Challenges in Pediatric Neurocritical Care, Clinician Demographics Identified in Survey

Raquel Farias-Moeller, MD

A recently performed survey-based study provided a scope of the characteristics and practice of child neurologists who self-identify as “intensive care neurologists,” including the top challenges they face and top priorities they feel are needed for an ideal pediatric neurocritical care service.

Led by Raquel Farias-Moeller, MD, assistant professor of neurology, Medical College of Wisconsin, the investigators sent a survey that included questions about demographics, training, pediatric neurocritical care service and job structure, teaching, academics, challenges, and views on the future of pediatric neurocritical care, and received responses from 55 child neurologists. The findings were intended to serve as a framework that can be utilized to perform subsequent studies of pediatric neurocritical care and the physicians who lead those teams.

Of those who responded, the majority (78%; n = 43) were between 31 and 50 years of age with at most 10 years of experience practicing neurocritical care. After completing child neurology training, 82% (n = 40) of the cohort claimed they pursued subspecialty training, while 27% (n = 13) claimed they pursued more than 1 subspecialty. All but 2 of those pursuing subspecialty training in pediatric neurocritical care reported practicing for less than 10 years, and the majority had been practicing for less than 5 years (64%; n = 7).

Institutional characteristics showed that most respondents practice at either university-based hospitals (66%; n = 36) or freestanding pediatric hospitals (56%; n = 30), which include more than 45 pediatric ICU and cardiac ICU beds. Pediatric critical care neurology services often composed of 6 or fewer attendings (66%; n = 29), staffed solely by neurologists (80%; n = 36), and included advanced practice providers (56%; n = 24).

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"Future research directed at pediatric critical care neurology practice variabilities, regionalization of care to centers with pediatric neurocritical care for specific neuro- critical care conditions, as well as the linkage of pediatric neurocritical care to outcomes utilizing standardized measures are pathways to enhance the field of pediatric neurocritical care," Farias-Moeller et al wrote.

The top 3 challenges reported by respondents were competing demands for time and focus, excessive volume, and communication with the critical care medicine team. When asked about their top priorities in an "ideal pediatric neurocritical care service" if money or time wasn’t an issue, respondents claimed their top focuses would be services comprised of attendings with subspecialty training in pediatric neurocritical care, attendings with subspecialty training in a field related to pediatric neurocritical care, and joint rounding with the critical care medicine team.

Child neurologists interested in pediatric intensive care neurology were also asked about their ideal training pathway. The top 3 choices recommended by respondents, not taking into account rank order, were a pediatric neurocritical care fellowship (83%; n = 29), a pediatric neurocritical care and epilepsy/clinical neurophysiology fellowship (57%; n = 20), or a pediatric stroke fellowship (34%; n = 12).

Four of the 7 respondents who answered the open-ended question about the future of pediatric neurocritical care shared the same common theme, which emphasized also focusing on the importance of nonacute aspects of care, for example, family meetings and palliative care considerations.

Respondents had a mean of 16 weeks (IQR, 7-18) dedicated each year to covering a pediatric neurocritical care service. While providing neurocritical care coverage, respondents simultaneously covered a median of 4 (IQR, 3-5) separate services, with the majority performing an average of 6-15 new consults and working over 70 hours per week. Additionally, 89% (n = 31) of respondents spent at least 1 full day per month in clinic and almost half (49%; n = 17) spend 5 or more days in clinic per month, most frequently staffing general neurology clinics and/or resident clinics.

Despite some of the inconsistencies in data, the Farias-Moeller et al referenced progress made within the space. A 2014 evaluation by Riviello et al described the inadequate practice of pediatric neurocritical care by the child neurologist, recommending the continued development of pediatric neurocritical care services, various levels of training needed for these services, development of treatment guidelines and protocols, improvement of multimodality monitoring for pediatric neurocritical care, and the need to perform clinical and basic science research to improve care.²

"Based on the results of our survey, the development of pediatric neurocritical care services appears to have evolved around a consultative model, and this is in keeping with prior reports," Farias-Moeller et al wrote. "However, within the consultative model, we found considerable heterogeneity; for example, the complement of intensive care units covered by respondents’ critical care neurology services varies widely, as does the call structure, ICU EEG interpretation practices, and incorporation of advanced practice providers. There remain gaps in our understanding of what constitutes the ideal pediatric neurocritical care service, and it is likely that the variability observed in this cohort, at least in part, reflects diverse institution-specific child neurology practice structures and resources."

REFERENCES
1. Farias-Moeller R, Jayakar A, Guerriero RM, et al. Pediatric critical care neurologsts in the United States and Canada: a survey of clinical practice experience. J Child Neurol. Published online January 17, 2022. doi:10.1177/08830738211070099

2. Riviello JJ, Chang C. The practice of pediatric neurocritical care by the child neurologist. Semin Pediatr Neurol. 2014;21(4):299‐ 302. doi:10.1016/j.spen.2014.12.007