Unexpected Transports

1. Meeting the Unexpected
During Patient Transport
By: Robert Browning

2. OBJECTIVES
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Results
“The patients who developed adverse effects (AEs)
during transport had significantly higher mortality
within 24 hours of transport (1.9% vs 0.3%”3
“Therefore, EMS in not just a ‘transport service’. We
ARE an integral part of the healthcare system & need to
be educated, treated, & reimbursed as such!”
Kevin Collopy, MHL, FP-C, NRP

3. OBJECTIVES
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I-Touch Study
of
Adverse
Effects
2022

4. OBJECTIVES
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2013 Study
Of
Unexpected
Events (UE’s)
• Saturation change (23%)
• Arterial blood pressure change (12%)
• Change in respiratory rate (10%)
• Arrhythmias (4%)
• Convulsion (2%)
• Cardiopulmonary arrest (1%)
EQUIPMENT
• Oxygen probe tangle/displacement (27%)
• ECG lead displacement (19%)
• IV-line tangle (5%)

5. OBJECTIVES
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2021 Study
Of
Patients in
transport
Diagnosis4
Sepsis, n (%) 795 (28)
Non-ST-elevation ACS, n (%) 241 (8.5)
Arrhythmia, n (%) 190 (6.7)
Venous thromboembolism, n (%) 173 (6.1)
Stroke not eligible for thrombolysis, n (%) 172 (6.1)
Interventions4
Monitoring evaluation, n (%) 12 (54.5)
Oxygen, n (%) 3 (13.6)
Analgesic, n (%) 3 (13.6)
IV saline solution, n (%) 2 (9.1)
Antihypertensive, n (%) 2 (9.1)

6. OBJECTIVES
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INTERVENTIONS
TOP FIVE INTERVENTIONS
• Suctioning of ETT
• IV fluids
• Supplemental oxygen
• Muscle relaxants
• Sedatives

7. O2
SATURATION
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• 0.4% accidental self-extubation
• 8% oxygen desaturation
• 17% airway-related equipment
• 11% equipment related events (probe disconnection,
ventilator circuit leaks and ventilator failure)
• 1% involve accidental extubation2

8. Arrhythmias
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• One study of patients with coronary artery disease
reported arrhythmias in 84% of patients transported
from the ICU
• Atrial fibrillation
• Ventricular arrhythmias

9. Arterial blood
pressure
>20%
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• 54% substantial decrease in blood pressure
• one patient developed significant hypotension (systolic
blood pressure <90 mmHg)

10. OBJECTIVES
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2014 Study of
minor traumatic
injuries
• The aim of this study was to compare vital signs of minimally injured and
moderately injured patients during ambulance transport and subsequent
emergency department (ED) assessment.
• Patients were divided into two groups: minimally injured patients with neck
pain (group 1) and moderately injured patients with a closed ankle or wrist
fracture (group 2).
• Groups 1 and 2 included 90 and 118 patients, respectively. In group 1,
systolic blood pressure was significantly lower (P=0.001, median
difference 8 mmHg) and heart rate was significantly higher (P<0.01,
median difference 3 beats/min) during transport than during ED
assessment.
• There was no significant difference in respiratory rate in group 1 or
any of the vital signs in group 2.
• We conclude that transport anxiety has minimal effect on vital signs. In
trauma, clinicians should exclude tissue injury before attributing increased
systolic blood pressure or heart rate to anxiety.

11. Neurological
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• Agitation
• Restlessness, anxiety on (RASS scale)
• Seizure

12. Cardiopulmonary
arrest
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• Between 0.34% and 1.6%

13. Discussion
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• Physical movement of the bed itself may affect the patient’s
physiology due to physical stimuli, discomfort caused, and
pain.
• limitations to the movements of the accompanying
attendants may hamper their ability to provide continuing
supportive care.
• Difference in attitude while transporting patients in
ambulances. Everyone’s outlook changes when transporting
the patient leading to less-than-optimal preparation. This
originates from the feeling that there is less chance of
unfortunate incidents and a very temporary discontinuation
of critical treatment may not cause too much harm.
• We therefore want to emphasize that this thinking needs to
change and there should be emphasis on thorough
preparation. All attempts should be made to provide
“mobile” ICU-like care during intrahospital hospital
transport.”

14. DNI
DNRCC
DNRCCA
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• Ohio has two types of DNR An individual may be a:
• Do Not Resuscitate Comfort Care (DNRCC)
• Do Not Resuscitate Comfort Care - Arrest
(DNRCC-Arrest)
• The difference between the two is when the DNR protocol
becomes active.
• The DNR protocol lists the actions that a healthcare provider
will and will not take during your care.4

15. DNRCC
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• DNRCC
• Is effective as soon as an authorized healthcare provider signs
the form. This means that as soon as the form is signed, your
patient will not receive any of the treatments listed in the
DNR protocol as ‘Will Not,’ including
• Resuscitative medications
• CPR
• Ventilator care
• Continuous cardiac monitoring, or defibrillation.4

16. DNRCCA
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• DNRCCA–
• Arrest does not become effective until you experience:
• cardiac arrest
• respiratory arrest.
• Up until the time your patient experience a cardiac or
respiratory arrest, you will receive all medical care necessary
to treat any illness or injury, including intubation.
• You should treat your patient as any other medical patient.
• Should your patient experience cardiac or respiratory arrest
during treatment, at that time the DNR protocol will be
initiated, and all resuscitative measures will stop.4

17. Southwest
Ohio
Paramedic
Protocol
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II. Protocol
• A. Individuals with either a DNRCC or DNRCC-Arrest, which is activated, will receive the following care:
• 1. Conduct an initial assessment
• 2. Perform basic medical care
• 3. Clear airway of obstruction or suction
• 4. If necessary, (for comfort of the patient) may administer oxygen, CPAP, or BiPAP
• 5. If necessary, (for comfort of the patient) may obtain IV access for hydration or pain medication to relieve discomfort, but not to prolong death
• 6. If possible, may contact other appropriate health care providers
• B. Once the DNR protocol is activated, EMS personnel will not:
• 1. Perform CPR
• 2. Insert artificial airway adjunct (intubation, ventilator, etc.)
• 3. Administer medications with the intent of restarting the heart or breathing
• 4. Defibrillate, cardiovert, or initiate pacing
• 5. Initiate continuous cardiac monitoring
• C. In the event a DNR is presented to EMS that is neither of the above (I.B.), then communication with a base hospital physician, EMS medical
advisor, personal physician, physician on the scene, physician assistant, or advanced practice registered nurse I shall be established.
• D. A DNR shall NOT BE HONORED where the patient is pregnant, where withholding CPR would terminate the pregnancy.
• E. In the case of any doubt or reservation as to the validity or authenticity of any DNR, and absent authorization by a base hospital physician,
EMS medical advisor, personal physician, physician on the scene, physician assistant, or advanced practice registered nurse I to withhold CPR,
the Medic/EMT shall provide CPR to the patient and shall document the reasons for not complying with the DNR.
• F. In the event resuscitation is initiated on a patient and then a valid DNR is subsequently identified, resuscitation may be terminated in
compliance with that DNR. Documentation shall be made on the run sheet indicating the events that happened set forth in chronological
order. In the event a DNR is identified after a patient has been intubated, the tube shall not be removed in the prehospital setting. If the initial
resuscitation has restored cardiac rhythm, the patient should be transported to the nearest appropriate medical facility with no further
procedures or pharmacological measures undertaken, except by authorization from the base hospital physician, medical advisor, or attending
physician. Communication with a physician should be established.
• G. When the DNR Comfort Care protocol is performed, the suggested documentation on the patient care report should include the following
information:
• 1. The document identifying the DNR Comfort Care status of the patient.
• 2. The method of verification of the patient’s identity if any was found through reasonable efforts.
• 3. DNR Comfort Care or DNR Comfort Care-Arrest classification. Page 23 of 211 A106 DO NOT RESUSCITATE ORDERS IN THE FIELD A106 Last
Modified: Academy of Medicine of Cincinnati – Protocols for SW Ohio Prehospital Care Clinical Practice Guidelines 2023 2023
• 4. All actions taken to implement the DNR Comfort Care protocol.
• 5. All unusual events occurring enroute or on scene including interactions with family members, bystanders, or health care providers.

18. Is Propofol
approved for
Medic
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• KY - must have a second Medic/R.N./M.D. and
must be through an IV Pump. Can not initiat
but can restart
• IND – NO
• OH - NO

19. What can a
RN do?
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• RN From hospital
• Ex. Patient sent from hospital receiving TPA. The
RN is only able to administer/maintain the TPA
• RN with service – Operates under that service
Standard operating procedure written by their
medical director.

20. References
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1. Zirpe KG, Tiwari AM, Kulkarni AP, Govil D, Dixit SB, Munjal M, Sinha S, Samavedam S, Singh YP, Kuragayala SD,
Chandankhede SR, Patil V, Agarwala B, Jain S, Pattajoshi S, Padyana M, Kumar A, Joshi Z, Sircar M, Khunteta S,
Pande R, Mishra R. Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter,
Prospective, Observational Study (I-TOUCH Study). Indian J Crit Care Med. 2023 Sep;27(9):635-641. doi:
10.5005/jp-journals-10071-24530. PMID: 37719359; PMCID: PMC10504651.
2. Venkategowda PM, Rao SM, Mutkule DP
, Taggu AN. Unexpected events occurring during the intra-hospital
transport of critically ill ICU patients. Indian J Crit Care Med. 2014 Jun;18(6):354-7. doi: 10.4103/0972-
5229.133880. PMID: 24987233; PMCID: PMC4071678.
3. Knight PH, Maheshwari N, Hussain J, Scholl M, Hughes M, Papadimos TJ, Guo WA, Cipolla J, Stawicki SP, Latchana
N. Complications during intrahospital transport of critically ill patients: Focus on risk identification and
prevention. Int J Crit Illn Inj Sci. 2015 Oct-Dec;5(4):256-64. doi: 10.4103/2229-5151.170840. PMID: 26807395;
PMCID: PMC4705572.
4. Pedrotti CHS, Accorsi TAD, Amicis Lima K, Filho JROS, Morbeck RA, Cordioli E. Cross-sectional study of the
ambulance transport between healthcare facilities with medical support via telemedicine: Easy, effective, and
safe tool. PLoS One. 2021 Sep 30;16(9):e0257801. doi: 10.1371/journal.pone.0257801. PMID: 34591876; PMCID:
PMC8483335.
5. de Anda HH, Moy HP. EMS Ground Transport Safety. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558971/
6. Knight PH, Maheshwari N, Hussain J, Scholl M, Hughes M, Papadimos TJ, Guo WA, Cipolla J, Stawicki SP, Latchana
N. Complications during intrahospital transport of critically ill patients: Focus on risk identification and
prevention. Int J Crit Illn Inj Sci. 2015 Oct-Dec;5(4):256-64. doi: 10.4103/2229-5151.170840. PMID: 26807395;
PMCID: PMC4705572.
7. Bruijns SR, Guly HR, Wallis LA. Vital signs during and following ambulance transfer. Eur J Emerg Med. 2014
Apr;21(2):136-8. doi: 10.1097/MEJ.0b013e32836188b4. PMID: 23611818.
8. Singh S, Kerndt CC, Davis D. Ringer's Lactate. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK500033/
9. Ohio Administrative Code Chapter 3701 – 62

21. THANK YOU
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network@paramedichs.org
Robert W. Browning