Pediatric Intensive Care Transport

Jonathan Cu, MDPediatric Emergency SpecialistNeonatal and Pediatric Critical Care Transport Specialist

Neonatal and Pediatric Intensive Care Transport Unit

Neonatal and Pediatric Intensive Care Transport

Unit

Goal and Objectives

Give a background on pediatric intensive care transport

Understand the goals and principles of pediatric transport

Identify the basic components of a pediatric intensive care transport team

Recognize factors involved in choosing various modes of transport

Case 1

37/F, pregnant, 28 weeks AOG

2-week vacation in far flung rural area

Went into preterm labor

Brought to community hospital and delivered

Outcome: preterm 28 weeks 800grams AGA delivered via SVD, live baby boy, APGAR 4,6

Case 1

Patient has poor activity, gasping, HR 140, pink centrally but has poor distal perfusion, Temp 34C sats 85%

Problem: no local neonatologist/intensivist and no ICU facilities

Local doctor were able to thermoregulate, give O2 support but has difficulty cannulating and reluctant to perform endotracheal intubation

Asking for help from tertiary referral centre

Case 2

3/M vacation in a beach with family

Near drowning, submerged for 5 minutes

Initially HR 0

CPR performed for 10 minutes with ROSC

Paramedics arrived, intubated the patient and transferred to a local hospital

Case 2

Upon arrival in ED of a local hospital, having hypotensive episodes and desaturations while on ambubagging

Problem: no local ICU facilities and no intensivist available

Called a tertiary referral centre asking for help

Problems

What can we offer in a community hospital setting

Who to talk to and how to refer to a tertiary referral centre

Who will arrange for an ICU bed

Who will coordinate for a safe transfer

What can we do for the patient while waiting for help to arrive

Bahala na si…

Neonatal and Pediatric Intensive Care Transport Unit

Specialized service dedicated in providing intensive care to critically ill child anywhere at any time

Provide expert clinical advise

Clinical coordinator

Emergency treatment and stabilization

Bringing ICU to the patient

Interhospital transport

Background

In the United States, Australia, UK and Canada, hospital-based neonatal transport programs were first created in the 1960s and 1970s

Similar programs for older infants and children emerged in the 1980s

Became well-developed in countries with a centralized healthcare system

Background

Neonatal-pediatric transport programs part of the continuum of care in a system of emergency medical services for children

They provide a safe, therapeutic environment for pediatric patients who must be transferred between health care institutions under urgent or emergent circumstances

Diagnostic Categories Of Children Transported

Specialized transport team vs. Paramedics

Paramedics Primary retrievals

Not equipped

Not trained in handling intensive care

Scoop and run principle

Specialized transport team

Secondary/hospital retrieval

Adequate planning and equipment

Intensive experience in ICU/Emergency care

Early goal-directed treament

Bringing ICU to the patient

The Tortoise and the Hare

The Golden Hour

Concept originated in 1973 by Cowley et al.

Referred to Army helicopter use Goal for soldiers to be within 35 minutes of

definitive life-saving care Stated a 3 fold increase in mortality

with every 30 minutes away from ‘definitive care

No available data to support claim Resulted in less field intervention in

favor of speed of transport Interventions on transport in 1973, not

comparable to our capabilities today

Pediatric arrest

Primary cardiac arrest in infants and children is rare

Pediatric cardiac arrest is often preceded by respiratory failure and/or shock and it is rarely sudden

Early intervention and continued monitoring can prevent arrest

The terminal rhythm in children is usually bradycardia that progresses to PEA and asystole

Septic shock is the most common form of shock in the pediatric population

80% of children in septic shock will require intubation and mechanical ventilation within 24 hours of admission

Interesting facts…

EMS programs for paramedics offers <10 hours pediatric training

No pediatric blood pressure cuffs (24%)

No pediatric airway equipments (79%)

Seidel JS et al. Circulation 1986

Interesting facts…

According to AAP, average EMS provider sees:

1 peds BVM case q 1.7 years

1 peds intubation q 3.3 years

1 peds IO line q 6.7 years

Interesting facts…

Paramedics were less confident in assessing vital signs for <2 years old

Children <14 years old undertreated as compared with adults

Gausche M et al, Acad Emerg Med 1998

Twice as many patients transported by standard paramedic/ambulance service died in the first 12 hours after admission

Bellingan G et al, Intensive Care Med 2000

Orr RA et al, Pediatrics 2009

Specialized Pediatric Transport Team

Fewer unplanned events (61% vs. 1.5%), 38 times higher for patients transported by nonspecialized team

Significantly lower mortality rate (23% vs. 9%), >2 times higher for patients transported by nonspecialized team

Orr RA, et al, Pediatrics 2009

Intensive Care Med 2004

Intensive Care Med 2004

Intensive Care Med 2004

Siriraj Hospital (Thailand)

Retrospective review of interhospital transport

Total number transported from 2001 to 2003: 36

All road transfers

Accompanying medical personnel: nurses (55%), the rest paramedics

63.9% intubated, 28% ongoing inotropes

J Med Assoc Thai 2005

Siriraj Hospital (Thailand)

Upon arrival, none of the patients had any record on important patient’s data (no vital signs monitoring, oxygen saturation or adverse events)

77.8% needed prolonged PICU stay

31% mortality rate

J Med Assoc Thai 2005

Goal of Pediatric Intensive Care Transport

Early direction and initiation of advanced care Treatment and monitoring with the expected

expertise and capabilities of the tertiary care center while the patient is still in the referring facility

Improve safety of the transport and patient outcome.

Initiation of ‘definitive’ care Definitive care begins with the arrival of

the transport team Early goal directed treatment improves

outcomes Needs to begin with the local emergency

departments and continue with the transport team

Early aggressive interventions to reverse shock can increase survival by 9 fold if proper interventions are done early!

Hypotension and poor organ perfusion worsens outcomes

“Further improvement in the outcome of critical illness is likely if the scoop-and-run mentality is replaced by protocol driven, early goal-directed therapy in the pretertiary hospital setting”

Stroud et al., 2008

Initiation of ‘definitive’ care

Ramnarayan (2009) Urgent vital interventions such as CPR,

intubation or central venous access required in the first hour after arrival in an ICU

May indicate that inadequate stabilization was completed during transport

McPhearson and Graf (2009) Attention to small details makes significant

difference in pediatric transport Securing ETT Early recognition and treatment of shock Adequate IV access

Essential components

Dedicated team proficient at providing neonatal and/or pediatric critical care during transport

Essential components

Medical control by qualified physicians Ground and/or air ambulance

capabilities Communications/dispatch capabilities 24/7 availability Written clinical and operational

guidelines

Essential components

Quality and performance improvement activities

Administrative resources Institutional endorsement and

financial support.

Med Control Physician

PEDS ER or PICU consultant with sufficient knowledge and experience in transport medicine

Accepts pt, consults subs

Sends appropriate team

Directs stabilization

Provides ongoing direction to transport team

How does it work?

Clinical Coordinato

r

Team Composition

Depends on the patient’s needs determined in consultation with

the team and medical control Dedicated pool of qualified

physicians, nurses, paramedics and/or respiratory therapists

Team Composition

Retrieval specialist

Critical care nurse / Nurse Practitioner

+/- Respiratory therapist

Ambulance driver/pilot

Team Composition

A team member’s degree is less important than his or her ability to provide the level of care required

Critical care during transport conditions is significantly different from an ICU or ED

Team Composition

Should not be assumed that a health care professional who is competent in the ICU or ED will function equally well in a mobile environment

Equipments Modified Stretcher/Incubator system

newborn, infant, toddler, adult system

Backpacks - ABCs

Medication bag – inotropes, surfactant, etc…

Syringe / infusion pumps with long battery life

+/- nitric oxide machine

Ambulance fitted with oxygen(4500L) and air(4500L), Zoll defibrillator, Laerdal electric suction, transilluminator, charger, refrigerator

Communication devices

Mode of Transport

Road Ambulance

Rotary wing

Fixed wing

Vehicle selection

Ground – space and option to stop

Fixed Wing – stability in bad weather

Helicopter – land at scene, speed

Determining mode

Four critical steps necessary for selection of the optimal mode Evaluation of the current patient status Evaluation of care the required before

and during transport Urgency of the transport Logistics of a patient transport (e.g.,

local resources available for transport, weather considerations, and ground traffic accessibility)

Ground Vs Air

Beyond 100 miles, a ground may become inefficient, costly to operate, and time consuming

Helicopter is used for up to 150 mile radius Fixed wing greater than 150

Ground Vs Air

Distance to the closest appropriate facility is too great for safe and timely transport by ground ambulance

The potential for transport delay that may be associated with the use of ground transport (e.g., traffic and distance) is likely to worsen the patient's clinical condition

Key Points

Good communication = good decision-making

Adequate resuscitation and proper stabilization prior to transport

Expect for the worst case scenario

Retrieval team’s worst nightmare –

Resuscitation / Arrest en route

Back to Case 1

Fortunately, there is an available Neonatal and Pediatric Intensive Care Transport Unit

Conference call made with the neonatologist oncall

Referring physician advised to keep the baby thermoregulated, instructed to use neopuff and gave step by step instruction on how to put an umbilical line to provide fluids and glucose while the retrieval team was being mobilised.

Back to Case 1 Upon arrival, patient was intubated, sedated, given

surfactant and connected to transport ventilator.

Vitals: HR 140 BP 70/40 sats 95%

Temp 36.5 C CRT 2secs

CXR done

Blood gas taken with iSTAT

Transferred to transport incubator

Brought back to tertiary referral centre uneventful

Back to Case 2

Conference call with PICU was arranged while to retrieval team went en route

GCS 3, HR 120, intubated on ambubagging, BP 70 systolic, CRT 3-4 secs.

Advised to give bolus of 20ml/kg pNSS and to start Dopa at 10mcg/kg/min

BP and perfusion improved

Back to Case 2 Team arrived within 1 hour

Hooked to transport ventilator, sedated and paralyzed

oxygen saturation improved and blood gas acceptable

Central line inserted for IV fluids and inotropes

Arterial line inserted for BP monitoring

Maintained on Temp 33-34 C

Transported back to tertiary referral centre uneventful

Stayed in PICU for 7 days and transferred to regular bed after with no neurologic deficit

Do we need a Specialized Transport System?

Utility vs Futility

The benefits of transport must outweigh the risks for the patient

limited space, equipment, staff

separation from family

The risks/costs of transport must be justified

Cost

The approximate cost of a medically configured ground ambulance is approximately $150 000 to $350 000, depending on the manufacturer and model selected

The annual maintenance and fuel costs might range from $10 000 to $25 000 per vehicle

Cost

Single-engine helicopter A‑Star or Bell 407 averages $2 million.

A light twin‑engine helicopter EC145 and Bell 430, both medium‑sized twin engine helicopters, cost between $4 and $6 million

While a large twin‑engine helicopter about $1-2 million more

Cost

Pilot salaries range from $60,000 to $85,000 annually; a staff of four is required to cover 24/7

Financial concerns include fixed and variable costs Fixed costs include insurance, taxes,

crew costs, overheads, interest, hanger fees and capital equipment

Variable (hourly) costs vary directly with the number of hours flown. These costs include fuel and oil, scheduled maintenance labor, etc

Cost Effectiveness

Cost effective for a centralized health care system Composed of a single retrieval unit covering for

the whole state Expensive to maintain but less costly than to put

up pediatric ICUs in rural hospitals

US retrieval system mostly hospital-based Improved patient outcome Patient transport safety Less expensive to maintain

What if Case 1…

Grandson of a business tycoon?

What if Case 2…

Child of a celebrity?

Questions?

Thank you!