Intensive care provided by local hospitals should be improved

EDITOR,—Joseph Britto and colleagues give a convincing argument for the further development of retrieval teams for critically ill children.1 But what of the quality of intensive care provided locally? The main interventions performed by the retrieval team were maintaining an airway (57%), ventilation (26%), and obtaining vascular access (86%). These interventions, however, should have been performed at the local hospital by suitably trained paediatricians and anaesthetists.

Surely the question that needs to be asked is why these essentials of advanced life support are not being provided locally. This is particularly pertinent when the diagnostic groups are looked at closely. Bronchiolitis accounted for a quarter of the patients studied, and these patients formed the group with the biggest change in the score obtained with the therapeutic intervention scoring system. Meningococcal disease (47% of patients) is a devastating disease with rapid deterioration requiring prompt intervention.

As Stuart Logan says in his commentary on the paper, centralisation of paediatric intensive care will be driven by public and professional opinion despite little evidence to support this move. As a consequence the quality of intensive care provided locally will continue to deteriorate unless those responsible for training and accreditation acknowledge the contribution that local services can, and must, make. Local units must recognise, and be recognised for, their role in contributing to the advances being made in paediatric intensive care by the tertiary units.

Britto and colleagues should ensure that those local hospitals that seem to provide a deficient service are alerted; they should be encouraged to provide appropriate training—for example, in paediatric advanced life support. This is preferable to the more obvious conclusion reached by the authors—that transfer of sick children is so safe that more is better.