Supplemental Table E1.
Comparison of PICU Hospital Bed Growth from 2001 to 2016*
PICU Bed Number
Number of PICUs in 2001
Change in PICU Beds by 2016
Median (Q1, Q3) Min. Max. Range
<7 71 1 (0, 4) -2 15 17
7-10 78 0 (0, 4) -3 14 17
11-14 55 1 (0, 8) -8 17 25
15-24 58 8 (2, 16) -13 79 92
>24 27 20 (14, 30) -32 48 80
*Includes the 289 PICUs that were there in both years.
Supplemental Table E2. Pairwise comparison of PICU Hospital bed growth from 2001 to 2016.
Pairwise Two-Sided Multiple Comparison Analysis Dwass, Steel, Critchlow-Fligner Method
Wilcoxon Z
DSCF Valu e
P value*
<7 vs. 7-10 0.0039 0.0056 1.00
<7 vs. 11-14 -0.6416 0.9073 0.97
<7 vs. 15-24 -5.1207 7.2417 <.0001
<7 vs. >24 -6.3906 9.0377 <.0001
7-10 vs. 11-14 -0.7061 0.9985 0.96
7-10 vs. 15-24 -5.2881 7.4785 <.0001 7-10 vs. >24 -6.5631 9.2816 <.0001 11-14 vs. 15-
24
-3.7540 5.3090 0.002
11-14 vs. >24 -5.8415 8.2611 <.0001 15-24 vs. >24 -3.6761 5.1988 0.002
* The bolded P values show a significant difference in the mean ranks of bed growth for the noted cmparisons. The adjusted P value for the 10 multiple comparisons was an alpha of 0.05/10=0.005.
There were no differences found in the <7 vs. 7-10 PICU beds, <7 vs. 11-14 PICU beds, and the 7-10 vs. 11-14 PICU bed comparisons.
The analysis of the paired bed growth was done using PICU beds in 2016 minus PICU beds in 2001, in PICUs present in both periods (N=289). Because the data were not normally distributed, the non- parametric Wilcoxon Rank Sum Test (aka Kruskal-Wallis Test) was used to compare the rankings of the bed growth data for each group. The P value for the overall comparisons was <0.0001 (Chi- square test statistic value 73.9, DF=4), showing differences in the mean ranks across all
comparisons. The Dwass, Steel, Critchlow-Fligner (DSCF) method was used to examine pairwise differences for the 10 comparisons:
Critchlow DE, Fligner MA. On distribution-free multiple comparisons in the one-way analysis of variance. In Communications in Statistics - Theory and Methods 1991;20:127-139.
Supplemental Table E3. Growth of pediatric intensive care units (PICUs), PICU Beds and Pediatric Population in the U.S. 2001 to 2016.
U.S. PICU Hospitals
Region Year ≤6
Beds
7-10 Beds
11-14 Beds
15-24 Beds
≥25 Beds
Total PICU Hospitals in
Region
Total PICU Beds in
Region
% Growth
Pediatric Population
Per Bed
East North Central 2001 14 15 9 7 5 50 606 - 19262
(OH, IN, IL, MI, WI) 2016 7 12 5 13 9 46 922 52 11489
West South Central 2001 19 8 8 10 4 49 604 - 14370
(AR, LA, OK, TX) 2016 6 9 12 11 10 48 882 46 11501
West North Central 2001 9 12 4 4 2 31 310 - 16048
(MN, IA, MO, ND, SD, NE, KS) 2016 6 7 4 5 5 27 433 40 11510
South Atlantic 2001 14 20 14 13 3 64 759 - 16595
(DE, MD, DC, VA, WV, NC, SC, GA, FL) 2016 12 20 11 10 15 68 1206 59 11587
Mountain 2001 7 2 7 2 3 21 271 - 18210
(MT, WY, ID, CO, NM, AZ, UT, NV) 2016 6 3 7 7 3 26 445 64 13003
Middle Atlantic 2001 25 9 10 6 3 53 549 - 17668
(NY, NJ, PA) 2016 18 9 5 11 6 49 678 23 13194
East South Central 2001 4 6 2 5 0 17 189 - 22709
(KY, TN, AL, MS) 2016 0 3 6 1 5 15 302 60 14340
Pacific 2001 9 17 5 11 7 49 704 - 17183
(WA, OR, CA, AK, HI) 2016 9 19 6 9 9 52 837 19 14597
New England 2001 6 2 2 2 1 13 143 - 23412
(MA, ME, NH, RI, CT, VT) 2016 2 6 1 3 1 13 203 42 14648
Total
2001 107 (30.8)
91 (26.2)
61 (17.6)
61 (17.3)
28
(8.1) 347 4135 - 17483
2016 66
(19.2) 88 (25.6)
57 (16.6)
70 (20.3)
63
(18.3) 344 5908 43 12465
Supplemental Table E4. Pediatric intensive care unit (PICU) beds in the U.S. in 2016 by Federal Emergency Management Area (FEMA) zone.
FEMA Zone* PICU beds
Pediatric Population
Beds per Pediatric Population
Beds per 100,000 Children Zone 1
2 03
2,973,6
07 14,648 6.83
Zone 2
4 70
6,165,3 11
13,1
18 7.62 Zone 3
5 44
6,593,8 91
12,1
21 8.25 Zone 4
1,1 64
14,385,1 32
12,3
58 8.09 Zone 5
1,0 73
11,880,8 16
11,0
73 9.03 Zone 6
9 17
10,565,8 80
11,5
22 8.68 Zone 7
2 63
3,305,8 70
12,5
70 7.96 Zone 8
1 66
2,939,2 55
17,7
06 5.65 Zone 9
9 05
11,709,7 98
12,9
39 7.73 Zone 10
1 80
3,122,7 25
17,3
48 5.76
* Excluding U.S. Territories.
Zone 1 Zone 2 Zone 3 Zone 4 Zone 5
Maine New York Pennsylvania Kentucky Minnesota
New Hampshire New Jersey Maryland Tennessee Wisconsin
Vermont West Virginia Mississippi Illinois
Massachusetts Virginia Alabama Indiana
Rhode Island Delaware Georgia Michigan
Connecticut DC S. Carolina Ohio
N. Carolina Florida
Zone 6 Zone 7 Zone 8 Zone 9 Zone 10
Texas Nebraska Colorado California Oregon
Oklahoma Kansas Utah Nevada Washington
New Mexico Missouri Wyoming Arizona Idaho
Arkansas Iowa South Dakota Hawaii Alaska
Louisiana North Dakota
Montana
Supplemental Figure E1. Method used to identify 2016 PICUs for this study.
363 identified hospitals with a PICU or an adult ICU in the 2001 Randolph et. al. study
72 hospitals did not have a PICU, 1 PICU only a burn unit, 1
duplicate hospital 433 identified hospitals with PICUs and/or children’s hospital from the American Hospital Association
- 263 identified prior - 35 did not have a PICU
- 7 hospitals located outside 50 U.S. states
- 22 only a rehabilitation hospital - 46 only a psychiatric hospital - 13 only an orthopedic hospital - 3 only other specialized hospital - 6 burn hospital
4 additional PICUs identified through separate web
search/colleague 38 additional
PICUs identified
13 additional PICUs identified
420 identified hospitals with PICUs from the PedsReady group
-288 identified prior
-19 hospitals located outside the 50 U.S. states
-102 did not have a PICU
344 hospitals with a
PICU
Supplemental Figure E2. Distribution of U.S. PICU beds in 2001 and 2016 reveals: A.) Increasing number of PICU beds across PICU hospitals; and B.) Increased percentage of total U.S. PICU beds are located in PICU hospitals with 25 or more PICU beds.
Supplemental Figure E3. Therapies provided in Intermediate or Progressive Care Units
Pressor Infusions
Inotrope Infusions
Insulin Infusion
Other Continuous infusion
Heliox
High Flow Nasal Canula
Non-Invasive Ventilation
Ventilation through a Tracheostomy 0
10 20 30 40 50 60 70 80 90 100
Supplemental Figure E4. Distribution of pediatric extracorporeal membrane oxygenation (ECMO) centers across the U.S.
Supplemental Figure E5. Pediatric subspecialist availability within an hour in U.S. PICUs by number of PICU beds per hospital.
SURVEY QUESTIONNAIRE
Responder Name: __________________________________________________________________
Hospital Name: ____________________________________________________________________
Please provide us with some information about your position.
1. What is your administrative position?
a. Physician Clinical Director
b. Designee of Physician Clinical Director c. Nurse Manager
d. Designee of Nurse Manager
e. Other : ___________________________________________________________________
2. Are you, or the physician medical director, board certified or eligible in pediatric critical care?
a. No b. Yes
3. Which of the following best describes your hospital?
a. Private and/or Community Hospital b. Health Maintenance Organization c. Government or Country Hospital
d. University Hospital and/or Tertiary Medical Center
e. Other: ____________________________________________________________________
4. Which of the following best describes your hospital’s classification?
a. Free Standing Children’s Hospital (Please go to PAGE 2) b. Children’s Hospital within a larger hospital
c. General Hospital (admits adults and children)
d. Other: ______________________________________________________________
5. A. Does your hospital contain ADULT intensive care units?
a. No (Please go to PAGE 2) b. Yes
B. If yes, for any of the following types of separate specialized units, please indicate whether your hospital currently has the kind of unit. By GENERAL we mean that ADULT patients are admitted to these specialized units.
UNIT TYPE NO YES Are Pediatric Patients (<18 yrs) ever placed in ADULT Unit?
Medical Intensive Care Unit (MICU)
No Yes Surgical Intensive Care Unit (SICU)
No Yes General Cardiac Care Unit
No Yes General Trauma Care Unit
No Yes General Neurosurgical Care Unit
No Yes Other Adult ICU (Please Specify):
No Yes ___________________________
Answers to the following questions will help us to better understand the infrastructure of pediatric care at your institutions.
For the purpose of this questionnaire, the term “Pediatric Intensive Care Unit (PICU)” is defined as beds set up in a separate unit to care for patients with life-threatening conditions requiring comprehensive
observation and care.
6. A. At your institution do you care for children with serious or critical burns?
a. No
b. Yes, in an adult burn unit with pediatric capabilities c. Yes, in a combined adult and pediatric burn unit d. Yes, in a pediatric burn unit
e. Yes, in a general PICU which also cares for pediatric burn patients
B. If yes, how many pediatric burn beds does your institution have? (numeric answers only please i.e. 10):
_____________________________________________________________________________
7. A. Please indicate if your institution has the following unit types. If YES, please indicate the bed number for that unit.
UNIT TYPE NO YES (bed #)
General Medical-Surgical PICU which DOES NOT care for cardiovascular patients
_______
Combined Medical-Surgical and Cardiovascular ICU
_______
Pediatric Cardiac Intensive Care Unit (CICU) or Cardiovascular Care Unit (CVICU)
_______
Pediatric Trauma Care Unit
_______
Pediatric Neuro-Critical Care Unit
_______
Neonatal Intensive Care Unit (NICU) or Intensive Care Nursery (ICN)
_______
Other specialized PICU (Please specify):
_______
B. If institution has a NICU, what is the maximum age for admission? _____________________
8. A. Does your general medical-surgical PICU or combined medical-surgical PICU have specialized rounding teams? (i.e. trauma service)
a. No b. Yes
B. If yes, Please name and describe your specialized rounding team.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
9. A. Where are pediatric patients who require monitoring, but minimal or no intensive care interventions placed?
a. In the PICU (Please proceed to question 10)
b. In a separate acute, intermediate, progressive and/or step-down care unit
c. Both in a separate acute, intermediate, progressive and/or step-down unit and in the PICU.
B. What is the name of the unit? _________________________________________________________
C. How many beds does this unit have? ___________________________________________________
D. Which, if any, technologies can you provide in your intermediate, progressive or step-down unit?
(Please mark all that apply)
Pressor Infusions (Norepinephrine, epinephrine, dopamine)
Heliox
Inotrope Infusions (Milrinone, Dobutamine)
High Flow Nasal Cannula
Insulin Infusions
Non-invasive Ventilation
Other Continuous Infusions
Ventilation through a Tracheostomy10. What is the TOTAL number of the pediatric beds at your hospital? By TOTAL we mean all pediatric ward, intermediate and pediatric specialized unit beds such as PICU and NICU beds. (numeric answers only, i.e.
10 and an estimate is acceptable)
_________________________________________________________________________________________
Answers to the following questions will help us to better understand the resources available in your ICU.
These answers will be confidential.
11. Which of the following best describes the availability in your emergency department for critically ill children?
a. Not available in our emergency department
b. One area is available with the capacity and equipment needed to resuscitate medical, surgical and trauma pediatric patients
c. Two areas available
d. Three or more areas available
12. At your institution which of the following services are provided? (Please mark all that apply)
An operating room available within 30 minutes, 24 hours per day, 7 days a week
A second operating room available within 45 minutes, 24 hours per day, 7 days a week
Cardiopulmonary Bypass
Flexible Bronchoscopy
Pediatric Endoscopy
Intermittent Hemodialysis
Continuous Hemofiltration Dialysis or Peritoneal Dialysis
Ventricular Assist Device
High Frequency Oscillation
Extracorporeal Membrane Oxygenation (ECMO)**How many available circuits? _____________________
13.
13. At your institution which of the following radiology services are provided? (Please mark all that apply)
Ultrasound
Pediatric angiography
Nuclear scanning
Fluoroscopy14. A. How quickly can each of the following PEDIATRIC physicians on your staff be at your hospital to provide patient care?
PEDIATRIC SPECIALTIES
Available within one hour, 24 hours per
day, every day
Usually Available Not Available
Pediatric Anesthesiologist
Pediatric Surgeon
Pediatric Cardiovascular Surgeon
Pediatric Neurosurgeon
Pediatric Otolaryngologist
Pediatric Orthopedic Surgeon
Pediatric Cardiologist
Pediatric Hematologist-Oncologist
Pediatric Nephrologist
Pediatric Neurologist
Pediatric Infectious Disease
Neonatologist
Pediatric Radiologist
Psychiatrist or Psychologist
B. How quickly can each of the following ADULT physicians on your staff be at your hospital to provide patient care?
ADULT SPECIALTIES
Available within one hour, 24 hours per
day, every day
Usually Available Not Available
Adult Anesthesiologist
Adult Cardiovascular Surgeon
Adult Otolaryngologist
Adult General Surgeon
Adult Neurosurgeon
Adult Orthopedic Surgeon
Adult Radiologist
Psychiatrist or Psychologist
15. Which of the following describes your system for transporting critically ill children, particularly pediatric patients who are intubated? (Please mark all that apply)
Have contract services with other transport mechanism (air or ground)
Transfer arrangements with a referral hospital
Use local emergency medical transport team
Utilize own transport teamThe questions below will help us understand staffing in your PICU. The questions below will be confidential.
16. How many attending staff members with subspecialty certification in
pediatric critical care or eligibility do you have on staff? ___________________
17. A. At your institution are any of these physicians (attendings) in-house 24 hours per day, all 7 days of the week?
a. No b. Yes
B. If no, what is the minimum response time for your pediatric intensivist(s) to be at your hospital for patient care when needed?
a. Less than 30 minutes
b. At least 30 minutes, but less than an hour c. One hour or longer
18. Which trainees and advanced practice providers, if any, rotate in your primary medical-surgical or combined medical-surgical and cardiovascular PICU during the DAY and NIGHT?
TRAINEES DAY NIGHT N/A
1st Year Pediatric Intern
2nd or 3rd Year Pediatric Resident
Emergency Medicine Resident
Family Medicine Resident
Pediatric Emergency Medicine Fellow
Pediatric Critical Care Fellow
Other: _____________________
ADVANCED PRACTICE PROVIDERS DAY NIGHT N/A
Pediatric Acute Care Nurse Practitioner
Family Nurse Practitioner
Physician Assistant
Board Certified or Eligible Pediatrician
(Hospitalist)
Other: _____________________
The following questions are about respiratory therapists at your institution.
19. Does your hospital have respiratory therapist assigned primarily to the PICU?
a. No, there is not a RT assigned solely to the PICU b. Yes, one is available 24 hours per day, every day
c. Yes, one is available, but less than 24 hours per day or not every day 20. Does your hospital have an in-house respiratory therapist available?
a. No, not available in-house
b. Yes, one is available 24 hours per day, every day
c. Yes, one is available, but less than 24 hours per day or not every day
Next we wish to know about nursing in your PICU.
21. A. Do you have a clinical nurse specialist available?
a. No we do not have a CNS
b. Yes, more than 20 hours per week c. Yes, less than 20 hours per week
B. If yes, what percentage of CCRN certified nurses do you have on staff? ___________________
22. How many PICU nurse full-time equivalents (FTEs) do you have on staff? ___________________
23. Do you have a nurse educator(s)? No Yes
24. Do you have a research nurse(s)? No Yes
25. Do you have an infection prevention/control nurse(s)? No Yes