Download PDF
Am J Perinatol 2022; 39(06): 646-651
DOI: 10.1055/s-0040-1718572
Original Article

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

Renee D. Boss
1   Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
2   Berman Institute of Bioethics, Baltimore, Maryland
,
Carrie M. Henderson
3   Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
4   Center for Bioethics and Medical Humanities, Jackson, Mississippi
,
Elliott M. Weiss
5   Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
6   Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington
,
Alison Falck
7   Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
,
Vanessa Madrigal
8   Department of Pediatrics, Children's National Medical Center, Washington, Dist. of Columbia
,
Miriam C. Shapiro
9   Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota
,
Erin P. Williams
2   Berman Institute of Bioethics, Baltimore, Maryland
,
Pamela K. Donohue
1   Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
10   Department of Population and Families, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
,
on behalf of the Pediatric Chronic Critical Illness Collaborative › Author Affiliations
› Further Information
    Permissions and Reprints

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.

Keywords

chronic illness - pediatrics - intensive care

* A complete list of nonauthor participating investigators appears in the [Supplementary Material], available in the online version.


Supplementary Material



Publication History

Received: 29 April 2020

Accepted: 07 September 2020

Article published online:
19 October 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Leyenaar JK, Ralston SL, Shieh MS, Pekow PS, Mangione-Smith R, Lindenauer PK. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States. J Hosp Med 2016; 11 (11) 743-749
    CrossrefPubMedGoogle Scholar
  • 2 Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med 2010; 182 (04) 446-454
    CrossrefPubMedGoogle Scholar
  • 3 Kahn JM, Werner RM, David G, Ten Have TR, Benson NM, Asch DA. Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness. Med Care 2013; 51 (01) 4-10
    CrossrefPubMedGoogle Scholar
  • 4 Berry JG, Hall M, Hall DE. et al. Inpatient growth and resource use in 28 children's hospitals: a longitudinal, multi-institutional study. JAMA Pediatr 2013; 167 (02) 170-177
    CrossrefPubMedGoogle Scholar
  • 5 Rogozinski L, Young A, Grybauskas C, Donohue P, Boss R, Biondi E. PCCI collaborative. Point Prevalence of Children Hospitalized With Chronic Critical Illness in the General Inpatient Units. Hosp Pediatr 2019; 9 (07) 545-549
    CrossrefPubMedGoogle Scholar
  • 6 Kahn JM, Le T, Angus DC. et al; ProVent Study Group Investigators. The epidemiology of chronic critical illness in the United States. Crit Care Med 2015; 43 (02) 282-287
    CrossrefPubMedGoogle Scholar
  • 7 Shapiro MC, Henderson CM, Hutton N, Boss RD. Defining pediatric chronic critical illness for clinical care, research, and policy. Hosp Pediatr 2017; 7 (04) 236-244
    CrossrefPubMedGoogle Scholar
  • 8 Burns KH, Casey PH, Lyle RE, Bird TM, Fussell JJ, Robbins JM. Increasing prevalence of medically complex children in US hospitals. Pediatrics 2010; 126 (04) 638-646
    CrossrefPubMedGoogle Scholar
  • 9 Marcin JP, Slonim AD, Pollack MM, Ruttimann UE. Long-stay patients in the pediatric intensive care unit. Crit Care Med 2001; 29 (03) 652-657
    CrossrefPubMedGoogle Scholar
  • 10 Henderson CM, Williams EP, Shapiro MC. et al. “Stuck in the ICU”: caring for children with chronic critical illness. Pediatr Crit Care Med 2017; 18 (11) e561-e568
    CrossrefPubMedGoogle Scholar
  • 11 Hebert LM, Watson AC, Madrigal V, October TW. Discussing benefits and risks of tracheostomy: what physicians actually say. Pediatr Crit Care Med 2017; 18 (12) e592-e597
    CrossrefPubMedGoogle Scholar
  • 12 Giambra BK, Mangeot C, Benscoter DT, Britto MT. Identification of hospitalized tracheostomy and ventilator dependent patients in administrative data. Pediatr Pulmonol 2018; 53 (07) 973-978
    CrossrefPubMedGoogle Scholar
  • 13 Geneslaw AS, Jia H, Lucas AR, Agus MSD, Edwards JD. Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both. J Crit Care 2017; 41: 268-274
    CrossrefPubMedGoogle Scholar
  • 14 Berry JG, Hall M, Dumas H. et al. Pediatric hospital discharges to home health and postacute facility care: a national study. JAMA Pediatr 2016; 170 (04) 326-333
    CrossrefPubMedGoogle Scholar
  • 15 Berry J, Wilson K, Dumas H. et al. Use of post-acute facility care in children hospitalized with acute respiratory illness. J Hosp Med 2017; 12 (08) 626-631
    CrossrefPubMedGoogle Scholar
  • 16 Maynard R, Christensen E, Cady R. et al. Home health care availability and discharge delays in children with medical complexity. Pediatrics 2019; 143 (01) e20181951
    CrossrefPubMedGoogle Scholar
  • 17 Carroll NW, Hearld LR, Joseph R. Hospital ownership of postacute care providers and the cost of care. Health Care Manage Rev 2019
    PubMedGoogle Scholar
  • 18 Boss RD, Williams EP, Henderson CM. et al. Pediatric chronic critical illness: reducing excess hospitalizations. Hosp Pediatr 2017; 7: 460-470
    CrossrefPubMedGoogle Scholar
  • 19 Kuo DZ, Cohen E, Agrawal R, Berry JG, Casey PH. A national profile of caregiver challenges among more medically complex children with special health care needs. Arch Pediatr Adolesc Med 2011; 165 (11) 1020-1026
    CrossrefPubMedGoogle Scholar
  • 20 Marcus KL, Henderson CM, Boss RD. Chronic critical illness in infants and children: a speculative synthesis on adapting ICU care to meet the needs of long-stay patients. Pediatr Crit Care Med 2016; 17 (08) 743-752
    CrossrefPubMedGoogle Scholar