Transporting Sick Children
Transporting Sick Children. Safety, Critical Incidents, Insurance. Importance. Rationale for dedicated retrievals is to offer better service than previously existed Evidence that specialised teams perform better.
Transporting Sick Children
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Transporting Sick Children Safety, Critical Incidents, Insurance
Importance • Rationale for dedicated retrievals is to offer better service than previously existed • Evidence that specialised teams perform better.
Barry PW, Ralston C. Adverse events occurring during inter-hospital transfer of the critically ill. Arch Dis Child 1994;71:8-11 • Observational study in Leicester of 56 children transferred in for PICU. • Adverse events in 42 (75%) – 13 were life threatening incidents • These transfers tended to have been undertaken by inexperienced staff.
Macnab, A. J. (1991). "Optimal escort for interhospital transport of pediatric emergencies." J Trauma 31(2): 205-9. • Chart review 130 paediatric transfers looking for adverse events during transit • 8% occurred with 8% occurred with specialized pediatric transport escorts who were accompanied by a tertiary care physician • 20% with specialized pediatric transport escorts alone • 72% with escorts who had not received specialized pediatric transport training
Edge WE, Kanter RK, Weigle CGM et al. Reduction of morbidity in inter-hospital transport by specialised paediatric staff. Crit Care Med 1994; 22: 1186-1191 • Prospective study of adverse events during transport Albany NY, Syracuse NY. • ICU related adverse events 1/47 specialised transports (2%) and 18/92 non-specialised (20%). • Physiological deterioration 5/47 specialised (11%), 11/92 non-specialised (12%).
Britto, J., S. Nadel, et al. Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team. BMJ 1995; 311: 836-9 • Prospective descriptive study 51 cases Mary’s PICU retrieved from DGH • 2 cases had preventable physiological deterioration • PRISM score improved during transfer and stabilisation
Why is it safer with specialist teams • Familiarity with age group • Familiarity with equipment • More experienced • Learned from previous ‘mistakes’
Learning from mistakes • Blame free • Critical incident reporting • Regular transport meetings • Enable prevention
Latent failures • Poor communication • Referral • With ambulance crew • Doctor-nurse • Poor process • No routine pattern • No check lists • Poor equipment maintenance • Includes kit checks
Example • Transfer from hospital 1 hour away • 30 mins into transfer ventilator stops • Patient transferred to Ayre’s T-piece from portable cylinder – no desaturation • Oxygen cylinder in ambulance empty – allegedly full (size F) at start of journey • Back up cylinder full – supply changed – ventilator connectors tightened
Who’s fault? • Was oxygen cylinder full at departure – not properly checked • Was ventilator checked prior to transfer – yes • Previous experience – ventialtors can develop leaks
Actions • Mannual check on ambulance oxygen supply re-emphasized • Check all ventilator connections after each change in oxygen supply
Importance of process • Sick neonate 32/40 NEC, high O2 requirement • Safely transferred 40 miles • Arrived NICU • Handover – staff started to move baby before this was complete – ‘don’t worry the ventilator’s set up’ • Ventilator failed – took 30 secs to recognise – baby desaturated • No bagging circuit attached – transport incubator had to be used as emergency back up
Action • Transporting doctor responsible for supervising all aspects of transfer until baby is stable on receiving unit’s ventilator • Full attention of all staff during verbal handover – no switching over of monitors etc. • Don’t move a patient until bagging circuit available and turned on
Think ahead • Identify problems before they occur • Surprises will happen – expect them and deal with them – ABC principles. • Ensure you can always isolate the patient quickly from equipment and use failsafe ABC - Ambubag
Safety points - patient • Medical equipment secure and visible • End tidal CO2 • All monitoring functioning prior to departure • Secure IV access • Secure ETT in correct position • Secured to trolley
Safety points -staff • Seatbelts • Use winch correctly • No interventions ‘on the move’ • Communicate with ambulance driver – comfort and speed • Blue light rarely needed
Air retrievals • Lack of power • Effects on pO2 • Pressurised vs unpressurised • Unforseen delays • Multiple patient movements • Trolley ambulance • Ambulance plane • Plane ambulance • Ambulance trolley
Stabilisation • Few situations scoop and run • Exceptions • Extradural haematoma • Blocked VP shunt • Much better to achieve stability prior to departure – may take some time.
Whitfield JM, Buser NNP. Transport stabilisation times for neonatal and paediatric transfers prior to interfacility transfer. Pediatr Emerg Care 1993; 9: 67-71. • Median stabilisation time for 1193 ventilated children - 74 mins • If receiving inotropes - 150 minutes.
Transferring patient with severe ARDS A – Secure ETT – check position on CXR – ensure minimal leak as high pressure ventilation necessary B – Realistic targets – O2sats 85 – 92%, pH >7.25 Use high PEEP – 10-15cm – needs to be active PEEP. Long Tinsp, High FiO2. Allow time to recruit alveoli. C – Good access, well filled, inotropes as required.
Oxygen calculation • Minute volume estimated journey time 2 – rounded up • D cylinder 340L • E cylinder 680L • F cylinder 1360L • Spare cylinder heads and O rings
Summary • PICU retrieval team have been specially trained for the purpose • Almost never acceptable to transfer patient if not stable • Air retrievals carry extra risks
