Has centralisation improved the neurological outcome of children requiring intensive care services in Yorkshire and Humber?
Describe how or why you chose this area to research. This may relate to your clinical area of interest, a personal experience or your having a question that you feels need answering. Think through the information you require to undertake your research or the questions you need to answer. It is important to be clear and focused, rather than broadly covering the whole clinical area
The aim of the paediatric intensive care is to prevent mortality in children with critical illness and preserve functional outcomes. We want to see if the centralisation has improved the morbidity and neurological outcome of children requiring intensive care by comparing outcome before (2003-2007) and after centralisation (2008-2011).
As we know from the literature papers as early as 1997 Pearson etal1 showed that the substantial reduction in the mortality rates can be achieved if every UK child who needed intubation for 12-24hrs is admitted to one of the specialist Paediatric ICU
With the improvements in critical care services although patients are surviving, they may have increased morbidity or secondary admissions with sepsis. It appears that Paediatric critical care may have exchanged improved mortality rates for increased morbidity rates2. From the recent PICANet data (A decade of data.2014 Annual Summary Report) PICU mortality is running all time low and it is less sensitive as a key performance indicator but it is the post PICU morbidity that is more important. We also have to understand that increasing number of children with poor functional status has implications not only on the rest of the life of the child but also on the family and NHS in terms of providing adequate individual support both medically and financially
As a result of changes in service provision from 2008 in Yorkshire and Humber, the establishment of a dedicated regional retrieval service, more patients were transferred out, using a guideline or matrix, backed up by consultant discussion with transport teams and regional centre.
PICU care was undertaken in one DGH (Hull Royal Infirmary) according to the model given for Acute Major General Hospital in Troop Report, as a hub and spoke arrangement with the regional centre. We want to do a retrospective cohort study looking at two groups pre and post centralization (2003-2007 vs 2008-2011). This information will guide us in improving the standards of our care towards critically ill children
Questions : Itemise the questions you are addressing in the review?
- Has centralization affected the mortality and morbidity of critically ill children?
Describe your search strategy, indicating the databases you used, the key words and the sort of studies you were looking for. Indicate how many articles you identified and why you choose the studies to review that you did. A systematic review is not required. but you are expected to have adopted a strategy that one might reasonably expect a clinician to take in the course of their work
Primary Source: Medline
Secondary Source: Pubmed, Pediatric Critical Care Medicine Journal
|1||Cetralisation and Outcome of critically ill children (Medline)||0|
|2||Neurological outcome of PICU patients (Medline)||0|
|3||Sepsis and PICU outcome (Medline)||2|
|4||Centralisation and Outcome of critically ill children (Pubmed)||5|
|5||Centralisation and Outcome of critically ill children
(Paediatric Critical Care Medicine Journal)
Review of the literature
Provide us with the answers to your questions. It helps to take each question in turn. Present the evidence you have found concisely, critically and clearly. It is sensible to summarise the studies in the form of table (which may include a column for comments on the quality of the study in question). This means that you can provide a your conclusions in a paragraph following the table. If there is no evidence for any question, then say so
(Population & comparisions)
|Study Type||Outcome||Key Result||Comments|
Lancet 2010; 376:698-704
(Great Ormond Street Hospital, UK)
|– Data from 29 PICU by admission source and type of retrieval team
– Compared unplanned admission from wards within the hospitals as PICU and from other hospitals; interhospital transfers by non-specialist and specialist retrieval teams; and patients transferred to their nearest PICU and those who are not
|Retrospective cohort||PICU Mortality rate||-16875 children were brought to PICU either by specialist retrieval teams or non-specialist retrieval team.
– Multivariable analysis showed significantly lower risk of death (0.58, 0.39-0.87) with specialist retrieval team transfers than with non-specialist team transfers after adjustments for case mix (age, sex, surgical status and variable s for PIM) and organizational factors (patient’s strategic health authority)
|“Within a centralised model of paediatric intensive care in England and Wales, Specialist retrieval teams, which are commonly used for interhospital transport of critically ill children were associated with reduced risk-adjusted mortality”|
|2||Muuray M.Pollack etal
Paed Critical Care Medicine 2014; 15:821-827
(Phoenix Children’s Hospital and University of Arizona College of Medicine- Phoenix
|– Data from 8 Medical and Cardiac PICU
– Morbidity before and after PICU admission were compared between 1990 group and 2011-2012 group
– FSS Functional status Score was used to assess the morbidity
|Functional Status Scale Scores (FSS) at hospital discharge
A new morbidity was defined as increase in FSS 3
|– Of the 5017 patients there were 242 new morbidities (4.8%), 99 PICU deaths (2%) and 120 hospital deaths (2.4%).
– This data was compared with data from 1990s where PICU mortality rate was 4.6% and PICU morbidity rate was 3.1%
|– The severity rates compared are not risk adjusted|
|3||Katie Moynihan etal.
Paed Critical Care Medicine 2016
(Starship Children’s Hospital, Auckland, New Zealand)
|– Evaluate the impact of paediatric critical care retrieval, distance traveled, level of ICU support at the referral centre on outcomes in unplanned admissions
– Comparisions were made between transported and non-transported patients
– 2,509 (45%) were retrieved and 3,100 (55%) were from the same institution
|Retrospective cohort||Length of stay in PICU
|– Transported patients had a median time of 29 hours longer PICU admission
– PICU-specific resource use was higher in the transported cohort
– Following risk adjustment using PIM2, PICU mortality rates were equivalent between retrieved and same institution unplanned admission
|– Looked in to the impact of centralisation on PICU mortality
– Post PICU mortality and morbidity were not determined
– Time critical transfers were not included
Namachivayam, Frank Shann etal, Pediatric Critical Care Medicine 2010; 11:549-555
(The Royal Children’s Hospital, Melbourne)
|– Data from cohorts of 1982, 1995 and 2005-2006 were compared||Retrospective cohort||– PICU mortality
– Post PICU morbidity
|– PICU mortality of children aged >1month at the time of admission fell substantially from 11% of (n=700) in 1982 to 4.8% (n=1733) in 2005-2006 (p<0.01)
– Children surviving with moderate or severe long term disability at long term follow up increased from 8.4% in 1982 to 17.9% in 2005 -2006 (p<0.0001)
– Quality of life in children aged >2yrs:
HSUV – Health State Utility Value
|– Follow up was available only for 43% in 2005-2006 cohort which is lower than for 1982 (100%) and 1995 (84%), and the follow up was only for a median time of 1.1yrs compared to approximately 3yrs in 1982 and 1995.|
End the literature review with a brief summary concluding what you have learnt from the review. Then lead the reader on to why research was needed in this area and the questions you hoped to answer through your project
On doing the search we had 12 articles looking in to effect of centralization and outcome of critically ill children. Out of these articles I found the 4 articles from different parts of the world including UK to be related more closely to our study.
The study from Great Ormond Street Hospital1 mainly focusing on the effects of centralisation on the PICU mortality in England and Wales suggests that use of specialist retrieval teams for interhospital transfer was associated with reduced risk adjusted mortality. The distance travelled by patients to access emergency paediatric critical care has not affected the outcome. We can see the similar results from the study in Newzealand3. However both these studies do not provide evidence on post ICU morbidity, the functional status pre and post PICU admission
The study by Murray Pollock etal2 looked in to the functional status scores of critically ill children before and after PICU admission. Functional Status scores were calculated before the PICU admission and at the time of discharge from the hospital. There is no clear information about at what time after the PICU discharge these scores were calculated. As we all know that the functional recovery improves with time. The data from December 2011 to August2012 (n=5000) is compared with the data from 1990s. The results show that the 2011-2012 patients had a morbidity rate of 4.8% and mortality rate of 2% compared to 3.1% and 4.6% in 1990s group. There is a wide variation in between two groups (1990 vs. 2011-2012) in terms of type of patients and the methods of management and this might affect the comparision. The severity rates mentioned are not risk adjusted so it makes it difficult to accept the numbers
The study from Melbourne4 comparing the PICU mortality and morbidity from population groups over the last three decades (1982,1995 and 2005-2006) showed a substantial fall in the PICU mortality of children aged >1month from 11% in 1982 to 4.8% in 2005-2006 (p<0.01). However the children with moderate or severe long term disability at long term follow up increased from 8.4% in 1982 to 17.9% in 2005 -2006 (p<0.0001). Only 43% of the children in 2005-2006 groups were followed up compared to 100% in the other cohorts. Estimated disability rate was used to include the patients who were lost to follow up. So these figures may not be accurate. There were no PIM scores for the 1982 and 1995 group so the data was not risk adjusted for these groups.
The results from this study again reinforce the fact that we are achieving improved mortality rates at the expense of increased morbidities. It also highlights that these improvements reflects the advancements in the critical care services and the changes in the type of illnesses we are seeing. This study showed that compared to 1982 group, in 2005-2006 group there was a decrease in the proportion of children admitted from accidents, epiglottitis and croup. This can be explained by improvements in road safety regulations, Haemophilus influenza immunization and early administration of corticosteroids in children with croup. There was an increase in the use of non-invasive ventilation from 0% in 1982, 1995 to 8% in 2005-2006 (p<0.01)
By the above discussion points we can say that there is a global improvement in the PICU mortality which can be attributed to advanced therapies and centralization. However we are also seeing increased numbers in the moderate or severe morbidity rates. As suggested in the recent PICANet recommendation5 we need to be monitoring these post-PICU discharge morbidity rates
We would like to study our population group pre and post centralisation and understand the PICU mortality and morbidity rates in each group. The availability of data from PICANet and the PIM scores make it possible to compare the two population groups and get a risk adjusted mortality and morbidity rates. Our main focus will be on the neurological outcome of these children although each group will be looked at various factors, which include demographics, type of illness, background illness/syndrome/disability, whether there was a need for mechanical ventilation/ ionotoropic support/ intracranial pressure monitoring or not. These results will guide us in improving the patient care and outcome
- Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study
– Padmanabhan Ramnarayan, Lancet 2010; 376:698-704
- Pediatric Intensive Care Outcome: Development of New Morbidities During Pediatric Critical care Paed Critical Care Medicine 2014; 15:821-827
- Impact of Retrieval, Distance Travelled, and Referral centre on Outcomes in Unplanned Admissions to A National PICU Paed Critical Care Medicine 2016
- Three Decades of pediatric intensive care: Who was admitted, what happened in intensive care, and what happened afterward
Poongundran Namachivayam, Lara Shekerdemian, Irene Van Sloten, Carmel Delzoppz, Pediatric Critical Care Medicine 2010; 11:549-555
- PICANet: A Decade of Data. 2014 Annual Summary Report
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