Structured Multidisciplinary Follow-Up After Pediatric Intensive Care: A Model for Continuous Data-Driven Health Care Innovation

Current provision and perceptions of paediatric intensive care unit follow-up services: A binational organisational and clinician survey

OBJECTIVES

The aim of this study was to (i) evaluate follow-up services in Australia and New Zealand for children surviving paediatric intensive care; (ii) assess clinician and service-wide knowledge of post-intensive care syndrome-paediatrics; and (iii) identify barriers to long-term follow-up services post paediatric intensive care unit admission.

METHODS

Two cross-sectional, web-based REDCap surveys were designed for organisational leadership and individual clinician respondents. All paediatric intensive care units with staffed paediatric beds in Australia and New Zealand were invited to participate.

RESULTS

Eleven paediatric intensive care units and 345 clinicians responded to the two surveys. None of the 11 paediatric intensive care units reported having any dedicated outpatient follow-up services. Only 53% of clinicians had heard of the term post-intensive care syndrome-paediatrics prior to the survey. However, most clinicians believed that follow-up care should be provided to children following a paediatric intensive care unit admission (96%) via a combination of modalities (49%) (e.g., telehealth and face-to-face) conducted by a multidisciplinary team (32%). Both the individual clinicians and the organisational leadership respondents identified staffing and budget restraints as the biggest barriers to follow-up care.

CONCLUSIONS

Despite growing international evidence to support the implementation of paediatric intensive care unit follow-up services, Australian and New Zealand paediatric intensive care units do not currently offer such services. In implementing paediatric intensive care unit follow-up practices, staffing and budgetary restraints need to be addressed. Improving clinician- and organisation-wide awareness and understanding of post-intensive care syndrome-paediatrics and its impacts may also help to reduce barriers to implementing follow-up services in Australian and New Zealand paediatric intensive care units.

Pediatric Post-Intensive Care Syndrome and Current Therapeutic Options

Post-intensive care syndrome (PICS) impacts most pediatric critical care survivors. PICS spans physical, cognitive, emotional, and social health domains and is increasingly recognized in survivorship literature. Children pose unique challenges in identifying and treating PICS given the inherent population heterogeneity in pediatric samples with biological differences across ages and neurodevelopmental stages, unique disease pathophysiology, strong environmental influences on disease and recovery, and lack of standardized measurements to identify morbidities or track response to intervention. Emerging literature and the recent development of specialized multidisciplinary clinics highlight opportunities for intervention across PICS domains in inpatient and outpatient settings.

Patient follow-up after discharge from the paediatric intensive care unit: A scoping review

BACKGROUND

Most children admitted to a paediatric intensive care unit (PICU) now survive because of improvements in care. Many studies have identified the psychological, functional, cognitive and social impact of PICU admission on a child and their family. However, expert recommendations on follow-up are lacking.

AIM

To identify the strategies of clinical follow-up after PICU discharge performed from 2001 to 2021.

STUDY DESIGN

This scoping review was undertaken between January and April 2021 using three databases: PubMed, EMBASE and CINAHL. The search strategy consisted of a combination of keywords, including PICU, post-PICU discharge and follow-up in articles published between 2001 and 2021. The results are reported according to PRISMA-ScR guidelines.

RESULTS

Six-hundred and fifty-two articles were identified and 68 were analysed. Median age was 4.5 years and the two main reasons for PICU admission were cardiorespiratory failure and sepsis. Median length of PICU stay was 8 days. Most follow-up was carried out by research units (88%), while 6% of studies reported follow-up by a multidisciplinary PICU team. The most common follow-up schedule included an assessment at PICU discharge, and then at 3, 6 and 12 months. Follow-up for >1 year was reported in 20% of studies. One third of studies focused on follow-up quality of life and neurological outcomes. Parental emotional impact was assessed in 7% of studies.

CONCLUSION

Follow-up after PICU discharge was highly heterogeneous regarding timing, health care professionals involved and assessment methods. There is an urgent need for standardization and coordination of PICU follow-up because of the increasing number of patients impacted by a PICU stay.

RELEVANCE TO CLINICAL PRACTICE

Although most patients admitted to a paediatric intensive care unit (PICU) now survive; they may develop paediatric post-intensive care syndrome (PICS-P). To our knowledge, there are currently no clinical guidelines regarding follow-up after PICU discharge. This review summarizes current approaches to follow-up after PICU discharge, including how it is carried out, who is involved and what the main aims of assessment are.

Pediatric intensive care unit follow-up: Thinking before acting

OBJECTIVE

It is now well established that post-intensive care syndrome is frequent in critically ill children after discharge from the pediatric intensive care unit (PICU). Nevertheless, post-intensive care follow-up is highly heterogenous worldwide and is not considered routine care in many countries. The purpose of this viewpoint was to report the reflections of the French PICU society working group on how to implement post-PICU follow-up.

METHODS

A working group was set up within the Groupe Francophone de Reanimation et d'Urgences Pédiatriques (GFRUP) to provide conceptual and practical guidance for developing post-PICU follow-up. The working group included psychologists, PICU physicians, physiotherapists, and nurses, from different French PICUs. Five virtual meetings have been held.

RESULTS

First, we described in this work the objectives of the follow-up program and the population to be targeted. We also provided a framework to implement post-PICU follow-up in clinical practice. Finally, we detailed the potential obstacles and challenges to consider.

CONCLUSION

Although implementing a post-PICU follow-up program is a challenge, the benefits could be significant for both patient and relatives, as well as for the health care professionals involved.

Long-term follow-up in pediatric intensive care-a narrative review

Pediatric intensive care is a rapidly developing medical specialty and with evolving understanding of pediatric pathophysiology and advances in technology, most children in the developed world are now surviving to intensive care and hospital discharge. As mortality rates for children with critical illness continue to improve, increasing PICU survivorship is resulting in significant long-term consequences of intensive care in these vulnerable patients. Although impairments in physical, psychosocial and cognitive function are well documented in the literature and the importance of establishing follow-up programs is acknowledged, no standardized or evidence-based approach to long-term follow-up in the PICU exists. This narrative review explores pediatric post-intensive care syndrome and summarizes the multifactorial deficits and morbidity that can occur in these patients following recovery from critical illness and subsequent discharge from hospital. Current practices around long-term follow-up are explored with discussion focusing on gaps in research and understanding with suggested ways forward and future directions.

Healthcare Burden and Resource Utilization After Pediatric Acute Respiratory Distress Syndrome: A Secondary Analysis of the Collaborative Pediatric Critical Care Research Network Acute Respiratory Distress Syndrome Study

OBJECTIVES

To describe family healthcare burden and health resource utilization in pediatric survivors of acute respiratory distress syndrome (ARDS) at 3 and 9 months.

DESIGN

Secondary analysis of a prospective multisite cohort study.

SETTING

Eight academic PICUs in the United States (2019-2020).

PATIENTS

Critically ill children with ARDS and follow-up survey data collected at 3 and/or 9 months after the event.

INTERVENTIONS

None.

METHODS AND MEASUREMENT

We evaluated family healthcare burden, a measure of healthcare provided by families at home, and child health resource use including medication use and emergency department (ED) and hospital readmissions during the initial 3- and 9-month post-ARDS using proxy-report. Using multivariable logistic regression, we evaluated patient characteristics associated with family healthcare burden at 3 months.

MAIN RESULTS

Of 109 eligible patients, 74 (68%) and 63 patients (58%) had follow-up at 3- and 9-month post-ARDS. At 3 months, 46 families (62%) reported healthcare burden including (22%) with unmet care coordination needs. At 9 months, 33 families (52%) reported healthcare burden including 10 families (16%) with unmet care coordination needs. At month 3, 61 patients (82%) required prescription medications, 13 patients (18%) had ED visits and 16 patients (22%) required hospital readmission. At month 9, 41 patients (65%) required prescription medications, 19 patients (30%) had ED visits, and 16 (25%) required hospital readmission were reported. Medication use was associated with family healthcare burden at both 3 and 9 months. In a multivariable analysis, preillness functional status and chronic conditions were associated with healthcare burden at month 3 but illness characteristics were not.

CONCLUSIONS

Pediatric ARDS survivors report high rates of healthcare burden and health resource utilization at 3- and 9-month post-ARDS. Future studies should assess the impact of improved care coordination to simplify care (e.g., medication management) and improve family burden.

Long-term multidisciplinary follow-up programs in pediatric cardiac arrest survivors

Long-term outcome studies after pediatric cardiac arrest (CA) are few. They require a CA registry and dedicated outcome teams. Learning about the long-term outcomes is very important for developing prognostication guidelines, improving post-cardiac care, counseling caregivers about the future of their child, and creating opportunities for therapeutic intervention studies to improve outcomes. Few PICUs worldwide provide a multidisciplinary follow-up program as routine practice at an outpatient clinic with standardized measurements, using validated instruments including neuropsychological assessments by psychologists. The primary goal of such a follow-up program should be to provide excellent care to children and their caregivers, thereby resulting in a high attendance. Pediatric psychologists, neurologists and pediatricians/pediatric intensivists should ideally be involved to screen for delayed development and psychosocial problems and offer appropriate care at the same time. Preferably, outcomes should consist of evaluation of morbidity (physical and neuropsychological), functional health and Health Related Quality Of Life (QoL) of the patient and their caregivers.