Transporting Sick ChildrenTransporting Sick Children

Safety, Critical Incidents, Safety, Critical Incidents, InsuranceInsurance

ImportanceImportance

• Rationale for dedicated retrievals is Rationale for dedicated retrievals is to offer better service than to offer better service than previously existedpreviously existed

• Evidence that specialised teams Evidence that specialised teams perform better.perform better.

Barry PW, Ralston C. Adverse events Barry PW, Ralston C. Adverse events occurring during inter-hospital transfer of occurring during inter-hospital transfer of the critically ill. Arch Dis Child 1994;71:8-11the critically ill. Arch Dis Child 1994;71:8-11

• Observational study in Leicester of Observational study in Leicester of 56 children transferred in for PICU.56 children transferred in for PICU.

• Adverse events in 42 (75%) – 13 Adverse events in 42 (75%) – 13 were life threatening incidents were life threatening incidents

• These transfers tended to have been These transfers tended to have been undertaken by inexperienced staff.undertaken by inexperienced staff.

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

• Chart review 130 paediatric transfers looking for Chart review 130 paediatric transfers looking for adverse events during transitadverse events during transit

• 8% occurred with 8% occurred with specialized 8% occurred with 8% occurred with specialized pediatric transport escorts who were pediatric transport escorts who were accompanied by a tertiary care physician accompanied by a tertiary care physician

• 20% with specialized pediatric transport escorts 20% with specialized pediatric transport escorts alonealone

• 72% with escorts who had not received 72% with escorts who had not received specialized pediatric transport trainingspecialized pediatric transport training

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

• Prospective study of adverse events Prospective study of adverse events during transport Albany NY, Syracuse NY. during transport Albany NY, Syracuse NY.

• ICU related adverse events 1/47 ICU related adverse events 1/47 specialised transports (2%) and 18/92 specialised transports (2%) and 18/92 non-specialised (20%). non-specialised (20%).

• Physiological deterioration 5/47 Physiological deterioration 5/47 specialised (11%), 11/92 non-specialised specialised (11%), 11/92 non-specialised (12%).(12%).

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

• Prospective descriptive study 51 Prospective descriptive study 51 cases Mary’s PICU retrieved from cases Mary’s PICU retrieved from DGH DGH

• 2 cases had preventable 2 cases had preventable physiological deterioration physiological deterioration

• PRISM score improved during PRISM score improved during transfer and stabilisationtransfer and stabilisation

Why is it safer with specialist Why is it safer with specialist teamsteams

• Familiarity with age groupFamiliarity with age group

• Familiarity with equipmentFamiliarity with equipment

• More experiencedMore experienced

• Learned from previous ‘mistakes’Learned from previous ‘mistakes’

Learning from mistakesLearning from mistakes

• Blame freeBlame free

• Critical incident reportingCritical incident reporting

• Regular transport meetingsRegular transport meetings

• Enable preventionEnable prevention

Latent failuresLatent failures

• Poor communicationPoor communication– ReferralReferral– With ambulance crewWith ambulance crew– Doctor-nurseDoctor-nurse

• Poor processPoor process– No routine patternNo routine pattern– No check listsNo check lists

• Poor equipment maintenancePoor equipment maintenance– Includes kit checksIncludes kit checks

ExampleExample

• Transfer from hospital 1 hour awayTransfer from hospital 1 hour away• 30 mins into transfer ventilator stops30 mins into transfer ventilator stops• Patient transferred to Ayre’s T-piece Patient transferred to Ayre’s T-piece

from portable cylinder – no from portable cylinder – no desaturationdesaturation

• Oxygen cylinder in ambulance empty – Oxygen cylinder in ambulance empty – allegedly full (size F) at start of journeyallegedly full (size F) at start of journey

• Back up cylinder full – supply changed Back up cylinder full – supply changed – ventilator connectors tightened– ventilator connectors tightened

Who’s fault?Who’s fault?

• Was oxygen cylinder full at departure Was oxygen cylinder full at departure – not properly checked– not properly checked

• Was ventilator checked prior to Was ventilator checked prior to transfer – yes transfer – yes

• Previous experience – ventialtors can Previous experience – ventialtors can develop leaksdevelop leaks

ActionsActions

• Mannual check on ambulance oxygen Mannual check on ambulance oxygen supply re-emphasizedsupply re-emphasized

• Check all ventilator connections after Check all ventilator connections after each change in oxygen supplyeach change in oxygen supply

Importance of processImportance of process

• Sick neonate 32/40 NEC, high OSick neonate 32/40 NEC, high O22 requirement requirement• Safely transferred 40 milesSafely transferred 40 miles• Arrived NICUArrived NICU• Handover – staff started to move baby before Handover – staff started to move baby before

this was complete – ‘don’t worry the this was complete – ‘don’t worry the ventilator’s set up’ventilator’s set up’

• Ventilator failed – took 30 secs to recognise – Ventilator failed – took 30 secs to recognise – baby desaturatedbaby desaturated

• No bagging circuit attached – transport No bagging circuit attached – transport incubator had to be used as emergency back incubator had to be used as emergency back upup

ActionAction

• Transporting doctor responsible for Transporting doctor responsible for supervising all aspects of transfer supervising all aspects of transfer until baby is stable on receiving until baby is stable on receiving unit’s ventilatorunit’s ventilator

• Full attention of all staff during Full attention of all staff during verbal handover – no switching over verbal handover – no switching over of monitors etc.of monitors etc.

• Don’t move a patient until bagging Don’t move a patient until bagging circuit available and turned oncircuit available and turned on

Think aheadThink ahead

• Identify problems before they occurIdentify problems before they occur

• Surprises will happen – expect them Surprises will happen – expect them and deal with them – ABC principles.and deal with them – ABC principles.

• Ensure you can always isolate the Ensure you can always isolate the patient quickly from equipment and patient quickly from equipment and use failsafe ABC - Ambubaguse failsafe ABC - Ambubag

Safety points - patientSafety points - patient

• Medical equipment secure and visibleMedical equipment secure and visible

• End tidal COEnd tidal CO22

• All monitoring functioning prior to All monitoring functioning prior to departuredeparture

• Secure IV accessSecure IV access

• Secure ETT in correct positionSecure ETT in correct position

• Secured to trolleySecured to trolley

SafetySafety

Safety points -staffSafety points -staff

• SeatbeltsSeatbelts

• Use winch correctlyUse winch correctly

• No interventions ‘on the move’No interventions ‘on the move’

• Communicate with ambulance driver Communicate with ambulance driver – comfort and speed– comfort and speed

• Blue light rarely neededBlue light rarely needed

CATS – Complications CATS – Complications 20022002

Ambulance relatedEquipment RelatedPatient relatedOther

CATS - Complication Rate 2002CATS - Complication Rate 2002

0

10

20

30

40

50

60

70

80

% Complications ofall Transfers

% Ambulance related

ChecklistsChecklists

Air retrievalsAir retrievals

Air retrievalsAir retrievals

• Lack of power Lack of power • Effects on pO2Effects on pO2• Pressurised vs unpressurisedPressurised vs unpressurised• Unforseen delaysUnforseen delays• Multiple patient movementsMultiple patient movements

– Trolley Trolley ambulance ambulance– Ambulance Ambulance plane plane– Plane Plane ambulance ambulance– Ambulance Ambulance trolley trolley

StabilisationStabilisation

• Few situations scoop and runFew situations scoop and run

• ExceptionsExceptions– Extradural haematomaExtradural haematoma– Blocked VP shuntBlocked VP shunt

• Much better to achieve stability prior Much better to achieve stability prior to departure – may take some time.to departure – may take some time.

Whitfield JM, Buser NNP. Transport Whitfield JM, Buser NNP. Transport stabilisation times for neonatal and stabilisation times for neonatal and paediatric transfers prior to interfacility paediatric transfers prior to interfacility transfer. transfer.

Pediatr Emerg Care 1993; 9: 67-71Pediatr Emerg Care 1993; 9: 67-71..

• Median stabilisation time for 1193 Median stabilisation time for 1193 ventilated children - 74 minsventilated children - 74 mins

• If receiving inotropes - 150 minutes.If receiving inotropes - 150 minutes.

Transferring patient with Transferring patient with severe ARDSsevere ARDS

A – Secure ETT – check position on CXR – ensure A – Secure ETT – check position on CXR – ensure minimal leak as high pressure ventilation minimal leak as high pressure ventilation necessarynecessary

B – Realistic targets – OB – Realistic targets – O22sats 85 – 92%, pH >7.25sats 85 – 92%, pH >7.25Use high PEEP – 10-15cm – needs to be active Use high PEEP – 10-15cm – needs to be active PEEP.PEEP.

Long TLong Tinsp, insp, High FHigh FiiOO22..Allow time to recruit alveoli.Allow time to recruit alveoli.

C – Good access, well filled, inotropes as C – Good access, well filled, inotropes as required.required.

Oxygen calculationOxygen calculation

•Minute volume Minute volume estimated estimated journey time journey time 2 – rounded up 2 – rounded up– D cylinder 340LD cylinder 340L– E cylinder 680LE cylinder 680L– F cylinder 1360LF cylinder 1360L

•Spare cylinder heads and O rings Spare cylinder heads and O rings

SummarySummary

• PICU retrieval team have been PICU retrieval team have been specially trained for the purposespecially trained for the purpose

• Almost never acceptable to transfer Almost never acceptable to transfer patient if not stablepatient if not stable

• Air retrievals carry extra risksAir retrievals carry extra risks

AMF YOYOAMF YOYO