Improving access to paediatric critical care
Thankfully, most of us will never have to think about our child requiring critical care. But for parents of a child who is critically ill, accessing the best care as quickly as possible is all there is to think about. Fortunately, paediatric critical care is a low volume specialty yet when it is needed, time is of the essence and access to specialist expertise is crucial to achieving the best possible outcome for the child.
Often a child who is critically ill will deteriorate rapidly. For a physician who may be highly competent in managing resuscitation in the adult population, but not be experienced in routinely providing paediatric resuscitation due to low demand, the critically ill child can present a significant clinical challenge.
That is why in October 2007, Ontario’s Critical Care Strategy introduced as a demonstration project, the first-ever Provincial Extramural Paediatric Critical Care Response Team Program. This new service, funded by the Ministry of Health and Long-Term Care and operated by CritiCall Ontario, is a natural extension of the intramural Paediatric Critical Care Response Team Program already successfully operating within the four paediatric academic health sciences centres (PAHSCs) in the province: The Hospital for Sick Children, Children’s Hospital of Eastern Ontario, McMaster Children’s Hospital, and the Children’s Hospital at London Health Sciences Centre. Under the extramural P-CCRT Program, any physician who is caring for a critically ill child anywhere in the province can have immediate telephone access to a paediatric intensivist, 24 hours a day, seven days a week. By calling CritiCall’s existing central number, 1-800-668-4357, referring physicians are able to consult with a paediatric intensivist regarding the management or potential transfer of a patient to a more appropriate care setting. In addition the extramural P-CCRT service allows CritiCall to track the movement of critically ill children in the province, thereby providing an accurate picture of a patient’s care journey.
The demonstration project builds on the success of the intramural Paediatric Critical Care Response Team Project and supports the goals of the province’s Paediatric Critical Care Network (PCCN) which are:
• To ensure that all children in Ontario have access to high quality, tertiary level critical care;
• To provide access to and support from paediatric intensivists to all community emergency department physicians and paediatricians caring for critically ill children in Ontario, and;
• In partnership with CritiCall Ontario, to streamline communications and increase the effectiveness and efficiency of the transfers to tertiary care facilities.
Uptake of the service has been remarkably quick. According to Rose Gaiteiro, project officer, Provincial Paediatric CCRT Demonstration Project: “Communicating the availability and reliability of the service to all Ontario hospitals and encouraging them to use it was a key component of our implementation planning. We are committed to ensuring that every physician in the province knows that the service is there for them, 24/7.”
An extensive communications plan is being implemented to educate community hospitals and physicians about the nature and availability of the service, and those efforts are working. During the first month of the program the median number of calls to the P-CCRT service was eight, representing 25 per cent of all calls made to the paediatric intensivist by community hospital-based physicians. Five months after the P-CCRT implementation, the median number of calls referred through CritiCall had risen to 37, or 86 per cent of calls through CritiCall. Clinician response to the service has been favourable and speaks to the scope of the need for this type of service.
All participating PAHSCs have put in place the technology required for telephone bridge conferencing and recording, which is supporting P-CCRT process development and quality control. In addition, data collection is a key activity of the program, providing the evidence to support both the need for and the continuous improvement and enhancement of the service.
The intra- and extramural P-CCRT programs are having a profound impact on the way we think about and deliver paediatric critical care across Ontario and indeed the world. Our experience in implementing paediatric critical care response teams here is setting the benchmark for the delivery of paediatric critical care across all jurisdictions. Many countries are looking to us as an example of how to build a system that works better for children and their families.
Working as a system, the extramural P-CCRT initiative has been able to achieve several key milestones in the advancement of paediatric critical care across the province, including:
• A rapid increase in calls through CritiCall to support the care needs of critically ill children
• The development of a one-number-to-call service for the entire province of Ontario
• The designation of defined referral boundaries to paediatric critical care in Ontario
By bringing critical care services outside the walls of the ICU to other areas of the hospital and beyond to community hospital based physicians, we are vastly improving our ability to function as a system, and in so doing, we are, quite literally, saving lives.