza coinfection. MAIN OUTCOME MEASURES Intensive care unit admission, receipt of mechanical ventilation, receipt of vasoactive infusions, receipt of blood product transfusions, in-hospital death, readmission within 14 days of hospital discharge, hospital length of stay, and cost of hospitalization. RESULTS Overall, 3382 of 9680 children with complicated pneumonia underwent pleural fluid drainage; 105 patients (3.1%) undergoing pleural drainage had influenza coinfection. A bacterial pathogen was identified in 1201 cases (35.5%); the most commonly identified bacteria were Staphylococcus aureus in children with influenza coinfection (22.9% of cases) and Streptococcus pneumoniae in children without coinfection (20.0% of cases). In multivariable analysis, influenza coinfection was associated with higher odds of intensive care unit admission and receipt of mechanical ventilation, vasoactive infusions, and blood product transfusions as well as higher costs and a longer hospital stay. Children with influenza coinfection were less likely to require readmission, although there was a trend toward higher odds of mortality for patients with coinfection. In a subanalysis stratified by bacteria, outcomes remained worse for coinfected children in the subgroups of children with S aureus and with no specified bacteria. CONCLUSIONS Influenza coinfection occurred in 3.1% of children with complicated pneumonia. Clinical outcomes for children with complicated pneumonia and influenza coinfection were more severe than for children without documented influenza coinfection.

Comparative effectiveness of pleural drainage procedures for the treatment of complicated pneumonia in childhood.

OBJECTIVE To determine the comparative effectiveness of common pleural drainage procedures for treatment of pneumonia complicated by parapneumonic effusion (ie, complicated pneumonia). DESIGN Multicenter retrospective cohort study. SETTING Forty childrens hospitals contributing data to the Pediatric Health Information System. PARTICIPANTS Children with complicated pneumonia requiring pleural drainage. MAIN EXPOSURES Initial drainage procedures were categorized as chest tube without fibrinolysis, chest tube with fibrinolysis, video-assisted thoracoscopic surgery (VATS), and thoracotomy. MAIN OUTCOME MEASURES Length of stay (LOS), additional drainage procedures, readmission within 14 days of discharge, and hospital costs. RESULTS Initial procedures among 3500 patients included chest tube without fibrinolysis (n = 1762), chest tube with fibrinolysis (n = 623), VATS (n = 408), and thoracotomy (n = 797). Median age was 4.1 years. Overall, 716 (20.5%) patients received an additional drainage procedure (range, 6.8-44.8% across individual hospitals). The median LOS was 10 days (range, 7-14 days across individual hospitals). The median readmission rate was 3.8% (range, 0.8%-33.3%). In multivariable analysis, differences in LOS by initial procedure type were not significant. Patients undergoing initial chest tube placement with or without fibrinolysis were more likely to require additional drainage procedures. However, initial chest tube without fibrinolysis was the least costly strategy. CONCLUSION There is variability in the treatment and outcomes of children with complicated pneumonia. Outcomes were similar in patients undergoing initial chest tube placement with or without fibrinolysis. Those undergoing VATS received fewer additional drainage procedures but had no differences in LOS compared with other strategies.

Very high serum ferritin levels are associated with increased mortality and critical care in pediatric patients

Objective: To determine whether an elevated serum ferritin level is independently associated with mortality and receipt of critical care in pediatric patients. Design: Retrospective cohort study, open population. Setting: Seattle Childrens Hospital, Seattle, WA, from September 2, 2003, to February 15, 2008. Patients: All patients tested for serum ferritin level from September 2, 2003, to August 16, 2007, with a level ≥1000 ng/mL. Interventions: None. Main Analysis: Cox regression. Measurements and Main Results: The predictor of interest was the patient-specific peak serum ferritin level, dichotomized a priori at 3000 ng/mL. The outcomes were mortality and intensive care unit admission. A total of 171 patients met the inclusion criteria. The observation time without death or intensive care unit admission ranged from 184 to 1621 days. The hazard ratio of death with peak ferritin of >3000 ng/mL was 4.32 (95% confidence interval 2.21–8.47, p < .001) compared to peak ferritin of 1000–3000 ng/mL. The hazard ratio of intensive care unit admission with peak ferritin of >3000 ng/mL was 2.49 (95% confidence interval 1.53–4.05, p < .001) compared to peak ferritin of 1000–3000 ng/mL. Both estimates were adjusted for bone marrow transplant, solid organ transplant, hemoglobinopathy, and existing rheumatologic disease. Conclusion: In this pediatric population, with serum ferritin levels of >3000 ng/mL, there was increased risk for both receipt of critical care and subsequent death.

Pediatric Critical Care Resource Use by Children with Medical Complexity

OBJECTIVES To examine the proportionate use of critical care resources among children of differing medical complexity admitted to pediatric intensive care units (ICUs) in tertiary-care childrens hospitals. STUDY DESIGN This is a retrospective, cross-sectional study of all children (<19 years of age) admitted to a pediatric ICU between January 1, 2012, and December 31, 2013, in the Pediatric Health Information Systems database. Using the Pediatric Medical Complexity Algorithm, we assigned patients to 1 of 3 categories: no chronic disease, noncomplex chronic disease (NC-CD), or complex chronic disease (C-CD). Baseline demographics, hospital costs, and critical care resource use were stratified by these groups and summarized. RESULTS Of 136 133 children with pediatric ICU admissions, 53.0% were categorized as having C-CD. At the individual-encounter level, ICU resource use was greatest among patients with C-CD compared with children with NC-CD and no chronic disease. At the hospital level, patients with C-CD accounted for more than 75% of all examined ICU resources, including ventilation days, ICU costs, extracorporeal membrane oxygenation runs, and arterial and central venous catheters. Children with a progressive condition accounted for one-half of all ICU resources. In contrast, patients with no chronic disease and NC-CD accounted for less than one-quarter of all ICU therapies. CONCLUSION Children with medical complexity disproportionately use the majority of ICU resources in childrens hospitals. Efforts to improve quality and provide cost-effective care should focus on this population.

Identifying Pediatric Severe Sepsis and Septic Shock: Accuracy of Diagnosis Codes

OBJECTIVES To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. STUDY DESIGN Multicenter retrospective study at 6 US childrens hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. RESULTS A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008). CONCLUSIONS Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction.

Common Endocrine Issues in the Pediatric Intensive Care Unit

Thyroid hormone is central to normal development and metabolism. Abnormalities in thyroid function in North America often arise from autoimmune diseases, but they rarely present as critical illness. Severe deficiency or excess of thyroid hormone both represent life-threatening disease, which must be treated expeditiously and thoroughly. Such deficiencies must be considered, because presentation may be nonspecific.

Oral injuries and occult harm in children evaluated for abuse

Objective To determine the frequency of occult trauma in children with oral injury evaluated for physical abuse. Design This was a retrospectively planned secondary analysis of a prospective, observational study. Setting Emergency departments supported by 20 US child abuse teams in the Examining Siblings to Recognize Abuse (ExSTRA) network. Patients Children <120 months old evaluated for physical abuse. Interventions Analysis of index children with oral injury on initial examination. Main outcome measures Rates of physician-recognised oral injury, as well as frequency and results of occult injury testing. Perceived abuse likelihood was described on a 7-point scale (7=definite abuse). Results Among 2890 child abuse consultations, 3.3% (n=96) of children had oral injury. Forty-two per cent were 0–12 months old, 39% 1–3 years old and 18% >3 years old. Oral injury was the primary reason for evaluation for 32 (33%). Forty-three per cent (42/96) had frenum injuries. Skeletal surveys were obtained for 84% and 25% of these identified occult fractures. Seventy-five per cent had neuroimaging; 38% identified injuries. Forty-one per cent of children with oral injuries had retinal examinations; 24% of exams showed retinal haemorrhages. More occult injuries were found in children with oral injuries than other ExSTRA subjects. A high level of concern for abusive injury was present in 67% of children with oral injury versus 33% without. Conclusions Children with oral injury are at high risk for additional occult abusive injuries. Infants and mobile preschoolers are at risk. Young children with unexplained oral injury should be evaluated for abuse.