Services or providers that may not be available at the tertiary PICU may be provided by another PICU. Data exist to support improved outcomes in children requiring specialized services when cared for in tertiary or quaternary facility or specialized level of care (512,19,20,2225). Extracorporeal membrane oxygenation rescue for cardiopulmonary resuscitation in pediatric patients. Pediatric Critical Care Medicine20(9):847-887, September 2019. Registered users can save articles, searches, and manage email alerts. No articles were found evaluating PICU discharge criteria, and only 14 relevant studies were found evaluating outcomes related to unplanned PICU readmissions, including impact of rapid response teams and Pediatric Early Warning Score. The Voting Panel reached 100% consensus that all CMC PICUs may outsource some, if not all, of their critical care transport activities; however, the transport service must have training in pediatric emergency and critical care. Hemodynamic monitoring must include the ability to monitor and capture heart rate and rhythm, blood pressure, oxygen saturation, central venous pressure (CVP), left atrial pressure, and pulmonary artery pressure if indicated. Competencies needed by graduate respiratory therapists in 2015 and beyond. Intensive Care Med 2012; 38:741751, 14. A tertiary PICU should have a quality program that evaluates its practice and compares risk-adjusted patient outcomes against similar institutions and national benchmarks. After matching, more pediatric cardiac surgery patients were cared for in a dedicated cardiac ICU than a nonspecialized PICU (6.2% vs 5.2%), and the majority of patient outcomes were better including mortality, reintubation, and good neurologic outcome. However, data evaluating the impact of 24/7 intensivist coverage on ICU mortality are mixed with recent adult studies revealing no impact (27,42,75). All CMC PICUs should have a unit-specific standardized program for QI and safety metrics. Although the patient population is defined as people younger than 18 years old, those 18 years old and older may be admitted to a PICU because of the disease process that is deemed best cared for by pediatric subspecialists and critical care experts. Inhaled nitric oxide (iNO) is an effective agent to treat acute pulmonary hypertension in children. Table 2 outlines the resources appropriate for each PICU level of care based on the Delphi results and task force consensus. Am J Crit Care 2016; 25:e9e13, 176. Units may be classified by one or more of the following designations: Regardless of what type of facility in which the PICU is located, specific criteria in the following areas should be in place. Found inside Page 4 Organ Dysfunction Score ) DORA ( Dynamic Objective Risk Assessment ) PELOD ( Pediatric Logistic Organ Dysfunction ) PIM ( Pediatric Index of Mortality ) ICU Admission Criteria Deciding when a pediatric patient needs intensive care Found inside Page 597FIG 20-1 A BJC Hospice Wings Pediatric Palliative Care and Hospice program nurse meets with one of the children benefiting Many hospice programs have admission criteria that do not permit therapies such as intravenous antibiotics, Incoming transports may also be from another PICU lacking a specific service or provider that is available at the receiving CMC PICU, whereas outgoing interfacility transports are usually attributable to need for a provider or service that is not available at the CMC PICU (see relationships with other PICUs above). Goal length of stay (GLOS) Lobos AT, Fernandes R, Willams K, et al. Heath B, Salerno R, Hopkins A, et al. Of the remaining 25 statements, 17 reached consensus cutoff score. addresses, at a minimum, patient admission, patient care, discharge and transfer criteria. Although consensus was not met, tertiary PICUs should at least be involved in providing community outreach through educational events that focus on technical skills needed for stabilization, resuscitation, and communication for the triage and transport of critically ill and injured children. Expertise in the care of the critically ill child is required in all PICU levels of care. Ann Pharmacother 2010; 44:432438, 39. Valentin A, Ferdinande P; ESICM Working Group on Quality Improvement: Recommendations on basic requirements for intensive care units: Structural and organizational aspects. The variety of equipment and technologies as well as their cost is continually evolving and may not be available in a CMC PICU. Outcomes of critically ill children requiring continuous renal replacement therapy. The HARRPS Tool is a collection of questions that calculates an overall readmission risk score for a pediatric patient. Dr. Coss-Bu disclosed that he is on the malnutrition committee for the American Society of Parenteral and Enteral Nutrition and the Young Investigator Research Award Committee for the Society of Pediatric Research. With an average patient volume of 863 and sd of 341, the investigators found a significant inverse relationship between patient volume and risk-adjusted mortality and length of stay (LOS). All levels of PICU should provide feedback to referral centers following the transfer of a patient to a PICU, which is essential for both QI and education. Pediatr Crit Care Med 2009; 10:588591, 166. Washington, DC, Academy Health, Available at: 57. In some institutions, PICUs are defined as open, where the admitting physicians may not be on the PICU staff. Volume-outcome relationships in pediatric intensive care units. Dharmar et al (161) compared processes of care delivered to 320 critically ill children receiving telehealth, telephone, or no consultation in five rural emergency departments. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. J Crit Care 2011; 26:104.e1104.e6, 40. Historically, intensive care models include a high-intensity staffing model characterized by an intensivist-led team responsible for patient management in a closed ICU setting in which the intensivist serves as the primary physician for all ICU patients or through mandatory consultation, in comparison to a low-intensity staffing model in which intensivist participation is through an elective consultation, either in an open ICU setting where patient care is managed by another physician or because there is no intensivist available. Similar survival outcomes have been observed in tertiary PICUs (132,133). Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes. Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care. The trainee is expected to assume progressive responsibility for the care of patients and satisfactorily complete at least 12 months at each training level. Supervisory experience must be an integral part of the total three-year program. Barnes TA, Gale DD, Kacmarek RM, et al. Aiken LH, Clarke SP, Sloane DM, et al. 1Department of Pediatrics and Critical Care Services, California Pacific Medical Center, San Francisco, CA. In order to take the General Pediatrics Certifying Examination, applicants must meet the following requirements: Graduation from Medical School ICP monitoring was associated with a reduction in mortality only in children with a GCS of 3 (OR, 0.64; 95% CI, 0.431.00). This highest level of PICU would have readily available resources to support an American College of Surgeons (ACS)-verified level I or level II Childrens Surgical Center or level I or level II Pediatric Trauma Center (3,4). Crit Care Clin 2015; 31:239255, 72. An older review of five trials (n = 623) had evaluated the use of iNO in patients with acute hypoxemic respiratory failure on oxygenation, mortality, ventilator-free days, and hospital LOS (118). A statement of reaffirmation for this policy was published on August 1, 2008. Several advanced hemodynamic monitoring devices are available for clinical use in critically ill children. Shle T, Eide PK. Although all levels of PICUs will not have the same resources available to promote extensive academic pursuits, some participation should be expected in advancing pediatric critical care science. Pediatrics 1993; 92:166175, 2. High-flow nasal cannula use in children with respiratory distress in the emergency department: Predicting the need for subsequent intubation. Both PICU and surgery services must be promptly available 24 hours a day. The AACNs pediatric critical care nurse certification signifies mastery of comprehensive pediatric critical care knowledge and is viewed as a best nursing practice measure to promote optimal patient management (83). Although individual states may have their own PICU guidelines, it is not the intent of this report to supersede already established state regulations. Of these, 13 studies were large . Appropriate use of resources and provision of care should be addressed by ongoing utilization review and case management. The specific clinical expertise and procedural competencies for hospitalists and APPs have predominately been determined by individual PICUs and institutions. A copy of the ECFMG certificate must be submitted to the American Board of Pediatrics (ABP) after submission of the application. Marcin et al (17) conducted a matched case-control cohort study involving 1,004 patients in a single PICU and found that higher nurse-to patient ratio was associated with decreased unplanned extubation. Criteria for admission of children to a regional hospital ICU or a Paediatric ward HDU. A clinical pharmacist involved in direct ICU patient management has been shown to improve patient safety and clinical outcomes in quaternary, tertiary, and community adult and PICUs (3040). Pediatr Pulmonol 2007; 42:8388, 111. This report provides admission and discharge guidelines for intermediate pediatric care. Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury. J Adv Nurs 2007; 57:3244, 95. Am J Crit Care 2007; 16:458468; quiz 469, 85. Critically ill children require nurses who have specialized knowledge, skills, and experience. Kim et al (78) conducted a retrospective cohort study of medical ICU patients in 169 hospitals (n = 107,324) linked to a statewide hospital survey to evaluate the effect of multidisciplinary care teams on ICU mortality. 11Pediatric Intensive Care, Wolfson Childrens Hospital, Gainsville, FL. Found inside Page 112Pediatric Intensive Care Unit admission criteria for haemato-oncological patients: a basis for clinical guidelines implementation. Pediatric Rep. 2011;3(2):e13. Piastra M, De Luca D, Pietrini D, Pulitan S, D'Arrigo S, Mancino A, et al. Citation: Ped Crit Care Med. The alignment of medical and surgical needs often requires transfer to a higher level of PICU care, but repatriation to the home PICU or hospital is also appropriate when acute issues have resolved, and care can be rendered closer to home where it is more convenient for the family. Trauma care should be collegial and a team effort by the PICU and trauma providers. Turner DA, Heitz D, Cooper MK, et al. A qualified medical provider who is able to respond within 5 minutes to all emergency patient care issues is necessary for optimal patient outcomes in all PICU levels of care. Carmel S, Rowan K. Variation in intensive care unit outcomes: A search for the evidence on organizational factors. The consensus was not achieved for research to be a requirement for all levels of PICU. A systematic review and meta-analysis by Kane et al (79) included a subanalysis of adult and PICU patients and found that reduced nurse staffing was associated with adverse patient outcomes. Admission criteria for specialized or quaternary facility PICUs identify the unique patient population (e.g., burns, trauma, cardiac surgery, neurologic) and match them to the resources available in the PICU and the hospital organizational characteristics (e.g., bed capacity, advanced technologies). Pronovost PJ, Thompson DA, Holzmueller CG, et al. Telehealth has also been proposed as a means of providing intensivist coverage to multiple ICUs without 24/7 coverage and has been endorsed by the Leapfrog Group (56) as an acceptable form of nighttime intensivist coverage. Tertiary PICUs serve children who require advanced medical or surgical care for the treatment of actual or potential life-threatening illnesses, injuries, or complications. 30 mins. For otherwise healthy full term infants, the risk of post-operative apnea after anesthesia is extremely low . Found inside Page 295Each institution has its own criteria for admission and transfer of pediatric patients , formulated in light of its mission and abilities and limitations ( Sigrest et al . , 2003 ) . The investigators speculated that findings may be attributable to differences in quality of care, unmeasured confounding variables, or calibration limitation of the severity of illness scores for higher-risk patients. PICUs may outsource some, if not all, of their critical care transport activities; however, the transport service used must have training in pediatric critical and emergency care. These include, but are not limited to: Tertiary PICUs require board-certified pediatric critical care specialists to provide direct care and coordinate care for patients who require multisystem or complex support. Found inside Page 97In the pediatric ambulatory setting, the anesthesia provider is frequently presented with clinical dilemmas. Patient and procedure selection, as well as availability of appropriate equipment and staff, may be issues in various practice The center would provide comprehensive care to all complex patients, including but not limited to those with significant cardiovascular disease, end-stage pulmonary disease, complex neurologic/neurosurgical issues, transplantation services (both bone marrow transplant and solid organ), multisystem trauma, and burns greater than 10% total body surface area (TBSA). The task force recognized that although there were many empiric limits imposed on this definition, the SCCM guidelines for adult critical care units defined the lower limit of adult patients as 18 years old, thus making this age the upper limit for this review. Intrafacility transport requirements should address the necessary components of moving critically ill patients within the facility, such as to and from the operating room, or for imaging procedures. Although direct evidence for monitoring devices reducing morbidity and mortality is sparse, goal-directed therapies would be impossible to reach without these devices. 97. Crit Care Med 2016; 44:21312138, 13. High-flow nasal cannula therapy for respiratory support in children. Tertiary PICUs should provide advanced ventilatory support such as HFOV and inotropic management but would not be expected to provide ECMO support. When a patient requires resources that are not readily available in a CMC PICU, transfer arrangements must be in place to ensure that the critically ill pediatric patient receives appropriate care. Level of PICU and patient outcomes (limited to 0 mo to 18 yr), Admission process/severity of illness for specific types of PICUs, Specialized PICU and patient outcomes (limited to 0 mo to 18 yr), Pediatric cardiac/neurosurgery/trauma ICU and patient outcomes, Annual volume in PICU and patient outcomes, Annual volume of mechanically ventilated patients and patient outcomes, ICU staffing/personnel (intensivist, nurse practitioners [NPs], physician assistants [PAs], hospitalists, nurses, etc) and patient outcomes, PICU unplanned readmissions and patient outcomes, Rapid response team/medical emergency response team and unplanned PICU transfer, Pediatric Early Warning Scores and unplanned PICU readmissions, Acute and chronic respiratory insufficiency (e.g., asthma, infection, acute lung injury, congenital airway, and pulmonary conditions), Circulatory failure (e.g., congenital cardiac disease, sepsis, heart failure), Infectious diseases leading to major organ system dysfunction, Metabolic disorders (e.g., recognition and stabilization and treatment of diabetic ketoacidosis and inborn errors of metabolism), Neurologic diseases (e.g., status epilepticus, encephalopathy, traumatic brain injury [TBI]), Acute and chronic respiratory insufficiency (e.g., asthma, infection, acute lung injury), Circulatory failure (e.g., sepsis, shock, heart failure not requiring ECMO, or surgical correction of congenital heart disease), Endocrine and metabolic disorders (e.g., diabetic ketoacidosis, recognition and stabilization of inborn errors of metabolism and mitochondrial disorders, hypothyroidism, and adrenal crisis), Neurologic diseases (e.g., status epilepticus, encephalopathy), Trauma (initial stabilization and ongoing care are resource dependent), Hematologic and oncologic disease (resource dependent). Physician assistants as physician extenders in the pediatric intensive care unit setting: A 5-year experience. ICP monitoring, neurosurgical, and neurologic availability are mandatory in quaternary facility ICUs and recommended in tertiary ICUs. Friese CR, Lake ET, Aiken LH, et al. Pediatric hospitalists, NPs, and PAs who provide first-line night coverage in PICUs must be skilled in advanced airway, line placement, and ventilator management. Which admission criteria, diseases, and severity of illness requiring higher level of PICU care are associated with improved patient outcomes? Arch Pediatr Adolesc Med 2006; 160:832836, 81. The physician should be at the PGY2 level or above and available to the PICU and ideally assigned to the PICU. The effect of an intensive care unit staffing model on tidal volume in patients with acute lung injury. Rana A, Brewer ED, Scully BB, et al. The text is supported throughout with explanatory line diagrams and photographs. However, in certain settings, such as PICUs in rural CMCs, these subspecialty and specialty resources may not be available, although these PICUs serve a vital and indispensable role. Despite differences in the staffing models, data continue to be generated demonstrating the superiority of the closed ICU model with high-intensity staffing to the open, low-intensity staffing model in improving patient outcomes. Found inside Page 1092OUTCOME OF PAEDIATRIC INTENSIVE CARE Depending on admission criteria, mortality in paediatric ICUs ranges from 5 to 15%. If patients with pre-existing severe disabilities are excluded, the majority of survivors have a normal or 1 The primary indication for inpatient pediatric hospitalizations is respiratory illness, including pneumonia, acute bronchiolitis, and asthma. Czaja et al (163) reviewed 117,923 admissions from 73 PICUs between 2005 and 2008 and found unplanned readmission was low (3.7%), but late readmissions (> 48hr after discharge) were associated with higher mortality (6.6% vs 3.3%; p < 0.001) and longer PICU LOS (11 vs 6 d; p < 0.0001) when compared with early readmissions (< 48hr). Although highly specialized knowledge and clinical skill are expected, other ICU-related factors, including the availability of personnel, surgeon technical skill, standardized management protocols, and other processes and systems, have a bigger impact on outcomes than ICU structure in specialized ICUs. Results revealed high-volume centers, defined as greater than 200 pediatric patients admitted per year, had the lowest severity-adjusted mortality (p < 0.05). Bennett et al (141) found significant between hospital variations in ICP monitoring. The medical home at 50: Are children with medical complexity the key to proving its value? Utilization of PAs and NPs at a level 1 trauma center effects on outcomes. Hemodialysis and peritoneal dialysis are required in tertiary PICU. Trauma patients should be cared for by both the trauma service (including trainees) and the PICU service in a collaborative manner. Telemedicine in pediatric cardiac critical care. Found inside Page 2637MODS was identified by laboratory and vital sign values from day of admission with International Pediatric Sepsis Consensus Conference criteria. Chronic illness was identified by secondary diagnoses, classified by modified Delphi method All critically ill children admitted to any PICU should be cared for by a pediatric intensivist, either board eligible, board certified, or undergoing maintenance of certification as a primary provider or in consultation while in the ICU setting. The use of VADs to augment cardiac function prior to transplantation has increased dramatically over the past 15 years (124). Inferior outcomes on the waiting list in low-volume pediatric heart transplant centers. Crit Care Med 2012; 40:21902195, 49. 3Department of Pediatrics, Saint Barnabas Medical Center, Livingston, NJ. Although CRRT may be initiated in all levels of PICUs, no studies were found comparing the initiation of CRRT in a community versus a tertiary or quaternary hospital. Regardless of what type of facility in which the PICU is located, specific criteria regarding resources and personnel should be in place. All PICU levels must have access to helium-oxygen. The alignment of medical and surgical needs often requires transfer to a higher level of PICU care, but repatriation to the home PICU or hospital is also appropriate when acute issues have resolved, and care can be rendered closer to home where it is more convenient for the family. Pediatric critical care telemedicine in rural underserved emergency departments. Sys Rev 2003(1): CDOO2787. The writing panel developed admission recommendations by level of care on the basis of voting results. A tertiary PICU also requires a designated medical director who is a board-certified pediatric critical care specialist to provide administrative oversight and management of the PICU. Pediatrics, Committee on Hospital Care and Section on Critical Care and Society of Critical Care Medicine, Pediatric Section Admission Criteria Task Force. Invasive intravascular monitoring is required to provide at a minimum systemic arterial and CVP monitoring. The score is then associated with a risk category of low, moderate, or high risk. The ACS requires that surgeons be the primary provider on all patients admitted with traumatic injuries, and therefore, programs where the attending surgeon has training and certification in surgical critical care may (institutional specific) allow for the primary attending with such expertise to be a surgeon working with the PICU attending. The specifics of each PICU level of care described above serve as a reference for minimum standards of quality care to guide appropriate PICU admissions and promote optimal patient outcomes. Admission Requirements. Am J Kidney Dis 2010; 55:316325, 150. J Trauma 2011; 70:560568, 70. Supported by the Society of Critical Care Medicine. Cochrane Database Syst Rev 2014; 7;3, 117. Admission and Discharge Criteria Level II Level II Admission Criteria Discharge to Level I Level II neonatal care may be indicated for 1 or more of the following: Premature birth with physiologic immaturity as indicated by 1 or more of the following: o Apnea of prematurity o Tachypnea (>60 breaths/minute) o Unstable body temperature Social workers and case managers should work closely with families and care providers to address housing, financial, and other issues. In addition to physician coverage, APPs, hospitalists, bedside nurses, and RTs should have special training to care for these critically ill patients. In 2019, SPR revised its membership criteria in response to member feedback and increased diversity of pediatric researchers career paths by eliminating the Senior and Affiliate member types, and by removing age criteria. Expertise in the care of the critically ill child is required in a community/tertiary/quaternary or specialty-based PICU. Pronovost PJ, Angus DC, Dorman T, et al. A multiorganizational policy statement led by the SCCM Ethics Committee (2016) provides guidance to ICU clinicians regarding difficult treatment decisions and recommends reserving the term futile to rare circumstances that an intervention simply cannot accomplish the intended physiologic goal and determined using process-based approach (180). Assessment to help identify, upon admission (or soon thereafter), patients at higher risk for an unmet health-related social need. ; Ontario Pediatric Critical Care Response Team Collaborative: Implementation of a multicenter rapid response system in pediatric academic hospitals is effective. Available at: 84. Some of the intensivists may have had additional training in another pediatric subspecialty, such as cardiology, neurology, pulmonology, or anesthesiology, enhancing their skills to care for these complex patients. Pediatr Nephrol 2015; 32:669678, 24. The training curriculum must be compatible with the program requirements, which are available on the ACGME website. Gajic O, Afessa B, Hanson AC, et al. High-flow nasal cannula therapy for infants with bronchiolitis. ; Berlin Heart Study Investigators: Prospective trial of a pediatric ventricular assist device. Crit Care Med 2016; 44:17691774. PICUs should have their own freestanding critical care transport program with their own team, equipment, and dedicated rig. In PICUs that support an ACS Childrens Surgical Center, there must be a childrens surgeon who serves within the medical leadership structure of the PICU. In the quaternary facility or specialized PICUs, the opinion of the task force is that the qualified medical provider should be a pediatric intensivist. 24Pediatrics and Pediatric Critical Care Medicine, Department of Pediatrics, Mount Sinai Beth Israel and Mount Sinai West Hospitals, New York City, NY. The use of ICP monitoring for nontraumatic causes of intracranial hypertension is limited primarily to case reports and case series. We intend to expand on this and add subspecialized PICUs to the mix. Care models and associated outcomes in congenital heart surgery. Tertiary PICUs provide advanced care for many medical and surgical illnesses in infants and children. Comparative review of use of physician assistants in a level I trauma center. Therefore, the updated ICU recommendations are primarily based on the Delphi consensus-based results. Resources for interfacility transfer should be defined between centers and include transport team, equipment, and different modes of transfer (e.g., ambulance, helicopter, fixed-wing aircraft). The current evidence is limited to small retrospective reviews. In a PICU that supports an ACS-verified childrens surgical center, an ICU team that demonstrates direct surgeon involvement in the day-to-day management of the surgical needs of the patient is essential. VAD utilization has shown improvement in mortality from 42% between 2000 and 2002 to 25% between 2007 and 2010 (p = 0.004) (124). The majority of the Voting Panel agreed that quaternary facility or specialized PICUs should have access to a dedicated transport program. The critical care physician shortage and ACGME restriction on resident duty hours have led to the use of alternative providers, including APPs and hospitalists, for in-house night coverage in all levels of PICUs. Change in regional (somatic) near-infrared spectroscopy is not a useful indicator of clinically detectable low cardiac output in children after surgery for congenital heart defects. Policies must be in place to address all transport scenarios, including intrafacility and interfacility transport.

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