When to Escalate Care: A Pediatric Critical Care Specialist's Perspective

Primary care providers play a critical role in recognizing when a child’s condition requires a higher level of care. For Michelle Adu-Darko, MD, a pediatric critical care specialist, collaboration between primary care and hospital teams can make a life-saving difference in a child’s outcome.

Adu-Darko discusses clinical signs that may warrant escalation to pediatric critical care, the importance of timely intervention, and how she partners with families and referring providers when a child is critically ill.

How can referring providers help their patients with early detection and diagnosis?

Referring providers can best help their patients with early detection and diagnosis by providing preventive care and anticipatory guidance during all visits. Engaging in meaningful conversations with families and letting them know you genuinely care will also facilitate open communication and prompt them to seek health care sooner rather than later.

What risk factors should referring providers be on the lookout for?

Referring providers should be on the lookout for subtle signs in the presentation of different disease states that may deviate from the garden variety. Again, they should take time to listen to their patients and go with their gut instinct. They are more often right than wrong. Referring patients sooner rather than later can be helpful. Detailed, symptom-directed history-taking is one way they will identify patient changes that warrant transfer. They should also communicate with us by phone and other means and seek a second opinion when needed.

What’s something about your specialty you wish every referring provider knew?

I wish every referring physician knew that:

• We appreciate all the hard work they do
• Their expert management and care help reduce patient morbidity and mortality, making our work easier.
• We appreciate the continued collaboration in discussing challenging cases with them and are willing to triage and discuss cases as needed.

What’s one thing that every primary care doctor could start doing today to help their patients?

As the adage goes, “Prevention is better than cure”. We encourage Primary Care physicians to continue emphasizing preventive medicine, providing anticipatory guidance, and encouraging their patients to seek help early.

When should providers refer their patients to your program? 

Providers should refer their patients to my program whenever they believe we can best serve them.

Preferably, this should be when they first recognize the red flags, changes in vitals, and clinical status, and when there is concern for organ failure, such as respiratory distress and declining hemodynamic status. Examples include patients with complex and unexplained symptoms; those requiring multidisciplinary care, specialized or novel therapies, or advanced diagnostic testing; and those for whom providers are unsure about next steps.

Even when the patient appears stable, they can start having conversations with us.

What’s your approach to working with referring providers?

My approach to working with referring providers is to know who they are, be familiar with their practice, maintain open communication, provide clear guidelines on what to do while the referral is pending (where applicable), and provide pertinent feedback and updates following the referral.

How do you handle meeting a newly referred patient?

First impressions count, and so when meeting a newly referred patient, I first work to establish a trusting patient-healthcare team relationship. I get to know them and attend to their needs as indicated. I obtain a thorough history, evaluate it, formulate a diagnostic and management plan, develop a patient- and family-centered care plan, listen to parents' and other healthcare workers’ concerns, and discuss them with colleagues. I update their parents/guardians frequently.

What made you decide to focus on your specialty?

I developed a great interest in pediatrics, anesthesia, and critical care medicine during my medical school training. I had the opportunity to complete an observership in the Johns Hopkins Pediatric Critical Care department during my residency application process and was intrigued by the many miracles that occurred for those who recovered, and by the level of empathy and support given to those with a more dire prognosis. This exposure, among others, solidified my decision to pursue Pediatric Critical Care Medicine.

What’s your favorite thing about practicing as a critical care specialist?

My favorite thing about practicing as a specialist is the variety of cases I encounter and the meaningful difference I can make, especially when all hope seems lost and my skills matter most.