Intensive Care Unit clinical outcomes

Our Paediatric (PICU), Neonatal (NICU) and Cardiac (CICU) Intensive Care Units provide medical treatment to children who are critically ill. The intensive care unit teams provide a tertiary referral service both nationally and internationally. Our specialist multidisciplinary service is one of the largest for children in the United Kingdom and Europe.

The primary outcome measure used in Intensive Care Units (ICU) is the survival rate for patients, measured at the time when they are discharged. Raw survival/mortality rates may be challenging to interpret as patients that are admitted in a sicker condition are at greater risk, and therefore the outcomes need to be ‘adjusted’ to consider the level of severity of the patients in respect of case mix.

The PIM3 (Paediatric Index of Mortality version 3) score is calculated for every child admitted to ICU and assesses severity of illness and risk of death on admission and is based on medical history, interventions and physiological measurements taken from time of first contact with an ICU doctor up to the first hour after admission. The standardised mortality ratio (SMR) is the ratio of the number of actual deaths compared to the number of expected deaths based on the PIM3 score: this is a method of benchmarking the outcomes between ICUs nationally – it makes assumptions of similar case mix.

The table and the funnel plots shown were provided by the Paediatric Intensive Care Audit Network body (PICANet) for admissions to the GOSH ICUs between January 2020 to December 2022.

Centre E1 is the combined GOSH Paediatric and Neonatal ICUs (PICU/NICU) and Centre E2 is GOSH Cardiac ICU (CICU). The adjusted SMR for PICU/NICU is slightly above 1, and below 1 for CICU. This means the mortality rates for both units fall within the expected range, as determined by the displayed confidence limits.

Please also see our Cardiothoracic outcomes page for benchmarked data from the National Congenital Heart Audit.

In 2016, a website called Understanding Children’s Heart Surgery Outcomes was launched to help parents and families to make sense of published survival data about children’s heart surgery in the UK and Ireland.

Table 1 Standardised Mortality Ratio (SMR) for PICU/NICU and CICU for Jan 2020 to Dec 2022, PIM3 Adjusted

Published with the permission of PICANet from “Paediatric Intensive Care Audit Network Annual Report 2023 (published December 2023): Universities of Leeds and Leicester.”

Figure 1 Standardised Mortality Ratio (SMR) funnel plot for PICU/NICU and CICU, Jan 2020 to Dec 2022, PIM3 Risk Adjusted (PIM3 Recalibrated 2023)

Published with the permission of PICANet from “Paediatric Intensive Care Audit Network Annual Report 2023 (published December 2023): Universities of Leeds and Leicester.”

The rate of re-admissions is a quality outcome indicator that is monitored to ensure appropriate discharge from ICU. Table 2 shows the rate of emergency re-admission within 48 hours of discharge. These relative re-admission rates are per organisation, relative to the equivalent rate over all PICUs. Relative re-admission rates higher than one indicate that a unit has a higher rate of emergency re-admissions within 48 hours than the overall average rate. Unlike the SMR, these figures are not adjusted for factors that may affect the rate. The rate of emergency re-admissions to GOSH CICUs was well below the average rate for all hospitals, likely indicating that children are not discharged too early from intensive care.

The higher rate in 2020 for PICU/NICU reflects the high numbers of PIMS-TS patients that were admitted to GOSH in the COVID 19 pandemic. The pathophysiology of this new disease was unknown at first and the wards were also struggling to source appropriate beds and clinical staff for these patients.

The rate of re-admissions for CICU is higher than previous years due to a general trend toward more complex case-mix related to increased highly specialised services activity, post pandemic increased cardiac surgical activity and limited capacity for high-dependency care in Cardiology ward.

Table 2 Relative rates of emergency re-admission within 48 hours of discharge, 2020 to 2022

Published with the permission of PICANet from “Paediatric Intensive Care Audit Network Annual Report 2023 (published December 2023): Universities of Leeds and Leicester.”

Intubation is the placement of a flexible plastic tube through the mouth to maintain an open airway and provide ventilator-assisted breathing during anaesthesia, sedation or critical illness. Extubation is the removal of that tube, which should happen in a planned way. Extubation can happen accidentally or due to removal by patient and so is an avoidable safety concern. Recording of the rate of unplanned extubations is therefore an important measure of care quality in the ICU environment.

Figure 2 shows unplanned extubation rates per 1000 intubated days. The average rate for all ICUs was 4.5 per 1000 intubated days. Over the three-year period, the rate for GOSH CICU at 2.9 per 1000 intubated days is below the national average indicating high quality care, and the GOSH PICU/NICU rate at 8.8 per 1000 intubated days is above the average rate.

Looking at these rates by year, we can see that the rise in the PICU/NICU rate to 11.3 in 2020 corresponded to the period of the pandemic during which pathways of care and staffing levels were subject to some changes with increased demands.

Table 3 Unplanned extubation rates for all admissions, 2020 to 2022

Published with the permission of PICANet from “Paediatric Intensive Care Audit Network Annual Report 2023 (published December 2023): Universities of Leeds and Leicester.”]

The full report can be found at Paediatric Intensive Care Audit Network (PICANet).

As part of continuous improvement, the Intensive Care Units are fully engaged in the Trust-wide quality improvement (QI) initiatives of the deteriorating child QI project and Trust-wide HDU provision QI project, and is monitoring the re-admission metric in the Clinical Governance meetings.