Optimal care for the unique needs of the seriously ill pediatric patient occurs best in an ICU specifically designed for children and separate from adult or neonatal facilities. During the 1970s, as technology advanced in the care of critically ill patients, healthcare professionals recognized that specialized units were needed for this specific group of patients. The first recognized ICU was developed in the 1950s, in Copenhagen, Denmark (1), with the primary purpose of caring for victims of the poliomyelitis epidemic (2). In the United States, ICUs for predominantly adult patients were developed in the 1960s; shortly thereafter, the earliest NICUs were formed (1).

The first PICU in the United States was opened in 1967 at Children’s Hospital of Philadelphia by Dr. John Downes (1). PICUs initially developed as free-standing units within hospitals during the late 1960s and early 1970s but were mostly found in large, metropolitan areas at large, free-standing children’s hospitals or within large, usually university-affiliated medical centers. During the 1980s, PICUs proliferated to essentially all free-standing children’s hospitals. The mean number of PICU beds per pediatric population in the United States in 2001 was 1:18,542 (3). Currently, the Society for Critical Care Medicine lists the United States as having 337 PICUs with ˜4044 beds, and over 1500 neonatal intensive care units with ˜20,000 beds (http://www.sccm.org/Communications/Pages/CriticalCareStats.aspx).

The development of PICUs in Europe predated the US experience, with the first PICU being founded at Children’s Hospital in Goteborg, Sweden, in the 1950s in response to the poliomyelitis epidemic that also resulted in the formation of the ICU in Copenhagen (2). PICUs proliferated in Europe as in the United States, with most being located within large multidisciplinary hospitals. For example, by 2000, Spain had 34 PICUs, all linked to the Public Health System (4). All were combined medical and surgical units, and 12 were combined pediatric and neonatal units.

Developing countries have a wide range of models and types of facilities to care for critically ill children depending on the financial resources available to the country. However, spurred by the Millennium Development Goals, the Global Sepsis Initiative, and other international and local projects, the last decade has witnessed significant progress in advancing pediatric intensive care to the developing world.

The resources required to support the demanding staffing and highly technical needs of critically ill and injured pediatric patients are often unevenly proportioned due to multiple factors, including population disparities, geographic limitations and financial constraints. Regionalization is defined in a statement from the AAP (5) as “a process for organizing resources within a geographic region to ensure access to medical care within a level appropriate to a patient’s needs.” In Pediatrics, regionalization of critical care services was developed initially for NICUs, such that the more critical and complex neonates were transported and cared for in those NICUs with the most sophisticated equipment and broader support staff. This concept spread with the advent of PICUs in the 1970s. Considering the relatively few critical or potentially unstable children with illness or injuries as compared to adults, and the broader range of diseases and injuries, the concept of regionalization makes even more sense for the pediatric population. Government or financial entities can mandate regionalization, but more commonly, regionalization has developed due to geographic constraints and well-developed referral patterns.

Studies (6,7) have supported the concept of regionalization (often called centralization in Europe) with their demonstration of better patient outcomes. A study that compared riskadjusted mortality in a centralized pediatric intensive care system in Australia with a no centralized system in England, where children were often cared for in adult ICUs, found twice the mortality rate in the noncentralized system (8). Regionalization or centralization was supported by a study that showed an inverse relationship between the volume of PICU
patients and the risk-adjusted mortality (or length of stay) (9). Regionalization has also been supported for pediatric cardiac surgery where there is less mortality in centers with the highest volumes (10,11).

In the United States, there continues to be wide variability in access of pediatric patients to specialized pediatric emergency and critical care. Due to concern about disaster preparedness for children, data were developed evaluating proximity of children to a PICU (12). In the United States, 81.5% of the pediatric population live within 50 miles of a PICU (as of 2008). However, there is state-by-state variability with some states having essentially all children within 50 miles of a PICU and others as little as 10% of the population living within that radius. A recent study utilized a telephone survey of 5% of the almost 5000 emergency departments listed in the National Emergency Department Inventory to evaluate resource availability for emergency pediatric services as recommended by the joint guidelines on care of children in the emergency department (13

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