The organization of a pediatric critical care transport program

Highly specialized pediatric critical care centers have matured significantly over the past two decades; however, access to this care is limited to tertiary care facilities and constrained by geography. With the advances of transport medicine, great distances can be spanned to bring critical care to the patient and provide effective treatment and safe transport systems where specialized care was previously unavailable. A patchwork of diverse transport systems perform pediatric transports with significant differences in the level of pediatric critical care. The optimal transport system has yet to be fully defined, but many successful systems share fundamental elements of organization.

Improving the patient transfer process at Bellin Hospital

PROJECT

To facilitate timely and efficient transfers of patients on the cardiac service.

PRINCIPALS

Nursing staff from the intensive care (ICU), intermediate care (IMCU), and step down units. Process Improvement Method: VALUE PLUS+, a scientific, problem-solving model developed at Bellin that requires statistical thinking. Timeline: March 1990-August 1991. Key Findings or Improvements: Mid-morning, early afternoon, and early evening are the ideal times for patient transfers; late morning and mid-to-late afternoon transfers should be avoided. Unit staff can plan transfers for preferable times by predicting the number of transfers from ICU and IMCU, based on a percentage of the previous day's census.

RESULTS

The number of process steps to transfer a patient was reduced from 21 to 13. 80 percent of transfers now occur during three designated time periods. The role of transport staff has been expanded to free up nursing time.

QI team shares ownership and gets results

The FOCUS-PDCA framework for process improvement developed by the Hospital Corporation of America helps the healthcare team look at work as a series of processes that can be improved rather than focus on the people involved in the processes. It is data driven, and it encourages teamwork and shared ownership in the process improvement opportunity. This article describes how, by using FOCUS-PDCA, the length of stay (LOS) quality improvement (QI) team at Hubbard Regional Hospital in Webster, MA, has decreased dramatically the time patients spend awaiting nursing home placement.

Ten years of maternal-fetal transport

One maternal-fetal transport system and the public health policies that supported its development are presented. System development, the components necessary for successful two-way maternal-fetal transports, and growth between 1981 and 1991 are summarized.

The nuts and bolts of organizing and initiating a pediatric transport team. The Sutter Memorial experience

Specialized interfacility transport teams are capable of delivering critical care medicine to the patient at the referring hospital and while en route to the tertiary care center. To do so effectively, however, requires adequate financial and human resources; management of equipment, supplies and personnel; ongoing education for transport team members; and an aggressive quality assurance program. Team members and team management should always be prepared for worst-case scenarios, and develop a method for problem resolution as troublesome issues arise. The ultimate goal of serving the needs of the critically ill child can be consistently met only if there is a high level of commitment of all involved--from the hospital administrator and medical director to the transport coordinator and team members.

Transport of the critically ill patient with upper airway obstruction

Upper airway obstruction is a life-threatening emergency requiring prompt evaluation and careful intervention. The pathophysiology of upper airway obstruction is reviewed. Assessment techniques and stabilization are discussed with specific attention to intervention and stabilization prior to transport.

Interhospital transport. A pediatric perspective

Interhospital transport of children must not be undertaken in a vacuum. Basic medical ethics and federal laws demand that there be some responsibility in providing adequate care during the transport process, and that this care meets or exceeds the level provided by the referring hospital. The care provided must also be appropriate to the severity of illness of the transported children. National guidelines and standards are needed to establish and coordinate a uniform interhospital transport process for critically ill children.

Intrahospital transport of critically ill patients

Intrahospital transport of critically ill patients must be considered as part of the critical care continuum. The level of care provided must be commensurate with the severity of illness. These transfers are intensive in terms of utilization of personnel and resources. Advance preparation and optimal coordination of the transport process go a long way toward safer transfers of the critically ill.

Freestanding surgery centers must establish transfer plans

The future of freestanding surgery centers in the United States is bright. Each year, an increasing percentage of surgical procedures is performed on an outpatient basis at these centers, and the quality of patient care must meet the same standards as that provided in inpatient facilities. Developing a plan for emergency patient transfer provides patients and staff members with the confidence and information necessary to handle transfers calmly and efficiently, and it will ensure that the patient receives the best quality care available.

The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit

We prospectively studied the relationship between interdisciplinary collaboration and patient outcomes in the medical intensive care unit (MICU) using nurses' and residents' reports of amount of collaboration involved in making decisions about transferring patients from the MICU to a unit with a less intense level of care. Either readmission to the MICU or death was considered a negative patient outcome. Nurses' reports of collaboration were significantly (p = 0.02) and positively associated with patient outcome, controlling for severity of illness. Patient predicted risk of negative outcome decreased from 16%, when the nurse reported no collaboration in decision making, to 5% when the process was fully collaborative. There was an interaction of collaboration with availability of alternative choices in the transfer decision-making situation. When alternatives were available, collaboration was more strongly associated with patient outcome. There was no significant relationship between residents' reports of collaboration and patient outcomes. The correlation between amount of collaboration reported by nurses and residents about the same decisions was quite low (r = 0.10).

Financial and operational impact of a transfer center

A tertiary care hospital established a transfer center to manage the large number of transfer requests from other hospitals in its catchment region. Motivating factors included occurrence of economic transfers, medically inappropriate transfers, poor interfacility communication, and a bed shortage. An interdisciplinary task force was convened to design and implement the transfer center, requiring two months from conception to implementation. Non-recurring direct costs were $3000. At the time of implementation, written transfer agreements were promoted and signed with many transferring hospitals. A retrospective audit covering 28 weeks of operation indicates that 1141 inpatient days were avoided for an average of 21.5 days per back-transferred patient. (Back-transfer refers to the return of a patient to the original hospital.) An additional 140 admissions were possible as a result of these avoided days. Approximately $550,000 in variable costs were saved on an annualized basis. Moreover, substantial improvements in communications and interfacility cooperation were realized. No cases of inappropriate denials or delays in transfer were identified. We conclude that a transfer center can be a highly cost-effective mechanism to manage the large number of patients transferred to a tertiary care center.

A successful decade of regionalized perinatal care in Tennessee: the neonatal experience

We hypothesized that successful implementation of regionalized perinatal care would result in early identification and antenatal referral of high-risk neonates, and also improved stabilization before and during transport of those transferred postnatally. We conducted a retrospective study of demographic characteristics and transport outcome in two defined groups of neonates transported to regional perinatal centers in Tennessee, one group (n = 218) from the first year of regionalization (1975), and a second group (n = 261) from the 12th year (1986). The percentage of outborn infants decreased, from 50% of all admissions in 1975 to 22% in 1986 (P = .005). Likewise, the percentage of low-birthweight neonates transported after birth decreased, from 59% of all transports to 32% (P = .002). The frequency of stabilization measures performed before and during transport increased between study years (intravenous line placement: 12% to 58%, P = .0001; assisted ventilation: 10% to 33%, P = .001). The incidence of complications during transport decreased between study years (cyanosis: 25% to 8%, P = .0001; hypothermia: 30% to 3%, P = .0001; acidemia: 33% to 13%, P = .011). Both transport-related mortality and neonatal mortality decreased between study years (2.8% to 0.8%, P = .043; 17% to 7%, P = .0001, respectively). We conclude that regionalization during its first decade has been successful in improving perinatal care in Tennessee as indicated by favorable changes in referral patterns and improved outcome of transported neonates.

Aeromedical patient transfer

Aeromedical evacuation involves the transfer of patients in a variety of aircraft types (both fixed-wing and helicopters). The patients' condition will hopefully be maintained or improved during the transfer. The escorting doctor should be aware of the differences between working in the airborne environment and working in the static ground-based facility.

Patient flow in the emergency department: the chest pain patient

Prompt treatment of the chest pain patient in the emergency department (ED) is crucial. To ensure prompt treatment, identification of factors that delay flow of these patients through the department is essential. To identify factors that delay patient flow through the ED, the authors conducted a prospective study of all chest pain patients, using a time-flow analysis. Eighty-eight (36%) of 245 patients required critical unit admissions and had an average department stay of 3 1/2 hours. Flow differences were seen between critical and noncritical care patients. Three primary sources of delay were identified: critical unit bed availability, the registration process, and the role of the unit admitting resident. Additional findings confirmed the efficacy and role of the triage nurse in patient flow. Nursing and medical education and staffing needs were addressed. The use of the community's emergency medical services was examined by analyzing the disposition of patients arriving at the ED by ambulance.

Transfer center can control, manage admissions

Despite Federal laws restricting inter-hospital transfers, some hospitals continue to transfer patients for purely financial reasons. To combat the financial strain of receiving inappropriate transfers, some large hospitals have established a centralized office to coordinate transfers. A well-run transfer center can aid in the overall treatment of appropriately transferred patients as well as reduce hospital costs.

Development of an interfacility transport program for critically ill cardiovascular patients

The expanding use of newer coronary artery intervention modalities in the treatment of critically ill cardiac patients has produced a profound change in the manner in which acute care is rendered to these patients. To meet the needs of community hospitals and to improve the safety of interfacility transport to tertiary care centers, a transport program was developed at The Hospital of the Good Samaritan, Los Angeles, California. Rapid transport by helicopter, fixed-wing aircraft or specialized ground ambulance services has been used to improve patient transit time and safety of transfer between the community hospital and tertiary care facility. Experience at The Hospital of the Good Samaritan (1,012 consecutive patients) compares favorably with other programs and proves to be safe and beneficial.