Joint Briefing from the ICS, PICS & APAGBI, June 2009
Managing very sick children in a pandemic
Introduction
One of the recurrent concerns – discussed in many forums over recent months – has been the dilemma about how NHS organisations will cope with potential high numbers of children who may become seriously ill if or when a pandemic occurs. Unfortunately one of the reasons that there has been little formal guidance on this is that there are no easy answers – but the recent formal declaration that a pandemic is now in process does create the need for a greater focus on this, and recent meetings have taken place to try to address some of the difficulties.
It is likely that many intensive care consultants who have been in their posts for more than 10 years will be aware of the historic legacy of centralising paediatric intensive care which has – in part at least – led us to the position that we are in now. It is perhaps worth clarifying this a little for those who may not be aware of this background, and so a brief summary may be useful for some.
History
In the 1980-90s it was normal practice for ventilated sick children to be cared for in general ICUs – or sometimes in paediatric wards with the close support of intensive care consultants or anaesthetists with specific interests in children. This was in part because District General Hospitals viewed this as their responsibility – but also because there were very few specialist paediatric intensive care units, and the pressure for the existing beds was such that only the more complex, sickest children could be accommodated in these units. Although there were undoubtedly many hospital ICUs which took these responsibilities very seriously and managed sick children very well, there were also unfortunately a number of events where outcomes could have been better, and consequently the perspective evolved that the UK did need to improve its paediatric intensive care services. This was particularly recognised by many trainees who took the opportunity of working overseas in specialist PICUs – and for many of whom the differences in the quality of care that could be provided undoubtedly had a significant impact – particularly when they returned to the UK and had to work within areas where access to more complex PICU interventions was very difficult.
It was as a result of these growing concerns that in the mid 1990s a campaign was initiated to increase the number or regional specialist PICUs. At the time few had any reservations about the need for greater numbers of PICU beds and the establishment of regional specialist centres. Where the controversy arose however, was in the extreme ‘centralist’ view that all children who required intensive care must be transferred to such units. A number of us protested this as strongly as we could – not with any intention of reducing the target of creating regional PICUs and significantly increasing bed numbers – but on the grounds that by preventing general intensive care units from preserving their paediatric skills and equipment the longer term impact would be potentially detrimental to sick children if the essential expertise for recognition and stabilisation were to progressively diminish.
Regrettably this was not acknowledged as being a valid concern – and in many parts of the country a policy of total centralisation was created. In some areas this undoubtedly led to a degree of tension between developing PICUs and general ICUs that had previously developed their paediatric services because of their commitments (and often because no other options had been available). Fortunately in other areas relationships with established regional PICUs have developed well – and in some regions the concept that general ICUs should be encouraged to maintain paediatric skills has been fully supported by the regional PICUs.
There is little doubt however that the overall standards of paediatric intensive care in the UK have improved significantly over the years since the decision to create regional specialist units was initiated – and it is also encouraging that trainees no longer have to find posts in other countries in order to become fully accredited paediatric intensivists. However, increasing pressure on the current number of PICU beds has – with the support of the current PICS leads – led to a more sensible and flexible ‘hub and spoke’ relationship that supports DGH care of ventilated children, with robust systems that ensure that any who are not responding to treatment, or deteriorating – can be rapidly referred and transferred to a specialist centre. The current position is therefore that the PICS and the ICS would like to see the historic legacy that resulted in some of these tensions ‘put to rest’ once and for all – and the current pandemic implications would seem to make this something of a priority.
Where we are now?
Even in the theoretical planning for a pandemic it was obvious to anyone who thought about it that there would not be enough PICU beds available at the peak of the event. Unfortunately however, the current H1N1 trend – although still being considerably uncertain – seems to be particularly targeting younger adults and children, and so the implications could end up being even more difficult than has been anticipated. Although it is very much hoped that the flu illness experienced by children will continue to be relatively mild and that rapid recovery to normal status will continue – there is also concern that during a second phase – which may occur in Autumn / Winter – H1N1 may have gone through an evolution to a more virulent status – and consequently the implications could be significant.
The inevitable conclusion of this potential is that if there are significant numbers of children who develop severe illness and who require intensive care support – many of them will have to be cared for in District General Hospitals (DGHs) or general ICUs – even if some of these do not currently provide paediatric intensive care services. For this reason the ICS and the PICS now see it as being an important priority that local arrangements are created to make the best possible use of existing resources, and that good working relationships are developed (or reinforced where already in place) to provide as much support as possible for the staff who have to take on these responsibilities.
As there are considerable variations in regional structures throughout the UK, there are no ‘one fits all’ recommendations that can be made – but the following principles are worthy of consideration, and should be pursued / amended according to local preferences / resources.
- Establishing / appointing individuals with appropriate organisational expertise in regional PICUs and DGHs to facilitate good communication and coordination of existing resources
- Setting an agreed age threshold with general ICUs for the care of ventilated children, with a degree of flexibility dependent on PICU bed availability, local nursing / medical confidence in caring for children, and the severity of the child’s illness.
- Arranging for ICU medical and nursing staff to be able to attend update training sessions in regional PICUs
- Creating collaborative working patterns with specialist colleagues who may be able to provide useful assistance in the care of ventilated children e.g. general intensivists / anaesthetists with specific paediatric expertise / experience, paediatricians, neonatologists, ED consultants or consultant paediatricians with former PICU training
- Preparing for the possibility of providing more ICU beds for children in regional centres by using nearby general ICU beds and supported by Regional PICU teams – and directing adult patients who need mechanical ventilation to units that are unable to provide paediatric care or are too far distant to be fully supported by PICU teams
- Encouraging regional unit consultant paediatric anaesthetists (who may be more available because of the cancellation of elective surgery) to consider working with DGHs to provide support for staff caring for ventilated children
- Encouraging NHS organisations and SHAs/Health Boards to assure staff that they will be fully supported despite having to work outside their normal areas of expertise, on the basis that they are doing so in the best interests of sick patients, and with recognition that the alternative may be an increase in the number of potentially avoidable deaths.
We know, and accept, that these are not ‘solutions’ – but we would like to believe that colleagues who have established their commitments to caring for patients in our specialities will be willing to do all that they reasonably can to help patients who are acutely ill if the pandemic hits in the way that we all hope that it will not. For this reason we recommend that ‘hub and spoke’ relationships between ‘referring centres’ and regional PICUs are reinforced as much as possible where they already exist. We would also be grateful if we could be made aware of any current concerns about existing services in order that we might be able to assist in rectifying these in the interests of all involved.
The bottom line is – we will all need to do the best that we can if we are going avoid as many child deaths as possible. There can be few more important priorities.
| Bruce Taylor | Ian Jenkins | Neil Morton |
| Hon Sec Intensive Care Society |
President, Paediatric Intensive Care Society |
President, Association of Paediatric Anaesthetists of Great Britain & Ireland |
| Bruce.Taylor@porthosp.nhs.uk | Ian.Jenkins@UHBristol.nhs.uk | neilmorton@mac.com |
