Pediatric intensive care unit

A pediatric intensive care unit (also paediatric), usually abbreviated to PICU (/ˈpɪkjuː/), is an area within a hospital specializing in the care of critically ill infants, children, teenagers, and young adults aged 0-21. A PICU is typically directed by one or more pediatric intensivists or PICU consultants[1] and staffed by doctors, nurses, and respiratory therapists who are specially trained and experienced in pediatric intensive care. The unit may also have nurse practitioners, physician assistants, physiotherapists, social workers, child life specialists, and clerks on staff, although this varies widely depending on geographic location. The ratio of professionals to patients is generally higher than in other areas of the hospital, reflecting the acuity of PICU patients and the risk of life-threatening complications.[2] Complex technology and equipment is often in use, particularly mechanical ventilators and patient monitoring systems. Consequently, PICUs have a larger operating budget than many other departments within the hospital.[3][4]

Pediatric intensive care unit
Specialtypediatric

History

Goran Haglund is credited with establishing the very first pediatric ICU in 1955; this PICU was located at Children’s Hospital of Goteburg in Sweden.[5] The first PICU in the United States was created at the Children’s Hospital of Philadelphia in 1967 by John Downes.[5] The PICU at Lurie Children's Hospital was also established in 1967, the same year as the unit at the Children's Hospital of Philadelphia. The establishment of these early units eventually led to hundreds of PICUs being developed across North America and Europe.

There were a variety of factors that led to the development of PICUs. John Downes identified five specialties of medicine that aided in the development. These specialties included adult respiratory ICUs, neonatal intensive care, pediatric general surgery, pediatric cardiac surgery, and pediatric anesthesiology.[5]

Between 1930 and 1950 the poliomyelitis epidemic had created a greater need for adult respiratory intensive care, including the iron lung. There were times when children would contract polio and would have to be treated in these ICUs as well.[5] This contributed to the need for a unit where critically ill children could be treated. Respiratory issues were also increasing in children because neonatal intensive care units were increasing the survival rates of infants. This was due to advances in mechanical ventilation. However, this resulted in children developing chronic lung diseases, but there was not a specific unit to treat these diseases.[5]

Advancements in pediatric general surgery, cardiac surgery, and anesthesiology were also a driving factor in the development of the PICU. The surgeries that were being performed were becoming more complicated and required more extensive postoperative monitoring. This monitoring could not be performed on the regular pediatric unit, which led to Children’s Hospital of Philadelphia’s development of the first American PICU.[5] Advancements in pediatric anesthesiology resulted in anesthesiologist treating pediatric patients outside of the operating room. This caused pediatricians to obtain skills in anesthesiology in order to make them more capable of treating critically ill pediatric patients. These pediatric anesthesiologists eventually went on to develop run PICUs.[5]

Characteristics

There are a variety of PICU characteristics that allow the healthcare providers to deliver the most optimal care possible. The first of these characteristics is the physical environment of the PICU. The layout of the unit should allow the staff to constantly observe the patients they are caring for. The staff should also be able to rapidly respond to the patients if there is any change in the patient’s clinical status.[6]

Correct staffing is the next vital component to a successful PICU. The nursing staff is highly experienced in providing care to the most critical patients. The nurse to patient ratio should remain low, meaning that the nurses should only be caring for 1-2 patients depending on the clinical status of the patients. If the patient's clinical status is critical, then they will require more monitoring and interventions than a patient that is stable.[6]

In most cases, the nurses and physicians are caring for the same patients for a long period of time. This allows the providers to build rapport with the patients, so that all of the patient’s needs are fulfilled. The nurses and physicians must work together as a collaborative team to provide optimal care. The successful collaboration between nurses and physician has resulted in lower mortality rates not just in PICUs, but all intensive care units.[6]

Levels of care

As medicine has matured over time, the development of the pediatrics intensive care unit has expanded to maintain a level one and a level two PICU. Among these two different levels, they are able to provide critical care and stabilization for each child before transferring to a different acuity.[7]

In the level one PICU, health care team members must be capable of providing a wide variety of care that typically involves intensive, rapidly changing, and progressive approach. In the level two PICU, patients will present with less complex acuity and will be more stable.[7]

Common conditions

Respiratory issues including acute respiratory distress syndrome (ARDS), asthma, apnea, sepsis, trauma (may include abuse), congenital heart defects, mechanical ventilation, and complications of diabetes ketoacidosis. Gastrointestinal conditions include gastrointestinal perforations, cancer / chemotherapy, organ transplants (kidney, heart), seizures, and poisoning.[8]

Nurse skills and certifications

As a PICU nurse, extended knowledge and certifications may be required. Recognition and interpretation are two of the many required skills for a PICU nurse.[7] This allows nurses to be able to detect any changes in the patient's condition and to respond accordingly. Other skills may include route of administration, resuscitation, respiratory and cardiac interventions, preparation and maintenance of patient monitors, and psycho-social skills to ensure comfort of patient and family.

There are a variety of certificates that are required for registered nurses to acquire in order to work in the PICU. One of these certifications is the Critical Care Registered Nurse (pediatric) certificate. This certificate allows nurses to care for critically ill pediatric patients in any setting, not just the PICU.[9] Other certificates include cardiopulmonary resuscitation, pediatric basic life support, and pediatric advance life support.

Factors leading to poor outcomes

The patients in the PICU are the most critically ill children in the hospital setting. There are times where these children do not have the best outcomes, which may result in permanent deficits or even death. There are times where nothing more could have been done to improve the outcome for these patients. However, there are times where care could have differed and the end result may have been better.

There are a variety of factors that have led to poor outcomes in PICU patients. The main factor that leads to inadequate care for PICU patients is improper health assessment by the healthcare providers. This may include not observing a change in the patient’s clinical status, delayed resuscitation efforts, delayed decision making, or a combination of any of these factors. If any of these factors do occur, it may result in permanent deficits in the most critical patients.[10]

Measures may be taken to prevent improper assessments from occurring. Proper education on how to conduct a proper assessment and how to recognize a critically ill pediatric patient can improve patient outcomes. This includes being able to recognize signs of deteriorating clinical status and perform proper triage of patients.[10] This education is not only for the PICU staff, but also for emergency medical services, the emergency department staff, and staff of the pediatric unit.

Working in the PICU result may in emotional stress and/or occupational burnout of the staff. For patients that do get discharged from the unit, often they are not free of chronic conditions or disabilities.[5] There are other factors that lead to stressful work conditions for the staff of the PICU. The staff often work for long periods of time in order to stabilize the most critically ill pediatric patients. They must collaborate with other members the healthcare team in order to develop the best plan of care. Once a plan of care is developed, then the staff must communicate the plan with the patient's family in order to see if it matches their beliefs.[5] If the plan of care does not match the family's beliefs, then it must be modified the plan causing more stress on the staff. All of this causes the staff a great deal of stress and each member of the unit must develop their own coping mechanisms in order to prevent burnout.

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See also
  • Intensive care unit
  • Intensive care medicine
  • Neonatal intensive care unit
  • Pediatrics

References
  1. Frankel, Lorry R; DiCarlo, Joseph V (2003). "Pediatric Intensive Care". In Bernstein, Daniel; Shelov, Steven P (eds.). Pediatrics for Medical Students (2nd ed.). Philadelphia: Lippincott illiams & Wilkins. p. 541. ISBN 978-0-7817-2941-3.
  2. Pronovost, PJ; Dang, D; Dorman, T; et al. (September 2001). "Intensive Care Unit Nurse Staffing and the Risk for Complications after Abdominal Aortic Surgery". Effective Clinical Practice. 4 (5): 199–206. PMID 11685977. Retrieved 2009-01-08.
  3. Moerer O; Plock E; Mgbor U; et al. (June 2007). "A German national prevalence study on the cost of intensive care: an evaluation from 51 intensive care units". Critical Care. 11 (3): R69. doi:10.1186/cc5952. PMC 2206435. PMID 17594475.
  4. Morton, Neil S (1997). Paediatric Intensive Care. Oxford University Press. ISBN 978-0-19-262511-3.
  5. Epstein, David; Brill, Judith E (2005-11-01). "A History of Pediatric Critical Care Medicine". Pediatric Research. 58 (5): 987–996. doi:10.1203/01.pdr.0000182822.16263.3d. ISSN 1530-0447. PMID 16183804.
  6. Schmalenberg, Claudia; Kramer, Marlene (September 2007). "Types of intensive care units with the healthiest, most productive work environments". American Journal of Critical Care. 16 (5): 458–468, quiz 469. doi:10.4037/ajcc2007.16.5.458. ISSN 1062-3264. PMID 17724243.
  7. "Guidelines and levels of care for pediatric intensive care units. Committee on Hospital Care of the American Academy of Pediatrics and Pediatric Section of the Society of Critical Care Medicine". Pediatrics. 92 (1): 166–175. July 1993. ISSN 0031-4005. PMID 8516070.
  8. "Brenner Children's Hospital - Pediatric Hospital in North Carolina". www.brennerchildrens.org. Retrieved 2017-11-02.
  9. "CCRN Pediatric Certification". www.aacn.org. Retrieved 2017-11-02.
  10. Hodkinson, Peter; Argent, Andrew; Wallis, Lee; Reid, Steve; Perera, Rafael; Harrison, Sian; Thompson, Matthew; English, Mike; Maconochie, Ian (2016-01-05). "Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death". PLOS ONE. 11 (1): e0145473. Bibcode:2016PLoSO..1145473H. doi:10.1371/journal.pone.0145473. ISSN 1932-6203. PMC 4712128. PMID 26731245.
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