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Frequency, Composition, and Predictors of In-Transit Critical Events During Pediatric Critical Care Transport
Jeffrey M Singh1, Anna C Gunz, Sonny Dhanani
11Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON, Canada.2Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.3Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.4Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.5Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.6Ornge Transport Medicine, Mississauga, ON, Canada.7Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
Insights
Nearly 12% of pediatric critical care transports involve in-transit critical events, often linked to pretransport instability. The Transport Pediatric Early Warning Score showed poor prediction, highlighting the need for better risk assessment in pediatric transport.
Area of Science:
- Pediatric Critical Care Medicine
- Transport Medicine
- Healthcare Systems Research
Background:
- Healthcare regionalization necessitates frequent transport of pediatric patients.
- Understanding in-transit critical events is crucial for patient safety during transport.
Purpose of the Study:
- To determine the frequency of in-transit critical events during pediatric critical care transport.
- To identify factors associated with these events and evaluate predictive scores.
Main Methods:
- Retrospective cohort study of pediatric critical care transports in Ontario, Canada (2005-2010).
- Analysis of administrative and clinical data to identify in-transit critical events and associated factors.
- Evaluation of the Transport Pediatric Early Warning Score's predictive performance.
Main Results:
- In-transit critical events occurred in 12.3% of transports, with hypotension, tachycardia, and bradycardia being most common.
- Factors like age, pretransport mechanical ventilation, cardiovascular instability, transport duration, and scene calls were associated with increased event risk.
- The Transport Pediatric Early Warning Score demonstrated low sensitivity (20%) in predicting events.
Conclusions:
- In-transit critical events are common in pediatric transports, particularly in unstable patients.
- The Transport Pediatric Early Warning Score is not a reliable predictor of these events.
- Further research is needed to optimize transport resource allocation for high-risk pediatric patients.
Objectives:
Transport of pediatric patients is common due to healthcare regionalization. We set out to determine the frequency of in-transit critical events during pediatric critical care transport and identify factors associated with these events.
Design:
Retrospective cohort study using administrative and clinical data.
Setting:
Single pediatric critical care transport provider in Ontario, Canada.
Patients:
All pediatric care transports between January 1, 2005, and December 31, 2010.
Measurements And Main Results:
The primary outcome was in-transit critical events, defined by an adaptation of a recent consensus definition. In-transit critical events occurred in 1,094 (12.3%) of 8,889 transports. Hypotension (3.6%), tachycardia (3.7%), and bradycardia (3.3%) were the most common critical events. Crews performed medical interventions in 194 transports (2.2%). The frequency and makeup of critical events varied across patient age groups. Age, pretransport mechanical ventilation, pretransport cardiovascular instability, transport duration, scene calls, and paramedic crew level were independently associated with increased risk of in-transit critical events in multivariate analysis. A Transport Pediatric Early Warning Score of 7 or greater predicted in-transit critical events with high specificity but low sensitivity (92.0% and 20.0%, respectively), but was not superior of the combination of pretransport mechanical ventilation and pretransport cardiovascular instability (sensitivity and specificity of 12.6% and 97.4%, respectively). Removal of early warning signs from the definition resulted in critical event rates comparable to those published in adults and improved predictive performance.
Conclusions:
Using new consensus definitions of transport-related critical events, we found critical events occurred in almost one in eight transports, and were strongly associated with pretransport cardiovascular instability. Transport Pediatric Early Warning Score was poorly predictive of in-transit critical events, and was not superior to the presence of pretransport mechanical ventilation and cardiovascular instability. Future prospective studies are required to elucidate the optimal matching of transport resources to patients, in particular those with both pretransport cardiovascular instability and mechanical ventilation.
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