Treatment Guideline Nonadherence Pretransport Associated With Need for Higher Level of Care in Children Transferred to a Pediatric Tertiary Care Center for Status Epilepticus.

OBJECTIVES: We sought to investigate the association between adherence to the American Epilepsy Society (AES) 2016 guidelines for management of convulsive status epilepticus (SE) and clinical outcomes among children requiring interhospital transport for SE. We hypothesized that pretransport guideline nonadherence would be associated with needing higher level of care posttransfer. METHODS: This was a retrospective cohort study of children aged 30 days to 18 years transferred to our pediatric tertiary center from 2017 to 2019 for management of SE. Their care episodes were classified as 2016 American Epilepsy Society guideline adherent or nonadherent. There were 40 referring hospitals represented in this cohort. RESULTS: Of 260 care episodes, 55 (21%) were guideline adherent, 184 (71%) were guideline nonadherent, and 21 (8%) had insufficient data to determine guideline adherence. Compared with the adherent group, patients in the nonadherent care group had longer hospitalizations (32 hours [17-68] vs 21 hours [7-48], P = 0.006), were more likely to require intensive care unit admission (47% vs 31%), and less likely to be discharged home from the emergency department (16% vs 35%; χ 2 test, P = 0.01). Intubation rates did not differ significantly between groups (25% vs 18%, P = 0.37). When we fit a multivariable model to adjust for confounding variables, guideline nonadherence was associated with need for higher level of care (odds ratio, 2.04; 95% confidence interval, 1.04-3.99). Treatment guideline adherence did not improve over the 3-year study period (2017: 22%, 2018: 19%, 2019: 29% [χ 2 test for differences between any 2 years, P = 0.295]). CONCLUSIONS: Guideline nonadherence pretransport was associated with longer hospitalizations and need for higher level of care among children transferred for SE at our institution. These findings suggest a need to improve SE guideline adherence through multifaceted quality improvement efforts targeting both the prehospital and community hospital settings.

Cardiopulmonary Resuscitation During Simulated Pediatric Interhospital Transport: Lessons Learned From Implementation of an Institutional Curriculum.

INTRODUCTION: Little is known about cardiopulmonary resuscitation (CPR) quality during pediatric interhospital transport; hence, our aim was to investigate its feasibility. METHODS: After implementing an institutional education curriculum on pediatric resuscitation during ambulance transport, we conducted a 4-year prospective observational study involving simulation events. Simulated scenarios were (1) interhospital transport of a child retrieved in cardiac arrest (Sim1) and (2) unanticipated cardiac arrest of a child during transport (Sim2). Cardiopulmonary resuscitation data were collected via Zoll RSeries defibrillators. Performance was evaluated using age-appropriate American Heart Association (AHA) Guidelines. Video recordings were reviewed for qualitative thematic analysis. RESULTS: Twenty-six simulations were included: 16 Sim1 [mannequins: Laerdal SimMan 3G (n = 13); Gaumard 5-year-old HAL (n = 3)] and 10 Sim2 [Gaumard 1-year-old HAL (n = 8); Laerdal SimBaby (n = 2)]. Median (IQR) CPR duration was 18 minutes 23 seconds (14-22 minutes), chest compression rate was 112 per minute (106-118), and fraction (CCF) was 1 (0.9-1). Five hundred eight 60-second resuscitation epochs were evaluated (Sim1: 356; Sim2: 152); 73% were AHA compliant for rate and 87.8% for CCF. Twenty-four minutes (4.7%) had pauses more than 10 seconds. One hundred fifty seven Sim1 epochs (44.1%) met criteria for excellent CPR (AHA-compliant for rate, depth, and CCF). Rates of excellent CPR were higher for learner groups with increased simulation and transport experience (59.1% vs. 35.3%, P < 0.001). Thematic analysis identified performance-enhancing strategies, stemming from anticipating challenges, planning solutions, and ensuring team's shared mental model. CONCLUSIONS: High-quality CPR may be achievable during pediatric interhospital transport. Certain transport-specific strategies may enhance resuscitation quality. Learners' performance improved with simulation and transport experience, highlighting ongoing education's role.

Interhospital Transport of Children With Peripheral Venous Catheters by Private Vehicle: A Mixed Methods Assessment.

BACKGROUND: Many children seeking emergency care at community hospitals require transport to tertiary centers for definitive management. Interhospital transport via ambulance versus patient's own vehicle (POV) are 2 possible modes of transport; however, presence of a peripheral venous catheter (PIV) can determine transport by ambulance. Caregiver satisfaction, patient comfort, and PIV complications related to POV transport have not been described. OBJECTIVE: The aims of the study were to examine caregivers' satisfaction and perceptions of POV transport in children with/without PIVs and to assess PIV-related complications during transport. METHODS: We performed a mixed-methods, prospective cohort study of children who presented with low-acuity conditions to a community hospital and subsequently required transfer to a pediatric tertiary center. Caregivers of patients with/without PIVs were given the choice of transport by POV or ambulance. Surveys completed after transport used dichotomous, 5-point Likert scale, and open-ended responses to assess satisfaction, perceptions, and PIV-related complications. Responses were quantitatively and qualitatively analyzed accordingly. The receiving hospital assessed PIV integrity. RESULTS: Sixty-nine of 78 eligible patients were enrolled; of those, 67 (97%) elected transport by POV and 55 (82%) completed surveys. Most caregivers had positive responses related to satisfaction, comfort, and safety. Results did not differ significantly between those with/without PIVs. The majority (96%) would choose POV transport again. There were no reported PIV complications; all PIVs were functional upon arrival. Qualitative analysis identified themes of comfort, convenience, and efficiency. CONCLUSIONS: In select scenarios, interfacility transport by POV is preferred by families and doing so with a saline-locked PIV does not result in complications.

Diagnostic Discordance in Pediatric Critical Care Transport: A Single-Center Experience.

OBJECTIVES: The aims of the study were to describe diagnostic discordance rates at our pediatric tertiary care center between the reason for transfer of critically ill/injured children (determined by the referring institution) and the inpatient admission diagnosis (determined by our accepting institution), to identify potential factors associated with discordance, and to determine its impact on patient outcomes. METHODS: We conducted a retrospective chart review of all critically ill/injured children transferred to the Johns Hopkins Children's Center between July 1, 2017, and June 30, 2018. All patients whose initial inpatient disposition was the pediatric intensive care unit were included. RESULTS: Six hundred forty-three children (median age, 51 months) from 57 institutions (median pediatric capability level: 3) met inclusion criteria: 46.8% were transported during nighttime, 86.5% by ground, and 21.2% accompanied by a physician. Nearly half (43.4%) had respiratory admission diagnoses. The rest included surgical/neurosurgical (14.2%), neurologic (11.2%), cardiovascular/shock (8.7%), endocrine (8.2%), infectious disease (6.8%), poisoning (3.1%), hematology-oncology (2.2%), gastrointestinal/metabolic (1.9%), and renal (0.3%). Forty-six (7.2%) had referral-to-admission diagnostic discordance: 25 of 46 had discordance across different diagnostic groups and 21 of 46 had clinically significant discordance within the same diagnostic group. The discordant group had higher need for respiratory support titration in transport (43.9% vs 27.9%, p = 0.02); more invasive procedures and vasopressor needs during the day of admission (26.1% vs 11.6%, P = 0.008; 19.6% vs 7%, P = 0.006); and longer intensive care unit (ICU) and hospital stays (5 vs 2 days; 11 vs 3 days, P < 0.001). When compared with respiratory admission diagnoses, patients with cardiovascular/shock and neurologic diagnoses were more likely to have discordant diagnoses (odds ratio [95% confidence interval], 13.24 [5.41-35.05]; 6.47 [2.48-17.75], P < 0.001). CONCLUSIONS: Seven percent of our critically ill/injured pediatric cohort had clinically significant referral-to-admission diagnostic discordance. Patients with cardiovascular/shock and neurologic diagnoses were particularly at risk. Those with discordant diagnoses had more in-transit events; a higher need for ICU interventions postadmission; and significantly longer ICU stays and hospitalizations, deserving further investigation.

A National Survey on Physician Trainee Participation in Pediatric Interfacility Transport.

OBJECTIVES: To ascertain the national experience regarding which physician trainees are allowed to participate in pediatric interfacility transports and what is considered adequate education and training for physician trainees prior to participating in the transport of children. DESIGN: Self-administered electronic survey. SETTING: Pediatric transport teams listed with the American Academy of Pediatrics Section on Transport Medicine. SUBJECTS: Leaders of U.S. pediatric transport teams. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-four of the 90 U.S. teams surveyed (49%) responded. Thirty-nine (89%) were university hospital-affiliated. Most programs (26/43, 60%) allowed trainees to participate in pediatric transport in some capacity. Mandatory transport rotations were reported for pediatric critical care (PICU) fellows (9/42, 21%), neonatology (neonatal ICU) fellows (6/42, 14%), pediatric emergency medicine fellows (4/41, 10%), emergency medicine residents (3/43, 7%), and pediatric residents (2/43, 5%). Fellow participation was reported by 19 of 28 programs (68%) with PICU fellowships, 12 of 25 programs (48%) with pediatric emergency medicine fellowships, and 10 of 34 programs (29%) with neonatal ICU fellowships. Transport programs with greater than or equal to 1,000 annual incoming transports were more likely to include PICU and pediatric emergency medicine fellows as providers (p = 0.04; 95% CI, 1.04-25.71 and p = 0.02; 95% CI, 1.31-53.75). Most commonly, trainees functioned as medical control physicians (86%), provided minute-to-minute medical direction for critically ill patients (62%), performed intubations (52%), and were code leaders for patients undergoing cardiopulmonary resuscitation during transport (52%). Most transport programs required pediatric residents, PICU, and pediatric emergency medicine fellows to complete a PICU rotation prior to participating in pediatric transports. The majority of transport programs did not use any metrics to determine airway proficiency of physician trainees. CONCLUSIONS: There is heterogeneity with regard to the types of physician trainees allowed to participate in pediatric interfacility transports, the roles played by physician trainees during pediatric transport, and the training (or lack thereof) provided to physician trainees prior to their participating in pediatric transports.

Pediatric Transport Triage: Development and Assessment of an Objective Tool to Guide Transport Planning.

OBJECTIVES: We developed a Pediatric Transport Triage Tool (PT3) to objectively guide selection of team composition and transport mode, thereby standardizing transport planning. Previously, modified Pediatric Early Warning Score for transport has been used to assess illness severity but not to guide transport decision making. METHODS: The PT3 was created for pediatric transport by combining objective evaluations of neurologic, cardiovascular, and respiratory systems with a systems-based medical condition list to identify diagnoses requiring expedited transport and/or advanced team composition not captured by neurologic, cardiovascular, and respiratory systems alone. A scoring algorithm was developed to guide transport planning. Transport data (mode, team composition, time to dispatch, patient disposition, and complications) were collected before and after PT3 implementation at a single tertiary care center over an 18-month period. RESULTS: We reviewed 2237 inbound pediatric transports. Transport mode, patient disposition, and dispatch time were unchanged over the study period. Fewer calls using a transport nurse were noted after PT3 implementation (33.9% vs 30%, P = 0.05), with a trend toward fewer rotor-wing transports and transports requiring physicians. The majority of users, regardless of experience level, reported improved transport standardization with the tool. Need to upgrade team composition or mode during transport was not different during the study period. No adverse patient safety events occurred with PT3 use. CONCLUSIONS: The PT3 represents an objective triage tool to reduce variability in transport planning. The PT3 decreased resource utilization and was not associated with adverse outcomes. Teams with dynamic staffing models, various experience levels, and multiple transport modes may benefit from this standardized assessment tool.

Assessment of a quality improvement intervention to improve the consistency of total body surface area burn estimates between referring facilities and a pediatric burn center.

BACKGROUND: Burns are a significant source of pediatric morbidity and frequently result in transfer of care to a pediatric burn center. Data suggest that referring facilities often overestimate the total body surface area (%TBSA) of burns in comparison to the subsequent assessment at the pediatric burn center. Such discrepancies may trigger inappropriately aggressive interventions with potential for patient harm. Our baseline assessment of data from 106 patients transferred to our pediatric burn center over a one-year period showed that 59/106 (56%) patients had a %TBSA recorded at the time of transfer and 18/59 (31%) had clinically significant differences (>5% difference) in estimates between the referring facility and the pediatric burn center. METHODS: Informed by this clinical audit and a root cause analysis, we implemented practices to enhance consistency of clinical assessments between referring facilities and our pediatric burn center. These practices included the use of a common clinical assessment instrument (a standardized Lund and Browder form) that was integrated into the interfacility transfer process as well as educational outreach at referring facilities for providers who treat children with burns, prioritizing facilities with the highest number of discrepancies. RESULTS: Follow up data was reviewed 16-23 months after initiating the intervention. Cumulatively, we found significant improvement in the proportion of patients with %TBSA recorded (94% vs 56%, p < 0.001) that achieved our goal to exceed 90% and a reduction in clinically significant discrepancies that exceeded our goal of 15% (10% vs 31%, p = 0.002). CONCLUSIONS: Referring facilities often overestimate the %TBSA in comparison to the subsequent assessment at the pediatric burn center. The consistency of the %TBSA estimates can be improved by interventions that utilize the sharing of a common clinical assessment instrument and standardization of the transfer intake process.

Trauma Bay Disposition of Infants and Young Children With Mild Traumatic Brain Injury and Positive Head Imaging.

OBJECTIVES: To describe the disposition of infants and young children with isolated mild traumatic brain injury and neuroimaging findings evaluated at a level 1 pediatric trauma center, and identify factors associated with their need for ICU admission. DESIGN: Retrospective cohort. SETTING: Single center. PATIENTS: Children less than or equal to 4 years old with mild traumatic brain injury (Glasgow Coma Scale 13-15) and neuroimaging findings evaluated between January 1, 2013, and December 31, 2015. Polytrauma victims and patients requiring intubation or vasoactive infusions preadmission were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two-hundred ten children (median age/weight/Glasgow Coma Scale: 6 mo/7.5 kg/15) met inclusion criteria. Most neuroimaging showed skull fractures with extra-axial hemorrhage/no midline shift (30%), nondisplaced skull fractures (28%), and intracranial hemorrhage without fractures/midline shift (19%). Trauma bay disposition included ICU (48%), ward (38%), intermediate care unit and home (7% each). Overall, 1% required intubation, 4.3% seizure management, and 4.3% neurosurgical procedures; 15% were diagnosed with nonaccidental trauma. None of the ward/intermediate care unit patients were transferred to ICU. Median ICU/hospital length of stay was 2 days. Most patients (99%) were discharged home without neurologic deficits. The ICU subgroup included all patients with midline shift, 62% patients with intracranial hemorrhage, and 20% patients with skull fractures. Across these imaging subtypes, the only clinical predictor of ICU admission was trauma bay Glasgow Coma Scale less than 15 (p = 0.018 for intracranial hemorrhage; p < 0.001 for skull fractures). A minority of ICU patients (18/100) required neurocritical care and/or neurosurgical interventions; risk factors included neurologic deficit, loss of consciousness/seizures, and extra-axial hemorrhage (especially epidural hematoma). CONCLUSIONS: Nearly half of our cohort was briefly monitored in the ICU (with disposition mostly explained by trauma bay imaging, rather than clinical findings); however, less than 10% required ICU-specific interventions. Although ICU could be used for close neuromonitoring to prevent further neurologic injury, additional research should explore if less conservative approaches may preserve patient safety while optimizing healthcare resource utilization.

A National Survey on Interhospital Transport of Children in Cardiac Arrest.

OBJECTIVES: To describe the U.S. experience with interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. DESIGN: Self-administered electronic survey. SETTING: Pediatric transport teams listed with the American Academy of Pediatrics Section on Transport Medicine. SUBJECTS: Leaders of U.S. pediatric transport teams. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty of the 88 teams surveyed (68%) responded. Nineteen teams (32%) from 13 states transport children undergoing cardiopulmonary resuscitation between hospitals. The most common reasons for transfer of children in cardiac arrest are higher level-of-care (70%), extracorporeal life support (60%), and advanced trauma resuscitation (35%). Eligibility is typically decided on a case-by-case basis (85%) and sometimes involves a short interhospital distance (35%), or prompt institution of high-quality cardiopulmonary resuscitation (20%). Of the 19 teams that transport with ongoing cardiopulmonary resuscitation, 42% report no special staff safety features, 42% have guidelines or protocols, 37% train staff on resuscitation during transport, 11% brace with another provider, and 5% use mechanical cardiopulmonary resuscitation devices for patients less than 18 years. In the past 5 years, 18 teams report having done such cardiopulmonary resuscitation transports: 22% did greater than five transports, 44% did two to five transports, 6% did one transport, and the remaining 28% did not recall the number of transports. Seventy-eight percent recall having transported by ambulance, 44% by helicopter, and 22% by fixed-wing. Although patient outcomes were varied, eight teams (44%) reported survivors to ICU and/or hospital discharge. CONCLUSIONS: A minority of U.S. teams perform interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. Eligibility criteria, transport logistics, and patient outcomes are heterogeneous. Importantly, there is a paucity of established safety protocols for the staff performing cardiopulmonary resuscitation in transport.

Use of Telemedicine During Interhospital Transport of Children With Operative Intracranial Hemorrhage.

OBJECTIVES: To analyze the impact of an intervention of using telemedicine during interhospital transport on time to surgery in children with operative intracranial hemorrhage. DESIGN: We performed a retrospective chart review of children with intracranial hemorrhage transferred for emergent neurosurgical intervention between January 1, 2011 and December 31, 2016. We identified those patients whose neuroimaging was transmitted via telemedicine to the neurosurgical team prior to arrival at our center and then compared the telemedicine and nontelemedicine groups. Mann-Whitney U and Fisher exact tests were used to compare interval variables and categorical data. SETTING: Single-center study performed at Johns Hopkins Hospital. PATIENTS: Patients less than or equal to 18 years old transferred for operative intracranial hemorrhage. INTERVENTIONS: Pediatric transport implemented routine telemedicine use via departmental smart phones to facilitate transfer of information and imaging and reduce time to definitive care by having surgical services available when needed. MEASUREMENTS AND MAIN RESULTS: Fifteen children (eight in telemedicine group; seven in nontelemedicine group) met inclusion criteria. Most had extraaxial hemorrhage (87.5% telemedicine group; 85.7% nontelemedicine group; p = 1.0), were intubated pre transport (62.5% telemedicine group; 71.4% nontelemedicine group; p = 1.0), and arrived at our center's trauma bay during night shift or weekend (87.5% telemedicine group; 57.1% nontelemedicine group; p = 0.28). Median trauma bay Glasgow Coma Scale scores did not differ (eight in telemedicine group; seven in nontelemedicine group; p = 0.24). Although nonsignificant, when compared with the nontelemedicine group, the telemedicine group had decreased rates of repeat preoperative neuroimaging (37.5% vs 57%; p = 0.62), shorter median times from trauma bay arrival to surgery (33 min vs 47 min; p = 0.22) and from diagnosis to surgery (146.5 min vs 157 min; p = 0.45), shorter intensive care stay (2.5 vs 5 d) and hospitalization (4 vs 5 d), and higher home discharge rates (87.5% vs 57.1%; p = 0.28). CONCLUSIONS: Telemedicine use during interhospital transport appears to expedite definitive care for children with intracranial hemorrhage requiring emergent neurosurgical intervention, which could contribute to improved patient outcomes.

Interhospital Transport of Children Undergoing Cardiopulmonary Resuscitation: A Practical and Ethical Dilemma.

OBJECTIVES: To discuss risks and benefits of interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. DESIGN: Narrative review. RESULTS: Not applicable. CONCLUSIONS: Transporting children in cardiac arrest with ongoing cardiopulmonary resuscitation between hospitals is potentially lifesaving if it enables access to resources such as extracorporeal support, but may risk transport personnel safety. Research is needed to optimize outcomes of patients transported with ongoing cardiopulmonary resuscitation and reduce risks to the staff caring for them.

Pediatric Critical Care Transport as a Conduit to Terminal Extubation at Home: A Case Series.

OBJECTIVES: To present our single-center's experience with three palliative critical care transports home from the PICU for terminal extubation. DESIGN: We performed a retrospective chart review of patients transported between January 1, 2012, and December 31, 2014. SETTING: All cases were identified from our institutional pediatric transport database. PATIENTS: Patients were terminally ill children unable to separate from mechanical ventilation in the PICU, who were transported home for terminal extubation and end-of-life care according to their families' wishes. INTERVENTIONS: Patients underwent palliative care transport home for terminal extubation. MEASUREMENTS AND MAIN RESULTS: The rate of palliative care transports home for terminal extubation during the study period was 2.6 per 100 deaths. The patients were 7 months, 6 years, and 18 years old and had complex chronic conditions. The transfer process was protocolized. The families were approached by the PICU staff during multidisciplinary goals-of-care meetings. Parental expectations were clarified, and home hospice care was arranged pretransfer. All transports were performed by our pediatric critical care transport team, and all terminal extubations were performed by physicians. All patients had unstable medical conditions and urgent needs for transport to comply with the families' wishes for withdrawal of life support and death at home. As such, all three cases presented similar logistic challenges, including establishing do-not-resuscitate status pretransport, having limited time to organize the transport, and coordinating home palliative care services with available community resources. CONCLUSIONS: Although a relatively infrequent practice in pediatric critical care, transport home for terminal extubation represents a feasible alternative for families seeking out-of-hospital end-of-life care for their critically ill technology-dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports to include patient screening tools, palliative care home discharge algorithms, transport protocols, and resource utilization and cost analyses.