ORGANIZATION OF THE PEDIATRIC INTENSIVE CARE UNIT

The PICU should be represented in the hospital by a multidisciplinary committee of the professional staff, including the medical and nursing directors, hospital administrators, and representatives from pediatric medicine, anesthesia, surgery, and the pediatric subspecialties. This committee should be responsible for policy and procedures pertaining to the PICU and should make recommendations regarding personnel staffing, equipment purchases, and structural and design changes within the unit.

The PICU staff should include a medical director whose special expertise and training in pediatric critical care qualify that person to oversee the quality of care provided to all patients in the unit. Additional responsibilities include patient triage, implementation of policy and procedures, in-service education, and coordination of multiple consultants. Physician coverage should be full-time geographic at the resident, fellow, or attending staff level. The medical director also functions as arbiter and patient advocate.

The nursing director should have special skills in pediatric intensive care, education, and personnel management. The medical director and nursing director must collaborate as a team. The registered nursing staff must be trained in all aspects of pediatric critical care and resuscitation, and staffing needs to be flexible enough to provide one-on-one coverage when necessary. A multidisciplinary in-service program for continuing education and orientation is essential.

Other team members should include respiratory therapists, physical therapists, nutritionists, social workers, psychiatrists, pharmacists, and psychologists for both patients and staff, as well as laboratory technologists. All support personnel are essential to the team effort and should be included in rounds and team meetings whenever possible.

The physical facility for the PICU should be self-contained and spacious enough to provide adequate work area around each bed space and enough storage to keep life-support equipment within reach. Because the PICU staff lives in the environment, space for reading, meeting, sleeping, and showering should be available. Parent and visitor space is essential to permit parents to sleep overnight. Facilities should be designed to encourage constant parental participation because parents are such an essential part of the therapeutic plan of any critically ill child.

Each bed space should be standardized so that the level of support and monitoring can be escalated. Private rooms are ideal, but if shared rooms are necessary, the distance between beds should be adequate to ensure privacy and minimize nosocomial infection. Complete precaution or isolation rooms should be available within the confines of the unit.

Along with life support equipment, devices for diversion and entertainment should be available for children who are conscious. Children's audiovisual equipment can often replace heavy sedation when patient cooperation is essential. On the other hand, there is no substitute for nursing involvement at the bedside in preventing accidental self-extubation or other inadvertent, potentially self-destructive behavior. Because of the need for close personal observation, centrally monitored nursing stations have little place in the PICU.