KING FAISAL SPECIALIST HOSPITAL AND RESEARCH CENTRE (GEN. ORG.) NURSING AFFAIRS. Scope of Service PEDIATRIC INTENSIVE CARE UNIT (PICU)

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1 PICU-Jan.2012 Page 1 of 7 Number of Beds: 18 Nurse Patient Ratio: 1:1-2 : The Pediatric Intensive Care Unit (PICU) provides 24 hour intensive nursing care for patients aged neonate through adolescence. The primary conditions and diagnoses treated are: Congenital heart disease, pre and post-operative cardiac surgery Hematology/Oncology, Immunocompromized patients Metabolic disorders Pediatric General Surgery, Neurosurgery Vascular Surgery, ENT, Endocrinology All sick medical patients requiring intensive care Frequent Procedures/Services/Functions: The PICU utilizes numerous nursing diagnostic and therapeutic modalities to facilitate patient care, including the following: Use of nursing process, assessment, planning, interventions, and evaluation IV Therapy Thermo-regulation Hemodynamic monitoring Cardiac and neurologic monitoring Ventilatory support, Invasive and non invasive. High frequency ventilation and nitric oxide therapy. Psychosocial care Patient and family education Medication administration Trauma care Continuous renal replacement therapy (CRRT) Pain management Hours of Operation: 24 hours a day, 7 days a week STAFFING PLAN Number and Mix of Staff: Staffing is provided by registered nurses functioning in a total care nursing system. There is a charge nurse assigned for each shift. This person is responsible for monitoring of quality of care delivered by nursing personnel during the shift. Shift assignments are made by the charge nurse and based on the following criteria: Complexity of patient s condition and required nursing care. Dynamics of patient s status, including the frequency with which the needs for specific nursing care activities change.

2 PICU-Jan.2012 Page 2 of 7 Type of technology employed in providing nursing care. Degree of supervision required by each nursing staff member based on her/his previously assessed level of competence. Availability of supervision appropriate to the assessed and current competence of nursing staff member. Relevant infection control and safety issues. Method of Adjusting to Staffing Variances: The charge nurse reassesses all patients for level of care required and determines if patients may be transferred to a less intensive level of care. Charge nurse may use temporarily reassigned nurses from other units or overtime is utilized to staff for variances in patient volume and acuity. QUALIFICATIONS OF STAFF: Qualifications/Licenses/Certifications Required Registered Nurses: 1. Registered Nurse with current nursing license from country of origin 2. Two years recent pediatric critical care experience 3. Bilingual nurses who meet the criteria are encouraged Ward Clerks: 1. High School education required 2. Bilingual in Arabic and English 3. Saudi Nationals required Patient Care Assistants: 1. Intermediate education required 2. Bilingual in Arabic and English 3. Saudi National required HOW ARE INSERVICES/CONTINUING EDUCATION PROGRAMS PROVIDED TO MAINTAIN STAFF COMPETENCY Continuing education is offered through Nursing Development & Saudization (ND&S) and at the Unit level coordinated by the Head Nurse and Clinical Instructor. Education needs are identified through needs assessment tools, treatment protocols, performance improvement activities, regulatory agencies, new technology, new equipment, new products and individual input and surveys. Topics other than those which are based upon mandates and updated protocols, are also arranged. These may be issues of interest raised by the Unit staff, topics selected from the departments needs assessment or information of interest or relevance from other departments. Required Competencies: Please see Competency Based Practice Orientation and Ongoing Education outline on the last page Annual review of education includes: Age Specific Care competency Performance Improvement Fire and Electrical Safety

3 PICU-Jan.2012 Page 3 of 7 Infection Control and prevention online modules Skin Care and Pressure Ulcer Prevention online module Wound Care Online module Point of Care Testing (POCT) Medication Safety Online module METHOD OF COMMUNICATION WITH OTHER DEPARTMENTS: Internal and External Methods of Communication: Internally and externally, communication is accomplished via direct verbal communication, telephone, fax, and intranet and written memos. Staff meetings are held on a monthly basis, or more frequently if required. Collaborative practice meetings are scheduled on a quarterly basis or as required. Other meetings are scheduled as required. Describe Collaborative Relationships With Other Departments: The Head Nurse and staff participate on many multidisciplinary committees, as well as on Hospital wide performance improvement groups and committees. Representatives from other departments are invited to attend staff meetings when new programs are introduced or if complicated issues arise, to facilitate a mutually desirable resolution. GOALS OF DEPARTMENT Ensure optimal flow of pediatric patients through the unit. To continue to function as the tertiary referral center for critically ill children in Saudi Arabia. Deliver high quality culturally sensitive care in a cost-effective manner Continue to develop quality improvement programs within the unit Improve quality care by reviewing and implementing evidence based practice To establish a family centered healing environment CRITERIA FOR ADMISSION TO SERVICE The PICU provides care to patients from newborn to 14 years. PICU patients may be admitted from the Emergency Department, other nursing units, surgery areas, OR, or from outlying hospitals via air and ground transport. These patients are critically ill and have at least one of the following requirements: For evaluation and treatment of life threatening illnesses or acute organ failure For evaluation and treatment of illnesses that are amenable to treatment and that require intensive monitoring For (evidence-based) concern of (pending) imminent physiological deterioration When the patient requires frequent (re)evaluation (including laboratory tests) When the patient requires intensive nursing care beyond the capabilities of regular in patient nursing unit. All admissions should be approved by the PICU intensivist OR designee. The criteria listed below provide algorithms for decision-making. Cardiovascular System Assessment: Life-threatening arrhythmia

4 PICU-Jan.2012 Page 4 of 7 Continuous infusion of anti-arrhythmic agent(s) Continuous infusion of vasoactive agent(s) Pericardial effusion with tamponade. Patients in cardiogenic shock Respiratory System Assessment: Respiratory rate > 40 or < 12 per minute, significant retractions/accessory muscle use, and/or unstable ventilatory pattern (e.g., Cheyne-Stokes respirations) PaO2 < 8.0 Kpa or SaO2 < 90% FiO2 > 0.50 or increasing FiO2 requirement over 4-8 hours PaCO2 > 6.0 Kpa and ph < 7.32 Concern that endotracheal intubation may be required within 4-8 hours Requires (aggressive) pulmonary toilet every 2 hours or more often Ventilation or oxygenation dependent on mechanical ventilator Acute airway obstruction or acutely impaired airway protective reflexes Gastrointestinal System Assessment: Acute upper or lower GI tract hemorrhage causing orthostatic hypotension. Suspected (or documented)> 2 units of acute PRBC blood loss. Hepatic dysfunction causing acute encephalopathy Clinical evidence of peritonitis Tense abdomen with concern that intra-abdominal hypertension is present Renal System Assessment: Newly diagnosed renal failure with fluid overload leading to cardio-pulmonary compromise Urine output < 0.1 ml/kg-hr for more than 3 hours (and especially when there is a concern regarding hemodynamic stability) not resolved by fluid challenges. Require new institution of Continuous Renal Replacement Therapy (CRRT). Acute hypertensive crisis Hypertensive encephalopathy. Central Nervous System Assessment Acute deterioration of Glasgow Coma Score < 8 New onset stupor or a decrease of 2 or more in the GCS within the last 12 hours Uncontrolled or poorly controlled seizures Progressive muscle weakness involving respiratory muscles Acute meningitis with neurological abnormalities Acute cerebral infarct status post thrombolytic administration and/or mechanical thrombolysis or requiring frequent nursing neurologic assessments and with fairly high probability for needed decompressive crainectomy Acute spinal cord injury for frequent hemodynamic monitoring Any condition that requires crainiotomy or ventriculostomy with risk of vasospasm Any condition associated with increased intracranial pressure associated with progressive neurological defects Impending or Actual Sepsis Evidence of Systemic Inflammatory Response Syndrome (SIRS) with a decrease in systolic blood pressure by 20% from the patient s baseline.

5 PICU-Jan.2012 Page 5 of 7 Lactic acidosis (lactate > 4.0 mmol/l) Cryptic (unexplained) shock with or without hypotension Other Conditions Acute drug intoxications with obtundation, compromised airway protective reflexes, hemodynamic instability, incipient cardiac arrhythmias. Acute drug intoxications requiring continuous infusion medications or frequent administration of intravenous medications Acute drug intoxications requiring dialysis Other metabolic conditions (e.g., severe rhabdomyolysis) requiring frequent monitoring or medical interventions Nursing Workload Requirements Requirements that I and O measured hourly for more than 8 hours Requirements that respiratory rate and quality measured every hour, the use of therapeutic inhalers, oxygen therapy, CPAP or BiPAP with nursing assessment at least every hour, intermittent suction required hourly, or hourly arterial blood gas determinations Requirements that debridement/irrigations/tubing, extensive application of ointments/preparations, extensive wound vac changes, multiple dressing changes, requirement for multiple staff in order to complete a dressing change Requires frequent (hourly) assessment and intervention related to cognition because of, altered consciousness, or who requires repeated medical therapy for cognitive support DISCHARGE CRITERIA Patients are discharged from PICU when Their acute illness is treated Their medical condition has stabilized They do not require frequent evaluation (including laboratory tests) and /or intensive nursing care It has been determined by the patient/family and physician that aggressive treatment such as is provided in an ICU setting is no longer appropriate. All discharges should be approved by the PICU intensivist OR designee. The criteria listed below provide algorithms for decision-making. Cardiovascular System Absence of life-threatening arrhythmia for 24 hours or at the discretion of the intensivist. No continuous infusion of vasoactive agent(s) No continuous anti-arrhythmic infusion Pericardial tamponade resolved of >24 hours or at the discretion of the intensivist. Respiratory System Respiratory rate between breaths/minute No significant retractions or accessory muscle use PaO2 > 8.0 KPa with FiO2 < 0.40, (non chronic lung disease patient)

6 PICU-Jan.2012 Page 6 of 7 PaCO2 < 6.0 Kpa and ph > 7.32, (non chronic lung disease patient) Requires pulmonary toilet less often than every four hours Extubated for at least 12 hours, if intubated for respiratory distress or failure Gastrointestinal System Assessment Stable or improving hepatic encephalopathy, if present during current PICU admission Resolved active GI bleeding Clinical evidence of peritonitis resolved (treated) Renal System Assessment Urine output > 0.5 ml/kg/hr, or dialysis program established for patients with chronic renal failure Off dialysis or conversion to intermittent hemodialysis Central Nervous System Glasgow coma score > 8 and stable and improving by requiring less frequent monitoring Seizures controlled on stable medical regimen for >24 hours Stable or improving respiratory muscle strength with Maximum Negative Inspiratory Force > 30 cm H2O Assessment for (Impending or Actual) Sepsis Stable Systolic blood pressure (Age in years X2 + 70mmHg) with resolving Systemic Inflammatory Response Syndrome Resolved Lactic acidosis (lactate > 4.0 mmol/l) Resolved Cryptic (unexplained) shock with or without hypotension Other Conditions Stable or improving consciousness and airway protection with resolving acute poisoning, without need for further monitoring Assessment of Nursing Workload Requirements Resolved Requirements that I and O need hourly measurement. Resolved Requirements that respiratory rate and quality need hourly measurement, as well as the use of therapeutic inhalers, oxygen therapy, CPAP or BiPAP with nursing assessment and intermittent suction, and arterial blood gas. Resolved Requirements that debridement/irrigations/tubing, extensive application of ointments/preparations, extensive wound vac changes, multiple dressing changes, requirement for multiple staff in order to complete a dressing change. Resolved Requirements of frequent (hourly) assessment and intervention.

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