The development of a pediatric emergency transport system

The pattern of intravenous drug administration during the transfer of critically ill children by a specialist transport team

BACKGROUND

There are few published data on the patterns of intravenous drug administration by specialist pediatric intensive care unit (PICU) transport teams during the transfer of critically ill children between hospitals.

METHODS

A retrospective review of retrieval documentation was undertaken for all patients transported by the Royal Manchester Children's Hospital PICU transport team over a period of 1 year.

RESULTS

A total of 257 patients were transported during the study period, 82 patients (32%) were excluded owing to incomplete or absent documentation, leaving a sample of 175 available for analysis. Intravenous drugs were administered to 168 of these patients (96%). In total, 38 different drugs were administered. The four most commonly administered drugs were midazolam (130 patients), morphine (129 patients), atracurium (108 patients), and heparin (53 patients). Ten drugs accounted for 90% of all prescription episodes (total number of infusions and bolus doses administered), whilst 16 drugs were prescribed only once. The mean number of drugs administered per patient was 3.25 with a mean of 1.96 drug infusions and 1.29 bolus drugs administered per patient.

CONCLUSIONS

A relatively small number of drugs are used frequently during the retrieval of critically ill children, but the total range of drugs that are used is large. This has implications for the rational carriage of drugs by PICU transport teams, the potential for drug errors and also for the development of advanced nurse practitioners whose prescribing-like activities may depend on the development of Patient Group Directions.

Measurement of pediatric illness severity using simple pretransport variables

OBJECTIVE

To test the hypothesis that pretransport variables can predict in-hospital mortality that will correlate with major interventions and unplanned events during interfacility transport.

METHODS

A cohort of children (n = 2,253) transported by a specialized pediatric team to a children's hospital were studied. At the time of referral, data collected included age (months), heart rate, systolic blood pressure, respiratory rate, retractions, stridor or wheezing, seizures, skin perfusion, oxygen requirement, and mental status. Using univariate and stepwise logistic regression, variables predictive of in-hospital mortality were selected from a training set (n = 1,111) and assigned integers based on their computed coefficients. Probability of in-hospital mortality was calculated using the total integer score and age. The risk of mortality derived from the training set was validated in the remaining patients (n = 1,142) by comparing the observed and predicted mortalities. Major interventions performed and unplanned events were determined for each of five predetermined mortality risk groups.

RESULTS

Variables (integers) predicting in-hospital mortality included systolic blood pressure (11), respiratory rate (6), oxygen requirement (11), and altered mental status (11). Observed mortality was similar to predicted mortality in all risk categories for the validation sample. As risk of mortality increased, so did the performance of major interventions and the occurrence of unplanned events.

CONCLUSION

Four pretransport variables predicted in-hospital mortality. Risk of mortality correlated with the incidence of major patient interventions, and the occurrence of unplanned events increased as well. This model might be useful in comparing different transport systems using severity-adjusted assessment of children requiring interfacility transport.

Transport of the critically ill child

During the past several decades, the transport of critically ill patients to and between hospitals has gradually improved. The major indications that necessitate emergency transport for adult patients are trauma and acute cardiac disease, and the establishment of transport teams trained in the care of these conditions has improved the outcome of adult patients. In critically ill children, the indications for emergency transport differ from those in adults; pediatric patients are most likely to be transported for respiratory and neurologic emergencies. The outcome for critically ill children is optimal when a dedicated pediatric transport team functions in the setting of a regional critical-care outreach program. Such a program emphasizes stabilization of the child's condition at the local hospital, followed by transport to a pediatric intensive-care facility by a specially trained pediatric transport team. In this review, we present an overview of the principles and operating procedures of such pediatric transport teams.

The organization of a pediatric critical care transport program

Highly specialized pediatric critical care centers have matured significantly over the past two decades; however, access to this care is limited to tertiary care facilities and constrained by geography. With the advances of transport medicine, great distances can be spanned to bring critical care to the patient and provide effective treatment and safe transport systems where specialized care was previously unavailable. A patchwork of diverse transport systems perform pediatric transports with significant differences in the level of pediatric critical care. The optimal transport system has yet to be fully defined, but many successful systems share fundamental elements of organization.

Intra-transport stabilization and management of the pediatric patient

During the period of interhospital transfer, a critically ill child is at risk from the disease, the therapy, and the transfer itself. This risk can be minimized by good communication between the referring and receiving caretakers, careful evaluation and management, anticipation of complications, and a well-equipped and well-trained transport team providing a level of care as close as possible to that available at the receiving critical care unit.

High risk pediatric emergency air transport

INTRODUCTION

Pediatric Emergency Air Transports (PEATs) at Massachusetts General Hospital, Boston, Massachusetts, were reviewed between November 1986 and December 1987. Severity of illness, complications, and outcome of PEATs were compared with ground transports. Factors associated with PEAT survival were identified.

METHODS

Severity of illness was measured using a modified Denver Patient Status Category (DPSC) method and the Therapeutic Intervention Scoring System (TISS). There were 35 PEATs (30 helicopter, five fixed-wing) and 96 ground transports.

RESULTS

Mean severity of illness for patients was greater in PEAT than for the ground transport (PEAT DPSC score=4.23+/-1.06 versus ground DPSC=3.57+/-0.89 [SD], p=.0005). The PEAT mortality was associated with a greater mean severity of illness (TISS survivors=19.1+/-11.4 versus non-survivors=44.3+/-9.5, p=.0001), but not with: the presence of an on-flight physician; transport delay; transport duration; age; sex; history of chronic illness; or intra-transport medical complications.

CONCLUSIONS

Compared to ground transports, PEATs were used for higher risk patients.

Pediatric critical care transport: is a physician always needed on the team?

We conducted a retrospective study of the interventions performed by physicians in 191 transfers by our pediatric critical care transport team. Currently, the team always includes a pediatrician or pediatric resident, a pediatric emergency department nurse, and a pediatric respiratory therapist. Procedures performed during transport were divided into those done only by physicians in our institution and those also performed by nurses or respiratory therapists. Physician procedures were performed in 9% of transports. Medications given during transport were divided into three categories. Category 1 included drugs used only in our ICU and therefore with a physician present. Category 2 drugs were usually given in the ICU but were occasionally administered on the floor with close physician involvement. Category 3 included drugs routinely given on the floor with rare physician involvement. Category 1 drugs were required on 19% of transports, category 2 was the highest level used on 15%, and category 3 drugs alone were used on 20%. No medications were administered on 46% of transports. At the completion of each trip, the transport physician was asked if he believed the transport would have been successful without a physician but with an experienced pediatric ED nurse and respiratory therapist. The answer was "yes" in 46% of the cases (n = 166), "no" in 43%, and "unsure" in 11%. In 91% of the transports, no procedures were performed that required a physician. In 66%, no medications were used that required physician presence. In at least 46%, the physician believed his expertise was not required for the transport's success.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency care of the injured child

Emergency care of the injured child can be rapid and efficient if the treatment facility is properly prepared to manage children. At Ochsner Foundation Hospital, a mobile tool cabinet is used to store the materials needed for standard pediatric emergency care. The initial evaluation involves rapid assessment of pulmonary function and cardiac action and control of external hemorrhage. Secondary evaluation covers all other areas of the body, with possible problems assessed in descending order of seriousness. In many cases, after initial care and stabilization, the severely injured child should be transported to a pediatric intensive care or trauma unit for definitive treatment.

Towards safer transport of sick and injured children

A Paediatric Emergency Transport Service has been operating from the Paediatric Intensive Care Unit of the Royal Children's Hospital, Melbourne, for the last three years. The records of the first 158 patients evacuated have been analysed and are reported. Problems relating to the care of the airway and artificial airway have been the most common. The need for careful pre-transport resuscitation and stabilisation is emphasised. The educational role of a transport service both at the time of initial consultation and at the time of retrieval is stressed.

A paediatric emergency transport service: one year's experience

A paediatric emergency transport service (PETS) has been developed in Melbourne to cater for the secondary evacuation of children beyond the neonatal period. A consultative and transport service is provided. Forty-six children were transported in the first year of operation and the details are now reported. It is believed that the service is fulfilling a hiatus in the delivery of emergency health care to regional centres and that it will reduce morbidity and mortality in this group of critically ill children.