There are over 400 pediatric intensive care units (PICUs) in the USA, as most recently estimated by the Society of Critical Care Medicine. These units vary widely in size, from 4 or 5 beds to fifty or more. The smaller units are generally found in community hospitals; the larger ones are usually in academic medical centers, often in designated children’s hospitals, of which there are 220.
Given this size range, it is not surprising the services provided at PICUs vary widely. There are no defined standards for what a PICU should be, although the American Academy of Pediatrics (AAP) suggested some over a decade ago. The AAP also suggested dividing PICUs into two categories, level I and level II, although in my experience no one pays much attention to the distinction. A great many of the recommendations are about what the equipment and staffing for a PICU should be. There is little if anything about the crucial issue of range of practice. Right now a PICU cares for whatever patients the facility wishes to care for. I don’t think this is the best way to do things, and there are a couple of examples from other specialties for which there are solid recommendations regarding appropriate scope of intensive care practice.
The oldest example is neonatology, which is practiced in neonatal intensive care units (NICUs) by pediatric specialists known as neonatologists. NICUs care for sick newborn babies, the overwhelming majority of which are infants born prematurely. The neonatal guidelines date back to 1976, when the March of Dimes Foundation spearheaded an effort to classify and sort out newborn care. They proposed three levels of units: level I was for normal newborns, level III was for the sickest babies, and level II was somewhere in between. These designations have been broadly adopted, carrying along with them the specific expectations of just what care a level III NICU should be able to offer. The guidelines were revisited and reaffirmed in 2012. Importantly, the guidelines also stated that level III NICUs had an obligation to provide outreach and training to their surrounding region to help smaller hospitals resuscitate and stabilize sick infants for transfer to a level III unit.
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