Escalation of care in children at high risk of clinical deterioration in a tertiary care children's hospital using the Bedside Pediatric Early Warning System.

BACKGROUND: Escalation and de-escalation are a routine part of high-quality care that should be matched with clinical needs. The aim of this study was to describe escalation of care in relation to the occurrence and timing of Pediatric Intensive Care Unit (PICU) admission in a cohort of pediatric inpatients with acute worsening of their clinical condition. METHODS: A monocentric, observational cohort study was performed from January to December 2018. Eligible patients were children: 1) admitted to one of the inpatient wards other than ICU; 2) under the age of 18 years at the time of admission; 3) with two or more Bedside-Paediatric-Early-Warning-System (BedsidePEWS) scores ≥ 7 recorded at a distance of at least one hour and for a period of 4 h during admission. The main outcome -the 24-h disposition - was defined as admission to PICU within 24-h of enrolment or staying in the inpatient ward. Escalation of care was measured using an eight-point scale-the Escalation Index (EI), developed by the authors. The EI was calculated every 6 h, starting from the moment the patient was considered eligible. Analyses used multivariate quantile and logistic regression models. RESULTS: The 228 episodes included 574 EI calculated scores. The 24-h disposition was the ward in 129 (57%) and the PICU in 99 (43%) episodes. Patients who were admitted to PICU within 24-h had higher top EI scores [median (IQR) 6 (5-7) vs 4 (3-5), p < 0.001]; higher initial BedsidePEWS scores [median (IQR) 10(8-13) vs. 9 (8-11), p = 0.02], were less likely to have a chronic disease [n = 62 (63%) vs. n = 127 (98%), p < 0.0001], and were rated by physicians as being at a higher risk of having a cardiac arrest (p = 0.01) than patients remaining on the ward. The EI increased over 24 h before urgent admission to PICU or cardiac arrest by 0.53 every 6-h interval (CI 0.37-0.70, p < 0.001), while it decreased by 0.25 every 6-h interval (CI -0.36-0.15, p < 0.001) in patients who stayed on the wards. CONCLUSION: Escalation of care was related to temporal changes in severity of illness, patient background and environmental factors. The EI index can improve responses to evolving critical illness.

Rising Unscheduled Healthcare Utilisation of Children and Young People: How Does the Rise Vary Across Deprivation Quintiles in UK Nations?

This retrospective population-based analysis assessed variations in urgent healthcare use by children and young people (CYP) across UK nations (England, Scotland and Wales) between 2007 and 2017. The study focused on urgent hospital admissions, short stay urgent admissions (SSUA) and Emergency Department (ED) attendances among CYP aged <25 years, stratified by age groups and Index of Multiple Deprivation (IMD) quintile groups. A linear mixed model was used to assess trends in healthcare activity over time and across deprivation quintiles. Urgent admissions, SSUA and ED attendances increased across all deprivation quintiles in all studied nations. Increasing deprivation was consistently associated with higher urgent healthcare utilisation. In England, the rise in urgent admissions and SSUA for CYP was slower for CYP from the quintile of greatest deprivation compared those from the least deprived quintile (respective mean differences 0.69/1000/y [95% CI 0.53, 0.85] and 0.25/1000/y [0.07, 0.42]), leading to a narrowing in health inequality. Conversely, in Scotland, urgent admissions and SSUA increased more rapidly for CYP from all deprivation quintiles, widening health inequality. Understanding the differences we describe here could inform changes to NHS pathways of care across the UK which slow the rise in urgent healthcare use for CYP.

Urgent Hospital Admissions Caused by Adverse Drug Reactions and Medication Errors-A Population-Based Study in Spain.

BACKGROUND: Adverse drug reactions (ADR) are a public health issue, due to their great impact on morbidity, mortality, and economic cost. OBJECTIVE: We aimed to study the percentage of patients admitted urgently as a result of an ADR, considered serious adverse event, or medication error. Also, we intended to identify possible risk factors which would lead to improvements in the prescription and use of medications. METHODS: This is a retrospective observational study conducted during February 2019, including patients admitted through the emergency department in our hospital. We evaluated the medical records of those with suspected ADR diagnoses to perform a descriptive analysis of the demographic characteristics. Moreover, after applying the Spanish Pharmacovigilance System causality algorithm, we performed a descriptive analysis of the identified ADR and the drugs involved. We also investigated those cases suspected of being a medication error. RESULTS: During the study period, 847 patients were urgently hospitalized. From those, 71 (29 women and 42 men) were admitted due to an ADR (8.4%, 95% CI 6.5%-10.3%). The mean age was 73 ± 15.9 years old and the mean number of prescribed medications was 7.3 ± 3.6 drugs/patient on admission. The most frequent ADR were opportunistic infections due to antineoplastic and immunomodulator drugs, and bleeding due to antiaggregants and anticoagulants. Five suspected medication errors occurred, being the incidence 0.6% (95% CI 0.08%-1.12%) of total admissions. CONCLUSIONS: 8.4% of urgent admissions were attributed to an ADR. Age (75% of patients were ≥ 65 years old), comorbidities and polymedication were the main risk factors. Although medication errors had a very low incidence (0.6% of urgent admissions), they were preventable and should be considered as a focus for action.