Caring for critically ill adults in paediatric intensive care units in England during the COVID-19 pandemic: planning, implementation and lessons for the future

OBJECTIVE

To describe the experience of paediatric intensive care units (PICUs) in England that repurposed their units, equipment and staff to care for critically ill adults during the first wave of the COVID-19 pandemic.

DESIGN

Descriptive study.

SETTING

Seven PICUs in England.

MAIN OUTCOME MEASURES

(1) Modelling using historical Paediatric Intensive Care Audit Network data; (2) space, staff, equipment, clinical care, communication and governance considerations during repurposing of PICUs; (3) characteristics, interventions and outcomes of adults cared for in repurposed PICUs.

RESULTS

Seven English PICUs, accounting for 137 beds, repurposed their space, staff and equipment to admit critically ill adults. Neighbouring PICUs increased their bed capacity to maintain overall bed numbers for children, which was informed by historical data modelling (median 280-307 PICU beds were required in England from March to June). A total of 145 adult patients (median age 50-62 years) were cared for in repurposed PICUs (1553 bed-days). The vast majority of patients had COVID-19 (109/145, 75%); the majority required invasive ventilation (91/109, 85%). Nearly, a third of patients (42/145, 29%) underwent a tracheostomy. Renal replacement therapy was provided in 20/145 (14%) patients. Twenty adults died in PICU (14%).

CONCLUSION

In a rapid and unprecedented effort during the first wave of the COVID-19 pandemic, seven PICUs in England were repurposed to care for adult patients. The success of this effort was underpinned by extensive local preparation, close collaboration with adult intensivists and careful national planning to safeguard paediatric critical care capacity.

End-of-life care in a pediatric intensive care unit: the impact of the development of a palliative care unit

BACKGROUND

The purpose of this paper is to describe how end-of-life care is managed when life-support limitation is decided in a Pediatric Intensive Care Unit and to analyze the influence of the further development of the Palliative Care Unit.

METHODS

A 15-year retrospective study of children who died after life-support limitation was initiated in a pediatric intensive care unit. Patients were divided into two groups, pre- and post-palliative care unit development. Epidemiological and clinical data, the decision-making process, and the approach were analyzed. Data was obtained from patient medical records.

RESULTS

One hundred seventy-five patients were included. The main reason for admission was respiratory failure (86/175). A previous pathology was present in 152 patients (61/152 were neurological issues). The medical team and family participated together in the decision-making in 145 cases (82.8%). The family made the request in 10 cases (9 vs. 1, p = 0.019). Withdrawal was the main life-support limitation (113/175), followed by withholding life-sustaining treatments (37/175). Withdrawal was more frequent in the post-palliative group (57.4% vs. 74.3%, p = 0.031). In absolute numbers, respiratory support was the main type of support withdrawn.

CONCLUSIONS

The main cause of life-support limitation was the unfavourable evolution of the underlying pathology. Families were involved in the decision-making process in a high percentage of the cases. The development of the Palliative Care Unit changed life-support limitation in our unit, with differences detected in the type of patient and in the strategy used. Increased confidence among intensivists when providing end-of-life care, and the availability of a Palliative Care Unit may contribute to improvements in the quality of end-of-life care.

[Trend of antimicrobial susceptibility in a neonatal and pediatric intensive care unit]

BACKGROUND

Nosocomial infections in intensive care units are a health problem worldwide due to their incidence, prevalence and clinical impact. The objective of this article was to describe the trend of antimicrobial susceptibility during a 10-years period in both a pediatric and a neonatal intensive care unit.

METHODS

This is a follow-up cohort study. In 10 years of follow-up, the antimicrobial used was considered the independent variable, and the antimicrobial susceptibility as the dependent variable. By using chi squared with Fisher exact test, the initial and final susceptibilities were compared, and also the most prevalent diagnoses and the antimicrobials. A two-tailed p value < 0.05 was considered statistically significant. SPSS 8 and Epi-Info 0.6 were used for statistical analysis.

RESULTS

Antimicrobial susceptibility decreased from 66 to 45 % in 10 years, representing a global loss of 13 % (p = 0.002). The most affected antimicrobials were first-generation cephalosporin (p = 0.02), ciprofloxacin (p = 0.05), erythromycin (p = 0.001), imipenem (p = 0.001), and trimethoprim/sulfamethoxazole (p = 0.05).

CONCLUSION

There is an alarming loss of effectiveness in antimicrobial agents.

Trends in the aggressiveness of end-of-life care for Korean pediatric cancer patients who died in 2007-2010

Background

In light of the Korean Supreme Court's 2009 ruling favoring a patient's right to die with dignity, we evaluated trends in aggressive care in a cohort of pediatric cancer patients.

Methods We conducted a population-based retrospective study that used administrative data for patients who died in 2007–2010 among the 5,203 pediatric cancer patients registered at the Korean Cancer Central Registry (KCCR) during 2007–2009.

Results

In the time period covered, 696 patients died. The proportion who had received chemotherapy in the last 30 days of life decreased from 58.1% to 28.9% (P<0.001), those who received new chemotherapy in the same time period decreased from 55.2% to 15.1% (P<0.001), and those who received treatment in the last 2 weeks of life decreased from 51.4% to 21.7% (P<0.001). In the last 30 days of life, the proportion of patients whose hospital admission period was over 14 days increased from 70.5% to 82.5% (P = 0.03), the proportion who received cardiopulmonary resuscitation decreased from 28.6% to 9.6% (P<0.001), and we found no statistically significant trends in the proportion of emergency department visits, intensive care unit admissions, or mechanical ventilation.

Conclusions

In this study, in contrast with earlier ones, the aggressiveness of end-of-life care of Korean pediatric cancer patients decreased dramatically.

Current trends in paediatric and neonatal ventilatory care -- a nationwide survey

AIM

To assess daily practices in paediatric and neonatal ventilatory care in Finland.

METHODS

All neonatal and paediatric intensive care units in Finland were sent a questionnaire on ventilatory strategies and were offered a 3-month prospective survey.

RESULTS

A total of 96% of units returned the questionnaire, and clinicians agreed on most of the principles of lung-protective ventilation. Seventeen hospitals (94%) joined the prospective survey. On average, 2.3 new ventilation episodes were started daily, and totally 211 episodes were monitored. Pulmonary problems (64%) were the main cause of treatment in neonates and postoperative care (68%) in older children. Synchronized intermittent mandatory ventilation with pressure support was the primary mode in 42% of episodes. Hypocapnia was observed repeatedly in all units. In adult intensive care units, children often received high oxygen fraction, leading to hyperoxia, and they were frequently sedated with propofol, which is not licensed for that purpose. A large proportion of children had only light sedation or no sedation at all. Despite the different strategies and practices, most episodes resulted in a favourable outcome.

CONCLUSION

Most of the principles of lung-protective ventilation have been well accepted by clinicians. More attention should be paid to achieving normocapnia and normoxia and to the correct use of sedatives, especially in units that only occasionally provide paediatric ventilation.

Coordination Group for National Survey of Development in Pediatric and Neonatal Intensive Care Units. [Development of pediatric and neonatal intensive care units: results of a national survey (2000 - 2009)]

OBJECTIVE

To understand the current situation and development of intensive care units for neonates and children (ICUs) in China.

METHODS

A form of survey was e-mailed to chief of each ICU who is one of the thirty five board members of Subspecialty group of Emergency Medicine Chinese Society of Pediatrics or Chinese Society of Emergency Medicine Pediatric Branch. The data from Jan. 1 to Nov. 30, 2009 were collected and compared with the first survey which was conducted during the year 2000(Group B).

RESULTS

Thirty three of 35 (94.3%) hospitals responded. Among them, 25 were children's hospitals (Group A1), 8 were pediatric department of general hospitals (Group B). The total number of ICU beds accounted for 6.9% and 5.8% of total numbers of hospital beds in Group A1 and B respectively, increased 1.1 percent. The doctor to bed ratio in Group A1 and B were 0.5:1 and 0.75:1, nurse to bed ratio in Group A1 and B was 1.17:1 and 1.38:1. The monitor to bed ratio in Group A1 were 1.44:1, Group B were 0.74:1 and the ventilator to bed ratio in Group A1 were 0.64:1, Group B were 0.46:1. The percentage of blood gas analyzers, portable X-ray, bedside ultrasound which ICUs owned in Group A1 and B were 100% (25/25) vs. 60% (16/27), 96% (24/25) vs. 70% (19/27) and 88% (22/25) vs. 30% (8/27) separately. The percentage of surfactant therapy use, blood purification therapy, high frequency ventilation and ECMO in Group A1 and B were 96% (24/25) vs. 48% (13/27), 80% (20/25) vs. 22% (6/27), 84% (21/25) vs. 37% (10/27) and 20% (5/25) vs. 0%. The survival rate of ventilated patients in group A1 and B were 77.5% (6393/8245) vs. 63.4% (809/1276) separately, Group B was lower than Group A1 (P < 0.001). The survival rate of premature infants weighted 1 - 1.5 kg in Group A1 and B were 88% (2183/2482) vs.75.1% (531/707), weighted > 1.5 - 2.5 kg were 93.7% (6836/7296) vs.84.1% (1890/2247), Group B were lower than group A1(P < 0.01). There were 12 659 and 1392 patients in Group A1 and A2 respectively for whom the Pediatric Critical Illness Scoring system (PCIS) was used to assess the severities of illness in PICU patients. Among them, the percentage of non critically ill (> 90) patients in group A1 and A2 were 3616 (28.6%) and 639 (45.9%) respectively, Group A1 was lower than A2 (P = 0.000). The mean bed occupation rate of PICU in Group A1 and A2 were 127.1% (103.3% - 186.0%) vs. 90.91% (71.0% - 126.0%), NICU in the above Groups were 138.0 (83.8 - 290.5) vs.108.9 (90.7 - 128.0).

CONCLUSION

The present study may roughly reflect the development of ICUs in the past ten years and current situation of neonatal and pediatric ICUs in tertiary hospitals in the mainland of China, especially development of PICUs. The percentage of ICU bed to hospital bed was increased. The equipments, new techniques and survival rates of patients treated in ICUs had been improved remarkably, but the occupation rate of bed was too high. A number of PICU beds were occupied by low risk patients and lack of human resource need to be urgently addressed.

[The future of pediatric intensive care]

Paediatric intensive care is born 40 years ago. It has been shown that admission of critically ill children in intensive care (ICU) where no paediatric intensivists worked increased significantly the mortality and the length of stay. The recognition of Paediatric Intensive Care (PICU) does not exist in Belgium and children are admitted in both adult and paediatric intensive care units. It is mandatory to recognise the PICU specificity and the usefulness of a fellowship in paediatric intensive care. Development of molecular biology and genetics will permit in the near future to understand reversible and irreversible cellular processes of the majority of problems responsible for mortality in critical care and to allow the development of new diagnostic and therapeutic techniques. Rapid development of information will permit the creation of multicenter databases including all PICU's data. The final goal is an intelligent tool for making decision process. Telemedecine is born which permits a virtual consultation of the patient. Technological progress must not impair the wellbeing of the child and its family. The PICU of the future must be "parents admitted". PICU profile is progressively changing, the way of taking care of the critically ill child and its family is also changing and improving. An ethical reflexion among the health care providers' team and a dialogue with parents will blossom.

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil

OBJECTIVES

To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil.

METHODS

A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000).

SETTING

Three PICUs in Porto Alegre, southern Brazilian region.

PATIENTS

Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000.

RESULTS

The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000.

CONCLUSION

We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

Growth of pediatric intensive care units in the United States from 1995 to 2001

OBJECTIVE

To describe the growth and distribution of pediatric intensive care unit (PICU) beds in the United States from 1995 to 2001 and the characteristics of PICUs in 2001.

STUDY DESIGN

This was a cross-sectional survey of PICUs in 1995 to 1996 and 2001 to 2002.

RESULTS

There were 306 general PICUs in the United States in 1995 and 349 in 2001 (13.7% growth). In both survey periods, approximately half of the PICUs had <or=8 beds. The largest growth (34.4%) was in PICUs with >or=15 beds. There were 3899 PICU beds in 2001 (23.9% increase from 1995), with a mean number of PICU beds per pediatric population (age <18 years) of 1/18542 in the United States (17.5% increase from 1995). There was an increase in the number of annual admissions, occupancy rate, length of stay, percentage intubated, mortality rate, and number of intensivists per PICU with increasing bed size. In 2001, 94% of PICUs had a pediatric intensivist on staff, and these specialists were in-house at night in 17% of all PICUs and in 30% of PICUs with >or=15 beds.

CONCLUSIONS

The number of PICU beds is growing more rapidly than the rate of pediatric population growth. The impetus for this growth is unclear.

Children with human immunodeficiency virus admitted to a paediatric intensive care unit in the United Kingdom over a 10-year period

OBJECTIVE

There is little published experience regarding the outcome of children with human immunodeficiency virus (HIV) infection treated on a paediatric intensive care unit (PICU). We describe the outcome of children with HIV infection in our hospital over a 10-year period.

METHOD

We performed a retrospective analysis of all children with HIV infection admitted to our PICU between August 1992 and July 2002. Their ages ranged from 2 months to 11 years (median 4 months). Information collected included demographic data, clinical presentation, investigations, treatment and outcome.

RESULTS

There were 42 children with HIV infection admitted to PICU during the study period, with 66 admission episodes. Sixteen (38%) children died in PICU, and 26 (62%) survived their last PICU admission. Of these, 5 died at a later date (between 1 and 32 months after discharge from PICU) and 21 survived to the time of reporting. The most frequent reason for PICU admission was respiratory failure, due either to Pneumocystis carinii pneumonia (45% of admissions) or to other respiratory pathogens (32%). Over 80% of current survivors had good outcomes in terms of growth and development; 6 children had evidence of spastic diplegia.

CONCLUSIONS

Although there is significant mortality among children with HIV infection admitted to PICU, many of them survive their admission, and over 80% of the survivors have good outcomes with the currently available highly active anti-retroviral therapy. This provides evidence that intensive care treatment is appropriate for this group of patients in the United Kingdom.

Nature of conflict in the care of pediatric intensive care patients with prolonged stay

OBJECTIVE

To determine the frequency, types, sources, and predictors of conflict surrounding the care of pediatric intensive care unit (PICU) patients with prolonged stay.

SETTING

A tertiary care, university-affiliated PICU in Boston.

PARTICIPANTS

All patients admitted over an 11-month period whose stay exceeded 8 days (the 85th percentile length of stay for the PICU under study), and intensive care physicians and nurses who were responsible for their care.

METHODS

We prospectively identified conflicts by interviewing the treating physicians and nurses at 2 stages during the patients' PICU stay. All conflicts detected were classified by type (team-family, intrateam, or intrafamily) and source. Using a case-control design, we then identified predictors of conflict through bivariate and multivariate analyses.

RESULTS

We enrolled 110 patients based on the length-of-stay criterion. Clinicians identified 55 conflicts involving 51 patients in this group. Hence, nearly one half of all patients followed had a conflict associated with their care. Thirty-three of the conflicts (60%) were team-family, 21 (38%) were intrateam, and the remaining 1 was intrafamily. The most commonly cited sources of team-family conflict were poor communication (48%), unavailability of parents (39%), and disagreements over the care plan (39%). Medicaid insurance status was independently associated with the occurrence of conflict generally (odds ratio = 4.97) and team-family conflict specifically (odds ratio = 7.83).

CONCLUSIONS

Efforts to reduce and manage conflicts that arise in the care of critically ill children should be sensitive to the distinctive features of these conflicts. Knowledge of risk factors for conflict may also help to target such interventions at the patients and families who need them most.

PIM2: a revised version of the Paediatric Index of Mortality

OBJECTIVE

To revise the Paediatric Index of Mortality (PIM) to adjust for improvement in the outcome of paediatric intensive care.

DESIGN

International, multi-centre, prospective, observational study.

SETTING

Twelve specialist paediatric intensive care units and two combined adult and paediatric units in Australia, New Zealand and the United Kingdom.

PATIENTS

All children admitted during the study period. In the analysis, 20787 patient admissions of children less than 16 years were included after 220 patients transferred to other ICUs and one patient still in ICU had been excluded.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

A revised model was developed by forward and backward logistic regression. Variable selection was based on the effect of including or dropping variables on discrimination and fit. The addition of three variables, all derived from the main reason for ICU admission, improved the fit across diagnostic groups. Data from seven units were used to derive a learning model that was tested using data from seven other units. The model fitted the test data well (deciles of risk goodness-of-fit chi(2 )8.14, p=0.42) and discriminated between death and survival well [area under the receiver operating characteristic (ROC) plot 0.90 (0.89-0.92)]. The final PIM2 model, derived from the entire sample of 19638 survivors and 1104 children who died, also fitted and discriminated well [chi(2 )11.56, p=0.17; area 0.90 (0.89-0.91)].

CONCLUSIONS

PIM2 has been re-calibrated to reflect the improvement that has occurred in intensive care outcome. PIM2 estimates mortality risk from data readily available at the time of ICU admission and is therefore suitable for continuous monitoring of the quality of paediatric intensive care.

Paediatric intensive care: out of commission

Problems with commissioning paediatric intensive care stem both from difficulties in recruitment and retention of nurses, and from incoherent or nonexistent national audit. Pyramidal career structures and patterns of remuneration that concentrate on administrative responsibility over clinical skills underlie the former, whereas poor audit conceals variations in both service quality and demand. Epidemiologically superior data are required if we are to solve commissioning problems. We need to know what happened to every child from a defined population receiving intensive care and whether a lack of resources means that some children are denied intensive care.

Computerized clinical documentation system in the pediatric intensive care unit

BACKGROUND

To determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity.

METHODS

Before and after implementation of CDS, a time study involving nursing care, medication delivery, and normalization of serum calcium and potassium values was performed. In addition, an evaluation of completeness of documentation and a clinician survey of shift to shift reporting were also completed. This was a modified one group, pretest-posttest design.

RESULTS

With the CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable.

CONCLUSIONS

When compared to a paper chart, the CDS provided a more legible, compete, and accessible patient record without affecting time spent in direct patient care. The availability of the CDS improved shift to shift reporting. Other observations showed that the CDS improved management capabilities; helped physicians deliver care; improved reimbursement; limited data entry errors; and reduced costs.

[Development of intensive care for pediatric infectious diseases over the last 20 years]

Intensive care and especially pediatric intensive care originated in connection with fatal forms of infectious diseases, some forty years ago. It has come a long way during the last quarter of the past century. Several infectious diseases have disappeared in France during this period such as poliomyelitis, dipteria and tetanus. Many other are receding. Nevertheless problems remain: serious infections by pneumococcus or staphylococcus, maternofoetal infections, whooping cough in very young infant. Now, thanks to liver transplantations and intensive care, the fatal forms of infectious hepatitis can be overcome in more than 50% of the cases. Meanwhile HIV appeared involving intensivists participation. Toxic shock, and especially the purpura fulminans, remains a major difficulty. Great advances in understanding its mechanisms have been made and it seems today like the result of excessive and unsuitable defence reactions. In addition, intensive care takes charge of more and more vulnerable ill persons: immunosuppressed, extreme premature babies, children who had to undergo heavy operations. In those cases, intensive care faces superinfections, nosocomial infections, multi-resistant germs, related in part to the particular working and environmental conditions and an unsuitable use of antibiotics. To conclude, it is necessary to optimize the technical and working conditions in intensive care units, to strictly observe the well established regulations of hygienics and to develop vaccinations.

Colonization and infection by Serratia species in a paediatric surgical intensive care unit

Serratia species are known for the infections they cause in adult and neonatal intensive care patients. Little is known about colonization and infection in paediatric intensive care patients. This study aims to describe the type of infections in critically ill newborns, infants and children, caused by Serratia spp., to compare patients colonized by Serratia spp. to patients colonized with other micro-organisms, and to assess the importance of the respiratory and digestive tracts as reservoirs. To this end, all microbiological samples taken from patients in our paediatric surgical intensive care unit between January 1986 and November 1993 were retrieved from the hospital database and patient records reviewed. Serratia spp. were isolated 1356 times from 97 patients. Eighty-five infections were diagnosed in 40 patients. Infections of the respiratory tract occurred most frequently (n= 65), followed by septicaemia (13), urinary tract infections (3), omphalitis (2), meningitis (1) and conjunctivitis (1). Colonization by Serratia spp. was associated with yearly age at admission, long ICU stay and high mortality. Both the respiratory and digestive tracts were frequently colonized. Our findings do not support the contention that the digestive tract is more important as reservoir than the respiratory tract in neonates.

The virtual pediatric intensive care unit. Practice in the new millennium

Patients and their families meet with health care providers in a complex marketplace. The information revolution is providing access to vast amounts of information and new ways to understand it. More important, perhaps, is that it also is providing new ways of communicating information not only about health but also about the health care delivery process. This occurrence makes it possible for patients not only to diagnosis and treat themselves but also see how well the professionals do it. Like all marketplaces, asymmetries in information define the value of the interaction. Patients see physicians because they have no way of overcoming this knowledge barrier, and health care is a highly regulated market because of these asymmetries in information. New information technologies in general and telemedicine (which, in this broad sense, include distance learning for patients) can address and erode these information asymmetries. This technology threatens to have a profound effect on health care. Telemedicine offers to increase greatly the reach (connectivity) and richness (bandwidth, customization, and interactivity) of the health care information marketplace. This radically will change the way in which physicians practice critical care. Intensivists must ensure that patients continue to receive high-quality critical care. This practice will require embracing these new technologies. Resisting them will be catastrophic. What is the VPICU? It is a committed group of pediatric intensivits who are dedicated to supporting pediatric critical care medicine in the enhancement of knowledge about pediatric critical care. It includes application of information technologies to support the practice of pediatric critical care. It primarily is focused on understanding the health care delivery process and providing the tools for pediatric intensive care practitioners to better understand the care they deliver. It is the desire of the VPICU to create a virtual community in which pediatric critical care practitioners work together to understand the way they practice and to identify and implement better ways to deliver pediatric critical care. This virtual community will be responsible for clinical and economic performance in the practice of pediatric critical care. The VPICU realizes that this requires the tools to make high-quality decisions and that these decisions depend on data and communication. The author invites all pediatric intensivists to participate in the VPICU to achieve the goals of better practice through the application of information technologies in pediatric critical care.

Differences in pediatric ICU mortality risk over time

OBJECTIVES

To compare pediatric intensive care unit (ICU) mortality risk using models from two distinct time periods; and to discuss the implications of changing mortality risk for severity systems and quality-of-care assessment.

DATA SOURCES AND SETTING

Consecutive admissions (n = 10,833) from 16 pediatric ICUs across the United States that participate in the Pediatric Critical Care Study Group were recorded prospectively. Data collection occurred during a 12-mo period beginning in January 1993.

METHODS

Data collection for the development and validation of the original Pediatric Risk of Mortality (PRISM) score occurred from 1980 to 1985. The original PRISM coefficients were used to calculate mortality probabilities in the current data set. Updated estimates of mortality probabilities were calculated, using coefficients from a logistic regression analysis using the original PRISM variable set. Quality-of-care tests were performed using standardized mortality ratios.

RESULTS

Risk of mortality from pediatric ICU admission improved considerably between the two periods. Overall, the reduction in mortality risk averaged 15% (p < .001). Analysis of mortality risk by age indicated a large improvement for younger infants. The mortality risk for infants <1 mo improved by 39% (p < .001). Mortality risk improved by 28% (p < .001) for infants between 1 and 12 mos. Analysis of mortality risk by principal diagnosis indicated substantial improvement in respiratory diseases, including respiratory diseases developing in the perinatal period. The mortality risk for respiratory diseases improved by 45% (p < .001). The improvement in mortality risk substantially deteriorated the calibration of the original PRISM severity system (p < .001). As a result of changing mortality risk, the standardized mortality ratios across the 16 pediatric ICUs demonstrated substantial disparities, depending on the choice of models.

CONCLUSIONS

This study documents differences in pediatric ICU risk of mortality over time that are consistent with a general improvement in the quality of pediatric intensive care. Despite continued widespread use of the original PRISM, recent improvements in pediatric ICU quality of care have negated its usefulness for many intended applications, including quality-of-care assessment.

Provision of paediatric intensive care services

Paediatric intensive care has developed into a highly specialized and labour-intensive clinical activity. The provision of adequate numbers of properly staffed children's intensive care beds within the UK, and the lack of national planning and coordination are both problematic. This article examines these problems and discusses current thinking on the provision of paediatric intensive care services.

[The evolution of care for the critical child: pediatric intensive care]

Pediatric intensive care units (PICUs) have been developed to provide intensive care for children between post-neonatal age and adolescence. These units have largely been developed in North America, mainly in tertiary hospitals. In Italy, critically ill children are still often nursed on adult ICU's, where medical and nursing staff often lack pediatric training. Here we report the first 5-year experience of the multidisciplinary PICU developed at the Department of Pediatrics, University of Padua, focusing on PICU and patients characteristics, as well as on the evaluation of outcome by means of the Pediatric Risk of Mortality (PRISM) score.

The historical evolution, current status, and prospective development of pediatric critical care

This article describes the multiple historic origins of pediatric critical care medicine and the evolution of the subspecialty, from the late 1950s with the first units dedicated to the care of critically ill and injured infants and children, to the present status as a recognized medical subspecialty. Also discussed are current major issues and future challenges that flow from both this historic background and a commitment to critically ill children. Presented are specific considerations for physicians in this subspecialty to address as they plan for the future.

[5th anniversary of the Trauma Unit in the Red Cross War Memorial Hospital for children]

The Trauma Unit at Red Cross Children's Hospital has celebrated its 5th birthday. We have briefly summarised its growth and development to keep the public informed about our activities at this unique Trauma Centre for Children.