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Stabilisation of critically ill children at the district general hospital prior to intensive care retrieval: a snapshot of current practice
  1. S Lampariello1,
  2. M Clement2,
  3. A P Aralihond2,
  4. D Lutman2,
  5. M A Montgomery2,
  6. A J Petros2,
  7. P Ramnarayan2
  1. 1Consultant in Paediatric Intensive Care, Nottingham University Hospital, Nottingham, UK
  2. 2Children's Acute Transport Service, Great Ormond Street Hospital, London, UK
  1. Correspondence to Dr Padmanabhan Ramnarayan, Children's Acute Transport Service, Great Ormond Street Hospital, 44 B Bedford Row, London WC1R 4LL, UK; ramnap{at}cats.nhs.uk

Abstract

Objective To describe current practice during stabilisation of children presenting with critical illness to the district general hospital (DGH), preceding retrieval to intensive care.

Design Observational study using prospectively collected transport data.

Setting A centralised intensive care retrieval service in England and referring DGHs.

Patients Emergency transports to intensive care during 2-month epochs from 4 consecutive years (2005–2008).

Interventions None.

Main outcome measures Proportion of key airway, breathing, and circulatory and neurological stabilisation procedures, such as endotracheal intubation, mechanical ventilation, vascular access, and initiation of inotropic agents, performed by referring hospital staff prior to the arrival of the retrieval team.

Results 706 emergency retrievals were examined over a 4-year period. The median age of transported children was 10 months (IQR, 18 days to 43 months). DGH staff performed the majority of endotracheal intubations (93.7%, CI 91.3% to 95.5%), initiated mechanical ventilation in 76.9% of cases (CI 73.0% to 80.4%), inserted central venous catheters frequently (67.4%, CI 61.7% to 72.6%), and initiated inotropic agents in 43.7% (CI 36.6% to 51.1%). The retrieval team was more likely to perform interventions such as reintubation for air leak, repositioning of misplaced tracheal tubes, and administration of osmotic agents for raised intracranial pressure. The performance of one or more interventions by the retrieval team was associated with severity of illness, rather than patient age, diagnostic group, or team response time (OR 3.62, 95% CI 1.47 to 8.92).

Conclusions DGH staff appropriately performs the majority of initial stabilisation procedures in critically ill children prior to retrieval. This practice has not changed significantly for the past 4 years, attesting to the crucial role played by district hospital staff in a centralised model of paediatric intensive care.

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Paediatric intensive care is a highly specialised area that has been subject to significant centralisation over the past decade.1,,3 However, for many critically ill or injured children, the first point of contact when they are acutely unwell will still be their nearest district general hospital (DGH).4 Most of these children will require stabilisation and subsequent transfer to a paediatric intensive care unit (PICU). Currently, most transfers are performed by PICU retrieval teams because preventable adverse events have been shown to occur frequently when nonspecialist staff transport patients to tertiary centres.5,,7 However, because it may take a retrieval team a median of 100–120 min to arrive at the patient's bedside, vital interventions required in the first few hours of stabilisation remain the responsibility of the referring hospital and cannot be deferred until the arrival of the retrieval team.8 9

What is already known on this topic

  • ▶. Paediatric intensive care is provided in centralised fashion at tertiary centres in the UK.

  • ▶. Since most acutely ill or injured children present to their nearest hospital, initial stabilisation prior to intensive care retrieval remains the responsibility of the district general hospital (DGH).

  • ▶. There is a scarcity of data regarding the nature of initial management of the critically ill child at the referring hospital and how this has changed with widespread use of intensive care retrieval teams.

What this study adds

  • ▶. Most critically ill children are stabilised adequately by the DGH prior to transport.

  • ▶. Because major interventions such as endotracheal intubation are almost always performed by the referring staff, other vital interventions such as repositioning of misplaced tracheal tubes and osmolar therapy for intracranial hypertension are undertaken by the retrieval team.

Stabilisation of a sick child at the DGH requires the input of a large multidisciplinary team comprising paediatricians, anaesthetists, adult intensivists, and senior nursing staff. In recent years, regionalisation of paediatric specialist services such as anaesthesia, elective surgery and emergency medicine,10,,12 and the resultant reduction in exposure to airway and procedural skills among DGH staff, has led to concerns that vital procedures such as intubation, mechanical ventilation, and vascular access may be delayed during stabilisation until a specialist retrieval team is available.13,,15 These concerns formed the focus of a recent report from a Department of Health (DH) working party with joint representation from the Royal Colleges of Anaesthesia as well as Paediatrics and Child Health. The report emphasised the importance of a team response from senior trained staff in ensuring optimal and timely stabilisation of critically ill children at the DGH, placing the onus of acquiring and maintaining necessary competencies on the referring hospital.16

Retrieval of children for intensive care in the regions of North Thames and East Anglia is undertaken by the Children's Acute Transport Service (CATS). CATS was established in 2001 as a centralised service following the merger of two existing PICU-based retrieval teams, with the aim of serving as a single point of contact for all intensive care referrals and providing a 24/7 service for telephone triage and immediate advice for DGHs in the region. Although a previous study from one London PICU which examined stabilisation before and after the introduction of a retrieval team indicated that DGH staff continued to perform a significant proportion of interventions, the study sample was limited to a small cohort in 1993 and 2000.17 In the context of the recent DH report, it is important that a comprehensive picture of current practice across a wide geographical region is available to clinicians and service commissioners. In this study, we examined stabilisation practice at the DGH by focusing on key interventions performed by referring staff on children transported for intensive care by the CATS service for a recent 4-year period.

Methods

Retrieval data are collected in prospective fashion at CATS within a structured paper form by medical and nursing staff undertaking the transfer. Information is later entered into a database (MS Access; Microsoft, Reading, UK) by clerical staff. For the purposes of this study, a report containing pseudonymised data was generated for analysis covering 2-month epochs (April and May) from four consecutive years (2005–2008). The months of April and May were chosen because they most closely represented the average annual case mix (p=0.05). Referrals in winter and summer were skewed towards respiratory and trauma diagnoses, respectively. Details were collected from all emergency patient referrals for intensive care. Calls for advice and nonurgent transports were excluded. Data analysed included brief demographic details (age and gender), clinical details (diagnostic group and Paediatric Index of Mortality 2 (PIM-2) score as a measure of severity of illness), operational intervals (team response time, ie, time to reach patient bedside), and details on a set of stabilisation procedures established a priori (table 1).

Table 1

List of interventions studied

Interventions were classified as airway, breathing, circulation, and neurology related. We identified these particular crucial interventions to ensure optimal patient management in the first few hours following acute presentation. They were also described in the recent DH report as key stabilisation procedures. Data collected from the four epochs were intended to serve as snapshots of practice in recent years, before and after the publication of the DH report. No attempt was made in this study to compare the time periods before and after the establishment of the retrieval service.

Our main analysis focused on the proportion of interventions performed by DGH staff. We also tested the association of age, diagnostic group, PIM-2 score, and team response time with the need for specific vital procedures (highlighted in table 1) by the retrieval team using a logistic regression model. Comparison of year-wise proportions was performed by using the Cochran–Armitage test for trend (two-tailed test). Nonparametric tests were used where appropriate. Statistical significance was defined as p <0.05. SPSS version 15 (SPSS, Chicago, Illinois) and XLSTAT (Addinsoft, New York, New York) were used for statistical tests.

Because the data for this project were analysed from data prospectively collected as part of routine clinical documentation, review by the Trust Research Ethics Committee was waived as per Great Ormond Street Hospital Policy.

Results

A total of 1302 children were referred to the service for the four time periods. Data were collected on 706 consecutive emergency transports. The remainder of referrals were for advice or classified as non-intensive care referrals and nonurgent transfers. Characteristics of the study cohort are summarised in table 2. The median age of retrieved patients was 10 months (range, 1 day to 16 years; interquartile range (IQR), 18 days to 43 months). Most patients were referred for respiratory illnesses and neurological conditions. This distribution remained consistent across the four time periods. Patient acuity was high: >80% were mechanically ventilated during transfer, and the median predicted mortality risk using PIM-2 was 6.4% (IQR 3.9–16.4).18

Table 2

Characteristics of the study cohort

Table 3 illustrates the performance of airway-related interventions.

Table 3

Airway interventions performed by referring hospitals and retrieval team

The proportion of children undergoing primary tracheal intubation by DGH staff remained consistently high during all snapshots (93.5%). However, the CATS team performed all reintubations (undertaken either for leak around an inappropriately small endotracheal tube (ETT) or for incorrectly positioned precut tracheal tubes). They also repositioned a number of tracheal tubes. Most patients were placed on a mechanical ventilator by the referring team (77%). However, it is worthy of note that the remainder were being hand ventilated when the retrieval team arrived. Inhaled nitric oxide was used on 41 transports (overall rate 5.8%), having been initiated by the referring neonatal unit in 18 patients.

Circulation-related procedures are summarised in table 4. A significant number of children had central venous catheters and arterial lines placed by the referring hospital team. In addition, DGH staff also commenced inotropic support on 43.8% (77/176) of patients needing cardiovascular support, mostly in the form of a peripheral infusion of dopamine and/or dobutamine. The CATS team added further inotropic agents in 48 patients, usually epinephrine and/or norepinephrine. A similar observation was seen with regard to fluid resuscitation (defined as fluid bolus administration of ≥40 ml/kg).

Table 4

Vascular access and circulatory support performed by referring hospitals during stabilisation

Table 5 summarises neurology-related interventions. Most patients were commenced on sedative agents at the referring hospital (79%). Similarly, the majority of CT scans were performed by DGH staff before the arrival of the retrieval team. However, administration of osmolar therapy for raised intracranial pressure was deferred until the retrieval team's arrival in nearly half of the patients in whom it was indicated.

Table 5

Neurological interventions and diagnostic tests performed during stabilisation

Figure 1 summarises key interventions across the entire study cohort and the team that performed them. Only PIM-2 score was found to be predictive for the performance of one or more vital stabilisation procedures by the retrieval team (OR 3.62, 95% CI 1.47 to 8.92, table 6).

Figure 1

Proportion of interventions performed by referring hospitals and intensive care retrieval teams during stabilisation of critically ill children.

Table 6

Multivariate analysis of factors associated with the retrieval team performing one or more vital interventions

Although we did not aim to directly compare the different time periods, it is noteworthy that there were no major differences in patient characteristics or the proportion of key stabilisation procedures performed by the referring hospital.

Discussion

Our study shows that referring hospitals continue to perform the vast majority of key stabilisation procedures on critically ill children referred for intensive care retrieval. This finding is consistent across the past 4 years for a large geographical region, despite no significant differences in the acuity of patients, distribution of diagnostic groups or change in team response times.

For the past few years, the role of the DGH in the ‘hub-and-spoke’ model of intensive care has been a subject of intense discussion. Staff at DGHs have frequently expressed concerns that centralisation of intensive care, widespread use of a retrieval team, and a significant reduction in exposure to airway and other procedures during elective surgery would result in the loss of procedural skills required for the stabilisation of a critically ill child. The effects of centralisation of PICU on service delivery at the DGH has not been studied systematically, despite its importance being highlighted a decade ago.19 The latest milestone in this process is the 2006 DH report on stabilisation of the ill or injured child at the DGH.16 The report emphasises the importance of a team approach, placing the responsibility of managing the critically ill child prior to intensive care transport on the DGH. Key interventions are described that cannot wait until the arrival of the retrieval team. Our study shows that most referring centres are initiating vital stabilisation procedures such as endotracheal intubation, vascular access and haemodynamic monitoring before the arrival of the transport team. It is unclear whether these encouraging findings are limited to our region, or whether these results can be generalised to other settings. Active and ongoing telephone advice from the retrieval service may play a crucial role in supporting and encouraging DGH staff to perform key interventions even while the team is en route to the patient,20 although the current study design does not help to clarify the true extent of this effect. The effect of regular CATS educational outreach at referring hospitals is also unclear. Concurrently, changes at DGHs, such as widespread exposure to Advanced Paediatric Life Support courses, rotational appointments with tertiary centres, and more hands-on care delivered by consultants may have played a part in influencing current practice.

A previous study in this journal showed that referring hospitals carried out a greater, rather than lesser, proportion of tracheal intubations in the period after the introduction of a PICU-based retrieval team in London (60% vs 85%).17 Our findings from a regional transport team serving a larger geographical region and a broad case mix confirm that this trend has persisted in recent years. The respective roles of the PICU and the DGH in the continuum of care of the acutely ill or injured child appear to have been clearly delineated within the current model of service delivery, thus maximising the benefits of centralisation for patients while minimising its presumed adverse effects. We chose to examine the performance of key interventions performed during emergency management at the referring hospital as markers of the quality of stabilisation.21,,23 We found that DGH staff are undertaking most key procedures in the hours prior to the arrival of the retrieval team and achieving a high level of patient care. Closer examination of our findings does suggest that, in some cases, further interventions were needed to optimise the condition of the child before transport, for example reintubation, ETT repositioning, and additional inotropic support. Interventions such as inhaled nitric oxide and osmolar therapy were also mainly initiated by the CATS team. In a small proportion of cases, children were being hand ventilated until the arrival of the retrieval team, which may adversely affect ventilation in critical illness.24 It is unclear whether these interventions were deferred, deemed unnecessary or unavailable — procedures required immediately after arrival of the retrieval team may reflect interventions that ought to have been performed by referring hospital staff. Patient-specific advice from the retrieval team during referral about appropriate tracheal tube size and length may also minimise the need for additional airway interventions. Overall, however, it appears that the majority of sick children benefit from the significant input provided by the referring hospital team. It remains the responsibility of the DGH to support local staff in maintaining their competencies by means of rotational posts with tertiary centres, and regular training and update sessions.

One of the main limitations of this study was that we were unable to determine whether most of the interventions were carried out by anaesthetic staff or paediatricians, particularly airway procedures. Our practice indicates that most tracheal intubations, central venous catheters, and arterial lines would be normally undertaken by anaesthetic staff. Although this information may have implications on future training and for maintaining competencies, it is less important from a patient perspective. We did not examine in detail the quality of interventions, that is, adverse events and complications of procedures; an increased rate of interventions carried out by DGH staff may be offset by a greater complication rate, resulting in the need for further corrective interventions. Our choice of outcome measures also does not fully cover the entire spectrum of emergency patient management (eg, clinical assessment, administration of vital medications, and adherence to established guidelines). Finally, since this was a retrospective study, we were unable to obtain specific data related to the impact of active telephone advice provision and remote consultation on practice at the referring hospital.

Conclusions

The widespread use of a regionalised intensive care retrieval service has not resulted in the loss of vital stabilisation skills at the referring hospital. The majority of initial stabilisation, notably endotracheal intubation and mechanical ventilation, continues to be performed by staff at DGHs. Ongoing maintenance of competencies in emergency stabilisation and maintenance of close communication with the regional retrieval service are likely to be key factors in ensuring that critically ill children continue to receive the best possible care at the right time.

References

Footnotes

  • Funding This work was carried out as part of NHS service delivery. No separate funding was identified.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Great Ormond Street Hospital Ethics Committee Chair, and informed consent was waived because of the retrospective nature of the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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