Great, thanks to Jake for the introduction and to all of you for being here. I'm excited to present on this topic that's very important to both of our patients as well as the families that we care for in the ICU. I have no relevant financial disclosures, and I'm not the anonymous internet figure cited there, but I think the sentiment is true. There's no worse feeling than having to tell an outlying facility that we cannot care for a critically ill child, which as many of you have experienced has become increasingly common over the course of the year. Three objectives for this talk. The first, understand the competing forces which may contribute to the limited pediatric ICU bed capacity, review trends in pediatric ICU epidemiology, and explore strategies to improve our capability to provide care for critically ill children. So when I was asked to give this talk, things were fine in the pediatric ICU world. As fine as things can ever be in the pediatric ICU world. And then since then, you've all read this in the New York Times, the Washington Post, your local newspapers. All of these things have really combined to highlight the lack of infrastructure that we have to care for critically ill children in the United States. They continue. So today, I'm gonna talk about four components which may contribute to some of the difficulty that we have actually caring for critically ill children in the United States. First, I'm gonna talk about access and capacity. I'm gonna talk about the pediatric ICU workforce. I'm gonna talk about our patient population and the changes in our patient population over time. I'm gonna talk about specific ICU specific technologies, and then talk finally about some potential strategies to actually mitigate some of these things. Two things before I start, which are really, intentionally putting my head in the sand here. The first, which will be covered by speakers later in this session, is that as we all know, a bed is only worthwhile if you're actually able to staff that bed with the people who are necessary to care for these children. And I'm not going to talk about that during my talk. And the United States has perhaps more pediatric ICU availability and capacity to care for critically ill children than basically anywhere else in the world. But we still struggle with actually being able to get every child who needs a bed to be in the bed. The first thing, like I said, I'm gonna talk about is capacity. So this is from our recent study using the Pediatric Health Information Systems Database, which if you're not familiar, as a Children's Hospital Association Database. And this study looked at 43 children's hospitals in the United States from a period of 2014 to 2019. And as you can see here, about 14% of all hospitalizations involve time spent in the pediatric ICU, which accounts for about 32% of all hospitalization days in these children's hospitals. And these proportions are increasing over time. So where do we care for these children? These panels are from a paper by Robin Hark et al, which show the distribution of pediatric ICU bed availability by patient population, as well as down in the bottom panel, the total PICU bed count at the time of the survey. In the United States, as well as my state in Minnesota, the vast majority of children live within 10 miles of pediatric ICU. But you can see that there are several, a not insignificant proportion of children who live more than 80 miles away. And frequently, that is the patient population that is the hardest to actually get appropriate care in a timely fashion. This study, which was published in Pediatrics in 2021, compared changes over time in pediatric beds, as well as pediatric ICU beds. So you can see here in the highlighted boxes that there are pediatric ICUs in about one in 12 hospitals in the United States. But with that has come increasing consolidation. So on the left, you see that we have a decrease in the number of PICUs, and the median size of the pediatric ICUs has increased. So increasingly, it is more difficult to access pediatric ICU beds out in a community, as opposed to in a more tertiary, quaternary care facility. In the unhighlighted boxes, I've showed the similar changes that you see in pediatric floor bed availability, which is even a more substantial drop and more substantial consolidation. This study, also published in Pediatrics, looks at something called the pediatric, basically readiness scale. And you can see along the x-axis that over time, that readiness scale has not significantly changed. So this study looks at the ability to provide definitive care for children out of an ICU, out of an emergency room, not necessarily out of an ICU. But as the annual volume of ED admissions goes up, you're not seeing much change. The images represented in gold are pediatric-specific hospitals that have higher pediatric preparedness. And in those situations, those patients have much higher ability to actually receive definitive care out of an emergency room. And this really highlights the fact that, again, with this increase in consolidation and our ability to only care for children in really specialized facilities, we are increasing the amount of time that it might take for them to receive definitive care, increasing the potential for transfer to another institution, and therefore delaying definitive care. The second thing that I'm gonna talk about is the availability of the pediatric ICU workforce. These data are all from the American Board of Pediatrics. We're a small specialty. Only about 3,000 people have ever been certified in pediatric critical care medicine. And you can see here the age distribution. In comparison to other specialties, pediatric ICU physicians tend to be younger as well as more male. And just like the prior slide that I showed from Dr. Horak, these APP data show the distribution of pediatric critical care practitioners by patient population. Much like election maps, this map is a little misleading. And so when you look here, you can actually see the distribution by county of pediatric ICU physicians. And you can see that there are large swaths of the country where there is no availability of a pediatric ICU physician. The next thing that I'm going to talk about is our patient population. A lot of these data come from that FIS paper that I discussed before. As you can see here, our patients tend to be young, they tend to be male, and they tend to come primarily from the south. Again, looking just at FIS-participating hospitals. They tend to have government insurance. And using the Child Opportunity Index, which is a neighborhood measure of child opportunity, it's a composite measure that looks at a lot of different things that are important for child development. Children who are cared for in the ICU are disproportionately disadvantaged in their neighborhoods, which I think is probably not surprising to any of us who actually care for these children and their families. They also tend to be medically complex, with more than half of them having at least one complex chronic condition as defined by Feutner et al. And those children actually comprise the majority of costs and bed days that accumulate for children in our ICUs. As all of us can tell you, there are many children who come back frequently to the intensive care unit. And that patient population, again, kind of collinear with the patient population who has chronic medical conditions and chronic critical illness, account for a significant burden on the ICU system. In the state of Minnesota, it's actually incredibly difficult for anyone to care for a child with complex medical needs in an institution. The vast majority of time, those children are stuck in an ICU, waiting for home nursing that may or may not ever become available. And certainly provides a significant backlog in our ability to meaningfully care for other children who may have more acute medical needs. So if I had given this talk a couple years ago, when we were talking about adult patients in the ICU, it mostly would have been adults with what's called either childhood onset chronic conditions or several other terms. We saw during, and we know, that that patient population can actually be a significant component of the individuals who we care for. So Jeff Edwards from Columbia has done several studies looking at that patient population in particular. And they represent up to 10 to 15% of the patients that we care for. So this is patients who are older than 18, really in kind of more traditional adult age as relates to who we think that we're caring for. In our recent study, we saw similar numbers. Of course, that was if the talk were several years ago. We all know that with COVID, a lot of things changed. And these are just some of the articles that have been published, but certainly personal experience and anecdotally from others. Lots of institutions transitioned their pediatric ICU beds to be able to care for critically ill adults. And that's not something that we've necessarily seen in response of adult institutions, particularly around this RSV, COVID, and flu surge in the fall that there's been a reciprocal response to. The last thing that I'm gonna talk about before getting onto potential solutions, because there are some things we might actually be able to do about this, is the ICU technology. So I'm sure that many of you have struggled with, whether personally or professionally, some of the policies and procedures that really dictate where patients are cared for in the hospital. So while there are general descriptions of what sorts of things are generally cared for in the pediatric ICU, many of those decisions are made on the ground, either because this is how we've always done it at an institution, or because we had a bad outcome, and therefore all children must be treated in the ICU for particular conditions, or any manner of other things. So this is information that's drawn from the Texas Medicaid use dataset published by Vias et al in 2020. And this shows the variability in where children with diabetic ketoacidosis are cared for in hospitals in Texas. And you can see that it ranges from very few of them on the left up to the majority of patients. And it's really an interesting distribution. If you look further in this paper, they talk about the difference between children's hospitals where the majority of patients are actually treated not in the ICU, and non-children's hospitals where the majority of patients are treated in the ICU. We also know that there's a plethora of literature about post-procedural admissions, kind of routine post-operative monitoring, and I've listed a few of them over on the right. But these are things like ENT procedures, post-onslectomy, tracheostomy decannulation, neurosurgical procedures like Chiari decompressions, or other relatively straightforward procedures, posterior spinal fusions, and cardiac catheterizations. And there's a lot of variability about in which institutions those patients can go to the floor, or an intermediate care unit versus the ICU. Most of us all know about the variability in respiratory support needs, and whether, again, how that dictates where a patient is cared for. So this infographic is from a study that was done in Canada that looked at whether institutions were able to care for children on hyponasal cannula for respiratory failure in the ICU versus on the floor. These data, like I said, are representative of the response in Canada, but several other studies over on the right show the same thing. A lot of variability, about half of institutions care for children with hyponasal cannula on the floor, about half not. Looking specifically at bronchiolitis, you can see here in the top panel, this is kind of the change in the proportion of patients over time who receive different types of respiratory support. And the bottom panel looks specifically at patients in the ICU. In this study, patients who are receiving hyponasal cannula are grouped into the light gray box where they're not getting any ventilatory support, and then non-invasive ventilatory support and invasive ventilatory support as we go down the gradations of gray. And so while we see increasing numbers, the majority of that ICU burden comes from patients who are on hyponasal cannula and not positive pressure or invasive mechanical ventilation. This matches what we saw in our phys study as well, where again, the proportion of patients receiving mechanical ventilation has gone up over time, but that non-invasive ventilation growth has been larger. And then we looked specifically at other non-ICU, sorry, other ICU-specific therapies, things like ECMO, vasoactives, renal replacement, and the proportion of patients who are receiving at least one of those in a composite outcome, that's the bottom row, is increasing over time, but still is perhaps not as high as you might anticipate for a population of critically ill children. So I'm gonna talk, like I promised, a little bit about potential strategies in each of these areas. I think one of the first things to think about in terms of capacity and access is the role that physicians and healthcare providers have in advocating for legislative and other policy and procedural changes to increase access to care. We see that all the way from primary care up through the most advanced technologies that we have available. That involves things like adequately reimbursing pediatric services, making sure that there are incentives for maintaining readiness to care for pediatric patients across the spectrum of care from pre-hospital all the way to the ICU, particularly in areas where you don't have a dedicated pediatric hospital or you may require several transfers to get there. And I think thirdly within this, having a well-thought-out process by which you create and practice plans for flex use of non-ICU beds for pediatric patients, whether in pediatric hospitals or not is really important. I think we saw that through the COVID pandemic and some of the changes that were made to really accommodate patients in non-traditional areas. And that's great in theory, but if you don't practice those things over time, the skill set is not going to be there when you need it. Similarly, talking about the workforce, developing potentially tele-ICU, which is not common in pediatrics, or other services to provide support specifically to those geographic areas that were white on that map, where there is no immediate access to pediatric critical care providers. Again, simulation, practice, and other methods to prepare critical care and other providers for high-risk, low-frequency events, which we've heard about as well. And then thinking about who else might be able to care for these patients, whether that's neonatologists for our youngest patients, whether it's adult intensivists for our older patients, particularly during surges and pediatric illness. Thinking a lot about how we can prevent patients from needing to be in the ICU to begin with. So ensuring adequate preventative healthcare services, care coordination, particularly for that patient population that has complex chronic conditions and who have recurrent ICU admissions. Really advocating for public health measures, which might reduce the potential for patients to need to be admitted to us, whether that's improving air quality, having access to safe and healthy areas for activity, reducing gun violence, which is, as we all know, a significant scourge on the American health system. And then creating robust processes to actually transition children and young adults when appropriate from care in pediatric institutions to care in adult institutions. And not just for preparing the patients and their families, but also for preparing adult providers to care for these patients who may or may not have had conditions that were previously survivable to the ages that we are now seeing. And then the last thing, when we think about the technology that we use in the ICU, are those actual meaningful use of the ICU? Can you safely provide this level of care elsewhere in the hospital? Can you safely provide this level of care at home or in other institutions? And if you are unable to provide them routinely outside of the ICU, how are you going to handle periods of stress? And so this again goes back to that preparatory phase of things, even though our tradition might be to provide high flow in the ICU only, how might we be able to extend ourselves in periods of surges, which are very common in pediatrics, particularly during the winter? And then thinking more critically about the need for routine post-procedural admissions to the ICU and assessing which patients might be able to be safely cared for in other places. So I don't mean that to be a complete list of mitigation strategies. We're gonna hear from some other speakers about the actual need to staff these beds as well. But I'm happy to take questions at the end and I appreciate your attention. Thank you.

pediatric ICU bed capacity

access and capacity issues

ICU-specific technologies

tele-ICU services

preventative healthcare