Trends in long-stay admissions to a UK paediatric intensive care unit.

OBJECTIVE: Prolonged admission to a paediatric intensive care unit (PICU) consumes significant healthcare resource. An increase in the number of long-stay admissions and bed utilisation has been reported elsewhere in the world but not in the UK. If an increasing trend of long-stay admissions is evident, this may have significant implications for provision of paediatric intensive care in the future. DESIGN/SETTING/PATIENTS: We retrospectively analysed prospectively collected data from Birmingham Children's Hospital, UK, over a 20-year period from 1998 to 2017. PICU admissions, bed-days, length of stay and mortality trends were analysed and reported over four different epochs (1998-2002, 2003-2007, 2008-2012 and 2013-2017) for long-stay admissions (PICU length of stay ≥28 days) and others. Differences in patient demographics, diagnostic categorisation and hospital utilisation were also analysed. RESULTS: In total, 24 203 admissions accounted for 131 553 bed-days over the 20-year period. 705 (2.9%) long-stay admissions accounted for 42 312 (32%) bed-days. Proportion of long-stay admissions and corresponding bed-days increased from 1.6% and 20.5% in 1998-2002 to 4.5% and 42.6%, respectively, in 2013-2017 (p<0.001). Long-stay patients had a significantly higher number of hospital admissions (median: 4 vs 2, p<0.001) per patient and overall hospital length of stay (median: 98 vs 15, p<0.001) bed-days compared with other patients. Long-stay admissions were associated with significantly higher crude mortality (23% vs 6%, p<0.001) compared with other admissions. CONCLUSIONS: A significant increase in the proportion of prolonged PICU admissions with disproportionately high resource utilisation and mortality is evident over two decades.

Calculating the need for intensive care beds.

AIM: Prompted by high refused admission rates, we sought to model demand for our 20 bed paediatric intensive care unit. METHODS: We analysed activity (admissions) and demand (admissions plus refused admissions). The recommended method for calculating the required number of intensive care beds assumes a Poisson distribution based upon the size of the local catchment population, the incidence of intensive care admission and the average length of stay. We compared it to the Monte Carlo method which would also include supra-regional referrals not otherwise accounted for but which, due to their complexity, tend to have a longer stay than average. For the new method we assigned data from randomly selected emergency admissions to the refused admissions. We then compared occupancy scenarios obtained by random sampling from the data with replacement. RESULTS: There was an increase in demand for intensive care over time. Therefore, in order to provide an up-to-date model, we restricted the final analysis to data from the two most recent years (2327 admissions and 324 refused admissions). The conventional method suggested 27 beds covers 95% of the year. The Monte Carlo method showed 95% compliance with 34 beds, with seasonal variation quantified as 30 beds needed in the summer and 38 in the winter. CONCLUSION: Both approaches suggest that the high refused admission rate is due to insufficient capacity. The Monte Carlo analysis is based upon the total workload (including supra-regional referrals) and predicts a greater bed requirement than the current recommended approach.

Hospital facilities for head injured children: UK national survey.

AIM: To assess how child emergency department (ED) attendances are distributed between hospitals across England, Wales and Northern Ireland and how care is organised for children with a head injury. METHODS: A cross-sectional survey was performed of the 245 hospitals in England Wales, Northern Ireland and the Crown Dependencies (Channel Islands and Isle of Man) which were eligible to participate in the enquiry from September 2009 to April 2010. The survey covered hospital details, departments and procedures, ED activity, imaging, admission and discharge procedures, referral and transfer, documentation, training and audit, information and advice, and non-accidental head injuries. RESULTS: 64% of hospitals have an established pathway for management of head injured children. Not infrequently hospitals asserting designation as specialist trauma or specialist neurosurgical centres do not offer an intensive care service for children. 82% of child ED attendances are to hospitals that would not care for a critically ill child on-site. Hospitals that do offer such care are much more likely to have children's trained staff available in the ED. They are also more likely to have access to surgical support beyond neurosurgery. CONCLUSION: Given the extent of variation between hospitals in the facilities available for head injured children, further comparative studies into the standards of care delivered and outcomes (including a confidential enquiry) are indicated.

Ambulance provision for children: a UK national survey.

BACKGROUND: The purpose of this national survey of UK ambulance services was to provide an up-to-date assessment of service provision for children in the prehospital setting and to identify the challenges faced in providing optimal services to this group. METHODS: Questionnaires were sent to clinical directors of the 16 UK NHS ambulance services in April 2009. RESULTS: Questionnaires were returned by 13 (81%) respondents. Paramedics and most emergency medical technicians receive a limited amount of paediatric training. An increasing amount of equipment suitable for children is becoming available, but services for children vary depending on location. For example, paediatric airway adjuncts (short of intubation) were often lacking, and only 62% reported having pulse oximetry suitable for use in children. Four or the 13 respondents (31%) considered it 'possible or highly likely' that someone with no specific training could be the first to respond to a child in an emergency, and seven (54%) indicated that the likelihood that the first response to a child could be someone with no current qualification specific to paediatrics was 'high'. There are large areas of the country where no formal medical support is available at any time of day. CONCLUSIONS: Despite improvements, paediatric care by front-line personnel is limited by resource and availability of staff with key skills. Accepted standards are often lacking. Collaborative audit, research and training initiatives should be carried out between services and acute trusts to meet local service requirements. This will reduce variation and maintain the safety of patients and quality of care.

Paediatric intensive care: out of commission.

Problems with commissioning paediatric intensive care stem both from difficulties in recruitment and retention of nurses, and from incoherent or nonexistent national audit. Pyramidal career structures and patterns of remuneration that concentrate on administrative responsibility over clinical skills underlie the former, whereas poor audit conceals variations in both service quality and demand. Epidemiologically superior data are required if we are to solve commissioning problems. We need to know what happened to every child from a defined population receiving intensive care and whether a lack of resources means that some children are denied intensive care.