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Guidelines and levels of care for pediatric intensive care units

Guidelines and levels of care for pediatric intensive care units

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Special Pediatric Article
Guidelines and levels of care for pediatric intensive care units
David I. Rosenberg, MD; M. Michele Moss, MD; and the American College of Critical Care Medicine of theSociety of Critical Care Medicine
he practice of pediatric criticalcare has matured dramaticallythroughout the past 3 de-cades. Knowledge of thepathophysiology of life-threatening pro-cesses and the technological capacity tomonitor and treat pediatric patients suf-fering from them has advanced rapidlyduring this period. Along with the scien-tific and technical advances has come theevolution of the pediatric intensive careunit (PICU), in which special needs of critically ill or injured children and theirfamilies can be met by pediatric special-ists. All critically ill infants and childrencared for in hospitals, regardless of thephysical setting, are entitled to receivethe same quality of care.In 1985, the American Board of Pedi-atrics recognized the subspecialty of pe-diatric critical care medicine and set cri-teria for subspecialty certification. The American Boards of Medicine, Surgery,and Anesthesiology gave similar recogni-tion to the subspecialty. In 1990, the Res-idency Review Committee of the Accred-itation Council for Graduate MedicalEducation completed its first accredita-tion of pediatric critical care medicinetraining programs. In 1986, the American Association of Critical Care Nurses devel-oped a certification program for pediatriccritical care, and in 1999, a certificationprogram for clinical nurse specialists inpediatric critical care was initiated.In view of recent developments, thePediatric Section of the Society of CriticalCare Medicine and the Section on CriticalCare Medicine and Committee on Hospi-tal Care of the American Academy of Pe-diatrics believe that the original guide-lines for levels of PICU care from 1993 (1)should be updated. This report representsthe consensus of the three aforemen-tioned groups and presents those ele-ments of hospital care that are necessaryto provide high-quality pediatric criticalcare. The concept of level I and level IIPICUs as established in the guidelines setforth in 1993 will be continued in thisreport. Individual states may have PICUguidelines, and it is not the intent of thisreport to supersede already establishedstate rules, regulations, or guidelines;however, these guidelines represent theconsensus report of critical care experts.Pediatric critical care is ideally pro- vided by a PICU that meets level I speci-fications. The level I PICU must providemultidisciplinary definitive care for a wide range of complex, progressive, andrapidly changing medical, surgical, andtraumatic disorders occurring in pediat-ric patients of all ages, excluding prema-ture newborns. Most, although not all,level I PICUs should be located in majormedical centers or within children’s hos-pitals. It is also recognized that in theappropriate clinical setting and as a resultof many forces, including but not limitedto the presence of managed care, the in-sufficient supply of trained pediatric in-tensivists, and geographic and transportlimitations, level II PICUs may be an ap-propriate alternative to the transfer of allcritically ill children to a level I PICU.The level I PICU should provide careto the most severely ill patient popula-tion. Specifications for level I PICUs arediscussed in detail in the text and aresummarized in Table 1. Level I PICUs will vary in size, personnel, physical charac-teristics, and equipment, and they maydiffer in the types of specialized care thatare provided (e.g., transplantation or car-diac surgery). Physicians and specializedservices may differ between levels, suchthat level I PICUs will have a full comple-ment of medical and surgical subspecial-ists, including pediatric intensivists. Eachlevel I and level II PICU should be able toaddress the physical, psychosocial, emo-tional, and spiritual needs of patients with life-threatening conditions and theirfamilies.Some pediatric patients with moder-ate severity of illness can be managed inlevel II PICUs. Level II PICUs may benecessary to provide stabilization of crit-ically ill children before transfer to an-other center or to avoid long-distancetransfers for disorders of less complexityor lower acuity. It is imperative that thesame standards of quality care be appliedto patients managed in level II PICUs andlevel I PICUs. Requirements for level II
 All committee reports from the American Academyof Pediatrics automatically expire 5 yrs after publica-tion unless reaffirmed, revised, or retired at or beforethat time.The American College of Critical Care Medicine(ACCM), which honors individuals for their achieve-ments and contributions to multidisciplinary criticalcare medicine, is the consultative body of the Societyof Critical Care Medicine (SCCM) that possesses rec-ognized expertise in the practice of critical care. TheCollege has developed administrative guidelines andclinical practice parameters for the critical care prac-titioner. New guidelines and practice parameters arecontinually developed, and current ones are system-atically reviewed and revised.Copyright © 2004 by the Society of Critical CareMedicine and Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0000142704.36378.E9
The practice of pediatric critical care medicine has matureddramatically during the past decade. These guidelines are pre-sented to update the existing guidelines published in 1993. Pedi-atric critical care services are provided in level I and level II units.Within these guidelines, the scope of pediatric critical care ser-vices is discussed, including organizational and administrativestructure, hospital facilities and services, personnel, drugs andequipment, quality monitoring, and training and continuing edu-cation. (Crit Care Med 2004; 32:2117–2127)
: pediatric critical care medicine; administrativestructure; hospital facilities and services; personnel; drugs andequipment; quality monitoring; continuing education
2117Crit Care Med 2004 Vol. 32, No. 10
Table 1.
Minimum guidelines and levels of care for pediatric intensive care units (PICUs)Level I Level III. Organization and administrative structure A. Category I facility E EB. Organization1. PICU committee E E2. Distinct administrative unit E E3. Delineation of physician and nonphysician privilege E EC. Policies1. Admission and discharge E E2. Patient monitoring E E3. Safety E E4. Nosocomial infection E E5. Patient isolation E E6. Family-centered care E E7. Trafc control E E8. Equipment maintenance E E9. Essential equipment breakdown E E10. System of record keeping E E11. Periodic reviewa. Morbidity and mortality E Eb. Quality of care E Ec. Safety E Ed. Critical care consultation E Ee. Long-term outcomes D Df. Supportive care D DD. Physical facility—external1. Distinct, separate unit E D2. Distinct unit (not necessarily physically separate) with auditory and visual separation E E3. Controlled access (no through trafc) E E4. Located near:a. Elevators E Db. Operating room D Dc. Emergency room D Dd. Recovery room D De. Physician on-call room E Df. Nurse managers ofce D Dg. Medical directors ofce D Dh. Waiting room E D5. Separate rooms availablea. Family counseling room E Db. Conference room D Dc. Staff lounge D Dd. Staff locker room D De. Storage lockers for patientspersonal effects (may be internal) E Ef. Family sleep area and shower E DE. Physical facility—internal1. Patient isolation capacity E E2. Patient privacy provision E E3. Satellite pharmacy D O4. Medication station with drug refrigerator and locked narcotics cabinet E E5. Emergency equipment storage E E6. Clean utility (linen) room E E7. Soiled utility (linen) room E E8. Nourishment station E E9. Counter, cabinet space E E10. Staff toilet E E11. Patient toilet E E12. Hand-washing facility E E13. Clocks E E14. Televisions, radios, toys E E15. Easy, rapid access to head of bed E E16.
12 electrical outlets per bed E E17.
2 oxygen outlets per bed E E18.
2 compressed air outlets per bed E E19. 2 vacuum outlets per bed E E20. Computerized laboratory reporting or efcient equivalent E D21. Building code or federal code conforming for:a. Heating, ventilation, air conditioning E Eb. Fire safety E Ec. Electrical grounding E Ed. Plumbing E Ee. Illumination E E
2118 Crit Care Med 2004 Vol. 32, No. 10
Table 1.
(Continued)Level I Level IIII. Personnel A. Medical director1. Appointed by appropriate hospital authority and acknowledged in writing E E2. Qualificationsa. Board certified or actively pursuing certification in one of the following:i. Pediatric critical care medicine E E
Initial board certication in pediatrics E E
Co-director if director is not a pediatrician E Dii. Anesthesiology with practice limited to infants and children and special qualifications in critical caremedicineE Eiii. Pediatric surgery with added qualication in surgical critical care medicine E E3. Responsibilities documented in writing E Ea. Acts as primary attending physician D Db. Has authority to provide consultation for any PICU patient on a daily basis E Ec. Assumes patient care if primary attending physician is not available E Ed. Participates in development, review, and implementation of PICU policies
E Ee. Maintains database and/or vital statistics
E Ef. Supervises quality control and quality assessment activities (including morbidity and mortality reviews)
E Eg. Supervises resuscitation techniques (including educational component)
E Eh. Ensures policy implementation
E Ei. Coordinates staff education
E E j. Participates in budget preparation
E Ek. Coordinates research
E D4. Substitute physician available to act as attending physician in medical directors absence E EB. Physician staf1. A physician in-house 24 hrs/day E Ea. A physician at the postgraduate year 2 level or above assigned to the PICU E Db. A physician at the postgraduate year 2 level or above available to the PICU (advanced practice nurse orphysician assistant may be used)E Ec. A physician at the postgraduate year 3 level or above (in pediatrics or anesthesiology) in house 24 hrs/day E O2. Available in
30 mins (24 hrs/day)Pediatric intensivist or equivalent E D3. Available in
1 hra. Anesthesiologist E Ei. Pediatric anesthesiologist E Db. General surgeon E Ec. Surgical subspecialistsi. Pediatric surgeon E Dii. Cardiovascular surgeon E O
Pediatric cardiovascular surgeon D Oiii. Neurosurgeon E E
Pediatric neurosurgeon E Oiv. Otolaryngologist E D
Pediatric otolaryngologist D O v. Orthopedic surgeon E D
Pediatric orthopedic surgeon D O vi. Craniofacial, oral surgeon D O4. Pediatric subspecialistsa. Intensivist E Eb. Cardiologist E Dc. Nephrologist E Dd. Hematologist/oncologist D De. Pulmonologist D Df. Endocrinologist D Dg. Gastroenterologist D Dh. Allergist D Di. Neonatologist E E j. Neurologist E Dk. Geneticist D D5. Radiologist E Ea. Pediatric radiologist E O6. Psychiatrist or psychologist E DC. Nursing staff 1. Manager/director E Ea. Training and clinical experience in pediatric critical care E Eb. Masters degree in pediatric nursing or nursing administration D D2. Nurse-to-patient ratio based on patient need E E3. Nursing policies and procedures in place E E4. Orientation to PICU E E5. Completion of clinical and didactic critical care course E E6. Address psychosocial needs of patient and family E E7. Participate in continuing education E E8. Completion of critical care registered nurse (pediatric) certication D D9. Completion of PALS or an equivalent course D D10. Nurse educator on staff (clinical nurse specialist) E Da. Responsible for pediatric critical care in-service education E D
2119Crit Care Med 2004 Vol. 32, No. 10

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