Interfacility Transport Of Patients Research Articles

Patient, Paramedic and Institutional Factors Associated with Delays in Interfacility Transport of Injured Patients by Air Ambulance

Background: Air ambulance services are commonly used to expedite interfacility transport of injured patients to trauma centers. There is a lack of evidence surrounding risk factors for delays in interfacility transport of these patients. The purpose of this study was to examine patient, paramedic, and institutional-related characteristics for delay and identify specific causes of delays in interfacility transfers by air ambulance. Methods: This was a retrospective cohort study of injured patients undergoing interfacility transfer to a trauma center who were transported by air ambulance. Quantile regression was used to evaluate the impact of patient, paramedic and institutional characteristics on various time intervals of the interfacility transport process. Results: There are three key findings in our study. First, the use of rotor-wing aircraft and hospital-based helipads had substantially lower transport times. Second, transports from academic centers take longer compared to sending facilities with fewer resources. Third, interfacility transport times are heavily skewed and delays disproportionately affect longer patient transports. Conclusions: Ventilator dependence, paramedic level of care, classification of sending facility and helipad availability are associated with delays to interfacility transport of injured patients. Efforts can be made at both the air ambulance and institutional levels to ensure timely and efficient transports.

ECMO retrieval: A case for Critical Care Paramedic integration into the team

ECMO retrieval: A case for Critical Care Paramedic integration into the team

On-scene Times for Inter-facility Transport of Patients with Hypoxemic Respiratory Failure.

Introduction Inter-facility transport of critically ill patients is associated with a high risk of adverse events, and critical care transport (CCT) teams may spend considerable time at sending institutions preparing patients for transport. The effect of mode of transport and distance to be traveled on on-scene times (OSTs) has not been well-described. Problem Quantification of the time required to package patients and complete CCTs based on mode of transport and distance between facilities is important for hospitals and CCT teams to allocate resources effectively. This is a retrospective review of OSTs and transport times for patients with hypoxemic respiratory failure transported from October 2009 through December 2012 from sending hospitals to three tertiary care hospitals. Differences among the OSTs and transport times based on the mode of transport (ground, rotor wing, or fixed wing), distance traveled, and intra-hospital pick-up location (emergency department [ED] vs intensive care unit [ICU]) were assessed. Correlations between OSTs and transport times were performed based on mode of transport and distance traveled. Two hundred thirty-nine charts were identified for review. Mean OST was 42.2 (SD=18.8) minutes, and mean transport time was 35.7 (SD=19.5) minutes. On-scene time was greater than en route time for 147 patients and greater than total trip time for 91. Mean transport distance was 42.2 (SD=35.1) miles. There were no differences in the OST based on mode of transport; however, total transport time was significantly shorter for rotor versus ground, (39.9 [SD=19.9] minutes vs 54.2 [SD=24.7] minutes; P <.001) and for rotor versus fixed wing (84.3 [SD=34.2] minutes; P=0.02). On-scene time in the ED was significantly shorter than the ICU (33.5 [SD=15.7] minutes vs 45.2 [SD=18.8] minutes; P <.001). For all patients, regardless of mode of transportation, there was no correlation between OST and total miles travelled; although, there was a significant correlation between the time en route and distance, as well as total trip time and distance. In this cohort of critically ill patients with hypoxemic respiratory failure, OST was over 40 minutes and was often longer than the total trip time. On-scene time did not correlate with mode of transport or distance traveled. These data can assist in planning inter-facility transports for both the sending and receiving hospitals, as well as CCT services. Wilcox SR , Saia MS , Waden H , McGahn SJ , Frakes M , Wedel SK , Richards JB . On-scene times for inter-facility transport of patients with hypoxemic respiratory failure. Prehosp Disaster Med. 2016;31(3):267-271.

Two Decades’ Experience With Interfacility Transport on Extracorporeal Membrane Oxygenation

Interfacility transport of patients on extracorporeal membrane oxygenation (ECMO) has been performed in large numbers at only a few programs. Limited data are available on outcomes after ECMO transport to justify expanding or discontinuing these programs. This was a retrospective review of a 20-year, single-institution experience with interhospital ECMO transport as well as a systematic review of reports of transfers of patients on ECMO. Results of both were compared with historical data from the international registry of the Extracorporeal Life Support Organization (ELSO). Between 1990 and 2012, ECMO was used to facilitate transport of 221 patients to our institution, and 135 (62%) survived to discharge. Review of an additional 27 case series describing ECMO transport of 643 patients showed an overall survival of 61%. After stratifying by age and primary indication for ECMO, survival of transported patients was not significantly different compared with all ECMO patients in the ELSO registry, with the exception of pediatric patients treated for respiratory failure (transported patients in this category had higher survival than those in the ELSO registry). Interfacility transport on ECMO is feasible and can be accomplished safely in the critically ill. Survival of transported patients is comparable to age-matched and treatment-matched ECMO patients at large.

Reduction in STEMI Transfer Times Utilizing a Municipal “911” Ambulance Service

The time interval from diagnosis to reperfusion therapy for patients experiencing ST-segment elevation myocardial infarction (STEMI) has a significant impact on morbidity and mortality. It is hypothesized that the time required for interfacility patient transfers from a community hospital to a regional percutaneous coronary intervention (PCI) center using an Advanced Life Support (ALS) transfer ambulance service is no different than utilizing the "911" ALS ambulance. Quality assurance data collected by a tertiary care center cardiac catheterization program were reviewed retrospectively. Data were collected on all patients with STEMI requiring interfacility transfer from a local community hospital to the tertiary care center's PCI suite, approximately 16 miles away by ground, 12 miles by air. In 2009, transfers of patients with STEMI were redirected to the municipal ALS ambulance service, instead of the hospital's contracted ALS transfer service. Data were collected from January 2007 through May 2013. Temporal data were compared between transports initiated through the contracted ALS ambulance service and the municipal ALS service. Data points included time of initial transport request and time of ambulance arrival to the sending facility and the receiving PCI suite. During the 4-year study period, 63 patients diagnosed with STEMI and transferred to the receiving hospital's PCI suite were included in this study. Mean times from the transport request to arrival of the ambulance at the sending hospital's emergency department were six minutes (95% CI, 4-7 minutes) via municipal ALS and 13 minutes (95% CI, 9-16 minutes) for the ALS transfer service. The mean times from the ground transport request to arrival at the receiving hospital's PCI suite when utilizing the municipal ALS ambulance and hospital contracted ALS ambulance services were 48 minutes (95% CI, 33-64 minutes) and 56 minutes (95% CI 52-59 minutes), respectively. This eight-minute period represented a 14% (P = .001) reduction in the mean transfer time to the PCI suite for patients transported via the municipal ALS ambulance. In the appropriate setting, the use of the municipal "911" ALS ambulance service for the interfacility transport of patients with STEMI appears advantageous in reducing door-to-catheterization times.

696

Introduction: Neurologic diagnoses (ND), in particular traumatic brain injury, account for significant morbidity and mortality in hospitalized children. Data on interfacility transport of patients with non-traumatic ND are lacking. The purposed of the study is to describe interfacility transport of children with and without ND by a specialized pediatric transport team. The long term objective is to use findings to inform treatment protocols and improve patient outcomes. Methods: Patients aged 1 month to 21 years that underwent interfacility transport by a non-trauma pediatric critical care transport team between October 1997 and February 2013 were studied from a prospectively collected database. Patients were categorized as having ND versus other diagnosis (OD) using data at hospital discharge. Groups were compared using Mann-Whitney U test. Univariate analysis identified variables that predict survival and a multivariate regression model was used to determine association with survival. Results: 12,855 patients met inclusion criteria. 2,155 with a ND, and 10,730 with OD. Children with ND were older (36m (IQR 83) vs 20 m (IQR 70)), had a higher median pre-hospital PRISM (6 (IQR 10) vs 0 (IQR 4)), a lower median GCS (10 (IQR 8) vs 14 (IQR 3)). In transport, children with ND had longer scene time in minutes (25 (IQR 22) vs 18 (IQR15)), were more likely to receive IV access (91 vs 80% (OR=2.6 [2.2-3.1])), interosseous access (5.2 vs 2.1% (OR=2.5 [2.0-3.2])) or intubation (36.3 vs 18.5% (OR 2.5 [2.3-2.8])), and were more likely to be admitted to the intensive care unit (ICU) (47.9 vs 36.7 % (OR 1.7 [1.5-1.8])) compared with children with OD. Children with ND had longer ICU and hospital length of stay and were more likely to die in the hospital (6.5 vs 4.4% (OR=1.5 [1.2-1.8])) than children with OD (all p<0.001). After accounting for variables that predicted survival in univariate analyses (PRISM, GCS, intubation status), a multivariate regression model showed that ND is associated with worse survival (negative coefficient) while transport time and mode of transport were not related to survival. The most frequent ND were seizure (66%), infection (11.5%) and anatomic abnormality (8.5%). Conclusions: In a population of children with non-traumatic ND, children with ND received more critical care interventions in transport, used more hospital resources and had worse outcomes than children with OD. Future directions include identifying interventions that may improve pre-hospital care and outcomes.

Impact of inter-facility transport on maternal mortality in the Free State Province

In December 2011, having identified inter-facility transport as a problem in the maternity service, the Free State Department of Health procured and issued 48 vehicles including 18 dedicated to maternity care. Subsequently, a sustained reduction in mortality was observed. We probed the role of inter-facility transport in effecting this reduction in mortality. A before-after analysis was performed of data from 2 separate databases, including the district health information system and the emergency medical and rescue services call-centre database. Data were compared for a 12-month prior- and 10-month post-intervention period using descriptive and correlation statistics. The maternal mortality decreased from 279/100 000 live births during 2011 to 152/100 000 live births during 2012. The mean dispatch interval decreased from 32.01 to 22.47 minutes. The number of vehicles dispatched within 1 hour increased from 84.2% to 90.7% (p<0.0001). Monthly mean dispatch interval curves closely mirrored the maternal mortality curve. Effective and prompt inter-facility transport of patients with pregnancy complications to an appropriate facility resulted in a reduction of maternal mortality. Health authorities should prioritise funding for inter-facility vehicles for maternity services to ensure prompt access of pregnant women to centres with skills available to manage obstetric emergencies.

169: Interfacility Helicopter Transport of Patients with Leaking Aortic Aneurysms Directly Into the Operating Room

Interfacility transport of patients with ruptured abdominal aortic aneurysm (RAAA) is time-critical. To streamline care of such patients, our helicopter transport program (MedFlight) and receiving trauma centers have collaborated on a protocol allowing for direct transport into the receiving center OR. Another MedFlight protocol allows for automatic, rotating-roster assignation of receiving hospital such that helicopter dispatch occurs before MD-to-MD communications. This study’s objectives were to assess performance of the direct-to-OR protocol, to determine if patients arriving at receiving hospitals during “off hours” (1900-0700 or on weekends) had delays in time-to-OR, and to determine if use of the roster system resulted in times-to-OR comparable to those achieved for patients in whom receiving hospitals had been identified prior to initial MedFlight call.

Interfacility Transport of Patients With Decompression Illness: Literature Review andConsensus Statement

Objective. Decompression illness (DCI) is a potentially lethal complication of diving andmay occur far from hyperbaric facilities. The need for prompt transport to a hyperbaric facility often involves air medical transport, but this may exacerbate DCI. The authors reviewed available literature to establish evidence-based transport strategies utilizing safe altitudes for patients, with DCI. Methods. MEDLINE, EMBASE, andmaterials from organizations with expertise in diving medicine were searched for the following terms: decompression sickness, caisson disease, hyperbaric oxygenation, depth intoxication, or diving. Two reviewers independently selected relevant citations involving patients with DCI andair medical transport for review andconsensus statement development by an expert working group. Results. A total of 341 citations were identified, and53 unique citations were reviewed. Nine relevant citations were selected for consensus statement development. There were no clinical trials or prospective cohort studies. Only two retrospective case series, including nine patients, specifically examined the effect of altitude on patients with DCI during transport. No symptom recurrence occurred when the cabin altitude remained within 500 feet of ground level. Seven citations were either letters or statements of expert opinion, recommending a maximum cabin altitude of 500–1000 feet (152–305 meters). Conclusions. The working group identified the paucity of clinical studies andevidence-based recommendations for air medical transport of patients with DCI. Transport selection should be based on minimizing total transport time and, when transporting by air, ensuring that a cabin altitude of the transporting vehicle does not exceed 500 feet (152 meters) above the departure point. Key words: decompression sickness; atmospheric pressure; depth intoxication; air ambulance; emergency medical services.

Interfacility Transport of Patients Admitted to the ICU: Perceived Needs of Family Members

Interfacility Transport of Patients Admitted to the ICU: Perceived Needs of Family Members

T HE E VOLVING R OLE OF H ELICOPTER E MERGENCY M EDICAL S ERVICES IN THE T RANSFER OF S TROKE P ATIENTS TO S PECIALIZED C ENTERS

Background. In 1996, when the Food and Drug Administration (FDA) approved use of thrombolytic therapy for ischemic stroke, interfacility transport of stroke patients assumed increasing urgency. Objective. To describe one helicopter emergency medical services (HEMS) program's 15-year experience with interfacility transport of patients with suspected stroke, with emphasis on reporting changing patterns seen after the advent of thrombolytic therapy for stroke. Methods. This was a retrospective study of patients undergoing HEMS transport, during 1985–1999, with a pretransport diagnosis of suspected ischemic stroke. Data collected included patient demographics and times of symptom onset, community hospital arrival, community hospital request for HEMS, and receiving hospital arrival. Patients were divided into pre-thrombolysis era (1985–1995) and thrombolysis era (1996–1999). Group characteristics were compared using Pearson chi-square, Fisher's exact, rank-sum, and logistic regression analysis. Results. There were 192 total transports, 76 (40%) pre-thrombolysis era and 116 (60%) thrombolysis era. Thrombolysis era patients were more likely (p < 0.0001) to have time of symptom onset documented, and also had significantly (p = 0.0003) shorter time intervals between referring and receiving hospital arrival. The shorter time intervals were due in part to decreased time lapse between referring hospital arrival and that hospital's request for helicopter transport; thrombolysis era patients were 2.5 times more likely than pre-thrombolysis era patients to have HEMS activation within three hours of community hospital arrival. Conclusions. Helicopter EMS transport is playing an increasing role in interfacility transfer of patients with ischemic stroke. Earlier HEMS activation is associated with decreased time lapse between referral and receiving hospital arrival.

U TILIZATION OF A IR M EDICAL T RANSPORT IN A L ARGE U RBAN E NVIRONMENT : A R ETROSPECTIVE A NALYSIS

Objective. To determine the utility of air medical transport in a large urban environment. Methods. The authors conducted a retrospective analysis of all air medical transports of patients in the Fire Department of the City of New York EMS (emergency medical services) Command for the period of January 1, 1996, to December 31, 1999. These data were evaluated for frequency of air medical transport, patient condition at time of flight, and necessity of air evacuation. Results. During the study period, some form of air medical transport was used 182 times. Of this number, 32 were for transports of patients from a scene of an incident to a hospital within New York City; 18 for interfacility transport of patients from a hospital facility within New York City to another facility within New York City; 122 for interfacility transfers of patients from medical facilities outside of the New York City area to a facility in New York City; and ten for transport of patients from New York City medical facilities to facilities out of the area. Conclusion. The Fire Department of the City of New York EMS Command utilizes air medical evacuation for patient transports very infrequently. The parameters of New York City's large urban environment may not be conducive to air medical transport. These data seem to be consistent with experiences of other large urban cities.