picu at the red cross war memorial childrens hospital: ten years - - PowerPoint PPT Presentation
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 Childrens
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
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
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
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.
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.
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.
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.
Referring physicians and receiving specialists
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
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
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.
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
2010;95:681–5.
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.
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.
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.
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.
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%
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 chi2 tests P < 0.05 significant Statistica (version 11)
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)
Hatherill 2003 n=202 Dimitriades Interim 2014 n=104 P Age (mts) 2.8 (1.1 – 14) 1.67 (0.25 – 10.5) Weight (kg) 3.5 (2.5 – 8.1) 3.4 (2.2 – 8.6) PIM2 (ROM) 0.15 (0.13-0.18) 0.08 (0.03 – 0.15) Type of illness Medical 99 (49%) 38 (36,5%) 0.04 Cardiac 22 (10,9%) 19 (18,2%) 0.07 Neonatal surgical 52 (25,7%) 30 (28,8%) 0.6 Hospital Academic 71 (35,1%) 52 (50%) 0.01 Metropolitan 70 (34,7%) 19 (18,3%) 0.003 Rural 61 (30,2%) 32 (30,8%) 0.9 Personnel PICU staff 20 (9,9%) 13 (12,5%) 0.5 Non-PICU staff 182 (90,1%) 91 (87.5%) 0.49
1 (1%) 0.02 Paramedics 165 (81,7%) 90 (86.5%) 0.28
Hatherill 2003 n=202 Dimitriades Interim 2014 n=104 P Transport Road 153 (75,7%) 79 (76%) 0.97 Helicopter 20 (9,9%) 0 (0%) 0.002 Fixed wing aircraft 29 (14,4%) 25 (24%) 0.035 Duration of transport (hours) 3.5 (2 – 6) 3.67 (2.1 – 8.73) Technical adverse events 72 (35,6%) 47 (45,2%) 0.1
Hatherill 2003 n=202 Dimitriades Interim 2014 n=104 P No functional venous access (total) 38 (18,8%) 1 (1%) <0.0001 Venous access placed 190 (94.1%) 103 (99%) 1 peripheral 159 (83.7%) 31 (30.1%) <0.0001 2 peripheral 19 (10%) 56 (54.4%) <0.0001 Central venous 6 (3.2%) 15 (14.6%) 0.0007 Insufficient monitoring (total) 26 (12.9%) 56 (53.8%) <0.0001 Intubated for transfer 118 (58,4%) 73 (70,2%) 0.04 Oral 74 (62,7%) 22 (30,1%) 0.006 Nasal 44 (37,3%) 47 (64,4%) <0.0001 ETT malpositioned 30 (25,4%) 12 (16,4%) 0.4
Hatherill 2003 n=202 Dimitriades Interim 2014 n=104 P Clinical adverse events 54 (26,7%) 28 (26,9%) 0.9 En route Arrival Shock 28 (13.9%) 7 (6.7%) 10 (9.6%) 0.6 Hypoxia 27 (13.4%) 5 (4.8%) 7 (6.7%) 0.6 Hypoglycaemia 12 (5.9%) 2 (1.9%) 5 (4.8%) 0.98 Critical adverse events 18 (8,9%) 5 (4,8%) 0.3 Immediate intubation 11 (5.4%) 3 (2.9%) 0.5 Cardiac and/or respiratory arrest 13 (6.4%) 2 (1.9%) 0.1 Mortality all cause 34 (16,8%) 9 (8,6%) 0.07 LOS ICU 5.1 (2.0 – 9.6)
Strengths
Prospective study
Similar methodology to prior study Weaknesses
Poor concensus prior to the commencent of the study on quality metrics
Rate of transfers unchanged Staffing structure of transfers unchanged Comparatively high rate of adverse events still
noted
Further research is required to improve the retrieval
process in to PICU
Novel approaches required
Strengthening of education and training Clinical Decision Facilitators