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The case mix of our paediatric intensive care units (PICU) is changing and not by design or commissioned intention. The results are presented of a data linkage between the Paediatric Intensive Care Audit Network (PICANET), Hospital Episode Statistics and the Office for National Statistics.1 By applying a customised coding framework taken from the International Classification of Diseases, the researchers identified that 57.6% of PICU admissions and 72.9% of deaths were for children with a life-limiting condition; proportions that have been increasing over the 11 years studied. This would be consistent with a trend identified in Australian data where over time children who would not have been admitted to intensive care in the past are now routinely offered intensive care.2 The life-limiting conditions defined by the authors are a broad list of diagnoses including congenital heart disease, cancers, genetic/metabolic diseases and others, and the increase in their proportion among intensive care admissions implies that the case mix of admission to UK PICUs is increasing in complexity. This is occurring alongside the already reported increase in prevalence of the same conditions in the population at large.3 The paper goes further in helping to characterise the case mix of modern PICU. Of the 89 000 patients with life-limiting conditions in the study, over 40 000 were admitted as part of a ‘planned’ admission, …

Aim To describe the frequency and causes of death in children with epilepsy, ascertain the contribution of seizure disorder to cause of death, and compare with rates of sudden unexplained death in children without epilepsy. Method This study was a retrospective review of clinical and death certificate records. It examined two UK population-based samples of deaths in children with epilepsy from 1 month to 18 years, together comprising the largest reported series of deaths in children with epilepsy (n=265). Results In approximately two-thirds, the death was not due to the seizure disorder. Rates of unexplained death were similar in the two samples at 7.3% and 9.7%: all were in children with symptomatic or presumed symptomatic epilepsy. There were no unexplained deaths in the children with idiopathic epilepsy. Four per cent of the deaths were of children experiencing acute symptomatic seizures as part of their final illness. The risk of unexpected, unexplained death in children with idiopathic epilepsy is not more than 65 per 100 000 child-years. Interpretation Epilepsy is associated with an increased risk of death in childhood but this risk is almost entirely confined to those with an associated neurodevelopmental disorder. The risk of unexpected, unexplained death in children with idiopathic epilepsy is extremely small.

Early warning scores are becoming increasingly topical and widespread in paediatrics. This article examines the evidence base behind them and reinforces the call for a nationally coordinated setup programme.

Aim To validate a descriptive tool for the causes of child death, which was designed to circumvent problems posed by the analysis of a confidential enquiry. Method 3 participants from different healthcare backgrounds used clinical data, including the entries on the medical certificate of the cause of death, to classify the root cause of 783 deaths from the Confidential Enquiry into Maternal and Child Health child death review. A bespoke hierarchical system was used. Unanimity of allocation within categories and inter-rater and intra-rater agreement were assessed. Two methods for treating disagreements were compared by assessing their effect upon the apparent incidence of different causes of death. Results The participants were most consistent in grouping deaths due to trauma, malignancy and sudden infant death. Each was highly consistent in allocating cases to groups (κ 0.85–0.99), but the agreement between participants, although “good”, was worse (κ 0.66–0.78). The greatest number of discrepancies was between diseases identified as congenital by the doctor and as chronic medical conditions by others. The method for treating disagreement between participants does not affect the commonest cause of death (trauma) but alters the ranking of the subordinate causes. Conclusion Agreement within diagnostic categories might be improved by greater training of assessors in the use of the technique. This level of performance compares well with that of other coding systems upon their target groups.

To provide an updated version of the Paediatric Index of Mortality 2 for assessing the risk of mortality among children admitted to an ICU.International, multicenter, prospective cohort study.Sixty ICUs that accept pediatric admissions in Australia, New Zealand, Ireland, and the United Kingdom.All children admitted in 2010 and 2011 younger than 18 years old at the time of admission and either died in ICU or were discharged. Patients who were transferred to another ICU were not included. Fifty-three thousand one hundred twelve patient admissions were included in the analysis.None.A revised prediction model was built using logistic regression. Variable selection was based on significance at the 95% level and overall improvement of the model's discriminatory performance and goodness of fit. The final model discriminated well (area under the curve, 0.88, 0.88-0.89); however, the model performed better in Australia and New Zealand than in the United Kingdom and Ireland (area under the curve was 0.91, 0.90-0.93 and 0.85, 0.84-0.86, respectively).Paediatric Index of Mortality 3 provides an international standard based on a large contemporary dataset for the comparison of risk-adjusted mortality among children admitted to intensive care.

Aim To describe the avoidable factors associated with child deaths identified by a confidential enquiry. Method In the Centre for Maternal and Child Enquiries confidential enquiry, a sample (13%) of cases was subjected to case note review by multidisciplinary panels attempting to identify avoidable factors associated with the deaths. Cases were selected blindly but in equal numbers from predetermined age bands and participating regions. The anonymised records were reviewed in regions remote to where the child lived and died. Panel composition, conduct and reporting were standardised. Results 119 of 126 cases reviewed by enquiry panels had sufficient information to determine avoidable factors. These cases were comparable with the whole dataset in terms of sex and causes of death. 31 (26%) of 119 had avoidable factors that were predominantly related to individuals or agencies with a direct responsibility to the child. 51 (43%) of 119 were defined as potentially avoidable. In all, 130 factors were considered in relation to these 82 cases, and 64% of the factors were healthcare related. Avoidable factors were more likely where life-limiting illness was not present. Recurring avoidable factors included failure to recognise serious illness at the point of presentation and death occurring in children who had been lost to follow-up. Conclusion Child Death Overview Panels now have the responsibility to review child deaths using similar methods but relying upon data forms rather than the case record. Analysis of contributory factors on a national scale has the potential to improve understanding of why children die and indicate strategies to reduce child mortality.

Aims 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. The survey also sought to identify challenges faced by services in providing optimal services to this group. The findings help inform future service provision and set the context for further audit, research and confidential enquiry. Method A questionnaire was sent to Clinical Directors of the 16 UK NHS ambulance services in April 2009. Non-responders were followed up three times after the initial deadline. Results Questionnaires were returned by 13 (81%) respondents. Paramedics and most emergency medical technicians receive a limited amount of paediatric training. Only a minority undertake certified courses (eg, PHPLS, PEPP). An increasing amount of equipment suitable for children is becoming available and paramedics are permitted to use more skills than in the past. However, services for children vary depending on location. Some children9s needs are not met due to insufficient equipment or inadequate skills. For example, paediatric airway adjuncts (short of intubation) were often lacking and only 62% reported having pulse oximetry suitable for use in children. A third of services (4/13) 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 over half (7/13) indicated that the likelihood that the first response to a child could be someone with no current recognised certified qualification specific to paediatrics was “high”. There are also large areas of the country where no additional medical support is available at any time of day. Conclusions The prehospital phase of a child9s care pathway is part of a continuum and cannot be viewed in isolation. Despite improvements, paediatric care by frontline personnel is limited by resources and skill availability and, when assessed by comparison by national guidelines (eg, JRCALC), accepted standards are often lacking. Audit, research and training initiatives should be carried out collaboratively between ambulance services and acute trusts to guide training, local service requirements and resource allocation. This will reduce variation and maintain the safety of patients and quality of care.

OBJECTIVE. To assess the Pediatric Risk of Mortality (PRISM, PRISM III-12, and PRISM III-24) systems and the Pediatric Index of Mortality (PIM and PIM2) systems for use in comparing the risk-adjusted mortality of children after admission for pediatric intensive care in the United Kingdom. METHODS. All PICUs in the United Kingdom were invited to participate. Predicted probability of PICU mortality was calculated using the published algorithms for PIM, PIM2, and PRISM and compared with observed mortality. These scores, along with PRISM III-12 and PRISM III-24, whose algorithms are not published, were optimized for the United Kingdom. RESULTS. Of 26 PICUs in the United Kingdom, 22 (85%) were recruited, and sufficient prospective data were collected from 18 (69%) units on 10197 (98%) of 10385 admissions between March 2001 and February 2002. All published tools were found to have poor calibration but provided good discriminatory power. After estimation of UK-specific coefficients, only PIM2, PRISM III-12, and PRISM III-24 had satisfactory calibration. All models provided good discriminatory power. Funnel plots for all of the recalibrated models indicated that the risk-adjusted mortality for all units was consistent with random variation. CONCLUSIONS. PIM2, PRISM III-12, and PRISM III-24 all were found to be suitable for use in a UK PICU setting. All tools provided similar conclusions in assessing the distribution of risk-adjusted mortality in UK PICUs. It now is important that these tools be used to monitor outcome and improve the quality of pediatric intensive care within the United Kingdom.

Mortality from meningococcal septic shock may be falling; however, it is difficult to be sure. Inter-unit comparisons of the sort precipitated by these articles and correspondence are inevitably distorted by confounding factors. These factors are not entirely removed by the use of mortality prediction models. Historically, mortality data for meningococcal septicaemia from the UK Public Health Laboratory Service Communicable Disease Surveillance Centre have always shown a lower mortality rate than that in many paediatric intensive care units. However, the comparison is regarded as inappropriate …

Following the introduction of a policy of early therapeutic filtration for presumed meningococcal septicaemic shock, the overall mortality has decreased.