OBJECTIVE: The goal was to test the hypothesis that interfacility transport performed by a pediatric critical care specialized team, compared with nonspecialized teams, would be associated with improved survival rates and fewer unplanned events during the transport process.
METHODS: A single-center, prospective, cohort study was performed between January 2001 and September 2002. A total of 1085 infants and children at referral community hospitals with requests for retrieval by the Children's Hospital of Pittsburgh transport team were studied; 1021(94%) were transported by a specialty team and 64 (6%) by nonspecialized teams. Unplanned events during the transport process and 28-day mortality rates were assessed.
RESULTS: Unplanned events occurred for 55 patients (5%) and were more common among patients transported by nonspecialized teams (61% vs 1.5%). Airway-related events were most common, followed by cardiopulmonary arrest, sustained hypotension, and loss of crucial intravenous access. After adjustment for illness severity, only the use of a nonspecialized team was independently associated with an unplanned event, and death was more common among patients transported by nonspecialized teams (23% vs 9%).
CONCLUSION: Transport of critically ill children to a pediatric tertiary care center can be conducted more safely with a pediatric critical care specialized team than with teams lacking specific training and expertise in pediatric critical care and pediatric transport medicine.
Comments
Pediatric Specialized Transport Teams And Improved Outcomes: are we seeing the full picture?
Dear Sir
Orr et al convincingly demonstrate that the rate of unplanned adverse events and hospital mortality were much higher when non-specialised transport teams transferred patients into their tertiary care centre (1). Although it represents a single centre’s experience, theirs is the first study to demonstrate how a specialist paediatric transport team (SPTT) has the potential to improve important patient outcomes.
As a busy regionalised paediatric intensive care transport service based in London, our own clinical experience leads us to support the authors’ conclusions. However, we are surprised by the high mortality reported in the group transported by the non-specialist team – hospital mortality for SPTT patients was 9% whereas nearly a quarter of the 64 patients transported by non-specialist teams died. In comparison, we examined data from a tertiary care PICU to which we transport patients and found that crude mortality for children transported by an SPTT and non- specialised team were 9% and 12.3% respectively – PICU deaths represent >90% of the total deaths in the hospital (2). Despite the authors’ attempts to minimise bias and the use of risk adjustment, significant differences between the groups were inevitable because the transport team was chosen by a non-random process; more patients with cardiac and neurological diagnoses were transported by non-specialist teams, a greater proportion required at least 1 major intervention, and they had higher pre -ICU PRISM scores. Some of these features may represent patients at high risk of hospital mortality despite adjustment for physiological status at initial referral (3). The pre-ICU PRISM score does not take into account ‘lethal’ diagnoses such as neurodegenerative disease or complex uncorrected cardiac disease such as those used in the Paediatric Index of Mortality score (PIM-2) for mortality risk prediction (4). Pre-ICU PRISM has also been shown to be a poor predictor of unplanned adverse events and the need for major interventions during transport (5). In addition, the pre-ICU PRISM score was derived and validated from data collected from PICU admissions, and its predictive value for other hospital admissions is not clear (6). It is possible that in children perceived to be ‘high- risk’, referring hospitals sought immediate transfer using non-specialist teams when an SPTT was unavailable, but for respiratory and other patient groups, they may have opted to wait until an SPTT became available. Additional information may help clarify these questions. Firstly, Orr et al may wish to compare the mortality for all children transferred by non- specialist teams, irrespective of whether they were referred to the SPTT or not, and compare the two subgroups. If the authors’ conclusions are true, an adverse effect on survival should be seen in both groups. Secondly, information on how many children were admitted to PICU and other hospital wards within each group, and their respective outcomes, may be useful. Data on team mobilisation times and refusals by SPTT classified by diagnostic group could also be provided.
We were also interested to note that despite having the same command physician for SPTT and non-specialised team transfers, the rate of unplanned adverse events during transport were much more frequent in the latter group. Do the authors feel that the physician providing medical control is unable to influence the course of transport once the team is mobilised, especially a non-specialist team? Can some unplanned adverse events be anticipated or prevented by closer monitoring of the team’s activity, either by telephone or in the future by telemedicine systems? Our practice is to have mandatory telephone discussions between the transport team and the supervising transport intensivist at a minimum of 3 time points during the transfer – at initial referral, on arrival at the local hospital, and before leaving the local hospital. The impact of this practice has not been formally measured, although our experience indicates that alterations to patient management occur frequently following these discussions, especially with relatively inexperienced teams. Clarification of these points would allow readers to confidently extrapolate the study findings to their own settings.
(1) Orr RA, Felmet KA, Han Y, McCloskey KA, Dragotta MA, Bills DM, Kuch BA, Watson RS. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics. 2009 Jul;124(1):40-8.
(2) Ramnarayan P, Craig F, Petros A, Pierce C. Characteristics of deaths occurring in hospitalised children: changing trends. J Med Ethics. 2007 May;33(5):255-60.
(3) Leteurtre S, Martinot A, Duhamel A, Proulx F, Grandbastien B, Cotting J, Gottesman R, Joffe A, Pfenninger J, Hubert P, Lacroix J, Leclerc F. Validation of the paediatric logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study. Lancet. 2003 Jul 19;362(9379):192-7.
(4) Slater A, Shann F, Pearson G; Paediatric Index of Mortality (PIM) Study Group. PIM2: a revised version of the Paediatric Index of Mortality. Intensive Care Med. 2003 Feb;29(2):278-85. Epub 2003 Jan 23.
(5) Orr RA, Venkataraman ST, Cinoman MI, Hogue BL, Singleton CA, McCloskey KA. Pretransport Pediatric Risk of Mortality (PRISM) score underestimates the requirement for intensive care or major interventions during interhospital transport. Crit Care Med. 1994 Jan;22(1):101-7.
(6) Kanter RK, Edge WE, Caldwell CR, Nocera MA, Orr RA. Pediatric mortality probability estimated from pre-ICU severity of illness. Pediatrics. 1997 Jan;99(1):59-63
Conflict of Interest:
None declared