David C. Cone, MD

Associate Professor of Emergency Medicine

Yale University School of Medicine

President 2007-2008, National Association of EMS Physicians

Current position

Honorary Research Fellow

Ambulance Research Institute

Ambulance Service of New South Wales

Senior Visiting Fellow

School of Public Health and Community

Medicine

University of New South Wales

Home position

Yale University

New Haven, Connecticut

Yale-New Haven Medical Center

Conflicts of Interest

No financial interest in any critical care

transport agency or system

No affiliation with any of the transport

services used as examples in this talk

Formerly (1999-2001) medical director

for a ground critical care transport team

Why is this important?

“Critical care transport is assuming an

increasing role in health care because

patients who have medical conditions

that exceed the capabilities of the initial

treating facility require timely, safe, and

effective transport to regional referral

centers.”

Uren et al. Emerg Med Clin N Am 2009;27:17–26

Desirable Characteristics

Timely: How important is speed?

Safe: No value to the patient (or the

crew!) if not safe.

Effective: What can the transport crew

do to ensure that the patient does not

deteriorate? Can the transport crew

actually improve the patient’s condition?

“The appropriate mode of

transportation … depends on numerous

factors. These considerations include

the distance and anticipated duration of

transport, the stability of the patient and

the urgency of the treatment to be

provided at the receiving hospital, the

transport expertise and resources

available at the sending facility, and

other situational factors.”

Uren et al. Emerg Med Clin N Am 2009;27:17–26

Selection of mode of transport

1. Speed / distance

2. Clinical abilities of crew

3. Equipment

Air vs Ground

“Air medical transport may be more

expensive and risky than ground

transport, but in most situations it is

faster, and air transport teams

usually are more highly trained, more

experienced, and better equipped

than ground transport teams.”

Uren et al. Emerg Med Clin N Am 2009;27:17–26

1. Speed / Distance

Is air transport actually faster?

May take more time request a helicopter

Takes more time to “launch” a helicopter

Helicopter crew may spend more time on

scene

Need to bring patient from rooftop helipad or

remote helipad into ED

Need to know your local system and

geography to make best choices

Buffalo, New York

GIS Study

“The air zone began

between 5 and 15 miles

from the trauma center; however, the ground zone projected

outward into the air zone along

expressways. Ground transport of injured

patients from locations on expressways

and near expressway entrances is often

more timely than helicopter transport at

greater distances from the trauma center.”Lerner EB et al. Acad Emerg Med 1999;6:1127

2. Clinical abilities of crew

Particularly in rural areas, air medical

crew may be the only “advanced life

support” personnel available.

Most critical care transport services

require substantial clinical or field

experience before hiring

Who should staff a critical care

transport?

Physicians?

Nurses?

Paramedics?

Respiratory therapists?

“Clinical management during

transport must aim to at least equal

management at the point of referral.” Aust/NZ Standards: www.cicm.org.au

Physicians

Expert knowledge of clinical issues

Very little (if any) knowledge of EMS /

out-of-hospital issues

Unless specifically trained or experienced in

these issues – this is rare in most areas.

Can a physician intubate a patient in a

moving ambulance?

Nurses

Generally a less expensive option for

the hospital or transport agency

Transport team nurses often have

additional formal training in transport

medicine

Often have specialty experience, such

as pediatric intensive care, or burn care

Paramedics

Best knowledge of EMS / out-of-hospital

issues

Comfortable working in out-of-hospital

setting

Less clinical knowledge than physicians

Less expensive option

Respiratory therapists

Many transport teams use respiratory

therapists because of the high numbers

of intubated/ventilated patients

Cross-training

LifeStar (Connecticut, USA)

Crew #1: Registered Nurse, also

credentialed as an EMT-Paramedic

Crew #2: Respiratory Therapist, also

credentialed as an EMT-Intermediate

3. Specialized Equipment

Neonatal isolettes

Intra-aortic balloon pumps

Left ventricular assist devices

ECMO

Transport ventilators

Transport is not risk-free

Summary of risk/benefit: 1

“Critically ill or injured patients are, by

definition, in relatively fragile condition.

Because interfacility transport requires

the movement of a patient from a secure

emergency department or inpatient unit

to the inherently less stable

environment of an ambulance, the

patient is subjected to additional risk

even if the transport is conducted by a

well-trained and well-equipped team.”

Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26

Summary of risk/benefit: 2

“Emergency medical transportation…

is itself a risky venture, whether

conducted by ground-based systems

or air medical services. Therefore it is

important that the potential benefit of

emergent transport outweigh the risk

and cost of the transfer.”

Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26

Potential Benefits:

Acute Ischemic Stroke

Intravenous tPA

Post-thrombolytic care

Endovascular thrombolysis/mechanical clot retrieval

Stroke center/stroke unit care

Neurological critical care specialization

Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26

Potential Benefits:

Cardiac Arrest

Therapeutic hypothermia

Endovascular cooling

Interventional cardiology

Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26

Potential Benefits:

Traumatic Brain Injury

Surgical drainage of extra-axial

hematomas

Neurological critical care

specialization

Intracranial pressure monitoring

Advanced neuroimaging

Uren B. Emerg Med Clin North Am. 2009 Feb;27(1):17-26

Systematic Review 2006

Adverse events and prognostic factors

associated with interfacility of intubated /

mechanically ventilated patients

Only five studies (with 245 total patients)

met inclusion criteria

All case series

2 prospective, 3 retrospective

Fan et al. Crit Care 2006;10:R6 (ccforum.com/content/10/1/R6)

Systematic Review 2006

“Insufficient data exist to draw firm

conclusions regarding the mortality,

morbidity, or risk factors associated with

the interfacility transport of intubated

and mechanically ventilated adult

patients.”

“Further study is required to define the

risks and benefits of interfacility transfer

in this patient population.”

Fan et al. Crit Care 2006;10:R6 (ccforum.com/content/10/1/R6)

Barriers to research

Difficulty choosing a control (non-

transported) group of patients

Under-reporting of adverse events,

errors, and complications

Limited monitoring and documentation

during transport

Lack of standard definitions for

transport-associated complications

Fan et al. Crit Care 2006;10:R6 (ccforum.com/content/10/1/R6)

There are many different models

“If you have seen one EMS system, you

have seen one EMS system.”

No two EMS systems are exactly alike.

No two critical care transport services

are exactly alike.

Hospital-Based Transport Team

Lutheran Hospital, Fort Wayne, Indiana

3 ground ambulances

One helicopter

Each staffed with nurse and paramedic

Hospital/Private Partnership

LifeLink:

University of Colorado

Rural/Metro Ambulance

Crew: EMT-Basic, EMT-Paramedic,

Registered Nurse

www.ruralmetrocolorado.com/Rural

Metro/CriticalCareTransport.aspx

Police-Based Air Transport

Maryland State Police

First civilian (non-military) helicopter

transport of a critical trauma patient

19 March 1970

Medical transport as well as law

enforcement, search & rescue, disaster

assessment

Pediatric Critical Care Transport

Children’s Mercy, Kansas City

Crew: RN, Respiratory Therapist,

EMT (400 hrs additional training)

Neonatal Transport

Royal Children’s Hospital Melbourne

Started neonatal critical care transport in

1976

Neonatal Emergency Transport Service

Gradually expanded

Paediatric Emergency Transport Service

Pediatrics

“”The importance of pediatric interhospitaltransport has increased dramatically in the past 5 to 10 years. Reasons include improved capabilities of tertiary care centers receiving transported patients, advances in availability of portable equipment that functions well in moving vehicles, and widespread recognition that pediatric transport differs from that of adult transport…

Research in the field remains preliminary …”

McCloskey KA. Current Opinion in Pediatrics. 1996:8:236

Benefit to pediatric team?

Specialized transport team (pediatricresident, pediatric intensive care nurse, and pediatric respiratory therapist; n=47) vs “standard” transport (n=92)

Adverse events: 1 of 49 transports (2%) by the specialized team vs 18 of 92 transports (20%) by nonspecialized personnel (p < 0.05).

Physiologic deterioration: 5 of 47 (11%) specialized team transports vs 11 of 92 (12%) transports by the nonspecializedteam (NS).

Edge WE et al. Crit Care Med 1994;22:1186

Transport Guidelines: US/Peds

American Academy of Pediatrics

“Guidelines for Air and Ground

Transport of Neonatal and Pediatric

Patients” – January 2007

US$ 45 at web site (www.aap.org)

Transport Guidelines: US

American College of Critical Care

Medicine – 2004

“…much of the published data comes

from retrospective reviews and

anecdotal reports. Experience and

consensus opinion form the basis of

much of these guidelines.”

Warren J et al. Crit Care Med 2004; 32:256 –262

Transport Guidelines: Aus/NZ

College of Intensive Care Medicine of

Australia and New Zealand, Australian

and New Zealand College of

Anaesthetists, and Australasian College

for Emergency Medicine - 2010

“Minimum Standards for Transport of

Critically Ill Patients”

Staffing, transport mode, equipment,

monitoring, training

Available at www.cicm.org.au – or search for title

Accreditation

Commission on Accreditation of Medical

Transport Systems (CAMTS)

“…dedicated to improving the quality of

patient care and safety of the transport

environment for services providing

rotorwing, fixed wing, and ground

transport systems.”

www.camts.org

CAMTS-Accredited Services

151 accredited services in 46 US states,

plus UK, Canada, South Africa, Hong

Kong (a US-based service)

CAMTS Leadership

Aerospace Medical Association

Air Medical Operations Association

Air Medical Physicians Association

American Academy of Pediatrics

American Association of Critical Care

Nurses

American Association for Respiratory

Care

American College of Emergency

Physicians

American College of Surgeons

Association of Air Medical Services

Association of Critical Care Transport

Emergency Nurses Association

National Air Transportation Association

National Association of Air Medical

Communications Specialists

National Association of EMS Physicians

National Association of Neonatal Nurses

National Association of State EMS

Officials

National EMS Pilots Association

Air & Surface Transport Nurses

Association

International Association of Flight

Paramedics

United States Transportation Command

CAMTS General Standards

Capabilities and resources of the service

Medical personnel

Medical director

Medical control physician

Clinical care supervisor

Staffing and physical requirements

Mission types

Initial and continuing education

Aircraft/Ambulance section

Medical configurations

Operational issues

Equipment

Communications

Management and administration

Management / policies

Quality management

Safety committee

Infection control

Sample Medical

Direction Standard

02.01.05 The medical director sets and reviews medical guidelines for current accepted medical practice, and medical guidelines are in a written format.

02.01.06 The medical director is actively involved in hiring, training and continuing education of all medical personnel for the service.

02.01.07 The medical director is actively involved in the care of critically ill and/or injured patients.

Sample Infection

Control Standard

02.06.07.1.b. Provide annual

tuberculosis testing and other testing,

screenings and vaccinations as

consistent with current national (CDC in

the U.S.) guidelines. This includes

medical personnel, pilots and

mechanics.

CAMTS Ground Standards

Vehicles

Qualifications of drivers

Maintenance and sanitation

Mechanic

Policies

CAMTS Rotorwing Standards

FAA certificate

Weather and weather minimums

Pilot staffing and training

Maintenance

Refueling

Community outreach

CAMTS Fixed-Wing Standards

FAA certificate

Aircraft

Weather

Pilot staffing and training

Policies

Maintenance

Refueling

Community outreach

Role of Physician Oversight

Prehosp Emerg Care 2002;6:455

NAEMSP Position Paper

Education, experience, licensure○ Ex. #9: Understanding of aircraft capabilities,

safety issues, weather minimums, and Federal Aviation Administration rules and regulations

Operational and administrative duties○ Ex: #14: Participates in the initial training and

continuing education of all air medical personnel to ensure that they are currently certified and meet appropriate training and certification specific to air medical transport

Contact Information

david.cone@yale.edu