Adults Are Not Just Large Kids: Caring for Adults in Pediatric Hospitals.

Abstract

What is the best inpatient care environment for adult survivors of childhood illness? The increased survival of childhood disease has led a growing number of adult patients to pursue care within pediatric facilities (1–3). These patients continue their care with pediatric providers for many reasons, including lack of access to adult specialists familiar with their illness, challenges with insurance coverage, long-term professional relationships between pediatric providers and patients, or perceptions about adult care (4). There is also a perceived moral obligation to care for the patients that we have successfully “created” by facilitating their survival into adulthood; a feat that was not previously assured. Adults admitted to children’s hospitals are often complex, with a high risk of readmission (5) and high frequency of chronic disease related to their childhood illness (6). These adult patients are more likely to stay longer and incur higher cost during hospitalization than their pediatric counterparts (3). There is also an increasing need for medical technology assistance among adult survivors of childhood disease (7), creating a high demand on the providers for these patients. For the pediatric critical care practitioner, adult patients represent a small but complex group of patients cared for in critical care units. In 2008, an evaluation of 70 PICUs demonstrated that 2.7% of all admissions were greater than 19 years old (8). In another analysis of patients admitted to pediatric critical care units across 43 hospitals participating in the Pediatric Health Information System database, 10.9% (67,730/623,511) were between the ages of 16 and 21, with an additional 1.5% of admissions (9,587/623,511) older than age 21 (9). These patients had higher risk-adjusted mortality compared with adolescent patients (using pediatric risk models) (8), making this a population that is deserving of attention due to its high risk. The risk and complexity of these patients require the creation of resilient processes in pediatric systems to care for adult patients. In this issue of Pediatric Critical Care Medicine, O’Halloran et al (10) present a retrospective analysis of in-hospital cardiac arrest (IHCA) in adult patients admitted to pediatric hospitals using the Get With the Guidelines-Resuscitation Registry. The study by O’Halloran et al (10) demonstrates the prevalence of adult IHCA in the included facilities and illustrates some of the challenges faced by providers caring for adult patients in pediatric hospitals. For example, they describe the initiation of cardiopulmonary resuscitation for symptomatic bradycardia in adult patients, which follows the pediatric advanced life support (ALS) algorithm rather than adult ALS. It is incumbent on pediatric hospitals to have clear processes and protocols to care for these adult patients to avoid confusion and deliver evidence-based care. The study from O’Halloran et al (10) also evaluates the quality of the care that these adults receive through whether they met the American Heart Association (AHA) recognition threshold. Only 79.5% of patients within their study received epinephrine within the first 5 minutes of cardiac arrest and only 68% of patients received defibrillation within 2 minutes of presenting with shockable rhythm, both of which are below the guidelines recommended by the AHA and do not meet ideal standards of care for either pediatric or adult patients. Assessing the quality of care for adults within pediatric hospitals often requires applying adult standards within the pediatric environment. Just as adult hospitals are not set up to evaluate adherence to pediatric standards of care (i.e., oxygen exposure for retinopathy of prematurity), pediatric hospitals are often not set up to assess whether standards of care for adult patients are met (such as initiation of prophylaxis for deep venous thrombosis). The application and assessment of standards within the study from O’Halloran et al (10) present a clear evaluation of goal-based care. The article by O’Halloran et al (10) also illustrates the need for database and registry-based research on adult survivors of congenital disease, especially as the field continues to explore the optimal locations for their care. This is a unique patient population where pediatric risk assessment (i.e., Pediatric Index of Mortality score) does not necessarily apply, while adult risk assessment (i.e., Acute Physiology and Chronic Health Evaluation scores) may not be employed and may not be relevant. Creating adequate risk assessment for these patients allows for improved recognition of severity of illness at admission and better assessment of quality of care, as well as creating a foundation for improving care over time. The medical community has an obligation to ensure that survivors of childhood illness have uninterrupted, high-quality care despite their age. The growing number of adults who have survived childhood illness with chronic disease and comorbidities present a challenge for the entire healthcare industry. There is a clear need to establish and use pathways for young adults to transition into the care of adult providers. There is also a need to create proficiency among adult providers in understanding the medical issues faced by these adults and in supporting the complex needs of these childhood illness survivors. This is particularly important for the growing subset of technology-dependent adult patients (7). It is important for pediatric providers to develop understanding and skill in caring for adults, including recognizing diseases of adulthood and navigating the changing social dynamics and ethical issues that occur with young adults, including issues of consent and access to private health information. Ideal healthcare for these complex adult patients will require partnerships between adult and pediatric providers and institutions, as it is unlikely that they will have all their healthcare needs met by either adult or pediatric teams. In addition, there should be identification of and investment in areas where continued care of adults at pediatric facilities is best for optimal outcomes for childhood illness survivors (i.e., congenital heart disease) or development of specialized centers where disease-specific adult and pediatric collaborative care exists. Finally, there needs to be development of disease-specific and age-based quality metrics and illness severity models to help assess the care provided for childhood illness survivors in both pediatric and adult facilities. Established pediatric and adult models do not adequately meet this need at present, making it difficult to assess the quality of care or risk for patients as they are admitted. To achieve this, adult and pediatric hospitals should participate in database and registries as adult survivors of congenital disease remain a small subset of the overall patient volume. In meeting these needs, practitioners can ensure that their pediatric patients continue to receive the healthcare that they need throughout their lives. As we continue to focus on the treatment strategies and therapies that help children survive disease, we must also focus on creating the care models that provide long-term, lifelong care. O’Halloran et al (10) provide further insight into the care of adults at pediatric hospitals, including the prevalence of cardiac arrest and the quality of cardiac arrest care, and illustrate the challenges faced by providers managing adults at pediatric hospitals. All too often, we as pediatricians implore our adult colleagues not to look at children as “little adults.” As a community, we must understand the challenges we face with this patient population and not fall victim to the reverse error; adults are not just big kids.