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Letters

Paediatric intensive care beds: the problem is distribution rather than numbers

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7033.773 (Published 23 March 1996) Cite this as: BMJ 1996;312:773
  1. S Tibby,
  2. M Hatherill,
  3. M J Marsh,
  4. I A Murdoch
  1. Fellow in paediatric intensive care Fellow in paediatric intensive care Consultant in paediatric intensive care Consultant in paediatric intensive care Intensive Care Unit, Guy's Hospital, London SE1 9RT

    EDITOR,—In the past few weeks the media have brought to the public's attention the apparent lack of provision of both paediatric and adult intensive care services in Britain. In July 1993 Shann noted that Britain's paediatric intensive care service was extraordinarily fragmented and suggested that it would be better to have 12-14 large paediatric units each with 14-16 beds.1 In November that year a working party of the British Paediatric Association made recommendations for improving the provision of intensive care services for children.2 While agreeing with most of Shann's comments, the report concluded that paediatric intensive care units should have a minimum of eight beds. We suspect that Shann is correct and that bigger units are the best way to provide care.3

    Since November 1994 we have provided 16 beds to cater for the needs of critically ill children. Other units have perhaps not been as fortunate. Currently (March 1996) there are reputedly 31 centres (197 beds) in Britain that purport to offer paediatric intensive care. Among these centres the median number of beds is 5, with the first and third quartiles being 4 and 7.5 beds respectively. Indeed, only three units have more than 14 beds, and 23 of the centres fail to meet the British Paediatric Association's recommendation regarding the minimum size of a unit.

    We are convinced that centralisation of beds into large centres, with the additional medical and nursing staff required to support them, will improve the care of critically ill children. Indeed, if the service were to be centralised along the lines suggested by Shann it is questionable whether more beds would be required than already exist (14x14=196 beds). Currently, although the 31 centres claim to have 197 beds in total, because of a shortage of skilled nurses many of the beds are closed. We believe that larger units are better placed to meet seasonal demands. To illustrate this we have compared the rate of refused admissions to our unit for two periods (1992-3, when the unit operated with seven beds, and 1994-5, when initially 11 and then 16 beds were open). The rate has fallen dramatically since the unit expanded: in the past two years only 12 (2.4%) of 498 children have been refused, compared with 40 (15.2%) of 264 in 1992-3 (Fisher's exact test, P<0.0001; odds ratio 7.23 (95% confidence interval 3.7 to 14.1)).

    If it is the aim of specialists in paediatric intensive care in Britain to look after virtually all critically ill children they must first be in a position to admit them.2 For this to be accomplished in the most clinically efficient and cost effective manner, small units need to be closed or amalgamated, or both, to meet the needs of the population.

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