In this week’s blog, and the 3rd in the CYP series Julie C Menzies @jmenzies1, Rebekah Overend, Lyvonne N Tume @lyvonnetume, discuss ‘Complexity, commissioning, capacity and capability: challenges for paediatric critical care provision’. 

Children and young people (CYP) represent a third of our population. Sustaining and improving their health and wellbeing is therefore a key priority¹.  However, there are huge challenges and inequalities in service provision for the most vulnerable: children experiencing critical illness or injury.

Complexity

The demographic of patients requiring paediatric critical care (PCC) is changing.  We have improved survival of infants born very preterm², increasing numbers of CYP with medical complexity and technology dependence³, alongside increased admissions associated with ethnicity, living in an area of deprivation and high air pollution^4,5,6. The demand for PICU continues to increase 5% year on year⁷.

Commissioning and capacity

Of 153 hospitals providing inpatient care for children, only 15% host mixed Level two (Intermediate) and three (Advanced) Critical Care Units: 315 beds in total compared to over 3800 in Adult Critical Care⁸.  Most units are over 90% full throughout the year, with the result that there are often no PICU beds in the whole country^9,10. Despite recommendations to expand high dependency services to reduce the demand on centres with a PICU, reduce transfers and enable children to be cared for closer to home, investment remains lacking^9,11,12.

Capability

Compounding this is the increasing shortage of Registered Nurses (RNs)¹³. Most units are unable to meet the Paediatric Critical Care Society (PCCS) standards for RN ratios per PICU bed¹⁴. Lower levels of RN staffing in Adult Critical Care negatively affect patient mortality, quality of care and family satisfaction^15,16 and there is emerging evidence that this is the same in paediatrics¹⁷.  The strain of increased demand and reduced workforce capacity forces difficult decisions: units running over capacity; taking risks with out-of-hours PICU discharges; cancelled elective surgery and suspension of staff training. All of this cumulatively impacts on staff moral distress, sickness, burnout and turnover¹⁸.

 So how do we address these challenges? 

Complexity: With the changing demographics and complexity of PCC patients, further research is needed to understand the impact of increasing Neonatal Intensive Care survivors and technology-dependent CYP with chronic and complex needs^2,3.  Alongside this, action is required to address deprivation and air pollution contributing to health inequalities⁶, with the aim of reducing disparities and improving health outcomes for all children.

Commissioning: Current commissioning is insufficient for service needs⁹ and increased Level 3 and Level 2 beds are required to optimise PICU bed utilisation and patient flow¹².  The ten PCC Operational Delivery Networks have a key role to engage with regional stakeholders, review regional variation and need and drive change to improve patient experience and outcomes^19,20.

Capacity: NHS Trusts are now mandated to offer 24/7 rapid review from critical care outreach teams to advise on escalation of support and ensure parental concerns are heard^21,22. This support will help with recognition of the deteriorating CYP, prevent unplanned PICU admission and/or PICU re-admission.  Recognising the demands on Level 3 beds and specialised transport services, planning and collaboration with Adult Critical Care colleagues who stabilise and manage critically ill CYP whilst awaiting retrieval is also required¹⁴.

Capability: We need robust, realistic workforce planning to recruit more paediatric critical care nurses²³, as well as research to understand the impact of alterations of RN staffing ratios on patient outcomes²⁴. The emphasis on staff wellbeing and retention must continue, however further research is required to evaluate the efficacy and cost-effectiveness of initiatives^25,26. RNs play a vital surveillance role in detection of patient deterioration²⁷. We need further investment in roles beyond PICU within critical care outreach teams and Advanced Practice roles to support optimum patient care¹⁴. Alongside all of this further investment in Critical Care Level 1 and 2 education for all paediatric units is required, with supervisory clinical educators, protected learning time and links with tertiary centre educators to assist in regional education^14,28.

A third of our population must be able to receive critical care when they need it. The pandemic demonstrated that capacity was not just about beds or a ventilator, but reliant on the presence of a knowledgeable, highly skilled RN^29,30. Action is required at all levels- from increased commissioning, investment in critical care outreach, education and training and compassionate retention initiatives that acknowledge the psychological burden associated with the speciality.  All of this is required to ensure we can continue to protect our most valuable and vulnerable resource – children.

References

1. NHS England. 2024. Children and young people. https://www.england.nhs.uk/get-involved/cyp/. Accessed 4^th September 2024.
2. van Hasselt TJ, Gale C, Battersby C, et al. 2024. Arch Dis Child Fetal Neonatal Ed. 109. F265–F271.
3. Kanthimathinathan HK,Plunkett A, Scholefield BR, et al. 2020. Arch Dis Child. 105. 558–562.
4. Parslow RC, Tasker RC, Draper ES, et al. 2009. Epidemiology of critically ill children in England and Wales: incidence, mortality, deprivation and ethnicity. Arch Dis Child. 94. 210-215
5. Paediatric Intensive Care Audit Network (PICANet). 2023. National Paediatric Critical Care Audit. State of the Nation Report 2023. Universities of Leeds and Leicester. 14th December 2023. https://www.picanet.org.uk/wp-content/uploads/sites/25/2023/12/PICANet-State-of-the-Nation-Report-2023_v1.0-14Dec2023.pdf    Accessed 16th August 2024.
6. Mitchell HK, Seaton SE, Leahy C et al. 2008. Contribution of ethnicity, area level deprivation and air pollution to paediatric intensive care unit admissions in the United Kingdom 2008–2021. eClinicalMedicine. 75. 102776,ISSN 2589-5370, https://doi.org/10.1016/j.eclinm.2024.102776.
7. Davis P, Stutchfield C, Evans TA, Draper E. 2018. Arch Dis Child 2018;103:341–345. doi:10.1136/archdischild-2017-313915
8. NHS England. 2024. Critical Care and Genera; & Acute Beds – Urgent and Emergency Care Daily Situation Reports 2023-2024: March 2024 data. https://www.england.nhs.uk/statistics/statistical-work-areas/bed-availability-and-occupancy/critical-care-and-general-acute-beds-urgent-and-emergency-care-daily-situation-reports/critical-care-and-general-acute-beds-urgent-and-emergency-care-daily-situation-reports-2023-24/ Accessed September 6^th
9. Morris K and Fortune P. 2022. Paediatric Critical Care GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/medical_specialties/paediatric-critical-care/ Accessed 23rd July 2024.
10. Thomas R, Hagopian A. 2024. Revealed: Tories accused of neglect as children’s critical care units run out of beds. The Independent. Friday 31 May 2024. https://www.independent.co.uk/news/health/children-critical-care-beds-nhs-crisis-b2546684.html. Accessed 2^nd September 2024.
11. NHS England. 2017. Paediatric critical care and specialised surgery in children review. https://www.england.nhs.uk/publication/paediatric-critical-care-and-specialised-surgery-in-children/ Accessed 5^th September 2024.
12. Royal College of Paediatrics and Child Health. 2018. High Dependency Care for Children – Time To Move On. A focus on the critically ill child pathway beyond the Paediatric Intensive Care Unit. https://www.rcpch.ac.uk/sites/default/files/2018-07/high_dependency_care_for_children_-_time_to_move_on.pdf Accessed 5th September 2024.
13. Holmes J. 2022. The NHS nursing workforce – have the floodgates opened? 1^st Oct 2022. https://www.kingsfund.org.uk/insight-and-analysis/blogs/nhs-nursing-workforce. Accessed 4^th September 2024.
14. Paediatric Critical Care Society 2021. Quality Standards for the Care of Critically Ill or Injured Children. 6^th October 2021. https://pccsociety.uk/wp-content/uploads/2021/10/PCCS-Standards-2021.pdf Accessed 4th September 2024.
15. Jansson MM, Syrjälä HP, Ala-Kokko TI. 2019. Association of nurse staffing and nursing workload with ventilator-associated pneumonia and mortality: a prospective, single-center cohort study. J Hosp Infect. 101(3):257-263. https://doi.org/10.1016/j.jhin.2018.12.001
16. Rae P, Pearce S, Greaves PJ, Dall’Ora C, Griffiths P, Endacott R. 2021. Outcomes sensitive to critical care nurse staffing levels: A systematic review. Intensive Crit Care Nurs. 67. 103110. doi: 10.1016/j.iccn.2021.103110.
17. Genna C, Thekkan KR, Raymakers-Janssen P, Gawronski P. 2023. Is nurse staffing associated with critical deterioration events on acute and critical care pediatrics wards? A literature review. European Journal of Pediatrics. 182, 1755–1770
18. Jones GAL, Colville GA, Ramnarayan P, et al. 2020. Psychological impact of working in paediatric intensive care. A UK-wide prevalence study. Arch Dis Child. 105. 470–5.doi:10.1136/archdischild-2019-317439
19. McDougall M, Ward H. 2021. Why do we need Operational Delivery Networks in paediatrics? Arch Dis Child.106:734–735.
20. NHS South West Critical Care ODN. 2024. South West Critical Care Operational Delivery network. https://southwestpccodn.nhs.uk/our-network/ Accessed 6^th September 2024.
21. National Outreach Forum (NOrF) (2020) Quality and Operational Standards for the provision of Critical Care Outreach Services. https://www.norf.org.uk/resources/Documents/QOS%20CCOS%20NOrF/NOrF%20QOS%20Final%20December%202020.pdf Accessed: 3^rd September 2024/
22. NHS England.   Martha rule.  https://www.england.nhs.uk/patient-safety/marthas-rule/ Accessed 4^th September 2024.
23. McCabe R, Schmit N, Christen P, et al. 2020. Adapting hospital capacity to meet changing demands during the COVID-19 pandemic. BMC Med. 18(1):329
24. Pattison N. 2021. An ever-thorny issue: Defining key elements of critical care nursing and its relation to staffing. Nurs Crit Care. 2021;26:421–424.
25. Butcher I, Morrison R, Webb S, Duncan H, Balogun O, Shaw R. 2022. Understanding what wellbeing means to medical and nursing staff working in paediatric intensive care: an exploratory qualitative study using appreciative inquiry. BMJ Open 12:e056742. doi:10.1136/bmjopen-2021-056742
26. Yeter E, Bhamra H, Butcher I, Morrison R, Donnelly P, Shaw R. 2024. Managing well-being in paediatric critical care: a multiperspective qualitative study of nurses’ and allied health professionals’ experiences. BMJ Open. 14:e084926. doi:10.1136/bmjopen-2024-084926
27. Royal College of Nursing. 2024. Definition and Principles of Nursing Definition and Principles of Nursing. Royal College of Nursing. https://www.rcn.org.uk/Professional-Development/Definition-and-Principles-of-Nursing Accessed 8th September 2024
28. Health Education England. 2023. Educator Workforce Strategy. Educator Workforce Strategy. https://nshcs.hee.nhs.uk/wpcontent/uploads/2023/03/EducatorWorkforceStrategy.pdf Accessed: 01 August 2024
29. Imbriaco G and Scelsi S. 2021. It is not just about equipment and beds: Critical care nursing meeting the challenge of the second COVID-19 wave in Italy. Nurs Crit Care. 26. 300–302. https://doi.org/10.1111/nicc.12580
30. Credland N. 2020. Critical care nurses will need our support as COVID-19 cases rise. Nursing Standard. 18^th March 2020. https://rcni.com/nursing-standard/opinion/comment/critical-care-nurses-will-need-our-support-covid-19-cases-rise-158836