Developing an Evidence - Informed Pediatric Retrieval System for Alberta

As medical care in developed countries has become increasingly specialized, health care resources by necessity have become more regionalized. The assessment and management of critical illness and injury in infants and children require specialized training and experience. To improve patient care and outcomes, specialized pediatric transport teams are commonly used to transfer critically ill or injured children from community hospitals to tertiary care hospitals. The goal of pediatric critical care (PCC) transport is to not only transport patients from community hospitals to tertiary care centers, but do so while providing patient care as close as possible to what would be provided in a Pediatric Intensive Care Unit (PICU). Communities in Alberta are scattered over a large geographic area. Critically ill or injured children are transferred to one of Alberta’s two children’s hospitals (Stollery Children’s Hospital (SCH) in Edmonton, or Alberta Children’s Hospital in Calgary) to receive specialized care. Over the last two decades, a hospital-based PCC transport team in SCH has functioned as the principal provider of inter-hospital transport of critically ill or injured infants and children for Northern Alberta as well as for the Western Arctic. This thesis project aimed: to better understand the unique aspects of PCC transport programs across Canada by characterizing the current workforce of each transport program; to characterize PCC transport activity in Northern Alberta and in the Western Arctic to explore the effect of adult intensive care services/specialties provided at referral hospitals and their association with patient outcomes; to examine the effect of physician non-accompanying PCC transport on patient outcomes; to identify factors that are currently being considered with regards to transport team composition when deploying the PICU transport team; and to explore the impact of patient transport itself on the outcomes of critically ill or injured children. First, in our national survey of PCC transport services, we revealed complexity and variability in transport team demographics, volumes, team compositions, decision-making processes, and quality assurance when comparing programs. Our study also found that many regions in Canada remain under-serviced by PCC transport teams. Second, we made several findings with respect to the currently operating PCC transport system in Northern Alberta and the Western Arctic, such as a low PICU admission rate following transports, an increasing trend in number and distance of transports, an increase in dispatch time over the period studied, significant monthly variations in transport activities, and an expansion in the areas/communities supported by the SCH PCC transport program. We also found that availability of adult intensive care services in referral hospitals might be associated with a higher probability of requiring PICU admission after inter-hospital transport; however, the difference was not consistent among the referral hospitals, suggesting that certain hospital-level factors might affect the likelihood of requiring PICU admission. Third, we found no difference in patient outcomes associated with the increasing use of a physician non-accompanying transport team in our current pediatric retrieval system. An appreciable variation was observed among triage physicians with respect to their team selection (i.e., either sending physician accompanying team or not). Although we did not examine how the triage decision by each physician affected outcomes, our findings suggest the need for a standardized approach to transport triage practice. Finally, we found that children admitted to a PICU who were transported from another hospital by a PCC transport team had higher mortality in the acute phase when compared to children presenting directly to a pediatric emergency department in a tertiary children’s hospital that required PICU admission. It was unclear whether worse outcomes stemmed from the specific patient population presenting to the rural sites, the care provided prior to the arrival of the PCC transport team, and/or the care provided by the PCC transport teams themselves; the existing disparity and its cause need to be further examined by future study.

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