European concepts for the domestic transport of highly infectious patients

Transport of Patients With High-Consequence Infectious Diseases: Development of European Capacity in Norway

Infection of Western aid workers with Ebola virus disease during the 2014-2016 West African outbreak demonstrated the need for medical evacuation to high-level isolation units in Europe and the United States. In Norway, an ad hoc preparedness team was established for aeromedical evacuation in case of need. In October 2014, this team transported an infected aid worker from the military section of Oslo Airport to Oslo University Hospital. To maintain and strengthen the capacity for domestic ambulance transport on the ground and in the air, the Norwegian Medical Emergency Response Team for High Consequence Infectious Diseases (in Norway known as "Nasjonalt medisinsk utrykningsteam for høyrisikosmitte"), or NORTH, was established as a permanent service in 2017. Recognizing the expertise of this domestic team, Norway was subsequently entrusted with the task of enhancing the European aeromedical transport capacity for high-consequence infectious diseases and establishing the Norwegian rescEU Jet Air Ambulance for Transport of Highly Infectious Patients, or NOJAHIP, in 2022. In this case study, we present experiences and lessons learned from these 2 services and discuss how they can be further developed.

Air Quality Monitoring During High-Level Biocontainment Ground Transport: Observations From Two Operational Exercises

OBJECTIVE

Stretcher transport isolators provide mobile, high-level biocontainment outside the hospital for patients with highly infectious diseases, such as Ebola virus disease. Air quality within this confined space may pose human health risks.

METHODS

Ambient air temperature, relative humidity, and CO₂ concentration were monitored within an isolator during 2 operational exercises with healthy volunteers, including a ground transport exercise of approximately 257 miles. In addition, failure of the blower unit providing ambient air to the isolator was simulated. A simple compartmental model was developed to predict CO₂ and H₂O concentrations within the isolator.

RESULTS

In both exercises, CO₂ and H₂O concentrations were elevated inside the isolator, reaching steady-state values of 4434 ± 1013 ppm CO₂ and 22 ± 2 mbar H₂O in the first exercise and 3038 ± 269 ppm CO₂ and 20 ± 1 mbar H₂O in the second exercise. When blower failure was simulated, CO₂ concentration exceeded 10 000 ppm within 8 minutes. A simple compartmental model predicted CO₂ and H₂O concentrations by accounting for human emissions and blower air exchange.

CONCLUSIONS

Attention to air quality within stretcher transport isolators (including adequate ventilation to prevent accumulation of CO₂ and other bioeffluents) is needed to optimize patient safety.

Long-Distance Aeromedical Transport of Patients with COVID-19 in Fixed-Wing Air Ambulance Using a Portable Isolation Unit: Opportunities, Limitations and Mitigation Strategies

Introduction

Aeromedical transport of patients with highly−infectious diseases, particularly over long distances with extended transport times, is a logistical, medical and organizational challenge. Following the 2014–2016 Ebola Crisis, sophisticated transport solutions have been developed, mostly utilizing large civilian and military airframes and the patient treated in a large isolation chamber. In the present COVID−19 pandemic, however, many services offer aeromedical transport of patients with highly−infectious diseases in much smaller portable medical isolation units (PMIU), with the medical team on the outside, delivering care through portholes.

Methods

We conducted a retrospective review of all transports of patients with proven or suspected COVID−19 disease, transported by Jetcall, Idstein, Germany, between April 1 and August 1, 2020, using a PMIU (EpiShuttle, EpiGuard AS, Oslo, Norway). Demographics and medical data were analyzed using the services’ standardized transport protocols. Transport−associated challenges and optimization strategies were identified by interviewing and debriefing all transport teams after each transport.

Results

Thirteen patients with COVID−19 have been transported in a PMIU over distances up to 7,400 kilometers (km), with flight times ranging from 02:15 hours to 11:10 hours. We identified the main limitations of PMIU transports as limited access to the patient and reduced manual dexterity when delivering care through the porthole gloves and disconnection of lines and tubes during loading and unloading procedures. Technical solutions such as bluetooth−enabled stethoscopes, cordless ultrasound scanners and communication devices, meticulous preparation of the PMIU and the patient following standardized protocols and scenario−based training of crew members can reduce some of the risks.

Discussion

Transporting a patient with COVID−19 or any other highly infectious disease in a PMIU is a feasible option even over long distances, but adding a significant layer of additional risk, thus requiring a careful and individualized risk−benefit analysis for each patient prior to transport.

Effectiveness of negative pressure isolation stretcher and rooms for SARS-CoV-2 nosocomial infection control and maintenance of South Korean emergency department capacity

Objective

There are growing concerns regarding the lack of COVID-19 pandemic response capacity in already overwhelmed emergency departments (EDs), and lack of proper isolation facilities. This study evaluated the effectiveness of the negative pressure isolation stretcher (NPIS) and additional negative pressure isolation rooms (NPIRs) on the maintenance of emergency care capacity during the COVID-19 outbreak.

Methods

A before and after intervention study was performed between February 27, 2020 and March 31, 2020 at the ED of Chungbuk National University Hospital, Cheongju, South Korea. A total of 2455 patients who visited the ED during the study period were included. Interventions included the introduction of the NPIS and additional NPIRs in the ED. The main outcome of the study was frequency of medical cessation. Secondary outcomes were the average number of ED visits and lengths of stay.

Results

After the intervention, average frequency of medical cessation was significantly decreased from 1.6 times per day (range 0–4) in the pre-intervention period to 0.6 times per day (range 0–3) in the post-intervention period (p-value <0.01). On the other hand, the number of patients visiting the ED increased significantly from 67.2 persons per day (range 58–79) pre-intervention to 76.3 persons per day (range 61–88) post-intervention (p value <0.01). However, there were no statistically significant differences in the average ED length of stay across the study phases (p value = 0.50).

Conclusions

This intervention may provide an effective way to prepare and meet the ED response needs of the COVID-19 pandemic.

Review of Literature for Air Medical Evacuation High-Level Containment Transport

INTRODUCTION

Aeromedical evacuation (AE) is a challenging process, further complicated when a patient has a highly hazardous communicable disease (HHCD). We conducted a review of the literature to evaluate the processes and procedures utilized for safe AE high-level containment transport (AE-HLCT) of patients with HHCDs.

METHODS

A literature search was performed in PubMed/MEDLINE (from 1966 through January 2019). Authors screened abstracts for inclusion criteria and full articles were reviewed if the abstract was deemed to contain information related to the aim.

RESULTS

Our search criteria yielded 14 publications and were separated based upon publication dates, with the natural break point being the beginning of the 2013-2016 Ebola virus disease epidemic. Best practices and recommendations from identified articles are subdivided into pre-flight preparations, inflight operations, and post-flight procedures.

CONCLUSIONS

Limited peer-reviewed literature exists on AE-HLCT, including important aspects related to healthcare worker fatigue, alertness, shift scheduling, and clinical care performance. This hinders the sharing of best practices to inform evacuations and equip teams for future outbreaks. Despite the successful use of different aircraft and technologies, the unique nature of the mission opens the opportunity for greater coordination and development of consensus standards for AE-HLCT operations.

Viral Hemorrhagic Fever Preparedness

The 2014–2016 outbreak of Ebola virus disease (EVD) in West Africa marked the 25th such occurrence but was noteworthy in its massive scope, causing more human morbidity and mortality than the previous 24 recorded outbreaks combined. As of April 2016, there were 28,652 cases resulting in at least 11,325 deaths, nearly all in the three nations of Guinea, Liberia, and Sierra Leone (Centers for Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html. Accessed 2 June 2016). Moreover, the 2014–2016 outbreak was the first in which patients, albeit few in number, were afforded sophisticated intensive care in the United States and in Europe. This “high-level containment care” (HLCC) was provided in specially designed purpose-built biocontainment units (BCUs). In this chapter, we explore the history and evolution of biocontainment, discuss its unique engineering and infection control modalities, and offer recommendations for the clinical and operational management of Ebola and other viral hemorrhagic fevers (VHFs).

[Specialized clinical facilities for the treatment of highly contagious, life-threatening infectious diseases : a comparison between Germany and 15 European nations]

BACKGROUND

Patients suffering from highly contagious, life-threatening infections should be treated in specialized clinical facilities that follow the highest infection control standards. Consensus statements defining technical equipment and operational procedures have been published in recent years, but the level of adherence to these has not been evaluated.

METHODS

Data summarized here comparing German and European isolation facilities are the partial results of a cross-sectional analysis conducted by the "European Network for Highly Infectious Diseases" that included 48 clinical care facilities in 16 European nations. Data collection was conducted using questionnaires and on-site visits, focussing on aspects of infrastructure, technical equipment, and the availability of trained personnel.

RESULTS

Although all centres enrolled were listed as "isolation units", all aspects evaluated differed broadly. Eighteen facilities fulfilled the definition of a 'High Level Isolation Unit', as 6/8 enrolled German facilities did. In contrast, 24 facilities could not operate independently from their co-located hospital.

DISCUSSION

Within and between nations contributing data disparities regarding the fulfilment of guidelines published were seen. German isolation facilities mostly fulfilled all criteria evaluated and performed on a high technical level. However, data presented do not reflect the current situation in Germany due to the time that has elapsed since the study was conducted. Hence, longitudinal data collection and harmonisation of terminology at least on national level needs to be implemented.

Transportation capacity for patients with highly infectious diseases in Europe: a survey in 16 nations

Highly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. In most European Union member states specialized isolation facilities are responsible for the management of such cases. Ground ambulances are often affiliated with those facilities because rapid relocation of patients is most desirable. To date, no pooled data on the accessibility, technical specifications and operational procedures for such transport capacities are available. During 2009, the ‘European Network for HIDs’ conducted a cross-sectional analysis of hospitals responsible for HID patients in Europe including an assessment of (a) legal aspects; (b) technical and infrastructure aspects; and (c) operational procedures for ground ambulances used for HID transport. Overall, 48 isolation facilities in 16 European countries were evaluated and feedback rates ranged from 78% to 100% (n = 37 to n = 48 centres). Only 46.8% (22/47) of all centres have both national and local guidelines regulating HID patient transport. If recommended, specific equipment is found in 90% of centres (9/10), but standard ambulances in only 6/13 centres (46%). Exclusive entrances (32/45; 71%) and pathways (30/44; 68.2%) for patient admission, as well as protocols for disinfection of ambulances (34/47; 72.3%) and equipment (30/43; 69.8%) exist in most centres. In conclusion, the availability and technical specifications of ambulances broadly differ, reflecting different preparedness levels within the European Union. Hence, regulations for technical specifications and operational procedures should be harmonized to promote patient and healthcare worker safety.