American Academy of Pediatrics Society of Critical Care Medicine
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AMERICAN ACADEMY OF PEDIATRICS SOCIETY OF CRITICAL CARE MEDICINE CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care David I. Rosenberg, MD; M. Michele Moss, MD; and the Section on Critical Care and Committee on Hospital Care Guidelines and Levels of Care for Pediatric Intensive Care Units ABSTRACT. The practice of pediatric critical care med- American Association of Critical Care Nurses devel- icine has matured dramatically during the past decade. oped a certification program for pediatric critical These guidelines are presented to update the existing care, and in 1999, a certification program for clinical guidelines published in 1993. Pediatric critical care ser- nurse specialists in pediatric critical care was initi- vices are provided in level I and level II units. Within ated. these guidelines, the scope of pediatric critical care ser- vices is discussed, including organizational and admin- In view of recent developments, the Pediatric Sec- istrative structure, hospital facilities and services, per- tion of the Society of Critical Care Medicine and the sonnel, drugs and equipment, quality monitoring, and Section on Critical Care Medicine and Committee on training and continuing education. Pediatrics 2004;114: Hospital Care of the American Academy of Pediat- 1114–1125; pediatric intensive care unit, PICU, critical rics believe that the original guidelines for levels of care services. PICU care from 19931 should be updated. This report represents the consensus of the 3 aforementioned ABBREVIATIONS. PICU, pediatric intensive care unit, EMS, groups and presents those elements of hospital care emergency medical services, PALS, pediatric advanced life that are necessary to provide high-quality pediatric support. critical care. The concept of level I and level II PICUs as established in the guidelines set forth in 1993 will INTRODUCTION be continued in this report. Individual states may he practice of pediatric critical care has ma- have PICU guidelines, and it is not the intent of this tured dramatically throughout the past 3 de- report to supersede already established state rules, Tcades. Knowledge of the pathophysiology of regulations, or guidelines; however, these guidelines life-threatening processes and the technologic capac- represent the consensus report of critical care ex- ity to monitor and treat pediatric patients suffering perts. from them has advanced rapidly during this period. Pediatric critical care is ideally provided by a PICU Along with the scientific and technical advances has that meets level I specifications. The level I PICU come the evolution of the pediatric intensive care must provide multidisciplinary definitive care for a unit (PICU), in which special needs of critically ill or wide range of complex, progressive, and rapidly injured children and their families can be met by changing medical, surgical, and traumatic disorders pediatric specialists. All critically ill infants and chil- occurring in pediatric patients of all ages, excluding dren cared for in hospitals, regardless of the physical premature newborns. Most, but not all, level I PICUs setting, are entitled to receive the same quality of should be located in major medical centers or within care. children’s hospitals. It is also recognized that in the In 1985, the American Board of Pediatrics recog- appropriate clinical setting and as a result of many nized the subspecialty of pediatric critical care med- forces including but not limited to the presence of icine and set criteria for subspecialty certification. managed care, the insufficient supply of trained pe- The American Boards of Medicine, Surgery, and An- diatric intensivists, and geographic and transport esthesiology gave similar recognition to the subspe- limitations, level II PICUs may be an appropriate cialty. In 1990, the Residency Review Committee of alternative to the transfer of all critically ill children the Accreditation Council for Graduate Medical Ed- to a level I PICU. ucation completed its first accreditation of pediatric The level I PICU should provide care to the most critical care medicine training programs. In 1986, the severely ill patient population. Specifications for level I PICUs are discussed in detail in the text and The guidance in this report does not indicate an exclusive course of treat- are summarized in Table 1. Level I PICUs will vary ment or serve as a standard of medical care. Variations, taking into account in size, personnel, physical characteristics, and individual circumstances, may be appropriate. doi:10.1542/peds.2004-1599 equipment, and they may differ in the types of spe- PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- cialized care that are provided (eg, transplantation or emy of Pediatrics. cardiac surgery). Physicians and specialized services 1114 PEDIATRICS Vol.Downloaded 114 No. 4 from October www.aappublications.org/news 2004 by guest on September 28, 2021 TABLE 1. Minimum Guidelines and Levels of Care for PICUs Level I Level II I. Organization and administrative structure A. Category I facility EE B. Organization 1. PICU committee EE 2.Distinct administrative unit E E 3.Delineation of physician and nonphysician privilege E E C. Policies 1. Admission and discharge EE 2. Patient monitoring EE 3. Safety EE 4. Nosocomial infection EE 5. Patient isolation EE 6. Family-centered care EE 7. Traffic control EE 8. Equipment maintenance EE 9. Essential equipment breakdown E E 10. System of record keeping EE 11. Periodic review a. Morbidity and mortality E E b. Quality of care EE c. Safety EE d. Critical care consultation E E e. Long-term outcomes DD f. Supportive care DD D. Physical facility—external 1. Distinct, separate unit ED 2. Distinct unit (not necessarily physically separate) with auditory and visual EE separation 3. Controlled access (no through-traffic) E E 4. Located near: a. Elevators ED b. Operating room DD c. Emergency room DD d. Recovery room DD e. Physician on-call room ED f. Nurse manager’s office DD g. Medical director’s office D D h. Waiting room ED 5. Separate rooms available a. Family counseling room E D b. Conference room DD c. Staff lounge DD d. Staff locker room DD e. Storage lockers for patients’ personal effects (may be internal) E E f. Family sleep area and shower E D E. Physical facility—internal 1. Patient isolation capacity EE 2. Patient privacy provision EE 3. Satellite pharmacy DO 4. Medication station with drug refrigerator and locked narcotics cabinet E E 5. Emergency equipment storage E E 6. Clean utility (linen) room EE 7. Soiled utility (linen) room EE 8. Nourishment station EE 9. Counter and cabinet space E E 10 .Staff toilet EE 11. Patient toilet EE 12. Hand-washing facility EE 13. Clocks EE 14. Televisions, radios, toys EE 15. Easy, rapid access to head of bed E E 16. 12 or more electrical outlets per bed E E 17. 2 or more oxygen outlets per bed E E 18. 2 or more compressed air outlets per bed E E 19. 2 vacuum outlets per bed EE 20. Computerized laboratory reporting or efficient equivalent E D 21. Building code or federal code conforming for: a. Heating, ventilation, and air conditioning E E b. Fire safety EE c. Electrical grounding EE d. Plumbing EE e. Illumination EE Downloaded from www.aappublications.org/news byAMERICAN guest on September ACADEMY 28, 2021 OF PEDIATRICS 1115 TABLE 1. Continued Level I Level II II. Personnel A. Medical director 1. Appointed by appropriate hospital authority and acknowledged in writing E E 2. Qualifications a. Board certified or actively pursuing certification in 1 of the following: i. Pediatric critical care medicine E E • Initial board certification in pediatrics E E • Codirector if director is not a pediatrician E D ii. Anesthesiology with practice limited to infants and children and special EE qualifications in critical care medicine iii. Pediatric surgery with added qualification in surgical critical care medicine E E 3. Responsibilities documented in writing E E a. Acts as primary attending physician D D b. Has authority to provide consultation when physician is not available E E c. Assumes patient care if primary attending physician is not available E E d. Participates in development, review, and implementation of PICU policies* E E e. Maintenance of database and/or vital statistics* E E f. Supervises quality-control and quality-assessment activities (including morbidity EE and mortality reviews)* g. Supervises resuscitation techniques (including educational component)* E E h. Ensures policy implementation* E E i. Coordinates staff education* E E j. Participates in budget preparation* E E k. Coordinates research* ED 4. Substitute physician available to act as attending physician in medical director’s EE absence B. Physician staff 1. A physician in-house 24 h per day E E a. A physician at the postgraduate year 2 level or above assigned to the PICU E D b. A physician at the postgraduate year 2 level or above available to the PICU EE (advanced practice nurse or physician assistant may be used) c. A physician at the postgraduate year 3 level or above (in pediatrics or EO anesthesiology) in-house 24 h per day 2. Available in 30 min or less (24 h per day) a. Pediatric intensivist or equivalent E D 3. Available in1horless a. Anesthesiologist EE i. Pediatric anesthesiologist E D b. General surgeon EE c. Surgical subspecialists i. Pediatric surgeon ED ii. Cardiovascular surgeon E O • Pediatric cardiovascular surgeon D O iii. Neurosurgeon EE • Pediatric neurosurgeon E O iv. Otolaryngologist ED • Pediatric otolaryngologist D O v. Orthopedic surgeon ED • Pediatric orthopedic surgeon D O vi. Craniofacial, oral surgeon D O 4. Pediatric subspecialists a. Intensivist EE b. Cardiologist ED c. Nephrologist ED d. Hematologist/oncologist D D e. Pulmonologist DD f. Endocrinologist DD g. Gastroenterologist DD h. Allergist DD i. Neonatologist EE j. Neurologist ED k. Geneticist DD 5. Radiologist EE a. Pediatric radiologist EO 6.