Intended for healthcare professionals


Authors' reply

BMJ 1996; 312 doi: (Published 13 January 1996) Cite this as: BMJ 1996;312:121
  1. Joseph Britto,
  2. Simon Nadel,
  3. Ian Maconochie,
  4. Michael Levin,
  5. Parviz Habibi
  1. Paediatric intensive care fellow Consultant in paediatric intensive care Clinical research fellow Professor Senior lecturer Department of Paediatrics, St Mary's Hospital, London W2 1NY

    EDITOR,—It is reassuring to find that there is agreement on the essence of our paper, which is that critically ill children should be transferred by specialised paediatric mobile intensive care teams. Unfortunately, this is not always the case in Britain. Quen Mok and colleagues report that substantially more critical incidents occurred in the 180 transfers by non-specialised teams to their paediatric intensive care unit, which emphasises the message of our paper.

    Our application of the therapeutic intervention scoring system (TISS) and the paediatric risk of mortality (PRISM) score was based on evidence of their use in retrievals.1 2 When the PRISM score was validated in Britain observation periods ranged from 8 to 32 hours and in some cases were shorter. Furthermore, it was suggested that the score could be used serially before, during, and after transfer.3 The PRISM score has been validated for use before transfer.4 Alan Morrison and Colin Runcie seem to have misunderstood the TISS score after retrieval in our study: it included only interventions performed by our mobile intensive care team and not those performed in the paediatric intensive care unit.

    It is important that the issue of transferring critically ill children does not get sidetracked by a debate on scores indicating severity of illness. The evidence is clear: mobile intensive care teams decrease the risk of morbidity during transfer. While scores indicating severity of illness are necessary tools for audit and health planning, they are of no use in the management of an individual child.

    A Raffles makes a valid point about the initial intensive care delivered by referring hospitals. In the past two years we have collected data on 275 children from 50 hospitals and have found that most of the skills required for initial resuscitation and stabilisation were available at the referring hospitals. Often these procedures had not been performed despite advice being given on the telephone by our mobile intensive care team. We agree that doctors who treat children should have specialised training in recognising and managing those who are seriously ill. An additional function of the mobile intensive care team is to impart specialised knowledge and skills to the team at the referring hospital, thereby improving the management of subsequent children.

    R M Cooper rightly highlights the risk of transfers within hospitals. A recent study of such transfers showed significant physiological deterioration in 72% of patients and mishaps related to equipment in 19%.5 Clearly, critically ill children should be transferred by a mobile intensive care team, however short the distance.


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