PICANet Annual Report 2013 - 2015
Source: data.gov.uk (2018-11-20)

Paediatric Intensive Care Audit - This data contains information on all admissions to Paediatric Intensive Care units in the UK and Ireland 2013-2015.

SUMMARY REPORT 
NOVEMBER 2016 
ANNUAL  
REPORT 
 
Paediatric Intensive 
Care Audit Network 
DATA COLLECTION PERIOD  
JANUARY 2013 – DECEMBER 2015 
 

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PICANet 2016 Annual Summary Report. 
KEY 
Cambridge, Addenbrooke's Hospital 
A 
Brighton, Royal Alexandra Hospital* 
B 
Cardiff, Noah’s Ark children’s Hospital for Wales 
C 
Manchester, Royal Children's Hospital 
D 
London, Great Ormond Street Hospital - PICU/NICU 
E1 
London, Great Ormond Street Hospital - CCCU 
E2 
London, Evelina Children’s Hospital 
F 
Hull Royal Infirmary 
G 
London, Kings College Hospital 
H 
Leeds General Infirmary 
I 
Newcastle, Great North Children’s Hospital 
K1K3 
Newcastle Freeman Hospital 
K2 
Stoke on Trent, Royal Stoke University Hospital. 
L 
Nottingham, Queen's Medical Centre 
M 
Oxford, John Radcliffe Hospital 
N 
London, Royal Brompton Hospital 
O 
Liverpool, Alder Hey 
P 
Sheffield Children's Hospital (PICU) 
Q 
Southampton Children’s Hospital 
R 
Middlesbrough, James Cook Hospital 
S 
London, St George's Hospital 
T 
London, St Mary's Hospital 
U 
Birmingham Children's Hospital 
V 
Bristol, Royal Hospital for Children 
W 
Leicester Glenfield Hospital 
X 
Leicester Royal Infirmary 
X 
Edinburgh Royal Hospital for Sick Children 
Y 
London, The Royal London Hospital 
Z 
Glasgow Royal Hospital for Children 
ZA 
Belfast, Royal Belfast Hospital for Sick Children 
ZB 
Dublin, Our Lady's Children's Hospital Crumlin 
ZC 
Dublin, Children's University Hospital Temple Street 
ZD 
London, Harley Street Clinic 
ZE 
London, The Portland Hospital 
ZF 
NWTS: North West and North Wales P.T.S 
T003 
Embrace: Yorkshire & Humber Infant & Children’s Service 
T002 
CATS - Children's Acute Transport Service 
T001 
STRS - South Thames Retrieval Service 
T004 
KIDS Intensive Care & Decision Support 
T005 
SCOTSTAR - Edinburgh team 
T016 
IPATS –Irish Paediatric Acute Transport Service 
T022 
WATCh -  Wales and West Acute Transport for Children 
T024 
NECTAR - North East Children's Transport and Retrieval 
T026 
SORT - Southampton, Oxford retrieval team 
T008 
NISTAR -Paediatric 
T010 
* Brighton is no longer designated as a PICU as of 2014 and so will not be included in future annual reports 
Published in the UK by the Paediatric Intensive Care Audit Network (PICANet). This work is 
copyright. 

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PICANet 2016 Annual Summary Report. 
Apart from any use as permitted under the Copyright, Designs and Patents Act 1988, no part may  
be reproduced by any 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 
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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 2013 - 2015 (published November 2016): Universities of Leeds and 
Leicester.  
 

4 
PICANet 2016 Annual Summary Report. 
 
CONTENTS 
CONTENTS .............................................................................................................................................. 4 
ACKNOWLEDGEMENTS .............................................................................................................................. 5 
FOREWORD ............................................................................................................................................ 6 
EXECUTIVE SUMMARY .............................................................................................................................. 7 
RECOMMENDATIONS ................................................................................................................................ 9 
BACKGROUND ....................................................................................................................................... 10 
GOVERNANCE ....................................................................................................................................... 10 
COMMISSIONING ................................................................................................................................... 11 
METHODS ............................................................................................................................................ 12 
DATA ANALYSIS: FINDINGS AND COMMENTARY ............................................................................................ 19 
DETECTION OF A MORTALITY OUTLIER IN THE PICANET ANNUAL REPORT DATA ................................................... 45 
DEALING WITH A MORTALITY OUTLIER IN YOUR UNIT – THE EXPERIENCE FROM ROYAL MANCHESTER 
CHILDREN’S HOSPITAL ............................................................................................................................. 52 
NEW DEVELOPMENTS & FUTURE WORK .................................................................................................... 54 
INVITED PAPERS ..................................................................................................................................... 56 
I-KID STUDY: EVALUATION OF EFFICACY, OUTCOMES & SAFETY OF A NEW INFANT HAEMODIALYSIS AND 
ULTRAFILTRATION MACHINE IN CLINICAL USE ............................................................................................... 60 
FEVER:  A FEASIBILITY STUDY OF A FORMAL RANDOMISED TRIAL OF A MORE LIBERAL APPROACH TO FEVER IN 
CRITICALLY ILL CHILDREN WITH SUSPECTED INFECTION ................................................................................... 65 
GLOSSARY ............................................................................................................................................ 67 
 
 
FOR THE TABLES AND FIGURES AND APPENDICES TO THIS REPORT  
PLEASE VISIT: 
WWW.PICANet.ORG.UK 
 
ISBN 978 0 85316 352 7 
 

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PICANet 2016 Annual Summary Report. 
ACKNOWLEDGEMENTS 
 
The ongoing success of this international clinical audit is dependent on the hard work and 
commitment of a large number of individuals working 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). 
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 Programme (NCA). 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, and in particular to increase the impact that clinical audit has on healthcare quality in 
England and Wales. HQIP holds the contract to manage and develop the NCA Programme, comprising 
of more than 30 clinical audits that cover care provided to people with a wide range of medical, 
surgical and mental health conditions. The PICANet Audit is funded by NHS England, the Welsh 
Government, NHS Lothian/National Service Division NHS Scotland, the Royal Belfast Hospital for Sick 
Children, The National Office of Clinical Audit (NOCA), Republic of Ireland and HCA Healthcare.  

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PICANet 2016 Annual Summary Report. 
FOREWORD 
It is a great privilege and a pleasure for me to introduce the 2016 PICANet annual 
report. This gives me the opportunity to thank PICANet, on behalf of the Italian 
Paediatric Intensive Care Network (TIPNet), for the excellent work they have 
carried out that has inspired us since our launch in 2004.   Data collection has 
expanded in Italy since then, thanks to private funding, and in 2010 TIPNet became 
a permanent database network, controlled by CINECA, collecting organizational and 
clinical data from 16 of the 21 Italian PICUs. An annual report is produced and 
discussed at our national meeting every year.  
In 2015, at the PICANet annual meeting, we were given the opportunity to present 
our TIPNet findings and to compare populations and outcomes for the two 
networks which have many similarities and offer possibilities for future 
collaboration. On October 14th 2016 we will have the pleasure of discussing our 
annual report with Elizabeth Draper in Milan.  
In order to support trials in the relatively small specialty of PIC we need to expand 
our horizons and collaborate with the wider international PIC Community. This will 
allow us to measure what we do, compare performance, improve our practice and 
provide evidence for standards. 
We hope that our meeting in Milan will provide a great opportunity for us to forge 
a new and lasting collaboration between Italy and the UK providing us with an 
opportunity to standardize our data collection, benchmark performance and 
outcomes, and establish a programme of collaborative research across the wider 
PIC community in Europe. Other Countries such as the Netherlands, Portugal, 
Croatia, France and Switzerland are also moving in this direction.   
Things are changing rapidly in Paediatric Intensive Care. In the last 20 years 
mortality rates have decreased to an all-time low of less than 5%. However one 
consequence of a reduction in mortality is an increase in the levels of chronic 
morbidity in the population. In paediatric intensive care we are now seeing children 
being readmitted with long term chronic diseases and severe disability. Morbidity is 
our most pressing challenge. As such we need to establish new outcome measures, 
revise our risk adjustment algorithms and review palliative care and end-of-life 
decision processes together.  
 Finally, as Michael Marsh stated in the Foreword to last year’s PICANet report,   
data are vital to inform choices, make decisions and enable the government to 
decide how to spend tax payers’ money”. PICU beds are expensive, therefore they 
must be used efficiently. To achieve this we need to consider all aspects of PIC 
including our work environment, staffing levels, the cost of the service and the 
changing epidemiology of PIC over time. The standardisation and integration of 
data sources, both national and international, will provide a benchmark for PICU 
performance. 
Times are difficult, but despite the major financial constraints we face our efforts 
are justified because we have a wonderful job! Thank you all. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dr Ida Salvo 
Tip.Net,  
Italian 
Paediatric 
Intensive Care 
Audit, 
Milan, Italy 
 

EXECUTIVE SUMMARY 
 
 
In 2015 10 (29%) PICUs met the nursing establishment levels currently recommended by 
the Paediatric Intensive Care Society, this is an improvement compared to last year, when 
only 5 PICUs met the nursing establishment levels. 
 
 
Overall use of agency and bank nursing staff to ensure adequate staffing levels ‘out of hours’ 
showed a substantial reduction in 2015 with 18% of nurses on duty in NHS hospitals in 
London from agencies or bank staff compared with 27% in 2014. 
 
 
Most PICUs, 23 out of 27 (85%), meet the specified standard (PICS standards 2015) for 
consultant medical levels. Six units meet this target using locum consultant staff.  
 
 
Over 90% of parents of children in PICU rated the performance of both the doctors and 
the nurses very highly (scores of 9 or 10 out of 10) at the two points of data collection using the 
EMPATHIC-30 questionnaire in 2015. 
 
 
The number of admissions recorded in PICANet remained at just under 20,000 per year with 
slight annual fluctuations and no obvious annual increase in admissions over the 3 year 
period. 
 
 
The rates of invasive ventilation vary between 18% and 90% across all PICUs and also by 
geographical region (36%-93%) reflecting differences in admission criteria and patient case-mix 
in different regions.  
 
 
The overall prevalence of admission to PICU in the UK remains fairly static at 146 per 100,000 
children per year.  Boys under one year have a 36% higher prevalence for admission than 
girl of the same age. 
 
 
There was a 2.9% increase in the number of bed days delivered in the reporting period 
2013-2015 compared with 2012-2014 continuing the trend of increased activity in some units. 
The majority of bed days are required by children <1 year of age (56%) reflecting the higher 
number of admissions in this age group (46%). Just over a quarter of patients have a length of 
stay of less than 24 hours and a further third stay between one and three days.  One in 5 children 
remain on the same PICU for seven or more days. 

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PICANet:  2016 Summary Annual Report. 
 
One in ten children admitted to PICU receive over half (58%) of the bed days delivered in 
2013-2015  
 
 
Readmission to PICU within 48 hours is accepted as an important quality indicator of PICU care. 
Crude rates of emergency readmissions to the same PICU within 48 hours (required for the NHS 
England PIC data dashboard) are presented by health organisation. In 2013-2015 the average 
emergency readmission rate was 1.7%, varying between 0% and 5% between 
organisations.  In 2015, the highest readmission rate was 3%. 
 
 
Data on unplanned extubation have been collected and analysed for 2015 as a further quality 
indicator that is required for the PIC dashboard and is calculated as a rate per 100 intubated 
days.  Overall rates are very low ranging between 0 and 1.1 accidental extubations per 100 
ventilated days. 
 
 
Further development in the reporting of referral and transport data has led to the production of 
new data tables, 79% of recorded referrals in 2015, are reported as being successfully 
accepted by a PICU. Of 15,844 transport events in the three year reporting period, 13,278 
(84%) were non-elective admissions to a PICU destination. For 92% of non-elective journeys 
no critical incidents were reported. The team leader was a Consultant or ST4-8 grade staff 
member for the majority of the non- elective journeys (78%). 
 
 
One in five referrals for admission to a PICU are refused, with nearly two thirds of these 
refusals due to no staffed bed being available.  While most children who require a PICU bed 
will eventually be admitted, the process of approaching many PICUs to find a bed is time-
consuming and stressful for parents and carers and hospital staff. 
 
 
Deaths on paediatric intensive care units continue to be very rare: over 96% of children were 
discharged alive in 2013-2015. With the exception of one PICU, risk-adjusted performance of 
all participating health organisations fell within acceptable limits in each individual year and 
when aggregated across the three year period. 
 
 
Excess mortality was detected in 2015 for the PICU at Royal Manchester Children’s Hospital. 
An investigation by PICANet suggested that this was not an issue with data quality and an 
external independent review panel have reported to the Trust. 
 
 

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PICANet:  2016 Summary Annual Report. 
RECOMMENDATIONS  
 
 
 
 
 
 
 
1.  Commissioners should continue to work closely with PICUs to ensure adequate staffing levels in 
accordance with professional standards.  
 
2.  Nurse Managers should ensure that the observed reduction in the use of Agency and Bank staff 
is maintained and shows continued improvement.  
 
3.  Commissioners should review the PICANet data concerning the year on year increase in critical 
care activity and ensure that sufficient resources are allocated to cover this increasing work load.  
 
4.  Options for long-stay, low acuity patients requiring care in specialist units should be investigated. 
This should form part of the ongoing critical care review. 
 
5.  Units should ensure complete and timely ascertainment of data submission to PICANet given the 
year on year increase in PIC admissions and seasonal variation in PIC requirement. This 
information is essential to facilitate appropriate resource planning and commissioning.  
 
6.  PICANet should work with the Paediatric Intensive Care Society and the Clinical Advisory Group 
to establish the standard for emergency readmission rates. 
 
7.  The 13% referral refusal rate due to a lack of staffed beds should be addressed in relation to 
staffing levels and organisational planning. 
 
8.  The current mortality risk adjustment model should be reviewed and its suitability for comparing 
risk adjusted SMRs between PICUs assessed in view of changing patient characteristics in 
paediatric intensive care. 
 
9. PICANet should work with national and international partners to develop a new means of 
assessing case-mix adjusted outcomes for PICU that do not solely focus on mortality 
 

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PICANet:  2016 Summary Annual Report. 
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 Sick 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 Children’s University 
Hospital, Temple Street, 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 of the online annual report section of the 
PICANet website. 
 
GOVERNANCE 
 
PICANet continues to receive support from the NHS Health Research Authority Confidentiality 
Advisory Group (CAG) (formerly the NIGB) to collect personally identifiable data on infants and 
children admitted to paediatric intensive care without consent.    
(http://www.hra.nhs.uk/documents/2016/08/piag-register-master.xls). 
 
Ethics approval has been granted by the Trent Medical Research Ethics Committee, ref. 05/MRE04/17 
+5. 
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. 
 

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PICANet:  2016 Summary Annual Report. 
 
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: 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 Hospital (TSCUH) is 
incorporated as a private limited company. Both receive funding from the Health Services Executive, 
charitable and private sources. 

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PICANet:  2016 Summary Annual Report. 
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, accident and emergency 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 34 PICUs and 6 specialist transport organisations 
currently submitting data to PICANet. 
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. 
 
 

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PICANet:  2016 Summary Annual Report. 
Data collected 
PICANet collects three core datasets:   
Admission data contains personal details of each child including their name, age, date of birth, NHS 
number, address and ethnic group;  it also records where children are admitted from, their 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 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 and patient and 
family experiences: 
Staffing data is collected each year in November to monitor staffing levels within PICUs as well as the 
PICS standards relating to staffing requirements. 
Parent/Carer satisfaction data is collected on an ad hoc basis as part of the work programme of the 
PICU families group. During 2015 this data was collected using the EMPATHIC 30 questionnaire 
developed by colleagues in the Netherlands to facilitate international comparisons and the results of 
this work are presented in this year’s annual report.    
 
Case ascertainment, data quality and validation 
We estimate that ascertainment is 99.9% complete for PICU admissions: 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 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 demand, assess interventions 
and outcomes and provide data to underpin research to facilitate the development of new standards 

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PICANet:  2016 Summary Annual Report. 
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 provided baseline data for the development of the 
I-KID, SANDWICH and FEVER trials discussed in this report by Dr Heather Lambert, Dr Bronagh 
Blackwood and Professor Mark Peters respectively in this report.  PICUs participating in these trials 
will be able to reduce the data collection burden by using the PICANet custom data download facility. 
 
Professional and Quality standards audited by PICANet 
The Paediatric Intensive Care Society (PICS) has developed a set of professional standards to make 
sure the quality of care provided by organisations involved in every aspect of intensive care is high. 
These standards are used in practice in all NHS organisations across the UK. The present standards [1] 
cover the whole patient pathway from the initial referral to paediatric intensive care, specialist 
transport and then inpatient care. PICANet has been an integrated part of the revisions of the PICS 
standards since their inception. Currently we audit 27 PICS Standards for the care of critically ill 
children using both the core PICANet data-set, retrievals data and the data collected via the staffing 
and PIC families surveys (Table 1). 
 
Table 1: Paediatric Intensive Care Society Standards audited by PICANet in the 2016 Annual Report 
PICS Standards 
101 
There should be a nominated lead consultant for the Retrieval Service responsible with the 
lead nurse (standard 105) for ensuring training, protocols and audit are in place, and for 
sustaining regular links with referring hospitals. 
103 
24 hour consultant advice should be available to the Retrieval Service and this consultant 
should be able to join the retrieval team if necessary. This consultant should not be providing 
cover for PICU at the same time as for the Retrieval Service. 
104 
A doctor appropriately trained and experienced to carry out retrieval should be available at all 
times. 
105 
There should be a nominated lead nurse for the Retrieval Service responsible, with the lead 
consultant (standard 101) for ensuring training, protocols and audit are in place and for 
sustaining links with referring hospitals. 
 
107 
A nurse or other non-medical member of staff trained and experienced to carry out retrievals 
should be available at all times. 
118 
The Retrieval Service should have written guidelines covering arrangements for transfer of 
parents. Wherever possible and appropriate, parents should be given the option to 
accompany their child during the transfer. Where this is not possible or appropriate, other 
arrangements should be made to transfer parents. 
122 
The Retrieval Service should audit and monitor requests for retrieval to which it is not able to 
respond. 
123 
The retrieval team should arrive at the referring unit within three hours of the decision to 

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PICANet:  2016 Summary Annual Report. 
retrieve the child. 
124 
Wherever possible, a child should undergo one retrieval journey only. 
126 
The Retrieval Service should be collecting data on, at least: 
Referrals, including those that do not result in transfer, Referral information completeness, 
Advice to referring hospitals, Pre-transfer patient condition and management, Retrievals, 
Ambulance response times, Untoward clinical incidents, 
Mortality and morbidity. 
These data should be collected all children for whom retrieval was requested, including those 
not retrieved by the Service. 
127 
The Retrieval Service should be submitting the required dataset to the Paediatric Intensive 
Care Audit Network (PICANet) within three months of the retrieval. 
129 
The Retrieval Service should produce an annual report summarising activity, compliance with 
quality standards, and clinical outcomes.  This report should identify actions required to meet 
expected quality standards and progress since the previous year’s annual report. This report 
should be shared with referring hospitals. 
144 
The following support services should be available; Interfaith support, Social workers, 
Interpreters, Bereavement support, Patient advice & advocacy, Family Psychological support, 
Staff psychological support. (Availability is not defined but should be appropriate to the case 
mix and needs of the patient) 
149 
Appropriately qualified play specialists should be available 7 days a week. 
156 
All paediatric intensive care consultants should have regular day time commitments on the 
paediatric intensive care unit. 
157 
For every 8 to 10 beds there should be at least one consultant available to the unit at all 
times. 
158 
During normal working hours one medical trainee (or equivalent grade doctor) should not 
normally be allocated more than five patients. 
159 
Outside normal working hours, for every eight PICU beds there should be at least one ST4 or 
above grade doctor available to the unit at all times. 
164 
The unit’s nursing establishment and nursing rosters should be appropriate to the anticipated 
number and dependency of patients. Staffing levels should be based on the ratios in Appendix 
13. Appendix 13:- the minimum number of qualified nurses required to staff 1 critical care bed 
is, at least 7.01 (WTE). 
167 
All nurses should have up to date paediatric resuscitation training. Senior nurses should have 
up to date advanced paediatric resuscitation training. 
168 
The unit should provide training for nursing staff in paediatric care in collaboration with local 
universities. 
169 
Each unit should have a discharge coordinator responsible for managing the discharge of 
children with complex care needs. 
170 
Daily sessional support should be available to the Paediatric Intensive Care Unit from 
pharmacy, physiotherapy and dietetic staff with competences in the care of critically ill 

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PICANet:  2016 Summary Annual Report. 
children who have time in their job plans allocated for their work on the unit. 
179 
The unit should be collecting data on all requests for admissions, including those who were 
not admitted.  The unit should obtain data from the Retrieval Service on the eventual 
destination and clinical outcome of children for whom admission was refused. 
180 
Average 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. 
181 
The unit should be submitting the required dataset to the Paediatric Intensive Care Audit 
Network (PICANet) within three months of discharge. 
Appendix 13 
Levels of Care & Patient Dependency, Paediatric Intensive Care Society (Clinically Based). Level 
1 requires nurse to patient Ratio of 0.5:1. Level 2 requires 1:1. Level 3 requires 1.5:1. Level 4 
requires 2:1. 
 
NHS England has developed a Quality Dashboard programme for specialised services to provide 
assurance on the quality of care by collecting new information about outcomes from healthcare 
providers [2]. One of the dashboards is specifically for paediatric intensive care and PICANet provides 
data which can be used to calculate several of the indicators required (Table 2). Discussions are 
currently underway concerning the revision of the core PICANet dataset to allow collection of all 
paediatric intensive care data dashboard measures. Decisions as to how this will be addressed will be 
made following the award of the next contract to run the national PIC audit.  
Table 2: NHS Specialised Services Quality Dashboard Measures audited by PICANet 
Dashboard Measure 
Description & Provenance 
PIC01 
Risk adjusted mortality 
PICANet is a clinical data base used by most / all PICU providers. 
PICANet produce a risk adjusted SMR that is accepted by Trusts. 
PIC02 
Refusal rate for emergency 
admissions 
Number of emergency admissions refused from within the 
defined catchment population served 
PIC04 
Emergency readmissions to PICU 
within 48 hours 
Emergency readmissions to PICU within 48 hours of a previous 
discharge / transfer from PICU 
PIC05a 
Bed occupancy 
PICU bed occupancy rates 
PIC08 
Unplanned extubation 
Rate of unplanned extubation of patients/100 ventilated days 
PIC10 
% of data submissions to PICANet 
within 3 months of discharge 
PICANet expects provider information to be complete and 
accurate 3 months after patient discharge 
PIC13 
% of refused requests for retrieval 
of a patient within defined 
catchment 
Ability to deliver a comprehensive retrieval service 
PIC14 
Mobilisation of PIC retrieval team 
Number of retrievals performed within the agreed mobilisation 
time 

17 
PICANet:  2016 Summary Annual Report. 
The NHS England Commissioning for Quality and Innovation (CQUIN) payment framework links a 
proportion of English healthcare providers' income to the achievement of local quality improvement 
goals, and both of the proposed National Paediatric Critical Care (PCC) CQUINs (prevention of 
unplanned readmissions to PIC within 48 hours and transfers out of normal catchment/network to 
PICU) are collected by PICANet [3]. 
 
Analytical techniques 
Statistical techniques used include simple cross tabulations, the use of logistic regression to 
recalibrate the mortality risk adjustment model based on a rolling 3-year data window; 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. Cox-
proportional hazards models and Kaplan-Meir graphs are used to assess survival trends using the 
mortality data obtained from the NHS Health and Social Care Information Centre to assess longer 
term survival. More sophisticated statistical techniques such as random effects logistic regression, 
propensity score matching and latent class analysis have been proposed to enable this rich dataset to 
be explored with greater subtlety. 
 
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 
(http://www.picanet.org.uk/Documentation/Policies/PICANet_Policy_on_Units_lying_outside_the_co
ntrol_limits%205_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 
2011.  On two specific occasions, PICUs have been identified as outliers with excess risk-adjusted 
mortality. In each case this was attributable to data quality issues and when corrected, the outliers fell 
within normal limits.  Both PICUs contributed an article in a previous PICANet annual report detailing 
their experiences and lessons learnt from the process. In this report, we outline how we dealt with an 
outlier that was not attributable to data quality and include a response from the PICU detailing their 
internal findings and the result of an external review. 
 

18 
PICANet:  2016 Summary Annual Report. 
Links with the clinical community, patients and their families 
The PICANet PICU Families Group currently has four Lay Representatives who are the parents of 
children who are currently or have previously received paediatric intensive care. In addition we have a 
standing Lay Representative on our Steering Group and work closely with the charity Well Child. Our 
Lay Representatives have worked closely with PICANet to develop the Annual Lay Report. To date all 
communications we have had from patients/parents have been to support PICANet and its work and 
to request further information. 
PICANet has the support of the Paediatric Intensive Care Society and the associated PICS Study Group, 
the PICANet Clinical Advisory Group and as well as the Clinical Reference group which oversees 
Paediatric Critical Care and PCC transport. 
 

19 
PICANet:  2016 Summary Annual Report. 
DATA ANALYSIS: FINDINGS AND COMMENTARY 
 
In this year’s summary report we describe our findings for the four proposed metrics (mobilisation 
time, nurse establishment, emergency readmissions and SMR), together with a measure of case 
ascertainment as an indicator of audit quality, identified in collaboration with the Care Quality 
Commission (CQC) and selected to answer three of the five CQC Key Questions relating to 
Responsiveness, Safety and Efficacy in the Paediatric Intensive Care Service.  We also report on 
unplanned extubation rates, children in adult ICUs, an assessment of the proportion of bed days used 
by individual children, staffing levels including preliminary analysis from the new medical 
establishment data collection forms and the results of our parents and carers survey, as well as 
presenting the investigation of a mortality outlier. The PICANet annual report comprises three 
sections and this summary report should be read in conjunction with the Tables and Figures and the 
Appendices for reference purposes. 
 
Case ascertainment 
Case ascertainment levels for the PICANet audit are 99.9%.  
 
Metric 1: Crude proportion of retrievals with mobilisation time <1 hour 
In this year’s report, the transport tables have changed to show information by transport 
organisation, instead of organisation that submitted the record. The transport tables focus on non- 
elective transports and over the three year reporting period 2013-2015 the majority (68.5%) of the 
non-elective mobilisation times have taken less than one hour (Figure 1). In 24.9% of cases the 
mobilisation time took more than 1 hour. In 6.7% of cases data on mobilisation times were not 
recorded. 

20 
PICANet:  2016 Summary Annual Report. 
Figure 1: Non- elective transports by year, by transport organisation & mobilisation time (minutes), 
2013-2015 
0
30
60
90
120
150
180
210
240
270
300
C
D
K1K3
M
N
T001
T002
T003
T004
T005
T008
T010
T016
T022
T024
T026
W
X
Y
ZA
ZB
Other
Unknown
 
 
Metric 2: Nursing establishment 
In 2015, 12 (34%) PICUs have met the nursing establishment levels and increase from just 5 PICUs in 
2014. Details on the staffing levels in PICUs are included in the Staffing Section. 
 
Metric 3: Crude 48 hour emergency readmission ratio 
Crude rates of emergency readmissions to the same PICU within 48 hours are calculated by health 
organisation. A funnel plot is used to compare the average readmission rate between organisations, 
for the three years reporting period (Figure 2). 

21 
PICANet:  2016 Summary Annual Report. 
Figure 2: Relative rates of emergency readmissions with 48 hours of discharge, 2013-2015 
G
ZF S B
K2
L
C
UZE
Z
Y
M
ZD
Q
ZB
T
H
K1K3A OD
W
NE2I X
R E1 ZA
P
ZC
F
V
0
2
4
6
8
10
0
1000
2000
3000
4000
Number of Admissions
 
All organisations, other than Q and V fall within the control limits. Organisation Q reports PICU bed 
data only but is a combined PICU/HDU which may lead to an overestimate of their emergency 
readmission rate and organisation V falls on the upper limit. In 2013-2015 the average emergency 
readmission rate was 1.7%, varying between 0% and 5% between organisations.  In 2015, the highest 
readmission rate was 3%. 
 
Metric 4: Standardized mortality ratio (SMR) 
Each year PIM2 is re-calibrated to be up-to-date with the latest dataset used in the annual report. 
Crude and standardised mortality ratios (SMRs) are then calculated, to show the performance of each 
unit. The SMR uses the risk adjusted data to compare the number of deaths in a specific time period 
with the number predicted by the PIM2 score. Crude mortality for the three year reporting period 
2013-2015 was 3.7%, varying between 0.7% and 6.1% across the different PICUs, predominately due 
to variations in case mix. Funnel plots are used to compare mortality ratios between units (Figure 3). 

22 
PICANet:  2016 Summary Annual Report. 
Figure 3: Standardized mortality rates (SMR), by health organisation, 2015 
 
 
In 2015 the risk-adjusted performance of one PICU fell outside acceptable limits triggering the 
established procedure for the investigation of an outlier. Details on the outlier can be found in the 
“Detection of a mortality outlier in the PICANet annual report data” section (see page 44). 
 
Unplanned extubation 
Unplanned extubation is a quality indicator that shows how well PICUs perform. The rate of 
unplanned extubation of patients per 100 intubated days is one of the measures included in the 
Quality Dashboard Programme for NHS England (PIC08). Unplanned extubation was introduced to the 
PICANet dataset in mid-2014, by the 1st January 2015 all units had started collecting this data. A new 
table and a figure have been introduced to this year’s Annual Report. Figure 4 shows unplanned 
extubation ratios by health organisation. 

23 
PICANet:  2016 Summary Annual Report. 
Figure 4: Unplanned extubation ratio by health organisation, 2015 
GZF
S
ZE
Z
L
Y
Q
A
C
M T
NZD
K2
ZB
K1K3
UH
E2
E1 X
O
I
ZA
D W
R
F
ZC
P
V
0
2
4
6
8
10
0
2000
4000
6000
Number of intubated days
 
An intubated day was defined if invasive ventilation via endotracheal tube was performed on that day.
Results show that overall rates are very low, ranging between 0 and 1.1 unplanned extubation events 
per 100 intubated days. As this is the first year we report on unplanned extubations, these numbers 
will be used as a baseline measure for future reference. 
 
High flow nasal cannula therapy 
In mid-2014 high flow nasal cannula therapy was added to the PICANet admission collection form in 
the daily interventions section. By the start of 2015 all units were reporting on high flow nasal cannula 
therapy. Preliminary results from this data collection are shown in table 3 which provides the number 
of high flow admissions by organisation with the number of days in which high flow nasal cannula 
therapy was administered and details of the median, minimum and maximum days of therapy. 
 

24 
PICANet:  2016 Summary Annual Report. 
Table 3: High flow nasal cannula therapy, by organisation, 2015 
  
  
HIGH FLOW NASAL CANNULA THERAPY 
Organisation 
Total 
admissions 
High flow admissions 
Days 
Median  
Minimum 
Maximum  
  
n 
(%) 
  
  
  
  
A 
616 
82 
(13.3) 
269 
8 
1 
40 
C 
466 
17 
(3.6) 
75 
7 
1 
20 
D 
643 
17 
(2.6) 
38 
7 
1 
40 
E1 
997 
0 
(0.0) 
0 
0 
0 
0 
E2 
816 
0 
(0.0) 
0 
0 
0 
0 
F 
1190 
0 
(0.0) 
0 
0 
0 
0 
G 
22 
0 
(0.0) 
0 
0 
0 
0 
H 
533 
67 
(12.6) 
250 
10 
1 
25 
I 
793 
187 
(23.6) 
436 
12 
4 
40 
K1K3 
597 
112 
(18.8) 
373 
6 
2 
15 
K2 
255 
79 
(31.0) 
468 
8 
3 
35 
L 
323 
9 
(2.8) 
20 
8 
3 
50 
M 
684 
1 
(0.1) 
4 
20 
10 
20 
N 
826 
234 
(28.3) 
732 
10 
3 
35 
O 
670 
75 
(11.2) 
228 
15 
2 
63 
P 
966 
178 
(18.4) 
453 
7 
2 
30 
Q 
477 
44 
(9.2) 
110 
13 
4 
60 
R 
957 
152 
(15.9) 
379 
14 
2 
40 
S 
123 
11 
(8.9) 
33 
8 
5 
30 
T 
639 
89 
(13.9) 
239 
15 
2 
45 
U 
317 
1 
(0.3) 
5 
20 
4 
20 
V 
1340 
240 
(17.9) 
665 
15 
5 
40 
W 
761 
188 
(24.7) 
580 
10 
3 
44 
X 
898 
61 
(6.8) 
190 
6 
1 
20 
Y 
381 
47 
(12.3) 
133 
15 
3 
50 
Z 
441 
37 
(8.4) 
88 
8 
1 
30 
ZA 
941 
245 
(26.0) 
1096 
9 
2 
30 
ZB 
630 
62 
(9.8) 
194 
8 
3 
30 
ZC 
942 
214 
(22.7) 
772 
9 
1 
40 
ZD 
456 
149 
(32.7) 
386 
7 
3 
50 
ZE 
199 
5 
(2.5) 
10 
12.5 
2 
24 
ZF 
68 
2 
(2.9) 
6 
6 
2 
15 
Total 
19967 
2605 
(13.0) 
8232 
10 
0 
63 
 
In 2015, 13% of admissions of children aged between 0-15 years were given high flow nasal cannula 
therapy, with the median value administered across all units being 10 l/min (range 1-63 l/min). The 
total number of days that high flow nasal cannula therapy was performed was 8,232, which 
represents 6.2% of all bed days for children aged 0-15 years. 
 
Children in adult ICUs 
In some cases children are admitted to adult ICUs, for example if the nearest PICU is a long distance 
away or so the child can be stabilised before transfer to a PICU. Data on children cared for in adult 
ICUs is presented and was provided by the Intensive Care Audit and National Research Centre 

25 
PICANet:  2016 Summary Annual Report. 
(ICNARC). Nearly 1,700 admissions of children to adult ICUs were recorded during the reporting 
period, slightly more males than females were admitted (54% vs. 46%) and over one third of child 
admissions (36%) were in the 11-15 years age group. When examining the primary diagnosis the 
highest proportions of children admitted to adult ICUs were in the respiratory (39%) and neurological 
(29%) groups. 
 
Proportion of bed days used by individual patients 
PICANet reports on bed activity (the number of bed days delivered) and this is a function of the 
number of admissions and length of stay. Here we present two figures: figure 5 gives the number of 
admissions by length of stay (excluding those stays over 100 days) and illustrates the small numbers 
of children who stay more than 30 days. 
Figure 5: PICU length of stay in the UK and Republic of Ireland, 2013-2015. 
Admissions (<16 years)
in the UK and the Republic of Ireland, 2013-2015
n=59,691
Length of stay over 100 days excluded
0
20000
40000
60000
0
20
40
60
80
100
Length of stay (days)
 
Figure 6 makes it clear that nearly 60% of bed days delivered by PICUs in the UK and Republic of 
Ireland are used by 10% of the patients. These figures suggest that there is a small group of children 
who use a high level of resource and it may be appropriate to investigate whether their care could be 
provided in a different setting, away from the high-turnover activity associated with acute admissions 
and post-operative care. 

26 
PICANet:  2016 Summary Annual Report. 
Figure 6: Percentage of PICU bed days used by percentage of patients in the UK and Republic of Ireland, 
2013-2015. 
Admissions (<16 years)
in the UK and the Republic of Ireland, 2013-2015
n=59,691
0
20
40
60
80
100
0
20
40
60
80
100
% of patients
 
 
Referral and transport 
PICANet referral and transport data collection was introduced in 2011. This has created two separate 
datasets which are complementary to the admissions data; one relating to referrals to PICUs and the 
other transports to PICU and other journeys carried out by paediatric intensive care specialist teams 
and PICU based teams. In this annual report twelve tables are presented; two relating to referrals and 
ten providing detailed information about the transport data collected. This year rather than the tables 
focusing on the organisation who submitted the data we have re-focused the analysis on the 
organisation conducting the transport or referral.  However, in the case of Table R2 (Tables & Figures) 
the focus is on admitting organisation as this table illustrates admission outcome. 
In mid-2014 significant changes were made to the referral dataset, now using two outcome 
measures, Transport Outcome and Admission Outcome, to replace the previous measure, Referral 
Decision and as such related tables are restricted to the 2015 data alone.  This analysis will be used as 
a baseline for future reports.   
In 2015 PICANet received data for 7,460 referrals, of which 6,577 (88%) were transported and 5,901 
(79%) were accepted for PICU admission. In the period 2013 to 2015 we received data for 15,844 
transports of which 13,278 (83.8%) records were non-elective transports to PICU. A number of PICS 
Standards (Standards 118, 122, 123 and 124) and Data Dashboard items (PIC02, PIC13, PIC14) are 
linked to transport and referral related data. During 2015 11.6% of referral cases were rejected due to 
a transport related issue and 20.7% were rejected due to an issue at the admitting PICU.  Over the 
three years 2013 to 2015 the vast majority (97.7%) of transport events recorded that the patient was 

27 
PICANet:  2016 Summary Annual Report. 
transported (transport of a child may not take place or journeys may not be completed if their clinical 
condition changes or if they die before or during a journey). Journey time data is now available and 
will be developed as more information on catchment areas and agreed mobilisation time is elicited.  
The majority of non-elective patient journeys to PICU (61.2%) were completed in under 1 hour, 
whereas only 1.4% took longer than 3 hours (Figure 7). 
Figure 7: Patient journey (mins) by transport organisation, 2013-2015 
0
30
60
90
120
150
180
210
240
A
B
C
D
E2
K1K3
L
M
N
S
T001
T002
T003
T004
T005
T008
T010
T016
T022
T024
T026
W
X
Y
ZA
ZB
Other
Unknown
 
 
Data quality and completeness 
The completeness of the PICANet dataset is a major strength and monitoring data quality and the 
evaluation of the timeliness of data collection are important aspects of the role of PICANet; measures 
are quantified within the PIC Data Dashboard (Item PIC10) and the PICS standards (127, 181). PICS 
Standard 181 states data must be submitted to PICANet within 3 months of discharge for each 
admission. The 2015 data shows that whilst there is still a wide variation between organisations in the 
percentage of records where this is attained (mean: 77%, range: 45%-100%), there has been a 
substantial improvement compared to 2014 (mean: 56%, range: 0% to 99%). 
 
Staffing  
The annual staffing survey was carried out during a specified week in November 2015 with details 
recorded at four specific ‘snapshot’ time periods (a weekday and a weekend at noon and midnight) as 
well as information about other professionals working on PICU. Complete data was returned by all 
PICANet units.  

28 
PICANet:  2016 Summary Annual Report. 
The units reported a total of 382 funded intensive care beds and 73 funded high dependency in the 
2015 survey. High dependency care beds are included in those critical care units where PICANet data 
is submitted for both intensive care and high dependency patients and staffing is provided by the 
same paediatric intensive care nursing and medical establishment. 
 
Staffing forms  
The forms used to collect the medical staffing data were changed this year to reflect the way that 
consultant contracts are calculated using Direct Clinical Care Programmed Activities, equivalent to 
sessions of activity defined as follows: 1 DCC PA =4 hours during daytime hours (approximately 7am 
to 7pm) and 1 DCC PA=3 hours for nights and weekends. New tables have been developed to reflect 
this change focussed at the DCC PA’s allocated to PICU care provision. A copy of these forms can be 
found in Appendix M. 
 
New PIC standards were introduced in December 2015 (after the PICANet annual staffing data 
collection) and so, with the exception of Figure 11 which uses the new PICs standard for the numbers 
of consultant staff required in PICU, all other data refers to the previous PICs standards (2010) 
allowing for direct comparison to our previous years’ results.  
 
Nursing staff  
Staff per bed 
PICS standard 164 (2010) details the qualified nursing establishment levels required. Figure 8 shows 
that in November 2015 29.4% (n = 10) of the UK PICUs met the standard of at least 7.01 WTE 
qualified nurses required to staff one critical care bed an increase from just five PICUs in 2014. A 
similar increase is seen for the previously defined PICS standard (2001) of 6.4 WTE per bed with a 
total of 47.1% (n =16) units meeting this target (an increase from 10 in 2014). This is a statistically 
significant increase in the number of UK PICUs that meet the nurse staffing standard over the period 
2013 to 2015 (Test for trend p=0.03) shown in Figure 9 and is reflected in the total number of 
qualified nursing staff in post which has shown a 13% increase from 2462.5 whole time equivalents 
(wte) in 2014 to 2795.1 wte in 2015. 

29 
PICANet:  2016 Summary Annual Report. 
Figure 8: Number of clinically qualified nursing staff in post (WTE) per bed, by health organisation, Nov 
2013-2015 against the PICS 2001 and PICS 2010 standards 
 
Figure 9: Proportion of health organisations meeting the PICs 2001 and 2010 standards for the number 
of clinically qualified nursing staff in post (WTE) per bed 2013-2015 
 

30 
PICANet:  2016 Summary Annual Report. 
Nurses on duty  
Table 4: Proportion of units meeting the PICS Standard 164 (2010) defined levels of care and patient 
dependency. 
Snapshot time period 
% Meeting Standard 
Wednesday 
Noon 
66.7 
  
Midnight 
45.5 
Sunday 
Noon 
45.5 
  
Midnight 
51.5 
 
For each snapshot time period Table 4 shows the proportion of units meeting PICS standard 164 with 
respect to the levels of care and patient dependency levels of the children being cared for on PICUs as 
defined in Appendix M; where Level 1 requires nurse to patient Ratio of 0.5:1. Level 2 requires 1:1. 
Level 3 requires 1.5:1 and Level 4 requires 2:1.  
Two thirds of units met the nurse to patient ratio at 12 noon on a weekday (66.7%).  As in previous 
years around half of units met this standard at midnight on a weekday and at 12 noon and midnight 
on the Sunday of the snapshot week in November 2015. 
Figure 10 shows the proportion of nursing staff that were agency and bank staff on duty during the 
four different snapshots recorded as part of the staffing survey in 2015 compared to the snapshot 
period for 2014. Whilst the largest proportion of bank and agency staff are once again in London, 15% 
on a weekday at noon and around 17-18% on the other three ‘out of hours’ time periods there has 
been a substantial reduction in the proportion of these staff being used (reduced from 27% in 2014 
12 midnight Sunday). It should be noted that this data was collected prior to the Government 
introducing caps for agency costs. 
 
 
 
 
 
 
 
 
 
 
 
 

31 
PICANet:  2016 Summary Annual Report. 
 compared to the snapshot periods for 2014. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical staff  
Consultant staff 
PICANet has worked with their Clinical Advisory Group to develop a new data collection tool in order 
to collect the number of direct clinical care (DCC) programmed activities attributable to paediatric 
intensive care to match the method used for consultant contracts for England, Scotland, Wales and 
Northern Ireland (29 health organisations). Eire and the private PICUs have been excluded from this 
consultant analysis as their contracts are calculated differently. Data was collected in November 2015 
with the refined questionnaire and is presented in this section here in a modified format to previous 
reports to allow for the more detailed results.  
Figure 10: Percentage of bank and agency staff working on PICU for the four snapshot time periods in
2015 (noon and midnight Wednesday and Sunday, week commencing 16th November 2015) 

32 
PICANet:  2016 Summary Annual Report. 
Table 5: Medical establishment: number of consultants DCC PAs in post and vacant posts by consultant 
type 
  
Paediatricians 
Anaesthetists 
Non-PICM 
consultants 
Associate 
specialists/staff 
grade 
TOTAL 
by 
grade 
Consultant area of work 
n 
(%) 
n 
(%) 
n 
(%) 
n 
(%) 
n 
ICU 
Number of staff in post  
xx-xxxx-xxxx 
(73.3) 
41.5 
(18.0) 
16.0 
(6.9) 
4.0 
(1.7) 
230.3 
Number of vacant posts  
13.0 
(89.7) 
1.5 
(10.3) 
0.0 
(0.0) 
0.0 
(0.0) 
14.5 
TOTAL ICU establishment posts 
181.8 
 
43.0 
 
16.0 
 
4.0 
 
244.8 
Combined total DCC PAs of 
    funded staff in post   
1410.7 
(82.4) 
243.3 (14.2) 
29.6 
(1.7) 
28.0 
(1.6) 
1711.6 
Combined total DCC PAs of 
vacant posts  
109.0 
(93.7) 
7.4 
(6.3) 
0.0 
(0.0) 
0.0 
(0.0) 
116.3 
Total DCC PAs for ICU medical 
establishment 
1519.7 
 
250.7 
 
29.6 
 
28.0 
 
1827.9 
Transport 
Number of staff in post 
7.0 
(70.0) 
2.0 
(20.0) 
0.0 
(0.0) 
1.0 
(10.0) 
10.0 
Number of vacant posts 
7.0 
(100.0) 
0.0 
(0.0) 
0.0 
(0.0) 
0.0 
(0.0) 
7.0 
Total transport establishment 
posts 
14.0 
 
2.0 
 
0.0 
 
1.0 
 
17.0 
Combined total DCC PAs of 
funded staff in post 
98.5 
(92.5) 
8.0 
(7.5) 
0.0 
(0.0) 
0.0 
(0.0) 
106.5 
Combined total DCC PAs of 
vacant posts 
61.0 
(100.0) 
0.0 
(0.0) 
0.0 
(0.0) 
0.0 
(0.0) 
61.0 
Total DCC PAs for transport 
medical establishment 
159.5 
 
8.0 
 
0.0 
 
0.0 
 
167.5 
 
 
 
 
 
 
 
 
 
 
 
Table 5 provides the medical establishment figures (with vacant posts) for all PICUs across England, 
Scotland, Wales and Northern Ireland by type of consultant and area of work. Overall 116.3 (6.4%) 
DCC PAs are vacant out of 1827.9 DCC PAs required for medical establishment to cover PICU beds. Of 
the filled consultant posts 57.6 (3.4%) DCC PAs are non-PICM consultants or Associate specialists/staff 
grade doctors and 243.3 (14.2%) DCC PAs are PIC anaesthetists. 
Of the 29 health organisations presented 21 are standalone PICUs with 1297.6 DCC PAs consultants in 
post and the remaining 8 are combined PICU and retrieval services using approximately one quarter 
(414.1) of the DCC PAs in post. Data concerning the staffing of the standalone retrieval services have 
not, to date, been included in the PICANet annual staffing study. 
Locum consultants currently fill around 10% of DCC PAs (157.8 (9.2%)). 
In PICS standard L3-202 (Dec 2015) consultant staffing requirements state that: 
The following consultant staffing should be available: 

33 
PICANet:  2016 Summary Annual Report. 
‘Normal working hours’: At least one consultant for up to 12 beds for children needing Level 3 critical 
care and for each subsequent 12 beds. 
Outside ‘normal working hours’: At least one consultant for up to 20 critical care beds and for each 
subsequent 20 beds. All consultants should have regular day-time commitments on the unit. 
The definition of working hours in the PICS standards is that it ‘should take into account times of peak 
activity’ and the difference in the requirement between ‘normal working hours’ and ‘outside normal 
working hours’ is not fully explained and may vary from PICU to PICU. In this analysis the same 
definition has been used for all PICUs with ‘normal working hours’ being defined as 7am to 7pm 
Monday to Friday. 
 
Figure 11: Combined total DCC PAs of funded staff in post for Consultant Paediatric Intensivists, by 
organisation, November 2015 against PICS standard L3-202 (December 2015) 
 
Figure 11 presents data for PICS standard L3-202 (Dec 2015) consultant staffing by individual health 
organisation by type of post. Most organisations meet the specified target (23/28, 82%); six units 
(21%) meet the target by using locum consultant staff. PICS standards are seen as ‘minimum target’ 
figures and depending on the availability of junior and middle grade staff (advanced nurse 
practitioners and nursing staff) other models may have been developed locally to ensure safe practice 
for the population served by any particular PICU. In calculating the “minimum target” figures we have 
made a number of assumptions based on assumed levels of activity: an expectation of actual 
consultant immediate availability or presence on units from 8am to midnight every day, and that 
there is consultant availability within 30 minutes and no responsibility for other hospital sites 
between midnight and 8am. However, models for individual PICUs will vary. 

34 
PICANet:  2016 Summary Annual Report. 
Junior and middle grade staff 
Table 6: Medical establishment: number of junior and middle grade staff (WTE) in post and vacant posts 
by training grade 
  
In post 
Vacant 
Total 
Junior staff by training grade  
n 
(%) 
n 
(%) 
n 
Overall 
ICU - Number of staff 
379.0 
(93.1) 
27.9 
(6.9) 
406.9 
ICU - Combined total WTE 
318.5 
(92.8) 
24.8 
(7.2) 
343.3 
Transport - Number of staff 
15.0 
(88.2) 
2.0 
(11.8) 
17.0 
Transport - Combined total WTE 
14.0 
(82.4) 
3.0 
(17.6) 
17.0 
Junior (FY1-2, ST 1-3) 
ICU - Number of staff 
86.0 
(97.3) 
2.4 
(2.7) 
88.4 
ICU - Combined total WTE 
39.8 
(93.4) 
2.8 
(6.6) 
42.6 
Transport - Number of staff 
0.0 
(0.0) 
0.0 
(0.0) 
0.0 
Transport - Combined total WTE 
0.0 
(0.0) 
0.0 
(0.0) 
0.0 
Middle Grade (ST 4-8) 
ICU - Number of staff 
293.0 
(92.0) 
25.5 
(8.0) 
318.5 
ICU - Combined total WTE 
278.7 
(92.7) 
22.0 
(7.3) 
300.7 
Transport - Number of staff 
15.0 
(88.2) 
2.0 
(11.8) 
17.0 
Transport - Combined total WTE 
14.0 
(82.4) 
3.0 
(17.6) 
17.0 
Table 6 presents the medical establishment for junior and middle grade medical staff for all UK PICUs. 
Overall 92.8% of junior and middle grades were filled in November 2015 and of the filled posts 278.7 
out of 318.5 whole time equivalents (wte) (87.5%) were middle grade (ST 4-8). However, given the 
potential scheduling difficulties for these mainly full shift rota staff some shifts may run on reduced 
levels of junior and middle grade medical staffing that do not always comply with PICS standards (see 
Table 7). The vast majority of junior and middle grade posts (77.3%) were UK trainee posts. Across the 
UK there were 17 wte posts allocated to PIC transport and not based in a separate transport team all 
of which were middle grade medical staff (ST 4-8). 
 
Other professionals 
The number of hours allocated to the medical rota by Advanced Nurse Practitioners / Physician 
Associates (APP) is presented in Table 7 for England, Scotland and Wales where they are an essential 
part of the medical establishment. There are no such posts in Northern Ireland, Eire and the private 
PICUs. Nearly one third of all APP hours on the medical rota occur in one of the two PICUs in Scotland.  
 

35 
PICANet:  2016 Summary Annual Report. 
Table 7: Other staff (ANPs/Physician associates) information by regions 
  
England 
Wales 
Scotland 
TOTAL by 
country 
Other staff (ANPs/Physician 
associates) by UK country 
n 
(%) 
n 
(%) 
n 
(%) 
n 
ICU 
Number of staff in post  
33.0 
(78.6) 
2.0 
(4.8) 
7.0 
(16.7) 
42.0 
Number of vacant posts  
3.0 
(100.0) 
0.0 
(0.0) 
0.0 
(0.0) 
3.0 
Total hours per week on 
medical rota 
698.0 
(64.6) 
75.0 
(6.9) 
307.5 
(28.5) 
1080.5 
Transport 
Number of staff in post 
12.0 
(100.0) 
0.0 
(0.0) 
0.0 
(0.0) 
12.0 
Number of vacant posts 
1.9 
(100.0) 
0.0 
(0.0) 
0.0 
(0.0) 
1.9 
Total hours per week on 
medical rota 
xx-xxxx-xxxx 
(100.0) 
0.0 
(0.0) 
0.0 
(0.0) 
xx-xxxx-xxxx 
 
Medical standards 
 
Table 8 shows the proportion of units meeting the recommended PICS standards (2010) for the 
defined levels of care and dependency levels of the children receiving care during the four snapshot 
periods in November 2015.  
Table 8: Proportion of units meeting the PICS standards (2010) at specified times 
Standard 
Snapshot 
time period 
% of units meeting 
standard 
157: Consultant availability at all times 
Wednesday 
Noon 
93.8 
Midnight 
75.0 
  
Sunday 
Noon 
68.8 
  
Midnight 
65.6 
158: Medical trainee allocation during 
normal working hours 
Wednesday 
Noon 
                  65.6 
159: ST4 or above availability outside normal 
working hours 
Wednesday 
Midnight 
53.1 
Sunday 
Noon 
71.9 
  
Midnight 
56.3 
 
Data collected for the four snapshot time periods in November 2015 showed that in 95% of units a 
consultant was available at noon on Wednesday (one consultant for every 8-10 beds); PICS standard 
157.  Over two thirds of units met this standard during the snapshot periods representing nights and 
weekends. Medical trainees were appropriately allocated for up to five patients for nearly two thirds 

36 
PICANet:  2016 Summary Annual Report. 
of units at the snapshot period representing normal working hours, thus meeting PICS standard 158 
(2010). PICS standard 159 (2010) requires that outside normal working hours, for every eight PICU 
beds there should be at least one ST4 or above grade doctor available at all times was met by just 
over half of the units at midnight on Wednesday and Sunday and by almost three quarters of units at 
noon on Sunday.  
 
Conclusion 
This year the PICANet staffing survey has shown a significant increase in whole time equivalent 
qualified nurses and in the proportion of health organisations meeting the PICS standards for the 
number of clinically qualified nursing staff in post. We have also shown that the use of bank and 
agency staff in PIC has reduced. New medical establishment data collection forms have been designed 
and preliminary data have been presented. We welcome any feedback from PIC staff and others 
regarding any additional analysis or alternative presentation of the data that they require. 
 
Parent Experience of PICU – EMPATHIC-30 
“Your Experience Counts” – the EMpowerment of PArents in THe Intensive Care (EMPATHIC-30) 
survey was developed in the Netherlands (ref) to collect information about the experiences of parents 
and carers during the admission of their child to a paediatric intensive care unit (PICU). PICANet have 
worked closely with Jos Latour, who developed the tool, to produce an English translation for use in 
the UK to monitor levels of parent satisfaction with the service. 
In this summary, the term “parents” is used to include mothers, fathers, carers, guardians and other 
adults with responsibility for caring for a child or young person. Individual reports have been 
produced and circulated to participating units. Here we present an overall summary of the 
quantitative study findings.  
In 2015 PICANet collected data during two time periods (the months of February and July) from 
parents of children who received paediatric intensive care across the UK. During each month of the 
data collection units were asked to distribute the EMPATHIC-30 questionnaire to the parents and 
carers of all children being discharged from the service asking them to complete the questionnaire 
and return it in the freepost envelope provided, via the designated box on each unit or the post to the 
PICANet office.  
The main section of the EMPATHIC-30 questionnaire comprises 30 questions about the parent 
experience and can be sub-divided into five sections relating to different areas of domains relating to 
parent experience of the care provided for their child: professional attitude, care and treatment, 
organisation, parental participation, and information. Answers to each question are recorded on a six 
point scale assessing their level of agreement with each statement from 1= definitely NO to 
6=definitely YES. Broadly scores of 1 of 2 indicate that parents were not satisfied with the subject of 
the statement, scores of 3 or 4 indicate that parents felt the care was ‘OK’ and scores of 5 to 6 
indicate that they were satisfied. In addition the final section of the questionnaire asks parents to rate 
the overall performance of the PIC staff using a ten point scale from extremely poor (1) to excellent 
(10) and provides space for additional comments. 

37 
PICANet:  2016 Summary Annual Report. 
Distribution of the questionnaires was controlled by each individual PICU and therefore we were 
unable to ascertain the total number of questionnaires given out by each unit. The response rate for 
the study has therefore been estimated using the total number of discharges from each unit during 
the specified months and is presented in Table 9. Due to the fact that staff may have missed some 
parents, excluded distribution to parents unable to read English or those whose child died or was 
discharged in specific circumstances (eg. for palliative care) the estimated denominator may be over 
inflated and therefore the presented response rate will be an underestimate of the true rate. 
PICUs have been provided with a summary of the responses for their unit compared to all PICUs. Here 
we present an overview of the findings for the UK and Ireland as a whole.  
 
Study findings 
In total 31 out of 34 PICUs participated in the study at each time point and 30 units participated in 
both time points.  Just over one fifth of the parents of children who were discharged from care during 
the periods of data collection completed and returned the EMPATHIC-30 questionnaire (Table 9). 
 
Table 9: Estimated response rate - EMPATHIC-30 questionnaire for PICUs in the UK & Ireland, 2015. 
For participating units 
February July 
Total 
Completed questionnaires 
347 
345 
692 
Children discharged during time period  
1596 
1665 
3261 
Percentage returned 
21.7% 
20.7% 
21.2% 
 
The results for the two time periods of the study have been combined for this report and are 
presented for the five separate domains identified earlier. For each domain a graph of the frequency 
distribution is presented for the level of agreement with each question. The vast majority of parents 
were very happy with their child’s stay on the PICU. Analysis by unit size (less than 10 beds vs 10 or 
more beds) and by length of stay (less than or equal to 2 days vs more than 2 days) produced similar 
results with no significant differences between the groups. 
 
Information 
There are five questions included in EMPATHIC-30 that cover the provision of information to parents. 
These questions are listed below in the order they are presented on the bar chart: 
 
Every day we discussed our child’s care and treatment with the Doctors 
 
Every day we discussed our child’s care and treatment with the Nurses 
 
The doctor clearly informed us about the possible effects of our child’s treatment 
 
We received clear information about the tests and procedures 
 
We were given clear information about the possible effects of the drugs used to treat our child 
 
 

38 
PICANet:  2016 Summary Annual Report. 
Figure 12: Level of satisfaction with information for parents - PICUs in the UK & Ireland 2015 
Discussed Care
Doctors
Discussed Care
Nurses
Treatment effects
Tests Procedures
Drug effects
Information
Questions
Percentage
0
20
40
60
80
100
Scale
1
2
3
4
5
6
 
Overall parents were very satisfied with the information they received about their child’s care on PICU 
with over 80% of parents providing the highest score for the questions regarding discussions with the 
Doctors, effect of treatments and information regarding procedures and over 90% of parents 
providing the highest score for discussions with the nurses (Figure 12). Highest scores were recorded 
for a lower proportion of parents, around 70%, concerning the information provision about the 
effects of drugs with a small proportion of parents (around 5%) indicating that they were not satisfied 
with the information they received.  
 
Care and treatment 
EMPATHIC-30 includes eight questions that cover the physical care and treatment of children in PICU 
once again listed below in the order they are presented on the bar chart: 
 
The doctors and nurses worked closely together  
 
We were well prepared for our child’s discharge from paediatric intensive care by the Doctors   
 
We were well prepared for our child’s discharge from paediatric intensive care by the Nurses 
 
The team closely observed our child to prevent and treat pain 
 
The comfort and wellbeing of our child was taken care of by the Doctors 
 
The comfort and wellbeing of our child was taken care of by the Nurses 

39 
PICANet:  2016 Summary Annual Report. 
 
Each day we knew which member of the staff was responsible for our child regarding the 
Doctors 
 
Each day we knew which member of the staff was responsible for our child regarding the 
Nurses 
Figure 13: Level of satisfaction with care and treatment - PICUs in the UK & Ireland 2015 
Worked Together
Discharge
Doctors
Discharge
Nurses
Treat pain
Comfort
Doctors
Comfort
Nurses
Responsible
Doctors
Responsible
Nurses
Care and Treatment
Questions
Percentage
0
20
40
60
80
100
Scale
1
2
3
4
5
6
 
Highest levels of agreement (between 85% and 95%) with statements were seen for all aspects of 
care provision by nurses and for team working (Figure 13). The levels of agreement with statements 
regarding aspects of care provision by the doctors were somewhat lower at 70% to 80% possibly 
reflecting the perception of parents that ‘care’ is part of the nursing role.  
Organisation 
Five of the EMPATHIC-30 questions cover organisational issues. 
 
The staff worked efficiently  
 
It was easy to contact the paediatric intensive care unit by telephone 
 
There was enough space around our child’s bed 
 
The paediatric intensive care unit was clean 
 
The paediatric intensive care unit was kept as quiet as possible 

40 
PICANet:  2016 Summary Annual Report. 
Figure 14: Level of satisfaction with organisation - PICUs in the UK & Ireland 2015 
Efficiently
Telephone contact
Bed space
Clean PICU
Quiet
Organizatsion
Questions
Percentage
0
20
40
60
80
100
Scale
1
2
3
4
5
6
 
The vast majority of parents scored the questions concerning organisational issues with the highest 
levels of agreement in terms of the efficiency of staff, ease of PICU contact by telephone and 
cleanliness (around 90%) (Figure 14). However adequacy of space around the child’s bed and noise 
levels on the unit scored somewhat lower with around 5% parents indicated that these were problem 
issues and provided written comments at the end of the questionnaire highlighting these areas of 
concern, in particular noise levels on the PICU. Some did, however, acknowledge that equipment 
noise was inevitable on an intensive care unit. 
Parent participation 
Six questions in the EMPATHIC-30 questionnaire cover parent participation in the care of their child on 
PICU.  
 
During our stay the paediatric intensive care staff regularly asked us how we were getting on 
 
We were actively involved in decision-making about the  care and treatment of our child 
 
We were encouraged to stay with our child 
 
We trusted the Doctors  

41 
PICANet:  2016 Summary Annual Report. 
 
We trusted the Nurses 
 
We could always stay with our child even during intensive care procedures and tests 
Figure 15: Level of satisfaction with parent participation - PICUs in the UK & Ireland 2015 
Asked how getting on
Decision making
Encouraged stay
Trust Doctors
Trust Nurses
Stay tests
Parent participation
Questions
Percentage
0
20
40
60
80
100
Scale
1
2
3
4
5
6
 
 
Parents indicated that they had very high levels of trust in both the doctors and the nurses with 
highest scores in around 95% responders (Figure 15). Between 5% and 10% of parents felt that they 
were not actively involved in the decision making for their child and reported that they were not 
encouraged to stay with their child during tests and procedures or to be around at all times as there 
was an expectation that they leave the unit at night. Provision of accommodation for parents varies 
widely across the PICUs in the UK and Ireland and this is reflected in the response to this question.  
Professional attitude 
EMPATHIC-30 has six questions covering the topic of professional attitude. 
 
We were treated with care and understanding by the Doctors 
 
We were treated with care and understanding by the Nurses  
 
Standards of cleanliness and hygiene were maintained by the team 
 
The staff respected the privacy of our child and ourselves 
 
Our child and our family were treated with respect by the staff 
 
When we arrived at the paediatric intensive care unit the staff made us feel welcome 

42 
PICANet:  2016 Summary Annual Report. 
Figure 16: Level of satisfaction with professional attitude - PICUs in the UK & Ireland 2015 
Understanding
Doctors
Understanding
Nurses
Team Hygiene
Privacy
Respect
Felt Welcome
Professional attitude
Questions
Percentage
0
20
40
60
80
100
Scale
1
2
3
4
5
6
 
 
All questions concerning the professional attitude of the PIC staff were scored very highly with few 
negative scores or comments (Figure 16).  
 
 
 
 
 
 
 

43 
PICANet:  2016 Summary Annual Report. 
Doctors and nurses 
Parents were finally asked to rate the performance of the paediatric intensive care staff separately for 
the doctors and nurses on a 10 point scale: extremely poor (1) to excellent (10)  
 
Figure 17: Parent rating of the overall performance of the doctors in PICU - 2015 
2
3
4
5
6
7
8
9
10
Overall perfomance for Doctors
Total Score
Percentage
0
20
40
60
80
100
Median 10.0 
 IQR 10.0 to 10.0 
 
The performance of both the doctors and nurses was rated very highly by almost all parents. Doctors’ 
performance was rated as 9 or 10 for round 90% of responders with less than 5% of parents rating 
their performance as less than 8 (Figure 17). Similarly nurses’ performance was rated as 9 or 10 for 
over 95% responders and less than 2% of parent rated their performance as less than 8 (Figure 18). 
 
 
 

44 
PICANet:  2016 Summary Annual Report. 
Figure 18: Parent rating of the overall performance of the nurses in PICU - 2015 
3
5
6
7
8
9
10
Overall perfomance for Nurses
Total Score
Percentage
0
20
40
60
80
100
Median 10.0 
 IQR 10.0 to 10.0 
 
Conclusion 
In 2015 the vast majority of parents who completed the EMPATHIC-30 questionnaire were very happy 
with the care provided for their child in PICU and they rated the performance of both the doctors and 
nurses very highly.  
 
 

45 
PICANet:  2016 Summary Annual Report. 
DETECTION OF A MORTALITY OUTLIER IN THE PICANET ANNUAL REPORT 
DATA 
 
Introduction 
Each year, following closure of the annual report dataset, PICANet runs preliminary analyses on data 
submitted by all PICUs to check data quality and consistency and to identify any outliers for specific 
outcome measures including risk-adjusted mortality. This year the PICU at Royal Manchester 
Children’s Hospital had a risk-adjusted SMR of 2.23 in 2015, falling above the upper control limit in 
the 2015 funnel plot. In accordance with PICANet policy, the excess mortality in this unit was 
investigated.   
This section of the report is divided into two parts: firstly, an account of the data analysis and findings 
together with a set of recommendations from PICANet; secondly, a report from the PICU at RMCH on 
their findings from an internal review and a summary of the findings from an independent panel 
commissioned by Central Manchester University Hospitals NHS Foundation Trust. 
 
Investigation and methods 
Mortality risk adjustment and SMRs 
PICANet uses a recalibrated version of the Paediatric Index of Mortality 2 (PIM2) to calculate the 
expected probability of mortality for each admission to PICU.  These expected probabilities of 
mortality are summed for the year to calculate the total number of expected deaths for the PICU.  
The risk-adjusted Standardised Mortality Ratio (SMR) is calculated as a ratio of the observed number 
of deaths to expected number of deaths. An SMR of 1 indicates expected performance, lower than 1 
better performance and greater than 1 worse performance.  As there is natural random variation in 
outcomes, statistical confidence limits (95% Confidence Intervals) are calculated to estimate the 
reliability of the SMR: if the intervals do include 1 the SMR is not considered statistically significantly 
different from 1. Note that mortality is measured for the year of admission: a child admitted in 2014 
who died in 2015 would be counted as a 2014 death for the purposes of calculating SMRs.  This does 
mean that the SMR for 2015 may not include children admitted in 2015 but who die in 2016 after the 
analysis has been carried out.  They would get picked up in subsequent years. 
PICANet recalibrates PIM2 each year to take into account changing patient case mix and 
improvements in survival.  To do this, the variables used in PIM2 were entered into a logistic 
regression model using current (2013-2015) data to provide revised PIM2 coefficients. For the 2016 
annual report this is denoted as pim2r2016. Earlier years have had a similar recalibration applied and 
use the same naming convention with just the year changing. 
We firstly calculated SMRs and associated funnel plots for the individual years 2013, 2014 and 2015. 
The methods of producing funnel plots and their interpretation are described in the outcomes section 
of the PICANet annual report. For 2015, the PICU at RMCH fell above the upper control limit of the 
funnel plot indicating significant excess mortality in this year.  

46 
PICANet:  2016 Summary Annual Report. 
To investigate the timing of the excess mortality we used an RSPRT (Risk-adjusted resetting 
probability ratio test) plot, a statistical graphical method of detecting outliers over time.  Between the 
orange ‘tramlines’ on the plot is a ‘safe zone’ with the variability you might expect day to day. 
Between the orange and red tramlines at the top of the plot can be regarded as a ‘warning zone’ for 
excess mortality; between the orange and red tramlines at the bottom of the plot performance is 
better than expected.  Until there is a death, the top line on the plot stays flat and the bottom line 
gradually drops. When a death occurs the top line moves up and the bottom line moves closer to 
zero. When either line touches the red tramline (at the bottom or the top), the graph resets to zero. 
This method showed four significant ‘spikes’ in mortality in 2015 in the upper zone that caused the 
plot to reset, an indicator of excess mortality at those time-points (see figure 19).  
 
Figure 19: RSPRT plot for RMCH PICU, 2013-2015 
 
An examination of the crude number of deaths in the three year reporting period revealed an 
increase in the percentage of deaths from 3.7% (24/648) in 2013 to 8.4% (56/664) in 2015 (see table 
10 below) 
Table 10: Number of admissions and vital status at discharge with predicted deaths based on 
pim2r2016 
Year 
Alive (%) 
Died (%) 
Total admissions 
Predicted deaths 
2013 
624 (96.3) 
24 (3.7) 
648 
30.0 
2014 
727 (94.3) 
44 (5.7) 
771 
31.6 
2015 
608 (91.6) 
56 (8.4) 
664 
25.5 
 

47 
PICANet:  2016 Summary Annual Report. 
 
Investigation into data quality and patient characteristics that may affect the SMR 
In accordance with the PICANet outlier policy, we investigated the elements of the mortality risk 
adjustment model (PIM2) for any unusual patterns in missing data or other changes in the frequency 
of the data items returned to PICANet. We also looked at the patient characteristics including 
ethnicity, age, sex and diagnostic group to determine if there were any substantial differences in 2015 
compared with other years. 
Our findings suggested little in the way of data-driven reasons for the increased mortality in 2015.  
There was an indication that diagnoses categorised as ‘low risk’ in PIM2 were not recorded in 2013 as 
the majority of these were returned as ‘other’. This may have reduced the overall SMR in 2013 but 
would have had no effect on the 2015 risk-adjusted mortality.  There was also a small reduction in the 
percentage of valid blood gases recorded in 2015 which may have contributed to an increase in SMR 
if valid values had been available but not recorded. 
We did identify a marked increase in the length of stay for those children who died in 2015 (see table 
11 below). This suggests that the characteristics of the children who died in 2015 were different to 
those who died in 2013 and 2014. It is not possible to ascertain what these differences are from the 
data available to PICANet. It does suggest closer scrutiny of their patient journey is warranted. 
Table 11: Length of stay in days for all admissions and non-survivors at RMCH PICU, 2013-2015 
Length of stay (days) 
2013 
2014 
2015 
All admissions 
 
 
 
Number 
648 
771 
664 
Mean 
6.30 
6.50 
6.65 
Min 
0.05 
0.02 
0.02 
Max 
203 
113 
187 
 
 
 
 
Non-survivors 
 
 
 
Number 
24 
44 
56 
Mean 
12.58 
10.86 
19.05 
Min 
0.24 
0.34 
0.16 
Max 
84 
113 
187 
 

48 
PICANet:  2016 Summary Annual Report. 
Results following dataset revision 
Re-analysis following data quality review by the PICU 
Following the initial report on an elevated SMR in 2015 for the PICU at RMCH, the PICU reviewed the 
data submitted for 297 out of 664 (45%) admission records (including all 54 deaths on the PICU) in 
2015, concentrating on those elements of the data that are used in the calculation of the mortality 
prediction model, PIM2.  The revised data was submitted to PICANet.  The final version of the PICANet 
annual report dataset was frozen on the 6th June 2016 and PIM2 was recalibrated using this final 
dataset. This is designated pim2r2016. This dataset included updated data from RMCH as well as from 
other units following validation and completeness queries. It ensures that our recalibration of PIM2 is 
based on the latest data for the reporting period. In this second analysis, we have used the final 
recalibrated version of pim2r2016 to look at both the initial data submitted to PICANet by RMCH as 
well as the revised data submitted after the initial report. 
The effect of recalibrating PIM2 using a more complete dataset 
Using the latest version of pim2r2016 that incorporates the updated dataset from 6th June, 2016, the 
expected number of deaths in 2015 from the initial dataset rose from 25.5 to 26.95 and the adjusted 
SMR decreased from 2.23 (95% CI 1.70,2.85) to 2.15 (95% CI 1.64, 2.75). This meant that our 
recalibration of PIM2 using additional and corrected data from all units including RMCH has resulted in 
a small decrease in SMR for RMCH based on their original data submission.  
The effect of review and correction of data submitted by RMCH PICU for children who died in 2015 
Following review, revised PIM2 data for 24 out of the 297 admission records reviewed were 
resubmitted to PICANet. Using the latest version of pim2r2016 and this revised data, the expected 
number of deaths increased from 25.5 in the original report to 29.45 resulting in an SMR of 1.92 (95% 
CI 1.46, 2.46). This meant that the recalibration of PIM2 combined with the changes to PIM2 data for 
those 297 admission records reviewed and resubmitted to PICANet, have resulted in increase in the 
expected number of deaths and decrease in the SMR. However, this decreased SMR still falls above the 
upper control limits. 
 
Conclusions 
The review of admissions records revealed a number of errors in the initial data submission.  
Correction of this data has resulted in 20 of those children having a higher expected probability of 
mortality.  As the SMR is calculated as the observed over the expected number of deaths this has 
resulted in a lower SMR.  This SMR still falls above the upper control limit and is therefore still 
regarded as an outlier.  
It should be noted that all admissions to PICU contribute to the expected number of deaths as each 
admission has some risk.  The PICU has reviewed data submitted for 45% of all admissions, a 
substantial amount of work.  It is still possible that there may have been only a partial correction of 
the overall expected probability of mortality and hence the calculated SMR, but this level of review is 
not conducted in most PICUs. It is also not possible to predict whether this would have a significant 
effect on the SMR. 

49 
PICANet:  2016 Summary Annual Report. 
The recalibration of PIM2 on a rolling 3 year basis is carried out to ensure that the model is based on 
the most recent data available. It does reveal a sensitivity of the model to changes in data that clearly 
have an effect on SMR.  This is not satisfactory and PICANet will investigate how mortality prediction 
can be improved. The newly established HQIP Methodology Advisory Group will be an ideal forum to 
debate this issue more widely and share experiences and expertise. 
Response from RMCH 
The outcome of the independent review of deaths on PICU is confidential to the RMCH but some of 
their comments have been included in the article below from Dr Stephen Playfor which details the 
RMCH PICU’s response to the process of outlier identification and reporting.  Dr Playfor notes that 
their internal review identified a significant number of children who had life-limiting syndromes or 
comorbidities that are not accounted for in PIM2 and this fact was picked up by the independent 
review panels.  For PICANet the potential failure of the mortality risk adjustment model used to 
monitor quality of care should be addressed urgently.  
PICANet report summaries and recommendations to RMCH PICU 
The summary and recommendations given below were contained in two reports sent to the PICU 
lead, Medical Director and Trust CEO. The first of these was sent on 3rd May 2016, the second on 4th 
July 2016.  These are reproduced in full here to allow readers a better understanding of the processes 
involved in dealing with an outlier. 
Summary from report dated 3rd May 2016 
 
Data submitted to PICANet for 2015 indicate that the risk-adjusted Standardised Mortality 
Ratio (SMR) for the Royal Manchester Children’s Hospital (RMCH) PICU falls outside the 
control limits of funnel plots designed to detect mortality outliers. 
 
The SMR was 2.23 (95% CI 1.7-2.85) in 2015 vs. 1.39 (95% CI 1.02-1.85) in 2014 and 0.81 (95% 
CI 0.52-1.19) in 2013. 
 
There were 56 deaths (8.4% of admissions) in 2015 compared to 24 (3.7%) in 2013 and 44 
(5.7%) in 2014. The overall crude in-PICU mortality rate for the UK and Ireland in the period 
2013-2015 was 3.8%. 
 
Further evidence of excess risk-adjusted mortality for 2015 has been confirmed by the use of 
resetting sequential probability ratio test (RSPRT) plots, a statistical graphical method of 
detecting outliers over time.  This method showed 4 significant ‘spikes’ in mortality in 2015 
that caused the plot to reset, an indicator of excess mortality at those time-points. 
 
In accordance with our policy on outliers, PICANet has investigated the nature of this elevated 
SMR in relation to data quality, demographics and case-mix using the standard PICANet 
dataset. 
 
There has been a small reduction in the percentage of valid blood gases recorded and an 
increase in the number of ‘low-risk’ reasons for admission used in the calculation of the 
mortality risk-adjustment model that may have had some minor effect of increasing the 
overall SMR if incorrect. 
 
Our investigations did not however, identify any marked data quality/data driven issues that 
may account for the magnitude of increase in the SMR. 

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PICANet:  2016 Summary Annual Report. 
 
We noted that the mean length of stay on PICU of those children who died was approximately 
65% higher in 2015 than 2013. Mean length of stay for survivors remained similar across the 
years.   
 
The increased length of stay of those children who died suggests that they were different in 
some way to the earlier cohorts. 
Recommendations from report dated 3rd May 2016 
1. A review of the variables that are used in the mortality risk adjustment model should be carried 
out by the PICU staff for all admissions in 2015, not just for children who died. 
2. Any revised data values should be uploaded to the PICANet database and a description of the 
reasons for any changes should be given for each data item for each patient. 
3. Following any revision of data, PICANet should re-run the analyses described in this report and 
send an updated report to RMCH. 
4. An independent review of the deaths that occurred in PICU in 2015 should be carried out by a 
suitable qualified PICU consultant. 
5. Any changes to the data notified to PICANet should be scrutinised and verified as correct by the 
same PICU consultant. 
6. The Clinical Lead at RMCH PICU should be given the opportunity to respond to the discovery of an 
outlier in their data in an article published in the PICANet Annual Report (due September 2016). 
7. If the outlier SMR persists after review and revision of the data, the RMCH, HQIP and the 
Universities of Leeds and Leicester should ensure that appropriate media releases are prepared in 
advance of the publication of the PICANet Annual Report with due regard to the sensitivity of this 
topic. 
 
Summary from report dated 4th July, 2016 
 
Initial data submitted to PICANet for 2015 indicated that the risk-adjusted Standardised 
Mortality Ratio (SMR) for the Royal Manchester Children’s Hospital (RMCH) PICU fell outside 
the control limits of funnel plots designed to detect mortality outliers. 
 
The SMR was 2.23 (95% CI 1.7-2.85) in 2015 vs. 1.39 (95% CI 1.02-1.85) in 2014 and 0.81 (95% 
CI 0.52-1.19) in 2013. 
 
The PICANet policy on outliers was followed and the PICU lead was informed of this finding.  
 
A report detailing our findings was sent to the PICU lead, Medical Director and Trust CEO on 
3rd May 2016 and was copied to HQIP, who manage the National Clinical Audit Outcome 
Programme. 
 
The PICU lead initiated a review of the data submitted to PICANet and clinical notes for 
297/664 (45%) admissions were examined, including all 54 deaths.  
 
An updated dataset with changes to 24 admission records (8% of those reviewed) was 
resubmitted for further analysis.  
 
An independent review of all deaths on the PICU in 2015 has been commissioned. 

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PICANet:  2016 Summary Annual Report. 
 
Out of the 24 resubmitted admission records, 4 had changes that reduced, and 20 had 
changes that increased, the expected probability of mortality. 
 
Reanalysis of the data included two elements: firstly, the mortality prediction model was 
recalibrated using a finalised dataset that included additional and validated data from all 
contributing PICUS and this was used to reanalyse the initial dataset submitted by RMCH; 
secondly, an analysis was performed on the updated data submitted by the RMCH after their 
review of 297 admissions records for 2015. 
 
Recalibration of the mortality prediction model using additional data resulted in a reduction 
in SMR from 2.23 to 2.15 but the PICU at RMCH remained an outlier, falling above the upper 
control limit of the funnel plot. 
 
Analysis of the updated data from RMCH produced an SMR of 1.92 (95% CI 1.46, 2.46) which, 
although lower, still remained above the upper control limit, indicating excess mortality 
persists in the data 
Recommendations from report dated 4th July 2016 
1. The RMCH should be given the opportunity to comment on and respond to the findings from 
PICANet, and this should be in the form of an article to be published in the PICANet Annual 
Report. 
2. The outcome of the independent review of deaths in the PICU at RMCH in 2015 should be used to 
provide the necessary context for interpreting the excess mortality indicated by the SMR outlier. 
3. A review of the suitability of the mortality prediction models used by PICANet to compare SMRs 
should be conducted in light of the sensitivity of the PIM2 model calibration to changes in the 
data and data quality. 
 

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PICANet:  2016 Summary Annual Report. 
DEALING WITH A MORTALITY OUTLIER – THE EXPERIENCE FROM ROYAL 
MANCHESTER CHILDREN’S HOSPITAL 
 
In April 2016 we were contacted by the Principal Investigator for the Paediatric Intensive Care Audit 
Network (PICANet) regarding the Standardised Mortality Ratio (SMR) for our unit in 2015. The data 
demonstrated a risk-adjusted SMR of 2.23, falling above the upper control limit in the 2015 funnel 
plot. The Paediatric Index of Mortality (PIM) scores predicted that we would see 26 deaths in 2015, 
whereas we actually saw 56; an ‘excess’ of 30 deaths. 
In keeping with standard procedures PICANet, as a member of the National Clinical Audit programme, 
made HQIP aware of our outlier status, who in turn informed the Deputy Chief Inspector of Hospitals. 
In response to the elevated SMR we initiated a review of the data submitted to PICANet and clinical 
notes for 297/664 (45%) admissions were examined, including all deaths. Recalibration of the 
mortality prediction model using additional corrected data resulted in a reduction in SMR from 2.23 
to 2.15 but we remained an outlier. 
An internal review of clinical records for all of the deaths was undertaken and an independent 
external panel was commissioned to review the data and provide a report. 
Prompt investigation of outlier status is important to ensure that high quality care is being delivered 
and throughout the process PICANet staff, and indeed all parties involved, were supportive and 
helpful. 
The internal review demonstrated patterns in the diagnoses and co-morbidities of the deaths which 
were unpredicted by PIM2; only 4 children could have been considered to have been well prior to 
PICU admission. A significant number of the children who died had suffered from life-limiting 
syndromes or co-morbidities which do not appear in the range of conditions which are recognised 
and ‘weighted’ in the PIM2 scoring system. As our independent external panel stated: 
‘the number of individuals admitted with any specific condition may be so small that each individual 
diagnosis cannot be included within the risk adjustment, but for any PICU admitting a larger 
proportion of patients with a range of life-limiting conditions as part of its case-mix, there may be an 
unfavourable effect on the risk-adjusted SMR’. 
As with most other PICUs we have seen an increase in the proportion of children admitted with 
complex chronic conditions; in several cases in 2015 life-sustaining therapies were withdrawn or 
withheld with the agreement of families following admission to PICU when this was thought to be in 
the child’s best interests. In these circumstances the degree of physiological derangement on 
admission often did not reflect the outcome. 
The report of the independent external panel did not identify any specific breaches in the standard of 
care delivered in PICU, but did recommend a more detailed evaluation of the PICU care delivered to 
one child who died there. The report made several valuable observations regarding the delivery of 
care prior to admission to PICU and related to the organisational processes which occur following the 
death of a child. 
 

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PICANet:  2016 Summary Annual Report. 
The National Clinical Audit Advisory Group has stated that performance indicators must provide a 
valid measure of a provider’s quality of care in that there is a clear relationship between the indicator 
and quality of care. It may be that the SMR can no longer be relied upon as a valid measure of a 
PICU’s quality of care given the changing population of critically ill children who we care for. As our 
patient population has evolved so our performance indicators must evolve to account for factors 
other than physiological derangement and a small number of pre-defined co-morbidities apparent at 
the time of admission. 
It has previously been suggested that there may be more valid indicators of quality of care than 
mortality given that more than 95% of children are discharged alive from PICU. In the future it may be 
that composite performance indicators which include both SMR and an assessment of clinical 
incidents such as drug errors, hospital-acquired infections and inadvertent extubations may provide a 
more valid indication of the overwhelmingly high quality care that is delivered in UK PICUs. 
 
Stephen Playfor, Consultant Paediatric Intensivist, PICU, Royal Manchester Children’s Hospital. 
 

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PICANet:  2016 Summary Annual Report. 
NEW DEVELOPMENTS & FUTURE WORK 
 
Updating and improving the data collected 
The information PICANet collects has changed over time and updates are needed to collect the most 
relevant information to patient care.  
One recent change has been to collect more information on ventilation of children in intensive care: 
 
High flow oxygen is now being used with increasing frequency in PICU but little is known 
about actual flow rates and how it is used in practice. Changes to the PICANet admission 
dataset allows recording of maximum daily flow in l/min to provide the necessary benchmark 
data to inform the use of this new technology. This will be reported in our next annual report. 
 
In August 2014 the PICANet dataset was updated allowing the collection of a new outcome: 
unplanned extubation to support the collection of Data Dashboard item PIC08. 
 
 
Customised data collection 
In the last twelve months customised data collection has been developed by PICANet and this is 
currently being utilised by two audit projects: 
PICANet renal replacement therapy audit  
A customised data collection tool is being piloted for a new renal replacement therapy dataset 
relating to paediatric patients who receive Continuous Renal Replacement Therapy (CRRT) in PICUs in 
the UK and Ireland. Clinical support for this audit is being provided by Dr Claire Westrope (Consultant 
PICU/ECMO, University Hospitals of Leicester NHS Trust) and the Paediatric Intensive Care Society 
Study Group (PICS SG) Renal Group. While it is clear that the use of CRRT in critically ill children is 
increasing, very little is known about outcomes, modality, timing of initiation and a host of other 
parameters. This pilot audit will provide baseline information on current practice that has not been 
available up until now. 
 
Supporting the development of new and updated standards  
The Paediatric Intensive Care Society is currently updating their Standards to ensure they are relevant 
and up to date; PICANet has collaborated in the development of updated PICS standards. 
Through the NHS England Clinical Reference Group PICANet is involved in the refinement of the Data 
Dashboard (http://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-e/e07/). Online 
reporting is being developed for units to allow them to be able to report as many dashboard items as 
possible from the PICANet dataset, including the referral and transport data.  Additional data items 
are being gathered and new methods of displaying the metrics are being developed to support units 
and make sure the latest figures are available to be reported to commissioners. We have now added a 
new table to the annual report to quantify the timely completeness of data submitted to PICANet 
which is required for both PICS Standard 181 (Table 1) and Data Dashboard item PIC10 (Table 2). 

55 
PICANet:  2016 Summary Annual Report. 
 
Providing units with reporting tools to improve access to information and reporting of activity 
PICANet provides reporting tools to PICUs so they can access their data and create online reports, this 
helps them measure the levels of care they are delivering and identify areas where additional capacity 
might be needed as well as carry out routine reporting on a day to day basis. This information can be 
used to report PICU activity to others including hospital managers, commissioning groups and other 
stakeholders. Ongoing work is being carried out to extend the available reports and provide additional 
reports for the referral and transport datasets. 
 
References 
 
1. 
Paediatric Intensive Care Society. Standards for the Care of Critically Ill Children.  2010  [cited 
24/06/2014 ]; Available from: www.ukpics.org.uk/documents/PICS_standards.pdf 
2. 
NHS Commissioning. Paediatric Intensive Care (PICU). Specialised Services Quality Dashboards  2014  
[cited 24/06/2015 ]; Available from: http://www.england.nhs.uk/commissioning/wp-
content/uploads/sites/12/2015/04/picu-def-15-16.pdf 
3. 
NHS England. Service Specification E07/S/a Paediatric Critical Care Level 3. [cited 10/10/2015]; 
Available from: http://www.england.nhs.uk/commissioning/wp-
content/uploads/sites/12/2015/01/e07-sa-paed-inten-care.pdf 
4. 
Shann, F., et al., Paediatric index of mortality (PIM): a mortality prediction model for children in 
intensive care. Intensive Care Med, 1997. 23(2): p. 201-7. 
5. 
Slater, A., F. Shann, and G. Pearson, PIM2: a revised version of the Paediatric Index of Mortality. 
Intensive Care Med, 2003. 29(2): p. 278-85. 
6. 
Straney, L., et al., Paediatric index of mortality 3: an updated model for predicting mortality in 
paediatric intensive care. Pediatr Crit Care Med, 2013. 14(7): p. 673-81. 
7. 
Health and Social Care Information Centre. Introduction to Healthcare Resource Groups.  2015  [cited 
2015, 8th July]; Available from: http://www.hscic.gov.uk/hrg 
8. 
Health and Social Care Information Centre. HRG4+ Summary of Changes: HRG4+ 2012/13 Reference 
Costs Grouper from HRG4 2011/12 Reference Costs Grouper.  2015  [cited 2015, 8th July]. 
9. 
The King’s Fund. Workforce planning in the NHS, 2015.[cited 2015, 5th October]; available from 
http://www.kingsfund.org.uk/publications/workforce-planning-nhs. 
10. 
Royal College of Nursing. Frontline First 2015 [cited 2015, 5th October]; available from 
http://frontlinefirst.rcn.org.uk/ 
11. 
A background report on nurse staffing in children’s and young people’s health care: A review and 
analysis of the evidence, commissioned by the Royal College of Nursing. 2012. Available from 
https://www.rcn.org.uk/__data/assets/pdf_file/0007/527272/004369.pdf 

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PICANet:  2016 Summary Annual Report. 
INVITED PAPERS 
 
This year we have concentrated on the role that PICANet has played in supporting clinical trials to 
drive improvement in the quality of care delivered by the paediatric intensive care service. 
The invited articles that follow include a trial that has been successfully completed as well as those 
that have been funded and are in the start-up phase  
We are very grateful to the authors for their contributions. 

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PICANet:  2016 Summary Annual Report. 
GENERALISING THE FINDINGS FROM THE CATCH TRIAL (CATHETER 
INFECTIONS IN CHILDREN) TO PAEDIATRIC INTENSIVE CARE ACROSS THE 
NHS: THE VALUE OF LINKING PICANET AND INFECTION SURVEILLANCE 
DATA. 
 
The CATCH trial was a 3-arm trial in which children receiving intensive care who required a central 
venous catheter (CVC) were randomised to antibiotic (minocycline and rifampicin) impregnated, 
heparin bonded, and standard CVCs [1, 2]. The primary outcome was time to bloodstream infection 
(BSI). 1485 children treated in 14 PICUs across England between 2010 and 2012 were included in the 
analyses. Results published earlier this year reported that BSI was recorded for 42 children, with 
higher rates in the standard group 18/502 (3.59%) and heparin group 17/497 (3.42%) than the 
antibiotic group 7/486 (1.44%).[1, 2] There was no significant difference in the primary outcome of 
time to first BSI comparing any impregnated CVC with the standard CVC [hazard ratio (HR) 0.71, 95% 
confidence interval (CI) 0.37 to 1.34; p = 0.29]. However, BSI risk was reduced for antibiotic compared 
with standard CVCs (HR 0.43, 95% CI 0.20 to 0.96; p = 0.04) and for antibiotic compared with heparin 
CVCs (HR 0.42, 95% CI 0.19 to 0.93; p = 0.03) but not for heparin compared with standard CVCs (HR 
1.04, 95% CI 0.53 to 2.03; p = 0.90). The risk difference in BSI comparing antibiotic versus standard 
CVCs was –2.15% (95% CI –4.09% to –0.20%). The number needed to treat with antibiotic instead of 
standard CVC to avoid one additional BSI was 47. There were no differences in the risks of adverse 
events, including antibiotic resistance [1-3]. 
CATCH was a large, pragmatic randomised trial designed to inform practice across the NHS. Before 
considering whether to adopt antibiotic CVCs, clinicians need to know i) whether this clinically 
effective intervention is also cost effective, and ii) the cost impact  of bulk purchasing antibiotic CVCs 
for all children who need a CVC in their paediatric intensive care unit (PICU). Antibiotic CVCs cost 
twice as much as standard CVCs but managing BSI in PICU is also extremely costly. The cost 
effectiveness analysis compared costs of care and outcomes in the three trial arms and showed no 
overall difference in cost at 6 months after randomisation (the primary analysis). However, sensitivity 
analyses showed that antibiotic CVCs were cost saving up to 120 days after randomisation [1]. 
We used PICANet data linked to national BSI surveillance data to help us determine the 
generalisability and cost impact of the trial findings across all PICUs in the NHS. Prior to the CATCH 
trial, standard CVCs were used for the majority of children in UK PICUs [4]. We reasoned that if 
antibiotic-impregnated CVCs were adopted for children, it is likely that they would be bulk-purchased 
and used for all children requiring CVCs in PICU, not just children like those in the trial. Decisions on 
whether to purchase antibiotic impregnated CVCs therefore need to take into account the absolute 
rate of BSI for all children requiring CVCs across all PICUs and how much this rate would be reduced 
by adopting antibiotic CVCs. We estimated BSI rates using standard CVCs through linkage of national 
PICANet data with laboratory surveillance data for England and Wales, held by Public Health England. 
We also surveyed PICUs to determine the type of CVCs used in routine practice [4-6]. We reported 
declining trends in BSI rates across PICUs [5, 7], and used local audit data to estimate the proportion 
of children requiring CVCs, as this variable is not yet collected in PICANet data [8]. We estimated that 
the additional cost of purchasing antibiotic CVCs would be less than the costs of managing BSI with 

58 
PICANet:  2016 Summary Annual Report. 
standard CVCs for PICUs with BSI rates above 1.2 per 1000 CVC-days [1, 8]. This cut-off is much lower 
than the estimated average for PICUs using standard CVCs of 4.6/1000 CVC days. The results from the 
CATCH trial on the effectiveness, cost effectiveness and cost impact of antibiotic versus standard CVCs 
are consistent with trials in adults [9, 10].  
 
CATCH was the first trial in the UK to use deferred consent for children [11]. Two-thirds of 
randomised patients were recruited during emergency insertion of a CVC, usually as part of 
resuscitation. The type of CVC was randomised at the bedside and parents were approached after 
CVC insertion for consent to have data collected for the trial. A qualitative study showed that once the 
trial was explained, parents were content with the use of deferred consent [12]. However, obtaining 
consent from parents after a child died was challenging, and resulted in under recruitment of children 
who died [11]. We therefore recommend that in future low-risk intervention trials using deferred 
consent, ethics committees should waive the need for consent after a patient dies provided 
reasonable efforts have been made to obtain consent [11].   
 
The CATCH trial was funded by the NIHR (project number 08/13/47). 
 
References 
 
4. Harron K, Mok Q, Dwan K, Ridyard CH, Moitt T, Millar M, et al. CATheter Infections in CHildren (CATCH): a 
randomised controlled trial and. Health Technol Assess. 2016;20(18):1-219. 
5. Gilbert RE, Mok Q, Dwan K, Harron K, Moitt T, Millar M, et al. Impregnated central venous catheters for 
prevention of bloodstream infection in. Lancet. 2016;387(10029):1732-42. 
6. Millar M, Mok Q, Harron K, Gilbert R. Antibiotic resistance: Authors' response. Lancet. 2016;(in press). 
7. Harron K, Ramachandra G, Mok Q, Gilbert R. Consistency between guidelines and reported practice for 
reducing the risk of. Intensive Care Med. 2011;37(10):xx-xxxx-xxxx. 
8. Harron K, Wade A, Muller-Pebody B, Goldstein H, Parslow R, Gray J, et al. Risk-adjusted monitoring of 
blood-stream infection in paediatric intensive care: a data linkage study. Intens Care Med. 2013;39(6):1080-
7. 
9. Harron K, Goldstein H, Wade A, Muller-Pebody B, Parslow R, Gilbert R. Linkage, evaluation and analysis of 
national electronic healthcare data: application to providing enhanced blood-stream infection surveillance 
in paediatric intensive care. PLoS One. 2013;8(12):e85278. 
10. Harron K, Parslow R, Mok Q, Tibby SM, Wade A, Muller-Pebody B, et al. Monitoring quality of care through 
linkage of administrative data: national. Crit Care Med. 2015;43(5):1070-8. 
11. Harron K, Mok Q, Hughes D, Muller-Pebody B, Parslow R, Ramnarayan P, et al. Generalisability and Cost-
Impact of Antibiotic-Impregnated Central Venous. PLoS One. 2016;11(3):0151348. 
12. Hockenhull JC, Dwan K, Boland A, Smith G, Bagust A, Dundar Y, et al. The clinical effectiveness and cost-
effectiveness of central venous catheters treated with anti-infective agents in preventing bloodstream 
infections: a systematic review and economic evaluation. Health Technol Assess. 2008;12(12):iii-iv, xi-xii, 1-
154. 
13. Wang H, Huang T, Jing J, Jin J, Wang P, Yang M, et al. Effectiveness of different central venous catheters for 
catheter-related infections: a network meta-analysis. J Hosp Infect. 2010;76(1):1-11. 

59 
PICANet:  2016 Summary Annual Report. 
14. Harron K, Woolfall K, Dwan K, Gamble C, Mok Q, Ramnarayan P, et al. Deferred consent for randomized 
controlled trials in emergency care settings Pediatrics. 2015;136(5):e1316-22. 
15. Woolfall K, Frith L, Gamble C, Gilbert R, Mok Q, Young B. How parents and practitioners experience 
research without prior consent (deferred consent) for emergency research involving children with life 
threatening conditions: a mixed method study. BMJ Open. 2015;5(9):xx-xxxx-xxxx. 
CONTRIBUTION FROM: 
 
Ruth Gilbert and Katie Harron 
UCL Institute of Child Health 

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PICANet:  2016 Summary Annual Report. 
I-KID STUDY: EVALUATION OF EFFICACY, OUTCOMES & SAFETY OF A NEW 
INFANT HAEMODIALYSIS AND ULTRAFILTRATION MACHINE IN CLINICAL USE 
 
Background 
There is a need for improved technology to provide renal replacement therapy (RRT) effectively and 
safely for small babies. Two main groups of babies are currently treated with RRT. Firstly those with 
intrinsic renal disease, which is often congenital, who are normally treated with peritoneal dialysis 
(PD), which frequently works well in the chronic situation. However some babies fail treatment with 
PD because of problems like catheter leakage, peritonitis; or cannot be treated with PD because of 
abdominal wall problems like gastroschisis or abdominal surgery. Alternative options for treating very 
small babies with standard intermittent haemodialysis are limited.  
The other group needing RRT are sick infants in paediatric intensive care units (PICU). Most of these 
babies do not have intrinsic renal disease and therefore have good potential for renal recovery, 
however they are reported to have higher mortality, longer length of stay and although most 
survivors are independent of RRT at discharge from PICU up to 30% may have long term renal 
sequelae. Babies treated with continuous RRT in PICU include i) those who have multisystem disease 
which includes acute kidney injury – for example babies with severe sepsis, ii) post operative babies – 
especially after cardiac surgery whose major problem is fluid overload and poor urine output and iii) 
babies with an inborn error of metabolism for example urea cycle defects causing 
hyperammonaemia. In these three groups of patients mortality and morbidity are different and 
related to the underlying diagnosis. PD often used in smaller babies in PICU but problems with 
catheter malfunction, leakage, infection (peritonitis) may limit its use. PD is often poorly effective in 
fluid removal and it is very poor at clearing toxic metabolites in babies with inborn errors of 
metabolism.  
Conventional haemofiltration (CVVH) machines are not licensed for use in babies 
weighing <8 kg because their technology for controlling ultrafiltration is inherently 
imprecise and presents a relatively large potential error with risk of dehydration or 
fluid overload for small babies. For small babies under 5kg, the large CVVH circuit 
volume exceeds the 10-15% of total blood volume removal considered safe and 
therefore the circuit is frequently primed with blood, or the infant has a 
simultaneous blood transfusion. The circuits may clot early when CVVH is used for 
the smallest babies related to poor blood flow. Hypotension requiring intervention is 
quite commonly reported on starting CVVH. However because of lack of alternatives 
the machines, designed for adults and older children, are frequently used outside 
recommendations. Recurrent themes emerge from published case series of babies 
who received RRT in PICU, indicating similar problems faced by clinicians world-wide 
and proposing the need to provide solutions. The need to improve technology has 
been recognised as an important target by research groups in Europe and the US. From PICANet 
reports we know that in UK PICUs approximately 300 infants under 8kg receive RRT each year split 
approximately equally between peritoneal dialysis (PD) and continuous haemofiltration (CVVH). 
 

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PICANet:  2016 Summary Annual Report. 
Nidus 
The Newcastle infant dialysis and ultrafiltration system (Nidus) is a new device developed within the 
NHS. It is the first device designed for babies 0.8 to 8kg, and has been shown to be efficacious in a 
pilot study in the development centre. Further data on efficacy and safety in clinical use outside the 
development centre are urgently needed. 
I-KID study 
The aim of the I-KID study is to compare Nidus with conventional RRT in PICU. The study is a 
randomised, stepped wedge cluster design: a one-way cross over with each unit acting as their own 
control. This was chosen over individual patient randomisation because of the strong views of 
parents, public and professionals regarding feasibility. Factors taken into account included 
recruitment, equipoise, ethics, training and safety in this specific urgent PICU situation with 
vulnerable patients. Parent and public involvement has been high from the early stages of the study 
design. The study population is babies under 8kg needing continuous RRT for renal impairment or 
fluid overload in PICU.  
The study intervention is Nidus, compared to current RRT either PD or 
CVVH (control). The primary outcome is precision of fluid removal. 
Secondary outcomes include survival, ventilator-free days, renal 
recovery, biochemical clearances, haemodynamic status (drop in BP 
requiring intervention) and adverse events such as transfusions, 
unplanned loss of circuits and access line changes. Views of staff on 
acceptability and usability and experience of parents will be sought by 
questionnaire and a safety profile of the Nidus will be produced. 
Assessments include accurate fluid measurements, routine biochemical 
analyses and clinical observations. In a 24 month recruitment period, we plan to recruit 100 babies 
from 5 UK centres. For the study duration and for 1 year post study, Nidus will be loaned by the 
manufacturers Allmed Group and consumables cost is comparable to current therapies.  
This study is designed to determine the clinical efficacy and feasibility of the novel infant 
haemodialysis machine, Nidus, compared to currently available therapy. Because Nidus is specifically 
designed for use in small babies (0.8 - 8kg), we predict using it may avoid many of the adverse effects 
associated with current therapy. Nidus offers the possibility of RRT for the smallest babies when 
peritoneal dialysis is not possible or is inadequate. Nidus is not simply a miniaturisation of existing 
machine systems but uses novel technology and an entirely different pump method which allows 
greater precision, a smaller circuit which avoids blood priming and smaller access lines.  
The proposed study, driven by clinical need and with considerable input from parents, has been 
developed by collaboration between front line clinicians, scientists, academics and manufacturers. 
The proposed study demonstrates a collaborative and committed UK effort to determine whether 
Nidus offers a significant improvement over conventional RRTs for babies in PICU.  
There is, however, sufficient evidence from the pilot study to anticipate Nidus has the potential to 
contribute significant benefits to the health of small babies needing RRT in the short and long term. 
Increasing success and breakthroughs in neonatal surgery including cardiac, will continue to produce 
a need for safe and effective post-operative management of fluid overload, acidosis and biochemical 
disturbance. The results will be applicable not just in the UK but worldwide and changes in clinical 
practice could take place rapidly. The study is due to start recruiting later in 2016, once the regulatory 
process of CE marking the Nidus device (currently underway) is complete. The I-Kid Study would not 

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PICANet:  2016 Summary Annual Report. 
have been possible to develop without the data provided by PICANet. Close collaboration with 
PICANet staff has been invaluable to all aspects of study design and will continue to be for the 
duration of the study 
 
CONTRIBUTION FROM: 
Heather Lambert 
Consultant Paediatric Nephrologist, Newcastle Hospitals NHS Trust. 

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PICANet:  2016 Summary Annual Report. 
THE SANDWICH TRIAL (SEDATION AND WEANING IN CHILDREN): WHAT 
IS IT ABOUT AND WHAT ARE THE POTENTIAL IMPLICATIONS FOR CARE IN THE 
PICU? 
Background 
Currently there is no UK consensus on weaning from invasive mechanical ventilation (IMV) in PICUs. 
Weaning from ventilation is a complex process involving a number of stages: recognition that the 
child is ready to begin the weaning process; steps to reduce ventilation while optimising sedation in 
order not to induce distress; and removing the endotracheal tube [1]. Delay at any stage can prolong 
the duration of IMV, therefore an intervention targeted at assisting clinicians to safely expedite this 
process will minimise the risks associated with IMV. The judgement and experience of clinicians is 
critical in guiding weaning from ventilation, however, as data from our feasibility study on paediatric 
usual practice show, there is wide variation both in sedation and ventilator weaning practices and 
junior staff are rarely involved in the process [2]. Various ICU studies have reported associations 
between rates of high inter-professional collaboration and patient mortality [3, 4]; and improved 
clinician-to-clinician communication with reductions in ICU length of stay [5]. A team-led approach 
that maximises engagement of all staff in early recognition of readiness and preparation for weaning 
ventilation could potentially reduce duration of IMV and PICU length of stay and relieve pressures for 
beds. As 67% of nurses employed in UK PICUs are Band 5 (junior) nurses, this would greatly maximise 
nursing contribution to the weaning process PICANet [6]. Our feasibility study findings yielded very 
few policies that specifically addressed sedation and weaning guidelines and staff interviews 
confirmed that a strategy for weaning sedation and ventilation was an important priority in most 
PICUs [2]. Staff also disclosed continuing uncertainty about readiness to wean, the benefits of an 
extubation readiness test and its potential impact on duration of IMV in the UK. Importantly the 
overwhelming majority of PICUs (83%) were willing to take part in a trial that tested an intervention to 
address these issues. 
Aims 
The SANDWICH trial will evaluate a coordinated approach using guidelines with greater involvement 
of nurses in weaning children from the ventilator. The trial will determine if this intervention:  
(1) 
reduces duration of time spent on the ventilator;  
(2) 
reduces length of stay in the PICU and the hospital;  
(3) 
does not cause additional harm;  
(4) 
is cost effective in the NHS;  
(5) 
is acceptable to staff delivering care and can be sustained. 
METHODs 
The intervention will involve greater collaboration among doctors and nurses in coordinating patient-
relevant sedation plans linked to regular assessment using the COMFORT sedation tool; regular daily 
assessment of ventilation parameters; and a spontaneous breathing trial when extubation readiness 

64 
PICANet:  2016 Summary Annual Report. 
criteria are met. This will be a multicentre stepped wedge trial cluster randomised trial conducted in 
at least 15 PICUs over a period of 20 months.  The trial will begin in all PICUs at the same time when 
data will be collected while usual practice is conducted. The intervention will commence, following a 
training period, in one PICU each month with the order of commencement determined by computer 
randomisation. The stepped wedge design allows delivery of the intervention at an organisational 
level with evaluation of outcome measures at a patient level.  One of the main strengths of the 
stepped wedge design is that we can offer the intervention to every PICU that takes part. 
Alongside the trial, we will explore the process of delivering the intervention to answer the question 
‘does it work?’ in a way that will help us distinguish between intervention failure and implementation 
failure. Additionally, this evaluation will deliver important evidence concerning the barriers and 
facilitators to adoption. This can not only help to explain trial outcomes, but also determine factors 
requiring attention if, post-trial, the intervention is to be further disseminated to other PICUs and 
sustained in practice. 
Potential implications 
This is an intervention that engages front line staff to maximise ward round opportunities to improve 
outcomes. It offers potential for greater engagement of the nursing workforce at all stages in the 
weaning process with a focus on optimal sedation to assist weaning and extubation.   The trial has the 
capacity to generate new knowledge on the intervention, its cost - effectiveness and the 
implementation process. First, it will be large enough to provide reliable evidence for or against a 
combined ventilator/sedation weaning protocol allowing clear, strong recommendations to be made 
on the use of this potentially low cost intervention. Second, it will determine the main organisational 
and process factors considered important for ensuring the intervention is optimally implemented in 
PICUs.   
References 
1. Blackwood B, Murray M, Chisakuta A, Cardwell CR, O'Halloran P. Protocolized versus non-protocolized 
weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients. 
Cochrane Database Syst Rev 2013; 7: Cd009082. 
2. Blackwood B, Tume L. The implausibility of 'usual care' in an open system: sedation and weaning practices 
in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK). Trials 2015; 16: 325. 
3. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major 
medical centres. Annals of Internal Medicine 1986; 104: 410-418. 
4. Wheelan S, Burchill C, Tilin F. The link between teamwork and patients' outcomes in intensive care units. 
Am J Crit Care 2003; 12: 527-534. 
5. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, 
Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the 
ICU. The New England journal of medicine 2006; 355: 2725-2732. 
6. PICANet. 2015  Annual  Report (published November 2015). 2015 [cited 2016 24 January]. Available from: 
http://www.picanet.org.uk/Audit/Annual-Reporting/PICANet_2015_Annual_Report_Summary.pdf. 
CONTRIBUTION FROM: 
Bronagh Blackwood 
Chief Investigator of the SANDWICH trial and Senior Lecturer at the Centre for Experimental 
Medicine, Queen’s University Belfast, Northern Ireland 

65 
PICANet:  2016 Summary Annual Report. 
FEVER:  A FEASIBILITY STUDY OF A FORMAL RANDOMISED TRIAL OF A 
MORE LIBERAL APPROACH TO FEVER IN CRITICALLY ILL CHILDREN WITH 
SUSPECTED INFECTION 
 
Fever has survived billions of years of evolution as accelerant of the immune response. Even plants 
raise their temperature during an infection. All warm-blooded animals raise a ‘central thermostat’ (a 
hypothalamic set-point) in response to infection. The resultant fever is currently often viewed as an 
unwanted by-product of increased metabolic activity involved in fighting an infection.  This, at least 
the pre-antibiotic era, was incorrect; fever itself increased the chance of clearing an infection.  
Thomas Sydenham called fever ‘Nature’s Engine; which she brings to the battlefield’. 
The power of fever is illustrated by classic studies in the 1970’s. Kluger and colleagues showed that 
the desert iguana (Dipsosaurus dorsalis) preferentially sits in the sun when infected; and if this 
environmental warming is not available, the iguanas die. 
In humans understanding of the curative potential of fever has waxed and waned. In 1927 Julius 
Wagner-Juaregg won the Nobel Prize for curing neurosyphilis by inoculating patients with malaria to 
induce a fever.  The advent of antibiotics (and his Nazi sympathies) mean that this insight was rapidly 
forgotten. Observational evidence support a benefit of fever in humans: antipyretics increase the 
length of virus shedding in chicken pox, rhinovirus and the parasite load in malaria. Despite this, and 
no evidence to support the treatment of fever, anti-pyretics are used routinely in children and adults. 
What of critically ill patients? Fever requires an increase in metabolism (approximately 10-12% for 
each degree centigrade rise), causes an increase in heart rate, and may affect blood pressure. These 
physiological changes may be detrimental in critical illness. A large-scale observational study of over 
600000 adults suggested that patients with a maximum temperature of 38.5-39.5oC on the first day of 
admission had the lowest adjusted odds of death. In particular, this was evident in patients with 
infection. This finding prompted the HEAT trial: the largest randomised controlled trial of treatment of 
fever with paracetamol in ICU patients to date. The results showed no difference in ICU length of stay 
or mortality. However three important points need to be borne in mind when interpreting the trial 
results: (a) the trial protocol allowed paracetamol use after the initial resolution of fever: 
consequently a third of patients in both paracetamol and placebo arms received paracetamol, (b) 
prospective consent was mostly required, which meant that on average patients were enrolled 32 
hours after admission to ICU, and (c) there was a no significant difference in temperature in the 
paracetamol and placebo arms (there was mean drop in temperature was 0.29oC with paracetamol 
and 0.28oC with placebo). 
What about children in PICU? In 2012 a Paediatric Intensive Care Society Study Group (PICS-SG) 
prioritisation exercise identified the need to answer the question ‘Should fever be treated on PICU?’ A 
survey of 462 members of PICS suggested there was equipoise to conduct this trial in UK PICUs. There 
is no consensus threshold for the treatment of fever. This has led to the design and planning of a trial 
from PICS-SG with PICANet as essential co-investigators. The National Institute of Heath Research 
Health Technology Assessment has recently confirmed support for FEVER:  a feasibility study of a 

66 
PICANet:  2016 Summary Annual Report. 
formal randomised trial of a more liberal approach to fever (compared to our current aggressive 
approach to fever control) in critical-ill children with suspected infection.   
FEVER consists of  
(a) Qualitative work with parents and guardians and healthcare workers to assess the acceptability of 
the trial design and the proposed interventions 
(b) Observational work to better understand the current treatment and impact of fever treatment, 
and 
(c) A 125 patient multiple centre pilot trial to assess trial design, inform on suitable outcomes, power 
calculations and clinician acceptability. 
 
This now sets us on the exciting journey towards a definitive answer to the question ‘Should we treat 
children with fever in PICU?’   
 
Gratifyingly, this study is only one of a number of peer-reviewed and funded ambitious interventional 
studies led by members of PICS-SG.   These include: Fluids in Shock (FiSh), Sedation and Weaning in 
Children (SANDWiCh), a novel infant dialysis system (I-KID) and Oxygenation Targets in ventilated 
children (Oxy-PICU). Much of this recent success arises from PICANet’s contribution by providing high 
quality baseline data demonstrating both need and feasibility. This dawning era of generating 
evidence puts the UK in the forefront of research in PIC worldwide.  We look forward to the data…. 
 
CONTRIBUTION FROM: 
Samiran Ray and Mark Peters 
Great Ormond Street Hospital for Children NHS Foundation Trust 

67 
PICANet:  2016 Summary Annual Report. 
GLOSSARY 
 
A 
 
 
 
APP  
Advanced Practice Practitioner 
 
AR 
Annual Report 
B 
 
 
 
BSI 
Blood Stream Infection 
C 
 
 
 
CAG 
Clinical Advisory Group 
 
Cardiovascular 
Relating to, or involving the heart and the blood vessels 
 
Cardiac Arrest 
A cardiac arrest happens when your heart stops pumping blood around 
the body due to failure of the heart to contract effectively. If you have a 
cardiac arrest, you lose consciousness almost at once. A cardiac arrest is 
different from a heart attack, where blood flow to the muscle of the 
heart is impaired 
 
Case Mix 
The term case mix refers to the type or mix of patients treated by a 
hospital 
 
Clinical Trial 
Clinical trials are research studies that compare different treatments and 
treatment strategies 
 
CTS 
Centralised Transport Service 
D 
 
 
 
Data Validation 
The process of ensuring the quality and reliability of data for a study or 
audit by checking against dataset rules and definitions 
 
Dataset 
A set of standardised data fields collected for an audit or trial, allowing 
comparisons between sites to be made 
 
DGH 
District General Hospital 
 
DH 
Department of Health 
E 
 
 
 
EMR 
Electronic Medical Record 
 
Event 
A single instance of paediatric intensive care (PIC) activity, such as a 
referral, transport or admission 
F 
 
 
 
Funnel plots 
Scatterplots of an outcome ratio (observed outcome divided by predicted 
outcome) against the number of eligible individuals. Used when 
observations for different critical care units/hospitals are based on 
varying sample sizes 
H 
 
 
 
Health Organisation Any unit or transport service involved in the provision of paediatric 
intensive care 

68 
PICANet:  2016 Summary Annual Report. 
 
HFNCT 
High Flow Nasal Cannula Therapy 
 
HQIP 
Healthcare Quality Improvement Partnership 
 
HRG 
Healthcare Resource Group 
 
HSCIC 
Health & Social Care Information Centre 
 
Hyperglycaemia 
The presence of an abnormally high concentration of glucose in the 
blood 
I 
 
 
 
ICNARC 
Intensive Care National Audit & Research Centre 
 
IV 
Invasive ventilation 
L 
 
 
 
LOS 
Length of stay 
M 
 
 
 
Mean 
The ‘average’ value (obtained by summing all values and dividing by the 
number of values) 
 
Median 
The middle number in a given sequence of numbers 
 
Mortality 
Death rate 
 
Musculoskeletal 
Relating to or involving the muscles and the skeleton 
N 
 
 
 
NHS 
National Health Service 
 
NIHR 
National Institute for Health Research 
 
NOCA 
National Office of Clinical Audit Ireland 
O 
 
 
 
Outcome 
Outcomes are measures of health, e.g. response to treatment, 
occurrence or recurrence of disease, a measure of well-being 
P 
 
 
 
Patient identifiable 
data 
Patient identifiable data, such as NHS Number, are confidential. 
 
PbR 
Payment by Results 
 
PCCMDS 
Paediatric Critical Care Minimum Data Set 
 
PICANet 
Paediatric Intensive Care Audit Network 
 
PICS 
Paediatric Intensive Care Society 
 
PICU 
Paediatric Intensive Care Unit 
 
PIM 
Paediatric Index of Mortality 
 
Poisson distribution 
Probability distribution that characterises discrete events occurring 
independently of one another in time 
 
Principal 
Investigator 
The lead person at a single site designated as taking responsibility within 
the research team for the conduct of the study 
 

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PICANet:  2016 Summary Annual Report. 
R 
 
 
 
RCT 
Randomised Controlled Trial 
 
Respiratory 
Of, relating to, used in, or affecting respiration 
S 
 
 
 
Sepsis 
The poisoned condition resulting from the presence of pathogens or their 
toxins 
 
SG 
Steering Group 
 
SMR 
Standardised Mortality Ratio 
 
Status Epilepticus 
A condition in which repeated epileptic seizures occur without the 
patient gaining consciousness between them 
T 
 
 
 
TBI 
Traumatic Brain Injury 
W 
 
 
 
WTE 
Whole Time Equivalent 
 
 
 

 
 
 
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