- Email: [email protected]
Effect of transport team interventions on stabilization time in neonatal and pediatric interfacility transports
Effect of Transport Team Interventions on Stabilization Time in Neonatal and Pediatric Interfacility Transports Patrick Chen,1 Andrew J. Macnab, MD,2 and Charles Sun, MD3
Introduction: During interfacility transport, the length of time taken by the transport team to prepare the patient for transport is often perceived as a problem by referring hospital staff. The purpose of this study was to examine the effects on time at the referring hospital of the number and complexity of interventions performed by the transport team to stabilize the patient prior to transfer. Setting: Interfacility transfers by the provincial infant transport team (ITT) to British Columbia’s Children’s Hospital. Methods: This was a prospective study of emergency neonatal and pediatric interfacility transfers. After each transport, the team completed a questionnaire about interventions performed and stabilization time. Transports were classified by the complexity of interventions performed: none, low (intravenous line, blood gas, nasogastric tube, Foley catheter, oxygen administration), or high (intubation, central venous access, arterial lines, chest tube insertion). Results: Thirty of 55 transports required no intervention (mean stabilization time = 52 ± 25 min). Sixteen transports required low level intervention (mean = 60 ± 22 min). Nine transports required high level intervention (mean = 140 ± 52 min). The stabilization times for “no” and “low” levels of intervention were not significantly different (P = .3), but the time for “high” level intervention was significantly higher (P < .01). Conclusions: The need for the transport team paramedics to perform high level interventions significantly increased the time at the referring hospital. In contrast, the time taken for them to perform or reperform low level interventions, whether one procedure or two, was not a significant source of delay.
Introduction Interfacility transports are necessary when a patient’s condition requires investigation or care beyond the capabilities of the referring hospital. Advances in transport medicine have provided access to effective treatment for critically ill patients and have reduced morbidity and mortality in these patients.1-3 With neonatal and pediatric intensive care units and specialized services available mainly at tertiary care centers, interfacility transports have become an important service for refer244
ring physicians4 and are becoming an increasingly important part of providing specialized medical care to sick children referred from rural or suburban areas. The term “stabilization time” refers to the time taken by the transport team to prepare a patient for transport, including performing or reperforming any interventions necessary to achieve stabilization. The importance of optimal stabilization prior to interfacility transport is established and has become the required standard of practice.5-8 Factors that affect the number of interventions performed by the referring hospital staff and by the transport team have been evaluated in a prospective study,9,10 and times for the duration of stabilization have been reported.11,12 However, prior studies that have examined the factors that affect stabilization time have been retrospective,13-15 and
1. Student, Faculty of Medicine, University of British Columbia 2. Professor, Division of Critical Care, Department of Pediatrics, University of British Columbia 3. Director of Medical Programs, British Columbia Ambulance Service; Associate Professor, Department of Medicine, University of British Columbia Address for correspondence: Andrew Macnab, Room 2D5, BC’s Children’s Hospital, 4480 Oak St, Vancouver, British Columbia, Canada, V6H 3V4; [email protected] Presented in part at the Western Society for Pediatric Research in Carmel, California, January 2004
Acknowledgments University of British Columbia Summer Student Research Program The authors also acknowledge the assistance of the Infant Transport Team 1067-991X/$30.00 Copyright 2005 by Air Medical Journal Associates doi:10.1016/j.amj.2005.08.003
Air Medical Journal 24:6
referring hospital staff members continue to be concerned that the stabilization time is often prolonged, perhaps unnecessarily, by re-evaluations and procedures performed or reperformed by the transport team. This belief, which occasionally results in disagreements between the transport team and referring hospital staff over the rationale for performing certain procedures that prolong stabilization time, can potentially harm collaboration over transports. Each transfer represents “an opportunity for success or failure” in this regard.1 The purpose of the study was to determine how stabilization time was affected by the number and level of complexity of procedures performed by the transport team at the referring hospital, independent of diagnosis, with the aim of identifying where improvements in this aspect of care could be made.
Table 1. Classification of Pretransport Procedural Interventions Level of intervention 1. No Interventions
Procedures None
2. Low level interventions
Peripheral intravenous insertion Oxygen administration Arterial blood gas assessment Nasogastric tube insertion Foley insertion
3. High level interventions
Intubation Arterial cannulation Central venous cannulation Chest tube insertion
Methods The British Columbia’s Children’s Hospital (BCCH) in Vancouver is the only pediatric tertiary care center in British Columbia, a province with a population of 4 million and a land area of 925,000 km2. The infant transport team (ITT), which comprises paramedics, performs all the acute neonatal, pediatric, and high risk maternal interfacility transports in the province, sometimes with and sometimes without physician escort.16 Data were collected prospectively over a 10-week period in the summer of 2003. For each emergent neonatal or pediatric interfacility transfer to BCCH, the ITT completed a questionnaire that elicited information on procedures performed by the referring hospital staff prior to ITT arrival, procedures performed or reperformed by ITT at the referring hospital, and the cause of any delays encountered. Stabilization time was defined as the time from arrival of ITT at the referring facility to the departure of the ITT from the referring facility. The stabilization time and the level of referring facility (primary vs. secondary care) were extracted from the transport record form. The ITT was not blinded to the purpose of the study, but there would have been no logical reason for altering usual practice. Each interfacility transfer was classified into Class 1, 2, or 3 as determined by the complexity of the interventions performed by the ITT. The classification of the interventions is shown in Table 1. Mean stabilization time and standard deviations were computed for each of the three groups. Independent-samples t-test was used to compare the mean stabilization time between the groups, and a 2-tailed α of 0.05 was considered statistically significant.
Results Data from 55 interfacility transports were collected. Demographics are presented in Table 2. Thirty of 55 (55%) transports, were Class 1 (no interventions), mean stabilization time 52 ± 25 minutes; 16 (29%) were Class 2 (low level interventions only), mean stabilization time 60 ± 22 minutes (not significantly different from Class 1, P = 0.30); and 9 (16%) were Class 3 (high-level interventions), mean stabilization time 140 ± 52 minutes (significantly greater than both Class 1 and Class 2, P < 0.0001). November-December 2005
Overall, a total of 137 low level interventions were performed to prepare and stabilize the patient for transport, of which 119 (87%) were performed by the referring hospital staff prior to the arrival of the ITT and 26 (19%) were performed or reperformed by the ITT at the referring hospital (ie, 8 procedures were reperformed). A total of 23 high level interventions were performed, of which 14 (61%) were performed by the referring hospital staff and 11 (48%) were performed or reperformed by the ITT (2 were reperformed). There was no statistically significant association between the number of low level interventions (range 1 to 2) performed by the ITT and the stabilization time (r = 0.23, P = .39, 95% CI: 0.30, 0.65) or between the number of high level interventions (range 1 to 5) and stabilization time (r = 0.30, P = .43, 95% CI: 0.45, 0.80). There were 20 neonatal transports, stabilization time 81.0 ± 45.5 minutes, and 35 pediatric transports, stabilization time 61.7 ± 50.0 minutes (P = .11)
Discussion Our results indicate that stabilization time more than doubled if the ITT paramedics had to perform or reperform high level interventions prior to transfer. However, the need to do low level interventions did not significantly prolong the length of time spent by the team at the referring hospital, even if more than one was required. The increased stabilization time associated with the need for high level interventions occurs partly as a result of the technical complexity of the procedures required but also from the related tests and measures necessary afterward to ensure that the procedure is complete and correct, and the need to check the patient’s physiological status. For example, the radiographs and/or blood gas(es) usually required in addition to careful physical assessment after endotracheal intubation all add to the time taken at the referring hospital. We did not find a significant association between the number of low level interventions performed by the ITT and stabilization time, which suggests that the time taken to perform low level interventions was negligible and that postprocedure checks are either brief or required infrequently. Thus, when only low level interventions were performed, the “stabiliza245
Table 2. Demographics Variable Frequency Total transports 55 Gender Male 34 Female 21 Age ≤ 28 days 20 1 month - 5 years 19 6-10 years 11 > 10 years 5 Reason for transport Medical 40 Sepsis 13 Respiratory 8 Neurological 9 Abdominal 5 Other 5 Trauma 15 Motor vehicle collision 5 Closed head injury 4 Other trauma 6
Percent 100 62 38 36 35 20 9 73 24 15 16 9 9 27 9 7 11
tion” time primarily involved handing over the patient, clinical evaluation, obtaining all necessary history and documents, formulating a transport plan, connecting monitors and infusion pumps, securing the patient and equipment, communicating with the receiving hospital/transport advisor and with parents/family, and completing a pretransport checklist.17 All are important steps in ensuring safe and efficient transport of the patient, and the time spent on these steps cannot be reduced to any large extent without potentially jeopardizing the safety of the patient. In a previous study,18 we identified that the time dedicated to communication with the family by a transport team member involves minimal cost because the time involved does not add substantially to stabilization time. However, transport teams should always be mindful of the desirability of avoiding any unnecessary delay, and programs should monitor time at the referring hospital as part of ongoing quality assurance. Some previous studies have examined the stabilization time in pediatric or neonatal interfacility transports11,13-15,19 and the effects of the type and number of interventions performed by the transport team on stabilization time. The mean times from our study were consistent with the stabilization times reported by Whitfield and Buser11 (from 55 minutes in all pediatric patients to 156 minutes for patients requiring ventilation with inotropes). Ammon et al14 also found that patients who needed supportive measures, such as endotracheal intubation (our Class 3), nasogastric tube, or Foley catheter (our Class 2), required longer total transport times. A similar association was found by Leicht et al15 for stabilization times and advanced procedures in adult interfa246
cility transports. In a prospective study Kronick et al9 reported that neonates being transported required more procedural interventions than did infants and children, but we found no significant difference between these groups in stabilization time. However, there was a trend to significance, but this was not the primary outcome measure, and our study lacks power in this regard. Beddingfield et al,13 in a retrospective study, found that the need for the transport team to perform major procedures occurred in 13% of patients and resulted in longer stabilization times (54 minutes for 2 or more procedures versus 35 to 38 minutes for none or one). Comparison with our data indicates that our stabilization times were longer: 140 minutes if any high level procedures were required versus 50 to 63 minutes for none or only low level procedure. However, in Beddingfield’s study, 60% of patients had major procedures performed prior to the arrival of the team, 13% had major procedures done by the team, and 8% required major procedures during transport, as compared with 26%, 22%, and 0%, respectively, in our study. While considerably more procedures were done by referring hospital staff in Beddingfield’s study, the fact that 8% of those patients required high-risk interventions during the transport journey implies that optimum stabilization did not occur at the referring hospital. Admittedly, whether or not stabilization has been achieved is subjective, to a degree, but the most robust evidence for its adequacy is probably whether or not the child is stable enough to complete the interfacility journey without deteriorating sufficiently to require any high-level interventions in transit. Certainly, other authors19,20 agree that inadequate stabilization prior to transport is the principle cause of complications during transfer. Our results indicate that our transport team performed a higher percentage of high level interventions (48%) than low level interventions (20%). This may be due to the complexity of some high level interventions being outside the scope of familiar practice of the hospital staff referring to our center. It is also necessary to consider the possibility that this finding is due to a lack of clarity in communication between our staff and those at the referring hospital or disagreement as to what procedures should be performed prior to arrival of the transport team. However, these data were not obtained in our study. Because this was a prospective study, we were able to collect information on all the interventions performed by the transport team and the cause of any delays encountered at the referring hospital. The main limitation of the study, however, was that it was not blinded. Members of the transport team were aware of the study’s purpose and they self-reported the questionnaires. Therefore, the results may be subject to bias. We also analyzed only on the basis of procedural complexity, not diagnosis. This factor could be examined in a larger future study. Although the length of time taken for stabilization has been identified as a contentious issue, the principle of optimal pretransport stabilization as the standard of care necessary to minimize morbidity and mortality is recognized. The only caveat to this is when unique circumstances exist: some trauma cases where rapid transfer is deemed preferable, cases Air Medical Journal 24:6
where there is consensus that achieving stability is beyond the collective abilities of those involved, or where adverse weather or flight logistics impose rigid time constraints. Review of the indications for and timing of acute procedural interventions during transit should be a key element of each team’s quality assurance process, as having to provide acute procedural interventions in vehicles and aircraft remains problematic. If staff at the referring hospital were able to perform all the required interventions/procedures effectively prior to arrival of the transport team, our data suggest that the time spent by the team at the referring hospital could, on average, be reduced by over an hour. Also, in unpublished data from a questionnaire on emergency care and transfer completed by 96 referring hospitals (58% response rate), we identified that medical staff in smaller hospitals ranked procedural issues among their highest priorities for continuing medical education (CME). This desire to focus CME on such issues may have bearing on our study findings. However, questions of practicality and cost benefit inevitably arise. It is costly to provide the advanced training required to the large number of individual physicians involved. Also, some of them may not be permanently based at the hospital in question, and it is problematic for the majority to maintain these skills if patients requiring the high level interventions we studied are infrequent. In many instances, patients requiring such interventions are only referred for transport every year or two from any given facility. The obvious alternative is to have a team that is fully trained in the required procedures available to conduct each transport. A process for ensuring skill maintenance is still necessary, but for many teams, including our own,16 this can usually be met by an adequate transport call volume. An additional criterion for this training model is the ability of the team to respond consistently within a time frame that meets patients’ needs. Nonetheless, our results suggest that acquiring the necessary advanced procedural skills is an option for physicians who want to reduce the time spent by transport teams at their hospital, provided all these skills are maintained and, where necessary, performed effectively prior to team arrival. More research is needed to continue examining factors that affect the stabilization of patients prior to transport and identify any measures that can be implemented to reduce the time it takes without increasing morbidity or mortality.
7. Kanter RK, Tompkins JM. Adverse events during hospital transport: physiological deterioration associated with pre-transport severity of illness. Pediatrics 1989;84:43-8. 8. Warren J, Fromm RE, Orr RA, Rotello LC, Horst HM, American College of Critical Care Medicine. Guidelines for inter- and intrahospital transfer of critically ill patients. Crit Care Med 2004;32:256-62. 9. Kronick JB, Frewen TC, Kissoon N, Lee R, Sommerauer JF, Reid WD, et al. Pediatric and neonatal critical care transport: a comparison of therapeutic interventions. Pediatr Emerg Care 1996;12:23-6. 10. Kronick JB, Frewen TC, Kissoon N, Lee R, Sommerauer JF, Reid WD, et al. Influence of referring physicians on interventions by a pediatric and neonatal critical care transport team. Pediatr Emerg Care 1996;12:73-7. 11. Whitfield JM, Busser MK. Transport stabilization times for neonatal and pediatric patients prior to interfacility transfer. Pediatr Emerg Care 1993;9:69-71. 12. Cray SH, Heard CMB. Transport for paediatric intensive care. Measuring the performance of specialist transport service. Paediatr Anaesth 1995;5:287-92. 13. Beddingfield III FC, Garrison HG, Manning JE, Lewis RJ. Factors associated with prolongation of transport times of emergency pediatric patients requiring transfer to a tertiary care center. Pediatr Emerg Care 1996;12:416-9. 14. Ammon AA, Fath JJ, Braughtigan M, Mehta R, Matthews J. Transferring patients to a pediatric trauma center: the transferring hospital’s perspective. Pediatr Emerg Care 2000;16:332-4. 15. Leicht MJ, Dula DJ, Brotman S, Anderson TE, Gessner HW, Parrish GA, et al. Rural interhospital helicopter transport of motor vehicle trauma victims: causes for delays and recommendations. Ann Emerg Med 1986;15:450-3. 16. Macnab AJ, Freeman J, Sun C. Air evacuation: costs, benefits and priorities. Br Columbia Med J 1995;37:251-6. 17. Macrae DJ. Pediatric intensive care transport. Arch Dis Child 1994;71:175-8. 18. Macnab AJ, Gagnon F, George S, Sun S. The cost of family-oriented communication before air medical interfacility transport. Air Med J 2001;20:20-2. 19. Whitfield JM. Audit of neonatal intensive care transport. Arch Dis Child 1995;72:F79-80. 20. Barry PW, Ralson C. Adverse events occurring during interhospital transfer of the critically ill. Arch Dis Child 1994;71:8-11.
References 1. Bose CL. An overview of the organization and administration of a perinatal transport service. In: McDonald MG, Miller MK, editors. Emergency transport of the perinatal patient. Boston/Toronto: Little Brown; 1989. pp. 34-75. 2. Pollack MM, Alexander SR, Clark N, Ruttimann UE, Tesselaar HM, Bachulis AC. Improved outcomes from tertiary pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities. Crit Care Med 1991;19:150-9. 3. Pon S, Notterman DA. The organization of a pediatric critical care transport program. Pediatr Clin North Am 1993;40:241-61. 4. Macnab AJ. Emergency pediatric interhospital transport: the referring physician’s perspective. Br Columbia Med J 1990;32:238-40. 5. Macnab AJ. Optimal escort for interhospital transport for pediatric emergencies. J Trauma 1991;31:205-9. 6. Day SE. Intratransport stabilization and management of the pediatric patient. Pediatr Clin North Am 1993;40:263-74.
November-December 2005
247
Introduction: During interfacility transport, the length of time taken by the transport team to prepare the patient for transport is often perceived as a problem by referring hospital staff. The purpose of this study was to examine the effects on time at the referring hospital of the number and complexity of interventions performed by the transport team to stabilize the patient prior to transfer. Setting: Interfacility transfers by the provincial infant transport team (ITT) to British Columbia’s Children’s Hospital. Methods: This was a prospective study of emergency neonatal and pediatric interfacility transfers. After each transport, the team completed a questionnaire about interventions performed and stabilization time. Transports were classified by the complexity of interventions performed: none, low (intravenous line, blood gas, nasogastric tube, Foley catheter, oxygen administration), or high (intubation, central venous access, arterial lines, chest tube insertion). Results: Thirty of 55 transports required no intervention (mean stabilization time = 52 ± 25 min). Sixteen transports required low level intervention (mean = 60 ± 22 min). Nine transports required high level intervention (mean = 140 ± 52 min). The stabilization times for “no” and “low” levels of intervention were not significantly different (P = .3), but the time for “high” level intervention was significantly higher (P < .01). Conclusions: The need for the transport team paramedics to perform high level interventions significantly increased the time at the referring hospital. In contrast, the time taken for them to perform or reperform low level interventions, whether one procedure or two, was not a significant source of delay.
Introduction Interfacility transports are necessary when a patient’s condition requires investigation or care beyond the capabilities of the referring hospital. Advances in transport medicine have provided access to effective treatment for critically ill patients and have reduced morbidity and mortality in these patients.1-3 With neonatal and pediatric intensive care units and specialized services available mainly at tertiary care centers, interfacility transports have become an important service for refer244
ring physicians4 and are becoming an increasingly important part of providing specialized medical care to sick children referred from rural or suburban areas. The term “stabilization time” refers to the time taken by the transport team to prepare a patient for transport, including performing or reperforming any interventions necessary to achieve stabilization. The importance of optimal stabilization prior to interfacility transport is established and has become the required standard of practice.5-8 Factors that affect the number of interventions performed by the referring hospital staff and by the transport team have been evaluated in a prospective study,9,10 and times for the duration of stabilization have been reported.11,12 However, prior studies that have examined the factors that affect stabilization time have been retrospective,13-15 and
1. Student, Faculty of Medicine, University of British Columbia 2. Professor, Division of Critical Care, Department of Pediatrics, University of British Columbia 3. Director of Medical Programs, British Columbia Ambulance Service; Associate Professor, Department of Medicine, University of British Columbia Address for correspondence: Andrew Macnab, Room 2D5, BC’s Children’s Hospital, 4480 Oak St, Vancouver, British Columbia, Canada, V6H 3V4; [email protected] Presented in part at the Western Society for Pediatric Research in Carmel, California, January 2004
Acknowledgments University of British Columbia Summer Student Research Program The authors also acknowledge the assistance of the Infant Transport Team 1067-991X/$30.00 Copyright 2005 by Air Medical Journal Associates doi:10.1016/j.amj.2005.08.003
Air Medical Journal 24:6
referring hospital staff members continue to be concerned that the stabilization time is often prolonged, perhaps unnecessarily, by re-evaluations and procedures performed or reperformed by the transport team. This belief, which occasionally results in disagreements between the transport team and referring hospital staff over the rationale for performing certain procedures that prolong stabilization time, can potentially harm collaboration over transports. Each transfer represents “an opportunity for success or failure” in this regard.1 The purpose of the study was to determine how stabilization time was affected by the number and level of complexity of procedures performed by the transport team at the referring hospital, independent of diagnosis, with the aim of identifying where improvements in this aspect of care could be made.
Table 1. Classification of Pretransport Procedural Interventions Level of intervention 1. No Interventions
Procedures None
2. Low level interventions
Peripheral intravenous insertion Oxygen administration Arterial blood gas assessment Nasogastric tube insertion Foley insertion
3. High level interventions
Intubation Arterial cannulation Central venous cannulation Chest tube insertion
Methods The British Columbia’s Children’s Hospital (BCCH) in Vancouver is the only pediatric tertiary care center in British Columbia, a province with a population of 4 million and a land area of 925,000 km2. The infant transport team (ITT), which comprises paramedics, performs all the acute neonatal, pediatric, and high risk maternal interfacility transports in the province, sometimes with and sometimes without physician escort.16 Data were collected prospectively over a 10-week period in the summer of 2003. For each emergent neonatal or pediatric interfacility transfer to BCCH, the ITT completed a questionnaire that elicited information on procedures performed by the referring hospital staff prior to ITT arrival, procedures performed or reperformed by ITT at the referring hospital, and the cause of any delays encountered. Stabilization time was defined as the time from arrival of ITT at the referring facility to the departure of the ITT from the referring facility. The stabilization time and the level of referring facility (primary vs. secondary care) were extracted from the transport record form. The ITT was not blinded to the purpose of the study, but there would have been no logical reason for altering usual practice. Each interfacility transfer was classified into Class 1, 2, or 3 as determined by the complexity of the interventions performed by the ITT. The classification of the interventions is shown in Table 1. Mean stabilization time and standard deviations were computed for each of the three groups. Independent-samples t-test was used to compare the mean stabilization time between the groups, and a 2-tailed α of 0.05 was considered statistically significant.
Results Data from 55 interfacility transports were collected. Demographics are presented in Table 2. Thirty of 55 (55%) transports, were Class 1 (no interventions), mean stabilization time 52 ± 25 minutes; 16 (29%) were Class 2 (low level interventions only), mean stabilization time 60 ± 22 minutes (not significantly different from Class 1, P = 0.30); and 9 (16%) were Class 3 (high-level interventions), mean stabilization time 140 ± 52 minutes (significantly greater than both Class 1 and Class 2, P < 0.0001). November-December 2005
Overall, a total of 137 low level interventions were performed to prepare and stabilize the patient for transport, of which 119 (87%) were performed by the referring hospital staff prior to the arrival of the ITT and 26 (19%) were performed or reperformed by the ITT at the referring hospital (ie, 8 procedures were reperformed). A total of 23 high level interventions were performed, of which 14 (61%) were performed by the referring hospital staff and 11 (48%) were performed or reperformed by the ITT (2 were reperformed). There was no statistically significant association between the number of low level interventions (range 1 to 2) performed by the ITT and the stabilization time (r = 0.23, P = .39, 95% CI: 0.30, 0.65) or between the number of high level interventions (range 1 to 5) and stabilization time (r = 0.30, P = .43, 95% CI: 0.45, 0.80). There were 20 neonatal transports, stabilization time 81.0 ± 45.5 minutes, and 35 pediatric transports, stabilization time 61.7 ± 50.0 minutes (P = .11)
Discussion Our results indicate that stabilization time more than doubled if the ITT paramedics had to perform or reperform high level interventions prior to transfer. However, the need to do low level interventions did not significantly prolong the length of time spent by the team at the referring hospital, even if more than one was required. The increased stabilization time associated with the need for high level interventions occurs partly as a result of the technical complexity of the procedures required but also from the related tests and measures necessary afterward to ensure that the procedure is complete and correct, and the need to check the patient’s physiological status. For example, the radiographs and/or blood gas(es) usually required in addition to careful physical assessment after endotracheal intubation all add to the time taken at the referring hospital. We did not find a significant association between the number of low level interventions performed by the ITT and stabilization time, which suggests that the time taken to perform low level interventions was negligible and that postprocedure checks are either brief or required infrequently. Thus, when only low level interventions were performed, the “stabiliza245
Table 2. Demographics Variable Frequency Total transports 55 Gender Male 34 Female 21 Age ≤ 28 days 20 1 month - 5 years 19 6-10 years 11 > 10 years 5 Reason for transport Medical 40 Sepsis 13 Respiratory 8 Neurological 9 Abdominal 5 Other 5 Trauma 15 Motor vehicle collision 5 Closed head injury 4 Other trauma 6
Percent 100 62 38 36 35 20 9 73 24 15 16 9 9 27 9 7 11
tion” time primarily involved handing over the patient, clinical evaluation, obtaining all necessary history and documents, formulating a transport plan, connecting monitors and infusion pumps, securing the patient and equipment, communicating with the receiving hospital/transport advisor and with parents/family, and completing a pretransport checklist.17 All are important steps in ensuring safe and efficient transport of the patient, and the time spent on these steps cannot be reduced to any large extent without potentially jeopardizing the safety of the patient. In a previous study,18 we identified that the time dedicated to communication with the family by a transport team member involves minimal cost because the time involved does not add substantially to stabilization time. However, transport teams should always be mindful of the desirability of avoiding any unnecessary delay, and programs should monitor time at the referring hospital as part of ongoing quality assurance. Some previous studies have examined the stabilization time in pediatric or neonatal interfacility transports11,13-15,19 and the effects of the type and number of interventions performed by the transport team on stabilization time. The mean times from our study were consistent with the stabilization times reported by Whitfield and Buser11 (from 55 minutes in all pediatric patients to 156 minutes for patients requiring ventilation with inotropes). Ammon et al14 also found that patients who needed supportive measures, such as endotracheal intubation (our Class 3), nasogastric tube, or Foley catheter (our Class 2), required longer total transport times. A similar association was found by Leicht et al15 for stabilization times and advanced procedures in adult interfa246
cility transports. In a prospective study Kronick et al9 reported that neonates being transported required more procedural interventions than did infants and children, but we found no significant difference between these groups in stabilization time. However, there was a trend to significance, but this was not the primary outcome measure, and our study lacks power in this regard. Beddingfield et al,13 in a retrospective study, found that the need for the transport team to perform major procedures occurred in 13% of patients and resulted in longer stabilization times (54 minutes for 2 or more procedures versus 35 to 38 minutes for none or one). Comparison with our data indicates that our stabilization times were longer: 140 minutes if any high level procedures were required versus 50 to 63 minutes for none or only low level procedure. However, in Beddingfield’s study, 60% of patients had major procedures performed prior to the arrival of the team, 13% had major procedures done by the team, and 8% required major procedures during transport, as compared with 26%, 22%, and 0%, respectively, in our study. While considerably more procedures were done by referring hospital staff in Beddingfield’s study, the fact that 8% of those patients required high-risk interventions during the transport journey implies that optimum stabilization did not occur at the referring hospital. Admittedly, whether or not stabilization has been achieved is subjective, to a degree, but the most robust evidence for its adequacy is probably whether or not the child is stable enough to complete the interfacility journey without deteriorating sufficiently to require any high-level interventions in transit. Certainly, other authors19,20 agree that inadequate stabilization prior to transport is the principle cause of complications during transfer. Our results indicate that our transport team performed a higher percentage of high level interventions (48%) than low level interventions (20%). This may be due to the complexity of some high level interventions being outside the scope of familiar practice of the hospital staff referring to our center. It is also necessary to consider the possibility that this finding is due to a lack of clarity in communication between our staff and those at the referring hospital or disagreement as to what procedures should be performed prior to arrival of the transport team. However, these data were not obtained in our study. Because this was a prospective study, we were able to collect information on all the interventions performed by the transport team and the cause of any delays encountered at the referring hospital. The main limitation of the study, however, was that it was not blinded. Members of the transport team were aware of the study’s purpose and they self-reported the questionnaires. Therefore, the results may be subject to bias. We also analyzed only on the basis of procedural complexity, not diagnosis. This factor could be examined in a larger future study. Although the length of time taken for stabilization has been identified as a contentious issue, the principle of optimal pretransport stabilization as the standard of care necessary to minimize morbidity and mortality is recognized. The only caveat to this is when unique circumstances exist: some trauma cases where rapid transfer is deemed preferable, cases Air Medical Journal 24:6
where there is consensus that achieving stability is beyond the collective abilities of those involved, or where adverse weather or flight logistics impose rigid time constraints. Review of the indications for and timing of acute procedural interventions during transit should be a key element of each team’s quality assurance process, as having to provide acute procedural interventions in vehicles and aircraft remains problematic. If staff at the referring hospital were able to perform all the required interventions/procedures effectively prior to arrival of the transport team, our data suggest that the time spent by the team at the referring hospital could, on average, be reduced by over an hour. Also, in unpublished data from a questionnaire on emergency care and transfer completed by 96 referring hospitals (58% response rate), we identified that medical staff in smaller hospitals ranked procedural issues among their highest priorities for continuing medical education (CME). This desire to focus CME on such issues may have bearing on our study findings. However, questions of practicality and cost benefit inevitably arise. It is costly to provide the advanced training required to the large number of individual physicians involved. Also, some of them may not be permanently based at the hospital in question, and it is problematic for the majority to maintain these skills if patients requiring the high level interventions we studied are infrequent. In many instances, patients requiring such interventions are only referred for transport every year or two from any given facility. The obvious alternative is to have a team that is fully trained in the required procedures available to conduct each transport. A process for ensuring skill maintenance is still necessary, but for many teams, including our own,16 this can usually be met by an adequate transport call volume. An additional criterion for this training model is the ability of the team to respond consistently within a time frame that meets patients’ needs. Nonetheless, our results suggest that acquiring the necessary advanced procedural skills is an option for physicians who want to reduce the time spent by transport teams at their hospital, provided all these skills are maintained and, where necessary, performed effectively prior to team arrival. More research is needed to continue examining factors that affect the stabilization of patients prior to transport and identify any measures that can be implemented to reduce the time it takes without increasing morbidity or mortality.
7. Kanter RK, Tompkins JM. Adverse events during hospital transport: physiological deterioration associated with pre-transport severity of illness. Pediatrics 1989;84:43-8. 8. Warren J, Fromm RE, Orr RA, Rotello LC, Horst HM, American College of Critical Care Medicine. Guidelines for inter- and intrahospital transfer of critically ill patients. Crit Care Med 2004;32:256-62. 9. Kronick JB, Frewen TC, Kissoon N, Lee R, Sommerauer JF, Reid WD, et al. Pediatric and neonatal critical care transport: a comparison of therapeutic interventions. Pediatr Emerg Care 1996;12:23-6. 10. Kronick JB, Frewen TC, Kissoon N, Lee R, Sommerauer JF, Reid WD, et al. Influence of referring physicians on interventions by a pediatric and neonatal critical care transport team. Pediatr Emerg Care 1996;12:73-7. 11. Whitfield JM, Busser MK. Transport stabilization times for neonatal and pediatric patients prior to interfacility transfer. Pediatr Emerg Care 1993;9:69-71. 12. Cray SH, Heard CMB. Transport for paediatric intensive care. Measuring the performance of specialist transport service. Paediatr Anaesth 1995;5:287-92. 13. Beddingfield III FC, Garrison HG, Manning JE, Lewis RJ. Factors associated with prolongation of transport times of emergency pediatric patients requiring transfer to a tertiary care center. Pediatr Emerg Care 1996;12:416-9. 14. Ammon AA, Fath JJ, Braughtigan M, Mehta R, Matthews J. Transferring patients to a pediatric trauma center: the transferring hospital’s perspective. Pediatr Emerg Care 2000;16:332-4. 15. Leicht MJ, Dula DJ, Brotman S, Anderson TE, Gessner HW, Parrish GA, et al. Rural interhospital helicopter transport of motor vehicle trauma victims: causes for delays and recommendations. Ann Emerg Med 1986;15:450-3. 16. Macnab AJ, Freeman J, Sun C. Air evacuation: costs, benefits and priorities. Br Columbia Med J 1995;37:251-6. 17. Macrae DJ. Pediatric intensive care transport. Arch Dis Child 1994;71:175-8. 18. Macnab AJ, Gagnon F, George S, Sun S. The cost of family-oriented communication before air medical interfacility transport. Air Med J 2001;20:20-2. 19. Whitfield JM. Audit of neonatal intensive care transport. Arch Dis Child 1995;72:F79-80. 20. Barry PW, Ralson C. Adverse events occurring during interhospital transfer of the critically ill. Arch Dis Child 1994;71:8-11.
References 1. Bose CL. An overview of the organization and administration of a perinatal transport service. In: McDonald MG, Miller MK, editors. Emergency transport of the perinatal patient. Boston/Toronto: Little Brown; 1989. pp. 34-75. 2. Pollack MM, Alexander SR, Clark N, Ruttimann UE, Tesselaar HM, Bachulis AC. Improved outcomes from tertiary pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities. Crit Care Med 1991;19:150-9. 3. Pon S, Notterman DA. The organization of a pediatric critical care transport program. Pediatr Clin North Am 1993;40:241-61. 4. Macnab AJ. Emergency pediatric interhospital transport: the referring physician’s perspective. Br Columbia Med J 1990;32:238-40. 5. Macnab AJ. Optimal escort for interhospital transport for pediatric emergencies. J Trauma 1991;31:205-9. 6. Day SE. Intratransport stabilization and management of the pediatric patient. Pediatr Clin North Am 1993;40:263-74.
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