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Interhospital Transfer of Children in Septic Shock: A Clinician Interview Qualitative Study
Folafoluwa O Odetola1,2, Renee R Anspach3, Yong Y Han4
11 Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, MI, USA.
Insights
Physicians transfer children with septic shock to a higher level of care when local treatments fail. Most doctors would transfer patients needing advanced therapies like ECMO, but some hesitate due to perceived local capability or unfamiliarity with advanced treatments.
Area of Science:
- Pediatric Intensive Care
- Septic Shock Management
- Interhospital Transfer Protocols
Background:
- Septic shock in children requires timely and appropriate intensive care.
- Level II Pediatric Intensive Care Units (PICUs) may face limitations in managing refractory cases.
- Understanding transfer decisions is crucial for optimizing patient outcomes.
Observation:
- Physicians assess perfusion and hemodynamic parameters like blood pressure, lactate, and ScvO2 to gauge severity.
- Catecholamine-resistant shock and oliguria prompt invasive mechanical ventilation.
- Lack of clinical improvement after initial resuscitation and ventilation is a key concern.
Findings:
- Most physicians (79%) would transfer children for extracorporeal membrane oxygenation (ECMO) or renal replacement therapy if refractory to escalated care.
- A minority (21%) would not transfer, citing perceived local capability, transfer unconventionality, or unawareness of advanced treatment options.
- Decision-making for transfer is influenced by perceived nonresponse to locally available therapies.
Implications:
- Transfer decisions for pediatric septic shock are complex and influenced by physician judgment and resource availability.
- Standardizing transfer criteria and enhancing awareness of advanced treatment options at all levels of care are needed.
- Further research into factors influencing transfer decisions can improve care coordination for critically ill children.
Objective::
To determine the factors that influence the decision to transfer children in septic shock from level II to level I pediatric intensive care unit (PICU) care.
Design::
Interviews with level II PICU physicians in Michigan and Northwest Ohio. A hypothetical scenario of a 14-year-old boy in septic shock was presented.
Baseline::
40 mL/kg fluid resuscitation, central venous and peripheral arterial access, and high-dose vasopressor infusions were provided.
Escalation Point::
After 2 hours. When the patient is in catecholamine-resistant shock and oliguric, invasive mechanical ventilation is initiated.
Measurements And Main Results::
All 19 eligible physicians participated. At baseline, respondents would assess measures of perfusion and hemodynamics: blood pressure (BP; 15 [79%]), lactate (12 [63%]), and central venous oxygen saturation (ScvO2; 10 [53%]). Poor clinical response was signified by low BP (11 [58%]), elevated lactate (9 [47%]), low urine output (8 [42%]), and low ScvO2 (6 [32%]). At the escalation point, 13 of 18 respondents felt there was <50% probability of clinical turnaround without escalating treatment, though only 3 (16%) would call to discuss transfer. Seven (37%) respondents would give more fluid, whereas 8 (42%) would use central venous pressure to guide fluid resuscitation. Ultimately, 15 (79%) respondents would transfer for extracorporeal membrane oxygenation (ECMO) or renal replacement therapy if there was no response to escalated care. Four (21%) respondents would not transfer the patient: 1 felt appropriate care could be provided in the level II PICU, 2 felt transfer was unconventional, and 1 was unaware ECMO could be provided in refractory septic shock.
Conclusions::
Level II to level I PICU transfer of children with septic shock is triggered by perceived nonresponse to locally available therapies. Few referring physicians do not transfer children in refractory septic shock. This study provides new insight into decision-making that influences the interhospital transfer of children with septic shock.
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