Educational Outcomes of Childhood Survivors of Critical Illness-A Population-Based Linkage Study

OBJECTIVES Major postintensive care sequelae affect up to one in three adult survivors of critical illness. Large cohorts on educational outcomes after pediatric intensive care are lacking. We assessed primary school educational outcomes in a statewide cohort of children who survived PICU during childhood. DESIGN Multicenter population-based study on children less than 5 years admitted to PICU. Using the National Assessment Program-Literacy and Numeracy database, the primary outcome was educational achievement below the National Minimum Standard (NMS) in year 3 of primary school. Cases were compared with controls matched for calendar year, grade, birth cohort, sex, socioeconomic status, Aboriginal and Torres Strait Islander status, and school. Multivariable logistic regression models to predict educational outcomes were derived. SETTING Tertiary PICUs and mixed ICUs in Queensland, Australia. PATIENTS Children less than 5 years admitted to PICU between 1998 and 2016. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Year 3 primary school data were available for 5,017 PICU survivors (median age, 8.0 mo at first PICU admission; interquartile range, 1.9-25.2). PICU survivors scored significantly lower than controls across each domain (p < 0.001); 14.03% of PICU survivors did not meet the NMS compared with 8.96% of matched controls (p < 0.001). In multivariate analyses, socioeconomic status (odds ratio, 2.14; 95% CI, 1.67-2.74), weight (0.94; 0.90-0.97), logit of Pediatric Index of Mortality-2 score (1.11; 1.03-1.19), presence of a syndrome (11.58; 8.87-15.11), prematurity (1.54; 1.09-2.19), chronic neurologic conditions (4.38; 3.27-5.87), chronic respiratory conditions (1.65; 1.24-2.19), and continuous renal replacement therapy (4.20; 1.40-12.55) were independently associated with a higher risk of not meeting the NMS. CONCLUSIONS In this population-based study of childhood PICU survivors, 14.03% did not meet NMSs in the standardized primary school assessment. Socioeconomic status, underlying diseases, and severity on presentation allow risk-stratification to identify children most likely to benefit from individual follow-up and support

Epidemiology and outcomes of out-of-hospital cardiac arrest in Qatar : A nationwide observational study

This is a pre-copyedited, author-produced pdf of an article accepted for publication in International Journal of Cardiology following peer review. The version of record, 'Epidemiology and outcomes of out-of-hospital cardiac arrest in Qatar: A nationwide observational study', F. B. Irfan, et.a., International Journal of Cardiology, Vol 223, pp 1007-1013, November 2016, first published on line on August 24, 2016, is available on line via doi: http;//dx.doi.org/10.1016/j.ijcard.2016.08.299 © 2016 Elsevier. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/Background Out-of-hospital cardiac arrest (OHCA) studies from the Middle East and Asian region are limited. This study describes the epidemiology, emergency health services, and outcomes of OHCA in Qatar. Methods This was a prospective nationwide population-based observational study on OHCA patients in Qatar according to Utstein style guidelines, from June 2012 to May 2013. Data was collected from various sources; the national emergency medical service, 4 emergency departments, and 8 public hospitals. Results The annual crude incidence of presumed cardiac OHCA attended by EMS was 23.5 per 100,000. The age-sex standardized incidence was 87.8 per 100,000 population. Of the 447 OHCA patients included in the final analysis, most were male (n = 360, 80.5%) with median age of 51 years (IQR = 39–66). Frequently observed nationalities were Qatari (n = 89, 19.9%), Indian (n = 74, 16.6%) and Nepalese (n = 52, 11.6%). Bystander cardiopulmonary resuscitation (CPR) was carried out in 92 (20.6%) OHCA patients. Survival rate was 8.1% (n = 36) and multivariable logistic regression indicated that initial shockable rhythm (OR 13.4, 95% CI 5.4–33.3, p = 0.001) was associated with higher odds of survival while male gender (OR 0.27, 95% CI 0.1–0.8, p = 0.01) and advanced cardiac life support (ACLS) (OR 0.15, 95% CI 0.04–0.5, p = 0.02) were associated with lower odds of survival. Conclusions Standardized incidence and survival rates were comparable to Western countries. Although expatriates comprise more than 80% of the population, Qataris contributed 20% of the total cardiac arrests observed. There are significant opportunities to improve outcomes, including community-based CPR and defibrillation training.Peer reviewe

Burden of disease and change in practice in Critically Ill Infants with Bronchiolitis

Bronchiolitis represents the most common cause of non-elective admission to paediatric intensive care units (ICUs)

Health effects of smoke from planned burns: a study protocol

Abstract Background Large populations are exposed to smoke from bushfires and planned burns. Studies investigating the association between bushfire smoke and health have typically used hospital or ambulance data and been done retrospectively on large populations. The present study is designed to prospectively assess the association between individual level health outcomes and exposure to smoke from planned burns. Methods/design A prospective cohort study will be conducted during a planned burn season in three locations in Victoria (Australia) involving 50 adult participants who undergo three rounds of cardiorespiratory medical tests, including measurements for lung inflammation, endothelial function, heart rate variability and markers of inflammation. In addition daily symptoms and twice daily lung function are recorded. Outdoor particulate air pollution is continuously measured during the study period in these locations. The data will be analysed using mixed effect models adjusting for confounders. Discussion Planned burns depend on weather conditions and dryness of ‘fuels’ (i.e. forest). It is potentially possible that no favourable conditions occur during the study period. To reduce the risk of this occurring, three separate locations have been identified as having a high likelihood of planned burn smoke exposure during the study period, with the full study being rolled out in two of these three locations. A limitation of this study is exposure misclassification as outdoor measurements will be conducted as a measure for personal exposures. However this misclassification will be reduced as participants are only eligible if they live in close proximity to the monitors

Regions of High Out-Of-Hospital Cardiac Arrest Incidence and Low Bystander CPR Rates in Victoria, Australia

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a major public health issue and research has shown that large regional variation in outcomes exists. Of the interventions associated with survival, the provision of bystander CPR is one of the most important modifiable factors. The aim of this study is to identify census areas with high incidence of OHCA and low rates of bystander CPR in Victoria, Australia. METHODS: We conducted an observational study using prospectively collected population-based OHCA data from the state of Victoria in Australia. Using ArcGIS (ArcMap 10.0), we linked the location of the arrest using the dispatch coordinates (longitude and latitude) to Victorian Local Government Areas (LGAs). We used Bayesian hierarchical models with random effects on each LGA to provide shrunken estimates of the rates of bystander CPR and the incidence rates. RESULTS: Over the study period there were 31,019 adult OHCA attended, of which 21,436 (69.1%) cases were of presumed cardiac etiology. Significant variation in the incidence of OHCA among LGAs was observed. There was a 3 fold difference in the incidence rate between the lowest and highest LGAs, ranging from 38.5 to 115.1 cases per 100,000 person-years. The overall rate of bystander CPR for bystander witnessed OHCAs was 62.4%, with the rate increasing from 56.4% in 2008-2010 to 68.6% in 2010-2013. There was a 25.1% absolute difference in bystander CPR rates between the highest and lowest LGAs. CONCLUSION: Significant regional variation in OHCA incidence and bystander CPR rates exists throughout Victoria. Regions with high incidence and low bystander CPR participation can be identified and would make suitable targets for interventions to improve CPR participation rates

Measuring Quality in the Paediatric Intensive Care Unit

ABSTRACT INTRODUCTION Variation in patient outcomes among health care providers may be indicative of differences in the quality of care. In order to make objective comparisons of patient outcomes between providers and over time it is necessary to adjust for differences in patient case-mix. Statistical tools known as risk-adjustment models are employed for this purpose. Disparities in adjusted patient outcomes can help to drive and direct quality improvement. Paediatric intensive care units (PICUs) play a crucial role in caring for the sickest of children. It is of interest to ensure that these units can effectively identify potential areas of deficiency relative to peers to facilitate continuous quality improvement. However, limited tools are available for contrasting outcomes in the PICU. Further, those models that have been developed have become outdated as the relationships between patient factors and outcomes change over time. Mortality, length of stay (LoS) and duration of respiratory support are important indicators of clinical performance and unit efficiency. Mortality is a common, easily understood and useful indicator of clinical performance. LoS provides insight into the efficiency of resource use and may also act as a surrogate for quality of care. Likewise duration of respiratory support may provide insights into the efficiency of resource use and also clinical practice regarding ventilator use . The aim of this research was to examine the relationships between patient characteristics at the time of admission with clinical outcomes and develop statistical methods that could adjust for differences in case-mix that would permit objective comparison of outcomes over time and among units. METHODS Statistical models for objectively contrasting patient outcomes in the PICU were developed. The models used patient characteristics at the time of admission as covariates in the models. Two methods were developed for contrasting variation in LoS among PICUs. The first model was a mixed-effects gamma regression model built using 47,068 admissions between 1997 and 2006 in Australian and New Zealand (ANZ) ICUs that accept paediatric admissions. The second model was a two compartment mixed-effects gamma regression model that was developed using 12,763 ANZ PICU admissions to quantify variation in mean LoS among short and long stay patients separately. A log-normal regression model for contrasting patient duration of respiratory support was constructed using a subset of the LoS data. A revised Paediatric Index of Mortality (PIM3) was developed using a logistic regression model and 45,706 admissions to Australian, New Zealand and UK PICUs between 2007 and 2008. RESULTS AND INTERPRETATION Site-level variation in patient outcomes was found. Among the 20 units which accepted paediatric ICU admissions, the first LoS model revealed 6 units that had an adjusted mean LoS that was significantly longer than expected and 5 that were significantly shorter. Cessation of respiratory support is likely to represent ‘readiness to discharge’. LoS over and above this point may represent unit inefficiency; however it may be confounded by bed block or unavailability of appropriate step-down facilities. Concurrent analysis of respiratory support duration and LoS contextualised the variation in LoS and indicated that bed block is not a significant confounder of variation in LoS in this study population. The two-compartment model for estimating site-level variation in short and long stay patients revealed differences in the site effect among short and long stay patients. Of the 8 PICUs studied, 4 sites had a statistically significant effect on long stay patients and 5 sites had a statistically significant effect on short stay patients. PIM3, the updated model for assessing mortality risk, provides more accurate assessments of mortality risk and unit performance, particularly among low risk patients. CONCLUSIONS Good quality assessment must encompass a broad range of indicators to paint a holistic picture of unit performance. The methods described enable units to assess clinical performance within the context of resource use. Clinical outcomes including LoS and duration and respiratory support may be adjusted for differences in case-mix among units allowing objective comparisons of performance to be made. In addition the results show that variation in patient outcomes exist among PICUs in Australia and New Zealand. These finding demonstrates that units may not be performing equally and provides direction for reviews of the practice of care

Disentangling the effects of risk factors and clinical care on subnational variation in early neonatal mortality in the United States

OBJECTIVE: Between 1990 and 2010, the U.S ranking in neonatal mortality slipped from 29(th) to 45(th) among countries globally. Substantial subnational variation in newborn mortality also exists. Our objective is to measure the extent to which trends and subnational variation in early neonatal mortality reflect differences in the prevalence of risk factors (gestational age and birth weight) compared to differences in clinical care. METHODS: Observational study using linked birth and death data for all births in the United States between 1996 and 2006. We examined health service area (HSA) level variation in the expected early neonatal mortality rate, based on gestational age (GA) and birth-weight (BW), and GA-BW adjusted mortality as a proxy for clinical care. We analyzed the relationship between selected health system indicators and GA-BW-adjusted mortality. RESULTS: The early neonatal death (ENND) rate declined 12% between 1996 and 2006 (2.39 to 2.10 per 1000 live births). This occurred despite increases in risk factor prevalence. There was significant HSA-level variation in the expected ENND rate (Rate Ratio: 0.73-1.47) and the GA-BW adjusted rate (Rate ratio: 0.63-1.68). Accounting for preterm volume (defined as <34 weeks), the number of neonatologist and NICU beds, 25.2% and 58.7% of the HSA-level variance in outcomes was explained among all births and very low birth weight babies, respectively. CONCLUSION: Improvements in mortality could be realized through the expansion or reallocation of clinical neonatal resources, particularly in HSAs with a high volume of preterm births; however, prevention of preterm births and low-birth weight babies has a greater potential to improve newborn survival in the United States

Venous vs arterial lactate and 30-day mortality in pediatric sepsis

10.1001/jamapediatrics.2017.1598JAMA Pediatrics1718813