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We read with disappointment the response of Dr Peters and colleagues1 to our article “Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery”.2 It is unfortunate that there appears to be a misunderstanding of the message of our study which demonstrated a significant improvement in the mortality of children with meningococcal disease (MD) over a period of time. Contrary to their concerns those results were achieved through genuine teamwork” as stated in our paper.
In answer to the specific points they raised: We and other intensivists are also aware that mortality in conditions other than MD is also improving. In our paper we did not state that MD was the only condition in which there is an improvement in mortality. Our paper referred to a study published in Critical Care Medicine which also showed improving survival rates of paediatric patients (with various diseases) over time in another paediatric intensive care (PIC) setting.3
With reference to the patients who died at the referring hospital and their exclusion from the study. Our paper clearly states “Logistic regression analysis, controlling for disease severity, age and sex, showed that over the study period (1992–97) the overall estimate for the reduction in the odds of death was 59% per year (odds ratio for the yearly trend 0.41, 95% CI p=0.000001). This estimate and significance remained the same after inclusion of the 29 deaths that occurred at local hospitals”.
We did not claim that mobile intensive care is the key element in improved survival. What we stated was: “Considerable changes in the management of patients with MD have occurred over the study period. While no single factor alone is likely to explain the reduction in mortality, several factors might have contributed to the improved outcome. In the past, few centres, including those with PICUs, admitted more than a small number of patients with MD annually. Furthermore, patients were often considered too sick to transfer to a specialist centre and were treated in the A&E department, paediatric ward or adult ICU of the local district general hospital. Establishment of a mobile intensive care team allowed the centralisation of care of children with MD at a specialist clinical and research unit, which in turn enabled extensive experience in the management of MD to be developed; this may be the most important reason for the improved outcome.... In other words, it was the increased experience in dealing with meningococcal disease that was the critical factor.
The role of mobile intensive care was more directly addressed when we stated that it “has probably been another important factor in improved outcome”, not the key factor.
The conclusions of our paper clearly state the multiple factors responsible for the results of the study, which have shown that a notable reduction in the case fatality rate for MD has been achieved.
The purpose of presenting our data was to emphasise the improvements in mortality in a particular group of patients brought about by a change in health care delivery. The key point being early intervention by a multidisciplinary team with a major research interest in the care of the critically ill child with infectious disease, who have the benefit of a “critical mass” experience.
The PICU at St Mary's Hospital, London was established in 1992, at the time primarily to facilitate the enrolment of children with meningococcal disease into clinical trials. As a large number of critically ill children were referred to our unit, we were subsequently able to record high-quality data regarding clinical status, severity of illness and outcome. We began to demonstrate a reduction in mortality from 1994 onwards, as it takes time to establish the clinical experience which can have a significant impact on the disease process.
The unit at St Mary's has been greatly involved in the development of a model of care involving “genuine teamwork” with the aim of improving the healthcare of children with MD. To this end we have been working with the meningitis charities which are acknowledged on the paper) and other agencies to develop guidelines, publish treatment algorithms and improve policies. In addition our research unit has played a key role in the design and implementation of clinical trials of adjunctive treatments in meningococcal disease, which has led to the publication of the only two large randomised, double blind, placebo controlled studies in childhood septic shock.4,5
Finally we are humbled by the magnitude of response from many other colleagues who have applauded our efforts. We believe, and have repeatedly stated, that what has been widely accepted as a major advance in the outcome of children with MD, could only have been achieved by multidisciplinary effort involving all sectors of health care delivery.