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Prediction of Pediatric Critical Care Resource Utilization for Disaster Triage
Elizabeth Y Killien1,2, Brianna Mills2, Nicole A Errett3
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA.
Insights
Pediatric illness severity scores can predict intensive care needs. A model using the 12-hour Pediatric Logistic Organ Dysfunction score accurately estimated resource use, aiding disaster triage.
Area of Science:
- Pediatric critical care medicine
- Health services research
- Disaster preparedness
Background:
- Pediatric disaster triage protocols lack validation data.
- The 2011 Pediatric Emergency Mass Critical Care Task Force recommended incorporating critical care duration into resource allocation.
- Existing pediatric illness severity scores may predict critical care resource utilization.
Purpose of the Study:
- To determine if current pediatric illness severity scores can predict the duration of critical care resource use.
- To develop and validate predictive models for pediatric intensive care unit (PICU) resource allocation during mass critical care events.
Main Methods:
- Retrospective cohort study of 3,206 PICU patients admitted to Seattle Children's Hospital from 2016-2018.
- Logistic and linear regression models were developed using two-thirds of the cohort to predict the need for and duration of PICU resources.
- Models utilized Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores, validated on the remaining one-third of the cohort.
Main Results:
- The 12-hour Pediatric Logistic Organ Dysfunction score demonstrated higher predictive accuracy than Pediatric Risk of Mortality or Pediatric Index of Mortality scores.
- A model incorporating the 12-hour Pediatric Logistic Organ Dysfunction score, age, and other clinical factors achieved an area under the receiver operating characteristic curve of 0.8831 for predicting the need for any PICU resource and 0.9157 for mechanical ventilation.
- Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and mechanical ventilation for 83.1%.
Conclusions:
- A model incorporating the 12-hour Pediatric Logistic Organ Dysfunction score effectively estimates the duration of PICU resource needs, particularly mechanical ventilation.
- Integrating likelihood for survival and critical care resource requirements into pediatric disaster triage algorithms can reduce subjectivity in resource allocation.
Objectives:
Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use.
Design:
Retrospective cohort study.
Setting:
Seattle Children's Hospital.
Patients:
PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206).
Interventions:
None.
Measurements And Main Results:
We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay.
Conclusions:
A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.
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