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

Patients who are appropriately triaged according to level of illness and services provided in community, tertiary, or quaternary PICU facilities will have comparable outcomes and quality of care. The specifics of each PICU level of care described above serve as a reference for minimum standards of quality care to guide appropriate PICU admissions and promote optimal patient outcomes.

Individual hospitals and their PICU leadership team should develop admission criteria to assist in the placement of critically ill children that are aligned with their PICU level of care.

Pediatric patients requiring specialized service interventions such as cardiac, neurologic, or traumarelated surgery have improved outcomes when cared for in a quaternary or tertiary ICU, and early interfacility transfer to the appropriate regional facility should be the standard of care.

Congenital heart surgery should only be performed in a hospital that has a PICU with a dedicated pediatric cardiac intensive care team, including but not restricted to pediatric intensivists and nurses with expertise in cardiac intensive care, cardiovascular surgeon with pediatric expertise, pediatric perfusionists, pediatric cardiologists, and pediatric cardiac anesthesiologists.

Expertise in the care of the critically ill child is required in all PICU levels of care.

All critically ill children admitted to any PICU should be cared for by a pediatric intensivist who is board eligible, board certified, or undergoing maintenance of certification as primary provider while in the ICU setting.

Trauma patients should be cared for by both the trauma service (including trainees) and the PICU service in a collaborative manner. The ACS requires that surgeons be the primary provider on all patients admitted with traumatic injuries. Programs in which the attending surgeon has training and certification in surgical critical care may (institution specific) allow for the primary attending to be a surgeon with such expertise working with the PICU attending.

Burn patients should be comanaged by the burn surgeon of record (discipline may be pediatric surgery, general surgery, or plastic surgery) and the PICU service.

In a PICU that supports an ACS-verified children’s surgical center, an ICU team that demonstrates direct surgeon involvement in the day-to-day management of the surgical needs of the patient is essential. Both PICU and surgery services must be promptly available 24 h per d.

Any level of PICU that supports advanced ACGME training programs such as pediatric residency, general surgery residency, pediatric critical care medicine fellowships, pediatric surgery fellowships, and pediatric surgical critical care fellowships (among others) will promote the participation of trainees in interprofessional care of patients providing appropriate communication and collaboration. Clear delineation of responsibilities will be sought on each patient. This requirement reflects the common program requirements outlined by the ACGME.

A qualified medical provider (in quaternary facility PICUs, the qualified medical provider should be a critical care specialist) who is able to respond within 5 min to all emergent patient issues (eg, airway management or cardiopulmonary resuscitation) is necessary for optimal patient outcomes in all levels of PICU. Specialized or quaternary facility PICUs have a minimum of an in-house critical care fellow.

A qualified surgical provider who is able to respond readily to emergency surgical issues in critically ill patients should be available. The designation of qualified is defined by the surgical problem, and availability should be commensurate with the level of care of the PICU and level of ACS Children’s Surgery Verification of the institution.

Night coverage response requirement for pediatric intensivists who are not in house, primarily in community and tertiary PICUs, includes being readily available by telephone and present in the PICU within 30 min of request.

The ICU structure and care delivery model components that are essential in all PICU levels of care include nursing staff and respiratory therapists with PICU expertise as well as multidisciplinary rounds. In tertiary and quaternary facility PICUs, 24/7 in-house coverage, a dedicated clinical pharmacist, a social worker, a child life specialist, and palliative care services are necessary.

All PICUs should have access to an on-site pediatric pharmacist who is available for daily rounds, pharmacy support, and ongoing educational activities.

All providers, including pediatric hospitalists, nurse practitioners, and physician assistants who provide first-line night coverage in PICUs, must be skilled in advanced airway, intravenous and intraosseous line placement, and ventilator management.

All PICUs must have access to a transfer and transport program that can ensure the safe and timely movement of a critically ill or injured child from a community hospital to an institution with a higher PICU level of care.

Quaternary facilities or specialized PICUs have access to a critical care transport program with a dedicated trained pediatric team and specialized equipment.

When PICUs require outsourcing of critical care transport activities, the transport service team members must all have training in pediatric emergency and critical care.

Quaternary facilities and tertiary levels of PICUs should participate in academic pursuits.

All quaternary facilities and tertiary levels of PICUs should be involved in providing peer community outreach education such as educational conferences, technical skill competencies, stabilization, and resuscitation (eg, PALS education).

Community and tertiary PICUs should be involved in providing community outreach through educational events that focus on technical skills needed for stabilization, resuscitation, and communication for the triage and transport of critically ill and injured children. These activities might include case conferences.

All levels of PICU should provide feedback to referral centers after transfer of a patient to a PICU, which is essential for both quality improvement and education.

Some emergency resuscitative therapies such as invasive and noninvasive respiratory support and central line access can be safely performed in community PICUs.

Renal replacement therapies (peritoneal dialysis, continuous hemofiltration and hemodialysis, and intermittent hemodialysis) may be offered in a community-based PICU when appropriately trained support personnel, which must include a nephrologist, are present.

All PICU levels must have access to helium-oxygen. In selected PICUs, epoprostenol sodium, nitric oxide, and anesthetic agents may be used if appropriate personnel and equipment are available for the safe delivery and monitoring of these agents.

The following are appropriate indications for PICU transfer from a community to a tertiary or quaternary level of care: intracranial pressure monitoring, acute hepatic failure leading to coma, congenital heart disease with unstable cardiorespiratory status, need for temporary cardiac pacing, head injury with initial GCS ≤8, multiple traumatic injuries, or heart failure requiring an interventional cardiologist. For complicated burns >10% TBSA, access to a specialized burn unit or burn center is recommended.

Each PICU should have clearly defined criteria for escalation and de-escalation of resources and, therefore, level of PICU required on the basis of the physiologic status of the patient.

All levels of PICU should have policies and protocols in place that specify when the patient’s physiologic status requires escalation of care, with transfer to a more appropriate level of care as expeditiously as needed.

When a patient’s physiologic status improves, discharge from the PICU can occur in many ways:

• Transfer to an appropriate acute care bed within that facility
• Return transfer to the referring facility
• Transfer to a skilled nursing or rehabilitation facility
• Discharge from the PICU to home

After discharge from the PICU, the following should take place:

• Appropriate communication with the accepting facility, including oral handoff, a clear and concise written summary, and exchange of necessary health information
• Discharge planning and communication with the family or caregivers if going home
• Communication with the primary care physician who will assume care of the child once the patient is returned to the community
• Communication with subspecialists caring for the child and appropriate follow-up arranged as necessary
• As needed, careful care coordination with outpatient services such as but not limited to:
  • Delivery and instruction in the use of durable medical equipment
  • Home pharmacy and nutrition support
  • Ongoing rehabilitation needs such as occupational or physical therapy
  • Ancillary support as required