Intensive Care Unit clinical outcomes

Clinical outcomes are measurable changes in health, function or quality of life that result from our care. Constant review of our clinical outcomes establishes standards against which to continuously improve all aspects of our practice.

Clinical outcomes are broadly agreed, measurable changes in health or quality of life that result from our care. Constant review of our clinical outcomes establishes standards against which to continuously improve all aspects of our practice.

About the Intensive Care Units

Our Paediatric and Neonatal Intensive Care Unit (PICU/NICU) and Cardiac Intensive Care Unit (CICU) 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.

Clinical outcome measures

1. PIM3 Adjusted Funnel Plot showing Mortality Rates for Paediatric Intensive Care

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 percentage of actual deaths compared to the percentage of expected deaths based on the PIM3 score: this is a method of benchmarking the outcomes between ICUs nationally.

The table and the funnel plots shown were provided by the Pediatric Intensive Care Audit Network body (PICANet) for admissions to the GOSH ICUs between Jan 2015 and Dec 2017.

Centre E1 is the combined GOSH Paediatric and Neonatal ICUs (PICU/NICU) and Centre E2 is GOSH Cardiac ICU (CICU). The adjusted SMR indicates that the mortality rate for CICU is slightly below 1 and the PICU/NICU rate is slightly above 1. The mortality rates for both units however, fall well 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 1.1 Standardised Mortality Ratio (SMR) for PICU/NICU and CICU for Jan 2015 to Dec 2017

2015-2017

Number of Admissions STANDARDISED MORTALITY RATIO
Unadjusted (95% CI) PIM3 Adjusted (95% CI)
Organisation SMR Lower Upper SMR Lower Upper
E1 2,985 1.57 1.35 1.81 1.19 1.02 1.37
E2 2,475 0.85 0.67 1.05 0.98 0.77 1.21

Published with the permission of PICANet from “Paediatric Intensive Care Audit Network Annual Report 2018 (published Nov 2018): Universities of Leeds and Leicester.”

Figure 1.1 Standardised Mortality Ratio (SMR) funnel plot for PICU/NICU and CICU, Jan 2015 to Dec 2017

Fig 1.1 Standardised Mortality Ratio funnel plot for PICU/NICU Jan 2015 to Dec 2017

Published with the permission of PICANet from “Paediatric Intensive Care Audit Network Annual Report 2018 (published Nov 2018): Universities of Leeds and Leicester.”

2. Emergency readmissions within 48 hours

The rate of readmissions is a quality outcome indicator that is monitored to ensure appropriate discharge from ICU. Figure 2.1 shows the rate of emergency re-admission within 48 hours of discharge. These relative re-admission rates are per organisation, where the rate over three years is divided by the overall rate. Unlike the SMR, these figures are not adjusted for factors that may affect the rate. The rate of emergency re-admissions to GOSH ICU’s was well below the average rate for all hospitals likely indicating that children are not discharged too early from intensive care.

Figure 2.1 Relative rates of emergency readmission within 48 hours of discharge, Jan 2015 to Dec 2017

Fig 2.1 Relative rates of emergency readmission within 48 hours of discharge, Jan 2015 to Dec 2017

Published with the permission of PICANet from “Paediatric Intensive Care Audit Network Annual Report 2018 (published Nov 2018): Universities of Leeds and Leicester.”

3. Unplanned extubation

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 carefully and 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 3.1 shows unplanned extubation rates per 100 intubated days. The average rate for all ICU’s was 0.4 per 100 intubated days, so the rate for both GOSH CICU at 0.1 per 100 intubated days and GOSH PICU and NICU at 0.2 per 100 intubated days is well below the average rate indicating high quality care.

Fig 3.1 Unplanned extubation rates for all admissions, Jan to Dec 2017

Fig 3.1 Unplanned extubation rates for all admissions, Jan to Dec 2017

Published with the permission of PICANet from “Paediatric Intensive Care Audit Network Annual Report 2018 (published Nov 2018): Universities of Leeds and Leicester.”

This information was published in March 2019, and will be updated annually.