|
 
 |
| GUIDELINE |
|
| Year : 2023 | Volume
: 10
| Issue : 2 | Page : 63-71 |
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Practical guideline for setting up a comprehensive pediatric care unit for critical care delivery at district hospitals and medical colleges under ECRP-II
Lokesh Tiwari1, Muralidharan Jayashree2, Atul Jindal3, Daisy Khera4, Amrita Banerjee1, Girish Chandra Bhatt5, Shalu Gupta6, Nameet Jerath7, Meenu Singh8, Prabhat Kumar Singh9
1 Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
2 Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chattisgarh, India
4 Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
5 Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
6 Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children Hospital, New Delhi, India
7 Department of Pediatrics, Indraprastha Apollo Hospital, New Delhi, India
8 Executive Director, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
9 Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar; Vice Chancellor, Uttar Pradesh University of Medical Sciences, Lucknow, Uttar Pradesh, India
| Date of Submission | 23-Feb-2023 |
| Date of Decision | 28-Feb-2023 |
| Date of Acceptance | 04-Mar-2023 |
| Date of Web Publication | 23-Mar-2023 |
Correspondence Address:
Dr. Lokesh Tiwari
Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpcc.jpcc_12_23
Pediatric critical care is highly sophisticated and precise and is possible only in specialized areas such as pediatric intensive care units (PICUs) or high dependency units equipped with round-the-clock monitoring facilities, skilled and trained staff, and treatment equipment. The need for critical care beds was sharply felt during the COVID-19 pandemic and the Government of India launched the COVID-19 emergency response and health system preparedness package: phase II (ECRP-II) with a hub and spoke model to strengthen pediatric critical care delivery at district level under the skilled supervision of state-level PICUs of the identified center of excellence (CoE). The CoEs will have well-equipped PICUs providing tele-ICU service, mentoring, and technical hand-holding to the district pediatric unit. This model was envisioned to be extended to critically ill children with nonCOVID illnesses after the pandemic abates. For achieving the proposed objectives under the ECRP-II scheme, this guideline aims to provide a practical framework for setting up comprehensive pediatric care units at district hospitals and medical colleges (spoke) well connected with a CoE (hub) for teleconsultation, knowledge exchange, referral, and back referral between hub and spokes.
Keywords: Capacity building, comprehensive pediatric care unit, ECRP-II, hub and spoke model for pediatric intensive care units, pediatric critical care, resource-limited setting
How to cite this article:
Tiwari L, Jayashree M, Jindal A, Khera D, Banerjee A, Bhatt GC, Gupta S, Jerath N, Singh M, Singh PK. Practical guideline for setting up a comprehensive pediatric care unit for critical care delivery at district hospitals and medical colleges under ECRP-II. J Pediatr Crit Care 2023;10:63-71 |
How to cite this URL:
Tiwari L, Jayashree M, Jindal A, Khera D, Banerjee A, Bhatt GC, Gupta S, Jerath N, Singh M, Singh PK. Practical guideline for setting up a comprehensive pediatric care unit for critical care delivery at district hospitals and medical colleges under ECRP-II. J Pediatr Crit Care [serial online] 2023 [cited 2023 Jun 8];10:63-71. Available from: http://www.jpcc.org.in/text.asp?2023/10/2/63/372434 |
| Background | |  |
Pediatric critical care services cater to children and adolescents with clinical conditions that are life-threatening or have the potential to become life-threatening. Such children need constant, vigilant, close monitoring and support from skilled staff, equipment, and medications to restore or maintain normal or near-normal organ functions.[1] This level of care is highly sophisticated and precise and is possible only in specialized areas such as pediatric intensive care units (PICUs) or high dependency units (HDUs) that are equipped with round-the-clock monitoring facilities, skilled and trained staff, and treatment equipment. Unlike adults, sick children need the presence of their parents inside the PICU or HDU to decrease anxiety and agitation and facilitate care processes. This important aspect needs to be accounted for while designing these specialized units for children.
The need for critical care beds was sharply felt during the COVID-19 pandemic and the Government of India launched the COVID-19 emergency response and health system preparedness package: phase II (ECRP-II) through the national health mission. This scheme aimed to accelerate health system preparedness for prevention, early detection, and management during the COVID-19 pandemic. The focus was on health infrastructure development, particularly for pediatric care with measurable outcomes.[2] Each state had to identify and nominate a pediatric center of excellence (CoE) for providing teleservices, mentoring and technical hand-holding to other medical colleges, and district pediatric units. To achieve this goal a hub and spoke model was proposed where a PICU at the CoE will act as a hub under which dedicated pediatric care units will be developed as spokes in all the districts of India at medical colleges or district hospitals based on the local need.[3] It was envisioned that this model would be extended to critically ill children with non-COVID illnesses after the pandemic abates. Establishing these pediatric care units will be crucial toward fulfilling the objectives of building capacities and improving the quality of care delivered to sick children in resource-limited settings (RLSs).
As a starting point, PICUs of some institutes of national importance (INI) and medical colleges were identified as CoEs under the ECRP-II to operationalize the pediatric critical care units in district hospitals of different states and union territory (UTs) through teleconsultation. In the absence of specific technical guidelines, CoEs and other medical colleges or district hospitals have not been able to develop a uniform operational model. As a result, this highly potential scheme for improving care delivery and building capacities in pediatric critical care remains under-utilized. Through this document, we aim to provide a practical framework for setting up a comprehensive pediatric care unit (CPCU) at district hospitals and medical colleges for achieving the proposed objectives under the ECRP-II scheme.
| Methodology | | |
A group of experts with vast experience in pediatric critical care and health-care delivery drafted the guidelines and practical recommendations to operationalize the hub and spoke model proposed under ECRP-II. The team enlisted all pertinent issues to develop the best-fit recommendations. A literature search was carried out in PubMed and the websites of relevant professional organizations. Guidelines, systematic reviews, trials, narrative reviews, and other descriptive reports were reviewed with respect to unit design, organization, equipment, staffing, consumables, admission and discharge criteria, and special needs during the COVID-19 pandemic. The first-hand experience of developing PICUs at INIs was utilized, in addition to guidelines published in the medical literature.[1],[4],[5],[6],[7],[8],[9],[10] The context, resources required, feasibility of implementation, values and preferences were considered. Deliberations and discussions among all experts were carried out through the exchange of drafts through E-mails and video-based conference meetings following which a consensus was arrived at. While developing this guideline, an integrated approach comprising of 4S framework (system, space, staff, and stuff), a preparatory tool commonly used for planning new projects was used.[5]
System
Establishing comprehensive pediatric care units (spokes) in all the 736 districts
For a district hospital with more than 100 beds (540 districts), there is provision for a 42-bedded pediatric care unit which will comprise of a 30-bedded oxygen-supported pediatric ward and a 12-bedded hybrid ICU (8 HDU and 4 ICU beds). For district hospitals with 100 or fewer beds (196 districts), there is a provision of a 32-bedded pediatric care unit which comprises of a 20 bedded oxygen-supported pediatric ward and a 12-bedded hybrid ICU.[3] We propose that this hybrid ICU be called a CPCU and each district should have at least one CPCU.
Establishing a center of excellence (hub) in each state/union territory
A CoE for pediatric critical care is to be established or identified in a medical college or a central hospital (such as AIIMS, INIs etc.) in each state/UT. The CoEs will have well-equipped PICUs providing Tele-ICU service, mentoring and technical hand-holding to the proposed CPCUs. The objective is to establish a state-level center-of-excellence PICU as a teleconsultation hub where multiple specialties for secondary and tertiary care are available. Each state/UT should have at least one CoE to provide hand-holding and capacity building in order to operationalize the CPCUs at district hospitals.[3],[4]
Space
Unit design
The PICU or CPCU should be a separate area dedicated to sick infants and children adjacent to the pediatric ward for quick transfer of children in the event of any sudden eventuality. The unit should preferably have a lift nearby to ensure easy transfer of sick patients from the emergency room, operation theatre, or other wards. It is also preferred that laboratory facilities must be in close vicinity. Besides the patient care area, the unit should have a scrub station, a staff changing area with locker facilities, at least one doctor's duty room, an intensivist's office, a storage facility for drugs, linens, stationary and other essential items, a medication preparation area, and a counselling room preferably within the main unit. A family waiting room just outside the unit and a receptionist's desk for general queries and visitation control are recommended for smooth functioning. The unit should be manned by security personnel and be preferably under electronic surveillance at all times.[6]
Unit set-up and layout
A PICU or CPCU with an average of 12 beds is desirable. Units with a bed capacity of less than 4 risk inefficiency, while those with more than 16, become too cumbersome to manage.[7] For every 4 patients admitted to a pediatric ward, one ICU bed should be available (4:1). CPCU with 4 ICU beds and 8 HDU beds within the same unit will be ideal at the district level with the possibility to convert to a 12 bedded PICU during pandemics and disasters. For PICUs at CoE, 12 ICU beds are desirable. Additional beds for oncological emergencies, trauma and postoperative care may be required. Each ICU bed should be equipped with one mechanical ventilator for possible utilization. Additional ventilators may be kept on standby in HDU for pandemics or disasters. Both central air conditioning and heating are preferred. Air exchange of at least 15/h preferably with high-efficiency particulate air filters is recommended. An uninterrupted power supply is essential with backup power sources like inverters and generators. Overhead warmers may be needed for small infants.
The layout of the room should be such that it allows actual visualization of all patients from a central station. This may be achieved by organizing the beds in a U-shaped layout around the central station [Figure 1]. The ideal size allocation for each PICU bed in an open area ranges between 100 and 150 sq. Ft. This allows enough space around each bed to perform procedures like intubation, central lines and chest tube placements and to maneuver portable X-ray, ultrasound and echocardiography machines. Adequate space will also ensure the neat placement of cables and wires arising from monitors, ventilators, and infusion pumps.[6],[8] In addition, 10% of beds should be isolation rooms/cubicles with sliding glass doors for taking care of patients with infectious diseases, burns of more than 10% of body surface area, and immunodeficiency. Isolation cubicles require a larger area (200–250 sq. ft) and facilities for negative pressure ventilation. | Figure 1: U shaped layout of CPCU. CPCU: Comprehensive pediatric care unit
Click here to view |
Beds should have removable headboards for easy access during airway management, maneuvrable head and foot end, and railings to prevent accidental falls. Privacy curtains around each bed should be cleaned every 3–4 days as they are potential sources for healthcare-associated infections.[9] Medical gas supplies and electrical circuits located near the head end, should ideally be two feet away. Two outlets, each of walled oxygen, air suction, and at least ten electrical outlets per bed are recommended. Crash carts, preferably two, located at two ends of the PICU, stocked with all emergency and essential drugs, and readily accessible portable monitor/defibrillator are essential.[10] Zones for sterile preparation of medicines and intravenous fluids and cabinets, including a refrigerator should be made available for storing medications and supplies.
A cabinet with drawers for storing patient-specific medicines with a side pouch for keeping radiology films, patient records and treatment charts and a broad, smooth, easy-to-clean, nonporous surface for keeping the monitoring chart should be placed at the foot end of each bed. This location helps the treating physician have a comprehensive review of patient vitals and address all acute concerns during every shift. For the nursing staff, access to medicines becomes organized and easy. Access to windows and natural lighting is desirable to prevent a sense of isolation for the patients and to save energy during the daytime. Bright-coloured walls and ceilings with child-friendly themes also help soothe a pediatric patient.
Staff
Manpower
In addition to faculty or consultant in charge of the PICU, medical, nursing, laboratory, and ancillary staff with defined responsibilities is required to make it a functional unit. A list of essential manpower and the scope of collaboration with other existing departments are given in [Table 1]. All doctors and nurses working in CPCUs should have onsite short-term or long-term training and exposure at CoE or similar PICU to understand the functioning and level of care provided in a PICU. Head nurse to supervise overall functioning, ensure regular crash cart drug checks, and immediate and ongoing replacement of drugs and consumables.
Stuff
General items
The unit should be equipped with at least two computers for online access to patient lab reports, discharge summary preparation and evidence-based literature search. A central monitor displaying continuous vital parameters and electrocardiogram recording is desirable although not essential. One cordless/mobile phone for contacting the PICU team on duty, and an additional PICU telephone helpline number make communication easy. An illuminated viewing box for X-rays is important. Covered, color-coded bins for disposal of contaminated waste, needles and sharp objects as per central pollution control guidelines is mandatory ideally one set for two beds.[11] Availability of clean scrubs at the entry point and a defined place for disposal of used scrubs are recommended.
Specific equipment
Some equipments are mandatory for the essential monitoring and care of a sick child in the ICU and HDU. Others depend on cost-benefit analysis, ease of use and skill of caregiver, patient demographics, troubleshooting requirements, maintenance requirements, and biomedical support available. One should refrain from purchase of expensive, high-end gadgets that may remain unused due to a lack of expertise or are difficult to maintain in the face of limited biomedical support at the district level. The equipment list for a district-level CPCU is provided in [Table 2]; this list should be modified, if needed, based on the availability of resources, and local needs. | Table 2: A suggestive list of equipment for a comprehensive pediatric care unit
Click here to view |
Drugs and consumables
The list of essential drugs and consumables is given in [Table 3]. For the sake of uniformity, ease of understanding and local applicability, the lists of items provided are for a prototype CPCU of 12 beds, working at full capacity with an average patient stay of 10 days. The actual scenario may differ, and wherever applicable, we advise reader discretion based on their local demography and admission statistics. Calculations are based on average infusion rates of enlisted drugs in ventilated or otherwise unstable patients assuming an average PICU stay of 10 days, with 5 days on a mechanical ventilator. This list will ensure a minimum quantity of drugs and consumables to start the service. The actual requirement of consumables may differ based on the patient profile and choice of drugs. Once service is established, the ongoing requirement should be based on 3–6 monthly consumption with the provision of 20%–30% additional buffer stock.
Unit functionality
Admission criteria
While it is encouraged for units to have their institutionalized admission criteria, the following can serve as a template for guiding the admission process for a newly established PICU before it has had time to come up with its own policies. Admission and discharge criteria vary substantially depending on the case mix, level of intervention provided, available resources, level of training of the staff, local demography, and discretion of the clinicians. Acutely sick children with life-threatening conditions should be admitted to an ICU bed in CPCU and smoothly transitioned to HDU beds once stabilized and consistent recovery is evident. Certain conditions which cannot be managed at CPCU, particularly those needing super speciality consult and/or extensive monitoring should be stabilized and referred to a higher medical college or CoE. While timely admission is essential for a sick child, one should exercise due justification before admitting each child to ensure the judicious use of precious resources.[12],[13],[14] Clinical discretion of the treating physician is advised in all cases. Common indications for PICU admission are listed in [Table 4].
Treatment protocols
To ensure uniformity in care and safety for patients there should be written protocols for specific conditions commonly seen in ICU. In the absence of unit-specific protocols and policies, commonly practised and acceptable protocols of INI or professional bodies in the field of paediatrics and paediatric intensive care may be followed with a common understanding of the treating teams.
Tele-consultation, knowledge exchange, referral and back referral between hub and spokes
Information exchange between the CoE (hub) equipped with a teleconsultation facility and dedicated experts and the spokes to guide and hand-hold is likely to significantly improve the capacity of the spokes. Customized tele-PICU kiosks can be created to serve the purpose. The hub will be tele-linked with the spokes to support clinical decision-making and to guide treatment plans of children admitted to paediatric units in real-time or on-demand [Figure 2]. If required, the complicated cases can also be referred to other medical colleges or to CoE by the specialists at CPCUs. Similarly, overcrowded medical colleges or CoE can back refer the stabilised patients to the CPCUs for further continuation of care, thus easing the burden on tertiary centres. This model would support offline, online, and interactive telemedicine creating a complete technological base for many services and modalities. A web-based access system for specialists from CoE or other centres may also be provided to address certain emergencies. Case-based interactive sessions among specialists of the hub and spoke units would ensure cross-learning and an appropriate treatment plan.[3] Boost-up onsite and online training sessions targeting specific skills will have an immediate and long-lasting impact on the quality of care delivered. | Figure 2: Hub and spoke model for teleconsultation between PICU at CoE and CPCUs at each district. PICU: Pediatric intensive care unit, CoE: Centre of excellence, CPCU: Comprehensive pediatric care unit
Click here to view |
Discharge criteria
Once the primary indication for admission is taken care of and the child has recovered without complications, discharge or transfer to step down unit should be planned. Timely transfer from ICU is equally important to reduce costs and secondary infections. It is important that each child is given a written PICU/CPCU transfer summary with a plan that can be followed during the further hospital stay or at home as the case may be.[13]
Visitation policy
Children have special needs as compared to adults and these need to be kept in mind while drafting visitation policy for each unit. Traditionally PICUs have followed restrictive visitation rules, allowing only brief parental visits, and disallowing visits of siblings and relatives. Unlike adults who can be left alone to be managed entirely by the nursing staff and doctors, infants and young children need the presence of their parents. Their heightened emotional need during sickness, the calming influence of a familiar voice and touch and the feeding needs of a breastfed infant are some of the factors that warrant parental presence in the PICU. Separation of children from their parents has been established as a source of significant psychological burden for the child as well as their family members.[15] Parents being the natural caregivers of a child, their presence decreases the child's anxiety, agitation, and incidence of accidental events like removal of oxygen masks, endotracheal tubes and/or intravenous cannulas. The reassuring presence of a parent also ensures that the child is able to rest, thereby decreasing metabolic demand, and promoting recovery. For a critically ill child, sedated and mechanically ventilated, parental visits are still necessary as it helps alleviate parental anxiety and stress. A recently published study has established that more flexible visiting arrangements reduce the heart rate and blood pressure of intensive care patients.[16] Open conversation between the treating team and parents is paramount to ensure continued parental cooperation. These visits also function as an opportunity for the parents to directly observe nursing care being given to their child which is an additional source of reassurance. However, there is a need to sensitize and brief the parent before such visits so that the sight of their child in a PICU bed with all tubes and monitors does not distress them. The COVID-19 pandemic had posed several unique challenges, one among them being the parental visiting policy. During the pandemic, parental visits in separate COVID PICUs were restricted for obvious reasons including the risk of infection to a visiting parent. Shortage of personal protection equipments and N95 masks were other compelling factors for adhering to restrictive visitation. During this time, telephone and video calls provided an effective alternative way of communication between the treating team and the parents of a sick child. The advantages of this model explored during the pandemic, can be easily extended to non-COVID PICUs as well.
Parent's counselling
The PICU setup should have a dedicated area for counseling the parents and caregivers. Counselling should be done by a reasonably senior member of the team who understands the disease process, parental concerns, and medicolegal issues. One should be empathetic while counselling parents of a sick child or a bereaved family member. A phone line may also be provided to parents of all the admitted children. Online platforms such as Google meet and zoom can be used for video counseling during designated counseling hours for specific situations; however, medico-legal implications may be a concern as this is an evolving field.
| Conclusion | | |
CPCUs in district hospitals as planned under ECRP-II are important to ensure timely stabilization and care of critically sick children. Linking these CPCUs with CoE PICUs using a hub and spoke model will facilitate skill training, empower district hospital doctors, and nurses and improve the quality of care delivered to sick children. Furthermore, it will ensure timely referral and back referral, a two-way process, creating a win-win situation for both hub and spoke units. This document provides a guidance note for establishing CPCUs relevant for capacity building in pediatric critical care in RLSs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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