Editorials
Who Should Get Pediatric Intensive Care When Not All Can? A Call for International Guidelines on Allocation of Pediatric Intensive Care Resources* Niranjan Kissoon, MD Division of Critical Care Medicine The University of British Columbia and BC Children’s Hospital Vancouver, BC, Canada Jeffrey Burns, MD, MPH Division of Critical Care Medicine Harvard University and Boston Children’s Hospital Boston, MA Mankind is not a circle with a single centre, but an ellipse with two focal points of which facts are one and ideas the other. —Victor Hugo
T
he facts are as follows: PICU services improve outcomes of critically ill children (1–3). Worldwide, many children who die have no access to PICUs (4, 5). The decision to admit a child to the PICU is not based on any uniformly accepted and applied criteria. When there are sufficient PICU beds, strict criteria are not necessary. However, limited beds and crisis standards of care which becomes a reality in the developed world only during pandemics and natural disasters is a daily reality for many of our colleagues worldwide including the PICU at Red Cross War Memorial Children’s Hospital (RCWMCH) (6, 7). In this issue of Pediatric Critical Care Medicine, Argent et al (8) discuss that some innovative ideas and solutions are therefore needed to guide allocation of these scarce resources. The PICU at RCWMCH in South Africa is a unique environment in which contemporary tertiary care including cardiothoracic and neonatal surgery, transplantation, and sophisticated vital organ support can be provided (8). However, the PICU exists in a milieu which includes townships
*See also p. 7. Key Words: children; critical illness; developing world; intensive care; resource allocation Dr. Burns’ institution received grant support from IBM, Genuine Interactive, and Lexicomp to develop an open-access, not-for-profit online education platform entitled OPENPediatrics. Dr. Kissoon has disclosed that he does not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000038
82
www.pccmjournal.org
with many patients plagued by poverty, poor transport systems, the inability to access emergency care, and “third world diseases,” such as sepsis complicated by malnutrition (9). These children present to RCWMCH in large numbers very late in the course of their disease and to the PICU in extremis. In this milieu, there is a daily struggle to determine “who gets the PICU bed.” Daily, clinicians are forced to balance the needs of the individual patient with those of the population a situation that places both those seeking care and those providing care under severe strain. Faced with almost 100% occupancy and patients needing PICU care, Argent et al (8) undertook a daunting task to determine who gets the bed in their PICU. They started by leveling out demands for elective surgical admissions using LEAN principles, reducing the length of stay by improved efficiency and reducing nosocomial infections. They then undertook a labor intensive and emotionally difficult process to formulate consistent criteria for admission that de-emphasized staff preferences. The model they used should be an example for others. In a series of meetings, they sought buy-in from all clinicians (nursing and medical staff of all specialties and referring physicians) and policy makers whose support will be needed for successful implementation. With adherence to sound principles of transparency, consistency, trust, equity, duty to provide care, and accountability, they were able to hammer out a series of criteria pertaining to those who will be admitted to the ICU and those who will be denied care. These guidelines are not perfect, and they revised admission criteria as patient outcomes and changing therapies dictated. They were also strategic and informed the Western Cape Department of Health of the downstream consequences of these policies including limited advances in healthcare and likely more deaths on wards in outlying areas; a clear message that likely short-term benefits should not preclude the long-term planning. Although the process is still evolving and outcome data are limited, it would seem that the program has yielded favorable outcomes in that there is enthusiastic engagement and no increase in hospital mortality. This program builds on innovative projects that have been enacted in other resource-poor environments. For instance, in Malawi, a reorganized emergency department to include appropriate triage and laboratory studies and protocols resulted in decreased mortality while attempts to prevent sepsis admission to the PICU is making inroads in conserving admission beds January 2014 • Volume 15 • Number 1
Editorials
(10, 11). In addition, Argent et al (8) also started the use of continuous positive-pressure ventilation on the wards, which may relieve PICU bed pressure and improve outcomes (12). Although these projects seem to give some hope that we can improve efficiency and throughput in the PICU without increasing morbidity or mortality, these are not easy to undertake. Even with the best laid plans, there are problematic issues. Argent et al (8) failed to appreciate the complexity of the process in that agonizing decisions had to be made with little evidence for the connection between diagnosis and outcomes, as well as what is acceptable risk when deciding whether a patient should be denied admission. In addition, the justification to provide ICU care when postICU care may not be available is also problematic (13). What have we learned from this endeavor and how do we leverage this experience? First, we must acknowledge that we make decisions about the allocation of Pediatric Intensive Care resources everyday regardless of our practice environment (14). For example, to accommodate the needs of sicker patients, we routinely transfer a patient out of the PICU even though that individual patient might still derive some small degree of benefit from ongoing monitoring. Those caring for critically ill children also routinely ration our time with each patient, balancing the needs of one patient against another. The reality of practice in PICUs is that patients are routinely denied some potential benefit—however small—through implicit allocation decisions made by physicians at the bedside. Furthermore, these decisions are necessary, unavoidable, and can be ethically justified, but such principles are best derived not by each individual clinician but by a thoughtful, structured hospital or community-wide process (15, 16) as was done by Argent et al (8). Second, we must seize the opportunity to build upon the work presented here by calling for a collaborative international effort to develop an explicit guideline around the allocation of pediatric intensive care resources that is sensitive to varying environments of care. Although reasonable people will have different views on a broadly accepted framework for allocating scarce lifesaving treatments, we believe that they can begin with agreement on some things that are not ethically justifiable: triage decisions should not be made on the basis of socioeconomic status, gender, race, or ethnicity; coexisting conditions that do not affect short-term prognosis should not bar consideration for allocation of life-sustaining resources; disabilities and handicaps should not be automatic barriers to receiving life-sustaining resources; and decisions should not be made covertly or in secret. The criteria for decisions and the process for making them should be transparent and publicly shared (17). A global effort will meld facts with ideas and goes a long way to ease the burden for our colleagues grappling in isolation with these
Pediatric Critical Care Medicine
difficult issues. The 7th World Congress on Pediatric Intensive and Critical Care, PICC 2014 in Istanbul, Turkey, presents a good opportunity to move this global discussion forward.
REFERENCES
1. Gilboa SM, Salemi JL, Nembhard WN, et al: Mortality resulting from congenital heart disease among children and adults in the United States, 1999 to 2006. Circulation 2010; 122:2254–2263 2. Kitchin OP, Masekela R, Becker P, et al: Outcome of human immunodeficiency virus-exposed and -infected children admitted to a pediatric intensive care unit for respiratory failure. Pediatr Crit Care Med 2012; 13:516–519 3. Namachivayam P, Shann F, Shekerdemian L, et al: Three decades of pediatric intensive care: Who was admitted, what happened in intensive care, and what happened afterward. Pediatr Crit Care Med 2010; 11:549–555 4. Baker T: Pediatric emergency and critical care in low-income countries. Paediatr Anaesth 2009; 19:23–27 5. Baker T: Critical care in low-income countries. Trop Med Int Health 2009; 14:143–148 6. Burkle FM Jr, Argent AC, Kissoon N; Task Force for Pediatric Emergency Mass Critical Care: The reality of pediatric emergency mass critical care in the developing world. Pediatr Crit Care Med 2011; 12:S169–S179 7. Stiff D, Kumar A, Kissoon N, et al: Potential pediatric intensive care unit demand/capacity mismatch due to novel pH1N1 in Canada. Pediatr Crit Care Med 2011; 12:e51–e57 8. Argent AC, Ahrens J, Morrow BM, et al: Pediatric Intensive Care in South Africa: An Account of Making Optimum Use of Limited Resources at the Red Cross War Memorial Children’s Hospital. Pediatr Crit Care Med 2014; 15:7–14 9. Kissoon N: Out of Africa–A mother’s journey. Pediatr Crit Care Med 2011; 12:73–79 10. Molyneux EM: Paediatric emergency care in resource-constrained health services is usually neglected: Time for change. Ann Trop Paediatr 2010; 30:165–176 11. Pollach G, Namboya F: Preventing intensive care admissions for sepsis in tropical Africa (PICASTA): An extension of the international pediatric global sepsis initiative: An African perspective. Pediatr Crit Care Med 2013; 14:561–570 12. Brown J, Machen H, Kawaza K, et al: A high-value, low-cost bubble continuous positive airway pressure system for low-resource settings: Technical assessment and initial case reports. PLoS One 2013; 8:e53622 13. Wiens MO, Kumbakumba E, Kissoon N, et al: Pediatric sepsis in the developing world: Challenges in defining sepsis and issues in postdischarge mortality. Clin Epidemiol 2012; 4:319–325 14. Truog RD, Brock DW, Cook DJ, et al; Task Force on Values, Ethics, and Rationing in Critical Care (VERICC): Rationing in the intensive care unit. Crit Care Med 2006; 34:958–963 15. White DB, Katz MH, Luce JM, et al: Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med 2009; 150:132–138 16. Scheunemann LP, White DB: The ethics and reality of rationing in medicine. Chest 2011; 140:1625–1632 17. Burns JP, Mitchell C: Resource allocation and triage in disasters and pandemics. In: Clinical Ethics in Pediatrics: A Case-Based Textbook. Diekema DS, Mercurio MR, Adam MB (Eds). Cambridge, UK: Cambridge University Press, 2011, pp 199–204
www.pccmjournal.org
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Who Should Get Pediatric Intensive Care When Not All Can? A Call for International Guidelines on Allocation of Pediatric Intensive Care Resources* Niranjan Kissoon, MD Division of Critical Care Medicine The University of British Columbia and BC Children’s Hospital Vancouver, BC, Canada Jeffrey Burns, MD, MPH Division of Critical Care Medicine Harvard University and Boston Children’s Hospital Boston, MA Mankind is not a circle with a single centre, but an ellipse with two focal points of which facts are one and ideas the other. —Victor Hugo
T
he facts are as follows: PICU services improve outcomes of critically ill children (1–3). Worldwide, many children who die have no access to PICUs (4, 5). The decision to admit a child to the PICU is not based on any uniformly accepted and applied criteria. When there are sufficient PICU beds, strict criteria are not necessary. However, limited beds and crisis standards of care which becomes a reality in the developed world only during pandemics and natural disasters is a daily reality for many of our colleagues worldwide including the PICU at Red Cross War Memorial Children’s Hospital (RCWMCH) (6, 7). In this issue of Pediatric Critical Care Medicine, Argent et al (8) discuss that some innovative ideas and solutions are therefore needed to guide allocation of these scarce resources. The PICU at RCWMCH in South Africa is a unique environment in which contemporary tertiary care including cardiothoracic and neonatal surgery, transplantation, and sophisticated vital organ support can be provided (8). However, the PICU exists in a milieu which includes townships
*See also p. 7. Key Words: children; critical illness; developing world; intensive care; resource allocation Dr. Burns’ institution received grant support from IBM, Genuine Interactive, and Lexicomp to develop an open-access, not-for-profit online education platform entitled OPENPediatrics. Dr. Kissoon has disclosed that he does not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000038
82
www.pccmjournal.org
with many patients plagued by poverty, poor transport systems, the inability to access emergency care, and “third world diseases,” such as sepsis complicated by malnutrition (9). These children present to RCWMCH in large numbers very late in the course of their disease and to the PICU in extremis. In this milieu, there is a daily struggle to determine “who gets the PICU bed.” Daily, clinicians are forced to balance the needs of the individual patient with those of the population a situation that places both those seeking care and those providing care under severe strain. Faced with almost 100% occupancy and patients needing PICU care, Argent et al (8) undertook a daunting task to determine who gets the bed in their PICU. They started by leveling out demands for elective surgical admissions using LEAN principles, reducing the length of stay by improved efficiency and reducing nosocomial infections. They then undertook a labor intensive and emotionally difficult process to formulate consistent criteria for admission that de-emphasized staff preferences. The model they used should be an example for others. In a series of meetings, they sought buy-in from all clinicians (nursing and medical staff of all specialties and referring physicians) and policy makers whose support will be needed for successful implementation. With adherence to sound principles of transparency, consistency, trust, equity, duty to provide care, and accountability, they were able to hammer out a series of criteria pertaining to those who will be admitted to the ICU and those who will be denied care. These guidelines are not perfect, and they revised admission criteria as patient outcomes and changing therapies dictated. They were also strategic and informed the Western Cape Department of Health of the downstream consequences of these policies including limited advances in healthcare and likely more deaths on wards in outlying areas; a clear message that likely short-term benefits should not preclude the long-term planning. Although the process is still evolving and outcome data are limited, it would seem that the program has yielded favorable outcomes in that there is enthusiastic engagement and no increase in hospital mortality. This program builds on innovative projects that have been enacted in other resource-poor environments. For instance, in Malawi, a reorganized emergency department to include appropriate triage and laboratory studies and protocols resulted in decreased mortality while attempts to prevent sepsis admission to the PICU is making inroads in conserving admission beds January 2014 • Volume 15 • Number 1
Editorials
(10, 11). In addition, Argent et al (8) also started the use of continuous positive-pressure ventilation on the wards, which may relieve PICU bed pressure and improve outcomes (12). Although these projects seem to give some hope that we can improve efficiency and throughput in the PICU without increasing morbidity or mortality, these are not easy to undertake. Even with the best laid plans, there are problematic issues. Argent et al (8) failed to appreciate the complexity of the process in that agonizing decisions had to be made with little evidence for the connection between diagnosis and outcomes, as well as what is acceptable risk when deciding whether a patient should be denied admission. In addition, the justification to provide ICU care when postICU care may not be available is also problematic (13). What have we learned from this endeavor and how do we leverage this experience? First, we must acknowledge that we make decisions about the allocation of Pediatric Intensive Care resources everyday regardless of our practice environment (14). For example, to accommodate the needs of sicker patients, we routinely transfer a patient out of the PICU even though that individual patient might still derive some small degree of benefit from ongoing monitoring. Those caring for critically ill children also routinely ration our time with each patient, balancing the needs of one patient against another. The reality of practice in PICUs is that patients are routinely denied some potential benefit—however small—through implicit allocation decisions made by physicians at the bedside. Furthermore, these decisions are necessary, unavoidable, and can be ethically justified, but such principles are best derived not by each individual clinician but by a thoughtful, structured hospital or community-wide process (15, 16) as was done by Argent et al (8). Second, we must seize the opportunity to build upon the work presented here by calling for a collaborative international effort to develop an explicit guideline around the allocation of pediatric intensive care resources that is sensitive to varying environments of care. Although reasonable people will have different views on a broadly accepted framework for allocating scarce lifesaving treatments, we believe that they can begin with agreement on some things that are not ethically justifiable: triage decisions should not be made on the basis of socioeconomic status, gender, race, or ethnicity; coexisting conditions that do not affect short-term prognosis should not bar consideration for allocation of life-sustaining resources; disabilities and handicaps should not be automatic barriers to receiving life-sustaining resources; and decisions should not be made covertly or in secret. The criteria for decisions and the process for making them should be transparent and publicly shared (17). A global effort will meld facts with ideas and goes a long way to ease the burden for our colleagues grappling in isolation with these
Pediatric Critical Care Medicine
difficult issues. The 7th World Congress on Pediatric Intensive and Critical Care, PICC 2014 in Istanbul, Turkey, presents a good opportunity to move this global discussion forward.
REFERENCES
1. Gilboa SM, Salemi JL, Nembhard WN, et al: Mortality resulting from congenital heart disease among children and adults in the United States, 1999 to 2006. Circulation 2010; 122:2254–2263 2. Kitchin OP, Masekela R, Becker P, et al: Outcome of human immunodeficiency virus-exposed and -infected children admitted to a pediatric intensive care unit for respiratory failure. Pediatr Crit Care Med 2012; 13:516–519 3. Namachivayam P, Shann F, Shekerdemian L, et al: Three decades of pediatric intensive care: Who was admitted, what happened in intensive care, and what happened afterward. Pediatr Crit Care Med 2010; 11:549–555 4. Baker T: Pediatric emergency and critical care in low-income countries. Paediatr Anaesth 2009; 19:23–27 5. Baker T: Critical care in low-income countries. Trop Med Int Health 2009; 14:143–148 6. Burkle FM Jr, Argent AC, Kissoon N; Task Force for Pediatric Emergency Mass Critical Care: The reality of pediatric emergency mass critical care in the developing world. Pediatr Crit Care Med 2011; 12:S169–S179 7. Stiff D, Kumar A, Kissoon N, et al: Potential pediatric intensive care unit demand/capacity mismatch due to novel pH1N1 in Canada. Pediatr Crit Care Med 2011; 12:e51–e57 8. Argent AC, Ahrens J, Morrow BM, et al: Pediatric Intensive Care in South Africa: An Account of Making Optimum Use of Limited Resources at the Red Cross War Memorial Children’s Hospital. Pediatr Crit Care Med 2014; 15:7–14 9. Kissoon N: Out of Africa–A mother’s journey. Pediatr Crit Care Med 2011; 12:73–79 10. Molyneux EM: Paediatric emergency care in resource-constrained health services is usually neglected: Time for change. Ann Trop Paediatr 2010; 30:165–176 11. Pollach G, Namboya F: Preventing intensive care admissions for sepsis in tropical Africa (PICASTA): An extension of the international pediatric global sepsis initiative: An African perspective. Pediatr Crit Care Med 2013; 14:561–570 12. Brown J, Machen H, Kawaza K, et al: A high-value, low-cost bubble continuous positive airway pressure system for low-resource settings: Technical assessment and initial case reports. PLoS One 2013; 8:e53622 13. Wiens MO, Kumbakumba E, Kissoon N, et al: Pediatric sepsis in the developing world: Challenges in defining sepsis and issues in postdischarge mortality. Clin Epidemiol 2012; 4:319–325 14. Truog RD, Brock DW, Cook DJ, et al; Task Force on Values, Ethics, and Rationing in Critical Care (VERICC): Rationing in the intensive care unit. Crit Care Med 2006; 34:958–963 15. White DB, Katz MH, Luce JM, et al: Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med 2009; 150:132–138 16. Scheunemann LP, White DB: The ethics and reality of rationing in medicine. Chest 2011; 140:1625–1632 17. Burns JP, Mitchell C: Resource allocation and triage in disasters and pandemics. In: Clinical Ethics in Pediatrics: A Case-Based Textbook. Diekema DS, Mercurio MR, Adam MB (Eds). Cambridge, UK: Cambridge University Press, 2011, pp 199–204
www.pccmjournal.org
83
