Association of Pediatric Early Warning Score with early intensive care unit readmission

2019-04-28Introduction: There are currently no clear guidelines to determine risk of ICU readmission when a child is transferred from intensive care units (ICU) to a Pediatric Ward. It is known that children readmitted to the ICU within a single hospital stay are at increased risk for poor clinical and financial outcomes. The development of a clinical tool to help medical staff assess a child’s risk of deterioration, requiring ICU readmission has been a common goal among pediatricians. ❧ Objective: To evaluate the association of a Pediatric Early Warning Score (PEWS) with early unplanned readmission to the Cardiothoracic Intensive Care Unit (CTICU) or Pediatric ICU (PICU) from a General Care Pediatric Ward. ❧ Study Design: Single-center case-control study at a tertiary care children's hospital. Children ≤ 18 years transferred from the PICU or CTICU to the Pediatric Ward from 1/1/10-3/30/13 were screened. Cases were defined as unplanned PICU or CTICU readmission from the Pediatric Ward within 48 hours of transfer out of the ICU. There were 84 ICU readmissions (PICU=38, CTICU=46). Those in the control group (N= 253) were not readmitted. Goal case to control ratio was 1:3. A PEWS score assigned in the PICU or CTICU (≤4 hours prior to transfer) and first PEWS assigned on the Pediatric Ward (≤4 hours after transfer) were collected for all patients. Median PEWS for cases vs. controls were compared using the Wilcoxon Rank Sum test. Logistic regression was used to calculate odds ratios and 95% confidence intervals and determine area under the receiver operating characteristic curve (ROC). ❧ Results: Age and sex were similar among cases and controls (p>0.05). Among patients with complex chronic conditions: Cardiovascular p-value= 0.001; Respiratory p-value <0.001; and Gastrointestinal p-value= 0.003, indicating PEWS parameters leading to increased likelihood of ICU readmission. PEWS prior to ICU discharge and first PEWS on the Pediatric Ward were higher for cases vs. controls, [median(IQR), 3(2,3) vs. 2(1,3); p<.001] and [2.5(2,3) vs. 2(1,3) ;p<.001], respectively. ❧ Conclusions: Higher PEWS prior to ICU discharge and first PEWS on the Pediatric Ward were associated with increased risk of unplanned ICU readmission and may help identify children at risk for early PICU or CTICU readmission. Including chronic disease components and patient origin in future iterations of PEWS scores may increase predictive ability and warrants further investigation