Pediatric Intensive Care Unit Admissions From The Emergency Departments in India The 2018 Academic College of Emergency Experts C
Pediatric Intensive Care Unit Admissions From The Emergency Departments in India The 2018 Academic College of Emergency Experts C
Pediatric Intensive Care Unit Admissions From The Emergency Departments in India The 2018 Academic College of Emergency Experts C
objective parameters and d) other criteria. The expert clinical status and his or her category of illness to direct initial
consensus panel then discussed and ranked proposed management priorities [17]. PAT can be relied as only objective
criteria according to scientific evidence, current standard early warning of children in or at high risk for clinical
of care, and expert opinion in the context of the Indian deterioration but does not define PICU admission. All these
health system. The general subject was addressed in triage system requies modifications targeted to young children
sections: admission criteria and benefits of different levels and children with a comorbid conditions and sometimes
of care, following the appraisal of the literature, misclassifies a substantial number of children who require ICU
discussion, and consensus, recommendations were admission [18].
written.
In addition to physiologic parameters and diagnoses,
Conclusion: Although these are consensus interpretation of the context of illness (acute vs exacerbation
recommendations, the subjects addressed encompass of chronic vs worsening of terminal illness), social implications,
complex ethical and medico-legal aspects of patient care and religious beliefs may also be taken into consideration
that affect daily clinical practice. The scarcity of high- when determining admission to the PICU. Lastly, local
quality evidence made it difficult to answer all the socioeconomic context and limitation of healthcare resources
questions asked related to ICU admission. Despite these must be considered the application of PICU admission criteria.
limitations, the members of the Task Force believe that
these recommendations provide a comprehensive Pediatric critical care units in India face many challenges. In
framework to guide practitioners in making informed the government sector of the health system, there are few
decisions during the admission process. This publication is critical care units that are well equipped and that have the
designed to assist in future development of health expertise to use sophisticated life sustaining technology.
policies to ensure effective resource allocation, maximize Furthermore, pediatric intensive care is poor or non-existent at
healthcare benefits and improve access to quality care for district hospitals in rural India, where 80% of the nation’s
children. population resides and overcrowding of PICUs in urban
settings is common [18-20]. Currently there is a lack of
Keywords: Pediatric intensive care; Admission criteria; universally accepted, peer-reviewed recommendations for
PICU; Consensus recommendations 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
Introduction health resource standpoint is critical for several reasons. First,
The PICU concept was initially developed about 40 years ago because intensive care is a precious commodity, especially in
with the first consensus conference on critical care admission resource-limited settings, clarity about criteria for PICU
held in 1983 by the National Institute of Health in the US [1,2]. admission assists local governments with resource allocation
The principle that emerged from this group continues to be and service provision planning. Second, accurate
relevant even today as it identifies patients who should be categorization of patients in the emergency department
admitted to the PICU as those who “reversible medical setting shortens the time it takes to admit critically ill children
conditions with a reasonable prospect of substantial recovery” to the proper care environment and also reduces unnecessary
[3,4]. As with any treatment, the decision to admit a patient to admissions for those who could be cared for safely and
the PICU should be based on potential benefit [5]. Pediatric appropriately in a lower intensity setting. Lastly, standardized
intensive care admission criteria should select those patients PICU admission criteria may be adopted and integrated by
who are the most likely to benefit from this level of care. Such clinical personnel, hospitals, and health administrators to
patients are generally those who are severely ill and unstable, createlocal, regional, and national PICU care standards in
with a high likelihood of functional recovery after treatment of context of location, environment and available resources. The
the acute illness [6,7]. Identification of patients who are “too current lack of recommendations is associated with significant
well” or “too severely ill” for PICU admission is a complicated provider variation in identifying pediatric intensive care needs
task and may be difficult if decisions are solely based upon and inconsistent use of PICU resources [21]. Once standard
diagnosis. Similarly, severity of illness scores such as the protocols and standardized indications of PICU admission are
Pediatric Risk of Mortality Score (PRISM), Acute Physiology and developed, India will move toward a more cost-effective use of
Chronic Health Evaluation (APACHE), and Simplified Acute its limited PICU resources [20]. Standardization of PICU
Physiology Scoring (SAPS) are inadequate and not validated to admission criteria has been accomplished in developed
predict which patients are likely to benefit from intensive care. countries through reviewed publications by professional
[8-11]. Various pediatric triage system has been evaluated and societies [22], but its lacking in India. The purpose of this
analysed its association with the following surrogate clinical manuscript is to provide India specific recommendations
outcome measures of severity: hospitalisation rate, intensive which can be adapted to the local context and integrated into
care unit (ICU) admission, length of ED stay, predictive value routine medical practices through a designated clinical and
for admission and length of hospitalization [12-16]. administrative body.
Purpose and Intended Application 400+ publications (Annex 2). The literature resource list was
shared with the remaining consensus team members while the
The purpose of these recommendations is to provide a core group developed an initial draft of an evidence based list
framework and reference for future policy development by of conditions potentially relevant for PICU admissions in the
professional societies and governments in India. These resource-limited context of India [22-28]. Furthermore, based
recommendations are intended as a consensus outline, but on previous approaches, the steering committee developed a
should be adapted to meet the operational needs of each framework for discussion and review of potential PICU
institution they are applied in, depending on the scope of parameters and defined the target outputs for the consensus
illnesses encountered and the resources available. The meeting [29,30].
definition of medical necessity for PICU admission reaches
beyond India and general concepts outlined here may be Consensus process
utilized across resource-limited environments in different
meetings. Application of these recommendations beyond the The entire consensus panel task force team was assembled
Indian context is feasible and suggestions for a process of for an in-person round table discussion at the Indo-US
implementation, monitoring, and evaluation are also included. Emergency and Trauma Collaborative conference during the
Once health policies have been created, policy compliance 2016 INDUSEM WORLD CONGRESS in Bengaluru, India. Team
along with clinical and administrative outcomes should be members reviewed and discussed the various PICU admission
monitored by health administrators designated to oversee criteria that were identified during the previous literature
PICU care in institutions. Pediatric intensive care policies review and presented by members of the core group at the
should be reviewed on a regular basis and revised as needed consensus meeting. The expert consensus panel then
based on available evidence to support change. 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,
Consensus Recommendations scientific expertise and location of practice we assemble
Development Process 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
Consensus panel task force drivers in drafting evidence based reviews and
The consensus process applied is based on a previous recommendations which were then further discussed by the
approach by the Society of Critical Care Medicine [21], defining full task force team until final consensus was obtained.
PICU admission criteria in high resource environments. These
consensus recommendations were developed by a consensus Rating and decision making models
panel task force team comprised of Indian and international
The decision about the necessity and appropriateness of
experts in pediatric critical care, emergency medicine, trauma,
PICU care was based on a variety or a combination of factors.
and health policy stakeholders. Members were identified
Our consensus team followed a previously utilized approach to
during the Indo-US Emergency and Trauma Collaborative
determine need of ICU admission based on a) prioritization
conference 2015 (INDUSEM - Delhi) as leaders in intensive care
modeling; b) general clinical criteria; c) clinical and objective
policies from a variety of backgrounds in India and
parameters and d) other criteria [22,24].
internationally.
Levels of recommendation: During the consensus process,
These individuals were invited to participate in a discussion
meeting members applied following previously validated
and consensus meeting during the 2016 annual INDUSEM
recommendation rating system [21].
WORLD CONGRESS at Bengaluru, India (Annex 1: Task force
team members). In preparation for the 2016 consensus Level 1: PICU admission justifiable on scientific evidence
meeting, a consensus panel task force steering committee alone.
completed a global literature search about PICU admission
Level 2: PICU admission reasonably justifiable on scientific
criteria development, reviewed PICU recommendations
evidence and strongly supported by consensus expert opinion.
published by a variety of professional organizations worldwide,
and performed a literature review of relevant publications Level 3: Scientific evidence generally lacking but supported
(Annex 2: Publications reviewed). The task force core group by available data and critical care expert opinion.
(Annex 1) performed a Pubmed literature search using Mesh
Terms [intensive care] [pediatrics] [admission criteria] and Consensus panel task force recommendations
identified relevant peer reviewed publications. In addition the
group reviewed previously published statements from
on criteria for PICU admission
professional societies in India and other LMIC and compiled Recommendations on location of pediatric intensive care
relevant publications in a literature resource list consisting of provision – High Dependency Units (Table 1).
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Pediatric intensive care can be provided at various locations within a healthcare facility. In addition to a designated PICU, many 2
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 (*).
Minimum services available to all patients: continuous cardiorespiratory monitoring; oxygen, suction, continuous monitoring, non- 3
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 a
PICU which can readily accept transfers if a patient can no longer be safely be managed in a HDU setting.
Recommendations on prioritization criteria for patients benefit most=Priority 1--to those who will benefit the
considered for PICU admission (Table 2). least=Priority 4.
Assigning appropriateness for PICU admission based on a
rating system which defined the patient populations who will
Priority 1: 1
Critically ill, unstable patients.
Patients who require monitoring, lifesaving 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
Examples
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.
Priority 2: 1
Patients who require intensive monitoring and MAY need lifesaving or life sustaining treatment in near future
Examples
Severe respiratory distress with impending respiratory failure requiring possibly ventilator support.
Shock responded to fluid boluses and MAY require monitoring for need of pressors.
Priority 3: 1
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)
Examples
Metastatic malignancy complicated by infections.
Priority 4: 1
PICU admission is not indicated
Monitoring and care can be provided outside PICU setting
Examples
Respiratory Illnesses without evidence of active or impending respiratory failure.
Cardiac conditions
Complex dysrhythmias requiring close monitoring and intervention, including new onset complete heart block 1
and after cardioversion
Hypertensive emergencies 1
Aortic dissection 1
Patients presenting to the emergency department with cardiorespiratory or neurologic compromise after high risk 1
intrathoracic or cardiac procedures
Hypertensive urgency 3*
Pulmonary conditions
Rapidly progressive upper or lower respiratory disease with risk of progression to respiratory failure 1
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Asthma-need for continuous administration of inhaled or nebulized medications to prevent respiratory failure 1*
Neurologic conditions
Status epilepticus which cannot be controlled well with more than 2 antiepileptic medications (diferent class) 1*
Progressive neuromuscular dysfunction with altered mental status (GCS < 8 or<10 and deteriorating), respiratory 1
or cardiovascular compromise
Toxicologic conditions
Ingestions leading to severe neurologic compromise (GCS<8 or<10 and deteriorating) or respiratory compromise 1
Gastrointestinal disorders
Esophageal perforation 1
Corrosive ingestion 1
Endocrinologic conditions
Diabetic keto-acidosis with hemodynamic instability, altered mental status, respiratory insufficiency or severe 1
acidosis (pH<7.1)
Diabetic keto-acidosis with severe acidosis (pH<7.1) but without hemodynamic instability, altered mental status, 1
or respiratory insufficiency
Patient with a recent history of congenital heart disease repair presenting with hemodynamic, neurologic or 1
respiratory compromise
Patients with recent open-intrathoracic surgeries presenting with hemodynamic, neurologic or respiratory 1
compromise
Radiologic findings
Cerebral vascular hemorrhage of any type with mental status change or focal neurologic signs 1
Tension pneumothorax 1*
Exchange transfusions 1
Plasmapheresis or leukopheresis 1*
Severe complications of sickle cell diseases such as acute chest syndrome, aplastic anemia or hemodynamic 1
instability
Head trauma with acutely increased ICP, ANY evidence of cerebral edema on imaging 1
Traumatic brain injury in patient with bleeding disorder or receiving anti-coagulation therapy 1
Flail chest 1
Crush injury 1
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Placement recommendation
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
Potassium>6+clinical symptoms (with arrhythmias or weakness) Potassium>6 without clinical symptoms with or 1
without EKG changes
2*
Ca>4 or iCa>10+/-clinical symptoms (hemodynamic instability or altered mental status (GCS<8 or<10 and 1
deteriorating)
HgB<5+symptoms 1*
Other conditions
Services not available at lower level care center: staffing shortages, drug shortages, equipment shortages 1*
Snakebites and insect bites associated with cardiopulmonary or neurologic compromise as defined in respective 2*
sections
more feasible to be in compliance with best practice admission will assist in effective resource allocation, maximize
standards, where care is safe, effective, and efficient. healthcare benefits for the population, reduce healthcare
resource waste, and improve access to quality care for
Limitations of applicability of these children. This publication discusses clinical conditions and
scenarios that warrant PICU or HDU admission but is not
recommendations intended to be utilized as an ethical or medical-legal document
Even though every effort was made to identify all relevant but as a resource for clinicians, hospital and systems
literature, it is possible that important publications may have administrators to standardize care processes, reduce variation
been missed in the search. Some references used date back to in care. Recommendations are provided based on
the 1980’s indicating the paucity of available literature in this prioritization modeling as well as on clinical conditions.
topic especially with application on low resource settings such
as India. Due to the complexity of medical conditions under Acknowledgements
review, high variability in the quantity and quality of literature
covering the spectrum of medicine and ICU indications, our We would like to acknowledge the INDUSEM organization,
team decided to utilize the level 1-3 rating system [19] over which was the driving force behind the development of these
more traditional Evidence level A-E rating system. recommendations. We would further like to acknowledge the
Government of India Ministry of Health and Family Welfare,
Even though every effort was made to have reputable
Medical Council of India, Indian Academy of Pediatrics, Indian
experts in emergency medicine, pediatrics and intensive care
Society of Critical Care Medicine and Shakti Krupa Charitable
with a variety of medical and working backgrounds participate
Trust for their support of this project.
in the consensus process, it may be possible that some
practitioners may have been over- and some
underrepresented. Even though literature review and drafting References
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