Critical Care Transport Service Research Articles

Push Dose Epinephrine Use in the Management of Hypotension During Critical Care Transport

Introduction: Hypotension is a critical event during the transport of critically ill patients. Push dose vasopressor use, though widely adopted by anesthesiologists, has only recently found use in the field of emergency medicine and may have utility in the management of out-of-hospital hypotension. This study aimed to characterize the hemodynamic effects and adverse events that occur following push dose epinephrine (PDE) administration by critical care transport (CCT) providers to correct documented hypotension. Methods: We performed a retrospective observational study of patients transported by a regional critical care transport service and who received PDE during transport to correct documented hypotension. Per protocol, 10–20 µg of 1:100,000 epinephrine was given intravenously every 2 min until: (1) the systolic blood pressure (SBP) was at least 90 mmHg, or (2) the mean arterial pressure (MAP) was 65 mmHg or greater. All patients were over 18 years of age and were transported between January 1, 2015 and December 31, 2016. Primary outcomes of interest were the primary diagnoses associated with PDE use, hemodynamic outcomes of the intervention, and adverse events. Results: During the study period 100 doses of push dose epinephrine were given during the transport of 58 patients. Of these, 94 (94.0%) were found to be appropriately dosed and indicated per protocol. The most common diagnoses associated with PDE use were: post-cardiac arrest (n = 24), sepsis (n = 9), altered mental status (n = 7), and cardiogenic shock (n = 3). The median increase in MAP across all doses was 13.0 (5.0–34.0) mmHg, and the heart rate increase was 2.0 (−1.0–9.3) beats per minute. Hypotension was resolved in 55 of 94 instances (58.5%). A single episode of transient extreme hypertension occurred after one PDE dose and did not result in patient harm. Conclusions: Push dose epinephrine may be an effective method of temporarily resolving hypotension during the CCT of critically ill patients. In the cases where PDE was administered, there was close adherence to the established protocol and adverse events were found to be rare directly following PDE administration. Further research is needed to validate these findings, establish optimal dosing, and evaluate use in non-CCT prehospital settings.

Interfacility Transport of the Pregnant Patient: A 5-year Retrospective Review of a Single Critical Care Transport Program

Introduction: Interfacility transport of the pregnant patient poses a challenge for prehospital providers as it is an infrequent but potentially high acuity encounter. Knowledge of clinically significant events (CSEs) that occur during these transports is important both to optimize patient safety and also to help enhance crew training and preparedness. This study evaluated a critical care transport program’s 5-year longitudinal experience transporting pregnant patients by ground and air, and described CSEs that occurred during the out-of-hospital phase of care. Methods: This study was a retrospective review of pregnant patients transported by a single critical care transport system into and within a large academic healthcare system. Patients who were pregnant, and were transported from a referring facility to one of the 2 receiving centers within Johns Hopkins Health System between January 1, 2012 and December 31, 2016 were included in this study. The primary outcome of interest was the occurrence of a predefined clinically significant event (CSE) during transport, while a secondary outcome of interest was the indication for transfer. Results: During the study period 1,223 pregnant patients were transported by our critical care transport service. There were 1,101 patients who met inclusion criteria; 693 (62.9%) of whom were transported by ground and 408 (37.1%) who were transported by rotor wing aircraft. The top 3 indications for transfer comprised 71.4% of all patients and included; preterm labor, hypertensive disorder of pregnancy, and other maternal life threatening disorder. The most common events that occurred across all transports were: exacerbation of hypertensive disease requiring intervention (4.5%), hypotension (1.3%), and altered mental status (0.2%). Conclusions: Incidence of CSEs during the interfacility transport of pregnant patients within our critical care transport system is low (6.0%). Knowledge of the clinically significant events that occur during EMS transport is a vital component of ensuring system quality and optimizing patient safety. This data can be used to augment and focus provider education and training to mitigate and optimize response to future events.

Risk-adjusted CPR Rates as a Measure of Quality During Interfacility Transports

Introduction Over the past decade, the health care industry has witnessed an unparalleled reporting of hospital-specific comparative outcomes. Clearly, there has been a growing consensus among a broad array of agencies and institutions around the importance of reporting quality measures, including those that measure clinical outcomes. Previous research suggests that there is substantial variability in care between hospitals, particularly in trauma centres. In 2006, the American College of Surgeons (ACS) Committee on Trauma launched the Trauma Quality Improvement Program (TQIP) to study the variability in outcomes between trauma centers to improve the quality of trauma care in North America. The primary goal of TQIP is to improve the quality of trauma care through outcomes-based, risk-adjusted benchmarking of trauma centers and feedback reports. However, differences in patient selection (selection bias), case mix, data quality, geography, and other factors inherent to different injured populations likely contribute in part to observed differences in outcome. Risk-adjustment is a methodology used to ensure that “like” patients are being compared, so that differences in outcome can be attributed solely to differences in the processes and quality of care provided. Transport services are beginning to use performance metrics to analyze for variations between ambulance and transport services in order to improve quality of care during transport. The “Ground Air Medical qUality Transport Quality Improvement” (GAMUT) Collaborative collects transport data in a large database to use as a free resource for transport teams to track, report, and analyze their performance on transport-specific quality metrics by comparing it to other program's. Because of the nature of transport, most of the metrics are process metrics or intermediate outcomes. Arguably, the only transport-related definitive outcome that GAMUT reports is rate of cardiac arrest during transport (Rate of CPR performed during transport). However, this rate is reported as an unadjusted rate: there is no risk-adjustment. We propose a simple methodology to allow for risk-adjustment of CPR rate during transport. Methods Ornge is the sole provider of Air Ambulance and Critical Care Transport Services to the province of Ontario, Canada. The province has a land mass of over 1 million square kilometers, and has a population of almost 14 million people. Ornge operates a fleet of Pilatus Next Generation PC-12 airplanes, Leonardo AW-139 helicopters, and Crestline Commander land ambulances, staffed with Critical Care and Advanced Care Paramedics. For low acuity patients requiring a lower level of care, Ornge uses a Standing Agreement to Chart Air Ambulance services from contract carriers, staffed by primary care paramedics. For interfacility transfer patients, we propose to compare CPR rates year over year for Ornge (2013-2017). SA transports will not be included, as they represent a very low-risk group. Risk adjustment will be done by adjusting for mechanical ventilation (yes/no), use of infusion(s) of vasopressors (yes/no), mechanical ventilation and pressors (yes/no), or none. Rates will be standardized to the distribution of cases during the reference year of 2013-14, and reported per thousand hours. Results Discussion Comparing variability in outcomes is helpful in improving quality of care. High performing centres can share their best practices to improve quality of care throughout the system. Risk adjustment is a methodology used to ensure that “apples” are being compared to “apples”, and that case selection is not affecting the analysis. Transport agencies are now reporting CPR rates during transports as an outcome measure, as part of their quality improvement programs. These rates are unadjusted, and are difficult to compare across groups. Air ambulances transport many different types of patients, such that standard risk adjustment methods may not be directly applicable. Risk adjustment for trauma patients is completely different than for post STEMI patients. As well, transport agencies only care for patients during a very short period of time. We presented a methodology of risk-adjustment for CPR rates during interfacility transports that have correlational validity with our changes in our quality processes over time.

Abstract P-006: INITIAL CHALLENGES OF ESTABLISHING A STAND-ALONE PAEDIATRIC CRITICAL CARE TRANSPORT SERVICE IN ENGLAND, UK

Aims & Objectives: The Children’s Medical Emergency Transport service (CoMET) is a stand-alone paediatric critical care transport service established in March 2017. The service has been commissioned to provide an acute transport service 24/7, and a repatriation service during daytime hours. CoMET serves the East Midlands region of England, with a population of more than 4.5 million. Aim: - We report the initial challenges of establishing CoMET, in the current scenario of limited finance and availability of trained staff in UK. Methods We retrospectively analysed feedback from incidents, staff, stakeholder events and data from the PICANet. (Paediatric Intensive Care Audit Network- UK National Database). Results CoMET faces challenges regarding recruitment to enable the full establishment of the service. In order to launch a 24/7 acute service on 4th December 2017, the repatriation service offered had to become ad-hoc (only 38% of shifts covered between December 2017- March 2018) Ambulance provision was not commissioned and the team relies on front line emergency vehicles which serve the whole region. As a result, CoMET is only able to comply with the national standards of mobilising within 30 minutes of acceptance (acute transfers) in 21 % of occasions (March- December 2017). Ambulance delays making up the majority of the incidents reported. Conclusions Achieving adequate staffing and a dedicated ambulance remains a major challenge. Openness, transparency and a flexible mind-set to learn from the challenges faced will continue to be the key in developing this service during its first steps, and into the future.

EMS Dispatches during Hurricanes Irene and Sandy in New Jersey

Background: Hurricanes Irene and Sandy heavily impacted New Jersey. Investigating EMS dispatch trends during these storms may allow us to prepare for future disasters. Objectives: Our objectives to characterize the types of EMS dispatches immediately before, during, and after landfall compared to a control period. Methods: This retrospective study was conducted at a large EMS dispatch center that provides first responders, Basic Life Support (BLS), Advanced Life Support (ALS), and critical care transport services to an area with approximately 20 receiving hospitals including a Level I Trauma Center. At peak staffing, there are 8–10 ALS vehicles, 25 BLS vehicles, and 3 critical care transport vehicles deployed. We included of the day of landfall and seven days before and after. We compared dispatch data to a control period in 2010 that mirrored Hurricane Sandy the dates of. Descriptive statistics and two way ANOVA were used to assess dispatch, gender and age differences. Results: We found Hurricane Sandy dispatches peaked 2 days after landfall. Both ALS and BLS had an increase in age in the post-Sandy period compared to the pre-Sandy (ALS 58.5 to 64.2, p = 0.005, ANOVA p = 0.078; BLS 47.4 to 56.3, p < 0.001, ANOVA p = 0.001). There were 17 “hurricane related” (loss of power related issues, oxygen supply depleted, evacuation) and 15 carbon monoxide dispatches in the post-Sandy period and none in the others, including peri-Irene. The average age of cardiac arrest dispatches was lower in the post-Irene group compared to pre-Irene (74.3 to 47.8, p = 0.023). There were no critical care requests before or after Hurricane Sandy, but there were 14 around Hurricane Irene and 10 surrounding the control period. Conclusions: Dispatch data can inform natural disaster planning. Education efforts can focus on geriatric patients, as well as resource distribution planning for an increase in geriatric populations. However, pattern variability between storms shows further study is needed to clarify exactly which resources should be utilized in order to maintain an ideal response to a natural disaster.

Intra-aortic Balloon Pump-Dependent Patient Transports by Critical Care Paramedics

ObjectiveTransport of intra-aortic balloon pump (IABP)-dependent patients between hospitals is increasingly common. The transports are typically time-sensitive and require personnel familiar with IABP operation and management of a potentially unstable patient. This study examined transports performed by specially trained critical care paramedics in a large air medical and land critical care transport service. MethodsThis retrospective, descriptive review prospectively collected data for IABP-dependent patient transports in Ontario, Canada in a 10-year interval beginning September 2003. Call records and patient care reports were reviewed to capture demographic, patient care, adverse events, and transport-related data. Adverse events, including resuscitation medication, procedure, and patient instability, were independently reviewed by 2 investigators. ResultsThere were 162 IABP-dependent patients transported. Seventy-one were performed by land critical care transport vehicles, 60 by helicopter, and 31 by fixed wing aircraft. The mean patient age was 63.7 ± 13.8 years; the majority (72.2%) were men. Fifty-nine patients (36.4%) were inotrope or vasopressor dependent, and 46 (28.4%) were intubated and mechanically ventilated. The most common indications for IABP insertion were acute myocardial infarction requiring prompt surgical intervention (n = 70), bridge to definitive care (n = 41), and cardiogenic shock (n = 37). The mean transport time was 92.7 ± 79.4 minutes. There were 48 adverse events in 35 patients, most commonly hypotension (systolic blood pressure < 90 mm Hg, n = 18) and tachyarrhythmia requiring therapy (n = 12). There were 3 IABP-related events and 3 cases in which the transport vehicle was inoperable resulting in a transport delay. One patient with cardiogenic shock died before departing the sending hospital. Paramedics managed all events without assistance from other health care personnel. ConclusionSpecially trained critical care flight paramedics can safely transport potentially unstable IABP-dependent patients to definitive cardiac surgical care.

Medical Transfer of Patients in Preterm Labor: Treatments and Tocolytics

Objective. To examine the epidemiology, effectiveness, and safety of tocolytics, and the variation in use of standard treatments and predictive testing for women in preterm labor (PTL) transported to tertiary care. Methods. This was a health record review of consecutive PTL patients (<38 weeks gestation) transported to a tertiary care facility by Ontario's air and land critical care transport service between January 1, 2006 and January 1, 2011. The primary outcome was the effectiveness of tocolytics in decreasing the frequency of contractions and incidence of delivery. Secondary outcomes included the type of tocolytics used, adverse events (defined a priori), use of standard treatments (corticosteroid, antibiotic), and use of predictive tests (cervical length measurement, fetal fibronectin). We report descriptive statistics and relative risk of contractions decreasing with tocolytics with 95% confidence intervals. Results. Of the 510 transports reviewed, 488 met all inclusion criteria with the following characteristics: mean age 26.1 years, mean gestational age 31.2 weeks, mean transport time 80 minutes, 61.0% multiparous, 13.3% twins, mean initial dilatation 1.8 cm, contraction <8 min apart 67.7%, and 66.8% from Northern Ontario. Tocolytics were used in 206 (42.2%), with nonsteroidal anti-inflammatory drugs and nitroglycerine being used most frequently. Eleven (2.3%) patients delivered during transport, 4 (36.4%) of which received tocolytics with relative risk (RR) 0.8 (95%CI 0–2.0), and number needed to treat (NNT) 165 (31.5–299.3). Among the 311 (63.7%) patients for which change in contractions was documented, 140 (45%) received tocolytics and of these patients, contractions decreased in 94 (67%), with an RR 0.6 (95%CI 0.3–0.9) and NNT 4.6 (3.1–6.2). Adverse events were documented in 67 (14%) patients (most commonly tachycardia 5.8%). Steroids were appropriately used in 268 (54.9%) patients and antibiotics were appropriately used in 286 (58.6%) patients. Predictive testing was performed in only 19 (3.9%) patients. Conclusions. Tocolytics were associated with decreased contraction frequency in more than two-thirds of those treated. However, nearly half those who did not receive the treatment also had decreased contractions, and the effect did not reach statistical significance. Variation in the type of tocolytic drug used suggests a need for clinical practice guidelines for tocolytic use during transport of PTL patients.

ABSTRACT 809

Background and aims: Transporting critically ill children to tertiary centres capable of providing intensive care is the mainstay of pediatric emergency transportation services worldwide. Conversely, where state of the art life-sustaining interventions fail to improve outcomes and when medical futility is reached, the transfer of such patients to their homes for comfort and palliative care is seldom described in medical literature. Our Children’s Hospital Emergency Transport Service (CHETS) is a dedicated neonatal and pediatric critical care transport service established in 2004 and on average performs 90 missions annually. Our intensivists offer families palliative transfers home as part of end-of-life discussions. Aims: We report our 10 year paediatric palliative transport experience. Methods: We performed a retrospective audit of CHETS records from 2004 to 2013. Results: Eight local palliative transfers were carried out within this period. Median age of patients was 6 years (range 11 days to 14 years). Diagnoses included complex congenital cyanotic heart disease with multiorgan failure, spinal muscular atrophy Type 1 with hypoxic ischemic encephalopathy (HIE) following cardiorespiratory arrest, HIE secondary to drowning, fulminant meningoencephalitis, inoperable brainstem glioma with respiratory arrest and relapsed primitive neuroectodermal tumour with sepsis. Six patients were transported home for withdrawal of life support and two to hospices for palliation. There were no intra-transfer adverse events. Conclusions: The availability of a dedicated critical care transport service allows for palliative transfers to be carried out safely. We propose that facilitating transport to allow withdrawal of life support at home is an acceptable and valuable option to families as part of holistic end-of-life care.

Abstract 315: Characterization of Out of Hospital Resuscitation Utilizing Blood Transfusion

Introduction: While blood transfusion in the hospital setting has been extensively studied, little data exists on out of hospital administration of blood products. We aimed to characterize patients receiving out of hospital blood product transfusion in a critical care transport network that carries blood products. Methods: We performed a retrospective review of patients transported by a regional critical care transport service from 1/1/2003 to 6/30/2012 who received blood products during transport. This service carries two units of un-crossmatched Packed Red Blood Cells (pRBCs) on every transport. We describe prehospital factors (vital signs, mechanism of injury, volume and type of blood product transfused) associated with blood transfusion. We further categorized out of hospital transfusions of blood products into three groups based on the volume transfused (lt350 ml, 350-700ml, gt700ml). We compared in-hospital outcomes (mortality, volume and type of subsequent blood transfusion, and need for emergent surgery [lt24 hours]) among these three groups to ascertain the impact of prehospital blood product transfusion. Results: We reviewed 1441 transports in which blood products were transfused. Most transfusions were inter-facility transfers (92%, CI 91-93%) and for non-traumatic illness (75%, CI 73-77%). The most common reason for transport was upper gastrointestinal bleeding (20%, 18-22%). A vast majority, 80% (CI 78-82%), of patients required subsequent in-hospital blood transfusion. In hospital 30-day mortality was high, 22% (CI 20-25%), as was need for emergent surgery 27% (CI 25-29%). Mean length of stay was 10.6 days and mean ICU length of stay was 7.2 days. Among those receiving blood products, those transfused with &amp;gt700ml had higher heart rates (94 vs. 103, p=0.01), whole blood lactate levels (3.5 vs. 6.2, p&amp;lt0.01), and lower systolic blood pressure (108 vs.122, p&amp;lt0.01) Conclusions: In this sample, the majority of patients receiving blood during critical care transport are during inter-facility transports and for non-traumatic conditions. Gastrointestinal hemorrhage is the most common indication for transfusion and 30-day mortality in this cohort is high.

Critical Care Transportation by Paramedics: A Cross-sectional Survey

ObjectiveThe purpose of this study was to gather data from paramedics practicing in the critical care transport setting to guide development of the education, training, and clinical practices for certification as a critical care paramedic. MethodsA paper survey of 1991 randomly selected nationally registered (NREMT) paramedics was conducted. Nine paramedics with residences in small US Pacific Island territories were not included in the survey. ResultsWe received 610 responses (30.6%). Respondents that stated that they provided critical care transport services reported using pediatric skills and equipment the most and intracranial pressure monitoring the least. Paramedics served as the primary provider for pediatric patients (72.5%), 12-lead electrocardiogram (66.3%), intravenous infusion pump (76.7%), mechanical ventilator (66.9%), central line management (63.1%), and chest tube management (63.3%). Paramedics served in a team member capacity most often with neonatal isolette (71.8%), intra-aortic balloon pump (79.2%), and ICP monitoring (64.9%). The majority provided ground critical care transport (249) compared to 44 rotor-wing and 6 fixed-wing. Sixteen respondents reported serving as primary providers on combinations of ground, rotor-, and fixed-wing services. ConclusionsParamedics reported being the primary provider on the critical care transport team and performing skills while using equipment and administering medications that exceeded their education and training as paramedic and, at times, without the benefit of any additional education or training. National appreciation of this reality should spur development of standardized education, licensing or certification, and continuing education to prepare paramedics for their role as critical care medical providers.

The obstetric caseload of a physician-based helicopter emergency medical service: case review and recommendations for retrieval physician training

BackgroundThe Greater Sydney Area Helicopter Emergency Medical Service provides physicians for undertaking prehospital and inter-hospital critical care. We quantified the obstetric caseload of our service with respect to primary diagnosis...

Rocuronium versus Succinylcholine in Air Medical Rapid-Sequence Intubation

Background. It is not known how rocuronium compares with succinylcholine in its effect on intubation success during air medical rapid-sequence intubation (RSI). Objective. To examine the impact of succinylcholine use on the odds of successful prehospital intubation. Methods. We performed a retrospective analysis of a critical care transport service administrative database containing patient encounters from 2004 to 2008. Rotor transports of patients ≥18 years old, requiring airway management (intubation or backup airway: laryngeal mask airway, Combitube, or cricothyrotomy), and receiving either rocuronium or succinylcholine were included in the analysis. Patients receiving both drugs were excluded. Multiple imputation was used to account for records that were missing data elements. A propensity score based on patient and encounter characteristics was calculated to control for the effect of clinical factors on the choice of drug by air medical personnel. Logistic regression was used to assess the impact of succinylcholine use on the odds of first-attempt intubation. Ordinal logistic regression was used to assess the impact of succinylcholine on the number of attempts required to intubate (1, 2, or ≥3 or backup airway). Results. A total of 1,045 patients met the criteria for analysis; 761 (73%) were male, and the median age was 41 years (interquartile range 26–56). Eight hundred seventy-six (84%) were transported from the scene, and 484 (46%) received succinylcholine. Six hundred twelve (59%) were intubated on the first attempt, 322 (31%) required two attempts, 69 required three or more attempts (7%), and 42 required a backup airway (4%). After propensity score adjustment, succinylcholine was associated with a higher incidence of first-attempt intubation (odds ratio 1.4, 95% CI 1.1–1.8), as well as improved odds for requiring fewer attempts to intubate (odds ratio 1.5, 95% CI 1.2–1.9), as compared with rocuronium. Conclusions. Rapid-sequence intubation was more successful with fewer attempts in patients intubated by air medical crews with succinylcholine as opposed to rocuronium. Prospective, randomized studies are needed to confirm these findings and to explore the impact of succinylcholine on the outcomes of air medical–transported patients. Key words: airway management; critical care; emergency medical services; neuromuscular blockade; succinylcholine; rocuronium; rapid-sequence intubation; intubation; air medical transport

Delay in Treatment

The adage “You can be sued by anyone, at anytime, for any reason” makes me consider things that are beyond just patient care for any patient transport. Air medical and critical care transport services are often exposed to numerous opportunities to be sued, although our intentions are always to provide the best care possible to patients in the most critical situations. Unfortunately, medical malpractice can occur for a number of reasons—error on the part of a surgeon, a missed diagnosis, prescribing the wrong medicine, delay in referral to tertiary care.

Attitudes of paediatric intensive care nurses to development of a nurse practitioner role for critical care transport

This paper is a report of a descriptive study of the attitudes and opinions of nurses before and after the introduction of independent Retrieval Nurse Practitioners into a critical care transport service for children. Little is known about nurses' attitudes to advanced practice roles, particularly when these function as part of a team in a high-risk, remote setting (distant to the base hospital). Increasing knowledge in this area may give insight into ways of improving team working and enhancing quality of patient care. A qualitative questionnaire was sent to nurses pre- (June 2006) and post- (July 2007) retrieval nurse practitioner introduction. Questionnaires were analysed using an adapted phenomenological method. The response rates were 62% (2006) and 48% (2007). The main themes that emerged included fear, communication, trust, team working, role conflict, role division and role boundaries. In the first survey, most nurses anticipated difficulties during retrieval with retrieval nurse practitioners and felt anxious about the prospect of being part of a team with an independent retrieval nurse practitioner. However, by the second survey (after retrieval nurse practitioner introduction), the majority reported confidence in the retrieval nurse practitioners' knowledge and skills. This advanced practice development has been a challenge for the nurses and the retrieval nurse practitioners, but initial anxieties and fears of a host of anticipated problems have been largely dispelled as enhanced communication and team working were reported.

Endotracheal Tube Cuff Pressures in Pediatric Patients Intubated Before Aeromedical Transport

Prolonged endotracheal tube cuff pressures (ETTCPs) greater than 30 cm H2O can cause complications. With increasing utilization of cuffed endotracheal tubes (ETTs) in pediatric patients comes the risk of overinflation. We evaluated the incidence of elevated ETTCP in pediatric patients intubated with cuffed ETTs, transported by a critical-care transport service and attempted to identify whether elevated ETTCP was associated with factors such as patient demographics, diagnostic category, and intubator credentials. In this prospective study, assessment of ETTCP was made upon transport crew arrival at the bedside. The study focused on a consecutive sample of pediatric patients undergoing transport with cuffed ETTs placed before transport team arrival. All patients had cuff pressures assessed by the same cuff manometry device. Pressures found to be greater than 30 cm H2O were corrected immediately. Forty-one percent of cases met the a priori defined cutoff for elevated ETTCP of 30 cm H2O; 30% of those elevated cuff pressures were twice that cutoff (>60 cm H2O). There were no associations between high ETTCP and any of the following independent variables: demographics, physician versus nonphysician intubator, and intubation location (ie, scene vs emergency department vs intensive care unit). A significant number of pediatric patients transported by a critical-care transport service had elevated ETTCP. Furthermore, there was no clear risk factor for elevated cuff pressures. This is further evidence that cuff pressures should be measured in all patients. Further research should focus on the effect of educational intervention and on the possible clinical results of elevated ETTCPs.

Pediatric Critical Care Transport Services

Codes 99466 and 99467 for critical care transport services for a patient 24 months or younger

52: Endotracheal Tube Cuff Pressures in Pediatric Patients Intubated Prior to Aeromedical Transport

Prolonged endotracheal tube cuff pressures (ETTCP) greater than 30 cm H2O can cause complications. Significantly elevated cuff pressures in an emergency setting have been demonstrated to be commonplace in adults. With increasing utilization of cuffed endotracheal tubes (ETT) in pediatric patients comes the risk of overinflation. This study's goals were to assess pediatric patients intubated with cuffed ETTs undergoing transport by a critical care transport (CCT) service to ascertain ETTCP and whether elevated ETTCP was associated with factors such as patient demographics, diagnostic category and intubator credentials.

CPT Code Changes for 2009

Significant changes are those made to the normal newborn care, delivery room management and resuscitation, neonatal and pediatric intensive and critical care services, and pediatric critical care transport services.

Characteristics of patients transported by an aeromedical service for acute toxicologic emergencies: A 5-year experience

Introduction Aeromedical services are used routinely in the prehospital and interhospital transfer of patients with trauma, neurosurgical, cardiac, and other conditions requiring specialized care. The use of aeromedical transport in patients with acute toxicologic emergencies is not well described. We sought to investigate and describe the characteristics of patients transported by our aeromedical service. Setting The study was performed at an urban critical care transport service operating both ground and aeromedical units and transporting an average of 3,362 patients per year during the study period. Methods Charts from the 5-year period of 2000 to 2004 for which a toxicologic emergency was coded as the primary diagnosis were identified and reviewed by the authors. Data abstracted included age, sex, toxin(s) involved, treatment rendered at the scene/bedside and en route by the transport team, and additional data (electrocardiogram [ECG] findings, serum levels) when appropriate. Results One hundred thirty-three patients were transported (for a total of 135 transports). Most (82%) were transported by air. Carbon monoxide was the most common toxic exposure, accounting for 16% of all transports. Fifty-seven percent of the patients were intubated, with 11% intubated by the flight crew. Antidotes were administered in 40 patients, with naloxone and bicarbonate being the most common. Conclusion Acute toxicologic emergencies accounted for a small percentage of total transports. The most common additional intervention by flight crews was endotracheal intubation. Identification of common poisonings encountered by flight crews may assist services in developing education and quality assurance programs.

Lack of correlation in welfare check distribution and transport patterns in a rural critical care transport service

Introduction Understanding patterns of use of emergency medical services is important for planning adequate programs, budgets, and schedules. Understanding the factors associated with use of these services can help systems target high-risk populations or behaviors and allocate budgetary resources appropriately. Previous data have shown an association between the use of emergency health care use and distribution of welfare check distribution in both the United States and Canada. These data have limitations. In these studies, no attempt was made to investigate whether this increase in use was for particular types of complaints (medical or traumatic) or true outside of an urban community. The purpose of this study was to investigate whether there were similar monthly associations in patterns of use of a regional transport service for either medical or traumatic complaints. Methods Med Flight is a regional aeromedical service operated by the University of Wisconsin. The service provides transport services to all hospitals and emergency medical services for critically ill or injured patients inside a radius of approximately 75 miles. The program transports approximately 1200 patients per year. Data for all transports for the years 1998-2004 were obtained. Daily numbers of transports were then compared for all patients and subsets of those with specifically traumatic or cardiac-related complaints. Results There were 7756 transports during the study period: 34% of the transports were trauma related; 30% were cardiac related. There was a significant association between trauma-related flights and both month of the year ( P < .0001) and day of the week ( P < .001), but not for total or cardiac-related flights. There was no association between day or week of the month and transports. Conclusion In contrast to previous studies, these findings show no association between use of a regional transport service and time of the month. Determinants of use of emergency services may differ between urban and nonurban areas.