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As paediatric intensivists in lead centres accredited for paediatric intensive care (PIC) training and responsible for the care of approximately 7000 cases per year, we read with concern the report from St Mary's Hospital which reported improved outcome of meningococcal disease (MD) in 1997 compared with previous years.1
Their reported reduction in mortality must be seen in the context of an overall reduction of childhood mortality and a widespread improvement in the outcome for many conditions requiring PIC such as acute respiratory failure,2 persistent pulmonary hypertension3 and complex congenital heart defects.4 Overall UK PIC mortality rates have fallen to a standardised mortality ratio (SMR) of 0.87 as assessed by the Paediatric Index of Mortality5 compared with the model generated in 1994.6
Their application of the severity of illness score (PRISM) is incorrect. No patient has a 100% predicted risk of mortality and therefore all deaths observed in any such study must increase the SMR. The exclusion of nearly half of the total deaths (29/62, 47%) who did not survive the long stabilisation and overall retrieval times must reduce SMR regardless of any other intervention. Whilst inclusion of these cases does not alter the direction of the relationship between SMR and year, it raises the overall mortality in the series towards 20% and more than doubles the headline mortality in 1997. Data from the last 4 years would be of interest. In addition, the lack of any data relating to the performance of the model in different risk groups fails to address the potential confounding factor of disease severity. Since all survivors will reduce SMR, one cause of apparent improvement in risk-adjusted survival is increased admission of low risk cases. Recent series from other institutions have followed the convention of presenting data by level of predicted risk.7–9
The claim that their “Mobile Intensive Care” service is the key element in improved survival is confusing when all the cases that died under the care of this service were excluded from both the analysis and the “headline” figure of 2% mortality for MD.
However, our greatest concern is the claim that these data support their particular “model” of care of critically ill children. This is not consistent with their report, as St Mary's had been performing transports since 1992 but the fall in mortality occurred some 4–5 years later. It should be remembered that PICU retrievals have been performed in Liverpool and Glasgow since the late 1970s. Their claim that this “model” has reduced mortality of meningococcal disease is also inconsistent with the similar improvements in outcome presented by other PICs.7–9
We feel the narrow focus of the paper on the ICU care of MD is misleading. It ignores the important contribution of many others including parents, charities, and healthcare workers. Their role in education, early identification, treatment, and immediate high quality resuscitation is discounted. To imply that ICU management after the initial resuscitation is the key factor in improved survival undermines the vital contributions of these groups.
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