Roger's Textbook of Pediatric Intensive Care - Chapter 5

Chapter 5
Physical Design and Personnel Organization of the PICU
M. Michele Moss
Shari Simone
PICU Organization
Optimal care for the unique needs of the seriously ill pediatric patient occurs best in an ICU specifically designed for children and separate from adult or neonatal facilities. During the 1970s, as technology advanced in the care of critically ill patients, healthcare professionals recognized that specialized units were needed for this specific group of patients. The first recognized ICU was developed in the 1950s, in Copenhagen, Denmark (24), with the primary purpose of caring for victims of the poliomyelitis epidemic (36). In the US, ICUs for predominantly adult patients were developed in the 1960s; shortly thereafter, the earliest NICUs were formed (24).
The first PICU in the US was opened in 1967 at Children's Hospital of Philadelphia by Dr. John Downes (24). PICUs initially developed as free-standing units within hospitals during the late 1960s and early 1970s but were mostly found in large, metropolitan areas at large, free-standing children's hospitals or within large, usually university-affiliated medical centers. During the 1980s, PICUs proliferated to essentially all free-standing children's hospitals. During the 1990s, a survey of hospitals (51) with PICUs revealed that these units had a variety of sizes and staffing. Few units—6%—had more than 18 beds, whereas >40% had only 4–6 beds. At the time, most of the PICUs were affiliated with medical schools and were in hospitals that were the primary teaching program sites for pediatrics. A 2001 survey of PICUs (54) revealed that 41% were in private or community hospitals and 43% were in university hospitals or tertiary-level medical centers. From 1995 to 2001, the number of PICUs increased 13.7%, with a corresponding 23.9% increase in the number of beds. The mean number of PICU beds per pediatric population in the US in 2001 was 1:18,542. The distribution of PICUs was similar by regions, but the individual states varied in number of PICU beds. Wyoming was listed as the only state without PICU beds (54).
The development of PICUs in Europe predated the US experience, with the first PICU being founded at Childrens' Hospital in Goteburg, Sweden, in the 1950s in response to the poliomyelitis epidemic that also resulted in the formation of the ICU in Copenhagen (36). PICUs proliferated in Europe as in the US, with most being located within large multidisciplinary hospitals. By 2000, Spain had 34 PICUs, all linked to the Public Health System (37). All were combined medical and surgical units, and 12 were combined pediatric and neonatal units. The size of the units varied; 15 had fewer than 7 beds, 8 units had between 7 and 12 beds, and another 8 units had between 13 and 18 beds.
In Latin America, the first PICUs were developed in 1972 in Peru and Venezuela followed by Brazil in 1974 (15). The current distribution of PICUs in South America reflects “a strong relationship between the financial stability of each region and the complexity and quality of pediatric intensive care” (50). Most PICUs are located in the more developed countries of Brazil, Uruguay, Venezuela, and Argentina (15). In Sao Paulo, Brazil, in 2004, 107 NICUs and PICUs were serving a pediatric population of approximately 2.6 million (20). In a survey of these units with an approximate 80% return rate, 1067 beds were identified. The PICUs were associated with philanthropic organizations (15%), private institutions (46%), and public institutions (46%) with the number of operational beds varying between 2 and 60 (20). Many units are staffed by neonatologists rather than by pediatric intensivists. Interestingly, geographic areas with the least population had the greatest number of beds.
In India, the first PICUs were established at Chennai, Chandigarh, in New Delhi during the 1990s (30). The number of PICUs in India has grown, with most being located in private hospitals and a few in teaching hospitals. Despite a pediatric population in excess of 300 million, India lags behind in pediatric critical care services because government financial support has in the past been directed toward higher-yield preventive health strategies.
Because of extremely limited resources in Africa, PICU beds are rare and extremely limited, as are ICU beds for adults (11). The patterns of disease caused by lack of basic public health services led to a high mortality rate for largely preventable diseases and an overburdened intensive care system. For example, in Zimbabwe, infant respiratory distress syndrome has a 46% mortality rate (33). The HIV epidemic in sub-Saharan Africa has overburdened an already stretched system, and pediatric patients with advanced disease have a poor outcome. A review of diagnoses in the PICU at King Edward Hospital, Durban, KwaZulu Natal, South Africa, noted that admissions due to diseases preventable by immunizations, such as measles, diphtheria, tetanus, and poliomyelitis, drastically decreased between 1971 and 1995 (31). However, the epidemics of HIV and Shigella dysenteriae type I and its association with hemolytic uremic syndrome have become more common diagnoses at time of admission. The PICU is a 12-bed unit serving the province of KwaZulu Natal and its pediatric population of 3–4 million. The major admission criterion is need for mechanical ventilation, with half of the beds dedicated to neonatal patients and half to older children.
In the early 1990s, the two major organizations that served pediatric critical care medical specialists [the Section on Critical Care and Committee on Hospital Care of the American

Academy of Pediatrics (AAP) and the Section on Pediatrics of the Society of Critical Care Medicine (SCCM)], jointly developed criteria for categorizing PICUs. The impetus was to better define the optimal staffing, design, equipment, and support services required for seriously and critically ill and injured pediatric patients. In the initial guidelines, PICUs were categorized into three levels of care, but in the revision published in 2004, they were categorized into Level I and Level II units (56). Level I units have staffing, facilities, and equipment to provide optimal care to the most severely ill or injured patients. The staffing of a Level I unit includes pediatric intensivists, nurses with extensive training in pediatric critical care, respiratory therapy staff primarily dedicated to the PICU, and immediate access to a broad range of pediatric medical and subspecialists, including but not limited to, anesthesiologists, surgeons, cardiac surgeons, neurologists, cardiologists, otolaryngologists, and radiologists. Level II units are staffed by pediatric intensivists, but other pediatric specialty physician support may be less readily available than in Level I units.
In 1997, the Intensive Care Chapter of the Indian Academy of Pediatrics was formed, followed by the formation of the Pediatric Section of the Indian Society of Critical Care Medicine in 1998. In 2002, these two groups published consensus guidelines for PICUs in India (34). As in the AAP/SCCM guidelines, unit design, necessary equipment, and staffing were among the areas addressed. Additionally, admission and discharge criteria for Level 3, or tertiary level units, and Level 2, or step-down level units, are discussed. Nursing staff recommendations include one nurse for each intubated patient and as many as two nurses for very unstable patients. More stable patients may share a nurse with another stable patient.
Regionalization of Pediatric Critical Care Services
The resources required to support the demanding staffing and highly technical needs of critically ill and injured pediatric patients are often unevenly proportioned due to multiple factors, including population disparities, geographic limitations, and financial constraints. Regionalization is defined in a statement from the AAP (4) as “a process for organizing resources within a geographic region to ensure access to medical care within a level appropriate to a patient's needs…” In Pediatrics, regionalization of critical care services was developed initially for NICUs, such that the more critical and complex neonates were transported and cared for in those NICUs with the most sophisticated equipment and broader support staff. This concept spread with the advent of PICUs in the 1970s. Considering the relatively few critical or potentially unstable children with illness or injuries as compared to adults, and the broader range of diseases and injuries, the concept of regionalization makes even more sense for the pediatric population. Government or financial entities can mandate regionalization, but more commonly, regionalization has developed due to geographic constraints and well-developed referral patterns.
Studies (55,63) have supported the concept of regionalization (often called centralization in Europe) with their demonstration of better patient outcomes. A study that compared a centralized system in Australia with a noncentralized system in England projected that more than half of risk-adjusted mortalities occur in the centralized system compared with the noncentralized system (48). Regionalization or centralization was supported by a study that showed an inverse relationship of the volume of PICU patients to the risk-adjusted mortality and length of stay (60). Regionalization has also been supported for pediatric cardiac surgery by a study that showed less mortality in centers with the highest volumes (32).
In the US, three geographic models of regionalization have been described (65). The first are regions comprised of large geographic areas, as seen in largely rural settings, with only one or two large urban centers that are able to support a high-level PICU. Such examples are found mostly in the western and southern states such as New Mexico or Arkansas. In this model, the geographic area is large but often not highly populated, so that few critically ill children are spread over large distances. The transport of patients to the appropriate PICU requires preparation and well-developed transport services.
The second model is a large geographic area that is both rural and suburban, with multiple urban centers capable of housing an upper-level PICU. Often, considerable overlap of services is found in these areas, such that referral patterns may not be the most geographically logical. “Competition” for patients may exist in these areas, and financial referral patterns are often seen. Illinois is an example of a state that has urban, suburban, and large rural areas and multiple PICUs.
The third type of geographic referral area is seen in the more populated eastern states. This model is a relatively small geographic area with a large population and, frequently, multiple PICUs. New York City is an example. Rather than geographic area, the local referral patterns and financial constraints define regionalization.
Regionalization of pediatric critical care includes both the PICU and the continuum of services from prehospital care, hospital-based emergency care, intensive care, and specialized services to rehabilitation services. Even the prehospital education components of injury prevention, recognition of serious and critical illness and injury, and accessing the total healthcare system available are parts of this continuum. Emergency medical services for children are part of this continuum and have been studied and supported by grants from Maternal and Child Health. In 1993, the Institute of Medicine recognized the importance of the development of this pediatric continuum in its report Emergency Medical Services for Children, which argued that “society has a special obligation to address the needs of children” (26). Often, pediatric services are buried within adult services, and adequate training and experience are lacking for caregivers to deliver optimal care to children. Training for prehospital and primary hospital caregivers is crucial to provide the best care and outcomes for children. Safe and efficient transport (again, with adequate training of the caregivers) to higher levels of care must also be provided for a system to be appropriate.
The state of California had early experience in the regionalization of pediatric critical care services. In 1981, the Pediatric Intensive Care Network of Northern and Central California was formed by the medical directors of the 10 PICUs that existed at that time (65). They undertook a study that examined pediatric intensive care resources and, from that, developed a model of regionalization. An extensive effort was undertaken to outline where patients who “could benefit from PICU intervention” were receiving their care. During the study in 1984, 3889 patients were admitted to one of the existing

PICUs, with a 5.8% rate of death and an average length of stay of 4.9 days (65). During the same period, 3,066 patients, ranging in age from 7 days to 18 years, were admitted to community hospitals that did not have designated PICUs. Due to a marked discrepancy in the severity of illness, the PICUs had a higher rate of death than did the community hospitals. Using this data and with a grant from the Division of Maternal and Child Health of the Department of Health and Human Services, a model for regionalization in northern California was developed. A networking process among the PICUs in the region resulted in cooperative data collection, educational programs, and development and review of statewide standards for PICUs (65).
Countries outside of the US have also struggled with the issues surrounding regionalization. Sweden undertook the task of centralizing pediatric cardiac surgery from four centers to two during the 1990s, resulting in a reduction in mortality rate from 9.5% to 1.9% over a 5-year period (38). The need for regionalization of pediatric care in India was recognized in an editorial in Indian Pediatrics that called for development of a four-tier system that would provide low-cost interventions and technology to children throughout the country and not just in the high-population and higher-income areas (30). The author proposed that caregivers able to recognize the need for urgent referral and access to oxygen, intravenous/intraosseous fluids, and antibiotics would be available at Primary Health Centers throughout the country. Level 1 hospitals would be able to handle serious pediatric illness, whereas Level 2 hospitals would have small, 4–6-bed PICUs that would function as Level 2 PICUs, according to guidelines for PICUs developed in India. Level 3 hospitals would be major teaching institutions located in each state and would have a tertiary PICU capable of state-of-the-art pediatric critical care. Embedded in the mission of these tertiary PICUs would be education of physicians, nurses, and healthcare workers, as well as research. A strong transport system would have to be developed throughout the country to address the need to move patients along the levels of care (30).
PICU Population
Patients admitted to PICUs represent a broad range of age groups and disease states. Generally, NICUs admit newborns who have complications of prematurity or delivery or who have congenital anatomic defects. PICUs admit patients from the neonatal period through adolescence. Additionally, because patients with chronic “pediatric” diseases are now living into adulthood, many of those critically ill patients are cared for in PICUs. The most common example would be adults with congenital heart diseases who need further congenital heart surgery and the expertise of a congenital heart surgeon and pediatric cardiologist. Postoperatively, they are often cared for in PICUs or in pediatric cardiac ICUs.
Admission criteria for PICUs have been defined by the Society for Critical Care Medicine and the AAP (3). In general, admission to a PICU requires acute respiratory, neurologic, or hemodynamic instability; some other specific organ dysfunction; or the imminent risk of instability. Often, the patients are postoperative patients who are at risk for respiratory or hemodynamic instability or specific organ dysfunction. Usually, patients require specific technologic intervention that can only be performed in an intensive care setting with its increased nursing staff. In the US, most patients cared for in PICUs in 2001 (54) were medical, with approximately one-third being surgical and another 10% being cardiac medical or surgical patients. In developing countries with limited resources, the admission criterion for a PICU is often the need for mechanical ventilation. Other types of intensive care, such as dialysis or close monitoring of vital signs in unstable patients, may occur outside the PICU, if at all.
Specialized PICUs have been developed in areas with large referral bases, such as pediatric burn ICUs, or, more commonly, pediatric cardiac ICUs. The latter have been proliferating since the mid-1990s, although several large programs have had dedicated cardiac ICUs since the 1980s. One perceived advantage of the separate pediatric cardiac ICU is that the staff training and experience are focused on cardiac medical and postoperative issues, allowing for more standardized practice and efficient care. Because the technology required to support these patients becomes increasingly complex with the proliferation of mechanical support devices and complex pharmacologic strategies, additional, extensive staff training is required.
The cardiac ICU patient management team is composed of nurses; respiratory therapists; mid-level practitioners, such as advanced practice nurses (APNs) or physician assistants (PAs); and physicians, including intensivists, pediatric cardiologists, pediatric cardiovascular surgeons, and pediatric cardiac anesthesiologists. Residents in pediatrics and cardiac surgery and fellows in critical care and cardiology play varying roles in these cardiac ICUs. The intensive care patient management is generally led by pediatric intensivists, pediatric cardiac anesthesiologists, pediatric cardiologists with intensive care experience, or physicians dually trained and board certified in pediatric critical care and cardiology. Currently, postgraduate fellowship programs exist that are generally 1 year in length and provide additional training in pediatric cardiac intensive care. These programs are not recognized by the Accreditation Council for Graduate Medical Education (ACGME) at this time, and board certification or special competency is not currently available in the discipline of pediatric cardiac intensive care.
Specialized PICUs are less common outside of the US and Europe, mostly because of limited resources. Pediatric burn patients in Russia, for example, are referred to the national burn hospital but are admitted to the general PICU (23).
PICU Personnel and Staffing Models
Optimal care for seriously ill and injured pediatric patients requires coordinated multidisciplinary care by physicians, nurses, respiratory therapists, and others, including pharmacists, child-life specialists, social workers, chaplains, nutritionists, and physical, occupational, and speech therapists. Pediatric intensivists should coordinate patient care among the pediatric medical and surgical subspecialists, physicians in training, and primary care physicians.
The development of the discipline of pediatric critical care medicine paralleled the development of PICUs. Care of the critically ill adult patient initially focused on organ-specific failure, and care was provided by a specialist; for example, a pulmonologist cared for patients with respiratory failure, or a

cardiologist managed patients with acute cardiac conditions. With the advent of neonatal intensive care, a new model of care developed. Premature and other seriously ill newborns were cared for by pediatricians who oversaw the complete patient, recognizing that all of the organs were at risk during critical illness. The model of the neonatologist was then translated into the pediatric intensivist model.
The pediatric intensivist oversees the “total” patient, with training in both specific organ failure and the interaction of whole-body systems. Training programs in pediatric critical care management initially developed from anesthesiology training programs and ultimately from pediatric training programs. Early on, anesthesiologists applied their intraoperative experience in caring for the whole patient with the need for extensive monitoring to the intensive care environment. Pediatricians, emulating both the anesthesiology and the neonatology model, progressed to the current pediatric intensivist model.
In 1985, the American Board of Pediatrics (ABP) led the recognition for the Pediatric Critical Care Medicine subspecialty and offered the first board exam in 1987. The first accreditation of postgraduate fellowship programs followed in 1990, with recognition by the Residency Review Committee of the Accreditation Council for Graduate Medical Education. Nursing also recognized pediatric critical care as a special entity. In 1986, the American Association of Critical Care Nurses offered a certification program in pediatric critical care and, in 1999, a program for clinical nurse specialists in pediatric critical care.
Currently, certification by the ABP for pediatric intensivists requires completion of 3 years of pediatric residency training with certification by the ABP in general pediatrics, and completion of 3 years of pediatric critical care fellowship training in an ACGME-approved training program. Certification is time limited, and the practitioner must be recertified every 7 years. The recertification process, overseen by the ABP, is changing toward an ongoing process that addresses the “Six Core Competencies” promoted by the ACGME, which include patient care, medical knowledge, practice-based learning and improvement, interpersonal skills and communication, professionalism, and systems-based practice. Pediatric anesthesiologists and pediatric surgeons can earn a certificate of Special Competency in Critical Care.
Worldwide certification in intensive care, and particularly pediatric intensive care, is varied and often not available. For some countries, intensive care is certified through specialty boards such as internal medicine or surgery. In Spain, Switzerland, Australia, New Zealand, and Hong Kong, for example, critical care is a primary specialty with separate certification (10). Training requirements vary throughout the world. Because of this variability and despite some similarities in curricula, a process was undertaken by the competency-based training program in intensive care medicine in Europe (CoBaTrICE) collaboration to develop core competencies for an international training program in adult critical care. This collaboration is composed of physicians from Europe, Asia, North America, South America, and Africa and is supported by various organizations, including the European Society of Intensive Care Medicine and the Society of Critical Care Medicine. Currently, no process is underway for an international training program in pediatric critical care. In many locations, physicians who practice in PICUs are pediatricians with special interest in intensive care who have been unable to train in an organized training program.
In addition to the expanding workload in PICUs due to pharmacologic and technologic advances, pediatric intensivists have a variety of other work-related activities. Because most PICUs are associated with pediatric and/or pediatric critical care training programs, most pediatric intensivists have teaching commitments for a variety of audiences, including residents, critical care fellows, nursing staff, and other medical caregivers. Additionally, many pediatric intensivists are members of an academic faculty, which means they also have research and administrative responsibilities such as medical direction of code teams, medical emergency teams, and transport systems. The clinical arena for the pediatric intensivist has broadened to include coordinating sedation programs for patients who need procedures outside of the operating room and participating in palliative care programs. In addition, due to the multidisciplinary roles in the PICU, pediatric intensivists actively participate in hospital and university committees. The 2003 Future of Pediatric Education II Survey of Sections project (8) revealed that, overall, pediatric intensivists devote ~15% time to teaching across all age groups. Younger intensivists (<40 years old) spend 14% of their time in research, whereas intensivists 40–49 years of age spend 10%, and those ≥50 years old spend 7%. Intensivists who are >50 years old spend approximately 20% of their time on administrative duties as compared to intensivists who are <40 years old, who spend on average ~12% of their time on administrative duties.
Multiple staffing models exist for PICUs throughout the world. In the US, most PICUs are staffed by ABP-certified or ABP-eligible pediatric intensivists (54). From 1995 to 2001, the number of PICUs staffed by pediatric intensivists rose from ~90% to 94% (54). Intensivists provide care through different staffing patterns, and most frequently, the intensivists are the primary physicians or they co-attend with a medical or surgical specialty service. In another model, intensivists serve as primary attendings on a small number of patients but consultants on all PICU patients. In the US, pediatric intensivists control most PICU admissions. Patient coverage in the PICU frequently involves residents or fellows in addition to the pediatric intensivists.
The effect of training programs on mortality has been shown to vary. One study suggested a higher risk of mortality when PICUs were staffed by residents alone and a much lower risk when staffed by intensive care fellows (51). Larger PICUs in the US more commonly than smaller units have 24-hour, in-house, attending-level coverage, with as many as 40% of those with >20 beds having attending-level, in-house coverage. A study in Malaysia showed that having pediatric intensivists in-house around the clock rather than only during the day, with the night time covered by general pediatricians, lowered standardized mortality ratios and decreased lengths of stay (29). Pediatric hospitalists who work with pediatric intensivists have also helped to improve outcomes (59).

Pediatric critical care nurses provide unique contributions to the delivery of care for medically unstable and vulnerable infants and children. The critical care nurse performs continuous, vigilant, compassionate care that is based on the needs and characteristics of the patient and family and that allows for ongoing physiologic patient assessments, implementation and evaluation of responses to the treatment plan, and assessment and development of plans to meet the needs of the family. An essential skill of the critical care nurse is the ability to effectively communicate with all members of the healthcare team and maintain ongoing dialog to ensure rapid responses to changes in the child's condition.
The current healthcare situation of a nurse shortage and an aging nurse workforce is a common experience worldwide and has created unique challenges in providing comprehensive care that optimizes patient outcomes. Nursing leadership has been challenged to develop innovative staffing and nursing care models to maintain a high quality of care. Adequate nurse staffing is critical to the delivery of quality patient care and directly influences the rate of preventable adverse events (43,53). In a study of unplanned extubations in a children's hospital PICU in the US, a patient-to-nurse ratio of 1:1 was significantly associated with a decrease in unplanned extubations (39). Not surprising, the presence of the nurse at the patient's bedside is essential to ensure patient safety.
A study conducted in Hong Kong found that 51% of incidents were detected by direct observation versus 27% by monitor detection (13). The investigators concluded that, despite advances in technology, there was no substitute for the expertise of the nurse providing direct patient care.
Nurse-to-patient ratios in ICUs are primarily based on patient census and acuity and may range from 1:3 to 2:1 (44). However, other factors must be considered in determining staffing needs, including the level of experience of the nurses who are providing the care, available technology, unit layout, and support staff. In addition, because the condition of critically ill children can rapidly change, maintaining flexibility in nursing staff is imperative.
Critical care nursing organizations such as the American Association of Critical Care Nurses, the Australian College of Critical Care Nurses, and the British Association of Critical Care Nurses have developed ICU nursing workforce position statements that outline nurse staffing standards based on best practice evidence; these statements are available at their respective websites. In addition, the World Federation of Critical Care Nurses, an organization comprised of over 20 critical care nursing associations, has developed minimum workforce requirements that can be adapted to meet the nursing staff and system requirements of a particular country or jurisdiction (64).
Care Delivery Models
Nursing care delivery models continue to evolve with the changing critical care environment; these models include an emphasis on the patient-family relationship, customer-focused behaviors, process improvement, safety, and achieving high-quality clinical and behavioral outcomes. Since 1990, the Magnet Nursing Services Recognition Program for Excellence in Nursing Services of the American Nurses Credentialing Center has honored national and international organizations that demonstrate excellence in nursing practice with Magnet status. Magnet hospitals have demonstrated higher-than-average nurse recruitment and retention rates, as well as other indicators of quality (1). One important component evaluated is the effective use of a patient care delivery model that promotes nursing responsibility, authority, and autonomy and one in which best practices are utilized. Nursing departments are charged to shape a patient care delivery model that fits the individual organization's core values and to design a structural framework that will help to operationalize those values through the delivery of quality patient care. Recent studies have reported improved patient outcomes within hospital environments that support professional nursing practice (2,27).
Expanded nursing roles have also been developed in response to changes in the healthcare system. In the United States, the role of nursing case management has greatly impacted discharge planning of medically complex patients. In other nations, similar specialist roles (i.e., liaison nurses) have been created to streamline ICU transitional care and reduce the impact and potential complications associated with transferring patients within the healthcare system (16).
Effective nursing leadership has been shown to be a key component in the retention of hospital nurses (12). The leadership characteristics of the nurse manager greatly affect the work environment of critical care nurses. Therefore, desirable qualifications of the nurse manager include substantial pediatric expertise and completion of a master's degree in nursing administration. The nurse manager must have a vision for the unit, which is a realistic and attractive future for the organization, the skills and expertise to lead the team, the trust of employees, and ongoing dialog with the PICU team.
Other nursing leadership roles that may have differing titles but similar functions around the world include clinical nurse specialists and critical care nurse consultants. The qualifications required for these advanced practice nursing roles include a master's degree in nursing and extensive expertise in pediatric critical care. The clinical nurse specialist in the US and Canada incorporates the roles of expert clinician, consultant, educator, and researcher. The roles of the nurse consultant in the UK parallel those of the clinical nurse specialist in the US and Canada, with the addition of functioning as a transformational leader who influences both organizational and educational development (18).
Professional Development
The professional development of the nursing staff in the PICU is the responsibility of experienced staff members, unit educators, mentors, and advanced practice nurses, including a clinical nurse specialist. The process is ideally coordinated by the pediatric clinical nurse specialist or similar advanced-practice nurse who holds a master's degree in nursing and has substantial pediatric critical care expertise. Staff education begins with a didactic and clinical orientation program that provides a foundation for novice nurses to safely care for critically ill children. In addition, designing a professional development program that outlines a realistic advancement plan and identifies those strategies necessary to achieve goals is an important responsibility of the PICU leadership team. Benner's model of knowledge and skill acquisition is a useful framework for identifying how a

nurse progresses from novice to expert practitioner (28). The characteristics of each of these levels of clinical expertise can be incorporated to meet the educational needs and promote successful advancement of the individual.
As the novice staff nurse gains expertise, the professional development plan should specify the education, mentoring, and skill acquisition required to prepare the novice to take on additional roles. Examples include charge nurse responsibilities, arrest team member, transport team member, trauma team member, preceptor for newly hired nurses, and mentor for nurses following orientation. Other important requirements to ensure mastery of skills include completion of pediatric advanced life support provider certification and an annual review of high-risk, low-volume therapies and patient-specific core competencies. Obtaining pediatric critical care nursing certification is desirable (6). The critical care registered nurse certification distinguishes nurses who have obtained an advanced body of knowledge necessary to care for critically ill patients.
Participation in ongoing educational programs specific to pediatric critical care is essential for nurses to build on previously acquired knowledge and skills. Continuing nursing education requirements are broadly defined by state nursing legislation, regulations, and professional organizations. Nursing education programs span the spectrum from unit-based in-services, hospital workshops, local seminars, and regional conferences, to national and international nursing conferences. All provide unique opportunities for nurses to expand knowledge and skills, exchange ideas, network, identify best practices from other institutions, and share information with the health care team.
The nursing staff is also responsible for participating in those unit functions necessary to support and improve the delivery of quality patient care. Activities include, but are not limited to, quality improvement programs; the development of policies, procedures, standards of care, critical pathways, and guidelines; and the evaluation of practice outcomes.
Mid-level Practitioners
Nurse practitioners (NPs) and PAs have become integral members of the PICU multidisciplinary team, primarily in the US. The emergence of these roles in the PICU environment was largely a result of pediatric residency curriculum changes combined with increasing PICU demands (22,41,62). In July 2003, all residency programs in the US were subject to the ACGME's new restriction in duty hours. PICU resources have been further impacted by the aging nurse workforce and the increasing complexity of patient care, coupled with the demands for improved patient and PICU outcomes. These changes have propelled modifications in traditional physician staffing patterns and have led to the addition of NPs and PAs to provide continuity and quality care to critically ill children.
Varieties of PICU collaborative practice models have been reported in which physicians, in combination with NPs and/or PAs, collectively use knowledge and skill sets to enhance patient care (21,22,40,41,42,62). In university-affiliated teaching hospitals, the traditional medical team of intensivists, fellows, and residents now includes NPs and PAs. Examples of patient care models in large PICUs include staffing two complete teams, one composed of residents and the other composed of NPs; a combined team of residents and NPs; a combined team of residents, PAs, and NPs; or a team of only NPs. Separate NP and resident teams allow faculty to provide education that is directed toward the specific needs of the group. For example, educational rounds for rotating residents may include a discussion of the evidence-based management for patients with status asthmaticus. In comparison, educational rounds for seasoned NPs may include a discussion on evidence-based therapies for acute respiratory failure when conventional management fails. Tailoring educational needs and clinical skills may result in improved satisfaction for NPs and rotating residents. However, teams composed of residents, NPs, and/or PAs provide unique leadership and mentoring opportunities for practitioners. Staffing patterns in smaller PICUs include various combinations of residents, NPs, and PAs. The team composition affects the distribution of responsibilities given to NPs and PAs, but in general, the primary focus involves managing a daily caseload of patients and often supplementing the 24-hour on-call coverage previously filled by residents and fellows. In centers without fellowship programs, NPs play a greater role in supervising resident teams. In community hospitals, the numbers of NPs and PAs in critical care are substantially greater, because more positions are required to provide daily 24-hour coverage.
Since the emergence of pediatric acute care and critical care NP programs during the early 1990s, the number of NPs in the PICU has increased exponentially. The differences and similarities between NPs and PAs are listed in Table 5.1. The educational preparation and clinical expertise of NPs and PAs differ; therefore, the clinicians' contributions to the delivery of care in the PICU are unique. PICU NPs are nurses who have typically completed a graduate program with a pediatric acute care or critical care emphasis; some may have completed a pediatric primary care program. All PICU NPs have pediatric clinical expertise prior to entering the graduate program, but the breadth of clinical expertise will vary. In comparison, PAs complete 2 years of college courses in basic science and behavioral sciences before entering a PA program that averages 26 months and consists of an intense curriculum with both clinical and didactic components. PAs are educated in the medical model, which is designed to complement physician training. They often have previous healthcare experience as emergency medical technicians or paramedics.
Table 5.1 Scope of practice of nurse practitioners and physician assistants
Responsibilities Nurse practitioners Physician assistants
Patient management
Assessment Comprehensive and problem-specific model of care Problem-specific model of care
Diagnosis and treatment Diagnosis rendered independently with awareness of the entire system and the patient's response to illness Diagnosis rendered under direct supervision of physician
Procedures Proficient to perform procedures to support/monitor patient condition, treat acute problems, or prevent complications independently by practice agreement Proficient to perform procedures under direction of physician
Prescription and documentation Full prescriptive authority, independent documentation Requires cosignature for prescription and documentation of practice
Patient education Promotes health maintenance Provides health education specific to medical treatment plan
Staff mentoring Mentors nurses, nurse practitioners, residents, and students Mentors physician assistants, residents, and medical students
Consultant Serves as a consultant for variety of nursing care issues
Participates on hospital committees as advanced nurse practitioner representative
Participates in development of policies/standards/ competencies for pediatric critical care
May participate in unit-specific activities
Primary role is direct patient management
Research Advances pediatric nursing knowledge by contributing to evidence-based practice May participate in research in a variety of roles
System management Advanced nursing skills promote system evaluation and efforts to improve care delivery No specific training in this area, but impacts care system
Published reports describe the NP and PA scope of practice and the debate surrounding best-practice models in the PICU setting (5,21,25,40,41,42,62). Two national surveys that describe the functions of pediatric and adult critical and acute practitioners demonstrate that the NP provides aspects of care that are reflective of advanced-practice nursing in addition to direct patient management responsibilities (35,62). Global responsibilities include providing comprehensive patient management combined with consultation, education, research, quality improvement, and leadership activities.
In contrast to the NP role, the PA philosophical basis mimics the medical model and is disease focused. PAs are licensed to practice medicine with physician supervision. In the PICU setting, PAs perform direct patient management, including conducting physical exams, diagnosing and treating patients, ordering and interpreting tests, and performing duties that require advanced technical skills. Few publications exist on the role of the PA in pediatric critical care (41). However, the literature describes the success of the PA in specialty care settings (14,46).

The first study to examine the use of NPs and PAs in pediatric critical care surveyed medical directors of PICUs in the US and found that 62.8% of responding institutions employed physician extenders (19). The physician respondents reported a skill level of NPs and PAs that was comparable to second- or third-year residents.
Since this early study, emerging research examines the quality of care administered by NPs and PAs in comparison to residents. An exploration of outcomes of patients who were cared for by NPs, PAs, or resident physicians revealed comparable results for each group (57). Similar findings were reported upon an examination of the trends in care by nonphysician clinicians, including NPs and PAs, over a 10-year span (25). Research specifically examining the effect of NP and PA care on patient and system outcomes is favorable. Beneficial outcomes include decreased lengths of stay, decreased costs of care, decreased adverse complications, enhanced communication and collaboration, parental and staff satisfaction, and continuity of care (17,40,45).
Because most nations of the world are experiencing rising healthcare costs and a shortage of healthcare providers, the need for alternative healthcare practitioners has resulted in the development of NP and PA roles in primary care settings since the early 1990s (47). These roles are rapidly evolving in acute care areas but remain in infancy in pediatric critical care. International colleagues may gain insight by examining the successes and mistakes of the US, because the advanced practice issues faced in role development and implementation, including educational standards, credentialing, licensure, titling, prescribing medications, liability, and reimbursement, are common to all.
Respiratory Therapists
Respiratory therapists are an integral part of the bedside care of the pediatric intensive care patient. Respiratory disease in most PICUs is the most common diagnosis, and the impairment of respiratory function complicates many other diseases. In addition to their expertise in mechanical ventilators, respiratory therapists provide pulmonary treatments, including inhaled medications, and they should be trained in pediatric modalities of aerosol delivery and mechanical ventilation. For all levels of PICUs, the American College of Critical Care Medicine of the SCCM recommends that an in-house respiratory therapist who is experienced in pediatric respiratory failure be available at all times (56). Frequently, respiratory therapists have expanded duties, including sampling and running blood gases and other bedside laboratories, participating in patient transport both intra- and interfacility, and participating in extracorporeal membrane oxygenation support. Their participation in the care of the PICU patient is crucial for optimal outcomes. In many countries outside the US, appropriately trained bedside nurses may provide a similar function to the respiratory therapist.
Other Ancillary Personnel
Multiple other personnel are required for the best care of the PICU patient. Pharmacists are an integral part of the PICU team. A satellite pharmacy should be close to the PICU; in lieu of that, a system must be available to allow immediate dispensing of medications. Additionally, the presence of a clinical

pharmacologist helps in the management of patients with complex medication regimens and variable pharmacokinetics. Nutritionists, physical therapists, occupational therapists, speech therapists, and social workers also play significant roles in the care of the PICU patient; consequently, they should have training in pediatric environments. Child life and play therapists also have an important role in helping patients and their families to adjust to critical illness. Chaplains and bereavement teams can also be instrumental in assisting a family to cope with the death of their child.
Physical Design
Environment of Care
When designing a PICU, several aspects must be taken into account, including regulations from oversight institutions such as government agencies and the Joint Commission, available physical space and location, expertise and needs to the PICU personnel, and pediatric patient- and family-centered concepts. The American College of Critical Care Medicine published guidelines for ICU design in 1995 (58). As in PICU patient care, a multidisciplinary approach was suggested that involves ICU leaders, including the nurse manager, medical director, architects, engineering staff, and hospital administration. Additionally, family, interior designers, nursing staff, physician staff, respiratory therapy staff, and others involved in patient care should be asked for design input.
The American College of Critical Care Medicine also included the environment of care as an important component to patient- and family-centered care in their Clinical Practice Guidelines for Support of the Family in the Patient-Centered ICU (7). The environment of care has been shown in multiple studies to have an impact on patient outcome. In addition to the design affecting infection control and improving patient outcomes by limiting spread of infections, it can affect other aspects of the patient experience. Initially, PICUs were of large, ward-type designs. Today, the recommendation is for individual rooms designed in such a way that the risk of infection is decreased, the staff can adequately visualize the patient and monitors, and the patient and family have privacy. Each room must be large enough to comfortably accommodate the patient's bed, increasingly complex types of medical equipment, and power and vacuum sources. The minimum recommended area for pediatric patients is 250 square feet (~23 square meters) per bed space (56). Because of the importance of family presence in the care of pediatric patients in the PICU setting, larger rooms are being designed to accommodate sleeping and private spaces for parents.
Unit Architectural Design
Individual Rooms
Infection is spread by both direct contact and airborne routes; having separate rooms for each bed space in the PICU minimizes direct-contact spread. Multiple numbers of sinks placed in easily accessible areas for handwashing also decreases infection spread by direct contact. Individual rooms can have specific air-flow patterns to prevent infection. Patients who are immunocompromised should be in rooms with positive air flow; i.e., the air in the room is sent out and not pulled in. Patients with potentially communicable diseases, including being colonized with resistant organisms, should be in rooms in which the air is pulled in and not sent out. Some systems allow the flow patterns to be changed depending on the type patient in the room.
ICUs of all types can be noisy environments because of the amount of equipment, alarms, and staff necessary for patient care and safety. Excessive noise has been shown to have a negative effect on patients, as noted by decreased oxygen saturations, decreased sleep, and increased blood pressure and heart rate (61). Ambient noise levels in hospitals may run as high as 45 to 70 dB; the World Health Organization recommendation is that ambient noise not exceed 35 dB (9). The multiple hard surfaces (e.g., floors and cabinetry) in hospitals and ICUs can accentuate noise levels. The use of various materials for floor coverings and ceilings can abate the noise level, while maintaining easy cleaning and infection control. Glass doors and counters can also reduce noise levels.
Lighting has also been shown to impact patient outcome. Most studies, which have evaluated adult patients, have shown that patients who are exposed to natural sunlight have decreased lengths of stay and improved mental status (61). Many state health departments stipulate that each ICU bed must have a window or, at the very minimum, a skylight. Some guidelines also recommend that the level of lighting for patient rooms not exceed 30 fc (foot candles), with the ability to dim the level to as low as 6.5 fc at night (58). Adequate lighting must be available for charting and for emergencies and procedures, thereby requiring lighting systems with multiple types of lights.
Electrical Requirements
Each room or bed space must have ample electrical power, oxygen, compressed air, and vacuum outlets. The SCCM (58) recommendation is for at least 16 electrical outlets and two each for oxygen and compressed air. A minimum of three vacuum outlets is required. Units with high levels of acuity may need more of those outlets, as well as outlets for nitrogen. Electrical outlets should be placed at the head of the bed and 36 inches (1 meter) above ground for easy access. Other outlets may be necessary in other parts of the room. The electrical power to the PICU should be delivered by a feeder separate from other parts of the hospital. Additionally, power should be connected to an emergency power source.
The PICU should have adequate hard-wire support, so that computers can be placed at each bedside, charting area, and other workspaces. Wireless connection to the Internet should be available in the PICU for both staff and families. Each PICU should have an area for viewing radiographic studies; it should also be equipped with digital radiograph viewing equipment, a personal computer for viewing outside studies on CD or DVD, and possibly digital ultrasound viewing equipment, especially if the unit has a high number of cardiac patients.
Emergency Power
The emergency power source for the hospital should be safe from the effects of potential disaster situations. For example,

emergency generators should not be in the basement of a hospital if the area is at any risk of flooding (49). Life-support equipment, such as extracorporeal membrane oxygenation circuits or mechanical ventilators, should be on outlets that are connected to emergency generator power, whereas other less critical pieces of equipment may be connected to outlets not supported during power shortages. Water must be available in each room for handwashing and other uses. If hemodialysis is to be performed at the bedside, the water source must be certified.
Central Areas
Central areas should have adequate visualization of the patient rooms and adequate desk space for all caregivers, including nurses, physicians, respiratory therapists, consultants, social workers, pharmacists, and others. A centralized monitoring system should be nearby.
In addition to the centralized charting and monitor areas, storage for emergency equipment and ventilators must be within the unit. Each unit should have “dirty” and “clean” utility areas as well as food and formula preparation areas. A satellite pharmacy is best for the PICU; in lieu of that, medication storage and preparation areas, with refrigeration and locked areas as indicated, should be available.
Family and Caregiver Areas
In addition to the patient rooms, the overall PICU should be designed to allow for optimal patient care and support for the caregivers. The unit should have an entry primarily for family and visitors that can be controlled for security. Another entry should be available for patient transport and medical personnel.
Further family-support areas (in addition to family space within the patient's room) are important. They should have a waiting room with seating for approximately two family members per patient. Waiting areas can include nourishment-support areas with refrigerators and microwaves, laundry support, access to telephones, and diversions, such as television, video games, and aquariums. Conference areas for private conferences between medical caregivers, social workers, and family should be available. A private area for lactation equipment should be available.
Additional Considerations
Age-appropriate diversion equipment, such as televisions, video game and DVD players, and music systems should be available in each patient room. Other age-appropriate toys that are easily disinfected can be provided as needed. An easily readable clock should be in each patient room. Twenty-four-hour atomic clocks are easily seen and can help to decrease time variability on documentation.
Conclusions and Future Directions
The primary objective of pediatric intensive care is to provide specialized care to patients ranging in age from neonates to adolescents. Seriously ill pediatric patients are best cared for in ICUs designed for them, and the physical design of the facility and personnel organization are integral components of PICUs. In the US, pediatric intensive care resources are regionalized into three models: large geographic areas that encompass rural areas, rural and suburban areas, and small geographic areas that house large populations. Healthcare providers in the PICU include multidisciplinary teams of intensivists, physicians, nurse practitioners, physician assistants, nurses, pharmacists, therapists, and others. These health professionals provide a care-delivery model focused on beneficial clinical and behavioral outcomes, patient-family relationships, and safety. Government and accreditation agencies regulate PICU physical design, including room design, noise level, and lighting and electrical requirements. Evidence suggests that the current model of pediatric intensive care provides unparalleled healthcare to a vulnerable patient population.
Because of the aging and limited workforce, the future of the field is challenged by the need for more physicians, nurses, mid-level practitioners, and other healthcare providers who are specialized in pediatric intensive care. As technology becomes more complicated, both staffing and unit design must adjust to meet the needs of the newer technologies. Additionally, the focus of the PICU, both in design and in treatment, must be the patients and their families.
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