321 - Delivering high valued care in the PICU: opportunity to convert intravenous gastrointestinal prophylactic medications to oral

Publication Number: 321.4100

Vanessa Toomey, Children's Hospital Los Angeles, Los Angeles, CA, United States; Eugene Laksana, Children's Hospital Los Angeles, Alhambra, CA, United States; Jillian Cotter, University of Colorado & Children's Hospital Colorado, Aurora, CO, United States; Jonathan M.. Tan, Children's Hospital Los Angeles, Los Angeles, CA, United States

Background: Gastrointestinal (GI) prophylaxis is widely used in the PICU to prevent upper GI ulcers and bleeds. GI prophylaxis can be delivered in both enteral and intravenous (IV) routes with similar efficacy, however enteral forms of prophylaxis costs significantly less. The safe, timely, and systematic transition of IV GI prophylaxis medications to enteral forms represents an important opportunity to improve the delivery of high value care in the PICU.

Objective: The primary objective was to determine the percent opportunity days of patients receiving IV GI prophylaxis across PICUs in the US. The secondary objective was to identify patient populations with high percent opportunity days to generate high value priority interventions for cost reduction initiatives through clinical practice standardization and quality improvement initiatives.

Design/Methods: We performed a retrospective study of patients ≤19 years old hospitalized 1/1/2021 to 12/31/2023 at 43 US pediatric hospitals in the Pediatric Health Information System (PHIS). Primary measures included Opportunity Days which was defined as the number of days a PICU patient received IV GI prophylaxis while receiving other medications enterally. Another measure of interest was the Percent Opportunity Days which was defined as Opportunity Days divided by the ICU length of stay (LOS) per encounter.

Results: There were 146,928 encounters from January 1st, 2021, to December 31st, 2023. The hospitals were stratified by PICU bed size quartiles: 0-25, 26-36, 37-47, and >48 PICU beds. Kruskal-Wallis tests were performed on ICU LOS and Opportunity Days per patient. There were significant differences across the PICU bed size quartiles (P value < 0.001). Percent Opportunity Days ranged from 2.5 to 46% per quarter and PICU bed size did not correlate with a pattern of Percent Opportunity Days. Patients who were admitted to the PICU for at least 12 days accounted for 50% of Opportunity Days. Patients with  3 complex chronic conditions also accounted for 50% of the Opportunity Days.

Conclusion(s): There is a large economic opportunity that exists across PICUs in the United States to intentionally transition patients from IV to enteral GI prophylaxis. Regardless of PICU size, there was wide variation in the percent of Opportunity Days available to each PICU to improve. To optimize GI prophylaxis, quality improvement and health system leaders should focus on patients with predicted longer length of stay and patients more complex chronic conditions.

Figure 1: Percent of opportunity days per quarter for 43 PHIS hospitals ordered by PICU bed size


Figure 2: Cumulative percent of opportunity days compared to percent of patient encounters sorted by PICU length of stay.
Abbreviations: LOS, length of stay

Figure 3: Cumulative percent of opportunity days compared to percent of patient encounters sorted by number of complex chronic conditions.
Abbreviations: CCC, complex chronic conditions

Figure 1: Percent of opportunity days per quarter for 43 PHIS hospitals ordered by PICU bed size


Figure 2: Cumulative percent of opportunity days compared to percent of patient encounters sorted by PICU length of stay.
Abbreviations: LOS, length of stay

Figure 3: Cumulative percent of opportunity days compared to percent of patient encounters sorted by number of complex chronic conditions.
Abbreviations: CCC, complex chronic conditions