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Critically ill children have better outcomes when treated in high- vs. low-volume pediatric ICUs

Pediatric intensive care units (PICUs) mushroomed during the 1980s. Many local hospitals added these units to their nurseries, even though they didn't treat large numbers of children in need of such services. Yet critically ill children treated at high-volume PICUs have lower mortality rates and length of ICU stay than similarly sick children treated in low-volume PICUs, according to a recent study that was supported in part by the Agency for Healthcare Research and Quality (HS09055). Creating larger high-volume regional PICUs, to which all critically ill children in a region would be referred, may improve efficiency and quality of care as well as the outcomes of these children, suggests John M. Tilford, Ph.D., of the University of Arkansas for Medical Sciences and Arkansas Children's Hospital.

Dr. Tilford and his colleagues examined the relationships between the volume of children hospitalized at 16 PICUs in 1993 and risk of death and length of ICU stay. Patient volume ranged from a low of 147 children treated during the year to a high of 1,378. Results showed that a 100 patient increase in PICU volume significantly decreased mortality risk (adjusted for severity of illness and mix of patients) and reduced length of stay. Other PICU characteristics—such as fellowship training programs, university hospital affiliation, number of PICU beds, and children's hospital affiliation—had no effect on deaths or length of stay.

The study provided no evidence that low-volume PICUs were less likely to use appropriate therapies or more likely to use inappropriate therapies. However, greater patient volume provides surgeons and other providers with more experience and leads to a "practice-makes-perfect" effect. Pediatric intensivists often are confronted with rare life-threatening illnesses where clinical experience plays an important role in determining outcome, notes Dr. Tilford.

See "Volume-outcome relationships in pediatric intensive care units," by Dr. Tilford, Pippa M. Simpson, Ph.D., Jerril W. Green, M.D., and others, in the August 2000 Pediatrics 106, pp. 289-294.

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