Irish Paediatric Critical Care Audit National Report 2021-2022 including key trends from 2018 to 2022

This is the third National Report from the Irish Paediatric Critical Care Audit (IPCCA) reporting on the 3,329 admissions to the two Paediatric Critical Care Units (PCCUs) in Ireland during 2021 and 2022, with key trends over the 5-year period 2018–2022 included.

There was a 14% increase in the number of children admitted to PCCUs in 2021 and 2022 compared to 2018. Both PCCUs showed high occupancy in 2021–2022 (above 85%), particularly in the winter months. A detailed analysis of these admissions shows that an increasing majority were secondary to seasonal viruses and respiratory syncytial virus (RSV) pathogen. The development of new vaccines for RSV could radically alter the annual surge of admissions to both children’s hospitals and PCCUs and in doing so influence its effect on bed occupancy and elective surgical deferrals.

Quality indicators of Unit strain, such as bed occupancy and out-of-hours discharges, showed an increase in 2021 and 2022. Children’s Health Ireland (CHI) at Crumlin had occupancy consistently over 95%; the recommended national standard is 85%. The number of qualified nurses per bed remains below the recommended standard in CHI at Temple Street for each of the 5 years examined. Admissions to CHI at Temple Street PCCU in 2022 (n=542) increased by 34% compared to 2018 (n=406). With the new National Children’s Hospital due to open in 2025 with an additional 10 PCCU beds, there is a need to plan for adequate resourcing to maintain an average bed occupancy of 85% and allow for acute surges in demand, staff sick leave and maternity leave.

The average annual number of bed days delivered by the two PCCUs within the 5-year period was 10,232; however, the number decreased significantly in 2020 (by almost 1,000 bed days). More than three-quarters (76%) of the bed days per annum were provided in the Unit in CHI at Crumlin. In 2021 and 2022, children aged under 1 month accounted for the highest proportion of bed days in both Units, in keeping with previous years.

Most PCCU admissions in 2021 and 2022 were unplanned. The proportion of unplanned admissions transferred to CHI at Crumlin increased from 32% (n=132) in 2020 to 45% (n=267) in 2021 and 43% (n=281) in 2022. There was less variation in CHI at Temple Street, where most admissions are transferred in. Developing regional Paediatric High Dependency Unit (PHDU) capacity would ease the strain on PCCUs. The plan to expand paediatric regional surgical units to Model 4 hospitals means that children can be treated at a local level for non-specialist surgical procedures. However, this needs to be backed up by the provision of PHDU to allow for enhanced postoperative care in a PHDU if required.

With the extension of the Irish Paediatric Acute Transport Service’s (IPATS) operational hours, there have been improvements in transport metrics, and the introduction of a new IPATS nurse-led repatriation service to bring children back to their local hospital will help patient flow.

Unplanned extubations have been included as a key metric for the first time. These are relatively rare events. CHI at Temple Street was an outlier for this metric in 2021 but initiated a quality improvement project, resulting in improved rates in 2022.

The crude mortality rates remain very low (4%) each year. Detailed analysis shows that most of the deaths occurred in the neonatal age group. The main causes of death for children in CHI at Crumlin were cardiovascular diagnoses, whereas in CHI at Temple Street the majority of deaths were due to external causes of accident or injury. The risk-adjusted standardised mortality ratio (SMR), which is an important high-level quality indicator, after allowing for the level of sickness at time of admission, showed that neither PCCU in the Republic of Ireland (ROI) had a mortality rate higher than expected.

For the first time, data are included on organ and tissue donation as this was added to the audit dataset in 2021. A small number of organ and tissue donations occur each year, but the data collected are limited. The appointment of dedicated hospital organ donation personnel has the potential to increase the number of organ donations.

There are ongoing challenges with audit data collection. Auditing PCCU activity is essential to identify shortfalls in quality of care, to  drive improvements in care and to document activity to guide resource allocation.