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Development of a score to predict clinical deterioration in hospitalized children
Christopher P Bonafide1, John H Holmes, Vinay M Nadkarni
1Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA. bonafide@email.chop.edu
Insights
A new 7-item score using non-vital signs can predict clinical deterioration in hospitalized children, identifying high-risk patients for closer monitoring and low-risk patients for reduced surveillance.
Area of Science:
- Pediatric hospital medicine
- Clinical risk prediction
- Patient safety
Background:
- Identifying children at high risk of deterioration is crucial for targeted monitoring and resource allocation.
- Previous methods relied on vital sign-based scores, detecting deterioration after it began.
- Non-vital sign characteristics offer potential for earlier risk stratification.
Purpose of the Study:
- To develop a predictive score for clinical deterioration in hospitalized children using non-vital sign characteristics.
- To enable risk stratification before deterioration becomes clinically apparent.
- To guide the intensity of monitoring for hospitalized children on non-intensive care units.
Main Methods:
- Case-control study conducted at a 460-bed children's hospital.
- Identified cases (n=141) of clinical deterioration (cardiopulmonary arrest, acute respiratory compromise, urgent ICU transfer) on non-ICU units.
- Selected controls (n=423) and analyzed exposures including complex chronic conditions, patient characteristics, and laboratory results.
Main Results:
- A 7-item predictive score was developed, including age <1 year, epilepsy, congenital/genetic conditions, transplant history, enteral tube use, hemoglobin <10 g/dL, and recent blood culture.
- Patients were stratified into risk groups based on their scores.
- The high-risk group showed an >80-fold increased probability of deterioration compared to baseline, while the very low-risk group had <0.5 times the baseline risk.
Conclusions:
- A set of non-vital sign characteristics effectively predicts clinical deterioration in hospitalized children.
- This 7-item score can aid in triaging monitoring intensity for non-ICU pediatric inpatients.
- The score facilitates proactive patient management to improve safety and resource utilization.
Background:
Identification of the characteristics that put hospitalized children at high risk of deterioration may help to target patients whose physiologic status should be intensively monitored for signs of deterioration, and reduce unnecessary monitoring in patients at very low risk. Previous studies have evaluated vital sign-based early warning scores to detect deterioration that has already begun.
Objective:
To develop a predictive score for deterioration using non-vital sign patient characteristics in order to risk-stratify hospitalized children before signs of deterioration are detectable.
Design:
Case-control study.
Setting:
A 460-bed children's hospital.
Patients:
Cases (n = 141) were children who deteriorated while receiving care on non-intensive care unit (non-ICU) inpatient units. Controls (n = 423) were randomly selected.
Measurements:
The exposures were complex chronic conditions, other patient characteristics, and laboratory studies. The outcome was clinical deterioration, defined as cardiopulmonary arrest, acute respiratory compromise, or urgent ICU transfer.
Results:
The 7-item score included age <1 year, epilepsy, congenital/genetic conditions, history of transplant, enteral tube, hemoglobin <10 g/dL, and blood culture drawn in the preceding 72 hours. We grouped the patients into risk strata based on their scores. The very low-risk group's probability of deterioration was less than half of baseline risk. The high-risk group's probability of deterioration was more than 80-fold higher than the baseline risk.
Conclusions:
We identified a set of characteristics associated with clinical deterioration in children. Used in combination as a score, these characteristics may be useful in triaging the intensity of monitoring and surveillance for deterioration that children receive while hospitalized on non-ICU units.