Critical Care Transport Team Research Articles

Myocardial Infarction Complicated by Ventricular Septal Rupture

Transporting patients with an ST segment elevation myocardial infarction (STEMI) is a fairly common practice for most critical care transport teams. When a STEMI is complicated by ventricular septal rupture, the care can become more challenging, especially if the rupture is not yet diagnosed. This article describes such a transport and reviews the pathophysiology of the process along with treatment options.

St. Louis Children's Hospital Critical Care Transport Team

From its humble beginnings in 1879 in a converted apartment house at 2834 Franklin Avenue, St. Louis Children's Hospital has emerged as a world class leader in pediatric medicine. Today, St. Louis Children's Hospital has 250 acute care beds, 26 pediatric intensive care unit (PICU) beds, 12 cardiac intensive care unit beds, and 75 neonatal intensive care unit (NICU) beds. Children's Hospital has the largest pediatric lung transplant program in the world and has active liver, heart, kidney, and bone marrow transplant programs. The hospital is also a level I pediatric trauma center and provides care for severely burned children. Recently, the hospital used an artificial lung as a bridge to lung transplantation in a 2-year-old suffering from pulmonary hypertension. The young patient survived his ordeal, thus becoming the youngest patient in the world to benefit from the Novalung. Children's routinely uses the Berlin Heart as a bridge to transplantation in very young children.

Incidence of re-arrest and critical events during prolonged transport of post-cardiac arrest patients

Aim To determine the feasibility of transporting post-cardiac arrest patients to tertiary-care facilities, the rate of re-arrest, and the rate of critical events during critical care transport team (CCTT) care. Methods Retrospective chart review of cardiac arrest patients transported via CCTT between 1/1/2001 and 5/31/2009. Demographic information, re-arrest, and critical events during transport were abstracted. We defined critical events as hypotension (systolic blood pressure < 90mm Hg), hypoxia (oxygen saturation < 90%), or both hypotension and hypoxia at any time during CCTT care. Comparisons were performed using Chi-squared test and a Cox proportional hazards model was employed to determine predictors of events. Results Of the 248 patients studied, the majority was male (61%), presented in ventricular fibrillation or ventricular tachycardia (VF/VT, 50%), and comatose (80%). Re-arrest was uncommon ( N = 15; 6%). Critical events affected 58 patients (23%) during transport. Median transport time was 63 min (IQR 51, 81) in both those who experienced a critical event and those who did not. Vasopressor use was associated with any decompensation during CCTT (Hazard Ratio 1.81; 95%CI 1.29, 2.54). Three patients (20%) suffering re-arrest survived to hospital discharge. Survival (Chi square 11.77; p < 0.01) and good neurologic outcome (Chi square 5.93; p = 0.01) were higher in patients who did not suffer any event during transport. Conclusions Transport of resuscitated cardiac arrest patients to a tertiary-care facility via CCTT is feasible, and the duration of transport is not associated with re-arrest during transport. Repeat cardiac arrest occurs infrequently, while critical events are more common. Outcomes are worse in those experiencing an event.

Pediatric critical care telemedicine in rural underserved emergency departments*

A disparity in access to health care exists between rural and urban areas. Although 21% of children in the United States live in rural areas, only 3% of pediatric intensivists practice in rural areas. In an attempt to address this issue, we implemented a program of pediatric critical care telemedicine consultations in rural emergency departments (EDs) and report our results. A prospective evaluation of pediatric critical care consultations in rural EDs was undertaken March 2006 through March 2008. A referral area with a population of 1,000,000 in 19 rural counties in Vermont and upstate New York comprised the study area. Sixty-three telemedicine consultations were performed in 10 rural EDs. The average number of consultations was 6.3 per site (range 2-17). Minor technical issues were identified in 18 consultations (29%). There were 12 primary diagnoses. Telemedicine was used to supervise the critical care transport team on 25 occasions (40%). Consulting intensivists made 236 specific recommendations. Consulting intensivists thought that telemedicine consultations improved patient care 89% of the time, were superior to telephone consultations 91% of the time, and provided good to very good provider-to-provider communications 98% of the time. Referring providers reported that telemedicine consultations improved patient care 88% of the time, were superior to telephone consultations 55% of the time, and provided good to very good communications 94% of the time. With telemedicine, it is feasible to provide urgent subspecialty critical care for children in underserved rural EDs, improve patient care, and provide a high degree of provider satisfaction. Pediatric critical care telemedicine may help to address the disparities in the access to and the outcome of medical care between rural and urban areas.

Pediatric and Neonatal Interfacility Transport Medicine After Mass Casualty Incidents

Pediatric and neonatal interfacility transport medicine is a relatively young but a rapidly evolving specialty. Transport teams are essential for the safe interfacility movement of critically ill patients. A mass casualty incident (MCI) can present major challenges for a critical care transport team. This article will examine the capabilities and limitations of pediatric and neonatal critical care transport teams. The predicaments brought about by Hurricane Katrina that hindered the evacuation of pediatric and neonatal patients out of ravaged hospitals are also reviewed. From these experiences, recommendations to improve the efficiency and efficacy of interfacility transport of pediatric patients will be presented.

The Feasibility of Daily Mannequin Practice to Improve Intubation Success

Introduction Opportunities to practice live intubations are limited, so other methods of skill development must be researched. Some experts claim that exceptional performance simply reflects extended periods of intense training. This study evaluates whether daily intubation practice using standard airway mannequins increases the success rate of providers when intubating actual patients. Methods Study participants were members of a ground critical care transport team. Investigators performed a review of previous trips, compiling the number of attempts at intubation and success rates. During the intervention period, participants were asked to perform repeated daily intubations of airway mannequins. Intubation success rates and compliance with study protocols were recorded. Results The rate of successful intubation of the mannequins was constant, with a linear regression slope of 0.00016 (95% confidence interval [CI]: −0.0039, 0.0042). A generalized estimation equations logistic regression comparing success rates between the pre-intervention and the intervention periods showed no statistical difference (P = .63, z = 0.48), with an odds ratio of 1.37 (95% CI: 0.38, 4.92). However, compliance with the study declined significantly over the intervention period, as indicated by a linear regression slope of 0.0239 (95% CI: −.0354, −0.0124). Conclusions Daily practice with standard airway mannequins by a critical care transport team did not improve intubation success on actual patients.

Transfer of Patients Dependent on an Intra-aortic Balloon Pump Using Critical Care Services

Introduction The intra-aortic balloon pump (IABP) is a hemodynamic support device that provides circulatory enhancement to patients whose cardiac output is compromised. Special clinical skills are required for management of the patient with an IABP in place. Few studies have discussed the transport of the IABP-dependent patient. The current study was designed to describe the transport of IABP-dependent patients, with a focus on pretransport interventions, transport interventions, quality improvement, and complications. Methods A review of all transports from January 1, 2004, through December 31, 2005, performed by a critical care transport program with a nurse/paramedic crew offering mobile intensive care unit (ICU), rotor-wing, and fixed-wing service was conducted. All patients who were maintained on an intra-aortic balloon pump (IABP) were eligible for inclusion. A certified perfusionist was available for consultation on all transports. Information about the IABP, including the pump timing, confirmation of balloon location, and inflation/deflation timing parameters, was collected. Proper balloon placement was verified and recorded at the sending hospital. Data were collected regarding interventions required before and during transport and complications during transport. Descriptive statistics were used. Results During the study period, 173 transports involving an IABP were performed. The average age was 60.8 years, and 67.8% were men. Forty-one percent were flown by rotor-wing, 36.4% were transported by the mobile ICU, and 21.4% were flown by the fixed-wing transport. In 1.2% of cases, there was a change in transport mode. Twelve percent of patients required some increase in oxygen supplementation, but only one patient required intubation before transport by the transport crew. The most common pretransport medications were heparin (69%), inotropes (55%), and other infusions (46.8%). Twenty-two percent had no written confirmation of the correct balloon placement. There were no significant complications found during transport, including hemorrhage, loss of trigger signals, or cardiac arrest. Twelve percent had some abnormalities in timing of balloon inflation or deflation. Conclusion IABP transports can be safely performed by a nurse/paramedic critical care transport team with perfusionist consultation. Few patients require significant intervention before transport. Attention must be paid to balloon inflation and deflation timing despite the existence of timing algorithms. Significant complications during transport were not seen. Future studies should explore the overall outcome of IABP-dependent patients and the role of transport mode on outcome.

Factors associated with unoffered trauma analgesia in critical care transport

ObjectivePain relief is a key out-of-hospital patient care outcome measure, yet many trauma patients do not receive prompt analgesia. Although specialty critical care transport (CCT) teams provide analgesia frequently, successfully, and safely, there is still a population of CCT patients to whom analgesia is not offered. We report the factors associated with non-administration of analgesia and with analgesic effect in trauma patients cared for by CCT teams. MethodsThis is a retrospective review of consecutive transport records for nonintubated trauma patients with self-reported pain during specialty CCT care. Patient demographics, CCT interventions, clinical traits, and pain self-reports are measured. Means comparisons are made with a univariate analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) are reported for between-group comparisons. ResultsOf the 209 enrolled patients, 169 (80.9%; 95% CI, 75.6%-86.2%) were treated (147 received analgesia and 22 offered analgesia but refused). In patients with pain scale documentation (n = 145), self-reported pain on a scale from 0 to 10 decreased from 6.8 ± 2.8 to 3.3 ± 2.4 (P ≤ .001). Three factors were associated with absence of analgesic administration: initial pain level (OR for administration, 0.13; 95% CI, 0.04-0.40), pain scale documentation (OR, 0.31; 95% CI, 0.15-0.60), and transport program (OR, 0.36; 95% CI, 0.17-0.74). No clinical factor was associated with analgesia effectiveness in treated patients. ConclusionThe identified factors may represent opportunities for CCT teams to optimize analgesic treatment.

Post-cardiac surgery tamponade

Cardiac tamponade may occur from many factors; however, it is most commonly seen in the cardiothoracic intensive care setting. Definitive treatment often involves entering the chest surgically to relieve the pressure and allow the heart to fill normally. Because it is not frequently encountered outside the hospital, cardiac tamponade is sometimes overlooked in the formation of a differential diagnosis by critical care transport teams. Even when the diagnosis is made, the thought process is to transfer the patient to a center with cardiothoracic surgical ability for definitive treatment. Air medical transport teams are frequently called on to complete these types of transports, because they offer not only speed but also an advanced skill set and training.

Transfer of Medication Administration Information from Critical Care Transport Teams to Trauma Teams

Transfer of Medication Administration Information from Critical Care Transport Teams to Trauma Teams

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Sedative use in patients receiving neuromuscular blocking agents from a helicopter flight team

Introduction Cognitive awareness under general anesthetic may occur in up to 0.2% of patients, with approximately twice the risk in chemically paralyzed patients. Patients in emergency and critical care areas frequently receive neuromuscular blocking agents (NMBA), but a recent survey indicated that only 90% to 96% of critical care nurses routinely provide concurrent sedative medications to those patients. We sought to determine the potential for awake paralysis in patients transported by helicopter critical care transport teams and to evaluate for associations with clinical factors. Methods A retrospective review was performed of the rotor-wing transport records of 103 consecutive patients receiving NMBAs and without cardiac arrest during their care. Using hospital-approved pharmacological references, independent reviewers determined whether individual patients were likely to be under the effects of sedative medications during their period of neuromuscular blockade. Descriptive statistics are reported, and the chi-square test was used to evaluate relationships. Results The sample population was 70.9% male, 89.3% adult, 53.4% trauma/surgical, 66% interhospital, and 88.3% normotensive (SBP > 90 mm Hg). Clinically, 91.3% of patients were judged as probably to have been under the effects of some sedative during their period of paralysis. There was not a significant association between the use of sedatives and any of the factors studied: sex, age, diagnosis, site of origin, flight nurse experience, or systolic blood pressure. Patients most commonly received benzodiazepine alone (70.2%), followed by benzodiazepine + opioid (23.4%), opioid alone (5.3%), and propofol (1.1%). Medication choice was also unrelated to any of the clinical factors studied. Discussion Awake paralysis is difficult to detect but is a serious practice complication. In anesthesia practice, 96% of such cases were considered substandard care, even with prompt recognition and management. Flight nurses administer sedatives at rates similar to other critical care nurses but not to all chemically paralyzed patients. We were unable to identify clinical correlations with medication use or omission. Additional phenomenological and quantifiable evaluations of consciousness during the transport of chemically paralyzed patients would be valuable studies. Conclusion Patients receiving NMBAs during transport by helicopter flight teams are at risk for awareness during paralysis. Both practice development and research efforts in this area would be useful.

Critical care transport teams: searching for evidence of effectiveness

Critical care transport teams: searching for evidence of effectiveness

Ground Critical Care Transport: A Lifesaving Intervention

“In Our Unit” highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an upcoming “In Our Unit, ” send it to CRITICAL CARE NURSE, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 3622049; e-mail, ccn@aacn.org. The critical care transport team can determine the outcome of a patient’s survival... a tremendous responsibility for each and every team member involved. In the past, critically ill or injured patients had few options for continuity of care while enroute from a critical care setting to a tertiary care facility. Paramedics transported these patients, and also provided critical care during transfer with little or no training in this specialized area. In fact, these paramedics often had to administer advanced pharmacological agents, operate high-tech equipment, and perform procedures and interventions necessary to maintain or improve overall patient outcome. Today, the challenges inherent in ground critical care transport (CCT) are being addressed and more options have become available. Without a doubt, any patient who is critically ill or injured requires rapid transport to a tertiary care facility with advanced diagnostics and specialty physicians who are capable of performing invasive and surgical procedures necessary to save lives and improve outcome. Aeromedical transport is the best mode of CCT for those who meet the requirements, but when this option is not available because of mechanical problems, inclement weather, unforeseen staffing problems, weights and balances, and high demand, CCT must be able to offer services that are at least equal to those offered by aeromedical services. With CCT, time is an issue; it takes much longer to transport via ground than by air. As a result, ground CCT teams must be able to function autonomously, which requires expertise in the critical care setting.

Intraosseous access in the setting of pediatric critical care transport

To demonstrate safety and efficacy of intraosseous needle placement among health care provider groups in the setting of pediatric critical care transport. Retrospective chart review. Pediatric critical care transports to a pediatric intensive care unit. Children undergoing pediatric critical care transport between January 1, 2000, and March 31, 2002, requiring intraosseous access before arrival to the pediatric intensive care unit. Intraosseous access placed for emergent vascular access. During the study period, the transport team performed 1,792 transports and identified 47 patients requiring 58 intraosseous placements. These were placed by emergency medical technician-paramedics (18%), referring emergency medicine physicians (42%), and the transport team members (40%). The intraosseous needles were placed with a mean of 1.2 attempts per placement and a first attempt success rate of 78%. Main site of placement was the proximal anterior tibia (95%). Access was maintained for a mean of 5.2 hrs. The intraosseous needle was used for fluids, medications, and laboratory studies. Admitting diagnoses included respiratory distress (28%), cardiopulmonary arrest (26%), neurologic insults (17%), dehydration (15%), sepsis (11%), and other (3%). Ages ranged from 3 wks to 14 yrs (mean 2.2 yrs) and weights from 2.1 to 60 kg (mean 12.3 kg). Complications were noted in seven of 58 (12%), all limited to local edema or infiltration. Intraosseous placement is frequently needed in the care of critically ill pediatric patients before they reach the pediatric intensive care unit. We have demonstrated that intraosseous needles can be placed safely with similar rates of success when comparing different provider groups. Emergency medical technician-paramedics, emergency medicine physicians, and pediatric critical care transport teams should be familiar with intraosseous placement.

Impact of a triage tool on air versus ground transport of cardiac patients to a tertiary center

Introduction The optimum method of transport for acute cardiac patients remains controversial. We proposed a physician-developed triage scheme for appropriate use of air versus mobile intensive care unit (ICU) in the transfer of cardiac patients and sought to determine the impact on the distribution of transport mode for cardiac patients in areas of personal characteristics and clinical factors and whether the triage scheme would be a valuable decision-making tool for physicians referring cardiac patients to tertiary centers. Methods This was a prospective, observational study of transport mode for cardiac patients transported to a tertiary care facility. A comparison was conducted with historical controls. The intervention studied was an educational program designed to teach a triage decision tool developed by a receiving cardiologist with input from the critical care transport team. Short-distance (less than 30 minutes) and long-distance transports were examined. A follow-up survey of referring hospitals was conducted. Results Short-distance transports enjoyed excellent compliance with 41 of 42 patients being transported by mobile ICU. Long-distance transports by mobile ICU increased from 55% to 65% during the study period. However, a third of the mobile ICU patients actually met air transport criteria. Long-distance patients transported by air had significantly higher transport costs, total hospital charges, and direct admission to the catheterization lab. Five of the 10 surveyed emergency department directors found the triage instrument useful in making transport decisions. Conclusions A physician-developed triage instrument to select an appropriate mode of transport for acute cardiac transfers was effectively used. Further studies must validate the cardiac triage criteria against clinical outcomes, and more effective dissemination of the triage instrument must be sought. Furthermore, this information must be perceived as useful by referring physicians to gain wider acceptance.

CAMTS sets the standard

In October 2004, the Commission on Accreditation of Medical Transport Systems (CAMTS) will publish the 6th edition of its accreditation standards. Revisions for the next edition begin almost immediately because we strive to publish standards that are concurrent with actual practice. Patient care and safety remain the two highest priorities. In developing new standards and revising current guidelines, the challenge is to raise the bar with each new edition, while keeping standards clear and meaningful with enough flexibility to address the unique variances of medical transport. Looking back at previous editions of CAMTS standards is like reviewing the changes we have experienced in the medical transport profession. When accreditation standards were first developed in 1991, we incorporated guidelines already developed by organizations such as the Association of Air Medical Services, the Helicopter Association International, Air & Surface Transport Nurses Association, and the National EMS Pilots Association. We held public forums to include input from individual professionals directly involved in medical transport. We wrote the first standards with great emphasis on the rotor-wing, hospital-based program because this is where the greatest challenges were in terms of safety and where most of the input originated. Since 1995, we have expanded the rotor-wing and fixed-wing sections to more appropriately address the independent medical transport systems that are not affiliated with hospitals and to address maintenance issues not previously included. By 1997, CAMTS changed its name to include standards and a process for ground critical care transport teams. These ground services, especially the pediatric and neonatal teams, wanted to demonstrate their level of quality and be eligible to apply for accreditation. In 2000, we also included ground advance life support (ALS)/basic life support (BLS) standards to meet the needs of expanding programs that wanted to have their entire transport service accredited by one body and through one site visit. Many air medical services were expanding into ground transport at all levels of care, so these standards were developed, and now ground ALS/BLS services can be included in the accreditation application if associated with an air or ground critical care service. In 2002, in an effort to de-emphasize titles (registered nurse and physician) as the only way to define critical care team members, we added an alternative means for programs to apply as a critical care team. Paramedic teams can apply as a critical care team if they demonstrate this level of care through mission profile, patient acuity, clinical experience, and educational requirements. Most importantly, outcome studies must show appropriate care is provided and a comprehensive performance improvement process must exist to review the critical care transports. As we move forward to the 2004 edition of standards, we will include a section for medical escort services and programs that provide medical escorts on commercial airlines or ground vehicles. We also will list criteria for human patient simulators that are appropriate in meeting the standards for initial and ongoing training. We have posted the first draft of revisions for the 6th edition on the Web site (www.camts.org). We value all suggestions and have included a comment section with the revisions. Your input will go directly to the accreditation standards committee and be considered for the second draft, which will be presented to the board of directors for approval at the July meeting.

Damage control laparotomy in the Australian military.

Damage control laparotomy (DCL) is a physiological approach to the management of selected critically injured patients where the surgical technique is directed at minimising the metabolic insult, rather than restoring anatomic integrity. DCL consists of an abbreviated initial laparotomy that is limited to control of haemorrhage and contamination, intra-abdominal packing, and temporary closure. Secondary resuscitation continues in the intensive care unit for 24-48 h until normal physiology has been restored. The subsequent reoperation involves removal of the packing with definitive repair and closure. Using this approach 50% of civilian patients who would previously have died undergoing a definitive trauma laparotomy will survive. Doctrinal change in Australia has yet to enshrine a strong focus on restoration of key physiological variables as a major objective in treatment of all wartime casualties. Yet the philosophy of damage control is uniquely suited to the Australian military environment. However, transition of DCL to the military setting has to take account of operational constraints. The most important unresolved issue is how to provide adequate postoperative intensive care. An evacuation capability incorporating critical care transport teams needs to be present, as the patient must reach definitive care within 48 h.

Utilization of Critical Care Transport Teams for International Education

Utilization of Critical Care Transport Teams for International Education

Management of Suspected Aortic Dissection During Interfacility Transport: Opportunity for Beneficial Intervention by the Critical Care Transport Cre

PURPOSE: Blood pressure control with antihypertensive therapy (AT) is a vital component of early critical care of patients with suspected acute aortic dissection (SAD). This study's objective was to assess the frequency and efficacy with which a critical care transport team (CCTT) instituted AT to patients undergoing interfacility (IF) transfer for a referring hospital (RH) diagnosis of SAD.