Original article
Paediatric high dependency provision: a case for urgent review in the United Kingdom

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Abstract

The issues surrounding paediatric high dependency provision require attention. The field of adult high dependency has revealed some useful studies, which promote the benefits of designated care. These relate to improved quality of care and reduced pressure on the availability of intensive care beds. This review outlines recent initiatives made in the development of paediatric intensive care units in Britain and demonstrates how practical lessons learnt in the adult critical care sector may be used to establish appropriate Level 1 care in paediatrics. Two paediatric clinical issues are reviewed that support the need for high dependency provision, these being: paediatric respiratory management and the management of sedation withdrawal. The options available to district general hospitals, specialist hospitals, as well as lead paediatric hospitals are discussed, and include quality issues, where education, training and clinical audit are integral to structural and staffing HDU considerations.

Introduction

The evaluation of paediatric high dependency unit (PHDU) provision is one of quality where evidence-based practice, clinical audit, appropriate care management, client satisfaction, research and clinical supervision all have integral parts to play. Frequently however decisions are delayed regarding the establishment of PHDUs. One initial barrier is deciding whether the formation of a PHDU will ease the pressures on intensive care units (ICUs) and lead to an improved quality of care. The question of high dependency care reducing mortality is challenged by Davies et al. (1999) and in turn supported by Turner et al. (1999).

Three fundamental aspects are important in relation to PHDU provision. Firstly, organisational, staffing and training strategies are necessary to ensure the effective integration of high dependency care within a quality paediatric critical care service (NHS Executive 2000 North West). The high dependency service must be fully integrated into the organisational structure for paediatric intensive care (PIC) provision suggested in Paediatric Intensive Care: A Framework for the Future (NHS Executive 1997a). This will be addressed through examination of the current initiatives within paediatric intensive care and their relevance to Level 1 care, which is defined in Box 1. High dependency relates to children who require “Level 1” care. It would not provide continuing care for children who need mechanical ventilation (Level 2 care) but the ability to establish ventilation and Level 2 care would be required prior to transfer to a PICU (NHS Executive 2000 North West).

Secondly, existing research examining ICU workload and client specification will be assessed (Kilpatrick et al. 1994) and unfortunately, due to a lack of paediatric research in this area, adult studies will have to be reviewed instead.

Finally, sub-optimal care pre- and post-admission to the intensive care unit will be discussed as it is a measurable aspect of “quality” and consequently of importance (McQuillan et al. 1998).

The tragic circumstances surrounding the death of Nicholas Geldard aged 10 (Ashworth 1996), prompted a national review of the services provided for critically ill children in the UK. Subsequent government publications (NHS Executive 1996a; NHS Executive 1997a, NHS Executive 1997b) all focused on creating a co-ordinated, structured approach to the provision of paediatric intensive care (PIC). Clinical and organisational standards were set to which DGHs, lead centres and specialist hospitals were expected to adhere. These standards referred not only to appropriate levels of care being given in appropriate settings but also provided guidelines that have implications for nurse staffing and training.

Initially the government plan was to create 55 more paediatric intensive care beds and high dependency beds by 2000 (NHS Executive 1996a). Greater numbers of paediatric intensive care nurses were to be trained and efforts made to retain and recruit nursing staff (NHS Executive 1999). It is noticeable, however, that the percentage of children’s trained intensive care nurses remained relatively static in 1996 and 1997, 48 and 47%, respectively despite the number of beds in UK rising during this time from 249 to 280 (NHS Executive 1997a). Nurse recruitment and retention strategies require ongoing audit, as providing financial aid to create more PIC beds will be ineffectual unless the specialist nurses can be found to staff them.

Reorganisation of PIC services to ensure a safer, more integrated approach was the immediate goal of the report (NHS Executive 1996a). As a consequence highly trained retrieval services were funded and organised (Taylor 1997) and a national co-ordinating service evolved with most regions now having a regional bed information service.

Much has been attempted in 5 years to eliminate the inefficiencies made evident in the Nicholas Geldard inquiry (Ashworth 1996). These changes have yet to be assessed for their effectiveness but in comparison, the promotion of specified paediatric high dependency provision remains confused.

Paediatric high dependency provision should be addressed with the kind of enthusiasm that welcomed the government publication for PIC proposals (NHS Executive 1997a). Indeed the guidelines related to admission and discharge state that “high dependency care should provide: a designated area where such care is provided.” (NHS Executive 1996b, pp 7).

Evidently, critical care provision can only become an effective, appropriate and integrated service if “Level 1” investment is made in both DGHs and paediatric lead centres. For valid clinical reasons sub-optimal care may be provided for children because the need for organised high dependency provision has not been identified (McQuillan et al. 1998). The speciality must not be viewed as an after thought or intensive care’s ‘poor relation.’ Initiatives need to be followed through and one of the best ways to begin this is to examine how adult high dependency provision has evolved.

Bion (1995) suggested that only 15% of British hospitals had adult high dependency units. Following this many hospital trusts assessed demand and evaluated the effect of such units whilst conceiving them (Thompson & Spiers 1998; Ryan et al. 1997, Dhond et al. 1998). Unfortunately though there are no randomised controlled studies, to date, that measure the effectiveness of high dependency provision. Consequently, some conflicting results exist with regard to the cost effectiveness of high dependency facilities (Davies et al. 1999, Turner et al. 1999).

The Leicester General Hospital and the Freeman Hospital in Newcastle both investigated their adult HDU provision. The three studies (two at Leicester) varied in methodology as the centres used their own specific approaches to assess patient occupancy, and utilised differing HDU classification criteria. However, all have some relevance to this discussion since they had the common aim of assessing the demand for high dependency care and its effect on intensive care occupancy, a factor that urgently requires assessment within paediatric critical care.

Leicester conducted two studies. (Thompson & Spiers 1998; Fox et al. 1999). The first explored the occupancy of a teaching hospital adult intensive care unit by high dependency patients and the second reviewed the impact (on ICU occupancy) of opening an adult high dependency unit. The authors in the first study (Thompson & Spiers 1998) identified that ICU resources may be being used inappropriately by treating PHDU patients within the intensive care facility. Patients were classified daily as being high dependency or intensive care, following guidelines from the NHS Executive (1996b, DOH). The authors “defined a patient as ICU status for the 24 h period from 08.00 to 08.00 h if at any time during that period the patient had been classified as ICU status” (Thompson & Spiers 1998, pp 590).

The study reported that from a total of 73, 19 were noted as being high dependency for the whole of their ICU stay. It was also evident that seven other patients had been managed by the ICU team in other areas of the hospital because the ICU was full. A further five patients were readmitted to ICU following discharge to the ward. Four patients had their surgery postponed and two patients who had been scheduled for postoperative ICU admission, were managed in a recovery ward and on a general surgical ward by the surgical teams (Thompson & Spiers 1998).

The study concluded that, “the current use of ICU and one-to-one nursing to manage high dependency patients is not an efficient use of resources” and that PHDU patients managed on the short staffed general wards did not constitute good quality care (Thompson & Spiers 1998, pp 592). They did however qualify their enthusiasm for the formation of a high dependency facility by stating how “closing ICU beds in order to open PHDU beds may limit the ability to cope with the inevitable peaks in demand for intensive care.” (Thompson & Spiers 1998, pp 592).

The second study (Fox et al. 1999) was completed after resources from closing one bed on the ICU had been diverted with other money to the establishment of a four-bedded HDU. The results demonstrated 11.2% of ICU hourly occupancy was still accounted for by HDU status patients. However, this compared to 21.6% before the HDU opened. Readmission rates to ICU had also considerably reduced (Fox et al. 1999). It was evident that the introduction of HDU beds had the capacity to reduce the inappropriate use of intensive care beds and reduce readmission.

The Freeman Hospital in Newcastle (Ryan et al. 1997), appraised patient classification, length of stay, outcome, ICU transfers in and out of the unit, elective surgical cancellations, refusals for admission to ICU and requests for admission to HDU. The data revealed that, “during the study period 66-bed days (21%) were occupied by HDU patients and on two-thirds of the 22 days when the unit was full at least one bed was occupied by an PHDU patient.” “Requests for admissions were refused on seven occasions” and on “three occasions when the ICU was full and an HDU patient occupied a bed, a patient requiring intensive care had to be transferred.” Of “four patients that were prematurely discharged to make room for emergency admissions, one had to be readmitted the same day and ventilated” (Ryan et al. 1997, pp 266).

The study revealed useful data regarding the clinical management of elective surgical cases, “86% could easily have been transferred to an HDU for care” (Ryan et al. 1997, pp 268).

The previous studies are useful to contemplate because they demonstrate the inappropriate use of scarce resources and the level of risk patients have been exposed to. However, paediatric critical care has its own specific considerations and these need to be reviewed before resources are allocated to creating another tier within paediatric critical care.

Respiratory management is the cornerstone of paediatric critical care management. The natural progression of the acute paediatric medical emergency tends to begin with a compromised respiratory system (Kissoon 1998). Respiratory arrests can occur quickly due to small, compliant upper airways that easily become occluded. Early detection of airway problems in children is vital as is prompt and sometimes aggressive treatment. A deteriorating child may spend only a short amount of time in a PHDU before necessitating transfer to ICU for ventilation. Alternatively, the more intensive level of nursing care and more immediate access to medical assessment, treatment and monitoring on a PHDU may prevent the condition deteriorating to a level that requires ventilation. It is possible that early airway management skills taught to PHDU nurses who are trained for advanced paediatric life support (APLS) or paediatric life support (PLS) may have a profound effect on outcome. Particularly in view of evidence produced in adults, which demonstrated that sub-optimal care prior to admission to ICU is a real concern (McQuillan et al. 1998).

An important paediatric aspect of critical care to be discussed which may be improved by effective PHDU provision, is the “withdrawal of sedation.” There is a growing awareness amongst clinicians that withdrawal states are common (Eddleston et al. 1997). Benzodiazepines are commonly used when a child is on PICU. Weaning protocols vary considerably between hospitals despite the acknowledgement that withdrawal can occur with only 1 days’ administration of Midazolam (Carnevale & Ducharme 1997). Suggested protocols state it may be prudent to reduce the IV benzodiazepine dose by 10% a day substituting the IV dose with oral Midazolam when possible (Eddleston et al. 1997). Notterman (1997) also recommends a tapering of the dose over several days with a 10% reduction over 24 h again administrating a longer acting benzodiazepine if symptoms of withdrawal appear.

Obviously this presents a problem for PICU provision. Ward staff are reluctant to accept children with Midazolam infusions due to their potential to cause reduced tidal volumes and in some cases apnoea (Pappagallo et al. 1992). The ward environment does not have appropriate staff/patient ratios to monitor children to the extent they would require and they do not have the facilities to artificially ventilate in the event of respiratory failure.

Consequently clinicians may be tempted to withdraw Midazolam administration quickly, as soon as the child is sufficiently recovered and can be extubated. This has the potential to produce a child who is discharged to the ward only to display the unpleasant hallucinations, behavioural abnormalities and physiological symptoms that withdrawal can cause in the crucial “step down” period. Attempts can be made to relieve symptoms with other drugs, e.g. chloral hydrate (a hypnotic) and promethazine an older antihistamine that is capable of penetrating the blood/brain barrier thereby inducing sedation (Rang & Dale 1991). However, neither one of these will be capable of occupying the “empty” GABA receptor sites (as they are not benzodiazepines) which have been implicated in the mechanism of pharmacological withdrawal of Midazolam (Eddleston et al. 1997). This is not an insignificant problem. Hughes et al. (1994) recorded an overall incidence of abnormal effects related to Midazolam infusions at 17% and parents in particular have been integral in noticing abnormal behaviour in their children following discharge from PICU (Hughes & Choonara 1998).

The establishment of an PHDU with increased nursing establishment and APLS skills may avoid the need for abrupt discontinuation of Midazolam infusions. This in turn may reduce the possibility of physiological withdrawal therefore improving the quality of care given following discharge from PICU (Taylor 1999). The child would be able to vacate the PICU bed but reside on PHDU whilst the infusion was being tapered by 10% every 24 h (Eddleston et al. 1997). Closer observation may ensure that the signs and symptoms of withdrawal were spotted earlier than they would be on a busy ward and treatment initiated sooner.

Issues related to the psychological effects of PICU are severely under-researched and clearly children may be suffering from the effects of poly-pharmacy or the ICU environment (Shafer 1998) and not just Midazolam withdrawal. A PHDU however, would provide a controlled area in which to study these effects as well as ensure correct nurse/patient ratios therefore giving adequate support to the child and parents.

Having outlined some of the clinical evidence regarding need to increase paediatric high dependency provision, the review will proceed to discuss how this might be facilitated.

It is vital that all hospitals accepting children through their accident and emergency departments review their provision for high dependency care. The “Framework for the Future” (NHS Executive 1997a) suggests hospitals should have the capacity to carry out Level 1 care and the ability to initiate Level 2 care. The initiative has been taken by the North West NHS Executive who have issued guidelines specifying the provision of paediatric high dependency care (NHS Executive 2000). The document covers provision within DGHs as well as lead paediatric and specialist centres.

The North West report on the “Provision of High Dependency Care” recognises that “high dependency” and “specialing” of children are not readily distinguished from each other (NHS Executive 2000). It is suggested that lead centres would need a multi-speciality facility of not less that 12 beds whereas a DGH may need a minimum of two. Nurse staffing has been recommended by other authors to ensure a ratio of 1:2 but the North West report goes further to recommend 1:1 at DGH facilities (1:2 at paediatric lead centres) with provision made for shift leaders and health care support workers. Clearly it is more labour intensive to look after a newly admitted, hypoxic, uncooperative, conscious child with intensely agitated parents than one who is ventilated sedated, paralysed and stable whose parents have become somewhat acclimatised to the ICU environment. In the former case a 1:2 nurse:patient ratio may be insufficient, an issue which is acknowledged by the NHS Executive (1996b, DOH). The need to isolate a child “in a cubicle” may also necessitate a greater level of nurse staffing (NHS Executive 2000, pp 3).

Both the “paediatric intensive care framework for the future” (NHS Executive 1997a) and the North West Report (2000) emphasise the importance of good communication between senior medical staff when transporting a child between hospitals and access to specialist advice is specifically mentioned.

The report recommends appointing a ward manager and a clinical nurse manager with a lead clinician (who is a consultant paediatrician) having overall administrative responsibility over the PHDU. There could however, be conflict when a particular clinician has overall control. This may be especially pertinant when competition for High Dependency medical, surgical and ICU step-down beds could be fierce during winter months. In this case it is possible to see how surgical cases may be cancelled to provide room for PICU step-down children. The potential for conflict associated with a scarcity of beds (Ridley 1998), could be addressed through the introduction of a nurse consultant in the PHDU who is also head of the critical care hospital outreach team.

McQuillan (1998) introduces the concept of doctors as “physiology police.” His identification of sub-optimal care before admission to ICU could give weight to the formation of a paediatric critical care outreach team that includes both senior nurses and doctors from ICU, PHDU and A&E that can ensure children receive “seamless” care (Fig. 1). Deteriorating children, whether they lie on the ward or on PHDU may then be spotted early and transfers organised. The team may also be fundamental in establishing uniform protocols and guidelines for transporting children between levels as they would be able to communicate with speciality hospitals as well as DGHs whilst being based at the lead centre.

To ensure good communication, it may be advisable to have the PHDU geographically linked to PICU in lead centres and to the medical unit in DGHs (NHS Executive 2000 North West Report). Much would depend on whether the greatest anticipated demand would come from theatres or whether winter pressures from upper respiratory infections would generate the highest caseload. Understandably any PHDU would need a “core staffing” element, but within the lead centre, rotation of staff between PICU and PHDU may be useful (McQuillan 1998). Rotation can sometimes be resisted initially but the increased unit management opportunities may be attractive to staff that get limited scope for this aspect of clinical development in PICU. Rotation could be a concept embraced by newly qualified nurses as long as it is structured and their experience is specified from the beginning of their contract. The expectations of newly qualified nurses must be assessed and met and encouragement given to those nurses who have elected to cross-train (Metzger 1986).

Certainly flexibility incentives may need to be given and staff encouraged with the promise of recognised training courses and in-house education which could lead to an improved quality of nursing (Clark et al. 1996). Inviting ward nurses to accept temporary placement within PHDU could rectify a potential problem regarding de-skilling ward staff, which is often a concern when developing another tier of specialist, nurses (Castledine 2000, Ridley 1998, pp 656). This may consequently have the effect of increasing the quality of care throughout the hospital generally as well as providing a source of specialist knowledge to the PHDU.

Education and training would need to be orientated around both high dependency and PIC courses. Senior Nurses who are APLS trained would be vital on PHDUs where medical access is not always immediate. PLS courses may be all that is needed on PICU where medical assistance is available constantly.

As previously stated, the critical care team may, as part of its responsibilities operate an outreach service that visits otherwards and hospitals giving advice on stable transport and PLS skills (Fig. 1). Millar (2000) reports on this initiative planned by Leicester Royal Infirmary. Communication and organised education is central to ensuring a child receives the same quality of high dependency care whether he/she is at a lead centre or DGH.

Fig. 1 represents an addition to the existing PICU structure outlined by the NHS Executive (1997a). Here major acute hospitals, speciality hospitals and district generals would all possess between 2 and 6 paediatric high dependency unit (PHDU) beds. Deteriorating children would be transferred from general areas such as accident and emergency, theatre and medical and surgical wards to their own hospital’s PHDU. If they became in need of Level 2 care the lead centre would be notified, the child stabilised and collected by the lead centre transport team. The lead centre PICU would only hold Level 2/3 children as Level 1 children would either be transferred back to their local PHDU or if readmission is a possibility, be moved to the lead high dependency unit. The lead centre PHDU should be large enough (12 beds) to prevent PICU beds being blocked by Level 1 children.

Education linked to care of the high dependency child could be co-ordinated by the paediatric critical care outreach team (based at the lead centre) including available secondments on the lead PHDU for staff at other smaller PHDUs. The outreach team would need to communicate well with all high dependency areas and any educational input that the speciality centre (burns, neurosurgery) can give highlighted as these children may present at District General Hospitals initially. Such a structure may prevent late admission to PICU and facilitate quality high dependency care.

Any new facility needs careful auditing to assess demand, supply and effectiveness. Clinical guidelines (Harrison 1998) evidence-based practice (Hamer & Collinson 1999) and benchmarking (Ellis 2000) all have roles to play within the clinical audit and can be used to ensure a quality service. Medical audits tend to focus on occupancy, length of stay, morbidity and mortality but the ethos of nursing demands that we audit the process and not just the outcomes (Morrell & Harvey 1999). The degree of parent/child satisfaction with the service provided must be ascertained. Staff satisfaction and perceptions of opportunities for clinical development are important, as dissatisfied nursing staff will threaten the existence of a PHDU. Clinical supervision (Fish & Twinn 1997) is essential. Critical incidents must be discussed openly with the opportunity given for all grades of staff to contribute to ensure dedication to quality exists throughout the unit.

Section snippets

Conclusion

The NHS Executive revealed that 61% critically ill children in the North West required Level 1 care in 1995/1996 in contrast to 39% requiring Levels “2 and 3” (NHS Executive 1997a). The government has focused quite rightly on addressing the shortfall in intensive care beds first. Surely though, organising and funding Level 1 care will not only improve “quality” within this sector but would also relieve the pressure on intensive care facilities making for a more effective critical care service.

Katrina J. Wade BSc Hons, RN/RNChild, PGCE, ENB415, Staff Nurse on the Paediatric Intensive Care Unit at Alder Hey Children’s Hospital/Liverpool, Eaton Road, Liverpool L12 2AP, UK. E-mail: [email protected]

(Requests for offprints to KJW)

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  • Cited by (0)

    Katrina J. Wade BSc Hons, RN/RNChild, PGCE, ENB415, Staff Nurse on the Paediatric Intensive Care Unit at Alder Hey Children’s Hospital/Liverpool, Eaton Road, Liverpool L12 2AP, UK. E-mail: [email protected]

    (Requests for offprints to KJW)

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