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LETTERS:
Andrew Berry, David R Goldhill, P Stuart Withington, Jon Nicholl, Jane Ratcliffe, Gale Pearson, and F Shann
Provision of intensive care for children
BMJ 1998; 317: 1320 [Full text]
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[Read Rapid Response] Evidence for tertiary care
Frank Shann   (6 November 1998)

Evidence for tertiary care 6 November 1998
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Frank Shann,
Professor of Critical Care Medicine
Royal Children's Hospital, Melbourne

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Re: Evidence for tertiary care

Goldhill, Withington, and Nicholl put great weight on the fact that the Dutch study of paediatric intensive care [1] found an increased mortality rate in low risk children in tertiary paediatric intensive care units. However, this difference was explained by the fact that treatment was limited or withdrawn because of severe and incurable chronic morbidity in 15 (60%) of the 25 low risk patients who died in the tertiary paediatric units.

In the tertiary paediatric intensive care units, there were 66 deaths compared to 68.1 deaths predicted by PRISM, so the standardised mortality rate was 0.969. In the nontertiary units, there were 9 deaths compared to 7.3 predicted, so the standardised mortality rate was 1.233. The ratio of the two rates was 1.233 / 0.969, or 1.27. The lower rate in the tertiary units occurred despite the fact that 15 of the 66 deaths in these units were because of limitation or withdrawal of treatment in low risk patients.

Dr Nicoll refers to the Nuffield study that found no relationship between volume (or, more accurately, the number of admissions) and mortality in adult intensive care. The debate in paediatric intensive care is about specialisation rather than volume: do specialist paediatric units do better than general units that admit mainly adults but also look after some children? The Dutch experience is consistent with the evidence from America [2], Australia and the UK [3] that children have a lower mortality in specialist paediatric intensive care units.

1. Gemke RJBJ, Bonsel GJ. The pediatric intensive care assessment of outcome (PICASSO) study group. Comparative assessment of pediatric intensive care: a national multicentre study. Crit Care Med 1995;23:238- 245.

2. Pollack MM, AlexanderSR, Clarke N, Ruttimann UE, Tesselaar HM, Bachulis AC. Improved outcomes from tertiary center pediatric intensive care: a state wide comparison of tertiary and non-tertiary care facilities. Crit Care Med 1991;19:150-159.

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;349:1213-1217.