Association Between Centralization and Outcome for Children Admitted to Intensive Care in Australia and New Zealand: A Population-Based Cohort Study.

OBJECTIVES: To describe regional differences and change over time in the degree of centralization of pediatric intensive care in Australia and New Zealand (ANZ) and to compare the characteristics and ICU mortality of children admitted to specialist PICUs and general ICUs (GICUs). DESIGN: A retrospective cohort study using registry data for two epochs of ICU admissions, 2003-2005 and 2016-2018. SETTING: Population-based study in ANZ. PATIENTS: A total of 43,256 admissions of children aged younger than 16 years admitted to an ICU in ANZ were included. Infants aged younger than 28 days without cardiac conditions were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was risk-adjusted ICU mortality. Logistic regression was used to investigate the association of mortality with the exposure to ICU type, epoch, and their interaction. Compared with children admitted to GICUs, children admitted to PICUs were younger (median 25 vs 47 mo; p < 0.01) and stayed longer in ICU (median 1.6 vs 1.0 d; p < 0.01). For the study overall, 93% of admissions in Australia were to PICUs whereas in New Zealand only 63% of admissions were to PICUs. The adjusted odds of death in epoch 2 relative to epoch 1 decreased (adjusted odds ratio [AOR], 0.50; 95% CI, 0.42-0.59). There was an interaction between unit type and epoch with increased odds of death associated with care in a GICU in epoch 2 (AOR, 1.63; 95% CI, 1.05-2.53 for all admissions; 1.73, CI, 1.002-3.00 for high-risk admissions). CONCLUSIONS: Risk-adjusted mortality of children admitted to specialist PICUs decreased over a study period of 14 years; however, a similar association between time and outcome was not observed in high-risk children admitted to GICUs. The results support the continued use of a centralized model of delivering intensive care for critically ill children.

Multi-incident analysis of reviews of serious adverse clinical events in children with serious bacterial infection and/or sepsis in Queensland, Australia between 2012 and 2017.

AIM: To report on findings from a multi-incident analysis of reviews of serious paediatric adverse clinical events related to serious bacterial infection and/or sepsis (hereafter referred to as sepsis for brevity) in Queensland, Australia, between 2012 and 2017. METHODS: The Queensland Paediatric Quality Council reviewed documentation from reviews of serious adverse events occurring in children (<18 years) with a diagnosis of sepsis at Queensland public hospitals between 2012 and 2017, including clinical details, coronial reports, autopsy reports and root cause analysis documents. A multi-incident tool was designed and used by an expert panel to identify patient and facility demographics, contributing factors, and human and system factors associated with paediatric serious adverse events. RESULTS: There were 28 serious adverse clinical events reported related to paediatric sepsis, characterised by a high proportion of deaths (23) and a predominance of children aged under 4 years. Approximately half of all facilities were classified as rural and remote health services. Contributing factors included difficulty in recognising and responding to the deteriorating patient, inadequate management/treatment, diagnostic error (mainly diagnostic delay) and escalation delay/failure. Major system factors included communication issues, incorrect use of the early warning tool, inadequate coordination of care planning, policy/protocol/guideline failures and workforce problems. CONCLUSION: Multi-incident analysis is a useful tool for identifying themes that recur in similar events and presents opportunities for system-wide improvement. Common themes and contributing factors were identified which may provide possibilities for earlier identification and intervention in childhood serious bacterial infection and/or sepsis.

Queensland Paediatric Cardiac Service: Lessons from evolution to a unified service in a tertiary children's hospital.

We describe a complex change process for the paediatric cardiac service in Queensland that involved transitioning the service out of an essentially adult hospital into one of two children's hospitals in Brisbane. This initial step was complex as the governance was changed from Queensland Health to Mater Health, an independent faith-based organisation who became the new employer. Six years later, the service was again transitioned; this time to the newly constructed Queensland Children's Hospital, with a Hospital and Health Services Board as the employer under the aegis of Queensland Health. This was a complex journey. As with all change processes there was resistance to change on the part of some individuals. Five years on from the second major change, the service is settled, has an excellent workplace culture, has excellent clinical outcomes and has become research intensive.

Implementation and strength of root cause analysis recommendations following serious adverse events involving paediatric patients in the Queensland public health system between 2012 and 2014.

AIM: This study evaluates the implementation rate and strength of the recommendations developed in all root cause analyses (RCAs) performed following serious clinical incidents involving children that have resulted in permanent harm or death in Queensland public hospitals over a 3-year period. METHODS: Severity assessment classification 1 events were identified from a Queensland Paediatric Quality Council database of paediatric clinical incidents that occurred in Queensland between 1 January 2012 and 31 December 2014. There were 150 recommendations extracted from RCAs pertaining to the 42 serious adverse events involving paediatric patients. RESULTS: Of the recommendations, 82% were implemented; 33% of recommendations were classified as stronger, 33% as intermediate and 34% weaker in terms of their potential to improve patient safety. CONCLUSIONS: This study describes the implementation of recommendations and classifies them in terms of potential to prevent patient harm and save lives. Future research is needed to determine if the RCA process does indeed prevent harm.

Diagnostic testing in influenza and pertussis related paediatric intensive care unit admissions,Queensland, Australia, 1997-2013.

Severe respiratory infections make up a large proportion of Australian paediatric intensive care unit (ICU) admissions each year. Identification of the causative pathogen is important and informs clinical management. We investigated the use of polymerase chain reaction (PCR) in the ICU-setting using data collated by the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry from five ICUs in Queensland, Australia. We describe diagnostic testing use among pertussis and influenza-related paediatric ICU admissions between 01 January 1997 and 31 December 2013.

The effectiveness of telemedicine for paediatric retrieval consultations: rationale and study design for a pragmatic multicentre randomised controlled trial.

BACKGROUND: In many health systems, specialist services for critically ill children are typically regionalised or centralised. Studies have shown that high-risk paediatric patients have improved survival when managed in specialist centres and that volume of cases is a predictor of care quality. In acute cases where distance and time impede access to specialist care, clinical advice may be provided remotely by telephone. Emergency retrieval services, attended by medical and nursing staff may be used to transport patients to specialist centres. Even with the best quality retrieval services, stabilisation of the patient and transport logistics may delay evacuation to definitive care. Several studies have examined the use of telemedicine for providing specialist consultations for critically ill children. However, no studies have yet formally examined the clinical effectiveness and economic implications of using telemedicine in the context of paediatric patient retrieval. METHODS/DESIGN: The study is a pragmatic, multicentre randomised controlled trial running over 24 months which will compare the use of telemedicine with the use of the telephone for paediatric retrieval consultations between four referring hospitals and a tertiary paediatric intensive care unit. We aim to recruit 160 children for whom a specialist retrieval consultation is required. The primary outcome measure is stabilisation time (time spent on site at the referring hospital by the retrieval team) adjusted for initial risk. Secondary outcome measures are change in patient's physiological status (repeated measure, two time points) scored using the Children's Emergency Warning Tool; change in diagnosis (repeated measure taken at three time points); change in destination of retrieved patients at the tertiary hospital (general ward or paediatric intensive care unit); retrieval decision, and length of stay in the Paediatric Intensive Care Unit for retrieved patients. The trial has been approved by the Human Research Ethics Committees of Children's Health Services Queensland and The University of Queensland, Australia. DISCUSSION: Health services are adopting telemedicine, however formal evidence to support its use in paediatric acute care is limited. Generalisable evidence is required to inform clinical use and health system policy relating to the effectiveness and economic implications of the use in telemedicine in paediatric retrieval. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12612000156886 .

Decision-making for children requiring interhospital transport: assessment of a novel triage tool.

OBJECTIVE: The use of specialist retrieval teams to transport critically ill children is associated with reduced risk-adjusted mortality and morbidity; however, there is a paucity of data to guide decision-making related to retrieval team activation. We aimed to assess the accuracy of a novel triage tool designed to identify critically ill children at the time of referral for interhospital transport. DESIGN: Prospective observational study. SETTING: Regional paediatric retrieval and transport services. PATIENTS: Data were collected for 1815 children referred consecutively for interhospital transport from 87 hospitals in Queensland and northern New South Wales. INTERVENTION: Implementation of the Queensland Paediatric Transport Triage Tool. MAIN OUTCOME MEASURES: Accuracy was assessed by calculating the sensitivity, specificity and negative predictive value for predicting transport by a retrieval team, or admission to intensive care following transport. RESULTS: A total of 574 (32%) children were transported with a retrieval team. Prediction of retrieval (95% CIs): sensitivity 96.9% (95% CI 95.1% to 98.1%), specificity 91.4% (95% CI 89.7% to 92.9%), negative predictive value 98.4% (95% CI 97.5% to 99.1%). There were 412 (23%) children admitted to intensive care following transport. Prediction of intensive care admission: sensitivity 96.8% (95% CI 94.7% to 98.3%), specificity 81.2% (95% CI 79.0% to 83.2%), negative predictive value 98.9% (95% CI 98.1% to 99.4%). CONCLUSIONS: The triage tool predicted the need for retrieval or intensive care admission with high sensitivity and specificity. The high negative predictive value indicates that, in our setting, children categorised as acutely ill rather than critically ill are generally suitable for interhospital transport without a retrieval team.

Changing patterns in paediatric medical emergency team (MET) activations over 20 years in a single specialist paediatric hospital.

BACKGROUND: The Medical Emergency Team (MET) model was first introduced in the early 1990s and aimed to intervene at an earlier stage of patient clinical deterioration. This study aimed to describe the changes in patient demographics, patterns of activation and clinical outcomes of MET activations at our specialist paediatric hospital across a 20-year period providing the longest duration Medical Emergency Team data set published to date. METHODS: This single-centre observational study prospectively collected data about MET events at a single specialist paediatric hospital in Australia from 1995 to 2014. Patient demographics, activation patterns and clinical outcomes from MET activations were analysed for the 20-year period. RESULTS: 771 MET events were included in analysis. Most MET events involved children aged <5 years (median age 36 months) with decreased incidence on weekends and night shift. The most frequent reasons stated for MET activation were seizure and respiratory compromise and the most commonly recorded MET interventions were bag-valve-mask ventilation and intravascular access. There was an increase in MET event frequency (MET events per 1000 hospital separations) in the second decade of the service compared to the first (3.25 vs 1.42, p â€‹< â€‹0.001) with fewer events for cardiopulmonary arrest but more for respiratory, cardiovascular or neurological compromise. CONCLUSIONS: This study describes the longest duration MET data set published to date. The 20-year span of data demonstrates increased utilisation of the MET system and activation for patients earlier in their deterioration. The data should inform both health service planning and educational requirements for MET providers.

Epidemiology of pertussis-related paediatric intensive care unit (ICU) admissions in Australia, 1997-2013: an observational study.

OBJECTIVE: To review the epidemiology of pertussis-related intensive care unit (ICU) admissions across Australia, over a 17-year period. DESIGN: Retrospective descriptive study. SETTING: Australian ICUs contributing data to the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry. The number of contributing ICUs increased over the study period, from 8 specialist paediatric ICUs in 1997 to 8 specialist paediatric and 13 general ICUs in 2013. PARTICIPANTS: All paediatric (<16 years) ICU admissions, coded as pertussis-related, between 1 January 1997 and 31 December 2013. RESULTS: A total of 373 pertussis-coded ICU admissions were identified in the ANZPIC Registry over the study period. Of these cases, 52.8% occurred during the 4 years of the recent Australian epidemic (2009-2012). ICU admissions were most likely to occur in infants aged younger than 6 weeks (41.8%, n=156) and aged 6 weeks to 4 months (42.9%, n=160). The median length of stay for pertussis-related ICU admissions was 3.6 days, with 77.5% of cases staying in ICU for <7 days. Approximately half of all admissions (54.8%) required some form of respiratory support, with 32.7% requiring invasive respiratory support. Over the study period, 23 deaths were recorded (6.2% of pertussis-related ICU admissions), of which 20 (87.0%) were infants <4 months old. CONCLUSIONS: Pertussis-related ICU admissions occur primarily in infants too young to be fully protected from active immunisation. More needs to be done to protect these high-risk infants, such as maternal immunisation.

Epidemiology of Australian Influenza-Related Paediatric Intensive Care Unit Admissions, 1997-2013.

BACKGROUND: Influenza virus predictably causes an annual epidemic resulting in a considerable burden of illness in Australia. Children are disproportionately affected and can experience severe illness and complications, which occasionally result in death. METHODS: We conducted a retrospective descriptive study using data collated in the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry of influenza-related intensive care unit (ICU) admissions over a 17-year period (1997-2013, inclusive) in children <16 years old. National laboratory-confirmed influenza notifications were used for comparison. RESULTS: Between 1997 and 2013, a total of 704 influenza-related ICU admissions were recorded, at a rate of 6.2 per 1,000 all-cause ICU admissions. Age at admission ranged from 0 days and 15.9 years (median = 2.1 years), with 135 (19.2%) aged <6 months. Pneumonia/pneumonitis and bronchiolitis were the most common primary diagnoses among influenza-related admissions (21.9% and 13.6%, respectively). More than half of total cases (59.2%) were previously healthy (no co-morbidities recorded), and in the remainder, chronic lung disease (16.7%) and asthma (12.5%) were the most common co-morbidities recorded. Pathogen co-detection occurred in 24.7% of cases, most commonly with respiratory syncytial virus or a staphylococcal species. Median length of all ICU admissions was 3.2 days (range 2.0 hours- 107.4 days) and 361 (51.3%) admissions required invasive respiratory support for a median duration of 4.3 days (range 0.2 hours- 107.5 days). There were 27 deaths recorded, 14 (51.9%) in children without a recorded co-morbidity. CONCLUSION: Influenza causes a substantial number of ICU admissions in Australian children each year with the majority occurring in previously healthy children.

National study of infants hospitalized with pertussis in the acellular vaccine era.

BACKGROUND: In Australia in 1999 acellular pertussis vaccine (DTPa) replaced locally manufactured whole cell vaccine given at 2, 4 and 6 months of age with coverage of about 95% by 12 months of age. Few data are available on pertussis hospitalizations or sources of infection in countries exclusively using DTPa. METHODS: In 2001 national active monthly surveillance of infant hospitalizations for pertussis was conducted through the Australian Pediatric Surveillance Unit, which surveys all child health specialists monthly. A standard questionnaire was completed for notified cases. RESULTS: There were 140 infants reported (median age at diagnosis, 8 weeks). The rate of hospitalization in indigenous infants was significantly higher than in nonindigenous infants (P < 0.01). Of 97 (69%) infants who had not been vaccinated for pertussis, 63 (65%) were <8 weeks old (before the first scheduled dose of DTPa vaccine). Of 76 infants age > or =8 weeks, only 28 (37%) were appropriately immunized for age. Of 68 coughing contacts whose ages were known, 46 (68%) were adults, usually one of the infant's parents. Of 32 child contacts 16 (50%) were siblings. Four infants <6 weeks old died. CONCLUSION: Despite universal vaccination with DTPa in Australia, pertussis remains an important cause of hospitalization, morbidity and death in infants, most of whom were too young to be vaccinated or had missed vaccinations. The most common source of infection was a parent. Strategies to improve pertussis control in countries with high DTPa coverage could include adult-formulated booster pertussis vaccines for adolescents and recent parents and/or accelerated pertussis vaccine schedules for infants.

The ANZPIC registry diagnostic codes: a system for coding reasons for admitting children to intensive care.

OBJECTIVE: To describe the uniform diagnostic coding system used in Australia and New Zealand to code reasons for admitting children to intensive care, and to highlight the benefits of a uniform approach. DESIGN: International, multicentre, observational study. SETTING: A registry of children admitted to intensive care in Australia and New Zealand. PATIENTS: The records of 19249 children admitted to intensive care between 1997 and 2000 were analysed. MEASUREMENTS AND RESULTS: The system was designed empirically using expert consensus. The principal diagnosis or main reason for intensive care admission and up to five associated diagnoses are coded. The system has four levels of coding: non-operative or post-procedural admission, diagnostic group, specific condition, and for injury and infection the aetiological factor. The main reason for intensive care admission was coded in all patient records, however, for 11.1% of records the code was limited to diagnostic group with the specific condition coded as "other diagnosis". Two or more diagnoses were coded in 61% of records. The most frequent reason for admission was asthma. CONCLUSIONS: The major advantage of the system is that units in the region use the same method of coding. A uniform international approach to coding reasons for admitting children to intensive care is needed.