The transport of a critically ill child from the emergency department in a community hospital to a regional center is rarely a scheduled event. Nevertheless, the transfer should proceed in an orderly fashion if protocols exist within the emergency department for referral of critically ill children. These protocols should provide information about each regional center to which a patient might be referred, including (1) special services available; (2) criteria for referral; (3) telephone numbers for consultation, referral, and transport; (4) distance and usual response time; (5) type of transport personnel and their capabilities; (6) type of transport vehicles; and (7) protocols for preparation of patients. It is also advisable to establish formal agreements with regional centers that outline the circumstances under which patients can be transported without prior administrative approval.
Once the decision has been made to transport a child, the referring hospital has certain obligations in addition to medical care. 7 The Consolidated Omnibus Budget Reconciliation Acts of 1985 and 1989 mandate some of these responsibilities. The referring physician must contact the receiving hospital and secure a receiving physician. The choice of receiving institution is critical because the referring physician is liable for the adequacy of that facility.
In preparation for transport, the referring hospital should assemble all available information pertinent to the current illness. This generally includes a copy of the emergency department record, laboratory data, radiographs, and old medical records if available. The referring physician should inform the parents of the need for transfer and discuss the mechanism by which the child will be transferred. Consent to transport should be obtained from a parent or other responsible individual.
Receiving physicians often make recommendations regarding stabilization of the patient. This information should be requested if necessary. However, referring physicians are not obligated to follow these recommendations if they are considered to be medically inappropriate or beyond the capabilities of the referring hospital. Under these circumstances, it is advisable for the referring and receiving physicians to develop an alternative plan.
A collaborative decision must also be made regarding who will assume the responsibility for transporting the patient. There are usually four options: private automobile, local ambulance service, local ambulance with personnel from the referring hospital, or service provided by the receiving hospital. The selection should be based on the appropriate balance between the needs of the patient and the resources of each type of provider. Cost should be a consideration only when more than one provider can satisfy the patient's needs.
For most critically ill pediatric patients, ideal care is provided when the emergency department of the referring hospital devotes its energy to providing emergent short-term care and the responsibility for transport is left to the regional center. This is particularly true for neonatal patients because of the special equipment and expertise required for transport. It is rarely in the best interest of critically ill children to "pick them up and run." When transport services are not provided by the regional center or when time is critical, it may be appropriate for the referring hospital to provide transport. In these circumstances, it is the referring hospital's responsibility to ensure the adequacy of care during transport. The converse is true if transport is conducted by the receiving hospital.
In many areas, physicians also have a choice between air and ground transportation. Again, this decision should be made collaboratively. 8 Air transport should be reserved for situations in which reduction of a critical period of time during transport is likely to reduce morbidity or mortality. In some emergencies, the critical period ends with the arrival of the receiving hospital's transport team because the team is able to administer a definitive intervention. Under these circumstances, the advantage of air compared to ground transport is directly related to the reduction in time between the referral and the arrival of the team at the referring hospital. Air transport may offer the greatest advantage when the definitive therapy is available only in the receiving hospital (e.g., a surgical procedure) because the patient benefits from the reduction in transit time for the round trip between the receiving and referring hospitals.
When the transport team arrives, the referring physician should be present to coordinate the transition of care. Under most circumstances, a transport team originating from a hospital other than the referring hospital does not receive a detailed history of the patient's illness prior to arrival. It is essential that the referring physician be available to provide this history and a brief review of recent events. In addition to the referring physician, one or two support personnel should also be available to aid the transport team with further stabilization.
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