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Objective: To evaluate the safety and practicality of using advanced neonatal nurse practitioners (ANNPs) to lead acute neonatal transfers.

Design: Comparison of transport times, transport interventions, and physiological variables, covering the first four complete years of operating a transport service that uses ANNPs and specialist paediatric registrars (SpRs) interchangeably.

Setting: Tertiary neonatal transport service.

Patients: The first 51 transfers of sick infants under 28 days of age by an ANNP led transport team into Nottingham compared with the next consecutive SpR led transfer after each ANNP led one.

Main outcome measures: Transport times; interventions and support given during stabilisation for transfer and during transfer; condition on completion of transfer, assessed from blood glucose, systolic blood pressure, pH, oxygenation, and temperature.

Results: The ANNP led team responded more rapidly to requests for transfer and took longer to stabilise babies. The groups undertook similar numbers of procedures during stabilisation, and there were no differences in the ventilatory and other support that infants needed in transit. The infants transferred by the doctor led group had worse values for pH (doctor led, 7.31 (6.50–7.46); ANNP led, 7.35 (7.04–7.50), p = 0.02) and PaO2 (doctor led, 6.7 (2.4–13.1); ANNP led, 8.7 (3.5–17.0); p = 0.008) before transfer (all values median (range)). Comparisons of the infant's condition before and after transfer showed a significant improvement in temperature for the infants transferred by ANNP led teams (36.8°C (34.0–37.8) v 37.0°C (34.6–38.0), p = 0.001) and in oxygen saturation (96% (88–100) v 98% (92–100), p = 0.01). There were no differences between the ANNP and doctor led groups in the values obtained for any variable after transfer.

Conclusions: Clinical condition on completion of transport is similar for babies transferred by ANNP and doctor led teams. ANNP led transport appears to be practical and safe.

OBJECTIVE--To evaluate the morbidity and severity of illness during interhospital transfer of critically ill children by a specialised paediatric retrieval team. DESIGN--Prospective, descriptive study. SETTING--Hospitals without paediatric intensive care facilities in and around the London area, and a paediatric intensive care unit at a tertiary centre. SUBJECTS--51 critically ill children transferred to the paediatric intensive care unit. MAIN OUTCOME MEASURES--Adverse events related to equipment and physiological deterioration during transfer. Paediatric risk of mortality score before and after retrieval. Therapeutic intervention score before and after arrival of retrieval team. RESULTS--Two (4%) patients had preventable physiological deterioration during transport. There were no adverse events related to equipment. Severity of illness decreased during stabilisation and transport by the retrieval team, suggested by the difference between risk of mortality scores before and after retrieval (P < 0.001). The median (range) difference between the two scores was 3.0 (-6 to 17). Interventions during stabilisation by the retrieval team increased, demonstrated by the difference between intervention scores before and after retrieval, median (range) difference between the two scores being 6 (-8 to 38) (P < 0.001). CONCLUSIONS--Our study indicates that a specialised paediatric retrieval team can rapidly deliver intensive care to critically ill children awaiting transfer. Such children can be transferred to a paediatric intensive care unit with minimal morbidity and mortality related to transport. There was no deterioration in the clinical condition of most patients during transfer.

Background

congenital and acquired airway anomalies represent a relatively common albeit challenging problem in a national tertiary care hospital. In the past, most of these patients were sent to foreign Centres because of the lack of local experience in reconstructive surgery of the paediatric airway. In 2009, a dedicated team was established at our Institute. Gaslini's Tracheal Team includes different professionals, namely anaesthetists, intensive care specialists, neonatologists, pulmonologists, radiologists, and ENT, paediatric, and cardiovascular surgeons. The aim of this project was to provide these multidisciplinary patients, at any time, with intensive care, radiological investigations, diagnostic and operative endoscopy, reconstructive surgery, ECMO or cardiopulmonary bypass. Aim of this study is to present the results of the first year of airway reconstructive surgery activity of the Tracheal Team.

Methods

between September 2009 and December 2010, 97 patients were evaluated or treated by our Gaslini Tracheal Team. Most of them were evaluated by both rigid and flexible endoscopy. In this study we included 8 patients who underwent reconstructive surgery of the airways. Four of them were referred to our centre or previously treated surgically or endoscopically without success in other Centres.

Results

Eight patients required 9 surgical procedures on the airway: 4 cricotracheal resections, 2 laryngotracheoplasties, 1 tracheal resection, 1 repair of laryngeal cleft and 1 foreign body removal with cardiopulmonary bypass through anterior tracheal opening. Moreover, in 1 case secondary aortopexy was performed. All patients achieved finally good results, but two of them required two surgeries and most required endoscopic manoeuvres after surgery. The most complex cases were the ones who had already been previously treated.

Conclusions

The treatment of paediatric airway anomalies requires a dedicated multidisciplinary approach and a single tertiary care Centre providing rapid access to endoscopic and surgical manoeuvres on upper and lower airways and the possibility to start immediately cardiopulmonary bypass or ECMO.

The preliminary experience of the Tracheal Team shows that good results can be obtained with this multidisciplinary approach in the treatment of complicated cases. The centralization of all the cases in one or few national Centres should be considered.

OBJECTIVE--To describe the demographic and haemodynamic variables of children presenting with primary pulmonary hypertension or pulmonary hypertension appearing or persisting after surgical correction of congenital heart defects and to assess the acute effect of vasodilator drugs on their pulmonary vascular bed. DESIGN--Retrospective review. SETTING--Paediatric cardiology department and intensive care unit of a large tertiary centre. PATIENTS--Fourteen consecutive patients presenting with primary pulmonary hypertension (group 1) or pulmonary hypertension persisting or appearing late after complete surgical repair (group 2). INTERVENTION--Baseline haemodynamic measurements were taken in room air at rest and repeated in 100% oxygen. With constant monitoring of heart rate and pulmonary and systemic arterial pressures, patients were given serial intravenous, sublingual, or oral incremental doses of vasodilators (mean 4.1 trials per patient). The maximum effect of the drug was charted. MAIN OUTCOME MEASURES--A positive response to acute vasodilator tests was defined as a decrease in mean pulmonary or mean systemic arterial pressure > 15% with the mean pulmonary artery pressure not reaching the systemic level and either no change or an increase in mean systemic arterial pressure. Haemodynamic variables between groups (1 v 2, responders v non-responders, patients experiencing or not experiencing adverse effects to vasodilators) were compared by a two tailed unpaired Student's t test, and their survival curves were compared by the log rank statistic. RESULTS--Groups are small and definitive conclusions are difficult to draw, but the baseline haemodynamic assessments were not significantly different between group 1 and 2 or between responders and non-responders to vasodilators. Patients experiencing adverse effects had a higher pulmonary vascular resistance (p = 0.04) and wedge pressure (p = 0.02) than those without adverse effects. Of the vasodilators used, tolazoline, hydralazine, salbutamol, phentolamine, and phenoxybenzamine were ineffective. A positive response was seen in five of 13 patients given oxygen, in one of eight given prostacyclin, four of 12 given nifedipine, four of eight given diltiazem, one of six given captopril, and two of seven given glyceryl trinitrate. Estimates of survival of the population with primary pulmonary hypertension were 37% at one year and 12% at 2.5 years. Survival was significantly shorter in the non-responders than in the responders (p = 0.005). CONCLUSION--Children with primary pulmonary hypertension present to the cardiologist at a young age (five of eight were younger than 7 years) but with advanced pulmonary vascular disease and have a poor prognosis. 64% of group 1 and group 2 patients had a positive response to acute treatment with at least one vasodilator. Calcium channel blockers were the most effective agents. There was a positive response to drugs despite a negative response to acute treatment with oxygen. The survival of non-responders was shorter than that of the responders.

Objective

To review the initial impact on mortality of infants with congenital heart disease of a new surgical technique that is now taken for granted.

Design

Retrospective cohort study.

Setting

A tertiary paediatric cardiology centre.

Subjects

325 consecutive neonates with simple transposition of the great arteries admitted before, during, and after the preferred management changed from the Senning operation to the arterial switch (1978-98); and 100 consecutive neonates requiring a different neonatal open heart operation that did not change in that period.

Main outcome measures

Mortality before and early after operation reconstructed sequentially as the series evolved and retrospectively once the series was complete; actuarial survival associated with the different treatment strategies.

Results

For both the transposition and the comparison group, early mortality in 1998 was lower than in 1978. During that period, however, there was a phase temporally related to the adoption of the switch operation in which early mortality for transposition increased. Actuarial survival of recent patients with “intention to treat” with arterial switch is superior to those with intention to treat with the Senning operation, as predicted when the switch operation was first adopted.

Conclusions

A period of increased hazard for individual patients may occur when a specialist community, a particular unit, and an individual surgeon are all learning a new technique concurrently. Obtaining informed consent during this time of uncertainty is helped by clarity about the objectives of treatment and availability of relevant local and international data.

OBJECTIVE--To identify the requirements of an interhospital transfer service for critically ill patients. DESIGN--Retrospective survey of the current functions of a specialist interhospital transfer team from data collected at the time of transfer and from records of intensive care unit. SETTING--Mobile intensive care unit based at a tertiary referral centre, which serves the west of Scotland. PATIENTS--All critically ill patients (378) transferred between hospitals by the unit from 1986 to 1988. RESULTS--365 Patients were transferred by road and 13 by air. There was a wide variation in age (range 6 weeks to 87 years), diagnosis, reason for transfer, support required, and distance travelled. Most patients (232) were transferred for respiratory or cardiovascular support; 100 were trauma cases. 300 Patients (79%) were mechanically ventilated during transfer. No patient died in transit, although the eventual mortality was 28% (105 patients). Mortality was significantly higher in patients transferred from hospitals with intensive care units than from those without (38% (125 patients) v 23% (253); p less than 0.005). IMPLICATIONS--Safe interhospital transfer of critically ill patients is feasible; the high eventual mortality in some patient groups emphasises the need for accurate prediction of outcome if inappropriate transfer is to be avoided. The findings may help in organising secondary transfer services in future.

Some achievements in the treatment of congenital heart defects are discussed. Special comments are made about the persistent ductus arteriosus, atrial septal defect, transposition of the great arteries and the Fontan operation. The differences and similarities between 'corrective' and 'palliative' operations are discussed. The history of the development of supraregional centres in England and Wales is described and the current situation outlined. The relationship between the number of operations performed and results is emphasised. Current and future training of paediatric cardiac surgeons is discussed and proposals made for the future organisation of care for children with congenital heart defects. The author speculates about how these problems will be solved in view of the decreasing number of children with congenital heart defects. Impact of treatment on the families of patients with congenital heart defects is also considered.

BACKGROUND:

Late transfer of children with critical illness from community hospitals undermines the advantages of community-based care. It was hypothesized that implementation of the Bedside Paediatric Early Warning System (Bedside PEWS) would reduce late transfers.

METHODS:

A prospective before-and-after study was performed in a community hospital 22-bed inpatient paediatric ward. The primary outcome, significant clinical deterioration, was a composite measure of circulatory and respiratory support before transfer. Secondary outcomes were stat calls and resuscitation team calls, paediatrician workload and perceptions of frontline staff.

RESULTS:

Care was evaluated for 842 patient-days before and 2350 patient-days after implementation. The median inpatient census was 13. Implementation of the Bedside PEWS was associated with fewer stat calls to paediatricians (22.6 versus 5.1 per 1000 patient-days; P<0.0001), fewer significant clinical deterioration events (2.4 versus 0.43 per 1000 patient-days; P=0.013), reduced apprehension when calling the physician and no change in paediatrician workload.

DISCUSSION:

Implementation of the Bedside PEWS is feasible and safe, and may improve clinical outcomes.

Objective

To assess the provisions made for the transfer of adolescents with juvenile idiopathic arthritis to adult rheumatology clinics in the UK and the impact of a transitional care programme.

Methods

An audit of the documentation of the provisions made for transfer in 10 centres participating in a controlled trial of transitional care. Each centre conducted a retrospective case note audit of the recent patients transferred to adult care before and 12–24 months after the start of the trial. Demographic details, age when transition was first discussed, age at transfer, transitional issues, multidisciplinary team involvement, adolescent self advocacy, and readiness were documented.

Results

There were improvements at follow up in documentation of transitional issues, disease specific educational needs, adolescent readiness, and parental needs with the exception of dental care, dietary calcium, and home exercise programmes. The age at which the concept of an independent clinic visit was introduced was lower (mean (SD): 16.8 (1.06) v 15.8 (1.46) years, p = 0.01) but there were no other changes in age related transitional milestones. Significantly more participants had preparatory visits to the adult clinic, had a transition plan, and had joint injections while awake at follow up.

Conclusions

The improvement in documentation suggests that involvement in the research project increased awareness of transitional issues. The difficulty of changing policy into practice was highlighted, with room for improvement, particularly at the paediatric/adult interface. The reasons for this are likely to be multiple, including resources and lack of specific training.

OBJECTIVE: To assess the current value of necropsy in paediatric cardiology and cardiothoracic surgery and determine its potential impact on clinical practice. DESIGN AND SETTING: Descriptive study of all paediatric cardiac deaths occurring over four years in a tertiary referral centre. Data were obtained from reviewing the hospital files, available necropsy records and specimens, and audit reports. PATIENTS: Paediatric patients with congenital or acquired heart disease, who died of a cardiac cause between January 1992 and July 1995. Inclusion criteria were that the diagnosis of heart disease was made before death, and that patients were managed thereafter medically and/or surgically at the referral centre. The value of necropsy was assessed according to its contribution in establishing the cause of death (confirmed, clarified, precise cause of death uncertain) and the anatomy (simple confirmation or additional information provided). For cases not submitted to necropsy the clinical information relating to the cause of death was assessed and the case assigned as cause of death firm, uncertain, or unknown. RESULTS: One hundred and six deaths were identified (61 males, age at death: one day to 20 years). Seventy occurred early (a month or less) after surgery and were graded as postoperative deaths. The rest were considered to be either medical or late surgical deaths. Necropsy was performed in 59 (55.6%). The precise cause of death was confirmed in 33 (55.9%), clarified in 22 (37.3%), and remained uncertain in four (7.8%). Additional information regarding the anatomy was found in eight (13.6%) cases. In five cases (8.5%) the necropsy detected findings which, if known before death, would probably have improved outcome. For the patients dying without a necropsy, the cause of death remained uncertain in 10 (21.3%) and unknown in seven (14.9%). In 36% of cases, therefore, a firm cause of death that might have been provided by a necropsy was missing. CONCLUSION: In paediatric cardiology necropsy continues to provide clinically relevant information at a high level. It remains vital for ensuring quality of medical care, in instigating improvements in future management, and increasing understanding of congenital heart disease. The procedure should therefore be sought actively in all cases.

Images

The most urgent recommendation expressed by physicians, Red Cross officials, ambulance operators and others polled in this ambulance survey was to make much more emergency medical care training available to ambulance personnel. Very few sick and injured receive first aid before an ambulance arrives. Therefore there is also an urgent need to train and motivate the public to provide first aid at the scene of the emergency. Urban ambulances usually respond within 10 minutes, but often rural ambulances take more than 30 minutes to reach an emergency. It is during this interim that lives which could be saved by prompt first aid are lost. Little use has been made of aircraft as emergency ambulances; in 1968, only one emergency trip in 1500 was made by helicopter. Also, California has fewer ambulances which make fewer emergency trips on a population basis than the country at large.

Communications at all levels need attention. Seventy-eight percent of the ambulance operations serving the public are not listed among the emergency numbers on the inside front page of telephone directories. Less than ten percent of ambulances have direct radio communication with hospitals.

In California most ambulance services are commercially operated and there are formidable financial problems which must be solved before these services can be brought into place as a part of the emergency medical care system.

BACKGROUND:

Tuberculosis (TB) is a major infection with nearly eight million cases annually worldwide. Although the majority of these cases are in the developing world, TB is also a problem in Canada.

OBJECTIVE:

To determine the cost of diagnosis and management of paediatric TB in Canada.

DESIGN:

Cross-sectional study.

SETTING:

In-patients and out-patients at The Hospital for Sick Children, Toronto, a tertiary care centre.

PATIENTS:

Patients were included if they had clinical or radiological evidence of TB infection with a positive tuberculin skin test or a positive culture result, and were treated from July 1, 1995, to June 30, 1996. Twenty-two patients met the criteria for inclusion in the study.

OUTCOME MEASURES:

Patient characteristics, types of disease, types and numbers of investigations, number of in-patient days and out-patient appointments, course of TB treatment, TB-related complications and antimicrobial resistance were obtained from charts. Costs were derived from allocated hospital costs, Ontario Health Insurance Plan billings and costs provided by the Pharmacy Department at The Hospital for Sick Children.

RESULTS:

The total cost for one year of management of paediatric TB in a tertiary care centre was $211,576. Pulmonary TB affected one-half of the study patients but accounted for one-quarter of the cost. One case of meningitis resulted in almost the same costs as all cases of pulmonary TB. Hospitalization was the largest contributor to overall cost, accounting for three-quarters of the total. The remaining costs in order of their contribution to overall costs were antimicrobial treatment, out-patient appointments, diagnostic imaging and TB cultures.

CONCLUSIONS:

From a hospital’s perspective, the costs of managing each of the 22 patients was approximately $10,000. However, there was great variability between patients, with much greater costs for those who required hospitalization or numerous investigations because TB was not suspected. To the authors’ knowledge, this is the first time that such a cost analysis has been performed for a paediatric population. A cost analysis provides a better measure of the burden of illness than is indicated by the absolute number of patients.

Background

Severe paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC.

Methods

Paediatric trauma patients over a two year period from the Sydney region with an Injury Severity Score (ISS) > 15 were retrospectively identified from a state wide trauma registry. Overall paediatric trauma system performance was assessed by comparisons of the availability of the physician staffed HEMS for patient characteristics, transport mode (direct versus indirect) and the times required for the patient to arrive at the paediatric trauma centre. The proportion of patients transported directly to a PTC was compared between the times that the HEMS service was available versus the time that it was unavailable to determine if the HEMS system altered the rate of direct transport to a PTC. Analysis of variance was used to compare the identifying systems for various patient characteristics when the HEMS was available.

Results

Ninety nine cases met the inclusion criteria, 44 when the HEMS system was operational. Patients identified for physician response by the HEMS system were significantly different to those that were not identified with higher median ISS (25 vs 18, p = 0.011), and shorter times to PTC (67 vs 261mins, p = 0.015) and length of intensive care unit stays (2 vs 0 days, p = 0.045). Of the 44 cases, 21 were not identified, 3 were identified by the paramedic system and 20 were identified by the HEMS system, (P < 0.001). Direct transport to a PTC was more likely to occur when the HEMS dispatch system was available (RR 1.81, 95% CI 1.20-2.73). The median time (minutes) to arrival at the PTC was shorter when HEMS available (HEMS available 92, IQR 50-261 versus HEMS unavailable 296, IQR 84-583, P < 0.01).

Conclusions

Physician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival.

Introduction

The timely provision of critical care to hospitalised patients at risk for cardiopulmonary arrest is contingent upon identification and referral by frontline providers. Current approaches require improvement. In a single-centre study, we developed the Bedside Paediatric Early Warning System (Bedside PEWS) score to identify patients at risk. The objective of this study was to validate the Bedside PEWS score in a large patient population at multiple hospitals.

Methods

We performed an international, multicentre, case-control study of children admitted to hospital inpatient units with no limitations on care. Case patients had experienced a clinical deterioration event involving either an immediate call to a resuscitation team or urgent admission to a paediatric intensive care unit. Control patients had no events. The scores ranged from 0 to 26 and were assessed in the 24 hours prior to the clinical deterioration event. Score performance was assessed using the area under the receiver operating characteristic (AUCROC) curve by comparison with the retrospective rating of nurses and the temporal progression of scores in case patients.

Results

A total of 2,074 patients were evaluated at 4 participating hospitals. The median (interquartile range) maximum Bedside PEWS scores for the 12 hours ending 1 hour before the clinical deterioration event were 8 (5 to 12) in case patients and 2 (1 to 4) in control patients (P < 0.0001). The AUCROC curve (95% confidence interval) was 0.87 (0.85 to 0.89). In case patients, mean scores were 5.3 at 20 to 24 hours and 8.4 at 0 to 4 hours before the event (P < 0.0001). The AUCROC curve (95% CI) of the retrospective nurse ratings was 0.83 (0.81 to 0.86). This was significantly lower than that of the Bedside PEWS score (P < 0.0001).

Conclusions

The Bedside PEWS score identified children at risk for cardiopulmonary arrest. Scores were elevated and continued to increase in the 24 hours before the clinical deterioration event. Prospective clinical evaluation is needed to determine whether this score will improve the quality of care and patient outcomes.

During two years, a rural ambulance helicopter programme saved 41 patients' lives. In 29 of these patients, the decisive medical interventions were carried out by the flight anaesthesiologist before reaching the hospital. We asked an expert panel to assess whether these interventions could have been carried out by a general practitioner (GP). This was the case for 17 (59%) of the 29 patients, while more advances skills, equipment or drugs were needed for 11 (38%). Among these 11, three patients would probably have died without the interventions. We conclude that GPs can manage a majority of life saving missions for a rural ambulance helicopter programme, but the lack of a flight anaesthesiologist may imply substantial health losses for a few patients.

A survey of Canadian hospitals providing obstetric care was undertaken to assess preparation, protocols, training and staff availability for neonatal resuscitation. Of the 721 hospitals contacted 577 (80%) responded. The reported availability of written guidelines for resuscitation varied greatly, depending on hospital size and proximity to a tertiary care centre. Many hospitals, especially those with 300 births or fewer annually, reported that they depend on family physicians or nurses to start and to continue neonatal resuscitation. Approximately one third of the hospitals had written guidelines for summoning personnel for additional help, and one third used a list of maternal or fetal indications for the presence of a physician specifically for the care of the infant at birth. Of 200 hospitals 138 (69%) had to summon additional medical help from outside the institution, 60% at all times. A neonatal resuscitation team in which members' roles were defined was established in 22% of the hospitals. Few hospitals held rehearsals for resuscitation. Nurses were permitted to perform intubation in 21 hospitals (4%), 7 of them in Alberta. National professional bodies should develop guidelines for training and skill maintenance, and hospitals should develop protocols for maintaining equipment and for neonatal resuscitation team activities, including regular practice. Training should be improved in family practice and obstetrics programs, and consideration should be given to training senior obstetric nurses and respiratory therapists in intubation of neonates.

Dilemmas about resuscitation and life-prolonging treatment for severely compromised infants have become increasingly complex as skills in neonatal care have developed. Quality of life and resource issues necessarily influence management. Our Institute of Medical Ethics working party, on whose behalf this paper is written, recognises that the ultimate responsibility for the final decision rests with the doctor in clinical charge of the infant. However, we advocate a team approach to decision-making, emphasising the important role of parents and nurses in the process. Assessing the relative burdens and benefits can be troubling, but doctors and parents need to retain a measure of discretion; legislation which would determine action in all cases is inappropriate. Caution should be exercised in involving committees in decision-making and, where they exist, their remit should remain to advise rather than to decide. Support for families who bear the consequences of their decisions is often inadequate, and facilitating access to such services is part of the wider responsibilities of the intensive care team. The authors believe that allowing death by withholding or withdrawing treatment is legitimate, where those closely involved in the care of the infant together deem the burdens to be unacceptable without compensating benefits for the infant. As part of the process accurate and careful recording is essential.

Background

This study assessed the feasibility, self-efficacy and cost of providing a high fidelity medical simulation experience in the difficult environment of an air ambulance helicopter.

Methods

Seven of 12 EM residents in their first postgraduate year participated in an EMS flight simulation as the flight physician. The simulation used the Laerdal SimMan™ to present a cardiac and a trauma case in an EMS helicopter while running at flight idle. Before and after the simulation, subjects completed visual analog scales and a semi-structured interview to measure their self-efficacy, i.e. comfort with their ability to treat patients in the helicopter, and recognition of obstacles to care in the helicopter environment. After all 12 residents had completed their first non-simulated flight as the flight physician; they were surveyed about self-assessed comfort and perceived value of the simulation. Continuous data were compared between pre- and post-simulation using a paired samples t-test, and between residents participating in the simulation and those who did not using an independent samples t-test. Categorical data were compared using Fisher's exact test. Cost data for the simulation experience were estimated by the investigators.

Results

The simulations functioned correctly 5 out of 7 times; suggesting some refinement is necessary. Cost data indicated a monetary cost of $440 and a time cost of 22 hours of skilled instructor time. The simulation and non-simulation groups were similar in their demographics and pre-hospital experiences. The simulation did not improve residents' self-assessed comfort prior to their first flight (p > 0.234), but did improve understanding of the obstacles to patient care in the helicopter (p = 0.029). Every resident undertaking the simulation agreed it was educational and it should be included in their training. Qualitative data suggested residents would benefit from high fidelity simulation in other environments, including ground transport and for running codes in hospital.

Conclusion

It is feasible to provide a high fidelity medical simulation experience in the difficult environment of the air ambulance helicopter, although further experience is necessary to eliminate practical problems. Simulation improves recognition of the challenges present and provides an important opportunity for training in challenging environments. However, use of simulation technology is expensive both in terms of monetary outlay and of personnel involvement. The benefits of this technology must be weighed against the cost for each institution.

Objective

To determine whether availability of neonatal intensive care cots is a problem in any or all parts of the United Kingdom.

Design

Three month census from 1 April to 30 June 1999 comprising simple data sheets on transfers out of tertiary units.

Setting

The 37 largest high risk perinatal centres in the United Kingdom.

Participants

One obstetric specialist and one neonatal specialist in each centre.

Main outcome measures

Suboptimal care resulting directly from pressure on service—that is, transfers out of tertiary units (either in utero or after delivery) because the unit was “full” and not because the hospital was incapable of providing the care needed.

Results

All units provided data. The number of intensive care cots in each unit was between five and 16. During the three months 309 transfers occurred (equivalent to 1236 per year), of which 264 were in utero and 45 postnatal. Sixty five in utero transfers involved multiple births, hence the census related to 382 babies (1528 per year). There was considerable regional variation. The reason for transfer in most cases was “lack of neonatal beds”.

Conclusions

Currently most major perinatal centres in the United Kingdom are regularly unable to meet in-house demand; this has implications for the service as a whole. The NHS has set no standards to help health authorities and primary care groups develop services relating to this specialty; such a step may well be an appropriate lever for change.

Background

Increasing the range and scope of early activation/auto launch helicopter emergency medical services (HEMS) may alleviate unnecessary injury mortality that disproportionately affects rural populations. To date, attempts to develop a quantitative framework for the optimal location of HEMS facilities have been absent.

Methods

Our analysis used five years of critical care data from tertiary health care facilities, spatial data on origin of transport and accurate road travel time catchments for tertiary centres. A location optimization model was developed to identify where the expansion of HEMS would cover the greatest population among those currently underserved. The protocol was developed using geographic information systems (GIS) to measure populations, distances and accessibility to services.

Results

Our model determined Royal Inland Hospital (RIH) was the optimal site for an expanded HEMS – based on denominator population, distance to services and historical usage patterns.

Conclusion

GIS based protocols for location of emergency medical resources can provide supportive evidence for allocation decisions – especially when resources are limited. In this study, we were able to demonstrate conclusively that a logical choice exists for location of additional HEMS. This protocol could be extended to location analysis for other emergency and health services.

Objective

The purpose of this study was to compare the outcomes of adult (aged > 15 yr) blunt trauma patients with an Injury Severity Score (ISS) ≥ 12 who were transported to a single tertiary trauma centre (TTC) by helicopter emergency medical service (HEMS) versus those transported by ground ambulance.

Methods

We retrospectively analyzed all adult (aged > 15 yr) trauma patients between March 27, 1998 and March 28, 2002 with an ISS score ≥ 12, as identified through the provincial trauma registry. We used the Trauma and Injury Severity Score (TRISS) methodology to determine a difference in outcomes between the 2 groups.

Results

We identified 823 patients; of these, we excluded 32 (3.9%) penetrating trauma patients. Of the blunt trauma cases (n = 791) 237 (30%) patients were transported by air and 554 were transported by ground (70%). A total of 770 (97.3%) patients were eligible for TRISS analysis. Using the TRISS methodology, the air group had a Z statistic of 2.77, yielding a W score of 6.40. This compared with the ground transport group, whose Z statistic was –1.97 and W score was –2.39.

Conclusion

The transport of trauma patients with an ISS ≥ 12 by a provincially dedicated rotor wing air medical service was associated with statistically significantly better outcomes than those transported by standard ground ambulance. This is the first large Canadian study to specifically compare the outcome of patients transported by ground with those transported by air.

The initial resuscitation and stabilization provided to a critically ill or injured child is often an important determinant of outcome. Before transfer to a tertiary care facility the initial care may be provided by physicians unaccustomed to managing critically ill children. The authors outline the unique aspects of resuscitation and stabilization of the critically ill child and give guidelines for the initial management of diseases affecting the central nervous system and respiratory tract (the most frequent indications for transfer to a tertiary care facility) and other, less frequent but important problems. In many situations it is worth while to enlist the expertise of the tertiary care centre, either by telephone consultation or by dispatch of a specially trained transport team.

Background

Ambulance personnel play an essential role in the ‘Chain of Survival’. The prognosis after out-of-hospital cardiac arrest was dismal on a rural Danish island and in this study we assessed the cardiopulmonary resuscitation performance of ambulance personnel on that island.

Methods

The Basic Life Support (BLS) and Automated External Defibrillator (AED) skills of the ambulance personnel were tested in a simulated cardiac arrest. Points were given according to a scoring sheet. One sample t test was used to analyze the deviation from optimal care according to the 2005 guidelines. After each assessment, individual feedback was given.

Results

On 3 consecutive days, we assessed the individual EMS teams responding to OHCA on the island. Overall, 70% of the maximal points were achieved. The hands-off ratio was 40%. Correct compression/ventilation ratio (30:2) was used by 80%. A mean compression depth of 40–50 mm was achieved by 55% and the mean compression depth was 42 mm (SD 7 mm). The mean compression rate was 123 per min (SD 15/min). The mean tidal volume was 746 ml (SD 221 ml). Only the mean tidal volume deviated significantly from the recommended (p = 0.01).

During the rhythm analysis, 65% did not perform any visual or verbal safety check.

Conclusion

The EMS providers achieved 70% of the maximal points. Tidal volumes were larger than recommended when mask ventilation was applied. Chest compression depth was optimally performed by 55% of the staff. Defibrillation safety checks were not performed in 65% of EMS providers.

The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation. The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff.

Trauma teams are a key component of most programmes which set out to improve trauma care. This article reviews the background of trauma teams, the evidence for benefit and potential techniques of performance assessment. The review was written after a PubMed, Ovid, Athens, Cochrane and guideline literature review of English language articles on trauma teams and their performance and hand searching of references from the relevant searched articles.

Aims: To determine the impact of a paediatric medical emergency team (MET) on cardiac arrest, mortality, and unplanned admission to intensive care in a paediatric tertiary care hospital.

Methods: Comparison of the retrospective incidence of cardiac arrest and death during 41 months before introduction of a MET service with the prospective incidence of these events during 12 months after its introduction. Comparison of transgression of MET call criteria in patients who arrested and died before and after introduction of MET.

Results: Cardiac arrest decreased from 20 among 104 780 admissions (0.19/1000) to 4 among 35 892 admissions (0.11/1000) (risk ratio 1.71, 95% CI 0.59 to 5.01), while death decreased from 13 (0.12/1000) to 2 (0.06/1000) during these periods (risk ratio 2.22, 95% CI 0.50 to 9.87). Unplanned admissions to intensive care increased from 20 (SD 6) to 24 (SD 9) per month. The incidence of transgression of MET call criteria in patients who arrested decreased from 17 to 0 (risk difference 0.16/1000, 95% CI 0.09 to 0.24), and in those who died, decreased from 12 to 0 (risk difference 0.11/1000, 95% CI 0.05 to 0.18) after introduction of MET.

Conclusions: Introduction of a medical emergency team service was coincident with a reduction of cardiac arrest and mortality and a slight increase in admissions to intensive care.