Pediatric Chronic Critical Illness: Reducing Excess Hospitalizations

Boss, Renee D.; Williams, Erin P.; Henderson, Carrie M.; Seltzer, Rebecca R.; Shapiro, Miriam C.; Hahn, Emily; Hutton, Nancy

doi:10.1542/hpeds.2016-0185

Cited by 28 publications

(30 citation statements)

References 35 publications

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“…Data from both clinicians and families suggest that the "poor fit" of the acute care hospital model for infants with CCI is itself partly responsible for their excess hospital days. 18 Yet the number of these infants and children with CCI is likely to remain high, suggesting the need for adaptations to inpatient care models and clinician training. 19 We have shown that ICU clinicians across the United States feel unprepared to manage chronic patients, citing gaps in clinical training and ancillary supports like case management.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2020

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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

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Section: Discussionmentioning

confidence: 99%

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

et al. 2020

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“…Outcomes of interest, such as LOS or cost, vary based on local access to non-ICU care sites (e.g., pediatric long-term care hospitals) and reimbursement structures (e.g., Maryland's Global Budget Revenue). 27 Additionally, as the studies in this review demonstrate, more refined methodologies are needed to account for the many patient, family, clinician, and hospital factors that shape chronic ICU management.…”

Section: Discussionmentioning

confidence: 99%

Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness

Troch

Schwartz

Boss

2020

J Pediatr Intensive Care

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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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“…Our findings support those of colleagues who noted that these deficiencies in PHHC quality and availability contributed to caregiver burden 20 and excess hospital days. 7,8 Pediatricians or care coordinators should ask how likely the designated PHHC agency is to staff the approved hours. They should also inquire about staffing continuity to help families anticipate filling in gaps or inquire about training new staff.…”

Section: Figurementioning

confidence: 99%

“…6 Without adequate PHHC to help families support their children at home, these children are vulnerable to spending excess days in the hospital. 7,8 Current guidelines suggest that the pediatrician is a fundamental member of the PHHC team, facilitating a coordinated plan of home care. 4,9 Although outpatient pediatrician knowledge of PHHC has not been described in the literature, data suggest that inpatient clinicians may not fully understand the resources needed for CMC at home.…”

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confidence: 99%

The Pediatric Home Health Care Process: Perspectives of Prescribers, Providers, and Recipients

et al. 2019

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BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) often require pediatric home health care (PHHC) to meet their daily intensive care needs. Pediatricians are central to planning, implementing, and maintaining quality PHHC for CMC, yet a comprehensive road map for this process is lacking. With this national study, we aim to fill that gap. METHODS: Semistructured interviews were conducted with parents and professionals from the 10 US Health Resources and Services Administration regions. Parents were recruited via advocacy groups for families of CMC; professionals with experience with PHHC for CMC were identified by using purposive and snowball sampling. Interview transcripts were qualitatively analyzed for themes. RESULTS: A comprehensive process of prescribing, providing, and maintaining PHHC requires 5 steps: identifying needs, investigating options, developing plans of care, initiating services, and navigating evolving needs. The success of the PHHC process is built on knowledge, anticipation, and early identification of needs; communication; care-coordination infrastructure; skilled home health providers; and the parent-provider relationship. CONCLUSIONS: Many CMC require PHHC to live safely outside of the hospital. Although the PHHC process involves multiple steps and participants, pediatricians' understanding of the process is the foundation of PHHC success. Fostering interagency relationships, increasing longitudinal care coordination, and investing in the PHHC infrastructure may reduce the burden placed on families and CMC as they navigate the complex process of PHHC.

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Pediatric Chronic Critical Illness: Reducing Excess Hospitalizations

Cited by 28 publications

References 35 publications

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

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

Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness

The Pediatric Home Health Care Process: Perspectives of Prescribers, Providers, and Recipients

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