Karin A. McCloskey

Pretransport Pediatric Risk of Mortality (prism) score underestimates the requirement for intensive care or major interventions during interhospital transport

Objective: To test the hypothesis that a pretransport Pediatric Risk of Mortality (PRISM) score underestimates the requirement for both intensive care and interventions during pediatric interhospital transport. Design: Prospective, descriptive study. Setting: All children were treated in a regional hospital and then transported to a pediatric tertiary care center by a pediatric critical care specialty team. Patients: Children (n = 156) with a median age of 1.3 yrs (range newborn to 18 yrs). Interventions: None related to the study. Measurements and Main Results: Two sets of Pediatric Risk of Mortality scores were calculated: one from data collected over the telephone at the time of the referral (Referral PRISM), and one from both the referring hospitals records and from data collected by the transport team on arrival at the referring hospital and before the team provided any intervention (Team PRISM). The admission area used on arrival at the tertiary care center (intensive care unit [ICU] vs. non‐ICU) and the number of major clinical interventions performed by both the referring hospital staff and the transport team were recorded. The Therapeutic Intervention Scoring System was used to assess the cumulative level of medical care provided up to 8 hrs after admission to the pediatric tertiary care hospital. No patient died during transport. The overall inhospital mortality rate was 5.1%. Median Therapeutic Intervention Scoring System scores were higher for patients admitted to the ICU (16 vs. 4, p < .001). Whereas median PRISM scores were significantly higher in those children admitted to the ICU (4 vs. 0, p < .001), 58 (75%) of 77 ICU admissions had a Team PRISM score of ≤10. Fortyfour (71%) of 62 children who required at least one major intervention at some time during the transport process and 15 (63%) of 24 children who required at least one major intervention by the transport team had a Team PRISM score of ≤10. Referral PRISM scores underestimated Team PRISM scores. Conclusions: PRISM scores determined before interhospital transfer of pediatric patients underestimated the requirement for intensive care and the performance of major interventions in the pretransport setting. Many patients with low PRISM scores required intensive care on admission to the receiving hospital and major interventions during the transport process, and, therefore, were not at “low risk” for clinical deterioration. The PRISM score should not be used as a severity of illness measure or triage tool for pediatric interhospital transport. (Crit Care Med 1994; 22:101‐107)

Critical care interhospital transports: predictability of the need for a pediatrician.

The Childrens Hospital of Alabama Critical Care Transport System provides a mobile intensive care unit for interhospital transfer of critically ill pediatric patients. The transport team consists of a pediatrician, a pediatric emergency nurse, and a respiratory therapist. We studied whether it was possible to determine in advance whether it was always necessary for a physician to be on the team. The transport physician made a determination of need for a physician based on data available prior to transport (preassessment). After the transport was completed, the physician made a retrospective determination of actual need for a physician (postassessment). Over a period of eight months, 148 questionnaires were analyzed. In 108 transports (73%), there was minimal or no change in need for a physician between the pre- and posttransport assessments. Therefore, an accurate prediction of need for a physician was possible in advance. Of the remaining transports in which the determination was significantly changed, 37 (25%) indicated a decrease in actual need for a physician after completion of the transport. There was a significant increase over the prediction in the actual need for a physician in only three cases (2%).

Pediatric critical care transport survey: team composition and training, mobilization time, and mode of transportation

A survey was conducted to determine the current standard of care with regard to team composition and training, mobilization time, and vehicle use for pediatric critical care transport. An evaluation of 30 pediatric referral centers revealed that 60% provide a critical care transport team. Of those teams, the mean number of transports per year was 304. Response time ranged from 10 to 90 minutes. All teams included a physician all or most of the time; 100% of teams included a critical care nurse, and 50% always included a respiratory therapist. Ambulances alone are used in 28% of systems, with the remainder using combinations of ambulances, helicopters, and fixed wing aircraft. A proposal is presented for future standards in pediatric critical care transport with regard to the factors discussed.

Variables predicting the need for a pediatric critical care transport team.

To determine when a pediatric critical care transport team is required to transport a patient to a referral center, this cross-sectional study evaluated 369 consecutive pediatric transports by stepwise multiple logistic regression analysis of six variables: age, vital signs, seizure activity, current endotracheal intubation, respiratory distress, and respiratory diagnosis.Models were developed for three outcome variables: 1) Major procedures were required in 8.9% of cases. The predicted probability of needing a major procedure was increased for intubated patients (probability of 12.9%), patients <1 year of age with unstable vital signs (12.9%), and patients meeting both these criteria (23.2%). 2) A posttransport assessment of need for a physician on the team was positive in 43% of cases. The probability of needing a physician was increased for intubated patients (probability of 68.8%), patients <1 year of age with unstable vital signs (58.7%), and patients meeting both these criteria (79.9%). 3) Category 1 drugs, ie, medications requiring ICU monitoring, were used in 19% of transports. The probability of this occurring was increased for intubated patients with stable vital signs (probability of 24.7%) and for intubated patients with unstable vital signs (41.4%). None of the other pretransport variables, alone or in pairs, was a significant predictor of any of the three outcome variables.The data indicate that intubation, age, and vital sign status can be used in predicting whether a transport team is needed.