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Complex, high-acuity services cannot be offered at every site where children receive medical care. These services are expensive and require personnel resources that are in limited supply. Thus, it is best to concentrate skilled caretakers and equipment in hospitals and medical centers that function as local, regional, or national or international referral centers. In the United States and other industrialized countries, implementing this principle has resulted in the development of interhospital referral networks reminiscent of the hub-and-spoke distribution system used by the airlines. In most cases, the referral centers, or hubs, have developed highly detailed protocols for the transfer of patients to their facilities, sometimes involving complex stabilization efforts at the referring facility and in transport.

The success of these protocols at a local level has resulted in the progressive adoption of basic standards and expectations around the transfer of patients at a more global level. These expectations invariably start with the clinician, who is first confronted with an acutely ill child and who must recognize that the problem exceeds the skills and resources immediately available and who becomes responsible for the preparations needed before the transport team is available. The important steps of recognizing the severity of the situation, establishing a first diagnostic evaluation, and implementing the necessary stabilization measures have been facilitated enormously by the wide distribution of the American Heart Association’s pediatric advanced life support (PALS) guidelines.1 PALS guidelines are updated frequently and are an invaluable repository of information and an excellent vehicle for the education of any clinician who cares for sick infants and children.

The scope of this chapter cannot include every possible scenario for stabilization and transport. Rather, the chapter details the most common circumstances and courses of action involved in the transfer process.

The effort to stabilize an acutely ill or unstable infant or child for transportation is dependent on both the physiological derangement and the speed with which the transfer can be carried out. The latter is obviously influenced by factors such as distance, available means of transportation, and frequently the weather in the area, particularly if an aircraft is used. The decision of which institution to send the patient should ideally be based on the perceived acuity and the type of illness/injury, and should generally favor the closest option that is equipped to care for the patient during the acute period and thereafter. Unfortunately, extraneous considerations such as the type of insurance the patient has or the existing patterns of referral often influence the course of action, not always in the best interest of the child.

Whether initiated in a primary care office, an emergency room, or a hospital, the preparations for transport always start with the recognition and summary evaluation of the patient’s problem. Every clinician should ideally be prepared to recognize, diagnose, and begin treatment for life-threatening respiratory, circulatory, and neurological impairments (see Chapters 102, 103, and 104). Often this ...

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