Legal issues in pediatric interfacility transport

Interfacility transport evolved because of the need for transport of ill or injured patients from one medical facility to another. Optimally this is accomplished in a safe, efficient, and medically expert fashion, and is always in the best interest of the patient. Interfacility transport systems vary by capabilities, equipment, personnel, and missions. Expert medical and logistical information is necessary before the implementation and use of such systems. While not usually at the forefront of planning for medical implementation, the legal issues, requirements, and restrictions inherent in interfacility transport are significant and must be considered. This article will review legal issues surrounding interfacility transport and identify potential pitfalls.     

The interfacility transport of critically ill newborns

The practice of paediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile intensive care units capable of delivering state-of-the-art critical care during paediatric and neonatal transport. While outcomes are best for high-risk infants born in a tertiary care setting, high-risk mothers often cannot be safely transferred. Their newborns may then have to be transported to a higher level of care following birth. The present statement reviews issues relating to transport of the critically ill newborn population, including personnel, team competencies, skills, equipment, systems and processes. Six recommendations for improving interfacility transport of critically ill newborns are highlighted, emphasizing the importance of regionalized care for newborns.     

Pediatric transport team: Intermountain Life Flight

The transport of the pediatric patient presents unique challenges. To assure the children receive the care they need during transport, the appropriate specialty team should be used. This article presents the role of a pediatric specialty team in patient transport and offers an example of a long-standing pediatric transport team.     

The state of pediatric interfacility transport: consensus of the second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference

Interfacility transport of pediatric and neonatal patients for advanced or specialty medical care is an integral part of our medical delivery system. Assessment of current services and planning for the future are imperative. As part of this process, the American Academy of Pediatrics and the Section on Transport Medicine held the second National Pediatric and Neonatal Transport Leadership Conference in Chicago in June 2000. Ninety-nine total participants, representing 25 states and 5 international locations, debated and discussed issues relevant to the developing specialty of pediatric transport medicine. These topics included: 1) the role of the medical director, 2) benchmarking of neonatal and pediatric transport programs, 3) clinical research, 4) accreditation, 5) team configuration, 6) economics of transport medicine in health care delivery, 7) justification of transport teams in institutions, and 8) international transport/extracurricular transport opportunities. Insights and conclusions from this meeting of transport leaders are presented in the consensus statement.     

Variables predicting the need for a pediatric critical care transport team.

To determine when a pediatric critical care transport team is required to transport a patient to a referral center, this cross-sectional study evaluated 369 consecutive pediatric transports by stepwise multiple logistic regression analysis of six variables: age, vital signs, seizure activity, current endotracheal intubation, respiratory distress, and respiratory diagnosis. Models were developed for three outcome variables: 1) Major procedures were required in 8.9% of cases. The predicted probability of needing a major procedure was increased for intubated patients (probability of 12.9%), patients less than 1 year of age with unstable vital signs (12.9%), and patients meeting both these criteria (23.2%). 2) A posttransport assessment of need for a physician on the team was positive in 43% of cases. The probability of needing a physician was increased for intubated patients (probability of 68.8%), patients less than 1 year of age with unstable vital signs (58.7%), and patients meeting both these criteria (79.9%). 3) Category 1 drugs, ie, medications requiring ICU monitoring, were used in 19% of transports. The probability of this occurring was increased for intubated patients with stable vital signs (probability of 24.7%) and for intubated patients with unstable vital signs (41.4%). None of the other pretransport variables, alone or in pairs, was a significant predictor of any of the three outcome variables. The data indicate that intubation, age, and vital sign status can be used in predicting whether a transport team is needed.     

Transport-related adverse events in critically-ill children: The role of a dedicated transport team

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.

     

A comparison of the radiographic interpretation skills of pediatric transport nurses and pediatric residents

OBJECTIVE: To compare the radiograph interpretation skills of pediatric/neonatal transport nurses to those of 3rd-year pediatric residents. DESIGN: A validation study of radiograph interpretation. METHODS: Twelve pediatric transport nurses and nine senior pediatric residents were asked to interpret 20 radiographs or sets of radiographs. These films had been previously selected and interpreted by a panel of pediatric radiologists. The subjects' interpretations were compared with those of the radiologists, and a score was assigned for each film or set of films. Five points were awarded for an interpretation in complete agreement with the radiologists' interpretation; 2.5 points were awarded for partial agreement. No points were awarded for complete disagreement. Subjects also answered questions about prior training and experience in radiograph interpretation. RESULTS: The 3rd-year residents' mean score was 66.34 (range 57.5-82.5), while the nurses had a mean score of 33.75 (range 17.5-47.5). This difference was significant (P < 0.001). The residents had a mean of 133.33 of formal radiology instruction, while the nurses had less than 10 hours of instruction. The nurses had received focused training in the identification of pneumothoraces. The nurses had higher mean scores than the residents on the two sets of films demonstrating pneumothoraces, but this difference was not significant. CONCLUSIONS: The 3rd-year residents had significantly higher mean scores on a test of radiograph interpretation. The major difference between the groups appears to be the amount of formal training afforded the residents. The nurses' performance on the films demonstrating pneumothoraces suggests that focused training may be an effective means by which to gain skills important to transport.     

Pediatric critical care transport survey: team composition and training, mobilization time, and mode of transportation

A survey was conducted to determine the current standard of care with regard to team composition and training, mobilization time, and vehicle use for pediatric critical care transport. An evaluation of 30 pediatric referral centers revealed that 60% provide a critical care transport team. Of those teams, the mean number of transports per year was 304. Response time ranged from 10 to 90 minutes. All teams included a physician all or most of the time; 100% of teams included a critical care nurse, and 50% always included a respiratory therapist. Ambulances alone are used in 28% of systems, with the remainder using combinations of ambulances, helicopters, and fixed wing aircraft. A proposal is presented for future standards in pediatric critical care transport with regard to the factors discussed.     

Adverse effects of neonatal transport between level III centres

Abstract The effect of neonatal transport between level III intensive care nurseries was studied by comparing the outcome of 40 infants inborn at a regional level III centre but transported to other level III nurseries for intensive care, with 80 matched inborn controls. Transport appeared to affect respiratory status adversely but transiently. However, transported infants grew less well than control infants (32% were below 3rd centile for weight at 36 weeks vs 15% of controls), were more likely to suffer periventricular haemorrhage (40 vs 21% of controls) and had a worse neurodevelopmental outcome (70% normal at follow up vs 83% of controls). It can be concluded that for infants inborn at the National Women's Hospital, Auckland, transport to another level III centre for intensive care is associated with an increased risk of adverse outcome.