Care Transitions Among PICU Patients

Transitions of care between healthcare teams are high-risk periods for patient safety (1). Care transitions involving patients in the PICU are complicated by critical illness, medical complexity, family needs, and unique care requirements. The healthcare teams involved in these transitions also have a variety of training backgrounds and may function under different departmental or institutional policies and cultures. These differences, the frequency of transitions, and variability of handoff communication, all contribute to the risk for adverse events. In 2023, the Agency for Healthcare Research and Quality (AHRQ) released a report that highlights the fraught nature of care transitions for hospitalized patients, emphasizing the threats to diagnostic safety with poor communication. The report provided a call to action for further research into interventions to optimize handoffs to prevent error across both common and less common types of transitions of care (2,3). In this Commentary for Pediatric Critical Care Medicine (PCCM), we take on the AHRQ imperative and focus on the current state and future research needed across the understudied—but rapidly increasing—types of transitions that PICU patients undergo. Ineffective communication is at the root of up to 80% of adverse events in patient care, based on data from the Joint Commission International advisory services (3,4). Handoff communication is thus, in theory, crucial to ensure safe transitions, serving as a vital checkpoint to ameliorate risk and allow clinicians to achieve a shared mental model for continuity of care. However, as an example of a gap between theory and contemporary practice, two recent reports in PCCM highlight the continued challenges during communication at the time of interfacility patient transfers to the PICU (5,6). Therefore, the focus of this PCCM Commentary is PICU transfers, including: 1) interfacility direct transfers to the PICU; 2) neonatal ICU (NICU) to PICU transfers; and 3) PICU to adult medical ICU (MICU) transfers (Fig. 1). In doing so, we highlight common gaps in handoff research and practice in pediatric critical care that may benefit from coordinated investigation and implementation.Figure 1.: The variety of care transitions involving PICU patients. ED = emergency department, MICU = medical ICU, NICU = neonatal ICU, OR = operating room, REHAB = rehabilitation.COMMON CARE TRANSITIONS AMONG PICU PATIENTS Critically ill patients undergo various types of care transitions, each with context-specific risks (2). Historically, from 2015 to 2019 (pre-COVID-19), the PICU literature mostly focused on transfers from a PICUs corresponding hospital emergency department (ED), surgical operating rooms (ORs), and general wards (7). “Intrahospital ED-to-PICU transfers” are common but vary in urgency and complexity. Transfer communication across clinicians can be complicated by varying perceptions of urgency compounded by differences in unit culture and policies. ED-to-PICU transitions have been improved by structured communication using custom Situation-Background-Assessment-Recommendation-based tools originally developed in adult clinical settings (8) and the I—illness severity, P—patient summary, A—action items, S—situation awareness, S—synthesis (I-PASS) program (9), which was initially implemented for inpatient pediatrics. The “OR-to-PICU transition” is perhaps the most well-studied PICU transition. Interventions to improve OR-to-PICU handoffs have used a variety of tool constructs, many of which have been used successfully in adult critical care settings (10). Quality improvement frameworks incorporating multidisciplinary checklists improve postoperative PICU communication (11). Now, in 2025, the American Association for the Surgery of Trauma Critical Care committee clinical consensus document recommends that “The operating room to ICU handoff should include patient demographics and history, anesthesia, operative, and postoperative information, and goals of care, including postoperative orders requiring review. The handoff should conclude with an opportunity for questions and clarification by both the delivering/transferring and receiving teams as needed” (12). The focus on “general ward-to-PICU transitions” emerged with the success of rapid response teams in improving both adult and pediatric outcomes. In pediatrics, current work in this area focuses on optimizing communication between the ward and responding teams, standardizing response workflows, and PICU-to-ward-discharge follow-up (13,14). In recent years, PICU patients have also experienced other types of care transitions, including interfacility PICU, NICU-to-PICU, and PICU-to-MICU transfers. Although less frequent, these transitions represent the growth of specific PICU populations, involve unique information needs, generate new challenges in communication across specialties and institutions, and require more involvement by patients and families in shared decision-making. Here, we comment on the characteristics and impact of these transitions, compare common and unique features of each and discuss future research directions (Table 1). TABLE 1. - Challenges and Opportunities Across Care Transitions Experienced by PICU Patients Care Transition Unique Challenges Current Mitigation Strategies Opportunities for Research and Care Innovations Interfacility transfers to the PICU Variable clinician expertise and resources at referring institution Use of structured interfacility handoff tools (only in a minority of PICUs) Evaluation of effectiveness of structured handoffs in improving communication, reducing adverse events, and improving patient outcomes Differential access to clinical information due to varying levels of electronic health record interoperability Early efforts to develop structured interfacility handoff programs to standardize communication between transport and PICU teams and between referring institutions and PICU team Identification of implementation strategies and adaptations tailored to varying PICU and communication needs Unique information needs for interfacility transfer (justification for PICU admission, plans for safe transport) NICU-to-PICU Dual priority of relaying current critical illness needs and salient hospitalization history Individual institutional transfer protocols Standardization of PICU transfer criteria and the transfer process Renegotiation of subspecialists’ roles Adaptation of practices used for patients with chronic critical illness and long-stay PICU patients Provision of opportunities for care overlap between the NICU and PICU before transfer Differences in unit culture require adjustment for families and clinical teams PICU-to-MICU Lack of resources commonly found in PICUs (e.g., child life services) Outpatient transition clinics Investigation of barriers to adult MICU transition Insufficient training and experience of providers regarding pediatric conditions that extend to adulthood Adaptation of handoff programs in current use for other transitions to use for ICU-to-ICU handoffs Standardization of MICU transfer criteria and the transfer process Differences in unit culture (adult vs. pediatric) require adjustment for patients/families and clinical teams Provision of opportunities for care overlap between the PICU and MICU before transfer MICU = medical ICU, NICU = neonatal ICU. INTERFACILITY TRANSFERS TO THE PICU In many countries, critically ill children are transferred from referring EDs to another hospital for a higher level of care (5,6,15–18). Interfacility transfers can put patients at risk for adverse events for several reasons (Table 1). In the United States, PICUs are geographically separated with attendant differences in clinical settings, expertise, policies, and culture. There is differential access to clinical data due to varying electronic health record interoperability. Furthermore, in a 2015–2017 cohort in British Columbia (Canada), we know that children admitted to PICUs from other institutions have more severe illness with longer lengths of stay and higher mortality compared with in-house transfers (19). Current Research In one single-center cohort of 110 PICU patients (reported in a 2025 research abstract), 56% of serious medical errors were found to be due to failures in interfacility handoffs, 80% of which resulted in avoidable clinical deterioration (20). Underrecognition of serious conditions has the potential to result in treatment delays and the subsequent need for urgent intervention en route or on arrival. Despite the importance of accurate and timely interfacility communication, a national survey of U.S. PICUs (at least ten beds) in 2023, with 60 respondents (35% of 170 total sample) gave a different picture (6). PICU Division Chiefs and Directors stated that although a verbal handoff between the referring clinician and a receiving PICU physician occurred in 93% of transfers, only 24% of responding PICUs used a structured handoff tool to guide communication. There was also substantial variability in how handoff information was disseminated to the rest of the PICU admitting team. In another study, which analyzed audio-recorded interfacility referral calls to a single-center PICU (2019–2020), key information such as the working diagnosis was often omitted, and PICU physicians rarely summarized information received to ensure accurate understanding (5). Despite efforts to standardize intrahospital handoffs, there are few published attempts to adapt structured handoff tools to interfacility transitions. One example is the development of the I-PASS-to-PICU tool, an I-PASS-based standard handoff program designed specifically for the interfacility transfer setting (21). It involves standardization of both verbal/written handoffs between referring clinicians and receiving physicians and transmission of handoff information to the rest of the PICU admitting team. Preliminary data on I-PASS-to-PICU shows promising results, with improvements in information transfer across the PICU team and increased preparedness for patient admission (20). Future Directions The use of structured handoffs for interfacility transitions to the PICU has been limited by lack of research compounded by the individual and institutional effort required to change ingrained workflows. Future work should focus on providing rigorous evidence on the impact of structured interfacility handoffs on communication, errors/harm, and outcomes of PICU patients, ideally through multicenter collaborations using cluster-randomized clinical trials. Future research will also need to provide insights on effective strategies for implementation, dissemination, and the needed adaptations for various types of PICUs and interfacility communication workflows. NICU-TO-PICU TRANSITIONS An increasing population of chronically critically ill infants requiring critical care beyond the neonatal period has led to more nonemergency NICU-to-PICU transfers in the United States, yet standardizing transfers remains the exception rather than the rule (Table 1). For example, in a 2023 cross-sectional survey of 115 PICUs in the Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU) network, out of 81 responding centers (70% response rate), only 33% of respondents reported their center had transfer protocols in place (22). And, as a 2011–2019 Virtual Pediatric Systems (VPS), LLC (Los Angeles, CA), database study has shown, such patients have a high degree of technology-dependence with an increased mortality risk relative to other patients (23). A 2016–2022 Pediatric Health Information Systems (PHIS) registry study indicates that NICU-to-PICU transfer rates range between 4.21% and 5.4% per year, with 20% occurring at greater than 100 days old (24). Therefore, transitioning these NICU patients to the PICU confers multiple unique challenges. Communicating the salient medical history of long-stay NICU patients is difficult given their complicated courses. Second, these patients are followed by multiple subspecialists acting as additional stakeholders whose roles must be renegotiated as patients transition from one primary ICU team to another. Finally, NICU-to-PICU transitions represent a substantial social change for families accustomed to NICU personnel and culture, who now need to adjust to the unfamiliar PICU team, unit design, team communication style, and approach to medical decision-making (25). Thus, although efforts have been made to make transfers from the NICU to the general wards or ambulatory care more efficient, PICU transitions remain challenging (26). Current Research At present, there are no agreed national professional guidelines for NICU-to-PICU transfers. In the 2023 survey of the PARK-PICU network, 52% of the 81 of 115 responding institutions had no clinical criteria for guiding transfers and only 33% had specific, locally agreed transfer protocols beyond general bedside nursing and frontline clinician handoffs (22). Given the lack of professional practice guidelines, there is utility in adapting evidence-based strategies used in care transitions for patients with chronic critical illness. In a pilot analysis of a 2022–2023 intervention for transitions of chronically ill NICU patients to the ward and/or home, investigators on behalf of the Pediatric Chronic Critical Illness Collaborative (26) developed a video series for families and clinicians, who found videos to be an effective learning method with high educational value. Concerns about the loss of provider-patient familiarity and ineffective transfer-related communication were key themes identified by these groups, which are also relevant for NICU-to-PICU transitions. Similarly, adapting existing continuity strategies for long-stay PICU patients can likely benefit patients transferred from the NICU. For example, consensus statements on continuity strategies for long-stay PICU patients from the Lucile Packard Foundation PICU Continuity Panel promote assigning primary intensivists and bedside nurses to long-stay patients and having regular multidisciplinary team meetings (27). Finally—as we have also learned from the 2023 PARK-PICU survey, see above (22)—institutions with standard protocols for NICU-to-PICU transfers often use multidisciplinary care team meetings, although 38% of those did not include parents/caregivers. Future Directions Despite limited data, institutions are focusing on NICU-to-PICU transfers. Future research should strive to develop evidence-based and/or consensus-based guidelines for effective NICU-to-PICU transitions. These guidelines must leverage social trust with families to facilitate family-centered care during transitions, with overlap in care between the NICU and PICU teams using strategies such as joint team “huddles,” regular inter-ICU meetings, or combined rounds around the time of transfer (22–26). PICU-TO-MICU TRANSITIONS Advances in critical care medicine have resulted in a declining PICU mortality rate. As an example, consider the recently reported 1997–2018 data from the Australian and New Zealand Paediatric Intensive Care Registry linked with the Australian National Death Index (28). In a dataset of 96,743, the investigators found that over the period 1997–2018, the risk of death decreased by 40%. The consequence of such improved survival, and the increasing numbers of medically complex children living into adulthood, is two-fold. On the one hand, this means that adolescents and young adults with cardiorespiratory conditions are being managed on the PICU because of medically complex childhood-onset or congenital disease, as indicated by the 2011–2022 PHIS registry database (29), and the American Heart Association 2000–2018 Get With the Guidelines-Resuscitation data (30). On the other hand, adults with complex childhood-onset conditions or disease are admitted to the MICU. Here, there is a paucity of epidemiological data. We do, however, have a 2008 two-cohort comparison study between the VPS dataset from 70 PICUs in 32 U.S. states, and the project-IMPACT dataset from 50 MICUs in 18 U.S. states (31). The retrospective study showed that patients with chronic conditions comprise 53% of PICU admissions while only contributing to 9% of MICU admissions. In addition, the adult patients with chronic conditions admitted to PICUs were more likely to be younger, had worse baseline functionality, and had an acute issue unrelated to trauma. These historical observations from 17 years ago need repeating and, if such observations are unchanged, they illustrate the possibility that young adults with complex pediatric conditions struggle to transition to the MICU. The reasons underlying this issue, historically, may have been due to a variety of reasons: adult healthcare providers’ and MICU teams’ lack of training/experience in pediatrics; lack of specialized personnel often found in children’s hospitals (e.g., child-life specialists); limited availability of appropriate-sized medical supplies (e.g., tracheostomy tube sizes); and differences in medical culture (e.g., family-oriented vs. patient-oriented). The challenge with PICU-to-MICU transitions relates to removing or mitigating barriers to transition itself, in addition to conducting the transition process smoothly (Table 1). Current Research There has been little research in this field. However, the guiding principles and evidence reported in the 2018 Transitions Clinical Report from the American Academy of Pediatrics (32) states that the absence of a structured pediatrics-to-adult care transition process is associated with increased complications, poorer health and well-being, problems with treatment and adherence, discontinuity of care, increased ED visits and hospital use, higher healthcare costs, and negative family experiences. In response, some children’s hospitals have established specific transitional clinics for medically complex patients to help facilitate care transitions, aiming to develop shared mental models between pediatric and adult providers. However, many of these clinics are illness-specific and primarily conducted in the outpatient setting. There are currently no analogous programs for inpatient pediatric-to-adult transitions. For critically ill patients, MICU admission usually only follows if the patient is already established with adult outpatient healthcare providers; otherwise, the default is to admit the patient to the PICU. Conversely, some patients may be abruptly admitted to the MICU by default because of their age without undergoing an appropriate transition process, which can be confusing and disruptive for patients and families. Future Directions Although outpatient initiatives are underway, future work needs to include the development of processes for effectively transitioning patients with complex and longstanding conditions or disease across all aspects of their care, including inpatient and critical care. A good start would be to investigate and mitigate potential barriers to transition. These may include issues such as: stocking MICUs with pediatric-sized medical supplies; ensuring availability of staff such as child-life specialists and pediatric-trained respiratory care professionals; providing MICU education on pediatric conditions and PICU education on adult age-related disease management; and bridging different critical care cultures. Families of medically complex patients are also often their full-time caregivers at home and are likely accustomed to participating in care alongside PICU providers to a much greater extent than in the MICU (33). Communicating expectations of both families and clinician teams and negotiating roles may thus help to facilitate to NICU-to-PICU transitions, in care with joint and meetings with both teams may help these issues as PICU patients experience a range of transitions, each with unique characteristics that need to be structured programs (Fig. 1). For the less common types of PICU transitions, as in this PCCM Commentary (Table communication tools such as can be to each of and to specific clinical teams’ needs and institutional tools need to an appropriate degree of while principles of information As in improvement understanding each of transition process and how is in specific settings is a to existing work and new workflows, by the for of handoff intervention for transition pediatric institutions and PICUs have varying workflows, and policies care transitions implementation of standard transition programs must involve the of institutional and tools must also be and with the involvement of clinicians, healthcare teams, and patients/families and across clinical teams and including and is crucial differences in in care, and of must be to result in efforts In the 2023 AHRQ report the for improved care at of transitions for hospitalized patients and the threats to diagnostic safety with poor communication. In this PCCM by of response, we focused on research from 2023 and a understanding of future for investigation into the transitions that PICU patients undergo. In interfacility PICU, NICU-to-PICU, and PICU-to-MICU transitions have unique features and which can be through structured communication The implementation of the in research should have a and will be of multidisciplinary PICU

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