Characteristics and Outcomes of Critical Illness in Children With Feeding and Respiratory Technology Dependence

Use of Latent Class Analysis to Predict Intensive Care Unit Admission and Mortality in Children with a Major Congenital Anomaly

OBJECTIVE

To define major congenital anomaly (CA) subgroups and assess outcome variability based on defined subgroups.

STUDY DESIGN

This population-based cohort study used registries in Denmark for children born with a major CA between January 1997 and December 2016, with follow-up until December 2018. We performed a latent class analysis (LCA) using child and family clinical and sociodemographic characteristics present at birth, incorporating additional variables occurring until age of 24 months. Cox proportional hazards regression models estimated hazard ratios (HRs) of pediatric mortality and intensive care unit (ICU) admissions for identified LCA classes.

RESULTS

The study included 27 192 children born with a major CA. Twelve variables led to a 4-class solution (entropy = 0.74): (1) children born with higher income and fewer comorbidities (55.4%), (2) children born to young mothers with lower income (24.8%), (3) children born prematurely (10.0%), and (4) children with multiorgan involvement and developmental disability (9.8%). Compared with those in Class 1, mortality and ICU admissions were highest in Class 4 (HR = 8.9, 95% CI = 6.4-12.6 and HR = 4.1, 95% CI = 3.6-4.7, respectively). More modest increases were observed among the other classes for mortality and ICU admissions (Class 2: HR = 1.7, 95% CI = 1.1-2.5 and HR = 1.3, 95% CI = 1.1-1.4, respectively; Class 3: HR = 2.5, 95% CI = 1.5-4.2 and HR = 1.5, 95% CI = 1.3-1.9, respectively).

CONCLUSIONS

Children with a major CA can be categorized into meaningful subgroups with good discriminative ability. These groupings may be useful for risk-stratification in outcome studies.

Tracheostomy and long-term invasive ventilation decision-making in children: A scoping review

An increasing number of children are surviving critical illnesses requiring tracheostomy/long-term ventilation (LTV). This scoping review seeks to collate the available evidence on decision-making for tracheostomy/LTV in children. Systematic searches of electronic databases and websites were conducted for articles and reports. Inclusion criteria included: (1) children 0-18 years old; (2) described use of tracheostomy or tracheostomy/LTV; and (3) information on recommendations for tracheostomy decision-making or decision-making experiences of family-caregivers or health care providers. Articles not written in English were excluded. Of the 4463 records identified through database search and other methods, a total of 84 articles, 2 dissertations, 1 book chapter, 3 consensus statement/society guidelines, and 8 pieces of grey literature were included. Main thematic domains identified were: (1) legal and moral standards for decision-making; (2) decision-making models, roles of decision-makers, and decisional aids towards a shared decision-making model; (3) experiences and perspectives of decision-makers; (4) health system and society considerations; and (5) conflict resolution and legal considerations. A high degree of uncertainty and complexity is involved in tracheostomy/LTV decision-making. There is a need for a standardized decision-support process that is consistent with a child's best interests and shared decision-making. Strategies for optimizing communication and mechanism for managing disputes are needed.

National Characteristics of Emergency Care for Children with Neurologic Complex Chronic Conditions

Introduction

Most pediatric emergency care occurs in general emergency departments (GED), where less pediatric experience and lower pediatric emergency readiness may compromise care. Medically vulnerable pediatric patients, such as those with chronic, severe, neurologic conditions, are likely to be disproportionately affected by suboptimal care in GEDs; however, little is known about characteristics of their care in either the general or pediatric emergency setting. In this study our objective was to compare the frequency, characteristics, and outcomes of ED visits made by children with chronic neurologic diseases between general and pediatric EDs (PED).

Methods

We conducted a retrospective analysis of the 2011-2014 Nationwide Emergency Department Sample (NEDS) for ED visits made by patients 0-21 years with neurologic complex chronic conditions (neuro CCC). We compared patient, hospital, and ED visits characteristics between GEDs and PEDs using descriptive statistics. We assessed outcomes of admission, transfer, critical procedure performance, and mortality using multivariable logistic regression.

Results

There were 387,813 neuro CCC ED visits (0.3% of 0-21-year-old ED visits) in our sample. Care occurred predominantly in GEDs, and visits were associated with a high severity of illness (30.1% highest severity classification score). Compared to GED visits, PED neuro CCC visits were comprised of individuals who were younger, more likely to have comorbid conditions (32.9% vs 21%, P < 0.001), and technology assistance (65.4% vs. 45.9%) but underwent fewer procedures and had lower ED charges ($2,200 vs $1,520, P < 0.001). Visits to PEDs had lower adjusted odds of critical procedures (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI] 0.62-0.87), transfers (aOR 0.14, 95% CI 0.04-0.56), and mortality (aOR 0.38, 95% CI 0.19-0.75) compared to GEDs.

Conclusion

Care for children with neuro CCCs in a pediatric ED is associated with less resource utilization and lower rates of transfer and mortality. Identifying features of PED care for neuro CCCs could lead to lower costs and mortality for this population.

Design and rationale of the Post-Intensive Care Syndrome - paediatrics (PICS-p) Longitudinal Cohort Study

INTRODUCTION

As paediatric intensive care unit (PICU) mortality declines, there is growing recognition of the morbidity experienced by children surviving critical illness and their families. A comprehensive understanding of the adverse physical, cognitive, emotional and social sequelae common to PICU survivors is limited, however, and the trajectory of recovery and risk factors for morbidity remain unknown.

METHODS AND ANALYSIS

The Post-Intensive Care Syndrome - paediatrics Longitudinal Cohort Study will evaluate child and family outcomes over 2 years following PICU discharge and identify child and clinical factors associated with impaired outcomes. We will enrol 750 children from 30 US PICUs during their first PICU hospitalisation, including 500 case participants experiencing ≥3 days of intensive care that include critical care therapies (eg, mechanical ventilation, vasoactive infusions) and 250 age-matched, sex-matched and medical complexity-matched control participants experiencing a single night in the PICU with no intensive care therapies. Children, parents and siblings will complete surveys about health-related quality of life, physical function, cognitive status, emotional health and peer and family relationships at multiple time points from baseline recall through 2 years post-PICU discharge. We will compare outcomes and recovery trajectories of case participants to control participants, identify risk factors associated with poor outcomes and determine the emotional and social health consequences of paediatric critical illness on parents and siblings.

ETHICS AND DISSEMINATION

This study has received ethical approval from the University of Pennsylvania Institutional Review Board (protocol #843844). Our overall objective is to characterise the ongoing impact of paediatric critical illness to guide development of interventions that optimise outcomes among children surviving critical illness and their families. Findings will be presented at key disciplinary meetings and in peer-reviewed publications at fixed data points. Published manuscripts will be added to our public study website to ensure findings are available to families, clinicians and researchers.

TRIALS REGISTRATION NUMBER

NCT04967365.

Delineating family needs in the transition from hospital to home for children with medical complexity: part 2, a phenomenological study

BACKGROUND

A systematic literature review on the transition from hospital-to-home (H2H) of families with a child with medical complexity (CMC), resulted in nine overarching themes. These demonstrated common needs and experiences despite the widely differing CMC diagnoses and family characteristics. However, none of the reported studies was conducted in the Netherlands, which hampers the creation of a tailored H2H care pathway, deemed essential for our recently established Transitional Care Unit in the Netherlands: the 'Jeroen Pit Huis'. Therefore, the aim of this study was to gain a deeper understanding of the needs and experiences of Dutch CMC parents on H2H transition and integrate these insights with the literature review into an evidence-based H2H care pathway for CMC and their families.

METHODS

A descriptive phenomenological approach was applied. Heterogeneous purposeful sampling methods were used to recruit participants according to the following criteria: parents of CMC from various regions in the Netherlands, who spoke Dutch fluently and who had been discharged home from a tertiary hospital within the previous five years. Semi-structured, open-ended interviews were conducted via video call by two researchers, who transcribed the audio recordings verbatim. Thematic analysis methods were used to identify emerging themes from the individual transcripts, involving a third and fourth researcher to reach consensus.

RESULTS

Between March and August 2021, 14 mothers and 7 fathers participated in 14 interviews. They elaborated on the H2H transition of 14 CMC with a wide range of underlying diseases: 7 male, 7 female, aged 6 months to 10 years. Eight overarching themes, consistent with the results of the systematic review, represent CMC parental needs and experiences during the H2H process in the Netherlands: (1) autonomy, (2) division of tasks and roles, (3) family emotions, (4) impact on family life, (5) communication, (6) coordination of care, (7) support system and (8) adaptation.

CONCLUSIONS

The H2H needs and experiences reported by the CMC families in this study align with the results of our systematic review. The H2H transition process is not linear but continuous, and should extend beyond the specific medical needs of the CMC to holistic care for the family as a whole. The overarching care needs and experiences, expressed by all CMC families, regardless of underlying symptoms and diagnoses, inform the H2H care pathway and its future evaluation. Our studies highlight the necessity to focus on the family needs rather than on the specific illness of the child, as well as the value of our interdisciplinary care team partnering with parents in the 'Jeroen Pit Huis' towards a safe and sustainable transition home.

Delineating family needs in the transition from hospital to home for children with medical complexity: part 1, a meta-aggregation of qualitative studies

BACKGROUND

Advances in diagnostic and therapeutic interventions for rare diseases result in greater survival rates, with on the flipside an expanding group of children with medical complexity (CMC). When CMC leave the protective hospital environment to be cared for at home, their parents face many challenges as they take on a new role, that of caregiver rather than care-recipient. However, an overview of needs and experiences of parents of CMC during transition from hospital-to-home (H2H) is lacking, which hampers the creation of a tailored H2H care pathway. Here we address this unmet medical need by performing a literature review to systematically identify, assess and synthesize all existing qualitative evidence on H2H transition needs of CMC parents.

METHODS

An extensive search in Medline, PsychINFO and CINAHL (up to September 2022); selection was performed to include all qualitative studies describing parental needs and experiences during H2H transition of CMC. All papers were assessed by two independent investigators for methodological quality before data (study findings) were extracted and pooled. A meta-aggregation method categorized the study findings into categories and formulated overarching synthesized findings, which were assigned a level of confidence, following the ConQual approach.

RESULTS

The search yielded 1880 papers of which 25 met eligible criteria. A total of 402 study findings were extracted from the included studies and subsequently aggregated into 50 categories and 9 synthesized findings: (1) parental empowerment: shifting from care recipient to caregiver (2) coordination of care (3) communication and information (4) training skills (5) preparation for discharge (6) access to resources and support system (7) emotional experiences: fatigue, fear, isolation and guilt (8) parent-professional relationship (9) changing perspective: finding new routines and practices. The overall ConQual Score was low for 7 synthesized findings and very low for 2 synthesized findings.

CONCLUSIONS

Despite the variability in CMC symptoms and underlying (rare disease) diagnoses, overarching themes in parental needs during H2H transition emerged. We will augment this new knowledge with an interview study in the Dutch setting to ultimately translate into an evidence-based tailored care pathway for implementation by our interdisciplinary team in the newly established 'Jeroen Pit Huis', an innovative care unit which aims for a safe and sustainable H2H transition for CMC and their families.

Healthcare Professionals' Attitudes towards and Knowledge and Understanding of Paediatric Palliative Medicine (PPM) and Its Meaning within the Paediatric Intensive Care Unit (PICU): A Summative Content Analysis in a Tertiary Children's Hospital in Scotland-"An In Vitro Study"

Background: Paediatric palliative medicine (PPM) is a holistic approach to care for children and their families. Services are growing and developing worldwide but significant disparity in service provision remains. The Paediatric Supportive and Palliative Care Team (PSPCT) at the Royal Hospital for Children in Glasgow was established in 2019, but there is still no clear integrated role within the paediatric intensive care unit (PICU) at present. Through analysing the attitudes, meaning, knowledge and understanding of PPM in the PICU environment, we hoped to explore the experiences of those providing paediatric palliative care and to identify any barriers to or facilitators of integrated working to gain a better understanding of providing this care. Methods: This qualitative study used a survey composed of five open-ended and five closed questions. Sixteen out of a possible thirty-two responses (50%) were accrued from PICU healthcare professionals, including consultants (n = 19), advanced nurse practitioners (n = 4) and band-seven nurses (n = 9). The data were comprehensively studied and analysed by two coders using summative content analysis with assistance from data management software. Codes were further developed to form categories and subcategories. Results: Two categories were found: (1) the role of palliative care and (2) experiences of providing palliative care. A total of five subcategories were found, demonstrating that the PSPCT can enhance care in PICU through collaborative working. Barriers identified included staffing, funding and stigma around palliative care. Conclusions: This study shows that PICU professionals have a good understanding of the concepts of PPM and view it as an essential part of PICU work. Barriers related to resources and misperceptions of palliative care can be overcome through improved education, funding and staff retention, but this would require buy-in from policymakers. The perspective from our relatively small team increases generalizability to growing teams across the country.

Long-term functional outcomes of children after critical illnesses: A cohort study

OBJECTIVE

To assess children's functional outcomes one year after critical illness and identify which factors influenced these functional outcomes.

DESIGN

Ambispective cohort study.

SETTING

Pediatric intensive care unit (PICU) in a tertiary academic center.

PARTICIPANTS

Children (1 month-17-year-old) and their caregivers.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Demographic, clinical, and functional status.

RESULTS

Of 242 patients screened, 128 completed the year follow-up. These children had significant changes in functional status over time (p<0.001). The functional decline occurred in 62% of children at discharge and, after one year, was persistent in 33%. Age>12 months was a protective factor against poor functional outcomes in two regression models (p<0.05). A moderately abnormal functional status and a severely/very severely abnormal functional status at discharge increased the risks of poor functional outcomes by 4.14 (95% CI 1.02-16.72; p=0.04), and 4.76 (CI 95% 1.19-19.0; p=0.02). A functional decline at discharge increased by 6.86 (95%CI: 2.16-21.79; p=0.001) the risks of children's long-term poor functional outcomes, regardless of the FSS scores.

CONCLUSION

This is the first study evaluating long-term functional outcomes after pediatric critical illnesses in Latin America. Our findings show baseline data and raise relevant questions for future multicentre studies in this field in Latin America, contributing to a better understanding of the effects of critical illnesses on long-term functional outcomes in children.

Defining Pediatric Chronic Critical Illness: A Scoping Review

OBJECTIVES

Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions.

DATA SOURCES

Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021.

STUDY SELECTION

We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening.

DATA EXTRACTION

We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed.

DATA SYNTHESIS

Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18).

CONCLUSIONS

Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.

Long Stay and Frequent Readmission in the Pediatric Intensive Care in The Netherlands; 15-Year Time Trends

To describe time trends and the burden of long-stay patients (LSP) and frequent-readmission patients (FRP) in the PICUs in The Netherlands.

DESIGN

Retrospective analysis of data from the nationwide Pediatric Intensive Care Evaluation registry including all PICU admissions in The Netherlands.

SETTING

All PICUs in The Netherlands.

PATIENTS

All PICU patients less than 18 years old admitted between 2003 and 2017. Two groups of patients were identified: LSP (admitted ≥30 d) and FRP (≥3 readmissions within the first year after their first admission).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 47,424 children were admitted on 59,759 occasions. LSP (3.3% of total cohort) and FRP (2.1%) accounted for 37.5% and 14.5% of cumulative admission days, respectively. Patients fulfilling both LSP and FRP criteria (0.6%) accounted for 9.9% of cumulative admission days. No significant time trends were observed between 2003 and 2017 for the number of LSP and FRP, nor for accounted cumulative admission days. Age and disease severity-adjusted mortality was significantly higher for LSP (odds ratio [OR], 2.16; 95% CI, 1.66-2.82; p < 0.001) and FRP OR 1.40 (95% CI, 0.97-2.01; p = 0.069) compared with the general PICU population. Overall PICU mortality decreased significantly between 2003 (6.5%) and 2017 (3.7%; p = 0.004), but remained constant over time for both LSP (17.2%) and FRP (6.3%).

CONCLUSIONS

The proportion of LSP and FRP and their burden on PICU capacity are considerable and remained constant between 2003 and 2017. Whereas age and disease severity-adjusted mortality decreased in the general PICU population, it did not change in LSP and FRP.

Pediatric Ventilation Liberation: A Survey of International Practice Among 555 Pediatric Intensivists

Pediatric ventilation liberation has limited evidence, likely resulting in wide practice variation. To inform future work, practice patterns must first be described.

Resource Utilization in Children who Receive a Pediatric Intensive Care Unit Consult in the Emergency Department: A Retrospective Cohort Study

OBJECTIVES

To describe the characteristics, critical care resource requirements, and outcomes of children who were hospitalized after a Pediatric Intensive Care Unit (PICU) consult in the Emergency Department (ED).

METHODS

In this single-centre retrospective cohort study, we conducted chart reviews for children (<18 years) hospitalized following a PICU consult in the ED to examine patient characteristics, timing of consult, ED length of stay, Medical Emergency Team (MET) utilization, PICU nursing workload, and critical care interventions for children who were and were not admitted to the PICU.

RESULTS

During the one-year study period, 247 PICU consults were performed in the ED resulting in 161 (65.2%) direct admissions to PICU and 1 indirect PICU admission via the ward. Of 105 children with complex chronic conditions, 73 (69.5%) were admitted to PICU, including 32 (91.4%) of 35 children with chronic home ventilatory needs, only 2 (6.2%) of whom received a critical care intervention beyond respiratory support. Within 24 h of hospitalization, 112 (69.1%) of 162 PICU admissions received a critical care-specific intervention. Of 86 (34.8%) ward admissions, 16 (18.6%) were reviewed by the MET. Children admitted to the ward had a significantly longer post-consult ED length of stay than children admitted to PICU (median 428 min vs. 130 min; p <0.0001).

CONCLUSIONS

Over two-thirds of children admitted to PICU from the ED required early critical care interventions, with the remainder potentially benefitting from closer monitoring or a higher frequency of non-critical care interventions than can be reasonably provided on general inpatient wards. More research is needed to evaluate critical care and hospital resource utilization when children are triaged to the ward following a PICU consult in the ED.

Feasibility of bioimpedance spectroscopy and long-term functional assessment in critically ill children

BACKGROUND & AIMS

Lean body mass loss due to critical illness in childhood could be detrimental to long term outcomes, including functional status and quality of life. We describe the feasibility of body composition assessment by bioimpedance spectroscopy (BIS) in the pediatric intensive care unit (PICU), and functional status and quality of life assessments up to 6 months following admission in a cohort of mechanically ventilated, critically ill children.

METHODS

We conducted a prospective, observational pilot study in a multidisciplinary PICU. Children aged 1 month to 18 years who required mechanical ventilation, with expected stay in the PICU of at least 5 days were included. We examined the feasibility of consenting, enrolling, and completing baseline and 6-month assessments of BIS variables, Functional Status Scale (FSS), and Pediatric Quality of Life (Peds QL), in eligible patients.

RESULTS

Of 32 patients approached, 23 (72%) completed baseline assessments [median (IQR) age 3.4 (1.0, 7.8) years, 14 (61%) male]; 6-month assessments were completed in 15 (65%) enrolled patients. Mean (SD) phase angle at study enrollment was 2.95 (0.93) and the impedance ratio was 0.90 (0.03). Phase angle (r_s = -0.58, p = 0.03) and impedance ratio (r_s = 0.61, p = 0.02) by BIS were significantly correlated with total FSS at PICU discharge. Median total FSS and FSS tech (feeding and respiratory domains of FSS) scores improved from enrollment [16 (13, 26) and 8 (7, 10)] to 6 months [6 (6, 9) and 2 (2, 4), respectively, p < 0.001]. Median Peds QL total, physical summary and psychosocial summary scores were not significantly different between PICU discharge and 6 months after PICU admission. Correlations between the total 6-month FSS and a) phase angle (-0.45, p = 0.197) and b) impedance ratio (0.56, p = 0.096) at PICU discharge were not significant.

CONCLUSIONS

We have demonstrated the feasibility of obtaining bedside BIS measurements in the PICU, and functional and quality of life assessments remotely following PICU discharge. Body composition and long-term assessment of functional outcomes and quality of life must be incorporated in nutrition trials in critically ill children.

Trajectory and Risk Factors of Persistent Decline in Health-Related Quality of Life after Septic Shock in Children with Preexisting Neurologic Disability

Preexisting neurologic disability is common among children with septic shock. Life After Pediatric Sepsis Evaluation (LAPSE) was a multicenter cohort study that evaluated health-related quality of life (HRQL) in children with community-acquired septic shock. In this secondary analysis of LAPSE, we described the burden, trajectory, and risk factors for reduced HRQL in children with preexisting neurologic disability. Children (1 month–18 years) with community-acquired septic shock were evaluated for HRQL at baseline (reflecting pre-hospitalization status), day 7 and 28, and month 3, 6, and 12 following admission using the Pediatric Quality of Life Inventory or the Stein–Jessop Functional Status Scale. HRQL was expressed as a percentage of baseline scores. Of 365 evaluable children, 133 (36%) had preexisting neurologic disability. Neurologically disabled children had less decline in HRQL at day 7 (median −15% [interquartile range IQR −38, 8] vs. −22% [−51, −3], p = 0.005) and day 28 (4% [−16, 22] vs. −11% [−37, 7], p < 0.001) than those without neurologic disability, and there was no difference in the extent of decline at month 3 (p = 0.241). Using multivariable modeling, higher baseline HRQL (odds ratio [OR] 1.04 [95% confidence interval [CI] 1.00, 1.08], p = 0.027) and acute renal dysfunction (OR 1.08 [1.02, 1.16], p = 0.007) were associated with HRQL less than 90% of baseline at month 3 in neurologically disabled children who survived. Children with preexisting neurologic disability recover to baseline HRQL after septic shock sooner than those without neurologic disability. Higher baseline HRQL and acute renal dysfunction are risk factors for reduced HRQL in neurologically disabled children who survive sepsis.

Pediatric Chronic Critical Illness: Validation, Prevalence, and Impact in a Children's Hospital

OBJECTIVES

Large populations of chronically critically ill patients test the critical care system's resource utilization ability. Defining and tracking this group is necessary for census predictions.

DESIGN

Retrospective cohort analysis.

SETTINGS

Tertiary academic center in United States.

PATIENTS

Patients admitted to PICU or neonatal ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographics and resource utilization variables were sampled in PICU, intermediate care unit, cardiovascular ICU, and neonatal ICU on 3 random days in 3 consecutive months. The attendings' perception of pediatric chronic critical illness was contrasted to Shapiro's definition of chronic critical care criteria. Each unit's active and maximal capacity census was computed: the occurrence rate of pediatric chronic critical illness was 34%, the prevalence was 44.5%, and the tolerance, or percentage pediatric chronic critical illness patients to all available beds, was 36.8%. The median length of stay for the nonpatients with pediatric critical care illness to patients with pediatric critical care illness was 9 versus 46 days (1/5.1). The attending's decision was 58 times more concordant with the criteria. Pediatric chronic critical illness bed occupancy was 40.6% in PICU, 97.2% in intermediate care unit, 47.8% in cardiovascular ICU, and 33.9% in neonatal ICU.

CONCLUSIONS

Pediatric chronic critical illness patients occupied more than one third of the ICU beds and have five times longer stay. This mounting load needs to be uniformly defined, addressed at regional and national levels, and considered in the current pandemic planning.

Social Factors Predictive of Intensive Care Utilization in Technology-Dependent Children, a Retrospective Multicenter Cohort Study

Objective: Technology-dependent children with medical complexity (CMC) are frequently admitted to the pediatric intensive care unit (PICU). The social risk factors for high PICU utilization in these children are not well described. The objective of this study was to describe the relationship between race, ethnicity, insurance status, estimated household income, and PICU admission following the placement of a tracheostomy and/or gastrostomy (GT) in CMC. Study Design: This was a retrospective multicenter study of children <19 years requiring tracheostomy and/or GT placement discharged from a hospital contributing to the Pediatric Health Information System (PHIS) database between January 2016 and March 2019. Primary predictors included estimated household income, insurance status, and race/ethnicity. Additional predictor variables collected included patient age, sex, number of chronic complex conditions (CCC), history of prematurity, and discharge disposition following index hospitalization. The primary outcome was need for PICU readmission within 30 days of hospital discharge. Secondary outcomes included repeated PICU admissions and total hospital costs within 1 year of tracheostomy and/or GT placement. Results: Patients requiring a PICU readmission within 30 days of index hospitalization for tracheostomy or GT placement accounted for 6% of the 20,085 included subjects. In multivariate analyses, public insurance [OR 1.28 (95% C.I. 1.12-1.47), p < 0.001] was associated with PICU readmission within 30 days of hospital discharge while living below the federal poverty threshold (FPT) was associated with a lower odds of 30-day PICU readmission [OR 0.7 (95% C.I. 0.51-0.95), p = 0.0267]. Over 20% (n = 4,197) of children required multiple (>1) PICU admissions within one year from index hospitalization. In multivariate analysis, Black children [OR 1.20 (95% C.I. 1.10-1.32), p < 0.001] and those with public insurance [OR 1.34 (95% C.I. 1.24-1.46), p < 0.001] had higher odds of multiple PICU admissions. Social risk factors were not associated with total hospital costs accrued within 1 year of tracheostomy and/or GT placement. Conclusions: In a multicenter cohort study, Black children and those with public insurance had higher PICU utilization following tracheostomy and/or GT placement. Future research should target improving healthcare outcomes in these high-risk populations.

Psychometric Testing of the Activity Measure for Post-Acute Care (AM-PAC) in the Pediatric Acute Care Setting

PURPOSE

To determine interrater reliability and construct validity of the Activity Measure for Post-Acute Care (AM-PAC) Inpatient "6-clicks" Short Forms for children in acute care.

METHODS

Eight physical therapists (PTs) scored the AM-PAC Basic Mobility, 30-second walk test (30SWT), and Timed Up and Go (TUG) for 54 patients (4-17 years); 6 occupational therapists (OTs) scored the AM-PAC Daily Activity and handgrip dynamometry for 50 patients (5-17 years). Correlations between the AM-PAC Basic Mobility, 30SWT, and TUG and between the Daily Activity AM-PAC and handgrip dynamometry were calculated for evidence of construct validity.

RESULTS

Interrater reliability for the AM-PAC was excellent for PTs and OTs. Validity was strong to moderate for Basic Mobility when compared with the 30SWT and TUG. Daily Activity had weak correlation with mean left handgrip strength and no correlation with mean right handgrip strength.

CONCLUSIONS

AM-PAC Short Forms have acceptable psychometrics for use among children in acute care.

Physical Functioning After Admission to the PICU: A Scoping Review

Supplemental Digital Content is available in the text.

Objectives:

To conduct a scoping review to 1) describe findings and determinants of physical functioning in children during and/or after PICU stay, 2) identify which domains of physical functioning are measured, 3) and synthesize the clinical and research knowledge gaps.

Data Sources:

A systematic search was conducted in PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidelines.

Study Selection:

Two investigators independently screened and included studies against predetermined criteria.

Data Extraction:

One investigator extracted data with review by a second investigator. A narrative analyses approach was used.

Data Synthesis:

A total of 2,610 articles were identified, leaving 68 studies for inclusion. Post-PICU/hospital discharge scores show that PICU survivors report difficulties in physical functioning during and years after PICU stay. Although sustained improvements in the long-term have been reported, most of the reported levels were lower compared with the reference and baseline values. Decreased physical functioning was associated with longer hospital stay and presence of comorbidities. A diversity of instruments was used in which mobility and self-care were mostly addressed.

CONCLUSIONS:

The results show that children perceive moderate to severe difficulties in physical functioning during and years after PICU stay. Longitudinal assessments during and after PICU stay should be incorporated, especially for children with a higher risk for poor functional outcomes. There is need for consensus on the most suitable methods to assess physical functioning in children admitted to the PICU.

Poor Functional Outcomes in Pediatric Intensive Care Survivors in Brazil: Prevalence and Associated Factors

Survivors of pediatric critical illnesses develop temporary or permanent functional impairments. We do not have enough data on Brazilian children, however, and the available evidence mainly shows results from high-income countries. Our objective was to assess changes in children and adolescents' functional status surviving critical illnesses in Brazil, and to identify which factors contribute to these functional changes at pediatric intensive care unit (PICU) discharge. To develop this cross-sectional study, two researchers blinded to previous patient information applied the Functional Status Scale (FSS) with patients and caregivers at two different times in a tertiary PICU. The FSS examines six function domains as follows: (1) mental status, (2) sensory functioning, (3) communication, (4) motor functioning, (5) feeding, and (6) respiratory status. The functional decline/poor outcome was defined as an increase in points sufficient to alter the FSS total scores at discharge when comparing to the total baseline score. A total of 303 patients completed the study. Of these, 199 (66%) were with previous chronic conditions. The prevalence of functional decrease was 68% at PICU discharge. Young age (<12 months) and mechanical ventilation time ≥11 days increased by 1.44 (95% confidence interval [CI]: 1.20–1.74, p < 0.001) and 1.74 (95% CI: 1.49–2.03, p < 0.001), respectively, the chances of poor functional results at PICU discharge. This study is the first in Brazil to show that during the episode of critical illness, young age (≤12 months) and duration of invasive mechanical ventilation independently increased the chances of functional impairment in children.

Physical Rehabilitation in Critically Ill Children: A Multicenter Point Prevalence Study in the United States

OBJECTIVES

With decreasing mortality in PICUs, a growing number of survivors experience long-lasting physical impairments. Early physical rehabilitation and mobilization during critical illness are safe and feasible, but little is known about the prevalence in PICUs. We aimed to evaluate the prevalence of rehabilitation for critically ill children and associated barriers.

DESIGN

National 2-day point prevalence study.

SETTING

Eighty-two PICUs in 65 hospitals across the United States.

PATIENTS

All patients admitted to a participating PICU for greater than or equal to 72 hours on each point prevalence day.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was prevalence of physical therapy- or occupational therapy-provided mobility on the study days. PICUs also prospectively collected timing of initial rehabilitation team consultation, clinical and patient mobility data, potential mobility-associated safety events, and barriers to mobility. The point prevalence of physical therapy- or occupational therapy-provided mobility during 1,769 patient-days was 35% and associated with older age (adjusted odds ratio for 13-17 vs < 3 yr, 2.1; 95% CI, 1.5-3.1) and male gender (adjusted odds ratio for females, 0.76; 95% CI, 0.61-0.95). Patients with higher baseline function (Pediatric Cerebral Performance Category, ≤ 2 vs > 2) less often had rehabilitation consultation within the first 72 hours (27% vs 38%; p < 0.001). Patients were completely immobile on 19% of patient-days. A potential safety event occurred in only 4% of 4,700 mobility sessions, most commonly a transient change in vital signs. Out-of-bed mobility was negatively associated with the presence of an endotracheal tube (adjusted odds ratio, 0.13; 95% CI, 0.1-0.2) and urinary catheter (adjusted odds ratio, 0.28; 95% CI, 0.1-0.6). Positive associations included family presence in children less than 3 years old (adjusted odds ratio, 4.55; 95% CI, 3.1-6.6).

CONCLUSIONS

Younger children, females, and patients with higher baseline function less commonly receive rehabilitation in U.S. PICUs, and early rehabilitation consultation is infrequent. These findings highlight the need for systematic design of rehabilitation interventions for all critically ill children at risk of functional impairments.

Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective

Advances in medical and surgical care for children in the pediatric intensive care unit (PICU) have led to vast reductions in mortality, but survivors often leave with newly acquired or worsened morbidity. Emerging evidence reveals that survivors of pediatric critical illness may experience a constellation of physical, emotional, cognitive, and social impairments, collectively known as the “post-intensive care syndrome in pediatrics” (PICs-P). The spectrum of PICs-P manifestations within each domain are heterogeneous. This is attributed to the wide age and developmental diversity of children admitted to PICUs and the high prevalence of chronic complex conditions. PICs-P recovery follows variable trajectories based on numerous patient, family, and environmental factors. Those who improve tend to do so within less than a year of discharge. A small proportion, however, may actually worsen over time. There are many gaps in our current understanding of PICs-P. A unified approach to screening, preventing, and treating PICs-P-related morbidity has been hindered by disparate research methodology. Initiatives are underway to harmonize clinical and research priorities, validate new and existing epidemiologic and patient-specific tools for the prediction or monitoring of outcomes, and define research priorities for investigators interested in long-term outcomes.

CHILDREN AND YOUTH WITH SPECIAL HEALTHCARE NEEDS: (DIS) CONTINUITY OF CARE

ABSTRACT Objective to investigate the follow-up and characteristics of children and youth with special healthcare needs within Primary Health Care services located in a city in the State of São Paulo, Brazil. Method this qualitative study was supported by the Primary Health Care framework, and interviews were held with 37 health workers from the primary health care units located in the interior of São Paulo. Data were collected from May to December 2018 and treated with inductive thematic analysis. Results from the perspective of the health workers, the characteristics of these children and youth are centered on the dependence of specific care such as to promote psychomotor development, and dependence on technology and pharmacological treatments. They reported the difficulty to access health services while the primary health care services do not implement systematic follow-up. Conclusion these children and youth demand continuous and longitudinal care, which, however, is not provided by primary health care services, considering the discontinuity of care and a lack of networked follow-up. Therefore, health services need to be reorganized to keep up with changes in the child and youth morbidity and mortality to ensure continuous, integral, and networked follow-up to this population.

Predictors of outcome in children with disorders of mitochondrial metabolism in the pediatric intensive care unit

BACKGROUND

The aim of this study was to identify factors predicting outcome in patients with mitochondrial disease admitted to pediatric intensive care units (PICU).

METHODS

Retrospective study of 2434 patients (age <21 years) admitted to a PICU from 1 January 2006 through 31 March 2016 and captured in the Virtual Pediatric Systems database with ICD9 diagnosis 277.87, disorders of mitochondrial metabolism. Factors influencing mortality and prolonged length of stay (≥14 days) were analyzed using logistic regression.

RESULTS

Predictors independently affecting mortality (adjusted odds ratios and 95% confidence intervals, p < 0.05): age 1-23 months 3.4 (1.7-6.6) and mechanical ventilation 4.7 (2.6-8.6) were risk factors; post-operative 0.2 (0.1-0.6), readmission 0.5 (0.3-0.9), and neurologic reason for admittance 0.3 (0.1-0.9) were factors reducing risk. Predictors affecting prolonged length of stay: mechanical ventilation 7.4 (5.2-10.3) and infectious reason for admittance 2.0 (1.3-3.2) were risk factors, post-operative patients 0.3 (0.2-0.5) had lower risk. The utility of PRISM and PIM2 scores in this patient group was evaluated.

CONCLUSIONS

The single most predictive factor for both mortality and prolonged length of stay is the presence of mechanical ventilation. Age 1-23 months is a risk factor for mortality, and infectious reason for admittance indicates risk for prolonged length of stay.

IMPACT

Presence of mechanical ventilation is the factor most strongly associated with negative outcome in patients with mitochondrial disease in pediatric intensive care. Age 1-23 months is a risk factor for mortality, and infectious reason for admittance indicates risk for prolonged length of stay PRISM3 and PIM2 are not as accurate in patients with mitochondrial disease as in a mixed patient population.

A systematic concept analysis of 'technology dependent': challenging the terminology

There are an increasing number of children who are dependent on medical technology to sustain their lives. Although significant research on this issue is taking place, the terminology used is variable and the concept of technology dependence is ill-defined. A systematic concept analysis was conducted examining the attributes, antecedents, and consequences of the concept of technology dependent, as portrayed in the literature. We found that this concept refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide ranging sequelae for the child and family, and health and social care delivery.Conclusion: The term technology dependent is increasingly redundant. It objectifies a heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. What is Known: • There are an increasing number of children who require medical technology to sustain their life, commonly referred to as technology dependent. This concept analysis critically analyses the relevance of the term technology dependent which is in use for over 30 years. What is New: • Technology dependency refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide-ranging sequelae for the child and family, and health and social care delivery. • The paper shows that the term technology dependent is generally portrayed in the literature in a problem-focused manner. • This term is increasingly redundant and does not serve the heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. More appropriate child-centred terminology will be determined within the TechChild project.

Outcome Measures Following Critical Illness in Children With Disabilities: A Scoping Review

Children with disabilities compose a substantial portion of admissions and bed-days in the pediatric intensive care unit (PICU) and often experience readmissions over time. Impacts of a PICU admission on post-discharge health status may be difficult to distinguish from pre-existing disability in this population. Efforts to standardize outcome measures used for children with disabilities may help identify morbidities associated with PICU hospitalizations. Although a scoping review of outcome measures to assess children after episodes of critical illness has recently been published, it is not known to what extent these measures are appropriate for use in children with disabilities. This limits our ability to effectively measure long-term outcomes following critical illness in this important patient population. Through mixed methodology of scoping review and multi-stakeholder consensus, we aimed to identify and describe instruments previously utilized for this purpose and to explore additional tools for consideration. This yielded 51 measures across a variety of domains that have been utilized in the PICU setting and may be appropriate for use in children with disabilities. We describe characteristics of these instruments, including the type of developmental domains assessed, availability of population data, validation and considerations regarding administration in children with disabilities, and ease of availability of the instrument to researchers. Additionally, we suggest needed alterations or accommodations for these instruments to augment their utility in these populations, and highlight areas for future instrument development.

Parental Conflict, Regret, and Short-term Impact on Quality of Life in Tracheostomy Decision-Making

OBJECTIVES

The prevalence of tracheostomy-dependence in critically ill children is increasing in the United States. We do not know the impact of this decision on parental outcomes. We aimed to determine the prevalence of decisional conflict and regret and explore the impact on quality of life among parents considering tracheostomy placement for their child.

SUBJECTS

Parents facing tracheostomy decision for their child.

DESIGN

Prospective, mixed-methods longitudinal study.

SETTING

PICU, cardiac ICU, and neonatal ICU of a single quaternary medical center.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Parents completed a decisional conflict survey at the time of tracheostomy decision and decisional regret and quality of life surveys at 2 weeks and 3 months after the decision regarding tracheostomy placement was made. We enrolled 39 parents, of which 25 completed surveys at all three time points. Thirty-five of 39 (89.7%) reported at least some decisional conflict, most commonly from feeling uninformed and pressured to make a decision. At 2 weeks, 13 of 25 parents (52%) reported regret, which increased to 18 of 25 participants (72%) at 3 months. Regret stemmed from feeling uninformed, ill-chosen timing of placement, and perceptions of inadequate medical care. At 2 weeks, the quality of life score was in the mid-range, 78.8 (SD 13.8) and decreased to 75.5 (SD 14.2) at 3 months. Quality of life was impacted by the overwhelming medical care and complexity of caring for a child with a tracheostomy, financial burden, and effect on parent's psychosocial health.

CONCLUSIONS

The decision to pursue tracheostomy among parents of critically ill children is fraught with conflict with worsening regret and quality of life over time. Strategies to reduce contributing factors may improve parental outcomes after this life-changing decision.