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## Complete Summary

#### GUIDELINE TITLE

Admission and discharge guidelines for the pediatric patient requiring
intermediate care.

#### BIBLIOGRAPHIC SOURCE(S)

Jaimovich DG, Committee on Hospital Care and Section on Critical Care.
Admission and discharge guidelines for the pediatric patient requiring
intermediate care. Pediatrics 2004 May;113(5):1430-3. \[6 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121967)

#### GUIDELINE STATUS

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years
by the authoring body, at which time a recommendation is made that the
policy be retired, revised, or reaffirmed without change. Until the
Board of Directors approves a revision or reaffirmation, or retires a
statement, the current policy remains in effect.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Illness requiring intermediate care, including:

-   Respiratory diseases

-   Cardiovascular diseases

-   Neurologic diseases

-   Hematologic/Oncologic diseases

-   Endocrine/Metabolic diseases

-   Gastrointestinal diseases

-   Surgery

-   Renal diseases

-   Multisystem and other diseases

#### GUIDELINE CATEGORY

Management

#### CLINICAL SPECIALTY

Cardiology\
Endocrinology\
Gastroenterology\
Hematology\
Neurology\
Nursing\
Oncology\
Pediatrics\
Pulmonary Medicine\
Surgery

#### INTENDED USERS

Hospitals\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To provide lists of criteria that may be incorporated into
    multidisciplinary guidelines for the admission and discharge of
    children requiring intermediate care

-   To provide guidance for the care of children requiring intermediate
    care in hospitals without a pediatric intensive care unit

#### TARGET POPULATION

Pediatric patients with a severity of illness that does not require
intensive care but does require greater services than those provided by
routine inpatient general pediatric care

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Assessment of patients for admission to intermediate care

2.  Discharge or transfer from intermediate care

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Guidelines for the Patient Requiring Intermediate Care**

I.  **Respiratory Diseases**

> Patients with moderate pulmonary or airway disease requiring
> multidisciplinary intervention and frequent monitoring, including but
> not limited to the following, may be admitted:

A.  Patients with the potential need for endotracheal intubation

B.  Patients requiring minimal support with mechanical ventilation
    delivered by mature and stable tracheostomy. This would apply
    primarily to children with chronic respiratory insufficiency.

C.  Patients with progressive pulmonary (lower or upper airway) disease
    of moderate severity with risk of progression to respiratory failure
    or with obstruction potential

D.  Patients acutely requiring supplemental oxygen (fraction of inspired
    oxygen [\>]{.underline}0.5), regardless of cause

E.  Stable tracheotomy patients

F.  Patients requiring frequent (at intervals \<2 hours), intermittent,
    or continuous nebulized medications (according to institutional
    guidelines)

G.  Patients requiring apnea work-up and cardiorespiratory monitoring

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II. **Cardiovascular Diseases**

> Patients with moderate cardiovascular disease requiring
> multidisciplinary intervention and frequent monitoring, including but
> not limited to the following, may be admitted:

A.  Patients with non--life-threatening dysrhythmias with or without the
    need for cardioversion

B.  Patients with non--life-threatening cardiac disease requiring
    low-dose intravenous inotropic or vasodilator therapy

C.  Patients undergoing high-risk cardiac procedures who require close
    monitoring and who do not have hemodynamic or respiratory compromise

D.  Patients who have undergone closed-heart cardiovascular and
    intrathoracic surgical procedures, including patent
    ductus-arteriosus repair, vascular shunts, permanent pacemaker
    placement, and open thoracotomy who do not have hemodynamic or
    respiratory compromise

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III. **Neurologic Diseases**

> Patients with non--life-threatening neurologic disease requiring
> multidisciplinary intervention, frequent monitoring, and neurologic
> assessment not more than every 2 hours, including but not limited to
> the following, may be admitted:

A.  Patients with seizures who are responsive to therapy but require
    continuous cardiorespiratory monitoring and who do not have
    hemodynamic compromise but have the potential for respiratory
    compromise

B.  Patients with altered sensorium in whom neurologic deterioration or
    depression is unlikely and neurologic assessment is required

C.  Postoperative neurosurgical patients requiring cardiorespiratory
    monitoring

D.  Patients with acute inflammation or infections of the central
    nervous system without neurologic deficiency or other complications

E.  Patients with head trauma without progressive neurologic signs or
    symptoms

F.  Patients with progressive neuromuscular dysfunction without altered
    sensorium requiring cardiorespiratory monitoring

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IV. **Hematologic/Oncologic Diseases**

> Patients with potentially unstable hematologic or oncologic disease or
> non--life-threatening bleeding requiring multidisciplinary
> intervention and frequent monitoring, including but not limited to the
> following, may be admitted:

A.  Patients with severe anemia without hemodynamic or respiratory
    compromise

B.  Patients with moderate complications of sickle cell crisis, such as
    respiratory distress, without acute chest syndrome

C.  Patients with thrombocytopenia, anemia, neutropenia, or solid tumor
    who are at risk of cardiopulmonary compromise but who are currently
    stable and, as a result, require close cardiorespiratory monitoring

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V.  **Endocrine/Metabolic Diseases**

> Patients with potentially unstable endocrine or metabolic disease
> requiring multidisciplinary intervention and frequent monitoring,
> including but not limited to the following, may be admitted:

A.  Patients with moderate diabetic ketoacidosis (blood glucose
    concentration \<500 mg/dL or pH [\>]{.underline}7.2) requiring
    continuous insulin infusion therapy without altered sensorium

B.  Patients with other moderate electrolyte and/or metabolic
    abnormalities (requiring cardiac monitoring and therapeutic
    intervention), such as:

    1.  Hypokalemia (blood potassium concentration \<2.0 mEq) and
        hyperkalemia (blood potassium concentration \>6.0 mEq)

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

    3.  Hypocalcemia or hypercalcemia

    4.  Hypoglycemia or hyperglycemia

    5.  Moderate metabolic acidosis requiring bicarbonate infusion.

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C.  Patients with inborn errors of metabolism requiring
    cardiorespiratory monitoring

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VI. **Gastrointestinal Diseases**

> Patients with potentially unstable gastrointestinal disease requiring
> multidisciplinary intervention and frequent monitoring, including but
> not limited to the following, may be admitted:

A.  Patients with acute gastrointestinal bleeding but who do not have
    hemodynamic or respiratory instability

B.  Patients with a gastrointestinal foreign body or other
    gastrointestinal problem requiring emergency endoscopy but who do
    not have cardiorespiratory compromise

C.  Patients who have chronic gastrointestinal or hepatobiliary
    insufficiency but do not have coma, hemodynamic, or respiratory
    instability

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VII. **Surgery**

> All patients requiring multidisciplinary intervention and frequent
> monitoring who have undergone surgical procedures but who do not have
> hemodynamic or respiratory instability, including but not limited to
> the following, may be admitted:

A.  Patients who have undergone cardiovascular surgery

B.  Patients who have undergone thoracic surgery

C.  Patients who have undergone neurosurgical procedures

D.  Patients who have undergone upper or lower airway surgery

E.  Patients who have undergone craniofacial surgery

F.  Patients who have had thoracic or abdominal trauma

G.  Patients being treated for multiple traumatic injuries

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VIII. **Renal Diseases**

> Patients with potentially unstable renal disease requiring
> multidisciplinary intervention and frequent monitoring, including but
> not limited to the following, may be admitted:

A.  Patients with hypertension without seizures, encephalopathy, or
    other symptoms, but who require frequent intermittent therapeutic
    intravenous or orally administered medication

B.  Patients with noncomplicated nephrotic syndrome (regardless of
    cause) with chronic hypertension requiring frequent blood pressure
    monitoring

C.  Patients with renal failure, regardless of cause

D.  Patients requiring chronic hemodialysis or peritoneal dialysis

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IX. **Multisystem and Other Diseases**

> Patients with potentially unstable multisystem disease requiring
> multidisciplinary intervention and frequent monitoring, including but
> not limited to the following, may be admitted:

A.  Patients requiring the application of special technologic needs,
    including:

    1.  Use of respiratory assistance, such as continuous positive
        airway pressure, bi-level positive airway pressure, or chronic
        home ventilation

    2.  Tracheostomy care requiring frequent pulmonary hygiene and
        suctioning

    3.  Pleural or pericardial drains after initial stabilization (for
        patients who do not have respiratory or hemodynamic compromise)

    4.  Medications or resource needs in excess of those provided in the
        general patient care unit

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B.  Patients who are direct admissions from another health care facility
    outside the hospital (may be directly admitted for intermediate
    care)

C.  Patients with uncomplicated toxic ingestion who do not have
    cardiovascular or respiratory compromise and who require
    cardiorespiratory monitoring

**Discharge and Transfer Guidelines for the Intermediate Care Patient**

Patients will be evaluated and considered for transfer to general care
or special care units when the disease process has reversed or the
physiologic condition that prompted admission has resolved and the need
for multidisciplinary intervention and treatment is no longer present.
The decision to transfer or discharge to home will be made on the basis
of the following criteria:

A.  If patient´s condition deteriorates and he or she requires care
    beyond the capabilities of the unit providing intermediate care, he
    or she should be admitted or readmitted to a pediatric intensive
    care unit.

B.  Patient should be transferred to a floor or specialty care unit or
    discharged from the hospital, as appropriate, if the following
    criteria apply:

    1.  Patient has stable hemodynamic parameters for at least 6 to 12
        hours.

    2.  Patient has stable respiratory status and has been extubated
        with evidence of acceptable gas exchange for more than 4 hours.

    3.  Patient has minimal oxygen requirements as evidenced by a
        fraction of inspired oxygen of 0.4 or less.

    4.  Intravenous inotropic support, vasodilators, and antiarrhythmic
        drugs are no longer required, or, when applicable, low doses of
        these medications may be administered to otherwise stable
        patients in a designated patient care unit.

    5.  Cardiac arrhythmias are controlled for a reasonable period of
        time but not less than 24 hours.

    6.  Patient has neurologic stability with control of seizures for a
        reasonable period of time.

    7.  All invasive hemodynamic monitoring devices have been removed
        (e.g., arterial lines).

    8.  Patient who had required chronic mechanical ventilation and has
        experienced resolution of the acute illness that required
        intermediate or intensive care has now returned to baseline
        clinical status.

    9.  Patient will require peritoneal dialysis or hemodialysis on a
        routine basis and therefore may receive these treatments as an
        outpatient or in a designated patient care unit.

    10. The need for multidisciplinary intervention is predictable and
        compatible with policies of the receiving patient care unit.

    11. The health care team, after careful multidisciplinary assessment
        and together with the patient´s family, decides that there would
        be no benefit to keeping the child hospitalized or that the
        course of treatment is medically futile.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting each recommendation is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

These criteria, based on expert opinion, may assist hospitals and
physicians in creating a safe environment for children with a higher
intensity of service needs.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The recommendations in this statement do not indicate an exclusive
    course of treatment or serve as a standard of medical care.
    Variations, taking into account individual circumstances, may be
    appropriate.

-   It is intended that these guidelines be modified by individual
    institutions, depending on the availability of resources, personnel,
    and equipment necessary to evaluate and treat a seriously ill child.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Jaimovich DG, Committee on Hospital Care and Section on Critical Care.
Admission and discharge guidelines for the pediatric patient requiring
intermediate care. Pediatrics 2004 May;113(5):1430-3. \[6 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121967)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 May

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society\
Society of Critical Care Medicine - Professional Association

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Committee on Hospital Care and Section on Critical Care

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee on Hospital Care, 2001-2002*: John M. Neff, MD,
*Chairperson*; Jerrold M. Eichner, MD; David R. Hardy, MD; Jack M.
Percelay, MD, MPH; Ted Sigrest, MD; Erin R. Stucky, MD

*Liaisons*: Susan Dull, RN, MSN, MBA, National Association of
Children\'s Hospitals and Related Institutions; Mary T. Perkins, RN,
DNSc, American Hospital Association; Jerriann M. Wilson, CCLS, MEd,
Child Life Council

*Consultants*: Timothy E. Corden, MD; Michael D. Klein, MD; Mary
O\'Connor, MD, MPH; Theodore Striker, MD

*Staff*: Stephanie Mucha, MPH

*Section on Critical Care, 2001-2002*: M. Michele Moss, MD,
*Chairperson*; Alice Ackerman, MD; Thomas Bojko, MD; Brahm Goldstein,
MD; Stephanie A. Storgion, MD; Otwell Timmons, MD

*Liaison*: Richard J. Brilli, MD, Society of Critical Care Medicine

*Consultants*: Lynda J. Means, MD; Anthony L. Pearson-Shaver, MD;
Timothy S. Yeh, MD, Immediate Past Chairperson

*Staff*: Sue Tellez

*Society of Critical Care Medicine, Pediatric Section, Admission
Criteria Task Force*: David G. Jaimovich, *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; Madolin Witte, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years
by the authoring body, at which time a recommendation is made that the
policy be retired, revised, or reaffirmed without change. Until the
Board of Directors approves a revision or reaffirmation, or retires a
statement, the current policy remains in effect.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Web
site](http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/5/1430).

Print copies: Available from American Academy of Pediatrics, 141
Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on July 2, 2004. The information
was verified by the guideline developer on August 4, 2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest
Point Blvd, Elk Grove Village, IL 60007.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008