Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, Rome, Italy.
Faculty of Health, School of Nursing and Midwifery, University of Plymouth, Plymouth, UK.
BMC Pediatr. 2022 Sep 7;22(1):530. doi: 10.1186/s12887-022-03555-0.
Escalation and de-escalation are a routine part of high-quality care that should be matched with clinical needs. The aim of this study was to describe escalation of care in relation to the occurrence and timing of Pediatric Intensive Care Unit (PICU) admission in a cohort of pediatric inpatients with acute worsening of their clinical condition.
A monocentric, observational cohort study was performed from January to December 2018. Eligible patients were children: 1) admitted to one of the inpatient wards other than ICU; 2) under the age of 18 years at the time of admission; 3) with two or more Bedside-Paediatric-Early-Warning-System (BedsidePEWS) scores ≥ 7 recorded at a distance of at least one hour and for a period of 4 h during admission. The main outcome -the 24-h disposition - was defined as admission to PICU within 24-h of enrolment or staying in the inpatient ward. Escalation of care was measured using an eight-point scale-the Escalation Index (EI), developed by the authors. The EI was calculated every 6 h, starting from the moment the patient was considered eligible. Analyses used multivariate quantile and logistic regression models.
The 228 episodes included 574 EI calculated scores. The 24-h disposition was the ward in 129 (57%) and the PICU in 99 (43%) episodes. Patients who were admitted to PICU within 24-h had higher top EI scores [median (IQR) 6 (5-7) vs 4 (3-5), p < 0.001]; higher initial BedsidePEWS scores [median (IQR) 10(8-13) vs. 9 (8-11), p = 0.02], were less likely to have a chronic disease [n = 62 (63%) vs. n = 127 (98%), p < 0.0001], and were rated by physicians as being at a higher risk of having a cardiac arrest (p = 0.01) than patients remaining on the ward. The EI increased over 24 h before urgent admission to PICU or cardiac arrest by 0.53 every 6-h interval (CI 0.37-0.70, p < 0.001), while it decreased by 0.25 every 6-h interval (CI -0.36-0.15, p < 0.001) in patients who stayed on the wards.
Escalation of care was related to temporal changes in severity of illness, patient background and environmental factors. The EI index can improve responses to evolving critical illness.
升级和降级是高质量医疗护理的常规部分，应与临床需求相匹配。本研究的目的是描述在儿科重症监护病房（PICU）入院的急性病情恶化的儿科住院患者队列中，与发生和时间相关的护理升级。
2018 年 1 月至 12 月进行了一项单中心、观察性队列研究。合格的患者为：1）入住 ICU 以外的住院病房之一；2）入院时年龄在 18 岁以下；3）入院期间至少相隔 1 小时记录了两次或两次以上床边儿科预警评分（BedsidePEWS）评分≥7，持续 4 小时。主要结局指标-24 小时处置-定义为入组后 24 小时内入住 PICU 或留在住院病房。护理升级使用作者开发的八点量表-升级指数（EI）进行测量。从患者被认为符合条件的那一刻起，每 6 小时计算一次 EI。分析使用多变量分位数和逻辑回归模型。
共纳入 228 例，计算了 574 个 EI。24 小时处置为 129 例（57%）在病房和 99 例（43%）在 PICU。在 24 小时内转入 PICU 的患者具有更高的 EI 得分[中位数（IQR）6（5-7）与 4（3-5），p<0.001]；更高的初始床边 PEWS 评分[中位数（IQR）10（8-13）与 9（8-11），p=0.02]；更不可能患有慢性病[n=62（63%）与 n=127（98%），p<0.0001]；并且医生认为发生心搏骤停的风险更高（p=0.01），而不是留在病房的患者。在紧急转入 PICU 或心搏骤停之前，EI 每 6 小时间隔增加 0.53（CI 0.37-0.70，p<0.001），而在留在病房的患者中，EI 每 6 小时间隔减少 0.25（CI -0.36-0.15，p<0.001）。
护理升级与疾病严重程度的时间变化、患者背景和环境因素有关。EI 指数可以改善对不断发展的危重病的反应。
