Interhospital transfer of children in respiratory failure: a clinician interview qualitative study

Abstract

PurposeTo investigate the decision making underlying transfer of children with respiratory failure from level II to level I pediatric intensive care unit care. MethodsInterviews with 19 eligible level II pediatric intensive care unit physicians about a hypothetical scenario of a 2-year-old girl in respiratory failure:Baseline: Ventilator settings: rate 25, peak inspiratory pressure 28, positive end-expiratory pressure 8, fraction of inspired oxygen (Fio2) 100%Escalation Point (EP) 1: after 8 hours. Higher ventilator settings; oxygenation index (OI) 32EP 2: 3 hours later. OI 40 ResultsAt baseline, indices critical to management were as follows: OI (53%), partial pressure of oxygen in arterial blood (Pao2)/Fio2 (32%), and inflation pressure (16%). Poor clinical response was signified by high OI, inflation pressure, and Fio2, and low Pao2/Fio2. At EP 1, 18 of 19 respondents would initiate high-frequency oscillatory ventilation, and 1 would transfer. At EP 2, 15 of 18 respondents would maintain high-frequency oscillatory ventilation, 9 of them calling to discuss transfer. All respondents would transfer if escalated therapies failed to reverse the patient's clinical deterioration. ConclusionInterhospital transfer of children in respiratory failure is triggered by poor response to escalation of locally available care modalities. This finding provides new insight into decision making underlying interhospital transfer of children with respiratory failure.