2004 OPEN FORUM Abstracts
EXPANDED RT ROLE IN A NEW STEP-UP UNIT AND THE IMPACT ON ICU ADMISSIONS IN A CHILDREN’S HOSPITAL
Donelly, RRT, Peter Betit, RRT, Michael Agus, MD. Children's
Hospital, Boston and Harvard Medical School, Boston, MA
Background: The demand for pediatric intensive care unit (PICU) beds in our institution has led to the development of a step-up unit (SUU). This is an intermediate care unit whose aim is to provide a higher level of care to patients whose level of acuity is not suitable for a general inpatient floor but not critical enough for the ICU. The SUU provides continuous cardio-respiratory monitoring, including ETCO2, as well as high staff: patient ratio. This four-bed unit, under medical direction, is staffed by two nurses and one critical care RRT. The RRT is depended upon for frequent patient assessment, respiratory treatment setup and delivery, and input into clinical decisions to wean or escalate therapy during twice-daily multidisciplinary rounds. Initially, main admission diagnoses included asthma, bronchiolitis, pneumonia, and diabetic keto-acidosis (DKA). We report our initial 9-month experience.
Method: We reviewed admission demographics, avoided ICU admissions, ICU transfers, and continuous aerosolized albuterol (CAA) use from 7/03 to 3/04.
Results: There were 356 patients treated in the SUU; asthma 150 (42%), bronchiolitis 56 (16%), DKA 49 (14%), pneumonia 69 (19%), metabolic disorder 18 (5%), and patients admitted for the monitoring capabilities of the SUU 13 (4%). A total of 240 (67%) patients avoided an ICU admission. Of the 150 patients with asthma, 102 (68%) avoided ICU admission of which 59 (58%) were treated with CAA and 43 (42%) with every 30-90 minute treatments. Transfer from the SUU to the ICU was required in 23 (6%) patients; 8 (35%) with asthma, and 15 (65%) with frequent episodes of desaturation associated with respiratory distress or airway compromise.
Conclusion: The expanded critical care RT role in a newly developed SUU has helped reduce the demand for ICU beds in our institution. As the program continues to develop, multidisciplinary monthly meetings are used to review patients and to evaluate statistics. ICU transfers and SUU readmissions are screened for either expected or unexpected patient clinical course and to identify opportunities to improve care. The success of the SUU has led to the expansion of admission diagnoses. Additional diagnoses include croup, toxic ingestions, obstructive sleep apnea, electrolyte abnormalities, and the initiation of BIPAP/CPAP.