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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.

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 children9s 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.

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.

Background Every day throughout the UK, ambulance services seek medical assistance in providing critically ill or injured patients with pre-hospital care. Objective To identify the current availability and utilisation of physician-based pre-hospital critical care capability across England, Wales and Northern Ireland. Design A postal and telephone survey was undertaken between April and December 2009 of all 13 regional NHS ambulance services, 17 air ambulance charities, 34 organisations affiliated to the British Association for Immediate Care and 215 type 1 emergency departments in England, Wales and Northern Ireland. The survey focused on the availability and use of physician-based pre-hospital critical care support. Results The response rate was 100%. Although nine NHS ambulance services recorded physician attendance at 6155 incidents, few could quantify doctor availability and utilisation. All but one of the British Association for Immediate Care organisations deployed ‘only when available’ and only 45% of active doctors could provide critical care support. Eleven air ambulance services (65%) operated with a doctor but only 5 (29%) operated 7 days a week. Fifty-nine EDs (27%) had a pre-hospital team but only 5 (2%) had 24 h deployable critical care capability and none were used regularly. Conclusion There is wide geographical and diurnal variability in availability and utilisation of physician-based pre-hospital critical care support. Only London ambulance service has access to NHS-commissioned 24 h physician-based pre-hospital critical care support. Throughout the rest of the UK, extensive use is made of volunteer doctors and charity sector providers of varying availability and capability.

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.

The Confidential Enquiry into Maternal and Child Health (CEMACH) has published a report entitled ‘Why Children Die: A Pilot Study’. The report contains the results of a large confidential enquiry into child death across one-third of England, all of Wales and all of Northern Ireland in 2006. The report contains a quantitative analysis of 957 deaths which shows some regional and ethnic variation in death rates. Also despite high rates of pre-existent and perhaps life-limiting illness/disability, most children die in hospital, with only small numbers in hospices. Child suicide rates were higher than expected and only one-quarter of these cases were known to mental health services. The report also contains a qualitative analysis of a sample of cases ( n = 126) which were subjected review by multidisciplinary panels. Avoidable factors were found in 26% and potentially avoidable in a further 43%. A recurring avoidable factor in relation to healthcare was ‘failed recognition of serious illness’ by healthcare workers not trained in paediatrics or not supervised by trained individuals.

The mortality rate is lower among children admitted to specialist paediatric intensive care units (ICUs) than among those admitted to mixed adult and paediatric units in non-tertiary hospitals. In the UK, however, few children receive intensive care in specialist paediatric units. We compared the ICU mortality rate in children from the area the Trent Health Authority, UK, with the rate in children from Victoria, Australia, where paediatric intensive care is highly centralised.We studied all children under 16 years of age from Trent and Victoria who received intensive care between April 1, 1994, and March 31, 1995. Children younger than 1 month were excluded unless they had cardiac disorders. We developed a logistic regression model that used information gathered at the time of admission to ICU to adjust for risk of mortality.The rates of admission of children to intensive care were similar for Trent and Victoria (1.22 and 1.18 per 1000 children per year), but the mean duration of an ICU stay was 3.93 days for Trent children compared with 2.14 days for children from Victoria. 74 (7.3%) of the 1014 children from Trent died, compared with 60 (5.0%) of the 1194 children from Victoria. With adjustment for severity of illness at the time of admission to ICU, the odds ratio for the risk of death for Trent versus Victoria was 2.09 (95% CI 1.37-3.19, p0.0005). There were 31.7 (14.0-50.4) excess deaths in Trent children, which is equivalent to 42.8% of the deaths in ICU, and 11.1% of all deaths in children between the ages of 1 month and 16 years in Trent.If Trent is representative of the whole country, there are 453 (200-720) excess deaths a year in the UK that are probably due to suboptimal results from paediatric intensive care. If the ratio of paediatric ICUs to children were the same in the UK as in Victoria, there would be only 12 paediatric ICUs in the country. Our findings suggest that substantial reductions in mortality could be achieved if every UK child who needed endotracheal intubation for more than 12-24 h were admitted to one of 12 large specialist paediatric ICUs.

To determine whether plasma filtration improves 28-day survival in infants and children with severe sepsis.A multicentre randomised controlled trial.Paediatric intensive care units in teaching hospitals.Forty-eight infants and children with severe sepsis.Patients were randomly assigned to receive plasma filtration (n = 25) or standard therapy (n = 23) for the treatment of septic shock. The primary outcome measure was 28-day survival. Secondary outcome measures included the number of failed organ systems on Day 7, a requirement for extracorporeal membrane oxygenation (ECMO), and the modified Glasgow outcome score (MGOS) at 6 months (where 1 is normal and 6 is dead).The trial was stopped early due to poor recruitment. Patients in the plasma filtration group had higher initial disease severity as measured by serum lactate level, inotrope score and MGOS. Ten (40%) children died in the plasma filtration group and 4 (17%) died in the control group. With intention-to-treat analysis and adjustment for lactate level, ventilation index, inotrope score and MGOS at admission using logistic regression, the odds ratio for death with plasma filtration was 1.20 (95% CI, 0.23-6.20; P = 0.82). The median number of failing organ systems at 7 days was 2 (interquartile range [IQR], 1-4) in the plasma filtration group versus 2 (IQR, 1-3) in the control group. Two children in the plasma filtration group required ECMO for 2.5 and 123 hours, and one child in the control group required ECMO for 45 hours. The median MGOS at 6 months was 4 (IQR, 2-6) in the plasma filtration group and 2 (IQR, 1-4) in the control group.Our study did not recruit enough patients to test the hypothesis that addition of plasma filtration to our standard care protocol reduces 28-day mortality in children with severe sepsis. However, mortality in the treatment and control groups was not significantly different after adjustment for severity of illness at the time of randomisation.

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.

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.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).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.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.

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.

In this edition of the journal Deasy et al 1 share some unique and original insights into hanging in children ( see page 411 ). These were only possible because of the use of an electronic database (VACAR), which has been backdated to include paper records from previous years in respect of out-of-hospital cardiac arrest. It includes hospital outcome to the level of detail of the paediatric cerebral performance category scale. The researchers were also able to validate their data against a national coroner information system. Comparable databases do not exist in Britain and so this analysis could not have been done here. Hanging was the fourth most common cause of out-of-hospital cardiac arrest and 91% were intentional, hence occurring during waking hours. The only survivors were when the event was witnessed and bystander resuscitation was prompt. Out …

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.

Background: In 2006 the Confidential Enquiry into Maternal and Perinatal Deaths was extended to pilot a collection of child deaths. This helped optimise data collection for local safeguarding children's boards, which, since April 2008, have a statutory responsibility to review all child deaths. Reviewing primary care records may highlight areas in which systems, skills, and care could be improved. Aim: To review the role and quality of primary care in child deaths. Design of study: Confidential enquiry into child deaths. Setting: Five regions of the UK: North-East, South-West and West Midlands, Wales, and Northern Ireland. Method: The confidential enquiry collected core data for all child deaths (age range 28 days to 17 years) and an age-stratified sample was assessed by multidisciplinary panels for avoidable factors. An independent detailed review was conducted of the primary care records on all children in the North-East region and all children who were reviewed by panel in the other four regions. Results: Primary care records were reviewed for 168 child deaths. There were 25 (15%) deaths from acute infection, 22 (13%) from cancer, and 11 (7%) from asthma or epilepsy. Fifty-nine (35%) deaths were sudden: sudden unexplained death in infancy, suicides, and assaults. Of 149 with immunisation records, only 88 (59%) had been fully vaccinated on time. One or more primary care professionals were involved in the management of 90 (54%) children. Avoidable primary care factors were identified in 18 (20%) of these deaths. Avoidable primary care factors included failure in the recognition and management of serious infection, failure to vaccinate, and inadequate management of asthma and epilepsy. Conclusion: Decisions made about diagnosis and management in primary care may affect the cause, time, and circumstances of a child's death. Maintaining skills in assessing the acutely ill child remains an essential part of good clinical practice. ©British Journal of General Practice.

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 …

To revise the Paediatric Index of Mortality (PIM) to adjust for improvement in the outcome of paediatric intensive care. International, multi-centre, prospective, observational study. Twelve specialist paediatric intensive care units and two combined adult and paediatric units in Australia, New Zealand and the United Kingdom. All children admitted during the study period. In the analysis, 20,787 patient admissions of children less than 16 years were included after 220 patients transferred to other ICUs and one patient still in ICU had been excluded. None. A revised model was developed by forward and backward logistic regression. Variable selection was based on the effect of including or dropping variables on discrimination and fit. The addition of three variables, all derived from the main reason for ICU admission, improved the fit across diagnostic groups. Data from seven units were used to derive a learning model that was tested using data from seven other units. The model fitted the test data well (deciles of risk goodness-of-fit χ2 8.14, p=0.42) and discriminated between death and survival well [area under the receiver operating characteristic (ROC) plot 0.90 (0.89–0.92)]. The final PIM2 model, derived from the entire sample of 19,638 survivors and 1,104 children who died, also fitted and discriminated well [χ2 11.56, p=0.17; area 0.90 (0.89–0.91)]. PIM2 has been re-calibrated to reflect the improvement that has occurred in intensive care outcome. PIM2 estimates mortality risk from data readily available at the time of ICU admission and is therefore suitable for continuous monitoring of the quality of paediatric intensive care.

Objectives: To compare intensive care admissions from a defined population of children in 1991 and 1999, during a period of organisational change and centralisation of paediatric intensive care. Design: Two 12-month population-based audits were compared. Data were collected from hospitals in Birmingham and the surrounding districts. Denominator data were obtained from the Office for National Statistics. The place and rate of intensive care admission, the use of mechanical ventilation at admission, mortality and length of stay were compared. Setting: Hospitals in the West Midlands. Participants: All children (

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

New procedures for reviewing child deaths should improve support for families and enable action to reduce mortality. Peter Sidebotham and Gale Pearson explain how they work