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      Abnormal Vital Signs Predict Critical Deterioration in Hospitalized Pediatric Hematology-Oncology and Post-hematopoietic Cell Transplant Patients


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          Introduction: Hospitalized pediatric hematology-oncology and post-hematopoietic cell transplant (HCT) patients have frequent deterioration requiring Pediatric Intensive Care Unit (PICU) care. Critical deterioration (CD), defined as unplanned PICU transfer requiring life-sustaining interventions within 12 h, is a pragmatic metric to evaluate emergency response systems (ERS) in pediatrics, however, it has not been investigated in these patients. The goal of this study was to evaluate if CD is an appropriate metric to assess effectiveness of ERS in pediatric hematology-oncology and post-HCT patients and if it is preceded by an actionable period of vital sign changes.

          Methods: A retrospective review of all unplanned PICU transfers and floor cardiopulmonary arrests in a dedicated pediatric hematology-oncology hospital between August 2014 and July 2016. Vital signs and physical exam findings 48 h prior to events were converted to Pediatric Early Warning System-Like Scores (PEWS-LS) using cardiovascular, respiratory, and neurologic criteria.

          Results: There were 220 deterioration events, with 107 (48.6%) meeting criteria for CD, representing a rate of 2.98 per 1,000-inpatient-days. Using the first event per hospitalization ( n = 184), patients with CD had higher mortality (17.4 vs. 7.6%, p = 0.045), fewer median ICU-free-days (21 vs. 24, p = 0.011), ventilator-free-days (25 vs. 28, p < 0.001), and vasoactive-free-days (27 vs. 28, p < 0.001). Using vital sign data 48 h prior to deterioration events, those with CD had higher PEWS-LS on PICU admission ( p < 0.001), spent more time with elevated PEWS-LS prior to PICU transfer ( p = 0.008 to 0.023) and had a longer time from first abnormal PEWS-LS ( p = 0.007 to 0.043). Significant difference between the two groups was observed as early as 4 h prior to the event ( p = 0.047).

          Conclusion: Hospitalized pediatric hematology-oncology and post-HCT patients have frequent deterioration resulting in a high mortality. In these patients, CD is over 13 times more common than floor cardiopulmonary arrests and associated with higher mortality and fewer event-free days, making it a useful metric in these patients. CD is preceded by a long duration of abnormal vital signs, making it potentially preventable through earlier recognition.

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          Most cited references21

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          Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study

          Introduction When the number of patients who require intensive care is greater than the number of beds available, intensive care unit (ICU) entry flow is obstructed. This phenomenon has been associated with higher mortality rates in patients that are not admitted despite their need, and in patients that are admitted but are waiting for a bed. The purpose of this study is to evaluate if a delay in ICU admission affects mortality for critically ill patients. Methods A prospective cohort of adult patients admitted to the ICU of our institution between January and December 2005 were analyzed. Patients for whom a bed was available were immediately admitted; when no bed was available, patients waited for ICU admission. ICU admission was classified as either delayed or immediate. Confounding variables examined were: age, sex, originating hospital ward, ICU diagnosis, co-morbidity, Acute Physiology and Chronic Health Evaluation (APACHE) II score, therapeutic intervention, and Sequential Organ Failure Assessment (SOFA) score. All patients were followed until hospital discharge. Results A total of 401 patients were evaluated; 125 (31.2%) patients were immediately admitted and 276 (68.8%) patients had delayed admission. There was a significant increase in ICU mortality rates with a delay in ICU admission (P = 0.002). The fraction of mortality risk attributable to ICU delay was 30% (95% confidence interval (CI): 11.2% to 44.8%). Each hour of waiting was independently associated with a 1.5% increased risk of ICU death (hazard ratio (HR): 1.015; 95% CI 1.006 to 1.023; P = 0.001). Conclusions There is a significant association between time to admission and survival rates. Early admission to the ICU is more likely to produce positive outcomes.
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            Development of heart and respiratory rate percentile curves for hospitalized children.

            To develop and validate heart and respiratory rate percentile curves for hospitalized children and compare their vital sign distributions to textbook reference ranges and pediatric early warning score (EWS) parameters. For this cross-sectional study, we used 6 months of nurse-documented heart and respiratory rates from the electronic records of 14,014 children on general medical and surgical wards at 2 tertiary-care children's hospitals. We developed percentile curves using generalized additive models for location, scale, and shape with 67% of the patients and validated the curves with the remaining 33%. We then determined the proportion of observations that deviated from textbook reference ranges and EWS parameters. We used 116,383 heart rate and 116,383 respiratory rate values to develop and validate the percentile curves. Up to 54% of heart rate observations and up to 40% of respiratory rate observations in our sample were outside textbook reference ranges. Up to 38% of heart rate observations and up to 30% of respiratory rate observations in our sample would have resulted in increased EWSs. A high proportion of vital signs among hospitalized children would be considered out of range according to existing reference ranges and pediatric EWSs. The percentiles we derived may serve as useful references for clinicians and could be used to inform the development of evidence-based vital sign parameters for physiologic monitor alarms, inpatient electronic health record vital sign alerts, medical emergency team calling criteria, and EWSs.
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              Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review.

              For critical care to be effective it must have a system in place to achieve optimal care for the deteriorating ward patient.

                Author and article information

                Front Oncol
                Front Oncol
                Front. Oncol.
                Frontiers in Oncology
                Frontiers Media S.A.
                24 March 2020
                : 10
                : 354
                [1] 1Division of Critical Care, St. Jude Children's Research Hospital , Memphis, TN, United States
                [2] 2Department of Global Pediatric Medicine, St. Jude Children's Research Hospital , Memphis, TN, United States
                [3] 3Department of Biostatistics, St. Jude Children's Research Hospital , Memphis, TN, United States
                Author notes

                Edited by: Michele Loi, University of Colorado Denver, United States

                Reviewed by: Jhon A. Guerra, HIMA San Pablo Oncologic, United States; Yoram Louzoun, Bar-Ilan University, Israel

                *Correspondence: Asya Agulnik asya.agulnik@ 123456stjude.org

                This article was submitted to Pediatric Oncology, a section of the journal Frontiers in Oncology

                Copyright © 2020 Agulnik, Gossett, Carrillo, Kang and Morrison.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                : 30 August 2019
                : 28 February 2020
                Page count
                Figures: 2, Tables: 3, Equations: 0, References: 24, Pages: 9, Words: 6218
                Funded by: American Lebanese Syrian Associated Charities 10.13039/100012524
                Original Research

                Oncology & Radiotherapy
                pediatric oncology,pediatric intensive care,pediatric early warning system (pews),critical deterioration,emergency response systems,cardiopulmonary arrest


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