title: Improved outcomes from tertiary center pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities.
abstract: OBJECTIVE
  To compare outcomes from pediatric intensive care in hospitals with different levels of resources.
  
  
  METHODS
  Prospective, blinded comparison of outcome and care.
  
  
  METHODS
  Tertiary (n = 3) and nontertiary (n = 71) hospitals in Oregon and southwestern Washington.
  
  
  METHODS
  All critically ill children admitted with respiratory failure and head trauma for 6 months.
  
  
  RESULTS
  Severity of illness adjusted mortality rates were determined using admission day, physiologic profiles (Pediatric Risk of Mortality score) and care modalities were assessed daily. The crude mortality rate of the tertiary patients was four times higher than for the nontertiary patients (23.4% vs. 6.0%, p less than .0001). In the tertiary patients, the numbers of outcomes were accurately predicted by physiologic profiles (observed: 30 deaths and 98 survivors; predicted: 29.3 deaths and 98.7 survivors, z = -.25, p greater than .4). However, for the nontertiary patients, the number of the deaths were significantly different than predicted (observed: 20 deaths and 315 survivors; predicted: 14.4 deaths and 320.6 survivors, z = -2.08, p less than .05). The odds ratios of dying in a nontertiary vs. a tertiary facility were about 1.1, 2.3, and 8 (p less than .05) for mortality risk groups of less than 5%, 5% to 30%, and greater than 30%. Patients in tertiary facilities received more (p less than .05) invasive (e.g., arterial catheters) and complex (e.g., mechanical ventilation) care, whereas patients in nontertiary facilities received more (p less than .05) labor-intensive care (e.g., hourly vital signs).
  
  
  CONCLUSIONS
  Care of the most seriously ill children in tertiary pediatric ICUs could improve their chances of survival.
authors.affiliation: Department of Critical Care Medicine, Children's Hospital National Medical Center, Washington, DC 20010.
authors.forename: M M
authors.initials: MM
authors.lastname: Pollack
authors.forename: S R
authors.initials: SR
authors.lastname: Alexander
authors.forename: N
authors.initials: N
authors.lastname: Clarke
authors.forename: U E
authors.initials: UE
authors.lastname: Ruttimann
authors.forename: H M
authors.initials: HM
authors.lastname: Tesselaar
authors.forename: A C
authors.initials: AC
authors.lastname: Bachulis
mesh_terms: D000293:Adolescent; D002648:Child; D006259:Craniocerebral Trauma / Q000628:therapy; D006801:Humans; D007263:Infusions, Parenteral; D015278:Intensive Care Units, Pediatric; D008991:Monitoring, Physiologic; D009026:Mortality; D009922:Oregon; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D012041:Regional Medical Programs; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000628:therapy; D012720:Severity of Illness Index