Turning Knowledge into Practice for Critically Ill Children
What is the problem??
Each year, Paediatric intensive care units (PICUs) and transport teams in the UK provide lifesaving care for approximately 19,000 children. Mortality has remained static in recent years at around 3%. However, PICUs often face demand which exceeds supply.
The strain on PICUs is influenced by several factors, including seasonal fluctuations in infections like influenza, variable regional availability of high-dependency services, and an increasingly complex medical landscape. This complexity is characterised by more children surviving extreme prematurity, long-stay admissions in PICUs, and requiring long-term ventilation.
Historically, paediatric management strategies have been derived from adult-focused research. This trend is seen in numerous paediatric guidelines and reviews, for example, those advising on the management of paediatric sepsis, paediatric acute respiratory distress syndrome, and paediatric acute liver failure.
Several factors explain reliance on adult research:
- Paediatric critical care, or intensive care, is a relatively new speciality, with the first collaborative research group founded in the 1990s.
- Paediatric studies face ethical constraints and typically involve smaller populations.
The growing demand and complexity of care in the paediatric intensive care unit (PICU) highlight the need for research tailored to children—not borrowed from adult studies. Children aren’t just small adults; their anatomy and physiology are fundamentally different. Applying adult-derived protocols in paediatrics risks delivering care that’s not only suboptimal but potentially harmful.
Growing research activity within PICUs.
Recognising that children aren’t simply smaller versions of adults, research in PICU has gained real momentum over the past 15 years. If you’ve spent time working in paediatric intensive care, you’ve probably come across one of the many national studies currently underway. One example is the PRESSURE randomised controlled trial led by Chief Investigator Dr David Inwald. This study explores whether aiming for a lower blood pressure target in critically ill children brings more benefit than harm—balancing the potential upsides against the risks of hypotension and the treatments needed to raise blood pressure.
Another great example is the GASTRIC-PICU trial, led by Chief Investigators Professor Lyvonne Tume and Professor Mark Peters. This randomised controlled trial tackles a very practical question: Does routinely measuring gastric aspirate—or gastric residual volume—actually help? The study compares standard practice with skipping routine measurements to see which approach is better at helping children meet their energy targets by 72 hours and supporting enteral feeding over the longer term, up to 30 days.
While trials are still in progress and results pending, findings from some significant PICU RCTs that evaluated key interventions within paediatric critical care have recently become available.
Take the FIRST-ABC Step-Down trial, published in 2022. This RCT looked at children who needed respiratory support after extubation and compared two common options: continuous positive airway pressure (CPAP) and high-flow nasal cannula (or “high-flow”). The trial was set up as a non-inferiority study, meaning the team was happy to accept slightly longer support times with high flow, given that it’s often more comfortable for patients and easier for staff to manage. But the results told a different story. Children on high-flow needed respiratory support for longer than the acceptable margin, meaning CPAP came out on top in terms of effectiveness.
Almost everyone who works in paediatrics will have heard of Oxy-PICU (2024). The Oxy-PICU RCT showed that conservative oxygenation targets (88-92%) for ventilated children were associated with a reduced duration of organ support or death compared to liberal oxygenation at 30 days.
At their core, clinical trials aim to generate evidence that can shape practice and ultimately improve care and outcomes for children. But the impact goes beyond the bedside. Sharing the findings from these studies is also a way of honouring the families who generously consented to their child taking part. It recognises their contribution to advancing paediatric care for future patients.
However, in many fields, it has increasingly been recognised that there is a time lag in research translation from bench to bedside, which may last decades.
So, how do we reduce the time lag?
Implementation science is the study of methods for adopting evidence-based practices and, hence, systematically improving healthcare quality. A 2024 systematic review of 129 studies showed that implementation strategies, including educational meetings, audit processes, staff champions, and materials distribution, significantly improve outcomes.
Knowledge mobilisation, the process of ensuring that scientific evidence is shared and applied in real-world settings, is the broader goal of implementation science.
Effective knowledge mobilisation is a core NIHR priority across all medical fields and is crucial within the high-risk field of paediatric critical care. This need is topical and globally recognised. A December 2024 position paper co-authored by 32 paediatric critical care experts, published in The Lancet Child & Adolescent Health, highlighted the implementation of evidence as one of the most pressing global priorities within our field.
How can implementation science benefit children, staff, and the wider health service?
Benefit for children and their families/carers
Key PICU trials, including FIRST-ABC and Oxy-PICU, have found that specific management strategies lead to reduced duration of organ support. Parents of critically ill children consistently value reduced duration of organ support as a high priority in PICU priority-setting exercises.
When high-quality trials give us clear guidance on how to care for critically ill children, putting those findings into practice can make a real difference. If the results are positive, implementation could mean shorter durations on life support, fewer complications linked to prolonged PICU stays, and even better long-term outcomes. All of this aligns with what really matters to families—safe, effective care that supports their child’s recovery and future.
Honouring the children and families who participated in these trials is also vital, fulfilling the promise that their contributions would drive change. Ensuring PICUs use evidence-based practices builds public trust and respects the participation of families in these trials (see Figure 1).
Benefits for health professionals
As described, in December 2024, experts within paediatric critical care identified the implementation of evidence as one of our most important global research priorities.
Implementing evidence-based practices on the ground can also benefit PICU staff. Providing evidence-based care can reduce burnout and moral injury.
PICU staff also prioritise survival and reducing the duration of organ support, key outcomes from these trials. Confidence in evidence-based decision-making enhances staff agency and improves tailored bedside care.
Benefit for health and care services
Large trials like Oxy-PICU (£1.5 million) and FIRST-ABC (£1.3 million) represent major investments—and they’re among the few critical care RCTs to produce clear, positive results. To ensure value for money—for both funders and the public—it’s crucial that we fully implement what these trials have taught us. Using evidence-based practices helps reduce unwarranted variation in care, minimises complications, and shortens PICU stays. That’s not just good medicine—it’s likely to save money, too, especially given the high cost of paediatric intensive care.
At the same time, the PICU community recognises that running one national RCT at a time over many years is slow and inefficient. That’s why the NIHR has recently funded PIVOTAL (NIHR164012), a new national platform trial for paediatric critical care. This pragmatic trial will test multiple research questions at once, with every child admitted to a UK PICU eligible for inclusion. It’s an exciting step forward in trial efficiency—but it also raises the stakes for implementation. Mobilising knowledge from a platform trial will be more complex, and we’ll need robust strategies to ensure findings are translated into practice across the board.
What evidence is out there about implementation science in PICU?
In November 2024, I searched OVID MEDLINE and Embase using the terms “paediatric critical care” alongside “implementation science” or “knowledge mobilisation.” The search returned 85 results—but very few were directly relevant to implementation science in the PICU setting. Most papers focused on quality improvement initiatives, such as hand hygiene compliance or adherence to clinical guidelines like those for traumatic brain injury. What was missing was striking: none of the studies evaluated how to implement evidence-based practices that emerged from PICU trials.
This gap highlights an urgent need for research into implementation science in paediatric critical care. If we want trial findings to make a real difference at the bedside, we need to understand how best to embed them into everyday practice.
Why is implementation science more challenging within PICUs?
Qualitative work emphasises that paediatric critical care faces a uniquely challenging context, which differs from other healthcare settings.
These challenges occur for several reasons. Teams work at near capacity under significant pressure. High-stakes decisions are made rapidly, hindering strict adherence to protocols. Teams are multi-faceted, necessitating targeting many groups. Hierarchical care means certain stakeholders have disproportionate sway. Family-centred care adds an important dynamic. Consequently, generic knowledge mobilisation studies are poorly applicable.
Looking ahead, there’s a clear need for research that goes beyond the trials themselves. In PICU, we need to measure how well the findings from key RCTs are being implemented, and identify the real-world barriers and enablers to putting evidence into practice. Crucially, future work should involve co-designing implementation strategies with those at the heart of PICU care—clinicians, researchers, and families. That’s how we ensure knowledge mobilisation isn’t just a buzzword, but a meaningful part of improving outcomes for critically ill children.
How can we achieve knowledge mobilisation within PICUs?
For anyone interested in implementation science in paediatric critical care, the 2023 position paper from the newly formed ECLIPSE group (Excellence in Paediatric Implementation Science) is a must-read. This multinational collaboration shines a spotlight on just how little implementation research exists in our field while powerfully arguing why we urgently need more. The paper is an excellent starting point for PICU professionals keen to explore this space, offering clear definitions, context, and a foundation in the existing literature.
Other than studies describing adherence to neurocritical care bundle programmes or guidelines, and a number of other implementation projects in non-PICU settings, a key PICU-based implementation project was cited, the ‘PICU Up!’ early mobilisation programme led by Prof Sapna Kudchadkar at Johns Hopkins in the United States. PICU Up! utilised educational resources to implement early mobilisation guidelines. The project found that post-implementation, the median number of mobilisations per patient by PICU day 3 increased from 3 to 6, and no adverse events occurred. This multidisciplinary project is a great example of future implementation work in PICU.
What is next?
I am hoping to lead a national research project that will quantify the implementation of key RCTs in paediatric critical care. This project will be called IMPACT—IMPlementation of PAediatric Critical Care Trial findings into practice.
- Firstly, I will use a data-based approach to identify whether and how much key trials have changed practice.
- Secondly, I will undertake mixed-methods research alongside key stakeholders, including families, to identify the best ways to develop knowledge mobilisation strategies for trials in future.
By establishing effective implementation strategies in PICU, we will create a scalable model that can support knowledge mobilisation from trials with complex designs and national scope, including platform trials.
If this topic sparks your interest and you’d like to explore it further, I’d love to hear from you. I’m keen to connect with PICU professionals from all disciplines to talk about how we can work together to drive knowledge mobilisation in paediatric critical care. Let’s make evidence-informed practice the norm—get in touch!
The bottom line
PICUs face increasing pressure in the context of seasonal variations, high bed capacity constraints and an evolving population of increasingly complex children.
New trials including FIRST-ABC, Oxy-PICU, GASTRIC-PICU and PRESSURE are paving the way for evidence-based, paediatric-specific care that could change practice and improve outcomes.
Understanding and overcoming the unique challenges inherent to PICU, including high-stakes decision-making and complex team dynamics, is essential for translating research into the real world.
Overall, conducting new trials is just as crucial as knowledge mobilisation – ensuring research findings are effectively translated from bench to bedside to achieve real improvements in the children we look after.
About PICSTAR
PICSTAR is a trainee-led research network open to all doctors, nurses and allied health trainees within Paediatric Intensive Care. We are the trainee arm of the Paediatric Critical Care Society – Study Group (PCCS-SG) and work with them on research, audit and service evaluation.
If you would like to join PICSTAR and get involved in projects, have ideas you would like to propose or get advice/mentorship via PCCS-SG, don’t hesitate to contact us at picstar.network@gmail.com. See their website for more: https://pccsociety.uk/research/picstar/
References
1. Paediatric Intensive Care Audit Network (PICANet). National Paediatric Critical Care Audit State of the Nation Report 2024 2024 [Available from: https://www.picanet.org.uk/wp-content/uploads/sites/25/2024/12/PICANet-NPCCA-State-of-the-Nation-Report-2024_v1.0-12Dec2024.pdf accessed 23rd December 2024).
2. NHS England. Paediatric Critical Care and Specialised Surgery in Children Review 2017 [Available from: https://www.england.nhs.uk/wp-content/uploads/2017/06/paeds-review-demand-capacity-analysis-v1-5.pdf accessed 23rd December 2024).
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