Paediatric Emergency Transport Service Research Articles

How should the neonatal retrieval team respond to the neonate referred with bilious vomiting?

Bilious vomiting (BV) in the neonatal period may herald malrotation with life-threatening volvulus. In New South Wales, contrast fluoroscopy is not available in non-tertiary paediatric centres; therefore, transfer is required. An infant with BV referred to Newborn and Paediatric Emergency Transport Service is prioritised for urgent retrieval to a surgical centre for contrast fluoroscopy and paediatric surgical review. This study analysed how many neonates with BV needed retrieval to prevent bowel loss or to save one life and to identify predictors of malrotation and/or volvulus. All neonatal referrals (<29 days) to Newborn and Paediatric Emergency Transport Service between 31 July 2014 and 31 July 2020 with BV or aspirates were examined. Data on time of onset of BV, time of call for retrieval, vital signs, lactate level and blood glucose at referral, time of arrival at the surgical centre and outcome were analysed. Of 391 neonates referred with BV, 113 (28.9%) had a surgical cause and 31 (7.9%) had a time-critical malrotation and/or volvulus. All 31 neonates were well at referral with normal vital signs including three neonates who subsequently died. Lactate levels at referral (1-7.5 mmol/L) were not predictive of outcome. The odds of a time-critical diagnosis increased with every day of age (odds ratio=1.097), heart rate >140 (P=0.04) and decreased for each kilogram of birthweight (odds ratio 0.475; confidence interval 0.294-0.768). Neonates with BV require urgent referral to paediatric surgery and contrast fluoroscopy. Thirteen urgent transfers are required to preserve the bowel integrity and life in one baby.

Management and referral of acute laryngotracheitis - Croup: The New South Wales Neonatal and Paediatric Emergency Transport Service experience.

To evaluate the experience of NETS (The Newborn and paediatric Emergency Transport Service) New South Wales (NSW) with children referred with a provisional diagnosis of croup. To examine the adherence of referral hospitals to NSW Health policy guidelines and to establish criteria for the need to transfer and the level of escort required for a child with croup to a higher level of care. A retrospective audit of all children with a provisional diagnosis of croup referred to NETS over the epoch: 2005-2015. The NETS database was searched for keywords: croup and laryngotracheitis. Demographics, retrieval characteristics and management strategies were collected. A total of 432 patients were identified. The number of children triaged to a medically led NETS team for transfer decreased (P< 0.001) whilst those transferred into more local regional or metropolitan hospitals (P< 0.001) increased. The number of adrenaline doses was not associated with intensive care admissions or the need for invasive ventilation. Medically led retrieval teams are not necessary for safe transfer of children with a provisional diagnosis of croup unless the airway is secured with an endotracheal tube. Transfer to more local hospitals for paediatric care should be considered and time allowed for medications to take effect prior to movement.

Pathways and factors that influence time to definitive trauma care for injured children in New South Wales, Australia

BackgroundTimely definitive paediatric trauma care influences patient and parental physical and emotional outcomes. New South Wales (NSW) covers a large geographical area with all three NSW paediatric trauma centres (PTC) located in two approximated major cities, meaning it is inevitable that some injured children receive initial treatment locally and then require transfer. Little is known about the factors that then impact timely arrival of injured children to definitive care. MethodsThis included children admitted between July 2015 and September 2016, <16 years with an injury severity (ISS) ≥9; or requiring intensive care admission; or deceased following injury. Children were identified through the three PTCs, NSW Trauma Registry and NSW Medical Retrieval Registry. ResultsThere were 593 children admitted following injury and 46% required transfer to a PTC. There was no significant difference in age, ISS, ICU admission or head injury (AIS >2) between transferred and directly transported cohorts. There were significant differences in mechanism of injury between the two groups (χ2(9) = 45.9, p < 0.001). The median (IQR) time to book a transfer from arrival at the referring facility, was 146.5 (86–238) minutes. Time from injury to arrival at the PTC more than doubled for children transferred, with significant and unwarranted variability between transporting agencies resulting in unwarranted delays to surgical intervention. For example, time spent at the referring facility by Aeromedical Retrieval Service was less than half that of the Newborn & paediatric Emergency Transport Service [53 (IQR:47–61) vs 115 (84–155) minutes (p <0.001)]. ConclusionClinicians caring for paediatric trauma patients in facilities outside trauma centres require the capability and opportunity to identify and notify early those requiring transfer for ongoing management. The provision of a streamlined referral and transfer process for all paediatric trauma patients requiring treatment in NSW PTCs would reduce the burden on the referring facility, reduce variation amongst transport providers and improve time to definitive care.

Improving diagnostic accuracy in neonates with left heart obstruction in a transport setting

Differentiating left heart obstruction (LHO) from other severe illness in the neonatal period is challenging, and important for guiding clinical management. The aim of this study was to identify factors distinguishing LHO from non-LHO in neonates. A retrospective, cohort study of neonates referred to the Newborn and Paediatric Emergency Transport Service, New South Wales, with suspected LHO during the epoch 1996-2016. A total of 273 neonates were included; 240 with confirmed LHO. Administration of prostaglandin E1 to infants with a structurally normal heart was not associated with impaired acid-base or oxygenation status. Pre-transport diagnostic accuracy of LHO was 74.4%; sensitivity 84.5%, positive predictive value 86.0%. On multivariable logistic regression, hepatomegaly (odds ratio 2.54; 95% confidence interval 1.05-6.16) was associated with confirmed LHO. A low threshold for prostaglandin E1 infusion should be maintained in infants with suspected LHO. Hepatomegaly is associated with a diagnosis of LHO and may be more useful than other parameters in predicting the condition.

Management of status epilepticus in children prior to medical retrieval: Deviations from the guidelines.

To evaluate the influence of adherence to treatment guidelines on outcomes in children presenting with status epilepticus (SE) using the Newborn and Paediatric Emergency Transport Service, New South Wales prospective registry. We reviewed the treatment of children with SE, transported by the Newborn And Paediatric Emergency Transport Service to a tertiary paediatric hospital, over 1 year. We evaluated variation in management from the New South Wales clinical practice guideline. There was excessive administration of benzodiazepines (BZD) and a delay in administration of appropriate second-line treatment of status (median 45 min). There was excessive use of BZD, with five or more doses of BZD associated with significantly higher odds for intubation. There is considerable scope to improve clinician compliance with the SE clinical practice guidelines.

Humidified high flow therapy in paediatric patients referred for retrieval to the NSW newborn and paediatric emergency transport service (NETS)

Humidified high flow therapy in paediatric patients referred for retrieval to the NSW newborn and paediatric emergency transport service (NETS)

Consistency of total body surface area assessment in severe burns: Implications for practice.

Paediatric burn injury is common and often serious. Injuries occur across New South Wales (NSW), with specialised treatment provided in a centralised burns unit. Early management prior to transfer is essential but variation is seen. To determine if differences exist between referring hospital estimates of the total body surface area (TBSA) of burns, and estimates for the same burns by the Burns Unit. To consider if differences in estimations influence initial and ongoing management, and decisions regarding transfer/retrieval. A retrospective record review of all patients referred to NSW Newborn and Paediatric Emergency Transport Service (NETS) with burn injury between January 2009 and January 2011. Both NETS and NSW Burns Unit records were analysed. A total of 123 patients were referred to NETS with burn injury. Approximately half (55/123 = 45%) were referred with a TBSA >10% and transferred to the NSW Burns Unit, where just over half (33/55 = 60%) were assessed as >10%. This means 40% of cases received an initial overestimation of TBSA by referring hospitals. NETS medical teams transferred 34 patients to the Burns Unit, eight (24%) of which on retrospective review did not meet the NSW Burn Transfer Guidelines criteria for a medical team transfer. Our review demonstrated significant differences between the TBSA assessment of referring hospitals and the NSW Burns Unit. These inconsistencies may have resulted in children receiving treatment and transport not indicated based on accurate TBSA assessment. Potentially unnecessary transfers have implications for the displacement of children and families but also impact overall health costs and resource availability.

Management of retrieval service patients within a paediatric emergency department.

The Victorian Paediatric Emergency Transport Service (PETS) transports critically unwell children to tertiary paediatric hospitals. Children not directly admitted to ICU go to a tertiary ED. These patients might require prolonged and high-level care. In light of the National Emergency Access Target, we describe this cohort, clinical care needs and process measures. A retrospective chart review of patients retrieved by PETS to the Royal Children's Hospital (Melbourne, Australia) ED in 2012. Demographics, illness parameters and process measures were extracted. The ED length of stay (LOS) and time to ward suitability (time at which physiological parameters stabilised and high acuity treatments ceased) were related to patient and illness characteristics. Data are presented descriptively and analysed using spss. In 2012, 120 patients were transported to the ED. Conditions included lower respiratory (44), neurological (28), upper respiratory (16) and trauma (14). The median ED LOS was 4.8 h (interquartile range 2.9, 7.7). On arrival, 73 (60.8%) were ward-suitable, but 51 (43%) had LOS less than 4 h. Twenty-five (20.8%) patients stayed longer than 8 h. Administrative delay (principally bed block) is responsible for the bulk of the LOS; however, 25 (20.8%) had markedly abnormal vital signs after 4 h of ED care, mainly patients with lower respiratory tract disease. Most patients retrieved to the ED ultimately go to a ward rather than ICU and most have an ED stay in excess of National Emergency Access Target. Several retrieval associated care issues, such as timely and appropriate ward disposition, can be addressed by administrative changes.

PO-0345 Management Of Retrieved Patients Within A Paediatric Emergency Department

Background/aims The Victorian Paediatric Emergency Transport Service (PETS) transports critically unwell children from referring to tertiary paediatric hospitals. One-third are dropped in Emergency Departments (ED), rather than ICU (with the intended destination a general ward). The Australian government dictates that patients stay less than 4 h in ED. We describe this cohort’s clinical care needs and process measures. Methods A retrospective chart review of patients retrieved by PETS to the Royal Children’s Hospital (Melbourne, Australia) ED in 2012. Demographics, illness type and parameters, process measures are related to ED length of stay (LOS) and time to ward-readiness (time at which physiological parameters stabilised and intensive treatments ceased). Results In 2012, 120 patients were transported to the ED. Diagnoses included asthma (22), seizures (19), croup (15) and bronchiolitis (14). The median ED LOS was 4.8 h (IQR 2.9,7.7). On arrival, 73 (60.8%) were ward-ready, but only 31 (26%) were transferred to the ward within 4 h. 25 (20.8%) patients stayed longer than 8 h in ED. 25 (20.8%) had abnormal vital signs after 4 h of ED care. Lower respiratory tract disease (asthma, bronchiolitis and pneumonia) and derangement of physiological criteria on ED arrival were both associated with prolonged LOS and delayed ward readiness. Conclusions Most retrieval patients stay too long in the ED. Administrative delays (primarily access block) is the dominant factor, however patients with asthma and bronchiolitis tend to stay longer and require longer periods of ED-based intensive treatment. This can be used to improve pre-arrival coordination and decision-making.

ABSTRACT 51

Background and aims: The Victorian Paediatric Emergency Transport Service (PETS) in Australia retrieves critically unwell children to tertiary paediatric hospitals. Children not requiring ICU care are initially admitted to the ED. Aims: We aim to describe this cohort, outline clinical care needs and process measures. Methods: A retrospective chart review of patients retrieved by PETS to the Royal Children’s Hospital (Melbourne, Australia) ED in 2012. Demographics, illness parameters and process measures were extracted. “Clinically suitable for ward” was determined from vital signs and interventions needed. Data are presented descriptively and related to length of stay (LOS). IRB approval was obtained. Results: 120 patients were transported to the ED. The most common diagnoses were asthma (18%), seizures (16%), croup (13%) and bronchiolitis (12%). Median age was 3.2 years. The median LOS was 3.5 hours (IQR 1.5–7.5). 88% were admitted to a ward, 8% to ICU and 4% discharged home. On arrival to ED, 64% were clinically suitable for immediate ward admission, but only 40% (26% overall) were transferred to the ward within 4 hours. Two-thirds of the 74% with LOS >4 hours were clinically suitable for ward admission at 4 hours. 22% stayed in ED >8 hours. Respiratory infections and physiological severity on arrival were associated with prolonged LOS; age, time of arrival were not. Conclusions: Many retrieval patients have excessive ED LOS, even though most were clinically stable. A proportion of retrieved patients receive prolonged periods of high-level care in ED. Pre-arrival coordination and decision-making of retrieval patients can be improved to decrease unnecessary ED delays.

Transporting children with toxicological emergencies

Each year, the Newborn and Paediatric Emergency Transport Service (NETS) receives over 3600 calls from health professionals regarding the management and transportation of critically ill children across New South Wales, with toxicological emergencies making up 1.5% of these calls. The aim of the present study is to describe the characteristics of patients transported for toxicological emergencies and their retrieval management. A retrospective review of patients referred for management of a toxicological emergency between 2007 and 2011. Extracted data included patient demographics, substances involved, consultation with toxicological expertise, interventions performed and major adverse outcomes. Two hundred and thirty patients, with 307 toxicological exposures, were referred to NETS, of whom 169 (73.5%) were subsequently transported. Pharmaceutical poisonings (223, 72.6%) were the most common, followed by non-pharmaceutical poisonings (61, 19.9%) and envenomation (23, 7.5%). Psychotropics, analgesics and chemicals were the most frequently ingested substances. The most common source of accidentally ingested pharmaceuticals was a family member. The most frequently given therapies were specific antidotes, in particular naloxone and N-acetylcysteine. Nearly half (43.2%) of transported children required only non-invasive monitoring. There was one death during the retrieval process. Many children with toxicological emergencies require only non-invasive monitoring, which could be provided by trained ambulance crews in select scenarios. Involvement of a toxicologist in the initial consultation to identify these patients might reduce retrieval numbers and costs. Children on regular medication and those living with family members on psychotropic or cardiac drugs were identified as high-risk groups that should be targeted for medication safety education.

Potentially avoidable neonatal retrievals in New South Wales: a retrospective analysis

To identify areas for improvement in outcomes in retrieved newborns by reviewing newborn retrieval activity and evaluating potentially avoidable retrievals from each referring hospital stratified by the level of service delivery over the study period. A retrospective analysis of newborn retrievals from 1 January 2006 to 31 December 2009. Newborn and Paediatric Emergency Transport Service (NETS). Newborns less than 72 hours old retrieved by NETS in the study period. Each retrieval was classified as potentially avoidable, unavoidable or unclassified, based on predefined criteria. Newborn retrieval rates (per 10,000 live births) and potentially avoidable retrievals for each referring hospital level and overall. There were 2494 newborn retrievals over the study period, with an annual mean of 623 total and 30 potentially avoidable retrievals. There was a reduction in the potentially avoidable retrieval rate (per 10,000 live births) over the study period (from 3.9 in 2006 and 4.2 in 2007 to 2.2 in 2008 and 2.3 in 2009) despite an increase in the total retrieval rate over the same time. Discretionary caesarean, defined as elective (pre-labour) caesarean section without documented fetal or maternal indications before 39 completed weeks of gestation, accounted for two-thirds of the potentially avoidable retrievals. Potentially avoidable retrievals were a small but significant proportion and are becoming less frequent. Discretionary caesarean is the most common cause of potentially avoidable retrieval. Strict implementation of the elective caesarean section policy directive has the potential to reduce morbidity and the costs related to retrieval.

Interhospital Transport of Children With Confirmed or Suspected Intussusception

The objective of this study was to compare medical and paramedic retrieval of children requiring interhospital transport with suspected or confirmed intussusception. Cases of confirmed or suspected intussusception referred to the New South Wales Newborn and Paediatric Emergency Transport Service from January 2001 to August 2011 were identified retrospectively using the Newborn and Paediatric Emergency Transport Service database. Univariate analyses were used to compare patients transported by medical and paramedic escort teams, and multivariable logistic regression was used to determine independent predictors of the decision to use medical escort teams. Two hundred twenty-two cases were identified over the 10-year period. Paramedic escort teams were used in 48% of cases. There were no major complications recorded during retrieval by medical and paramedic escort teams. Only the presence of blood-stained stools (odds ratio, 1.9; 95% confidence interval, 0.93-3.86; P = 0.08) and increasing heart rate (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; P = 0.002) were found to be predictors of the decision to use a medical escort retrieval team. No factors were found to be associated with increased medical intervention in the subgroup of patients transported by a medical escort team. Well children requiring interhospital transport for suspected or confirmed intussusception can be transported safely without a medical escort team if they have normal heart rates.

Transporting newborns with transposition of the great arteries

The aim of the study was to examine the prevalence and management of outborn babies with a post-natally confirmed diagnosis of transposition of the great arteries (TGA) requiring transport by the Newborn and Paediatric Emergency Transport Service (NETS), New South Wales during the epoch 1991-2010. A retrospective audit of NETS database and case notes. The physiological status, interventions and any complications encountered from the point of referral to NETS (pre-transport), stabilisation (transport) and subsequent admission to the receiving hospital (post-transport) were evaluated. One hundred fifty-seven infants with TGA were transported, with an average of eight per year (1:11,598 births). Seven (4%) had an antenatal diagnosis, and 72 (46%) had a post-natal diagnosis prior to referral. Physiological and clinical parameters demonstrated overall clinical stability; however, 47% of the babies had a PaO(2) <30 mmHg, and approximately one-fifth had oxygen saturations <70%. Rates of mechanical ventilation and prostaglandin E(1) administration were approximately 50%. A quarter of transported babies encountered a transport-related event, including one death and two babies for which a decision was reached to forego life-sustaining treatment at the referring hospital. Most newborns with TGA remain stable or improve during transport. There is a rate of adverse events; however, this reinforces the need to facilitate delivery where there is ready access to interventional paediatric cardiology services.

An illness severity score and neonatal mortality in retrieved neonates

The Clinical Risk Index for Babies (CRIB) score is a simple tool to measure clinical risk and illness severity in very low birth weight infants. The aim of this study was to determine if a modified CRIB score (MCRIB) used at first telephone contact with a transport service differentiated between retrieved infants who did or did not die in the neonatal period and hence might be a useful triage tool. A retrospective cohort study of 2504 infants, median gestational age 36 weeks and birth weight 2782 g, transported by the New South Wales Newborn and Paediatric Emergency Transport Service (NETS) was performed. MCRIB was calculated at four time points during the retrieval process. The MCRIB score at the time of the first call and the change in the MCRIB score over the retrieval process were related to outcome (neonatal death or survival). The mean MCRIB score at the time of first call was higher in those infants who died during the neonatal period (4.37) than in those who survived (2.63), (P < 0.0001). MCRIB performed better (area under the receiver operator characteristic curves of 0.72) with regard to predicting mortality than gestational age (0.56) or birth weight (0.52). The mean MCRIB score fell progressively from the time of first call to admission at the accepting NICU (P < 0.0001); infants whose MCRIB score increased were more likely to die (P < 0.0001). these results suggest an illness severity score, applied at the time of first call to a transport service would be helpful in setting priorities for retrievals.

New south wales newborn and paediatric emergency transport service (NETS)

New south wales newborn and paediatric emergency transport service (NETS)

New South Wales newborn and paediatric emergency transport service (NETS)

Objective: To compare the neonatal outcome (survival, intraventricular hemorrhage and bronchopulmonary dysplasia) of inborn and outborn very-low-birth-weight infants accounting for sociodemographic, obstetric and perinatal variables. Study design: Ninety-one premature infants with birth weights of 750–1250 g delivered between 1990 and 1994 in a hospital providing neonatal intensive care were compared with 76 premature babies delivered in a referring hospital. In the statistical analysis, variables with a statistically significant association with the outcome variables and dissimilar distributions in the two hospitals were identified and entered together with the hospital of birth as explanatory variables in a logistic regression. Results: No statistically significant differences between the outcome variables of the two populations examined were observed, whether before or after accounting for the covariates. The odds ratios (outborns relative to inborns) were 1.18 for mortality, 1.25 for bronchopulmonary dysplasia and 1.53 for severe intraventricular hemorrhage. In the multivariate analyses, respiratory distress syndrome was significantly associated with mortality; both low birth weight and the presence of respiratory distress syndrome were associated with the development of bronchopulmonary dysplasia; the evolvement of severe intraventricular hemorrhage was associated with respiratory distress syndrome, initial low Apgar score, advanced multiparity and delivery at the 28–29th week compared to the 23rd–27th week. Antenatal steroid administration had a protective effect. Conclusion: Our results concur with the notion that a tertiary center is the optimal location for delivery of the high risk neonate. Improvement in medical and nursing care prenatally and at delivery and transportation, including frequent administration of antenatal steroids and earlier administration of surfactant prior to transportation, may minimize the disadvantage of delivery in a referring hospital.

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.