Paediatric Intensive Care Network Audit (PICANet) Context Page

  • CQC have collaborated with audit bodies and agreed to present these ‘key’ metrics about the quality of services.
  • This document provides guidance to assist interpretation of the key metrics from the Paediatric Intensive Care Network Audit (PICANet) as selected by the University of Leeds and the University of Leicester. Full audits can be reviewed where it is necessary to further inform an inspection.
  • A total of 28 designated paediatric intensive care units in the UK participated in the audit in 2015-2017.

Metrics:

1. Case ascertainment

Case ascertainment nationally is estimated to be almost 100% complete for PICU admissions[1]. PICANet Web allows units to obtain reports on their own data to check monthly admissions totals. In addition, during validation visits a cross check is carried out against records held on PICU (e.g. in-house data collection systems) and PICANet Web. These on-site validation visits are a core element of the audit’s data quality assurance process.

[1]PICANet 2018 Summary Report, p 1

2. Proportion of emergency retrievals with mobilisation time <1 hour (mobilisation time is defined as time period between retrieval team departing transport base and the referral being accepted for retrieval)

  • Rationale: Timely retrieval of critically ill paediatric patients from referring units to specialist centres is likely to optimise patient outcomes; this metric is known to vary across regions – particularly in times of high demand.
  • Guideline/mapping: This metric maps exactly to PIC14 (a commissioning standard on NHS England’s Specialised Services Quality Dashboard until 2016/17[2]); the audit endorses NHS England’s aspirational target that 95% of mobilisation times for urgent retrievals should be less than an hour.
  • Graph/relative performance: The performance relates to whether the unit met the aspirational standard or not. Higher values are better.
  • Quality improvement prompt question: If the unit is not meeting the aspirational standard this should prompt questions about the availability of specialist paediatric retrieval teams, barriers to timely deployment (including training exercises), appropriate governance (such as timely and complete submission of essential retrieval data to PICANet) and actions which the Trust is taking to improve mobilisation times.

2. Crude number of qualified nurses per bed (measured as Wte [whole time equivalents])

  • Rationale: Safe management of critically ill paediatric patients is dependent on the provision of adequate numbers of clinical staff.
  • Guideline/mapping: This metric maps exactly to PICS standard L3-207[3]; the standard specifies an aspirational target of 7.01Wte qualified nurses per 1 critical care bed. This takes into account a number of factors that could affect nursing staffing levels, such as training, sickness and maternity leave.
  • Graph/relative performance: The performance relates to whether the unit met the aspirational standard or not.
  • Quality improvement prompt question: If the unit is not meeting the aspirational standard this should prompt inspectors to ask questions about the adequacy of critical care staffing and its impact on bed capacity and patient outcomes as well as actions which the hospital is taking to address the deficiency.

3. Crude 48-hour emergency readmission ratio (defined as the number of emergency readmissions within 48 hours of discharge of transfer out from the unit divided by the total number of discharges or transfers out from the unit; excludes direct Paediatric Intensive Care Unit [PICU] to PICU transfers)

  • Rationale: Emergency readmission within 48 hours can reflect inappropriately expedited discharge from the PICU or a failure to provide adequate step-down care.
  • Guideline/mapping: This metric maps exactly to PIC04[1]; the target for this metric is to set a baseline %. The audit recommends that they work with the Paediatric Intensive Care Society and the Care Quality Commission and other stakeholders to establish the standard for emergency readmission rates[2].[1]NHS England Specialist Services Quality Dashboard, PIC04

    [2]PICANet 2018 Summary Report, p 11

  • Graph/relative performance: PICUs emergency readmission rates are compared against other PICUs and the national average (see key 1). Lower values indicate better performance. PICUs which are negative outliers have a readmission ratio than is expected by chance alone (outside upper 99.9% control limits). Positive outliers are also possible. PICUs classified as within expected range have rates which are similar to (i.e. not statistically different from) the national average.
  • Quality improvement prompt question: Alarm-level outlier status should prompt inspectors to ask questions about the protocols governing discharge from the PICU (including seniority of clinical decision making), availability of appropriate step-down care, evidence of good governance (such as case note review to identify causes of readmission) and actions which the trust is taking to reduce its emergency readmission ratio. Where data is collected for a combined PICU/HDU, this may overestimate their emergency readmission rate[1].[1]PICANet 2016 Summary Report, p 21

4. Risk-adjusted standardised mortality ratio (mortality within a PICU)

  • Rationale: Although death on a paediatric intensive care unit (PICU) is quite rare, it is important to assess whether more (or fewer) deaths than expected occur, as this can indicate that there is something different happening in a PICU; this metric uses case-mix adjustment to ensure that hospitals dealing with sicker patients are compared fairly against those with a less complex case mix; the adjustment is re-calibrated each year.
  • Guideline/mapping: This metric maps exactly to PIC01[1].[1]NHS England Specialist Services Quality Dashboard, PIC01
  • Graph/relative performance: PICUs adjusted rates are compared against other PICUs and the national average (see key 1). Lower values indicate better performance. PICUs with high mortality identified as negative outliers are followed-up by the audit body as part of the audit outlier process[1]. PICUs which are negative outliers have a mortality ratio than is expected by chance alone (outside upper 99.9% control limits). Positive outliers are also possible. PICUs classified as within expected range have rates which are similar to (i.e. not statistically different from) the national average. Adjusted rates means that the comparison across providers takes into account the differences in the mix of patients treated. This means that differences in outcomes are not due to the types of patient seen. 
  • Quality improvement prompt question: Alarm-level outlier status should prompt inspectors to investigate the circumstances that have given rise to the outlier status, such as adverse case mix.