Trends in long-stay admissions to a UK paediatric intensive care unit

Kanthimathinathan, Hari Krishnan; Plunkett, Adrian; Scholefield, Barnaby R; Pearson, Gale; Morris, Kevin

doi:10.1136/archdischild-2019-317797

Cited by 24 publications

(44 citation statements)

References 13 publications

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“…While LSPs make up a small proportion of tertiary PICU patients, they have a disproportionate impact on those units. In single-centered studies, patients with stays ≥28 days represented <5% of patients but accounted for 21-63% of total admission days, 4,6,30 and the proportion of total admission days these LSPs used more than doubled from previous decades. 4,30 Such resource utilization can strain PICUs and potentially delay admissions of other critically ill children and elective surgeries.…”

Section: Discussionmentioning

confidence: 99%

A Single-Centered Randomized Controlled Trial of Primary Pediatric Intensivists and Nurses

Edwards

Williams

Wagman

et al. 2022

J Intensive Care Med

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Background: For long-stay patients (LSP) in pediatric intensive care units (PICU), frequently rotating providers can lead to ineffective information sharing and retention, varying goals and timelines, and delayed decisions, likely contributing to prolonged admissions. Primary intensivists (one physician serves as a consistent resource for the patient/family and PICU providers) and primary nurses (a small team of PICU nurses provide consistent bedside care) seek to augment usual transitory PICU care, by enhancing continuity and, potentially, decreasing length of stay (LOS). Methods: A single-centered, partially blinded randomized controlled trial of primary intensivists and nurses versus usual care. PICU patients admitted for or expected to be admitted for >10 days and who had ≥1 complex chronic condition were eligible. A block randomization with 1:1 allocation was used. The primary outcome was PICU LOS. Multiple secondary outcomes were explored. Results: Two hundred LSPs were randomized—half to receive primaries and half to usual care. The two groups were not significantly different in their baseline and admission characteristics. LSPs randomized to receive primaries had a shorter, but non-significant, mean LOS than those randomized to usual care (32.5 vs. 37.1 days, respectively, p = .19). Compared to LSPs in the usual care group, LSPs in the primary group had fewer unplanned intubations. Among LSPs that died, DNR orders were more prevalent in the primary group. Other secondary outcome and balance metrics were not significantly different between the two groups. Conclusion: Primary intensivists and nurses may be an effective strategy to counteract transitory PICU care and serve the distinctive needs of LSPs. However, additional studies are needed to determine the ways and to what extent they may accomplish this.

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Section: Discussionmentioning

confidence: 99%

A Single-Centered Randomized Controlled Trial of Primary Pediatric Intensivists and Nurses

Edwards

Williams

Wagman

et al. 2022

J Intensive Care Med

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“…Hospitalization rates of children with multiple CCC in the United States increased 98% from 1991 to 1993 to 2003–2005 (39). Proportions of long-stay patients (the vast majority of whom have severe chronic illness) among PICU patients have similarly increased—from 2% in 2002 to 21% in 2017 in one U.K. PICU (40).…”

Section: Picu Experience With Children With Severe Chronic Illnessmentioning

confidence: 99%

The Child With Severe Chronic Illness in the ICU: A Concise Review

Edwards

Goodman

2022

Critical Care Medicine

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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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“…9 Against this background, advances in medicine mean that increasing numbers of children with complex care needs are surviving for longer and occupying a greater proportion of hospital bed-days. 10 Invariably, such patients fall under numerous medical teams and social agencies, each trying to serve the needs and wishes of the child and their family. Commonly, a lack of dedicated leadership results in incoordinate decision-making, the family confused and the best interests of the child overlooked.…”

Section: What This Study Addsmentioning

confidence: 99%

Factors affecting decision-making in children with complex care needs: a consensus approach to develop best practice in a UK children’s hospital

Birchley

Thomas-Unsworth

Mellor

et al. 2022

bmjpo

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BackgroundChildren with complex care needs are a growing proportion of the sick children seen in all healthcare settings in the UK. Complex care needs place demands on parents and professionals who often require many different healthcare teams to work together. Care can be both materially and logistically difficult to manage, causing friction with parents. These difficulties may be reduced if common best practice standards and approaches can be developed in this area.ObjectiveTo develop a consensus approach to the management of complexity among healthcare professionals, we used a modified Delphi process. The process consisted of a meeting of clinical leaders to develop candidate statements, followed by two survey rounds open to all professionals in a UK children’s hospital to measure and establish consensus recommendations.ResultsNinety-nine professionals completed both rounds of the survey, 69 statements were agreed. These pertained to seven thematic areas: standardised approaches to communicating with families; processes for interprofessional communication; processes for shared decision-making in the child’s best interests; role of the multidisciplinary team; managing professional–parental disagreement and conflict; the role of clinical psychologists; and staff support. Overall, the level of consensus was high, ranging from agreement to strong agreement.ConclusionsThese statements provide a consensus basis that can inform standardised approaches to the management of complexity. Such approaches may decrease friction between parents, children and healthcare professionals.

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Trends in long-stay admissions to a UK paediatric intensive care unit

Cited by 24 publications

References 13 publications

A Single-Centered Randomized Controlled Trial of Primary Pediatric Intensivists and Nurses

A Single-Centered Randomized Controlled Trial of Primary Pediatric Intensivists and Nurses

The Child With Severe Chronic Illness in the ICU: A Concise Review

Factors affecting decision-making in children with complex care needs: a consensus approach to develop best practice in a UK children’s hospital

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