PICANet Annual Report 2015-2017
Source: data.gov.uk (2019-12-05)

Paediatric Intensive Care Audit - This data contains information on all admissions to Paediatric Intensive Care units in the UK and Ireland 2015-2017.

1 
 
 
 
Summary Report 
Paediatric Intensive Care 
Audit Network 
Annual Report 2018 
Data collection period  
January 2015–December 2017 

2 
PICANet 2018 annual summary report 
Organisation key 
A 
Addenbrooke's Hospital, Cambridge 
C 
Noah’s Ark Children’s Hospital for Wales, Cardiff 
D 
Royal Manchester Children’s Hospital 
E1 
Great Ormond Street Hospital, London (PICU/NICU) 
E2 
Great Ormond Street Hospital, London (CICU) 
F 
Evelina London Children’s Hospital 
H 
King’s College Hospital, London 
I 
Leeds General Infirmary 
K2 
Freeman Hospital, Newcastle upon Tyne 
K3 
Great North Children’s Hospital, Newcastle upon Tyne 
L 
Royal Stoke University Hospital 
M 
Queen’s Medical Centre, Nottingham 
N 
John Radcliffe Hospital, Oxford 
O 
Royal Brompton Hospital, London 
P 
Alder Hey Children’s Hospital, Liverpool 
Q 
Sheffield Children’s Hospital 
R 
Southampton Children’s Hospital 
S 
James Cook University Hospital, Middlesbrough 
T 
St George’s Hospital, London 
U 
St Mary’s Hospital, London 
V 
Birmingham Children’s Hospital 
W 
Bristol Royal Hospital for Children 
X1 
Glenfield Hospital, Leicester 
X2 
Leicester Royal Infirmary 
Y 
Royal Hospital for Sick Children, Edinburgh 
Z 
The Royal London Hospital 
ZA 
Royal Hospital for Children, Glasgow 
ZB 
Royal Belfast Hospital for Sick Children 
ZC 
Our Lady’s Children’s Hospital, Crumlin, Dublin 
ZD 
Temple Street Children’s University Hospital, Dublin 
ZE 
Harley Street Clinic, London 
ZF 
The Portland Hospital, London 
T001 
Children’s Acute Transport Service (CATS) 
T002 
Embrace: Yorkshire & Humber Infant & Children’s Transport Service 
T003 
North West and North Wales Paediatric Transport Service (NWTS) 
T004 
South Thames Retrieval Service (STRS) 
T005 
KIDS Intensive Care and Decision Support 
T008 
Southampton Oxford Retrieval Team (SORT) 
T010 
Northern Ireland Specialist Transport and Retrieval (NISTAR) Paediatric 
T016 
ScotSTAR Paediatric Retrieval Service (Edinburgh) 
T017 
ScotSTAR Paediatric Retrieval Service (Glasgow) 
T020 
Scotland Specialist Transport and Retrieval (ScotSTAR) 
T022 
Irish Paediatric Acute Transport Service (IPATS) 
T024 
Wales and West Acute Transport for Children (WATCh) 
T026 
North East Children’s Transport and Retrieval Service (NECTAR) 
T027 
Children’s Medical Emergency Transport Service (CoMET) 
 
Published in the UK by the Paediatric Intensive Care Audit Network (PICANet). This work is copyright. Apart from 
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process without permission from PICANet. 
Requests and enquiries concerning reproduction rights should be directed to PICANet at:  
PICANet, School of Medicine, Room 8.49 Worsley Building, University of Leeds, Leeds, LS2 9JT 
Telephone xx-xxxx-xxxx  Email xxx@xxx.xx 
In all cases, PICANet must be acknowledged as the source when reproducing or quoting any part of this 
publication. Please use the following format when citing this report: Paediatric Intensive Care Audit Network 
Annual Report 2018 (published November 2018): Universities of Leeds and Leicester 
© 2018 The University of Leeds, University of Leicester and the Healthcare Quality Improvement Partnership 
The ISBN number for this publication is 978 0 85316 358 9 

 
3 
Contents 
Acknowledgements ................................................................................................................ 5 
Introduction ............................................................................................................................ 7 
Key findings ........................................................................................................................... 8 
Recommendations ............................................................................................................... 11 
How we present our results.................................................................................................. 13 
Headline figures: Admission numbers and bed days ............................................................ 14 
Headline figures: Admission rates by country ...................................................................... 16 
Headline figures: Death in PICU .......................................................................................... 18 
Headline figures: Unplanned extubation............................................................................... 20 
Headline figures: Referral for transport ................................................................................ 22 
Headline figures: Use of bank and agency nurses ............................................................... 24 
Headline figures: Bed occupancy during ‘normal hours’ and ‘out of hours’ ........................... 26 
Metric 1: Case ascertainment and timeliness of data submission......................................... 28 
Metric 2: Retrieval mobilisation times ................................................................................... 30 
Metric 3: Number of qualified nurses per bed ....................................................................... 32 
Metric 4: Emergency readmissions within 48 hours ............................................................. 34 
Metric 5: Mortality in PICU ................................................................................................... 36 
Referral and transport winter pressures ............................................................................... 38 
References .......................................................................................................................... 41 
Additional information .......................................................................................................... 43 
 
For the Tables, Figures and Appendices relating to this report, please visit the PICANet 
website www.picanet.org.uk. 
 
 


Acknowledgements 
5 
Acknowledgements 
This work uses data provided by patients and collected by the NHS, the Health Service 
Executive or private hospitals as part of their care and support. 
The continued success of this international clinical audit is due to the hard work and 
commitment of those within the paediatric intensive care community. We are very grateful to 
all the audit clerks, secretaries, nurses and doctors who support and contribute to the 
Paediatric Intensive Care Audit Network (PICANet) from their own paediatric intensive care 
units (PICUs) and centralised transport services (CTS). 
PICANet was established in collaboration with the Paediatric Intensive Care Society (PICS) 
and their active support continues to be a key component of our successful progress. The 
PICANet Steering Group (SG) has patient, academic, clinical, government and NHS 
members all of whom are thanked for their continuing assistance and advice. Members of the 
Clinical Advisory Group (CAG) provide a formal interface between PICANet and the clinical 
care teams and their valuable support and contribution is gratefully acknowledged. 
We are also grateful for the support and commitment given by members of the PIC Families 
Group. 
The PICANet Audit is commissioned by the Healthcare Quality Improvement Partnership 
(HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), 
the Welsh Health Specialised Services, NHS Lothian/National Services Division NHS 
Scotland, the Royal Belfast Hospital for Sick Children, The National Office of Clinical Audit 
(NOCA), Republic of Ireland and HCA Healthcare UK. HQIP is led by a consortium of the 
Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its 
aim is to promote quality improvement in patient outcomes, and in particular, to increase the 
impact that clinical audit, outcome review programmes and registries have on healthcare 
quality in England and Wales. HQIP holds the contract to commission, manage and develop 
the NCAPOP, comprising around 40 projects covering care provided to people with a wide 
range of medical, surgical and mental health conditions. The programme is funded by NHS 
England, the Welsh Government and, with some individual projects, other devolved 
administrations and crown dependencies. 
www.hqip.org.uk/national-programmes 
 


Introduction 
7 
Introduction 
We are delighted to present the fifteenth annual PICANet clinical audit report describing 
paediatric intensive care (PIC) activity in the United Kingdom (UK) and Republic of Ireland 
(ROI). The purpose of PICANet is to improve critical care services provided to patients as 
part of PIC services by measuring the quality of care and outcomes against pre-determined 
standards, using data from the UK and Republic of Ireland as a whole as a benchmark. 
We have again made minor changes to the layout and information presented in this year’s 
Summary Report so that it is easier to read. In addition to the standard headline figures on 
PICU activity, mortality, transport referrals, staffing, occupancy and the five quality measures, 
we focus on referral and transport data examining the impact of winter pressures. We 
provide this information for the whole of the UK and Republic of Ireland, and by individual 
country. 
This report provides information on five key metrics: case ascertainment, retrieval 
mobilisation times, number of qualified nurses per bed, emergency readmissions within 
48 hours and mortality in PICU. However, for metrics such as unplanned extubation and 
emergency readmissions within 48 hours, there is no agreed standard as to the acceptable 
level. We therefore present each PICU in comparison to the overall average for the UK and 
Republic of Ireland. Importantly, PICANet will be in a position to contribute robust clinical 
audit data when needed so that these standards can be agreed and are evidence based. 
Once again a comprehensive set of tables and figures have been produced, which 
complement the Summary Report and are available as a separate PDF document or for 
download as an Excel spreadsheet in addition to the Appendices. These represent crucial 
descriptors of PICU activity and outcomes across the UK and Republic of Ireland for both 
commissioners and clinicians, identifying key areas to focus on in order to improve PIC 
services at a local and national level. 
PICANet continues to play a vital role within the Paediatric Critical Care Review, providing 
key intelligence on PIC activity and outcomes to support evidence based recommendations 
emerging from the Review, and which is expected to be published in 2019. 
 
Richard Feltbower 
Liz Draper 
Principal Investigators 
 

8 
PICANet 2018 annual summary report 
Key findings 
▪ 
Across the UK and Republic of Ireland , there were approximately 20,000 admissions 
to paediatric intensive care per year in the period 2015–2017. There was a small 
reduction in the number of admissions in 2017 compared to 2016, attributable to all 
PICUs except those in the Republic of Ireland. 
▪ 
The number of bed days delivered has fluctuated during the three year reporting 
period, with a higher number of bed days delivered in 2016. The decrease in 2017 is 
possibly due to the fall in the number of admissions in the same year. 
▪ 
There was geographical variation in admission rates for paediatric intensive care, 
ranging from 124 and 141 admissions per 100,000 children in the Republic of Ireland 
and England to 184 admissions per 100,000 children in Northern Ireland in the 3 year 
reporting period. 
▪ 
More than 96% of patients were discharged alive from PICU between 2015 and 2017, 
showing that the risk of death remains low. The proportion of deaths occurring in 
PICUs out of the total number of childhood fatalities in the population is around one in 
six. 
▪ 
Unplanned extubation rates in PICU for 2017 were typically around 4 per 1,000 days 
of invasive ventilation for the UK and Republic of Ireland combined.  
▪ 
Few agency and bank nursing staff are used on PICUs to provide care for critically ill 
children in the UK & Republic of Ireland during normal working hours. However in 
November 2017 in NHS hospitals in London 13.7% of the nursing staff working at 
midday on census Wednesday and around one fifth (19.8%) of nursing staff ‘out of 
hours’ on census Sunday at midday were bank or agency employees. No bank or 
agency staff were in use at any census point in either the Republic of Ireland or 
Wales in 2016 or 2017. 
▪ 
Specialist PIC transport services provided a rapid response for 92% (15,978) of 
requests for emergency transport over the period 2015–2017. Fewer than 1 in 20 
requests were not accepted due to a lack of PIC transport team availability. 
▪ 
Reported rates of occupancy in PICUs were very high during the staffing census 
week with intensive care (IC) bed occupancy rates of at least 90% in England (NHS), 
Scotland and Northern Ireland and a high dependency bed occupancy rate of 100% 
in England (NHS) and Wales during normal working hours. Rates of bed occupancy 
showed little reduction ‘out of hours’ across the UK and the Republic of Ireland. 
However ‘out of hours’ rates for both IC and high dependency beds were low for 
Wales (33.3%, and 27.3%, respectively). 
▪ 
For children requiring urgent transport, four out of five (78.2%) journeys were started 
within 1 hour. A small proportion (6.1%) of these journeys started more than 3 hours 
after the decision was made that the child required urgent transport. 
▪ 
In 2017, of the specialist PIC transport services, eight out of 14 organisations (Figure 
9) mobilised their team within 1 hour for more than three quarters of urgent 
transports, and mobilised within 30 minutes for 60.2% of all urgent transports. 

Key findings 
9 
▪ 
Overall the establishment figures for PICUs across the UK and Republic of Ireland 
show that in 2017 few units met the current PICS standards (n=3, 9% of PICUs), 
although if all the recorded vacancies for qualified nurses were filled (n=6, 18%), 
PICUs would have met this standard. However, despite few PICUs meeting these 
standards, staffing data from the census shows that the units ensure that their staffing 
levels are appropriate for the number of children on the unit and their care 
requirements.  
▪ 
Virtually all admissions in 2017 were reported to PICANet so that our estimated case 
ascertainment was 99.4%. In terms of overall timeliness of data completion, 80% of 
units’ admissions met the PICS standard for reporting to PICANet within 3 months of 
their discharge from the unit. 
▪ 
We found that 1.6% of children admitted to PICUs were discharged and then 
readmitted as an emergency within 48 hours. Although these readmission rates 
varied by country, there was no evidence that any individual PICU discharged 
children too early during 2015–2017. 
 


Recommendations 
11 
Recommendations 
 
 
 
1. 
PICANet should continue to work with the Paediatric Intensive Care Society, 
the Care Quality Commission and other stakeholders to develop new quality 
indicators and an evidence-base for current standards and quality metrics 
reported by PICANet, in particular unplanned extubation and emergency 
readmission within 48 hours. 
2. 
PICANet should continue to monitor trends in admissions and number of bed 
days delivered to confirm whether the stabilisation in activity levels in 2017 is 
sustained. 
3. 
PICANet should work with PICUs and the Paediatric Intensive Care Society to 
consider whether the current clinical standards for the minimum number of 
qualified nurses per critical care bed are appropriate. This should be carried 
out in conjunction with the Royal College of Nursing and the National 
Paediatric Critical Care Review. 
4. 
National nursing professional bodies should develop recruitment and retention 
initiatives for paediatric intensive care nurses to ensure all PICUs have 
adequate staffing levels. 
5. 
Paediatric intensive care centralised transport service teams should continue 
to monitor mobilisation response times for retrievals and urgent transport of 
children to PICUs. 
6. 
The high levels of occupancy in designated intensive care and high 
dependency beds in PICUs should inform the recommendations emerging 
from the National Paediatric Critical Care Review. 
7. 
PICANet should work with PICUs to develop support processes that will 
enhance the timeliness of data. 
 


How we present our results 
13 
How we present our results 
Results are presented in tables, figures and as maps. We use what are called ‘funnel plots’ 
to compare individual PICUs with the overall average for the UK and the Republic of Ireland 
for a number of the outcomes we measure including: mortality, emergency readmissions 
within 48 hours and unplanned extubation. Each measure is explained in the results and 
metrics sections of this report under the heading “What are we measuring?” 
We describe below how funnel plots should be interpreted. 
Figure 1: Example funnel plot 
 
Figure 1 is a simple diagram of what a funnel plot might look like. The ‘funnel’ is created 
using statistical methods that tell us what range of values we might expect for each measure, 
given that there are normal ‘ups and downs’ (natural variation). The limits are wider where 
there are fewer admissions because with only a few values we cannot be as certain about 
our findings. With more values we can be more confident that the outcome is likely to fall 
within narrower limits.  
The blue dots represent the individual PICUs with different numbers of admissions. The red 
dot indicates a PICU that is outside the upper limit. We say that this is ‘statistical outlier’ and 
we have a process for investigating why this has occurred. 
The blue line in the middle of the funnel represents the ratio where the observed and 
expected number of events are equal for each outcome based on the UK and the Republic of 
Ireland findings as a whole. You would always expect a scatter of dots above and below this 
line if you know the average. The whole point about funnel plots is to allow us to see 
differences between units taking into account natural variation. 
 

14 
PICANet 2018 annual summary report 
Headline figures: Admission numbers and 
bed days 
What are we measuring? 
Table 1 and Table 2 below summarise the number of admissions to paediatric intensive 
care units in the UK and Republic of Ireland between 2015 and 2017 among children aged 
under 16 years and the number of bed days of paediatric intensive care that were delivered 
during this period. 
What did we find? 
On average, there were approximately 20,000 annual admissions to PICUs in 2015, 2016 
and 2017 across the UK and Republic of Ireland, although there was a slight fall in 2017 in all 
countries except the Republic of Ireland and the English non-NHS PICUs. The number of 
bed days provided fluctuated throughout the 3 year reporting period in all the admitting 
countries with a consistent peak in 2016 in most countries with the exception of Northern 
Ireland. 
Table 1: Number of admissions by country and year 
Country 
2015 
2016 
2017 
England (NHS) 
15,811 
15,964 
15,462 
England (non-NHS) 
270 
336 
502 
Wales 
466 
530 
493 
Scotland 
1,321 
1,487 
1,393 
Northern Ireland 
630 
557 
522 
Republic of Ireland 
1,397 
1,401 
1,463 
Total 
19,895 
20,275 
19,835 
Table 2: Number of bed days delivered by country and year 
Country 
2015 
2016 
2017 
England (NHS) 
107,700 
113,827 
110,174 
England (non-NHS) 
3,292 
3,473 
2,413 
Wales 
2,353 
2,757 
2,451 
Scotland 
8,747 
11,020 
10,768 
Northern Ireland 
3,822 
3,480 
3,695 
Republic of Ireland 
10,174 
10,319 
9,607 
Total 
136,088 
144,876 
139,108 
 
What does this mean? 
There continues to be high demand placed upon paediatric intensive care services in the UK 
and Republic of Ireland based upon the number of patient admissions and bed days 
delivered. Substantial variation in service demand by country demonstrates the need for 
continued careful monitoring in the future. 

Headline figures: Admission numbers and bed days 
15 
Further details 
Definitions and methods 
Every admission to a PICU in the UK and the Republic of Ireland is counted for each year, 
2015–2017. If a child has been readmitted during that period this will also be counted. A ‘bed 
day’ is counted if a child is in a PICU bed for a day or part of a day. We have only given 
figures for children less than 16 years old (the normal age limit for admission to PICU) and 
have excluded any admissions where the age at admission was unknown. 
Why is this important? 
The number of admissions and the number of bed days tell us how busy the PICUs are and 
helps the commissioners who provide funding for paediatric intensive care to work out how 
many staff and beds are required to meet the demand. This is important as too few beds 
might mean that a child may not receive intensive care when they need it or there may be a 
delay. Although it is unlikely, if the commissioners overestimate demand, it is possible that 
staff and beds would be under-utilised which would be a waste of resources. 
The data regarding PICU admissions and bed days delivered is being considered by the 
current Paediatric Critical Care Review for England. 
 

16 
PICANet 2018 annual summary report 
Headline figures: Admission rates by 
country 
What are we measuring? 
Annual rates of admissions to PICU between 2015 and 2017 are presented in Figure 2 below 
by country, calculated per 100,000 children in the population. This identifies what fraction of 
the childhood population are treated by paediatric intensive care services in each country 
every year. 
What did we find? 
Rates were highest in Northern Ireland, reaching 184 admissions for every 100,000 children, 
followed by Scotland (163), Wales (144), England (142) and the Republic of Ireland (124). 
For the UK and Republic of Ireland combined, admissions rates were 143 per 100,000 
population per year. 
Figure 2: Rate of admissions per 100,000 childhood population 2015–2017 
 
What does this mean? 
There is clear geographical variation in admissions rates to PICU by country, with Northern 
Ireland for example exhibiting 50% higher rates compared to the Republic of Ireland. The 
reasons for these differences are likely to be complex and multifactorial but could include the 
proximity of patients to the PICUs, variation in admission policies between countries and the 
extent of other services available to treat critically ill children. 

Headline figures: Admission rates by country 
17 
Further details 
Definitions and methods 
Having counted the admission numbers, we have then worked out how many admissions 
there are for every 100,000 children under 16 in each of the UK countries and the Republic 
of Ireland in 2015–2017. This is called the admission rate. We have used national census 
data to find out what the childhood population is in each country. 
Why is this important?  
It is important for each country participating in PICANet to know the rate of admission to 
paediatric intensive care to allow them to plan services effectively. 
 

18 
PICANet 2018 annual summary report 
Headline figures: Death in PICU 
What are we measuring? 
All deaths that occur prior to discharge from PICU are recorded and reported here for 
children under 16 who were admitted between 2015 and 2017. Deaths were broken down in 
two ways: firstly, based on the country of admission (i.e. PICU location) and secondly based 
on the patient’s recorded country of residence. 
What did we find? 
Table 3 summarises the number of deaths in PICU by country of admission and year. The 
percentages are calculated based on the total number of admissions for that year. For the 
UK and Republic of Ireland there were 2,179 deaths in total over the three years. This means 
that for every one hundred children admitted to PICU at least 96 are discharged alive. Table 
4 presents the number of deaths in PICU based on the country of residence alongside the 
total number of deaths in the population. The percentages of PICU deaths are calculated 
based on the total number of deaths in the population registered for each year. For the UK 
and Republic of Ireland from 2015–2017, PICU deaths accounted for 16% of the total 
number of children’s deaths. 
Table 3: Number of deaths in PICU by country of admission and year 
Country of admission 
2015 
2016 
2017 
England (NHS) 
626 (4.0%) 
576 (3.6%) 
598 (3.9%) 
England (non-NHS) 
5 (1.9%) 
9 (2.7%) 
3 (0.6%) 
Wales 
8 (1.7%) 
11 (2.1%) 
10 (2.0%) 
Scotland 
30 (2.3%) 
36 (2.4%) 
35 (2.5%) 
Northern Ireland 
20 (3.2%) 
9 (1.6%) 
18 (3.5%) 
Republic of Ireland 
72 (5.2%) 
53 (3.8%) 
60 (4.1%) 
Total 
761 (3.8%) 
694 (3.4%) 
724 (3.7%) 
Table 4: Number of deaths in PICUs as a proportion of all children’s deaths in 
the population: UK and Republic of Ireland, 2015–2017 
Country of residence 
2015 
2016 
2017 
UK 
675 (15.8%) 
624 (14.9%) 
644 (15.6%) 
Republic of Ireland* 
67 (22.0%) 
51 (18.2%) 
52 (20.1%) 
* For 2016 and 2017, the numbers of total deaths for the Republic of Ireland are provisional and subject to 
change 
What does this mean? 
Risk of death in paediatric intensive care remains rare, with 96.4% of patients being 
discharged alive between 2015 and 2017. Deaths in PICU account for about one in every six 
of all children’s deaths in the UK and Republic of Ireland in any given year. 

Headline figures: Death in PICU 
19 
Further details 
Definitions and methods 
We have recorded the number of deaths in PIC by year and by country of admission for 2015 
to 2017 (Table 3). The percentages in Table 3 are based on the number of admissions to 
PICUs over this period, not the number of individual children. In Table 4 we present deaths 
on PICUs (2015–2017) as a proportion of all child deaths in the UK and the Republic of 
Ireland. 
Why is this important? 
Death on PICU is rare and the rate of PICU death has reduced year on year since PICANet 
started collecting data in 2002: It is important to record the number of deaths to facilitate the 
investigation of these trends over time. It also highlights any differences in death rates 
between countries. Where there are very small numbers of deaths we need to be cautious 
about making comparisons as apparently large differences may happen by chance. 
 

20 
PICANet 2018 annual summary report 
Headline figures: Unplanned extubation 
What are we measuring? 
Children who need help with their breathing may require a tube down their throat connected 
to a machine: this is called invasive ventilation. If the tube is accidentally dislodged, this is 
referred to as unplanned extubation. Here we measure the number of unplanned 
extubations for every thousand days of invasive ventilation. 
What did we find? 
In 2017 the number of unplanned extubations in the UK and Republic of Ireland was 260 out 
of a total of 68,000 days of invasive ventilation. This is equivalent to a rate of 4 unplanned 
extubations for every 1,000 days of invasive ventilation. Figure 3 shows the  rate of 
unplanned extubation by organisation. 
Table 5: Unplanned extubations per 1,000 days of invasive ventilation: UK and 
Republic of Ireland, 2017 
 
2017 
Country 
Number 
Rate 
England (NHS) 
210 
4 
England (non-NHS) 
0 
0 
Wales 
3 
3 
Scotland 
21 
5 
Northern Ireland 
5 
3 
Republic of Ireland 
21 
4 
Total 
260 
4 
Figure 3: Unplanned extubation ratios by health organisation 2017 
 

Headline figures: Unplanned extubation 
21 
What does this mean? 
Unplanned extubation remains a relatively rare event within paediatric intensive care 
services with a recorded annual rate of 4 per 1,000 days of invasive ventilation on average.  
Further details 
Definitions and methods 
When a child is intubated and ventilated it means that they have a tube placed in their throat 
attached to a machine that helps them to breathe. The machine can be used to provide 
different levels of oxygen to help their recovery. If the tube is accidentally removed this is 
called an unplanned extubation. As we are comparing PICUs, we need to calculate a rate of 
unplanned extubation based on how many days of invasive ventilation are provided in each 
PICU, as the more patients that are ventilated on a PICU the more likely an unplanned 
extubation will occur. To calculate the rate we take the number of unplanned extubations for 
every 1,000 invasive ventilation days delivered. That makes comparisons between units with 
different volumes of invasive ventilation possible. Unplanned extubation is referred to as an 
‘adverse event’.  Data for this analysis was limited to 2017 admissions only. 
Why is this important? 
Unplanned extubation is the most common adverse event related to airway management in 
intensive care: it can cause complications such as hypoxaemia (very low blood oxygen), 
hypercarbia (high blood carbon dioxide) and sometimes, but very rarely, death1. Clearly, it is 
best to avoid unplanned extubation if at all possible but there are no established guideline 
levels: the NHS England service specification notes the threshold is still to be agreed2. 
Kanthimathinathan and colleagues do refer to a notional threshold of 1/100 invasive 
ventilation days, which is equivalent to 10/1000 days1. By continuously monitoring unplanned 
extubation rates it may be possible to detect when a change in practice occurred (such as 
the change in the adhesive tapes that caused an increase in unplanned extubation rates 
noted by Kanthimathinathan and colleagues1). 
 

22 
PICANet 2018 annual summary report 
Headline figures: Referral for transport 
What are we measuring? 
If a child needs specialist paediatric intensive care (PIC) transport, a referral is made to the 
PIC transport team. Sometimes the initial referral may not result in a transport and this is 
called a refusal. We have recorded the number of referrals during the period 2015–2017, the 
number which were successful and the number which were refused. We have also looked at 
the reason why they were refused. 
What did we find? 
We recorded details of the 17,395 referrals for PIC transport, of which 92% (15,978) were 
accepted for transport. Less than 1 in 10 (1,408) were not accepted for transport and of 
these just over half (53.5%) were refused because no PIC transport team was available 
(Figure 4). Reasons for the remaining refusals were due to the condition of the child being 
assessed as time critical (22.2%) or that the transport of the child could be delivered 
appropriately by another team (24.3%) known as being ‘out of scope’, for example a neonatal 
transfer team who provide transport for small babies. 
Figure 4: Reason transport not undertaken following referral for urgent 
paediatric intensive care transport: UK and Republic of Ireland 2015–2017 
 
What does this mean? 
When a transport team receives a referral and the specialist PIC doctor agrees that the child 
requires transfer from the original admitting hospital to a PICU in another hospital, they also 
need to confirm that the PICU has a bed available to care for the child. If a bed is not 
available at the nearest PICU the PIC transport team will seek an available bed in an 
alternative PICU. Over the period 2015–2017 the specialist PIC transport service were able 
to provide a rapid response to over 90% of requests for transport. 
When the transport team refuse the referral because they are already busy with other 
transfers (53.5%), urgent referrals may be passed to another PIC transport team or the child 
may remain at the local hospital with ongoing provision of support and advice about 
treatment being provided by the specialist PIC transport doctor until a staffed transport team 
is available.  
PIC transport may also be provided for children who are transferred from one PICU to 
another, to another specialist service, a hospice or home. 
22.2%
24.3%
53.5%
0
200
400
600
800
Time critical transfer
Out of scope of care
No transport team available
Number of referrals
Reason for refusal

Headline figures: Referral for transport 
23 
All children requiring PIC transport (agreed by the PIC specialist doctor) will be cared for and 
transferred by a PIC transport service or another transport provider. 
Further details 
Definitions and methods 
We have recorded how many children have a referral for a specialist PIC transport team to 
collect them and transfer them to a PICU. Where the transport does not happen, we have 
recorded the reasons given by the transport teams. 
Why is this important? 
In 2015 to 2017 15,978 (91.9%) referrals were accepted for urgent transfer to PIC. Of the 
1,408 refusals 753 (53.5%) were refused because there was no PIC team available. These 
requests may be passed to another PIC specialist transport team or the child may remain in 
the care of their local hospital under close supervision from the PIC team until transport can 
be mobilised. However this may result in the child being moved to a PICU in another part of 
the country. 
Delays in receiving intensive care may have clinical implications and can cause stress for the 
patients and their carers. 
Sometimes the PIC transport team advise that the local hospital transfer the child themselves 
to urgently access specialist treatment e.g. a child with a serious head injury. This is 
recorded by PICANet as a time critical transfer. In cases where the PIC transport team 
assess that the specialist transport required is out of their scope of care, the transport is 
provided by another specialist transport team (e.g. a neonatal team providing transport for an 
extremely preterm infant). 
The ability of a PIC transport team to transfer a child to a PICU also depends on there being 
a PIC bed available. 
 

24 
PICANet 2018 annual summary report 
Headline figures: Use of bank and agency 
nurses 
What are we measuring? 
In the PICANet annual staffing survey we record the proportion of qualified nursing staff that 
were from a bank or agency on duty in PICUs during ‘normal hours’ and ‘out of hours’. Here 
we present these results for a Wednesday and a Sunday at midday in November 2015, 2016 
and 2017 for the UK countries and the Republic of Ireland. 
What did we find? 
The largest proportion of bank and agency nursing staff working during both ‘normal hours’ 
and ‘out of hours’ in 2017 was in the London PICUs: 13.7% midday Wednesday and 19.8% 
midday Sunday. No bank and agency staff were used in Wales, Northern Ireland and the 
Republic of Ireland at the ‘normal hours’ midday census point on a Wednesday. However, at 
the ‘out of hours’ census point on midday Sunday Northern Ireland reported using 8.3% of 
bank and agency staff. 
Figure 5: Percentage of bank and agency nursing staff working on PICU midday 
Wednesday (‘normal hours’) and midday Sunday (‘out of hours’), November 
2015–2017 
 
What does this mean? 
At both presented census time points the main use of bank and agency nursing staff is in the 
London PICUs where at midday Wednesday they comprised just under one eighth of the 
nursing workforce and at midday Sunday this was even higher at around one fifth of the 
nursing workforce. Use of agency and bank staff may be a reflection of the additional 
pressures on nurse staffing in London. There is a large demand for staff in London where 
around one third of English PICUs are located. 
0
5
10
15
20
25%
England
(excl.
London)
Wales
Scotland Northern
Ireland
Republic
of Ireland
London
(NHS)
England
(excl.
London)
Wales
Scotland Northern
Ireland
Republic
of Ireland
London
(NHS)
2015
2016
2017
Midday Wednesday
Midday Sunday

Headline figures: Use of bank and agency nurses 
25 
Further details 
Definition and methods 
Each year PICANet carries out a staffing study to monitor staffing levels within PICUs and to 
audit the appropriate standards of the Paediatric Intensive Care Society: currently the PICS 
Quality Standards for the Care of Critically Ill Children (5th Edition, December 2015). Staffing 
data is collected in the November of each year. Figure 5 compares the findings from 2017 
with the two previous years: 2015 and 2016. 
In 2017 questionnaires were sent to the lead doctor and senior nurse in each PICU. 
Information was collected on the medical and nurse establishment for each PICU including 
details of any vacant posts due to illness, maternity leave or if posts are unfilled during the 
week beginning 20 November. Completed questionnaires were received from all PICUs. 
Details were collected about the number of staff working at four ‘snapshot’ time periods: a 
weekday and weekend at noon and midnight including the use of any bank and agency 
nursing staff. For the purposes of calculating the ‘normal hours’ use of bank and agency 
nursing staff, information was analysed using the data from Wednesday at noon (Figure 5). 
‘Out of hours’ use of bank and agency staff was recorded for a Wednesday at midnight, 
Sunday at midday and Sunday at midnight (Figure 5). Determination of whether each PICU 
met the appropriate PICS standard are calculated using information about the number of 
children being cared for on each PICU and the level of care they required. 
Why is this important? 
PICUs need to be able to monitor whether they have adequate nursing staff available to run 
their unit efficiently. Use of bank and agency staff highlights problems with current staffing 
levels which may be due to staff illness or problems with staff recruitment and/or retention. 
Many PICUs use regular hospital bank staff who are familiar with unit policies, working 
practices and equipment. 
Use of staff provided by an external agency may compromise the efficiency of the unit in 
terms of team working and a lack of continuity of care. In addition these staff may have 
limited knowledge about unit policies, working practices and equipment and may not be able 
to administer medication until they have been assessed as competent. The use of bank and 
agency staff places an additional financial burden on the hospital. 
 

26 
PICANet 2018 annual summary report 
Headline figures: Bed occupancy during 
‘normal hours’ and ‘out of hours’  
What are we measuring? 
The annual staffing study for PICANet also collects information about the number of open 
beds in PICUs that were occupied at midday on a weekday and a weekend day during the 
week beginning 20 November 2017 in the UK and Republic of Ireland. The number of open 
beds is the number of intensive care (IC) and high dependency (HD) beds on a PICU for 
whom staff were available. 
What did we find? 
At the ‘normal hours’ census point (midday Wednesday) in 2017 at least 90% of intensive 
care beds were occupied in England (NHS), Scotland and Northern Ireland and 100% of high 
dependency beds were occupied in England (NHS) and Wales. 
At the ‘out of hours’ census point at midday on a Sunday similar levels of IC bed occupancy 
were reported for England (NHS) and Northern Ireland (more than 90%) although these 
occupancy levels were only around one third for Wales. ‘Out of hours’ occupancy for HD 
beds was reported as 100% in the Republic of Ireland and 90% in England (NHS) with low 
rates of around a quarter being reported for Wales.  
Figure 6: Percentage of funded critical care beds occupied at midday 
Wednesday and midday Sunday in November 2017 
 
What does this mean? 
Across the UK reported bed occupancy rates in PIC remain high both during ‘normal hours’ 
and ‘out of hours’. This reflects the ongoing increase in activity in PICUs observed over since 
the start of PICANet in 2002–03. PICANet data is being analysed and used to inform the 
current paediatric critical care review in England. 
0
10
20
30
40
50
60
70
80
90
100%
England
(NHS)
Wales
Scotland Northern
Ireland
Republic
of Ireland
Private
England
(NHS)
Wales
Scotland Northern
Ireland
Republic
of Ireland
Private
IC
HD
Midday Wednesday
Midday Sunday

Headline figures: Bed occupancy during ‘normal hours’ and ‘out of hours’ 
27 
Further details 
Definition and methods 
Information about bed occupancy is collected each year as part of the PICANet staffing 
study. The survey collected details about the total number of open and funded intensive care 
and high dependency care beds and the number of actual children being cared for on each 
PICU by the level of care requirement for four ‘snapshot’ time periods: a weekday and 
weekend at noon and midnight. The proportion of open and funded beds occupied during 
‘normal hours’ (Wednesday at noon) and ‘out of hours’ (Wednesday at midnight, Sunday at 
midday and Sunday at midnight) were then calculated. In Figure 6 we present the data for 
midday on a Wednesday and Sunday. 
Why is this important? 
Information about levels of bed occupancy are important for both the commissioners and 
providers of PIC to ensure that there is adequate provision of paediatric critical care beds 
and is important information for the current paediatric critical care review being carried out in 
England. PICS standard 180 (2010) states that average bed occupancy on the unit should 
not exceed 80%. The unit should be monitoring occupancy and there should be evidence of 
escalation within the Hospital and involvement of Health Boards/Commissioners if occupancy 
exceeds 80% for more than two successive months. Bed occupancy is also used as an NHS 
Services Quality Dashboard measure (PICO 5a). 
 

28 
PICANet 2018 annual summary report 
Metric 1: Case ascertainment and 
timeliness of data submission 
What are we measuring? 
Case ascertainment is a measure of how many admissions are reported to PICANet. This is 
one aspect of data quality. 100% ascertainment would mean we received information for all 
admissions. We also measure the timeliness of data collection and present how many of the 
admission events are completed within 3 months of discharge – a requirement of the PICS 
standards. 
What did we find? 
In the 15 PICUs visited in 2017, we found that almost all admissions were reported to 
PICANet. In 2017 our case ascertainment was estimated to be 99.4%. The completeness of 
patients’ admission data within 3 months of their discharge from the unit was 79.9% for the 
three year period from 2015 to 2017. There was some variation in 3 month completeness 
between PICUs in different countries (Figure 7). 
Figure 7: Proportion of records completed within 3 months of discharge by 
country of admission 2015–2017 
 
What does this mean? 
High levels of case ascertainment ensure that we are confident our findings will be 
representative of the events and care processes that take place in PICUs. PICUs in England, 
Wales and Scotland had high or very high standards of timeliness of submission of 
admission data, although Northern Ireland and the Republic of Ireland displayed lower levels 
of data timeliness. 
48
63
81
83
90
98%
52
37
19
17
10
2
0
20
40
60
80
100%
Northern Ireland
Republic of Ireland
England (NHS)
England (non-NHS)
Scotland
Wales
Records completed within 3 months
Country of admission
Complete
Incomplete

Metric 1: Case ascertainment and timeliness of data submission 
29 
Further details 
Definitions and methods 
Every PICU receives a validation visit from the PICANet research nurse on a rolling 
programme. At those visits, the numbers of admissions recorded locally are compared with 
the numbers held on the PICANet database. Any discrepancies are followed up by the PICU. 
This is called an ascertainment check. Not every PICU is visited each year, so our 
ascertainment check is based on those PICUs that have received a visit. We also monitor the 
timeliness of data completion, benchmarking against the PICS standard for reporting 
admissions to PICANet within 3 months of discharge from the unit. 
Why is this important? 
We want to base our analyses on all admissions to be sure that we can interpret our 
findings appropriately. If a significant proportion of admissions are missing we cannot be as 
confident about our conclusions. For example, if a number of admissions of children who had 
died on PICU were missing, we may make the wrong conclusion when comparing 
standardised mortality rates between PICUs. Our high ascertainment rate therefore means 
that we can be confident about our findings. 
As well as ensuring we collect data on as many admissions as possible, we also want to 
ensure that data is collected in a timely manner,that data are accurate and that all relevant 
data are available for analysis. 
 

30 
PICANet 2018 annual summary report 
Metric 2: Retrieval mobilisation times 
What are we measuring? 
Some children need to be transported to a PICU in a different hospital for urgent care (non-
elective transports). For 2017 we have calculated how long it takes for the PIC centralised 
transport service (CTS) team to start their journey to pick up a child who needs urgent PIC 
following a clinical decision that PIC transport is required. We present the proportion of these 
journeys that started within 30 minutes, 31 to 60 minutes, 61 to 180 minutes and over 180 
minutes for the UK and Republic of Ireland overall. This information is summarised for the 
individual PIC transport teams. 
What did we find? 
Overall, just under four fifths of journeys (78.2%) were started within 1 hour, with just over 1 
in 20 journeys started more than 3 hours after the decision was made that the child required 
urgent transport (Figure 8). 
Of the specialist PIC transport services, eight out of 14 organisations (Figure 9) mobilised 
their team within 1 hour for more than three quarters of urgent transports in 2017. Of these 
journeys for urgent transport 60.2% were mobilised within 30 minutes. 
Figure 8: Number of non-elective PIC CTS transports mobilised by time to 
mobilisation: UK and Republic of Ireland, 2017 
 
Figure 9: Proportion of non-elective transports mobilised by PICU CTS team by 
time to mobilisation: UK and Republic of Ireland, 2017 
 
6.1%
15.7%
18.0%
60.2%
0
500
1000
1500
2000
2500
181+ minutes
61-180 minutes
31-60 minutes
0-30 minutes
Number of transports
Time to mobilisation
0
25
50
75
100%
X
M
T024
T020
T027
T026
T001
T008
T022
T003
T002
T005
T010
T004
Transport team
0-30 minutes
31-60 minutes
61+ minutes

Metric 2: Retrieval mobilisation times 
31 
What does this mean? 
In the vast majority of cases PIC CTS teams take less than an hour to start their journey to 
pick up a child who requires urgent critical care. The Care Quality Commission have said that 
the target should be under 1 hour although most teams aim to depart base within 30 minutes 
of accepting a child for urgent transport. In those cases where it takes longer for the team to 
depart the reason for this may relate to the availability of staff, a transport vehicle or a PICU 
bed. 
Some journeys may require road and air transport which will require additional planning 
before the team can depart. 
 
Further details 
Definitions and methods 
Once a specialist transport organisation has agreed to transport a child they have a target 
set by the Care Quality Commission to start their journey within 1 hour. We measured the 
time from when the team agreed to the transport to the time they set off in the ambulance (or 
helicopter / plane) for what are called ‘non-elective’ or urgent transports – these are not 
planned transfers from one PICU to another or from a PICU to a district general hospital. 
Prior to the launch of COMET (T027) in March 2017 the East Midlands Paediatric Transport 
Service provided the transport for X1 and X2. This is represented as X in Figure 9. 
Why is this important? 
Any delay in receiving intensive care could put the sick child at risk as the referring hospital 
may not have the resources to look after a critically ill child. Delays in getting the team 
mobilised may just mean that it is very busy e.g. during periods of ‘winter pressures’. 
Persistent delays may mean that there are insufficient resources in the transport organisation 
or there are some other organisational issues that need to be addressed. By measuring the 
time it takes to mobilise the transport team continuously over a long period of time PICANet 
are able to monitor and report back on performance, enabling the transport organisations to 
make changes to improve the quality of their service if appropriate. 
 

32 
PICANet 2018 annual summary report 
Metric 3: Number of qualified nurses per 
bed 
What are we measuring? 
In November of each year we ask PICUs to record how many qualified nursing staff are 
employed on their PICU: both their establishment (i.e.total funded posts) and any vacant 
posts. 
The Paediatric Intensive Care Society (PICS) Standards state a minimum number of 
7.01 Whole Time Equivalent (WTE) qualified nurses are needed to staff one level 3 critical 
care bed (2015). Previous PICS Standards (2010) endorsed the bench mark of 6.4 WTE 
qualified nurses to staff one level 3 critical care bed. 
What did we find? 
Overall the establishment figures for PICUs across the UK and the Republic of Ireland show 
that in 2017 few units meet either of the PICS standards: 3 (9%) PICUs meet 7.01 WTEs per 
bed and 7 (22%) PICUs meet the previous standard of 6.4 WTEs. 
However if all the recorded vacancies for qualified nurses were filled 6 (18%) PICUs would 
meet the standard of 7.01 WTEs per bed and 17 (53%) of PICUs would meet the previous 
standard of 6.4 WTE. 
Figure 10: Number of clinically qualified nursing staff in post (WTE) per bed by 
health organisation, November 2015–2017 
 
What does this mean? 
Based on the data provided by UK and Republic of Ireland PICUs in November 2017, the 
establishment of very few PICUs meets the recommended standard of Paediatric Intensive 
Care Society. However, despite few PICUs meeting these standards, staffing data from the 
census shows that the units ensure that their staffing levels are appropriate for the number of 
6.4 WTE
7.01 WTE
0
1
2
3
4
5
6
7
8
9
10
A
C
D E1 E1 E1 E2 F
H
I
K2 K3 L
M N
O
P
Q
R
S
T
U
V W X1 X2 Y
Z ZA ZB ZC ZD ZE ZF
Nursing staff
Organisation
Vacancies
2017
2016
2015
NICU
PICU

Metric 3: Number of qualified nurses per bed 
33 
children on the unit and their care requirements. This may be achieved by unit staff working 
flexibly, undertaking additional shifts or using bank or agency staff. 
This data should be used to inform the future planning of PIC. 
 
Further details 
Definition and methods 
Each year PICANet carries out a staffing study to monitor staffing levels within PICUs and to 
audit the appropriate standards of the Paediatric Intensive Care Society: currently the PICS 
Quality Standards for the Care of Critically Ill Children (5th Edition, December 2015). Staffing 
data is collected in the November of each year: the week beginning 20 November in 2017. 
Figure 10 presents the percentage of PICUs meeting the recommended level of nurse 
staffing per funded critical care bed. 
The recommended number of nurses required (or nurse staffing establishment), in order to 
provide the appropriate levels of care for the number and given dependency of the bed, is 
calculated according to the PICS Standards for Intensive Care (one nurse to one bed) and 
high dependency (one nurse for every 2 beds). 
Why is this important? 
PICUs need to be able to monitor whether they have adequate nursing staff available to run 
their unit efficiently. PICS Standard L3-207 and guidance from the PICS Nurse Workforce 
Planning document for Level 3 Paediatric Critical Care Units, October 2016 states that ‘the 
minimum number of qualified nurses required to staff one level 3 critical care bed is a 
minimum of 7.01 WTE’. The availability of specialist PIC nurses is affected by many factors 
external to PIC including nursing salaries and the cost of living in capital cities. Staff 
recruitment and retention is currently under review as part of the paediatric critical care 
review. Some PICUs are developing the role of band 4 health care assistants to support 
qualified staff in critical care units. 
 

34 
PICANet 2018 annual summary report 
Metric 4: Emergency readmissions within 
48 hours 
What are we measuring? 
For each PICU, we record the frequency of emergency readmissions within 48 hours in 
comparison to the average for the UK and Republic of Ireland. This is calculated using the 
admission and discharge dates and times. This relative re-admission rate (Figure 11) allows 
us to compare PICUs with each other. 
What did we find? 
Around 300 children per year (or 1.6 out of every 100 admissions) were discharged from 
PICU but then readmitted as an emergency within 48 hours (Table 6). Rates of emergency 
readmissions varied by country with Scotland having slightly higher rates in 2016 and 2017 
(2.2–2.4%) whilst Wales, Northern Ireland and Republic of Ireland had lower rates. No 
outliers were evident when relative emergency readmission rates were compared across all 
PICUs (Figure 11). 
Table 6: Number of emergency readmissions within 48 hours 2015–2017 
Country 
2015 
2016 
2017 
England (NHS) 
250 (1.6%) 
250 (1.6%) 
261 (1.7%) 
England (non-NHS) 
2 (0.7%) 
2 (0.6%) 
3 (0.6%) 
Wales 
14 (3.0%) 
6 (1.1%) 
5 (1.0%) 
Scotland 
17 (1.3%) 
37 (2.5%) 
33 (2.4%) 
Northern Ireland 
8 (1.3%) 
10 (1.8%) 
5 (1.0%) 
Republic of Ireland 
19 (1.4%) 
21 (1.5%) 
19 (1.3%) 
Total 
310 (1.6%) 
326 (1.6%) 
326 (1.6%) 
Figure 11: Relative 48 hour emergency readmission rate by health organisation 
2015–2017 
 

Metric 4: Emergency readmissions within 48 hours 
35 
What does this mean? 
There is no evidence that children are being discharged from PICU too early during the 
reporting period of 2015 to 2017. 
 
Further details 
Definitions and methods 
We defined an emergency readmission within 48 hours as any unplanned admission to the 
same PICU or another PICU within 48 hours of their last discharge from PICU. So if a child 
was admitted on 1 March at 12:00 and discharged on 2 March at 17:00 but then admitted as 
an emergency (an unplanned admission) on 4 March at 04:30, they would have been 
counted in our analysis as they returned to PICU after 35½ hours. We then counted the 
number of emergency readmissions within 48 hours for every 100 admissions in each PICU 
to give a rate per 100 admissions. This allows us to compare PICUs with different numbers 
of admissions.  
There is no standard set for the maximum acceptable rate of emergency readmissions within 
48 hours so we used the average for all PICUs contributing to PICANet. We then used the 
funnel plot method described at the beginning of this report to assess if any PICU has a 
higher rate than expected, based on the ratio of observed to expected numbers of 
readmissions. 
Why is this important? 
Emergency readmission within 48 hours is an undesirable outcome. From the patient 
perspective, it suggests that their health has deteriorated in a short space of time and that 
they require further intensive care treatment. This will cause stress to the patient, their 
families and their carers. For a busy PICU, each admission also creates additional demand 
on a service which usually operates close to capacity. 
It should be noted that although emergency readmission is used as a quality indicator, we do 
not know the cause of the readmission therefore PICANet is unable to assess whether the 
child was discharged too early, or into the wrong care environment, or whether the need for 
future intensive care was not foreseen. 
 

36 
PICANet 2018 annual summary report 
Metric 5: Mortality in PICU 
What are we measuring? 
Mortality (death) rates are assessed for every PICU based on a statistical approach which 
accounts for the severity of the child’s illness at the time of admission. This method is known 
as risk adjustment. The number of children we predict to die is calculated and then compared 
to the number who actually die to derive the risk-adjusted Standardised Mortality Rate 
(SMR). 
What did we find? 
The risk-adjusted SMR for each PICU in the UK and Republic of Ireland is plotted in Figure 
12 according to the number of admissions for the period from 2015 to 2017. There was no 
evidence that any PICU had an excess mortality rate compared to what we would expect 
during the three year reporting period. 
Figure 12: Risk-adjusted SMR by health organisation 2015–2017 
 
The ‘risk-adjustment’ method used to calculate expected mortality was the Paediatric Index 
of Mortality 3 (PIM3) 
What does this mean? 
Compared with the overall mortality for the UK and Republic of Ireland there were no PICUs 
for which mortality rates were higher than expected during the three year reporting period, 
after allowing for the level of sickness at the time of admission. 

Metric 5: Mortality in PICU 
37 
Further details 
Definitions and methods 
Clinical data collected on admission is used in a statistical model to predict the probability 
that each child might die: the worse their clinical condition is on admission, the higher the 
probability that they might die. These probabilities are added up for each PICU to give an 
overall expected number of deaths in any one period. We then count the actual (observed) 
number of deaths and calculate what is called a Standardised Mortality Ratio by dividing the 
observed number of deaths by the expected number. We then use the funnel plot to assess 
the level of mortality in the PICUs against what is expected. 
Why is this important? 
Although death on PICU is quite rare, it is important to assess whether more (or fewer) 
deaths than expected occur, as this can indicate that there is something different happening 
in a PICU. It only represents a statistical measure of mortality and it is very important to use 
this as an indicator that further investigation is required, not as a true measure of the quality 
of care delivered. 
 
 
 

38 
PICANet 2018 annual summary report 
Referral and transport winter pressures 
PICANet collects a referrals and transport dataset to supplement the admission dataset for 
paediatric intensive care (PIC) activity. This referral and transport data has been collected 
since 2012 and includes information about referral calls and associated retrieval or transfer 
activities. 
In this first detailed analysis of the referral and transport data we investigate the impact of 
‘winter pressures’ on the number of referral, transport and admission events submitted to 
PICANet to inform the commissioners and providers of specialist services. 
Respiratory illnesses in winter, particularly in infants and small children, are known to be 
responsible for the peaks in PICU bed demand3–5. At times of high demand PICUs are often 
at capacity and therefore in order to find a PICU bed children may be transferred many miles 
away from their home. This results in additional demands on the PIC specialised transport 
services as well as PICUs. 
Method 
When specialist PIC clinicians agree that a child requires PIC transport and/or a paediatric 
intensive care bed a PICANet Web referral form is completed. Once the child is accepted for 
PIC transport the PIC specialist transport team will then call a PICU to request a bed. If the 
first PICU is full then the team will contact other PICUs until an available bed is found. For 
each PICU contacted that is unable to accept the child a referral form is completed recording 
the admission outcome of “Refused – no staffed bed available”. So for each referral episode 
there can be multiple referral forms generated for any one child which may eventually result 
in one acceptance for PICU admission. 
A referral event should also be completed for other transport requests where the child will be 
receiving intensive care during the journey, e.g. transportation to a secondary transport 
service, hospice or home. 
Following acceptance for PIC transport a PICANet Web transport form is completed by the 
PIC centralised transport service (CTS) or PICU team providing the transport for a retrieval 
or transfer. 
Data from the referral and transport dataset for 2016–2017 for the UK and the Republic of 
Ireland have been analysed to investigate variation in the seasonal frequency of these 
events in relation to overall PIC admissions. In addition the mobilisation times for specialist 
PIC transport services for urgent (non-elective) cases are investigated to assess the potential 
impact of the “winter pressure” on the service. For this purpose summer has been defined as 
the months of June, July and August and winter as November, December and January. The 
definition of mobilisation time is the time from which a PIC specialist agrees that PIC 
transport is necessary for a child to the time the PIC CTS departs from the team base. The 
Care Quality Commission has set a target of one hour for this to be carried out and NHS 
England Clinical Reference Group for Paediatric Critical Care Transport Dashboard uses a 
target of 30 minutes6.  
Referral data for the STRS PIC CTS was not available for 2017 and therefore is excluded 
from the analysis of referral data but is included in the transport data. 
Results 
Over the two-year period 2016 to 2017 there was a total number of 17,637 referrals across 
the UK and the Republic of Ireland. For the vast majority of children accepted for PICU 
admission by a PIC CTS only one PICANet referral form was completed, representing 85.8% 

Referral and transport winter pressures 
39 
of the total: median=1, range 1 to 24. Figure 13 presents the monthly number of referral, 
transport and admission forms completed on PICANet Web over the period 2016 to 2017. 
The lowest number of both referral and transport forms were completed in the August of 
each year (referrals: 396, 390 and transports: 311, 310, respectively). Peaks in both referrals 
and transport can be seen in the November and December of each year (referrals: 853 in 
November 2016 and 991 in December 2017; and transports: 521 November 2016 and 556 in 
December 2017). 
The pattern of admissions for PIC is similar to the referral and transport data although the 
summer plateau is less well defined due to planned admission for elective procedures which 
may have been delayed over the winter period. 
Similar patterns were found for the individual countries of the UK and in the Republic of 
Ireland. 
Figure 13: Number of PICANet Web referral, transport and admission forms 
recorded: UK and Republic of Ireland 2016–2017 
 
The potential impact of winter pressures on mobilisation times for the PIC CTS is shown in 
Figure 14 where the variation in mobilisation times is presented for the individual PIC CTS 
teams. In the winter months the proportion of transports mobilised within 30 minutes ranged 
from 4.8% to 82.8% and within 60 minutes (the CQC target) from 23.8% to 89.5%. Overall 
the median time to mobilisation in the winter was 30 minutes (interquartile range: 16 to 74 
minutes). In the summer months the proportion of transports mobilised within 30 minutes 
ranged from 10.3% to 88.7% and within 60 minutes (the CQC target) from 29.2% to 94.0%. 
Overall the median time to mobilisation in the summer was 25 minutes (interquartile range: 
15 to 47 minutes), slightly faster than in the winter which may reflect a level of reduced 
pressure on the service during the summer months. 
0
500
1000
1500
2000
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
2016
2017
Number of forms
Referrals
Transports
Admissions

40 
PICANet 2018 annual summary report 
Figure 14: Proportion of urgent transports by mobilisation time and PIC CTS: 
Summer and Winter UK and Republic of Ireland 2016–2017 
 
Despite the winter peaks in referral, transports and admissions for PIC in the UK and 
Republic of Ireland in 2016 and 2017, this increased workload does not seem to have a 
major impact on the vast majority of mobilisation times. However at times of highest demand 
children may have to be transported over long distances and it may take many referrals 
before an available PIC bed is identified. This situation is illustrated in the vignette below. 
 
 
 
 
0
25
50
75
100%
T001
T002
T003
T004
T005
T008
T010
T020
T022
T024
T026
T027
Transport 
team
0-30 min
31-60 min
61+ min
Summer
0
25
50
75
100%
0-30 min
31-60 min
61+ min
Winter
Vignette 
In December 2017 an infant was admitted to the local district general hospital with 
bronchiolitis, a viral respiratory illness. Coughs and colds are common in children over 
winter. A common viral respiratory infection responsible for increased admissions in the 
winter is respiratory syncytial virus (RSV). For certain groups of children, especially 
premature infants with other medical conditions, RSV can be quite serious. 
The infant’s condition deteriorated and the paediatrician at the local hospital called the 
specialist PIC transport service to discuss the situation. The hospital were advised to 
insert a breathing tube to help the infant breathe and at 09:35 hours the paediatric 
intensive care transport service (PIC CTS) agreed to collect the infant for transfer to a 
paediatric intensive care unit (PICU). The PIC CTS called the local PICU to request a bed 
but the PICU was full. A further 16 PICUs were contacted before a bed was found at a 
hospital located 132 miles from the original admitting hospital. 
The PIC CTS departed base at 11:04 to travel by road to collect the infant from the district 
general hospital, arriving at 12:40. The infant was stabilised for transfer by helicopter, and 
was then admitted to the PICU at 16:00. 
The transport team left the admitting PICU at 16:45 to travel by road and arrived back at 
the transport team base at 18:50. 

References 
41 
References 
1. Kanthimathinathan HK, et al (2015). Unplanned extubation in a paediatric intensive 
care unit: prospective cohort study. Intensive Care Med 41: 1299–1306 
2. NHS England (2015). https://www.england.nhs.uk/commissioning/wp-
content/uploads/sites/12/2015/01/e07-sa-paed-inten-care.pdf  
3. Gupta P, Beam BW, Rettiganti M (2016). Temporal Trends of respiratory Syncytial 
Virus-Associated Hospital and ICU Admissions Across the United States. Pediatr Crit 
Care Med 17: e343–e351 
4. Soilly AL, et al (2012). Paediatric intensive care admissions for respiratory syncytial 
virus bronchiolitis in France: results of a retrospective survey and evaluation of the 
validity of a medical information system programme. Epidemiol Infect 140: 608–616 
5. McShane P, et al (2013). Paediatric Intensive Care Audit Network (PICANet). Effects 
of out-of-hours and winter admissions and number of patients per unit on mortality in 
paediatric intensive care. J Pediatr 163: 1039–44 
6. NHS England CRG Paediatric Critical Care Transport (2015). Service Specifications, 
Appendix 1: Domain 1, number 2 https://www.england.nhs.uk/commissioning/wp-
content/uploads/sites/12/2015/01/e07-spec-paedi-intens-care-retrvl-transp.pdf 
7. Straney L, Clements A, Parslow RC, Pearson G, Shann F, Alexander J, Slater A, 
Group APS, the Paediatric Intensive Care Audit N. Paediatric index of mortality 3: an 
updated model for predicting mortality in pediatric intensive care. Pediatr Crit Care 
Med 2013;14(7):673-81 
 
 


Additional information 
43 
Additional information 
Background 
PICANet was established in 2001 with funding from the Department of Health and started 
collecting data from English and Welsh paediatric intensive care units in November 2002. 
The PICUs at the Royal Hospital for Sick Children, Edinburgh and the Royal Hospital for 
Children, Glasgow started submitting data in December 2004 and March 2007 respectively. 
The Royal Belfast Hospital for Sick Children joined in April 2008 and Our Lady’s Children’s 
Hospital, Crumlin and the Temple Street Children’s University Hospital, both based in Dublin, 
have submitted anonymised data to PICANet since 2010. The Harley Street Clinic PICU 
started contributing data in September 2010, and the PICU at the Portland Hospital from 
October 2013, allowing both these non-NHS units to compare their performance against the 
national benchmark provided by PICANet. 
A full list of participating PICUs can be found in Appendix A. 
Governance 
PICANet continues to receive support from the NHS Health Research Authority 
Confidentiality Advisory Group (NHS HRA CAG) (formerly the NIGB) to collect personally 
identifiable data without consent on infants and children admitted to paediatric intensive care. 
(See https://www.hra.nhs.uk/documents/1409/piag-register-master-2018.xls) 
Ethics approval has been granted by the Trent Medical Research Ethics Committee, ref. 
05/MRE04/17 +5. 
PICANet supports transparency in its data processing and has patient information sheets 
and posters on display in PICUs and issues a Privacy Notice and Fair Processing Statement 
on its website outlining the legal basis for processing of data under the new General Data 
Protection Regulations (May 2018). Details can be found at https://www.picanet.org.uk/. 
PICANet receives support and advice from a Clinical Advisory Group (CAG) drawing on the 
expertise of doctors and nurses working within the speciality and a Steering Group (SG), 
whose membership includes Health Services Researchers, representatives from the Royal 
Colleges of Paediatrics and Child Health, Nursing and Anaesthetics, a lay member and 
commissioners. We also have a PIC Families Group to consider the impact of admission to 
intensive care on children and their families. Appendices B, C and D provide a full list of 
CAG, SG and PIC Families group members. Additional support from the clinical community 
is provided through the UK Paediatric Intensive Care Society. 
Commissioning 
The following organisations commission paediatric intensive care in the UK: 
▪ 
England: NHS England Specialised Services  
▪ 
Wales: Specialist Health Service Commission for Wales (SHSCW) 
▪ 
Scotland: NHS Lothian/National Services Division of NHS National Services Scotland 
▪ 
Northern Ireland: Health and Social Care Board 
In the Republic of Ireland, Our Lady’s Children’s Hospital, Crumlin is governed by a Board of 
Directors and is a company limited by guarantee. Temple Street Children’s University 

44 
PICANet 2018 annual summary report 
Hospital (TSCUH) is incorporated as a private limited company. Both receive funding from 
the Health Services Executive, charitable and private sources. 
Methods 
Basic methodology 
Most critically ill children who need complex clinical care and life support are treated in 
Paediatric Intensive Care Units (PICUs). These children may have had complex surgery, an 
accident or a severe infection and may arrive in the PICU from an operating theatre, 
emergency department or from a hospital ward. In some cases they may have been 
transferred from another hospital and, rarely, admitted directly from home. 
PICANet is an audit that collects personal, organisational and clinical data on all children with 
a clinically determined need for paediatric intensive care in the UK and Ireland, to compare 
outcomes and activity between PICUs and specialist transport organisations and also 
between health regions and nations. 
Data are stored on a secure database. Each organisation is able to view and download their 
own data and reports on their data quality and activity as well as comparative national data. 
An annual report is produced each autumn that includes a summary of what has happened 
to children admitted to PICU including why they were admitted, where they were admitted 
from, how long they stayed, what treatments they received and their outcome at the time of 
discharge. Comparisons between PICUs are made to assess how well they perform against 
established clinical standards and guidelines. 
In addition to the annual report, PICANet provides technical and statistical support for the 
use of its data for local audit and research, regional and national commissioning, national 
and international research and to provide baseline information for clinical intervention trials. 
Participating organisations and data submission 
PICANet has collected data from all PICUs in England and Wales since 2002. The two 
PICUs in Scotland, one from Northern Ireland and two from the Republic of Ireland, along 
with two non-NHS units based in London have joined PICANet at different times so that 
coverage is now for the whole of the UK and the Republic of Ireland. There are 32 PICUs 
and 12 specialist transport organisations currently submitting data to PICANet. The Royal 
Alexandra Hospital, Brighton, and Hull Royal Infirmary are no longer submitting data because 
they are no longer commissioned as paediatric intensive care units. 
Data are submitted by individual PICUs prospectively, using our secure web-based data 
collection application with real-time online validation reporting, systematic monthly validation 
review by our research nurse and regular on-site validation visits. Data submission can 
involve direct entry of patient data or an upload of a data file from an existing clinical 
information system. PICANet provides full documentation on data definitions, which have 
been developed in collaboration with our Clinical Advisory Group, as well as technical 
specifications for IT and database professionals. In addition, standardised data collection 
forms are supplied to all organisations where there is no in-house provision for data 
collection. 

Additional information 
45 
Data collected 
PICANet collects three core datasets: 
▪ 
Admission data contains demographic details of each child including their name*, date 
of birth, NHS/CHI/H&C number, address* and ethnic group; it also records where children 
are admitted from, their date of admission and clinical diagnoses, some physiological 
parameters on admission including blood gases, blood pressure, medical history and 
ventilation status. Data on outcome and discharge details are included. The medical 
interventions received on each day by each child are recorded as part of the audit and to 
help NHS organisations in England to supply information on the cost of their activity. 
▪ 
Referral data for all children where clinicians agree a paediatric intensive care bed 
and/or paediatric intensive care transport is required includes details of the referring 
hospital, demographic details of the child, grade of the referring doctor or nurse, the 
outcome of the referral, the transport team involved and the destination PICU. 
▪ 
Transport data for all children transported to a PICU from their original admitting hospital 
or who are transported by a specialist PIC transport service but are not admitted to a 
PICU includes patient details as well as information about their presenting physiology. 
Details about the composition of the transport team, journey times, any interventions 
carried out and critical incidents are also recorded. 
Additional data collection takes place to understand more about staffing on PICU: 
▪ 
Staffing data is collected each year in November to monitor staffing levels within PICUs 
as well as the PICS standards relating to staffing requirements. 
* Not collected for data from Republic of Ireland 
Analytical techniques 
Statistical techniques used include simple cross tabulations, the calculation of crude and risk-
adjusted SMRs and 95% confidence intervals; the construction of crude and risk-adjusted 
funnel plots of SMRs; and local provision of Risk Adjusted Resetting Sequential Probability 
Ratio Test (RA-RSPRT) plots to assess real-time performance related to in-PICU mortality. 
Risk adjusted SMRs were calculated using the latest version of the Paediatric Index of 
Mortality, PIM37. 
Assessing case ascertainment, data quality and validation 
PICANet Web allows PICU staff to obtain reports on their own data to check monthly 
admissions totals. In addition, during validation visits by the PICANet research nurse a cross 
check is carried out against records held on PICU (such as admission books, or in–house 
data collection systems) and PICANet Web. These checks allow us to assess case 
ascertainment and the on-site validation visits are a core element of our data quality 
assurance process. 
Data is validated on-line via PICANet Web using logic and range checks as well as flagging 
missing data items. The Modulus 11 algorithm is used to validate the NHS number based on 
a check digit – this is a standard method of ensuring the NHS number is a true NHS number 
and improves our ability to trace patients through the PICANet database and in linked 
healthcare data. 
Collaborative working supporting policy, commissioning, 
research and clinical trials 
PICANet has become established as the definitive source of data on paediatric intensive 
care activity in the UK and Ireland. Its data has been used to plan PIC services, model 

46 
PICANet 2018 annual summary report 
demand, assess interventions and outcomes and provide data to underpin research to 
facilitate the development of new standards for critical care provision for children. We have 
provided baseline data for the two largest clinical trials in paediatric intensive care (CHiP 
(Control of Hyperglycaemia in Paediatric Intensive Care) and CATCH (CATheter infections in 
Children)). PICANet has also provided baseline data for the development of the I-KID, 
SANDWICH and FEVER trials, all of which have been funded and will make use of the 
routinely collected PICANet data using the custom data download facility. This allows local 
control over the data. Over the next few years we will be working closely with the NIHR 
funded DEPICT study, which is investigating the effect of differences in access to emergency 
paediatric intensive care and care during transport on clinical outcomes and patient 
experience. 
Small number policy 
Publication of PICANet data is subject to scrutiny for small numbers. When small numbers of 
admissions are involved, other data items may become identifiable i.e. a living individual may 
be identified from the data. This is still the case in aggregated data where small groups of 
individuals are presented. These are reviewed and in some cases, categories are combined 
or cells anonymised where necessary. 
Outlier Policy 
When unusual performance is detected following routine or bespoke analysis which suggests 
that a PICU is an outlier, PICANet follow the established procedure outlined in our outlier 
policy (https://www.picanet.org.uk/wp-
content/uploads/sites/25/2018/05/PICANet_Policy_on_Units_lying_outside_the_control_limit
s-5_oct2015.pdf), which relates specifically to assessment of risk-adjusted mortality. We also 
follow the more detailed guidance on outliers subsequently developed by HQIP published in 
2017. On three specific occasions, PICUs have been identified as outliers with excess risk-
adjusted mortality. In two of these cases this was attributable to data quality issues and when 
corrected, the outliers fell within normal limits. In one case this was not attributable to data 
quality and resulted in internal and external reviews. 
Links with the clinical community, patients and their families 
The PICANet PICU Families Group comprises both Lay representatives (parents of children 
who are currently or have previously received paediatric intensive care) and a 
multidisciplinary group of health professionals including Family Liaison Sisters, critical care 
nurses, audit staff, PIC consultants and members of the PICANet team. In addition, we have 
a standing Lay Representative on our Steering Group and work closely with the charity Well 
Child. To date, all communications we have had from patients/parents have been very 
positive, supporting PICANet and its work and requesting further information. 
PICANet has the support of the Paediatric Intensive Care Society and the associated PICS 
Study Group, the PICANet Clinical Advisory Group and the Clinical Reference group which 
oversees Paediatric Critical Care and PCC transport. 
 


 
 
Richard Feltbower 
Melpo Kapetanstrataki 
Lee Norman 
Sophie Butler 
Victoria Hiley 
 
xxx@xxx.xx 
xx-xxxx-xxxx 
PICANet 
Leeds Institute of Cardiovascular and 
Metabolic Medicine 
School of Medicine 
University of Leeds 
Clarendon Way 
Leeds 
LS2 9JT 
 
Elizabeth Draper 
Caroline Lamming 
Martin Perkins 
Tracy Harris 
Lyn Palmer 
Sarah Seaton 
 
xxx@xxx.xx 
xx-xxxx-xxxx 
PICANet 
Department of Health Sciences 
University of Leicester 
George Davies Centre 
University Road 
Leicester 
LE1 7RH 
University of Leicester 
University of Leeds 
www.picanet.org.uk 
xxx@xxx.xx