Craig J. Huang
• Outcomes for critically ill and injured children improve when treatment is provided by skilled pediatric specialist transport teams.
• Appropriate medical care for any patient with an emergent condition should never be delayed because of inability to find a caregiver or guardian to give consent for treatment.
• The referring physician is responsible for stabilizing the patient’s condition, within the capabilities of the referring institution, before the patient is transferred to another institution.
• Limitation of resuscitation orders (DNR) may be revoked at any time according to the parents or legal guardians’ wishes.
• Composition of team personnel is driven by the needs of the patient being transported.
• Transport personnel must be familiar with their protocols and the limitations and responsibilities of their specific profession’s scope of practice.
• A quality management program is essential for a well-run transport service.
• Stresses of flight affect both the patient and crew members and should always be taken into consideration when transporting a patient.
• At high altitude, a child may become hypoxic and pneumothoraxes can expand.
Specialized transport systems have evolved from military conflicts; the earliest references date from the Napoleonic wars. The first reported transport of a patient via aircraft took place in 1915; and the helicopter saw its first use in air medical transport in Burma in 1944.1 Development of specialized pediatric transport teams began in the 1970s with the establishment of neonatal intensive care units. The need for rapid and safe transport of critically ill and injured children has driven the formation of specialized pediatric transport teams to improve outcomes when treatment is provided by skilled pediatric specialists.
Approximately 2% to 3% of all children seeking treatment in an emergency department (ED) are not accompanied by a parent or legal guardian. All efforts to obtain consent for treatment and transfer of a pediatric patient should be made and documented, but appropriate medical care for the patient with an urgent or emergent condition, including transport, should never be withheld or delayed because of problems obtaining consent.
Federal law under the Emergency Medical Treatment and Active Labor Act (EMTALA) mandates a medical screening for every patient seeking treatment in an ED of any hospital that participates in programs that seek federal funding, regardless of reimbursement considerations. EMTALA mandates therapy for emergency medical conditions up to and including surgical intervention.2 If definitive care cannot be rendered at the local hospital, the patient should be transferred to a hospital that has the resources and capabilities to care for the patient. Prior to transfer, the referring physician is responsible for stabilizing the patient’s condition within the capabilities of the referring institution, initiating transfer and selecting the mode of transport, and ensuring that the receiving facility is able to deliver the necessary care and agrees to accept the transfer.3 The transport team should be aware of any limitation of resuscitation orders that may be in place, especially in the case of a chronically ill child. If special state out-of-hospital “Do Not Resuscitate” orders (DNR) exist, they should be discussed with the medical control physician before transporting the child and must be complied with. DNR orders may be revoked at any time according to the wishes of the parent or legal guardian.
The legal responsibility for medical decisions and interventions at the referring facility is complex. Although the specialty pediatric transport team may lead the process of preparing the child for transport, the referring physician and other hospital personnel remain legally responsible for the patient. If at any time the referring physician deems it in the best interest of the patient to intervene or cancel the transfer, the physician has a right and a duty to do so. Although EMTALA states that the referring physician has legal responsibility, the transport service clearly assumes some liability when it begins rendering care. In reality, there is shared responsibility on the part of both parties.
TEAM COMPOSITION AND TRAINING
Transport teams involve a variety of professional personnel, including physicians, nurses, respiratory care practitioners, paramedics, and emergency medical technicians that should be dedicated to the transport program and trained to work as a team. The ideal composition of the team is driven by the needs of the patient being transported (Table 148-1).4 Transport literature indicates that non–physician-based transport team members are efficient and competent to perform advanced procedures, including intubations. It is essential that all transport team members have an opportunity to develop and maintain these skills on an ongoing basis. The incidence of transport-related morbidity increases significantly when personnel without specialized training in pediatrics transport critically ill children. Only 10% of EMS transports involve pediatric patients, and many adult EMS providers lack all but basic training in the treatment of critically ill children, mainly owing to limited pediatric exposure. Specialized pediatric transport teams fill a needed void to help stabilize and transport critically ill and injured children to a tertiary care pediatric facility.5
Potential Advantages and Disadvantages of Various Personnel for Neonatal Pediatric Transport Teams
Interfacility transports require coordination and communication between multiple care providers and facilities to assure the safety of patients and transport personnel. The transfer center should be staffed 24 hours a day, 7 days a week. The transfer center coordinator receives the initial call, facilitates communication between the referring and receiving providers, dispatches the appropriate team, tracks the locations of dispatched teams, and assures ongoing communication with the referring facility. The teams are also in direct communication with the medical control physician via the transfer center. The transfer center can also coordinate follow-up information for referring facilities while adhering to Health Insurance Portability and Accountability Act (HIPAA) regulations.
It is essential that all communications pertaining to transport are recorded and the recordings are preserved. Communication with outside facilities can be streamlined by having an easily accessible contact number and standardized basic questions for easy identification of the appropriate receiving hospital unit, such as the ED or an intensive care unit. Handoff communication should also be standardized wherever possible by the caregivers; a transport outreach liaison can facilitate preparation for transport by communicating regularly with referring facilities, providing them with information on how to contact the transport service, and how to best prepare the child for transport.
EQUIPMENT AND MEDICATION
Equipment and medication requirements for transport depend on the type of patient that the team encounters. The transport mission limitation policy should address the types of patients a facility has the capability to transport. Special equipment consideration is needed for basic life support (BLS) and advanced life support (ALS) transports, neonates, children, and adult-size patients. Pediatric equipment lists are available for EMS providers. This list should satisfy all city and state requirements, and be regularly updated by the transport medical director. Storage of medication should be addressed since some medications need to be refrigerated. Multiple doses of medications and extra equipment need to be available for emergencies and long transports. Special regulations exist surrounding the use of narcotics. Medications should be checked daily (for quantity and expiration) and after each transport. The lists of all equipment and supplies should be checked regularly to ensure presence, functionality, and nonexpiration. Policies and procedures should be developed to ensure compliance with this standard.
Transport teams should have written, easily accessible, straightforward protocols to direct patient care, under the authority and regular revision of the transport medical director. Input should be sought from the teams utilizing the protocols, including legal counsel when necessary. Protocols serve as a guideline for care until the teams can contact the medical control physician. Transport personnel must be familiar with the protocols, and the limitations and responsibilities of their specific profession’s scope of practice. They need to seek help from their medical control physician or the physician on transport when they are outside their scope of practice.
The medical director of the transport service is “a physician who is responsible for supervising and evaluating the quality of the medical care provided by the medical personnel.”6 He or she should be involved in hiring and education of the team members; development of policies, procedures, and transport protocols; infection control principles; quality assurance; and overall safety of the program for the patients and staff. The medical director should “promote open communication with referring and accepting physicians and be accessible for concerns expressed by referring and accepting physicians regarding controversial issues and patient management.”6 The medical director of the transport team may be the medical control physician or he or she may have a designee.
The medical control physician provides “on-line” medical advice to the referring physician (with regard to stabilization of the patient prior to the team’s arrival) and at any time to the teams prearrival, at arrival, and during transport. He or she may help in selection of the most appropriate mode of transport. All communication between the medical control physician and transport personnel should be recorded. The medical control physician should have the appropriate skill level necessary for the patient population served by the transport service.
REGULATORY REQUIREMENTS/CERTIFICATION STANDARDS
Interfacility transport services must meet city and state requirements for ambulance services, as well as meet all hospital standards. If they have flight capabilities, they must also comply with FAA (Federal Aviation Administration) regulations. If they choose to do so, transport services may wish to become accredited by Commission on Accreditation of Medical Transport Systems (CAMTS). CAMTS evaluates compliance with accreditation standards that demonstrate the ability of the transport service to deliver specific services to patients and is supported by 16-member organizations, including the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP). Both Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and CAMTS are voluntary bodies, which set minimum standards for quality of patient care and safety in the medical environment; CAMTS focusing on quality of patient care and safety specifically during transport. In 1990, the AAP formed a Section of Transport Medicine to address the interfacility transport of infants, children, and adolescents. In 1993, the AAP published Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. This manual serves as an invaluable resource for neonatal and pediatric transport services.7
It is important that transport programs have a quality management program that is “integrated and includes activities related to patient care (including customer satisfaction), communications and all aspects of transport operations and equipment maintenance.”6
There should be oversight and active participation by the medical director and all team members. Quality metrics should be chosen to best satisfy the needs of the patients being transported, the safety of the teams, and needs of the referral community they serve. At the 2012 Quality Metrics Summit of the Section on Transport Medicine of the American Academy of Pediatrics, a number of standard quality metrics were developed for neonatal and pediatric transport (Table 148-2). As part of a well-developed safety management system and quality assurance program, all members of the team should have a mechanism to communicate safety and quality concerns with each transport.
Quality Metrics for Neonatal/Pediatric Transport
STABILIZATION FOR TRANSPORT
The goal of interfacility transport is to improve care provided to a patient. The advice of the accepting and/or medical control physician in preparing the child for transport and the interventions needed by the referring team and/or the transport team before leaving the referring facility can help address the aim of making the child as stable as possible for transport. The transport team and medical control physician can guide the situation to address the basic concepts of medical care. For example, deciding on the best strategy for stabilizing a patient in respiratory distress with an unexpectedly difficult airway involves appropriate skills for the primary medical team, the appropriate resources for the transport team, and the best collaboration between the medical control physician and other referring and transport caregivers. Some referring facilities will have anesthesia back-up should a problematic airway be encountered. Laryngeal mask airways (LMAs) are a temporizing measure, but are not considered stable airways for transport in many facilities.8 It is also important to ensure that a child has adequate intravenous access prior to transport. Pneumothoraxes should be treated prior to flight.
MODES OF TRANSPORT
Children may be transported by ground ambulance, helicopter, or fixed-wing aircraft. Advantages to transporting a child by ground ambulance include adequate space to perform emergency interventions and to permit transport of a family member, ease of halting to facilitate emergency interventions, lack of need for an airport or helicopter landing zone, and minimal risk of delay owing to inclement weather. It is the safest and most common mode of transport. The major disadvantage is the travel time needed to cover long distances, particularly if the child is critically ill.
Helicopter transport is fast and is becoming increasingly popular as most hospitals have a space for a helicopter to land. It is often available for scene transports, particularly in remote and difficult terrain. Disadvantages include the stresses of flight, lack of space to perform emergency interventions, and lack of availability in inclement weather. The distance a helicopter can travel depends on multiple factors (Table 148-3). Fixed-wing aircraft is usually reserved for long-distance interfacility transports. There is usually room on the plane to perform emergency interventions and to accommodate a parent. Problems include altitude considerations, weather limitations, the need for an airport, and the need for ground transportation to pick up and return at each end of the transport. Determining the mode of transport ultimately depends on a number of factors but are primarily related to the acuity of the child’s illness, the resources available, the time of day, the distance to be traveled, traffic, and weather; travel needs to be the safest possible for both the patient and the team.
Determining the Mode of Transport
SAFETY/ALTITUDE PHYSIOLOGY AND AIR MEDICAL CONSIDERATIONS
Air and ground transports are not without risk. King and Woodward published a 5-year review of accidents involving pediatric and neonatal transports in 2002 and found that accident rates were approximately 1 per 1000 transports, accidents rates where an injury was sustained were 0.546 per 1000 accidents, and all eight fatalities occurred with air transports.9 According to the National Transportation Safety Board (NTSB), accident rates and the number of flight hours have increased substantially since this study was concluded.
Safety considerations should be part of a team’s initial and continuing training. Transport personnel must be familiar with safety features of the various transport vehicles in which they will be traveling. Policies and procedures should specifically address safety considerations, including considering weather, use of lights and sirens on the ambulance, use of restraints, weight limitations for flight, and vehicular maintenance. In the case of hazardous weather conditions, the final decision as to safety of travel should reside with the pilot or driver of the transport vehicle, and should be supported by the transport medical director, erring on the side of caution for patient and personnel safety.
Personal protective equipment is important to protect the team members. The NTSB has stated that “helmets, flame-and-heat-resistant uniforms, and protective footwear can help reduce or prevent injury” in accidents.10 Appropriate universal infectious disease precautions should be undertaken when dealing with all patients, not just those patients with known infections or who are bleeding. Gowns, gloves, and masks should be used whenever appropriate and possible, and transport policies should mirror the institutional-based policies in the case of accidental needle stick injuries or exposure to blood and/or body fluids.
It is important to provide appropriate equipment to personnel to prevent injury when lifting patients. Much media attention has focused on the growing problem of obesity in children and equipment such as hydraulic stretchers should be available to the teams to minimize back injuries. Policies and procedures are necessary to protect the teams from disruptive patients and parents, including addressing the possession of firearms and knives by family members. Psychiatric patients require special consideration, such as the need for restraint.
MEDICAL SAFETY ISSUES AND ALTITUDE PHYSIOLOGY
There are multiple medical stresses that need to be taken into consideration when transporting critically ill and injured children by air. Stresses of flight affect both the patient and crew members. These include changes in barometric pressure, hypoxia, temperature, dehydration, noise, vibration, g-forces, third spacing, and fatigue. Teams may suffer visual problems and spatial disorientation, particularly when flying at night. Teams and patients also need protection from potential toxic hazards in the air medical transport environment (Table 148-4).11
Stresses of Flight
Changes in barometric pressure and hypoxia are perhaps the most significant stressor to the patient and crew. During ascent, the barometric pressure falls unless it is controlled by the aircraft. Boyle’s law states that the volume of a gas is inversely proportional to its pressure, when temperature is constant; therefore, as barometric pressure is reduced, gases expand. At 8000 ft, which is effective cabin altitude for most pressurized aircraft, gas expansion is approximately 30% greater than at sea level. This can result in a small clinically insignificant pneumothorax -becoming a life-threatening tension pneumothorax during flight. Air in other body cavities can also expand. In the brain this can lead to intracranial hypertension. Air in the stomach can cause nausea and vomiting and gastric distension that can interfere with lung expansion. In the middle ear, it can cause significant pain if the eustachian tube is blocked. Air in endotrachial (ET) tube cuffs can expand, resulting in compressive forces on the inner trachea. Thus, preventive measures are undertaken to minimize the risk of gas expansion. Pneumothoraxes are drained prior to flight, nasogastric tubes inserted to decompress the stomach, and cuff pressures on ET tubes are monitored and decompressed as necessary. If a child is awake, he or she should be encouraged to suck on a pacifier and/or chew on descent. The aircraft should ascend and descend slowly, or fly at a lower altitude. A team member with a significant upper respiratory infection or blocked eustachian tube may not be able to participate in an air transport. Another medical implication of altitude is the fact that the amount of gas dissolved in solution is directly proportional to the pressure of the gas over the solution (Henry’s law). As barometric pressure falls with altitude, less gas is dissolved in solution, so there is less oxygen dissolved in blood and the child can become hypoxic just by the change in altitude. At sea level, the percentage oxygen saturation in room air is 98%; at 8000 ft, this saturation falls to 93% based on barometric pressure alone. This has implications for patients who are already hypoxic or are very sensitive to oxygen content in the blood, such as children with pulmonary hypertension. Therefore, oxygen administration may be increased prior to ascent, or consideration may be given to flying at lower altitude.
As altitude increases the air cools and humidity drops. For each 1000-ft gain in altitude there is a 2°C drop in temperature. Ambient humidity in a pressurized aircraft after 1 hour of flying is <5%. Pumping additional gas into an airplane may cause the environment to be cooler and dryer. Patients and team members need warm, light clothing. Temperature and hydration are monitored, particularly with neonates who are already more vulnerable to cold. Using a hat will reduce up to 60% of radiated heat loss. Transporting an infant in an isolette is also protective. Teams and patients may need to wear ear protection to protect against noise stress, as damage to hearing from noise-induced causes is permanent. Hearing tests should be administered annually to transport team members who fly. Vibration and g-forces may cause nausea and fatigue and should be minimized where possible (Table 148-5).11
Prevention of Complications During Air Transport of Neonatal and Pediatric Patients
SPECIFIC CLINICAL TRANSPORT ISSUES
Neonates, particularly if they are premature, are very vulnerable to environmental changes and it is essential that they be kept warm. Furthermore, neonates do not have extensive glucose stores; thus, their blood glucose must be closely monitored. Special equipment needs to be available for the transport of neonates (small ET tubes, isolette, transwarmer, neonatal ventilator, etc.) A child weighing less than 10 kg should be transported in a secure fashion in a transport isolette to protect them from environmental hazards such as cold, noise, and turbulence.
ACTIVE CARDIAC ARREST
Interfacility transport teams are occasionally called to transport a child in active cardiac arrest that occurs at the referring institution. The medical control physician should be actively involved in the decision for and timing of transport of the patient. It is reasonable to deploy the transport team to the referring facility, but the child must be alive at the time the decision is made to transport. If the child has a stable airway, a pulse, and a manageable blood pressure, the transport may proceed, but the parents or guardians of the child must be informed of the high risk of repeated episodes of cardiac arrest and death during transport. It is important to try and identify the cause of the arrest prior to transport, so necessary interventions may be implemented to prevent further arrest.
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10. National Transportation Safety Board. Aviation Special Investigation Report: Special Investigation Report On Emergency Medical Service Operations. Washington, DC: National Transportation Safety Board; 2006. http://www.ntsb.gov/doclib/safetystudies/SIR0601.pdf. Accessed May 29, 2013.
11. American Academy of Pediatrics. Section on Transport Medicine; Woodware G, Insoft R, Kleinman M, eds. Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2007.