Doctor, this patient is sick From the ward to the PICU

1. �Doctor, this patient is sick� From the ward to the PICU John Tsukahara MD Pediatric ICU California Pacific Medical Center

2. I have no relevant financial relationships that might create any personal conflicts of interest.

3. �Doctor, this patient is sick.� Important concepts Recognize critically ill or deteriorating patients early. Manage critically ill patients aggressively before they are transferred to the Pediatric ICU.

4. Ward patients are sicker and more complicated than they used to be

5. Procedures are just as difficult as they used to be

6. Pediatric ward nurses work hard.

7. Pediatric residents have less experience with critically ill patients

8. The line between the pediatric ward and the Pediatric ICU is not precise.

9. Subtle changes in patients can be difficult to detect and difficult to articulate

10. The decision to transfer a patient from the ward to the PICU can be difficult.

11. The pediatric hospitalist is key

12. From ward to PICU: the typical process The ward team rounds in the morning, evaluates the patients and develops plans for the day During the day, a child has an acute event or deteriorates. The bedside nurse is concerned The nurse alerts the resident The resident evaluates the patient and speaks with the hospitalist The hospitalist evaluates the patient and decides that the child should go to the PICU The hospitalist contacts the PICU and speaks with the fellow or pediatric intensivist The PICU staff checks staffing and bed availablity The PICU accepts the patient The child is transferred from the ward to the PICU

13. �Doctor, this patient is sick.� Important concepts Recognize critically ill or deteriorating patients early. Manage critically ill patients aggressively before they are transferred to the Pediatric ICU.

14. PICU outcome: Does it make a difference where the patient came from? OdetolaFO. Do outcomes vary according to the source of admission to the pediatric intensive care unit? PedCritCareMed. 2008Jan;9(1):20 University of Michigan, Ann Arbor Tertiary care university children�s hospital. 16 bed med-surg PICU and 15 bed cardiac PICU 6 years, 8,897 patients

15. PICU outcome: Does it make a difference where the patient came from? PRISM III: Pediatric Risk of Mortality score A prognostic scoring system derived from 17 physiologic variables measured in the first 12 hours of PICU hospitalization Vital signs Laboratory results Neurologic signs Diagnoses Well-validated measure of severity of illness