1. Pediatric Intensive Care Transport Jonathan Cu, MD Pediatric Emergency Specialist Neonatal and Pediatric Critical Care Transport Specialist

2. Neonatal and Pediatric Intensive Care Transport Unit

4. Goal and Objectives  Give a background on pediatric intensive care transport  Understand the goals and principles of pediatric transport  Identify the basic components of a pediatric intensive care transport team  Recognize factors involved in choosing various modes of transport

5. Case 1  37/F, pregnant, 28 weeks AOG  2-week vacation in far flung rural area  Went into preterm labor  Brought to community hospital and delivered  Outcome: preterm 28 weeks 800grams AGA delivered via SVD, live baby boy, APGAR 4,6

6. Case 1  Patient has poor activity, gasping, HR 140, pink centrally but has poor distal perfusion, Temp 34C sats 85%  Problem: no local neonatologist/intensivist and no ICU facilities  Local doctor were able to thermoregulate, give O 2 support but has difficulty cannulating and reluctant to perform endotracheal intubation  Asking for help from tertiary referral centre

7. Case 2  3/M vacation in a beach with family  Near drowning, submerged for 5 minutes  Initially HR 0  CPR performed for 10 minutes with ROSC  Paramedics arrived, intubated the patient and transferred to a local hospital

8. Case 2  Upon arrival in ED of a local hospital, having hypotensive episodes and desaturations while on ambubagging  Problem: no local ICU facilities and no intensivist available  Called a tertiary referral centre asking for help

9. Problems  What can we offer in a community hospital setting  Who to talk to and how to refer to a tertiary referral centre  Who will arrange for an ICU bed  Who will coordinate for a safe transfer  What can we do for the patient while waiting for help to arrive

10. Bahala na si…

11. Neonatal and Pediatric Intensive Care Transport Unit  Specialized service dedicated in providing intensive care to critically ill child anywhere at any time  Provide expert clinical advise  Clinical coordinator  Emergency treatment and stabilization  Bringing ICU to the patient  Interhospital transport

12. Background  In the United States, Australia, UK and Canada, hospital-based neonatal transport programs were first created in the 1960s and 1970s  Similar programs for older infants and children emerged in the 1980s  Became well-developed in countries with a centralized healthcare system

13. Background  Neonatal-pediatric transport programs part of the continuum of care in a system of emergency medical services for children  They provide a safe, therapeutic environment for pediatric patients who must be transferred between health care institutions under urgent or emergent circumstances

14. Diagnostic Categories Of Children Transported

15. Specialized transport team vs. Paramedics Paramedics  Primary retrievals  Not equipped  Not trained in handling intensive care  Scoop and run principle Specialized transport team  Secondary/hospital retrieval  Adequate planning and equipment  Intensive experience in ICU/Emergency care  Early goal-directed treament  Bringing ICU to the patient

17. The Tortoise and the Hare

18. The Golden Hour  Concept originated in 1973 by Cowley et al.  Referred to Army helicopter use  Goal for soldiers to be within 35 minutes of definitive life-saving care  Stated a 3 fold increase in mortality with every 30 minutes away from ‘definitive care  No available data to support claim  Resulted in less field intervention in favor of speed of transport  Interventions on transport in 1973, not comparable to our capabilities today

19. Pediatric arrest  Primary cardiac arrest in infants and children is rare  Pediatric cardiac arrest is often preceded by respiratory failure and/or shock and it is rarely sudden  Early intervention and continued monitoring can prevent arrest  The terminal rhythm in children is usually bradycardia that progresses to PEA and asystole  Septic shock is the most common form of shock in the pediatric population  80% of children in septic shock will require intubation and mechanical ventilation within 24 hours of admission

20. Interesting facts…  EMS programs for paramedics offers <10 hours pediatric training  No pediatric blood pressure cuffs (24%)  No pediatric airway equipments (79%) Seidel JS et al. Circulation 1986

21. Interesting facts… According to AAP, average EMS provider sees:  1 peds BVM case q 1.7 years  1 peds intubation q 3.3 years  1 peds IO line q 6.7 years

22. Interesting facts…  Paramedics were less confident in assessing vital signs for <2 years old  Children <14 years old undertreated as compared with adults Gausche M et al, Acad Emerg Med 1998  Twice as many patients transported by standard paramedic/ambulance service died in the first 12 hours after admission Bellingan G et al, Intensive Care Med 2000

23. Orr RA et al, Pediatrics 2009

24. Specialized Pediatric Transport Team  Fewer unplanned events (61% vs. 1.5%), 38 times higher for patients transported by nonspecialized team  Significantly lower mortality rate (23% vs. 9%), >2 times higher for patients transported by nonspecialized team Orr RA, et al, Pediatrics 2009

25. Intensive Care Med 2004

28. Siriraj Hospital (Thailand)  Retrospective review of interhospital transport  Total number transported from 2001 to 2003: 36  All road transfers  Accompanying medical personnel: nurses (55%), the rest paramedics  63.9% intubated, 28% ongoing inotropes J Med Assoc Thai 2005

29. Siriraj Hospital (Thailand)  Upon arrival, none of the patients had any record on important patient’s data (no vital signs monitoring, oxygen saturation or adverse events)  77.8% needed prolonged PICU stay  31% mortality rate J Med Assoc Thai 2005

30. Goal of Pediatric Intensive Care Transport  Early direction and initiation of advanced care  Treatment and monitoring with the expected expertise and capabilities of the tertiary care center while the patient is still in the referring facility  Improve safety of the transport and patient outcome.

31. Initiation of ‘definitive’ care  Definitive care begins with the arrival of the transport team  Early goal directed treatment improves outcomes  Needs to begin with the local emergency departments and continue with the transport team  Early aggressive interventions to reverse shock can increase survival by 9 fold if proper interventions are done early!  Hypotension and poor organ perfusion worsens outcomes “Further improvement in the outcome of critical illness is likely if the scoop-and-run mentality is replaced by protocol driven, early goal-directed therapy in the pretertiary hospital setting” Stroud et al., 2008

32. Initiation of ‘definitive’ care  Ramnarayan (2009)  Urgent vital interventions such as CPR, intubation or central venous access required in the first hour after arrival in an ICU  May indicate that inadequate stabilization was completed during transport  McPhearson and Graf (2009)  Attention to small details makes significant difference in pediatric transport  Securing ETT  Early recognition and treatment of shock  Adequate IV access

33. Essential components  Dedicated team proficient at providing neonatal and/or pediatric critical care during transport

34. Essential components  Medical control by qualified physicians  Ground and/or air ambulance capabilities  Communications/dispatch capabilities  24/7 availability  Written clinical and operational guidelines

35. Essential components  Quality and performance improvement activities  Administrative resources  Institutional endorsement and financial support.

36. Med Control Physician  PEDS ER or PICU consultant with sufficient knowledge and experience in transport medicine  Accepts pt, consults subs  Sends appropriate team  Directs stabilization  Provides ongoing direction to transport team

37. How does it work? Clinical Coordinator Retrieval Consultant Accepting Specialist Retrieval Team Referring Doctor

38. Team Composition  Depends on the patient’s needs  determined in consultation with the team and medical control  Dedicated pool of qualified physicians, nurses, paramedics and/or respiratory therapists

39. Team Composition  Retrieval specialist  Critical care nurse / Nurse Practitioner  +/- Respiratory therapist  Ambulance driver/pilot

40. Team Composition  A team member’s degree is less important than his or her ability to provide the level of care required  Critical care during transport conditions is significantly different from an ICU or ED

41. Team Composition  Should not be assumed that a health care professional who is competent in the ICU or ED will function equally well in a mobile environment

42. Equipments  Modified Stretcher/Incubator system newborn, infant, toddler, adult system  Backpacks - ABCs  Medication bag – inotropes, surfactant, etc…  Syringe / infusion pumps with long battery life  +/- nitric oxide machine  Ambulance fitted with oxygen(4500L) and air(4500L), Zoll defibrillator, Laerdal electric suction, transilluminator, charger, refrigerator  Communication devices

45. Mode of Transport  Road Ambulance  Rotary wing  Fixed wing

46. Vehicle selection  Ground – space and option to stop  Fixed Wing – stability in bad weather  Helicopter – land at scene, speed

47. Determining mode  Four critical steps necessary for selection of the optimal mode  Evaluation of the current patient status  Evaluation of care the required before and during transport  Urgency of the transport  Logistics of a patient transport (e.g., local resources available for transport, weather considerations, and ground traffic accessibility)

48. Ground Vs Air  Beyond 100 miles, a ground may become inefficient, costly to operate, and time consuming  Helicopter is used for up to 150 mile radius  Fixed wing greater than 150

49. Ground Vs Air  Distance to the closest appropriate facility is too great for safe and timely transport by ground ambulance  The potential for transport delay that may be associated with the use of ground transport (e.g., traffic and distance) is likely to worsen the patient's clinical condition

51. Key Points  Good communication = good decision-making  Adequate resuscitation and proper stabilization prior to transport  Expect for the worst case scenario Retrieval team’s worst nightmare – Resuscitation / Arrest en route

52. Back to Case 1  Fortunately, there is an available Neonatal and Pediatric Intensive Care Transport Unit  Conference call made with the neonatologist oncall  Referring physician advised to keep the baby thermoregulated, instructed to use neopuff and gave step by step instruction on how to put an umbilical line to provide fluids and glucose while the retrieval team was being mobilised.

53. Back to Case 1  Upon arrival, patient was intubated, sedated, given surfactant and connected to transport ventilator.  Vitals: HR 140 BP 70/40 sats 95% Temp 36.5 C CRT 2secs  CXR done  Blood gas taken with iSTAT  Transferred to transport incubator  Brought back to tertiary referral centre uneventful

54. Back to Case 2  Conference call with PICU was arranged while to retrieval team went en route  GCS 3, HR 120, intubated on ambubagging, BP 70 systolic, CRT 3-4 secs.  Advised to give bolus of 20ml/kg pNSS and to start Dopa at 10mcg/kg/min  BP and perfusion improved

55. Back to Case 2  Team arrived within 1 hour  Hooked to transport ventilator, sedated and paralyzed  oxygen saturation improved and blood gas acceptable  Central line inserted for IV fluids and inotropes  Arterial line inserted for BP monitoring  Maintained on Temp 33-34 C  Transported back to tertiary referral centre uneventful  Stayed in PICU for 7 days and transferred to regular bed after with no neurologic deficit

56. Do we need a Specialized Transport System?

57. Utility vs Futility  The benefits of transport must outweigh the risks for the patient limited space, equipment, staff separation from family  The risks/costs of transport must be justified

58. Cost  The approximate cost of a medically configured ground ambulance is approximately $150 000 to $350 000, depending on the manufacturer and model selected  The annual maintenance and fuel costs might range from $10 000 to $25 000 per vehicle

59. Cost  Single-engine helicopter A ‑ Star or Bell 407 averages $2 million.  A light twin ‑ engine helicopter EC145 and Bell 430, both medium ‑ sized twin engine helicopters, cost between $4 and $6 million  While a large twin ‑ engine helicopter about $1-2 million more

60. Cost  Pilot salaries range from $60,000 to $85,000 annually; a staff of four is required to cover 24/7  Financial concerns include fixed and variable costs  Fixed costs include insurance, taxes, crew costs, overheads, interest, hanger fees and capital equipment  Variable (hourly) costs vary directly with the number of hours flown. These costs include fuel and oil, scheduled maintenance labor, etc

61. Cost Effectiveness  Cost effective for a centralized health care system  Composed of a single retrieval unit covering for the whole state  Expensive to maintain but less costly than to put up pediatric ICUs in rural hospitals  US retrieval system mostly hospital-based  Improved patient outcome  Patient transport safety  Less expensive to maintain

62. What if Case 1… Grandson of a business tycoon?

63. What if Case 2… Child of a celebrity?

64. Questions? Thank you!