University Hospital of Wales Paediatric Intensive Care Unit Guideline Printed on Wed 23-jul-08
Pandemic Flu Staged Response (ENHANCE document)
Critical Care Contingency Planning
Care of the Critically Ill Child in Abnormal Circumstances
- The centralisation of paediatric intensive care (PIC) has resulted in many District General Hospitals (DGHs) no longer providing ventilatory support for sick children, or this being restricted to a limited period of time during stabilisation prior to transfer to a paediatric intensive care unit (PICU).
- The extent to which DGHs have withdrawn from PIC provision is variable throughout the UK, depending on issues such as the availability of local tertiary beds, support of PICUs for maintaining PIC facilities in referring hospitals, and the willingness of general ICUs to preserve critical care support for sick children.
- As a result of increasingly expressed concerns over de-skilling in care of critically ill children, The Royal College of Anaesthetists has issued recommendations on the maintenance of core resuscitation and stabilisation skills, and the Department of Health has also produced a draft web-based document on the Care of the Acutely Ill Child in the District General Hospital.
- It is against this background that the prospect of an influenza pandemic (or other major event which could produce a sudden significant increase in the number of children who require mechanical ventilation) has to be considered.
- It is recognised that existing PICU facilities are likely to be rapidly overwhelmed in such circumstances, and that even strategies to increase PICU capacity in tertiary centres will almost certainly prove inadequate to cope with the increase in demand (even with the cancellation of all elective paediatric surgical procedures).
- It is therefore predictable that DGH intensive care specialists and paediatricians will find themselves having to manage the care of acutely ill children, some of whom may require ventilatory support.
- Sustaining such a service at the same time as coping with the equally predictable increase in demand for adult intensive care beds will present a significant challenge. However, the ability to do so may prevent avoidable deaths in children, and providing ventilatory support for children with single organ system failure may also help preserve PICU bed availability for very small children and those with multiple organ failure.
- It is strongly recommended that any DGHs with Emergency Departments and paediatric inpatient facilities should give serious consideration to how they may be able to preserve or enhance their paediatric critical care facilities in order to cope with such an eventuality. As the range of existing paediatric facilities in DGHs is wide, it is not practicable to produce comprehensive guidance on how this can be achieved, but the purpose of this document is to outline some of the strategies that may be considered.
- Care of ventilated children in a general ICU
9.1 Although some general ICUs have adopted the term 'adult ICU' and no longer admit children (or would only do so under exceptional circumstances) many others have established agreements with regional PICUs that support reasonable periods of mechanical ventilatory support for children to avoid unnecessary transfers (e.g. febrile convulsions, post-ictal management) of otherwise straightforward cases).
9.2 Units which have maintained such expertise are likely to be able to manage children with respiratory failure who require mechanical ventilation, and should ideally formalise agreements with their local PICU on this basis.
9.3 The number of children, the age range, and complexity of the degree of organ dysfunction that they would be prepared to manage must be a matter for local discussion.
9.4 Other strategies for support and reassurance may be necessary (see below), which may include input from paediatricians, anaesthetists and neonatologists and experienced critical care / paediatric / neonatal nursing staff where appropriate / available.
- Upgrading paediatric HDU facilities
10.1 Some DGHs may have developed paediatric high dependency areas where sick children who require Level 2 care can be safely managed, and in some of these the use of CPAP and non-invasive ventilation may be routine.
10.2 It is recommended that consideration should be given to enhancing such facilities to allow invasive ventilatory support for affected children in abnormal circumstances, ideally in collaboration with local PICUs. Support from intensivists, anaesthetists, neonatologists and experienced critical care / paediatric / neonatal nurses may also be essential.
- Role of the Regional PICU
11.1 Although it is likely that regional PICU services will be under considerable pressure in attempting to care for a significantly increased number of patients, there may nevertheless be a necessity to establish methods of providing 'outreach' support for DGHs that have had to undertake Level 3 care for affected children.
11.2 The extent of this support is likely to vary from telephone interactions to a requirement for physical presence if there are problems or concerns about a child's condition.
11.3 Consideration should therefore be given to how such services might be sustained by the regional PICU service, and should include the provision of PIC nursing support / availability.
- Role of regional centre medical staff with paediatric expertise
12.1 In addition to having trained paediatric intensivists, many tertiary centres are also likely to have clinicians with paediatric expertise who may prove a valuable resource in the support of DGH clinicians undertaking Level 3 PIC; these might include paediatric / cardiac anaesthetists, paediatricians with PICU training, and neonatologists (anaesthetists are perhaps more likely to be available if / when elective surgical procedures are cancelled).
12.2 Although in the initial phases of a major event such individuals may be able to contribute more efficiently to expanding tertiary PICU services, there may be circumstances where their ability to travel to neighbouring DGHs to provide assistance and support may be very helpful.
- Role of DGH Staff with paediatric expertise
13.1 In DGHs with inpatient paediatric facilities there may be consultants from a number of specialities (anaesthetists, paediatricians, neonatologists, emergency medicine) who have experience and expertise in PIC and who may be able to provide assistance / support in the care of ventilated children.
13.2 Neonatologists and paediatricians who share responsibility for neonatal care may be particularly useful in providing support for the care of ventilated infants.
- CEPD
14.1 All DGH staff who have existing expertise or previous training in PIC should be encouraged to maintain/update these skills. This may be facilitated by secondments to regional PICUs, and/or paediatric anaesthesia sessions in specialist/regional centres.
14.2 Update training sessions on the stabilisation and care of critically ill children may also prove valuable as a means of maintaining confidence and developing teamwork responses.
- Telemedicine
15.1 Although currently not a major component of UK-based hospital practice, there is accumulating evidence from US adult critical care that remote supervision / advice using computer-based telemedicine techniques can improve the management and efficiency of intensive care patients in units that lack appropriate medical supervision.
15.2 Consideration should perhaps be given to developing such techniques in order to allow PICU specialists to provide real-time support and advice for the care of children who have to be ventilated in DGH settings.
