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Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Availability of Pediatric Inpatient Services in the United States. Pediatrics 2021; 148:peds.2020-041723. [PMID: 34127553 PMCID: PMC8642812 DOI: 10.1542/peds.2020-041723] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to evaluate trends in pediatric inpatient unit capacity and access and to measure pediatric inpatient unit closures across the United States. METHODS We performed a retrospective study of 4720 US hospitals using the 2008-2018 American Hospital Association survey. We used linear regression to describe trends in pediatric inpatient unit and PICU capacity. We compared trends in pediatric inpatient days and bed counts by state. We examined changes in access to care by calculating distance to the nearest pediatric inpatient services by census block group. We analyzed hospital characteristics associated with pediatric inpatient unit closure in a survival model. RESULTS Pediatric inpatient units decreased by 19.1% (34 units per year; 95% confidence interval [CI] 31 to 37), and pediatric inpatient unit beds decreased by 11.8% (407 beds per year; 95% CI 347 to 468). PICU beds increased by 16.0% (66.9 beds per year; 95% CI 53 to 81), primarily at children's hospitals. Rural areas experienced steeper proportional declines in pediatric inpatient unit beds (-26.1% vs -10.0%). Most states experienced decreases in both pediatric inpatient unit beds (median state -18.5%) and pediatric inpatient days (median state -10.0%). Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit. Low-volume pediatric units and those without an associated PICU were at highest risk of closing. CONCLUSIONS Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children's hospitals. Policy and surge planning improvements may be needed to mitigate the effects of these changes.
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Affiliation(s)
- Anna M. Cushing
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Emily M. Bucholz
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Alyna T. Chien
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Daniel A. Rauch
- Division of Pediatric Hospital Medicine, Tufts Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts
| | - Kenneth A. Michelson
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
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Gallagher JJ, Adamski J. Mass Casualties and Disaster Implications for the Critical Care Team. AACN Adv Crit Care 2021; 32:76-88. [PMID: 33725109 DOI: 10.4037/aacnacc2021235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Preparing for disasters both natural and anthropogenic requires assessment of risk through hazard vulnerability analysis and formulation of facility and critical care-specific disaster plans. Disaster surge conditions often require movement from conventional to contingency or crisis-level operations to meet the needs of the many under our care. Predisaster planning for modification of critical care space, staffing, and supplies is essential to successful execution of operations during a surge. Expansion of intensive care unit beds to nonconventional units such as perioperative areas, general care units, and even external temporary units may be necessary. Creative, tiered staffing models as well as just-in-time education of noncritical care clinicians and support staff are important to multiply capable personnel under surge conditions. Finally, anticipation of demand for key equipment and supplies is essential to maintain stockpiles, establish supply chains, and sustain operations under prolonged disaster scenarios.
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Affiliation(s)
- John J Gallagher
- John J. Gallagher is Professor, Department of Acute & Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15213
| | - Jennifer Adamski
- Jennifer Adamski is Adult-Gerontology Acute Care Nurse Practitioner Program Director and Assistant Professor, Emory University, Atlanta, GA; and Critical Care Nurse Practitioner, Critical Care Flight Team, Cleveland Clinic, Cleveland, Ohio
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Hamele M, Neumayer K, Sweney J, Poss WB. Always ready, always prepared-preparing for the next pandemic. Transl Pediatr 2018; 7:344-355. [PMID: 30460186 PMCID: PMC6212382 DOI: 10.21037/tp.2018.09.06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A future global pandemic is likely to occur and planning for the care of critically ill children is less robust than that for adults. This review covers the current state of federal and regional resources for pediatric care in pandemics, a strategy for pandemic preparation in pediatric intensive care units and regions focusing on stuff, space, staff and systems, considerations in developing surge capacity and triage protocols, special circumstances such as highly infectious and highly lethal pandemics, and a discussion of ethics in the setting of pediatric critical care in a pandemic.
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Affiliation(s)
- Mitchell Hamele
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, USA
| | - Katie Neumayer
- Division of Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jill Sweney
- Division of Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - W Bradley Poss
- Division of Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
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Pediatric Triage in a Severe Pandemic: Maximizing Survival by Establishing Triage Thresholds. Crit Care Med 2017; 44:1762-8. [PMID: 27071069 DOI: 10.1097/ccm.0000000000001759] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To develop and validate an algorithm to guide selection of patients for pediatric critical care admission during a severe pandemic when Crisis Standards of Care are implemented. DESIGN Retrospective observational study using secondary data. PATIENTS Children admitted to VPS-participating PICUs between 2009-2012. INTERVENTIONS A total of 111,174 randomly selected nonelective cases from the Virtual PICU Systems database were used to estimate each patient's probability of death and duration of ventilation employing previously derived predictive equations. Using real and projected statistics for the State of Ohio as an example, triage thresholds were established for casualty volumes ranging from 5,000 to 10,000 for a modeled pandemic with peak duration of 6 weeks and 280 pediatric intensive care beds. The goal was to simultaneously maximize casualty survival and bed occupancy. Discrete Event Simulation was used to determine triage thresholds for probability of death and duration of ventilation as a function of casualty volume and the total number of available beds. Simulation was employed to compare survival between the proposed triage algorithm and a first come first served distribution of scarce resources. MEASUREMENTS AND MAIN RESULTS Population survival was greater using the triage thresholds compared with a first come first served strategy. In this model, for five, six, seven, eight, and 10 thousand casualties, the triage algorithm increased the number of lives saved by 284, 386, 547, 746, and 1,089, respectively, compared with first come first served (all p < 0.001). CONCLUSIONS Use of triage thresholds based on probability of death and duration of mechanical ventilation determined from actual critically ill children's data demonstrated superior population survival during a simulated overwhelming pandemic.
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Morton MJ, DeAugustinis ML, Velasquez CA, Singh S, Kelen GD. Developments in Surge Research Priorities: A Systematic Review of the Literature Following the Academic Emergency Medicine Consensus Conference, 2007-2015. Acad Emerg Med 2015; 22:1235-52. [PMID: 26531863 DOI: 10.1111/acem.12815] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 07/13/2015] [Accepted: 07/04/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In 2006, Academic Emergency Medicine (AEM) published a special issue summarizing the proceedings of the AEM consensus conference on the "Science of Surge." One major goal of the conference was to establish research priorities in the field of "disasters" surge. For this review, we wished to determine the progress toward the conference's identified research priorities: 1) defining criteria and methods for allocation of scarce resources, 2) identifying effective triage protocols, 3) determining decision-makers and means to evaluate response efficacy, 4) developing communication and information sharing strategies, and 5) identifying methods for evaluating workforce needs. METHODS Specific criteria were developed in conjunction with library search experts. PubMed, Embase, Web of Science, Scopus, and the Cochrane Library databases were queried for peer-reviewed articles from 2007 to 2015 addressing scientific advances related to the above five research priorities identified by AEM consensus conference. Abstracts and foreign language articles were excluded. Only articles with quantitative data on predefined outcomes were included; consensus panel recommendations on the above priorities were also included for the purposes of this review. Included study designs were randomized controlled trials, prospective, retrospective, qualitative (consensus panel), observational, cohort, case-control, or controlled before-and-after studies. Quality assessment was performed using a standardized tool for quantitative studies. RESULTS Of the 2,484 unique articles identified by the search strategy, 313 articles appeared to be related to disaster surge. Following detailed text review, 50 articles with quantitative data and 11 concept papers (consensus conference recommendations) addressed at least one AEM consensus conference surge research priority. Outcomes included validation of the benchmark of 500 beds/million of population for disaster surge capacity, effectiveness of simulation- and Internet-based tools for forecasting of hospital and regional demand during disasters, effectiveness of reverse triage approaches, development of new disaster surge metrics, validation of mass critical care approaches (altered standards of care), use of telemedicine, and predictions of optimal hospital staffing levels for disaster surge events. Simulation tools appeared to provide some of the highest quality research. CONCLUSION Disaster simulation studies have arguably revolutionized the study of disaster surge in the intervening years since the 2006 AEM Science of Surge conference, helping to validate some previously known disaster surge benchmarks and to generate new surge metrics. Use of reverse triage approaches and altered standards of care, as well as Internet-based tools such as Google Flu Trends, have also proven effective. However, there remains significant work to be done toward standardizing research methodologies and outcomes, as well as validating disaster surge metrics.
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Affiliation(s)
- Melinda J. Morton
- Department of Emergency Medicine; Johns Hopkins University School of Medicine; Baltimore MD
- Center for Refugee and Disaster Response; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- National Center for the Study of Critical Event Preparedness and Response; Johns Hopkins University; Baltimore MD
| | | | - Christina A. Velasquez
- Department of Emergency Medicine; Johns Hopkins University School of Medicine; Baltimore MD
| | - Sonal Singh
- Department of Medicine Division of General and Internal Medicine; Johns Hopkins University School of Medicine; Baltimore MD
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- Department of Public Health and Human Rights; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Gabor D. Kelen
- Department of Emergency Medicine; Johns Hopkins University School of Medicine; Baltimore MD
- National Center for the Study of Critical Event Preparedness and Response; Johns Hopkins University; Baltimore MD
- Johns Hopkins Office of Critical Event Preparedness and Response; Johns Hopkins University; Baltimore MD
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Hick JL, Einav S, Hanfling D, Kissoon N, Dichter JR, Devereaux AV, Christian MD. Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2015; 146:e1S-e16S. [PMID: 25144334 DOI: 10.1378/chest.14-0733] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This article provides consensus suggestions for expanding critical care surge capacity and extension of critical care service capabilities in disasters or pandemics. It focuses on the principles and frameworks for expansion of intensive care services in hospitals in the developed world. A companion article addresses surge logistics, those elements that provide the capability to deliver mass critical care in disaster events. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with injured or critically ill multiple patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify evidence on which to base key suggestions. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force were also included for validation by the expert panel. RESULTS This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care, including the role of critical care in disaster planning; the surge continuum; targets of surge response; situational awareness and information sharing; mitigating the impact on critical care; planning for the care of special populations; and service deescalation/cessation (also considered as engineered failure). CONCLUSIONS Future reports on critical care surge should emphasize population-based outcomes as well as logistical details. Planning should be based on the projected number of critically ill or injured patients resulting from specific scenarios. This should include a consideration of ICU patient care requirements over time and must factor in resource constraints that may limit the ability to provide care. Standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and used in disaster events.
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Pediatric triage and allocation of critical care resources during disaster: Northwest provider opinion. Prehosp Disaster Med 2014; 29:455-60. [PMID: 25247776 DOI: 10.1017/s1049023x14000909] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Following Hurricane Katrina and the 2009 H1N1 epidemic, pediatric critical care clinicians recognized the urgent need for a standardized pediatric triage/allocation system. This study collected regional provider opinion on issues of care allocation and pediatric triage in a disaster/pandemic setting. METHODS This study was a cross-sectional survey of United States (US) health care providers and public health workers who demonstrated interest in critical care and/or disaster care medicine by attending a Northwest regional pediatric critical care symposium on disaster preparation, held in 2012 at Seattle Children's Hospital in Seattle, Washington (USA). The survey employed an electronic audience response system and included demographic, ethical, and logistical questions. Differences in opinions between respondents grouped by professions and work locations were evaluated using a chi-square test. RESULTS One hundred and twelve (97%) of 116 total attendees responded to at least one question; however, four of these responders failed to answer every question. Sixty-two (55%) responders were nurses, 29 (26%) physicians, and 21 (19%) other occupations. Fifty-five (51%) responders worked in pediatric hospitals vs 53 (49%) in other locations. Sixty-three (58%) of 108 successful responses prioritized children predicted to have a good neuro-cognitive outcome. Seventy-one (68%) agreed that no pediatric age group should be prioritized. Twenty-two (43%) of providers working in non-pediatric hospital locations preferred a triage system based on an objective score alone vs 14 (26%) of those in pediatric hospitals (P = .038).
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Goodhue CJ, Lin AC, Burke RV, Berg BM, Upperman JS. Consider the children: pediatric disaster planning. Nurs Manag (Harrow) 2013; 44:44-51. [PMID: 24157805 DOI: 10.1097/01.numa.0000432222.09629.df] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Catherine J Goodhue
- At the Children's Hospital Los Angeles (Calif.), Catherine J. Goodhue is the research program manager of Pediatric Surgery, Ann Lin is the program assistant for the Trauma Program, Rita V. Burke is the senior research associate of Pediatric Surgery, Bridget M. Berg is the administrative manager at the Pediatric Disaster Resource and Training Center, and Jeffrey S. Upperman is the director of the Trauma Program and Pediatric Disaster Resource and Training Center and an associate professor of surgery at the University of Southern California's Keck School of Medicine, Los Angeles
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Sills MR, Hall M, Fieldston ES, Hain PD, Simon HK, Brogan TV, Fagbuyi DB, Mundorff MB, Shah SS. Inpatient capacity at children's hospitals during pandemic (H1N1) 2009 outbreak, United States. Emerg Infect Dis 2012; 17:1685-91. [PMID: 21888795 PMCID: PMC3320222 DOI: 10.3201/eid1709.101950] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Marion R Sills
- University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Barfield WD, Krug SE, Kanter RK, Gausche-Hill M, Brantley MD, Chung S, Kissoon N. Neonatal and pediatric regionalized systems in pediatric emergency mass critical care. Pediatr Crit Care Med 2011; 12:S128-34. [PMID: 22067921 PMCID: PMC4561175 DOI: 10.1097/pcc.0b013e318234a723] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Improved health outcomes are associated with neonatal and pediatric critical care in well-organized, cohesive, regionalized systems that are prepared to support and rehabilitate critically ill victims of a mass casualty event. However, present systems lack adequate surge capacity for neonatal and pediatric mass critical care. In this document, we outline the present reality and suggest alternative approaches. METHODS In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. TASK FORCE RECOMMENDATIONS States and regions (facilitated by federal partners) should review current emergency operations and devise appropriate plans to address the population-based needs of infants and children in large-scale disasters. Action at the state, regional, and federal levels should address legal, operational, and information systems to provide effective pediatric mass critical care through: 1) predisaster/mass casualty planning, management, and assessment with input from child health professionals; 2) close cooperation, agreements, public-private partnerships, and unique delivery systems; and 3) use of existing public health data to assess pediatric populations at risk and to model graded response plans based on increasing patient volume and acuity.
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Affiliation(s)
- Wanda D Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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