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Indian Pediatr 2017;54:942-945 |
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Transport-related
Adverse Events in Critically-ill Children: The Role of a
Dedicated Transport Team
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Sumant Prabhudesai, Mohanbabu Kasala, Nitin Manwani, Ravikumar
Krupanandan and Bala Ramachandran
From Department of Paediatric Critical Care, Kanchi
Kamakoti CHILDS Trust Hospital, Chennai, India.
Correspondence to: Dr Sumant Prabhudesai, Department
of Paediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, 12A,
Nageswara Road, Nungambakkam, Chennai, India.
Email:
[email protected]
Received: July 22, 2016;
Initial Review: December 13, 2016;
Accepted: July 22, 2017.
Published online:
August 24, 2017.
PII:S097475591600081
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Objective: To compare the frequency of
transport-related adverse events in children during specialized,
non-specialized or unassisted transports. Methods: Patients were
grouped based on transport team involved – specialized (Group-1);
non-specialized (Group-2); unassisted transport (Group-3). Demographics,
events during transport and condition on arrival were recorded.
Results: Group-1 children had a lower incidence of adverse events
compared to Group-2 and Group-3 (4.3%, 82.6% and 85.4% respectively;
P<0.001). At arrival, children in Group-1 had a lower incidence of
respiratory distress and airway compromise (P< 0.001).
Conclusion: Transport of critically ill children by a specialized
transport team is associated with fewer transport-related adverse
events.
Keywords: Airway compromise, Emergency care, Intubation,
Respiratory failure.
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M edical transport is a key element in the chain of
survival for critically ill children, especially in resource-limited
settings where critical care services are scarce. The challenges in
pediatric transports differ considerably from those in adults. Limited
training with pediatric patients may restrict the ability of general
transport teams to transfer seriously ill children. Evidence shows that
children transported by specialized teams have fewer Transport-related
adverse events (TRAEs), a more stable physiology upon arrival, and lower
in-hospital mortality [1-5]. In India, specialized pediatric transport
teams are few [6], and data on transport practices are scarce [7]. We
conducted this study to determine whether inter-hospital transport by
specialized transport teams reduces the incidence of TRAEs in children
in comparison to non-specialized teams and unassisted transports.
Methods
This prospective observational study was conducted at
a tertiary care children’s referral hospital in Chennai, India from
February 2014 to September 2014. Approval was obtained from the Hospital
Ethics Committee.
All patients aged between 1 month and 18 years who
were transported to the hospital’s Emergency Room (ER) and required
Pediatric intensive care unit (PICU) admission were included. Depending
on the mode of transportation, they were assigned to one of three
groups: Group-1: transported by a specialized pediatric transport team;
Group-2: transported by a general transport team; or Group-3: brought by
caregivers without medical assistance. A specialized team was defined as
one which: (i) was attached to a hospital having a dedicated
children’s transport team; (ii) had a doctor trained or
undergoing training in pediatrics, pediatric anesthesia or pediatric
critical care, and skilled in airway management and cardiopulmonary
resuscitation; (iii) had a nurse with pediatric experience; and (iv)
had an ambulance equipped for emergency airway management, vascular
access, oxygen, drug delivery and a multi-parameter monitor. Transport
teams not meeting all these criteria were considered general transport
teams.
Data on demographics, transport-related adverse
events, interventions during transport, condition and interventions at
arrival to ER were collected. The primary outcome measured was the
occurrence of TRAEs. A TRAE included hypoxia, airway compromise
requiring intervention, pneumothorax, tachycardia, bradycardia,
hypotension, cardiac arrest or hypoglycemia (all defined as per PALS
guidelines [8]), which were recognized during transport or immediately
after arrival in ER. The secondary outcomes measured were PICU length of
stay and mortality. Severity of illness was assessed by the Pediatric
Risk of Mortality (PRISM) III score.
Statistical analysis: Student’s t test was used
for parametric data and Kruskal-Wallis test for non-parametric data.
Fisher’s exact test was used for categorical variables. Variables
significant on univariate analysis were further analyzed by logistic
regression. A two-tailed P value of <0.05 was considered
significant.
Results
We included, 204 children; majority (58.3%) in
Group-3. In Group-2, 9 (23.1%) patients were accompanied by a doctor
while 30 (76.9%) were accompanied by paramedical staff. In Group-3, 15
(12.6%) children were brought by ambulance without paramedical staff
while the other 104 (87.4%) were brought by private vehicles.
Children who were younger (P=0.003), had a
respiratory problem (P=0.03), or required transportation over
distances less than 5 km (P=0.01) were more often transported by
specialized teams than non-specialized ones (Table I).
TABLE I Characteristics of Children Transported to the Emergency Department (N=204)
|
Total |
Group-1(n= 46) |
Group-2 (n= 39) |
Group-3(n= 119) |
P value |
Age* (mo) |
19.5 (9- 69.2) |
12 (5.2- 25.8) |
30 (10-92) |
24 (9- 72) |
0.003 |
Females |
80 (39.2) |
18 (39) |
14 (35.9) |
48 (40.3) |
0.88 |
PRSIM III score* |
3 (0.75- 6) |
3 (0- 7) |
3 (2- 6) |
3 (1.5- 5.5) |
0.98 |
Indication for transport |
Neurological |
76 (37.3) |
14 (30.4) |
20 (51.3) |
42 (35.3) |
0.03 |
Respiratory |
85 (41.7) |
23 (50) |
14 (35.9) |
48 (40.3) |
|
Metabolic |
18 (8.8) |
0 (0) |
1 (2.6) |
17 (14.3) |
|
Shock |
12 (5.9) |
4 (8.7) |
1 (2.6) |
7 (5.9) |
|
Trauma |
13 (6.4) |
5 (10.9) |
3 (7.6) |
5 (4.2) |
|
Distance (km) |
<5 |
28 (13.7) |
12 (26.1) |
2 (5.1) |
14 (11.8) |
0.01 |
5-10 |
59 (28.9) |
8 (17.4) |
8 (20.5) |
43 (36.1) |
|
10-20 |
30 (14.7) |
7 (15.2) |
6 (15.4) |
17 (14.3) |
|
>20 |
87 (42.6) |
19 (41.3) |
23 (58.9) |
45 (37.8) |
|
Transport support |
Private vehicle |
105 (51.5) |
0 (0) |
0 (0) |
104 (87.4) |
|
Ambulance |
99 (48.5) |
46 (100) |
39 (100) |
15 (12.6) |
|
Doctor |
55 (26.9) |
46 (100) |
9 (23.1) |
0 (0) |
|
Paramedic |
76 (37.3) |
46 (100) |
30 (76.9) |
0 (0) |
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Group-1: transport by specialised teams;
Group-2: transport by general/unspecialised teams teams;
Group-3: unassisted transport. Variables are expressed as
*median (IQR) or numbers (percentage); PRISM: Pediatric Risk of
Mortality.
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TRAEs occurred in 142 (69.6%) children (Table
II). Group-1 children had a significantly lower incidence of TRAEs
compared to Group-2 and Group-3 (4.3%, 82.6% and 85.4% respectively,
P<0.001). Airway compromise, hypoxia and tachycardia were less
common in Group-1 compared to Group-2 and Group-3 ( P <0.001).
TABLE II Transport-related Adverse Event (TRAE), Emergency Interventions and Outcome in Study Children (N=204)
TRAEs |
Total |
Group-1(n= 46) |
Group-2(n= 39) |
Group-3(n= 119) |
P value |
At least 1 TRAE |
142 (69.6) |
2 (4.3) |
38 (97.4) |
102 (85.7) |
<0.001 |
Hypoxia |
81 (39.7) |
0 (0) |
24 (61.5) |
57 (47.9) |
<0.001 |
Hypotension |
14 (6.9) |
1 (2.2) |
3 (7.7) |
10 (8.4) |
0.36 |
Tachycardia |
100 (49) |
0 (0) |
26 (66.6) |
74 (62.2) |
<0.001 |
Hypoglycemia |
3 (1.5) |
1 (2.2) |
1 (2.6) |
1 (0.84) |
0.67 |
Airway compromise |
53 (25.9) |
0 (0) |
19 (48.7) |
34 (28.6) |
<0.001 |
Condition at arrival |
Shock |
47 (23) |
11 (23.9) |
6 (15.4) |
30 (25.2) |
0.44 |
Respiratory distress |
79 (38.7) |
4 (8.7) |
23 (58.9) |
52 (43.7) |
<0.001 |
Low GCS(<8/15) |
40 (19.6) |
6 (13) |
10 (25.6) |
24 (20.2) |
0.34 |
Emergency interventions at arrival |
Oxygen |
92 (45.1) |
5 (10.9) |
16 (41) |
71 (59.7) |
<0.001 |
Intubation/ re-intubation |
49 (24) |
1 (2.2) |
17 (43.6) |
31 (26.1) |
<0.001 |
Fluid bolus |
68 (33.3) |
12 (26.1) |
9 (23.1) |
47 (39.5) |
0.09 |
Inotropes |
20 (9.8) |
6 (13) |
4 (10.3) |
10 (8.4) |
0.58 |
Outcome |
*PICU length of stay (d) |
4 (3- 6) |
4 (2- 7) |
5 (3- 7) |
4 (3- 5) |
0.24 |
Death |
35 (17.1) |
8 (17.4) |
9 (23.1) |
18 (15.1) |
0.52 |
Transport by: Group-1: specialized teams; Group-2:
general/unspecialized teams; Group-3: unassisted transport.
Variables are expressed as n(%) or *median (IQR); GCS: Glasgow
Coma Scale. |
Group-1 children had a lower incidence of respiratory
distress (P<0.001), requirement of oxygen support (P<0.001)
and emergency intubation (P<0.001) upon arrival to ER. The length
of stay and mortality were not significantly different between the three
groups.
On univariate analysis, neurological problems,
transport distance >5 km, non-specialized/unassisted transport and
transport time >3 hours were identified as risk factors for TRAEs. On
multivariate logistic regression, transport time >3 hours (P=0.002)
and non-specialized/ unassisted transport (P<0.001) were
independent risk factors for TRAEs. The relative risk of TRAEs with non-specialised/unassisted
transport was 20.4.
Discussion
In this observational study, we observed that the
large majority of pediatric transports occurred unassisted or by
non-specialized teams wherein the risks of airway compromise,
respiratory distress and tachycardia were high.
Having no prior data on existing transport practices,
we could not calculate a sample size; therefore the study duration and
patient recruitment was arbitrary. The unavailability of pre-transport
clinical details was a major limitation. The large difference in the
number of patients per group resulting from recruitment of consecutive
patients presenting to the ER may well have affected statistical
analysis. This difference largely reflects the prevalent referral
practices in the region.
Systematic information on pediatric transport
practices in India is scarce. A recent study from Delhi reported that
the majority of children referred to the ER from another facility
arrived by ambulance unassisted [7]. A retrospective analysis of records
in neonates showed nearly 45% of the babies were transported by
paramedical or non-medical persons [9]. In another study, only 29% of
neonates were transported by ambulance, the others being brought by
private vehicles or public transport [10].
Worldwide, data on pediatric transport are mainly
available from countries with established emergency transport systems.
North American studies have shown that adverse events were less when
children were accompanied by a tertiary-care physician and higher when
team members had no pediatric transport training [2,3]. Transportation
by non-specialized teams was associated with more unplanned events and
higher mortality [5,11,12]. We did not find any difference in mortality
in our study.
Kumar, et al. [13] documented that distance or
duration of transport did not affect the risk of adverse events and
outcomes in neonates transported by a qualified transport team [13]. In
our study, the greater risk associated with longer durations likely
reflects the fact that most long distance transports were unassisted or
done by non-specialized teams.
In conclusion, utilizing specialized pediatric
transport teams can reduce the incidence of adverse effects during
transport. Further large-scale and multicentric studies are necessary to
determine whether this translates to reduced morbidity and mortality.
Acknowledgement: The CHILDS Trust Medical
Research Foundation for their support in conducting this study.
Contributors: MK, RK NM: data collection;
RK, SP, MK, BR: data analysis; SP, NM, MK, BR:
manuscript preparation; RK, SP, BR: manuscript drafting All authors
contributed to manuscript revision and its final approval.
Funding: None; Competing interest: None
stated.
What This Study Adds?
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Utilizing specialized pediatric
transport teams results in fewer transport-related adverse
events in critically-ill children.
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References
1. Chance GW, Matthew JD, Gash J, Williams G,
Cunningham K. Neonatal transport: A controlled study of skilled
assistance. Mortality and morbidity of neonates less than 1.5 kg birth
weight. J Pediatr. 1978;93:662-6.
2. Edge WE, Kanter RK, Weigle CG, Walsh RF. Reduction
of morbidity in interhospital transport by specialized pediatric staff.
Crit Care Med. 1994;22:1186-91.
3. Macnab AJ. Optimal escort for interhospital
transport of pediatric emergencies. J Trauma. 1991;31:205-9.
4. Vos GD, Nissen AC, Nieman FH, Meurs MM, van
Waardenburg DA, Ramsay G, et al. Comparison of inter-hospital
pediatric intensive care transport accompanied by a referring specialist
or a specialist retrieval team. Intensive Care Med. 2004;30:302-8.
5. Hatherill Maggie Z, Reynolds L’Argent A. Transport
of critically ill children in a resource-limited setting. Intensive Care
Med. 2003;29:1547-54.
6. Khilnani P. Available from: http://www.
pediatriconcall. com/fordoctor/Conference_abstracts/report.aspx?
reportid=450. Accessed January 08, 2015.
7. Sankar J, Singh A, Narsaria P, Dev N, Singh P,
Dubey N. Prehospital transport practices prevalent among patients
presenting to the pediatric emergency of a tertiary care hospital.
Indian J Crit Care Med. 2015;19:474-8.
8. Kleinman ME, Chameides L, Schexnayder SM, Samson
RA, Hazinski MF, Atkins DL, et al. Part 14: Pediatric Advanced
Life Support 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010;122: S876- S908.
9. Kumar PP, Kumar CD, Venkatlakshmi A. Long distance
neonatal transport–the need of the hour. Indian Pediatr. 2008;45:920-2.
10. Narang M, Kaushik JS, Sharma AK, Faridi M.
Predictors of mortality among the neonates transported to referral
centre in Delhi, India. Indian J Public Health. 2013;57:100-4
11. Orr RA, Felmet KA, Han Y, McCloskey KA, Dragotta
MA, Bills DM, et al. Pediatric specialized transport teams are
associated with improved outcomes. Pediatrics. 2009; 124:40-8.
12. Ramnarayan P, Thiru K, Parslow RC, Harrison DA,
Draper ES, Rowan KM. Effect of specialist retrieval teams on outcomes in
children admitted to paediatric intensive care units in England and
Wales: A retrospective cohort study. Lancet. 2010;376:698-704.
13. Kumar PP, Kumar CD, Shaik FA, Ghanta SB, Venkatalakshmi A.
Prolonged neonatal interhospital transport on road: Relevance for
developing countries. Indian J Pediatr. 2010;77:151-4.
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