Reducing PICU Mortality in Resource-Limited Settings.

Discharge from PICU is an important milestone in the trajectory of recovery from critical illness. When a patient leaves the PICU, the patient’s new care team may be unfamiliar with the details of the patient’s critical illness course. The transition from high-intensity to low-intensity care poses several challenges to continuity of patient care (1). For patients whose primary critical illness has not resolved, where new complications have arisen, and where gaps occur in continuity of care, a discharge from ICU might represent a high-risk time for clinical decompensation and PICU readmission. Repeated illness and unplanned PICU readmissions can lead to physical and psychologic morbidity for patients and considerable stress for families and staff (2, 3). Early unplanned readmissions are a measure of healthcare quality, may be preventable, and are associated with increased length of stay, increased rates of mortality, morbidity, and resource consumption. Studies from high-income countries (HICs) (4–8) have identified the rates of early and late readmissions, risk factors, and mortality rates. However, the epidemiology of PICU readmissions in resource-limited countries is less well characterized. In this issue of Pediatric Critical Care Medicine, Mat Bah et al (9) reported data from a retrospective cohort of children admitted to the PICU in a single institution in Malaysia over an 8-year period. They hypothesized that in their resource-limited setting, the rate of PICU readmission will be higher and with different risk factors for readmission compared to HIC. Despite the differences in pediatric critical care practice settings, remarkable similarities are observed in clinical characteristics of PICU readmissions reported by the authors and HIC. The rates of early and late readmissions reported by Mat Bah et al (9) were 2.5% and 3.9%, respectively, higher than those from PICU of North America (1.2–1.8%) (4, 5, 7) but lower than those reported from Australia (10.2%) (8). The median time from discharge to PICU readmission was 21–22 hours, similar to previous reports (4, 6); and patients had the same primary diagnosis as the index PICU admission (4, 6). Independent risk factors associated with early PICU readmission were Pediatric Index Mortality score greater than or equal to 15, chronic cardiovascular conditions, and oxygen supplementation upon discharge, similar to previous reports. The median time from discharge to late readmission was 6 days; and infancy, having cardiovascular and other chronic complex conditions, was an independent risk factor for late readmission, similar to previous reports (4, 6). The similarity, however, ends in the mortality rates. Previous studies have reported significantly higher mortalities in the early readmission group compared to index PICU admission (3.3% vs 2.8% [4], 6% vs 3.8% [6], 7.2% vs 4.4%; p = 0.03 [7], and 8% vs 3.8% [10]). However, Mat Bah et al (9) reported no significant differences in the mortality rates of early (12.9%), late (13.3%), and no readmissions (10.7%) (p = 0.48–0.88); meaning that a readmission, whether early or late, to the PICU does not confer a high mortality risk in their setting. What do these mortality rates mean? As the authors explained, the main reason there was no significant increase in mortality in the early versus no readmission or early versus late readmission is the high mortality rate in the index PICU admission. Indeed, the reported mortality of 10.7% in index PICU admission is much higher than that in HIC (2.5–4.4%) (4, 6). In Brazil, a country that is equivalent to Malaysia’s in terms of income level, the reported mortality of index PICU admission was 5.1% (11). The true mortality rate in the no PICU readmission reported by Mat Bah et al (9) might be higher because another 81 patients discharged against medical advice (DAMA) were excluded. The DAMA group represented 2.8% of the cohort, almost equivalent to the early readmission rate. The absence of pediatric intensivists and trained nurses could explain the high mortality of the index PICU admission. What quality improvement techniques can middle-income countries leverage in their resource-limited settings? First, where a PICU has technology resources but lacks subspecialty expertise, enhanced networking through telemedicine or telephone consultations with a tertiary care institution will assist the care of the seriously ill child. Studies have shown that with telemedicine, and to a limited extent with telephone consultations, urgent critical care can be provided to children in underserved rural emergency departments (12), to the satisfaction of providers and patients. Second, the mortality of the early readmissions, although not significantly higher than those with no readmissions in the study by Mat Bah et al (9), is still higher than the range of 3.3–7.2% reported in HIC (4, 6, 7). How could limited resources be optimized to maximize safety for high-risk transitions from PICU to general wards? Bedside Pediatric Early Warning Scores (7, 13) may further flag those at higher risk of early readmission. *See also p. e959.