Executive Summary: Criteria for Critical Care of Infants and … · POLICY STATEMENT Organizational...
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POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance Benson S. Hsu, MD, MBA, FAAP, a Vanessa Hill, MD, FAAP, b Lorry R. Frankel, MD, FCCM, c Timothy S. Yeh, MD, MCCM, d Shari Simone, CRNP, DNP, FCCM, FAANP, FAAN, e Marjorie J. Arca, MD, FACS, FAAP, f Jorge A. Coss-Bu, MD, g Mary E. Fallat, MD, FACS, FAAP, h Jason Foland, MD, i Samir Gadepalli, MD, MBA, j Michael O. Gayle, BS, MD, FCCM, k Lori A. Harmon, RRT, MBA, CPHQ, l Christa A. Joseph, RN, MSN, m Aaron D. Kessel, BS, MD, n Niranjan Kissoon, MD, MCCM, o Michele Moss, MD, FCCM, p Mohan R. Mysore, MD, FAAP, FCCM, q Michele . Papo, MD, MPH, FCCM, r Kari L. Rajzer-Wakeham, CCRN, MSN, PCCNP, RN, s Tom B. Rice, MD, t David L. Rosenberg, MD, FAAP, FCCM, u Martin K. Wakeham, MD, v,t Edward E. Conway, Jr, MD, FCCM, MS, w Michael S.D. Agus, MD, FAAP, FCCM x abstract This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this signi ficant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care. BACKGROUND INFORMATION Pediatric critical care medicine has evolved over the last 3 decades into a highly respected, board-certified specialty that has become an a Pediatric Critical Care, Sanford School of Medicine, University of South Dakota, Vermillion, South Dakota; b Hospital Medicine, Baylor College of Medicine and Children’ s Hospital of San Antonio, San Antonio, Texas; c Department of Pediatrics and Critical Care Services, California Pacific Medical Center, San Francisco, California; d Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey; e PICU, Medical Center, University of Maryland, Baltimore, Maryland; f Divisions of Pediatric Surgery and t Pediatric Critical Care Medicine, v Medical College of Wisconsin and Children’ s Hospital of Wisconsin, Milwaukee, Wisconsin; g Pediatrics and Critical Care Medicine, Baylor College of Medicine and Texas Children’ s Hospital, Houston, Texas; h Division of Pediatric Surgery, University of Louisville and Norton Children’ s Hospital, Louisville, Kentucky; i Pediatric Intensive Care, Studer Family Children’ s Hospital, Ascension Sacred Heart, Pensacola, Florida; j Division of Pediatric Surgery, University of Michigan, Ann Arbor, Michigan; k Pediatric Intensive Care, Wolfson Children’ s Hospital, Jacksonville, Florida; l Department of Quality, Society of Critical Care Medicine, Mount Prospect, Illinois; m Pediatric Intensive Care, Children’ s Hospital Oakland, Oakland, California; n Pediatric Critical Care Medicine, Cohen Children’ s Medical Center, New Hyde Park, New York; o Medical Affairs, British Columbia Children’ s Hospital, Vancouver, Canada; p Pediatric Critical Care Medicine, Arkansas Children’ s Hospital, Little Rock, Arkansas; To cite: Hsu BS, Hill V, Frankel LR, et al. Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance. Pediatrics. 2019; 144(4):e20192433 PEDIATRICS Volume 144, number 4, October 2019:e20192433 FROM THE AMERICAN ACADEMY OF PEDIATRICS C by guest on March 14, 2021 www.aappublications.org/news Downloaded from
Transcript of Executive Summary: Criteria for Critical Care of Infants and … · POLICY STATEMENT Organizational...
POLICY STATEMENT Organizational Principles to Guide and Define the Child HealthCare System and/or Improve the Health of all Children
Executive Summary: Criteria for CriticalCare of Infants and Children: PICUAdmission, Discharge, and TriagePractice Statement and Levels ofCare GuidanceBenson S. Hsu, MD, MBA, FAAP,a Vanessa Hill, MD, FAAP,b Lorry R. Frankel, MD, FCCM,c Timothy S. Yeh, MD, MCCM,d
Shari Simone, CRNP, DNP, FCCM, FAANP, FAAN,e Marjorie J. Arca, MD, FACS, FAAP,f Jorge A. Coss-Bu, MD,g
Mary E. Fallat, MD, FACS, FAAP,h Jason Foland, MD,i Samir Gadepalli, MD, MBA,j Michael O. Gayle, BS, MD, FCCM,k
Lori A. Harmon, RRT, MBA, CPHQ,l Christa A. Joseph, RN, MSN,m Aaron D. Kessel, BS, MD,n Niranjan Kissoon, MD, MCCM,o
Michele Moss, MD, FCCM,p Mohan R. Mysore, MD, FAAP, FCCM,q Michele . Papo, MD, MPH, FCCM,r
Kari L. Rajzer-Wakeham, CCRN, MSN, PCCNP, RN,s Tom B. Rice, MD,t David L. Rosenberg, MD, FAAP, FCCM,u
Martin K. Wakeham, MD,v,t Edward E. Conway, Jr, MD, FCCM, MS,w Michael S.D. Agus, MD, FAAP, FCCMx
abstractThis is an executive summary of the 2019 update of the 2004 guidelines and levels ofcare for PICU. Since previous guidelines, there has been a tremendoustransformation of Pediatric Critical Care Medicine with advancements in pediatriccardiovascular medicine, transplant, neurology, trauma, and oncology as well asimprovements of care in general PICUs. This has led to the evolution of resourcesand training in the provision of care through the PICU. Outcome and qualityresearch related to admission, transfer, and discharge criteria as well as literatureregarding PICU levels of care to include volume, staffing, and structure werereviewed and included in this statement as appropriate. Consequently, the purposesof this significant update are to address the transformation of the field and codifya revised set of guidelines that will enable hospitals, institutions, and individuals indeveloping the appropriate PICU for their community needs. The target audiences ofthe practice statement and guidance are broad and include critical careprofessionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatricsurgical subspecialists; pediatric imaging physicians; and other members of thepatient care team such as nurses, therapists, dieticians, pharmacists, socialworkers, care coordinators, and hospital administrators who make dailyadministrative and clinical decisions in all PICU levels of care.
BACKGROUND INFORMATION
Pediatric critical care medicine has evolved over the last 3 decades intoa highly respected, board-certified specialty that has become an
aPediatric Critical Care, Sanford School of Medicine, University ofSouth Dakota, Vermillion, South Dakota; bHospital Medicine, BaylorCollege of Medicine and Children’s Hospital of San Antonio, SanAntonio, Texas; cDepartment of Pediatrics and Critical Care Services,California Pacific Medical Center, San Francisco, California;dDepartment of Pediatrics, Saint Barnabas Medical Center, Livingston,New Jersey; ePICU, Medical Center, University of Maryland, Baltimore,Maryland; fDivisions of Pediatric Surgery and tPediatric Critical CareMedicine, vMedical College of Wisconsin and Children’s Hospital ofWisconsin, Milwaukee, Wisconsin; gPediatrics and Critical CareMedicine, Baylor College of Medicine and Texas Children’s Hospital,Houston, Texas; hDivision of Pediatric Surgery, University of Louisvilleand Norton Children’s Hospital, Louisville, Kentucky; iPediatric IntensiveCare, Studer Family Children’s Hospital, Ascension Sacred Heart,Pensacola, Florida; jDivision of Pediatric Surgery, University ofMichigan, Ann Arbor, Michigan; kPediatric Intensive Care, WolfsonChildren’s Hospital, Jacksonville, Florida; lDepartment of Quality,Society of Critical Care Medicine, Mount Prospect, Illinois; mPediatricIntensive Care, Children’s Hospital Oakland, Oakland, California;nPediatric Critical Care Medicine, Cohen Children’s Medical Center, NewHyde Park, New York; oMedical Affairs, British Columbia Children’sHospital, Vancouver, Canada; pPediatric Critical Care Medicine,Arkansas Children’s Hospital, Little Rock, Arkansas;
To cite: Hsu BS, Hill V, Frankel LR, et al. ExecutiveSummary: Criteria for Critical Care of Infants andChildren: PICU Admission, Discharge, and Triage PracticeStatement and Levels of Care Guidance. Pediatrics. 2019;144(4):e20192433
PEDIATRICS Volume 144, number 4, October 2019:e20192433 FROM THE AMERICAN ACADEMY OF PEDIATRICS
C
by guest on March 14, 2021www.aappublications.org/newsDownloaded from
indispensable service for inpatientprograms of most children’s hospitalsas well as a highly valued resourcesupporting most community-basedprograms. The earlier publishedguidelines for pediatric critical caremedicine were used to help establishthe basic needs for a state-of-the-artPICU. These guidelines were used byboth physician leadership and policymakers to advocate for personnel,supplies, and space that were unique toPICUs. However, there has beena tremendous transformation ofpediatric critical care medicine over thepast 10 years, with explosive growth inspecialized PICUs in pediatriccardiovascular medicine, transplant,neurology, trauma, and oncology aswell as improvements of care ingeneral PICUs. This has led to theevolution in both human and materialresources and training in more highlyspecialized areas such ascardiovascular medicine, neurosurgicalICUs, and trauma care.1,2
STATEMENT OF PROBLEM
To provide a 2019 update of theAmerican Academy of Pediatrics andSociety of Critical Care Medicine’s 2004Guidelines and levels of care for PICUs.3
EVIDENCE BASIS
Methodology
A group of nationally andinternationally recognized clinicalexperts in pediatric critical caremedicine made up the pediatriccritical care admission guidelines taskforce. The task force reviewed thework of the previous guidelines andmade decisions regarding topicselection inclusion. The topicselection for the guidelines addressedPICU characteristics and interventionsby the PICU level of care, includingquaternary or specialized, tertiary, andcommunity. Interventions addressedincluded PICU admission, teamstructure, transport and transfermechanisms, outreach programs, andquality metrics.
TABLE 1 Recommendations Summary
Recommendations
Recommended PICU level of care admission criteriaPatients who are appropriately triaged according to level of illness and services provided in
community, tertiary, or quaternary PICU facilities will have comparable outcomes and quality ofcare. The specifics of each PICU level of care described above serve as a reference for minimumstandards of quality care to guide appropriate PICU admissions and promote optimal patientoutcomes.
Individual hospitals and their PICU leadership team should develop admission criteria to assist in theplacement of critically ill children that are aligned with their PICU level of care.
Pediatric patients requiring specialized service interventions such as cardiac, neurologic, or trauma-related surgery have improved outcomes when cared for in a quaternary or tertiary ICU, and earlyinterfacility transfer to the appropriate regional facility should be the standard of care.
Congenital heart surgery should only be performed in a hospital that has a PICU with a dedicatedpediatric cardiac intensive care team, including but not restricted to pediatric intensivists andnurses with expertise in cardiac intensive care, cardiovascular surgeon with pediatric expertise,pediatric perfusionists, pediatric cardiologists, and pediatric cardiac anesthesiologists.
Recommended ICU structure and provider staffing modelExpertise in the care of the critically ill child is required in all PICU levels of care.All critically ill children admitted to any PICU should be cared for by a pediatric intensivist who is
board eligible, board certified, or undergoing maintenance of certification as primary providerwhile in the ICU setting.
Trauma patients should be cared for by both the trauma service (including trainees) and the PICUservice in a collaborative manner. The ACS requires that surgeons be the primary provider on allpatients admitted with traumatic injuries. Programs in which the attending surgeon has trainingand certification in surgical critical care may (institution specific) allow for the primary attendingto be a surgeon with such expertise working with the PICU attending.
Burn patients should be comanaged by the burn surgeon of record (discipline may be pediatricsurgery, general surgery, or plastic surgery) and the PICU service.
In a PICU that supports an ACS-verified children’s surgical center, an ICU team that demonstratesdirect surgeon involvement in the day-to-day management of the surgical needs of the patient isessential. Both PICU and surgery services must be promptly available 24 h per d.
Any level of PICU that supports advanced ACGME training programs such as pediatric residency,general surgery residency, pediatric critical care medicine fellowships, pediatric surgeryfellowships, and pediatric surgical critical care fellowships (among others) will promote theparticipation of trainees in interprofessional care of patients providing appropriatecommunication and collaboration. Clear delineation of responsibilities will be sought on eachpatient. This requirement reflects the common program requirements outlined by the ACGME.
A qualified medical provider (in quaternary facility PICUs, the qualified medical provider should bea critical care specialist) who is able to respond within 5 min to all emergent patient issues (eg,airway management or cardiopulmonary resuscitation) is necessary for optimal patient outcomesin all levels of PICU. Specialized or quaternary facility PICUs have a minimum of an in-house criticalcare fellow.
A qualified surgical provider who is able to respond readily to emergency surgical issues in criticallyill patients should be available. The designation of qualified is defined by the surgical problem, andavailability should be commensurate with the level of care of the PICU and level of ACS Children’sSurgery Verification of the institution.
Night coverage response requirement for pediatric intensivists who are not in house, primarily incommunity and tertiary PICUs, includes being readily available by telephone and present in thePICU within 30 min of request.
Recommended ICU personnel and resourcesThe ICU structure and care delivery model components that are essential in all PICU levels of care
include nursing staff and respiratory therapists with PICU expertise as well as multidisciplinaryrounds. In tertiary and quaternary facility PICUs, 24/7 in-house coverage, a dedicated clinicalpharmacist, a social worker, a child life specialist, and palliative care services are necessary.
All PICUs should have access to an on-site pediatric pharmacist who is available for daily rounds,pharmacy support, and ongoing educational activities.
All providers, including pediatric hospitalists, nurse practitioners, and physician assistants whoprovide first-line night coverage in PICUs, must be skilled in advanced airway, intravenous andintraosseous line placement, and ventilator management.
All PICUs must have access to a transfer and transport program that can ensure the safe and timelymovement of a critically ill or injured child from a community hospital to an institution witha higher PICU level of care.
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A comprehensive literature search onthe topics and agreed-on questionsdetermined by the task force wasperformed by a dedicated Society of
Critical Care Medicine librarian inselected biomedical databases. The2004 guidelines and levels of care forPICUs served as the starting point for
searches in Medline (Ovid), Embase(Ovid), and PubMed on articlespublished from 2004 to 2016.Members of the task force receivedthe set of citations and abstractsrelevant to the section of theguidelines; references not directlyrelated to the content area wereexcluded from the review. The full-text articles were retrieved andreviewed to determine appropriateinclusion for appraisal.
The admission to the PICU literaturesearch identified 832 articles. Thereview of article titles resulted in 299relevant articles, of which allabstracts were reviewed. The full textof 75 articles and 12 additionalarticles obtained by hand searchingreference lists were reviewed.Twenty-one relevant pediatric studiesin which outcomes related topediatric level of care, specializedPICU, patient volume, or personnelwere evaluated were found. Thedischarge and unplanned readmissionliterature search yielded 68 articles.The full text of 24 articles and 6additional articles obtained by handsearching reference lists werereviewed. No articles were found inwhich PICU discharge criteria wereevaluated, and only 14 relevantstudies were found in whichoutcomes related to unplanned PICUreadmissions were evaluated. Sincepublication of the 2004 revisedguidelines, evidence on evaluating theimpact of the level of PICU care onpatient outcomes remains limited.After deliberation, the task forcedetermined that the strength andquality of the current pediatricevidence for the selected topics wasinsufficient to use the Grading ofRecommendations, Assessment,Development, and Evaluation systemin supporting evidence-basedrecommendations. The sparseliterature and the nature of thequestions under review did not lenditself to the use of the population,intervention, comparison, andoutcome format. Therefore,
TABLE 1 Continued
Recommendations
Quaternary facilities or specialized PICUs have access to a critical care transport program witha dedicated trained pediatric team and specialized equipment.
When PICUs require outsourcing of critical care transport activities, the transport service teammembers must all have training in pediatric emergency and critical care.
Recommended performance improvement and patient safetyQuaternary facilities and tertiary levels of PICUs should participate in academic pursuits.All quaternary facilities and tertiary levels of PICUs should be involved in providing peer community
outreach education such as educational conferences, technical skill competencies, stabilization,and resuscitation (eg, PALS education).
Community and tertiary PICUs should be involved in providing community outreach througheducational events that focus on technical skills needed for stabilization, resuscitation, andcommunication for the triage and transport of critically ill and injured children. These activitiesmight include case conferences.
All levels of PICU should provide feedback to referral centers after transfer of a patient to a PICU,which is essential for both quality improvement and education.
Recommended equipment and technologySome emergency resuscitative therapies such as invasive and noninvasive respiratory support and
central line access can be safely performed in community PICUs.Renal replacement therapies (peritoneal dialysis, continuous hemofiltration and hemodialysis, and
intermittent hemodialysis) may be offered in a community-based PICU when appropriately trainedsupport personnel, which must include a nephrologist, are present.
All PICU levels must have access to helium-oxygen. In selected PICUs, epoprostenol sodium, nitricoxide, and anesthetic agents may be used if appropriate personnel and equipment are availablefor the safe delivery and monitoring of these agents.
The following are appropriate indications for PICU transfer from a community to a tertiary orquaternary level of care: intracranial pressure monitoring, acute hepatic failure leading to coma,congenital heart disease with unstable cardiorespiratory status, need for temporary cardiacpacing, head injury with initial GCS #8, multiple traumatic injuries, or heart failure requiring aninterventional cardiologist. For complicated burns .10% TBSA, access to a specialized burn unitor burn center is recommended.
Recommended PICU discharge and transfer criteriaEach PICU should have clearly defined criteria for escalation and de-escalation of resources and,
therefore, level of PICU required on the basis of the physiologic status of the patient.All levels of PICU should have policies and protocols in place that specify when the patient’s
physiologic status requires escalation of care, with transfer to a more appropriate level of care asexpeditiously as needed.
When a patient’s physiologic status improves, discharge from the PICU can occur in many ways:Transfer to an appropriate acute care bed within that facilityReturn transfer to the referring facilityTransfer to a skilled nursing or rehabilitation facilityDischarge from the PICU to home
After discharge from the PICU, the following should take place:Appropriate communication with the accepting facility, including oral handoff, a clear and concise
written summary, and exchange of necessary health informationDischarge planning and communication with the family or caregivers if going homeCommunication with the primary care physician who will assume care of the child once the
patient is returned to the communityCommunication with subspecialists caring for the child and appropriate follow-up arranged as
necessaryAs needed, careful care coordination with outpatient services such as but not limited to:Delivery and instruction in the use of durable medical equipmentHome pharmacy and nutrition supportOngoing rehabilitation needs such as occupational or physical therapyAncillary support as required
ACGME, Accreditation Council for Graduate Medical Education; ACS, American College of Surgeons; GCS, Glasgow ComaScale; PALS, Pediatric Advanced Life Support; TBSA, total body surface area.
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a modified Delphi process wasundertaken, seeking expert opinion todevelop consensus-basedrecommendations where gaps in theevidence exist.
Modified Delphi Methodology
Members were selected to be on thepanel on the basis of their experienceas PICU directors, administrators, orother leadership roles and werechosen to represent a variety of
hospital settings, from academiccenters to community hospitals. TheAmerican Academy of Pediatrics alsoappointed a hospitalist and criticalcare physician liaison to serve on thepanel and to assist in the developmentof the guideline. An American Collegeof Critical Care Board of Regentsmember served as a liaison to thecommittee to support its work.
The guidelines panel consisted of 2groups: a voting group consisting of
30 members and a writing group of20 members. The voting panel usedan iterative collaborative approach toformulate 30 statements on the basisof the literature review and commonpractice. Five of the 30 statementswere multicomponent statementsspecific to PICU level of care,including team structure, technology,education and training, academicpursuits, and indications for transferto a tertiary or quaternary PICU.
TABLE 2 PICU Resources by Level of Care
Resources by Organ System Quaternary orSpecialized Facility
Tertiary Community
CardiovascularHemodynamic monitoringNoninvasive Essential Essential EssentialInvasive Essential Essential Essential
Inotropic support Essential Essential EssentialEchocardiogram (24-h availability) Essential Essential EssentialECMO or ECLS Essential Optional NEVADs Essential Optional NETransplant: heart Desirable Optional NE
GastrointestinalUpper and lower endoscopy Essential Essential DesirableTransplant: liver Desirable Optional NE
HematologicPlasmapheresis or leukapheresis Essential Essential DesirableTransplant: bone marrow Essential Optional NE
NeurologicIntracranial pressure monitoring Essential Essential DesirableExternal ventricular drain Essential Essential DesirableLumbar drain Essential Essential DesirableContinuous EEG Essential Essential OptionalVideo EEG Essential Essential Optional
RespiratoryNoninvasive ventilation (HFNC, CPAP, BIPAP, NPV) Essential Essential EssentialConventional mechanical ventilation Essential Essential EssentialAdvanced mechanical ventilation (HIFV, HFOV) Essential Essential DesirableConventional inhalation therapies (heliox or continuous albuterol) Essential Essential EssentialNitric oxide Essential Essential DesirableAdvanced inhalation gases (flolan or anesthetic agents) Essential Desirable OptionalBronchoscopy Essential Essential DesirableTransplant: lungs Desirable Optional NE
RenalContinuous renal replacement therapy Essential Essential OptionalHemodialysis Essential Essential OptionalPeritoneal dialysis Essential Essential OptionalCharcoal hemofiltration Essential Essential DesirableTransplant: kidney Essential Optional NE
RadiologyDiagnostic imaging, including CT (24-h availability) Essential Essential EssentialAdvanced Diagnostic Imaging, including MRI (with sedation) Essential Essential DesirableInterventional neuroradiology Essential Desirable OptionalInterventional cardiology Essential Desirable OptionalCardiac MRI Essential Desirable Optional
BIPAP, biphasic positive airway pressure; CPAP, continuous positive airway pressure; CT, computed tomography; ECLS, extracorporeal life support; ECMO, extracorporeal membraneoxygenation; HFNC, high-flow nasal cannula; HFOV, high-frequency oscillatory ventilation; HIFV, high-inspiratory flow ventilation; NE, not expected; NPV, negative pressure ventilation; VAD,ventricular assist device.
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TABLE3PICU
Levelof
Care
Matched
toPersonnel
Staff
Qualifications
Roles
Quaternary
orSpecialized
Tertiary
Community
Leadership
Medical
director
•Boardcertified
forpediatriccriticalcaremedicine
aftercompletionofan
ACGM
E-accreditedpediatric
criticalcare
medicinefellowship
•Primaryattendingphysician
Essential
Essential
Essential
•Participates
intraining
tomeetongoing
education
andcertificationrequirem
ents
•Provides
consultationforPICU
patients
•Participates
indevelopm
ent,review
,and
implem
entationof
policies
•Supervises
quality
controland
assessmentactivities
•Supervises
andcoordinatesallmedical
staff
educationandcompetencies
•Participates
inprogram
developm
ent,including
budgetarypreparationandpolicyimplem
entation
•Availableto
thePICU
24hperd,
7dperwkfor
both
clinical
andadministrativeissues
(orsimilar
qualified
physician)
Nursemanager
ordirector
•Training
andexpertisein
pediatriccriticalcare
•Ensuresappropriatenurseto
patient
ratios
Essential;nurseto
patient
ratios:1:1,1:2,
2:1
Essential;nurseto
patient
ratios:1:1,1:2
Essential;nurseto
patient
ratios:1:1,1:2
•Master’s
degree
inpediatricnursingor
nursing
administration
•Participates
indevelopm
ent,review
,and
implem
entationof
unitandnursingpoliciesand
procedures
•Participates
ineducationandtraining
tomeet
ongoingeducationandcertificationrequirem
ents
•Assuranceof
nursingorientationandcompetency,
performance
review
s•Participates
inprogram
developm
ent,including
budgetarypreparationandpolicyimplem
entation
•Participates
indevelopm
entof
quality
improvem
entprojects
•Availableto
PICU
forclinical
andadministrative
issues
24hperd(orqualified
designee)
Surgical
director
orleader
•Boardcertified
forpediatricsurgeryafter
completionof
anACGM
E-accreditedpediatric
surgeryfellowship.Additional
certificationin
surgical
criticalcare
isdesirablebutnot
required.
•Achildren’ssurgeonwho
serves
withinthemedical
leadership
structureof
thePICU
(who
may
bedesignated
asthesurgical
director)andis
responsibleforsettingpoliciesanddefining
administrativeneedsrelatedto
PICU
patientswith
generalor
subspecialtypediatricsurgical
needs
Essential
Essential
Desirable(a
general
surgeonwith
pediatric
interest
would
bean
alternative)
Traumadirector
•Boardcertified
forpediatricsurgeryafter
completionof
anACGM
E-accreditedpediatric
surgeryfellowship
•Achildren’ssurgeonwho
serves
withinthemedical
leadership
structureof
thePICU
(who
may
bedesignated
asthetraumadirector)andis
responsibleforsettingpoliciesanddefining
administrativeneedsrelatedto
PICU
patientswith
traumaticinjuries
(the
surgical
director
orleader
may
servein
thiscapacityfornontraum
acenters)
Essential
Essential
Desirable(a
general
surgeonwith
pediatric
interest
would
bean
alternative)
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TABLE3
Continued
Staff
Qualifications
Roles
Quaternary
orSpecialized
Tertiary
Community
Primarymedical
and
surgical
providers
Pediatricintensivistor
equivalent
•Boardeligibleor
boardcertified
inpediatric
criticalcaremedicineaftertraining
inan
ACGM
E-accreditedprogram
•Physicianin-house
24hperd
Essential
Essential(desirable:
physicianin-house
24hperd)
Essential(optional:
physicianin-house
24h
perd)
•Participates
intraining
tomeetongoing
education
andcertificationrequirem
ents
forpediatric
criticalcare
•Availablein
#30
min
(24hperd)
•Provides
medical
care
andoversightforcare
provided
byphysicians
intraining,NPs,and
PAsfor
allPICU
patients
•Participates
indevelopm
entof
quality
improvem
entprojects
Pediatricsurgeon
•Boardcertified
forpediatricsurgeryafter
completionof
anACGM
E-accreditedpediatric
surgeryfellowship.Additional
certificationin
surgicalcriticalcareisdesirablebutn
otrequired
•Availablein
#1hto
thePICU
Essential
Essential
Desirable(a
general
surgeonwith
pediatric
interest
would
bean
alternative)
•Participates
intraining
tomeetongoing
education
andcertificationrequirem
ents
forpediatric
surgery
•Provides
surgical
care
andoversightforcare
provided
byphysicians
intraining,N
Ps,and
PAs
•Participates
indevelopm
entof
quality
improvem
entprojects
Otherphysicians:
hospitalists,
pediatrictrainees,
surgical
trainees
•Postgraduate
year
2levelor
higher
assigned
toPICU
•In
housePICU
coverage
24h/dwithin
ACGM
Erestrictions
Essential(m
ayincludecombination
ofhospitalists
and
NPs)
Essential(may
include
combinationof
hospitalists
andNPs)
Desirable(m
ayinclude
combinationof
hospitalists
andNPs)
•ACGM
E-accreditedpediatricor
surgerycritical
care
with
focuson
pediatriccriticalcare
residencyprogram
•Participates
inmonitoring
ofquality
improvem
ent
projects
Participatein
training
tomeetongoingeducation
andcertificationrequirem
ents
APPs
orNPs
•Training
andexpertisein
pediatriccriticalcare
•Providecollaborative,comprehensive
managem
ent
ofPICU
patients
Desirable(m
ayincludecombination
ofhospitalists
and
NPs)
Desirable(m
ayincludecombination
ofhospitalists
and
NPs)
Desirable(m
ayinclude
combinationof
hospitalists
andNPs)
•PediatricNP
certification;
preferredacutecare
•Performance
ofadvanced
therapeutic
procedures
•Masterof
sciencein
nursingor
doctoratein
nursingpractice
•Participateindevelopm
entof
quality
improvem
ent
projects
•Participates
intraining
tomeetongoing
education
andcertificationrequirem
ents
PA•Training
andexpertisein
pediatriccriticalcare
•Direct
patient
managem
entwith
physician
supervision
Desirable(m
ayincludecombination
ofhospitalists
and
PAs)
Desirable(m
ayincludecombination
ofhospitalists
and
PAs)
Desirable(m
ayinclude
combinationof
hospitalists
andPAs)
•Graduate
ofPA
program
•Performance
ofadvanced
therapeutic
procedures
•Participates
intraining
tomeetongoing
education
andcertificationrequirem
ents
•Participates
inmonitoring
ofquality
improvem
ent
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TABLE3
Continued
Staff
Qualifications
Roles
Quaternary
orSpecialized
Tertiary
Community
Additionalmedical
and
surgical
providers
Pediatricmedical
subspecialists
•Cardiologist
•Available24
hperd
Essential
Essential
Essential
•Pulmonologist
•Neonatologist
•Nephrologist
•Available24
hperd
Essential
Essential
Desirable
•Hematologistand/or
oncologist
•Endocrinologist
•Gastroenterologist
•Neurologist
•Infectious
diseasespecialist
Interventionalcardiologist
•Available24
hperd
Essential
Desirable
Optional
•Allergist
•Geneticist
•Rheumatologist
•Child
advocacy
Pediatricsurgical
subspecialists
•Cardiovascular
surgeon
•Availablein
#1hto
thePICU
Essential
Desirable(essential:
nonpediatric)
Optional(desirable:
nonpediatric)
•Neurosurgeon
•Otolaryngologist
•Orthopedicsurgeon
•Ophthalmologist
•Plastic
surgeon
•Urologist
Pediatricanesthesia
•Anesthesiologist
•Availablein
#1hto
thePICU
Essential
Essential
Desirable(essential:
nonpediatric)
Pediatricradiologists
•Radiologist
•Available24
hperd
Essential
Essential
Desirable(essential:
nonpediatric)
•Interventionalradiologist
•Available24
hperd
Essential
Essential
Desirable(essential:
nonpediatric)
•Neuroendovascular
•Available24
hperd
Essential
Desirable
Optional
Psychiatrist
orpsychologist
•Availableforconsultation
Essential
Essential
Essential
Nursingstaff
RNs
•Bachelor
ofsciencein
nursingdegree
preferred
•Provisionof
continuous
care
basedon
theneeds
andcharacteristicsof
thepatient
Essential
Essential(desirable:
pediatricCCRN
certification)
Essential(desirable:
pediatricCCRN
certification)
•Hospitalswith
magnetdesignationrequire,10%
non-BSNRN
s•Provisionof
physiologicassessments,
implem
entation,andevaluationof
responsesto
treatm
entplan
•Completionof
PICU
orientation
•Skilled
inadvanced
technology
monitoring
•Continuing
educationrequirem
ents
forlicensure
renewal
•AppropriateNo.nursestrainedin
highly
specialized
therapiessuch
asCRRT
androles,
including:
•BLSandPALS
Charge
nurse
•PediatricCCRN
certification
Arrest
team
nurse
•Maintenance
ofdesignated
PICU
competencies
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TABLE3
Continued
Staff
Qualifications
Roles
Quaternary
orSpecialized
Tertiary
Community
Transportteam
nurse
Traumateam
nurse
•Preceptorfornovice
nurses
•Participates
indevelopm
entandmonitoring
ofquality
improvem
entprojects
Nurseeducator
orclinical
nurse
specialist
•Training
andexpertisein
pediatriccriticalcare
•Participates
inandcoordinatesnursingstaff
education
Essential
Essential
Desirable
•Masterof
sciencein
nursingor
educationor
doctorateor
DNPprepared
•Clinical
resource
fornursingstaff
•Pediatricnursingexpertise
•Participates
indevelopm
entof
quality
improvem
entprojects
•PediatricCCRN
certification
•Participates
inclinical
research
efforts
•BLSandPALS
Nursingassistants
orunlicensedpersonnel
•AssistsRN
sin
patient
care
tasks
Desirable
Desirable
Optional
•Supervised
bynursingstaff
Respiratorytherapystaff
Supervisor
•Registered
respiratorytherapistwith
training
and
expertisein
pediatriccriticalcare
•Responsiblefortraining
therapists
Essential
Essential
Essential
•Clinical
resource
fortherapists
Respiratorytherapists
•Registered
respiratorytherapist
•Therapistassigned
toPICU
24hperd
Essential
Essential
Essential
•BLSandPALS
•Skill
inmanagem
entof
pediatricpatientswith
respiratorydisease
•Demonstrate
competencewith
pediatric
mechanicalventilation
•Maintenance
ofequipm
entandquality
controland
review
•Adjunctiverespiratorytherapiesincludinggases
Otherteam
mem
bers
Pediatricpharmacist
•Pediatricclinical
doctor
ofpharmacy
•Available24
hperd
Essential
Essential
Desirable(essential:
nonpediatric)
Rehabilitationservices
•Physical
therapist,occupationaltherapist,and
speech
therapist
•Availableforconsultation
Essential
Essential
Essential
Nutritionistor
clinical
dietitian
•Availableforconsultation
Essential
Essential
Essential
Social
worker
•Availableforconsultation
Essential
Essential
Essential
Clergy
•Availableforconsultation
Essential
Essential
Essential
Child
lifespecialist
•Availableforconsultation
Essential
Essential
Desirable
Pain
team
•Availableforconsultation
Essential
Essential
Desirable
Palliativecare
•Availableforconsultation
Essential
Desirable
Desirable
Rapidresponse
team
•Available24
hperd
Essential
Essential
Essential
Transportteam
•Available24
hperd
Essential
Essential
Desirable
Ethics
committee
•Availableforconsultation
Essential
Essential
Essential
Quality
andsafety
•Availableforconsultation
Essential
Essential
Essential
Legalor
risk
managem
ent
•Availableforconsultation
Essential
Essential
Essential
Biom
edical
technician
•In-hospitalor
availablewithin
1h,
24hperd
Essential
Essential
Essential
Radiologyservices
•Availablein
#1h
Essential
Essential
Essential
Laboratory
services
•Available24
hperd
Essential
Essential
Essential
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These statements were thenpresented via an online anonymousvoting tool to a voting group by usinga 3-cycle interactive forecastingDelphi method. With each cycle ofvoting, statements were refined onthe basis of votes received andcomments. Consensus was deemedachieved once 80% or higher scoresfrom the voting group were recordedon any given statement or when therewas consensus after review ofcomments provided by voters. Of the25 final statements, 17 met theconsensus cutoff score. The writingpanel evaluated the survey data andtogether with literature findingsformulated admissionrecommendations.
RECOMMENDATIONS
Critically ill or injured pediatricpatients should be cared for ina child- and family-centeredenvironment by a multidisciplinarypediatric critical care team. Threelevels of care are described in theserecommendations on the basis of theresults of the Delphi survey andexpert panel consensus: community-based PICU, tertiary PICU, andquaternary or specialized PICU.
Community medical center PICUsplay an important role in health caresystems that provide care to infantsand children. In the previouslypublished guidelines, these centerswere categorized as level II PICUs.These units provide a broad range ofservices and resources that may differon the basis of institution, hospitalsize, and referral base. The majorityof these will be located in generalmedical-surgical institutions with thecapability of treating pediatricpatients. Tertiary PICUs provideadvanced care for many medical andsurgical illnesses in infants andchildren. In the previously publishedguidelines, these units werecategorized as level I PICUs, asdistinguished from level II PICUs.Tertiary PICUs should provide
advanced ventilatory support such ashigh-frequency oscillatory ventilationand inotropic management but wouldnot be expected to provideextracorporeal membraneoxygenation support. There would beready access to most pediatricmedical subspecialties but there maynot be in-house coverage. Aquaternary or specialized PICUfacility provides regional care andserves large populations or hasa large catchment area. The centershould provide comprehensive careto all complex patients. Uniquely,a specialized PICU providesdiagnosis-specific care for selectpatient populations. This highest levelof PICU facility should have readilyavailable resources to support anAmerican College of Surgeons (ACS)verified Level I or Level II Children’sSurgical Center or Level I or Level IIPediatric Trauma Center. Of note,premature newborns are notaddressed in these guidelines unlessthey require complex cardiovascularsurgical interventions.
Specific recommendations aredetailed in Table 1 regarding the PICUlevel of care admission criteria, thestructure and provider staffing model,the personnel and resources, thequality metrics and education, theequipment and technology, and thedischarge and transfer criteria.Table 2 reveals the necessaryresources needed for each level ofcare. Table 3 reveals the personnelneeded, including the qualifications,competencies, roles, andresponsibilities based on each levelof PICU.
This practice statement and guidanceaddress important specifications foreach PICU level of care, including theteam structure and resources,technology and equipment, educationand training, quality metrics,admission and discharge criteria, andindications for transfer to a higherlevel of care. The sparse high-qualityevidence led the panel to usea modified Delphi process to seekTA
BLE3
Continued
Staff
Qualifications
Roles
Quaternary
orSpecialized
Tertiary
Community
•Providebasichematologic,chemistry,bloodgas,
andtoxicology
analysis
Bloodbank
services
•Available24
hperd
Essential
Essential
Essential
Neurodiagnostic
services
•EEGavailableon
callforem
ergencies
Essential
Essential
Desirable
Unitclerk
•Staffed24
hperd
Essential
Essential
Desirable
ACGM
E,AccreditationCouncilfor
Graduate
MedicalEducation;APP,advanced
practiceprovider;BLS,basiclifesupport;BSN,
bachelor
ofsciencein
nursing;CCRN
,criticalcare
registered
nurse;CRRT,continuous
renalreplacementtherapy;DN
P,doctor
ofnursingpractice;NP,nurse
practitioner;PA,p
hysician
assistant;PALS,PediatricAdvanced
Life
Support;RN
,registerednurse.
PEDIATRICS Volume 144, number 4, October 2019 9 by guest on March 14, 2021www.aappublications.org/newsDownloaded from
expert opinion to develop consensus-based recommendations where gapsin the evidence exist. Despite thislimitation, the members of the taskforce believe these recommendationsprovide guidance to practitioners inmaking informed decisions regardingpediatric admission or transfer to theappropriate level of care to achievebest outcomes. Additional well-designed clinical investigations areneeded to determine and address theconfounding factors that impact
admission, discharge, and transfer ofchildren in all levels of PICUs.
ACKNOWLEDGMENTS
We thank the members of theprevious PICU admission and levelsof care guidelines task forces for theirpreliminary contributions. Themembers of the ADT task forceacknowledge the limitations of thispractice statement and guidance. Asa result of the vast medical and healthcare management information to
consider, constraints to evaluaterapidly available new evidence,human fallibility, and otherconsiderations, readers should usetheir judgment on how best to applyour suggestions andrecommendations.
ABBREVIATION
ACS: American College of Surgeons
qPediatrics, Critical Care Medicine, College of Medicine, Medical Center, University of Nebraska, Omaha, Nebraska; rPICU, Medical City Children’s Hospital, Dallas,
Texas; sPediatric Critical Care Medicine, Children’s Hospital of Wisconsin, Wauwatosa, Wisconsin; uPediatrics and Pediatric Intensive Care, Grand Strand Medical
Center, Myrtle Beach, South Carolina; wPediatrics and Pediatric Critical Care Medicine, Jacobi Medical Center, the Bronx, New York; and xDivision of Medical Critical
Care, Boston Children’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However,
policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they
represent.
The guidance in this statement 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.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before
that time.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements
with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
DOI: https://doi.org/10.1542/peds.2019-2433
Address correspondence to Benson S. Hsu, MD, MBA, FAAP. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
REFERENCES
1. Committee on Hospital Care of theAmerican Academy of Pediatrics;Pediatric Section of the Society ofCritical Care Medicine. Guidelines andlevels of care for pediatric intensivecare units. Committee on Hospital Careof the American Academy of Pediatricsand Pediatric Section of the Society of
Critical Care Medicine. Pediatrics. 1993;92(1):166–175
2. Rosenberg DI, Moss MM; American Collegeof Critical Care Medicine of the Society ofCritical Care Medicine. Guidelines andlevels of care for pediatric intensive careunits. Crit Care Med. 2004;32(10):2117–2127
3. American Academy of Pediatrics,Society of Critical Care Medicine.Criteria for critical care of infantsand children: PICU admission,discharge, and triage practicestatement and levels of careguidance. Crit Care Med. 2019;in press
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DOI: 10.1542/peds.2019-2433 originally published online September 5, 2019; 2019;144;Pediatrics
E. Conway Jr and Michael S.D. AgusRajzer-Wakeham, Tom B. Rice, David L. Rosenberg, Martin K. Wakeham, Edward
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Marjorie J. Arca, Jorge A. Coss-Bu, Mary E. Fallat, Jason Foland, Samir Gadepalli, Benson S. Hsu, Vanessa Hill, Lorry R. Frankel, Timothy S. Yeh, Shari Simone,
GuidanceAdmission, Discharge, and Triage Practice Statement and Levels of Care
Executive Summary: Criteria for Critical Care of Infants and Children: PICU
ServicesUpdated Information &
http://pediatrics.aappublications.org/content/144/4/e20192433including high resolution figures, can be found at:
Referenceshttp://pediatrics.aappublications.org/content/144/4/e20192433#BIBLThis article cites 3 articles, 1 of which you can access for free at:
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DOI: 10.1542/peds.2019-2433 originally published online September 5, 2019; 2019;144;Pediatrics
E. Conway Jr and Michael S.D. AgusRajzer-Wakeham, Tom B. Rice, David L. Rosenberg, Martin K. Wakeham, Edward
Kissoon, Michele Moss, Mohan R. Mysore, Michele C. Papo, Kari L. Michael O. Gayle, Lori A. Harmon, Christa A. Joseph, Aaron D. Kessel, Niranjan
Marjorie J. Arca, Jorge A. Coss-Bu, Mary E. Fallat, Jason Foland, Samir Gadepalli, Benson S. Hsu, Vanessa Hill, Lorry R. Frankel, Timothy S. Yeh, Shari Simone,
GuidanceAdmission, Discharge, and Triage Practice Statement and Levels of Care
Executive Summary: Criteria for Critical Care of Infants and Children: PICU
http://pediatrics.aappublications.org/content/144/4/e20192433located on the World Wide Web at:
The online version of this article, along with updated information and services, is
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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