Critical Care Thresholds in Children with Bronchiolitis

Economic burden and influence factors among hospitalized children with bronchiolitis or pneumonia: a multiregional study in China

BACKGROUND

Bronchiolitis and pneumonia are both significant lower respiratory tract infections with a profound impact on children's health. The purpose of this study is to explore the economic burden and related influence factors of pediatric patients with bronchiolitis and pneumonia in China.

METHODS

A face-to-face interview was employed for the investigation of hospitalized patients (≤5 years old) with bronchiolitis and pneumonia, along with their guardians from January to October 2019. Demographic and costs were collected from Shanghai, Zhengzhou, and Kunming, representing three regions with different levels of economic development in China. Multiple linear regression analysis was used to explore factors associated with the economic burden of the diseases.

RESULTS

A total of 338 patients with bronchiolitis and 529 patients with pneumonia were included in the analysis. The average hospitalization and total cost for patients with bronchiolitis are 4,162 CNY and 5,748 CNY, respectively, while those with pneumonia are 6,096 CNY and 7,783 CNY. Patients from Shanghai, both bronchiolitis and pneumonia, exhibited the lowest cost expenditures, with average total costs of 3,531 CNY and 3,488 CNY, respectively. Multiple regression analysis indicated that, among bronchiolitis patients, factors such as region, medical insurance, relationship, loss of work time, and length of stay were found to be significantly associated with both hospitalization cost and total cost (p < 0.05). For pneumonia patients, the hospitalization cost and total cost were significantly impacted by region, medical insurance, and length of stay (p < 0.05).

CONCLUSION

Bronchiolitis and pneumonia in children put substantial economic burden on families of affected children. The financial strain varies significantly across different regions, with families in underdeveloped areas and those dealing with pneumonia facing particularly daunting challenges. Targeted policies to reduce healthcare costs and improve insurance coverage, especially in economically disadvantaged regions are needed.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit

PURPOSE

We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines.

METHODS

Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology.

RESULTS

This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting.

CONCLUSION

These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Escalation of care in children at high risk of clinical deterioration in a tertiary care children's hospital using the Bedside Pediatric Early Warning System

BACKGROUND

Escalation and de-escalation are a routine part of high-quality care that should be matched with clinical needs. The aim of this study was to describe escalation of care in relation to the occurrence and timing of Pediatric Intensive Care Unit (PICU) admission in a cohort of pediatric inpatients with acute worsening of their clinical condition.

METHODS

A monocentric, observational cohort study was performed from January to December 2018. Eligible patients were children: 1) admitted to one of the inpatient wards other than ICU; 2) under the age of 18 years at the time of admission; 3) with two or more Bedside-Paediatric-Early-Warning-System (BedsidePEWS) scores ≥ 7 recorded at a distance of at least one hour and for a period of 4 h during admission. The main outcome -the 24-h disposition - was defined as admission to PICU within 24-h of enrolment or staying in the inpatient ward. Escalation of care was measured using an eight-point scale-the Escalation Index (EI), developed by the authors. The EI was calculated every 6 h, starting from the moment the patient was considered eligible. Analyses used multivariate quantile and logistic regression models.

RESULTS

The 228 episodes included 574 EI calculated scores. The 24-h disposition was the ward in 129 (57%) and the PICU in 99 (43%) episodes. Patients who were admitted to PICU within 24-h had higher top EI scores [median (IQR) 6 (5-7) vs 4 (3-5), p < 0.001]; higher initial BedsidePEWS scores [median (IQR) 10(8-13) vs. 9 (8-11), p = 0.02], were less likely to have a chronic disease [n = 62 (63%) vs. n = 127 (98%), p < 0.0001], and were rated by physicians as being at a higher risk of having a cardiac arrest (p = 0.01) than patients remaining on the ward. The EI increased over 24 h before urgent admission to PICU or cardiac arrest by 0.53 every 6-h interval (CI 0.37-0.70, p < 0.001), while it decreased by 0.25 every 6-h interval (CI -0.36-0.15, p < 0.001) in patients who stayed on the wards.

CONCLUSION

Escalation of care was related to temporal changes in severity of illness, patient background and environmental factors. The EI index can improve responses to evolving critical illness.