Dear Sir
Orr et al convincingly demonstrate that the rate of unplanned adverse
events and hospital mortality were much higher when non-specialised
transport teams transferred patients into their tertiary care centre (1).
Although it represents a single centre’s experience, theirs is the first
study to demonstrate how a specialist paediatric transport team (SPTT) has
the potential to improve important patient outcomes.
As a busy regionalised paediatric intensive care transport service
based in London, our own clinical experience leads us to support the
authors’ conclusions. However, we are surprised by the high mortality
reported in the group transported by the non-specialist team – hospital
mortality for SPTT patients was 9% whereas nearly a quarter of the 64
patients transported by non-specialist teams died. In comparison, we
examined data from a tertiary care PICU to which we transport patients and
found that crude mortality for children transported by an SPTT and non-
specialised team were 9% and 12.3% respectively – PICU deaths represent
>90% of the total deaths in the hospital (2). Despite the authors’
attempts to minimise bias and the use of risk adjustment, significant
differences between the groups were inevitable because the transport team
was chosen by a non-random process; more patients with cardiac and
neurological diagnoses were transported by non-specialist teams, a greater
proportion required at least 1 major intervention, and they had higher pre
-ICU PRISM scores. Some of these features may represent patients at high
risk of hospital mortality despite adjustment for physiological status at
initial referral (3). The pre-ICU PRISM score does not take into account
‘lethal’ diagnoses such as neurodegenerative disease or complex
uncorrected cardiac disease such as those used in the Paediatric Index of
Mortality score (PIM-2) for mortality risk prediction (4). Pre-ICU PRISM
has also been shown to be a poor predictor of unplanned adverse events and
the need for major interventions during transport (5). In addition, the
pre-ICU PRISM score was derived and validated from data collected from
PICU admissions, and its predictive value for other hospital admissions is
not clear (6). It is possible that in children perceived to be ‘high-
risk’, referring hospitals sought immediate transfer using non-specialist
teams when an SPTT was unavailable, but for respiratory and other patient
groups, they may have opted to wait until an SPTT became available.
Additional information may help clarify these questions. Firstly, Orr et
al may wish to compare the mortality for all children transferred by non-
specialist teams, irrespective of whether they were referred to the SPTT
or not, and compare the two subgroups. If the authors’ conclusions are
true, an adverse effect on survival should be seen in both groups.
Secondly, information on how many children were admitted to PICU and other
hospital wards within each group, and their respective outcomes, may be
useful. Data on team mobilisation times and refusals by SPTT classified by
diagnostic group could also be provided.
We were also interested to note that despite having the same command
physician for SPTT and non-specialised team transfers, the rate of
unplanned adverse events during transport were much more frequent in the
latter group. Do the authors feel that the physician providing medical
control is unable to influence the course of transport once the team is
mobilised, especially a non-specialist team? Can some unplanned adverse
events be anticipated or prevented by closer monitoring of the team’s
activity, either by telephone or in the future by telemedicine systems?
Our practice is to have mandatory telephone discussions between the
transport team and the supervising transport intensivist at a minimum of 3
time points during the transfer – at initial referral, on arrival at the
local hospital, and before leaving the local hospital. The impact of this
practice has not been formally measured, although our experience indicates
that alterations to patient management occur frequently following these
discussions, especially with relatively inexperienced teams. Clarification
of these points would allow readers to confidently extrapolate the study
findings to their own settings.
(1) Orr RA, Felmet KA, Han Y, McCloskey KA, Dragotta MA, Bills DM,
Kuch BA, Watson RS. Pediatric specialized transport teams are associated
with improved outcomes. Pediatrics. 2009 Jul;124(1):40-8.
(2) Ramnarayan P, Craig F, Petros A, Pierce C. Characteristics of
deaths occurring in hospitalised children: changing trends. J Med Ethics.
2007 May;33(5):255-60.
(3) Leteurtre S, Martinot A, Duhamel A, Proulx F, Grandbastien B,
Cotting J, Gottesman R, Joffe A, Pfenninger J, Hubert P, Lacroix J,
Leclerc F. Validation of the paediatric logistic organ dysfunction (PELOD)
score: prospective, observational, multicentre study. Lancet. 2003 Jul
19;362(9379):192-7.
(4) Slater A, Shann F, Pearson G; Paediatric Index of Mortality (PIM)
Study Group. PIM2: a revised version of the Paediatric Index of Mortality.
Intensive Care Med. 2003 Feb;29(2):278-85. Epub 2003 Jan 23.
(5) Orr RA, Venkataraman ST, Cinoman MI, Hogue BL, Singleton CA,
McCloskey KA. Pretransport Pediatric Risk of Mortality (PRISM) score
underestimates the requirement for intensive care or major interventions
during interhospital transport. Crit Care Med. 1994 Jan;22(1):101-7.
(6) Kanter RK, Edge WE, Caldwell CR, Nocera MA, Orr RA. Pediatric
mortality probability estimated from pre-ICU severity of illness.
Pediatrics. 1997 Jan;99(1):59-63
Conflict of Interest:
None declared
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