Survey of occupancy of paediatric intensive care units by children who are dependent on ventilators

Introduction

Children dependent on ventilators who are being treated in paediatric intensive care units in the United Kingdom present a dilemma1 because there is a shortage of appropriately staffed beds for emergency admissions.2 The hypothesis that more admissions could be accommodated prompted a survey to assess the number of children chronically dependent on ventilators occupying these beds and to calculate the potential number of extra admissions that could occur should these beds become available.

Methods and results

In February 1996 we sent a questionnaire to the medical directors of all 24 paediatric intensive care units in England and Scotland; Wales did not have a paediatric intensive care unit recognised by the NHS executive. We obtained a 100% response rate with follow up questionnaires and telephone interviews. Chronic dependence on ventilation was defined as a failure to wean from mechanical respiratory support by three months after its initiation. We recorded the number of beds staffed, the number of admissions and refusals, and the number of patients dependent on ventilators from January to March 1996. We calculated the average length of stay per child in each unit using the number of bed days available to each unit (bedsxdays) and the number of children admitted. By then calculating the number of bed days taken up by each child dependent on a ventilator and by knowing the average length of stay for each acute admission, we were able to calculate the number of potential extra admissions to each unit had the beds occupied by the children dependent on ventilators been available. The actual number is less than the potential number of extra admissions since only children who were refused admission could then be accepted into an available bed.

The 24 units surveyed provided a total of 191 beds, of which 152 were staffed. Eighteen children were dependent on ventilators in eight units, thus they occupied around 12% (18/152) of available beds. During the survey 267 children, including 143 children at the eight affected units, were refused admission. The potential spare bed capacity generated if the 18 beds used by the children dependent on ventilators had been available would have allowed for an extra 273 admissions. An additional 120 children could have been admitted to the eight affected units. The number of patients refused could therefore have been reduced from 267 (124 in units I-X plus 143 in units A-H) to 142 (124 in units I-X plus 23 in units A-H). This would have been a fivefold reduction from 143 to 23 patients in units A-H which translates to a total reduction in refusal rate of 45%, from 267 to 147 patients (table 1).

Comment

Children who are dependent on ventilators remain inappropriately in hospital for prolonged periods of time and are occupying much needed acute paediatric intensive care unit beds.3 The obstacles to discharging these patients fall into three categories: coordination of agencies, lack of institutional alternatives, and responsibility for funding. Coordinating the relevant agencies takes time, and early liaison is crucial once it becomes apparent that a child is dependent on a ventilator. If placement at home or in a local hospital is not possible, the availability of facilities such as community rehabilitation centres or hospital based long term ventilation units would allow intensive care beds to be released for emergency admissions. Which authority has financial responsibility for these children is unclear, and problems with funding delay discharge; health authorities need to accept that they are obliged to fund home care programmes, or money must be provided supraregionally.

During the winter months of January to March 1996, 12% of available beds in paediatric intensive care units were occupied by children dependent on ventilators. Alternative placements for these patients are needed urgently. Emergency admissions to these units were prevented because beds were occupied by children dependent on ventilators. With better prioritisation, the current number of beds is sufficient to accommodate a large proportion of acute admissions.