Quality and capacity indicators for hospitalized pediatric oncology patients with critical illness: A modified delphi consensus

Abstract

Background: Hospitalized pediatric hematology-oncology (PHO) patients are at high risk for critical illness, especially in resource-limited settings. Unfortunately, there are no established quality indicators to guide institutional improvement for these patients. The objective of this study was to identify quality indicators to include in PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), an assessment tool to evaluate the capacity and quality of pediatric critical care services offered to PHO patients.

Methods: A comprehensive literature review identified relevant indicators in the areas of structure, performance, and outcomes. An international focus group sorted potential indicators using the framework of domains and subdomains. A modified, three-round Delphi was conducted among 36 international experts with diverse experience in PHO and critical care in high-resource and resource-limited settings. Quality indicators were ranked on relevance and actionability via electronically distributed surveys.

Results: PROACTIVE contains 119 indicators among eight domains and 22 subdomains, with high-median importance (≥7) in both relevance and actionability, and ≥80% evaluator agreement. The top five indicators were: (a) A designated PICU area; (b) Availability of a pediatric intensivist; (c) A PHO physician as part of the primary team caring for critically ill PHO patients; (d) Trained nursing staff in pediatric critical care; and (e) Timely PICU transfer of hospitalized PHO patients requiring escalation of care.

Conclusions: PROACTIVE is a consensus-derived tool to assess the capacity and quality of pediatric onco-critical care in resource-limited settings. Future endeavors include validation of PROACTIVE by correlating the proposed indicators to clinical outcomes and its implementation to identify service delivery gaps amenable to improvement.

Keywords: clinical cancer research; pediatric cancer; translational research.

FIGURE 1

Flow diagram of studies selection. The PRISMA flow diagram details the process of article identification and selection for inclusion. The initial database search resulted in 749 records; after duplicates removed, 680 abstracts were screened. This process left 74 records to assess for eligibility by screening the full‐text articles. An additional six records were identified from other sources. Twenty‐four articles were finally included for the development of quality indicators. PRISMA = preferred reporting items for systematic reviews and meta‐analyses

FIGURE 2

Modified delphi study algorithm. An initial set of 290 possible quality indicators were identified. The focus group narrowed the list to 175 potential indicators to be included in the consensus rounds. Only indicators with high median importance (score of 7‐9) in both relevance (captures key aspects in the clinical process) and actionability (can be acted upon to improve patient care) and ≥80% evaluator agreement were selected as part of the final set of capacity and quality indicators

FIGURE 3

Percentage of quality indicators that achieved consensus. The final PROACTIVE tool contains 119 capacity and quality indicators. The experts added four new indicators and merged two indicators after round one, totaling 178 indicators for ranking on a scale of 1‐9. A total of 115 indicators achieved consensus after three consensus rounds. The focus group rescued seven indicators and combined three indicators, totaling 119 indicators that were finally accepted into the PROACTIVE tool