Admission and discharge guidelines for the pediatric patientrequiring intermediate care

David G. Jaimovich, MD; and the Committee on Hospital Care and Section on Critical Care

T he purpose of this statement isto provide lists of criteria thatmay be incorporated into mul-tiple disciplinary guidelines

for the admission and discharge of chil-dren requiring intermediate care. Be-cause of the continuous and rapidlychanging developments in critical carepediatrics, these criteria may require pe-riodic revision. Equally important, be-cause of significant differences in person-nel, facilities, and diagnostic andtreatment capabilities from hospital tohospital, no single set of criteria will ap-ply to every institution providing inter-mediate care.

Intermediate care is provided in acutecare hospitals to a patient populationwith a severity of illness that does notrequire intensive care but requiresgreater services than those provided byroutine inpatient general pediatric care.These patients may require frequentmonitoring of vital signs and/or nursinginterventions but usually will not requireinvasive monitoring. The development ofintermediate care services has been pro-posed as an appropriate means to en-hance resource utilization for intermedi-ately ill patients (1–4). In light of therecent emphasis on cost containment, in-termediate care promotes flexibility inpatient triage, provides pediatric patientswith monitoring and therapies tailored totheir severity of illness, and may be acost-effective alternative to admission toa pediatric intensive care unit. Patientswith a low risk of, but potential for, sig-nificant deterioration and who are admit-ted for routine monitoring are excellentcandidates for intermediate care.

Intermediate care is ideally providedin facilities that have a pediatric intensivecare unit (5). However, these resourcesmay not be widely available, particularlyin geographically remote regions, wheretertiary pediatric centers may be severalhours and hundreds of miles away.Therefore, this statement is also intendedto provide guidance for the care of chil-dren requiring intermediate care in hos-

pitals without a pediatric intensive careunit. These hospitals should ensure thatthe resources, facilities, and personnelneeded to provide care beyond the level ofa general pediatric medical-surgical unitare available; furthermore, they shouldhave the immediate availability to stabi-lize a child who becomes critically ill. Inaddition, these hospitals should identifyfacilities with pediatric intensive careunits to which patients can be transferredif their condition worsens (6). Estab-lished transfer policies with these facili-ties can ensure timely and effective tran-sition of care for these patients.

In a hospital that has a pediatric in-tensive care unit, these intermediate careadmission and discharge guidelinesshould be compatible with the admissionand discharge guidelines for the hospi-tal’s pediatric intensive care unit (6). Thisstatement provides a framework for indi-vidual hospitals to establish admission anddischarge criteria for intermediate pediatriccare. It is intended that these guidelines bemodified by individual institutions, depend-ing on availability of resources, personnel,and equipment necessary to evaluate andtreat a seriously ill child.

Physiologic parameters may be addedto these guidelines according to individ-ual patient care unit and institutionalpolicies so that triage may be providedappropriately in and out of intermediatecare. There is a need for evaluation of

From Hope Children’s Hospital, Oak Lawn, IL.The American College of Critical Care Medicine

(ACCM), which honors individuals for their achieve-ments and contributions to multiple disciplinary criticalcare medicine, is the consultative body of the Societyof Critical Care Medicine (SCCM) that possesses rec-ognized expertise in the practice of critical care. TheCollege has developed administrative guidelines andclinical practice parameters for the critical care prac-titioner. New guidelines and practice parameters arecontinually developed, and current ones are system-atically reviewed and revised. All clinical reports fromthe American Academy of Pediatrics automatically ex-pire 5 yrs after publication unless reaffirmed, revised,or retired at or before that time.

Publishing simultaneously in Pediatrics.Copyright © 2004 by the Society of Critical Care

Medicine and Lippincott Williams & Wilkins

DOI: 10.1097/01.CCM.0000126001.23141.4F

During the past three decades, the specialty of pediatric crit-ical care medicine has grown rapidly, leading to a number ofpediatric intensive care units being opened across the country.Many patients who are admitted to the hospital require a higherlevel of care than the routine inpatient general pediatric care, yetnot to the degree of intensity as pediatric critical care; therefore,an intermediate care level has been developed in institutionsproviding multiple disciplinary subspecialty pediatric care. Thesepatients may require frequent monitoring of vital signs and nurs-ing interventions but usually do not require invasive monitoring.The admission of the pediatric intermediate care patient is guided

by physiologic parameters depending on the respective organsystem involved relative to the institution’s resources and capac-ity in caring for a patient in a general care environment. Thisreport provides admission and discharge guidelines for interme-diate pediatric care. Intermediate care promotes greater flexibilityin patient triage and provides a cost-effective alternative to ad-mission to a pediatric intensive care unit. This level of care mayenhance the efficiency of care and improve the healthcare afford-ability for patients receiving intermediate care. (Crit Care Med2004; 32:1215–1218)

KEY WORDS: intermediate care; discharge; guidelines

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these criteria with outcomes over thenext several years, such as is done forpediatric intensive care units nationwide.Until that time, these criteria based onexpert opinion may assist hospitals andphysicians in creating a safe environmentfor children with increased intensity ofservice needs.

GUIDELINES FOR THE PATIENTREQUIRING INTERMEDIATECARE

I. Respiratory Diseases

Patients with moderate pulmonary orairway disease requiring multiple disci-plinary intervention and frequent moni-toring, including but not limited to thefollowing, may be admitted:

A. Patients with the potential need forendotracheal intubation.

B. Patients requiring minimal supportwith mechanical ventilation deliveredby mature and stable tracheostomy.This would apply primarily to childrenwith chronic respiratory insufficiency.

C. Patients with progressive pulmo-nary (lower or upper airway) disease ofmoderate severity with risk of progres-sion to respiratory failure or with ob-struction potential.

D. Patients acutely requiring supple-mental oxygen (fraction of inspired ox-ygen of 0.5 or greater), regardless ofcause.

E. Patients with stable tracheotomy.

F. Patients requiring frequent (at in-tervals shorter than 2 hrs) intermittentor continuous nebulized medications(according to institutional guidelines).

G. Patients requiring apnea work-upand cardiorespiratory monitoring.

II. Cardiovascular Diseases

Patients with moderate cardiovasculardisease requiring multiple disciplinaryintervention with frequent monitoring,including but not limited to the follow-ing, may be admitted:

A. Patients with non–life-threateningdysrhythmias with or without the needfor cardioversion.

B. Patients with non–life-threateningcardiac disease requiring low-dose in-travenous inotropic or vasodilatortherapy.

C. Patients undergoing high-risk car-diac procedures who require closemonitoring and who do not have he-modynamic or respiratory compro-mise.

D. Patients who have undergoneclosed-heart cardiovascular and in-trathoracic surgical procedures, in-cluding patent ductus-arteriosis repair,vascular shunts, permanent pacemakerplacement, and open thoracotomy,who do not have hemodynamic or re-spiratory compromise.

III. Neurologic Diseases

Patients with non–life-threateningneurologic disease requiring multipledisciplinary interventions, frequent mon-itoring, and neurologic assessment notmore often than every 2 hrs, includingbut not limited to the following, may beadmitted:

A. Patients with seizures who are re-sponsive to therapy but require contin-uous cardiorespiratory monitoring andwho do not have hemodynamic com-promise but have the potential for re-spiratory compromise.

B. Patients with altered sensorium inwhom neurologic deterioration or de-pression is unlikely and neurologic as-sessment is required.

C. Postoperative neurosurgical pa-tients requiring cardiorespiratorymonitoring.

D. Patients with acute inflammation orinfections of the central nervous sys-tem without neurologic deficiency orother complications.

E. Patients with head trauma withoutprogressive neurologic signs or symp-toms.

F. Patients with progressive neuro-muscular dysfunction without alteredsensorium requiring cardiorespiratorymonitoring.

IV. Hematologic/OncologicDiseases

Patients with potentially unstable he-matologic or oncologic disease or non–life-threatening bleeding requiring multi-ple disciplinary intervention and frequentmonitoring, including but not limited tothe following, may be admitted:

A. Patients with severe anemia withouthemodynamic or respiratory compro-mise.

B. Patients with moderate complica-tions of sickle cell crisis, such as respi-ratory distress, without acute chestsyndrome.

C. Patients with thrombocytopenia,anemia, neutropenia, or solid tumorwho are at risk of cardiopulmonarycompromise but who are currently sta-ble and, as a result, require close car-diorespiratory monitoring.

V. Endocrine/Metabolic Diseases

Patients with potentially unstable en-docrine or metabolic disease requiringmultiple disciplinary intervention andfrequent monitoring, including but notlimited to the following, may be admitted:

A. Patients with moderate diabetic ke-toacidosis (blood glucose concentra-tion �500 mg/dL or pH �7.2) requir-ing continuous insulin infusiontherapy without altered sensorium.

B. Patients with other moderate elec-trolyte and/or metabolic abnormalities(requiring cardiac monitoring andtherapeutic intervention), such as:

1. Hypokalemia (blood potassium con-centration �2.0 mEq) and hyperkale-mia (blood potassium concentration�6.0 mEq)

2. Hyponatremia and hypernatremiawith alterations in clinical status (i.e.,seizures or altered mental status)

3. Hypocalcemia or hypercalcemia.

4. Hypoglycemia or hyperglycemia.

5. Moderate metabolic acidosis requir-ing bicarbonate infusion.

C. Patients with inborn errors of me-tabolism requiring cardiorespiratorymonitoring.

VI. Gastrointestinal Diseases

Patients with potentially unstable gas-trointestinal disease requiring multipledisciplinary intervention and frequentmonitoring, including but not limited tothe following, may be admitted:

A. Patients with acute gastrointestinalbleeding but who do not have hemody-namic or respiratory instability.

B. Patients with a gastrointestinal for-eign body and other gastrointestinaldisease requiring emergency endos-copy but who do not have cardiorespi-ratory compromise.

C. Patients who have chronic gastroin-

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testinal or hepatobiliary insufficiencybut do not have coma, hemodynamic,or respiratory instability.

VII. Surgery

All patients requiring multiple disci-plinary intervention and frequent moni-toring and who have undergone surgicalprocedures but who do not have hemo-dynamic or respiratory instability, in-cluding but not limited to the following,may be admitted:

A. Patients who have undergone car-diovascular surgery.

B. Patients who have undergone tho-racic surgery.

C. Patients who have undergone neu-rosurgical procedures.

D. Patients who have undergone upperand lower airway surgery.

E. Patients who have undergonecraniofacial surgery.

F. Patients who have had thoracic orabdominal trauma.

G. Patients being treated for multipletraumatic injuries.

VIII. Renal Diseases

Patients with potentially unstable re-nal disease requiring multiple disciplin-ary intervention and frequent monitor-ing, including but not limited to thefollowing, may be admitted:

A. Patients with hypertension withoutseizures, encephalopathy, or othersymptoms but who require frequentintermittent therapeutic intravenousor orally administered medication.

B. Patients with noncomplicated ne-phrotic syndrome (regardless of cause)with chronic hypertension requiringfrequent blood pressure monitoring.

C. Patients with renal failure, regard-less of the cause.

D. Patients requiring chronic hemodi-alysis or peritoneal dialysis.

IX. Multiple System and OtherDiseases

Patients with potentially unstablemultiple system disease requiring multi-ple disciplinary intervention and frequentmonitoring, including but not limited tothe following, may be admitted:

A. Patients requiring the application ofspecial technological needs, includingthe following:

1. Use of respiratory assistance, such ascontinuous positive airway pressure,bilevel positive airway pressure, orchronic home ventilation.

2. Tracheostomy care requiring fre-quent pulmonary hygiene and suction-ing.

3. Pleural or pericardial drains afterinitial stabilization and who do nothave respiratory or hemodynamiccompromise.

4. Medications or resource needs inexcess of that provided in the generalpatient care unit.

B. Patients who are direct admissionsfrom another healthcare facility out-side the hospital (may be directly ad-mitted for intermediate care).

C. Patients with uncomplicated toxicingestion who do not have cardiovas-cular or respiratory compromise andwho require cardiorespiratory moni-toring.

DISCHARGE AND TRANSFERGUIDELINES FOR THEINTERMEDIATE CARE PATIENT

Patients will be evaluated and consid-ered for transfer to general care or specialcare units when the disease process hasreversed or the physiologic condition thatprompted admission has resolved and theneed for multiple disciplinary interven-tion and treatment is no longer needed.The decision to transfer or discharge tohome will be made on the basis of thefollowing criteria:

A. If the patient’s condition deterio-rates and he or she requires care be-yond the capabilities of the unit pro-viding intermediate care, the patientshould be admitted or readmitted to apediatric intensive care unit.

B. The patient should be transferred toa floor or specialty care unit or dis-charged to home, as appropriate, if thefollowing criteria apply:

1. The patient has stable hemodynamicparameters for at least 6–12 hrs.

2. The patient has stable respiratorystatus and has been extubated with ev-idence of acceptable gas exchange for�4 hrs.

3. The patient has minimal oxygen re-

quirements as evidenced by a fractionof inspired oxygen of 0.4 or less.

4. Intravenous inotropic support, vaso-dilators, and antiarrhythmic drugs areno longer required or, when applicable,low doses of these medications may beadministered in otherwise stable pa-tients in a designated patient care unit.

5. Cardiac arrhythmias are controlledfor a reasonable period of time but not�24 hrs.

6. Patient has neurologic stability withcontrol of seizures for a reasonable pe-riod of time.

7. All invasive hemodynamic monitor-ing devices have been removed (e.g.,arterial catheter).

8. The patient who had requiredchronic mechanical ventilation andhas had resolution of the acute illnessthat required intermediate or intensivecare and has now returned to baselineclinical status.

9. The patient will require peritonealdialysis or hemodialysis on a routinebasis and, therefore, may receive thesetreatments as an outpatient or a desig-nated patient care unit.

10. The need for multiple disciplinaryintervention is predictable and com-patible with policies of the receivingpatient care units.

11. The healthcare team, after carefulmultiple disciplinary assessment, to-gether with the patients’ family decidesthat there would be no benefit in keep-ing the child hospitalized or that thecourse of treatment is medically futile.

The guidance in this report does notindicate an exclusive course of treatmentor serve as a standard of medical care.Variations, taking into account individ-ual circumstances, may be appropriate.

Committee on Hospital Care, 2001–2002: John M. Neff, MD, Chairperson,Jerrold M. Eichner, MD, David R. Hardy,MD, Jack M. Percelay, MD, MPH, TedSigrest, MD, Erin R. Stucky, MD; Liai-sons: Susan Dull, RN, MSN, MBA, Na-tional Association of Children’s Hospitalsand Related Institutions, Mary T. Perkins,RN, DNSc, American Hospital Associa-tion, Jerriann M. Wilson, CCLS, Med,Child Life Council; Consultants: TimothyE. Corden, MD, Michael D. Klein, MD,Mary O’Connor, MD, MPH, TheodoreStriker, MD; Staff: Stephanie Mucha,MPH; Section on Critical Care, 2001–2002: M. Michele Moss, MD, Chairperson,

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Alice Ackerman, MD, Thomas Bojko, MD,Brahm Goldstein, MD, Stephanie A. Stor-gion, MD, Otwell Timmons, MD; Liaison:Richard J. Brilli, MD, Society of CriticalCare Medicine; Consultants: Lynda J.Means, MD, Anthony L. Pearson-Shaver,MD, Timothy S. Yeh, MD, Immediate PastChairperson; Staff: Sue Tellez, Society ofCritical Care Medicine; Pediatric Section,Admission Criteria Task Force: David G.Jaimovich, MD, Chairperson, Lucian K.DeNicola, MD, Gabriel “Gabby” Hauser,MD, Jan Kronick, MD, Kristan Outwater,MD, Tom Rice, MD, Kathy Rosenthal, RN,

MN, CCRN, Sara White, MD, MadolinWitte, MD.

REFERENCES

1. Zimmerman JE, Wagner DP, Knaus WA, et al:The use of risk predictions to identify candi-dates for intermediate care units: Implicationsfor intensive care utilization and cost. Chest1995; 108:490–499

2. Teres D, Steingrub J: Can intermediate caresubstitute for intensive care? Crit Care Med1987; 15:280

3. Popovich J Jr: Intermediate care units: Gradedcare options. Chest 1991; 99:4–5

4. Kalb PE, Miller DH: Utilization strategies forintensive care units. JAMA 1989; 261:2389–2395

5. American Academy of Pediatrics, Committeeon Hospital Care; and Society of Critical CareMedicine, Pediatric Section: Guidelines andlevels of care for pediatric intensive care units.Pediatrics 1993; 92:166–175

6. American Academy of Pediatrics, Committeeon Hospital Care and Section on Critical Care,and Society of Critical Care Medicine, Pediat-ric Section Admission Criteria Task Force:Guidelines for developing admission and dis-charge policies for the pediatric intensive careunit. Pediatrics 1999; 103:840–842

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