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.