PM2060: Identifying Potential Areas for Improvement in Unanticipated PICU Transfers

Background: In recent years, both locally and nationally, code blue events occurring outside of the Pediatric Intensive Care Unit (PICU) have declined. However, unanticipated transfers to the PICU remain significant. Escalation of care within 24 hours of admission may have associations with patient and clinical factors identifiable prior to admission. This study aims to describe the population of patients admitted to the pediatric ward who were transferred to the PICU within 24 hours of admission. This effort is part of an ongoing study to identify potential predictive factors to optimize patient triage and to decrease rapid and emergency transfers to the PICU.

Methods: This ongoing study is being conducted at a quaternary children’s hospital with two Emergency Departments (EDs), Critical Care Transport (CCT) and a PICU. From July 2020 to December 2021, clinical information was gathered via chart review for patients admitted to the inpatient wards from the ED, CCT, local emergency medical services (EMS), and direct admissions from outpatient clinics who were transferred to the PICU within 24 hours. The demographic variables (Table 1) and clinical characteristics among this patient cohort were reviewed by a multidisciplinary team. Definitions applicable to this study include rapid transfer (PICU transfer within 6 hours of admission) and emergency transfer (intubation, inotropes, or > 60 cc/kg fluid within 1 hour of PICU transfer).

Results: There were 233 patients requiring transfer to the PICU within 24 hours of admission with the largest number arriving from our ED (n=113) and CCT (n=86). Patients under 2 years of age comprised the largest age group (n=114, 49%), and respiratory etiology was the primary admission diagnosis for over 60% of unanticipated transfers. The primary reason for PICU transfer was respiratory distress/failure (n=163, 70%). Of patients transferred to the PICU, 71% had pertinent past medical history, with the most common conditions being prematurity, medical complexity, and asthma. A large number of transfers occurred within 6 hours of admission (n=98, 42%) (Figure 1) with 90 arising during evening or night shifts. Admit sources with the highest percentage of rapid transfers were local EMS (58%, n=8/14) and direct (65%, n=13/20). In total, there were 8 emergency transfers which includes 3 rapid transfers.

Conclusion: Preliminary data is shared from our local collaborative group comprised of ED, PICU, hospitalists, and transport services. Eighteen months of data suggest nearly half of all rapid transfers occur in children less than 2 years of age with the majority due to respiratory distress/failure. Emergency transfers happen within the first 6 hours of admission. Our initial data suggest there are opportunities for improvement in determining patient disposition on hospital admission. Further investigation and data analysis continues and needs to be validated nationally to determine optimal patient disposition.