Pediatric Severe Sepsis: Current Trends and Outcomes From... : Pediatric Critical Care Medicine (original) (raw)

Feature Articles

Current Trends and Outcomes From the Pediatric Health Information Systems Database*

Ruth, Amanda MD1,2; McCracken, Courtney E. PhD2; Fortenberry, James D. MD, MCCM1,2,3; Hall, Matthew PhD4; Simon, Harold K. MD, MBA2,3; Hebbar, Kiran B. MD, FCCM1,2,3

1Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA.

2Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.

3Division of Critical Care Medicine, Children’s Healthcare of Atlanta, Atlanta, GA.

4Children’s Hospital Association, Kansas City, MO.

* See also p. 899.

The article falls under nonhuman subject category and was approved by Children’s Healthcare of Atlanta and Children’s Hospital Association Institutional Review Board.

Dr. Ruth performed background research, design and concepts of study, guided data extraction, directed analysis, prepared article, and approved final version as submitted. She had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr. McCracken assisted in the study methodology, carried out the initial statistical analyses, developed the figures and tables, reviewed and revised the article, and has approved the article as submitted. Dr. Fortenberry carried out the initial analyses, prepared the article, reviewed and revised the manuscript and figures, and approved the article as submitted. Dr. Hall is principal biostatistician at Children’s Hospital Association and extracted and built database. Dr. Simon was involved with design, data analysis and critical review of the article, and approved the article as submitted. Dr. Hebbar conceptualized and designed the study, prepared the article, and approved the article as submitted.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

All expenses incurred covered by funds originated from the Division of Pediatric Critical Care of Emory University School of Medicine.

Presented, in part, at the Annual Congress, Society of Critical Care Medicine Annual Congress, San Francisco, CA, January 17–21, 2014.

Dr. Simon consulted for the Center for Heath Organization Transformation (Industry Board Chair for a National Science Foundation collaborative). His institution received grant support from Venaxis Pharma (advisory Board Member and Site investigator for a biomarker trial for identifying Appendicitis in Children with Abdominal Pain), Baxter Pharma (Site PI for a rehydration study in the ED), the National Institutes of Health (NIH) (site PI for the National Children's Study, NICHD multicentered study on environment and health outcomes), the NIH subcontract (Emory Site PI to Univ of Michigan/Pediatric Emergency Care Research Network, Planning grant for study on Progesterone for Traumatic Brain Injury), and Aspen Pharma/Venaxis Pharma (Site PI for biomarker study for identification of patients with appendicitis). The remaining authors disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]

Abstract

Objective:

To 1) describe the characteristics and outcomes over time of PICU patients with severe sepsis within the dedicated U.S. children's hospitals, 2) identify patient subgroups at risk for mortality from pediatric severe sepsis, and 3) describe overall pediatric severe sepsis resource utilization.

Design:

Retrospective review of a prospectively collected multi-institutional children’s hospital database.

Setting:

PICUs in 43 U.S. children’s hospitals.

Patients:

PICU patients from birth to younger than 19 years were identified with severe sepsis by modified Angus criteria and International Classification of Diseases, 9th Revision, codes for severe sepsis and septic shock.

Interventions:

None.

Measurements and Main Results:

Data from the Pediatric Health Information System database collected by the Children’s Hospital Association from 2004 to 2012. Pediatric severe sepsis was defined by 1) International Classification of Diseases, 9th Revision, codes reflecting severe sepsis and septic shock and 2) International Classification of Diseases, 9th Revision, codes of infection and organ dysfunction as defined by modified Angus criteria. From 2004 to 2012, 636,842 patients were identified from 43 hospitals. Pediatric severe sepsis prevalence was 7.7% (49,153) with an associated mortality rate of 14.4%. Age less than 1 year (vs age 10 to < 19) (odds ratio, 1.4), underlying cardiovascular condition (odds ratio, 1.4) and multiple organ dysfunction, conferred higher odds of mortality. Resource burden was significant with median hospital length of stay of 17 days (interquartile range, 8–36 d) and PICU length of stay of 7 days (interquartile range, 2–17 d), with median cost/day of 4,516andmediantotalhospitalizationcostof4,516 and median total hospitalization cost of 4,516andmediantotalhospitalizationcostof77,446. There was a significant increase in the severe sepsis prevalence rate from 6.2% to 7.7% from 2004 to 2012 (p < 0.001) and a significant decrease in mortality from 18.9% to 12.0% (p < 0.001). Center mortality was negatively correlated with prevalence (_r_s = –0.48) and volume (_r_s = –0.39) and positively correlated with cost (_r_s = 0.36).

Conclusions:

In this largest reported pediatric severe sepsis cohort to date, prevalence increased from 2004 to 2012 while associated mortality decreased. Age, cardiovascular comorbidity, and organ dysfunction were significant prognostic factors. Pediatric severe sepsis remains an important cause for PICU admission and mortality and leads to a substantial burden in healthcare costs. Individual center’s prevalence and volume are associated with improved outcomes.