(1344) Rates of Unsafe Intensive Care Unit Transfers in Hospitalized Children With Cancer

Introduction: Children with cancer often deteriorate and require pediatric intensive care unit (PICU) care. Delays in intervention lead to worse outcomes. Unsafe PICU transfers, defined as a transfer in which intubation, vasoactives, or 3 or more fluid boluses are required prior to or within 1 hour of transfer, is a metric to evaluate prompt identification of clinical deterioration. However, it has not been investigated in these high-risk patients. The goal of this study is to describe the rates of unsafe PICU transfers, critical care interventions, and short-term outcomes in hospitalized children with cancer.

Methods: This is a retrospective cohort study of floor-to-PICU transfers of children with cancer hospitalized from 2020-2023. Virtual Pediatric Systems and the medical record were used to identify PICU transfers, respiratory support, vasoactives, fluid resuscitation, mortality prediction scores, Bedside Pediatric Early Warning Scores (PEWS), PICU length of stay (LOS), and hospital mortality.

Results: Of 160 PICU transfers, 28 (18%) met criteria for unsafe transfer. Of these, 12 (43%), 10 (36%), and 9 (33%) met criteria by intubation, vasoactives, and fluid resuscitation, respectively. Patients with unsafe transfer were older (median 17 vs 12 years, p=0.01) and during their PICU stay had higher rates of intubation (78% vs 48%, p=0.003) and vasoactive requirement (79% vs 37%, p< 0.001), with shorter time to vasoactive initiation (median 0.1 vs 1.3 days, p< 0.001). In 117 encounters where PEWS were available, median PEWS were not different for unsafe and safe transfers, 4.5 (IQR 4, 6) and 5 (IQR 3, 8), p=0.7. Unsafe transfer was associated with higher Pediatric Index of Mortality (PIM) 3 (median -2.7 vs -2.8, p=0.003) and Pediatric Risk of Mortality (PRISM) 3 (median 11.5 vs 7, p=0.004) scores. Hospital mortality and PICU LOS did not differ significantly between groups.

Conclusions: Hospitalized children with cancer frequently experienced unsafe PICU transfers that were associated with higher rates of critical care interventions, presenting an opportunity for early identification and intervention. Bedside PEWS were low and not indicative of unsafe PICU transfer, suggesting the system is suboptimal in identifying early deterioration in children with cancer.