Paediatric Intensive Care Nursing

Michaela Dixon, Doreen Crawford

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118301876
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Paediatric Intensive Care Nursing

The needs of critically ill children are unique and highly specialised. Paediatric Intensive Care Nursing is an essential manual of care and an invaluable resource to all those involved in the care of critically ill children and young people. Covering all the key aspects of paediatric intensive care, it is a fully comprehensive textbook which provides an evidence-based and up-to-date guide for all nurses who work with critically ill children.

Paediatric Intensive Care Nursing is structured in four user-friendly sections:

• The first section looks at the general background of paediatric intensive care.
• Section two employs a systems approach, with each chapter focusing on a specific disease and following the same framework. This includes treating children with cardiac conditions, acute neurological dysfunction, muscular skeletal injuries and gastrointestinal and endocrine care.
• Section three looks at the essential care of managing pain relief, transportation needs and treating wounds.
• The final section explores the holistic aspects of nursing – nutrition and fluid management, infection control issues, safeguarding children, spirituality and bereavement.

Written by a team of experts in the field, Paediatric Intensive Care Nursing is indispensable reading for nurses and health care professionals working with critically ill children.

Section 1

INTRODUCTION TO PAEDIATRIC INTENSIVE CARE NURSING

Chapter 1

INTRODUCTION TO CHILDREN’S INTENSIVE CARE

Dave Clarke

Cardiff School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK

Introduction and Background

It is widely accepted that paediatric intensive care (PIC) is a service for children and young people with potentially recoverable diseases, who can benefit from more detailed observation and treatment than is generally available in the ward environment (DH 1997). While this describes the nature of the care on the unit, the paediatric intensive care unit (PICU) is much more complex, and many elements contribute to the intensive care environment. Children’s nurses and their medical colleagues are experienced and educated to a high standard in very specific and advanced care practices. The physical environment is dominated by advanced technology, which plays an ever-increasing role in monitoring, treating and supporting children and young people who are critically unwell. However, the core of the ethos of care in the PICU are the children, young people and their families, for whom this experience will be one of the most stressful events of their lives.

The criticality of the situation for many of the children and young people admitted to the PICU is immense, however the most recent audit of PIC services in the United Kingdom (UK) demonstrates that the large majority (>95%) survive beyond their admission to the PICU (PICANet 2010). In the period 2006–8 there were 47 125 PIC admissions to 28 NHS hospitals in the UK, with children under 1 year of age comprising 47% of all admissions, and an overall excess of boys (56%) over girls (44%). The majority of admissions (57%) were unplanned and 78% of children who are retrieved are done so by specialist PIC teams (PICANet 2009). It is clear that PIC makes a large contribution to the care of children and young people in the UK, offering specialist skills, care and knowledge, alongside ever-advancing treatment.

The organisation of PICU Care

PICUs, like paediatric high dependency units, historically have been organised in an ad hoc manner. They were often located in specialist children’s hospitals or supported specialist services, such as cardiology and neurosurgery. During the early 1980s the Paediatric Intensive Care Society and the British Paediatric Association started to raise concerns about the patchy organisation and lack of standards for children and young people requiring intensive care.

In 1993 a multidisciplinary working party published a report, based on a retrospective survey of 12 882 children identified as having received intensive care in 1991, which highlighted issues facing the provision of paediatric intensive care (British Paediatric Association 1993).Their findings indicated that 29% of children were cared for in children’s wards, 20% in adult intensive care units and only 51% in PICUs. Of the 2 627 children cared for in adult units, 23% were <1 year and almost 5% were <1 month old. In adult units fewer than 2% of nurses had a children’s nursing qualification. Only 36% of PICUs provided a transport service for retrieving critically ill children. The working party expressed particular concern about facilities where medical and nursing staff had not received specific training and where the staffing levels were too low for managing critically ill children, for example in children’s wards.

While the findings were shocking when compared to the high standard of care and organisation associated with the modern PICU service, the report was largely ignored until the death of a young person (NG) in 1995. NG died in a PICU as the result of a cerebral haemorrhage. Before reaching the unit he had been moved from the admitting hospital to another hospital for computed tomography (CT) scanning and only then to an intensive care unit (in another region) for management. After the publication of the resulting inquiry (Ashworth 1996), the Secretary of State commissioned a report on the development of paediatric intensive care services and the Department of Health (DH) set up a national coordinating group to develop a policy framework.

The evidence gathered and documentation recognised that the national PIC service was disorganised, having developed over a 20-year period in a makeshift manner. They recognised that the service was a low-volume but high-cost provision and identified that there were no national standards or evidence base. Ten of the 29 PICUs identified had three beds or fewer, placing in question their ability to offer services to the most critically ill children. Paediatric Intensive Care: A Framework for the Future (DH 1997) set out a strategy for developing and integrating the service for critically ill children within a geographical area. During the following three years lead centres for PICU care were identified, and within each region one, or at most two, lead centres were designated, to serve a population of at least 500 000 children. Lead centres had to be based in hospitals with a full range of tertiary paediatric services, run a 24-hour transport service for the region and have sufficient throughput to maintain staff expertise and act as educational and training centres. Lead centres were also responsible for the provision of retrieval training to referring hospitals and compiling audit and quality data for their regional service.

While this hub-and-spoke arrangement generally worked well, some areas (e.g. the London region, the Midlands and Scotland) had more than one large PICU within a geographical locality. The introduction in 2001 of Managed Clinical Networks (MCNs – partnerships of healthcare professionals and organisations involved in the commissioning, planning and provision of a health service in a specific geographical area) has furthered the development of paediatric intensive care services, offering more opportunities for joint working and service coordination, especially where duplicated services existed. MCNs were recommended for neonatal intensive care services in 2003 following a service review (DH 2003) and the National Service Framework for Children and Maternity Services (DH and DfES 2004) recommends MCNs for all children and young people’s services. Their aim is to provide quality of care by dismantling the barriers between primary, secondary, tertiary and social care. They require multidisciplinary management and ensure that all staff working with a particular patient adhere to the same protocols and policies (DH and DfES 2005). For paediatric intensive care services in particular, MCNs enable the development of core training, treatment pathways and standards. They include referring hospitals, local lead PICUs, Accident and Emergency Departments as members, with the aim of ensuring high quality and safe paediatric intensive care services. The largest MCN for PICU services is the Pan Thames Consortium, which includes nine core hospitals and two retrieval services (see www.picupt.nhs.uk for further information).

Differentiating Paediatric Intensive Care

Paediatric intensive care can be distinguished from other forms of care by the severity of illness the child or young person is experiencing, the standard level of care being that available on a ward, with high dependency care being an intermediate level, followed by intensive care. Within intensive care it is important to recognise the level of dependency a child or young person presents with, as this will have an impact on the nurse staffing levels required to ensure safe and appropriate care. The DH (1997) report identified one level of high dependency care, two main levels of intensive care, while alluding to a fourth level, which includes treatment with Extra Corporeal Membrane Oxygenation (ECMO). The Paediatric Intensive Care Society (2010) has developed the criteria further (Table 1.1).

Table 1.1 Differentiating paediatric intensive care

Level/recommended staffing ratio	Descriptor
Level 1 High dependency care requiring a nurse-to-patient ratio of 0.5:1	Close monitoring and observation required, but not acute mechanical ventilation. Examples include the recently extubated child who is stable and awaiting transfer to a general ward; the child undergoing close postoperative observation with ECG and pulse oximetry, receiving intravenous fluids or parenteral nutrition. Children requiring long-term chronic ventilation with tracheostomy are included in this category.
Level 2 Intensive care requiring a nurse-to-patient ratio of 1:1	The child requires continuous nursing supervision and is usually intubated and ventilated (including CPAP). Also included is the unstable, non-intubated child, for example, some cases with acute upper airway obstruction who may be receiving nebulised adrenaline. The recently extubated child. The dependency of a Level 1 patient increases to Level 2 if the child is nursed in a cubicle.
Level 3 Intensive care requiring a nurse-to-patient ratio of 1.5:1	The child requires intensive supervision at all times and needs additional complex therapeutic procedures and nursing, for example, unstable ventilated children on vasoactive drugs and inotropic support or with multiple organ failure. The dependency of a Level 2 patient increases to Level 3 if the child is nursed in a cubicle.
Level 4 Intensive care requiring a nurse-to-patient ratio of 2:1	Children requiring the most intensive interventions such as particularly unstable patients, Level 3 patients managed in a cubicle, those on ECMO or other extracorporeal support and children undergoing renal replacement therapy.

Commissioning Auditing and Costing

The DH utilises a non-clinical system to assess levels of care and dependency for audit and costing purposes. Health care Resource Groups (HRGs) have been used to cost care since 2007, based on seven levels:

• HRG1 – High Dependency (HD1)
• HRG2 – High Dependency Advanced (HD2)
• HRG3 – Intensive Care Basic (IC1)
• HRG4 – Intensive Care Basic Enhanced (IC2)
• HRG5 – Intensive Care Advanced (IC3)
• HRG6 – Intensive Care Advanced Enhanced (IC4)
• HRG7 – Intensive Care – ECMO/ECLS (IC5)

While this further division of dependency may be more sensitive, it is widely regarded as too cumbersome and complex for clinical use and takes no account of the individual and holistic care needs for the child’s parents or carers and sibling...

Table of contents

• Cover
• Title page
• Copyright page
• LIST OF CONTRIBUTORS
• ACKNOWLEDGEMENTS
• Section 1: INTRODUCTION TO PAEDIATRIC INTENSIVE CARE NURSING
• Section 2: SYSTEMS APPROACH
• Section 3: ESSENTIAL CARE
• Section 4: HOLISTIC CARE
• Index