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Emergency Medicine Australasia (2014) 26, 596–601

doi: 10.1111/1742-6723.12311

PAEDIATRIC EMERGENCY MEDICINE

Management of retrieval service patients within a paediatric emergency department Sarah L ANDREWS,1 Stuart LEWENA,1,2 Felix OBERENDER,4,5 Franz E BABL,1,2,6 Adam WEST3 and Sandy M HOPPER1,2 1 Emergency Department, Royal Children’s Hospital, Melbourne, Victoria, Australia, 2Murdoch Children’s Research Institute, Melbourne, Victoria, Australia, 3Emergency Department, Monash Health, Melbourne, Victoria, Australia, 4Paediatric Emergency Transport Service, Royal Children’s Hospital, Melbourne, Victoria, Australia, 5Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia, and 6The University of Melbourne, Melbourne, Victoria, Australia

Abstract Objective: The Victorian Paediatric Emergency Transport Service (PETS) transports critically unwell children to tertiary paediatric hospitals. Children not directly admitted to ICU go to a tertiary ED. These patients might require prolonged and high-level care. In light of the National Emergency Access Target, we describe this cohort, clinical care needs and process measures. Methods: A retrospective chart review of patients retrieved by PETS to the Royal Children’s Hospital (Melbourne, Australia) ED in 2012. Demographics, illness parameters and process measures were extracted. The ED length of stay (LOS) and time to ward suitability (time at which physiological parameters stabilised and high acuity treatments ceased) were related to patient and illness characteristics. Data are presented descriptively and analysed using spss. Results: In 2012, 120 patients were transported to the ED. Conditions included lower respiratory (44), neurological (28), upper respiratory (16) and trauma (14). The median ED LOS was 4.8 h (interquartile range 2.9, 7.7). On

arrival, 73 (60.8%) were wardsuitable, but 51 (43%) had LOS less than 4 h. Twenty-five (20.8%) patients stayed longer than 8 h. Administrative delay (principally bed block) is responsible for the bulk of the LOS; however, 25 (20.8%) had markedly abnormal vital signs after 4 h of ED care, mainly patients with lower respiratory tract disease. Conclusion: Most patients retrieved to the ED ultimately go to a ward rather than ICU and most have an ED stay in excess of National Emergency Access Target. Several retrieval associated care issues, such as timely and appropriate ward disposition, can be addressed by administrative changes. Key words: critical care, emergency service, length of stay, paediatrics, patient transfer.

Introduction In Victoria, the Paediatric Emergency Transport Service (PETS) transports critically unwell children to tertiary paediatric hospitals. The ED is the primary destination for children who do not require ICU,

Correspondence: Dr Sandy M Hopper, Emergency Department, Royal Children’s Hospital, 50 Flemington Road, Parkville, VIC 3055, Australia. Email: sandy.hopper @rch.org.au Sarah L Andrews, MBBS, Registrar; Stuart Lewena, MBBS (Hons), BMedSci, FRACP, Paediatric Emergency Physician; Felix Oberender, MRCPCH, PhD, FCICM, Paediatric Intensive Care Specialist, Retrieval Consultant; Franz E Babl, MD, MPH, FRACP, Paediatric Emergency Physician, Associate Professor; Adam West, MBBS, DRANZCOG, FACEM, Director Paediatric Emergency; Sandy M Hopper, MBBS, FRACP, FACEM, Paediatric Emergency Physician. Accepted 8 September 2014

Key findings • Retrieved paediatric patients have prolonged emergency department length of stay. • This is due to access block rather than clinical instability. • Patients with lower respiratory tract disease tend to be slow to improve. rather than direct admission to a general ward or high-dependency unit (HDU) as has been reported in adult services. Published literature is sparse on the impact and outcomes of paediatric retrieval patients transported to tertiary hospital EDs. Retrieval literature has focused on the management of retrieval patients before arrival in the tertiary institutions by establishing reference times for retrieval services,1,2 investigating causes of transfer delays,3 predictors of the need for intensive care admission4 and ICU management of retrieval patients.5 Prolonged length of stay (LOS) and paediatric ED overcrowding have been recognised as having a deleterious effect on patient care.6,7 In light of the recently introduced National Emergency Access Target (NEAT), which mandates a maximum ED LOS of 4 h for an increasing proportion of patients,8 it is important to identify areas for improvement around retrieval patients given their potential for prolonged stay and high intensity medical care in the ED. We present a cohort of retrieved patients who were transported to a tertiary ED rather than directly admitted

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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to an ICU. The research question of the present study was whether retrieved children have a prolonged LOS in the ED and to what extent administrative or clinical factors contribute. In particular, we set out to identify retrieval patients who might have a predictably prolonged LOS because of the level of care required.

Methods Design and setting This retrospective chart review study was performed at The Royal Children’s Hospital (RCH), Melbourne, Australia. RCH is one of two tertiary paediatric referral hospitals for the state of Victoria and is the designated paediatric trauma centre for Victoria. The ED 2012 census was 77 700 presentations with a 22% admission rate. In 2012, RCH treated 34 784 inpatients.9 RCH has 320 beds of which 19 are ICU beds. There is no discrete stand-alone HDU facility at RCH, rather HDU beds are scattered throughout the general wards and are managed by each inpatient unit rather than centrally. The PETS is based at RCH. PETS retrieves unwell children from hospitals in the state of Victoria and transports them to either RCH or Monash Health. More severely unwell patients go to ICUs; less unwell patients are transported to the EDs. This decision is made unilaterally by PETS. Currently at RCH, there are no direct admissions to general wards for non-elective cases: all acute transfers present to the ED for reception and assessment and to a variable degree clerking and documentation. The PETS team currently does not routinely contact the prospective admitting team as a part of the retrieval process, unless there is a need for time-critical management required on arrival to RCH. For example, neurosurgery would be contacted in advance for a neurosurgical emergency. The inclusion criteria were all PETS transfers to RCH ED over calendar year 2012. Patients were excluded if the notes were unavailable. Patient data were obtained from the PETS database that contains routinely collected retrieval data including demographic details and transfer location.

Study process Electronic scanned medical records were the primary source of information, including the PETS retrieval document, ED clinical notes, observation charts, medication charts and progress notes. Using a standardised abstraction form, age, sex, diagnosis, ward admission location and various time points (PETS arrival, ED arrival time and ward transfer) were recorded. The principal investigator (SLA) performed the record review, with quality control obtained by an independent investigator extracting the data from 10% random patient’s files to ensure 80% concordance with the primary investigator’s results.10 The referring hospital location was grouped into metropolitan A, metropolitan B, non-metropolitan A and non-metropolitan B. Metropolitan A and non-metropolitan A have inpatient paediatric capabilities, whereas metropolitan B and non-metropolitan B do not. Hospitals are classed as being metropolitan if they are within metropolitan Melbourne, whereas nonmetropolitan are hospitals within Victoria yet are outside metropolitan Melbourne.

Outcomes The primary outcome measure was the ED LOS with a key cut-off of 4 h (to relate to NEAT targets). Secondary outcomes included a number of clinical (abnormal vital signs and high acuity treatments) and administrative factors. Other post-ED secondary outcomes were MET activation on the ward, transfer to ICU and death.

Definitions ‘Administrative delays’ refers to the delays encountered in a ward bed becoming available to transfer ED patients to. This includes delays in a bed being requested and access/bed block: that a staffed ward bed is unavailable. ‘Ward-suitable’ was defined as the time at which the patient was clinically ready for the ward. This occurred when (i) there were normal vital signs and (ii) the patient was not

receiving high acuity treatment. This definition aims to separate clinical factors from administrative factors. • Vital signs: The RCH observation chart contains shaded zones that indicate marked vital sign abnormality (greater than 95th centile for age) and trigger a Medical Emergency Team (MET) response for patients on a ward.11,12 Transgression of these vital signs is defined as a marker for severe disease and precludes a child from transfer from ED to a ward bed. • High acuity treatments that cannot be delivered on a general ward: By RCH high-dependency guidelines, these treatments exceed the clinical caregiving capacity of a standard ward bed: respiratory support, such as intubation and ventilation; non-invasive ventilation; intravenous magnesium sulphate and/or aminophylline for asthma (not solely IV steroids); more than one adrenaline nebulisation for croup; circulatory support including ongoing fluid resuscitation (>20 ml/kg); use of inotropes or intravenous cardioactive medication; infusions requiring high intensity monitoring (e.g. calcium and concentrated potassium); and ongoing intravenous antiepileptic medications.

Analysis Data were entered into Excel (2007, Microsoft, Redmond, WA, USA) and analysed using spss statistics (version 22.0, IBM, Armonk, New York, NY, USA). Data were presented descriptively. Key percentages are presented with 95% confidence intervals; continuous data are presented with medians and interquartile ranges (IQRs). Pearson’s χ 2 was used to compare groups, and Mann–Whitney (rank sum) tests were used to compare non-parametric continuous variables. The RCH ethics committee approved this project. Patient consent was not required.

Results In 2012, PETS retrieved 437 patients, with 272 (62.2%) transported to RCH and 165 (37.8%) to Monash Health. Of the RCH patients, 152 (55.9%)

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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TABLE 1.

SL ANDREWS ET AL.

Length of stay related to clinical and outcome factors

Demographics Age, years Median (IQR) Sex (male) Disease Cardiovascular Trauma Miscellaneous Neurological Lower respiratory Upper respiratory Origin hospital Metropolitan A Metropolitan B Non-metropolitan A Non-metropolitan B Destination Home PICU Ward Ward (SSU) Severity factors MET breaches pre-hospital‡ MET breaches in ED High acuity treatment in ED PICU from ED MET call on ward in 24 h PICU within 24 h from ward Time factors Not ward-suitable on arrival Not ward-suitable by 3 h Not ward-suitable by 4 h Never ward-suitable Time from arrival to ward-suitable†, median (IQR) (h) Time from ward-suitable to ward†, median (IQR) (h)

Total, n (%)

ED length of stay >4 h, n = 69

ED length of stay 4 h LOS >8 h LOS, median (IQR) (h) LOS >4 h LOS >8 h

Total, n = 120

Ward-suitable by 4 h, n = 95

Not ward-suitable by 4 h, n = 25

Result

2.6 (0.9, 5.0) 72 (60.0)

1.9 (0.7, 4.8) 58 (61.1)

3.6 (2.6, 5.3) 14 (56.0)

NS NS

7 14 11 28 44 16

(5.8) (11.7) (9.2) (23.3) (36.7) (13.3)

7 12 9 22 31 14

(7.4) (12.6) (9.5) (23.2) (32.6) (14.7)

0 2 2 6 13 2

(0) (8.0) (8.0) (24.0) (52.0) (8.0)

NS

49 10 29 32

(40.8) (8.3) (24.2) (26.7)

37 8 25 25

(38.9) (8.4) (26.3) (26.3)

12 2 4 7

(48.0) (8.0) (16) (28)

NS

5 9 82 24

(4.2) (7.5) (68.3) (20.0)

5 3 67 20

(5.3) (3.2) (70.5) (21.1)

0 6 15 4

(0.0) (24.0) (60.0) (16.0)

NS

43 (36.8) 47 (39.2)

29 (31.5) 22 (23.2)

14 (56) 25 (100)

51 27 4.8 51 27

40 20 4.8 40 20

11 7 4.3 11 7

(42.5) (22.5) (2.9, 7.7) (42.5) (22.5)

(42.1) (21.1) (3.0, 7.4) (42.1) (21.1)

(44) (28) (2.5, 10.1) (44) (28)

0.033 0.0001 NS NS NS NS NS

†n = 117, three missing values. For other definitions, see footnote of Table 1.

4 h and over a fifth longer than 8 h. The study attempts to analyse the components of an ED stay and factors that influence this. The PETS/ED cohort was not directly matched to a non-PETS/ED cohort for comparison. To give an indication of LOS times in RCH ED, there was a median of 5.2 h (IQR 3.7, 7.2) in 2012 for category 2 and 3 presentations (not just PETS transfers) (personal communication, Tony Stratford, decision support, RCH). Both of these cohorts have LOS that breached the NEAT target. There are several process factors that make the PETS cohort different from the standard ED presentations. The PETS patients routinely receive a triage category of 1, 2 or 3, are seen rapidly, their diagnosis is usually known and the need for a bed is established several

hours before arrival. As such, there are opportunities for expedited care in retrieved patients that do not exist for undifferentiated newly arrived patients. This in part forms a rationale for the present study. Administrative delays, rather than clinical factors, are the dominant factors. We suggest that access block, rather than clinical assessment and documentation, is the major factor. Bed block and overcrowding are common to all EDs and public hospitals. The major difference in the PETS cohort is that the need for a bed is known several hours before arrival in comparison with general ED patients. The data call for improvement in coordination and bed management before arrival. We have identified a group of children, with lower respiratory tract infections (asthma, bronchiolitis and

pneumonia), who remain unwell despite aggressive treatment at the referring hospital and via the retrieval team. They can be predicted to remain unwell and so suffer delays in ward suitability. Children with these diagnoses require careful coordination as to the suitable ward destination, with receiving hospital processes in mind: our findings suggest direct transfer to a high-dependency bed should be the default destination in these circumstances. The greater proportion of this cohort had normal observations on arrival (65%), with that number increasing to 71.2% by the 4-h mark. Only a small percentage required high acuity treatment or transfer to intensive care (7.5%), and only 2.5% went on to have MET calls on the ward. As this cohort appears to have been relatively clinically stable in ED, the

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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question as to the role of ED care is raised (and for that matter, even the indication for transfer to a tertiary centre). The possibility of direct ward admissions for a selected group of patients deserves consideration. This would of course require a robust reception and assessment service in the general wards, especially after-hours when general ward medical staffing drops by 80%. If direct admission is not possible due to staffing issues on the wards, a process could be developed to streamline PETS patients who are ward-suitable on arrival after initial rapid assessment by ED staff. Regardless, as EDs have skilled staffing around the clock and have critical care capacity, ED might continue to be an attractive de facto HDU for these more complicated patients, in addition to the holding bay role it currently undertakes.

Conclusion

Limitations

Author contributions

The current RCH ED information system does not record ‘ward-suitable’ time, and so we used a combination of documented clinical factors to determine ward suitability: there might be undocumented yet valid reasons for delay. The issues with bed access are also inferred from the study. It was rarely documented in the notes whether the delay was due to bed block or whether there was other clinical management occurring that was not recorded. This is a single institution study, with a relatively small number of patients. We relied on local rules of MET criteria and ward suitability criteria, and these might not be generalisable. Medical charts are not designed to be research tools, and therefore the interpretation of the patient’s clinical picture based remains limited. The determination of ward suitability is a multifaceted decision that has been inferred from numbers on an observation chart and clinical notes rather than direct observation and without attention to the broader context of the ED, ICU and hospital at large. The study also described discrete points in time, which by nature do not reflect the dynamic nature of an acute paediatric illness.

All authors contributed to the design and methodology. SLA abstracted the data. SMH performed the analysis. SLA and SMH wrote the initial draft. All authors contributed to modification and editing towards the final draft. SLA takes responsibility for the paper as a whole.

Many retrieval patients have prolonged ED LOS. Administrative factors (most likely access block) rather than clinical need are the dominant factors, and many patients do not appear to require any ED-specific treatment. Nevertheless, patients with slow-toimprove asthma and bronchiolitis tend to stay longer and require longer periods of ED-based high acuity treatment. This information can be used to improve pre-arrival coordination and refine destination decision-making.

Acknowledgements The investigators acknowledge Ms Eleanor J Angley for performing the quality control, Mr Andrew Kerekes BBSc (Hons) for database analysis and Ms Shradha Balia for maintenance of the PETS database.

Competing interests None declared.

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4. Freishtat RJ, Klein BL, Teach SJ et al. Admission predictor modeling in pediatric interhospital transport. Pediatr. Emerg. Care 2004; 20: 443– 7. 5. Odetola FO, Clark SJ, Gurney JG, Dechert RE, Shanley TP, Freed GL. Effect of interhospital transfer on resource utilization and outcomes at a tertiary pediatric intensive care unit. J. Crit. Care 2009; 24: 379–86. 6. Bekmezian A, Chung PJ. Boarding admitted children in the emergency department impacts inpatient outcomes. Pediatr. Emerg. Care 2012; 28: 236–42. 7. Sills MR, Fairclough D, Ranade D, Kahn MG. Emergency department crowding is associated with decreased quality of care for children. Pediatr. Emerg. Care 2011; 27: 837–45. 8. Council of Australian Governments. National Health Reform Agreement – National Partnership Agreement on Improving Public Hospital Services. Internet 2011. [Cited May 2014.] Available from URL: http:// www.federalfinancialrelations.gov.au/ content/npa/health_reform/national -workforce-reform/national _partnership.pdf 9. Royal Children’s Hospital. About The Royal Children’s Hospital. Victoria, Australia: The Royal Children’s Hospital, 2013 [Website] [updated 2 November 2013]. [Cited Nov 2013.] Available from URL: http://www .rch.org.au/rch/about/ 10. Gilbert EH, Lowenstein SR, Koziol-McLain J, Barta DC, Steiner J. Chart reviews in emergency medicine research: where are the methods? Ann. Emerg. Med. 1996; 27: 305–8. 11. Royal Children’s Hospital. Clinical Practice Guidelines: MET Criteria. Victoria, Australia: The Royal Children’s Hospital, 2014 [Webpage]. [Cited March 2013.] Available from URL: http://www.rch.org.au/ clinicalguide/guideline_index/ MET_Criteria_Call_777_for_help/ 12. Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Arch. Dis. Child. 2005; 90: 1148–52.

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Management of retrieval service patients within a paediatric emergency department.

The Victorian Paediatric Emergency Transport Service (PETS) transports critically unwell children to tertiary paediatric hospitals. Children not direc...
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