The impact of hospital command centre on patient flow and data quality: findings from the UK National Health Service

In the last 6 years, hospitals in developed countries have been trialling the use of command centres for improving organizational efficiency and patient care. However, the impact of these command centres has not been systematically studied in the past. It is a retrospective population-based study. Participants were patients who visited the Bradford Royal Infirmary hospital, Accident and Emergency (A&E) Department, between 1 January 2018 and 31 August 2021. Outcomes were patient flow (measured as A&E waiting time, length of stay, and clinician seen time) and data quality (measured by the proportion of missing treatment and assessment dates and valid transition between A&E care stages). Interrupted time-series segmented regression and process mining were used for analysis. A&E transition time from patient arrival to assessment by a clinician marginally improved during the intervention period; there was a decrease of 0.9 min [95% confidence interval (CI): 0.35-1.4], 3 min (95% CI: 2.4-3.5), 9.7 min (95% CI: 8.4-11.0), and 3.1 min (95% CI: 2.7-3.5) during 'patient flow program', 'command centre display roll-in', 'command centre activation', and 'hospital wide training program', respectively. However, the transition time from patient treatment until the conclusion of consultation showed an increase of 11.5 min (95% CI: 9.2-13.9), 12.3 min (95% CI: 8.7-15.9), 53.4 min (95% CI: 48.1-58.7), and 50.2 min (95% CI: 47.5-52.9) for the respective four post-intervention periods. Furthermore, the length of stay was not significantly impacted; the change was -8.8 h (95% CI: -17.6 to 0.08), -8.9 h (95% CI: -18.6 to 0.65), -1.67 h (95% CI: -10.3 to 6.9), and -0.54 h (95% CI: -13.9 to 12.8) during the four respective post-intervention periods. It was a similar pattern for the waiting and clinician seen times. Data quality as measured by the proportion of missing dates of records was generally poor (treatment date = 42.7% and clinician seen date = 23.4%) and did not significantly improve during the intervention periods. The findings of the study suggest that a command centre package that includes process change and software technology does not appear to have a consistent positive impact on patient safety and data quality based on the indicators and data we used. Therefore, hospitals considering introducing a command centre should not assume there will be benefits in patient flow and data quality.

Associations of health-related quality of life with major adverse cardiovascular and cerebrovascular events for individuals with ischaemic heart disease: systematic review, meta-analysis and evidence mapping

OBJECTIVE

To investigate the association between health-related quality of life (HRQoL) and major adverse cardiovascular and cerebrovascular events (MACCE) in individuals with ischaemic heart disease (IHD).

METHODS

Medline(R), Embase, APA PsycINFO and CINAHL (EBSCO) from inception to 3 April 2023 were searched. Studies reporting association of HRQoL, using a generic or cardiac-specific tool, with MACCE or components of MACCE for individuals with IHD were eligible for inclusion. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale to assess the quality of the studies. Descriptive synthesis, evidence mapping and random-effects meta-analysis were performed stratified by HRQoL measures and effect estimates. Between-study heterogeneity was assessed using the Higgins I2 statistic.

RESULTS

Fifty-one articles were included with a total of 134 740 participants from 53 countries. Meta-analysis of 23 studies found that the risk of MACCE increased with lower baseline HeartQoL score (HR 1.49, 95% CI 1.16 to 1.93) and Short Form Survey (SF-12) physical component score (PCS) (HR 1.39, 95% CI 1.28 to 1.51). Risk of all-cause mortality increased with a lower HeartQoL (HR 1.64, 95% CI 1.34 to 2.01), EuroQol 5-dimension (HR 1.17, 95% CI 1.12 to 1.22), SF-36 PCS (HR 1.29, 95% CI 1.19 to 1.41), SF-36 mental component score (HR 1.18, 95% CI 1.08 to 1.30).

CONCLUSIONS

This study found an inverse association between baseline values or change in HRQoL and MACCE or components of MACCE in individuals with IHD, albeit with between-study heterogeneity. Standardisation and routine assessment of HRQoL in clinical practice may help risk stratify individuals with IHD for tailored interventions.

PROSPERO REGISTRATION NUMBER

CRD42021234638.

The effects of exposure to NO2, PM2.5 and PM10 on health service attendances with respiratory illnesses: A time-series analysis

The associations of exposure to air-pollutants and respiratory illness remains inconsistent and studies have not adequately addressed the non-linearity and delayed effects of exposure. This is a retrospective cohort study using linked routine health and pollution data collected between January 2018 and December 2021. Participants were patients who visited General Practice (GP) or accident and emergency (A&E) services for respiratory illness. Time-series analysis, distributed lagged models, was used to address the potential non-linearity and delayed effects of exposure. There were 114,930 GP and 9878 A&E respiratory visits. For every 10 μg/m3 increase in NO2 and PM2.5 above the WHO recommended 24-hr thresholds, the immediate relative risk of GP respiratory visits was 1.09 (95% CI: 1.07 to 1.05) and 1.06 (95% CI: 1.01 to 1.10), respectively. The respective relative risk of A&E visit was 1.10 (95% CI: 1.07 to 1.14) and 1.07 (95% CI: 1.00 to 1.14). Exposure to 10-unit increases in NO2, PM2.5 and PM10 above the WHO recommended 24-hr thresholds, was associated with lagged relative risks of 1.49 (95% CI: 1.42 to 1.56), 5.26 (95% CI: 4.18 to 6.61) and 2.32 (95% CI: 1.66 to 3.26), respectively, for GP respiratory attendances. The lagged relative risk of A&E respiratory visits for same units of exposure in NO2, PM2.5, and PM10 at the peak lag days were 1.98 (95% CI: 1.82 to 2.15), 4.52 (95% CI: 3.37 to 6.07) and 3.55 (95% CI: 1.85 to 6.84). A third of GP and half of A&E respiratory visits were attributable to exposure to NO2 beyond the WHO threshold. The combined cost of these visits over the study period was 1.95 million (95% CI: 1.82 to 2.09). High pollution events are related to increased health service use for respiratory illness, with impacts persisting up to 100 days post exposure. The burden of respiratory illness related to air-pollution may be considerably higher than previously reported.

Effect of a hospital command centre on patient safety: an interrupted time series study

BACKGROUND

Command centres have been piloted in some hospitals across the developed world in the last few years. Their impact on patient safety, however, has not been systematically studied. Hence, we aimed to investigate this.

METHODS

This is a retrospective population-based cohort study. Participants were patients who visited Bradford Royal Infirmary Hospital and Calderdale & Huddersfield hospitals between 1 January 2018 and 31 August 2021. A five-phase, interrupted time series, linear regression analysis was used.

RESULTS

After introduction of a Command Centre, while mortality and readmissions marginally improved, there was no statistically significant impact on postoperative sepsis. In the intervention hospital, when compared with the preintervention period, mortality decreased by 1.4% (95% CI 0.8% to 1.9%), 1.5% (95% CI 0.9% to 2.1%), 1.3% (95% CI 0.7% to 1.8%) and 2.5% (95% CI 1.7% to 3.4%) during successive phases of the command centre programme, including roll-in and activation of the technology and preparatory quality improvement work. However, in the control site, compared with the baseline, the weekly mortality also decreased by 2.0% (95% CI 0.9 to 3.1), 2.3% (95% CI 1.1 to 3.5), 1.3% (95% CI 0.2 to 2.4), 3.1% (95% CI 1.4 to 4.8) for the respective intervention phases. No impact on any of the indicators was observed when only the software technology part of the Command Centre was considered.

CONCLUSION

Implementation of a hospital Command Centre may have a marginal positive impact on patient safety when implemented as part of a broader hospital-wide improvement programme including colocation of operations and clinical leads in a central location. However, improvement in patient safety indicators was also observed for a comparable period in the control site. Further evaluative research into the impact of hospital command centres on a broader range of patient safety and other outcomes is warranted.

Evaluating the safety and patient impacts of an artificial intelligence command centre in acute hospital care: a mixed-methods protocol

INTRODUCTION

This paper presents a mixed-methods study protocol that will be used to evaluate a recent implementation of a real-time, centralised hospital command centre in the UK. The command centre represents a complex intervention within a complex adaptive system. It could support better operational decision-making and facilitate identification and mitigation of threats to patient safety. There is, however, limited research on the impact of such complex health information technology on patient safety, reliability and operational efficiency of healthcare delivery and this study aims to help address that gap.

METHODS AND ANALYSIS

We will conduct a longitudinal mixed-method evaluation that will be informed by public-and-patient involvement and engagement. Interviews and ethnographic observations will inform iterations with quantitative analysis that will sensitise further qualitative work. Quantitative work will take an iterative approach to identify relevant outcome measures from both the literature and pragmatically from datasets of routinely collected electronic health records.

ETHICS AND DISSEMINATION

This protocol has been approved by the University of Leeds Engineering and Physical Sciences Research Ethics Committee (#MEEC 20-016) and the National Health Service Health Research Authority (IRAS No.: 285933). Our results will be communicated through peer-reviewed publications in international journals and conferences. We will provide ongoing feedback as part of our engagement work with local trust stakeholders.

Effects of computerised clinical decision support systems (CDSS) on nursing and allied health professional performance and patient outcomes: a systematic review of experimental and observational studies

OBJECTIVE

Computerised clinical decision support systems (CDSS) are an increasingly important part of nurse and allied health professional (AHP) roles in delivering healthcare. The impact of these technologies on these health professionals' performance and patient outcomes has not been systematically reviewed. We aimed to conduct a systematic review to investigate this.

MATERIALS AND METHODS

The following bibliographic databases and grey literature sources were searched by an experienced Information Professional for published and unpublished research from inception to February 2021 without language restrictions: MEDLINE (Ovid), Embase Classic+Embase (Ovid), PsycINFO (Ovid), HMIC (Ovid), AMED (Allied and Complementary Medicine) (Ovid), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), Social Sciences Citation Index Expanded (Clarivate), ProQuest Dissertations & Theses Abstracts & Index, ProQuest ASSIA (Applied Social Science Index and Abstract), Clinical Trials.gov, WHO International Clinical Trials Registry (ICTRP), Health Services Research Projects in Progress (HSRProj), OpenClinical(www.OpenClinical.org), OpenGrey (www.opengrey.eu), Health.IT.gov, Agency for Healthcare Research and Quality (www.ahrq.gov). Any comparative research studies comparing CDSS with usual care were eligible for inclusion.

RESULTS

A total of 36 106 non-duplicate records were identified. Of 35 included studies: 28 were randomised trials, three controlled-before-and-after studies, three interrupted-time-series and one non-randomised trial. There were ~1318 health professionals and ~67 595 patient participants in the studies. Most studies focused on nurse decision-makers (71%) or paramedics (5.7%). CDSS as a standalone Personal Computer/LAPTOP-technology was a feature of 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile/handheld-technology.

DISCUSSION

CDSS impacted 38% of the outcome measures used positively. Care processes were better in 47% of the measures adopted; examples included, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling and documenting care. Patient care outcomes in 40.7% of indicators were better; examples included, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity and triaging appropriateness.

CONCLUSION

CDSS may have a positive impact on selected aspects of nurses' and AHPs' performance and care outcomes. However, comparative research is generally low quality, with a wide range of heterogeneous outcomes. After more than 13 years of synthesised research into CDSS in healthcare professions other than medicine, the need for better quality evaluative research remains as pressing.

Peer mentorship to improve self-management of hip and knee osteoarthritis: a randomised feasibility trial

OBJECTIVE

To determine the feasibility of conducting a randomised controlled trial (RCT) of a peer mentorship intervention to improve self-management of osteoarthritis (OA).

DESIGN

Six-month parallel group non-blinded randomised feasibility trial.

SETTING

One secondary care and one primary care UK National Health Service Trust.

PARTICIPANTS

Fifty adults aged ≥55 years old with hip and/or knee OA.

INTERVENTIONS

Participants were allocated 1:1 to the intervention or control group using an online randomisation service. Intervention group participants received usual care (information resources) and up to eight community-based self-management support sessions delivered by a peer mentor (trained volunteer with hip and/or knee OA). Control group participants received usual care only.

OUTCOME MEASURES

Key feasibility outcomes were participant and peer mentor recruitment and attrition, intervention completion and the sample size required for a definitive RCT. Based on these feasibility outcomes, four success criteria for proceeding to a definitive RCT were prespecified. Patient-reported outcomes were collected via questionnaires at baseline, 8 weeks and 6 months.

RESULTS

Ninety-six individuals were screened, 65 were eligible and 50 were randomised (25 per group). Of the 24 participants who commenced the intervention, 20 completed it. Four participants did not complete the 6-month questionnaire. Twenty-one individuals were eligible for the peer mentor role, 15 were trained and 5 withdrew prior to being matched with a participant. No intervention-related harms occurred. Allowing for 20% attrition, the sample size required for a definitive RCT was calculated as 170 participants. The intervention group showed improvements in self-management compared with the control group.

CONCLUSIONS

The feasibility outcomes achieved the prespecified criteria for proceeding to an RCT. The exploratory analyses suggest peer mentorship may improve OA self-management. An RCT of the OA peer mentorship intervention is therefore warranted with minor modifications to the intervention and trial procedures.

TRIAL REGISTRATION NUMBER

ISRCTN:50675542.

Oral glucocorticoids and incidence of hypertension in people with chronic inflammatory diseases: a population-based cohort study

BACKGROUND

Only a few population-based studies have examined the association between glucocorticoids and hypertension, with inconsistent results. We aimed to investigate the effect of oral glucocorticoids on incidence of hypertension in adults with chronic inflammatory diseases.

METHODS

We analyzed electronic health records from 389 practices in England during 1998-2017 of adults diagnosed with any of 6 chronic inflammatory diseases but with no previous diagnosis of hypertension. We used glucocorticoid prescription data to construct time-variant daily and cumulative variables of prednisolone-equivalent dose (cumulated from 1 year before the start of follow-up) and estimated incidence rates and adjusted hazard ratios (HRs) for hypertension using Cox regression analysis.

RESULTS

Among 71 642 patients in the cohort, 24 896 (34.8%) developed hypertension during a median follow-up of 6.6 years. The incidence rate of hypertension was 46.7 (95% confidence interval [CI] 46.0-47.3) per 1000 person-years. Incidence rates increased with higher cumulative glucocorticoid prednisolone-equivalent dose, from 44.4 per 1000 person-years in periods of nonuse to 45.3 per 1000 person-years for periods with between > 0.0 and 959.9 mg (HR 1.14, 95% CI 1.09-1.19), to 49.3 per 1000 person-years for periods with 960-3054.9 mg (HR 1.20, 95% CI 1.14-1.27), and to 55.6 per 1000 person-years for periods with ≥ 3055 mg (HR 1.30, 95% CI 1.25-1.35). Cumulative effects were seen for the 6 diseases studied, but dose-response effects were not found for daily dose.

INTERPRETATION

Cumulative dose of oral glucocorticoids was associated with increased incidence of hypertension, suggesting that blood pressure should be monitored closely in patients routinely treated with these drugs. Given that glucocorticoids are widely prescribed, the associated health burden could be high. Trial registration: ClinicalTrials. gov, no. NCT03760562.

Dose dependency of iatrogenic glucocorticoid excess and adrenal insufficiency and mortality: a cohort study in England

CONTEXT

Adrenal insufficiency and Cushing's syndrome are known adverse events of glucocorticoids. However, no population estimates of dose-related risks are available.

OBJECTIVE

To investigate dose-related risks of adrenal dysfunction and death in adults with six chronic inflammatory diseases treated with oral glucocorticoids.

DESIGN AND SETTING

Retrospective record-linkage open-cohort study spanning primary and hospital care in England.

PATIENTS

70,638 people oral glucocorticoid-users and 41,166 non-users aged ≥18 years registered in 389 practices in 1998-2017.

MAIN OUTCOME MEASURES

Incidence rates and hazard ratios (HRs) of diagnosed adrenal dysfunction and death.

RESULTS

During a median follow-up of 5.5 years, 183 patients had glucocorticoid-induced adrenal insufficiency and 248 glucocorticoid-induced Cushing's syndrome. A total of 22,317 (31.6%) and 7,544 (18.3%) deaths occurred amongst glucocorticoid users and non-users, respectively. Incidence of all outcomes increased with higher current daily and cumulative doses. For adrenal insufficiency, the increases in HRs were of 1.07 (95% CI 1.04-1.09) for every increase of 5mg per day and of 2.25 (95% CI 2.15-2.35) per 1000mg of cumulative prednisolone-equivalent dose over the past year. The respective increases in HRs for Cushing's syndrome were of 1.09 (95% CI 1.08-1.11) and 2.31 (95% CI 2.23-2.40) and for mortality of 1.26 (95% CI 2.24-1.28) and 2.05 (95% CI 2.04-2.06).

CONCLUSION

We report a high glucocorticoid dose-dependent increased risk of adrenal adverse events and death. The low observed absolute risk of adrenal insufficiency highlights a potential lack of awareness, and a need for increased physician and patient education about the risks of adrenal dysfunction induced by glucocorticoids.

Incidence and Burden of Wheezing Disorders, Eczema, and Rhinitis in Children: findings from the Born in Bradford Cohort

BACKGROUND

Bradford city has high infant mortality and there is a major health concern in the community due to environmental pollution. The aim of the study was to investigate the incidence and burden of wheezing disorders, eczema, and rhinitis in children aged 3-7 years .

METHODS

It is a prospective cohort study; the participants were 13 734 children from the Born in Bradford cohort.

RESULTS

There were a total of 22.1% (95% Confidence Interval (CI) 21.4, 22.8%), 52.4% (95% CI 51.5%, 53.2%), and 19.3% (95% CI 18.6, 19.9%) incidence cases of wheezing disorders, eczema, and rhinitis respectively. A total of 37% (95% CI 36.2%, 37.8%), 19.5% (95% CI 18.9%, 20.2%,) and 5.9% (95% CI 5.5%, 6.3%) of the children were affected by only one, two, and three diseases respectively. Boys to girls incidence rate ratios for wheezing disorders, eczema, and rhinitis was 1.41 (95% CI 1.31, 1.51), 1.02 (95% CI 0.97, 1.07), and 1.18 (95% CI 1.09, 1.28) respectively. The respective incidence rate ratios of Pakistani to White British were 0.94 (95% CI 0.87, 1.02), 1.31 (95% CI 1.24, 1.39), and 2.03 (95% CI 1.83, 2.25) respectively.

CONCLUSION

This study shows that the burden of wheezing disorders, eczema, and rhinitis in this cohort is higher than previously reported in earlier studies. In addition, it indicates that while boys are more likely to suffer from wheezing disorders, rhinitis, and multiple diseases than girls, Pakistani children are more likely to suffer from eczema, rhinitis, and multiple diseases than White British children.

Effects of birth weight and growth on childhood wheezing disorders: findings from the Born in Bradford Cohort

OBJECTIVES

To examine the effects of birth weight and childhood growth on childhood wheezing disorders. We hypothesised that low birth weight and fast growth during early age would increase the risk of wheezing disorders.

SETTING

Observational secondary analysis of data from the Born in Bradford cohort.

PARTICIPANTS

All children who were born at the Bradford Royal Infirmary hospital between March 2007 and December 2010 were eligible for the study. A total of 13,734 and 1598 children participated in the analyses of the effects of birth weight and growth on wheezing disorders, respectively.

PRIMARY AND SECONDARY OUTCOME MEASURES

Wheezing disorders diagnosis (diagnosed as asthma or had wheezing symptom) during the ages of 0-7 years were the primary outcome measures. Diagnosis of asthma and occurrence of wheezing during the same period were secondary outcome measures. Birth weight was classified as normal (2.5-4.0 kg), low (<2.5 kg) and high (>4.0 kg). Growth mixture models were used to drive growth pattern outcomes which were classified as 'normal', 'fast' and 'slow' growth based on their velocities between birth and 36 months.

RESULTS

The adjusted relative risks (RRs) of wheezing disorders diagnosis for the low and high birthweight children were 1.29 (95% CI 1.12 to 1.50; p=0.001) and 0.91 (95% CI 0.79 to 1.04; p=0.17), respectively. The adjusted RRs of wheezing disorders diagnosis were 1.30 (95% CI 0.56 to 3.06; p=0.54) and 0.60 (95% CI 0.16 to 2.18; p=0.44), respectively, for the 'fast' and 'slow' growth as compared with the 'normal' growth.

CONCLUSIONS

Low birth weight is associated with an increased risk of wheezing disorders; however, there is a weak evidence that suggests high birthweight children have a reduced risk in this birth cohort. Low birth weight coupled with a slower growth until 3 months and a sharp growth between 3 and 12 months has an increased risk of wheezing disorders diagnosis.

Childhood body mass index and wheezing disorders: a systematic review and meta-analysis

BACKGROUND

It has been claimed that overweight/obesity, childhood asthma and wheezing disorders are associated, although the results of observational studies have remained inconsistent. We conducted a systematic review and meta-analysis to investigate this.

METHODS

An online search of published papers linking childhood asthma and wheezing with overweight/obesity up to May 2014 using EMBASE and MEDLINE medical research databases was carried out. Summary odds ratios (OR) were estimated using random-effects models. Subgroup meta-analyses were performed to assess the robustness of risk associations and between-study heterogeneity.

RESULTS

A total of 38 studies comprising 1,411,335 participants were included in our meta-analysis. The summary ORs of underweight (<5th percentile), overweight (>85th to <95th percentile) and obesity (≥ 95 th percentile) were 0.85 (95% CI: 0.75 to 0.97; p = 0.02), 1.23 (95% CI: 1.17 to 1.29; p < 0.001) and 1.46 (95% CI: 1.36 to 1.57, p < 0.001), respectively. Heterogeneity was significant and substantial in all three weight categories, and not accounted for by pre-defined study characteristics.

CONCLUSION

Our results suggest that underweight is associated with a reduced risk of childhood asthma, and overweight and obesity are associated with an increased risk of childhood asthma. Although our findings assert that overweight/obesity and childhood asthma are associated, the causal pathway and temporal aspects of this relationship remain unanswered and deserve further epidemiological investigation.

Birth weight and childhood wheezing disorders: a systematic review and meta-analysis

BACKGROUND

Previous observational studies have claimed that birth weight and childhood wheezing disorders are associated although the results remained inconsistent. One systematic review and two systematic reviews that included meta-analyses reported inconsistent results. We aimed to conduct a systematic review and meta-analysis to investigate this.

METHODS

An online search of published papers linking childhood asthma and wheezing disorders with birth weight up to February 2014 was carried out using EMBASE and Medline medical research databases. Summary ORs were estimated using random-effects models. Subgroup meta-analyses were performed to assess the robustness of risk associations and between-study heterogeneity.

RESULTS

A total of 37 studies comprising 1,71, 737 participants were included in our meta-analysis. The unadjusted summary ORs for risk of childhood wheezing disorders associated with low birth weight (<2.5 kg) were 1.60 (95% CI 1.39 to 1.85, p<0.001) and 1.37 (95% CI 1.05 to 1.79, p=0.02) when compared with ≥2.5 and 2.5-4.0 kg birthweight groups, respectively. The overall summary OR for high birth weight (>4 kg) as compared to the 2.5-4.0 kg birthweight group was 1.02 (95% CI 0.99 to 1.04, p=0.13). There was substantial heterogeneity in the unadjusted low birth weight risk estimates which was not accounted for by predefined study characteristics. There was no significant heterogeneity in the high birth weight risk estimates. There was some evidence of funnel plot asymmetry and small study effects in the low birth weight (2.5 vs ≥2.5 kg and <2.5 vs 2.5-4 kg) OR estimates.

CONCLUSIONS

Our results suggest that low birth (<2.5 kg) is an independent risk factor for wheezing disorders during childhood and adolescence although there was substantial heterogeneity among the risk estimates. However, we found no significant association of high birth weight with wheezing disorders.

Weight-for-age distribution and case-mix adjusted outcomes of 14,307 paediatric intensive care admissions

Aims

To determine whether the paediatric intensive care (PIC) population weight distribution differs from the UK reference population and whether weight-for-age at admission is an independent risk factor for mortality.

Methods

Admission weight-for-age standard deviation scores (SDS) were calculated for all PIC admissions (March 2003–December 2011) to Great Ormond Street Hospital: this is the number of standard deviations (SD) between a child’s weight and the UK mean weight-for-age. Categorised into nine SDS groups, standardised mortality ratios (SMR) and logistic regression were used to assess the relationship between weight-for-age at admission and risk-adjusted mortality.

Results

Out of 12,458 admissions, mean weight-for-age was 1.04 SD below the UK reference population mean (p < 0.0001). Based on 942 deaths, risk-adjusted mortality was lowest in those with mild-to-moderately raised weight-for-age (SDS 0.5–2.5) and highest in children with extreme under- or overweight (SDS < −3.5 and SDS > +3.5). Logistic regression indicated that age, gender, ethnicity and weight-for-age are independent risk factors for mortality. South Asian and ‘other’ ethnicities had significantly increased risk of death compared to children of white and black ethnic origin.

Conclusion

The PIC population mean weight-for-age is significantly lower than the UK reference mean. The extremes of weight-for-age are over-represented, especially underweight. Weight-for-age at admission is an independent risk factor for mortality. A U-shaped association between weight and risk-adjusted mortality exists, with the lowest risk of death in children who are mild-to-moderately overweight. Future studies should determine the impact of malnutrition on risk-adjusted mortality and investigate the aetiology of risk disparities with ethnicity.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-014-3381-x) contains supplementary material, which is available to authorized users.