title: Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death.
abstract: OBJECTIVE
  Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided.
  
  
  METHODS
  A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors.
  
  
  RESULTS
  The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children.
  
  
  CONCLUSIONS
  The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.
authors.affiliation: Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Peter
authors.initials: P
authors.lastname: Hodkinson
authors.affiliation: Department of Paediatrics, University of Cape Town, Cape Town, South Africa.
authors.forename: Andrew
authors.initials: A
authors.lastname: Argent
authors.affiliation: Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Lee
authors.initials: L
authors.lastname: Wallis
authors.affiliation: Directorate of Primary Health Care, University of Cape Town, Cape Town, South Africa.
authors.forename: Steve
authors.initials: S
authors.lastname: Reid
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Rafael
authors.initials: R
authors.lastname: Perera
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Sian
authors.initials: S
authors.lastname: Harrison
authors.affiliation: Department of Family Medicine, University of Washington, Seattle, United States of America.
authors.forename: Matthew
authors.initials: M
authors.lastname: Thompson
authors.affiliation: Nuffield Department of Medicine, Oxford University, Oxford, UK and KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
authors.forename: Mike
authors.initials: M
authors.lastname: English
authors.affiliation: Paediatric Emergency Medicine, Imperial College, London, UK and NIHR BRC funded researcher Imperial College, London.
authors.forename: Ian
authors.initials: I
authors.lastname: Maconochie
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Alison
authors.initials: A
authors.lastname: Ward
mesh_terms: D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015601:Injury Severity Score; D015278:Intensive Care Units, Pediatric / Q000706:statistics & numerical data*; D008297:Male; D010343:Patient Admission / Q000706:statistics & numerical data*; D011786:Quality Control; D011787:Quality of Health Care / Q000592:standards / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D013019:South Africa; D013997:Time Factors; D017749:Total Quality Management / Q000379:methods; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*