O3288: Implementation of Direct Admission to the OR Procedure for Children Transported with Airway Emergencies

Background: Given regionalization of US pediatric subspecialty care, outcomes of children with airway emergencies are impacted by their safe and timely transport to centers with pediatric airway expertise. Secondary transports of children with airway emergencies are infrequent - yet high-risk - therefore posing unique challenges. One of the most frequently encountered pediatric airway emergencies is airway obstruction due to suspected aspirated foreign body (FB). In our quaternary center, airway complaints represent < 3%, while suspected aspirated FBs represent < 0.3% of our incoming pediatric transports. Our standard protocols dictate that children with emergent medical conditions are transported to our pediatric ED for evaluation, or pediatric ICU for admission. In an attempt to optimize patient outcomes, our transport team – in collaboration with pediatric surgical, anesthesia, and perioperative services colleagues - implemented a direct admission to the OR protocol for children requiring emergent surgical intervention.

Methods: We conducted a retrospective chart review of patients ≤18 years old with airway complaints transferred to our center between 7/1/2013 and 3/1/2023, then identified those with suspected aspirated FB who subsequently required emergent surgical intervention (Level I surgical case). We assessed whether patients had been transported directly to the OR by the transport team (“OR Transport” protocol) vs. taken to the OR post-transfer via pediatric ED/ICU (“Standard” protocol). Demographics and data pertaining to initial presentation, transport, surgery, and hospital course (including outcomes) were compared between these groups using t-test and Mann-Whitney U test, as applicable.

Results: During the study period, we transported 27 children who required emergent surgery for suspected aspirated FB: 14 (51.9%) via “Standard” and 13 (48.1%) via “OR Transport” protocol (Table 1). Demographics, referring hospital characteristics, time of transfer request, need for mechanical ventilation pre-transport, and transport mode were not different, while rates of critical care transports and transports accompanied by a physician were significantly higher for the “OR Transport” vs. “Standard” group (p=0.016 and p=0.054, respectively). Compared to the “Standard” group, the “OR Transport” group had significantly shorter median (IQR) times from transport arrival to start of surgery (8 (0-15.5) vs. 94.5 (27-139) minutes, p< 0.001) and from transport dispatch to surgery (103 (65.5-136) vs. 179 (115.5-265) minutes, p=0.035). Many FBs were bronchial; nearly 2/3 were plastic, nut, or metal (Table 2). While not statistically significant, patients in the “OR Transport” group had higher discharge rates post-surgery (61.5% vs. 35.7%) and, implicitly, fewer hospitalizations compared to the “Standard” group; similarly, fewer patients required ICU and mechanical ventilation post-operatively (with shorter duration of mechanical ventilation) in the “OR Transport” vs. “Standard” group, which could be clinically significant.

Conclusion: Direct admission to the OR is feasible, expedites definitive treatment, and may decrease hospitalization rate for children with airway obstruction who require interhospital transport for emergent surgical management.