How to make transport of children safer
When a 4-week-old, failure-to-thrive, dehydrated infant arrived at the emergency department (ED) at Children’s Hospital in Columbus, OH, after being transported by ambulance from another facility, the baby had decreased skin turgor and was tachypneic and lethargic, recalls Joyce Brezny, RN, RRT, clinical leader for the hospital’s children’s transport program.
The transporting crew did not recognize the clinical condition of the child, she explains. "The mother told us the physician at the referral facility didn’t want to wait for our team to get there," says Brezny. The child received a fluid bolus upon arrival, says Brezny. "Luckily, the trip was only an hour and 15 minutes," she adds. "There was a potential adverse outcome because of dehydration if it was any longer."
During pediatric transport, adverse outcomes including death can occur as a result of inappropriate medical care due to lack of pediatric experience, warns Denny Swick, RN, CEN, EMT-P, the facility’s emergency medical services (EMS) coordinator. Here are ways to improve transport of pediatric patients:
• Allow both facilities to make decisions about transport.
Swick advises allowing the receiving facility to assist in making decisions regarding air or ground transport and team composition. "If you are the referring facility, take an honest look at your transport capabilities," he adds. "A local EMS crew is probably not appropriate for transporting a critical child over a long distance."
• Comply with EMTALA.
Swick says he recalls several scenarios where the Emergency Medical Treatment and Labor Act (EMTALA) regulations were not followed appropriately. EMTALA requires that a patient must be transported by an "appropriate" crew, explains Swick, which he acknowledges is a subjective term. "However, if something negative occurred during a transport by a crew without specialized pediatric experience and resulted in injury to the patient, and the case went to court, it could be interpreted as an error in judgment and EMTALA violation," he says. Critical, unstable, or potentially unstable children need to be transported by a crew with pediatric critical care experience, Swick argues.
• Allow the patient’s guardian to be present.
A comprehensive past medical history and family history is necessary to give appropriate care en route to the facility, Brezny says. Parents can assist with this information and should accompany the transport team, she explains. (For more information on family members and pediatric transport, see "Bring parents along on air transport," in ED Nursing, July 2001, p. 118.) She adds that parents know best how to calm the patient. "We also have videotapes and DVDs that we can play en route, so it is helpful to know their favorite movies," she says.
• Address risk of hypothermia.
During the winter, pediatric patients are at increased risk for hypothermia, especially children with a large surface area-to-weight ratio and a lack of subcutaneous fat, Brezny warns. An isolette should be used to reduce the risks of hypothermia, which could increase the oxygen demand on an already compromised respiratory syncytial virus patient, she says.
• Don’t rush to transport the child out of your ED.
Most EDs that transfer pediatric patients want to get the child out of their facility as soon as possible, says Swick, and may subsequently make unsafe decisions about transport in order to accomplish this. "The truth is, this child is better off staying at that facility a while longer, under direct care of a physician, waiting for an appropriately staffed pediatric crew to arrive," he says.
He gives this example of a child who was transported by a local EMS crew as opposed to a pediatric transport team: A 6-year-old trauma patient was transported from a facility 130 miles away after a motor vehicle accident. "This patient had a couple of fractures and a history of loss of consciousness, but was deemed OK for transport by local EMS crew’ by the referring physician," says Swick.
Upon the patient’s arrival, the crew was alarmed to find a heart rate of 100 and blood pressure of 100/66. Assuming the child to be tachycardic and hypotensive, they administered two fluid boluses. However, based on the child’s size and age, these vital signs actually were within normal limits — the crew had used adult vital signs, explains Swick. "They assumed he was in or was approaching uncompensated shock, when his vital signs actually indicated that he was hemodynamically stable," he says.
Since the higher trained crew member was more comfortable driving fast, only an intermediate emergency medical technician remained with the child, Swick adds. "Due to their discomfort with the child, they made this 130-mile trip in one hour and 25 minutes," he reports. "This is typically a two and a half hour drive. Had the child actually decompensated en route, the results could have been disastrous."
Sources
For more information on improving pediatric transport, contact:
• Joyce Brezny, RN, RRT, Clinical Leader, Children’s Transport Team, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-6571. Fax: (614) 722-4778. E-mail: [email protected].
• Dennis Swick, RN, CEN, EMT-P, EMS Coordinator, Emergency Services, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-4350. Fax: (614) 722-6890. E-mail: [email protected].
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