Prehospital triage should match patient needs with hospital service availability. For emergency medical services (EMS), hospital destination choices are guided by patient condition, transport times, jurisdictional resources, local hospital capabilities, and patient/family preference. Evidence-based guidelines (EBG) have been developed to aid EMS destination choices for adult patients suffering from trauma, myocardial infarction, and stroke. However, analogous guidelines do not exist for any pediatric condition other than trauma.
Regionalization of care has concentrated pediatric specialty/critical care services, magnifying the consequences of the destination decisions of EMS and increasing rates of interfacility transport (IFT) and secondary transport. Studies have identified several specific medical conditions that frequently necessitate secondary or interfacility transport. Additionally, preventable patient harms due to secondary and interfacility transport have been identified. To avoid such harms, and better serve the definitive care needs of the estimated 1.8 million children transported by EMS annually in the USA, EBG development should be explored for pediatric conditions beyond trauma.
The most salient literature attempts to identify the circumstances/medical conditions which justify direct transport by EMS to pediatric specialty/critical care centers. That literature identifies a wide variety of circumstances/conditions:
Apparent Life-Threatening Events (ALTEs)
ALTEs with three significant risk factors were predictive of the need for specialty/critical care: facial and body cyanosis, more than one ALTE in 24 hours, or history of resuscitation attempt.
Seizures, particularly in younger children or infants, with three significant risk factors were identified as significant risk factors for specialty/critical care needs: history of developmental delay, active seizures at the time of EMS arrival, and/or EMS administration of midazolam.
Isolated Orthopedic Injury
Patients with isolated orthopedic injuries that necessitated secondary transport frequently had an obvious deformity on EMS’s initial assessment and were more likely to be younger. Specific anatomic injury sites that likely required secondary transport included: humeral supracondylar fractures, humeral condyle fractures, or elbow dislocations. It is noted that secondary transport for isolated orthopedic injuries is dependent upon regional variation in general orthopedic capability and pediatric orthopedic availability.
Patients with respiratory distress with two significant risk factors were at increased likelihood of requiring specialty care: EMS provider administration of oxygen regardless of the patients’ oxygen saturation level, and EMS administration of a combination of albuterol and ipratropium bromide nebulizer treatments, as opposed to albuterol alone. Prehospital oxygen administration in the absence of hypoxia suggests oxygen administration was administered for work of breathing rather than hypoxia. The decreased likelihood of secondary transport for patients receiving albuterol only nebulizer treatments further suggests prehospital providers may be able to identify asthma/respiratory distress patients who do not require a higher level of care.
Children with Special Health Care Needs (CSHCN)
CSHCN are noted to have disproportionately high rates of EMS usage and IFT, suggesting higher incidences of secondary transport.
The Dangers of Secondary and Interfacility Transport
Secondary transport and IFT patients are exposed to a multitude of risks . Both forms of transport are associated with delays in definitive care and the inherent risk of motor vehicle collisions while en route to the final destination. Studies also associate IFT with other patient harms, such as suboptimal care or undertreatment of pediatric illness at local hospitals prior to IFT. Other studies identify increased morbidity in pediatric intensive care unit (PICU) patients who underwent IFT, including higher mechanical ventilation rates and longer length-of-stay. Part of the excess morbidity was attributed to adverse events during the actual transport. Additionally, children who are cared for at two separate emergency departments may undergo repeat laboratory and radiographic tests, the latter of which increases exposure to ionizing radiation.
Prehospital and Hospital Predictive Scoring Tools
To avert those harms, researchers have tested specific variables and predictive models to determine which pediatric patients require specialty/critical care or IFT. Surprisingly, vital signs, physiologic markers, and scoring systems derived from those data do not function as accurate or reliable predictors. For example, a meta-analysis examining capillary refill time found it was a specific, but not sensitive marker for critical illness. Scoring systems such as the Pediatric Risk of Admission Score (PRISA) and Transport Risk Assessment in Pediatrics (TRAP) had only fair predictive value for hospital or PICU admission, respectively. Furthermore, PRISA and a modified pediatric early warning score (T-PEWS) showed poor interrater reliability between transport team and referring hospital scores, suggesting potential inconsistent application in the prehospital setting.
While the above-discussed quantitative criteria do not alone reliably predict the need for pediatric specialty/critical care, qualitative criteria have improved predictive value. The Pediatric Assessment Triangle (PAT) is an accurate “from the door” prehospital assessment tool that can also predict subsequent hospital admission. The PAT was also accurately used by paramedics in the field with high interrater reliability between paramedic and hospital staff. For pneumonia patients, altered mental status and chest retractions significantly predict critical illness. Algorithms combining qualitative assessments with physiologic data accurately predict PICU admission for patients with respiratory distress. Any potential EBG for EMS destination choices must mind the practical constraints of the prehospital environment. In addition to the PAT, a triage scale combining vital signs and qualitative assessments demonstrated good interrater reliability between prehospital and emergency department personnel.
Numerous patient conditions have been identified that predispose patients to an increased risk of secondary and interfacility transport. These conditions include ALTEs, seizures, respiratory distress, isolated orthopedic injuries (particularly of the upper arm and elbow), as well as children with special health care needs. Significantly, all these conditions can be accurately assessed by prehospital providers. There are inherent risks to secondary transport and IFT relating to the transportation itself, sub-optimal care or under-treatment before arriving at the site of definitive care as well as a prolonged wait for definitive care. In an effort to predict which children will need specialized or comprehensive care, numerous predictive models have been tested. However, the only model that has been shown to be both accurate and maintain interrater reliability is the Pediatric Assessment Triangle (PAT). In the future to minimize the frequency of a potentially harmful IFT and/or secondary transport, pediatric prehospital destination EBGs should be developed and prospectively validated, incorporating the PAT, high-risk conditions, and qualitative assessments.
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