Pediatric Intensive Care Unit Care Research Articles

Risk factors predicting need for the pediatric intensive care unit (PICU) post-hematopoietic cell transplant, PICU utilization, and outcomes following HCT: a single center retrospective analysis.

Hematopoietic cell transplant (HCT) is a curative treatment for multiple malignant and non-malignant disorders. While morbidity and mortality have decreased significantly over the years, some patients still require management in the pediatric intensive care unit (PICU) during their HCT course for additional respiratory, cardiovascular, and/or renal support. We retrospectively reviewed pediatric patients (0-18 years) who underwent HCT from January 2015-December 2020 at our institution to determine risk factors for PICU care and evaluate PICU utilization and outcomes. We also assessed pulmonary function testing (PFT) data to determine if differences were noted between PICU and non-PICU patients as well as potential evolution of pulmonary dysfunction over time. Risk factors of needing PICU care were lower age, lower weight, having an underlying inborn error of metabolism, and receiving busulfan-based conditioning. Nearly half of PICU encounters involved use of each of respiratory support types including high-flow nasal cannula, non-invasive positive pressure ventilation, and mechanical ventilation. Approximately one-fifth of PICU encounters involved renal replacement therapy. Pulmonary function test results largely did not differ between PICU and non-PICU patients at any timepoint aside from individuals who required PICU care having lower DLCO scores at one-year post-HCT. Future directions include consideration of combining our data with other centers for a multi-center retrospective analysis with the goal of gathering and reporting additional multi-center data to work toward continuing to decrease morbidity and mortality for patients undergoing HCT.

Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus.

Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.

Healthcare Professionals' Attitudes towards and Knowledge and Understanding of Paediatric Palliative Medicine (PPM) and Its Meaning within the Paediatric Intensive Care Unit (PICU): A Summative Content Analysis in a Tertiary Children's Hospital in Scotland-"An In Vitro Study".

Background: Paediatric palliative medicine (PPM) is a holistic approach to care for children and their families. Services are growing and developing worldwide but significant disparity in service provision remains. The Paediatric Supportive and Palliative Care Team (PSPCT) at the Royal Hospital for Children in Glasgow was established in 2019, but there is still no clear integrated role within the paediatric intensive care unit (PICU) at present. Through analysing the attitudes, meaning, knowledge and understanding of PPM in the PICU environment, we hoped to explore the experiences of those providing paediatric palliative care and to identify any barriers to or facilitators of integrated working to gain a better understanding of providing this care. Methods: This qualitative study used a survey composed of five open-ended and five closed questions. Sixteen out of a possible thirty-two responses (50%) were accrued from PICU healthcare professionals, including consultants (n = 19), advanced nurse practitioners (n = 4) and band-seven nurses (n = 9). The data were comprehensively studied and analysed by two coders using summative content analysis with assistance from data management software. Codes were further developed to form categories and subcategories. Results: Two categories were found: (1) the role of palliative care and (2) experiences of providing palliative care. A total of five subcategories were found, demonstrating that the PSPCT can enhance care in PICU through collaborative working. Barriers identified included staffing, funding and stigma around palliative care. Conclusions: This study shows that PICU professionals have a good understanding of the concepts of PPM and view it as an essential part of PICU work. Barriers related to resources and misperceptions of palliative care can be overcome through improved education, funding and staff retention, but this would require buy-in from policymakers. The perspective from our relatively small team increases generalizability to growing teams across the country.

Impaired echocardiographic left ventricular global longitudinal strain after pediatric cardiac arrest children is associated with mortality

BackgroundGlobal longitudinal strain (GLS) is an echocardiographic method to identify left ventricular (LV) dysfunction after cardiac arrest that is less sensitive to loading conditions. We aimed to identify the frequency of impaired GLS following pediatric cardiac arrest, and its association with hospital mortality. MethodsThis is a retrospective single-center cohort study of children <18 years of age treated in the pediatric intensive care unit (PICU) after in- or out-of-hospital cardiac arrest (IHCA and OHCA), with echocardiogram performed within 24 hours of initiation of post-arrest PICU care between 2013 and 2020. Patients with congenital heart disease, post-arrest extracorporeal support, or inability to measure GLS were excluded. Echocardiographic LV ejection fraction (EF) and shortening fraction (SF) were abstracted from the chart. GLS was measured post hoc; impaired strain was defined as LV GLS ≥ 2 SD worse than age-dependent normative values. Demographics and pre-arrest, arrest, and post-arrest characteristics were compared between subjects with normal versus impaired GLS. Correlation between GLS, SF and EF were calculated with Pearson comparison. Logistic regression tested the association of GLS with mortality. Area under the receiver operator curve (AUROC) was calculated for discriminative utility of GLS, EF, and SF with mortality. ResultsGLS was measured in 124 subjects; impaired GLS was present in 46 (37.1%). Subjects with impaired GLS were older (median 7.9 vs. 1.9 years, p < 0.001), more likely to have ventricular tachycardia/fibrillation as initial rhythm (19.6% versus 3.8%, p = 0.017) and had higher peak troponin levels in the first 24 hours post-arrest (median 2.5 vs. 0.5, p = 0.002). There were no differences between arrest location or CPR duration by GLS groups. Subjects with impaired GLS compared to normal GLS had lower median EF (42.6% versus 62.3%) and median SF (23.3% versus 36.6%), all p < 0.001, with strong inverse correlation between GLS and EF (rho −0.76, p < 0.001) and SF (rho −0.71, p < 0.001). Patients with impaired GLS had higher rates of mortality (60% vs. 32%, p = 0.009). GLS was associated with mortality when controlling for age and initial rhythm [aOR 1.17 per 1% increase in GLS (95% CI 1.09–1.26), p < 0.001]. GLS, EF and SF had similar discrimination for mortality: GLS AUROC 0.69 (95% CI 0.60–0.79); EF AUROC 0.71 (95% CI 0.58–0.88); SF AUROC 0.71 (95% CI 0.61–0.82), p = 0.101. ConclusionsImpaired LV function as measured by GLS after pediatric cardiac arrest is associated with hospital mortality. GLS is a novel complementary metric to traditional post-arrest echocardiography that correlates strongly with EF and SF and is associated with mortality. Future large prospective studies of post-cardiac arrest care should investigate the prognostic utilities of GLS, alongside SF and EF.

Determinants of Blood Culture Use in Critically Ill Children: A Multicenter Qualitative Study.

We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics. We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts. Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.

Supporting families during pediatric critical illness: Opportunities identified in a multicenter, qualitative study.

Critical illness resulting in a pediatric intensive care unit (PICU) admission is a profoundly stressful experience for a child and their family. Increasing evidence for emotional and behavioral sequelae post-PICU emphasizes a need to provide better support for families throughout this period of care and recovery. The aim of this qualitative investigation was to identify salient and modifiable aspects of a critical care experience that can be addressed to better support families of critically ill children. Individual semi-structured interviews were conducted with 26 caregivers of children who survived a PICU admission. Interviews were audio-recorded and transcribed verbatim; themes were identified via thematic analysis. Caregivers were enrolled using convenience sampling from seven tertiary care PICUs in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Themes from caregiver interviews were identified within two overarching categories containing three themes each. Advice for future PICU families: (1) Be intentional about caring for your own well-being, (2) speak up, ask questions, and challenge decisions you're not comfortable with, and (3) continue to engage with your child. Characteristics of a satisfactory PICU experience: (1) A caregiver-provider relationship of mutual trust established through clear communication and respectful collaboration, (2) hospital environments that provide physical and social supports to maintain humanity in healthcare, and (3) preparing families for care transitions. Targeted, interdisciplinary approaches to partner with families during critical care may improve their PICU experience and contribute to improved long-term outcomes for PICU survivors.

The Determining Factors for Outcome of Pediatric Intensive Care Admitted Children After Stem Cell Transplantation.

Requiring pediatric intensive care unit (PICU) admission relates to high mortality and morbidity in patients who received hematopoietic stem cell transplantation (HSCT). In this study, we aimed to evaluate the indications for PICU admission, treatments, and the determining risk factors for morbidity and mortality in patients who had allogeneic HSCT from various donors. In this retrospective study, we enrolled to patients who required the PICU after receiving allogeneic HSCT at our Pediatric Bone Marrow Transplantation Unit between 2005 and 2020. We evaluated to indication to PICU admission, applications, mortality rate, and the determining factors to outcomes. Thirty-three (7%) patients had 47 PICU admissions and 471 patients underwent bone marrow transplantation during 16-year study period. Also, 14 repeated episodes were registered in 9 different patients. The median age of PICU admitted patients was 4 (0.3 to 18) years and 29 (62%) were male. The main reasons for PICU admission were a respiratory failure, sepsis, and neurological event in 20, 8, and 7 patients, respectively. The average length of PICU stay was 14.5 (1 to 80) days, 14 (43%) of patients survived and the mortality rate was 57%. Multiple organ failure ( P =0.001), need for respiratory support ( P =0.007), inotrope agents ( P =0.001), and renal replacement therapy ( P =0.013) were found as significant risk factors for mortality. Allogeneic HSCT recipients need PICU admission because of its related different life-threatening complications. But there is a good chance of survival with quality PICU care and different advanced organ support methods.

30: SOCIAL VULNERABILITY INDEX AND CHILD OPPORTUNITY INDEX HIGH IN ASTHMA BUT NOT LINKED TO PICU STAY

Introduction: Racial and socioeconomic disparities in pediatric asthma prevalence, severity, and use of primary and emergency care have been well studied. However, understanding of the impact of these disparities on risk of hospitalization in the pediatric intensive care unit (PICU) is limited. We used composite measures of socioeconomic risk factors through the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), and the Child Opportunity Index (COI) 2.0 to compare patients admitted for status asthmaticus to the PICU or pediatric ward at Children’s Hospital Los Angeles (CHLA). We hypothesized patients with a high SVI and low COI are at higher risk for PICU level care. Methods: Following IRB approval, patients were identified using ICD-10 codes for asthma. The outcome of interest was need for PICU versus ward care. Patients were included as requiring PICU level of care if admitted to the PICU during their stay. Patient registered street address was geocoded and linked to US Census-American Community Survey 2019 Data (5-Year) at the census tract level. Bivariate analysis with the patient’s SVI, COI, hospital length of stay (LOS), and PICU admission were conducted. Statistical analysis used SAS, STATA, and ArcGIS Pro. Results: From [October 2015 – May 2022], there were 4,766 admissions matched to addresses from 3,617 distinct patients of which 626 (13.1%) required PICU admission. Overall median SVI for all patients was 0.86 with no difference between groups for SVI: median (1,3 IQR) PICU 0.86 (0.67, 0.93) Ward 0.86 (0.69, 0.93) p=0.56; or for COI: PICU 27 (9, 50) Ward 24 (10, 50) p=0.82. Hospital LOS was significantly longer for those requiring PICU admission: PICU 3 (3, 5) Ward 2 (2, 3) (days) p< 0.001. Conclusions: We found that children admitted to CHLA for asthma had an elevated SVI overall reflecting a patient population among the lowest socioeconomic status in the United States. The median 0.86 SVI score indicates a population that is more socially vulnerable than all but 14% of the US population. Similarly, the COI score demonstrated a population at risk. Yet, there was no difference between groups for the SVI or COI scores indicating we care for children at increased socioeconomic risk, but this did not increase PICU use for asthma admissions.

Practice Variability and Unplanned Extubation Rates across Pediatric Intensive Care Units

AbstractThe purpose of this study was to describe the care of intubated patients in pediatric critical care. Acknowledging there are several perceived factors that contribute to unplanned extubations, a secondary objective was to describe how practice variation may relate to observed differences in unplanned extubation rates. A survey about practices related to the care of intubated patients was distributed to all pediatric intensive care units (PICUs) participating in the Virtual Pediatric Systems (VPS, LLC). Unplanned extubation rates for 2019 to 2020 were obtained from VPS. Univariate and bivariate analyses were performed to describe the responses, with unplanned extubation rates calculated as means. The text responses about perceived causes of unplanned extubation in participants' sites were explored using thematic content analysis. A total of 44 PICUs were included in this study (response rate 37.0%). The mean unplanned extubation rate for the sample was 0.41 (95% confidence interval: 0.31–0.50) per 100 intubation days. Variability was found across several aspects that impact care, including staffing, the frequency of procedures (e.g., chest radiography), and treatment-related goals (e.g., sedation and mobilization). The perceived causes of unplanned extubations in the sample included patient-, staff-, and equipment-related factors. We found practice variability in pediatric critical care units related to the care of intubated patients, which may contribute to the frequency of adverse events. As evidence emerges and professional associations and organizations recommend the best practices, knowledge translation will be required for the implementation and deimplementation of practices to improve the quality of care in PICUs.

What you see may not be what you get! Simulate towards effective planning of pediatric intensive care unit.

Aims and objectivesThis study aimed to describe the application of low-cost inter-professional simulation over 4 phases in identifying structural and design issues, latent safety threats as well as test systems, processes, including facilitated team training during the design of a new pediatric intensive care unit (PICU).Materials and methodsThe four-phase inter-professional simulation sessions involving clinical and non-clinical teams were conducted over a 3-month period in a corporate hospital during the designing of a new PICU. Low-cost resources, such as floor tapes, low-tech manikins, reused sterilized consumables, and actual patient beds and equipment, were used for the in situ simulation sessions. A plus-delta method of debriefing was done, and changes agreed on consensus were implemented after each simulated session.ResultsThere were 10 simulation sessions conducted over 4 phases during the 3-month period of designing the PICU. The participants included 10 doctors from PICU and adult critical care, 25 critical care nurses, 12 members from the project team, and 2 hospital administrators in various combinations. The first phase led to the re-design of workspace and clinical areas for better space utilization. The second phase required further revision to facilitate better mobility and facilities. In the third phase, the number of beds was reduced to 6 beds following the simulated drills involving the actual placement of patient cots and equipment. The fourth phase had thematic 5 simulated exercises involving the newly recruited clinical teams that enabled the identification of systems and process issues. Cognitive aids and video orientation of the setup, team training, and human factors training were addressed, and the unit was open for patient care in a week.ConclusionA phased inter-professional simulation exercise with low-cost resources can enable the identification of structural challenges, design issues, latent safety threats, test systems, processes, patient flow, and facilitated team training during the design of a new PICU. Further studies are needed to understand the generalization of the study findings into designing PICU.

Discussion Guide for the Alves Article.

Discussion Guide for the Alves Article.

Group Concept Mapping Conceptualizes High-Quality Care for Long-Stay Pediatric Intensive Care Unit Patients and Families

To describe and conceptualize high-quality care for long-stay pediatric intensive care unit (PICU) patients using group concept mapping (GCM). We convened an expert panel to elucidate domains of high-quality care for this growing patient population for which transitory care models fail to meet their needs. Thirty-one healthcare professionals and 7 parents of patients with previous prolonged PICU hospitalizations comprised a diverse, interprofessional multidisciplinary panel. Participants completed the prompt "For PICU patients and families experiencing prolonged lengths of stay, high quality care from the medical team includes ______", with unlimited free text responses. Responses were synthesized into individual statements, then panelists sorted them by idea similarity and rated them by perceived importance. Statement analysis using GCM software through GroupWisdom generated nonoverlapping clusters representing domains of high-quality care. Participants submitted 265 prompt responses representing 313 unique ideas, resulting in 78 final statements for sorting and rating. The resultant cluster map best representing the data contained 8 domains: (1) Family-Centered Care and Shared Decision Making, (2) Humanizing the Patient, (3) Clinician Supports and Resources, (4) Multidisciplinary Coordination of Care, (5) Family Well-Being, (6) Anticipatory Guidance and Care Planning, (7) Communication, and (8) Continuity of Care. GCM empowered a panel of healthcare professionals and parents to explicitly describe and conceptualize high-quality care for patients and families experiencing prolonged PICU stays. This information will aid the effort to address shortcomings of transitory PICU care models.

Association of Acute Respiratory Failure in Early Childhood With Long-term Neurocognitive Outcomes

Approximately 23 700 US children undergo invasive mechanical ventilation for acute respiratory failure annually, with unknown long-term effects on neurocognitive function. To evaluate neurocognitive outcomes of children who survive pediatric intensive care unit (PICU) hospitalization for acute respiratory failure compared with their biological siblings. Prospective sibling-matched cohort study conducted at 31 US PICUs and associated neuropsychology testing centers. Patients were 8 years or younger with a Pediatric Cerebral Performance Category score of 1 (normal) before PICU admission and less than or equal to 3 (no worse than moderate neurocognitive dysfunction) at PICU discharge, excluding patients with a history of neurocognitive deficits or who were readmitted and underwent mechanical ventilation. Biological siblings were aged 4 to 16 years at testing, with Pediatric Cerebral Performance Category score of 1 and no history of mechanical ventilation or general anesthesia. A total of 121 sibling pairs were enrolled from September 2, 2014, to December 13, 2017, and underwent neurocognitive testing starting March 14, 2015. The date of the final follow-up was November 6, 2018. Critical illness and PICU treatment for acute respiratory failure. The primary outcome was IQ, estimated by the age-appropriate Vocabulary and Block Design subtests of the Wechsler Intelligence Scale. Secondary outcomes included measures of attention, processing speed, learning and memory, visuospatial skills, motor skills, language, and executive function. Evaluations occurred 3 to 8 years after hospital discharge. Patients (n = 121; 55 [45%] female patients) underwent PICU care at a median (IQR) age of 1.0 (0.2-3.2) years, received a median (IQR) of 5.5 (3.1-7.7) days of invasive mechanical ventilation, and were tested at a median (IQR) age of 6.6 (5.4-9.1) years. Matched siblings (n = 121; 72 [60%] female siblings) were tested at a median (IQR) age of 8.4 (7.0-10.2) years. Patients had a lower mean estimated IQ than matched siblings (101.5 vs 104.3; mean difference, -2.8 [95% CI, -5.4 to -0.2]). Among secondary outcomes, patients had significantly lower scores than matched siblings on nonverbal memory (mean difference, -0.9 [95% CI, -1.6 to -0.3]), visuospatial skills (mean difference, -0.9 [95% CI, -1.8 to -0.1]), and fine motor control (mean difference, -3.1 [95% CI, -4.9 to -1.4]) and significantly higher scores on processing speed (mean difference, 4.4 [95% CI, 0.2-8.5]). There were no significant differences in the remaining secondary outcomes, including attention, verbal memory, expressive language, and executive function. Among children, survival of PICU hospitalization for respiratory failure and discharge without severe cognitive dysfunction was associated with significantly lower subsequent IQ scores compared with matched siblings. However, the magnitude of the difference was small and of uncertain clinical importance.

Cost Efficacy of Rapid Whole Genome Sequencing in the Pediatric Intensive Care Unit.

The diagnostic and clinical utility of rapid whole genome sequencing (rWGS) for critically ill children in the intensive care unit (ICU) has been substantiated by multiple studies, but comprehensive cost-effectiveness evaluation of rWGS in the ICU outside of the neonatal age group is lacking. In this study, we examined cost data retrospectively for a cohort of 38 children in a regional pediatric ICU (PICU) who received rWGS. We identified seven of 17 patients who received molecular diagnoses by rWGS and had resultant changes in clinical management with sufficient clarity to permit cost and quality adjusted life years (QALY) modeling. Cost of PICU care was estimated to be reduced by $184,846 and a total of 12.1 QALYs were gained among these seven patients. The total cost of rWGS for patients and families for the entire cohort (38 probands) was $239,400. Thus, the net cost of rWGS was $54,554, representing $4,509 per QALY gained. This quantitative, retrospective examination of healthcare utilization associated with rWGS-informed medicine interventions in the PICU revealed approximately one-third of a QALY gained per patient tested at a cost per QALY that was approximately one-tenth of that typically sought for cost-effective new medical interventions. This evidence suggests that performance of rWGS as a first-tier test in selected PICU children with diseases of unknown etiology is associated with acceptable cost-per-QALY gained.

Clinico-laboratory profile, outcome, and risk factors for pediatric intensive care admission among hospitalized COVID-19–infected children from Eastern India

Background: Children had been affected less by COVID-19 than adults. But as the pandemic progressed more cases of severe pediatric COVID infection were reported. Aim of this study is to describe the clinical characteristics, laboratory parameters, treatments, and predictors of pediatric intensive care unit (PICU) admission among hospitalized children with SARS-CoV-2 infection.Subjects and Methods: This was a retrospective, observational study performed in a tertiary care COVID referral hospital among hospitalized children aged from 1 month to 12 years, from May 2020 to March 2021. Children treated in the pediatric ward were compared with those admitted in the PICU to assess predictors of intensive care admission.Results: Out of 447 hospitalized patients with confirmed COVID-19 infection, 92 (20.58%) required admission in the PICU. Mean age of the study population was 44.58 (16.77–72.39) months. Thirty-eight patients (8.50%) fulfilled multisystem inflammatory syndrome in children (MIS-C) diagnostic criteria. Invasive mechanical ventilation and inotropic support were needed for 28.26% and 36.96% of PICU-admitted patients, respectively. The mortality rate was 1.57%. Independent risk factors for PICU admission were infant age group, longer duration of fever (>5 days), shortness of breath, presence of shock, underlying comorbidities and higher pediatric early warning score (PEWS ≥5), poor Glasgow coma scale (GCS <7), MIS-C, elevated C-reactive protein (CRP >50 mg/L), neutrophil–lymphocyte ratio (NLR ≥4.5), and hypoalbuminemia (<2.5 g/dL).Conclusions: Clinical factors such as infancy, prolonged fever, respiratory distress at admission, shock, higher PEWS, poor GCS, and comorbidities indicate at risk for severe disease. Simple laboratory parameters such as CRP, NLR ≥4.5, and albumin may be considered as screening at admission to predict need of PICU care.

A Snapshot of Chronic Critical Illness in Pediatric Intensive Care Units.

Children with chronic critical illness (CCI) represent the sickest subgroup of children with medical complexity. In this article, we applied a proposed definition of pediatric CCI to assess point prevalence in medical, cardiovascular, and combined pediatric intensive care units (PICUs), screening all patients admitted to six academic medical centers in the United States on May 17, 2017, for pediatric CCI (PCCI) eligibility. We gathered descriptive data to understand medical complexity and resource needs of children with PCCI in PICUs including data regarding hospitalization characteristics, previous admissions, medical technology, and chronic multiorgan dysfunction. Descriptive statistics were used to characterize the study population and hospital data. The study cohort was divided between PICU-prolonged (stay > 14 days) and PICU-exposed (any time in PICU); comparative analyses were conducted. On the study day, 185 children met inclusion criteria, 66 (36%) PICU-prolonged and 119 (64%) PICU-exposed. Nearly all had home medical technology and most ( n = 152; 82%) required mechanical ventilation in the PICU. The PICU-exposed cohort mirrored the PICU-prolonged with a few exceptions as follows: they were older, had fewer procedures and surgeries, and had more recurrent hospitalizations. Most ( n = 44; 66%) of the PICU-prolonged cohort had never been discharged home. Children with PCCI were a sizable proportion of the unit census on the study day. We found that children with PCCI are a prevalent population in PICUs. Dividing the cohorts between PICU-prolonged and PICU-exposed helps to better understand the care needs of the PCCI population. Identifying and studying PCCI, including variables relevant to PICU-prolonged and PICU-exposed, could inform changes to PICU care models and training programs to better enable PICUs to meet their unique needs.

P0487 / #1684: PARENT SATISFACTION WITH CARE IN FOUR PEDIATRIC INTENSIVE CARE UNITS IN RIO DE JANEIRO/BRAZIL: A FAMILY-REPORTED OUTCOME MEASURED AT DISCHARGE

Aims & Objectives: Patient and family-reported outcomes are of increasing importance in Pediatric Intensive Care Units (PICU). Caring of critically ill children is a complex task and family’s perceived care is of great interest to improve performance and provide support and guidance to families. In the pediatric context, family satisfaction can be used as an important indicator for health professionals, allowing benchmarking and also tailoring quality improvement programs. The objective of this study is to assess parent satisfaction with care using a PICU specific multidimensional instrument. Methods: Multicenter study carried out in four PICUs in Rio de Janeiro/Brazil. The interviews were conducted with 160 parents at PICU discharge using the EMPATHIC-30 instrument. The overall scores were calculated, as also dimension scores: information, care and treatment, organization, parent participation and professional attitude. Group means were compared with T-Test using demographic and clinical variables. Results: The mean average satisfaction score reported was 117,8 (SD 34,8). The information dimension was the best evaluated, followed by care and treatment, professional attitude, organization and parent participation. There was no difference between male and female parent responses (125.3 vs. 118.9; p=0.193), and parents of children who presented shock (as proxy of severe disease) stated lower satisfaction scores than those without (125.3 vs. 98.1; p=0.041). Conclusions: The results indicate a high level of satisfaction with PICU care in the four units evaluated, as well as in its five dimensions. It is noteworthy that satisfaction with care is an important quality of performance indicator, allowing the identification of problems and proposals for improvements.

Cost analysis of pediatric intensive care: a low-middle income country perspective

BackgroundGlobally, Pediatric Intensive Care Unit (PICU) admissions are amongst the most expensive. In low middle-income countries, out of pocket expenditure (OOP) constitutes a major portion of the total expenditure. This makes it important to gain insights into the cost of pediatric intensive care. We undertook this study to calculate the health system cost and out of pocket expenditure incurred per patient during PICU stay.MethodsProspective study conducted in a state of the art tertiary level PICU of a teaching and referral hospital. Bottom-up micro costing methods were used to assess the health system cost. Annual data regarding hospital resources used for PICU care was collected from January to December 2018. Data regarding OOP was collected from 299 patients admitted from July 2017 to December 2018. The latter period was divided into four intervals, each of four and a half months duration and data was collected for 1 month in each interval. Per patient and per bed day costs for treatment were estimated both from health system and patient’s perspective.ResultsThe median (inter-quartile range, IQR) length of PICU stay was 5(3–8) days. Mean ± SD Pediatric Risk of Mortality Score (PRISM III) score of the study cohort was 22.23 ± 7.3. Of the total patients, 55.9% (167) were ventilated. Mean cost per patient treated was US$ 2078(₹ 144,566). Of this, health system cost and OOP expenditure per patient were US$ 1731 (₹ 120,425) and 352 (₹ 24,535) respectively. OOP expenditure of a ventilated child was twice that of a non- ventilated child.ConclusionsThe fixed cost of PICU care was 3.8 times more than variable costs. Major portion of cost was borne by the hospital. Severe illness, longer ICU stay and ventilation were associated with increased costs. This study can be used to set the reimbursement package rates under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). Tertiary level intensive care in a public sector teaching hospital in India is far less expensive than developed countries.

Long-Term Neurodevelopmental and Functional Outcomes of Normally Developing Children Requiring PICU Care for Bronchiolitis

Bronchiolitis is a common pediatric intensive care unit (PICU) illness and often affects generally healthy children, making it a promising disease in which to study long-term neurodevelopmental outcomes. We previously found that approximately 15% of critical bronchiolitis patients have evidence of post-PICU morbidity using coarse definitions available in administrative data sets. In this study, we measured neurodevelopmental outcomes using four more precise tools. Children who had previously been admitted to our PICU with bronchiolitis were included; those with evidence of developmental delay at PICU admission were excluded. Approximately 1 to 2 years after PICU discharge, the parent of each subject completed two questionnaires (Ages and Stages Questionnaire and Pediatric Evaluation of Disability Inventory Computer Adaptive Test). Each subject also underwent two in-person assessments administered by a certified examiner (Bayley Scales of Infant and Toddler Development, 3rd edition, and the Amiel-Tison neurological assessment). For each domain of each test, a score of > 1 standard deviation below the norm for the subject's age defined "moderate" disability and a score ≥ 2 standard deviations below the norm defined "severe" disability. Eighteen subjects (median ages of 3.7 months at PICU admission and 2.3 years at testing) were enrolled, 17 of whom were supported by high-flow nasal cannula and/or mechanical ventilation. Fifteen children (83%) scored abnormally on ≥ 1test. Eight children (44%) had disabilities in ≥ 3 domains and/or ≥ 1 severe disability identified. Our findings that motor, language, and cognitive disabilities are commonly observed months to years after critical bronchiolitis require larger studies to confirm this finding, assess causality, and identify modifiable risk factors.

1. PROMOTING RESIDENT WELLNESS: A NOVEL CLINIC SCHEDULING MODEL DURING PEDIATRIC INTENSIVE CARE UNIT ROTATIONS

Background Pediatric residents at our program self-reported feeling “moral distress” when leaving the pediatric intensive care unit (PICU) for multiple half-day continuity clinics. Few studies have outlined alternative clinic scheduling during PICU months beyond X+Y scheduling or clinic cancellation. Objective To implement and evaluate a novel continuity clinic schedule and measure changes in moral distress and continuity of care. Methods Each pediatric resident was scheduled for one half-day continuity clinic session and one full-day continuity clinic session during their PICU rotation. Residents were not scheduled for clinic on a call day. Residents who had completed at least one PICU rotation were invited to fill out a baseline survey on their perceptions of continuity clinic attendance during the PICU rotation. Following implementation of the new schedule, a post-intervention survey was distributed. Survey questions used Likert scales (range 1-5; 1=never, 5=almost always). Baseline and post-intervention survey data was analyzed using a two-sided Wilcoxon two-sample rank-sum test. Results The pre-intervention survey found over 50% of residents felt moral distress and perceived PICU care was compromised when leaving for clinic. Post-intervention surveys showed a decrease in residents reporting moral distress and compromised PICU care (p Conclusions This novel continuity clinic scheduling model is associated with a decrease in moral distress and improvement in perceived continuity clinic value. Additionally, this model decreased the number of PICU handoffs, which potentially decreased opportunities for medical errors.