New three-tier hierarchy of care needed for critically ill children, says new report

Calls to reduce inequity for critically ill children as Royal College of Paediatrics and Child Health (RCPCH) also recommends:

  • Higher training and competence requirements for professionals caring for severely ill children

  • A single commissioning host for all paediatric critical care services to avoid fragmentation of services

Children’s health experts are calling for a new three-tier hierarchy system of critical care, enhanced staff training, reorganisation of services and a more consistent funding model to bridge the gap between critical care delivered to children in children’s wards and high dependency units and that delivered in intensive care.*

Recommendations

The ‘High Dependency Care for Children – Time to Move on’ report, published today by the Royal College of Paediatrics and Child Health (RCPCH), makes a series of recommendations which aim to improve the delivery of safe, high-quality critical care for children outside the paediatric intensive care ward.

One recommendation is a bold change in the way critical care is delivered. The report suggests a hierarchy of three levels of paediatric critical care along with the development of clear care pathways for children to allow patients to move from high dependency care (level 1 and 2) to intensive care, (level 3) as and when needed. A new level 2 critical care model has been proposed in order to deliver a level of care that is currently not possible outside of the paediatric intensive care unit.

Produced by a multidisciplinary working group and led by the RCPCH, Paediatric Intensive Care Society and Royal College of Nursing, the ‘High Dependency Care for Children – Time to Move on’ report also recommends:

  • All hospitals who admit children should be able to deliver Level 1 Critical Care
  • A limited number of hospitals should be designated to deliver Level 2 care
  • Paediatric Critical Care Operational Delivery Networks should be established along with clear guidelines and clinical pathways for patients to ensure care is co-ordinated across the network
  • Case discussion ‘trigger points’ with specialised paediatric transport services should be introduced, to allow existing transport services to provide advice, decision support, and where necessary specialist transportation of a critically ill child to Level 2 and Level 3 units

Dr Kevin Morris, Fellow of the Royal College of Paediatrics and Child Health, Past-President of the Paediatric Intensive Care Society and Clinical Lead for the report, said:

“Whilst considerable progress has been made in the UK in delivering intensive care for children over the last 10 years, ongoing care for the critically ill child outside the intensive care setting has not progressed to the same degree.

“That’s due to a number of factors such as inconsistent meanings of the term ‘high dependency care’, patchy and inconsistent funding, differences in staffing levels, staff training and competence and bed capacity.

“These are services that manage the care of some of the most critically ill children so it’s crucial that we catch up – this report aims to kick-start this process.”

The report also makes a number of recommendations aimed at the nursing and medical workforce. These include:

  • Nurses new to critical care should work a minimum of 75 hours of supervised practice in a level 1/2 critical care unit to gain the essential skills required to deliver quality care
  • Higher levels of training and competence for nurses and junior doctors working in level 2 critical care units
  • At least 6 months training in paediatric intensive care for consultants providing cover to level 2 units

Dr Morris continues: “Significant change is needed if we are to bridge the gap between what is currently delivered in high dependency care areas and PICUs. But while many of the recommendations require commitment from a number of stakeholders and may take time to implement, there are others that can be actioned right away.

“I urge all health professionals to review the delivery of critical care to children within their own organisations against these recommendations and to establish a plan to ‘move on’”

Fiona Smith, the Royal College of Nursing’s Children and Young People’s Adviser, said:

“Inconsistent service arrangements mean that critically ill children aren’t always receiving the high quality care that they desperately need.

“It’s crucial to ensure that services have enough staff with the required skills to deliver safe and effective care. Health service organisations must make sure staff are meeting the relevant training competencies and are supported in keeping their children’s critical care specialist skills refreshed and up to date.

“The recommended changes contained in this report would go a long way to ensuring that critically ill children and their family get the best possible care.”

Further information

To read the report or to find out more, visit the High Dependency Care webpage.