Paediatric Retrieval Research Articles

Book Review: Cases in Paediatric Critical Care Transfer and Retrieval Medicine by Shelley Riphagen and Sam Foster

Book Review: <i>Cases in Paediatric Critical Care Transfer and Retrieval Medicine</i> by Shelley Riphagen and Sam Foster

Endoscopic pediatric endonasal retrieval of transorbital projectile: An illustrative multimedia report

Air guns, particularly BB (ball-bearing or bullet ball) guns, have gained significant power and velocity over the last few decades. More than 145,000 pediatric patients suffered injuries attributed to air guns in the United States between 2001 and 2011, and approximately 22,000 pediatric emergency department visits are attributed to air gun-related injuries annually (Hyak et al., 2020 [1]). This study aims to describe an effective surgical technique in addressing maxillofacial injuries caused by BB gun projectiles in the pediatric population. We present a detailed surgical approach for endoscopic endonasal retrieval of a transorbital projectile in a 13-year-old male who sustained a maxillofacial BB gun injury, with the goal of restoring sinonasal function in a minimally invasive fashion.

Use of Intraosseous Access in Neonatal and Pediatric Retrieval-Neonatal and Pediatric Emergency Transfer Service, New South Wales.

Pediatric patients who are critically unwell require rapid access to central vasculature for administration of life-saving medications and fluids. The intraosseous (IO) route is a well-described method of accessing the central circulation. There is a paucity of data surrounding the use of IO in neonatal and pediatric retrieval. The aim of this study was to review the frequency, complications, and efficacy of IO insertion in neonatal and pediatric patients in retrieval. A retrospective review of cases referred to neonatal and pediatric emergency transfer service, New South Wales over the epoch 2006 to 2020. Medical records documenting IO use were audited for patient demographic data, diagnosis, treatment details, IO insertion and complication statistics, and mortality data. Intraosseous access was used in 467 patients (102 neonatal/365 pediatric). The most common indications were sepsis, respiratory distress, cardiac arrest, and encephalopathy. The main treatments were fluid bolus, antibiotics, maintenance fluids, and resuscitation drugs. Return of spontaneous circulation after resuscitation drugs occurred in 52.9%; perfusion improved with fluid bolus in 73.1%; blood pressure improved with inotropes in 63.2%; seizures terminated with anticonvulsants in 88.7%. Prostaglandin E1 was given to eight patients without effect. Intraosseous access-related injury occurred in 14.2% of pediatric and 10.8% of neonatal patients. Neonatal and pediatric mortality rates were 18.6% and 19.2%, respectively. Survival in retrieved neonatal and pediatric patients who required IO is higher than previously described in pediatric and adult cohorts. Early insertion of an IO facilitates early volume expansion, delivery of critical drugs, and allows time for retrieval teams to gain more definitive venous access. In this study, prostaglandin E1 delivered via a distal limb IO had no success in reopening the ductus arteriosus.

Is it time for mandatory airway assessments for emergency medicine trainees?

Emergency Medicine AustralasiaEarly View Trainee Focus Is it time for mandatory airway assessments for emergency medicine trainees? Caroline Venner FACEM, MBBS, BMedSci, MPHTM, Corresponding Author Caroline Venner FACEM, MBBS, BMedSci, MPHTM Staff Specialist, Paediatric Retrieval Fellow [email protected] Gladstone Hospital, Gladstone, Queensland, Australia Children's Health Queensland Retrieval Service, Brisbane, Queensland, Australia Correspondence: Dr Caroline Venner, Gladstone Hospital, Park Street, Gladstone, QLD 4680, Australia. Email: [email protected]Search for more papers by this author Caroline Venner FACEM, MBBS, BMedSci, MPHTM, Corresponding Author Caroline Venner FACEM, MBBS, BMedSci, MPHTM Staff Specialist, Paediatric Retrieval Fellow [email protected] Gladstone Hospital, Gladstone, Queensland, Australia Children's Health Queensland Retrieval Service, Brisbane, Queensland, Australia Correspondence: Dr Caroline Venner, Gladstone Hospital, Park Street, Gladstone, QLD 4680, Australia. Email: [email protected]Search for more papers by this author First published: 02 April 2023 https://doi.org/10.1111/1742-6723.14210Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

What Happens When you Ask for Feedback? Anticipating and Addressing Challenges Can Be Effective for Eliciting Parents' Views About Their Critically Ill Child's Retrieval to Paediatric Intensive Care.

User feedback is an important element of health-service evaluation and can be used to improve services but can be difficult to obtain, particularly in acute care situations. As part of a national study, we explored stakeholders' perspectives on paediatric critical care retrieval processes through questionnaires and interviews. Obtaining feedback in a highly charged, stressful and busy paediatric intensive care unit (PICU) environment is fraught with difficulties so we aimed to optimise each stage of data collection by being both proactive and reactive. Patient and public involvement occurred throughout and engagement with sites and supporting local research staff to approach and recruit families were prioritised. High-quality study materials were developed to reduce local staff burden and promote and maintain study awareness. We describe strategies used and what worked/did not work. We suggest approaches for optimising elicitation of parents' experiences in difficult circumstances, highlighting the importance of engagement and commitment of PICU staff.

Effects of COVID-19 pandemic restrictions on an Australian neonatal and paediatric retrieval service.

AimThe COVID‐19 pandemic and associated travel and social distancing restrictions have reduced paediatric intensive care unit admissions for respiratory illnesses. The effects on retrieval (transport) services remain unquantified. Our study examined the utility of statistical process control in assessing the impact of the COVID‐19 pandemic on the number of neonatal and paediatric transfers in an Australian retrieval service.MethodsData collected prospectively from the SA Ambulance Service MedSTAR Emergency Retrieval database in South Australia were analysed from January 2015 to June 2021. Statistical process control methodology, a combination of a time series analysis and assessment for common and special cause variation, was used to assess the impact of the COVID‐19 pandemic on retrieval workload (primary outcome of interest).ResultsA total of 5659 neonatal and paediatric transfers occurred during the study period and were included. A significant decrease in paediatric transfers occurred after the initial lockdown measures in March 2020 were announced in South Australia (special cause variation). However, a similar reduction was not observed for neonatal transfers (common cause variation).ConclusionOur study demonstrates that statistical process control may be effectively used to understand the effects of external events and processes on usual activity patterns in the retrieval setting. We found a reduction in retrieval numbers for paediatric transfers but no effect on neonatal transfer numbers. The decline in paediatric transfers was primarily attributed to reduced respiratory cases.

EP.TU.1068Developing a Major Trauma Nursing Education Framework in Manchester

Abstract Aims The opening of the Major Trauma Ward (MTW) at Manchester University Hospitals NHS Trust represents a key milestone for managing major adult trauma within the Greater Manchester conurbation. We present an overview of the development of a novel Major Trauma Nursing Education Framework incorporating both the induction and continuing professional development of trauma nurses. Methods The MTW nursing skillset combines elements from acute surgical specialities and rehabilitation medicine. A framework for education was constructed from the Adult Nursing Competencies for the Major Trauma Patient (National Major Trauma Nursing Group) and the Trauma Intermediate Life Support curriculum. An induction programme was developed with a Competencies Workbook for an interim period including external courses for band 5 (Nurse Trauma and Critical Care course) and senior nurses (ALS and Neonatal, Adult and Paediatric Safe Transfer and Retrieval Course). An annual training programme will renew these competencies. Results Feedback from the first cohort for the induction programme has been positive, particularly with the third of nurses who did not feel confident managing trauma patients prior to induction (Wilcoxin-signed rank test, p = 0.00116). Free text comments ranged from the completeness of the topics covered to the delivery methods of the curriculum and how to work effectively within the wider multidisciplinary team. Conclusions The development of a formal Major Trauma Nursing Education Framework is necessary for a modern trauma workforce. Feedback has so far been positive. Continual audit of the framework will be necessary to ensure and improve the quality of delivery of education.

Using a genetic algorithm to solve a non-linear location allocation problem for specialised children’s ambulances in England and Wales

ABSTRACT Since 1997, special paediatric intensive care retrieval teams (PICRTs) based in 11 locations across England and Wales have been used to transport sick children from district general hospitals to one of 24 paediatric intensive care units. We develop a location allocation optimisation framework to help inform decisions on the optimal number of locations for each PICRT, where those locations should be, which local hospital each location serves and how many teams should station each location. Our framework allows for stochastic journey times, differential weights for each journey leg and incorporates queuing theory by considering the time spent waiting for a PICRT to become available. We examine the average waiting time and the average time to bedside under different number of operational PICRT stations, different number of teams per station and different levels of demand. We show that consolidating the teams into fewer stations for higher availability leads to better performance.

Retrieval of neonatal and paediatric patients on extracorporeal membrane oxygenation support in New South Wales, Australia.

New South Wales has recently added the capability of extracorporeal membrane oxygenation to the neonatal and paediatric retrieval process and this paper describes the early experiences and protocol development for the first eight cases transported.

Clinical impact of implementing humidified high-flow nasal cannula on interhospital transport among children admitted to a PICU with respiratory distress: a cohort study

BackgroundThere is a limited evidence for humidified high-flow nasal cannula (HHFNC) use on inter-hospital transport. Despite this, its use during transport is increasing in children with respiratory distress worldwide. In 2015 HHFNC was implemented on a specialized pediatric retrieval team serving for Victoria. The aim of this study is to investigate the effect of the HHFNC implementation on the retrieval team on the paediatric intensive care unit (PICU) length of stay and respiratory support use.MethodsWe performed a cohort study using a comparative interrupted time-series approach controlling for patient and temporal covariates, and population-adjusted analysis. We studied 3022 children admitted to a PICU in Victoria with respiratory distress January 2010–December 2019. Patients were divided in pre-intervention era (2010–2014) and post-intervention era (2015–2019).Results1006 children following interhospital transport and 2016 non-transport children were included. Median (IQR) age was 1.4 (0.7–4.5) years. Pneumonia (39.1%) and bronchiolitis (34.3%) were common. On retrieval, HHFNC was used in 5.0% (21/420) and 45.9% (269/586) in pre- and post-intervention era. In an unadjusted model, median (IQR) PICU length of stay was 2.2 (1.1–4.2) and 1.7 (0.9–3.2) days in the pre- and post-intervention era in transported children while the figures were 2.4 (1.3–4.9) and 2.1 (1.2–4.5) days in non-transport children. In the multivariable regression model, the intervention was associated with the reduced PICU length of stay (ratio 0.64, 95% confidential interval 0.49–0.83, p = 0.001) with the predicted reduction of PICU length of stay being − 10.6 h (95% confidential interval − 16.9 to − 4.3 h), and decreased respiratory support use (− 25.1 h, 95% confidential interval − 47.9 to − 2.3 h, p = 0.03). Sensitivity analyses including a model excluding less severe children showed similar results. In population-adjusted analyses, respiratory support use decreased from 4837 to 3477 person-hour per year in transported children over the study era, while the reduction was 594 (from 9553 to 8959) person-hour per year in non-transport children. With regard to the safety, there were no escalations of respiratory support mode during interhospital transport.ConclusionsThe implementation of HHFNC on interhospital transport was associated with the reduced PICU length of stay and respiratory support use among PICU admissions with respiratory distress.

Decision-making for children requiring interhospital transport: assessment of a novel triage tool

ObjectiveThe use of specialist retrieval teams to transport critically ill children is associated with reduced risk-adjusted mortality and morbidity; however, there is a paucity of data to guide decision-making related...

Paediatric admissions to a district general hospital adult intensive care unit over a six year period: A single centre retrospective case series, with review of practitioner confidence and competence in paediatric critical care.

Critically ill children presenting to district general hospitals (DGH) are admitted to adult intensive care units (AICUs) for stabilisation prior to transfer to paediatric intensive care units (PICUs). Current training in PICU for adult intensive care physicians is only three months. This single centre retrospective case series examines the case mix of children presenting to a DGH AICU and a multidisciplinary survey assesses confidence and previous experience, highlighting continued training needs for DGH AICU staff. all paediatric admissions to AICU and paediatric retrievals were reviewed over a 6-year period (2014-2019). Cases were identified from the Electronic Patient Record (EPR) and from data provided by the regional paediatric retrieval service. A questionnaire survey was sent to AICU doctors and nurses to assess confidence and competence in paediatric critical care. Between 2014-2019, 284 children were managed by AICU. In total 35% of cases were <1 y, 48% of cases were <2 y and 64% of cases were <5 y, and 166/284 (58%) children were retrieved. Retrieval reduced with increasing age (OR 0.49 [0.40-0.60], p < 0.0001). The survey had an 82% response rate, and highlighted that only 13% of AICU nurses and 50% of doctors had received prior PICU training. At least one critically unwell child presents to the AICU each week. Assessment, stabilisation and management of critically unwell children are vital skills for DGH AICU staff, but confidence and competence are lacking. Formalised strategies are required to develop and maintain paediatric competencies for AICU doctors and nurses.

Safety of early norepinephrine infusion through peripheral vascular access during transport of critically ill children.

Study objectiveIn prehospital and emergency settings, vasoactive medications may need to be started through a peripheral intravenous catheter. Fear of extravasation and skin injury, with norepinephrine specifically, may prevent or delay peripheral vasopressor initiation, though studies from adults suggest the actual risk is low. We sought to study the risk of extravasation and skin injury with peripheral administration of norepinephrine in children in the prehospital setting.MethodsWe performed a retrospective study of pediatric patients (≤18 years) who received a vasopressor during prehospital transport. We collected data from retrieval and hospital records from 2 pediatric medical retrieval teams in the Paris/Ile‐de‐France region. Patients were eligible if they had documentation of distributive or obstructive shock and administration of norepinephrine through a peripheral catheter (intravenous or intraosseous) during retrieval. The primary outcomes were the occurrence of extravasation and evidence of skin injury. We also examined approach to norepinephrine administration (concentration, duration, proximal vs distal site) and hospital outcomes.ResultsOver a 3‐year‐period, 37 pediatric patients received norepinephrine through a peripheral catheter (33 intravenous, 4 intraosseous). Median patient age was 1.8 years. Thirty‐two patients (86.5%) had septic shock. The median total duration of norepinephrine infusion was almost 4 hours. One patient (2.7%, 95% confidence interval 0.5%, 13.8%) had suspected extravasation from a 24‐gauge intravenous catheter in the hand, with local skin hypoperfusion. Skin changes were noted after 135 minutes of norepinephrine infusion. Perfusion normalized after catheter removal, and there were no other sequelae.ConclusionsIn a 3‐year sample of pediatric patients from a large metropolitan area, we found only 1 patient with evidence of any harm with peripheral administration of norepinephrine. This finding is consistent with the adult literature but requires multicenter and multiyear investigation before a firm recommendation for this practice can be made.

P0166 / #753: FACTORS RELATED TO TIMELINESS OF ACCESS TO PAEDIATRIC INTENSIVE CARE –PARENT AND STAFF PERSPECTIVES

Aims & Objectives: Specialist paediatric intensive care retrieval teams (PICRTs) were established to transfer critically ill children to regional paediatric intensive care units (PICUs). There is national variation in how services are delivered and our study aimed to explore the impact of these differences on factors including timeliness through describing the experiences of different service stakeholders Methods: Fifty clinicians were invited to participate in interviews from PICUs, PICRTs and general district hospitals using purposive sampling to ensure diversity of clinical role and place of work. Thirty parents were recruited while in PICU and purposively sampled for diversity in: age, presenting medical illness, whether a parent travelled with the child to PICU and PICRT used. Interviews were either face-to-face or over the phone. All interviews were recorded and transcribed verbatim. A qualitative approach using Framework Analysis in NVIVO was used to identify themes related to experiences of the transfer and factors which influenced this experience. Results: Factors that influenced timeliness of access to PICU included: communication between the teams involved in the care (referring hospital, PICRTs and PICU); patients’ readiness for transfer (preparation and planning); confidence and competence of staff at each location; patient-related factors (e.g. how sick the child was); seasonal aspects (e.g. winter pressures); service resources and the geographical location of each service. Conclusions: Understanding factors that influence timeliness of access to PICU, from the perspective of those who use or deliver the service, provides valuable insight about the delivery of effective transport services. Acknowledgement: this study was funded by the NIHR HS&DR.

Parental presence during pediatric retrieval: the caregiver’s perspective

The presence of family at the bedside of critically ill children is recommended, as part of "family-centered care." The study aimed to understand if such recommendation was applied by our neonatal and pediatric retrieval team and the second aim was their perception of parental presence. We first conducted a 6-month monocentric prospective observational study where the transport teams had to rate parental presence after each retrieval. A second survey was filled out by all team members, to explore their perception of parental presence in a general manner, without referring to a specific transport. Three hundred seventeen questionnaires from the prospective survey were returned, with parents being present in the ambulance for 47% of retrievals. There was a significant difference in parental accompaniment between newborns (< 24 h) and older children. The parental presence was rated as neutral or positive for 99% of transportation, whereas approximately ¼ of the crew feared "a priori" parental presence during transport in the second survey.Conclusion: This study suggests at least one parent was present at almost half of the retrievals conducted in our sample during the study period. Very few negative experiences were reported in the prospective study by the caregivers who allowed parental presence. What is Known: •The concept of family-centered care is an approach that recognizes the importance of family engagement and involvement and encourages collaboration between families and healthcare professionals. •Parents wish to accompany their child. What is New: •The perception of parental presence, by transport team members, was neutral or positive in 99% of retrievals during the study. •Newborns' parents were less present during retrieval than older children's parents.

Improving Intubation Success in Pediatric and Neonatal Transport Using Simulation.

Pediatric and neonatal first-pass intubation rates are higher in adult trained retrieval services than in neonatal or pediatric trained services. Some authors have attributed this to more frequent opportunities to practice the skill in the adult population. The aim of this study was to increase the first-pass intubation rate without adverse events by introducing daily intubation simulation at our mixed neonatal and pediatric retrieval service. This prospective cohort study performed from July to December 2018 in our mixed neonatal and pediatric retrieval service involved 16 medical staff performing simulated intubation at commencement of their retrieval shift with a retrieval nurse. Checklists for neonatal and pediatric intubation were introduced to the retrieval service for the intervention cohort. Participants were asked to complete questionnaires about intubation performed on retrieval to gather data not routinely collected by the service. Seven hundred and sixty-eight patients were retrieved by the service and 70 patients required intubation by the retrieval team during the intervention period. First-pass intubation rates were higher during the intervention period compared with a historical cohort, despite less intubations being performed overall. First-pass intubation rates improved from 59% to 78% in neonatal patients (P = 0.032), 58% to 65% in pediatric patients (P = 0.68) and from 58% to 74% overall (P = 0.043). There were no severe adverse events detected during the intervention period. Minor adverse events were associated with multiple attempts at intubation (P < 0.001). Overall compliance with simulation protocol was 43.5%, and on average, each doctor completed simulation once per month. Simulation is a useful adjunct to support neonatal and pediatric intubation training in the current environment of reducing intubation frequency.

Systematic review of rigid and flexible esophagoscopy for pediatric esophageal foreign bodies

BackgroundEsophageal foreign body (EFB) is a common presentation in pediatric hospitals. Rigid and flexible esophagoscopy are both primary modalities used for EFB removal. By systematically reviewing the literature, we sought to assess success and complication rates of both rigid and flexible esophagoscopy in pediatric EFB retrieval. MethodsA systematic search of the literature was performed in MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, CINAHL. Two authors independently reviewed 74 abstracts and included studies that documented success rates of flexible and rigid esophagoscopy for EFB retrieval. The certainty and quality of the overall body of evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development and Evaluation approach. ResultsFive retrospective chart reviews published between 1993 and 2016 identified 955 patients with a mean age of 4.2 (range 3.2–5.3 years). Foreign bodies were localized to the upper esophagus in 69.6%, middle esophagus in 13.0% and lower esophagus in 11.5%. Coins (82.1%) and food boluses (8.5%) comprised the majority of EFB. The success rate of foreign body retrieval was 95.4% with rigid esophagoscopy and 97.4% with flexible esophagoscopy. Complication rates were 2.4% for rigid esophagoscopy and 3.4% for flexible esophagoscopy. Rates of successful foreign body retrieval (odds ratio [OR] = 1.9 [95% CI 0.9–3.8; p = 0.07]) and complications (OR = 0.9 [95% CI 0.3–2.3; p = 0.79]) were not significantly different across modalities. There were no mortalities in any of the studies analyzed. ConclusionFlexible and rigid esophagoscopy are equally safe and effective for the retrieval of EFB in children. Otolaryngologists, gastroenterologists, and pediatric general surgeons can be consulted for foreign body retrieval depending on institutional policies and resource availability.

Preventing critical failure. Can routinely collected data be repurposed to predict avoidable patient harm? A quantitative descriptive study

ObjectivesTo determine whether sharing of routinely collected health service performance data could have predicted a critical safety failure at an Australian maternity service.DesignObservational quantitative descriptive study.SettingA public hospital maternity service...

Modelling the allocation of paediatric intensive care retrieval teams in England and Wales

BackgroundFollowing centralisation of UK paediatric intensive care units in 1997, specialist paediatric intensive care retrieval teams (PICRTs) were established to transport critically ill children from district general hospitals (DGHs). The...

Endotracheal intubation by a specialised paediatric retrieval team.

Intubation of critically ill children is an infrequent procedure, and is associated with significant risk. We set out to describe intubations carried out by the Children's Health Queensland Retrieval Service (CHQRS), with the intention to identify areas for improvement in the performance of intubation in the retrieval setting. Paediatric patients undergoing transport while intubated were identified, and cases where intubation occurred after the arrival of the CHQRS team were examined. Over the study period of January 2015 to September 2018, 498 intubated retrievals were undertaken; 85 patients were intubated after the arrival of CHQRS; the age range was 1 day to 16.5 years (median 0.5, interquartile range [IQR] 0.11-3 years). The median weight was 6.2 kg (IQR 3.7-16.5 kg). The pathology requiring intubation included respiratory 36 (42.3%), sepsis 21 (24.7%), neurological 11 (12.9%) and trauma 7 (8.2%). A total of 470 of 498 (94.4%) of intubated patients were from regional referral or tertiary hospitals, 28 of 498 (5.6%) were from rural and remote facilities. Of 85 patients, 57 (67.1%) were intubated by CHQRS and 28 (32.9%) were intubated by a doctor from the referring facility. The CHQRS team was more likely to perform the intubation in smaller children (median weight 5.0 vs 9.9 kg, P = 0.03). The mean scene time was 2.8 h. The scene time was shorter if the intubation was performed by CHQRS (mean 2.6 h, median 2.5, IQR 1.8-3.3; median 3, IQR 2.2-3.9; P = 0.048). The scene time was shorter when the intubation was predicted from tasking information (2.6 vs 3.1 h; P = 0.03). Paediatric endotracheal intubation is an infrequent procedure in our service. An airway registry could improve documentation and gather information to identify specific training requirements and areas for practice improvement.