Deborah Lerner, George E. Lister, and Julio Pérez Fontán
Complex, high-acuity services cannot be offered at every site where children receive medical care. These services are expensive and require personnel resources that are in limited supply. Thus, it is best to concentrate skilled caretakers and equipment in hospitals and medical centers that function as local, regional, or national or international referral centers. In the United States and other industrialized countries, implementing this principle has resulted in the development of interhospital referral networks reminiscent of the hub-and-spoke distribution system used by the airlines. In most cases, the referral centers, or hubs, have developed highly detailed protocols for the transfer of patients to their facilities, sometimes involving complex stabilization efforts at the referring facility and in transport.
The success of these protocols at a local level has resulted in the progressive adoption of basic standards and expectations around the transfer of patients at a more global level. These expectations invariably start with the clinician, who is first confronted with an acutely ill child and who must recognize that the problem exceeds the skills and resources immediately available and who becomes responsible for the preparations needed before the transport team is available. The important steps of recognizing the severity of the situation, establishing a first diagnostic evaluation, and implementing the necessary stabilization measures have been facilitated enormously by the wide distribution of the American Heart Association’s pediatric advanced life support (PALS) guidelines.1 PALS guidelines are updated frequently and are an invaluable repository of information and an excellent vehicle for the education of any clinician who cares for sick infants and children.
The scope of this chapter cannot include every possible scenario for stabilization and transport. Rather, the chapter details the most common circumstances and courses of action involved in the transfer process.
The effort to stabilize an acutely ill or unstable infant or child for transportation is dependent on both the physiological derangement and the speed with which the transfer can be carried out. The latter is obviously influenced by factors such as distance, available means of transportation, and frequently the weather in the area, particularly if an aircraft is used. The decision of which institution to send the patient should ideally be based on the perceived acuity and the type of illness/injury, and should generally favor the closest option that is equipped to care for the patient during the acute period and thereafter. Unfortunately, extraneous considerations such as the type of insurance the patient has or the existing patterns of referral often influence the course of action, not always in the best interest of the child.
Whether initiated in a primary care office, an emergency room, or a hospital, the preparations for transport always start with the recognition and summary evaluation of the patient’s problem. Every clinician should ideally be prepared to recognize, diagnose, and begin treatment for life-threatening respiratory, circulatory, and neurological impairments (see Chapters 102, 103, and 104). Often this can be done with remote consultation from the appropriate specialists (eg, critical care medicine, neonatology, or cardiology) once a referral center is selected, but nothing can replace the careful, calm assessment of a capable clinician with direct access to the patient. When such distant consultations are established, it is important that the two parties have an explicit understanding of their responsibility for the individual’s care.2-5
Whenever the experience and skill of the local physician allows it, final decisions on the therapeutic course are best made locally. In most instances, however, it is easy to arrive to the best management strategy through repeated discussion and reevaluation. Many referral centers monitor and record these conversations for legal reasons and to ensure that the process occurs without misunderstanding. Although appealing in principle, video-conferring and other forms of clinical data transmission included under the general rubric of telemedicine6-7 have not yet been fully incorporated into the transport routine in the United States at the time of this writing.
Not all patients who require transfer are critically ill. Many require expertise or equipment that are not available locally. Even in those cases, it is often preferable to entrust the transport to a professional team rather than impose on the family to assume the risk. Level of care required in transit, cost, availability, and distance are important factors in this decision.8-10
Occasionally, families request that a child be transferred from one institution to another for reasons that may not relate directly to the availability of resources but rather to convenience or preference. The reasons for such transfers are often quite powerful, particularly when a child becomes ill or is injured in a distant, unfamiliar place, but they always must be balanced against the risk involved for the child and the transport team.
PREPARATION FOR TRANSPORT
Most transports start with a telephone call and, whenever possible, a discussion with the family about the proposed plan. It is essential that this call be routed to individuals who can make the necessary arrangements and can initiate the joint management process that usually precedes the complete transfer of care to the transport team and the accepting institution. Most hospitals in the United States have developed policies and protocols that are implemented in a stepwise manner depending on the situation.8 It has become standard that a transport team be activated within minutes and become available at the referring site within hours of the first request. On occasion, the referring institution makes a transport team available. Provided that there is no difference in capability, this offers advantages in terms of saving time and perhaps by providing a more gradual transition of care if the team includes individuals who know the patient.
Outside of large academic centers, many institutions utilize independent transport teams with variable pediatric specialty care capabilities to transport patients to their pediatric facilities. The decision to accept a team with limited pediatric expertise to expedite transfer is not always an easy one, particularly for long-distance transports. The process can be simplified by stipulating the composition of the team in mutual transfer agreements. In the end, it is the responsibility and choice of the referring facility to determine the type of team utilized in the transport.2,3
The composition of the transport team is usually a matter of local convention. The traditional inclusion of physicians, often in training, has given way to transport nurses, respiratory therapists, and paramedic personnel, who provide a high level of professionalism and consistency.8,11-14
Careful attention to the early stages of the transfer of care is essential for the proper execution of the process. The transport team should be activated as early as possible, because of expediency and because it allows the referring clinicians to consult with specialists or more experienced physicians at the accepting facility. While some confusion due to the rapid exchange of information is unavoidable when dealing with pressing situations, all participants must quickly and clearly delineate responsibilities and exchange data. Teleconferencing and other forms of simultaneous communication such as e-mail have simplified this task enormously. Although situations can change dramatically, the goal is the transport team should be prepared to address every eventuality that might emerge during the process. This requires forethought. For example, a newborn infant with cyanosis soon after birth may respond initially to the administration of oxygen, but the transport team must be ready to administer prostaglandin E1 if further developments suggest the presence of a ductus-dependent heart defect.
Preparations are not limited to the referring site and the transport team. Identifying a proper destination for the patient, consulting with medical and surgical specialists, and alerting the necessary individuals are steps that must be taken in a timely succession before the patient arrives. Discussions concerning patient disposition at the accepting institution should not delay the transport process. Often, additional information becomes available or can be provided after the transport is on course and adjustments can be made.
One of the first decisions that face the transport team is the choice of transportation method. Once again, this choice is usually based on knowledge of the local geography and weather conditions and on an assessment of the potential needs of the patient during transport (Table 110-1).8 Ground transportation by ambulance is slower than air transportation by helicopter or fixed-wing aircraft and is sometimes impractical for long distances or congested roads.15 However, it does offer better opportunities for continuous assessment and stabilization en route and is often the only choice in bad weather.
Table 110-1. Guidelines for Selecting Mode of Transportation for Acutely Ill Children
Arrival of the transport team is often met with relief, particularly by those caring for a severely ill child. The exchange of clinical information and the transfer of the patient’s monitoring and therapeutic lines to the equipment used for transport must happen expeditiously and carefully. Errors at this point are common, and great care must be exercised with dosing of medications and with unsecured vascular lines and endotracheal tubes.16,17 The transport team should make every effort to meet the patient’s family to obtain informed consent and to provide as much information and comfort to them as possible. Even if the encounter is short, as is typical, families must put a great deal of trust in the team, who in return should exhibit a great deal of sensitivity toward the family and to the referring team. It is often possible to have at least a parent accompany the child during transport. Doing so reduces parental and patient anxiety and provides the receiving personnel with an immediate firsthand account of events preceding hospitalization.
Table 110-2. Some Indications for Considering Institution of Mechanical Ventilatory Support in Patients Undergoing Transport
MONITORING AND TREATMENT DURING TRANSPORT
No matter how advanced, airplanes, helicopters, and ambulances offer challenging environments for the care of critically ill infants and children. Acoustic conditions are difficult, access is poor, and vibration and movement prevent any delicate procedures from being performed. It is therefore essential that appropriate monitoring is instituted before leaving the referring site and that precautions are taken to ensure that respiratory and circulatory function can be supported appropriately if necessary.
The need for compact, reliable monitoring equipment for transport has given rise to an entire industry. Modern self-contained transport units combine a stretcher or incubator with mechanical ventilation and monitoring devices in a manner that accommodates the most stringent space limitations. The use of monitors does not obviate the need to assess frequently for physical findings such as changes in color and perfusion, respiratory distress, and variations in the state of consciousness. Basic monitoring equipment that can usually be used in the transport of a critically ill infant or child includes electrocardiogram; heart and respiratory rate monitor; blood pressure device (preferably an automatic device or an indwelling arterial catheter); arterial oxygen saturation (pulse oximetry) monitor; and, in patients undergoing mechanical ventilation, end-tidal CO2 monitor (see Chapter 102).
The ability to respond to sudden worsening in vital functions may be quite limited in transit. Consequently, transport teams are frequently faced with the decision of whether to support respiratory or circulatory function in anticipation that such support becomes necessary. This decision requires careful judgment, because intubation of the trachea and the need for sedation and even muscle relaxation also pose substantial risks, including unrecognized tube dislodgement during transport. The availability of a clinician capable of intubating the airway18-20 (especially if the airway is difficult to visualize), the distance, and the intended means of transportation are important factors in this decision. A reasonable approach is to consider early institution of mechanical ventilation in patients with some of the conditions and examples listed in Table 110-2. Anticipatory administration of inotropic or vasoactive medications is not indicated.
Placement of vascular catheters sometimes presents a similar dilemma (see Chapter 107). A secure venous catheter is essential in almost every circumstance. The need for central venous and arterial access for monitoring must be balanced against the delay that placing these catheters often represents.
MANAGEMENT AFTER ARRIVAL
Every transport involves two transfers of care, one from the referring team to the transport team and another from the transport team to the accepting team. Both offer opportunities for the loss of information. Here is where protocol fills a fundamental function in ensuring that no important items are overlooked. It is also of paramount importance that both the referring and responsible receiving physicians have a means to reach one another. It is quite common to need additional information after a child arrives; it is equally important for the referring team to receive updated information about the child.
Updating the referring team once the final transfer of care is complete has become an essential part of the process. This exchange offers a chance to review the main aspects of the transport and to identify areas for improvement. It also helps establish a confident interinstitutional relationship that is invaluable for the care of patients and their families. Finally, maintaining contact with the hospital staff and the family may be invaluable for planning long-range follow-up care by the referring or primary care physician.