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May 02, 2022
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Q&A: ‘Accumulated experience’ guides new AAP recommendations on pediatric IMCUs

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The AAP recently updated its recommendations for pediatric intermediate care units for the first time since 2004, providing new guidance for their development and operation.

The guidance was written by a nine-member AAP task force that included experts on hospital care, critical care and surgery. It was published in a policy statement in Pediatrics.

Healio spoke with co-author Nicholas A. Ettinger, MD, PhD, an assistant professor of pediatrics and critical care at Baylor College of Medicine, about the new guidance.

Nicholas Ettinger

Healio: What are the most notable changes to the guidance for pediatric intermediate care units (IMCUs)?

Ettinger: I think that there are two key takeaways to this policy statement. First, as noted within the policy statement, there is very little pediatric-specific literature regarding IMCUs. Even in the adult literature, IMCU-related publications are very heterogeneous and not high-quality data.

When we began our discussions, it was clear that our recommendations were going to be based on the little pediatric literature that is out there, plus the accumulated experience of the group from the various children’s hospitals that we all work at. It became clear very quickly that all of us had a slightly different picture in our heads of what IMCU care looked like because of the very heterogeneous nature of the institutions that we all work at, and that this heterogeneity was in fact reflective of the state of IMCUs already in existence across the country.

Therefore, we felt it was important to clarify — both for units that already exist and especially for institutions that might be interested — things about establishing a pediatric IMCU, and the core essential principles to follow to safely establish and maintain an IMCU. These include clear triage guidelines to guide IMCU admission, clear policies and procedures about ongoing assessment of patients in an IMCU, and clear thresholds for when patients in an IMCU should be transferred to a pediatric ICU (PICU). In addition, we felt it was essential for any IMCU to have a very clear and well-established relationship with a PICU.

The second key takeaway was regarding nursing care and nurse-to-patient ratios. Part of what defines an ICU bedspace is typically the 1:1 or 1:2 nursing ratios due to the patient acuity and nursing complexity. For multiple types of IMCU-appropriate populations, we felt that an essential foundational element of what allows those patients to be appropriate for an IMCU-type unit is only if there is 1:2 or 1:3 maximum nurse-to-patient ratios. Larger ratios than this make the close nursing attention and close nursing care that is essential for an IMCU patient impossible.

Healio: What is often overlooked in ensuring a well-run IMCU?

Ettinger: For both PICUs and IMCUs, the importance of adequately trained and adequately staffed nursing teams, along with adequately trained ancillary personnel — especially respiratory therapists and physical/occupational therapists — is often overlooked or undervalued. Without excellently trained bedside nurses supported by well-trained and experienced respiratory therapists and physical/occupational therapists, it is very hard for many complex patients in the PICU and IMCU to make consistent progress and to recover from their acute illness or acute-on-chronic illnesses.

In addition — especially in an IMCU, where the practice of discharging patients directly from the unit is much more common than in a PICU, as compared with transferring patients to a regular hospital floor first before discharge readiness — there is a large body of pediatric research supporting that it is absolutely essential to have experienced and knowledgeable case managers and social workers who can help navigate the exceptionally complex world of home health technology, nursing and support.

Healio: What is the major takeaway from the guidance?

Ettinger: The main takeaway from this policy statement is that as PICU care continues to improve, more and more children will survive extremely complex critical illness and many of the children will come out the other end with complex health needs. IMCUs in the U.S. are currently a heterogenous group related to the particular characteristics of the institution where they are located. Appropriately staffed and designed IMCUs can be the inpatient “medical home” for these complex children, in addition to handling children with acute critical illness who require close, frequent monitoring and care and select pre- or post-surgical patients who also require close, frequent monitoring and care.

References:

Ettinger N, et al. Pediatrics. 2022;doi:10.1542/peds.2022-057009.