Interfacility Transport Research Articles

Correlation between EtCO2 and PCO2 in patients undergoing critical care transport

ABSTRACT OBJECTIVES End-tidal carbon dioxide (EtCO2) monitoring is widely used as a surrogate for the partial pressure of carbon dioxide (PCO2) in critically ill patients receiving manual or mechanical ventilation in prehospital, emergency, and critical care settings. Specific targets for ETCO2 are a key component of Emergency Medical Services (EMS) protocols, especially for specific patient groups such as those with traumatic brain injury. However, the correlation between EtCO2 and venous or arterial PCO2 is uncertain. We aimed to assess the correlation between EtCO2 and PCO2 in intubated patients undergoing critical care transport (CCT), and in specific subgroups of patients. METHODS We performed a retrospective review of patients undergoing emergency transport by a multi-state CCT agency. Patients were included if they had an advanced airway and both an EtCO2 and PCO2 reading within 5 minutes of each other. We obtained data on patient demographics, transport characteristics, medical categories, vital signs, lab values, and specific interventions. We performed univariable and multivariable binary logistic regression to assess the association between delta PCO2 and these characteristics. RESULTS We included 6,459 patients (mean age 58.4 years [SD 18.5], 57.1% male), of which a subset of 551 patients had multiple EtCO2-PCO2 measurements within 5 minutes. The median (IQR) initial delta PCO2 was 12.9 mmHg (7.1, 21.9). 3,967 (61.4%) patients had a delta PCO2 >10 mmHg and 1,843 (28.5%) had a delta PCO2 >20 mmHg. We identified an independent association between delta PCO2 >10 mmHg and age, male sex, interfacility transport, venous sampling site, respiratory rate, hypotension, hypoxia, and thoracostomy. In patients with multiple blood gas measurements, 76% had delta PCO2 >10 mmHg over the duration of the transport. CONCLUSIONS We identified substantial differences between EtCO2 and PCO2 across patients with medical and traumatic conditions undergoing critical care transport. The PCO2 assessment should be strongly considered as part of ventilatory management in patients encountered in emergency and critical care settings.

Appropriately matching transport care units to patients in an interhospital Transport Care: an implementation report.

In interfacility transport care, a critical challenge exists in accurately matching ambulance response levels to patients' needs, often hindered by limited access to essential patient data at the time of transport requests. Existing systems cannot integrate patient data from sending hospitals' electronic health records (EHR) into the transfer request process, primarily due to privacy concerns, interoperability challenges, and the sensitive nature of EHR data. We introduce a distributed digital health platform, Interfacility Transport Care (ITC)-InfoChain, designed to solve this problem without compromising EHR security or data privacy. This report details the implementation of Interfacility Transport Care (ITC)-InfoChain, a secure, blockchain-based platform designed to enhance real-time data sharing without compromising data privacy or EHR security. The ITC-InfoChain platform prototype was implemented on AWS cloud infrastructure, employing Hyperledger Fabric as a permissioned blockchain. Key elements included participant registration, identity management, and patient data collection isolated from the sending hospital's EHR system. The client program submits encrypted patient data to a distributed ledger, accessible to the receiving facility's critical care unit at the time of transport request and EMS teams during transport through the PatienTrack web application. Performance was evaluated through KPIs such as data transaction times and scalability across transaction loads. The ITC-InfoChain demonstrated strong performance and scalability. Data transaction times averaged 3.1 seconds for smaller volumes (1-20 transactions) and 6.4 seconds for 100 transactions. Optimized configurations improved processing times to 1.8-1.9 seconds for 400 transactions. These results confirm the platform's capacity to handle high transaction volumes, supporting timely, real-time data access for decision-making during transport requests and patient transfers. The ITC-InfoChain platform addresses the challenge of matching appropriate transport units to patient needs by ensuring data privacy, integrity, and real-time data sharing, enhancing coordination of patient care. The platform's success suggests potential for regional pilots and broader adoption in secure healthcare systems. Stakeholder resistance due to blockchain unfamiliarity and data privacy concerns remains. Funding has been sought to support a pilot program to address these challenges through targeted education and engagement.

Caregiver Accompaniment in Pediatric Critical Care Transport: A Systematic Scoping Review.

Family-centered care is a critical component of critical care interfacility and medical retrieval transport (MRT) services. These services provide a critical bridge for a physiologically and psychologically unique population often best served in specialized, tertiary centers. Caregivers often wish to accompany patients during MRT. However, there is currently little research on the impact of caregiver accompaniment on MRT. The aim of the study is to determine: 1) What are caregiver attitudes to accompanied and unaccompanied MRT? 2) What are healthcare provider attitudes to caregiver presence? 3) What are patient attitudes to caregiver presence? and 4) Are there differences in patient outcome depending on caregiver presence? Data sources are MEDLINE, Embase, and CINAHL. Studies with a focus on patient, caregiver, or family-oriented care practices in MRT. Reviewed articles were not restricted unless they discussed neonatal transport, palliative transport, were non-English, or were conference proceedings. We screened 1373 articles, with 45 full-text articles reviewed. After removal of duplicates and abstract-only results, 25 articles remained. Three additional articles were found in references of reviewed articles. Articles generally supported caregiver presence on MRT, with caregivers and providers in agreement. However, for many services, space was a limiting factor controlling when caregivers could travel. There is a paucity of literature on this topic, and studies were entirely from English-speaking countries. Caregivers and healthcare providers largely prefer caregiver accompaniment on MRT services. There is little data on patient perspectives and transport-related adverse events affecting patient outcomes.

Investigating the Risk Factors Associated With Acute Neurologic Dysfunction in Pediatric Hyperglycemic Emergencies on Transport.

This study aims to identify key characteristics of hyperglycemic emergencies in pediatric patients and those at risk for acute neurologic dysfunction during transport. We conducted a retrospective chart review of pediatric patients during interfacility transport by Ornge, Ontario's critical care transport service, from January 1, 2009, to December 31, 2019. Data were extracted from electronic patient care records and included demographic, clinical, and transport-specific variables. Two multiple logistic regression models were utilized to analyze associations between predictor variables and neurologic dysfunction (GCS, <14). Of the 399 patients included, 24% (n = 95) had a GCS score of <14. Patients with a GCS score of <14 were more acidotic compared with those with a GCS score of ≥14 (median pH, 6.9 [IQR, 6.8-7.1] vs median, pH 7.0 [IQR, 1.0-7.2]; P < 0.001). Higher median corrected sodium for glucose values were observed in patients with a GCS score of <14 compared to those with a GCS score of ≥14 (145.7 mmol/L [IQR, 140.6-149.9 mmol/L] vs 141.7 mmol/L [IQR, 138.3-146.4 mmol/L]; P < 0.001). Multiple logistic regression identified younger age (aOR, 0.91; 95% CI, 0.84-0.98; P = 0.01), severe acidosis (pH <7.10; aOR, 3.56; 95% CI, 1.33-11.62; P = 0.02), and higher creatinine (aOR, 1.01; 95% CI, 1.01-1.02; P < 0.001) as risk factors for acute neurologic dysfunction. Our findings reveal associations between acute neurologic dysfunction, younger age, severe acidosis, and elevated corrected sodium for glucose values in pediatric hyperglycemic emergencies during transport. Education and adherence to guidelines are recommended to improve outcomes in this population.

Assessing the Risk of Interfacility Transport in Pregnant Patients Due to Progression of Labor: Lessons From a Specialized Maternal-Fetal Transport Program.

Background Pregnant laboring patients sometimes require interfacility transfer to a higher level of care. There is a paucity of evidence to inform when it is safe to transfer a laboring patient and when delivery may be too imminent to transfer. Methods This is a retrospective study of pregnant patients undergoing interfacility transfer with a specialized obstetric transport team deployed from a large Midwest regional healthcare system. The primary outcome was delivery prior to or within one hour of arrival at the receiving institution due to progression of labor. Data collected included basic demographics, vital signs, gravidity, parity, gestational age, contraction frequency if contractions were present, and cervical dilation. We sought to define the association between these variables and the primary outcome to inform risk assessment for precipitous delivery among patients being considered for interfacility transfer. Results Of the 370 pregnant patients for whom the specialized transfer team was requested, 11 (3%) met the primary outcome. Those with more advanced cervical dilation and those who did not receive regular prenatal care were more likely to meet the criteria for the primary outcome. For every centimeter of cervical dilation, the odds of meeting the primary outcome increased 2.3-fold (95% CI: 1.5-3.4). Conclusions We identified risk factors for early delivery among pregnant patients for whom an interfacility transfer was requested and described patients who were high-risk for obstetric interfacility transport due to the progression of labor. Our results can help inform risk assessments for transferring potentially high-risk laboring patients.

Management of Patients With Cardiac Arrest Requiring Interfacility Transport: A Scientific Statement From the American Heart Association.

People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

152: Predictors of bleeding complications during interfacility transport of ECMO patients

152: Predictors of bleeding complications during interfacility transport of ECMO patients

Hemodynamic Collapse After Intubation in Critical Care Transport

Objectives The aim of this study was to describe the incidence of and modifiable risk factors for post intubation hemodynamic collapse in prehospital and interfacility critical care transport. Methods Single center retrospective chart review of adult patients (≥18 years) intubated by a critical care transport team between January 2017 and May 2023. The primary outcome was incidence of hemodynamic collapse (systolic blood pressure <90 mmHg for greater than 30 min, new vasopressor requirement, vasopressor dose increase, fluid bolus of >15 mL/kg, systolic blood pressure <65 mmHg at least once, or cardiac arrest). Secondary outcomes included post intubation hypoxia, as well as association of hemodynamic collapse with potentially modifiable risk factors including pre intubation shock index, pre intubation heart rate, pre intubation systolic blood pressure, and induction agent. Results Three hundred and thirty-three patients were included. Ninety-seven (29.1%) patients experienced hemodynamic collapse and 36 (10.8%) of patients experienced life threatening hemodynamic collapse. Pre intubation shock index >1 (OR 3.18, 95% CI 1.15–8.74) was associated with post intubation hemodynamic collapse. Choice of induction agent, fluid bolus prior to intubation, location of intubation, presence of traumatic injury, and age were not correlated with risk of hemodynamic collapse. The number of intubation attempts and methods of intubation were similar between groups. Conclusions Hemodynamic collapse and life-threatening hemodynamic collapse after intubation occurred frequently in this critical care transport cohort. Shock index greater than one was associated with significantly higher risk of hemodynamic collapse and life-threatening hemodynamic collapse.

A simulation-based approach to analysing delays in the transport of critically ill neonates

ABSTRACT Neonatal interfacility transport ensures that critically ill neonatal patients can receive higher levels of care when needed. Delays in the transport process impact the quality of care and increase the risk of medical complications. The objective of this study is to investigate the operations-related factors that contribute to transport delays and explore the role of discrete-event simulation in improving the transport process. Semi-structured interviews were conducted with stakeholders to understand the neonatal interfacility transport process. Analysis of historical call logs and transport data was performed to identify inputs to the discrete-event simulation model. Statistical tests were used to identify the effect of various factors on wait time and transport time in the simulation model. High patient volume and limited bed capacity at the receiving hospitals are identified as bottlenecks that lead to extended wait time and transportation time. Additionally, having more geographically distributed ambulance resources does not significantly help with the time delays when the receiving hospital capacity stays unchanged. Discrete-event simulation models can be used to investigate the effects of operations-related factors in the interfacility transport of critically ill neonates to support future process improvement.

EMS Bypass to Endovascular Stroke Centers is Associated with Shorter Time to Thrombolysis and Thrombectomy for LVO Stroke

Objectives Large vessel occlusion (LVO) strokes may be eligible for treatment with intravenous thrombolysis (IVT) and endovascular therapy (EVT). Patients selected for treatment have better neurologic outcomes with EVT, and delays in this therapy lead to worse outcomes. However, EVT is offered at a limited number of hospitals, referred to as endovascular stroke centers (ESC). This poses a difficult decision for EMS: to take potential stroke patients to the closest primary stroke center (PSC) or longer transport time to a more distant ESC. We hypothesized that patients with LVO stroke undergoing EVT transported directly to an ESC would have more favorable outcomes as measured by the modified Rankin scale (mRS) at 90 days, compared to transport to a PSC followed by transfer to an ESC. Methods The OPUS-REACH consortium examined transportation patterns and outcomes in patients with LVO stroke who received endovascular treatment. This cohort includes 2400 patients with LVO stroke throughout eight endovascular centers in the Northeast U.S. from 2015 to 2020. All patients enrolled in the OPUS-REACH database were eligible for inclusion. Patients were excluded if they were missing the pickup address, had an in-hospital stroke, or arrived via mobile stroke unit. The remaining patients were separated into two groups: the bypass group, with transportation by EMS to an ESC by bypassing PSC, and the non-bypass group, with initial transport to PSC and interfacility transport to an ESC. The primary outcome was the modified Rankin scale (mRS) at 90 days, where 0–2 was defined as “good”. Results The primary outcome did not reach significance with 40% of the bypass group as compared with the 33.1% of the non-bypass group having a “good” outcome. However, the bypass group underwent shorter times from last-known-well to both thrombolysis (120.9 vs 153.3 min, p < 0.001) and thrombectomy (356.1 vs 454.8 min, p = 0.001). Conclusions In patients with LVO stroke who undergo thrombectomy, EMS transport directly to an ESC results in shorter time thrombectomy, although we did not observe a difference in 90-day functional outcomes. Additionally, bypass to reach a more capable endovascular stroke center does not delay administration of IVT from time of LKW.

Do Hospitals Get EMS Patient Care Reports?

Background: EMS patient care reports (PCRs) are an important component of the EMS system and a foundational element of quality improvement. In many cases, PCRs provide hand-offs between providers, and may be the only context for patient presentation. Little data exists regarding the frequency and timeliness of PCR provision to Emergency Departments (ED). Objective: To describe the frequency of missing PCRs following EMS transport and timing of receipt by EDs within a regional healthcare system. Methods: We performed a retrospective study of EMS PCRs for patients transported to a single health system from 1/1/21 – 7/1/22. We stratified agencies by 911 response or interfacility transport. PCR receipt and time of EPIC upload were obtained from EPIC Crystal Report® query. Primary outcome was frequency of PCR receipt by EDs (in aggregate and by agency). Secondary outcome was interval from EMS ED arrival to EMR upload (greater or less than 120 minutes of arrival). We provide descriptive statistics reporting proportion of receipt of PCR (mean, range) by hospital and agency Results: There were 106,496 patients transported by 62 agencies, 87.3% were 911 responders. Overall, receipt of PCRs varied substantially by hospital – 54.2% (13.5% - 80.1%). 30.7% (2.4% - 63.4%) were uploaded within 120 minutes of ED arrival. PCR submission rate varied substantially by agency, 45.8% (2.5% - 96.8%). Interfacility EMS services were far less likely to submit a PCR after ED transport (35.9% vs. 56.9%). Conclusions: PCR’s are frequently missing after EMS transport within this large hospital system, and infrequently available for timely review. Interfacility transport agencies are less likely to submit compared to 911 responders. Although hospital manual upload of PCRs may impact time of their receipt, this does not explain the overall rate of missing PCRs. Further work is needed to identify obstacles to PCR delivery and assure their availability.

Patient-related Factors Associated with Potentially Unnecessary Transfers for Pediatric Patients with Asthma: A Retrospective Cohort Study.

Asthma is a common chronic medical condition among children and the most common diagnosis associated with interfacility transports for pediatric patients. As many as 40% of pediatric transfers may be unnecessary, resulting in potential delays in care and unnecessary costs. Our objective was to identify the patient-related factors associated with potentially unnecessary transfers for pediatric patients with asthma. We used patient care data from the California Department of Health Care Access and Information patient discharge and emergency department (ED) datasets to capture ED visits where a pediatric patient (age 2-17years) presented with asthma and was transferred to another ED or acute care hospital. The outcome of interest was a potentially unnecessary transfer, defined as a visit where length of stay after transfer was <24 hours and no advanced services were used, such as respiratory therapy or critical care. Patient-related characteristics were extracted, including age, gender, race/ethnicity, primary language, insurance status, and clinical characteristics. First, we used descriptive statistics to compare necessary vs unnecessary transfers. Second, we used generalized estimating equations accounting for clustering by ED to estimate odds ratios (OR) and identify factors associated with potentially unnecessary transfers. A total of 4,233 pediatric ED patients were transferred with a diagnosis of asthma, including 461 (11%) transfers that met criteria as potentially unnecessary. Median age was 12years (interquartile range 7-15), and 46% were female. Factors associated with increased odds of potentially unnecessary transfer while controlling for key factors included younger age (eg, 2-5years, OR 2.0, 95% confidence interval [CI] 1.4-2.9), male gender (OR 1.4, 95% CI 1.1-1.7), and Hispanic ethnicity (OR 1.6, 95% CI 1.2-2.1), while multiple hospitalizations for asthma per year was associated with decreased odds (OR 0.2, 95% CI 0.1-0.4). Several patient-related factors were associated with increased or decreased odds of potentially unnecessary transfers among pediatric patients presenting to the ED with asthma. These factors can be considered in future work to better understand, predict, and reduce unnecessary transfers and their negative consequences.

LifeFlight Case Studies: Lessons Learned From Notable Flights.

Air medical providers are responsible for the care of an incredibly diverse patient population. When it is time to transport a patient, providers must be prepared for complex situations, each requiring different skills, medications, and critical thinking. Scene flights will have providers landing and providing care in the prehospital setting where an interfacility transport requires the patient to be taken from one hospital to another. Specialty flights require special equipment, personnel, and aircraft preparedness to be completed. The case studies provided within this article highlight the complexity and diversity that is encountered each shift at Allegheny LifeFlight.

Direct vs. redirected admission of critically ill children to PICU after interfacility transfer: a retrospective cohort study.

Critically ill children must often be transported long distances for access to critical care resources in Canada. This study aims to describe and compare characteristics and outcomes in patients presenting in the community and requiring inter-facility transport and admission to a Pediatric Intensive Care Unit (PICU). This is a retrospective cohort study of children admitted to the ICU at the Hospital for Sick Children from 2016 to 2019 after inter-facility transport. Characteristics and outcomes were compared between children admitted to the PICU within 24 h from their initial critical care transport request, and children admitted after initial redirection to a non-ICU care setting, 24-72 h from request. The primary outcome was severity of illness at PICU admission. Secondary outcomes included duration of mechanical ventilation, organ dysfunction, PICU length of stay and mortality. A total of 2,730 patients were admitted after inter-facility transport to either the medical/surgical or cardiac ICU within 72 h of initial critical care transport request. Of these children, 2,559 (94%) were admitted within 24 h and 171 (6%) were admitted between 24 and 72 h. Children admitted after initial redirection were younger and residing in more rural centers. Children who were initially redirected had lower severity of illness (PRISM-IV median score 3 vs. 5, p = 0.047) and lower risk of mortality. Initial redirection to a non-ICU care setting rather than directly admitting to the PICU did not result in increased severity of illness or mortality. This study highlights the need to better understand which factors influence disposition decision-making at the time of initial transport request. Further research should focus on the impact of transport factors on clinical outcomes after PICU admission.

Redesigning Prehospital Care: Fiji's Response to the COVID-19 Pandemic.

The benefits of emergency care systems in low- and middle-income countries are well-described. Passed in the wake of the coronavirus disease 2019 (COVID-19) pandemic, the World Health Assembly (WHA) Resolution 76.2 emphasizes the importance of communication, transportation and referral mechanisms, and the linkages between communities, primary care, and hospital care. Literature describing prehospital care and ambulance system development is scarce, with little data on the effectiveness and cost effectiveness of different options. Prehospital care systems in Pacific Island countries are under-developed. In Fiji, out-of-hospital care is fragmented with an uncoordinated patchwork of ambulance providers. There is no scope of practice or training requirement for providers and no patient care records. There are no data relating to demand, access, and utilization of ambulance services.In response to a surge of COVID-19 cases in 2021, the Fiji government created a Prehospital Emergency Care Coordination Center (PHECCC) in the capital Suva, which was operational from July-October 2021. Access was via a toll-free number, whereby the public could receive a medical consultation followed by phone advice or dispatch of an ambulance for a home assessment, followed by transportation to hospital, if required. The PHECCC also provided coordination of inter-facility transport and retrieval of the critically ill.The system that was created met many of the prehospital care standards set by emergency care leaders in the region and created the first dataset relating to ambulance demand and utilization. This is the first article to document prehospital system development in the Pacific region.

Reverse shock index multiplied by the motor component of the Glasgow Coma Scale predicts mortality and need for intervention in pediatric trauma patients.

Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (GCS) (rSIM) would perform equivalently to reverse shock index times the total GCS (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma. The 2017-2020 National Trauma Data Bank data sets were used. We included all patients 16 years or younger who had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the receiver operating characteristic curve (AUROC) was used for comparison. Our primary outcome was mortality before hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography) <4 hours following hospital arrival and intensive care unit admission. After application of exclusion criteria, 77,996 patients were included in our analysis. Reverse shock index times GCS-motor and rSIG performed equivalently as predictors of mortality in the 1- to 2- ( p = 0.05) and 3- to 5-year-old categories ( p = 0.28), but rSIM was statistically outperformed by rSIG in the 6- to 12- (AUROC, 0.96 vs. 0.95; p = 0.04) and 13- to 16-year-old age categories (AUROC, 0.96 vs. 0.95; p < 0.01). Reverse shock index times GCS-motor and rSIG also performed similarly with respect to prediction of secondary outcomes. Reverse shock index times GCS-total and rSIM are both outstanding predictors of mortality following pediatric trauma. Statistically significant differences in favor of rSIG were noted in some age groups. Because of the simplicity of calculation, rSIM may be a useful tool for pediatric trauma triage. Diagnostic Tests or Criteria; Level III.

A Review of an Interfacility Transport Program Pediatric Stroke Clinical Practice Guideline.

Pediatric acute ischemic stroke is a rare diagnosis that requires timely recognition and definitive management to prevent morbidity and mortality. Children often present to primary care offices, urgent care clinics, and adult emergency departments for evaluation of symptoms that may be signs and symptoms of stroke. Currently, there are no published prehospital or transport protocols specific to pediatric acute ischemic stroke. The Children's Mercy Hospital Critical Care Transport Team (CMCCT) created a pediatric-specific clinical practice guideline (CPG) for suspected acute ischemic stroke. This retrospective, descriptive study reports pediatric patients aged younger than 18 years who met criteria for the pediatric stroke CPG and required interfacility transport by CMCCT over a 4- year period. Large vessel occlusion (LVO) scores used in adults were calculated retrospectively. Seventeen patients met inclusion criteria. Four (24%) of 17 had radiographic evidence of acute thrombus, 3 of whom received alteplase and/or endovascular clot retrieval. Median age of confirmed stroke was 83 months (interquartile range, 65-148) compared with 177 months for nonstroke (interquartile range, 169-191), P = 0.126. The most common presenting symptom was hemiplegia in the confirmed stroke group. The confirmed stroke group scored significantly lower on the Glasgow Coma Scale (median of 8 vs 15, P = 0.014), significantly higher on the Los Angeles Motor Scale LVO score (median 4 vs 0, P = 0.021), and significantly higher on the Rapid Arterial Occlusion Evaluation LVO (median 4 vs 0, P = 0.036). To our knowledge, the CMCCT CPG is the first pediatric transport protocol aimed at recognition and management of pediatric stroke described in the literature. Retrospective calculation of LVO scores show that they may be helpful in application to pediatric patients.

Severity-Driven Trends in Mortality in a Large Regionalized Critical Care Transport Service

ObjectiveThe epidemiology accompanying helicopter emergency medical services (HEMS) transport has evolved as agencies have matured and become integrated into regionalized health systems, as evidenced primarily by nationwide systems in Europe. System-level congruence between Europe and the United States, where HEMS is geographically fragmentary, is unclear. In this study, we provide a temporal, epidemiologic characterization of the largest standardized private, nonprofit HEMS system in the United States, STAT MedEvac. MethodsWe obtained comprehensive timing, procedure, and vital signs data from STAT MedEvac prehospital electronic patient care records for all adult patients transported to UPMC Health System hospitals in the period of January 2012 through October 2021. We linked these data with hospital electronic health records available through June 2018 to establish length of stay and vital status at discharge. ResultsWe studied 90,960 transports and matched 62.8% (n = 57,128) to the electronic health record. The average patient age was 58.6 years ( 19 years), and most were male (57.9%). The majority of cases were interfacility transports (77.6%), and the most common general medical category was nontrauma (72.7%). Sixty-one percent of all patients received a prehospital intervention. Overall, hospital mortality was 15%, and the average hospital length of stay (LOS) was 8.8 days ( 10.0 days). Observed trends over time included increases in nontrauma transports, level of severity, and in-hospital mortality. In multivariable models, case severity and medical category correlated with the outcomes of mortality and LOS. ConclusionIn the largest standardized nonprofit HEMS system in the United States, patient mortality and hospital LOS increased over time, whereas the proportion of trauma patients and scene runs decreased.

Assessing Provider Understanding of Interfacility Emergency Medical Services Transport

Background: Interfacility transfer between hospitals is an integral component of regional healthcare systems. The decisions referring providers make regarding emergency medical services (EMS) level of care and transport modality (ground versus air) can dramatically impact patient care, emergency departments' workflow, hospital length of stay, and EMS resource availability. Limited research has been done to assess understanding of interfacility transport by emergency medicine providers. &#x0D; Methods: We developed six patient scenarios to test knowledge of level of care and mode of interfacility transfer. Seven board-certified EMS physicians determined the optimal answer to each patient scenario. We distributed a survey with the scenarios to regional healthcare partners via a database of persons who utilize or interface with interfacility transport services. We collected answers to the patient scenarios and provider characteristics (primary practice site, sex, age, specialty, years since graducation, provider degree, EMS training received). Descriptive statistics were performed and Fisher's exact tests described differences in correct answers as they varied by specialty (emergency medicine or other specialty), provider type (physician or advanced practice provider), and reported training in EMS level of care. &#x0D; Results: Seventy-six emergency medicine providers responded, including 68 physicians and 8 advanced practice providers. The mean total score on the case scenarios was 66%, with scores ranging from 33% to 100%. The mean scores on questions testing level of care and transport modality were 67% and 70%, respectively. No significant difference was found in test scores between emergency medicine and other specialties (p=0.718) or provider level of training (p=0.799). Training in EMS level of care was correlated with higher scores on the transport modality questions (p=0.003) but not on the level of care questions (p=0.231).&#x0D; Conclusion: Variability exists in the knowledge of providers on interfacility transport throughout the state. Emergency medicine providers could benefit from education on interfacility transfer resources.

Natural Experiment Outcomes Studies in Rotor Wing Air Medical Transport: Systematic Review and Meta-Analysis of Before-and-After and Helicopter-Unavailable Publications From 1970 to 2022

ObjectiveHelicopter emergency medical services (HEMS) is widely used for prehospital and interfacility transport, but there is a paucity of HEMS outcomes data from studies using randomized controlled trial designs. In the absence of robust randomized controlled trial evidence, judgments regarding HEMS potential benefit must be informed by observational data. Within the study design set of observational analyses, the natural experiment (NE) is notable for its high potential methodologic quality; NE designs are occasionally denoted “quasi-experimental.” The aim of this study is to examine all NE outcomes studies in the HEMS literature and to discern what lessons can be learned from these potentially high-quality observational data. MethodsHEMS NE studies were identified during the development of a new HEMS Outcomes Assessment Research Database (HOARD). HOARD was constructed using a broad-ranging search of published and gray literature resources (eg, PubMed, Embase, and Google Scholar) that used variations of the terms “helicopter EMS,” “air ambulance,” and “air medical transport.” Among the 221 studies ultimately included in HOARD, 16 NE publications describing 13 sets of observational data comprising myriad diagnostic groups were identified. Of these 16 HEMS NEs, 4 HEMS NE studies assessing trauma outcomes were used in a meta-analysis. A meta-analysis was also performed of 4 HEMS NE studies. ResultsAlthough the disparity of studies (in terms of both case mix and end points) precluded the generation of a pooled effect estimate of an adjusted mortality benefit of HEMs versus ground emergency medical services, HEMS was found to be associated with outcomes improvement in 8 of the 13 cohorts. ConclusionThe weight of the NE evidence supports a conclusion of some form of HEMS-mediated outcomes improvement in a variety of patient types. Meta-analysis of 4 HEMS NE studies assessing trauma outcomes generated a model with acceptable heterogeneity (I2 = 43%, Q test: P = .16), which significantly (P < .01) favored HEMS use with a pooled HEMS survival odd ratio estimate of 1.66 (95% confidence interval, 1.23-2.22).