Transporting Critically Ill Children
In times of emergency when a child needs urgent medical attention at a tertiary care facility, the role of the transport team is crucial. There are four modes of transport routinely used for patients coming to California Pacific Medical Center. The appropriate mode is determined by the Accepting Physician in conjunction with the Referral Physician. Factors that contribute to this decision include:
- Child’s age and severity of illness;
- Potential for deterioration;
- Location of the patient (ex. in SF County vs. out of SF County; medical office vs. hospital)
Moreover, there are numerous regulatory requirements from California Children’s Services (CCS) and Emergency Medical Services (EMS) that govern the decision-making process. As a result, there are times when a higher level of transport is initiated by California Pacific to comply with these regulations. A description of each transport level follows:
- Basic Life Support (BLS) Transport: This refers to EMT-only transport and is rarely appropriate for patients referred to California Pacific due to the ability to provide only minimal support during transport. Examples of appropriate use of this mode might be isolated extremity fracture and mild dehydration.
- Advanced Life Support (ALS) Transport: Transport by one or more paramedics with advanced training including airway support, venous access and more extensive monitoring and assessment. Examples of appropriate use of this mode include ALTE, mild to moderate respiratory distress requiring modest oxygen support, or toxic ingestions without mental status changes.
- California Pacific Critical Care Transport: Neonatal Nurse Practitioner or Transport MD with PICU or NICU nurse and two ambulance personnel. This is the highest level of care and is appropriate for ALTE, severe respiratory distress, altered mental status and seizures.
- Flight Transport Team: Advanced practice critical care nurse with Air Ambulance company. This option is used for transport requests beyond a reasonable driving time. Most times, California Pacific’s Transport MD accompanies the Flight Team to retrieve the patient.
Transport physicians at California Pacific Medical Center are board certified in pediatrics and current in Newborn Resuscitation Program (NRP) and Pediatric Advanced Life Support (PALS). Additionally, they have experience and training in pediatric and neonatal critical care specialties and are able to provide life-saving interventions such as intubation, central line placement and thoracentesis in the pre-hospital setting.
Nurses and paramedics have additional training in neonatal and pediatric transport medicine. California Pacific’s critical care nurses must have at least six months of bedside experience to be eligible to join the transport team.
This year, California Pacific’s Transport Program will coordinate nearly 300 neonatal and pediatric transports from all over Northern and Central California. The majority of these are full-team, physician-led transports. We also receive many transport calls from pediatric offices with the need for immediate evaluation and transport.
Case Study
A 3-week old previously well infant was brought into the primary MD’s office for what was described as a “dusky spell.” Mom had been holding the child and had noted the child go limp and blue for approximately 30-45 seconds. The infant responded to vigorous stimulation but was slow to recover. There was no history of emesis, fever or excessive somnolence. Mother’s prenatal course was unremarkable. On examination in the office, the infant appeared pink and was well saturated with stable vital signs; the chest was clear; CV evaluation was unremarkable; abdomen was benign. At this point, the physician deemed the infant stable, but requested further evaluation at California Pacific Medical Center. The parents were instructed to drive the infant to the city for admission. Shortly after admission, the infant had two more dusky episodes requiring positive pressure ventilation by the nursing staff. The work-up revealed gastroesophageal reflux on fluoroscopy and a + pH probe for the same. The infant was placed on H2 blockers and a promotility agent with success.
Fortunately, the infant had no events during the parent transport to California Pacific. However, a safer mode of transport would have been either an ALS team or California Pacific’s transport team.
Transport medicine is highly litigious. It is important for Referral Physicians to understand that once a patient has been accepted by phone for admission to California Pacific or a transport referral has been initiated, the Accepting Physician shares the medical and legal responsibility for any adverse events or outcomes with the Referring Provider. As a result, judicious care is given in weighing options for the safest mode of transport. At times, the safest transport mode may not be the most expeditious; however, this is a minor inconvenience to minimize the chance for a potentially negative occurrence.
California Pacific Medical Center’s Neonatal and Pediatric Service is committed to providing safe, efficient and timely inter-facility transport of sick infants and children.
For Neonatal and Pediatric Transport Referrals to California Pacific, call:
1-866-PEDS-911
This number may also be used for neonatal and/or pediatric consultation with a
neonatologist, pediatric intensivist or pediatric hospitalist.