Sociodemographic Factors and the Risk of Pediatric Out-of-Hospital Cardiac Arrest in Ontario, Canada: A Province-Wide Case-Control Study.

BACKGROUND: Pediatric out-of-hospital cardiac arrest (POHCA) is associated with significant mortality and poor neurological outcomes. We aimed to describe the association between sociodemographic factors and POHCA risk in Ontario, Canada. METHODS AND RESULTS: We conducted a province-wide case-control study at ICES, where patient records are linked across administrative databases. The case group included children (aged 1 day to 17 years) who experienced an out-of-hospital cardiac arrest between 2004 and 2020. Controls were matched up to 1:4 on age, sex, index date, and key comorbidities. We used conditional logistic regression to measure the association between sociodemographic indicators and POHCA risk. The case and control groups included 1826 and 7254 children, respectively. Children living in areas with the highest levels of material deprivation (adjusted odds ratio [aOR], 2.35 [95% CI, 1.94-2.85]) and dependency (aOR, 1.22 [95% CI, 1.01-1.48]) had a higher odds of POHCA, relative to children living in regions with the lowest levels of material deprivation and dependency, respectively. Children living in neighborhoods with the lowest levels of ethnic diversity had a higher odds of POHCA (aOR, 1.62 [95% CI, 1.30-2.01]), relative to children living in neighborhoods with the highest levels of ethnic diversity. The odds of POHCA were lower in immigrants (aOR, 0.67 [95% CI, 0.47-0.95]), relative to the general population. Northern urban residence was associated with a higher odds of POHCA (aOR, 1.45 [95% CI, 1.13-1.87]), relative to southern urban residence. CONCLUSIONS: Children living in neighborhoods with high levels of marginalization may have an elevated risk of experiencing POHCA. These findings highlight the importance of addressing disparities through targeted prevention and intervention efforts.

Epidemiology of paediatric out-of-hospital cardiac arrest in Ontario, Canada.

Background: There are no Canadian epidemiological studies of Paediatric Out-of-Hospital Cardiac Arrest (POHCA) for ≥20 years. Understanding the epidemiology of POHCA is key to prevention, education, and management strategies. Methods: We applied a validated algorithm to hospital administrative databases to describe paediatric (age 1 day to ≤18 years) atraumatic OHCA in Ontario from 2004-2020. Results: The cohort included 1,839 paediatric patients with atraumatic POHCA occurring at a median (IQR) age of 2 (0-12) years with 721 (39.2%) POHCA events in <1-year-olds. Males accounted for 71.1% (n = 1123) of the cohort. Crude incidence of children with POHCA who were transported to an Emergency Department was 4.2/100,000 with an increase annually over the study period (p = 0.0065). Thirty percent (n = 560) lived in a neighbourhood with the lowest income quintile, while 13.6% (n = 251) lived in a neighbourhood with the highest income quintile, 78.6% (n = 1444) presented to a non-academic hospital, and the majority (n = 1533, 83.4%) did not have significant comorbidities. Survival to hospital discharge was achieved in 167 (9.1%). Less than 6 (<3.6%) patients had a repeat POHCA in the year following the index event. Conclusions: This is the largest Canadian POHCA cohort and the first to describe its incidence, comorbidities, and sociodemographic characteristics. We found an increase in annual crude incidence, POHCA mostly occurred in healthy children, and survival was similar to other cohorts. There were more than double the number of POHCA events in children living in the lowest income quintile neighborhoods compared to the highest. Most children presented to non-academic hospitals first.

Evaluation of hospital management of paediatric out-of-hospital cardiac arrest.

Introduction: Pediatric out of hospital cardiac arrest (POHCA) is rare, with high mortality and neurological morbidity. Adherence to Pediatric Advanced Life Support guidelines standardizes in-hospital care and improves outcomes. We hypothesized that in-hospital care of POHCA patients was variable and deviations from guidelines were associated with higher mortality. Methods: POHCA patients in the London-Middlesex region between January 2012 and June 2020 were included. The care of children with ongoing arrest (intra-arrest) and post-arrest outcomes were reviewed using the Children's Hospital, London Health Sciences Centre (LHSC) patient database and the Adverse Event Management System. Results: 50 POHCA patients arrived to hospital, with 15 (30%) patients admitted and 2 (4.0%) surviving to discharge, both with poor neurological outcomes and no improvement at 90 days. Deviations occurred at every event with intra-arrest care deviations occurring mostly in medication delivery and defibrillation (98%). Post-arrest deviations occurred mostly in temperature monitoring (60%). Data missingness was 15.9% in the intra-arrest and 1.7% in the post-arrest group. Discussion: Deviations commonly occurred in both in-hospital arrest and post-arrest care. The study was under-powered to identify associations between DEVs and outcomes. Future work includes addressing specific deviations in intra-arrest and post-arrest care of POHCA patients and standardizing electronic documentation.

Sociodemographic factors associated with paediatric out-of-hospital cardiac arrest: A systematic review.

BACKGROUND: Paediatric out-of-hospital cardiac arrest (POHCA) is associated with poor survival and severe neurological sequelae. We conducted a systematic review on the impact of sociodemographic factors across different stages of POHCA. METHODS: We searched MEDLINE, EMBASE, and Web of Science from database inception to October 2022. We included studies examining the association between sociodemographic factors (i.e., race, ethnicity, migrant status and socioeconomic status [SES]) and POHCA risk, bystander cardiopulmonary resuscitation (CPR) provision, bystander automated external defibrillator (AED) application, survival (at or 30-days post-discharge), and neurological outcome. We synthesized the data qualitatively. RESULTS: We screened 11,097 citations and included 18 articles (arising from 15 studies). There were 4 articles reporting on POHCA risk, 5 on bystander CPR provision, 3 on bystander AED application, 13 on survival, and 6 on neurological outcome. In all studies on POHCA risk, significant differences were found across racial groups, with minority populations being disproportionately impacted. There were no articles reporting on the association between SES and POHCA risk. Bystander CPR provision was consistently associated with race and ethnicity, with disparities impacting Black and Hispanic children. The association between bystander CPR provision and SES was variable. There was little evidence of socioeconomic or racial disparities in studies on bystander AED application, survival, and neurological outcome, particularly across adjusted analyses. CONCLUSIONS: Race and ethnicity are likely associated with POHCA risk and bystander CPR provision. These findings highlight the importance of prioritizing at-risk groups in POHCA prevention and intervention efforts. Further research is needed to understand underlying mechanisms.

"We Aren't Meant to Go Through the Hardest Parts of Our Lives Alone": Family Experience With Restricted PICU Presence During the COVID-19 Pandemic.

CONTEXT: PICUs across Canada restricted family presence (RFP) in response to the COVID-19 pandemic from allowing two or more family members to often only one family member at the bedside. The objective of this study was to describe the experiences and impact of RFP on families of critically ill children to inform future policy and practice. HYPOTHESIS: RFP policies negatively impacted families of PICU patients and caused moral distress. METHODS AND MODELS: National, cross-sectional, online, self-administered survey. Family members of children admitted to a Canadian PICU between March 2020 and February 2021 were invited to complete the survey. RFP-attributable distress was measured with a modified distress thermometer (0-10). Closed-ended questions were reported with descriptive statistics and multivariable linear regression assessed factors associated with RFP-attributable distress. Open-ended questions were analyzed using inductive content analysis. RESULTS: Of 250 respondents who experienced RFP, 124 (49.6%) were restricted to one family member at the bedside. The median amount of distress that families attributed to RFP policies was 6 (range: 0-10). Families described isolation, removal of supports, and perception of trauma related to RFP. Most families (183, 73.2%) felt that policies were enforced in a way that made them feel valued by PICU clinicians, which was associated with less RFP-attributable distress. Differential impact was seen where families with lower household income indicated higher RFP-attributable distress score (2.35; 95% CI, 0.53-4.17; p = 0.03). Most respondents suggested that future policies should allow at least two family members at the bedside. INTERPRETATIONS AND CONCLUSIONS: Families of children admitted to PICUs during the COVID-19 pandemic described increased distress, trauma, and removal of supports due to RFP policies. Vulnerable families showed an increased odds of higher distress. Healthcare professionals played an important role in mitigating distress. Allowance of at least two family members at the bedside should be considered for future policy.

Evaluation of Local Pediatric Out-of-Hospital Cardiac Arrest and Emergency Services Response.

Background: Survival after pediatric out-of-hospital cardiac arrest is poor. Paramedic services provide critical interventions that impact survival outcomes. We aimed to describe local pediatric out-of-hospital cardiac arrest (POHCA) events and evaluate the impact of the paramedic service response to POHCA. Methods: The Canadian Resuscitation Outcomes Consortium and corresponding ambulance call records were used to evaluate deviations from best practice by paramedics for patients aged 1 day to <18 years who had an atraumatic out-of-hospital cardiac arrest between 2012 and 2020 in Middlesex-London County. Deviations were any departure from protocol as defined by Middlesex-London Paramedic Services. Results: Fifty-one patients were included in this study. All POHCA events had at least one deviation, with a total of 188 deviations for the study cohort. Return of spontaneous circulation (ROSC) was achieved in 35.3% of patients and 5.8% survived to hospital discharge. All survivors developed a new, severe neurological impairment. Medication deviations were most common (n = 40, 21.3%) followed by process timing (n = 38, 20.2%), vascular access (n = 27, 14.4%), and airway (n = 27, 14.4%). A delay in vascular access was the most common deviation (n = 25, 49.0%). The median (IQR) time to epinephrine administration was 8.6 (5.90-10.95) min from paramedic arrival. Cardiac arrests occurring in public settings had more deviations than private settings (p = 0.04). ROSC was higher in events with a deviation in any circulation category (p = 0.03). Conclusion: Patient and arrest characteristics were similar to other POHCA studies. This cohort exhibited high rates of ROSC and bystander cardiopulmonary resuscitation but low survival to hospital discharge. The study was underpowered for its primary outcome of survival. The total deviations scored was low relative to the total number of tasks in a resuscitation. Epinephrine was frequently administered outside of the recommended timeframe, highlighting an important quality improvement opportunity.

Validation of ICD-10 codes for the identification of paediatric out-of-hospital cardiac arrest patients.

AIM: There is a need for large-scale epidemiological studies of paediatric out-of-hospital cardiac arrest (POHCA). To enable this, we developed and validated international classification of disease (ICD-10) search algorithms for the identification of POHCA patients from health administrative data. METHODS: We validated the algorithms with a registry of POHCA (CanRoc) as the reference standard. The reference standard included all atraumatic POHCA in Middlesex-London region for January 2012-June 2020. All algorithms included 1 day to <18-year-old patients transported to emergency department (ED) by ambulance and excluded trauma. We tested three algorithms, which were applied to the National Ambulatory Care Reporting System and Discharge Abstract Database. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ration (NLR) were calculated for each algorithm. RESULTS: During the study period, 17,688 children presented to the ED by ambulance. The reference standard included 51 POHCA patients. The algorithm using only ICD-10 code for cardiac arrest had a sensitivity of 65.5% and PPV of 90%. The algorithm with the highest sensitivity of 87.3% added sudden infant death syndrome, drowning or asphyxiation with CPR in addition to the cardiac arrest codes for inpatient and ED records. This algorithm had a specificity of 99.9%, PPV of 81.4% and NPV of âˆ¼100.0%. CONCLUSION: It is important that algorithms used for cohort identification are validated prior to use. The ICD-10 code for cardiac arrest alone misses many POHCA cases but the use of additional codes can improve the sensitivity while maintaining specificity.

Clinical and Physiologic Factors Associated With Mode of Death in Pediatric Severe TBI.

Aims and Objectives: Severe traumatic brain injury (sTBI) is the leading cause of death in children. Our aim was to determine the mode of death for children who died with sTBI in a Pediatric Critical Care Unit (PCCU) and evaluate factors associated with mortality. Methods: We performed a retrospective cohort study of all severely injured trauma patients (Injury Severity Score ≥ 12) with sTBI (Glasgow Coma Scale [GCS] ≤ 8 and Maximum Abbreviated Injury Scale ≥ 4) admitted to a Canadian PCCU (2000-2016). We analyzed mode of death, clinical factors, interventions, lab values within 24 h of admission (early) and pre-death (48 h prior to death), and reviewed meeting notes in patients who died in the PCCU. Results: Of 195 included patients with sTBI, 55 (28%) died in the PCCU. Of these, 31 (56%) had a physiologic death (neurologic determination of death or cardiac arrest), while 24 (44%) had withdrawal of life-sustaining therapies (WLST). Median (IQR) times to death were 35.2 (11.8, 86.4) hours in the physiologic group and 79.5 (17.6, 231.3) hours in the WLST group (p = 0.08). The physiologic group had higher partial thromboplastin time (PTT) within 24 h of admission (p = 0.04) and lower albumin prior to death (p = 0.04). Conclusions: Almost half of sTBI deaths in the PCCU were by WLST. There was a trend toward a longer time to death in these patients. We found few early and late (pre-death) factors associated with mode of death, namely higher PTT and lower albumin.

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest.

INTRODUCTION: In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. METHODS: We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. RESULTS: There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86). CONCLUSIONS: Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Development of a Mortality Prediction Tool in Pediatric Severe Traumatic Brain Injury.

Severe traumatic brain injury (sTBI) is a leading cause of pediatric death, yet outcomes remain difficult to predict. The goal of this study was to develop a predictive mortality tool in pediatric sTBI. We retrospectively analyzed 196 patients with sTBI (pre-sedation Glasgow Coma Scale [GCS] score <8 and head Maximum Abbreviated Injury Scale (MAIS) score >4) admitted to a pediatric intensive care unit (PICU). Overall, 56 patients with sTBI (29%) died during PICU stay. Of the survivors, 88 (63%) were discharged home, and 52 (37%) went to an acute care or rehabilitation facility. Receiver operating characteristic (ROC) curve analyses of admission variables showed that pre-sedation GCS score, Rotterdam computed tomography (CT) score, and partial thromboplastin time (PTT) were fair predictors of PICU mortality (area under the curve [AUC] = 0.79, 0.76, and 0.75, respectively; p < 0.001). Cutoff values best associated with PICU mortality were pre-sedation GCS score <5 (sensitivity = 0.91, specificity = 0.54), Rotterdam CT score >3 (sensitivity = 0.84, specificity = 0.53), and PTT >34.5 sec (sensitivity = 0.69 specificity = 0.67). Combining pre-sedation GCS score, Rotterdam CT score, and PTT in ROC curve analysis yielded an excellent predictor of PICU mortality (AUC = 0.91). In summary, pre-sedation GCS score (<5), Rotterdam CT score (>3), and PTT (>34.5 sec) obtained on hospital admission were fair predictors of PICU mortality, ranked highest to lowest. Combining these three admission variables resulted in an excellent pediatric sTBI mortality prediction tool for further prospective validation.

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review.

CONTEXT: Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted. OBJECTIVE: To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation. DATA SOURCES: Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020. STUDY SELECTION: 3200 titles were retrieved in the initial search; 36 ultimately included for review. DATA EXTRACTION: Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology. RESULTS: The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child's resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority. LIMITATIONS: English language only; lack of randomized control trials; quality of the publications. CONCLUSIONS: Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes. PROSPERO REGISTRATION NUMBER: CRD42020140363.

Pediatric Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation.Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

Paediatric health care access in community health centres is associated with survival for critically ill children who undergo inter-facility transport: A province-wide observational study.

BACKGROUND: Diverse settlement makes inter-facility transport of critically ill children a necessary part of regionalized health care. There are few studies of outcomes and health care services use of this growing population. METHODS: A retrospective study evaluated the frequency of transports, health care services use, and outcomes of all critically ill children who underwent inter-facility transport to a paediatric intensive care unit (PICU) in Ontario from 2004 to 2012. The primary outcome was PICU mortality. Secondary outcomes were 24-hour and 6-month mortality, PICU and hospital lengths of stay, and use of therapies in the PICU. RESULTS: The 4,074 inter-facility transports were for children aged median (IQR) 1.6 (0.1 to 8.3) years. The rate of transports increased from 15 to 23 per 100,000 children. There were 233 (5.7%) deaths in PICU and an additional 78 deaths (1.9%) by 6 months. Length of stay was median (IQR) 2 (1 to 5) days in PICU and 7 (3 to 14) days in the receiving hospital. Lower PICU mortality was independently associated with prior acute care contact (odds ratio [OR]=0.3, 95% confidence interval [CI]: 0.2 to 0.6) and availability of paediatric expertise at the referral hospital (OR=0.7, 95% CI: 0.5 to 1.0). CONCLUSIONS: We found that in Ontario, children undergoing inter-facility transport to PICUs are increasing in number, consume significant acute care resources, and have a high PICU mortality. Access to paediatric expertise is a potentially modifiable factor that can impact mortality and warrants further evaluation.

Total Daily Production and Periodicity of Melatonin Metabolite in Critically Ill Children.

OBJECTIVES: To determine whether total daily 6-sulfatoxymelatonin excretion and diurnal variation of melatonin secretion was maintained during the early phase of PICU admission through examination of the melatonin urinary metabolite, 6-sulfatoxymelatonin. DESIGN: Exploratory prospective, observational study. SETTING: Twelve-bed medical-surgical PICU of a Children's Hospital. PATIENTS: Fifty children 3 months to 18 years old enrolled within 24 hours of PICU admission with access for urinary sampling. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Urine samples were collected at 4-hour intervals for 24 hours and stored at -80C. 6-sulfatoxymelatonin was determined in duplicate by direct enzyme-linked immunosorbent assay. Patients were heterogeneous for diagnosis, had a mean age of 8.1 years (SD = 6.1 yr), and median (interquartile range) Pediatric Risk of Mortality III of 10 (4-13). Mean (SD) total daily 6-sulfatoxymelatonin production was 30.0 µg (25.6 µg) for the first 24 hours, which did not differ significantly from the means on days 2 (p = 0.56) or 3 (p = 0.29), and was similar to literature controls. Mean 6-sulfatoxymelatonin production for the population fit a periodic function well, with a reliable amplitude of 326 ng/hr and peak excretion from 04:00 to 08:00 (F = 4.4, p = 0.01), even when 6-sulfatoxymelatonin was corrected for body weight (F = 3.4, p = 0.03) and when sedation was included in the model (F = 3.95, p = 0.004). There was no significant correlation between lighting and 6-sulfatoxymelatonin excretion at any time period (R values: 0.11-0.25, p = 0.10-0.94). Mean 6-sulfatoxymelatonin excretion did not fit the model for a periodic function well for the subpopulations studied (sepsis [n = 18, F = 1.1, p = 0.32], respiratory failure requiring deep sedation [n = 10, F = 0.4, p = 0.66], and neurologic injury [n = 7, F = 0.6, p = 0.55]). CONCLUSIONS: Total daily and diurnal variation of 6-sulfatoxymelatonin excretion is heterogeneously maintained early in pediatric critical illness. However, this may not hold true for specific diagnostic categories.

Impact of Deferring Critically Ill Children Away from Their Designated Pediatric Critical Care Unit: A Population-Based Retrospective Cohort Study.

BACKGROUND: The impact of deferring critically ill children in referral hospitals away from their designated pediatric critical care unit (PCCU) on patients and the healthcare system is unknown. We aimed to identify factors associated with deferrals and patient outcomes and to study the impact of a referral policy implemented to balance PCCU bed capacity with regional needs. METHODS: We conducted a population-based retrospective cohort study of admissions to a PCCU following inter-facility transport from 2004 to 2016 in Ontario, Canada. RESULTS: Of 10,639 inter-facility transfers, 24.8% (95% confidence interval [CI]: 23.5-26.1%) were deferred during pre-implementation and 16.0% (95% CI: 15.1-16.9%) during post-implementation of a referral policy. Several factors, including previous intensive care unit admissions, residence location, presenting hospital factors, patient co-morbidities, specific designated PCCUs and winter (versus summer) season, were associated with deferral status. Deferrals were not associated with increased mortality. CONCLUSIONS: Deferral from a designated PCCU does not confer an increased risk of death. Implementation of a referral policy was associated with a consistent referral pattern in 84% of transfers.