Pediatric Intensive Care and Pediatric Emergency, St John’s Medical College Hospital, Bangalore, India
Received Date: January 02, 2019; Accepted Date: January 23, 2019; Published Date: January 30, 2019
Citation: Lalitha AV (2019) Pediatric Intensive Care Unit Admissions from the Emergency Departments in India - The 2018 Academic College of Emergency Experts Consensus Recommendations. J Emerg Trauma Care Vol.4 No.1:2.
There are global variations in policies that define clear indications for PICU (Pediatric Intensive care unit) admissions. In resource limited countries where PICU service availability is limited, the admission criteria to PICU are urgently needed to optimize the utilization of available intensive care services and to maximize patient benefit. The objective of these consensus recommendations on PICU admission criteria is to provide a framework and reference for future policy development by professional societies and governments.
Design: The consensus recommendations were developed by a multidisciplinary consensus task force comprised of international experts in pediatric critical care, emergency medicine, trauma, critical care, and health policy stakeholders during the 2016 annual INDUSEM WORLD CONGRESS in Bengaluru, India.
Measurements and main results: A task force steering committee completed a global literature search about PICU admission criteria development; reviewed PICU admission guidelines published by a variety of professional organizations worldwide, and performed a literature review of relevant publications. The objectives of this Task Force is to provide a framework for validated approach to determine appropriateness of ICU admission in India(resource limited setting) based on a) prioritization modeling; b) general clinical criteria; c) clinical and objective parameters and d) other criteria. The expert consensus panel then discussed and ranked proposed criteria according to scientific evidence, current standard of care, and expert opinion in the context of the Indian health system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, following the appraisal of the literature, discussion, and consensus, recommendations were written.
Conclusion: Although these are consensus recommendations, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. The scarcity of high-quality evidence made it difficult to answer all the questions asked related to ICU admission. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission process. This publication is designed to assist in future development of health policies to ensure effective resource allocation, maximize healthcare benefits and improve access to quality care for children.
Pediatric intensive care; Admission criteria; PICU; Consensus recommendations
The PICU concept was initially developed about 40 years ago with the first consensus conference on critical care admission held in 1983 by the National Institute of Health in the US [1,2]. The principle that emerged from this group continues to be relevant even today as it identifies patients who should be admitted to the PICU as those who “reversible medical conditions with a reasonable prospect of substantial recovery” [3,4]. As with any treatment, the decision to admit a patient to the PICU should be based on potential benefit . Pediatric intensive care admission criteria should select those patients who are the most likely to benefit from this level of care. Such patients are generally those who are severely ill and unstable, with a high likelihood of functional recovery after treatment of the acute illness [6,7]. Identification of patients who are “too well” or “too severely ill” for PICU admission is a complicated task and may be difficult if decisions are solely based upon diagnosis. Similarly, severity of illness scores such as the Pediatric Risk of Mortality Score (PRISM), Acute Physiology and Chronic Health Evaluation (APACHE), and Simplified Acute Physiology Scoring (SAPS) are inadequate and not validated to predict which patients are likely to benefit from intensive care. [8-11]. Various pediatric triage system has been evaluated and analysed its association with the following surrogate clinical outcome measures of severity: hospitalisation rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission and length of hospitalization [12-16].
The most common being Pediatric Assessment Triangle (PAT) which is a rapid evaluation tool that establishes a child’s clinical status and his or her category of illness to direct initial management priorities . PAT can be relied as only objective early warning of children in or at high risk for clinical deterioration but does not define PICU admission. All these triage system requies modifications targeted to young children and children with a comorbid conditions and sometimes misclassifies a substantial number of children who require ICU admission .
In addition to physiologic parameters and diagnoses, interpretation of the context of illness (acute vs exacerbation of chronic vs worsening of terminal illness), social implications, and religious beliefs may also be taken into consideration when determining admission to the PICU. Lastly, local socioeconomic context and limitation of healthcare resources must be considered the application of PICU admission criteria.
Pediatric critical care units in India face many challenges. In the government sector of the health system, there are few critical care units that are well equipped and that have the expertise to use sophisticated life sustaining technology. Furthermore, pediatric intensive care is poor or non-existent at district hospitals in rural India, where 80% of the nation’s population resides and overcrowding of PICUs in urban settings is common [18-20]. Currently there is a lack of universally accepted, peer-reviewed recommendations for PICU admission criteria resource-limited settings and, in India national standards for pediatric critical care admission, practice and quality of care measures have not been established. Efficient use of intensive care services from a health resource standpoint is critical for several reasons. First, because intensive care is a precious commodity, especially in resource-limited settings, clarity about criteria for PICU admission assists local governments with resource allocation and service provision planning. Second, accurate categorization of patients in the emergency department setting shortens the time it takes to admit critically ill children to the proper care environment and also reduces unnecessary admissions for those who could be cared for safely and appropriately in a lower intensity setting. Lastly, standardized PICU admission criteria may be adopted and integrated by clinical personnel, hospitals, and health administrators to createlocal, regional, and national PICU care standards in context of location, environment and available resources. The current lack of recommendations is associated with significant provider variation in identifying pediatric intensive care needs and inconsistent use of PICU resources . Once standard protocols and standardized indications of PICU admission are developed, India will move toward a more cost-effective use of its limited PICU resources . Standardization of PICU admission criteria has been accomplished in developed countries through reviewed publications by professional societies , but its lacking in India. The purpose of this manuscript is to provide India specific recommendations which can be adapted to the local context and integrated into routine medical practices through a designated clinical and administrative body.
The purpose of these recommendations is to provide a framework and reference for future policy development by professional societies and governments in India. These recommendations are intended as a consensus outline, but should be adapted to meet the operational needs of each institution they are applied in, depending on the scope of illnesses encountered and the resources available. The definition of medical necessity for PICU admission reaches beyond India and general concepts outlined here may be utilized across resource-limited environments in different meetings. Application of these recommendations beyond the Indian context is feasible and suggestions for a process of implementation, monitoring, and evaluation are also included. Once health policies have been created, policy compliance along with clinical and administrative outcomes should be monitored by health administrators designated to oversee PICU care in institutions. Pediatric intensive care policies should be reviewed on a regular basis and revised as needed based on available evidence to support change.
Consensus panel task force
The consensus process applied is based on a previous approach by the Society of Critical Care Medicine , defining PICU admission criteria in high resource environments. These consensus recommendations were developed by a consensus panel task force team comprised of Indian and international experts in pediatric critical care, emergency medicine, trauma, and health policy stakeholders. Members were identified during the Indo-US Emergency and Trauma Collaborative conference 2015 (INDUSEM - Delhi) as leaders in intensive care policies from a variety of backgrounds in India and internationally.
These individuals were invited to participate in a discussion and consensus meeting during the 2016 annual INDUSEM WORLD CONGRESS at Bengaluru, India (Annex 1: Task force team members). In preparation for the 2016 consensus meeting, a consensus panel task force steering committee completed a global literature search about PICU admission criteria development, reviewed PICU recommendations published by a variety of professional organizations worldwide, and performed a literature review of relevant publications (Annex 2: Publications reviewed). The task force core group (Annex 1) performed a Pubmed literature search using Mesh Terms [intensive care] [pediatrics] [admission criteria] and identified relevant peer reviewed publications. In addition the group reviewed previously published statements from professional societies in India and other LMIC and compiled relevant publications in a literature resource list consisting of 400+ publications (Annex 2). The literature resource list was shared with the remaining consensus team members while the core group developed an initial draft of an evidence based list of conditions potentially relevant for PICU admissions in the resource-limited context of India [22-28]. Furthermore, based on previous approaches, the steering committee developed a framework for discussion and review of potential PICU parameters and defined the target outputs for the consensus meeting [29,30].
The entire consensus panel task force team was assembled for an in-person round table discussion at the Indo-US Emergency and Trauma Collaborative conference during the 2016 INDUSEM WORLD CONGRESS in Bengaluru, India. Team members reviewed and discussed the various PICU admission criteria that were identified during the previous literature review and presented by members of the core group at the consensus meeting. The expert consensus panel then discussed and ranked proposed criteria according to scientific evidence, current standard of care, and expert opinion. Review to recommendation process: Based on field of practice, scientific expertise and location of practice we assemble subgroup teams (consensus panel core group members) who can provide content, specialty, research and methodological expertise in the review process and who were the primary drivers in drafting evidence based reviews and recommendations which were then further discussed by the full task force team until final consensus was obtained.
Rating and decision making models
The decision about the necessity and appropriateness of PICU care was based on a variety or a combination of factors. Our consensus team followed a previously utilized approach to determine need of ICU admission based on a) prioritization modeling; b) general clinical criteria; c) clinical and objective parameters and d) other criteria [22,24].
Levels of recommendation: During the consensus process, meeting members applied following previously validated recommendation rating system .
Level 1: PICU admission justifiable on scientific evidence alone.
Level 2: PICU admission reasonably justifiable on scientific evidence and strongly supported by consensus expert opinion.
Level 3: Scientific evidence generally lacking but supported by available data and critical care expert opinion.
Consensus panel task force recommendations on criteria for PICU admission
Recommendations on location of pediatric intensive care provision – High Dependency Units (Table 1).
|Pediatric Intensive Care Provision In High Dependency Units||Level of
|Pediatric intensive care can be provided at various locations within a healthcare facility. In addition to a designated PICU, many hospitals within India operate a High Dependency Unit (HDU) where intensive care can be provided, however staffing ratios and available equipment standards may differ from a standard PICU setup. The consensus task force panel identifies conditions which may be eligible to be cared for in a HDU setting if medical care for a specific condition can be delivered with equal quality when compared to the PICU setting. Conditions identified as eligible for HDU care are marked with an asterisk (*).||2|
|The minimum care standard for the HDU includes:
Minimal staffing requirements: 1:3 nurse to patient ratio; 1 resident level provider is available 24/7 to provide optimal medical supervision. The resident should be trained in pediatric advanced life support skills .The nurse should have substantial pediatric expertise.
|Minimum services available to all patients: continuous cardiorespiratory monitoring; oxygen, suction, continuous monitoring, non-invasive ventilation modality, crash cart, defibrillator, lab 24/7, arterial blood gas, portable x-ray.
HDU must have immediate access to a dedicated PICU within their facility or have a relationship with an institution that has an PICU which can readily accept transfers if a patient can no longer be safely be managed in a HDU setting.
|The minimum care standard for the PICU includes:
Unit design,equipment ,organization and staffing and ancillary support services as recommended by ISCCM and IAP (25)
Table 1: Pediatric Intensive Care Provision in High Dependency Units
Recommendations on prioritization criteria for patients considered for PICU admission (Table 2).
|Prioritization Model Based PICU Admission||Level|
Critically ill, unstable patients.
Patients who require monitoring, life saving or life sustaining treatment that cannot be provided outside the PICU
Extent and duration of therapy are not limited by preexisting conditions or patient/family wishes
Respiratory failure requiring ventilator support
Continuous vasoactive drug infusions (pressors, milrinone,…)
Acute decompensated shock with signs of end organ failure
Intentional or unintentional drug overdose, poisoning with end organ failure
Patients who require intensive monitoring and MAY need lifesaving or life sustaining treatment in near future
Severe respiratory distress with impending respiratory failure requiring possibly ventilator support
Shock responded to fluid boluses and MAY require monitoring for need of pressors
Critically ill patients with underlying life limiting illness
Limits in place as to extent of therapy (i.e. patients with co-morbid conditions whose parents or guardians have decided against receiving resuscitation and /or lifesaving interventions)
Metastatic malignancy complicated by infections
PICU admission is not indicated
Monitoring and care can be provided outside PICU setting
Respiratory Illnesses without evidence of active or impending respiratory failure
Table 2: Prioritization Model Based PICU Admission
Assigning appropriateness for PICU admission based on a rating system which defined the patient populations:
who will bene it most=Priority 1.
to those who will benefit the least=Priority 4.
General clinical conditions that warrant PICU admission
Ideally, a patient should be admitted to the PICU setting before the condition reaches a point from where recovery is not possible. The minimum standards of PICU regarding the unit design, equipment, and organization and staffing as described. Early identification of clinical warning signs is important and requires health personnel who are trained and equipped to perform cardio-respiratory and neurologic assessments/interventions and to have decision-making skills. If a patient is diagnosed with a critical illness at a healthcare facility which does not have the capacity to provide the appropriate level of care, transfer to ahigher level facility should be initiated immediately after the patient has been stabilized to the greatest extent possible.
General clinical conditions and indications warranting PICU admission
• All respiratory or cardiac arrest,
• Unstable airway,
• Inability to oxygenate (O2 Sat less than 90% on>50% oxygen requirement,
• Inability to ventilate with rising PCO2 levels with respiratory insufficiency,
• Glasgow Coma Scale (GCS) score<8 or sudden fall in score by>2 points,
• Status epilepticus,
• Critical values of age specific vital signs parameters.
Clinical diagnosis and objective parameters that warrant PICU admission.
This model uses speci ic well-de ined clinical conditions which warrant PICU admissions (Table 3).
|Clinical Diagnosis Model Based PICU Admission Criteria||Level of Recommendation|
|Cardiogenic shock, myocardial dysfunction: infectious and other||1|
|Complex dysrhythmias requiring close monitoring and intervention, including new onset complete heart block and after cardioversion||1|
|Acute congestive heart failure requiring hemodynamic support||1|
|After cardiac arrest and post-resuscitation||1|
|Congenital heart disease with cardiopulmonary instability||1|
|Patients presenting to the emergency department with cardiorespiratory or neurologic compromise after high risk
intrathoracic or cardiac procedures
|Need for invasive cardiac monitoring||1|
|Need for cardiac pacing||1|
|Pericardial effusion requiring drainage, signs of tamponade||1|
|Acute respiratory insufficiency or failure requiring invasive
|Hemoptysis with shock or airway compromise||1|
|Newborns with signs of severe respiratory distress||1|
|Rapidly progressive upper or lower respiratory disease with risk of
progression to respiratory failure
|High supplemental oxygen need >6lpm or non-rebreather mask or
FiO2>50% on CPAP/BiPAP to keep oxygen >94%
|Acute barotraumas (i.e. decompression illness)||1*|
|Asthma -Need for continuous administration of inhaled or nebulized
medications to prevent respiratory failure
|Risk of complete airway obstruction||1|
|BRUE (brief resolved unexplained event) – recurrent||2*|
|Status epilepticus which cannot be controlled well with more than 2
antiepileptic medications (diferent class)
|Progressive neuromuscular dysfunction with altered mental status (GCS <8 or <10 and deteriorating), respiratory or cardiovascular
|Non-traumatic Intracranial hemorrhage with evidence of increased
|Acute non-traumatic intracranial hemorrhage (epidural, subdural,
|Chronic progressive CNS disorders with deteriorating neurologic or
|Spinal cord compression or acute spinal lesions||1|
|Stroke with acute presentation||1*|
|Neurosurgical procedures requiring invasive monitoring of ICP||1|
|Hypertensive encephalopathy with PRES changes on imaging||1|
|Glasgow coma scale: GCS<8 →ICU; 9-13→ICU or HDU||1, 1*|
|Ingestions leading to severe neurologic compromise (GCS <8 or <10
and deteriorating) or respiratory compromise
|Ingestions known to be associated with a high risk or cardio-
respiratory events (eg recent organophosphate poisoning)
|Ingestions leading to hemodynamic instability, bleeding or organ
|Seizures following drug ingestion||1|
|Envenomation (snake/scorpion/bee stings)||1|
|GI bleeding leading to hemodynamic instability, altered mental status
|After emergency removal of foreign bodies||1*|
|Hepatic encephalopathy Grade >2||1|
|Diabetic keto-acidosis with hemodynamic instability, altered mental status, respiratory insufficiency or severe acidosis (pH<7.1)||1|
|Diabetic keto-acidosis with severe acidosis (pH<7.1) but without hemodynamic instability, altered mental status, or respiratory
|Hyperosmolar state with altered mental status and or hemodynamic
|Adrenal crisis with hemodynamic instability||1|
|Inborn errors of metabolism with risk of respiratory, cardiovascular
or neurologic decompensation
|Thyroid storm with hemodynamic instability||1|
|Surgical or Post-Surgical Conditions Presenting in the Emergency Department Setting|
|Patients after recent surgery presenting with hemodynamic,
neurologic or respiratory compromise
|Patient with a recent history of congenital heart disease repair
presenting with hemodynamic, neurologic or respiratory compromise
|Patients with recent open -intrathoracic surgeries presenting with
hemodynamic, neurologic or respiratory compromise
|Patients with recent organ transplantation presenting with
hemodynamic, neurologic or respiratory compromise
|Cerebral vascular hemorrhage of any type with mental status change
or focal neurologic signs
|Ruptured viscera, bladder, uterus, liver esophagus||1|
|Bleeding of any type with hemodynamic instability||1|
|Dissecting aortic aneurisms||1|
|Foreign body before extraction with risk of perforation: batteries,
|Pleural effusion with cardiovascular or respiratory compromise||1*|
|Mediastinal mass with risk of obstruction||1*|
|Pulmonary embolism on CT <5d||1|
|Children with Special Conditions – Malignancies and Hematologic Conditions|
|Plasmapheresis or leukopheresis||1*|
|Severe coagulopathy with active or high risk of bleeding||1|
|Severe complications of sickle cell diseases such as acute chest
syndrome, aplastic anemia or hemodynamic instability
|Tumor lysis syndrome||1*|
|Tumors or masses threatening airway, vital vessels or organs||1*|
|Febrile neutropenia with airway and hemodynamic compromise||1|
|Conditions Associated with Trauma|
|Multiple trauma injury||1|
|Head trauma with acutely increased ICP, ANY evidence of cerebral
edema on imaging
|Severe head injury with altered mental status, respiratory
|Traumatic brain injury with GCS <8 or <10 and deteriorating||1|
|Traumatic brain injury in patient with bleeding disorder or receiving
|Cardiac contusion, pulmonary contusion||1|
|Patients requiring placement of an extraventricular drainage device
|Acute spinal cord injury||1|
|Trauma with intraabdominal organ injury||1*|
|Pelvic fracture with retroperitoneal hematoma||1|
|Grade 3 or 4 solid organ injury||1|
(regardless of underlying etiology)
|Trauma + 1 of the Following
Requires massive blood transfusion Base deficit >5
Seizures Pregnancy Hypothermia
Patients with severe traumatic injuries, intraabdominal injuries, TBI
|GCS <8, crush injuries, or those likley requiring urgent surgical interventions should preferentially be admitted to ICU with
availability of pediatric surgery and neurosurgery
|Intensive pain care needed: PCA, initiation of continuous infusion of
|Objective Parameters, Laboratory Parameters|
|Potassium >6 + clinical symptoms (with arrhythmias or weakness) Potassium >6 without clinical symptoms with or without EKG
|Potassium <2.5 + clinical symptoms (with arrhythmias or weakness)||1|
|Ca >14 or iCa>10 +/- clinical symptoms (hemodynamic instability or
altered mental status (GCS <8 or <10 and deteriorating)
|Ca 12-14 or iCa 8-10 + clinical symptoms||2*|
|Ca <8 with or without symptoms (eg seizures)||1*|
|Hyponatremia with Serum Na <125mmol/l or hypernatremia >160
mmol/l with clinical symptoms (eg altered mental status or seizures)
|Hyponatremia with Na <125 mmol/l WITHOUT symptoms||3*|
|HgB<5 + symptoms||1*|
|HgB<7 with active bleeding||1|
|Shock of any etiology||1|
|Invasive Hemodynamic monitoring||1|
|Services not available at lower level care center: staffing shortages,
drug shortages, equipment shortages
|Renal failure and need for acute hemodialysis||1*|
|Crush injury with acute renal insufficiency||1|
|Documented or suspected malignant hyperthermia||1|
|Snakebites and insect bites associated with cardiopulmonary or
neurologic compromise as defined in respective sections
Table 3: Clinical diagnosis model based PICU admission criteria.
Numeric labels 1-3 designate level of recommendations (see above).
Asterisk indicates that such conditions can potentially be managed in an HDU.
This document is designed to serve as a resource for hospitals and policy makers in resource-limited settings to determine appropriateness of PICU admissions for optimal utilization of available scarce resources within their own care environment.
Local stakeholders must take steps to achieve integration of PICU admission criteria into hospital care standards and health. Recommendations must be interpreted and applied in the local context of care, resources and health policy and should be adapted to meet the local needs. For successful integration into clinical practice, a hospital or region must appoint a physician director on the basis of qualification and leadership skill. This individual must be able to provide clinical, administrative, and educational direction to local staff to integrate these recommendations into standard medical practice. Quality improvement processes need to be implemented to assure patient safety, to monitor compliance and to appropriate steps for continuous refinement of local policies.
Collaboration and integration of nursing staff, ancillary staff, and directors of other units within the hospital is essential to ensure transparency of the quality improvement process. The ultimate decision responsibility for acceptance and refusal of PICU admission is in the hands of the transferring and accepting physician, who may deviate from the recommendation if this deviation is in the best interest of the patient. Ideally a multidisciplinary team should conduct non-threatening reviews of protocol deviations, adverse patient events, and hospitalization outcomes in order to further refine applicability of these recommendations. By establishing a culture that focuses on systems issues and re-education as opposed to blame and punishment, institutions will find it more feasible to be in compliance with best practice standards, where care is safe, effective, and efficient.
Limitations of applicability of these recommendations
Even though every effort was made to identify all relevant literature, it is possible that important publications may have been missed in the search. Some references used date back to the 1980’s indicating the paucity of available literature in this topic especially with application on low resource settings such as India. Due to the complexity of medical conditions under review, high variability in the quantity and quality of literature covering the spectrum of medicine and ICU indications, our team decided to utilize the level 1-3 rating system  over more traditional Evidence level A-E rating system.
Even though every effort was made to have reputable experts in emergency medicine, pediatrics and intensive care with a variety of medical and working backgrounds participate in the consensus process, it may be possible that some practitioners may have been over- and some underrepresented. Even though literature review and drafting evidence based recommendations for final review and inputs was accomplished by team members with topic specific clinical, research and methodological research, we did not include subspecialists in the consensus process. Due to the complexity of health care systems within India between the public and private sector, variation in staffing, staff competency, availability of equipment between hospitals, urban-rural healthcare delivery discrepancies, state and institution specific variable definitions of HDU, staffing standards, etc. and considering a variety of other factors, the authors realize that a uniform application of these recommendations is not possible and is also not intended. The authors see this publication as a reference and starting point for institutions who are interested in engaging in the process of defining PICU admission criteria. These recommendations are also not designed or intended to serve as ethical or medico-legal criteria to be applied to decide about “appropriateness” of care, placement of patients and transfer of patients and are not meant to replace clinical judgment and the local definition of appropriate care. Overcrowding, high caseloads exceeding hospital capacity and limited bed availability in HDU and PICU units are commonly encountered in India; however these recommendations are not designed to address eligibility of transfer-in and transfer-out policies in these units and provide a universally applicable recommendation on overflow scenarios.
This publication is designed to provide recommendation of clinical criteria for PICU admissions for children from the emergency department. The authors see this publication as a reference and starting point for institutions who are interested in engaging in the process of defining PICU admission criteria, to assist key stakeholders in the development of hospital operational standards, to define appropriateness of PICU admission will assist in effective resource allocation, maximize healthcare benefits for the population, reduce healthcare resource waste, and improve access to quality care for children. This publication discusses clinical conditions and scenarios that warrant PICU or HDU admission but is not intended to be utilized as an ethical or medical-legal document but as a resource for clinicians, hospital and systems administrators to standardize care processes, reduce variation in care. Recommendations are provided based on prioritization modeling as well as on clinical conditions.
We would like to acknowledge the INDUSEM organization, which was the driving force behind the development of these recommendations. We would further like to acknowledge the Government of India Ministry of Health and Family Welfare, Medical Council of India, Indian Academy of Pediatrics, Indian Society of Critical Care Medicine and Shakti Krupa Charitable Trust for their support of this project.
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