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Hibberd O, Price J, Laurent A, Agrawal S, Barnard E. Paediatric Major Trauma: A Retrospective Observational Comparison of Mortality in Prehospital Bypass and Secondary Transfer in the East of England. Cureus 2023; 15:e36808. [PMID: 37123802 PMCID: PMC10146472 DOI: 10.7759/cureus.36808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
Background More than half of seriously injured children are not initially treated at a major trauma centre (MTC). Children may be transported by private vehicle to a trauma unit (TU). Children may also be transported by emergency medical services (EMS) to the nearest TU with approximately one in five of these undergoing secondary transfer to an MTC. Most trauma networks permit TU bypass to an MTC. However, the evidence on outcomes between transfer and bypass is limited. This study aimed to evaluate the use of the trauma network by comparing outcomes between paediatric major trauma patients by the method of presentation. Methods In this retrospective observational study, a consecutive sample of paediatric (<16 years old) major trauma patients transported to the regional MTC (Cambridge University Hospitals NHS Foundation Trust (CUH)) between 1st January 2015 and 31st December 2020 was included. Patients were excluded if they arrived at the MTC >24 hours post-injury or were transported to the MTC as the nearest hospital. Patients were divided into four groups: self-presented to MTC, MTC as nearest hospital, bypass and secondary transfer. Results A total of 315 patients (28 'self-presented', 55 'nearest', 58 'bypass' and 174 'secondary transfers') were included. The median age was 9.4 [3.7-13.6] years, and n=209 (66.3%) were male. The median Injury Severity Score (ISS) was 16.0 [9.0-25.0] and n=190 (60.3%) had an ISS >15. There was no difference in 30-day mortality between the 'bypass' and 'secondary transfer' groups. There was a significantly longer hospital and intensive care unit length of stay (LOS) in the bypass group compared to other groups, both p<0.001. The median time to definitive care was five hours greater in the secondary transfer group compared to 'bypass' (bypass 117.6 minutes [100.8-136.6], secondary transfer 418.8 minutes [315.6-529.8]). Conclusion There was no significant difference in 30-day mortality of paediatric major trauma patients who underwent secondary transfer compared to those transported directly from the scene to the MTC, despite significant time delays in reaching definitive care.
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Akinkugbe O, Saxena R, Ramnarayan P. Comparison of Specialist and Nonspecialist Transport Teams for Emergency Neurosurgery. Pediatr Emerg Care 2023; 39:173-178. [PMID: 36083193 DOI: 10.1097/pec.0000000000002844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Current guidance in the United Kingdom recommends that children requiring emergency neurosurgical intervention should be transported by referring hospital (RH) teams. We aimed to compare transports performed by RH teams and by specialized pediatric critical care transport (PCCTs) teams in terms of timings and patient outcomes. METHODS We conducted a retrospective analysis over a 5-year period of children admitted from an external hospital to the pediatric intensive care unit at a pediatric neurosurgical center and receiving emergency neurosurgery within 24 hours of admission. Data were collected on RH characteristics, patient demographics, clinical status, transfer method (RH or PCCT team), timings (arrival at neurosurgical center, neurosurgical procedure), and clinical outcomes (length of stay and mortality). Univariate analysis was used to compare patient characteristics, times, and outcomes between RH and PCCT team transfers. Survival analysis was performed to analyze arrival time by transfer modality. RESULTS During the study period, 75 children with acute neurosurgical emergencies were transferred. Median age was 6.7 years (interquartile range, 1.8-10.7), and 63% had nontraumatic diagnoses. The commonest mode of transfer was by RH teams after initial referral to a PCCT team (53.3%). The median distance was greatest for transfers by RH teams (14 km). Overall median arrival time was 5 hours (interquartile range, 3.6-7.4) with no significant difference between groups ( P = 0.3). Median length of pediatric intensive care unit stay and mortality did not differ between groups. CONCLUSIONS Specialist critical care transport teams are involved in one third of transfers of children with acute neurosurgical emergencies. While the overriding priority is timely transfer, a tailored approach to the use of PCCTs may be appropriate particularly for children presenting to hospitals nearer to neurosurgical centers.
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Affiliation(s)
| | - Romit Saxena
- From the Children's Acute Transport Service (CATS), Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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Joseph AM, Horvat CM, Evans IV, Kuch BA, Kahn JM. Helicopter versus ground ambulance transport for interfacility transfer of critically ill children. Am J Emerg Med 2022; 61:44-51. [PMID: 36037589 DOI: 10.1016/j.ajem.2022.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/07/2022] [Accepted: 08/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Following initial stabilization, critically ill children often require transfer to a specialized pediatric hospital. While the use of specialized pediatric transport teams has been associated with improved outcomes for these patients, the additional influence of transfer mode (helicopter or ground ambulance) on clinical outcomes remains unknown. METHODS We investigated the association between transport mode and outcomes among critically ill children transferred to a single pediatric hospital via a specialized pediatric transport team. We designed a retrospective cohort study to reduce indication bias by limiting analysis to patients for whom a helicopter transport was initially requested. We compared outcomes for those who ultimately traveled via helicopter, and for those who ultimately traveled via ground ambulance due to non-clinical factors. RESULTS We compared transport times, in-hospital mortality, and hospital length of stay by transport mode. Transport time in minutes was shorter for helicopter transports (median = 143, interquartile range [IQR]: 118-184) compared to ground ambulance transports (median = 289, IQR: 213-258; difference in medians = 146, 95% CI: 12 to 168, p < 0.001). In unadjusted analysis, helicopter transport was not associated with a difference in in-hospital mortality (helicopter = 6.0%, ground ambulance = 7.0%; 95% CI for difference: -6.6% to 3.3%; p = 0.64) but was associated with a statistically significant reduction in median hospital days (helicopter = 4, ground ambulance = 5; 95% CI -3 to 0; p = 0.04). In adjusted analyses, there were no statistically significant associations. These results were consistent across sensitivity analyses. CONCLUSIONS Among critically ill pediatric patients without traumatic injuries transported by a specialty team, those patients who would have been transferred by helicopter if available but were instead transferred by ground ambulance reached their site of definitive care approximately 2.5 h later. Helicopter transport for these patients was not associated with in-hospital mortality, but was potentially associated with reduced hospital length of stay.
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Affiliation(s)
- Allan M Joseph
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America.
| | - Christopher M Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America.
| | - Idris V Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America.
| | - Bradley A Kuch
- Center for Emergency Medicine of Western Pennsylvania and STAT MedEvac, Pittsburgh, PA, United States of America.
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; Department of Health Policy & Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, United States of America.
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Peripheral and Central/Intraosseous Vasoactive Infusions During and After Pediatric Critical Care Transport: Retrospective Cohort Study of Extravasation Injury. Pediatr Crit Care Med 2022; 23:626-634. [PMID: 35481954 DOI: 10.1097/pcc.0000000000002972] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the prevalence of adverse events related to vasoactive drug infusions administered via a peripheral venous catheter versus a central venous or intraosseous catheter. DESIGN Retrospective observational study. SETTING A pediatric critical care transport team, and the PICUs and regional hospitals within the North Thames and East Anglia regions of the United Kingdom. PATIENTS Children (up to 18 yr old) transported by the Children's Acute Transport Service receiving an infusion of a vasoactive drug (epinephrine, dobutamine, dopamine, norepinephrine, and vasopressin). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The medical records of all children transported between April 2017 and May 2020 receiving a vasoactive drug infusion were reviewed and cross-referenced with the service critical incident database. The outcome measure was anatomic catheter-related adverse events (including extravasation) reported during transport or in the first 24 hours on the PICU. During the study period, the service undertook 3,836 transports. Vasoactive drugs were administered during 558 patient transports (14.5%). During 198 of 558 transports (35.5%), vasoactive drugs were administered via a peripheral venous catheter, with seven of 198 (3.5%) adverse events. One extravasation event resulted in tissue necrosis. The median time to injury after the infusion was commenced was 60 minutes (interquartile range, 30-60 min). During 360 of 558 transports (64.5%), vasoactive infusions were administered by central venous or intraosseous catheter, with nine of 360 (2.5%) adverse events. CONCLUSIONS During pediatric critical care transport, we did not find a difference in prevalence of adverse events following the administration of vasoactive drugs via peripheral venous catheters or via central venous and intraosseous catheters.
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Espuny Pujol F, Pagel C, Brown KL, Doidge JC, Feltbower RG, Franklin RC, Gonzalez-Izquierdo A, Gould DW, Norman LJ, Stickley J, Taylor JA, Crowe S. Linkage of National Congenital Heart Disease Audit data to hospital, critical care and mortality national data sets to enable research focused on quality improvement. BMJ Open 2022; 12:e057343. [PMID: 35589356 PMCID: PMC9121475 DOI: 10.1136/bmjopen-2021-057343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To link five national data sets (three registries, two administrative) and create longitudinal healthcare trajectories for patients with congenital heart disease (CHD), describing the quality and the summary statistics of the linked data set. DESIGN Bespoke linkage of record-level patient identifiers across five national data sets. Generation of spells of care defined as periods of time-overlapping events across the data sets. SETTING National Congenital Heart Disease Audit (NCHDA) procedures in public (National Health Service; NHS) hospitals in England and Wales, paediatric and adult intensive care data sets (Paediatric Intensive Care Audit Network; PICANet and the Case Mix Programme from the Intensive Care National Audit & Research Centre; ICNARC-CMP), administrative hospital episodes (hospital episode statistics; HES inpatient, outpatient, accident and emergency; A&E) and mortality registry data. PARTICIPANTS Patients with any CHD procedure recorded in NCHDA between April 2000 and March 2017 from public hospitals. PRIMARY AND SECONDARY OUTCOME MEASURES Primary: number of linked records, number of unique patients and number of generated spells of care. Secondary: quality and completeness of linkage. RESULTS There were 143 862 records in NCHDA relating to 96 041 unique patients. We identified 65 797 linked PICANet patient admissions, 4664 linked ICNARC-CMP admissions and over 6 million linked HES episodes of care (1.1M inpatient, 4.7M outpatient). The linked data set had 4 908 153 spells of care after quality checks, with a median (IQR) of 3.4 (1.8-6.3) spells per patient-year. Where linkage was feasible (in terms of year and centre), 95.6% surgical procedure records were linked to a corresponding HES record, 93.9% paediatric (cardiac) surgery procedure records to a corresponding PICANet admission and 76.8% adult surgery procedure records to a corresponding ICNARC-CMP record. CONCLUSIONS We successfully linked four national data sets to the core data set of all CHD procedures performed between 2000 and 2017. This will enable a much richer analysis of longitudinal patient journeys and outcomes. We hope that our detailed description of the linkage process will be useful to others looking to link national data sets to address important research priorities.
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Affiliation(s)
- Ferran Espuny Pujol
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Katherine L Brown
- Cardiorespiratory Division, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - James C Doidge
- Intensive Care National Audit and Research Centre, London, UK
| | - Richard G Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - Rodney C Franklin
- Department of Paediatric Cardiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Arturo Gonzalez-Izquierdo
- Institute of Health Informatics, University College London, London, UK
- Health Data Research UK, London, UK
| | - Doug W Gould
- Intensive Care National Audit and Research Centre, London, UK
| | - Lee J Norman
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - John Stickley
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Julie A Taylor
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
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Riphagen S, Bird R. Ventilatory management of critically ill children in the emergency setting, during transport and retrieval. Paediatr Anaesth 2022; 32:330-339. [PMID: 34865291 DOI: 10.1111/pan.14358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 01/22/2023]
Abstract
Critical illness in children is uncommon. The acute stabilization and resuscitation of critically ill children remains challenging to even the most experienced operator. Cardiorespiratory illness represents the largest subgroup of diseases causing critical illness and, thus adds a layer of complexity and additional challenge to the safe intubation and establishment of effective ventilation of this group of children. Children have unique physiological and anatomical differences to adults, and present the team involved in their resuscitation and stabilization with challenges exaggerated by critical illness. The consideration of pathophysiological implications of disease and the equipment available during transport and retrieval from the roadside or nonspecialist setting to pediatric intensive care allows the clinician involved in resuscitation, stabilization, and establishment of ventilation to employ targeted strategies to optimize ventilatory success. This review focuses on the types of ventilatory challenges that must be addressed when managing critically ill children in the local settings in which they present, and the resources available to optimize the outcome prior to and during transfer to a higher level of care.
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Affiliation(s)
| | - Ruth Bird
- Hospital for Sick Children, Toronto, Ontario, Canada
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Kwok KH, Leung KKY, Hon KL. Fast Versus Safe Transport: Does Time Taken by a Pediatric Critical Care Transport Team Affect Survival? Pediatr Emerg Care 2021; 37:e495. [PMID: 34225330 DOI: 10.1097/pec.0000000000002496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ka Hang Kwok
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital Kowloon Bay, Hong Kong
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Seaton SE, Draper ES, Pagel C, Rajah F, Wray J, Ramnarayan P. The effect of care provided by paediatric critical care transport teams on mortality of children transported to paediatric intensive care units in England and Wales: a retrospective cohort study. BMC Pediatr 2021; 21:217. [PMID: 33941116 PMCID: PMC8089132 DOI: 10.1186/s12887-021-02689-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/15/2021] [Indexed: 12/21/2022] Open
Abstract
Background Centralisation of paediatric intensive care units (PICUs) has the increased the need for specialist paediatric critical care transport teams (PCCT) to transport critically ill children to PICU. We investigated the impact of care provided by PCCTs for children on mortality and other clinically important outcomes. Methods We analysed linked national data from the Paediatric Intensive Care Audit Network (PICANet) from children admitted to PICUs in England and Wales (2014–2016) to assess the impact of who led the child’s transport, whether prolonged stabilisation by the PCCT was detrimental and the impact of critical incidents during transport on patient outcome. We used logistic regression models to estimate the adjusted odds and probability of mortality within 30 days of admission to PICU (primary outcome) and negative binomial models to investigate length of stay (LOS) and length of invasive ventilation (LOV). Results The study included 9112 children transported to PICU. The most common diagnosis was respiratory problems; junior doctors led the PCCT in just over half of all transports; and the 30-day mortality was 7.1%. Transports led by Advanced Nurse Practitioners and Junior Doctors had similar outcomes (adjusted mortality ANP: 0.035 versus Junior Doctor: 0.038). Prolonged stabilisation by the PCCT was possibly associated with increased mortality (0.059, 95% CI: 0.040 to 0.079 versus short stabilisation 0.044, 95% CI: 0.039 to 0.048). Critical incidents involving the child increased the adjusted odds of mortality within 30 days (odds ratio: 3.07). Conclusions Variations in team composition between PCCTs appear to have little effect on patient outcomes. We believe differences in stabilisation approaches are due to residual confounding. Our finding that critical incidents were associated with worse outcomes indicates that safety during critical care transport is an important area for future quality improvement work. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02689-x.
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Affiliation(s)
- Sarah E Seaton
- Department of Health Sciences, University of Leicester, Leicester, LE1 7RH, UK.
| | - Elizabeth S Draper
- Department of Health Sciences, University of Leicester, Leicester, LE1 7RH, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Fatemah Rajah
- Yorkshire and Humber Infant and Children's Transport Service (Embrace), Barnsley, UK
| | - Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service (CATS), Great Ormond Street Hospital NHS Foundation Trust, London, UK.,Respiratory, Critical Care and Anaesthesia Section, Infection, Immunity and Inflammation Research & Teaching Department, UCL GOS Institute of Child Health, London, UK
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