Maraccini, Amber M. PhD; Slonim, Anthony D. MD, DrPH

The overall health and well-being of children can be attributed to an “ecology of care” that incorporates the educational, healthcare, social, and financial aspects of a given community (¹). From a systems perspective, unplanned PICU readmissions represent much more than a series of quantifiable negative outcomes; rather, the rate at which they occur may be recognized as an indicator of the community’s current health and healthcare climate. Contextual elements within a given community such as resource availability (e.g., healthy foods, opportunities for exercise), health literacy (e.g., bicycle helmets, gun violence), health prevention (e.g., obesity, immunizations), and primary and specialty care access are critical factors that impact the overall health status of children; increase the likelihood that a patient will require medical attention in a PICU; and may also affect their outcome and the necessity for an unplanned PICU readmission (¹). If we continue to view the PICU as a series of encounter-based interactions that are disconnected from the antecedent and consequent events of the encounter, and also unassociated with the difficulties inherent in the context of care, we will continue to miss vital opportunities to improve child health in the patients and communities we serve.

In this issue of Critical Care Medicine, Edwards et al (²) performed a study that examined the prevalence and risk factors associated with unplanned readmissions in 92 PICUs. This retrospective analysis utilized a variety of measures including the frequency of, latency to, and predictors associated with the causes of PICU readmission (²). Of the patient population examined, results demonstrated that 11% had been readmitted within 1 year to the same PICU and 3.4% had been readmitted on two or more occasions. Risk predictors for these readmissions such as race, insurance status, and disposition were also identified. Most notable, though, was the key finding that patients with complex chronic conditions (CCCs) were most vulnerable to PICU readmission (²).

Research has repeatedly demonstrated that patients who are readmitted to an ICU are more likely to experience longer lengths of stay, increased morbidity, and in some cases higher rates of mortality (^3–6). A few published studies have already demonstrated these results as they pertain to PICUs (¹, ^7–9). Nonetheless, the contribution of Edwards et al (²) still has value since it both 1) provides further evidence of the increased risk and prevalence associated with PICU readmissions and also 2) identifies a population whose readmission rates may be reduced and potentially prevented. Specifically, by enhancing awareness around CCCs and their impact on PICU readmission risks, efforts to help mitigate upstream and downstream care gaps within the community may help to reduce unplanned PICU readmissions.

In order to begin targeting unplanned readmissions, we need to continue framing the PICU, and adult ICUs for that matter, as an important structural element within the broader context of care. Said differently, unplanned readmissions will only be reduced when we have a better understanding of why they are happening and, thus, how to target them within a given community. Assessment tools like the Community Health Needs Assessment (¹⁰), made available by non-for-profit hospitals and their community partners at least once every 3 years, is one avenue by which healthcare providers may gain better insights into the unique needs of the patients, families, and communities they serve. Using this information, or similar information gained elsewhere, interventions may then be strategically developed to impact community perceptions and behaviors relevant to CCCs and other high-risk factors associated with unplanned PICU readmissions.

As healthcare systems evolve to be accountable for the quality and cost of care for entire populations of patients, children with CCCs represent a cohort whose needs require systematic design and implementation efforts (¹¹). Within the system of care, primary and specialty providers are important elements for addressing the needs of children with CCCs both before and after a PICU admission or hospitalization. Unfortunately, many postacute services for children including primary and specialty care, home care, rehabilitation care, and hospice care that may be needed after discharge are limited in contrast to services available for adult patients. Hence, although Edwards et al (²) have framed readmissions from a negative perspective, readmissions may actually represent an important safety net for children and families experiencing CCCs, whose communities lack the necessary services to appropriately care for children outside of the acute care environment (e.g., those with limited access to primary care due to their insurance status).

The prevalence of PICU readmissions remains an important problem for anyone interested in the issue of child health. Continuing to describe the problem and the associated risk factors for readmitted patients within the isolation of the PICU, however, does little to impact or advance child health. The work of Edwards et al (²) should be viewed as a launch point to targeting child health by advancing our efforts beyond the walls of the PICU. In other words, Edwards et al (²) may hopefully serve as a catalyst for our communities to petition for and invest in the services necessary, to support the needs of our children, particularly those with CCCs who require better primary and postacute care.

REFERENCES

community health; critical care; pediatrics; population health; readmissions