title: Outcome of children with different accessibility to tertiary pediatric intensive care in a developing country--a prospective cohort study.
abstract: OBJECTIVE
  Lack of direct access to tertiary pediatric intensive care services in rural hospitals may be associated with poorer outcome among critically ill children. Inter-hospital transport by non-specialized teams may also lead to increased morbidity and even mortality. We therefore studied the outcome of children with different accessibility to tertiary pediatric care in Malaysia.
  
  
  METHODS
  We prospectively compared the Pediatric Risk of Mortality (PRISM II) adjusted standardized mortality ratio (SMR), unanticipated deaths and length of stay of 131 patients transported from rural hospitals (limited access) with 215 transferred from the casualty wards or other in-hospital wards (direct access) to a tertiary pediatric ICU.
  
  
  RESULTS
  The transported patients were younger than the in-hospital patients (median age 1.0 versus 6.0 months, p=0.000) and were more likely to have respiratory diseases. Other baseline characteristics did not differ significantly. Differences in access to tertiary intensive care from community hospitals was associated with an extended median length of stay (4.0 versus 2.0 days, p=0.000) but did not affect SMR (0.92 versus 0.84, rate ratio 1.09, 95% CI 0.57-2.01; p=0.348) or percentage of unexpected deaths (4.8% versus 2.8%, p=0.485). The adjusted odds ratio for mortality (1.7, 95% CI 0.7-4.3) associated with transfer was not statistically significant (p=0.248).
  
  
  CONCLUSIONS
  The outcome of critically ill children transferred from community hospitals did not differ from that of those who develop ICU needs in the wards of a tertiary center, despite being transported by non-specialized teams. Outcome was not affected by initial inaccessibility to intensive care if the children finally received care in a tertiary center.
authors.affiliation: Pediatric Intensive Care Unit, University Malaya Medical Center, 50603 Kuala Lumpur, Malaysia. adriangoh@um.edu.my
authors.forename: Adrian Yu-Teik
authors.initials: AY
authors.lastname: Goh
authors.forename: Mohd El-Amin
authors.initials: Mel-A
authors.lastname: Abdel-Latif
authors.forename: Lucy Chai-See
authors.initials: LC
authors.lastname: Lum
authors.forename: Mohd Nazir
authors.initials: MN
authors.lastname: Abu-Bakar
mesh_terms: D002648:Child; D002675:Child, Preschool; D016638:Critical Illness / Q000401:mortality*; D003906:Developing Countries; D005260:Female; D006297:Health Services Accessibility; D017052:Hospital Mortality; D006780:Hospitals, Rural; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007902:Length of Stay; D016015:Logistic Models; D008296:Malaysia; D008297:Male; D015999:Multivariate Analysis; D010360:Patient Transfer; D011446:Prospective Studies; D012372:ROC Curve; D016896:Treatment Outcome