An audit of transfers into the picu at the red cross war memorial childrens hospital: ten years later 29 October 2013 Dr K Dimitriades 1 Prof BM Morrow 1 Prof AC Argent 1 Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hospital; and School of Child and Adolescent Health, University of Cape Town, South Africa
Background Post centralisation of paediatric intensive care services – international move towards specialised paediatric retrieval services South Africa has not adopted a specialised paediatric retrieval service and relies on trasfers performed by general paramedic services Previous study in the Western Cape revealed high rate of adverse events
Literature Search Outcomes prior to SRT’s Outcomes of SRT’s Use of Pre-transfer Communication Requirements of Specialised Retrieval Units Perceptions Surrounding SRT’s Concerns Regarding SRT’s PIM scoring and the retrieval process Previous Study on Paediatric Transfers in the Western Cape Province
Outcomes Prior to SRT’s Rate of Adverse Events 20 – 75% No Diffence in Physiologic Deterioration Significant Difference in Intensive Care related events Kanter RK, Boeing NM, Hannan WP, et al. Excess morbidity associated with interhospital transport. Pediatrics 1992; 90 :893 – 8. Increase in Adverse Events with increased distance and level of required therapy Barry PW, Ralston C. Adverse events occurring during interhospital transfer of the critically ill. Archives of Disease in Childhood 1994; 71 :8 – 11. Significant Correlation between lack of experience and increase in Adverse Events Edge WE, Kanter RK, Weigle CG, et al. Reduction of morbidity in interhospital transport by specialized pediatric staff. Crit Care Med 1994; 22 :1186 – 91.
Outcomes of SRT’s Increase in interventions performed during the retrieval process. Improvement in the severity of illness as assesed by PRISM scoring. Fewer Adverse Events in transfers by SRT’s as compared to non - SRT’s Fewer Adverse Events in transfers by SRT’s compared to transfers accompanied by the referring specialist. Reduced risk of mortality with SRT’s Britto J, Nadel S, Maconochie I, et al. Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team. BMJ 1995; 311 :836 – 9. Mok Q, Tasker R, Macrae D, et al. Impact of specialised paediatric retrieval teams. Intensive care provided by local hospitals should be improved. BMJ 1996; 312 :119 – 21. Vos GD, Nissen AC, Nieman FHM, et al. Comparison of interhospital pediatric intensive care transport accompanied by a referring specialist or a specialist retrieval team. Intensive Care Medicine 2004; 30 :302 – 8.
Use of Pre-transfer Communication Pre-transfer communication can prevent problems that occur during different phases of the transfer process. Pre-transfer communication leads to earlier interventions and appropriate stabilisation of patients. The use of communication checklists allows for improved clarity, shorter communication times and better planning for the transfer process. Henning R, FFARACS, McNamara V. Difficulties encountered in transport of the critically ill child. Pediatric Emergency Care 1991; 7 :133. Goh AY, El-Amin Abdel-Latif M. Transport of critically ill children in a resource-limited setting: alternatives to a specialized retrieval team. Intensive Care Medicine 2004; 30 :339.
Requirements of Specialised Retrieval Units Various team members (Doctor, Nurse, Paramedic) Teams evolve depending on requirements and level of function Crabtree I. “A bridge to the future”: impact on high dependency and intensive care. J Child Health Care 2001; 5 :150 – 4. Orr RA, Felmet KA, Han Y, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics 2009; 124 :40 – 8. Perez A, Butt WW, Millar KJ, et al. Long-distance transport of critically ill children on extracorporeal life support in Australia. Crit Care Resusc 2008; 10 :34. Equipment must be standardized and must meet the requirement for mobile intensive care. Continuous monitoring should be utilized Minimum levels and standards of equipment are changing Vos GD, Buurman WA, van Waardenburg DA, et al. Interhospital paediatric intensive care transport: a novel transport unit based on a standard ambulance trolley. Eur J Emerg Med 2003; 10 :195 – 9. Vos G, Engel M, Ramsay G, et al. Point-of-care blood analyzer during the interhospital transport of critically ill children. Eur J Emerg Med 2006; 13 :304 – 7.
Perceptions surrounding SRT’s Referring physicians and receiving specialists found the use of SRT’s favorable. Browning Carmo KA, Williams K, West M, et al. A quality audit of the service delivered by the NSW Neonatal and Paediatric Transport Service. J Paediatr Child Health 2008; 44 :253 – 72. Nurses were in favor of the development of nurse practioners in critical care transport and felt that they were adequately trained. Davies J, Bickell F, Tibby SM. Attitudes of paediatric intensive care nurses to development of a nurse practitioner role for critical care transport. J Adv Nurs 2011; 67 :317 – 26. Parents accompanying SRT’s found the process to be safe and beneficial. Staff noted they were able to perform their duties without hinderance. Davies J, Tibby SM, Murdoch IA. Should parents accompany critically ill children during inter-hospital transport? Archives of Disease in Childhood 2005; 90 :1270 – 3.
Concerns regarding SRT’s Concern regarding loss of skills in referring institutions. 2 studies investigated this concern and both concluded that there was no loss in skills as noted by the increase in airway management procedures and central line placement prior to the retrieval process. Ramnarayan P, Britto J, Tanna A, et al. Does the use of a specialised paediatric retrieval service result in the loss of vital stabilisation skills among referring hospital staff? Archives of Disease in Childhood 2003; 88 :851 – 4. Lampariello S, Clement M, Aralihond AP, et al. Stabilisation of critically ill children at the district general hospital prior to intensive care retrieval: a snapshot of current practice. Archives of Disease in Childhood 2010; 95 :681 – 5.
Use of PIM in transfers PIM preferred over PRISM due to the ease in collecting required variables Point of care collection of data in PIM not affected by the retrieval process. Over estimation of predicted mortality. Tibby SM, Taylor D, Festa M, et al. A comparison of three scoring systems for mortality risk among retrieved intensive care patients. Archives of Disease in Childhood 2002; 87 :421 – 5.
Previous Study on Paediatric Transfers in the Western Cape Province Study by Hatherill et al Prospective study over one year period Technical Adverse Event in 36% Clinical Adverse Event 27% Critical Adverse Event in 9% Hatherill M, Waggie Z, Reynolds L, et al. Transport of critically ill children in a resource-limited setting. Intensive Care Medicine 2003; 29 :1547 – 54.
Objective of the Study To perform an audit on transfers in to the paediatric intensive care unit at Red Cross War Memorial Children’s Hospital and to describe adverse events as well as their effect on outcomes.
Specific Aims Primary Objective To describe the adverse events that occurred during the interfacility transfer process. Technical Adverse Events Clinical Adverse Events Critical Adverse Events Secondary Objective To describe the mortality of patients transferred in to the PICU from other institutions Tertiary Objective To describe the effect of staff, mode of transport, duration of transfer as well as the level of referring institution on adverse events and outcomes.
Study Design To reliably indicate any changes from the 2003 study – the study design was unchaged Prospective Observational Study Population Children admitted to the PICU at RCWMCH Sample Size and Selection All children transferred directly in to the PICU from other insitutions (1 December 2013 – 30 November 2014) Exclusions Children Transferred from within the hospital Children with a PIM Risk of Mortality of <1%
Study Method Patients identified at time of arrival or through the admission register Data is extracted from the patient file, paramedic transfer log and in discussion with the admitting doctor within 24 hours of the admission Data Analysis Strategy Nonparametric descriptive and chi 2 tests P < 0.05 significant Statistica (version 11)
Ethics HREC approval 702/13 Ethics approved the study with waived consent Observational study Risk of breech of confidentiality minimized by de- identifying data. This study conforms to the principles stated in the Declaration of Helsinki (2008)
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