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

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

A Snapshot of Chronic Critical Illness in Pediatric Intensive Care Units

“…More information on the larger study has been published elsewhere. 8,22,23 For the purpose of the current study, the main cohort was narrowed to focus on those children who were in a PICU -medical, cardiovascular, or combined-for any length of time during the current admission ("PICU-all"). All of the children were also required to demonstrate either dependence on medical technology or chronic medical problems in !2 organ systems.…”

An agenda to develop Pediatric Palliative care programs to serve children with life-threatening and life-limiting conditions in the Gulf Cooperation Council countries

“…In addition, mortality data cannot account for the fact that children can move in and out of palliative care as their condition improves, such as extremely premature neonates who stabilize, or teens who live into adulthood as medical advances prolonging living with childhood diseases. 6,7,16 There are approaches that determine the prevalence of patients with specific diseases carrying a high probability of death during childhood and qualify them for PPC. 1,15 These diseases are not limited to high-risk curable conditions (e.g.…”

“…As a result, more children with LTC/LLCs are living longer. 7 , 15 , 16 Therefore, updated data on the numbers of such patients is a research priority. Such population-based research would develop an evidence base to support and inform local PPC planning.…”

Defining Pediatric Chronic Critical Illness: A Scoping Review*

“…The concept of complexity in these 10 studies was described variably, including dependence on technology to sustain organ function (n = 5), persistent "multiple organ system involvement" (n = 4), presence of "complex and chronic medical conditions" (n = 5), and/or having an "uncertain prognosis" (n = 1) (Supplemental Content E, http://links.lww.com/PCC/ C264). Technology dependence included tracheostomy, invasive or noninvasive mechanical ventilation, gastrostomy or jejunostomy tube, hemodialysis, central catheters, intracranial shunts, and history of organ or bone marrow transplant (27,28,31,32). The most specific description of "multiple organ system involvement" in any efinition was, "a chronic medical problem in ≥2 organ systems that has already or was expected to last >3 months" (31).…”