The Vigilance Gradient: Eleven Years of Adverse Event Trends in Pediatric Critical Care

OBJECTIVES: To examine 11-year trends in adverse events (AEs) in a pediatric critical care unit (PCCU), assess the impact of the COVID-19 pandemic on patient safety, and evaluate associations between patient acuity and AE severity. DESIGN: Retrospective cohort study using interrupted time series analyses and mixed-effects multinomial regression. SETTING: A single-center PCCU monitored via the Adverse Event Management System from January 2013 to December 2023. PATIENTS: A total of 7290 critically ill and injured pediatric patients admitted to the PCCU over the study period. INTERVENTIONS: None (observational study). Exposure variables included the COVID-19 pandemic period, invasive mechanical ventilation and noninvasive ventilation. MEASUREMENTS AND MAIN RESULTS: Demographics, length of stay (LoS), disposition, and AE severity were assessed. The baseline AE rate was 11.94 events per 100 cases. At pandemic onset, AE rates rose by 5.20 events per 100 cases (p = 0.004), then declined 0.81 events per 100 cases quarterly (p = 0.010). Post-pandemic, rates increased 1.94 events per 100 cases quarterly (p = 0.009). LoS decreased 0.01 days quarterly pre-pandemic (p = 0.009), was stable during the pandemic, then increased 0.25 days quarterly post-pandemic (p = 0.033). Higher Pediatric Index of Mortality 2 scores were associated with fewer "near miss" events and more "MinModSev" (minimal, moderate, or severe) AEs. Both mechanical ventilation (p = 0.039) and noninvasive ventilation (p = 0.015) increased the odds of "MinModSev" AEs. CONCLUSIONS: This PCCU experienced a transient increase in AEs during COVID-19, followed by recovery and a post-pandemic rise in both AE rates and LoS. Higher illness severity and respiratory support were associated with more severe AEs. These findings underscore the importance of data-driven monitoring systems to sustain patient safety during and after healthcare crises.