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ritical Care Pediatric Nursing

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Growing Demands for Critical Care Beds and Recommendations for more Pediatric Nurse Practitioners

In the Dallas area, children’s hospitals frequently transport pediatric patients to open critical care beds due to full capacity in the pediatric ICUs.

For that reason, "we need more ICU beds," John O’Neill, CEO of Medical City Children’s Hospital, said. "That’s why Children’s (Medical Center in Dallas) is expanding downtown — and we’re expanding here as well to help meet that need."

According to the "Dallas Business Journal," "the pediatric population nationwide is expected to grow by 1% by 2012."  In North Texas, "It is growing at six times the national average, increasing the demand for pediatric services," O’Neill said.  In Plano, the pediatric population is expected to grow by more than 20% in the next three years.  The demand for pediatric critical care services seems to exceed the growth of the population."  This could be due to the increase in pediatric surgical cases resulting from an increase in pediatric surgical specialists by nearly 24% in the last decade.

Cleveland Clinic has seen a patient volume increase of 26 percent in six pediatric specialized care units in the last year.   Services continue to grow for these pediatric patients while increasing the demand for beds to care for them.

In 2005, for example, Children’s Hospital of Wisconsin admitted more than 22,243 children to the hospital, an increase of 13.3 percent over five years.  In addition, nearly 250,000 children were seen in the hospital’s specialty outpatient clinics, a 46 percent increase since 2000.  In the same five years, there was an increase of 28.2 percent in Emergency Department visits, while surgical cases increased 14 percent.  There is an overall increase in volume for referral to pediatric specialty services in the areas of critical care, surgery and emergency services.  The increased demand for specialty care services, especially in the area of critical care, has created an increase in demand for critical care beds and nursing services.

It seems that there is a decrease in the number of critical care beds at smaller hospitals with fewer available pediatric services.  This places an increased demand on larger hospitals, especially children’s hospitals.  As a result, many of the children’s hospitals are expanding their services in critical care (see chart below).  To meet this increase in demand for critical care services, hospitals could consider hiring more Pediatric Nurse Practitioners (PNP).  According to the National Association of Pediatric Nurse Practitioners, PNPs provide health care to newborns, infants, children, adolescents and young adults, including ordering diagnostic, tests, prescribing medications, educating children and families, coordinating services, and making referrals to other professionals as appropriate.  PNPs are in demand due to consumer recognition, acceptance and satisfaction.  They also offer a revenue stream, an increased quality of care, and an increase in quality of physician lifestyle which results in an overall increase in patient and family satisfaction.  In addition, many academic centers have begun to utilize acute care PNPs to offset gaps in coverage and improve continuity with the ACGME residency work hour (http://www.acgme.org/DutyHours/dutyHrs_Index.asp ) restrictions. Furthermore in surgical specialties, PNPs are able to provide non-operative patient care, in both inpatient and outpatient arenas, which frees up the surgeon to perform procedures. 

Results of the 2002 Emergency Pediatric Services and Equipment Supplement to the National Hospital Medical Care Survey, Division of Healthcare Statistics, Kimberly Middleton BSN MPH states as follows:

Nationally there are opportunities for growth in the utilization of PNPs in Pediatric Emergency Departments and Trauma Services. 

Ø  37% of all pediatric ED visits are for injury

Ø  3% of EDs have a separate pediatric emergency service area (ESA)

Ø  18% of hospitals with EDs have a pediatric 24-hour observation unit

Ø  16% of hospitals with EDs have a coordinated pediatric trauma service

Ø  10% of hospitals with EDs have a PICU

Journal of Pediatric Orthopedics, September 2009 - Volume 29 - Issue 6 – pp. 612-617

Background:  Trauma continues to be the leading cause of morbidity and mortality among children.  There is a perception among pediatric orthopedists that the volume of pediatric orthopedic trauma care is increasing.  We hypothesized that the change in trauma volume was greater than the local and regional population change.

Methods:  This retrospective analysis (1996 to 2006) of our institution's trauma registry analyzed changes in general trauma and orthopedic trauma admissions, surgical volumes, patient and population demographics and hospital reimbursement.

Results:  For that decade, the local pediatric population increased annually by only 2% to 3%.  During that same period, there was an increase in the proportion of patients treated from outside the immediate county, from 13% in 1996 to 28% in 2006.  Total general trauma patient admissions increased at an average of 10% per year from 1996 to 2006, whereas total orthopedic trauma admissions and orthopedic trauma admissions requiring operative treatment increased by an annual average of 18%.  Orthopedic trauma admissions as a percentage of total trauma admissions steadily increased from 26% in 1996 to 45% in 2006.  During 2005 and 2006, an average total of 1,216 orthopedic trauma cases per year were performed generating an average 10,465 work relative value units per year.  Between 1996 and 2005, the hospital's gross charges for pediatric orthopedic trauma increased by an average of 26% annually; however, the percentage of total charges collected decreased from 67% in 1999 to 28% in 2005.

Conclusions:  Pediatric orthopedic trauma at this level 1 trauma center increased dramatically and more rapidly than the local population over the last decade, increasing the demand for physician and hospital resources. Physicians, hospitals, and the communities they serve face financial and logistical problems of providing care for an expanding volume of pediatric orthopedic trauma patients with decreasing reimbursements, changing referral patterns and a decreasing population of pediatric orthopedic specialists.  Care of the pediatric orthopedic trauma patient could become a national crisis.

This relationship between higher percent increase in demand for pediatric specialty care and a smaller percent of growth in the pediatric population is seen across all areas of specialty care.  Therefore, percentage growth in the pediatric population growth is not a one-to-one predictor of the demand for pediatric specialty care medical services.   The demand for these services has been a multiple of the pediatric population growth.  The demand for specialty services, specifically, critical care services, is influenced by the increase in availability of these services and the advancement of pediatric medical services, procedures and their outcomes.

Level of Evidence:  Economic analysis-level III.

Odetola  FO, Clark SJ, Davis MM.

Department of Pediatrics and Communicable Diseases, Division of Pediatric Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI, USA.

OBJECTIVE:  Pediatric intensive care units (PICUs) have grown in number and size over time in aggregate across the United States, but the factors promoting such changes have not been well characterized.  This study was conducted to explore the establishment, expansion, and closure of PICUs.

DESIGN:   A cross-sectional in-depth telephone interview survey of executive hospital administrators.

SETTING:  Fourteen institutions representing four newly established PICUs, two PICU expansions, and eight PICU closures.

MEASUREMENTS AND MAIN RESULTS:  Officials' comments indicate that the establishment of PICUs is driven primarily by the need to care for patients requiring intensive cardio-respiratory monitoring and/or postoperative surgical care, and to respond to the needs of outlying community hospitals. The main factors that drive PICU expansion are institutional growth in pediatric subspecialist medical and surgical support for critically ill patients and the need to match increases in demand and patient volume experienced by existing PICUs.  With regard to PICU closures, competition from other institutions within the same market for patients and subspecialty care providers, lower-than-expected volumes of patients, and/or negative financial margins were cited as key factors.

CONCLUSIONS:  This study provides new insight into decision-making that influences the availability of critical care services for children.  The establishment, expansion, and closure of PICUs are driven predominantly by local demand for pediatric critical care services, whereas availability of subspecialists as well as competition between PICUs within the same market affect the long-term sustainability of such services.

Quick Facts: From ACS Health Policy Research

From: American College of Surgeons Health Policy Research: http://www.acshpri.org/documents/ACSHPRI_FS3.pdf

Number of pediatric surgeons

                1981: 464

                2006: 2,474

Number of children (ages 0–19) per pediatric generalist surgeon

                1981: 154,728

                2006: 108,305

In 2006, only 399 (12.8%) of the 3,107 US counties had a pediatric surgeon.

By 2006, there were 2.27 pediatric surgical specialists for every one pediatric generalist surgeon.

Pediatric Surgeons:  Subspecialists Increase Faster than Generalists

Stephanie Poley; Thomas Ricketts, Ph.D., M.P.H.; Daniel Belsky; Katie Gaul, MA

Pediatric surgical subspecialists have only been identifiable in the AMA Physician Masterfile data since the early 1990s.  Many of these surgeons served the pediatric population prior to the addition of those specialty codes to the AMA Physician Masterfile survey.  For this reason it is difficult to assess change in this segment of the pediatric surgical workforce during the full 25-year study period; however, recent

trends of strong growth in pediatric surgical subspecialties are evident (Figure 1).  In all likelihood, these data underestimate the number of providers serving the pediatric population in all years.  By 2006, there were 2.27 pediatric surgical specialists for every pediatric generalist surgeon in the U.S.  Pediatric orthopedic surgeons and ophthalmologists accounted for more than 55% of all pediatric surgical subspecialists in 2006.

Pediatric Surgeons Cluster in Urban Areas, Some Diffuse into Rural Counties

Overall, only 399 of the country’s 3,107 counties had any pediatric surgeons in 2006, and 28,774,439 children under the age of 19 lived in those counties.  Just over half of the counties with pediatric surgeons (n=216) had a pediatric generalist surgeon, while pediatric specialist surgeons were located in 371 counties.  The distribution of pediatric surgeons is denser in more urbanized areas of the country; however, the magnitude of this varies from place to place, and the difference in distribution between  rural and urban areas is striking.  Ninety-seven percent of rural counties lacked any pediatric surgeons in 2006, a small improvement from 1981 when 99.3% had none (Figure 2).  While it is clear that some previously underserved areas gained pediatric surgeons and that the average ratio of pediatric surgeons to children improved in both rural and urban areas between 1981-2006, geographic maldistribution of

the pediatric surgical workforce remains a significant issue in many parts of the country, particularly for rural areas (Figure 3).

 Large areas of the country, particularly in the Midwestern and Southern regions of the country have no pediatric surgeons, and many states have only a few counties with any pediatric surgeons (Figure 3). Three states, Montana, North Dakota and Wyoming, have no pediatric generalist surgeons and Hawaii has only one to serve all of the islands.

Something to think about…

Pediatric Critical Care Surge Capacity

Markovitz, Barry P. MD, MPH

Abstract

For many pediatric intensive care units that routinely operate at near maximal census, planning for a surge of critically ill children in the event of a disaster can be daunting.  This brief review discusses the framework of surge planning, alterations of standards of care, and providing critical care outside of the pediatric intensive care unit.  There are general consensus-based guidelines on conceptualizing and operationalizing critical care surge planning, but there is little published on modeling outcomes of disasters affecting large numbers of children.

Legislation. A new version of the Patient-Focused Critical Care Enhancement Act was introduced to the U.S. House and Senate in March and May of 2009, respectively. The act seeks to optimize the delivery of critical care services by conducting research on optimal critical care delivery models and by providing support for research into therapies and treatments. The Society is monitoring the bill’s progress closely, as the legislation also would seek to improve care in the rural and underserved areas most affected by the workforce shortage and to invest in new technologies, such as telemedicine.

Staffing. Developing and inventing new staffing models also may also help alleviate demand for critical care physicians. Physician assistants and nurse practitioners trained in critical care could play a larger role in caring for intensive care patients. In line with this thinking, SCCM continues to encourage use of its Fundamental Critical Care Support (FCCS) program, with special attention to those in rural and underserved areas. FCCS works to educate non-intensivist physicians, nurses, physician assistants, and other providers about critical care and could have a key role in offsetting portions of the shortage. Growth in participation in FCCS has been dramatic, with 15% more individuals being training in the program in 2009 than the prior year, which also saw substantial growth.

For more information visit: http://www.sccm.org/Publications/Critical_Connections/Archives/August2009/Pages/PhysicianWorkforce.aspx

Summary Chart of Children’s Hospital Expansion in Critical Care

Recommendation: To meet the growing demand of pediatric critical care services nationwide, given the limited supply of specialty care physicians we recommend considering modeling processes and systems in PICUs/CICUs, surgical rooms and emergency/trauma departments at leading children’s hospitals that engage the expertise and skills of acute care certified pediatric nurse practitioners.  Consider using AC-PNPs, traveling specialty care physicians, and telemedicine collaboratively as solutions to consider. 

For more information on telemedicine in pediatric specialties, see: http://www.uofmchildrenshospital.org/about/Publications/c_659182.asp, http://pediatrics.aappublications.org/cgi/content/full/113/1/130

Does the training and certification differ between PNP and AC PNP?

Yes, according to the Pediatric Nursing Certification Board (PNCB) the primary care CPNP role is designed to meet the specialized physiologic and psychological needs of children in the areas of health maintenance and promotion and management of disease process. The CPNP PC provides wellness management of children incorporating competencies related to health promotion, protection, and disease prevention. The treatment focus of pediatric nurse practitioner practice is to maximize wellness and assist children and families in the prevention and management of common pediatric acute and chronic conditions.  This differs from the Certified Pediatric Nurse Practitioner Acute Care (CPNP AC).  According to the PNCB, the Acute Care CPNP role is designed to meet the specialized physiological and psychological needs of children with complex acute and chronic health conditions. Acute Care CPNPs® respond to rapidly changing clinical conditions, including the recognition and management of emerging health crises, organ dysfunction and failure. In accordance with this practice focus, CPNP-AC® role activities encompass a wide range of NP practice strategies including contributions to the management of children's illness/health states, the client nurse relationship, the teaching-coaching function, the professional role, managing and negotiating health care delivery systems, monitoring and ensuring quality of health care practice, providing family-centered care, and demonstrating cultural competency. The short-term goal of care is stabilization of the child, minimizing complications and providing physical and psychological care measures. The long term goal of care is to restore maximal health potential through implementation of NP strategies to reduce health risks. The continuum of care spans the geographical settings including but not limited to emergency departments, hospitals, subspecialty clinics and intensive care units. 

For more information about the difference in Primary Care and Acute Care CPNP exams visit http://www.pncb.org/ptistore/control/exams/ac/faq.

For more information about the Roles of Primary Care and Acute Care CPNP roles visit http://www.pncb.org/ptistore/control/exams/pnp/docs.

Are there enough Masters programs available to train Acute Care Pediatric Nurse Practitioners?  Currently there are not enough.  Even with great distance programs, the costs can be prohibitive to pay for the programs and travel.  The field is competitive and at this time there are not enough graduates to meet the need but that new programs are opening around the country.  At any one time, most of the major children’s hospitals have a standing request with Melnic Consulting Group for PICU and CICU Pediatric Nurse Practitioners because there seems to be a consistent shortage.

For Questions regarding the use of Acute Care Pediatric Nurse Practitioners in a Critical Care setting: 

Beth Nachtsheim Bolick, RN DNP

PNP-BC CPNP-AC CCRN

Associate Professor/Nurse Practitioner

Coordinator Acute/Chronic Care Pediatric Nurse Practitioner Program

Rush University College of Nursing

Women's and Children's Health Nursing

600 S. Paulina St. Ste. 1080

Chicago, IL 60612

Email:Beth_N_Bolick@rush.edu

Karin Reuter-Rice, PhD, NP

Board certified PNP-AC/PC, CCRN

Rady Children's Hospital, San Diego

Division of Pediatric Critical Care

3020 Children's Way, Mail Code 5065

San Diego, CA 92123

Email: kreuter-rice@adelphia.net

Lisa Sansalone MSN, RN, CPNP-AC

Division Director, Dept of Pediatric Surgery/

Division of Pediatric Advanced Care Practitioners

6431 Fannin, MSB 5.246

Houston, TX 77030

Email: lisa.sansalone@uth.tmc.edu

Patricia Chibbaro CPNP-BC

New York University Medical Center

Craniofacial Department

Email:patricia.chibbaro@nyumc.org

Mary E. McCulley, RN, MS, CPNP-AC

Assistant Clinical Professor

Clinical Coordinator, ACPNP Program

UCSF Dept. of Family Health Care

2 Koret Way, #N-431B

San Francisco, CA  94143-0606

Email:  Mary.McCulley@nursing.ucsf.edu

Dawn Tucker RN, MSN, CPNP-PC/AC

Cardiovascular Nurse Practitioner

Heart Institute

Children's Hospital of Orange County

Email:  dtucker@choc.org

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Telephone:: 800.886.7906 Email: Jill@Melnic.com