Critical Care Transport Research Articles

Postintubation Sedation After a Formulary Change From Succinylcholine to Rocuronium in a Critical Care Transport Organization

ObjectiveRocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine. MethodsBoston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019. ResultsWe analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P < .001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine. ConclusionsIntubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation.

Evaluation of a Disposable Vascular Pressure Device for Pre- and Postmembrane Pressure Monitoring During Venovenous Extracorporeal Membrane Oxygenation.

Membrane pressure monitoring during extracorporeal membrane oxygenation (ECMO) is integral to monitoring circuit health. We compared a disposable vascular pressure device (DVPD) to the transducer pressure bag arterial line (TPBAL) monitoring system to determine whether the DVPD can reliably and accurately monitor membrane pressures during venovenous extracorporeal membrane oxygenation (VV ECMO). We analyzed existing quality assurance data collected at a single center as part of routine circuit performance monitoring and process improvement on a convenience sample of four VV ECMO circuits. We placed and zeroed a DVPD in line with the pre- and postmembrane TPBAL setups in coordination with a standard transducer setup. We recorded DVPD and TPBAL pressure measurements every 4 hours for 2.5 days on the four separate VV ECMO circuits. We compared the standard and DVPD pressures using Bland-Altman plots and methods that accounted for repeated measures in the same subject. We recorded 58 pre/postmembrane pressures. Mean membrane pressure values were similar in the DVPD (pre: 208 mmHg [SD, 50.8]; post: 175 mmHg [46.3]) compared to the standard TPBAL setup (pre: 205 mmHg [52.0]; post: 177 mmHg [46.3]). Using Bland-Altman methods, premembrane pressures were found to be 2.2 mmHg higher (95% confidence interval [CI]: -5.3 to 9.7) in the standard TPBAL setup compared to DVPD and 1.8 mmHg higher (95% CI: -5.3 to 8.9) than the postmembrane pressures. The DVPD provided an accurate measurement of circuit pressure as compared to the TPBAL setup. Across the range of pre- and postmembrane pressures, both methods reliably agreed. Future trials should investigate DVPD accuracy in different environments such as prehospital field cannulation or critical care transport of ECMO patients.

Impact of Inter-facility Critical Care Transport System in Saudi Arabia: Acute Aortic Dissection Case Report

The critical care transport service (CCT) is an important factor in the successful delivery of high-quality services by any healthcare system or programme. It is conducted by well-trained, qualified paramedics, nurses and respiratory therapists. The cornerstone of CCT is to ensure, during the transport of patients, continuity of the critical care initiated by the referring provider until arrival at the receiving provider. We report a case of a patient with acute aortic dissection who presented to a general hospital in Riyadh, requiring emergent advanced surgical intervention that is available only in tertiary hospitals. The coordination of the patient’s transfer was arranged by the emergency medical services’ team leader within the health cluster that includes both the general and tertiary hospitals involved in the case. This process resulted in the required service being provided within record time, with excellent outcomes. This case report highlights the impact and importance of inter-facility critical care transport systems.

Statin Administration for ST-Elevation Myocardial Infarction During Rotor Wing Transport

ObjectiveThe aim of this study was to evaluate the feasibility of statin administration by a critical care transport medicine (CCTM) team during rotor wing transport for ST-elevation myocardial infarction patients to a percutaneous intervention–capable center. MethodsWe conducted a retrospective study at a single CCTM program after an intervention focused on statin administration for ST-elevation myocardial infarction that included a formulary change and a single brief educational presentation to flight physicians. A comparison group of flight nurse practitioners underwent training after the study period and were used as a control. Two authors completed an independent chart review to collect data. Descriptive statistics and chi-square or Mann-Whitney U testing were used to compare groups. ResultsStatin administration (or documentation of statin administration before CCTM crew arrival or contraindication to statin administration) occurred during 15 of 19 (79%) transports staffed by trained providers and 3 of 18 (17%) transports staffed by untrained providers (P < .001 by chi-square test). Scene times were not significantly different between transports by trained and untrained providers. ConclusionIn summary, we demonstrate the feasibility and safety of a protocol for statin administration in the CCTM setting.

Articles That May Change Your Practice: Bougie and First-Attempt Intubation

The inability to maintain airway patency or inadequate oxygenation and ventilation is an emergency situation and an indication for an advanced airway. The quickest and most effective means of establishing a definitive airway is through rapid sequence intubation (RSI). RSI is a requisite skill for practitioners in the air medical and land critical care transport setting. Although these providers have been shown to have a higher first-attempt success rate for tracheal intubation in the prehospital setting compared with other prehospital providers, their rates of first-attempt success are lower than intubations performed in the emergency department by physicians.

Improving Mobilization Times of a Specialized Neonatal and Pediatric Critical Care Transport Team

ObjectivesThe Ground and Air Medical Quality Transport database identifies the average mobilization time (AMT) of the transport team as a metric for benchmarking. Our specific aim was to decrease our AMT to < 25 minutes for our expanded role, ground, nonsimultaneous transports by the end of quarter 4 of 2018. MethodsStandardization of data collection with awareness building, ambulance vendor involvement, and team-focused interventions were the different phases of project implementation. Documentation of reasons for delay was performed pre- and postimplementation. ResultsOur AMT decreased from a baseline of 30.3 minutes to 24.5 minutes after project implementation. Communication delays (19.0%), reason for delay not documented (16.5%), no team available (14.0%), rotor wing vendor delays (12.4%), and ambulance vendor delays (7.4%) were the common reasons for delay on our preimplementation Pareto analysis. Communication and pharmacy delays were the most common reasons during all 3 phases of our project. ConclusionsImplementation of the project allowed us to achieve our goal of improving our AMT. Understanding the reasons for delay is a crucial consideration, and success depends on careful change management. Further iterations will need to focus on improving communication and the pharmacy medication dispatch process.

Interfacility Transport of Mechanically Ventilated Patients with Suspected COVID-19 in the Prone Position

Objective Prone positioning during mechanical ventilation in patients with severe respiratory failure is an important intervention with both physiologic and empiric rationale for its use. This study describes a consecutive cohort of patients with severe hypoxemic respiratory failure due to COVID-19 who were transported in the prone position in order to determine the incidence of serious adverse events (SAEs) during transport. Methods This retrospective study used prospectively collected data from a provincial air and land critical care transport system where specially trained critical care paramedic crews transported intubated and mechanically ventilated patients with COVID-19 in the prone position. SAEs were determined a priori, and included markers of new hemodynamic or respiratory instability, new resuscitative measures, and equipment or vehicle malfunction. Two authors independently reviewed each patient care record to identify SAEs during transport, and the ability of the crews to successfully manage such events. Results From April 2020 to June 2021, 127 intubated and mechanically ventilated patients were transported in the prone position. Of these, 117 were transported by land vehicle, 7 by rotor-wing, and 3 by fixed wing aircraft. 67 (52.8%) were vasopressor-dependent, 5 (3.9%) were receiving inhaled vasodilators, 9 (7.1%) were hypoxic (SpO2 < 88%), and 3 (2.4%) were hypotensive (SBP < 90 or MAP < 65 mm Hg) when the transport crew made patient contact at the sending hospital. Of the 122 (96.1%) patients in which a pre-transport PaO2/FiO2 ratio was available, the mean (median; range) was 86.7 (81; 47–144), with 27 patients greater having a ratio greater than 100. The mean (median; range) transport time was 49 (45; 14–176) minutes. There were 19 SAEs in 18 (14.2%) patients during transport, the most common of which was new hypoxia requiring ventilator adjustments (15 of 18 patients). All SAEs were successfully managed by the transport crews. No patient experienced tracheal tube obstruction, unintentional extubation, cardiac arrest, or died during transport. Conclusion Patients with severe hypoxemic respiratory failure due to COVID-19 can be safely transported in the prone position by specially trained critical care paramedic crews.

Severity of Illness Scoring for Pediatric Interfacility Transport: A North American Survey.

Severity of illness scoring during pediatric critical care transport may provide objective data to determine illness trajectory and disposition and contribute to quality assurance data for pediatric transport programs. The objective of this study was to ascertain the breadth of severity of illness scoring tool application among North American pediatric critical care transport teams. A cross-sectional quantitative survey using REDCap was distributed to 137 North American pediatric transport programs. Baseline team characteristics were established along with questions related to severity of illness tool application.Descriptive statistics were used for analysis. There were 55 responses (40%), and of those, 13 (24%) use a severity of illness scoring tool within their practice. A variety of tools were used including: Transport Risk Index of Physiologic Stability, Children's Hospital Medical Center Cincinnati, Canadian Triage and Acuity Score, Transport Risk Assessment in Pediatrics, Pediatric Early Warning Scores, Levels of Acuity, Transport Pediatric Early Warning Scores, and an unspecified tool. The timing of scoring, team personnel who applied the score, and the frequency of analysis varied between transport programs. Severity of illness scoring is not consistently performed by pediatric interfacility transport programs in North America. Among the programs that use a scoring tool, there is variability in its application. There is no universally accepted or performed severity of illness scoring tool for pediatric interfacility transport.Future research to validate and standardize a pediatric transport severity of illness scoring tool for North America is necessary.

Noninvasive Respiratory Support during Pediatric Critical Care Transport: A Retrospective Cohort Study

AbstractNoninvasive respiratory support (NRS) including high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP) is increasingly used for children with respiratory failure requiring interhospital transport by pediatric critical care transport (PCCT) teams. In this retrospective observational study of children receiving NRS on transport between January 1st, 2017 and December 31st, 2019 by a single PCCT service in England, we describe a cohort of children, looking at patient characteristics, journey logistics, adverse events, and failure of NRS (as defined by emergency intubation on transport or within 24 hours of arriving on the pediatric intensive care unit), and to attempt to identify risk factors that were associated with NRS failure. A total of 3,504 patients were transported during the study period. Three hundred and seventeen (9%) received NRS. Median age was 4.9 months (IQR: 1.0–18.2); median weight was 5.1 kg (IQR: 3.1–13). The primary diagnostic category was cardiorespiratory in 244/317 (77%) patients. Comorbidities were recorded in 189/317 (59.6%) patients. Median Pediatric Index of Mortality-3 (PIM3) score was 0.024 (IQR: 0.012–0.045). Median stabilization time was 80 minutes while median patient journey time was 40 minutes. Nineteen adverse events were described (clinical deterioration, equipment failure/interface issues) affecting 6% of transports. The incidence of NRS failure was 6.6%. No risk factors associated with NRS failure were identified. We concluded that NRS can be considered safe during pediatric transport for children with a wide range of diagnoses and varying clinical severity, with a low rate of adverse events and need for intubation on transport or on the PICU.

Implementation of a Rapid Sequence Intubation Checklist Improves First Pass Success and Reduces Peri-Intubation Hypoxia in Critical Care Transport

<h3>Objectives</h3> We measured the impact of a rapid sequence intubation checklist (RSIC) on first pass success (FPS) during endotracheal intubation by US flight crews, taking into consideration human factors of checklist utilization. We also examined the effects of the RSIC on definitive airway sans hypoxia or hypotension on first pass among adult patients (abbreviated as DASH1a). <h3>Methods</h3> This is a before-and-after observational study within a helicopter ambulance company. The RSIC was used by the crews (Flight Paramedic and Flight Nurse) over a three-year period. Data were evaluated for 8 quarters before- and 8 quarters after- checklist implementation, spanning December 2014 to March 2019. Data included: reason for intubation, use of checklist during intubation, and correlation with the prehospital difficult airway prediction tool, HEAVEN (Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurological injury) compared with airway management prior to implementation of the checklist. The primary outcome was FPS, and this was compared among those who received RSI before the checklist, versus those who received RSI with the checklist. Also, definitive airway sans hypoxia on first pass among adult patients (DASH1a) was measured before and after RSI checklist implementation. Outcome scenarios were recorded to analyze effectiveness of the checklist. <h3>Results</h3> A total of 10,405 intubations were attempted during the study. First pass success was achieved in 90.9% of patients prior to RSIC, and 93.3% achieved FPS post-implementation (p=<0.001). In the epoch prior to the RSI checklist, there were 4015 (91.9%) of intubations that met the DASH1a metric. After RSI checklist implementation, DASH1a success improved to 94% (p<0.001). Reasons for intubation were similar between the cohorts, although there were more HEAVEN criteria, indicating more difficult airway characteristics, among the post-checklist cohort. It is also noteworthy that overall intubation success without hypoxia improved between the study timeframes, with 89.5% prior versus 93.1% of patients intubated without hypoxia after RSI checklist training, p<0.001. <h3>Conclusion</h3> Implementation of a standardized Rapid Sequence Intubation checklist is a best practice to optimize DASH1a and thereby prevent adverse events related to hypotension or hypoxia in the peri-intubation period. Data suggest that these observations held true even with more objectively difficult EMS airways, based on the higher prevalence of one or more HEAVEN criteria after the checklist implementation.

Compliance and Attitudes of Critical Care Transport Providers Regarding a Prehospital Rapid Sequence Intubation Checklist

<h3>Background</h3> Checklists have been adopted in various acute care settings with reasonable compliance and acceptance. In the Air Medical industry, checklists have been implemented by different teams for critical clinical procedures such as rapid sequence intubation (RSI). However, compliance and attitudes toward these Human Factors innovations in the critical care transport setting are not well-described. <h3>Methods</h3> We conducted an IRB-exempt, retrospective review of checklist usage to assess compliance with a required RSI checklist by critical care transport providers. We also conducted an IRB-exempt survey of critical care transport providers with 5 questions based on Rogers' theory of diffusion of innovation that had graded responses on a 1-5 Likert scale. The distribution of responses for each question was determined and summarized using means and standard deviations. A free-marginal Kappa along with 95% confidence interval was determined to measure inter-rater consistency. <h3>Results</h3> Checklist compliance was 92% over the period reviewed after checklist implementation. There was a 10% response to the survey questions and a total of 314 individual responses were recorded. Questions regarding compatibility with practice and difficulty of use were favorable. The response to how the checklist flows with current RSI performance was 4.07 (SD 1.060). The average response to the questions regarding difficulty of learning the list and teaching the list were 4.53 (SD 0.861) and 4.10 (SD 1.056) respectively. But, with questions regarding observable change to practice, there was slight difference. The response to the question regarding the checklist effect on reduction of cognitive load was less strong at 3.74 (SD 1.290). Crew members, however, did believe that helped make sure they did not miss anything during the RSI procedure with an average response of 4.10 (SD 1.125) <h3>Conclusions</h3> Process compliance with checklist implementation was excellent. Most respondents felt that the innovation of using the checklist fit well into their existing practice and was not difficult to learn or teach. The majority of respondents also felt it was helpful at preventing procedural errors.

Warmed IV Fluids to Neonates

Warmed IV Fluids to Neonates

Missed Application of the Field Trauma Triage Standard in Secondary Interfacility Transfers of Injury

Introduction The Field Trauma Triage Standard (FTTS) is used to identify patients who would benefit from direct transfer to a lead trauma hospital (LTH). This study determined the frequency that patients who underwent secondary interfacility trauma transfer initially met the FTTS and assessed the delay to LTH. Methods Retrospective cohort study of all injured patients undergoing interfacility transfer to a LTH with Ornge, the provincial critical care transport organization in Ontario, Canada over a 1-year period. Frequency of missed FTTS application and delay to LTH were measured. Results A total of 460 adult interfacility transfer trauma patients were included in the study, of these 372 met FTTS (80.8%). The median time from initial hospital arrival to LTH was 5.7 hours for those patients requiring interfacility transport that initially would have met FTTS on scene. Conclusion Missed application of FTTS was overwhelming, occurring in over eighty percent of our population, contributing an average delay to definitive care of 5.7 hours. Older age was a commonly missed criterion. The addition of recreational vehicle collisions to the FTTS should be considered. The Field Trauma Triage Standard (FTTS) is used to identify patients who would benefit from direct transfer to a lead trauma hospital (LTH). This study determined the frequency that patients who underwent secondary interfacility trauma transfer initially met the FTTS and assessed the delay to LTH. Retrospective cohort study of all injured patients undergoing interfacility transfer to a LTH with Ornge, the provincial critical care transport organization in Ontario, Canada over a 1-year period. Frequency of missed FTTS application and delay to LTH were measured. A total of 460 adult interfacility transfer trauma patients were included in the study, of these 372 met FTTS (80.8%). The median time from initial hospital arrival to LTH was 5.7 hours for those patients requiring interfacility transport that initially would have met FTTS on scene. Missed application of FTTS was overwhelming, occurring in over eighty percent of our population, contributing an average delay to definitive care of 5.7 hours. Older age was a commonly missed criterion. The addition of recreational vehicle collisions to the FTTS should be considered.

30th Critical Care Transport Medicine Conference

The Perdido Beach Resort in Orange Beach, Alabama has been selected to host the 30th Annual Critical Care Transport Medicine Conference (CCTMC), scheduled for April 11 - 13, 2022. This luxurious, yet family-friendly destination is affordable, and offers the perfect setting to blend business and pleasure.

Operational Policies and Procedures for Critical Care Transport During a Respiratory Pandemic

The severe acute respiratory syndrome coronavirus 2 pandemic of 2020 to 2021 created unprecedented challenges for health care organizations, including those in the critical care transport sector. Critical care transport services had to rapidly adjust to changing patient demographics, distribution of diagnoses, and transport utilization stratagem. To evolve with the pandemic, organizations developed new protocols and guidelines in rapid succession. The growth bore out of a need to cater to this new patient population and their safety as well as the safety of the crewmembers from severe acute respiratory syndrome coronavirus 2. The critical changes to operations involved adaptability, efficient communication, continual reassessment, and implementation of novel approaches. Although these lessons learned were specific to coronavirus disease 2019, many processes will apply to future respiratory epidemics and pandemics.The severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic of 2020 to 2021 created unprecedented challenges for health care organizations, including critical care transport (CCT) organizations. The changes were numerous, including a change in the patient population, with a rapid decrease in trauma and pediatrics to a preponderance of adult patients with acute hypoxemic respiratory failure. CCT teams were called on to transport these patients at potential risk to themselves, especially early in 2020, before the effectiveness of personal protective equipment (PPE) was determined. Even seemingly simple tasks, such as defining a person under investigation (PUI) for coronavirus disease 2019 (COVID-19), varied from institution to institution, putting transport organizations in the middle of conflicts.Agility has always been an essential part of any CCT organization because clinicians and managers must adapt to an unpredictable environment. However, the frequency and speed of changes occurring during the COVID-19 pandemic were unprecedented. This report offers our best practices based on our experience and the available data. Although these procedures were developed for the COVID-19 pandemic, they will logically apply to future respiratory outbreaks and illuminate helpful changes for otherwise quotidian operations.

Point-of-Care Ultrasound Curriculum for Endotracheal Tube Confirmation for Pediatric Critical Care Transport Team Through Remote Learning and Teleguidance

ObjectivePoint-of-care ultrasound (POCUS) is used to manage patients in real time. This study aimed to teach pediatric critical care team members to use POCUS for endotracheal tube (ETT) placement confirmation. A secondary aim was to assess the feasibility of a remote curriculum for this purpose. MethodsThe Kern 6-step approach was used. The curriculum involved virtual didactics, asynchronous learning modules, and remote hands-on sessions using teleguidance with the Butterfly IQ+ probe, Butterfly Network, Inc, Guilford, CT. Participants learned direct and indirect methods of ETT placement confirmation and were directed to practice independently. Outcomes included attitudes and satisfaction, knowledge and skills acquisition and retention, and the use of POCUS on shift. ResultsTen participants completed the curriculum. The average knobology and quiz scores improved by 29.3% and 20.8%, respectively. Improvement was sustained at re-evaluation. Seven of 10 participants performed independent scans. At the 3-month reassessment, most demonstrated mastery of thoracic scans. All required prompting for satisfactory tracheal scans. All felt positively toward POCUS and the remote curriculum. ConclusionPediatric critical care team members acquired and retained knowledge and skills for POCUS basics and ETT placement confirmation through a remote curriculum. Participants were satisfied with the course. Further studies are needed to reassess longer-term knowledge and skill retention and the effects on patient outcomes.

Time to specialty care and mortality after cardiac arrest.

Out of hospital cardiac arrest (OHCA) patients are often transported to the closest emergency department (ED) or cardiac center for initial stabilization and may be transferred for further care. We investigated the effects of delay to transfer on in hospital mortality at a receiving facility. We included OHCA patients transported from the ED by a single critical care transport service to a quaternary care facility between 2010 and 2018. We calculated dwell time as time from arrest to critical care transport team contact. We abstracted demographics, arrest characteristics, and interventions started prior to transport arrival. For the primary analysis, we used logistic regression to determine the association of dwell time and in-hospital mortality. As secondary outcomes we investigated for associations of dwell time and mortality within 24h of arrival, proximate cause of death among decedents, arterial pH and lactate on arrival, sum of worst SOFA subscales within 24h of arrival, and rearrest during interfacility transport. We included 572 OHCA patients transported from an outside ED to our facility. Median dwell time was 113 (IQR=85-159) minutes. Measured in 30min epochs, increasing dwell time was not associated with in-hospital mortality, 24-h mortality, cause of death and initial pH, but was associated with lower 24-h SOFA score (p=0.01) and lower initial lactate (p=0.03). Rearrest during transport was rare (n=29, 5%). Dwell time was associated with lower probability of rearrest during transport (OR=0.847, (95% CI 0.68-1.01), p=0.07). Dwell time was not associated with in-hospital mortality. Rapid transport may be associated with risk of rearrest. Prospective data are needed to clarify optimal patient stabilization and transport strategies.

Influence of Critical Care Transport Ventilator Management on Intensive Care Unit Care

ObjectiveHigh tidal volume ventilation is associated with ventilator-induced lung injury. Early introduction of lung protective ventilation improves patient outcomes. This study describes ventilator management during critical care transport and the association between transport ventilator settings and ventilator settings in the intensive care unit (ICU). MethodsThis was a retrospective review of mechanically ventilated adult patients transported to an academic medical center via a critical care transport program between January 2018 and April 2019. Ventilator settings during transport were compared with the initial and 6- and 12-hour postadmission ventilator settings. ResultsThree hundred eighty patients were identified; 114 (30%) received tidal volumes > 8 mL/kg predicted body weight at the time of transfer. The transport handoff tidal volume strongly correlated with the ICU tidal volume (Pearson r = 0.7). Patients receiving high tidal volumes during transport were more likely to receive high tidal volumes initially upon transfer (relative risk [RR] = 4.6; 95% confidence interval [CI], 3.3-6.5) and at 6 and 12 hours after admission (RR = 2.6; 95% CI, 1.8-3.8 and RR = 2.7; 95% CI, 1.7-4.3, respectively). ConclusionExposure to high tidal volumes during transport is associated with high tidal volume ventilation in the ICU, even up to 12 hours after admission. This study identifies opportunities for improving patient care through the application of lung protective ventilation strategies during transport.

Compliance and Attitudes of Critical Care Transport Providers Regarding a Prehospital Rapid Sequence Intubation Checklist

Human factors engineering innovations, such as checklists, have been adopted in various acute care settings to improve safety with reasonable compliance and acceptance. In the air medical industry, checklists have been implemented by different teams for critical clinical procedures such as rapid sequence intubation. However, compliance and attitudes toward these human factors engineering innovations in the critical care transport setting are not well described. In this institutional review board–exempt, retrospective review of checklist usage, we assessed rapid sequence intubation checklist compliance and surveyed providers with 5 questions based on Rogers’ theory of diffusion of innovation to examine why or why not there was compliance. Our results indicated that compliance with checklist implementation was excellent. The survey questions were consistent with process improvement factors that enhance the spread and acceptance of innovation.

Characteristics associated with delays in decision to transfer injured patients

Introduction The regionalized nature of trauma care necessitates interfacility transfer which is vulnerable to delays given its complexity. Little is known about the interval of time a patient spends at the sending hospital prior to when the transfer is initiated—the “decision to transfer” time. This primary objective of the study was to explore the impact of patient, environmental, and institutional characteristics on decision to transfer time. Methods This was a retrospective cohort study of injured adult patients who underwent emergent interfacility transfer by a provincial critical care transport organization over a 31-month period. Quantile regression was used to evaluate the impact of patient, environmental, and institutional characteristics on the time to decision to transfer. Results A total of 1128 patients were included. The median decision to transfer time was 2.42 h and the median total transport time was 3.12 h. The following variables were associated with an increase in time to decision to transfer at the 90th percentile of time: age &gt;75 (+2.47 h), age 66–75 (+3.70 h), age 56–65 (+1.20 h), transfer between 00:00 and 07:59 (+2.08 h), and transfer in the summer (+2.25 h). The following variables were associated with a decrease in time to decision to transfer at the 90th percentile of time: Glasgow Coma Scale 3–8 (−2.21 h), respiratory rate &gt;30 (−2.01 h), sending site being a community hospital with &lt;100 beds (−4.11 h), or the sending site being a nursing station (−5.66 h). Conclusion Time to decision to transfer was a sizable proportion of the patients interfacility transfer. Older patients were associated with a delay in decision to transfer as were patients transferred overnight and in the summer. These findings may be used to support the implementation of geriatric trauma triage guidelines and promote ongoing education and quality improvement initiatives to decrease delay.