Paediatric Levels of Care: A Provincial Approach to Planning a System of Care for Paediatric Inpatients in Ontario
In 2011, the Provincial Council for Maternal and Child Health (PCMCH) partnered with Local Health Integration Networks (LHINs) to implement standardized definitions of maternal and newborn levels of care across hospitals in Ontario. Recognizing that these levels aim to provide equitable access to care at the appropriate level for all pregnant women and newborns in Ontario, there was acknowledgement that implementing standardized definitions for the paediatric inpatient population would do the same. These would also strive to establish a formal, integrated system for the provision of paediatric care in Ontario.
A Paediatric Levels of Care Work Group (PLC-WG) was assembled and recommended standardized level of care definitions for paediatric inpatients, endorsed by PCMCH. Several steps were undertaken by the PLC-WG to develop a comprehensive understanding of the system, and to develop recommendations that accurately reflected the challenges and opportunities of the paediatric healthcare system in Ontario. Throughout their development, these definitions were vetted by external stakeholders, including clinical and administrative representatives from hospitals, senior clinical and administrative leadership at Paediatric Academic Health Sciences Centres (PAHSCs), and other stakeholders from across Ontario that have direct impact on the paediatric inpatient population.
The following principles were developed and used by the PLC-WG to guide this work:
- Patients should be admitted to the level they require, as close to home as possible and be retro-transferred when appropriate
- Levels of care for patients will need to take into account disease process, expertise required, and likelihood of interventions and treatments
- Decisions will be guided by best-practice and be evidence-based whenever possible
- Organizations will oversee patient safety and quality of care
- Whenever feasible, technology and shared-care between organizations should be leveraged
- Services must be available 24/7/365 regionally, and not restricted by LHIN boundaries
- An efficient paediatric system will have clear designations and consistent scopes of services to facilitate the appropriate flow of patients and be able to manage surges; this will allow for improved local and regional planning
- Exceptions cannot drive the system
The overarching goal of the standardized definitions related to the paediatric levels of care is to ensure that quality services are provided to paediatric patients and their families as close to home as possible, in other words, care provided in the right place at the right time by the right providers. Inherent to the Paediatric Levels of Care framework is that organizations will operate within a regional system of care in which collaboration related to clinical and system issues is essential and where organizations have different roles, responsibilities and relationships including capacity building, outreach education, clinical support and dissemination of best practices.
The standardized definitions of paediatric levels of care are intended to:
- Provide a clear, consistent, and transparent understanding of services provided by any given site;
- Enable healthcare professionals to know where to call for advice and consultation;
- Support the flow of patients to both higher and lower levels of care, including transfers back;
- Foster shared-care management of patients when appropriate;
- Facilitate dialogue that will help to identify gaps and opportunities for capacity building, quality initiatives, etc. at the organizational, regional and even provincial level; and
- Enable a seamless system of care across the maternal-newborn-paediatric continuum.
Paediatric Levels of Care Framework
The levels of care framework consists of three distinct, yet inter-related components:
- The levels of inpatient care, of which there are three (Level I, Level II, and Level III)
- The classification of paediatric medical and surgical patients by acuity/complexity and procedural complexity
- Paediatric requirements related to physician/nursing skills and education needs; organizational/continuous quality improvement requirements; allied health human resource requirements; and diagnostic imaging, procedures, treatments, and equipment.
It is also important to note:
- A patient’s entry into the system can occur at any of the three levels;
- A patient’s movement (up or down) can occur from one distinct level to another, and can also occur between Level II organizations – due to the range of scope available within Level IIs;
- A “higher” or “lower” level of care is not necessarily determined by the actual number of the level (i.e. Level II) but rather, it is based on the patient’s care needs and whether the organization can meet those needs;
- Transfer to a “higher” level of care does not always mean that the patient would be transferred to a Level III organization. Patients may also be transferred from a Level I to a Level II, or between Level II organizations when and where appropriate;
- Although equally important, the paediatric inpatient levels of care framework does not apply to inpatient mental health services at this time; in order to establish levels of care for inpatient mental health services, a separate work group would need to be convened; and
The paediatric levels of care framework provides a foundation on which organizations can identify, and will help drive improvements and standards of support regarding patient safety/quality, consistency of care, and best practices.
In October 2018, PCMCH, in partnership with LHINs, will ask all hospitals in Ontario to complete an online organizational self-assessment survey by Tuesday, December 4th, 2018. In order to appreciate the true picture of service availability for paediatric inpatients, it will be important that hospitals answer the survey as accurately as possible. This process is not about increasing or decreasing capacity. It is intended to formally acknowledge the paediatric services hospitals are able to provide with current resources, and to identify whether gaps exist in the provision of paediatric care. Data from this survey will be collected by PCMCH and shared with LHINs and the Ministry Of Health and Long-Term Care (MOHLTC) for the purposes of making recommendations so that needs may be addressed from a capacity planning perspective at the local and regional levels. This information will lay the groundwork for future LHIN-based and provincial planning decisions.