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de Souza DC, Paul R, Mozun R, Sankar J, Jabornisky R, Lim E, Harley A, Al Amri S, Aljuaid M, Qian S, Schlapbach LJ, Argent A, Kissoon N. Quality improvement programmes in paediatric sepsis from a global perspective. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:695-706. [PMID: 39142743 DOI: 10.1016/s2352-4642(24)00142-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 08/16/2024]
Abstract
Sepsis is a major contributor to poor child health outcomes around the world. The high morbidity, mortality, and societal cost associated with paediatric sepsis render it a global health priority, as summarised in Paper 1 of this Series. Sepsis is characterised by a dysregulated host response to infection that manifests as organ failure, and children are uniquely susceptible to sepsis, as discussed in Paper 2. The focus of this third Series paper is quality improvement in paediatric sepsis. The 2017 WHO resolution on sepsis outlined key aims to reduce the burden of sepsis. As of 2024, only a small number of countries have implemented systematic, paediatric-focused quality improvement programmes to raise sepsis awareness, enhance recognition of sepsis, promote timely treatment, and provide long-term support for paediatric sepsis survivors. We examine programme successes and systematic barriers to quality improvement targeting paediatric sepsis. We highlight the need for programme design to consider the entire patient journey, starting with prevention, caregiver awareness, recognition at home, education of the health-care workforce, development of health-care systems, and establishment of long-term family and survivor support extending beyond the intensive care unit. Building on lessons learnt from existing quality improvement programmes, we outline implementation strategies and measures to enable benchmarking. Ultimately, quality improvement on a global scale can only be accelerated through a global learning platform focusing on paediatric sepsis.
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Affiliation(s)
- Daniela C de Souza
- Latin American Sepsis Institute, São Paulo, Brazil; Pediatric Intensive Care Unit, Hospital Universitário da Universidade de São Paulo, São Paulo, Brazil; Pediatric Intensive Care Unit, Hospital Sírio Libanês, São Paulo, Brazil.
| | - Raina Paul
- Children's Hospital of Orange County, Orange, CA, USA; Improving Pediatric Sepsis Outcomes Collaborative, Children's Hospital Association, Washington, DC, USA
| | - Rebeca Mozun
- Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jhuma Sankar
- All India Institute of Medical Sciences, New Delhi, India
| | - Roberto Jabornisky
- Universidad Nacional del Nordeste, Corrientes, Argentina; LARed Network, Montevideo, Uruguay; SLACIP Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, Monterrey, Mexico
| | - Emma Lim
- Department of Paediatric Infectious Diseases, Immunology and Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amanda Harley
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia; Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Samirah Al Amri
- Nursing Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Maha Aljuaid
- Nursing Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Suyun Qian
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | | | - Niranjan Kissoon
- Global Child Health Department of Pediatrics and Emergency Medicine, British Columbia Women and Children's Hospital and the University of British Columbia, Vancouver, BC, Canada
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Mortamet G, Birsan S, Zini J, Morin L, Kolev K, Pelluau S, Pouletty M, Thiberghien D, Beldjilali S, Brissaud O, Milési C, Brotelande C, Dupont A, Giraud M, Hassid SA, Tsapis M, Essid A, Villemain C, De Sampaio S, Troff S, Micaelli D, Levy M. Pediatric intensive care unit follow-up: Thinking before acting. Anaesth Crit Care Pain Med 2024; 43:101401. [PMID: 38823635 DOI: 10.1016/j.accpm.2024.101401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE It is now well established that post-intensive care syndrome is frequent in critically ill children after discharge from the pediatric intensive care unit (PICU). Nevertheless, post-intensive care follow-up is highly heterogenous worldwide and is not considered routine care in many countries. The purpose of this viewpoint was to report the reflections of the French PICU society working group on how to implement post-PICU follow-up. METHODS A working group was set up within the Groupe Francophone de Reanimation et d'Urgences Pédiatriques (GFRUP) to provide conceptual and practical guidance for developing post-PICU follow-up. The working group included psychologists, PICU physicians, physiotherapists, and nurses, from different French PICUs. Five virtual meetings have been held. RESULTS First, we described in this work the objectives of the follow-up program and the population to be targeted. We also provided a framework to implement post-PICU follow-up in clinical practice. Finally, we detailed the potential obstacles and challenges to consider. CONCLUSION Although implementing a post-PICU follow-up program is a challenge, the benefits could be significant for both patient and relatives, as well as for the health care professionals involved.
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Affiliation(s)
- Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, La Tronche, France; Univ. Grenoble Alpes, Grenoble, France.
| | - Sandrine Birsan
- Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France.
| | - Justine Zini
- Pediatric Intensive Care Unit, Raymond Poincaré Hospital, Assistance Publique des Hôpitaux de Paris, Garches, France.
| | - Luc Morin
- Pediatric and Neonatal Intensive Care Unit, DMU3 Santé de l'enfant, Bicêtre Université Paris Saclay Hospital, Assistance Publique des Hôpitaux de Paris, Le Kremlin-Bicêtre, France.
| | - Karine Kolev
- Pediatric Intensive Care Unit, Hospital for Mother, Women and Children, Lyon, France.
| | - Sonia Pelluau
- Pediatric Intensive Care Unit, Purpan Hospital, Toulouse, France.
| | - Marie Pouletty
- Pediatric Intensive Care Unit, Necker Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France.
| | - Denis Thiberghien
- Child Psychiatry Unit, Raymond Poincaré Hospital, Assistance Publique des Hôpitaux de Paris, Garches, France.
| | - Sophie Beldjilali
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France.
| | - Olivier Brissaud
- Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France.
| | - Christophe Milési
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France.
| | - Camille Brotelande
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France.
| | - Audrey Dupont
- Pediatric Intensive Care Unit, Fondation Lenval, Nice, France.
| | - Marion Giraud
- Pediatric Intensive Care Unit, Purpan Hospital, Toulouse, France.
| | - Sophie Ariane Hassid
- Pediatric Intensive Care Unit, Timone Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille, France.
| | - Michael Tsapis
- Pediatric Intensive Care Unit, Timone Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille, France.
| | - Aben Essid
- Pediatric Intensive Care Unit, Raymond Poincaré Hospital, Assistance Publique des Hôpitaux de Paris, Garches, France.
| | - Clélia Villemain
- Pediatric Intensive Care Unit, Raymond Poincaré Hospital, Assistance Publique des Hôpitaux de Paris, Garches, France.
| | | | - Sarah Troff
- Pediatric Intensive Care Unit, Raymond Poincaré Hospital, Assistance Publique des Hôpitaux de Paris, Garches, France.
| | - Delphine Micaelli
- Pediatric Intensive Care Unit, Robert-Debré Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Michael Levy
- Pediatric Intensive Care Unit, Robert-Debré Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Cité, Paris, France.
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Reddy AR, Stinson HR, Alcamo AM, Pinto NP, Fitzgerald JC. Pediatric Sepsis Requiring Intensive Care Admission: Potential Structured Follow-Up Protocols to Identify and Manage New or Exacerbated Medical Conditions. Risk Manag Healthc Policy 2023; 16:1881-1891. [PMID: 37736598 PMCID: PMC10511018 DOI: 10.2147/rmhp.s394458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023] Open
Abstract
Pediatric sepsis is a leading cause of morbidity and mortality in children globally. Children who require the pediatric intensive care unit (PICU) are at high risk for new or worsening co-morbidities, as well as readmission. This review describes the current state of protocolized follow-up after pediatric sepsis requiring PICU admission. We searched Medline and EMBASE databases for studies published in English from 2005 to date. Duplicates, review articles, abstracts and poster presentations were excluded; neonatal intensive care unit (NICU) patients were also excluded since neonatal sepsis is variably defined and differs from the pediatric consensus definition. The search yielded 418 studies of which 55 were duplicates; the subsequent 363 studies were screened for inclusion criteria, yielding 31 studies for which full article screening was completed. Subsequently, 23 studies were excluded due to wrong population (9), wrong publication type (10), duplicate data (3) or wrong outcome (1). In total, nine studies were included for which we described study design, setting, population, sample size, outcomes, PICU core outcome domain, and results. There were 4 retrospective cohort studies, 4 prospective cohort studies, 1 retrospective case series and no prospective trials. These studies show the varying trajectories of recovery after discharge, with the common finding that new or worsening morbidities are worse within months of discharge, but may persist. Sepsis survivors may have distinct needs and a different post-PICU trajectory compared to other critically ill children, particularly in quality of life and neurocognitive outcomes. Future research should focus on developing screening protocols and studying protocolized follow-up trials to reduce morbidity after pediatric sepsis.
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Affiliation(s)
- Anireddy R Reddy
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hannah R Stinson
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alicia M Alcamo
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Neethi P Pinto
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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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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Spear MB, Miller K, Press C, Ruzas C, LaVelle J, Mourani PM, Bennett TD, Maddux AB. Unplanned Admissions, Emergency Department Visits, and Epilepsy After Critical Neurological Illness Requiring Prolonged Mechanical Ventilation in Children. Neurohospitalist 2023; 13:31-39. [PMID: 36531841 PMCID: PMC9755613 DOI: 10.1177/19418744221123628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Background and Purpose Long-term outcomes after pediatric neurocritical illness are poorly characterized. This study aims to characterize the frequency and risk factors for post-discharge unplanned health resource use in a pediatric neurocritical care population using insurance claims data. Methods Retrospective cohort study evaluating children who survived a hospitalization for an acute neurologic illness or injury requiring mechanical ventilation for >72 hours and had insurance eligibility in Colorado's All Payers Claims database. Insurance claims identified unplanned readmissions and emergency department [ED] visits during the post-discharge year. For patients without pre-existing epilepsy/seizures, we evaluated for post-ICU epilepsy identified by claim(s) for a maintenance anti-seizure medication during months 6-12 post-discharge. Multivariable logistic regression identified factors associated with each outcome. Results 101 children, median age 3.7 years (interquartile range (IQR) .4-11.9), admitted for trauma (57%), hypoxic-ischemic injury (17%) and seizures (15%). During the post-discharge year, 4 (4%) patients died, 26 (26%) were readmitted, and 48 (48%) had an ED visit. Having a pre-existing complex chronic condition was independently associated with readmission and emergency department visit. Admission for trauma was protective against readmission. Of those without pre-existing seizures (n = 86), 25 (29%) developed post-ICU epilepsy. Acute seizures during admission and prolonged ICU stays were independently associated with post-ICU epilepsy. Conclusions Survivors of pediatric neurocritical illness are at risk of unplanned healthcare use and post-ICU epilepsy. Critical illness risk factors including prolonged ICU stay and acute seizures may identify cohorts for targeted follow up or interventions to prevent unplanned healthcare use and post-ICU epilepsy.
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Affiliation(s)
- Matthew B. Spear
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Kristen Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Craig Press
- Department of Pediatrics, Division of Neurology, University of Pennsylvania School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher Ruzas
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Jaime LaVelle
- Pediatrics, Children’s Hospital Colorado, Aurora, CO, USA
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s, Little Rock, AR, USA
| | - Tellen D. Bennett
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, Section of Informatics and Data Science, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
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Carlton EF, Gebremariam A, Maddux AB, McNamara N, Barbaro RP, Cornell TT, Iwashyna TJ, Prosser LA, Zimmerman J, Weiss S, Prescott HC. New and Progressive Medical Conditions After Pediatric Sepsis Hospitalization Requiring Critical Care. JAMA Pediatr 2022; 176:e223554. [PMID: 36215045 PMCID: PMC9552050 DOI: 10.1001/jamapediatrics.2022.3554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/20/2022] [Indexed: 12/15/2022]
Abstract
Importance Children commonly experience physical, cognitive, or emotional sequelae after sepsis. However, little is known about the development or progression of medical conditions after pediatric sepsis. Objective To quantify the development and progression of 4 common conditions in the 6 months after sepsis and to assess whether they differed after hospitalization for sepsis vs nonsepsis among critically ill children. Design, Setting, and Participants This cohort study of 101 511 children (<19 years) with sepsis or nonsepsis hospitalization used a national administrative claims database (January 1, 2010, to June 30, 2018). Data management and analysis were conducted from April 1, 2020, to July 7, 2022. Exposures Intensive care unit hospitalization for sepsis vs all-cause intensive care unit hospitalizations, excluding sepsis. Main Outcomes and Measures Primary outcomes were the development of 4 target conditions (chronic respiratory failure, seizure disorder, supplemental nutritional dependence, and chronic kidney disease) within 6 months of hospital discharge. Secondary outcomes were the progression of the 4 target conditions among children with the condition before hospitalization. Outcomes were identified via diagnostic and procedural codes, durable medical equipment codes, and prescription medications. Differences in the development and the progression of conditions between pediatric patients with sepsis and pediatric patients with nonsepsis who survived intensive care unit hospitalization were assessed using logistic regression with matching weights. Results A total of 5150 survivors of pediatric sepsis and 96 361 survivors of nonsepsis intensive care unit hospitalizations were identified; 2593 (50.3%) were female. The median age was 9.5 years (IQR, 3-15 years) in the sepsis cohort and 7 years (IQR, 2-13 years) in the nonsepsis cohort. Of the 5150 sepsis survivors, 670 (13.0%) developed a new target condition, and 385 of 1834 (21.0%) with a preexisting target condition had disease progression. A total of 998 of the 5150 survivors (19.4%) had development and/or progression of at least 1 condition. New conditions were more common among sepsis vs nonsepsis hospitalizations (new chronic respiratory failure: 4.6% vs 1.9%; odds ratio [OR], 2.54 [95% CI, 2.19-2.94]; new supplemental nutritional dependence: 7.9% vs 2.7%; OR, 3.17 [95% CI, 2.80-3.59]; and new chronic kidney disease: 1.1% vs 0.6%; OR, 1.65 [95% CI, 1.25-2.19]). New seizure disorder was less common (4.6% vs 6.0%; OR, 0.77 [95% CI, 0.66-0.89]). Progressive supplemental nutritional dependence was more common (1.5% vs 0.5%; OR, 2.95 [95% CI, 1.60-5.42]), progressive epilepsy was less common (33.7% vs 40.6%; OR, 0.74 [95% CI, 0.65-0.86]), and progressive respiratory failure (4.4% vs 3.3%; OR, 1.35 [95% CI, 0.89-2.04]) and progressive chronic kidney disease (7.9% vs 9.2%; OR, 0.84 [95% CI, 0.18-3.91]) were similar among survivors of sepsis vs nonsepsis admitted to an intensive care unit. Conclusions and Relevance In this national cohort of critically ill children who survived sepsis, 1 in 5 developed or had progression of a condition of interest after sepsis hospitalization, suggesting survivors of pediatric sepsis may benefit from structured follow-up to identify and treat new or worsening medical comorbid conditions.
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Affiliation(s)
- Erin F. Carlton
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Aline B. Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora
| | - Nancy McNamara
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Ryan P. Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Timothy T. Cornell
- Lucille Packard Children’s Hospital, Stanford University, Palo Alto, California
| | - Theodore J. Iwashyna
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Lisa A. Prosser
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Jerry Zimmerman
- Seattle Children’s Hospital, Harborview Medical Center, University of Washington School of Medicine, Seattle
| | - Scott Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Children’s Hospital of Philadelphia, Pediatric Sepsis Program, Philadelphia, Pennsylvania
| | - Hallie C. Prescott
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor
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Maddux AB, Zimmerman JJ, Banks RK, Reeder RW, Meert KL, Czaja AS, Berg RA, Sapru A, Carcillo JA, Newth CJL, Quasney MW, Mourani PM. Health Resource Use in Survivors of Pediatric Septic Shock in the United States. Pediatr Crit Care Med 2022; 23:e277-e288. [PMID: 35250001 PMCID: PMC9203867 DOI: 10.1097/pcc.0000000000002932] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate postdischarge health resource use in pediatric survivors of septic shock and determine patient and hospitalization factors associated with health resource use. DESIGN Secondary analyses of a multicenter prospective observational cohort study. SETTING Twelve academic PICUs. PATIENTS Children greater than or equal to 1 month and less than 18 years old hospitalized for community-acquired septic shock who survived to 1 year. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For 308/338 patients (91%) with baseline and greater than or equal to one postdischarge survey, we evaluated readmission, emergency department (ED) visits, new medication class, and new device class use during the year after sepsis. Using negative binomial regression with bidirectional stepwise selection, we identified factors associated with each outcome. Median age was 7 years (interquartile range, 2-13), 157 (51%) had a chronic condition, and nearly all patients had insurance (private [n = 135; 44%] or government [n = 157; 51%]). During the year after sepsis, 128 patients (42%) were readmitted, 145 (47%) had an ED visit, 156 (51%) started a new medication class, and 102 (33%) instituted a new device class. Having a complex chronic condition was independently associated with readmission and ED visit. Documented infection and higher sum of Pediatric Logistic Organ Dysfunction--2 hematologic score were associated with readmission, whereas younger age and having a noncomplex chronic condition were associated with ED visit. Factors associated with new medication class use were private insurance, neurologic insult, and longer PICU stays. Factors associated with new device class use were preadmission chemotherapy or radiotherapy, presepsis Functional Status Scale score, and ventilation duration greater than or equal to 10 days. Of patients who had a new medication or device class, most had a readmission (56% and 61%) or ED visit (62% and 67%). CONCLUSIONS Children with septic shock represent a high-risk cohort with high-resource needs after discharge. Interventions and targeted outcomes to mitigate postdischarge resource use may differ based on patients' preexisting conditions.
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Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Jerry J. Zimmerman
- Seattle Children’s Hospital, Seattle Research Institute, University of Washington School of Medicine, Seattle, WA
| | | | | | - Kathleen L. Meert
- Children’s Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI
| | - Angela S. Czaja
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Anil Sapru
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christopher J. L. Newth
- Department of Pediatrics, Section of Critical Care, University of Southern California, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Michael W. Quasney
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, AR
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Maddux AB, Mourani PM, Miller K, Carpenter TC, LaVelle J, Pyle LL, Watson RS, Bennett TD. Identifying Long-Term Morbidities and Health Trajectories After Prolonged Mechanical Ventilation in Children Using State All Payer Claims Data. Pediatr Crit Care Med 2022; 23:e189-e198. [PMID: 35250002 PMCID: PMC9058185 DOI: 10.1097/pcc.0000000000002909] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify postdischarge outcome phenotypes and risk factors for poor outcomes using insurance claims data. DESIGN Retrospective cohort study. SETTING Single quaternary center. PATIENTS Children without preexisting tracheostomy who required greater than or equal to 3 days of invasive mechanical ventilation, survived the hospitalization, and had postdischarge insurance eligibility in Colorado's All Payer Claims Database. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used unsupervised machine learning to identify functional outcome phenotypes based on claims data representative of postdischarge morbidities. We assessed health trajectory by comparing change in the number of insurance claims between quarters 1 and 4 of the postdischarge year. Regression analyses identified variables associated with unfavorable outcomes. The 381 subjects had median age 3.3 years (interquartile range, 0.9-12 yr), and 147 (39%) had a complex chronic condition. Primary diagnoses were respiratory (41%), injury (23%), and neurologic (11%). We identified three phenotypes: lower morbidity (n = 300), higher morbidity (n = 62), and 1-year nonsurvivors (n = 19). Complex chronic conditions most strongly predicted the nonsurvivor phenotype. Longer PICU stays and tracheostomy placement most strongly predicted the higher morbidity phenotype. Patients with high but improving postdischarge resource use were differentiated by high illness severity and long PICU stays. Patients with persistently high or increasing resource use were differentiated by complex chronic conditions and tracheostomy placement. CONCLUSIONS New morbidities are common after prolonged mechanical ventilation. Identifying phenotypes at high risk of postdischarge morbidity may facilitate prognostic enrichment in clinical trials.
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Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s, Little Rock, AR
| | - Kristen Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Todd C. Carpenter
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | | | - Laura L. Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Department of Biostatistics and Informatics, Colorado School of Public Health, Children’s Hospital Colorado, Aurora, CO
| | - R. Scott Watson
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington School of Medicine and Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Tellen D. Bennett
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
- Department of Pediatrics, Section of Informatics and Data Science, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
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Ravikumar N, Sankar J, Das RR. Functional Outcomes in Survivors of Pediatric Sepsis: A Scoping Review and Discussion of Implications for Low- and Middle-Income Countries. Front Pediatr 2022; 10:762179. [PMID: 35345613 PMCID: PMC8957211 DOI: 10.3389/fped.2022.762179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 01/11/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pediatric sepsis is an important cause of mortality and morbidity in low- and middle-income countries (LMIC), where there is a huge burden of infectious diseases. Despite shortage of resources, adapting protocol-based care has reduced sepsis-related deaths but survivors of pediatric sepsis are at risk of poor functional outcomes. OBJECTIVES To perform a scoping review of the literature on functional outcomes of pediatric sepsis survivors after discharge from the intensive care unit (ICU) and discuss the implications for patients in LMICs. The outcomes include prevalence of survival with reduced functional outcomes or quality of life (QoL) and changes over time during follow-up or recovery, and these outcomes were compared with other groups of children. METHODS We searched major medical electronic databases for relevant literature from January 2005 until November 2021, including Medline (via PubMed), Embase, CINAHL, and Google Scholar databases. We included observational studies and follow-up data from clinical trials involving children/adolescents (≤18 years) who were admitted to pediatric intensive care unit (PICU) and got discharged finally. Major focus was on survivors of sepsis in LMIC. We followed PRISMA guidelines for scoping reviews (PRISM-ScR). RESULTS We included eight papers reporting data of functional outcomes in 2,915 children (males = 53%, and comorbidity present in 56.6%). All included studies were either a prospective or retrospective cohort study. Studies were classified as Level II evidence. Disabilities affecting physical, cognitive, psychological, and social function were reported in children following discharge. Overall disability reported ranged between 23 and 50% at hospital discharge or 28 days. Residual disability was reported at 1, 3, 6, and 12 months of follow-up with an overall improving trend. Failure to recover from a baseline HRQL on follow-up was seen in one-third of survivors. Organ dysfunction scores such as pSOFA, PeLOD, vasoactive inotrope score, neurological events, immunocompromised status, need for CPR, and ECMO were associated with poor functional outcome. CONCLUSIONS The research on functional outcomes in pediatric sepsis survivors is scarce in LMIC. Measuring baseline and follow-up functional status, low-cost interventions to improve management of sepsis, and multidisciplinary teams to identify and treat disabilities may improve functional outcomes.
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Affiliation(s)
- Namita Ravikumar
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India
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Long DA, Fink EL. Transitions from short to long-term outcomes in pediatric critical care: considerations for clinical practice. Transl Pediatr 2021; 10:2858-2874. [PMID: 34765507 PMCID: PMC8578758 DOI: 10.21037/tp-21-61] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022] Open
Abstract
Most children are surviving critical illness in highly resourced pediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development over many years, termed post-intensive care syndrome-pediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations. In research studies, primary and secondary outcomes are largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized vs. individualized, but some PICU centers are discovering how to overcome them and are providing this service to families-sometimes specific populations-in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU. Finally, we should seek the strong backing of the PICU community and families to insist that long-term outcomes become our new clinical standard of care. PICUs should consider development of a multicenter, multinational collaborative to assess clinical outcomes and optimize care delivery and patient and family outcomes. The aim of this review is to present the potential considerations of implementing long-term clinical follow-up following pediatric critical illness.
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Affiliation(s)
- Debbie A Long
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Pediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Ericka L Fink
- Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
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Raman S, English A, O'Keefe M, Harley A, Steele M, Minogue J, Weller K, Long D, Irwin A, Lister P. Designing Support Structures Post Sepsis in Children: Perspectives of the Queensland Paediatric Sepsis Program. Front Pediatr 2021; 9:759234. [PMID: 34869116 PMCID: PMC8636900 DOI: 10.3389/fped.2021.759234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/21/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: Paediatric post sepsis syndrome is poorly defined and causes physical, neurocognitive, psychosocial morbidity, and family dysfunction. Families of sepsis survivors report unmet needs during care. Worldwide, the provision of post sepsis care is in its infancy with limited evidence to design clinical support pathways. Perspective: The Queensland Paediatric Sepsis Program (QPSP) developed a family support structure (FSS) to improve care during all stages of childhood sepsis. It was designed in partnership with consumers guided by information from consumers and it is partly delivered by consumers. Key areas include online, multimodal education for families and the ability to connect with other families affected by sepsis. The FSS is delivered by a multidisciplinary team (MDT) acting with clinicians local to the child. Families can join the FSS registry at any stage of their sepsis journey which connects them to our MDT team and opens opportunities to participate in future research and other initiatives. Improving public awareness is a critical outcome for our consumers and they have co-designed media and digital campaigns. Discussion: The ideal FSS for post sepsis syndrome management is a clinical pathway designed in partnership with consumers of interventions proven to improve outcomes from sepsis that meets their requirements. The QPSP FSS is novel as it is co-designed with, and partly delivered by, consumers with interventions aimed to improve the entire spectrum of morbidities suffered by survivors and their families, not just physical sequelae. Evaluation is embedded in the program and outcomes will guide evolution of the FSS.
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Affiliation(s)
- Sainath Raman
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia.,Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, QLD, Australia.,The Faculty of Medicine, Centre for Children's Health Research, The University of Queensland, Brisbane, QLD, Australia
| | - Alana English
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia.,Queensland Paediatric Rehabilitation Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Meagan O'Keefe
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia.,Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Amanda Harley
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia.,The Faculty of Medicine, Centre for Children's Health Research, The University of Queensland, Brisbane, QLD, Australia.,School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Mary Steele
- Independent Researcher, Brisbane, QLD, Australia
| | - Jess Minogue
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kate Weller
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia.,Centre for Clinical Research, The University of Queensland (UQ), Brisbane, QLD, Australia
| | - Debbie Long
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, QLD, Australia.,Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Adam Irwin
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia.,Centre for Clinical Research, The University of Queensland (UQ), Brisbane, QLD, Australia.,Infectious Diseases, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Paula Lister
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia.,The Faculty of Medicine, Centre for Children's Health Research, The University of Queensland, Brisbane, QLD, Australia.,Paediatric Intensive Care, Sunshine Coast University Hospital, Birtinya, QLD, Australia
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