Q&A: Children’s hospitals need a standard outcome for clinical deterioration

Key takeaways:

• Unrecognized clinical deterioration in children is common and can be life-threatening.
• No gold standard outcome exists to guide care for clinical deterioration outside the ICU.

There is no gold standard outcome to guide care for unrecognized clinical deterioration outside the ICU among hospitalized children despite the high risk for morbidity and mortality these patients face, experts noted recently in Pediatrics.

Meghan M. Galligan, MD, MSHP, an attending physician in the division of general pediatrics at The Children’s Hospital of Philadelphia, and colleagues argued that developing a “standard, consensus outcome ... is a critical first step to preventing this type of harm.”

We spoke with Galligan about clinical deterioration and what a standard outcome would look like.

Healio: How can clinical deterioration be defined for those unfamiliar with the concept?

Galligan: In children’s hospitals, clinical deterioration describes a situation in which a child hospitalized for an acute illness develops a concerning change in their clinical status requiring an urgent or emergent response from the health care team. As an example, if a child admitted with an acute asthma flare develops progressively labored breathing that requires urgent use of breathing supports such as positive pressure ventilation, we would consider this an example of clinical deterioration.

Among patients hospitalized on a general medical/surgical ward, clinical deterioration can be particularly life-threatening — patients may require chest compressions, intubation or other emergent interventions not routinely performed by health care teams that practice outside of an ICU. As such, early recognition of and response to signs of clinical deterioration is critical to ensuring that children can be escalated to an appropriate care setting where they are able to receive the specialty care and resources needed to keep them safe from harm.

Healio: What do you recommend in terms of a standard outcome?

Galligan: I think it’s important to acknowledge that the process of aligning on a consensus standard outcome for clinical deterioration will need to incorporate the important perspectives of several stakeholder groups who lead work in this space — for example, clinical and operational leaders with expertise in resuscitation science, patient safety and harm prevention.

Our author team would advocate for potential consideration of an outcome that encapsulates both conservative markers of clinical deterioration —for example, use of chest compressions in a cardiac arrest — along with emerging proximal markers of clinical deterioration that have been associated with adverse patient outcomes, such as initiation of vasoactive medications within 1 hour of ICU escalation. An outcome that combines both of these features would have the advantage of comprehensively identifying clinical deterioration while also adequately powering the analyses required to guide harm prevention and improvement work.

Healio: What should providers take away from this?

Galligan: As a practicing attending in pediatric hospital medicine, I know the competing priorities that busy health care providers face in their everyday work. I also know we all come to work every day to provide excellent care for our patients and to keep them safe from harm. Our team hopes this article will bring awareness and attention to the fact that unrecognized clinical deterioration is a potential source of significant and preventable harm to our patients.

References:

Galligan MM, et al. Pediatrics. 2023;doi:10.1542/peds.2023-061625.