Impact of Quality-of-Care Factors on Pediatric Intensive Care Unit Mortality

OBJECTIVE: To determine the importance of the following care factors previously associated with hospital quality on survival from pediatric intensive care: size of the intensive care unit (ICU), medical school teaching status of the hospital housing the ICU, specialist status (pediatric intensivist), and unit coordination. DESIGN: After a national survey, consecutive case series were collected at 16 sites randomly selected to represent unique combinations of quality-of-care factors. SETTING: Pediatric ICUs. PATIENTS: Consecutive admissions to each site. MAIN OUTCOME MEASURE: Patient mortality adjusted for physiologic status, diagnosis, and other mortality risk factors. RESULTS: There were 5415 pediatric ICU admissions and 248 ICU deaths. The ICUs differed significantly with respect to descriptive variables, including mortality (range, 2.2% to 16.4%). Analysis of risk-adjusted mortality indicated that the hospital teaching status and the presence of a pediatric intensivist were significantly associated with a patient's chance of survival. The probability of patient survival after hospitalization in an ICU located in a teaching hospital was decreased (relative odds of dying, 1.79; 95% confidence interval CI, 1.23 to 2.61; P = .002). In contrast, the probability of patient survival after hospitalization in an ICU with a pediatric intensivist was improved (relative odds of dying, 0.65; 95% CI, 0.44 to 0.95; P = .027). Post hoc analysis indicated that the higher severity-adjusted mortality in teaching hospitals may be explained by the presence of residents caring for ICU patients. CONCLUSION: Characteristics indicative of the best overall hospital quality may not be associated, or may be negatively associated, with quality of care in specialized care areas, including the pediatric ICU.