The relationship between the location of pediatric intensive care unit facilities and child mortality: A county-level ecologic study

Objective: To describe the relationship between the location of Pediatric Intensive Care Unit (PICU) facilities and county-level child mortality in the USA. Design: Cross-sectional ecologic study. Setting: 3110 counties in the contiguous USA. Pediatric Care Area (PCA) was specified as counties within a 60-mile radius of the geographic center of a county with PICU facilities. Interventions: None Measurements and main results: In 1997, PICU facilities were present in 9% of USA counties and were predominantly urban (98%) in location. Over half (58%) of USA counties were included in PCAs. There were 96,413 deaths of children 0- 14 years during the study period from 1996 to 1998. In bivariate analyses, residence within a PCA was related to lower mortality from trauma (incidence rate ratio [IRR] = 0.85, 95% confidence interval [CI] 0.83-0.87) and congenital anomalies (IRR= 0.98, 95% CI: 0.97-0.99). Controlling for residence in rural counties, poverty, and presence of pediatric intensivists, residence in a PCA remained associated with lower mortality from trauma (IRR= 0.87, 95% CI 0.85- 0.89) and congenital anomalies (IRR = 0.97, 95% CI 0.96-0.99) compared to residence outside a PCA. Mortality from conditions of perinatal origin, infectious diseases, and benign neoplasms was higher in counties within PCAs compared to those outside PCAs. Conclusion: Proximity to PICU facilities is associated with significant differences in child mortality particular to specific causes at the county level. These associations have implications for the establishment of PICU facilities, and warrant further study at the level of the individual patient.Master of Public Healt

Transfer hospitalizations for pediatric severe sepsis or septic shock: resource use and outcomes

Abstract Background Sepsis is a major cause of child mortality and morbidity. To enhance outcomes, children with severe sepsis or septic shock often require escalated care for organ support, sometimes necessitating interhospital transfer. The association between transfer admission for the care of pediatric severe sepsis or septic shock and in-hospital patient survival and resource use is poorly understood. Methods Retrospective study of children 0–20 years old hospitalized for severe sepsis or septic shock, using the 2012 Kids’ Inpatient Database. After descriptive and bivariate analysis, multivariate regression methods assessed the independent relationship between transfer status and outcomes of in-hospital mortality, duration of hospitalization, and hospital charges, after adjustment for potential confounders including illness severity. Results Of an estimated 11,922 hospitalizations (with transfer information) for pediatric severe sepsis and septic shock nationally in 2012, 25% were transferred, most often to urban teaching hospitals. Compared to non-transferred children, transferred children were younger, and had a higher frequency of extreme illness severity (84% vs. 75%, p < .01), and of multiple organ dysfunction (32% vs. 24%, p < .01). They also had higher use of invasive medical devices including arterial catheters, invasive mechanical ventilation, and central venous catheters; and of specialized technology, including renal replacement therapy (6.2% vs. 4.6%, p < .01) and extracorporeal membrane oxygenation (5.7% vs. 1.8%, p < .01). Transferred children had longer hospitalization and accrued higher charges than non-transferred children (p < .01). Crude mortality was higher among transferred than non-transferred children (21.4% vs.15.0%, p < .01), a difference no longer statistically significant after multivariate adjustment for potential confounders (Odds Ratio:1.04, 95% Confidence interval: 0.88–1.24). Similarly, adjusted length of hospital stay and hospital charges were not statistically different by transfer status. Conclusion One in four children with severe sepsis or septic shock required interhospital transfer for specialized care associated with greater use of invasive medical devices and specialized technology. Despite higher crude mortality and resource consumption among transferred children, adjusted mortality and resource use did not differ by transfer status. Further research should identify quality-of-care factors at the receiving hospitals that influence clinical outcomes and resource use.http://deepblue.lib.umich.edu/bitstream/2027.42/173183/1/12887_2019_Article_1577.pd

Interhospital transfer of critically ill and injured children: An evaluation of transfer patterns, resource utilization, and clinical outcomes

OBJECTIVE To describe patterns of transfer, resource utilization, and clinical outcomes associated with interhospital transfer of critically ill and injured children. DESIGN Secondary analysis of administrative claims data. PARTICIPANTS Children 0 to 18 years in the Michigan Medicaid program who underwent interhospital transfer for intensive care from January 1, 2002 to December 31, 2004. The 3 sources of transfer from referring hospitals were: emergency department (ED), ward, or intensive care unit (ICU). MEASUREMENTS Mortality and duration of hospital stay at the receiving hospitals. RESULTS Of 1643 interhospital transfer admissions to intensive care at receiving hospitals, 62%, 31%, and 7% were from the ED, ward, and ICU of referring hospitals, respectively. Nineteen percent had comorbid illness, while 11% had organ dysfunction at the referring hospital. After controlling for comorbid illness, patient age, and pretransfer organ dysfunction; compared with ED transfers, mortality in the receiving hospital was higher for ward transfers (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.02–3.03) but not for ICU transfers. Also, compared with ED transfers, hospital stay was longer by 1.5 days for ward transfers and by 13.5 days for ICU transfers. CONCLUSION In this multiyear, statewide sample, mortality and resource utilization were higher among children who underwent interhospital transfer to intensive care after initial hospitalization, compared with those transferred directly from emergency to intensive care. Decision-making underlying initial triage and subsequent interhospital transfer of critically ill children warrants further study. Journal of Hospital Medicine 2009;4:164–170. © 2009 Society of Hospital Medicine.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/62039/1/418_ftp.pd

Effect of interhospital transfer on resource utilization and outcomes at a tertiary pediatric intensive care unit

Purpose: The study aimed to examine the effect of interhospital transfer on resource utilization and clinical outcomes at a tertiary pediatric intensive care unit (PICU) among patients with sepsis or respiratory failure. Materials and methods: Data on 2146 consecutive admissions with respiratory failure or sepsis to the PICU were analyzed. Data included demographics, admission source, and outcomes. Admission source was classified as interhospital transfer from the emergency departments (ED), wards, or PICUs of referring hospitals; or from the study hospital ED (direct). Results: Compared with direct admissions, inter-PICU transfers had higher crude mortality (odds ratio, 1.93; 95% confidence interval, 1.31-2.84) but not significant mortality difference (odds ratio, 1.16; 95% confidence interval, 0.71-1.86) after adjusting for illness severity, age, and sex. Conversely, ED transfers had lower PICU mortality than direct ED admissions. Children with transfer admissions stayed significantly longer and used more intensive care technology in the study PICU than children directly admitted (P \u3c .01). In comparisons within quartiles of mortality risk, inter-PICU transfers had longer hospitalization and higher mortality in all but the highest quartile. Conclusions: Interhospital transfer, particularly inter-PICU transfer, was associated with significant hospital resource consumption that often correlated with admission illness severity. Future prospective studies should identify determinants of pretransfer illness severity and investigate decision making underlying interhospital transfer. © 2009 Elsevier Inc. All rights reserved

Factors associated with interhospital transfer of children with respiratory failure from level II to level I pediatric intensive care units

Purpose: Of all sources of admission to level I pediatric intensive care units (PICUs), interhospital transfer admissions from level II PICUs carry the highest mortality and resource use burden. We sought to investigate factors associated with transfer of children with respiratory failure from level II to level I PICUs. Methods: A case-control study was conducted among children with respiratory failure admitted to 6 level II PICUs between January 1, 1997, and December 31, 2007, with frequency matching of 466 nontransferred children (controls) to 187 transferred children (cases). Results: Among 653 children, transferred children were younger and had more comorbidities. After multivariable analysis, transferred children were more likely to have comorbidities (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.36-2.98) and receive escalated care including high-frequency ventilation (OR, 2.57; 95% CI, 1.04-6.37) and surfactant therapy (OR, 5.33; 95% CI, 1.35-21.0). Conclusions: The study identified patient-level and process-of-care factors associated with transfer from level II to level I PICUs. These findings highlight the influence of escalated care on transfer decision making for critically ill children in respiratory failure

Factors associated with interhospital transfer of children with respiratory failure from level II to level I pediatric intensive care units

Purpose: Of all sources of admission to level I pediatric intensive care units (PICUs), interhospital transfer admissions from level II PICUs carry the highest mortality and resource use burden. We sought to investigate factors associated with transfer of children with respiratory failure from level II to level I PICUs. Methods: A case-control study was conducted among children with respiratory failure admitted to 6 level II PICUs between January 1, 1997, and December 31, 2007, with frequency matching of 466 nontransferred children (controls) to 187 transferred children (cases). Results: Among 653 children, transferred children were younger and had more comorbidities. After multivariable analysis, transferred children were more likely to have comorbidities (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.36-2.98) and receive escalated care including high-frequency ventilation (OR, 2.57; 95% CI, 1.04-6.37) and surfactant therapy (OR, 5.33; 95% CI, 1.35-21.0). Conclusions: The study identified patient-level and process-of-care factors associated with transfer from level II to level I PICUs. These findings highlight the influence of escalated care on transfer decision making for critically ill children in respiratory failure

Factors associated with interhospital transfer of children with respiratory failure from level II to level I pediatric intensive care units

PURPOSE: Of all sources of admission to Level I Pediatric Intensive Care Units (PICUs), interhospital transfer admissions from Level II PICUs carry the highest mortality and resource use burden. We sought to investigate factors associated with transfer of children with respiratory failure from Level II to Level I PICUs. METHODS: A case-control study was conducted among children with respiratory failure admitted to six Level II PICUs between January 1, 1997, and December 31, 2007, with frequency-matching of 466 non-transferred children (controls) to 187 transferred children (cases). RESULTS: Among 653 children, transferred children were younger and had more comorbidities. After multivariable analysis, transferred children were more likely to have comorbidities (Odds Ratio [OR]: 2.02; 95% Confidence Interval [CI]: 1.36 – 2.98) and receive escalated care including high frequency ventilation (OR: 2.57; 95%: 1.04 – 6.37) and surfactant therapy (OR 5.33; 95% CI: 1.35 – 21.0). CONCLUSIONS: The study identified patient-level and process-of-care factors associated with transfer from Level II to Level I PICUs. These findings highlight the influence of escalated care on transfer decision-making for critically ill children in respiratory failure

Characteristics and outcomes of interhospital transfers from level II to level I pediatric intensive care units

OBJECTIVE: To examine the characteristics, resource utilization, and outcomes for transfer admissions from level II to level I pediatric intensive care units (PICUs). DESIGN: Retrospective study. SETTING: A 16-bed level I PICU in a tertiary care children\u27s hospital. PATIENTS: All transfer admissions from level II PICUs from January 1, 1997, through December 31, 2003; admissions for cardiac surgery were excluded. Patient characteristics, resource utilization, and outcomes were described and then compared across predefined strata (low \u3c5%, moderate 5-30%, and high \u3e30%) of predicted probability of death. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 168 transfer admissions, 45%, 30%, and 25% were in the low, moderate, and high mortality risk groups, respectively. Length of stay at the referring PICU was shortest for the high-risk admissions. The most frequent diagnoses among all risk groups were respiratory failure (49%) and sepsis (14%). High-risk admissions were more likely to receive advanced therapies such as extracorporeal membrane oxygenation (41.5% high risk vs. 39.2% moderate vs. 6.6% low risk, p \u3c .01) and renal replacement therapy (34.2% vs. 17.7% vs. 2.6%, p \u3c .01). The high-risk admissions had longer PICU length of stay and the highest death rates (34% vs. 10% vs. 4%, p \u3c .01) when compared with the moderate- and low-risk admissions, respectively. CONCLUSIONS: This study highlights significant differences in patient characteristics, resource utilization, and outcomes across mortality risk-stratified groups of critically ill and injured children transferred from level II to level I PICU care. Further studies are warranted to investigate decision making that prompt inter-PICU transfers. ©2006 The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies