SCCM Resource Library-PICU Non-Physician Workforce

Video Transcription

Welcome, everyone. I am Michaela White-Nesfield, a critical care attending at Children's National.  Today, we will be looking at PICU-associated parental PTSD beyond the first year. These are my co-authors. So why look at post-traumatic stress beyond the first year?  A child's admission to the Pediatric Intensive Care Unit is stressful for the entire family.  At up to 12 months, almost half of parents are at risk for developing post-traumatic stress. Post-traumatic stress in parents can negatively affect a family's well-being.  It can negatively affect a patient's mental health and potentially patient physical healing. So what information are we adding?  For the first time, we're looking at prevalence and risk factors of parental PICU-associated PTSD and PTSS greater than 18 months post-discharge  and the ability to compare those diagnosed in the subacute phase versus the long term.  We enrolled 265 parents from two Pediatric Intensive Care Units using inclusion criteria stated below.  Exclusion criteria included parents with a prior psychiatric history who had recently been admitted to a psychiatric institution within the last two years  or had an ongoing diagnosis of post-traumatic stress disorder who were non-English speaking because our tools were not validated in other languages and who had child death.  We felt that grief, post-traumatic stress disorder, and an intense prior psychiatric history would all influence our post-traumatic stress disorder screening  and, if anything, we would underestimate instead of overestimate this population. The following shows our timeline of assessments.  After consent during admission, we performed the patient health questionnaire to ascertain for parental undiagnosed mental health disorders  and additional questionnaires looking at prior traumas, socioeconomics, and demographics.  On the children, we looked at functional status using the functional status score, pediatric overall performance category, and pediatric cerebral performance category  as well as additional medical questions.  At discharge T1, we looked at acute stress disorder using a validated screening score and again looked at functional status of the child post-discharge.  At T2, three to nine months post-discharge, we assessed for post-traumatic stress disorder using the validated interview scale PSSI-5 for DSM-5  and additional questionnaires related to socioeconomics and the admission. We performed on the child additional questionnaires related to medical health.  At 18 to 30 months, we repeated our T2 assessment. The results show us the characteristics of who was affected.  When looking at our parent characteristics, we had a predominance in females of about 58%,  though very proud of our 42% father or male gendered subjects. We had pre-existing parental psychiatric disorders, about 24%.  When looking at our kids enrolled, about 51% had a history of prior chronic disease, though most of them were expected to survive at admission with PRISM 3 score of 3.  And our child prior ICU admission was about half, a little more than half actually of our children.  When evaluating our 265 enrolled parents, we defined PTSD qualification and PTSS qualification by the validated cutoff points provided by the developers of the PSSI-5.  At 3 to 9 months, we retained 75% of our cohort and had a PTSD qualification rate of 15%.  At 18 to 30 months, we retained 66% of our cohort and had a PTSD rate of 12.6% and a PTSS qualification rate of 34%.  160 participants or 60% were assessed at T2 and T3. Of these, 11 participants met qualification at both of these time points.  Roughly half of the individuals that met qualification at 18 to 30 months also met qualification at 3 to 9 months.  Meaning that post-traumatic stress disorder in parents of PICU admits is a significant and persistent problem.  Univariate analysis at 3 to 9 months showed us parental mental health disorders carried 4 times increased risk for anxiety and 7 times increased risk for acute stress disorder.  Parent concerns also carried significant risk as well as child factors such as decrease in functioning or readmission to the hospital.  Multivariate logistic regression at T2 for PTSD showed us that inpatient issues such as parent concerns on permanent death and knowledge of child injury as well as acute stress disorder diagnosis was heavily weighted towards post-traumatic stress disorder.  We also have how the child left the ICU, so the pediatric overall performance category, being heavily weighted as well.  Similarly to multivariate logistic regression of PTSD at this time point, we have parent prior history, so history of abuse or history of mental health disorder as per the PHQ on admission being significant risk factors.  We also have parental concerns being heavily weighted here, where we have parental concerns of child death and permanent child injury and also looking at whether or not the child had a new diagnosis at discharge.  PTSD at 18 to 30 months on univariate analysis showed acute stress disorder was still with a 5 times increased risk.  Parental concerns also still carried 40% increased risk.  And for outcomes, parents who reported post-traumatic stress disorder were 5 times more likely to also report divorce or separation from their partner and 6 times more likely to report a decrease in household income from T2 to T3.  Logistic regression at 18 to 30 months showed that the only thing prior to admission that affected this outcome was having a family member admitted to the ICU previously.  Acute stress disorder on discharge was still heavily associated with post-traumatic stress disorder at this time point, as well as continued concerns.  So, parents who were more concerned about child susceptibility to death post-discharge also carried increased risk of 58% per score point.  And these parents were more likely to report a decrease in household income, 9 times more likely.  For moderate to severe post-traumatic stress at this time point, again, we see acute stress diagnosis being heavily with a 10 times increased risk.  And parent concerns of their child's susceptibility to death post-discharge also being associated in this category with 51% increased risk.  New things was a child's PICU readmission, so discharge and then readmitted to the ICU, carrying a 4 times increased risk. And for the first time, we see patient age.  So, this has been reported before in qualitative analysis in this niche, where parents feel like the older their child is, the more connected they are to them, the more they know them, the more stressed out they feel when their child's life is at risk.  In comparing parental PTSD risk at T2 versus T3, you can see that overall T2 risk factors seem to be associated mainly with the admission.  And in T3, you're starting to see, at least in these bottom two, decrease in income and parental concerns of susceptibility to death, we're seeing more of a concern for the post-discharge period.  Seeing that this is a persistent problem, now we think of when do we intervene?  So, in admission, we have risk factors here that can be screened for on admission and allow us to intervene and possibly mitigate post-traumatic stress disorder altogether.  At discharge, we have acute stress disorder, which was associated across the board with post-traumatic stress disorder at all time points.  And parents' concerns and perceptions lead us to be able to intervene after discharge with support or referrals.  And even post-discharge, when we are seeing parents in the pediatric setting outpatient, do we screen for post-traumatic stress disorder and intervene then, allowing us at each time point to be able to capture parents who are struggling and improve the overall functioning of the family and hopefully the recovery of our children.  Limitations included loss of follow-up potential for recall bias. We did not use the gold standard for acute stress disorder or post-traumatic stress disorder.  This study may not be generalizable, seeing that our ICUs, though in different places, were similar in makeup. We excluded non-English speaking parents.  And this cohort was designed to establish potential risk factors and was not powered to determine causes. So what does this all mean?  Parental PTSD associated with PICU admission is a significant and persistent problem our parents and families face.  Risk factors are multifactorial, but most of them are identifiable during the PICU admission. Parents' stress reaction is one of our biggest predictors.  Identification and intervention to mitigate parental PTSD is needed. These are some of our references. Thank you for your time.

Video Summary

In this video, Dr. Michaela White-Nesfield discusses the prevalence of parental post-traumatic stress disorder (PTSD) beyond the first year of a child's admission to the Pediatric Intensive Care Unit (PICU). Nearly half of parents are at risk for developing PTSD within the first year, which can negatively affect the well-being of the family and the child's health. The study looked at risk factors for parental PTSD and found that acute stress disorder, parental concerns about their child's susceptibility to death, and decreased household income were all associated with increased risk. Intervening at different stages, such as admission, discharge, and outpatient visits, may help improve outcomes for families.

Asset Subtitle

Administration, 2022

Asset Caption

Children's hospitals, and pediatric ICUs (PICUs) specifically, face a number of ongoing challenges that have only intensified in the era of COVID-19. Budget constraints, workforce shortages, new demands for staffing models, and decreased reimbursements by public and private payers have increased the administrative strain on PICU faculty and critical care management. This session aims to identify major administrative challenges facing pediatric critical care leaders. Each presentation will highlight strategic approaches to mitigating these challenges today and in anticipation of additional unforeseen health system pressure.

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Pediatric Intensive Care Unit PICU

Tag Workforce

Year 2022

Keywords

parental post-traumatic stress disorder

Pediatric Intensive Care Unit

prevalence

risk factors

interventions

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