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The Wild West Approach to PICUs


I spent my early and mid-career years working in a pediatric intensive care unit (PICU) at a large academic center. We did almost everything except for a few things that were esoteric at the time — small bowel transplants, a few kinds of experimental surgery. I’m now in my late career (but have no plans to quit anytime soon!) and work in a smaller PICU. I am frequently confronted with the issue of just what a smaller unit should be doing. Some of these questions are easy.

For example, we don’t do kidney dialysis in children, so any child who might need that gets sent to a larger academic PICU. We also don’t do heart surgery in children, although we care for children before and after their surgical repairs done elsewhere. But you can easily see how this can get complicated, even murky, as we think about the vast array and spectrum of severity of childhood illness and injuries. For example, I frequently care for children with severe respiratory failure who need a mechanical ventilator. But our PICU does not (and should not) offer the most sophisticated form of respiratory support — extracorporeal membrane oxygenation (ECMO). Deciding when things have deteriorated to such an extent that a child might need ECMO, and hence transfer, is a total judgment call. We don’t want to transfer too early, but we certainly don’t want to do it too late, when the child is much more unstable.

When PICUs began, they were located in major academic medical centers. Now we have smaller units like mine scattered across the landscape. And “scattered” is the correct way to think about it because where you may find a PICU is a bit random. Essentially what happens is that a larger community hospital decides they want a PICU. I can tell you from personal observation this decision is often made with little-detailed planning and without consideration of what having a PICU really means — what specific services you are going to offer or are compelled to offer. Several organizations I know of just hired some pediatric intensivists (and never enough of them), bought some ventilators, stuck a PICU sign on the wall, and declared themselves open for business.

Several organizations, including the American Academy of Pediatrics (AAP), have published guidelines of what a PICU should consist of, but it has no teeth, and no one has decided exactly what services are appropriate. Besides, the guidelines are now a decade old. A very crude measure would simply use the metric of number of PICU beds and yearly patient census, but even that’s not done. There are some guidelines for specific procedures, such as liver transplantation, but on the whole, it’s whatever people want to do. It’s pretty chaotic.

I’ve seen some bad things happen because of this Wild West approach to PICU practice. In densely populated areas such as the Northeast, you find places where PICUs are sitting cheek-by-jowl and competing intensely with each other for patients. In contrast, in the West, the nearest PICU may be hundreds of miles away, and the referring physician has no choice at all. The issue, of course, is twofold: it is inefficient and cruel to families to transfer children to big PICUs when they could be appropriately cared for closer to home. Yet, it can be dangerous to keep children in smaller PICUs when they have or might develop problems that require a higher level of expertise. Of course, this is not a problem unique to PICUs. It applies to other aspects of acute medical care. Critical care is a flashpoint for the question because there may not be time for a leisurely referral to a faraway specialist. Decisions, sometimes simply based upon the best guess, need to be made.

My own modest suggestion toward solving this problem is that every smaller PICU should have a formalized, agreed upon protocol for consultation and transfer of patients. In other words, there should be some type of formal regionalization for pediatric critical care. The PICU I work in is fortunate to have a tight relationship with a major children’s hospital. I can call at any time on a direct number just to bounce ideas off another intensivist, ask for specific advice, or arrange transfer. I have many colleagues around the country who, when they wish for that sort of help, must go through layers of obstruction to get it. Sometimes when they want to transfer a patient to a bigger PICU they essentially need to “pitch and sell” the patient to the larger facility, who may even refuse the transfer for non-medical reasons. This is not the way to go. I think every PICU that doesn’t offer the complete range of critical care services should have some sort of arrangement with a larger unit. Right now most have only an informal, vague, “this is what we generally do” protocol. It needs to be better than that.

Christopher Johnson, MD, is a pediatric intensive care physician and author of Keeping Your Kids Out of the Emergency Room: A Guide to Childhood Injuries and Illnesses; Your Critically Ill Child: Life and Death Choices Parents Must Face; How to Talk to Your Child’s Doctor: A Handbook for Parents; and How Your Child Heals: An Inside Look At Common Childhood Ailments. He blogs at his self-titled site, Christopher Johnson, MD.

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