Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance

Pediatric critical care medicine has evolved over the last 3 decades into a highly respected, board-certified specialty that has become an indispensable service for inpatient programs of most children’s hospitals as well as a highly valued resource supporting most community-based programs. The earlier published guidelines for pediatric critical care medicine were used to help establish the basic needs for a state-of-the-art PICU. These guidelines were used by both physician leadership and policy makers to advocate for personnel, supplies, and space that were unique to PICUs. However, there has been a tremendous transformation of pediatric critical care medicine over the past 10 years, with explosive growth in specialized PICUs in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution in both human and material resources and training in more highly specialized areas such as cardiovascular medicine, neurosurgical ICUs, and trauma care.^1,2 

To provide a 2019 update of the American Academy of Pediatrics and Society of Critical Care Medicine’s 2004 Guidelines and levels of care for PICUs (https://journals.lww.com/pccmjournal/Fulltext/2019/09000/Criteria_for_Critical_Care_Infants_and_Children_.7.aspx).³ 

A group of nationally and internationally recognized clinical experts in pediatric critical care medicine made up the pediatric critical care admission guidelines task force. The task force reviewed the work of the previous guidelines and made decisions regarding topic selection inclusion. The topic selection for the guidelines addressed PICU characteristics and interventions by the PICU level of care, including quaternary or specialized, tertiary, and community. Interventions addressed included PICU admission, team structure, transport and transfer mechanisms, outreach programs, and quality metrics.

A comprehensive literature search on the topics and agreed-on questions determined by the task force was performed by a dedicated Society of Critical Care Medicine librarian in selected biomedical databases. The 2004 guidelines and levels of care for PICUs served as the starting point for searches in Medline (Ovid), Embase (Ovid), and PubMed on articles published from 2004 to 2016. Members of the task force received the set of citations and abstracts relevant to the section of the guidelines; references not directly related to the content area were excluded from the review. The full-text articles were retrieved and reviewed to determine appropriate inclusion for appraisal.

The admission to the PICU literature search identified 832 articles. The review of article titles resulted in 299 relevant articles, of which all abstracts were reviewed. The full text of 75 articles and 12 additional articles obtained by hand searching reference lists were reviewed. Twenty-one relevant pediatric studies in which outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel were evaluated were found. The discharge and unplanned readmission literature search yielded 68 articles. The full text of 24 articles and 6 additional articles obtained by hand searching reference lists were reviewed. No articles were found in which PICU discharge criteria were evaluated, and only 14 relevant studies were found in which outcomes related to unplanned PICU readmissions were evaluated. Since publication of the 2004 revised guidelines, evidence on evaluating the impact of the level of PICU care on patient outcomes remains limited. After deliberation, the task force determined that the strength and quality of the current pediatric evidence for the selected topics was insufficient to use the Grading of Recommendations, Assessment, Development, and Evaluation system in supporting evidence-based recommendations. The sparse literature and the nature of the questions under review did not lend itself to the use of the population, intervention, comparison, and outcome format. Therefore, a modified Delphi process was undertaken, seeking expert opinion to develop consensus-based recommendations where gaps in the evidence exist.

Members were selected to be on the panel on the basis of their experience as PICU directors, administrators, or other leadership roles and were chosen to represent a variety of hospital settings, from academic centers to community hospitals. The American Academy of Pediatrics also appointed a hospitalist and critical care physician liaison to serve on the panel and to assist in the development of the guideline. An American College of Critical Care Board of Regents member served as a liaison to the committee to support its work.

The guidelines panel consisted of 2 groups: a voting group consisting of 30 members and a writing group of 20 members. The voting panel used an iterative collaborative approach to formulate 30 statements on the basis of the literature review and common practice. Five of the 30 statements were multicomponent statements specific to PICU level of care, including team structure, technology, education and training, academic pursuits, and indications for transfer to a tertiary or quaternary PICU. These statements were then presented via an online anonymous voting tool to a voting group by using a 3-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and comments. Consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or when there was consensus after review of comments provided by voters. Of the 25 final statements, 17 met the consensus cutoff score. The writing panel evaluated the survey data and together with literature findings formulated admission recommendations.

Critically ill or injured pediatric patients should be cared for in a child- and family-centered environment by a multidisciplinary pediatric critical care team. Three levels of care are described in these recommendations on the basis of the results of the Delphi survey and expert panel consensus: community-based PICU, tertiary PICU, and quaternary or specialized PICU.

Community medical center PICUs play an important role in health care systems that provide care to infants and children. In the previously published guidelines, these centers were categorized as level II PICUs. These units provide a broad range of services and resources that may differ on the basis of institution, hospital size, and referral base. The majority of these will be located in general medical-surgical institutions with the capability of treating pediatric patients. Tertiary PICUs provide advanced care for many medical and surgical illnesses in infants and children. In the previously published guidelines, these units were categorized as level I PICUs, as distinguished from level II PICUs. Tertiary PICUs should provide advanced ventilatory support such as high-frequency oscillatory ventilation and inotropic management but would not be expected to provide extracorporeal membrane oxygenation support. There would be ready access to most pediatric medical subspecialties but there may not be in-house coverage. A quaternary or specialized PICU facility provides regional care and serves large populations or has a large catchment area. The center should provide comprehensive care to all complex patients. Uniquely, a specialized PICU provides diagnosis-specific care for select patient populations. This highest level of PICU facility should have readily available resources to support an American College of Surgeons (ACS) verified Level I or Level II Children’s Surgical Center or Level I or Level II Pediatric Trauma Center. Of note, premature newborns are not addressed in these guidelines unless they require complex cardiovascular surgical interventions.

Specific recommendations are detailed in Table 1 regarding the PICU level of care admission criteria, the structure and provider staffing model, the personnel and resources, the quality metrics and education, the equipment and technology, and the discharge and transfer criteria. Table 2 reveals the necessary resources needed for each level of care. Table 3 reveals the personnel needed, including the qualifications, competencies, roles, and responsibilities based on each level of PICU.

This practice statement and guidance address important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the task force believe these recommendations provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes. Additional well-designed clinical investigations are needed to determine and address the confounding factors that impact admission, discharge, and transfer of children in all levels of PICUs.

We thank the members of the previous PICU admission and levels of care guidelines task forces for their preliminary contributions. The members of the ADT task force acknowledge the limitations of this practice statement and guidance. As a result of the vast medical and health care management information to consider, constraints to evaluate rapidly available new evidence, human fallibility, and other considerations, readers should use their judgment on how best to apply our suggestions and recommendations.

ACS

American College of Surgeons