SURVIVAL RATES IN A PAEDIATRIC / NEONATAL INTENSIVE CARE … · Dedicated paediatric intensive care...

For peer review only

SURVIVAL RATES IN A PAEDIATRIC / NEONATAL

INTENSIVE CARE UNIT

Journal: BMJ Open

Manuscript ID bmjopen-2015-010850

Article Type: Research

Date Submitted by the Author: 15-Dec-2015

Complete List of Authors: Ballot, Daynia E.; Univ Witwatersrand, Paediatrics and Child Health Davies, Victor; University of the Witwatersrand, Paediatrics and Child Health Cooper, Peter; University of the Witwatersrand, Paediatrics and Child Health Chirwa, Tobias; University of the Witwatersrand, School of Public Health Argent, Andrew; Red Cross War Memorial Childrens Hospital, Paediatric Intensive Care Unit

Mer, Mervyn; University of the Witwatersrand, Internal Medicine

<b>Primary Subject Heading</b>:

Paediatrics

Secondary Subject Heading: Intensive care, Epidemiology

Keywords: Paediatric intensive & critical care < PAEDIATRICS, NEONATOLOGY, HEALTH SERVICES ADMINISTRATION & MANAGEMENT

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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SURVIVAL RATES IN A PAEDIATRIC / NEONATAL INTENSIVE CARE

UNIT

Daynia E Ballot1, 4*

Victor A Davies1

Peter A Cooper 1

Tobias Chirwa 2

Andrew Argent3

Mervyn Mer4, 5

1. Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the

Witwatersrand, Johannesburg, South Africa

2. Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health

Sciences, University of the Witwatersrand, Johannesburg, South Africa

3. School of Child and Adolescent Health, Faculty of Health Sciences, University of Cape Town,

Cape Town, South Africa

4. Wits- UQ Critical care Infection Collaboration, Johannesburg South Africa

5. Department of Internal Medicine, Division of Critical Care and Pulmonology Faculty of Health


∗ Corresponding author

Postal address

Private Bag X 39

Johannesburg

2000

Email: [email protected]

Keywords

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Intensive care units, neonatal; Intensive care units, paediatric; Critical Care; South Africa

Word count: 2494

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Contributorship statement

• DE Ballot conceptualised the study, collected and analysed the data and wrote up the

manuscript

• VA Davies assisted with the concept, data collection and reviewed the write up of the

manuscript.

• PA Cooper assisted with the study concept and review of the write up of the manuscript

• T Chirwa assisted with data analysis and review of the write up of the manuscript

• A Argent provided advice and input into the final write up of the manuscript.

• M Mer provided advice and input into the final write up of the manuscript.

Data sharing statement

No additional data is available.

Conflict of interest

The authors declare that they have no conflicts of interest

Funding

There was no funding for the study reported in this article

Acknowledgements

The authors gratefully acknowledge the help of Dr Debbie White, Dr Edgar Kalimba, Dr Priya

Wallabh, Dr Lea Chirwa, Dr Tanusha Ramdin, Dr David Raketsoane and Dr Faustine Agaba with data

collection, and Mr Lebogang Rapola , Miss Patricia Hanrahan and Mr Milton Reinecke with data

management.

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ABSTRACT

Objective

Dedicated paediatric intensive care unit (PICU) facilities are frequently unavailable in low to middle

income countries. This study aimed to report on the survival to discharge of children admitted to a

combined paediatric / neonatal ICU in Johannesburg, South Africa.

Design and setting

This was a cross-sectional review of admissions to a combined paediatric / neonatal intensive care

unit in a single tertiary hospital in South Africa.

Participants

The study included all admissions (both paediatric and neonatal) to the unit between 1 January 2013

and 30 June 2015.

Outcome measures

Survival to discharge was the primary outcome variable. Severity of illness was not scored during the

study period.

Results

There were a total of 1,454 admissions, of which 182 records of admissions were not traceable,

leaving 1,272 admissions for review. Overall mortality rate was 25.7% (327/1272) There were

statistically significant differences in mortality in different age groups, with the mortality rate being

41.4% (121/292) (95% CI 35.8-47.1) for very low birth weight babies, 26.6% (120/451) (95%CI 22.5-

30.5) for bigger babies and 16.2% (86/529) (95%CI 13.1-19.3)for paediatric patients.

Conclusions

The mortality rate for both neonatal and paediatric age groups in this unit is high. Efforts should be

made to improve paediatric intensive care in combined ICU facilities.

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ARTICLE SUMMARY

• Many critically ill children are not cared for by dedicated paediatric intensivists, even in a

tertiary hospital in a middle income country.

• The mortality of both critically ill neonates and older children is higher in a combined

paediatric/neonatal ICU than in a dedicated unit.

• Paediatric ICU admissions are often at the expense of critically ill neonates

• Severity of illness scoring was not available during the study period, so only unadjusted

mortality rates are reported.

• This was a retrospective analysis of a computerised database, so not all records were

available for inclusion.

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BACKGROUND

Provision of both paediatric and neonatal intensive care in a low to middle income country (LMIC) is

challenging.[1] Difficulties include lack of medical and nursing staff, insufficient medication and

equipment and inadequate diagnostic facilities.[1,2] Identifying the optimal use of PICU beds in a

resource-limited situation is difficult. The use of ICU admission criteria attempt to ensure that the

limited facilities benefit those who will gain most; children without a reasonable chance of

functional recovery are not routinely admitted to PICU.[1,3] Argent et al discussed an approach to

optimising the use of limited PICU facilities at the Red Cross War Memorial Children’s Hospital

(RCWMCH) in Cape Town, South Africa, stating that hospitals need to develop “explicit policies for

utilisation of PICU resources” using “a reasonable process for fair and equitable utilisation of scarce

resources… that may extend beyond the priorities of individual patients”.[3]

Mortality and infection rates in PICU in developing countries are influenced by the income level of

the country.[4] The average PICU mortality rate in Latin American countries was 13.39% compared

to 5.4% in European countries.[5] The mean PICU mortality rate in Turkey was reported to be

14.6%.[2] PICU mortality at the RCWMCH in Cape Town, however, has declined from 10.6% in 2006

to 9% in 2010.[3,6] The mortality rate of children admitted to general ICU facilities in other African

countries is far higher than the RCWMCH experience, ranging from 36% to 40%.[7,8,9]

Children admitted to a centralised dedicated paediatric ICU have better survival rates than those

treated in general or shared ICU facilities, even in developing countries.[10,11] Dedicated PICU

facilities are uncommon in South Africa. Critical care beds in South Africa are concentrated in the

more affluent provinces (Gauteng, Kwa-Zulu Natal and the Western Cape) and in the private

sector.[12,13] Only 19.6% of the total ICU beds were for paediatric and neonatal intensive care, and

mixed surgical and medical units admit children in most hospitals.[12] Lack of dedicated PICU

facilities is common in many other African countries. In Uganda, for example, there is one general

ICU bed per million people.[9]

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Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) is a quaternary referral hospital with a

single combined paediatric / neonatal ICU (PNICU) with 14 ventilator beds. This unit serves

neonates, general paediatrics, paediatric sub-specialities and paediatric surgery; renal dialysis and

high frequency ventilation are available. The age of admission ranges from birth to 14 years. . It is

often not possible to admit patients because of a lack of available beds. The unit has no dedicated

paediatric intensivist, but is run by other subspecialists, mainly neonatologists. Nasal continuous

positive airways pressure (NCPAP) is the first line of ventilatory support for neonates with

respiratory failure.[14] Patients who require “high care” observation or treatment are not routinely

admitted; the PNICU essentially functions as a ventilator unit. Additional information regarding the

CMJAH PNICU is provided in the supplementary file, available online. There is a lack of information

on admissions to the CMJAH PNICU. This study therefore aimed to review the survival to discharge

of patients admitted to the unit. Secondary objectives included comparing the survival rate between

paediatric and neonatal patients, determining the disease profile of patients, establishing predictors

of death and evaluating the impact on bed availability of the use of NCPAP.

SUBJECTS AND METHODS

This was a retrospective cross-sectional record review of all patients admitted to the CMJAH PNICU

between 1 January 2013 and 30 June 2015. Patients were admitted and cared for at the discretion of

the attending physician, using age-related norms and treatment protocols. Patient charts were

reviewed on discharge from PNICU and demographic, clinical and outcome data were captured.

Variables were recorded as positive if there had been any occurrence during their time in the PNICU.

Detailed definitions of the variables used in the study are provided in the supplementary file

available online.

Patient data were entered into computerised databases for clinical audit and quality improvement.

These databases are managed by Research Electronic Data Capture (REDCAP) hosted by the

University of the Witwatersrand.[15] The data were de-identified and entered into IBM SPSS (version

22) for the purposes of analysis. Ethical clearance for the study was obtained from the Human

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Research Ethics Committee of the University of the Witwatersrand. Patients with no retrievable

information were excluded from the study.

Definitions of patient categories

Neonates were classified as those < 28 days of age who had never been discharged home, and who

had been admitted directly to PNICU from other hospitals or the neonatal nursery at CMJAH.

Neonates who had been discharged home and then readmitted to PNICU were classified as

paediatric patients. Neonates were further divided into very low birth weight (VLBW) infants (< 1500

grams birthweight) and bigger babies (> 1500 grams birthweight). Children older than 14 years were

usually admitted to the adult ICU. All neonates admitted to PNICU in this study were intubated and

ventilated; some paediatric patients were not intubated but admitted for high care treatment.

Statistical analysis

Continuous variables such as age at admission were described using mean and standard deviation

(SD) or median with inter-quartile range (IQR), depending on whether the data were normally

distributed. Categorical variables were described as frequencies and percentages. Survival to

discharge from ICU was considered the primary outcome variable for comparison.

Univariate analysis comparing different characteristics between survivors and non-survivors used an

independent t-test for normally-distributed data and the Mann-Whitney U-test for skewed data. A

Chi-square test was used to compare differences in survival for categorical variables. A p value of <

0.05 was considered to be statistically significant. Variables with a p value < 0.05 in the univariate

analysis were entered into a multiple stepwise logistic regression model to establish determinants of

survival to PNICU discharge. Neonates and older paediatric patients have different disease profiles

and different risk factors for mortality. Data were therefore analysed separately for VLBW, bigger

babies and paediatric patients.

.RESULTS

A total of 1,454 patients were admitted to the PNICU during the study period. Records could not be

retrieved for 182 patients, so the study included 1,272 patients. There were 292 VLBW babies

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(22.9%), 451 bigger babies (35.4%) and 529 paediatric (41.5%) admissions. The overall proportion

dying was 25.7% (327 /1272). There was a statistically significant difference in the proportion of

deaths between patients of different ages, with the death rate being 41.4% (95% CI 35.8-47.1) in

VLBW babies, 26.6% (95% CI 22.5-30.5) in bigger babies and 16.2% (95% CI 13.1-19.3) in paediatric

patients (p < 0.0001).

Non-invasive ventilatory support in the form of NCPAP was provided to an additional 395 bigger

babies and 651 VLBW babies. A total of 2,318 patients therefore received ventilatory support during

the study period (846 bigger babies, 943 VLBW babies and 529 paediatric patients). Almost half

(43.7%, 1,015/2,318) of the patients who received ventilatory support were treated successfully with

NCPAP without requiring admission to PNICU. The overall mortality rate for babies who received any

ventilatory support was 20.8% (483/2318), or 28.1 % (265/943) for the VLBW babies and 15.6%

(132/846) for the bigger babies (see Figure 1).

Paediatric ICU admissions

Details of the 529 paediatric admissions are shown in Table 1. The median age at admission was 8.7

months (IQR 46.5). There was no statistically significant difference in the median age of admissions

between survivors and non-survivors [10.5 months (IQR 50.7) vs 7.3 months (IQR 35.7); p=0.412].

Similarly, the median duration of ICU stay was not significantly different for survivors and non-

survivors (approximately 3 days in both groups) (p=0.540). The majority of patients (471/529; 89%)

were intubated and ventilated. More than half (305/529; 57.7%) of the paediatric patients were

surgical admissions. The most common problem in medical paediatric patients was lower respiratory

tract illness (191/529; 36.1%).

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Table 1

Factors associated with survival in the 529 paediatric patients admitted to CMJAH PNICU between 1

January 2013 and 30 June 2015

Variable Children with the

condition (%)

Percentage of

children with the

condition that died

(95% CI)

Percentage of

children without

the condition that

died (95% CI)

P Value

Male 292 (55.2) 16.1 (11.9–20.3) 17.4 (12.3–22.5) 0.477

HIV exposed* 106 (20)

30.2 (21.5–38.9)

12.2 (9.1–16.1)

< 0.001

HIV PCR positive* 30 (5.7) 30 (13.6–46.4) 15.4 (12.2–18.6) 0.036

Recurrent

admission

52 (9.8) 11.5 (2.8–20.1) 16.8 (13.4–20.2) 0.604

Post cardiac arrest* 34 (6.4) 47 (30.2–63.8) 13.4 (10.4–16.4) < 0.001

Intubated and

ventilated

471 (89) 17.2 (13.8–20.6) 8.6 (1.3-15.8) 0.095

Surgical patients* 305 (57.7) 9.8 (6.3–13.3) 25.0 (19.3–30.7) < 0.001

Post-operative* 239 (45.2) 7.5 (4.2–10.8) 23.6 (18.7–28.6) < 0.001

Trauma 75 (14.2) 18.6 (9.8–27.4) 15.8 (12.4–19.2) 0.542

Inotropic support* 53 (10.0) 60.4 (47.2–73.6) 11.2 (8.3–14.1) < 0.001

Upper respiratory

tract*

61 (11.5) 6.5 (0.3–12.7) 17.5 (14.6–20.9) 0.029

Lower respiratory

tract*

191 (36.1) 25.6 (19.4–31.8) 10.9 (7.6–14.2) < 0.001

Cardiovascular* 97 (18.3) 28.9 (19.9–37.9) 13.4 (10.2–16.6) < 0.001

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*Statistically significant predictors of survival on univariate analysis

Binary logistic regression analysis with survival to discharge from PNICU as the outcome variable

showed that poor outcome was associated with post cardiac arrest (OR 0.21, 95% CI 0.09-0.49),

inotropic support (OR 0.085, 95% CI 0.04-0.17), hypernatraemia (OR 0.16, 95% CI 0.04-0.6), bacterial

sepsis (OR 0.32, 95% CI 0.16-0.65) and lower respiratory tract infection (OR 0.54, 95% CI 0.30-0.97).

Post- operative patients had an increased chance of survival to discharge (OR 2.96, 95% CI 1.49-

5.92).

Bigger babies

Characteristics of the 451 bigger babies admitted to PNICU and factors associated with their survival

to ICU discharge are shown in Table 2. The median duration of ventilation for bigger babies was 3

days (IQR 75). Those babies who died had a significantly shorter duration of ventilation compared to

Neurological 125 (23.6) 22.5 (15.2–29.9) 16.7 (12.8–20.6) 0.086

Gastrointestinal* 65 (12.3) 26.1 (15.4–36.8) 14.9 (11.7–18.1) 0.021

Renal* 18 (3.4) 29.4 (6.3–52.5) 15.6 (12.5–18.8) 0.024

Haematology /

Oncology (incl.

anaemia)

108 (20.4) 13.8 (7.3–20.3) 16.8 (13.2–20.4) 0.559

Hypernatraemia* 15 (2.8) 33.3 (9.5–15.2) 14.8 (11.7–17.9) < 0.001

Hyperglycaemia* 6 (1.1) 50 (9.9–90.0) 15.8 (12.7–18.9) 0.024

Hypoglycaemia* 11 (2.1) 45.4 (15.9–74.8) 15.6 (12.7–18.7) 0.008

Metabolic acidosis* 26 (4.9) 46.2 (27.0–65.4) 14.7 (11.6–17.8) < 0.001

Poisoning 17 (3.2) 23.5 (3.3–43.7) 15.8 (12.6–19.0) 0.494

Drowning 7 (1.3) 14.2 (11.7–40.1) 16.4 (13.2–19.6) 0.824

Bacterial sepsis* 64 (12.1) 32.8 (21.3–44.3) 13.7 (10.5–16.9) < 0.001

Viral infection 34 (6.4) 17.6 (4.8–30.4) 16.2 (12.9–19.5) 0.974

Fungal infection 16 (3.0) 31 (8.3–51.7) 15.6 (12.4–18.8) 0.229

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survivors (2 days (IQR 6) vs 4 days (IQ R6); p < 0.001). The mean gestational age of bigger babies

admitted to PNICU was 36.97 ± 3.6 weeks and mean birth weight was 2,603 ± 736 grams. There

were no statistically significant differences between survivors and non-survivors in gestational age

(36.89 ± 3.6 weeks vs 37.23 ± 3.5 weeks; p = 0.404) or birth weight (2,617 ± 763 grams vs 2,576 ±

663 grams; p = 0.615). Just over one third of bigger babies (34.3%) were surgical patients.

Table 2

Characteristics and predictors of survival in 451 bigger babies admitted to CMJAH PNICU between

1 January 2013 and 30 June 2015

Variable Number of children

Percentage of

babies with the

condition that died

(95% CI)

Percentage of

babies without

the condition that

died (95% CI)

p value

Place of birth:

Another unit

Before arrival

CMJAH

220 (48.7)

14 (3.1)

186 (41.2)

34.1 (27.8–40.4)

28.6 (4.9 – 52.3)

30.1 (23.5 – 36.7)

0.577

Antenatal care 302 (67) 27.2 (22.2–32.2) 26.8 (18.0–35.6) 0.827

Maternal HIV 127 (28.2) 32.3 (24.2-40.4) 24.9 (20.0-29.9) 0.231

Caesarean section 169 (37.4) 23.6 (17.0–30.2) 32.9 (25.9–40.0) 0.31

Male 274 (60.8) 27.7 (22.4–33.0) 25.3 (18.8–31.8) 0.491

Resuscitated at birth 98 (21.7) 28.6 (19.7–37.6) 26.1 (21.5–30.7) 0.619

Early onset sepsis 20 (4.4) 20 (2.5–37.5) 27.1 (22.8–31.4) 0.664

Meconium aspiration 75 (16.6) 25.3 (15.5–35.1) 26.9 (22.4–31.4) 0.784

Hyaline membrane

disease*

89 (19.7) 16.9 (9.1–24.7) 29.0 (24.3–33.7) 0.02

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PPHN1*

45 (10.0) 46.7 (32.1–61.3) 24.4 (20.2–28.6) 0.002

Surfactant therapy 108 (23.9) 21.3 (13.4–29.0) 28.7 (13.4–29.0) 0.518

Hypotension requiring

inotropes*

55 (12.2) 54.5 (41.3–67.7) 22.7 (18.6–26.8) < 0.001

CHD2* 37 (8.2) 54.1 (38.0–70.2) 25.3 (21.1–29.5) <0.001

NEC3 43 (9.5) 37.2 (22.8–51.7) 25.3 (21.1–29.5) 0.35

Surgery (excluding

NEC)

129 (28.6) 23.3 (16.0–30.6) 28.0 (23.1–32.9) 0.395

Hyperglycaemia* 46 (10.2) 41.3 (27.1–55.5) 24.9 (20.7–29.1) 0.017


Late onset sepsis 119 (26.4) 29.4 (21.2–37.6) 25.6 (20.9–30.3) 0.420

Major birth defect* 146 (32.4) 36.3 (28.5–44.1) 22.0 (17.4–26.7) 0.002


1. PPHN Persistent pulmonary hypertension of the neonate

2. CHD congenital heart disease

3. NEC necrotising enterocolitis

Binary logistic regression analysis for factors associated with survival in bigger babies showed major

birth defects (OR 0.44, 95%CI 0.26-0.74), PPHN (OR 0.44, 95% CI 0.21–0.91) metabolic acidosis (OR

0.23, 95% CI 0.12–0.74), inotropic support (OR 0.23, 95% CI 0.12–0.45) and CHD (OR 0.29, 95% CI

0.13–0.62) were all predictive of poor survival.

Very low birth weight babies

Characteristics of the 292 VLBW babies admitted to the PNICU are shown in Table 3. The mean birth

weight was 1,133.2 ± 182 grams and mean gestational age 28.95 ± 8.17 weeks. There were no

statistically significant differences between survivors and non-survivors in mean birth weight (1,149

± 182 vs 1,109 ± 180 grams; p = 0.063) or gestational age (29.01 ± 2.1 vs 28.86 ± 2.1 weeks; p

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=0.540). The median duration of ventilation was 5 days (IQR 8). The duration of ventilation was

significantly shorter in VLBW babies who died (4 days (IQR 10) vs 6 days (IQR 7); p < 0.001).

Table 3

Characteristics and predictors of survival for 292 VLBW babies admitted to the CMJAH PNICU

between 1 January 2013 and 30 June 2015

Variable

Number of babies

with the condition

Percentage of

babies with the

condition that

died (95% CI)

Percentage of

babies without

the condition that

died (95% CI)

p value

Place of birth*

Born before arrival

Born at another unit

Born at CMJAH

19 (6.5)

97 (33.2)

176 (60.3)

68.4 (47.5–89.3)

32.0 (22.7–41.3)

43.8 (36.5–51.1)

0.008

Antenatal care 171 (58.6) 39.8 (32.5–47.1) 43.8 (35.0–52.6) 0.49

Antenatal steroids 86 (29.5) 43.0 (32.5–53.5) 40.8 (34.1–47.5) 0.722

Maternal HIV 98 (33.6) 49.0 (39.1–58.9) 37.6 (30.8–44.4) 0.063


Male 164 (56.2) 42.7 (35.1–50.3) 40.2 (31.7–48.7) 0.638



IVH1 ¾* 32 (10.9) 53.1 (35.8–70.4) 33.3 (26.6–40.0) < 0.001

Hyaline membrane disease 268 (91.8) 41.4 (35.5–47.3) 41.6 (21.9–61.3) 0.981

Surfactant 228 (78.1) 39.9 (33.5–46.3) 46.9 (34.7–59.1) 0.318

Patent ductus arteriosus* 83 (28.4) 26.5 (17.0–36.0) 47.3 (40.5–54.1) < 0.001

NEC2* 72 (24.7) 62.5 (51.3–73.7) 34.5 (28.2–40.8) < 0.001

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NEC surgery* 39 (13.4) 56.4 (40.8–72.0) 39.1 (33.1–45.1) 0.041

Other surgery 36 (12.3) 50 (33.7–66.3) 40.2 (34.2–46.2) 0.265

Blood transfusion 88 (30.1) 38.7 (32.0–45.4) 47.7 (37.3–58.1) 0.152

Hyperglycaemia 68 (22.3) 51.5 (39.6–63.4) 38.4 (32.0–44.8) 0.055

Hypoglycaemia 38 (13.0) 42.1 (26.4–57.8) 41.3 (35.2–47.4) 0.929

Hypernatraemia 22 (7.5) 40.9 (20.4–61.4) 41.5 (35.6–47.4) 0.958

Metabolic acidosis* 39 (13.4) 19.2 (54.7–83.7) 37.2 (31.2-43.2) < 0.001


Major birth defect 19 (6.5) 42.1 (19.9–64.3) 41.4 (36.4–46.4) 0.951


1. IVH intraventricular haemorrhage


Binary logistic regression showed that the following factors were associated with reduced survival in

VLBW babies: birthweight (OR 0.997, 95% CI 0.995–0.999), born before arrival (OR 0.21, 95%CI 0.05–

0.84), maternal HIV exposure (OR 0.54, 95%CI 0.30–0.99), resuscitation at birth (OR 0.49, 95% CI

0.25–0.94), metabolic acidosis (OR 0.25, 95% CI 0.10–0.60) and NEC (OR 0.23, 95% CI 0.12–0.46).

DISCUSSION

This review of admissions to a combined PNICU shows an overall mortality rate of 25.7%. The

paediatric mortality rate was 16.2%, which is higher than the mortality rate at the dedicated

paediatric ICU at Red Cross Children’s Hospital[3], but lower than that reported for children

admitted to general ICUs in other African countries.[7,8,9]

Possible reasons for the high mortality rate in this study may lie outside the PNICU, such as late

referral and inadequate resuscitation, or within, such as insufficient beds and inadequate staffing.

The lack of a paediatric intensivist may contribute to the mortality rate; dedicated paediatric

intensivists reduce the mortality rate of children in ICU and improve the utilisation of beds.[16] The

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PNICU in this study was run mainly as a ventilator unit, with very few high care admissions, so a

sicker cohort of children may have been admitted to the CMJAH PNICU compared with other PICUs.

Mortality risk scores such as the PIM allow proper comparisons between different units.[17]

Although PIM data were not collected during the study period, predictors of poor outcome were

similar to the PIM, including post cardiac arrest, inotropic support and metabolic acidosis.[17]

The mortality was higher in neonates than paediatric patients. Mortality of ventilated neonates was

similar to that reported from units in India.[18] The very high mortality of the VLBW group in the

PNICU is not surprising as these patients had failed initial NCPAP and were therefore very sick

babies; the mortality rate of VLBW infants was similar to that reported for ventilated VLBW babies in

a study in China.[19] Birthweight, the strongest predictor of outcome in VLBW infants in our setting

[20], remained a significant factor associated with survival in the ventilated VLBW babies.

Both HIV infection and HIV exposure were significant predictors of outcome in the univariate

analysis, but not in the logistic regression. There is, however, selection bias, as only those HIV-

exposed infants who were expected to recover were admitted to the PNICU.

There were some apparent anomalies in our data. The low incidence of viral infections and

hyperglycaemia may reflect lack of active surveillance for these conditions. The low number of

fungal isolates may be explained by the fact that fungal organisms are difficult to isolate on

paediatric low volume blood cultures.

We found that the use of NCPAP had a big impact on the need for ventilator beds in the unit. An

additional 1,046 babies were treated successfully with NCPAP in a neonatal ward without requiring

admission to PNICU. We therefore recommend that the use of non-invasive ventilation provided in a

general ward, such as NCPAP, should be expanded to older children.

This study raises the issue of children’s rights to healthcare. A report from 2007 showed that only a

fraction of ICU beds in South Africa are dedicated to the care of children.[12] Our study raises the

issue of balancing the rights of older children and neonates in a combined unit. Only the very sickest

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neonates were admitted to the PNICU, which may be a form of discrimination. There are no easy

ways to identify which patients to admit to PNICU, especially in a resource-limited setting.[1,3]

Children must not come to ICU to die, yet many who are critically ill, with an increased risk of death,

may have a better chance of recovery if treated in ICU. We found that post-operative patients had

good outcomes, which may reflect the optimal use of ventilator beds in this unit, or may indicate

that many of these patients did not require ICU. Increasing the number of “high care” admissions,

would decrease the PNICU mortality rate, but this would often be at the expense of a sicker child

requiring ventilation.

This study had several limitations. The raw proportion of deaths in the CMJAH PNICU is higher than

other units, but may reflect a different level of severity of illness. As with all retrospective analysis,

not all information was available for inclusion in the study. The use of a standardised illness code

such as the ANZPIC system would have been preferable.[21]

CONCLUSIONS AND RECOMMENDATIONS

The unadjusted mortality rate of children admitted to this PNICU is higher than that reported in a

dedicated PICU in the same country.[3] Incorporation of a paediatric intensivist, even in poorer

countries, improves the outcome for children, both in terms of mortality and length of stay. [10,16]

Ongoing PICU training for all paediatric registrars, general paediatricians and other subspecialists is

recommended. Future clinical audit is should include a severity of illness score such as the PIM [21],

hospital paediatric mortality rate and the number of children denied admission to PNICU, together

with outcome data.

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References

1. Basnet S, Adhikari N, Koirala J. Challenges in setting up pediatric and neonatal intensive care units

in a resource-limited country. Pediatrics 2011;128(4):e986-92 doi: 10.1542/peds.2010-

3657[published Online First: Epub Date]|.

2. Koroglu TF, Atasever S, Duman M. A survey of pediatric intensive care services in Turkey. Turk J

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3. Argent AC, Ahrens J, Morrow BM, et al. Pediatric intensive care in South Africa: an account of

making optimum use of limited resources at the Red Cross War Memorial Children's

Hospital. Pediatr Crit Care Med 2014;15(1):7-14 doi:

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in pediatric intensive care units of 16 limited-resource countries: international Nosocomial

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5. Campos-Mino S, Sasbon JS, von Dessauer B. [Pediatric intensive care in Latin America]. Medicina

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6. Ghani AS, Morrow BM, Hardie DR, et al. An investigation into the prevalence and outcome of

patients admitted to a pediatric intensive care unit with viral respiratory tract infections in

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7. Embu HY, Yiltok SJ, Isamade ES, et al. Paediatric admissions and outcome in a general intensive

care unit. Afr J Paediatr Surg 2011;8(1):57-61 doi: 10.4103/0189-6725.78670[published

Online First: Epub Date]|.

8. El-Nawawy A. Evaluation of the outcome of patients admitted to the pediatric intensive care unit

in Alexandria using the pediatric risk of mortality (PRISM) score. J Trop Pediatr

2003;49(2):109-14

9. Kwizera A, Dunser M, Nakibuuka J. National intensive care unit bed capacity and ICU patient

characteristics in a low income country. BMC Res Notes 2012;5:475 doi: 10.1186/1756-0500-

5-475[published Online First: Epub Date]|.

10. Pearson G, Shann F, Barry P, et al. Should paediatric intensive care be centralised? Trent versus

Victoria. Lancet 1997;349(9060):1213-7 doi: 10.1016/s0140-6736(96)12396-5[published

Online First: Epub Date]|.

11. Goh AY, Lum LC, Abdel-Latif ME. Impact of 24 hour critical care physician staffing on case-mix

adjusted mortality in paediatric intensive care. Lancet 2001;357(9254):445-6 doi:

10.1016/s0140-6736(00)04014-9[published Online First: Epub Date]|.

12. Bhagwanjee S, Scribante J. National audit of critical care resources in South Africa - unit and bed

distribution. S Afr Med J 2007;97(12 Pt 3):1311-4

13. Naidoo K, Singh J, Lalloo U. A critical analysis of ICU/HC beds in South Africa: 2008-2009. S Afr

Med J 2013;103(10):751-3 doi: 10.7196/samj.6415[published Online First: Epub Date]|.

14. Jardine C, Ballot DE. The use of nasal CPAP at Charlotte Maxeke Johannesburg Academic

Hospital. S Afr J Child Health 2015;9(1):4

15. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—A metadata-

driven methodology and workflow process for providing translational research informatics

support. J Biomed Inform 2009;42(2):377-81 doi:

http://dx.doi.org/10.1016/j.jbi.2008.08.010[published Online First: Epub Date]|.

16. Pollack MM, Katz RW, Ruttimann UE, et al. Improving the outcome and efficiency of intensive

care: the impact of an intensivist. Crit Care Med 1988;16(1):11-7

17. Straney L, Clements A, Parslow RC, et al. Paediatric index of mortality 3: an updated model for

predicting mortality in pediatric intensive care*. Pediatr Crit Care Med 2013;14(7):673-81

doi: 10.1097/PCC.0b013e31829760cf[published Online First: Epub Date]|.

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18. Iqbal Q, Younus MM, Ahmed A, et al. Neonatal mechanical ventilation: Indications and outcome.

Ind J Crit Care Med 2015;19(9):523-7 doi: 10.4103/0972-5229.164800[published Online First:

Epub Date]|.

19. Ma L, Liu CQ, Meng LZ, et al. [Prospective study on in-hospital mortality and its risk factors in

very low birth weight infants requring mechanical ventilation]. Zhongguo Dang Dai Er Ke Za

Zhi 2012;14(10):737-41

20. Ballot DE, Chirwa T, Ramdin T, et al. Comparison of morbidity and mortality of very low birth

weight infants in a Central Hospital in Johannesburg between 2006/2007 and 2013. BMC

Pediatr 2015;15:20 doi: 10.1186/s12887-015-0337-4[published Online First: Epub Date]|.

21. Slater A, Shann F, McEniery J. The ANZPIC registry diagnostic codes: a system for coding reasons

for admitting children to intensive care. Intensive Care Med 2003;29(2):271-7 doi:

10.1007/s00134-002-1600-3[published Online First: Epub Date]|.

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Figure 1

Ventilatory support in neonates admitted to CMJAH between 1 January 2013 and 30 June 2015

Key: NCPAP nasal continuous positive airways pressure; IPPV intermittent positive pressure

ventilation

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Figure 1

Ventilatory support in neonates admitted to CMJAH between 1 January 2013 and 30 June 2015

Key: NCPAP nasal continuous positive airways pressure; IPPV intermittent positive pressure ventilation

127x76mm (150 x 150 DPI)

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Paediatric ICU in South Africa

There are many challenges with the provision of paediatric intensive care in South Africa.

Inadequate funding may result in insufficient or poorly maintained equipment, lack of adequately

trained staff and limited supplies of expensive medicines. Patients are often severely ill, present late

and suffer from multi-system diseases. Regional hospitals frequently do not have ICU facilities, so

tertiary centres receive referrals from a wide geographic area.

Severity of illness scores have been developed using predictors of poor outcome such as metabolic

acidosis and cardiac arrest. Two such scores are the Paediatric Risk of Mortality (PRISM)[10] and

Paediatric Index of Mortality (PIM)[11]. These scores are not designed for triage but are useful for

quality control, health planning and comparing the performance of different units[12]. These

severity of illness scores were developed in richer countries and standardised on the basis of data

from these countries. LMICs may have a different profile of patients and different outcomes. In a

recent study, however, Solomon et al [13] demonstrated that the PIM2 score was both accurate and

well calibrated in a South African PICU.

The HIV epidemic in South Africa has further complicated the question of admission criteria to PICU.

Both HIV exposure and infection are predictive of increased mortality in PICU [6]. Kitchin et al [14]

reported a case fatality rate of 30% for HIV-exposed children ventilated for respiratory failure.

Cytomegalovirus co-infection seemed to confer a worse outcome, although the mechanism of this is

unclear. In 2007, children with established HIV infection and “whose lives are in danger from AIDS-

related disease” had a poor prognosis and were not admitted to PICU.[3] Children established on

antiretroviral therapy and with an unrelated reason for PICU admission were, however suitable for

admission. More recently, with the advent of readily available antiretroviral therapy for children, this

approach may no longer be appropriate.

The PNICU was staffed by a PNICU consultant on call; the resident staff included two paediatric

registrars and a medical officer. After hours, a resident registrar and medical officer cover PNICU and

the whole neonatal service. Nurse to patient ratios follow neonatal norms – of 1 nurse to 2 patients.

Hypernatraemia was defined as 150 mmol/l, but most patients who died with the condition had

much higher levels of sodium. Congenital heart disease associated with mortality included

hypoplastic left heart syndrome and various complex congenital heart defects.

Comment [M1]: This statement also needs a

reference.

Comment [M2]: Again, this statement needs a

reference.

Comment [M3]: This statement also needs a

reference.

Comment [M4]: In your abstract, you mention

that you did not use severity of illness scores during

the study. You could, therefore, delete this

paragraph to reduce the word count.

Comment [M5]: Again, this paragraph could be

reduced to reduce word count. You might consider

online-only content discussing ‘Admission criteria to

PICU in African countries’ or similar.

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Children who had a poor chance of survival or risk of severe neurological handicap were not

routinely admitted to the PNICU. HIV-exposed children not in multi-organ failure were admitted to

the PICU during the study period. Neonates weighing less than 900 grams at birth were not

routinely admitted to PNICU during the study period.

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STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies

Item

No Recommendation

Page

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the

abstract

4

(b) Provide in the abstract an informative and balanced summary of what was

done and what was found

4

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being

reported

6,7

Objectives 3 State specific objectives, including any prespecified hypotheses 7

Methods

Study design 4 Present key elements of study design early in the paper 7

Setting 5 Describe the setting, locations, and relevant dates, including periods of

recruitment, exposure, follow-up, and data collection

7

Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of

participants

7

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders,

and effect modifiers. Give diagnostic criteria, if applicable

7

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of

assessment (measurement). Describe comparability of assessment methods if

there is more than one group

Supplementary

file

Bias 9 Describe any efforts to address potential sources of bias

Study size 10 Explain how the study size was arrived at 7

Quantitative

variables

11 Explain how quantitative variables were handled in the analyses. If

applicable, describe which groupings were chosen and why

8

Statistical methods 12 (a) Describe all statistical methods, including those used to control for

confounding

8

(b) Describe any methods used to examine subgroups and interactions

(c) Explain how missing data were addressed

(d) If applicable, describe analytical methods taking account of sampling

strategy

(e) Describe any sensitivity analyses

Results 9 to 14

Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers

potentially eligible, examined for eligibility, confirmed eligible, included in

the study, completing follow-up, and analysed

(b) Give reasons for non-participation at each stage

(c) Consider use of a flow diagram

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical,

social) and information on exposures and potential confounders

(b) Indicate number of participants with missing data for each variable of

interest

Outcome data 15* Report numbers of outcome events or summary measures

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted

estimates and their precision (eg, 95% confidence interval). Make clear

which confounders were adjusted for and why they were included

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2

(b) Report category boundaries when continuous variables were categorized

(c) If relevant, consider translating estimates of relative risk into absolute risk

for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and

sensitivity analyses

Discussion

Key results 18 Summarise key results with reference to study objectives 15

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias

or imprecision. Discuss both direction and magnitude of any potential bias

17

Interpretation 20 Give a cautious overall interpretation of results considering objectives,

limitations, multiplicity of analyses, results from similar studies, and other

relevant evidence

17

Generalisability 21 Discuss the generalisability (external validity) of the study results

Other information

Funding 22 Give the source of funding and the role of the funders for the present study

and, if applicable, for the original study on which the present article is based

2

*Give information separately for exposed and unexposed groups.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at www.strobe-statement.org.

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A RETROSPECTIVE CROSS SECTIONAL REVIEW OF

SURVIVAL RATES IN CRITICALLY ILL CHILDREN ADMITTED

TO A COMBINED PAEDIATRIC / NEONATAL INTENSIVE CARE

UNIT IN JOHANNESBURG, SOUTH AFRICA, 2013-2015

Journal: BMJ Open

Manuscript ID bmjopen-2015-010850.R1

Article Type: Research

Date Submitted by the Author: 19-Feb-2016

Complete List of Authors: Ballot, Daynia E.; Univ Witwatersrand, Paediatrics and Child Health Davies, Victor; University of the Witwatersrand, Paediatrics and Child Health Cooper, Peter; University of the Witwatersrand, Paediatrics and Child Health Chirwa, Tobias; University of the Witwatersrand, School of Public Health Argent, Andrew; Red Cross War Memorial Childrens Hospital, Paediatric Intensive Care Unit Mer, Mervyn; University of the Witwatersrand, Internal Medicine

<b>Primary Subject

Heading</b>: Paediatrics

Secondary Subject Heading: Intensive care, Epidemiology

Keywords: Paediatric intensive & critical care < PAEDIATRICS, NEONATOLOGY, HEALTH SERVICES ADMINISTRATION & MANAGEMENT


BMJ Open on June 5, 2020 by guest. P

rotected by copyright.http://bm

jopen.bmj.com

/B

MJ O

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1

A RETROSPECTIVE CROSS SECTIONAL REVIEW OF SURVIVAL RATES IN

CRITICALLY ILL CHILDREN ADMITTED TO A COMBINED PAEDIATRIC /

NEONATAL INTENSIVE CARE UNIT IN JOHANNESBURG, SOUTH AFRICA,

2013-2015

Daynia E Ballot1, 4*

Victor A Davies1

Peter A Cooper 1

Tobias Chirwa 2

Andrew Argent3

Mervyn Mer4, 5

1. Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the

Witwatersrand, Johannesburg, South Africa

2. Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health


3. School of Child and Adolescent Health, Faculty of Health Sciences, University of Cape Town,

Cape Town, South Africa

4. Wits- UQ Critical Care Infection Collaboration, Johannesburg South Africa

5. Department of Internal Medicine, Division of Critical Care and Pulmonology Faculty of Health


∗ Corresponding author

Postal address

Private Bag X 39

Johannesburg

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2

2000

Email: [email protected]

Keywords

Intensive care units, neonatal; Intensive care units, paediatric; Critical Care; South Africa

Word count: 2689

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Contributorship statement

• DE Ballot conceptualised the study, collected and analysed the data and wrote up the

manuscript

• VA Davies assisted with the concept, data collection and reviewed the write up of the

manuscript.

• PA Cooper assisted with the study concept and review of the write up of the manuscript

• T Chirwa assisted with data analysis and review of the write up of the manuscript

• A Argent provided advice and input into the final write up of the manuscript.

• M Mer provided advice and input into the final write up of the manuscript.

Data sharing statement

No additional data is available.

Conflict of interest

The authors declare that they have no conflicts of interest

Funding

There was no funding for the study reported in this article

Acknowledgements

The authors gratefully acknowledge the help of Dr Debbie White, Dr Edgar Kalimba, Dr Priya

Wallabh, Dr Lea Chirwa, Dr Tanusha Ramdin, Dr David Raketsoane and Dr Faustine Agaba with data

collection, and Mr Lebogang Rapola , Miss Patricia Hanrahan and Mr Milton Reinecke with data

management.

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ABSTRACT

Objective:

Report on survival to discharge of children in a combined paediatric / neonatal intensive care unit

(PNICU)

Design and setting:

Retrospective cross-sectional record review

Participants:

All children (both medical and surgical patients) admitted to PNICU between 1 January 2013 and 30

June 2015.

Outcome measures:

Primary outcome - Survival to discharge.

Secondary outcomes – disease profiles and predictors of mortality in different age categories.

Results

There were 1,454 admissions, 182 missing records, leaving 1,272 admissions for review. Overall

mortality rate was 25.7% (327/1272). Mortality rate was 41.4% (121/292) (95% CI: 35.8-47.1) for

very low birth weight (VLBW) babies, 26.6% (120/451) (95% CI: 22.5-30.5) for bigger babies and

16.2% (86/529) (95%CI 13.1-19.3) for paediatric patients. Risk factors for a reduced chance of

survival to discharge in paediatric patients included post cardiac arrest (OR 0.21 95% CI: 0.09 – 0.49),

inotropic support (OR 0.085, 95% CI: 0.04 – 0.17), hypernatraemia (OR 0.16, 95% CI: 0.04 – 0.6),

bacterial sepsis (OR 0.32, 95% CI: 0.16 – 0.65) and lower respiratory tract infection (OR 0.54, 95% CI:

0.30-0.97). Major birth defects (OR 0.44, 95% CI: 0.26 – 0.74), persistent pulmonary hypertension of

the new born (OR 0.44, 95% CI: 0.21 – 0.91), metabolic acidosis (OR 0.23, 95% CI: 0.12 – 0.74),

inotropic support (OR 0.23, 95% CI: 0.12 – 0.45) and congenital heart defects (OR 0.29, 95% CI: 0.13

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5

and 0.62) predicted decreased survival in bigger babies. Birthweight (OR 0.997, 95% CI: 0.995 –

0.999), birth outside the hospital (OR 0.21, 95% CI: 0.05 – 0.84), HIV exposure (OR 0.54, 95% CI: 0.30

– 0.99), resuscitation at birth (OR 0.49, 95% CI 0.25 – 0.94), metabolic acidosis (OR 0.25, 95% CI: 0.10

– 0.60) and necrotising enterocolitis (OR 0.23, 95% CI: 0.12 – 0.46) predicted poor survival in VLBW

babies.

Conclusions

Ongoing mortality review is essential to improve provision of paediatric critical care.

Strengths and limitations of the study

• This is a cross sectional retrospective review of a large sample of critically ill children cared

for in a predominantly neonatal intensive care unit.

• The study adds information about the outcome of critically ill children in sub-Saharan Africa.

• Predictors of mortality are reported for different age categories.

• Severity of illness scoring was not available during the study period, so only unadjusted

mortality rates are reported.

• This was a retrospective analysis of a computerised database, so not all records were

available for inclusion.

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•

BACKGROUND

The World Health Organisation reports that 5.9 million children under the age of 5 years died in

2015, 75% of whom were infants (under the age of 1 year) and most infants who died were from the

WHO African region.[1] The outcome of critically ill children may be improved by adequate intensive

care. Provision of both paediatric and neonatal intensive care in a low to middle income country

(LMIC) is challenging.[2] Difficulties include lack of medical and nursing staff, insufficient medication

and equipment and inadequate diagnostic facilities.[2, 3] Identifying the optimal use of PICU beds in

a resource-limited situation is difficult. The use of ICU admission criteria attempt to ensure that the

limited facilities benefit those who will gain most; children without a reasonable chance of

functional recovery are not routinely admitted to PICU.[2, 4] Argent et al discussed an approach to

optimising the use of limited PICU facilities at the Red Cross War Memorial Children’s Hospital

(RCWMCH) in Cape Town, South Africa, stating that hospitals need to develop “explicit policies for

utilisation of PICU resources” using “a reasonable process for fair and equitable utilisation of scarce

resources… that may extend beyond the priorities of individual patients”.[4]

Mortality and infection rates in PICU in developing countries are influenced by the income level of

the country.[5] The average PICU mortality rate in Latin American countries was 13.39% compared

to 5.4% in European countries.[6] The mean PICU mortality rate in Turkey was reported to be

14.6%.[3] PICU mortality at the RCWMCH in Cape Town, however, has declined from 10.6% in 2006

to 9% in 2010.[4, 7] The mortality rate of children admitted to general ICU facilities in other African

countries is far higher than the RCWMCH experience, ranging from 36% to 40%.[8-10]

Children admitted to a centralised dedicated paediatric ICU have better survival rates than those

treated in general or shared ICU facilities, even in developing countries.[11, 12] Dedicated PICU

facilities are uncommon in South Africa. Critical care beds in South Africa are concentrated in the

more affluent provinces (Gauteng, Kwa-Zulu Natal and the Western Cape) and in the private

sector.[13, 14] Only 19.6% of the total ICU beds were for paediatric and neonatal intensive care, and

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mixed surgical and medical units admit children in most hospitals.[13] Lack of dedicated PICU

facilities is common in many other African countries. In Uganda, for example, there is one general

ICU bed per million people.[10]

Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) is a quaternary referral hospital with a

single combined paediatric / neonatal ICU (PNICU) with 14 ventilator beds. This unit serves

neonates, general paediatrics, paediatric sub-specialities and paediatric surgery; renal dialysis and

high frequency ventilation are available. The age of admission ranges from birth to 14 years. It is

often not possible to admit patients because of a lack of available beds. The unit has no dedicated

paediatric intensivist, but is run by other subspecialists, mainly neonatologists. Nasal continuous

positive airways pressure (NCPAP) is the first line of ventilatory support for neonates with

respiratory failure.[15] Patients who require “high care” observation or treatment are not routinely

admitted; the PNICU essentially functions as a ventilator unit. Additional information regarding the

CMJAH PNICU is provided in the supplementary file, available online. There is a lack of information

on admissions to the CMJAH PNICU. This study therefore aimed to review the survival to discharge

of patients admitted to the unit. Secondary objectives included comparing the survival rate between

paediatric and neonatal patients, determining the disease profile of patients and establishing

predictors or factors associated with poor survival.

SUBJECTS AND METHODS

This was a retrospective cross-sectional record review of all patients admitted to the CMJAH PNICU

between 1 January 2013 and 30 June 2015. The PNICU admitted both neonates and older children

who suffered from medical or surgical conditions. Patients were admitted and cared for at the

discretion of the attending physician, using age-related norms and treatment protocols. Owing to

limited availability of PNICU beds, patients with an anticipated poor outcome, including those with

advanced HIV related disease, were not routinely ventilated. Similarly, neonates below 900 grams

birth weight were not usually offered mechanical ventilation. Exposure to HIV alone was not a

reason for exclusion from PNICU.

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Patient charts were reviewed on discharge from PNICU and demographic, clinical and outcome data

were captured. Variables were recorded as positive if there had been any occurrence during their

time in the PNICU. Detailed definitions of the variables used in the study are provided in the

supplementary file available online.

Patient data were entered into computerised databases for clinical audit and quality improvement.

These databases are managed by Research Electronic Data Capture (REDCAP) hosted by the

University of the Witwatersrand.[16] The data were de-identified and entered into IBM SPSS (version

22) for the purposes of analysis. Ethical clearance for the study was obtained from the Human

Research Ethics Committee of the University of the Witwatersrand. Patients with no retrievable

information were excluded from the study.

Definitions of patient categories

The group of patients was divided into paediatric patients (> 28 days of age) and neonates. Neonates

were classified as those < 28 days of age who had never been discharged home, and who had been

admitted directly to PNICU from other hospitals or the neonatal nursery at CMJAH. Neonates who

had been discharged home and then readmitted to PNICU were classified as paediatric patients.

Neonates were further divided into very low birth weight (VLBW) infants (< 1500 grams birthweight)

and bigger babies (> 1500 grams birthweight). Children older than 14 years were usually admitted to

the adult ICU. All neonates admitted to PNICU in this study were intubated and ventilated; some

paediatric patients were not intubated but admitted for high care treatment.

Surgical patients were defined as all children who had a surgical condition as their presenting

complaint. Post-operative admissions were defined those surgical patients who were electively

admitted to PNICU post- surgery.

Statistical analysis

Continuous variables such as age at admission were described using mean and standard deviation

(SD) or median with inter-quartile range (IQR), depending on whether the data were normally

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distributed. Categorical variables were described as frequencies and percentages. Survival to

discharge from ICU was considered the primary outcome variable for comparison.

Univariate analysis comparing different characteristics between survivors and non-survivors used an

independent t-test for normally-distributed data and the Mann-Whitney U-test for skewed data. A

Chi-square test was used to compare differences in survival for categorical variables. A p value of <

0.05 was considered to be statistically significant. Variables with a p value < 0.05 in the univariate

analysis were entered into a multiple stepwise logistic regression model to establish determinants of

survival to PNICU discharge. Neonates and older paediatric patients have different disease profiles

and different risk factors for mortality. Data were therefore analysed separately for VLBW, bigger

babies and paediatric patients.

RESULTS

A total of 1,454 patients were admitted to the PNICU during the study period. Records could not be

retrieved for 182 patients, so the study included 1,272 patients. There were 292 VLBW babies

(22.9%), 451 bigger babies (35.4%) and 529 paediatric (41.5%) admissions. The overall proportion

dying was 25.7% (327 /1272). There was a statistically significant difference in the proportion of

deaths between patients of different ages, with the death rate being 41.4% (121/292) (95% CI: 35.8-

47.1) in VLBW babies, 26.6% (120/451) (95% CI: 22.5-30.5) in bigger babies and 16.2% (86/529) (95%

CI: 13.1-19.3) in paediatric patients (p < 0.0001).

Paediatric ICU admissions

Details of the 529 paediatric admissions are shown in Table 1. The median age at admission was 8.7

months (IQR = 46.5). There was no statistically significant difference in the median age of admissions

between survivors and non-survivors [10.5 months (IQR = 50.7) vs 7.3 months (IQR = 35.7); p=0.412].

Similarly, the median duration of ICU stay was not significantly different for survivors and non-

survivors (approximately 3 days in both groups) (p=0.540). The majority of patients (471/529; 89%)

were intubated and ventilated. More than half (305/529; 57.7%) of the paediatric patients were

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surgical admissions. The most common problem in medical paediatric patients was lower respiratory

tract illness (191/529; 36.1%).

Table 1

Factors associated with survival in the 529 paediatric patients admitted to CMJAH PNICU between 1

January 2013 and 30 June 2015

Variable Children with the

condition (%)

Percentage of

children with the

condition that died

(95% CI)

Percentage of

children without

the condition that

died (95% CI)

P Value

Male 292 (55.2) 16.1 (11.9–20.3) 17.4 (12.3–22.5) 0.477

HIV exposed* 106 (20)

30.2 (21.5–38.9)

12.2 (9.1–16.1)

< 0.001

HIV PCR positive* 30 (5.7) 30 (13.6–46.4) 15.4 (12.2–18.6) 0.036

Recurrent

admission

52 (9.8) 11.5 (2.8–20.1) 16.8 (13.4–20.2) 0.604

Post cardiac arrest* 34 (6.4) 47 (30.2–63.8) 13.4 (10.4–16.4) < 0.001

Intubated and

ventilated

471 (89) 17.2 (13.8–20.6) 8.6 (1.3-15.8) 0.095

Surgical patients* 305 (57.7) 9.8 (6.3–13.3) 25.0 (19.3–30.7) < 0.001

Post-operative* 239 (45.2) 7.5 (4.2–10.8) 23.6 (18.7–28.6) < 0.001

Trauma 75 (14.2) 18.6 (9.8–27.4) 15.8 (12.4–19.2) 0.542

Inotropic support* 53 (10.0) 60.4 (47.2–73.6) 11.2 (8.3–14.1) < 0.001

Upper respiratory

tract*

61 (11.5) 6.5 (0.3–12.7) 17.5 (14.6–20.9) 0.029

Lower respiratory 191 (36.1) 25.6 (19.4–31.8) 10.9 (7.6–14.2) < 0.001

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Binary logistic regression analysis with survival to discharge from PNICU as the outcome variable

showed that poor outcome was associated with post cardiac arrest (OR 0.21, 95% CI: 0.09-0.49),

inotropic support (OR 0.085, 95% CI: 0.04-0.17), hypernatraemia (OR 0.16, 95% CI: 0.04-0.6),

bacterial sepsis (OR 0.32, 95% CI: 0.16-0.65) and lower respiratory tract infection (OR 0.54, 95% CI:

0.30-0.97). Post- operative patients were very unlikely to die during the PNICU admission (OR 2.96,

95% CI: 1.49-5.92).

tract*

Cardiovascular* 97 (18.3) 28.9 (19.9–37.9) 13.4 (10.2–16.6) < 0.001

Neurological 125 (23.6) 22.5 (15.2–29.9) 16.7 (12.8–20.6) 0.086

Gastrointestinal* 65 (12.3) 26.1 (15.4–36.8) 14.9 (11.7–18.1) 0.021

Renal* 18 (3.4) 29.4 (6.3–52.5) 15.6 (12.5–18.8) 0.024

Haematology /

Oncology (incl.

anaemia)

108 (20.4) 13.8 (7.3–20.3) 16.8 (13.2–20.4) 0.559

Hypernatraemia* 15 (2.8) 33.3 (9.5–15.2) 14.8 (11.7–17.9) < 0.001

Hyperglycaemia* 6 (1.1) 50 (9.9–90.0) 15.8 (12.7–18.9) 0.024

Hypoglycaemia* 11 (2.1) 45.4 (15.9–74.8) 15.6 (12.7–18.7) 0.008


Poisoning 17 (3.2) 23.5 (3.3–43.7) 15.8 (12.6–19.0) 0.494

Drowning 7 (1.3) 14.2 (11.7–40.1) 16.4 (13.2–19.6) 0.824

Bacterial sepsis* 64 (12.1) 32.8 (21.3–44.3) 13.7 (10.5–16.9) < 0.001

Viral infection 34 (6.4) 17.6 (4.8–30.4) 16.2 (12.9–19.5) 0.974

Fungal infection 16 (3.0) 31 (8.3–51.7) 15.6 (12.4–18.8) 0.229

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Bigger babies

Characteristics of the 451 bigger babies admitted to PNICU and factors associated with their survival

to ICU discharge are shown in Table 2. The median duration of ventilation for bigger babies was 3

days (IQR = 75). Those babies who died had a significantly shorter duration of ventilation compared

to survivors (2 days (IQR = 6) vs 4 days (IQR = 6); p < 0.001). The mean gestational age of bigger

babies admitted to PNICU was 36.97 ± 3.6 weeks and mean birth weight was 2,603 ± 736 grams.

There were no statistically significant differences between survivors and non-survivors in gestational

age (36.89 ± 3.6 weeks vs 37.23 ± 3.5 weeks; p = 0.404) or birth weight (2,617 ± 763 grams vs 2,576

± 663 grams; p = 0.615). Binary logistic regression showed that birthweight did not influence

survival in this sub category (p=0.614). Just over one third of bigger babies (34.3%) were surgical

patients.

Table 2

Characteristics and predictors of survival in 451 bigger babies admitted to CMJAH PNICU between

1 January 2013 and 30 June 2015

Variable

Children with

condition (%)

Percentage of

babies with the

condition that died

(95% CI)

Percentage of

babies without

the condition that

died (95% CI)

p value

Place of birth:

Another unit

Born outside health

facility

CMJAH

220 (48.7)

14 (3.1)

186 (41.2)

34.1 (27.8–40.4)

28.6 (4.9 – 52.3)

30.1 (23.5 – 36.7)

0.577

Antenatal care 302 (67) 27.2 (22.2–32.2) 26.8 (18.0–35.6) 0.827

Maternal HIV 127 (28.2) 32.3 (24.2-40.4) 24.9 (20.0-29.9) 0.231

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Male 274 (60.8) 27.7 (22.4–33.0) 25.3 (18.8–31.8) 0.491



Meconium aspiration 75 (16.6) 25.3 (15.5–35.1) 26.9 (22.4–31.4) 0.784

Hyaline membrane

disease*

89 (19.7) 16.9 (9.1–24.7) 29.0 (24.3–33.7) 0.02

PPHN1*

45 (10.0) 46.7 (32.1–61.3) 24.4 (20.2–28.6) 0.002

Surfactant therapy 108 (23.9) 21.3 (13.4–29.0) 28.7 (13.4–29.0) 0.518

Hypotension requiring

inotropes*

55 (12.2) 54.5 (41.3–67.7) 22.7 (18.6–26.8) < 0.001

CHD2* 37 (8.2) 54.1 (38.0–70.2) 25.3 (21.1–29.5) <0.001

NEC3 43 (9.5) 37.2 (22.8–51.7) 25.3 (21.1–29.5) 0.35

Surgery (excluding

NEC)

129 (28.6) 23.3 (16.0–30.6) 28.0 (23.1–32.9) 0.395

Hyperglycaemia* 46 (10.2) 41.3 (27.1–55.5) 24.9 (20.7–29.1) 0.017



Major birth defect* 146 (32.4) 36.3 (28.5–44.1) 22.0 (17.4–26.7) 0.002


1. PPHN Persistent pulmonary hypertension of the neonate

2. CHD congenital heart disease


Binary logistic regression analysis for factors associated with survival in bigger babies showed major

birth defects (OR 0.44, 95%CI 0.26-0.74), PPHN (OR 0.44, 95% CI: 0.21–0.91) metabolic acidosis (OR

0.23, 95% CI: 0.12–0.74), inotropic support (OR 0.23, 95% CI: 0.12–0.45) and CHD (OR 0.29, 95% CI:

0.13–0.62) were all predictive of poor survival.

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Very low birth weight babies

Characteristics of the 292 VLBW babies admitted to the PNICU are shown in Table 3. The mean birth

weight was 1,133.2 ± 182 grams and mean gestational age 28.95 ± 8.17 weeks. There were no

statistically significant differences between survivors and non-survivors in mean birth weight (1,149

± 182 vs 1,109 ± 180 grams; p = 0.063) or gestational age (29.01 ± 2.1 vs 28.86 ± 2.1 weeks; p

=0.540). The median duration of ventilation was 5 days (IQR = 8). The duration of ventilation was

significantly shorter in VLBW babies who died (4 days (IQR = 10) vs 6 days (IQR = 7); p < 0.001).

Table 3

Characteristics and predictors of survival for 292 VLBW babies admitted to the CMJAH PNICU

between 1 January 2013 and 30 June 2015

Variable

Babies with the

condition (%)

Percentage of

babies with the

condition that

died (95% CI)

Percentage of

babies without

the condition that

died (95% CI)

p value

Place of birth*

Born outside health facility

Born at another unit

Born at CMJAH

19 (6.5)

97 (33.2)

176 (60.3)

68.4 (47.5–89.3)

32.0 (22.7–41.3)

43.8 (36.5–51.1)

0.008

Antenatal care 171 (58.6) 39.8 (32.5–47.1) 43.8 (35.0–52.6) 0.49

Antenatal steroids 86 (29.5) 43.0 (32.5–53.5) 40.8 (34.1–47.5) 0.722

Maternal HIV 98 (33.6) 49.0 (39.1–58.9) 37.6 (30.8–44.4) 0.063


Male 164 (56.2) 42.7 (35.1–50.3) 40.2 (31.7–48.7) 0.638



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IVH1 ¾* 32 (10.9) 53.1 (35.8–70.4) 33.3 (26.6–40.0) < 0.001

Hyaline membrane disease 268 (91.8) 41.4 (35.5–47.3) 41.6 (21.9–61.3) 0.981

Surfactant 228 (78.1) 39.9 (33.5–46.3) 46.9 (34.7–59.1) 0.318

Patent ductus arteriosus* 83 (28.4) 26.5 (17.0–36.0) 47.3 (40.5–54.1) < 0.001

NEC2* 72 (24.7) 62.5 (51.3–73.7) 34.5 (28.2–40.8) < 0.001

NEC surgery* 39 (13.4) 56.4 (40.8–72.0) 39.1 (33.1–45.1) 0.041

Other surgery 36 (12.3) 50 (33.7–66.3) 40.2 (34.2–46.2) 0.265

Blood transfusion 88 (30.1) 38.7 (32.0–45.4) 47.7 (37.3–58.1) 0.152

Hyperglycaemia 68 (22.3) 51.5 (39.6–63.4) 38.4 (32.0–44.8) 0.055

Hypoglycaemia 38 (13.0) 42.1 (26.4–57.8) 41.3 (35.2–47.4) 0.929

Hypernatraemia 22 (7.5) 40.9 (20.4–61.4) 41.5 (35.6–47.4) 0.958

Metabolic acidosis* 39 (13.4) 19.2 (54.7–83.7) 37.2 (31.2-43.2) < 0.001


Major birth defect 19 (6.5) 42.1 (19.9–64.3) 41.4 (36.4–46.4) 0.951


1. IVH intraventricular haemorrhage


Binary logistic regression showed that the following factors were associated with reduced survival in

VLBW babies: birthweight (OR 0.997, 95% CI: 0.995–0.999), born before arrival (OR 0.21, 95%CI

0.05–0.84), maternal HIV exposure (OR 0.54, 95%CI 0.30–0.99), resuscitation at birth (OR 0.49, 95%

CI: 0.25–0.94), metabolic acidosis (OR 0.25, 95% CI: 0.10–0.60) and NEC (OR 0.23, 95% CI: 0.12–

0.46).

DISCUSSION

This review of admissions to a combined PNICU shows an overall mortality rate of 25.7%. The

paediatric mortality rate was 16.2%. This is higher than the mortality rate at the dedicated paediatric

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ICU at Red Cross Children’s Hospital, [4] but lower than that reported for children admitted to

general ICUs in other African countries.[8-10]

Possible reasons for the high mortality rate in this study may lie outside the PNICU, such as late

referral and inadequate resuscitation, or within, such as insufficient beds and inadequate staffing.

The lack of a paediatric intensivist may partly contribute to the mortality rate; dedicated paediatric

intensivists have been shown to reduce the mortality rate of children in ICU and improve bed

utilisation.[17] This PNICU was run mainly as an invasive ventilator unit, with limited high

dependency care admissions; 89% of paediatric patients and all neonates admitted to PNICU were

intubated and ventilated. Therefore this may represent a sicker cohort of children compared with

other PICUs. Mortality prediction risk scores such as the PIM allow objective comparisons between

different units.[18] Although PIM data was not collected during the study period, the predictors of

poor outcome in the current study were similar to the PIM, including post cardiac arrest, inotropic

support and metabolic acidosis.

The mortality was higher in neonates than paediatric patients. Mortality of ventilated neonates was

similar to that reported from units in India.[19] The very high mortality of the VLBW group in the

PNICU is not surprising as these patients had failed initial NCPAP and were therefore very sick babies

The mortality rate of ventilated VLBW infants was similar to that reported in a study in China.[20]

Birthweight, the strongest predictor of outcome in VLBW infants in our setting, [21] remained a

significant factor associated with survival in the ventilated VLBW babies.

Both HIV infection and HIV exposure were significant predictors of outcome in the univariate

analysis, but not in the logistic regression. There is, however, selection bias, as only those HIV-

exposed infants who were expected to recover were admitted to the PNICU.

Other potential sources of bias were considered. The age of paediatric patients was skewed towards

younger children who would be expected to have a higher mortality than their older counterparts.

There was a slight preponderance of infants (<1 year of age) in the paediatric age group (274/529

(51.8%). However, there was no significant difference in the number of deaths between infants and

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older children (53/274 (19.3%) vs 33/245 (13.5%) p =0.077). Similarly, neonates weighing above

2500 grams are expected to have a different disease profile and mortality rate to those weighing less

than 2500 grams. Babies > 2500 grams could therefore have been another source of bias in the

category of bigger babies, however, binary logistic regression showed that birthweight did not

influence survival in this category (p=0.614).

There were some apparent anomalies in our data. The low incidence of viral infections and

hyperglycaemia may reflect lack of active surveillance for these conditions. The low number of

fungal isolates may be explained by the fact that fungal organisms are difficult to isolate on

paediatric low volume blood cultures.

.

This study raises the issue of children’s rights to healthcare. A report from 2007 showed that only

19.6% of ICU beds in South Africa are dedicated to the care of children.[13] Our study raises the

issue of balancing the rights of older children against those of neonates in a combined paediatric /

neonatal ICU. Only the very sickest neonates (those who failed NCPAP) were admitted to the PNICU,

which may be a form of discrimination. There are no easy ways to identify which patients to admit to

PNICU, especially in a resource-limited setting.[2, 4] Children must not come to ICU to die, yet many

who are critically ill, with an increased risk of death, may have a better chance of recovery if treated

in ICU. We found that post-operative patients had good outcomes, which may reflect the optimal

use of ventilator beds in this unit, or may indicate that many of these patients did not require ICU.

Increasing the number of “high care” admissions would decrease the PNICU mortality rate, but this

would often be at the expense of a sicker child requiring ventilation.

This study had several limitations. The raw proportion of deaths in the CMJAH PNICU is higher than

other units, but may reflect a different level of severity of illness. As may be the case with

retrospective analyses, not all information was available for inclusion in the study. The use of a

standardised illness code such as the ANZPIC system may have been preferable.[22]

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CONCLUSIONS AND RECOMMENDATIONS

The unadjusted mortality rate of children admitted to this combined PNICU is higher than that

reported in a dedicated PICU in the same country.[4] Incorporation of a paediatric intensivist, even

in poorer countries, improves the outcome for children, both in terms of mortality and length of

stay.[11, 17] Ongoing training in the stabilisation and management of critically ill children is

essential for all paediatric registrars, general paediatricians and other sub-specialists. Future clinical

audits should include a severity of illness score such as the PIM,[22] hospital paediatric mortality

rate and the number of children denied admission to PNICU, together with outcome data.

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References

1. WHO. Global Health Observatory Data. 2015 [cited 2016 27 January]; Available from:

http://www.who.int/gho/child_health/mortality/neonatal_infant_text/en/.

2. Basnet, S., N. Adhikari, and J. Koirala, Challenges in setting up pediatric and neonatal

intensive care units in a resource-limited country. Pediatrics, 2011. 128(4): p. e986-92.

3. Koroglu, T.F., S. Atasever, and M. Duman, A survey of pediatric intensive care services in

Turkey. Turk J Pediatr, 2008. 50(1): p. 12-7.

4. Argent, A.C., et al., Pediatric intensive care in South Africa: an account of making optimum

use of limited resources at the Red Cross War Memorial Children's Hospital*. Pediatr Crit

Care Med, 2014. 15(1): p. 7-14.

5. Rosenthal, V.D., et al., Socioeconomic impact on device-associated infections in pediatric

intensive care units of 16 limited-resource countries: international Nosocomial Infection

Control Consortium findings. Pediatr Crit Care Med, 2012. 13(4): p. 399-406.

6. Campos-Mino, S., J.S. Sasbon, and B. von Dessauer, [Pediatric intensive care in Latin

America]. Med Intensiva, 2012. 36(1): p. 3-10.

7. Ghani, A.S., et al., An investigation into the prevalence and outcome of patients admitted to

a pediatric intensive care unit with viral respiratory tract infections in Cape Town, South

Africa. Pediatr Crit Care Med, 2012. 13(5): p. e275-81.

8. Embu, H.Y., et al., Paediatric admissions and outcome in a general intensive care unit. Afr J

Paediatr Surg, 2011. 8(1): p. 57-61.

9. El-Nawawy, A., Evaluation of the outcome of patients admitted to the pediatric intensive care

unit in Alexandria using the pediatric risk of mortality (PRISM) score. J Trop Pediatr, 2003.

49(2): p. 109-14.

10. Kwizera, A., M. Dunser, and J. Nakibuuka, National intensive care unit bed capacity and ICU

patient characteristics in a low income country. BMC Res Notes, 2012. 5: p. 475.

11. Pearson, G., et al., Should paediatric intensive care be centralised? Trent versus Victoria.

Lancet, 1997. 349(9060): p. 1213-7.

12. Goh, A.Y., L.C. Lum, and M.E. Abdel-Latif, Impact of 24 hour critical care physician staffing on

case-mix adjusted mortality in paediatric intensive care. Lancet, 2001. 357(9254): p. 445-6.

13. Bhagwanjee, S. and J. Scribante, National audit of critical care resources in South Africa - unit

and bed distribution. S Afr Med J, 2007. 97(12 Pt 3): p. 1311-4.

14. Naidoo, K., J. Singh, and U. Lalloo, A critical analysis of ICU/HC beds in South Africa: 2008-

2009. S Afr Med J, 2013. 103(10): p. 751-3.

15. Jardine, C. and D.E. Ballot, The use of nasal CPAP at Charlotte Maxeke Johannesburg

Academic Hospital. S Afr J Child Health, 2015. 9(1): p. 4.

16. Harris, P.A., et al., Research electronic data capture (REDCap)--a metadata-driven

methodology and workflow process for providing translational research informatics support.

J Biomed Inform, 2009. 42(2): p. 377-81.

17. Pollack, M.M., et al., Improving the outcome and efficiency of intensive care: the impact of

an intensivist. Crit Care Med, 1988. 16(1): p. 11-7.

18. Straney, L., et al., Paediatric index of mortality 3: an updated model for predicting mortality

in pediatric intensive care*. Pediatr Crit Care Med, 2013. 14(7): p. 673-81.

19. Iqbal, Q., et al., Neonatal mechanical ventilation: Indications and outcome. Indian J Crit Care

Med, 2015. 19(9): p. 523-7.

20. Ma, L., et al., [Prospective study on in-hospital mortality and its risk factors in very low birth

weight infants requring mechanical ventilation]. Zhongguo Dang Dai Er Ke Za Zhi, 2012.

14(10): p. 737-41.

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21. Ballot, D.E., et al., Comparison of morbidity and mortality of very low birth weight infants in a

Central Hospital in Johannesburg between 2006/2007 and 2013. BMC Pediatr, 2015. 15: p.

20.

22. Slater, A., F. Shann, and J. McEniery, The ANZPIC registry diagnostic codes: a system for

coding reasons for admitting children to intensive care. Intensive Care Med, 2003. 29(2): p.

271-7.

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1

STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies

Item

No Recommendation

Page

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the

abstract

4

(b) Provide in the abstract an informative and balanced summary of what was

done and what was found

4

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being

reported

6,7

Objectives 3 State specific objectives, including any prespecified hypotheses 7

Methods

Study design 4 Present key elements of study design early in the paper 7

Setting 5 Describe the setting, locations, and relevant dates, including periods of

recruitment, exposure, follow-up, and data collection

7

Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of

participants

7

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders,

and effect modifiers. Give diagnostic criteria, if applicable

7

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of

assessment (measurement). Describe comparability of assessment methods if

there is more than one group

Supplementary

file

Bias 9 Describe any efforts to address potential sources of bias

Study size 10 Explain how the study size was arrived at 7

Quantitative

variables

11 Explain how quantitative variables were handled in the analyses. If

applicable, describe which groupings were chosen and why

8

Statistical methods 12 (a) Describe all statistical methods, including those used to control for

confounding

8

(b) Describe any methods used to examine subgroups and interactions

(c) Explain how missing data were addressed

(d) If applicable, describe analytical methods taking account of sampling

strategy

(e) Describe any sensitivity analyses

Results 9 to 14

Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers

potentially eligible, examined for eligibility, confirmed eligible, included in

the study, completing follow-up, and analysed

(b) Give reasons for non-participation at each stage

(c) Consider use of a flow diagram

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical,

social) and information on exposures and potential confounders

(b) Indicate number of participants with missing data for each variable of

interest

Outcome data 15* Report numbers of outcome events or summary measures

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted

estimates and their precision (eg, 95% confidence interval). Make clear

which confounders were adjusted for and why they were included

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2

(b) Report category boundaries when continuous variables were categorized

(c) If relevant, consider translating estimates of relative risk into absolute risk

for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and

sensitivity analyses

Discussion

Key results 18 Summarise key results with reference to study objectives 15

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias

or imprecision. Discuss both direction and magnitude of any potential bias

17

Interpretation 20 Give a cautious overall interpretation of results considering objectives,

limitations, multiplicity of analyses, results from similar studies, and other

relevant evidence

17

Generalisability 21 Discuss the generalisability (external validity) of the study results

Other information

Funding 22 Give the source of funding and the role of the funders for the present study

and, if applicable, for the original study on which the present article is based

2

*Give information separately for exposed and unexposed groups.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at www.strobe-statement.org.

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Paediatric ICU at CMJAH

There is a combined paediatric/neonatal ICU (PNICU) which serves the general paediatric

population, the neonatal service, all sub-specialities and paediatric surgery. Cardiothoracic patients

are managed in a separate ICU. CMJAH Inadequate funding may result in insufficient or poorly

maintained equipment, lack of adequately trained staff and limited supplies of expensive medicines.

Patients are often severely ill, present late and suffer from multi-system diseases. Regional hospitals

frequently do not have ICU facilities, so the CMJAH PNICU receives referrals from a wide geographic

area, including neighbouring states. Children who have a poor chance of survival or risk of severe

neurological handicap are not routinely admitted to the PNICU. HIV-exposed children not in multi-

organ failure were admitted to the PICU during the study period. Neonates weighing less than 900

grams at birth were not routinely admitted to PNICU during the study period. Ventilatory support in

the form of nasal CPAP was provided in the neonatal wards to babies between 750 and 900 grams

birth weight.

The HIV epidemic in South Africa has further complicated the question of admission criteria to PICU.

Both HIV exposure and infection are predictive of increased mortality in PICU [1]. Kitchin et al [2]

reported a case fatality rate of 30% for HIV-exposed children ventilated for respiratory failure.

Cytomegalovirus co-infection seemed to confer a worse outcome, although the mechanism of this is

unclear. In 2007, children with established HIV infection and “whose lives are in danger from AIDS-

related disease” had a poor prognosis and were not admitted to PICU.[3] Children established on

antiretroviral therapy and with an unrelated reason for PICU admission were, however suitable for

admission. More recently, with the advent of readily available antiretroviral therapy for children, this

approach may no longer be appropriate.

Severity of illness scores have been developed using predictors of poor outcome such as metabolic

acidosis and cardiac arrest. Two such scores are the Paediatric Risk of Mortality (PRISM)[3] and

Paediatric Index of Mortality (PIM)[4]. These scores are not designed for triage but are useful for

quality control, health planning and comparing the performance of different units[5]. These severity

of illness scores were developed in richer countries and standardised on the basis of data from these

countries. LMICs may have a different profile of patients and different outcomes. In a recent study,

however, Solomon et al [6] demonstrated that the PIM2 score was both accurate and well calibrated

in a South African PICU.

The PNICU was staffed by a PNICU consultant on call; the resident staff included two paediatric

registrars and a medical officer. After hours, a resident registrar and medical officer cover PNICU and

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the whole neonatal service, including labour ward, the transitional nursery and 75 neonatal patients.

Nurse to patient ratios follow neonatal norms – of 1 nurse to 2 patients.

Definitions used in the study are shown in Table 1. Hypernatraemia was defined as 150 mmol/l, but

most patients who died with the condition had much higher levels of sodium. Congenital heart

disease associated with mortality included hypoplastic left heart syndrome and various complex

congenital heart defects.

Table 1

Definitions of illnesses used in the study

Variable Definition

Hypotension The need for inotropic support to maintain a

normal blood pressure

Hypoglycaemia Blood sugar < 2.6 mmol/l

Hyperglycaemia Blood sugar > 7 mmol/l

Hypernatraemia Serum sodium > 150 mmol/l; neonates > 155

mmol/l

Metabolic acidosis Base Excess > -16 mmol/l

Bacterial / fungal sepsis Bacterial/fungal organisms isolated on blood

culture

Diagnosis Major organ systems involved. A patient could

be classified in two categories e.g. a child with

bronchopneumonia and anaemia would be

lower respiratory tract and haematology

Cardiovascular Shock, arrhythmias, cardiac failure and

anatomical cardiac lesions

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Surgical patients Post-operative, trauma and patients admitted

from the surgical wards for other indications.

The majority of post-operative admissions were

elective (Personal communication DEB) but this

information was not recorded during the study

period.

Upper respiratory tract Upper airway obstruction including croup,

foreign body, retropharyngeal abscess, subglottic

stenosis

Lower respiratory tract Pneumonia, pneumonitis, asthma, bronchiolitis,

non-cardiogenic pulmonary oedema, empyema,

effusion, pneumothorax

Haematology oncology Malignancies, blood dyscrasias and anaemia

requiring blood transfusion

Renal Renal failure, dialysis, renal transplant

Gastrointestinal Liver pathology, gastroenteritis

Neurological Seizure disorders, meningitis, apnoea, paralysis

References

1. Ghani AS, Morrow BM, Hardie DR, et al. An investigation into the prevalence and outcome of

patients admitted to a pediatric intensive care unit with viral respiratory tract infections in

Cape Town, South Africa. Pediatr Crit Care Med 2012;13(5):e275-81 doi:

10.1097/PCC.0b013e3182417848[published Online First: Epub Date]|.

2. Kitchin OP, Masekela R, Becker P, et al. Outcome of human immunodeficiency virus-exposed and -

infected children admitted to a pediatric intensive care unit for respiratory failure. Pediatr

Crit Care Med 2012;13(5):516-9 doi: 10.1097/PCC.0b013e31824ea143[published Online

First: Epub Date]|.

3. Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med

1988;16(11):1110-6

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4. Straney L, Clements A, Parslow RC, et al. Paediatric index of mortality 3: an updated model for

predicting mortality in pediatric intensive care*. Pediatr Crit Care Med 2013;14(7):673-81

doi: 10.1097/PCC.0b013e31829760cf[published Online First: Epub Date]|.

5. Costa GA, Delgado AF, Ferraro A, et al. Application of the pediatric risk of mortality (PRISM) score

and determination of mortality risk factors in a tertiary pediatric intensive care unit. Clinics

(Sao Paulo, Brazil) 2010;65(11):1087-92

6. Solomon LJM, B. M.; Argent, A. Paediatric Index of Mortality scores: An evaluation of function in

the paediatric intensive care unit of the Red Cross War Memorial Children’s Hospital. South

African Journal of Critical Care 2014;30(1):5 doi: DOI:10.7196/SAJCC.166[published Online

First: Epub Date]|.

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SURVIVAL RATES IN A PAEDIATRIC / NEONATAL INTENSIVE CARE … · Dedicated paediatric intensive care...

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