Use pediatric teams to transport children
By Barbara Coffel, RN, MSN
Lead Transport Nurse
Neonatal Pediatric Critical Care Transport Team
Riley Hospital for Children, Indianapolis
When an 18-month-old infant was transferred from a facility 28 miles away, the local hospital appropriately diagnosed meningiococcemia and started appropriate antibiotic therapy. What they didn’t recognize was that this child was in rapidly progressing shock and in need of fluid resuscitation. Additionally, she was in impending respiratory failure and needed an airway.
The child arrived in our emergency department (ED) with a panicky medic in respiratory and circulatory failure, dusky, and gasping. Her oxygen saturation was very low with poor respiratory effort and very low blood pressure. Her initial blood gas showed severe respiratory acidosis that improved after she was intubated and adequately ventilated.
Regardless of the cause, this child suffered a significant period of time with insufficient oxygen delivery to tissues and inadequate clearance of metabolites. Outcome is potentially poorer with every minute that end organ perfusion is inadequate. In this case, the infant required a prolonged stay in the pediatric intensive care unit and was on a ventilator for several weeks. The first organ to take a serious hit in shock states is the kidney. She was on continuous venovenous hemofiltration for renal replacement therapy for a period of time. Fortunately, she regained renal function and has done well.
No one could argue reasonably that this child received an appropriate level of care during her transport or that it did not adversely affect her outcome. What too often happens in pediatric transport is a lack of understanding that children are not just small adults. They are very different and, as such, require specialized care. Research has demonstrated that outcomes are better when transport is done by a specialized pediatric transport team.1,2
The education that the emergency medical services community receives is brief, and it is unfair to expect them to be experts in pediatric critical care. There are a couple of philosophies of transport. The first is "swoop and scoop," which applies to most air services, with the goal of transporting the patient as quickly as possible to a tertiary care center. The second philosophy is "stay and play."
Most pediatric teams prefer the latter. The intent is to transport the intensive care unit to the child, provide whatever is necessary to stabilize, and then transport him or her back to tertiary care. The problem arises when nervous staff just "want this kid out of my ED" and use whatever service is immediately available to do that. It is a fact that there may be a wait period while a dedicated team is en route to the referring facility. However, in the long run, the child receives the definitive intensive care that he or she requires more quickly.
Consider the very ill child who requires transport to a tertiary pediatric intensive care unit. The local hospital wants him or her to go as fast as possible and chooses a non-pediatric specialty team to transport the child. These teams most certainly provide expert adult care, but they frequently are out of their element with a child.
Cardiopulmonary arrest in infants and children rarely is a sudden event. It is most often the result of progressive deterioration in respiratory and circulatory function. No matter what the cause, the end result is cardiopulmonary failure and possible cardiopulmonary arrest. Once the child’s condition is allowed to deteriorate to this point, the chances of a positive outcome are drastically compromised.
The goal of caregivers must be to prevent deterioration resulting in a shock state that may compromise end organ perfusion and result in damage to vital systems. Caregivers accustomed to caring for adults may misinterpret when an irritable, restless child becomes quiet as "improving" when in fact he or she actually is worn out completely and arrest is imminent.
During the time that this child is being transported, there may be adverse effects on outcome, if the people transporting do not recognize a child that is in pending respiratory failure or in rapidly progressing shock. For those of us who specialize in critically ill infants and children, this is a quality of care issue.
It is the responsibility of ED staff and managers to be aware of local pediatric emergency critical care transport teams and know how to access them. An emergency transport should not be something that you think about in the heat of the moment. It should be well thought out ahead of time, because it’s not a matter of if you will need one, but rather when.
You also need to give forethought as to what your limitations are. For example, "we can take care of children with X amount of an oxygen need, but at X amount, we will refer this patient." It is also important, and I think frequently forgotten, that if you have a very ill child in your ED and have telephone access to the control physician at the tertiary care center, the child is better off to stay put until the transport team arrives.
Putting a child in the back of an ambulance in many cases decreases level of care, and that is never OK.
[Editor’s note: Coffel can be reached at Riley Hospital for Children, Clarian Health Partners, 702 Barnhill Drive, Room 1960, Indianapolis, IN 46202-5210. Telephone: (317) 274-4386. Fax: (317) 274-4354. E-mail: [email protected].]
References
1. Pon S, Notterman DA. Organization of a pediatric critical care transport team. Pediatr Clin North Am 1993; 40:241-261.
2. Selvan JS, Fields WW, et al. Critical care transport: Outcome evaluation after interfacility transfer and hospitalization. Ann Emerg Med 1999; 33:33-43.
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