DISCUSSION
This multicenter survey was performed to assess the characteristics of critical care organization for children with cancer across Europe. The general PICU organization appeared fairly comparable among the participating countries with the 24/7 presence of an intensivist, use of general PICU protocols, nurse-to-bed ratio, and available PICU resources. Half of the participating centers had ECMO facilities. Almost all centers were able to administer chemotherapy in PICU and had daily rounds of the oncologists at the PICU. However, a low number of centers has oncology specific PICU protocols, joint mortality-morbidity, complex-case discussions, and participation of parents in daily rounds.
ICU size was equally distributed within the total group, with a median of 12 beds per PICU. Albeit the range was from 3- 50 beds, this is comparable with previous studies carried out in Europe and the USA.10,12,13,15 The total number of annual PICU admissions differed more between the different countries varying from 150 admissions in Poland to 755 in the UK. At the same time, annual PICU admissions of oncology and HSCT patients were similar between the different regions.
Patients with cancer represent among the most complex patient populations in medicine [16], and acute critical illness adds additional complexity. Given the improving survival rates alongside advances in therapeutic options, more pediatric cancer patients are expected to require advanced life support for cancer-related complications, treatment-related toxicities, and severe infections. Specialization in other critical care areas such cardiac ICU (CICU) has been well established and recognized followed by improved outcome. Therefore, development of dedicated oncological PICUs or further specialization in critical care oncology may need to be explored. So far, no studies have enlightened the effect of differences in organizational structure and processes of care, hospital and PICU case volume, multidisciplinary approach, availability of supporting services such palliative care services on pediatric cancer patient outcomes.
In 71% of the participating PICUs in our survey, there were 24/7 in-house intensivists, which is comparable to a previous European PICU survey in 2000.13 There are multiple studies showing improved outcomes with 24h in-hospital pediatric critical care physician.17,18 In some countries, 50% of the PICUs medical staff was not pediatric intensivists. This could partly be explained by some traditions of anesthesiologist leading ICUs or joint NICU/PICUs or adult ICU/PICU.19 In our survey, the nurse-to-bed ratio in most PICUs was 1:1 or 1:2, which is in line with the ratios found in a large survey among PICUs in the USA.12 In adults, it has been shown that a higher nurse staffing was associated with improved survival.20 An increase of the nurse-to-bed ratio from 1:2 to 1:1,5 was associated with a 1.8% decrease in mortality. No data are available on associations of nurse-to-bed-ratio with survival of pediatric ICU patients.
As has been shown in adult cancer patients, close collaboration between oncologists and intensivists for care planning and the joint setting of daily goals were independently associated with lower hospital mortality and more efficient ICU resource use.11 In our survey, daily rounds of the oncologist at the PICU were documented in 93% of the participating centers. Setting or changing goals of care took place both at the PICU and the ward in almost 2/3 of the centers, and often the PICU consultants were involved in these goals of care discussions. The co-location of the PICU and oncology wards in 97% of the participating centers may have facilitated communication amongst the PICU physicians and oncologists. Nowadays, participation of parents in daily rounds is advocated. Parental involvement in multidisciplinary rounds in pediatrics is associated with shortened stays, earlier discharges, reduced costs, and improved provider satisfaction.21,22 In 43% centers of the participating centers, parents participate in clinical rounds. Implementing standardized process for multidisciplinary rounds, including the presence of parents, may improve communication amongst the healthcare team, facilitate dialogue between patients’ families and the healthcare team, and reduce safety events.23
Co-location of oncology ward and PICU also allows for timely review of clinically deteriorating patients. The outcome of critically ill patients with cancer is in part determined by timely recognition of clinical deterioration and the treatment they received before their PICU admission. Physicians and nurses who take care of cancer patients should therefore be skilled at detecting warning signs of clinical deterioration and be familiar with the essential therapeutic measures needed. Medical emergency teams that are staffed by members of the critical care team may support the teams on the ward with identifying and managing deteriorating patients and may facilitate the transition to PICU. Rapid response teams and cardiac arrest teams were present in 75-80% of the hospitals – both mostly occupied with pediatric intensivists (60%) and otherwise staffed with anesthetists, adult intensivist, senior or junior pediatricians, and PICU nurses. In 10 centers there were daily rounds of PICU physicians at the oncology and HSCT wards. Surprisingly, only 40% of the participating centers were using an early warning score. There is some evidence showing significant benefits from PEWS on patients’ outcome while others fail to depict the same beneficial outcome benefits.24-27 A recent systematic review shows that there is still a gap of knowledge in both predictive performance and impact of PEWS in the high-risk population of pediatric oncology patients.28
Palliative care is a key component of comprehensive care for patients with cancer and should be an essential collaborator to PICU care.29 Eighty-five percent of the centers have a palliation service. Psychology service for patients and/or parents was available in 98% of the participating centers. However, in only 63% of centers, psychology service was available for the staff members. One aspect of critical care for patients with cancer that is often overlooked is the impact on the health care providers taking care of the patients with cancer. The ICU environment is stressful not only for patients but also for the ICU staff. Caring for patients with cancer often presents critical care teams with unique medical and ethical challenges that can lead to conflict, moral distress, and burnout.30-32 Perceived inappropriateness of ICU care can cause job dissatisfaction in ICU nurses and physicians.33
Our study has several important limitations. Due to incomplete response from PICU units across Europe and the survey originating in the POKER network a higher percentage of participation in hospitals with pediatric oncology could potentially induce selection bias. There is also risk of less participation from minor units as not all pediatric intensivists are ESPNIC members or receive ESPNIC correspondence.34For example, Poland was the only country from eastern Europe participating in the survey. As we included 77 units out of a total of 226 PICUs in the participating European countries, it is highly likely that this may limit the external validity of this study. Finally, we surveyed general characteristics of onco-critical care, but we did not assess severity of illness scores, patient outcomes, or resource use in the PICU. We acknowledge that in-depth information is needed to determine whether differences in care are associated with short and long-term outcomes, and more efficient resource utilization. Further analysis of key factors in structure and organization may thus help us to improve overall quality of care for the oncology patients in the pediatric ICU.
This is the first cross-sectional study depicting size, workflow, attending staff, service provisions, and resources of European PICUs with focus on patients with underlying malignancies. Albeit size, staffing and service provisions seems comparable there is also variation, especially regarding multidisciplinary care. In addition to providing optimal care to critically ill patients, multidisciplinary teams offer the ideal platform to perform multidisciplinary research which is required to achieve significant improvements in the care of critically ill pediatric patients with cancer.35Future studies should address severity illness across European PICUs to determine baseline comparability and the effect of the differences found in the delivery of care on patient outcomes and ICU resource use.