Causes of Delay During Interfacility Transports of Injured Patients Transported by Air Ambulance

Assessing the effectiveness of a rural distribution program in reducing time to prothrombin complex concentrate administration in patients taking warfarin

STUDY OBJECTIVES

Reversal of warfarin-induced anticoagulation using prothrombin complex concentrate (PCC4) is more rapidly achieved than with traditional methods, such as fresh frozen plasma (FFP). In many rural facilities, the availability of both FFP and PCC4 has been limited. A tertiary hospital instituted a program to provide PCC4 to rural sites using an air transport team and pharmacy exchange. We hypothesized that increasing accessibility of PCC4 would shorten time to INR reversal.

METHODS

This was a retrospective study with the primary outcome being time to INR reversal (INR ≤ 1.6) and time to PCC4 administration from outside hospital admission. Active warfarin prescription, transfer to a tertiary facility, and administration of anticoagulation reversal between January 2013 and December 2020 were required for inclusion. Patients were grouped by dates before and after implementation of the program in August 2016. Linear regressions were performed to determine the effect of the variable and INR reversal methods on the time to INR reversal as well as the time to PCC4 administration. Time-to-event analysis was used to analyze the primary outcome between comparison groups. p values of less than 0.05 were considered significant.

RESULTS

Chart review identified 189 patients: 56 within the pre-implementation group and 133 within the post-implementation group. Statistics were compared between these two groups. The post-implementation group had a shorter time to INR reversal (median 9.97 h) compared with the pre-implementation group (median 14.58 h, p = 0.00004). Time to PCC4 administration was also significantly decreased (p = 0.023). No statistically significant differences were found for hospital survival or 30-day mortality.

CONCLUSION

In rural hospitals, increasing availability of PCC4 using air medical transport along with a medication exchange program significantly reduces time to PCC4 administration in warfarin anticoagulated patients.

Pre-alerts from critical care ambulances to trauma centers: a quantitative survey of trauma team leaders in Ontario, Canada

INTRODUCTION

Pre-alerts from paramedics to trauma centers are important for ensuring the highest quality of trauma care. Despite this, there is a paucity of data to support best practices in trauma pre-alert notifications. Within the trauma system of Ontario, Canada, the provincial critical care transport organization, Ornge, provides pre-alerts to major trauma centers, but standardization is currently lacking. This study examined the satisfaction of trauma team leaders' (TTLs) satisfaction with current trauma pre-alerts and their preferences for logistics, content, and structure.

METHODS

This was a quantitative survey of TTLs at adult and pediatric trauma centers across Ontario, Canada. Recruitment was through email to trauma directors, with follow-up efforts to target low-response sites to achieve good geographical representation. The survey was completed online and contained a combination of single or multiple-choice questions, Likert scales and free text options.

RESULTS

In total, 79 TTLs from adult and pediatric lead trauma centers across Ontario responded to the survey, which took place over a 120-day period. The survey achieved good geographical representation. Given the current processes, TTLs describe moderate satisfaction with room for improvement (median score 3, IQR 3-4 on a 5-point Likert scale). Their overall preference was for timely and direct communication, with some concerns about multiple channels of communication around logistics. Most TTLs agreed on the important and less important content details found in common standardized framework tools. For structure, 28/79 TTLs strongly preferred the cognitive aid ATMIST, 13/79 preferred IMIST-AMBO, and 8/79 preferred MIST or SBAR as the most useful.

CONCLUSIONS

There is room for improvement through standardizing communication and streamlined pre-alert channels. Some disagreements exist between TTLs, particularly regarding logistics. Further research should examine TTL satisfaction after implementing the change in the pre-alert notification framework, which can address localized issues through stakeholder meetings with individual TTLs.

Prehospital Trauma Compendium: Traumatic Pneumothorax Care - a position statement and resource document of NAEMSP

Emergency Medical Services (EMS) clinicians manage patients with traumatic pneumothoraces. These may be simple pneumothoraces that are less clinically impactful, or tension pneumothoraces that disturb perfusion, lead to shock, and impart significant risk for morbidity and mortality. Needle thoracostomy is the most common EMS treatment of tension pneumothorax, but despite the potentially life-saving value of needle thoracostomy, reports indicate frequent misapplication of the procedure as well as low rates of successful decompression. This has led some to question the value of prehospital needle thoracostomy and has prompted consideration of alternative approaches to management (e.g., simple thoracostomy, tube thoracostomy). EMS clinicians must determine when pleural decompression is indicated and optimize the safety and effectiveness of the procedure. Further, there is also ambiguity regarding EMS management of open pneumothoraces. To provide evidence-based guidance on the management of traumatic pneumothoraces in the EMS setting, NAEMSP performed a structured literature review and developed the following recommendations supported by the evidence summarized in the accompanying resource document.NAEMSP recommends:EMS identification of a tension pneumothorax must be guided by a combination of risk factors and physical findings, which may be augmented by diagnostic technologies.EMS clinicians should recognize the differences in the clinical presentation of a tension pneumothorax in spontaneously breathing patients and in patients receiving positive pressure ventilation.EMS clinicians should not perform pleural decompression in patients with simple pneumothoraces but should perform pleural decompression in patients with tension pneumothorax, if within the clinician's scope of practice.When within scope of practice, EMS clinicians should use needle thoracostomy as the primary strategy for pleural decompression of tension pneumothorax in most cases. EMS clinicians should take a patient-individualized approach to performing needle thoracostomy, influenced by factors known to impact chest wall thickness and risk for iatrogenic injury.Simple thoracostomy and tube thoracostomy may be used by highly trained EMS clinicians in select clinical settings with appropriate medical oversight and quality assurance.EMS systems must investigate and adopt strategies to confirm successful pleural decompression at the time thoracostomy is performed.Pleural decompression should be performed for patients with traumatic out-of-hospital circulatory arrest (TOHCA) if there are clinical signs of tension pneumothorax or suspicion thereof due to significant thoraco-abdominal trauma. Empiric bilateral decompression, however, is not routinely indicated in the absence of such findings.EMS clinicians should not routinely perform pleural decompression of suspected or confirmed simple pneumothorax prior to air-medical transport in most situations.EMS clinicians may consider placement of a vented chest seal in spontaneously breathing patients with open pneumothoraces.In patients receiving positive pressure ventilation who have open pneumothoraces, chest seals may be harmful and are not recommended.EMS physicians play an important role in developing curricula and leading quality management programs to both ensure that EMS clinicians are properly trained in the recognition and management of tension pneumothorax and to ensure that interventions for tension pneumothorax are performed appropriately, safely, and effectively.

Correlating Simulation Training and Assessment With Clinical Performance: A Feasibility Study

OBJECTIVE

Simulation education and assessment are increasingly used in prehospital curriculums. The objective of this study was to assess the challenges and feasibility of correlating evaluation data from an airway management simulation assessment with clinical performance.

METHODS

This study was undertaken in Ontario, the most populous province in Canada, where 13 bases are distributed in geographically diverse areas, from urban to rural and remote locations. This is a retrospective cohort study of paramedics who had completed simulation education and assessment in rapid sequence intubation. Logistic regression was used to assess for correlation between assessment scores (ie, the global score and the overall score and the definitive airway sans hypoxia/hypotension on the first attempt [DASH-1A] success in the field).

RESULTS

DASH-1A success when grouped by base varied from 25% to 100%. The odds of DASH-1A success increased for paramedics who had a higher overall score (odds ratio [OR]: 1.03; 95% confidence interval [CI], 0.96-1.11) and for paramedics who had a higher global rating (OR: 1.27; CI, 0.73-2.21) when accounting for base intubation frequency. The odds of DASH-1A success increased for paramedics who had a higher overall score (OR: 1.01; CI, 0.93-1.09) and decreased for paramedics who had a higher global rating (OR: 0.96; CI, 0.47-1.96) when accounting for base geography.

CONCLUSION

Although this study lacked a sample size large enough to draw conclusions, it provides a foundation and areas to improve in future work exploring the relationship between simulation assessments and clinical performance.

Use of Fixed Wing Modified Scene Air Ambulance Responses for Injured Patients in Northern Ontario: A Pilot Study

OBJECTIVE

Timely access to a lead trauma hospital (LTH) saves lives; however, the vast geography of Northern Ontario creates a barrier to equitable access to an LTH. Paramedics in Ontario follow the field trauma triage standard (FTTS) to identify which patients should be directly brought to an LTH. A pilot project was launched using a fixed wing modified scene response (MSR) to transport patients from Northern Ontario who met the FTTS directly to an LTH. This study aimed to 1) explore the impact of the fixed wing MSR pilot program on the time to LTH arrival for injured patients in Northern Ontario compared with the traditional interfacility transfer (IFT) process and 2) determine the frequency and specific FTTS criteria that were fulfilled.

METHODS

This was a retrospective cohort study of injured patients in Northern Ontario who were emergently transported to an LTH by the provincial air ambulance service between January 2016 and October 2021. Electronic patient care records were manually reviewed, and patient cases were grouped by their sending and receiving facilities to evaluate time differences between MSR and IFT.

RESULTS

For same-distance transports, the average time from injury to trauma center arrival was reduced with MSR (292.8 minutes) compared with IFT (507.8 minutes), with a mean difference of 130.3 minutes. All MSR cases and 90% of IFT cases met at least 1 FTTS criterion.

CONCLUSION

Fixed wing MSR improves access to timely definitive care for injured patients in Northern Ontario, and all patients transported in this pilot project met the trauma bypass criteria.

Transport of the patient with trauma: a narrative review

Trauma and injury place a significant burden on healthcare systems. In most high-income countries, well-developed acute pre-hospital and trauma care systems have been established. In Europe, mobile physician-staffed medical teams are available for the most severely injured patients and apply a wide variety of lifesaving interventions at the same time as ensuring patient comfort. In trauma systems providing pre-hospital care, medical interventions are performed earlier in the patient journey and do not affect time to definite care. The mode of transport from the accident scene depends on the organisation of the healthcare system and the level of hospital care to which the patient is transported. This varies from 'scoop and run' to a basic community care setting, to advanced helicopter emergency medical service transport to a level 4 trauma centre. Secondary transport of trauma patients to a higher level of care should be avoided and may lead to a delay in definitive care. Critically injured patients must be accompanied by at least two healthcare professionals, one of whom must be skilled in cardiopulmonary resuscitation and advanced airway management techniques. Ideally, the standard of care provided during transport, including the level of monitoring, should mirror hospital care. Pre-hospital care focuses on the critical care patient, but the majority of injured patients need only close observation and pain management during transport. Providing comfort and preventing additional injury is the responsibility of the whole transport team.

Prepatching Reduces Paramedic In-Hospital Time for Emergent Interfacility Transfers of Patients Requiring Mechanical Ventilation or Vasopressors: A Retrospective Cohort Study

OBJECTIVE

Regionalization of specialty medical services may necessitate an interfacility transfer. Prepatching is a model of care adopted by critical care transport organizations to reduce the transfer time to specialty care. In this model, paramedics communicate with a transport medical physician before arrival at the sending hospital to discuss a patient's condition and management plan, allowing paramedics to focus solely on packaging the patient when he or she arrives at the sending hospital. The objective of this study was to assess the impact of prepatching on paramedic in-hospital time for emergent interfacility transfers of patients requiring mechanical ventilation or vasopressor support.

METHODS

This is a retrospective cohort study of all emergent interfacility transfers by Ornge, the provincial critical care transport organization in Ontario, Canada, over a 4-year period. All patients over 18 years old who were either intubated or on vasopressor medications were included in the study population. Quantile regression was used to evaluate the impact of prepatching as well as patient and paramedic characteristics on paramedic in-hospital time.

RESULTS

A total of 4,466 emergent interfacility transports were included. Of these, 1,898 were completed with prepatching, and 2,568 were not. Vasopressor use was associated with significantly higher prepatching rates. Overall, prepatching reduced in-hospital time by 9 minutes at the 90th quantile across all patients. Increased in-hospital time was noted for patients on mechanical ventilation, on vasopressor medications, and transported by a fixed wing vehicle by 38, 29, and 49 minutes at the 90th quantile, respectively (P < .05). Conversely, patients transported by a critical care paramedic crew configuration were associated with a 27-minute decrease in in-hospital time at the 90th quantile compared with transport by an advanced care paramedic crew configuration (P < .05).

CONCLUSION

Prepatching reduced paramedic in-hospital time for emergent interfacility transports for patients who were mechanically ventilated or require vasopressors. These results suggest that prepatching can reduce the overall time to definitive care in high-risk patients, potentially improving patient outcomes in critically ill patients.

Characteristics associated with delays in decision to transfer injured patients

Introduction

The regionalized nature of trauma care necessitates interfacility transfer which is vulnerable to delays given its complexity. Little is known about the interval of time a patient spends at the sending hospital prior to when the transfer is initiated—the “decision to transfer” time. This primary objective of the study was to explore the impact of patient, environmental, and institutional characteristics on decision to transfer time.

Methods

This was a retrospective cohort study of injured adult patients who underwent emergent interfacility transfer by a provincial critical care transport organization over a 31-month period. Quantile regression was used to evaluate the impact of patient, environmental, and institutional characteristics on the time to decision to transfer.

Results

A total of 1128 patients were included. The median decision to transfer time was 2.42 h and the median total transport time was 3.12 h. The following variables were associated with an increase in time to decision to transfer at the 90th percentile of time: age >75 (+2.47 h), age 66–75 (+3.70 h), age 56–65 (+1.20 h), transfer between 00:00 and 07:59 (+2.08 h), and transfer in the summer (+2.25 h). The following variables were associated with a decrease in time to decision to transfer at the 90th percentile of time: Glasgow Coma Scale 3–8 (−2.21 h), respiratory rate >30 (−2.01 h), sending site being a community hospital with <100 beds (−4.11 h), or the sending site being a nursing station (−5.66 h).

Conclusion

Time to decision to transfer was a sizable proportion of the patients interfacility transfer. Older patients were associated with a delay in decision to transfer as were patients transferred overnight and in the summer. These findings may be used to support the implementation of geriatric trauma triage guidelines and promote ongoing education and quality improvement initiatives to decrease delay.

Association of Interfacility Helicopter versus Ground Ambulance Transport and in-Hospital Mortality among Trauma Patients

BACKGROUND

Relatively few studies have compared outcomes between helicopter transport (HT) and ground transport (GT) for the inter-facility transfer of trauma patients to tertiary trauma centers (TTC). Mixed results have been reported from these studies ranging from a slight increase in odds of survival for the severely injured to no evident benefit for HT patients. We hypothesized there was no adjusted difference in mortality between patients transported interfacility by HT or GT taking into account distance from TTC.

METHODS

Data from an inclusive statewide trauma registry was used to conduct a retrospective cohort study of adult (18+ years old) trauma patients who initially presented to a non-tertiary trauma center (NTC) before subsequent transfer by HT or GT to a TTC. Records from the NTC and TTC were linked (N = 9880). We used propensity adjusted, multivariable Cox proportional hazards models to assess the association of HT on mortality at 72-hour and within the first 2 weeks of arrival at a TTC; these multivariable analyses were stratified by distance (miles) between NTC and TTC: 21-90, and greater than 90.

RESULTS

Mean distance between NTC and TTC was greater for HT patients, 96.7 miles versus 69.9 miles for GT. A higher proportion of patients among the HT group had an ISS of 16 or higher (24.6% vs 10.9%), an initial SBP < 90 mmHg (7.3% vs 2.8%), and GCS < 10 (12.5% vs 3.7%) than the GT group. HT was associated with significantly decreased 72-hour mortality (HR 0.65, 95%CI 0.48-0.90) for patients transferred from a NTC <90 miles from the TTC. No association was seen for patients transferred more than 90 miles to the TTC. No significant association of HT and 2-week mortality was seen at any distance from the TTC.

CONCLUSIONS

Only for patients transferred from an NTC <90 miles from the receiving TTC was HT associated with a significantly decreased hazard of mortality in the first 72 hours. Many HT patients, especially from the most distant NTCs, had minor injuries and normal vital signs at both the NTC and TTC suggesting the decision to use HT for these patients was resource-driven rather than clinical.

Reduction in Interfacility Transfer Response Time after Implementation of an AutoLaunch Protocol

Background: Interfacility transfers (IFTs) are an essential component of healthcare systems to allow movement of patients between facilities. It is essential to limit any delays in patients receiving the care they require at the receiving facility. The primary objective of this study was to assess whether IFT response time was reduced after implementation of an AutoLaunch protocol, in which an ambulance is dispatched to the sending facility prior to acceptance of the patient by the receiving facility. The secondary objective was to describe the frequency and amount of time ambulances had to stage outside the sending facility in situations where the ambulance arrived prior to the patient being accepted by the receiving facility. Methods: This was a retrospective pre-post analysis of patients undergoing IFT for services not available at the sending facility between October 1, 2018 and September 30, 2019, with the AutoLaunch protocol being implemented on March 25, 2019. IFT response time was defined as the time the transfer request was initially made to the time the ambulance arrived at the sending facility. Dispatch call logs and transport records were analyzed before and after implementation of the AutoLaunch protocol to assess for a difference in IFT response time as well as frequency and amount of time ambulances had to stage. Results: Of 1,881 IFTs analyzed, 885 (47.0%) were completed under the traditional protocol and 996 (53.0%) were completed under the AutoLaunch protocol. The median IFT response time under the traditional protocol was 27.5 minutes (interquartile range (IQR): 17.9, 43.3), compared with 19.9 minutes (IQR: 12.8, 28.2) under the AutoLaunch protocol (p < 0.01), representing a 27.6% reduction in response time, or 7.6 minutes saved. Of the 996 AutoLaunch transfers, there were 215 incidents (21.6%) in which the IFT ambulance had to stage, and the median staging time was 10.1 minutes (IQR: 4.9, 24.2). Conclusions: Implementation of our AutoLaunch protocol resulted in a significant reduction in ambulance response time for interfacility transfers. Further studies are needed to assess whether the reduction in response time is associated with improved patient outcomes for certain conditions.

Rural family physician perspectives on communication with urban specialists: a qualitative study

OBJECTIVE

Communication is a key competency for medical education and comprehensive patient care. In rural environments, communication between rural family physicians and urban specialists is an essential pathway for clinical decision making. The aim of this study was to explore rural physicians' perspectives on communication with urban specialists during consultations and referrals.

SETTING

Newfoundland and Labrador, Canada.

PARTICIPANTS

This qualitative study involved semistructured, one-on-one interviews with rural family physicians (n=11) with varied career stages, geographical regions, and community sizes.

RESULTS

Four themes specific to communication in rural practice were identified. The themes included: (1) understanding the contexts of rural care; (2) geographical isolation and patient transfer; and (3) respectful discourse; and (4) overcoming communication challenges in referrals and consultations.

CONCLUSIONS

Communication between rural family physicians and urban specialists is a critical task in providing care for rural patients. Rural physicians see value in conveying unique aspects of rural clinical practice during communication with urban specialists, including context and the complexities of patient transfers.

Impact of Prepatching on Paramedic In-Hospital Times for Emergent Interfacility Transfers

Background: The care required for patients at times necessitates they be transferred to another hospital capable of providing specialized care, a process known as an interfacility transfer. Delays to appropriate care for critically ill patients are associated with increased morbidity and mortality. Improving efficiencies in interfacility transport process can thus expedite the time to critical treatment. Traditionally paramedics would patch to a transport medicine physician (TMP) after initial patient contact to discuss the case and expected management during transport. The concept of prepatch shifts this discussion between the TMP and paramedics prior to initial patient contact. The objective of this study was to assess if prepatching with paramedics prior to arrival at the patient reduced the in-hospital time for emergent interfacility transfers transported by a provincial critical care transport organization. Methods: This was a retrospective cohort study of all emergent, adult interfacility transports for patients transported by a provincial critical care transport organization in Ontario, Canada from January 2016 to December 2019. Quantile regression was used to evaluate the impact of prepatching as well as patient and paramedic characteristics on paramedic in-hospital time. Results: A total of 10,088 patients were included in the study, with 3,606 patients having a prepatch conducted and 6,482 without. Ventilated patients and vasopressor use were associated with higher prepatch rates; with the use of prepatch in these patients increasing over subsequent years of the study. Additionally, patients requiring higher levels of care, including being mechanically ventilated or dependent on vasopressors, were associated with longer in-hospital times. Prepatching reduced in-hospital time by 4 minutes at the 90^th quantile across all patients. Conclusion: Prepatching reduced paramedic in-hospital time for emergent interfacility transports. Although the clinical impact of this reduction in time is uncertain, prepatching may serve in facilitating shared mental modeling between paramedics and TMPs which may be beneficial to patient safety and team performance.