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Effective medical retrieval a pre-requisite to centralised pædiatric intensive care.
- Andrew Berry (24 May 1998)
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Provision of intensive care for children in Trent
- P W Barry (1 June 1998)
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Provision of intensive care for children
- Jon Nicholl (16 June 1998)
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Paediatric Intensive Care
- D R Goldhill (17 June 1998)
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Its time to stop making excuses about paediatric intensive care
- G A Pearson, F Shann (28 July 1998)
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Andrew Berry, Medical Director NETS (NSW newborn/pædiatric Emergency Transport Service
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The recommendations of this paper are well supported by improved outcomes referred to. However, the reasons sick children have been treated in small, low activity and ill-equipped units are not addressed. These reasons may seem self-evident; such as a community preference for a 'local care' option and the perceived disadvantage/harm of transfer to a distant city. In our experience, community perceptions have to be changed so that 'best care' is seen as preferable to 'nearby care'. This must depend on a rapid response medical retrieval service whose ICU expertise can be deployed to the referring hospital quickly enough to create the impression that the PICU is functionally closer than it is geographically. This may only be possible with retrieval services whose activity levels are high enough to maintain not only a 24 hour service but medical, nursing and support staff on immediate standby for that 24 hours. Our experience is that retrieval activity of over 1,000 per annum is required to meet this goal. This may require the establishment of regional pædiatric medical retrieval services independent of particular PICUs rather than one in each PICU. They need access to dedicated transport vehicles to minimise delays. Such services can deploy teams independently of the stafffing constraints of a particular PICU. Yet they can form close clinical links with PICUs which maintain professional standards and expertise. To change the way a Nicholas Geldard of the future might be handled, the proposed new system would have to include a 'tele-triage' process which offered immediate telephone access to senior clinical advice and the collaboration of relevant clinicians and ambulance transport personnel to ensure that the appropriate pre-transfer care decisions were made and a management plan devised (including the optimal destination). Success in regionalisation of PICU depends on an effective and responsive medical retrieval infrastructure. Such an infrastructure has to be developed around the needs of the referring hospital. It should act as an advocate for their patients' needs; launching teams to their patients regardless of any shortage of PICU beds or other problems. Unless medical retrieval made an effective part of the solution; a 'glue' linking the layers in the regionalisation model; the death of a child who dies in transit from a hospital that has been told no longer to care for that kind of patient will lead to calls to reverse the regionalisation process. |
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P W Barry, Lecturer in Child Health University of Leicester
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A small correction to Dr Ratcliffe's otherwise excellent article. Paediatric intensive care provision in Trent WAS fragmented in nineteen centres at the time of the Trent-Victoria study, but is now provided in three centres, albeit with some on split sites. Where split site working is occuring, the centres are moving towards a unified structure that will try to fulfill the requirements of the Framework Document. This will not satisfy everyone, and the units involved must be proactive in demonstrating that the Trent solution is effective. However, it is important to appreciate that the magical number of 500 admissions in the Framework Document is not supported, or refuted, by any evidence. The ideal number could be 1,000, or it could be 300. The most important point in the editorial, in my opinion, is the last, that continued research and audit needs to be undertaken to find valid quality and outcome measures for intensive care for children, and to ensure that all units collect and publish such data. |
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Jon Nicholl, Director, Medical Care Research Unit University of Sheffield
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Dr. Ratcliffe has re-iterated the claim that several studies have shown that paediatric intensive care services should be centralised(1). However, a different view can be taken of all of this evidence. The study of Trent Region in England vs Victoria State in Australia(2), which claimed that risk adjusted mortality in Victoria was half that in Trent, was not a study of children in the two areas, as Dr. Ratcliffe asserts, but of admissions. All children admitted to local intensive care services and then transferred to central facilities (mainly Victoria) were double counted. First as low risk survivors from the local unit, and then as higher risk deaths or survivors from the central unit. This may be why length of stay was so short in the Victoria group (because it was actually length of stay for that admission, not for that episode), and could explain all of the difference in risk adjusted mortality between areas. Two other studies are referenced. Both found that for children who have the highest risk of death care in tertiary facilities is associated with a reduction in that risk. However, the Dutch PICASSO study(3) also found a substantially increased risk of death in tertiary facilities for low risk children, and the only Unit in that study whose casemix adjusted mortality significantly exceeded that expected was the largest Unit. The other study excluded all transfers and deaths before admission(4), which makes the value of this data for assessing the benefits of a tertiary referral system doubtful. The fact is that a positive relationship between volume and outcomes has not been shown to hold true generally(5), and has been shown specifically not to hold in adult intensive care(6). This is an uncertain evidence base on which to implement a policy of centralisation. References (1) Ratcliffe J. Provision of intensive care for children. BMJ, 1998; 316: 1547-1548. (2) Pearson G, Shann F, Barry P, Vyas J, Thomas D, Powell C, et al. Should paediatric intensive care be centralised? Trent versus Victoria. Lancet, 1997; 349: 1213-1217. (3) Gemke RJBJ, Bonsel GJ. The pediatric intensive care assessment of outcome (PICASSO) study group. Comparative assessment of pediatric intensive care: a national multicenter study. Crit Care Med, 1995; 23: 238-245. (4) Pollack MM, Alexander SR, Clarke N, Ruttimann UE, Tesselaar HM, Bachulis AC. Improved outcomes from tertiary center pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities. Crit Care Med, 1991; 19: 150-159. (5) Effective Health Care. Hospital volume and health care outcomes, costs and patient access. Nuffield Institute for Health, University of Leeds, and NHS Centre for Reviews and Dissemination, University of York. December, 1996, 2(8). ISSN 0965-0288. (6) Jones J, Rowan K. Is there a relationship between the volume of work carried out in intensive care and its outcome? Int J Technol Assess Health Care, 1995; 11: 762-769. |
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D R Goldhill, Senior Lecturer The Royal London Hospital
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27 May, 1998 The Editor The British Medical Journal Dear Editor Re: Provision of intensive care for children Like Dr Ratcliffe we would like to improve paediatric intensive care [1]. We support the need for specialist tertiary paediatric intensive care units and an investment in training and organisation. However, we do not agree that all, or even most, acutely ill children have medical needs which are fundamentally different from critically ill adults. The experience of the child who died after being moved between several hospitals is repeated regularly by adults requiring intensive care [2]. The excess mortality for paediatric intensive care patients reported in Trent [3] may reflect the general under provision of intensive care in the United Kingdom [2]. The study by Gemke [4] concluded that differences in mortality rates among paediatric intensive care units were largely explained by differences in severity of illness. Indeed for the low-risk patients, case-mix adjusted mortality was higher in the tertiary centres than in non-specialists centres. Many children, particularly the older ones, have straightforward intensive care problems and demonstrate the same pathophysiological response and depend on essentially the same equipment and principles that are used in general intensive care. For example an adolescent with multiple injuries may be better cared for in a centre dealing regularly with trauma rather than in a hospital concentrating on neonates and infants. There are many disadvantages to over centralising care including deskilling of local hospitals, the breakdown of family centred care and the additional cost of patient transport. We feel that the ‘framework’ document [5] relies heavily on data skewed towards neonatal/infant care, inadequately represents general intensive care opinion, and doubt the ability to provide level 2 and 3 care as described. If no difference in outcome can be demonstrated, children with critical illness are best cared for close to where their parents live. Resources for intensive care are scarce. They may be better spent on improving the majority of units and providing additional support for straightforward paediatric admissions rather than being expended on an elaborate, expensive and unproved paediatric intensive care system. There needs to be some mechanism for deciding when a child requires the special services provided by a tertiary paediatric centre. Perhaps clinical judgement could be used rather than a decree from on high mandating that anyone less than 16 years old needing intensive care has to treated in a specialist unit. References 1. Ratcliffe J. Provision of intensive care for children. BMJ 1998; 316: 1547-8. 2. Ryan DW. Providing intensive care. BMJ 1996: 312: 654-5. 3. Pearson G, Shann F, Barry P, Vyas J, thomas D, Powell C et al. Should paediatric intensive care be centralised? Trent versus Victoria. Lancet 1997; 349: 1213-7. 4. Gemke RJBJ, Bonsel GJ. The pediatric intensive care assessment of outcome (PICASSO) study group. Comparative assessment of pediatric intensive care: A national multicenter study. Critical Care Medicine 1995; 23: 238-45. 5. National Coordinating Group on Paediatric Intensive Care. Paediatric intensive care: a framework for the future. London: Department of Health, 1997. Yours sincerely David R. Goldhill MA, MBBS, FRCA Senior Lecturer P. Stuart Withington MBBS, FRCA Senior Lecturer The Royal London Hospital Whitechapel London E1 1BB telephone: 0171 377 7725 e-mail: D.Goldhill@mds.qmw.ac.uk |
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G A Pearson, Consultant Paediatric Intensivist (Pearson) Director of Intensive Care (Shann) Birmingham Children's Hospital (Pearson), Royal Childrens Hospital, Melbourne (Shann), F Shann
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Dear Sir Several of your correspondents have referred to our study of all children from Trent (UK) and Victoria (Australia) who received intensive care in a 12 month period [1]. The admission rate was 1.2 per 1000 children in both places but crude mortality was 45% higher in Trent. This difference persisted after severity of illness adjustment. We suggested that mortality was low in Victoria because almost all children are admitted to a single large specialist paediatric intensive care unit (ICU) staffed by full time paediatric intensivists and nurses. Professor Nicholl (16 June 1998) suggests that the higher risk-adjusted mortality rate in Trent might be because more Victorian children were transferred from one ICU to another and were therefore counted twice. In fact most Victorian children were transferred directly, bypassing their local ICU, whereas Trent children were more often admitted to their local ICU. Only seven transfers were counted twice in Victoria, compared to 24 in Trent. Transfers do not explain the differences in mortality or length of stay. Professor Nicholl has also suggested that a lower rate of ventilation in the first hour might explain the higher risk-adjusted mortality rate in Trent. However without ventilation, a logistic model shows the odds ratio for risk of death rises from 2.09 to 2.37, so the outcome in Trent is even worse if ventilation is ignored. Dr Goldhill (17 June 1998) is not correct. The poor results we found in Trent do not reflect "under provision" of intensive care. In fact, the admission rates were almost identical but children stayed 84% longer in ICU in Trent. Many more ICU bed days were used so more money was being spent on looking after children in ICU in Trent with a higher mortality rate. Dr Berry (24 May 1998) rightly stresses the need for high quality retrieval services However, 1000 retrievals per annum are only needed if there is a free-standing retrieval service - as in New South Wales, where Dr Berry works. The retrieval service in Victoria performs approximately 200 transports each year. The cost of this system is lower than a free-standing one because the existing ICU infrastructure is used to support the transport service. There is clear evidence from this study, that is supported by studies in other countries, that very ill children are best looked after by medical and nursing staff who work full time in paediatric intensive care. Surely it is time to stop looking for excuses for the high mortality in Trent, and for the UK to ensure that all children who are intubated for more than 12-24 hours are looked after in large specialist paediatric ICUs. 1. Pearson G, Shann F. Should paediatric intensive care be centralised? Trent versus Victoria. Lancet 1997;349:1213-17. Dr Gale Pearson Cons Paediatric Intensivist Birmingham Children's Hospital, Birmingham UK Prof F. Shann Director of Intensive care Royal CHildren Hospital Melbourne, Australia |
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