Transforming pediatric intensive care unit outcomes in pediatric hematology-oncology and hematopoietic stem cell transplantation through golden hour care in a low- and middle-income country: a 10-year analysis.

Abstract

Objective: To evaluate the impact of a care improvement bundle focused on early intervention, communication, and multidisciplinary collaboration by comparing outcomes across two 5-year periods before and after its implementation.

Methods: A single-center, retrospective study was conducted in the Onco-Critical Care pediatric intensive care unit of a tertiary cancer referral hospital in South India, comparing outcomes from two eras: the pre-bundle cohort (2014 - 2018) and the post-bundle cohort (2019 - 2023). The study included children aged 1 month to 18 years, excluding those with postoperative, palliative, and end-of-life conditions. The care improvement bundle, introduced in 2019, aimed to enhance communication between oncology/transplant teams and the pediatric intensive care unit, enabling timely recognition and intervention ("golden hour care") for at-risk patients on the wards. The pre-bundle cohort had 4,000 hospital admissions and 533 pediatric intensive care unit admissions; the post-bundle cohort had 5,007 hospital admissions and 760 pediatric intensive care unit admissions.

Results: From 2014 - 2018, 516 hematopoietic stem cell transplantations and 336 new oncology cases were managed; from 2019 - 2023, these increased to 579 hematopoietic stem cell transplantations and 784 new oncology patients. Despite increased pediatric intensive care unit admissions and a higher proportion of transplanted infants in the later cohort, pediatric intensive care unit mortality declined significantly from 21.8% to 11.4% (p < 0.0001). The use of costly interventions decreased, with invasive ventilation dropping from 30.9% to 18.0% (p < 0.0001) and renal replacement therapy from 14.8% to 4.3% (p = 0.0001), indicating both improved outcomes and reduced resource utilization.

Conclusion: The implementation of a care improvement bundle to foster interdisciplinary collaborative communication and earlier recognition of critical illness enabled golden hour care on the floors, resulting in significant improvements in outcomes for pediatric oncology and hematopoietic stem cell transplantation patients. This care improvement bundle is feasible, easily scalable, and can be systemically incorporated across the centers.