Pediatric Intensive Care Transport Jonathan Cu, MD Pediatric Emergency Specialist Neonatal and Pediatric Critical Care Transport Specialist Neonatal and Pediatric Intensive Care Transport Unit Neonatal and Pediatric Intensive Care Transport Unit Goal and Objectives Give a background on pediatric intensive care transport Understand the goals and principles of pediatric transport Identify the basic components of a pediatric intensive care transport team Recognize factors involved in choosing various modes of transport Case 1 37/F, pregnant, 28 weeks AOG 2-week vacation in far flung rural area Went into preterm labor Brought to community hospital and delivered Outcome: preterm 28 weeks 800grams AGA delivered via SVD, live baby boy, APGAR 4,6 Case 1 Patient has poor activity, gasping, HR 140, pink centrally but has poor distal perfusion, Temp 34C sats 85% Problem: no local neonatologist/intensivist and no ICU facilities Local doctor were able to thermoregulate, give O2 support but has difficulty cannulating and reluctant to perform endotracheal intubation Asking for help from tertiary referral centre Case 2 3/M vacation in a beach with family Near drowning, submerged for 5 minutes Initially HR 0 CPR performed for 10 minutes with ROSC Paramedics arrived, intubated the patient and transferred to a local hospital Case 2 Upon arrival in ED of a local hospital, having hypotensive episodes and desaturations while on ambubagging Problem: no local ICU facilities and no intensivist available Called a tertiary referral centre asking for help Problems What can we offer in a community hospital setting Who to talk to and how to refer to a tertiary referral centre Who will arrange for an ICU bed Who will coordinate for a safe transfer What can we do for the patient while waiting for help to arrive Bahala na si… Neonatal and Pediatric Intensive Care Transport Unit Specialized service dedicated in providing intensive care to critically ill child anywhere at any time Provide expert clinical advise Clinical coordinator Emergency treatment and stabilization Bringing ICU to the patient Interhospital transport Background In the United States, Australia, UK and Canada, hospital-based neonatal transport programs were first created in the 1960s and 1970s Similar programs for older infants and children emerged in the 1980s Became well-developed in countries with a centralized healthcare system Background Neonatal-pediatric transport programs part of the continuum of care in a system of emergency medical services for children They provide a safe, therapeutic environment for pediatric patients who must be transferred between health care institutions under urgent or emergent circumstances Diagnostic Categories Of Children Transported Specialized transport team vs. Paramedics Paramedics Specialized transport team Primary retrievals Secondary/hospital Not equipped Adequate planning and Not trained in handling intensive care Scoop and run principle retrieval equipment Intensive experience in ICU/Emergency care Early goal-directed treament Bringing ICU to the patient The Tortoise and the Hare The Golden Hour Concept originated in 1973 by Cowley et al. Referred to Army helicopter use Goal for soldiers to be within 35 minutes of definitive life-saving care Stated a 3 fold increase in mortality with every 30 minutes away from ‘definitive care No available data to support claim Resulted in less field intervention in favor of speed of transport Interventions on transport in 1973, not comparable to our capabilities today Pediatric arrest Primary cardiac arrest in infants and children is rare Pediatric cardiac arrest is often preceded by respiratory failure and/or shock and it is rarely sudden Early intervention and continued monitoring can prevent arrest The terminal rhythm in children is usually bradycardia that progresses to PEA and asystole Septic shock is the most common form of shock in the pediatric population 80% of children in septic shock will require intubation and mechanical ventilation within 24 hours of admission Interesting facts… EMS programs for paramedics offers <10 hours pediatric training No pediatric blood pressure cuffs (24%) No pediatric airway equipments (79%) Seidel JS et al. Circulation 1986 Interesting facts… According to AAP, average EMS provider sees: 1 peds BVM case q 1.7 years 1 peds intubation q 3.3 years 1 peds IO line q 6.7 years Interesting facts… Paramedics were less confident in assessing vital signs for <2 years old Children <14 years old undertreated as compared with adults Gausche M et al, Acad Emerg Med 1998 Twice as many patients transported by standard paramedic/ambulance service died in the first 12 hours after admission Bellingan G et al, Intensive Care Med 2000 Orr RA et al, Pediatrics 2009 Specialized Pediatric Transport Team Fewer unplanned events (61% vs. 1.5%), 38 times higher for patients transported by nonspecialized team Significantly lower mortality rate (23% vs. 9%), >2 times higher for patients transported by nonspecialized team Orr RA, et al, Pediatrics 2009 Intensive Care Med 2004 Intensive Care Med 2004 Intensive Care Med 2004 Siriraj Hospital (Thailand) Retrospective review of interhospital transport Total number transported from 2001 to 2003: 36 All road transfers Accompanying medical personnel: nurses (55%), the rest paramedics 63.9% intubated, 28% ongoing inotropes J Med Assoc Thai 2005 Siriraj Hospital (Thailand) Upon arrival, none of the patients had any record on important patient’s data (no vital signs monitoring, oxygen saturation or adverse events) 77.8% needed prolonged PICU stay 31% mortality rate J Med Assoc Thai 2005 Goal of Pediatric Intensive Care Transport Early direction and initiation of advanced care Treatment and monitoring with the expected expertise and capabilities of the tertiary care center while the patient is still in the referring facility Improve safety of the transport and patient outcome. Initiation of ‘definitive’ care Definitive care begins with the arrival of the transport team Early goal directed treatment improves outcomes Needs to begin with the local emergency departments and continue with the transport team Early aggressive interventions to reverse shock can increase survival by 9 fold if proper interventions are done early! Hypotension and poor organ perfusion worsens outcomes “Further improvement in the outcome of critical illness is likely if the scoop-and-run mentality is replaced by protocol driven, early goal-directed therapy in the pretertiary hospital setting” Stroud et al., 2008 Initiation of ‘definitive’ care Ramnarayan (2009) Urgent vital interventions such as CPR, intubation or central venous access required in the first hour after arrival in an ICU May indicate that inadequate stabilization was completed during transport McPhearson and Graf (2009) Attention to small details makes significant difference in pediatric transport Securing ETT Early recognition and treatment of shock Adequate IV access Essential components Dedicated team proficient at providing neonatal and/or pediatric critical care during transport Essential components Medical control by qualified physicians Ground and/or air ambulance capabilities Communications/dispatch capabilities 24/7 availability Written clinical and operational guidelines Essential components Quality and performance improvement activities Administrative resources Institutional endorsement and financial support. Med Control Physician PEDS ER or PICU consultant with sufficient knowledge and experience in transport medicine Accepts pt, consults subs Sends appropriate team Directs stabilization Provides ongoing direction to transport team How does it work? Retrieval Consultant Referring Doctor Clinical Coordinator Retrieval Team Accepting Specialist Team Composition Depends on the patient’s needs determined in consultation with the team and medical control Dedicated pool of qualified physicians, nurses, paramedics and/or respiratory therapists Team Composition Retrieval specialist Critical care nurse / Nurse Practitioner +/- Respiratory therapist Ambulance driver/pilot Team Composition A team member’s degree is less important than his or her ability to provide the level of care required Critical care during transport conditions is significantly different from an ICU or ED Team Composition Should not be assumed that a health care professional who is competent in the ICU or ED will function equally well in a mobile environment Equipments Modified Stretcher/Incubator system newborn, infant, toddler, adult system Backpacks - ABCs Medication bag – inotropes, surfactant, etc… Syringe / infusion pumps with long battery life +/- nitric oxide machine Ambulance fitted with oxygen(4500L) and air(4500L), Zoll defibrillator, Laerdal electric suction, transilluminator, charger, refrigerator Communication devices Mode of Transport Road Ambulance Rotary wing Fixed wing Vehicle selection Ground – space and option to stop Fixed Wing – stability in bad weather Helicopter – land at scene, speed Determining mode Four critical steps necessary for selection of the optimal mode Evaluation of the current patient status Evaluation of care the required before and during transport Urgency of the transport Logistics of a patient transport (e.g., local resources available for transport, weather considerations, and ground traffic accessibility) Ground Vs Air Beyond 100 miles, a ground may become inefficient, costly to operate, and time consuming Helicopter is used for up to 150 mile radius Fixed wing greater than 150 Ground Vs Air Distance to the closest appropriate facility is too great for safe and timely transport by ground ambulance The potential for transport delay that may be associated with the use of ground transport (e.g., traffic and distance) is likely to worsen the patient's clinical condition Key Points Good communication = good decision-making Adequate resuscitation and proper stabilization prior to transport Expect for the worst case scenario Retrieval team’s worst nightmare – Resuscitation / Arrest en route Back to Case 1 Fortunately, there is an available Neonatal and Pediatric Intensive Care Transport Unit Conference call made with the neonatologist oncall Referring physician advised to keep the baby thermoregulated, instructed to use neopuff and gave step by step instruction on how to put an umbilical line to provide fluids and glucose while the retrieval team was being mobilised. Back to Case 1 Upon arrival, patient was intubated, sedated, given surfactant and connected to transport ventilator. Vitals: HR 140 BP 70/40 sats 95% Temp 36.5 C CRT 2secs CXR done Blood gas taken with iSTAT Transferred to transport incubator Brought back to tertiary referral centre uneventful Back to Case 2 Conference call with PICU was arranged while to retrieval team went en route GCS 3, HR 120, intubated on ambubagging, BP 70 systolic, CRT 3-4 secs. Advised to give bolus of 20ml/kg pNSS and to start Dopa at 10mcg/kg/min BP and perfusion improved Back to Case 2 Team arrived within 1 hour Hooked to transport ventilator, sedated and paralyzed oxygen saturation improved and blood gas acceptable Central line inserted for IV fluids and inotropes Arterial line inserted for BP monitoring Maintained on Temp 33-34 C Transported back to tertiary referral centre uneventful Stayed in PICU for 7 days and transferred to regular bed after with no neurologic deficit Do we need a Specialized Transport System? Utility vs Futility The benefits of transport must outweigh the risks for the patient limited space, equipment, staff separation from family The risks/costs of transport must be justified Cost The approximate cost of a medically configured ground ambulance is approximately $150 000 to $350 000, depending on the manufacturer and model selected The annual maintenance and fuel costs might range from $10 000 to $25 000 per vehicle Cost Single-engine helicopter A-Star or Bell 407 averages $2 million. A light twin-engine helicopter EC145 and Bell 430, both medium-sized twin engine helicopters, cost between $4 and $6 million While a large twin-engine helicopter about $1-2 million more Cost Pilot salaries range from $60,000 to $85,000 annually; a staff of four is required to cover 24/7 Financial concerns include fixed and variable costs Fixed costs include insurance, taxes, crew costs, overheads, interest, hanger fees and capital equipment Variable (hourly) costs vary directly with the number of hours flown. These costs include fuel and oil, scheduled maintenance labor, etc Cost Effectiveness Cost effective for a centralized health care system Composed of a single retrieval unit covering for the whole state Expensive to maintain but less costly than to put up pediatric ICUs in rural hospitals US retrieval system mostly hospital-based Improved patient outcome Patient transport safety Less expensive to maintain What if Case 1… Grandson of a business tycoon? What if Case 2… Child of a celebrity? Thank you! Questions?