A set of updated recommendations on critical care for infants and children including criteria for admission and discharge and levels of care in the pediatric intensive care unit (PICU) are presented in Pediatric Critical Care Medicine. The journal is published in the Lippincott portfolio by Wolters Kluwer. The recommendations are released jointly by the Society of Critical Care Medicine (SCCM) and the American Academy of Pediatrics (AAP), and an executive summary is also published in the journal Pediatrics.
"We have created a new practice statement and guidance that will enable hospitals, institutions, and individuals to develop the appropriate PICUs for the needs their communities," according to the report by a task force of nationally and internationally recognized clinical experts in pediatric critical care medicine. The full evidence-based statement which updates the 2004 American Academy of Pediatrics/Society for Critical Care Medicine PICU guidelines is published in the September issue of Pediatric Critical Care Medicine.
â€œThis new guidance is extremely important, as it reflects the changes in pediatric critical care over the past decade, said task force chair Lorry R. Frankel, MD, FCCM, of California Pacific Medical Center, San Francisco. Dr. Frankel also participated in an SCCM iCritical Care Podcast interview, to be released with the article, which explains the recommendations in depth. The podcast will be available at sccm.org/iCriticalCare.
Statement recommends new categories for level of PICU care
The task force identified and evaluated research evidence on the organization and outcomes of PICU care for critically ill infants and children. Because separate guidelines exist, the practice statement did not address newborns, except those requiring complex cardiovascular surgery.
A research review identified only 21 studies evaluating patient outcomes related to pediatric level of care, specialized PICUs, patient volume, or personnel. Due to the lack of high-quality evidence, consensus recommendations were developed based on expert opinion, following a formal voting process.
The updated statement specifies characteristics for ascending levels of PICU care, including team structure, technology, education and training, academic pursuits, and indications for transferring patients to a higher level of care. Building on previous classifications, the statement proposes three levels of units providing care for critically ill infants and children:
- Community-based PICUs (previously categorized as level II), mainly located in general hospitals. Community PICUs are further classified as rural, suburban, or urban and academic versus nonacademic.
- Tertiary PICUs (previously categorized as level I), capable of providing advanced care for critically ill children with a wide range of medical and surgical conditions.
- Quaternary PICUs, a new category of PICUs providing comprehensive care to all children with complex conditions. These units may be found in children's hospitals, but also in specialized general hospitals. Some quaternary PICUs provide specialized care for conditions such as cardiovascular disease, transplantation, trauma, and cancer.
For each level of care, the statement addressed the populations served, types of diseases treated, necessary healthcare team members and support services, coverage responsibilities, equipment and technology, quality measurement and patient safety, relationships with other ICUs, and patient transport and transfer.
Recommendations for ICU structure and provider staffing include the statement, "Expertise in the care of the critically ill child is required in all PICU levels of care." An important focus is determining the appropriate level of care associated with improved outcomes. The statement includes recommendations for transfer to a higher level of care and criteria for discharge from the PICU, including patient follow-up and support.
The updated statement acknowledges the lack of evidence addressing many or most of the areas addressed, including ICU structure and staffing models. The authors conclude: "Despite this limitation, the members of the task force believe that these recommendations provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve the best outcomes."
About the Society of Critical Care Medicine
The Society of Critical Care Medicine (SCCM) is the largest nonprofit medical organization dedicated to promoting excellence and consistency in the practice of critical care. With members in more than 100 countries, SCCM is the only organization that represents all professional components of the critical care team. The Society offers a variety of activities that ensure excellence in patient care, education, research and advocacy. SCCMs mission is to secure the highest-quality care for all critically ill and injured patients. Visit www.sccm.org for more information. Follow @SCCM or visit us on Facebook.
About Pediatric Critical Care Medicine
Pediatric Critical Care Medicine is the official journal of the Society of Critical Care Medicine, the World Federation of Pediatric Intensive and Critical Care Societies, the Pediatric Intensive Care Society UK, the Latin American Society of Pediatric Intensive Care, and the Japanese Society of Pediatric Intensive and Critical Care. This exciting journal is the first scientific, peer-reviewed publication to focus exclusively on pediatric critical care medicine and critical care neonatology.