NICU to PICU transitions: Ongoing patient needs, opportunities for standardization and optimal transition of patients from neonatal to ex-preemie care.
All right, so shifting gears a little bit, um, I just wanted to um invite one of our other um pulmonary and critical care medicine colleagues, Andres you know, to talk to us a little bit about our transitions in care and um we can probably do be better with that. So good. Thank you. Uh, thanks, Pam, for the introduction. Um, so I specialize in pulmonary and critical care medicine and I started working at PCH 4 years ago. So I'm gonna be focusing on, uh, some of the challenges that the NICU to PIQ transitions pose and what are some of the strategies that could potentially facilitate the transfer process of infants between the NICU and the PQ. I don't have any financial conflicts of interest to disclose. So we know that both the NICU and the PQ share similar capabilities to provide care for critically ill infants. Typically, the NICU team cares for the premature babies and neonates that have not yet left the hospital, while the PQ typically directly admits and neonates and infants that continue to require intensive care services after they have been discharged home and are accustomed to taking care of these sort of like all their ex-prey population. There is clearly an overlap in the capacity for both units to care for critically ill infants, and there are usually discussions regarding when and what's the optimal transition process of such patients between the two units. So there's a lot of variation between center to center on the exact timing and criteria for transfer from the NICU to the PQ with some setters uh starting as early as 48 weeks correct gestational age, while some others delay this process until at least 1 year of age. This certainly remains an area of opportunity for standardization. But discussions typically will occur when infants age out of the typical NICU criteria and then the ongoing care needs can be met by the ICU team, by the PQ team. So what are these patient populations that are usually uh seeing as appropriate for transfer. Uh there are different ones. I'm gonna be focusing on the ones that, you know, the literature has shown um that have the best outcomes when this transition happens between units. This typically involves infants that are older than 1 month of age and are expected to require at least an additional 2 weeks of intensive care services prior to discharge home. Most of these children, of course, are technology dependent and have multiple subspecialists guiding their care. They have transitioned from these acute life-threatening status to a more chronically critically ill status. Um, this is the reason why most of these patients are viewed as more stable. Uh, even though they're still medically complex, and this is the reason why, uh, often these are the first patients to be considered for transfer when there is an acute decrease in the NICU admission capacity or an increase in the acuity in the NICU as well. Of course, typically the acute need for an ICU bed capacity arises in the middle of the night with unexpected admissions or with changes in acuity of other patients with limited bedside staffing. Uh, despite the perceived ability of a lot of these NICU graduates, the transfer of these patients from the NICU to the PQ can also pose significant challenges that can result in patient complications, family dissatisfaction. Medical personnel frustration if this is not performed in a coordinated multidisciplinary fashion. So I'm gonna be uh now focusing on the different uh individual challenges about the transfer process between the NICU and the PQ handovers being uh the first one. So handovers of transitioning care as we know are times of increased risk for patients. Over the past several years we've seen a significant change in the transition in care, primarily because of the changes in staffing models and our restrictions for how staff. Uh, this basically means that there are more caring transitions and patient care handoffs. Expanding research, um, in the adult literature has shown that there is an increased mortality rate in adult patients, uh, with transitions in care team, uh, and these are also contributing factors in sentinel events. How can we make this handoff process less Error prone. There have been different strategies to try to mitigate some of the errors in the transition in care, trying to use different templates on the handover process and even though these have been shown to improve the communication skills between teams, uh, there is no specific data, at least, uh, in the transition of infants from the NICU to the PQ regarding uh outcomes. And nighttime transfers, um. This is another significant challenge, um, uh, primarily because um this um happen acutely in the middle of the night as there's a decrease in the bedside capacity in the NICU or as uh the acuity in the NICU increases significantly. Transfers are usually based on the needs of the unit rather than the needs of the patient. We all know that the ICU beds are usually limited. This is primarily secondary to uh staffing shortages and then the new admissions that can happen unexpectedly. Uh, so the ICU bed mobilization typically will favor moving less critically ill patients in order to care for the more acutely ill, uh, population. Dating adults has also shown that transferring adults at night uh between units uh is associated with increased mortality. There's like a 1.2-fold increase in the mortality uh when these transfers happen in the middle of the night. In terms of patient complexity, we know that NICU patients uh overall are medically complex individuals, so they're more prone uh and vulnerable to medical error. There are higher risks of medication errors as well in this patient populations. This is the reason why some hospitals have designated a separate multidisciplinary team to ensure this family centered coordinated and efficient continuity of care. Uh, we do not have any standard protocols to follow that delineated the disease process of all the different patients' populations that get transferred from the NICU to the PQ, which also pose a significant challenge. So the care plans that are executed are usually forged over days, small titrations in feeds and ventilator settings. Uh, we also know that many NICU graduates require unusual doses of medications or medications are used for off-label reasons. So, uh, assuming or assumptions about the dosing or indications can potentially lead to Mismanagement without specific attention to these details. So some small variations in the care of these children of these infants as they transition to the PQ uh can be significantly impactful due to this uh medical fragility. In terms of the family experience, uh, we know that caring for a pretty little child is a stressful experience for families. It also involves the ICU teams to care for the family and trying to optimize the family center approach. Uh, the admission to the NICU is generally secondary to a sudden unexpected life-threatening event and can potentially be surrounded by, you know, uncertain prognosis as well. So over the course of the NICU admission, families uh develop a significant bond with their care teams. They become familiar with the NICU routines and then develop close relationships with the care teams which enables an understanding of the specific areas of concern and effective methods of communication as well. So if there's poor preparation for transfer of care, uh, or NICU graduation, uh, this can potentially be a clear source of parental stress. Primarily related to the uncertainty regarding the future clinical course of the child, the therapeutic trust or competency of the new care team as well. And this is primarily because the routines in the NICA and the PIs are different, uh, even though, uh, the patient, uh, sort of like, um, satisfaction, uh, goes first, uh, the way we approach problems in the different units is different. Um, in terms of applying the evidence, so all I've shown about the association between adult mortality with nighttime transfers, uh, the increased risk of, um, medical errors, particularly in the medically complex patients and then increased parental anxiety. This is not unique to each particular institution, um, and even though it might not be specific to our NICU or RPQ, uh, we do know that, you know, these concerns are universally applicable to the different institutions and this is, uh, primarily the reason why there is a need for a staged coordinated multidisciplinary uh protocol to mitigate some of these risks. So what are some of the general characteristics and outcomes of the NICU to PIQ transfers? We know that in the NICU mortality is associated not only with age, um, but also with the time and timing, the type and timing of critical care support that's provided. With the recent technological developments in the NICU clinical management, uh, survival overall has improved in, uh, a lot of the NICU survivors, uh, particularly in patients that have, uh, respiratory complications such as BPD. The data has also shown that the length of stay of these particular patients, their respiratory population tends to be higher, primarily because this patient population continues to have significant comorbidities that require ongoing intensive care. They're either recovering from procedures like tracheostomy placement or there's a need for long-term regulatory support and time to allow them to grow as well. Some of these circumstances may require prolonged critical care services. Uh, and some patients might age out of the NICU, which is the reason why there's a consideration to transfer these patients to a PQ primarily to free up some beds if the capacity is low or if the acuity is higher than. In terms of the respiratory population, most of these patients have some form of chronic respiratory failure, uh, which represents the primary need for prolonged use of mechanical vision. Some of the underlying diagnoses are listed there with severe BPD being one of the uh leading ones. These are some general criteria, uh, after doing, uh, some literature search on what are the guidelines that are out there, um, in terms of considering uh infants suitable, uh, to transfer out of the EU into the PQ for ongoing intensive care services. So this is applicable for infants that are older than 36, 37 weeks, uh. Menstrual age or 4 to 6 months corrected age. They weigh typically greater than 2.5 kg. Uh, they are at an age where neonatal resusciation is no longer applicable. They don't have any human economically significant but they know heart disease, and there's a continued, uh, need for intensive care services like potentially CRRT and invasive or non-invasive mechanicalization. And with infants with severe BPD they are requiring basic mechanical malation, tracheostomy has to be in place and uh in some institutions they also require that patients are on a home care ventilator with stable settings. Uh, a lot of this is only applicable when the IQ bed capacities are greater than 80 or 90% or if the acuity level is high. Again, this is not um. Particular to a specific institution, this is after doing some uh literature search, what criteria are used out there uh to potentially consider some of these NICU graduates uh that require ongoing ICU services to transition to a PQU. Uh, most of these guidelines that have been developed have, uh, a staged approach on how the transfer processes, uh, in the pre-transfer stage this typically happens before, uh, the day of the transfer, um. Within days of, you know, conversations between the NICU and the PQ, uh, with the day prior to the transfer, uh, being sort of like the opportunity for the parents to tour the PQ, it's an opportunity, uh, to do the handovers at all levels, uh, residents, interns, potentially, uh, fellows, attendings, dieticians, respiratory therapists. Uh, and it also involves the joint rounds between the NICU and PQ, uh, primarily to become familiar with all, uh, the aspects of care surrounding the infant being transferred, and then there has to be staffing commitment, uh, on the day of the transfer and onward. This is primarily uh to prevent bounce backs. The day of the transfer that also involves um formal bedside handover uh with the family participating in rounds, uh, ideally this should happen midweek uh during the daytime hours, and then there has to be a process. To review the orders and then the formal sign up between the residents and then following the transfer uh either the day after or the days following the transfer, uh again, uh, a lot of institutions, um. Promote joint rounds between the PQ and the NICU, uh, primarily to uh guarantee that all of the aspects of care have been addressed. Um, in terms of the goals of this transfer process, um, The main goal is to improve the patient and family satisfaction and while urgent care, urgent transfers may still be required, when we engage in these elements that have been outlined, um, and implementing this shared follow-up rounding, uh, we will potentially mitigate some of the, uh, risks, uh, in the transfer process itself. Avoiding transfers in the middle of the night is another one of the goals, and when they actually occur for different reasons, ensuring that all the steps that were skipped in the process are addressed by the team on the next day is also extremely important. In terms of other strategies that have been implemented to potentially mitigate some of these risks, a lot of institutions have developed specific guidelines for different patient populations. This is a very interesting one. Um, that has been implemented by Boston Children's. This was published in Theatr Pulmonology in 2023, uh, where, you know, the institution has developed a multidisciplinary BPD team, uh, and they facilitate or they ensure that this The process goes uh as smooth as possible. Uh, this has been shown to also improve hospital outcomes including survival to hospital discharge, length of stay and growth, the implementation of the multidisciplinary BPD uh care team. Um, we do know that there are differences in the respiratory humanamics strategy between the NICU PQ sedation and this uh developmental care, nutritional support, uh, which is why implementing, uh, a, a program like this, uh, guarantees that all of the aspects of care of these high-risk infants, uh, remains. The transition between units also offers unique opportunities for collaboration and improvement in existing systems of care primarily between the NICU and the PQ. Uh there are different management approaches between the two units. Uh, this is primarily because of the different, uh, sort of like protocols that each unit uses in terms of sedation strategies, ventilator weaning, regulatory support, um. And some of the uniqueness of this uh patient populations with BPD are again uh surrounding uh the ventilator management, uh, recognizing the different of phenotypes of BPD uh and then the ongoing nutritional and developmental care needs uh for the former pre. These are some of the different developmental goals, um. Of the different sort of like stages of uh infants with severe BPD uh and we can see here that particularly in this institution of also of children they delay even later weaning until sort of like the later stages when the infant has shown a significant stability, um, and this is something that um Most PQs don't necessarily understand because again we don't typically uh deal with this patient population on a daily basis. Uh, so the recognition of all these different stages and what the main goals are for each state is extremely important to guarantee a smooth transition and a successful again uh ventilator strategy. These multidisciplinary BPD rounds, uh, at least, uh, the one has, uh, that has been implemented in most children's typically happens on a weekly basis. Uh, it allows for robust discussions about the interactions with different aspects of the patient's care. Uh, it reiterate also the, uh, different strategies for nutritional support, the use of diuretics, systemic corticosteroids, sedation weaning, and then developmental care as well. There's a consistent approach in terms of ventilator adjustments, delaying this until again, uh, the in has shown medical stability. And then it also allows for the error recognition of some of these complications that are related to prematurity that again are not always screened in the PQ. Um, it also allows for uh review of the medications and not the later strategies and then uh the implementation of weaning calendars for, uh, some of the medications that can potentially impact the bone health like uh steroids or diuretics uh as well as sedatives and analgesics. It prioritizes the continuation of parental medications to expedite the process of removing uh central venous uh catheters um and then uh the dieticians also monitor the weight and the linear growth uh with adjusting, adjustments in the calories uh or the feeding volumes as needed. It also includes uh PTOT, and speech primarily to ensure the critical development of milestones, um. And uh the ability to tolerate ventilator weeding is also an important sign of developmental progress that will be consistent with the child's neurological state. They also involve developmental specialists which plan the age-appropriate activities and participation in uh cares uh are typically scored and tracked over time. Uh, child of therapists are also involved primarily to assist in creating daily schedules and then in coping with medical interventions as well. The rounds also serve as a regular reminding to screen for different uh comorbidities of prematurity like retinopathy of prematurity or anemia prematurity and then to plan for uh vaccinations as well. Families are encouraged to participate in these multidisciplinary rounds, uh, which again facilitates the open communication, uh, and, you know, discussion of uh the goals prior to discharge. So in conclusion, the transfer of patients between units and the teams in the hospital is a time of increased risk for medical error. Uh, the complexity of these NICU, uh, patients, um, can significantly adds to the risk of error. Avoiding uh nighttime transfers and implementing stage multidisciplinary process when transferring these NICU patients to the PQ will likely improve patient outcomes and family satisfaction. And then in terms of the timing of the transfer, what's the best uh age or degree of medical stability prior to transfer and then the best practice methods for this transfer process uh and you know, uh the handovers are still areas that will need uh further uh study. And then a multidisciplinary care model such as the one that has been implemented in other institutions can potentially provide a more in-depth understanding of the natural history of the disease, uh, and, uh, guarantee, uh, sort of like the individualized approach uh to infants that are transferred uh from the NICU to the king. Those are my references. Thank you very much.
