Has centralisation improved the neurological outcome of children requiring intensive care services in Yorkshire and Humber?
Improvements in the critical care services particularly the centralisation and establishment of specialist retrieval teams has helped in the reduction of mortality rates7. Evidence to suggest that although there is reduced mortality16, there is an increase in the number of children surviving with disability following a critical care admission. We wanted to have a look at this in our population in Yorkshire and Humber.
To assess the neurological outcome of critically ill children requiring intensive care pre and post centralisation.
This is a retrospective cohort study looking at two cohorts of critically ill children admitted to intensive care during pre (2003-2007) and post centralisation (2008-2011) periods. Neurological outcome was assessed using King’s Outcome Score for Children with Head Injury (KOSCHI). This was done at four months after the discharge from critical care by a forty-minute follow up appointment. The cohorts are assessed for any differences in the epidemiology and risk of mortality. The expected mortality was calculated by using the PIM data. Chi-square method was used to compare the cohorts.
There were 214 patients in the pre-centralisation cohort (2003-2007 group) and 104 patients in the post-centralisation cohort (2008-2011 group). There was no significant difference in both the groups in terms of age, expected mortality and pre-existing illness. The mortality risk was 144 per 1000 for cohort 1 and 112 per 1000 for the cohort 2. Standardised mortality rate (SMR) was noted to be 0.73 (95% CI 0.49 to1.04) in cohort1 and 1.05 (95% CI 0.6 to 1.67) in cohort2. KOSCHI score 5 which represents good recovery was seen in 93% of the children from pre-centralisation cohort compared to 82% in the post-centralisation cohort. Similarly KOSCHI score 2-4 which represents the children with new disability after the critical care admission was seen only in 7% in the former compared to 18% in the latter with a statistically significant p-value of <0.001.
Standardised mortality rate was within the confidence intervals but there was a statistically significant difference in the neurodisability of children in between the cohorts. As observed in the other studies we found that there is a trend of increase in the numbers of post critical care morbidity. However we suggest doing further studies looking in to the most recent data with a larger sample size in the post-centralisation cohort.
The aim of the paediatric intensive care is to prevent mortality in children with critical illness and preserve the functional outcomes. We want to see if the centralisation has improved the morbidity and neurological outcome of children requiring intensive care by comparing cohorts before (2003-2007) and after centralisation (2008-2011).
Literature from as early as 1997(Pearson etal1) shows that a substantial reduction in mortality rates can be achieved if every UK child who needed intubation for 12-24hrs is admitted to one of the specialist paediatric intensive care unit.
There were concerns of volume overload affecting the outcome due to centralisation. Tilford etal10 showed an inverse relationship between volume of patients in PICU to risk adjusted mortality or patient length of stay.
With the improvements in critical care services patients are surviving though may have increased morbidity or require secondary admissions with sepsis. It appears that Paediatric critical care may have exchanged improved mortality rates for increased morbidity rates2. From the recent PICANet data5 PICU mortality is running at all time low and is less sensitive as a key performance indicator, however it is the post PICU morbidity that is more important. We also have to understand that increasing numbers of children with poor functional status has implications not only on the rest of the child’s life 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 plus 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 wanted to do a retrospective cohort study looking at the neurological outcome of two groups pre and post centralisation (2003-2007 vs. 2008-2011). This information will help us to understand the impact of centralisation on the morbidity of our population.
Aim of the project:
To assess the neurological outcome of critically ill children requiring intensive care pre and post centralisation.
Research questions/ objectives:
Centralisation of intensive care unit services has improved the neurological outcome of children requiring critical care. This is compared with no improvement as the null hypothesis.
This is a retrospective cohort study comparingtwo cohorts of critically ill children admitted to intensive care pre (2003-2007) and post centralisation (2008-2011).
All children up to eighteen years of age who were admitted for critical care at Hull Royal Infirmary. For the cohort 1 we included all admissions from 1st January 2003 till 31st December 2007 and for cohort 2 from 1st January 2008 till 31st December 2011.
Exclusion criteria – Children who died during the critical care were excluded from the data analysis in order to keep the focus mainly on the neurological outcome of survivors. Although we have mentioned the mortality, this was to show that both the groups are similar in the predicted mortality.
Case identification, data collection was performed with the help of PICANet & hospital records. The main focus was on the neurological outcome however information relating to baseline characteristics like demographics, type of illnesses, background illness, syndrome, disability, need for mechanical ventilation or intracranial pressure monitoring was obtained. All children with pre-existing illness (chronic illness, syndrome) were scored depending on whether they reached to the similar stage of neurodisability prior to getting unwell.
Traumatic brain injury (TBI) is a non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness50.
Raised intracranial pressure (ICP) is defined as intracranial pressure above 20mm of Hg.51
Risk adjusted mortality model:
Mortality is something, which is influenced by a number of factors. In order to make sure that the cohorts are similar we usedPaediatric index mortality6 data (PIM2) to obtain the expected mortality. Standardised mortality rate (SMR) was calculated as a ratio of observed deaths in PICU and expected deaths. The data for PIM2 and SMR was obtained from PICANet.
We examined the neurological outcome of survivors using Kings Outcome Scale for Childhood Head Injury3 (KOSCHI, table 1) during a forty minute follow up appointment, four months after the discharge from intensive care. In cases where we did not have a follow up we used the case notes to establish the neurological outcome.
Table1 King’s Outcome Score category definitions
|2||Vegetative||The child is breathing spontaneously and may have sleep/wake cycles. He may have non-purposeful or reflex movements of limbs or eyes. There is no evidence of ability to communicate verbally or non-verbally or to respond to commands|
|5||Good recovery||a) This should only be assigned if the head injury has resulted in a new
Condition which does not interfere with child’s well being and or functioning; for example:
– Abnormalities on brain scan without any detectable new problem
b) Implies that the information available is that the child has made a complete recovery with no detectable sequelae from the head injury
Chi-square test was used to analyse the two cohorts. P value <0.001 was considered statistically significant.
This project is considered for service evaluation and the data was obtained from PICANet so ethical approval was not needed. We had approval from the hospital clinical governance committee to access the patient records.
A total of 255 patients were included in cohort1 and 127 patients in cohort2. As we were interested in only the morbidity of the survivors we excluded the patients who died during the illness. Forty patients died in cohort 1 and twenty patients in cohort 2. One patient in cohort 1 and three patients in cohort 2 were lost from follow up, therefore not included in the study. This left us with a total number to be 214 in the former and 104 in the latter group. Nearly two-third of the children were male in both the groups. Median age was 2.5yrs in cohort1 and 1.2yrs in cohort2.
Table2. Summary of the results
|Cohort 1||Cohort 2||P- value|
|Dates||2003 to 2007||2008 to 2011|
|Number of cases (n)||214||104|
|Age- Median & Range||2.5yrs (0-16yrs)||1.2yrs(0-17yrs)|
|Age – Standard deviation||4.9||5.4|
|Gender (M)||136 (64%)||63 (61%)|
|PIM2 Score – 5th centile – 95th centile||0.008 – 0.2||0.005 – 0.1|
|Ventilated||178 (83%)||88 (85%)||0.59|
|Primary sepsis||89 (42%)||36 (35%)||0.23|
|Post-operative cases||34 (16%)||19(18%)||0.61|
|Pre-existing chronic illness||58 (27%)||32 (31%)||0.50|
|Raised intracranial Pressure (ICP)||51(24%)||19 (18%)||0.27|
|Traumatic brain injury (TBI)||39 (18%)||12 (12%)||0.13|
|Trauma||43 (20%)||20 (19%)||0.86|
|Disability (KOSCHI 2-4)||14 (7%)||19 (18%)||<0.001|
|Good (KOSCHI 5)||200 (93%)||85 (82%)|
Table 3 – Chi-square test:
E = 214X33/318 = 22
E = 214X285/318 = 192
2008 – 2011
E = 104X33/318 = 11
E = 104X285/318 = 93
= (O-E) 2/E
= (14-22)2/22 + (200-192)2/192+ (19-11)2/11+ (85-93)2/93
= 64/22+ 64/192+64/11+64/93
= 2.9+0.33+5.8+ 0.68 = 9.71 = P<0.001
Figure 1 Illustrating features of two cohorts
(ICP – Intracranial pressure, TBI – Traumatic brain injury)
Table 4 – Demonstrating the organ system involvement in both the groups
(This table excludes Trauma /Burns/metabolic – On addition of these cases it will be 100%)
|System of Primary dysfunction||2003-2007 (n=214)||2008-2011 (n=104)|
|Central Nervous System (CNS)||52 (24%)||39 (38%)|
|Respiratory||45 (21%)||33 (32%)|
|Cardiac||10 (5%)||3 (3%)|
|Gastrointestinal Tract (GIT)||4 (2%)||2 (2%)|
|Multi-organ involvement||35 (16%)||7 (7%)|
Figure 2 – Showing the organ system involvement in both the groups
Figure 3 – Percentage of post-operative cases in each group
Figure 4 – Types of surgery among the cases
Figure 5 Showing the KOSCHI scores in both the cohorts (KOSCHI – King’s outcome scale for childhood head injury)
Figure 6 – Illustrating the actual number of deaths (deaths in PICU plus deaths within 30 days of critical care) & the predicted deaths
Figure 7- Showing the Standardised Mortality Rates in each group
Figure 8- Scatter plot showing PIM2 Scores from 2003 – 2007 group (For two cases we did not had the PIM2 score)
Figure 9- Scatter plot showing the PIM2 Scores from 2008 – 2011 group
The retrospective cohort study showed an increase in the number of children surviving with disability in the post centralisation cohort.
KOSCHI score five represents good recovery and was seen in 93% of the children from pre-centralisation cohort compared to 82% in the post-centralisation cohort. Similarly KOSCHI score two to four represents children with new disability after the critical care admission, was seen only in 7% in the former compared to 18% in the latter with a statistically significant p-value of <0.001.
The cohorts were almost similar in majority of the aspects. Pre-existing illness (31% vs 27%), primary sepsis (42% vs 35%) & traumatic brain injury (18% vs 12%) was seen in slightly higher percentage in the pre-centralisation cohort. There were more children with the neurological (41% vs 24%)& respiratory (33% vs 21%) illnesses in the post-centralisation cohort.
Children requiring mechanical ventilation were almost similar in both the cohorts (83% vs 85%). With current advances in the non-invasive ventilation we would have expected this figure to be less in the post-centralisation cohort but we didn’t see that in our study. This could be because we had 12% more cases with respiratory illnesses in the post-centralisation cohort.
The severity of illness on admission as reflected by PIM2 scores were almost similar with 5th – 95th centile scores of 0.008 to 0.2 for cohort1, 0.005 to 0.1 for cohort2. The expected mortality in each cohort was identified to see if both the groups were similar in terms of mortality risk. It was 144 per 1000 for cohort 1 and 112 per 1000 for cohort 2. The Standardised mortality rate was 1.05 (95% CI 0.6 to 1.7) in cohort2 and 0.7 (95% CI 0.49 to 1.04) in cohort1. As you can see the SMR was marginally higher in cohort2 however the confidence intervals were almost similar.
Our neurological outcome results correlate with what other studies have shown in the literature review. Pollack etal2 compared morbidity before and after PICU admission between 1990 group and 2011-2012 groups, showed a rise in numbers to 4.8% from 3.1%. Namachivayam & Frank Shann etal study4 from Melbourne showed 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).
Aspesberroetal18 did a literature review looking at articles from 1980 to 2015 on children surviving critical illness. It also concluded similar results. They mentioned that thekey determinant of the outcome in critically ill children is multi-factorial. This includes diagnosis (trauma19-21, sepsis17, 22, meningo-encephalitis23-27), presence of chronic co-morbid conditions28-39 and type of treatment received (prolonged CPR40-42, long-stay patients43-47, invasive technology48, 49). Our study had 14% more neurological illness in the post-centralisation cohort when compared to the other cohort. However the severity of the illness was similar in each group as suggested by the PIM2 scores from PICANet.
Important figure to note was that 82% of the cases were back to pre-morbid status in the post-centralisation cohort. This was significantly better than figures from the other studies like Namachivayam & Frank Shann etal study4 had 69% and Pollack etal2 had 63%.
Looking in to the clinical practice pre and post-centralisation there were changes in terms of how we manage critically ill children. During the pre-centralisation period, the patients experienced a uniform care13 provided by the experienced Intensivist and nursing staff at the bedside. Compliance with the international consensus guidelines for the treatment of sepsis was adhered. Mean BP was targeted at 50th centile during the course of illness. We know that these measures help us in decreasing the organ dysfunction and thereby improving the outcome.12, 14
Post-centralisation sees a different system where the local intensive care team is involved in a telephonic conversation with an Intensivist at the regional PICU. This may make the decision making process difficult as the clinician providing advice is not by the bedside. It is hard to calculate how much impact this has on the decision making process and ensuring appropriate management when compared to the care provided at bedside by an Intensivist. There are studies9, 11 to suggest that telemedicine has helped the improved outcome in children admitted from emergency department.
The higher morbidity and mortality in the post-centralisation cohort could also be due to the fact that we are analysing the results from immediate post-centralisation period. As expected, like with any change we bring in practice, there is a learning curve period, which might not show the best results. If we repeat a review further down the period from the time of centralisation we might have a different outcome. For this reason we would recommend further future studies.
The cohorts belong to two different periods with different types of illnesses; however they were similar in terms of age, gender and severity of illness on presentation as supported by the PIM2 data.
– Sample size in the post-centralisation cohort (n=104) is small compared to the other group (n=214). Adding more numbers to the post-centralisation cohort might influence the outcome.
– The outcome was measured in clinic at four months after discharge. Five cases in 2008 – 2011 group and eight cases in 2003-2007 group did not attend the clinic appointment; therefore the case notes had to be looked at to establish the outcome. Due to non-attendance, the outcome was not measured at four months, but as close to four months as possible.
– This study gives a short-term morbidity soon after the critical care as we are
assessing the patients only four months after the discharge. However similar studies looking at the long-term morbidity two years after the critical care has shown better outcomes8 with the majority reaching the pre-admission functional status. This suggests long-term morbidity figures might be different.
– Having a morbidity score for the pre-existing morbidity prior to PICU admission and another score after discharge from PICU would have helped us in better understanding of the outcome.
– Sample data is collected over a period of 8yrs (2003-2011). Due to the advancements in research and technology, medical care keeps changing over the time. It is difficult to establish how much this has influenced the results. Looking at our results, certainly the post-centralisation cohort (2008-2011) did not benefit from it.
Conclusion and future research:
In this study we have attempted to show the neurological outcome of critically ill children pre (2003-2007) and post centralisation (2008-2011). Similar to other studies there is a significant increase in children with neurodisability in the post-centralisation cohort. However we suggest doing more studies looking in to the most recent data with large sample size in the post-centralisation cohort.
1. Gale Pearson, Frank Shann, Peter Barry, Julian Vyas, etal. Should paediatric intensive care be centralised? Trent versus Victoria, The Lancet; Apr26, 1997; Vol 349 1213-1217.
2. Murray M Pollack, Richard Holubkov, Tomohiko Funai, Amy Clark, etal.Paediatric Intensive Care Outcomes: Development of New Morbidities During Pediatric Critical Care, Pediatirc Crit Care Med 2014; 15:821-827.
3. MCrouchman L Rossiter, T Colaco, R Forsyth. A practical outcome scale for paediatric head injury Arch Dis Child 2001; 84:120-124.
4. PNamachivayam, Frank Shann, Lara Shekerdemian, Anna Taylor, Irene van Sloten, Carmel Delzoppo, Claire Daffey, Warwick Butt. Three decades of paediatric intensive care: Who was admitted, what happened in intensive care and what happened afterwards. Paed Critical Care medicine 2010, Vol 11, No 5.
6. Frank Shann, Gale Pearson, A. Slater, K. Wilkinson. Paediatric Index of mortality (PIM): A mortality prediction model for children in intensive care. Intensive Care Medicine (1997) 23:201-207.
7. Padmanabhan Ramnarayan, Krish Thiru, Roger C Parslow, David A Harrison, Elizabeth S Draper, Kathy M Rowan Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study. Lancet 2010:376:698-704.
8. Volaki E, Sdougka M etal, Functional outcome following paediatric intensive care: Paediatric cerebral performance category and paediatric overall performance category during a prospective two year follow up period. The Greek E-Journal of Perioperative Medicine 2015; 13(a): 2-15.
9. Dayal, Parul etalImpact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children’s Hospital PICU. Pediatric Critical Care Medicine: June 2016 – Volume 17 – Issue 6 – p 516–521.
10. John M. Tilford, Pippa M. Simpson, etal. Volume–Outcome Relationships in Pediatric Intensive Care Units. Pediatrics; Aug 2000, Vol 106, Issue 2.
11. Dharmar M, Kuppermann N, Romano PS, etal Telemedicine consultations and medication errors in rural emergency departments. Pediatrics 2013; 132:1090–1097.
12. Balamuth F., Weiss S.L., Fitzgerald J.C., Hayes K., etal Protocolized Treatment Is Associated with Decreased Organ Dysfunction in Pediatric Severe Sepsis. Pediatric Critical Care Medicine. 17 (9) (pp 817-822), 2016. Date of Publication: 01 Sep 2016.
13.Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M. Impact of quality-of-care factors on pediatric intensive care unit mortality.. JAMA. 1994 Sep 28; 272(12): 941-6.
14. Tenner PA, Dibrell H, Taylor RP. Improved Survival with hospitalists in a paediatric intensive care unit. Critical Care Medicine 2003 Mar; 31(3): 847-52.
15 Patrícia T. Alievi, Paulo R. A. Carvalho, Eliana A. Trotta, Ricardo Mombelli Filho. The impact of admission to a paediatric intensive care unit assessed by means of global and cognitive performance scales. J Pediatric (Rio J). 2007; 83(6): 505-511.
16. Ruth A, McCracken CE, Fortenberry JD, Hall M, Simon HK, Hebbar KB.Pediatric severe sepsis: current trends and outcomes from the Pediatric Health Information Systems database. Ped Crit Care Med. 2014 Nov; 15(9): 828-38.
17.Lin JC, Spinella PC, Fitzgerald JC, Tucci M, Bush JL, Nadkarni VM, Thomas NJ, Weiss SL; Sepsis Prevalence, Outcomes, and Therapy Study Investigators.
New or Progressive Multiple Organ Dysfunction Syndrome in Pediatric Severe Sepsis: A Sepsis Phenotype With Higher Morbidity and Mortality.
Pediatric Crit Care Med. 2017 Jan; 18(1): 8-16.
18. F Aspesberro, R Mangione-smith, JJ Zimmerman. Health-related quality of life following pediatric critical illness. Intensive care Med (2015) 41:1235-1246.
19. Janssens L, Gorter JW, Ketelaar M,Kramer WLM, Holtslag HR. Health-related quality-of-life measures for long-term follow-up in children after major trauma. Qual Life Res17:701–713 (2008).
20. Janssens L, Gorter JW, Ketelaar M,Kramer WLM, Holtslag HR. Long-term health condition in major pediatric trauma: a pilot study (2009). J PedSurg 44:1591–1600.
21. Martin-Herz SP, Zatzick DF, McMahonRJ. Health-related quality of life in children and adolescents following traumatic injury: a review (2012). Clin ChildFam Psychol Rev 15(3):192–214.
22. Farris RW, Weiss NS, Zimmerman JJ (2013). Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial. Ped Crit Care Med 14:835–842
23. Namachivayam O, Taylor A, Montague T, Moran K et al (2012). Long-stay children in intensive care: long-term functional outcome and quality of life from a 20-yr institutional study. Pediatric Crit Care Med 13:520–528.
24. Buysse CM, Raat H, Hazelzet JA, Hop WC, Maliepaard M, Joosten KF (2008). Surviving meningococcal septic shock: health consequences and quality of life in children and their parents up to 2 years after pediatric intensive care unit discharge. Crit Care Med 36(2): 596–602.
25. Buysse C, Vermunt L, Raat H, Hazelzet JA (2010). Surviving meningococcal septic shock in childhood: longterm overall outcome and the effect on health-related quality of life. Crit Care 14(3): R124.
26. Edmond K, Dieye Y, Griffiths UK, Fleming J, Ba O, Diallo N, Mulholland K (2010). Prospective cohort study of disabling sequelae and quality of life in children with bacterial meningitis in urban Senegal. Pediatric Infect Dis J 29(11): 1023–1029.
27. Als LC, Nadel S, Cooper M, Pierce CM, Sahakian BJ et al (2013). Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children. Crit Care Med 41:1094–1103.
28 Buysse CM, Raat H, Hazelzet JA, Hop WC, Maliepaard M, Joosten KF (2008). Surviving meningococcal septic shock: health consequences and quality of life in children and their parents up to 2 years after pediatric intensive care unit discharge. Crit Care Med 36(2): 596–602.
29 Polic B, Mestrovic J, Markic J, Mestrovic M et al (2013). Long-term quality of life of patients treated inpaediatric intensive care unit. Eur J Pediatr 172:85–90.
30 Feudtner C, Christakis DA, Connell FA(2000) Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington. State, 1980–1997. Pediatrics 106(1 Pt2): 205–209.
31. Mestrovic J, Kardum G, Sustic A, PolicB et al (2007) Neuro -developmental disabilities and quality of life after intensive care treatment. J Paediatr Child Health 43:673–676.
32. Jones S, Rantell K, Stevens K, Colwell et al (2006) Outcome at 6 months after admission for pediatric intensive care: a report of a national study of pediatric intensive care units in the United Kingdom. Pediatrics 118:2101.
33 Dosa NP, Boeing NM, Ms N, KanterRK (2001) Excess risk of severe acute illness in children with chronic health conditions. Pediatrics 107(3): 499–504.
34. Odetola FO, Gebremariam A, Davis MM (2010) Comorbid illnesses among critically ill hospitalized children: impact on hospital resource use and mortality, 1997–2006. Pediatr Crit Care Med 11(4):457–463.
35. Burns KH, Casey PH, Lyle RE, Bird TM, Fussell JJ, Robbins JM (2010) Increasing prevalence of medically complex children in US hospitals. Pediatrics 126(4): 638–646.
36. Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, Visser S, Kogan MD (2011) Trends in the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics127 (6): 1034–1042.
37. Edwards JD, Houtrow AJ, Vasilevskis EE, Rehm RS, Markovitz BP, Graham RJ, Dudley RA (2012) Chronic conditions among children admitted to U.S. pediatric intensive care units: their prevalence and impact on risk for mortality and prolonged length of stay. Crit Care Med 40(7): 2196–2203.
38. Cunha F, Almeida-Santos L, Teixeira- Pinto A, Neves F et al (2012) Health related quality of life of pediatric intensive care survivors. J Pediatr 88(1): 25–32.
39. Typpo KV, Petersen NJ, Petersen LA, Mariscalco MM (2010) Children with chronic illness return to their baseline functional status after organ dysfunction on the first day of admission in the pediatric intensive care unit. J Pediatr 157:108–113.
40. Matos RI, Watson RS, Nadkarni VM, Huang HH et al (2013) Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation 127:442–451.
41. Ebrahim S, Singh S, Hutchinson JS, Kulkarni AV et al (2013) Adaptive behavior, functional outcomes, and quality of life outcomes of children requiring urgent ICU admission. Pediatric Crit Care Med 14:10–18.
42. Polic B, Mestrovic J, Markic J, Mestrovic M et al (2013) Long-term quality of life of patients treated in paediatric intensive care unit. Eur J Pediatr 172:85–90.
43. Conlon NP, Breatnach C, O’Hare BP, Mannion DW, Lyons BJ (2009) Health related quality of life after prolonged pediatric intensive care unit stay. Pediatr Crit Care Med 10:41–44.
44. Pollack MM, Wilkinson JD, Glass NL (1987) Long-stay pediatric intensive care unit patients: outcome and resource utilization. Pediatrics 80:855–860
45. Butt WW (2009) Outcome assessment—what outcome do we want? Pediatric Crit Care Med 10(1): 133–134.
46. Marcin JP, Slonim AD, Pollack MM, Ruttimann UE (2001) Long-stay patients in the pediatric intensive care unit. Crit Care Med 29:652–657.
47. Namachivayam O, Taylor A, Montague T, Moran K et al (2012) Long-stay children in intensive care: long-term functional outcome and quality of life from a 20-yr institutional study. Pediatric Crit Care Med 13:520–528.
48. Rennick JE, Johnson CC, Dougherty G, Platt R, Ritchie JA (2002) Children’s psychological responses after critical illness and exposure to invasive technology. J Dev Behav Pediatr 23:133–144.
49 Guerra GG, Robertson CMT, Alton GY, Joffe AR, Moez EK, Dinu IA, Ross DB, Rebeyka IM, Lequier L, Western Canadian Complex Pediatric Therapies Follow-Up Group (2014) Health-related quality of life in pediatric cardiac extracorporeal life support survivors. Pediatric Crit Care Med 15:720–727.
50. Segun Toyin Dawodu. Traumatic Brain Injury (TBI) – Definition and Pathophysiology. http://emedicine.medscape.com/article/326510-overview.
51. Monitoring and interpretation of intracranial pressure M Czosnyka, J D Pickard J Neurol Neurosurg Psychiatry 2004; 75:813–821.
Cite This Work
To export a reference to this article please select a referencing stye below:
Related ServicesView all
Related ContentAll Tags
Content relating to: "Health and Social Care"
Health and Social Care is the term used to describe care given to vulnerable people and those with medical conditions or suffering from ill health. Health and Social Care can be provided within the community, hospitals, and other related settings such as health centres.
The Association between Infant Food Practices and the Increased Risk of Allergic Diseases
The Association between Infant Food Practices and the Increased Risk of Allergic Diseases Outline Abstract Introduction Hypothesis Exposure to a variety of food antigens as early as 4-6 months wi...
Fall Prevention in Post-stroke Patients: The Power of Social Interactions
Fall Prevention in Post-stroke Patients: The Power of Social Interactions Introduction: Stroke is a health priority in New Zealand (NZ) as it is the most common cause of disability and affects appr...
DMCA / Removal Request
If you are the original writer of this research project and no longer wish to have your work published on the UKDiss.com website then please: