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This report describes how children requiring high dependency care can be identified and proposes guidelines for their care in acute and speciality hospitals.
It was produced for the Paediatric Intensive Care National Co-ordinating Group as part of the process of implementing Framework for the Future - and was endorsed at the group’s November 2001 meeting.
The aim of this guidance is to ensure appropriate levels of care for sick children; to make best use of trained staff; and to relieve unnecessary long and short-term pressures on PIC, where these are caused by lack of high dependency facilities Background
The report of the National Co-ordinating Group on paediatric intensive care Framework for the Future described the features of the paediatric intensive care service as it was then, drew together the evidence on ways of achieving the best quality of care and outcomes for critically ill children, suggested standards which should apply in all hospitals providing paediatric intensive care and described an organisational framework to provide a unified paediatric intensive care service in each area of the country. The strategy is now in the 5th year of planned implementation. Implementation has established a hub and spoke system, with central funding to assist in building capacity and expertise at the hubs, which provide critical care to the very sickest children, in the first instance. Stage two of the implementation is now looking to consolidate, and build on these excellent foundations, by building up capacity and expertise in the spokes.
hdcchildren.doc and Last printed 03/09/02 13:43 High dependency care for children
There has been a lack of clarity on what constitutes high dependency care in children. It was reported in Paediatric Intensive Care “A Framework for the Future” that there had been little attempt to differentiate between intensive and high dependency care. But the report stated that high dependency "describes care provided to a child who may require closer observation and monitoring than is usually available on an ordinary children’s ward, although much of this care is already provided, with higher staffing levels than usual, in such locations".
Thus one of the purposes of this report was to agree what formed high dependency care for children wherever it was to be provided. High dependency is largely defined by the nature of the condition or care received and is dependent on disease, intervention or condition. This approach takes account of compromised organ functions e.g. respiratory, cardiovascular, neurological or renal. This report provides a core set of high dependency categories to
enable comparative audit and monitoring of workload between units.
The report also suggests guidelines for the provision of high dependency
care derived from a variety of sources [refs 1-5] after consideration by an expert
advisory group (membership in Annex B).
Location of high dependency care
The majority of children receiving high dependency care rightly start and finish their care on units other than paediatric intensive care units.
The demand for high dependency care differs between acute general hospitals and the regional speciality or tertiary centres.
hdcchildren.doc and Last printed 03/09/02 13:43 Acute General hospitals
These hospitals provide a range of paediatric and children’s surgical care. In many of the medium and smaller size hospitals there is only one children’s ward shared for all specialities and ages of childhood. Others have more children's wards although these also may be shared between the surgical specialities treating children and the speciality of paediatrics. Children’s units are usually associated with an A&E department though this is not always on the same site as The majority of high dependency care is provided for children who need this as part of their hospital stay, for most of whom transfer to a PICU does not occur at any time during the course of their illness ( between 5 to 15 % of all DGH High dependency care is also required by those needing initiation of level 2 intensive care and stabilisation whilst pending transfer by a retrieval team to a paediatric intensive care unit ( amounting to about 0.5% to 1 % of all acute general hospital children’s admissions). For many of these children the need for transfer for intensive care is apparent on admission to hospital but a few develop this need if their illness progresses later after their admission to hospital.
Speciality/Tertiary Units
The majority of paediatric intensive care arises in such specialty and tertiary hospitals including predicted intensive or high dependency care following complex medical or surgical treatments. Tertiary hospitals provide a range of paediatric specialities such as nephrology, neurology or oncology, and children’s specialist surgical care such as neurosurgery or cardiac surgery and paediatric surgery. Most are likely to have PIC units, some of which will be lead centres.
Some hospitals are single specialty ones such as those with burns units.
Recommended Guidelines
All hospitals providing care for children (including those only providing dental or surgical care either as an elective , day case or emergency patient) should have arrangements in place for HD care. These arrangements should include 24
hdcchildren.doc and Last printed 03/09/02 13:43 hour availability of medical staff with the appropriate competency in
advanced paediatric life support.
High dependency care on children's wards
Arrangements for HD provision will vary according to ward design, size and layout. Contingency arrangements should be agreed to provide HD care for
children who need it recognising that at times this need will arise suddenly
and unpredictably. Arrangements for provision will vary in different situations
An emergency room for resuscitation and a mobile trolley able to take the necessary equipment to another ward location as required.
Contingency plans for HD provision in bed/cot areas or cubicles and
each hospital will need to identify at least one such area.
HD units: some hospitals may establish a HD unit within their children's
department containing one or more beds/cots.
Even in hospitals which have a HD unit additional areas – preferably located closely together- will need to be identified in order to expand capacity to meet demands arising in children of differing ages or at the times of the year which have peak incidence of illnesses. Thus identification of cubicles and ward areas equipped for HD care should take account of the guidance proposed in this report. A number of HD
allocated beds for every unit should be identified.
HD arrangements in specialty/ tertiary hospitals
Many of the tertiary centres are likely to have PIC units, some of which will be lead centres. Isolation and cubicles will be needed both for HD and PICUs.
PICUs need HD step down and step up HD facilities linked to the PIC. Other more specialised units will have their own HD beds. Single specialty hospitals treating children must also comply with guidance for HD and PIC as set out in the hdcchildren.doc and Last printed 03/09/02 13:43 PIC and HD reports. In specialist/tertiary hospitals HD care also may be provided on children's wards each of which should comply with this guidance.
Lead clinician for high dependency care
All hospitals caring for children should have a designated lead clinician for HD
care responsible for ensuring that emergency facilities are available and that
protocols are in place for resuscitation.
He/she should lead a multidisciplinary users group and develops links with the relevant PICU to agree protocols for resuscitation and stabilisation, transfer, and criteria for admission, discharge and treatment of all major conditions concerned.
The group would also ensure that standards were implemented across all Trust departments and would have close links with A&E and adult critical care.
The lead clinician might be a paediatrician, senior children's nurse, surgeon, or anaesthetist, and should be responsible to the clinical director, paediatrics, or equivalent, for overseeing the establishment and running of the service. These responsibilities would include ensuring the following: • Availability of appropriate facilities • Provision of appropriate equipment and drugs • Availability of trained and suitably skilled staff • Development of protocols for the management of common conditions • Agreed arrangements for transfer to the Paediatric Intensive Care Unit • Procedures to be followed in the event of bed / staff/ equipment shortage • Close liaison with the relevant Paediatric Intensive Care Unit, and with other departments within the hospital (especially A & E, and ITU) • Training and audit • Provision of adequate support and accommodation for parents Clinical governance
All hospitals that admit children who are or may become critically ill must have a programme of clinical audit and critical incident reporting so that quality of the hdcchildren.doc and Last printed 03/09/02 13:43 Categories of high dependency care
It is necessary both to identify children receiving HD care and the type of facility in which it should be provided. This is to enable planning of service provision and to aid in identifying workload for audit purposes. The following table sets out agreed categories of children who should be regarded as receiving high dependency care. These categories will not cover all instances but they form the core set to which others may be added. The table also shows the type of HD facilities where care could be provided : (a) In a children's wards in a DGH either in HD unit or identified beds/cots - ( HD (b) In a HDU which is attached to a PICU ( HD-PIC).
Note those children in a DGH with disorders in the HD-PIC category
(e) In a specialty HD unit ( Speciality HDU) hdcchildren.doc and Last printed 03/09/02 13:43 Table : Disorders constituting high dependency care. This list is illustrative but
not exhaustive.

Where care can
be provided

Prolonged (e.g. over 1 hour) or recurrent convulsions Circulatory instability due to hypovolaemia other than meningococcal diseaseDiabetic Ketoacidosis with drowsiness Patient with pain which is difficult to control Meningococcal septicaemia – stable state Intravenous fluid resuscitation >10ml/kg & < 30 ml/kg Continuous intravenous drug infusion (except analgesia alone)Acute renal failure (urine output <1ml/kg/hour) FiO2>0.5 via headbox or facemask or, nasal CPAP for Upper airway obstruction – close observation Poisoning/substance misuse with potential for significant HD -child ward Pre or post-operative patients with complex fluid management, analgesia, bleeding, complex surgery,( bookedor emergency)Cardiac arrhythmia which has responded to first line therapy ( other than cardio version)Stable long term ventilation hdcchildren.doc and Last printed 03/09/02 13:43 Disorders

Arrhythmia which fails to respond to first line therapy Possibility of progressive deterioration to the point of needing ventilation (e.g. recurrent apnoeas, airway obstruction)The need for intravenous infusion of vasoactive drugs to support cardiac output or control BPNebulised adrenaline for upper airway obstruction after 2 doses or morePatients recently extubated following prolonged ventilation Post-op patient with multiple chest drains requiring hourly fluid replacementAny airway intervention (e.g. tracheal intubation) Ventilated or assisted respiration (e.g. bag and mask) other than during recovery from anaestheticCardiopulmonary resuscitation Central Nervous System depression sufficient to compromise the airway protective reflexes/respiratory drive or potential to progressUncontrolled shock needing repeated volume &/or inotropics or greater than 30 ml/kg resuscitation volumeDiabetic Ketoacidosis with deteriorating level of consciousness after start of therapyTracheostomy for acute illness Patient receiving multiple drug therapy (eg complex chemotherapy) Bone marrow transplant/severe neutropenia Acute renal replacement therapy (haemodialysis, haemofiltration) (a) For more severe illnesses e.g. meningococcal disease with shock, othercriteria than the diagnosis will usually indicate need for either PIC or HDU -PIC.
(b) Children in a DGH with disorders in the HD-PIC category should bereferred to a PICU.
Transfer to PICU
The above table includes categories of disorder for which transfer to a PIC unit isadvised.
The Paediatric Intensive Care Society (PICS ) [ref 2] has listed indications forreferral to a PICU in its 2001 guidance as follows: hdcchildren.doc and Last printed 03/09/02 13:43 Paediatric intensive care admission is essential for patients likely to requireadvanced respiratory support (i.e. acute, short, or medium term mechanicalventilation). But the following children should also be considered for discussion withthe PICU • If it is highly likely that they will need an intensive care dependent procedure ( • Who have symptoms or evidence of shock, severe respiratory distress or • Who have the potential to develop airway compromise.
• Who have an unexplained deteriorating level of consciousness.
• Who have required resuscitation or who are requiring some form of continuing • Who have received a significant , that is major, injury.
• After prolonged surgery or any surgical procedure that is medium or high risk or of a specialist nature, even if this surgery is elective.
• Who have potential or actual severe metabolic derangement, fluid or electrolyte • Who have an acute organ (or organ-system) failure.
• Who have established chronic disease (or organ-system failure) and who experience a severe acute clinical deterioration or secondary failure in anotherorgan-system.
• Who require one to one nursing because of the complexity of an acute or acute 24. The Paediatric Intensive Care Society (PICS ) regards the following “procedures” as being “intensive care dependent” [ref 2]. It advises "under normalcircumstances when required they should usually be performed on children withina paediatric critical care environment". The DH expert group found this advicehelpful, recognizing that it included some examples of high dependency carealthough many required provision in a PICU and comments are added inbrackets- • Nasopharyngeal and endotracheal intubation,• Endotracheal continuous positive airway pressure (CPAP) (acute short and • Artificial/mechanical ventilation (acute, short and medium term)• Continuous invasive cardiovascular monitoring (e.g. central venous or arterial • Use of antiarrhythmic, inotropic or vasoactive drug infusions,• Acute renal support (haemodialysis, haemofiltration, plasmafiltration and hdcchildren.doc and Last printed 03/09/02 13:43 • Acute or external cardiac pacing,• Mechanical circulatory support,• Intracranial pressure monitoring,( for acute illness this requires PICU care but elective pressure monitoring can be carried out on wards or HDUs) • Complex intravenous nutrition and drug scheduling,( in e.g. oncology, similar care can be carried out on wards or HDUs) • Complex anticonvulsant therapy• Frequent or pressurised infusions of blood products,• Active or forced diuresis,• Induced hypothermia,• Balloon tamponade of oesophageal varices,• Emergency thoraco- or pericardiocentesis.

Expertise and supervision
Within a high dependency service, a senior children’s nurse will haveresponsibility for directing the plan of nursing care and also supervision andeducation of nurses working within the high dependency area.
A registered children’s nurse, who has completed an advanced life supportcourse e.g. PLS/APLS/PALS, should be present at all times throughout every 24hour period.
The provision of high quality high dependency care is dependent on theavailability of appropriately trained nursing staff. Appropriate induction andpreceptorship for nurses working within the high dependency setting should beprovided. Nurses undertaking any clinical procedure for the first time must bedirectly supervised by colleagues who have the necessary skills, competenceand experience until such time they have acquired the relevant degree ofexpertise.
Staffing Levels
The numbers of highly dependent children a nursing team is able to manage willdepend on both the availability of appropriately trained staff and dependency ofother patients within the care area.
Where Level 1 care (High Dependency) is being provided, for each child at least1 registered children's nurse will carry out close monitoring and observation; thismay mean a nurse is caring for only 2 children at any 1 time. These nurses willbe advised by an experienced nurse with intensive care qualifications. Thisadvice may be provided from within the host hospital or from a lead centre. hdcchildren.doc and Last printed 03/09/02 13:43 From " Bridge to the future ": NHSE 19912.
29. At present there are only a limited number -though increasing- of recognised
courses to prepare nurses to care for high dependency children e.g. components ofENB 920 or 415, some being competency based and others theoretical. Therefore,a mixture of both formal courses and competencies development should beidentified. The training required by the nurse to care for high dependency childrenmay vary depending on the clinical setting he/she is working in, though there aresome commonalties across all settings in intensive care and children's nursingpractice.
30. In education programme for nurses working within the high dependency area will need to address the competencies required to meet the needs of the highlydependent child and their family. This should include the ongoing availability ofscenario training in emergency situations including respiratory/cardiac arrest and themanagement of high dependency children to enable nurses working within thesetting to participate every 6 months. All trained nurses caring for children will havesuccessfully completed basic life support training and this should be updatedannually. Competency based high dependency care training should becommissioned and available for nurses working within the HD care area and shouldinclude training in the skills necessary to communicate with and provide emotionalsupport for parents and children. Collaboration with the local PIC service will enabledevelopment of unified standards and skills for the care of acutely ill children.
Professional development
Each HD service should have an integrated strategy for retention and recruitmentof nursing staff. This may include conjoined recruitment strategies with PICproviders and enabling secondment or rotation within the PIC clinical network.
hdcchildren.doc and Last printed 03/09/02 13:43 EQUIPMENT
(For a more detailed examplar check list of equipment please refer to Annex A) Each HD area will require the following equipment: Piped medical gases - oxygen and air - and vacuum Multi-module monitor (compatible with ICU/Theatres) providing:- ECG/Respiration monitor with apnoea alarm- Invasive pressure monitoring- pulse oximetry- Non-invasive BP with a variety of cuffs- End tidal CO2- Temperature The following will need to be immediately available: • Resuscitation trolley - fully equipped • Easy access to CPAP driver and anaesthetic machine Within the DGH, easy access to a ventilator is essential to facilitate the initiationof level 2 intensive care and stabilisation of a child requiring level 2 care. Themodel chosen should be familiar to anaesthetic, paediatric and A&E staff withinthe DGH and the lead PIC centre can form a source of advice on selection.
Within a DGH unit, a variety of disposables not usually available should bestocked A fully equipped transport box should be available, containing everything neededto transfer a sick intubated child safely. Although usual practice will involve thePIC service retrieval team, this will still be needed as a reserve option.
hdcchildren.doc and Last printed 03/09/02 13:43 Medications: A list of available drugs should be agreed with colleagues includingIntensivists and anaesthetists. A examplar list is given in Annex A hdcchildren.doc and Last printed 03/09/02 13:43 ANNEX A CHECK LIST FOR MINIMUM EQUIPMENT REQUIREMENTS FOR

Monitoring disposables
ECG leadsECG electrodes (3 packs)SaO2 leadSaO2 probes - selectionNon-invasive BP tubingNon-invasive BP cuffs - neonatal to adult sizesTemperature probes (2) Items for Intravenous Access
Intraosseous needlesSingle lumen Seldinger type central venous catheter set 19 & 20GTriple lumen central venous catheter set 5F 5 7 8 cmSyringes Pressure monitoring extension lines 10cm , 50cm ,200cm3-way taps3-way taps with extensionIV injection capsSpirit wipesSplints Cannula and ET Tube Fixation
Sutures - silk on hand size needles (W675)Zinc oxide tape 0.5”Transpore table 1”Elastoplast tape 1”Crinx bandageTegaderm dressingsSterile scissorsArtery forceps - large and smallDisposable scalpels 10,11&15Swabs Airway Management
Oxygen tubingOxygen therapy mask (paediatric including 0,00 and 000)Nasal cannulae - infant & paediatricNebuliser and mask hdcchildren.doc and Last printed 03/09/02 13:43 J-R modified Ayres T-piece (disposable)1L reservoir bagCondenser humidifiersSelf inflating bags - adult & paediatricSwivel ET connectorCatheter mountAnaesthetic face masks 1,2,3,4,5Guedel airways 000,00,0,1,2,3,4Endotracheal tubes (2.0-5.5 (2 each size) 6.0-7.5 ( plain and cuffed)Intubation stylets - small and mediumMinitrach setEpidural kitLaryngoscope handles - penlightLaryngoscope blades - straight and curve, neonatal to adult sizesMagill forceps - small and mediumPenlight torchLubricating jelly Chest Drain Set
Heimlich valves½ x ¼ straight connectorsChest drains 8-16F Miscellaneous
Gloves - L,M,SNasogastric tubes 6-14FSuction catheters Yankauer high, regular, fineFlexible 6-12FSputum trapSpace blanket - adult sizeSilver swaddlerStiff neck collars - assorted sizesStethoscope/oesophageal stethoscopePaediatric ICU FormularyICU chartsSpare batteries for laryngoscopesSpare bulbs for laryngoscopesGlucostixDrug additive labelsSyringe labelsRoll of “Gamgee” (cotton wadding) hdcchildren.doc and Last printed 03/09/02 13:43 DRUGS FOR PAEDIATRIC HD CARE
Note: The list of drugs stocked for HD care in a hospital should be agreed
between paediatric and anaesthetic colleagues locally and with the regional PICU.
The following list is provided as an illustration.

Adrenaline 1:10,000AtropineCalcium chlorideSodium Bicarbonate 8.4% Adrenaline 1:1000DobutamineDopamineIsoprenalineNoradrenalineLabetalol EtomidateKetamineMidazolamThiopentoneTrimeprazine or similiar AtracuriumPancuroniumVecuroniumSuxamethonium PhenytoinLorazepamParaldehydePhenobarbitoneDiazepam/Diazemuls hdcchildren.doc and Last printed 03/09/02 13:43 CefotaximeCeftazidimeBenzylpenicillinAcyclovirMetronidazole Ipratropium NebuliserSalbutamol NebuliserSalbutamol IVAminophyllineHydrocortisoneDexamethasone Mannitol 10 or 20%4.5% Human Albumin solution0.9% Normal saline0.45 % saline10% Dextrose4% Dextrose/ 0.18% salineGelofusine 500mlHaemaccel 500ml FrusemideLignocaine 1and 2%Potassium chlorideWater for injectionHeparinAmpoules of 0.9% saline hdcchildren.doc and Last printed 03/09/02 13:43 Members of expert advisory group:
Dr Stephen Cronin, Consultant Paediatrician, South Tyneside Hospital Dr Keith Dodd, Consultant Paediatrician, Derby Children’s Hospital; Chairman - HealthServices Committee, Royal College of Paediatrics and Child Health; Member of PIC Co-ordinating Group Dr Liz Draper, Paediatric Epidemiologist, University of Leicester Dr Gillian Fairfield, Consultant in Public Health Medicine; Medical Director, HullCommunity Trust Dr John Henderson, Consultant Paediatrician, Bristol Royal Hospital for Sick Children Dr Roderick MacFaul, Consultant Paediatrician Pinderfields Hospital and Medical
Adviser, Paediatrics and Child Health, Department of Health ( Chair)
Dr Rob Ross Russell, Consultant in Paediatric Intensive Care, Addenbrooke’s Hospital Dr Charles Stack; Consultant in Paediatric Intensive Care, Sheffield Children’s Hospital(Hon Secretary Paediatric Intensive Care Society) Miss Fiona Wray, Senior Nurse Advisor Hospital for Sick Children, Great Ormond Street Mrs Susan Wood, Children’s Ward Manager and Clinical Nurse Specialist , PinderfieldsHospital, Wakefield Dr C S Ralston, Consultant Paediatric Anaesthetist and Medical Director PICUBirmingham Children's Hospital Steelhouse Lane Birmingham Department of Health
Mrs Jane Scott, Team Leader, Child Health Branch DoH hdcchildren.doc and Last printed 03/09/02 13:43 REFERENCES
Paediatric High Dependency care NHS Executive North West Paediatric Intensive Care Society Standards Document 2001 National guidance "Paediatric Intensive Care - A Framework for the Future’.
NHSE 1997.
Which critically ill children benefit from transfer to a tertiary paediatric intensiveunit ( PICU) A prospective audit study. SW Region R&D 1996-1999.
Future Configuration of Paediatric Units. 1996. BPA ( Now RCPCH) MacFaul R, Jones S, Werneke U. Clinical training experience in district generalhospitals. Arch Dis Child 2000; 83: 39-44 Fairfield G. Yorkshire paediatric intensive and high dependency study.
1997.Nuffield Institute, Leeds.
Haines L Pollock J Scrivener R Report on a prospective study of intensive careutilisation in the North west region. 1996. Research unit RCPCH.
Draper L et al Trent regional paediatric intensive care study 10. Dodd KL Data from Derby Children’s Hospital personal communication Henderson J, Garland L, Warne S, Bailey L, Weir P, Edees S. Mortality ofcritically ill children treated in intensive care units in a defined geographicalregion of the United Kingdom: results from the South West Critically Ill ChildrenStudy. Arch Dis Child : in press.
hdcchildren.doc and Last printed 03/09/02 13:43


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