In a new article published in The Lancet Global Health, a global group of researchers proposed a more inclusive and standardized definition of acute pediatric critical illness, which has been endorsed by multiple national and international critical care societies. The proposed definition provides the global research community with the clarity needed for a unified approach to defining, characterising and selecting populations of children with critical illness for health studies—allowing for the comparison of outcomes across settings, regardless of resource availability.Together with their colleagues at St. Jude Children’s Research Hospital, two Indiana University School of Medicine professors, Adnan T. Bhutta, MD, who is the division Chief of pediatric critical care medicine, a clinical professor of pediatrics, and a Riley Children’s Health provider, and Michael Lintner-Rivera, MD, MSC, an assistant professor of clinical pediatrics, worked on a research team to develop this definition.
Read on for a Q&A with Bhutta, who explains how the definition was developed.
Q: How did the lack of a consensus definition for acute pediatric critical illness and patient eligibility criteria emerge as a topic of interest?
Bhutta: In the past three decades, the global under-5 years of age mortality has decreased by more than 60%, thanks in large to concerted efforts to improve preventive care through concerted global efforts. However, more than 5 million children still die every year from common childhood illnesses such as pneumonia, diarrhea, and sepsis. More than 80% of these deaths occur in low and middle-income countries, primarily in Sub-Saharan Africa and South Asia. Children with these illnesses often present to hospitals when they are critically ill, where many succumb to their illness. The lack of availability of high-quality critical care services is an important reason for these deaths, most of which could be avoided. We defined the epidemiology of critical illness by doing a systematic review (paper currently under review at the Lancet Global) and a prospective, point prevalence study. However, we encountered the fact that there was no standard definition of critical illness. Thus, the need arose to develop a standard definition of critical illness, which could be applied across all resource settings.
Q: How did your research team go about solving these challenges?
A: We initially put together a small group of experts to help refine our idea and create the framework of the study. We then brought together a wider panel representing multiple specialties and disciplines (pediatricians, critical care doctors, emergency room physicians, nurses, pharmacists) from most of the regions of the world, with a special emphasis on those representing low-and-middle-income countries to participate in the Modified Delphi process. The modified Delphi Process is a way to generate a consensus statement by providing a group of experts with various scenarios and quantifying their answers to rate various possibilities. Multiple rounds of rating answers to the various scenarios are conducted until one or more answers achieve consensus between the experts.
Q: Your proposed definition has two principal domains : acute physiological instability and a clinical support requirement. What makes these two domains so crucial to your definition?
A: We wanted to move away from thinking about Critical Care based on the space (ICUs) or equipment (specialized monitors or equipment like ventilators) to focus on which patients are critically ill and what makes them critically ill. Through the Modified Delphi process amongst our expert panel, we settled upon two fundamental qualities that are present in all critically ill patients: 1) they have signs and symptoms consistent with physiologic instability, and 2) they would benefit from increased monitoring. Our definition thus helps move the focus to the actual patient rather than any geographical constraints within a hospital.
Q: What’s the next step for your research? Any other challenges you foresee?
A: The next steps currently underway are to use this definition to better define the epidemiology of critical illness. Once we define the epidemiology in different regions and countries, we hope to create models in different resource settings that can substantially reduce hospital mortality from acute illnesses. This model will focus on improving and strengthening local health systems for quality improvement and research; improving the training of healthcare personnel; increasing the availability of equipment, supplies, and medications; and maximizing space utilization. This tall order will take a global concerted effort to become a reality.
