1997 OPEN FORUM Abstracts
A SCORING SYSTEM FOR PEDIATRIC ASTHMA IMPROVES APPROPRIATE ICU ADMISSION RATE
Timothy R, Myers, RRT. Carolyn Kercsmar MD and Robert Chatburn RRT. Rainbow Babies & Childrens Hospital and Case Western Reserve University, Cleveland, OH.
At our facility, appropriate pediatric intensive care unit (PICU) admissions for status asthmaticus are patients that require aerosols more frequently than Q2H. Patients treated less frequently are admitted to general divisions. All patients, regardless of setting, are placed on an inpatient care path when treatment reaches Q2H. Admission setting is based on the subjective impression of the emergency department (ED) attending physician. A retrospective analysis of 280 consecutive admissions from the ED indicated that 226 division admissions (100%) were appropriately placed. Of the 54 PICU admissions, 29 were appropriate (54%) and 25 were inappropriate (46%). Our data show inappropriately admits to the PICU from the ED have the same average length of stay (LOS) as patients admitted to our divisions (1.9 days vs. 1.8 days; p=0.9999). The average cost difference is $1,858 / patient. Objective: To determine if an assessment-based ED scoring system can make more appropriate PICU admissions for children in status asthmaticus than the current subjective admission method. Participants: All children, ages 1-16, consecutively admitted to our hospital from the ED over 5 months. Methodology: All patients were treated using an ED asthma care path, consisting of standard assessment criteria (wheeze, air exchange, accessory muscle usage, pulse oximetry and respiratory rate) and set treatment intervals (Q20 minutes). Patients that failed to respond to treatment were admitted after receiving 6 aerosol treatments or continuous aerosols for one hour. Admit destination was determined by the ED attending physician. For this study, a numerical scoring system was invented based on weighted assessment criteria. Scores were based on each patient's first and last ED assessments. Receiver operating-characteristic curves were plotted to determine the threshold value that best discriminated appropriate division and PICU admissions. A Fisher Exact test was used to compare the proportion of appropriate admissions as they actually occurred with what would have happened if admissions were based on the score. Results: A mean score of >=10.5 was found to best discriminate appropriate PICU admission. Supplemental criteria were: an increasing score (indicating worsening despite treatment) or continuous aerosol therapy. A score of < 10.5 indicated appropriate admission to the divisions. The objective scoring system would have reduced inappropriate PICU admissions from 46% to 20% compared to the current subjective physician impression (see below):
Objective Subjective p-value
PICU Admits 0.0136
Appropriate 28 29
Inappropriate 7 25
Floor Admits >0.9999
Appropriate 244 226
Inappropriate 1 0
Conclusion: The proposed objective scoring system is better at assigning appropriate PICU admissions than subjective admission decisions. Based on the average difference in hospital cost, the scoring system would have saved $33,444 (18 inappropriate admits). With an average of 140 PICU asthma admissions (46% of admits inappropriate) from the ED, the scoring system would save approximately $67,631 / year. A prospective test of the system is underway.