Letters

Provision of intensive care for children

BMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7168.1320 (Published 07 November 1998) Cite this as: BMJ 1998;317:1320

Effective transport systems are essential

  1. Andrew Berry, Medical director
  1. Newborn/Paediatric Emergency Transport Service, New South Wales
  2. Royal London Hospital, London E1 1BB
  3. Medical Care Research Unit, University of Sheffield, Sheffield S1 4DA
  4. Royal Liverpool Children's NHS Trust, Alder Hey, Liverpool L12 2AP
  5. Birmingham Children's Hospital, Birmingham B16 8ET
  6. Royal Children Hospital, Melbourne, Australia

    EDITOR—Ratcliffe's recommendations for paediatric intensive care are well supported by the improved outcomes she refers to.1 However, she did not address the reasons why sick children are treated in small, low activity, and ill equipped units. These reasons may seem self evident—for example, community preference for local care a community perceptions have to be changed so that best care is seen as preferable to nearby care.This depends on a rapid response medical retrieval service with expertise in intensive care that can be deployed to the referring hospital quickly enough to create the impression that the paediatric unit is closer than it actually is. This may require retrieval services with a high enough activity to maintain a 24 hour service with medical, nursing, and support staff on immediate standby. Our experience is that an activity of over 1000 retrievals a year is needed to meet this goal, which may mean having regional retrieval services acting for several paediatric intensive care units rather than one for each unit. The service must have dedicated ambulances to minimise delays. Regional services can deploy teams independently of staffing constraints on a particular unit yet can form close links with units to maintain professional standards and expertise.

    To avoid another child dying in transit any new system would have to include a “teletriage” process offering immediate telephone access to senior clinical advice. It would also need the collaboration of relevant clinicians and ambulance staff to ensure that care before transfer was appropriate and that a management plan was devised (including the optimal destination).

    Successful regionalisation of paediatric intensive care depends on an effective and responsive infrastructure for transporting patients. The infrastructure must be developed around the needs of the referring hospital and the patients; it should launch teams to patients regardless of shortage of intensive care beds or other problems. Unless medical retrieval is made an important part of the system the death of a child while being moved from a hospital that has been told not to provide intensive care will inevitably lead to calls to reverse the regionalisation process.

    References

    Tertiary centres are unproved

    1. David R Goldhill, Senior lecturer (D.Goldhill{at}mds.qmw.ac.uk),
    2. P Stuart Withington, Senior lecturer
    1. Newborn/Paediatric Emergency Transport Service, New South Wales
    2. Royal London Hospital, London E1 1BB
    3. Medical Care Research Unit, University of Sheffield, Sheffield S1 4DA
    4. Royal Liverpool Children's NHS Trust, Alder Hey, Liverpool L12 2AP
    5. Birmingham Children's Hospital, Birmingham B16 8ET
    6. Royal Children Hospital, Melbourne, Australia

      EDITOR—Like Dr Ratcliffe we would like to improve paediatric intensive care.2 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 those of critically ill adults. The experience of the child who died after being moved between several hospitals is repeated regularly by adults requiring intensive care.3

      The excess mortality among paediatric intensive care patients reported in Trent4may reflect the general underprovision of intensive care in the United Kingdom.3Gemke andBonsel concluded that differences in mortality among paediatric intensive care units were largely explained by differences in severity of illness.5Indeed, for the low risk patients mortality was higher in the tertiary centres than in non-specialist centres after case mix was adjusted for.

      Many children, particularly the older ones, have straightforward intensive care problems. They show the same pathophysiological response as adults 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 than in a hospital concentrating on neonates and infants. There are many disadvantages to overcentralising care, including deskilling of local hospitals, the breakdown of family centred care, and the additional cost of transporting patients.

      We feel that the framework document6relies heavily on data skewed towards neonatal and 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 shown, 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 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 judgment could be used rather than a decree from on high that anyone less than 16 years old needing intensive care has to be treated in a specialist unit.

      References

      1. 2.
      2. 3.
      3. 4.
      4. 5.
      5. 6.

      Evidence does not support tertiary care

      1. Jon Nicholl, Director. (j.nicholl{at}sheffield.ac.uk)
      1. Newborn/Paediatric Emergency Transport Service, New South Wales
      2. Royal London Hospital, London E1 1BB
      3. Medical Care Research Unit, University of Sheffield, Sheffield S1 4DA
      4. Royal Liverpool Children's NHS Trust, Alder Hey, Liverpool L12 2AP
      5. Birmingham Children's Hospital, Birmingham B16 8ET
      6. Royal Children Hospital, Melbourne, Australia

        EDITOR—Ratcliffe states that several studies have shown that paediatric intensive care services should be centralised.7 However, the evidence to support this policy is not clear cut.

        The comparison of Trent region in England with Victoria State in Australia, which showed that risk adjusted mortality in the centralised Victoria system was half that in the distributed Trent system, was not a study of children in the two areas but of admissions.8 All children admitted to local intensive care services and then transferred to central facilities (mainly in Victoria) were double counted: firstly, as survivors from the local unit and then as deaths or survivors from the central unit. This may help to explain why length of stay was so short in Victoria (because it was actually length of stay for that admission not for that episode) and could explain the difference in risk adjusted mortality between areas.

        Ratcliffe refers to two other studies. 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 paediatric intensive care assessment of outcome (PICASSO) study also found an increased risk of death in tertiary facilities for low risk children,9and the only unit in that study whose mortality significantly exceeded that expected after adjustment for case mix was one of the largest units. The other study excluded all transfers and deaths before admission,10which makesthe value of these data for assessing the benefits of a tertiary referral system doubtful.

        A positive relation between volume and outcomes has not been shown to hold true generally, and has been shown specifically not to hold in adult intensive care.11This is an uncertain evidence base on which to implement a policy of centralisation based on “lead” centres identified mainly by their volume of activity rather than production of good outcomes.

        Ratcliffe observes that there is no validated paediatric scoring system for severity of illnessin the United Kingdom and no information about long term outcome. Until these gaps in the knowledge base are remedied, it will be difficult, if not impossible, to identify the optimum configuration for paediatric intensive care services in the United Kingdom.

        References

        1. 7.
        2. 8.
        3. 9.
        4. 10.
        5. 11.

        Author's reply

        1. Jane Ratcliffe, Consultant in paediatric intensive care.
        1. Newborn/Paediatric Emergency Transport Service, New South Wales
        2. Royal London Hospital, London E1 1BB
        3. Medical Care Research Unit, University of Sheffield, Sheffield S1 4DA
        4. Royal Liverpool Children's NHS Trust, Alder Hey, Liverpool L12 2AP
        5. Birmingham Children's Hospital, Birmingham B16 8ET
        6. Royal Children Hospital, Melbourne, Australia

          EDITOR—The correspondence highlights the question whether the structure of the paediatric intensive care service should be changed before detailed information on outcomes is available from research in the United Kingdom.

          Such research must assess premorbid clinical state, morbidity, and mortality. It will take at least five years to complete, and research proposals have been submitted. The importance of such research was acknowledged by the national coordinating group, which identified an urgent need to improve the organisation and integration of the service.12The group defined the standards of care that are essential for managing a critically ill child from acute presentation onwards, and the configuration of the service developed from this. These standards included appropriately experienced multidisciplinary staff, sufficient patient throughput to maintain skills, and the resources to staff and run a transport service. The stand alone transport service suggested by Berry would not fit easily into the distribution of tertiary paediatric centres within the United Kingdom.

          Goldhill and Withington state that the framework for the future document12is skewed towards infant and neonatal care. Numerically, the paediatric intensive care population is concentrated in the younger age range, with 40% of patients being younger than 1 year and 70% younger than 5.13There are overlaps with some aspects of neonatal intensive care but it is a distinct area of practice.

          Nicholl suggests that the research supporting centralisation of paediatric intensive care is not clear cut. Pearson and Shann have reanalysed their data in the light of his comments (personal communication). Admission rates were similar for the two populations but crude mortality was 45% higher in Trent, and this difference remained after adjustment for severity of illness. The lower lengths of stay for Victorian children were not explained by possible double counting in the process of transfer. Using a logistic regression model without ventilation, the odds ratio for risk of death rose from 2.09 to 2.37; a worse outcome for Trent children. In the Dutch study,14the increased rate of death for lower risk children in tertiary facilities related to severe and incurable chronic disease which the PRISM score does not encompass.

          I believe there is enough evidence to change the organisational configuration of paediatric intensive care to provide a more integrated service. The next stage must be informed by detailed United Kingdom paediatric intensive care research.

          References

          1. 12.
          2. 13.
          3. 14.

          Results of Trent and Victoria study are valid

          1. Gale Pearson, Consultant paediatric intensivist.,
          2. F Shann, Consultant in paediatric intensive care. (gale.pearson{at}bhamchildrens.wmids.nhs.uk)
          1. Newborn/Paediatric Emergency Transport Service, New South Wales
          2. Royal London Hospital, London E1 1BB
          3. Medical Care Research Unit, University of Sheffield, Sheffield S1 4DA
          4. Royal Liverpool Children's NHS Trust, Alder Hey, Liverpool L12 2AP
          5. Birmingham Children's Hospital, Birmingham B16 8ET
          6. Royal Children Hospital, Melbourne, Australia

            EDITOR—Several of the electronic responses on the BMJ's website have referred to our study of all children from Trent (England) and Victoria (Australia) who received intensive care over 12 months.15 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 was adjusted for. We suggested that mortality was low in Victoria because almost all children are admitted to a single, large specialist paediatric intensive care unit staffed by full time paediatric intensivists and nurses.

            Nicholl suggests that the higher risk adjusted mortality in Trent might be because more children from Victoria were transferred from one intensive care unit to another and were therefore counted twice. In fact most children were transferred directly, bypassing their local unit, whereas Trent children were more often admitted to their local intensive care unit. Only seven transfers were counted twice in Victoria compared with 24 in Trent. Transfers do not explain the differences in mortality or length of stay.

            Nicholl also suggests that a lower rate of ventilation in the first hour might explain the higher risk adjusted mortality in Trent. However, without ventilation 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.

            The poor results we found in Trent do not reflect underprovision of intensive care. In fact, the admission rates were almost identical, but children stayed 84% longer in intensive care in Trent. This meant many more bed days so more money was being spent on looking after children in intensive care in Trent with a higher mortality.

            Berry rightly stresses the need for high quality retrieval services. However, 1000 retrievals ayear are needed only if there is a freestanding transport service, as in New South Wales. The retrieval service in Victoria transports roughly 200 patients a year. The cost of this system is lowerthan a freestanding one because the existing intensive care infrastructure is used to support the transport service.

            Our study provides clear evidence, which 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 Britain to ensure that all children who are intubated for more than 12-24 hours are looked after in large specialist paediatric intensive care units.

            References

            1. 15.