Andrew Argent Criteria for admission and refusal to PICU

Criteria for admission andrefusal for PICUAndrew C ArgentRed Cross War Memorial Children’s Hospital andUniversity of Cape Town

introduction• triage– primarily about allocation of resources– prioritization of the sickest• but sometimes may need to limit admission of thosewho are the sickest, but have the highest risk of dyingdespite the allocation of resources– prioritization of those most likely to benefit• elective procedure vs. emergency admission• overall context of health servicerationing is universalRudolf Klein, King's Fund BMJ 1998

Land MassChildrenworldmapper.com

HIVMortality1-4 yearsworldmapper.com

ChildrenPublic HealthExpenditureworldmapper.com

PICU at the RCWMCH• 300 bed children’s hospital• 20 (18-22) bed multidisciplinary PICU• 1100-1300 patients per annum– 700+ paediatric emergencies– 210 elective cardiac surgical cases– 200 elective surgical cases– 30 – 40 major burns– 30 - 40 Road traffic accidents (mostly head injury)

PICU at the RCWMCH – staffing• medical staff:– 4 consultants (3 for last year)– 2-4 fellows (2 funded posts)– 4 registrars and 2 medical officers (outside help forafter hours)• nursing staff– approximately 60 registered nurses (20 with ICUtraining)– approximately 40 enrolled and auxiliary nurses

the challenge• not enough beds to admit all referred patients• maintaining a patient throughput that– meets the patient needs– allows an “adequate” standard of care withreasonable risks of adverse events– does not burn out the staff• optimize the utilization of resources to provideoptimal benefit

the good we aim to achieve• monitoring of high risk patients to rapidly identify lifethreateningproblems– early intervention to prevent major complications• provision of life support therapy– ventilation– circulatory support– other organ system support• provision of definitive diagnosis and therapy – allow majorsurgical intervention• return children to healthwhere does palliative care fit in?

…. a fundamental concept is that the aim of intensive supports isnot to treat symptoms or to cure diseases, but to care for thepatient. The object (better, the subject) of the curing/caringprocess is always the patient. The intensive supports should beused as long as they are useful to the patient, according to her/hiswishes and project of life.The way things are done can be at least as important as thespecific content of every action. In particular, the decisionshould be clear, known, and shared by all the involved subjects,

can we do harm?• is it possible that we prolong or create suffering?– for the child– for the family• do we really understand the long-term impact of the PICUstay?• adverse events in the PICU• what is the impact of the PICU on the rest of the institution?• what about the staff who work in intensive care?

use of resourcesDiscipline Count % Averagedurationof stay% beddaysMortalityPaediatrics 411 54.44 5.4 66.61 15.6Cardiac 107 14.17 3.92 12.59 3.74Thoracic 16 2.12 3.8 1.82 0Abdominalsurgery 63 8.34 1.96 3.71 1.5Neurosurgery 26 3.44 3.11 2.43 0Other surgeryincludingaccidentsand burns 65 8.61 4.7 9.17 13.8

the response …• development of a policy• dissemination of the policy throughout theinstitution and through the health system• ongoing monitoring• feedback and response

agreement on the principles• is this in the child’s best interest– who makes that decision– we need the best available information• there has to be equity of access– geographical– discipline– emergency vs elective• there has to be a sense of fairness– for patients– within the health system

who should be admitted?anyone who can benefit fromwhat we have to offer

who should not be admitted• care deemed futile– admission to PICU will not affect final outcome• underlying lethal condition– even if they survive this admission to PICU, they will die sooner ratherthan later• currently poor outcome– in our hands these patients do badly(this is problematic in the sense of developing new therapy and approachto management)• the child who is “too well”concerns regarding the development of alternative care plans

when should life-sustaining therapyNOT be offered?• These situations include– the brain dead child– the child in permanent vegetative state– the “no chance” situation– the “no purpose ” situation– the “unbearable ” situationWithholding Or Withdrawing Life Sustaining Treatment inChildren. A Framework for Practice. Royal College ofPaediatrics and Child Health. 2004

underlying lethal condition …• this is not a static concept– HIV• initial• current• what is the data?• what do we aim to do– palliation is a perfectly reasonable reason foradmission

20022003(16 m)2006 2007 2011Exposed 136 96 79 63 42Infected 118 68 43 34 60ICU survival(% infected)73 75 74 70Hospital survival(% infected)Alive and at Followup or transferred(%)Lost to follow up(%)46 51 51 ± 6514 19 5532 5where to now?Sean Barnabus

currently poor outcome• in our hands these patients do really badly– kwashiorkior with severe sepsis– AVSD with pulmonary stenosis• do we have the data?– or how will we collect it?• these patients are not always that clearly defined• are we simply maintaining the status quo – with nochance of improvement

the child who is too well• where is the margin?• is there a margin of safety• do we understand the risks in particularpatients and in particular conditionsthe closer we operate to the marginsthe higher the probability ofcatastrophic error

the review

issues on implementation• dissemination of information on ongoing basis• consistency of application of policy• feedback (or lack of … from clinicians)• concerns about quality of palliative care• failure to address resource issues– attempts have been made but ….recurrent pressures to “ring-fence” beds

patients referred to PICU• all patients referred to PICU for possibleadmission over a 6 month period• reviewed both decision on admission andreason for that decisionn %accepted 618 80.9refused 146 19.1total 764Ahrens et al, unpublished data

easons for refusalsn %no beds 95 65.1futility 20 13.7too ill 5 3.4not ill enough 26 17.8total 146Ahrens et al, unpublished data

what happened to the patients?Acceptedpatients% Futile /AIDS%Not illenough%Nobedsnobeds%2 10 18 69.23 62 76.5Discharged 420 69.8p

admittedrefused

data with PIM2Year Admissions Deaths MortalityPIM2Risk(ave)PIM2 Risk(median)SMR2006 1074 114 0.106 0.138 0.058 0.762007 1067 131 0.122 0.1388 0.053 0.882008 1330 139 0.104 0.129 0.059 0.812009 1141 141 0.124 0.131 0.742010 1265 115 0.090 0.132 0.056 0.68(2011) 943 79 0.083 0.135 0.052 0.62

PICU data on treatment of septic shockMedian time (minutes )from RCWMCHpresentation toACCM/APLS guidelines(minutes)1 st fluid bolus 52 5intubation 135 15starting inotropes 217 15PICU admission 240 60Median time (minutes)from RCWMCH PICUadmission to1 st fluid bolus 15intubation 301 st dosehydrocortisone1140 60Rossouw et al, unpublished data, 2011

what happens to our patients?• ventilator associated pneumoniaMorrow et al, Pediatr Crit Care Med, 2011Morrow & Argent, J Paediatr Child Health, 2009Morrow et al, J Paediatr Child Health, 2006Figaji et al, Childs Nerv Syst, 2009• other studies including nosocomial infection,fluid, cardiac patientsHatherill et al, Intensive Care Med, 2007Hatherill et al, Arch Dis Child, 2005

A 4 RDaniels and Sabin, Health Affairs, 1998Martin and Singer, Health Care Analysis, 2003

Duty to provide careEquityTrustTransparencyConsistencyInclusivenessResponsivenessAccountabilityThe process was an attempt to provide care to as many children as possible,within the resources available. In South African law the principle has beenestablished that the health care services cannot provide all services to allpeople (Subramoney case)No particular groups were excluded. In fact attempts were made to improveaccess to care for children from outside the major teaching hospitals.Development of trust in the system is an ongoing concern and will have to bereviewed and assessedThe process was open to comment, and was made public to clinicians andmanagers within the health system. It was not transparent to the generalpublic, or to specific groups of people who were potentially (or actually)affected by the process. Where possible the rationale behind specificexclusions was provided in the documentationImplementation of a specific policy improved overall consistency, butindividual consultants were aware of some variability in their implementationof the policyThe process was focused primarily on health professionals, and there was notadequate involvement of other stakeholdersThere were mechanisms within the system to respond to changes incircumstances, and there were mechanisms established to appeal againstspecific decisions.The clinicians whose patients were affected by the process had everyopportunity to appeal against decisions. In reality this happened very rarely.Managers and administrators were given details of the implications of theresources available and the attempts to use those resources appropriately.

and the staff …

conclusions• it is essential to optimize utilization of PICUresources– we have to be accountable for the resources that weuse• the A4R process may be a useful process– clarify for ourselves and for others what it is that wedo and why• need to balance the processes for control ofpolicy and implementation