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Retrospective Cohort Study of Emergency Department to PICU Transfers: Emergency Department Factors Associated With
Tomas Leng1,2, Hanin H Ali3, Justin E McKone1
1Department of Pediatrics, Mayo Clinic Children's, Rochester, MN.
Insights
Pediatric delirium (PD) in the PICU is linked to emergency department (ED) factors like mechanical ventilation and urinary catheterization. Early delirium assessment in the ED may predict longer PICU stays and higher mortality scores.
Area of Science:
- Pediatric Critical Care Medicine
- Emergency Medicine
- Neuroscience
Background:
- Many pediatric intensive care unit (PICU) admissions originate in the emergency department (ED).
- The relationship between ED factors and the development of pediatric delirium (PD) within 24 hours of PICU admission is not well understood.
- Understanding these associations can inform early detection and intervention strategies.
Purpose of the Study:
- To investigate emergency department (ED) related factors associated with the development of pediatric delirium (PD) within 24 hours of PICU admission.
- To identify predictors of PD in critically ill children.
- To explore the correlation between initial delirium assessment scores and patient outcomes.
Main Methods:
- Retrospective cohort study conducted at a single quaternary referral center in the United States.
- Included children under 18 admitted to the PICU from the ED between January 2022 and December 2023 with positive delirium screening within 24 hours.
- Data analyzed included demographics, interventions, and delirium assessment scores (Cornell Assessment of Pediatric Delirium - CAPD).
Main Results:
- 37% (51/138) of patients developed PD within 24 hours of PICU admission.
- Mechanical ventilation (OR 3.42) and intermittent urinary catheterization (OR 3.7) in the ED were significantly associated with increased odds of PD.
- Hypoactive delirium was the most common subtype (53%).
Conclusions:
- Mechanical ventilation and intermittent urinary catheterization during ED presentation are associated with a higher likelihood of developing pediatric delirium (PD) within 24 hours of PICU admission.
- Initial CAPD scores correlate positively with PICU length of stay and Pediatric Index of Mortality 3 (PIM 3) scores.
- Initial CAPD scores negatively correlate with the Emergency Severity Index (ESI) in the ED, suggesting a potential role for early delirium screening in risk stratification.
Objectives:
Many PICU admissions start with presentation in the emergency department (ED). However, we do not know whether there are any ED-related factors associated with the subsequent development of pediatric delirium (PD) within 24 hours of PICU admission.
Design:
Retrospective cohort study.
Setting:
Single-center ED and PICU serving a quaternary referral center in the United States.
Patients:
Children younger than 18 years old presenting to the ED between January 2022 and December 2023 who required direct admission to the PICU, and who had at least one positive delirium screening within 24 hours of the admission.
Interventions:
None.
Measurements And Main Results:
The presence of delirium in the PICU was defined as a Cornell Assessment of Pediatric Delirium (CAPD) score of 9 and higher. We identified 138 patients for the final analysis. Overall, 51 of 138 patients (37%) developed PD within 24 hours of admission. The majority of delirium cases were classified as hypoactive (53%, 27/51) and mixed (31%, 16/51) subtypes, while only 16% (8/51) were identified as hyperactive delirium. Factors associated with greater odds (95% CI) of delirium in the PICU in multivariable analysis were use of mechanical ventilation (odds ratio [OR], 3.42 [95% CI, 1.09-10.78]; p = 0.04) and intermittent urinary catheterization (OR, 3.7 [95% CI, 1.21-11.30]; p = 0.02). Initial CAPD score positively correlated with PICU length of stay (LOS; r = 0.32; p < 0.01), Pediatric Index of Mortality 3 (PIM 3) score ( r = 0.26; p < 0.01), and negatively correlated with emergency severity index (ESI) in the ED ( r = -0.35; p < 0.01).
Conclusions:
Mechanical ventilation and intermittent urinary catheterization in the ED are associated with greater odds of PD within 24 hours of PICU admission. CAPD at admission positively correlates with PICU LOS, PIM 3 scores, and negatively correlates with ESI in the ED.
