Summary of paediatric and congenital cardiac services by health system complexity levels
| Level of care complexity | Basic paediatric and congenital cardiac services level 1 (PCCSL-1) | Intermediate paediatric and congenital cardiac services level 2 (PCCSL-2) | Complex/Advanced paediatric and congenital cardiac services level 3 (PCCSL-3) | Complex/Advanced paediatric and congenital cardiac services level 4 (PCCSL-4) | Complex/Advanced paediatric and congenital cardiac services level 5 (PCCSL-5) |
| Type of facility (DCP3 classification) | Health centre | First-level hospital | Referral hospital: second level | Referral hospital: third level | Referral hospital: National Children’s Hospital. |
| Responsibilities | Basic screening for cardiac disease Triage and referral Training and education Liaison with referral centres for follow-up care | Basic diagnostic cardiology Superficial postoperative wound care Treatment of patent ductus arteriosus-dependent disease with intravenous prostaglandin E2 Triage and referral Training and education Liaison with referral centres for follow-up care | Comprehensive screening and non-invasive diagnostic cardiology Outpatient, inpatient and emergency cardiac care Training and education Triage and referral | Elective and emergent cardiac catheterisations Cardiac surgeries Training and education | All elective or emergent cardiac catheterisations and cardiac surgeries including neontal cardiac procedures. Training, education, and research. |
| Age treated | All | All | All | All | All |
| Anaesthesia | No | Expert conscious sedation skills | General anaesthesia skills | Paediatric and congenital heart anaesthesia(s) or adult cardiac anaesthesia(s) with paediatric experience | Paediatric and congenital heart anaesthesia(s) or adult cardiac anaesthesia(s) with paediatric experience and credentials. |
| Human resources | Nurses and staff with basic paediatric training | Cardiac sonographers (anyone with some congenital heart disease imaging experience) Paediatric nurses Paediatric physicians Visiting paediatric cardiologist | In addition to what is needed in PCCSL1 and 2, paediatric cardiologists with basic interventional cardiology experience Cardiac surgery backup | Paediatric and congenital heart surgeon(s) or adult cardiac surgeon(s) with paediatric experience.Appropriately trained pediatric interventional cardiologist. | Paediatric and congenital heart surgeon(s) with expertise in neonatal cardiac surgeries. Pediatric interventional cardiologist with experience in neontal cardiac procedures. |
| Required skills | Basic cardiac history, examination and pulse oximetry. Ability to measure blood pressures. | Diagnostic echocardiography Resuscitation and stabilisation Basic medical management Superficial wound care Basic pain management | Comprehensive cardiac diagnosis, imaging and medical care Resuscitation and stabilisation Basic intensive care including ICU facilities for neonates on Prostaglandins. Emergent cardiac catheterisation procedures (pericardiocentesis, temporary pacemaker insertion, balloon atrial septostomy) | Fetal echocardiography Electrophysiology services Cardiac intensive care Cardiac catheterisation (PREDIC3T categories 0–4) Cardiac surgery: RACHS-2 categories 1 and 2 STAT 1 and 2 ABC 1 and 2 PRAIS2 10 - 15 | Cardiac catheterisation: all procedures. Cardiac surgery: all procedures. Adult CHD services. Cardiac transplant/LVAD/ECMO. |
| Infrastructure | Basic outpatient Infrastructure Transportation and referral system Investing in a low-cost telemedicine platform for timely consultation from higher-level centres | Basic inpatient and outpatient infrastructure Transportation and referral system | Infrastructure for basic inpatient cardiology services Transportation and referral system | Functionally and physically separate paediatric echocardiography lab Infrastructure for CICU, cardiac catheterisation and cardiac surgery (can be functionally separate but physically shared facility with adult services) | Functionally and physically separate CICU preferably including ECMO. Functionally and preferably physically separate cardiac catheterisation services. Infrastructure for advanced cardiac surgery. |
| Equipment and supplies | Basic medical equipment Pulse oximeters Stethoscopes ECG Chest X-ray (if available) Blood pressure apparatus See online supplemental appendix table 2 | See online supplemental appendix table 2 | See online supplemental appendix tables 2 and 3 | Equipment and supplies to support the proposed complexity of children’s cardiac care See online supplemental appendix tables 1–3 | See online supplemental appendix tables 1-3. |
| Quality and safety | CME and CPD of healthcare providers around use of pulse oximetry and cardiac-specific history taking, examination and blood pressure measurement. Quality audits of transport and referral mechanisms. | QI framework for diagnostic accuracy in echocardiography adapted from ACPC QNET of the ACC51 52 | In addition to what is required in PCCSL 1 and 2, reporting of inpatient complication rate, infection rate, crude mortality rate for emergency interventions and length of stay Regular M&M meetings . | In addition to what is present in other lower-level centres, a QI and safety representative QI framework for diagnostics, cardiac catheterisation and cardiac surgery by preferably being on international registries like IQIC, ACC QNET, etc Long-term care plan for patients undergoing cardiac surgery, as a way to develop adult CHD service | In addition to above, multidisciplinary programme review, additional advanced echocardiography metrics from ACPC QNET, adherence to lifelong CHD care guidelines. |
ABC, Aristotle Basic Complexity; ACC, American College of Cardiology; ACPC QNET, Adult Congenital & Paediatric Cardiology Quality Network; CHD, congenital heart disease; CICU, cardiac intensive care unit; CME, continuous medical education; CPD, continuous professional development; ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; IQIC, International Quality Improvement Collaborative; LVAD, left ventricular assist device; M&M, morbidity and mortality; PRAIS2, partial risk adjustment in surgery; PREDIC3T, Procedural Risk in Congenital Cardiac Catheterisation; QI, quality improvement; RACHS, Risk Adjustment for Congenital Heart Surgery; RHD, rheumatic heart disease; STAT, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery; TEE, trans-oesophageal echocardiography.