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Ettinger NA, Hill VL, Russ CM, Rakoczy KJ, Fallat ME, Wright TN, Choong K, Agus MSD, Hsu B, Mack E, Day S, Lowrie L, Siegel L, Srinivasan V, Gadepalli S, Hirshberg EL, Kissoon N, October T, Tamburro RF, Rotta A, Tellez S, Rauch DA, Ernst K, Vinocur C, Lam VT, Romito B, Hanson N, Gigli KH, Mauro M, Leonard MS, Alexander SN, Davidoff A, Besner GE, Browne M, Downard CD, Gow KW, Islam S, Saunders Walsh D, Williams RF, Thorne V. Guidance for Structuring a Pediatric Intermediate Care Unit. Pediatrics 2022; 149:186777. [PMID: 35490284 DOI: 10.1542/peds.2022-057009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.
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Affiliation(s)
- Nicholas A Ettinger
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Vanessa L Hill
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine/The Children's Hospital of San Antonio, San Antonio, Texas
| | - Christiana M Russ
- Intermediate Care Program.,Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine J Rakoczy
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Tuft's Children's Hospital, Boston, Massachusetts
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Karen Choong
- Division of Critical Care, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Michael S D Agus
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Benson Hsu
- Division of Critical Care, Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
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Neonatal sepsis definitions from randomised clinical trials. Pediatr Res 2021; 93:1141-1148. [PMID: 34743180 PMCID: PMC10132965 DOI: 10.1038/s41390-021-01749-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Neonatal sepsis is a leading cause of infant mortality worldwide with non-specific and varied presentation. We aimed to catalogue the current definitions of neonatal sepsis in published randomised controlled trials (RCTs). METHOD A systematic search of the Embase and Cochrane databases was performed for RCTs which explicitly stated a definition for neonatal sepsis. Definitions were sub-divided into five primary criteria for infection (culture, laboratory findings, clinical signs, radiological evidence and risk factors) and stratified by qualifiers (early/late-onset and likelihood of sepsis). RESULTS Of 668 papers screened, 80 RCTs were included and 128 individual definitions identified. The single most common definition was neonatal sepsis defined by blood culture alone (n = 35), followed by culture and clinical signs (n = 29), and then laboratory tests/clinical signs (n = 25). Blood culture featured in 83 definitions, laboratory testing featured in 48 definitions while clinical signs and radiology featured in 80 and 8 definitions, respectively. DISCUSSION A diverse range of definitions of neonatal sepsis are used and based on microbiological culture, laboratory tests and clinical signs in contrast to adult and paediatric sepsis which use organ dysfunction. An international consensus-based definition of neonatal sepsis could allow meta-analysis and translate results to improve outcomes.
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Cheng DR, Hui C, Langrish K, Beck CE. Anticipating Pediatric Patient Transfers From Intermediate to Intensive Care. Hosp Pediatr 2021; 10:347-352. [PMID: 32220935 DOI: 10.1542/hpeds.2019-0260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To explore characteristics of patients who were admitted to the intermediate care (IC) unit at a tertiary academic institution. In particular, we sought to compare the characteristics of IC patients who were transferred with the characteristics of those who were not transferred to PICU care and evaluate predictors of patient transfer. METHODS Data were collected on all admitted IC patients between July 2016 and June 2018. Patients whose index IC admission was from the PICU were excluded. Data collected included demographics and physiologic characteristics: heart rate, respiratory rate, temperature, oxygen therapy, as well as Bedside Pediatric Early Warning System (BPEWS) score. RESULTS In this time period, 427 eligible patient visits occurred, with 66 patients (15.46%) being transferred to the PICU. Patients were commonly transferred early in their IC course (1.41 days into admission [0.66-3.87]); transferred patients had higher median admission BPEWS scores (7 [4.25-9] vs 5 [3-7]; P < .01). In the univariate analysis, no individual physiologic characteristic was predictive for transfer. In the multivariate analysis, BPEWS (P < .001) and need for any form of respiratory support (P = .04) were significant predictive factors for transfer (R 2 = 0.56). CONCLUSIONS The need for close monitoring of physiologic parameters remains paramount, especially in the first 48 hours of admission, in predicting the need for transfer from the IC to PICU. The need for any form of respiratory support is predictive of transfer. Situational awareness and assessment including BPEWS score is of critical importance.
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Affiliation(s)
- Daryl R Cheng
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; .,Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Carlton, Victoria, Australia; and
| | | | - Kate Langrish
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
| | - Carolyn E Beck
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics.,Pediatric Outcomes Research Team and
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Lewis KM, Parekh SM, Ramnarayan P, Gilbert R, Hardelid P, Wijlaars L. Emergency paediatric critical care in England: describing trends using routine hospital data. Arch Dis Child 2020; 105:1061-1067. [PMID: 32444447 PMCID: PMC7588403 DOI: 10.1136/archdischild-2019-317902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 03/10/2020] [Accepted: 04/10/2020] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To determine trends in emergency admission rates requiring different levels of critical care in hospitals with and without a paediatric intensive care unit (PICU). DESIGN Birth cohort study created from Hospital Episode Statistics. SETTING National Health Service funded hospitals in England. PATIENTS 8 577 680 singleton children born between 1 May 2003 and 31 April 2017. OUTCOME MEASURES Using procedure and diagnostic codes, we assigned indicators of high dependency care (eg, non-invasive ventilation) or intensive care (eg, invasive ventilation) to emergency admissions. INTERVENTIONS Children were followed up until their fifth birthday to estimate high dependency and intensive care admission rates in hospitals with and without a PICU. We tested the yearly trend of high dependency and intensive care admissions to hospitals without a PICU using logistic regression models. RESULTS Emergency admissions requiring high dependency care in hospitals without a PICU increased from 3.30 (95% CI 3.09 to 3.51) per 10 000 child-years in 2008/2009 to 7.58 (95% CI 7.28 to 7.89) in 2016/2017 and overtook hospitals with a PICU in 2015/2016. The odds of an admission requiring high dependency care to a hospital without a PICU compared with a hospital with a PICU increased by 9% per study year (OR 1.09, 95% CI 1.08 to 1.10). The same trend was not present for admissions requiring intensive care (OR 1.01, 95% CI 0.99 to 1.03). CONCLUSIONS Between 2008/2009 and 2016/2017, an increasing proportion of admissions with indicators of high dependency care took place in hospitals without a PICU.
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Affiliation(s)
- Kate Marie Lewis
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sanjay M Parekh
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK,Children and Families Policy Research Unit, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Ruth Gilbert
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK,Children and Families Policy Research Unit, UCL Great Ormond Street Institute of Child Health, London, UK,Health Data Research UK, London, UK
| | - Pia Hardelid
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Linda Wijlaars
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK,Children and Families Policy Research Unit, UCL Great Ormond Street Institute of Child Health, London, UK
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Barriers and Enablers to Implementing a High-Dependency Care Model in Pediatric Care: A Preimplementation Study. J Nurs Care Qual 2019; 34:370-375. [PMID: 30889080 DOI: 10.1097/ncq.0000000000000398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND As the level of acuity of pediatric hospital admissions continues to increase, additional pressure is being placed on hospital resources and the nursing workforce. LOCAL PROBLEM Currently, there is no formalized approach to care for high-acuity patients on our pediatric inpatient unit. METHODS We used a qualitative descriptive design, guided by the Theoretical Domains Framework and Capability, Opportunity, Motivation-Behaviour (COM-B) model, to conduct focus groups and interviews with clinicians and administrators to identify potential barriers and enablers to implementing a high-dependency care (HDC) model. An HDC model focuses on the relationship between adequate nursing staff resources and patient acuity to improve patient health outcomes. RESULTS Participants identified the need for clear guidelines and supportive physical structures to facilitate HDC implementation. Anticipated benefits included enhanced nursing confidence and family-centered care. CONCLUSIONS Study findings highlight multilevel factors to consider prior to implementing an HDC model on a pediatric inpatient unit.
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Thangaratinam S, Allotey J, Marlin N, Dodds J, Cheong-See F, von Dadelszen P, Ganzevoort W, Akkermans J, Kerry S, Mol BW, Moons KGM, Riley RD, Khan KS. Prediction of complications in early-onset pre-eclampsia (PREP): development and external multinational validation of prognostic models. BMC Med 2017; 15:68. [PMID: 28356148 PMCID: PMC5372261 DOI: 10.1186/s12916-017-0827-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/23/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Unexpected clinical deterioration before 34 weeks gestation is an undesired course in early-onset pre-eclampsia. To safely prolong preterm gestation, accurate and timely prediction of complications is required. METHOD Women with confirmed early onset pre-eclampsia were recruited from 53 maternity units in the UK to a large prospective cohort study (PREP-946) for development of prognostic models for the overall risk of experiencing a complication using logistic regression (PREP-L), and for predicting the time to adverse maternal outcome using a survival model (PREP-S). External validation of the models were carried out in a multinational cohort (PIERS-634) and another cohort from the Netherlands (PETRA-216). Main outcome measures were C-statistics to summarise discrimination of the models and calibration plots and calibration slopes. RESULTS A total of 169 mothers (18%) in the PREP dataset had adverse outcomes by 48 hours, and 633 (67%) by discharge. The C-statistics of the models for predicting complications by 48 hours and by discharge were 0.84 (95% CI, 0.81-0.87; PREP-S) and 0.82 (0.80-0.84; PREP-L), respectively. The PREP-S model included maternal age, gestation, medical history, systolic blood pressure, deep tendon reflexes, urine protein creatinine ratio, platelets, serum alanine amino transaminase, urea, creatinine, oxygen saturation and treatment with antihypertensives or magnesium sulfate. The PREP-L model included the above except deep tendon reflexes, serum alanine amino transaminase and creatinine. On validation in the external PIERS dataset, the reduced PREP-S model showed reasonable calibration (slope 0.80) and discrimination (C-statistic 0.75) for predicting adverse outcome by 48 hours. Reduced PREP-L model showed excellent calibration (slope: 0.93 PIERS, 0.90 PETRA) and discrimination (0.81 PIERS, 0.75 PETRA) for predicting risk by discharge in the two external datasets. CONCLUSIONS PREP models can be used to obtain predictions of adverse maternal outcome risk, including early preterm delivery, by 48 hours (PREP-S) and by discharge (PREP-L), in women with early onset pre-eclampsia in the context of current care. They have a potential role in triaging high-risk mothers who may need transfer to tertiary units for intensive maternal and neonatal care. TRIAL REGISTRATION ISRCTN40384046 , retrospectively registered.
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Affiliation(s)
- Shakila Thangaratinam
- Women’s Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Multidisciplinary Evidence Synthesis Hub (mEsh), Queen Mary University of London, London, UK
| | - John Allotey
- Women’s Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Multidisciplinary Evidence Synthesis Hub (mEsh), Queen Mary University of London, London, UK
| | - Nadine Marlin
- Pragmatic Clinical Trials Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Julie Dodds
- Women’s Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Multidisciplinary Evidence Synthesis Hub (mEsh), Queen Mary University of London, London, UK
| | - Fiona Cheong-See
- Women’s Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Multidisciplinary Evidence Synthesis Hub (mEsh), Queen Mary University of London, London, UK
| | - Peter von Dadelszen
- Institute of Cardiovascular and Cell Sciences, St George’s, University of London, London, UK
| | - Wessel Ganzevoort
- Departments of Obstetrics and Gynecology, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Joost Akkermans
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sally Kerry
- Pragmatic Clinical Trials Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Ben W. Mol
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
- The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Karl G. M. Moons
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Richard D. Riley
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire UK
| | - Khalid S. Khan
- Women’s Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Multidisciplinary Evidence Synthesis Hub (mEsh), Queen Mary University of London, London, UK
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Curtis P, Northcott A. The impact of single and shared rooms on family-centred care in children's hospitals. J Clin Nurs 2017; 26:1584-1596. [DOI: 10.1111/jocn.13485] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 01/18/2023]
Affiliation(s)
- Penny Curtis
- School of Nursing and Midwifery; University of Sheffield; Sheffield UK
| | - Andy Northcott
- School of Healthcare Sciences; Cardiff University; Cardiff UK
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