Kissoon, Niranjan MD, CPE; Argent, Andrew MD; Devictor, Denis MD, PhD; Madden, Maureen A. RN, MSN; Singhi, Sunit MD, PhD; van der Voort, Edwin MD; Latour, Jos M. RN, MSN
From the Acute and Critical Care Programs (NK), Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Paediatric Intensive Care Unit (AA), Red Cross War Memorial Children’s Hospital and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa; Service de Réanimation Pédiatrique (DD), Assistance Publique-Hôpitaux de Paris, Département de recherche en éthique, Université Paris-sud 11, Hôpital de Bicêtre, Bicêtre, France; Department of Pediatrics (MAM), UMDNJ- Robert Wood Johnson Medical School, Department of Pediatic Critical CareNew Brunswick, NJ; Department Of Pediatrics (SS), and Pediatric Emergency and Intensive care Services, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India; Department of Pediatrics (EvdV), Sophia Children’s Hospital, University Hospital, Rotterdam, The Netherlands; and Department of Pediatrics (JML), Division of Pediatric Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands.
The authors have not disclosed any potential conflicts of interest.
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In September 1997, The World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS) was established in Paris. It arose from the vision of several world leaders in the field of pediatric critical care who saw the opportunity to combine international expertise, experience, and influence to improve the outcomes of children suffering from life-threatening illness and injury. These leaders understood that more could be achieved by an international network of national societies than by any nation alone. They envisioned a global community that would set priorities and link working groups to further the research and knowledge needed to care for critically ill infants and children.
WFPICCS is committed to a global environment in which all children have access to intensive and critical care of the highest standard. With this in mind, WFPICCS has defined its mission as educational, scientific, and charitable in nature (Fig. 1). It exists to find ways of improving the care of critically ill children throughout the world, and making that knowledge available to those who care for such children. We define critical care as the treatment of the child with a life-threatening illness or injury in its broadest sense, without regard for the location and including prehospital and emergency and intensive care. This definition is more inclusive than the traditional definition of intensive care.
This document is intended to outline our agenda, inform member societies, and stimulate discussion to the best strategies for achieving our goals.
A global environment where all children have access to a high standard of critical care based on research and education and free dissemination of knowledge across international borders.
* To develop an understanding of the needs for critical care for children across the world.
* To encourage the development of new clinical treatments and the appropriate application of new and existing critical care technologies and treatments to infants, children, and adolescents with life-threatening illnesses.
* To promote educational programs and the dissemination of scientific information relevant to the specialty.
* To recommend desirable standards and guidelines for the training of Pediatric Critical Care practitioners.
* To provide information regarding opportunities for postgraduate clinical and research training worldwide.
* To encourage research into all aspects of Pediatric Critical Care.
* To advance collaboration and professional development of Pediatric Critical Care physicians, nurses, and allied health professional by initiating and supporting educational activities.
* To organize a World Congress of Pediatric Intensive and Critical Care at regular intervals and promote regional congresses. We need to encourage meetings of various subspecialties of pediatric critical care and make provisions for them to meet where appropriate at the World Congress.
* To assist and encourage the development and formation of national and regional organizations dedicated to pediatric intensive and critical care.
* To advise on request National and International organizations.
From its modest beginnings, the World Federation has grown into an internationally recognized organization. Its most recent world congress has been very successful, especially considering the diversity of participants and the enthusiastic, fruitful interaction of colleagues from different areas of the world. WFPICCS also has a high-quality journal, an active and interactive website (www.wfpiccs.org) and now wishes to reaffirm its vision and objectives to best serve the interests of critically ill children globally.
However, WFPICCS cannot be everything for everyone and our success has led us to examine our role in different parts of the world. It is well recognized that critically ill children are present in disproportionate numbers in the developing world, where resources are limited and, in some cases, nonexistent. On the other hand, great strides and innovations in critical care such as transplantation, cardiovascular surgery, trauma, and organ support have been made in the developed world where resource limitations are less of an issue. There is, therefore, a tension between WFPICCS involvement in strategies that would benefit the largest numbers in the developing world and its role in pushing the frontiers of the science of critical care in the developed world. Ideally, WFPICCS should support both rich and poor countries and all critically ill and injured children should be afforded a spectrum of care that ensures the best outcome possible. This care, which links prehospital care through rehabilitation and nontertiary care with tertiary care centers (Fig. 2), is available in many parts of the developed world. However, care priorities differ in much of the world, where such systems do not exist.
Regardless of environmental constraints, care should be delivered with the intent of achieving the greatest societal good with the available resources. In the rich as well as the poorer countries, health systems are usually organized with this intent. Low-cost, high-yield initiatives such as mass immunizations and prevention of injury are the foundation of health care, with more resource intensive programs serving fewer (Fig. 3). That intensive care is available to a few stems from many reasons including lack of access to intensive care facilities and inability to afford services when present. However, critical care can serve many. If one gets appropriate early emergency/critical care interventions, much of the subsequent clinical course is smoother and shorter. Early care is even more important in poorer countries because tertiary care centers are often nonexistent or poorly resourced in the developing world and much of the care, therefore, is provided by district and secondary level hospitals and by nurses, village health workers, and nonspecialist doctors (Fig. 3).
Given this model of care delivery, how does WFPICCS fulfill its global role? Clearly, WFPICCS needs to have a global understanding of issues that impact child health. We need to understand many aspects of these issues including geography, economics, public health infrastructure, ecological issues, (including factors such as global warming and all its possible ramifications), politics, patterns of infectious diseases and nutrition, cultural diversity, and the implication of differences in culture and environment on the health and outcome of children. We also need to recognize the wide range of individuals and organizations that play significant roles in child health throughout the world, and how a variety of organizations, nations, cultures, and environments can work synergistically to improve the situation in child health. All these issues are important and should inform and dictate our responses, although it is also well recognized that many of these issues are outside our area of expertise and primary focus. Indeed, we would propose that the involvement of WFPICCS vary depending on local circumstances, as outlined in Figure 3.
Our proposed level of involvement across the globe is difficult to illustrate graphically. Indeed, the sanitized graphic depiction of decreasing level of involvement is a crude approximation. The world is not clearly demarcated into “haves and have nots,” or are countries or even cities homogeneous. Rather, they may be comprised of areas of wealth and access to ideal critical care that border areas of poverty and no access to basic care. Therefore, the directness of our involvement may vary, running the spectrum between teaching critical care and advocating broadly for the needs of children. Figure 4 illustrates that the relationship of wealth, needs, and outcomes are complex. Although income or gross domestic product is a reasonable surrogate for health care quality and access (Fig. 4), this relationship is nonlinear. If one considers Cuba, Croatia, and the United States (Fig. 4), one can see five-fold (Croatia) and 20-fold (United States) increases in gross domestic product compared with Cuba but similar survival statistics. Hence WFPICCS level of involvement will not only vary from country to country, but regionally within countries and may change with time.
Our vision of an environment where all children have access to a high standard of critical care will take time and resources that are not available at present, nor will be in the near future in many cases. The question, therefore, is how do we position ourselves to do the best for the acutely injured or critically ill child within resource limitations and cognizant of other competing and compelling interests? We suggest that we be involved in all areas that are congruent with our objectives and are in the best interests of the critically ill child. For example, in the developed world or where intensive care exists, our involvement will be concentrated in these areas, with involvement in secondary level care as it intersects with tertiary care. This involvement will enable us to encourage new developments, foster research, promote training, and evaluate the application of new techniques. The assumption here is that the ideal model is already in place (Fig. 2) and efforts should focus on expanding the frontiers of sophisticated, technologically advanced care.
In the developing world, most critically ill children will be treated in nontertiary facilities. Transport, emergency, and critical care services are underdeveloped or nonexistent (Fig. 2). WFPICCS should encourage the development of local, national, and continental scientific societies in critical or intensive care medicine in these countries. WFPICCS should also be involved in fostering the development of tertiary critical care services in these areas when appropriate, and assisting in the development of alternative models of care for the critically ill.
The breadth of our vision, as described above, has the potential to be a liability unless we are able to focus on exactly where our roles and priorities lie. We are an organization composed of societies with the discipline of pediatric critical care as a common feature. Our role is to enhance communications among the WFPICCS member societies. We also need to be advocates for the care of the critically ill children in its broadest sense. Our efforts also have to be congruent with those of other organizations involved in promoting and caring for the critically ill.
For example, the World Health Organization program for improving the care of sick children in the developing world is clearly extremely important and the overall issues and direction of that program are compatible with the values of WFPICCS. Our specific relationship with the WHO would ideally involve supporting overall initiative while providing specific input into aspects of that program that involve the care of critically ill children and networking with people who may be able to provide additional and valuable input. In our relationship with the International Pediatric Association, we view ourselves as coworkers providing input on and support to any aspect of their programs relating to the care of critically ill or injured children. Likewise, we will continue to work with the World Federation of Societies of Intensive and Critical Care Medicine, including participating in their meetings.
In all instances, we would be promoting the needs of critically ill or injured children; providing support and potentially training for those who have to work with children and stimulating and facilitating research wherever possible. We will also focus on working with pediatric, neonatal, emergency medicine, and acute care groups in countries where critical care is not well established. For example, we have started the development of the African Pediatric Critical Care Association, in which we have brought together individuals with an interest in the care of critically ill or injured children or neonates in Africa. That juxtaposition of people from diverse settings with different interests and expertise promises to create many opportunities for development of pediatric critical care.
As a group, we intend to develop and publish editorials, reviews and prospective documents that outline the position of critical care for children within the context of child health priorities in diverse settings as possible. We also need to encourage the development of Intensive and Critical Care Scientific Societies in developing countries. WFPICCS could provide information and advice to facilitate this development.
Although in the ideal world, all children should have access to state-of-the-art critical care services, this is unlikely to happen anytime soon. Faced with this reality, the member societies of WFPICCS will strive to develop the best model and provide the best care for critically ill and injured children worldwide.
*See also p. 608 and 610. Cited Here...
©2009The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies