Summary Report
Source: data.gov.uk (2022-01-27)

PICANet Annual Report 2018-2020. Paediatric Intensive Care Audit - This data contains information on all admissions to Paediatric Intensive Care units in the UK and Ireland 2018-2020.

PICANet 2021 Report 
Paediatric Intensive Care 
Audit Network 
Annual Report 2021 
Data collection period  
January 2018–December 2020 

 
2 
PICANet 2021 annual summary report 
Organisation key 
A 
Addenbrooke’s Hospital, Cambridge 
C 
Noah’s Ark Children’s Hospital for Wales, Cardiff 
D 
Royal Manchester Children’s Hospital 
E1 
Great Ormond Street Hospital, London (PICU/NICU) 
E2 
Great Ormond Street Hospital, London (CICU) 
F 
Evelina London Children’s Hospital 
H 
King’s College Hospital, London 
I 
Leeds General Infirmary 
K2 
Freeman Hospital, Newcastle upon Tyne 
K3 
Great North Children’s Hospital, Newcastle upon Tyne 
L 
Royal Stoke University Hospital 
M 
Nottingham Children’s Hospital, Queens Medical Centre, Nottingham 
N 
John Radcliffe Hospital, Oxford 
O 
Royal Brompton Hospital, London 
P 
Alder Hey Children’s Hospital, Liverpool 
Q 
Sheffield Children’s Hospital 
R 
Southampton Children’s Hospital 
S 
James Cook University Hospital, Middlesbrough 
T 
St George’s Hospital, London 
U 
St Mary’s Hospital, London 
V 
Birmingham Children’s Hospital 
W 
Bristol Royal Hospital for Children 
X1 
Glenfield Hospital, Leicester 
X2 
Leicester Royal Infirmary 
Y 
Royal Hospital for Sick Children, Edinburgh 
Z 
The Royal London Hospital 
ZA 
Royal Hospital for Children, Glasgow 
ZB 
Royal Belfast Hospital for Sick Children 
ZC 
Children’s Health Ireland at Crumlin, Dublin (formerly Our Lady’s Children’s Hospital, Crumlin) 
ZD 
Children’s Health Ireland at Temple Street, Dublin (formerly Temple Street Children’s University Hospital) 
ZE 
Harley Street Clinic, London 
ZF 
The Portland Hospital, London 
T001 
Children’s Acute Transport Service (CATS) 
T002 
Embrace: Yorkshire & Humber Infant & Children’s Transport Service 
T003 
North West and North Wales Paediatric Transport Service (NWTS) 
T004 
South Thames Retrieval Service (STRS) 
T005 
KIDS Intensive Care and Decision Support 
T008 
Southampton Oxford Retrieval Team (SORT) 
T010 
Northern Ireland Specialist Transport and Retrieval (NISTAR) Paediatric 
T020 
Scotland Specialist Transport and Retrieval (ScotSTAR) 
T022 
Irish Paediatric Acute Transport Service (IPATS) 
T024 
Wales and West Acute Transport for Children (WATCh) 
T026 
North East Children’s Transport and Retrieval Service (NECTAR) 
T027 
Children’s Medical Emergency Transport Service (CoMET) 
T028 
Heartlink ECMO Children’s Service 
 
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Requests and enquiries concerning reproduction rights should be directed to PICANet at: 
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Telephone xx-xxxx-xxxx ∙ Email xxx@xxx.xx 
In all cases, PICANet must be acknowledged as the source when reproducing or quoting any part of this 
publication. Please use the following format when citing this report: Paediatric Intensive Care Audit Network 
Annual Report 2021 (published January 2022): Universities of Leeds and Leicester 
For this report content is © 2022 The Healthcare Quality Improvement Partnership. 
The ISBN number for this publication is 978-85316-363-3 
 

 
 
 
3 
Contents 
Acknowledgements ................................................................................................................ 5 
Introduction ............................................................................................................................ 7 
Key findings ........................................................................................................................... 8 
Recommendations ............................................................................................................... 11 
How we present our results .................................................................................................. 12 
Important notes .................................................................................................................... 13 
Headline figures: Admission numbers and bed days ............................................................ 14 
Headline figures: Admission rates by country of residence .................................................. 18 
Headline figures: Death in PICU .......................................................................................... 20 
Headline figures: Unplanned extubation............................................................................... 22 
Headline figures: Bed occupancy during ‘normal hours’ and ‘out of hours’ ........................... 26 
Metric 1: Case ascertainment and timeliness of data submission ......................................... 30 
Metric 2: Retrieval mobilisation times ................................................................................... 34 
Metric 3: Number of nurses providing clinical care per bed .................................................. 38 
Metric 4: Emergency readmissions within 48 hours.............................................................. 40 
Metric 5: Mortality in PICU ................................................................................................... 44 
References .......................................................................................................................... 49 
Glossary .............................................................................................................................. 51 
 
For the Supplementary Special Chapters, Tables, Figures and Appendices relating to this 
report, please visit the PICANet website www.picanet.org.uk. 
 
 


 
 
Acknowledgements 
5 
Acknowledgements 
The Paediatric Intensive Care Audit Network (PICANet) gathers information on all patients 
admitted to paediatric intensive care units (PICUs) in the UK and Republic of Ireland, in 
conjunction with centralised transport services (CTS). 
We are indebted to the efforts of all the audit clerks, secretaries, nurses and doctors who 
support and contribute to PICANet from their own PICUs and CTS. We are particularly 
grateful for everyone’s support and contributions over the past year given the significant 
challenges of the COVID-19 pandemic. 
PICANet also continues to rely on the expertise and support from the Paediatric Critical Care 
Society (PCCS), the PICANet Steering Group and members of the Clinical Advisory Group 
who provide an essential link between PICANet and the clinical care teams. We would like to 
acknowledge this support, which enables the PICANet audit to continue to be a success. 
We are also grateful to colleagues at Evelina London Children’s Hospital for writing one of 
the special chapters this year on diabetic ketoacidosis (DKA). 
The PICANet Audit is commissioned by the Healthcare Quality Improvement Partnership 
(HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), 
the Welsh Health Specialised Services, NHS Lothian/National Services Division NHS 
Scotland, the Royal Belfast Hospital for Sick Children, The National Office of Clinical Audit 
(NOCA) for the Republic of Ireland and HCA Healthcare UK. HQIP is led by a consortium of 
the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. 
Its aim is to promote quality improvement in patient outcomes, and in particular, to increase 
the impact that clinical audit, outcome review programmes and registries have on healthcare 
quality in England and Wales. HQIP holds the contract to commission, manage and develop 
the NCAPOP, comprising around 40 projects covering care provided to people with a wide 
range of medical, surgical and mental health conditions. The programme is funded by NHS 
England, the Welsh Government and, with some individual projects, other devolved 
administrations and crown dependencies. 
www.hqip.org.uk/national-programmes 
 
 


 
 
Introduction 
7 
Introduction 
This is the eighteenth PICANet annual clinical audit report describing paediatric critical care 
activity which occurred within paediatric intensive care units in the United Kingdom (UK) and 
Republic of Ireland (ROI) between 2018 and 2020. The annual report forms one important 
component of PICANet’s contracted obligations, cataloguing comprehensive information on 
referral, transport and admission events to monitor the delivery and quality of care in relation 
to agreed standards and evaluate clinical outcomes to inform national policy in paediatric 
critical care. 
We report on five key metrics relevant to Paediatric Intensive Care services: case 
ascertainment including timeliness of data submission, retrieval mobilisation times, number 
of qualified nurses per bed, emergency readmissions within 48 hours of discharge and 
mortality in PICU. Although a formal outlier analysis and policy is only recommended for in-
PICU mortality, we continue to provide real-time ‘RSPRT’ plots to enable PICUs to monitor 
their mortality outcomes on a much more regular basis.  
This year, we have three special chapters included in a supplementary document. Two of the 
special chapters relate to the impact of the COVID-19 pandemic on paediatric intensive care 
units and provision: one provides an overview of the children with a confirmed coronavirus 
diagnosis treated in a PICU in the UK; the second investigates the impact of the pandemic 
on PIC beds, PICUs and staffing. Additionally, a third special chapter investigates how 
presentations and outcomes for diabetic ketoacidosis (DKA) admissions to PICUs have 
changed over the last ten years. 
As in previous reports, we also provide a full set of tables and figures which document 
transport, referrals and admissions activity within PICUs between 2018 and 2020. Individual 
tables and figures can be downloaded in electronic form from the main PICANet website 
www.picanet.org.uk. 
We also plan further enhancements to the PICANet web platform and underlying database to 
provide a more user-friendly and interactive experience so that all key performance data for 
units can be easily interrogated and visualised through an online dashboard. 
 
Professor Liz Draper 
Professor Richard Feltbower, 
Principal Investigators 
 
 

 
8 
PICANet 2021 annual summary report 
Key findings 
▪ 
The number of admissions to paediatric intensive care across the UK and Republic of 
Ireland in 2020 showed a reduction due to the COVID-19 pandemic from just over 20,000 
per year from 2018–19 to 16,400 in 2020. This reduction is reflected across all countries 
of the UK and Republic of Ireland. 
▪ 
The reduction in admissions was also reflected in the number of bed days delivered 
across the UK and ROI, which fell by 20% in 2020 compared to the two previous years. 
▪ 
Admission rates to paediatric intensive care also showed a reduction of around 20% 
across all nations, ranging from 83 per 100,000 children in the Republic of Ireland to 
rates of 136 in Scotland. 
▪ 
Despite the pandemic, the likelihood of dying whilst being treated within PICUs remained 
very low with 96.4% of admissions discharged alive in 2020. The proportion of deaths 
within PICU showed a slight reduction in 2020, comprising around one in six of all 
children’s deaths in the UK and one in every five in the ROI. 
▪ 
Annual rates of reported unplanned extubation varied between 3.4 in Wales and 6.1 in 
Scotland for every 1,000 days of invasive ventilation throughout the reporting period. Two 
thirds of all units reported a decrease in the number of unplanned extubations in 2020 
compared to 2019. 
▪ 
The PICANet staffing census week coincided with the second wave of the pandemic in 
November 2020 and were consequently noticeably lower than previous years. The total 
intensive care occupancy rates were 65% in ‘normal’ hours, ranging from 45% to 67%. 
High dependency bed occupancy in ‘normal’ hours showed a similar decrease with an 
average of 47% in 2020 compared to over 80% in 2019. Intensive care bed occupancy 
out of hours ranged from 55% to 78%. For high dependency care, ‘out of hours’ bed 
occupancy was an average of 43%, ranging from 29% to 59%.  
▪ 
89% of units across the UK and Republic of Ireland (excluding Northern Ireland) provided 
complete and timely admissions’ data to PICANet within three months of discharge. 
Fifteen units achieved completeness within three months for at least 98% of their 
admissions in 2020 compared to nine units in 2019. Excluding units affected by major IT 
issues, three units completed fewer than 60% of their admission records within this 
timescale. 
▪ 
There was a 30% decrease in the average number of child retrievals compared to the 
previous two years. Of the 2,896 journeys carried out for children requiring urgent 
transport to a PICU, 64% were started within 30 minutes, with over 80% started within 
one hour of the clinical decision being made. Just over 1 in 30 journeys (3%) started 
more than three hours after the decision.  
▪ 
Overall, the establishment figures for nursing staff across the UK and ROI showed that 
six PICUs (18%) met the PICS standards for nursing staff of 7.01 WTE (whole time 
equivalents), when all staff providing clinical care (including non-registered health care 
staff: Bands 2–4) are included. However, if all recorded vacancies were filled, then 16 
PICUs (48%) would meet this standard. As in previous years the annual PICANet staffing 
census shows that both in ‘normal’, and ‘out of hours’ units ensure their staffing levels are 
appropriate for the number and care level provided for children on their unit despite 
COVID-19 pressures on staff and resources. 
▪ 
Overall rates of emergency readmission within 48 hours of discharge remained stable at 
around 1.7% over the period 2018–2020. However in 2020 it varied by country, from 
0.8% in Wales to 2.1% in Scotland. 

 
 
Key findings 
9 
▪ 
No negative statistical outliers were identified for mortality rates for any unit between 
2018 and 2020. There were three units which were defined as positive outliers for 
mortality, indicating substantially lower numbers of deaths than would be predicted with 
these units having completed the PICANet outlier process. Further work will be carried 
out to identify particular areas of excellence within units for shared learning. 
▪ 
In terms of COVID-19 in PICU, this report highlights the importance of screening as an 
infection control measure as more than 20% of children with a confirmed diagnosis of 
COVID-19 (without PIMS-TS) were asymptomatic during PICU admission and were 
detected only on routine screening. 
▪ 
PICUs were able to collect additional custom audit data relating to COVID-19 and PIMS-
TS cases in a timely manner despite significant resource limitations which has allowed for 
important monitoring and modelling to be undertaken throughout the pandemic for 
planning purposes. 
▪ 
The impact of COVID-19 on PICU staffing during the time period from 7 February 2020 to 
29 April 2021 was twofold. Firstly, over half (16 out of 31) PICUs received adult patients 
at some point in this time period. Overall paediatric bed occupancy was unchanged for 
55% (17) PICUs with some variation, whilst 9 PICUs reported a decrease in PICU 
activity. Extra capacity beds were created in PICUs, the highest number was 172 extra 
beds opened to meet demand from March to June 2020, whilst 10% of the maximum total 
of beds open were closed to paediatric admissions. Secondly, 55% of PICUs redeployed 
their staff, predominantly nursing and medical staff. The majority of staff were used to aid 
Adult Intensive Care Units. 29% of PICUs were required to relocate children to another 
PICU or designated area. It is important to report the impact that COVID-19 has had on 
bed occupancy however, the data should not be used in the usual way for planning. 
▪ 
The proportion of children admitted to PICU with a primary diagnosis of diabetic 
ketoacidosis more than doubled in 2020 to 1.3% compared with the average proportion of 
0.6% for 2010 to 2019. This increase is in keeping with emerging evidence in 
international reports of an association of COVID-19 and diabetes.  
▪ 
Diabetic ketoacidosis admissions in 2020 had similar outcomes (mortality and length of 
stay) and requirement for support (ventilation, intravenous vasoactive treatment and renal 
replacement therapy) to the preceding years. 
▪ 
Changes in national diabetic ketoacidosis guidelines (2015 and 2020) do not appear to 
have had an impact on mortality or the incidence of cerebral oedema and acute renal 
failure in children presenting to PICU with a diagnosis of DKA. 
 
 


 
 
Recommendations 
11 
Recommendations 
1. Continue to monitor the impact of COVID-19 on admissions to paediatric intensive units 
across the UK and ROI, working closely with NHS organisations to support service 
planning. 
Action: NHS England, Paediatric Intensive Care Units (PICUs), commissioners, 
Operational Delivery Networks (ODNs) 
2. Review data collection processes and procedures, to ensure ability to meet future two 
month timeliness standard as stated in the 2021 PCCS Quality Standards [1], and 
PIC10a (PICU Quality Dashboard 2021/2022).  
Action: organisations not meeting the timeliness standards for completion of data 
to PICANet 
3. Review staffing levels following the pandemic to ensure adequate levels of care are 
maintained within paediatric intensive care. 
Action: National nursing professional bodies 
4. Share examples of best practice with PICANet, to enable onward sharing with other 
PICUs. 
Action: PICUs which are positive outliers for mortality 
5. Consider continuing to screen all children admitted to PICU for SARS-CoV-2 infection  
Action: PICUs 
6. Continue to report COVID-19/PIMS-TS patients via PICANet notification/custom audit to 
aid early detection of patterns and trends that require a coordinated regional and/or 
national response. 
Action: PICUs, PICANet 
7. Explore the positive and negative outcomes of the remodelling strategies used during the 
pandemic (such as caring for critically ill adult patients and redeployment of staff) to 
assess the potential for future adoption/application. 
Action: Commissioners, ODNs. 
8. Consider increased provision of Level 2 care to reduce the pressure on PICUs as the 
majority of DKA children did not require invasive ventilation or intravenous vasoactive 
therapy, in line with the paediatric critical care review in 2019. 
Action: Commissioners, ODNs. 
 
 

 
12 
PICANet 2021 annual summary report 
How we present our results 
Results are presented in tables and figures. This Report focuses on children aged 0–15 
years (unless otherwise specified); each specific measure of interest is explained in the 
results and metrics sections below under the heading “What are we measuring?”. 
Measures include the number of admissions, how many days patients are in PICU, the types 
of treatments patients receive and clinical outcomes such as death. We present data 
according to age, sex, country of admission, treating PICU as well as country of residence 
and where the child is living.  
Data are presented in more granular detail in the “Tables and Figures”. In general, data are 
presented for children aged 0–15 years and do not include any admissions where the child’s 
age is unknown, however, some tables also include data relating to all patients admitted to 
PICU (including those who are 16 years and older or where we don’t know the patient’s age; 
these tables will have footnotes explaining this.  
Rates 
We present certain information in the form of rates, enabling comparisons to be made 
between countries even though the population size in each country is different. Rates are 
usually presented as the number per 1,000 or per 100,000 of the relevant population. 
When we want to compare two rates we divide one rate by the other, to get a relative rate. 
For example, to compare the admission rate in Scotland to that in England we would divide 
the Scottish admission rate by the English admission rate. If the two rates were the same 
then the relative rate would be one. If the Scottish rate was higher than the English rate then 
the relative rate would be greater than one. If the Scottish rate was lower than the English 
rate then the relative rate would be less than one. This measure allows us to talk about the 
Scottish rate in comparison (or relative) to the English rate. 
Deaths 
We measure how poorly children were at the point when they were admitted to PICU using 
the Paediatric Index of Mortality version 3 (PIM3)[2]. This takes into account many factors 
(such as whether the child was admitted as an emergency and whether they needed help 
breathing) to estimate how likely each child is of dying. 
When comparing deaths in PICU, we calculate the risk-adjusted standardised mortality ratio 
(SMR). This compares the number of deaths that have happened in a PICU and how many 
deaths we expected to happen given how poorly children were when they were admitted to 
PICU. We also use ‘funnel plots’ to compare individual PICUs in terms of mortality which 
enables us to display and compare the risk-adjusted SMR on the same graph. These plots 
tell us what range of values we might expect to see for the SMR in each PICU, given that we 
expect a certain amount of variation as these calculations are based on a very small number 
of deaths. Further details on funnel plots and how to interpret them are provided in the 
“Metric 5: Mortality in PICU” section. 
 
 
 

 
 
Important notes 
13 
Important notes 
COVID-19 pandemic 
The COVID-19 pandemic had an impact on all UK and ROI PICUs and PICANet data have 
been used or referenced in a number of peer-reviewed journal articles looking at both 
COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with 
COVID-19 (PIMS-TS) patients [3]. Some PICUs closed to paediatric admissions entirely and 
some accepted admissions for both paediatric and adult patients [4]; this reduction in 
paediatric intensive care (PIC) provision is reflected throughout the data presented in this 
report in terms of workload and bed occupancy. We explore the impact of the pandemic on 
PIC and staffing in more detail in the COVID-19 special chapter. 
Data collection issues 
Northern Ireland had a pause in data collection in 2018 causing a delay in data submission 
which impacted 2018 and 2019 data completion timelines. The Republic of Ireland had a 
pause in data collection in 2020 due to a cyber-attack on the country’s health service 
systems which impacted on data completion timelines and on data cleaning for this Annual 
Report. 
Closure of ZE – Harley Street PICU 
One non-NHS PICU (ZE) closed to paediatric admissions permanently in March 2020 such 
that 2020 data presented below for this unit does not represent a full calendar year. Data for 
2020 for this unit is therefore not directly comparable to 2018 and 2019. 
 
 

 
14 
PICANet 2021 annual summary report 
Headline figures: Admission numbers and 
bed days 
What are we measuring? 
Table 1 and Figure 1 below summarise the number of admissions to paediatric intensive 
care units in the UK and Republic of Ireland between 2018 and 2020 among children aged 
under 16 years at the time of admission. Table 2 and Figure 2 summarise the number of 
bed days of paediatric intensive care that were delivered during this period. 
What did we find? 
There were approximately 20,000 admissions to PICUs in 2018 and 2019 across the UK and 
Republic of Ireland; there was a fall in 2020 to just under 16,500 admissions which is likely to 
be attributable to the COVID-19 pandemic. This represented a reduction of around one-fifth 
(19.5%) from the number of admissions in 2019. We present further information on the 
COVID-19 pandemic and its impact on paediatric intensive care (PIC) in a special chapter.  
The number of admissions to NHS PICUs in England reduced from approximately 16,000 per 
year in 2018 and 2019 to around 13,000 in 2020. There was also a small but steady 
reduction in admissions year on year in Northern Ireland and Wales, from just over 500 in 
2018 to just over 350 in 2020. The number of admissions in Scotland had a peak of almost 
1,700 in 2019, an increase of approximately 350 admissions from 2018. In 2020, the number 
of admissions in Scotland decreased to just under 1,200. Admissions in the Republic of 
Ireland remained fairly constant at around 1,400 to 1,500 admissions in each year. The 
number of admissions to non-NHS PICUs in England continued to decrease over the 
reporting period from a peak of over 350 admissions in 2018 to 200 admissions in 2020; one 
of the two non-NHS PICUs closed permanently to paediatric admissions in March 2020 
which contributed to some of the reduction. 
As with the reduction in the overall number of admissions in 2020 (Table 1), there was also a 
reduction in the number of bed days delivered in 2020; the number of bed days delivered fell 
from around 144,000 in 2018 and 2019 to 114,000 in 2020.  
Table 1: Number of admissions by country of PICU and year of admission 
Country of admission 
2018 
2019 
2020 
England (NHS) 
16,038 
15,905 
12,956 
England (non-NHS) 
351 
303 
202 
Wales 
510 
489 
363 
Scotland 
1,351 
1,697 
1,178 
Northern Ireland 
501 
492 
353 
Republic of Ireland 
1,429 
1,514 
1,377 
Total 
20,180 
20,400 
16,429 
 

 
Headline figures: Admission numbers and bed days 
15 
Table 2: Number of bed days delivered by country of admission and year of 
provision 
Country of admission 
2018 
2019 
2020 
England (NHS) 
114,729 
111,807 
90,298 
England (non-NHS) 
2,695 
3,281 
1,095 
Wales 
2,509 
2,626 
2,117 
Scotland 
10,319 
12,055 
8,666 
Northern Ireland 
3,275 
3,422 
2,669 
Republic of Ireland 
10,176 
10,393 
9,312 
Total 
143,703 
143,584 
114,157 
 
Figure 1: Number of admissions to PICU by country of admission and year of 
admission 
 
Based on date of admission within the reporting period. 
 
 
0
5,000
10,000
15,000
England (NHS)
England (non-NHS)
Wales
Scotland
Northern Ireland
Republic of Ireland
Number of admissions
Country
2018
2019
2020

 
16 
PICANet 2021 annual summary report 
Figure 2: Number of bed days delivered by country of admission and year of 
provision 
  
Presented based on year bed day provided regardless of admission date (note: this could include admissions for 
children who were admitted prior to the reporting period if they were still receiving PIC care in 2018–2020). 
What does this mean? 
Due to the COVID-19 pandemic, some PICUs temporarily closed to paediatric admissions in 
2020 and/or admitted adult patients alongside children. Consequently, paediatric intensive 
care services saw a sharp fall in the number of admissions for children aged 0-15 years of 
around 20% in 2020 compared to 2018-19. This was reflected in a parallel reduction of 
around 20% in the number of bed days. The COVID-19 special chapter explores the impact 
of the pandemic on PIC care in more detail. It is important that we continue to closely monitor 
trends in PICU demand not only in terms of admission burden but equally for the number of 
bed days provided to ensure sufficient care provision is available, particularly as we move 
through and beyond the COVID-19 pandemic. 
Further details 
Definitions and methods 
Every admission to a PICU in the UK and the Republic of Ireland is counted for each year, 
2018 to 2020. If a child has been readmitted during that period this will be counted as a 
separate admission. A ‘bed day’ is counted if a child is in a PICU bed for a day or part of a 
day which occurs within the reporting period (i.e. between 1 January 2018 and 31 December 
2020) even if the child was admitted to PICU prior to the reporting period. 
We have only provided figures for children less than 16 years old (the normal age limit for 
admission to PICU). All designated PICUs across the UK and ROI provided data to PICANet 
including the two private providers1 of PIC based in England up to the end of 2020. 
                                               
1 As noted above, one non-NHS PICU closed to paediatric admissions permanently in March 2020. 
0
25,000
50,000
75,000
100,000
125,000
England (NHS)
England (non-NHS)
Wales
Scotland
Northern Ireland
Republic of Ireland
Number of bed days
Country
2018
2019
2020

 
Headline figures: Admission numbers and bed days 
17 
Why is this important? 
The number of admissions and the number of bed days tell us how busy the PICUs are and 
helps the commissioners, who provide funding for paediatric intensive care, to work out how 
many staff and beds are required to meet the demand. This is important, as too few beds 
might mean that a child may not receive intensive care when they need it, or there may be a 
delay. Although it is unlikely, if the commissioners overestimate demand, it is possible that 
staff and beds would be under-utilised, which would be a waste of resources. 
 
 

 
18 
PICANet 2021 annual summary report 
Headline figures: Admission rates by 
country of residence 
What are we measuring? 
Annual rates of admissions to PICU between 2018 and 2020 are presented in Table 3 by 
country of residence, calculated per 100,000 children in the population. This identifies what 
proportion of the childhood population are treated by paediatric intensive care services in 
each country every year.  
What did we find? 
Overall between 2018 and 2020, PICU admission rates were highest in Scotland, reaching 
161 admissions for every 100,000 children, followed by Northern Ireland (136), England 
(132), Wales (132), and the Republic of Ireland (128). For the UK and Republic of Ireland 
combined, admissions rates were 134 per 100,000 population per year.  
Reflecting the impact of the COVID-19 pandemic, admission rates were lower in all countries 
in 2020. The largest decrease was seen in Northern Ireland with the rate in 2020 being half 
that in 2018 (83 admissions per 100,000 compared with 167 in 2018). In 2019, admission 
rates in Scotland increased to 192 per 100,000 from 154 in 2018 before dropping to 136 in 
2020. Rates in Wales and England remained steady across 2018 and 2019 before dropping 
in 2020. In the Republic of Ireland rates were similar across all three years, ranging from 121 
to 133 admissions.  
Table 3: Rate of admissions per 100,000 childhood population, 2018-2020 
Country of admission 
2018 
2019 
2020 
2018–2020 
England 
141.1 
141.1 
115.2 
132.4 
Wales 
139.6 
140.2 
114.6 
131.5 
Scotland 
154.3 
191.8 
136.4 
160.8 
Northern Ireland 
166.6 
159.3 
83.3 
136.4 
Republic of Ireland 
127.8 
133.4 
121.3 
127.5 
Total 
141.6 
144.3 
116.1 
134.0 
Based on country of residence. 
Children with unknown country of residence or country of residence outside of the UK or ROI were excluded 
from this analysis leaving n=55,466 admissions.  
What does this mean? 
There was substantial geographical variation in admissions rates to PICU between countries 
ranging between 128 and 161 in 2020, meaning this is essential information required for the 
planning of national PIC services. Possible explanations for these findings could involve 
differences in admission policies between each country, variation in response to the COVID-
19 pandemic, the availability of specialised critical care and transport services at the time of 
admission and distance to the nearest PICUs. 

 
Headline figures: Admission rates by country of residence 
19 
Further details 
Definitions and methods 
For each of the UK countries and the Republic of Ireland, the number of admissions was 
divided by the number of children in the population; this number was multiplied by 100,000 to 
give the number of admissions per 100,000 children aged under 16 to give the admission 
rate. We used national census data to estimate the childhood population in each country [5, 
6]. 
Why is this important?  
It is important for each country participating in PICANet to know the rate of admission to 
paediatric intensive care to allow them to plan services effectively. The variation in admission 
rates could be investigated to understand if these are real geographical differences (e.g. 
proximity to PICU, level of urbanicity) or explained by differences in clinical practise or 
commissioning in the populations for each nation. 
 
 

 
20 
PICANet 2021 annual summary report 
Headline figures: Death in PICU 
What are we measuring? 
All deaths that occur after admission but prior to discharge from PICU are recorded and 
reported here for children under 16 who were admitted between 2018 and 2020. Deaths are 
presented based on the country of admission (i.e. PICU location) as deaths must be 
registered in the country where the person died. In Table 4, percentages were calculated for 
each country based on the total number of admissions for that year. 
What did we find? 
Table 4 summarises the number of child deaths in PICU by country of admission and year. 
There was a total of 1,966 deaths over the three year period, equivalent to 966 children 
being discharged alive out of every 1,000. The proportions of in-PICU death remained similar 
across all three years, ranging from 3.4% to 3.6%. 
Table 5 shows the proportion of deaths in PICU compared to all childhood deaths in the UK 
and Republic of Ireland reported from routine national government statistics [7-10]. For 
context, we also present the total number of deaths in PICU in brackets. For children 
admitted in the UK, PICU deaths accounted for between 15–16% of the total number of 
children’s deaths. For children admitted in the Republic of Ireland, PICU deaths accounted 
for between 21–25% of the total number of children’s deaths. 
Table 4: Proportion of deaths in PICU of all PICU admissions, by country of 
admission and year 
Country of admission 
2018 
2019 
2020 
2018–2020 
England 
3.4% (n=562) 
3.6% (n=576) 
3.7% (n=488) 
3.6% (n=1,626) 
Wales 
4.3% (n=22) 
2.0% (n=10) 
3.3% (n=12) 
3.2% (n=44) 
Scotland 
2.4% (n=33) 
1.9% (n=33) 
2.3% (n=27) 
2.2% (n=93) 
Northern Ireland 
2.4% (n=12) 
2.3% (n=11) 
2.0% (n=7) 
2.2% (n=30) 
Republic of Ireland 
4.1% (n=59) 
4.0% (n=60) 
3.9% (n=54) 
4.0% (n=173) 
Total 
3.4% (n=688) 
3.4% (n=690) 
3.6% (n=588) 
3.4% (n=1,966) 
Data are presented based on date of admission 
Due to small numbers, data for non-NHS and NHS organisations in England are presented combined. 
 
Table 5: Proportion of deaths in PICUs of all children’s deaths in the population: 
UK and Republic of Ireland, 2018–2020 
Country of admission 
2018 
2019 
2020 
2018–2020 
UK 
15.6% (n=629) 
15.9% (n=630) 
14.6%** (n=534) 
15.4% (n=1,793) 
Republic of Ireland 
25.2% (n=59) 
22.1%* (n=60) 
21.1%* (n=54) 
22.7% (n=173) 
Based on country of admission 
* The numbers of total deaths for the Republic of Ireland for 2019 and 2020 are currently provisional and subject 
to change. 
** The number of total deaths for Northern Ireland for 2020 is provisional and subject to change. 
 

 
Headline figures: Death in PICU 
21 
What does this mean? 
Risk of death in paediatric intensive care is low with 96.6% of patients being discharged alive 
between 2018 and 2020. Deaths in PICU account for about one in every six of all children’s 
deaths in the UK and about one in every five children’s deaths in the Republic of Ireland in 
any given year. The difference between the UK and the Republic of Ireland could be due to 
organisational factors relating to paediatric services; in 2018 and 2019 the Republic of 
Ireland had the lowest rates of admission to PICU (Table 3) which could indicate differences 
in admission thresholds for PIC care between the two countries.  
Further details 
Definitions and methods 
We have recorded the number of deaths in PIC by year and by country of admission for 2018 
to 2020. The percentages in Table 4 are based on the number of admissions to PICUs over 
this period, not the number of individual children (i.e. if the same child had two admissions in 
the same time period, this would count as two admissions). In Table 5, we present deaths on 
PICUs (2018–2020) as a proportion of all child deaths (0–15 years) in the UK and the 
Republic of Ireland. 
Why is this important? 
Death on PICU is rare and the rate of PICU death has fallen steadily since PICANet started 
collecting data in 2002. It is important to record the number of deaths to facilitate the 
investigation of mortality trends over time. It also highlights any differences in death rates 
between countries. Where there are very small numbers of deaths, caution should be applied 
when making comparisons as apparently large differences may happen by chance. 
 
 

 
22 
PICANet 2021 annual summary report 
Headline figures: Unplanned extubation 
What are we measuring? 
PICU patients who need help with their breathing may require a tube placed in their throat 
connected to a machine: this is called invasive ventilation. If the tube is accidentally 
dislodged, this is referred to as unplanned extubation2. In Table 6, we present the number 
of unplanned extubations for every thousand days of invasive ventilation for 0–15 year olds 
that were reported based on country of admission. Figure 3 shows the rate of unplanned 
extubation by organisation for each year of the reporting period, ranked by the 2020 rate. 
What did we find? 
There were 339 unplanned extubations (Table 6) reported in the UK and Republic of Ireland 
in 2018 which occurred over approximately 67,000 days of invasive ventilation; this equates 
to an unplanned extubation rate of 5.0 (95% confidence interval (CI): 4.5–5.6) per 1,000 days 
of invasive ventilation. In 2019, there were slightly fewer unplanned extubations (n=307) and 
there were also fewer days of invasive ventilation provided (around 64,000) leading to a rate 
of 4.8 (95% CI: 4.2–5.3). In 2020 the number of unplanned extubations fell to 209 and the 
number of days of invasive ventilation provided in PICUs also fell to under 50,000, equivalent 
to the lowest rate observed in the reporting period of 4.3 (95% CI: 3.7–4.9) unplanned 
extubations for every 1,000 days of invasive ventilation. 
Table 6: Rate of unplanned extubation per 1,000 days of invasive ventilation by 
country of admission and year of unplanned extubation, 2018–2020 
 
2018 
2019 
2020 
2018–2020 
England  
5.1 (n=284) 
4.7 (n=248) 
4.5 (n=176) 
4.8 (n=708) 
Wales 
2.4 (n=3) 
2.9 (n=3) 
6.0 (n=4) 
3.4 (n=10) 
Scotland 
6.4 (n=25) 
6.2 (n=25) 
5.7 (n=16) 
6.1 (n=66) 
Northern Ireland 
3.5 (n=5) 
5.9 (n=8) 
0.9 (n<3) 
3.6 (n=14) 
Republic of Ireland 
4.0 (n=22) 
4.2 (n=23) 
2.5 (n=12) 
3.6 (n=57) 
Total 
5.0 (n=339) 
4.8 (n=307) 
4.3 (n=209) 
4.7 (n=855) 
Data are presented based on date of unplanned extubation rather than date of admission and therefore this 
table may include children who were admitted prior to the reporting period who were still in PICU. 
Due to small numbers, data for non-NHS and NHS organisations in England are presented combined. 
 
Unplanned extubations rates in England showed a steady reduction from 5.1 unplanned 
extubations per 100,000 ventilated days in 2018 to 4.5 in 2020. Scotland showed a similar 
pattern with a rate of 6.4 in 2018 reducing to a rate of 5.7 in 2020. Wales showed large 
variation between years due to small but consistent numbers of unplanned extubations in 
each year and small numbers of ventilated days (ranging from approximately 1,200 days in 
2018 to 650 days in 2020). Unplanned extubations rates in Northern Ireland showed large 
variation between years ranging from 5.9 in 2019 and reducing to 0.9 in 2020; the number of 
ventilated days for Northern Ireland was small but fairly similar across all years (ranging 
between 1,100 and 1,500) and the reduction in rate is likely partially down to this but also 
                                               
2 PICANet definition of unplanned extubation: a dislodgement of the endotracheal tube from the 
trachea, without the intention to extubate immediately and without the presence of airway competent 
clinical staff in the bed space, appropriately prepared for the procedure 

 
Headline figures: Unplanned extubation 
23 
due to a reduction in the number of unplanned extubations recorded (dropping from eight in 
2019 to less than three in 2020). 
Nineteen PICUs demonstrated a decrease in their unplanned extubation rate in 2020 when 
compared with 2019 and 11 units had an increase in rate (Figure 3). Increased rates ranged 
between 1.3 and 5.4 of the 2019 rate—however it is important to remember that the number 
of unplanned extubations this relates to is relatively small.  
There were two units for which there were no unplanned extubation events reported in any 
year of the reporting period. Four further units reported no unplanned extubations 20203. It is 
important to understand the reasons for these observations in terms of whether this reflects 
high performing units or differing standards of data reporting. 
 
Figure 3: Unplanned extubation rates per 1,000 days of invasive ventilation by 
health organisation, 2018-2020 
 
Ranked by unplanned extubations rate for 2020. 
This figure includes admissions where the patient was aged 16+ years at admission or where the patient’s age 
was unknown. 
Data are presented based on date of unplanned extubation rather than date of admission and therefore this 
table may include children who were admitted prior to the reporting period who were still in PICU. 
Data behind this Figure can be found in Table 44 of the Tables and Figures.  
 
What does this mean? 
Unplanned extubation remains a relatively rare event within paediatric intensive care 
services with a recorded annual rate of between four and five per 1,000 days of invasive 
ventilation on average in 2018–2020. All units reported unplanned extubation rates below 14 
per 1,000 intubated days in 2020. This is still a relatively new data item and quality 
assurance of this metric was undertaken in all three years of this reporting period for the first 
time. Changes in rates of unplanned extubation should still be carefully monitored over the 
                                               
3 This includes one non-NHS PICU closed to paediatric admissions permanently in March 2020 where 
data presented does not represent a whole calendar year and two units where paediatric beds were 
closed during the first and/or second wave of the COVID-19 pandemic.  
Two units reported no unplanned 
extubation events in any reporting year
0
5
10
15
S ZF M ZE N U K3 ZB ZC I H P F L A D X1 O Y R E2 Z ZD W C V ZA K2 E1 T X2 Q
Rate
Organisation
2018
2019
2020

 
24 
PICANet 2021 annual summary report 
next few years and consideration may be given to including unplanned extubations as a key 
metric in future. 
Further details 
Definitions and methods 
When a child is intubated and ventilated it means that they have a tube placed in their throat 
attached to a machine that helps them to breathe. The machine can be used to provide 
different levels of oxygen to help their recovery. If the tube is accidentally removed, this is 
called an unplanned extubation. As we are comparing such events between PICUs, we need 
to calculate a rate of unplanned extubation, based on how many days of invasive ventilation 
are provided in each PICU, as the more patients that are ventilated on a PICU, the more 
likely an unplanned extubation will occur. To calculate the rate, we take the number of 
unplanned extubations for every 1,000 invasive ventilation days delivered. This makes 
comparisons between units with different volumes of invasive ventilation possible. Unplanned 
extubation is referred to as an ‘adverse event’.  
Why is this important? 
Unplanned extubation is an adverse event leading to disconnection from a ventilator and 
airway compromise. This can lead to complications such as hypoxaemia (low blood oxygen), 
and/or hypercarbia (high blood carbon dioxide), and these adverse events are associated 
with mortality, prolonged mechanical ventilation, longer PICU stays and increased costs [11] 
and rarely death [12], and therefore should be avoided where at all possible. The Paediatric 
Intensive Care (PICU), Quality Dashboard 2021/2022 [13] aim for a threshold of less than 5 
in 1,000 ventilator days, and therefore these adverse events need to be monitored to 
demonstrate whether this clinical outcome is being achieved. In addition, by continuously 
monitoring unplanned extubation rates units may be able to detect risk factors associated 
with unplanned extubation such as high-risk children, sedation scoring, longer term 
ventilation, staff/patient ratios, endotracheal tube care, and changes in clinical practice [11, 
12]. 
 
 


 
26 
PICANet 2021 annual summary report 
Headline figures: Bed occupancy during 
‘normal hours’ and ‘out of hours’ 
What are we measuring? 
The annual staffing study for PICANet collects information about the number of open and 
funded (commissioned), intensive care and high dependency care beds in PICUs during the 
week beginning 2 November 2020 in the UK and Republic of Ireland. The number of open 
beds is the number of intensive care (IC) and high dependency (HD) beds on a PICU for 
whom staff were available. The term ‘normal hours’ refers to midday on Wednesday (one 
time), and ‘out of hours’ refers to midnight and weekend hours (three times, midnight 
Wednesday, and midday and midnight Sunday). 
What did we find? 
Overall the occupancy figures for both IC and HD beds were on average 15% lower than 
previous years reflecting the impact of COVID-19 on PICU admission rates for 2020. 
At the ‘normal hours’ census point (midday Wednesday) in 2020, IC bed occupancy at the 
highest point was 67% for England (NHS), and Northern Ireland, decreasing to 63% in ROI, 
50% for Scotland, and below 45% for Wales and England (non NHS). HD occupancy in 
‘normal hours’ at its highest was 71% in England (NHS), dropping to 50% in Wales, 44% in 
England (non-NHS), with lower percentages for Scotland and the ROI (Figure 4). 
At the ‘out of hours’ census report for all three times, there were again lower bed occupancy 
numbers. IC bed occupancy was highest at 78% for ROI, then Northern Ireland at 67%, 
dropping to an average of 55% for England (NHS), Wales and Scotland. Similarly, for HD 
‘out of hours’ bed occupancy, the highest at 59% was England (NHS), 56% for England (non 
NHS), decreasing to 40% for ROI, and below 35% for Wales and Scotland (Figure 5). 
Figure 4: Percentage bed occupancy at midday Wednesday ‘normal hours’ and 
midday Sunday ‘out of hours’ in November, 2020 
 
Number of funded beds reported in the appendices. The red line shows 85% bed occupancy. 
67
44
43
50
67
63
56
33
57
53
67
78
71
44
50
33
40
59
56
25
33
40
85% bed occupancy
0
25
50
75
100%
England
(NHS)
England
(non-NHS)
Wales
Scotland Northern
Ireland
Republic
of Ireland
England
(NHS)
England
(non-NHS)
Wales
Scotland Northern
Ireland
Republic
of Ireland
MIDDAY WEDNESDAY
MIDDAY SUNDAY
Beds occupied (%)
Intensive care
High dependency

 
Headline figures: Bed occupancy during ‘normal hours’ and ‘out of hours’ 
27 
Figure 5: Percentage of beds occupied at midday Wednesday and midday 
Sunday in November, 2018–2020 
 
Number of funded beds reported in the appendices. 
 
What does this mean? 
Bed occupancy refers to an open bed within a PICU that is occupied and staff available to 
care for that patient. Across the UK reported bed occupancy rates in PIC have dropped 
significantly in 2020 during ‘normal hours’ and ‘out of hours’. This reflects decreased activity 
in PICUs observed since the start of PICANet in 2002–2003, and highlights the impact of the 
COVID-19 pandemic in admission rates to PICU in 2020, with reduction in elective 
respiratory ‘winter’ admissions, and non-elective admissions post-surgery, although there 
was variation between units and specialities [14]. 
The number of funded IC beds reported to PICANet has remained consistent over the last 
three years for IC beds in England, Wales, Scotland, Northern Ireland and the ROI. For HD 
units these numbers also remain consistent apart from a decrease in the private sector in 
England. 
85% bed occupancy
0
25
50
75
100%
2018
2020
2018
2020
2018
2020
2018
2020
2018
2020
2018
2020
England
(NHS)
England
(non-NHS)
Wales
Scotland
Northern
Ireland
Republic
of Ireland
Beds occupied
Intensive care
High dependency
MIDDAY WEDNESDAY
85% bed occupancy
0
25
50
75
100%
2018
2020
2018
2020
2018
2020
2018
2020
2018
2020
2018
2020
England
(NHS)
England
(non-NHS)
Wales
Scotland
Northern
Ireland
Republic
of Ireland
Beds occupied
Intensive care
High dependency
MIDDAY SUNDAY

 
28 
PICANet 2021 annual summary report 
Overall occupancy of beds recorded as a snapshot of activity in November each year does 
show some variation between the countries for 2018, and 2019. Figure 5 shows that for 
England (NHS), there was a small reduction from 93% in 2018 to 80% in 2019, whilst in 
Scotland IC bed occupancy was above 85% for both 2018 and 2019. However overall bed 
occupancy is greatly reduced for all units in 2020. Whilst this may be to some degree a 
limitation of data collection at ‘census’ time points, or a change in provision of critical care or 
changing practice, this uniform reduction in bed occupancy is supported by the overall 
reduction in PICU admission in 2020. 
It is important to note that the PICANet 2020 staffing survey snapshot was taken in the week 
beginning 2 November, coinciding with the second wave of the COVID-19 pandemic as 
defined by the Coronavirus Infection Survey (2021). 
To place context within the decrease in bed occupancy PICANet undertook an extra staffing 
survey to ascertain whether the impact of COVID-19 in bed occupancy such as: admission of 
adults patients onto PICU; staff redeployment, staff shielding, and relocation of children, 
affected bed occupancy. The results are summarised in the special chapter.  
Further details 
Definition and methods 
Information about bed occupancy is collected each year as part of the PICANet staffing 
study. The survey collects details about the total number of open and funded (commissioned) 
intensive care and high dependency care beds, and the number of actual children being 
cared for on each PICU by the level of care requirement for four ‘snapshot’ time periods: a 
weekday; and weekend; at noon and midnight. The proportion of open and funded beds 
occupied during ‘normal hours’ (Wednesday at noon) and ‘out of hours’ (Wednesday at 
midnight, Sunday at midday and Sunday at midnight) are then calculated. In Figure 4 we 
present the data for midday on a Wednesday and Sunday, and in Figure 5 we compare this 
data for a three year period 2018–2020. 
Additional data for ‘out of hours’ bed occupancy is reported in the Tables and Figures section 
of the PICANet Annual Report. 
Why is this important? 
Information about levels of bed occupancy is important for both the commissioners and 
providers of PIC to ensure that there is adequate provision of paediatric critical care beds. 
PICANet data was used to model and plan bed capacity in advance of the first wave of 
COVID-19. Readers should be reminded that the 2020 data has been completely affected by 
COVID-19 and the data should therefore not be used in the usual way for planning. However, 
it is important to report the impact that COVID-19 has had on bed occupancy, in particular 
around potential respiratory syncytial virus (RSV) surge planning following low rates in the 
previous year due to the social distancing measures in place to reduce the transmission of 
COVID-19. 
The NHS England recent paediatric critical care review also used this information to inform 
their review of the service. PICS standard L3-704 [15], states that average bed occupancy on 
the unit exceeding 85% for more than two successive months should be specifically 
reviewed. 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 85% for more than two successive months. Bed occupancy is also used as an NHS 
Services Quality Dashboard measure (PICO 5a). 
 

 
Headline figures: Bed occupancy during ‘normal hours’ and ‘out of hours’ 
29 
 

 
30 
PICANet 2021 annual summary report 
Metric 1: Case ascertainment and 
timeliness of data submission 
What are we measuring? 
PICANet collect data from all 32 PICUs in the UK and ROI giving 100% coverage of the 
PICU network. Within each PICU we measure case ascertainment which is a measure of the 
proportion of total admissions that are reported to PICANet. This is one aspect of data 
quality. 100% case ascertainment would mean we received information for all admissions. 
Case ascertainment is usually assessed independently of the PICUs by the PICANet Team 
during routine validation visits. Due to the COVID-19 pandemic it was not possible for these 
validation visits to be undertaken in 2020 and as such we are unable to present this metric 
this year due to lack of independent assurance. 
We also measure the timeliness of data collection and present how many of the admission 
events are completed on the PICANet database within three months of discharge—a 
requirement of the PICS standards. An admission record was defined as complete when all 
validation checks relating to PICU admission, discharge and care in PICU had been fulfilled 
(i.e. excluding any validation checks on 30 day follow-up). Figure 6 shows the proportion of 
admission records defined as complete within three months of patient discharge in each 
country and Figure 7 provides a breakdown for individual PICUs. All admissions are included 
in these metrics regardless of the age of the patient. 
What did we find? 
Timeliness of data submission 
The completeness of patients’ admission data within three months of their discharge from the 
unit was 86.2% for the three-year period from 2018 to 2020 across the UK and Republic of 
Ireland (Figure 6). The rate increased to 88.7% when excluding Northern Ireland, which had 
a pause in data submission due to the introduction of the General Data Protection Regulation 
(GDPR) so that the unit could not submit within the required timelines, and the Republic of 
Ireland, which had pause in data collection in 2020 due to a cyber-attack on the health 
service’s systems. 
 

 
Metric 1: Case ascertainment and timeliness of data submission 
31 
Figure 6: Proportion of all admission records completed within 3 months of 
discharge by country of admission, 2018–2020 
 
This figure is ordered by overall rate of completion within 3 months for each country. 
This figure excludes any patients still in PICU at the time of analysis and includes admissions where the patient 
was aged 16+ years at admission or where the patient’s age was unknown. 
Northern Ireland had a pause in data collection in 2018 causing a delay in data submission. Republic of Ireland 
had a pause in data collection in 2020 due to a cyber-attack on the ROI health service systems. 
The ‘Overall’ category combines all admissions and calculates the timely completion rate overall, it is not 
calculated by taking an average of each unit’s completion rate.  
 
Wales had the highest overall rate of timely completion at 98%, followed by Scotland at 91% 
and England (NHS) at 88%. Wales consistently had timely completion rates of over 95% in 
each year of the reporting period. Scotland had a reduction from 99% to 86% between 2018 
and 2019 before increasing to 91% in 2020. NHS units in England saw an increase from 81% 
in 2018 to 92% in 2019 which was sustained into 2020; a similar trend was seen in non-NHS 
PICUs. Both the Republic of Ireland and Northern Ireland was impacted by unavoidable 
pauses in data collection during the reporting period; as such the rate of timely completion in 
86.2%
82.1%
87.7%
89.2%
88.3%
81.3%
91.6%
93.0%
83.1%
78.1%
86.1%
87.1%
98.0%
98.0%
99.4%
96.3%
91.3%
99.1%
85.5%
90.6%
18.7%
7.3%
3.2%
56.2%
76.0%
96.8%
72.0%
58.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Overall
2018
2019
2020
Overall
2018
2019
2020
Overall
2018
2019
2020
Overall
2018
2019
2020
Overall
2018
2019
2020
Overall
2018
2019
2020
Overall
2018
2019
2020
UK & ROI
England
(NHS)
England
(non-NHS)
Wales
Scotland
Northern
Ireland
Republic of
Ireland
Records completed within 3 months
Country / Year
Completed in 3 months
Not completed in 3 months

 
32 
PICANet 2021 annual summary report 
ROI fell over the three-year period, from 97% to 59%, and rose in Northern Ireland, from less 
than 10% in 2018 and 2019 to 56% in 2020. 
In 2020, of the 32 PICUs, 27 (84%) units had a timely completion rate of over 80% including 
15 units which had at least 98.8% of records complete within three months (Figure 7). Six 
units provided 100% of admissions data within the expected timeframe. Four units had less 
than 60% of records completed within three months of discharge including one from the 
Republic of Ireland affected by the data pause. 
Figure 7: Proportion of admission records completed within 3 months of 
discharge by PICU, 2020 
 
The ‘Overall’ category combines all admissions and calculates the timely completion rate overall, it is not 
calculated by taking an average of each unit’s completion rate.  
This figure excludes any patients still in PICU at the time of analysis and includes admissions where the patient 
was aged 16+ years at admission or where the patient’s age was unknown. 
Republic of Ireland had a pause in data collection in 2020 due to a cyber-attack on the ROI health service 
systems (ZC and ZD).  
ZE closed permanently to paediatric admissions in March 2020 and data above only represent three months’ 
worth of data as opposed to a whole year.  
47.8%
56.2%
56.4%
59.4%
79.1%
80.5%
83.5%
85.3%
87.3%
89.2%
89.5%
92.6%
93.2%
93.4%
95.8%
95.9%
96.3%
96.6%
98.8%
98.9%
99.2%
99.2%
99.4%
99.5%
99.6%
99.8%
99.8%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
0%
25%
50%
75%
100%
ZC
ZB
F
H
Y
M
ZF
ZD
N
Overall
K2
U
A
O
X1
Z
C
X2
E2
P
ZA
D
L
Q
S
E1
W
I
K3
R
T
V
ZE
Records completed within 3 months
PICU
Completed in 3 months
Not completed in 3 months

 
Metric 1: Case ascertainment and timeliness of data submission 
33 
What does this mean? 
High levels of case ascertainment ensure that we are confident our findings will be 
representative of the events and care processes that take place in PICUs. PICUs in England, 
Wales, Scotland and England had more than 80% of admission data submitted in a timely 
manner over the whole reporting period; Northern Ireland and the Republic of Ireland both 
had unavoidable pauses in data collection in 2018 and 2020 respectively. Despite this, data 
timeliness overall has been increasing over the three year period, rising to around 90% 
overall in 2020.  
Further details 
Definitions and methods 
Every PICU receives a validation visit from the PICANet research nurse on a rolling 
programme. At those visits, the numbers of admissions recorded locally are compared with 
the numbers held on the PICANet database. Any discrepancies are followed up by the PICU. 
This is called an ascertainment check. Not every PICU is visited each year, so our 
ascertainment check is based on those PICUs that have received a visit in the most recent 
year of the reporting period. Due to the COVID-19 pandemic it was not possible for any 
validation visits to be undertaken in 2020 and as such we have been unable to present an 
independently validated estimate of case ascertainment. We also monitor the timeliness of 
data completion, benchmarking against the PICS standard for reporting admissions to 
PICANet within three months of discharge from the unit. 
Why is this important? 
We want to base our analyses on all admissions to be sure that we can interpret our 
findings appropriately. If a significant proportion of admissions is missing we cannot be as 
confident about our conclusions. For example, if a number of admissions of children who had 
died on PICU were missing, we may make the wrong conclusion when comparing 
standardised mortality ratios (SMRs) between PICUs. We were unable to present data on 
case ascertainment for 2020 due to the COVID-19 pandemic, however PICANet has 
consistently had high case ascertainment (e.g. between 2015 and 2019 our estimate of case 
ascertainment was greater than 97% each year) and it is unlikely that the pandemic would 
have reduced our case ascertainment rate. Even though we don’t have an exact estimate of 
case ascertainment for 2020, previously high case ascertainment rates mean that we can be 
confident about our findings. 
As well as ensuring we collect data on as many admissions as possible, we also want to 
ensure that data are collected in a timely manner, that data are accurate and that all relevant 
data are available for analysis. 
Please note that as from 1st January 2022, PICANet will be moving to a two month 
submission guideline in accordance with L3-702 of the PCCS Quality Standards for Critically 
Ill or Injured Children (2021), and PIC10a of the Paediatric Intensive care Quality Dashboard 
2021/2022. 
 
 

 
34 
PICANet 2021 annual summary report 
Metric 2: Retrieval mobilisation times 
What are we measuring? 
Some children need to be transported to a PICU in a different hospital for urgent care (non-
elective transports). PICANet have calculated how long it takes for the PIC centralised 
transport service (CTS) team to mobilise and start their journey to retrieve a child needing 
urgent PIC admission once the decision has been made that PIC transport is required. The 
mobilisation times of 30 minutes, 31 to 60 minutes, 61 to 180 minutes, and over 180 minutes 
are represented for the UK and ROI for 2020. This information is further summarised for the 
individual PIC transport teams. 
What did we find? 
For 2018 and 2019, the average number of non-elective transports was just over 4,200 
journeys. For 2020 this number decreased by 30% to 2,896 non-elective (emergency) 
transports. Figure 8 shows that 64% of all PIC transport teams mobilised within 30 minutes, 
an increase from 59% in 2018 and 2019. 
Of these, eight of the 12 organisations, mobilised within 30 minutes for more than half of their 
transports. During 2020 for over half of the specialist PIC transport teams, over four-fifths of 
their journeys commenced within one hour after the decision was taken that the child 
required emergency transport. 
Figure 8: Number on non-elective PIC transports mobilised by time to 
mobilisation 
 
Organisations are ranked by the NHS England 30 minute target. Northern Ireland, Scotland, Wales and the 
Republic of Ireland are exempt from this target but included in the figure. 
 
Just over 1 in 30 journeys (3%) started more than three hours after this decision. For the 
three-year period 2018–2020 (Figure 9), the time taken to mobilisation was consistent with at 
least 77% of journeys started within one hour of the decision to transport each year, although 
there was a 30% reduction in the number of journeys carried out in 2020. 
3%
6%
6%
14%
17%
17%
18%
18%
18%
64%
59%
59%
0
500
1,000
1,500
2,000
2,500
3,000
2020
2019
2018
Number of transports
Time to 
mobilisation 
/ Year
0-30 minutes
31-60 minutes
61-180 minutes
181+ minutes

 
Metric 2: Retrieval mobilisation times 
35 
 
Figure 9: Proportion of non-elective transports mobilised by PIC CTS team by 
time to mobilisation: UK and Republic of Ireland, 2020 
 
*Organisations are ranked by the NHS England 30 minute target. Northern Ireland, Scotland, Wales and the 
Republic of Ireland are exempt from this target but included in the figure. 
What does this mean? 
In the vast majority of cases, PIC transport teams take less than an hour to start their journey 
to pick up a child who requires urgent critical care. The NHS England Quality Dashboard 
recommends that the team departs the transport base within 30 minutes from the time the 
referral is accepted for retrieval. Most PIC transport teams aim to depart base within 30 
minutes of accepting a child for urgent transport. In those cases where it takes longer for the 
team to depart, the reason for this may relate to the availability of staff, a transport vehicle or 
a PICU bed. 
At busy times identifying an available paediatric intensive care bed may delay departure and 
some journeys require road and air transport which also requires additional planning before 
the team can depart. 
Time to mobilise does show some variation between transport teams due to covering 
different and sometimes remote geographical areas, using both road and air travel to achieve 
their retrieval. The planning required to effect these types of transport may further delay 
departure from base.  
Further details 
Definitions and methods 
Once a specialist transport organisation has agreed to transport a child they have a target 
set by the Care Quality Commission to start their journey within one hour and NHS England 
Quality Dashboard monitors the percentage of emergency retrievals undertaken where the 
team departs the transport base within 30 minutes from the time the referral is accepted for 
retrieval. Standards for mobilisation time have not been defined for the devolved nations and 
12%
20%
23%
48%
55%
57%
60%
67%
70%
74%
78%
87%
0
25
50
75
100%
*T010
*T022
*T020
T026
*T024
T027
T001
T008
T005
*T003
T002
T004
Transports mobilised
Transport team
0-30 minutes
31-60 minutes
61-180 minutes
181+ minutes

 
36 
PICANet 2021 annual summary report 
ROI. We measured the time from when the team agreed to the transport to the time they set 
off in the ambulance (or helicopter / plane) for what are called ‘non-elective’ or urgent 
transports—these are not planned transfers from one PICU to another or from a PICU to a 
district general hospital. 
Why is this important? 
Any delay in receiving intensive care could put the sick child at risk, as the referring hospital 
may not have the resources to look after a critically ill child. Delays in getting the team 
mobilised may just mean that it is very busy, e.g. during periods of ‘winter pressures’. 
Persistent delays may mean that there are insufficient resources in the transport organisation 
or there are some other organisational issues that need to be addressed. By measuring the 
time it takes to mobilise the transport team continuously over a long period of time PICANet 
are able to monitor and report back on PIC transport teams performance, enabling the 
transport organisations to make changes to improve the quality of their service if appropriate. 
The time it takes the PIC centralised transport service (CTS) team to start their journey to 
pick up a child who needs urgent PIC care and the time taken by the team to travel, from the 
journey start point to the child’s bedside in the referring hospital, are added together to 
provide a measure called the ‘time to bedside’. 
Reaching the bedside of a critically ill child within three hours of agreeing the child requires 
urgent PIC care is a key target for Paediatric Critical Care Transport Teams (PCCTs) to 
achieve in the United Kingdom. Whilst timely access to specialist care is necessary for these 
children, a study from England and Wales, undertaken by DEPICT [16] showed no evidence 
that reducing the time-to-bedside target for PIC CTS teams will improve the survival of 
critically ill children. 
 


 
38 
PICANet 2021 annual summary report 
Metric 3: Number of nurses providing 
clinical care per bed 
What are we measuring? 
In November of each year, we ask PICUs to record how many clinically qualified nurses and 
non-registered health care staff are employed on their PICU, both in terms of their 
establishment (i.e. total funded posts) and any vacant posts. 
The Paediatric Intensive Care Society (PICS) Standards (2015), state a minimum number of 
7.01 Whole Time Equivalent (WTE) qualified (registered) nurses are needed to staff one 
level 3 critical care bed. Non-registered staff with appropriate competencies may be included 
in calculations of staffing levels per child requiring critical care, so long as they are working 
under direct supervision of a registered nurse at all times.  
What did we find? 
Overall the establishment figures from PICUs across the UK and the Republic of Ireland 
show that in 2020 only one PICU (3%) met the PICS standards for nursing staff of 7.01 
WTEs per bed of clinically qualified nurses. This increased to six PICUs (18%) when non- 
registered health care staff (Bands 2–4) providing clinical care were included (Figure 10).  
However, if all the recorded vacancies for qualified nurses and non-registered health care 
staff working clinically were filled, 16 (48%) PICUs would meet the PIC standard of 7.01 
WTEs per bed.  
Figure 10: Number of registered and non-registered nursing staff providing 
clinical care in post (WTE) per bed by band and by health organisation, 2020 
 
Ranked by total staff per bed (WTE) for bands 2–7 combined.  Data behind this Figure can be viewed in Table S1c 
in the Tables and Figures.  
PICS standards state a minimum number of 7.01 WTE 
nurses are needed to staff one level 3 critical care bed
0
2
4
6
8
10
S
L
R
V
X2
M
C
Q
ZC
X1
D
F
P
A
E2
K3
K2
ZB
E1 PICU
Y
H
E1 NICU
W
I
T
U
ZD
ZA
N
O
Z
ZF
Staff per bed (WTE)
PICU
Band 2-4 vacancies
Band 5-7 vacancies
Band 2-4
Band 5-7

 
Metric 3: Number of nurses providing clinical care per bed 
39 
What does this mean? 
Based on the data provided by UK and Republic of Ireland PICUs in November 2020, only 
one PICU met the recommended standard of the Paediatric Intensive Care Society for the 
minimum number of WTE nurse establishment of 7.01. The addition of bands 2–4 delivering 
clinical care has enabled five additional PICUs to meet this standard. However, despite few 
PICUs meeting these standards, staffing data from the census shows that the units ensure 
that their staffing levels are appropriate for the number of children on the unit and their care 
requirements, despite NHS and staff working under pressure during the COVID-19 
pandemic. This may be achieved by unit staff working flexibly, undertaking additional shifts or 
using bank or agency staff. The data should be used to inform the future planning of PIC 
particularly post COVID-19 workforce planning. 
Further details 
Definition and methods 
Each year PICANet carries out a staffing study to monitor staffing levels within PICUs and to 
audit the appropriate standards of the Paediatric Critical Care Society. These are currently 
the PCCS Quality Standards for the Care of Critically Ill or Injured Children (6th Edition, 
October 2021). Staffing data are collected in the November of each year: for the week 
beginning 2 November in 2020, PICANet present the percentage of PICUs meeting the 
recommended level of nurse staffing per funded critical care bed. PICS Quality Standards for 
the Care of Critically Ill Children (5th Edition, December 2015) were in place at the time of 
the 2020 staffing data collection. 
The recommended number of nurses required (or nurse staffing establishment), in order to 
provide the appropriate levels of care for the number and given dependency of the bed, is 
calculated according to the PICS Standards (2015), (one nurse to one bed) and high 
dependency (one nurse for every two beds). 
Why is this important? 
PICUs need to be able to monitor whether they have adequate nursing staff available to run 
their unit efficiently. PICS Standard L3-207 (2015), and guidance from the PICS Nurse 
Workforce Planning document for Level 3 Paediatric Critical Care Units, October 2016 states 
that ‘the minimum number of qualified nurses required to staff one level 3 critical care bed is 
a minimum of 7.01 WTE’. Non-registered staff (health care assistants) with appropriate 
competencies may be included in calculations of staffing levels per child requiring critical 
care so long as they are working under direct supervision of a registered nurse at all times.  
The availability of specialist PIC nurses is affected by many factors external to PIC including 
nursing salaries and the cost of living in capital cities. Some PICUs are developing the role of 
band 2–4 health care assistants to support qualified staff in delivering clinical care in critical 
care units. Whilst staff recruitment and retention was considered as part of the critical care 
review, unfortunately the impact of COVID-19 pandemic has shifted the focus to flexible 
ways of working, alternative staff/patient ratio [17, 18] and staff well-being aimed at retention 
of staff rather than recruitment [19]. The UKCCNA has emphasised a review of recruitment 
and retention strategies post pandemic [20].  
 
 

 
40 
PICANet 2021 annual summary report 
Metric 4: Emergency readmissions within 
48 hours 
What are we measuring? 
For each PICU, we record the frequency of emergency readmissions to the discharging 
PICU within 48 hours of discharge in comparison to the average for the UK and Republic of 
Ireland (Table 7). This is calculated using the admission and discharge dates and times. The 
emergency readmission rate for each nation was calculated by dividing the number of 
emergency readmissions by the total number of admissions occurring in that nation for a 
given year. 
We also consider relative emergency readmission rates; these allow us to compare each 
PICU’s rate of emergency readmission within 48 hours with the equivalent rate over the UK 
and Republic of Ireland combined (Figure 11), by dividing their 48 hour emergency 
readmission rate by the combined UK and Republic of Ireland rate. Relative readmission 
rates higher than one indicate that a PICU has a higher rate of emergency readmissions 
within 48 hours than the overall rate for the UK and Republic of Ireland. 
What did we find? 
On average between 2018 and 2020 around 310 children (equivalent to about 1.7 out of 
every 100 admissions) on average were discharged from PICU but then readmitted as an 
emergency within 48 hours each year (Table 7). Rates of emergency readmissions remained 
steady in England over the reporting period. Wales and Northern Ireland both saw a peak in 
emergency readmissions in 2018 with rates falling in 2019 and 2020. Rates in Scotland were 
steady in 2018 and 2019 but increased slightly in 2020. In the Republic of Ireland, 
emergency readmission rates were lowest in 2018 and remained at 1.7% in 2019 and 2020.  
In 2020, the rate of readmissions for individual PICUs ranged between 0% and 3.7%; 
however, it is important to note that not all PICUs were open to paediatric admissions for the 
whole of 2020 due to the COVID-19 pandemic. The rate of readmission for individual PICUs 
over the three years of the reporting period combined ranged between 0.2% and 2.6%. 
Table 7: Number of emergency readmissions within 48 hours, 2018–2020 
Country 
2018 
2019 
2020 
2018–2020 
England 
268 (1.6%) 
244 (1.5%) 
216 (1.6%) 
728 (1.6%) 
Wales 
15 (2.9%) 
8 (1.6%) 
3 (0.8%) 
26 (1.9%) 
Scotland 
26 (1.9%) 
31 (1.8%) 
25 (2.1%) 
82 (1.9%) 
Northern Ireland 
14 (2.8%) 
8 (1.6%) 
4 (1.1%) 
26 (1.9%) 
Republic of Ireland 
18 (1.3%) 
26 (1.7%) 
24 (1.7%) 
68 (1.5%) 
Total 
341 (1.7%) 
317 (1.6%) 
272 (1.7%) 
930 (1.6%) 
Readmissions within 48h defined as an unplanned admission to the discharging PICU within 48 hours of 
discharge from that PICU. 
Due to small numbers, data for non-NHS and NHS organisations in England are presented combined. 
 

 
Metric 4: Emergency readmissions within 48 hours 
41 
The emergency readmission rate for each PICU for the 3-year reporting period ranged from 
0.1 to 1.6 times the overall UK and Republic of Ireland rate. We would expect to see 
substantial variation in each PICU because of the low number of emergency admissions 
within 48 hours within each individual unit. 
Figure 11: Relative rate of emergency readmission within 48 hours of discharge 
by PICU for 2018–2020 
 
Emergency readmission rates for each individual unit are relative to the overall rate of 1.63, the horizontal 
dotted line shows where a bar would sit if a unit had an emergency readmission rate that was exactly the same 
as the overall rate. 
Data behind this Figure can be found in Table 42 in the Tables and Figures 
What does this mean? 
The proportion of patients requiring emergency re-admission within 48 hours of discharge 
from PICU was low in all countries, with around 1.6 per 100 admissions. There was 
substantial variation in the relative emergency readmission rate between PICUs and within 
PICUs year on year. This must be interpreted within context of the waves of the COVID-19 
pandemic as some units closed to paediatric admissions for part of 2020. 
Further details 
Definitions and methods 
We defined an emergency readmission within 48 hours as any unplanned admission to the 
same PICU within 48 hours of their last discharge from PICU. So if a child was admitted on 
1 March at 12:00 and discharged on 2 March at 17:00, but then admitted as an emergency 
(an unplanned admission) before 4 March at 17:00, they would have been counted in our 
analysis as they returned to PICU within 48 hours. We then calculated the number of 
emergency readmissions within 48 hours for every 100 admissions in each PICU to give a 
rate per 100 admissions. This allows us to compare PICUs with different numbers of 
admissions. 
There is no standard set for the acceptable rate of emergency readmissions within 48 hours, 
so in order to calculate relative rates we used the overall readmission rate for each specific 
If a PICU had an emergency readmission rate 
equal to the overall rate, then the relative 
rate would equal 1.0
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
ZE ZF E2 L ZD H K2 F K3 T
I X2 N D Y R O W U E1 X1 ZC C ZB A P M V Z ZA S Q
Relative rate
PICU

 
42 
PICANet 2021 annual summary report 
year based on all PICUs contributing to PICANet as the standard. We then compared the 
48-hour emergency readmission rate for each individual PICU to this overall rate. When 
interpreting the data, PICUs with relative readmission rates below one have a lower 
readmission rate than that seen in the UK and Republic of Ireland combined and PICUs with 
a relative rate above one have a higher readmission rate. 
Why is this important? 
Emergency readmission within 48 hours is an undesirable outcome. From an individual 
child’s perspective, it suggests that their health has deteriorated in a short space of time and 
that they require further intensive care treatment. This will cause stress to the child, their 
families and their carers. For a busy PICU, each admission also creates additional demand 
on a service that usually operates close to capacity. 
It should be noted that although emergency readmission is used as a quality indicator, we 
cannot say that the sole or primary readmission was a reflection of the care provided. 
PICANet is therefore unable to assess whether the child was discharged too early, or into the 
wrong care environment, or whether the need for future intensive care was not foreseen. 
Relative rates of emergency readmission within 48 hours compared with the overall rate for 
the UK and Republic of Ireland show considerable variation year on year, although some of 
this variation could be due to small numbers of emergency readmissions within 48 hours in 
each PICU. This suggests that emergency readmission rates should be monitored on an 
ongoing basis. 
 
 


 
44 
PICANet 2021 annual report 
Metric 5: Mortality in PICU 
What are we measuring? 
Mortality (death) rates are assessed for every PICU based on a statistical approach that 
accounts for the severity of the child’s illness at the time of admission. This method is known 
as risk adjustment. The number of children who actually die (the ‘observed’ number) is 
compared to the number we predict to die (the ‘expected’ number, based on their clinical 
characteristics at the time of admission) to derive the risk-adjusted Standardised Mortality 
Ratio (SMR). The risk-adjustment method used to calculate expected mortality was the 
Paediatric Index of Mortality version 3 (PIM3)[2], which has been recalibrated based on the 
data within this reporting period. Further details on recalibration can be found in the Tables 
and Figures document. This year we present risk-adjusted SMRs only for admissions for 
children aged 0–15 years (as opposed to previous years where we presented based on all 
admissions); this is because PIM3 was created and validated on data from children rather 
than all admissions and as such the risk-adjustment is most appropriate in this age group. 
What did we find? 
The risk-adjusted SMR for each PICU in the UK and Republic of Ireland for the three-year 
reporting period 2018–2020 is plotted in Figure 12. There was no evidence that any PICU 
had an excess mortality rate compared to what would be expected either when looking at just 
children (0–15 year olds). Three PICUs had a substantially lower mortality rate than would be 
expected even after allowing for natural variation: Edinburgh, Middlesbrough and 
Southampton. 

 
Metric 5: Mortality in PICU 
45 
Figure 12: Risk-adjusted Standardised Mortality Ratio (SMR) by health 
organisation for 0–15 year olds, 2018–2020 
 
Risk-adjustment based on PIM3 calculations recalibrated in 2021. 
Data behind this Figure can be found in Table 47 in the Tables and Figures. 
 
What does this mean? 
No PICUs had substantially more deaths than was to be expected after allowing for the level 
of sickness of the patient at the time of admission; three PICUs had substantially fewer 
deaths than expected. 

 
46 
PICANet 2021 annual report 
 
How to read a funnel plot 
Figure 13 is a simple example of what a funnel plot might look like. The ‘funnel’ is created using 
statistical methods that tell us what range of values we might expect for mortality, given that there 
are normal ‘ups and downs’ (natural variation). The limits are wider where there are fewer 
admissions because with only a few observations we cannot be as certain about our findings. 
With more observations we can be more confident that the outcome is likely to fall within 
narrower limits. 
Figure 13: Example funnel plot 
 
The blue dots represent individual PICUs. They are plotted from left to right (horizontal-axis) 
based on the number of admissions to each PICU. 
The blue line in the middle of the funnel represents what is “expected”, in other words if a dot 
were to fall exactly on this line then this would mean that the number of deaths observed and the 
number of expected deaths are equal to each other (so there are no more or fewer deaths than 
we anticipate). It would be quite rare for a dot to fall exactly on this line and you would always 
expect a scatter of dots above and below this line. The whole point about funnel plots is to allow 
us to see differences between units taking into account natural variation. 
Any dot that falls within the funnel shape is within the limits of what we would expect to see so 
the number of observed deaths is no greater (or smaller) than the number we expect. We 
therefore have no concerns about PICUs with blue dots within the ‘funnel’. 
If a dot is above the funnel shape (like the red dot in Figure 13) we say that it is outside the upper 
limit and is a ‘statistical outlier’. This means that the number of deaths in the PICU are higher 
than the number we expect and that this is possible due to a cause other than natural variation. 
There are many reasons that a PICU could have a dot which lies above the upper limit including 
the fact we may not have properly accounted for how sick patients are when they enter the ward, 
or purely due to chance alone. We have a specifically designed process for investigating whether 
these PICUs really do have a higher number of deaths than expected and is a ‘true outlier’. 

 
Metric 5: Mortality in PICU 
47 
Further details 
Definitions and methods 
Clinical data collected on admission are used in a statistical model to predict the probability 
that each child might die in PICU: the worse a patient’s clinical condition is on admission, the 
higher the probability that they might die. These probabilities are added up for each PICU to 
give an overall expected number of deaths in any one period. We then count the actual 
(observed) number of deaths and calculate what is known as a Standardised Mortality Ratio 
(SMR) by dividing the observed number of deaths by the expected number. We then use the 
funnel plot to assess the level of mortality in the PICUs against what is expected. 
Why is this important? 
Although death whilst receiving care on a PICU is extremely rare, it is important to assess 
whether more (or fewer) deaths than expected occur, as this can indicate that there is 
something different happening in a PICU. It only represents a statistical measure of mortality 
and it is very important to use this as an indicator that further investigation is required, not as 
a true measure of the quality of care delivered. 
 
 


 
References 
49 
References 
1. 
Paediatric Critical Care Society, PCCS Quality Standards for the care of Critically Ill 
or Injured Children (6th Edition). 2021. 
2. 
Straney, L., et al., Paediatric Index of Mortality 3: An Updated Model for Predicting 
Mortality in Pediatric Intensive Care. Pediatric Critical Care Medicine, 2013. 14(7): p. 
673-681. 
3. 
Kanthimathinathan, H.K., et al., Characteristics of severe acute respiratory syndrome 
coronavirus-2 infection and comparison with influenza in children admitted to UK 
PICUs. Critical Care Explorations, 2021. 3(3). 
4. 
Sinha, R., et al., Caring for critically ill adults in paediatric intensive care units in 
England during the COVID-19 pandemic: planning, implementation and lessons for 
the future. Archives of Disease in Childhood, 2021. 106(6): p. 548-557. 
5. 
Office for National Statistics. Population estimates for the UK, England and Wales, 
Scotland and Northern Ireland: mid-2019, using April 2020 local authority district 
codes. 2021; Available from: 
https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/popu
lationestimates/datasets/populationestimatesforukenglandandwalesscotlandandnorth
ernireland. 
6. 
Central Statistics Office. 2016 Census population estimates, Republic of Ireland. 
Available from: https://data.cso.ie/product/C2016SR1  
7. 
Office for National Statistics. Deaths registered in England and Wales. Available from: 
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/de
aths/datasets/deathsregisteredinenglandandwalesseriesdrreferencetables. 
8. 
National Records of Scotland. Table DT.03: Deaths, by sex and single year of age, 
Scotland 1974 to 2020. Available from: https://www.nrscotland.gov.uk/statistics-and-
data/statistics/statistics-by-theme/vital-events/deaths/deaths-time-series-data. 
9. 
Northern Ireland Statistics and Research Agency. Deaths by Age 1955-2019. 
Available from: https://www.nisra.gov.uk/publications/death-statistics  
10. 
Central Statistics Office (Republic of Ireland), via information request. 
11. 
da Silva, P.S.L., et al., Care bundles to reduce unplanned extubation in critically ill 
children: a systematic review, critical appraisal and meta-analysis. Archives of 
disease in childhood, 2021. 
12. 
Kanthimathinathan, H.K., et al., Unplanned extubation in a paediatric intensive care 
unit: prospective cohort study. Intensive Care Med, 2015. 41(7): p. 1299-306. 
13. 
NHS England. Paediatric Intensive care (PICU) Quality Dashboard 2021/2022. 2021. 
14. 
NHS England. Paediatric Intensive care Planned Surgical Activity Review – 
September 2020. 2020. 
15. 
Paediatric Intensive Care Society, PICS Quality Standards for the care of Critically Ill 
Children (5th Edition). 2015. 
16. 
Seaton, S.E., et al., Does time taken by paediatric critical care transport teams to 
reach the bedside of critically ill children affect survival? A retrospective cohort study 
from England and Wales. BMC Pediatrics, 2020. 20(1): p. 301. 
17. 
Paediatric Critical Care Society. RE: Nursing Ratios. 2020 9/4/2020; Available from: 
https://pccsociety.uk/wp-content/uploads/2020/04/Nursing-ratios-letter-v1.0-
16April2020.pdf  
18. 
UK Critical Care Nursing Alliance. UKCCNA Position Statement: Nurse Staffing 
during COVID-19: Jan 2021. 13/01/2021; Available from: 
https://ficm.ac.uk/sites/ficm/files/documents/2021-
10/ukccna_position_final_13.01.2021_.pdf. 
19. 
NHS Employers. COVID-19: Guidance for the NHS workforce community on 
managing COVID-19.; Available from: https://www.nhsemployers.org/covid19. 
20. 
UK Ciritical Care Nursing Alliance. UKCCNA position statement: Critical Care nursing 
workforce post COVID-19. 2020; Available from: https://pccsociety.uk/wp-
content/uploads/2020/05/UKCCNA-position-statement-Critical-Care-nursing-
workforce-post-COVID-xx-xxxx-xxxx.pdf. 


 
Glossary 
51 
Glossary 
CAG 
Clinical Advisory Group 
CHI 
Community Health Index 
CTS 
Central Transport Services 
GDPR 
General Data Protection Regulation 
HD 
High dependency 
HQIP 
Healthcare Quality Improvement Partnership 
HRA 
Health Research Authority 
HRG  
Healthcare Resource Group 
IC 
Intensive Care 
NCAPOP 
National Clinical Audit and Patient Outcomes Programme 
NHS 
National Health Service 
NOCA 
National Office of Clinical Audit 
ODN 
Operational Delivery Networks 
PCCS 
Paediatric Critical Care Society 
PCCT 
Paediatric Critical Care Transport 
PIC 
Paediatric Intensive Care 
PICANet 
Paediatric Intensive Care Audit 
PICS 
Paediatric Intensive Care Society 
PICU 
Paediatric Intensive Care Unit 
PIM3 
Paediatric Index of Mortality 3 
RA-RSPRT 
Risk Adjusted Resetting Sequential Probability Ratio Test 
ROI 
Republic of Ireland 
SG 
Steering Group 
SMR 
Standardised mortality ratio 
UKCCNA 
UK Critical Care Nursing Alliance 
UK 
United Kingdom 
WHSSC 
Welsh Health Specialised Service Committee 
WTE 
Whole time equivalent  
 
 
 

 
 
 
 
Richard Feltbower 
Hannah Buckley  
Zoe Cosker 
Kirsten Cromie 
Christopher Leahy 
Hannah Lever 
Lee Norman 
Laura Stubbs 
 
PICANet 
Leeds Institute for Data Analytics 
School of Medicine 
University of Leeds 
Clarendon Way 
Leeds 
LS2 9JT 
 
Elizabeth Draper 
Lyn Palmer 
Martin Perkins 
Sarah Seaton 
Ruth Matthews 
 
PICANet 
Department of Health Sciences 
University of Leicester 
George Davies Centre 
University Road 
Leicester 
LE1 7RH 
 
University of Leicester 
University of Leeds 
www.picanet.org.uk 
xxx@xxx.xx