SECTION ON TRANSPORT MEDICINE

SCHEDULE

SUNDAY, OCTOBER 10, 1999

SECTION ON TRANSPORT MEDICINE and SECTION ONEMERGENCY MEDICINE JOINT SESSION2:00 pm - 5:00 pmRoom 31, Washington Convention Center

The Emergency Department and Patient Transport

2:00 pm New Technologies and Transport Medi-cineDavid G. Jaimovich, MD, FAAP

Transport Medicine Scientific Abstract Presentations

2:45 pm Oral Presentation

1) Safe Restraint of Pediatric Patients forAmbulance Transport: InterdisciplinaryCollaboration In Pediatric AmbulanceTransportNadine R. Levick, MD. Johns Hopkins Uni-versity School of Medicine, Baltimore, MD

Poster Presentations

2) A Novel Pediatric Residency TransportRotation Curriculum: Meeting the RRCRequirements and Beyond.Robert M. Insoft, MD, FAAP; Anita Carew,RN. Massachusetts General Hospital, Bos-ton, MA

Impact of Not Following Pre-TransportRecommendations on Outcome In Pediat-ric Transports.M. Bugnitz, D. Newton, P. Hess, M. Quasney.LeBonheur Children's Medical Center,Memphis, TN

Patient Outcomes After Conversion to aNurse-Led Transport Team: A PreliminaryReport .Robin L. Foster, MD, FAAP; Brent R. King,MD, FAAP; Kathryn McCans, MD, FAAP.The Medical College of Virginia, Richmond,VA; University of Texas Houston MedicalSchool, Houston, TX; The University ofMedicine and Dentistry of New Jersey,Camden, NJ

The Effectiveness of Seat Belts at Reduc-ing Injury Severity to School-Age Chil-dren.Stephen Halman, BASc, MSc, MDCM; MaryChipman, MSc; Patricia Parkin, MD, FRCP(C);James Wright, MD, MPH, FRCS(C). Hospitalfor Sick Children, Toronto, Ontario

Pediatric Specialty Care Teams are Associ-ated with Reduced Morbidity During Pe-diatric Interfacility Transport.Karin McCloskey, MD, FAAP; Richard Orr,MD, FAAP; Shekhar Venkataraman, Neal Seid-berg, Michelle Dragotta, Janine Janosky. Uni-versity of Texas Southwestern, Dallas, TX;University of Pittsburgh, Pittsburgh, PAAre Infant Transport Patients at IncreasedRisk for latrogenic Related ComplicationsWhile at Referral Facilities?

8)

Gary B. Zuckerman, MD; Bruce J. Grossman,MD; Frank V. Castello, MD; Patrice M. Greg-ory, PhD.; Robert Wood Johnson MedicalSchool, New Brunswick, NJVehicular Accidents Involving Pediatricand Neonatal Transport Teams.George A. Woodward, MD, MBA, FAAP; BrentKing, MD, FAAP. University of Pennsylva-nia School of Medicine, Philadelphia, PA;University of Texas Houston MedicalSchool, Houston, TX

9) The S.T.A.B.L.E Transport Education Pro-gram: Assessment of Transportability toRegional Centers in the United States.Kristine A. Karlsen, MD; Tracy B. Karp. ParkCity, UT.

3:00 pm Disaster Planning for Natural and Man-Made DisastersFred Burkle, MD, FAAP

3:45 pm Break and poster viewing

4:00 pm So You Experienced a Disaster: ProblemSolving and Lessons LearnedDee Hodge III, MD, FAAP

5:00 pm Adjourn

TRANSPORT MEDICINE SESSION

1SAFE RESTRAINT OF PEDIATRIC PATIENTS FORAMBULANCE TRANSPORT: INTERDISCIPLINARYCOLLABORATION IN PEDIATRIC AMBULANCETRANSPORT SAFETY.

Levick, Nadine R., MD, FACEM, Division of Pediatric EmergencyMedicine Johns Hopkins University School of Medicine, Balti-more, Maryland, USA

Background: Ambulance crash fatalities have been reported in-temationally, some involving children. Approximately one in tenpatient transports involves a child. The special needs of trans-ported pediatric patients raise unique safety issues beyond thoseof domestic pediatric transport. Testing standards and design ofchild restraints for domestic vehicles are well developed, howeverthere is no federal standard or testing requirement for ambulancepediatric restraint devices or practices. Commonly used restraintpractices for children in ambulances have not been subjected tocomprehensive dynamic safety testing to validate occupant safety.This study describes in an interdisciplinary framework, the safetytesting of currently available devices and practices in addition toprototype devices currently being developed to address this prob-lem. Aims: To pilot dynamic safety tests of devices for pediatricpatient transport. Methods: A range of currently used or availablerestraint devices for the transport of pediatric patients were as-sembled, as well as prototype devices. A standard ambulancegurney was secured to an approved sled test rig. All restraintdevices were tested secured to the gurney as in current ambulancepractice. These devices were tested in a simulated 30 mph frontalimpact, equivalent to a deceleration force of 24 G. Crash testdummies of 3, 9 and 15 kilograms, were used in the testing.Endpoints were ejection of the dummy or disruption of the re-straint device. High speed video and digital imaging and comput-erized analysis of the crash impact data were performed. Results:The restraint systems tested which were available for transport or

PEDIATRICS Vol. 104 No. 3 September 1999 791

3)

4)

5)

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7)

in current use, failed preliminary dynamic testing, some cata-strophically. Outcomes included either ejection of the occupant,disruption of the device or both. In contrast, newly developedprototype restraint systems adequately restrained the occupantand maintained structural integrity during testing. Conclusions:This preliminary study suggests that some currently availableambulance pediatric restraint devices may be ineffective. A mul-tidisciplinary approach to the development of such devices isneeded, with a focus on clinical needs and safety engineeringexpertise. The direction of future research and development in thesafety of all ambulance patients, occupants and equipment shouldbe reviewed. Video footage will demonstrate testing.

ments along with marketplace economic forces have resulted insignificantly fewer pediatric residents participating nationwide ininterhospital tertiary transport teams. However, to ensure ade-quate resident training in the initial management of critically illpatients, we have implemented a newly-designed curriculum inpediatric transport to complement their required core ICU rota-tions. We feel that this comprehensive rotation addresses therealistic training needs of pediatric housestaff in accordance withthe RRC in a cost-effective manner while still maintaining highpatient care standards and enhancing community physician andnetwork affiliations.

32

A NOVEL PEDIATRIC RESIDENCY TRANSPORTROTATION CURRICULUM: MEETING THE RRCREQUIREMENTS AND BEYOND.

Robert M. Insoft, MD, FAAP and Anita Carew, R.N., PediatricTransport Program, Massachusetts General Hospital, PartnersHealthCare Systems and Harvard Medical School, Boston, MA.

Background: The recent policies of the Pediatric Residency Re-view Committee (RRC) simply require residents to learn about thebasics of "resucitation, stabilization, and transportation of patientsto the ICU's" and participate "in decision making in the admitting,discharge and transfer of patients in the ICU's". Residents are notrequired to participate directly in prehospital emergency transportteams. In fact, residents now participate in < 20% of academicmedical center teams. Focus currently is on increasing residentrotations in outpatient primary care settings. However, it is ourcontention that to become a well-prepared pediatrician, residentsshould feel confident in the initial stabilization and managementof critically ill newborns and children prior to hospital admission.Methods: In order to achieve proficiency in pre-ICU stabilizationskills and to adhere to the RRC mandated guidelines, we designeda comprehensive clinical and didactic curriculum in interhospitaltransport for PL-2 and 3 Pediatric and PL-2, 3 and 4 Medicine/Pediatric residents to complement their ICU rotations. During oneor two separate two week rotations each resident participatesdirectly in the physician/nurse ICU transport team as the physi-cian team leader, responding to a myriad of critically ill patients invarying community settings. Until core clinical proficiencies aremet, physician backup is provided by ICU attendings and fellows.Time is also allotted for the residents to work directly with pedi-atric anesthesia attendings in the OR, thereby refining their skillsin airway management. The transport program director providesindividualized resident tutorials covering basic transport topicsincluding pharmacology, case studies, literature reviews and anoverview of medical-legal issues. A didactic course in basic avia-tion physiology is given; but residents are not required to fly onrotor-wing transports, as per hospital policy. A practical ambu-lance ride-along experience with the Boston City paramedics is alsoavailable. To complement their clinical training each resident cri-tiques their transports daily as well as leads a teaching conferenceon pre-hospital or office emergency preparation. Results: Since1997, 52 residents have finished 66 rotations. Upon completion,each resident has an oral and written evaluation and gives directfeedback. The residents evaluated their overall experience (essen-tial, valuable or not valuable), with 76% responding that thisrotation is an "essential" part of training and 20% marking it as a"valuable" part of their residency. Ninety percent of the residentselected not to fly, attributing pregnancy, motion sickness or po-tential safety issues as the major reasons. A random survey ofreferring network physicians reflects continued satisfaction withresidents participating on the transport team in a leadership roleas long as there is direct ICU personnel backup available whenneeded. Also, a rotation syllabus has been compiled which in-cludes policies and procedures as well as reprints and attending-written core transport lectures. Conclusions: Revised RRC require-

IMPACT OF NOT FOLLOWING PRE-TRANSPORTRECOMMENDATIONS ON OUTCOME IN PEDIATRICTRANSPORTS.

M Bugnitz, D Newton, P Hess, and M Quasney. Le BonheurChildren's Medical Center, University of Tennessee, Memphis,Memphis, TN.

Background: An important element in pediatric transports ispre-transport stabilization. We wished to determine if failure ofreferring physicians to follow pre-transport recommendationswould have an impact on flight team ground time, PICU orhospital length of stay (LOS) or mortality.

Methods: We prospectively studied all pediatric transports for 2years to determine if pre-transport physician recommendations(i.e. intubation, IV placement, C-spine immobilization) were fol-lowed. Recommendations and patient demographics were re-corded on pre-transport intake forms. A post-transport reportrecorded ground time and extent to which pre-transport recom-mendation were followed.Medical records were reviewed for LOS in PICU/hospital and

mortality. Statistical analysis was performed using two-tailed T-test.

Results: For transports in which recommendations were notfollowed, ground time and PICU LOS were longer. The patientswere younger on transports in which recommendations were notfollowed.

Not Followed Followed p

Number (N=168) 83 85 -

Age (months) 34.9 ± 39.3 54.5 ± 54.7 .009Ground Time (min) 50.9 ± 20.9 43.9 ± 18.5 .02ICU LOS (days) 5.96 ± 11.8 2.93 ± 5.74 .04Hospital LOS (days) 14.09 ± 19.55 9.89 ± 17.14 .14Mortality 12/83 12/85

*Results reported as mean + SEConclusion: Transport ground times were longer as was LOS in

PICU when pre-transport recommendations were not followed byreferring physicians. Younger age of patient may be a factor inreferring MD not following recommendations.

4PATIENT OUTCOMES AFTER CONVERSION TO ANURSE-LED TRANSPORT TEAM: A PRELIMINARYREPORT.

Brent R. King, MD FAAP, Robin Foster, MD FAAP, KathrynMcCans MD, FAAP. Departments of Emergency Medicine andPediatrics, The University of Texas Houston Medical School,Houston Texas. Department of Pediatrics, The Medical College ofVirginia, Richmond VA. Departments of Emergency Medicine andPediatrics, The University of Medicine and Dentistry of NewJersey, Camden NJ.

Background: Pediatric and neonatal transport teams utilize sev-eral different types of personnel including, physicians, nurses,respiratory therapists, and paramedics. The ideal team composi-

792 SUPPLEMENT

tion, while somewhat dependent upon the team's mission, re-mains controversial. There is little definitive information in themedical literature to help address this question. This preliminaryreport details patient outcomes after a pediatric and neonataltransport team converted from a physician-led team to a nurse-ledteam. In 1995-96, the pediatric and neonatal transport team (TT) atSt. Christopher's Hospital for Children (SCHC) underwent a con-version to a nurse-led team. The TT performs an average of 1600patient transports per year. Before the conversion, physiciansaccompanied the TT on approximately 60% of transports. Theremaining 40% were low acuity patients who were transported byone nurse and the ambulance crew. The physicians were pediatricresidents and fellows. During weekday daytime hours these wereresidents on a transport rotation. "Moonlighters" provided cover-age on nights and weekends. The conversion process included, 1)an expanded TT (6 nurses before, 14 after), 2) didactic and proce-dure training for the nurses, 3) development of protocols, and 4)change in the medical command from Critical Care and Neona-tology to Emergency Medicine and Neonatology. This report rep-resents information collected on 100 patients, after the conversion.Methods: Data was prospectively collected by the transport nurseson all patient transports during a 3-month period after the con-version. This included demographic information about the patientand the referring center, a record of specific time intervals betweenthe call for a transport and the TT's return to the SCHC, and anassignment of two Pediatric Risk of Mortality (PRISM) scores; thefirst based upon information received by the referring center andthe second based upon the TT's assessment at the referring center.During the patient's hospitalization or after discharge, the medicalrecord was reviewed by one of the investigators. The investigatorsassigned a third PRISM score based upon the patient's conditionupon arrival. They also looked for evidence of potential morbiditydirectly related to the transport. This included medical interven-tions or major therapeutic changes performed in the first 6 hoursafter arrival as well as potential diagnostic errors. The length ofstay (LOS) and patient outcome were also recorded. Results:Nurses alone performed 56 (56%) of the transports, a 2 nurse TTperformed 36 (36%), a physician accompanied the TT on 8 trans-ports (8%) Ages were recorded for 91 patients. There were 11neonates, 12 children over one month but less than one year and68 children over 1 year old (mean 6 years; range 1-17 years).Sixty-three (63%) children came from facilities within 5 miles ofSCHC and 88 (88%) from within 20 miles. Seventy-one (71%) weretransferred from emergency departments. PRISM scores were asfollows: Pre-transport score: Mean = 2.22; range 0-21, transportscore mean = 2.25; range = 0-36; post-transport score mean = 2.60range = 0-38. There are no significant differences between thesescores. There was no morbidity related to the transport in 97 (97%)of cases. There was one case of possible morbidity. In 2 cases thedata was not recorded. LOS was recorded for 86 (86%) patients.The mean LOS was 6.5 days (range 1-45 days). Outcome wasrecorded for 92 (92%). Eighty-six (86%) children went home, 6were transferred to other hospitals, and 2 died. The Ti success-fully intubated 3 patients (no failed intubations), started intrave-nous lines 12 times (12%), and gave medication not already startedby the referring center 6 times. Conclusions: A pediatric/neonatalTi staffed mostly by well-trained nurses with selected use ofphysicians performs acceptably with regard to patient outcomeand interventional skill.

5THE EFFECTIVENESS OF SEAT BELTS AT REDUCINGINJURY SEVERITY TO SCHOOL-AGE CHILDREN.

Stephen Halman BASc, MSc, MDCM, Hospital for Sick Children,Toronto, Ontario; Mary Chipman MSc, University of Toronto;Patricia Parkin MD FRCP(C); James Wright MD, MPH,FRCS(C), Hospital for Sick Children, Toronto, Ontario.

Background: Motor vehicle collisions (MVCs) are the leadingcause of death to school-aged children in North America. How-ever, there are no restraints designed specifically for them; in-stead, they are placed in adult seat belts. This study investigateswhich of the adult restraints (lap-torso belt or lap belt) is better forthese children. Specifically, the purpose of this study was todetermine (1) if adult restraints reduced injury severity to thesechildren when compared to no restraint, (2) if lap-torso belts werebetter than lap belts, and (3) if children were as well protected asadults. Methods: Linear and logistic multiple regression analyseswere performed using data from Transport Canada's PassengerCar Study in order to evaluate the Injury Severity Score (ISS) for200 children involved in MVCs, while adjusting for belt type,Barrier Equivalent Velocity (BEV), age, and seat position. Results:Results for school-age children demonstrated that the lap-torsobelt, in the front right seat reduced the mean ISS by 2.64, from 3.42(95% CI: 1.96 to 6.29) to 0.78 (95% CI: 0.48 to 1.18). Similarly, thelap belt in the rear left seat reduced the mean ISS by 1.07, from 2.05(95% CI: 1.17 to 3.61) to 0.98 (95% CI: 0.58 to 1.55). These reduc-tions compared favourably with adults who realized injury reduc-tions of 1.38 (from 3.03 to 1.65) and 1.09 (2.16 to 1.07), respectively.The odds ratio of sustaining at least a moderately severe injury(ISS14) for unrestrained children compared to children restrainedby the lap-torso belt was 9.81 (95% CI: 2.43 to 39.4) and 2.74 (95%CI: 1.21 to 6.18 compared to those wearing the lap belt. Again,these odds ratios were at least as good for children as they werefor adults (i.e. adult odds ratios of 2.39 for the lap-torso belt, and2.57 for the lap belt). Finally, there was no statistical difference inthe mean ISS for children restrained by the lap-shoulder belt inany seat (ISS= 1.54; 95% CI: 0.47 to 5.06) as opposed to the lap belt(ISS = 1.15; 95% CI: 0.70 to 1.83). Similarly, the odds ratio ofsustaining at least a moderate injury while wearing the lap belt asopposed to the lap-torso belt was 1.35 (95% CI: 0.75 to 2.34), whichwas not statistically different. Conclusion: The analyses demon-strated that lap-torso and lap belts protected school aged childrenbetter than no restraint; however, there was no difference betweenthe two restraints in injury reduction. Moreover, school-age chil-dren were as well protected as adults by these restraints.

6PEDIATRIC SPECIALTY CARE TEAMS ARE ASSOCIATEDWITH REDUCED MORBIDITY DURING PEDIATRICINTERFACILITY TRANSPORT.

Karin McCloskey, FAAP, Richard Off, FAAP, Shekhar Venkat-araman, Neal Seidberg, Michelle Dragotta, Janine Janosky. De-partment of Pediatrics, Division of Emergency Medicine, Univer-sity of Texas Southwestern, Dallas, TX, 75235-9063 andDepartment of Anesthesiology/CCM & Pediatrics, Clinical Epide-miology & Preventative Medicine, University of Pittsburgh, 3705Fifth Avenue, Pittsburgh, PA, 15213.

Background: The benefit of pediatric specialty care transportteams has not been determined. Yet, tertiary centers expend valu-able critical care resources for the transport of infants and chil-dren, assuming that this provides optimal care in the transportenvironment. We tested the hypothesis that transport performedby specialty care personnel reduces morbidity during the trans-port process. Methods: Over a one-year period, 1085 children weretransported to a single tertiary center. 1030 children were trans-ported by a pediatric specialty care team (PSCT) and 55 childrenwere transported by a non-specialized team (NST) when the PSCTwas not available. Using a case-control study design, we com-pared PSCT with NST for the incidence of morbidity as describedby unplanned events: dislodged or plugged endotracheal tube,loss of essential IV used for inotropic drugs, equipment malfunc-tion with resultant patient deterioration, medication errors, cardi-ac/respiratory arrest, pneumothorax, and sustained hypotensionor hyopoxia. Severity of illness was determined using a pretrans-port Pediatric Risk of Mortality Score as previously described.'

793

Odds ratios (OR) and 95% confidence intervals were described forthe occurrence of at least one unplanned event between PSCT andNST. Results: An unplanned event occurred at least once in 41patients (3.8%): 25/55 (45.4%) transported by NST vs. 16/1030(1.5% ) by PSCT [p<0.001; OR 47.9 (29.7-77.2)]. For patients whosepretransport mortality risk was < 10%, at least one unplannedevent occurred in 11/35 (31.4%) patients transported by NST vs7/868 (0.8%) by PSCT [p<0.001; OR 56.4 (30.1-105.6)]. When pre-transport mortality risk was 2 10%, 14/20 (70.0%) patients trans-ported by NST had at least one unplanned event vs. 9/162 (5.5%)patients transported by PSCT [p<0.001; OR 23.2 (9.47-56.8)]. Con-clusion: Pediatric specialty care teams may reduce patient morbid-ity in the transport setting. Pediatric specialty care transport teamsshould be considered for interfacility transport of critically illchildren for the provision of optimal care.

'Pediatrics 1997;99:59-63. Supported by 1-MCH-424003-01-0

7ARE INFANT TRANSPORT PATIENTS AT INCREASEDRISK FOR IATROGENIC RELATED COMPLICATIONSWHILE AT REFERRAL FACILITIES?

Gary B. Zuckerman MD*, Bruce J. Grossman MD*, Frank V.Castello MD*, Patrice M. Gregory PhD', Depts of Pediatrics* andFamily Medicine', Robert Wood Johnson Medical School, NewBrunswick, NJ

Background: Pediatric patients often arrive at non-tertiary carefacilities requiring transport to a Pediatric Intensive Care Unit.While at the referral facilities, iatrogenic related complications(RF-IRC) may arise. Such complications may impact on morbidityand mortality. No recently published studies have sought to de-termine whether infant transport patients are at higher risk forRF-IRCs than are their older pediatric counterparts. The objectiveof this study is to determine whether the incidence of RF-IRCs isgreater in infants less than 6 months than in the rest of thepediatric transport patient population.

Methods: The charts of all patients, less than 18 years of age,transported to the Robert Wood Johnson University Hospital Pe-diatric Intensive Care Unit from 7-1-95 through 6-30-98, wereretrospectively analyzed. Demographic data was abstracted andthe occurrence of RF-IRCs noted. RF-IRCs were defined as referralfacility patient assessments or management decisions which werenot in accordance with Pediatric Advanced Life Support Guide-lines. RF-IRCs were grouped as follows: Triage Errors; Airway,Breathing, Circulation, Neurologic, and Metabolic managementerrors. Patients were divided into 2 groups: < 6 months and 6months to < 18 years. The average Pediatric Risk of Mortality(PRISM) scores for the 2 groups were calculated and comparedusing the t Test. The incidence of each IRC category was calculatedand compared between the 2 groups using the chi-square test. Pvalues of less than 0.05 were considered to be statistically signif-icant.

Results: During the study period, 564 patients were transportedto our facility.

< 6 mos. 6 mos to <18yrs(n=116) (n=448)

PRISM Score 5.9 4.0Triage Errors (%) 13.8* 7.1*Airway (%) 12.9 7.6Breathing (%) 23.3* 12.3*Circulation (%) 7.8 4.5Neurologic (%) 1.7 1.1Metabolic (%) 13.8 8.7Total (%) 66.4* 38.6*

* P<0.05Conclusions: The total incidence of RF-IRCs was significantly

higher for infants than for older pediatric transport patients. RF-

IRCs related to Triage Errors and Breathing management weresignificantly higher in the infant group. Infants had higher inci-dences of all other RF-IRCs, however, statistical significance wasnot achieved. This study suggests that infants requiring interhos-pital transport may be at higher risk for RF-IRCs than their olderpediatric counterparts.

8VEHICULAR ACCIDENTS INVOLVING PEDIATRIC ANDNEONATAL TRANSPORT TEAMS

Brent R. King, MD, FAAP and George A. Woodward MD, MBA,FAAP. Departments of Emergency Medicine and Pediatrics, TheUniversity of Texas Houston Medical School, Houston, TX andDepartment of Pediatrics, The University of Pennsylvania Schoolof Medicine, Philadelphia, PA.

Background: Each year thousands of children are transferredbetween hospitals via pediatric or neonatal transport teams. Mostresearch into the risks of patient transport has focused uponmedical complications. However, patient transport also involvesthe potential risk of vehicular collision. This study reports theapproximate incidence of vehicular accidents among transportteams and describes factors that may prevent or contribute to suchincidents. Methods: A survey was sent to 153 transport teams. Thisthree-part instrument asked for basic demographic information,about the overall incidence and impact of vehicular accidents, and,for those teams without accidents, about factors which may havecontributed to their safety record. Results: Ninety surveys (59%)were retumed but only 51 responders (51/90=57%) included thetotal number of annual transports performed by their teams. These51 teams perform a total of 34,600 annual transports (mean = 660transports per team.) If these data are extrapolated to include the39 teams that did not report their total annual transports then thetotal number of transports performed by these 90 teams is approx-imately 59,000. Thirty-eight of the 90 teams (42%) reported at leastone accident in the previous five years. There were a total of 66crashes reported by these 90 teams, (mean = 1.75 accidents perteam; range 1-4 accidents; 0.15 accidents per team per year orapproximately 0.0002 accidents per transport). Consequences ofaccidents included 1) crew disability (mean work days missed-2.32), 2) litigation (4 teams), and 3) operational changes includeddecreased use of lights/sirens, changes in vehicle provider, andchanges in crew composition. Details for 64 of 66 accidents werereported. Vehicles involved included: 55 ambulances, 6 helicop-ters, 2 helicopters, and 3 fixed wing aircraft. Injuries to the patientand crew included 28 minor injuries, 10 moderate to severe inju-ries, and 8 deaths. Additionally, 3 patients became disconnectedfrom necessary medical equipment. Twelve accidents were causedby weather, 21 by the team (includes the driver/pilot), 22 byanother party, 3 by mechanical failure, and the remainder wereattributed to other factors. Accident free teams attributed theirsafety records to safety policies of the team itself or of the vehicleprovider. These teams frequently reported: 1) restricting travel ininclement weather, 2) restricting the use of lights/sirens, 3) havingshift limits for personnel, and 4) enforcing compliance with safetyrules. Finally, a few teams reported being "lucky". Conclusions:Accidents among transport teams are unusual. Infants and chil-dren being transferred from one facility to another are at littleadditional risk from the transport itself. Most accidents are causedby another party, a member of the team, and/or the weather. Themajority of accidents result in no injuries, no lost workdays, andno litigation. However, among these 66 reported crashes, therewere 8 deaths, 10 cases of moderate to severe injury, and 3 casesin which medical equipment was disconnected. Accident freeteams attribute their record to specific safety policies or to luck.

794 SUPPLEMENT

9THE S.T.A.B.L.E. TRANSPORT EDUCATION PROGRAM:ASSESSMENT OF TRANSPORTABILITY TO REGIONALCENTERS IN THE UNITED STATES.

Kristine A. Karlsen and Tracy B. Karp S.T.A.B.L.E. TransportEducation Program, Park City, Utah.

Background: Appropriate and timely pre-transport stabilizationof sick neonates will reduce morbidity and mortality, thereforecommunity hospital caregivers must be prepared for this contin-gency. The S.T.A.B.L.E. Transport Education Program is a neona-tal outreach education program that was developed for commu-nity hospital staff in the care of a sick infant in the period betweenresuscitation of the newborn and arrival of the transport team. TheProgram was developed between 1991 and 1996 and made com-mercially available in May 1996. The S.T.A.B.L.E. Program doesnot replace communication and consultation with the tertiaryhospital, but provides referral hospital staff with a concise anddirective tool to help organize the pre-transport stabilization of thesick neonate. The mnemonic S.T.A.B.L.E. was developed to helpwith organization of the stabilization process and to assist recall.S.T.A.B.L.E. stands for Sugar, Temperature, Artificial breathing,Blood pressure, Lab work, and Emotional support for the family.The extensive pre-transport stabilization content built around themnemonic is presented to the leamer as a one day didactic-interactive seminar. Evaluation includes cognitive knowledge as-sessment measured through pre and post testing. Participantsopinions on acceptability, efficiency and effectiveness of the pro-gram are assessed through a Likert scale. As part of the programdevelopment a pilot study (IRB approved) was conducted involv-ing 49 (25 RN & 24 non-RN) participants from 4 communityhospitals. The one-day seminars were presented by the author ofthe S.T.A.B.L.E. Program. The pilot study showed significantchange in pre and post test scores and high scores for acceptabil-ity, efficiency and effectiveness (8 of 29 sample questions ) of theprogram (see below). Following pilot testing, the program wascommercially distributed. The purpose of this descriptive studywas to assess if the results achieved in the pilot study, whentaught by the author, could be generalized to a larger populationwhen the program was presented by many instructors in manyregions. Methods: In implementing the S.T.A.B.L.E. program theregional outreach educators were encouraged to return pre andpost test scores and program evaluations. Means and standarddeviations were calculated on pre and post-test scores and the

evaluation questions. Results: Six programs returned data [TestsN=423 (355 RN; 9 MD, 39 RT, 20 LPN); Evaluations N=350]. Pilotand outreach educators groups are shown below.

n

Pilot group [PG] (n = 49)Outreach educator group[OEG] (n = 423)

Selected Mean EvaluationScores (n-350)[1 =strong disagree,5=strong agree]

I would have preferredself-paced learning (noinstructor or lecture)

I liked the format of thisprogram

I felt program complexitywas appropriate for mylevel of expertise

I felt this program wasthe best way to learnthis material

I felt this was a good useof my time

I have learned things thatwill help with futureneonatal stabilization

I learned new informationI gained more confidence

in my ability to care forinfants needingtransport

Recommend the program?: Yes:Eliminate the program: 0%

Pretestrnean score(SD) (%)74(11)83 (9)

PG

1.3

4.8

4.2

4.6

4.8

4.9

4.84.7

Post testmean score(SD) (%)

89 (7) p < .00192 (5) p <.001

OEG

2

4.4

4.1

4.3

4.4

4.6

4.54.4

80%; Yes with revision: 20%,

Conclusion: We believe the program is transportable to otherlearners when it is taught by expert neonatal outreach educatorsas test data continue to change in the positive direction; evalua-tions indicate participants believe the program is acceptable, effi-cient, effective and should be continued. We further speculate thatthe S.T.A.B.L.E. program is an effective means of providing auniform and focused approach to neonatal pre-transport stabili-zation education. Funded by S.T.A.B.L.E. Transport EducationProgram, Kristine A. Karlsen has equity in S.T.A.B.L.E. TransportEducation Program. Tracy Karp is a consultant for S.T.A.B.L.E.Transport Education Program.

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