Pediatric Transport Team Research Articles

A Pediatric and Neonatal Critical Care Transport Team’s Standard of Care for Suspected Stroke of a Pediatric Patient

A Pediatric and Neonatal Critical Care Transport Team’s Standard of Care for Suspected Stroke of a Pediatric Patient

IPASS Handoff: Decreasing communication failures by utilizing a standardized patient handoff for neonatal and pediatric transport

Background: The Pediatric and Neonatal Transport Team recognized variability of team member presence and information sharing at transport patients’ bedside handoffs. Hassenfeld Children's Hospital at NYU adopted and implemented a standardized handoff tool, IPASS, to decrease communication failures and improve patient safety. Aim: To utilize standardized IPASS handoff for all patient transports with …

Inter-facility transports of critically ill neonates

Purpose: Interfacility transports (IFTs) of critically ill neonates (CINs) for a higher level of care are fraught with risk. Data on outcomes of IFTs of CINs requiring intensive monitoring and therapeutic interventions are scant. Our purpose was to compare IFTs of CINs and matched controls to a quarternary center by a specialized pediatric transport team. Specifically, we compared a) clinical characteristics and pre-transport status, b) unplanned events (UEs) and therapeutic interventions (TIs) during IFT and c) status on arrival, using the validated Transport risk index of physiologic stability …

A National Survey on Physician Trainee Participation in Pediatric Interfacility Transport

Purpose: There is a paucity of data in the medical literature on physician trainee readiness prior to participating in pediatric interfacility transports. The aims of this study were to ascertain the national experience regarding which physician trainees are allowed to participate in pediatric interfacility transports and what is considered adequate education and training for physician trainees prior to participating in the transport of children. Methods: An electronic survey was sent to leaders of pediatric transport teams listed with the American Academy of Pediatrics Section on Transport Medicine (AAP-SOTM) …

Do infants with transposition of the great arteries born outside a specialist centre have different outcomes?

Infants born with undiagnosed transposition of the great arteries continue to be born in district general hospitals despite the improvements made in antenatal scanning. Evidence indicates improved outcomes with early definitive treatment after birth, hence the recommendation of delivery in a tertiary centre. The role of specialist paediatric and neonatal transport teams, to advise, stabilise, and transport the infants to a tertiary centre in a timely manner, is critical for those infants born in a district general hospital. This pilot study aims to compare outcomes between infants born in district general hospitals and those who were born in a tertiary maternity unit in South West England and South Wales. This was a secondary data analysis of data collected from the local Paediatric Intensive Care Audit Network and the local transport database. Infants born with a confirmed diagnosis of transposition of the great arteries, that required an arterial switch operation as the definitive procedure between April, 2012 and March 2018 were included. Forty-five infants with a confirmed diagnosis of transposition of the great arteries were included. Statistical analysis demonstrated there were no significant differences in the time to balloon atrial septostomy (p = 0.095), time to arterial switch operation (p = 0.461), length of paediatric ICU stay (p = 0.353), and hospital stay (p = 0.095) or mortality between the two groups. We found no significant differences in outcomes between infants delivered outside the specialist centre, who were transferred in by a specialist team.

Cross-sectional Survey of Canadian Pediatric Critical Care Transport.

This study aimed to better understand the unique aspects of pediatric critical care transport programs across Canada by characterizing the current workforce of each transport program. A cross-sectional questionnaire was sent to the 13 medical directors of Canada's pediatric critical care transport teams, and to 2 nonhospital-affiliated transport services. If a children's hospital did not have a dedicated team for pediatric transport, the regional transport team providing this service was identified. Eight of the 13 pediatric intensive care units surveyed have unit-based pediatric transport teams. The median annual transport volume for the 8 hospital-based teams was 371 (range, 45-2300) with a total of 5686 patients being transported annually. Among patients transported by the 8 teams, 45% (2579 patients) were pediatric patients (older than 28 days and younger than 18 years) and 40% (1022 patients) of the pediatric patients were admitted to the pediatric intensive care units. Eighty-eight percent of the responding teams also transported neonates (older than 28 days), and 38% transported premature infants.A team composition of registered nurse-respiratory therapist-physician was used by 6/13 teams (75%); however, it accounted for only a small proportion of the transports for most of the teams (median, 2%; range, 2%-100%).The average transport time from dispatch (from team home site) to arrival at receiving facility was reported by 6 teams, and has a median of 195 minutes (range, 90-360 minutes). The median distance from home site to the farthest referral site in the catchment area was 700 km (range, 15-2500 km). This is the first Canadian nationwide study of pediatric critical care transport programs. It revealed a complexity and variability in transport team demographics, transport volume, team composition, and decision-making process.

Uncuffed Endotracheal Tubes: Not Appropriate for Pediatric Critical Care Transport

ObjectiveThe effect of using uncuffed endotracheal tubes in children during interfacility critical care transport has not yet been assessed. We hypothesized that many children with uncuffed endotracheal tubes experience complications leading to replacement with a cuffed tube after arrival at a tertiary pediatric care facility. MethodsWe conducted a retrospective case review of all intubated patients transported by our dedicated pediatric critical care transport team to our pediatric intensive care unit over a 3-year period. The incidence of urgent reintubation was studied. ResultsA total of 213 children were referred for transport with an endotracheal tube in place, with 55 of those with an uncuffed endotracheal tube (25.8% of all intubated patients). Of those with uncuffed tubes, 24 patients needed their tubes replaced on an urgent basis by the medical team because of issues with ineffective ventilation (43.6% of patients with uncuffed tubes or 11.3% of all intubated patients). No cuffed tubes required replacement. ConclusionPlacing an uncuffed endotracheal tube in the critically ill child who is referred to tertiary pediatric care results in a significant number of these patients undergoing a repeat laryngoscopy, with all associated risks, to replace the uncuffed tube with a cuffed tube.

A Survey Assessing Pediatric Transport Team Composition and Training.

The aim of this study was to assess national pediatric/neonatal specialty transport teams' composition and training requirements to determine if any current standardization exists. This was a survey of the transport teams listed with the American Academy of Pediatrics via SurveyMonkey. While most of the teams maintain internal criteria for team competency and training, there is large variation across team compositions. The vast majority of the teams have a nurse-led team with the addition of another nurse, medic, and/or respiratory therapist regardless of mode of transport. Many of the teams report adjusting team composition based on acuity. Fewer than 15% of teams have a physician as a standard team member. More than 80% required a minimum number of supervised intubations prior to independent practice; however, the number varied largely from as little as 3 to as many as 30. Eighty-eight percent of the teams report using simulation as part of their education program, but again there were marked differences between teams as to how it was used. There is tremendous variability nationally among pediatric/neonatal transport teams regarding training requirements, certifications, and team composition. The lack of standardization regarding team member qualifications or maintenance of competency among specialized transport teams should be looked at more closely, and evidence-based guidelines may help lead to further improved outcomes in the care of critically ill pediatric patients in the prehospital setting.

A Pediatric and Neonatal Critical Care Transport Team's Standard of Care for Suspected Stroke of a Pediatric Patient

Background A 314 bed free standing Children's Hospital is the region's first and only dedicated pediatric stroke center offering comprehensive, individualized treatment protocols for children (Children's Mercy, 2018). The WHO estimates 1-2/210,000 children will have a stroke. Mortality is 2-11% but persistent neurological deficit will occur in 68-73% of children who experience a stroke (Bernard Ann Neurol 2008). Recognition and early intervention are critical to minimizing brain damage (Mutka Sharma, MD). Depending on the length of time since the stroke, treatment options can vary. Rapid identification and treatment can be lifesaving and/or potentially improve neurologic outcomes (Children's Mercy 2018). Objectives To provide a Pediatric and Neonatal Critical Care Transport team the training, job aides and standardization for the recognition and treatment of a pediatric patient with stroke symptoms requiring transport to a Pediatric Stroke Center. ●Identify pediatric patients with symptoms concerning for stroke ●Initiate a Stroke Alert Protocol if child has focal neurologic deficit and meets criteria for activation ●Aid in the pre Pediatric Stroke Center triage process and stroke evaluation ●Provide rapid assessment, stabilization, and transport of children with stroke-like symptoms to pediatric center ●Initiate neuroprotective measures designed to minimize secondary neurologic injury IMPLEMENTATION ●Clinical Practice Guideline ●Suspected Stroke Checklist ●tPA Administration and Monitoring Guidelines Results Because symptoms of a pediatric ischemic stroke can vary greatly from an adult ischemic stroke, our Critical Care Transport Team is specially trained and prepared to transport a pediatric patient with stroke symptoms from anywhere in the area. If a pediatric ischemic stroke is suspected by a referral and/or our transport team, our collaborative team of Medical Control Physicians (MCP), Transport Personnel, Referral Physicians and Emergency Room Physicians are all specially trained to activate our stroke protocol immediately should a patient present with stroke symptoms. Since implementation we have transported and treated 2 patients with basilar artery stroke. Both patients had successful clot retrieval and full neurological recovery! Several other critical diagnosis as a result of being a stroke mimicker were made during the stroke alert and/or stroke activation procedure including brain tumor, HSV encephalitis, brain abscess, Schawannoma and Moya Moya disease. Conclusion There has been an increase in rapid diagnosis, early recognition and treatment of pediatric patients with acute ischemic stroke and other stroke mimickers that required emergent intervention following implementation of our Stroke Alert Protocol, Clinical Practice Guideline, Suspected Stroke Checklist and tPA Administration and monitoring Guideline for Pediatric and Neonatal Critical Care Transport.

Impact of Interfacility Transport Method and Specialty Teams on Outcomes of Pediatric Trauma Patients.

The aim of the study was to evaluate the impact of ground versus air transport and use of pediatric specialty versus generalist transport teams on outcomes of pediatric trauma victims requiring interfacility transport. A retrospective review of our hospital's trauma registry database was performed. Children with traumatic injuries who were transported from a referring hospital by either our pediatric specialty transport team or an outside generalist transport team were included in the analysis. Comparisons were made by mode of transport (air vs ground), team type (specialty vs generalist), and by transport mode and team type combined. Total transport time was significantly shorter for generalist air transport than other modes. Severity of injury as determined by Pediatric Trauma Score (PTS) was equivalent for all patients at the referring hospital, but there was a statistically significant greater decrease (worsening) in PTS from referral to arrival for generalist team air transports versus all other transport modes. Similarly, there was a statistically significant greater decrease (worsening) in Glasgow Coma Score from referral to arrival for generalist team air transport versus all other transport modes. Hospital discharge disposition to home was greater for all ground teams versus air teams and for specialty team air versus generalist team air. In our system, air transport by a generalist team occurred more rapidly than ground or air transport by a specialty team. However, generalist air transport is associated with significant worsening in patients' PTS and Glasgow Coma Score despite similar severity of injury at referral, and differences in hospital discharge disposition were present.

Interhospital Transport of Critically Ill Children to PICUs in the United Kingdom and Republic of Ireland: Analysis of an International Dataset.

International data on characteristics and outcomes of children transported from general hospitals to PICUs are scarce. We aimed to 1) describe the development of a common transport dataset in the United Kingdom and Ireland and 2) analyze transport data from a recent 2-year period. Retrospective analysis of prospectively collected data. Specialist pediatric critical care transport teams and PICUs in the United Kingdom and Ireland. Critically ill children less than 16 years old transported by pediatric critical care transport teams to PICUs in the United Kingdom and Ireland. None. A common transport dataset was developed as part of the Paediatric Intensive Care Audit Network, and standardized data were collected from all PICUs and pediatric critical care transport teams from 2012. Anonymized data on transports (and linked PICU admissions) from a 2-year period (2014-2015) were analyzed to describe patient and transport characteristics, and in uni- and multivariate analyses, to study the association between key transport factors and PICU mortality. A total of 8,167 records were analyzed. Transported children were severely ill (median predicted mortality risk 4.4%) with around half being infants (4,226/8,167; 51.7%) and nearly half presenting with respiratory illnesses (3,619/8,167; 44.3%). The majority of transports were led by physicians (78.4%; consultants: 3,059/8,167, fellows: 3,344/8,167). The median time for a pediatric critical care transport team to arrive at the patient's bedside from referral was 85 minutes (interquartile range, 58-135 min). Adverse events occurred in 369 transports (4.5%). There were considerable variations in how transports were organized and delivered across pediatric critical care transport teams. In multivariate analyses, consultant team leader and transport from an intensive care area were associated with PICU mortality (p = 0.006). Variations exist in United Kingdom and Ireland services for critically ill children needing interhospital transport. Future studies should assess the impact of these variations on long-term patient outcomes taking into account treatment provided prior to transport.

Epidemiology of Pediatric Critical Care Transport in Northern Alberta and the Western Arctic.

Specialized pediatric critical care transport teams are essential to pediatric retrieval systems. This study aims to describe the contemporary transports performed by a Canadian pediatric critical care transport team and to compare the treatment and outcomes of children referred from high-level care (hospitals offering pediatric services where an adult ICU exists) and nonhigh-level care (all other hospitals) hospitals. A descriptive cohort study. The Stollery Children's Hospital in Edmonton, Alberta, Western Canada. Children younger than 17 years old transported by the transport team from referral hospitals within the Stollery Children's Hospital catchment area to Stollery Children's Hospital between 1998 and 2015. None. Characteristics of transports, patient demographics presenting vital signs, and outcomes were described overall and compared by transport-related time and referral hospital types (high-level care and nonhigh-level care). In total, 3,352 transports met the inclusion criteria; 1,049 were retrieved from eight high-level care hospitals and 2,303 from 53 nonhigh-level care hospitals; the median one-way transport distance was 383 kilometers, and 70% of the transports were air transports. The annual number of transports has increased during the study period. The PICU admission rate was between 40% and 55%. Transports from high-level care hospitals had significantly higher odds of being admitted to the PICU (odds ratio, 1.96; 95% CI, 1.31-2.93). The odds of intubation at the referral hospital were higher in the high-level care group, but the odds of intubation upon PICU admission was similar between the two groups. Mortality during or after transport was not significantly different between high-level care and nonhigh-level care hospitals. The current transport system has multiple priorities with regard to efficiency and quality. The medical services at referral hospitals may affect the likelihood of PICU admission and subsequent PICU length of stay; however, no negative impact was observed in other outcomes including mortality.

Asthma Scores: A reliable tool to determine the need for advanced asthma management in the pediatric patient

Purpose As a pediatric transport team, we notice patients at referring facilities with higher CAS scores waiting for transfer, often experience a deterioration of clinical condition as noted by an elevation of their CAS score. This score is used in conjunction with the Clinical Practice Guideline for Asthma Care in the Emergency Department to determine the need for transfer and care recommendations prior to patient arrival at our facility. Our team wanted to determine if the asthma score currently utilized at our facility was valid, reliable and consistent. Methods The committee conducted database …

The Effect of Team Configuration on the Incidence of Adverse Events in Pediatric Critical Care Transport

ObjectiveSpecialty pediatric transport teams are widely used for pediatric interfacility transport in the United States, with little industry consensus on optimal team configuration. The aim of this study is to assess the quality of the nurse/paramedic specialty team configuration as indirectly measured by the rate of adverse events in these transports. MethodsRetrospective analysis of pediatric transport data from a hospital-based dedicated pediatric/neonatal transport team was conducted for patients transported in 2016. Data were categorized by general characteristics of transport and analyzed for the occurrence of adverse events. ResultsFive hundred sixty-four cases were analyzed. Cases were described by team configuration and then by transport mode, duration, time, patient age and acuity, and disposition. The overall rate of adverse event incidence was 8.3%, chiefly centered in device and process domains. There was no significant difference in the rate of adverse events between team configurations. ConclusionThere was no significant difference in the rate of adverse event occurrence in nurse/paramedic team configurations versus nurse/nurse configuration. Using critical care paramedics on pediatric transport teams enables a larger volume of patients to be transported to definitive care without concerns for decrease in quality or safety.

The Effect of Telemedicine on Resource Utilization and Hospital Disposition in Critically Ill Pediatric Transport Patients.

Pediatric transport teams rely on communication to report patient data to medical command officers, who create care plans and determine disposition. Common destinations are the emergency department (ED), pediatric intensive care unit (PICU), or regular inpatient care area (RIPCA). Telephone report does not result in complete understanding of the patient's condition. Further workup in the ED is often required. Telemedicine allows the patient to be directly seen; parents to be interviewed; and laboratory studies, radiographs, and vital signs to be reviewed. We hypothesized that telemedicine would improve understanding of the patient and result in more accurate disposition. Patients within our hospital from 2012 to 2013 were compared with patients transported using our telemedicine program from April 2014 to April 2015. From 2012 to 2013, a total of 4,662 transports were performed. Of these, 4,067 were inbound transports, 2,302 of these patients were sent to ED (56.6%), 1,062 were sent to RIPCA (26%), and 431 were sent to PICU (10.6%). Over a year-long period of telemedicine implementation, 212 patients used telemedicine and were analyzed. ED utilization decreased to 27% (p < 0.0001), PICU increased to 34.4% (p < 0.0001), and RIPCA rates remained the same at 28% (p = 0.203). Of ED dispositions, 58.6% were admitted to RIPCA for further care, 13.7% to PICU for escalation of care, and 24.1% were discharged. Of RIPCA dispositions, 10% had rapid responses; 0 had code blues. Of PICU dispositions, 90.4% had care escalation; 9.6% were observed in the PICU without escalation. Telemedicine use in transported pediatric patients can positively alter disposition patterns.

Abstract 2: Asthma Scores May Be a Reliable Tool to Determine the Need for Advanced Asthma Management in the Pediatric Patient

As a pediatric transport team, we notice patients at referring facilities with higher CAS scores waiting for transfer, often experience a deterioration of clinical condition as noted by an elevation of their CAS score. This score is used in conjunction with the Clinical Practice Guideline for Asthma Care in the Emergency Department to determine the need for transfer and care recommendations prior to patient arrival at our facility. Our team wanted to determine if the asthma score currently utilized at our facility was valid, reliable and consistent.

The effect of transport on the physiologic stability of neonates with ductal-dependent single-ventricle lesions

Objective: To compare the status of infants with hypoplastic left heart syndrome (HLHS) or pulmonary atresia-hypoplastic right heart (PA-HRH) before and following transport using the validated Transport Risk Index of Physiologic Stability (TRIPS) score.Methods: In this retrospective review of infants with HLHS or PA-HRH transported to a Children’s Hospital by a pediatric transport team, an increase in TRIPS score (temperature, blood pressure, respiratory status, and response to stimuli) following transport was defined as deterioration. Statistical analyses included t-test (paired and independent), χ2, and McNemar’s tests for comparisons between groups with and without deterioration and before and after transport.Results: Our cohort [n = 64; 39 (61%) HLHS and 25 (39%) PA-HRH] was predominantly female (61%), black (56%), and diagnosed antenatally (78%). Median transport time was 20 (10–30) min and age was <12 h in 48 (75%) infants. TRIPS scores worsened after transport in 24 (37.5%) infants, due to temperature (n = 10) or respiratory (n = 7) dysregulation. Infants who deteriorated during transport had HLH more often (83 versus 48%) and lower pH [7.27 (0.12) versus 7.33 (0.07)]. HLH was significantly predictive of deterioration during transport [OR 5.60 (95% C.I. 1.18–26.62)].Conclusions: The physiologic deterioration in a third of infants with single ventricle following short transports is intriguing and may have implications on their optimal place of birth.

Attitudes towards fever amongst UK paediatric intensive care staff

Staff on paediatric intensive care units in the United Kingdom and Ireland tends to treat temperatures within the febrile range. There was a willingness to conduct a randomized controlled trial of treatment of fever. What is known: • The effect of fever on the outcome in paediatric critical illness is unknown. • Paediatricians have traditionally been reluctant to allow fever in sick children. What is new: • Paediatric intensive care staff report a tendency towards treating fever, with a median reported treatment threshold of 38°C. • There is widespread support amongst PICU staff in the UK for a randomized controlled trial of temperature in critically ill children. • Within a trial setting, PICU staff attitudes to fever are more permissive than in clinical practice.

Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport?

ABSTRACTIntroduction: Studies show that pediatric trauma centers produce better outcomes and reduced mortality for injured children. Yet, most children do not have timely access to a pediatric trauma center and require stabilization locally with subsequent transfer. Investigators have demonstrated that pediatric transport teams (PTT) improve outcomes for critically ill children; however, these studies did not differentiate outcomes for injured children. It may be that moderate to severely injured children actually fare worse with PTT due to slower transport times inherent to their remote locations and thus delays in important interventions. Objective: The purpose of this study was to determine if outcomes for injured children are affected by use of PTT for inter-hospital transfer. Methods: We conducted a retrospective chart review of 1,177 children transferred to a pediatric trauma center for injury care between March 1st, 2012 and December 31st, 2013. We compared children who were transported by PTT (ground/air) to those transported by ground advanced life support (ALS) and air critical care (ACC). We described patient characteristics and transport times. For PTT vs. ALS and ACC, we compared hospital length of stay (LOS), transport interventions and adverse events. Results: 1,177 injured children were transferred by the following modes: 68% ALS, 13% ACC, 11% Ground PTT, and 9% Air PTT. Children transported by PTT were younger and had higher ISS and lower GCS scores. PTT had a longer total transport time, departure preparation time, and patient bedside time. After controlling for age, ISS, GCS, transport mode, distance, and time, we found no significant difference in LOS between PTT vs. ALS and ACC. A subgroup analysis of children with higher ISS scores demonstrated a 65% longer LOS for children transported by ACC vs. PTT. There were no differences between transport teams with regard to acidosis, hypocarbia or hypercarbia, or maintenance of tubes and lines. Conclusions: Children transported by PTT were younger and sicker (vs. ACC and ALS). Despite longer transport times, children transported by PTT did not have a longer hospital LOS or adverse events during transport. However, for those children with higher ISS, transport by ACC resulted in longer hospital LOS vs. PTT.

Improving Standardized Hand-Off Communication Through Education for a Pediatric Neonatal Critical Care Transport Team

Introduction: The Critical Care Transport Team at University of California Davis Medical Center Children's Hospital provides safe and expedient transport of critically ill children and neonates through collaboration with a Pediatric or Neonatal ICU attending physician (MCP). Clear and concise communication is essential in the care of these fragile patients. According to JCAHO, a standardized hand-off communication tool is necessary. It was determined that there was a need for a practice change and therefore an educational quality improvement project was initiated.