Professional Dissertation Writing
Help in Australia

(1) Literature review

Title – Has centralisation improved the neurological outcome of children requiring intensive care services in Yorkshire and Humber?

Introduction

Describe how or why you chose this area to research. This may relate to your clinical area of interest, a personal experience or your having a question that you feels need answering. Think through the information you require to undertake your research or the questions you need to answer. It is important to be clear and focused, rather than broadly covering the whole clinical area

The aim of the paediatric intensive care is to prevent mortality in children with critical illness and preserve functional outcomes. We want to see if the centralisation has improved the morbidity and neurological outcome of children requiring intensive care by comparing outcome before (2003-2007) and after centralisation (2008-2011).

As we know from the literature papers as early as 1997 Pearson etal¹ showed that the substantial reduction in the mortality rates can be achieved if every UK child who needed intubation for 12-24hrs is admitted to one of the specialist Paediatric ICU

With the improvements in critical care services although patients are surviving, they may have increased morbidity or secondary admissions with sepsis. It appears that Paediatric critical care may have exchanged improved mortality rates for increased morbidity rates². From the recent PICANet data (A decade of data.2014 Annual Summary Report) PICU mortality is running all time low and it is less sensitive as a key performance indicator but it is the post PICU morbidity that is more important. We also have to understand that increasing number of children with poor functional status has implications not only on the rest of the life of the child but also on the family and NHS in terms of providing adequate individual support both medically and financially

As a result of changes in service provision from 2008 in Yorkshire and Humber, the establishment of a dedicated regional retrieval service, more patients were transferred out, using a guideline or matrix, backed up by consultant discussion with transport teams and regional centre.

PICU care was undertaken in one DGH (Hull Royal Infirmary) according to the model given for Acute Major General Hospital in Troop Report, as a hub and spoke arrangement with the regional centre. We want to do a retrospective cohort study looking at two groups pre and post centralization (2003-2007 vs 2008-2011). This information will guide us in improving the standards of our care towards critically ill children

Questions : Itemise the questions you are addressing in the review?

1. Has centralization affected the mortality and morbidity of critically ill children?

Search Strategy
Describe your search strategy, indicating the databases you used, the key words and the sort of studies you were looking for. Indicate how many articles you identified and why you choose the studies to review that you did. A systematic review is not required. but you are expected to have adopted a strategy that one might reasonably expect a clinician to take in the course of their work

Primary Source: Medline
Secondary Source: Pubmed, Pediatric Critical Care Medicine Journal

S.No	Search term	Results
1	Cetralisation and Outcome of critically ill children (Medline)	0
2	Neurological outcome of PICU patients (Medline)	0
3	Sepsis and PICU outcome (Medline)	2
4	Centralisation and Outcome of critically ill children (Pubmed)	5
5	Centralisation and Outcome of critically ill children (Paediatric Critical Care Medicine Journal)	7

Review of the literature

Provide us with the answers to your questions. It helps to take each question in turn. Present the evidence you have found concisely, critically and clearly. It is sensible to summarise the studies in the form of table (which may include a column for comments on the quality of the study in question). This means that you can provide a your conclusions in a paragraph following the table. If there is no evidence for any question, then say so

 

 

 

 

 

 

 

	Citation	Study group (Population & comparisions)	Study Type	Outcome	Key Result	Comments
1	Padmanabhan Ramnarayan Lancet 2010; 376:698-704 (Great Ormond Street Hospital, UK)	– Data from 29 PICU by admission source and type of retrieval team  – Compared unplanned admission from wards within the hospitals as PICU and from other hospitals; interhospital transfers by non-specialist and specialist retrieval teams; and patients transferred to their nearest PICU and those who are not	Retrospective cohort	PICU Mortality rate	-16875 children were brought to PICU either by specialist retrieval teams or non-specialist retrieval team.  – Multivariable analysis showed significantly lower risk of death (0.58, 0.39-0.87) with specialist retrieval team transfers than with non-specialist team transfers after adjustments for case mix (age, sex, surgical status and variable s for PIM) and organizational factors (patient’s strategic health authority)	“Within a centralised model of paediatric intensive care in England and Wales, Specialist retrieval teams, which are commonly used for interhospital transport of critically ill children were associated with reduced risk-adjusted mortality”
2	Muuray M.Pollack etal Paed Critical Care Medicine 2014; 15:821-827  (Phoenix Children’s Hospital and University of Arizona College of Medicine- Phoenix	– Data from 8 Medical and Cardiac PICU  – Morbidity before and after PICU admission were compared between 1990 group and 2011-2012 group – FSS Functional status Score was used to assess the morbidity	Prospective cohort	Functional Status Scale Scores (FSS) at hospital discharge  A new morbidity was defined as increase in FSS 3	– Of the 5017 patients there were 242 new morbidities (4.8%), 99 PICU deaths (2%) and 120 hospital deaths (2.4%).  – This data was compared with data from 1990s where PICU mortality rate was 4.6% and PICU morbidity rate was 3.1% – The highest new morbidity rates were in neurological diagnoses (7.3%), acquired cardiovascular disease (5.9%), cancer (5.3%) and congenital cardiovascular disease (4.9%)	– The severity rates compared are not risk adjusted
3	Katie Moynihan etal. Paed Critical Care Medicine 2016  (Starship Children’s Hospital, Auckland, New Zealand)	– Evaluate the impact of paediatric critical care retrieval, distance traveled, level of ICU support at the referral centre on outcomes in unplanned admissions  – Comparisions were made between transported and non-transported patients – Data over 10 year period at Starship PICU -5,609 unplanned admissions were included in the analysis – 2,509 (45%) were retrieved and 3,100 (55%) were from the same institution	Retrospective cohort	Length of stay in PICU  PICU Mortality	– Transported patients had a median time of 29 hours longer PICU admission  – PICU-specific resource use was higher in the transported cohort – Following risk adjustment using PIM2, PICU mortality rates were equivalent between retrieved and same institution unplanned admission	– Looked in to the impact of centralisation on PICU mortality  – Post PICU mortality and morbidity were not determined – Time critical transfers were not included
4	Poongundran Namachivayam, Frank Shann etal, Pediatric Critical Care Medicine 2010; 11:549-555  (The Royal Children’s Hospital, Melbourne)	– Data from cohorts of 1982, 1995 and 2005-2006 were compared	Retrospective cohort	– PICU mortality  – Post PICU morbidity	– PICU mortality of children aged >1month at the time of admission fell substantially from 11% of (n=700) in 1982 to 4.8%  (n=1733) in 2005-2006 (p<0.01)  – Children surviving with moderate or severe long term disability at long term follow up increased from 8.4% in 1982 to 17.9% in 2005 -2006 (p<0.0001) – Quality of life in children aged >2yrs: Good (HSUV 1.00-0.70) – 84% (n=727) in 1995 & 68% (n=375) in 2005 – 2006 (p<0.0001) HSUV – Health State Utility Value	– Follow up was available only for 43% in 2005-2006 cohort which is lower than for 1982 (100%) and 1995 (84%), and the follow up was only for a median time of 1.1yrs compared to approximately 3yrs in 1982 and 1995.

Conclusions:
End the literature review with a brief summary concluding what you have learnt from the review. Then lead the reader on to why research was needed in this area and the questions you hoped to answer through your project

On doing the search we had 12 articles looking in to effect of centralization and outcome of critically ill children. Out of these articles I found the 4 articles from different parts of the world including UK to be related more closely to our study.

The study from Great Ormond Street Hospital¹ mainly focusing on the effects of centralisation on the PICU mortality in England and Wales suggests that use of specialist retrieval teams for interhospital transfer was associated with reduced risk adjusted mortality. The distance travelled by patients to access emergency paediatric critical care has not affected the outcome. We can see the similar results from the study in Newzealand³. However both these studies do not provide evidence on post ICU morbidity, the functional status pre and post PICU admission

The study by Murray Pollock etal² looked in to the functional status scores of critically ill children before and after PICU admission. Functional Status scores were calculated before the PICU admission and at the time of discharge from the hospital. There is no clear information about at what time after the PICU discharge these scores were calculated. As we all know that the functional recovery improves with time. The data from December 2011 to August2012  (n=5000) is compared with the data from 1990s. The results show that the 2011-2012 patients had a morbidity rate of 4.8% and mortality rate of 2% compared to 3.1% and 4.6% in 1990s group. There is a wide variation in between two groups (1990 vs. 2011-2012) in terms of type of patients and the methods of management and this might affect the comparision. The severity rates mentioned are not risk adjusted so it makes it difficult to accept the numbers

The study from Melbourne⁴ comparing the PICU mortality and morbidity from population groups over the last three decades  (1982,1995 and 2005-2006) showed a substantial fall in the PICU mortality of children aged >1month from 11% in 1982 to 4.8% in 2005-2006 (p<0.01). However the children with moderate or severe long term disability at long term follow up increased from 8.4% in 1982 to 17.9% in 2005 -2006 (p<0.0001).  Only 43% of the children in 2005-2006 groups were followed up compared to 100% in the other cohorts. Estimated disability rate was used to include the patients who were lost to follow up. So these figures may not be accurate. There were no PIM scores for the 1982 and 1995 group so the data was not risk adjusted for these groups.
The results from this study again reinforce the fact that we are achieving improved mortality rates at the expense of increased morbidities. It also highlights that these improvements reflects the advancements in the critical care services and the changes in the type of illnesses we are seeing. This study showed that compared to 1982 group, in 2005-2006 group there was a decrease in the proportion of children admitted from accidents, epiglottitis and croup. This can be explained by improvements in road safety regulations, Haemophilus influenza immunization and early administration of corticosteroids in children with croup. There was an increase in the use of non-invasive ventilation from 0% in 1982, 1995 to 8% in 2005-2006 (p<0.01)

By the above discussion points we can say that there is a global improvement in the PICU mortality which can be attributed to advanced therapies and centralization. However we are also seeing increased numbers in the moderate or severe morbidity rates. As suggested in the recent PICANet recommendation⁵ we need to be monitoring these post-PICU discharge morbidity rates

We would like to study our population group pre and post centralisation and understand the PICU mortality and morbidity rates in each group. The availability of data from PICANet and the PIM scores make it possible to compare the two population groups and get a risk adjusted mortality and morbidity rates. Our main focus will be on the neurological outcome of these children although each group will be looked at various factors, which include demographics, type of illness, background illness/syndrome/disability, whether there was a need for mechanical ventilation/ ionotoropic support/ intracranial pressure monitoring or not. These results will guide us in improving the patient care and outcome
References:
 

1. Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study
   – Padmanabhan Ramnarayan, Lancet 2010; 376:698-704
2. Pediatric Intensive Care Outcome: Development of New Morbidities During Pediatric Critical care Paed Critical Care Medicine 2014; 15:821-827
3. Impact of Retrieval, Distance Travelled, and Referral centre on Outcomes in Unplanned Admissions to A National PICU Paed Critical Care Medicine 2016
4. Three Decades of pediatric intensive care: Who was admitted, what happened in intensive care, and what happened afterward
   Poongundran Namachivayam, Lara Shekerdemian, Irene Van Sloten, Carmel Delzoppz, Pediatric Critical Care Medicine 2010; 11:549-555
5. PICANet: A Decade of Data. 2014 Annual Summary Report

 Research Project

Title – Has centralisation improved the neurological outcome of children requiring intensive care services in Yorkshire and Humber?

Abstract:

Background:
Improvements in the critical care services particularly the centralisation and establishment of specialist retrieval teams has helped in the reduction of mortality rates⁷. Evidence to suggest that although there is reduced mortality¹⁶, there is an increase in the number of children surviving with disability following a critical care admission. We wanted to have a look at this in our population in Yorkshire and Humber.

Aim:
To assess the neurological outcome of critically ill children requiring intensive care pre and post centralisation.

Methods:

This is a retrospective cohort study looking at two cohorts of critically ill children admitted to intensive care during pre (2003-2007) and post centralisation (2008-2011) periods. Neurological outcome was assessed using King’s Outcome Score for Children with Head Injury (KOSCHI). This was done at four months after the discharge from critical care by a forty-minute follow up appointment. The cohorts are assessed for any differences in the epidemiology and risk of mortality. The expected mortality was calculated by using the PIM data. Chi-square method was used to compare the cohorts.
 

Results:

There were 214 patients in the pre-centralisation cohort (2003-2007 group) and 104 patients in the post-centralisation cohort (2008-2011 group). There was no significant difference in both the groups in terms of age, expected mortality and pre-existing illness. The mortality risk was 144 per 1000 for cohort 1 and 112 per 1000 for the cohort 2. Standardised mortality rate (SMR) was noted to be 0.73 (95% CI 0.49 to1.04) in cohort1 and 1.05 (95% CI 0.6 to 1.67) in cohort2. KOSCHI score 5 which represents good recovery was seen in 93% of the children from pre-centralisation cohort compared to 82% in the post-centralisation cohort. Similarly KOSCHI score 2-4 which represents the children with new disability after the critical care admission was seen only in 7% in the former compared to 18% in the latter with a statistically significant p-value of <0.001.

Conclusion:
Standardised mortality rate was within the confidence intervals but there was a statistically significant difference in the neurodisability of children in between the cohorts. As observed in the other studies we found that there is a trend of increase in the numbers of post critical care morbidity. However we suggest doing further studies looking in to the most recent data with a larger sample size in the post-centralisation cohort.

Introduction:

The aim of the paediatric intensive care is to prevent mortality in children with critical illness and preserve the functional outcomes. We want to see if the centralisation has improved the morbidity and neurological outcome of children requiring intensive care by comparing cohorts before (2003-2007) and after centralisation (2008-2011).

Literature from as early as 1997(Pearson etal¹) shows that a substantial reduction in mortality rates can be achieved if every UK child who needed intubation for 12-24hrs is admitted to one of the specialist paediatric intensive care unit.

There were concerns of volume overload affecting the outcome due to centralisation. Tilford etal¹⁰ showed an inverse relationship between volume of patients in PICU to risk adjusted mortality or patient length of stay.

With the improvements in critical care services patients are surviving though may have increased morbidity or require secondary admissions with sepsis. It appears that Paediatric critical care may have exchanged improved mortality rates for increased morbidity rates². From the recent PICANet data⁵ PICU mortality is running at all time low and is less sensitive as a key performance indicator, however it is the post PICU morbidity that is more important. We also have to understand that increasing numbers of children with poor functional status has implications not only on the rest of the child’s life but also on the family and NHS in terms of providing adequate individual, support both medically and financially.

As a result of changes in service provision from 2008 in Yorkshire and Humber plus the establishment of a dedicated regional retrieval service, more patients were transferred out, using a guideline or matrix, backed up by consultant discussion with transport teams and regional centre.

PICU care was undertaken in one DGH (Hull Royal Infirmary) according to the model given for Acute Major General Hospital in Troop Report, as a hub and spoke arrangement with the regional centre. We wanted to do a retrospective cohort study looking at the neurological outcome of two groups pre and post centralisation (2003-2007 vs. 2008-2011). This information will help us to understand the impact of centralisation on the morbidity of our population.

Aim of the project:
To assess the neurological outcome of critically ill children requiring intensive care pre and post centralisation.

Research questions/ objectives:
– Centralisation of intensive care unit services has improved the neurological outcome of children requiring critical care. This is compared with no improvement as the null hypothesis.
 

Method:

Study design:
This is a retrospective cohort study comparingtwo cohorts of critically ill children admitted to intensive care pre (2003-2007) and post centralisation (2008-2011).

Population:
All children up to eighteen years of age who were admitted for critical care at Hull Royal Infirmary. For the cohort 1 we included all admissions from 1^st January 2003 till 31^st December 2007 and for cohort 2 from 1^st January 2008 till 31^st December 2011.

Exclusion criteria – Children who died during the critical care were excluded from the data analysis in order to keep the focus mainly on the neurological outcome of survivors. Although we have mentioned the mortality, this was to show that both the groups are similar in the predicted mortality.

Data collection:
Case identification, data collection was performed with the help of PICANet & hospital records. The main focus was on the neurological outcome however information relating to baseline characteristics like demographics, type of illnesses, background illness, syndrome, disability, need for mechanical ventilation or intracranial pressure monitoring was obtained. All children with pre-existing illness (chronic illness, syndrome) were scored depending on whether they reached to the similar stage of neurodisability prior to getting unwell.

Definitions:
Traumatic brain injury (TBI) is a non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness⁵⁰.

Raised intracranial pressure (ICP) is defined as intracranial pressure above 20mm of Hg.⁵¹
Risk adjusted mortality model:
Mortality is something, which is influenced by a number of factors. In order to make sure that the cohorts are similar we usedPaediatric index mortality⁶ data (PIM2) to obtain the expected mortality. Standardised mortality rate (SMR) was calculated as a ratio of observed deaths in PICU and expected deaths. The data for PIM2 and SMR was obtained from PICANet.

Outcome measures:
We examined the neurological outcome of survivors using Kings Outcome Scale for Childhood Head Injury³ (KOSCHI, table 1) during a forty minute follow up appointment, four months after the discharge from intensive care. In cases where we did not have a follow up we used the case notes to establish the neurological outcome.
 

Table1 King’s Outcome Score category definitions

Score	Category	Definition
1	Death
2	Vegetative	The child is breathing spontaneously and may have sleep/wake cycles. He may have non-purposeful or reflex movements of limbs or eyes. There is no evidence of ability to communicate verbally or non-verbally or to respond to commands
3	Severe disability	The child is least intermittently able to move part of the body/eyes to command or make purposeful spontaneous movements; for example confused child pulling at nasogastric tube, lashing out at carers, rolling over in bed. May be fully conscious and able to communicate but not yet able to carry out any self care activities such as feeding. Implies a continuing high level of dependency, but the child can assist in daily activities; for example, can feed self or walk with assistance or help to place items of clothing. Such a child is fully conscious but may still have a degree of post-traumatic amnesia
4	Moderate disability	The child is mostly dependent but needs a degree of supervision/actual help for physical or behavioural problems. Such a child has overt problems; for example, 12 yr old with moderate hemiplegia and dyspraxia insecure on stairs or needing help with dressing The child is age appropriately independent but has residual problems with learning/behaviour or neurological sequelae affecting function. He probably would have special needs assistance but his special needs may not have been recognized/met. Children with symptoms of post-traumatic stress are likely to fall into this category
5	Good recovery	a) This should only be assigned if the head injury has resulted in a new  Condition which does not interfere with child’s well being and or functioning; for example: – Minor head aches not interfering with social or school functioning – Abnormalities on brain scan without any detectable new problem – Prophylactic anti-convulsants in the absence of new seizures – Unsightly scarring of face or head likely to need cosmetic surgery at some stage – Mild neurological asymmetry but no evidence of affect on function of the limb. Includes isolated change in hand dominance in a young child b) Implies that the information available is that the child has made a complete recovery with no detectable sequelae from the head injury

Data analysis:
Chi-square test was used to analyse the two cohorts.  P value <0.001 was considered statistically significant.

Ethics:
This project is considered for service evaluation and the data was obtained from PICANet so ethical approval was not needed. We had approval from the hospital clinical governance committee to access the patient records.

Results:
A total of 255 patients were included in cohort1 and 127 patients in cohort2. As we were interested in only the morbidity of the survivors we excluded the patients who died during the illness. Forty patients died in cohort 1 and twenty patients in cohort 2. One patient in cohort 1 and three patients in cohort 2 were lost from follow up, therefore not included in the study. This left us with a total number to be 214 in the former and 104 in the latter group. Nearly two-third of the children were male in both the groups.  Median age was 2.5yrs in cohort1 and 1.2yrs in cohort2.

Table2. Summary of the results

	Cohort 1	Cohort 2	P- value
Dates	2003 to 2007	2008 to 2011
Number of cases (n)	214	104
Age- Median & Range	2.5yrs (0-16yrs)	1.2yrs(0-17yrs)
Age – Standard deviation	4.9	5.4
Gender (M)	136 (64%)	63 (61%)
PIM2 Score – 5th centile – 95th centile	0.008 – 0.2	0.005 – 0.1
Ventilated	178 (83%)	88 (85%)	0.59
Primary sepsis	89 (42%)	36 (35%)	0.23
Post-operative cases	34 (16%)	19(18%)	0.61
Pre-existing chronic illness	58 (27%)	32 (31%)	0.50
Raised intracranial Pressure (ICP)	51(24%)	19 (18%)	0.27
Traumatic brain injury (TBI)	39 (18%)	12 (12%)	0.13
Trauma	43 (20%)	20 (19%)	0.86
Neurological Outcomes
Disability (KOSCHI 2-4)	14 (7%)	19 (18%)	<0.001
Good (KOSCHI 5)	200 (93%)	85 (82%)

Table 3 – Chi-square test:

	Outcome 2-4	Outcome 5	Total
2003-2007	14   E = 214X33/318 = 22	200   E = 214X285/318 = 192	214
2008 – 2011	19   E = 104X33/318 = 11	85   E = 104X285/318 = 93	104
TOTAL	33	285	318

 = (O-E) ²/E
= (14-22)²/22 + (200-192)²/192+ (19-11)²/11+ (85-93)²/93
= 64/22+ 64/192+64/11+64/93
= 2.9+0.33+5.8+ 0.68     = 9.71 = P<0.001

Figure 1 Illustrating features of two cohorts
(ICP – Intracranial pressure, TBI – Traumatic brain injury)

Table 4 – Demonstrating the organ system involvement in both the groups
(This table excludes Trauma /Burns/metabolic – On addition of these cases it will be 100%) 

System of Primary dysfunction	2003-2007 (n=214)	2008-2011 (n=104)
Central Nervous System (CNS)	52 (24%)	39 (38%)
Respiratory	45 (21%)	33 (32%)
Cardiac	10 (5%)	3 (3%)
Gastrointestinal Tract (GIT)	4 (2%)	2 (2%)
Multi-organ involvement	35 (16%)	7 (7%)

 

Figure 2 – Showing the organ system involvement in both the groups

 

 

Figure 3 – Percentage of post-operative cases in each group

 

 

 

 

 

 

 

Figure 4 – Types of surgery among the cases

Figure 5 Showing the KOSCHI scores in both the cohorts
(KOSCHI – King’s outcome scale for childhood head injury)

 

 

 

Figure 6 – Illustrating the actual number of deaths (deaths in PICU plus deaths within 30 days of critical care) & the predicted deaths

 

Figure 7- Showing the Standardised Mortality Rates in each group

 

 

 

Figure 8- Scatter plot showing PIM2 Scores from 2003 – 2007 group
(For two cases we did not had the PIM2 score)

 

 

Figure 9- Scatter plot showing the PIM2 Scores from 2008 – 2011 group

 

 

 

 

Discussion:

The retrospective cohort study showed an increase in the number of children surviving with disability in the post centralisation cohort.

KOSCHI score five represents good recovery and was seen in 93% of the children from pre-centralisation cohort compared to 82% in the post-centralisation cohort. Similarly KOSCHI score two to four represents children with new disability after the critical care admission, was seen only in 7% in the former compared to 18% in the latter with a statistically significant p-value of <0.001.

The cohorts were almost similar in majority of the aspects. Pre-existing illness (31% vs 27%), primary sepsis (42% vs 35%) & traumatic brain injury (18% vs 12%) was seen in slightly higher percentage in the pre-centralisation cohort. There were more children with the neurological (41% vs 24%)& respiratory  (33% vs 21%) illnesses in the post-centralisation cohort.

Children requiring mechanical ventilation were almost similar in both the cohorts (83% vs 85%). With current advances in the non-invasive ventilation we would have expected this figure to be less in the post-centralisation cohort but we didn’t see that in our study. This could be because we had 12% more cases with respiratory illnesses in the post-centralisation cohort.

The severity of illness on admission as reflected by PIM2 scores were almost similar with 5^th – 95^th centile scores of 0.008 to 0.2 for cohort1, 0.005 to 0.1 for cohort2. The expected mortality in each cohort was identified to see if both the groups were similar in terms of mortality risk. It was 144 per 1000 for cohort 1 and 112 per 1000 for cohort 2. The Standardised mortality rate was 1.05 (95% CI 0.6 to 1.7) in cohort2 and 0.7 (95% CI 0.49 to 1.04) in cohort1. As you can see the SMR was marginally higher in cohort2 however the confidence intervals were almost similar.

Our neurological outcome results correlate with what other studies have shown in the literature review. Pollack etal² compared morbidity before and after PICU admission between 1990 group and 2011-2012 groups, showed a rise in numbers to 4.8% from 3.1%. Namachivayam & Frank Shann etal study⁴ from Melbourne showed children surviving with moderate or severe long term disability at long term follow up increased from 8.4% in 1982 to 17.9% in 2005 -2006 (p<0.0001).

Aspesberroetal¹⁸ did a literature review looking at articles from 1980 to 2015 on children surviving critical illness. It also concluded similar results. They mentioned that thekey determinant of the outcome in critically ill children is multi-factorial. This includes diagnosis (trauma^19-21, sepsis^{17, 22}, meningo-encephalitis^23-27), presence of chronic co-morbid conditions^28-39 and type of treatment received (prolonged CPR^40-42, long-stay patients^43-47, invasive technology^{48, 49}).  Our study had 14% more neurological illness in the post-centralisation cohort when compared to the other cohort. However the severity of the illness was similar in each group as suggested by the PIM2 scores from PICANet.

Important figure to note was that 82% of the cases were back to pre-morbid status in the post-centralisation cohort. This was significantly better than figures from the other studies like Namachivayam & Frank Shann etal study⁴ had 69% and Pollack etal2 had 63%.

Looking in to the clinical practice pre and post-centralisation there were changes in terms of how we manage critically ill children. During the pre-centralisation period, the patients experienced a uniform care¹³ provided by the experienced Intensivist and nursing staff at the bedside. Compliance with the international consensus guidelines for the treatment of sepsis was adhered. Mean BP was targeted at 50^th centile during the course of illness. We know that these measures help us in decreasing the organ dysfunction and thereby improving the outcome.^{12, 14}

Post-centralisation sees a different system where the local intensive care team is involved in a telephonic conversation with an Intensivist at the regional PICU. This may make the decision making process difficult as the clinician providing advice is not by the bedside. It is hard to calculate how much impact this has on the decision making process and ensuring appropriate management when compared to the care provided at bedside by an Intensivist. There are studies^{9, 11} to suggest that telemedicine has helped the improved outcome in children admitted from emergency department.

The higher morbidity and mortality in the post-centralisation cohort could also be due to the fact that we are analysing the results from immediate post-centralisation period. As expected, like with any change we bring in practice, there is a learning curve period, which might not show the best results. If we repeat a review further down the period from the time of centralisation we might have a different outcome. For this reason we would recommend further future studies.

Strengths:

The cohorts belong to two different periods with different types of illnesses; however they were similar in terms of age, gender and severity of illness on presentation as supported by the PIM2 data.

Limitations:

– Sample size in the post-centralisation cohort (n=104) is small compared to the other group (n=214). Adding more numbers to the post-centralisation cohort might influence the outcome.

– The outcome was measured in clinic at four months after discharge. Five cases in 2008 – 2011 group and eight cases in 2003-2007 group did not attend the clinic appointment; therefore the case notes had to be looked at to establish the outcome. Due to non-attendance, the outcome was not measured at four months, but as close to four months as possible.

– This study gives a short-term morbidity soon after the critical care as we are
assessing the patients only four months after the discharge. However similar studies looking at the long-term morbidity two years after the critical care has shown better outcomes⁸ with the majority reaching the pre-admission functional status. This suggests long-term morbidity figures might be different.

– Having a morbidity score for the pre-existing morbidity prior to PICU admission and another score after discharge from PICU would have helped us in better understanding of the outcome.

– Sample data is collected over a period of 8yrs (2003-2011). Due to the advancements in research and technology, medical care keeps changing over the time. It is difficult to establish how much this has influenced the results. Looking at our results, certainly the post-centralisation cohort (2008-2011) did not benefit from it.

Conclusion and future research:

In this study we have attempted to show the neurological outcome of critically ill children pre (2003-2007) and post centralisation (2008-2011). Similar to other studies there is a significant increase in children with neurodisability in the post-centralisation cohort. However we suggest doing more studies looking in to the most recent data with large sample size in the post-centralisation cohort.

References:

1. Gale Pearson, Frank Shann, Peter Barry, Julian Vyas, etal. Should paediatric intensive care be centralised? Trent versus Victoria, The Lancet; Apr26, 1997; Vol 349 1213-1217.

2. Murray M Pollack, Richard Holubkov, Tomohiko Funai, Amy Clark, etal.Paediatric Intensive Care Outcomes: Development of New Morbidities During Pediatric Critical Care, Pediatirc Crit Care Med 2014; 15:821-827.

 

3. MCrouchman L Rossiter, T Colaco, R Forsyth. A practical outcome scale for paediatric head injury Arch Dis Child 2001; 84:120-124.

4. PNamachivayam, Frank Shann, Lara Shekerdemian, Anna Taylor, Irene van Sloten, Carmel Delzoppo, Claire Daffey, Warwick Butt. Three decades of paediatric intensive care: Who was admitted, what happened in intensive care and what happened afterwards. Paed Critical Care medicine 2010, Vol 11, No 5.

 

5. http://www.picanet.org.uk/Audit/Annual-Reporting/Annual-Report-Archive.
6. Frank Shann, Gale Pearson, A. Slater, K. Wilkinson.  Paediatric Index of mortality (PIM): A mortality prediction model for children in intensive care. Intensive Care Medicine (1997) 23:201-207.

7. Padmanabhan Ramnarayan, Krish Thiru, Roger C Parslow, David A Harrison, Elizabeth S Draper, Kathy M Rowan Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study. Lancet 2010:376:698-704.

8. Volaki E, Sdougka M etal, Functional outcome following paediatric intensive care: Paediatric cerebral performance category and paediatric overall performance category during a prospective two year follow up period. The Greek E-Journal of Perioperative Medicine 2015; 13(a): 2-15.

9. Dayal, Parul etalImpact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children’s Hospital PICU. Pediatric Critical Care Medicine: June 2016 – Volume 17 – Issue 6 – p 516–521.

10. John M. Tilford, Pippa M. Simpson, etal. Volume–Outcome Relationships in Pediatric Intensive Care Units. Pediatrics; Aug 2000, Vol 106, Issue 2.
11. Dharmar M, Kuppermann N, Romano PS, etal Telemedicine consultations and medication errors in rural emergency departments. Pediatrics 2013; 132:1090–1097.
12. Balamuth F., Weiss S.L., Fitzgerald J.C., Hayes K., etal Protocolized Treatment Is Associated with Decreased Organ Dysfunction in Pediatric Severe Sepsis. Pediatric Critical Care Medicine. 17 (9) (pp 817-822), 2016. Date of Publication: 01 Sep 2016.
13.Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M. Impact of quality-of-care factors on pediatric intensive care unit mortality.. JAMA. 1994 Sep 28; 272(12): 941-6.

14. Tenner PA, Dibrell H, Taylor RP. Improved Survival with hospitalists in a paediatric intensive care unit. Critical Care Medicine 2003 Mar; 31(3): 847-52.

15 Patrícia T. Alievi, Paulo R. A. Carvalho, Eliana A. Trotta, Ricardo Mombelli Filho. The impact of admission to a paediatric intensive care unit assessed by means of global and cognitive performance scales. J Pediatric (Rio J). 2007; 83(6): 505-511.

16. Ruth A, McCracken CE, Fortenberry JD, Hall M, Simon HK, Hebbar KB.Pediatric severe sepsis: current trends and outcomes from the Pediatric Health Information Systems database. Ped Crit Care Med. 2014 Nov; 15(9): 828-38.
17.Lin JC, Spinella PC, Fitzgerald JC, Tucci M, Bush JL, Nadkarni VM, Thomas NJ, Weiss SL; Sepsis Prevalence, Outcomes, and Therapy Study Investigators.
New or Progressive Multiple Organ Dysfunction Syndrome in Pediatric Severe Sepsis: A Sepsis Phenotype With Higher Morbidity and Mortality.
Pediatric Crit Care Med. 2017 Jan; 18(1): 8-16.

18. F Aspesberro, R Mangione-smith, JJ Zimmerman. Health-related quality of life following pediatric critical illness. Intensive care Med (2015) 41:1235-1246.

19. Janssens L, Gorter JW, Ketelaar M,Kramer WLM, Holtslag HR. Health-related quality-of-life measures for long-term follow-up in children after major trauma. Qual Life Res17:701–713 (2008).
20. Janssens L, Gorter JW, Ketelaar M,Kramer WLM, Holtslag HR. Long-term health condition in major pediatric trauma: a pilot study (2009). J PedSurg 44:1591–1600.
21. Martin-Herz SP, Zatzick DF, McMahonRJ. Health-related quality of life in children and adolescents following traumatic injury: a review (2012). Clin ChildFam Psychol Rev 15(3):192–214.

22. Farris RW, Weiss NS, Zimmerman JJ (2013). Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial. Ped Crit Care Med 14:835–842

23. Namachivayam O, Taylor A, Montague T, Moran K et al (2012). Long-stay children in intensive care: long-term functional outcome and quality of life from a 20-yr institutional study. Pediatric Crit Care Med 13:520–528.
 

24. Buysse CM, Raat H, Hazelzet JA, Hop WC, Maliepaard M, Joosten KF (2008). Surviving meningococcal septic shock: health consequences and quality of life in children and their parents up to 2 years after pediatric intensive care unit discharge. Crit Care Med 36(2): 596–602.
25. Buysse C, Vermunt L, Raat H, Hazelzet JA (2010). Surviving meningococcal septic shock in childhood: longterm overall outcome and the effect on health-related quality of life. Crit Care 14(3): R124.

26. Edmond K, Dieye Y, Griffiths UK, Fleming J, Ba O, Diallo N, Mulholland K (2010). Prospective cohort study of disabling sequelae and quality of life in children with bacterial meningitis in urban Senegal. Pediatric Infect Dis J 29(11): 1023–1029.
 

27. Als LC, Nadel S, Cooper M, Pierce CM, Sahakian BJ et al (2013). Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children. Crit Care Med 41:1094–1103.
28 Buysse CM, Raat H, Hazelzet JA, Hop WC, Maliepaard M, Joosten KF (2008). Surviving meningococcal septic shock: health consequences and quality of life in children and their parents up to 2 years after pediatric intensive care unit discharge. Crit Care Med 36(2): 596–602.
29 Polic B, Mestrovic J, Markic J, Mestrovic M et al (2013). Long-term quality of life of patients treated inpaediatric intensive care unit. Eur J Pediatr 172:85–90.
30 Feudtner C, Christakis DA, Connell FA(2000) Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington. State, 1980–1997. Pediatrics 106(1 Pt2): 205–209.

31. Mestrovic J, Kardum G, Sustic A, PolicB et al (2007) Neuro -developmental disabilities and quality of life after intensive care treatment. J Paediatr Child Health 43:673–676.
 

32. Jones S, Rantell K, Stevens K, Colwell et al (2006) Outcome at 6 months after admission for pediatric intensive care: a report of a national study of pediatric intensive care units in the United Kingdom. Pediatrics 118:2101.

33 Dosa NP, Boeing NM, Ms N, KanterRK (2001) Excess risk of severe acute illness in children with chronic health conditions. Pediatrics 107(3): 499–504.
34. Odetola FO, Gebremariam A, Davis MM (2010) Comorbid illnesses among critically ill hospitalized children: impact on hospital resource use and mortality, 1997–2006. Pediatr Crit Care Med 11(4):457–463.
35. Burns KH, Casey PH, Lyle RE, Bird TM, Fussell JJ, Robbins JM (2010) Increasing prevalence of medically complex children in US hospitals. Pediatrics 126(4): 638–646.
36. Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, Visser S, Kogan MD (2011) Trends in the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics127 (6): 1034–1042.
37. Edwards JD, Houtrow AJ, Vasilevskis EE, Rehm RS, Markovitz BP, Graham RJ, Dudley RA (2012) Chronic conditions among children admitted to U.S. pediatric intensive care units: their prevalence and impact on risk for mortality and prolonged length of stay. Crit Care Med 40(7): 2196–2203.

38. Cunha F, Almeida-Santos L, Teixeira- Pinto A, Neves F et al (2012) Health related quality of life of pediatric intensive care survivors. J Pediatr 88(1): 25–32.
39. Typpo KV, Petersen NJ, Petersen LA, Mariscalco MM (2010) Children with chronic illness return to their baseline functional status after organ dysfunction on the first day of admission in the pediatric intensive care unit. J Pediatr 157:108–113.
40. Matos RI, Watson RS, Nadkarni VM, Huang HH et al (2013) Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation 127:442–451.
41. Ebrahim S, Singh S, Hutchinson JS, Kulkarni AV et al (2013) Adaptive behavior, functional outcomes, and quality of life outcomes of children requiring urgent ICU admission. Pediatric Crit Care Med 14:10–18.
42. Polic B, Mestrovic J, Markic J, Mestrovic M et al (2013) Long-term quality of life of patients treated in paediatric intensive care unit. Eur J Pediatr 172:85–90.

43. Conlon NP, Breatnach C, O’Hare BP, Mannion DW, Lyons BJ (2009) Health related quality of life after prolonged pediatric intensive care unit stay. Pediatr Crit Care Med 10:41–44.

44. Pollack MM, Wilkinson JD, Glass NL (1987) Long-stay pediatric intensive care unit patients: outcome and resource utilization. Pediatrics 80:855–860
45. Butt WW (2009) Outcome assessment—what outcome do we want? Pediatric Crit Care Med 10(1): 133–134.
46. Marcin JP, Slonim AD, Pollack MM, Ruttimann UE (2001) Long-stay patients in the pediatric intensive care unit. Crit Care Med 29:652–657.

47. Namachivayam O, Taylor A, Montague T, Moran K et al (2012) Long-stay children in intensive care: long-term functional outcome and quality of life from a 20-yr institutional study. Pediatric Crit Care Med 13:520–528.

 

48. Rennick JE, Johnson CC, Dougherty G, Platt R, Ritchie JA (2002) Children’s psychological responses after critical illness and exposure to invasive technology. J Dev Behav Pediatr 23:133–144.

49 Guerra GG, Robertson CMT, Alton GY, Joffe AR, Moez EK, Dinu IA, Ross DB, Rebeyka IM, Lequier L, Western Canadian Complex Pediatric Therapies Follow-Up Group (2014) Health-related quality of life in pediatric cardiac extracorporeal life support survivors. Pediatric Crit Care Med 15:720–727.

50. Segun Toyin Dawodu. Traumatic Brain Injury (TBI) – Definition and Pathophysiology.  http://emedicine.medscape.com/article/326510-overview.

51. Monitoring and interpretation of intracranial pressure M Czosnyka, J D Pickard J Neurol Neurosurg Psychiatry 2004; 75:813–821.