Interfacility Transport of Critically Ill Patients

ECMO cannulation across New England

BACKGROUND

Over the last 15 years, clinicians have increasingly used extracorporeal membrane oxygenation (ECMO) as a rescue technique, including cannulating patients in community hospitals without ECMO capabilities, leading to secondary ECMO transports.

OBJECTIVES

The objective was to evaluate the changes in cannulations and the number of cannulating centers over time.

METHODS

This is a retrospective review of transports across New England to ECMO centers in Boston from 2011 to 2022.

RESULTS

Over the years studied, 202 patients were cannulated and transported. VA ECMO was the most common configuration. This was a high-acuity cohort, with 26.4 % of VA ECMO patients having undergone cannulation during cardiopulmonary resuscitation (ECPR) and 6.1 % having central cannulation. The number of cannulations per year increased from 6 patients in 2011 to 36 in 2019 (p = 0.055). Cannulating centers also increased from 3 in 2011 to 14 in 2022. ECPR showed a similar trend, with increases in both ECPR patients and ECPR sites per year (p = 0.055).

CONCLUSIONS

The number of ECMO cannulations in the community has increased, with a high-acuity cohort of many patients undergoing ECPR. The number of patients cannulated at non-ECMO centers highlights the need for transport organizations and ECMO centers to address the needs of this high-acuity patient population.

Understanding How Hospital Nurses Address Operational Failures That Impact Patients: An Exploratory Study of Problem-Solving Behaviors

Operational failures in hospitals, such as communication breakdowns and equipment malfunctions, challenge nurses by disrupting patient care, workflow, and clinical processes. These failures are primarily addressed with short-term solutions, rather than comprehensive, long-term strategies. This study investigates the impact of operational failures on patients and examines whether nurses alter their problem-solving behavior in response to the perceived direct impact on patients. A qualitative, exploratory study was conducted in 23 wards across five Belgian hospitals. Data were collected through in-depth semi-structured interviews with 26 nurses and a group discussion with ward managers (n = 6). Findings reveal that barriers such as nurses' limited awareness regarding the broader impact of operational failures on patients, poor communication, and excessive workloads hinder problem-solving efforts. However, when operational failures result in patient harm, nurses are more likely to take corrective action to prevent recurrence. Enablers to enhance problem-solving behaviors include using narrative medicine to highlight patient safety risks, improvements to communication frameworks, the streamlining of reporting systems, and the allocation of adequate time and resources to address underlying issues. Furthermore, a proactive approach, grounded in Safety-II principles, emphasizes nurses' flexibility and adaptability, recognizing their indispensable role in learning from successful outcomes and making real-time adjustments to strengthen resilience within healthcare systems.

Effect of a Standardized Education Program for Interhospital Transport of Critically Ill Patients on Knowledge and Confidence in South Korea: A Pilot Study

Critical care transport (CCT) education and training for health care providers are important for patient safety. In this study, a structured education and training program for CCT was implemented as a pilot in South Korea, and the effects of improving knowledge and confidence among health care providers were evaluated. This retrospective observational study analyzed pre- and post-test scores and survey responses from participants in the education program. The education program consisted of a didactic lecture, skill practice, and simulation for 9 categories lasting 80 hours. The participants included nurses and emergency medical technicians with experience in emergency or critical care. The study consisted of 2 phases, with data collected through web-based evaluation forms and structured questionnaires. The program involved 20 participants across the 2 phases. Posteducation assessments revealed significant improvements in knowledge and confidence in CCT practices. The participants were especially satisfied with their skill in trauma management and advanced CCT simulations. The Korean Critical Care Transport Curriculum education program effectively enhanced the knowledge and confidence of health care providers in CCT. This standardized education model should be considered by policy makers and stakeholders to improve patient safety in emergency medical systems.

Outcomes and risk factors of transported patients with extracorporeal membrane oxygenation: An ECMO center experience

Background

Extracorporeal membrane oxygenation (ECMO) has been proven to be a support method and technology for patients with cardiopulmonary failure. However, the transport of patients under ECMO support is challenging given the high-risk technical maneuvers and patient-care concerns involved. Herein, we examined the safety of ECMO during the transport of critically ill patients and its impact on mortality rates, to provide more secure and effective transport strategies in clinical practice.

Method

To assess the safety of ECMO patient transport, this study conducted a retrospective analysis on critically ill adults who required ECMO support and transport at the intensive care unit (ICU) center between 2017 and 2023. The study utilized standard ECMO transport protocols and conducted a comprehensive statistical analysis of the collected clinical data and transport processes. The 28-day survival rate for ECMO patients was determined using Kaplan-Meier analysis, while logistic regression identified prognostic factors.

Result

Out of 303 patients supported with ECMO, 111 (36.6%) were transported. 69.4% of the transport group were male, mean age was (42.0±17.0) years, mean body mass index was (24.4±4.6) kg/m2, and veno-arterial-ECMO accounted for 52.5%. The median transportation distance was 190 (interquartile range [IQR]: 70-260) km, and the longest distance was 8100 km. The median transit time was 180 (IQR: 100-260) min, and the maximum duration was 1720 min. No severe adverse events including death or mechanical failure occurred during transportation. The 28-day survival rate was 64.7% (n=196) and ICU survival rate was 56.1% (n=170) for the entire cohort; whereas, the 28-day survival rate was 72.1% (n=80) and ICU survival rate was 66.7% (n=74) in the transport group. A non-significant difference in 28-day survival was observed between the two groups after propensity score matching (P=0.56). Additionally, we found that acute physiology and chronic health evaluation II score (odds ratio [OR]=1.06, P <0.01), lactate levels (>5 mmol/L, OR=2.80, P=0.01), and renal replacement therapy initiation (OR=3.03, P <0.01) were associated with increased mortality risk.

Conclusion

Transporting patients on ECMO between medical facilities is a safe procedure that does not increase patient mortality rates, provided it is orchestrated and executed by proficient transport teams. The prognostic outcome for these patients is predominantly influenced by their pre-existing medical conditions or by complications that may develop during the course of ECMO therapy. These results form the basis for the creation of specialized ECMO network hubs within healthcare regions.

Appropriately Matching Transport Care Units to Patients in Interhospital Transport Care: Implementation Study

BACKGROUND

In interfacility transport care, a critical challenge exists in accurately matching ambulance response levels to patients' needs, often hindered by limited access to essential patient data at the time of transport requests. Existing systems cannot integrate patient data from sending hospitals' electronic health records (EHRs) into the transfer request process, primarily due to privacy concerns, interoperability challenges, and the sensitive nature of EHR data. We introduce a distributed digital health platform, Interfacility Transport Care (ITC)-InfoChain, designed to solve this problem without compromising EHR security or data privacy.

OBJECTIVE

This study aimed to detail the implementation of ITC-InfoChain, a secure, blockchain-based platform designed to enhance real-time data sharing without compromising data privacy or EHR security.

METHODS

The ITC-InfoChain platform prototype was implemented on Amazon Web Services cloud infrastructure, using Hyperledger Fabric as a permissioned blockchain. Key elements included participant registration, identity management, and patient data collection isolated from the sending hospital's EHR system. The client program submits encrypted patient data to a distributed ledger, accessible to the receiving facility's critical care unit at the time of transport request and emergency medical services (EMS) teams during transport through the PatienTrack web app. Performance was evaluated through key performance indicators such as data transaction times and scalability across transaction loads.

RESULTS

The ITC-InfoChain demonstrated strong performance and scalability. Data transaction times averaged 3.1 seconds for smaller volumes (1-20 transactions) and 6.4 seconds for 100 transactions. Optimized configurations improved processing times to 1.8-1.9 seconds for 400 transactions. These results confirm the platform's capacity to handle high transaction volumes, supporting timely, real-time data access for decision-making during transport requests and patient transfers.

CONCLUSIONS

The ITC-InfoChain platform addresses the challenge of matching appropriate transport units to patient needs by ensuring data privacy, integrity, and real-time data sharing, enhancing the coordination of patient care. The platform's success suggests potential for regional pilots and broader adoption in secure health care systems. Stakeholder resistance due to blockchain unfamiliarity and data privacy concerns remains. Funding has been sought to support a pilot program to address these challenges through targeted education and engagement.

Feasibility and Safety of Targeted Temperature Management During Interhospital Transport of Post-Cardiac Arrest Patients

OBJECTIVES

Early initiation of targeted temperature management (TTM) is crucial for post-resuscitation care. Although TTM is initiated prior to transport and continued during interhospital transport (IHT), its feasibility and safety during IHT for cardiac arrest patients have not been thoroughly assessed. This study aims to evaluate the feasibility and safety of interhospital TTM for post-resuscitation patients.

METHODS

A retrospective analysis of post-cardiac arrest patients transported by a dedicated critical care transport team between January 2016 and April 2023 was conducted. Adult patients resuscitated from cardiac arrest without mental recovery were enrolled. The study population was divided into those who received TTM during IHT (IHT-TTM group) and those who did not (non-IHT-TTM group). The primary outcome was body temperature drop during transport, with hypotension, or desaturation during transport considered as secondary outcomes. Multivariable conditional logistic regression analysis was performed after frequency matching.

RESULTS

Among 593 post-cardiac arrest patients, 332 were included in the analysis after exclusions. Of these, 44 (13.3%) received TTM during IHT. Conditional logistic regression analysis showed significantly higher likelihood for a drop in body temperature during IHT for the IHT-TTM group, with an odds ratio (OR) of 12.91 (95%CI: 5.28-31.53). No significant association was found for hypotension (OR (95%CI): 0.72 (0.13-3.97)), or desaturation during IHT (0.65 (0.15-2.82)).

CONCLUSIONS

Administration of TTM during IHT for post-cardiac arrest patients appears to be feasible and safe. These findings support the implementation of dedicated critical care transport systems capable of providing TTM during IHT for post-cardiac arrest patients.

Management of Patients With Cardiac Arrest Requiring Interfacility Transport: A Scientific Statement From the American Heart Association

People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

Aeromedical Transport for Critically Ill Patients

Aeromedical transport (AMT) is an integral part of healthcare systems worldwide. In this article, the personnel and equipment required, associated safety considerations, and evidence supporting the use of AMT is reviewed, with an emphasis on helicopter emergency medical services (HEMS). Indications for HEMS as guideded by the Air Medical Prehospital Triage Score are presented. Lastly, physiologic considerations, which are important to both AMT crews and receiving clinicians, are reviewed.

Gamification in Critical Care Education and Practice

OBJECTIVES

To explore gamification as an alternative approach to healthcare education and its potential applications to critical care.

DATA SOURCES

English language manuscripts addressing: 1) gamification theory and application in healthcare and critical care and 2) implementation science focused on the knowledge-to-practice gap were identified in Medline and PubMed databases (inception to 2023).

STUDY SELECTION

Studies delineating gamification underpinnings, application in education or procedural mentoring, utilization for healthcare or critical care education and practice, and analyses of benefits or pitfalls in comparison to other educational or behavioral modification approaches.

DATA EXTRACTION

Data indicated the key gamification tenets and the venues within which they were used to enhance knowledge, support continuing medical education, teach procedural skills, enhance decision-making, or modify behavior.

DATA SYNTHESIS

Gamification engages learners in a visual and cognitive fashion using competitive approaches to enhance acquiring new knowledge or skills. While gamification may be used in a variety of settings, specific design elements may relate to the learning environment or learner styles. Additionally, solo and group gamification approaches demonstrate success and leverage adult learning theory elements in a low-stress and low-risk setting. The potential for gamification-driven behavioral modification to close the knowledge-to-practice gap and enable guideline and protocol compliance remains underutilized.

CONCLUSIONS

Gamification offers the potential to substantially enhance how critical care professionals acquire and then implement new knowledge in a fashion that is more engaging and rewarding than traditional approaches. Accordingly, educational undertakings from courses to offerings at medical professional meetings may benefit from being gamified.

A comparative analysis of current out-of-hospital transfusion protocols to expert recommendations

Aim

This study aimed to compare current out-of-hospital transfusion (OHT) protocols in Canadian civilian critical care transport organizations (CCTO) to expert recommendations and explore the variability and potential benefits of standardizing OHT practices across Canada.

Methods

A comprehensive cross-sectional study was conducted, encompassing all seven Canadian CCTOs that provide OHT. The study assessed adherence to expert recommendations and examined specific aspects of the transfusion process, such as indications for transfusion and cessation criteria.

Results

The study found an 89% adherence to expert recommendations for OHT among Canadian CCTOs. It highlighted a strong alignment between current practices and recommendations, possibly attributed to collaborative frameworks like the CAN-PATT network. However, notable variability and ambiguity were observed in transfusion indications and cessation criteria. The study also emphasized the potential benefits of standardizing OHT practices, such as improved policy formulation, better interpretation of emerging literature, and evaluation of OHT efficacy.

Conclusion

This cross-sectional study assessed how Canadian CCTOs implement OHT practices compared to expert-recommended practices. The findings underscore the importance of structured protocols in trauma management. Given the consistency in OHT protocol adoption and the comprehensive approach across CCTOs, there's a solid foundation for managing trauma patients in prehospital and transport settings across Canada. As OHT practices continue to evolve, sustained efforts are vital to refine, adapt, and elevate patient care standards in trauma management.

State-of-the-Art Evaluation of Acute Adult Disorders of Consciousness for the General Intensivist

OBJECTIVES

To provide a concise review of knowledge and practice pertaining to the diagnosis and initial management of unanticipated adult patient disorders of consciousness (DoC) by the general intensivist.

DATA SOURCES

Detailed search strategy using PubMed and OVID Medline for English language articles describing adult patient acute DoC diagnostic evaluation and initial management strategies including indications for transfer.

STUDY SELECTION

Descriptive and interventional studies that address acute adult DoC, their evaluation and initial management, indications for transfer, as well as outcome prognostication.

DATA EXTRACTION

Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for adult critical care practice.

DATA SYNTHESIS

Acute adult DoC may be categorized by etiology including structural, functional, infectious, inflammatory, and pharmacologic, the understanding of which drives diagnostic investigation, monitoring, acute therapy, and subsequent specialist care decisions including team-based local care as well as intra- and inter-facility transfer.

CONCLUSIONS

Acute adult DoC may be initially comprehensively addressed by the general intensivist using an etiology-driven and team-based approach. Certain clinical conditions, procedural expertise needs, or resource limitations inform transfer decision-making within a complex care facility or to one with greater complexity. Emerging collaborative science helps improve our current knowledge of acute DoC to better align therapies with underpinning etiologies.

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BACKGROUND

A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.

METHODS

The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.

RECOMMENDATIONS

The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.