Making care better in the pediatric intensive care unit.

The relatively young field of pediatric critical care has seen a shift from an approach with little consideration for the complications and adverse effects resulting from the procedures and medications to a more cautious approach with careful concern for the associated risks. Many senior pediatric intensivists recall a time when nearly every patient had a central venous line and arterial line; and hospital acquired infections, pressure injuries, unplanned extubations, and venous thromboemboli were expected costs of aggressive care. In addition to the morbidity and mortality associated with many of the health care-acquired conditions (HACs) in children, the attributable cost due to these HACs contributes to the unsustainable health care financial crisis. The Centers for Medicare and Medicaid Services (CMS) often penalize hospitals for HACs, and also are beginning to reimburse in a bundled fashion such that complications become the institution's burden. In children, payors and patients' families are often saddling this burden of costs attributable to HACs. The direct attributable costs per event are staggering. Payors, families, patients, and health care teams now demand a circumspect approach to care: do no harm, but how?