Intro/Membership | Resources | Chair's Letter | Home


ambulance

SECTION ON
Transport Medicine

helicopter
Awards
The Section on Transport Medicine provides an annual forum for the discussion of clinical matters or research related to the field of pediatric transport medicine. Abstracts and posters are presented during the Section's educational and scientific program at the AAP's National Conference & Exhibition (NCE), and awards are given for the best presentations.

The Submission Deadline for AAP National Conference
& Exhibition abstracts is the middle of APRIL. Authors
are notified of their status via email in early summer.

The C ROBERT CHAMBLISS MD BEST PAPER AWARD recognizes the best abstract or poster presentation given during the SOTM education program by a non-student or non-resident transport professional.

The BEST-IN-TRAINING PAPER recognizes the best abstract or poster presentation given during the SOTM education program by a student, resident, or post-graduate fellow.

2013 | 2012 | 2011 | 2010

2013

C ROBERT CHAMBLISS MD BEST PAPER AWARD -- 2013

Michael Stroud, MD, FAAP, presenter, received an award of $500.
Goal-Directed Resuscitative Interventions During Pediatric Interfacility Transport (The GRIPIT Trial)
Michael Stroud, MD, FAAP1, Maria S Melguizo-Castro, MS1, Todd Nick, PhD2 and M. Michele Moss, MD, FAAP, FCCM, FACC1, (1)University of Arkansas for Med Sciences, Little Rock, AR, (2)Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR

Purpose: To determine the effect of goal-directed therapy administered during inter-facility transport on the outcomes of critically ill children. Advances in therapeutic interventions have improved outcomes of pediatric critical illness. Goal-directed therapy has been instrumental in this change. Specialized pediatric transport teams are evolving into mobile intensive care units (ICU) capable of delivering ICU-level interventions in the field. Specialized teams have been shown to improve care delivery and outcomes of critically ill children. Goal-directed therapy administered by specialized pediatric transport teams could further impact the outcomes of critically ill children.
Methods: A before-and-after trial design was used to test the hypothesis that goal-directed therapy during inter-facility transport will improve the outcomes of critically ill children with SIRS (Systemic Inflammatory Response Syndrome). Prospective data was collected for 10 months on all transport patients meeting age-adjusted consensus SIRS criteria at Arkansas Children's Hospital. An educational intervention utilizing high-fidelity simulation was performed, followed by routine protocolized, goal-directed resuscitation of transport patients with SIRS. Data was collected for an additional 10 months, followed by comparison of the two groups. In addition, non-invasive cerebral oxygenation monitoring data was collected on a convenience sample of patients in both groups. This study was funded by the Eunice Kennedy Shriver National Institute of Child Health (ClinicalTrials.gov Identifier: NCT01293500).
Results: 255 children with SIRS were enrolled, 136 pre-intervention (A) and 119 post-intervention (B). Demographic data and severity of illness using pre-transport PIM-II scores were equivalent. The intervention group had a significantly shorter hospital length of stay [13.1±18.1 days (A) vs. 6.8±9.8 days (B); p=0.011]. ICU length of stay was shorter but did not reach statistical significance [5.8±8.5 days (A) vs. 3.8±5.2 days (B); p=0.18]. Patients in the post-intervention group required fewer ICU interventions [TISS-28 Scores: 19.4±6.8 (A) vs. 17.2±6.6 (B); p=0.037] and showed a trend toward a lower incidence of organ dysfunction (PELOD Scores; p=0.067). Patients in the post-intervention had higher mean cerebral oxygenation, utilizing non-invasive NIRS monitoring [66±14 (A) vs. 71±18 (B); p<0.05]. Overall mortality was 2% (3 subjects in each group).
Conclusions: Specialized pediatric transport teams are evolving into mobile ICU's capable of delivering goal-directed therapy for critical illness in the field. Interventions prior to tertiary care center arrival have the potential to impact the outcomes of critically ill children with SIRS. Relevant pediatric transport medicine research, including multi-center studies, is urgently needed to evaluate equipment, interventions, and therapeutic protocols aimed at improving the clinical and functional outcomes of critically ill children.

BEST-IN-TRAINING PAPER AWARD -- 2013

Kate Steffen, MD, presenter, received an award of $250.
Training of Pediatric Critical Care Transport Teams for ECMO Transports- Use of a Standardized Checklist to Enhance Team Communication and Patient Safety
Kate Steffen, MD1, Kristen Nelson McMillan, MD1, Philomena Costabile, RN2, Gary Oldenburg, CRT2, Guillermo Herrera, CRT2, Eric Henderson, EMT-P2 and Melania Bembea, MD, MPH1, (1)Johns Hopkins School of Medicine, Baltimore, MD, (2)Johns Hopkins Hospital, Baltimore, MD

Purpose: Transport of pediatric patients on ECMO involves a small proportion of all specialty team transports and thus is a high risk, low volume event. As such, these transports require extensive multidisciplinary pre-planning to identify threats to patient safety. Use of standardized checklists to ensure completion of critical tasks for such events may enhance team communication and patient safety.
Methods: Transport team members participated in a high-fidelity simulation involving transport of a 5 year old placed on VA-ECMO at an outside hospital (OSH) following a witnessed cardiac arrest. Each team was responsible for role assignment, stretcher set-up, all patient transfers and patient management throughout the simulation without direction from study team members. A standardized ECMO transport checklist organized in systems-based format was developed prior to simulations and was used by team 2, but not team 1. Specific complications instituted during the simulation were hypotension due to hemorrhage and ventricular tachycardia with hemodynamic compromise. Primary outcome measure was time to administration of blood products due to hemorrhage, utilizing checklist as compared to no use. Secondary outcomes measures included: 1) time to defibrillation, 2) time off ECMO during transition to transport ECMO pump and 3) performance of team huddle prior to leaving on transport and 4) prior to leaving OSH with patient, comparing use of checklist to no use.
Results: 18 transport team members participated: 2 physicians, 6 nurses, 4 ECMO specialists and 6 paramedics, split between 2 teams. Time to administration of blood products from onset of hypotension (team 1 vs team 2): 19 minutes vs 4 minutes. Although team 1 leader recognized hypotension due to hemorrhage within 2 minutes, she was not aware of blood product availability brought with transport team until almost 18 minutes of hypotension and administered albumin while blood products were ordered by the OSH. Team 2 recognized need for blood products within 3 minutes of hypotension and blood from transport cooler was administered following discussion with team leader. Time to defibrillation (team 1 vs 2): 51 seconds vs 48 seconds. Time off ECMO (team 1 vs 2) 55 seconds vs 40 seconds. Both team leaders performed a huddle prior to leaving on transport, with team 2 huddle performed using the checklist. During pre-transport huddle for team 2, there was a review of available blood products as part of the checklist. Only team 2 leader performed a huddle with the team prior to leaving OSH, also utilizing the checklist.
Conclusion: Use of a standardized checklist enhanced effective closed loop team communication, allowing rapid identification and management of complications encountered. Identification of latent threats to patient safety may be identified through such high-fidelity simulations and strategies to minimize these threats can be implemented prior to actual transports.

~ top ~

2012 C ROBERT CHAMBLISS MD BEST PAPER AWARD -- 2012

David J. Mathison, MD, MBA,
presenter, received an award of $500.

Using a Resource Allocation Decision-Support Tool to Increase Operational Efficiency for a Pediatric Interfacility Transport Team
David J. Mathison, Emergency Medicine, Children's National Medical Center, Washington, DC and Jennifer Schuette, Division of Transport
Medicine, Children's National Medical Center, Washington, DC


Background: Resource utilization for pediatric interfacility transport is highly variable among different centers. It is unclear how best to balance and
distribute these resources as teams expand their services from specialized single-unit critical care.

Purpose: This study evaluates the use of an original resource allocation decision-support tool for prioritizing and dispatching interfacility neonatal/
pediatric transports. This tool more explicitly defines the capabilities of different team members and the recommendations for different team configura-
tions and mode of transport based on the specifics of each intake call (figure 1). The primary outcomes were personnel on transports (team configura-
tion) and mode of transport (ground vs. air), while evaluating for adverse outcomes associated with lower levels of care. We hypothesized that the use
use of this tool would increase the number of rotorwing flights and paramedic-only (delta) ground transports.

Methods: This retrospective analysis compared all interfacility transports to Children's National Medical Center between two four-month periods (Dec
2010—Mar 2011 vs. Dec 2011—Mar 2012). The resource allocation tool was implemented in November 2011. This decision-support tool was created
based on the local scope of practice for different transport providers and a priority assessment of the timeliness for common diagnoses, created by
faculty neonatologists, pediatric emergency and pediatric critical care physicians. Day level analysis was used to compare the mean number of trans-
ports for each team configuration and mode (pediatric and neonatal) during the two time periods.

Results: Similar total transports occurred before (1888) and after (1933) the intervention [N=121 days for each period]. The mean number of paramedic-
only (delta) transports per day increased 1700% from 0.24 [+/- 0.53] to 4.26 [+/- 2.41] (p<0.001). The mean number of paramedic-nurse (charlie) trans-
ports per day decreased 30% from 13.41 [+/- 3.36] to 9.31 [+/- 2.97] (p<0.001). The mean daily use of rotorwing transport increased by 23% from 1.15
[+/- 1.13] to 1.50 [+/- 1.14] (p<.05). There was a marginal increase in the use of respiratory therapists that was not statistically significant [1.93 +/- 1.34 vs.
2.18 +/- 1.49] (p=0.171). There were no adverse patient outcomes associated with paramedic-only (delta) transports. In one case, a paramedic-only unit
responded lights-and-sirens because the child was in compensated shock, but no additional interventions would have been performed if more
specialized personnel were available.

Conclusion: Our resource allocation triage/dispatch tool demonstrates a systematic approach for an interfacility team to distribute resources by need
rather than by convenience. If staffing is adjusted accordingly, the team can allocate resources to decrease operational costs and function more
efficiently without compromising patient care.


Figure 1 -- resource allocation decision-support tool
Figure 1

Table 1
table 1

BEST-IN-TRAINING PAPER AWARD -- 2012


Michael E. Valente, MD, presenter, received an award of $250.
Cerebral Perfusion during Vehicle Acceleration In Pediatric and Neonatal Emergency Transport
Michael Valente, MD and Lowe Calvin, Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA

Purpose: Acceleration studies have demonstrated the association between acceleration and cerebral perfusion decreases (as indicated by cere-
bral regional saturation of oxygen; rSO2) in adult pilots. Some in the field of transport medicine have advocated certain patient head positioning
tioning to minimize the effect of head-to-toe acceleration forces that lead to blood pooling and decreases in cerebral perfusion. Our study
objectives were to measure the peak acceleration forces during pediatric patient transport, to determine whether drops in rSO2 occurred during transport, and to determine whether patient positioning (i.e., head-to-front of vehicle (HTF), head-to-back of vehicle (HTB) was associated with
drops in rSO2.
Methods: A cerebral oximeter (INVOS, Somanetics) was used to monitor 20% decreases in rSO2 from baseline (generally accepted as clinically
significant) in a sample of neonatal and pediatric patients during transport via ground ambulance, helicopter, and fixed-wing aircraft. During
transport, Z-axis accelerations (axis aligned with spine) were recorded by an accelerometer (SENSR GP1) bolted to the patient's isollette or gurney.
Results: The Z-axis acceleration peaks (g) of each transport type were: ground ambulance takeoff 0.05 to 0.23 (M=0.16, SD=0.09) and landing
0.01 to 0.16 (M=0.08, SD=0.05), helicopter takeoff 0.02 to 0.26 (M= 0.16, SD=0.10) and landing 0.03 to 0.05 (M=0.04, SD=0.01), and fixed-wing
aircraft takeoff 0.03 to 0.24 (M=0.14, SD=0.10) and landing 0.03 to 0.49 (M=0.20, SD=0.18). Across transport types, the proportions of patients
who experienced rSO2 drop were: ground ambulance 6/11, helicopter 3/6, and fixed-wing aircraft 2/5. During takeoff, rSO2 was measured in 20
patients (7 HTF, 13 HTB). The 2 patients with rSO2 drop were in the HTF group. During landing, rSO2 was measured in 21patients (8 HTF, 13
HTB). All 4 patients with rSO2 drop were in the HTB group. Fisher's exact test revealed no significant associations between patient positioning
and rSO2 drop (ps>0.11).
Conclusion: The peak Z-axis acceleration forces generated by the three types of transport vehicles were small and similar in magnitude. Also,
the proportions of patients who experienced rSO2 drop were similar across transport types. Although Fisher's exact test results were non-
significant potentially due to low statistical power from our small sample size), it is noteworthy that two patients with rSO2 drop during takeoff
were in the HTF position and four patients with rSO2 drop during landing were in the HTB position. Further investigation with a larger sample is
warranted to clarify the relationship between patient positioning and decreases in cerebral perfusion.

~ top ~

2011

C ROBERT CHAMBLISS MD BEST PAPER AWARD -- 2011

James Cappon, MD, CPHQ, presenter, was awarded a $500 prize.
Pilot Study of the Pediatrics Early Warning System (PEWS) During Pediatric Interfacility Intermediate-Level (ACLS) Transports
James Cappon, MD, CPHQ, Quality & Patient Safety, Children's Hospital of Orange County (CHOC), Orange, CA and Jason Knight, MD, FAAP,
Critical Care, CHOC Children's Hospital, Orange, CA


Purpose: Our freestanding children's hospital implemented PEWS on non-ICU inpatients two years ago. PEWS is a physiology-based nurse assess-
ment tool that serially scores and trends respiratory, cardiovascular and neurobehavioral status. Additional high-risk markers can be assigned (Table).
Internal and external data demonstrate that worsening PEWS scores are associated with imminent patient deterioration, need for ICU care and resus-
citation events. We postulated that through Emergency Transport Service Team (ETS) application of our inpatient PEWS to ACLS patients at the time of
ETS field evaluation, we could reduce the number of transported Medical-Surgical patients who experience early deterioration after admission. More-
over, we aimed to eliminate indeterminate-status transport patients requiring a brief PICU triage evaluation upon transport completion (“fly-bys ”).

Table !

Methods: Our ETS team (annual volume >4000) transports approximately 2500 ACLS children each year for Med-Surg admission. We have previously
proven the validity of our pre-transport triage process for differentiating ACLS (ETS RN and RT) vs. Critical Care-level (Advanced Scope ETS RN, RT, ±
MD) transports, with a “failure” rate of <1/1000. Prior to the pilot, a PEWS curriculum was delivered to all ETS members, including test scenario patients.
Pilot patients with concerning PEWS scores (≥5 or 3 [= maximum] in any individual category) per ETS were discussed with the medical control physi-
cian during transport, and a destination confirmed.

Results: PEWS scores were assigned to 602 consecutive ACLS patients during a 15 week period in 2010. Concerning PEWS scores were present in
15 (2.5%). Following discussion, 8 of these patients were changed to PICU status (PEWS >6: 3/3; 6: 2/4; 5: 1/6; “max 3”: 2/2). Notably, 0/594 patients
triaged to Med-Surg required unplanned transfers to PICU within 4 hours (our organization marker of inappropriate triage). Three “fly-bys” occurred, all
within the first five weeks of the pilot.

Conclusion: PEWS is an increasingly utilized marker of pediatric non-ICU inpatient potential deterioration. Application of this score by transport teams
during the interfacility transport process can accurately identify children at risk for imminent deterioration after admission, resulting in appropriate unit
assignment and markedly reduced unplanned escalation of care. The inpatient Med-Surg PEWS score as assigned by ETS RNs was completely trans-
latable to the transport setting. Undesired and inefficient triage “fly-by” assessments can also be reduced.

BEST-IN-TRAINING PAPER -- 2011

Crystal Joyce, DO, presenter, was awarded a $250 prize.
Pediatric Critical Care Transport In the Primary Care Setting: Is This Where We Should Be?
Crystal Joyce, DO, Department of Pediatrics, Akron Children's Hospital, Akron, OH, M. David Gothard, MS, Rebecca D. Considine Clinical Research
Center, Akron Children's Hospital, Akron, OH, Hamilton P. Schwartz, MD, FAAP, Department of Pediatrics, Cincinnati Children's Hospital Medical Center,
Cincinnati, OH and Michael T. Bigham, MD, FAAP, Department of Pediatrics, Division of Critical Care Medicine and Rebecca D. Considine Clinical
Research Institute, Children's Hospital Medical Center of Akron, Akron, OH


Purpose: Approximately 200,000 infants and children in the United States are transported each year from one hospital to another for specialty neonatal
or pediatric care unavailable at their community hospitals. Interfacility transports are commonly performed by specialty pediatric critical care transport
(SPCCT) teams. Ill children may present to non-hospital settings such as primary care offices or urgent cares and require emergency care and trans-
port. Some non-hospital settings are ill-equipped to manage an unstable child, and the care providers must decide the appropriate means of transport:
EMS or SPCCT. Herein, we sought to describe a single-center’s experience with specialized critical care transport from these non-hospital settings.

Methods: This IRB-approved study sought to evaluate retrospectively children (0-18 years) transported by our SPCCT team from non-hospital settings
in 2010. Data were extracted from an institution-specific database. When appropriate, statistical tests were applied including Fisher’s exact test and
Mann-Whitney U using SPSSv17.0 software.

Results: Twenty-six patients were identified with an average age of 5.4±7.14yrs and weight of 21.4±21.6kg (mean±SD). Of the 22 patients (84.6%) with
insurance, Medicaid and private insurance were equally represented. Half of the transport requests identified respiratory distress as the primary com-
plaint and the average SPCCT response time was 48±21min. The pre-transport care included IV access in 9(34.6%) of patients, IVF bolus in 7(26.9%),
and antibiotics in 4(15.4%) of patients. Albuterol treatment was provided in 13(50%) of patients and 9(34.6%) received steroids. After arrival of the
SPCCT team an IV was placed in 6(23%) additional patients, 5(19.2%) got an IVF bolus, and 1(3.8%) received antibiotics. Four (15.4%) children were
transported to the children’s hospital emergency department, of which 3 (11.5%) were discharged home. Six (23.1%) were admitted directly to the PICU,
1 to the NICU, and the remainder (15, 57.5%) to the general care floor. For the 6 PICU patients the median LOS was 7.8; 1.7–9.3days (median; IQR).
All patients survived to hospital discharge with a hospital LOS of 2.1; 0.8-5.7days. Critical care transports in this cohort had billed charges of $2660.14
±940 (mean±SD). Posthoc analysis of urgent care vs. physician offices showed that children originating in the urgent cares were more likely to be
directly discharged home (p=0.046) though no differences existed in PICU or hospital LOS.

Conclusions: Ill children present to primary care offices and urgent cares and require emergency care and transport. The most common SPCCT inter-
ventions are IV access and IVF bolus. Response times for SPCCT teams are typically longer than EMS and most transported children are not in need
of critical care. Our small cohort rarely demonstrates application of additional critical care interventions beyond those provided by the referring office or
urgent care, suggesting that SPCCT team response to non-hospital setting might be resource overutilization.

~ top ~

2010

C ROBERT CHAMBLISS MD BEST PAPER AWARD -- 2010

Kyong-Soon Lee, MD, FRCP, MSc, presenter, was awarded a $500 prize.
Mortality Rates and NICU Outcomes of Neonates Born at the Limits of Viability in Inborn Vs Outborn Centres
Kyong-Soon Lee and Hilary Whyte, Paediatrics, Hospital for Sick Children, Toronto, ON, Canada

Background: At the limits of viability, outcomes are less than optimal and decisions re-
garding resuscitation are difficult. There has been a recent trend for increasing resuscita-
tion of infants born at the limits of viability. It has been shown that preterm infants born in
perinatal centres (inborn) have significantly better outcomes compared with those born in
non-perinatal centres and transported after birth to NICUs (outborns). However, previous
data comparing
inborns and outborns have grouped infants at the limits of viability with

Table: Mortality rates of inborn vs outborn infants born at 23-25 GA
table
higher gestational ages (GA) and outcome data for infants
at the limits of viability have represented mostly inborn
infants. For deliveries at the limits of viability that continue
to occur in significant proportions in non-perinatal centres,
outcome data for outborn infants is required to guide
counseling and decision making.

Purpose:
To determine the mortality and NICU outcomes
of inborn vs outborn infants born at 23 to 25 weeks GA.

Methods: The records of all neonates born at 23-25 weeks
GA who were referred to the 3 NICUs in our region during
January 2005 to December 2007 were reviewed for mor-
tality and NICU outcomes. These 3 NICUs provide tertiary
NICU care for 50% of Ontario births.

Results: Among 318 neonates born at 23-25 wk GA, 211
(66%) were inborn and 107 (34%) were outborn. Intuba-
tion at delivery was used as a proxy for significant resus-
citation. Among intubated infants, mortality rates for GA
23-25 weeks was 33% for inborns compared with 50%
for outborns (p=0.006). See Table for further results. The
proportion of infants with grade III/IV IVH or PVL was 42%,
grade IV ROP or ROP requiring surgery was 19% and
need for respiratory support at 36 weeks corrected GA
was 66%. There were no significant differences in these
NICU outcomes among the 3 GA groups or between in-
vs outborn infants.

Conclusion: A significant proportion of 23 week GA infants
born in inborn centres were not resuscitated. Consistent
with previous studies, the mortality rate for infants born at
23-25 weeks GA was higher for outborns vs inborns. At
the limits of viability where outcomes are already tenuous,
this difference in mortality between inborns vs outborns
places 24 week GA outborn infants at major risk of mor-
tality (60%). These data support an aggressive approach
to the transfer of women with threatened preterm labor to
a perinatal centre. If maternal transfer does not occur,
these differences in outcomes between inborn vs outborn
infants should be considered during counseling and
decision making.
BEST-IN-TRAINING PAPER -- 2010

Sarah B. Kandil, MD, presenter, was awarded a $250 prize.
Pediatric Transport Triage Using the Transport Risk Assessment in Pediatrics (TRAP) Score
Sarah B. Kandil, MD and John S. Giuliano Jr., MD, Pediatric Critical Care, Yale University School of Medicine, New Haven, CT

Purpose: The purpose of this study was to evaluate the Transport Risk Assessment in Pediatrics (TRAP) score for triage of pediatric patients. This
novel transport scoring tool was derived from physical signs and symptoms to assist in appropriate triage of children transported from other facilities.
The score ranges from 0 – 16, with 16 representing the most abnormal physiologic variables. We hypothesized that a higher TRAP score would corre-
late with pediatric intensive care unit (PICU) admission.

Methods: We conducted a bidirectional observational cohort study of pediatric patients transported by a specialized ground transport team to a tertiary
care center before and after implementation of the TRAP scoring tool. Patients were eligible if transported by the pediatric ground transport team for
direct admission to the children’s hospital. Patients transported by air, standard ambulance crew, or who were brought directly to the emergency
department were excluded. The TRAP score was obtained by chart review for patients included prior to implementation of the TRAP scoring tool. It was
formed prospectively at first encounter of transported patients after implementation. Categorical data was analyzed using chi-square and Fisher’s
exact tests, while continuous data was analyzed using student t-test and Wilcoxon-Mann Whitney test.

Results: A total of 269 patients were identified from September 2008 – February 2009 and September 2009 – February 2010. Of these, 238 patients
were included in the study. All patients in the historical group (n=115) were scored by chart review and flow sheet documentation. There were 123
patients in the prospective group with 108 (88%) having TRAP scores completed at first encounter. The remaining scores were completed based on
flow sheet documentation. The two groups had similar baseline characteristics including age, weight, gender, diagnosis category, severity of illness
scores, disposition, and critical events/interventions during transport. The mean TRAP scores calculated for the historical cohort were not significantly
different than those of the prospective cohort (4.30 vs. 3.84, p=0.19). The combined mean TRAP score was 4.06 (SD 2.69) with a median of 4.00 (IQR
0 to13). Using logistic regression for associations between potential risk factors and outcomes, a higher TRAP score was found to have a strong
association with PICU admission (OR 1.40, p <0.0001). For every point increase there was a 40% increase in odds of going to the PICU. Patients with
a higher score were also less likely to have a change in disposition within 24 hours (OR 0.79, p <0.0001).

Conclusion: The TRAP score, a novel objective pediatric transport assessment tool, can assist with triage decisions of children admitted from outside
institutions. Children with higher TRAP scores are more likely to require pediatric ICU admission for greater than 24 hours.


~top~
 
08/14