Alexandre Fiset was only a few days old when he was transferred to the Pediatric Intensive Care Unit (PICU) at The Montreal Children’s Hospital (MCH) of the McGill University Health Centre (MUHC). A virus had attacked his young heart and his heart was failing. “He was very critical and we knew his chances of survival were slim,” says Alexandre’s mother, Shirley Salah, who lives with her family in Saint-Jean-sur-Richelieu. Upon arriving at the MCH, Alexandre was put on an extracorporeal membrane oxygenation (ECMO) machine to replace his heart and lung function.

Alexandre’s heart was not able to adequately heal on ECMO and 19 days after being admitted to the hospital he received a heart transplant. Ms. Salah says the medical support and care Alexandre received was exceptional. “They gave us a lot of support and as parents, we felt we were at the best hospital for our son. If it weren’t for the doctors and nurses, Alexandre would not be alive today. We call him our miracle baby.”

Alexandre is not alone. The MCH PICU is world renowned for its clinical care, training and research. The highly skilled, multidisciplinary team provides advanced critical care to some 700 children a year. The PICU’s role also includes first-line resuscitative care and longer-term, intermediate and rehabilitative care.

“Our 16-bed unit provides tertiary and quaternary care to a mixed, medical-surgical population ranging in age from birth to 18 years of age and occasionally, older patients,” says Dr. Ronald Gottesman, Medical Director, PICU. “A third of our patients come from the emergency room, half from the operating room and the rest from other MCH wards and other hospitals. We offer specialized, comprehensive care to children in Montreal, across Quebec and Canada, and even around the world. The cohesive, integrated team of experts ensures that our PICU provides excellent family and patient-centered care.”

It’s all about the team
The PICU team is comprised of about 65 specialized personnel from many disciplines. It includes physicians, nurses, advance practice nurses, respiratory therapists, a physiotherapist, an occupational therapist and a pharmacist. Each is trained and certified in their own pediatric critical care field. The critical care medical team includes specialists with core certification in Pediatrics, Pediatric Surgery and Pediatric Anesthesia. A comprehensive psychosocial team is also a vital component of the PICU and includes a social worker, child life worker, psychologist, ethicist, and chaplain. “For any one child, there are about 10 PICU experts looking after their care,” says Dr. Gottesman.

Team members are equipped to diagnose, treat and manage cases that range from the clear-cut to the more complex—everything from pneumonia, septic shock and poisonings, to burns, brain tumours and level 1 trauma. Congenital malformations of the head and neck requiring craniofacial and tracheal reconstructions, and renal transplants make up only part of the unit’s complex caseload. “We have a very active congenital cardiac surgery program,” says Dr. Gottesman. “We do about 120 “open cardiac cases” a year, including heart transplants.”  The PICU also takes on intricate orthopedic cases that other pediatric institutions are unable to treat such as complicated scoliosis that often involve other genetic diseases.

Advanced technical and specialized care helps children with life-threatening conditions
The PICU offers high-level, specialized care to help children and teens recover from severe illnesses or injuries. “We treat patients with life-threatening organ failure by supporting their vital functions,” explains Dr. Sam Shemie, Medical Director of the Extracorporeal Life Support Program. “We’re able to sustain their lives until either time heals the disease or until treatment can reverse the disease. We use a variety of life support technologies, with ECMO being the most sophisticated and complex.”

“Children admitted to the PICU usually have multiple problems,” adds Dr. Gottesman. “Primary problems like heart failure often lead to kidney failure, brain and liver problems. We’re experts in providing and coordinating multiple organ support and care through a variety of mechanical devices.”

The MCH PICU provides advanced life support for organ failure and state-of-the-art monitoring equipment and technology. Mechanical ventilators in the unit include high frequency oscillatory ventilation. Hemodialysis machines are also specialized. Dr. Gottesman explains, “We can apply continuous renal replacement therapy (CRRT) that acts as bedside artificial kidneys.”

Extracorporeal Membrane Oxygenation Program (ECMO) supports newborns with heart and respiratory failure
The MCH PICU is the only provincial referral centre in Quebec that offers ECMO for newborn respiratory failure. “ECMO is a very advanced, technologically complex treatment that replaces heart and lung function,” says Dr. Shemie. “It is an artificial heart—or a pump—that circulates blood in place of a failed or completely arrested heart. It has an artificial lung and kidney in its circuit as well.”

Prior to the introduction of ECMO, the prognosis was very bleak for babies and children who did not respond to conventional life-support technologies. “This machine provides an additional chance to those who would otherwise certainly die,” says Dr. Shemie. The ECMO service at the MCH consists of a highly trained team of four PICU staff physicians, fellows and 12 highly skilled pump specialists, who provide 24/7 service. The ECMO machine kept Alexandre alive by replacing his heart function. When his heart did not recover, his only chance of survival was heart transplantation and he was fortunate enough to receive one in time.

Alexandre’s miracle was twofold—he had access to this life-saving treatment at the MCH and he received a new heart thanks to a family who donated their child’s organs after death.

Skilled nursing and humanized care – another critical part of the equation
Sophie Baillargeon, Nurse Manager of the Pediatric Intensive Care Unit and Hemodialysis Unit says her nursing staff’s knowledge, training and critical thinking ensure every patient receives the necessary physical care.

“They also humanize the care they give. They are empathetic and help families go through the medical crisis.” An effective team approach is also an important factor. “Interdisciplinary teamwork is our strength,” says Ms. Baillargeon. “Our work climate is very positive and along with everyone’s expertise we provide the best possible care to children whose lives are hanging in the balance.”

Point-of-care testing: immediate results when it matters most
A point-of-care testing laboratory allows for on-the-spot, bedside blood tests to be processed and the results available within minutes. Immediate medical imaging, testing and results also allow the PICU team to ensure quick intervention and treatment. An online digitized information system for medical imaging means all medical imaging studies, whether regular X-rays, ultrasounds, MRIs, or CT scans, can be viewed within minutes anywhere in the PICU, hospital or MUHC network.

A satellite pharmacy not only assures the safety and accuracy of dispensed drugs but the promptness and efficiency required in a critical care setting. The team’s pharmacist is an integral part of the PICU doing rounds with doctors.

Encouraging parents to be part of the care team
The MCH PICU takes a unique approach with parents, one that is rarely seen in other pediatric ICUs. “We allow access to information and access to their child,” says Ms. Baillargeon. There are no set visiting hours. Parents are included in the doctors’ rounds when their child’s condition is being discussed and evaluated. “Parents may not always understand, but they do have an opportunity to ask questions and we have an opportunity to teach them about what is happening to their child,” she says.

Alexandre’s parents, Shirley Salah and Sylvain Fiset, appreciated the openness shown by the PICU staff when their son was hospitalized. “They always told us what was happening and what to expect,” says Ms. Salah. “It was difficult to hear sometimes, but at least we were aware of the total picture. They were also so great at giving us the support we needed at that time.”

Parents’ involvement in the hands-on care of their children is key to making sure they feel included and connected to their child who is lying in bed hooked up to machines and monitors. “We want them to feel they are still parents so we encourage them to participate in their child’s care,” explains Ms. Baillargeon. “It could be something as simple as putting cream on their child’s lips or washing an arm that’s free of catheters and IV lines. Our philosophy is to include the parents as much as possible so they are part of every phase of their child’s treatment.”

A comprehensive psychosocial team is also a vital part of the PICU. “They offer valuable emotional and instrumental support to families whose child is going through a medical crisis,” says Marie Antonacci, assistant head nurse and psychosocial team co-coordinator. “Parents often say they feel like they’re on a roller coaster, depending on the status of their child.” The psychosocial team provides crisis intervention at a time when parents are having difficulty coping and maneuvering their way through their child’s unexpected illness or injury. “Different team members will step in when it’s appropriate,” says Ms. Antonacci.

Consultation line and referrals – a phone call away, 24 hours a day: 514 412-4238
Any physician or healthcare professional may call the PICU directly at any time to speak with a specialized ICU fellow or the ICU attending staff person. “We offer advice over the phone to healthcare professionals whose patients are likely going to need critical care,” says Dr. Gottesman. “We advise them on how to prepare their patient for transfer so that they arrive at the MCH in the safest and best shape possible. Transfers may be done locally, provincially, nationally or internationally”.

Recognized innovation and award-winning research
The MCH PICU is at the forefront of innovative research and clinical care. It was the first ICU in Canada, in conjunction with the hospital’s Congenital Heart Program, to apply the Berlin Heart Mechanical Assist Device to a young child.

Studies are under way in the application of predictive outcome scores in Pediatic Clinical Care, the application of computerized weaning processes in mechanical ventilation and the investigation of Technology Enhanced Learning for residents.

The PICU’s comprehensive clinical and bench research program has led to its staff being recognized with numerous awards in medical education, and organ donation research and development. The MCH PICU is recognized on the world stage for its academic education and research programs, and continually attracts candidates from across the globe.

Source: The Montreal Children’s Hospital Resource Guide 2009