Emergency Transfers: An Important Predictor of Adverse Outcomes in Hospitalized Children

Unrecognized in-hospital deterioration can result in tragic consequences for pediatric patients. The majority of deterioration events have antecedents such as increasingly abnormal vital signs and new concerns from nurses.¹ Recent meta-analyses have shown that rapid response systems (RRSs), which include trigger mechanisms such as a pediatric early warning score (PEWS), are associated with a reduced rate of arrests and in-hospital mortality.^2,3 Cardiopulmonary arrest rates are useful metrics to judge the effectiveness of the system to identify and respond to deteriorating adult patients; however, there are important challenges to their use as an outcome measure in pediatrics. Arrests, which have been relatively uncommon in pediatric patients, are now even less frequent since the adoption of a RRS in the majority of children’s hospitals.^4,5 Several innovations in these systems will be context-dependent and hence best first evaluated in a single center, where arrests outside of the intensive care unit (ICU) may occur rarely. Identification of valid, more frequent proximal measures to arrests may better identify the risk factors for deterioration. This could potentially inform quality improvement efforts to mitigate clinical deterioration.

Bonafide et al. at the Children’s Hospital of Philadelphia developed and validated the critical deterioration event (CDE) metric, demonstrating that children who were transferred to the ICU and who received noninvasive ventilation, intubation, or vasopressor initiation within 12 hours of transfer had a >13-fold increased risk of in-hospital mortality.⁶ At Cincinnati Children’s Hospital Medical Center, an additional proximal outcome measure was developed for unrecognized clinical deterioration, now termed emergency transfers (ETs).^7-9 An ET is defined as any patient transferred to the ICU where the patient received intubation, inotropes, or three or more fluid boluses in the first hour after arrival or before transfer.⁹ Improvement science work that aimed at increasing clinician situation awareness was associated with a reduction in ETs,⁸ but the association of ETs with mortality or other healthcare utilization outcomes is unknown. The objective of this study was to determine the predictive validity of an ET on in-hospital mortality, ICU length of stay (LOS), and overall hospital LOS.

We conducted a case–control study at Cincinnati Children’s Hospital, a free-standing tertiary care children’s hospital. Our center has had an ICU-based RRS in place since 2005. In 2009, we eliminated the ICU consult such that each floor-to-ICU transfer is evaluated by the RRS. Nurses calculate a Monaghan PEWS every four hours on the majority of nursing units.

Patients of all ages cared for outside of the ICU at any point in their hospitalization from January 1, 2013, to July 31, 2017, were eligible for inclusion. There were no other exclusion criteria. The ICU included both the pediatric ICU and the cardiac ICU.