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) – have been jointly released by the Society of Critical Care
Medicine (SCCM) and the American Academy of Pediatrics (AAP). The
recommendations define new categories for levels of PICU care, in an effort to
improve critical care for children.
created a new practice statement and guidance that will enable hospitals,
institutions, and individuals to develop the appropriate PICUs for the needs of
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
(published online Sept. 4). An
executive summary is also published in the journal Pediatrics (published
online Sept. 5).
“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.
Dr. Frankel also
participated in an SCCM iCritical Care Podcast interview, to be released on
Sept. 5 to explain the recommendations in depth. The podcast will be available
Recommends New Categories for Level of PICU Care
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.
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:
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.
PICUs (previously categorized as level I), capable of
providing advanced care for critically ill children with a wide range of
medical and surgical conditions.
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.
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.
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."
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. SCCM’s 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 the American Academy of Pediatrics
The American Academy of Pediatrics is an
organization of 67,000 primary care pediatricians, pediatric medical
subspecialists and pediatric surgical specialists dedicated to the health,
safety and well-being of infants, children, adolescents and young adults. For
frequent updates on AAP recommendations, Pediatrics studies, AAP in the news,
public awareness campaigns, information for parents and more, follow us on
Twitter at http://twitter.com/AmerAcadPeds.
For parent-friendly health information from the AAP, visit www.HealthyChildren.org. This
award-winning site offers thousands of articles in English and Spanish that can
serve as links to include in your stories on children’s health and safety.