The pem specialist: Applying and developing their unique skillsets in the early management of pims-ts

ABSTRACT

Background Between March 2020 and February 2021, 160 patients with acute covid infections and the associated paediatric inflammatory disorder, PIMS-TS, were transferred to paediatric intensive care units by the largest regional transport service in Europe. Local paediatric emergency departments have become attuned to the presentation of these patients, implementing early monitoring, workup and treatment in line with evolving national guidance. We have identified there has been reduction in the time taken to identify PIMS-TS, to initiate treatments and referral to PICU transport teams, potentially improving patient outcomes. The role and skillset of the PEM specialist is vital in providing early identification and management of this patient group. We make the case that point of care ultrasound scanning (POCUS) and applied PICU clinical skills make this a subset of specialists with potential to further improve PIMS-TS outcomes. Objectives This retrospective review compares two cohorts of PIMS-TS patients, the first and second covid waves, who required transport to paediatric intensive care units (PICU). The objective is to 1. Describe any differences in presenting phenotypes of the two cohorts 2. Review timeliness of investigations and treatment interventions 3. Analyse changes in patient outcomes 4. Highlight where further improvement could be made, specifically around hypotension assessment and management in paediatric ED Methods A retrospective review was performed for all patients with suspected PIMS-TS and COVID-19 infection transferred to PICUs by the regional transport team between 1st March 2020 and 28th February 2021. A cross-reference of local hospital, CATS and PICU notes were used to obtain necessary clinical data. This service evaluation project was registered with the trust and local GDPR guidelines were followed. Results Data analysis is ongoing. The following areas will be reported on Conclusions Data analysis is ongoing. Early findings suggest local hospitals are more familiar with the presenting features of PIMS-TS and the spectrum of conditions it has phenotypical overlap with. In the first wave there were delays in diagnosis, in the second wave there is a suggestion of potential over diagnosis - attention and caution around this is vital. Teams were vigilant around hypotension, with early use of vasoactive agents rather than large fluid resuscitation volumes. The number of ECHOs (particularly POCUS assessments) performed increased guiding decisions around transfer and vasoactive choice. Frontline PEM clinicians have an important skillset in early detection and management of PIMS-TS patients, especially those needing cardiovascular support. Applying POCUS training for clinical assessment of cardiac function and inserting peripheral arterial lines under local anaesthetic to obtain accurate BP recordings can guide prompt and appropriate treatment for patients with PIMS-TS. This has wider-reaching implications on PEM training and their evolving role within the paediatric service.