SCCMPod-575 PCCM: Bridging Care Between the NICU and PICU

Dr. Madden: Hello and welcome to the Society of Critical Care Medicine podcast. I'm your host, Maureen Madden. Today, I'm speaking with Dr. Philip Cohen, MD, MSC, about the article, Non-Emergent Neonatal ICU to PICU Transfers in the United States, Cross-Sectional Survey of Neonatologists and Pediatric Intensivists, published in the May 2026 issue of Pediatric Critical Care Medicine. To access the full article, visit pccmjournal.org. Dr. Cohen is a T32 Research Fellow in Pediatric Critical Cardiopulmonary Disease in the Division of Pediatric Critical Care Medicine at the Johns Hopkins School of Medicine, Johns Hopkins Children's Center in Baltimore, Maryland. A graduate of the MHS in Clinical Investigation through the Johns Hopkins School of Public Health Graduate Training Program in Clinical Investigation, Dr. Cohen's research focuses on improving delivery of critical care for the benefit of patients, parents, and providers. So welcome, Dr. Cohen. Before we start, do you have any disclosures to report?

Dr. Cohen: Thank you so much for having me, Maureen. I'm thrilled to be here. I do not have any disclosures to report.

Dr. Madden: Excellent. So before we start, congratulations on having this research published. I'm very excited about it.

I've only worked in pediatric critical care for my career. And I will tell you that I have experienced the non-urgent transfer of the NICU to the PICU. And my experiences certainly were reflected in some of the discussion that you had in your article.

So I'm excited to have the opportunity to talk to you about it. First, what prompted this original research? I mean, this article we're discussing today comes on the heels of the original research.

So you have two articles that have been published regarding this. So what prompted your interest in this?

Dr. Cohen: Well, thank you, Maureen, for that background and for the question. Like you, I had experienced these non-emergent NICU to PICU transfers as a resident, as a frontline clinician resident in the PICU, as a hospitalist in a PICU, and then as a fellow in a separate PICU where I'm training now at Hopkins. And when I was tasked with figuring out what I wanted my fellowship research to be, I really wanted it to be about something that I thought was an issue, a problem, something that wasn't working well in the ICU environments that I'd been in.

And I was thinking about being a fellow and looking towards 30 years in a career and thinking about the things that are going to either make this job wholly engrossing, exciting, worthwhile, what I went into it for versus things that were pain points. And if there were pain points that I thought I could start to address with some fellowship research, that was going to be the most worthwhile effort to take. And so as a first-year fellow, we had a couple of transfers from the NICU to the PICU non-emergently and things didn't go great.

Kids who came down on high ventilator settings and we had worked up for sepsis and paralyzed increased sedation on within 48 hours of them arriving to the PICU or an infant who was transferred and parents were quite upset with how different things were in the PICU than the NICU. And it got me wondering and thinking about what people do about this nationally and how we can start to address this pain point. And so this was a tremendous opportunity then to start to look into that.

And when I looked into the literature, there just wasn't a lot there. So you talked about your lived experience and how some of that is echoed in what you read in PCCM. And what I wanted to do is see what evidence we could provide or what results, I guess, would come from investigating what people do and what those experiences are like, start to build that evidence base.

Dr. Madden: So I've had a long career and you're projecting a long career, which I love. And looking at this, as we both kind of alluded to, this is a small, and your research actually states it, it's a small number of transfers per year. So the need to look at this is not necessarily high risk, but high acuity.

And I'm a strong advocate on family-centered care. And as you clearly stated, how well the parents, the transition that goes with this, how well they have been either prepared for it or anticipatory guidance, I guess, is a big concern for mine. And also thinking about with a small number of transfers that the personnel, so the frontline providers, they're not having this experience very often either.

So there's going to be a need to continually educate providers about standardization or protocol if it actually exists. So let's talk a little bit about that.

Dr. Cohen: Yeah, I think it's a great question. I think, as you've stated, the median number of non-emergent transfers annually was five or six in each hospital. And so we're talking about relatively rare events.

Now these kids are in hospitals for six, nine, 12 months, even longer at a time. And so if you're looking at bed days, it's quite a larger number, obviously. But in terms of growing protocolization and having culture embedded within an institution that can make these transfers effective, I think there are two major points that can help do so even with these small numbers.

One is that what's come across in some of the survey results is how important it is to have champions of these processes. And so whether it's unit medical directors, nurse managers, other invested attendings, or APPs, other individuals who are invested in this work who can help champion this work, not necessarily by saying I'm going to be the primary attending for every patient who comes down to the PICU or transfers from the NICU, but just sort of being involved in that process and help facilitating it along. And I think the other main point and probably the more important thing is what's come out in terms of just trying to incorporate thinking about and talking about these patients in the systems that already exist.

So in places that have complex care rounds or have bronchopulmonary dysplasia teams, in places that have sort of discharge rounds in the NICU, how do we sort of incorporate PICU stakeholders into some of these things that already happen on a weekly or monthly basis so that we are thinking about these kids long before they're actually being transferred to the PICU. And so some of it's trying to leverage the many ways in which our institutions individually try to keep track of and move our patients along in sort of these existing meetings and other spaces.

Dr. Madden: Yes. And at the same time, though, I'll tell you from, as you said, my lived experience, these are non-emergent transfers. And oftentimes, the impetus is bed availability.

So all of a sudden, they're anticipating where they have an influx of new patients to the NICU, and this child, either by weight or by age, can be transitioned. So that's how they're selected as the one to be transferred. So all of a sudden, this is occurring, and you're missing what you just spoke about, though, because they weren't necessarily anticipating that this is the child who's going to be moved or transitioned to another type of facility.

They were still going along in their routine and hoping to improve this child's care to the point that potentially being discharged to home. So now all of a sudden, something changes, and the missed opportunities of what you discussed have really gone by.

Dr. Cohen: Yeah. I think that certainly came out in some of the survey responses as sort of how do we... The reality is bed throughput and census is going to dictate a lot of sort of the pressure to get kids transferred.

I think the experience, at least we've had at Hopkins, as we've started to build our own process to try to standardize transfers is that we've just made sure that we are starting to talk about these kids long before they might actually need to be transferred. So what comes through in the survey responses too is that this shouldn't be two days before, a week before we start talking about this kid. It should be weeks to months before we actually are transferring patients that we're starting to get some of this information.

I think the other part of this is once you have a standardized process in place, it can be a checklist of things. There can be hard stops in that to say, if we haven't had this pre-transfer meeting with families and providers from both teams yet, it will not be accepted to the PICU. Sometimes we do have to draw hard lines to say, while clinically there might not be a specific reason we're not moving this kid, there's still a hard stop to say we're not going to transfer this patient at this very moment.

I think the places where we've seen the most positive responses about effectiveness have drawn some of those hard lines in the sand and that's just become part of the norm there then. You have to establish something and then people start to abide by it because we see that's the culture and that's what we're doing.

Dr. Madden: Absolutely. As you speak about that, I looked at some of the variables in terms of standardization or what they included in their protocol. I will say that I was surprised at some of the variables that were listed in the table, particularly in terms of attending to attending or frontline provider to frontline provider handoffs, and that it wasn't 100%.

Tell me your thoughts about that.

Dr. Cohen: I've noted that too when we were doing the data analysis. I think, Maureen, some places where there may just be an attending in-house, so maybe that place is only the attending is signing out for whatever reason, or, wow, we think these kids are so complex that we definitively want the attending involved and we're, for some reason, are not going to include the frontline clinician, which feels like that should be pretty rare. Now, there are plenty of places from just my own discussion with colleagues around the country where attendings may not be getting direct handoff on all the patients who are coming up or down from the NICU to the PICU, and that may be all that's relied upon is frontline clinician handoff.

I think what comes through from the survey responses and from some subsequent work that we've done is how important it is to have handoff at these multiple levels all completed and to try to improve communication by making sure that as many people as part of the care team can be included in that handoff are included.

Dr. Madden: Absolutely. These are, as you said, individuals, children who have been hospitalized for their entire lives at this point in time, and maybe for a very long period of time, and they have that degree of complexity. So, my own opinion, I'd love to see 100% across the board there.

You got 100% for bedside nurse handoff, thankfully, but whether or not you consider it requires an attending to attending or an APP or a resident or fellow handoff, I'd love for this work to start to drive those numbers up to achieve the 100%. So, when you talk about in your discussion the standardization and evaluation of effectiveness, is there a definition of effectiveness that you used?

Dr. Cohen: You know, this is one of the hard parts of doing some survey-based research is you don't want to inundate your respondents with lots more explanation than is necessary if you want people to complete things, right? And so, we thought effectiveness was a word that could have some subjective interpretation, but that was at least, you know, something that we all talk about all the time in terms of the care that we provide. And so, we left a little bit of that up to the eye of the beholder or the respondent themselves, acknowledging that there's going to be some differential interpretation there.

Dr. Madden: Okay. And, you know, going on the side of the parent and family of this child. So, if they haven't had adequate preparation and it becomes a short period of time, all of a sudden that their child's being transferred, they're going to be understandably nervous about this.

And it all depends upon how it's framed for them. Oftentimes, it's framed. Oh, this is a progress.

This is a step forward versus bed space and throughput. That how do we ensure with a protocol or a standardization that all of these elements are included? So, you've talked about that it's valuable for broader adaptation or adoption.

And the numbers in your survey demonstrate that it really doesn't yet exist. So, how do you think the influence of this publication and your research will push this?

Dr. Cohen: You know, it's been fascinating. So, as a trainee, right, having the privilege to do this work and get it published during fellowship and the previous publication that you mentioned, which was a survey of intensivists meant that I was able to go and present this at conferences nationally and internationally and talk to a bunch of people and get people's feedback. And, you know, the number of people who pulled me aside to ask, okay, what should we be doing?

Give me the three things that we need to do, right? Or what's the right age to transfer a kid? And I think it went to show me how much interest there is in trying to get this right amongst our colleagues nationally.

And that was exciting for me and sort of has helped inspire me to continue this work and see where it can go. I think ultimately what's clear is that in this country, children's hospitals are too heterogeneous to say these are the five things that have to happen. I think where this is all going more likely is that, okay, these are the things that we want to affect.

We want to make sure that parents feel that they are partners in this care and that their voices are being heard. That's important to all of us, right? We want to make sure that we're thinking about what's best for the patient in terms of timing and not what's best for bed throughput and census, right?

So, there are multiple ways of doing all of these things. And at different institutions, there may be four different ways of addressing this one issue, right? For census, for example, you could say, we're going to schedule these transfers like OR dates and make sure that they're on the schedule like an OR would and talk about them in our morning huddle like ORs and therefore they're going to happen that day.

You could say, there's just a hard rule that we don't do these transfers on nights and weekends, right? There are different ways of trying to put that in place in terms of making sure parents feel heard and seen and can ask their questions. Is it that everybody has to have a pre-transfer multidisciplinary meeting with the family?

Not necessarily. That may work for a lot of places, but it may just mean that a PICU consult comes and talks to the family and there are sort of background conversations between the care teams and or that the family comes and tours the PICU with someone from the pediatric ICU and can ask their questions and sort of hear about how things are different. So, I sort of envision this as there are going to be themes or things that we definitely want to address with any protocol, but that the exact actions taken to address those themes are going to be dependent on one's own children's hospital and how it makes sense within that institution to try to make this a reality, right?

Getting back to the idea that this has to be something that can happen practically. And so, what you don't want to do is try to impose a certain protocol on any place. You want this to be something that can sort of organically work within the sort of the structure and processes that already exist in that hospital.

Dr. Madden: Absolutely, but at the same time, there are elements that are universal. So, there are some ways to think about whether or not on your side or the people you've worked with on this research, is there a role for development of a tool that has some kind of implementation science into it where you improve standardization? It's kind of like the checklist of one day, or when you're taking a transport intake and knowing that you have something in front of you that delineates all of the steps or all of the elements and that can then be customized to suit the environment or the institution, etc.

I love that you said that the parents come and tour, that they come to see the new environment. So, it decreases some of the, hopefully, decreasing some of the anxiety and the stress by getting, you know, visualization and answers up front because they've now spent months somewhere and we know that we do speak differently about clinical care and some of the decisions and maybe to negate, as you said, when you've had the experience of a child transferring and now all of a sudden, because we don't know them as intimately as the NICU environment personnel have, that we're doing a sepsis work on them or we're doing, you know, we're paralyzing them and going up on their ventilator settings maybe to avoid some of those things.

So, what do you think? Do you have a role going forward in this?

Dr. Cohen: Well, I certainly hope so. Thanks for the question, Maureen. I think that's where this is all leading is developing a tool and I think the key is that it's adaptable, right?

And saying it doesn't have to be A, B, and C, but it has to be something in this category for A and something in this category for B. And that's what I mean by being adaptable to different institutions. I think the fact is that with, you know, five median non-emergent transfers annually at, you know, most centers that we're going to need to band together as multiple institutions to try to perform the study that's going to provide the evidence that really moves this work forward.

And so, I'm thrilled to be here because part of the excitement of being here is I can reach out, say to the SCCM community, you know, if there are other institutions that want to partner on implementing something and, you know, investigating how that changes the results of these transfers. And we're excited to do that, certainly at Hopkins and among some of our partner institutions. So, I think that's what it's going to be.

This work is ripe for implementation science. We just have to have a big enough N and a big enough group of slightly heterogeneous places coming together to implement this stuff in order to actually build the evidence base about just how standardization and protocolization can affect patient outcomes, sort of caregiver understanding and perceptions of hospitalization, as well as our provider satisfaction with how these transfers go with our jobs, which is, you know, the other part of this work that's important to me.

Dr. Madden: Absolutely. Well, I'm going to push back at you though a little bit. Yes, there's absolutely still a need for the research and to get all of that.

But to wait on some of that research where we really do know some of the elements that are necessary, the fundamentals or the foundational pieces, that you can start to drive this forward with this group of institutions. You already have a captive group that they can start to come together to look at what does that adaptable tool look like without waiting for the science. It's more now going into quality where you're going to continue to refine it.

Or as we said, they're going to adapt it to the individual environment.

Dr. Cohen: I think that's totally true. Where I'd wait still and take a pause is, you know, what's clear from this is how important other stakeholders are, not just physicians. And so all the work that we've done and published so far has been on physician perspectives on these transfers.

I think having our APP colleagues, our nursing colleagues also sort of provide some input before we say this is the tool. And most importantly, it is caregivers, right? I mean, this work is important because it's about maintaining that therapeutic relationship with caregivers.

And so until their voices are part of this evidence base, then I would have a lot of reluctance in saying, you know, this is the tool we should move forward. And so that's some of the work that we're doing now is trying to incorporate our parent and caregiver perspectives, sort of to make implementing a tool in any QI work that's being done involving all the key stakeholders when we do it.

Dr. Madden: Excellent. Well, I'm very excited that you've already taken those steps forward. And one of the discussion points I wanted to touch on, but you've started already, is the impact of this work.

So you've already had people, as you said, when you presented, come up to you individually, which is wonderful. And now you have this new publication. And I'm anticipating that hopefully the dissemination of this is not just via the podcast, but that you'll have other opportunities to highlight this in larger audiences and have that personal engagement.

But tell me, you've already alluded to additional work. What's your future of this type of work that you're doing?

Dr. Cohen: Yeah, I think first and foremost, it's really getting those other stakeholders input like we were just talking about. So I think the hard part, frankly, is there are great groups, and we've partnered with some of them, of NICU parents, and some good groups of PICU parents. But this subset of patients that are NICU to PICU patients, they don't necessarily have a national organization that brings them all together.

So finding caregivers that come from multiple institutions is just difficult all in one fell swoop. And so we are working on reaching out to, again, these groups that they might be part of just by other identifiers of them, but that's been the challenge. But I think until we have caregivers and parents involved in this work, it can only be so meaningful.

And then the second part of this, and my own experience tells me that a lot of the time when these patients are transferred, it can be a pain point for physicians, sure. But the fact is that if something goes not well or not perfectly at the bedside, it's often via discussions with nursing and through that sort of group that complaints and discussions, productive conversations happen. And so making sure that we're partnering closely with our nursing colleagues while we try to build the right tool or checklist to make these transfers happen is, I can't stress how important that will be to this work.

And so that's the next step to try and to make sure that this work can move forward in a way that actually includes all key stakeholders and can do right are, again, patients, providers, and caregivers.

Dr. Madden: I like your vision of your stakeholders. I'd want to put a plug in that you also have as part of your variables, both pre and post follow-up transition that because we're talking about transfers within the same facility, you still have accessibility to that NICU group of providers that cared for this patient for so long that having some continued, for a short period of time, probably, having them come in and review how the patient's doing, any questions, any updates that maybe prevent some of those investigations that we've done because we were less familiar with the patient or just as a reassurance for all providers that the transition has been optimized.

So just putting a plug in for that one.

Dr. Cohen: Yeah, I think that's right. Having some sense of overlap, right? When the PICU being present in the NICU prior to transfer and the NICU can be present in the PICU post-transfer and letting families see that.

We talk a lot. I think that the inclination among intensivists and I think among neonatologists too, based on the discussions I've had, is that these are very different units and we do things so differently. And there's evidence to suggest that that's true, but I think if we are only emphasizing that to families or that's what's coming across to families, then we are shooting ourselves in the foot.

I think the fact is that, by and large, we are much more similar in how we operate and how we think about patients and what we want for patients, certainly, and how we want to partner with patients than we are disparate. And so trying to emphasize to families that there is some continuity in philosophy is also important when we do this work.

Dr. Madden: Absolutely. And from my own experience with these long-term hospitalizations, families do have their everyday lives and they do have to return to them and resume to them. And it's been identified personally that there's a difference in NICU families versus potentially PICU families, you know, so they may not have the opportunity to be there each and every day or whatever, but they're still wanting to be updated and informed.

So ensuring these transition pieces and that they have an appreciation, I think it really is quite important, as you just said. So I really do appreciate that. And we're about at the end of our time.

So I just wanted to make sure, though, is there anything else that we haven't brought up or touched on that you would really like the audience to hear?

Dr. Cohen: I think, you know, that the motivation for this study that we're discussing today, this survey of neonatologists, was to show that for this incredibly complex patient population, that there is consensus among neonatologists and intensivists, despite our many evidence differences, that there's consensus, that standardization and protocolization is desired for these patients, and that there's some association or evidence that it seems to be working and that we think we're doing a better job when we do standardize and protocolize.

And that's true across both units. So that's just to say, there seems to be motivation, energy, and agreement from both units that it's worthwhile to pursue those things. So sort of a little bit of just a reassurance and call to action for intensivists across the country and people working in pediatric ICUs across the country that, you know, our neonatologist colleagues are our partners in this.

And then, you know, certainly my goal and the goal of many of us is that we can improve these transfers over the next couple of years and get to a place where we really do feel like we're in a different spot and that we are, you know, supporting these families and patients as effectively as possible.

Dr. Madden: Well, I'm very interested to see how your continued body of research and work comes out. I think it's incredibly worthwhile and congratulations for that. So at this point, this concludes another episode of the Society of Critical Care Medicine podcast.

If you're listening on your favorite podcast app and you like what you heard, consider rating and leaving a review for the Society of Critical Care Medicine podcast. I'm Maureen Madden.

Announcer: Maureen A. Madden, DNP, RN, CPNC, AC, CCRN, FCCM, is a professor of pediatrics at Rutgers Robert Wood Johnson Medical School and a pediatric critical care nurse practitioner in the Pediatric Intensive Care Unit at Bristol-Myers Squibb Children's Hospital in New Brunswick, New Jersey. Join or renew your membership with SCCM, the only multi-professional society dedicated exclusively to the advancement of critical care.

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