Pediatric Deterioration Risk Score

Thousands of hospitals have implemented rapid response systems in recent years in attempts to reduce mortality outside the intensive care unit (ICU).1 These systems have 2 components, a response arm and an identification arm. The response arm is usually comprised of a multidisciplinary critical care team that responds to calls for urgent assistance outside the ICU; this team is often called a rapid response team or a medical emergency team. The identification arm comes in 2 forms, predictive and detective. Predictive tools estimate a patient's risk of deterioration over time based on factors that are not rapidly changing, such as elements of the patient's history. In contrast, detective tools include highly time‐varying signs of active deterioration, such as vital sign abnormalities.2 To date, most pediatric studies have focused on developing detective tools, including several early warning scores.38

In this study, we sought to identify the characteristics that increase the probability that a hospitalized child will deteriorate, and combine these characteristics into a predictive score. Tools like this may be helpful in identifying and triaging the subset of high‐risk children who should be intensively monitored for early signs of deterioration at the time of admission, as well as in identifying very low‐risk children who, in the absence of other clinical concerns, may be monitored less intensively.

METHODS

Detailed methods, including the inclusion/exclusion criteria, the matching procedures, and a full description of the statistical analysis are provided as an appendix (see Supporting Online Appendix: Supplement to Methods Section in the online version of this article). An abbreviated version follows.

RESULTS

DISCUSSION

Despite the widespread adoption of rapid response systems, we know little about the optimal methods to identify patients whose clinical characteristics alone put them at increased risk of deterioration, and triage the care they receive based on this risk. Pediatric case series have suggested that younger children and those with chronic illnesses are more likely to require assistance from a medical emergency team,1112 but this is the first study to measure their association with this outcome in children.

Most studies with the objective of identifying patients at risk have focused on tools designed to detect symptoms of deterioration that have already begun, using single‐parameter medical emergency team calling criteria1316 or multi‐parameter early warning scores.38 Rather than create a tool to detect deterioration that has already begun, we developed a predictive score that incorporates patient characteristics independently associated with deterioration in hospitalized children, including age <1 year, epilepsy, congenital/genetic defects, history of transplant, enteral tube, hemoglobin <10 g/dL, and blood culture drawn in the preceding 72 hours. The score has the potential to help clinicians identify the children at highest risk of deterioration who might benefit most from the use of vital sign‐based methods to detect deterioration, as well as the children at lowest risk for whom monitoring may be unnecessary. For example, this score could be performed at the time of admission, and those at very low risk of deterioration and without other clinically concerning findings might be considered for a low‐intensity schedule of vital signs and monitoring (such as vital signs every 8 hours, no continuous cardiorespiratory monitoring or pulse oximetry, and early warning score calculation daily), while patients in the intermediate and high‐risk groups might be considered for a more intensive schedule of vital signs and monitoring (such as vital signs every 4 hours, continuous cardiorespiratory monitoring and pulse oximetry, and early warning score calculation every 4 hours). It should be noted, however, that 37 cases (26%) fell into the very low‐risk category, raising the importance of external validation at the point of admission from the emergency department, before the score can be implemented for the potential clinical use described above. If the score performs well in validation studies, then its use in tailoring monitoring parameters has the potential to reduce the amount of time nurses spend responding to false monitor alarms and calculating early warning scores on patients at very low risk of deterioration.

Of note, we excluded children hospitalized for fewer than 24 hours, resulting in the exclusion of 31% of the potentially eligible events. We also excluded 40% of the potentially eligible ICU transfers because they did not meet urgent criteria. These may be limitations because: (1) the first 24 hours of hospitalization may be a high‐risk period; and (2) patients who were on trajectories toward severe deterioration and received interventions that prevented further deterioration, but did not meet urgent criteria, were excluded. It may be that the children we included as cases were at increased risk of deterioration that is either more difficult to recognize early, or more difficult to treat effectively without ICU interventions. In addition, the population of patients meeting urgent criteria may vary across hospitals, limiting generalizability of this score.

In summary, we developed a predictive score and risk stratification tool that may be useful in triaging the intensity of monitoring and surveillance for deterioration that children receive when hospitalized on non‐ICU units. External validation using the setting and frequency of score measurement that would be most valuable clinically (for example, in the emergency department at the time of admission) is needed before clinical use can be recommended.

Thousands of hospitals have implemented rapid response systems in recent years in attempts to reduce mortality outside the intensive care unit (ICU).1 These systems have 2 components, a response arm and an identification arm. The response arm is usually comprised of a multidisciplinary critical care team that responds to calls for urgent assistance outside the ICU; this team is often called a rapid response team or a medical emergency team. The identification arm comes in 2 forms, predictive and detective. Predictive tools estimate a patient's risk of deterioration over time based on factors that are not rapidly changing, such as elements of the patient's history. In contrast, detective tools include highly time‐varying signs of active deterioration, such as vital sign abnormalities.2 To date, most pediatric studies have focused on developing detective tools, including several early warning scores.38

In this study, we sought to identify the characteristics that increase the probability that a hospitalized child will deteriorate, and combine these characteristics into a predictive score. Tools like this may be helpful in identifying and triaging the subset of high‐risk children who should be intensively monitored for early signs of deterioration at the time of admission, as well as in identifying very low‐risk children who, in the absence of other clinical concerns, may be monitored less intensively.

METHODS

Detailed methods, including the inclusion/exclusion criteria, the matching procedures, and a full description of the statistical analysis are provided as an appendix (see Supporting Online Appendix: Supplement to Methods Section in the online version of this article). An abbreviated version follows.

RESULTS

DISCUSSION

Despite the widespread adoption of rapid response systems, we know little about the optimal methods to identify patients whose clinical characteristics alone put them at increased risk of deterioration, and triage the care they receive based on this risk. Pediatric case series have suggested that younger children and those with chronic illnesses are more likely to require assistance from a medical emergency team,1112 but this is the first study to measure their association with this outcome in children.

Most studies with the objective of identifying patients at risk have focused on tools designed to detect symptoms of deterioration that have already begun, using single‐parameter medical emergency team calling criteria1316 or multi‐parameter early warning scores.38 Rather than create a tool to detect deterioration that has already begun, we developed a predictive score that incorporates patient characteristics independently associated with deterioration in hospitalized children, including age <1 year, epilepsy, congenital/genetic defects, history of transplant, enteral tube, hemoglobin <10 g/dL, and blood culture drawn in the preceding 72 hours. The score has the potential to help clinicians identify the children at highest risk of deterioration who might benefit most from the use of vital sign‐based methods to detect deterioration, as well as the children at lowest risk for whom monitoring may be unnecessary. For example, this score could be performed at the time of admission, and those at very low risk of deterioration and without other clinically concerning findings might be considered for a low‐intensity schedule of vital signs and monitoring (such as vital signs every 8 hours, no continuous cardiorespiratory monitoring or pulse oximetry, and early warning score calculation daily), while patients in the intermediate and high‐risk groups might be considered for a more intensive schedule of vital signs and monitoring (such as vital signs every 4 hours, continuous cardiorespiratory monitoring and pulse oximetry, and early warning score calculation every 4 hours). It should be noted, however, that 37 cases (26%) fell into the very low‐risk category, raising the importance of external validation at the point of admission from the emergency department, before the score can be implemented for the potential clinical use described above. If the score performs well in validation studies, then its use in tailoring monitoring parameters has the potential to reduce the amount of time nurses spend responding to false monitor alarms and calculating early warning scores on patients at very low risk of deterioration.

Of note, we excluded children hospitalized for fewer than 24 hours, resulting in the exclusion of 31% of the potentially eligible events. We also excluded 40% of the potentially eligible ICU transfers because they did not meet urgent criteria. These may be limitations because: (1) the first 24 hours of hospitalization may be a high‐risk period; and (2) patients who were on trajectories toward severe deterioration and received interventions that prevented further deterioration, but did not meet urgent criteria, were excluded. It may be that the children we included as cases were at increased risk of deterioration that is either more difficult to recognize early, or more difficult to treat effectively without ICU interventions. In addition, the population of patients meeting urgent criteria may vary across hospitals, limiting generalizability of this score.

In summary, we developed a predictive score and risk stratification tool that may be useful in triaging the intensity of monitoring and surveillance for deterioration that children receive when hospitalized on non‐ICU units. External validation using the setting and frequency of score measurement that would be most valuable clinically (for example, in the emergency department at the time of admission) is needed before clinical use can be recommended.

Thousands of hospitals have implemented rapid response systems in recent years in attempts to reduce mortality outside the intensive care unit (ICU).1 These systems have 2 components, a response arm and an identification arm. The response arm is usually comprised of a multidisciplinary critical care team that responds to calls for urgent assistance outside the ICU; this team is often called a rapid response team or a medical emergency team. The identification arm comes in 2 forms, predictive and detective. Predictive tools estimate a patient's risk of deterioration over time based on factors that are not rapidly changing, such as elements of the patient's history. In contrast, detective tools include highly time‐varying signs of active deterioration, such as vital sign abnormalities.2 To date, most pediatric studies have focused on developing detective tools, including several early warning scores.38

In this study, we sought to identify the characteristics that increase the probability that a hospitalized child will deteriorate, and combine these characteristics into a predictive score. Tools like this may be helpful in identifying and triaging the subset of high‐risk children who should be intensively monitored for early signs of deterioration at the time of admission, as well as in identifying very low‐risk children who, in the absence of other clinical concerns, may be monitored less intensively.

METHODS

Detailed methods, including the inclusion/exclusion criteria, the matching procedures, and a full description of the statistical analysis are provided as an appendix (see Supporting Online Appendix: Supplement to Methods Section in the online version of this article). An abbreviated version follows.

RESULTS

DISCUSSION

Despite the widespread adoption of rapid response systems, we know little about the optimal methods to identify patients whose clinical characteristics alone put them at increased risk of deterioration, and triage the care they receive based on this risk. Pediatric case series have suggested that younger children and those with chronic illnesses are more likely to require assistance from a medical emergency team,1112 but this is the first study to measure their association with this outcome in children.

Most studies with the objective of identifying patients at risk have focused on tools designed to detect symptoms of deterioration that have already begun, using single‐parameter medical emergency team calling criteria1316 or multi‐parameter early warning scores.38 Rather than create a tool to detect deterioration that has already begun, we developed a predictive score that incorporates patient characteristics independently associated with deterioration in hospitalized children, including age <1 year, epilepsy, congenital/genetic defects, history of transplant, enteral tube, hemoglobin <10 g/dL, and blood culture drawn in the preceding 72 hours. The score has the potential to help clinicians identify the children at highest risk of deterioration who might benefit most from the use of vital sign‐based methods to detect deterioration, as well as the children at lowest risk for whom monitoring may be unnecessary. For example, this score could be performed at the time of admission, and those at very low risk of deterioration and without other clinically concerning findings might be considered for a low‐intensity schedule of vital signs and monitoring (such as vital signs every 8 hours, no continuous cardiorespiratory monitoring or pulse oximetry, and early warning score calculation daily), while patients in the intermediate and high‐risk groups might be considered for a more intensive schedule of vital signs and monitoring (such as vital signs every 4 hours, continuous cardiorespiratory monitoring and pulse oximetry, and early warning score calculation every 4 hours). It should be noted, however, that 37 cases (26%) fell into the very low‐risk category, raising the importance of external validation at the point of admission from the emergency department, before the score can be implemented for the potential clinical use described above. If the score performs well in validation studies, then its use in tailoring monitoring parameters has the potential to reduce the amount of time nurses spend responding to false monitor alarms and calculating early warning scores on patients at very low risk of deterioration.

Of note, we excluded children hospitalized for fewer than 24 hours, resulting in the exclusion of 31% of the potentially eligible events. We also excluded 40% of the potentially eligible ICU transfers because they did not meet urgent criteria. These may be limitations because: (1) the first 24 hours of hospitalization may be a high‐risk period; and (2) patients who were on trajectories toward severe deterioration and received interventions that prevented further deterioration, but did not meet urgent criteria, were excluded. It may be that the children we included as cases were at increased risk of deterioration that is either more difficult to recognize early, or more difficult to treat effectively without ICU interventions. In addition, the population of patients meeting urgent criteria may vary across hospitals, limiting generalizability of this score.

In summary, we developed a predictive score and risk stratification tool that may be useful in triaging the intensity of monitoring and surveillance for deterioration that children receive when hospitalized on non‐ICU units. External validation using the setting and frequency of score measurement that would be most valuable clinically (for example, in the emergency department at the time of admission) is needed before clinical use can be recommended.