Intensive Care Med (2001) 27: 1670±1673

DOI 10.1007/s001340101072 B R I E F RE PO RT

G. Pearson Changes in the profile of paediatric

P. Barry
C. Timmins intensive care associated with
J. Stickley
M. Hocking centralisation

Received: 16 January 2001

Final revision received: 25 May 2001
Accepted: 30 July 2001
Published online: 23 August 2001
 Springer-Verlag 2001
Funded in part by West Midlands Regional
Health Authority
)
G. Pearson ( ) ´ P. Barry ´ C. Timmins ´
J. Stickley ´ M. Hocking
Birmingham Children's Hospital,
Steelhouse Lane, Birmingham B4 6NH,
UK
E-mail: Gale.pearson@bhamchildrens.
wmids.nhs.uk
Phone: +44-1 21-3 33 96 71
Fax: +44-1 21-3 33 96 51
Abstract Objectives: To compare
intensive care admissions from a de-
fined population of children in 1991
and 1999, during a period of organi-
sational change and centralisation of
paediatric intensive care.
Design: Two 12-month population-
based audits were compared. Data
were collected from hospitals in Bir-
mingham and the surrounding dis-
tricts. Denominator data were ob-
tained from the Office for National
Statistics. The place and rate of in-
tensive care admission, the use of
mechanical ventilation at admission,
mortality and length of stay were
compared.
Setting: Hospitals in the West Mid-
lands.
Participants: All children (< 15 yrs)
living in Birmingham who received
intensive care during the study peri-
ods.
Measurements and results: The
number of Birmingham resident
children admitted for intensive care
increased from 277 to 510
(p < 0.0001) i.e. from 1.3 to 2.3 ad-
missions per 1,000 children per year.
The proportion of admissions to the
principal paediatric intensive care
unit increased from 60 % to 90 %
(p < 0.0001) in association with its
expansion from 6 to 18 beds. Length
of ICU stay decreased from 103 to
74 h (difference 29 h, 95 %CI,
4.78±54.2 h, p = 0.0117). Child mor-
tality fell over this period by 34
deaths per 100,000 children (95 %CI
16±51, p < 0.0001). The proportion
of children requiring mechanical
ventilation at admission to intensive
care was unchanged.
Conclusions: Centralisation by ex-
pansion of the lead centre was asso-
ciated with a large increase in the
numbers of children receiving in-
tensive care consistent with an un-
met need for paediatric intensive
care in 1991, which may still exist.
Centralisation of paediatric inten-
sive care may have contributed to
the fall in child mortality over this
time period.
Keywords Intensive care
utilisation ´ Bed occupancy ´ Health
services research ´ England

a difference in the incidence of critical illness in children

Introduction
In 1993 it was asserted that paediatric intensive care ser-
vices in the United Kingdom were inadequate [1, 2, 3].
Admission rates to intensive care were very low com-
pared to those in Australia and the United States [4].
There was considerable debate as to whether this re-
flected a higher threshold for intensive care admission,
in the United Kingdom or a failure of provision in terms
of numbers or organisation of intensive care beds [5]. At
that time relatively few children received intensive care
in dedicated paediatric intensive care units, and a large
number of general intensive care units provided inci-
dental intensive care for children as and when required.
In 1996 a `Framework for the Future' [6] was introduced
 1671

Table 1 Children's use of intensive care in Birmingham: 1999 compared to 1991

1991 1999 Absolute Ratio p
change
Children resident in Birmingham 212,700 222,200 9,500 1.04
Number of deaths 221 156 ±65 0.71 < 0.0001
Birmingham child residents enter study 297 590 293 1.99 < 0.0001
Birmingham child residents get admitted to an ICU 277 510 233 1.84 < 0.0001
Birmingham child residents > 28 days old admitted to ICU 245 427 182 1.74 < 0.0001
Child ICU admissions per 1,000 children in the population 1.30 2.30 1 1.77
Number of deaths in the study 28 34 6 1.21 0.051
Number of deaths occurring in ICU 26 32 6 1.23 0.080
Number of deaths in ICU (excluding neonates, £28 days at admission) 24 26 2
Number of sites where children admitted to intensive care 10 10 0 1
ICU mortality (%) 9.39 6.27 ±3 0.67
Non-neonatal ICU mortality 9.8 6.0 3.8 0.61
Percentage of all deaths occurring in ICU 11.76 20.51 9 1.74
Percentage of ICU admissions occurring to a PICU 61 90.20 29.2 1.58 < 0.0001
ICU child deaths per 100,000 children in the population 12.22 14.40 2.18 1.18
Deaths per 1000 children in the population 1.04 0.70 ±0.34 0.67
Percentage male 57 57 ± ±
Median age (years) 1.58 1.26 ± ± 0.787

that planned increasing centralisation of paediatric in-
tensive care in `Lead centres'. By 1999 some of these
changes in configuration had been implemented in Bir-
mingham. We therefore analysed population-based
data from 1991 and 1999 to assess any associated change
in paediatric intensive care activity and outcome.
for severity of illness to detect a change in the pattern of care from
`high dependency care' to `intensive care'. This assumes that the
threshold for initiating mechanical ventilation remains the same.
The significance of differences between the two time periods were
calculated using the c2 statistic (with Fisher's exact test when fre-
quencies were small). Confidence intervals for differences in pro-
portions were calculated using confidence interval analysis soft-
ware version 1 [8].

Method
Patients entered the 1991 study [7] if they were aged less than
15 years on admission to hospital and received intensive care. The
data were collected throughout the study period by the principal
researcher (a physician in training) visiting hospitals in the four
Birmingham Health Authorities and each of the neighbouring
health authorities. The data for the year 1999 was extracted from
a larger database collected prospectively from all hospitals in the
West Midlands region by ward nursing staff coordinated by a full-
time researcher. The entry criteria used in the 1991 study were ap-
plied to the 1999 database to give comparative information. Data
from hospitals not included in the former study were excluded. `In-
tensive care' was defined as admission to an intensive care unit or
the use of a `unique intensive care treatment' (mechanical ventila-
tion, continuous vascular or intracranial pressure monitoring or va-
soactive drug infusion). Children on neonatal intensive care units
who had not been discharged from hospital since birth were ex-
cluded. Residence within Birmingham was subsequently deter-
mined by the patient's postcode. Denominator data for both ep-
ochs were provided by the Office for National Statistics.
The incidence, pattern of provision and outcome of critical care
for children resident in Birmingham were compared. The degree
of centralisation was expressed as the proportion of the total num-
ber of intensive care admissions occurring in the largest (highest
volume of child admissions) intensive care unit. The principal pae-
diatric intensive care unit was known to be the same in the two ep-
ochs. It serves a larger population than the residents of Birming-
ham. The use of mechanical ventilation at admission to intensive
care was known for both time periods. This was used as a surrogate
Results
Between 1991 and 1999 the number of beds available in
the principal paediatric intensive care unit increased
from 6 to 18. Additionally a second paediatric intensive
care unit opened in a district general hospital north of
the city. There was an associated increase in use of in-
tensive care by Birmingham children from 277 admis-
sions to 510, or from 1.3 to 2.3 admissions per thousand
children and 29 % more children received their inten-
sive care in a paediatric intensive care unit (PICU;
95 %CI 23±35 %, p < 0.0001). The change in activity be-
tween the two epochs is shown in Table 1, with the level
of significance where appropriate. Table 2 shows the
distribution of the deaths between adult and paediatric
intensive care units in the two epochs. The predominant
increase in activity occurred in the lead centre, which
delivered 61 % (169 patients) of Birmingham children's
intensive care in 1991 compared to 90 % (460 patients)
in 1999. Only 9 Birmingham residents were admitted to
the new unit outside the city in the second study period.
Furthermore, two hospitals stopped delivering intensive
care to children in the interval between the studies, one
of which closed altogether. Its workload transferred to
other hospitals remaining in the study. Of the absolute
1672
Table 2 Distribution of patients between adult and paediatric in-
tensive care units: Birmingham residents
1991 1999
Admis- Deaths Admis- Deaths
sions sions
Birmingham Chil- 169 14 451 32
dren's Hospital PICU
Other PICU 0 0 9 0
Adult intensive 108 12 50 0 Beds per PICU
care unit
increase in activity for Birmingham residents shown in
Table 1, 70 % was due to new `general paediatric' admis-
sions. The greatest absolute increases in admission fre-
quency were those for respiratory and neurological di-
agnoses. As might be anticipated, the number of cardiac
and neonatal surgical cases were relatively fixed.
The use of mechanical ventilation on admission to in-
tensive care was the same in the two periods (78 % in
1991 and 81 % in 1999, p = 0.36). As there was no major
change in policy regarding the use of mechanical venti-
lation, this finding supports the premise that there was
no large change in severity of illness between the two
periods. However, the overall child mortality rate fell
by 0.34 deaths per 1000 children (95 %CI 0.16±0.51,
p < 0.0001) which is 75 less child deaths (based on the
1999 population size). Patients stayed in intensive care
for a shorter period of time. The mean length of stay
fell from 103 h to 74 h, a difference of 29.5 h (95 %CI
4.78±54.2 h, p = 0.0117).
Discussion
This analysis of population based data from 1991 and
1999 demonstrates a virtual doubling of intensive care
use by Birmingham children. Childhood mortality de-
creased in the same time period. Improved performance
of intensive care for children is implied by the lower in-
tensive care unit mortality and the shorter length of
stay, but the former change is not quite significant be-
cause of the low number of deaths.
The number of children resident in Birmingham who
were admitted to intensive care increased significantly
between the two epochs and was higher in 1999 than in
the West Midlands region as a whole (which was 1.55
per thousand children). This could reflect a change in
the severity of illness of the children or a change in the
threshold for intensive care admission. It is more likely
to reflect partial resolution of an under-provision of
paediatric intensive care. It is not possible to distinguish
the major factor directly.
These results do not prove a causal link between cen-
tralisation and reduced mortality, but they do concur in
Table 3 Projected intensive care bed requirements for England
and Wales
Model 1 Model 2 Model 3
Admission rate per thousand 2.3 1.55 1.55
children
Mean length of stay (Days) 3.08 3.08 2.1
Number of PICUs 16 16 16
Mean occupancy 0.8 0.7 0.8
22 18 16
direction with those of a previous study in which centra-
lised and decentralised paediatric intensive care were
compared [9]. The excess deaths in the decentralised
system in that study accounted for a large proportion of
the difference in child mortality rates between the par-
ent populations. In this study, larger differences in child
mortality occurred (33 % reduction as opposed to
11 %), but other factors will have contributed to the
change. This study also included neonates (excluded in
the former study), but the differences in ICU mortality
persist regardless of whether neonates are included (Ta-
ble 1).
As in the former study, this comparison used popula-
tion-based data in preference to unit-based data. This
approach is preferred because the results are less sus-
ceptible to case-mix effects such as those related to the
referral status of the hospitals involved. The apparent
beneficial effects of centralisation could still be due to
a positive volume:outcome relation [10] both within the
lead PICU alone, which actually admitted a total of
1278 patients during the 1999 period of data collection
versus 713 in 1991, and in the moving of children from
small volume units to the large volume unit. Fifteen of
the fifty children admitted to adult intensive care units
in 1999 were subsequently transferred to the lead cen-
tre. Furthermore, the improved outcome may be occur-
ring despite the influence of the hospitals training status
[11].
Over the period 1991±1999 the national child mortal-
ity rate (England and Wales) decreased by the same
amount as that for Birmingham residents (ratio of stan-
dardised ratios 1.01, 95 % confidence interval
0.852±1.18). Changes in Birmingham might therefore
mirror those in other regions. However, the degree of
centralisation evident in Birmingham in 1991 was al-
ready much greater than that in other cities [3, 9] and re-
gional variations may persist.
Data collected in 1991 did not include a risk adjust-
ment tool, and the tool used in the 1999 study [12] was
not available in 1991. Risk adjustment techniques, how-
ever, assume that intensive care is provided and to the
standard that applied in their derivation datasets. They
do not help interpret the outcome for children who do
 1673

not receive intensive care, which was the accusation in
1993 [1, 2]. Nevertheless, even though the strength of
this comparison is arguably reduced by the lack of ªse-
verity of illnessº data for the 1991 epoch, the need for
ventilation serves as a surrogate for severity of illness.
The fact that the incidence of mechanical ventilation at
the outset of intensive care did not change, argues
against a change in the threshold for intensive care ad-
mission. There was either a lack of provision of inten-
sive care for children in 1991 or by 1999, a change in ad-
mission threshold for intensive care had occurred ac-
companied by an increase in this intervention.
The number of PICU beds required to serve the pop-
ulation of England and Wales (10 million children) can
be extrapolated from the 1999 data by approximation
to a Poisson distribution [6, 13]. Table 3 shows three
such models. Models 1 and 2 were derived using the
length of stay and admission rates reported here for Bir-
mingham and the West Midlands as a whole. Typical
projected mean occupancy rates were used. Model 3,
for interest, uses the length of stay from Victoria, Aus-
tralia, in 1994 [9].
Conclusion
Over the period 1991±1999 there was an increased cen-
tralisation of paediatric intensive care for children living
in Birmingham. This was achieved by increasing the
numbers of beds available in the lead centre. The num-
ber of children receiving intensive care rose, and child
mortality and length of intensive care stay fell over the
same period. These data are consistent with an unmet
need for paediatric intensive care in 1991, which may
still exist. Centralisation of paediatric intensive care
may have contributed to the fall in child mortality over
this time period.

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