Pediatric Critical Care

Pediatric Critical Care Outcomes

2019

PICU Hospital-Acquired Infection Rates

2014-2019

CAUTI = catheter-associated urinary tract infection

CLABSI = central line-associated bloodstream infection

PICU Hospital-Acquired Pressure Injuries

2017-2019

Standardized Mortality Ratio, Unplanned Readmissions, and Length of Stay Ratio

2014-2019

Standardized mortality ratio (SMR) is the ratio of actual deaths to predicted deaths. The number of predicted deaths is calculated using the Pediatric Risk of Mortality III (PRISM III) score or the Pediatric Index of Mortality 3 (PIM 3) score. These are physiology-based mortality risk tools widely used to predict the intensive care outcomes of children.

An SMR of 1 indicates that observed mortality is equal to predicted mortality. An SMR > 1 suggests that more patients died than predicted using PRISM III or PIM 3, whereas an SMR < 1 indicates that fewer patients than predicted died. PIM 3 uses physiologic data from the first hour of admission to the pediatric intensive care unit (PICU). However, data from the immediate pre-ICU time frame may be used if the intensivist treated the patient before arrival to the PICU. Other variables used to calculate the PIM 3 include: the use of mechanical ventilation, whether the admission was elective, whether the patient was in the PICU primarily for postoperative recovery, the use of cardiac bypass, and the presence of certain high- and low-risk diagnoses.

PRISM III uses data from the first 12 hours of admission to the PICU to predict risk of mortality, using the most extreme values documented in the data collection time frame. Compared with PRISM III, PIM 3 is less likely to be biased by the quality of treatment after admission to the PICU, but may be subject to bias from different intervention thresholds. Utilizing PRISM III as an indicator of severity of illness, standardized length-of-stay ratios are calculated by comparing the observed with the expected length of stay.

Quality Measures2014 (%)2015 (%)2016 (%)2017 (%)2018 (%)2019 (%)
SMR based on PRISM III
Cleveland Clinic0.660.971.291.470.930.88
Reference groupᵃ0.9511.051.030.950.98

SMR based on PIM 2

In 2019, SMR was based on PIM 3, instead of PIM 2.

Cleveland Clinic0.360.670.990.900.630.72
Reference groupᵃ0.820.920.980.950.890.98
Unplanned readmissions within 24 hours
Cleveland Clinic0.731.40.851.311.141.05
Reference groupᵃ0.920.880.880.830.880.86
Standardized length of stay ratio based on PRISM III
Cleveland Clinic1.10.960.910.971.020.97
Reference groupᵃ1.111.010.990.990.94

PIM = Pediatric Index of Mortality

PRISM = Pediatric Risk of Mortality

SMR = Standardized Mortality Ratio

ᵃData obtained from Virtual PICU Systems (VPS), LLC (ww.myvps.org).

In 2019, SMR was based on PIM 3, instead of PIM 2.

Unplanned Extubations

2015-2019

An uplanned extubation is defined as dislodgement or removal of the endotracheal tube from the trachea in a patient receiving invasive mechanical ventilation at a time that was not specifically intended or ordered by a physician. ¹

Unplanned extubations were decreased by 67% in 2018.

¹Merkel L, Beers K, Lewis MM, Stauffer J, Mujsce DJ, Kresch MJ. Reducing Unplanned Extubations in the NICU. Pediatrics. 2014;133(5). doi:10.1542/peds.2013-3334.

Blood Culture Stewardship: Number of Blood Cultures per Patient-Day in the PICU

2018-2019

Recommendations to limit unnecessary blood culture testing were introduced within the PICU in October of 2019. The mean number of blood cultures during the pre-introduction period was 15.2 cultures per 100 patient-days. Following implementation, the mean number of blood cultures decreased 39.3% to 9.3 cultures per 100 patient-days. In 2019, these efforts are estimated to have avoided 277 unnecessary cultures.

MonthSample Size (n)
1/1/18688
2/1/18580
3/1/18633
4/1/18678
5/1/18673
6/1/18632
7/1/18505
8/1/18643
9/1/18657
10/1/18663
11/1/18581
12/1/18684
1/1/19666
2/1/19620
3/1/19669
4/1/19636
5/1/19594
6/1/19674
7/1/19638
8/1/19651
9/1/19593
10/1/19670
11/1/19691
12/1/19759

PICU= Pediatric Intensive Care Unit