PEDIATRICS Vol. 119 No. 3 March 2007, pp. 648-649 (doi:10.1542/peds.2006-3254)
LETTER TO THE EDITOR |
Unplanned Transport Events and Severity of Illness: Are We Conveying the Whole Picture?
Bradley A. Kuch, RRT-NPSDepartment of Critical Care Medicine/Transport
Children's Hospital of Pittsburgh
Pittsburgh, PA 15213
Ricardo Munoz, MD, FAAP, FCCM
Departments of Critical Care Medicine, Pediatrics, and Surgery
Richard A. Orr, MD
Departments of Critical Care Medicine and Pediatrics
R. Scott Watson, MD, MPH
Clinical Research and Systems Modeling of Acute Illness Laboratory
Departments of Critical Care Medicine and Pediatrics
University of Pittsburgh School of Medicine
Pittsburgh, PA 15261
To the Editor.—
We congratulate Yeager et al on their recently published report, "Pretransport and Posttransport Characteristics and Outcomes of Neonates Who Were Admitted to a Cardiac Intensive Care Unit."1 A study addressing the outcomes of infants requiring transport to a regionalized pediatric cardiac ICU (CICU) is long overdue. As the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery stated in their guidelines for pediatric cardiovascular centers, pediatric cardiovascular centers must be able provide the "diagnostic services and the full range of treatments, interventions, and surgeries needed to produce high-quality outcomes."2 We believe that the first step in this continuum of care is the safe and timely transport of out-born neonates to these tertiary care centers. Although transport of these infants is rather common, little is found in the literature regarding the safety and quality of care rendered by transport teams during these transfers.
As we read this report with much interest, several questions arose in terms of the cause of the suboptimal clinical and laboratory values in the out-born group, the authors' definition of "major transport complications," and the identification of those patients who were clinically unstable. First, 55 (45%) of the out-born infants had "suboptimal" values on arrival to the receiving CICU. This figure seems high. In addition to being related to the severity of cardiac disease (defined by the Risk Adjustment for Congenital Heart Surgery-1 [RACHS-1] score), can the authors estimate the degree to which these derangements were caused by poor transport care? Although they occurred in both the local and the longer-distance transports, surely not all suboptimal values were inevitable. Were suboptimal values associated with the use of nonpediatric specialty care teams? More importantly, was there an increased mortality rate found in the transported infants who arrived with "out-of-range" clinical parameters when compare to those who did not?
The group also reported no major transport complications in this article. However, they describe 2 patients who were not intubated and had arterial saturation (SpO2) of <50% on arrival to the CICU, problems classified as metabolic deterioration but not unplanned transport events. Both of these patients had normal saturation levels before leaving the outlying facility. We would consider profound hypoxemia to be very much an unplanned transport event, especially in 2 nonintubated patients. If hypoxia of this level is present, should it not be treated, even in infants with congenital heart disease? Clearly, situations such as these are reflective of the team's performance and not only the patient's underlying severity of illness.
Finally, we would be very interested in knowing more about the degree of physiologic instability of the cohort. The RACHS-1 score, which categorizes lesion complexity and risk of repair, nicely illustrated that locally born infants suffer from more complex cardiac lesions when compared with out-born infants. However, the RACHS-1 score does not incorporate any physiologic variables, which makes it difficult to assess the degree to which adverse events in the transported patients were related to underlying disease, overall clinical status, or management during transport. For example, did any of the patients have hypotension, evidence of poor cardiac output (eg, decreased urine output, prolonged capillary refill time), or seizures (all of which have been associated with mortality in the newborn population3) before or during transport? Reporting the physiologic data would help us to assess and design interventions needed to improve the interfacility transport of critically ill infants with congenital heart disease
As the pediatric interfacility transport setting becomes a growing area of research interest, we must ensure that we define major transport complications consistently and control as much as possible for severity of illness. By using standard variables and quantifying mortality risk, those who practice in the area of transport medicine will be able to accurately evaluate and meet quality-of-care benchmarks while achieving the best-practice outcomes in children with congenital heart disease.
REFERENCES
- Yeager SB, Horbar JD, Greco KM, Duff J, Thiagarajan RR. Pretransport and posttrasnport characteristics and outcomes of neonates who were admitted to a cardiac intensive care unit.
Pediatrics. 2006;118
:1070
–1077
[Abstract/Free Full Text] - American Academy of Pediatrics, Section on Cardiology and Cardiac Surgery. Guidelines for pediatric cardiovascular centers.
Pediatrics. 2002;109
:544
–549
[Abstract/Free Full Text] - Richardson DK, Corcoran JD, Escobar G, Lee SK; Canadian NICU Network; Kaiser Permanente Neonatal Minimum Data Set Wide Area Network; SNAP-II Study Group. SNAP-II and SNAPPE-II: simplified newborn illness severity and mortality risk score. J Pediatr. 2001;138 :92 –100[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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