Pediatric emergency medicine trisk 80
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referring facility. This online “medical control” or “medical command” model
enables clinicians to direct care after assessments are transmitted to them.
Typically, after the transport team makes contact with the patient and completes
an assessment, the team contacts the medical command physician to review the
management plan and prepare for the transport back to the accepting institution.
At that time, additional clinical information may be reviewed between the team
and the medical command physician. Additionally, electronically transmitted
data, such as ECGs, and transferred images, including plain radiographs and CTs
may be reviewed and discussed real time. Online medical command may be
particularly important in tertiary and quaternary care patient populations, where
patients may require unique interventions (e.g., patients with complex congenital
heart disease, or metabolic disorders). Potential drawbacks include additional
reporting time spent at the referring institution (can be mitigated by on
communications en route), time demands on the receiving medical staff directing
care, potential decision-making inconsistency within variable medical control
staff, and technical problems with the communications equipment. Accomplished
efficiently and appropriately, however, direct online communications (in
conjunction with off-line training, guidelines, and protocols) can help support the
primary goals of interfacility transport, including stabilization, improvement, and
seamless transition to next stage of care via improved awareness (by the most
experienced clinicians) of current state, response (or not) to interventions, and
preparation of needs at next stage/location of care.
Indirect Medical Control
Indirect medical control includes the medical management of a transport system
through the use of established care guidelines in place before the call for help
arrives. The medical director for a service, who is ultimately responsible for every
aspect of patient care, authorizes the personnel to utilize standard protocols for
the care of patients in order to save time and reduce the variability of orders. This
has the benefit of saving time in critical situations, as well as reducing
interoperator variability in patient assessment and medical decision making. In
most systems, the option remains for personnel to speak with a clinician for direct
medical control, if they have questions, or if the protocol does not clearly apply.
This may also be necessary for certain procedures or medications considered to
be higher risk to the patient. In EMS, the protocols may be established by the
regional or state EMS authority, while in interfacility transport, these are
determined by the transporting service, often in conjunction with physician
content experts. Medical control physicians should be literate with transport
guidelines, protocols, personnel capabilities, medications, and equipment to be
able to add the most value in an efficient manner during the transport process.
Interfacility transport teams often use a combination of care guidelines, orders,
and protocols (indirect control), with review by predetermined medical control
physicians (direct control) at various points of the transport assessment and care.
FIGURE 11.6 A–C: Transfer of patient during transport process. Patient transfer between
vehicles or stretchers can be risky to the patient. Tube, line, oxygen, or medication
disconnection or disruption, as well as shifts in immobilization, must be avoided. (A, C: Used
with permission, © The Children’s Hospital of Philadelphia, Philadelphia, PA; B: From
Hahnemann University Hospital, University MedEvac, Philadelphia, PA, with permission.)
PEDIATRIC TRANSPORT TEAM STRUCTURE AND
LOGISTICS
There are several common models of pediatric transport teams across the country.
Dedicated pediatric transport teams are often freestanding teams whose primary
responsibility is to transport patients. These teams do not take on direct patient
care assignments, though often assist throughout the hospital during their “downtime.” Many dedicated teams transport both neonatal as well as “pediatric”
patients, though some teams are exclusively “neonatal or pediatric.” Another
model is the “unit-based” team. These teams mobilize team members from
clinical units when a transport request is made. For example, a NICU nurse is
pulled from a patient assignment to go retrieve a patient for the NICU. Finally,
there are some programs that utilize hybrid models of the above.
Many types of providers can function effectively as part of a pediatric transport
team. Nurses, advanced practice providers (NP, PA), respiratory therapists, EMTs,
paramedics, and physicians serve on various transport teams. In general, the
personnel chosen for the transport team should have experience in the care of
critically ill infants and/or children, and be competent in the transport
environment. Excellent bedside clinicians may be less effective in the transport
environment if they do not know where to find resources in the ambulance or
helicopter, how to turn on the oxygen or suction. Additionally, motion sickness
impairs the clinician’s ability to optimally care for the patient. The team may not
be ideal if one of the providers is limited in ability to perform specific patient care
tasks, such as medication administration and delivery. Finally, while the transport
environment is a tremendous place to learn patient care in austere settings, space
constraints often limit the addition of additional learners.
The primary mission of the team must be kept in mind when selecting
personnel and planning training. For example, a team devoted to neonatal
transport should consider team members with experience in the care of critically
ill neonates, whereas teams that also perform transports from nonhospital
locations may want to employ personnel with prehospital care experience. Teams
that have more broad-based missions, such as those that transport both neonates
and older children, should attempt to recruit team members from varied hospital
areas, including the NICU, PICU, CICU, and emergency department. **By
necessity, such teams have to devote considerable time to the medical crosstraining of staff members. However, having team members from varied
