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

and respect; practicing complex communication; acknowledging
patient, family, and other perspectives; sharing trust, value, and
power; and thinking about systems.48 For example, if a particular
PICU is interested in successfully transitioning patients receiving
active cardiopulmonary resuscitation onto extracorporeal life support (ECPR), the simulation must include surgeons, intensivists,
nurses, pump technicians, respiratory care personnel, and social
work providers. Educational siloes related to ECPR cannot achieve
the desired outcome. As noted previously, all of critical care is a
team activity, and team education around any clinical standard
work must be an essential component of continuous process improvement that will inform design for the next PDSA cycle. Realtime team debriefing around critical events (doing in context)
represents a particularly effective interdisciplinary simulation
teaching modality.49

clinical practices that are supported by high-quality evidence. It
includes the following recurring steps: (1) conduct quarterly
evidence searches, (2) decide which evidence-based practices to
implement, (3) support implementation of selected practices, and
(4) monitor progress.
The second, less obvious benefit is promoting wellness and
resiliency among critical care providers. Constant, significant
stressors related to provision of pediatric intensive care represent
real risk factors for burnout syndrome and a number of related
adverse outcomes for PICU practitioners49 (see Chapter 22). Participation of the interdisciplinary team in shared education and
research/quality improvement activities affords opportunities for
critical care providers to unwind, debrief, and reflect, to provide
mutual support, and to reinvigorate a sense of purpose for the
important work of pediatric critical care.

Benefits of a Learning Healthcare
Environment

Key References

In a learning healthcare environment, the activities of patient
care, clinical research, and shared education are inexorably linked
to two common purposes (Fig. 7.3). The first obvious benefit is
generation or identification of best available evidence to support
best practice. In addition to facilitating and participating in clinical research related to pediatric critical care, PICUs might also
consider implementation of E-SCOPE—evidence scanning for
clinical, operational, and practice efficiencies.49 E-SCOPE is a
systematic approach to identify and then rapidly implement
Facilitates identification, delivery of high value patient and family care

Fostering
A Learning
Healthcare
Environment

Ely EW. The ABCDEF Bundle: Science and philosophy of how ICU liberation serves patients and families. Crit Care Med. 2017;45(2):321-330.
Lane-Fall MB, Miano TA, Aysola J, Augoustides JGT. Diversity in the
emerging critical care workforce: analysis of demographic trends
in critical care fellows from 2004 to 2014. Crit Care Med. 2017;
45(5):822-827.
Meade MO, Ely EW. Protocols to improve the care of critically ill
pediatric and adult patients. JAMA. 2002;288(20):2601-2603.
Mendoza FS, Walker LR, Stoll BJ, et al. Diversity and inclusion training
in pediatric departments. Pediatrics. 2015;135(4):707-713.

Rivara FP, Alexander D. Randomized controlled trials and pediatric
research. Arch Pediatr Adolesc Med. 2010;164(3):296-297.
Rotenstein LS, Jena AB. Lost Taussigs: the consequences of gender
discrimination in medicine. N Engl J Med. 2018;378(24):2255-2257.
Smith MD, et al., eds, for the Committee on the Learning Health Care
System in America. Best Care at Lower Cost: The Path to Continuously
Learning Health Care in America. Washington DC: National Academy
Press; 2013.
Walrath JM, Muganlinskaya N, Shepherd M, et al. Interdisciplinary
medical, nursing, and administrator education in practice: the Johns
Hopkins experience. Acad Med. 2006;81(8):744-748.

Promotes wellness for the community ICU practitioners and patients

• Fig. 7.3  ​Fostering a learning healthcare environment.

The full reference list for this chapter is available at ExpertConsult.com.


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e3

Abstract: A learning healthcare system occurs when patient care,
interdisciplinary education, and clinical research are so integrated
and intercalated that they are basically inseparable. Each element
synergistically benefits from and informs the other. Benefits of a
learning healthcare system include generation or identification of
best available evidence to support best practice and promoting
wellness and resiliency among critical care providers.

Key Words: Learning healthcare system, diversity, inclusion, bestpractice clinical care, clinical research, quality improvement,
shared educational model, evidence-based medicine, burnout,
wellness, resiliency

8
Challenges of Pediatric Critical Care
in Resource-Poor Settings
AMÉLIE VON SAINT ANDRÉ–VON ARNIM, JHUMA SANKAR, ANDREW ARGENT,
AND ERICKA FINK



•

Life-threatening illnesses are a global phenomenon with markedly disparate outcomes depending on available resources and
access to care. Low- to middle-income countries (LMICs) are
economies defined by a gross national income per capita of $995
or less, and $996 to $3895 in 2017, respectively (eFig. 8.1).1 In
high-income countries (HICs), caring for critically ill patients
involves a coordinated system of (1) triage, (2) transport networks, (3) emergency and intensive care provided in wellresourced units and by trained personnel with (4) access to contemporary laboratory services, (5) imaging, (6) transfusion, and
(7) surgical services. This cohesive system is resource intensive
and, hence, less affordable for many LMICs, where care is fragmented. The burden of critical illness remains inordinately high
in LMICs, despite an overall decrease in global childhood mortality (Fig. 8.2).2 Thus, access to quality care for the critically ill
child with sudden and serious reversible disease, in addition to
trauma and postoperative critical care support, should be a universal shared goal. Delivery of critical care in low-resource settings (LRSs) is in need of a tiered approach to scaling toward a
gold standard that includes both strengthening capacity for public health and critical care services.
For the purposes of this chapter, we define pediatric critical care
as the care of children who suffer an acutely life-threatening illness
or injury regardless of the location where care is provided. For example, irrespective of the setting—whether in a district health
center with minimal resources and personnel or a tertiary care

•

•

•





•

Global child mortality is declining due to decreasing poverty
and increasing basic medical care access and quality.
Given the large burden and high mortality of critical illness
and availability of low-cost therapies, there is ample rationale for expanding critical care services in least-developed
countries.
Pediatric critical care services do not have to be costly,
nor do they need to be overtly reliant on high-end
technology.





•



PEARLS
Publicly funded intensive care unit treatment remains limited
in low-income countries (LICs), and its introduction requires
careful resource allocation.

Healthcare systems improvements for the critically ill should
involve a graded approach of strengthening capacity to provide
health maintenance, basic critical care, and publicly funded
intensive care services as overall health indices improve.
Critical care research from LICs is sorely needed to guide
effective and efficient care and advocate for resources.

setting—treatment of severe lower respiratory infections, malaria,
or diarrhea with dehydration is critical care.5 In contrast, intensive
care is defined as care provided for the critically ill or injured or
those who have undergone major surgical procedures in an intensive care unit (ICU) with mechanical ventilators and equipment
for close patient monitoring.

Child Mortality Rates
Current Trends and Health Maintenance
Globally, child and adolescent deaths decreased 51.7%, from
13.77 million in 1990 to 6.64 million in 2017.6 However, aggregate disability increased 4.7% to a total of 145 million years
lived with disability globally.6 Progress was uneven and inequity
increased, with low- and low- to middle-income regions experiencing 82.2% of deaths, up from 70.9% in 1990. The gains are
partly attributable to attention by individual countries to the Millennium Development Goals (MDGs), especially MDG 4, which
was related to decreasing the under-5-years-old mortality rate by
two-thirds by 2015 from 1990 baseline. The overall improvements in other sectors—poverty, water, sanitation and hygiene,
and socioeconomic indices—along with increasing vaccination
rates, basic education, access to perinatal and other medical care
and improving quality of care, have further helped to reduce mortality in infants and children globally.
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