From Survival to Recovery: 25 Years of Pediatric Critical Care Transformation in Israel

From Survival to Recovery: 25 Years of Pediatric Critical Care Transformation in Israel | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Survival to Recovery: 25 Years of Pediatric Critical Care Transformation in Israel Uri Pollak, Adi Avniel Aran, Ezra Weinblatt, Isaac Manaster, David Kleid, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7190513/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To evaluate 25-year national trends in pediatric intensive care utilization, patient outcomes, rehospitalizations, and regional resource distribution in Israel. Methods: Retrospective, population-based cohort study of all acute pediatric (0–17 years) hospitalizations in Israel from January 1, 1999, to December 31, 2023 (≈ 180 000 admissions), excluding neonatal and maternity ICU stays. We linked the National Hospital Discharge Register with pediatric ICU bed capacity data and Central Bureau of Statistics population estimates. Outcomes included age-adjusted ICU admission rates, in-hospital and one-year post-discharge mortality, rehospitalization at 7, 30, and 365 days, and pediatric ICU beds per 100 000 children. Trends were assessed in five-year intervals using SAS 9.4. Results: The proportion of hospitalizations involving ICU care increased from 3.3–6.5%. In-hospital mortality among ICU patients declined from 3.8–1.4% (63.2% relative reduction), and one-year post-discharge mortality decreased from 3.0–1.9% (36.7% relative reduction). One-year rehospitalization occurred in 46% of ICU survivors versus 29% of non-ICU patients (20% vs 3% requiring subsequent ICU). Between 2018 and 2023, national pediatric ICU bed capacity rose by 23%, yet regional bed-to-population ratios varied up to 2.6-fold. Conclusions: Over 25 years, Israeli pediatric ICU utilization and capacity nearly doubled, accompanied by marked reductions in mortality. However, persistently high rehospitalization rates and pronounced regional disparities underscore the need for structured post-ICU follow-up, standardized admission criteria, equitable resource allocation, and further research to clarify drivers of ICU utilization and long-term outcomes. Limitations include reliance on administrative data lacking individual illness-severity measures. Intensive Care Units Pediatric Hospital Mortality Patient Readmission Outcome Assessment (Health Care) Registries Figures Figure 1 Figure 2 What is Known PICU admissions and survival have increased over decades, yet long-term rehospitalization rates and regional resource gaps remain underexplored . The COVID-19 pandemic and rising chronic disease prevalence have further changed PICU demand and outcomes . What is New: In Israel (1999–2023), PICU utilization nearly doubled, and in-hospital mortality fell by 63%, yet one-year rehospitalization remains 46% . Reveals up to 2.6-fold regional ICU bed disparities and underscores the need for structured post-ICU follow-up and equitable resource allocation. Introduction Pediatric intensive care emerged as a separate discipline during the 1950s polio epidemic, with the first ICUs established in the late 1950s-1960s [ 1 – 3 ]. Since then, the field has evolved beyond a primary focus on survival, emphasizing recovery trajectories and the promotion of long-term functioning for both children and their families [ 4 – 7 ]. Technological advancements have transformed critical care through sophisticated physiologic monitoring, enhanced infusion technologies, computerized medication administration systems, point-of-care diagnostics, and pharmaceutical innovations [ 8 ]. Concurrently, ICU design has incorporated evidence-based practices to better meet the needs of patients, families, and healthcare providers [ 9 ]. Israel's healthcare system provides universal coverage through four competing health maintenance organizations serving approximately 10 million people [ 10 ]. With children comprising 33% of the population, pediatric healthcare faces unique demands [ 11 ]. The epidemiology of pediatric critical illness has shifted significantly, with preventive care reducing traditional ICU admissions while improved management of congenital and chronic conditions has created a growing population of medically complex children requiring specialized care [ 12 – 14 ]. In the United States, the proportion of hospitalized children requiring ICU care increased from 10.6–15.5% between 2001–2019, with more children having underlying comorbidities (46.2–57.0%) and technology dependence (16.4–23.5%) [ 15 ]. With these changes, ICU mortality decreased from 2.5–1.8%, though hospital costs nearly doubled [ 15 ]. Despite clinical importance, comprehensive longitudinal studies examining utilization trends, outcomes, and resource allocation in pediatric intensive care remain scarce. Key knowledge gaps persist regarding long-term utilization patterns across populations, evolving mortality and post-discharge outcomes, geographic disparities in resource distribution, and the impact of systemic disruptions such as the COVID-19 pandemic [ 16 – 19 ]. To address these gaps, we conducted a 25-year (1999–2023) national analysis of pediatric critical care in Israel. Our objectives were to: (1) describe temporal trends in PICU utilization; (2) assess changes in inpatient and post-discharge mortality; (3) characterize rehospitalization patterns following critical illness; (4) evaluate regional variation in critical care resource distribution; (5) examine the relationship between patient characteristics and care outcomes; and (6) assess the impact of major external events on PICU services. This study aims to inform clinical decision-making, strategic resource planning, and health policy development in Israel and in other nations with comparable healthcare systems, as the field increasingly prioritizes recovery and long-term outcomes for critically ill children and their families. Materials and Methods Study Design and Data Sources This retrospective, population-based study analyzed all pediatric hospitalizations in Israel between January 1, 1999, and December 31, 2023. Data were obtained from the Israeli National Hospital Discharge Register, supplemented with pediatric ICU bed capacity from the National Registry of Health Care Facilities and population statistics from the Israeli Central Bureau of Statistics. Study Population All acute care hospitalizations of patients aged 0–17 years were included. Maternity and neonatal ICU admissions were excluded. Nearly 180,000 patients were identified and categorized into five age groups: <1, 1–4, 5–9, 10–14, and 15–17 years. Definitions and Outcomes ICU hospitalization was defined as any stay in a pediatric intensive care unit, excluding neonatal ICUs. Surgical status was assigned based on the presence of at least one surgical procedure prior to ICU admission. Outcomes included the proportion of hospitalizations with ICU care, age-adjusted ICU admission rates, in-hospital and one-year post-discharge mortality, rehospitalization rates at 7, 30, and 365 days, and regional ICU bed capacity per 100,000 children. Statistical Analysis Trends were examined by five-year intervals and stratified by age, gender, and surgical status. Age-adjusted mortality rates were standardized to the annual pediatric population. Statistical significance was determined using principles of binary distribution. All analyses were performed with SAS version 9.4. Ethical Considerations The study was approved by the Israeli Ministry of Health Institutional Review Board with a waiver of informed consent for de-identified data. The study was conducted in accordance with the Declaration of Helsinki and reported following the STROBE guidelines. Results Trends in Pediatric ICU Utilization Over the 25-year period, the proportion of pediatric hospitalizations involving ICU care increased substantially, with age-adjusted ICU admission rates rising by 31%. This trend was consistent across all five-year intervals (Table 1 ). Males had higher ICU utilization rates than females throughout the study period. Notable increases were observed during 2004–2005 and especially 2019–2023, with the steepest year-over-year rise occurring between 2020 and 2021 (Fig. 1 ). Table 1 Trends in Pediatric ICU Utilization and mortality rates by 5-Year Periods (1999–2023 and 1999–2022 for One-Year Post-Discharge Mortality) Characteristic 1999–2003 2004–2008 2009–2013 2014–2018 2019–2023 % Change Overall 3.5% 4.1% 4.4% 4.8% 6.1% 74.3% Age Group < 1 year 4.8% 5.5% 5.9% 6.2% 8.0% 66.7% 1–4 years 3.1% 3.8% 4.1% 4.7% 5.9% 90.3% 5–9 years 2.9% 3.5% 3.8% 4.4% 5.4% 86.2% 10–14 years 3.0% 3.6% 3.9% 4.5% 5.6% 86.7% 15–17 years 3.0% 3.5% 3.8% 4.2% 5.0% 66.7% Gender Male 3.9% 4.5% 4.8% 5.2% 6.6% 69.2% Female 3.1% 3.7% 4.0% 4.4% 5.6% 80.6% Surgical Status Surgical 8.2% 9.0% 9.4% 9.8% 13.6% 65.9% Non-surgical 2.3% 2.9% 3.1% 3.6% 4.4% 91.3% In-hospital Mortality ICU patients 3.8% 3.4% 2.6% 2.4% 1.4% -63.2% Non-ICU patients 0.1% 0.1% 0.1% 0.1% 0.0% -100.0% One-Year Post-Discharge Mortality ICU patients 3.0% 3.4% 3.1% 2.5% 1.9% -36.7% Non-ICU patients 1.0% 0.8% 0.7% 0.5% 0.4% -60.0% This table summarizes the proportion of pediatric hospitalizations involving ICU care, age-specific and gender-specific ICU utilization, surgical vs. non-surgical status, and mortality rates (in-hospital and one-year post-discharge) among ICU and non-ICU patients, across five-year intervals from 1999 to 2023. ICU, intensive care unit. Age-Specific and Clinical Patterns Infants (< 1 year) consistently exhibited the highest ICU admission rates, while all age groups demonstrated rising utilization over time. The most pronounced relative increases were among children aged 1–4 and 5–9 years (Table 1 ). ICU admission was more common in patients with longer hospital stays and among those undergoing surgical procedures. These associations are depicted in Fig. 2 a. Mortality Outcomes In-hospital mortality for ICU patients declined markedly over the study period, while one-year post-discharge mortality also improved (Table 1 ). In contrast, both in-hospital and post-discharge mortality among non-ICU patients remained consistently low. Rehospitalization Patterns Children with a history of ICU admission experienced substantially higher rates of rehospitalization at all measured time points, including at one-year post-discharge, compared to those without an ICU stay (Table 2 ). Subsequent ICU admissions were also more common in this group. Table 2 Rehospitalization Rates Following ICU vs. Non-ICU Hospitalization Rehospitalization Type 7-day 30-day 365-day Any Rehospitalization ICU index hospitalization 11% 21% 46% Non-ICU index hospitalization 7% 13% 29% ICU Rehospitalization ICU index hospitalization 4% 8% 20% Non-ICU index hospitalization 0% 1% 3% This table displays rates of any rehospitalization and rates of ICU rehospitalization at 7-, 30-, and 365-days post-discharge for children with a previous ICU stay compared to those with non-ICU hospitalizations. ICU, intensive care unit. ICU Bed Capacity and Regional Disparities Between 2018 and 2023, national pediatric ICU bed capacity increased by 23%. However, considerable regional disparities persisted, with up to a 2.6-fold difference in bed-to-population ratios across districts (Table 3 ). The evolution of ICU utilization proportions over time is illustrated in Fig. 2 b. Table 3 Regional Distribution of Pediatric ICU Beds (2018 vs. 2023) Region Beds 2018 Beds per 100,000 (2018) Beds 2023 Beds per 100,000 (2023) % Change in Ratio National Total 152 5.18 187 5.97 15.3% Tel Aviv 43 8.98 58 11.40 27.0% Center 38 7.42 45 8.03 8.2% Jerusalem 18 4.44 23 5.31 19.6% Haifa 23 6.47 18 4.67 -27.8% North 16 4.05 19 4.41 8.9% South 14 3.30 24 4.39 33.0% This table presents the number and rate of pediatric intensive care unit (ICU) beds per 100,000 children across six administrative regions of Israel (Tel Aviv, Center, Jerusalem, Haifa, North, South) for the years 2018 and 2023, along with percentage change in bed-to-population ratio. ICU, intensive care unit; N/A, not applicable. Discussion This comprehensive 25-year national analysis of pediatric critical care in Israel highlights significant shifts in ICU utilization, patient outcomes, and resource distribution between 1999 and 2023. The findings underscore a transformation in the epidemiology and delivery of pediatric intensive care, with notable implications for clinical decision-making, health system planning, and research prioritization. Increasing Utilization of Pediatric ICU Services The steady rise in the proportion of pediatric hospitalizations involving ICU care—from 3.3% in 1999 to 6.5% in 2023—reflects a substantial shift in pediatric healthcare, possibly indicating fundamental changes in pediatric disease burden, healthcare delivery practices, availability of technologies and beds or all the above. While similar trends have been reported in other high-income countries, the magnitude of increase observed in Israel is particularly pronounced [ 7 , 20 ]. Several factors likely underlie the increasing rate of pediatric ICU utilization above and beyond the increase in availability of beds. Advances in medical technology and pharmacotherapy have improved survival among children with complex congenital and chronic conditions, contributing to a growing population with ongoing intensive care needs [ 12 ]. Evolving clinical guidelines have also broadened the criteria for ICU admission, as accumulating evidence supports the benefits of early critical care intervention [ 21 ]. Additionally, the implementation of pediatric early warning systems and rapid response teams has likely enhanced the early identification of clinical deterioration, facilitating more timely ICU transfers [ 22 ]. The particularly sharp increase in ICU utilization between 2019 and 2023 (from 4.8–6.1%) coincided with the COVID-19 pandemic, which profoundly disrupted healthcare systems worldwide. Although pediatric ICU admissions for acute COVID-19 were relatively uncommon compared to adults [ 16 ], the pandemic likely influenced care-seeking behaviors, delayed presentations of routine pediatric illnesses, and contributed to greater illness severity at the time of admission. In addition, the emergence of novel conditions such as Multisystem Inflammatory Syndrome in Children (MIS-C)—a syndrome frequently requiring intensive care—may have further increased ICU demand during this period [ 23 ]. Improving Survival in Pediatric Critical Care One of the most encouraging findings in our study is the substantial reduction in in-hospital mortality for pediatric ICU patients, from 3.8% in 1999–2003 to 1.4% in 2019–2023—a 63.2% relative reduction. This dramatic improvement suggests significant advances in the quality of pediatric critical care over the study period. Comparable mortality reductions have been reported in other high-income countries [ 4 , 24 ], though the magnitude of improvement observed in Israel is particularly impressive. Several factors likely contributed to the observed improvements in pediatric ICU survival. Advances in critical care management—such as lung-protective ventilation strategies, goal-directed therapies, and enhanced sepsis management—were widely adopted during the study period [ 25 ]. In parallel, the development of pediatric-specific clinical protocols, specialized training programs, and quality improvement initiatives likely promoted standardization of care and reduced the incidence of preventable complications [ 26 ]. The decline in pediatric ICU mortality may also be partly attributable to expanded access to specialized critical care services, as reflected by the 23% increase in ICU bed capacity between 2018 and 2023. This expansion may have reduced delays in critical care delivery—delays that have been previously associated with increased mortality in both pediatric and adult populations [ 27 ]. However, it is important to note that changes in admission criteria and case mix over time may partially explain the observed mortality trends. With expanded ICU capacity and potentially lower thresholds for ICU admission, the average severity of illness among admitted patients may have decreased over time, contributing to improved survival rates. Further research incorporating illness severity scores would be valuable to adjust for this potential confounding factor. Age-Specific Vulnerabilities and Implications Our findings reinforce that hospitalized infants under one year of age constitute a particularly vulnerable subgroup, exhibiting consistently higher ICU admission rates across all time periods (6.1% overall, compared to 3.9–4.2% in older pediatric age groups). This pattern aligns with previous studies demonstrating infants’ increased susceptibility to critical illness, attributed to their immature immune systems, limited physiologic reserves, and distinct pathophysiologic responses to illness and injury [ 28 ]. The markedly greater relative increase in ICU utilization among children aged 1–4 years (90.3% from 1999–2003 to 2019–2023), compared to infants (66.7%), is noteworthy and may reflect evolving patterns of childhood illness or shifting ICU admission criteria for this age group. This trend warrants further investigation, particularly in light of potential preventive opportunities through vaccination programs, injury prevention efforts, and early management of chronic conditions [ 29 ]. The consistently higher ICU utilization rates across all pediatric age groups in recent years compared to earlier periods of the study emphasize the need for continued investment in pediatric critical care resources and specialized training across the developmental spectrum. Age-specific clinical guidelines and quality metrics may be warranted to address the unique needs of different pediatric populations [ 5 ]. Long-term Outcomes and Rehospitalization Patterns Our analysis of rehospitalization patterns reveals concerning disparities between children with and without ICU admission. One year after discharge, rehospitalization rates were substantially higher among children who had an ICU stay (46% vs. 29%), suggesting that critical illness in childhood may have enduring effects that extend beyond the index hospitalization. Particularly striking is that 20% of these children required subsequent ICU admission within one year, compared to just 3% of those initially hospitalized outside the ICU. These findings align with emerging literature on post-intensive care syndrome in pediatrics (PICS-p), which encompasses a new or worsening physical, cognitive, emotional, and social morbidities that persist after critical illness [ 30 ]. The high rate of subsequent ICU admissions suggests that many critically ill children either have underlying vulnerabilities that predispose them to recurrent critical illness or develop new vulnerabilities because of their ICU stay [ 31 ]. The transient increase in one-year post-discharge mortality among ICU patients—from 3.0% in 1999–2003 to 3.4% in 2004–2008 before subsequently declining—warrants further investigation. This temporary rise may reflect changes in discharge practices during that period, with sicker children potentially being discharged earlier or could be related to evolving availability and quality of post-discharge care services [ 32 ]. These findings highlight the importance of comprehensive discharge planning and robust post-discharge follow-up programs for children who have experienced critical illness. Dedicated post-ICU follow-up clinics, integration with community pediatric services, and long-term developmental monitoring may be necessary to address the ongoing needs of this vulnerable population [ 33 ]. Demographic and Clinical Risk Factors Our analysis identified several key demographic and clinical factors associated with ICU utilization. The notably higher rate of ICU admission among children undergoing surgical procedures (10% vs. 3% for non-surgical patients) underscores the substantial physiological stress associated with major surgery and the importance of appropriate perioperative risk assessment and management [ 34 ]. This finding has important implications for surgical planning, resource allocation, and the development of enhanced recovery pathways specifically designed for pediatric surgical patients [ 35 ]. The observed gender difference in ICU utilization − 5% for males versus 4% for females- is consistent with prior studies suggesting increased vulnerability to certain critical illnesses among male children [ 36 ]. This disparity may be influenced by a combination of biological factors, including sex-based differences in immune response and hormonal regulation, as well as behavioral patterns that increase injury risk among males [ 37 ]. The persistently higher age-adjusted mortality rates for males throughout the study period further supports this gender-based vulnerability. The strong association between hospital length of stay and underscores the need for heightened clinical vigilance in children with prolonged hospitalizations. The sharp rise in ICU admission rates—from 1.5–1.9% for stays of 0–2 days to 43.9% for stays ≥ 15 days—likely reflects both the complexity of underlying illness and the accumulating risk of clinical deterioration over time [ 38 ]. This finding emphasizes the importance of proactive monitoring systems and escalation protocols for children with extended hospital stays [ 39 ]. Regional Variations and Health System Implications The documented regional disparities in pediatric ICU bed capacity raise important questions about equity of access to critical care services across Israel. The 2023 data reveal a 2.6-fold difference between the highest (Tel Aviv: 11.40 beds per 100,000 children) and lowest (South: 4.39 beds per 100,000 children) regional ratios. Such disparities may result in differential thresholds for ICU admission, decreased or delayed inter-hospital transfers, and potentially delayed access to critical care for children in underserved regions [ 40 ]. The overall increase in national bed capacity ratio from 5.18 to 5.97 beds per 100,000 children between 2018 and 2023 represents a positive development, though it remains unclear whether this expansion has been optimally distributed to address regional needs. The concerning decrease in bed-to-population ratio in the Haifa district (from 6.47 to 4.67) warrants particular attention, as decreasing capacity in the context of increasing demand may create significant access challenges [ 41 ]. These findings highlight the need for national strategic planning for pediatric critical care resources that balances centralization of highly specialized services with equitable geographic access [ 42 ]. Alternative models such as hub-and-spoke systems, telemedicine support for community hospitals, and enhanced transportation networks may help bridge these regional gaps while maintaining quality of care [ 43 ]. Impact of the COVID-19 Pandemic The marked rise in ICU utilization and age-adjusted mortality rates between 2020 and 2022 aligns with the COVID-19 pandemic and represents one of the most significant disruptions to pediatric healthcare delivery in recent history. Although the direct burden of COVID-19 infection was generally milder in children compared to adults [ 44 ], our findings indicate substantial strain on pediatric critical care services during this period. Several factors may account for this trend. Direct effects of COVID-19—including complications such as MIS-C—created new demands for critical care [ 45 ]. Indirect effects, such as delayed care-seeking for common pediatric conditions, may have led to more severe illness at presentation [ 46 ]. Additionally, resource constraints—including staff shortages and the repurposing of pediatric facilities for adult patients—likely further compromised care delivery during pandemic peaks [ 47 ]. Notably, ICU utilization remained elevated in 2023 (6.5%), even after the acute phase of the pandemic, suggesting possible enduring shifts in disease patterns or healthcare delivery. These findings underscore the need for continued surveillance and research into the long-term consequences of the pandemic on child health and healthcare systems [ 48 , 49 ]. Strengths and Limitations This study offers several notable strengths, including its comprehensive national scope, a 25-year longitudinal design, and the integration of diverse healthcare utilization and outcome metrics. These features provide a robust foundation for examining trends in pediatric critical care at a population level. However, several limitations should be acknowledged. First, the reliance on administrative data limits our ability to assess illness severity—an important contextual factor for interpreting trends in ICU utilization and outcomes. Second, changes in diagnostic coding, admission criteria, and healthcare delivery models over the study period may affect the consistency and comparability of data across time. Third, our analysis of regional variations was restricted to the years 2018–2023, limiting the ability to assess long-term regional trends. Follow-up-Year rehospitalizations and mortality was limited to 1999–2022 since data for 2024 was not yet complete. In addition, while we characterized patterns in resource use and mortality, the dataset lacks information on survivors’ quality of life, functional status, and developmental outcomes—critical dimensions of pediatric critical care that remain underexplored. Finally, we did not evaluate the role of socioeconomic factors, which are likely to influence both access to and outcomes of critical care services. Conclusions This comprehensive national study documents substantial changes in pediatric critical care in Israel over the past 25 years, marked by increased ICU utilization and significant reductions in mortality. While these improvements reflect advancements in clinical care, technology, and system capacity, ongoing challenges remain. Notably, high rates of post-discharge rehospitalization and pronounced regional disparities in ICU resources continue to affect outcomes for critically ill children. To address these challenges, future research should explore the underlying drivers of increased ICU admissions, distinguishing between changing disease epidemiology and evolving admission practices. There is also a pressing need for strategies to support children and families following critical illness, including enhanced transitional care, multidisciplinary follow-up, and targeted interventions for those at highest risk of recurrent ICU admission. Reducing regional inequities will require coordinated national planning to ensure equitable access to high-quality pediatric critical care across all districts. From a policy perspective, investment in pediatric ICU capacity must be matched by efforts to standardize care quality and strengthen the interface between acute and community-based services. Development and implementation of national quality metrics specific to pediatric critical care could facilitate benchmarking and continuous improvement. Finally, lessons from the COVID-19 pandemic underscore the importance of resilience and adaptability within healthcare systems to ensure continuity of pediatric critical care during future public health emergencies. Abbreviations ICU – intensive care unit PICU – pediatric intensive care unit COVID-19 – coronavirus disease 2019 Declarations Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author Contributions Statement: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ziona Haklai, Joseph Mendlovic, Shulamit Gordon, and Yael Applbaum. The first draft of the manuscript was written by Uri Pollak and Adi Avniel Aran, and all authors commented on previous versions of the manuscript. Critically review and revision of the manuscript performed by Ezra Weinblatt, Isaac Manaster, and David Kleid. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work. Ethics approval: The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Ethics approval by the Ministry of Health Internal Review Board (IRB). Given that the data were anonymized and did not involve direct interaction with individuals, the requirements for informed consent was waived by the Ministry of Health Internal Review Board (IRB). Data Sharing Statement: The dataset analyzed in this study is based on national registry data from the Israeli Ministry of Health, including the National Hospital Discharge Register and the National Registry of Health Care Facilities. Due to legal and ethical restrictions, the data are not publicly available and cannot be shared by the study authors. Access to the raw data requires authorization from the Israeli Ministry of Health and compliance with national data protection regulations. Qualified researchers may apply for access to these datasets by submitting a formal request to the Israeli Ministry of Health. Author Contributions Statement Uri Pollak : Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Supervision, Project administration. Adi Avniel Aran : Conceptualization, Methodology, Formal analysis, Data curation, Writing – original draft, Writing – review & editing. Ezra Weinblatt : Methodology, Formal analysis, Writing – review & editing, Visualization. Isaac Manaster: Formal analysis, Data curation, Writing – review & editing, Visualization. David Kleid : Formal analysis, Data curation, Writing – review & editing. Ziona Haklai : Conceptualization, Investigation, Data curation, Resources, Validation, Writing – review & editing. Joseph Mendlovic : Methodology, Data curation, Resources, Writing – review & editing. Shulamit Gordon : Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Resources, Validation, Writing – review & editing. Yael Applbaum : Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Resources, Validation, Writing – review & editing, Project administration. All authors reviewed, approved the final manuscript, and agreed to be accountable for all aspects of the work. References Epstein D, Brill JE. A history of pediatric critical care medicine. Pediatr Res . 2005;58(5):987-996. doi:10.1203/01.PDR.0000182822.16263.3D Downes JJ. The historical evolution, current status, and prospective development of pediatric critical care. Crit Care Clin . 1992;8(1):1-22. Kinsella JP, Truog WE, Walsh WF, et al. 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Intensive Care Med . 2020;46(Suppl 1):10-67. doi:10.1007/s00134-019-05878-6 Lalgudi Ganesan S, Garros D, Foster J, Di Genova T, Fontela PS, Murthy S. Pediatric critical care capacity in Canada. Paediatr Child Health . 2024;30(1):30-39. Published 2024 Jun 7. doi:10.1093/pch/pxae024 Tanem J, Triscari D, Chan M, Meyer MT. Workforce Survey of Pediatric Interfacility Transport Systems in the United States. Pediatr Emerg Care . 2016;32(6):364-370. doi:10.1097/PEC.0000000000000448 Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Trends in the epidemiology of pediatric severe sepsis. Pediatr Crit Care Med . 2013;14(7):686-693. doi:10.1097/PCC.0b013e3182917fad Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr . 2014;14:199. Published 2014 Aug 8. doi:10.1186/1471-2431-14-199 Manning JC, Pinto NP, Rennick JE, Colville G, Curley MAQ. Conceptualizing Post Intensive Care Syndrome in Children-The PICS-p Framework. Pediatr Crit Care Med . 2018;19(4):298-300. doi:10.1097/PCC.0000000000001476 Pinto NP, Rhinesmith EW, Kim TY, Ladner PH, Pollack MM. Long-Term Function After Pediatric Critical Illness: Results From the Survivor Outcomes Study. Pediatr Crit Care Med . 2017;18(3):e122-e130. doi:10.1097/PCC.0000000000001070 Rees G, Gledhill J, Garralda ME, Nadel S. Psychiatric outcome following paediatric intensive care unit (PICU) admission: a cohort study. Intensive Care Med . 2004;30(8):1607-1614. doi:10.1007/s00134-004-2310-9 Watson RS, Choong K, Colville G, et al. Life after Critical Illness in Children-Toward an Understanding of Pediatric Post-intensive Care Syndrome. J Pediatr . 2018;198:16-24. doi:10.1016/j.jpeds.2017.12.084 Brindle ME, Heiss K, Scott MJ, et al. Embracing change: the era for pediatric ERAS is here. Pediatr Surg Int . 2019;35(6):631-634. doi:10.1007/s00383-019-04476-3 Rove KO, Edney JC, Brockel MA. Enhanced recovery after surgery in children: Promising, evidence-based multidisciplinary care. Paediatr Anaesth . 2018;28(6):482-492. doi:10.1111/pan.13380 Bindl L, Buderus S, Dahlem P, et al. Gender-based differences in children with sepsis and ARDS: the ESPNIC ARDS Database Group. Intensive Care Med . 2003;29(10):1770-1773. doi:10.1007/s00134-003-1948-z Muenchhoff M, Goulder PJ. Sex differences in pediatric infectious diseases. J Infect Dis . 2014;209 Suppl 3(Suppl 3):S120-S126. doi:10.1093/infdis/jiu232 Bonafide CP, Brady PW, Keren R, Conway PH, Marsolo K, Daymont C. Development of heart and respiratory rate percentile curves for hospitalized children. Pediatrics . 2013;131(4):e1150-e1157. doi:10.1542/peds.2012-2443 Parshuram CS, Dryden-Palmer K, Farrell C, et al. Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial. JAMA . 2018;319(10):1002-1012. doi:10.1001/jama.2018.0948 França UL, McManus ML. Trends in Regionalization of Hospital Care for Common Pediatric Conditions. Pediatrics . 2018;141(1):e20171940. doi:10.1542/peds.2017-1940 Horak RV, Griffin JF, Brown AM, et al. Growth and Changing Characteristics of Pediatric Intensive Care 2001-2016. Crit Care Med . 2019;47(8):1135-1142. doi:10.1097/CCM.0000000000003863 Kanter RK. Regional variation in child mortality at hospitals lacking a pediatric intensive care unit. Crit Care Med . 2002;30(1):94-99. doi:10.1097/00003246-200201000-00015 Yager PH, Cummings BM, Whalen MJ, Noviski N. Nighttime telecommunication between remote staff intensivists and bedside personnel in a pediatric intensive care unit: a retrospective study. Crit Care Med . 2012;40(9):2700-2703. doi:10.1097/CCM.0b013e3182591dab Zimmermann P, Curtis N. Why is COVID-19 less severe in children? A review of the proposed mechanisms underlying the age-related difference in severity of SARS-CoV-2 infections. Arch Dis Child . 2021;106(5):429-439. Published 2021 Apr 21. doi:10.1136/archdischild-2020-320338 Swann OV, Holden KA, Turtle L, et al. Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. BMJ . 2020;370:m3249. Published 2020 Aug 27. doi:10.1136/bmj.m3249 Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health . 2020;4(5):e10-e11. doi:10.1016/S2352-4642(20)30108-5 Remy KE, Verhoef PA, Malone JR, et al. Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists. Pediatr Crit Care Med . 2020;21(7):607-619. doi:10.1097/PCC.0000000000002429 Shah R, Ali FM, Nixon SJ, Ingram JR, Salek SM, Finlay AY. Measuring the impact of COVID-19 on the quality of life of the survivors, partners and family members: a cross-sectional international online survey. BMJ Open . 2021;11(5):e047680. Published 2021 May 25. doi:10.1136/bmjopen-2020-047680 Kanthimathinathan HK, Pollak U, Shekerdemian L. Paediatric intensive care challenges caused by indirect effects of the COVID-19 pandemic. Intensive Care Med . 2021;47(6):698-700. doi:10.1007/s00134-021-06400-7 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7190513","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":496690476,"identity":"e094bc37-19d2-4b4d-8881-a59d05b8bc15","order_by":0,"name":"Uri Pollak","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYFACxgYGhgKbBAaGBBDvAEQwoYCQFoM0dC0GhGwyOIymhQGPFoPbh9sefDA4n8ffnvz444+aOwz80scvMDzAp+VcYrvhDIPbxRJnnplJ8xx7xiDZl1OA12EGZxjbpHkMbic23EgwY2ZgOwwU4UkgRsu5xPk30j9//PGPeC0HEjfcyDGQ4G0DaWE/gFeL5BlGkF+SEzeeeVMmzdt3mEeyh4fhAD4tfGfYnz34UGGXOO94+uaPP74dluPnYX/48EcFbi1AwIbC4wEigwN4NaBrAQL2BwR0jIJRMApGwQgDAJ5+VskqmqP+AAAAAElFTkSuQmCC","orcid":"","institution":"Hadassah University Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Uri","middleName":"","lastName":"Pollak","suffix":""},{"id":496690477,"identity":"2dc243b0-cee2-4c31-b00e-cd236a4e7522","order_by":1,"name":"Adi Avniel Aran","email":"","orcid":"","institution":"Hadassah University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Adi","middleName":"Avniel","lastName":"Aran","suffix":""},{"id":496690478,"identity":"8a2cca3b-7d16-4fa9-8fe2-eaff698bd803","order_by":2,"name":"Ezra Weinblatt","email":"","orcid":"","institution":"Hadassah University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ezra","middleName":"","lastName":"Weinblatt","suffix":""},{"id":496690479,"identity":"2c868945-9ffc-4bb5-a2e0-177d93e423fb","order_by":3,"name":"Isaac Manaster","email":"","orcid":"","institution":"Hadassah University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Isaac","middleName":"","lastName":"Manaster","suffix":""},{"id":496690480,"identity":"b2ad46ae-ad5a-4b8f-bb45-800006aaed14","order_by":4,"name":"David Kleid","email":"","orcid":"","institution":"Hadassah University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Kleid","suffix":""},{"id":496690481,"identity":"5481e135-ca5e-4260-b1b4-e03c60f4b9a8","order_by":5,"name":"Ziona Haklai","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Ziona","middleName":"","lastName":"Haklai","suffix":""},{"id":496690482,"identity":"22293a4e-4fda-4931-b655-0431bed5bd8e","order_by":6,"name":"Joseph Mendlovic","email":"","orcid":"","institution":"Shaare Zedek Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Mendlovic","suffix":""},{"id":496690483,"identity":"a0e2d5c5-431d-478f-878e-965e338ae0be","order_by":7,"name":"Shulamit Gordon","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Shulamit","middleName":"","lastName":"Gordon","suffix":""},{"id":496690484,"identity":"2851334d-53e0-49fb-a0a7-af51f8612321","order_by":8,"name":"Yael Applbaum","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Yael","middleName":"","lastName":"Applbaum","suffix":""}],"badges":[],"createdAt":"2025-07-22 21:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7190513/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7190513/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88647418,"identity":"1099f8f0-2bc0-4c89-8a99-dfe18096313a","added_by":"auto","created_at":"2025-08-08 16:41:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1742382,"visible":true,"origin":"","legend":"\u003cp\u003eAge-Adjusted Pediatric ICU Admission Rates per 100,000 Population in Israel (1999-2023)\u003c/p\u003e\n\u003cp\u003eThe figure displays 25-year trends in age-adjusted ICU utilization rates per 100,000 population among Israeli children aged 0-17 years. The blue line represents overall ICU utilization rates, while the green line represents females and the red line represents males. Shaded areas indicate 95% confidence intervals. The data shows a consistent gender disparity, with males having consistently higher ICU utilization rates than females throughout the study period. Notable increases in utilization occurred during 2004-2005 and more dramatically during 2019-2023, with the steepest rise between 2020-2021 coinciding with the COVID-19 pandemic. The overall rate increased by 31.0% from 1999 (232.9) to 2023 (302.2), with the male rate increasing by 30.3% and the female rate by 29.2% during this period.\u003c/p\u003e","description":"","filename":"Figure1EJP.png","url":"https://assets-eu.researchsquare.com/files/rs-7190513/v1/bb0f6df53601214452888371.png"},{"id":88647416,"identity":"1c157d69-1348-4aa0-9f99-84641354b7b6","added_by":"auto","created_at":"2025-08-08 16:41:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1670353,"visible":true,"origin":"","legend":"\u003cp\u003eProportions of Pediatric Critical Care Admissions in Israel (1999-2023)\u003c/p\u003e\n\u003cp\u003eThe left figure (2a) illustrates the correlation between acute care hospital length of stay (excluding maternity) and the percentage of hospitalizations that included an ICU stay. The data demonstrates a strong positive correlation between hospital duration and likelihood of ICU admission. For shorter stays (0-2 days), ICU utilization remained low (1.5-1.9%) but increased progressively with longer hospitalizations - reaching 11.8% for 6-day stays, 21.1% for 10-day stays, and 43.9% for hospitalizations of 15 days or longer. This pattern suggests that longer hospitalizations are often associated with increased illness severity requiring intensive care interventions. The right figure (2b) illustrates the annual proportion of hospital admissions requiring pediatric critical care from 1999 through 2023. The proportion values represent the relative burden and necessity for intensive care among hospitalized pediatric patients on a yearly basis. The 2020 peak correlates with COVID-19 when a decrease in total hospitalizations was evident while critical care admissions remained stable.\u003c/p\u003e","description":"","filename":"Figure2EJP.png","url":"https://assets-eu.researchsquare.com/files/rs-7190513/v1/f6cc5239ffd20306c5ad38f5.png"},{"id":90616701,"identity":"4fd923f2-9c3c-4729-90a7-dcf2296576bb","added_by":"auto","created_at":"2025-09-04 18:46:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4108981,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7190513/v1/02b2f890-daca-4412-9efe-3fc430bbc765.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Survival to Recovery: 25 Years of Pediatric Critical Care Transformation in Israel","fulltext":[{"header":"What is Known","content":"\u003cul\u003e\n \u003cli\u003ePICU admissions and survival have increased over decades, yet long-term rehospitalization rates and regional resource gaps remain underexplored\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eThe COVID-19 pandemic and rising chronic disease prevalence have further changed PICU demand and outcomes\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is New:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eIn Israel (1999\u0026ndash;2023), PICU utilization nearly doubled, and in-hospital mortality fell by 63%, yet one-year rehospitalization remains 46%\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eReveals up to 2.6-fold regional ICU bed disparities and underscores the need for structured post-ICU follow-up and equitable resource allocation.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003ePediatric intensive care emerged as a separate discipline during the 1950s polio epidemic, with the first ICUs established in the late 1950s-1960s [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Since then, the field has evolved beyond a primary focus on survival, emphasizing recovery trajectories and the promotion of long-term functioning for both children and their families [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Technological advancements have transformed critical care through sophisticated physiologic monitoring, enhanced infusion technologies, computerized medication administration systems, point-of-care diagnostics, and pharmaceutical innovations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Concurrently, ICU design has incorporated evidence-based practices to better meet the needs of patients, families, and healthcare providers [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIsrael's healthcare system provides universal coverage through four competing health maintenance organizations serving approximately 10\u0026nbsp;million people [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. With children comprising 33% of the population, pediatric healthcare faces unique demands [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The epidemiology of pediatric critical illness has shifted significantly, with preventive care reducing traditional ICU admissions while improved management of congenital and chronic conditions has created a growing population of medically complex children requiring specialized care [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In the United States, the proportion of hospitalized children requiring ICU care increased from 10.6\u0026ndash;15.5% between 2001\u0026ndash;2019, with more children having underlying comorbidities (46.2\u0026ndash;57.0%) and technology dependence (16.4\u0026ndash;23.5%) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. With these changes, ICU mortality decreased from 2.5\u0026ndash;1.8%, though hospital costs nearly doubled [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite clinical importance, comprehensive longitudinal studies examining utilization trends, outcomes, and resource allocation in pediatric intensive care remain scarce. Key knowledge gaps persist regarding long-term utilization patterns across populations, evolving mortality and post-discharge outcomes, geographic disparities in resource distribution, and the impact of systemic disruptions such as the COVID-19 pandemic [\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e To address these gaps, we conducted a 25-year (1999\u0026ndash;2023) national analysis of pediatric critical care in Israel. Our objectives were to: (1) describe temporal trends in PICU utilization; (2) assess changes in inpatient and post-discharge mortality; (3) characterize rehospitalization patterns following critical illness; (4) evaluate regional variation in critical care resource distribution; (5) examine the relationship between patient characteristics and care outcomes; and (6) assess the impact of major external events on PICU services.\u003c/p\u003e\u003cp\u003eThis study aims to inform clinical decision-making, strategic resource planning, and health policy development in Israel and in other nations with comparable healthcare systems, as the field increasingly prioritizes recovery and long-term outcomes for critically ill children and their families.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design and Data Sources\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis retrospective, population-based study analyzed all pediatric hospitalizations in Israel between January 1, 1999, and December 31, 2023. Data were obtained from the Israeli National Hospital Discharge Register, supplemented with pediatric ICU bed capacity from the National Registry of Health Care Facilities and population statistics from the Israeli Central Bureau of Statistics.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStudy Population\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll acute care hospitalizations of patients aged 0\u0026ndash;17 years were included. Maternity and neonatal ICU admissions were excluded. Nearly 180,000 patients were identified and categorized into five age groups: \u0026lt;1, 1\u0026ndash;4, 5\u0026ndash;9, 10\u0026ndash;14, and 15\u0026ndash;17 years.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDefinitions and Outcomes\u003c/em\u003e\u003c/p\u003e\u003cp\u003eICU hospitalization was defined as any stay in a pediatric intensive care unit, excluding neonatal ICUs. Surgical status was assigned based on the presence of at least one surgical procedure prior to ICU admission. Outcomes included the proportion of hospitalizations with ICU care, age-adjusted ICU admission rates, in-hospital and one-year post-discharge mortality, rehospitalization rates at 7, 30, and 365 days, and regional ICU bed capacity per 100,000 children.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eTrends were examined by five-year intervals and stratified by age, gender, and surgical status. Age-adjusted mortality rates were standardized to the annual pediatric population. Statistical significance was determined using principles of binary distribution. All analyses were performed with SAS version 9.4.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEthical Considerations\u003c/em\u003e\u003c/p\u003e\u003cp\u003e The study was approved by the Israeli Ministry of Health Institutional Review Board with a waiver of informed consent for de-identified data. The study was conducted in accordance with the Declaration of Helsinki and reported following the STROBE guidelines.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eTrends in Pediatric ICU Utilization\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOver the 25-year period, the proportion of pediatric hospitalizations involving ICU care increased substantially, with age-adjusted ICU admission rates rising by 31%. This trend was consistent across all five-year intervals (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Males had higher ICU utilization rates than females throughout the study period. Notable increases were observed during 2004\u0026ndash;2005 and especially 2019\u0026ndash;2023, with the steepest year-over-year rise occurring between 2020 and 2021 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eTrends in Pediatric ICU Utilization and mortality rates by 5-Year Periods (1999\u0026ndash;2023 and 1999\u0026ndash;2022 for\u003c/b\u003e One-Year Post-Discharge \u003cb\u003eMortality)\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1999\u0026ndash;2003\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2004\u0026ndash;2008\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2009\u0026ndash;2013\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2014\u0026ndash;2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2019\u0026ndash;2023\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e% Change\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e6.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e74.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge Group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e66.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;4 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e90.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u0026ndash;9 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e86.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;14 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e86.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u0026ndash;17 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e66.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e6.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e69.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e80.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e13.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e65.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-surgical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e91.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIn-hospital Mortality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-63.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-ICU patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-100.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOne-Year Post-Discharge Mortality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-36.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-ICU patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-60.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eThis table summarizes the proportion of pediatric hospitalizations involving ICU care, age-specific and gender-specific ICU utilization, surgical vs. non-surgical status, and mortality rates (in-hospital and one-year post-discharge) among ICU and non-ICU patients, across five-year intervals from 1999 to 2023. ICU, intensive care unit.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eAge-Specific and Clinical Patterns\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInfants (\u0026lt;\u0026thinsp;1 year) consistently exhibited the highest ICU admission rates, while all age groups demonstrated rising utilization over time. The most pronounced relative increases were among children aged 1\u0026ndash;4 and 5\u0026ndash;9 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). ICU admission was more common in patients with longer hospital stays and among those undergoing surgical procedures. These associations are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003ea.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eMortality Outcomes\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn-hospital mortality for ICU patients declined markedly over the study period, while one-year post-discharge mortality also improved (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In contrast, both in-hospital and post-discharge mortality among non-ICU patients remained consistently low.\u003c/p\u003e\u003cp\u003e\u003cem\u003eRehospitalization Patterns\u003c/em\u003e\u003c/p\u003e\u003cp\u003eChildren with a history of ICU admission experienced substantially higher rates of rehospitalization at all measured time points, including at one-year post-discharge, compared to those without an ICU stay (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Subsequent ICU admissions were also more common in this group.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRehospitalization Rates Following ICU vs. Non-ICU Hospitalization\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRehospitalization Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7-day\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30-day\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e365-day\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny Rehospitalization\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU index hospitalization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-ICU index hospitalization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eICU Rehospitalization\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU index hospitalization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-ICU index hospitalization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eThis table displays rates of any rehospitalization and rates of ICU rehospitalization at 7-, 30-, and 365-days post-discharge for children with a previous ICU stay compared to those with non-ICU hospitalizations. ICU, intensive care unit.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eICU Bed Capacity and Regional Disparities\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBetween 2018 and 2023, national pediatric ICU bed capacity increased by 23%. However, considerable regional disparities persisted, with up to a 2.6-fold difference in bed-to-population ratios across districts (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The evolution of ICU utilization proportions over time is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003eb.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRegional Distribution of Pediatric ICU Beds (2018 vs. 2023)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBeds 2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBeds per 100,000 (2018)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBeds 2023\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBeds per 100,000 (2023)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e% Change in Ratio\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNational Total\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e15.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTel Aviv\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e27.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCenter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJerusalem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e19.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaifa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-27.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNorth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e33.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eThis table presents the number and rate of pediatric intensive care unit (ICU) beds per 100,000 children across six administrative regions of Israel (Tel Aviv, Center, Jerusalem, Haifa, North, South) for the years 2018 and 2023, along with percentage change in bed-to-population ratio. ICU, intensive care unit; N/A, not applicable.\u003c/td\u003e\u003c/tr\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This comprehensive 25-year national analysis of pediatric critical care in Israel highlights significant shifts in ICU utilization, patient outcomes, and resource distribution between 1999 and 2023. The findings underscore a transformation in the epidemiology and delivery of pediatric intensive care, with notable implications for clinical decision-making, health system planning, and research prioritization.\u003c/p\u003e\u003cp\u003e\u003cem\u003eIncreasing Utilization of Pediatric ICU Services\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe steady rise in the proportion of pediatric hospitalizations involving ICU care\u0026mdash;from 3.3% in 1999 to 6.5% in 2023\u0026mdash;reflects a substantial shift in pediatric healthcare, possibly indicating fundamental changes in pediatric disease burden, healthcare delivery practices, availability of technologies and beds or all the above. While similar trends have been reported in other high-income countries, the magnitude of increase observed in Israel is particularly pronounced [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral factors likely underlie the increasing rate of pediatric ICU utilization above and beyond the increase in availability of beds. Advances in medical technology and pharmacotherapy have improved survival among children with complex congenital and chronic conditions, contributing to a growing population with ongoing intensive care needs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Evolving clinical guidelines have also broadened the criteria for ICU admission, as accumulating evidence supports the benefits of early critical care intervention [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, the implementation of pediatric early warning systems and rapid response teams has likely enhanced the early identification of clinical deterioration, facilitating more timely ICU transfers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe particularly sharp increase in ICU utilization between 2019 and 2023 (from 4.8\u0026ndash;6.1%) coincided with the COVID-19 pandemic, which profoundly disrupted healthcare systems worldwide. Although pediatric ICU admissions for acute COVID-19 were relatively uncommon compared to adults [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the pandemic likely influenced care-seeking behaviors, delayed presentations of routine pediatric illnesses, and contributed to greater illness severity at the time of admission. In addition, the emergence of novel conditions such as Multisystem Inflammatory Syndrome in Children (MIS-C)\u0026mdash;a syndrome frequently requiring intensive care\u0026mdash;may have further increased ICU demand during this period [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eImproving Survival in Pediatric Critical Care\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOne of the most encouraging findings in our study is the substantial reduction in in-hospital mortality for pediatric ICU patients, from 3.8% in 1999\u0026ndash;2003 to 1.4% in 2019\u0026ndash;2023\u0026mdash;a 63.2% relative reduction. This dramatic improvement suggests significant advances in the quality of pediatric critical care over the study period. Comparable mortality reductions have been reported in other high-income countries [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], though the magnitude of improvement observed in Israel is particularly impressive.\u003c/p\u003e\u003cp\u003eSeveral factors likely contributed to the observed improvements in pediatric ICU survival. Advances in critical care management\u0026mdash;such as lung-protective ventilation strategies, goal-directed therapies, and enhanced sepsis management\u0026mdash;were widely adopted during the study period [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In parallel, the development of pediatric-specific clinical protocols, specialized training programs, and quality improvement initiatives likely promoted standardization of care and reduced the incidence of preventable complications [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe decline in pediatric ICU mortality may also be partly attributable to expanded access to specialized critical care services, as reflected by the 23% increase in ICU bed capacity between 2018 and 2023. This expansion may have reduced delays in critical care delivery\u0026mdash;delays that have been previously associated with increased mortality in both pediatric and adult populations [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, it is important to note that changes in admission criteria and case mix over time may partially explain the observed mortality trends. With expanded ICU capacity and potentially lower thresholds for ICU admission, the average severity of illness among admitted patients may have decreased over time, contributing to improved survival rates. Further research incorporating illness severity scores would be valuable to adjust for this potential confounding factor.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAge-Specific Vulnerabilities and Implications\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOur findings reinforce that hospitalized infants under one year of age constitute a particularly vulnerable subgroup, exhibiting consistently higher ICU admission rates across all time periods (6.1% overall, compared to 3.9\u0026ndash;4.2% in older pediatric age groups). This pattern aligns with previous studies demonstrating infants\u0026rsquo; increased susceptibility to critical illness, attributed to their immature immune systems, limited physiologic reserves, and distinct pathophysiologic responses to illness and injury [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe markedly greater relative increase in ICU utilization among children aged 1\u0026ndash;4 years (90.3% from 1999\u0026ndash;2003 to 2019\u0026ndash;2023), compared to infants (66.7%), is noteworthy and may reflect evolving patterns of childhood illness or shifting ICU admission criteria for this age group. This trend warrants further investigation, particularly in light of potential preventive opportunities through vaccination programs, injury prevention efforts, and early management of chronic conditions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The consistently higher ICU utilization rates across all pediatric age groups in recent years compared to earlier periods of the study emphasize the need for continued investment in pediatric critical care resources and specialized training across the developmental spectrum. Age-specific clinical guidelines and quality metrics may be warranted to address the unique needs of different pediatric populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eLong-term Outcomes and Rehospitalization Patterns\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOur analysis of rehospitalization patterns reveals concerning disparities between children with and without ICU admission. One year after discharge, rehospitalization rates were substantially higher among children who had an ICU stay (46% vs. 29%), suggesting that critical illness in childhood may have enduring effects that extend beyond the index hospitalization. Particularly striking is that 20% of these children required subsequent ICU admission within one year, compared to just 3% of those initially hospitalized outside the ICU.\u003c/p\u003e\u003cp\u003eThese findings align with emerging literature on post-intensive care syndrome in pediatrics (PICS-p), which encompasses a new or worsening physical, cognitive, emotional, and social morbidities that persist after critical illness [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The high rate of subsequent ICU admissions suggests that many critically ill children either have underlying vulnerabilities that predispose them to recurrent critical illness or develop new vulnerabilities because of their ICU stay [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe transient increase in one-year post-discharge mortality among ICU patients\u0026mdash;from 3.0% in 1999\u0026ndash;2003 to 3.4% in 2004\u0026ndash;2008 before subsequently declining\u0026mdash;warrants further investigation. This temporary rise may reflect changes in discharge practices during that period, with sicker children potentially being discharged earlier or could be related to evolving availability and quality of post-discharge care services [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These findings highlight the importance of comprehensive discharge planning and robust post-discharge follow-up programs for children who have experienced critical illness. Dedicated post-ICU follow-up clinics, integration with community pediatric services, and long-term developmental monitoring may be necessary to address the ongoing needs of this vulnerable population [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eDemographic and Clinical Risk Factors\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOur analysis identified several key demographic and clinical factors associated with ICU utilization. The notably higher rate of ICU admission among children undergoing surgical procedures (10% vs. 3% for non-surgical patients) underscores the substantial physiological stress associated with major surgery and the importance of appropriate perioperative risk assessment and management [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This finding has important implications for surgical planning, resource allocation, and the development of enhanced recovery pathways specifically designed for pediatric surgical patients [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe observed gender difference in ICU utilization \u0026minus;\u0026thinsp;5% for males versus 4% for females- is consistent with prior studies suggesting increased vulnerability to certain critical illnesses among male children [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This disparity may be influenced by a combination of biological factors, including sex-based differences in immune response and hormonal regulation, as well as behavioral patterns that increase injury risk among males [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The persistently higher age-adjusted mortality rates for males throughout the study period further supports this gender-based vulnerability.\u003c/p\u003e\u003cp\u003eThe strong association between hospital length of stay and underscores the need for heightened clinical vigilance in children with prolonged hospitalizations. The sharp rise in ICU admission rates\u0026mdash;from 1.5\u0026ndash;1.9% for stays of 0\u0026ndash;2 days to 43.9% for stays\u0026thinsp;\u0026ge;\u0026thinsp;15 days\u0026mdash;likely reflects both the complexity of underlying illness and the accumulating risk of clinical deterioration over time [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis finding emphasizes the importance of proactive monitoring systems and escalation protocols for children with extended hospital stays [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eRegional Variations and Health System Implications\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe documented regional disparities in pediatric ICU bed capacity raise important questions about equity of access to critical care services across Israel. The 2023 data reveal a 2.6-fold difference between the highest (Tel Aviv: 11.40 beds per 100,000 children) and lowest (South: 4.39 beds per 100,000 children) regional ratios. Such disparities may result in differential thresholds for ICU admission, decreased or delayed inter-hospital transfers, and potentially delayed access to critical care for children in underserved regions [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe overall increase in national bed capacity ratio from 5.18 to 5.97 beds per 100,000 children between 2018 and 2023 represents a positive development, though it remains unclear whether this expansion has been optimally distributed to address regional needs. The concerning decrease in bed-to-population ratio in the Haifa district (from 6.47 to 4.67) warrants particular attention, as decreasing capacity in the context of increasing demand may create significant access challenges [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings highlight the need for national strategic planning for pediatric critical care resources that balances centralization of highly specialized services with equitable geographic access [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Alternative models such as hub-and-spoke systems, telemedicine support for community hospitals, and enhanced transportation networks may help bridge these regional gaps while maintaining quality of care [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eImpact of the COVID-19 Pandemic\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe marked rise in ICU utilization and age-adjusted mortality rates between 2020 and 2022 aligns with the COVID-19 pandemic and represents one of the most significant disruptions to pediatric healthcare delivery in recent history. Although the direct burden of COVID-19 infection was generally milder in children compared to adults [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], our findings indicate substantial strain on pediatric critical care services during this period. Several factors may account for this trend. Direct effects of COVID-19\u0026mdash;including complications such as MIS-C\u0026mdash;created new demands for critical care [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Indirect effects, such as delayed care-seeking for common pediatric conditions, may have led to more severe illness at presentation [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Additionally, resource constraints\u0026mdash;including staff shortages and the repurposing of pediatric facilities for adult patients\u0026mdash;likely further compromised care delivery during pandemic peaks [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Notably, ICU utilization remained elevated in 2023 (6.5%), even after the acute phase of the pandemic, suggesting possible enduring shifts in disease patterns or healthcare delivery. These findings underscore the need for continued surveillance and research into the long-term consequences of the pandemic on child health and healthcare systems [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrengths and Limitations\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis study offers several notable strengths, including its comprehensive national scope, a 25-year longitudinal design, and the integration of diverse healthcare utilization and outcome metrics. These features provide a robust foundation for examining trends in pediatric critical care at a population level.\u003c/p\u003e\u003cp\u003eHowever, several limitations should be acknowledged. First, the reliance on administrative data limits our ability to assess illness severity\u0026mdash;an important contextual factor for interpreting trends in ICU utilization and outcomes. Second, changes in diagnostic coding, admission criteria, and healthcare delivery models over the study period may affect the consistency and comparability of data across time. Third, our analysis of regional variations was restricted to the years 2018\u0026ndash;2023, limiting the ability to assess long-term regional trends. Follow-up-Year rehospitalizations and mortality was limited to 1999\u0026ndash;2022 since data for 2024 was not yet complete.\u003c/p\u003e\u003cp\u003eIn addition, while we characterized patterns in resource use and mortality, the dataset lacks information on survivors\u0026rsquo; quality of life, functional status, and developmental outcomes\u0026mdash;critical dimensions of pediatric critical care that remain underexplored. Finally, we did not evaluate the role of socioeconomic factors, which are likely to influence both access to and outcomes of critical care services.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e This comprehensive national study documents substantial changes in pediatric critical care in Israel over the past 25 years, marked by increased ICU utilization and significant reductions in mortality. While these improvements reflect advancements in clinical care, technology, and system capacity, ongoing challenges remain. Notably, high rates of post-discharge rehospitalization and pronounced regional disparities in ICU resources continue to affect outcomes for critically ill children.\u003c/p\u003e\u003cp\u003eTo address these challenges, future research should explore the underlying drivers of increased ICU admissions, distinguishing between changing disease epidemiology and evolving admission practices. There is also a pressing need for strategies to support children and families following critical illness, including enhanced transitional care, multidisciplinary follow-up, and targeted interventions for those at highest risk of recurrent ICU admission. Reducing regional inequities will require coordinated national planning to ensure equitable access to high-quality pediatric critical care across all districts.\u003c/p\u003e\u003cp\u003eFrom a policy perspective, investment in pediatric ICU capacity must be matched by efforts to standardize care quality and strengthen the interface between acute and community-based services. Development and implementation of national quality metrics specific to pediatric critical care could facilitate benchmarking and continuous improvement. Finally, lessons from the COVID-19 pandemic underscore the importance of resilience and adaptability within healthcare systems to ensure continuity of pediatric critical care during future public health emergencies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eICU \u0026ndash; intensive care unit\u003c/p\u003e\n\u003cp\u003ePICU \u0026ndash; pediatric intensive care unit\u003c/p\u003e\n\u003cp\u003eCOVID-19 \u0026ndash; coronavirus disease 2019\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement:\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by \u003cem\u003eZiona Haklai, Joseph Mendlovic, Shulamit Gordon, and Yael Applbaum.\u003c/em\u003e The first draft of the manuscript was written by \u003cem\u003eUri Pollak and Adi Avniel Aran,\u003c/em\u003e and all authors commented on previous versions of the manuscript. Critically review and revision of the manuscript performed by \u003cem\u003eEzra Weinblatt, Isaac Manaster, and David Kleid.\u0026nbsp;\u003c/em\u003eAll authors read and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThe study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Ethics approval by the Ministry of Health Internal Review Board (IRB). Given that the data were anonymized and did not involve direct interaction with individuals, the requirements for informed consent was waived by the Ministry of Health Internal Review Board (IRB).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sharing Statement:\u0026nbsp;\u003c/strong\u003eThe dataset analyzed in this study is based on national registry data from the Israeli Ministry of Health, including the National Hospital Discharge Register and the National Registry of Health Care Facilities. Due to legal and ethical restrictions, the data are not publicly available and cannot be shared by the study authors. Access to the raw data requires authorization from the Israeli Ministry of Health and compliance with national data protection regulations. Qualified researchers may apply for access to these datasets by submitting a formal request to the Israeli Ministry of Health.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUri Pollak\u003c/strong\u003e: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing, Supervision, Project administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdi Avniel Aran\u003c/strong\u003e: Conceptualization, Methodology, Formal analysis, Data curation, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEzra Weinblatt\u003c/strong\u003e: Methodology, Formal analysis, Writing \u0026ndash; review \u0026amp; editing, Visualization.\u003c/p\u003e\n\u003cp\u003eIsaac Manaster: Formal analysis, Data curation, Writing \u0026ndash; review \u0026amp; editing, Visualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDavid Kleid\u003c/strong\u003e: Formal analysis, Data curation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eZiona Haklai\u003c/strong\u003e: Conceptualization, Investigation, Data curation, Resources, Validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJoseph Mendlovic\u003c/strong\u003e: Methodology, Data curation, Resources, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShulamit Gordon\u003c/strong\u003e: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Resources, Validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYael Applbaum\u003c/strong\u003e: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Resources, Validation, Writing \u0026ndash; review \u0026amp; editing,\u0026nbsp;Project administration.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed, approved the final manuscript, and agreed to be accountable for all aspects of the work.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEpstein D, Brill JE. 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Long-Term Function After Pediatric Critical Illness: Results From the Survivor Outcomes Study. \u003cem\u003ePediatr Crit Care Med\u003c/em\u003e. 2017;18(3):e122-e130. doi:10.1097/PCC.0000000000001070\u003c/li\u003e\n\u003cli\u003eRees G, Gledhill J, Garralda ME, Nadel S. Psychiatric outcome following paediatric intensive care unit (PICU) admission: a cohort study. \u003cem\u003eIntensive Care Med\u003c/em\u003e. 2004;30(8):1607-1614. doi:10.1007/s00134-004-2310-9\u003c/li\u003e\n\u003cli\u003eWatson RS, Choong K, Colville G, et al. Life after Critical Illness in Children-Toward an Understanding of Pediatric Post-intensive Care Syndrome. \u003cem\u003eJ Pediatr\u003c/em\u003e. 2018;198:16-24. doi:10.1016/j.jpeds.2017.12.084\u003c/li\u003e\n\u003cli\u003eBrindle ME, Heiss K, Scott MJ, et al. 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Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. \u003cem\u003eBMJ\u003c/em\u003e. 2020;370:m3249. Published 2020 Aug 27. doi:10.1136/bmj.m3249\u003c/li\u003e\n\u003cli\u003eLazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. \u003cem\u003eLancet Child Adolesc Health\u003c/em\u003e. 2020;4(5):e10-e11. doi:10.1016/S2352-4642(20)30108-5\u003c/li\u003e\n\u003cli\u003eRemy KE, Verhoef PA, Malone JR, et al. Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists. \u003cem\u003ePediatr Crit Care Med\u003c/em\u003e. 2020;21(7):607-619. doi:10.1097/PCC.0000000000002429\u003c/li\u003e\n\u003cli\u003eShah R, Ali FM, Nixon SJ, Ingram JR, Salek SM, Finlay AY. Measuring the impact of COVID-19 on the quality of life of the survivors, partners and family members: a cross-sectional international online survey. \u003cem\u003eBMJ Open\u003c/em\u003e. 2021;11(5):e047680. Published 2021 May 25. doi:10.1136/bmjopen-2020-047680\u003c/li\u003e\n\u003cli\u003eKanthimathinathan HK, Pollak U, Shekerdemian L. Paediatric intensive care challenges caused by indirect effects of the COVID-19 pandemic. \u003cem\u003eIntensive Care Med\u003c/em\u003e. 2021;47(6):698-700. doi:10.1007/s00134-021-06400-7\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Intensive Care Units, Pediatric, Hospital Mortality, Patient Readmission, Outcome Assessment (Health Care), Registries","lastPublishedDoi":"10.21203/rs.3.rs-7190513/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7190513/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e\u003cp\u003eTo evaluate 25-year national trends in pediatric intensive care utilization, patient outcomes, rehospitalizations, and regional resource distribution in Israel.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eRetrospective, population-based cohort study of all acute pediatric (0\u0026ndash;17 years) hospitalizations in Israel from January 1, 1999, to December 31, 2023 (\u0026asymp;\u0026thinsp;180 000 admissions), excluding neonatal and maternity ICU stays. We linked the National Hospital Discharge Register with pediatric ICU bed capacity data and Central Bureau of Statistics population estimates. Outcomes included age-adjusted ICU admission rates, in-hospital and one-year post-discharge mortality, rehospitalization at 7, 30, and 365 days, and pediatric ICU beds per 100 000 children. Trends were assessed in five-year intervals using SAS 9.4.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThe proportion of hospitalizations involving ICU care increased from 3.3\u0026ndash;6.5%. In-hospital mortality among ICU patients declined from 3.8\u0026ndash;1.4% (63.2% relative reduction), and one-year post-discharge mortality decreased from 3.0\u0026ndash;1.9% (36.7% relative reduction). One-year rehospitalization occurred in 46% of ICU survivors versus 29% of non-ICU patients (20% vs 3% requiring subsequent ICU). Between 2018 and 2023, national pediatric ICU bed capacity rose by 23%, yet regional bed-to-population ratios varied up to 2.6-fold.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eOver 25 years, Israeli pediatric ICU utilization and capacity nearly doubled, accompanied by marked reductions in mortality. However, persistently high rehospitalization rates and pronounced regional disparities underscore the need for structured post-ICU follow-up, standardized admission criteria, equitable resource allocation, and further research to clarify drivers of ICU utilization and long-term outcomes. Limitations include reliance on administrative data lacking individual illness-severity measures.\u003c/p\u003e","manuscriptTitle":"From Survival to Recovery: 25 Years of Pediatric Critical Care Transformation in Israel","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-08 16:33:53","doi":"10.21203/rs.3.rs-7190513/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ded6f2c1-be99-4aea-bb41-67e6a7d501d7","owner":[],"postedDate":"August 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T08:27:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-08 16:33:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7190513","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7190513","identity":"rs-7190513","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}