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Arias AV, Sakaan FM, Puerto-Torres M, Al Zebin Z, Bhattacharyya P, Cardenas A, Gunasekera S, Kambugu J, Kirgizov K, Libes J, Martinez A, Matinyan NV, Mendez A, Middlekauff J, Nielsen KR, Pappas A, Ren H, Sharara-Chami R, Torres SF, McArthur J, Agulnik A. Development and pilot testing of PROACTIVE: A pediatric onco-critical care capacity and quality assessment tool for resource-limited settings. Cancer Med 2023; 12:6270-6282. [PMID: 36324249 PMCID: PMC10028058 DOI: 10.1002/cam4.5395] [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: 06/06/2022] [Revised: 10/12/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Nearly 90% children with cancer reside in low- and middle-income countries, which face multiple challenges delivering high-quality pediatric onco-critical care (POCC). We recently identified POCC quality and capacity indicators for PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), a tool that evaluates strengths and limitations in POCC services. This study describes pilot testing of PROACTIVE, development of center-specific reports, and identification of common POCC challenges. METHODS The original 119 consensus-derived PROACTIVE indicators were converted into 182 questions divided between 2 electronic surveys for intensivists and oncologists managing critically ill pediatric cancer patients. Alpha-testing was conducted to confirm face-validity with four pediatric intensivists. Eleven centers representing diverse geographic regions, income levels, and POCC services conducted beta-testing to evaluate usability, feasibility, and applicability of PROACTIVE. Centers' responses were scored and indicators with mean scores ≤75% in availability/performance were classified as common POCC challenges. RESULTS Alpha-testing ensured face-validity and beta-testing demonstrated feasibility and usability of PROACTIVE (October 2020-June 2021). Twenty-two surveys (response rate 99.4%) were used to develop center-specific reports. Adjustments to PROACTIVE were made based on focus group feedback and surveys, resulting in 200 questions. Aggregated data across centers identified common POCC challenges: (1) lack of pediatric intensivists, (2) absence of abstinence and withdrawal symptoms monitoring, (3) shortage of supportive care resources, and (4) limited POCC training for physicians and nurses. CONCLUSIONS PROACTIVE is a feasible and contextually appropriate tool to help clinicians and organizations identify challenges in POCC services across a wide range of resource-levels. Widespread use of PROACTIVE can help prioritize and develop tailored interventions to strengthen POCC services and outcomes globally.
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Affiliation(s)
- Anita V Arias
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Firas M Sakaan
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zebin Al Zebin
- Pediatric Hematology and Oncology, King Hussein Cancer Center, Amman, Jordan
| | | | - Adolfo Cardenas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Sanjeeva Gunasekera
- Department of Pediatric Oncology, National Cancer Institute Sri Lanka, Maharagama, Sri Lanka
| | - Joyce Kambugu
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | | | - Jaime Libes
- Department of Pediatric Hematology and Oncology, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - Angelica Martinez
- Pediatric Hemato-Oncology Unit, Hospital General de Tijuana, Tijuana, Baja California, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica (UNOP), Guatemala City, Guatemala
| | - Janet Middlekauff
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Katie R Nielsen
- Division of Pediatric Critical Care, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Andrew Pappas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Hong Ren
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai, China
| | - Rana Sharara-Chami
- Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Silvio F Torres
- Pediatric Intensive Care Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Asya Agulnik
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Cardenas-Aguirre A, Hernandez-Garcia M, Lira-De-Leon B, Munoz-Brugal YL, Wang H, Villanueva-Diaz I, Ruiz-Perez E, Mijares-Tobias JM, Giles-Gonzalez AO, McArthur J, Escamilla-Aisan G, Arias A, Devidas M, Agulnik A. Outcomes for critical illness in children with cancer: Analysis of risk factors for adverse outcome and resource utilization from a specialized center in Mexico. Front Oncol 2022; 12:1038879. [DOI: 10.3389/fonc.2022.1038879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/03/2022] [Indexed: 12/02/2022] Open
Abstract
IntroductionChildren with cancer have a higher risk of adverse outcomes during critical illness than general pediatric populations. In Low- and middle-income countries, lack of resources can further negatively impact outcomes in critically ill children with cancer.MethodsIn this study, we describe the outcomes of a large cohort of children with cancer including mortality and resource utilization. We performed a retrospective review of all patients admitted to our PICU between December 12th, 2013 and December 31st, 2019. Outcomes were defined as recovery or death and resource utilization was described via use of critical care interventions, Length of stay as well as PICU- and Mechanical Ventilation- free days.ResultsOverall mortality was 6.9% while mortality in the unplanned admissions was 9.1%. This remained lower than expected mortality based on PIM2 scoring. Type of PICU admission, Neurological Deterioration as a cause of PICU admission, and PIM2 were significant as risk factors in univariate analysis, but only PIM2 remained significant in the multivariate analysis.DiscussionOur Study shows that high survival rates are achievable for children with cancer with critical illness in resource-limited settings with provision of high-quality critical care. Organizational and clinical practice facilitating quality improvement and early identification and management of critical illness may attenuate the impact of known risk factors for mortality in this population.
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A Single-center Report of the Admission to Intensive Care Unit Effectiveness on Treatment and Survival of Children Diagnosed with Cancer in Iran. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2022. [DOI: 10.5812/ijcm.117517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Childhood cancer is the second leading cause of death in children. Approximately, 40% of children with cancer need to be admitted to the intensive care unit (ICU), which plays a key role in their treatment procedure and overall survival. Objectives: In this study, we aimed at evaluating the impact of ICU admission on pediatric patients’ survival and prognosis at Mahak Pediatric Cancer Treatment and Research Center (MPCTRC), Tehran, Iran. Methods: Amongst a total number of 2693 hospitalized patients who were referred to our center from March 2014 to September 2019, 674 patients younger than 14 years of age who were at least admitted once to the ICU were included in this study. All the collected data were analyzed using IBM-SPSS software version 22. Results: Totally, 48.96% of patients were female and 51.03% of them were male. The most frequent types of cancer were central nervous system tumors (33.23%) and Leukemia (18.99%). Additionally, 43.62% of admitted patients were in the 1 - 4 age group, with the mean age of 1.5 ± 0.30. The mortality rate in ICU was 40.20% and the overall survival (OS) rate was 29.5% ± 2.6. Moreover, the OS in children with solid tumors and non-solid tumors were 27.1% ± 5.5 and 32.6% ± 3.1, respectively. Conclusions: The results of this conducted study provide a complete report on the status of children admitted to the ICU ward in Mahak Hospital. Because of this fact that the most frequent type of cancer was CNS tumors and children with CNS tumors are usually admitted to the ICU in the late stages of their disease, the overall survival rate in our study was 29.80%, which is lower than other studies.
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Agulnik A, Cárdenas A, Carrillo AK, Bulsara P, Garza M, Alfonso Carreras Y, Alvarado M, Calderón P, Díaz R, de León C, Del Real C, Huitz T, Martínez A, Miralda S, Montalvo E, Negrín O, Osuna A, Perez Fermin CK, Pineda E, Soberanis D, Juárez Tobias MS, Lu Z, Rodriguez-Galindo C. Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort. Cancer 2021; 127:1668-1678. [PMID: 33524166 PMCID: PMC8248122 DOI: 10.1002/cncr.33411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hospitalized pediatric hematology-oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource-limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event-level and center-level risk factors for mortality. METHODS In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU-level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018). RESULTS Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%-79% or 0.36-5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU-level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center-level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality. CONCLUSIONS Hospitalized PHO patients who experience CDEs in resource-limited settings frequently require floor-based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high-risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee.,Division of Critical Care, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Adolfo Cárdenas
- Critical Care Medicine, Hospital Infantil Teletón de Oncología, Queretaro, Mexico
| | - Angela K Carrillo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Purva Bulsara
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Marcela Garza
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Manuel Alvarado
- Critical Care, Hospital del Niño Dr. José Renán Esquivel, Panama City, Panama
| | - Patricia Calderón
- Oncology, Hospital Infantil Manuel de Jesús Rivera, Managua, Nicaragua
| | - Rosdali Díaz
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Claudia de León
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Claudia Del Real
- Pediatric Oncology, Benemérito Hospital General con Especialidades ¨Juan María de Salvatierra", La Paz, Mexico
| | - Tania Huitz
- Pediatric Oncology, Centro Estatal de Oncología de Campeche, Campeche, Mexico
| | | | - Scheybi Miralda
- Pediatric Critical Care, Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Erika Montalvo
- Pediatric Critical Care, Sociedad de Lucha contra el Cáncer Núcleo de Quito, Quito, Ecuador
| | - Octavia Negrín
- Hematology, Hospital Infantil Dr. Robert Reid Cabral, Santo Domingo, Dominican Republic
| | - Alejandra Osuna
- Hematology/Oncology, Hospital Pediátrico de Sinaloa, Sinaloa, Mexico
| | - Clara Krystal Perez Fermin
- Hematology/Oncology, Hospital Infantil Regional Universitario Dr. Arturo Guillón, Santiago, Dominican Republic.,Biomedical and Clinical Research Center, Santiago, Dominican Republic
| | - Estuardo Pineda
- Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dora Soberanis
- Hematology/Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | - Zhaohua Lu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
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