SAN FRANCISCO — The number of hospital admissions for pediatric status asthmaticus seems to be decreasing, but at the same time both the number and the proportion of patients with status asthmaticus who are admitted to the ICU appear to be increasing, Dr. Mary E. Hartman said at the annual congress of the Society of Critical Care Medicine.
In New Jersey over the 10-year period from 1992 to 2001, ICU admissions for status asthmaticus increased from 10 per 100,000 children to 18 per 100,000, an increase of 80%, said Dr. Hartman of the University of Pittsburgh.
At the same time, total hospital admissions for status asthmaticus declined from 4,170 in 1992 to 2,361 in 2001, a decline of 43%.
Dr. Hartman and her colleagues examined an administrative database from New Jersey that tabulated every pediatric hospitalization in the state's hospitals. For the years 1992, 1995, 1999, 2000, and 2001, the investigators identified all admissions with the ICD-9 codes for status asthmaticus.
The database included demographic information as well as information on admission characteristics such as length of stay and whether the child was admitted to an ICU.
The investigators were also able to determine which of the 108 hospitals had a pediatric ICU (PICU) and which had only an adult ICU or no ICU at all.
During the 10-year period, there were 17,066 pediatric status asthmaticus admissions. Fifty-nine percent of the children were male, and 70% were less than 10 years old. The proportion of uninsured children was 8.1%. These demographic characteristics did not change appreciably over the study period.
Overall, 9.3% of status asthmaticus admissions involved an ICU stay. But that increased from 4.4% in 1992 to 17.7% in 2001.
This pattern of increased ICU use did not reflect overall trends in hospitalization during that period. When all hospitalizations and all ICU admissions were considered, total pediatric hospitalizations decreased just 9%, compared with 43% for status asthmaticus. Likewise, total pediatric ICU cases increased by 51%, compared with 127% for status asthmaticus.
Deaths were infrequent during the study period and remained stable over time. A total of eight children died during the 5 years studied. On the other hand, the number of children who required mechanical ventilation declined steadily from 1995 to 2001.
“The drop in ventilated cases corresponds to an increase in ICU admissions during that time, and we believe that these data represent a trend in increased vigilance … toward more aggressive management of status asthmaticus patients in the ICU,” Dr. Hartman said.
One of the more interesting aspects of the study concerned whether children were admitted to a PICU or to an adult ICU. Despite the fact that only 17 of 108 hospitals had a PICU, three-quarters of the children with status asthmaticus who needed intensive care were seen in PICUs. In 1992, only 8% of all admissions for status asthmaticus received intensive care in PICU hospitals. By 2001, 40% of all such admissions ended up in the PICU.
“Adult hospitals are not performing the same way [as children's hospitals],” Dr. Hartman said. “While the overall trends are the same—[adult hospitals] did indeed lower the total number of admissions and also had a higher proportion of admitted patients cared for in the ICU over 10 years—the size of this change is minuscule, compared to what was happening in children's hospitals.”
Dr. Hartman suggested that hospitals with PICUs may have more effective triage than hospitals with only adult ICU beds. “Adult hospitals still have far too many lower-acuity admissions for status asthmaticus,” she said.
“If there's one take-home point I'd like you all to remember today, it's that ICU admissions for status asthmaticus are increasing linearly over time,” she continued.
“We need to ask ourselves if we're prepared for the increase in admissions that is certainly ahead. Second, I think this study clearly raises questions about the regionalization of ICU care. Children's hospitals have changed in ways adult hospitals have not.”