{"id":2854,"date":"2024-09-13T17:26:55","date_gmt":"2024-09-13T16:26:55","guid":{"rendered":"https:\/\/blogs.bmj.com\/ebn\/?p=2854"},"modified":"2024-09-14T10:41:48","modified_gmt":"2024-09-14T09:41:48","slug":"complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/ebn\/2024\/09\/13\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\/","title":{"rendered":"Challenges for paediatric critical care provision."},"content":{"rendered":"

In this week’s blog, and the 3rd in the CYP series Julie C Menzies @jmenzies1<\/span>, Rebekah Overend, Lyvonne N Tume @lyvonnetume, <\/span>discuss ‘Complexity, commissioning, capacity and capability: challenges for paediatric critical care provision’.\u00a0<\/span><\/p>\n

\"\"<\/a>\"\"<\/a>\"\"<\/a><\/p>\n

Children and young people (CYP) represent a third of our population. Sustaining and improving their health and wellbeing is therefore a key priority1<\/sup>. \u00a0However, there are huge challenges and inequalities in service provision for the most vulnerable: children experiencing critical illness or injury.<\/p>\n

Complexity<\/strong><\/p>\n

The demographic of patients requiring paediatric critical care (PCC) is changing. \u00a0We have improved survival of infants born very preterm2<\/sup>, increasing numbers of CYP with medical complexity and technology dependence3<\/sup>, alongside increased admissions associated with ethnicity, living in an area of deprivation and high air pollution4,5,6<\/sup>. The demand for PICU continues to increase 5% year on year7<\/sup>.<\/p>\n

Commissioning and capacity<\/strong><\/p>\n

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<\/sup>. \u00a0Most units are over 90% full throughout the year, with the result that there are often no PICU beds in the whole country9,10<\/sup>. 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 lacking9,11,12. <\/sup><\/p>\n

Capability<\/strong><\/p>\n

Compounding this is the increasing shortage of Registered Nurses (RNs)13<\/sup>. Most units are unable to meet the Paediatric Critical Care Society (PCCS) standards for RN ratios per PICU bed14<\/sup>. Lower levels of RN staffing in Adult Critical Care negatively affect patient mortality, quality of care and family satisfaction15,16<\/sup> and there is emerging evidence that this is the same in paediatrics17<\/sup>.\u00a0 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<\/sup>.<\/p>\n

\u00a0So how do we address these challenges?\u00a0 <\/em><\/p>\n

Complexity: <\/strong>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 needs2,3<\/sup>. \u00a0<\/strong>Alongside this, action is required to address deprivation and air pollution contributing to health inequalities6<\/sup>, with the aim of reducing disparities and improving health outcomes for all children.<\/p>\n

Commissioning: <\/strong>Current commissioning is insufficient for service needs9<\/sup> and increased Level 3 and Level 2 beds are required\u00a0to optimise PICU bed utilisation and patient flow12<\/sup>.\u00a0 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 outcomes19,20<\/sup>.<\/p>\n

Capacity: <\/strong>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 heard21,22<\/sup>. This support will help with recognition of the deteriorating CYP, prevent unplanned PICU admission and\/or PICU re-admission. \u00a0Recognising 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<\/sup>.<\/p>\n

Capability: <\/strong>We need robust, realistic workforce planning to recruit more paediatric critical care nurses23<\/sup>, as well as research to understand the impact of alterations of RN staffing ratios on patient outcomes24<\/sup>. The emphasis on staff wellbeing and retention must continue, however further research is required to evaluate the efficacy and cost-effectiveness of initiatives25,26<\/sup>. RNs play a vital surveillance role in detection of patient deterioration27<\/sup>. We need further investment in roles beyond PICU within critical care outreach teams and Advanced Practice roles to support optimum patient care14<\/sup>. 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 education14,28<\/sup>.<\/p>\n

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 RN29,30<\/sup>. 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.\u00a0 All of this is required to ensure we can continue to protect our most valuable and vulnerable resource – children.<\/p>\n

References<\/p>\n

    \n
  1. NHS England. 2024. Children and young people. https:\/\/www.england.nhs.uk\/get-involved\/cyp\/<\/a>. Accessed 4th<\/sup> September 2024.<\/li>\n
  2. van Hasselt TJ, Gale C, Battersby C, et al. 2024. Arch Dis Child Fetal Neonatal Ed. 109. F265\u2013F271.<\/li>\n
  3. Kanthimathinathan HK,Plunkett A, Scholefield BR, et al. 2020. Arch Dis Child. 105. 558\u2013562.<\/li>\n
  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<\/li>\n
  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\u00a0\u00a0\u00a0 Accessed 16th August 2024.<\/li>\n
  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\u20132021. eClinicalMedicine. 75. 102776,ISSN 2589-5370, https:\/\/doi.org\/10.1016\/j.eclinm.2024.102776<\/a>.<\/li>\n
  7. Davis P, Stutchfield C, Evans TA, Draper E. 2018. Arch Dis Child 2018;103:341\u2013345. doi:10.1136\/archdischild-2017-313915<\/li>\n
  8. NHS England. 2024. Critical Care and Genera; & Acute Beds \u2013 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\/<\/a> Accessed September 6th<\/sup><\/li>\n
  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.<\/li>\n
  10. Thomas R, Hagopian A. 2024. Revealed: Tories accused of neglect as children\u2019s 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<\/a>. Accessed 2nd<\/sup> September 2024.<\/li>\n
  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 5th<\/sup> September 2024.<\/li>\n
  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<\/a>.<\/li>\n
  13. Holmes J. 2022. The NHS nursing workforce \u2013 have the floodgates opened? 1st<\/sup> Oct 2022. https:\/\/www.kingsfund.org.uk\/insight-and-analysis\/blogs\/nhs-nursing-workforce<\/a>. Accessed 4th<\/sup> September 2024.<\/li>\n
  14. Paediatric Critical Care Society 2021. Quality Standards for the Care of Critically Ill or Injured Children. 6th<\/sup> October 2021. https:\/\/pccsociety.uk\/wp-content\/uploads\/2021\/10\/PCCS-Standards-2021.pdf Accessed 4th September 2024<\/a>.<\/li>\n
  15. Jansson MM, Syrj\u00e4l\u00e4 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<\/li>\n
  16. Rae P, Pearce S, Greaves PJ, Dall\u2019Ora 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.<\/li>\n
  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\u20131770<\/li>\n
  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\u20135.doi:10.1136\/archdischild-2019-317439<\/li>\n
  19. McDougall M, Ward H. 2021. Why do we need Operational Delivery Networks in paediatrics? Arch Dis Child.106:734\u2013735.<\/li>\n
  20. NHS South West Critical Care ODN. 2024. South West Critical Care Operational Delivery network. https:\/\/southwestpccodn.nhs.uk\/our-network\/<\/a> Accessed 6th<\/sup> September 2024.<\/li>\n
  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: 3rd<\/sup> September 2024\/<\/li>\n
  22. NHS England. \u00a0 Martha rule.\u00a0 https:\/\/www.england.nhs.uk\/patient-safety\/marthas-rule\/<\/a> Accessed 4th<\/sup> September 2024.<\/li>\n
  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<\/li>\n
  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\u2013424.<\/li>\n
  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<\/li>\n
  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\u2019 and allied health professionals\u2019 experiences. BMJ Open. 14:e084926. doi:10.1136\/bmjopen-2024-084926<\/li>\n
  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<\/a><\/li>\n
  28. Health Education England. 2023. Educator Workforce Strategy. Educator Workforce Strategy. https:\/\/nshcs.hee.nhs.uk\/wpcontent\/uploads\/2023\/03\/EducatorWorkforceStrategy.pdf<\/a> Accessed: 01 August 2024<\/li>\n
  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\u2013302. https:\/\/doi.org\/10.1111\/nicc.12580<\/a><\/li>\n
  30. Credland N. 2020. Critical care nurses will need our support as COVID-19 cases rise. Nursing Standard. 18th<\/sup> March 2020. https:\/\/rcni.com\/nursing-standard\/opinion\/comment\/critical-care-nurses-will-need-our-support-covid-19-cases-rise-158836<\/li>\n<\/ol>\n

    <\/p>\n","protected":false},"excerpt":{"rendered":"

    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’.\u00a0 Children and young people (CYP) represent a third of our population. Sustaining and improving their health and wellbeing is therefore a key […]<\/p>\n

    Read More…<\/a><\/p>\n","protected":false},"author":509,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3803],"tags":[],"class_list":["post-2854","post","type-post","status-publish","format-standard","hentry","category-intensive-care"],"yoast_head":"\nChallenges for paediatric critical care provision. - Evidence-Based Nursing blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/ebn\/2024\/09\/13\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Challenges for paediatric critical care provision. - Evidence-Based Nursing blog\" \/>\n<meta property=\"og:description\" content=\"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’.\u00a0 Children and young people (CYP) represent a third of our population. Sustaining and improving their health and wellbeing is therefore a key [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/ebn\/2024\/09\/13\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\/\" \/>\n<meta property=\"og:site_name\" content=\"Evidence-Based Nursing blog\" \/>\n<meta property=\"article:published_time\" content=\"2024-09-13T16:26:55+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2024-09-14T09:41:48+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/blogs.bmj.com\/ebn\/files\/2024\/09\/JMenzies-April-2020.png\" \/>\n<meta name=\"author\" content=\"drkerrygaskin\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"drkerrygaskin\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"8 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/2024\\\/09\\\/13\\\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/2024\\\/09\\\/13\\\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\\\/\"},\"author\":{\"name\":\"drkerrygaskin\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/#\\\/schema\\\/person\\\/866d84274e6c59dce3bccfd38a880dd8\"},\"headline\":\"Challenges for paediatric critical care provision.\",\"datePublished\":\"2024-09-13T16:26:55+00:00\",\"dateModified\":\"2024-09-14T09:41:48+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/2024\\\/09\\\/13\\\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\\\/\"},\"wordCount\":1539,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/2024\\\/09\\\/13\\\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/files\\\/2024\\\/09\\\/JMenzies-April-2020.png\",\"articleSection\":[\"intensive care\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/2024\\\/09\\\/13\\\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/2024\\\/09\\\/13\\\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/ebn\\\/2024\\\/09\\\/13\\\/complexity-commissioning-capacity-and-capability-challenges-for-paediatric-critical-care-provision\\\/\",\"name\":\"Challenges for paediatric critical care provision. - 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