Introduction: Medical toxicology consultation in cases of toxicological exposure requiring care in the pediatric intensive care unit (PICU) has been associated with decreased mortality and shorter hospital stay compared to not having consultation. The goal of this study is to assess the impact of evidenced-based guidelines, designed by a multidisciplinary team, on the PICU admission rate of poisoned patients. Methods: A team of PICU physicians and advanced practice providers, toxicologists, hospitalists, nurses, and emergency medicine clinicians collaborated to develop guidelines for patient placement on admission after toxicological exposure. Local data were extracted from Virtual Pediatric Systems based on ICD10 codes and included age, assigned sex, lengths of stay, survival outcome, hospital disposition, procedural interventions, and both pediatric overall performance category and pediatric cerebral performance category scores for patients admitted to the PICU during three time periods. These included periods before and after cardiac monitoring (CRM) was available to the entire hospital as well as a 5 month period after admission guideline publication. Two clinicians independently and retrospectively reviewed the cases to determine if, according to the guideline and institutional policy, patients may have been safely admitted to the acute care floor instead of to the PICU. Results: Of the 459 patients admitted to the PICU 1/2019-3/2022, 44% (n=203) did not meet criteria for PICU admission. From 9/2022-1/2023, 28% (n=12) of patients could have been safely admitted to acute care. There were only 29 patients with toxicological exposure admitted to the PICU in the 5 months after the guideline was published, a 32% decrease compared to the 5 months evaluated after CRM availability was expanded and before the guideline was published. Of those, 31% (n=9) of them could have been admitted to acute care. Inter-rater agreement was strong (κ=0.92, observed agreement 96%). Conclusions: While availability of CRM and institutional variability certainly influence patient placement in hospitalization of children after toxicological exposures, interdisciplinary collaboration including medical toxicologists may decrease unnecessary utilization of intensive care resources.
Tuttle et al. (Sun,) studied this question.