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Predicting unplanned readmissions to a pediatric cardiac intensive care unit using predischarge Pediatric Early
Ashley R Kroeger1, Jacqueline Morrison2, Andrew H Smith1
1Department of Pediatrics, Section of Critical Care Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA.
Insights
Pediatric Early Warning Scores (PEWS) did not reduce unplanned readmissions after pediatric cardiac intensive care unit (CICU) discharge. However, a model incorporating PEWS and other factors effectively identified at-risk patients for readmission.
Area of Science:
- Pediatric critical care medicine
- Cardiology
- Patient safety
Background:
- Unplanned readmissions to the pediatric cardiac intensive care unit (CICU) are linked to increased morbidity and mortality.
- The Pediatric Early Warning Score (PEWS) is used to identify ward patients at risk of decompensation.
Purpose of the Study:
- To evaluate if PEWS, assessed before transfer from the CICU, can predict unplanned readmissions in pediatric cardiac patients.
- To determine the effectiveness of pre-transfer PEWS in identifying patients at risk for readmission.
Main Methods:
- Retrospective analysis of patients discharged from a tertiary children's hospital CICU (September 2012 - August 2015).
- PEWS assessed post-transfer to ward; pre-transfer PEWS implemented in January 2014.
- Pre-transfer PEWS scores exceeding a threshold triggered further stability assessments.
Main Results:
- No significant reduction in unplanned readmission rates after pre-transfer PEWS implementation (10.2% vs. 9.2%).
- Cardiac-specific PEWS scores were a strong independent predictor of readmission (OR 1.78).
- A multivariate model incorporating PEWS elements showed good predictive ability for readmission (AUC 0.77).
Conclusions:
- Pre-transfer PEWS assessment alone did not decrease unplanned readmissions in this cohort.
- A multivariate model combining pre-transfer PEWS with other patient characteristics effectively identifies patients at high risk for readmission.
- Further research is needed to establish objective measures for pre-transfer discharge readiness to reduce readmissions.
Objective:
Unplanned readmission to the pediatric cardiac intensive care unit (CICU) is associated with significant morbidity and mortality. The Pediatric Early Warning Score (PEWS) predicts ward patients at risk for decompensation but has not been previously reported to identify at-risk patients with cardiac disease prior to ward transfer. This study aimed to determine whether PEWS prior to transfer may serve as a predictor of unplanned readmission to the CICU.
Design:
All patients discharged from a tertiary children's hospital CICU from September 2012 through August 2015 were included for analysis. PEWS assessment was performed following transfer to the cardiac ward, and starting in January 2014, PEWS scores were also assigned by bedside CICU nurse prior to transfer from the CICU. Scores exceeding a predetermined threshold prompted further stability assessment by provider team prior to transfer.
Results:
Among 1320 discharges of 1082 patients during the study period, there were 130 unplanned readmissions during their hospitalization. Following implementation of pretransfer PEWS scoring, there was no significant reduction in unplanned readmission frequency (10.2% vs 9.2%, P = .39). A secondary analysis of PEWS scores revealed cardiac scoring as a strong discriminator of those likely to experience an unplanned readmission, independent of other significant clinical predictors of readmission (OR 1.78, 95% CI 1.17-2.71, P = .007). The resultant multivariate model was a good predictor of unplanned readmission (AUC 0.77, 95% CI 0.71-0.83, P < .001).
Conclusion:
While implementation of a pretransfer PEWS assessment did not reduce the frequency of unplanned readmissions in this small single-center cohort, a multivariate model including pretransfer elements of an early warning scoring system, along with other patient characteristics serves as a good discriminator of patients likely to experience an unplanned readmission following CICU discharge. Further prospective investigation is needed to define objective measures of pretransfer discharge readiness to potentially reduce the likelihood of unplanned readmissions.
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