‘Seriously ill kids not getting to ICU on time’

Average 12.3 hour delay – study

THE SICKEST and worstinjured children in Cape Town are not getting a fair shot at survival, with a new study showing it can take as much as 12 hours for them to be admitted to the paediatric ICU after they arrive at a healthcare centre.

About half of the 30 critically ill or injured children who died at Red Cross and other referring hospitals during the year- long academic study potentially might have been saved, researchers found, if it wasn’t so difficult for their parents and caregivers to access vital care and treatment.

The study, published in PLOS One, was the product of the PhD research of Dr Peter Hodkinson, of UCT’s emergency medicine division. It was based on a Wellcome Trustfunded collaborative research project between researchers from UCT and Oxford University.

It focused on children admitted to the paediatric ICU at Red Cross, but was unique because it examined the entire system of accessing emergency care, from being injured or leaving home to go to a clinic or the nearest medical facility with a sick child, through to being admitted to the ICU.

This allowed for a systemwide evaluation of the nature and quality of care for a group of the sickest and worst injured children in Cape Town.

Hodkinson said the findings showed a “significant proportion of deaths of children may be avoidable” and highlighted delays in accessing quality emergency care for children as a major concern.

“While children received excellent care at many steps, the overall system does not always provide the care that we would aspire to,” he said.

Hodkinson said the particular challenge of caring for critically ill or injured children within a healthcare system was that outcomes were related to the overall functioning of the entire system. When there were multiple steps in a process, even if most stages provided excellent care, the overall outcome could be compromised by problems at certain stages.

“Caregivers, particularly in communities with limited resources, face enormous obstacles in accessing emergency care for sick babies and children, starting with finding transport to the nearest facility, which is often far from home.

“Once at a facility they face queues of other sick people and adults, often with unclear directions of where to queue and sometimes ‘grey’ systems for prioritising sick children,” he said, warning even once

Empowering and

was also vital

children got to see a doctor, the battle was far from over.

The research highlighted that improved identification of children with severe illness, with rapid initiation of appropriate care at lower levels of the referral pathway, could reduce referrals to specialist hospitals and delays in getting others admitted to the ICU.

Researchers interviewed caregivers of 282 children who were admitted to the ICU, as well as those who died in referring hospitals. They also scrutinised medical records across healthcare services.

The study found it took an average 12.3 hours from the time of first presentation to healthcare services before children were admitted to a ICU.

“It was found that three of the 30 deaths could have been avoided prior to ICU admission. Another 14 we judged ‘potentially avoidable’.

“Potentially this means, in our expert opinion as the retrospective panel, that some acute intervention in the health pathway could maybe have prevented the deaths. Likewise, the severity of illness on arrival at ICU may have been avoided in up to 74 percent of children enrolled in the study, had they received better care along the referral chain en-route to ICU,” Hodkinson said.

Many of the children in the study were diagnosed with respiratory infections. The research suggested referral delays could be reduced by fasttracking patients directly to ICU, better prioritisation of emergency medical services, and early warning systems in the hospital setting.

“Mothers perceive that their battle is done and their child has arrived in the best hands once they get to the regional paediatric hospital. And they are right. The care is excellent and the practitioners are all very familiar and comfortable with children. But they are overburdened with sick children, with a bottleneck of children waiting for ICU beds,” Hodkinson said, adding that Red Cross had just 22 ICU beds.

Researchers said empowering and educating parents about when, where and how to access care was also vital.

They also suggested a centralised paediatric emergency line for emergency advice.

Hodkinson described the methods of the study as unique and valuable, saying it offered benefits for health systems in low and middle-income settings in developing countries.

Professor Andrew Argent, Red Cross ICU medical director, said it demonstrated the commitment of local authorities to quality control, and “focusing on how patient care can be improved within the resources available”.