Outcome of children transported for paediatric intensive care to a tertiary care setting in Sri Lanka

Introduction: Patient transport remains a necessary facet of today’s health care environment and transport conditions bear a major impact on the outcome. There is a recent move in Sri Lanka to establish retrieval teams. Thus, identifying problems faced by the present system will be of utmost importance in development of transport teams. Objective: To evaluate the present system of transportation of sick children to the Medical Intensive Care Unit (MICU), Lady Ridgeway Hospital for Children (LRH), Colombo. Method: A prospective, descriptive, observational study of transferred patients was conducted at the MICU LRH, Colombo. All children admitted to MICU from 1 March 2014 to 1 June 2014 were included in the study. Data was collected using a selfadministered questionnaire. The Wilcoxon significant rank test and the Chi squared test were utilized in statistical analysis. Results: There were 200 patients comprising 105 (52.5%) out-of-hospital transfers and 95 (47.5%) inhospital transfers. Of the admissions, 72% were live discharges while 28% expired; 42.5% of transfers were from the Colombo district. Pneumonia was the ___________________________________________ Senior Registrar in Paediatric Intensive Care, Lady Ridgeway Hospital for Children, Colombo, Consultant Paediatric Intensivist, Medical Officer, Consultant Paediatrician, Medical Intensive Care Unit, Lady Ridgeway Hospital for Children, Colombo, Lecturer, Faculty of Medicine, University of Kelaniya *Correspondence: deshan80520@gmail.com (Received on 28 July 2015: Accepted after revision on 18 September 2015) The authors declare that there are no conflicts of interest Personal funding was used for this project. Open Access Article published under the Creative Commons Attribution CC-BY License. commonest diagnosis, occurring in 38.5%. The pretransfer Paediatric Risk Mortality (PRISM) scores had a median of 12, mean of 13.7±7.8 and Q1-8 to Q3-18. The 12 hour PRISM scores, after excluding patients with PRISM scores of less than 5, showed a median of 14, mean of 18.5±11.7 and a ‘p’ value 0.0002. There was no outcome difference between inhospital vs out-of-hospital transfers based on the Chi squared test. A written summary was available only in 61 (30.5%) patients. Conclusion: A rise in the PRISM score after transfer indicates that the patients had deteriorated during the transfer and transfer conditions need to be improved. DOI: http://dx.doi.org/10.4038/sljch.v45i2.7998 (


Introduction
Patient transport remains a necessary facet of today's healthcare environment.However, adverse events are common during transport and increased transport time is associated with adverse outcome 1 .There are standard practices before, during and after transport to minimize these adverse effects.In this study we assessed the adherence to standard practices during transportation of sick children 2 .Scoring systems in paediatric intensive care units are used to measure illness severity, assess therapeutic requirements and determine prognosis.The PRISM score 111 is an improved version of the PRISM score developed at the Children's National Medical Centre in Washington DC.It has been validated in several studies done worldwide. .Using 17 variables the PRISM score 111 is used to assess the disease severity prior to transfer and after transfer 3,4 .If transfer conditions are ideal the scores should be equal or should have improved at the receiving end.Thus it would reflect the transfer conditions.The outcomes of these children were also evaluated.

Objectives
General Objective Evaluate the present system of transport of sick children to MICU LRH, Colombo.This meant that the PRISM score had improved after the transfer.Therefore a re-analysis was done after excluding those patients with pre transfer PRISM scores of less than 5.This analysis showed a median of 14, mean of 18.5±11.7 and a p=0.0002.This means that the patient's clinical conditions had deteriorated during transfer.Thus the transfer conditions of patients should be improved.There was also no outcome difference between in-hospital vs out-of-hospital transfers based on the Chi squared test.There were no significant differences between the pre-transfer PRISM scores of in-hospital vs. outof-hospital transfers (p=0.5153)nor were there significant differences between the outcome of inhospital vs out-of-hospital transfers.
An analysis was carried out to assess the standard practices of gaining intravenous access, blood pressure documentation, patient catheterization, capillary blood sugar check, endotracheal tube size and depth specification, post intubation chest X-ray and documentation of a clear patient summary in inhospital vs out-of-hospital transfers.There were no significant differences except in the case of documentation (p= 0.0003).A large proportion (79%) of in-hospital transfers did not have a written summary and 60% of out-of-hospitals transfers did not have a written summary.

Discussion
The MICU, LRH caters to patients from the entire island but mostly covers the Western Province.The commonest cause of MICU admission was childhood pneumonia which emphasizes the need for thorough medical management of pneumonia as well as immunization of children in order to reduce the incidence and prevalence of childhood pneumonia.
Our study showed that 16% of medical officers who accompany critically ill patients lack the knowledge and skills of endotracheal intubation and management of cardiac arrest.This is a significant problem.Thus it is important to arrange in-service training programmes in order to improve these skills and test them regularly to prevent them being lost.

Table 1 : Reasons for MICU admissions (n=200)
Pneumonia was the commonest principal diagnosis occurring in 77 (38.5%).The reasons for MICU admission are shown in Table 1.
stMarch 2014 to 1 st June 2014 were included in the study.Children above 12 years and those who were transferred for routine procedures (plasmapheresis, central venous line insertion) were excluded from the study.A data collection sheet was used to obtain information regarding the condition on arrival and from the Colombo district.Transfers from the districts of Gampaha, Kalutara, Kandy and Puttalam were 26 (13%), 16 (8%), 14 (7%) and 13 (6.5%)respectively.Out of the 200 transfers 162 (81%) patients were accompanied by middle grade medical officers and 38 (19%) by house officers.In 163 (81.5%) transfers, the accompanying medical officer was able to intubate, while 37 (18.5 %) did not have the ability.One hundred and sixty five (82.5%) accompanying medical officers knew the correct dose of adrenaline in cardiac arrest while 35 (17.5%) did not know it.The route of administration of adrenaline in a cardiac arrest was correctly known by 166

Table 2 :
Problems during Transfer 5udewa et al showed that there were significant deficiencies in information provided in the transfer forms of the patients transferred to LRH5.It is imperative to provide accurate data about the transferred patients to optimize the care at the receiving hospital.Limitations of our study include the sample size, single centre design, lack of inclusion of paediatric trauma victims and paediatric cardiac (post-surgical) patients.National guidelines on stabilization and transport of the critically ill child should be developed and all medical professionals should have an in-service training on emergency management at regular intervals in their career Conclusions 1. Medical officer's competence of managing cardiac arrest and intubation is substantially low.2. A rise of the median PRISM score indicates that the patients had deteriorated during the transfer and that the transfer conditions need to be improved.3. 172 (86%) had problems during transfer indicating that pre-transfer stabilization was inadequate.4. Stabilizing of the critically ill child with attention to the airway, breathing and circulation prior to transfer was significantly low.