Introduction: Formal guidelines to transfer critically ill children (pts) to PTCs have been proposed. Critics claim such guidelines are unnecessary and that an informal system of referral effectively transfers pts to PTCs. To determine the efficacy of this informal system we compared the number of deaths in PTCs versus non-PTCs for head trauma(HT) and/or respiratory failure (ARF). We assumed that children who died were critically ill. We hypothesized that if the informal system is functioning efficiently, then few children (<10%) would die in non-PTCs.

Methods: Using the NJ Dept. of Health's UB82 database for 1993 and appropriate ICD-9 codes, we obtained data for all in-patient pediatric mortalities admitted to NJ hospitals for HT and/or ARF. Patients who expired in an emergency department were excluded from the analysis. Hospitals were classified as PTCs or non-PTCs based on recently published guidelines.

Results: 82 hospitals cared for children with HT and/or ARF. 7 hospitals met criteria as PTCs. 170 pts died. An analysis of mortality follows: Table

Table 1
Full size table

Conclusion: 63 pts (35%) died in non-PTCs despite no difference in age, length of stay, race, hospital charge, or head trauma as the initial diagnosis. Therefore, the informal referral system does not insure transfer of a significant number of such pts to PTCs.