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Mitterer S, Zimmermann K, Fink G, Simon M, Gerber AK, Bergsträsser E. Hospitalization- and death-related financial and employment effects in parents of children with life-limiting conditions: a fixed-effects analysis. Eur J Pediatr 2024; 183:4215-4227. [PMID: 38985175 DOI: 10.1007/s00431-024-05680-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/24/2024] [Accepted: 06/30/2024] [Indexed: 07/11/2024]
Abstract
The purpose of this study is to investigate out-of-pocket non-medical expenses and employment-related outcomes in families of children with life-limiting conditions, specifically, to quantify the financial and employment implications of two events: a child's hospitalization and death. This cohort study used panel data collected prospectively for a larger study investigating the effectiveness of specialized pediatric palliative care. Participants were recruited by medical professionals between November 2019 and May 2022 at four Swiss children's hospitals. The care follow-up and bereavement follow-up assessments were 330 and 300 days, respectively. We measured out-of-pocket non-medical expenses, individual full-time equivalent units, and personal income, as well as sick leave and vacation days taken. Analyses included descriptive statistics and two-way linear fixed-effects regressions. The analysis included 110 parents (mothers n = 59, fathers n = 51) of 61 children. Children were hospitalized for a median of 7 days (interquartile range 0-21, range 0-227). The fixed-effects models found a positive association between hospitalization, i.e., length of stay, and travel and accommodation expenses (coefficient 4.18, 95% confidence interval 2.20-6.16). On average, for each week of hospitalization, parents spent an additional 29 Swiss francs on travel and accommodation. During the 300-day bereavement follow-up, six (26%) of 23 parents increased their work commitments, while one reported a decrease. CONCLUSIONS Families incur higher travel and accommodation expenses during hospitalization than during non-hospitalized periods. Instrumental support, e.g., parking vouchers, can help families minimize these costs. Future studies should investigate whether early return to work during bereavement is driven by economic considerations or a desire for distraction. CLINICAL TRIAL REGISTRATION Data analyzed in this study were collected as part of a clinical trial, registered on ClinicalTrials.gov, No. NCT04236180, 15 March 2019 What Is Known: • Families of children with life-limiting conditions are at risk of substantial financial burden from high out-of-pocket medical expenses. • It is also known that parents often have to incur out-of-pocket non-medical expenses and reduce their work commitments. Little is known about the economic consequences of losing a child to a life-limiting condition. WHAT IS NEW • We provide new longitudinal evidence on the hospitalization- and death-related financial and employment implications for families of children with life-limiting conditions. • Child hospitalizations add to families' financial burden through increased travel and accommodation expenses. Work commitments rose during early bereavement.
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Affiliation(s)
- Stefan Mitterer
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, CH-4065, Basel, Switzerland
| | - Karin Zimmermann
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, CH-4065, Basel, Switzerland.
- Paediatric Palliative Care and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
| | - Günther Fink
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Michael Simon
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, CH-4065, Basel, Switzerland
| | - Anne-Kathrin Gerber
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, CH-4065, Basel, Switzerland
| | - Eva Bergsträsser
- Paediatric Palliative Care and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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Wu PC, Tsai SJ, Bai YM, Hsu JW, Su TP, Chen TJ, Chen MH. Risks of developing major psychiatric disorders among child and adolescent intensive care unit survivors. J Affect Disord 2024; 362:772-778. [PMID: 39032708 DOI: 10.1016/j.jad.2024.07.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 06/25/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The mental health of child and adolescent intensive care unit (ICU) survivors is increasingly being researched. However, the literature on how various types of critical illness influence specific psychiatric disorders remains limited. METHODS This study analyzed the data of 8704 child and adolescent ICU survivors and 87,040 age-, sex-, family income-, and residence-matched controls who were followed from enrollment to the end of 2013; the data covered the period from 1996 to 2013 and were extracted from a nationwide data set. The primary outcomes were the risks of five major psychiatric disorders (MPDs), namely schizophrenia, bipolar disorder (BD), major depressive disorder (MDD), obsessive compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). RESULTS Relative to the controls, the child and adolescent ICU survivors (mean age = 10.33 years) exhibited higher risks of developing five MPDs. The associated hazard ratios (HRs) and confidence intervals (CIs) are as follows: PTSD, HR = 4.67, 95 % CI = 2.42-9.01; schizophrenia, HR = 3.19, 95 % CI = 2.27-4.47; BD, HR = 2.02, 95 % CI = 1.33-3.05; OCD, HR = 1.96, 95 % CI = 1.21-3.16; and MDD, HR = 1.68, 95 % CI = 1.44-1.95. The risks of developing MPDs varied across multiple types of critical illness related to ICU admission. CONCLUSIONS The risks of MPDs were significantly higher among the child and adolescent ICU survivors than among the controls. The development of appropriate MPD prevention strategies should be emphasized for this vulnerable population.
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Affiliation(s)
- Ping-Chung Wu
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Jen Tsai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Mei Bai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ju-Wei Hsu
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tung-Ping Su
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Psychiatry, General Cheng Hsin Hospital, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Family Medicine, Taipei Veterans General Hospital, Hsinchu Branch, Hsinchu, Taiwan
| | - Mu-Hong Chen
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Ramnarayan P, Wood D, Draper E, Palmer L, Feltbower R, Buckley HL, Griksaitis MJ, Lutman DH, Kanaris C, O'Shea D, Seaton SE. Transport of critically ill children to paediatric intensive care units in the UK and Ireland: 2013-2022. Arch Dis Child 2024:archdischild-2024-327088. [PMID: 39209528 DOI: 10.1136/archdischild-2024-327088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 08/17/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To explore the trends and changes in the transport of children to paediatric intensive care units (PICUs) between 2013 and 2022. DESIGN Retrospective analysis of routinely collected data. PATIENTS Children transported for care in a PICU in the UK and Ireland aged<16 years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 43 058 transports to a PICU involving 36 438 children from 2013 to 2022 with the majority of children requiring only one transport. The number of transports increased from 4131 (2013) to 4792 (2022). Over the study period the percentage of children aged under 1 year who were transported decreased from 50.2% to 45.2% and similarly, the percentage who were invasively ventilated also decreased from 81.1% to 70.2%. Conversely, the use of non-invasive ventilation during transports increased slightly from 4.0% to 7.0%. The percentage of transports where a parent was able to accompany the child increased over time (2013: 66.2% to 2019: 74.9%), although there were reductions due to the COVID-19 pandemic and requirements for social distancing (2020: 52.4%). CONCLUSIONS We have demonstrated an increased use of specialist paediatric transport services and changes in the PICU population over time. Routine data collection from the transport services provide a means to measure improvements and changes over time in the service provided to critically ill children and young people who need transport to the PICU.
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Affiliation(s)
| | - Dora Wood
- Wales and West Acute Transport for Children Service (WATCh), Bristol Royal Hospital for Children, Bristol, UK
| | - Elizabeth Draper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Lyn Palmer
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | | | | | - Michael J Griksaitis
- Paediatric Intensive Care Unit, Southampton Children's Hospital, Southampton, UK
- University of Southampton Faculty of Medicine, Southampton, UK
| | - Daniel Henry Lutman
- Children's Acute Transport Service, Great Ormond Street Hospital For Children NHS Trust, London, UK
| | | | | | - Sarah E Seaton
- Department of Population Health Sciences, University of Leicester, Leicester, UK
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4
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Daham S, Larsson E, Eksborg S, Hamrin TH. Mortality following admission to the paediatric intensive care unit: A Swedish longitudinal cohort study. Acta Paediatr 2024. [PMID: 38994852 DOI: 10.1111/apa.17352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/25/2024] [Accepted: 07/01/2024] [Indexed: 07/13/2024]
Abstract
AIM This study aimed to compare outcomes post-admission to a Swedish paediatric intensive care unit (PICU) in children with complex chronic conditions (CCC) and without CCC. METHODS In this observational registry-based study, consecutive admissions to the Astrid Lindgren Children's Hospital PICU from 1 January 2008 to 31 December 2016 were analysed. Data on demographics, predicted death rates (PDR), admission diagnoses and causes of death were collected. Mortality was recorded up to 15 years after admission and compared between groups. RESULTS Patients with CCC constituted 64.6% (n = 3026) of PICU admissions and 83.5% (n = 111) of PICU deaths. The crude mortality rate in PICU was 2.84% overall. CCC-patients were 2.83 times more likely to die in PICU compared to non-CCC (OR 2.83; 95% CI: 1.78-4.49). Mortality increased in the CCC-cohort up to 5 years after PICU discharge, while non-CCC patients generally survived if they survived in PICU. Of the patients who died in PICU, the median PDR was 22.9% for CCC-patients and 66.5% in the non-CCC cohort. CONCLUSION Children with CCC accounted for most admissions and deaths in PICU. Despite lower severity of illness scores upon admission, CCC patients were nearly three times more likely to die in PICU compared to non-CCC patients.
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Affiliation(s)
- Shanay Daham
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Emma Larsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Staffan Eksborg
- Department of Paediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Tova Hannegård Hamrin
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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5
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Widyaratne A, Bally JMG. Utilization of the Keeping Hope Possible Toolkit with parents of children with life limiting and life threatening illnesses during the COVID-19 pandemic: Exploring pediatric nurses and allied healthcare provider opinions. J Pediatr Nurs 2024; 77:e177-e186. [PMID: 38627171 DOI: 10.1016/j.pedn.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND For families with children diagnosed with complex illnesses, the COVID-19 pandemic added many challenges. In order to mitigate inevitable disruptions in pediatric care settings, caregivers may need added supports and resources. The Keeping Hope Possible (KHP) Toolkit is a self-administered intervention intended to enhance caregiving experiences of parents with a child with multiple needs. However, little is known about effectively disseminating the Toolkit. PURPOSE AND METHODS A qualitative, thematic analysis was conducted to explore the opinions and perceptions of pediatric nurses and allied healthcare providers (HCPs) in relation to the dissemination and use of the KHP Toolkit for use by families with complex medical needs. Structured interview data were analyzed from a sample of seven pediatric HCPs working in various care settings in one Canadian province. FINDINGS Five themes were developed including: Recognising Importance of the KHP Toolkit; Needing Support and Direction; Implementation and Use of the KHP Toolkit; Realizing Important Considerations for Success; and, Emphasizing Connection through Isolated Times. DISCUSSION Participants recognized the importance of the KHP Toolkit for parents and extended family in a variety of settings to encourage self-care, daily structure, and connectedness. Thus, pediatric nurses' awareness and openness to the initial dissemination of the Toolkit is essential, and a subsequent interprofessional team approach will ensure consistent reminders and support for families. APPLICATION TO PRACTICE Careful assessment of family readiness for learning about and using the KHP Toolkit is essential, along with an interprofessional approach to consistent inquiry and support at each family encounter.
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Affiliation(s)
- Amaya Widyaratne
- College of Arts & Science, University of Saskatchewan, 9 Campus Drive, Saskatoon, SK S7N 5A5, Canada.
| | - Jill M G Bally
- College of Nursing, University of Saskatchewan, 104 Clinic Drive, Saskatoon, SK S7N 2Z4, Canada
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Keane E, Johnson M, Laycock H. Rethinking paediatric peri-operative cardiac arrest: proactive preparation and tailored training. Anaesthesia 2024; 79:567-572. [PMID: 38462789 DOI: 10.1111/anae.16276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/12/2024]
Affiliation(s)
- E Keane
- Department of Anaesthesia and Critical Care, University Hospital Limerick, Limerick, Ireland
| | - M Johnson
- Department of Paediatric Intensive Care and Department of Anaesthesia, Great Ormond Street Hospital, London, UK
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - H Laycock
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
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7
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Reid BB, Brogan P. Nurses' experiences of providing palliative care for children with life-limiting conditions. Int J Palliat Nurs 2024; 30:212-224. [PMID: 38885152 DOI: 10.12968/ijpn.2024.30.5.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Paediatric palliative care (PPC) has evolved in response to the increased prevalence of children who have been diagnosed with life-limiting conditions. Nursing care is a fundamental aspect of PPC and understanding nurses' experiences is imperative to the provision and development of quality holistic child-centred services. AIM To review nurses' experiences of providing palliative care for children with life-limiting conditions. METHOD A systematic database search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Ovid Medline and Scopus was undertaken. Key words consisted of 'palliative care' or 'terminal care' or 'dying' or 'end-of-life care' and children* or paediatric* or pediatric* and 'nurs* experience*' or 'nurs* view*' or 'nurs* perspective*' or 'nurs* feeling*'. Inclusion criteria included peer-reviewed studies published between 2016-2023 in the English language. FINDINGS A thematic approach was adopted with the 11 papers selected for the review and each study critically analysed to identify three recurring themes. The themes included: 'a broken wreck', 'makes a life worth living' and 'challenges in doing 100%'. Findings point to mixed feelings among nurses in providing PPC and suggest that nurses experience emotional distress when caring for dying children. With appropriate supports and inspiration from their paediatric patients, nurses are determined to provide a 'good death' for the children in their care. Nevertheless, the perceived lack of knowledge and experience, communication struggles and personal dilemmas can be predisposing factors in triggering negative experiences among nurses when providing palliative care for children with life-limiting conditions. RECOMMENDATIONS Education and policy development is required to meet the practice needs and support the emotional needs of nurses engaged in PPC. Further research is required to generate PPC evidence-based nursing interventions. In doing so, high quality PPC practice will be promoted, thereby ensuring high quality PPC for the children and their families.
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Affiliation(s)
- Bernie B Reid
- Ulster University, Derry/Londonderry, Northern Ireland
| | - Patricia Brogan
- Nursing Student, Ulster University, Derry/Londonderry, Northern Ireland
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8
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Seaton SE, Battersby C, Davis PJ, Fenton AC, Anderson J, van Hasselt TJ, Draper E. Characteristics of children requiring admission to neonatal care and paediatric intensive care before the age of 2 years in England and Wales: a data linkage study. Arch Dis Child 2024; 109:387-394. [PMID: 38346868 DOI: 10.1136/archdischild-2023-325986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/13/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To quantify the characteristics of children admitted to neonatal units (NNUs) and paediatric intensive care units (PICUs) before the age of 2 years. DESIGN A data linkage study of routinely collected data. SETTING National Health Service NNUs and PICUs in England and Wales PATIENTS: Children born from 2013 to 2018. INTERVENTIONS None. MAIN OUTCOME MEASURE Admission to PICU before the age of 2 years. RESULTS A total of 384 747 babies were admitted to an NNU and 4.8% (n=18 343) were also admitted to PICU before the age of 2 years. Approximately half of all children admitted to PICU under the age of 2 years born in the same time window (n=18 343/37 549) had previously been cared for in an NNU.The main reasons for first admission to PICU were cardiac (n=7138) and respiratory conditions (n=5386). Cardiac admissions were primarily from children born at term (n=5146), while respiratory admissions were primarily from children born preterm (<37 weeks' gestational age, n=3550). A third of children admitted to PICU had more than one admission. CONCLUSIONS Healthcare professionals caring for babies and children in NNU and PICU see some of the same children in the first 2 years of life. While some children are following established care pathways (eg, staged cardiac surgery), the small proportion of children needing NNU care subsequently requiring PICU care account for a large proportion of the total PICU population. These differences may affect perceptions of risk for this group of children between NNU and PICU teams.
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Affiliation(s)
- Sarah E Seaton
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Peter J Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, Bristol, UK
| | - Alan C Fenton
- Newcastle Neonatal Service, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Tim J van Hasselt
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Elizabeth Draper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
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9
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Iten R, O'Connor M, Gill FJ. Palliative care for infants with life-limiting conditions: integrative review. BMJ Support Palliat Care 2023:spcare-2023-004435. [PMID: 38123923 DOI: 10.1136/spcare-2023-004435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Infants with life-limiting conditions are a heterogeneous population. Palliative care for infants is delivered in a diverse range of healthcare settings and by interdisciplinary primary healthcare teams, which may not involve specialist palliative care service consultation. OBJECTIVE To synthesise the literature for how palliative care is delivered for infants aged less than 12 months with life-limiting conditions. METHODS An integrative review design. MEDLINE, CINAHL, ProQuest, Cochrane, Joanna Briggs Institute and EMBASE were searched for research published in English language, from 2010 to 2022, and peer reviewed. Critical appraisal was completed for 26 patient case series, 9 qualitative, 5 cross-sectional and 1 quality improvement study. Data analysis involved deductive content analysis and narrative approach to summarise the synthesised results. RESULTS 37 articles met the eligibility for inclusion. Two models of palliative care delivery were examined, demonstrating differences in care received and experiences of families and health professionals. Health professionals reported lack of palliative care education, challenges for delivering palliative care in intensive care settings and barriers to advance care planning including prognostic uncertainty and transitioning to end-of-life care. Families reported positive experiences with specialist palliative care services and challenges engaging in advance care planning discussions. CONCLUSION There are complex issues surrounding the provision of palliative care for infants. Optimal palliative care should encompass a collaborative and coordinated approach between the primary healthcare teams and specialist palliative care services and prioritisation of palliative care education for nurses and physicians involved in providing palliative care to infants.
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Affiliation(s)
- Rebecca Iten
- Curtin University, Perth, Western Australia, Australia
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | | | - Fenella J Gill
- Curtin University, Perth, Western Australia, Australia
- Perth Children's Hospital, Nedlands, Western Australia, Australia
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Neto J, Casimiro HJ, Reis-Pina P. Palliative Extubation in Pediatric Patients in the Intensive Care Unit and at Home: A Scoping Review. Int J Pediatr 2023; 2023:6697347. [PMID: 38058590 PMCID: PMC10697771 DOI: 10.1155/2023/6697347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/15/2023] [Accepted: 10/13/2023] [Indexed: 12/08/2023] Open
Abstract
Aim This scoping review is aimed at systematically mapping the evidence on palliative extubation in the pediatric intensive care unit. Methods MEDLINE, EBSCO, and Cochrane databases were searched for articles published between January 2018 and December 2022, in English. Critical appraisal of sources of evidence was done using the Joanna Briggs Institute tools. PRISMA guidelines for scoping reviews were followed. Results Six studies were included, with 366 patients, from the USA (n = 4), Brazil (n = 1), and Germany (n = 1). Three were high-quality studies, two were moderate, and one was a low-quality study. Most studies were retrospective analysis; two were narrative approaches; two were evidence-based recommendation and quality improvement project; one study was a prospective intervention. Conclusion Symptom control is crucial pre- and postextubation. A checklist (symptom management and family support) and a postdebriefing template improve team communication and staff support postextubation. Critical care transports from the hospital are feasible to provide extubation at home. A framework addressing common planning challenges and resource management is recommended for extubation at home. The provision of pediatric palliative extubation is necessary since futile measures and prolongation of suffering violate the principle of nonmaleficence. Future research on this subject will result in more benefits for patients, parents, and professionals.
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Affiliation(s)
- Joana Neto
- Faculty of Medicine, University of Lisbon, Portugal
| | - Hugo Jorge Casimiro
- Faculty of Medicine, University of Lisbon, Portugal
- Hospital Palliative Care Team, Setúbal Hospital Centre, Setúbal, Portugal
| | - Paulo Reis-Pina
- Faculty of Medicine, University of Lisbon, Portugal
- Bento Menni's Palliative Care Unit, Casa de Saúde da Idanha, Sintra, Portugal
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11
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O'Callaghan C, Cloutman-Green E, Brierley J. Pandemic preparedness: is the UK ready for a pandemic that affects children? BMJ 2023; 383:2804. [PMID: 38016735 DOI: 10.1136/bmj.p2804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Affiliation(s)
- Chris O'Callaghan
- University College London, Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre. London
| | - Elaine Cloutman-Green
- Great Ormond Street Hospital, Great Ormond Street, London
- Department of Civil, Environmental and Geomatic Engineering, University College London
| | - Joe Brierley
- Paediatric Bioethics Centre, Great Ormond Street Hospital, London
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12
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Noriega EC, Siden H, Lavergne MR. Infants, children, youth and young adults with a serious illness in British Columbia: a population-based analysis using linked administrative data. CMAJ Open 2023; 11:E1118-E1124. [PMID: 38052476 DOI: 10.9778/cmajo.20220181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Pediatric palliative care aims to improve quality of life among infants, children, youth and young adults with serious illnesses, sometimes over years, but estimates of infants, children, youth and young adults requiring pediatric palliative care have been highly variable and need refinement. We sought to describe this population in British Columbia and identify clinical instability to inform program planning in pediatric palliative care. METHODS We conducted a population-based analysis using linked administrative health data from 2012/13 to 2016/17. We applied a coding framework validated in the United Kingdom to estimate the number of BC residents aged 0-25 years with serious illnesses and to identify 5 clinical stages. We describe demographics, estimate prevalence and model risk of instability, defined as having urgent hospital admissions, admissions to the intensive care unit or death. RESULTS About 2500 infants, children, youth and young adults were admitted to hospital with a serious illness diagnosis each study year, of which around 50% were infants, 60% or so of whom had perinatal or congenital diagnoses. Compared with children aged 1-4 years, infants had the highest risk of instability (odds ratio [OR] 6.59, 95% confidence interval [CI] 5.97-7.29). Compared with oncology patients, infants, children, youth and young adults with neurological (OR 1.43, 95% CI 1.21-1.70) and otherwise specified diagnoses (OR 1.55, 95% CI 1.39-1.73) had a higher risk of instability. INTERPRETATION The population of infants, children, youth and young adults with serious illnesses in BC is substantially larger than that currently receiving pediatric palliative care. Future planning of these services needs to consider expanding its reach, focusing particularly on infants and other subpopulations with high risk of instability.
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Affiliation(s)
- Elisa Castro Noriega
- Canuck Place Children's Hospice (Castro Noriega, Siden); British Columbia Children's Hospital Research Institute (Siden); Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC; Department of Family Medicine, Faculty of Medicine (Lavergne), Dalhousie University, Halifax, NS
| | - Harold Siden
- Canuck Place Children's Hospice (Castro Noriega, Siden); British Columbia Children's Hospital Research Institute (Siden); Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC; Department of Family Medicine, Faculty of Medicine (Lavergne), Dalhousie University, Halifax, NS
| | - M Ruth Lavergne
- Canuck Place Children's Hospice (Castro Noriega, Siden); British Columbia Children's Hospital Research Institute (Siden); Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC; Department of Family Medicine, Faculty of Medicine (Lavergne), Dalhousie University, Halifax, NS
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13
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Kwon JE, Kim YH. Changes in the End-of-Life Process in Patients with Life-Limiting Diseases through the Intervention of the Pediatric Palliative Care Team. J Clin Med 2023; 12:6588. [PMID: 37892726 PMCID: PMC10607513 DOI: 10.3390/jcm12206588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Kyungpook National University Children's Hospital initiated pediatric palliative care (PPC) services in January 2019, focusing on children and adolescents with life-limiting conditions (LLC). A study examined changes in the end-of-life processes in patients with LLC before and after a PPC intervention. This study included 48 deceased patients under 18 years at the hospital, divided into two groups: January 2015 to December 2016 without PPC (25 patients, Period 1) and January 2019 to April 2022 with PPC (23 patients, Period 2). Analysis of medical records revealed the following: no age/sex differences; more active advanced care planning in Period 2 (15/23 vs. 7/25, p = 0.01); discussing withholding/withdrawing treatment increased in Period 2 (91.3% vs. 64.0%, p = 0.025); intubation and CPR were less frequent in Period 2 (intubation 2/23 vs. 19/25, p = 0.000; CPR 3/23 vs. 11/25, p = 0.018); Period 1 had more deaths in the ICU (18/25 vs. 10/23, p = 0.045); and 3 patients in Period 2 chose home deaths. A survey in Period 2 revealed high satisfaction with emotional support (91.7%), practical assistance (91.6%), and symptom management (83.3%). PPC facilitated discussions on advanced care planning and treatment choices, ensuring peaceful and prepared farewells for children with LLC and their families.
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Affiliation(s)
| | - Yeo Hyang Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Pediatric Palliative Care Center, Kyungpook National University Children’s Hospital, Daegu 41404, Republic of Korea;
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14
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Yoo S, Choi JY, Yang SS, Koh SE, Jeong MH, Song MK. Medical service utilization by children with physical or brain disabilities in South Korea. BMC Pediatr 2023; 23:487. [PMID: 37752492 PMCID: PMC10521495 DOI: 10.1186/s12887-023-04309-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/13/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Children with physical or brain disabilities experience several functional impairments and declining health complications that must be considered for adequate medical support. This study investigated the current medical service utilization of children expressing physical or brain disabilities in South Korea by analyzing medical visits, expenses, and comorbidities. METHODS We used a database linked to the National Rehabilitation Center of South Korea to extract information on medical services utilized by children with physical or brain disabilities, the number of children with a disability, medical visits for each child, medical expenses per visit, total medical treatment cost, copayments by age group, condition severity, and disability type. RESULTS Brain disorder comorbidities significantly differed between those with mild and severe disabilities. Visits per child, total medical treatment cost, and copayments were higher in children with severe physical disabilities; however, medical expenses per visit were lower than those with mild disabilities. These parameters were higher in children with severe brain disabilities than in mild cases. Total medical expenses incurred by newborns to three-year-old children with physical disorders were highest due to increased visits per child. However, medical expenses per visit were highest for children aged 13-18. CONCLUSION Medical service utilization varied by age, condition severity, and disability type. Severe cases and older children with potentially fatal comorbidities required additional economic support. Therefore, a healthcare delivery system for children with disabilities should be established to set affordable medical costs and provide comprehensive medical services based on disability type and severity.
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Affiliation(s)
- Sunyong Yoo
- Department of ICT Convergence System Engineering, Chonnam National University, Gwangju, Republic of Korea
| | - Ja Young Choi
- Department of Physical and Rehabilitation Medicine, Chungnam National University College of Medicine, Daegeon, Republic of Korea
| | - Shin-Seung Yang
- Department of Physical and Rehabilitation Medicine, Chungnam National University College of Medicine, Daegeon, Republic of Korea
| | - Seong-Eun Koh
- Department of Physical & Rehabilitation Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Myeong-Hyeon Jeong
- Department of ICT Convergence System Engineering, Chonnam National University, Gwangju, Republic of Korea
| | - Min-Keun Song
- Department of Physical & Rehabilitation Medicine, Chonnam National University Medical School & Hospital, 160 baekseo-ro Dong-gu, Gwangju, 61479, Republic of Korea.
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15
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Boerman GH, Haspels HN, de Hoog M, Joosten KF. Characteristics of Long-Stay Patients in a PICU and Healthcare Resource Utilization After Discharge. Crit Care Explor 2023; 5:e0971. [PMID: 37644970 PMCID: PMC10461958 DOI: 10.1097/cce.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES To examine the characteristics of long-stay patients (LSPs) admitted to a PICU and to investigate discharge characteristics of medical complexity among discharged LSP. DESIGN We performed a retrospective cohort study where clinical data were collected on all children admitted to our PICU between July 1, 2017, and January 1, 2020. SETTING A single-center study based at Erasmus MC Sophia Children's Hospital, a level III interdisciplinary PICU in The Netherlands, providing all pediatric and surgical subspecialties. PATIENTS LSP was defined as those admitted for at least 28 consecutive days. INTERVENTIONS None. MEASUREMENTS Length of PICU stay, diagnosis at admission, length of mechanical ventilation, need for extracorporeal membrane oxygenation, mortality, discharge location after PICU and hospital admission, medical technical support, medication use, and involvement of allied healthcare professionals after hospital discharge. MAIN RESULTS LSP represented a small proportion of total PICU patients (108 patients; 3.2%) but consumed 33% of the total admission days, 47% of all days on extracorporeal membrane oxygenation, and 38% of all days on mechanical ventilation. After discharge, most LSP could be classified as children with medical complexity (CMC) (76%); all patients received discharge medications (median 5.5; range 2-19), most patients suffered from a chronic disease (89%), leaving the hospital with one or more technological devices (82%) and required allied healthcare professional involvement after discharge (93%). CONCLUSIONS LSP consumes a considerable amount of resources in the PICU and its impact extends beyond the point of PICU discharge since the majority are CMC. This indicates complex care needs at home, high family needs, and a high burden on the healthcare system across hospital borders.
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Affiliation(s)
- Gerharda H Boerman
- Division of Pediatric Intensive Care, Department of Neonatology and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Heleen N Haspels
- Division of Pediatric Intensive Care, Department of Neonatology and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Pediatric Intensive Care Unit, Amsterdam Reproduction, and Development, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Transitional Care Unit Consortium, The Netherlands
| | - Matthijs de Hoog
- Division of Pediatric Intensive Care, Department of Neonatology and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Transitional Care Unit Consortium, The Netherlands
| | - Koen F Joosten
- Division of Pediatric Intensive Care, Department of Neonatology and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Transitional Care Unit Consortium, The Netherlands
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16
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Mukherjee S, Richardson N, Beresford B. Hospital healthcare experiences of children and young people with life-threatening or life-shortening conditions, and their parents: scoping reviews and resultant conceptual frameworks. BMC Pediatr 2023; 23:366. [PMID: 37460965 PMCID: PMC10351142 DOI: 10.1186/s12887-023-04151-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 06/24/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Patient experience is a core component of healthcare quality. Patient-reported experience measures (PREMs) are increasingly used to assess this, but there are few paediatric PREMs. This paper reports the first stage of developing two such measures, one for children and young people (0-18 years) (CYP) with a life-threatening or life-shortening condition (LT/LSC), and one for their parents. It comprised parallel scoping reviews of qualitative evidence on the elements of health service delivery and care that matter to, or impact on, CYP (Review 1) and parents (Review 2). METHODS Medline and PsychINFO (1/1/2010 - 11/8/2020) and CINAHL Complete (1/1/2010 - 4/7/2020) were searched and records identified screened against inclusion criteria. A thematic approach was used to manage and analyse relevant data, informed by existing understandings of patient/family experiences as comprising aspects of staff's attributes, their actions and behaviours, and organisational features. The objective was to identity the data discrete elements of health service delivery and care which matter to, or impact on, CYP or parents which, when organised under higher order conceptual domains, created separate conceptual frameworks. RESULTS 18,531 records were identified. Sparsity of data on community-based services meant the reviews focused only on hospital-based (inpatient and outpatient) experiences. 53 studies were included in Review 1 and 64 in Review 2. For Review 1 (CYP), 36 discrete elements of healthcare experience were identified and organized under 8 higher order domains (e.g. staff's empathetic qualities; information-sharing/decision making; resources for socializing/play). In Review 2 (parents), 55 elements were identified and organized under 9 higher order domains. Some domains were similar to those identified in Review 1 (e.g. professionalism; information-sharing/decision-making), others were unique (e.g. supporting parenting; access to additional support). CONCLUSIONS Multiple and wide-ranging aspects of the way hospital healthcare is organized and delivered matters to and impacts on CYP with LT/LSCs, and their parents. The aspects that matter differ between CYP and parents, highlighting the importance of measuring and understanding CYP and parent experience seperately. These findings are key to the development of patient/parent experience measures for this patient population and the resultant conceptual frameworks have potential application in service development.
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Affiliation(s)
- Suzanne Mukherjee
- Social Policy Research Unit, School of Business and Society, University of York, York, YO10 5ZF, UK.
| | - Natalie Richardson
- Social Policy Research Unit, School of Business and Society, University of York, York, YO10 5ZF, UK
| | - Bryony Beresford
- Social Policy Research Unit, School of Business and Society, University of York, York, YO10 5ZF, UK
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17
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Stoesslein S, Gramm JD, Bender HU, Müller P, Rabenhorst D, Borasio GD, Führer M. "More life and more days"-patient and care characteristics in a specialized acute pediatric palliative care inpatient unit. Eur J Pediatr 2023; 182:1847-1855. [PMID: 36795188 PMCID: PMC10167193 DOI: 10.1007/s00431-023-04813-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/30/2022] [Accepted: 01/06/2023] [Indexed: 02/17/2023]
Abstract
UNLABELLED Only a few acute hospital inpatient units dedicated to pediatric palliative care (PPC) patients exist today. Clinical data on the patients and care provided at specialized acute PPC inpatient units (PPCUs) are scarce. This study aims at describing patient and care characteristics on our PPCU to learn about the complexity and relevance of inpatient PPC. A retrospective chart analysis was performed on the 8-bed PPCU of the Center for Pediatric Palliative Care of the Munich University Hospital, including demographic, clinical, and treatment characteristics (487 consecutive cases; 201 individual patients; 2016-2020). Data were analyzed descriptively; the chi-square test was used for comparisons. Patients' age (1-35.5 years, median: 4.8 years) and length of stay (1-186 days, median 11 days) varied widely. Thirty-eight percent of patients were admitted repeatedly (range 2-20 times). Most patients suffered from neurological diseases (38%) or congenital abnormalities (34%); oncological diseases were rare (7%). Patients' predominant acute symptoms were dyspnea (61%), pain (54%), and gastrointestinal symptoms (46%). Twenty percent of patients suffered from > 6 acute symptoms, 30% had respiratory support incl. invasive ventilation, 71% had a feeding tube, and 40% had full resuscitation code. In 78% of cases, patients were discharged home; 11% died on the unit. CONCLUSION This study shows the heterogeneity, high symptom burden, and medical complexity of the patients on the PPCU. The high dependency on life-sustaining medical technology points to the parallelism of life-prolonging and palliative treatments that is typical for PPC. Specialized PPCUs need to offer care at the intermediate care level in order to respond to the needs of patients and families. WHAT IS KNOWN • Pediatric patients in outpatient PPC or hospices present with a variety of clinical syndromes and different levels of complexity and care intensity. • There are many children with life-limiting conditions (LLC) in hospitals, but specialized PPC hospital units for these patients are rare and poorly described. WHAT IS NEW • Patients on a specialized PPC hospital unit show a high symptom burden and a high level of medical complexity, including dependency on medical technology and frequent full resuscitation code. • The PPC unit is mainly a place for pain and symptom management as well as crisis intervention, and needs to be able to offer treatment at the intermediate care level.
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Affiliation(s)
- Sophie Stoesslein
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Julia D Gramm
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Hans-Ulrich Bender
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.,Pediatric Palliative Care, Department of Pediatrics, Bern University Hospital, Bern, Switzerland
| | - Petra Müller
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Dorothee Rabenhorst
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.
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18
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Serrano-Pejenaute I, Carmona-Nunez A, Zorrilla-Sarriegui A, Martin-Irazabal G, Lopez-Bayon J, Sanchez-Echaniz J, Astigarraga I. How do hospitalised children die? The context of death and end-of-life decision-making. J Paediatr Child Health 2023; 59:625-630. [PMID: 36752181 DOI: 10.1111/jpc.16354] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/11/2023] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
AIM The decrease in childhood mortality, the growing clinical complexity and the greater technification of intensive care units have changed the circumstances of death of paediatric patients. The aim of this study is to describe the context of death and end-of-life decision-making. METHODS Single-centre, retrospective, observational study of deaths in inpatients or home hospitalised children under 18 years old between 2011 and 2021. Demographic data, pathological history and circumstances of death were obtained from the medical record. The whole study period was divided into two halves for the analysis of the temporal trends. RESULTS A total of 358 patients died, 63.2% under the age of 1 year old; 86.9% had underlying life-limiting illnesses and 73.2% died in the intensive care unit, with no differences between the two time periods. Death at home was significantly higher in the second study period (3.8% vs. 9%). A total of 20.1% died during advanced cardiopulmonary resuscitation. Life-sustaining treatment was withheld or withdrawn in 53.6%, with no differences between the time courses. Life-sustaining treatment was withheld mainly in patients with neurological, metabolic and oncological conditions, and less frequently in patients with cardiovascular or respiratory diseases or who were previously healthy. Most patients coded as palliative care (PC) or followed up by PC teams had an advance care plan (ACP) recorded, while in the others it was infrequent. PC coding, following by PC teams and ACP recording increased in the last years of the study. CONCLUSIONS Death of children in our setting usually occurs in relation to complex underlying pathology and after the decision of withdrawing or withholding life-sustaining treatment. In this context, PC and ACP acquire greater importance. In our study, PC involvement resulted in better documentation of ACP and PC coding.
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Affiliation(s)
- Idoya Serrano-Pejenaute
- Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain.,Doctoral Programme in Medicine and Surgery, University of the Basque Country, Leioa, Bizkaia, Spain
| | | | | | | | - Julio Lopez-Bayon
- Pediatric Palliative Care and Home Hospitalisation, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Jesus Sanchez-Echaniz
- Pediatric Palliative Care and Home Hospitalisation, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Itziar Astigarraga
- Department of Pediatrics, Faculty of Medicine, University of the Basque Country, Leioa, Bizkaia, Spain.,Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain.,Pediatric Hematology and Oncology, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
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19
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Verlaat CW, Zegers M, Klein R, van Waardenburg D, Kuiper JW, Riedijk M, Kneyber M, Timmers B, van Heerde M, Hazelzet JA, van der Hoeven J, Lemson J. Adverse Events in Pediatric Critical Care Nonsurvivors With a Low Predicted Mortality Risk: A Multicenter Case Control Study. Pediatr Crit Care Med 2023; 24:4-16. [PMID: 36521013 PMCID: PMC9799043 DOI: 10.1097/pcc.0000000000003103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Some patients with a low predicted mortality risk in the PICU die. The contribution of adverse events to mortality in this group is unknown. The aim of this study was to estimate the occurrence of adverse events in low-risk nonsurvivors (LN), compared with low-risk survivors (LS) and high-risk PICU survivors and nonsurvivors, and the contribution of adverse events to mortality. DESIGN Case control study. Admissions were selected from the national Dutch PICU registry, containing 53,789 PICU admissions between 2006 and 2017, in seven PICUs. PICU admissions were stratified into four groups, based on mortality risk (low/high) and outcome (death/survival). Random samples were selected from the four groups. Cases were "LN." Control groups were as follows: "LS," "high-risk nonsurvivors" (HN), and "high-risk survivors" (HS). Adverse events were identified using the validated trigger tool method. SETTING Patient chart review study. PATIENTS Children admitted to the PICU with either a low predicted mortality risk (< 1%) or high predicted mortality risk (≥ 30%). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 419 patients were included (102 LN, 107 LS, 104 HN, and 106 HS). LN had more complex chronic conditions (93.1%) than LS (72.9%; p < 0.01), HN (49.0%; p < 0.001), and HS (48.1%; p < 0.001). The occurrence of adverse events in LN (76.5%) was higher than in LS (13.1%) and HN (47.1%) ( p < 0.001). The most frequent adverse events in LN were hospital-acquired infections and drug/fluid-related adverse events. LN suffered from more severe adverse events compared with LS and HS ( p < 0.001). In 30.4% of LN, an adverse event contributed to death. In 8.8%, this adverse event was considered preventable. CONCLUSIONS Significant and preventable adverse events were found in low-risk PICU nonsurvivors. 76.5% of LN had one or more adverse events. In 30.4% of LN, an adverse event contributed to mortality.
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Affiliation(s)
- Carin W Verlaat
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Zegers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard Klein
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick van Waardenburg
- Department of Pediatric Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem Kuiper
- Department of Pediatric Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maaike Riedijk
- Department of Pediatric Intensive Care, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Martin Kneyber
- Department of Pediatric Intensive Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Brigitte Timmers
- Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc van Heerde
- Department of Pediatric Intensive Care, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jan A Hazelzet
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Joris Lemson
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
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20
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McSherry ML, Rissman L, Mitchell R, Ali-Thompson S, Madrigal VN, Lobner K, Kudchadkar SR. Prognostic and Goals-of-Care Communication in the PICU: A Systematic Review. Pediatr Crit Care Med 2023; 24:e28-e43. [PMID: 36066595 DOI: 10.1097/pcc.0000000000003062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Admission to the PICU may result in substantial short- and long-term morbidity for survivors and their families. Engaging caregivers in discussion of prognosis is challenging for PICU clinicians. We sought to summarize the literature on prognostic, goals-of-care conversations (PGOCCs) in the PICU in order to establish current evidence-based practice, highlight knowledge gaps, and identify future directions. DATA SOURCES PubMed (MEDLINE and PubMed Central), EMBASE, CINAHL, PsycINFO, and Scopus. STUDY SELECTION We reviewed published articles (2001-2022) that examined six themes within PGOCC contextualized to the PICU: 1) caregiver perspectives, 2) clinician perspectives, 3) documentation patterns, 4) communication skills training for clinicians, 5) family conferences, and 6) prospective interventions to improve caregiver-clinician communication. DATA EXTRACTION Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology. DATA SYNTHESIS Of 1,420 publications screened, 65 met criteria for inclusion with several key themes identified. Parent and clinician perspectives highlighted the need for clear, timely, and empathetic prognostic communication. Communication skills training programs are evaluated by a participant's self-perceived improvement. Caregiver and clinician views on quality of family meetings may be discordant. Documentation of PGOCCs is inconsistent and most likely to occur shortly before death. Only two prospective interventions to improve caregiver-clinician communication in the PICU have been reported. The currently available studies reflect an overrepresentation of bereaved White, English-speaking caregivers of children with known chronic conditions. CONCLUSIONS Future research should identify evidence-based communication practices that enhance caregiver-clinician PGOCC in the PICU and address: 1) caregiver and clinician perspectives of underserved and limited English proficiency populations, 2) inclusion of caregivers who are not physically present at the bedside, 3) standardized communication training programs with broader multidisciplinary staff inclusion, 4) improved design of patient and caregiver educational materials, 5) the development of pediatric decision aids, and 6) inclusion of long-term post-PICU outcomes as a measure for PGOCC interventions.
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Affiliation(s)
- Megan L McSherry
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD
| | - Lauren Rissman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Riley Mitchell
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD
| | - Sherlissa Ali-Thompson
- Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Vanessa N Madrigal
- Division of Critical Care Medicine, Department of Pediatrics, George Washington University, Washington, DC
- Pediatric Ethics Program, Children's National Hospital, Washington, DC
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University, Baltimore, MD
| | - Sapna R Kudchadkar
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD
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21
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Fraser LK, Gibson-Smith D, Jarvis S, Papworth A, Neefjes V, Hills M, Doran T, Taylor J. Polypharmacy in Children and Young People With Life-limiting Conditions From 2000 to 2015: A Repeated Cross-sectional Study in England. J Pain Symptom Manage 2022; 64:213-221.e1. [PMID: 35675847 DOI: 10.1016/j.jpainsymman.2022.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/06/2022] [Accepted: 05/31/2022] [Indexed: 11/20/2022]
Abstract
CONTEXT Polypharmacy is often appropriate for children with life-limiting conditions but is associated with an increase in hospitalizations and inappropriate prescribing, and can affect the quality of life of children and their families as they manage complex medication schedules. Despite this, little is known about polypharmacy in this population. OBJECTIVE To describe the prevalence and patterns of polypharmacy in children with a life-limiting condition in a nationally representative cohort in England. METHODS Observational study of children (age 0-19 years) with a life-limiting condition in a national database from 2000 to 2015. Common definitions of polypharmacy were used to determine polypharmacy prevalence in each year based on unique medications and regular medications. Hierarchical regression analyses were used to explore factors associated with polypharmacy. RESULTS Data on 15,829 individuals were included. Each year 27%-39% of children were prescribed ≥5 unique medications and 8%-12% were prescribed ≥10. Children with a respiratory (OR 7.6, 95%CI 6.4-9.0), neurological (OR 2.8, 95%CI 2.4-3.2), or metabolic (OR 2.2, 95%CI 1.7-2.8) condition were more likely than those with a congenital condition to experience polypharmacy. Increasing age, being diagnosed with a LLC under one year of age, having >1 life-limiting or chronic condition or living in areas of higher deprivation were also associated with higher prevalence of polypharmacy. CONCLUSION Children with life-limiting conditions have a high prevalence of polypharmacy and some children are at greater risk than others. More research is needed to understand and address the factors that lead to problematic polypharmacy in this population.
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Affiliation(s)
- Lorna K Fraser
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK.
| | - Deborah Gibson-Smith
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK
| | - Stuart Jarvis
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK
| | - Andrew Papworth
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK
| | | | - Michelle Hills
- Martin House Hospice (M.H.), Wetherby, UK; Leeds Teaching Hospitals NHS Trust (M.H.), Leeds, UK
| | - Tim Doran
- University Hospitals of Leicester NHS Trust (V.N., T.D.), UK
| | - Johanna Taylor
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK
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22
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Hill K, McCabe C, Brenner M. Organisation of care in paediatric intensive care units during the first 18 months of the COVID-19 pandemic: a scoping review protocol. BMJ Open 2022; 12:e054398. [PMID: 35613808 PMCID: PMC9133726 DOI: 10.1136/bmjopen-2021-054398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The emergence of COVID-19 has had a significant impact on hospital services, particularly care delivered to those in intensive care units (ICUs) and paediatric ICUs (PICUs) across the world. Although much has been written about healthcare delivery and the healthcare setting since COVID-19 began, to the authors' knowledge, this is the first scoping review to investigate the organisation of care and changes implemented in PICUs during the COVID-19 pandemic. The aim is to conduct a scoping review of the literature to map out the existing studies about care delivery in PICUs during the COVID-19 pandemic and the changes made to the organisation of care in these units during the first 18 months of the pandemic. This review will also identify gaps in current knowledge in this area. METHODS AND ANALYSIS This study will be guided by the Joanna Briggs Institute's methodology for scoping reviews, using Arksey and O'Malley's six-stage scoping review framework: (1) identifying the research question; (2) identifying relevant studies; (3) selecting the studies; (4) data charting; (5) collating, summarising and reporting results; and (6) consulting with experts. A comprehensive search will be conducted using the following databases: CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE. A search strategy with predefined inclusion and exclusion criteria will be used to uncover relevant research in this area. This study will include quantitative, qualitative and mixed research methods studies published in English from 2019 to May 2021. ETHICS AND DISSEMINATION Ethical approval is not required for this scoping review. The results from this study will be disseminated through conferences and in peer-reviewed academic journals for those working in the healthcare arena.
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Affiliation(s)
- Katie Hill
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Catherine McCabe
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
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23
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Smith S, Flanigan M, Haynes S, Michael A, Wolff T. Evaluating a community respiratory physiotherapy service for children with neurodisability. BMJ Open Qual 2022; 11:bmjoq-2021-001683. [PMID: 35241438 PMCID: PMC8896052 DOI: 10.1136/bmjoq-2021-001683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/12/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Children with neurodisability are at an increased risk of respiratory problems and complications, which often result in prolonged, frequent hospital admissions and are the biggest cause of mortality in this client group. The Children's Community Respiratory Physiotherapy Service (CCRPS) was established in 2010 to support children with severe neurodisabilities at home during acute chest infections and to prevent emergency department attendances and hospital admissions. This service evaluation looked at patient/parent satisfaction and prevented admissions to ensure clinical and cost-effectiveness, despite the rising demand for the service. METHODS Over a 3-month period, patients and parents/carers on the CCRPS caseload were given a Picker feedback survey following 100 emergency visits from the team. The number of prevented hospital admissions for respiratory tract infection over 12 months (April 2019-March 2020) was identified from existing CCRPS data and hospital admissions costs saved were estimated. RESULTS The Picker survey responses were extremely positive with all respondents reporting that they felt well looked after and that the main reason for the emergency visit was dealt with well. Based on key indicators, the CCRPS prevented 182 hospital admissions for respiratory tract infection in 2019/2020, equating to 1638 bed days and estimated cost savings ranging between £751 728 and £1 009 986. CONCLUSIONS The Picker survey response demonstrates the positive impact that the CCRPS has on both quality of life and experience for patients and families. The CCRPS rapid response service prevents hospital admissions for respiratory tract infections in children and young people with severe neurodisability and the cost savings from admissions prevented allows the service to more than pay for itself.
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Affiliation(s)
- Samantha Smith
- The Children's Development Centre, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Moira Flanigan
- The Children's Development Centre, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Sarah Haynes
- The Children's Development Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Anastasia Michael
- The Children's Development Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Toni Wolff
- The Children's Development Centre, Nottingham Children's Hospital, Nottingham, UK
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24
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Ko MSM, Poh PF, Heng KYC, Sultana R, Murphy B, Ng RWL, Lee JH. Assessment of Long-term Psychological Outcomes After Pediatric Intensive Care Unit Admission: A Systematic Review and Meta-analysis. JAMA Pediatr 2022; 176:e215767. [PMID: 35040918 PMCID: PMC8767488 DOI: 10.1001/jamapediatrics.2021.5767] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE The pediatric intensive care unit (PICU) exposes children to stressful experiences with potential long-term psychological repercussions. However, current understanding of post-PICU psychological outcomes is incomplete. OBJECTIVE To systematically review and evaluate reported long-term psychological outcomes among children previously admitted to the PICU. DATA SOURCES A systematic search of the Cumulative Index to Nursing and Allied Health Literature, Embase, MEDLINE (PubMed), and PsycINFO was conducted from database inception to June 2021. Search terms included phrases related to intensive care (eg, intensive care units and critical care) and terms for psychological disorders (eg, posttraumatic stress disorder, depressive disorder, conduct disorder, and neurodevelopmental disorder) limited to the pediatric population. STUDY SELECTION This systematic review and meta-analysis included randomized clinical trials and observational studies reporting psychological disorders among children younger than 18 years who were admitted to the PICU with follow-up for at least 3 months. Psychological disorders were defined using the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Children were excluded if they were admitted to the PICU for primary brain conditions (eg, traumatic brain injury, meningoencephalitis, and brain tumors) or discharged to the home for palliative care. DATA EXTRACTION AND SYNTHESIS Titles and abstracts were independently screened by 2 reviewers, with data extraction conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Data were pooled using a random-effects model during meta-analysis. MAIN OUTCOMES AND MEASURES Age-corrected IQ scores and long-term psychological outcomes measured by scales such as the Child Behavior Checklist (higher scores indicate more behavioral problems) among children admitted to the PICU. RESULTS Of 9193 records identified, 31 independent studies (5 randomized clinical trials and 26 observational studies) involving 7786 children (mean age, 7.3 years [95% CI, 6.2-8.4 years]; 4267 boys [54.8%]; race and ethnicity were not reported by all studies) admitted to the PICU were included. Overall, 1 of 19 children (5.3%) to 14 of 16 children (88.0%) previously admitted to the PICU were reported to have at least 1 psychological disorder. Studies that examined posttraumatic stress disorder reported that 6 of 60 children (10.0%) to 31 of 102 children (30.4%) met the diagnostic criteria for the disorder at 3 to 6 months of follow-up. Compared with healthy children, those admitted to the PICU had lower IQ scores at 1 to 2 years of follow-up (mean, 89.40 points [95% CI, 88.33-90.47 points] vs 100.70 points [95% CI, 99.43-101.97 points]; P < .001) and 3 to 5 years of follow-up (mean, 88.54 points [95% CI, 83.92-93.16 points] vs 103.18 [95% CI, 100.36-105.99 points]; P < .001) and greater total emotional and behavioral problems at 4 years of follow-up (mean, 51.69 points [95% CI, 50.37-53.01 points] vs 46.66 points [95% CI, 45.20-48.13 points]; P < .001). CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis found a high burden of psychological sequelae among children previously admitted to the PICU, suggesting that risk stratification and early interventions are needed for high-risk groups.
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Affiliation(s)
| | - Pei-Fen Poh
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | | | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Beverly Murphy
- Medical Center Library and Archives, Duke University, Durham, North Carolina
| | - Regina Wan Leng Ng
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Jan Hau Lee
- MD Programme, Duke-NUS Medical School, Singapore,Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
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25
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Schuetze D, Ploeger C, Hach M, Seipp H, Kuss K, Bösner S, Gerlach FM, van den Akker M, Erler A, Engler J. Care practices of specialized outpatient pediatric palliative care teams in collaboration with parents: Results of participatory observations. Palliat Med 2022; 36:386-394. [PMID: 34927494 PMCID: PMC8894953 DOI: 10.1177/02692163211065294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Collaboration between parents and professional care providers is an essential part of pediatric palliative care. As children are embedded in family systems and many of the patients are not able to communicate verbally, their parents are the primary interaction partners for palliative care providers. International standards for pediatric palliative care in Europe state that parents should be supported, acknowledged as the primary carers and involved as partners in all care and decisions. AIM To find out through which care practices pediatric palliative care teams shape collaboration with parents in everyday care. DESIGN Ethnographic method of participatory observations. Field notes were analyzed using thematic analysis. SETTING/PARTICIPANTS Researchers accompanied three pediatric palliative care teams on home visits to eight different families caring for a child with life-limiting conditions. RESULTS Care practices of palliative care teams were characterized by familiarity, a resource-oriented attitude, empowerment of parents, shared decision-making and support for parents. Palliative care teams not only provided palliative medical treatment for the children, but also developed a trusting care partnership with parents. The teams employed a sensitive and multifaceted communication style in their collaboration with parents. CONCLUSIONS Care practices in pediatric palliative care require time, communication skills, and a high level of psychosocial competence, to develop a trusting, collaborative relationship with parents. This should be taken into consideration when establishing pediatric palliative care structures, preparing guidelines, training staff, and deciding upon appropriate remuneration.
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Affiliation(s)
- Dania Schuetze
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Cornelia Ploeger
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Michaela Hach
- Professional Association of Specialized Outpatient Palliative Care in Hesse, Wiesbaden, Germany
| | - Hannah Seipp
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Katrin Kuss
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Marjan van den Akker
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany.,Department of Family medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Antje Erler
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Jennifer Engler
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
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26
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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27
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Buang SNH, Loh SW, Mok YH, Lee JH, Chan YH. Palliative and Critical Care: Their Convergence in the Pediatric Intensive Care Unit. Front Pediatr 2022; 10:907268. [PMID: 35757116 PMCID: PMC9226486 DOI: 10.3389/fped.2022.907268] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
Palliative care (PC) is an integral component of optimal critical care (CC) practice for pediatric patients facing life-threatening illness. PC acts as an additional resource for patients and families as they navigate through critical illness. Although PC encompasses end of life care, it is most effective when integrated early alongside disease-directed and curative therapies. PC primarily focuses on improving quality of life for patients and families by anticipating, preventing and treating suffering throughout the continuum of illness. This includes addressing symptom distress and facilitating communication. Effective communication is vital to elicit value-based goals of care, and to guide parents through patient-focused and potentially difficult decision-making process which includes advanced care planning. A multidisciplinary approach is most favorable when providing support to both patient and family, whether it is from the psychosocial, practical, emotional, spiritual or cultural aspects. PC also ensures coordination and continuity of care across different care settings. Support for family carries on after death with grief and bereavement support. This narrative review aims to appraise the current evidence of integration of PC into pediatric CC and its impact on patient- and family-centered outcomes. We will also summarize the impact of integration of good PC into pediatric CC, including effective communication with families, advanced care planning, withholding or withdrawal of life sustaining measures and bereavement support. Finally, we will provide a framework on how best to integrate PC in PICU. These findings will provide insights on how PC can improve the quality of care of a critically ill child.
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Affiliation(s)
- Siti Nur Hanim Buang
- Pediatric Palliative Care Service, Department of Pediatric Subspecialities, KK Women's and Children's Hospital, Singapore, Singapore
| | - Sin Wee Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
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28
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Zanin A, Brierley J, Latour JM, Gawronski O. End-of-life decisions and practices as viewed by health professionals in pediatric critical care: A European survey study. Front Pediatr 2022; 10:1067860. [PMID: 36704131 PMCID: PMC9872024 DOI: 10.3389/fped.2022.1067860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND AIM End-of-Life (EOL) decision-making in paediatric critical care can be complex and heterogeneous, reflecting national culture and law as well as the relative resources provided for healthcare. This study aimed to identify similarities and differences in the experiences and attitudes of European paediatric intensive care doctors, nurses and allied health professionals about end-of-life decision-making and care. METHODS This was a cross-sectional observational study in which we distributed an electronic survey to the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) members by email and social media. The survey had three sections: (i) 16 items about attitudes to EOL care, (ii) 14 items about EOL decisions, and (iii) 18 items about EOL care in practice. We used a 5-point Likert scale and performed descriptive statistical analysis. RESULTS Overall, 198 questionnaires were completed by physicians (62%), nurses (34%) and allied health professionals (4%). Nurses reported less active involvement in decision-making processes than doctors (64% vs. 95%; p < 0.001). As viewed by the child and family, the child's expected future quality of life was recognised as one of the most critical considerations in EOL decision-making. Sub-analysis of Northern, Central and Southern European regions revealed differences in the optimal timing of EOL decisions. Most respondents (n = 179; 90%) supported discussing organ donation with parents during EOL planning. In the sub-region analysis, differences were observed in the provision of deep sedation and nutritional support during EOL care. CONCLUSIONS This study has shown similar attitudes and experiences of EOL care among paediatric critical care professionals within European regions, but differences persist between European regions. Nurses are less involved in EOL decision-making than physicians. Further research should identify the key cultural, religious, legal and resource differences underlying these discrepancies. We recommend multi-professional ethics education to improve EOL care in European Paediatric Intensive Care.
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Affiliation(s)
- Anna Zanin
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Joe Brierley
- Critical Care Units, Great Ormond Street Hospital, London, United Kingdom
| | - Jos M Latour
- School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Service, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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29
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Wolff T, Dorsett C, Connolly A, Kelly N, Turnbull J, Deorukhkar A, Clements H, Griffin H, Chhaochharia A, Haynes S, Webb K, Manning JC. Chameleon project: a children's end-of-life care quality improvement project. BMJ Open Qual 2021; 10:bmjoq-2021-001520. [PMID: 34930720 PMCID: PMC8689180 DOI: 10.1136/bmjoq-2021-001520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 11/20/2021] [Indexed: 11/28/2022] Open
Abstract
In response to there being no specialist paediatric palliative care (PPC) team in a region of England, we undertook a 12-month quality improvement project (funded by National Health Service England’s Marginal Rate Emergency Threshold and Readmission fund) to improve children’s end-of-life care. Improvements were implemented during two plan–do–study–act (PDSA) cycles and included specialist experts, clinical champions, focused education and training, and tools and materials to support identification, care planning and communication. A lead paediatrician with expertise in PPC (10 hours/week) led the project, supported by a PPC nurse (3 days/week) and a network administrator (2 days/week). Children who died an expected death were identified from the child death review teams. Numbers of non-elective hospital admissions, bed days, and costs were identified. Twenty-nine children died an expected death during the 12 months of the project and coincidentally 29 children died an expected death during the previous 12 months. The median number of non-elective admissions in the last 12 months of life was reduced from two per child to one. There was a reduction in specialist hospital (14%) and district general hospital (38%) bed days. The percentage of children who died an expected death who had anticipatory care plans rose from 50% to 72%. The results indicate that a network of clinicians with expertise in PPC working together across a region can improve personalised care planning and reduce admissions and bed days for children in their last year-of-life with reduced bed utilisation costs.
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Affiliation(s)
- Toni Wolff
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Caroline Dorsett
- Paediatric Palliative Care Team, Nottingham Children's hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alexander Connolly
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nicola Kelly
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, UK
| | - Jennifer Turnbull
- Paediatric Oncology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Anjum Deorukhkar
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Helena Clements
- Paediatrics, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Hayley Griffin
- Paediatrics, Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | | | - Sarah Haynes
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kerry Webb
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joseph C Manning
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Centre for Children and Young Peoples Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK
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30
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A study of sex difference in infant mortality in UK pediatric intensive care admissions over an 11-year period. Sci Rep 2021; 11:21838. [PMID: 34750426 PMCID: PMC8575897 DOI: 10.1038/s41598-021-01173-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 10/14/2021] [Indexed: 01/03/2023] Open
Abstract
Within the UK, child mortality from all causes has declined for all ages over the last three decades. However, distinct inequality remains, as child mortality rates are generally found to be higher in males. A significant proportion of childhood deaths in the UK occur in Paediatric Intensive Care Units (PICU). We studied the association of sex with infant mortality in PICUs. We included all infants (0 to 12 months old) admitted to UK PICUs from 01/01/2005 to 31/12/2015 using the Paediatric Intensive Care Audit Network (PICANet) dataset. We considered first admissions to PICU and fitted a cause-specific-hazard-ratio (CSHR) model, and a logistic model to estimate the adjusted association between sex and mortality in PICU. Pre-defined subgroups were children less than 56-days old, and those with a primary diagnosis of infection. Of 71,243 cases, 1,411/29,520 (4.8%) of females, and 1,809/41,723 (4.3%) of males died. The adjusted male/female CSHR was 0.87 (95%-CI 0.81 to 0.92) representing a 13% higher risk of death for females. The adjusted OR for male to female mortality is 0.86 (95%-CI 0.80 to 0.93). Analyses in subgroups yielded similar findings. In our analysis, female infants have a higher rate of PICU mortality compared to male infants.
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31
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Fraser LK, Murtagh FE, Aldridge J, Sheldon T, Gilbody S, Hewitt C. Health of mothers of children with a life-limiting condition: a comparative cohort study. Arch Dis Child 2021; 106:987-993. [PMID: 33653713 PMCID: PMC8461446 DOI: 10.1136/archdischild-2020-320655] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/17/2021] [Accepted: 01/31/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This study aimed to quantify the incidence rates of common mental and physical health conditions in mothers of children with a life-limiting condition. METHODS Comparative national longitudinal cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink in England. Maternal-child dyads were identified in these data. Maternal physical and mental health outcomes were identified in the primary and secondary care datasets using previously developed diagnostic coding frameworks. Incidence rates of the outcomes were modelled using Poisson regression, adjusting for deprivation, ethnicity and age and accounting for time at risk. RESULTS A total of 35 683 mothers; 8950 had a child with a life-limiting condition, 8868 had a child with a chronic condition and 17 865 had a child with no long-term condition.The adjusted incidence rates of all of the physical and mental health conditions were significantly higher in the mothers of children with a life-limiting condition when compared with those mothers with a child with no long-term condition (eg, depression: incidence rate ratio (IRR) 1.21, 95% CI 1.13 to 1.30; cardiovascular disease: IRR 1.73, 95% CI 1.27 to 2.36; death in mothers: IRR 1.59, 95% CI 1.16 to 2.18). CONCLUSION This study clearly demonstrates the higher incidence rates of common and serious physical and mental health problems and death in mothers of children with a life-limiting condition. Further research is required to understand how best to support these mothers, but healthcare providers should consider how they can target this population to provide preventative and treatment services.
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Affiliation(s)
| | - Fliss Em Murtagh
- Hull York Medical School, University of Hull, Hull, Kingston upon Hull, UK
| | - Jan Aldridge
- Clinical Psychology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Trevor Sheldon
- School of Medicine, Queen Mary University of London, London, UK
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32
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Fraser LK, Gibson-Smith D, Jarvis S, Norman P, Parslow RC. Estimating the current and future prevalence of life-limiting conditions in children in England. Palliat Med 2021; 35:1641-1651. [PMID: 33323043 PMCID: PMC8532217 DOI: 10.1177/0269216320975308] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Previous studies showed increasing number of children with a life-limiting or life-threatening condition who may benefit from input from pediatric palliative care services. AIM To estimate the current prevalence of children with a life-limiting condition and to model future prevalence of this population. DESIGN Observational study using national inpatient hospital data. A population-based approach utilizing ethnic specific population projections was used to estimate future prevalence. SETTING/PARTICIPANTS All children aged 0-19 years with a life-limiting condition diagnostic code recorded in Hospital Episodes Statistics data in England from 2000/01 to 2017/18. RESULTS Data on 4,543,386 hospital episodes for 359,634 individuals were included. The prevalence of children with a life-limiting condition rose from 26.7 per 10,000 (95%CI 26.5-27.0) in 2001/02 to 66.4 per 10,000 (95% CI: 66.0-66.8) in 2017/18. Using a more restricted definition of a life-limiting condition reduced the prevalence from 66.4 to 61.1 per 10,000 (95%CI 60.7-61.5) in 2017/18. Highest prevalence was in the under 1-year age group at 226.5 per 10,000 and children with a congenital abnormality had the highest prevalence (27.2 per 10,000 (95%CI: 26.9-27.5)).The prevalence was highest among the most deprived group and in children of Pakistani origin.Predicted future prevalence of life-limiting conditions ranged from 67.0 (95%CI 67.7-66.3) to 84.22 (95%CI 78.66-90.17) per 10,000 by 2030. CONCLUSIONS The prevalence of children with a life-limiting or life-threatening condition in England has risen over the last 17 years and is predicted to increase. Future data collections must include the data required to assess the complex health and social care needs of these children.
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Affiliation(s)
- Lorna K Fraser
- Department of Health Sciences, Martin House Research Centre, University of York, York, UK
| | - Deborah Gibson-Smith
- Department of Health Sciences, Martin House Research Centre, University of York, York, UK
| | - Stuart Jarvis
- Department of Health Sciences, Martin House Research Centre, University of York, York, UK
| | - Paul Norman
- School of Geography, University of Leeds, Leeds, UK
| | - Roger C Parslow
- Leeds Institute of Cardiovascular and Molecular Medicine, School of Medicine, University of Leeds, Leeds, UK
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Wu ET, Wang CC, Huang SC, Chen CH, Jou ST, Chen YC, Wu MH, Lu FL. End-of-Life Care in Taiwan: Single-Center Retrospective Study of Modes of Death. Pediatr Crit Care Med 2021; 22:733-742. [PMID: 33767073 DOI: 10.1097/pcc.0000000000002715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Medical advances and the National Health Insurance coverage in Taiwan mean that mortality in the PICU is low. This study describes change in modes of death and end-of-life care in a single center, 2011-2017. SETTING Multidisciplinary PICU in a tertiary referral Children's Hospital in Taiwan. PATIENTS There were 316 deaths in PICU patients. INTERVENTIONS Palliative care consultation in the PICU service occurred after the 2013 "Hospice Palliative Care Act" revision. MEASUREMENTS AND MAIN RESULTS In the whole cohort, 22 of 316 patients (7%) were determined as "death by neurologic criteria". There were 94 of 316 patients (30%) who had an event needing cardiopulmonary resuscitation within 24 hours of death: 17 of these patients (17/94; 18%) died after failed cardiopulmonary resuscitation without a do-not-resuscitate order, and the other 77 of 94 patients (82%) had a do-not-resuscitate order after cardiopulmonary resuscitation. Overall, there were 200 of 316 patients (63%) who had a do-not-resuscitate order and were entered into the palliative program: 169 of 200 (85%) died after life-sustaining treatment was limited, and the other 31 of 200 (15%) died after life-sustaining treatment was withdrawn. From 2011 to 2017, the time-trend in end-of-life care showed the following associations: 1) a decrease in PICU mortality utilization rate, from 22% to 7% (p < 0.001); 2) a decrease in use of catecholamine infusions after do-not-resuscitate consent, from 87% to 47% (p = 0.001), in patients having limitation in life-sustaining treatment; and 3) an increase in withdrawal of life-sustaining treatment, from 4% to 31% (p < 0.001). CONCLUSIONS In our practice in a single PICU-center in Taiwan, we have seen that the integration of a palliative care consultation service, developed after the revision of a national "Palliative Care Act," was associated with increased willingness to accept withdrawal of life-sustaining treatment and a lowered PICU care intensity at the end-of-life.
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Affiliation(s)
- En-Ting Wu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Ching-Chia Wang
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chieh-Ho Chen
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Yih-Charng Chen
- Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Frank Leigh Lu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
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Taylor J, Murphy S, Chambers L, Aldridge J. Consulting with young people: informing guidelines for children's palliative care. Arch Dis Child 2021; 106:693-697. [PMID: 33208396 DOI: 10.1136/archdischild-2020-320353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Increasingly the views of young people are sought when improving healthcare; however, it is unclear how they shape policy or practice. This paper presents a consultation with young people commissioned by the National Institute for Health and Care Excellence (NICE) to inform clinical guidelines for paediatric palliative care (end-of-life care for infants, children and young people). METHODS The consultation involved qualitative thematic analysis of data from 14 young people (aged 12-18 years) with a life-limiting or life-threatening condition who took part in focus groups or interviews. The topics explored were predefined by NICE: information and communication; care planning; place of care; and psychological care. Data collection consisted of discussion points and activities using visual cues and was informed by a pilot consultation group with five young adults (aged 19-24 years). Findings were shared with participants, and feedback helped to interpret the findings. RESULTS Four overarching themes were identified, cutting across the predetermined topic areas: being treated as individuals with individual needs and preferences; quality of care more important than place; emotional well-being; and living as a young person. Importantly, care planning was viewed as a tool to support living well and facilitate good care, and the young people were concerned less about where care happens but who provides this. CONCLUSION Young people's priorities differ from those of parents and other involved adults. Incorporating their priorities within policy and practice can help to ensure their needs and preferences are met and relevant research topics identified.
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Affiliation(s)
- Johanna Taylor
- Department of Health Sciences, University of York, York, North Yorkshire, UK .,Martin House Research Centre, University of York, York, UK
| | - Sarah Murphy
- School of Psychology, Cardiff University, Cardiff, South Glamorgan, UK
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Green DJ, Bennett E, Olson LM, Wawrzynski S, Bodily S, Moore D, Mansfield KJ, Wilkins V, Cook L, Delgado-Corcoran C. Timing of Pediatric Palliative Care Consults in Hospitalized Patients with Heart Disease. J Pediatr Intensive Care 2021; 12:63-70. [PMID: 36742256 PMCID: PMC9894702 DOI: 10.1055/s-0041-1730916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023] Open
Abstract
Pediatric palliative care (PPC) provides an extra layer of support for families caring for a child with complex heart disease as these patients often experience lifelong morbidities with frequent hospitalizations and risk of early mortality. PPC referral at the time of heart disease diagnosis provides early involvement in the disease trajectory, allowing PPC teams to longitudinally support patients and families with symptom management, complex medical decision-making, and advanced care planning. We analyzed 113 hospitalized pediatric patients with a primary diagnosis of heart disease and a PPC consult to identify timing of first PPC consultation in relation to diagnosis, complex chronic conditions (CCC), and death. The median age of heart disease diagnosis was 0 days with a median of two CCCs while PPC consultation did not occur until a median age of 77 days with a median of four CCCs. Median time between PPC consult and death was 33 days (interquartile range: 7-128). Death often occurred in the intensive care unit ( n = 36, 67%), and the most common mode was withdrawal of life-sustaining therapies ( n = 31, 57%). PPC referral often occurred in the context of medical complexity and prolonged hospitalization. Referral close to the time of heart disease diagnosis would allow patients and families to fully utilize PPC benefits that exist outside of end-of-life care and may influence the mode and location of death. PPC consultation should be considered at the time of heart disease diagnosis, especially in neonates and infants with CCCs.
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Affiliation(s)
- Danielle J. Green
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States,Address for correspondence Danielle J. Green, MD Department of Pediatrics, Division of Pediatric Critical CarePO Box 581289, Salt Lake City, UT 84158United States
| | - Erin Bennett
- Department of Pediatrics, Division of Critical Care, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Lenora M. Olson
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States
| | - Sarah Wawrzynski
- University of Utah College of Nursing, Salt Lake City, Utah, United States,Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Stephanie Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Dominic Moore
- Department of Pediatrics, Division of Palliative Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Kelly J. Mansfield
- Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Victoria Wilkins
- Department of Pediatrics, Division of Inpatient Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Lawrence Cook
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States
| | - Claudia Delgado-Corcoran
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States,Department of Pediatrics, Division of Palliative Care Medicine, University of Utah, Salt Lake City, Utah, United States
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Moynihan KM, Heith CS, Snaman JM, Smith-Parrish M, Bakas A, Ge S, Cerqueira AV, Bailey V, Beke D, Wolfe J, Morell E, Gauvreau K, Blume ED. Palliative Care Referrals in Cardiac Disease. Pediatrics 2021; 147:peds.2020-018580. [PMID: 33579811 DOI: 10.1542/peds.2020-018580] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES With evidence of benefits of pediatric palliative care (PPC) integration, we sought to characterize subspecialty PPC referral patterns and end of life (EOL) care in pediatric advanced heart disease (AHD). METHODS In this retrospective cohort study, we compared inpatient pediatric (<21 years) deaths due to AHD in 2 separate 3-year epochs: 2007-2009 (early) and 2015-2018 (late). Demographics, disease burden, medical interventions, mode of death, and hospital charges were evaluated for temporal changes and PPC influence. RESULTS Of 3409 early-epoch admissions, there were 110 deaths; the late epoch had 99 deaths in 4032 admissions. In the early epoch, 45 patients (1.3% admissions, 17% deaths) were referred for PPC, compared with 146 late-epoch patients (3.6% admissions, 58% deaths). Most deaths (186 [89%]) occurred in the cardiac ICU after discontinuation of life-sustaining therapy (138 [66%]). Medical therapies included ventilation (189 [90%]), inotropes (184 [88%]), cardiopulmonary resuscitation (68 [33%]), or mechanical circulatory support (67 [32%]), with no temporal difference observed. PPC involvement was associated with decreased mechanical circulatory support, ventilation, inotropes, or cardiopulmonary resuscitation at EOL, and children were more likely to be awake and be receiving enteral feeds. PPC involvement increased advance care planning, with lower hospital charges on day of death and 7 days before (respective differences $5058 [P = .02] and $25 634 [P = .02]). CONCLUSIONS Pediatric AHD deaths are associated with high medical intensity; however, children with PPC consultation experienced substantially less invasive interventions at EOL. Further study is warranted to explore these findings and how palliative care principles can be better integrated into care.
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Affiliation(s)
- Katie M Moynihan
- Departments of Cardiology and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Catherine S Heith
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jennifer M Snaman
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Melissa Smith-Parrish
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Anna Bakas
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Valerie Bailey
- Cardiovascular and Critical Care Nursing Patient Services and
| | - Dorothy Beke
- Cardiovascular and Critical Care Nursing Patient Services and
| | - Joanne Wolfe
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Emily Morell
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Kimberlee Gauvreau
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elizabeth D Blume
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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37
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Almossawi O, Friend A, Palla L, Feltbower R, De Stavola B. Is there a sex difference in mortality rates for deaths occurring in paediatric intensive care units? Systematic literature review protocol. BMJ Open 2021; 11:e046794. [PMID: 33550270 PMCID: PMC7925908 DOI: 10.1136/bmjopen-2020-046794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 01/21/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION In the general population, female children have been reported to have a survival advantage. For children admitted to paediatric intensive care units (PICUs), mortality has been reported to be lower in males despite the higher admission rates for males into intensive care. This apparent sex reversal in PICU mortality is not well studied. To address this, we propose to conduct a systematic literature review to summarise the available evidence. Our review will study the reported differences in mortality between males and females aged 0-17, who died in a PICU, to examine if there is a difference between the two sexes in PICU mortality, and if so, to describe the magnitude and direction of this difference. METHODS AND ANALYSIS Studies that directly or indirectly addressed the association between sex and mortality in children admitted to intensive care will be eligible for inclusion. Studies that directly address the association will be eligible for data extraction. The search strings were based on terms related to the population (children in intensive care), the exposure (sex) and the outcome (mortality). We used the databases MEDLINE (1946-2020), Embase (1980-2020) and Web of Science (1985-2020) as these cover relevant clinical publications. We will assess the reliability of included studies using the risk of bias in observational studies of exposures tool. We will consider a pooled effect if we have at least three studies with similar periods of follow up and adjustment variables. ETHICS AND DISSEMINATION Ethical approval is not required for this review as it will synthesise data from existing studies. This manuscript is a part of a larger data linkage study, for which Ethical approval was granted. Dissemination will be via peer-reviewed journals and via public and patient groups. PROSPERO REGISTRATION NUMBER CRD42020203009.
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Affiliation(s)
- Ofran Almossawi
- Department of Population, Policy and Practice, UCL GOS Institute of Child Health, London, UK
| | - Amanda Friend
- Department of Paediatrics, Leeds Children's Hospital, Leeds, UK
| | - Luigi Palla
- Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Rome, Italy
- Department of Medical Statistics, LSHTM, London, UK
- Department of Global Health, Nagasaki University Institute of Tropical Medicine, Nagasaki, Japan
| | | | - Bianca De Stavola
- Department of Population, Policy and Practice, UCL GOS Institute of Child Health, London, UK
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Impact of palliative care on end-of-life care and place of death in children, adolescents, and young adults with life-limiting conditions: A systematic review. Palliat Support Care 2021; 19:488-500. [PMID: 33478607 DOI: 10.1017/s1478951520001455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the impact of palliative care (PC) on end-of-life (EoL) care and the place of death (PoD) in children, adolescents, and young adults with life-limiting conditions. METHOD Eight online databases (PubMed, Medline, EMBASE, Cochrane Library, CINAHL, Airiti, GARUDA Garba Rujukan Digital, and OpenGrey) from 2010 to February 5, 2020 were searched for studies investigating EoL care and the PoD for pediatric patients receiving and not receiving PC. RESULTS Of the 6,468 citations identified, 14 cohort studies and one case series were included. An evidence base of mainly adequate- and strong-quality studies shows that inpatient hospital PC, either with or without the provision of home and community PC, was found to be associated with a decrease in intensive care use and high-intensity EoL care. Conflicting evidence was found for the association between PC and hospital admissions, length of stay in hospital, resuscitation at the time of death, and the proportion of hospital and home deaths. SIGNIFICANCE OF RESULTS Current evidence suggests that specialist, multidisciplinary involvement, and continuity of PC are required to reduce the intensity of EoL care. Careful attention should be paid to the need for a longer length of stay in a medical setting late in life, and earlier EoL care discussion should take place with patients/caregivers, especially in regard to attempting resuscitation in toddlers, adolescents, and the young adult population. A lack of robust evidence has identified a gap in rigorous multisite prospective studies utilizing data collection.
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Moynihan KM, Taylor L, Crowe L, Balnaves MC, Irving H, Ozonoff A, Truog RD, Jansen M. Ethical climate in contemporary paediatric intensive care. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106818. [PMID: 33431646 DOI: 10.1136/medethics-2020-106818] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 06/12/2023]
Abstract
Ethical climate (EC) has been broadly described as how well institutions respond to ethical issues. Developing a tool to study and evaluate EC that aims to achieve sustained improvements requires a contemporary framework with identified relevant drivers. An extensive literature review was performed, reviewing existing EC definitions, tools and areas where EC has been studied; ethical challenges and relevance of EC in contemporary paediatric intensive care (PIC); and relevant ethical theories. We surmised that existing EC definitions and tools designed to measure it fail to capture nuances of the PIC environment, and sought to address existing gaps by developing an EC framework for PIC founded on ethical theory. In this article, we propose a Paediatric Intensive Care Ethical Climate (PICEC) conceptual framework and four measurable domains to be captured by an assessment tool. We define PICEC as the collective felt experience of interdisciplinary team members arising from those factors that enable or constrain their ability to navigate ethical aspects of their work. PICEC both results from and is influenced by how well ethical issues are understood, identified, explored, reflected on, responded to and addressed in the workplace. PICEC encompasses four, core inter-related domains representing drivers of EC including: (1) organisational culture and leadership; (2) interdisciplinary team relationships and dynamics; (3) integrated child and family-centred care; and (4) ethics literacy. Future directions involve developing a PICEC measurement tool, with implications for benchmarking as well as guidance for, and evaluation of, targeted interventions to foster a healthy EC.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Taylor
- Office of Ethics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Liz Crowe
- Department of Pediatric Intensive Care, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Mary-Claire Balnaves
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Helen Irving
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Centre for Children's Health Ethics and Law, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Al Ozonoff
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melanie Jansen
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Pediatric Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
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40
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Schütze D, Engler F, Ploeger C, Ulrich LR, Hach M, Seipp H, Kuss K, Bösner S, Gerlach FM, van den Akker M, Erler A, Engler J. Specialised outpatient paediatric palliative care team-parent collaboration: narrative interviews with parents. BMJ Support Palliat Care 2021; 12:e664-e670. [PMID: 33402383 DOI: 10.1136/bmjspcare-2020-002576] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/14/2020] [Accepted: 12/12/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE In Germany, children with life-limiting conditions and complex symptoms are eligible for specialised outpatient palliative care (SOPC). In the federal state of Hesse, SOPC for children (SOPPC) is delivered by teams with paediatric expertise. While burdened by the life-limiting condition of their child, parents must also fulfill their roles as main care providers and decision makers. Collaboration between parents and SOPPC teams is important, as the intermittent care and uncertainty it entails often lasts for several months or years. We explored parents' experiences and their demands of collaboration with SOPPC teams. METHODS We conducted nine narrative interviews with 13 parents of children and adolescents with life-limiting conditions and used a grounded theory approach to analyse interview data. RESULTS Parents stressed the importance of paediatric expertise, honesty, psychosocial support, an individualised approach, experience of self-efficacy and the need to be recognised as experts for their children. The narrative interviews showed that collaboration between parents and SOPPC teams was characterised by parents' need for specialised professional assistance and their simultaneous empowerment by SOPPC teams. CONCLUSIONS Parents' perceptions of what good collaboration with SOPPC teams entails are manifold. To meet these complex needs, SOPPC requires time and specialised expertise.
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Affiliation(s)
- Dania Schütze
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fabian Engler
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Cornelia Ploeger
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Lisa-R Ulrich
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany.,German Federal Rehabilitation Council (BAR e. V.), Frankfurt am Main, Germany
| | - Michaela Hach
- Professional Association of Specialized Outpatient Palliative Care in Hesse, Wiesbaden, Germany
| | - Hannah Seipp
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Katrin Kuss
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Marjan van den Akker
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany.,Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Antje Erler
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Jennifer Engler
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
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Karaarslan U, Topal S, Ayhan Y, Ağın H. The Differences in Viral Etiologies between Children with and without Severe Disability Admitted to the Pediatric Intensive Care Unit with Acute Respiratory Illness. J PEDIAT INF DIS-GER 2020. [DOI: 10.1055/s-0040-1718541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Objectives The objectives of this study were to evaluate the differences in the viral etiologies and variability in the clinical course between children with and without severe disability (SD) admitted to the pediatric intensive care unit (PICU) with acute respiratory illness (ARI).
Methods The medical records of patients admitted to our PICU between June 2017 and July 2019 were retrospectively reviewed for viral etiology and clinical course.
Results Forty-eight of 136 patients included in the study had SD. The rates of requiring positive pressure ventilation (43.5% vs. 20.5%) or inotropic support (39.9% vs. 15.9%), and the median length of stay (11 [10] vs. 5 [8]) were significantly higher in children with SD (p < 0.01, each). Influenza infection was significantly higher in children with SD (20.8% vs. 2.3%; p < 0.01) whereas respiratory syncytial virus (RSV) infection was more common in children without SD (47.7% vs. 4.2%; p < 0.01). There was no statistically significant difference in terms of other viruses between study groups.
Conclusion In this present study, influenza was an important pathogen for children with SD, while RSV was the main cause of ARI-associated PICU admission in children without SD. By focusing on increasing the rate of immunization against influenza in children with SD and their caregivers the burden of influenza-associated PICU admissions could be decreased.
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Affiliation(s)
- Utku Karaarslan
- Department of Pediatric Critical Care, University of Health Sciences Behçet Uz Children’s Hospital, Izmir, Turkey
| | - Sevgi Topal
- Department of Pediatric Critical Care, University of Health Sciences Behçet Uz Children’s Hospital, Izmir, Turkey
| | - Yüce Ayhan
- Department of Medical Microbiology, University of Health Sciences Behçet Uz Children’s Hospital, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Critical Care, University of Health Sciences Behçet Uz Children’s Hospital, Izmir, Turkey
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42
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Allnutt B, Stanworth S, Ray S. Prevalence of anaemia in patients discharged from the paediatric intensive care unit. Transfus Med 2020; 30:513-514. [PMID: 33145858 DOI: 10.1111/tme.12737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/22/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Beatrice Allnutt
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, UK
| | - Simon Stanworth
- Transfusion Medicine, National Health Service (NHS) Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
| | - Samiran Ray
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, UK.,Respiratory, Critical Care and Anaesthesia Section, UCL GOSH Institute of Child Health, London, UK
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Unplanned PICU Readmission in a Middle-Income Country: Who Is at Risk and What Is the Outcome? Pediatr Crit Care Med 2020; 21:e959-e966. [PMID: 32590834 DOI: 10.1097/pcc.0000000000002406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To study the rate of unplanned PICU readmission, determine the risk factors and its impact on mortality. DESIGN A single-center retrospective cross-sectional study. SETTING Tertiary referral PICU in Johor, Malaysia. PATIENTS All children admitted to the PICU over 8 years were included. Patients readmitted into PICU after the first PICU discharge during the hospitalization period were categorized into "early" (within 48 hr) and "late" (after 48 hr), and factors linked to the readmissions were identified. The mortality rate was determined and compared between no, early, and late readmission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 2,834 patients in the study with 70 early and 113 late readmissions. Therefore, the rate of early and late PICU readmission was 2.5% (95% CI, 1.9-3.0%) and 3.9% (95% CI, 3.2-4.7%), respectively. The median length of stay of the second PICU admission for early and late readmissions was 2.7 days (interquartile range, 1.1-7.0 d) and 3.2 days (interquartile range, 1.2-7.5 d), respectively. The majority of early and late readmissions had a similar diagnosis with their first PICU admission. Multivariable multinomial logistic regression revealed a Pediatric Index Mortality 2 score of greater than or equal to 15, chronic cardiovascular condition, and oxygen supplement upon discharge as independent risk factors for early PICU readmission. Meanwhile, an infant of less than 1 year old, having cardiovascular, other congenital and genetic chronic conditions and being discharged between 8 AM and 5 PM was an independent risk factor for late readmission. There was no significant difference in the mortality rate of early (12.9%), late (13.3%), and no readmission (10.7%). CONCLUSIONS Despite the lack of resources and expertise in lower- and middle-income countries, the rate and factors for PICU readmission are similar to those in high-income countries. However, PICU readmission has no statistically significant association with mortality.
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Akinkugbe O, Cooke FJ, Pathan N. Healthcare-associated bacterial infections in the paediatric ICU. JAC Antimicrob Resist 2020; 2:dlaa066. [PMID: 34223023 PMCID: PMC8210264 DOI: 10.1093/jacamr/dlaa066] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/01/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND An estimated 3.2 million patients annually develop healthcare-associated infections (HCAIs) in Europe alone amid the major challenge of increasing antimicrobial resistance. Critically ill children warrant specific evaluation because of differences in epidemiology, causative organisms and infection sites. OBJECTIVES To examine the prevalence and antimicrobial susceptibility patterns of three types of HCAI in critically ill children and determine the effect on their disease course. MATERIALS AND METHODS Retrospective cohort review of critically ill children admitted to a general paediatric ICU (PICU) at a regional academic tertiary referral centre over a 3 year period. RESULTS There were 1930 admissions with a median age of 38 months. Children with HCAIs had a higher incidence of comorbidities (74% versus 24%) and a longer median length of stay (8 days versus 3 days). We identified 26 positive isolates (blood, lower respiratory and urine) taken 48 h or more after admission. The combined incidence was 1.34%. Hospital-acquired pneumonia accounted for 58% of HCAIs, urinary tract infections for 31% and bloodstream infections for 11%. The majority (61.5%) of HCAIs were caused by Gram-negative organisms. Seven isolates were resistant to antimicrobials used to treat HCAI. All of these were Gram-negative organisms (Pseudomonas aeruginosa, Klebsiella oxytoca and Escherichia coli). CONCLUSIONS These data revealed a low incidence of HCAIs, 27% of which were resistant Gram-negative organisms. Critically ill children with HCAIs were more likely to have comorbidities and an increased length of stay. These factors may increasingly impact on PICU bed availability, an already limited resource.
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Affiliation(s)
- Olugbenga Akinkugbe
- Paediatric Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Fiona J Cooke
- Clinical Microbiology and Public Health Laboratory, National Infection Service, PHE, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Girton College, University of Cambridge, Cambridge, UK
| | - Nazima Pathan
- Paediatric Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- King’s College, University of Cambridge, Cambridge, UK
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Carrilero N, Dalmau-Bueno A, García-Altés A. Comorbidity patterns and socioeconomic inequalities in children under 15 with medical complexity: a population-based study. BMC Pediatr 2020; 20:358. [PMID: 32731853 PMCID: PMC7391621 DOI: 10.1186/s12887-020-02253-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/21/2020] [Indexed: 11/11/2022] Open
Abstract
Background Children with medical complexity (CMC) denotes the profile of a child with diverse acute and chronic conditions, making intensive use of the healthcare services and with special health and social needs. Previous studies show that CMC are also affected by the socioeconomic position (SEP) of their family. The aim of this study is to describe the pathologic patterns of CMC and their socioeconomic inequalities in order to better manage their needs, plan healthcare services accordingly, and improve the care models in place. Methods Cross-sectional study with latent class analysis (LCA) of the CMC population under the age of 15 in Catalonia in 2016, using administrative data. LCA was used to define multimorbidity classes based on the presence/absence of 57 conditions. All individuals were assigned to a best-fit class. Each comorbidity class was described and its association with SEP tested. The Adjusted Morbidity Groups classification system (Catalan acronym GMA) was used to identify the CMC. The main outcome measures were SEP, GMA score, sex, and age distribution, in both populations (CMC and non-CMC) and in each of the classes identified. Results 71% of the CMC population had at least one parent with no employment or an annual income of less than €18,000. Four comorbidity classes were identified in the CMC: oncology (36.0%), neurodevelopment (13.7%), congenital and perinatal (19.8%), and respiratory (30.5%). SEP associations were: oncology OR 1.9 in boys and 2.0 in girls; neurodevelopment OR 2.3 in boys and 1.8 in girls; congenital and perinatal OR 1.7 in boys and 2.1 in girls; and respiratory OR 2.0 in boys and 2.0 in girls. Conclusions Our findings show the existence of four different patterns of comorbidities in CMC and a significantly high proportion of lower SEP children in all classes. These results could benefit CMC management by creating more efficient multidisciplinary medical teams according to each comorbidity class and a holistic perspective taking into account its socioeconomic vulnerability.
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Affiliation(s)
- Neus Carrilero
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain.,Department of Experimental and Health Sciences (DCEXS), Universitat Pompeu Fabra, Barcelona, Spain.,Institut de Recerda de l'Hospital de la Santa Creu i Sant Pau (IR Sant Pau), Barcelona, Spain
| | - Albert Dalmau-Bueno
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain
| | - Anna García-Altés
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain. .,CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain. .,Institut d'Investigació Biomèdica (IIB Sant Pau), Carrer de Roc Boronat, 81-95, 08005, Barcelona, Spain.
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46
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Fraser LK, Bluebond-Langner M, Ling J. Advances and Challenges in European Paediatric Palliative Care. Med Sci (Basel) 2020; 8:medsci8020020. [PMID: 32316401 PMCID: PMC7353522 DOI: 10.3390/medsci8020020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/16/2022] Open
Abstract
Advances in both public health and medical interventions have resulted in a reduction in childhood mortality worldwide over the last few decades; however, children still have life-threatening conditions that require palliative care. Children's palliative care is a specialty that differs from palliative care for adults in many ways. This paper discusses some of the challenges, and some of the recent advances in paediatric palliative care. Developing responsive services requires good epidemiological data, as well as a clarity on services currently available and a robust definition of the group of children who would benefit from palliative care. Once a child is diagnosed with a life-limiting condition or life-limiting illness, parents face a number of complex and difficult decisions; not only about care and treatment, but also about the place of care and ultimately, place of death. The best way to address the needs of children requiring palliative care and their families is complex and requires further research and the routine collection of high-quality data. Although research in children's palliative care has dramatically increased, there is still a dearth of evidence on key components of palliative care notably decision making, communication and pain and symptom management specifically as it relates to children. This evidence is required in order to ensure that the care that these children and their families require is delivered.
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Affiliation(s)
- Lorna K Fraser
- Martin House Research Centre, University of York, York YO10 5DD, UK;
| | - Myra Bluebond-Langner
- Palliative Care for Children and Young People, Louis Dundas Centre, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Julie Ling
- European Association for Palliative Care, 1800 Vilvoorde, Belgium
- Correspondence:
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Polito A, Combescure C, Levy-Jamet Y, Rimensberger P. Long-stay patients in pediatric intensive care unit: Diagnostic-specific definition and predictors. PLoS One 2019; 14:e0223369. [PMID: 31577836 PMCID: PMC6774522 DOI: 10.1371/journal.pone.0223369] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/19/2019] [Indexed: 11/30/2022] Open
Abstract
Aims To stipulate a new definition for long-stay patients (LSPs) in pediatric intensive care unit (PICU). We defined LSPs as the 10% of patients with the longest PICU length-of-stay (LOS) for each age and diagnostic group. To assess whether the thresholds (days of PICU stay) for the definition of LSPs in PICU significantly differ among diagnostic and age categories. To determine whether independent associations exist between patients’ characteristics at admission and LSPs diagnosis in pre-specified diagnostic and age groups. Methods This was a multicenter retrospective cohort study including all PICUs in Switzerland. Multivariable regression analysis was used to seek for association between patients’ variables at admission and LSPs Results We included 22,284 patients with a median (IQR) age of 12 (1–84) months. Significantly different thresholds across diagnostic and age subgroups are identified. Readmission to PICU, higher PIM2 and NEMS (a score used to quantify nursing workload at intensive care unit level) at admission were associated with higher likelihood of becoming LSPs. Conclusions Our results showed a significantly different definitions of LSPs for specific diagnoses and age categories. Readmission to PICU and higher acuity at admission are associated with longer PICU length-of-stay in the majority of diagnostic groups. A more personalized definition of LSPs in children based on actual patients’ characteristics should probably be used in an effort to optimize care and reduce costs.
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Affiliation(s)
- Angelo Polito
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
- * E-mail:
| | - Christophe Combescure
- Division of Clinical Epidemiology, Faculty of Medicine, University of Geneva, and Geneva University Hospitals, Geneva, Switzerland
| | - Yann Levy-Jamet
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Peter Rimensberger
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
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Jackson AW. Postoperative Recovery and Survivorship After Acute Hospitalization for Serious Life-Limiting Illness. Surg Clin North Am 2019; 99:977-989. [PMID: 31446922 DOI: 10.1016/j.suc.2019.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This article provides a road map for discharge planning of adult patients with serious life-limiting illnesses. The need for early and guided conversations with specific prompts is offered to assist in the transition of care process. Transparent, patient-centered interactions are emphasized throughout with an acknowledgment that this type of direct, interpersonal communication may challenge a clinical team's typical mode of operation. Nevertheless, when done well, this approach can lead to better outcomes for everyone involved. This framework for discharge planning has led to greater patient and family satisfaction, lower mortality, reduced societal costs, and fewer instances of hospital readmission.
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Affiliation(s)
- Ann Wilborn Jackson
- MacLean Center for Clinical Medical Ethics, University of Chicago, Flossmoor, IL, USA.
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49
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Doing more of less: what registry data tell us about death in PICU. Intensive Care Med 2019; 45:1272-1274. [DOI: 10.1007/s00134-019-05714-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/25/2019] [Indexed: 11/25/2022]
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50
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Rennick JE, St-Sauveur I, Knox AM, Ruddy M. Exploring the experiences of parent caregivers of children with chronic medical complexity during pediatric intensive care unit hospitalization: an interpretive descriptive study. BMC Pediatr 2019; 19:272. [PMID: 31387555 PMCID: PMC6683527 DOI: 10.1186/s12887-019-1634-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 07/17/2019] [Indexed: 12/03/2022] Open
Abstract
Background Children with medical complexity (CMC) account for an increasing proportion of pediatric intensive care unit (PICU) admissions across North America. Their risk of unscheduled PICU admission is threefold compared to healthy children, and they are at higher risk of prolonged length of stay and PICU mortality. As a result of their sophisticated home care needs, parents typically develop significant expertise in managing their children’s symptoms and tending to their complex care needs at home. This can present unique challenges in the PICU, where staff may not take parents’ advanced expertise into account when caring for CMC. The study aimed to explore the experiences of parents of CMC during PICU admission. Methods This interpretive descriptive study was performed in the PICU of one Canadian, quaternary care pediatric hospital. Semi-structured interviews were conducted with 17 parent caregivers of 14 CMC admitted over a 1-year period. Results Parents of CMC expected to continue providing expert care during PICU admission, but felt their knowledge and expertise were not always recognized by staff. They emphasized the importance of parent-staff partnerships. Four themes were identified: (1) “We know our child best;” (2) When expertise collides; (3) Negotiating caregiving boundaries; and (4) The importance of being known. Results support the need for a PICU caregiving approach for CMC that recognizes parent expertise. Conclusions Partnership between staff and parents is essential, particularly in the case of CMC, whose parents are themselves skilled caregivers. In addition to enhanced partnerships with health care professionals, needs expressed by parents of CMC during PICU hospitalization included improved communication with staff, and more attention to continuity of care in the PICU and across hospital services. Parent-staff partnerships must be informed by ongoing communication and negotiation of caregiving roles throughout the course of the child’s PICU hospitalization.
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Affiliation(s)
- Janet E Rennick
- The Montreal Children's Hospital, McGill University Health Centre (MUHC), 1001 Decarie Boulevard, Montreal, Quebec, H4A 3J1, Canada. .,Ingram School of Nursing, Faculty of Medicine, McGill University, 680 Sherbrooke West, #1800, Montreal, Quebec, H3A 2M7, Canada. .,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve West, 3F.47, Montreal, Quebec, H4A 3S5, Canada.
| | - Isabelle St-Sauveur
- The Montreal Children's Hospital, McGill University Health Centre (MUHC), 1001 Decarie Boulevard, Montreal, Quebec, H4A 3J1, Canada.,Ingram School of Nursing, Faculty of Medicine, McGill University, 680 Sherbrooke West, #1800, Montreal, Quebec, H3A 2M7, Canada
| | - Alyssa M Knox
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve West, 3F.47, Montreal, Quebec, H4A 3S5, Canada
| | - Margaret Ruddy
- The Montreal Children's Hospital, McGill University Health Centre (MUHC), 1001 Decarie Boulevard, Montreal, Quebec, H4A 3J1, Canada
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