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The practice of pediatric critical care medicine has matured structure, hospital facilities and services, personnel, drugs and
dramatically during the past decade. These guidelines are pre- equipment, quality monitoring, and training and continuing edu-
sented to update the existing guidelines published in 1993. Pedi- cation. (Crit Care Med 2004; 32:2117–2127)
atric critical care services are provided in level I and level II units. KEY WORDS: pediatric critical care medicine; administrative
Within these guidelines, the scope of pediatric critical care ser- structure; hospital facilities and services; personnel; drugs and
vices is discussed, including organizational and administrative equipment; quality monitoring; continuing education
T
he practice of pediatric critical tion to the subspecialty. In 1990, the Res- level I PICUs should be located in major
care has matured dramatically idency Review Committee of the Accred- medical centers or within children’s hos-
throughout the past 3 de- itation Council for Graduate Medical pitals. It is also recognized that in the
cades. Knowledge of the Education completed its first accredita- appropriate clinical setting and as a result
pathophysiology of life-threatening pro- tion of pediatric critical care medicine of many forces, including but not limited
cesses and the technological capacity to training programs. In 1986, the American to the presence of managed care, the in-
monitor and treat pediatric patients suf- Association of Critical Care Nurses devel- sufficient supply of trained pediatric in-
fering from them has advanced rapidly oped a certification program for pediatric tensivists, and geographic and transport
during this period. Along with the scien- critical care, and in 1999, a certification limitations, level II PICUs may be an ap-
tific and technical advances has come the program for clinical nurse specialists in propriate alternative to the transfer of all
evolution of the pediatric intensive care pediatric critical care was initiated. critically ill children to a level I PICU.
unit (PICU), in which special needs of In view of recent developments, the The level I PICU should provide care
critically ill or injured children and their Pediatric Section of the Society of Critical to the most severely ill patient popula-
families can be met by pediatric special- Care Medicine and the Section on Critical tion. Specifications for level I PICUs are
ists. All critically ill infants and children Care Medicine and Committee on Hospi- discussed in detail in the text and are
cared for in hospitals, regardless of the tal Care of the American Academy of Pe- summarized in Table 1. Level I PICUs will
physical setting, are entitled to receive diatrics believe that the original guide- vary in size, personnel, physical charac-
the same quality of care. lines for levels of PICU care from 1993 (1) teristics, and equipment, and they may
In 1985, the American Board of Pedi- should be updated. This report represents differ in the types of specialized care that
atrics recognized the subspecialty of pe- the consensus of the three aforemen- are provided (e.g., transplantation or car-
diatric critical care medicine and set cri- tioned groups and presents those ele- diac surgery). Physicians and specialized
teria for subspecialty certification. The ments of hospital care that are necessary services may differ between levels, such
American Boards of Medicine, Surgery, to provide high-quality pediatric critical that level I PICUs will have a full comple-
and Anesthesiology gave similar recogni- care. The concept of level I and level II ment of medical and surgical subspecial-
PICUs as established in the guidelines set ists, including pediatric intensivists. Each
forth in 1993 will be continued in this level I and level II PICU should be able to
All committee reports from the American Academy report. Individual states may have PICU address the physical, psychosocial, emo-
of Pediatrics automatically expire 5 yrs after publica- guidelines, and it is not the intent of this tional, and spiritual needs of patients
tion unless reaffirmed, revised, or retired at or before
that time. report to supersede already established with life-threatening conditions and their
The American College of Critical Care Medicine state rules, regulations, or guidelines; families.
(ACCM), which honors individuals for their achieve- however, these guidelines represent the Some pediatric patients with moder-
ments and contributions to multidisciplinary critical consensus report of critical care experts. ate severity of illness can be managed in
care medicine, is the consultative body of the Society
of Critical Care Medicine (SCCM) that possesses rec- Pediatric critical care is ideally pro- level II PICUs. Level II PICUs may be
ognized expertise in the practice of critical care. The vided by a PICU that meets level I speci- necessary to provide stabilization of crit-
College has developed administrative guidelines and fications. The level I PICU must provide ically ill children before transfer to an-
clinical practice parameters for the critical care prac- multidisciplinary definitive care for a other center or to avoid long-distance
titioner. New guidelines and practice parameters are
continually developed, and current ones are system-
wide range of complex, progressive, and transfers for disorders of less complexity
atically reviewed and revised. rapidly changing medical, surgical, and or lower acuity. It is imperative that the
Copyright © 2004 by the Society of Critical Care traumatic disorders occurring in pediat- same standards of quality care be applied
Medicine and Lippincott Williams & Wilkins ric patients of all ages, excluding prema- to patients managed in level II PICUs and
DOI: 10.1097/01.CCM.0000142704.36378.E9 ture newborns. Most, although not all, level I PICUs. Requirements for level II
Level I Level II
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 one of the following:
i. Pediatric critical care medicine E E
Y Initial board certification in pediatrics E E
Y Co-director if director is not a pediatrician E D
ii. Anesthesiology with practice limited to infants and children and special qualifications in critical care E E
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 for any PICU patient on a daily basis E E
c. Assumes patient care if primary attending physician is not available E E
d. Participates in development, review, and implementation of PICU policiesa E E
e. Maintains database and/or vital statisticsa E E
f. Supervises quality control and quality assessment activities (including morbidity and mortality reviews)a E E
g. Supervises resuscitation techniques (including educational component)a E E
h. Ensures policy implementationa E E
i. Coordinates staff educationa E E
j. Participates in budget preparationa E E
k. Coordinates researcha E D
4. Substitute physician available to act as attending physician in medical director’s absence E E
B. Physician staff
1. A physician in-house 24 hrs/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 (advanced practice nurse or E E
physician assistant may be used)
c. A physician at the postgraduate year 3 level or above (in pediatrics or anesthesiology) in house 24 hrs/day E O
2. Available in ⱕ30 mins (24 hrs/day)
Pediatric intensivist or equivalent E D
3. Available in ⱕ1 hr
a. Anesthesiologist E E
i. Pediatric anesthesiologist E D
b. General surgeon E E
c. Surgical subspecialists
i. Pediatric surgeon E D
ii. Cardiovascular surgeon E O
Y Pediatric cardiovascular surgeon D O
iii. Neurosurgeon E E
Y Pediatric neurosurgeon E O
iv. Otolaryngologist E D
Y Pediatric otolaryngologist D O
v. Orthopedic surgeon E D
Y Pediatric orthopedic surgeon D O
vi. Craniofacial, oral surgeon D O
4. Pediatric subspecialists
a. Intensivist E E
b. Cardiologist E D
c. Nephrologist E D
d. Hematologist/oncologist D D
e. Pulmonologist D D
f. Endocrinologist D D
g. Gastroenterologist D D
h. Allergist D D
i. Neonatologist E E
j. Neurologist E D
k. Geneticist D D
5. Radiologist E E
a. Pediatric radiologist E O
6. Psychiatrist or psychologist E D
C. Nursing staff
1. Manager/director E E
a. Training and clinical experience in pediatric critical care E E
b. Master’s degree in pediatric nursing or nursing administration D D
2. Nurse-to-patient ratio based on patient need E E
3. Nursing policies and procedures in place E E
4. Orientation to PICU E E
5. Completion of clinical and didactic critical care course E E
6. Address psychosocial needs of patient and family E E
7. Participate in continuing education E E
8. Completion of critical care registered nurse (pediatric) certification D D
9. Completion of PALS or an equivalent course D D
10. Nurse educator on staff (clinical nurse specialist) E D
a. Responsible for pediatric critical care in-service education E D
Level I Level II
Level I Level II
Level I Level II
E. Monitoring equipment
1. Capability of continuous monitoring of:
a. Electrocardiography, heart rate E E
b. Respiration E E
c. Temperature E E
d. Systemic arterial pressure E E
e. Central venous pressure E E
f. Pulmonary arterial pressure E D
g. Intracranial pressure E D
h. Esophageal pressure D O
i. Capability to measure 4 pressures simultaneously E D
j. Capability to measure 5 pressures simultaneously D D
k. Arrhythmia detection and alarm E E
l. Pulse oximetry E E
m. End-tidal CO2 E E
2. Monitor characteristics
a. Visible and audible high and low alarms for heart rate, respiratory rate, and all pressures E E
b. Hard copy capability E E
c. Routine testing and maintenance E E
d. Patient isolation E E
e. Central station E E
V. Prehospital care
A. Integration and communication with EMS system E E
B. Transfer arrangements with referral hospital E E
C. Transfer arrangement with level I PICU NA E
D. Educational programs in stabilization and transportation for EMS personnel E D
E. Transport system (including transport team) E O
F. Emergency communication into PICU and PACU (e.g., phone, radio) 24 hrs/day E E
G. Communication link to poison control center E E
VI. Quality improvement
1. Collaborative quality assessment E E
2. Morbidity and mortality review E E
3. Utilization review E E
4. Medical records review E E
5. Discharge criteria (planning) E E
6. Safety review E E
7. Long-term follow-up of patients and family D D
VII. Training and continuing education
A. Physician training
1. Unit in facility with accredited pediatric residency program D O
2. Unit provides clinical rotation for pediatric residents in pediatric critical care D O
3. Fellowship program in pediatric critical care D O
4. Cardiopulmonary resuscitation certification E E
5. PALS or advanced pediatric life support E E
6. Ongoing continuing medical education for physicians specific to pediatric critical care E E
7. Staff physicians to attend and participate in regional and national meetings in areas related to pediatric critical care E E
B. Unit personnel
1. Cardiopulmonary resuscitation certification for nurses and respiratory therapists E E
2. Resuscitation practice sessions E E
3. Ongoing continuing education (on-site and/or off-site workshops and programs for nurses respiratory therapists, E E
clinical pharmacists)
4. Certified by the American Association of Critical Care Nurses D D
5. PALS or advanced pediatric life support certification E E
6. Critical care registered nurse certification D D
C. Regional education
1. Participation in regional pediatric critical care education E O
2. Service as educational resource center for public education in pediatric critical care D D
3. Prehospital care and interhospital transport D O
E, essential; D, desired; O, optional; NA, not applicable; PALS, pediatric advanced life support; PACU, pediatric acute care unit; BUN, blood urea nitrogen;
EEG, electroencephalogram; EMS, emergency medical services.
a
In conjunction with nurse manager.
PICUs differ from those for level I PICUs units should be located according to doc- for timely referral of patients who need
primarily with respect to the type and umented demand or need and in concert care that is not available in the level II
immediacy of physician presence and with accepted principles of regionaliza- PICU. Although other special care units
hospital resources. A level II PICU does tion of medical care (2). Each level II unit may be appropriate for hospitals with
not require a full spectrum of subspecial- must have a well-established communi- small pediatric inpatient services, they
ists, as outlined in the Table. Level II cations system with a level I unit to allow should not be considered PICUs.