Interfacility Pediatric Transport And Improved Outcomes
Interfacility Pediatric Transport and Improved Outcomes
Dominique Jean Larrey, a military surgeon, was the first to recognize the need for emergency medical services in the early 1800s (Welling, Burris, & Rich, 2006). He organized an ambulance system that included medics, aides, supplies, and food to care for the wounded during battles. His ideas continued to influence emergency medical services (EMS) long after his death in 1842. While today’s EMS provides an invaluable service to the adult population, pediatric patients only comprise about 10% of ground and regional flight EMS calls (Stroud, Prodhan, Moss, & Anand, 2008). Lack of experience, lack of appropriate sized equipment, and the EMS scoop-and-run mentality can lead to the under-treatment of critically-ill pediatric patients. While the EMS system has continued to evolve for the last century, neonatal and pediatric transport is a rather new concept that emerged in the 1970s (Ajizian & Nakagawa, 2007).
Due to the centralization of pediatric critical care in urban areas, pediatric patients in rural areas will present to outlying hospitals and require a transport to the nearest or best-equipped tertiary care center (Orr et al., 2009). These transfers are carried out by personal vehicle, local EMS, adult critical care team, or a specialized pediatric team. While a local EMS or adult team may expedite the transfer, they may not be in the best interest of the patient due lack of training and pediatric sized equipment. Pediatric specialty teams can vary in terms of scope and practice (Orr et al., 2013). Team members can include registered nurses, respiratory therapists, nurse practitioners, physicians, physician assistants, or paramedics. Training for team members can depend on their past experience and can vary but should include skills they will be required to perform, interventions they will provide, and the standards of care they will be required to follow. Procedures such as oral intubation, chest tube placement, intraosseous placement, and arterial line placement are performed by the team in less than ideal situations (Ajizian & Nakagawa, 2007). Team members are required to maintain competency of their high level skills as well as have advanced pediatric assessment skills and knowledge of the different medications used in pediatric medicine. A medical control officer (MCO) dispatches the team and directs care as he sees appropriate based on the team’s assessment. The goal of a specialized pediatric team is to bring the critical care environment of the pediatric intensive care unit (PICU) to the outlying hospital and to maintain that environment throughout the transfer. While the referral physician may prefer to use a local EMS or adult crew to expedite the transfer process, Orr et al. (2009) found that patients transferred by a pediatric specialized transport team had fewer unplanned events during the transfer process leading to better outcomes for the patient. Data specific pediatric transport is lacking, however, by examining different facets of EMS and pediatric specialty teams, do patients transferred by pediatric specialty team have improved outcomes?
The PICO question was developed from the following format: Population (P): Pediatric patients requiring interfacility transfer; Intervention (I): Transfer by a pediatric specialty team; Comparison (C): Transfer by local EMS or adult critical care team; Outcome (O): improved patient outcomes. The PICO question I have developed is: do pediatric patients transferred from by a pediatric specialty team have better outcomes than those transferred by local EMS or adult critical care teams?
A literature search was conducted utilizing the following electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systemic Reviews, and ProQuest. The following primary search terms were used, alone or in combination: pediatric transport, EMS, and pediatric. The search was supplemented by tracking citations and reviewing the reference lists to find primary studies. The resources were filtered to include those studies in English, peer-reviewed journals, and published within the last seven years. One primary study fell out of this time period, however, I find it to be a landmark study and have included it in my evidence. In order to answer the research question, the articles that were chosen correlate to pediatric interfacility transport, EMS knowledge of pediatric patients, and outcomes.
Summary of Evidence
Orr et al. (2009) hypothesized that pediatric patients transferred by a pediatric critical care specialty team would improve survival rates and experience fewer unplanned events during transfer than patients who were transferred by non-specialized teams. This cohort study compared patients who were transferred from outlying facilities to Children’s Hospital of Pittsburgh’s (CHP) PICU from January 2001 until September 2002. This study ranks a B on the AACN Evidence-Ranking System (Armola et al., 2009). Transport data including the patient’s age, vital signs, required interventions, and diagnosis was entered into the database within 24 hours of the transport. Interventions included fluid resuscitation of >20 mL/kg for hypotension or shock, use of resuscitative drugs, use of pressors, intubation, use of osmotic agents or sedation to decrease intracranial hypertension, chest tube placement, and central line placement. Unplanned events were also noted in the database. These included airway events, cardiac or respiratory arrest, pneumothorax upon arrival in the PICU, equipment malfunctions with patient deterioration, hypotension and/or hypoxia with no documented intervention, hypothermia, and medication-related events (Orr et al., 2009).
1085 patients were transferred into CHP during the study time period (Orr et al., 2009). 94% were transferred by the pediatric specialty team. 6% were transferred by a non-specialty team. Orr et al. (2009) found that patients who were transferred by the non-specialty team were at a much higher risk of experiencing an unplanned event during the transfer (p<0.001). Death was also more likely to occur either during transfer or in the first 28 days after transfer (p<0.001). This study does show that patients that were transferred by the pediatric specialty team experienced fewer unplanned events and were at a lower risk of death. There were several limitations on this study. Due to the amount of pediatric transports done by the specialty team, non-specialized teams may have less experience than those in a different geographical area. Patient bias was limited in that the same process for deciding mode of transport and which team would transfer the patient. This was a single center study only gathering data from interfacility transfer where the referral physician specifically requested the pediatric specialty team (Orr et al., 2009).
Stroud et al. (2015) hypothesized that pediatric patients that received goal-directed therapy during interfacility transport for the treatment of systemic inflammatory response syndrome (SIRS) have better outcomes than those who did not. Goal-directed therapy is defined as "a more definitive resuscitative strategy" with a goal-oriented strategy (Rivers et al., 2001). This cohort study compared pre- and post-intervention patient outcomes (Stroud et al., 2015). The data for this study was collected over a 20 month time period. This study ranks a B on the AACN Evidence-Ranking System (Armola et al., 2009). Demographics, illness severity, length of hospital stay, length of ICU stay, prevalence of multiple organ dysfunction syndrome (MODS), need for therapeutic ICU interventions, and mortality rates were collected (Stroud et al., 2015). The Angel One Transport team received education on the goal-directed resuscitative protocol prior to its’ institution.
Two hundred and forty-two patient encounters met the criteria to be included in this study with 7 patients who required 2 transfers during the time period (Stroud et al., 2015). The demographic and clinical data were similar in both the pre- and post-intervention group. There was a trend towards increased fluid resuscitation in the post-intervention group for patients with an increased mortality risk, however, it was not statistically significant (p=0.46). A significant reduction in hospital length of stay was noted in the post-intervention group who stayed an average of 3.5 days less than the pre-intervention group (p=0.02). Other outcomes were not found to be statistically significant, however, the authors felt with an increased sample size, these outcomes would be found to be statistically significant. Limitations of this study are that it was a single center study and was not randomized in design (Stroud et al., 2015). The sample size was small, however, this study would be easily replicated by other pediatric specialty teams as the Angel One’s team composition is similar to that of most teams in the country (Stroud et al., 2015).
Vos et al. (2004) compared interfacility transfers into four PICUs in the Netherlands. The authors hypothesized that patients who were transferred by non-specialized referring specialists required more interventions upon admission and experienced more complications during transfer. They also noted the availability of equipment and materials for the transfer. This study rated a B based on the AACN Evidence-Rating System (Armola et al., 2009). Data was collected for a seven-month period. 381 patients were transferred during this period, however, the authors only received complete data for 249 patients (Vos et al., 2004). 55% were transferred by a non-specialty care team. Age, Pediatric Risk of Mortality (PIM) score, admission diagnosis, and other physiological characteristics were collected for each patient. Critical complications were defined as loss or obstruction of the endotracheal tube, cyanosis, bradycardia, circulatory arrest, and hypotension. Serious complications included a decline in mental status, desaturation, hypothermia, hyperthermia, loss of venous access, tachycardia, and hypertension.
Patients transferred by the non-specialty team received more interventions upon admission with critical procedures such as endotracheal intubation (p=0.003), additional oxygen (p=0.001), and mechanical ventilation (p=0.003) (Vos et al., 2004). More interventions were done prior to transfer by the specialized team. Complications such as hypotension (p=0.015), cyanosis (p=0.025), bradycardia (p=0.068), and circulatory arrest (p=0.068) were significantly higher in the patients that were transferred by the non-specialty team. 12 of 37 patients with circulatory insufficiency transferred by a non-specialty team did not have blood pressure monitoring during transfer. All of the patients with circulatory insufficiency being transferred by the specialty retrieval team had an invasive blood pressure monitoring device. Non-specialty teams did not have the proper equipment for transferring pediatric patients much of the time. The lack of equipment for noninvasive blood pressure monitoring, suction, intubation equipment, or intraosseous needle placement and the lack of medications required for seizures and circulation disorders were all statistically significant in comparison to the equipment carried by the specialty care team (Vos et al., 2004). The characteristics of the patients were not statistically different based on the PRISM and PIM scores, which excludes bias for those transferred by the specialty team. The authors found that many of the patients transferred by the non-specialty team required intubation and mechanical ventilation immediately upon admission. These patients may have benefitted from more respiratory interventions prior to transfer, however, from personal communication with these teams, the most common reason for not providing more respiratory support during transfer was lack of skill, training, and equipment for pediatric ventilatory support. This study replicated in another area with a larger number of transfers may further strengthen the authors’ hypothesis (Vos et al., 2004). This study published in 2004 is beyond the seven-year data search, yet, the data remains pertinent to the research question and is frequently cited in more current articles.
Hewes et al. (2016) set out to evaluate how often EMS providers assess blood pressure, respiratory rate, heart rate, and pulse oximetry for pediatric patients and if education would increase the frequency vital sign documentation. This study ranked a B based on the AACN Evidence-Rating System (Armola et al., 2009). Vital sign data was pulled from the EMS POLARIS database for 2007 through 2014 for patients less than 18 years of age (Hewes et al., 2016). Three educational opportunities were developed after gathering the first three years of data. Improvement was seen in vital sign documentation after the education interventions, with pulse oximetry, becoming the most consistent at 90% in 2014. Blood pressure remained the most inconsistent with patients under the age of three lacking documentation of blood pressure <50% of the time (Hewes et al., 2016).
EMS agencies are required to put all obtained vital signs into the statewide database or they will receive a warning, therefore, it is unlikely that the missing vital signs were obtained and not documented (Hewes et al., 2016). One limitation of this study was that it did not include separation between ALS and BLS providers. This information may have indicated the severity of illness, the requirements for documentation, and available equipment at the time of transfer (Hewes et al., 2016). Further investigation into the lack of vital sign documentation should be done to increase the EMS providers’ knowledge about providing safe transfer of pediatric patients.
The purpose of this study was to understand current EMS practices and knowledge when transporting pediatric patients (O’Neil et al., 2014). A convenience sample was taken over a one-year period on patients who were transferred by EMS to the emergency department or outpatient clinic of a tertiary children’s hospital. A certified child passenger safety technician (CPST) was available at the tertiary children’s facility from 9am to 9pm. The EMS providers who agreed to participate allowed the CPST to observe how they restrained the patient in the ambulance and received a survey that would assess their knowledge and training on the child passenger restraint devices. This study ranked a B by the AACN Evidence-Level System (Armola et al., 2009).
The CPSTs observed 63 EMS providers transporting 40 pediatric patients (O’Neil et al., 2014). The EMS providers, on average, transport more than 20 pediatric patients per year. Only 30% of patients were transported with an age and weight appropriate device that was applied correctly. 32.5% of the patients were transferred using an inappropriate restraint device that was applied incorrectly with five of these patients being transported on the mother’s lap. 7.5% were transferred using an incorrect restraint device but it was used correctly. 27.5% of patients were transferred with the proper device but applied incorrectly. Incorrect application included loose harness straps, the chest clip being placed in the wrong position, or loose stretcher anchoring straps. >80% of the EMS providers queried stated that their service had specific guidelines for safely restraining pediatric patients. When appropriate devices were not available in the ambulance, the patients were often transferred on the mother’s lap. Limitations to this study included a small sample size from one area transferring to a large tertiary facility. The authors felt that the EMS providers may have not answered the questions on the survey honestly and gave answers that they felt were the right answers. This bias seemed limited, however, as the answers on the surveys did correlate with the data. CPSTs were only instructed to approach the EMS providers if the patient appeared to be medically stable. This in conjunction with not noting the patient’s diagnosis or reason for transport may have skewed the data (O’Neil et al., 2014).
Discussion and Conclusion
Based on the above studies, EMS providers lack the skill, education, and equipment to safely transport pediatric patients. Ambulance crashes occur an estimated 6500 times per year (O’Neil et al., 2014). Using improper restraining devices for the patient could lead to a catastrophic and unnecessary injury. Pediatric specialty teams carry all the necessary equipment for monitoring, treatment administration, and safety restraints (Vos et al., 2004). Blood pressure is a critical vital sign to document for pediatric patients as it may alert the care provider to the patient going into shock before other vital signs. Blood pressure and capillary refill time are used in the current guidelines for the treatment of shock in pediatric patients (Han et al., 2003).
A specialized pediatric team has advanced pediatric assessment skills and may recognize patient decompensation prior to the patient having an unplanned event on transfer (Orr et al., 2009). Specialty teams were noted by Orr et al. (2009) and Vos et al. (2004) to perform more interventions prior to transfer than the non-specialty teams. Stroud et al. (2015) found that patients that received goal-directed therapy, provided by the pediatric specialty team, received increased cardiovascular treatment during transfer and had fewer days in the hospital by 3.5 days.
The patient population and lack of predictability of interfacility transport make it difficult to do random and double blind studies. All studies ranked a B on the AACN Evidence-Level System (Armola et al., 2009). In the late 90s and early 2000s, many studies on pediatric transport were performed. Today, studies on interfacility transfer mainly look at best standards of care, team composition, and transport time. While these are all important, critically ill pediatric patients continue to be transferred by non-specialty teams because it usually expedites the process. Specialty care teams can be expensive and must frequently justify their need to the hospital or service they are owned by (Stroud et al., 2013). By continuing to compare data for specialty teams and improved outcomes will further strengthen the need for pediatric teams.
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