Admit to discharge: integration of peds imc and ICU

nursenmom3 · Jul 7, 2019

I have not encountered this, but as a parent of a technology dependent child who spends a lot of time in the PICU, I would love to learn more.

PeakRN · Jul 9, 2019

Quite a few PICUs will discharge directly from the unit, especially those without true stepdown units. Often our medically complex patients are too difficult to appropriately organize care or have the needed training on the floor (vent care, PD, TPN, et cetera), and it is better to keep them on the floor for a few more days before discharging to home health.

There are a small number of cardiac PICUs across the country. They are historically difficult to staff.

You have to find nurses who either have or are willing to train to both cardiac and non-cardiac kids, and I've found this to be pretty to find. A lot of non-cardiac PICU nurses are fearful of how close to the edge of life those kids live, a lot of cardiac nurses struggle with dirty kids and the less perfect approach to care.

For the same reasons it can be very difficult to find cardiac trained pediatric intensivists who still want to care for non-cardiac patients.

It's also fairly difficult to plan out staffing. Trying to remember who can take hearts, traumas, transplants, HFOV, ECMO, CRRT, and so on becomes a nightmare.

nursenmom3 · Jul 10, 2019

22 hours ago, PeakRN said:
Quite a few PICUs will discharge directly from the unit, especially those without true stepdown units. Often our medically complex patients are too difficult to appropriately organize care or have the needed training on the floor (vent care, PD, TPN, et cetera), and it is better to keep them on the floor for a few more days before discharging to home health.
There are a small number of cardiac PICUs across the country. They are historically difficult to staff.
You have to find nurses who either have or are willing to train to both cardiac and non-cardiac kids, and I've found this to be pretty to find. A lot of non-cardiac PICU nurses are fearful of how close to the edge of life those kids live, a lot of cardiac nurses struggle with dirty kids and the less perfect approach to care.
For the same reasons it can be very difficult to find cardiac trained pediatric intensivists who still want to care for non-cardiac patients.
It's also fairly difficult to plan out staffing. Trying to remember who can take hearts, traumas, transplants, HFOV, ECMO, CRRT, and so on becomes a nightmare.

Can you explain a little bit more about what you mean by this?

PeakRN · Jul 10, 2019

1 hour ago, nursenmom3 said:
Can you explain a little bit more about what you mean by this?

Pediatric cardiac nurses are perfectionists. Every mL is counted, total fluids need to be precise every hour, fluid balance should be at goal every shift perfect.

Especially nurses from old school CVICUs love invasive monitors CVP, TIMs, art lines (and many of them, someinted multiple extremities, aortic root, UACs), bladder pressures, indwelling temperature monitors, pulse oximeter on multiple extremities, and so on.

Most of our non-cardiac kids are far less fragile, especially compared to a fresh Norwood. This isn't to say that our non-cardiac kids can't be very sick or even the sickest patient in the hospital at a given moment, but we tend to have far more wiggle room in their management.

PICUs get nurses from all different kinds of specialties, some that just were never really that dirty. We get some nurses from adult CVICUs, cardiac units, NICUs, and oncology and the simple matter that the kids have germs and make secretions makes them uncomfortable.

Sometimes those nurses, especially those from adult CVICUs and NICUs feel a lot less comfortable when we give a large fluid bolus or our total fluids don't make sense (particularly if we keep kids on full TPN while reintroducing feeds).

We also typically have a lot less invasive monitoring outside of cardiac patients (both in the adult world and peds), and some cardiac nurses become uncomfortable without having that.

There is certainly a lot of variation and generalizations are going to perfectly apply to everyone. Nursing and medicine continues to sub-specialize, and from a staffing perspective can add some challenges that didn't exist to nearly the same extent even a decade ago.

adventure_rn, MSN, NP · Jul 12, 2019

It's interesting because that's the standard of care in most NICUs, and it seems to work quite well for families and staff.

In our cardiac PICU, there is a small handful of kids who are discharged straight from the unit; it generally either applies to kids who will be discharged so quickly that it doesn't make sense to move them (i.e. a kid with a hx of cardiac repair who spikes a fever at home and is readmitted for a few days to be worked up), or to kids who are going home with certain technologies that our step-down rarely sees (like Heartmate/Heartware VADs). Most of our kids (especially the complex repairs who are going to be in the hospital convalescing for months) transfer to a cardiac-specific step-down, but they rarely go out to the floor. It works well for those kids to stay within a cardiac-specific unit (either cardiac ICU or cardiac step-down), as we are familiar with the defects as well as the technology that kids usually require (trachs, g-tubes, home PICCs, etc.). We hold onto kids in the ICU longer than we probably need to; we don't want to send kids who are borderline to step-down and have them rapid respond back to the ICU every few days (which would be stressful for the families), so a ton of our kids are stepdown-eligible, but hang out in ICU for a long time.

There has been some discussion of combining our units into a giant cardiac ICU/step-down for admit to discharge, and there's been a tremendous amount of push-back from nurses in both ICU and step-down. The ICU nurses hate it because they like having only one or two patients with a ton of invasive monitoring, and they don't want to care for three or four lower-acuity kids. The step-down nurses hate it because they are terrified of how quickly our kids decompensate and how easily they can code. The step-down nurses are fantastic at spotting our step-down kids who are beginning to decompensate and call early RRTs (we have very, very few codes in our cardiac step-down because the nursing care is so awesome). That said, I think that there are different types of nurses who enjoy ICU vs. step-down, and we'd probably have a mass exodous of if we told both floors that they needed to cross-train to both.