A retrospective review of the transfer of critically ill children to tertiary care in KwaZulu-Natal, South Africa

Abstract

Background.Obtaining care for an acutely ill child in specialised paediatric services relies on referral from lower-level facilities. In South Africa, it is common practice for acutely ill children to be transported far distances by non-specialist teams with limited equipment, knowledge and skills. Objectives. To describe the transfer of these children and to determine whether they deteriorate from the time of referral to the time of arrival at a tertiary centre. Furthermore, we sought to identify modifiable factors that might improve outcomes during resuscitation and transfer. Methods. The study was a retrospective review of emergency referrals of children aged 1 month -12 years to Grey's Hospital paediatric ward or paediatric intensive care unit (PICU), from lower-level facilities in KwaZulu-Natal between January and June 2012. In conjunction with an assessment by the receiving clinician at Grey's Hospital, Triage Early Warning Signs (TEWS) scores were obtained during telephonic referral and compared with the TEWS score on arrival in order to determine if a deterioration had occurred. Results. A total of 57 PICU referrals and 79 ward referrals were analysed. The mortality rate prior to transportation was 8.8%. Mean transfer distance was 131 km and mean transfer time 9 hours. Advanced life support teams undertook transportation in 76.7% of PICU and 25% of ward transfers and few adverse events were reported in transfer logs. However, 31.5% of PICU and 11.3% of ward referrals required immediate resuscitation on arrival. When the TEWS scoring system was applied 78.5% of PICU and 30.4% of ward referrals fell into the 'very urgent' and 'emergency' categories. Conclusion. Pretransport and in-transit care failed to stabilise children and this may reflect lack of skill of attending healthcare workers, transport delays or illness progression. Interventions to improve resuscitation and transfer are needed, and the use of retrieval teams should be investigated.

A national retrospective review of neonatal critical care transfers in dedicated critical care transport services in the private sector

“…Owing to this shortage, the transfer of critically ill neonates may occur frequently and often over vast distances. [5,6] In high-income countries, critical care transports (CCTs) of neonates are most often undertaken by specialised physician-based teams with additional training. This is not the case in SA, where emergency medical services (EMS) are responsible for all interfacility transfers (IFTs) regardless of the patient's condition, and it is likely to remain this way owing to a shortage of physicians [7] and specialist neonatologists.…”

“…Consequently, many critical neonates may be transported by EMS personnel with very limited neonatal care experience and knowledge, as well as limited equipment capabilities. [5,6] Numerous international studies describe higher rates of adverse events and increased morbidity when neonates are transported by non-specialist units. Similarly, studies undertaken in SA have reported increased rates of adverse events.…”

“…Similarly, studies undertaken in SA have reported increased rates of adverse events. [5,6,8] In response to this risk, some EMS in SA have started the process of developing dedicated paramedic-based CCT services. However, these are in short supply and mostly contained in the private sector.…”

Pentalogy of Cantrell and anaesthesia: a case report

“…In South Africa, it is common practice for children to be referred from lower-level facilities to higher-level facilities to access resources, specialist knowledge and skills for diagnosis and treatment. 12 Our South African experience shows the limited capacity to provide adequate care to complicated cases that present in the peripheral health service, as is evidenced by up to 34% mortality for these referrals within the first 24 h of admission to a tertiary facility. 13 There is a reliance on a referral system in the current South African public health care system due to centralisation for the provision of specialist paediatric and intensive care in tertiary institutions.…”

“…13 There is a reliance on a referral system in the current South African public health care system due to centralisation for the provision of specialist paediatric and intensive care in tertiary institutions. 12 Due to the vast resource constraints and distances to be travelled in some regions of the country, appropriate and timely referral is quite difficult. 14 In conclusion, these patients generally have a poor prognosis depending on the severity of the cardiac and associated malformations.…”