Improved outcomes from tertiary center pediatric intensive care: A statewide comparison of tertiary and nontertiary care facilities

OBJECTIVETo compare outcomes from pediatric intensive care in hospitals with different levels of resources. DESIGNProspective, blinded comparison of outcome and care SETTINGTertiary (n = 3) and nontertiary (n = 71) hospitals in Oregon and southwestern Washington. PATIENTSAll critically ill children admitted with respiratory failure and head trauma for 6 months. MEASUREMENTS AND MAIN RESULTSSeverity of illness adjusted mortality rates were determined using admission day, physiologic profiles (Pediatric Risk of Mortality score) and care modalities were assessed daily. The crude mortality rate of the tertiary patients was four times higher than for the nontertiary patients (23.4% vs. 6.0%, p < .0001). In the tertiary patients, the numbers of outcomes were accurately predicted by physiologic profiles (observed30 deaths and 98 survivors; predicted29.3 deaths and 98.7 survivors, z = −.25, p > A). However, for the nontertiary patients, the number of the deaths were significantly different than predicted (observed20 deaths and 315 survivors; predicted14.4 deaths and 320.6 survivors, z = −2.08, p < .05). The odds ratios of dying in a nontertiary vs. a tertiary facility were about 1.1,2.3, and 8 (p < .05) for mortality risk groups of 30%. Patients in tertiary facilities received more (p < .05) invasive (e.g., arterial catheters) and complex (e.g., mechanical ventilation) care, whereas patients in nontertiary facilities received more (p < .05) labor-intensive care (e.g., hourly vital signs). CONCLUSIONSCare of the most seriously ill children in tertiary pediatric ICUs could improve their chances of survival. (Crit Care Med 1991; 19:150)