Introduction

This chapter addresses the secondary transportation of patients; that is, inter-facility transfer. Primary transport (pre-hospital or scene transfer) is beyond the scope of the chapter. In particular, the role of ‘medical retrieval’ transfer is discussed. That is, where expertise normally associated with an intensive care unit (ICU) is sent from a central location to the patient and then transports the patient back to an ICU or tertiary paediatric emergency department (ED). Additionally, most medical retrieval transports of children require an emergency response because the problem is time-critical for the team expertise to reach the patient and/or the patient to reach the ICU.

It is often said that children are not small adults and in several important respects their physiology, pathophysiology and behaviour are different from adults. In patient transport, not only are these differences relevant, but the organisation of critical care services and hospital networks is also different. There is a more centralised organisation of specialist and intensive medical care for children than adults and this has implications for their transport and how transport systems are delivered.

Regionalisation

Different hospitals within a region offer differing levels of care for children. There are broadly three levels of care for children: (1) basic; (2) specialist; and (3) tertiary. In Australia and New Zealand, intensive or critical care tends to be centralised to a few tertiary hospitals. (There are 22 neonatal ICUs in Australia and six in New Zealand. There are seven full-time paediatric ICUs in Australia and one in New Zealand. Some adult units have a specialist interest in paediatric ICU as well.) This principle is based on evidence that a ‘centralised’ approach produces better outcomes than having a larger number of hospitals in a region each doing a small amount of critical care.^1,2 As a result:

Basic hospitals admit children with non-life-threatening illnesses. Regional and urban hospitals with specialist paediatric services take care of children with significant illness but not those needing intensive care. Children who need intensive care will usually require a medical retrieval team to move them safely to a tertiary hospital. Other children admitted to rural or basic hospitals with less-critical conditions may be appropriate for transfer using local clinical escorts and admission to a regional specialist hospital.

What’s different about children?

This general question is addressed in other chapters. However, from a transport point of view, the type of illness or injury and the process by which a clinical diagnosis is reached are often different in children. For instance, some conditions, such as bronchiolitis, are not only largely unique to children, but manifest in quite different ways from adults. In the first few months of life, presentation with ‘apnoea’ along with a history of close-family upper respiratory infection suggests this diagnosis even though there may be no signs of respiratory distress or problem with gas exchange. Making this diagnosis is often possible ‘over the phone’ by clinicians who are experienced in paediatric critical care and offering advice from a distance. Assessing conscious state in a young child with a head injury requires knowledge of developmental milestones. A baby presenting unexpectedly at 1 week of age with ‘shock’ is more likely to have a congenital heart lesion, such as left heart obstruction, than more traditional causes of shock. These and other examples require patient transfer decisions to be made by clinicians aware of these differences and skilled in eliciting information that will clarify the situation.

Referring a patient to another hospital

Referring doctor/hospital → referral doctor/hospital

Referring a patient for a higher level of care involves a dialogue between clinicians. For emergency transfers this generally involves a telephone call to a selected referral hospital or physician. The referrer usually makes this selection on the basis that the referral clinician has the skills and resources to deal with the problem and is geographically proximate. The ISBAR (Introduction, Situation, Background, Assessment and Recommendation)^3,4 communication technique is a useful tool to assist in this clinical conversation (Table 27.1.1).

Table 27.1.1 ISBAR

I – Introduction. ‘I am (name and role) calling from …..… on behalf of (clinician in charge)’ S – Situation. ‘I have a patient (age and weight) who is a) seriously ill, critically injured, unstable with slow/rapid deterioration, stable but I have concerns’ B – Background. ‘The story is’ (give information pertinent to clinical problem/age-group. May include date/time of injury/presentation, presenting signs and symptoms/medications/recent vital signs/test results/trends in status. I’ve already spoken to……. (where appropriate) A – Assessment. ‘On the basis of the above, the patient’s condition is…. They are at risk of…. There is a need for ……’ R – Recommendation. ‘Be clear about what you are requesting, e.g. the patient needs to be intubated/in an ICU/assessed by a surgeon/sent for urgent imaging/etc. I need your advice but at this stage do not require transfer’.

The process of telephone triage (teletriage) requires skills of careful listening and intelligent questioning by the person taking the call. It is not learnt overnight. Clinical discussion should precede and determine the logistics of transport, not the other way around. Referral of a critical-care patient can be confounded by resource and logistic issues with the potential to prevent or impair an appropriate and constructive clinical discussion. Keep the focus of the discussion on the patient.

This clinical conversation is complicated by the need to decide what level of care the patient requires and whether a rural treating clinician should call a regional or a tertiary hospital. Some regional hospitals have their own retrieval capacity, allowing a child to be transported to that hospital by a non-specialist team. In some cases, a paediatric specialist may be able to travel to the referring hospital to offer on-site resuscitation, assistance and assessment in parallel with a specialist paediatric medical retrieval team responding from a distance. In some regions, highly trained paramedics or flight nurses offer a level of transport clinical escort higher than regular ambulance transport. Decisions about how these children move and whether transport should be to a regional hospital or a tertiary hospital can be difficult. Sometimes a discussion with both will help determine the best plan.

The relationships between the three levels of care are shown diagrammatically in Fig. 27.1.1.

Fig. 27.1.1 The relationship between the three levels of care.

A dialogue with one referral hospital option may recommend that the other is a more appropriate destination. Unfortunately, a series of discussions with different referral hospitals can be time-consuming and may interfere with direct patient care.

Various means have been introduced to streamline this process. In some referral hospitals, there is often a designated person available to take such calls. Occasionally, a specific telephone number in the referral hospital is advertised for that purpose. However, if that number takes the referrer down a one-way path (e.g. to a personal cellular phone), he or she may need to make other calls or await a ‘call-back’. Now that hospital voice-response systems with menus designed for the public and long queues awaiting an operator have become common, simply calling the switchboard of a hospital no longer provides ‘direct’ access for the referring doctor.

In an ideal world the referring doctor would make just one call. After all, the clinical problem, which by definition exceeds them and/or their hospital, often requires their full attention. Only the treating doctor can place the cannula, intubate, etc. Subverting these clinical activities to make several (or many) phone calls can significantly compromise patient care and outcome. As referral hospitals become busier and/or more efficient, the availability of resources to accept the referred patient can dominate the referral process. Too often, the question of whether a ‘Bed’ (defined as: Space + Equipment + Nurses + Doctors + Other Resources) is available intrudes on the referral call and can interrupt the conversation with an invitation to ‘try elsewhere’. Whenever the clinical referral process becomes a question of ‘bed-finding’, many referring doctors respond by delegating the task to others. Such staff won’t necessarily have any clinical knowledge of the patient or the problem requiring transfer. Some referral hospitals have similarly delegated the process of ‘bed-locating’ to managers whose focus is on managing the ‘bed’ resource rather than entering into a clinical discussion about the patient. This combination results in lost opportunities for clinical decisions that can change the course of events independently of the transport process. For instance, an incorrect diagnosis or treatment may be recognised and corrected as the result of a clinical discussion. Having discussed the patient, an alternative referral hospital may be recommended on ‘clinical’ grounds. A conversation along these lines is desirable and possible, regardless of bed availability.

In regions where there are several referral hospitals serving the same referring hospitals, a single point of contact is provided for transport of a critical-care patient. In most cases, however, such ‘single number’ systems are designed to facilitate the logistics of transport and the clinical referral process requires a separate, additional phone call. Translated simply, this amounts to: ‘find the bed and we’ll arrange transport’. An integrated approach is possible, where the same number is used not only as a clinical conduit into the referral hospital ‘system’ but also to activate the logistics of transport.⁵

Which patients?

Selecting patients for retrieval transfer depends on the threshold for referral in each hospital; based on the role that hospital has for treating patients with problems of varying and different severity. The important point is that discussing the possibility of transfer should be part of a clinical consultation about the patient. The following list suggests conditions that should prompt that discussion with a paediatric ICU or retrieval service:

Head injury (symptomatic).

Altered level of consciousness (for any reason).

Hypoxia despite oxygen therapy.

High oxygen requirement.

Respiratory failure (e.g. bronchiolitis, severe asthma, apnoea).

Upper airway obstruction.

Near drowning (especially with neurological depression or respiratory symptoms).

Ingestion with risk of circulatory, airway or neurological compromise.

Envenomation.

Burns:

• >10%

• encircling the neck or involving the airway, face, hands, feet, perineum, or inner joint surfaces

• associated other significant injury

• electrical or chemical burns.

Seizures (with persisting neurological depression).

Major trauma (including spinal injury)

Metabolic disturbance, e.g.

• diabetic ketoacidosis

• acidaemia

• severe biochemical abnormality.

Heart failure or arrhythmia (symptomatic).

Shock (requiring treatment with volume replacement or inotropes), e.g.

• blood or fluid loss

• dehydration

• septicaemia.

Other causes of neurological depression:

• central nervous system (CNS) infection

• acute life-threatening episode.

Any condition with the potential for sudden cardiovascular or neurological deterioration.

Adapting such a list may be helpful in determining the local policy. If in doubt, consult.

Who will move the patient and how?

After an appropriate clinical discussion, the question of how the patient should be moved can be addressed. This can be straightforward or complex, depending on circumstances. The transfer of a patient from referring hospital to referral hospital can be accomplished in several ways. In a patient transfer, an escort transports the patient and then returns (in Fig. 27.1.1, T followed by R). In a retrieval transfer, the dispatch of a team (response) is followed by patient transport (R followed by T).

Decisions need to be made about three main topics:

Clinical escort.

a. Patient transfer:

• ambulance officer (various levels of skill may be available)

• nurse

• doctor.

b. Retrieval transfer:

• flight nurse or flight paramedic

• doctor (medical retrieval)

• other.

Degree of urgency.

a. Urgent (immediate response).

b. Emergency (specify expectation of response).

c. Time window (before a particular time).

d. Elective.

Type of vehicle.

a. Surface (road, boat, train, etc.).

b. Air:

• rotary wing

• fixed wing.

A patient transfer is one in which the skill level of the escort is at or below that of the referring hospital. That is, the patient can be escorted by ambulance personnel (ambulance transfer). Alternatively, staff from the referring hospital may accompany the patient (medical or nursing transfer). In theory these options offer a more rapid process, although review of actual experience often shows that time benefits can be overrated. Using local resources on an ad hoc basis is often slower to mobilise than anticipated. A doctor or nurse from the referring hospital may well offer an adequate level of care but the implications for that hospital during their absence may include a significant staffing reduction for that hospital. The smaller the hospital, the greater the impact that this will have on local cover and, since distances tend to be greater for smaller hospitals, the longer this impact will last. A hospital clinician who, having cared for the patient for some time already, then leaves town escorting a patient may experience significant fatigue. There may be problems finding transport back.

On the other hand, the level of care available to the patient should not regress during the transport process. Indeed, care should increase at each stage of the patient’s progress through the system. If the patient’s condition is unstable, it may be better to continue treatment in the referring hospital and await the arrival of a retrieval team.

In the retrieval transfer, options for clinical escort include a flight nurse or paramedic attached to an air ambulance service. Exact team composition will vary according to local practice and the regulations governing the skills and certification required for administration of specific treatments and drugs.

Doctors participate in medical retrieval teams in Europe, South Africa and Australasia but less so in North America. Most doctors are tasked from the referral hospital but others are attached as a regional or state-wide retrieval service.

The principle of medical retrieval is to bring the required critical care skills to the patient from an ICU setting and initiate that care prior to transport. In a randomised trial, medical retrieval has been shown to offer significant benefits to preterm infants in terms of mortality and morbidity.⁶ However, evidence is not so clear-cut in older age groups. Medical retrieval offers a higher level of care both during transport and, importantly, prior to travel. Patients can be stabilised prior to transport using skills and equipment not normally available in the referring hospital. This approach is preferable to hurriedly rushing from A to B with the patient in an unstable condition (the ‘mercy dash’) and risking en-route deterioration. To the extent that the arrival of the retrieval team in the referring hospital represents the patient’s ‘arrival’ in intensive care, the patient should not suffer any time penalty from using the ‘retrieval’ rather than the ‘transfer’ strategy.

The exceptions are conditions requiring a procedure or an investigation that a retrieval team cannot supply. In children, the situations where this is the case are fewer than in adults. Examples include head injury requiring urgent neurosurgery, some cases of penetrating trauma, volvulus with ischaemia and transposition of the great arteries with intact septum. Some procedures may be possible in the referring hospital if those skills are part of the retrieval team. Examples include taking a surgeon (neurosurgery, ENT) or obstetrician to selected cases to perform an emergency procedure such as decompressing raised intracranial pressure or fibre-optic endoscopy for foreign body. Such options need to be planned rather than an ad hoc response.

On the other hand, there is the additional time awaiting the arrival of the ‘retrieval team’. It is often tempting to say, ‘we could have been there by now!’ However, young children and newborns travel poorly if inadequately stabilised and the lost ground may never be regained.

Assessing the level of urgency requires assessment of how quickly skills or intervention are required in the referring hospital and also how quickly the patient needs definite care in a referral hospital. In most cases, the operational response in reaching the patient is more relevant.