AJN, American Journal of Nursing:
Experienced pediatric and neonatal nurses can improve outcomes for children in transit.
Andrew B. Loehr is director of transport clinical services at Children's Mercy Hospitals and Clinics, Kansas City, MO. Patricia R. Messmer is a nursing education and research consultant for the Miami Dade College School of Nursing, Miami, FL. Contact author: Andrew B. Loehr, firstname.lastname@example.org. The authors have disclosed no potential conflicts of interest, financial or otherwise.
An adult emergency medical services (EMS) team transports a 22-month-old child from a hospital to a pediatric facility two and a half hours away. The child has an initial diagnosis of dehydration and tachycardia, so she's given two normal saline boluses en route. Due to the nature of the diagnosis, the medics don't call to update clinicians at the receiving institution of any changes in assessment.
Upon arrival, the child is admitted directly to the inpatient unit and found to have supraventricular tachycardia, with a heart rate of 220 beats per minute. The patient immediately receives cardioversion and is transferred to the pediatric ICU.
Many members of adult EMS transport teams lack the experience and training to identify the subtle changes that indicate a deteriorating condition in a pediatric patient. They typically haven't had experience caring for this vulnerable population, and aren't necessarily trained in pediatric advanced life support or pediatric and neonatal airway management.
Despite the fact that the patient described above was on a cardiac monitor, the medics failed to recognize that a heart rate of more than 180 beats per minute with little variability could indicate supraventricular tachycardia, which, in a child this age, can lead to heart failure and thus requires immediate intervention. Members of a pediatric and neonatal specialty transport team, by contrast, would have likely recognized this and attempted early, noninvasive cardioversion maneuvers. Studies show that improved survival rates and fewer unexpected events are linked to the use of these specialty teams, which are generally associated with dedicated pediatric and neonatal tertiary care centers.
Whereas an adult EMS transport team tends to consist of a paramedic and emergency medical technician, a specialty transport team might include two RNs and either a paramedic or a respiratory therapist. The latter can be a significant asset, because a majority of pediatric ailments—asthma, respiratory syncytial virus, bronchiolitis, and croup, for example—are respiratory related. Specialty team members typically have years of extensive training in pediatric and neonatal critical care and only transport children. Most acquire advanced training and certification.
Most EMS teams consult with referring, adult-focused physicians only when needed, but pediatric and neonatal specialty teams work closely with pediatric intensivists and neonatologists at the receiving facility while in transit. These physicians provide assistance and make recommendations to the referring physician before the specialty team arrives and remain in contact with the crew throughout the trip.
Specialized teams carry equipment unique to their purpose, such as inhaled gas therapy—heliox, inhaled nitric oxide, and nitrogen—that can be lifesaving. Their ambulances include specialized restraint systems designed for infants and children, as well as toys and DVD players that can provide much-needed distraction. These crew members are more likely than their adult EMS team colleagues to know when distraction might be just as effective as pain medication.
A significant shift in practice should be made to better utilize pediatric and neonatal specialty teams. Referring providers need to be aware of the presence of these teams in their area and should learn how to enlist their help. Although every sick child doesn't require a specialized transport team, all children should be transported by caregivers who are comfortable with and able to care for them.