Despite strong arguments in favour of centralising care of critically ill children to paediatric intensive care units, around 2000 children per year are cared for in non-paediatric intensive care units in Australia and New Zealand. This paper reports a survey of consultants from 13 such units that admitted over 50 children in 2002 and 2003, to find out what factors affect the decision to keep critically ill children locally or transfer them to a paediatric intensive care unit and what infrastructure existed to support local care of these children. The results of this survey form the basis for a proposal to improve care of critically ill children in the non-paediatric intensive care units. The four key elements of this proposal are: the use of protocols, routine consultation with the regional paediatric intensive care unit, the use of telemedicine, and enhancing skills and experience of local staff. Evidence supporting these measures as well as the evidence for centralising care of critically ill children is reviewed.
NortonL., SlaterA.Report of the Australian and New Zealand Paediatric Intensive Care Registry 2003. Carlton, Victoria, ANZICS, 2004.
2.
HiglettT., AndersonT., HartG.K.Review of Intensive Care Resources and Activity 2001/2002.Melbourne, Victoria, ANZICS Research Centre for Critical Care Resources2004.
3.
HiglettT., BishopN., HartG.K., and HicksP.Review of Intensive Care Resources and Activity 2002/2003.ANZICS Research Centre for Critical Care Resources, Melbourne2005; p. 40.
4.
PearsonG., ShannF., BarryP., VyasJ., ThomasD., PowellC.Should paediatric intensive care be centralised? Trent versus Victoria.Lancet1997; 349: 1213–1217.
5.
BussP.Should paediatric intensive care be centralised?Lancet1997; 350: 67–68.
6.
Tarnow-MordiW., TuckerJ., ParryG.Should paediatric intensive care be centralised?Lancet1997; 350: 66–67.
7.
TaskerR.C.Should paediatric intensive care be centralised?Lancet1997; 350: 66–68.
8.
StackC.G., BennettN.R., GoddardJ.M.Should paediatric intensive care be centralised?Lancet1997; 350: 65–66.
9.
MaybloomB., ChappleJ., DavidsonL., MawerC.Should paediatric intensive care be centralised? Steering Group for Pan Thames Study of Critically ill Children.Lancet1997; 350: 65–68.
10.
GemkeR.J.Centralisation of paediatric intensive care to improve outcome.Lancet1997; 349: 1187–1188.
11.
PearsonG., ShannF.Provision of intensive care for children. Results of Trent and Victoria study are valid.BMJ1998; 317: 1321.
12.
NichollJ.Provision of intensive care for children. Evidence does not support tertiary care.BMJ1998; 317: 1320–1321.
13.
GoldhillD.R., WithingtonP.S.Provision of intensive care for children Tertiary centres are unproved.BMJ1998; 317: 1320.
14.
BerryA.Provision of intensive care for children. Effective transport systems are essential.BMJ1998; 317: 1320.
15.
RatcliffeJ.Provision of intensive care for children. A geographically integrated service may now be achieved.BMJ1998; 316: 1547–1548.
16.
FraserJ., MaskreyC., TaylorH.Evaluation of the Paediatric Index of Mortality in children managed on adult intensive care units.Arch Dis Child2004; 89: 974–976.
17.
HendersonA.J., GarlandL., WarneS., BaileyL., WeirP., EdeesS.Risk adjusted mortality of critical illness in a defined geographical region.Arch Dis Child2002; 86: 194–199.
18.
GemkeR.J., BonselG.J.Comparative assessment of pediatric intensive care: a national multicenter study. Pediatric Intensive Care Assessment of Outcome (PICASSO) Study Group.Crit Care Med1995; 23: 238–245.
19.
PollackM.M., AlexanderS.R., ClarkeN., RuttimannU.E., TesselaarH.M., BachulisA.C.Improved outcomes from tertiary center pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities.Crit Care Med1991; 19: 150–159.
20.
HallJ.R., ReyesH.M., MellerJ.L., LoeffD.S., DembekR.The outcome for children with blunt trauma is best at a pediatric trauma center.J Pediatr Surg1996; 31: 72–76.
21.
WangJ.N., WuJ.M., ChiouY.Y., LuoC.Y.Comparison of intensive care of injured children between pediatric-based and nonpediatric-based intensive care units in a university hospital in Taiwan.Acta Paediatr Taiwan1999; 40: 400–405.
22.
SanchezJ.L., LucasJ., FeustelP.J.Outcome of adolescent trauma admitted to an adult surgical intensive care unit versus a pediatric intensive care unit.J Trauma2001; 51: 478–480.
23.
FarrellL.S., HannanE.L., CooperA.Severity of injury and mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units versus other hospitals.Pediatr Crit Care Med2004; 5: 5–9.
24.
NakayamaD.K., CopesW.S., SaccoW.Differences in trauma care among pediatric and nonpediatric trauma centers.J Pediatr Surg1992; 27: 427–431.
25.
PearsonG., BarryP., TimminsC., StickleyJ., HockingM.Changes in the profile of paediatric intensive care associated with centralisation.Intensive Care Med2001; 27: 1670–1673.
26.
TilfordJ.M., SimpsonP.M., GreenJ.W., LensingS., FiserD.H.Volume-outcome relationships in pediatric intensive care units.Pediatrics2000; 106: 289–294.
27.
RuttimannU.E., PatelK.M., PollackM.M.Relevance of diagnostic diversity and patient volumes for quality and length of stay in pediatric intensive care units.Pediatr Crit Care Med2000; 1: 133–139.
28.
MarcinJ.P., SongJ., LeighJ.P.The impact of pediatric intensive care unit volume on mortality: a hierarchical instrumental variable analysis.Pediatr Crit Care Med2005; 6: 136–141.
29.
PollackM.M., CuerdonT.T., PatelK.M., RuttimannU.E., GetsonP.R., LevetownM.Impact of quality-of-care factors on pediatric intensive care unit mortality.JAMA1994; 272: 941–946.
30.
CarmelS., RowanK.Variation in intensive care unit outcomes: a search for the evidence on organizational factors.Curr Opin Crit Care2001; 7: 284–296.
31.
IapichinoG., GattinoniL., RadrizzaniD., SiminiB., BertoliniG., FerlaL.Volume of activity and occupancy rate in intensive care units. Association with mortality.Intensive Care Med2004; 30: 290–297.
32.
KanterR.K.Regional variation in child mortality at hospitals lacking a pediatric intensive care unit.Crit Care Med2002; 30: 94–99.
33.
GohA.Y., LumL.C., Abdel-LatifM.E.Impact of 24 hour critical care physician staffing on case-mix adjusted mortality in paediatric intensive care.Lancet2001; 357: 445–446.
34.
GrimshawJ.M., RussellI.T.Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations.Lancet1993; 342: 1317–1322.
35.
McDowellK.M., ChatburnR.L., MyersT.R., O'RiordanM.A., KercsmarC.M.A cost-saving algorithm for children hospitalized for status asthmaticus.Arch Pediatr Adolesc Med1998; 152: 977–984.
36.
RobertsonR.C., DarseyE., FortenberryJ.D., PettignanoR., HartleyG.Evaluation of an opiate-weaning protocol using methadone in pediatric intensive care unit patients.Pediatr Crit Care Med2000; 1: 119–123.
37.
BriassoulisG.C., ZavrasN.J., HatzisMD T.D.Effectiveness and safety of a protocol for promotion of early intragastric feeding in critically ill children.Pediatr Crit Care Med2001; 2: 113–121.
38.
HughesM.R., SmithC.D., TecklenburgF.W., HabibD.M., HulseyT.C., EbelingM.Effects of a weaning protocol on ventilated pediatric intensive care unit (PICU) patients.Top Health Inf Manage2001; 22: 35–43.
39.
SchultzT.R., LinR.J., WatzmanH.M., DurningS.M., HalesR., WoodsonA.Weaning children from mechanical ventilation: a prospective randomized trial of protocol-directed versus physician-directed weaning.Respir Care2001; 46: 772–782.
40.
NussK.E., DietrichA.M., SmithG.A.Effectiveness of a pediatric trauma team protocol.Pediatr Emerg Care2001; 17: 96–100.
41.
RestrepoR.D., FortenberryJ.D., SpainhourC., StockwellJ., GoodfellowL.T.Protocol-driven ventilator management in children: comparison to nonprotocol care.J Intensive Care Med2004; 19: 274–284.
42.
PopernackM.L., ThomasN.J., LuckingS.E.Decreasing unplanned extubations: utilization of the Penn State Children's Hospital Sedation Algorithm.Pediatr Crit Care Med2004; 5: 58–62.
43.
Van WaningN.R., KleiberC., FreyenbergerB.Development and implementation of a protocol for transfers out of the pediatric intensive care unit.Crit Care Nurse2005; 25: 50–55.
44.
KrishnanJ.A., MooreD., RobesonC., RandC.S., FesslerH.E.A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation.Am J Respir Crit Care Med2004; 169: 673–678.
45.
GrundyB.L., CrawfordP., JonesP.K., KileyM.L., ReismanA., PaoY.H.Telemedicine in critical care: an experiment in health care delivery.JACEP1977; 6: 439–444.
46.
RosenfeldB.A., DormanT., BreslowM.J., PronovostP., JenckesM., ZhangN.Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care.Crit Care Med2000; 28: 3925–3931.
47.
BreslowM.J., RosenfeldB.A., DoerflerM., BurkeG., YatesG., StoneD.J.Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing.Crit Care Med2004; 32: 31–38.
48.
MarcinJ.P., ScheppsD.E., PageK.A., StruveS.N., NagrampaE., DimandR.J.The use of telemedicine to provide pediatric critical care consultations to pediatric trauma patients admitted to a remote trauma intensive care unit: a preliminary report.Pediatr Crit Care Med2004; 5: 251–256.
49.
MarcinJ.P., NesbittT.S., KallasH.J., StruveS.N., TraugottC.A., DimandR.J.Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California.J Pediatr2004; 144: 375–380.
50.
KofosD., PitettiR., OrrR., ThompsonA.Telemedicine in pediatric transport: a feasibility study.Pediatrics1998; 102: E58.
51.
CeliL.A., HassanE., MarquardtC., BreslowM., RosenfeldB.The eICU: it's not just telemedicine.Crit Care Med2001; 29: N183–N189.
52.
PollackM.M., KatzR.W., RuttimannU.E., GetsonP.R.Improving the outcome and efficiency of intensive care: the impact of an intensivist.Crit Care Med1988; 16: 11–17.
