Outcomes for critically ill and injured children improve when skilled pediatric specialist transport teams provide treatment.
The needs of the patient being transported should drive the composition of the team.
Transport personnel must be familiar with their protocols and the limitations and responsibilities of their specific profession’s scope of practice.
The referring physician is responsible for stabilizing the patient’s condition, within the capabilities of the referring institution, before the patient is transferred to another institution.
Limitation of resuscitation orders (“Do Not Resuscitate” [DNR]) may be revoked at any time according to the parents’ or legal guardians’ wishes.
A quality management program is essential for a well-run transport service.
Stresses of flight affect both the patient and crewmembers and should always be taken into consideration when transporting a patient.
At high altitude, a child may become hypoxic and pneumothoraxes can expand.
Specialized transport systems have evolved from military conflicts; the earliest references date from the Napoleonic wars. The first reported transport of a patient via aircraft took place in 1915, and the helicopter saw its first use in air medical transport in Burma in 1944.1 Development of specialized pediatric transport teams began in the 1970s with the establishment of neonatal intensive care units. The need for rapid and safe transport of critically ill and injured children has driven the formation of specialized neonatal and pediatric transport teams that have demonstrated improved patient outcome. Recently, quality improvement initiatives have led to the development of the Ground and Air Medical Quality Transport (GAMUT) database in 2014 to track, report, and analyze transport programs.
Federal law under the Emergency Medical Treatment and Active Labor Act (EMTALA) mandates a medical screening for every patient seeking treatment in an emergency department (ED) of any hospital that participates in programs that seek federal funding, regardless of reimbursement considerations. EMTALA mandates therapy for emergency medical conditions up to and including surgical intervention.2 If definitive care cannot be rendered at the local hospital, the patient should be transferred to a hospital that has the resources and capabilities to care for the patient. Prior to transfer, the referring physician is responsible for stabilizing the patient’s condition within the capabilities of the referring institution, initiating transfer and selecting the mode of transport, and ensuring that the receiving facility is able to deliver the necessary care and accepts the transfer.3 It is recommended that all treatment facilities have interfacility transfer agreements and guidelines to ensure timely and appropriate transfer of patients to the appropriate level of emergency care. The transport team should be aware of any limitation of resuscitation orders that may be in place, especially in the case of a chronically ill child. If special state out-of-hospital “Do Not Resuscitate” orders (DNR) exist, they should be discussed with the medical control physician before transporting the child and must be complied with. DNR orders may be revoked at any time according to the wishes of the parent or legal guardian.
The legal responsibility for medical decisions and interventions at the referring facility is complex. Although the specialty pediatric transport team may lead the process of preparing the child for transport, the referring physician and other hospital personnel remain legally responsible for the patient. If at any time the referring physician deems it in the best interest of the patient to intervene or cancel the transfer, the physician has a right and a duty to do so. Although EMTALA states that the referring physician has legal responsibility, the transport service clearly assumes some liability when it begins rendering care. In reality, there is shared responsibility on the part of both parties.
Transport teams involve a variety of professional personnel, including physicians, nurses, respiratory care practitioners, paramedics, and emergency medical technicians who should be dedicated to the transport program and trained to work as a team. The ideal composition of the team is driven by the needs of the patient being transported (Table 149-1).4 Transport literature indicates that non–physician-based transport team members are efficient and competent to perform advanced procedures, including intubations. It is essential that all transport team members have an opportunity to develop and maintain these skills on an ongoing basis. The incidence of transport-related morbidity increases significantly when personnel without specialized training in pediatrics transport critically ill children. Only 10% of emergency medical services (EMS) transports involve pediatric patients, and many adult EMS providers lack all but basic training in the treatment of critically ill children, mainly owing to limited pediatric exposure. Specialized pediatric transport teams fill a needed void to help stabilize and transport critically ill and injured children to a tertiary care pediatric facility.5
| Transport Personnel | Advantages | Disadvantages |
|---|---|---|
| Specialty-trained attending physician | Expertise; public relations; critical care training and skills | High salary cost; limited availability for full-time coverage; care and supervision limited to one patient at a time |
| Nonintensive care-, nonneonatology-, or nonemergency medicine–trained attending physician | Expertise; public relations | High salary cost; limited availability for full-time coverage; care and supervision limited to one patient at a time; critical care skill acquisition as needed |
| Fellow trainee | Expertise; valuable training experience | Transport demands might overburden other aspects of training availability; availability might be limited by Accreditation Council for Graduate Medical Education (ACGME) work rules |
| Resident trainee | Valuable training experience; salary cost may be built into the training program | Demands of transport compete with other aspects of training and education; limited clinical experience; availability might be limited by ACGME work rules |
| Advanced practice neonatal or pediatric nurse practitioner | Expertise; consistent quality of care | High salary costs; usually limited to discipline for which they are trained (e.g., neonatal nurse practitioner vs. pediatric nurse practitioner); acceptance as specialized provider by referring care team can be an issue if community expectations are for physician-led team |
| Critical care nurse | Availability; expertise with appropriate training; uniform quality of care | Initial acceptance by referring care team can be an issue; requires intensive training to function independently in the transport environment |
| Respiratory therapist | Focused respiratory assessments; knowledge of respiratory equipment; advanced airway and ventilator expertise | Focused airway training and experience; requires intensive training to expand to more global patient care |
| Paramedic or emergency medical technicians | Expertise in prehospital setting; availability; less costly than other team members | Less formal medical and pediatric training and perhaps experience; requires intensive training to assist with other areas of patient care |
Interfacility transports require coordination and communication between multiple care providers and facilities to assure the safety of patients and transport personnel. The transfer center should be staffed 24 hours a day, 7 days a week. The transfer center coordinator receives the initial call, facilitates communication between the referring and receiving providers, dispatches the appropriate team, tracks the locations of dispatched teams, assures ongoing communication with the referring facility, and assures direct communication of the teams with the medical control physician. The transfer center can also coordinate follow-up information for referring facilities while adhering to Health Insurance Portability and Accountability Act (HIPAA) regulations.
It is essential that all communications pertaining to transport are recorded and the recordings are preserved. Communication with outside facilities can be streamlined by having an easily accessible contact number and standardized basic questions for easy identification of the appropriate receiving hospital unit, such as the ED or an intensive care unit. Handoff communication should also be standardized wherever possible by the caregivers. A transport outreach liaison can facilitate preparation for transport by communicating regularly with referring facilities, providing them with information on how to contact the transport service and how to best prepare the child for transport, and providing feedback after the transport.
Equipment and medication requirements for transport depend on the type of patient the team encounters. The transport mission limitation policy should address the types of patients a facility has the capability to transport. Special equipment considerations are needed for basic life support (BLS) and advanced life support (ALS) transports, including those for neonates, children, and adult patients. Pediatric equipment lists available for EMS providers should satisfy all city and state requirements and be regularly updated by the transport medical director. Storage of medication should be addressed, since some medications need to be refrigerated. Multiple doses of medications and extra equipment need to be available for emergencies and long transports. Special regulations exist surrounding the use of narcotics. Medications should be checked daily (for quantity and expiration) and after each transport. The lists of all equipment and supplies should be checked regularly to ensure presence, functionality, and nonexpiration. Policies and procedures should be developed to ensure compliance with this standard.
Transport teams should have written, easily accessible, straightforward protocols to direct patient care, under the authority and regular revision of the transport medical director. Input should be sought from the teams utilizing the protocols, including legal counsel when necessary. Protocols serve as a guideline for care until the teams can contact the medical control physician. Transport personnel must be familiar with the protocols and the limitations and responsibilities of their specific profession’s scope of practice. They need to seek help from their medical control physician or the physician on transport when they are outside their scope of practice.
