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

Abstract

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.