1. Transporting Sick Children Safety, Critical Incidents, Insurance

2. Importance Rationale for dedicated retrievals is to offer better service than previously existed Rationale for dedicated retrievals is to offer better service than previously existed Evidence that specialised teams perform better. Evidence that specialised teams perform better.

3. Barry PW, Ralston C. Adverse events occurring during inter-hospital transfer of the critically ill. Arch Dis Child 1994;71:8-11 Observational study in Leicester of 56 children transferred in for PICU. Observational study in Leicester of 56 children transferred in for PICU. Adverse events in 42 (75%) – 13 were life threatening incidents Adverse events in 42 (75%) – 13 were life threatening incidents These transfers tended to have been undertaken by inexperienced staff. These transfers tended to have been undertaken by inexperienced staff.

4. Macnab, A. J. (1991). "Optimal escort for interhospital transport of pediatric emergencies." J Trauma 31(2): 205-9. Chart review 130 paediatric transfers looking for adverse events during transit Chart review 130 paediatric transfers looking for adverse events during transit 8% occurred with 8% occurred with specialized pediatric transport escorts who were accompanied by a tertiary care physician 8% occurred with 8% occurred with specialized pediatric transport escorts who were accompanied by a tertiary care physician 20% with specialized pediatric transport escorts alone 20% with specialized pediatric transport escorts alone 72% with escorts who had not received specialized pediatric transport training 72% with escorts who had not received specialized pediatric transport training

5. Edge WE, Kanter RK, Weigle CGM et al. Reduction of morbidity in inter-hospital transport by specialised paediatric staff. Crit Care Med 1994; 22: 1186-1191 Prospective study of adverse events during transport Albany NY, Syracuse NY. Prospective study of adverse events during transport Albany NY, Syracuse NY. ICU related adverse events 1/47 specialised transports (2%) and 18/92 non-specialised (20%). ICU related adverse events 1/47 specialised transports (2%) and 18/92 non-specialised (20%). Physiological deterioration 5/47 specialised (11%), 11/92 non-specialised (12%). Physiological deterioration 5/47 specialised (11%), 11/92 non-specialised (12%).

6. Britto, J., S. Nadel, et al. Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team. BMJ 1995; 311: 836-9 Prospective descriptive study 51 cases Mary’s PICU retrieved from DGH Prospective descriptive study 51 cases Mary’s PICU retrieved from DGH 2 cases had preventable physiological deterioration 2 cases had preventable physiological deterioration PRISM score improved during transfer and stabilisation PRISM score improved during transfer and stabilisation

7. Why is it safer with specialist teams Familiarity with age group Familiarity with age group Familiarity with equipment Familiarity with equipment More experienced More experienced Learned from previous ‘mistakes’ Learned from previous ‘mistakes’

8. Learning from mistakes Blame free Blame free Critical incident reporting Critical incident reporting Regular transport meetings Regular transport meetings Enable prevention Enable prevention

10. Latent failures Poor communication Poor communication –Referral –With ambulance crew –Doctor-nurse Poor process Poor process –No routine pattern –No check lists Poor equipment maintenance Poor equipment maintenance –Includes kit checks

11. Example Transfer from hospital 1 hour away Transfer from hospital 1 hour away 30 mins into transfer ventilator stops 30 mins into transfer ventilator stops Patient transferred to Ayre’s T-piece from portable cylinder – no desaturation Patient transferred to Ayre’s T-piece from portable cylinder – no desaturation Oxygen cylinder in ambulance empty – allegedly full (size F) at start of journey Oxygen cylinder in ambulance empty – allegedly full (size F) at start of journey Back up cylinder full – supply changed – ventilator connectors tightened Back up cylinder full – supply changed – ventilator connectors tightened

12. Who’s fault? Was oxygen cylinder full at departure – not properly checked Was oxygen cylinder full at departure – not properly checked Was ventilator checked prior to transfer – yes Was ventilator checked prior to transfer – yes Previous experience – ventialtors can develop leaks Previous experience – ventialtors can develop leaks

13. Actions Mannual check on ambulance oxygen supply re-emphasized Mannual check on ambulance oxygen supply re-emphasized Check all ventilator connections after each change in oxygen supply Check all ventilator connections after each change in oxygen supply

14. Importance of process Sick neonate 32/40 NEC, high O 2 requirement Sick neonate 32/40 NEC, high O 2 requirement Safely transferred 40 miles Safely transferred 40 miles Arrived NICU Arrived NICU Handover – staff started to move baby before this was complete – ‘don’t worry the ventilator’s set up’ Handover – staff started to move baby before this was complete – ‘don’t worry the ventilator’s set up’ Ventilator failed – took 30 secs to recognise – baby desaturated Ventilator failed – took 30 secs to recognise – baby desaturated No bagging circuit attached – transport incubator had to be used as emergency back up No bagging circuit attached – transport incubator had to be used as emergency back up

15. Action Transporting doctor responsible for supervising all aspects of transfer until baby is stable on receiving unit’s ventilator Transporting doctor responsible for supervising all aspects of transfer until baby is stable on receiving unit’s ventilator Full attention of all staff during verbal handover – no switching over of monitors etc. Full attention of all staff during verbal handover – no switching over of monitors etc. Don’t move a patient until bagging circuit available and turned on Don’t move a patient until bagging circuit available and turned on

16. Think ahead Identify problems before they occur Identify problems before they occur Surprises will happen – expect them and deal with them – ABC principles. Surprises will happen – expect them and deal with them – ABC principles. Ensure you can always isolate the patient quickly from equipment and use failsafe ABC - Ambubag Ensure you can always isolate the patient quickly from equipment and use failsafe ABC - Ambubag

17. Safety points - patient Medical equipment secure and visible Medical equipment secure and visible End tidal CO 2 End tidal CO 2 All monitoring functioning prior to departure All monitoring functioning prior to departure Secure IV access Secure IV access Secure ETT in correct position Secure ETT in correct position Secured to trolley Secured to trolley

18. Safety

19. Safety points -staff Seatbelts Seatbelts Use winch correctly Use winch correctly No interventions ‘on the move’ No interventions ‘on the move’ Communicate with ambulance driver – comfort and speed Communicate with ambulance driver – comfort and speed Blue light rarely needed Blue light rarely needed

20. CATS – Complications 2002

21. CATS - Complication Rate 2002

22. Checklists

23. Air retrievals

24. Lack of power Lack of power Effects on pO2 Effects on pO2 Pressurised vs unpressurised Pressurised vs unpressurised Unforseen delays Unforseen delays Multiple patient movements Multiple patient movements –Trolley  ambulance –Ambulance  plane –Plane  ambulance –Ambulance  trolley

25. Stabilisation Few situations scoop and run Few situations scoop and run Exceptions Exceptions –Extradural haematoma –Blocked VP shunt Much better to achieve stability prior to departure – may take some time. Much better to achieve stability prior to departure – may take some time.

26. Whitfield JM, Buser NNP. Transport stabilisation times for neonatal and paediatric transfers prior to interfacility transfer. Pediatr Emerg Care 1993; 9: 67-71. Median stabilisation time for 1193 ventilated children - 74 mins Median stabilisation time for 1193 ventilated children - 74 mins If receiving inotropes - 150 minutes. If receiving inotropes - 150 minutes.

27. Transferring patient with severe ARDS A – Secure ETT – check position on CXR – ensure minimal leak as high pressure ventilation necessary B – Realistic targets – O 2 sats 85 – 92%, pH >7.25 Use high PEEP – 10-15cm – needs to be active PEEP. Long T insp, High F i O 2. Allow time to recruit alveoli. C – Good access, well filled, inotropes as required.

28. Oxygen calculation Minute volume  estimated journey time  2 – rounded up Minute volume  estimated journey time  2 – rounded up –D cylinder 340L –E cylinder 680L –F cylinder 1360L Spare cylinder heads and O rings Spare cylinder heads and O rings

29. Summary PICU retrieval team have been specially trained for the purpose PICU retrieval team have been specially trained for the purpose Almost never acceptable to transfer patient if not stable Almost never acceptable to transfer patient if not stable Air retrievals carry extra risks Air retrievals carry extra risks

30. AMF YOYO