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doi:10.1378/chest.07-0222
(Chest. 2007; 132:1361-1367)
© 2007 American College of Chest Physicians
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Interfacility Transport of the Critically Ill Pediatric Patient*

Samuel J. Ajizian, MD and Thomas A. Nakagawa, MD

* From the Department of Anesthesiology, Section on Pediatric Critical Care, Wake Forest University School of Medicine, Winston-Salem, NC.

Correspondence to: Samuel Ajizian, MD, Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1009; e-mail: sajizian{at}wfubmc.edu

Abstract

Care of the critically ill and injured child has evolved over the last 20 years, with growth of regional pediatric critical care services, attendant subspecialties, and the proliferation of pediatric critical care training programs nationally. Concurrent with this evolution has been recognition of the need for specialty care of the critically ill child during air or ground transport to a regional pediatric center. The American Academy of Pediatrics Section on Transport Medicine has provided standards that have been adopted by many neonatal and pediatric transport teams. Team composition varies, but all share the mission of specialized transport for critically ill and injured children in a safe and expeditious process while ultimately improving patient outcome. Specialized pediatric transport teams are costly to maintain. Declining reimbursement for specialized care and reduced profit margins have resulted in extended roles for transport team members within children’s hospitals. More stringent budgetary constraints have created challenges for pediatric transport teams in our constantly changing medical environment.

Key Words: critical care • pediatric • team • transport

Kids are not just little adults. This statement is especially true for adult practitioners faced with a child requiring critical care services. For the emergency medicine physician, general surgeon, pediatrician in a small community hospital, and emergency medical system (EMS) personnel in the field, care of a critically ill child can be challenging. This is especially true in children with underlying chronic medical conditions. Many practitioners welcome the ability to contact pediatric specialists in emergency medicine, critical care, and surgery at regional pediatric centers. In addition to diagnostic and therapeutic advice, activation of the pediatric transport team can be initiated to efficiently transport the critically ill child to a pediatric center that can provide the higher level of care requested.

Historical Perspective

Specialized transport systems have evolved from military experience. Some of the earliest references related to transport of the injured are from the Napoleonic wars in the early 1800s. Dominique Jean Larrey, one of Napoleon’s battle surgeons, is credited with several initial concepts that remain cornerstones in modern transport medicine. Larrey developed the concept of triage (from the French verb trier meaning to sort) to efficiently categorize the injured. Additionally, he recognized the importance of trained individuals to care for the wounded in the field. This care had to be extended during rapid transport to a field medical facility with care provided en route. To accomplish this, he employed the ambulance volante or "flying ambulance." This large horse-drawn carriage was used to ferry the wounded to the field hospital.1 Ongoing refinements of our current civilian transport system have been driven in large part through the use of battlefield evacuation and treatment techniques during the course of conflicts over the last century and a half. The latest leap in transport technology was the introduction of the air ambulance in the form of a rotary wing aircraft. Such aircraft were used with great success in the late 1950s and early 1960s during the Korean and Vietnam wars. In the 1960s, civilian trauma surgeons and neonatologists began to apply military transport concepts and resources to trauma victims and infants, respectively.2

Origins of our current pediatric critical care transport teams evolved from the initial neonatal foundations established in the 1970s. Usher3 described a 50% reduction in mortality rate for critically ill newborns who received care at regional centers. Other studies45 supported this work and confirmed improved infant mortality rates when these neonates were transported to regional centers. Not surprising, outcomes for critically ill children improve when treatment is provided by skilled pediatric specialists.67 The need for rapid and safe transport of critically ill and injured children to a tertiary pediatric care center has driven the formation of specialized pediatric transport teams.

The American Academy of Pediatrics (AAP) published "Guidelines for Air and Ground Transportation of Pediatric Patients" in 1986.8 This document was the AAP response to provide standardized guidelines for transport of critically ill and injured children. These guidelines have been revised twice, in 19939 and again in 2007.10 During this time, active organization within the arena of pediatric transport medicine has been crystallized by the AAP Section on Transport Medicine (SOTM). Established in 1990, the SOTM provides expert leadership by neonatologists, pediatric intensivists, and pediatric emergency medicine physicians for medical personnel dealing with interfacility transport of critically ill neonates, children, and adolescents. The SOTM also coordinates research and education, and provides an online discussion forum for pediatric transport personnel.11

National growth of pediatric ICUs (PICUs) has increased significantly over the past 10 years. One study12 revealed 349 PICUs in the United States, with the largest growth (34.4%) in PICUs with ≥ 15 beds; approximately one half of the PICUs in this study operate ≤ 8 beds. The national growth of PICUs may reflect the need for more specialized care of children in rural areas. Some of these children will require transfer to a tertiary care pediatric facility for ongoing medical care or surgical intervention. Although the actual number of pediatric transport teams in the United States is currently not available, many regional pediatric centers of excellence have established teams to safely and efficiently transport children referred to their institutions. The SOTM published a partial list of neonatal and pediatric teams in the United States13; the information is self-reported and unverified but is an important initial step toward a vitally needed comprehensive database of teams.

Team Composition

The pediatric transport team is a natural physical extension of the PICU. This specialized team is able to provide advanced critical care management for children at remote sites and during transport to a tertiary care center. Such care can be provided in both ground and air transport operations. Care of critically ill children during transport is under the direction of a medical control officer (MCO). Careful consideration must be given to selecting personnel and the role they play during transport. Team composition can include pediatric critical care nurses, pediatric respiratory therapists, physicians (residents, fellows, or attending staff), and paramedics. The ideal combination of personnel varies by region and hospital. Many teams are composed of a pediatric critical care or pediatric emergency department nurse, and a pediatric respiratory therapist, all with extensive pediatric training. National data documenting the spectrum of pediatric transport team composition are not currently available. The presence of a physician on the team is by no means uniform. Data indicate that in nearly one half of all pediatric transports, physician presence is not required.14 One study15 revealed a low incidence of complications in intubated infants and children when transported by personnel trained in pediatrics. The incidence of transport-related morbidity increases significantly when personnel without specialized pediatric training transport critically ill children.1617 Although it is costly to train and maintain strict competencies for pediatric transport team personnel, data indicate a significant cost-benefit ratio by preventing intratransport morbidity and its attendant costs during the hospitalization.18

Specific Roles and Advantages of Pediatric Transport Teams

Rapid response, establishing basic and advanced life support in the field, and efficient ground or air transport are cornerstones for EMS and major hospital transport teams throughout the nation. Trauma and myocardial infarction are two common clinical entities encountered by adult EMS transports. Many EMS transports involve adult trauma victims, although children are also victims of trauma. In fact, only 10% of EMS transports involve pediatric patients.19 Many adult EMS providers lack appropriate knowledge about pediatric physiology, diseases, and skills required to transport critically ill children because of limited pediatric exposure.20 EMS personnel are trained to provide supportive care until the patient reaches an emergency department, where ongoing stabilization and correction of life-threatening situations can occur. Once stabilized, specialized pediatric transport teams fill a needed void to transport critically ill and injured children to a tertiary care pediatric facility. Individuals with specific pediatric training can deliver optimal care for this specialized group of patients during transport to a tertiary care facility.1417

The most common clinical problems encountered in children in need of transport involve the respiratory system. Injury to the CNS including traumatic brain injury is second.21 Transport personnel must be well versed in establishing and maintaining the airway of a child. Basic airway skills including jaw thrust, use of oral airways, nasal trumpets, bag valve mask (BVM) ventilation, and endotracheal intubation are requisite for team members. Half of all critical care pediatric transports require some form of airway intervention.22 Importantly, most cardiac arrest situations in children are due to respiratory causes.2324 Evidence suggests that BVM ventilation is equivalent to endotracheal intubation by EMS personnel in the field.25 Gausche and associates25 showed that BVM ventilation was not only equivalent to endotracheal intubation in terms of neurologic outcome and survival to discharge, but also led to significantly shorter transport times for pediatric patients cared for EMS personnel in the field. Additional studies262728 document the high incidence of inappropriate size, placement, and failed endotracheal intubation in pediatric patients by EMS personnel in the field. These studies underscore the importance of basic noninvasive ventilation for airway support. BVM ventilation, while often life-saving, is rarely the modality of choice for airway support during interfacility transport of a critically ill child. Competency in BVM ventilation is essential and often overlooked by team members intent on maintaining intubation skills. Team coordinators and directors must stress noninvasive airway management skills as much as intubation skills during training.

Pediatric transport personnel may also encounter children with tracheostomies. One must be comfortable caring for patients with this type of airway. The ability to rapidly change a pediatric tracheostomy tube is crucial to the successful transport of a child with an artificial airway that can potentially become obstructed. Transport personnel must understand concepts of mechanical ventilation and potential hazards and complications when utilizing positive pressure ventilation.22 Ventilator management and strategies to maintain oxygenation and ventilation are best reserved for pediatric critical care specialists working in conjunction with pediatric respiratory therapists or other trained personnel who routinely deal with mechanical ventilation in children.

Following airway support, the need to establish vascular access is a common and often challenging problem in smaller children and infants. Peripheral cannulation of veins is preferred. However, in emergent situations, placement of an interosseous needle can be life-saving. Central venous access is not routinely pursued by pediatric transport personnel in the field or at the referring center except in neonatal patients where umbilical venous catheters are frequently placed. Additional procedural skills required for patient stabilization and management include chest tube placement and, on occasion, arterial cannulation for hemodynamic monitoring. These procedures are often performed in a less-than-optimal environment. Therefore, high standards of procedure competency must be maintained. Team administrators must enforce these competencies to ensure personnel can perform procedures under less than ideal circumstances.10

In addition to the practical procedural skills mentioned, transport team personnel must possess advanced pediatric assessment skills. The preponderance of respiratory emergencies in children requires transport team members to be experts in rapid, efficient, pediatric assessment of the respiratory system. Inaccurate assessment can lead to delay in definitive care causing inadvertent and preventable morbidity. Team members should possess advanced critical thinking skills to rapidly diagnose and intervene in situations where the child’s condition is deteriorating.

Team members should be comfortable with and have significant experience using medications commonly used in a critical care setting. Transport personnel regularly employ rapid sequence induction for intubation, and are required to manage all patients who require analgesia and sedation during transport.29 A wide variety of medications are available to the team, at the discretion of the MCO. These pharmacologic agents include, but are not limited to, opiates, sedative/hypnotics including benzodiazepines and barbiturates, nondepolarizing neuromuscular blocking agents, and inotropic agents. Commonly used agents and dosages are shown in Tables 1, 2 .


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  		Table 1.. Rapid Sequence Intubation Medications*

 

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  		Table 2.. Common Analgesic and Sedative Agents*

 
Complications from transport of a critically ill child occur secondary to inadequate stabilization of the airway and lack of appropriate monitoring. Severity of illness and duration of transport are also associated with adverse events.30 Combative or unrestrained patients may extubate themselves or dislodge IVs and, equally important, may present a danger to themselves and the transport crew, especially during air transports. Appropriate pain control and sedation are imperative to promote tolerance of the endotracheal tube and provide comfort for the child. Lack of appropriate monitoring may result in hypoxemia secondary to endotracheal tube dislodgement that may go unrecognized for a prolonged period, especially in the chemically paralyzed patient.31

Effective and Safe Team Deployment
The decision to transport by air or ground requires careful consideration by multiple personnel to ensure patient and team safety. Safety must always be the overriding factor in initial transport mode determination. Advantages and disadvantages of each mode of transport must be evaluated on a case-by-case basis. Selection of the most efficient and, most importantly, safe transport mode for any child requires coordination of multiple personnel, including ground and air dispatch, pilot, team members and composition, and the MCO. Patient acuity, vehicle/helicopter availability, weather, site limitations, patient locality, distance from the receiving medical center, and capabilities of the team caring for the patient at the outlying facility must be considered. Taking all these factors into account leads to a team-oriented, informed decision ensuring a safe and efficient transport for a critically ill or injured child.

Rotary wing vs ground ambulance transport criteria include, but are not limited to, excessive distance resulting in a lengthy transport time by ground, and specific emergency treatment required at the receiving facility resulting in the need for rapid patient transfer (ie, evacuation of an epidural hematoma). Other considerations include patient location that is inaccessable to ground vehicles or local traffic conditions in major metropolitan centers prohibiting rapid ground transport.10

Transport MCOs must understand that accidents occur with ground, fixed wing, and rotary wing transports. King and Woodward32 showed accident rates for pediatric air and ground transport at approximately 1 per 1,000 transports. Collisions where injury was sustained occur at a rate of 0.546 per 1,000 transports. This retrospective review32 found eight fatalities during a 5-year period, all occurring with air accidents. Results of a comprehensive analysis of medical air transport accidents in the United States from 1990 to 2005 by the National Transportation and Safety Board revealed that accident rates and number of flight hours significantly increased during the period examined.33 Recommendations from this study include using stricter standards for transport flight safety delineated in 14 Code of Federal Regulations, part 135, rather than the current more widely accepted and less stringent standards within the 14 Code of Federal Regulations, part 91. Additional recommendations to improve flight safety include following formal preadmission risk analysis procedures, using dispatchers with aviation experience to constantly evaluate changing weather conditions and communicate this information to the air crew, and use of aircraft fitted with terrain awareness and warning systems.

In summary, air and ground transports are not without risk. Mission safety is the primary consideration for transport of the critically ill child and the transport team. A team-oriented decision regarding timing and modality of transport taking all factors into account will lead to a safe and efficient transport.

Team Administration

A knowledgeable and experienced team administrator is central to the success of any pediatric transport team. The AAP recommends a transport coordinator and a medical director to oversee operations of the pediatric transport team. The transport team coordinator is responsible for the daily operations of the team. The coordinator ensures the team is used efficiently, and assists with transport triage in conjunction with the MCO. Additionally, the coordinator directs training of personnel, and coordinates budget, scheduling, continuous quality improvement, treatment protocols, and transport team data collection. Many coordinators also provide patient care directly by staffing transports.10 Pediatric transport team coordinators are usually pediatric nurses with extensive clinical experience in neonatal or pediatric critical care, or pediatric emergency medicine coupled with varying degrees of administrative experience.

Transport team medical directors are usually pediatric intensivists or pediatric emergency physicians. In some institutions, separate medical directors exist for pediatric and neonatal transports. Each director oversees clinical operations within his/her discipline and coordinates team education. The medical director also assists in budget design, and functions with the transport coordinator as a liaison to hospital administration. The role of the medical director also includes outreach, assisting with marketing of the transport team and the institution, and education of professionals in the immediate referral area.

The MCO is the physician on duty for transport consultation and facilitation of patient transport from the outlying facility. This physician can be a pediatric intensivist or pediatric emergency physician. Referrals are routed to this physician for transport consultation and transport initiation. The MCO provides patient management suggestions to the referring physician in an effort to stabilize the child for transport. Additionally, the MCO directs care of the child provided by the transport team until arrival at the accepting facility. The MCO can alter team composition and make dispositions between air or ground transport as the preferred modality of patient transport based on patient acuity.

Administrative and Regulatory Challenges

Specialized teams composed of highly trained individuals are costly propositions. The costs to run a specialized pediatric transport team continue to increase annually. In addition to salary, benefits, and insurance, transport teams have unique routine costs including vehicle maintenance, fuel, and specific medical supplies such as transport monitors, ventilators, infant isolettes, and stretchers. Significant additional cost is incurred in the form of team training and quality assurance measures. Pediatric transport ground services are typically billed under a global charge in addition to mileage. Fixed wing and rotary wing transports are typically billed using a lift-off charge, and a further charge based on nautical miles flown. Medical directors, transport coordinators, and hospital administration must apply a keen understanding of fixed and variable transport costs to the process of setting fees for given transport services. Additionally, contracting with payers and institutions directly can aid team service billing while establishing important ties with key referral sources.

Billing for attending physician services rendered before and during transport may help to offset the significant cost of transport. It is imperative that medical directors be familiar with the following current procedural terminology (CPT) codes, and monitor their appropriate use by attending physicians overseeing transport. CPT code 99373 is used to bill for telephone consultation with the referring physician before the transport team arrives, while CPT 99288 can be used for non–face-to-face medical direction of transport by the MCO. For face-to-face care of a critically ill or injured child provided directly by an attending physician during transport, CPT code 99289 (first 30 to 74 min) and 99290 (each additional 30 min) are used for patients ≤ 24 months old. For children > 24 months old, physicians providing face-to-face care during transport may utilize CPT code 99291(first 30 to 74 min of care), provided intratransport documentation supports the level of care billed. Additional time beyond 74 min can be billed in 30-min increments using CPT 99292 for patients > 24 months of age.10

Many transport teams continue to see decreasing profit margins, and administrations are demanding more for their investment. In an era of declining reimbursement, team administrators are being forced to justify their teams’ existence and find ways to utilize personnel when not transporting patients. Transport nurses and paramedics can function in a variety of roles when they are not actively involved on a transport. These care providers can be part of a rapid response team, provide IV access for routine or difficult patients, and assist with intrahospital transport of patients from various units. Utilization of extended-care providers such as paramedics can be a valuable asset to the pediatric transport team. In addition to their training in safely operating larger transport vehicles, paramedics can also be utilized to help maintain airway support, provide vascular access, and administer medications in emergency situations. Continuing education and licensure requirements must be considered if paramedics are used as a full-time resource. The coordinator and medical director of a pediatric transport team in our health-care environment must creatively think how best to utilize personnel and, in doing so, make the team an indispensable part of the children’s hospital and the overall mission to provide the best possible care to children.

Future Directions

More pediatric transport outcome-based studies need to be done. Such research is difficult to conduct in the transport arena, and prospective studies are often prohibitive both ethically and practically. However, the formation of a national registry of teams for the deposition of transport data and subsequent analysis could begin to identify trends to create more powerful and useful studies contributing to the literature. Such a central database may also aid in coordinating regional transport assets in national disasters. Sharing data related to team construction, costs, and training through such a database may also lead to streamlined team structure, expenditures, and improvement in team function.

Conclusion

The pediatric transport team plays a vital role in the transport of critically ill and injured children to tertiary pediatric facilities. Pediatric transport practitioners are experienced personnel with a wide range of high level clinical competence dealing with diseases affecting children. They are comfortable performing independently, at remote sites, and under duress during transport by ground or air. The pediatric transport team is vital to successful patient care during transport to a tertiary care center. This highly specialized team brings the basic services of the PICU to the patient’s bedside.

Footnotes

Abbreviations: AAP = American Academy of Pediatrics; BVM = bag valve mask; CPT = current procedural terminology; EMS = emergency medical system; MCO = medical control officer; PICU = pediatric ICU; SOTM = Section on Transport Medicine

The authors have no conflicts of interest to disclose.

Received for publication January 24, 2007. Accepted for publication April 30, 2007.

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Related Editorial

Challenges of Pediatric Medical Transport in the 21st Century Health-Care Landscape
Scott A. Kunkel and Robert A. Sinkin
Chest 2007 132: 1113-1115. [Full Text] [PDF]



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