Race to the Rescue — Pediatric ICU Transport
Monday June 28, 2004
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Photo by Howard Heyman
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critically ill children to medical centers that offer specialty care.
Emergency nurses see it all and quickly learn to deal with the challenging situations that arrive at their doorstep. They cope with the debilitated and the intoxicated. They learn to calm distraught families and intercede with difficult patients. They can - and do - handle almost everything. One situation, however, can cause fear in even the most seasoned ED nurse, and that is when the ED is not equipped to handle a seriously ill or injured child.
Pediatric nurses deal with sick children every day. They know how to calm frightened children and reassure anxious parents. They know how to watch for quick changes that can take a child from merely sick to critically ill. And they know when they need help.
Certainly, there are health care facilities equipped to handle all situations. They are the trauma centers, the regional medical centers, and the large teaching facilities that are equipped with the latest treatments that neonatal and pediatric intensive care units (PICUs) offer. But other facilities that may not be able to support such specialized care have discovered a mobile alternative, so every child can safely and efficiently reach the treatment necessary for optimum care.
New Relationships
The facilities that are unable to support an intensive care center for children and infants have developed transfer policies with medical centers that offer these specialties. The Bristol-Myers Squibb Children's Hospital (BMSCH) at Robert Wood Johnson University Hospital in New Brunswick, N.J., offers a state-of-the-art PICU on wheels. It's a mobile PICU designed specifically for the transfer of intensely ill children and infants.
When nurses sign on to work in the PICU at BMSCH, they are also signing up for an adventure. "We have the only vehicle in the state of New Jersey that is dedicated solely to pediatric intensive care transport," says Linda Palkoski, RN, MPH, director of the PICU at BMSCH. "Our PICU nurses, along with our team of specially trained physicians, respiratory therapists, and emergency medical technicians, provide critical care transportation for the most medically fragile children and infants from any hospital in the tri-state area."
On any given day and on any shift, there is a PICU nurse who is free to go out on transports. "Our goal is to have all of our PICU nurses trained to do transport," says Joy Hultman, RN, MSN, head nurse, PICU, BMSCH. The transport team attends a full-day training class and is certified in pediatric advanced life support (PALS). The nurses must complete three transports with an experienced nurse before going out with the team. "Our transport nurses come directly from the PICU and have years of pediatric critical care experience," adds Maureen Madden, RN, MSN, PCCNP, FCCM, pediatric critical care nurse practitioner. "It's a natural selection process. This isn't something you could do without a PICU background."
And when the PICU staff says that everyone goes on these transports, they mean everyone. Madden, the nurse practitioner on the team, teaches the transport course, coordinates the team, and is actively involved in many transports. Even Palkoski has gone on transports. "It's essential," she says. "We all go out, we all actively participate, and it gives us a perspective on what it is like to transport these critically ill children."
Well Traveled Unit
BMSCH has been providing transportation for critically ill children for years and after examining the 2001-2002 transport statistics, the staff realized the need was growing. "In 2002, we did 250 transports," says Palkoski. In January 2003, the mobile PICU was put into operation, while the team began doing outreach with community and area facilities. "In 2003, we did 496 pediatric and neonatal transports and we are predicting between 600 and 700 transports for this year. To this date, 36 health care facilities have called us to transport infants and children to our unit," Palkoski adds.
To ensure the program's success, the PICU staff used a tiered approach to inform the community. "Our medical group went out to speak to area physicians, while other staff members went directly to the health care facilities to speak with the staff," Madden explains. "Our focus was on the emergency departments."
The first contact with the transport team is a 1-800 phone call. The referring physician talks directly to a pediatric intensive care physician at BMSCH and the transport nurse calls the nurse caring for the patient to get a nursing report. "Our goal is to be out the door and on the road in 30 minutes," says Hultman. Members of the transport team include the physician, nurse, respiratory therapist (if needed), and an EMT. "Depending on the acuity of the patient," Madden adds, "we may decide to include an attending physician and/or an NP. If the transport involves a neonate, we will take a NICU nurse and neonatal physician."
On the mobile PICU, everything is in place to care for an acutely ill child. The vehicle can hold incubators for neonates or backboards for critically injured 21-month-olds.
"Everything, every piece of equipment, is size appropriate," Madden says. "We have specialized gases, ventilators, and medications." Moreover, to make sure all of the child's needs are considered, the mobile PICU has a DVD player so a movie can be shown during transport. "We make every effort to ensure that the interior is non-threatening for the child," Madden adds.
Transition from PICU to the Road
Although these nurses have experience in caring for critically ill children, they are flexible in their skills because a shift in nursing strategy is necessary when they hit the road. "The team is required to change their focus from diagnosis or treatment to stabilization: 'Is this child stable enough to take on the road?'" explains Madden. "The training class focuses on the usual pediatric system problems, cardiovascular, respiratory, and neurology, but with a focus on preparing the child for a travel time that can be unpredictable. That recognition factor, of knowing when a child can be transported, is so important," she adds.
According to the Emergency Nurses Association Position Statement,1 there are several factors that can compromise a safe and effective transfer, including -
· Limited knowledge and/or lack of experience in managing the pediatric patient.
· Apprehension by health care workers related to pediatric assessment and interventions.
· Failure to recognize the severity of condition.
· Limited knowledge and/or lack of familiarity related to the pre-transfer stabilization process.
· Limited understanding of pediatric patient needs during transport.
· Lack of availability and/or lack of awareness of specialized pediatric transport teams.
In addition, according to the statement, inadequate personnel, equipment, and re-sources at referring institution, and during transport, can result in the delivery of sub-optimal care that may affect the patient's outcome.
Case in Point
Equipment, experience, training, and teamwork are essential, but even this team has had its share of challenges. They have traveled to France to bring home an adolescent who became ill while vacationing there. Another memorable trip involved the transportation of an 8-year-old who was suffering from smoke inhalation. "We got a call from the burn center," recalls Hultman. "One of [the] attending physicians was there. The child did not have extensive burns, but was not tolerating the ventilator as a result of the smoke inhalation. The physician called and said, 'Come get this child.' He said that she would die without the transfer."
While the team physician received a detailed report from the attending physician, the pharmacists at BMSCH made up the IV medication for the transfer. Hultman and Madden were the RN and NP part of the team. "Since the patient was on vasoactive drips, it was great to have an NP along," Hultman recalls, "so we could be starting new lines and adjusting the drips."
Going against their own rules, the team couldn't wait for the young girl's condition to improve. "We spoke to the family, we tried to optimize the situation, but we couldn't wait for her to stabilize," Hultman remembers. With a plan established prior to leaving the burn unit, the team began their trip with the attending physician following in his car. "We couldn't put her on our vent," Hultman says, "so we hand-ventilated her the whole way back, during rush hour." It took the team one hour to make the trip. "It was not optimal, but we had no choice," Hultman adds. Thanks to the team's intervention, the little girl not only survived the trip, but also made a remarkable recovery.
Mobile Nurses
The nurses who work in the PICU at BMSCH are an integral part of the mobile PICU team. "It is a nice transition from one facility to another, when nurses are present for the transfer," says Madden. "We work with the families. We tell them that we are the nurses who they will see on the unit. We let them know that we are the same nurses who will care for their child." At the transport, the nurses give families a brochure about the facility and answer questions. And just as nurses in every ED or on every pediatric unit know, caring for a critically ill child means nursing care for the whole family.
"We allow one parent to ride in the front of the ambulance," Madden adds. "And when they arrive, we work hard to make the 14-bed PICU as parent-friendly as possible." There is an area in each patient room where a parent can stay overnight; there are locked storage areas, showers, refrigerators, and laundry facilities.
"In pediatric nursing, we know that we can't separate the child from the family," Hultman says. "A critical illness or injury in a child is an extremely stressful time for all. We always provide that family focus."
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