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Polcz VE, Barrios EL, Larson SD, Efron PA, Rincon JC. Charting the course for improved outcomes in chronic critical illness: therapeutic strategies for persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Br J Anaesth 2024:S0007-0912(24)00273-3. [PMID: 38902117 DOI: 10.1016/j.bja.2024.05.005] [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: 03/05/2024] [Revised: 04/29/2024] [Accepted: 05/07/2024] [Indexed: 06/22/2024] Open
Abstract
Enhanced critical care delivery has led to improved survival rates in critically ill patients, yet sepsis remains a leading cause of multiorgan failure with variable recovery outcomes. Chronic critical illness, characterised by prolonged ICU stays and persistent end-organ dysfunction, presents a significant challenge in patient management, often requiring multifaceted interventions. Recent research, highlighted in a comprehensive review in the British Journal of Anaesthesia, focuses on addressing the pathophysiological drivers of chronic critical illness, such as persistent inflammation, immunosuppression, and catabolism, through targeted therapeutic strategies including immunomodulation, muscle wasting prevention, nutritional support, and microbiome modulation. Although promising avenues exist, challenges remain in patient heterogeneity, treatment timing, and the need for multimodal approaches.
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Affiliation(s)
- Valerie E Polcz
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Evan L Barrios
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Shawn D Larson
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Jaimar C Rincon
- Department of Surgery, University of Florida, Gainesville, FL, USA.
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Lin M, Williams D, Vitcov G, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. Parent Preferences and Experiences in Advance Care Planning in the Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:e1783-e1791. [PMID: 37201532 DOI: 10.1055/s-0043-1768960] [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: 05/20/2023]
Abstract
OBJECTIVE Our objective was to evaluate the preferences and experiences of bereaved parents around advance care planning (ACP) in the neonatal intensive care unit (NICU). STUDY DESIGN Single-center cross-sectional survey of bereaved parents who experienced the death of a child in the Boston Children's Hospital NICU between 2010 and 2021 was carried out. Chi-square, Fisher's exact, Fisher Freeman Halton, and Wilcoxin rank sum tests were used to evaluate differences between parents who did and did not receive ACP. RESULTS Out of eligible parents, 40 out of 146 (27%) responded to our survey. Most parents (31 out of 33, 94%) rated ACP as being very important and 27 out of 33 (82%) reported having ACP discussions during their child's admission. Parents preferred initial ACP discussions to occur early in their child's illness trajectory with members of the primary NICU team, with most parents' experiences aligning with these preferences. CONCLUSION Parents value ACP discussions suggesting a further role for ACP in the NICU. KEY POINTS · NICU parents value and participate in advance care planning discussions. · Parents prefer advance care planning with members of the primary NICU, specialty, and palliative care teams. · Parents prefer advance care planning early in their child's illness trajectory.
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Affiliation(s)
- Matthew Lin
- Division of Hospital Medicine, Department of Pediatrics, Children's National Medical Center, Pediatric Palliative Care Program, Washington, District of Columbia
| | - David Williams
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Giselle Vitcov
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sadath Sayeed
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Christy Cummings
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
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Campbell S, Moola FJ, Gibson JL, Petch J, Denburg A. The Unspeakable Nature of Death & Dying During Childhood: A Silenced Phenomenon in Pediatric Care. OMEGA-JOURNAL OF DEATH AND DYING 2024; 89:88-107. [PMID: 35029516 PMCID: PMC11017694 DOI: 10.1177/00302228211067034] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In pediatric settings, the concept of hope is frequently positioned as a fundamental aspect of care and at odds with the possibility and proximity of death. This arguably fosters silence about death and dying in childhood despite evidence indicating the benefits of open communication at the end of life. In this paper, we describe the unspeakable nature of death and dying in childhood, including its conceptual and clinical causes and dimensions, its persistence, and the associated challenges for children and youth facing critical illnesses, their families, and society. We explore how the tension between hope and death can be reframed and apply our analysis to the context of medical assistance in dying for mature minors in Canada. Considering the lack of related literature, this paper offers initial reflections to form a framework for the unspeakable nature of death and dying in childhood and to advance the crucial need for research.
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Affiliation(s)
- Sydney Campbell
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Fiona J. Moola
- School of Early Childhood Studies, Ryerson University, Toronto, ON, Canada
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, The University of Toronto, Toronto, ON, Canada
| | - Jennifer L. Gibson
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jeremy Petch
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Data Science and Digital Health, Hamilton Health Science Centre, Hamilton, ON, Canada
- Division of Cardiology, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Avram Denburg
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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4
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Kalvas LB, Harrison TM. Screen time and sleep duration in pediatric critical care: Secondary analysis of a pilot observational study. J Pediatr Nurs 2024; 76:e101-e108. [PMID: 38307758 PMCID: PMC11081838 DOI: 10.1016/j.pedn.2024.01.025] [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: 08/28/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/04/2024]
Abstract
PURPOSE Quantify and describe screen time (screen type, child engagement, adult co-viewing) in eight critically ill children and determine its association with sleep duration before (parent report) and during (actigraphy) a 24-h period in the PICU. DESIGN AND METHODS Exploratory secondary analysis of 24-h video and actigraphy recordings in eight children 1-4 years old in the PICU. Videos were coded for screen time using Noldus Observer XT® software. Screen time was compared to American Academy of Pediatrics recommendations (0 h/day <2 years, ≤1 h/day 2-5 years). Parents completed the Brief Infant Sleep Questionnaire-Revised-Short Form (BISQ-R-SF) to understand children's pre-hospital sleep. Actigraphy was used to measure PICU sleep duration. Associations between screen time and sleep were determined with bivariate analyses. RESULTS Average age was 23.1 months (SD = 9.7). Daily screen time was 10.7 h (SD = 7), ranging from 2.4 to 21.4 h. Children (15.1% of sampling intervals) and adults (16.3%) spent little time actively engaged with screen media. BISQ-R-SF scores ranged from 48.9 to 97.7. Children had an average of 7.9 (SD = 1.2) night shift (19:00-6:59) sleep hours. Screen time was associated with worse pre-hospital sleep quality and duration with large effect sizes (rs= -0.7 to -1) and fewer nighttime sleep hours with a medium effect size (rs= -0.5). CONCLUSIONS All children exceeded screen time recommendations. Screen time was associated with worse pre-hospital sleep quality and duration, and decreased PICU sleep duration. Large-scale studies are needed to explore PICU screen time and sleep disruption. PRACTICE IMPLICATIONS Clinicians should model developmentally appropriate screen media use in PICU.
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Affiliation(s)
- Laura Beth Kalvas
- The Ohio State University Center for Clinical & Translational Science, 236A Newton Hall, 333 W. 10(th) Ave., Columbus, OH 43210, USA.
| | - Tondi M Harrison
- The Ohio State University College of Nursing, 360 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, USA.
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Boss RD, Maddox K, Thorndike D, Keppel K, Batson L, Smith B, Weaver MS, Munoz-Blanco S. Building clinician-parent partnerships to improve care for chronically critically Ill children: A pilot project. PATIENT EDUCATION AND COUNSELING 2024; 122:108152. [PMID: 38232672 DOI: 10.1016/j.pec.2024.108152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE Multicenter pilot to assess feasibility, acceptability, and educational value of videos for families and clinicians regarding unique inpatient challenges of pediatric chronic critical illness. METHODS Videos were developed for 3 hospitalization timepoints: 1) chronic critical illness diagnosis, 2) transfers, 3) discharge. Parents of hospitalized children, and interdisciplinary clinicians, were recruited to watch videos and complete surveys. RESULTS 33 parents (16 English-speaking, 17 Spanish-speaking) and 34 clinicians participated. Enrollment was better for families than clinicians (78% vs. 43%). Video acceptability was high: families and clinicians endorsed verisimilitude of depicted hospitalization challenges for chronic critical illness. All families felt the videos would help other families, all clinicians felt they would help other clinicians. Families gained expectations for the hospital course, discovered resources for hospitalization challenges, and learned there are other families in similar situations. Clinicians learned to recognize chronic critical illness, and how families experience hospitalizations, transfers, and discharges. CONCLUSION Educational videos about pediatric chronic critical illness were overall feasible, acceptable, and educational for hospitalized families and clinicians. PRACTICE IMPLICATIONS Just-in-time hospital education about pediatric chronic critical illness is valuable to families and clinicians; next steps are to assess potential to reduce gaps in care of children with chronic critical illness.
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Affiliation(s)
- Renee D Boss
- Johns Hopkins School of Medicine, 600 N. Wolfe St, Baltimore, MD 21287 USA; Johns Hopkins Berman Institute of Bioethics, 1801 Ashland Ave, Baltimore, MD 21287 USA.
| | - Katherine Maddox
- The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Dorte Thorndike
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Kristopher Keppel
- Johns Hopkins School of Medicine, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Lora Batson
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Brandon Smith
- Johns Hopkins School of Medicine, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | | | - Sara Munoz-Blanco
- Johns Hopkins School of Medicine, 600 N. Wolfe St, Baltimore, MD 21287 USA; The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
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6
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Arias AV, Lintner-Rivera M, Shafi NI, Abbas Q, Abdelhafeez AH, Ali M, Ammar H, Anwar AI, Adabie Appiah J, Attebery JE, Diaz Villalobos WE, Ferreira D, González-Dambrauskas S, Irfan Habib M, Lee JH, Kissoon N, Tekleab AM, Molyneux EM, Morrow BM, Nadkarni VM, Rivera J, Silvers R, Steere M, Tatay D, Bhutta AT, Kortz TB, Agulnik A. A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus. Lancet Glob Health 2024; 12:e331-e340. [PMID: 38190831 PMCID: PMC11089938 DOI: 10.1016/s2214-109x(23)00537-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 01/10/2024]
Abstract
The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.
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Affiliation(s)
- Anita V Arias
- Division of Critical Care and Pulmonary Medicine, Department of Pediatrics, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Michael Lintner-Rivera
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nadeem I Shafi
- Division of Pediatric Critical Care, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Abdelhafeez H Abdelhafeez
- Department of Surgery, St Jude Children's Research Hospital Memphis, TN, USA; Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Muhammad Ali
- Department of Pediatric Oncology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Halaashuor Ammar
- Department of Paediatrics, School of Medicine, University of Benghazi, Children's Hospital of Benghazi, Benghazi, Libya
| | - Ali I Anwar
- Lincoln Memorial University-DeBusk College of Osteopathic Medicine, Knoxville, TN, USA
| | - John Adabie Appiah
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Jonah E Attebery
- Division of Critical Care, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | | | - Sebastián González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Montevideo, Uruguay; Facultad de Medicina, Universidad de la República, Montevideo, Uruguay; Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | | | - Jan Hau Lee
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore; Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Atnafu M Tekleab
- Department of Pediatrics and Child Health, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jocelyn Rivera
- Pediatric Emergency Department, Hospital Infantil Teletón de Oncología, Querétaro, México
| | - Rebecca Silvers
- Institute for Global Health Sciences and the University of California San Francisco, San Francisco, CA, USA; UCSF School of Nursing, San Francisco, CA, USA; Division of Critical Care, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Mardi Steere
- Royal Flying Doctor Service (South Australia/Northern Territory), SA, Australia; Department of Paediatric Emergency Medicine, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Daniel Tatay
- Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina
| | - Adnan T Bhutta
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Teresa B Kortz
- Institute for Global Health Sciences and the University of California San Francisco, San Francisco, CA, USA; Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Asya Agulnik
- Division of Critical Care and Pulmonary Medicine, Department of Pediatrics, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
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Henderson CM, Boss RD. Establishing Goals of Care in Serious and Complex Pediatric Illness. Pediatr Clin North Am 2024; 71:71-82. [PMID: 37973308 DOI: 10.1016/j.pcl.2023.08.008] [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] [Indexed: 11/19/2023]
Abstract
An increasing number of children are living for months and years with serious/complex illness characterized by long-term prognostic uncertainty, intensive interactions with medical systems, functional limitations, and often home medical technologies that shape the child's and family's quality of life. These families face many medical decision points that require intentional and iterative discussions about goals of care. Threats to cohesive goals of care include prognostic uncertainty, diffusion of medical responsibility, individual family context, and blended goals of care. This article offers strategies for addressing each of these challenges.
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Affiliation(s)
- Carrie M Henderson
- Department of Pediatrics, Center for Bioethics and Medical Humanities, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Renee D Boss
- Department of Pediatrics, Johns Hopkins School of Medicine, Johns Hopkins Berman Institute of Bioethics, 200 North Wolfe Street, Suite 2019, Baltimore, MD 21287, USA.
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Chung J, Pecora PJ, Sinha A, Prichett L, Lin FY, Seltzer RR. A gap in the data: Defining, identifying, and tracking children with medical complexity in the child welfare system. CHILD ABUSE & NEGLECT 2024; 147:106600. [PMID: 38118290 DOI: 10.1016/j.chiabu.2023.106600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Among nearly 400,000 children in US foster care, an estimated 10 % are medically complex. Yet, population-level data about children with medical complexity (CMC) served by the child welfare system, both for prevention and foster care services, are largely unavailable. OBJECTIVE To understand how US child welfare agencies define, identify, and track CMC. PARTICIPANTS AND SETTING Child welfare agencies across the US. METHODS Agencies were recruited to complete a survey as part of a larger study exploring how CMC are served by the child welfare system. Survey responses related to defining, identifying, and tracking CMC were included in analysis. Descriptive statistical analysis was conducted with Stata. Qualitative content and thematic analysis were applied to free text responses. RESULTS Surveys were completed by agencies from 28 states and 2 major cities. Nearly half of the agencies did not have a clear definition to identify CMC; those that did have a definition often lacked standardization. The majority of agencies could not easily identify CMC or access CMC-related data within data systems. Agencies described lack of a clear definition as a barrier to collecting population level data. CONCLUSIONS Many US child welfare agencies lack a clear definition to identify and track CMC, impacting the ability to tailor care and service delivery to meet their unique needs. To address this, a clear definition for CMC should be developed and consistently applied within child welfare data systems. Once CMC are identifiable, future research can collect population-level data and provide recommendations for best practices and policies.
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Affiliation(s)
- Joyce Chung
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Peter J Pecora
- University of Washington School of Social Work, Seattle, WA, United States of America; Casey Family Programs, Seattle, WA, United States of America
| | - Aakanksha Sinha
- Casey Family Programs, Seattle, WA, United States of America
| | - Laura Prichett
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Fang-Yi Lin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Rebecca R Seltzer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America; Berman Institute of Bioethics, Baltimore, MD, United States of America.
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Patterson SG, Lamb CK, Gong W, Resser J, Lindsell CJ, Van Driest SL, Stark RJ. Pediatric Persistent Inflammation, Immunosuppression, and Catabolism Syndrome Prevalence in Sepsis-Related Mortalities: A 23-Year Institutional History. Chest 2023; 164:1204-1215. [PMID: 37164130 PMCID: PMC10635837 DOI: 10.1016/j.chest.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Delayed mortality in sepsis often is linked to a lack of resolution in the inflammatory cascade termed persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Limited research exists on PICS in pediatric patients with sepsis. RESEARCH QUESTION What is the prevalence of pediatric PICS (pPICS) in patients who died of sepsis-related causes and what associated pathogen profiles and comorbidities did they have compared with those patients without pPICS who died from sepsis? STUDY DESIGN AND METHODS A retrospective study of a single institution using a de-identified database from 1997 through 2020 for all patients aged 21 years or younger who died of culture-positive sepsis from a known source and who had laboratory data available were evaluated for the presence of pPICS. RESULTS Among records extracted from the institutional database, 557 patients had culture-positive sepsis, with 262 patients having pPICS (47%). Patients with pPICS were more likely to have underlying hematologic or oncologic disease or cardiac disease. In addition, patients who had pPICS showed increased odds of associated fungal infection compared with those patients who did not (OR, 2.69; 95% CI, 1.59-4.61; P < .001). When assessing laboratory criteria, having a sustained absolute lymphocyte count of < 1.0 × 103/μL was most closely associated with having pPICS compared with other laboratory parameters. Finally, the results of multivariate logistic regression analysis indicated that patients with pPICS were more common in the cardiac ICU, as opposed to the PICU (OR, 3.43; CI, 1.57-7.64; P = .002). INTERPRETATION Pediatric patients who died of a sepsis-related cause have a pPICS phenotype nearly one-half of the time. These patients are more likely to be in the cardiac ICU than the pediatric ICU and have associated fungal infections. Special attention should be directed toward this population in future research.
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Affiliation(s)
| | - Celia K Lamb
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Wu Gong
- Department of Biostatistics and Bioinformatics, Vanderbilt University Medical Center, Nashville, TN
| | - Jackson Resser
- Department of Biostatistics and Bioinformatics, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher J Lindsell
- Division of Biostatistics, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Sara L Van Driest
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan J Stark
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
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10
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Kalvas LB, Harrison TM, Curley MAQ, Ordway MR, Redeker NS, Happ MB. An observational pilot study of sleep disruption and delirium in critically ill children. Heart Lung 2023; 62:215-224. [PMID: 37591147 PMCID: PMC10592139 DOI: 10.1016/j.hrtlng.2023.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/10/2023] [Accepted: 08/06/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Sleep disruption is frequently observed in children with delirium in the pediatric intensive care unit (PICU). OBJECTIVES This observational pilot study explores relationships among modifiable characteristics of the PICU environment (i.e., light, sound, clinician caregiving patterns), sleep disruption, and delirium. METHODS Ten children, 1 to 4 years old, were recruited within 48 h of PICU admission and followed until discharge. A light meter, dosimeter, and video camera were placed at bedside to measure PICU environmental exposures. Sleep was measured via actigraphy. Twice daily delirium screening was conducted. Descriptive statistics were used to describe the PICU environment, sleep, and delirium experienced by children. Bivariate analyses were performed to determine relationships among variables. RESULTS Average participant age was 21 (SD = 9.6) months. Eight (80%) were admitted for respiratory failure. Median PICU length of stay was 36.7 (IQR[29.6, 51.5]) hours, which limited data collection duration. Delirium prevalence was 60% (n = 6). Children experienced low daytime light levels (x¯ = 112.8 lux, SD = 145.5) and frequent peaks (x¯ = 1.9/hr, SD = 0.5) of excessive sound (i.e., ≥ 45 A-weighted decibels). Clinician caregiving episodes were frequent (x¯ = 4.5/hr, SD = 2.6). Children experienced 7.3 (SD = 2.1) awakenings per hour of sleep and a median sleep episode duration of 1.4 (IQR[0.6, 2.3]) hours. On average, children with delirium experienced 1.1 more awakenings per sleep hour and 42 fewer minutes of sleep per sleep episode during the night shift. Increased clinician care frequency and duration were associated with worse sleep quality and delirium. CONCLUSIONS Study results will inform future, large-scale research and nurse-driven sleep promotion interventions.
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Affiliation(s)
- Laura Beth Kalvas
- The Ohio State University Center for Clinical and Translational Science, 236A Newton Hall, 333 W. 10th Ave., Columbus, OH, 43210, USA.
| | - Tondi M Harrison
- The Ohio State University College of Nursing, 360 Newton Hall, 1585 Neil Avenue, Columbus OH 43210, USA
| | - Martha A Q Curley
- Ruth M. Colket Endowed Chair in Pediatric Nursing, Children's Hospital of Philadelphia, PA 19104, USA; University of Pennsylvania School of Nursing, 425 Claire M. Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104-4217, USA
| | - Monica R Ordway
- Yale School of Nursing, Office 21403, 400 West Campus Drive, Orange, CT 06477, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing, 313 Augustus Storrs Hall, 231 Glenbrook Road, Unit 4026, Storrs, CT 06269-4026, USA
| | - Mary Beth Happ
- The Ohio State University College of Nursing, 360 Newton Hall, 1585 Neil Avenue, Columbus OH 43210, USA
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谭 子, 李 恩, 钟 卫, 杨 东, 马 可, 赖 志, 陈 素, 郑 曼. [Etiology composition and prognosis of pediatric chronic critical illness in a pediatric intensive care unit]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:843-848. [PMID: 37668033 PMCID: PMC10484089 DOI: 10.7499/j.issn.1008-8830.2302053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/12/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVES To explore the etiology composition and outcomes of pediatric chronic critical illness (PCCI) in the pediatric intensive care unit (PICU). METHODS The children who were hospitalized in the PICU of Dongguan Children's Hospital Affiliated to Guangdong Medical University and met the diagnostic criteria for PCCI from January 2017 to December 2022 were included in the study. The etiology of the children was classified based on their medical records and discharge diagnoses. Relevant clinical data during hospitalization were collected and analyzed. RESULTS Among the 3 955 hospitalized children in the PICU from January 2017 to December 2022, 321 cases (8.12%) met the diagnostic criteria for PCCI. Among the 321 cases, the most common etiology was infection (71.3%, 229 cases), followed by unintentional injury (12.8%, 41 cases), postoperation (5.9%, 19 cases), tumors/immune system diseases (5.0%, 16 cases), and genetic and chromosomal diseases (5.0%, 16 cases). Among the 321 cases, 249 cases (77.6%) were discharged after improvement, 37 cases (11.5%) were discharged at the request of the family, and 35 cases (10.9%) died in the hospital. Among the deaths, infection accounted for 74% (26/35), unintentional injury accounted for 17% (6/35), tumors/immune system diseases accounted for 6% (2/35), and genetic and chromosomal diseases accounted for 3% (1/35). From 2017 to 2022, the proportion of PCCI in PICU diseases showed an increasing trend year by year (P<0.05). Among the 321 children with PCCI, there were 148 infants and young children (46.1%), 57 preschool children (17.8%), 54 school-aged children (16.8%), and 62 adolescents (19.3%), with the highest proportion in the infant and young children group (P<0.05). The in-hospital mortality rates of the four age groups were 14.9% (22/148), 8.8% (5/57), 5.6% (3/54), and 8.1% (5/62), respectively. The infant and young children group had the highest mortality rate, but there was no statistically significant difference among the four groups (P>0.05). CONCLUSIONS The proportion of PCCI in PICU diseases is increasing, and the main causes are infection and unintentional injury. The most common cause of death in children with PCCI is infection. The PCCI patient population is mainly infants and young children, and the in-hospital mortality rate of infant and young children with PCCI is relatively high.
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Grandjean C, Perez MH, Ramelet AS. Comparison of clinical characteristics and healthcare resource use of pediatric chronic and non-chronic critically ill patients in intensive care units: a retrospective national registry study. Front Pediatr 2023; 11:1194833. [PMID: 37435169 PMCID: PMC10331166 DOI: 10.3389/fped.2023.1194833] [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: 03/27/2023] [Accepted: 06/12/2023] [Indexed: 07/13/2023] Open
Abstract
Introduction Chronic critically ill patients (CCI) in pediatric intensive care unit (PICU) are at risk of negative health outcomes, and account for a considerable amount of ICU resources. This study aimed to (a) describe the prevalence of CCI children, (b) compare their clinical characteristics and ICU resources use with non-CCI children, and (c) identify associated risk factors of CCI. Methods A retrospective national registry study including 2015-2017 data from the eight Swiss PICUs of five tertiary and three regional hospitals, admitting a broad case-mix of medical and surgical patients, including pre- and full-term infants. CCI patients were identified using an adapted definition: PICU length of stay (LOS) ≥8 days and dependence on ≥1 PICU technology. Results Out of the 12,375 PICU admissions, 982 (8%) were CCI children and compared to non-CCI children, they were younger (2.8 vs. 6.7 months), had more cardiac conditions (24% vs. 12%), and higher mortality rate (7% vs. 2%) (p < 0.001). Nursing workload was higher in the CCI compared to the non-CCI group (22 [17-27]; 21 [16-26] respectively p < 0.001). Factors associated with CCI were cardiac (aOR = 2.241) and neurological diagnosis (aOR = 2.062), surgery (aORs between 1.662 and 2.391), ventilation support (aOR = 2.278), high mortality risk (aOR = 1.074) and agitation (aOR = 1.867). Conclusion the results confirm the clinical vulnerability and the complexity of care of CCI children as they were defined in our study. Early identification and adequate staffing is required to provide appropriate and good quality care.
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Affiliation(s)
- Chantal Grandjean
- Pediatric Intensive and Intermediate Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Pediatric Intensive and Intermediate Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Pediatric Intensive and Intermediate Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Abstract
Children who survive the pediatric intensive care unit (PICU) are at risk of developing post-intensive care syndrome in pediatrics (PICS-p). PICS-p, defined as new physical, cognitive, emotional, and/or social health dysfunction following critical illness, can affect the child and family. Historically, synthesizing PICU outcomes research has been challenging due to inconsistency in study design and in outcomes measurement. PICS-p risk may be mitigated by implementing intensive care unit best practices that limit iatrogenic injury and by supporting the resiliency of critically ill children and their families.
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Edwards JD. A Focused Review of Long-Stay Patients and the Ethical Imperative to Provide Inpatient Continuity. Semin Pediatr Neurol 2023; 45:101037. [PMID: 37003634 DOI: 10.1016/j.spen.2023.101037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/17/2023] [Accepted: 02/19/2023] [Indexed: 04/03/2023]
Abstract
Long-stay patients are an impactful, vulnerable, growing group of inpatients in today's (and tomorrow's) tertiary hospitals. They can outlast dozens of clinicians that necessarily rotate on and off clinical service. Yet, care from such rotating clinicians can result in fragmented care due to a lack of continuity that insufficiently meets the needs of these patients and their families. Using long-stay PICU patients as an example, this focused review discusses the impact of prolonged admissions and how our fragmented care can compound this impact. It also argues that it is an ethical imperative to provide a level of continuity of care beyond what is considered standard of care and offers a number of strategies that can provide such continuity.
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Affiliation(s)
- Jeffrey D Edwards
- Section of Critical Care, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY..
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15
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Abstract
OBJECTIVES Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions. DATA SOURCES Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021. STUDY SELECTION We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening. DATA EXTRACTION We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed. DATA SYNTHESIS Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18). CONCLUSIONS Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.
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A Call for Defining Pediatric Chronic Critical Illness: Moving Beyond I Know It When I See It. Pediatr Crit Care Med 2023; 24:179-181. [PMID: 36661425 DOI: 10.1097/pcc.0000000000003168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Affiliation(s)
- Ellen Pittman
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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18
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Carvalho-Salemi J, Phillips W, Wong Vega M, Swanson J, Becker PJ, Salemi JL. Malnutrition among Hospitalized Children in the United States: A 2012-2019 Update of Annual Trends. J Acad Nutr Diet 2023; 123:109-116. [PMID: 35659540 DOI: 10.1016/j.jand.2022.05.021] [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: 04/25/2018] [Revised: 05/24/2022] [Accepted: 12/22/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Malnutrition is associated with adverse clinical outcomes and increased health care utilization for hospitalized children. Yet pediatric malnutrition often goes undiagnosed and national prevalence research in this population is scarce. OBJECTIVE The aim was to assess change in the coded diagnosis of malnutrition (CDM) among US hospitalized children given increased awareness of the need for improved recognition and standardized diagnosis. DESIGN Retrospective, cross-sectional analysis using nationally representative data from the Nationwide Inpatient Sample. PARTICIPANTS/SETTING Our sample was 13.2 million hospitalizations from 2012 to 2019 among pediatric patients between age 1 month and 17 years. MAIN OUTCOME MEASURE CDM using International Classification of Diseases Ninth and 10th Revision-Clinical Modification diagnosis codes. STATISTICAL ANALYSES Descriptive statistics and sampling weights were used to estimate the national frequency and prevalence of CDM. Temporal trends in CDM overall and stratified by age, race/ethnicity, and hospital type were analyzed using joinpoint regression. RESULTS CDM prevalence increased from 3.9% in 2012 to 6.4% in 2019. During this period, failure to thrive decreased from 40.6% to 23.3% of all cases with concomitant increases in the diagnosis of protein-calorie malnutrition and children identified with more than one malnutrition subtype. Differences in CDM diagnoses are evident by hospital type, race/ethnicity, and age of the patient. CONCLUSIONS Although pediatric malnutrition continues to be underdiagnosed in hospital settings, this study demonstrates improvement over time. There continues to be a need for continued professional education regarding best practices for diagnosis to improve health care provider knowledge and self-efficacy on this topic, especially in nonteaching hospitals.
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Affiliation(s)
| | | | | | - Justin Swanson
- College of Public Health, University of South Florida, Tampa, Florida
| | | | - Jason L Salemi
- College of Public Health, University of South Florida, Tampa, Florida
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19
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Leland BD, Wocial LD, Madrigal VN, Moon MM, Ramey-Hunt C, Walter JK, Baird JD, Edwards JD. Group Concept Mapping Conceptualizes High-Quality Care for Long-Stay Pediatric Intensive Care Unit Patients and Families. J Pediatr 2023; 252:48-55.e1. [PMID: 35973447 PMCID: PMC9772094 DOI: 10.1016/j.jpeds.2022.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe and conceptualize high-quality care for long-stay pediatric intensive care unit (PICU) patients using group concept mapping (GCM). STUDY DESIGN We convened an expert panel to elucidate domains of high-quality care for this growing patient population for which transitory care models fail to meet their needs. Thirty-one healthcare professionals and 7 parents of patients with previous prolonged PICU hospitalizations comprised a diverse, interprofessional multidisciplinary panel. Participants completed the prompt "For PICU patients and families experiencing prolonged lengths of stay, high quality care from the medical team includes ______", with unlimited free text responses. Responses were synthesized into individual statements, then panelists sorted them by idea similarity and rated them by perceived importance. Statement analysis using GCM software through GroupWisdom generated nonoverlapping clusters representing domains of high-quality care. RESULTS Participants submitted 265 prompt responses representing 313 unique ideas, resulting in 78 final statements for sorting and rating. The resultant cluster map best representing the data contained 8 domains: (1) Family-Centered Care and Shared Decision Making, (2) Humanizing the Patient, (3) Clinician Supports and Resources, (4) Multidisciplinary Coordination of Care, (5) Family Well-Being, (6) Anticipatory Guidance and Care Planning, (7) Communication, and (8) Continuity of Care. CONCLUSIONS GCM empowered a panel of healthcare professionals and parents to explicitly describe and conceptualize high-quality care for patients and families experiencing prolonged PICU stays. This information will aid the effort to address shortcomings of transitory PICU care models.
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Affiliation(s)
- Brian D Leland
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN.
| | - Lucia D Wocial
- John J. Lynch, MD Center for Ethics, MedStar Washington Hospital Center, Washington, DC
| | - Vanessa N Madrigal
- Division of Critical Care Medicine, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC; Pediatric Ethics Program, Children's National Hospital, Washington, DC
| | - Michelle M Moon
- Palliative Care and Symptom Management, Swedish Health Systems, Issaquah, WA
| | - Cheryl Ramey-Hunt
- Integrated Care Management, Case Management, and Social Work, Indiana University Health & Riley Hospital for Children, Indianapolis, IN
| | - Jennifer K Walter
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Pediatric Advanced Care Team, Justin Michael Ingerman Center for Palliative Care, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer D Baird
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, CA
| | - Jeffrey D Edwards
- Section of Critical Care, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY
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20
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Lin M, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. The Case for Advance Care Planning in the NICU. Pediatrics 2022; 150:189893. [PMID: 36321383 DOI: 10.1542/peds.2022-057824] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
Many NICUs have reached an inflection point where infant deaths following limitation of life-sustaining treatments outnumber those following unsuccessful resuscitations, and many infants who survive continue to require intensive supports. Families of such infants with serious illness may benefit from a standardized, process-oriented approach in decisional-support. Advance care planning (ACP), or communication that supports patients, or their surrogate decision-makers, in sharing values, goals, and preferences for future medical care, is recognized as a valuable strategy in supporting adults with serious and chronic illness. Although the role of ACP in older children and adolescents is evolving, its utility has not been systematically explored in the perinatal context. This article builds a case for formalizing a role for ACP in the NICU by defining ACP and appraising recent outcomes research, reviewing the current state of parental needs for decisional support and serious illness in the NICU, and describing how ACP may address current limitations in primary and specialty pediatric palliative care and challenges for decision-making in the newborn period.
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Affiliation(s)
- Matthew Lin
- Pediatric Palliative Care Program, Children's National Medical Center, Washington, District of Columbia
| | | | | | - Joanne Wolfe
- Departments of Psychosocial Oncology and Palliative Care and Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
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21
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Deming RS, Mazzola E, MacDonald J, Manning S, Beight L, Currie ER, Wojcik MH, Wolfe J. Care Intensity and Palliative Care in Chronically Critically Ill Infants. J Pain Symptom Manage 2022; 64:486-494. [PMID: 35840043 DOI: 10.1016/j.jpainsymman.2022.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Increasingly, chronically critically ill (CCI) infants survive to discharge from Neonatal Intensive Care Units (NICUs). Little is known about their care intensity and the primary and specialty palliative care families receive at and following discharge. OBJECTIVES To describe care intensity and primary and specialty palliative care received by NICU CCI infants at discharge and one year. METHODS Chart abstraction of CCI infants at three academic centers discharged at ≥42 weeks corrected gestational age with medical technology between 2016 and 2019, including demographics, care intensity, and primary and specialty palliative care received at discharge and one year. RESULTS Among 273 infants, NICU median stays were 45 [IQR 23-92] days. Primary diagnoses included congenital and/or genetic conditions (68.5%), prematurity (28.2%), and birth events (3.3%). At discharge, surgical feeding tubes (75.1%) and tracheostomies (24.5%) were the most common technologies. Infants received a median of 6 [IQR 4-9] medications and were followed by a median of 8 [IQR 7-9] providers. At one year, 91.4% continued with one or more technologies, similar numbers of medications and specialty providers. In the NICU, nearly all families had social work involvement, 78.8% had chaplaincy and 53.8% child life; 19.8% received specialty palliative care consultation. At one year, only 13.2% were followed by palliative care. CONCLUSIONS CCI infants receive intensive medical care including multiple medical technologies, medications, and specialty follow up at discharge and remain complex at one year of life. Most receive primary interprofessional palliative care in the NICU, however these infants and their families may have limited access to specialty palliative care in the short- and long-term.
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Affiliation(s)
- Rachel S Deming
- Department of Psychosocial Oncology and Palliative Care (R.S.D., E.M., L.B., J.W.), Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Emanuele Mazzola
- Department of Psychosocial Oncology and Palliative Care (R.S.D., E.M., L.B., J.W.), Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeanne MacDonald
- Department of Pediatrics (J.M.), Massachusetts General Hospital for Children, Boston, MA, USA
| | - Simon Manning
- Department of Pediatric Newborn Medicine (S.M.), Brigham and Women's Hospital, Boston, MA, USA
| | - Leah Beight
- Department of Psychosocial Oncology and Palliative Care (R.S.D., E.M., L.B., J.W.), Dana-Farber Cancer Institute, Boston, MA, USA
| | - Erin R Currie
- School of Nursing (E.R.C.), University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monica H Wojcik
- Divisions of Newborn Medicine and Genetics and Genomics, Department of Pediatrics (M.H.W.), Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care (R.S.D., E.M., L.B., J.W.), Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, MA, USA
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22
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Kalvas LB, Harrison TM, Solove S, Happ MB. Sleep disruption and delirium in critically ill children: Study protocol feasibility. Res Nurs Health 2022; 45:604-615. [PMID: 35986659 PMCID: PMC9529999 DOI: 10.1002/nur.22259] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/12/2022] [Accepted: 07/31/2022] [Indexed: 08/19/2023]
Abstract
Delirium is a serious complication of pediatric critical illness. Sleep disruption is frequently observed in children with delirium, and circadian rhythm dysregulation is one proposed cause of delirium. Children admitted to the pediatric intensive care unit (PICU) experience multiple environmental exposures with the potential to disrupt sleep. Although researchers have measured PICU light and sound exposure, sleep, and delirium, these variables have not yet been fully explored in a single study. Furthermore, caregiving patterns have not often been included as a component of the PICU environment. Measuring the light and sound exposure, caregiving patterns, and sleep of critically ill children requires continuous PICU bedside data collection. This presents multiple methodological challenges. In this paper, we describe the protocol for an observational pilot study of the PICU environment, sleep, and delirium experienced by a sample of 10 critically ill children 1-4 years of age. We also evaluate and discuss the feasibility (i.e., acceptability, implementation, practicality) of the study protocol. Light and sound exposure were measured with bedside sensors. Caregiving was quantified through video recording. Sleep was measured via actigraphy and confirmed by video recording. Delirium screening with the Cornell Assessment of Pediatric Delirium was conducted twice daily, either in person or via video review. This study provides a refined measurement framework to inform future, large-scale studies and the development of nurse-driven sleep promotion interventions.
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Affiliation(s)
- Laura Beth Kalvas
- Post-Docotral Fellow
- The Ohio State University College of Nursing, Columbus, OH
| | - Tondi M. Harrison
- The Ohio State University College of Nursing, Columbus, OH
- Associate Professor
| | - Sandra Solove
- The Ohio State University College of Nursing, Columbus, OH
- Research Regulatory Coordinator
| | - Mary Beth Happ
- The Ohio State University College of Nursing, Columbus, OH
- Senior Associate Dean for Research and Innovation
- Distinguished Professor of Critical Care Research
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23
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Affiliation(s)
- Neethi P Pinto
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.,Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.,Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Torbert N, Neumann M, Birge N, Perkins D, Ehrhardt E, Weaver MS. Discipline-Specific Perspectives on Caring for Babies with Trisomy 13 or 18 in the Neonatal Intensive Care Unit. Am J Perinatol 2022; 39:1074-1082. [PMID: 33285605 DOI: 10.1055/s-0040-1721496] [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: 10/22/2022]
Abstract
OBJECTIVE Care offerings vary across medical settings and between families for babies with trisomy 13 or 18. The purpose of this qualitative descriptive study was to explore nurse, advanced practice practitioner, and neonatologist perspectives on care for babies with trisomy 13 or 18 in the intensive care unit. STUDY DESIGN Voice-recorded qualitative interviews occurred with 64 participants (41 bedside nurses, 14 advance practice practitioners, and 9 neonatologists) from two neonatal intensive care units (NICU) in the midwestern United States. Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Content analyses occurred utilizing MAXQDA (VERBI Software, 2020). RESULTS Over half of NICU staff perceived care for babies with trisomy 13 or 18 as different from care for other babies with critical chronic illness. Qualitative themes included internal conflict, variable presentation and prognosis, grappling with uncertainty, family experiences, and provision of meaningful care. Neonatologists emphasized the variability of presentation and prognosis, while nurses emphasized provision of meaningful care. Phrases "hard/difficult" were spoken 31 times; primarily describing the comorbidities, complexities, and prognostic uncertainty. CONCLUSION Care for babies with these genetic diagnoses reveals need for a shared dialogue not only with families but also across staff disciplines. While perspectives differ, participants depicted striving to offer compassionate, family-centered care while also balancing biomedical uncertainty about interventions for children with trisomy 13 and 18. KEY POINTS · Care for babies with trisomy 13 or 18 has been recognized as shifting.. · Controversy exists across the diverse and changing range of care models.. · This study describes perspectives of bedside neonatal nurses, advanced practitioners, and neonatologists.. · Differences in perspectives warrant attentiveness to insights and dialogue across disciplines..
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Affiliation(s)
- Nicholas Torbert
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Marie Neumann
- Division of Palliative Care, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Nicole Birge
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Donnetta Perkins
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Elizabeth Ehrhardt
- Division of Neonatology, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
| | - Meaghann S Weaver
- Division of Palliative Care, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska
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Heneghan JA, Goodman DM, Ramgopal S. Demographic and Clinical Differences Between Applied Definitions of Medical Complexity. Hosp Pediatr 2022; 12:654-663. [PMID: 35652303 DOI: 10.1542/hpeds.2021-006432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify the degree of concordance and characterize demographic and clinical differences between commonly used definitions of multisystem medical complexity in children hospitalized in children's hospitals. METHODS We conducted a retrospective, cross-sectional cohort study of children <21 years of age hospitalized at 47 US Pediatric Health Information System-participating children's hospitals between January 2017 to December 2019. We classified patients as having multisystem complexity when using 3 definitions of medical complexity (pediatric complex chronic conditions, pediatric medical complexity algorithm, and pediatric chronic critical illness) and assessed their overlap. We compared demographic, clinical, outcome, cost characteristics, and longitudinal healthcare utilization for each grouping. RESULTS Nearly one-fourth (23.5%) of children hospitalized at Pediatric Health Information System-participating institutions were identified as meeting at least 1 definition of multisystem complexity. Children with multisystem complexity ranged from 1.0% to 22.1% of hospitalized children, depending on the definition, with 31.2% to 95.9% requiring an ICU stay during their index admission. Differences were seen in demographic, clinical, and resource utilization patterns across the definitions. Definitions of multisystem complexity demonstrated poor agreement (Fleiss' κ 0.21), with 3.5% of identified children meeting all 3. CONCLUSIONS Three definitions of multisystem complexity identified varied populations of children with complex medical needs, with poor overall agreement. Careful consideration is required when applying definitions of medical complexity in health services research, and their lack of concordance should result in caution in the interpretation of research using differing definitions of medical complexity.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - Sriram Ramgopal
- Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Ettinger NA, Hill VL, Russ CM, Rakoczy KJ, Fallat ME, Wright TN, Choong K, Agus MSD, Hsu B, Mack E, Day S, Lowrie L, Siegel L, Srinivasan V, Gadepalli S, Hirshberg EL, Kissoon N, October T, Tamburro RF, Rotta A, Tellez S, Rauch DA, Ernst K, Vinocur C, Lam VT, Romito B, Hanson N, Gigli KH, Mauro M, Leonard MS, Alexander SN, Davidoff A, Besner GE, Browne M, Downard CD, Gow KW, Islam S, Saunders Walsh D, Williams RF, Thorne V. Guidance for Structuring a Pediatric Intermediate Care Unit. Pediatrics 2022; 149:186777. [PMID: 35490284 DOI: 10.1542/peds.2022-057009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.
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Affiliation(s)
- Nicholas A Ettinger
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Vanessa L Hill
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine/The Children's Hospital of San Antonio, San Antonio, Texas
| | - Christiana M Russ
- Intermediate Care Program.,Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine J Rakoczy
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Tuft's Children's Hospital, Boston, Massachusetts
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Karen Choong
- Division of Critical Care, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Michael S D Agus
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Benson Hsu
- Division of Critical Care, Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
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Abstract
OBJECTIVES To describe the demographic, clinical, outcome, and cost differences between children with high-frequency PICU admission and those without. DESIGN Retrospective, cross-sectional cohort study. SETTING United States. PATIENTS Children less than or equal to 18 years old admitted to PICUs participating in the Pediatric Health Information System database in 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We assessed survivors of PICU admissions for repeat PICU admissions within a year of their index visit. Children with greater than or equal to 3 PICU admissions within a year were classified as high-frequency PICU utilization (HFPICU). We compared demographic, clinical, outcome, and cost characteristics between children with HFPICU and those with only an index or two admissions per year (nHFPICU). Of 95,465 children who survived an index admission, 5,880 (6.2%) met HFPICU criteria. HFPICU patients were more frequently younger, technology dependent, and publicly insured. HFPICU patients had longer lengths of stay and were more frequently discharged to a rehabilitation facility or with home nursing services. HFPICU patients accounted for 24.8% of annual hospital utilization costs among patients requiring PICU admission. Time to readmission for children with HFPICU was 58% sooner (95% CI, 56-59%) than in those with nHFPICU with two admissions using an accelerated failure time model. Among demographic and clinical factors that were associated with development of HFPICU status calculated from a multivariable analysis, the greatest effect size was for time to first readmission within 82 days. CONCLUSIONS Children identified as having HFPICU account for 6.2% of children surviving an index ICU admission. They are a high-risk patient population with increased medical resource utilization during index and subsequent ICU admissions. Patients readmitted within 82 days of discharge should be considered at higher risk of HFPICU status. Further research, including validation and exploration of interventions that may be of use in this patient population, are necessary.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, MN
| | - Manzilat Akande
- Division of Pediatric Critical Care, Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, OK
| | - Denise M Goodman
- Division of Pediatric Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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King MA, Matos RI, Hamele MT, Borgman MA, Zabrocki LA, Gadepalli SK, Maves RC. PICU in the MICU: How Adult ICUs Can Support Pediatric Care in Public Health Emergencies. Chest 2022; 161:1297-1305. [PMID: 35007553 PMCID: PMC8739819 DOI: 10.1016/j.chest.2021.12.648] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/24/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
Initial waves of the COVID-19 pandemic have largely spared children. With the advent of vaccination in many older age groups and the spread of the highly contagious Delta variant, however, children now represent a growing percentage of COVID-19 cases. PICU capacity is far less than that of adult ICUs. Adult ICUs may need to support pediatric care, much as PICUs provided adult care earlier in the pandemic. Critically ill children selected for care in adult settings should be at least 12 years of age and ideally have conditions common in children and adults alike (eg, community-acquired sepsis, trauma). Children with complex, pediatric-specific disorders are best served in PICUs and are not recommended for transfer. The goal of such transfers is to maintain critical capacity for those children in greatest need of the PICU's unique abilities, therefore preserving systems of care for all children.
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Affiliation(s)
| | - Renee I Matos
- Brooke Army Medical Center, Fort Sam Houston, TX; Uniformed Services University, Bethesda, MD
| | - Mitchell T Hamele
- Uniformed Services University, Bethesda, MD; Tripler Army Medical Center, Honolulu, HI
| | - Matthew A Borgman
- Brooke Army Medical Center, Fort Sam Houston, TX; Uniformed Services University, Bethesda, MD
| | - Luke A Zabrocki
- Uniformed Services University, Bethesda, MD; Naval Medical Center, San Diego, CA
| | | | - Ryan C Maves
- Uniformed Services University, Bethesda, MD; Wake Forest School of Medicine, Winston-Salem, NC.
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29
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Boss RD, Henderson CM, Weiss EM, Falck A, Madrigal V, Shapiro MC, Williams EP, Donohue PK. The Changing Landscape in Pediatric Hospitals: A Multicenter Study of How Pediatric Chronic Critical Illness Impacts NICU Throughput. Am J Perinatol 2022; 39:646-651. [PMID: 33075841 DOI: 10.1055/s-0040-1718572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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..
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Affiliation(s)
- Renee D Boss
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Berman Institute of Bioethics, Baltimore, Maryland
| | - Carrie M Henderson
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
- Center for Bioethics and Medical Humanities, Jackson, Mississippi
| | - Elliott M Weiss
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington
| | - Alison Falck
- Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa Madrigal
- Department of Pediatrics, Children's National Medical Center, Washington, Dist. of Columbia
| | - Miriam C Shapiro
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | | | - Pamela K Donohue
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Population and Families, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Abstract
OBJECTIVES Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs. DATA SOURCES English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed. STUDY SELECTION Original articles, review articles, and commentaries were considered. DATA EXTRACTION Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review. DATA SYNTHESIS Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured. CONCLUSIONS The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.
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31
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Zorko D, McNally JD, Rochwerg B, Pinto N, Couban R, O'Hearn K, Choong K. Pediatric Chronic Critical Illness: Protocol for a Scoping Review. JMIR Res Protoc 2021; 10:e30582. [PMID: 34596576 PMCID: PMC8520133 DOI: 10.2196/30582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/30/2021] [Accepted: 07/30/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Improvements in the delivery of intensive care have increased survival among even the most critically ill children, thereby leading to a growing number of children with chronic complex medical conditions in the pediatric intensive care unit (PICU). Some of these children are at a significant risk of recurrent and prolonged critical illness, with higher morbidity and mortality, making them a unique population described as having chronic critical illness (CCI). To date, pediatric CCI has been understudied and lacks an accepted consensus case definition. OBJECTIVE This study aims to describe the protocol and methodology used to perform a scoping review that will describe how pediatric CCI has been defined in the literature, including the concept of prolonged PICU admission and the methodologies used to develop any existing definitions. It also aims to describe patient characteristics and outcomes evaluated in the included studies. METHODS We will search four electronic databases for studies that evaluated children admitted to any PICU identified with CCI. We will also search for studies describing prolonged PICU admission, as this concept is related to pediatric CCI. Furthermore, we will develop a hybrid crowdsourcing and machine learning (ML) methodology to complete citation screening. Screening and data abstraction will be performed by 2 reviewers independently and in duplicate. Data abstraction will include the details of population definitions, demographic and clinical characteristics of children with CCI, and evaluated outcomes. RESULTS The database search, crowd reviewer recruitment, and ML algorithm development began in March 2021. Citation screening and data abstraction were completed in April 2021. Final data verification is ongoing, with analysis and results anticipated to be completed by fall 2021. CONCLUSIONS This scoping review will describe the existing or suggested definitions of pediatric CCI and important demographic and clinical characteristics of patients to whom these definitions have been applied. This review's results will help inform the development of a consensus case definition for pediatric CCI and set a priority agenda for future research. We will use and demonstrate the validity of crowdsourcing and ML methodologies for improving the efficiency of large scoping reviews. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/30582.
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Affiliation(s)
- David Zorko
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - James Dayre McNally
- Children's Hospital of Eastern Ontario Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Neethi Pinto
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Karen Choong
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, McMaster University, Hamilton, ON, Canada
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Miller JJ, Serwint JR, Boss RD. Clinician-family relationships may impact neonatal intensive care: clinicians' perspectives. J Perinatol 2021; 41:2208-2216. [PMID: 34091604 PMCID: PMC8178652 DOI: 10.1038/s41372-021-01120-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Collaborative clinician-family relationships are necessary for the delivery of successful patient- and family-centered care (PFCC) in the NICU. Challenging clinician-family relationships may undermine such collaboration and the potential impacts on patient care are unknown. STUDY DESIGN Consistent caregivers were surveyed to describe their relationships and collaboration with families of infants hospitalized ≥ 28 days. Medical record review collected infant and family characteristics hypothesized to impact relationships. Mixed methods analysis was performed. RESULTS Clinicians completed 243 surveys representing 77 families. Clinicians reported low collaboration with families who were not at the bedside and/or did not speak English. Clinicians perceived most clinician-family relationships impact the infant's hospital course. Negative impacts included communication challenges, mistrust or frustration with the team and disruptions to patient care. CONCLUSION This study identifies features of clinician-family relationships that may negatively impact an infant's NICU stay. Targeting supports for these families is necessary to achieve effective PFCC.
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Temsah MH, Abouammoh N, Al-Eyadhy A, AlRuthia Y, Hassounah M, Alsohime F, Alhaboob A, Almazyad M, Alabdulhafid M, Aljamaan F, Alhasan K, Jamal A. Predictors and Direct Cost Estimation of Long Stays in Pediatric Intensive Care Units in Saudi Arabia: A Mixed Methods Study. Risk Manag Healthc Policy 2021; 14:2625-2636. [PMID: 34188573 PMCID: PMC8235993 DOI: 10.2147/rmhp.s311100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/03/2021] [Indexed: 11/25/2022] Open
Abstract
Background Several factors influence patients’ length of stay (LOS) in pediatric intensive care units (PICUs). This study explored the factors and cost associated with long LOS among pediatric patient population across various PICUs and pediatric surgical cardiac intensive care units (SCICUs). Methods This is a multi-center concurrent mixed-methods study that was conducted in different PICUs and SCICUs in Riyadh, Saudi Arabia. The units’ leaders were qualitatively interviewed to explore the potential factors contributing to long LOSs in PICUs and SCICUs, and deductive content analysis was used. Microcosting was utilized to estimate the inpatient costs for a sample of long-stay patients (LSPs) and the potential cost savings if those patients were transferred to step-down care units (SDUs) for those who stayed ≥60 days. Results Ten (90%) leaders of PICUs and SCICUs who were invited had participated. Changing the admission criteria, patient transfer to SDUs, family engagement in the decision-making process, and adopting a national do-not-resuscitate (DNR) policy were factors contributing to short LOSs. On the other hand, administrative constraints, staff avoidance of code status decisions, lack of palliative care resources, and complex patient characteristics were factors associated with long LOSs. The mean inpatient cost per patient was SAR 3.63 million (USD 0.97 million), and the total cost for the 48 patients was SAR 172.95 million (USD 46.12 million). Conclusion If the recommendation to transfer LSPs after a 60-day PICU stay to SDUs is taken, the estimated cost savings among this sample of patients alone can be as high as SAR 109.47 million (USD 29.19 million). Therefore, future studies should examine the factors contributing to long LOSs in PICUs and SCICUs as well as the effectiveness of different policies aimed at improving the resource allocation and management using more robust study designs and diverse patient population.
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Affiliation(s)
- Mohamad-Hani Temsah
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Noura Abouammoh
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.,Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Al-Eyadhy
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Marwah Hassounah
- Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Alsohime
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Ali Alhaboob
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Almazyad
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Majed Alabdulhafid
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Fadi Aljamaan
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.,Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Alhasan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Amr Jamal
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.,Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Evidence-Based Health Care & Knowledge Translation Research Chair, King Saud University, Riyadh, Saudi Arabia
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Demirkiran H, Kilic M, Tomak Y, Dalkiran T, Yurttutan S, Basaranoglu M, Tuncer O, Derme T, Tekeli AE, Bahar I, Keskin S, Oksuz H. Evaluation of the incidence, characteristics, and outcomes of pediatric chronic critical illness. PLoS One 2021; 16:e0248883. [PMID: 34048449 PMCID: PMC8162636 DOI: 10.1371/journal.pone.0248883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/06/2021] [Indexed: 11/18/2022] Open
Abstract
Our aim was to determine characteristics of children with chronic critical illness (CCI) admitted to the pediatric intensive care unit (PICU) of a tertiary care children's hospital in Turkey. The current study was a multicenter retrospective cohort study that was done from 2014 to 2017. It involved three university hospitals PICUs in which multiple criteria were set to identify pediatric CCIs. Pediatric patients staying in the ICU for at least 14 days and having at least one additional criterion, including prolonged mechanical ventilation, tracheostomy, sepsis, severe wound (burn) or trauma, encephalopathy, traumatic brain injury, status epilepticus, being postoperative, and neuromuscular disease, was accepted as CCI. In order to identify the newborn as a chronic critical patient, a stay in the intensive care unit for at least 30 days in addition to prematurity was required. Eight hundred eighty seven (11.14%) of the patients who were admitted to the PICU met the definition of CCI and 775 of them (87.3%) were discharged to their home. Of CCI patients, 289 (32.6%) were premature and 678 (76.4%) had prolonged mechanical ventilation. The total cost values for 2017 were statistically higher than the other years. As the length of ICU stay increased, the costs also increased. Interestingly, high incidence rates were observed for PCCI in our hospitals and these patients occupied 38.01% of the intensive care bed capacity. In conclusion, we observed that prematurity and prolonged mechanical ventilation increase the length of ICU stay, which also increased the costs. More work is needed to better understand PCCI.
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Affiliation(s)
- Hilmi Demirkiran
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
- * E-mail:
| | - Mehmet Kilic
- Department of Pediatrics, Hisar Intercontinental Hospital, Istanbul, Turkey
| | - Yakup Tomak
- Anesthesiology and Intensive Care Unit, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Tahir Dalkiran
- Pediatric Intensive Care Unit, Necip Fazil City Hospital, Kahramanmaras, Turkey
| | - Sadik Yurttutan
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
| | - Murat Basaranoglu
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Oguz Tuncer
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Turan Derme
- Department of Pediatrics, Division of Neonatology, Ministry of Health Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Arzu Esen Tekeli
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Ilhan Bahar
- Internal Medicine Critical Care Unit, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Siddik Keskin
- Department of Biostatistics, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Hafize Oksuz
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
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Morbidity and Mortality in Critically Ill Children. II. A Qualitative Patient-Level Analysis of Pathophysiologies and Potential Therapeutic Solutions. Crit Care Med 2021; 48:799-807. [PMID: 32301845 DOI: 10.1097/ccm.0000000000004332] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe at the individual patient level the pathophysiologic processes contributing to morbidity and mortality in PICUs and therapeutic additions and advances that could potentially prevent or reduce morbidity and mortality. DESIGN Qualitative content analysis of intensivists' conclusions on pathophysiologic processes and needed therapeutic advances formulated by structured medical record review. SETTING Eight children's hospitals affiliated with the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS A randomly selected cohort of critically ill children with a new functional morbidity or mortality at hospital discharge. New morbidity was assessed using the Functional Status Scale and defined as worsening by two or more points in a single domain from preillness baseline. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 292 children, 175 (59.9%) had a new morbidity and 117 (40.1%) died. The most common pathophysiology was impaired substrate delivery (n = 158, 54.1%) manifesting as global or regional hypoxia or ischemia due to low cardiac output or cardiac arrest. Other frequent pathophysiologies were inflammation (n = 104, 35.6%) related to sepsis, respiratory failure, acute respiratory distress syndrome, or multiple organ dysfunction; and direct tissue injury (n = 64, 21.9%) including brain and spinal cord trauma. Chronic conditions were often noted (n = 156, 53.4%) as contributing to adverse outcomes. Drug therapies (n = 149, 51.0%) including chemotherapy, inotropes, vasoactive agents, and sedatives were the most frequently proposed needed therapeutic advances. Other frequently proposed therapies included cell regeneration (n = 115, 39.4%) mainly for treatment of neuronal injury, and improved immune and inflammatory modulation (n = 79, 27.1%). CONCLUSIONS Low cardiac output and cardiac arrest, inflammation-related organ failures, and CNS trauma were the most common pathophysiologies leading to morbidity and mortality in PICUs. A research agenda focused on better understanding and treatment of these conditions may have high potential to directly impact patient outcomes.
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Abstract
OBJECTIVES Prolonged critical illness after congenital heart surgery disproportionately harms patients and the healthcare system, yet much remains unknown. We aimed to define prolonged critical illness, delineate between nonmodifiable and potentially preventable predictors of prolonged critical illness and prolonged critical illness mortality, and understand the interhospital variation in prolonged critical illness. DESIGN Observational analysis. SETTING Pediatric Cardiac Critical Care Consortium clinical registry. PATIENTS All patients, stratified into neonates (≤28 d) and nonneonates (29 d to 18 yr), admitted to the pediatric cardiac ICU after congenital heart surgery at Pediatric Cardiac Critical Care Consortium hospitals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 2,419 neonates and 10,687 nonneonates from 22 hospitals. The prolonged critical illness cutoff (90th percentile length of stay) was greater than or equal to 35 and greater than or equal to 10 days for neonates and nonneonates, respectively. Cardiac ICU prolonged critical illness mortality was 24% in neonates and 8% in nonneonates (vs 5% and 0.4%, respectively, in nonprolonged critical illness patients). Multivariable logistic regression identified 10 neonatal and 19 nonneonatal prolonged critical illness predictors within strata and eight predictors of mortality. Only mechanical ventilation days and acute renal failure requiring renal replacement therapy predicted prolonged critical illness and prolonged critical illness mortality in both strata. Approximately 40% of the prolonged critical illness predictors were nonmodifiable (preoperative/patient and operative factors), whereas only one of eight prolonged critical illness mortality predictors was nonmodifiable. The remainders were potentially preventable (postoperative critical care delivery variables and complications). Case-mix-adjusted prolonged critical illness rates were compared across hospitals; six hospitals each had lower- and higher-than-expected prolonged critical illness frequency. CONCLUSIONS Although many prolonged critical illness predictors are nonmodifiable, we identified several predictors to target for improvement. Furthermore, we observed that complications and prolonged critical care therapy drive prolonged critical illness mortality. Wide variation of prolonged critical illness frequency suggests that identifying practices at hospitals with lower-than-expected prolonged critical illness could lead to broader quality improvement initiatives.
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Temsah MHA, Al-Eyadhy AA, Al-Sohime FM, Hassounah MM, Almazyad MA, Hasan GM, Jamal AA, Alhaboob AA, Alabdulhafid MA, Abouammoh NA, Alhasan KA, Alwohaibi AA, Al Mana YT, Alturki AT. Long-stay patients in pediatric intensive care units. Five-years, 2-points, cross-sectional study. Saudi Med J 2021; 41:1187-1196. [PMID: 33130838 PMCID: PMC7804226 DOI: 10.15537/smj.2020.11.25450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objectives: To explore the changing patterns of long-stay patients (LSP) to improve the utilization of pediatric intensive care units (PICUs) resources. Methods: This is a 2-points cross-sectional study (5 years apart; 2014-2019) conducted among PICUs and SCICUs in Riyadh, Saudi Arabia. Children who have stayed in PICU for more than 21 days were included. Results: Out of the 11 units approached, 10 (90%) agreed to participate. The prevalence of LSP in all these hospitals decreased from 32% (48/150) in 2014 to 23.4% (35/149) in 2019. The length of stay ranged from 22 days to 13.5 years. The majority of LSP had a neuromuscular or cardiac disease and were admitted with respiratory compromise. Ventilator-associated pneumonia was the most prevalent complication (37.5%). The most commonly used resources were mechanical ventilation (93.8%), antibiotics (60.4%), and blood-products transfusions (35.4%). The most common reason for the extended stay was medical reasons (51.1%), followed by a lack of family resources (26.5%) or lack of referral to long-term care facilities (22.4%). Conclusion: A long-stay is associated with significant critical care bed occupancy, complications, and utilization of resources that could be otherwise utilized as surge capacity for critical care services. Decreasing occupancy in this multicenter study deserves further engagement of the healthcare leaders and families to maximize the utilization of resources.
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Affiliation(s)
- Mohamad-Hani A Temsah
- Pediatric Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail.
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Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective. CHILDREN-BASEL 2021; 8:children8040254. [PMID: 33805106 PMCID: PMC8064072 DOI: 10.3390/children8040254] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/17/2021] [Accepted: 03/20/2021] [Indexed: 12/14/2022]
Abstract
Advances in medical and surgical care for children in the pediatric intensive care unit (PICU) have led to vast reductions in mortality, but survivors often leave with newly acquired or worsened morbidity. Emerging evidence reveals that survivors of pediatric critical illness may experience a constellation of physical, emotional, cognitive, and social impairments, collectively known as the “post-intensive care syndrome in pediatrics” (PICs-P). The spectrum of PICs-P manifestations within each domain are heterogeneous. This is attributed to the wide age and developmental diversity of children admitted to PICUs and the high prevalence of chronic complex conditions. PICs-P recovery follows variable trajectories based on numerous patient, family, and environmental factors. Those who improve tend to do so within less than a year of discharge. A small proportion, however, may actually worsen over time. There are many gaps in our current understanding of PICs-P. A unified approach to screening, preventing, and treating PICs-P-related morbidity has been hindered by disparate research methodology. Initiatives are underway to harmonize clinical and research priorities, validate new and existing epidemiologic and patient-specific tools for the prediction or monitoring of outcomes, and define research priorities for investigators interested in long-term outcomes.
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Grandjean C, Ullmann P, Marston M, Maitre MC, Perez MH, Ramelet AS. Sources of Stress, Family Functioning, and Needs of Families With a Chronic Critically Ill Child: A Qualitative Study. Front Pediatr 2021; 9:740598. [PMID: 34805041 PMCID: PMC8600118 DOI: 10.3389/fped.2021.740598] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022] Open
Abstract
PICU hospitalization is particularly stressful for families. When it is prolonged and the prognostic is uncertain, it can significantly and negatively affect the whole family. To date, little is known on how families with a chronic critically ill (CCI) child are affected. This national study explored the specific PICU-related sources of stress, family functioning and needs of families of CCI patients during a PICU hospitalization. This descriptive qualitative study was conducted in the eight pediatric intensive care units in Switzerland. Thirty-one families with a child meeting the CCI criteria participated in semi-structured interviews. Interviews, including mothers only (n = 12), fathers only (n = 8), or mother and father dyads (n = 11), were conducted in German, French, or English by two trained researchers/clinical nurses specialists. Interviews were recorded, transcribed verbatim, and analyzed using deductive and inductive content analyses. Five overarching themes emerged: (1) high emotional intensity, (2) PICU-related sources of stress, (3) evolving family needs, (4) multi-faceted family functioning, and (5) implemented coping strategies. Our study highlighted the importance of caring for families with CCI children. Parents reported high negative emotional responses that affect their family functioning. Families experience was highly dependent on how HCPs were able to meet the parental needs, provide emotional support, reinforce parental empowerment, and allow high quality of care coordination.
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Affiliation(s)
- Chantal Grandjean
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Pascale Ullmann
- School of Healthcare, University of Applied Sciences and Arts, Fribourg, Switzerland
| | - Mark Marston
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland.,University Children's Hospital Basel, Basel, Switzerland
| | - Marie-Christine Maitre
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
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40
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Murphy Salem S, Graham RJ. Chronic Illness in Pediatric Critical Care. Front Pediatr 2021; 9:686206. [PMID: 34055702 PMCID: PMC8160444 DOI: 10.3389/fped.2021.686206] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
Abstract
Children and Youth with Special Healthcare Needs (CYSHCN), children with medical complexity (CMC), and children with chronic, critical illness (CCI) represent pediatric populations with varying degrees of medical dependance and vulnerability. These populations are heterogeneous in underlying conditions, congenital and acquired, as well as intensity of baseline medical needs. In times of intercurrent illness or perioperative management, these patients often require acute care services in the pediatric intensive care (PICU) setting. This review describes epidemiologic trends in chronic illness in the PICU setting, differentiates these populations from those without significant baseline medical requirements, reviews models of care designed to address the intersection of acute and chronic illness, and posits considerations for future roles of PICU providers to optimize the care and outcomes of these children and their families.
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Affiliation(s)
- Sinead Murphy Salem
- Department of Anesthesiology, Boston Children's Hospital, Critical Care and Pain Medicine and Harvard Medical School, Boston, MA, United States
| | - Robert J Graham
- Department of Anesthesiology, Boston Children's Hospital, Critical Care and Pain Medicine and Harvard Medical School, Boston, MA, United States
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Heneghan JA, Sobotka SA, Hallman M, Pinto N, Killien EY, Palumbo K, Murphy Salem S, Mann K, Smith B, Steuart R, Akande M, Graham RJ. Outcome Measures Following Critical Illness in Children With Disabilities: A Scoping Review. Front Pediatr 2021; 9:689485. [PMID: 34277522 PMCID: PMC8283563 DOI: 10.3389/fped.2021.689485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/08/2021] [Indexed: 11/13/2022] Open
Abstract
Children with disabilities compose a substantial portion of admissions and bed-days in the pediatric intensive care unit (PICU) and often experience readmissions over time. Impacts of a PICU admission on post-discharge health status may be difficult to distinguish from pre-existing disability in this population. Efforts to standardize outcome measures used for children with disabilities may help identify morbidities associated with PICU hospitalizations. Although a scoping review of outcome measures to assess children after episodes of critical illness has recently been published, it is not known to what extent these measures are appropriate for use in children with disabilities. This limits our ability to effectively measure long-term outcomes following critical illness in this important patient population. Through mixed methodology of scoping review and multi-stakeholder consensus, we aimed to identify and describe instruments previously utilized for this purpose and to explore additional tools for consideration. This yielded 51 measures across a variety of domains that have been utilized in the PICU setting and may be appropriate for use in children with disabilities. We describe characteristics of these instruments, including the type of developmental domains assessed, availability of population data, validation and considerations regarding administration in children with disabilities, and ease of availability of the instrument to researchers. Additionally, we suggest needed alterations or accommodations for these instruments to augment their utility in these populations, and highlight areas for future instrument development.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, IL, United States
| | - Madhura Hallman
- Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Neethi Pinto
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
| | - Kathryn Palumbo
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, United States
| | - Sinead Murphy Salem
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Kilby Mann
- Department of Physical Medicine and Rehabilitation, Children's Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - Barbara Smith
- Departments of Physical Therapy and Pediatrics, University of Florida, Gainesville, FL, United States
| | - Rebecca Steuart
- Division of Hospital Medicine, Cincinnati Children's Medical Center, Cincinnati, OH, United States
| | - Manzilat Akande
- Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma, OK, United States
| | - Robert J Graham
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
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Troch R, Schwartz J, Boss R. Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness. J Pediatr Intensive Care 2020; 9:233-240. [PMID: 33133737 DOI: 10.1055/s-0040-1713160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022] Open
Abstract
There is a growing population of children with prolonged intensive care unit (ICU) hospitalization. These children with chronic critical illness (CCI) have a high health care utilization. Emerging data suggest a mismatch between the ICU acute care models and the daily care needs of these patients. Clinicians and parents report that the frequent treatment alterations typical for ICU care may be interrupting and jeopardizing the slow recoveries typical for children with CCI. These frequent treatment titrations could therefore be prolonging ICU stays even further. The aim of this study is to evaluate and summarize existing literature regarding pace and consistency of ICU care for patients with CCI. We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (of September 2018). PubMed (biomedical and life sciences literature), Excerpta Medica database (EMBASE), and The Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for English-language studies with data about CCI, care models, and pacing of clinical management. Four unique papers were identified. Our most important finding was that quality data on chronic ICU management, particularly for children, is sparse. All papers in this review confirmed the unique needs of chronic patients, particularly related to respiratory management, which is a common driver of ICU length of stay. Taken together, the papers support the hypothesis that protocols to reduce interdisciplinary management variability and to allow for slower management pacing should be studied for their impact on patient and health system outcomes. Optimizing value in ICU care requires mapping of resources to patient needs, particularly for patients with the most intense resource utilization. For children with CCI, parents and clinicians report that rapid treatment changes undermine recovery and prolong ICU stays. This review highlights the lack of quality pediatric research in this area and supports further investigation of a "slow and steady" approach to ICU management for children with CCI.
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Affiliation(s)
- Rachel Troch
- Department of Neonatology, Children's National Hospital, Washington, District of Columbia, United States
| | - Jamie Schwartz
- Department of Ananthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Renee Boss
- Department of Ananthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Neonatal - Perinatal Medicine, Berman Institute of Bioethics, Baltimore, Maryland, United States
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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: 7] [Impact Index Per Article: 1.4] [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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Rogozinski L, Young A, Grybauskas C, Donohue P, Boss R, Biondi E. Point Prevalence of Children Hospitalized With Chronic Critical Illness in the General Inpatient Units. Hosp Pediatr 2019; 9:545-549. [PMID: 31201203 DOI: 10.1542/hpeds.2018-0208] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Children with medical complexity (CMC) have high rates of mortality and morbidity, prolonged lengths of stay, and use a disproportionately high amount of health care expenditures. A subset of children with CMC have chronic critical illness requiring even higher levels of clinical support and resource use. We aimed to describe the point prevalence of children hospitalized in general inpatient care units with pediatric chronic critical illness (PCCI). METHODS Point prevalence analysis across 6 pediatric tertiary medical centers in the United States on a "snapshot day" (May 17, 2017). On the day of sampling, a number of demographic, historical, and clinical descriptors were collected. A previously published definition of PCCI was used to establish inclusion criteria. RESULTS The point prevalence of patients with PCCI in general inpatient care units was 41% (232 out of 571). Of these, 91% (212 out of 232) had been admitted more than once in the previous 12 months, 50% (117 out of 232) had a readmission within 30 days of a previous admission, and 20% (46 out of 232) were oncology patients. Only 1 had a designated complex care team, and there were no attending physicians designated primarily for medically complex children. CONCLUSIONS Children with chronic critical illness, a subset of CMC, may make up a substantial proportion of pediatric patients hospitalized in general inpatient care units. There is a critical need to understand how to better care for this medically fragile population. In our data, it is suggested that resources should be allocated for PCCI in nonintensive care clinical areas.
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Affiliation(s)
- Lindsay Rogozinski
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York; and
| | - Ashley Young
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York; and
| | | | - Pamela Donohue
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - Renee Boss
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
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Needle JS, Liaschenko J, Peden-McAlpine C, Boss R. Stopping the Momentum of Clinical Cascades in the PICU: Intentional Responses to the Limits of Medicine. J Palliat Care 2019; 36:12-16. [PMID: 31142203 DOI: 10.1177/0825859719851487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jennifer S Needle
- Department of Pediatrics, Center for Bioethics, 5635University of Minnesota, Minneapolis, MN, USA
| | - Joan Liaschenko
- Department of Pediatrics, Center for Bioethics, 5635University of Minnesota, Minneapolis, MN, USA
| | - Cynthia Peden-McAlpine
- Department of Pediatrics, Center for Bioethics, 5635University of Minnesota, Minneapolis, MN, USA
| | - Renee Boss
- 1466Johns Hopkins University, Baltimore, MD, USA
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Wheeler DS, Stalets EL. A day in the life. Transl Pediatr 2018; 7:242-245. [PMID: 30460174 PMCID: PMC6212388 DOI: 10.21037/tp.2018.09.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Boss RD, Falck A, Goloff N, Hutton N, Miles A, Shapiro M, Weiss EM, Donohue PK. Low prevalence of palliative care and ethics consultations for children with chronic critical illness. Acta Paediatr 2018; 107:1832-1833. [PMID: 29751362 DOI: 10.1111/apa.14394] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - Naomi Goloff
- University of Minnesota Masonic Children's Hospital; Minneapolis MN USA
| | - Nancy Hutton
- Johns Hopkins Children's Center; Baltimore MD USA
| | - Alison Miles
- Johns Hopkins Children's Center; Baltimore MD USA
| | - Miriam Shapiro
- University of Minnesota Masonic Children's Hospital; Minneapolis MN USA
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Woodger O, Menon K, Yazbeck M, Acharya A. A Pragmatic Method for Identification of Long-Stay Patients in the PICU. Hosp Pediatr 2018; 8:636-642. [PMID: 30190266 DOI: 10.1542/hpeds.2018-0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To develop a pragmatic method of identifying long-stay patients (LSPs) in the PICU. METHODS We surveyed 40 expert stakeholders in 14 Canadian PICUs between February 2015 and March 2015 to identify key factors to use for defining LSPs in the PICU. We then describe a pragmatic method using these factors to analyze 523 admissions to an academic, tertiary-care PICU from February 1, 2015, to January 31, 2016. RESULTS The overall response rate was 70% (28 of 40). Of respondents, 75% (21of 28) stated that it was important to define LSPs and identified present and future resource consumption (18 of 21 [86%] and 16 of 21 [76%], respectively) as the key reasons for defining LSPs. Respondents valued a definition that was consistent and ranked a percentile cutoff as the preferred analytic method for defining LSPs. Of respondents, 86% (24 of 28) though the LSP definition should include factors other than length of stay. We developed a surrogate marker for LSPs using mechanical ventilation and presence of a central venous catheter in our sample population to compare to varying percentile cutoffs. We identified 108 patients at the 80th percentile as LSPs who used 67% of total bed days and had a median length of stay of 11.3 days. CONCLUSIONS We present a pragmatic method for the retrospective identification of LSPs in the PICU that incorporates unit- and/or patient-specific characteristics. The next steps would be to validate this method using other patient and/or unit characteristics in different PICUs and over time.
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Affiliation(s)
- Owen Woodger
- Department of Economics, Carleton University, Ottawa, Ontario, Canada
| | - Kusum Menon
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; and .,Departments of Pediatrics and
| | - Myra Yazbeck
- Economics, University of Ottawa, Ottawa, Ontario, Canada
| | - Anand Acharya
- Department of Economics, Carleton University, Ottawa, Ontario, Canada
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Donohue PK, Williams EP, Wright-Sexton L, Boss RD. “It's Relentless”: Providers' Experience of Pediatric Chronic Critical Illness. J Palliat Med 2018; 21:940-946. [DOI: 10.1089/jpm.2017.0397] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pamela K. Donohue
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Population, Family, and Reproductive Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Erin P. Williams
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
| | - Laura Wright-Sexton
- Division of Critical Care Medicine, Department of Pediatrics, University of Mississippi, Mississippi, Missouri
| | - Renee D. Boss
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
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