- Email: [email protected]
Specialty Pediatric Transport in Primary Care or Urgent Care Settings
ORIGINAL RESEARCH
Specialty Pediatric Transport in Primary Care or Urgent Care Settings Crystal N. Joyce, DO,1 John S. Giuliano Jr, MD,2 Michael D. Gothard, MS,3 Hamilton P. Schwartz, MD,4 and Michael T. Bigham, MD1
Abstract Objective: We sought to describe a single center’s experience with specialized critical care transport from non-hospital settings, including primary care offices and urgent care centers. We hypothesized that the majority of patients will require procedures outside the scope of practice of most EMS providers and will be better served by specialized pediatric critical care transport (SPCCT) teams. Methods: This study sought to retrospectively evaluate instances where children (0–18 years old) were transported by our SPCCT team from nonhospital settings, including primary care offices and urgent care centers, in 2009 and 2010. Data were extracted from a customized database and appropriate statistical tests were applied, including Fisher’s exact test for categorical comparisons and Mann-Whitney U test for non-parametric data comparisons. Results: Fifty-two patients were included. Most of the children were transported for respiratory distress (78%), and many were treated with albuterol (42%) and steroids (42%) prior to the SPCCT team arrival. The most common interventions performed by the SPCCT team were obtaining IV access and administering IV fluid boluses; 4 (7.7%) patients required advanced critical care treatments unique to SPCCT. Most patients (n = 34; 65%) were directly admitted to the general care floor, but a high number of patients (n = 12; 23%; PICU = 11, NICU = 1) required pediatric or neonatal intensive care unit admission. Only 3 patients (5.7%) were dis-
1. Akron Children’s Hospital, Department of Pediatrics, Akron, OH, USA 2. Yale University School of Medicine, Department of Pediatrics, Division of Critical Care, New Haven, CT, USA 3. Biostats Inc, East Canton, OH, USA 4. Cincinnati Children’s Hospital, Department of Pediatrics, Division of Emergency Medicine, Cincinnati, OH, USA Address for correspondence: Michael T. Bigham, MD, Department of Pediatrics, Division of Critical Care Medicine, One Perkins Square, Akron, OH 44308, [email protected] Presented as an oral abstract at the American Academy of Pediatrics National Conference and Exhibition, Section on Transport Medicine, October 2011, Boston, MA. 1067-991X/$36.00 Copyright 2014 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2013.12.003 March-April 2014
charged home without hospital admission. For the 11 patients admitted to the PICU, the median length of stay (LOS) was 2.5 days (IQR 0.14–13.2). All patients survived to hospital discharge with an additional hospital LOS of 1.3 days (IQR 0.2–6.7). Patients were billed for these critical care transports an average of $2,660.14 ± $940. Conclusion: Our small cohort demonstrates infrequent application of advanced critical care interventions beyond those provided by the referring primary care office or urgent care centers. This supports the practice of SPCCT teams providing transport services for select critically ill children at primary care offices and urgent care centers, but not as a standard practice for most pediatric patients in these settings.
Introduction Approximately 200,000 infants and children in the United States are transported each year for specialty neonatal or pediatric care unavailable at the referral hospital.1 Interfacility transports are commonly performed by specialty pediatric critical care transport (SPCCT) teams, although sick and injured children also present to a variety of nonhospital settings including school, primary care offices, or urgent care centers and may require emergency care and/or transport to a pediatric hospital for further management. Typically, for pediatric emergencies in the community, local emergency medical services (EMS) are activated via the public safety access point (911) where processes are in place for rapid response and transport to the nearest emergency department (ED). A community ED is often supported by a regional pediatric hospital with its regional SPCCT team available for transport when a higher level of care is required. However, for providers in primary care offices and urgent care centers, there is often no standardized process for mobilizing emergency transport resources to transfer children directly to a tertiary care children’s hospital.2 A medical emergency is defined by Heath et al3 as an event that requires equipment and intervention beyond the usual and customary scope of pediatric office practice. Medical emergencies in pediatric offices and urgent care centers are not rare. In Connecticut, pediatric offices report a median of 24 emergencies each year.4 Other studies indicate weekly emergencies in 62% of pediatric offices and monthly emergencies in 82% of pediatric offices.4-6 Moreover, 46% to 66% of primary care offices have called local EMS providers in the previous 12 months.3,7 However, the use of local EMS by primary care providers is sporadic. Some providers are unsure if 71
Table 1. Patient Demographics Category/Subcategory Sex Male Female Race White Black Other/nonwhite Age Age (y), median (IQR) Weight Weight (kg), median (IQR) Chronic medical conditions Asthma Congenital heart disease Down syndrome Seizure Other diabetes, failure to thrive, genetic abnormalities, lupus
Total Patients (N ⫽ 52) n (%) 32 (61.5) 20 (38.5) n (%) 44 (84.6) 3 (5.8) 5 (9.6) 2.01 (0.6-7.0) 13.5 (8-21) n (%) 23 (44.2) 8 (34.7) 5 (21.7) 2 (8.7) 3 (13.0) 10 (43.4)
IQR ⫽ interquartile range. “Other” chronic medical conditions included patients with choanal atresia (n ⫽ 1), biliary atresia (n ⫽ 1), systemic lupus erythematosus (n ⫽ 1), Cornelia de Lange Syndrome (n ⫽ 1), cerebral palsy (n ⫽ 2), diabetes mellitus (n ⫽ 2), and feeding intolerance with gastrostomy tube dependence (n ⫽ 2). Some patients had more than one chronic medical conditions.
Figure 1. Transport request chief complaint. The category “other” included seizure, ruptured appendix, temporal bone fracture, motor vehicle accident, hyperglycemia, failure to thrive, and renal failure.
EMS providers are skilled with pediatric emergencies, whereas other providers choose not to call EMS because of improved efficiency with the family car (61.8%), cost savings to the family (9.3%), and failure to consider EMS (6.5%).8 Many pediatric offices are ill equipped for pediatric emergencies.2,4-6 A study in Wisconsin showed that baseline preparedness for medical and surgical emergencies in physician offices ranges from 37% with intraosseous needles to 96% with albuterol solution.5 Additionally, only 26% of offices require physician certification in pediatric advanced life support.5 Little data exist on pediatric emergency preparedness in 72
the urgent care center setting related to staff, equipment, and the frequency of critical illness requiring transfer of care to a pediatric specialty hospital. There is variability in the willingness and readiness of SPCCT teams to respond to primary care offices and urgent care centers across the country. Furthermore, there are no studies describing the impact of SPCCT teams on transports from these nonhospital clinical settings. Herein, we sought to generate pilot data to describe a single center’s experience with specialized critical care transport response to nonhospital primary care and urgent care settings. We hypothesized that the majority of patients will require procedures outside the scope of practice of most EMS providers and will be better served by SPCCT teams.
Methods This study was an institutional review board–approved retrospective chart review of a 2-year period from January 2009 through December 2010. Our SPCCT fleet comprises 4 mobile intensive care units and 1 dedicated helicopter. The SPCCT team composition is a 3-person crew including a transport nurse, transport respiratory therapist, and transport paramedic. The SPCCT fleet serves over 20 counties encompassing 12,000 square miles and performs 2,500 neonatal and pediatric transports annually. Decisions regarding transport by SPCCT are made after telephone triage, which includes a telephone conversation between the referral physician or practitioner and the SPCCT team medical control physician. The triage includes a discussion about the appropriate mode of transportation, which is influenced by the medical control physician’s opinion that the patient does or might need critical care therapies, although, ultimately, we oblige with sending SPCCT if that is the decision of the referring physician. The triage telephone call does include an assigned disposition for patients transported by local EMS (ED or direct admission), whereas disposition for SPCCT patients is deferred until the assessment of the patient’s status. Only those patients transported by SPCCT were included, and patients referred and triaged but not receiving SPCCT were not included in the analysis. This study included an analysis of all SPCCT team transports that originated from nonhospital settings (primary care office or urgent care center setting). Primary care offices included general pediatrician offices located throughout the region or pediatric subspecialty clinics not located within the hospital campus. Urgent care settings describe communitybased urgent care outpatient settings located outside of the hospital setting. Community-based freestanding EDs are located in the region but were not included in this cohort. The patients were identified through a local transport database that specifies the origin of each transport. Once transports were identified, patient data were extracted from the referral medical record, the transport record, and the inpatient medical record. Data periods were assigned as follows: 1) pretransport care: all care for the patient before the arrival Air Medical Journal 33:2
Figure 2. Pretransport and transport care. IV ⫽ intravenous, IVF ⫽ intravenous fluid, CXR ⫽ chest radiograph.
of the SPCCT, 2) transport care: all care provided to the patient by the SPCCT team either at the referral institution or en route to the tertiary care center, and 3) hospital care: all care provided after arrival at the tertiary care setting including patient outcome data. The data were compiled in a custom database (Excel 2007; Microsoft, Redmond, WA). Descriptive statistics, including means with standard deviations and medians with interquartile ranges (IQRs), were calculated. Statistical tests were applied, including the Fisher exact test for categoric comparisons and the MannWhitney U test for nonparametric data comparisons (SPSSv17.0; SPSS, Armonk, NY).
Results During the 2-year period, a total of 52 patient transports occurred from primary care offices (n ⫽ 42, 81%) or urgent care centers (n ⫽ 10, 19%) using the SPCCT teams. The median age was 2.0 years (IQR ⫽ 0.6-7.0), and the median weight was 13.5 kg (IQR ⫽ 8-21). The majority were male. Underlying chronic medical conditions were common; asthma was the most common (34.7%) (Table 1). There was no prevailing time of day or day of the week for these transfers, although the month of October had the highest number of referral SPCCT transfers (n ⫽ 9). Transport requests were made primarily for respiratory distress (Fig. 1). The most common pretransport therapies provided by referring physicians included the administration of albuterol (42.3%) and steroids (42.3%). Additional pretransTable 2. Critical Care Intervention (n ⫽ 4, 7.7%) Critical Care Intervention Tracheostomy care and ventilator management (n ⫽ 1) Prostaglandin infusion (n ⫽ 1) Insulin infusion (n ⫽ 1) Continuous positive airway pressure (n ⫽ 1)
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port interventions included obtaining a chest radiograph (34.6%), acquiring intravenous (IV) access (28.8%), and administering racemic epinephrine (26.9%) and IV fluid boluses (17.3%). The most common transport interventions provided by the SPCCT team included IV access (26.9%) and IV fluid boluses (26.9%) (Fig. 2). There were 4 (7.7%) patients who received advanced critical care treatments that were not in the typical scope of practice for EMS providers (Table 2). All patients were transported to the tertiary children’s hospital with the majority of patients in this cohort directly admitted to either the general care floor (n ⫽ 34, 65%) or the intensive care units (n ⫽ 12, 23%; pediatric intensive care unit [PICU] ⫽ 11, neonatal intensive care unit ⫽ 1). Three patients (5.7%) were discharged home without hospital admission (Fig. 3). For the 11 patients admitted to the pediatric intensive care unit, the median length of stay (LOS) was 2.5 days (IQR ⫽ 1.0-7.8). All admitted patients survived to hospital discharge with a median hospital LOS of 1.3 days (IQR ⫽ 0.9-4.0). The average SPCCT response time was 48 ⫾ 21 minutes (Table 3). Critical care transports in this cohort were billed $2,660.14 ⫾ $940. Post hoc analysis of primary care office versus urgent care center referrals showed that children originating in the urgent care centers were more likely to be discharged home (0% vs. 30%, respectively; P ⫽ .006), although no differences existed in the PICU or hospital LOS for admitted patients based on the referral origin.
Discussion Contrary to our hypothesis, this study shows that advanced critical care treatments are applied by pediatric SPCCT teams rarely (7.7%) to pediatric patients transported from primary care and urgent care centers. With the exception of 4 patients requiring advanced critical care treatments not typically available to local EMS services, the majority of patients would have access to the necessary acute care therapies if transported by local EMS with the appropriate minimum level of training and experience. The assessment and management of critical illness and injury in pediatric patients can be challenging and requires specialized training and experience.9,10 Pediatric experience in EMS is variable. In areas where specialized pediatric emergency and critical care are unavailable or children undergo interfacility transport by teams without specialty pediatric transport training, patient outcomes are adversely affected with increased morbidity and mortality.9-12 Prospective studies are needed to compare morbidity and mortality rates of similar pediatric patients
Patient Age (y) 1 0.02 15 10
Diagnosis Acute on chronic respiratory failure Coarctation of the aorta Diabetic ketoacidosis Acute respiratory failure, Cornelia de Lange
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Figure 3. Hospital disposition for transported patients. PICU ⫽ pediatric intensive care unit, Floor ⫽ general inpatient unit, NICU ⫽ neonatal intensive care unit, ED ⫽ emergency department, Other ⫽ a single patient transport to another hospital.
Table 3. SPCCT and EMS Response Times Transport Service Model Response Time SPCCT 48 ⫾ 21 min (mean ⫾ SD) EMS (national average, all service types)a 8 min 18 s Volunteer service 9 min 41 s Nonvolunteer 8 min 13 s Mixed service 8 min 24 s EMS ⫽ emergency medical services; SD ⫽ standard deviation; SPCCT ⫽ specialty pediatric critical care transport. aData from Britto et al.17
who are transported from primary care offices and urgent care centers by local EMS versus SPCCT teams. These studies should also focus on delays in care and the effect on patient outcomes to assess the benefits of using SPCCT teams for primary care transport. Alternatively, future studies could potentially incorporate the recently published Transport Risk Assessment in Pediatrics or Transport Pediatric Early Warning System scores to help identify patients who would benefit the most from SPCCT.13,14 In the current “economy of health care” debate, resource overutilization is commonly viewed negatively. The SPCCT team’s response to nonhospital settings could be considered by some as an example of resource overutilization. In this cohort, 23.1% of patients were admitted to the intensive care unit. This would suggest that the availability of pediatric critical care stabilization at the referral center and the provision of critical care monitoring and interventions during transport were necessary for a minority of patients. By taking the level of care commensurate with a PICU to the patient’s bedside in the form of an SPCCT team and equipment, time-sensitive and goal-directed therapies can be initiated early to improve patient outcomes.15-18 However, the response times for SPCCT teams average 40 minutes longer than EMS response times. Based on the longer response times for SPCCT teams to reach the referral location, 74
the referring provider and staff are required to continue necessary high-acuity clinical interventions until SPCCT team arrival. This time commitment, when compared with the national average of 8 to 9 minutes for EMS response times (Table 3), often results in delays in the care of other patients within the primary care offices or urgent care centers.19 Although EMS may be less experienced than SPCCT teams at delivering pediatric care, the referring office staff may be even less qualified and less equipped depending on the local equipment and training.2,3,9,20-23 In the critical care interfacility transport setting, Orr et al11 showed that specialized pediatric transport teams took almost twice as long to arrive at the referral site and spent twice as long on scene but had better outcomes than EMS. The study by Orr et al only looked at interhospital transport, presumably when acute life support could be implemented in the referring ED/pediatric inpatient unit while waiting for the pediatric transport team to arrive. In most situations, timeliness to definitive care, whether delivered by an SPCCT team on site or by transfer to the tertiary care center by EMS, favors EMS over SPCCT in the primary care office/urgent care center setting. Furthermore, in this small, retrospective study, understanding the economic impact on patients who receive more optimal care and ultimately improved outcomes related to SPCCT team care is difficult to discern. The “value” debate requires consideration of the quality of care delivered (ie, efficiency and effectiveness), although the true cost in dollars cannot be ignored. SPCCT teams are costly with a billed fee of $2,660.14 ⫾ $940 in our cohort, whereas representative EMS charges from local services range from free (fully taxpayer funded) to fees of a $725 flat rate or $180 ⫹ $5.50 per loaded mile (Spradlin W., Representative EMS charges, 2012, unpublished data). However, the pediatric advanced skill set makes SPCCT teams inherently more capable of managing critically ill children. This cost, with an ultimate ICU admission rate of 23.1%, suggests that over 75% of patients may have accrued excessive transport costs. There are limitations to this study that warrant discussion. First, this was a retrospective study, and data were extracted without direct input from the SPCCT team caring for each patient or from practitioners at the local referral center. This makes it difficult to draw any conclusions as to why the SPCCT team versus the local EMS was called. Also, having not accounted for patients triaged through the central call center but not transported by SPCCT based on triage acuity or referral preference could have biased this study in an unknown direction. Additionally, the retrospective design and small cohort size limit the strength of the outcome analysis when care was provided by our SPCCT team. We opted to include the use of antibiotics in transport as an intervention within the scope for EMS, although antibiotic use by prehospital EMS teams is variable by state, which may have underestimated by 1 patient the need for SPCCT in this cohort. Furthermore, the single-centered study design may prevent generalizability of the study conclusions. Locally, the individuals responsible for calling Air Medical Journal 33:2
SPCCT teams in our cohort were not surveyed to see if protocols for office emergencies were in place or whether they preferred the SPCCT team to local EMS in times of emergency. Despite these limitations, this is the first description of specialized pediatric transport teams being used to transport patients from nonhospital outpatient clinics and urgent care centers.
Conclusion Our study shows that in a small percentage of patients, advanced critical care treatments are provided by the SPCCT team beyond what can typically be provided by the primary care offices, urgent care centers, or local EMS. Based on these findings, the use of SPCCT teams for primary care and urgent care center transportation should be limited to patients with an anticipated need for advanced critical care therapies. Those patients benefitting most in our cohort and in other regions might include patients with diabetic ketoacidosis requiring insulin infusions, those patients with suspicion of ductal-dependent congenital heart disease with acute ductal closure, or complex technology-dependent patients needing transport management. The majority of patients at the primary care and urgent care settings are better served by local EMS transport. These decisions are best established before transport activation through emergency transport planning between referring providers and the receiving hospital transport service. Finally, collaborative research from other pediatric transport centers is crucial to understanding the needs of these patients nationally.
13. Kandil SB, Sanford HA, Northrup V, Bigham MT, Giuliano JS Jr. Transport disposition using the Transport Risk Assessment in Pediatrics (TRAP) score. Prehosp Emerg Care. 2012;16:366-373. 14. Petrillo-Albarano T, Stockwell J, Leong T, Hebbar K. The use of a modified pediatric early warning score to assess stability of pediatric patients during transport. Pediatr Emerg Care. 2012;28:878-882. 15. Ajizian SJ, Nakagawa TA. Interfacility transport of the critically ill pediatric patient. Chest. 2007;132:1361-1367. 16. Stroud MH, Prodhan P, Moss MM, Anand KJ. Redefining the golden hour in pediatric transport. Pediatr Crit Care Med. 2008;9:435-437. 17. Britto J, Nadel S, Maconochie I, Levin M, Habibi P. Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team. BMJ. 1995;311:836-839. 18. Jouvet P, Lacroix J. Improving interhospital paediatric transport. Lancet. 2010;376:660-661. 19. National EMS Information System (NEMSIS): National Reporting. http://nemsis.org/ reportingTools/reports/nationalReports/password.html. Accessed January 15, 2013. 20. Babl FE, Vinci RJ, Bauchner H, Mottley L. Pediatric pre-hospital advanced life support care in an urban setting. Pediatr Emerg Care. 2001;17:5-9. 21. Barry PW, Ralston C. Adverse events occurring during interhospital transfer of the critically ill. Arch Dis Child. 1994;71:8-11. 22. Klig JE, O'Malley PJ. Pediatric office emergencies. Curr Opin Pediatr. 2007;19:591-596. 23. McCloskey KA, Orr RA. Pediatric transport issues in emergency medicine. Emerg Med Clin North Am. 1991;9:475-489.
References 1. HCUPnet, Healthcare Cost and Utilization Project. http://hcupnet.ahrq.gov/. Accessed January 20, 2013. 2. Santillanes G, Gausche-Hill M, Sosa B. Preparedness of selected pediatric offices to respond to critical emergencies in children. Pediatr Emerg Care. 2006;22:694-698. 3. Heath BW, Coffey JS, Malone P, Courtney J. Pediatric office emergencies and emergency preparedness in a small rural state. Pediatrics. 2000;106:1391-1396. 4. Flores G, Weinstock DJ. The preparedness of pediatricians for emergencies in the office. What is broken, should we care, and how can we fix it? Arch Pediatr Adolesc Med. 1996;150:249-256. 5. Walsh-Kelly CM, Bergholte J, Erschen MJ, Melzer-Lange M. Office preparedness for pediatric emergencies: baseline preparedness and the impact of guideline distribution. Pediatr Emerg Care. 2004;20:289-294. 6. Fuchs S, Jaffe DM, Christoffel KK. Pediatric emergencies in office practices: prevalence and office preparedness. Pediatrics. 1989;83:931-939. 7. Davis CO, Rodewald L. Use of EMS for seriously ill children in the office: a survey of primary care physicians. Prehosp Emerg Care. 1999;3:102-106. 8. Baker MD, Ludwig S. Pediatric emergency transport and the private practitioner. Pediatrics. 1991;88:691-695. 9. Seidel JS, Hornbein M, Yoshiyama K, Kuznets D, Finklestein JZ, St Geme JW Jr. Emergency medical services and the pediatric patient: are the needs being met? Pediatrics. 1984;73:769-772. 10. American Academy of Pediatrics. Committee on Pediatric Emergency Medicine. American College of Critical Care Medicine. Society of Critical Care Medicine. Consensus report for regionalization of services for critically ill or injured children. Pediatrics. 2000;105:152-155. 11. Orr RA, Felmet KA, Han Y, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics. 2009;124:40-48. 12. McPherson ML, Graf JM. Speed isn't everything in pediatric medical transport. Pediatrics. 2009;124:381-383.
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Specialty Pediatric Transport in Primary Care or Urgent Care Settings Crystal N. Joyce, DO,1 John S. Giuliano Jr, MD,2 Michael D. Gothard, MS,3 Hamilton P. Schwartz, MD,4 and Michael T. Bigham, MD1
Abstract Objective: We sought to describe a single center’s experience with specialized critical care transport from non-hospital settings, including primary care offices and urgent care centers. We hypothesized that the majority of patients will require procedures outside the scope of practice of most EMS providers and will be better served by specialized pediatric critical care transport (SPCCT) teams. Methods: This study sought to retrospectively evaluate instances where children (0–18 years old) were transported by our SPCCT team from nonhospital settings, including primary care offices and urgent care centers, in 2009 and 2010. Data were extracted from a customized database and appropriate statistical tests were applied, including Fisher’s exact test for categorical comparisons and Mann-Whitney U test for non-parametric data comparisons. Results: Fifty-two patients were included. Most of the children were transported for respiratory distress (78%), and many were treated with albuterol (42%) and steroids (42%) prior to the SPCCT team arrival. The most common interventions performed by the SPCCT team were obtaining IV access and administering IV fluid boluses; 4 (7.7%) patients required advanced critical care treatments unique to SPCCT. Most patients (n = 34; 65%) were directly admitted to the general care floor, but a high number of patients (n = 12; 23%; PICU = 11, NICU = 1) required pediatric or neonatal intensive care unit admission. Only 3 patients (5.7%) were dis-
1. Akron Children’s Hospital, Department of Pediatrics, Akron, OH, USA 2. Yale University School of Medicine, Department of Pediatrics, Division of Critical Care, New Haven, CT, USA 3. Biostats Inc, East Canton, OH, USA 4. Cincinnati Children’s Hospital, Department of Pediatrics, Division of Emergency Medicine, Cincinnati, OH, USA Address for correspondence: Michael T. Bigham, MD, Department of Pediatrics, Division of Critical Care Medicine, One Perkins Square, Akron, OH 44308, [email protected] Presented as an oral abstract at the American Academy of Pediatrics National Conference and Exhibition, Section on Transport Medicine, October 2011, Boston, MA. 1067-991X/$36.00 Copyright 2014 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2013.12.003 March-April 2014
charged home without hospital admission. For the 11 patients admitted to the PICU, the median length of stay (LOS) was 2.5 days (IQR 0.14–13.2). All patients survived to hospital discharge with an additional hospital LOS of 1.3 days (IQR 0.2–6.7). Patients were billed for these critical care transports an average of $2,660.14 ± $940. Conclusion: Our small cohort demonstrates infrequent application of advanced critical care interventions beyond those provided by the referring primary care office or urgent care centers. This supports the practice of SPCCT teams providing transport services for select critically ill children at primary care offices and urgent care centers, but not as a standard practice for most pediatric patients in these settings.
Introduction Approximately 200,000 infants and children in the United States are transported each year for specialty neonatal or pediatric care unavailable at the referral hospital.1 Interfacility transports are commonly performed by specialty pediatric critical care transport (SPCCT) teams, although sick and injured children also present to a variety of nonhospital settings including school, primary care offices, or urgent care centers and may require emergency care and/or transport to a pediatric hospital for further management. Typically, for pediatric emergencies in the community, local emergency medical services (EMS) are activated via the public safety access point (911) where processes are in place for rapid response and transport to the nearest emergency department (ED). A community ED is often supported by a regional pediatric hospital with its regional SPCCT team available for transport when a higher level of care is required. However, for providers in primary care offices and urgent care centers, there is often no standardized process for mobilizing emergency transport resources to transfer children directly to a tertiary care children’s hospital.2 A medical emergency is defined by Heath et al3 as an event that requires equipment and intervention beyond the usual and customary scope of pediatric office practice. Medical emergencies in pediatric offices and urgent care centers are not rare. In Connecticut, pediatric offices report a median of 24 emergencies each year.4 Other studies indicate weekly emergencies in 62% of pediatric offices and monthly emergencies in 82% of pediatric offices.4-6 Moreover, 46% to 66% of primary care offices have called local EMS providers in the previous 12 months.3,7 However, the use of local EMS by primary care providers is sporadic. Some providers are unsure if 71
Table 1. Patient Demographics Category/Subcategory Sex Male Female Race White Black Other/nonwhite Age Age (y), median (IQR) Weight Weight (kg), median (IQR) Chronic medical conditions Asthma Congenital heart disease Down syndrome Seizure Other diabetes, failure to thrive, genetic abnormalities, lupus
Total Patients (N ⫽ 52) n (%) 32 (61.5) 20 (38.5) n (%) 44 (84.6) 3 (5.8) 5 (9.6) 2.01 (0.6-7.0) 13.5 (8-21) n (%) 23 (44.2) 8 (34.7) 5 (21.7) 2 (8.7) 3 (13.0) 10 (43.4)
IQR ⫽ interquartile range. “Other” chronic medical conditions included patients with choanal atresia (n ⫽ 1), biliary atresia (n ⫽ 1), systemic lupus erythematosus (n ⫽ 1), Cornelia de Lange Syndrome (n ⫽ 1), cerebral palsy (n ⫽ 2), diabetes mellitus (n ⫽ 2), and feeding intolerance with gastrostomy tube dependence (n ⫽ 2). Some patients had more than one chronic medical conditions.
Figure 1. Transport request chief complaint. The category “other” included seizure, ruptured appendix, temporal bone fracture, motor vehicle accident, hyperglycemia, failure to thrive, and renal failure.
EMS providers are skilled with pediatric emergencies, whereas other providers choose not to call EMS because of improved efficiency with the family car (61.8%), cost savings to the family (9.3%), and failure to consider EMS (6.5%).8 Many pediatric offices are ill equipped for pediatric emergencies.2,4-6 A study in Wisconsin showed that baseline preparedness for medical and surgical emergencies in physician offices ranges from 37% with intraosseous needles to 96% with albuterol solution.5 Additionally, only 26% of offices require physician certification in pediatric advanced life support.5 Little data exist on pediatric emergency preparedness in 72
the urgent care center setting related to staff, equipment, and the frequency of critical illness requiring transfer of care to a pediatric specialty hospital. There is variability in the willingness and readiness of SPCCT teams to respond to primary care offices and urgent care centers across the country. Furthermore, there are no studies describing the impact of SPCCT teams on transports from these nonhospital clinical settings. Herein, we sought to generate pilot data to describe a single center’s experience with specialized critical care transport response to nonhospital primary care and urgent care settings. We hypothesized that the majority of patients will require procedures outside the scope of practice of most EMS providers and will be better served by SPCCT teams.
Methods This study was an institutional review board–approved retrospective chart review of a 2-year period from January 2009 through December 2010. Our SPCCT fleet comprises 4 mobile intensive care units and 1 dedicated helicopter. The SPCCT team composition is a 3-person crew including a transport nurse, transport respiratory therapist, and transport paramedic. The SPCCT fleet serves over 20 counties encompassing 12,000 square miles and performs 2,500 neonatal and pediatric transports annually. Decisions regarding transport by SPCCT are made after telephone triage, which includes a telephone conversation between the referral physician or practitioner and the SPCCT team medical control physician. The triage includes a discussion about the appropriate mode of transportation, which is influenced by the medical control physician’s opinion that the patient does or might need critical care therapies, although, ultimately, we oblige with sending SPCCT if that is the decision of the referring physician. The triage telephone call does include an assigned disposition for patients transported by local EMS (ED or direct admission), whereas disposition for SPCCT patients is deferred until the assessment of the patient’s status. Only those patients transported by SPCCT were included, and patients referred and triaged but not receiving SPCCT were not included in the analysis. This study included an analysis of all SPCCT team transports that originated from nonhospital settings (primary care office or urgent care center setting). Primary care offices included general pediatrician offices located throughout the region or pediatric subspecialty clinics not located within the hospital campus. Urgent care settings describe communitybased urgent care outpatient settings located outside of the hospital setting. Community-based freestanding EDs are located in the region but were not included in this cohort. The patients were identified through a local transport database that specifies the origin of each transport. Once transports were identified, patient data were extracted from the referral medical record, the transport record, and the inpatient medical record. Data periods were assigned as follows: 1) pretransport care: all care for the patient before the arrival Air Medical Journal 33:2
Figure 2. Pretransport and transport care. IV ⫽ intravenous, IVF ⫽ intravenous fluid, CXR ⫽ chest radiograph.
of the SPCCT, 2) transport care: all care provided to the patient by the SPCCT team either at the referral institution or en route to the tertiary care center, and 3) hospital care: all care provided after arrival at the tertiary care setting including patient outcome data. The data were compiled in a custom database (Excel 2007; Microsoft, Redmond, WA). Descriptive statistics, including means with standard deviations and medians with interquartile ranges (IQRs), were calculated. Statistical tests were applied, including the Fisher exact test for categoric comparisons and the MannWhitney U test for nonparametric data comparisons (SPSSv17.0; SPSS, Armonk, NY).
Results During the 2-year period, a total of 52 patient transports occurred from primary care offices (n ⫽ 42, 81%) or urgent care centers (n ⫽ 10, 19%) using the SPCCT teams. The median age was 2.0 years (IQR ⫽ 0.6-7.0), and the median weight was 13.5 kg (IQR ⫽ 8-21). The majority were male. Underlying chronic medical conditions were common; asthma was the most common (34.7%) (Table 1). There was no prevailing time of day or day of the week for these transfers, although the month of October had the highest number of referral SPCCT transfers (n ⫽ 9). Transport requests were made primarily for respiratory distress (Fig. 1). The most common pretransport therapies provided by referring physicians included the administration of albuterol (42.3%) and steroids (42.3%). Additional pretransTable 2. Critical Care Intervention (n ⫽ 4, 7.7%) Critical Care Intervention Tracheostomy care and ventilator management (n ⫽ 1) Prostaglandin infusion (n ⫽ 1) Insulin infusion (n ⫽ 1) Continuous positive airway pressure (n ⫽ 1)
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port interventions included obtaining a chest radiograph (34.6%), acquiring intravenous (IV) access (28.8%), and administering racemic epinephrine (26.9%) and IV fluid boluses (17.3%). The most common transport interventions provided by the SPCCT team included IV access (26.9%) and IV fluid boluses (26.9%) (Fig. 2). There were 4 (7.7%) patients who received advanced critical care treatments that were not in the typical scope of practice for EMS providers (Table 2). All patients were transported to the tertiary children’s hospital with the majority of patients in this cohort directly admitted to either the general care floor (n ⫽ 34, 65%) or the intensive care units (n ⫽ 12, 23%; pediatric intensive care unit [PICU] ⫽ 11, neonatal intensive care unit ⫽ 1). Three patients (5.7%) were discharged home without hospital admission (Fig. 3). For the 11 patients admitted to the pediatric intensive care unit, the median length of stay (LOS) was 2.5 days (IQR ⫽ 1.0-7.8). All admitted patients survived to hospital discharge with a median hospital LOS of 1.3 days (IQR ⫽ 0.9-4.0). The average SPCCT response time was 48 ⫾ 21 minutes (Table 3). Critical care transports in this cohort were billed $2,660.14 ⫾ $940. Post hoc analysis of primary care office versus urgent care center referrals showed that children originating in the urgent care centers were more likely to be discharged home (0% vs. 30%, respectively; P ⫽ .006), although no differences existed in the PICU or hospital LOS for admitted patients based on the referral origin.
Discussion Contrary to our hypothesis, this study shows that advanced critical care treatments are applied by pediatric SPCCT teams rarely (7.7%) to pediatric patients transported from primary care and urgent care centers. With the exception of 4 patients requiring advanced critical care treatments not typically available to local EMS services, the majority of patients would have access to the necessary acute care therapies if transported by local EMS with the appropriate minimum level of training and experience. The assessment and management of critical illness and injury in pediatric patients can be challenging and requires specialized training and experience.9,10 Pediatric experience in EMS is variable. In areas where specialized pediatric emergency and critical care are unavailable or children undergo interfacility transport by teams without specialty pediatric transport training, patient outcomes are adversely affected with increased morbidity and mortality.9-12 Prospective studies are needed to compare morbidity and mortality rates of similar pediatric patients
Patient Age (y) 1 0.02 15 10
Diagnosis Acute on chronic respiratory failure Coarctation of the aorta Diabetic ketoacidosis Acute respiratory failure, Cornelia de Lange
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Figure 3. Hospital disposition for transported patients. PICU ⫽ pediatric intensive care unit, Floor ⫽ general inpatient unit, NICU ⫽ neonatal intensive care unit, ED ⫽ emergency department, Other ⫽ a single patient transport to another hospital.
Table 3. SPCCT and EMS Response Times Transport Service Model Response Time SPCCT 48 ⫾ 21 min (mean ⫾ SD) EMS (national average, all service types)a 8 min 18 s Volunteer service 9 min 41 s Nonvolunteer 8 min 13 s Mixed service 8 min 24 s EMS ⫽ emergency medical services; SD ⫽ standard deviation; SPCCT ⫽ specialty pediatric critical care transport. aData from Britto et al.17
who are transported from primary care offices and urgent care centers by local EMS versus SPCCT teams. These studies should also focus on delays in care and the effect on patient outcomes to assess the benefits of using SPCCT teams for primary care transport. Alternatively, future studies could potentially incorporate the recently published Transport Risk Assessment in Pediatrics or Transport Pediatric Early Warning System scores to help identify patients who would benefit the most from SPCCT.13,14 In the current “economy of health care” debate, resource overutilization is commonly viewed negatively. The SPCCT team’s response to nonhospital settings could be considered by some as an example of resource overutilization. In this cohort, 23.1% of patients were admitted to the intensive care unit. This would suggest that the availability of pediatric critical care stabilization at the referral center and the provision of critical care monitoring and interventions during transport were necessary for a minority of patients. By taking the level of care commensurate with a PICU to the patient’s bedside in the form of an SPCCT team and equipment, time-sensitive and goal-directed therapies can be initiated early to improve patient outcomes.15-18 However, the response times for SPCCT teams average 40 minutes longer than EMS response times. Based on the longer response times for SPCCT teams to reach the referral location, 74
the referring provider and staff are required to continue necessary high-acuity clinical interventions until SPCCT team arrival. This time commitment, when compared with the national average of 8 to 9 minutes for EMS response times (Table 3), often results in delays in the care of other patients within the primary care offices or urgent care centers.19 Although EMS may be less experienced than SPCCT teams at delivering pediatric care, the referring office staff may be even less qualified and less equipped depending on the local equipment and training.2,3,9,20-23 In the critical care interfacility transport setting, Orr et al11 showed that specialized pediatric transport teams took almost twice as long to arrive at the referral site and spent twice as long on scene but had better outcomes than EMS. The study by Orr et al only looked at interhospital transport, presumably when acute life support could be implemented in the referring ED/pediatric inpatient unit while waiting for the pediatric transport team to arrive. In most situations, timeliness to definitive care, whether delivered by an SPCCT team on site or by transfer to the tertiary care center by EMS, favors EMS over SPCCT in the primary care office/urgent care center setting. Furthermore, in this small, retrospective study, understanding the economic impact on patients who receive more optimal care and ultimately improved outcomes related to SPCCT team care is difficult to discern. The “value” debate requires consideration of the quality of care delivered (ie, efficiency and effectiveness), although the true cost in dollars cannot be ignored. SPCCT teams are costly with a billed fee of $2,660.14 ⫾ $940 in our cohort, whereas representative EMS charges from local services range from free (fully taxpayer funded) to fees of a $725 flat rate or $180 ⫹ $5.50 per loaded mile (Spradlin W., Representative EMS charges, 2012, unpublished data). However, the pediatric advanced skill set makes SPCCT teams inherently more capable of managing critically ill children. This cost, with an ultimate ICU admission rate of 23.1%, suggests that over 75% of patients may have accrued excessive transport costs. There are limitations to this study that warrant discussion. First, this was a retrospective study, and data were extracted without direct input from the SPCCT team caring for each patient or from practitioners at the local referral center. This makes it difficult to draw any conclusions as to why the SPCCT team versus the local EMS was called. Also, having not accounted for patients triaged through the central call center but not transported by SPCCT based on triage acuity or referral preference could have biased this study in an unknown direction. Additionally, the retrospective design and small cohort size limit the strength of the outcome analysis when care was provided by our SPCCT team. We opted to include the use of antibiotics in transport as an intervention within the scope for EMS, although antibiotic use by prehospital EMS teams is variable by state, which may have underestimated by 1 patient the need for SPCCT in this cohort. Furthermore, the single-centered study design may prevent generalizability of the study conclusions. Locally, the individuals responsible for calling Air Medical Journal 33:2
SPCCT teams in our cohort were not surveyed to see if protocols for office emergencies were in place or whether they preferred the SPCCT team to local EMS in times of emergency. Despite these limitations, this is the first description of specialized pediatric transport teams being used to transport patients from nonhospital outpatient clinics and urgent care centers.
Conclusion Our study shows that in a small percentage of patients, advanced critical care treatments are provided by the SPCCT team beyond what can typically be provided by the primary care offices, urgent care centers, or local EMS. Based on these findings, the use of SPCCT teams for primary care and urgent care center transportation should be limited to patients with an anticipated need for advanced critical care therapies. Those patients benefitting most in our cohort and in other regions might include patients with diabetic ketoacidosis requiring insulin infusions, those patients with suspicion of ductal-dependent congenital heart disease with acute ductal closure, or complex technology-dependent patients needing transport management. The majority of patients at the primary care and urgent care settings are better served by local EMS transport. These decisions are best established before transport activation through emergency transport planning between referring providers and the receiving hospital transport service. Finally, collaborative research from other pediatric transport centers is crucial to understanding the needs of these patients nationally.
13. Kandil SB, Sanford HA, Northrup V, Bigham MT, Giuliano JS Jr. Transport disposition using the Transport Risk Assessment in Pediatrics (TRAP) score. Prehosp Emerg Care. 2012;16:366-373. 14. Petrillo-Albarano T, Stockwell J, Leong T, Hebbar K. The use of a modified pediatric early warning score to assess stability of pediatric patients during transport. Pediatr Emerg Care. 2012;28:878-882. 15. Ajizian SJ, Nakagawa TA. Interfacility transport of the critically ill pediatric patient. Chest. 2007;132:1361-1367. 16. Stroud MH, Prodhan P, Moss MM, Anand KJ. Redefining the golden hour in pediatric transport. Pediatr Crit Care Med. 2008;9:435-437. 17. Britto J, Nadel S, Maconochie I, Levin M, Habibi P. Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team. BMJ. 1995;311:836-839. 18. Jouvet P, Lacroix J. Improving interhospital paediatric transport. Lancet. 2010;376:660-661. 19. National EMS Information System (NEMSIS): National Reporting. http://nemsis.org/ reportingTools/reports/nationalReports/password.html. Accessed January 15, 2013. 20. Babl FE, Vinci RJ, Bauchner H, Mottley L. Pediatric pre-hospital advanced life support care in an urban setting. Pediatr Emerg Care. 2001;17:5-9. 21. Barry PW, Ralston C. Adverse events occurring during interhospital transfer of the critically ill. Arch Dis Child. 1994;71:8-11. 22. Klig JE, O'Malley PJ. Pediatric office emergencies. Curr Opin Pediatr. 2007;19:591-596. 23. McCloskey KA, Orr RA. Pediatric transport issues in emergency medicine. Emerg Med Clin North Am. 1991;9:475-489.
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