NORMS.pptx

Norms, Policies, Protocols,
Practices, Standards &
Documentation for paediatric
care unit
14-11-2022 1

INTRODUCTION
• PICU stands for paediatric intensive care unit where children are taken when they require the
highest level of quality care. Most PICUs are in tertiary care hospitals, along with smaller PICUs in
community hospitals also exist.
• Intensive care is defined as “ a service for patients with the potentially recoverable disease who can
benefit from more detailed observation and treatment . It is a low volume, high-cost specialty that
enquires a highly trained multi-disciplinary team together with specialized tertiary expertise and
diagnostic equipment.
14-11-2022 2

Definition
• The PICU is the section of the hospital that provides sick children with the highest level of medical
care.
• The PICU also lets medical staff provide therapies that might not be available in other parts of the
hospital. These can include ventilators and medicines that are used only under close medical
supervision.
14-11-2022 3

 Respiratory failure
 Unstable airway
 Inability to oxygenate (O2 sat less than 90% on >50%
oxygen requirement)
 Inability to ventilate with rising PCO2 levels with
respiratory insufficiency
 Glasgow Coma Scale (GCS) score <8
 Status epilepticus
 Acute respiratory distress syndrome (ARDS)
 Sepsis , Shock , Trauma
 Congenital heart defects
 Cancer/chemotherapy
 Organ transplants
 Poisoning
14-11-2022 5

• The following is a description of specific
guidelines regarding:
(i) Unit design
(ii) Equipment
(iii) Organization and staffing
(iv) Ancillary support services
(v) Levels of PICU care and admission and
discharge criteria.
14-11-2022 6

1. Unit Design
• Should take into consideration future adaptability , expansion and must maximize the resource of space,
equipment, and personnel .
• The unit should be located near the lift with easy access to the emergency department, operation theatre,
laboratory, and radiology department.
• The doctor duty room / office should be close to PICU with an intercom facility.
• Other facilities nearby should include a staff area with locker cabinets, a family waiting area to provide for
at least one (preferably two) person per admitted patient with bathroom, shower and telephone facility, as
feasible.
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(a) Size of PICU
• Six to ten beds are desirable.
• For the total paediatric ward, beds up to 25 and a PICU of six to eight beds is ideal. Additional
beds may be required if specialized surgery such as heart surgery, neurosurgery, and trauma surgery
cases are routinely expected.
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( b ) Room layout and bed area
• Should allow actual visualization of all patients from the central station.
• The patient area in the open PICU should be 150 to 200 sq. ft. In a cubicle, the minimum area should be 200 to 250 square feet with at
least one wash basin for two beds.
• An isolation capability with an area of 250 square feet with a separate area at least 20 square feet for hand washing and separate
ventilation.
• The area around the bed should allow enough space for performing routine ICU procedures such as central lines, chest tube placement,
as well as for easy access for the portable X-ray machines .
• Easy access to the head end of the patient for emergency airway management is a must on all beds. Wall and ceilings should be
constructed of materials with high sound absorption capabilities. Wall oxygen outlets (two), air outlets (one), two suction outlets, and at
least ten electrical outlets per bed are recommended for various equipment. Adequate lighting, child-friendly wallpapering or paintings
with soothing colours and curtains are desirable.
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( c ) Power supply and temperature control
• Centrally air-conditioned and central heating for temperature control.
Overhead warmers should be available. Uninterrupted power supply
and backup power sources such as invertors and generators should be
there.
( d) Beds
• Ability to maneuver head end and foot end , availability of two or
more air/water mattresses to prevent bedsores. All beds must have a
railing .
• Each bed should have an emergency alarm button . A cart at the
bedside is important to hold personal belongings and required patient
items.
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( e ) Crash Cart
• A crash cart with emergency drugs and a portable monitor/defibrillator should be readily accessible. This area
should be monitored by security personnel.
( f) Central station
• A central station should provide visibility to all patient areas. Have capacity for all necessary staff functions.
Patient records should be easily available.
• Adequate space for computers, printers and a central monitor is essential. Ample space for doctors to write on
patient files and space for unit secretarial staff is essential. At least two telephone lines should be available. If
possible, a telephone line dedicated to incoming calls only to facilitate critical care trans-port requests is
desirable.
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( g) X-ray viewing area
• A distinctive area in PICU should be chosen for viewing and storage of patient X-rays. An illuminated
viewing box should allow the viewing of several films.
( h) Storage
• Storage for vital supplies should be located within or closely adjoining to PICU. A refrigerator is essential .
• An area must be provided for storage of large patient care equipment items not in active use. An area must be
provided for stretchers and wheel chairs.
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( i) Clean and dirty utility room
( j) Waste disposal
• Mechanism of disposal of contaminated waste (segregation of garbage and contaminated medical waste) and
adequate disposal of needles and sharp objects needs to be as per standard applicable pollution control
guidelines.
( k) Conference room
• A room for intensivist and staff for education, discussion of difficult cases and other necessary meetings
related to quality improvement is desirable. This room should have a small library facility with ready access
to important intensive care books, journals and policy manuals.
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( l ) Stat laboratory
• A mini laboratory with arterial blood gas, electrolyte, blood sugar, urea, creatinine, prothrombin time, partial
thromboplastin time, complete blood count and urine examination with gram stain should be considered
adjacent to the PICU.
• Twenty-four-hour availability of on site or in hospital arterial blood gas is essential.
• As an alternative to stat laboratory adjacent to PICU, a central main laboratory facility with a turnaround time
(reporting time) of less than one hour for stat laboratory test results is acceptable.
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2. Equipments
The selection of equipment should be based on following criteria:
Cost benefit analysis, accuracy and adaptability for paediatric population, ease of use for care givers, proven use
on paediatric patients, maintenance requirements and biomedical support of the company and the hospital.
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3. Organization and staffing
• Medical director/Intensivist incharge ( 5 ) in charge should be a paediatrician trained and experienced in
critical care of children with following responsibilities:
(a) Establishing policies and protocols with the help of a group of experts including but not limited to Paediatric
consultants and subspecialists, nursing director, administration, laboratory and blood bank representatives;
(b) Smooth functioning of PICU with implementation of policies and protocols including admission and
discharge criteria;
(c) Quality assurance and improvement .
14-11-2022 22

(d) Advise administration regarding equipment needs;
(e) Establishing teaching and training system of medical, nursing and ancillary staff;
( f ) Maintaining PICU statistics for mortality and morbidity;
(g) Being member of infection control committee.
14-11-2022 23

( b) Staffing requirements
MEDICAL STAFF The medical staff should be round the clock post graduate level paediatrician
in PICU with good airway and paediatric advanced life support skills and
active PALS certification.
NURSING STAFF  A ventilated patient needs one paediatric/ICU trained nurse by the bed
side.
 A very unstable patient may require two nurses .
 Other unventilated/relatively stable patients may require only one nurse
per 2-3 patients.
14-11-2022 24

4.Ancillary Staff
• Physiotherapists, dieticians and respiratory technicians .
• In addition, technicians, radiographers, and biomedical engineers should be available on a 24 hours (in hospital)
basis for emergencies/problems that require immediate attention such as power failure, central gas supply
problems, malfunctioning equipments, or need for urgent X-ray .
• Clerical staff is essential to carry out communication as well as paper work necessary for smooth functioning of
the unit. It is also essential to have cleaning staff that is efficient .
• Presence of social worker is desirable to help support families emotionally as well as financially in stressful
circumstances.
14-11-2022 25

5. Levels of PICU care and admission and discharge criteria
14-11-2022 26
Level 3 Care
(tertiary level
PICU)
Two levels of PICU care are identified, level 3 and level 2.
Level 3 (tertiary) PICU can be organized with level 2 (step down/high dependency) service in nearby but separate
area.
 Defined admission, discharge policies ;
 4-6 ventilator beds ;
 More than 200 ventilated patients per annum ;
 Paediatric intensivist heading the unit ;
 One paediatrician with post graduate training and experience in critical care present in PICU at
all times ;
 Minimum one to one nursing on ventilated patients ;
 24-hour access to blood bank, pharmacy, pathology, operating theatre, and imaging services ;
 Quality review

14-11-2022 27
Admission criteria to
level 3 care PICU
The usual admission criteria to level 3 care are:
(i)All patients requiring mechanical ventilation;
(ii) Respiratory failure
(ii) All paediatric patients after successful resuscitation
(iv) Comatose patients (v) Shock/hemodynamic instability
(vi) Cardiac arrhythmias (vii) Hypertensive Emergencies
(viii) Severe acid base disorders (ix) Severe electrolyte abnormalities
(x) Acute renal failure (xi) Post operative patients
(xii) Patients requiring ECMO , nitric oxide therapy
(xiii) Malignant hyperpyrexia
(xiv) Acute hepatic failure , post transplant patients

14-11-2022 28
Admission criteria
to level 2 care (step
down/High
dependency PICU )
The usual admission criteria to level 2 care are
• All ward patients requiring close monitoring due to potentially unstable conditions
• Croup (laryngotracheobronchitis) requiring oxygen
• Asthma requiring hourly nebulization/getting tired with increasing oxygen
requirement/mental status change
• All patients requiring more than 50% oxygen to maintain saturations
• Closed head injury/skull fracture
• Diabetes ketoacidosis with pH <7.2
• Abdominal trauma with suspected renal/splenic/hepatic injury
• Severe dehydration with mental status change
• Post operative patients after major surgery with significant post operative pain/blood
loss/stress
• Patients recovering from critical illness (level 3 care), but requiring close monitoring.

• Quaternary Facility/Specialized PICU Level of Care
• A quaternary PICU facility is defined as one that is commonly found in university or children’s hospitals that
provide regional care and serve large populations .The center would provide comprehensive care to all complex
patients, including but not limited to those with significant cardiovascular disease, end-stage pulmonary disease,
complex neurologic/neurosurgical issues, transplantation services (both bone marrow transplant and solid organ),
ECMO (extra corporeal membrane oxygenation), multisystem trauma, and burns greater than 10% total body
surface area. A specialized PICU provides diagnosis-specific care for select patient populations. Examples of this
might include a cardiac ICU or a burn unit that provide pediatric critical care.
• These ICUs have specialized equipment and supplies as well as medical, nursing, and other members of the
patient care team with specific skills dedicated to a certain discipline. Such units are few in number but slowly
coming up in various parts of our country. Currently our guidelines do not distinguish quaternary level from
tertiary care level 3 units.
14-11-2022 29

PEDIATRIC CRITICAL CARE
• It is a specialised facility within a children’s hospital charged with
the care of infants and children, by a specialist team of intensivists,
critical care nursing and allied health staff with specialty training in
PCCM. It provides an increased level of detailed clinical
observation, invasive monitoring, focused interventions and technical
support to facilitate the care of critically .
• A PCCU will care for patients that are typically aged between birth
and their 16th birthday, diagnosed with life-threatening potentially
recoverable conditions; postoperative patients who may benefit from
close nursing or technical support.
14-11-2022 36

• National levels of critical care have been accepted and agreed – from the 2011 National Standards for Adult
Critical Care Services.
• In 2013, National Standards for Paediatric Critical Care were developed by the Paediatric Critical Care Group
(PCCG) and endorsed by JFICMI and the Intensive Care Society of Ireland (ICSI), and later updated in 2018.
• The National Standards for Paediatric Critical Care Services 2018 define minimum requirements for an ICU in
terms of resourcing, staffing, delivery and governance requirements.
• The national standards also define minimal facility requirements for critical care delivery.
14-11-2022 38

14-11-2022 39
• Level 0: Ward-based care .
• Level 1: High dependency care requiring a nurse-to-patient ratio of 0.5:1 . Close monitoring and observation
are required but not acute mechanical ventilation.
• Patients who require basic respiratory/circulatory/ neurological or renal support whose needs cannot be met on
the acute ward and require the input of the critical care team, or in the case of a regional High Dependency Unit
(RHDU), the agreed paediatric cover according to the standards.
Level 1: HDU: care in addition to providing enhanced observation and basic system supports, Level 1 RHDUs, due
to the availability of subspecialty expertise, may continue to care for those requiring more complex care, such as a
continuation of long-term ventilation via tracheostomy or non-invasively.

14-11-2022 40
Level 2: Critical care requiring a nurse-to-patient ratio of 1:1 A child requiring continuous nursing supervision who is
receiving advanced respiratory support (complex non-invasive ventilation or invasive ventilation).
Level 2 also pertains to the unstable non-intubated child, e.g., the haemodynamically unstable patient requiring
invasive cardiovascular monitoring, frequent fluid challenges and vasoactive drug infusions.
Level 3: Critical care requiring a nurse-to-patient ratio of 1:1 The critically ill child with two or more organ failures,
requiring intensive supervision, who needs additional complex therapeutic procedures.
For example, patients requiring respiratory support, patients with multiple organ failure requiring vasoactive and
inotropic medications, postoperative patients requiring ventilation and vasoactive medications .
Level 3S: Critical care requiring a nurse-to-patient ratio of 2:1 The critically ill child requiring the most intensive
therapeutic interventions, e.g., paediatric cardiac critical care, including ECLS, paediatric renal replacement therapy
(RRT) and neurosurgical critical care. These criteria may change with advances in technology.

DOCUMENTATION
Written evidence of the interactions between and among health professionals, patients and among health professionals,
patients and their families; the administration of procedures, treatments and diagnostic tests; the patient’s response to them and
education of the family support unit.
14-11-2022 41

DEFENSIVE DOCUMENTATION
To document the care given to the patient giving a clear and complete picture of the patient. Documents act as a communication
from one professional to another. A well documented medical record can be their greatest legal asset . The chart is a very
persuasive witness because it is the description of the facts at the time. There should be no unanswered questions in the patient’s
record . Documentation reflects : character, competency and the care delivered by the nurse.
 Avoid using empty, meaningless charting phrases such as, “physician notified of patient’s condition”.
 When communicating with a charge nurse or another nurse recognized as a resource documentation of
discussion seen as consultation and should be documented.
 Don’t squeeze information into the chart.
14-11-2022 42

 Don’t write between the lines.
 If there is an error ,draw a single line through it, date it ,initial it.
 In a courtroom the medical record will represent the nurse ,rather than the nurse’s bedside manner or caring
attitude.
 Ensures that quality of care provided is in accordance with professional nursing practice standards.
 Can lead to the state licensing board suspending or revoking the nurse’s licensure.
 Nurses ,therefore have little or no recollection of the events surrounding the case and must rely on their
documentation for what occurred.
 The general duty is to “record pertinent information including the response to interventions”.
 Courts have held that poor documentation creates presumption of poor care.
14-11-2022 43

INTENSIVE DOCUMENTATION REQUIRED
 Sudden decline in patient’s condition.
 Patient injuries/medication errors.
 Equipment failure/incorrect use.
 Failure of provider to respond.
 Unresolved disagreements in patient care between providers.
 Frequency and completeness – must follow the established rules of documentation , rules come from federal
regulations ,state statutes ,accreditation boards ,policies and procedures of the hospital and the standards set
by professional organizations.
 The chart must truly reflect that the standard of care for patient was met.
14-11-2022 44

CONCLUSION
• PICU stands for paediatric intensive care unit and is where children are taken when they require the
highest level of quality paediatric care. The PICU also lets medical staff provide therapies that might not
be available in other parts of the hospital. These can include ventilators and medicines that are used only
under close medical supervision. Description of specific guidelines regarding unit design, equipment ,
organization and staffing , ancillary support services and levels of PICU care and admission and discharge
criteria.
14-11-2022 46

REFERENCES
• Zeecheng Janine. What is the paediatric intensive care unit? An introduction. INDIANA UNIVERSITY
School of Medicine 27,2018. https://medicine.iu.edu/blogs/pediatrics/what-is-the-pediatric-intensive-care-
unit-an-introduction
• Sivabarathy P.Norms ,policies and protocols of paediatric care unit.SCRIBD.Jan 28, 2021.
https://www.scribd.com/presentation/492421645/3-Norms-policies-and-protocols-of-pediatric-care
• Paediatric intensive care unit. WIKIPEDIA the free encyclopaedia.
https://en.wikipedia.org/wiki/Pediatric_intensive_care_unit#2019_AAP_Guidance_and_Recommendations
14-11-2022 47

• AV Lalitha,Fassl Bernhard etal.pediatric intensive care unit admissions from the emergency departments in India-
the 2018 academic college of emergency expert’s consensus recommendations. Jan 30,2019.Journal of
emergency and trauma care. Vol 4 no.1:2.iMedPub Journals. https://www.imedpub.com/articles/pediatric-
intensive-care-unit-admissions-from-the-emergency-departments-in-india--the-2018-academic-college-of-
emergency-experts-c.pdf
• Model of care for paediatric critical care. National clinical programme for critical care & national clinical
programme for paediatrics. https://www.hse.ie/eng/about/who/cspd/ncps/critical-care/moc/model-of-care-for-
paediatric-critical-care.pdf
• Adelsperger Donna.Documentation.Slideshare. https://www.slideshare.net/cslonern/documentation-4617068
14-11-2022 48

• Bhalala Utpal S , Khilnani Praveen. Pediatric critical care medicine training in India : Past , Present and
Future.Frontiers in Pediatrics . 2018 Feb 26 [ cited 2022 June 19].MINI Review . Volume 6 .Article 34.
file:///C:/Users/Lenovo/Downloads/Pediatric_Critical_Care_Medicine_Training_in_India.pdf
• Torres Adalberto. When your child’s in the pediatricintensive care unit.KidsHealth.Nemours children’s health.
https://kidshealth.org/en/parents/picu.html
• Khilani Praveen. Indian Society of Critical Care Medicine (Paediatric Section) and Indian Academy of Paediatrics
(Intensive Care Chapter).Consensus Guidelines for Paediatric Intensive Care Units in India. Indian Pediatrics.Indian
Paediatrics2002;39;43-50.https://indianpediatrics.net/jan2002/jan-43-
50.htm#:~:text=Room%20layout%20should%20allow%20actual,wash%20basin%20for%20two%20beds
• Kaur Sandy. Pediatrics intensive care unit. SlideShare. 2013 Nov,20[cited 2022 June 19].
https://www.slideshare.net/sandykaur1829/pediatrics-intensive-care-
unit#:~:text=1(b)%20Room%20Layout%20and,wash%20basin%20for%20two%20beds.
14-11-2022 49

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