Abstract
Pediatric cardiac critical care medicine plays a central role in the care of patients with complex congenital and acquired heart disease. Over the last two decades, specialized cardiac intensive care units have emerged as central components in the management of critically ill neonatal, pediatric, and adult patients with congenital and/or acquired heart disease. Although data regarding the optimal method of care delivery to this specific patient population continue to emerge, there are significant center variations based on surgical volume, medical staff organization, and space allocation. What seems to remain paramount in the care of this highly specialized patient population is that a dedicated team of professionals be tasked with the comprehensive care of critically ill pediatric and adult patients with congenital and/or acquired heart disease.
Key Words
Pediatric cardiac intensive care unit, multidisciplinary, cardiology, care delivery, family-21centered care
Pediatric cardiac critical care medicine plays a central role in the care of patients with complex congenital and acquired heart disease. Over the last 20 years it has evolved into a distinct subspecialty with a clearly defined role in a congenital heart program. In most centers the pediatric cardiac intensive care unit (PCICU) forms the core of an integrated congenital heart program with a direct link to all the subspecialty services within the heart center ( Fig. 5.1 ). The PCICU patient populations are heterogeneous in their demographics, anatomy, physiology, procedures, and outcomes, which results in an unpredictable environment where constant high-quality evaluation and management is essential. This resource-intensive environment not only stresses the people who work in the PCICU, but also consumes a lot of hospital resources
The concept of a PCICU originated from the unique challenges encountered in the preoperative and postoperative management of children with critical cardiac disease. In the early years of development of congenital heart surgery, pediatric cardiac surgeons were primarily responsible for the postoperative care. Over the last two decades, specialized cardiac intensive care units (ICUs) have emerged as a central component in the management of critically ill neonatal, pediatric, and adult patients with congenital and/or acquired heart disease. In addition, the scope of practice of the PCICU has grown to include patients with cardiac disease who have undergone noncardiac surgery or who are critically ill from noncardiac diseases such as acute respiratory failure. As a result of this specialization, outcomes have improved dramatically during this time period with patients surviving into adulthood as commonplace. Although the reasons for this progress are multifactorial, advances in cardiac intensive care medicine have contributed to these improvements. The PCICU advances have been largely in the areas of clinical care model development and delivery, preoperative and early and late postoperative management strategies, patient monitoring, standardization of medical and nursing care pathways, development of quality and safety processes, nutrition, and multidisciplinary care delivery, including physical, occupational, and speech therapies.
Although data regarding the optimal method of care delivery to this specific patient population continue to emerge, there is significant center variation based on surgical volume, medical staff organization, and space allocation. The physician organization remains somewhat heterogeneous with units staffed with combinations of general intensivists, cardiac intensivists, cardiologists, and/or cardiac surgeons. Additionally, there may be differences in the protocols and best practices implemented in the care of the patients from unit to unit. What seems to remain paramount in the care of this highly specialized patient population is that a dedicated team of professionals be tasked with the comprehensive care of critically ill pediatric and adult patients with congenital and/or acquired heart disease.
It is important to note that outcomes after cardiac surgery are now being reported transparently and publicly. Parents, colleagues, and referral groups should be able to know these data to help decide their plans for this high-stress situation. The role of the PCICU is paramount in achieving excellent outcomes. Two commonly used public recording databases that rank performance are the Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery (STAT) score ( Box 5.1 ) and the U.S. News & World Report Ranking ( Table 5.1 ). As can be seen from both of these scorings, the PCICU is a major contributor to these important rankings and as such, an area of high focus. To achieve these goals a dedicated team specializing in children’s heart care has been shown to improve outcome.
The STAT score is a tool designed to analyze the risk for mortality associated with congenital heart surgery procedures.
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STAT Category 1 cases are less complex procedures that have a low risk of complications (e.g., closures of atrial septal defects and ventricular septal defects).
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STAT Category 2 cases are procedures that have an increased risk of complications (e.g., coarctation of the aorta repair, congenitally corrected transposition of the great arteries, ventricular septal defect repair).
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STAT Category 3 cases are complex procedures that have an increased risk of complications (e.g., hemi-Fontan and arterial switch operation).
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STAT Category 4 cases are more complex procedures that have a higher risk of complications (e.g., tetralogy of Fallot repairs and truncus arteriosus repairs).
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STAT Category 5 cases are the most complex procedures and have the highest risk of complications (e.g., Norwood procedure and heart-lung transplant).
Operative mortality is defined as (1) all deaths occurring during the hospitalization in which the procedure was performed, even after 30 days (including patients transferred to other acute care facilities), and (2) those deaths occurring after discharge from the hospital but within 30 days of the procedure.
The three categories of ratings are based on a participant’s overall risk-adjusted O/E operative morality ratio:
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One star: higher-than-expected operative mortality; the 95% confidence interval (CI) for a participant’s risk-adjusted O/E mortality ratio was entirely above the number 1.
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Two stars: as-expected operative mortality; the 95% CI for a participant’s risk-adjusted O/E mortality ratio overlapped with the number 1.
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Three stars: lower-than-expected operative mortality; the 95% CI for a participant’s risk-adjusted O/E mortality ratio was entirely below the number 1.
O/E, Observed-to-expected; STAT, Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery.
| Category | PCICU Role |
|---|---|
| Outcomes/Experience | |
| Survival post CHD surgery | Co-own |
| Survival post CHD complex surgery | Co-own |
| Survival post Norwood | Co-own |
| Survival post transplant | Co-own |
| Prevent infections | Co-own |
| Prevent ICU infections | Own |
| Prevent pressure ulcers | Own |
| Numbers | |
| Surgeries | None |
| Catheterizations | None |
| Norwood/hybrid | None |
| Program | |
| RN staffing | Co-own |
| CHD program | Co-own |
| Adult CHD | None |
| Heart transplant | None |
| Clinical services (OR) | Co-own |
| Clinical support services | Co-own |
| Advanced technology | Co-own |
| Specialized clinics/programs (balloon/stents) | Co-own |
| Full-time subspecialists | Own |
| Professional Recognition | |
| RN magnet | Co-own |
| MD reputation | Co-own |
| QI Efforts | |
| Best practices (M&M) | Own |
| QI efforts | Own |
| Health information technology | |
| Fellowship | Own |
| Clinical research | Own |
| Patient Support | |
| Family help | Own |
| Families in structuring care | Own |
Patient Population
The patient population in a PCICU can be stratified into three main categories:
- 1.
Patients with congenital or acquired heart disease undergoing cardiovascular surgery (cardiac surgical patients)
- 2.
Patients with congenital or acquired heart disease undergoing noncardiac surgery (noncardiac surgical patients)
- 3.
Patients with congenital or acquired heart disease presenting with acute cardiorespiratory decompensation or other critical illnesses (cardiac medical patients)
Although the majority of patients fall into these three main categories, patient age may play a role in where they are ultimately admitted (e.g., extremely premature infant with hypoplastic left heart syndrome may be admitted to the neonatal intensive care unit [NICU]). Some centers adopt the approach of congenital cardiac critical care in which the unit provides care to patients of all ages from newborn to adulthood. Although this model provides a lifetime of continuity of care, the majority of the team is typically pediatric trained and may not have as much expertise in the management of comorbidities associated with aging, such as coronary artery disease, diabetes mellitus, obesity, and chronic obstructive pulmonary disease in adults with congenital heart disease (ACHD patients). The most commonly practiced model of PCICU in the larger heart centers is one that cares for patients from newborn up to 18 to 25 years of age. With such an approach the PCICU will capture up to 85% of critically ill patients with congenital heart disease (CHD) within a congenital heart program. Rarely the PCICU may take care of all postneonatal patients up to 18 to 25 years of age, whereas newborns with cardiac disease receive care in a NICU setting in the preoperative and postoperative periods. A growing model among small- to medium-sized programs is one in which all newborns receive their preoperative care in the NICU, and the immediate preoperative and post-operative management occurs in the PCICU. Finally, a model that has seen the most growth is one in which patient care, neonates included, preoperatively and postoperatively is delivered in the PCICU. One patient population, ACHD patients, remains a point of controversy as to where best to administer their care in the context of the complexities of their physiology and comorbidities, not to mention the social aspect of an adult cared for in a pediatric unit. Although each of these models has its merits and demerits ( Table 5.2 ), there is an inherent tendency for variations in aspects of the patients’ management. For instance, there may be some differences in fluid and electrolyte management of the newborn with CHD in the NICU versus the same newborn in the PCICU. To eliminate these care variations there is a strong need for multidisciplinary integration of care at both the nursing and physician levels and joint development of protocols and standardized care pathways to optimize outcome. It is also essential to cross-train staff and develop specific metrics to assess protocol adherence.
| Pros | Cons | |
|---|---|---|
| PICU model | When patient numbers low; provides consolidated ICU | Decentralized |
| PCICU model (NICU pre/post) | When patient numbers are higher and PCICU bed numbers are not enough, provides ICU level of care | Lack of preoperative and postoperative continuity of care Neonatal management differences Multiple transitions of care Dichotomized expertise in separate locations |
| PCICU model + IMU | Preoperative dedicated neonatal care Shared responsibilities Shared mental model Efficiencies in care Focused QI More established model Practical model for medium programs with limited ICU space More favorable model for research and training | Lack of preoperative and postoperative continuity of care Several transitions of care Dichotomized expertise in separate locations |
| PCICU model single stay | Continuity of care (preoperatively and postoperatively) Standardized preoperative and postoperative management More comprehensive approach to care involving all subspecialties More favorable model for research and training Fewer handoffs | Larger space requirements ICU less educated on D/C planning |
Pediatric Cardiac Intensive Care Unit Care Model
Operational Components
The care model adopted by the PCICU is central to the overall function of the cardiac program. It is structured to be the core of an integrated care delivery system that supports both inpatient and outpatient areas of the cardiovascular program and plays a paramount role in the establishment of the continuum of care within the cardiovascular program. The successful PCICU positions itself to be readily available to provide immediate care to all critically ill cardiac patients in a calm, cordial, and efficient manner. It instills a culture of patient safety and multidisciplinary collaboration and delivers excellent clinical care while catering to the needs of the patients, their families, and referring physicians.
Philosophy and Approach
One of the central tenets of the evolution and maturation of cardiac intensive care has been the development of the multidisciplinary culture that includes all aspects of care, including pharmacy, dietary and nutrition, physical therapy, occupational therapy, speech therapy, social work, and child life. This approach allows for the recognition that each member of the team has ownership in the program and care of the patient. Ultimately, the expertise of each subspecialty is fully integrated in management algorithms for the benefit of the patient. A unique aspect of cardiac intensive care that sets it apart from general intensive care is the continuum of care provided. As noted earlier, some PCICUs provide preoperative management in the immediate postnatal period, postoperative management, and discharge planning and, in addition, play some role in aspects of interstage management of single-ventricle patients. The provision of such a continuum of care requires the understanding of preoperative and intraoperative management, which may facilitate the care of the patient in the postoperative period. Important as well are individualized and anticipatory approaches to the care of patients within the PCICU with continuous reevaluation of the management and the patients’ response to interventions. Finally, the anticipatory culture is critical in the cardiac ICU for early recognition and timely response to changes in a patient’s condition.
Patient Care
As much as possible, medical management of patients should be standardized with care pathways, protocols, and clearly delineated order sets. For effective implementation and tracking, the development of these tools require a multidisciplinary approach. As an example, an early extubation protocol cannot be successfully implemented without involvement of cardiac anesthesia providers. Also, the use of feeding protocols will need partnership with the dietary team and other providers outside the ICU. Such standardization not only minimizes errors but also alerts the team about patients who may have an unexpected course. For instance, a standardized postoperative inotrope regimen helps the PCICU team in early identification of patients who may have had an unexpected intraoperative course. Although most patients in the cardiac ICU have an uncomplicated course, the reported rate of significant complications ranges from 3% to 52% depending on the complication examined. Some of these complications may be unavoidable, but the ability of the PCICU to recognize and promptly treat them is dependent on the quality of care delivered by the unit.
Organizational Structure.
The complexity of the pediatric intensive care unit (PICU) and the high visibility/resource use, as well as the central role that the PCICU plays in the heart center, requires all stakeholders to have input. Managing these multiple factions requires the PCICU medical director, surgical director, and managers to develop a consistent and comprehensive strategy to monitor and improve performance and the team. We have suggested a group of standing meetings that we have found helpful ( Table 5.3 ). These meetings will drive change as long as they have specific goals, data-driven agendas, follow-up, and communication back to the team. Several different challenges will be outlined in the following sections.
| Name | Goal | Members | Ownership | Frequency |
|---|---|---|---|---|
| Heart center leadership | Align all disciplines to achieve team goals | Senior clinicians, Ops | Heart center directors | Monthly |
| Surgical case conference | Discuss upcoming cases | All heart center clinicians | Cardiology/CV surgery | Weekly |
| PCICU safety | Identify opportunities to improve quality of care | PCICU faculty, CV surgery, cardiologists, RN management, staff and allied professionals | PCICU medical director/RN manager | Monthly |
| PCICU M&M | Review outcomes to determine systematic changes (e.g., CLABSI) | PCICU faculty, CV surgery, cardiologists, RN management, staff and allied professionals | PCICU medical director/RN manager | Monthly |
| PCICU Ops | Identify high-impact multidisciplinary areas for improvement and process improvement | PCICU medical director, RN manager, pharmacy, respiratory care | PCICU medical director/RN manager | Monthly |
| PCICU clinical case review | Review current/interesting cases to develop consensus | PCICU faculty/fellows/APP | PCICU faculty on service | Weekly |
| Code review | Review details of all codes/near code events | PCICU faculty, CV surgery, cardiologists, RN management, staff and allied professionals | PCICU code director | Monthly |
| Family meetings | Consolidate plans and identify communication concerns | PCICU attending/team/RN on service, social work, quality of care | PCICU clinical team | Done when needed or after 2 weeks in PCICU |
| Quality of care rounds | Identify barriers in care and care transitions | PCICU clinicians/staff, quality of care team, social work, transition of care teams | PCICU clinical team | Weekly |
| “Brain” rounds | Optimize neurologic outcomes | PCICU attending/team/on service, neurology | PCICU team | Weekly |
| Family advisory council | Identify family-directed initiatives to improve quality of care | Parents, PCICU clinicians, CV surgeons, cardiologists, PCICU nurse manager/staff | Family council lead/PCICU director/RN manager | Monthly |
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