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A Cross-sectional Survey of Levels of Care and Response Mechanisms for Evolving Critical Illness in Hospitalized Children

Departments of ^a Critical Care Medicine
^c Pediatrics
^b Centre for Safety Research
Programs of ^g Child Health Evaluative Sciences
^d Integrative Biology, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
Departments of ^h Health Policy, Management, and Evaluation
^e Pediatrics
^f Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada

	ABSTRACT

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OBJECTIVES. Recognition and treatment of evolving critical illness is a fundamental element of hospital care. Hospital systems should triage patients to receive appropriate levels of care. We describe here the levels of care, the frequency of near or actual cardiopulmonary arrest (code-blue events), identification mechanisms, and responses to evolving critical illness in hospitalized children.

METHODS. A cross-sectional telephone survey of Canadian and American hospitals with 50 pediatric acute care beds or 2 pediatric wards was performed. Regression analysis identified factors associated with the frequency of code-blue events after adjustment for hospital volume.

RESULTS. Responses from 388 (84%) hospitals identified the 181 eligible pediatric hospitals included in this survey. All had a PICU, 99 (55%) had high-dependency units, 101 (56%) had extracorporeal membrane oxygenation therapy, and 69 (38%) used extracorporeal membrane oxygenation therapy for refractory cardiopulmonary arrest. All of the hospitals had immediate-response teams. They were activated 4676 times in the previous 12 months. Twenty-four percent of hospitals had activation criteria for immediate-response teams. Urgent-response teams to treat children who were clinically deteriorating but not at immediate risk of cardiopulmonary arrest were available in 136 (75%) hospitals; 29 (17%) had formal medical emergency teams, and 92 (51%) consulted the PICU. Code-blue events were more common in hospitals with extracorporeal membrane oxygenation therapy, cardiopulmonary bypass, and larger PICU size.

CONCLUSIONS. Currently, the organization of Canadian and American pediatric hospitals includes dedicated areas to match patient acuity and additional personnel to stabilize and facilitate transfer. The functioning of these systems of care results in calls for immediate medical assistance for ward patients 5000 times annually.

Key Words: resuscitation • medical emergency team • cardiopulmonary arrest

Abbreviations: HDU—high-dependency unit • MET—medical emergency team • ECMO—extracorporeal membrane oxygenation therapy • ECPR—extracorporeal cardiopulmonary resuscitation • IQR—interquartile range • PMET—pediatric medical emergency team

The recognition and treatment of children admitted to hospital wards with evolving critical illness is a fundamental element of hospital care. The ultimate consequence of incomplete recognition or ineffective treatment is cardiopulmonary arrest.^1–3 High mortality and neurocognitive morbidity in survivors makes cardiopulmonary arrest extremely undesirable. Near arrest is also associated with considerable morbidity and hospital mortality.^4–6

Multiple safeguards exist to prevent and treat cardiopulmonary arrest including the frontline care provided by ward nurses and physicians, the closer observation and advanced therapies possible in high-dependency units (HDUs), and the invasive monitoring and pharmacologic and mechanical therapies available in ICUs. Broad guidelines exist for the admission of children to HDUs and ICUs; however, inspection reveals that these guidelines are not well suited for decision-making in individual patients.^7–9

Acute management and transitions between levels of care for the child who is clinically deteriorating can be facilitated by ward nurses and physicians, the use of urgent-response teams, such as medical emergency teams (METs),¹⁰ and in cases of immediate medical need by formal resuscitation ("code-blue") teams. The purpose of urgent-response teams is to provide required care to improve the child's condition, thus preventing the need for escalation in the level of care, to facilitate timely admission to the HDU or ICU, or to discuss appropriate end-of-life care. METs have been widely implemented in adult hospitals despite limited evidence to support their introduction.^5,11 The current frequency of implementation of METs and other urgent-response mechanisms in pediatric hospitals is unknown. To better understand current practice in large- and medium-sized North American pediatric hospitals, we conducted a cross-sectional survey to describe the available levels of care and response mechanisms to evolving critical illness in children.

	METHODS

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A telephone survey was designed, pretested, and administered to clinician administrators in Canadian and American acute care pediatric hospitals. Its purpose was to describe the number and capacity of the levels of care provided in the hospital, the types of response teams for children who were recognized to be clinically deteriorating, their composition, and frequency of activation. Eligible hospitals had 2 (nonneonatal) pediatric wards and/or 50 acute inpatient beds for patients aged 18 years of age.

Survey Development
The questionnaire was developed by 2 investigators (Ms VandenBerg and Dr Parshuram) and consisted of 42 questions. The levels of care available in each hospital were documented by asking respondents about the numbers of acute care, HDU and ICU beds, and the availability of pediatric cardiopulmonary bypass, extracorporeal membrane oxygenation therapy (ECMO), and the use of ECMO, through extracorporeal cardiopulmonary resuscitation (ECPR), to restore circulation in children with refractory cardiopulmonary arrest.

Respondents were asked to describe the availability, composition, activation criteria, and frequency of activation for "immediate" (code-blue or cardiac arrest) and "urgent" response teams. We defined immediate (code-blue) response teams as those who were called to treat ward patients with impending or actual cardiopulmonary arrest. Urgent-response teams were defined as those who treated ward patients who were appreciated to be clinically deteriorating but who were not at risk of imminent cardiopulmonary arrest. When a hospital had 1 team functioning as both the immediate and urgent-response team, the team was classified as an immediate-response team, and the composition of the urgent-response team was described as a code-blue team. Ward patients were defined as all of the hospital inpatients aged 18 years who were cared for outside the ICU, operating room, or delivery room areas. The survey was reviewed by members of the Canadian Critical Care Trials Group for content and face validity and was pretested in 5 health care professionals representing 5 different hospitals.

Hospital Identification
A database of potentially eligible hospitals was created from an existing database of the investigators,¹² Internet searches for hospitals by province or state, and local knowledge of respondents in surveyed hospitals. The American Hospital Directory¹³ was searched to identify freestanding pediatric hospitals and general hospitals with >450 acute care beds. These were included in the list of hospitals to be contacted.

Survey Administration and Data Collection
The survey was administered by telephone. The informed respondents included resuscitation committee chairs, pediatric intensive care directors, and acute care clinical nurse specialists. Contact with potential respondents was either made directly, or telephone appointments were made. The professional background and administrative position of the respondent and the number of contact episodes were recorded. We did not ask respondents to specify the source of their information.

Analysis
The data about levels of care and response teams were represented by median and interquartile ranges (IQRs). Linear regression analyses were performed to evaluate the association of the occurrence of urgent and immediate-response teams with available level of care and response team variables. The number of acute care beds was kept in all of the models to control for the effect of hospital volume. The raw data from the survey data were entered into a custom-made Microsoft Access Database (Redmond, CA) and were analyzed using SAS 9.1 (SAS Inc, Cary, NC).

	RESULTS

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The survey was conducted over an 8-week period ending July 26, 2005. A total of 464 eligible North American hospitals from 51 states or commonwealths of the United States of America and 12 provinces of Canada were identified and contacted. Responses were received after 1091 contact episodes with 964 health care professionals from 388 hospitals, for a response rate of 84%. The main reason for nonresponse was failure to contact the potential respondent directly. Of the responding hospitals, 181 (47%) hospitals met inclusion criteria; 16 (8%) were Canadian hospitals; 165 (92%) were American; and 85 (47%) were freestanding pediatric acute care hospitals. These hospitals represented 24874 acute care pediatric beds, composed of 6861 NICU, 2811 PICU, 715 HDU, and 14487 general beds. The primary respondents from these hospitals were PICU staff physicians or chairs of code-blue committees in 87 hospitals (48%) and acute care nurse specialists in the remaining 103 hospitals (52%).

Levels of Care
All 181 of the hospitals had a PICU, 170 hospitals (94%) had a NICU, 99 (55%) had an HDU, 108 (60%) had cardiopulmonary bypass, 101 (56%) used ECMO, and 69 (38%) used ECMO for ECPR. The median number of acute care beds was 113 (Table 1). There were 64 hospitals (35%) with 150 acute care beds.

Urgent-Response Mechanisms
The child who was appreciated to be clinically deteriorating but was not at risk of imminent cardiopulmonary arrest was treated by a team other than the primary service in 136 hospitals (75%). These urgent-response personnel were staff from the PICU in 92 (51%), a team identified as a pediatric MET (PMET) in 29 (17%), the pediatric code-blue team in 14 (8%), and an adult MET in 1 (0.6%) of the hospitals surveyed. Having a specific PMET was not associated with the numbers of acute care beds (P = .85), PICU beds (P = .65), HDU beds (P = .47), or with hospitals having cardiopulmonary bypass (P = .62), ECMO (P = .95), or using ECPR (P = .29).

The 29 PMETs were composed of 1 to 9 members, with a median number of members of 3 (IQR: 1–6) in the day and 2.5 (IQR: 1–5) at night (P = .13). In the daytime there were 12 "teams" with 1 member. These were staff physicians (n = 9), registered nurses (n = 2), and a pediatric resident (n = 1). Two of the 29 hospitals provide PMET only during the day. There were 9 single-member teams composed of staff physicians (n = 5), registered nurses (n = 2), and pediatric residents (n = 2). There was a designated leader in all but 1 team, and a designated airway staff in 14 teams (Table 2). Team members were required to have a formal pediatric resuscitation qualification in 27 hospitals (93%).

Urgent-response personnel were called a median of 48 times per year (IQR: 12–144). This was not associated with the number of acute care, HDU, or PICU beds or the number of code-blue events per year (all P > .47).

Immediate-Response Teams
A team was organized to respond to a call for immediate medical assistance to treat near or actual cardiopulmonary arrest in all of the hospitals. Formal pediatric resuscitation teams were used in 173 hospitals (96%). The remaining 8 hospitals used either an adult cardiac arrest team (n = 2) or an informal pediatric team (n = 6). Immediate-response teams had 2 to 15 members, 169 (98%) had a predesignated leader, and 159 (91%) had predesignated airway staff. The median team size was 7 (IQR: 5–9) at night and 8 (IQR: 6–9) in the day (P < .0001). At night there were fewer teams with a staff physician (76 vs 41; P < .0001; Fig 1). Training for immediate-response teams occurred in 173 hospitals (96%). The median frequency of training was 12 (IQR: 4–12) times per year. The maximum training frequency was twice per week.

View larger version (21K): [in this window] [in a new window]   FIGURE 1 The total number of staff physicians attending in code-blue teams in the daytime and at night. Data are from a survey of 181 North American hospitals with 50 pediatric acute care beds and 2 pediatric wards.

View larger version (20K): [in this window] [in a new window]   FIGURE 2 Hospital size and the number of near or actual cardiopulmonary arrests per annum. Data are from a survey of 181 North American hospitals with 50 pediatric acute care beds and 2 pediatric wards. These hospitals had 24874 acute care beds and had 4676 code-blue events per year. The histogram shows the total number of calls to the immediate-response team of each hospital per year.

	DISCUSSION

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Our survey provides a cross-sectional description of large- and medium-sized pediatric hospitals in Canada and the United States. We found that comprehensive infrastructure existed in the 181 hospitals surveyed. All had 2 levels of care (ward, HDU, PICU, and ECMO) to deliver care to children as determined by their severity of illness. Children admitted to hospital wards who were clinically deteriorating could be treated by their primary service in all and by urgent-response personnel in 75% of hospitals. Children who had progressed to near or actual cardiopulmonary arrest were treated by immediate-response (code-blue) teams in all of the hospitals.

Despite this comprehensive system of care, code-blue teams were activated 5000 times each year to provide immediate treatment for children with near or actual cardiopulmonary arrest. This represents a significant source of acquired morbidity and mortality,^4–6 which may be preventable.^14,15 Assuming a bed occupancy of 80%, this translates into a mean of 0.71 events per 1000 bed days. With bed occupancy at 100%, the event rate is 0.52 events per 1000 patient days. These rates are lower than the 1.5 code-blue events per 1000 patient days in our center.¹⁴

The reasons for the disconnect between the existing systems of care and the high frequency of near or actual cardiac arrest are likely to be complex.¹⁶ Several explanations may be extrapolated from our data. First, we found 3 hospital characteristics that were associated with the frequency of calls for immediate medical assistance to treat near or actual cardiopulmonary arrest. Hospitals with cardiopulmonary bypass, ECMO, and those with larger PICUs may tend to care for children who are, on average, more complex and at higher risk for clinical deterioration.

Unlike the ACADEMIA (Antecedents to Cardiac Arrests, Deaths, and Emergency Intensive Care Admissions in Australia and New Zealand) investigators, we found that hospitals with more PICU beds had more frequent code-blue events.¹⁷ Several factors associated with larger PICUs may explain this finding; the patients in inpatient wards of hospitals with larger PICUs may be sicker; the health care professionals working outside the PICUs of hospitals with greater centralization of critical care expertise may be either relatively deskilled or have a higher threshold for calling for help; and the movement of patients between the inpatient wards and the PICU may be relatively inefficient, or premature ICU discharges may be more common in larger hospitals. Other factors, including patient acuity, the nurse/patient ratio, and local arrest or near-arrest reporting practices may be important determinants that were not measured in this survey.

Having an MET or HDU beds was not associated with lower rates of near or actual cardiopulmonary arrest. It seems reasonable to suggest that hospitals with higher baseline (pre-MET) rates of near or actual cardiopulmonary arrest are more likely to have either implemented a MET team or to have an HDU. However, it cannot be assumed that METs are effective in the light of limited pediatric data¹⁵ and a negative-cluster randomized trial of 120000 adult admissions in 23 hospitals.⁵ Despite this, an additional 23 hospitals (13%) reported that they were in the process of developing a PMET.

Second, we found that less than a quarter of hospitals had specific criteria to identify patients in need of referral to urgent and immediate-response teams. Delays in the identification and referral of patients with evolving critical illness to response teams in hospitals with and without identification criteria have been described previously.⁵ The MET calling criteria listed by respondents were generally subjective and imprecise (unstable vital signs and decreasing oxygen saturation). Items such as "clinical concern," judgment, and experience can also be used to identify sick patients.^18,19 Although this approach is widely used, it has not eradicated the need for immediate assistance to prevent cardiopulmonary arrest in this and other reports.^15,20–22

Third, diurnal staffing patterns of hospital inpatient wards may be contributing to the frequency of near or actual cardiopulmonary arrest. We found reduced staffing of code-blue and intermediate-response teams at night versus the day and, specifically, reductions in the inclusion of staff physician(s) on the team. Although the delivery of health care is predominantly organized on a Monday to Friday daytime basis,^23,24 critical illness is a 24-hour, 7-day phenomenon. Reduced hospital staffing at night is likely to increase rather than decrease the need for staff to respond to children who are clinically deteriorating and to increase the risk of adverse events, such as cardiopulmonary arrest.

Finally, it may be that the roles of urgent and immediate-response teams are merging. Formal resuscitation teams, such as the code-blue team, may already be performing the role anticipated of the MET or vice versa. This phenomenon was described in the Australian adult MET study⁵ and in 1 pediatric hospital.¹⁵ Our data taken with recent data from the National Registry of Cardiopulmonary Resuscitation²¹ suggest that the proportion of code-blue calls that are for children with actual cardiopulmonary arrest is probably small. In turn, this suggests that the roles of pediatric MET and code-blue teams may have significant overlap.

	LIMITATIONS

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There are several limitations to this survey. First, this cross-sectional survey was administered by telephone to voluntary respondents. Respondents had limited time to confirm the data that they provided, and the investigators did not verify the accuracy of the responses, nor did we ask the source of the data on which the response was based. However, respondents were senior clinician administrators, from physician and nursing backgrounds, thus, we believe that the information is likely to be representative in each institution. Second, the results may not be generalizable to other hospitals. The 84% response rate suggests that the results are likely to be representative of large- and medium-sized pediatric hospitals; however, they may not apply to hospitals with <50 beds or in other cultural and geographic areas. Third, our data are cross-sectional, and we are unable to provide information about the temporal trends in pediatric inpatient resuscitation. Finally, whereas it can be argued that immediate calls for medical assistance are a manifestation of system failure, the clinical significance of late recognition and treatment of critical illness in children has not been well quantified.¹⁵ Previous work suggests that adults and children can be identified well before near or actual cardiopulmonary arrest^14,25–27 and that "near" cardiac arrests are associated with morbidity and mortality.^4,6 However, further work is required to evaluate the clinical impact of timely identification and referral of children with evolving critical illness to urgent-response teams.

	CONCLUSIONS

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This cross-sectional survey of 181 North American pediatric hospitals found that the infrastructure exists to meet the requirements that the spectrum of disease severity anticipated in hospitalized children. The systems of care included specific response personnel to facilitate that transfer of sicker children to higher levels of care in three quarters of hospitals. Calls for immediate medical assistance were made 5000 times in the preceding year. Reorganization of current systems of care is required if cardiopulmonary arrest is to be prevented and the outcomes of hospitalization improved.

	ACKNOWLEDGMENTS

 
Ms VandenBerg was in part supported by the Samuel Lunenfeld Summer Research Program. The Pediatric Early Warning System research program is supported by Heart and Stroke Foundation of Canada grant NA 5380. Dr Parshuram is a Career Scientist of the Ministry of Health and Long Term Care of Ontario.

The Pediatric Early Warning System investigators are Jacques Lacroix and Catherine Farrell (Sainte-Justine, Montreal, Quebec, Canada); Ari Joffe (Stollery Children's Hospital, Edmonton, Alberta, Canada); Heather Duncan (Birmingham Children's Hospital, Birmingham, England); and James Hutchison, Patricia Parkin, Joseph Beyene, and Christopher Parshuram (Hospital for Sick Children, Toronto, Ontario, Canada).

	FOOTNOTES

 
Accepted Oct 23, 2006.

Address correspondence to Christopher S. Parshuram, MBChB, DPhil, Department of Paediatric Critical Care Medicine, Child Health Evaluative Sciences Program, Research Institute, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. E-mail: christopher.parshuram{at}sickkids.ca

The authors have indicated they have no financial relationships relevant to this article to disclose.

	REFERENCES

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