|Year : 2019 | Volume
| Issue : 2 | Page : 155-162
|2019 WACEM - Academic college of emergency experts consensus recommendations on admission criteria to pediatric intensive care unit from the emergency departments in India
AV Lalitha1, Bernhard Fassl2, Ramon E Gist3, Binita R Shah3, Nitin Chawla4, Ajay Singh5, Arun Baranawal6, Shivakumar Shamarao7, Raghavendra Vanaki8, Prashant Mahajan9, Reena Patel2, Vivek Chauhan10, Prerna Batra11, Abhijeet Saha12, Sagar Galwankar13, Santosh Soans14
1 Department of Pediatrics, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
2 Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
3 Department of Pediatrics, SUNY Downstate Medical Center, Brooklyn, NY, USA
4 Pediatric Emergency, Kamineni Super Speciality Hospital, Hyderabad, Telangana, India
5 Department of Orthopedics, King George's Medical University, Lucknow, Uttar Pradesh, India
6 Department of Pediatrics, PGIMER, Chandigarh, India
7 Pediatric Intensive Care Unit, Manipal Hospital, Bengaluru, Karnataka, India
8 Department of Pediatrics, S.N. Medical College, Bagalkot, Karnataka, India
9 Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
10 Kangra University and Medical Center, Dharamsala, Himachal Pradesh, India
11 Department of Pediatrics, University College of Medical Sciences and Guru Tegh Bahadur Hospital, Delhi, India
12 Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
13 Department of Emergency Medicine, Sarasota Memorial Hospital, Florida State University, Sarasota, Florida, USA
14 Department of Pediatrics, AJ Institute of Medical Science, Mangalore, Karnataka, India
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|Date of Submission||27-Jan-2019|
|Date of Acceptance||03-Feb-2019|
|Date of Web Publication||30-May-2019|
| Abstract|| |
There is a global variation in policies that define clear indications for pediatric intensive care unit (PICU) admissions. In resource-limited countries where PICU service availability is limited, the admission criteria to PICU are urgently needed to optimize the utilization of available intensive care services and to maximize patient benefit. The objective of these consensus recommendations on PICU admission criteria is to provide a framework and reference for future policy development by professional societies and governments. Design: The consensus recommendations were developed by a multidisciplinary consensus task force comprised of international experts in pediatric critical care, emergency medicine, trauma, critical care, and health policy stakeholders during the 2016 annual INDUSEM WORLD CONGRESS in Bengaluru, India. Measurements and Main Results: A task force steering committee completed a global literature search about PICU admission criteria development, reviewed PICU admission guidelines published by a variety of professional organizations worldwide, and performed a literature review of relevant publications. The objectives of this task force is to provide a framework for validated approach to determine appropriateness of intensive care unit (ICU) admission in India (resource-limited setting) based on (a) prioritization modeling; (b) general clinical criteria; (c) clinical and objective parameters; and (d) other criteria. The expert consensus panel then discussed and ranked proposed criteria according to scientific evidence, the current standard of care, and expert opinion in the context of the Indian health system. The general subject was addressed in sections: admission criteria and benefits of different levels of care. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Conclusion: Although these are consensus recommendations, the subjects addressed encompass complex ethical and medicolegal aspects of patient care that affect daily clinical practice. The scarcity of high-quality evidence made it difficult to answer all the questions asked related to ICU admission. Despite these limitations, the members of the task force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission process. This publication is designed to assist in future development of health policies to ensure effective resource allocation, maximize healthcare benefits, and improve access to quality care for children.
Keywords: Admission criteria, consensus recommendations, pediatric intensive care, pediatric intensive care unit
|How to cite this article:|
Lalitha A V, Fassl B, Gist RE, Shah BR, Chawla N, Singh A, Baranawal A, Shamarao S, Vanaki R, Mahajan P, Patel R, Chauhan V, Batra P, Saha A, Galwankar S, Soans S. 2019 WACEM - Academic college of emergency experts consensus recommendations on admission criteria to pediatric intensive care unit from the emergency departments in India. J Emerg Trauma Shock 2019;12:155-62
|How to cite this URL:|
Lalitha A V, Fassl B, Gist RE, Shah BR, Chawla N, Singh A, Baranawal A, Shamarao S, Vanaki R, Mahajan P, Patel R, Chauhan V, Batra P, Saha A, Galwankar S, Soans S. 2019 WACEM - Academic college of emergency experts consensus recommendations on admission criteria to pediatric intensive care unit from the emergency departments in India. J Emerg Trauma Shock [serial online] 2019 [cited 2020 May 26];12:155-62. Available from: http://www.onlinejets.org/text.asp?2019/12/2/155/259196
| Introduction|| |
The pediatric intensive care unit (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., 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 have “reversible medical conditions with a reasonable prospect of substantial recovery.”, As with any treatment, the decision to admit a patient to the PICU should be based on potential benefit. 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., 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 on diagnosis. Similarly, severity of illness scores such as the Pediatric Risk of Mortality Score, Acute Physiology and Chronic Health Evaluation, and Simplified Acute Physiology Scoring are inadequate and not validated to predict which patients are likely to benefit from intensive care.,,, Various pediatric triage system has been evaluated and analyzed its association with the following surrogate clinical outcome measures of severity: hospitalization rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission, and length of hospitalization.,,,,
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. 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 systems require modifications targeted to young children and children with a comorbid conditions and sometimes misclassify a substantial number of children who require ICU admission.
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. Finally, local socioeconomic context and limitation of healthcare resources must be considered as 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 nonexistent at district hospitals in rural India, where 80% of the nation's population resides and overcrowding of PICUs in urban settings is common.,, Currently, there is a lack of universally accepted, peerreviewed recommendations for PICU admission criteria in resourcelimited settings. In many developing countries, national standards for pediatric critical care admission, practice, and quality of care measures has not yet 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. Finally, standardized PICU admission criteria may be adopted and integrated by clinical personnel, hospitals, and health administrators to create local, 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. 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. Standardization of PICU admission criteria has been accomplished in developed countries through reviewed publications by professional societies, but it is 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, 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. 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. The task force core group performed a PubMed literature search using Mesh Terms (intensive care) (pediatrics) (admission criteria) and identified relevant peerreviewed publications. In addition, the group reviewed previously published statements from professional societies in India and other low- and middle-income countries and compiled relevant publications in a literature resource list consisting of 400+ publications. 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.,,,,,, 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.,
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.,
Levels of recommendation: During the consensus process, meeting members applied following previously validated recommendation rating system.
- 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 the location of pediatric intensive care provision – High Dependency Units (HDUs) [Table 1].
- Recommendations on prioritization criteria for patients considered for PICU admission [Table 2].
Assigning appropriateness for PICU admission based on a rating system, which defines the patient populations who will benefit 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 by ISCCM and IAP. Early identification of clinical warning signs is important and requires health personnel who are trained and equipped to perform cardiorespiratory 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 a higher 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 are as follows:
- All respiratory or cardiac arrest
- Unstable airway
- Inability to oxygenate (O2 Sat <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 are shown in [Table 3].
|Table 3: Clinical diagnosis model-based pediatric intensive care unit admission criteria|
Click here to view
This model uses specific well-defined clinical conditions which warrant PICU admissions.
Numeric labels 1–3 designate level of recommendations (as discussed earlier).
Asterisk indicates that such conditions can potentially be managed in an HDU.
| Administrative Recommendations to Facilitate Appropriate Pediatric Intensive Care Unit Admission|| |
This document is designed to serve as a resource for hospitals and policymakers in resource-limited settings to determine the appropriateness of PICU admissions for optimal utilization of available scarce resources within their own care environment.
Local stakeholders must take steps to achieve the 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 are 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 nonthreatening reviews of protocol deviations, adverse patient events, and hospitalization outcomes to further refine applicability of these recommendations. By establishing a culture that focuses on system issues and reeducation 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 1980s 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 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 overrepresented 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, 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 medicolegal 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.
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. It is intended to assist key stakeholders in the development of hospital operational standards, to define appropriateness of PICU admission. These consensus guidelines 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 medicolegal document but as a resource for clinicians, hospitals, and system administrators to standardize care processes and reduce variation in care. Recommendations are provided based on prioritization modeling as well as on clinical conditions.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bone RC, McElwee NE, Eubanks DH, Gluck EH. Analysis of indications for intensive care unit admission. Clinical efficacy assessment project: American College of Physicians. Chest 1993;104:1806-11.
NIH consensus conference-critical care medicine. JAMA 1983;2506:798-804.
Mulley AG. The allocation of resources for medical intensive care. In: President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research: Securing Access to Health Care. Vol. 3. Washington, DC: Government Printing Office; 1983. p. 285-311.
Kollef MH, Schuster DP. Predicting intensive care unit outcome with scoring systems. Underlying concepts and principles. Crit Care Clin 1994;10:1-8.
Nasraway SA, Cohen IL, Dennis RC, Howenstein MA, Nikas DK, Warren J, et al.
Recommendations on admission and discharge for adult intermediate care units. Crit Care Med 1998;26:607-10.
Charlson ME, Sax FL. The therapeutic efficacy of critical care units from two perspectives: A traditional cohort approach vs. a new case-control methodology. J Chronic Dis 1987;40:31-9.
Ron A, Aronne LJ, Kalb PE, Santini D, Charlson ME. The therapeutic efficacy of critical care units. Identifying subgroups of patients who benefit. Arch Intern Med 1989;149:338-41.
Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med 1988;16:1110-6.
Smith G, Nielsen M. ABC of intensive care. Criteria for admission. BMJ 1999;318:1544-7.
Swenson MD. Scarcity in the intensive care unit: Principles of justice for rationing ICU beds. Am J Med 1992;92:551-5.
Wagner DP, Knaus WA, Harrell FE, Zimmerman JE, Watts C. Daily prognostic estimates for critically ill adults in intensive care units: Results from a prospective, multicenter, inception cohort analysis. Crit Care Med 1994;22:1359-72.
Gravel J, Fitzpatrick E, Gouin S, Millar K, Curtis S, Joubert G, et al.
Performance of the Canadian triage and acuity scale for children: A multicenter database study. Ann Emerg Med 2013;61:27-32000.
Gravel J, Manzano S, Arsenault M. Validity of the Canadian paediatric triage and acuity scale in a tertiary care hospital. CJEM 2009;11:23-8.
Roukema J, Steyerberg EW, van Meurs A, Ruige M, van der Lei J, Moll HA, et al.
Validity of the Manchester triage system in paediatric emergency care. Emerg Med J 2006;23:906-10.
Green NA, Durani Y, Brecher D, DePiero A, Loiselle J, Attia M, et al.
Emergency severity index version 4: A valid and reliable tool in pediatric emergency department triage. Pediatr Emerg Care 2012;28:753-7.
Ganapathy S, Yeo JG, Thia XH, Hei GM, Tham LP. The Singapore paediatric triage scale validation study. Singapore Med J 2018;59:205-9.
Horeczko T, Enriquez B, McGrath NE, Gausche-Hill M, Lewis RJ. The pediatric assessment triangle: Accuracy of its application by nurses in the triage of children. J Emerg Nurs 2013;39:182-9.
Vidyasagar D, Singh M, Bhakoo ON, Paul VK, Narang A, Bhutani V, et al.
Evolution of neonatal and pediatric critical care in India. Crit Care Clin 1997;13:331-46.
Yeolekar ME, Mehta S. ICU care in India – Status and challenges. Editorial. J Assoc Phys India 2008;56:221-2.
Udwadia F, Guntupallu K. Critical care in India. Crit Care Clin 1997;13:317.
Prayag S. ICUs worldwide: Critical care in India. Crit Care 2002;6:479-80.
|22.|AAP Policy Statement: American Academy of Pediatrics – Committee on Hospital Care and Section on Critical Care. Guidelines for Developing Admission and Discharge Policies for the Pediatric. Pediatrics 1999;103:840-2.
Recommendations for Intensive Care Unit Admission, Discharge and Triage. Taskforce of the American college of critical care medicine, society of critical care medicine. Crit Care Med 1999;27:633-8.
Clinical Practice Recommendations for Admission to the Pediatric Intensive Care Unit. MOH Paediatrics Clinical Recommendations. CWMH & Lautoka Hospital; 2010.
Nates JL, Nunnally M, Kleinpell R, Blosser S, Goldner J, Birriel B, et al.
ICU admission, discharge, and triage guidelines: A framework to enhance clinical operations, development of institutional policies, and further research. Crit Care Med 2016;44:1553-602.
Rosenberg D, Moss M; American College of Critical Care Medicine of the Society of Critical Care Medicine. Recommendations and levels of care for pediatric intensive care units. Crit Care Med 2004;32:2117-27.
Khilnani P; Indian Society of Critical Care Medicine (Pediatric Section), Indian Academy of Pediatrics (Intensive care Chapter). Consensus guidelines for pediatric intensive care units in India. Indian Pediatr 2002;39:43-50.
Govil YC. Pediatric intensive care in India: Time for introspection and intensification. Indian Pediatr 2006;43:675-8.
Dr. A V Lalitha
St. Johns Medical College and Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]