Transferring critically ill or injured child from a level II pediatric intensive care unit to a highly specialized and more technologically advanced, or level I, pediatric ICU can greatly improve a patient’s chance for survival, say researchers at the University of Michigan C.S. Mott Children’s Hospital.

In a new study - published in this month’s issue of Pediatric Critical Care Medicine - they found that children at high risk of mortality were transferred to level I pediatric ICUs earlier than children with a lower risk of death, and most often with a diagnosis of respiratory failure or sepsis, a serious infection. The most critically ill transfer patients also received the most highly aggressive and resource-intensive care.

Lead author Folafouwa O. Odetola, M.D., MPH, hopes by gaining a better understanding of the characteristics and outcomes of inter-hospital pediatric ICU transfers, these findings will work to improve care for these critically ill children and help to establish criteria for level II to level I pediatric ICU transfers.

“Care for critically ill and injured children could be greatly enhanced if only the most appropriate and severely ill children were transferred from level II to level I pediatric ICUs,” says Odetola, assistant professor and member of the Child Health Evaluation and Research (CHEAR) Unit in the Division of General Pediatrics at U-M C.S. Mott Children’s Hospital.

“The study revealed that one-third of children with high risk of mortality died, even with the highly resource-intensive care of a level I pediatric ICU. That’s proof that we need to gain a better understanding of the medical decision-making process to transfer a critically ill child from a level II to a level I pediatric ICU.”

Currently, there are no published criteria to aid the decision to transfer critically ill and injured children from level II to level I pediatric ICUs. According to published guidelines from the Society for Critical Care Medicine and the American Academy of Pediatrics, however, level II pediatric ICUs are expected to stabilize the most severely ill and injured children, and subsequently transfer them to a level I pediatric ICU, such as the 16-bed pediatric ICU at U-M C.S. Mott Children’s Hospital.

The level I pediatric ICU at Mott is known for its excellence in the care of children with respiratory failure, especially those who require artificial organ support. It also has nationally recognized programs in artificial organ support with extracorporeal membrane oxygenation, or ECMO, a life support system created at U-M for infants, children and adults to oxygenate blood outside the body and allow underdeveloped or ailing lungs to rest and grow stronger.

During the study period (Jan. 1, 1997 to Dec. 31, 2003), there were 1,048 transfer admissions to the Mott pediatric ICU. Of those, 168 were transferred from a level II pediatric ICU to Mott, and included in the study.

Of the 168 patient transfers, 45 percent, 30 percent and 25 percent were categorized as low, moderate and high risk of mortality, respectively.

Respiratory failure was the most common diagnosis among all groups, occurring in about half of the study group, followed by sepsis, an infection in the bloodstream, usually by bacteria. which occurred in one-third of the high risk admissions.

Nearly 65 percent of these patients were transferred to the level I pediatric ICU for subspecialty evaluation and care such as sold organ transplantation, ECMO therapy, and care of uncommon pediatric disorders. Only a small portion of these patients was transferred because of a parent’s request for care at an alternate hospital.

The greater the severity of illness or injury, the more hospital resources were used to care for the patient at the level I pediatric ICU. High-risk patients were more likely to require advanced technology support therapies, such as ECMO, and need blood transfusions. Low-risk patients, however, were more likely to undergo certain surgical procedures such as gastrostomy, which creates an opening in the stomach to help a child ingest food, and tracheostomy, which creates an opening in a child’s neck and windpipe to help get air in and out of the lungs.

Eighty-eight percent, or 129 patients, of 168 the patients survived, and were transferred to the pediatric ward of the hospital. Fifteen patients were transferred back to the level II pediatric ICU.

While this study serves as the first step toward establishing transfer criteria for critically ill and injured children from level II to level I pediatric ICUs in the United States, Odetola notes future study is needed to investigate the medical decisions that prompt interhospital transfers.

In addition to Odetola, U-M study authors were Thomas P. Shanley, M.D., James G. Gurney, Ph.D., Sarah J. Clark, MPH, Ronald E. Dechert, RRT, DrPH, Gary L. Freed, M.D., and Matthew M. Davis, M.D., M.A.P.P.

Reference: Pediatric Critical Care Medicine, Vol. 7, No. 6, pp. 536-540.