Variation in therapy and outcome for pediatric head trauma patients.

OBJECTIVE: This 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. METHODS: Admission severity was measured as the worst recorded physiological derangement during the period 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). CONCLUSIONS: Therapies 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.

Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments.

OBJECTIVE: Given the current focus on outcomes, there is a crucial need for easily utilized measures that can effectively quantify morbidity or disability after a child's critical illness or injury. The purpose of this study is to significantly extend the research on two such promising measures: the Pediatric Overall Performance Category (POPC) and the Pediatric Cerebral Performance Category (PCPC). DESIGN: Cross-sectional analysis of a sample of pediatric intensive care unit (PICU) discharges and a prospective follow-up of this cohort of children. SETTING: Arkansas Children's Hospital. PATIENTS: Two hundred children (ranging in age from birth to 21 yrs) discharged from a PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were collected at PICU discharge, hospital discharge, and 1- and 6-month follow-up assessments after hospital discharge. Measures utilized included the POPC (at PICU discharge), PCPC (at PICU discharge), Stanford-Binet Intelligence Scale, fourth edition (at hospital discharge), Bayley Scales of Infant Development, second edition (at hospital discharge), and the Vineland Adaptive Behavior Scales (at 1 and 6 months after discharge). Stanford-Binet Intelligence Quotients and Bayley Mental Developmental Index scores were significantly different across PCPC categories (p < .0001). Bayley Psychomotor Developmental Index scores and Vineland Adaptive Behavior Scales scores varied significantly across POPC categories (p < .0001). The test for linear trend was also significant for each of the comparisons. CONCLUSIONS: The results of this study offer additional support for the use of the PCPC and POPC. These brief and easily completed measures can provide useful information regarding probable outcomes for pediatric intensive care patients when more extensive psychometric testing is not feasible or desirable.

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 children's 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.

Relationship of illness severity and length of stay to functional outcomes in the pediatric intensive care unit: a multi-institutional study.

OBJECTIVE: The purpose of this study was to establish relationships between illness severity, length of stay, and functional outcomes in the pediatric intensive care unit (PICU) by using multi-institutional data. We hypothesized that a positive relationship exists between functional outcome scores, severity of illness, and length of stay. DESIGN: The study used a prospective multicentered inception cohort design. SETTING: The study was conducted in 16 PICUs across the United States that were member institutions of the Pediatric Critical Care Study Group of the Society of Critical Care Medicine. PATIENTS: In total, 11,106 patients were assessed, representing all admissions to these intensive care units for 12 consecutive months. MEASUREMENTS: Functional outcomes were measured by the Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scales. Both scales were assessed at baseline and discharge from the PICU. Delta scores were formed by subtracting baseline scores from discharge scores. Other measurements included admission Pediatric Risk of Mortality scores, age, operative status, length of stay in the PICU, and diagnoses. Interrater reliability was assessed by using a set of ten standardized cases on two occasions 6 months apart. MAIN RESULTS: Baseline, discharge, and delta POPC and PCPC outcome scores were associated with length of stay in the PICU and with predicted risk of mortality (p < .01). Incorporation of baseline functional status in multivariate length of stay analyses improved measured fit. Mild baseline cerebral deficits in children were associated with 18% longer PICU stays after controlling for other patient and institutional characteristics. Moderate and severe baseline deficits for both the POPC and PCPC score predict increased length of stay of between 30% and 40%. On the standardized cases, interrater consensus was achieved on 82% of scores with agreement to within one neighboring class for 99.7% of scores. CONCLUSIONS: These data establish current relationships for the POPC and PCPC outcome scales based on multi-institutional data. The reported relationships can be used as reference values for evaluating clinical programs or for clinical outcomes research.

Differences in pediatric ICU mortality risk over time.

OBJECTIVES: To compare pediatric intensive care unit (ICU) mortality risk using models from two distinct time periods; and to discuss the implications of changing mortality risk for severity systems and quality-of-care assessment. DATA SOURCES AND SETTING: Consecutive admissions (n = 10,833) from 16 pediatric ICUs across the United States that participate in the Pediatric Critical Care Study Group were recorded prospectively. Data collection occurred during a 12-mo period beginning in January 1993. METHODS: Data collection for the development and validation of the original Pediatric Risk of Mortality (PRISM) score occurred from 1980 to 1985. The original PRISM coefficients were used to calculate mortality probabilities in the current data set. Updated estimates of mortality probabilities were calculated, using coefficients from a logistic regression analysis using the original PRISM variable set. Quality-of-care tests were performed using standardized mortality ratios. RESULTS: Risk of mortality from pediatric ICU admission improved considerably between the two periods. Overall, the reduction in mortality risk averaged 15% (p < .001). Analysis of mortality risk by age indicated a large improvement for younger infants. The mortality risk for infants <1 mo improved by 39% (p < .001). Mortality risk improved by 28% (p < .001) for infants between 1 and 12 mos. Analysis of mortality risk by principal diagnosis indicated substantial improvement in respiratory diseases, including respiratory diseases developing in the perinatal period. The mortality risk for respiratory diseases improved by 45% (p < .001). The improvement in mortality risk substantially deteriorated the calibration of the original PRISM severity system (p < .001). As a result of changing mortality risk, the standardized mortality ratios across the 16 pediatric ICUs demonstrated substantial disparities, depending on the choice of models. CONCLUSIONS: This study documents differences in pediatric ICU risk of mortality over time that are consistent with a general improvement in the quality of pediatric intensive care. Despite continued widespread use of the original PRISM, recent improvements in pediatric ICU quality of care have negated its usefulness for many intended applications, including quality-of-care assessment.

Differentiation of systemic infection and congenital obstructive left heart disease in the very young infant.

BACKGROUND: The differentiation of severe systemic infection, such as sepsis or meningitis, from a congenital obstructive left heart abnormality presents a unique challenge to clinicians responsible for the care of such infants in the first few weeks of life. Clinical findings are very similar in the two populations. Failure to identify the need for specific intervention, such as prostaglandin administration, by the primary care or emergency physician may result in increased morbidity or death in these infants. METHODS: We undertook a retrospective review of critically ill infants 0 to 28 days of age presenting with either bacterial sepsis or meningitis or a congenital obstructive left heart syndrome (COLHS), in order to identify historical, physical, or laboratory findings which might differentiate the two groups at presentation. Discriminant analysis was performed using the presence or absence of COLHS as the dependent variable. A COLHS index was derived to determine its sensitivity and specificity for differentiating the two groups. RESULTS: The presence of cardiomegaly predicted COLHS with 85% sensitivity and 95% specificity. Cardiomegaly had a positive predictive value for COLHS of 0.95. Unfortunately, most of the other variables which, individually or in combination, were significantly different between the two groups demonstrated poor sensitivity for prediction of the presence of obstructive left heart disease. Eleven of the predictor variables were chosen for inclusion in the multivariate model, and a COLHS index was developed which correctly classified 62/63 cases (98% sensitivity, 100% specificity). CONCLUSIONS: We conclude that while it is very difficult to differentiate these two groups at presentation, early clinical suspicion of COLHS with attention to key clinical parameters identified in this study may expedite appropriate intervention and enhance outcome. The multivariate model derived may provide a template from which further research can elucidate a more clinically useful tool for the clinician.

Decomplexification in critical illness and injury: relationship between heart rate variability, severity of illness, and outcome.

OBJECTIVES: To determine if decomplexification of heart rate dynamics occurs in critically ill and injured pediatric patients. We hypothesized that heart rate power spectra, a measure of heart rate dynamics, would inversely correlate with measures of severity of illness and outcome. DESIGN: A prospective clinical study. SETTING: A 12-bed pediatric intensive care unit (ICU) in a tertiary care children's hospital. PATIENTS: One hundred thirty-five consecutive pediatric ICU admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared heart rate power spectra with the Pediatric Risk of Mortality (PRISM) score, the Pediatric Cerebral Performance Category (PCPC), and the Pediatric Overall Performance Category (POPC). We found significant negative correlations between minimum low-frequency and high-frequency heart rate power spectral values recorded during ICU stay and the maximum PRISM score (log low-frequency heart rate power vs. PRISM, r2 = .293, p < .001; and log high-frequency heart rate power vs. PRISM, r2 = .243, p < .001) and outcome at ICU discharge (log low-frequency heart rate power vs. POPC or PCPC, r2 = .429, p < .001; and log high-frequency heart rate power vs. POPC or PCPC, r2 = .271, p < .001). CONCLUSIONS: Our data support the hypothesis that measures of heart rate power spectra are inversely related and negatively correlated to severity of illness and outcome in critically ill and injured children. The phenomenon of decomplexification of physiologic dynamics may have important clinical implications in critical illness and injury.

Tibial length following intraosseous infusion: a prospective, radiographic analysis.

Intraosseous infusion is a well accepted means of obtaining emergency intravascular access in children. Despite the low incidence of serious complications from intraosseous infusions, the potential exists for growth plate injury and subsequent growth disturbance following intraosseous infusion. We conducted a prospective, blinded observational study of 10 subjects to evaluate tibial length discrepancy radiographically one year or more following intraosseous infusion. We found no significant difference in mean tibial length between the legs that had intraosseous infusions and the opposite legs, which served as controls. We conclude that intraosseous infusion does not appear to produce subsequent leg length discrepancy one year after infusion.

Long-term functional outcome of inpatient pediatric cardiopulmonary resuscitation.

OBJECTIVE: There is limited information published regarding the long-term outcome of pediatric survivors of inpatient cardiopulmonary resuscitation (CPR). The purpose of this study was to document the long-term (i.e., > or = 1 year after the arrest) functional outcome of children surviving inpatient CPR. METHODS: We reviewed the medical records of children (i.e., less than 18 years of age) receiving advanced CPR (i.e., chest compressions, assisted ventilation, and resuscitation medications) as inpatients in a tertiary care children's hospital. Prospective telephone follow-up of the survivors a minimum of one year after the arrest was performed. A change in the survivors' Pediatric Cerebral Performance Category (PCPC) scale was determined. RESULTS: Approximately half of the 92 subjects were diagnosed with sepsis syndrome. None (0/44) of the patients with sepsis syndrome survived at one year. None (0/24) of the patients who experienced a single episode of advanced CPR > or = 30 min in duration survived one year. Although 36% (33/92) of the patients resuscitated were alive 24 h after their arrest, the proportion surviving fell steadily to 10% (9/92) at one year. Although five of the nine survivors were moderately to severely disabled at one year, the majority (8/9) had little or no change in their PCPC score at one year compared to their prearrest level of function. CONCLUSION: Survival of inpatient pediatric CPR is small. Children surviving inpatient advanced CPR may have little or no change from prearrest function. The survival of hospitalized children with sepsis syndrome requiring CPR or receiving greater than > 30 min of advanced CPR is extremely low.

Prediction of three outcome states from pediatric intensive care.

OBJECTIVE: To develop a method based on admission day data for predicting patient outcome status as independently functional, compromised functional, or dead. DESIGN: Prospectively acquired development and validation samples. SETTING: A pediatric intensive care unit located in a tertiary care center. PATIENTS: Consecutive admissions (n = 1,663) for predictor development, and consecutive admissions (n = 1,153) for predictor validation. METHODS: Pediatric Risk of Mortality score, baseline Pediatric Overall Performance Category score, age, operative status, and primary diagnosis classified into ten organ systems and nine etiologies were recorded at the time of intensive care unit admission. Predictor was developed by stepwise polychotomous logistic regression analysis for the outcome functional, compromised, and dead. Model fit was evaluated by chi-square statistics; prediction performance was measured by the area under the receiver operating characteristic curve, and classification table analysis of observed vs. predicted outcomes. MEASUREMENTS AND MAIN RESULTS: The resulting predictor included Pediatric Risk of Mortality, baseline Pediatric Overall Performance Category, operative status, age, and diagnostic factors from four systems (cardiovascular, respiratory, neurologic, gastrointestinal), and six etiologies (infection, trauma, drug overdose, allergy/immunology, diabetes, miscellaneous/undetermined). Its application to the validation sample yielded good agreement between the total number expected and the observed outcomes for each state (chi-square = 3.16, 2 degrees of freedom, p = .206), with area indices of 0.96 +/- 0.01 for discrimination of fully functional vs. the combination of the two poor outcome states (compromised or death), and 0.94 +/- 0.02 for discrimination of fully or compromised functional vs. death. The 3 x 3 classification resulted in correct classification rates of 83.2%, 74.4%, and 81.3%, for the outcomes functional, compromised, and death, respectively. CONCLUSIONS: Prediction of three outcome states using physiologic status, baseline functional level, and broad-based diagnostic groupings at admission is feasible and may improve the relevance of quality of care assessment.

Emergency medical services for children and pediatric subspecialty practice: a call to action.

For many pediatric subspecialists, their role in the emergency medical services for children system is unclear. However, subspecialists have an affirmative responsibility to contribute to development of a system that integrates consumers and providers from each subsystem. Avoiding fragmentation with an integrated system will yield the best outcome for patients while minimizing resource utilization. Additional roles for the subspecialist include responsibilities for advocacy, for guiding policy decisions and implementation, and for education, quality assurance, and research.

Contribution of heritable disorders to mortality in the pediatric intensive care unit.

OBJECTIVES: To determine the percentage of patients dying in the pediatric intensive care unit (PICU) who have heritable disorders and to compare vital statistics classification of underlying cause of death with underlying heritable disorder identified from medical record review. DESIGN: Retrospective medical record review. SETTING: The PICU of a university-affiliated hospital. METHODS: Medical records were reviewed for all deaths occurring in the PICA over a 5-year period. Further review, including hospital course, clinical findings, and the presence or absence of a genetic evaluation, was accomplished for those patients found to have a chromosome abnormality, recognized syndrome, single major malformation, or unrecognized syndrome. Underlying cause of death classification obtained from the Center for Health Statistics, Arkansas Department of Health was reviewed to determine the frequency with which the underlying heritable disorder was recorded. RESULTS: Fifty-one of 268 (19%) deaths during the study period were in patients with heritable disorders. Of these 51 patients, eight (16%) had chromosome abnormalities, 17 (33%) had a recognized syndrome, 15 (29%) had a single primary defect in development, and 11 (22%) had an unrecognized syndrome. Genetic evaluation was carried out on 45% of patients, with the frequency of evaluation differing between categories of patients with heritable conditions. When underlying cause of death from vital statistics classification was reviewed, 21 of 51 (41%) records did not include the underlying heritable disorder. CONCLUSIONS: Heritable disorders are a frequent cause of mortality in the PICU. Vital statistics classification of underlying cause of death in this population often fails to identify heritable disorders, leading to an underascertainment of these conditions in mortality statistics. Improved cause of death classification procedures will be necessary to target public health interventions to etiology-specific populations.

Outcome evaluations as measures of quality in pediatric intensive care.

In recent years, interest in assessing quality of care has blossomed. Quality care may be defined as providing the most appropriate treatment and providing it with great technical and managerial skill and proficiency in a manner that gains patient acceptance. For assessment purposes, variation in risk-adjusted outcomes between providers should be attributable to quality of care differences. Some methods for measuring outcomes and risk-adjustment for pediatric intensive care populations have been developed, but additional tools are needed for applications in outcomes management, continuous quality improvement, and outcomes research.

Prevention of hypoxemia during lumbar puncture in infancy with preoxygenation.

Hypoxemia has previously been reported during lumbar puncture (LP) in infancy. The purpose of this study was to determine whether preoxygenation before the LP would reduce hypoxemia during the procedure in infants. Twenty-one infants (one to 15 weeks of age) undergoing LP for evaluation of possible sepsis were randomly assigned to the control group (12) or treatment group (9). The treatment group was preoxygenated breathing oxygen (FiO2 = 1.0) spontaneously via snug face mask for three minutes prior to being positioned for the LP. The control group spontaneously breathed room air during this interval. Oxyhemoglobin saturation was measured prior to, and continuously during, the LP with pulse oximetry. The groups were comparable in age, resting respiratory rate, baseline saturation, and duration of the procedure. The treatment group developed significantly less desaturation during the procedure than the control group (P < 0.05). We conclude that preoxygenation prior to LP prevents most of the hypoxemia resulting from the procedure in infants.

Tension pneumopericardium in an infant.

Pneumopericardium in newborns is most often a complication of mechanical ventilation and frequently results in fatal cardiac tamponade. We report the case of a mechanically ventilated 33-day-old full-term gestation infant with interstitial pneumonitis who developed tension pneumopericardium. Treatment includes lowering peak inspiratory pressure and decompressing the pericardial space with tube drainage following pericardiocentesis.