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Variation in Triage to Pediatric vs Adult ICUs Among Adolescents and Young Adults With Asthma Exacerbations
Burton H Shen1, Aaron C Dobie1, Sara L Shusterman1
1Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
Insights
Hospitals often admit young patients with severe asthma exacerbations to pediatric intensive care units (PICUs) until age 18. After 18, triage shifts significantly toward adult intensive care units (ICUs).
Area of Science:
- Pediatric critical care medicine
- Adolescent health
- Respiratory medicine
Background:
- Severe asthma exacerbations lead to over 90,000 US hospitalizations annually.
- A significant portion (5-34%) of these hospitalizations require intensive care unit (ICU) admission.
- Triage practices for adolescents and young adults with severe asthma between pediatric (PICU) and adult ICUs are not well understood.
Purpose of the Study:
- To investigate how US hospitals triage adolescents and young adults (ages 12-26) with asthma exacerbations between PICUs and adult ICUs.
- To characterize the factors influencing ICU admission decisions for this patient population.
Main Methods:
- Retrospective cohort study using the PINC AI database (2016-2022).
- Included 3,946 admissions from 93 hospitals for patients aged 12-26 with asthma exacerbations admitted to a PICU or adult ICU.
- Nested hierarchical multivariable regression models were used to assess variation in triage decisions.
Main Results:
- A notable decrease of 26.9% in PICU admissions occurred between ages 17 and 18.
- Intraclass correlation coefficient (ICC) analysis revealed that age was a significant factor in triage decisions.
- The ICC decreased substantially from 28.7% (empty model) to 4.5% (age-adjusted model), indicating age as a primary determinant.
Conclusions:
- Age 18 or younger is a strong predictor for PICU triage in severe asthma exacerbations.
- Further research is necessary to explore disparities in care and outcomes between PICUs and adult ICUs.
- Investigating the role of intermediate care units in triage decision-making is also warranted.
Background:
More than 90,000 children and adults in the United States are hospitalized with an asthma exacerbation annually, and between 5% and 34% of these hospitalizations include admission to an ICU. It is unclear how adolescent and young adults with severe asthma exacerbations are triaged in the inpatient setting between PICUs and adult ICUs. Using a large multicenter US cohort, we characterized how hospitals triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs.
Research Question:
How do hospitals across the United States triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs?
Study Design And Methods:
This was a retrospective cohort study carried out from 2016 through 2022 using the enhanced-claims PINC AI database. Participants were patients aged 12 to 26 years who were hospitalized with an asthma exacerbation and admitted to a PICU or adult ICU. We used nested hierarchical multivariable regression models to quantify changes in the intraclass correlation coefficient (ICC; a measure of variation in triage decisions attributable to hospital of admission after accounting for covariables).
Results:
Analyses included 3,946 admissions from 93 hospitals. Stratified by age, the percent of patients admitted to PICUs dropped by 26.9% between 17 and 18 years of age. In the nested models, the ICC showed a large decrease going from the empty model (28.7%) to the age-adjusted model (4.5%), but was similar between the age-adjusted and fully adjusted model (3.4%).
Interpretation:
Our results showed that among adolescents and young adults with asthma exacerbations, age of 18 years or younger was a strong determinant of PICU triage. Further research is needed to understand differences in asthma care and outcomes between PICUs and adult ICUs, as well as how intermediate care units affect triage decision-making from wards and the ED.
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