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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.

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transporting sick children

Transporting Sick Children

Safety, Critical Incidents, Insurance

importance
Importance
  • Rationale for dedicated retrievals is to offer better service than previously existed
  • Evidence that specialised teams perform better.
slide3
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.
slide4
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
slide5

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%).
slide6

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
Why is it safer with specialist teams
  • Familiarity with age group
  • Familiarity with equipment
  • More experienced
  • Learned from previous ‘mistakes’
learning from mistakes
Learning from mistakes
  • Blame free
  • Critical incident reporting
  • Regular transport meetings
  • Enable prevention
latent failures
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
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
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
Actions
  • Mannual check on ambulance oxygen supply re-emphasized
  • Check all ventilator connections after each change in oxygen supply
importance of process
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
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
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
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
Safety points -staff
  • Seatbelts
  • Use winch correctly
  • No interventions ‘on the move’
  • Communicate with ambulance driver – comfort and speed
  • Blue light rarely needed
air retrievals1
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
Stabilisation
  • Few situations scoop and run
  • Exceptions
    • Extradural haematoma
    • Blocked VP shunt
  • Much better to achieve stability prior to departure – may take some time.
slide26

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
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
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
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