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Growth in PICUs Prompts Updated Guidance on Levels and Practice of Care

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The Society of Critical Care Medicine (SCCM) and the American Academy of Pediatrics (AAP) have jointly released a set of updated recommendations that define new categories for ascending levels of pediatric intensive care unit (PICU) care for infants and children. The full evidence-based statement is published in the September issue of Pediatric Critical Care Medicine.

“[W]e have created a new practice statement and guidance that will enable hospitals, institutions, and individuals to develop the appropriate PICUs for the needs of their community,” 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. An executive summary is also published in the journal Pediatrics.

“This 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. The task force identified and evaluated research evidence on the organizations 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 and 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.

“The emergence of specialized PICUs to care for critically ill children with organ-specific needs has evolved. Tertiary PICUs are able to provide complex care to a specific segment of the pediatric population, while community PICUs continue to provide a very important resource to patients and their families with more common pediatric critical illnesses. These three levels of PICUs will provide the best possible care to the critically ill pediatric patient in an environment that is most appropriate for the medical or surgical issues facing the child and his/her family,” noted Dr. Frankel.

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.”