For ACEM 2011 participation : Critical Care transfer

1. David C. Cone, MD
Associate Professor of Emergency Medicine
Yale University School of Medicine
President 2007-2008, National Association of EMS Physicians

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. Home position
Yale University
New Haven, Connecticut
Yale-New Haven Medical Center

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. 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. 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.  “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. Selection of mode of transport
 1. Speed / distance
 2. Clinical abilities of crew
 3. Equipment

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. 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. Buffalo, New York
GIS 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. 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. Who should staff a critical care
transport?
 Physicians?
 Nurses?
 Paramedics?
 Respiratory therapists?
 “Clinical management during
transport must aim to at least equal
management at the point of referral.”
 Aust/NZ Standards: www.cicm.org.au

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. 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. 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. Respiratory therapists
 Many transport teams use respiratory
therapists because of the high numbers
of intubated/ventilated patients

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. 3. Specialized Equipment
 Neonatal isolettes
 Intra-aortic balloon pumps
 Left ventricular assist devices
 ECMO
 Transport ventilators

20. Transport is not risk-free

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. 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. 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. Potential Benefits:
Cardiac Arrest
 Therapeutic hypothermia
 Endovascular cooling
 Interventional cardiology
Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26

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. 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 (ccforum.com/content/10/1/R6)

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 (ccforum.com/content/10/1/R6)

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 (ccforum.com/content/10/1/R6)

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. Hospital-Based Transport Team
 Lutheran Hospital, Fort Wayne, Indiana
 3 ground ambulances
 One helicopter
 Each staffed with nurse and paramedic

31. Hospital/Private Partnership
 LifeLink:
 University of Colorado
 Rural/Metro Ambulance
 Crew: EMT-Basic, EMT-Paramedic,
Registered Nurse
www.ruralmetrocolorado.com/Rural
Metro/CriticalCareTransport.aspx

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. Pediatric Critical Care Transport
 Children’s Mercy, Kansas City
 Crew: RN, Respiratory Therapist,
EMT (400 hrs additional training)

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. 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. 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. 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 (www.aap.org)

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. 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 www.cicm.org.au – or search for title

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.”
 www.camts.org

41. CAMTS-Accredited Services
 151 accredited services in 46 US states,
plus UK, Canada, South Africa, Hong
Kong (a US-based service)

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. 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. Sample Medical
Direction 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. Sample Infection
Control Standard
 02.06.07.1.b. 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. CAMTS Ground Standards
 Vehicles
 Qualifications of drivers
 Maintenance and sanitation
 Mechanic
 Policies

47. CAMTS Rotorwing Standards
 FAA certificate
 Weather and weather minimums
 Pilot staffing and training
 Maintenance
 Refueling
 Community outreach

48. CAMTS Fixed-Wing Standards
 FAA certificate
 Aircraft
 Weather
 Pilot staffing and training
 Policies
 Maintenance
 Refueling
 Community outreach

49. Role of Physician Oversight
Prehosp Emerg Care 2002;6:455

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. Contact Information
 david.cone@yale.edu