The Importance of Ground Critical Care Transport

Mobile Critical Care in Resource-Limited Settings: An Unmet Need

Care of the critically ill in resource-limited areas, inside or outside the intensive care unit (ICU), is indispensable. Murthy and Adhikari noted that about 70% of patients in low-middle income (LMIC) areas could benefit from good critical care. Many patients in resource-limited settings still die before getting to the hospital. Investing in capacity building by strengthening and expanding ICU capability and training intensivists, critical care nurses, respiratory therapists, and other ICU staff is essential, but this process will take years. Also, having advanced healthcare facilities that are still far from remote areas will not do much to alleviate distance and mode of transportation as barriers to achieving good critical care. This paper discusses the importance of mobile critical care units (MCCUs) in supporting and enhancing existing emergency medical systems. MCCUs will be crucial in addressing critical delays in transportation and time to receive appropriate lifesaving critical care in remote areas. They are incredibly versatile and could be used to transfer severely ill patients to a higher level of care from the field, safely transfer critically ill patients between hospitals, and, sometimes, almost more importantly, provide standalone short-term critical care in regions where ICUs might be absent or immediately inaccessible. MCCUs should not be used as a substitute for primary care or to bypass readily available services at local healthcare centers. It is essential to rethink the traditional paradigm of 'prehospital care' and 'hospital care' and focus on improving the care of critically ill patients from the field to the hospital.

Nurse escorts' perceptions of nurse-led inter-hospital ambulance transfer in the Wheatbelt region of Western Australia: A descriptive survey study

INTRODUCTION

The Western Australia (WA) Country Health Service (WACHS) requires the ward or emergency department (ED) registered nurse (RN) to assume the responsibility of conducting nurse-led interhospital patient road ambulance transfers, in the absence of an available registered paramedic (RP). The generalist nurse escort with no specialised training is allocated to the patient transport from their rostered shifts when the need arises, and, in some instances, this nurse may not have been in an ambulance before. Patients requiring transfer are usually prioritised over hospital patient care because of the life-threatening nature of these situations and the urgency to get them to tertiary care facilities. This study explored nurses' perceptions about caring for a patient during road ambulance transfer, with an aim of supporting future policy formulation and decision-making to guide nurses' training, induction and ongoing education on interhospital transfers.

OBJECTIVE

To examine the perceptions of hospital-employed registered nurses caring for a patient during road ambulance transfer from rural Western Australia.

DESIGN

A descriptive survey design included 23 questions to clarify the level of experience and training, the prevalence of clinical deterioration and the confidence to manage patient care.

FINDINGS

Findings from the surveys indicated that nurses often felt overwhelmed by the responsibility of the patient transfer, unclear guidelines, limited preparation and handover, lack of orientation to the ambulance environment, difficulty escalating care during transfer and no insight into the return to base process.

DISCUSSION

To explore how the RN who normally works within a well-organised and accessible multidisciplinary team manages caring for a patient in an unfamiliar mobile environment, the study was conducted within WACHS in the Wheatbelt Region of WA involving 27 health care sites. Participating nurses were asked several broad questions to explore their perceptions on how well-equipped they are in managing clinical care and deterioration during transfer; what are the challenges that they face while doing so and how confident they are about their knowledge, skill level and scope of clinical practice in supporting patients during interhospital transfer?

CONCLUSION

Wheatbelt nurse escorts were capable, generalist nurses with a demonstrated skill set in managing patient care during transfer when needed. The 'back of the ambulance' was a challenging environment for nurses to engage in the type of care usually provided in the hospital setting, which come with a high level of uncertainty and anxiety for both patient outcome and own well-being.

Outcomes of Patients Transported in the Prone Position to a Regional Extracorporeal Membrane Oxygenation Center: A Retrospective Cohort Study

Prone positioning is associated with improved mortality in patients with moderate/severe acute respiratory distress syndrome (ARDS) and has been increasingly used throughout the COVID-19 pandemic. In patients with refractory hypoxemia, transfer to an extracorporeal membrane oxygenation (ECMO) center may improve outcome but may be challenging due to severely compromised gas exchange. Transport of these patients in prone position may be advantageous; however, there is a paucity of data on their outcomes.

OBJECTIVES

The primary objective of this retrospective cohort study was to describe the early outcomes of ARDS patients transported in prone position for evaluation at a regional ECMO center. A secondary objective was to examine the safety of their transport in the prone position.

DESIGN

Retrospective cohort study.

SETTING

This study used patient charts from Ornge and Toronto General Hospital in Ontario, Canada, between February 1, 2020, and November 31, 2021.

PARTICIPANTS

Patient with ARDS transported in the prone position for ECMO evaluation to Toronto General Hospital.

MAIN OUTCOMES AND MEASURES

Descriptive analysis of patients transported in the prone position and their outcomes.

RESULTS

One hundred fifteen patients were included. Seventy-two received ECMO (63%) and 51 died (44%) with ARDS and sepsis as the most common listed causes of death. Patients were transported primarily for COVID-related indications (93%). Few patients required additional analgesia (8%), vasopressors (4%), or experienced clinically relevant desaturation during transport (2%).

CONCLUSIONS AND RELEVANCE

This cohort of patients with severe ARDS transported in prone position had outcomes ranging from similar to better compared with existing literature. Prone transport was performed safely with few complications or escalation in treatments. Prone transport to an ECMO center should be regarded as safe and potentially beneficial for patients with ARDS and refractory hypoxemia.

Air Versus Ground Transport Times in an Urban Center

PURPOSE

Given that the benefits of helicopter transport vary with geography and healthcare systems, we assessed transport times for rotor wing versus ground transport over a 10 year period in an urban setting.

MATERIALS AND METHODS

All completed transports from 153 sending hospitals in New England from 2009 through 2018 to 8 local tertiary care centers were extracted from an administrative database. The primary outcome of interest was patient-loaded transport time for rotor wing versus ground transports. Overall, 25,483 patient transports met the inclusion criteria and were included in this study. We assessed patient-loaded transport time for all transports, and determined mean time to arrive at the scene, scene to patient time, the bedside time, and distance at which the patient-loaded transport time was faster for rotor wing than for ground transport. We also performed subgroup analyses, evaluating transport times by time of day, day of the week, and destination.

RESULTS

The most common indication for transport was adult trauma, (n = 6,008, 23.6%) followed by adult cardiac (n = 4359, 17.1%), adult neuro (3729 14.6%), and adult medical (n = 3691, 14.5%). The median miles traveled for all transports was 26.0, IQR 14-38, ranging from 1 to 264 miles. The median patient-loaded transport time was 27 min (IQR 15-40) for all transports. Nearly all time intervals were shorter for rotor wing versus ground transports, and patient-loaded transport time was significantly shorter at 15 minutes compared to 38 minutes (IQR 12-22 vs 28-33, p < 0.001). There was no distance at which the patient-loaded transport time was faster for ground transport than for rotor wing.

CONCLUSIONS

In over 25,000 transports over 10 years, in a compact metropolitan area with relatively short transport distances and times, the use of the helicopter was associated with substantial time savings.

Interfacility Transport of Critically Ill Patients

OBJECTIVES

To assess recent advances in interfacility critical care transport.

DATA SOURCES

PubMed English language publications plus chapters and professional organization publications.

STUDY SELECTION

Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients.

DATA EXTRACTION

Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport.

DATA SYNTHESIS

The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis.

CONCLUSIONS

Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Evaluation of statewide utilization of helicopter emergency medical services for interfacility transfer

BACKGROUND

Helicopter emergency medical services (HEMSs) are used with increasing frequency for the transportation of injured patients from the scene and from treatment facilities to higher levels of care. Improved outcomes have been difficult to establish, and reports of overutilization and financial harm have been published. Our study was performed to evaluate statewide utilization for interfacility transfers (IFTs).

METHODS

Data from the North Carolina state trauma registry from 2013 to 2017 were evaluated and ground, and helicopter IFTs were compared.

RESULTS

Overall interfacility use of HEMSs peaked at 7,861 patient transports in 2016, and the percent of all IFTs fell from 17% to 13.3% over the study period. Helicopter emergency medical services patients were more likely to be male (69.8%) and younger (48.0 vs. 56.2 years), and have higher Injury Severity Scores (14.6 vs. 9.0) and higher mortality (10.5% vs. 2.8%) than ground emergency medical services (GEMSs) patients. When adjusted for age, sex, Injury Severity Score, and transport distance, HEMSs survival was significantly higher (odds ratio, 0.353; 95% CI, 0.308-0.404; p < 0.0001). Normal prehospital vital signs (VSs) and Glasgow Coma Scale score motor component (GCS-M) were associated with low mortality rates in both groups. Abnormal prehospital VSs and GCS-M were associated with an 11.8% mortality rate in HEMSs patients and 3.1% in GEMSs patients. Normal referring facility VSs and GCS-M did not confer similar protection with a mortality rate of 10.0% in HEMSs patients and 2.8% in GEMSs. Changes in prehospital to referring facility VSs did not demonstrate a low mortality group. Abbreviated Injury Scale and changes in VSs did not identify HEMSs transport benefit groups.

CONCLUSION

The proportion of HEMSs transfers fell over the study period and, while associated with a 10.5% mortality rate, had an outcome benefit compared with GEMSs. These patients could not be sorted into risk categories for transportation choice based on VSs or GCS-M derangement or by changes thereof, and opportunities for system improvement were not identified.

LEVEL OF EVIDENCE

Prognostic/epidemiological study, level III; Care Management, level IV.

Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19

Background

While emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic.

Objective

We review the current evidence on hypoxemia in COVID-19 and place it in the context of known evidence-based management of hypoxemic respiratory failure in the emergency department.

Discussion

COVID-19 causes mortality primarily through the development of acute respiratory distress syndrome (ARDS), with hypoxemia arising from shunt, a mismatch of ventilation and perfusion. Management of patients developing ARDS should focus on mitigating derecruitment and avoiding volutrauma or barotrauma.

Conclusions

High flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.

Transport of a Nonintubated Prone Patient with Severe Hypoxemic Respiratory Failure Due to COVID-19

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster. Prone positioning improves mortality in severe hypoxemic respiratory failure, including COVID-19. While this is effective for intubated patients with moderate-to-severe ARDS, it has also been shown to be beneficial for non-intubated patients. Critical care transport (CCT) has become an essential component of combating COVID-19, frequently transporting patients to receive advanced respiratory therapies and distribute patients in concert with available resources. With increasing awake proning, CCT teams may encounter patients supported in the prone position. Historically, transporting in the prone position has not been embraced due to substantial risks of desaturation during transport. In this case report, we describe the first known report of transporting a non-intubated, critically ill COVID-19 patient in the prone position.

Changes in Oxygen Saturation and Mean Arterial Pressure With Inhaled Epoprostenol in Transport

OBJECTIVE

Patients with hypoxemic respiratory failure have traditionally been considered one of the riskiest patient populations to transport, given the potential for desaturation with movement. We performed a retrospective cohort study to analyze our experience using inhaled epoprostenol in transport, with a primary objective of assessing change in the oxygen saturation throughout the transport.

METHODS

The transport records of patients with severe hypoxemic respiratory failure or right heart failure, transported on inhaled epoprostenol, were reviewed. The primary outcome was the change in SpO₂ from the start of the inhaled epoprostenol transport to the time of handover of care at the receiving institution. The secondary outcome was the change in the mean arterial pressure (MAP).

RESULTS

Comparing the initial SpO₂ to the final, there was no significant difference in oxygenation between time 0 and the transfer of care at the receiving hospital at 91% versus 93% (interquartile range [IQR] 86.0-93.5 vs 87.5-96.0, P = .49). Comparing the SpO₂ for those who had inhaled epoprostenol started by the transport team showed a larger change at 86% compared to 93% (IQR: 83.0-91.0 vs 86.5-94.5, P = .04). There was no change in the median MAP from time 0 to the end of the transport (77 vs 75 mm Hg, IQR, 67.5-84.8 vs 68.5-85.8, P = .70).

CONCLUSIONS

In this study, patients with severe cardiopulmonary compromise transported on inhaled epoprostenol had no significant change in their median oxygen saturations, with the overall population increasing from 91% to 93%. When inhaled epoprostenol was initiated by the transport team, the improvement was clinically and statistically significant with an increase in SpO₂ from 86% to 93%, with a final oxygen saturation comparable to those who were on the medication at the time of the team's arrival.

Inhaled Epoprostenol to Facilitate Safe Transport in Legionnaires' Disease

Hypoxemic patients often desaturate further with movement and transport. While inhaled epoprostenol does not improve mortality, improving oxygenation allows for transport of severely hypoxemic patients to tertiary care centers with a related improvement in mortality rates. Extracorporeal membrane oxygenation (ECMO) use is increasing in frequency for patients with refractory hypoxemia, and with increasing regionalization of care, safe transport of hypoxemic patients only becomes more important. In this series, four cases are presented of young patients with severe hypoxemic respiratory failure from Legionnaires' disease transported on inhaled epoprostenol to ECMO centers for consideration of cannulation. With continued climate changes, Legionella and other pathogens are likely to be a continued threat. As such, optimizing oxygenation to allow for transport should continue to be a priority for critical care transport (CCT) services.

Critical Care Transport of Patients With Brain Injuries

Critical care transport began in the 1970s as a response to the growing need to be able to transport critically ill and injured patients to tertiary care centers for higher levels of care or specialized treatments. Patients in critical condition now are transported great distances to receive potentially lifesaving treatment and interventions. Modes of critical care transport include ambulances, helicopters, and airplanes. Critical care transport teams consist of highly skilled paramedics, registered nurses, respiratory therapists, nurse practitioners, and physicians. Many patient populations benefit from transfer to a higher level of care via critical care transport, including patients who suffer acute neurologic insult such as spontaneous intracranial hemorrhage and ischemic stroke.

Outcomes of Ventilated Patients With Sepsis Who Undergo Interhospital Transfer: A Nationwide Linked Analysis

OBJECTIVES

The outcomes of critically ill patients who undergo interhospital transfer are not well understood. Physicians assume that patients who undergo interhospital transfer will receive more advanced care that may translate into decreased morbidity or mortality relative to a similar patient who is not transferred. However, there is little empirical evidence to support this assumption. We examined country-level U.S. data from the Nationwide Readmissions Database to examine whether, in mechanically ventilated patients with sepsis, interhospital transfer is associated with a mortality benefit.

DESIGN

Retrospective data analysis using complex survey design regression methods with propensity score matching.

SETTING

The Nationwide Readmissions Database contains information about hospital admissions from 22 States, accounting for roughly half of U.S. hospitalizations; the database contains linkage numbers so that admissions and transfers for the same patient can be linked across 1 year of follow-up.

PATIENTS

From the 2013 Nationwide Readmission Database Sample, 14,325,172 hospital admissions were analyzed. There were 61,493 patients with sepsis and on mechanical ventilation. Of these, 1,630 patients (2.7%) were transferred during their hospitalization. A propensity-matched cohort of 1,630 patients who did not undergo interhospital transfer was identified.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The exposure of interest was interhospital transfer to an acute care facility. The primary outcome was hospital mortality; the secondary outcome was hospital length of stay. The propensity score included age, gender, insurance coverage, do not resuscitate status, use of renal replacement therapy, presence of shock, and Elixhauser comorbidities index. After propensity matching, interhospital transfer was not associated with a difference in in-hospital mortality (12.3% interhospital transfer vs 12.7% non-interhospital transfer; p = 0.74). However, interhospital transfer was associated with a longer total hospital length of stay (12.8 d interquartile range, 7.7-21.6 for interhospital transfer vs 9.1 d interquartile range, 5.1-17.0 for non-interhospital transfer; p < 0.01).

CONCLUSIONS

Patients with sepsis requiring mechanical ventilation who underwent interhospital transfer did not have improved outcomes compared with a cohort with matched characteristics who were not transferred. The study raises questions about the risk-benefit profile of interhospital transfer as an intervention.