Critical patient transfer cone - bangkok


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For ACEM 2011 participation : Critical Care transfer

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Critical patient transfer cone - bangkok

  1. 1. David C. Cone, MD Associate Professor of Emergency Medicine Yale University School of MedicinePresident 2007-2008, National Association of EMS Physicians
  2. 2. Current position Honorary Research Fellow Ambulance Research Institute Ambulance Service of New South Wales Senior Visiting Fellow School of Public Health and Community Medicine University of New South Wales
  3. 3. Home positionYale UniversityNew Haven, ConnecticutYale-New Haven Medical Center
  4. 4. Conflicts of Interest No financial interest in any critical care transport agency or system No affiliation with any of the transport services used as examples in this talk Formerly (1999-2001) medical director for a ground critical care transport team
  5. 5. Why is this important? “Critical care transport is assuming an increasing role in health care because patients who have medical conditions that exceed the capabilities of the initial treating facility require timely, safe, and effective transport to regional referral centers.” Uren et al. Emerg Med Clin N Am 2009;27:17–26
  6. 6. Desirable Characteristics Timely: How important is speed? Safe: No value to the patient (or the crew!) if not safe. Effective: What can the transport crew do to ensure that the patient does not deteriorate? Can the transport crew actually improve the patient’s condition?
  7. 7.  “The appropriate mode of transportation … depends on numerous factors. These considerations include the distance and anticipated duration of transport, the stability of the patient and the urgency of the treatment to be provided at the receiving hospital, the transport expertise and resources available at the sending facility, and other situational factors.” Uren et al. Emerg Med Clin N Am 2009;27:17–26
  8. 8. Selection of mode of transport 1. Speed / distance 2. Clinical abilities of crew 3. Equipment
  9. 9. Air vs Ground “Air medical transport may be more expensive and risky than ground transport, but in most situations it is faster, and air transport teams usually are more highly trained, more experienced, and better equipped than ground transport teams.” Uren et al. Emerg Med Clin N Am 2009;27:17–26
  10. 10. 1. Speed / Distance Is air transport actually faster?  May take more time request a helicopter  Takes more time to “launch” a helicopter  Helicopter crew may spend more time on scene  Need to bring patient from rooftop helipad or remote helipad into ED Need to know your local system and geography to make best choices
  11. 11. Buffalo, New YorkGIS Study “The air zone began between 5 and 15 miles from the trauma center; however, the ground zone projected outward into the air zone along expressways. Ground transport of injured patients from locations on expressways and near expressway entrances is often more timely than helicopter transport at greater distances from the trauma center.” Lerner EB et al. Acad Emerg Med 1999;6:1127
  12. 12. 2. Clinical abilities of crew Particularly in rural areas, air medical crew may be the only “advanced life support” personnel available. Most critical care transport services require substantial clinical or field experience before hiring
  13. 13. Who should staff a critical caretransport? Physicians? Nurses? Paramedics? Respiratory therapists? “Clinical management during transport must aim to at least equal management at the point of referral.”  Aust/NZ Standards:
  14. 14. Physicians Expert knowledge of clinical issues Very little (if any) knowledge of EMS / out-of-hospital issues  Unless specifically trained or experienced in these issues – this is rare in most areas. Can a physician intubate a patient in a moving ambulance?
  15. 15. Nurses Generally a less expensive option for the hospital or transport agency Transport team nurses often have additional formal training in transport medicine Often have specialty experience, such as pediatric intensive care, or burn care
  16. 16. Paramedics Best knowledge of EMS / out-of-hospital issues Comfortable working in out-of-hospital setting Less clinical knowledge than physicians Less expensive option
  17. 17. Respiratory therapists Many transport teams use respiratory therapists because of the high numbers of intubated/ventilated patients
  18. 18. Cross-training LifeStar (Connecticut, USA) Crew #1: Registered Nurse, also credentialed as an EMT-Paramedic Crew #2: Respiratory Therapist, also credentialed as an EMT-Intermediate
  19. 19. 3. Specialized Equipment Neonatal isolettes Intra-aortic balloon pumps Left ventricular assist devices ECMO Transport ventilators
  20. 20. Transport is not risk-free
  21. 21. Summary of risk/benefit: 1 “Critically ill or injured patients are, by definition, in relatively fragile condition. Because interfacility transport requires the movement of a patient from a secure emergency department or inpatient unit to the inherently less stable environment of an ambulance, the patient is subjected to additional risk even if the transport is conducted by a well-trained and well-equipped team.” Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26
  22. 22. Summary of risk/benefit: 2 “Emergency medical transportation… is itself a risky venture, whether conducted by ground-based systems or air medical services. Therefore it is important that the potential benefit of emergent transport outweigh the risk and cost of the transfer.” Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26
  23. 23. Potential Benefits:Acute Ischemic Stroke Intravenous tPA Post-thrombolytic care Endovascular thrombolysis/mechanical clot retrieval Stroke center/stroke unit care Neurological critical care specialization Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26
  24. 24. Potential Benefits:Cardiac Arrest Therapeutic hypothermia Endovascular cooling Interventional cardiology Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26
  25. 25. Potential Benefits:Traumatic Brain Injury Surgical drainage of extra-axial hematomas Neurological critical care specialization Intracranial pressure monitoring Advanced neuroimaging Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26
  26. 26. Systematic Review 2006 Adverse events and prognostic factors associated with interfacility of intubated / mechanically ventilated patients Only five studies (with 245 total patients) met inclusion criteria  All case series  2 prospective, 3 retrospective Fan et al. Crit Care 2006;10:R6 (
  27. 27. Systematic Review 2006 “Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients.” “Further study is required to define the risks and benefits of interfacility transfer in this patient population.” Fan et al. Crit Care 2006;10:R6 (
  28. 28. Barriers to research Difficulty choosing a control (non- transported) group of patients Under-reporting of adverse events, errors, and complications Limited monitoring and documentation during transport Lack of standard definitions for transport-associated complications Fan et al. Crit Care 2006;10:R6 (
  29. 29. There are many different models “If you have seen one EMS system, you have seen one EMS system.” No two EMS systems are exactly alike. No two critical care transport services are exactly alike.
  30. 30. Hospital-Based Transport Team Lutheran Hospital, Fort Wayne, Indiana 3 ground ambulances One helicopter Each staffed with nurse and paramedic
  31. 31. Hospital/Private Partnership  LifeLink:  University of Colorado  Rural/Metro Ambulance  Crew: EMT-Basic, EMT-Paramedic, Registered
  32. 32. Police-Based Air Transport Maryland State Police First civilian (non-military) helicopter transport of a critical trauma patient  19 March 1970 Medical transport as well as law enforcement, search & rescue, disaster assessment
  33. 33. Pediatric Critical Care Transport Children’s Mercy, Kansas City Crew: RN, Respiratory Therapist, EMT (400 hrs additional training)
  34. 34. Neonatal Transport Royal Children’s Hospital Melbourne Started neonatal critical care transport in 1976  Neonatal Emergency Transport Service Gradually expanded  Paediatric Emergency Transport Service
  35. 35. Pediatrics “”The importance of pediatric interhospital transport has increased dramatically in the past 5 to 10 years. Reasons include improved capabilities of tertiary care centers receiving transported patients, advances in availability of portable equipment that functions well in moving vehicles, and widespread recognition that pediatric transport differs from that of adult transport… Research in the field remains preliminary …” McCloskey KA. Current Opinion in Pediatrics. 1996:8:236
  36. 36. Benefit to pediatric team? Specialized transport team (pediatric resident, pediatric intensive care nurse, and pediatric respiratory therapist; n=47) vs “standard” transport (n=92) Adverse events: 1 of 49 transports (2%) by the specialized team vs 18 of 92 transports (20%) by nonspecialized personnel (p < 0.05). Physiologic deterioration: 5 of 47 (11%) specialized team transports vs 11 of 92 (12%) transports by the nonspecialized team (NS). Edge WE et al. Crit Care Med 1994;22:1186
  37. 37. Transport Guidelines: US/Peds American Academy of Pediatrics “Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients” – January 2007 US$ 45 at web site (
  38. 38. Transport Guidelines: US American College of Critical Care Medicine – 2004 “…much of the published data comes from retrospective reviews and anecdotal reports. Experience and consensus opinion form the basis of much of these guidelines.” Warren J et al. Crit Care Med 2004; 32:256 –262
  39. 39. Transport Guidelines: Aus/NZ College of Intensive Care Medicine of Australia and New Zealand, Australian and New Zealand College of Anaesthetists, and Australasian College for Emergency Medicine - 2010 “Minimum Standards for Transport of Critically Ill Patients” Staffing, transport mode, equipment, monitoring, training Available at – or search for title
  40. 40. Accreditation Commission on Accreditation of Medical Transport Systems (CAMTS) “…dedicated to improving the quality of patient care and safety of the transport environment for services providing rotorwing, fixed wing, and ground transport systems.”
  41. 41. CAMTS-Accredited Services 151 accredited services in 46 US states, plus UK, Canada, South Africa, Hong Kong (a US-based service)
  42. 42. CAMTS Leadership Aerospace Medical Association  Emergency Nurses Association Air Medical Operations Association  National Air Transportation Association Air Medical Physicians Association  National Association of Air Medical American Academy of Pediatrics Communications Specialists American Association of Critical Care  National Association of EMS Physicians Nurses  National Association of Neonatal Nurses American Association for Respiratory Care  National Association of State EMS American College of Emergency Officials Physicians  National EMS Pilots Association American College of Surgeons  Air & Surface Transport Nurses Association of Air Medical Services Association Association of Critical Care Transport  International Association of Flight Paramedics  United States Transportation Command
  43. 43. CAMTS General Standards Capabilities and  Aircraft/Ambulance resources of the service section Medical personnel  Medical configurations Medical director  Operational issues Medical control  Equipment physician  Communications Clinical care supervisor  Management and Staffing and physical administration requirements  Management / policies Mission types  Quality management Initial and continuing  Safety committee education  Infection control
  44. 44. Sample MedicalDirection Standard 02.01.05 The medical director sets and reviews medical guidelines for current accepted medical practice, and medical guidelines are in a written format. 02.01.06 The medical director is actively involved in hiring, training and continuing education of all medical personnel for the service. 02.01.07 The medical director is actively involved in the care of critically ill and/or injured patients.
  45. 45. Sample InfectionControl Standard Provide annual tuberculosis testing and other testing, screenings and vaccinations as consistent with current national (CDC in the U.S.) guidelines. This includes medical personnel, pilots and mechanics.
  46. 46. CAMTS Ground Standards Vehicles Qualifications of drivers Maintenance and sanitation Mechanic Policies
  47. 47. CAMTS Rotorwing Standards FAA certificate Weather and weather minimums Pilot staffing and training Maintenance Refueling Community outreach
  48. 48. CAMTS Fixed-Wing Standards FAA certificate Aircraft Weather Pilot staffing and training Policies Maintenance Refueling Community outreach
  49. 49. Role of Physician Oversight Prehosp Emerg Care 2002;6:455
  50. 50. NAEMSP Position Paper Education, experience, licensure ○ Ex. #9: Understanding of aircraft capabilities, safety issues, weather minimums, and Federal Aviation Administration rules and regulations Operational and administrative duties ○ Ex: #14: Participates in the initial training and continuing education of all air medical personnel to ensure that they are currently certified and meet appropriate training and certification specific to air medical transport
  51. 51. Contact Information