THE PEDIATRIC INTENSIVE CARE UNIT (PICU): A HIGHLY SPECIALIZED AREA OF CARE FOR INFANTS/CHILDREN/ADOLESCENTS
A Pediatric Intensive Care Unit, usually abbreviated as “PICU,” is an area within a hospital specializing in the care of critically ill infants and children, generally from two months old through 17 years of age. A PICU differs from a NICU (Neonatal Intensive Care Unit) in that NICUs provide care for newborn babies, typically from birth until the baby leaves the hospital for the first time or is moved to a PICU.
The doctors, nurses, and other personnel that work on a PICU should be specially trained to handle the unique challenges for this special population.
Level I versus Level II PICU
Hospitals often advertise that they have a Level I or a Level II PICU. The original guidelines for Level I and Level II PICUs were initially presented in 1993 by the American Academy of Pediatrics and the Society of Critical Care Medicine. They were then updated in 2004. The basic difference is that Level I PICUs provide care to the most severely ill patients. Your local hospital will have either a Level I or a Level II PICU.
Some pediatric patients with an illness of moderate severity can be managed in a Level II PICU. At times, Level II PICUs are utilized to stabilize critically ill children before they can be transferred to a higher level of care at a facility with a Level I PICU. The guidelines for Level I PICUs require that almost all services be available 24 hours per day with specifically trained pediatric personnel across all aspects of care.
The Level I PICU must be capable of providing definitive care for a wide range of complex, progressive, rapidly changing, medical, surgical, and traumatic disorders, often requiring a multidisciplinary approach. Such units are usually found in major medical centers or within designated children’s hospitals. Level II units exist primarily in areas distant from a Level I PICU that do not have the population base to support a Level I unit; these units will generally care for fewer severely ill patients. Patients in Level II units will have less complex and more stable disorders, whose course is more predictable. Because of the difference in patient population, both the physicians and their specialized services will differ between levels. Level I PICUs will have a complete complement of subspecialists, including pediatric intensivists, whereas Level II PICUs will not require the full spectrum of subspecialists or their services. Each Level II unit must have a well-established communications system with a Level I unit for timely referral of patients who need care unavailable at the Level II PICU.
What Makes the PICU Different from the Rest of the Hospital?
The care of the pediatric patient differs significantly from the adult patient. Equipment is smaller; dosage of medicine is lower; advanced life support techniques are specific to infants and children. Healthcare personnel not specifically trained in the care of the critically ill pediatric patient could compromise the care of the patients in their care.
Monitoring of patients in the PICU requires nurses who are specially trained in the care of critically ill infants/children and who also pay close attention to detail. Nurses in the PICU provide care for children, but they also must take into consideration the needs and concerns of parents. If a parent has a concern regarding something going on with their child, the nurse should not ignore their concern but should assess the situation and address the concern. Parents worry. Sometimes those worries are justified, and sometimes they aren’t. A good PICU nurse can tell the difference and can help parents understand their child’s illness and the beneficial role the parents can play in their child’s PICU care. Afterall, parents often notice subtle, but significant, changes in their child’s condition before the assigned nurse recognizes those changes.
PICU Equipment and Services
Caring for infants and children requires special equipment. Hospitals with a Level I PICU should have:
- An emergency department with at least two areas having the capacity and equipment to resuscitate any pediatric patient. The emergency department needs to be staffed, in-house, 24 hours a day with physicians trained in pediatric emergency medicine.
- An operating room available within 30 minutes, 24 hours per day, and a second room available within 45 minutes.
- Capabilities in the operating room must include cardiopulmonary bypass (use of a machine to temporarily take over the function of the heart and lungs during surgery), pediatric bronchoscopy (fiber-optic cable passed into the windpipe in order to visualize parts of the lung), endoscopy (a tube introduced into the body to visualize internal organs), and radiography (x-ray and others – see below).
- Pediatric radiology services must include portable radiography, fluoroscopy (equipment that allows real-time visualization on a monitor of x-rays ray images), computerized tomography scanning (CT scan), and ultrasonography (use of ultrasound pulses to delineate objects or areas of different densities in the body), nuclear scanning angiography (imaging using a radiopharmaceutical injected into the patient, which shows the functionality of blood vessels), and magnetic resonance imaging (MRI).
- Clinical laboratories capable of a one-hour turnaround time for most labs and a 15-minute turnaround time for blood gases.
- Ability to provide diagnostic cardiac and neurologic studies with technicians with special training in pediatrics.
- Electrocardiograms, 2-dimensional echocardiograms with color Doppler, and electroencephalograms (EEG, measuring brain function) should be available 24 hours per day.
- A catheterization laboratory or angiography (examination by x-ray of blood or lymph vessels carried out after introduction of a radiopaque substance) suite equipped to perform studies in pediatric patients.
- Doppler ultrasonography devices and evoked potential monitoring equipment (equipment that records responses of the nervous system) are desirable but not mandatory.
And the PICU itself should have:
- Bedside monitors with the capability for continuously monitoring heart rate and rhythm, respiratory rate, temperature, invasive and non-invasive blood pressure parameters, oxygen saturation, and end-tidal CO2 (the level of carbon dioxide exhaled from the body). Monitors must have high and low alarms for heart rate, respiratory rate, and all pressures. The alarms must be audible and visible. All monitors must be maintained and tested routinely.
- Hospital pharmacy capable of dispensing all necessary medications for pediatric patients of all types and ages 24 hours per day. A satellite pharmacy close to the unit is desirable. A qualified pediatric clinical pharmacist is highly desirable for hospitals with Level I PICUs and optional for hospitals with Level II PICUs.
PICUs are very specialized medical units that require very specialized skills by the caregivers and availability of myriad services 24 hours a day. Because patients in a PICU are typically very sick and must be watched very, very closely, mistakes – even small ones – can cause major problems. And because much of the care delivered in a PICU is sophisticated, providers must be at the top of their game to ensure that patients remain safe and safely cared for at all times.
PICU and Medical Errors
Unfortunately, errors in the PICU happen every day. Examples include misdiagnosis, medications errors (medication dosing is much more individualized in the pediatric population), failure to notify a physician of a change in condition of the patient, failure of the hospital to have the necessary services available in a timely manner, failure to transport to a higher level of care (Level II PICU to Level I PICU), poor communication between Level II and Level I PICUs, and use of healthcare personnel not adequately trained to care for this patient population.
The Eisen Law Firm is experienced in cases involving mistakes made in a PICU. One example is the recently-resolved case of C.J., a 2 month old infant, who lost several fingers and his thumb on his right hand after a pediatric intensivist placed an unnecessary arterial line (a line that monitors blood pressure continuously) in his axillary artery (near the armpit). Placement of this line caused a blood clot to form that then traveled to his right hand and fingers. Nursing personnel ignored his mother’s concerns regarding his fingers changing colors. By the time nursing personnel realized that C.J.’s mother was correct, it was too late to restore adequate blood flow to his right hand and save his fingers and thumb. Sadly, medical errors do happen, and when they do, you need an experience medical malpractice team fighting on your behalf. If you have an infant or child who has suffered injury or death due to any type of negligence while a patient in a PICU (or a NICU), contact Cleveland’s experienced medical malpractice attorneys at The Eisen Law Firm for a free consultation today at 216-687-0900 or contact us online.