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Pediatric code events: does in-house intensivist coverage improve outcomes?*
Christopher L Carroll1, Kathleen Sala, Daniel Fisher
1Division of Pediatric Critical Care, Connecticut Children's Medical Center, Hartford, CT.
Insights
Implementing 24/7 in-house intensivist coverage in a children's hospital significantly improved survival rates for pediatric code events. This change enhanced patient safety outcomes by ensuring expert critical care availability.
Area of Science:
- Pediatric critical care medicine
- Patient safety research
- Hospital quality improvement
Background:
- Children's hospitals are transitioning to models with full-time, in-house intensivist supervision.
- Evaluating the impact of this coverage model change on patient safety is crucial.
- Pediatric code events require timely and expert intervention.
Purpose of the Study:
- To assess the influence of in-house attending intensivist coverage on the occurrence and outcomes of pediatric code events.
- To compare patient safety metrics before and after the implementation of 24/7 intensivist supervision.
Main Methods:
- Retrospective review of all pediatric code events over two distinct periods: pre- and post-implementation of in-house intensivist coverage.
- Comparison of code event prevalence, interventions, and outcomes.
- Data collected from a 187-bed children's hospital.
Main Results:
- Survival following code events significantly improved with in-house intensivist coverage (OR, 4.3; P = 0.003).
- While overall code rates did not change significantly, ward codes increased (0.71 vs 0.2 codes/1,000 patient-days; P = 0.013).
- Intensivist presence during codes increased dramatically (OR, 28; P = 0.001), with lower acuity on the ward.
Conclusions:
- In-house intensivist supervision is associated with improved survival rates for hospitalized children experiencing code events.
- Continuous availability of intensivists may enhance pediatric patient safety and outcomes.
- The findings support the implementation of 24/7 in-house intensivist coverage in pediatric critical care settings.
Objectives:
A change in our children's hospital coverage model to providing full-time in-house supervision by intensivists allowed us to evaluate the impact of this change on patient safety outcomes. Our aim was to determine whether in-house attending coverage influenced the prevalence and outcomes of pediatric code events.
Design:
We conducted a retrospective review of all code events between October 2005 and October 2007 (before in-house intensivist supervision) and compared the prevalence, interventions, and outcomes of these codes with those occurring between April 2008 and April 2010 (after in-house intensivist supervision). A code event was defined as any activation of the code system.
Setting:
One hundred eighty-seven bed children's hospital.
Subjects:
All children with code events.
Interventions:
None.
Measurements And Main Results:
There were 99 codes during these two periods: 39 codes occurring prior to in-house intensivist coverage (of which eight on the ward and 31 in the ICU) and 60 occurring following in-house attending coverage (30 on the ward and 30 in the ICU). Survival was significantly improved following the implementation of in-house coverage (odds ratio, 4.3; 95% CI, 1.7-10.8; p = 0.003). There was no significant change in the overall rate of codes during these two periods (0.82 codes/1,000 patient-days before implementation vs 1.17 codes/1,000 patient-days after implementation). However, there were significantly more codes on the ward following in-house intensivist coverage (0.2 codes/1,000 patient-days before implementation vs 0.71 codes/1,000 patient-days after implementation; p = 0.013). An intensivist was significantly more likely to be present during these events (odds ratio, 28; 95% CI, 3-273; p = 0.001); however, the acuity of the children with codes on the ward was significantly lower during the in-house coverage period (p = 0.001). There were no changes in the rate or outcomes of codes occurring in the ICU with this change in coverage.
Conclusions:
In the period following implementation of in-house intensivist supervision, children with code events were more likely to survive to hospital discharge. Having an intensivist in-house 24 hr/d, 7 d/wk may be associated with improved outcomes in hospitalized children.
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