Transporting Sick Children

1
Transporting Sick Children

• Safety, Critical Incidents, Insurance

2
Importance

• Rationale for dedicated retrievals is to offer
  better service than previously existed
• Evidence that specialised teams perform better.

3
Barry PW, Ralston C. Adverse events occurring
during inter-hospital transfer of the critically
ill. Arch Dis Child 1994718-11

• Observational study in Leicester of 56 children
  transferred in for PICU.
• Adverse events in 42 (75) 13 were life
  threatening incidents
• These transfers tended to have been undertaken by
  inexperienced staff.

4
Macnab, A. J. (1991). "Optimal escort for
interhospital transport of pediatric
emergencies." J Trauma 31(2) 205-9.

• Chart review 130 paediatric transfers looking for
  adverse events during transit
• 8 occurred with 8 occurred with specialized
  pediatric transport escorts who were accompanied
  by a tertiary care physician
• 20 with specialized pediatric transport escorts
  alone
• 72 with escorts who had not received specialized
  pediatric transport training

5
Edge WE, Kanter RK, Weigle CGM et al. Reduction
of morbidity in inter-hospital transport by
specialised paediatric staff. Crit Care Med 1994
22 1186-1191

• Prospective study of adverse events during
  transport Albany NY, Syracuse NY.
• ICU related adverse events 1/47 specialised
  transports (2) and 18/92 non-specialised (20).
• Physiological deterioration 5/47 specialised
  (11), 11/92 non-specialised (12).

6
Britto, J., S. Nadel, et al. Morbidity and
severity of illness during interhospital
transfer impact of a specialised paediatric
retrieval team. BMJ 1995 311 836-9

• Prospective descriptive study 51 cases Marys
  PICU retrieved from DGH
• 2 cases had preventable physiological
  deterioration
• PRISM score improved during transfer and
  stabilisation

7
Why is it safer with specialist teams

• Familiarity with age group
• Familiarity with equipment
• More experienced
• Learned from previous mistakes

8
Learning from mistakes

• Blame free
• Critical incident reporting
• Regular transport meetings
• Enable prevention

9
(No Transcript)
10
Latent failures

• Poor communication
• Referral
• With ambulance crew
• Doctor-nurse
• Poor process
• No routine pattern
• No check lists
• Poor equipment maintenance
• Includes kit checks

11
Example

• Transfer from hospital 1 hour away
• 30 mins into transfer ventilator stops
• Patient transferred to Ayres T-piece from
  portable cylinder no desaturation
• Oxygen cylinder in ambulance empty allegedly
  full (size F) at start of journey
• Back up cylinder full supply changed
  ventilator connectors tightened

12
Whos fault?

• Was oxygen cylinder full at departure not
  properly checked
• Was ventilator checked prior to transfer yes
• Previous experience ventialtors can develop
  leaks

13
Actions

• Mannual check on ambulance oxygen supply
  re-emphasized
• Check all ventilator connections after each
  change in oxygen supply

14
Importance of process

• Sick neonate 32/40 NEC, high O2 requirement
• Safely transferred 40 miles
• Arrived NICU
• Handover staff started to move baby before this
  was complete dont worry the ventilators set
  up
• Ventilator failed took 30 secs to recognise
  baby desaturated
• No bagging circuit attached transport incubator
  had to be used as emergency back up

15
Action

• Transporting doctor responsible for supervising
  all aspects of transfer until baby is stable on
  receiving units ventilator
• Full attention of all staff during verbal
  handover no switching over of monitors etc.
• Dont move a patient until bagging circuit
  available and turned on

16
Think ahead

• Identify problems before they occur
• Surprises will happen expect them and deal with
  them ABC principles.
• Ensure you can always isolate the patient quickly
  from equipment and use failsafe ABC - Ambubag

17
Safety points - patient

• Medical equipment secure and visible
• End tidal CO2
• All monitoring functioning prior to departure
• Secure IV access
• Secure ETT in correct position
• Secured to trolley

18
Safety
19
Safety points -staff

• Seatbelts
• Use winch correctly
• No interventions on the move
• Communicate with ambulance driver comfort and
  speed
• Blue light rarely needed

20
CATS Complications 2002
21
CATS - Complication Rate 2002
22
Checklists
23
Air retrievals
24
Air retrievals

• Lack of power
• Effects on pO2
• Pressurised vs unpressurised
• Unforseen delays
• Multiple patient movements
• Trolley ? ambulance
• Ambulance ? plane
• Plane ? ambulance
• Ambulance ? trolley

25
Stabilisation

• Few situations scoop and run
• Exceptions
• Extradural haematoma
• Blocked VP shunt
• Much better to achieve stability prior to
  departure may take some time.

26
Whitfield JM, Buser NNP. Transport stabilisation
times for neonatal and paediatric transfers prior
to interfacility transfer. Pediatr Emerg Care
1993 9 67-71.

• Median stabilisation time for 1193 ventilated
  children - 74 mins
• If receiving inotropes - 150 minutes.

27
Transferring patient with severe ARDS

• A Secure ETT check position on CXR ensure
  minimal leak as high pressure ventilation
  necessary
• B Realistic targets O2sats 85 92, pH gt7.25
• Use high PEEP 10-15cm needs to be active
  PEEP.
• Long Tinsp, High FiO2.
• Allow time to recruit alveoli.
• C Good access, well filled, inotropes as
  required.

28
Oxygen calculation

• Minute volume ? estimated journey time ? 2
  rounded up
• D cylinder 340L
• E cylinder 680L
• F cylinder 1360L
• Spare cylinder heads and O rings

29
Summary

• PICU retrieval team have been specially trained
  for the purpose
• Almost never acceptable to transfer patient if
  not stable
• Air retrievals carry extra risks

30
AMF YOYO