EMS Pediatric Transport Safety and Secondary Transport

Issues of Concern

Secondary and Interfacility Transport

Patients inadequately triaged in the prehospital setting may require secondary transport, including in-field escalation to a higher level of EMS care or a subsequent transport to the definitive destination when the initial facility defers or requests bypass. Interfacility transport is transport after initial evaluation and stabilization at the initial receiving facility, followed by identification of the need for a higher level of care, specialist services, or additional medical capabilities. Interfacility transport may involve an EMS agency that has not previously managed the patient.

Potential Risks of Secondary and Interfacility Transport

Each patient transport undertaken by an EMS agency carries inherent risks to both the patient and EMS providers. Risks include transport-related accidents, injury to patients and EMS providers, and patient deterioration en route without immediately available personnel or equipment.

Secondary and interfacility transport may involve a different EMS agency, which can increase patient risk. Additional risks include medical errors stemming from unfamiliarity with the patient’s clinical history and prior care. Secondary and interfacility transport generally carries a higher risk compared with a single EMS transport due to the cumulative burden of repeated transfers.

Most EMS providers possess adequate training and experience to triage prehospital patients accurately, although pediatric populations may present additional challenges. Optimal outcomes depend on appropriate triage at the initial prehospital encounter to determine the most suitable destination facility, thereby reducing the need for secondary or interfacility transport.

Factors Impacting Emergency Medical Services Pediatric Transport Decision-Making

Attempts to identify circumstances and medical conditions that influence direct EMS transport of pediatric patients to pediatric specialty or critical care centers have been described in the literature.[9] These circumstances and conditions span a wide range and may influence on-scene EMS transport decisions, as well as overall transport outcomes. The Pediatric Assessment Triangle (PAT) is a reliable and accurate decision-making tool that assists EMS providers in determining the appropriateness and necessity of direct transport of pediatric patients to tertiary pediatric centers.[10] EMS transport directly from the emergency scene to a tertiary pediatric center may be warranted in nearly all instances involving the factors described in the following sections.

Apparent life-threatening events 

In pediatrics, a brief resolved unexplained event (BRUE), formerly termed "apparent life-threatening event," may predict the need for specialty or critical care, particularly when associated with the following 3 significant risk factors: facial and body cyanosis, more than 1 BRUE within 24 hours, or a history of resuscitation attempts. Pediatric patients presenting to EMS with a BRUE should be transported to a tertiary pediatric center, unless immediate stabilization is required at the nearest emergency department. In some regions, transport to a tertiary-level facility aligns with standard EMS practice for suspected BRUE, reinforcing EMS providers' knowledge, experience, and training in pediatric triage and potentially reducing the need for secondary or interfacility transport.[11]

Seizures

Seizures, particularly in younger children and infants, have been identified as a significant risk factor for subsequent need for specialty or critical care. Three key risk factors in pediatric patients with seizures have been identified: a history of developmental delay, active seizures at the time of EMS arrival, and administration of midazolam by EMS. Unless immediate stabilization is required at the nearest available emergency department, pediatric patients presenting to EMS with seizures should, in most cases, be transported to a tertiary pediatric center.

Isolated orthopedic injury

Patients with isolated orthopedic injuries requiring secondary transport frequently present with obvious deformity on initial in-field EMS assessment and are more commonly of younger age. Specific anatomic injury sites associated with increased likelihood of secondary transport include humeral supracondylar or condyle fractures and elbow dislocations. Secondary transport for isolated orthopedic injuries depends on regional variation in general orthopedic capabilities and the availability of pediatric orthopedic services.

Secondary transport for definitive orthopedic management in pediatric patients with isolated orthopedic injuries may delay time to definitive intervention.[12] Pediatric patients with isolated orthopedic injuries who require secondary transport to an appropriately capable pediatric care center are more likely to undergo repeat imaging, which increases exposure to ionizing radiation and may elevate the risk of adverse outcomes associated with unnecessary imaging.[13]

Asthma or respiratory distress

Patients with respiratory distress who have 2 significant risk factors have an increased likelihood of requiring specialty care—EMS administration of oxygen regardless of oxygen saturation level and EMS administration of a combination of albuterol and ipratropium bromide via nebulizer, rather than albuterol alone. Prehospital oxygen administration in the absence of hypoxia suggests oxygen delivery is driven by increased work of breathing rather than hypoxemia. Reduced likelihood of secondary transport among patients receiving albuterol-only nebulizer treatments further suggests that prehospital providers may identify patients with asthma or respiratory distress who do not require a higher level of care. Among patients with pneumonia, altered mental status and chest retractions are significant predictors of critical illness.[14][15][16] 

Cases involving children with special healthcare needs 

Children with special healthcare needs demonstrate disproportionately high rates of EMS utilization. Increased EMS utilization increases the likelihood of secondary and interfacility transport requirements.

The Dangers of Secondary and Interfacility Transport

Secondary and interfacility transport expose patients to multiple risks. Both transport types are associated with delays in definitive care and the inherent risk of motor vehicle collisions during transit to the final destination. Interfacility transport has also been associated with patient harm, including suboptimal care or undertreatment of pediatric illness at local hospitals prior to transfer to a higher level of care.

Additional studies identify increased morbidity among patients in the pediatric intensive care unit (PICU) who undergo interfacility transport, including higher rates of mechanical ventilation and longer length of stay. A portion of the increased morbidity has been attributed to adverse events occurring during transport. Pediatric patients evaluated at 2 emergency departments may undergo repeat laboratory and radiographic testing, resulting in increased exposure to ionizing radiation. Secondary transport and interfacility transfer also increase the number of handoffs between care teams, which may heighten the risk of adverse patient outcomes.[17]

Prehospital and Hospital Predictive Scoring Tools

Researchers have evaluated specific variables and predictive models to reduce preventable harms associated with secondary and interfacility transport and to help identify pediatric patients requiring specialty or critical care.[18] Vital signs, physiologic markers, and scoring systems derived from such data are not consistently accurate or reliable predictors, although further research and development of EBGs remain necessary.[19]

A meta-analysis examining capillary refill time found the measure to be specific but not sensitive for critical illness. Scoring systems, such as the Pediatric Risk of Admission Score (PRISA) and Transport Risk Assessment in Pediatrics (TRAP), demonstrated only fair predictive value for hospital and PICU admission, respectively. In addition, the Pediatric Risk of Admission Score and the modified transport pediatric early warning score (TPEWS) showed poor interrater reliability between transport teams' and referring hospital assessments, indicating potential inconsistency in prehospital application.

While the quantitative criteria discussed above do not consistently predict the need for pediatric specialty care or critical care, qualitative criteria demonstrate greater predictive value. The PAT is an accurate “from the door” prehospital assessment tool that can predict subsequent hospital admission. The PAT has also been applied accurately by paramedics in the field, with high interrater reliability between paramedics and hospital staff.

Algorithms that combine qualitative assessments with physiologic data have demonstrated accurate prediction of PICU admission in patients with respiratory distress. Any parameters, EBGs, or assessment tools used to guide EMS destination decisions must account for the practical constraints of the prehospital environment.

In addition to the PAT, a triage scale that integrates vital signs with qualitative assessments has demonstrated good interrater reliability between prehospital personnel and emergency department staff. Evidence also supports the use of algorithmic tools that incorporate both quantitative and qualitative data into transport decision-making, helping EMS providers select appropriate triage decisions and destination facilities for pediatric patients.[20]

Clinical Significance

Numerous patient conditions have been identified that increase the risk of secondary and interfacility transport. These conditions include BRUEs, seizures, respiratory distress, isolated orthopedic injuries (particularly involving the upper arm and elbow), and situations involving children with special healthcare needs. Each of these conditions is often accurately assessed by prehospital providers.

Secondary and interfacility transport carry inherent risks related to the transport process itself, suboptimal care or undertreatment prior to arrival at the definitive care facility, and delays in receiving definitive care. Numerous predictive models have been evaluated to identify pediatric patients requiring specialized or comprehensive care. Among available tools, the PAT is the only model demonstrating both accuracy and interrater reliability.

The development and prospective validation of pediatric prehospital destination EBGs are warranted to minimize unintended harms associated with secondary and interfacility transport. Such guidelines should incorporate the PAT, high-risk clinical conditions, and qualitative assessment components.