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Trends in unplanned non-surgical paediatric oncology admissions to paediatric intensive care units in England between
Rebecca A Ward1,2, Matthew R Solomons3,2, Abhisekh Chatterjee4,2
1Department of Paediatrics, John Radcliffe Hospital, Oxford, UK.
Insights
Unplanned pediatric intensive care unit (PICU) admissions for children with cancer increased, but overall mortality decreased. This improvement is likely due to more low-acuity cases being admitted, not necessarily better care.
Area of Science:
- Pediatric critical care medicine
- Pediatric oncology
- Health services research
Background:
- Significant improvements in mortality for unplanned pediatric intensive care unit (PICU) oncology admissions have been observed over decades.
- Previous studies faced challenges in drawing conclusions due to heterogeneous patient populations and outcome measures.
- Overall mortality for children with oncological diagnoses in PICUs across England has decreased.
Purpose of the Study:
- To analyze trends in management and outcomes for a large cohort of unplanned PICU admissions in children with cancer.
- To identify changes in clinical practice and their impact on mortality rates.
- To understand the factors contributing to improved survival in this vulnerable patient group.
Main Methods:
- A retrospective cohort study of all unplanned oncology admissions to English PICUs between 2008 and 2022, using the PICANet database.
- Inclusion criteria: unplanned PICU admissions for children aged 1 month to 16 years with oncology diagnoses; exclusion of patients with benign diseases.
- Analysis of admission trends, interventions (ventilation, vasoactive agents, renal support), acuity scores (PIM), and mortality rates.
Main Results:
- Unplanned oncology admissions increased from 1.2% to 1.9% of all PICU admissions between 2008 and 2020, with hematological malignancies showing the largest rise.
- Presentations with infections became more common, exceeding half of oncology admissions by 2022.
- Invasive ventilation decreased, while PIM scores indicated lower overall acuity; mortality fell from 16.7% to 12.2%.
Conclusions:
- Unplanned PICU admissions for children with cancer continue to carry a high risk of mortality.
- The observed decrease in overall PICU mortality percentage is likely attributable to an increased number of lower-acuity admissions.
- Further research is needed to determine if specific clinical or oncological care improvements have contributed to better outcomes.
Abstract:
Children with cancer requiring PICU admission have a relatively high mortality. This study reports trends in management and outcomes for a large cohort of unplanned PICU admissions for children with underlying oncology diagnoses. A retrospective cohort study, analysing all unplanned oncology admissions for all English PICUs from 2008 to 2022, captured by PICANet, a quality-assured, prospectively collected national database. Unplanned oncology admissions to the PICU aged 1 month to 16 years were included. Patients with benign disease were excluded. A total of 4371 admissions from 3277 children underwent further analysis. Unplanned oncology admissions increased from 209 in 2008, peaking at 357 in 2020, representing 1.2 and 1.9%, respectively, of all PICU admissions in those years. Haematological malignancies had the largest rise. Presentations with infections also rose, making up over half of oncology admissions by 2022. The percentage invasively ventilated fell from 55.8 to 48.1%, but significant changes in the use of vasoactive agents, non-invasive ventilation and renal support were not seen. Mean PIM score (0.085 to 0.06) at admission fell, reflecting lower overall acuity. Mortality in unplanned oncology admissions fell from 16.7 to 12.2%. Survival, when banded for PIM risk group, showed no improvement except possibly in those with over 30% risk of death, where a downward trend in actual mortality was seen.
Conclusions:
Unplanned admissions of children with cancer to PICU remain at a relatively high risk of death. The cause of the improved overall percentage mortality is likely related to increased low-acuity admissions.
What Is Known:
• Significant improvements have been seen in mortality for unplanned oncology admissions to the PICU over the last few decades. • Studies have attempted to define these trends; however, heterogeneity between patient populations and outcome measures included makes it difficult to draw meaningful conclusions from them.
What Is New:
• Overall mortality in all PICU admissions for children with oncological diagnoses in England decreased. • The improvement in PICU percentage mortality is likely due to a reduced admission threshold rather than specific improvements in clinical or oncological care for these patients.
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