Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness
Rachel Troch1, Jamie Schwartz2, Renee Boss2,3
1Department of Neonatology, Children's National Hospital, Washington, District of Columbia, United States.
Insights
Children with chronic critical illness (CCI) in the intensive care unit (ICU) may benefit from slower, more consistent care. Frequent treatment changes may prolong their recovery and ICU stays, highlighting a need for further pediatric research.
Area of Science:
- Pediatric critical care medicine
- Healthcare management
- Systematic review methodology
Background:
- A growing number of children experience prolonged intensive care unit (ICU) hospitalizations, leading to chronic critical illness (CCI).
- Current ICU acute care models may not align with the specific, long-term needs of pediatric CCI patients.
- Frequent treatment alterations in the ICU are anecdotally linked to disrupted recovery and extended ICU stays for these children.
Purpose of the Study:
- To systematically review and summarize existing literature on the pace and consistency of ICU care for pediatric patients with CCI.
- To identify gaps in knowledge regarding chronic critical illness management in pediatric ICUs.
- To explore the potential impact of care pacing on patient outcomes and healthcare utilization.
Main Methods:
- Systematic literature review conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
- Searched major databases including PubMed, EMBASE, and CINAHL for English-language studies.
- Included studies focusing on chronic critical illness (CCI), ICU care models, and clinical management pacing in pediatric populations.
Main Results:
- A scarcity of high-quality research specifically addressing chronic critical illness management in pediatric ICUs was identified.
- All reviewed papers acknowledged the distinct care requirements of chronic patients, especially concerning respiratory management.
- Evidence suggests that rapid treatment changes may hinder recovery and prolong ICU length of stay for children with CCI.
Conclusions:
- The current literature supports the hypothesis that protocols promoting reduced interdisciplinary variability and slower management pacing warrant investigation for pediatric CCI patients.
- Optimizing ICU care value necessitates aligning resources with patient needs, particularly for high-resource-utilizing populations like pediatric CCI.
- Further research into a "slow and steady" approach to ICU management is recommended to improve outcomes for children with chronic critical illness.
Abstract:
There is a growing population of children with prolonged intensive care unit (ICU) hospitalization. These children with chronic critical illness (CCI) have a high health care utilization. Emerging data suggest a mismatch between the ICU acute care models and the daily care needs of these patients. Clinicians and parents report that the frequent treatment alterations typical for ICU care may be interrupting and jeopardizing the slow recoveries typical for children with CCI. These frequent treatment titrations could therefore be prolonging ICU stays even further. The aim of this study is to evaluate and summarize existing literature regarding pace and consistency of ICU care for patients with CCI. We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (of September 2018). PubMed (biomedical and life sciences literature), Excerpta Medica database (EMBASE), and The Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for English-language studies with data about CCI, care models, and pacing of clinical management. Four unique papers were identified. Our most important finding was that quality data on chronic ICU management, particularly for children, is sparse. All papers in this review confirmed the unique needs of chronic patients, particularly related to respiratory management, which is a common driver of ICU length of stay. Taken together, the papers support the hypothesis that protocols to reduce interdisciplinary management variability and to allow for slower management pacing should be studied for their impact on patient and health system outcomes. Optimizing value in ICU care requires mapping of resources to patient needs, particularly for patients with the most intense resource utilization. For children with CCI, parents and clinicians report that rapid treatment changes undermine recovery and prolong ICU stays. This review highlights the lack of quality pediatric research in this area and supports further investigation of a "slow and steady" approach to ICU management for children with CCI.
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