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.