{
  "abstract": "Background: An efficient referral system is an important but often under-recognized determinant of survival in critically ill children. Previous studies have reported high mortality rates among pediatric patients transferred to tertiary care facilities. This study aimed to identify factors associated with Pediatric Intensive Care Unit (PICU) mortality among critically ill children transferred and admitted to a tertiary-level referral hospital in Yogyakarta, Indonesia. Material and methods: This prospective cohort study was conducted over a 12-month period (July 1, 2023, to June 30, 2024) and included all critically ill children admitted to the PICU following interhospital referral. Demographic, clinical, referral, and transport data were prospectively collected. Univariable and multivariable logistic regression analyses were performed to identify factors independently associated with PICU mortality. Results: A total of 334 children were included, with a median age of 6 years. PICU mortality was 25.4%. The most common referral indication based on the Pediatric Assessment Triangle (PAT) was central nervous system dysfunction. Pre-referral management most commonly included oxygen therapy, antibiotic administration, and fluid resuscitation. Compared with survivors, non-survivors had higher PELOD-2 scores and were more likely to require intubation, mechanical ventilation, and vasoactive support before referral. In the multivariable analysis, pre-referral vasoactive support (adjusted OR 2.23, 95% CI 1.20–4.15; P = 0.011) and higher PELOD-2 scores within the first 24 hours after PICU admission (adjusted OR 1.32 per 1-point increase, 95% CI 1.20–1.45; P < 0.001) were independently associated with PICU mortality. Referral distance, decision time, and transfer time were not independently associated with mortality. Conclusion: PICU mortality among critically ill children transferred and admitted to a tertiary-care hospital in Indonesia remains high. Pre-referral vasoactive support and higher PELOD-2 scores at PICU admission were independently associated with PICU mortality. These findings generate the hypothesis that improvements in early stabilization and communication may improve outcomes, warranting prospective evaluation.",
  "abstract_shown": true,
  "affiliations": [
    "Department of Child Health, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/DR Sardjito General Hospital, Yogyakarta, Indonesia",
    "Department of Child Health, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia",
    "Department of Pediatric Intensive Care, Emma Children’s Hospital/Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands"
  ],
  "article_type": "Research Article",
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  "author_total": 6,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Desy Rusmawatiningtyas",
      "orcid": "0000-0003-1676-8383"
    },
    {
      "affs": [
        0
      ],
      "name": "Indah Kartika Murni"
    },
    {
      "affs": [
        0
      ],
      "name": "Dwi Astuti Dharma Putri",
      "orcid": "0000-0002-5225-8834"
    },
    {
      "affs": [
        1
      ],
      "name": "Antonius H. Pudjiadi"
    },
    {
      "affs": [
        2
      ],
      "name": "Hennie Knoester"
    },
    {
      "affs": [
        2
      ],
      "name": "Job B.M. van Woensel"
    }
  ],
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  "cited_by": 0,
  "doi": "10.1371/journal.pone.0361504",
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  "issns": [
    "1932-6203"
  ],
  "landing_url": "https://doi.org/10.1371/journal.pone.0361504",
  "language": "en",
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
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  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
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  "published": "2026-10-27",
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  "subjects": [
    {
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  "title": "Factors associated with mortality among critically ill pediatric patients referred to a tertiary hospital in Indonesia",
  "title_text": "Factors associated with mortality among critically ill pediatric patients referred to a tertiary hospital in Indonesia",
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