American academy of pediatrics society of critical care medicine

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AMERICAN ACADEMY OF PEDIATRICS

SOCIETY OF CRITICAL CARE MEDICINE

CLINICAL REPORT

Guidance for the Clinician in Rendering Pediatric Care

David I. Rosenberg, MD; M. Michele Moss, MD; and the Section on Critical Care and Committee on Hospital Care

Guidelines and Levels of Care for Pediatric Intensive Care Units

ABSTRACT. The practice of pediatric critical care medicine has matured dramatically during the past decade. These guidelines are presented to update the existing guidelines published in 1993. Pediatric critical care services are provided in level I and level II units. Within these guidelines, the scope of pediatric critical care services is discussed, including organizational and administrative structure, hospital facilities and services, personnel, drugs and equipment, quality monitoring, and training and continuing education. Pediatrics 2004;114: 1114?1125; pediatric intensive care unit, PICU, critical care services.

ABBREVIATIONS. PICU, pediatric intensive care unit, EMS, emergency medical services, PALS, pediatric advanced life support.

INTRODUCTION

The practice of pediatric critical care has matured dramatically throughout the past 3 decades. Knowledge of the pathophysiology of life-threatening processes and the technologic capacity to monitor and treat pediatric patients suffering from them has advanced rapidly during this period. Along with the scientific and technical advances has come the evolution of the pediatric intensive care unit (PICU), in which special needs of critically ill or injured children and their families can be met by pediatric specialists. All critically ill infants and children cared for in hospitals, regardless of the physical setting, are entitled to receive the same quality of care.

In 1985, the American Board of Pediatrics recognized the subspecialty of pediatric critical care medicine and set criteria for subspecialty certification. The American Boards of Medicine, Surgery, and Anesthesiology gave similar recognition to the subspecialty. In 1990, the Residency Review Committee of the Accreditation Council for Graduate Medical Education completed its first accreditation of pediatric critical care medicine training programs. In 1986, the

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. doi:10.1542/peds.2004-1599 PEDIATRICS (ISSN 0031 4005). Copyright ? 2004 by the American Academy of Pediatrics.

American Association of Critical Care Nurses developed a certification program for pediatric critical care, and in 1999, a certification program for clinical nurse specialists in pediatric critical care was initiated.

In view of recent developments, the Pediatric Section of the Society of Critical Care Medicine and the Section on Critical Care Medicine and Committee on Hospital Care of the American Academy of Pediatrics believe that the original guidelines for levels of PICU care from 19931 should be updated. This report represents the consensus of the 3 aforementioned groups and presents those elements of hospital care that are necessary to provide high-quality pediatric critical care. The concept of level I and level II PICUs as established in the guidelines set forth in 1993 will be continued in this report. Individual states may have PICU guidelines, and it is not the intent of this report to supersede already established state rules, regulations, or guidelines; however, these guidelines represent the consensus report of critical care experts.

Pediatric critical care is ideally provided by a PICU that meets level I specifications. The level I PICU must provide multidisciplinary definitive care for a wide range of complex, progressive, and rapidly changing medical, surgical, and traumatic disorders occurring in pediatric patients of all ages, excluding premature newborns. Most, but not all, level I PICUs should be located in major medical centers or within children's hospitals. It is also recognized that in the appropriate clinical setting and as a result of many forces including but not limited to the presence of managed care, the insufficient supply of trained pediatric intensivists, and geographic and transport limitations, level II PICUs may be an appropriate alternative to the transfer of all critically ill children to a level I PICU.

The level I PICU should provide care to the most severely ill patient population. Specifications for level I PICUs are discussed in detail in the text and are summarized in Table 1. Level I PICUs will vary in size, personnel, physical characteristics, and equipment, and they may differ in the types of specialized care that are provided (eg, transplantation or cardiac surgery). Physicians and specialized services

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TABLE 1. Minimum Guidelines and Levels of Care for PICUs

I. Organization and administrative structure A. Category I facility B. Organization 1. PICU committee 2.Distinct administrative unit 3.Delineation of physician and nonphysician privilege C. Policies 1. Admission and discharge 2. Patient monitoring 3. Safety 4. Nosocomial infection 5. Patient isolation 6. Family-centered care 7. Traffic control 8. Equipment maintenance 9. Essential equipment breakdown 10. System of record keeping 11. Periodic review a. Morbidity and mortality b. Quality of care c. Safety d. Critical care consultation e. Long-term outcomes f. Supportive care D. Physical facility--external 1. Distinct, separate unit 2. Distinct unit (not necessarily physically separate) with auditory and visual separation 3. Controlled access (no through-traffic) 4. Located near: a. Elevators b. Operating room c. Emergency room d. Recovery room e. Physician on-call room f. Nurse manager's office g. Medical director's office h. Waiting room 5. Separate rooms available a. Family counseling room b. Conference room c. Staff lounge d. Staff locker room e. Storage lockers for patients' personal effects (may be internal) f. Family sleep area and shower E. Physical facility--internal 1. Patient isolation capacity 2. Patient privacy provision 3. Satellite pharmacy 4. Medication station with drug refrigerator and locked narcotics cabinet 5. Emergency equipment storage 6. Clean utility (linen) room 7. Soiled utility (linen) room 8. Nourishment station 9. Counter and cabinet space 10 .Staff toilet 11. Patient toilet 12. Hand-washing facility 13. Clocks 14. Televisions, radios, toys 15. Easy, rapid access to head of bed 16. 12 or more electrical outlets per bed 17. 2 or more oxygen outlets per bed 18. 2 or more compressed air outlets per bed 19. 2 vacuum outlets per bed 20. Computerized laboratory reporting or efficient equivalent 21. Building code or federal code conforming for: a. Heating, ventilation, and air conditioning b. Fire safety c. Electrical grounding d. Plumbing e. Illumination

Level I

E

E E E

E E E E E E E E E E

E E E E D D

E E

E

E D D D E D D E

E D D D E E

E E D E E E E E E E E E E E E E E E E E

E E E E E

Level II

E

E E E

E E E E E E E E E E

E E E E D D

D E

E

D D D D D D D D

D D D D E D

E E O E E E E E E E E E E E E E E E E D

E E E E E

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TABLE 1. Continued

II. Personnel A. Medical director 1. Appointed by appropriate hospital authority and acknowledged in writing 2. Qualifications a. Board certified or actively pursuing certification in 1 of the following: i. Pediatric critical care medicine ? Initial board certification in pediatrics ? Codirector if director is not a pediatrician ii. Anesthesiology with practice limited to infants and children and special qualifications in critical care medicine iii. Pediatric surgery with added qualification in surgical critical care medicine 3. Responsibilities documented in writing a. Acts as primary attending physician b. Has authority to provide consultation when physician is not available c. Assumes patient care if primary attending physician is not available d. Participates in development, review, and implementation of PICU policies* e. Maintenance of database and/or vital statistics* f. Supervises quality-control and quality-assessment activities (including morbidity and mortality reviews)* g. Supervises resuscitation techniques (including educational component)* h. Ensures policy implementation* i. Coordinates staff education* j. Participates in budget preparation* k. Coordinates research* 4. Substitute physician available to act as attending physician in medical director's absence B. Physician staff 1. A physician in-house 24 h per day a. A physician at the postgraduate year 2 level or above assigned to the PICU b. A physician at the postgraduate year 2 level or above available to the PICU (advanced practice nurse or physician assistant may be used) c. A physician at the postgraduate year 3 level or above (in pediatrics or anesthesiology) in-house 24 h per day 2. Available in 30 min or less (24 h per day) a. Pediatric intensivist or equivalent 3. Available in 1 h or less a. Anesthesiologist i. Pediatric anesthesiologist b. General surgeon c. Surgical subspecialists i. Pediatric surgeon ii. Cardiovascular surgeon ? Pediatric cardiovascular surgeon iii. Neurosurgeon ? Pediatric neurosurgeon iv. Otolaryngologist ? Pediatric otolaryngologist v. Orthopedic surgeon ? Pediatric orthopedic surgeon vi. Craniofacial, oral surgeon 4. Pediatric subspecialists a. Intensivist b. Cardiologist c. Nephrologist d. Hematologist/oncologist e. Pulmonologist f. Endocrinologist g. Gastroenterologist h. Allergist i. Neonatologist j. Neurologist k. Geneticist 5. Radiologist a. Pediatric radiologist 6. Psychiatrist or psychologist C. Nursing staff 1. Manager/director a. Training and clinical experience in pediatric critical care b. Master's degree in pediatric nursing or nursing administration 2. Nurse-to-patient ratio based on patient need 3. Nursing policies and procedures in place 4. Orientation to PICU 5. Completion of clinical and didactic critical care course 6. Address psychosocial needs of patient and family

Level I

E

E E E E

E E D E E E E E

E E E E E E

E E E

E

E

E E E

E E D E E E D E D D

E E E D D D D D E E D E E E

E E D E E E E E

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Level II

E

E E D E

E E D E E E E E

E E E E D E

E D E

O

D

E D E

D O O E O D O D O O

E D D D D D D D E D D E O D

E E D E E E E E

TABLE 1. Continued

7. Participate in continuing education 8. Completion of critical care registered nurse (pediatric) certification 9. Completion of PALS or an equivalent course 10. Nurse educator on staff (clinical nurse specialist)

a. Responsible for pediatric critical care in-service education 11. Nurse coordinator for regional continuing education D. Respiratory therapy staff 1. Supervisor responsible for training registered respiratory therapy staff 2. Maintenance of equipment and quality control and review 3. Respiratory therapist in-house 24 h per day assigned primarily to PICU 4. Respiratory therapist in-house 24 h per day 5. Respiratory therapists familiar with management of pediatric patients with

respiratory failure 6. Respiratory therapists competent with pediatric mechanical ventilators 7. Completion of PALS or an equivalent course E. Other team members 1. Biomedical technician (in-hospital or available within 1 h, 24 h per day) 2. Unit clerk on staff 24 h per day with a written job description 3. Child life specialist 4. Clergy 5. Social worker 6. Nutritionist or clinical dietitian 7. Physical therapist 8. Occupational therapist 9. Pharmacist (24 h per day) 10. Pediatric clinical pharmacist 11. Radiology technician 12. Bereavement coordinator III. Hospital facilities and services A. Emergency department 1. Covered entrance 2. Separate entrance 3. Adjacent helipad 4. Staffed by physician 24 h per day

a. Trained in pediatric emergency medicine 5. Resuscitation area

a. 2 or more areas with capacity and equipment to resuscitate medical, surgical, and trauma pediatric patients

b. 1 or more areas as described above B. Intermediate care unit or step-down unit separate from PICU and pediatric acute care

unit C. Pediatric rehabilitation unit D. Blood bank

1. Comprehensive (all blood components) 2. Type and cross match within 1 h E. Radiology services and nuclear medicine 1. Portable radiograph 2. Fluoroscopy 3. Computed tomography scan 4. Magnetic resonance imaging 5. Ultrasound 6. Angiography 7. Nuclear scanning 8. Radiation therapy F. Laboratory with microspecimen capability 1. Available within 15 min

a. Blood gases 2. Available within 1 h

a. Complete blood cell, platelet, and differential counts b. Urinalysis c. Chemistry profile (electrolytes, serum urea nitrogen, glucose, calcium, and

creatinine) d. Clotting studies e. Cerebrospinal fluid analysis 3. Available within 3 h a. Ammonia concentration b. Drug screening c. Osmolality d. Magnesium and phosphorus concentrations e. Toxicology screen 4. Preparation available 24 h per day a. Bacteriology (culture and Gram-stain) 5. Point-of-care diagnostic testing

Level I

E D D E E O

E E E E E

E D

E E E E E E E E E D E D

E E D E D

E

E D

D

E E

E E E E E E E D

E

E E E

E E

E E E E E

E D

Level II

E D D D D O

E E D E E

E D

E D D E E E E E E D E D

E D D E D

D

E D

D

E E

E D E D E O O O

E

E E E

E E

E E E E D

E D

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TABLE 1. Continued

G. Department of surgery 1. Operating room available within 30 min, 24 h per day 2. Second operating room available within 45 min, 24 h per day 3. Capabilities a. Cardiopulmonary bypass b. Bronchoscopy (pediatric) c. Endoscopy (pediatric) d. Radiograph in operating room

H. Cardiology department with pediatric capability 1. Electrocardiography 2. Echocardiography a. Two-dimensional echocardiography with Doppler 3. Catheterization laboratory (pediatric)

I. Neurodiagnostic laboratory 1. EEG 2. Evoked potentials 3. Transcranial Doppler flow

J. Hemodialysis K. Peritoneal dialysis or continuous renal replacement therapy L. Pharmacy with pediatric capability

1. Available 24 h per day for all requests 2. Located near PICU and pediatric acute care unit 3. Urgent drug-dosage form at bedside 4. Satellite pharmacy located in PICU 5. Pediatric pharmacist available for medical rounds M. Rehabilitation department with pediatric capability 1. Physical therapy 2. Speech therapy 3. Occupational therapy IV. Drugs and equipment A. Emergency drugs B. Portable equipment 1. Emergency cart 2. Procedure lamp 3. Doppler ultrasonography device 4. Infusion pumps (with microinfusion capability) 5. Defibrillator and cardioverter 6. Electrocardiography machine 7. Suction machine (in addition to bedside) 8. Thermometers 9. Expanded scale electronic thermometer 10. Automated blood pressure apparatus 11. Otoscope and ophthalmoscope 12. Automatic bed scale 13. Patient scales 14. Cribs (with head access) 15. Beds (with head access) 16. Infant warmers, incubators 17. Heating and cooling blankets 18. Bilirubin lights 19. Transport monitor 20. EEG machine 21. Isolation cart 22. Blood warmer 23. Pacer (transthoracic or transvenous) C. Small equipment 1. Tracheal intubation equipment 2. Endotracheal tubes (all pediatric sizes) 3. Oropharyngeal and nasopharyngeal airways 4. Vascular access equipment 5. Cut-down trays 6. Tracheostomy tray 7. Flexible bronchoscope 8. Cricothyroidotomy tray D. Respiratory support equipment 1. Bag-valve-mask resuscitation devices 2. Oxygen tanks 3. Respiratory gas humidifiers 4. Air compressor 5. Air-oxygen blenders 6. Ventilators of all sizes for pediatric patients 7. Inhalation therapy equipment 8. Chest physiotherapy and suctioning 9. Spirometers 10. Continuous oxygen analyzers with alarms

Level I

E E

E E E E

E

E D

E D D E E E E D E D D

E E E

E

E E E E E E E E E E E E E E E E E E E E E E E

E E E E E E E E

E E E E E E E E E E

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Level II

E D

D D D E

E

E O

E D O O O E E O E O O

E E E

E

E E E E E E E E E E E D E E E E E E D E E E E

E E E E E E D E

E E E E E E E E E E

TABLE 1. Continued

E. Monitoring equipment 1. Capability of continuous monitoring of: a. Electrocardiography, heart rate b. Respiration c. Temperature d. Systemic arterial pressure e. Central venous pressure f. Pulmonary arterial pressure g. Intracranial pressure h. Esophageal pressure i. Capability to measure 4 pressures simultaneously j. Capability to measure 5 pressures simultaneously k. Arrhythmia detection and alarm l. Pulse oximetry m. End-tidal CO2 2. Monitor characteristics a. Visible and audible high and low alarms for heart rate, respiratory rate, and all pressures b. Hard-copy capability c. Routine testing and maintenance d. Patient isolation e. Central station

V. Prehospital care A. Integration and communication with EMS system B. Transfer arrangements with referral hospital C. Transfer arrangement with level I PICU D. Educational programs in stabilization and transportation for EMS personnel E. Transport system (including transport team) F. Emergency communication into PICU and pediatric acute care unit (eg, phone, radio) 24 h per day G. Communication link to poison control center

VI. Quality improvement 1. Collaborative quality assessment 2. Morbidity and mortality review 3. Utilization review 4. Medical records review 5. Discharge criteria (planning) 6. Safety review 7. Long-term follow-up of patients and family

VII. Training and continuing education A. Physician training 1. Unit in facility with accredited pediatric residency program 2. Unit provides clinical rotation for pediatric residents in pediatric critical care 3. Fellowship program in pediatric critical care 4. Cardiopulmonary resuscitation certification 5. PALS or advanced pediatric life support 6. Ongoing continuing medical education for physicians specific to pediatric critical care 7. Staff physicians to attend and participate in pediatric critical care B. Unit personnel 1. Cardiopulmonary resuscitation certification for nurses and respiratory therapists 2. Resuscitation practice sessions 3. Ongoing continuing education (on-site and/or off-site workshops and programs for nurses respiratory therapists, clinical pharmacists) 4. Certified by the American Association of Critical Care Nurses 5. PALS or advanced pediatric life support certification 6. Critical care registered nurse certification C. Regional education 1. Participation in regional pediatric critical care education 2. Service as educational resource center for public education in pediatric critical care 3. Prehospital care and interhospital transport

E indicates essential; D, desired; O, optional; NA, not applicable. * In conjunction with nurse manager.

Level I

E E E E E E E D E D E E E

E

E E E E

E E NA E E E

E

E E E E E E D

D D D E E E

E

E E E

D E D

E D D

Level II

E E E E E D D O D D E E E

E

E E E E

E E E D O E

E

E E E E E E D

O O O E E E

E

E E E

D E D

O D O

may differ between levels, such that level I PICUs will have a full complement of medical and surgical subspecialists including pediatric intensivists. Each level I and level II PICU should be able to address the physical, psychosocial, emotional, and spiritual needs of patients with life-threatening conditions and their families.

Some pediatric patients with moderate severity of illness can be managed in level II PICUs. Level II PICUs may be necessary to provide stabilization of critically ill children before transfer to another center or to avoid long-distance transfers for disorders of less complexity or lower acuity. It is imperative that the same standards of quality care be applied to

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