Title: Benchmarking Mortality in a Small PICU: Impact of Comprehensive, Evidence-Based Interventions
INTRODUCTION/HYPOTHESIS: Most of the published literature in pediatric critical care reflects the practices of large, stand-alone children’s hospitals, but a significant proportion of critically ill children are treated in smaller PICUs within general hospitals. A recent study suggests that freestanding children’s hospitals have better survival rates than other hospitals. We hypothesize that a small PICU could reduce the risk-adjusted mortality by using comprehensive, evidence-based interventions.
Methods: This is an observational, retrospective study. The 9-bed PICU participated in the Virtual Pediatric Systems (VPS) network of PICUs that collects structured data on all PICU admissions. Mortality ratios were calculated using the pediatric index of mortality-2 (PIM-2) and the pediatric risk of mortality-3 (PRISM-3). The interventions were implemented over a relatively short period of time of 24-36 months and included: a) Protocols (central venous catheter bundle, bedside ultrasound, a ventilator-associated pneumonia prevention bundle, daily goals, daily patient-safety checklists, universal screening for MRSA); b) Operational policies (family-centered care rounding model, intensive physician staffing); and c) Hospital-wide interventions (rapid-response team, early-warning pediatric score (PEWS), direct physician-to-physician communication for inter-hospitals transfers).
Results: The risk-adjusted mortality ratio started at a level higher than the reference population but showed a distinct trend to decrease over time, becoming statistically significantly lower than the reference group at various points. The ranking in risk-adjusted mortality within the network went from average to one of the top 10 spots. Because the acuity in the index population was lower than in the reference population, a secondary analysis looks at the worst quartile of severity only, with results mirroring the findings in the whole population. The average LOS and the readmissions rates were lower than the reference group.
Conclusion: A small PICU can obtain outcomes that are comparable to those of larger, stand-alone PICUS in freestanding children’s hospitals by applying comprehensive, evidence-based interventions.
