Supplementary Chapters
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.

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

2
PICANet 2021 Annual Report: Supplementary Chapters
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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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

Special Chapter 1: COVID 19 and PIMS TS in PICU
3
Contents
Special Chapter 1: COVID-19 and PIMS-TS in PICU ............................................................. 5
Special Chapter 2: COVID-19 Staffing Survey ..................................................................... 31
Special Chapter 3: Diabetic ketoacidosis in English PICUs: the impact of COVID-19 .......... 47
References .......................................................................................................................... 57

For the Tables, Figures and Appendices relating to this report, please visit the PICANet
website www.picanet.org.uk.

Special Chapter 1: COVID-19 and
PIMS-TS in PICU
1. Introduction
This chapter presents data on children with a confirmed coronavirus (COVID-19)
diagnosis treated in a paediatric intensive care unit (PICU) in the United Kingdom (UK) but
excludes data from the Republic of Ireland. It should be noted that the reason for admission
to PICU for these children may not be due to COVID-19. In this report, we use the term
COVID-19 to describe all forms of presentations related to SARS-Co-V-2 infection as
described below.
COVID-19 is an infectious disease caused by the severe acute respiratory syndrome
coronavirus-2 (SARS-CoV-2) virus. Children make up only a small proportion of COVID-19
cases compared to adults, and most show less severe symptoms [1-4]. Nevertheless, some
children with a diagnosis of COVID-19 have required admission to PICUs in the United
Kingdom with associated morbidity and mortality [5-9].
SARS-CoV-2 infection has also been linked with a multisystem inflammatory illness in
children. This is commonly referred to as paediatric inflammatory multisystem syndrome
temporally associated with SARS-CoV-2 (PIMS-TS). PIMS-TS is typically characterised by
single or multi-organ dysfunction, although less serious symptoms include abdominal pain,
vomiting and diarrhoea [10].
Children described in this chapter may have presented with 1) COVID-19 only (i.e.,
confirmed SARS-CoV-2 infection without PIMS-TS, which may or may not have been
symptomatic or the reason for admission) 2) COVID-19 and PIMS-TS (PIMS-TS patients with
a positive SARS-CoV-2 polymerase chain reaction (PCR) result)); or 3) PIMS-TS only
(SARS-CoV-2 PCR negative regardless of antibody test results), as can be seen in Figure 1.
Owing to the established links between COVID-19 and PIMS-TS, we have also included a
small section of this special chapter focusing on PIMS-TS (Table 3 and Section 3.2).
Figure 1: Relationship between the three cohorts featured in this chapter

6
PICANet 2021 Annual Report: Supplementary Chapters
2. Methods
2.1 Data collection and caveats
A PICANet customised audit was established at the start of the COVID-19 pandemic
following a request by NHSE to facilitate the collection of additional information concerning:
1) All children who tested positive for COVID-19 either prior to or during their PICU
admission, and;
2) Children who remained COVID-19 suspected or probable after repeated COVID-19
negative laboratory test results and in the presence of no other positive virology and
bacteriology results. This included children admitted with PIMS-TS exclusive of other
anti-microbial causes1.
Additional data items included details about testing for COVID-19, symptoms, co-infection
laboratory markers, echocardiogram findings and medication used. Details about testing for
children was required to understand the use of different sampling for the identification of
COVID-19. This included: COVID-19 status on admission, up to three rounds of testing
including date and time of testing, reason for testing (suspected infection or routine testing),
types of samples taken, results of each test, laboratory markers at admission, co-infections,
symptoms, and medications. With regards to testing, multiple different types of tests can be
undertaken in the same testing episode.
2.2 Data definitions and handling
2.2.1 Admission episode
An admission episode was defined as any continuous period of intensive care, including
direct transfers between PICUs. For children readmitted to PICU more than 48 hours post
PICU discharge the re-admission was considered separately as a new admission. Analyses
based on PICU care episodes (Tables 1-3) used the first available patient characteristics and
admission details and the last available discharge information. Details of treatment provided
in a single care episode was an aggregate of all information available. Length of stay was
calculated based on duration of PICU care as the difference in days between the admission
date and discharge date; in cases where the child was re-admitted to PICU within 48 hours
of PICU discharge or transferred, the calculation of length of stay included the period where
the child was not being treated within a PICU.
2.2.2 Co-morbidities
Co-morbidities were reviewed for all children and grouped into major diagnostic categories:
▪
Inherited genetic / Chromosomal abnormalities
▪
Chronic Pulmonary Disease
▪
Congenital Heart / Cardiac Disease
▪
Malignancy including leukaemia, lymphoma, solid tumours
▪
Neurological/Developmental incl. autism, epilepsy, cerebral palsy
▪
Metabolic/Endocrine incl. diabetes
▪
Preterm

1 PIMS-TS data was consistently collected from January 2021 and some units may have
retrospectively provided data on children admitted with PIMS-TS prior to this.

Special Chapter 1: COVID 19 and PIMS TS in PICU
7
2.2.3 Pandemic phases
In some instances, we present data according to two phases of the COVID-19 pandemic.
Children in the COVID-19 only cohort (Section 3.1.1) were categorised as falling into one of
two phases based on the date of the first positive confirmation of COVID-19 via PCR:
1. On or before 31 August 2020 (Phase 1)
2. On or after 1 September 2020 (Phase 2)
These dates were used to define phases for the whole of the UK for the analyses in Section
3.1 and Figure 2. This two-phase approach mirrors that used in other published reports on
COVID-19 in critical care [11].
For instances where a child had multiple recorded admissions to PICU, they were
categorised into a phase based on the date of the first positive confirmation of COVID-19 via
PCR, during their first recorded admission to PICU.
Eleven children did not have a date of the first positive confirmation of COVID-19 via PCR
recorded by the date of data cut-off (27 July 2021) and so were excluded from the analysis.
2.2.4 Townsend deprivation index
The Townsend deprivation index [12] is a census-based, area-level index which is widely
used in healthcare research. Townsend scores were allocated to children by postcode of
residence to provide a general measure of deprivation. Positive Townsend scores are
indicative of high levels of deprivation, whereas negative scores indicate relative low levels of
deprivation.
2.3 Data analysis
Descriptive data were reported as numbers and percentages for categorical variables and
medians with interquartile ranges (IQR) and mean and standard deviations for continuous
variables. Z-scores are a widely used measure to display and monitor growth measurements
[13]. In childhood, weight-for-age z-scores can be used to assess growth and nutritional
status. These are derived by comparing individual growth measurements against
standardised growth data, or charts from a ‘normal’, or reference population. A z-score is the
distance and direction of an observation away from the population mean. These were
calculated using the UK-WHO Growth References [14], accounting for pre-term birth where
required, to compare the weight of a child in PICU to the mean weight for a comparable child
of the same sex and age. Estimates and 95% confidence intervals (CIs) for the difference
between the COVID-19 and influenza cohorts (Table 2) were obtained using t-tests for
continuous data, a type of inferential statistic which is commonly used to determine if there is
a significant difference between the means of two groups. A two-sample test of proportions
was used to compare discrete variables.

8
PICANet 2021 Annual Report: Supplementary Chapters
3. Results
3.1 COVID-19 only cohort
3.1.1 Analysis population
This section focuses on children who were positive for COVID-19 (as defined in Section 2.2)
but did not present with PIMS-TS (Figure 2).
Figure 2: COVID-19-only cohort

Focusing on children with COVID-19-only allows for robust comparisons:
▪
Of patient characteristics across the two phases of the COVID-19 pandemic; and
▪
With a cohort of flu patients admitted in 2019

The influenza cohort included children admitted to a UK PICU between 1 January and
31 December 2019 with a primary diagnosis of influenza. This comparator group was chosen
as it is known that influenza infections are associated with significant morbidity and mortality
in children of all ages and that, as another respiratory infection, these cases may have
several similarities with COVID-19 [3].
3.1.2 Overview of COVID-19 only cohort
There were 217 PICU care episodes for 209 COVID-19 positive children who presented
without PIMS-TS2. Eleven of these children did not have a date of first positive COVID PCR
test recorded and therefore are excluded from analysis as they could not be assigned to a
phase. This means that the COVID-19 only cohort comprises 198 children.
Figure 3 presents the number of PICU care episodes (UK PICUs) by week of first positive
confirmation of COVID-19 via PCR, for all 209 children with confirmed COVID-19 (without
PIMS-TS) between the 14 March 2020 and 19 July 2021.
Characteristics recorded in the first PICU care episode for each child in the COVID-19 cohort
(n=198) are presented in Table 1a.

2 With a recorded date of the first positive confirmation of COVID-19 via PCR.

Special Chapter 1: COVID 19 and PIMS TS in PICU
9
▪
The median age of COVID-19 positive children when first admitted to PICU was
9 years (interquartile range (IQR): 1–13 years). 60% of children were aged 6 years
and above.
▪
Around 62% of the children were male.
▪
Just over two fifths of children were White (43%), just over one quarter were
Asian (27%) and approximately one-sixth were Black (17%). Data on ethnicity were
unavailable for 4% of children.
▪
64% of children were admitted to PICU for infections or respiratory conditions
with a further 12% for neurological problems and 6% for gastrointestinal problems.
▪
91% (n=180) of the initial admissions for these children were unplanned admissions
to PICU (where the admission was not expected and therefore was an emergency
admission).

Figure 3: Number of PICU care episodes (UK PICUs) by week of first positive confirmation of COVID-19 via PCR, for children with
confirmed COVID-19 (without PIMS-TS)

6
9 9 9
4
3
4
3
3
3
4
3
4
9
3
5
6 6
5
12
11
16
8
6
5
4
2
4
2
3
3
0
2
4
6
8
10
12
14
16
Number of PICU
care episodes
Week commencing
Value suppressed (<3)

12
PICANet 2021 Annual Report: Supplementary Chapters
Table 1a: Characteristics and treatment details for all children (<18 years) with
a confirmed COVID-19 (without PIMS-TS) diagnosis and treated in a paediatric
intensive care unit (PICU) in the United Kingdom (UK), overall and for two
phases of the COVID-19 pandemic alongside comparisons from previous years

All COVID-19
positive
children π

n=198
COVID-19
positive
children
(Phase 1 Ω)
n=55
COVID-19
positive
children
(Phase 2 Ω)
n=143
Proportions
from PICU
admissions
2017–2019*
Age group at first PICU admission, n (%)
Neonate <30 days
Infant 31–365 days
Young child 1y–5y
Older child 6–12y
Teenager 13–18y

8 (4.0)
29 (14.7)
41 (20.7)
56 (28.3)
64 (32.3)

4 (7.3)
9 (16.4)
10 (18.2)
15 (27.3)
17(30.9)

4 (2.8)
20 (14.0)
31 (21.7)
41 (28.7)
47 (32.9)

12.9%
29.3%
28.8%
17.3%
11.7%
Male, n (%)
122 (61.6)
33 (60.0)
89 (62.2)
56.7%
Ethnicity, n (%)
White
Asian
Black
Other
Mixed
Unknown

87 (43.9)
54 (27.3)
33 (16.7)
12 (6.1)
7 (3.5)
5 (2.5)

21 (38.2)
16 (29.1)
12 (21.8)
3 (5.5)
3 (5.5)
0 (-)

66 (46.2)
38 (26.6)
21 (14.7)
9 (6.3)
4 (2.8)
5 (3.5)

60.7%
9.5%
4.1%
2.2%
2.8%
20.0%
Weight z-score
n (%)
Mean (SD)
Median (IQR)

189 (95.5)
0.3 (2.0)
0.2 (-0.7–1.6)

51 (92.7)
0.2 (2.0)
-0.1 (-1.1–1.4)

138 (96.5)
0.3 (2.1)
0.2 (-0.7–1.7)

/ *
Townsend deprivation index score
n (%)
Mean (SD)
Median (IQR)

191 (96.4)
2.8 (3.8)
3.0 (-0.3–6.1)

55 (100.0)
3.1 (4.0)
3.9 (-0.6–6.7)

136 (95.1)
2.8 (3.7)
2.9 (0.1–5.7)

/ *
Unplanned admission, n (%)
180 (90.9)
51 (92.7)
129 (90.2)
/ *
Comorbidity††, n (%)
Neurological/Developmental‡
Congenital Heart/Cardiac Disease
Inherited genetic/chromosomal
abnormalities
Pre-term
Malignancy†
Metabolic/Endocrine**
Chronic Pulmonary Disease
Otherβ
No recorded comorbidities

45 (22.7)
21 (10.6)
17 (8.6)

14 (7.1)
4 (2.0)
3 (1.5)
6 (3.0)
12 (6.0)
120 (60.6)

14 (25.5)
5 (9.1)
9 (16.4)

6 (10.9)
<3 (<5.5)
<3 (<5.5)
<3 (<5.5)
3 (5.5)
28 (50.9)

31 (21.7)
16 (11.2)
8 (5.6)

8 (5.6)
<3 (<2.1)
<3 (<2.1)
4 (2.8)
9 (6.3)
92 (64.3)

9.9%
11.5
3.8%

9.1%
0.4%
0.3%
3.3%
/ *
71.0%
PIM3 POD %
Mean (SD)
Median (IQR)

3.7 (5.5)
1.6 (1.2–3.9)

5.0 (7.6)
3.2 (1.2–6.0)

3.1 (4.3)
1.5 (1.2–3.6)

3.3 (8.2)
1.2 (0.5–3.3)

Special Chapter 1: COVID 19 and PIMS TS in PICU
13
Respiratory support
Total length¶ of respiratory support in PICU
(days)
n (%)
Mean (SD)
Median (IQR)

140 (70.7)
9.1 (15.4)
4.5 (2.5–9.5)

39 (70.9)
12 (23.0)
5.0 (3.0–11.0)

101 (70.6)
8.0 (11.2)
4.0 (2.0–9.0)

/ *
Maximum respiratory support ¶, n (%)
High frequency oscillatory or jet ventilation
Invasive mechanical ventilation
Non-invasive ventilation
High flow nasal cannula therapy
None

11 (5.6)
104 (52.5)
20 (10.1)
18 (9.1)
45 (22.7)

4 (7.3)
33 (60.0)
<3 (<5.5)
<3 (<5.5)
14 (25.5)

7 (4.9)
71 (49.7)
18 (12.6)
16 (11.2)
31 (21.7)

0.1%
55.6%
12.2%
7.1%
25.0%
Invasive ventilation
Total length¶ of invasive ventilation in PICU
(days)
n (%)
Mean (SD)
Median (IQR)

115 (58.1)
9.6 (16.1)
5.0 (2.0–10.0)

37 (67.3)
11.7 (22.5)
5.0 (3.0–11.0)

78 (54.5)
8.6 (12.0)
4.0 (2.0–9.0)

61.0%
6.4 (15.7)
3 (2–6)
Vasoactive support
Total length¶ of vasoactive support in PICU
(days)
n (%)
Mean (SD)
Median (IQR)

63 (31.8)
5.6 (8.6)
3.0 (2.0–5.0)

21 (38.2)
6.9 (8.6)
5.0 (3.0–6.0)

42 (29.4)
5.0 (8.6)
2.5 (2.0–3.0)

30.8%

Inhaled nitric oxide¶, n (%)
15 (7.6)
6 (10.9)
9 (6.3)
3.3%
Renal replacement therapy¶, n (%)
9 (4.6)
3 (5.5)
6 (4.2)
3.1%
Extracorporeal life support¶, n (%)
3 (1.5)
<3 (<5.5)
<3 (<2.1)
1.2%
Outcomeϕ, n (%)
Discharged alive
Died in PICU
Unknown

185 (93.4)
11 (5.6)
2 (1.0)

49 (89.1)
6 (10.9)
0 (-)

136 (95.1)
5 (3.5)
2 (1.4)

96.6%
3.5%
-
Total length¶ of PICU care (days)
n (%)
Mean (SD)
Median (IQR)

196 (99.0)
9.0 (16.1)
4.4 (2.1–9.6)

55 (100.0)
11.0 (20.1)
5.0 (2.7–11.6)

141 (98.6)
8.2 (14.2)
4.1 (1.9–9.0)

6.0 (15.8)
2.4 (1.0–5.6)
Abbreviations: CI = confidence interval; SD = standard deviation; IQR = interquartile range; PIM3 POD =
paediatric index of mortality 3 predicted probability of death;
π COVID-19 only cohort with a date of first positive PCR test between 14 March and 19 July.
Ω Phases of the COVID-19 pandemic are defined as follows:
Phase 1: 14 March–30 August 2020; Phase 2: 1 September 2020–19 July 2021.
*2017–2019 figures are based on 0-18 year olds. They are also based on admissions and not PICU care episodes,
as is the case in this special chapter. For the COVID cohort, admissions are presented based on the first PICU
care episode if there was more than one. In contrast, the 2017–2019 figures include multiple admissions for
individuals. These proportions should therefore not be used for direct comparison.
†† comorbidities not mutually exclusive;
‡ Neurological/developmental including epilepsy, cerebral palsy;
**metabolic/endocrine including diabetes;
† malignancy including leukaemia, lymphoma, solid tumours;
β other including autism and attention deficit hyperactive disorder (ADHD)
¶ where a child had multiple admission events the number of days is summed across all events;
ϕ where a child had multiple admission events, the status from the last recorded admission is presented

14
PICANet 2021 Annual Report: Supplementary Chapters
3.1.3 Patient characteristics by phase
Characteristics of the 198 children in the COVID-19-only cohort are presented by phase of
the pandemic in Table 1a.
▪
Over two-thirds (72%) of this cohort were admitted in Phase 2 (n=143 of 198).
▪
The age distribution was fairly constant across Phase 1 and 2. Admissions to PICU
from young children (aged 1–5 years) increased slightly from Phase 1 to Phase 2.
Admissions in this age group accounted for fewer than 18% of all admissions in
Phase 1, compared to 22% of all admissions in Phase 2.
▪
The proportion of males in each phase was similar at around 60%.
▪
A higher proportion of White children were first admitted to PICU in Phase 2 (38%
vs 46%) whereas the proportion of Asian and Black children was lower in the
second phase (Asian: 29% vs 27%, Black: 22% vs 15%).
▪
Distribution of weight z-scores varied considerably across the two phases.
Children first admitted in Phase 1 had the lowest median z-score (-0.1, IQR: -1.1 to
1.4). This contrasted with the higher median weight z-score of children admitted
during Phase 2 (0.2, IQR: -0.7 to 1.7), consistent with children first admitted during
the Phase 2 being heavier.
▪
Townsend deprivation index scores decreased from a median of almost 4.0 in
Phase 1 to 2.9 in Phase 2, indicative of a slightly higher proportion of children
admitted to PICU in Phase 1 from more deprived areas.
▪
Neurological/developmental and congenital heart/cardiac disease comorbidities
were most common, being recorded in 23% and 12% of cases respectively.
▪
Children were sicker at presentation (according to PIM3 score) when admitted to
PICU during Phase 1, compared to children admitted during Phase 2. The estimated
probability of death for children, taking into account their sickness levels at admission
more than halved for children admitted during Phase 2 (1.5, IQR: 1.2 to 3.6)
compared to Phase 1 (3.2, IQR: 1.2 to 6.0).
3.1.4 Management and outcomes
A range of interventions were reported in the COVID-19 only cohort. Table 1a displays
information on interventions given during the child’s first PICU care episode.
▪
Respiratory support was required in most children (71%) with similar proportions in
both phases. Children required on average one day less respiratory support if
admitted in Phase 2 than Phase 1 (median 4 days vs 5 days).
▪
Over half (53%, n=104) received the highest level of respiratory support (invasive
ventilation). During Phase 2, a lower proportion of the cohort received invasive
ventilation (55%) compared to those diagnosed during Phase 1 (67%). In Phase 2,
children required on average one less day invasive ventilation than in Phase 1
(median of 4 days vs 5 days).
▪
Overall, just under one-third of children received vasoactive support during their first
PICU care episode. The proportion of children requiring vasoactive interventions
was higher for those diagnosed during Phase 1 (38%) compared to Phase 2
(29%). The length of vasoactive support provided was also longer in Phase 1 with
a median of 5 days (IQR: 3–6 days) compared with 3 days in Phase 2 (IQR: 2–3
days).
▪
Very small numbers of children received inhaled nitric oxide, renal replacement
therapy and extracorporeal membrane oxygenation (ECMO).

Special Chapter 1: COVID 19 and PIMS TS in PICU
15
▪
PICU length of stay was shorter for those diagnosed in Phase 2 (4 days, IQR: 2 to
11 days) compared to Phase 1 (5 days, IQR: 3 to 12 days).
▪
Eleven children in the COVID-19 only cohort died whilst on PICU, although two of
these deaths occurred more than 28 days after the first recorded positive COVID-19
test. 11% of children (n=6) first treated during Phase 1 in PICU died compared with
4% (n=5) of those first treated in Phase 2. It is possible that the cause of death in at
least some children is unrelated to COVID-19 infection.
3.1.5. Testing and symptoms
Testing details presented in Table 1b relate to the first recorded positive PCR test for each
child for the COVID-19 only cohort.
▪
A positive COVID-19 result was most commonly obtained on the date of admission
to PICU (82 children, 41%) or more than 24 hours prior to PICU admission
(68 children, 34%).
▪
Most of the cohort were first tested for COVID-19 due to a suspected infection
(n=131, 72%); the other 51 children had COVID-19 detected during routine
screening (28%). As more tests became available and there was a shift clinically to
conduct more asymptomatic screening, the proportion of children identified when
testing for suspected infections decreased from 78% in Phase 1 to 70% in
Phase 2.
▪
Over 85% of children had no confirmed co-infections recorded, however, 27 children
(14%) had at least one other viral, bacterial or fungal infection (Table 2). Viral co-
infections were recorded in 18 children (9%), bacterial infections in eight children
(4%) and fungal infections in three children (2%)3. Proportions were similar across
both waves for all co-infection types.

3 Infection types were not mutually exclusive so a child could have had both a bacterial co-infection
and a viral co-infection hence the numbers total more than 27.

16
PICANet 2021 Annual Report: Supplementary Chapters
Table 1b: Symptoms and details of first positive microbiological testing for
children in the COVID-19 only cohort (n=198) treated in a paediatric intensive
care unit (PICU) in the United Kingdom (UK) across two phases of the COVID-19
pandemic
π COVID-19 only cohort with a date of first positive PCR test between 14 March and 19 July.
Ω Phases of the COVID-19 pandemic are defined as follows:
Phase 1: 14 March–30 August 2020; Phase2: 1 September 2020–19 July 2021.
† Co-infection types not mutually exclusive;
‡ Symptoms not mutually exclusive;

All
COVID-19
positive
children π
n=198
COVID-19
positive
children
(Phase 1 Ω)
n=55
COVID-19
positive
children
(Phase 2 Ω)
n=143
Timing of first laboratory confirmation of COVID-19 in
relation to first PICU admission, n (%)

Pre PICU admission
More than 24h prior to admission
Within 24h prior to admission
On date of admission
Post PICU admission
Less than two days after admission
2–7 days after admission
>7 days after admission

83 (41.9)
68 (81.9)
15 (18.1)
82 (41.4)
33 (16.7)
19 (57.6)
10 (30.3)
4 (12.1)

27 (49.1)
12 (44.4)
15 (55.6)
17 (30.9)
11 (20.0)
6 (54.6)
3 (27.3)
<3 (<27.3)

56 (39.2)
56 (39.2)
0 (-)
65 (45.5)
22 (15.4)
13 (59.1)
7 (31.8)
<3 (<13.6)
Reason for testing when first tested positive, n (%)
Suspected infection
Routine screening

131 (72.0)
51 (28.0)

40 (78.4)
11 (21.6)

91 (69.5)
40 (30.5)
Other confirmed infection†, n (%)
No other infection recorded

Number of children with bacterial infections†
Number of children with viral infections†
Number of children with fungal infections†

171 (86.4)

8 (4.0)
18 (9.1)
3 (1.5)

48 (87.3)

<3 (<5.5)
4 (7.3)
3 (5.5)

123 (86.0)

6 (4.2)
14 (9.8)
0 (-)
Symptoms‡, n (%)
Fever >37.8°C
Cough
Abdominal pain
Diarrhoea
Rash
Shock
Sore throat
Conjunctivitis
Runny nose
Anosmia
Other symptoms

No symptoms

103 (52.0)
71 (35.9)
18 (9.1)
22 (11.1)
11 (5.6)
12 (6.1)
9 (4.5)
3 (1.5)
9 (4.6)
3 (1.5)
75 (37.9)

43 (21.7)

29 (52.7)
17 (30.9)
7 (12.7)
11 (20.0)
8 (14.6)
8 (14.6)
6 (10.9)
<3 (<5.5)
<3 (<5.5)
0 (-)
30 (54.6)

9 (16.4)

74 (51.8)
54 (37.8)
11 (7.7)
11 (7.7)
3 (2.1)
4 (2.8)
3 (2.1)
<3 (<2.1)
7 (4.9)
3 (2.1)
45 (31.5)

34 (23.8)

Special Chapter 1: COVID 19 and PIMS TS in PICU
17
Details of the symptoms recorded in the COVID-19 only cohort are also summarised in
Table 1b, a child may have had more than one symptom recorded.
▪
Of the common symptoms, 52% (n=103) reported fever (>37·8°C) and 36% (n=71)
cough.
▪
Presentation of symptoms differed across the two phases of the pandemic: the
proportion of the cohort presenting with a fever was similar between Phase 1
(53%) and Phase 2 (52%). However, a higher proportion of children (11%)
presented with a sore throat in the first phase, compared to just 2% in Phase 2.
▪
A higher proportion of the cohort who were diagnosed in Phase 1 also presented
with shock (15%) and a rash (15%), compared to around 2% in Phase 2.
▪
Overall, 43 (22%) children reported no symptoms; this increased from 16% (n=9) in
Phase 1 to 24% (n=34) in Phase 2.

3.1.6 Comparisons with 2017–2019 PICU admissions
In this section we present information based on the COVID-19 only cohort of 198 children
alongside information relating to PICU admission between 2017 and 2019. Historic figures
are based on 0–18 year olds; they are also based on admissions and not PICU care
episodes, as is the case in this special chapter. For the COVID cohort, admissions are
presented based on the first PICU care episode if there was more than one; in contrast, the
2017–2019 figures include multiple admissions for individuals. These proportions should
therefore not be used for direct comparison.
▪
62% of children in the COVID-19 (without PIMS-TS) cohort were male, compared to
around 57% of male admissions for 2017–2019.
▪
60% of children with COVID-19 fell into the 6+ (years) age category. This contrasts
with usual age at admission to PICU (2017–2019), where 43% of admissions were in
children aged less than one year and around a quarter of admissions were in children
aged 1–4 years.
▪
The ethnic distribution of COVID-19 and 2017–2019 admissions varied considerably.
There was a much higher proportion of Black (17%) and Asian (27%) children in
the COVID-19 (without PIMS-TS) cohort, compared to the admissions to PICU
between 2017 and 2019 (Black: 3%, Asian: 8%).

3.1.7 Comparison with Influenza admissions from 2019
The characteristics of 193 children from the COVID-19 only cohort4 were compared with a
2019 cohort of 243 children admitted to PICU with influenza in Table 2.

4 n=5 children in the COVID cohort had a previous influenza admission to PICU in 2019 and so were
excluded from the COVID-19 cohort prior to analysis.

18
PICANet 2021 Annual Report: Supplementary Chapters
Table 2: Characteristics and treatment details for n=193 children in the
COVID-19 only cohort (with no influenza admission in 2019) and treated in a
paediatric intensive care unit (PICU) in the United Kingdom (UK) and n=243
children with an influenza PICU admission in 2019

COVID-19
positive
children

(n=193*)
Children
admitted to
PICU with
influenza in
2019
(n=243)
Difference in
mean/proportion
(95% CI)
Age group at first PICU admission, n (%)
Neonate <30 days
Infant 31–365 days
Young child 1y–5y
Older child 6–12y
Teenager 13–18y

8 (4.2)
29 (15.0)
39 (20.2)
55 (28.5)
62 (32.1)

7 (2.9)
47 (19.3)
99 (40.7)
64 (26.4)
26 (10.7)

2.0% (-2.2% to 4.8%) α
-5.3% (-11.4% to 2.8%) α
-20.5% (-28.9% to -12.1%) α
2.9% (-6.3% to 10.5%) α
21.6% (13.8% to 29.1%) α
Male, n (%)
120 (62.1)
142 (58.4)
3.7% (-5.5% to 13.0%) α
Ethnicity, n (%)
White
Asian
Black
Other
Mixed
Unknown

86 (44.6)
52 (26.9)
33 (17.1)
11 (5.7)
6 (3.1)
5 (2.6)

137 (56.4)
34 (14.0)
9 (3.7)
9 (3.7)
5 (2.0)
49 (20.2)

/ φ

Weight z-score
n (%)
Mean (SD)
Median (IQR)

185 (95.9)
0.3 (2.0)
0.2 (-0.7–1.6)

110 (45.3)
-0.5 (2.0)
-0.4 (-1.4–0.6)

/ φ
Townsend deprivation index score
n (%)
Mean (SD)
Median (IQR)

186 (96.4)
2.9 (3.8)
3.2 (-0.1–6.1)

225 (92.6)
1.5 (3.8)
1.2 (-1.8–4.4)

1.4 (0.7 to 2.1) τ
Unplanned admission, n (%)
175 (90.7)
235 (96.7)
-6.0% (-7.6% to 0.7%) α
Comorbidity††, n (%)
Neurological/Developmental‡
Congenital Heart/Cardiac Disease
Inherited genetic/chromosomal
abnormalities
Pre-term
Malignancy†
Metabolic/Endocrine**
Chronic Pulmonary Disease
Otherβ
No recorded comorbidities

43 (22.3)
21 (10.9)
16 (8.3)

14 (7.3)
4 (2.1)
3 (1.6)
6 (3.1)
12 (6.2)
117 (60.6)

59 (24.3)
17 (7.0)
9 (3.7)

30 (12.3)
<3 (<1.2)
0 (-)
18 (7.4)
15 (6.2)
169 (69.5)

/ λ

PIM3 POD %
Mean (SD)
Median (IQR)

3.6 (5.5)
1.6 (1.2–3.8)

4.7 (6.87)
3.3 (1.2–5.1)

-1.1 (-2.3 to 0.5) τ
Respiratory support

Special Chapter 1: COVID 19 and PIMS TS in PICU
19
Days¶ of respiratory support in PICU
n (%)
Mean (SD)
Median (IQR)

136 (70.5)
8.7 (15.0)
4.5 (2.5–9.0)

217 (89.3)
10.5 (29.8)
5.0 (3–10)

-19.1% (-26.5% to -11.7%)α
Maximum respiratory support ¶, n (%)
High frequency oscillatory or jet ventilation
Invasive mechanical ventilation
Non-invasive ventilation
High flow nasal cannula therapy
None

11 (5.7)
101 (52.3)
18 (9.3)
18 (9.3)
45 (23.3)

22 (9.1)
161 (66.3)
19 (7.8)
26 (10.7)
15 (6.2)

-3.4% (-5.4% to 12.6%) α
-13.0% (-22.3% to 3.9%) α
-1.5% (-4.2% to 6.4%) α
-1.7% (-7.5% to 3.9%) α
17.1% (10.4% to 23.8%) α
Invasive ventilation
Days¶ of invasive ventilation in PICU
n (%)
Mean (SD)
Median (IQR)

112 (58.0)
9.1 (15.7)
5 (2.0–10.0)

181 (74.5)
10.8 (31.9)
5 (3.0–10.0)

-1.7% (-25.3% to -7.6%)α
Vasoactive support
Days¶ of vasoactive support in PICU
n (%)
Mean (SD)
Median (IQR)

61 (31.6)
5.5 (8.7)
3.0 (2.0–5.0)

83 (34.2)
5.8 (7.8)
4.0 (2.0–7.0)

0.2% (-11.4% to 6.3%)α
Inhaled nitric oxide¶, n (%)
15 (7.8)
18 (7.4)
0.4% (-4.6% to 5.4%) α
Renal replacement therapy¶, n (%)
9 (4.7)
16 (6.6)
1.9% (-6.2% to 2.4%) α
Extracorporeal life support¶, n (%)
<3 (<1.6)
4 (1.6)
0.6% (-2.8% to 1.5%) α
Outcome, n (%)
Discharged alive
Died in PICU
Unknown

180 (93.3)
11 (5.7)
2 (1.0)

228 (93.8)
15 (6.2)
0 (-)
-0.5% (-5.2% to 4.1%)α δ
Total length¶ of PICU care (days) Ω
n (%)
Mean (SD)
Median (IQR)

191 (99.0)
8.0 (13.0)
4.3 (2.1–9.3)

243 (99.6)
10.7 (12.2)
4.8 (2.4–9.7)

-1.2 (-1.5 to 7.6) γ

*n=5 children with a confirmed diagnosis of COVID-19 had a previous influenza admission to PICU in 2019 and so
were excluded from the COVID-19 cohort prior to analysis.
Abbreviations: CI = confidence interval; SD= standard deviation; IQR = interquartile range; PIM3 POD %=
paediatric index of mortality 3 predicted probability of death; PICU = paediatric intensive care unit;
γ: obtained from two sample independent t-test assuming unequal variances; α obtained from two sample test
of proportions;
τ obtained from two sample independent t-test assuming equal variances;
φ no difference or confidence intervals presented due to the differential proportions of missing data;
λ no statistical testing conducted due to difference in completion styles of comorbidities between units.
†† comorbidities not mutually exclusive;
‡ Neurological/developmental including epilepsy, cerebral palsy;
**metabolic/endocrine including diabetes;
† malignancy including leukaemia, lymphoma, solid tumours;
β other including autism and attention deficit hyperactive disorder
¶ where a child had multiple admission events the number of days is summed across all events;
ϕ where a child had multiple admission events, the status from the last recorded admission is presented;
δ difference calculated based on proportion of children surviving PICU;
Ω for completed PICU admissions

▪
Compared with the influenza cohort, children in the COVID-19 only cohort were:
o older at admission (median [IQR]: 9 [1–13] years vs 3 [1–8] years);

20
PICANet 2021 Annual Report: Supplementary Chapters
o similar in terms of sex and total duration of PICU care;
o less sick on presentation to PICU based on PIM3 predicted mortality risk at
admission;
o less likely to be admitted to PICU as an unplanned admission (91% vs 97%);
o from more deprived areas.
▪
In addition, there were notably higher proportions of children of Black and Asian
ethnicity (n=85, 44%) in the COVID-19 only cohort compared to the influenza cohort
(n=43, 18%), although one-fifth of the influenza cohort had missing ethnicity data
compared with only 3% of the COVID-19 only cohort.
▪
There was a considerable difference in the distribution of weight z-scores between
the COVID-19 only and influenza cohorts; the COVID-19 only cohort had a median
z-score of 0.2, compared to -0.4 for the influenza cohort. This is suggestive of the
COVID-19 only children being heavier.

3.2 PIMS-TS cohort
3.2.1 Analysis population
This final section examines children who presented with PIMS-TS regardless of whether they
had been confirmed COVID-19 positive or not (Figure 4).
A child was defined to have PIMS-TS based on clinical judgement.
Figure 4: PIMS-TS cohort

3.2.2 Overview of PIMS-TS cohort

Special Chapter 1: COVID 19 and PIMS TS in PICU
21
▪
There were 459 PICU admissions for 444 children (<18 years) where a child was
admitted with PIMS-TS. As in Figure 4 above, this includes children presenting with
and without COVID-19.
▪
Figure 5 presents the number of weekly admissions to UK PICUs for children with
PIMS-TS where date of admission is between 14 March 2020 and 19 July 2021.
▪
83 of the 444 children had confirmed COVID-19 (i.e. SARS-CoV-2 PCR positive) in
addition to a PIMS-TS diagnosis (19%) whilst the remaining 361 children (81%) had
PIMS-TS with no confirmation of COVID-19 recorded.
▪
Almost 60% of children (n=255, 57%) presenting with PIMS-TS were admitted to
PICUs in London, with a further 39% (n=175) admitted to PICUs in the rest of
England, whilst the remaining 3% (n=14) of children were admitted to PICUs in the
devolved UK nations.
▪
26 of 30 PICUs had at least one child admitted with PIMS-TS.

3.2.3 Patient characteristics
Table 3 compares the characteristics of the 444 children in the PIMS-TS cohort.
▪
The median age of children in the PIMS-TS cohort when first admitted to PICU was 9
years (IQR: 6 to 13 years). 75% of children were aged 6 years and above.
▪
Around 60% of the children were male.
▪
34% were White, one quarter were Asian (25%) and just over one fifth were Black
(22%). Data on ethnicity were unavailable for 9% of children in the PIMS-TS cohort.
▪
Just under 50% of children were admitted to PICU for endocrine or metabolic
conditions with a further 33% for neurological problems and 14% for infection or
respiratory conditions.
▪
Almost all of the initial admissions for these children (n=439, 99%) were unplanned
admissions to PICU (where the admission was not expected and therefore an
emergency admission).
▪
Comorbidities in the PIMS-TS cohort were recorded infrequently; the most
common types of comorbidities were neurological/developmental (5%) and congenital
heart/cardiac disease (4%).

Figure 5: Number of admissions to UK PICUs by week of admission for children with Paediatric Multisystem Inflammatory
Syndrome (PIMS-TS)

8
19
30
27
26
14
9
4
6
5
3
8
3
5
3
5 5
7
12
10
4
9
8
14
12
24
26
27
2222
13
19
14
7
8
4
6
3
0
5
10
15
20
25
30
Number of
admissions
Week commencing
Value suppressed (<3)

24
PICANet 2021 Annual Report: Supplementary Chapters
Table 3: Patient and clinical characteristics and treatments for all children
(<18 years) treated in a paediatric intensive care unit (PICU) in the United
Kingdom (UK) presenting with Paediatric Multisystem Inflammatory Syndrome
(PIMS-TS) phenotype (n=444)

PIMS-TS cohort
n=444
Age group at first PICU admission, n (%)
Neonate <30 days
Infant 31–365 days
Young child 1y–5y
Older child 6–12y
Teenager 13–18y

0 (-)
10 (2.3)
100 (22.5)
130 (51.8)
104 (23.4)
Male, n (%)
264 (59.5)
Ethnicity, n (%)
White
Asian
Black
Other
Mixed
Unknown

149 (33.6)
113 (25.5)
98 (22.1)
19 (4.3)
24 (5.4)
41 (9.2)
Weight z-score
n (%)
Mean (SD)
Median (IQR)

436 (98.2)
0.6 (2.6)
0.7 (-0.2–1.6)
Townsend deprivation index score
n (%)
Mean (SD)
Median (IQR)

436 (98.2)
2.7 (3.8)
2.8 (-0.4–5.9)
Unplanned admission, n (%)
439 (98.9)
Admitted from, n (%)
Same hospital
Other hospital

130 (29.3)
314 (70.7)
Comorbidity††, n (%)
Neurological/Developmental≠
Congenital Heart/Cardiac Disease
Inherited genetic/chromosomal abnormalities
Pre-term
Malignancy†
Chronic Pulmonary Disease
Metabolic/Endocrine**
Otherβ
No recorded co-morbidities

20 (4.5)
15 (3.6)
<3 (<0.5)
<3 (<0.5)
<3 (<0.5)
0 (-)
<3 (<0.5)
6 (1.4)
405 (91.2)
PIM3 POD %
Mean (SD)
Median (IQR)

3.0 (3.1)
1.8 (1.4–3.8)

Special Chapter 1: COVID 19 and PIMS TS in PICU
25
Respiratory support
Days‡ of respiratory support in PICU
n (%)
Mean (SD)
Median (IQR)

141 (31.8)
5.5 (13.4)
3.0 (2.0–5.0)
Maximum respiratory support ‡, n (%)
High frequency invasive ventilation
Invasive ventilation
Non-invasive ventilation
HFNCT
None

3 (0.7)
87 (19.6)
18 (4.1)
41 (9.2)
295 (66.2)
Invasive ventilation
Days‡ of invasive ventilation in PICU
n (%)
Mean (SD)
Median (IQR)

87 19.6)
7.0 (16.5)
4.0 (3.0–6.0)
Vasoactive support
Days‡ of vasoactive support in PICU
n (%)
Mean (SD)
Median (IQR)

325 (73.2)
3.2 (2.5)
3.0 (2.0–4.0)
Inhaled nitric oxide‡, n (%)
4 (0.9)
Renal replacement therapy‡, n (%)
7 (1.6)
Extracorporeal life support‡, n (%)
<3 (<0.5)
Outcome, n (%)
Discharged alive
Died in PICU
Unknown

440 (99.0)
<3 (<0.5)
2 (0.5)
Total length λ of PICU care (days)*
n (%)
Mean (SD)
Median (IQR)

442 (99.5)
3.7 (8.2)
2.5 (1.2–4.0)
Abbreviations: PIMS-TS = Paediatric multisystem inflammatory syndrome temporally associated with COVID-19;
IQR = interquartile range; PIM3 POD = Paediatric Index of Mortality 3 predicted probability of death; HFNCT =
high flow nasal cannula therapy.
†† not mutually exclusive;
≠ Neurological/developmental including epilepsy, cerebral palsy;
**Metabolic/endocrine including diabetes;
† malignancy including leukaemia, lymphoma, solid tumours;
β other including autism and attention deficit hyperactivity disorder
‡ where a child had multiple admission events the number of days is summed across all events for calculations;
λ where a child had multiple admission events the status from the last recorded admission is presented;
* for completed PICU admissions.

26
PICANet 2021 Annual Report: Supplementary Chapters
3.2.4 Management and outcomes
Table 3 displays information on interventions given during the child’s first PICU care episode
(n=444).
▪
Respiratory support was required in just under one-third of children (n=141, 32%).
▪
One-fifth required the highest level of invasive ventilation (n=90, 20%) for a median
of 4 days (IQR: 3–6 days).
▪
Nearly three-quarters of children received vasoactive support (73%) for a median of
3 days (IQR: 2–4 days).
▪
Very small numbers of children received inhaled nitric oxide, renal replacement
therapy and extracorporeal membrane oxygenation (ECMO).
▪
The median length of PICU stay was 2.5 days (IQR: 1–4 days).
▪
Less than three children died whilst on PICU (<1%).

3.2.5 Comparison with COVID-19 only cohort
Differences in terms of both patient characteristics, management and outcomes of the
COVID-19 only cohort when compared with the PIMS-TS cohort are detailed in this section.
▪
In both cohorts, children were of a similar average age (median 9 years) but the
PIMS-TS cohort had a much smaller interquartile range than the COVID-19 only
cohort (IQR of 6–13 years compared with 1–13 years).
▪
Both groups were made up of a similar proportion of males (approximately 60%).
▪
COVID-19 and PIMS-TS cohorts had a similar proportion of Asian children
(around one-quarter) whereas the PIMS-TS cohort had a higher proportion of
Black children (22% vs 17%) and a lower proportion of White children (34% vs
43%) than the COVID-19 only cohort.
▪
In the PIMS-TS cohort, 99% of first PICU admissions were unplanned compared
with 91% in the COVID-19 only cohort.
▪
Much higher proportions of neurological/developmental and congenital
heart/cardiac disease comorbidities were observed in the COVID-19 only cohort
than the PIMS-TS cohort (23% vs 5%, and 12% vs 4% respectively).
▪
Respiratory support was required by just under one-third of the PIMS-TS cohort
compared with 71% of the COVID-19 only cohort. On average, respiratory support
was required for slightly longer in the COVID-19 group compared with the PIMS-
TS group (4.5 days vs 3.0 days).
▪
Invasive ventilation was also required by fewer children in the PIMS-TS cohort
than the COVID-19 cohort (20% vs 53%) and these children had invasive ventilation
for a median of 4 days compared with 5 days.
▪
Vasoactive support was provided in nearly three-quarters of PIMS-TS cases
compared with just under one-third of COVID-19 only cases. Both cohorts received
vasoactive support for a median of 3 days.
▪
Median length of stay in the COVID-19 only cohort was longer than in the PIMS-
TS cohort at approximately 4.5 days compared with 2.5 days.
▪
The proportion of deaths on PICU in the COVID-19 only cohort was higher at
around 6% than the proportion in the PIMS-TS cohort (<1%).

Special Chapter 1: COVID 19 and PIMS TS in PICU
27
4. Discussion
This report confirms that while the numbers and proportions of children affected with COVID-
19 or related illness was small, its impact was significant. The impact of COVID-19 was
disproportionately higher among children of Black and Asian ethnicities, children from
deprived families and children of school age compared to overall PICU case-mix from
previous years. The report highlights the importance of screening as an infection control
measure as more than 20% of children were asymptomatic during PICU admission and were
detected only on routine screening. Approximately 10% of children with COVID-19 had a viral
co-infection reported in Phase-2 despite a reasonably ‘quiet’ season for viral illnesses. With
seasonal and inter-seasonal resurgence of respiratory viruses forecast, clinicians must be
vigilant to the possibility of children being affected by multiple pathogens.
Clear differences in characteristics between the COVID-19 and PIMS-TS patients are
described. For instance, a large majority of children admitted with PIMS-TS had no recorded
co-morbidities and were admitted predominantly for vasoactive support rather than
respiratory support, in contrast with patients admitted with COVID-19. While the survival
outcomes reported were good compared to reports from adult critical care units, sadly 10–15
children died during their PICU admission. Given we do not collect causes of death, we are
unable to confirm whether, at least in some cases, children may have died of unrelated
health conditions. Finally, this report is a testament to the commitment of all contributing
PICUs who were able to report additional custom-audit data in a timely manner despite
significant workforce and re-organisation related challenges.

28
PICANet 2021 Annual Report: Supplementary Chapters
5. Appendix
5.1 COVID-19 customised data collection form
A PICANet COVID-19 customised data collection form is completed for all admissions to
PICU, for whom the diagnosis of COVID-19 was confirmed as positive by laboratory testing
and; for those admissions who are COVID-19 suspected or probable after repeat negative
testing, but clinicians agree that the clinical presentation is consistent with COVID-19
infection. This includes multi-system inflammatory syndrome exclusive of any other microbial
cause (PIMS-TS).

Special Chapter 1: COVID 19 and PIMS TS in PICU
29

Special Chapter 2: COVID-19 Staffing
Survey
1 Introduction
Many articles have been written describing the effects of the coronavirus (COVID-19) on
critical illness and specifically the relatively minimal impact on critical illness in children
compared to adults, two examples pertaining to the UK are included [4, 15]. Data collected
from the 31 PICUs covered by PICANet showed a reduction in all PICU admissions (18%),
unplanned admissions (20%), planned admissions (15%), and bed days (25%). It is known
that during the first wave of the COVID-19 pandemic there was a significant demand for adult
intensive care beds. Remodelling of intensive care beds to meet the surge in adult critical
care demand led to the utilisation of paediatric intensive care beds located within a paediatric
intensive care unit (PICU) [16-19]. PICUs therefore as well as supporting this adult critical
care expansion through loaning equipment and space, also repurposed themselves (staff
included), to receive and care for adult patients. Sinha et al in 2021 [18], described the
experiences of 7 PICUs who had repurposed to care for adult patients during the first wave
of the COVID-19 pandemic. Through real time data collection PICANet were aware that there
were more than seven PICUs providing this service, in a variety of ways, which also occurred
during the latter half of 2020 and early 2021. In addition, children were being transported to
other hospitals to free up adult critical care beds in PICUs. There was very little evidence of
the skill mix of staff looking after adults in PICUs, and staff as well as child movement. This
chapter considers the impact of the pandemic on paediatric intensive care units through a
review of PICU activity including adult admissions, paediatric admissions, paediatric bed
closures and the relocation of children. The impact on PICU staff in terms of staff relocation
is also discussed.
1.1 Data collection
PICANet undertook an extra staffing survey in June 2021 and all 31 PICUs responded to the
collection of data. They were asked to retrospectively relate PICU and staff activity over three
time periods. These time periods were related to the timelines of the UK coronavirus
lockdowns, March 2020 to March 2021 (Institute for Government Analysis, 2021)[19]. At the
time of the survey there was some debate as to the evolvement of the actual number of
COVID waves in the UK, and it is still unclear as to the start and end dates of the waves. The
Office of National Statistics (ONS), in its publications refers to two waves, but dates of these
vary according to publication, and indeed state that there is no clear definition when a wave
starts and ends [20, 21]. Add in geographical variation in the transmission of the virus and
the boundaries become even more blurred. It was decided to use the starting dates of the
coronavirus lockdown as a reflection of a peak in the reproduction (R) number and positivity
rate. The end of the time periods reflect the period of lockdown restrictions easing overall
taking into account geographical differences that are less diverse than the pandemic waves.
In addition PICUs that were affected in terms of adult admissions and staff relocation were
asked to state the dates when this actually occurred in their unit. The time periods that were
used were:
▪
First Period: 23 March to 30 June 2020
▪
Second Period : 5 November to 20 December 2020
▪
Third Period: 6 January to 30 April 2021

32
PICANet 2021 Annual Report: Supplementary Chapters
A series of questions were asked, repeated for each time period of the pandemic. These
comprised:
▪
Bed occupancy on PICU, adult and paediatric, extra capacity, and bed closure
▪
Staffing, skill mix of staff looking after adult patients, and redeployment of staff by
location, discipline, and grade
▪
Relocation of children
Data is presented from all 31 PICUs in England, Wales, Scotland, Northern Ireland and the
Republic of Ireland, both NHS and private. Inclusion was based on the completion by a
designated senior nurse or clinician of a Microsoft Forms survey sent and received
electronically. All units that received the form responded (100% response rate).
2 Results
2.1 Bed occupancy in PICU
Table 4 shows the data illustrating the caseload for the different PICUs in respect of the
number of the number of PICUs accepting adult and paediatric patients.
Table 4: Total number of beds open for adult and paediatric patients in PICU
and as a percentage of the total of 31 PICUs

1st period
2nd period
3rd period

Beds
PICUs
Beds
PICUs
Beds
PICUs
Open for adults
204
14 (45%)
40
6 (19%)
137
11 (35%)
Open for paediatrics
426
26 (84%)
472
31 (100%)
436
28 (90%)

A total of 16 different PICUs accepted adult patients and the data shows a variation over the
three time periods in the number of adults admitted to those PICUs. The number of beds
open to adult patients, and the number of PICUs accepting adults were at the highest in the
first period (204) beds, and 14 (45%) PICUs, decreasing in the second period when 6 PICUs
(19%) had 40 adult beds open, and an increase in the third period when 11 PICUs (35%),
provided 137 adult beds.
Next, the survey looked at whether the PICUs accepted only adult patients, a mixture of
adults and paediatrics or just continued to accept paediatric patients only. This is not a
reflection of the individual PICUs but rather organisational decisions regarding geographical
location, number of beds, and consideration of continuing non elective work [16, 17].
The case mix for the all the PICUs are shown in Table 5.
Table 5: Case mix for all PICUs over the three time periods

1st period
2nd period
3rd period
Adults only
5
0
3
Adults and Paediatrics
10
6
10
Paediatrics only
16
25
18
Total
31
31
31

During the first time period five out of the 15 PICUs (33%) that accepted adult patients, were
only open for adults. During the second period no PICUs were only open to adults. During

Special Chapter 1: COVID 19 and PIMS TS in PICU
33
the third time period, 3 out of 12 (25%) PICUs that were accepting adult patients were adult
only, compared to 33% in the first period.
2.1.1 Adult bed occupancy in PICU
Table 4 illustrated the variation in adult and paediatric activity in PICU over the three time
periods. Figure 6 shows the time variation of admission to PICUs of adult from the times
documented by PICUs in the survey as to the start and end dates of having adult patients.
The earliest date recorded of receiving adult patients was the 7 February 2020 and the last
date recorded was the 29 April 2021.
Figure 6: Time line of adult patients admitted to PICUs

Most of the activity featuring adult patients occurred in the first and third time periods with
very few PICUs (three) accepting adults in the second lockdown time period. Four PICUs
accepted adult patients before the first lockdown period, and three PICUs accepted adult
patients beyond the first lockdown period. Similarly three PICUs accepted adult patients
before the third lockdown period, and one PICU accepted adult patients extending through
the second and third lockdown period without a break, reflecting the ongoing peak in adult
activity from December 2020. Reviewing workforce models in December 2020, NHS England
and NHS Improvement supported Trusts in maintaining both acute and elective paediatric
Dec 2019
Mar 2020
Jul 2020
Oct 2020
Jan 2021
May 2021
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Calendar period
PICU
Lockdown
Time period where adults accepted
A
C
D
E1
E2
F
H
I
K2
K3
L
M
N
O
P
Q
R
S
T
U
V
W
X1
X2
Y
Z
ZA
ZB
ZC
ZD
ZF

34
PICANet 2021 Annual Report: Supplementary Chapters
services with various staff and resource initiatives [22]. There was a focus on empowering
acute adult wards with training and resources to care for severely unwell adult COVID-19
patients, proven therapeutics, and early detection and care in the community, thus reducing
ICU and PICU burden. It is difficult to estimate how far these initiatives affected the numbers
of PICUs accepting adults, but there was certainly less demand in the second wave,
although there was an increase in the third wave.
The survey then considered the burden on paediatric activity with the demand for adult
intensive care beds.

2.1.2 Paediatric activity in PICU
The number of paediatric beds open was then surveyed in response to admission of adult
patients. Table 4 showed that out of 31 PICUs participating in the survey 17 had no change
to paediatric bed occupancy over the three time periods (55%). Of the 45% remaining PICUs
two had more paediatric beds occupied in the first period than in both the second and the
third.
Three PICUs had an increasing number of beds open from the first to the third time period,
and one PICU had less beds open in the second period although they were not open to adult
patients. The number of PICUs open for paediatrics showed a decrease in the second
period, with an increase in the third period and more PICUs open for paediatrics than both
periods.
Figure 7 shows in more detail the variation of both paediatric bed activity over the three time
periods by organisation matched against the number of adult beds open within the same unit
(where relevant), to place context of paediatric bed activity during these periods.

Special Chapter 1: COVID 19 and PIMS TS in PICU
35
Figure 7: The number of paediatric and adult beds open by period and PICU

For the first time period for 9 PICUs (D, F, H, L, N, O, S, U, and X), adult activity corresponds
to a decrease in paediatric activity. The second period of adult activity on PICUs, of which
there were only 5 PICUs, had little or no impact on paediatric bed activity. In the third time
period, of the 11 PICUs reporting adult admissions, five PICUs had a corresponding
decrease in PICU admissions. One PICU (R), showed no increase or decrease in PICU
activity despite adult admissions.
1st period
2nd period
3rd period
1st period
2nd period
3rd period
A
C
D
E1
E2
F
H
I
K2
K3
L
M
N
O
P
Q
R
S
T
U
V
W
X1
X2
Y
Z
ZA
ZB
ZC
ZD
ZF
60
50
40
30
20
10
0
10
20
30
40
50
60
PICU
Beds
Paediatric beds
Adult beds

36
PICANet 2021 Annual Report: Supplementary Chapters
The survey then looked at whether extra beds had been opened on units in order to meet
increased demand (Table 6).
Table 6: The number of adult, paediatric, and extra beds open during the three
time periods

1st period
2nd period
3rd period

Beds
PICUs
Beds
PICUs
Beds
PICUs
Open for adults
204
14 (45%)
40
6 (19%)
137 11 (35%)
Open for Paediatrics
426
26 (84%)
472
31 (100%)
436 28 (90%)
Extra beds opened
172
13 (42%)
34
3 (9%)
146
7 (22%)
Total of open beds
802

546

719

Regarding extra capacity beds this showed an overall downward trend from 172 in the first
time period, a steep drop in the second time period by 66% to 34, but an increase in the third
period to 146, which was also 22% less than those initially opened in the first period.
Demand was still high in the third period although less than the first period, but considerably
higher than the second period
The data obtained from the survey was then compared to the number of funded paediatric
beds on each unit for each wave (Figure 8).

Special Chapter 1: COVID 19 and PIMS TS in PICU
37
Figure 8: Paediatric and adult beds open as a proportion of funded beds by
PICU and period.

In the first period 17 PICUs exceeded 100% of funded beds, with 4 PICUs reaching equal to
or greater than 200% (F, P, R, and ZD). Of these four it is to be noted that three (75%)
capacity comprised of a mixture of adult and paediatric patients, whereas ZD exceeded
200% capacity with only paediatric patients, and had created extra capacity only for
paediatric patients. One PICU (R) exceeded 300% capacity. In the second period even
though there was less adult bed activity nine PICUs were over 100% of their funded activity,
most notably E1, where regional paediatrics patients were taken as part of remodelling of
paediatric critical care in the region (this regional bed activity was also shown in the first and
third period). In the third period 13 PICUs had exceeded the 100% capacity whilst 4 PICUs
had reached or exceeded 200% capacity.
Creating extra capacity, and opening PICU beds to adults may have had an impact on the
closure of paediatric beds. PICANet data for 2020 shows that there was an overall reduction
ZF
ZD
ZC
ZB
ZA
Z
Y
X2
X1
W
V
U
T
S
R
Q
P
O
N
M
L
K3
K2
I
H
F
E2
E1
D
C
A
0%
100%
200%
300%
PICU
First period
ZF
ZD
ZC
ZB
ZA
Z
Y
X2
X1
W
V
U
T
S
R
Q
P
O
N
M
L
K3
K2
I
H
F
E2
E1
D
C
A
0%
100%
200%
300%
Second period
ZF
ZD
ZC
ZB
ZA
Z
Y
X2
X1
W
V
U
T
S
R
Q
P
O
N
M
L
K3
K2
I
H
F
E2
E1
D
C
A
0%
100%
200%
300%
Proportion of funded beds
Third period
Paediatric
open %
Adult
open %

38
PICANet 2021 Annual Report: Supplementary Chapters
by 20% of PICU admissions of both elective and emergency admissions. Consideration then
also needed to be given as to whether there were paediatric bed closures during the three
time periods (Table 7).
Table 7: The number of paediatric beds closed by the number of PICUs per
period

1st period
2nd period
3rd period

Beds
PICUs
Beds
PICUs
Beds
PICUs
Paediatric beds closed
82
9
30
5
57
7
Total number of open beds
802

546

713

From this, it can be seen that the highest number of paediatric beds closed occurred in the
first period, where 10% of the total beds open within PICU sites were closed to paediatric
patients. During the second period this dropped to 5% of the total beds open and in the third
period 8% of the total beds open were closed to paediatric admissions. As with all PICUs that
were open to adults and paediatrics there are variations between units.
Of those units that had paediatric beds closed the rationale was increased adult intake
(7 PICUs stated this over the different waves), staff redeployment (5 PICUs cited this), and
2 PICUs gave staffing issues as ‘other’ reason for paediatric bed closure. On further
exploration this referred to staffing issues such as sickness, staff shielding, staff vacancies,
and maternity leave.
Figure 9: Rationale for bed closure by number of PICUs and by periods

The survey then looked at issues surrounding staffing, firstly the nursing staff that cared for
the adult patients, representing those that delivered the day-to-day care for adult patients,
and secondly whether staff were relocated, and if so by discipline and grade, and thirdly the
location where the staff were deployed.
0
5
10
15
1st period
2nd period
3rd period
Number
of PICUs
Pandemic time period
Other
Staff redeploymant
Increased adult intake

Special Chapter 1: COVID 19 and PIMS TS in PICU
39
2.2 Staffing
2.2.1 Staffing in the PICU
The question was asked as to who delivered the nursing care to these adult patients,
whether it was adult trained staff, paediatric trained staff, or a mixture of both (Table 8 &
Figure 8).
Table 8: Type of staff caring for adult patients in PICU by time period

1st period 2nd period 3rd period
PICU staff only
7
3
6
Adult and paediatric staff
5
2
2
Adult staff only
2
0
1
Other
2
1
2

There was a predominance of PICU only staff during all three periods in relation to other
combinations of staff. During the first time period there was also a larger mixture of adult and
paediatric staff together than in the next two periods. Two PICUs only had adult staff caring
for patients in the first period and one PICU in the second period. Recruitment of ‘other’ staff,
occurred more in the first and third period. This group of staff were documented in the free
text as, non PICU children’s nurses, non-adult ICU nurses, theatre nursing staff, and staff
from the Burns Unit.
Figure 10: Type of staff caring for adult patients in PICU by time period

2.2.2 Relocation of staff
During the three lockdown periods of the pandemic both nursing and medical staff were
redeployed to other areas. In the first period 17 PICUs (55%) had staff that were relocated or
redeployed, this dropped to 10 PICUs (32%) in the second period and rose to 13 PICUs
(42%) by the third period.
Overall through the three time periods both medical and nursing staff were relocated (Figure
11
0
5
10
15
PICU staff
Mix of adult and PICU staff
Adult staff
Other
Number of PICUs
Type of staff
1st period
2nd period
3rd period

40
PICANet 2021 Annual Report: Supplementary Chapters
Figure 11: Relocation by discipline

What was shown was the nursing staff were involved in redeployments more frequently than
medical staff. In the first period 6 PICUs (20%), sent only nursing staff to other areas, whilst
4 PICUs (13%), sent a mixture of both nursing and medical staff. These figures were exactly
the same for the second period, despite PICU bed capacity being reduced. In the third period
8 PICUs (26%), redeployed only nursing staff, whilst 5 PICUs (16%), sent nursing and
medical staff. Overall more staff were redeployed during the third period than the first or
second. No PICUs sent only medical staff.
2.2.2.1 Relocation of medical staff
With regard to redeployment of staff, for those PICUs who did not accept adult patients the
majority did redeploy their staff to adult ICUs, mainly within their own hospital but for two
PICUs it was to adult ICUs external to their Trust. The grades of both medical and nursing
staff redeployed were reviewed and Table 9 shows the grade of medical staff relocated.
Advanced Nurse Practitioners (ANP), who were on the medical establishment were included
in the staffing figures (Table 9 and Figure 12).
Table 9: Grade of medical staff redeployed over the three time periods
Medical grade
1st period
2nd period
3rd period
Consultant
9 (29%)
9 (32%)
16 (34%)
Associate Specialist
0
7 (24%)
0
ST 4–8
7 (23%)
7 (24%)
12 (26%)
ST 1–3
5 (16%)
0
7 (15%)
Foundation Year
4 (13%)
4 (13%)
4 (8%)
ANP
6 (19%)
2 (7%)
8 (17%)
Total
31
29
47

0
1
2
3
4
5
6
7
8
1st period
2nd period
3rd period
Number
of PICUs
Discipline / Pandemic period
Nursing staff only
Both nursing and medical staff

Special Chapter 1: COVID 19 and PIMS TS in PICU
41
Figure 12: Grade of medical staff redeployed over the three time periods

As can be seen, the Consultant medical staff were redeployed the most frequently in all three
periods, rising from 29% in the first period to 32%, and then 34% in the third period. ST 4–8
redeployment follows a similar pattern and were the next highest group to be redeployed,
with 23% in the first period, followed by a slight increase to 24%, rising to 26% in the third
period.
ANPs were also redeployed with the highest number of ANPs in the third period, a third less
in the second period and just 7% (2) in the third.
ST 1–3 were redeployed in the first and third period only, whilst Foundation Year medical
staff were redeployed in all three periods. Associate specialist medical staff were only
redeployed in the third period.
2.2.2.2 Relocation of nursing staff
The nursing grades of staff relocated were then reviewed (Table 10), this included healthcare
assistants who delivered clinical care.
Table 10: Grades of nursing staff and healthcare assistants redeployed over the
three time periods
Grade of Nurse
1st period
2nd period
3rd period
Band 8
6 (3%)
2 (2%)
6 (4%)
Band 7
37 (21%)
19 (20%)
33 (22%)
Band 6
46 (26%)
28 (29%)
41 (28%)
Band 5
64 (37%)
42 (44%)
46 (31%)
Band 4
0
0
6 (4%)
Band 3
10 (6%)
0
6 (4%)
Band 2
11 (7%)
5 (5%)
11 (7%)
Total
174
96
149

0
5
10
15
Consultant
Associate
Specialist
ST 4-8
ST 1-3
Foundation
Year
ANP
Number
of PICUs
Grade of medical staff / Pandemic period
1st period
2nd period
3rd period

42
PICANet 2021 Annual Report: Supplementary Chapters
During the first period Band 5 nursing staff were the highest group of the total workforce to
be redeployed at 37%, followed by Band 6 at 26%, then Band 7 at 21%. Bands 2 and 3 were
next at 7% and 6%, with the lowest percentage being redeployed were those at Band 8 (3%).
In the second period again the highest proportion by Band of nursing grade were those of
Band 5 at 44%, then Band 6 at 29%, followed by Band 7 at 20%. There was less
redeployment in this period for Band 2, and Band 8, with no Band 3 being redeployed.
The third period follows the same pattern with the highest proportion of nursing being
redeployed at Band 5 (31%), followed by Band 6 at 28%, Band 7 at 22%, Band 2 at 7% and
Bands 8, 4, and 3 at 4% of the total workforce being deployed.
This emphasis on Band 5 redeployment is also shown in the percentage of PICUs that
redeployed nursing staff by grade shown in Figure 13.
Figure 13: Grade of nursing staff and healthcare assistants redeployed over the
three time periods

2.2.2.3 Location of staff redeployment
Where staff had been redeployed the units were asked to indicate where the staff had moved
to for each time period (Table 11).
Table 11: Location of staff redeployed
Location
1st period
2nd period
3rd period
Adult ICU
16 (52%)
9 (29%)
12 (39%)
Children’s Ward
4 (13%)
1 (3%)
2 (6%)
Other PICU within the same Trust
1 (3%)
0
1 (3%)

For all three time periods the majority of staff were sent to Adult Intensive Care. The number
of PICUs relocating staff was at its highest in the first period, decreasing in the second period
and rising again in the third period, although not at the same levels as the first period. A
small number of PICUs sent staff to the Children’s wards during the three time periods, only
one PICU sent staff to another PICU located within the same Trust.
The survey then looked at the relocation of children from PICU.
0%
10%
20%
30%
40%
50%
60%
Band 8
Band 7
Band 6
Band 5
Band 4
Band 3
Band 2
Proportion
of PICUs
Grade of nursing staff / Pandemic period
1st period
2nd period
3rd period

Special Chapter 1: COVID 19 and PIMS TS in PICU
43
2.3 Relocation of children
The PICUs were asked whether their children were relocated, and if pertinent whether this
was within their own hospital, within the same Trust, or moved to a location within another
Trust, over the three time periods (Figure 14).
Figure 14: Location of child moved during the three time periods

Overall, there appears to be less movement of children during the second and third periods.
Five PICUs in the first period relocated their children within the same hospital, to their HDU
where possible, or to reconfigured children’s wards. Those relocated within the same Trust
utilised children’s wards within the organisation, whilst the few PICUs that transferred
children outside the Trust were documented as going to Birmingham Children’s Hospital and
Great Ormond Street Hospital.
3. Summary of findings and discussion
3.1 Bed occupancy in PICU
Between 7 February 2020 and 29 April 2021, 16 out of 31 PICUs accepted adult patients
with variation over the three time periods. The highest number occurred in the first period
(45%), the next highest in the third period (35%), and the lowest in the second time period.
This pattern of lower demand during the second time period also featured in the PICUs who
had only adult patients (16%, 0, 10%), although those units receiving both adult and
paediatric patients showed the same demand for both the first and the third period (32%).
The number of PICUs receiving only paediatric patients for the three time periods (52%, 80%
and 58%), reflects not only the demand for adult bed occupancy (48%, 20%, and 42%), but
also the fluctuations in demand for adult beds over the three time periods. Extra bed capacity
was created during this period, again reflecting demand with 102 beds in the first period, 34
in the second and 146 in the third time period, and this was also demonstrated in the
percentage of PICUs exceeding 100% funded capacity.
In March 2020, the Paediatric Intensive Care Society (PICS) and PICANet proposed a
modelling of minimum paediatric intensive care capacity required for predicted demand for
adult critical care during the COVID-19 pandemic [16]. This included PICUs being prepared
to reduce their bed base to accept adult critical care patients. Figure 6 showed the
distribution over time of PICUs accepting adult patients over the three time periods. Inherent
0
1
2
3
4
5
1st period
2nd period
3rd period
Number
of PICUs
Location / Pandemic period
Within the same hospital
Within the same Trust
Another Trust

44
PICANet 2021 Annual Report: Supplementary Chapters
in this modelling though was also the caveat that some PICU beds remained open for
elective and paediatric surgical cases where a delay may impact on the child’s potential
outcome and ultimately become an emergency admission. Therefore there is variation
inherent in the number of PICUs able to offer adult critical care capacity, with some able to
offer adult beds only, other PICUs accepting adults but maintaining some PIC activity, and
those stand-alone children’s hospitals who scaled up PICU capacity to relieve other PICUs,
such as Birmingham Childrens and Great Ormond Street, shown in Figure 14.
3.2 Staffing
Predominantly over the three time periods paediatric intensive care nurses and healthcare
assistants delivered care to adult patients, aided by adult intensive care staff, and some
nursing staff from ‘other’ areas such as theatres. Overall, as there were less adult intake
there was less demand on intensive care and other staff as shown in the second and third
period (Table 8). This was also in line with government initiatives and proposals. NHS
England and NHS Improvement recognised in December 2020 [22], that previous strategies
to provide extra workforce to critical care areas looking after adult critically ill patients needed
to be reviewed. In the first pandemic wave the response had been to utilise theatre staff for
example by cancelling surgical procedures, outpatient staff had also been redeployed with
the closure of clinics, and in particular both medical and nursing students had also been part
of the workforce. Consideration needed to then be given to ensure that attention was not
diverted from elective and screening services whilst also dealing with emergency
admissions. The focus was then on expanding critical care services to be able to provide
COVID-19 and non COVID-19 services and major surgery. This may reflect the decrease in
number of adult patients in PICU in the second and third wave, although what is common
throughout all the tables is the marked decrease in adult activity in PICUs during the second
wave.
It is to be noted that for the medical staff there was a higher proportion redeployed during the
third time period, although the highest numbers of nurses being redeployed was in the first
time period.
In addition the review, along with recommendations from the PICS, also endorsed allocating
resources for additional staff training, to deliver additional workforce supply outside of the
individual hospital staff base (return to work schemes), and a focus on the health and
wellbeing of the workforce [22, 23]. It is beyond the scope of this report to comment on the
latter recommendations. What it can show is the organisation and strategies undertaken to
achieve the extra capacity demand either within an individual PICU or moving staff to care for
the extra capacity. The comments made indicated that on the whole where there was a
paediatric HDU, the PICU patients were transitioned to this and the adult patients occupied
the designated PICU beds. This strategy however did change over time and demand, where
demand for adult capacity was less some PICUs remained as paediatric and the adults went
to PHDU (usually less PHDU beds than PICU beds). One PICU adopted an ad hoc approach
where admission of adults to PICU was dependent on daily bed availability at the time it was
requested. In these cases the PICU supported the adult cardiac surgery speciality and
therefore only cared for elective adult admissions. One PICU commented that although their
PICU was closed to paediatric patients they relied on the paediatric critical care outreach
team that supported deteriorating paediatric patients on the wards.
The proposals from NHS England and NHS Improvement [22] also promoted moving staff (in
teams), the use of rostering to ensure time for rest, and recommended staff/patient ratios.
Whilst staff to patient ratios were not considered in this survey, it was clear from survey
responses that over time units responded to redeploying staff in a more organised way,
through rotas, assessment of availability, and a combination of scheduled and voluntary
shifts.

Special Chapter 1: COVID 19 and PIMS TS in PICU
45
Criticism of the survey may be that lockdown periods were used as timelines versus actual
peaks or waves of the pandemic. However the waves and timing were not as clear cut as the
lockdown periods and were in response to a rise in the R number as an indication of the
acute mortality and morbidity being experienced. Also the survey was limited in not asking all
PICUs whether staff were not working due to shielding, although this was documented in the
free text by three PICUs.
4 Conclusion
What is clear from this survey is that the disruption to PICUs was twofold. Those who
accepted adult patients experienced disruption in their environment through experiencing
technology geared for adults, learning how to care for adult critically ill patients, and
transferring their intensive care skills from paediatric to the demands of adult critical care. In
addition they had to support a range of staff sent to support them. Secondly, even if a PICU
did not accept adult patients then COVID-19 still impacted on the PICU through
redeployment of paediatric staff for adult critical care or children’s ward areas, also
experiencing a rapid transition to learning new skills outside of their particular skill set, and in
addition to the burden of working shifts in full PPE, and staff shortages through shielding,
sickness and vacancies.
This survey set out to demonstrate the impact of COVID-19 through a deeper exploration of
issues in PICUs during these three time periods in terms of bed occupancy, staffing of adult
beds, staff and child relocation. Although these issues varied in the different PICUs and over
the three time periods it does give an indication of the burden placed upon PICUs during a
time of unprecedented adult intensive critical care activity, and the strategies undertaken by
PICUs and their responses to meet these demands.

Special Chapter 3: Diabetic ketoacidosis
in English PICUs: the impact of COVID-19
Why this chapter now?
During the 2020 COVID-19 pandemic there were international reports of an increase in the
number of general paediatric patients and adults presenting with ketoacidosis [24, 25].
However, there are currently no UK reports of the impact of COVID-19 on children presenting
to paediatric intensive care (PIC) with diabetic ketoacidosis (DKA).
In addition, there is a lack of recent detailed information regarding the demographics,
complications and outcomes of children with diabetic ketoacidosis admitted to paediatric
intensive care units (PICUs) in England. In fact, it has been more than a decade since this
group of patients was reviewed using data extracted from the PICANet database covering
the period from 2003–2007 [26].
The aim of this special chapter was to review trends in DKA admissions to PICUs in England
during the last eleven years (2010–2020), focusing on the impact of the COVID-19 pandemic
on these admissions comparing 2020 PICU activity to 2010–2019.
Methods
PICANet collects prospective data on all admissions to PICUs in the UK and Republic of
Ireland. For this report, data were extracted retrospectively on admissions to NHS PICUs in
England occurring between January 2010 and December 2020 for children aged 0–15 years
where the primary or secondary diagnoses were either: diabetes; Type 1 diabetes; diabetic
ketoacidosis (DKA); or diabetes mellitus (recorded via Read Codes CTV3). Any admissions
to PICUs which were re-designated as a Level 2 paediatric critical care episode during the
study period were excluded from analysis.
Pseudonymised data available included: primary and secondary diagnostic codes, date of
admission, sex, age, blood pressure and ethnic group. Interventions included in the analysis
were fluid bolus (any episodes of > 80ml/kg in a 24-hour period) during the admission, use of
invasive ventilation, intravenous vasoactive therapy and renal replacement therapy including
continuous veno-venous haemofiltration (CVVH) and peritoneal dialysis (PD). Expected
probability of mortality was calculated using the Paediatric Index of Mortality (PIM3) [27].
Outcomes included in the analysis were length of stay, acute renal failure, cerebral oedema
and mortality. Blood pressure centile data were computed from the blood pressure, age and
sex of the child as height and weight data were often missing [28].
A descriptive analysis was carried out with summary statistics presented as medians and
interquartile ranges for continuous data, and frequency and percentages for categorical data.
Differences between 2020 and 2010–2019 are presented as difference in medians or
proportions as appropriate with associated 95% confidence intervals.
Where comparisons are made to the general PICU population, information was extracted
from last year’s 2020 PICANet Annual Report which covered the period 2017–2019 [29]. This
general population includes children admitted to PICU with DKA.

48
PICANet 2021 Annual Report: Supplementary Chapters
Results
Analysis population
Of the 23 NHS PICUs in England included in this analysis, 19 (83%) had patients admitted
with a diagnosis of DKA during the study period; the remaining four PICUs were all cardiac
centres. Of the 150,426 total admissions to these 19 non-cardiac PICUs within the 11 year
study period, there were 959 DKA admissions (0.7%).
Trends in admissions
Between 2010 and 2019 the proportion of DKA admissions per year varied between 0.45% in
2017 and 0.73% in 2011 (Figure 15). In 2020 the proportion of children admitted with DKA
more than doubled compared to the preceding ten years; the mean percentage of DKA
admissions averaged 0.58% per year between 2010 and 2019 (95% confidence interval:
0.54–0.62%) compared with 1.3% of admissions in 2020.
Figure 15: Total number of annual paediatric intensive care admissions to non-
cardiac paediatric intensive care units alongside annual diabetic ketoacidosis
(DKA) admissions

2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
%
0.68
0.73
0.56
0.49
0.52
0.56
0.62
0.45
0.56
0.64
1.30
0.00
0.25
0.50
0.75
1.00
1.25
% DKA admissions
Year of admission

Special Chapter 1: COVID 19 and PIMS TS in PICU
49
Figure 16 shows the number of DKA admissions per month in 2020 compared with the
number in preceding years and the number of children admitted to PICU with COVID in
2020. In 2020, there were a higher number of DKA admissions from May to September
(more than 15 per month) with a peak of 20 admissions in July, which was twice as many as
admitted during the highest months of the previous ten years (December and January). The
peak DKA admissions did not occur at the same time as the peak COVID admissions which
occurred in April 2020 (n=29 admissions).
Figure 16: Diabetic ketoacidosis (DKA) admissions per month in 2020 compared
to median admissions per month during 2010–2019 and to COVID-19
admissions in 2020

DKA 2011-2019
DKA 2020
COVID 2020
0
5
10
15
20
25
30
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
Admissions
Month of admission

50
PICANet 2021 Annual Report: Supplementary Chapters
Patient characteristics
Table 12 shows the characteristics of the 959 children admitted to PICU with DKA within the
study period. Just over half were female (55%) and the median age was 10 years
(interquartile range (IQR): 5–14 years). By contrast, in general PICU admissions, males
accounted for a higher proportion than females (57%) and the median age was
approximately one year old. During the study period, 10 DKA admissions required
cardiopulmonary resuscitation (CPR) prior to PICU admission; there was a higher proportion
recorded in 2020 than in the preceding years (2.5% vs 0.8%).
Table 12: Characteristics of children admitted to PICU with DKA

DKA admissions
2010–2020
n=959
2010–2019

n=805
2020

n=154
Difference *
(95% CI)
Male, n(%)
436 (45%)
45%
47%
1.8%
(-6.6 to 10.2%)
Age (years)
n†(%)
Median (IQR)

959 (100)
10 (4–13)

805 (100)
10 (4–13)

154 (100)
10 (5-13)

0.2
(-0.7 to 1.0)
Weight (kg)
n†(%)
Median (IQR)

439 (46)
32 (14–47)

340 (42)
32 (14–48)

99 (64)
33 (17–42)

1.0
(-3.5 to 5.5)
Blood pressure centile
n†(%)
Median (IQR)

805 (84)
92nd (58–99)

670 (83)
91st (55–99)

135 (88)
93rd (72–99)

6.6
(-0.8 to 12.4)
Lactate
n†(%)
Median (IQR)

597 (63)
1.7 (1.1–2.5)

469 (58)
1.7 (1.1–2.6)

128 (83)
1.6 (1.3–2.3)

1.7
(-0.2 to 3.6)
PIM3 POD (%)
n†(%)
Median (IQR)

959 (100)
0.6 (0.2–1.0)

805 (100)
0.6 (0.2–1.0)

154(100)
0.5 (0.2–0.8)

0.7
(-0.2 to 1.7)
CPR prior to admission
n†(%)
CRP recorded, n(%)

884 (92)
10 (1.1)

730 (90)
6 (0.8)

154 (100)
4 (2.5)

1.7
(-0.8 to 4.3)
Abbreviations: IQR=interquartile range; PIM3 POD=paediatric index of mortality predicted probability of death;
†n=data available.
*Difference relates to 2020 compared with all previous years combined which acted as the control value

Special Chapter 1: COVID 19 and PIMS TS in PICU
51
Looking at the age distribution in more detail (Figure 17a), only 7% of the DKA admissions
occurred among those less than one year of age compared to the 45% of the overall PICU
admissions. 45% of the DKA cohort were aged between 11–15 years whilst this age group
only represented 13% of the general PICU population [29].
Figure 17a: Age distribution of all admissions compared to DKA (in age
categories)

Figure 17b provides a more detailed breakdown of the DKA admissions demonstrating a bi-
modal peak with children under two years of age accounting for 17% of PICU admissions
and then a larger peak with the admissions between 12–14 years of age accounting for 32%.
Figure 17b: Age distribution of DKA admissions

0%
10%
20%
30%
40%
50%
<1 year
1-4 years
5-10 years
11-15 years
Admissions (%)
Age category
All admissions
DKA admissions
0%
2%
4%
6%
8%
10%
12%
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
DKA admissions
Age in years

52
PICANet 2021 Annual Report: Supplementary Chapters
Figure 18 shows the ethnic breakdown of children admitted with DKA in the study period.
Although the distribution of ethnic groups may appear different in the two time periods this
could be due to better coding with only 9% of admissions in the “not stated/not known”
category in 2020 compared to 28% between 2010 and 2019.
Figure 18: Percentage of diabetic ketoacidosis (DKA) admissions reported in
each ethnic group

Unknown includes both "not stated"
and "not known"
0%
10%
20%
30%
40%
50%
60%
70%
White
Mixed
Asian
Black
Other
Unknown
DKA admissions
Ethnic group
2010-2019
2020

Special Chapter 1: COVID 19 and PIMS TS in PICU
53
Interventions and complications
Table 13 shows a breakdown of interventions delivered during DKA PICU admissions as well
as complications.
Table 13: Interventions delivered during diabetic ketoacidosis paediatric
intensive care unit admissions and complications
Overall
n=959
2010–2019
n=805
2020
n=154
% difference*
(95% CI)
Invasive ventilation, n(%)
185 (19)
157 (20)
28 (18)
-1.3
(-8.0 to 5.3)
IV vasoactive therapy, n(%)
109 (12)
95 (12)
14 (9)
-3.0
(-8.1 to 2.0)
Fluid bolus >80ml/kg, n(%)
38 (4)
31 (4)
7 (5)
0.6
(-2.9 to 4.2)
Low GCS, n(%)
82 (9)
47 (6)
35 (23)
16.7
(9.9 to 23.5)
Cerebral oedema, n(%)
44 (5)
39 (5)
5 (3)
-1.6
(-4.7 to 1.5)
Acute Renal Failure, n(%)
49 (5)
42 (5)
7 (5)
0.7
(-4.3 to 2.9)
Renal replacement, n(%)
39 (4)
32 (4)
7 (5)
0.5
(-3.1% to 4.0)
Abbreviations: IV=intravenous; GCS=Glasgow Coma Scale; CPR=cardiopulmonary resuscitation; CI = confidence
interval
*Difference relates to 2020 compared with all previous years combined which acts as the control value.
Percentages were compared using the equality of proportions test for large-sample statistics, and continuous
data via the two sample t test.
The percentage of admissions receiving invasive ventilation for the DKA cohort (19%) was
much lower than the general PICU population (63%, [29]). Likewise, the proportion receiving
intravenous (IV) vasoactive drugs was lower at 12% compared to 32% among general PIC
admissions [29]. However, the proportions receiving invasive ventilation and IV vasoactive
therapy were similar in 2020 to those in 2010–2019 (19% vs 17% and 12% vs 9%
respectively). Approximately 4% of DKA admissions in both time periods received >80ml/kg
in a 24-hour period.
Cerebral oedema or diabetic encephalopathy were included in the primary or secondary
diagnostic codes in 44 admissions (5%) out of all DKA admissions; in 2010–2019 these
diagnoses were recorded in 5% of DKA admissions compared with 3% in 2020. However,
there was a higher proportion of children with a low Glasgow Coma Score (GCS) recorded
during their admission in 2020 at 22% compared to 6% in all the preceding years, an
increase of 16% (95% CI: 10 to 23%).
Acute renal failure was included in the primary or secondary diagnostic code in 49 (5%) of
DKA admissions with 39 (4%) requiring renal replacement therapy. This was higher than
among the general PIC admissions in which renal replacement therapy was only recorded in
2.9% of admissions [29].

54
PICANet 2021 Annual Report: Supplementary Chapters
Outcomes
The median length of stay for the DKA PICU population was 1 day (IQR: 1–3 days). This was
slightly shorter when compared to the median length of stay for all PICU admissions
combined, at around 2.5 days [29].
Overall, there were 15 deaths reported among the DKA admissions during the study period,
equivalent to a crude mortality rate of 1.6%. The majority (n=14) of these deaths occurred
prior to 2020 with no evidence of a change in mortality throughout the study period. In the
general PICU population, the proportion of children dying on PICU in England was generally
higher at around 3.5% [29].
Discussion
The total number of DKA PICU admissions from 2010–2020 ranged from 62 to 154 per year
which is slightly higher than the 57 to 94 admissions seen between 2003 and 2006 in the
previous review of the PICANet cohort [26]. However, the proportion of DKA admissions out
of all admissions to English PICUs in the study period was 0.59% in comparison to 0.61% in
the 2010 report.
The age distribution of children admitted to PICU with DKA was similar to a report of children
admitted to UK hospitals with DKA, both series having a median age of 10 years [30].
Although the bi-modal distribution of this cohort has not been described elsewhere, it is
reported that children < 2 years are at increased risk of presenting with DKA compared to
older children: Lokulo-Sodipe et al [30], reported that children < 2 years accounted for 80% of
the DKA presentations. A systematic review by Usher-Smith et al [31], published in 2011,
identified that children < 2 years of age had three times the risk of presenting in ketoacidosis
as older children (odds ratio 3.41, 95% confidence interval 2.54 – 4.59).
From 2010 to 2019, the proportion of DKA admissions to PICU ranged between 0.48% and
0.73% with a median of 0.60%; in 2020, at the start of the COVID-19 pandemic, this
proportion was double, totalling 1.3% of admissions. The increased number of PICU DKA
admissions in 2020 is in keeping with international reports of an association with an
increased number of DKA presentations in children and adults at the time of the COVID-19
pandemic [24, 25, 32, 33]. Our data identifies no clear differences between the cohorts
admitted before and during the COVID pandemic apart from a higher proportion of patients
with documented low GCS and more children requiring CPR in the latter group. However,
this could be explained by improved reporting of GCS and CPR in the PICANet database
over the same time period.
There are three potential reasons for the increase in PICU DKA admissions in 2020:
1. delayed presentation to hospital of children with DKA who therefore require PIC;
2. increased incidence of DKA due to direct pancreatic islet cell damage caused by
Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2, the virus which
causes COVID-19) [33]; or
3. changes in British Society for Paediatric Endocrinology and Diabetes (BSPED)
guidelines on the management of DKA in January 2020.
During 2020, 32% of 4,075 paediatricians surveyed by the British Paediatric Surveillance
Unit (BPSU) reported children presenting late to emergency departments and paediatric
assessment units during the COVID-19 pandemic [34]; a new diagnosis of DKA was one of
the most common conditions reported in this publication. This finding would be consistent
with a higher proportion of children having a low GCS recorded in PICU and requiring CPR in
the 2020 PICU DKA cohort.

Special Chapter 1: COVID 19 and PIMS TS in PICU
55
However, there are also several reports of a higher incidence of diabetes and DKA
associated with COVID-19 [24, 25, 32, 33] and this would be consistent with our findings that
despite an increased number of DKA admissions in 2020 the requirement for ventilation, IV
vasoactive treatment and renal replacement therapy was comparable to the preceding ten
years. Specifically, the data does not support theories that patients required more support in
2020 or that the threshold for admissions to PICU was lower during this time as the acuity of
the cohorts was similar to previous years.
In the last ten years national guidelines published by National Institute for Clinical Excellence
(NICE 2021) and British Society for Paediatric Endocrinology and Diabetes (BSPED 2020)
have been revised twice (2015 and 2020). It is not known if the revised guidance has had an
impact on the admissions to PIC and some PIC clinicians have raised a concern about the
impact of a more liberal fluid regimen on DKA outcomes, specifically the incidence of
cerebral oedema [35]. However, this study did not demonstrate significant differences in the
2020 admissions compared to the previous decade nor temporal changes related to the
introduction of the 2015 guidance. This suggests that national guideline changes may have
had minimal impact on mortality, incidence of cerebral oedema or acute renal failure in
children presenting to PICU with a diagnosis of DKA. Alternatively, a database study such as
this and the descriptive analysis undertaken may not be able to identify subtle changes in
these outcomes.
Despite being the largest data set studied of paediatric critical care patients with DKA, some
complications such as acute kidney injury (AKI) are likely to be under-reported. Only 5% of
the patients admitted had a diagnostic code of AKI which was far lower than other studies
looking at AKI and DKA [36, 37]. This is likely to reflect the different levels and standard of
reporting of diagnoses across PICUs which is reliant on clinical coding.
There was evidence of improved reporting and clinical coding in 2020 PICU admissions
compared to the previous decade. The number of children with ‘not stated /not known’ ethnic
category reduced from an average of 28% to 9% in 2020. This trend was also noted in the
recording of weight: an average of 42% admissions with documented weight prior to 2019
improved to 64% in 2020 and lactate recording increased from 58% (2010–2019 average) to
83% of admissions in 2020.
There does not appear to have been a significant change in mortality since the previous
PICANet cohort was analysed in 2003–2007, in which there were five deaths reported with a
crude mortality of 1.5%. The latest cohort showed a very similar number of deaths (n=15)
equivalent to a crude mortality rate of 1.5% between 2010 and 2020. In addition, the analysis
did not reveal any change in mortality over time during the period studied.
As mortality is low, median length of stay is one day and the majority of patients did not
require inotropes nor ventilation, this group could be appropriately managed in a level 2
critical care setting.
A key strength of this review is that it included all admissions to PICUs in England for more
than a decade. The data were collected and presented in a standardised format which
facilitated comparison across the whole country and different time periods, providing a broad
and longitudinal perspective of children admitted to PICU with a primary diagnosis of DKA.
Limitations are primarily that historical data relied on coding and there was no access to
granular data such as specific GCS or creatinine values to explore complications of DKA
such as cerebral oedema or AKI more thoroughly. The improvement in the submission of
data over time (e.g. ethnic coding) may have contributed to some of the findings (e.g. low
GCS).

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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