Pediatric Intensive Care Should be Centralized and Regionalized

In this era of managed care, many pediatricians are frustrated by managed care decisions concerning where their patients will receive specialized care, including intensive care. Some health care financing organizations do not differentiate between pediatric-trained subspecialists and resources and subspecialists and resources primarily directed to adult patients because they may maintain that there are few data proving that specialized pediatric care is superior. A recent report from Australia presents evidence that critically ill children fared much better in regional pediatric intensive care units than in multiple, dispersed ICUs—most of which did not have full-time pediatric intensive care expertise.1

Pearson and colleagues studied ICU admissions of children residing in two regions, one in Australia (Trent) and the other in the United Kingdom (Victoria). These regions have similar populations. Children from Trent were cared for in 19 separate ICUs. In Victoria, 85% of children were admitted to a single, regional dedicated pediatric intensive care unit. Although it may be inappropriate to compare two areas separated by half of the world, the populations and diseases are probably similar.

The rates and indications for ICU admission were similar for Trent and Victoria, but the mean duration of ICU stays was longer (3.93 vs 2.14 days) and mortality was higher (7.3% vs 5.0%) in the children from Trent compared to those from Victoria. Pearson et al estimate that there were 31.7 excess deaths in children from Trent that could be attributed to inadequate intensive care.

The dispersed, non-pediatric oriented ICU situation in Trent was considered representative of most of Australia. Pearson et al estimate that annually in Australia, there may be 453 (200-720) excess children’s deaths due to suboptimal intensive care. The authors believe that a substantial reduction in pediatric mortality would be realized by regionalization of pediatric intensive care.

It is clear that outcomes of care and better results for critical illnesses are influenced by the training and experience of those physicians and nurses providing them. Not to transfer a child who requires intensive care to an appropriate regional PICU may be costly and dangerous for the patient. —hap

Reference

1. Pearson G, et al. Should pediatric intensive care be centralized? Trent versus Victoria. Lancet 1997; 349:1213-1217.