Preparing a Pediatric Patient for Transport

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1 Goals/Objectives Preparing a Pediatric Patient for Transport Melinda Lucas, M.S., M.D., F.A.A.P. Apply Basic Principles of transport medicine in the evaluation, stabilization and transport of pediatric patients. Apply basic principles of emergency medicine in the evaluation, stabilization of a pediatric patients prior to transport. Optimal Preparation for Transfer Resuscitation Details using PALS, ATLS, PFCCS (Pediatric Fundamental Critical Care Support), APLS Documentation Choice of Transfer Personnel and Methods 5 Initial Decision Points What resources are available for transporting this patient for definitive care? Can timely transport to an appropriate hospital reduce disability and total health care cost for critically ill and injured children? What should be the training, composition, and skills of the transport team? Under what circumstances are air medical services appropriate? What are the responsibilities of the referring and receiving institutions and health care professionals for transported patients? 6 Decisions for each Interfacility Transport Availability of Transport Resources Team and vehicle/aircraft Weather Conditions / Traffic Conditions Bed Availability and Subspecialty Availability & Patient Acuity Distance Cost Legal Issues 5 Methods of Transport Transfer by Private Vehicle Use of Local ambulance Service Local EMS Personnel Accompanying Support Personnel from Referring Hospital Use of a Helicopter Transport Team with most experience in trauma victims and adult cardiac/stroke patients Pediatric Critical Care Transport Team or Neonatal Transport Team Fixed Wing Transports Minimal Monitoring Equipment EKG Monitor Pulse Oximeter? End Tidal CO 2 Monitor Defibrillator with batter backup and transcutaneous pacing capability Oxygen Analyzer and Oxygen Tank Ventilator Appropriate for Infants & Children & Adults Infusion Pumps Portable Suction Unit Noninvasive Blood Pressure Monitor

2 Team Composition COBRA/OBRA Legislation Paramedic & EMT Nurse Respiratory Therapists Attending Pediatrician Dedicated Pediatric Transport Team Dedicated Neonatal Transport Team Pediatric Resident or Fellow Assure Safe Patient Transfers Patient s Condition is Stable Receiving Hospital Contacted Patient Understands the Nature of the Case Physician Willing to Assume/Accept Case On-Call physicians to respond to ER requests for inpatient Care: Benefits of Transfer outweigh Risks of Admission Written Consent Written Risks and Benefits of Transfer & Explanations Specialty Hospitals required to accept appropriate transfers if space and facilities available Appropriate Medical Screening Examination (not triage) to all patients who present to E.D. to determine whether Emergency Medical Condition exists. Provide necessary stabilizing treatment to an individual with an emergency medical condition or a woman in labor Provide for an appropriate transfer of the patient if either the patient requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the emergency medical condition (or capability or capacity to admit the individual) If the patient refuses care, they must be informed of the risks and/or benefits If an individual has an emergency medical condition which has not been stabilized, the hospital may not transfer the patient unless: The individual requests a transfer in writing afater being informed of the hospital s obligation and risk of transfer, or A Qualified Medical Personnel certifies that medical benefits reasonably expected from treatment at another facility outweigh increased risks. If the transfer is refused, but the sending hospital transfers the patient anyway, once the patient is on the receiving hospital s property, the receiving hospital must provide a MSE and stabilize (or transfer appropriately). Violations Physicians $50,000 per violation Exclusion from participation in federal & state healthcare programs (for gross and flagrant or repeated violations). Hospitals: $25,000 (<100 beds) to $50,000 (>100 beds) per violation Exclusion from participation in federal healthcare programs.

3 Inappropriate Judgments Does not apply: After patient has been seen and medically screened Emergency Medical Condition does not exist Patient Admitted to hospital * Court of Appeals in our Circuit has held that EMTALA applies until the patient is stabilized, even if the patient is admitted. Patient Deemed Stable for Local EMS Transports Crisis occurs for which team is ill-equipped to handle, untrained, or inexperienced Trained Pediatric Team available for very critically ill patient and Adult oriented team is chosen instead Crisis occurs for which team is ill-equipped to handle, untrained, or inexperienced 20% Guideline for Pediatric Experience Inappropriate Judgments The faster the patient is on the way (i.e. out of my ED) the better No evidence that Speed of Transfer regardless of level of care is beneficial to Patient Exceptions: Immediate Surgical Emergencies Safety Enroute with Vehicles Safety Enroute with Helicopters Helicopter Shopping Helicopter Wars Initial: Physician to Physician Demographics: Name, Age, Sex, Date of Birth Vital Signs, Weight (kilograms) Pertinent Physical Exam Relevant Laboratory and Radiographic Results Interventions and Responses Timing of Events AMPLE Immunizations Working Diagnosis Patient Status Documentation: Accepting MD (& Referring MD) Accepting Hospital (& Referring Hospital) Recommendations Initial Pysician to Physician Conversation Method of Transport Nature of Transport: Isolette, Pediatric Stretcher, Infant/Pediatric Ventilator, Heliox, etc. Team Composition Reason for Mode of Transport (patient acuity, distance, weather, etc.) Anticipated/required Equipment To Transport Personnel Airway Maintenance Fluid Volume Replacement Anticipated Special Procedures Scoring System: Glasgow Coma Score Revised Trauma Score Pediatric Trauma Score Asthma Scoring System From Transport Personnel Departure, Enroute, Arrival at Receiving Hospital

4 Physician Updates at any Time during Transfer Process Nurse-to-Nurse s Time of Acceptance Time of Departure Vital Signs Current Clinical Status Estimated Time of Arrival Preparation for Transport Copy all Records Copy all Radiology Exams A Report is not the same as the Exam Obtain Transport Consent Secure all Lines and Tubes Stabilize C-Spine and Fractures Prepare Blood Products if appropriate Remain at Bedside and/or Be Available for Consultation Risk to the Patient During Transport can be minimized through careful planning, use of appropriately qualified personnel, and selection and preparation of appropriate equipment The mode of transport and the composition of the transport team should be based on the acuity and complexity of care required by the individual patient The 4 Key Elements for Transport are: Each Time Responsibility for Patient Care is Transferred. Personnel Equipment When a critically Ill child requires transport, the same level of monitoring that occurs in the ICU should be maintained. Mode of Transportation Transport of the critically ill or injured pediatric patient is best performed by a team experienced in such care, even if awaiting their arrival creates a delay at the referring hospital

5 Difficulty in achieving and ensuring adequate stabilization in a patient may be considered a relative contraindication to transport. However, the problem may be that true stabilization is possible only at the receiving hospital. If there is any concern about maintaining airway patency for the duration of the transport process, the patient must have the airway secured. Pediatric Fundamental Critical Care Support (PFCCS) Pediatric Section of Society of Critical Care Medicine, ISBN ( Wallen E, Venkataraman ST, Grosso MJ, Kiene K, Orr RA. Intrahospital Transport of Critically Ill Pediatric Patients. Crit Care Med. 1995;23: Warren J, Fromm RE, Orr RA, Rotello RC, Horst HM. SCCM Guidelines for the Inter- and Intrahospital Transport of Critically Ill Patients. Crit Care Med. 2004;32 (1): Pediatric Transport Course, Section on Pediatric Transport Medicine, AAP 2008 National Conference & Exhibition (NCE), Boston. Available from AAP. Pediatric Transport Medicine ListServe from AAP Section on Pediatric Transport Medicine. Emergency Medical Services for Children: The Role of the Primary Care Provider. Committee on Pediatric Emergency Medicine AAP, ISBN X Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients 3 rd Edition. Section on Transport Medicine AAP, ISBN 10: McCloskey K, Orr R, eds. Pediatric Transport Medicine. St. Louis, MO: Mosby ISBN X ATLS Student Course Manual 8 th Edition, American College of Surgeons Committee on Trauma, ISBN Jaimovich, DG and Vidyasagar, D. ed. Handbook of Pediatric and Neonatal Transport Medicine, 2 nd Ed. Hanley & Belfus, Inc. Philadelphia, ISBN Pediatric Protocols for PreHospital Care Nichols, DG ed. Rogers Textbook of Pediatric Intensive Care, 4 th Ed. Chapter 24, Wolters Kluwer, Baltimore, ISBN

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