89 13 Pediatric Critical Care Transport LAUREN RAKES, REID W D FARRIS, AND GEORGE A (TONY) WOODWARD • The goal of interfacility transport is to ensure critical care delivery to the patient, provide ac[.]
13 Pediatric Critical Care Transport LAUREN RAKES, REID W.D FARRIS, AND GEORGE A (TONY) WOODWARD PEARLS • The goal of interfacility transport is to ensure critical care delivery to the patient, provide acute and ongoing stabilization, and to anticipate disease progression as well as the evolution of respiratory failure and cardiovascular instability in a high-risk environment • For most disease processes, speed of transport should not take precedence over providing quality resuscitation • Transfer by specialized pediatric critical care transport teams may improve patient outcomes • Necessary components of a transport system include a standard communication process, appropriately trained team members, reliable equipment, continuing education, competency assessments, and quality and safety monitoring • The legal responsibility for selection of the interfacility transport process rests mostly with the referring facility However, the pediatric intensivist who acts as the medical control physician (MCP, also called medical command physician) can play an important role in assessing the situation (medical and logistical), recommending management, anticipating disease progression, and minimizing risk of deterioration of pediatric patients en route to tertiary care As pediatric emergency and critical care centers have become more regionalized, the need for quality interfacility transport increases More than 89% of pediatric emergency department (ED) visits occur in nonpediatric EDs, where the extent of illness or injury is assessed and initial stabilization is provided.1,2 Many community hospitals not have the personnel, facilities, provider/staff skill, or equipment to administer critical care to infants or children beyond the period of initial stabilization, necessitating transfer In transport, children may be subjected to a high-risk environment with limited resources and monitoring capabilities The goal during transport should be to minimize the risk of deterioration or secondary injury during transport while advancing the care initiated at the receiving facility For most pediatric critical illness, definitive care involves early and continued administration of standard therapies Many of these interventions, including timely initiation of resuscitation fluids, inotropes administered via peripheral intravenous line, and antibiotic therapy, can improve outcomes.3,4 If appropriate resuscitation waits until the transport team arrives at the referring facility or the child arrives in the pediatric intensive care unit (PICU), benefits of early action may be lost Therapies must begin before and continue during transport for the benefits noted in these studies to occur Significant barriers to realizing this ideal state exist, including the tension that exists between the need to transfer patients as rapidly as possible and the desire to make transfers as safe as possible This chapter summarizes the physiology relevant to pediatric transport, particularly air transport It is emphasized that a wellrun interfacility transport team that is focused on the specific needs of children can make a significant difference in patient outcomes Information about appropriate vehicles, medication, and equipment for transport is best summarized in the American Academy of Pediatrics (AAP) Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients.5 Pediatric Transport Systems In many regions of the United States, medical transport teams that emphasize adult care, such as emergency medical services (EMS) or regional flight teams (referred to as nonspecialized transport teams here), are scattered throughout the community, close to referring hospitals, whereas specialized pediatric transport teams are often located at the sponsoring tertiary care facility Because they are so accessible to referring hospitals, nonspecialized teams transport the majority of critically ill children Training and protocols of these teams may be primarily focused on the major causes of mortality in the adult population, such as myocardial infarction, stroke, and trauma, disease processes for which rapid transfer to definitive care is an important determinant of outcome.6 Pediatric intensivists coordinating interfacility transfers need to be aware of the concerns that lead referring physicians to prefer rapid transport by a nonspecialized team over transfer by a specialized pediatric team originating at the accepting facility These concerns are summarized in Table 13.1 Two independent studies reported that, as recently as 2003, only 6% of EDs were completely equipped to care for children.7 In an assessment of the compliance by EDs with nationally recognized guidelines on the care of children in EDs, improvements since 2003 were noted, although deficits in equipment and safety procedures remain common.8 Limited pediatric training coupled with infrequent exposure to pediatric patients may hamper the 89 90 S E C T I O N I I Pediatric Critical Care: Tools and Procedures TABLE Arguments Against and for Use of Specialized Pediatric Transport Teams 13.1 Against Use For Use Specialized teams take too long to get to the patient Concern for bed flow in small referring EDs and/or facilities without significant critical care staff/resources is real, but when we direct and provide goal-directed ICU care to the patient, the time to initiating time-sensitive therapies may be shortened Specialized teams spend too much time on the scene Scene time is necessary for stabilization, but the need for additional measures may be underappreciated by the referring hospital Much of this care can be anticipated, recommended, and directed by the transport medical command physician If the referring team is guided through and is able to provide the care suggested the transport team can then be more efficient with assessing the care provided and securing the patient for the transport process Time to definitive care is longer with When interventions only available at the accepting facility are the most important determination of outcome this may specialized teams be true; however, in general, with specialized team, total transport time has not been shown to correlate with negative outcomes Critical care delivery should start at the moment of contact by the referral center to the MCP It should not wait until team arrival or arrival at the referring center Adult teams have PALS training and can the same thing Nonspecialized teams often lack experience with children, may be less experienced in assessment of children, and may have difficulty maintaining learned skills with limited frequency of exposures Specialized teams are expensive and True, but pediatric critical care transport systems are an integral part of a tiered community response to the needs of resource intensive ill and injured children, many of whom not initially present to tertiary care, pediatric EDs, or pediatric critical care–capable hospitals Having a skilled process to allow for effective pediatric critical care regionalization is important and in the patients’ and communities’ best interest EDs, Emergency departments; ICU, intensive care unit; MCP, medical control physician; PALS, Pediatric Advanced Life Support ability of ED and EMS providers to respond appropriately to pediatric emergencies Fewer than 10% of all EMS runs nationwide involve infants and children, and a small percentage of these involve advanced life support (ALS) or critical care.9,10 Babl and colleagues demonstrated that, in a program with 50 active ALS providers, each provider is estimated to have one pediatric bagvalve-mask case every 1.7 years, one pediatric intubation every 3.3 years, and one intraosseous cannulation every 6.7 years.11 Without repeated reinforcement, providers’ knowledge and skills deteriorate over time.12,13 Underutilization of these skills may impact abilities as well as drive aversion to performing procedures in children Multiple investigators have documented a disconcertingly low percentage of successful intubations in children compared with adult patients.14–18 In a retrospective study comparing prehospital intervention of pediatric and adult patients with head injury, paramedics had difficulty with intubation in 69% of children compared with 21% of adults, and they were unable to establish IV access in 34% of children versus 14% of adults.19 These interventions are key components of resuscitation of the critically ill pediatric patient as respiratory insufficiency, seizures, and shock are common reasons for referral to tertiary care One study identified shock in 37% of children transferred to tertiary centers regardless of the reason for referral.20 It is increasingly recognized that rapid resuscitation is critical to the management of pediatric shock.21 Han and colleagues reported that, when community physicians aggressively resuscitated and successfully reversed shock before a transport team arrived, patients had a ninefold increase in their odds of survival.22 These studies defy the popular notion that pretransport stabilization and management wastes time and delays definitive therapy The MCP should recognize that the opportunity to provide pediatric critical care starts at the moment of contact from a referring provider and should not wait unit arrival of the transport team or patient arrival at the receiving facility Specialized Teams Improve Outcome In 1978, Chance and associates23 demonstrated reduced mortality and more stable physiology in neonates weighing less than 1.5 kg who were transported by a specialized team Since that time, several investigators have reported a decrease in the number of preventable insults in children transported by a pediatric critical care team compared with a multispecialty team.24–28 In a 2001 study of children transported with head injury, Macnab and colleagues determined that $135,952 in additional costs of care resulted from secondary adverse events occurring during transport by nonspecialized teams.29 In a prospective cohort study in which allocation of teams depended on team availability, not severity of illness, Orr and colleagues showed that use of a specialized team resulted in decreased severity-adjusted mortality (9% vs 23%) compared with use of a nonspecialized team.30 Similarly, a large retrospective study of unplanned PICU admissions demonstrated that transfer by a specialty team was associated with improved survival in a multivariable analysis controlling for severity of illness.31 Pediatric specialized teams often perform additional stabilization maneuvers at the referring facility prior to transport In a prospective observational study, pediatric teams initiated sedation 23% of the time, inotropes 44% of the time, and osmolar therapies for intracranial hypertension nearly 50% of the time when the referring facility had failed to so.32 Transport teams also initiated mechanical ventilation, acquired central venous access, and placed or adjusted tracheal tubes.30 Time at the bedside for specialized transport teams can be relatively long owing to these interventions, but scene time has not been associated with mortality.28 Meaningful stabilization and therapeutic interventions should also continue en route In a before-and-after intervention trial, introduction of a goal-directed resuscitation protocol decreased CHAPTER 13 Pediatric Critical Care Transport the number of interventions required in the ICU and decreased the hospital length of stay for pediatric patients transported with systemic inflammatory response syndrome.33 In a prospective randomized controlled trial, enhanced monitoring of blood pressure during pediatric interfacility transport resulted in more aggressive resuscitation during transfer, shorter ICU stay, and less organ dysfunction.34 Components of a Specialized Interfacility Transport Team Pediatric transport is part of a critical care continuum that includes EMS, the referring site of care, secondary transfer, and the receiving critical care facility An ideal system would provide excellent communication between the referring and receiving hospitals; give clear, efficient, and experienced advice to support the referring staff’s care; bring high-level critical care to the patient at the referring institution; and continue optimal care through transport and into the PICU Ideally, physicians and other caregivers from emergency medicine, neonatology, surgery, and intensive care all take an active role in designing each segment of the continuum and maintaining quality assurance The critically ill child ultimately will be the responsibility of the pediatric intensivist; thus it behooves the intensivist to have significant input into system design and protocols The specialized transport system has a responsibility to the referral community to make tertiary care widely accessible Differences in topography, weather patterns, and the distribution of hospitals and population centers mean that the ideal transport system will differ from region to region Regardless, a transport system should include a communications center, administrative staff, appropriately trained team members, reliable equipment, and a safety and quality improvement program Communications Ideally, a communications center should be easily accessible and staffed around the clock by communication specialists who are trained in handling emergency calls and who have no other distracting duties.35,36 The communication specialist should function as both an informational hub and someone who helps facilitate the conversations required to arrange all physical aspects of the transport These efforts should free the transferring physician, MCP, and transport team members to focus their attention on patient care Protocols may help to streamline the process and prevent errors The capability for ongoing communication between team members and the communication center throughout the transport process should be available A detailed log of transport requests, including times, demographic data, diagnosis, and vehicle issues, should be kept for both administrative review and medical-legal documentation Staffing The administrative staff of a transport system should include, at a minimum, a medical director, transport coordinator, and MCPs.35,36 The medical director should be a specialist in pediatric or neonatal critical care or emergency medicine This individual should be experienced in both air and ground transport (as appropriate to the specialist’s specific system) and should understand patient 91 care capabilities and limitations in the transport environment The medical director must be actively involved in the development and renewal of transport protocols; quality management; and the hiring, training, competency assessments, and continuing education of all transport personnel This individual must orient the physicians who provide online medical control to the policies, procedures, and patient care protocols and should act as a liaison to the referral community for teaching and outreach.35,36 The transport coordinator, usually a nurse or paramedic, collaborates with the medical director with regard to training, protocols, scheduling, data collection, quality management, and marketing The medical director and transport coordinator should participate in patient transport whenever possible to observe and assess the team capabilities and maintain clinical transport skills and perspective An MCP should participate in every transport and provide advice to the referring physician and transport team as necessary In many cases, the MCP will also be the receiving physician The MCP should be experienced in handling transport calls, obtaining focused information, and providing efficient and concise management suggestions for the period before arrival of the transport team The MCP should be knowledgeable about the availability of resources and have the ability to efficiently accept transferred patients without further consultation, to perform triage, and to activate backup systems when necessary Team composition and training strategies vary considerably among transport programs A two-person team composed of a nurse and respiratory therapist is the most common configuration for specialized pediatric teams.37 Transport crew members should be experienced in the care of critically ill pediatric/neonatal patients and be able to manage complex environments and limited resources They must be highly skilled in airway management, resuscitation, and vascular access They should have a fundamental knowledge of field priorities and be able to make decisions independently The team transporting a critically ill pediatric patient should include a team leader who is experienced in managing life-threatening illnesses or injuries in neonates and children, most commonly a transport nurse or advanced practitioner Routine physician presence on specialized transport teams in the United States was recently estimated to be low.37 All team members should have specific training in transport medicine, which includes methods of functioning in a moving environment, troubleshooting for equipment-related problems, and knowledge of aeromedical physiology as appropriate Each program should define the cognitive knowledge and technical skills required for each professional group and should include a method to document the acquisition and maintenance of these skills Instruction typically includes didactic sessions designed to assist personnel to acquire cognitive knowledge, a skill development and maintenance program, and a supervised orientation period Simulation has been shown to improve adherence to protocols in the training of crisis-response teams and may be a useful adjunct to team member training.38,39 Equipment For a thorough discussion of transport equipment and options, readers are referred to the AAP Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients.5 Equipment taken on transport should be complete and adequate to provide continuing intensive care throughout the trip Oxygen capacity and reserve should be calculated for each patient transported and 92 S E C T I O N I I Pediatric Critical Care: Tools and Procedures should be at least twice the amount needed for the expected duration of the trip in case of delays or equipment malfunction For air medical transport, weight and space restrictions must be considered when selecting equipment and range of medications Safety and Quality Improvement Safety should be a high priority in any transport program Emergency vehicle operation carries substantial risks, not only to the crew and patient but also to others in its vicinity Accidents that occur during medical transport are rare but can result in significant morbidity and mortality During ground transport, ambulance drivers should be discouraged from using lights and sirens to circumvent traffic rules, as there is no evidence to support a positive effect on patient outcomes.40 Aeromedical transport involves a unique set of safety issues Pilots who are under pressure to fly or who are sensitive to competition among aeromedical services within a region may fail to observe minimal weather standards, contributing to accidents Pilots should be isolated from patient care issues to give them the freedom to make sound decisions based on the flight conditions The transport team should be adept at survival techniques for their region and should always be prepared to deal with an off-airport landing Regular sessions to review safety and emergency procedures for each transport mode should be provided for the transport team members The Commission on Accreditation of Medical Transport Systems (CAMTS) has a long history as a peer review organization that aims to improve quality and safety of medical transport through a voluntary accreditation process that includes an application process, site surveys, and program evaluation.41 Regardless of membership in the CAMTS, a robust quality improvement (QI) program is an essential component to any transport team Elements of a strong QI program include chart audit and case review, compliance with national metrics, and a process for continuous improvement Twelve core quality metrics for pediatric and neonatal transport were identified by national transport leaders in 2015.42 In addition, the Ground Air Medical Quality in Transport (GAMUT) QI collaborative was founded in 2013, which established an international, multicenter database to facilitate tracking and benchmarking of transport-specific metrics.43,44 Stresses of the Transport Environment Interfacility transport is always risky for the patient Movement of vehicles and ambient noise make examination difficult and monitor function less reliable Each transfer of the stretcher or isolette from hospital to vehicle or between ambulance and aircraft adds potential for disruption of necessary tubes or devices Fear and anxiety produced by the transport environment can worsen some conditions; for this and other reasons, the authors recommend that a parent travel with the child as able In spite of the space and environment limitations, technologic advances have allowed some specialized transport teams to make the modern pediatric ICU mobile Advanced therapies—including inhaled nitric oxide, noninvasive positive pressure ventilatory support, and extracorporeal life support—are now routinely used in the transport environment.45–48 Air transport adds complexity and unique physiologic considerations Atmospheric pressure changes associated with increasing cabin altitude impact atmospheric—and therefore alveolar— oxygen tension as well as the volume of gas-filled spaces The United States Federal Aviation Administration regulations mandate cabin altitude less than 8000 feet in fixed-wing flight Most fixed-wing medical flights maintain a cabin pressure equivalent to 6000 to 8000 feet.49 Rotor/wing aircraft usually fly relatively close to the ground and not routinely have the ability to pressurize when they go to a higher altitude (when in an area of high altitude or crossing mountains) Atmospheric pressure drops from 760 at sea level to 565 mm Hg O2 at 8000 feet with a corresponding drop in the partial pressure of oxygen Predicting Pao2 at altitude is an inexact science; all that can be said conclusively is that patients with a marginal Pao2 at ground level will be worse at cruising altitude In practice the impact of a cabin pressure in this range can usually be overcome with supplemental oxygen.49 Oxygen should be used prophylactically in patients who are sensitive to alveolar hypoxia, such as those with reactive pulmonary hypertension Boyle’s law describes the relationship between pressure and volume of a gas at a given temperature The formula for Boyle’s law is: P1V1 P2V2 where P1 is the pressure at altitude 1, V1 is volume of gas at altitude 1, P2 is pressure at altitude 2, and V2 is volume of gas at altitude This relationship becomes clinically significant when considering gas-filled spaces during changes in altitude and the resultant expansion and contraction of those gases Common examples include gases present in the bowel, sinuses, and pleural space A change from sea level to 8000 feet will result in a 30% increase in volume of gases Even at altitudes used by rotorcraft (generally ,2000 feet above ground level), the relatively small volume of air in a tracheal tube cuff may be subject to clinically significant pressure changes Studies have shown that significant increases in tracheal tube cuff pressure occur in rotor/wing transports even when ground-level cuff pressures are appropriate.50,51 Tracheal tube cuff pressures should be measured and adjusted during flight Air removed at altitude may need to be replaced during descent In addition, most ventilators are calibrated for performance at sea level Tidal volumes delivered by the LTV 1000 (Pulmonetic Systems Inc.), a commonly used transport ventilator, may vary from 5% to 12% at a simulated altitude of 4000 and 8000 feet in volume control mode At 15,000 feet LTVdelivered tidal volumes may be 30% to 37% greater than set tidal volumes.52 Similar findings have been reported with the Drager Oxylog ventilator (Drägerwerk AG & Co.).53 In addition to the effects on atmospheric pressure, other challenges are encountered in the aeromedical transport environment Temperature drops significantly with increasing altitude, potentially complicating patient temperature regulation, especially for the smallest patients The noise and vibration produced by rotorcraft make auscultation and simple procedures nearly impossible Flight crews must rely on monitoring that does not depend on audible sounds, such as noninvasive blood pressure readings, capnometry, and pulse oximetry to assess patients in flight The main advantage of rotor-wing transport is the speed at which the transport team can be deployed and return with the patient Fixed-wing transport is most commonly used for long-distance travel or when weather conditions may not be appropriate for rotor-wing flights In addition, some fixed-wing aircraft have the capability to pressurize the cabin, thus mitigating the effects of flight altitude on the patient However, acceleration and deceleration forces during takeoff and landing can cause clinically significant fluid shifts In most aircraft the stretcher must be positioned head forward, which may cause blood to pool in the legs during acceleration or takeoff and in the head during deceleration of CHAPTER 13 Pediatric Critical Care Transport landing.49 In a patient with shock, raising the feet can minimize the decrease in cardiac output owing to decreased venous return associated with takeoff In a patient with increased intracranial pressure, the head should be raised during landing to minimize the increase in intracranial pressure associated with landing in this position Referring Hospital Responsibilities Transfer of patients from one institution to another in the United States is regulated by federal statute The current legal standard was established by the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 and its amendment in 1989, which created requirements for patient stabilization and transfer, guaranteeing equal access to emergency treatment to all regardless of ability to pay.54,55 The Emergency Medical Treatment and Labor Act (EMTALA) established by the COBRA legislation further delineates rules for interfacility transfer Appropriate transfers must meet the following criteria: (1) the transferring hospital must provide care and stabilization within its ability; (2) the referring physician certifies that the medical benefits expected from the transfer outweigh the risks; (3) the patient consents to transfer after being informed of the risks of transfer; (4) the receiving facility must have available space and qualified personnel and agree to accept the transfer; (5) copies of medical records and imaging studies should accompany the patient; and (6) the interfacility transport must be made by qualified personnel with the necessary equipment Under COBRA, the referring hospital bears primary responsibility for the safety of interfacility transfer Ideally, the decision about choice of team and mode of transport would be made jointly between the referring and receiving physicians Summary The potential limited pediatric training and pediatric critical care exposure and experience of nonspecialized transport personnel— coupled with the differences in size, anatomy, physiology, and psychosocial aspects unique to children—will continually challenge these providers The approach that prioritizes rapidity of transport over stabilization and initiation of care may not result in the best outcomes for children The need for pediatric-specific 93 intensive care begins long before the patient arrives in the tertiary care center Children transported by nonspecialized teams are at higher risk of transport-related adverse events and worse outcomes The primary goals in the majority of pediatric transports should be recognition of severity of illness, timely initiation of appropriate therapies, and providing a high level of clinical care with a focus on safety The unique perspective of the pediatric intensivist is valuable and can help to change practice in the referring community Key References AAP Section on Transport Medicine, Romito J, Insoft RM, Schwartz HP Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients Manual 4th ed Elk Grove Village, IL: American Academy of Pediatrics; 2015 Aspiotes CR, Gothard MQ, Gothard MD, Parrish R, Schwartz HP, Bigham MT Setting the Benchmark for the Ground and Air Medical Quality in Transport International Quality Improvement Collaborative Air Med J 2018;37:244-248 Cheema B, Welzel T, Rossouw B Noninvasive ventilation during pediatric and neonatal critical care transport: a systematic review Pediatr Crit Care Med 2019;20:9-18 Commission on Accreditation of Medical Transport Systems CAMTS https://www.camts.org/ Davis AL, Carcillo JA, Aneja RK, et al American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock Crit Care Med 2017;45:10611093 Gausche-Hill M, Ely M, Schmuhl P, et al A national assessment of pediatric readiness of emergency departments JAMA Pediatr 2015;169: 527-534 Ground and Air Medical Quality in Transport http://gamutqi.org/ Orr RA, Felmet KA, Han Y, et al Pediatric specialized transport teams are associated with improved outcomes Pediatrics 2009;124:40-48 Patel SC, Murphy S, Penfil S, Romeo D, Hertzog JH Impact of interfacility transport method and specialty teams on outcomes of pediatric trauma patients Pediatr Emerg Care 2018;34:467-472 Stroud MH, Sanders Jr RC, Moss MM, et al Goal-directed resuscitative interventions during pediatric interfacility transport Crit Care Med 2015;43:1692-1698 The full reference list for this chapter is available at ExpertConsult.com ... but the need for additional measures may be underappreciated by the referring hospital Much of this care can be anticipated, recommended, and directed by the transport medical command physician... interventions only available at the accepting facility are the most important determination of outcome this may specialized teams be true; however, in general, with specialized team, total transport... team arrival or arrival at the referring center Adult teams have PALS training and can the same thing Nonspecialized teams often lack experience with children, may be less experienced in assessment