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.

2012 | 2011 | 2010

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 resuscitation 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. Moreover, we aimed to eliminate indeterminate-status transport patients requiring a brief PICU triage evaluation upon transport completion (“fly-bys”).

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 physician 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 translatable 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 MedicalCenter, 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 transport. 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 complaint 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 interventions 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
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 mortality 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. Intubation at delivery was used as a proxy for significant resuscitation. 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 inborn 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 mortality (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 correlate 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 performed 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~