Post-surgical care

The NICU and the PICU

After an operation, the patient was taken to an intensive care unit. There were two ICUs where pediatric cardiac cases might be sent: the neonatal intensive care unit (NICU) and the pediatric intensive care unit (PICU). Both units were staffed by specially trained intensive care nurses and each had a doctor on duty who specialized in intensive care medicine.

Diagram 3.5 Neonatal intensive care unit Fourth floor, Winnipeg Children's Hospital

The NICU

The neonatal intensive care unit (NICU) at the Health Sciences Centre was built in 1985 on the fourth floor in the older part of Children's Hospital, one floor above the Pediatric Intensive Care Unit and the Children's Hospital's operating rooms. The NICU was an eighteen-bed unit that provided intensive care for babies less than six weeks of age.

The NICU medical staff consisted of doctors, referred to as neonatologists, who specialized in the care of the critically ill newborn. During 1994, staff neonatologists were on call in the NICU every two months for a week at a time. On-call neonatologists were responsible for all medical care within the unit, including being present for briefings when new patients were admitted, as well as monitoring any critically ill babies who needed to be managed closely.

Neonatologists in the NICU also had responsibility for the care of newborns in the intermediate care nursery at the Women's Pavilion. Staff neonatologists were expected to provide medical care on the Pavilion's labour floor and in the resuscitation room if required. To meet the demands associated with those responsibilities, there were two neonatologists on call in the NICU at all times, one of whom was usually a resident.

Pediatricians whose patients were transferred into the NICU continued to be involved in their patients' care, but the NICU medical team essentially took over treatment of the child.

Diagram 3.6 Pediatric intensive care unit Third Floor, Winnipeg Children's Hospital

The PICU

The pediatric intensive care unit (PICU) was located on the third floor in the south wing of the old part of Children's Hospital, just down the hall from the operating room. The PICU had a total of thirteen beds: eight for acute care patients and five for chronic patients. The unit dealt with children aged from six weeks of age to eighteen years of age.

Critically ill patients received one-to-one nursing care, while for other less ill children the ratio was two-to-one. The area for chronic patients was also called the pediatric extended care unit (PECU). This was separated from the rest of the PICU by a door.

Both the PICU and the NICU were staffed by persons with specialized training and dealt with children with a wide range of serious medical problems. Care was not restricted only to children who had undergone pediatric cardiac surgery. In addition, while certain procedures could be performed in the units, the units had to be specially prepared-for example, by obtaining all necessary equipment.

Preparing for intensive care

Up to one hour might pass from the time the patient's chest was closed until the patient was delivered to the intensive care unit. A bed would be brought from the ICU for the patient, rather than moving the patient to a stretcher and then to a bed in the ICU. The patient was carefully moved from the operating table to this ICU (portable) bed. Part of the difficulty in moving the patient was that each patient usually had six or more monitoring lines. The OR staff would detach the lines from the monitors and then reattach them to portable monitors. After this was done, the anaesthetist needed to check the various monitor readings and alter drug therapies in response to any changes in the patient's condition.

Before the patient left the OR, the nurses would phone ahead and brief the ICU as to the outcome of the operation and what preparations needed to be made to receive the patient. The transfer of the patient from the operating room to the ICU was done under the supervision of the anaesthetist, who continued to monitor the patient until the ICU staff assumed care and responsibility.

Transfer to the Intensive Care Units

After the patient arrived in the ICU, an assessment was quickly made to determine stability of the child's condition. All lines were connected to permanent monitors in the unit. Some patients might be breathing on their own by that time and could have the ventilation tube removed (or be 'extubated'). In more complex cases, the patients would continue to need artificial ventilation. After vital signs were measured, reports were given to the ICU staff. If the patient was stable, the operating team would hand over responsibility for the child. If the patient was not stable, the operating team would usually continue to participate in care.

Responsibility for care

Only medical staff from the intensive care unit could write medical orders for patients transferred into the ICU. This policy was put in place in order to avoid the potential for confusion and danger that could arise in the event of conflicting directions written by separate doctors. Private pediatricians or consultants were allowed to note in the chart what they wanted done for their patients, but before any treatment was carried out by a nurse or a resident in the unit, such a request had to be confirmed by a staff doctor. If there was disagreement over a particular course of treatment, doctors, as professionals, were expected to work their problems out. However, if there was ongoing disagreement, the unit doctors would make the final decision about treatment.