Keywords

Pediatric intensive care; Admission criteria; PICU; Consensus recommendations

Introduction

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 [5]. 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 [17]. 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 [18].

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 [21]. 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 [20]. Standardization of PICU admission criteria has been accomplished in developed countries through reviewed publications by professional societies [22], 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.

Purpose and Intended Application

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 Recommendations Development Process

Consensus panel task force

The consensus process applied is based on a previous approach by the Society of Critical Care Medicine [21], 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].

Consensus process

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 [21].

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).

Table 1: Pediatric Intensive Care Provision in High Dependency Units

Recommendations on prioritization criteria for patients considered for PICU admission (Table 2).

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).

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.

Administrative Recommendations to Facilitate Appropriate Paediatric ICU Admission

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 [19] 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.

Summary

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.

Acknowledgements

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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