Variation in Triage to Pediatric vs Adult ICUs Among Adolescents and Young Adults With Asthma Exacerbations

Abstract

Background: More than 90,000 children and adults in the United States are hospitalized with an asthma exacerbation annually, and between 5% and 34% of these hospitalizations include admission to an ICU. It is unclear how adolescent and young adults with severe asthma exacerbations are triaged in the inpatient setting between PICUs and adult ICUs. Using a large multicenter US cohort, we characterized how hospitals triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs.

Research question: How do hospitals across the United States triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs?

Study design and methods: This was a retrospective cohort study carried out from 2016 through 2022 using the enhanced-claims PINC AI database. Participants were patients aged 12 to 26 years who were hospitalized with an asthma exacerbation and admitted to a PICU or adult ICU. We used nested hierarchical multivariable regression models to quantify changes in the intraclass correlation coefficient (ICC; a measure of variation in triage decisions attributable to hospital of admission after accounting for covariables).

Results: Analyses included 3,946 admissions from 93 hospitals. Stratified by age, the percent of patients admitted to PICUs dropped by 26.9% between 17 and 18 years of age. In the nested models, the ICC showed a large decrease going from the empty model (28.7%) to the age-adjusted model (4.5%), but was similar between the age-adjusted and fully adjusted model (3.4%).

Interpretation: Our results showed that among adolescents and young adults with asthma exacerbations, age of 18 years or younger was a strong determinant of PICU triage. Further research is needed to understand differences in asthma care and outcomes between PICUs and adult ICUs, as well as how intermediate care units affect triage decision-making from wards and the ED.

Keywords: MICU; PICU; asthma; practice variation.

Figure 1 –

A, Line graph showing unadjusted rates of PICU admission, stratified by age, among patients admitted to an ICU with an asthma exacerbation. B, Unadjusted proportion of patients admitted to a ward unit, intermediate care unit, and ICU stratified by age among all patients admitted to any hospital with an asthma exacerbation.

Figure 2 –

Caterpillar plot showing empty model, age-adjusted model, and fully-adjusted model with variables listed in Table 1 (in each panel, hospitals are rank-ordered from lowest to highest predicted probability of PICU admission).