The Pediatric Intensive/Intermediate Care Unit (PICU/IMC) at UF Health Shands Children’s Hospital is located on the tenth floor of the North Tower. The unit is comprised of 24 private patient rooms. There is an average daily census of 16.4 patients.
The average length of stay is 3.49 days. The length of stay is influenced by a complement of long-term technology dependent children and overnight recovery patients, and the seasonality of some illnesses. A central core support area houses office and storage space, on call rooms, nutrition area, and a 24-hour satellite pharmacy. Four of the 24 bed spaces are designed for strict and respiratory isolation with negative airflow. The remaining bed spaces are equipped with clean/neutral airflow. Each bed space is constructed with glass-sliding entrance doors and charting areas framed with abutted glass. Each bed space is visible from one or more vantage points from the two nursing stations and medication preparation areas. Bedside monitoring including heart rate, respiratory rate, blood pressure, temperature, and pulse oximetry are standard. Expanded monitoring of invasive pressures, end tidal CO2, and mechanical ventilation are also available as the patient’s condition warrants. In addition, advanced monitoring including brain tissue oxygenation and regional oximetry are provided as needed. A family room sponsored by the Ronald McDonald House is located just outside the unit to provide families with a place to relax, prepare and eat meals, contact family members, and sleep in the hospital if necessary.
Description of Patient Populations
The PICU/IMC provides critical care services for children from the newborn period through twenty-one years of age twenty-four hours per day, seven days per week. The referral base extends from southern Georgia to Miami. The most common medical diagnoses include asthma, pneumonia, respiratory distress, seizures, altered level of consciousness, toxic ingestions, and sepsis. Frequently encountered surgical diagnoses and procedures include multiple trauma, head trauma, various surgeries related to cancer, Nissen fundoplication, direct laryngoscopy and bronchoscopy for diagnostic and therapeutic purposes, pectus excavatum repair, spinal fusion, craniotomy for tumors, exploratory laparotomy for gastrointestinal tract obstruction, and kidney transplantation.
The nursing staff is committed to family-centered and innovative patient care through the assessment, diagnosis, planning, treatment and evaluation of: pain, fluid and electrolyte abnormalities, hemodynamic instability, alteration in neurologic status, respiratory compromise, impairment in skin integrity, developmental delay, and family anxiety related to the intensive care experience. The PICU/IMC role specific job descriptions identify the patient populations, clinical parameters monitored, safety precautions initiated, and emergency events encountered.
Health Care Team
A multidisciplinary approach is utilized to provide intensive and comprehensive care for the entire spectrum of pediatric diseases, including congenital, acquired, and injury-related. Patients are admitted to the Pediatric Critical Care Medicine service with consultation provided by a variety of pediatric medical and surgical subspecialties including, but not limited to, Endocrinology, Gastroenterology, Genetics, Hematology-Oncology, Immunology, Infectious Diseases, Nephrology, Neurology, and Pulmonology, Neurosurgery, Orthopedics, Otolaryngology, Pediatric surgery, Plastic surgery, and Urology.
The Pediatric Critical Care Medicine team provides primary care for all PICU/IMC patients 24 hours per day/7 days per week. The medical direction for the PICU/IMC is provided by the Division Chief of Pediatric Critical Care Medicine. Multidisciplinary, comprehensive care of pediatric intensive care and intermediate care unit patients and families is provided by Medicine, Nursing, Social Work Services, Child Life, Case Management, Pastoral Care, Food and Nutritional Services, clinical Pharmacists, and other health care providers as indicated by the patient’s health status and identified needs. A hospital-based school teacher from the Alachua County School Board is available during the school year to work with children requiring repeated or extended hospitalizations. Care conferences are held as necessary to address short and long term goals for patients with complex medical problems or those with extended hospitalizations.
Nursing leadership for the unit includes registered nurses in the positions of Nurse Manager and Clinical Leader.
Registered nurses deliver autonomous, accountable total nursing care to all patients on a 24-hour/7 days per week basis and are assisted by support technicians. Additional staff who provide support to the PICU include pediatric clinicians, transplant coordinators, and ARNPs who work with pediatric critical care medicine, pediatric neurology, neurosurgery, pediatric hematology-oncology, and transplant patients. Respiratory and ventilator care is provided by respiratory therapists trained in pediatrics.
Registered nurses in PICU meet the basic requirements for Registered Nurse staff and function in accordance with the unit-based job description, as described in the Hospital Plan for Nursing Care. Additional unit requirements for registered nurses to prepare them to care for critically ill children are met through an extensive orientation program. Following orientation, specific additional educational objectives are met by the end of the probationary period and annually. Nurses are expected to demonstrate a positive attitude toward family-centered care, and the ability, willingness, and interest to work with the age-appropriate and developmental needs of patients.
Support Technicians meet the basic requirements for their positions and function in accordance with their unit-based job description, as described in the Hospital Plan for Nursing Care. Additional unit requirements for support techs include having a positive attitude toward family-centered care.
The nursing care provided to patients utilizing a total patient care approach, with the RN assuming care for the patient. The unit is staffed by a charge nurse on all shifts. The charge nurse is a staff registered nurse who is in charge of bed assignments, staffing needs, crisis intervention and the general work flow on the unit. In addition, the charge nurse carries the pediatric code beeper and coordinates the transfer placement of children with other pediatric charge nurses and the medical teams.
Nursing Care is provided for acutely and chronically ill children as described in the Hospital Plan for Nursing Care. The skill mix in PICU is 100% Registered Nurse-licensed staff supported by a fixed support tech staff. The usual nurse:patient ratios are 1:1 or 1:2 for ICU patients, and 1:3 for IMC patients. Unit staffing is based upon budgeted nursing hours per patient day (HPPD) which is formulated using national benchmarks and historical unit acuity data. Daily staffing is adjusted based on unit census and feedback from charge nurses to account for special circumstances that increase patient acuity, such as the need for a sitters, increased number of 1:1 patients, etc. Patient care assignments are made each shift by the charge nurse, with input from the staff nurses, based on nursing competency and expertise. Additional unit-based considerations for staffing include:
- amount of patient/family teaching needs and degree of complexity
- amount of child/parental anxiety
- impact of complex social situations
- stability of the child
- number and complexity of medications, treatments, and procedures
- amount of supervision required for children without family members in attendance
- procedural sedation procedures
- requirement of the RN to accompany the patient off the unit for tests/procedures
Additional staffing needs are met in the PICU as described in the Hospital Plan for Nursing Care. The need for extra shifts/overtime is determined by the Nurse Manager or designee.
Scheduled time off for unit management and for unit staff is coordinated such that patient care is not compromised. Requests are reviewed by the Nurse Manager or designee prior to approval. Staff attendance at meetings, educational offerings, and other activities are coordinated so that the patient care coverage is continuous, as reflected on the shift assignment sheets.
Assignment sheets are completed every shift to designate patient care assignments. Assignment sheets will contain the following information:
- Date and shift.
- Person in charge.
- Identification of staff by title, i.e. RN, LPN, Certified Nursing Assistant (NA), Sitters, etc.
- Patient assignment.
- Any changes in patient assignment.
- Resource/preceptor for orientee or float personnel, if other than the charge.
- RN responsible for LPN and/or NA patient care teams, as appropriate.
In the event of an emergency, such as severe weather conditions or other disaster, the minimum amount of staff required to safely operate the unit up to 75% capacity would be 13 licensed personnel and 2 support techs.