Use of Post-Acute Facility Care in Children Hospitalized With Acute Respiratory Illness

The Changing Landscape in Pediatric Hospitals: A Multicenter Study of How Pediatric Chronic Critical Illness Impacts NICU Throughput

OBJECTIVE

Pediatric inpatient bed availability is increasingly constrained by the prolonged hospitalizations of children with medical complexity. The sickest of these patients are chronic critically ill and often have protracted intensive care unit (ICU) stays. Numbers and characteristics of infants with chronic critical illness are unclear, which undermines resource planning in ICU's and general pediatric wards. The goal of this study was to describe infants with chronic critical illness at six academic institutions in the United States.

STUDY DESIGN

Infants admitted to six academic medical centers were screened for chronic, critical illness based on a combination of prolonged and repeated hospitalizations, use of medical technology, and chronic multiorgan involvement. Data regarding patient and hospitalization characteristics were collected.

RESULTS

Just over one-third (34.8%) of pediatric inpatients across the six centers who met eligibility criteria for chronic critical illness were <12 months of age. Almost all these infants received medical technology (97.8%) and had multiorgan involvement (94.8%). Eighty-six percent (115/134) had spent time in an ICU during the current hospitalization; 31% were currently in a neonatal ICU, 34% in a pediatric ICU, and 17% in a cardiac ICU. Among infants who had been previously discharged home (n = 55), most had been discharged with medical technology (78.2%) and nearly all were still using that technology during the current readmission. Additional technologies were commonly added during the current hospitalization.

CONCLUSION

Advanced strategies are needed to plan for hospital resource allocation for infants with chronic critical illness. These infants' prolonged hospitalizations begin in the neonatal ICU but often transition to other ICUs and general inpatient wards. They are commonly discharged with medical technology which is rarely weaned but often escalated during subsequent hospitalizations. Identification and tracking of these infants, beginning in the neonatal ICU, will help hospitals anticipate and strategize for inpatient bed management.

KEY POINTS

· 35% of inpatients with chronic critical illness are infants.. · Nearly 90% of these infants spend some time in an intensive care unit.. · 78% are discharged with medical technology..

National survey of health services provided by pediatric post-acute care facilities in the US

PURPOSE

The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff.

METHODS

An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery.

RESULTS

Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%).

CONCLUSION

PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.

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

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

Children dependent on respiratory support: A 10-year review from one pediatric postacute care hospital

OBJECTIVE

Pediatric postacute care hospitals (PACH) provide long-term care for children with medical complexity including children dependent on respiratory support. Descriptions of PACH respiratory care populations and outcomes, however, remain under-reported. Our aim was to describe demographics, respiratory outcome, and longitudinal trend of children with respiratory support admitted to a single PACH in the United States.

METHODS

Using electronic records from 2009 to 2018, data were examined for all children dependent on respiratory support. Children were identified for inclusion using respiratory level of care classifications (type of support) as outlined in hospital policy. Outcome was defined as change in level from first admission to final discharge. Number of admissions by level and year during the study timeframe were analyzed.

RESULTS

There were 1423 admissions for 767 children requiring respiratory support during the study timeframe. Children with higher respiratory classification level (eg, mechanical ventilation) at initial admission had more admissions to PACH (P < .001) and longer length of stays (P < .001). From first admission to final discharge, there was a significant change (reduction) in respiratory level (z = -4.588, P < .001). An increase in the overall number of admissions for children with respiratory support during the study timeframe was noted, with the largest increase for children requiring the highest level of support.

CONCLUSION

There has been a consistent increase in the number of children requiring respiratory support at admission to PACH. Reduction in respiratory support with postacute care occurs but children admitted with a higher level of support stay longer and experience multiple admissions.

Risk factors for hospitalizations due to bacterial respiratory tract infections after tracheotomy

OBJECTIVE

Identify characteristics associated with hospital readmission due to bacterial respiratory tract infections (bRTI) after tracheotomy.

STUDY DESIGN

Retrospective study of 8009 children 0-17 years undergoing tracheotomy from 2007 to 2013 at 48 children's hospitals in the Pediatric Health Information System database. The primary outcome was first hospital admission after tracheotomy for bRTI (ie, primary diagnosis of bRTI or a primary diagnosis of bRTI symptom and secondary diagnosis of bRTI). We used Cox-proportional hazard modeling to assess associations between patient demographic and clinical characteristics and bRTI hospital readmission.

RESULTS

Median age at tracheotomy admission was 5 months (interquartile range [IQR]: 1-50 months). Thirty-six percent (n = 2899) had at least one bRTI admission. Median time-to-readmission for bRTI was 275 days (IQR: 141-530). Factors independently associated with increased risk for bRTI readmission were younger age (eg, age < 30 days vs 13-17 years [aHR 1.32; 95%CI: 1.11-1.58]), Hispanic race/ethnicity (vs non-Hispanic White; aHR: 1.34; 95%CI: 1.20-1.50), government insurance (vs private; aHR 1.21; 95%CI: 1.10-1.33), >2 complex chronic conditions (vs zero; aHR 1.96; 95%CI: 1.34-2.86) and discharge to home (vs post-acute care setting; aHR 1.19; 95%CI: 1.08-1.32). Trauma diagnosis at tracheotomy (aHR 0.83; 95%CI: 0.69-1) and ventilator dependency (aHR 0.88; 95%CI: 0.81-0.97) were associated with decreased risk.

CONCLUSIONS

Young, Hispanic children with multiple complex chronic conditions who use Medicaid insurance and are not discharged to post-acute care are at the highest risk for hospital readmission for bRTI post-tracheotomy. Future research should investigate strategies to mitigate this risk for these children.