In 2004, the AAP published a clinical report on the development and operation of pediatric intermediate care units (IMCUs) for hospitalized pediatric patients who do not require intensive care but need more services than provided on general inpatient units. Since then, advances in pediatric therapeutics and improvements in pediatric critical care have resulted in significant changes to the acuity and complexity of children who require hospital admission.
A new AAP policy statement has been developed to replace the clinical report. It sets a foundation for decision-makers and clinicians in developing a local IMCU, clarifies target populations and makes recommendations regarding staffing and payment. It is intended for institutions, administrators, providers, health care funders and policymakers in all settings — from rural to urban, from community hospitals to major academic centers, and from communities with low- to high-density pediatric intensive care units (PICUs).
The policy Guidance for Structuring a Pediatric Intermediate Care Unit, from the Section on Critical Care, Committee on Hospital Care and Section on Surgery, is available at https://doi.org/10.1542/peds.2022-057009 and will be published in the May issue of Pediatrics.
Principles for developing, operating IMCUs
IMCUs can function as high-dependency units, progressive units or step-up units for patients who need more care than provided on a general floor or as step-down units for patients recovering from critical illness or a surgical intervention that required ICU admission.
Since research evaluating pediatric IMCUs is limited, the AAP established a task force to review and revise the 2004 clinical report, with its emphasis on an “organ system-based” list of admission and discharge criteria to include today’s best evidence regarding IMCUs.
Establishment of an IMCU can occur not only in tertiary or quaternary PICUs but also in hospitals without a physical PICU. However, an IMCU should be established only with extensive institutional planning and care.
Reflecting the diversity of existing IMCUs, core principles for the successful development and operation of an IMCU include ensuring the presence of clear triage guidelines to guide IMCU admissions, delineating policies and procedures for ongoing assessment of IMCU patients, and establishing thresholds and efficient processes for rapid transfer to a PICU. All IMCUs should have a clear relationship with a PICU, including a comprehensive plan for how to cover urgent and emergent medical issues.
Nurse staffing ratios should be 1:2 or 1:3 depending on patients’ needs and acuity. Essential to the smooth functioning of IMCUs are experienced and appropriately trained ancillary staff as well as care managers and social workers well-versed in the medical complexities of contemporary home care.
Following are priority areas for pediatric IMCU research:
- Describe current national pediatric IMCU structures and staffing models.
- Describe and analyze associations of IMCU structures and staffing with specific patient outcomes.
- Develop national standardized quality and safety benchmarks and outcomes for IMCU populations.
- Explore and define the role of pediatric hospitalists in IMCUs.
- Advocate for the Centers for Medicare & Medicaid Services to recognize the IMCU level of care with associated hospital payment.
Dr. Ettinger is a lead author of the policy statement and a member of the AAP Section on Critical Care Executive Committee.
The policy statement at https://doi.org/10.1542/peds.2022-057009 includes a table of examples, organized by organ system, of conditions and care requirements that make children and adolescents potentially suitable for an intermediate care unit.