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 1994;71:8-11 • 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 Mary’s 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

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 Ayre’s 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. Who’s 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 – ‘don’t worry the ventilator’s 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 unit’s ventilator • Full attention of all staff during verbal handover – no switching over of monitors etc. • Don’t 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 >7.25 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