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Pediatric Emergency Transport: Communication and Coordination Are Key to Improving Outcomes

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Table of Contents
About This Issue

This issue reviews the interfacility transfer process and discusses how coordination and preparedness can improve patient outcomes. In this issue, you will learn:

How to decide which patients require interfacility transfer

The roles of emergency clinicians involved in interfacility transfers and factors to consider when determining the composition of a transport team

The pros and cons of various transport modalities and how to decide which is most appropriate for your patient

What equipment and which medications are commonly used in interfacility transfers 

Which diagnostic studies should be performed at the referring facility and those that should be done during transport

Special considerations to take into account when transporting patients who are (or will be) extremely premature, those with hypoxic-ischemic injuries, ductal-dependent congenital heart disease, burns, and patients with special healthcare needs

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Interfacility Pediatric Transport Teams and Resources
    1. Transport Team Personnel
      1. Transport Physician
      2. Respiratory Therapist and Registered Nurse
    2. Communication Hub/Access Center
  6. Transport Modalities
    1. Ground Transportation
    2. Air Transportation
  7. Transport Equipment
  8. Transport Medications
  9. Diagnostic Studies
    1. Studies Conducted at the Referring Facility
    2. Studies Conducted During Transport
    3. Standardized Scoring Systems
  10. Treatment
  11. Special Considerations
    1. Extreme Prematurity
    2. Hypoxic-Ischemic Injury
    3. Ductal-Dependent Congenital Heart Disease
    4. Burns
    5. Patients With Special Healthcare Needs
  12. Controversies and Cutting Edge
    1. Transport Risk Scores
    2. Use of Surfactant
    3. Use of Inhaled Nitric Oxide
    4. Telemedicine
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls When Planning the Transport of Pediatric Patients
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathways
    1. Clinical Pathway for Interfacility Transfer of Pediatric Patients: The Emergency Department Perspective
    2. Clinical Pathway for Interfacility Transfer of Pediatric Patients: The Transport Team Perspective
  19. Table
    1. Table 1. Common Medications and Intravenous Fluids Used During Transport
  20. References



Pediatric patients who are critically ill or who require urgent subspecialty evaluation or specialized imaging, equipment, or procedures must often be transferred to tertiary care centers. The safe execution of interfacility transfer requires the coordination between the facility healthcare teams at each end of the transfer as well as the transport team. This issue discusses the process of interfacility transfer, the required services, the role of the emergency clinician, the role of the pediatric transport team, and the commonly used diagnostic studies and treatment needed during interfacility transfers of pediatric patients.


Case Presentations

A 10-year-old boy presents to your community ED complaining of nausea, vomiting, and “side pain” for 1 day. In the last few hours, he has had shortness of breath and chest pain. His mother states that the boy has had increased thirst and urination for about the last month, which she attributed to the exceptionally hot weather in their desert community. While you consider a diagnosis of diabetic ketoacidosis, the boy’s mental status begins to deteriorate, and he quickly progresses from confusion to agitation. As you get ready to sedate and treat this patient, you also recognize the need for pediatric critical care and endocrinology—subspecialties available only at the tertiary care children’s hospital 100 miles away. How do you decide on the appropriate level of transport care for this critically ill and unstable patient?

A full-term 1-day-old infant who was born at home presents to your ED after turning blue. Upon initial evaluation, the patient is lethargic, cyanotic, and has mottled skin. He is placed on a cardiac monitor, and his heart rate is 170 beats/min. He is breathing comfortably at 68 breaths/min. His blood pressure is 51/37 (mean arterial pressure, 42) mm Hg, with preductal saturation at 68% and postductal saturation at 82%. On examination, there is no murmur, no abnormal breath sounds, and his pulses are normal. You suspect that your patient has a ductal-dependent congenital heart lesion and his decompensation is likely attributable to his ductus arteriosus closing. After starting prostaglandin E1, you begin to think of the most appropriate disposition. What kind of services and subspecialty care will this patient require? What other interventions can you utilize to minimize the risk of adverse events during transport?



The community-based emergency department (ED) healthcare infrastructure that serves pediatric patients has been shown to be inadequately equipped to stabilize and treat patients in need of subspecialty and critical care.1-3 Only 5.5% of EDs have the recommended pediatric medical supplies, 12.4% have all recommended pediatric vascular access supplies, and 62% have access to a pediatric-trained provider.4 Given the array of pediatric subspecialty needs, coupled with the centralization of tertiary pediatric care in urban centers, a dedicated mechanism of transfer is essential. Interfacility transport by specialized pediatric critical care transport teams has been shown to have fewer adverse events and improved mortality compared to transfer by non–pediatric-specific teams.5 Still, this specialized transport mechanism is not without its challenges. A 2016 study reviewing adverse outcomes found in-transit critical events, such as hemodynamic instability or hypoxia, in nearly 1 in every 8 transports.6 Ultimately, the emergency clinician must take these factors into consideration during the decision-making process of whether to arrange for critical care transport to a higher level of care. This issue of Pediatric Emergency Medicine Practice will review the resources and limitations of the pediatric critical care transport team and the decision-making process behind the determination whether to transfer a patient to a higher level of care.


Critical Appraisal of the Literature

A review of the literature was performed to evaluate the evidence supporting the history, best practices, protocols, and patient outcomes of pediatric critical care transport teams. A search was performed in PubMed using the MeSH terms transportation of patients, patient transfer, transport AND critical care AND resuscitation AND pediatric. A total of 758 articles were found. Of these, the 198 cohort studies provided the bulk of the evidence used for this issue, which includes outcomes data of patients transported by pediatric critical care transport teams. Additionally, consensus statements and guidelines published by the American Academy of Pediatrics (AAP) Section on Transport Medicine are derived primarily from these cohort studies. Most recently updated in 2015, The Fourth Edition of Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients offers the most up-to-date guidelines.7

Overall, the state of the literature on pediatric critical care transport is fair. The majority of the literature is comprised of individual case reports and retrospective cohort studies. There have been very few randomized controlled trials or systematic reviews, which offer the highest standard of evidence for decision making. This may be due to several factors, including ethical considerations of distinct treatment arms and the lack of patient volume needed to power such studies. Nonetheless, the available observational studies provide a solid basis for standardized practice.


Risk Management

1. “I was certain my patient was going to need to be transferred, but I wanted to wait until all her labs came back before I started the transfer process.”

The transport process should be started as early as practically possible to account for all potential delays. The process itself may take longer than expected, especially if a provider is not familiar with the process. Other factors in transport delay include the availability of a bed at the accepting hospital, the unavailability of the transport team due to simultaneous calls, and delay of the arrival of the transport team due to inclement weather. These delays in care may lead to an increased risk of clinical deterioration.

5. “While transferring a patient designated to go to the pediatric ward, his clinical status worsened substantially. We brought the patient to the ICU, but they weren’t ready for the patient, so we had to take him to the ED.”

It is important for the transport team to communicate with the designated communication hub when there is any change in disposition. This will allow for communication with the receiving team and ensure appropriate allocation of resources.

6. “The mom was asleep and looked extremely tired after staying up with her sick toddler all night, so I decided to do what I thought was best, and I started the transfer.”

The referring institution is responsible for informing the patient or surrogate of the risks and benefits of the transfer and obtaining consent prior to transfer. Most pediatric transfers are minors, and consent will need to be obtained from the surrogate, typically parents or legal guardians. In cases where they are not readily available, a transfer can still legally occur on the grounds of the emergency exception rule, also known as the doctrine of implied consent. In this case, a minor with a condition that poses a threat to his or her life or health can be transferred without obtaining consent from the appropriate surrogate.



Table 1. Common Medications and Intravenous Fluids Used During Transport



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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  2. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics. 2007;120(6):1229-1237. (Cross-sectional survey; 1524 institutions)
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  5. McPherson ML, Graf JM. Speed isn’t everything in pediatric medical transport. Pediatrics. 2009;124(1):381-383. (Commentary/opinion)
  6. Singh JM, Gunz AC, Dhanani S, et al. Frequency, composition, and predictors of in-transit critical events during pediatric critical care transport. Pediatr Crit Care Med. 2016;17(10):984-991. (Retrospective cohort study; 8889 patients)`
  7. Section on Transport and Medicine American Academy of Pediatrics, Insoft RM, Schwartz HP, et al. Guidelines for Air & Ground Transport of Neonatal and Pediatric Patients Manual. 4th ed. Elk Grove Village: American Academy of Pediatrics; 2015. (Textbook)
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  19. Stroud MH, Prodhan P, Moss M, et al. Enhanced monitoring improves pediatric transport outcomes: a randomized controlled trial. Pediatrics. 2011;127(1):42-48. (Randomized controlled trial; 1995 patients)
  20. Orr RA, Venkataraman ST, McCloskey KA, et al. Measurement of pediatric illness severity using simple pretransport variables. Prehosp Emerg Care. 2001;5(2):127-133. (Prospective cohort study; 2253 patients)
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  26. Wheeler DS, Poss WB. Pediatric Transport Medicine. In: Wheeler D, Wong H, Shanley T, eds. Resuscitation and Stabilization of the Critically Ill Child. London: Springer; 2009. (Textbook chapter)
  27. Fuller J, Frewen T, Lee R. Acute airway management in the critically ill child requiring transport. Can J Anaesth. 1991;38(2):252-254. (Retrospective review; 39 patients)
  28. McDonald TB, Berkowitz RA. Airway management and sedation for pediatric transport. Pediatr Clin North Am. 1993;40(2):381-406. (Commentary)
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  30. Warner B, Musial MJ, Chenier T, et al. The effect of birth hospital type on the outcome of very low birth weight infants. Pediatrics. 2004;113(1 Pt 1):35-41. (Population-based cohort study; 848 live births of infants weighing 500 to 1499 g)
  31. Schierholz E. Therapeutic hypothermia on transport: providing safe and effective cooling therapy as the link between birth hospital and the neonatal intensive care unit. Adv Neonatal Care. 2014;14 Suppl 5:S24-S31. (Review)
  32. Akula VP, Joe P, Thusu K, et al. A randomized clinical trial of therapeutic hypothermia mode during transport for neonatal encephalopathy. J Pediatr. 2015;166(4):856-861. (Multicenter randomized clinical trial; 100 newborns undergoing cooling)
  33. Goel N, Mohinuddin SM, Ratnavel N, et al. Comparison of passive and servo-controlled active cooling for infants with hypoxic-ischemic encephalopathy during neonatal transfers. Am J Perinatol. 2017;34(1):19-25. (Retrospective review)
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  44. Rahiman S, Sadasivam K, Ridout DA, et al. Comparison of three different timeframes for pediatric index of mortality data collection in transported intensive care admissions. Pediatr Crit Care Med. 2014;15(3):e120-e127. (Retrospective cohort study; 759 patients)
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  48. Biniwale M, Kleinman M. Safety of surfactant administration before transport of premature infants. Air Med J. 2010;29(4):170-177. (Retrospective review; 955 infants born at 24 to 34 weeks’ gestation)
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  50. Kinsella JP, Griebel J, Schmidt JM, et al. Use of inhaled nitric oxide during interhospital transport of newborns with hypoxemic respiratory failure. Pediatrics. 2002;109(1):158-161. (Prospective cohort study; 25 newborns on iNO during transport)
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  54. Fenton SJ, Lee JH, Stevens AM, et al. Preventable transfers in pediatric trauma: A 10-year experience at a level I pediatric trauma center. J Pediatr Surg. 2016;51(4):645-648. (Retrospective review; 6380 transferred trauma patients)
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Publication Information

Abraham Gallegos, MD; Vijay Prasad, MD, MPH; Calvin G. Lowe, MD, FAAP

Peer Reviewed By

Stephen Patterson, MD, FACEP; Kristy Williamson, MD, FAAP

Publication Date

April 2, 2018

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