Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort

Abstract

Background: Hospitalized pediatric hematology-oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource-limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event-level and center-level risk factors for mortality.

Methods: In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU-level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018).

Results: Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%-79% or 0.36-5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU-level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center-level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality.

Conclusions: Hospitalized PHO patients who experience CDEs in resource-limited settings frequently require floor-based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high-risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer.

Keywords: Latin America; Pediatric Early Warning Systems (PEWS); clinical deterioration; intensive care; pediatric oncology; resource-limited settings.

Figure 1

Clinical deterioration event (CDE) characteristics and the percent mortality are illustrated among hospitalized pediatric hematology‐oncology patients who had CDEs according to (A) the requirement for intensive care unit‐level interventions during the CDE (n = 553), (B) categories of sepsis at the time of transfer to a higher level of care (n = 498), and (C) the number of organs with dysfunction at the time of transfer to a higher level of care (n = 498). BiPAP indicates bilevel positive airway pressure; CPAP, continuous positive airway pressure; CPR, cardiopulmonary resuscitation; HFNC, high‐flow nasal cannula; HFOV, high‐flow oscillatory ventilation; Mech, mechanical.

Figure 2

Center variations in the rates of clinical deterioration events (CDEs) and mortality are illustrated. Variations in the rates of CDE per 1000 inpatient days, floor intensive care unit‐level interventions per 1000 inpatient days, floor cardiopulmonary arrests per 1000 inpatient days, CDE mortality per 1000 inpatient days, and the percent mortality of all documented CDEs are depicted. Each dot color represents 1 center (n = 16), and the dark black line indicates the median in each category.