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Admission and Discharge for Pediatric Intensive Care Unit (PICU) (2.1.33)

Admission and Discharge for Pediatric Intensive Care Unit (PICU) (2.1.33) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.33


UW HEALTH CLINICAL POLICY 1
Policy Title: Admission & Discharge for Pediatric Intensive Care Unit (PICU)
Policy Number: 2.1.33
Category: UW Health
Type: Inpatient
Effective Date: October 20, 2017

I. PURPOSE

To ensure appropriate use of the Pediatric Intensive Care Unit (PICU).

II. POLICY ELEMENTS
A. Intensive Care Status
The Pediatric Intensive Care Unit (PICU) serves critically ill or injured pediatric patients from birth through
young adulthood, as well as adults with specific congenital heart disease, who present with illness or injury
affecting one or more vital organ systems demonstrating an immediate or potential threat to life. Such life-
threatening circumstances may present with actual or impending shock, hypotension, cardiac dysrhythmias,
major impairment of central nervous system function and the need for airway support, mechanical
ventilation, and/or continuous vasoactive infusion. These patients require frequent or continuous nursing
observation and interventions, active or stand-by life support systems, sophisticated monitoring equipment,
and concentrated support services. Pediatric Intensive Care Unit beds and staffing will be assigned to
patients on a priority basis, based on illness severity and urgency of clinical need.
i. Priority I (PICU Status): Patients with one or more severe organ systems failure that is life
threatening and requires invasive monitoring and/or support. In addition, patients requiring a
moderate to high level of support and monitoring or with potential for acute physiologic
decompensation will be Priority I PICU Status. Some examples of patients admitted to the PICU in
this category include those with:
a. Respiratory Disorders
1. Acute respiratory failure requiring ventilator management or non-invasive positive
pressure ventilation.
2. Respiratory insufficiency requiring continuous non-invasive support for treatment
or to prevent deterioration.
b. Cardiovascular Disorders
1. Post cardiac arrest.
2. Life threatening cardiac dysrhythmias.
3. Severe hemodynamic compromise requiring continuous assessment and
ongoing fluid resuscitation needs or vasoactive drug infusion.
4. Life-threatening or unstable cardiovascular disease including progressive
congestive heart failure, congenital heart disease, dysrhythmia, or the need for
arterial, central venous or pulmonary artery pressure measurements.
5. Post-operative care for congenital heart disease, thoracic surgery and after
cardiopulmonary bypass.
6. Extracorporeal life support.
7. Adults with single ventricle cardiac physiology requiring critical care admission for
a cardio respiratory reason.
c. Neurologic Disorders
1. Acute intracranial hypertension, or any intracranial hypertension requiring active
management.
2. Acute stroke.
3. Status epilepticus with respiratory insufficiency.
4. Acute mental status changes with respiratory compromise.
5. Neurologic impairment including frequent seizures, progressive mental status
depression, or progressive neuromuscular changes requiring frequent
intervention and/or monitoring.
d. Metabolic, Renal and Endocrine Disorders
1. Acute hyperkalemia or other metabolic disorder requiring hemodialysis.
2. Unstable endocrine, metabolic or renal disease requiring frequent and rapid
laboratory evaluation and intervention.
e. Gastrointestinal Disorders
1. Acute GI bleeding with hemodynamic instability.



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission & Discharge for Pediatric Intensive Care Unit (PICU)
Policy Number: 2.1.33

2. Hepatic failure.
3. Patients requiring acute surgical procedures of the abdomen that may lead to
cardiorespiratory compromise.
f. Hematologic/oncologic conditions that are potentially life threatening including
coagulopathy, thrombocytopenia, or severe anemia requiring rapid or frequent
transfusions, need for exchange transfusion, or acute tumor lysis syndrome leading to
metabolic or renal dysfunction.
g. Multi-organ system disorders that are life threatening including toxic ingestions, acute
surgical emergencies, and multisystem trauma.
ii. Priority II (Intermediate Care (IMC) Status): Patients who are clinically more stable than Priority I
patients yet require a moderate level of monitoring and/or treatment. These patients require a level
of care and monitoring that cannot be provided on the general pediatric care unit.
a. Patients with systemic or multiple system disease that require complex therapy.
b. Patients that require a level of nursing or respiratory care that is not available on the
general pediatric wards.
c. Patients preparing for discharge that are technology dependent such as those with
tracheostomies that are ventilator dependent or dependent on non-invasive positive
pressure ventilation (CPAP or BiPAP) at home.
d. Patients requiring telemetry to monitor for potentially life-threatening cardiac rhythms
requiring rapid recognition and therapy.
e. Patients with ICP monitoring for diagnostic purposes.
f. Post-operative cardiac patients not meeting criteria for Priority I.
B. Neonatal patients
i. The PICU will admit critically ill patients once discharged from a nursery or Neonatal Intensive Care
Unit (NICU). In general, patients ≥ 35 weeks EGA and ≥ 1.8 kg can be admitted to the PICU from a
referring hospital, emergency department, PICU or NICU when subspecialty medical or surgical
care is needed and not available at the referring hospital. Neonates < 35 weeks EGA or < 1.8 kg
can be admitted to the PICU after discussion with the AFCH neonatologist.
C. Adult patients
i. Patients > 18 years old and < 22 years old that are followed by a Pediatric Surgical or Medical
Specialty may be admitted to the PICU. The medical care of these patients will be assumed by the
PICU team and the primary Pediatric Surgical or Pediatric Medical Services as described in III B
below. Patients over the age of 16years may be transferred to an adult ICU if beds are available
and when the PICU census threatens the closure of the PICU. Specific younger patients (i.e.,
pregnant teenagers or violent offenders) may be more appropriately cared for by adult services and
will be discussed on a case-by-case basis. This transfer will only occur after acceptance of the
patient by the adult ICU attending.
ii. Patients > 18 years old cared for by adult services may occasionally be admitted to the PICU in the
event that beds are not available in the adult ICU which would usually admit those patients and
beds are available in the PICU. Patients admitted from an adult service require approval by the
PICU attending physician on service prior to admission. Patient care will be assumed by the adult
service unless otherwise specified. Adult patients that are not cooperative, are violent, or have a
history of violent behavior will not be admitted to the PICU.
D. General Care overflow during AFCH bed capacity situations
i. When AFCH experiences constraints in bed availability and there are beds available in the PICU,
the PICU will provide general care to patients to avoid deferring of any pediatric patient. General
care patients that remain in the PICU may, at the discretion of the attending intensivist, continue to
be cared for by the PICU team until they are physically transferred out of the PICU.
a. Priority for general care patients in the PICU will be for patients that are recovering from a
critical illness and are waiting for transfer to the pediatric ward.
b. Other populations to consider are scheduled admissions such as:
1. Post-op surgical admissions geared to average length of stay (ALOS) of 4 or less
days and or scheduled general care admissions.
2. Video EEG patients.
3. General Pediatric Care Unit Patients:
General pediatric care unit patients may be admitted to the PICU when beds are
not available on the general pediatric care inpatient units. These patients require
communication with the PICU attending physician on service prior to admission.



UW HEALTH CLINICAL POLICY 3
Policy Title: Admission & Discharge for Pediatric Intensive Care Unit (PICU)
Policy Number: 2.1.33

E. Triage of patients during times of high census in the PICU
i. One bed in the PICU will remain open for emergent admissions such as Level I Trauma, Pediatric
Blue Carts, and emergent Priority I admissions from the OR or ED.
ii. The PICU Attending will determine which patients meet criteria for admission to the PICU or need
to remain in the PICU. These decisions will be made in collaboration with co-managing teams.
iii. Patients that do not meet criteria for Priority I or II above (II.A.i. and II.A.ii) will be transferred to the
pediatric ward.
iv. The PICU Attending or Fellow may assess patients prior to admission to the PICU to ensure they
meet criteria for PICU admission.
III. PROCEDURE
A. Admission.
i. Scheduled Admissions to PICU.
a. The primary requesting attending physician will evaluate the patient for the need for PICU
admission based on the potential that the patient's medical status will require PICU
services during the hospitalization as defined by II. A above.
b. For expected patients who will require admission to the PICU, the primary attending
physician or their designee must call the PICU for a bed reservation at least 24 hours
before the anticipated PICU admission. The following information will be provided to the
PICU: the date the reservation is needed, patient name, MR number, birth date, diagnosis,
procedure planned and requesting service/attending physician. This information will be
recorded on the PICU reservation board. Failure to make a reservation for a scheduled
admission may lead to a delay in admission when the PICU census is high. These
patients may need to be held in the PACU following procedures until a bed becomes
available.
c. The Medical Director of the PICU and the Clinical Nurse Manager will review prospective
scheduled admissions on a regular basis to assess the allocation of resources.
ii. Unscheduled Admissions.
a. From within UW Hospital including the Operating Room, Pediatric Inpatient Unit, Pediatric
Clinics and Emergency Department, the requesting primary attending physician or their
designee will:
1. Contact the attending PICU physician and the Access Center as soon as the
need for a PICU bed is anticipated and prior to actual PICU admission.
2. Identify the patient whose clinical status warrants placement in the PICU and
provide a physician to physician handoff.
3. Place a comprehensive transfer summary in the Progress Notes prior to or
immediately following the actual transfer of the patient.
b. The actual decision to admit the patient to the PICU will be made jointly between the PICU
attending and the primary requesting attending. The PICU attending will confer with the
PICU Clinical Nurse Manager/PICU Charge Nurse who will be involved with the decision
to admit the patient to the PICU. At times of high census they will work with the UWHC
Nursing Coordinator and UW Access Center. In emergency situations requiring immediate
transfer, both the responsible attending staff and the PICU attending must be notified by
Graduate Medical Education (GME) trainees and/or nursing prior to transfer. From outside
UW Hospital:
1. The requesting referring physician or their designee will contact the Access
Center to request a PICU transfer. The Access Center will page the attending
PICU physician on call and the fellow on call and connect the call with the
referring provider. The patient's condition and management will be discussed as
a handoff prior to transfer to UWHC.
2. The Access Center, UWHC Nursing Coordinator, attending PICU physician, and
PICU Clinical Nurse Manager/Charge Nurse will jointly determine placement.
3. Pediatric Med Flights: The PICU attending physician must be contacted and
informed by Med Flight of all Pediatric Med Flight transports.
4. Children's Hospital Emergency Transport Ambulance (CHETA) transports: the
Access Center will notify Critical Care Transport (CCT) dispatch of all CHETA



UW HEALTH CLINICAL POLICY 4
Policy Title: Admission & Discharge for Pediatric Intensive Care Unit (PICU)
Policy Number: 2.1.33

transports. The PICU attending physician must be contacted and notified prior to
all CHETA transports.
5. Patients may be directly admitted to the PICU from referring hospitals (in-patient
or ER) with PICU attending physician acceptance through the Access Center.
6. Other outpatients that are acutely ill and require emergency admission should be
assessed, provided emergency care, and triaged by a physician prior to
admission to the PICU. The PICU will not directly admit such patients from home
or from a clinic.
B. Assignment of patients:
i. All patients (Priority I/PICU Status and Priority II/IMC Status) admitted to the PICU will be either (a)
primarily managed by the PICU team or (b) co-managed between the PICU team and Primary
Admitting Service.
a. PICU Team Managed Patients: The primary care is the responsibility of, and assigned to
the PICU attending staff and team. This includes all medical admissions to the PICU. The
PICU service team will write all orders. The transferring service will remain as a
consultant. Appropriate attempts will be made for the two teams to round together on
patients.
b. Co-managed Patients: Surgical and Trauma patients will be co-managed with the surgical
attending leading the team. Ideally, both services will discuss and approve of major
changes in patient plans of care. Timely and respectful communications will occur
between services regarding patient care issues, orders written by each service will be
communicated to the other service in a timely fashion, and attempts should be made to
round on patients jointly or to have a representative from each team present during the
respective patient care discussions.
ii. Consultants will not write orders on PICU patients unless approved by the attending PICU
physician.
C. Transfer from the PICU.
i. Transfer criteria:
a. Resolution or reduction of the acuity of the underlying problem(s), which necessitated
admission in II.A.i and II.A.ii above.
b. PICU monitoring and/or management is no longer required.
c. Patient should:
1. Be hemodynamically stable.
2. Have stable respiratory status.
3. Demonstrate stable neurological status.
4. Demonstrate stable metabolic/endocrine status.
ii. Transfer Procedure from PICU:
a. For patients whose primary service is the Pediatric Intensive Care Medical team:
1. The Pediatric Intensive Care team (PICU nurses and physicians), and Primary
Service when appropriate, will evaluate appropriateness for transfer to an
inpatient general pediatric care unit. Identification of possible transfers out of the
PICU should be identified the day prior and evaluation for transfer
appropriateness is preferably at or before morning rounds the day of transfer.
2. Prior to transfer, the attending PICU physician or designee will contact the
accepting attending physician or designee.
3. The accepting resident team will be contacted and informed of the patient's
clinical condition by the PICU resident team prior to or at the time of transfer.
Transfer orders will be written by PICU team and reviewed with the primary
service assuming responsibility for the patient.
4. A Transfer Summary note will be completed prior to or at the time of transfer.
b. For patients co-managed by a Primary Service and the Pediatric Intensive Care Medical
team:
1. Transfer decisions are made by the primary team in collaboration with the PICU
team. The attending PICU physician must assess the patient and agree to the
transfer prior to actual patient transfer.
2. Transfer orders will be written by the PICU Team. When PICU beds and nursing
staff are in shortage, the transfer orders will be complete within 1 hour of a
transfer decision.



UW HEALTH CLINICAL POLICY 5
Policy Title: Admission & Discharge for Pediatric Intensive Care Unit (PICU)
Policy Number: 2.1.33

D. Discharge.
i. When discharge from the PICU is appropriate, Discharge Planning Process (UW Health Clinical
Policy #2.1.25) will be followed, including discharge teaching and referral to home care agencies as
appropriate.
ii. Patients that are potential discharges from the PICU should be identified as early as possible in the
hospitalization so that all administrative paperwork can be completed in a timely manner. On the
day of discharge the patient should be evaluated and a decision to discharge should be made prior
to rounds when possible.

IV. COORDINATION

Author: Medical Director, Pediatric Intensive Care Unit; Nurse Manager, Pediatric Intensive Care Unit
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: None
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: September 18, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. References

UW Health Clinical Policy #2.1.25, Discharge Planning Process

VII. REVIEW DETAILS

Version: Revision
Last Full Review: October 20, 2017
Next Revision Due: October 2020
Formerly Known as: Hospital Administrative policy #7.18