Packard Children’s Hospital enhances intensive care unit

More beds, additional staff and new procedures are among a series of recent steps to help young, critically ill patients return to health

Lucile Packard Children's Hospital

Whether they’re fighting severe illness or mending from surgery or trauma, patients in the pediatric intensive care unit share a need for compassionate care and careful attention to detail. Now, thanks to a year of intense growth, the critical care team at Lucile Packard Children’s Hospital is even better prepared to help critically ill children return to health.

“Even in the most dire circumstances, many children bounce back,” said Deborah Franzon, MD, associate medical director of the pediatric intensive care unit. “It’s one of the most rewarding aspects of working in critical care.”

“It's our goal to replace fear with legitimate hope,” said David Cornfield, MD, who has been the chief of critical care medicine and medical director of the PICU at Packard Children's since 2007.

To help young patients recover, Packard Children’s has expanded its PICU bed capacity, made key hires on the critical care team, improved emergency transport capability and instituted new ways to track patient outcomes. The changes arose from intense scrutiny of every aspect of critical care offerings.

“We have adopted a layered approach to care,” Cornfield said. That approach starts at the bedside, where attending physicians collaborate closely with specialty practitioners, nurses, pharmacists, respiratory therapists and patients’ families to tailor care to each child. And it extends to programmatic upgrades now benefiting every patient who passes through the PICU doors.

PICU capacity grows

In September, Packard Children’s PICU capacity jumped from 12 to 18 beds, with another four beds still to be added as the unit completes ongoing renovations in early 2010. Already, the extra beds have made a sizeable dent in the number of children who must be turned away from the PICU.

“For a long time we were very constrained, but with the expanded bed capacity we are in a position to serve the community better,” Cornfield said, adding that the PICU has been operating at or near capacity since the new beds opened up.

The increased bed capacity has been accompanied by significant change in the model of PICU care. Now, two attending physicians and two complete medical teams are on the ward at all times, an approach that has been successful in large pediatric intensive care units around the country.

“Having two attendings on the unit seven days a week allows for the correct amount of focus to be given to each child,” Cornfield said. Both teams will deal with direct bedside needs, as well as the considerable emotional and social issues that each child and family confront in the context of critical, life-threatening illness.

As part of the expansion, five critical care physicians have joined Packard Children’s from some of the top children’s hospitals in the country. The new hires include Eloa Adams, MD, and Nathan Luna, MD, who completed their fellowship training at Packard Children’s; Truc Le, MD, who trained at Vanderbilt; Felice Su, MD, who joined the team from the Children’s Hospital of Philadelphia; and Julie Williamson, DO, who completed a dual fellowship in critical care and pediatric anesthesia at Johns Hopkins. In addition to their clinical roles, these physicians will pursue research in fields such as pulmonary medicine, pharmacokinetics, metabolic disease and health outcomes research. Also, Cristina Alvira, MD, has been promoted from instructor to assistant professor after completing her fellowship training at Packard Children's.

Tracking patient care

To complement the team’s expansion and monitor its effectiveness, Cornfield has implemented several pilot projects in clinical resource management.

For instance, Packard Children’s PICU recently became the first in the country to automatically populate each patient’s electronic medical record with data from monitors, then use that data to generate an individualized, continually updated Pediatric Risk of Mortality, or PRISM, score. Based on the first five months of automated PRISM tracking, the team’s observed outcomes are approximately two standard deviations above mean mortality levels predicted by statistical models of PRISM scores, Cornfield said.

With the new system, not only is it easy to track aggregate outcomes, but each patient can be followed more closely than if all tracking were done by hand. “It allows us to use our nursing staff and other resources more judiciously,” Cornfield said.

Other initiatives include changes to minimize unnecessary orders for labs, X-rays and blood transfusions. For instance, if a practitioner requests a transfusion for a patient whose hemoglobin level exceeds 8 g/dl, the computer system generates a reminder that the patient doesn’t meet standard transfusion criteria and asks why the transfusion is needed.

“Essentially, we’re asking people to make conscious decisions,” Franzon said. The team is now collecting data on the efficacy of the changes.

Faster, safer trips to the hospital

Packard Children’s critical care expertise extends beyond the hospital walls, too. As of May, pediatric transport specialists are available 24 hours a day, seven days a week to travel to other hospitals and accompany critically ill children back to the PICU. It’s a big improvement from the 12 hours per day that the team used to be available.

“Sending the transport team is better for the patient,” said Franzon. The team can evaluate a patient’s needs before and during the trip to the hospital and communicate continuously with PICU physicians to prepare for arrival. The approach saves precious minutes over other transport options, Franzon said, because “someone without pediatric training may not realize how sick a child really is.”

The transport team consists of six RN transport specialists, experienced PICU nurses who have received specialized training in moving sick and injured kids. Each trip is led by one of these specialists, accompanied by a second ICU nurse and, if the child’s condition warrants, a respiratory therapist or physician. Transports are performed by ambulance, life-flight helicopter and fixed-wing plane.

Franzon anticipates that the team will complete more than 500 transports in 2009, up from 317 in 2008. They have also cut by 25 percent the time it takes to mobilize the team, and are working to make response times even faster.

Multidisciplinary collaboration

At the core of Packard Children’s critical care philosophy, Cornfield concluded, is the conviction that multidisciplinary collaboration leads to the best care. Physicians in the PICU maintain close ties to subspecialty providers appropriate to each child’s case, and also draw on the expert knowledge of specially-trained PICU nurses, respiratory therapists, social workers and pharmacists. They strive to maintain appropriate contact with referring physicians, either directly or through other hospital services. And they include each patient’s family on care decisions.

“The family is a really valuable part of the team because they know their child best,” Franzon said. “And the PICU, by its nature, really lends itself to the team approach.”

“By caring for both the patient and the family, we are truly able to wed the art and the science of medicine," Cornfield said. "It is our great privilege.”