Outcome-Based Clinical Decision-Making in Pediatric Critical Illness

Optimizing patient outcome, the goal of our care efforts, has always been the focus of conscientious physicians. Besides rescuing patients, pediatric critical care providers are increasingly focused on assuring that the care provided is safe, that preventable harm is limited, and that best outcomes are achieved at the lowest reasonable cost. Thus, it is important for intensivists to understand terms such as “value,” “quality,” and “standards of care” and how they are applied within the PICU. Furthermore, intensivists should know how to improve performance. They should also understand the use of various sources of data, such as administrative data sets and patient registries, to assess quality of care. Unfortunately, “quality” has become difficult to describe and quantify because of various definitions used to describe it. Today, certain outcomes are tied to reimbursement and financial reward through the current “pay for performance” system. However, many of these designated outcomes are not in fact outcomes but instead are process measures that are plausibly linked to desired outcomes. Within pediatric critical care medicine, commonly measured outcome measures include severity of illness-adjusted mortality rates for all PICU patients as well as for the subset of congenital heart surgery patients, cost and length of stay measures that are disease group and case mix specific, and risk-adjusted measures of functional outcomes (impairment) following pediatric critical illness. In addition, there are other outcome measures including ventilator-associated events, central venous catheter-related bacteremia, and accidental extubation, to name a few. The most important purpose of outcome measurement is improvement of care, not keeping score. Outcome measurement and performance improvement are powerful tools that have the additional benefit of bringing teams together, which improves collaboration and unit functioning. These efforts provide opportunities for evidence-based learning and performance improvement, which require different methods from traditional randomized controlled trials. Early success with the development of standardized risk-adjusted outcome measures with broad PICU participation is a promising start, but much more can and should be done.