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Unplanned PICU Readmissions: A Representation of Care Gaps Within the Community.

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000002468 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 this remains controversial as other reports, like that of Lascarrou et al (1), have also discouraged antibiotic prophylaxis in comatose patients, including out-of-hospital cardiac arrest patients (7). Studies have failed to show a reduction in mortality or mechanical ventilation duration with antibiotic prophylaxis in this cohort of patients. Although a delay in antibiotic therapy during sepsis has been associated with increased morbidity and mortality, antibiotic prescription after aspiration should be reserved to patients with a high clinical suspicion for BAP and bacteriologically documented pneumonia as unnecessary antibiotic prescription can result in avoidable adverse effects and antimicrobial resistance. Real-time multiplex polymerase chain reaction can further facilitate stewardship efforts more promptly with a high sensitivity and specificity (8). Clinical suspicion alone does not suggest infection, as demonstrated in this article where only 43 (47%) of the 92 patients had positive TPC cultures. The presence of fever, tachycardia, increased secretions or oxygen requirement, and/or radiographic changes within 48 hours of an aspiration event does not necessarily suggest an infectious process has occurred. Lascarrou et al (1) illustrated the lack of any clinical or laboratory variable that dependably predicted BAP. Furthermore, witnessing an aspiration, even during intubation, does not suggest infection, as evidence has shown healthy people with no history of dysphagia frequently aspirate during sleep with no clinical consequences (9). Controversy in distinguishing pneumonia from pneumonitis in an effort to safely discontinue antibiotics may still remain as TPC is not routinely available in the United States. Auspiciously, Lascarrou et al (1) have shown that antibiotics can safely be withheld without the need for TPC sampling in comatose patients without a suspected BAP. This may further strengthen our efforts to reduce healthcare costs, morbidity, mortality, and antimicrobial resistance.