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20

S E C T I O N I   Pediatirc Critical Care: The Discipline

TABLE
Key PICU Processes
2.3

Rounding Process

Transitions of Care

Medication reconciliation
Daily multidisciplinary rounds
(including medical and surgical
subspecialists)
Daily goals sheet

Operating room to ICU hand-offs

Daily shift huddles

Other hand-offs

Primary nursing assignments

Discharge planning

PICU leadership walk rounds

Bundles

Protocols

Central line insertion bundle

Clinical pathways
Standard care protocols (e.g.,
extubation readiness testing,
sedation/analgesia protocols)

VARI bundle

Condition-specific protocols
(e.g., status asthmaticus, sepsis,
diabetic ketoacidosis, traumatic
brain injury)

Urinary catheter care bundle
Pressure ulcer prevention bundle
Peripheral IV care bundle
IV, Intravenous; PICU, pediatric intensive care unit; VARI, ventilator-associated respiratory
infection.
Modified from Riley C, Poss WB, Wheeler DS. The evolving model of pediatric critical care
delivery in North America. Pediatr Clin North Am. 2013;60:545–562.

the combination of elements performed consistently and in
aggregate that drive improvement. The ABCDEF ICU liberation
bundle is a recent example of large-scale bundle use in adult
ICUs that, when used reliably, is linked to improved survival,
reduced delirium, and decreased ICU readmissions.60 Large collaborations between children’s hospitals, such as the Children’s

Hospitals’ Solutions for Patient Safety, have contributed to the
development of pediatric specific best practices and HAC prevention clinical care bundles, including those aimed at surgical
site infection, catheter-associated urinary tract infection, and
pressure injury reductions. The use of these bundles leads to
HAC rate reduction.61–64 Finally, sepsis recognition and treatment bundles are increasingly common. Work published by Evans et al. assessing the use of the New York sepsis guidelines
demonstrated improved outcomes when a sepsis bundle (antibiotics, cultures, and fluid) was completed within 1 hour.65 Balamuth et al. demonstrated improved outcomes with use of a sepsis
identification bundle in the emergency department in combination with the electronic medical record to generate automatic
alerts to identify patients at risk of sepsis.66,67 Checklists have also
been used to improve care of critically ill children admitted to the
PICU. The NEAR4KIDS group developed an Airway Bundle
Checklist to identify tracheal intubation risk factors, improve
team situation awareness, improve the use of time-outs,
and mitigation plan generation.68 Clinical pathways are flowcharts or algorithms to guide provider decision-making and
offer education to learners about evidence behind clinical
care recommendations.69 Consistent use of pathways decreases

hospital LOS, increases adherence to evidence-based practices,
and improves flow through emergency departments when applied to care for common pediatric conditions such as asthma
and acute gastroenteritis.69–71 Finally, structured communication
during multidisciplinary rounds and hand-offs are additional
key processes driving quality and improved outcomes in the
PICU.72–74 An example of the efficacy of structured hand-off
communication is I-PASS (illness severity, patient summary,
action list, situational awareness, and synthesis by receiver). Reliable use of this nursing hand-off bundle demonstrated improvements in hand-off completeness and quality. However, there was
no evidence that clinical outcomes improved.75
When elements of structure and process come together successfully, a unit begins to function as an HRO. Several PICUs are
adopting characteristics of HROs to drive improvements in safety
and quality.11,76 To the extent that these principles (see Table 2.1)
are operational, errors and adverse events should dramatically
decrease, thus improving outcomes.

Safety II is another important concept in the pursuit of improved outcomes and error reduction that is receiving increased
attention in healthcare, in particular in high-functioning organizations and systems. Safety I involves a retrospective investigation of
adverse events (find and fix) while Safety II focuses on what is going
right (proactive anticipation of harm to come) in high-functioning
systems.77 Erik Hollnagel, an early Safety II pioneer, identified four
components of the concept: monitoring, anticipating, responding,
and learning.78 Merandi et al. analyzed staff behaviors related to
safety in a complex quaternary PICU environment, which already
had good safety outcomes.8,77 Four Safety II behavior themes
emerged: (1) relying on teamwork when novel therapies or approaches are considered, (2) using teams to respond to challenging
circumstances, (3) maintaining healthy skepticism, and (4) bringing atypical approaches from other environments.77 As organizations become more reliable and adverse events are less common,
Safety II is likely to become an increasingly important field of study
with an opportunity to significantly improve outcomes.

Outcomes
It is a challenge to compare outcomes between PICUs given the
marked heterogeneity in case mix and illness severity. No single
measure is sufficient to adequately summarize the overall quality of
care that a critically ill child receives in a particular PICU. We believe
that a panel of metrics, including both process and outcome measures, is necessary. Some panels, albeit without process measures, are
already in use. The Center for Medicare and Medicaid Service’s
Agency for Healthcare Research and Quality has three PICUspecific outcomes in their Pediatric Quality Measure Program.79
These include risk assessment for pressure ulcers, appropriateness of
red blood cell transfusion, and baseline screening of nutritional status within 24 hours of PICU admission. Other outcome measures,
such as HAC rates, should also be included. The Preventable Harm
Index is currently used to aggregate total events of harm over a given
time for hospitals or groups of hospitals and can be customized to
specific units, such as a PICU.2,3,9 Virtual Pediatric Systems is a data
collecting network of over 135 PICUs across the country used for
numerous research endeavors, including recalibration of commonly

used mortality and length-of-stay prediction models.80
Variations on these models have existed for many years. The
two most commonly used today (PIM 2 and PRISM III) represent several iterations and recalibrations of their original forms
(see Chapter 12). PIM 2 focuses on the first hour of intensivist


CHAPTER 2  High-Reliability Pediatric Intensive Care Unit: Role of Intensivist and Team in Obtaining Optimal Outcomes

contact; PRISM III focuses on the first 12 to 24 hours to predict
risk of mortality. These models are physiologically based severityof-illness scoring systems. They are used to identify observed-topredicted outcomes, in particular for mortality and LOS. These
observed-to-predicted ratios can be used to compare outcomes
between ICUs with similar severity of illnesses.81 The Virtual
PICU, using recurrent neural networks, has developed a severityof-illness model that continually updates as new data are added
from participating PICUs.82
An outcome in Donebedian’s construct that deserves further
mention is value. Today, this is an increasingly important consideration when evaluating any process, particularly in healthcare.
Schleien documented many financial aspects related to PICU care
delivery and discusses ways to enhance revenue and decrease cost
in a system, which in the United States is largely based on fee for
service.83 He anticipates that, over time, the overall payment system will shift to capitation and many incentives currently in place
for overutilization of various diagnostic and therapeutic resources
may shift. If this results in limitations on use of expensive unproven technologies and medications, when these services and
products would have been available previously, it may present
challenges for pediatric intensivists to provide high-quality care
with optimal value-based outcomes.

21

Further impacting the cost of care is the previously
described shortage in pediatric intensivists. This factor, in addition to higher staffing demands on intensivists, growth of specialized ICUs—such as cardiac intensive care units (CICUs)

and neuro-ICUs—and changes in duty hour requirements for
trainees, will impact the professional cost of providing pediatric
intensive care.

Summary
A modern PICU is a complex system interacting with multiple
other complex systems. To attain, or even approach, HRO-level
performance, the pediatric intensivist will need more than just
clinical expertise. As leader of a multidisciplinary PICU team, the
pediatric intensivist must consistently reinforce and model HRO
principles while understanding and managing delivery of optimal
clinical care, including addressing the realities of personnel shortages, rapidly changing reimbursement mechanisms, and the everincreasing expectations of patients and their families. Intensivists
have a history of rising to great challenges in the past—there is
every reason to expect that spirit to continue.
The full reference list for this chapter is available at ExpertConsult.com.


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e3

Abstract: Pediatric intensivists, as leaders of multidisciplinary
pediatric intensive care unit (PICU) teams, require an enhanced
understanding of the PICU as a system within the greater hospital
system, including management and evaluation of PICU operations and outcomes. Integrated into this chapter’s discussion are
specific challenges to attaining high-reliability care delivery. We

examine three key dimensions: structure (the setting in which care
is delivered, including ICU staffing and physical design), process
(how care is provided), and outcomes (end points of care).
Key Words: High reliability, intensivist-led ICU, safety culture,
quality outcomes, multidisciplinary teams