Dr Mok Yee Hu - Transport of the sick child
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Dr Mok Yee Hui relates her experience and gives a rundown on the complicated task known as paediatric retrieval
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Dr Mok Yee Hu - Transport of the sick child
- 1. Transport of the Sick Child Mok Yee Hui Children’s Intensive Care Unit Department of Paediatric Subspecialities 13th April 2014 1
- 2. Overview 1. Evolution of transport 2. The “need for speed” 3. What’s special about specialized teams? 4. All about us 2
- 3. 3 The “golden hour”
- 4. Transport scene • Scene primary medical care facility • Medical care facility specialist centre • ICU Other departments 4
- 5. Primary and secondary transports • Early goal directed therapy in the ED – Sepsis and septic shock • Early goal-directed therapy in the treatment of severe sepsis and septic shock. Rivers et al. NEJM 2001 • Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Han YY, Carcillo JA, Dragotta MA et al. Pediatrics 2003 5
- 6. So are all transports the same? • Scene-related trauma vs inter-facility transport • EMS personnel vs specialized personnel • “Scoop and Run” vs “Stay and Play” • Adults vs paediatric/neonates 6
- 7. Overview • Evolution of transport • The “need for speed” • What’s special about specialized teams? • All about us 7
- 8. Pediatric specialized transport teams Providing as high a standard of intensive care as is available on the intensive care unit 8
- 9. 9
- 10. 10
- 11. Evidence we should exist? • Less risk of adverse events • Improved survival regardless of time taken or distance travelled • Survival benefit independent of stabilization time 11
- 12. 12 Paediatric critical care transport
- 13. Specialized paediatric transport team composition 1. Trained personnel – Individuals with skills and experience that best meets the needs of the patient – Dependent on resources available 1. Specialized equipment 2. Transport vehicles – Ground ambulances, fixed or rotary wing aircraft, water vehicles 1. transport co-ordinator – Emergency care or critical care specialist 13
- 14. Paediatric critical care personnel • Transport Medicine • Paediatric Medicine • Critical Care medicine • Multi-disciplinary communication skills and ability to anticipate and react to rapid change in a high stress environment 14
- 17. Kids aren’t small adults • Anatomy • Physiology • Disease processes • Drug doses 17
- 18. Critical Care experience • Skills • Knowledge – Critical care physiology – Use of invasive monitoring – Mechanical ventilation in children • Equipment – Appropriately sized – Mechanical ventilators 18
- 19. Pediatric Specialized Transport Teams • Transport physiology • Paediatric specialty experience • Critical care skills 19 • Transport time of specialty team • What service is required • Economics • Risk-benefit ratio
- 20. Pediatric Specialized Transport Teams • Early goal directed therapy (and stabilization) • Specialized skills and knowledge • Equipment • “Stay and Play” – Extension of the PICU 20 Why?
- 21. Overview • Evolution of transport • The “need for speed” • What’s special about specialized teams? • All about us 21
- 22. KKH Children’s Emergency Transport Service (CHETS) 22 <Insert cover image here>
- 24. • 90-100 missions/year • Local “Out of door”: 15- 30 min • Stabilization: 15 min – 5 hours • “Mobile ICU” 24
- 25. • 35% of patients required interventions on-site • 7.4% IA lines, 2.7% CVL, 6% ETT change/insertion, CPR 1% • 56% on mechanical ventilation, 12.6% on vasoactive medications 25
- 26. ECMO transport • development of a formal protocol • currently still case-by-case basis for off-site cannulation • Close co-operation with CTS surgeon and referring hospital team • Capabilities for intra-hospital transfers 26
- 27. “To improve the outcomes of critically ill or injured paediatric patients who are not in proximity to a hospital that provides the required level of care.” - AAP guidelines on pediatric interfacility transport 27
- 28. To the dedicated staff who make this service possible 28 Thank You
Editor's Notes
- Thank you for the kind introduction. I’d like to thank the organizers for inviting me to speak today on the transport of the sick child. I realize I stand between you and lunch, so I’ll try to be short and sweet. Critical care transport has evolved significantly over the last 2 decades. The increasing focus on the specialized transport of the critically ill child has led to improved outcomes and decreased transport-related adverse events in this vulnerable group of patients. This little dumpling here is just one of the hundreds of ill children we have transported over the last 10 years.
- In the next 15-20 minutes, I’ll be talking about the evolution of transport, and why “the need for speed”’ may not always be the standard approach to ALL transports. I will also touch on what constitutes a pediatric critical care transport team; and why it leads to improved outcomes. Finally, I’ll share a little on the transport service that KKH provides locally and regionally for the transport of critically ill children.
- The concept of “the golden hour” is not new; and has been used in the context of many medical emergencies such as acute myocardial infarcts, traumatic brain injuries and septic shock. In transport medicine, the golden hour refers to that “life saving” critical few hours where the swift recognition and treatment of disease or injury, results in maximal improved outcomes. These interventions are often not available at the scene, and thus require quick stabilization of the patient to allow transfer to an appropriate medical facility. The concept of a specialized transport system was first described during Napoleonic wars in the 1800s with injured soldiers on the battlefield; and modern specialized transport systems arise from a military history. In the early 1960s, neonatologists began to apply these military transport concepts to transfer infants needing tertiary level care. The origins of our pediatric critical care transport teams evolved from the initial neonatal foundations in the 1970s.
- The transport can thus be divided into: PRIMARY transport: where Transport is usually carried out by EMS personnel from scene to a primary medical care facility where early goal directed therapy is initiated. This usually demands the “Swoop and Scoop” approach to minimize delay to medical treatment. The result is a patient, who is often transported at high speeds, with desperate urgency. Such an approach, however, is rarely appropriate for secondary transfers. SECONDARY transport: then really refers to the Transfer of a patient between hospitals or hospital environments. This may consist of movement of the patient to an intensive care unit, or from an ICU to other areas such as diagnostic imaging or the operating theatre. The overall approach of such secondary transports is one of meticulous preparation and anticipation of adverse events. This may include resuscitation and stabilization of patients prior to transfer, and is often described as a “Stay and Play” approach. (click mouse): Intensive care retrievals are almost universally secondary transports, and as such, should be conducted methodically.
- One of the reasons for the difference in approach between primary and secondary transports is the ability to implement early goal directed therapy, as opposed to spending time on a hasty transfer without first resuscitating a potentially unstable patient, when resources are actually available to do so. The concept of Early Goal Directed Therapy is not new. In Dr Emanuel Rivers’ landmark trial in 2001 on patients with sepsis and septic shock in the emergency department, early goal directed therapy targeting restoration of tissue perfusion, demonstrated significant survival benefit. This has been further corroborated in other studies in emergency departments. Early goal directed therapy has also been demonstrated to improve mortality in neonates and children with sepsis; and doesn’t require a specialist to initiate. In a paediatric paper in 2003, goal-directed therapy in the emergency department provided by community physicians aimed at shock reversal improved survival by nine-fold.
- So… are all transports the same? This is a no-brainer, the answer has to be no. There are fundamental differences in whether it is a primary or secondary transport, who the transport personnel are, what the approach to the transfer is, and who is the patient demographic being transferred. These differences necessitate an individualized approach to transport based on patient, location, and transport team capabilities.
- What then is special about paediatric specialized transport teams, and why can’t any doctor or nurse perform a transfer for a critically ill child?
- As described by the American Academy of Pediatrics, the aim of a pediatric specialized, or critical care transport team, is to provide as high a standard of intensive care as is available on the intensive care unit. I often tell my transport staff; if you’re stand there, assessing a patient and wonder if you should proceed with an intervention, stop and ask yourself if this is something you would do if the patient were already in the ICU. If the answer is “yes, I would”, then proceed with the intervention… but tell me first
- In a single centre prospective cohort study conducted at the Childrens’ Hospital of Pittsburgh and published in 2009; just over 1000 infants and children with requests for retrieval within a 240km radius were studied. In view of limited resources, in the event of the unavailability of the pediatric critical care transport team, a non-specialist air medical team was deployed instead; in the event of multiple simultaneous calls with limited team availability, the patient judged to be the most critical was assigned the specialist team. (click): In this cohort, patients transferred by the specialized team had significantly longer total transport times. (click): Despite a similar distribution of diagnostic categories, patients transported by a nonspecialized team had significantly worse pre-ICU PRISM scores. PRISM, or pediatric risk of mortality score, is a scoring system based on a composite of 14 variables, which in this case, was measured in the 24 hours prior to ICU admission (and in these patients represented the time during the transfer period and at the referral hospital). Unplanned events were more common in non-specialized team transfers, as was mortality. (Click): When adjusting for the pre-ICU PRISM scores, the presence of a non-specialized team was a statistically significant predictor of more than 1 unplanned event occuring during transport. This was also true for the prediction of in-hospital death.
- In a paper published in Lancet in 2010, the authors from Children’s Acute Transport Service, Great Ormond Street Hospital retrospectively studied the outcome of children transferred from local hospitals to PICUs in England and Wales over 4 years. Of an impressive 57, 000 admissions, approximately 33,500 were unplanned admissions, and nearly half of these were trasnfers from other hospitals. Patients transferred by specialized versus non-specialized teams had similar PRISM scores at admission, but those transferred by specialized teams subsequently required higher resource use (invasive ventilation, vasoactive drugs, renal replacement therapy) than non specialized teams. Despite this, the use of a specialist team for transfer was significantly associated with higher ICU survival rates; while additional distance travelled to PICU was not associated with risk of mortality.
- Is there evidence that paediatric critical care teams are effective? Definitely. Evidence demonstrates that outcomes for critically ill children improve dramatically when treatment is provided by skilled paediatric specialists, and that’s really because initiation of intensive care starts when the team arrives, not when patient arrives at the receiving hospital. There’s less risk of adverse events peri-transfer, improved survival regardless of distance or time taken; and the survival benefit is independent of duration of stabilization time.
- So, what comprises paediatric critical care transport then?
- The components of a pediatric transport team includes 3 to 4 main arms -&gt; trained personnel -&gt; this is usually in the form of staff trained in transport and paediatric medicine, with critical care or emergency care skills. Specific additional skill sets include familiarity with logistical difficulties that may be encountered (and this includes issues with oxygen supply, fluids, drugs, electrical supply). The team also needs to be familiar with the vehicle used and the idiosyncrasies of the purpose-built equipment that they carry. This knowledge needs to be sufficient for them to solve logistical or technical problems that would otherwise be delegated to others in a hospital environment. 2. Specialized equipment may consist of ICU-capable ventilators, invasive catheters and drains, and monitors capable of invasive haemodynamic monitoring. 3. Transport vehicles are dependent on where the patient is: all local transfers occur by road ambulance, and use of aircraft vs water vehicles depends on what is available regionally. I have transported a patient from Maldives, where part of the journey was via those tiny boats that shuttle between islands, and I remember wondering, how would I report the loss of a piece of equipment to my unit sister, if it fell into the Indian Ocean… thankfully that didn’t happen. 4. For an effective transfer, there should be a transport plan in place with clarity on the who’s (who’s the patient, who’s the referring doctor, who’s arranging ground and air logistics); on the what’s (what’s wrong with the patient, what support is he on; what potential interventions is he likely to need); and the where’s (where is the patient, where’s the receiving hospital, what’s the distance btw); there should be a detailed hand-off between referral, transport and receiving physicians; and ideally a single transport co-ordinator to provide oversight to all aspects of the transfer process. This is usually an emergency or critical care specialist.
- The personnel require skills and training in transport medicine, pediatrics, critical care and must have the ability to manage multi-disciplinary communications, and be able to react and respond appropriately to rapid changes in a high stress environment.
- Transport medicine can be a separate field or specialty on its own. (click): I think this is New Delhi, we’re on the tarmac at a refueling stop. This is one of the air ambulances we commonly use for our international transfers, the learjet 45, an extremely small plane. The environment during patient transports often colludes to thwart attempts at providing an equivalent standard of intensive care in a hospital setting. (next slide): This is the inside of the lear 45 (explain the slide). It’s small, and cramped, and inevitably chaotic. Space constraints cause physical discomfort, and restricts access to the patient, especially when coupled with blankets, straps to hold the patient down, tubings, drains and catheters. Cramped environments may also be exacerbated by low light conditions which further aggravate the sensory deprivation of the transport team. Motion disturbances during transport are often unpredictable (such as turbulence on a flight or the sudden braking of an ambulance); this can result in team related issues such as nausea and fatigue; it may also cause patient related incidents such as tube dislodgement; or equipment, baggage or passenger movements which may pose a danger to all within the vehicle. The vibration and low-frequency high amplitude motion (such as that produced by engines) also aggravate motion sickness and fatigue; and can disrupt many modes of patient monitoring such as pulse oximetry, cardio-respiratory monitoring and oscillometric blood pressure determination. Ambient noise also impairs communication, and blunts the response to auditory cues from patient monitors and alarms. Altitude also affects gas tensions and volumes at different levels, and this is particularly important in patients with pneumothoraces, bowel obstruction, sinusitis, cuffed endotracheal tubes and tidal volumes deliverable by pressure-regulated ventilators. Fixed wing aircraft can also subject patients to marked acceleration and deceleration forces, which may have haemodynamic or regional effects (eg. Cerebral blood flow, depending on where the head of patient is placed).
- The transport team also has to be mindful of safety; both to patient and to the team. Equipment can be heavy. Very heavy. I don’t know about you, but our porters at KK are often these nice old amahs and uncles, and they come with us for our transports. Why, I’m not sure. I always worry the porter or my ambulance driver will get a slipped disc while lifting our transport decks. If not strapped securely, equipment such as oxygen cylinders, battery packs, infusion pumps can become lethal projectiles in the event of sudden movements. Especially peculiar to pediatrics, the team transports not only the patient, but oftentimes their family as well. The team’s actions are always visible to the family during the transfer, and they often have to manage the stress and delicate communications with referring physicians, highly anxious family members and between transport team members in a professional manner.
- Kids aren’t small adults; they differ in basic anatomy as well as cardiopulmonary physiology. Children respond differently than adults in the face of haemodynamic instabiliy; and have much less respiratory reserves than adults in the face of respiratory pathology. Disease processes are also remarkably different; and hence therapeutic interventions: an adult with respiratory distress is unlikely to have the same pathology as a neonate with respiratory distress. Drug doses are also another issue: for adults, 1 vials or ampoule is usually equilvalent to a single standardized adult dose. Children vary in size and weight from 500g to 60kg; so adrenaline can be 0.3 ml or 5 ml depending. Pharmacokinetics are also different depending on their age; neonates can have a degree of renal tubulopathy, and the cytochrome p450 system activity varies according to age.
- To be able to continue to provide ongoing intensive care to a critically ill child, the transport team needs to have critical care skills and knowledge, this includes the ability to provide advanced airway support, central line access and monitoring, continuous arterial pressure monitoring, prescription and titration of vasoactive agents.
- Ultimately, though, whether a pediatric specialized transport team is needed (with its ability to provide aggressive continued intensive care interventions and monitoring throughout the transport process) has to be balanced with how long it’s going to take to get there, whether the patient really requires critical care interventions, and unfortunately, in our regional setting, the economics of the transfer.
- I’ll end off this segment with a quick summary: the benefits of a pediatric specialized transport team include provision of early goal directed therapy and stabilization, with the benefit of specialist skills, knowledge and equipment, and ultimately, the ability to start providing critical care treatment
- I’ll end off with a quick introduction to our hospital’s emergency transport service.
- KKH children’s emergency transport service has provided emergency transport for critically ill infants and children since 2004. Its team comprises of a paediatric or neonatal critical care trained physician and critical care nurse, with specialized equipment and customized transport decks.
- In our 10 year history, we remain the ONLY dedicated fully equipped pediatric and neonatal transport service for critically ill patients in the SEA region. 10-15% of our missions are international; we just completed a transfer of a patient from Papua New Guinea 2 days ago.
- We perform about 90-100 missions per year, with targeted out of door times for local transfers at 15-30 minutes. So from the time you activate us, we expect to arrive at your doors within 30 minutes in an emergency. Stabilization of the patient prior to transfer back can take anywhere from 15 minutes to 5 hours, and we are essentially a mobile ICU.
- In terms of statistics, 35% of our patients required interventions, these included fluid boluses, IV or IA access or endotracheal manipulation. Just over 50% of our patients were on mechanical ventilation, and 12% were on vasoactive medications. Adverse event: hypotension, cyanosis, bradycardia, circulatory arrest, ETT dislodgement, ET obstruction Critical adverse event rate (transfer): 4.5%
- We have recently started a formal in-hospital ECMO programme at KKH, and there are plans to incorporate an inter-hospital ECMO transport programme in the near future. To date, we have performed 2 inter-hospital pediatric ECMO transfers, and about 5-6 intra-hospital transfers since the introduction of the programme. (show picture) This is a recent transfer we did of a post-op cardiac patient on ECMO who required a transfer to DI for a thoracic CT angiogram. Off-site cannulation for ECMO is still currently on a case by case basis and we work closely with the referral team and CTS surgeons. If you have case that you feel strongly requires ECMO, please call us early (very very early, probably within 5 minutes of CPR) to optimise best outcomes for the patient.
- To conclude, the overall objective of a pediatric critical care team is to improve the outcomes of critically ill or injured pediatric patients who are not in proximity to a hospital that provides the required level of care. To that end, best care starts when the patient arrives in your emergency department under your care, and continues when the specialist team arrives to continue further stabilization.
- With that, I thank you for your time and attention, I’ll be happy to answer any questions. I’d also like to take this opportunity to thank our dedicated staff who help make this service possible.