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The Myth of Preventable PICU Readmissions: A Review Using a Local Clinical Database

Sunday, October 21, 2012
Room 210 (Morial Convention Center)
Brittany K. Potts, MD, Akron Children's Hospital, Akron, OH and Michael L. Forbes, MD, FAAP, Critical Care, Akron Children's Hospital, Akron, OH

Purpose:   Increased morbidity and mortality as well as increased utilization of healthcare resources are associated with unplanned ICU readmissions.  There is a current void in the literature revealing modifiable, therefore preventable, risk factors for unplanned readmissions to ICUs. 

Objectives:  The specific aims of this study were to determine (a) the temporal relationship between ICU discharge to readmission and (b) the patient characteristics and systemic elements of preventability of each event.

Methods: We reviewed a local PICU clinical database (VPS [http://www.myvps.org], paper charts, and electronic medical records of all patients with unplanned readmissions to Akron Children’s Hospital PICU from June 2009-October 2011. Data elements included all demographics, clinical course and diagnostic testing as well as severity of illness indices.  Reviewers determined preventability of readmissions, change in care plan after transfer from PICU, and failure to communicate care plan to acute care providers.  All readmissions with indeterminate preventability were analyzed as preventable.  Data analysis included descriptive statistics and Chi-squared comparisons of proportions.  Significance was defined as p≤0.05. 

Results: Data from 55 patients, representing 61 readmissions were analyzed.  One chart was excluded due to unavailability of paper charting.  Most readmissions occurred after 24 hours (78.6%) and were due to either acute respiratory (47.5%) or neurologic (21.3%) failure.   There were 7 (11%) preventable and 6 (10%) indeterminate readmissions.  One (2%) had insufficient documentation, and 47 (77%) were not preventable.  Readmissions occurring within 24 hours of transfer were almost 4 times more likely to be preventable than those occurring after 24 hours. (positive LR 3.92, 95%CI 1.35-10.58, p=0.003).  There was a difference in the proportion of readmissions among nursing units (range 9.8%-27.9%).

Conclusion:   There is a difference between early (within 24 hours) and late (after 24 hours) unscheduled readmissions.  Acute respiratory and brain failure account for nearly 80% of all readmissions.  While the majority are late, preventability is more likely with early readmissions.  Additionally, there is a disparity in likelihood of readmission as a function of the nursing unit.  Our study suggests that multiple, complex systematic elements and patient characteristics conspire to facilitate each readmission event.  The premise that all PICU readmissions are preventable is based, in part, on the assumption that a unifying systemic process failure drives all readmissions.  Presently, all PICU readmissions are reviewed with a standardized format.  Our study suggests that early and late readmissions may represent separate processes requiring unique review strategies.  Further studies are necessary to clarify systematic and patient-level drivers of PICU readmission with the goal of prevention.