Pediatric Transport Overview

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Pediatric Transport Overview

• Toni Petrillo-Albarano, MD
• Childrens Healthcare of Atlanta

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Goal and Objectives

• Understand goals of Pediatric Transport
• Identify make up and skills of a competent team
• Recognize factors involved in choosing various
  modes
• Understand rules of governance

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Background

• In the United States, hospital-based neonatal
  transport programs were first created in the
  1960s and 1970s
• Similar programs for older infants and children
  emerged in the 1980s

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Background

• Neonatal-pediatric transport programs part of the
  continuum of care in a system of emergency
  medical services for children

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Background

• They provide a safe, therapeutic environment for
  pediatric patients who must be transferred
  between health care institutions under urgent or
  emergent circumstances

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Diagnostic Categories Of Children Transported
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Goal

• Early direction and initiation of advanced care
• Improve safety of the transport and patient
  outcome.

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Goal

• Treatment and monitoring with the expected
  expertise and capabilities of the tertiary care
  center while the patient is still in the
  referring facility

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Essential components

• Dedicated team proficient at providing neonatal
  and/or pediatric critical care during transport

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Essential components

• Sufficient volume of critically ill and injured
  patients to enable team to maintain expertise

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Essential components

• On-line medical control by qualified physicians
• Ground and/or air ambulance capabilities
• Communications/dispatch capabilities
• Prospectively written clinical and operational
  guidelines

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Essential components

• Quality and performance improvement activities
• Administrative resources
• Institutional endorsement and financial support.

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Team Composition

• Depends on the patients needs
• determined in consultation with the team and
  medical control
• Dedicated pool of qualified physicians, nurses,
  paramedics and/or respiratory therapists

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Team Composition

• A team members degree is less important than his
  or her ability to provide the level of care
  required
• Critical care during transport conditions is
  significantly different from an ICU or ED

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Team Composition

• Should not be assumed that a health care
  professional who is competent in the ICU or ED
  will function equally well in a mobile environment

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Team Composition

• Many dedicated teams include a physician
• Little published evidence that this configuration
  results in improved outcome compared with
  non-physician teams

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Team Composition

• Qualifications include the following
• Educational and experiential background
• Clinical and technical competence
• Leadership skills
• Critical thinking skills
• Communication and interpersonal skills
• Appreciation of public and community relations

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Team Training

• Pediatric courses
• Required
• PNCCT
• PALS, APLS
• Optional
• PEPP
• Pediatric BTLS
• ATLS

• Neonatal courses
• Required
• NRP or NALS
• Optional
• S.T.A.B.L.E

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Team Training

• Procedures
• Advanced airway management
• Specialized Medication Administration (PGEs,
  surfactant, vasopressors)
• Chest decompression

• Chest tube insertion
• Hemodynamic monitoring
• Vascular access
• ICP monitoring
• Ventilator management
• Isolette

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Consent

• The basic concept is that informed consent must
  be obtained for the purposes of any treatment of
  a patient

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Consent

• With a minor the law requires that a reasonable
  effort must be made to contact the parents for
  consent unless physicians have determined that
  the delay would endanger the patient

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How to choose

• The decision based on many factors
• Patient acuity
• Current and available levels care
• Number of staff required
• Distance to the referring institution
• Traffic congestion and weather conditions.

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Determining mode

• Four critical steps necessary for selection of
  the optimal mode
• Evaluation of the current patient status
• Evaluation of care the required before and during
  transport
• Urgency of the transport
• Logistics of a patient transport (e.g., local
  resources available for transport, weather
  considerations, and ground traffic accessibility)

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Ground Vs Air

• Distance to the closest appropriate facility is
  too great for safe and timely transport by ground
  ambulance

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Ground Vs Air

• The potential for transport delay that may be
  associated with the use of ground transport
  (e.g., traffic and distance) is likely to worsen
  the patient's clinical condition

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Ground Vs Air

• Beyond 100 miles, a ground may become
  inefficient, costly to operate, and time
  consuming
• Helicopter is used for up to 150 mile radius
• Fixed wing greater than 150

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Performance Comparison Ground vs. Air

• Ground Ambulance
• 70 MPH
• 100 minutes to Ellijay
• 2 hours for peds specialty care
• 3.7 hours trip time

• Helicopter
• 155 MPH
• 23 minutes to Ellijay
• 30 Minutes for peds specialty care
• 53 min trip time

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Concern about Safety of Flight
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HEMS Industry Statistics
7.5
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HEMS Industry Growth
Number of Personnel in HEMS 1980-2001
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HEMS Industry Growth
Number of HEMS Helicopters 1980-2001
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Who Chooses?

• The mode of transport, as per EMTALA, is
  officially determined by the referring physician

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EMTALA

• The federal Emergency Medical Treatment and Labor
  Act has been in effect since 1986 to regulate
  access to medical care and restrict transfers
  unless they comply with provisions of the law

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EMTALA

• One of the major responsibilities under EMTALA is
  that the hospital must provide a medical
  screening examination and stabilizing care to any
  patient that comes to the hospital and requests
  care

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EMTALA

• Law applies to
• Patients on / in hospital premises (including
  parking areas, streets, alleys and sidewalks)
• Within 250 yards of the main hospital buildings
• Patients presenting at off-site urgent cares or
  walk-in clinics
• Any patient in a hospital owned and operated
  ambulance no matter where it is located

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EMTALA

• The critical elements of documentation required
  by EMTALA are
• Patient consent to transfer
• Physician certification of risks and benefits
• Hospital acceptance for transfer
• Physician order for mode, level of attendant
  care, and special equipment
• Copy of medical records, tests, and radiology
  films
• Physician signature at departure from sending ED

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EMTALA

• Hospitals do not have a right to divert,
  however
• A more accurate description would be that
  diversion is a request by the hospital to EMS to
  assist in managing an overflow situation or other
  emergency

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EMTALA

• EMTALA regulations state that if a hospital
  directs an ambulance (or air medical unit) to
  divert, the hospital must still care for the
  patient if the ambulance enters onto hospital
  property

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EMTALA

• A patient may instruct an ambulance to go to a
  hospital of their choice, even if that facility
  is on diversion which could delay care and
  endanger the patient

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EMTALA

• The point is that the hospital will still be
  required by EMTALA to treat the patient who
  arrives, even if they were told to go elsewhere.

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Liability/Responsibility

• Typically, the hospital staff steps back and
  allows the transport crew complete control of
  the patient in the mistaken belief that the
  transport crew has assumed care.

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Liability/Responsibility

• They are illusions that fail to properly reflect
  the overlapping responsibility issues this
  setting produces

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Liability/Responsibility

• EMTALA specifically places medical control of the
  patient in the hands of the transferring
  physician until the moment of departure

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Liability/Responsibility

• At the same time, however, the transport team has
  a medical responsibility to the patient as well
  it is concurrent and it must be coordinated.

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Liability/Responsibility

• Responsibility then diminishes from the referring
  facility and increases to the receiving facility
  as the distance changes

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Liability/Responsibility

• The transport team retains medical responsibility
  until that proper hand-off has occurred, even
  though the receiving facility shares
  responsibility

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Cost

• The approximate cost of a medically configured
  ground ambulance is approximately 150 000 to
  350 000, depending on the manufacturer and model
  selected
• The annual maintenance and fuel costs might range
  from 10 000 to 25 000 per vehicle

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Cost

• Single-engine helicopter A-Star or Bell 407
  averages 2 million.
• A light twin-engine helicopter EC145 and Bell
  430, both medium-sized twin engine helicopters,
  cost between 4 and 6 million
• While a large twin-engine helicopter about 1-2
  million more

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Cost

• Pilot salaries range from 60,000 to 85,000
  annually a staff of four is required to cover
  24/7
• Financial concerns include fixed and variable
  costs
• Fixed costs include insurance, taxes, crew costs,
  overheads, interest, hanger fees and capital
  equipment
• Variable (hourly) costs vary directly with the
  number of hours flown. These costs include fuel
  and oil, scheduled maintenance labor, etc

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Cost

• The aviation-related expenses alone for a leased
  medical helicopter operating expense typically
  starts at more than 1 million for a
  single-engine helicopter and increases to almost
  2 million for a large twin-engine helicopter

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Questions?????