Emergency • SNAPSHOT
With advancing medical technology, neonates and children are surviving premature births and diseases at rates that would not have been possible years ago. Consequently, an increasing number of critically ill children require rapid transport to tertiary care facilities that has driven the need for specialized pediatric teams in an effort to provide safe transportation of pediatric patients.1
Pediatric transport nurses have become a vital and unique part of the healthcare system by providing specialized care and critical management of acutely ill pediatric patients in need of rapid air or ground transportation to tertiary pediatric hospitals. Further, pediatric transport nurses are considered an extension of the tertiary care hospital;1 thus, they only transport pediatric patients from other hospitals, not from a scene of an accident.
Each year, the number of pediatric inter-facility transports has increased, as has the utilization of medical helicopters as a means of providing transportation to tertiary care facilities. Presently, there are 103 hospitals in the U.S. that provide neonatal and/or pediatric specialty transports.2
In Pennsylvania alone, there are more than 5,400 medical helicopter transports of children or neonates to tertiary care centers every year.2 Subsequently, interfacility transports of neonatal and pediatric patients for advanced medical care have become a vital part of the healthcare system.3
Team Composition
Specialty transport teams are comprised of pediatric critical care nurses functioning as team leaders, as well as other medical team members with advanced training such as paramedics and adult-trained nurses, to navigate patient care in the unpredictable transport environment. Usually, the transport nurses work in teams of two, but sometimes a third person such as a paramedic will be involved in the transportation of a child.
In addition, all the transport nurses taking care of patients outside a tertiary care center in Pennsylvania must possess a pre-hospital registered nurse (PHRN) certification to be able to care for a patient under the indirect supervision of a medical command physician.
The Hazardous Environment
The role and the working environment of pediatric transport nurses are incredibly unique, often hazardous and entirely different from the traditional bedside nursing role. The pediatric transport nurse performs her duties in a capricious environment, which consists of care in the back of a helicopter or ambulance with limited medical supplies and physical space, along with 1-2 other teammates.
Also, the pediatric transport nurse is the team leader aboard the helicopter or ambulance and, therefore, is in charge of the patient's assessment, the physician's orders, all medications administered, and the functioning of equipment upon arriving at the referring hospital and throughout the transfer back to the tertiary care hospital.
During the transportation process, the medical command physician is waiting at the tertiary care hospital and is available to the nurses aboard the helicopter or ambulance via pager for verbal orders and medical direction. Consequently, it is the responsibility of the pediatric nurse to make the immediate critical decisions until the medical command physician until he can be reached for further direction.
A Transport Journey
It was 9:45 a.m. when a call came into the dispatch office that a critically ill infant with hypoplastic left heart syndrome needed an immediate transport to a children's hospital for treatment. The report was given to the transport nurse from the cardiac attending physician; 38 weeks gestation, 2.72 kg, born 4 hours ago, blood is only mixing at the patent ductus arteriosus, extremely poor arterial blood gases and vital signs, and currently on prostaglandins, vasopressors and fentanyl. Further, the limiting blood mixing in the heart was causing the patient to decompensate; therefore, a transport team needed to be in the air as soon as possible to retrieve the patient.
Within 30 minutes from receiving the report, the pediatric transport nurse along with an adult transport nurse and paramedic were up in the air, en route to retrieve a patient in a completely unfamiliar hospital environment. During the hourlong flight to the hospital, the pediatric transport nurse has to mentally review the potential need for various equipment, medications, coding scenarios and a contingency plan if the patient is much worse than initially described. Consequently, it can be nerve-wracking pondering the what ifs when working in such an unpredictable environment.
When the team arrived to the referring hospital's NICU, the patient was found to be intubated, on inotropes and sedatives, and had arterial, umbilical and peripheral lines in place. Immediately, the pediatric transport nurse sought report from the referring physician and the bedside registered nurse, while performing a review of the X-rays of the endotracheal tube and umbilical lines for correct placement.
After receiving report, the pediatric transport nurse quickly jumped into assessing the patient, the airway, the continuous infusions and the ventilator, as well as obtaining an arterial blood gas for evaluation. Since a short bedside time is crucial for any transport, the transport team has to work together transferring over the continuous infusions and ventilator to their own equipment. During this time, the transport team has to quickly learn how the referring hospitals' equipment functions on "the fly," and how to transfer it over to their own equipment without disrupting the treatments the patient is receiving.
In addition, while the pediatric transport nurse has to maneuver the small infant, protecting the precarious airway is always paramount because small movements can potentially dislodge the endotracheal tube during the actual physical transfer of the infant from the NICU isolette to the transport isolette. Fortunately with this patient, she tolerated the quick switch of her inotropes to the transport pumps with only a small dip in her blood pressure. In addition, she tolerated the new connection to the isolette ventilator with no change in her oxygen saturation.
One of the hardest tasks during the transfer of care is obtaining consents from very frightened parents. Time is always of the essence, especially with a critically ill patient. However, much compassion and patience must be shown to the parents when explaining the transportation process. Unfortunately, with a patient this critically ill, no parents are allowed to accompany the team back to the children's hospital; therefore, they must put their blind faith in the team's expertise in caring for sick pediatric patients in an extremely unpredictable environment.
Before the patient is completely packaged up, the pediatric transport nurse must contact the medical command physician, in this case the cardiac attending, with an update before the team is allowed to leave the bedside. This is always done after the assessment and transfer of the continuous infusions and ventilator is complete. All the data collected by the pediatric transport nurse was reported back to the physician who gave further verbal orders to maintain care and safety during the transport back to the children's hospital.
Once the transport team leaves the bedside to fly back to the children's hospital, it can be an anxiety-provoking experience. Many things can go wrong from equipment failure, to the patient reacting poorly to an increased altitude and constant movement, or to restricted access to medical supplies. If the patient were to decompensate or even code, there are only one or maybe two other people to rely on to bag the patient, draw up medications, and perform an assessment or chest compressions.
If any equipment malfunctions such as medication pumps or the isolette ventilator, it has to be immediately corrected because there may not be an adequate backup system. The transport team members always have to be vigilant in continually assessing the patient and the equipment for possible concerns. Fortunately, in this case, the patient made the hourlong flight back with minimal issues that were easily corrected with additional medications.
Because pediatric transport nurses are an integral part of the transport process, it has been recommended by the American Academy of Pediatrics and the Section of Transport Medicine that a pediatric registered nurse be present as the team leader on every transport.3 As a result, these nurses are crucial to facilitating successful patient care during the transport process.1
References for this article can be accessed at www.advanceweb.com/nurses. Click on Resources, then References.
Susan Birkhoff is a clinical nurse at The Children's Hospital of Philadelphia.