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.     

Pediatric interhospital critical care transport: consensus of a national leadership conference

As pediatric interhospital critical care transport has evolved toward a distinct discipline, practitioners in this field have recognized the need for guidelines for transport program development and patient care. At a gathering of medical directors of pediatric transport programs, the following topics were discussed: team composition and transport staffing, training requirements for pediatric and nonpediatric transport teams, goals and design of a transport data base, and medical-legal issues, including the responsibilities of the referring and receiving institutions. Consensus recommendations were made for the major issues in each of these areas. Several questions were raised which may be answered by multiinstitutional studies.     

Anesthesia by the pediatric specialist

There is increasing evidence that involvement of pediatric anesthesiologists in the perioperative care of infants and children can positively impact outcome. Considerable data have emerged in the past several years that clearly show that infants and small children experience untoward events at a much higher rate than do older children and adults. Herein the author presents some of this literature as well as data suggesting that anesthesiologists with interest and additional training in the care of infants and children can improve anesthesia outcomes. Even in these days of cost containment, it makes sense to provide the best pediatric team to care for the pediatric patient during the perioperative experience.     

The multi-disciplinary approach to adolescent bariatric surgery

The multi-disciplinary team is essential for the success of an adolescent bariatric surgical program. This article will describe the components of the team and their roles. Essential members include a pediatrician or pediatric subspecialist with an interest and expertise in adolescent obesity, a pediatric surgeon with bariatric expertise, or an adult bariatric surgeon with adolescent experience, adolescent/child psychologist, pediatric nutritionist, exercise physiologist or physical therapist, nursing support, and a patient coordinator. Some programs have found a social worker to be helpful as well. The function of the team members is more important than the title. A physical therapist may develop an activity program or a social worker may function as the coordinator. The whole team, led by the pediatric bariatrician, makes decisions concerning the selection of candidates for bariatric surgery. During team rounds, each patient is discussed and treatment decisions are made.     

Evaluation of a home care program for children with cancer

The home care team dependent from the pediatric oncology unit in our institution started working in April, 1997. We evaluate in this paper the medical activities accomplished in seventeen month experience. The team is constituted by a pediatric oncologist, two pediatric nurses and a clinical assistant with experience in the specialty. The geographic area we cover is la Communidad Valenciana. We directly attend children living in Valencia city and its metropolitan area. For the rest of patients, we coordinate the interventions of the local primary care teams and local hospitals. 127 patients have been admitted in the home care unit in 433 occasions. The immediate reasons for the admission were: early discharge from the hospital (61%), followed by the administration of antibiotics (18%) and chemotherapy (12%) at home. We attended 17 children in the terminal phase of their diseases. Five of them required opioid treatment for pain control. Six out of eight patients living in the area of direct intervention of the home care team died at home. The most common cause of discharge (73%) was the achievement of the goals planned when the patient was included in the program. Only in two cases (0.5%) we did not found enough cooperation from the parents and the treatment was completed in the hospital. This program has been well accepted by our patients and their parents and permits to shorten the stay in the hospital.     

Aeromedical transport services accepting pediatric patients and their abidance by published guidelines.

The number of aeromedical transport services accepting pediatric patients (ATSP) in the United States has increased greatly over the past decade. Most aeromedical transport services are primarily designed for adults but will also transport children. Suggested guidelines for ATSP were published by the American Academy of Pediatrics (AAP) in 1986. This survey of 65 ATSP and their abidance by the major AAP guidelines showed that two thirds of the ATSP were based at facilities with pediatric tertiary care capabilities; most ATSP were not directed by pediatric critical care (PCC) or pediatric emergency care (PEC) specialists; most transport team personnel were not trained in PCC or PEC; most ATSP had specific protocols for different clinical situations; most ATSP had separate equipment appropriate for pediatric patients; and there was little variation in transport team composition based on different clinical situations. In summary, all ATS surveyed transported children, but few were aware of the AAP guidelines, and only one in 65 was in complete abidance with the recommendations.     

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.     

Resident training in pediatric critical care transport medicine: a survey of pediatric residency programs

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) Program Requirement for Pediatrics includes specific objectives that pediatric residents participate in both the pre-hospital care of acutely ill or injured patients and the stabilization and transport of patients to critical care areas. Previously, residents were often included as the physician component for many pediatric critical care transport teams. Subsequent regionalization of transport services and development of nurse-only transport teams prompted us to determine the current level of resident participation in pediatric critical care transport as well as how individual residency programs were meeting the educational objectives. METHODS: A questionnaire was mailed to each pediatric residency program listed in the 1996-1997 GME Directory. Information was obtained regarding the size of the hospital and the residency program, the presence of a pediatric critical care transport team, the number of annual transports, and transport team leader. In addition, the use of pediatric residents for transports was ascertained, as well as their specific role, training requirements, and method of evaluation. RESULTS: Data were received from 138 programs for a return rate of 65%. Eighty percent of programs offered a pediatric critical care transport service. Nurse-led teams were used for 51% of NICU and 44% of PICU transports. Of the 82 NICU and 84 PICU teams that used residents, the majority used them as team leaders (60% and 70%; respectively) with only the minority requiring that they be at the PL-3 year or greater. The training and/or certification required for resident participation in transports varied among programs, with 85% requiring completion of a NICU or PICU rotation, and 94% requiring NRP or PALS certification. Programs that did not allow resident participation provided exposure to Transport Medicine by various mechanisms, including lectures and emergency department (ED) rotations. CONCLUSION: Pediatric resident participation in critical care transport varies widely among pediatric critical care transport teams. The degree to which residents participate in the transport team would appear to have diminished in comparison to previous studies. Transport teams often use other resources, such as nurses, fellows, or attendings, to lead their transport teams. Pediatric resident exposure to and participation in Transport Medicine varies among programs, as do the methods used to prepare residents for their experience.     

Comparison of intubation skills between interfacility transport team members

OBJECTIVE: To compare intubation skill level and success rate between interfacility transport team members. DESIGN: Prospective collection of data. SETTING: University affiliated children's hospital interfacility transport team. PATIENTS: One hundred thirty-two pediatric patients (age range 4 days to 11 years) intubated prior to transport by a specialized team. INTERVENTIONS: None. METHODS: Prospective data was gathered from June 1992 November 1996. In 3616 transports reviewed, 132 intubations were performed by the team at the referring facility. Patient ages ranged from 4 days to 11 years with a mean age of 23 months. We compared resident physicians and respiratory care practitioners (RCPs) to a standard threshold of 1 attempt per successful intubation. An attempt was defined as passage of the endotracheal tube into the oropharynx in an effort to pass it through the vocal cords. Patients were sedated and paralyzed for the procedures. The physicians were 2nd and 3rd year pediatric or emergency medicine residents. They received intubation training in Pediatric Advanced Life Support (PALS), Neonatal Resuscitation Program (NRP), and during rotations through neonatal and pediatric intensive care units. RCPs had an average of 3.5 years of experience overall on the transport team. They received training primarily on mannequins and written tests while in school. They were certified in PALS and NRP and required to participate in annual skill laboratories, which consisted of mannequin intubations and a written examination. RESULTS: The results showed the RCPs to have greater overall success as well as greater success of intubation on first attempt compared to the resident physicians. CONCLUSION: In our experience, RCPs on the interfacility transport team were very successful in performing endotracheal intubations and were more successful than resident physicians. RCPs are established members of not only the transport team, but also the intensive care units and, therefore, should be considered qualified to routinely perform endotracheal intubations in those settings as well.     

A-TEAM: An Interprofessional Approach to Mandated Reporting in the Hospital Setting

Reporting suspected child maltreatment in pediatric settings presents unique challenges. Variation in mandated reporter training may lead to discomfort and emotional dysregulation. Failure to collaborate inter-professionally potentially results in suboptimal care for vulnerable children and families. A-TEAM promotes awareness, transparency, empathy, a nonjudgmental strategy, and management by an interprofessional team when referring patients for child protective services evaluation. A faculty trained in pediatric trauma nursing led the development of A-TEAM. Integrating nursing and social work expertise protects the integrity of family-centered patient care. The A-TEAM approach may be a valuable contribution to the continuing education of pediatric health care professionals.     

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??Establishing a regional pediatric transport network is crucial to treatment of critically ill children and implementation of hierarchical medical system. The transport mainly include s communication before transport??assessing and stabilizing patients in local hospital??life support during transport and high quality handoff communication between physicians in receiving hospitals. The transport team members should master the pediatric emergency skills??and the transport equipment and supplies must be in good condition. The transfer center should carry out quality control to improve the quality of transport??and train medical staff in the region and carry out scientific research to improve treatment for critically ill children.     

Leadership, surgeon well-being and non-technical competencies of pediatric cardiac surgery

Expectations of pediatric cardiac surgeons grow as the specialty evolves and yesterday's challenges become tomorrow's routine. The pioneering era of fast-paced major technical advances is behind us. Integration of surgery, cardiology and intensive care is now the basis of incremental improvements in perioperative and long term outcomes. Surgeons can be natural leaders of this process because their skills, roles and experience are crucial in the preoperative, intra-operative and postoperative care of the patient and their family. However, the personality traits that draw physicians to the specialty and contribute to the drive to become a successful technical surgeon may be at odds with the collaborative aspects of this microsystem, both inside and outside the operating room. The potential for disruptive behavior on the part of the surgeon to impede the functioning of a large multidisciplinary team providing care of the upmost complexity raises fundamental questions about how to design reliable pediatric cardiac surgery teams. A new dynamic is needed to support team members, including the surgeon, in times of extreme stress and to help them avoid destructive, maladaptive responses. Focusing these efforts around the clinical microsystem requires a detailed analysis of the team interactions, the underlying culture and support, and the clinical engagement of staff. Building and nurturing a resilient system in a highly specialized environment where burnout, bullying and loss of staff exist remains a constant challenge.     

Development of a pediatric palliative care team.

The American Academy of Pediatrics has provided clinical recommendations for palliative care needs of children. This article outlines the steps involved in implementing a pediatric palliative care program in a Midwest pediatric magnet health care facility. The development of a Pediatric Advanced Comfort Care Team was supported by hospital administration and funded through grants. Challenges included the development of collaborative relationships with health care professionals from specialty areas. Pediatric Advanced Comfort Care Team services, available from the time of diagnosis, are provided by a multidisciplinary team of health care professionals and individualized on the basis of needs expressed by each child and his or her family.     

基层综合性医院儿科危重症救治模式的探讨

目的 探讨二级综合医院利用成人ICU设备和护士资源、儿科专科医师管理的救治模式在小儿急救方面的应用.方法 回顾性分析我院近5年来在成人急诊观察区域建立儿科观察室,利用成人急诊ICU设备和护士资源救治具有转运高风险的危重患儿的预后和疾病谱.结果 5年来急诊观察室收治儿科患者5076例次,约占年门急诊量的3.40%.入观患儿中危重者464例,占入观患儿的9.14%,其中转院251例(54.09%),因转运高风险而收住成人急诊ICU 35例(7.54%),14例需要呼吸机支持.其疾病谱主要以儿童意外损害为主,包括创伤、中毒和溺水等,内科疾病主要是严重感染和爆发性心肌炎等.经过止血、呼吸支持、纠正休克、维护重要脏器功能等综合治疗,取得令人满意的效果,痊愈好转率达77.14%,机械通气患儿的存活率>85%.结论 在我国,儿科急诊医疗服务体系还没完善前,基层综合性医院利用优势的成人ICU设备和护理团队,以经培训的儿科医师为主体的危重病救治模式是可行的,符合我国的国情.     

Pediatric Critical Care Interfacility Transport

The interfacility transport of critically ill and injured children can be safely performed by pediatric transport services. Specially trained transport staff, armed with appropriate equipment and medications and guided by off-line protocols and on-line medical control, provide a vital service for these children, facilitating timely access to tertiary care. Transport team members are trained to provide this specialized care in various environments, including ambulance, rotor wing, and fixed wing aircraft. Team training, continuing education, and quality improvement processes assist in further refining the skills and practices of the team members. Pediatric transport teams provide a unique service for these children and their families.     

Critical care interhospital transports: predictability of the need for a pediatrician

The Children's Hospital of Alabama Critical Care Transport System provides a mobile intensive care unit for interhospital transfer of critically ill pediatric patients. The transport team consists of a pediatrician, a pediatric emergency nurse, and a respiratory therapist. We studied whether it was possible to determine in advance whether it was always necessary for a physician to be on the team. The transport physician made a determination of need for a physician based on data available prior to transport (preassessment). After the transport was completed, the physician made a retrospective determination of actual need for a physician (postassessment). Over a period of eight months, 148 questionnaires were analyzed. In 108 transports (73%), there was minimal or no change in need for a physician between the pre- and posttransport assessments. Therefore, an accurate prediction of need for a physician was possible in advance. Of the remaining transports in which the determination was significantly changed, 37 (25%) indicated a decrease in actual need for a physician after completion of the transport. There was a significant increase over the prediction in the actual need for a physician in only three cases (2%).     

Transport of critically ill children: How to utilize resources in the developing world

Safe transport of critically ill children remains a globally important issue, particularly in the developing countries such as India and Africa where the high risk mortality and morbidity exists during the transport process that may be less than optimal due to personnel and resource limitation. This article is intended to familiarize the reader with essential components of a good ground pediatric critical care transport program with special reference to developing countries. Essential equipment, medications, training requirement and responsibilities of transport team have been discussed in detail. In addition, recommendations from American (American academy of pediatrics-Transport section) and British pediatric critical care transport systems have been included, keeping in mind the practical feasibility in the Indian scenario where resources are limited.     

Intraosseous access in the setting of pediatric critical care transport.

OBJECTIVE: To demonstrate safety and efficacy of intraosseous needle placement among health care provider groups in the setting of pediatric critical care transport. DESIGN: Retrospective chart review. SETTING: Pediatric critical care transports to a pediatric intensive care unit. PATIENTS: Children undergoing pediatric critical care transport between January 1, 2000, and March 31, 2002, requiring intraosseous access before arrival to the pediatric intensive care unit. INTERVENTIONS: Intraosseous access placed for emergent vascular access. MEASUREMENTS AND MAIN RESULTS: During the study period, the transport team performed 1,792 transports and identified 47 patients requiring 58 intraosseous placements. These were placed by emergency medical technician-paramedics (18%), referring emergency medicine physicians (42%), and the transport team members (40%). The intraosseous needles were placed with a mean of 1.2 attempts per placement and a first attempt success rate of 78%. Main site of placement was the proximal anterior tibia (95%). Access was maintained for a mean of 5.2 hrs. The intraosseous needle was used for fluids, medications, and laboratory studies. Admitting diagnoses included respiratory distress (28%), cardiopulmonary arrest (26%), neurologic insults (17%), dehydration (15%), sepsis (11%), and other (3%). Ages ranged from 3 wks to 14 yrs (mean 2.2 yrs) and weights from 2.1 to 60 kg (mean 12.3 kg). Complications were noted in seven of 58 (12%), all limited to local edema or infiltration. CONCLUSIONS: Intraosseous placement is frequently needed in the care of critically ill pediatric patients before they reach the pediatric intensive care unit. We have demonstrated that intraosseous needles can be placed safely with similar rates of success when comparing different provider groups. Emergency medical technician-paramedics, emergency medicine physicians, and pediatric critical care transport teams should be familiar with intraosseous placement.     

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.     

Pediatric physical therapy in a rehabilitation setting

Pediatric rehabilitation is a rapidly growing field. Managing the pediatric patient requires experience and the appreciation of the contributions of health, social and educational professionals: physician, nurse, occupational therapist, learning specialist, recreational therapist, psychologist, social worker, and physical therapist. The responsibility of this multidisciplinary team is to assist the family and the child in attaining the highest realistic physical independence, to prevent musculoskeletal deformity and, therefore, to improve the overall quality of life. Successful rehabilitation will depend on the degree to which each professional considers the whole child when working to alleviate specific handicaps. The long-term rehabilitation of the pediatric patient is a joint team-family responsibility, and for treatment to be translated into daily life, full cooperation and commitment from the family is crucial. The physician is the coordinator of the rehabilitation team and is responsible for the initial assessment and diagnosis from which the team undertakes appropriate management. Ideally, the physician and team members communicate frequently to ensure congruent goals of treatment. The role of the physical therapist in the management of the pediatric rehabilitation patient relates to classifications of diagnosis. The authors present this guide to families and health professionals for using physical therapy resources.