Handover and transport of critically ill children: An integrative review

Clinical Care Trajectory Assessment of Children With Congenital Diaphragmatic Hernia and Neurodevelopmental Impairment

BACKGROUND

Interdisciplinary long-term health surveillance identifies opportunities to mitigate CDH-related multisystem morbidity, particularly in patients with neurodevelopmental impairment (NDI). However, no studies to date have assessed the impact of these morbidities on the patient/family. Our aim was to describe the clinical trajectory of patients with CDH and NDI (CDH-NDI), and to explore the lived experience and satisfaction of families with existing support resources.

METHODS

A multi-phase explanatory study (REB 2023-8964) was conducted. Phase 1: Review of clinical data for CDH-NDI patients attending a longitudinal follow-up clinic; Phase 2: Satisfaction assessment of CDH-NDI families with existing hospital resources. Standard statistical analyses were performed for Phases 1 and 2, respectively.

RESULTS

Of 91 patients included, 27 had NDI, stratified into mild (n = 2), moderate (n = 7), and severe (n = 18) cohorts. Ventilation (16 vs. 8; p < 0.001), ICU (34 vs. 18; p < 0.001) and hospital (41 vs. 22; p < 0.001) days were significantly longer in the severe cohort. The severe cohort required significantly more unscheduled visits, particularly in the first four years of life (p < 0.05). Despite high family satisfaction with existing resources, team communication during ICU-ward transfers could be improved. Parents also desired to share experiences with other CDH families.

CONCLUSION

CDH children with NDI require increased support, particularly in the first four years of life. While clinic satisfaction is high, improvement of team communication and access to support resources remain high priorities for parents.

LEVEL OF EVIDENCE

Level II (prospectively collected data, retrospective analysis).

Enhancing team success in the neonatal intensive care unit: challenges and opportunities for fluid teams

Fluid teams, characterized by frequent changes in team membership, are vital in the neonatal intensive care unit (NICU) due to high patient acuity and the need for a wide range of specialized providers. However, many challenges can hinder effective teamwork in this setting. This article reviews the challenges related to fluid teamwork in the NICU and discusses recommendations from team science to address each challenge. Drawing from the current literature, this paper outlines three challenges that can hinder fluid teamwork in the NICU: incorporating patient families, managing hierarchy among team members, and facilitating effective patient handoffs. The review concludes with recommendations for managing NICU teamwork differently using strategies from team science.

Der Übergabeprozess in der zentralen Notaufnahme – Konsentierung von Inhalten im Rahmen eines Delphi-Verfahrens

Hintergrund und Ziel der Arbeit

Für die Übergabe in der Notaufnahme – der Nahtstelle von prähospitaler zu klinischer Versorgung – stellen Merkhilfen („mnemonics“) das „Rückgrat“ für eine strukturierte Übermittlung von relevanten Informationen dar. In Deutschland existiert bis zum heutigen Tag keine Standardisierung bzw. konkrete Vorgabe, welche Merkhilfe zur Übergabe genutzt werden soll. Die vorliegende Untersuchung definiert erstmalig anhand eines strukturierten und mehrstufigen Konsentierungsprozesses (Delphi-Verfahren) von Experten (Mandatsträgern), welche Übergabeinhalte für erforderlich gehalten werden. Ziel dabei ist die Schaffung einer Grundlage zur Entwicklung einer bundeseinheitlichen Merkhilfe.

Methodik

Durchgeführt wurde ein Delphi-Verfahren, welches sich an den Regularien der Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften e. V. (AWMF) orientiert.

Ergebnisse

Im Rahmen des durchgeführten Delphi-Verfahrens konnte neben konkreten Inhalten der Merkhilfe auch deren Reihenfolge festgelegt werden. Übergabeinhalte wurden zu den Punkten Crew Resource Management (CRM) und Patientenidentifikation, Beschreibung der Notfallsituation, Notfallpriorität (ABCDE-Schema) und Vitalparameter, durchgeführte Maßnahmen, Anamnese, Zusammenfassung mit der Möglichkeit für Rückfragen durch das übernehmende Team sowie Zeitdauer definiert.

Diskussion

Die Ergebnisse der Arbeit bilden die evidenzbasierte Grundlage für die Entwicklung einer konkreten Merkhilfe („mnemonic“). Weitere Untersuchungen sollten sich nach Entwicklung einer geeigneten Merkhilfe darauf fokussieren, diese im Rahmen einer (prä-)klinischen Anwendungsstudie auf Praxistauglichkeit zu testen. Gleichzeitig sollte ein entsprechendes Schulungskonzept ausgearbeitet werden. Langfristig wird als Ziel eine bundesweit einheitliche Einführung angestrebt.

Pediatric Critical Care Transport: Survey of Current State in Latin America. Latin American Society of Pediatric Intensive Care Transport Committee

METHODS

An electronic, anonymous, multicenter survey housed by Monkey Survey was sent to physicians in LA and included questions about hospital and pediatric critical transport, resources available and level of car. Nineteen Latin-American countries were asked to complete the survey.

RESULTS

A total of 212 surveys were analyzed, achieving a representativity of 19 LA countries, being most participants (59.4%, n = 126) from South America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay and Venezuela). Most surveys were conducted by physicians of tertiary level centers (60.8%, n = 129), most of the institutions were classified by the participants as public health care centers (81.6%, n = 173). Most of the surveyed physicians (63.7%, n = 135) reported that there is a coordination center for critical care transport (CCT). In most cases, physicians report that a unified transport system for pediatric critical patients does not exist in their countries (67.45%, n = 143). Only 59 (30.7%) surveys reported the use of an exclusively pediatric critical care transport system. Most of these transport systems are described as a mixture of public and private efforts (51.56%, n = 99), but there is also a considerable involvement of government-funded critical transport systems (43.75%, n = 84). Specific training for personnel devoted to transportation of critically ill patients is reported in 55.6% (90), and the medical equipment necessary to carry out the transport is available in 67.7%. The majority (83.95%, n = 136) mentioned that access to advanced life support courses is possible. Training in triage and disaster is available in 44.1%. Physicians and registered nurse were identified as the transport providers in 41.5%, and only one third were made by pediatricians-pediatric nurse. The main reasons for transfers were respiratory illness, neonatal pathologies, trauma, infectious diseases, and neurological conditions. Overall, pediatric transport was reported as insufficient (70.19%, n = 148) by the surveyed physicians in LA and nonexisting by some of them (6.83%, n = 15). There were no regulations or laws in the majority of the surveyed countries (63.13%), and in the places where physicians reported regulatory laws, there were no dissemination (84.9%) by the local authorities.

CONCLUSIONS

In LA, there is a great variability in personnel training, equipment for pediatric-neonatal transport, transport team composition, and characterization of critical care transport systems. Continued efforts to improve conditions in our countries by generating documents that standardize practices and generating scientific information on the epidemiology of pediatric transfers, especially of critically ill patients, may help reduce patient morbidity and mortality.

Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: A pilot ethnography

PURPOSE

The effect of communication between referring and accepting clinicians during patient transitions to the pediatric intensive care unit (PICU) on diagnostic quality is largely unknown. This pilot study aims to determine the feasibility of using focused ethnography to understand the relationship between referral communication and the diagnostic process for critically ill children.

MATERIALS AND METHODS

We conducted focused ethnography in an academic tertiary referral PICU by directly observing the referral and admission of 3 non-electively admitted children 0-17 years old. We also conducted 21 semi-structured interviews of their parents and admitting PICU staff (intensivists, fellows/residents, medical students, nurses, and respiratory therapists) and reviewed their medical records post-discharge.

RESULTS

Performing focused ethnography in a busy PICU is feasible. We identified three areas for additional exploration: (1) how information transfer affects the PICU diagnostic process; (2) how uncertainty in patient assessment affects the decision to transfer to the PICU; and (3) how the PICU team's expectations are influenced by referral communication.

CONCLUSIONS

Focused ethnography in the PICU is feasible to investigate relationships between clinician referral communication and the diagnostic process for critically ill children.

Patient handover between ambulance crew and healthcare professionals in Icelandic emergency departments: a qualitative study

Background

Ambulance services play an important role in the healthcare system when it comes to handling accidents or acute illnesses outside of hospitals. At the time of patient handover from emergency medical technicians (EMTs) to the nurses and physicians in emergency departments (EDs), there is a risk that important information will be lost, the consequences of which may adversely affect patient well-being. The study aimed to describe healthcare professionals’ experience of patient handovers between ambulance and ED staff and to identify factors that can affect patient handover quality.

Methods

The Vancouver School’s phenomenological method was used. The participants were selected using purposive sampling from a group of Icelandic EMTs, nurses, and physicians who had experience in patient handovers. Semi-structured individual interviews were conducted and were supported by an interview guide. The participants included 17 EMTs, nurses, and physicians. The process of patient handover was described from the participants’ perspectives, including examples of communication breakdown and best practices.

Results

Four main themes and nine subthemes were identified. In the theme of leadership, the participants expressed that it was unclear who was responsible for the patient and when during the process the responsibility was transferred between healthcare professionals. The theme of structured framework described the communication between healthcare professionals before patient’s arrival at the ED, upon ED arrival, and a written patient report. The professional competencies theme covered the participants’ descriptions of professional competences in relation to education and training and attitudes towards other healthcare professions and patients. The collaboration theme included the importance of effective teamwork and positive learning environment.

Conclusions

A lack of structured communication procedures and ambiguity about patient responsibility in patient handovers from EMTs to ED healthcare professionals may compromise patient safety. Promoting accountability, mitigating the diffusion of responsibility, and implementing uniform practices may improve patient handover practices and establish a culture of integrated patient-centered care.

Adverse Events During Intrahospital Transport of Critically Ill Children: A Systematic Review

Intrahospital transport of a critically ill patient is often required to achieve a diagnostic and/or therapeutic objective. However, clinicians who recommend a procedure that requires transport are often not fully aware of the risks of transport. Clinicians involved in the care of critically ill children may therefore benefit from a clear enumeration of adverse events that have occurred during transport, risk factors for those events, and guidance for event prevention. The objective of this review was to collect all published harm and adverse events that occurred in critically ill children in the context of transport within a medical center, as well as the incidence of each type of event. A secondary objective was to identify what interventions have been previously studied that reduce events and to collect recommendations for harm prevention from study authors. Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and CINAHL were searched in January 2018 and again in December 2018. Terms indicating pediatric patients, intrahospital transport, critical illness, and adverse events were used. Titles and abstracts were screened and full text was reviewed for any article meeting inclusion criteria. If articles included both children and adults, incidence data were collected only if the number of pediatric patients could be ascertained. Of 471 full-text articles reviewed, 40 met inclusion criteria, of which 24 included only children, totaling 4104 patient transports. Heterogeneity was high, owing to a wide range of populations, settings, data collection methods, and outcomes. The incidence of adverse events varied widely between studies. Examples of harm included emergent tracheostomy, pneumothorax, and cardiac arrest requiring chest compressions. Respiratory and airway events were the most common type of adverse event. Hypothermia was common in infants. One transport-associated death was reported. When causation was assessed, most events were judged to have been preventable or potentially mitigated by improved double-checks and usage of checklists. Prospective studies demonstrated the superiority of mechanical ventilation over manual ventilation for intubated patients. Risk of adverse events during critical care transport appears to relate to the patient's underlying illness and degree of respiratory support. Recommendations for reducing these adverse events have frequently included the use of checklists. Other recommendations include optimization of the patient's physiological status before transport, training with transport equipment, double-checking of equipment before transport, and having experienced clinicians accompany the patient. All available recommendations for reducing transport-associated adverse events in included articles were collated and included.

Facilitating educational experiences in a paediatric handover: A qualitative case study

AIM

Handovers have been established as a valuable educational tool; nevertheless, a paucity of literature exists evaluating contributors to the educational experience. Our study aimed to investigate participants' educational experiences based on a paediatric handover, and the facilitators and barriers towards teaching and learning during this process.

METHODS

A case study was conducted using semi-structured interviews. Data were collected exploring participants' perspectives of their educational experiences within a handover. An inductive, thematic content analysis was performed to identify key themes, assisted by nVivo software.

RESULTS

Four key themes contributing to the educational experience within a handover were identified related to the organisation of a handover, team dynamics, teaching and learning moments and tensions between the clinical tasks and education. A model is proposed aimed at optimising education within this context.

CONCLUSIONS

Our study identified contributing factors towards the educational experiences at handovers and provides strategies to optimise these.

Challenges in the handover process of the new-born with congenital heart disease

INTRODUCTION

A new-born with congenital heart disease requires care that involves numerous specialists. Such care can be provided at tertiary referral hospitals and transportation is often needed. A crucial factor is the handover process, when the child is born at a distance, with transfer of both professional responsibility and continued care from one healthcare professional to another.

AIM

The aim of this study was to identify crucial factors for the receiving healthcare professionals that influence the handover process of the new-born with congenital heart disease.

METHOD

A cross-sectional questionnaire study with 53 receiving healthcare professionals at a paediatric intensive care unit at a tertiary referral university hospital in Sweden. The response rate was 48/53. Numerical variables were computed and a content analysis was performed.

FINDINGS

The handover process of the new-born with heart disease transferred to a tertiary referral hospital is complicated. A clear majority of the respondents identified one or more flaws in this process. Crucial factors identified were: relevant and structured information, clear communication, adequate patient knowledge and an enabling environment.

CONCLUSION

A standardised procedure in the different phases of the handover process could improve communication, the working situation for healthcare professionals and thereby increase patient safety.

The impact of a standardized inter-department handover on nurses' perceptions and performance in Republic of Korea

AIMS

To evaluate the impact of a standardized inter-department nursing handover protocol from intensive care units to general wards on the nurses' perceptions and performance.

METHODS

We developed an inter-department nursing handover protocol based on the situation, background, assessment and recommendation technique. All participating paediatric nurses were trained in this new protocol, which was then implemented for nine months in eight units of a children's hospital in the Republic of Korea. Data were extracted from a questionnaire and handover auditing using audio recording.

RESULTS

Following the protocol's introduction, nurses' perceptions of handover effectiveness significantly improved (F = 5.17, p = .007), while their experience of handover errors significantly decreased (F = 12.85, p < .001). Furthermore, the prevalence of additive calls per handover decreased from 70.7% to 45.9% (χ²  = 9.88, p = .002), and the prevalence of handover-related errors decreased from 51.2% to 32.4% (χ²  = 5.63, p = .023). Handover accuracy significantly increased (t = -5.12, p < .001) without prolonging the handover duration.

CONCLUSIONS

The handover protocol positively influenced the nurses' perception of handover and clinical performance.

IMPLICATIONS FOR NURSING MANAGEMENT

A standardized inter-department handover helped intensive care unit nurses to improve their organisation and to provide ward nurses with sufficient information during handover, which could ensure safer transitions from intensive care units to wards.

Improving the handover and transport of critically ill pediatric patients

AIMS AND OBJECTIVES

The aims of this project were to (a) determine barriers to current handover and transport process, (b) develop a new protocol and process for team-to-team handover, and (c) evaluate staff satisfaction with the new process.

BACKGROUND

The handover and transport of critically ill patients from the paediatric emergency department to the paediatric intensive care unit is a period of vulnerability associated with adverse events.

DESIGN

A mixed-methods study using a quasi-experimental design and qualitative approach.

METHODS

Focus groups were conducted to determine the barriers and facilitators of the current handover and transport process. Using these themes, a multidisciplinary team developed and implemented a new process including establishment of eight patient criteria for specialised transport and a standardised, interdisciplinary handover tool for team-to-team handover. Staff satisfaction was examined pre- and postintervention.

RESULTS

Content analysis of focus groups revealed five categories: need for improved communication, cultural dissonance among units, defects in system and processes, need for standardisation and ambiguity between providers regarding acuity. Staff members reported improvements in their perceptions of satisfaction, safety, communication and role understanding associated with the new process.

CONCLUSIONS

Standardisation through the establishment of severity of illness criteria and communication tools creates shared mental models and decreases risks to safety. A paradigm shift of team-to-team handover and transport is recommended.

RELEVANCE TO CLINICAL PRACTICE

This paper suggests the importance of improving communication during the handover and transport process through establishing standardised patient severity of illness criteria, use of standardised tools and team-to-team handover processes.