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Association of Critical Care Transport
www.ACCTforPatients.org
Critical Care Transport StandardsVersion 1.0
Dedication
Suzanne Wedel, MD
These Standards and the ongoing project are dedicated toDr. Suzanne
Wedel,agiftedphysician,scientist,leader,andhealer.Suzanne’spassion
for excellence and advocacy for patients inspired and led the work to
developtheseStandards.Suzannecontinuallytaughtandremindedusto
alwaysputpatientsfirstandatthecenterofthemedicalenterprise.Her
rigorous and continuing commitment to a safer, better, andmeasured
criticalcaremedicalsystemforeachpatientisatouchstoneforusallas
weundertakecareandthegiftofservice.
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ExecutiveSummaryWiththecontinuedregionalizationofhealthcare,changesinhealthcarereimbursement,andthe
advancementsinclinicaltherapies,theAssociationofCriticalCareTransport(ACCT)anticipatesthatthe
needforcriticalcaretransport(CCT)willcontinuetoincrease.Yet,therearecurrentlynoagreed-upon
consensusnationalstandardsoreveninternationalstandardsforcriticalcareinter-hospitaltransport.
Whatconstitutescriticalcaretransportstandards?Apatchworkofeffortshasattemptedtoaddressthe
differentsegmentsofpatienttransport.Regulatorshavepromulgatedlicensingandregulationatthe
jurisdictionallevel;theEuropeanCommitteeforStandardization(CEN)haspublishedambulancevehicle
standards;professionalsocietiessuchastheAmericanAcademyofPediatricshavepublishedbest
practicesandrecommendations,andaccreditingorganizationssuchastheCommissiononthe
AccreditationofMedicalTransportSystems(CAMTS)andtheEuropeanAirMedicalInstitute(EURAMI)
havedevelopedvoluntaryaccreditationstandards.
ThislackofaunifiedCCTstandardallowswidevariationinpractice,education,availablemedical
therapies,vehiclerequirements,andclinicaldocumentation.Mostimportantly,thelackof
standardizationpresentsriskstopatientsthatareoftennottransparenttoreferringandreceiving
clinicians,ortopatients,theirfamilies,northepublic(e.g.,failuretorecognizeorinterveneon
compromisedcriticalpatientsduetoinexperiencedand/orill-equippedclinicians).Astheneedforhigh
acuityCCTincreases,patientsandcliniciansalikewillbenefitfromstandardsofpractice.
Throughamulti-yearinteractiveprocess,ACCThasdevelopedasetofrecommendedclinicalstandards
forinter-hospitalCCT.Therecommendations,whicharepresentedintheAppendices,havebeen
conceivedandwrittentoapplytoallmodesoftransport
Indevelopingtheserecommendedstandards,ACCTfirstdistinguishesbetweenprimaryemergency
sceneresponseandinter-hospitaltransport.Secondly,ACCTrecognizesthewidespectrumofpatient
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acuityintransport.Noteverypatientrequiresthehighestlevelofcriticalcareduringtransport,nordoes
everyagencyneedtoprovide,withinitsmission,everypotentialtherapytoeverypatientregardlessof
ageandcomplexity.Transport,clinicalprovidersandagencies,however,mustbetransparentandclear
onthescopeofmissiontheyarepreparedtoundertakeforanyemergent,unscheduled,inter-hospital
transfer.
Toooften,inter-hospitaltransportisablackholebetweenreferringandreceivingcenterslackingin
consistentstandards,quality,outcomemetrics,documentation,andreportingtooversightagencies.
AppropriateandeffectiveCCTreducesmorbidityanddownstreamin-patientcost.Thefailureorinability
toinitiatecriticalacutemedicalinterventionsincreasestheriskofmortalityforpatients.Consistent,
transparent,andagreeduponstandardsprotectvulnerablepatientsandreduceliabilityriskfor
cliniciansresponsibleforinter-hospitaltransferdecisions.Ataminimum,CCTteamsshouldmaintain
continuityorimprovethelevelofpatientcareoneverytransportbetweenhospitals.
CCTisadistinctspecialtyintheprovisionofout-of-hospitalcare.CCTprovidesadditionalresources
necessaryforpatientswhoareclinicallyunstableorhavethepotentialforlifethreateningclinical
instabilityandwhorequiremoreadvancedandspecializedproviderknowledge,training,and
experience,aswellasdiagnosticandinterventionalcapabilities,equipmentandtherapeutics.Boththe
CCTagencyandCCTclinicalprovidersmusthavesufficientcapabilitiestomeetboththeexpectedand
potentialmedicalneedsofcriticalcarepatientsatreferralhospitalsandduringtransport.
Thechoiceoftransportmodality—ground,fixedwingorrotorwing—isbasedonmultiplefactors
includingpatientacuityandmedicalcondition,needfortimesensitive,definitivecare,out-of-hospital
time,(e.g.,aorticdissection,STelevationmyocardialinfarction,ortraumaticevent)andlogistical
considerations,includingdistanceandweather.Accordingly,criticalcaretransportpatientsmaybe
transportedbyanyvehiclemodalitydependingontheindividualcircumstancespresentatthetime.The
choiceofaparticularvehiclemodalitydoesnotinferthatatransportisorisnotacriticalcaretransport.
Thelevelofmedicalcarerequiredtotransportacriticalcarepatientincludesbutisnotlimitedto:
! anexpertlevelofcriticalcareproviderknowledge,experience,andskillsutilizingevidence-
basedcriticalcareguidelinesappropriatetothemedicalneedsofsuchpatients;
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! apatientcareenvironmentcommensuratewiththecriticalcareinterventionsprovided,
includingthenecessaryequipment,medicationsandsupplies;
! theabilitytoaddresstheaddedenvironmentalandlogisticalchallengesandstressorsof
transport;
! initiating,maintaining,andpotentiallyimprovingthecontinuityoftertiaryorquaternary
hospitalcareduringtransport;and,
! avehicle(ground,fixedwing,orrotorwing)equippedtosupportthedeliveryofmedicalcareto
criticalcarepatientsduringtransport(e.g.inverterpower,range,oxygenduration,andfull
patientaccess).
InMay2012,theAssociationofCriticalCareTransport(ACCT)StandardsCommitteeinitiatedawork
grouptoaddressthestandardsgapandcreateamodeldefinitionofcriticalcaretransport.Thework
groupcomprisedofcriticalcarephysicians,nurses,paramedics,respiratorytherapists,andhospital/
transportagencyadministratorsadoptedbyconsensusadefinitionofcriticalcaretransportandan
initialframeworkofstandards.
DefinitionofCriticalCareTransport:
Theprovisionofmedicalcarebyacriticalcare
transportteamtoapatientrequiringcriticalcare
transportbyacriticalcaretransportagencysuch
thatthefailuretoassess/recognizeresuscitation
needsandurgentlyinitiateandmaintainacute
medicaldiagnosticsand/orinterventions,
pharmacologicalinterventions,ortechnologies
wouldlikelyresultinsudden,clinicallysignificantor
lifethreateningdeteriorationinthepatient'scondition.ThesecapabilitiesexceedthoseofanAdvanced
LifeSupportEMSunit(subjecttothecorrespondingdefinitionsbelow).Ideally,CCTextendsamajority
ofthecriticalcarecapabilitiesofthetertiaryreceivingfacilitytothepatient,isinitiatedatpatient
contact,andisprovidedthroughoutthetransport.
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DefinitionofPatientRequiringCriticalCareTransport:
ApatientrequiringCCThasacriticalillnessorinjurythatacutelyimpairsoneormorevitalorgan
systemssuchthatthereisahighprobabilityofimminentorlifethreateningdeteriorationinthe
patient'sconditionduringtransport.Examplesofvitalorgansystemfailurethatmaycontributeto
morbidityormortalityinclude,butarenotlimitedto:centralnervoussystemfailure,circulatoryfailure,
shock,renal,hepatic,metabolic,and/orrespiratoryfailure.
DefinitionofCriticalCareTransportTeam:
CCTservicesaredeliveredbyaCCTteamconsistingofatleasttwoclinicalpersonnelwhopossessa
scopeofpractice,education,training,experience,andrequisitedecisionmakingskillstoassessand
supportahighlycomplexpatientactiveorpotentialvitalorgansystemfailureand/orto,atminimum,
preventfurtherlifethreateningdeteriorationofthepatient'sconditionduringtransport.
DefinitionofCriticalCareTransportAgency:
Thecriticalcaretransportagencymusthaveessentialsystemsandoversightinplacetomeetthe
medicalneedsofcriticalcarepatientsevidencedbylicensing,credentialing,andphysicianoversight.The
agencymustbelicensedand/orcredentialedtooperateinthestateinwhichitisbasedandatthe
highestclinicallevelestablishedinthestate.Theagencyhasphysicianmedicaloversightconsistentwith
theacuityandconditionsofthecriticalcarepatientstransported.Thismaybeacombinationofmedical
directorsoraphysicianteamsupplementedbytheadditionofconsultingspecialists.Suchappropriate
medicaloversightincludesanactivelypracticingphysicianwithcompetencyincriticalcaretransport
medicineandboardcertificationinaspecialtyrelevanttotheprovideragencymission,orexperiencein
criticalcaretransportmedicineconsistentwiththetypes,acuityandseverityofpatientstransported.
Theagencyalsohasstructuredphysician-directedclinicalqualitymanagementandclinicalperformance
improvementprogramsthatareconsistentwiththeconditionsofcriticalcarepatientstheorganization
cares.Theagencymustdemonstratecontinuousprocessimprovementforprovidingpatientcarethat
requiresactiveinvolvementbyaphysicianmedicaldirectortoensurequalityandadherenceto
appropriatestandards.Theprocessimprovementsystemalsomustincludereportingrequirements
relatedtoqualityassurance,utilizationreview,outcomes,proficiencymeasuresandpatientsafety.
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Withthesecoredefinitionsasstartingpoints,theACCTstandardsgrouphasworkedtodetailwhatis
neededwithintheentirescopeofCCT.ThefollowingappendicesworkthroughthelayersofCCTandare
thelatestiterationofrecommendedstandards,asadoptedbyACCT’sBoardofDirectorsinMarch,2016.
Althoughthesixstandardsarepresentedinseparateappendices,andeachonefocusesonaparticular
elementofCCT,theyshouldbeconsideredasawhole.Theinitialappendicesdetail:
Appendix1. ScopeofPracticeandclinicalcapabilityofproviders
Appendix2. Minimummedicalequipment,technology,andformulary
Appendix3. Minimumvehicleconfigurationandequipmentnecessarytosupportpatientcare
Appendix4. DocumentationStandards
Appendix5: “AlwaysandNeverEvent”qualitymeasuresincriticalcaretransport
Appendix6: Recommendedmetricsforcriticalcaretransport(inprocess)
Appendix7: StandardsReferences
Appendix8: Definitions
Mostimportantly,theserecommendationsshouldnotbeconsideredall-inclusive,asthecriticalcare
andemergencymedicaltransportindustryisamongthemostdynamicareasofmedicine.Theseinitial
recommendationsarepartofacontinuingevolutionaryprocessinadynamichealthcareenvironmentto
improvecareandtransportforpatientswithtimesensitiveandcriticalillnessorinjury.Additional
appendicesforMedicalOversightandadditionalQuality,processandoutcomemetricsarein
development.Further,ACCTexpectstocontinuallyreview,refine,andaddstandardsusingatri-annual
reviewschedule.
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ReferenceDocuments:
APPENDIX1:CRITICALCARETRANSPORTSCOPEOFPRACTICE_________________________________________7
APPENDIX2:CRITICALCARETRANSPORTMINIMUMEQUIPMENT/DEVICELIST _________________________17
APPENDIX3:CRITICALCARETRANSPORTVEHICLEATTRIBUTESTOSUPPORTCRITICALCARE________________25
APPENDIX4:CRITICALCARETRANSPORTDOCUMENTATIONSTANDARDS_______________________________32
APPENDIX5:CRITICALCARETRANSPORT–“ALWAYSEVENTS”AND“NEVEREVENTS”_____________________38
APPENDIX6:RECOMMENDEDMETRICSFORCRITICALCARETRANSPORT _______________________________53
APPENDIX7:REFERENCES _____________________________________________________________________59
APPENDIX8:DEFINITIONS&ACRONYMS_________________________________________________________62
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Appendix1:CriticalCareTransportScopeofPracticeBackgroundScopeofpracticecanbeidentifiedbythreecategories.Tobewithinascopeofpractice,therequirementsforpracticingaskillorprofessionmustsatisfyallthreecriteria:
! Educationandtraining—Hastheproviderbeeneducatedacademicallyoron-the-jobandhavedocumentationprovingeducationtodotheprocedureortreatmentinquestion?
! Governingbody—Doesthestate,district,provinceorfederalgovernmentalagencythatoverseestheskillorprofessionallow(ornotexplicitlydisallow)theiteminquestion?
! Institution—Doestheinstitutionallowaproviderortheprovider’sprofessiontoperformtheskillinquestion?
AprecursortothedevelopmentofthesestandardsincludedacompilationandreviewofstateRulesandprotocolsforairmedicaltransport.TheRulesvarywidelyinscope,breadth,andconstruct.Whileanumberofstateshavedefinedsomelevelofscopeofpracticeandreferencenationalaccreditationstandards,onlyonestate,Massachusetts,wasidentifiedtohaveacomprehensiverulesprocessdefiningcriticalcare.Uponevaluationofstate-definedscopeofpracticeformembersofCCTteams,mostwerefoundnottohavedefinedCCTspecificscopesofpractice,leadingtowidevariationsinstandardsofcare.Furthermore,scopesofpracticevaryinstatesthathaveworkingdefinitions.MedicaltransportprofessionalassociationssuchasAir&SurfaceTransportNursesAssociation(ASTNA)andInternationalAssociationofFlight&CriticalCareParamedics(IAFCCP)havedocumentedwhatthescopeofpracticeforaflightnurseorflightparamedicmaybe,butdonotprovideaunifiedCCTscopeofpractice.NeitherdotheseindividualAssociationsaddressphysicianlevelinterventionorcontinuityofcare,thoughthesearecommonlyaddressedoutsideofNorthAmerica.The“silos”thatseparatemanyprofessions,jobfunctionsanddisciplinescontributetoinconsistencyindefinitions.Thislackofconsistencyleadstodeliveryofsafeandeffectivepatientcare.Consequently,confusedandinaccurateexpectationsofscopeofpracticebyrequestinghospitalclinicianscanpotentiallyleadtoinappropriateteamselectionandpoorpatientoutcomes.ACCTbelievesCCTisaspecialtythatdrawsupontheskillsetstraditionallyheldbymultipledisciplines.CCTprovidersmayhaveformaltrainingasregisterednurses(RN),advancedpracticeregisterednurses(APRN),paramedics,physicians,physicianassistants(PA),orregisteredrespiratorytherapists(RRT);
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however,formalizedcivilianmedicaleducationdoesnotsufficientlyprepareanyonedisciplinetocareforthesepatientsinthetransportenvironment.Therefore,forthefutureofCCT,ACCTbelievesthatitisinthebestinterestofcriticallyillorinjuredpatientstobetransportedbypersonnelspeciallytrainedinCCT.ThescopeofpracticeforaCCTprovideriswellbeyondthescopeofafieldparamedic,asdefinedintheNationalHighwayTrafficSafetyAdministration(NHTSA)NationalEMSScopeofPracticeModelaswellasbeyondthetypicaltrainingreceivedbyatertiaryhospitalRN,asettingthathasthesupportofcountlessspecialtypersonnelonstaff.TheCriticalCareTransportAgency(CCTA)anditsmedicaldirectorhavetheresponsibilityofensuringalloftheirprovidersarewelltrained,wellequipped,andcompetentinthescopeofpracticetheyintendtoprovide.
ScopeofPractice1.
1.1. CriticalCareTransportAgency
1.1.1. TheCCTAmusthaveessentialsystemsandoversighttomeettheneedsofcriticalcarepatients.Thisshouldincludemedicaldirection,education,training,andqualityprocesses.
1.1.2. TheCCTAmustbelicensedand/orcredentialedtooperateinthestateinwhichit
isbasedandatthehighestapplicableclinicallevelofferedbythestate.1.1.3. TheCCTAhasphysicianmedicaloversightconsistentwiththeacuityandconditionsof
thecriticalcarepatientsbeingtransported.Thismaybeacombinationofmedicaldirectorsoraphysicianteamsupplementedbytheadditionofconsultingspecialists.Suchappropriatemedicaloversightincludesanactivelypracticingphysicianwhoparticipatesinthehiringprocess,orientationandtraining,qualityandsafetymeetings.ThemedicaldirectorwillhavecompetencyinCCTmedicineandboardcertificationinaspecialtyrelevanttotheprovideragencymission,orhaveexperienceinCCTmedicineconsistentwiththetypes,acuityandseverityofpatientstransported.CCTAphysiciansinvolvedwithmedicaloversightshouldattendongoingeducationandtrainingthatfocusesonmedicaldirectorresponsibilityinsupervising,evaluatingandensuringhighqualitymedicalcareisprovided.
1.1.4. TheCCTAhasstructuredphysician-directedclinicalqualitymanagementandclinical
performanceimprovementprogramsconsistentwiththeconditionofcriticalcarepatientsbeingtransported.Theseprogramsdemonstrateacontinuousprocessforimprovingcare,includingstandardsthatrequireactiveinvolvementbyphysicianmedicaldirectors.Medicaldirectorsensurequalityandadherencetoappropriate
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standardsandreportingrequirementsrelatedtoqualityassurance,utilizationreview,outcomes,proficiencymeasures,andpatientsafety.
1.2. CriticalCareTransportTeam
1.2.1. CCTteamsmustconsistofatleasttwoCCTproviders,withtheabilitytoprovide
acutemedicalinterventions,pharmacology,andtechnologicallifesupportsystemsconsistentwithtertiarylevelcare.Contemporaryteamsconsistofvariouscombinationsofprovidersthatinclude:RNs,APRNs,paramedics,physicians,PAs,andRRTs.CCTisrecognizedasmedicalcarethatisbeyondthetypicalpatientcaredeliveredwithintheUS911emergencysystem,whichreliesuponprovidersactingwithintheNHTSAEMSScopeofPracticeModel,DOTHS810657,February2007.
1.2.2. CCTproviderswillhavedocumentedcompetencyandexperienceinthecareand
transportofcriticalcarepatients.AllCCTteamprovidersshouldbeemployedbyoraffiliatedwiththeagencyprovidingtransport.
1.2.3. AtleastoneCCTprovidershallbelicensedasanRN,APRN,physician,orPAwith
documentedcompetencyandexperienceintheprovisionofcriticalcareinatertiarycriticalcareunitcommensuratewiththetypeandacuityofpatientstransportedandreceivestraininginthetransportenvironmentpursuanttotheCCTA’spolicy.Totheextentthatastate,province,orcountrymaydevelopcredentialingforaCCTproviderthatincludesotherlicensedcaregiverswhomeetthequalificationrequirementsin(1.1.2)aboveandthatrequiressuchcaregiverstohavethecompetencycomparabletothreefull-timeyearsinatertiarycriticalcareunitasaprimarycaregiver,suchcredentialingwillbeconsideredformeetingthisrequirement.Itisstronglyrecommendedthattransportprovidershaveaminimumof3700hoursofcriticalcarepatientcontactortheequivalentindynamichumanpatientsimulator(HPS)trainingoraminimumof5yearsofexperiencecaringforacutelyillorinjuredpatientsinacriticalcareenvironment.
1.2.4 AtleastoneCCTproviderhasspecialtycertificationinCriticalCareTransport(e.g.,
CertifiedFlightRegisteredNurse(CFRN),CertifiedTransportRegisteredNurse(CTRN),CertifiedNeonatalandPediatricTransport(CNPT),FlightParamedicCertified(FP-C),CriticalCareParamedicCertified(CCP-C),orrelevantphysicianspecialtypracticeachievedthroughavalidatedexamadministeredbyanindependententitynotassociatedwithaspecificcourseorprogramofeducation.TheagencyshouldhaveapolicyrequiringeventualtransportcertificationforeveryCCTprovider.
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1.2.5 Whentreatingspecialpatientpopulations(e.g.high-riskobstetric,pediatric,neonatal),additionalclinicalexperience,training,equipmentandtechnologymustbeincorporatedintotheteamanditsdeliveryofcriticalcareasappropriatetothemedicalconditionsofthepatient.
1.2.6 ACCTteammaybeaugmentedby
addingtertiaryteamsofspecialtyproviderstrainedtodelivercaretopatientswithhighlyspecializedcharacteristics,equipment,ormedicalconditions.SuchprovidersmaybeemployedbyanentityotherthantheCCTAbutshouldmeettheminimumrequirementsconsistentwiththeapplicabletertiarycarestandardforthepatientbeingtransported(e.g.,ExtracorporealMembraneOxygenation(ECMO),NeonatalIntensiveCareUnit(NICU)PediatricIntensiveCareUnit,(PICU),orHighRiskObstetrics(HROB).
1.3. CriticalCareTransportProviderQualificationsandTraining
1.3.1. CCTProviderQualifications
1.3.1.1. TheCCTprovidershallbelicensed,credentialed,orcertifiedasrequiredbythe
state,province,countryregulatorasaparamedic,RN,RRT,APRN,PAorphysician.TheCCTproviderfunctionsunderhisorherlicenseandassumesresponsibilityforthecareprovided.
1.3.1.2. Pre-hire,thenon-paramedicCCTproviderwillhaveaminimumofthree
yearsoffull-timeexperienceofcaringforcriticallyillorinjuredpatientsinacriticalcareenvironment.Thecandidate’sclinicaltimeisvalidatedbyaclinicalsupervisorpriortotheCCTteamorientationprocess.
1.3.1.3. Pre-hire,theparamedicCCTproviderwillhaveaminimumofthreeyearsoffull-timeexperienceofcaringforacutelyillorinjuredpatientsintheprehospitaland/orinter-hospitaltransportenvironmentinaprogressiveALSsystem.Thecandidate’sclinicaltimeisvalidatedbyaclinicalsupervisorpriortotheorientationprocess.
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1.3.1.4. PriortoemploymentbyaCCTA,theCCTproviderwillhaveaminimumofBasicCardiacLifeSupport(BCLS),AdvancedCardiacLifeSupport(ACLS)and/orPediatricAdvancedLifeSupport(PALS),orequivalentcertifications.TheymustalsoobtainNeonatalResuscitationProgram(NRP)certificationpriortoorientationcompletionifhigh-riskobstetrictransportisincludedinthescopeofpractice.
1.3.1.5. InordertobecredentialedasaCCTprovider,theorientationprocessshall
followguidelinesfortransportorientationthathavebeensetforthbyorganization-approvededucationalstandardssuchtheCommissiononAccreditationofMedicalTransportSystems(CAMTS),AirSurfaceTransportNurseAssociation(ASTNA),InternationalAssociationofFlight&CriticalCareParamedics(IAFCCP),UnitedStatedDepartmentofTransportation-NationalHighwayTrafficSafetyAdministration(USDOT-NHTSA).
1.3.1.6. Withinoneyearaftercompletionoforientation,theCCTprovidermustobtain
certificationinrespectivediscipline,(i.e.CertifiedFlightRegisteredNurse(CFRN),CertifiedTransportRegisteredNurse(CTRN),CertifiedNeonatalandPediatricTransport(CNPT),FlightParamedicCertified(FP-C)&/orCriticalCareParamedicCertified(CCP-C)).Duringthisfirstyear,theymustalsoobtainanadvancedtraumacertificationsuchasAdvancedTraumaLifeSupport(ATLS),Pre-hospitalTraumaLifeSupport(PHTLS),orTransportProviderAdvancedTraumaCertification(TPATC),iftraumaisincludedinthescopeofpractice.
1.4. CriticalCareTransportSpecialistQualifications
1.4.1. MeetsalltherequirementsofaCCTprovider.
1.4.2. Maintaincertificationinrespectivediscipline(e.g.CertifiedFlightRegisteredNurse
(CFRN),CertifiedTransportRegisteredNurse(CTRN),CertifiedNeonatalandPediatricTransport(CNPT),FlightParamedicCertified(FP-C)&CriticalCareParamedicCertified(CCP-C).
1.4.3. Completes150criticalcaretransports,ofwhich20maybedynamicHPS
transportsimulationsandaminimumof2yearsofexperienceasaCCTprovider.
1.5. Training
1.5.1. AlltrainingwillbedeterminedbytheCCTA’sscopeofpracticeandthepatient
populationserved
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1.5.2. Didactics:Criticalcarepatientmanagementinthetransportenvironment,advancedairwayandventilatormanagement,advancedcardiaccare,cardiaccriticalcare,medicalandsurgicaltrauma,advancedcareandtreatmentofthecriticallyillpatient
1.5.3. ClinicalLabTraining:Anatomyandphysiology,agespecificforscopeofpractice,advancedairwaylab,advancedmechanicalventilation,Intra-AorticBalloonPump(IABP),extracorporealmembraneoxygenation(ECMO),invasivehemodynamicmonitoring,CardiacAssistDevices(VADs),Intra-CranialPressure(ICP)monitoring.
1.5.4. ClinicalTime:Criticalcare,emergencydepartment/trauma,PICU,NICU,laborand
delivery.Clinicaltimemaybereplacedoraugmentedwithactualcriticalcarepatienttransportsandsimulatedcriticalcarepatientsandtransportsinahighfidelitysimulationlab.AllformsofclinicaltimeorreplacementswillhaveclearlydefinedobjectivesthatmeettheareaslistedaboveandareconsistentwiththeCCTA’sscopeofpracticeandpatientpopulation
1.5.5. AviationandGroundOperations:AirMedicalCrewResourceManagement,Aircraft
andGroundSafetyandAwarenessTraining,survivalskills,EMScommunications,hazardousmaterialstraining,NationalIncidentManagementSystem(NIMS)100,200,AltitudePhysiology&StressorsofFlight.
1.5.6. Certifications:Obtainremainingcertificationsaspertransportagenciesscopeof
practice(e.g.NeonatalResuscitationProgram(NRP),AdvancedTraumaLifeSupport(ATLS),Pre-hospitalTraumaLifeSupport(PHTLS),TransportProfessionalAdvancedTraumaCourse(TPATC)orequivalent).
1.5.7. TransportCertification:Withinoneyearaftercompletionoforientation,the
transportprovidermustobtaincertificationinrespectivediscipline(e.g.CFRN,CTRN,CNPT,FP-Cand CCP-C).
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1.6. CriticalCareTransportProviderSkills
CCTproviders’andspecialists’skillswillbebasedontheCCTA’sscopeofpracticeanddefinedpatientpopulation.Theyareabletopracticeundertheirdefineddiscipline’sscopeofpracticeinadditiontothefollowingprocedures.Thislistisnotintendedtobeall-inclusivenorisitexpectedthateveryCCTteamhastheabilitytoperformallofthelistedprocedures.Forexample,aCCTteamthatdoesnottransportneonatalpatientswouldnotneedtoperformumbilicalvein/arterycannulation.Theintentofthislistofadvancedskillsandproceduresistodemonstratethesignificantdifference,includingahigherlevelofknowledgeandtraining,betweenaCCTteamandanadvancedlifesupport(ALS)orCMS-definedspecialtycaretransport(SCT).
1.6.1. Airway/Respiratory
! AdvancedAirwayManagement:o Videoanddirectoral
laryngoscopyo RapidSequenceInduction
(RSI)
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o Supraglotticdeviceinsertion(e.g.LMAorKINGairway)o Needleandsurgicalcricothyroidotomy
! Chest/LungCompromiseo Needle,simple,andtubethoracostomyo Drainagesysteminitiationandmanagement
! Ventilation! Mechanicalventilationinitiationandmanagementofallmodesofventilation;to
includebutnotlimitedto:highfrequencyoscillating;volume,pressure,anddualmodeventilation;non-invasivepositivepressureventilation.CapabilitiesforallagegroupsintheCCTA’sscopeofpractice.
1.6.2. Cardiovascular
! ManagementofVentricularAssistDevice(VAD):includingbutnotlimitedto:percutaneousorcentralLVAD,RVAD,andBiVAD
! ManagementofExtracorporealMembraneOxygenation(ECMO)withorwithoutheater/coolercapability
! Intra-AorticBalloonPump(IABP)counterpulsation! Performandinterpret12LeadECGswithcatheterizationlabactivationcapabilities! Intraossesousaccess(e.g.EZ-IO,FAST1,etc.)! Indwellingportaccess(e.g.Hickman,Port-a-Cath,etc.)! Transcutaneous,transvenous,andepicardialwirepacemakercapabilities! Pericardiocentesis! Invasivehemodynamicmonitoring(e.g.CVP,PulmonaryArtery
Pressures,AbdominalPressures,arterialpressures,intracranialpressures)
! Blood/fluidwarmingdevices! Bloodproductadministration(e.g.PRBCs,plasma,platelets)! Operationofsingleandmulti-channelinfusionpump(s),includingbutnotlimited
toIntravascular,intraosseous,intrathecal,andintra-arterialroutes! CardiovascularDoppler/ultrasoundmonitoring! Arterialcannulation,radialand/orfemoral! Centralvenouscannulation,femoral,subclavian,andinternaljugular! Woundclosureincludingbutnotlimitedto:suturing,stapling,skinglue! Laboratorysampling,PointofCaretesting,resultinterpretation,andtreatment! Non-invasivetissueoxygenationmonitoring! Hemorrhagecontrolincludingbutnotlimitedto:tourniquetuse,chemical
clottingagents,Eshermanchestseal,tranexamicacid(TXA)andplasmaadministration
1.6.3. Gastro/Urinary
! Gastrictubeplacementandmanagement! Urinarycatheterinitiationandmanagement
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1.6.4. PHARMACOLOGY
! Abilitytocalculateandindependentlyadministermedicationsapplicabletothecriticalcareenvironmentandcoveredinprotocols,guidelines,orstandingorders.o Vasoactiveagentso Paralyticso Anxiolyticso Anti-inflammatoryo Anticonvulsanto Narcoticso Anesthetico Thrombolyticso Inhaledgases:Heliox,NitrousOxide,NitricOxide,Anesthesiagaseso Nebulizedmedications
o Antiemetico Antibioticso ACLSmedications:Epinephrine,Lidocaine,Atropine,Anti-arrhythmico Electrolytes:Potassium,Magnesium,Calciumo Prostaglandin,Surfactanto BloodandBloodProductso Tranexamicacid(TXA)
1.6.5. Other
! Radiographicinterpretation! Performandinterpretultrasoundimagingincludingutilizationforplacement
ofmedicaldevices! Abilitytomanageandtransportanyindwellingmedicaldevice! Invasiveandnon-invasivetemperaturemonitoring! Initiationandmanagementofnon-invasiveandinvasivethermoregulationdevices! Thoracicandextremityescharotomyandfasciotomy
1.6.6. Specialty
! Temperaturestabilization! Fetalheart/uterinemonitoring! Umbilicalvein/arterycannulation! Inhalednitricoxide! Surfactantadministration! Esophagealcompressiontubes! Peri-mortemcesareansection! Suprapubiccystostomy! Esophagealcoolingtubes
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TheCCTprovidermayberequiredtoperformskillsnototherwiselistedinthisdocumentviadirectorvideoremotemedicaloversight.BasedontheCCTA’spatientpopulation,theneedfortheseskillsshouldbeanticipatedandincludedintrainingandcompetencyassessment.SummaryACCTbelievesthatCriticalCareTransportandtheCCTprovidershouldberecognizedasahigherleveloftransportthantheCentersforMedicareServices(CMS)-definedreimbursementforSpecialtyCareTransport,whichprovidesreimbursementforcarebeyondthescopeofparamedicpractice.Itisessentialthatcriticallyillandinjuredpatientsreceivecarebyhighlytrainedandqualifiedclinicians.Duringinter-hospitalCCT,theCCTteamshould,ataminimum,providecriticalcarecommensuratewiththereferringfacility.Optimally,theCCTteamshouldadvancethelevelofcriticalcaretowardsthatofthereceiving,tertiaryhospital.Thegoalofstandardizedqualificationsandtrainingwouldallowforreferralprovidersandpatientstobeconfidentthattheirlevelofcareisnotcompromisedduringtransport.
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Appendix2:CriticalCareTransportMinimumEquipment/DeviceList
BackgroundCriticalCareTransport(CCT)MedicalEquipment:Maintainingtheinteroperabilityandcontinuityoftertiarylevelcarebetweenhospitalsandinitiatingtertiary-levelassessmentandinterventioncapabilitiesinreferralhospitalsettingsarecorerequirementsforthecriticalcaretransportagency(CCTA).WhileallmedicaltransportagenciesdonotprovideCCT,andallpatientsdonotrequirecriticalcaresupportduringtransport,theCCTAmustbeabletoprovideallcapabilitiesforanyunscheduledtransport.Essentialmedicalequipment,devices,andpharmaceuticalformulariesmustbeimmediatelyavailable,stockedonallvehiclesassigned,andaccessibletoclinicianstomanageanycriticallyillorinjuredadult,pediatricandneonatalpopulations,basedontheCCTA’sstatedmissionandscopeofpractice.TheCCTAmustmaintain,andhaveimmediatelyavailable,basicandadvancedlife-supportequipmentasrequiredbythejurisdictionalregulatorandlicensingauthority.SomeCCTAslimittheirscopeofpracticetotransportingspecificpatientpopulationssuchasneonatal,pediatric,andhigh-riskobstetrics(HROB)andtheminimumequipmentlistcanbemodifiedtoreflecttheneedsoftheirspecificpatientpopulation.CCTAsthatdonotexcludepatientpopulationsintheirscopeofpracticemustbecapableofemergentresponseandtransportforallpatientpopulationsandmustassuretheavailabilityofallrequiredtypesandsizesofmedicalequipment,devices,andpharmaceuticalformularyasnotedbelow.TheCCTAmusthavemedicalequipmentthatistestedandfunctionsinexpectedtemperature,atmosphericpressure,andhumidityconsistentwiththeCCTAservicearea.Ifthisisnotfeasibleforaregion(e.g.,wheretemperaturesmayroutinelydropbelow-18oCduringwintermonths),processes,guidelines,andstaffeducationmustaddresstheuseofthisequipmentasitpertainstostorageanduseinpatientcare.
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Electricallypoweredmedicalequipmentanddevicesshallfunctioncontinuouslyasintendedduringloading,transport,andtransferofcarewithbatteriessufficienttoprovidecontinuouslifesupportwithoutinterruptionduringallphasesoftransport.Fixation,storage,placementandprotectionofmedicalequipmentanddevicesmustmeetapplicableregulatorystandardsandbelocatedasnecessarytoprovideimmediateaccessasneededfor
resuscitationormanagementofmedicalemergenciesintransport.TheCCTAmusthavewrittenpolicyanddocumentationthatequipmentisfullymaintainedinaccordancewithmanufacturers,biomedicalandregulatoryrequirementsatprescribedintervals,consistentwithreferringandreceivinghospitalrequirementsforpatientsbeingtransportedbytheCCTA.
ThisminimummedicalequipmentandpharmaceuticalformularyshouldbebasedontheCCTA’sscopeofpracticeandpatientpopulation.Equipmentwillinclude,butnotbelimitedtothefollowing:
Equipment2.
2.1. PatientMonitoringEquipment
2.1.1. Patientmonitor(monitoringequipment)withthefollowingcapabilities:! Cardiacmonitoringtoinclude12Leadcapabilities! Pulseoximetry(neonatal/pediatricteamrequiresdualSpO2capabilityforpreand
postductalcontinuoussaturationmonitoring)! In-linecontinuouswaveformcapnographymonitoring! Non-invasiveandcoretemperaturemonitoring(e.g.esophageal/rectaland
skinprobes/tympanic)appropriateforpatientpopulationsmanagedortreatmentsadministered(i.e.targetedtemperaturemanagement)
! Aminimumoftwoinvasivelinemonitoringports(Arterial,PulmonaryArtery(PA),CentralVenousPressure(CVP),Intra-cranialPressure(ICP),etc.)andtransducers
! Non-InvasiveBloodPressure(NIBP)monitoring! Cardiacdefibrillation,cardioversion,andtranscutaneouspacingcapabilities
thatmeetILCORandAHA/ACLSguidelines! Abilitytotrendandprintpatientvitalsignsandpertinentclinical
managementevents(e.g.defibrillation)
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2.1.2. Doppler(certainmodelshavedifferentsensitivitybasedonpatientpopulations)! CardiacDopplerforteamsassessingextremitycirculation,VSassessmentfor
shockpatients,etc.! FetalDopplerforteamstransportingHROBpatients(unlessequippedwith2.1.3.)
2.1.3. ExternalfetalmonitoringisrequiredforHROBteams
2.1.4. Endotrachealcuffpressuremanometerrequiredinairtransportmodesand
stronglyencouragedingroundCCT,especiallyinmountainousregions.
2.1.5. Glucometerunlessincludedin2.1.6.
2.1.6. Pointofcarelabvalues’
testing/monitoring(i.e.hemoglobin/hematocrit,electrolytes,arterialbloodgas,INR,lactate,etc.)isstronglyrecommendedforCCTAswithextendedtransporttimes(greaterthan2hours),whorespondtoreferralhospitalsthatdonothavefullyavailablelaboratorycapabilities,orwhooffercriticalcareinterventionorcapabilitiesthatmaybeguidedbythelabresults(e.g.plasmainitiationtoreverseCoumadin).
2.1.7. Appropriatesize/agespecificstethoscope(s)forassessingheart,lung,andabdominalsounds.
2.2. RespiratorySupportEquipment:
2.2.1. Multi-modetransportventilatorthatisspecifictopatientageandidealweight
byheightspecificationsandscopeofpractice:! Volumeandpressurecontrolventilationwithstronglyrecommendedmode
ofPressureRegulatedVolumeControlled(PRVC)! Invasiveventilationcontrolmodesofcontrolled,AssistControlled(AC),
SynchronizedIntermittentMechanicalVentilation(SIMV)withPressureSupport(PS)available,PositiveEndExpiratoryPressure(PEEP),andtheabilitytoadjustinspiratorytime
! ContinuousPositiveAirwayPressure(CPAP)withtheabilitytoadjustpressureandFiO2from21%to100%
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! Non-invasivepositivepressureventilation(NPPV)(e.g.BiphasicPositiveAirwayPressure)withtheabilitytoadjustiPAP,ePAP,FiO2from21%to100%,RiseTime,iTime,flowandtimetermination
! Ventilatorshouldprovideclinicianstheabilitytoassesskeyrespiratorymonitoringoutputs(e.g.respiratoryrate,PIP,MAP,PlateauPressures,expiredVt,minutevolumes,etc.)
! Forneonatalteams,blendinggascapabilitydowntoroomairisrequiredandifinhaledNitricOxide(NO)isadministered,theproperadministrationdevicewhichintegratesintotransportventilatorisrequiredforallpatientpopulations
! Highfrequencyventilatorforneonataltransportteamsifwithinscopeofpractice! Humidification/artificialnoseforneonataltransportteams.! VentilatorcircuitsforallpatientpopulationstransportedbyCCTA’sscopeof
practice
2.2.2. TheabilitytoprovideelectiveEndotrachealTubeIntubation(ETI)remainsthegoldstandardforpatientsatriskforlossofairwayduringtransport.Acompleteselectionoflaryngoscopebladesandendotrachealtubesspecifictotheage/scopeofpracticearerequiredonalltransports.
2.2.3. Recentstudiesindicatethatvideo-assistedlaryngoscopy(VL)providessignificantrisk
reductionthroughimprovedfirstpasssuccessandsuccess-to-attemptratios.WhileVLshavebecomestandardequipmentforrescueoffailedETI,VLsareconsideredprimaryrequiredequipmentforCCTAsinwhichvehicle/patientconfigurationissuchthatstandardlaryngoscopyissuboptimalornotpossibleduetoinaccessibilitytotheheadofthestretcher.
2.2.4. Acompleteselectionofairwayadjunctsandperi/supraglotticalternateairway
devices(e.g.,LMAsandKingAirways)tomanagedifficultairwayoccurrencesofallpatientswithintheCCTA’sscopeofpracticearerequiredonalltransports.
2.2.5. Adultand/orpediatricsurgicalandneedlecricothyroidotomykitappropriateto
theCCTA’sscopeofpractice.
2.2.6. Tensionpneumothoraxneedledecompression,chesttubethoracostomy,andpericardiocentesiskitsthatareageappropriateforthepatientpopulationoftheCCTA’sscopeofpractice
2.2.7. HROBandneonatalteamsshouldhavemeconiumaspirators,suctioncathetersand
bulbsyringesincludedintheirdeliverykits.
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2.2.8. Fixed,oxygencylinderorliquidoxygensystemwithatleasttwoflowmetersandasourceat50psi,andcompressedairorotherrequiredinhaledagenttomeetspecificpatientneedsandtransportdurationfortheCCTA’scoveragearea.TheminimumgasvolumeavailablemustbeabletomeetanyventilatorandpatientspecificflowrequirementforthelongestpossibletransportbytheCCTA+a30-minutereserve.Forplannedlongtransportswhenitisimpossibletocarrytheamountofoxygenrequiredtocompletethetransportthereshouldbeaplaninplacetoreplenishthesupply.Afixedminimumcapacityof3000gaseouslitersforhelicoptersandfixedwingaircraftisrequired.CCTAsmustmaintainasystemforcalculationofflowratesandcapacityofoxygen.
2.2.9. Portablereserveoxygen/compressedairorotherrequiredinhaledagentwith30-
minuteminimumcapacityatpatientrequiredflowratefortransferofcareandemergencybackupiffixedsystemfailsoranunexpectedtransportdelayisincurred.Securestorageforportabletanksisnecessary.
2.2.10. Vehicle-poweredandportablesuctionsystemcapableofcontinuous300mmHg
suctionwithin4secondsofclosureofsuctionport.Vehicle-fixedsuctionsystemmustbecapableofoperationwithoutcompromisingvehicleenginepower,haveavisiblepressuregauge,rigidandsoftsuctioncathetersandendotrachealtubesuctioningcapability.
2.3. HemodynamicSupportEquipment:
2.3.1. Cardioversion/defibrillatorwithtranscutaneouspacingcapabilityincludingjoule
settingsandpadsforpediatricandadultpatients.NeonatalcapabilityconsistentwithpatientpopulationofCCTA.
2.3.2. Temporarytransvenous/epicardialpacemakercapabilities(Adult)
2.3.3. Consideranexternalchestcompressiondevice(e.g.LucasDevice)ifthe
CCTA’sprotocolsandpoliciesanticipatethepossibleprovisionofCPRduringtransport
2.3.4. Intra-AorticBalloonPump(IABP)forCCTAsthathaveIABPcounterpulsationaspart
oftheirscopeofpractice.IABPmustbeconfiguredforsecureplacementinvehiclewithacertifiedmanufacturedmountandhaveabatterypowercapabilitythatallowsforcontinuouscounterpulsationfromthehospitaltothevehicleandfromthevehiclebackintoatertiarycarecenter.
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2.3.5. ForCCTAsthatsupportortransportExtracorporealMembraneOxygenation(ECMO)andVentricularAssistDevices(VADs)aspartoftheirscopeofpractice,adequateadjuncts(i.e.,powerdelivery,invasivelinemonitoring,medicationformulary,infusionpumpsandcertifiedmanufacturedequipmentmounts)mustbeavailable.AppropriatelytrainedstafftomanagethepatientandequipmentmaybeaddedtoCCTcrewswhenappropriatelytrainedtothetransportenvironmentandsupervisedbyasafetyofficer.
2.3.6. TheabilitytoadministermultipleconcurrentmedicationsviaIVpumpwith
medicationformularyanddosagecalculatortomeetspecificpatientpopulationrequirementsincludingbackupandpatientspecificIVpumpssuchassyringepumpsfornewborns.ItisrecommendedthatIVpumpscontaincustomizablemedicationdosinglibrariesandthattheycanbesafelysecuredinthetransportvehicle.
2.3.7. IVplacementequipmentviaperipheral,intraosseousand/orcentralIVaccessor
othersuitablemeansformedicationandorfluidadministration.
2.3.8. Pressureinfusiondevice
2.3.9. UmbilicalarteryandumbilicalveininsertiondevicesandsetsforUA/UVCforneonatalandHROBteams
2.4. OtherEquipment:
2.4.1. Incubatorand/ortransportisolettesystemwithactivetemperature,ventilator,
andpharmaceuticalcontrolandsupportforneonatalandHROBteams
2.4.2. Warmingmattress(neonatalspecific)forneonatalandHROBteams(e.g.Transwarmer®)
2.4.3. Patientprotectiveequipmentincludingpediatrictransportequipment/systems
tomodifyadultstretcherasneeded
2.4.4. Pediatricrestraint/immobilizationdevice
2.4.5. Obstetricaldeliverykit
2.4.6. Appropriatesize/agegastricdecompressiondevices
2.4.7. Bleedingcontroldevices(e.g.clottingagents,glue,chestsealsandtourniquets)
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2.4.8. Bleedingcontrolinterventionssuchastheadministrationoftranexamicacid(TXA)
andthecontinuationorinitiationofthawedplasmaarestronglyencouragedforCCTAs.
2.4.9. Pelvicstabilizationdevices
2.4.10. Escharotomy/fasciotomysupplies
2.4.11. Thoraxdrainage/suctionequipment
2.4.12. Patientpackagingand/orthermoregulationdevice(i.e.IVFwarmer/cooler,Ready-Heat™,etc.)appropriateforgeographicserviceareameteorologicalconditionsandpatient-specificrequirementssuchashemodynamicshockstatesinpediatricpatients.
2.4.13. ProvisionsfortheinitiationandcontinuationofTargetedTemperature
Management(TTM)
2.4.14. Provisionsfortheisolationandmanagementofpatientswithhighlyinfectiousdiseasestates
2.4.15. System to protect and maintain vehicle cabin temperature (heat/cooling)
withinprescribedlimitsforpharmaceuticals,blood,andallothertemperaturesensitivesupplies
2.4.16. Communicationsequipmentconsistentwiththeabilitytoaccessmedicaloversightat
alltimes.Insomeregionsthismaynotbepossibleandmedicalguidelinesshouldspecificallyaddressprocessesforsuchinstances.
2.5. Formulary:
MinimumrequirementswillbebasedontheCCTA’sscopeofpracticeandneedsoftheagency’spatientpopulation.CCTAsmustmaintainsufficientmedicationforthemaximumdurationoftransport,plusa30-minutereserve.
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TheCCTAmustassuretemperaturestabilizationofallpharmaceuticalswithinlimitsprescribedbymanufacturerandincludingbloodproductsifcarriedbytheCCTA.Formularymayincludeallofthefollowing:
! Vasoactiveagents! Musclerelaxants/medicationsnecessaryforelectiveintubation! Anxiolytics/Sedatives! Anti-inflammatory/steroids! Anticonvulsants! Opioids/analgesiaagents! Inhaledgases:Oxygenandmedicalair! Otherinhaledgases,ifapplicabletotheCCTAscopeofmission/practice:Heliox,nitric
oxide! Nebulizedmedications(AlphaandBeta2-adrenergicagonist)! Antiemetics! Antibiotics! ACLSmedications:Epinephrine,Lidocaine,Atropine,anti-arrhythmic,etc.! Electrolytes:Potassium,Magnesium,Calcium! Tocolyticmedicationtomanagepretermlabor! VitaminK! Prostaglandins,surfactanttherapy(iftransportofneonatesiswithinCCTA’sstatedscope
ofpractice)! HypertonicNormalSaline! Osmoticdiuretics! Bloodglucosecontrolagents! BloodproductsifapplicabletotheCCTAscopeofmission/practice,geographicservice
areaandlimitationsofreferringhospitals
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Appendix3:CriticalCareTransportVehicleAttributestoSupportCriticalCareBackgroundCriticalCareTransport(CCT)MedicalEquipment:Maintainingtheinteroperabilityandcontinuityoftertiarylevelcarebetweenhospitalsandinitiatingtertiary-levelassessmentandinterventioncapabilitiesincriticalaccesshospitalsettingsarecorerequirementsforthecriticalcaretransportagency(CCTA).
Emergent,time-sensitiveCCTrequestsoftenmaynotallowforadhocreconfigurationofvehiclesandequipmentneededforsafeandeffectivecriticalcaretransport.NotallmedicaltransportagenciesneedtoprovideCCT,andnoteverypatientrequirescriticalcaresupportduringtransport.However,theCCTAmustassuretheimmediateavailabilityofconfiguredCriticalCare
TransportVehicles(CCTVs),includinggroundambulances,helicopterambulances,and/orfixedwingambulances,thatprovideallofthecapabilitieswithintheCCTA’sscopeofmission/practiceforanyunscheduledtransport.Thefollowingstandardsreflecttheconfigurationandsupportsystemsforessentialmedicalequipmentthatmustbeimmediatelyavailable,stockedandaccessibletomanagethecriticallyillandinjuredadult,pediatric,andneonatalpopulationsbasedontheCCTA’sstatedmissionandscopeofpractice.Itisrecognizedthatenvironmentalconditionsfortransportaremorevariablethanthoseofahospital;however,temperature,humidity,atmosphericpressure,vibrationandshockcausedbyCCTVmovementshouldbeminimizedtomaintainpatienthemodynamic,respiratory,neurologicalandmetabolicstatusduringtransport.Note:ThesestandardsdonotreflectalloftherequiredsafetyandoperationalattributesofaCCTV,suchasdesign,materials,engineperformance,exteriorlighting,communications,oronboardsafety
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equipment.Groundambulanceandairambulanceoperationalvehiclestandardsareregulatedbyapplicablegovernmentalagencies.ItisrecognizedthatsomeCCTAslimittransportstospecificpatientpopulationssuchasneonatal,pediatric,andhigh-riskobstetrics(HROB)andtheCCTVconfigurationmaybemodifiedtoreflecttheneedsofthespecificpopulationandscopeofpractice.TheseminimumCCTVconfigurationsandattributesshouldincludethefollowingbasedontheCCTA’sscopeofpracticeandmission.Climateandterrainoftheserviceareashouldalsobeconsidered.
VehicleAttributestoSupportCriticalCare3.
3.1. General:
3.1.1. TheCCTVmustmeetallstandardandregulatoryrequirementsfortherelevantjurisdictionalregulator.
3.1.2. TheCCTVshallbedesignedandof
sufficientsizetoaccommodateallpersonnelneededtoprovidetransportwithasafeworkingandoperationalenvironmentincludingapplicablecrew/passengerseatingandpatientstretcher;eachwithapplicableregulator(FAA,OSHA,DOT)approvedratedrestraintsystems.
3.1.3. TheCCTVwillbedesignedwiththepower,fuelendurance,andrangetomeetthe
95thpercentiletransportoftheCCTA’sserviceareaandenvironment.
3.1.4. TheCCTVisdesignedandequippedtoprovidecontinuouspatientcarewithinteroperabilityandinterchangeabilityofnecessarypatientsupportsystems.
3.1.5. The vehicle interior, equipment and all surfaces should be latex-free construction.
Whenlatex-freeequipmentisnotavailableorinpreexistingvehicles,latexshouldbeidentifiedtominimizepatientexposure.
3.1.6. TheCCTVdoorsmustbefullyoperationalfromtheinteriorandcapableofbeing
heldfullyopenbyamechanicaldevice.
3.1.7. TheCCTVmusthavesufficientandsecuredstorage tomaintainall criticalcareequipment,devices,andsupplies,aswellasallbasicandadvancedlife
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supportequipmentasrequiredbythejurisdictionalregulatorandlicensingauthority.
3.1.8. Intheaviationenvironment,theCCTAwillhaveasystemforregularly
documentingtheweightofallcarryonboardmedicalequipment,devicesandsupplies.
3.1.9. TheCCTVmustbedesignedandofsufficientsizetoallowloadingandunloadingofa
patientwithoutexcessivemaneuvering(nomorethan45degreesaboutthelateralaxisor30degreesaboutthelongitudinalaccess)thatcouldcompromiseanypatientmonitoringsystemsortherapeuticequipmentordevicessuchasventilationorinfusionsystems.
3.2. PatientTreatmentCompartment:
3.2.1. TheCCTVshallbeof
sufficientdimensionstoincorporateaminimumoftwoseatsformedicalpersonnelandonestretcherapprovedbytheapplicableregulatorycrashstandardsforcapacityandfixationtothevehicle.
3.2.2. Thepatientstretchershall
haveatminimumafive-pointrestraintsystemandabilitytoraisethepatient’shead30degreesduringtransport.
3.2.3. CCTprovidersmustbeabletomaintainfreeaccesstothepatient’shead,chest,abdomen,andpelvisatalltimesandunimpededaccessasnecessaryforexpectedcareandemergencyinterventions.IfHROBisincludedintheCCTA’sscopeofpracticeandthereisasignificantpotentialfordeliveryofaninfantduringtransport,adequatespaceandpatientaccessmustbeavailableforthedelivery,careofthemother,andcareoftheinfant(s).
3.2.4. CCTprovidersmustbeabletoaccessandmaintainapatient’sairwaywhileseated
to minimize the need to become unrestrained. CCTAs should evaluate thecapabilityofvideolaryngoscopestoimproveairwayplacementintheconfinesofamovingCCTV.
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3.2.5. ProvidingCardioPulmonaryResuscitation(CPR)inamovingvehicleissuboptimalclinically.ItcarrieshighriskforpatientsafetyastheabilitytocompressthechestwithadequatedepthandratepercurrentILCOR/AHAguidelinesforanextendedperiodrequiresmultipleproviderswhoarenotseatedorrestrained.Thesuccessfulapplicationofeithermanualormechanicalcompressionsinamovingvehicleisnotsupportedbyevidence.ResuscitationshouldbeavoidedifatallpossibleduringthetransportphaseandCCTAsshouldhaveclearpolicyonloadingapatientintoatransportvehiclewitheitherCPRinprogressorifthepatientisexpectedtoarrest.IftheCCTAcontemplatestheneedforCPRintheirclinicalguidelines(e.g.patientsexperiencingcardiacarrestduetoprofoundhypothermia<30oC),theCCTAshouldconsidertheuseofamechanicaldeviceratherthanmanualcompressionstomaintainsafety.
3.2.6. ThepatientcompartmentshallbedesignedsuchthatCCTprovidersareableto
access,view,andmanageallmedicalequipment,devices,andsuppliesnecessarytoresuscitateand/ormaintainacriticallyillpatient,ideallywithouttheneedtoremoveCCTproviderrestraints.
3.2.7. Medicalequipmentanddevicealarmsandcapacitygaugesforgasesshallbe
visibletotheCCTprovidersfrominsidethepatienttransportcompartmentwithoutobstruction.
3.2.8. Medicalgas/airsupplypointsorgaugeswillbecolorcodedandprotected/padded
topreventinjury.Oxygenandothergassupplytanksmustallowcompleteshutoffofflowfromtheinteriorofthevehicle
3.2.9. Thepatientcompartmentshallbedesignedtoprotectheadstrikesincluding
protectionfromallequipmentanddeviceconnections(oxygenregulators,IVhooks,andsuctionregulators)
3.2.10. Fixation(rail),storage,andplacementandprotectionofmedicalequipmentand
devicesmustmeetapplicableregulatorystandardsandbelocatedasnecessarytoprovideimmediateaccessasneededforresuscitationormanagementofmedicalemergenciesintransport.
3.2.11. Thepositioningofmedicalequipmentanddevicesshallallowforoperation
withoutobstructingemergencyegress.
3.2.12. TheCCTVwillbedesignedandconstructedforeaseofcleaning,decontamination,anddisinfectionofallsurfaces(e.g.ceiling,walls,floor).
3.2.13. Theconstructionofthemedicalinteriorwillbeflameresistant/retardantconsistentwithapplicableregulatorystandards.
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3.2.14. Helicopterfuelsystemsarerequiredtomeetthecrashworthinessrequirementsof
14CodeofFederalRegulations27.952or29.952.
3.3 EnvironmentalConditions
3.3.1 Tomaintainpatientthermalstability,theCCTVmusthaveanenvironmentalcontrolsystemcapableofraisingand/orloweringandthenmaintainingthetemperatureinthepatientcompartmentbetween60and80degreesF.Duringtimesofextremetemperatures,therewillbeadditionalmeans(i.e.equipment,processes,etc.)ofmaintainingthepatient’sbodytemperature.
3.3.2 Activeauxiliaryheatingandcoolingsystemsshouldbeavailablewhenthevehicleisstationary.
3.3.3 TheCCTVshouldprovidenormalambienthumidityconditionsforpatienttreatmentifpossible.
3.3.4 TheCCTVshouldhaveprovisionstomaintainapprovedthermalstabilityfor
medicationsandbloodproductsasstockedbytheCCTA.
3.3.5 FixedwingCCTVsthatoperateregularlyatflightaltitudeof15,000’shallhaveapressurizedcabincapableofmaintainingatmosphericpressureequivalentto3500’.
3.3.6 Interiorlightingshallbeprovidedwithaminimumof50lumensinpatientcompartmentareawith300lumensoverstretcherareaanda400-lumendirectionalspotlight.Allinteriorlightingwillbedimmable.
3.3.7 Abatterypoweredlightsourcewillbeavailableforemergencyoperationsandfilteredasnecessaryfornightvisiongoggles(NVG)operationsintherotorwing(RW)environment.Ifaportableflashlightisusedthepilotshouldbeshieldedfromthelight.
3.3.8 Thepilotand/ordriverofaCCTVwillbeshielded,withacurtainordoor,frompatientcompartmentlightingfornightoperationsoralightingsystemmustbeinplacetoprotectpilotordrivernightvision.
3.3.9 AlllightingintheRWenvironmentwillbeapprovedandcapableoffilteringforNVGoperationsasapplicable.
3.3.10 TheCCTVwillhaveapositiveorfreeflowventilationsystemdesignedtoprovidewashoutairflowandtoprotectpatientandclinicalpersonnelfromexcessiveairflow.
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3.3.11 IfnoiseexposureintheCCTVexceeds85dB(A)soundprotectionforbothallpersonnelandthepatient(s)willbeprovided.
3.3.12 AninternalcommunicationsystemwillbeavailableifthenoiseexposureintheCCTVexceeds85dB(A).
3.4 ElectricalSupply
3.4.1 Electricallypoweredmedicalequipmentanddevicesshallfunctioncontinuouslyasintendedduringloading,transport,andtransferofcarewithbatteriessufficienttoprovidecontinuouslifesupportwithoutinterruptionduringallphasesoftransport.
3.4.2 TheCCTVwillhaveaminimumoffour(4)12Vdcand120/240Vacoutletsseparatelyprotectedwithanominalvoltageof13.8V.
3.4.3 Alloutletswillbemarkedforvoltageandamperagecapacitywithavisualindicatorforpowertotheoutlet.
3.4.4 Electricalpowerthroughaninverterorappropriatepowersourcewillprovidesufficientamperagetocontinuouslysupportallrequiredmedicalequipmentanddeviceswithoutcompromisingtheoperationofthevehicleelectricalequipment.
3.4.5 TheCCTVwillhave“shoreline”powercapabilitytosupportoutletsinthepatientcompartmenttoprovideforcontinuouscurrentwhenthevehicleisnotoperating.
3.4.6 TheCCTVwillhavesufficientelectricalorenginevacuumpowertoprovidecontinuoussuctionof300mmHgwithoutcompromisingtheoperationalperformanceoftheCCTV.
3.4.7 ThedesignoftheRWandFWCCTVelectricalsystemsshallisolatemedical
equipmentanddevicesandcommunicationssystemstopreventinterferencebetweenthevehicleelectricaloravionicsystemsandpatientsupportsystems.
3.5 Other
3.5.1 TheCCTVmusthavefixedoxygencylindersorliquidoxygensystemswithcapacityforthelongesttransportpossiblefortheCCTAwithatleast15LPMflowcapacityandtoincludea30-minutereservecapacity.
3.5.2 Atleastoneoxygenoutletwillbea50-psisource.
3.5.3 Therewillbeaminimumoftwooxygenoutletsandtwosuction/vacuumpumps.
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3.5.4 TheCCTVmusthavefixedorportablemedicalair,compressedgas,orotherinhaledgaseswithcapacityforexpectedtransportsandreserves.Portablesystemsmustbeadequatelysecuredconsistentwithregulatoryrequirements.
3.5.5 Fixedandsecuredsharpscontainersshouldbeavailableinthepatientcompartment.
3.5.6 Afireextinguisherwillbeavailableinpatientcompartmentandaccessibletoclinicalpersonnelwithouttheneedtobecomeunrestrained.
3.5.7 Carryonspecializedmedicalequipmentsuchastransportisolettes,IABP,cardiacassistdevices,andECMOmusthaveindividualsecurefasteningsystemsandarenottobestrappedintoseatsorpatientstretcherwithseatbelts.
3.5.8 PediatricrestraintsystemsareavailablewithabilitytosecuretostretcherorairframeconsistentwithregulatoryrequirementsifpediatricsiswithintheCCTA’sscopeofpractice.
3.5.9 Communicationssystemstoallowmedicalcommunicationsthroughouttheentiretransportwithoutcompromisingvehiclerequiredcommunications.
3.5.10 Tominimizetheneedforrefuelingwithapatientonboard,theCCTVfuelcapacityshallmeetthe95thpercentiletransportprofileoftheCCTA’sservicearea.SelectionofahelicopterorfixedwingCCTVshouldincludethefollowingconsiderations:! Appropriatepowerforallenvironmentalconditionstoavoidtheneedto
decreasefuelcapacityorclinicalpersonnelinhightemperature,humidity,oraltitudeconditionsconsistentwiththeCCTAservicearea
! Minimizedtimefortransport! Limitednumberofgroundstops! Sufficientworkroomandenvironmentalconditionsnecessarytopositively
affectpatientcare! Sufficientworkroomandcapacityforadditionalmedicalpersonnelasneeded
byspecificpatientsandfortrainingpurposes! FixedwingCCTVsshouldhaveminimumthree-hourflighttimeendurancein
conditionsexpectedforservicearea.
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Appendix4:CriticalCareTransportDocumentationStandards
BackgroundCriticalCareTransport(CCT)Documentation:Itisthroughdocumentationthatpatientassessments,treatmentsandresponsesduringstabilizationandtransportarerecordedandmadeavailabletosubsequentcareproviderstoassurecontinuityofcareandthelongitudinalabilitytomeasureoutcomesandsystemeffectiveness.Accuratedocumentationisessentialtoimprovingprocessandperformancemeasures.Conversely,missingand/orinaccurateinformationexchangeduringatransitionofcarebetweenproviderscontinuestopresentsignificantrisktopatients.Accuratedocumentationandprompttransmittalofthepatientcarerecordtosubsequentcliniciansarticulatesthecriticalcarelevelofservice/interventionandmostimportantlyprotectsthepatientfromtheriskofiatrogenicadverseeventsinthetransitionofcare.TheCCTAmusthaveasystemizedandthoroughdocumentationprocesswithwrittenpolicyforclinicaldocumentationstandardsandappropriatehandlingofprotectedhealthinformation(PHI).Documentstandardsshouldinclude,butarenotlimitedtothefollowing:
DocumentationStandards4.
4.1 GeneralRequirements
4.1.1 Thepatientcarerecord(PCR)isspecifictoasinglepatientandispresentedinanorganizedrecordconsistentwiththechronologyofcare(preferablyanelectronicPCR).Thefinalreportwillcontainasingletreatmentsummarythathasvitalsignsandmedicalcrewinterventionsinchronologicalorder.
4.1.2 AllPCRsarehandledinamannerconsistentwithstateandnationalprivacystatues.AlltransportagencystaffwhocreateorhaveaccesstoPCRsreceivetrainingregardingconfidentiality.
4.1.3 PatientnameandauniqueidentifieraredocumentedoneachpageofthePCR.
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4.1.4 Contentisstandardized,legible,andifabbreviationsareallowed,anapprovedabbreviationlistisavailable.Nomedicationsshouldbeabbreviated.
4.1.5 UpontransferofcarefromtheCCTteamtothereceivingfacility’scareprovider(s),
theCCTproviderwillprovideawrittendocumentthatincludes:
! Patientname,ageandweight(ifknown)! Onsetofinjuryorsymptomsthatpromptedtransport! Fullnameofreferringindividual,agencyorproviderandphysical
locationoftransportinitiation! Significantphysicalassessmentfindings! Summaryofprocedures,treatments,medicationsandfluidsadministered
duringthetransportaswellaspatientresponseandperiodicvitalsigns
4.2 Fulldocumentationofcareshouldoccurwithin24hoursofthetransport.
4.2.1 AllentriesandupdatestothePCRmustbedatedandsigned.
4.2.2 AllcareprovidersontransportmustbenotedinthePCRbyfullnameandprofessionaldiscipline.
4.3 Documentationmustincludetimelineoftransportrelatedactivities:
! TimerequestreceivedbytheCCTA! Timeweather/roadconditions(is)arecheckedasapplicable! TimerequestisacceptedbyCCTteam! Timeenroute! Timeofarrivalatreferringlocationorscene! Timeassessmentandcareinitiated! Timedepartingreferringlocationorscene! Timearrivingatreceivingfacilityordestination! Timeofhandoffofcareatthereceivingfacility! Iffamilymembersaccompanypatientasaridealong,theirfullnameandpresencemustbe
documentedinthePCRordispatchrecord.! Fullnameoftherequestingindividual,agency,orproviderandthephysicallocationofthe
referringfacility/scenemustbedocumentedinthePCR.! Fullnameofthereceivingfacility,provider,andthedepartment/physicallocationof
patientcarehandoffistobedocumentedinthePCR.! Unexpecteddelaysintimeintervalsortheprovisionofcaremustbedocumentedinthe
PCR.
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4.4 ClinicalRequirements
4.4.1 HistoryofPresentIllness(HPI)mustdescribethechronologicalprocessofthepatient’sillnessorinjury,includingenoughdetailtopresentaclinicalpictureofthepatientpriortothetransitionofcaretotheCCTcrewsfortransport.
4.4.2 TheHPImustalsoincludethereasonforcriticalcaretransportandtheprovidersinvolvedinthedecision-makingprocessregardingbothdestinationandmodeoftransport.
4.4.3 Aclinicalimpression(working/fielddiagnosis)isdocumented.
4.4.4 Thepatient’spastmedical,surgical,andfamilyhistorysignificanttothecurrentclinicalimpressionaretobedocumentedinthePCR.Anobstetricalhistoryshouldbeincludedonallwomenwhoareorwererecentlypregnant.
4.4.5 CurrentpatientmedicationsandanyknownallergiesaretobedocumentedinthePCRwhenknown.
4.4.6 ChiefComplaint–Patientcomplaintandpertinentpositiveandnegativesignsandsymptomssupportingthecomplaintaretobedocumented.
4.4.7 Documentationoftreatmentanddiagnosticspriortoarrival(PTA)toinclude:! Summaryofclinicallypertinentprocedures,treatments,medications(doseand
timeifknown)andfluid/bloodproductinputandoutput(amount,typeandtimeifknown)PTAofthetransportteam.
! Descriptionofanyindwellingdevices(type,size,depth,location,placementverification,placementdate,securityandfunctionasappropriatetothedevice)
! Laboratory,radiologicandotherdiagnosticfindingssignificanttopatient’sclinicalcondition
4.4.8 Initialassessmentsandvitalsigns
topotentiallybedocumentedinclude(aprioritized,targetedassessmentandphysicalexamisanticipatedformostCCTpatients):! Ageappropriateassessments
ofheartrate,respiratoryrateandworkofbreathing,bloodpressure,temperature,pulse
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oximetryreading,endtidalCO2(ifindicated),capillaryrefilltime,painlevel,glucose(ifindicated),andGlasgowComaScale
! Forhigh-riskobstetricalpatients(HROB),additionalassessmentsincludecontractionfrequency,durationandintensity,uterinerestingtone,fundalheight,fetalheartrateandfetalmovement.IftheCCTA’sguidelinesallowforcervicaldilatationandeffacement,thesewouldalsobedocumented.
! PhysicalExamtoincludebothpertinentpositiveandnegativefindingsaretobedocumentedusingastandardformatistobeincludedinthePCR.Ifaspecificexamisdeferred,areasonfordeferralistobedocumented.
! GeneralAssessment-aninitialimpressionofpatient’sphysicalpresentationandthemostsignificantphysicalordiagnosticfindings.
! HEENT–visualandtactileassessmentofthecranium,eyes,ears,noseandthroat! Chest–visual,tactileandauscultoryassessmentofchesttoincludeheartand
breathsounds! Abdomen–visualandtactileassessmentofabdomen,dividedintofourquadrants
ifindicated! Back-visualandtactileassessmentofbackincludingcervical,thoracicandlumbar
portionsofthespine! Pelvis/GI/GU-visualandtactileassessmentofthepelvicandgenitalarea,as
necessaryandpertinenttoclinicalconditionorinjuries! Skin–generalassessmentofskin.Ifconditioninvolvesburns,documentationof
percentageofbodysurfaceareaanddegreeistobeincluded.! Extremities–visualandtactileassessmentoftheextremities,upperandlower,left
andright,includingcirculation,motorfunction,sensationandrangeofmotionwhenindicatedbyclinicalcondition
4.4.9 Continuingassessmentsandvitalsignsaretobedocumentedatleastevery15
minutesormorefrequentlyifindicatedbypatientcondition.
4.4.10 ChronologicalPCRentriesthatdescribetheprocessandtimingofassessments,treatments,stabilization,andtransportactivitiesaretobeincludedinthePCR.
4.4.11 Patientconditionathandoffofcaretoincludegeneralassessmentandvitalsigns.
4.5 DocumentationSpecifictoDiagnosticandTherapeuticProcedures
4.5.1 ForallproceduresperformedbymembersoftheCCTteam,documentationinthePCRmustincludeclinicalindications,time,specificprovider,outcome(successfulorunsuccessful),specificlocation,patienttoleranceandresponsetoprocedure,andanycomplications.
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4.5.2 Additionalspecific
documentationincludesbutisnotlimitedto:! Oxygenadministration–
methodanddevice,rateofflow,FiO2asappropriate
! Peripheralvenous/interosseousaccess-size,type,site,skinpreparation,securityandfunction
! Centralvenousandarterialaccess–size,type,location,skinpreparation,security,functionandifmonitored
! Fluidsadministeredincludinginputandoutputamounts! Bloodproductadministration–patientbloodtypeandRhfactor(ifknown),product
(e.g.,PRBCs,plasma,platelets,etc.),productunitABOtypeandRhfactor,expirationdate,andproductunitnumber,infusionrate,amountadministered(canbedocumentedintransportI&O),infusionsite,heartandrespiratoryrateandpatienttemperaturepriortoadministrationandat5,10and20minutesafterproductinitiation,timeinfusioncomplete,documentationofanytransfusionreactionandcrewresponse
! Medications–fullname,dose,route,time,rateofadministration,administrationsite,andeffectofmedicationincludinganyadversereaction
! Medicationdrips–fullname,concentration,basesolution,dose,rateofadministration,administrationsite,andeffectofmedicationincludinganyadversereactionandcrewresponsetoreaction
! Airwaymanagement–vitalsignsatonsetofprocedure,intendedmethod,documentationofpreparation,oralornasalplacement,blade(size/typeanddirectorvideolaryngoscope),useofstylet,useofendotrachealtubeintroducers(gumelasticbougie),tubesize,depthofinsertion,confirmationmethods,methodofsecuring,lowestoxygensaturationduringprocedure,vitalsignsat5,10and15minutesfollowingprocedure,endotrachealtubecuffpressure,verificationofplacementincludingfirstEtCO2andreverificationaftereachpatientmovement(i.e.,tostretcher,intotransportvehicle,outofvehicle,offstretcher)
! Invasivemechanicalventilation–mode,sensitivity,tidalvolume,inspiratorypressure,rate,FiO2,inspiratorytime,pressuresupport,PEEP,peakinspiratorypressure,exhaledtidalvolume,plateaupressure,meanairwaypressure,alarmsettingsasappropriatetomodedelivered
! Non-invasivepositivepressureventilation–inspiratorypressure,expiratorypressure,FiO2,rate(ifapplicable),ramp,flowtermination,spontaneousexpiratorytidalvolumes
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! Labs–POCversuslabtesting,typeofsample,site,specificlaboratorymarker(s)(e.g.glucose,sodium,pH,pCO2,lactate,etc.),result,laboratoryunit(e.g.,mg/dl,mmol,etc.),andthenormalrangeforspecificmarker(s)testedperCollegeofAmericanPathologists(CAP)standards
! Needleandsurgicalthoracostomy–site,size,typeofdevice,skinpreparation,initialair/fluidoutput,placementtoHeimlichvalveorsuction,responsetointervention,andcomplications
! Pericardiocentesis–puncturesite,needle/cathetersizeandtype,skinpreparation,initialoutput,responsetointervention,andcomplications
! Escharotomy/Fasciotomy–site,descriptionofincisions,skinpreparation,patientresponse(e.g.,respirationstatus,distalpulsestatus)
! Cricothyroidotomy–airwaysizeandtype,skinpreparation,proceduremethodtype,patientresponsetointervention,andcomplicationsOG/NGtube–tubesizeandtype,depthofinsertion,methodofverifyingplacement,securement,initialandongoingoutput(maybedocumentedinI&O),suction(e.g.,capped,openortolowintermittent/continuoussuction),patientresponsetointervention,andcomplications
! Urinarycatheter–tubesize,sitepreparation,initialandongoingoutput(maybedocumentedinI&O),patientresponsetointervention,andcomplications
! Cardioversion–presentingrateandrhythm,ifsynchronized,energysetting,padlocation,resultingrhythm,andcomplications
! Defibrillation-presentingrateandrhythm,energysetting,padlocation,resultingrhythm,andcomplications
! CardiacPacing–presentingrateandrhythm,pacermode,rate,setenergy,pad/catheter/wirelocation,patientresponsetointervention(e.g.,electricalandmechanicalcapture)andcomplications.Fortransvenouspacingorepicardialwires:pacingmode,mAforpacing,mVforsensing,thresholds,sitestatus,andsecurement
! Administrationofspecialgases(nitricoxide,Helioxornitrousoxide)–initiationtime,methodofadministration,patientresponsetointervention,andcomplications
! Useoftraumadevices(tourniquets,occlusivedressings,pelvicsplints,immobilizationdevices,tractionsplints)–indication,typeandlocation,timeofapplication(alsodocumenteddirectlyontoanytourniquetplaced),patientresponsetointervention,andcomplications
! Useofothercardiacandrespiratoryassistdevices(intra-aorticballoonpump,leftventricularassistdevice,bi-ventricularassistdeviceorextracorporealmembraneoxygenation)-cannulationsite,conditionofdressings,clinicallypertinentsettingsspecifictodeviceanddistalperfusion
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Appendix5:CriticalCareTransport–“AlwaysEvents”and“NeverEvents”BackgroundACCTiscommittedtoassuringanaccountableandsafeairandgroundCriticalCareTransport(CCT)systemthatrecognizestheinterestsofpatientsasthefirstpriority.Reducingandeliminatingpreventableinjuryandfatalitiesisanecessaryandever-continuingobjectivewithinmedicine.TheInstituteofMedicine’s1999reportToErrisHumanireporthighlightedtheenormouschallengeoferrorinmedicineandtheneedtorelentlesslysearchforstrategiestoimprovepatientsafety.Asmedicinebecomesevermorecomplex—withever-greaterbenefit,thechanceforerrorincreases.Theriskoferrorisintroducedateachlayerofassessment,decision,andinterventionandincreasesthepossibilitythattheexpectedoutcome,animprovementinhealthstatus,isnotachieved.TheToErrisHumanreportestimated44,000to98,000prematuredeathsoccurredeachyearinU.S.hospitalsduetoiatrogeniccauses.iiFifteenyearslater,thereremainsalongroadtoasafersystem.Recentstudies,withbetterreporting,estimate210,000to440,000prematuredeathsoccurannuallyinU.S.hospitalsduetomedicalerror.iiiThisstaggeringfigureranksiatrogenicmedicalerrorasthethirdleadingcauseofdeathinthecountry.CMS’findingspointtowidevariationintwomainareas:qualityofmedicalcareandhospitalsafetypractices.RecentestimatesbyMedicareProviderAnalysisandReview(MedPAR),examiningtheaverageriskofadjustedin-hospitalmortality,indicatethatifallhospitalsperformedatthehighestlevel,asrankedbythisCMSperformancereviewprogram,anestimated235,378deathsand183,534adverseeventsresultinginpatientharmwouldhavebeenavoidedbetween2009and2011.ivEmergencymedicalcareischaracterizedbydifficultattributes:eventsareunscheduled,unpredictable,andoften-unplannedwithcaredeliveredinuncontrolledsettings.Criticalcaremedicineiscomplex,urgent,andresourceintensive,withroutineapplicationofhighconsequenceinterventionsbyhighly
iKohnL,CorriganJ,DonaldsonM,eds.ToErrorisHuman:BuildingaSaferHealthSystem.CommitteeonQualityofHealthcareinAmerica,InstituteofMedicine,NationalAcademyPress,WashingtonD.C.2000iiKohnL,CorriganJ,DonaldsonM,eds.ToErrorisHuman:BuildingaSaferHealthSystem.CommitteeonQualityofHealthcareinAmerica,InstituteofMedicine,NationalAcademyPress,WashingtonD.C.2000iiiJames,JT,ANewEvidence-basedEstimateofPatientHarmsAssociatedwithHospitalCare,JournalofPatientSafety:Sept2013;Vol.9,Issue3ivAmericanHospitalQualityOutcomes2013:HealthgradesReporttotheNation,November2013
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trainedprofessionalsroutinelypracticingunderdemandingconditions.Thebenefitsofmoderncriticalcaremedicineareunparalleled,andyetthesebenefitscomewithpotentialrisksandcosts.Becausetime-emergentandcriticalcareinterventionsoccuratthehighestlevelsofconsequenceinmedicalpractice,extraordinaryattentiontodetailinmaintainingthehigheststandardsofqualityandpatientsafetyiscrucial.Criticalcareresponseandtransportmedicinecreatesauniquesynergybetweentransportationandmedicine.Therapiddeploymentofexpertclinicianswithskills,knowledge,experience,andequipmentcanliterallybringtertiarycaretoapatient’sside,allowingimmediatestabilizationofcriticalinjuryorillness–whetheronthesideofaroadorinacommunitycriticalaccesshospitalfollowedbydirecttransporttoaspecialtycarecenter.Whileevidencedemonstratesthebenefitofthisuniquetetheringoftwodistincttechnologies,aswithallbenefitsinmedicine,theinterfacebetweenthetwosystemsiscomplex.Thecomplexityitselfincreasesopportunityforerror.Similarly,themedicaltransportenvironment,whetheronthegroundorintheair,isamongtheuniqueandcomplexofmedicalarenas.ThisisespeciallytrueofhelicopterEMSoperationswherelimitedplanningtime,criticalclinicalneed,24-houroperationsandmarginalweatherconditionscombinedwithlimitedweatherreporting,andanoverallhazardous,unstructuredenvironmentconvergeinonesetting.Thisscenariorequiresextraordinaryattentiontodetailinmaintaininghighqualityandsafeoperations.TheNationalTransportationSafetyBoard(NTSB),theFederalAviationAdministration(FAA),andstateregulatoryoversightagenciesallhavehighlightedtheneedtoimprovesafetywithinthemedicaltransportenvironment.Assuringpatientsafetyisthefirstandforemosttaskofmedicalproviders.Leadingmedicalproviderorganizationsandphysicianshaveestablishedaframeworkforeventsthatshouldalwaysoccurandsimultaneously,aframeworkofeventsthatshouldneveroccurduringpatientcare.Togethertheseimprovetheoverallsafetyofpatientsduringmedicaltransportation.Thefollowingsuggestionsshouldbeconsideredaninitialstepinthedevelopmentof“alwaysevents”and“neverevents”frameworksforcriticalcaretransportagencies.Itmaybehelpfultoconceptualizethemastwosidesofacoinindevelopingsystemsandmeasurementtoolstoimprovepatientsafety.TheworkgrouphasusedtheNationalQualityForum(NQF)formattodescribetheseevents.ThePickerInstituteforPatientandFamilyCenteredCare,andmorerecentlytheInstituteforHealthcareImprovement(IHI),developedtheconceptof“AlwaysEvents”which“refertoaspectsofthepatientexperiencethataresoimportanttopatientsandfamiliesthathealthcareprovidersmustperformthemconsistentlyforeverypatient,everytime.”vAlwayseventswithinthecontextofcriticalcaretransportcanbethoughtofaspositivebehaviorsandsafetypracticesinthemanagementofcriticallyillandinjuredpatients.
vPickerInstitute.AlwaysEvents:CreatinganOptimalPatientExperience.Oct.2011AvailablethroughtheInstituteforHealthcareImprovement
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“NeverEvents”werefirstintroducedbyDr.KenKizer,theformerCEOoftheNQF,tobetterunderstandandhighlighttheneedtoaddressparticularlyegregiousmedicalerrors,suchasawrongsitesurgery.TheNQFhasexpandedthelistovertimetoidentifyunambiguousadversemedicaleventsthatareclearlyidentifiable,measureable,andpreventable.NevereventsarealsooftendefinedasSeriousReportableEvents(SRE)bystateregulators,theJointCommission,andtheAgencyforHealthCareResearchandQuality.TheNQFandtheCentersforMedicareandMedicaid(CMS)publishedalistof“neverevents”measures.Thetwolistsoverlaponsomemeasures,butwhiletheNQFisfocusedonthepreventionofunambiguouspreventableharm,CMSisfocusedonpreventableoccurrencesdeemednon-reimbursablebyMedicaresuchasserioushospitalacquiredinfections.ThispaperdoesnotspeaktoMedicarereimbursement.Nevereventswithinthecontextofcriticalcaretransportincludenotonlyactualdocumentedharm,death,ordisabilitytopatientsincurredwhileunderthecareatransportagencybutalsoincludepreventableadverseoccurrenceswheretheriskofharmoractualharmtoapatientwasgreaterthananypossibleclinicallybeneficialoutcomeforthepatient.CCTNeverEventsshouldbeevaluatedbystateregulatorsandtheCommissionfortheAccreditationofMedicalTransportSystems(CAMTS)forinclusioninsentinelorSREregistries.
ACCTencouragescriticalcaretransportagencies(CCTAs)toadoptthesemeasuresandcontinuethedialogueforadditionalevidencedbasedmeasures.CCTAsneedtodevelopinternalregistryreportingsystemsforbothnearmissandadverseeventsandareencouragedtodeveloporworkwithpatientsafetyorganizations,whichcanaggregateandsharede-identifieddataforwiderhealthcarecommunitylearning.
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ALWAYSEVENTS PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance1. CareCoordinationand
TransitionIncludes:a) CCTteamassuranceof
obtainingwrittenrecordsvs.verbalreportpriortointerfacilitytransport
b) DevelopingwrittenSBARtypecommunicationsforreceivingclinicians
Thiseventisintendedtocapture:! Processesassurethatallnecessary
documentationrelatedtothecareofapatientisobtainedpriortotransportandtransmittedtoreceivingclinicians
Caretransitionhasbeendemonstratedtobeoneoftheleadingrisksforpatientsduetolossormissedcrucialhealthinformation,recordofinterventions,diagnostics,andresultsinatimelymanner.CCTAsmustdevelopreliableprocessestoassurethatcarecoordinationandtransitionisseamlessandthorough.
2. Physicalcomfort,painrelief,emotionalsupport,andalleviationoffearandanxiety
Includes:a) Administrationof
adequateanalgesiaincludingbasicpainrelieftechniquessuchaspositioningandgentlehandling
b) Processestoimprovetheexperienceofcare
c) Assuranceofenvironment(visual,temperature,light,humidity,soundprotections,etc.)thatprotectspatientfromsecondaryexposurestophysiologicoremotionalstressors
Thiseventisintendedtocapture:! Proceduresforalleviatingpatient
painandfearbecausetheonsetofasuddencriticalillnessorinjuryisoftenbewilderingandfrightening.Uncontrolledpainandstressreactionsincreasemorbidity.
Inthefastpaceofhightechhealthcareitispossibletoinadvertentlylose“hightouch.”CCTAsmustdeveloppromptprocessestomanagepainanddiscomfortadequately,includingholdingapatient’shands,speakingsoftly,movingabitmoreslowly,andintroducingcalmtochaos.Developingacultureandmeasurablegoalsofsupportingpatientsisasimportantasthroughput.Sometimes“fastisslowandslowisfast.”
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ALWAYSEVENTS PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance3. Preventinvasivelineor
woundinfections.Includes:a) Placementofany
invasiveintravenouslineorinvasivedevicesuchasendotrachealtubesorurinarycatheters
b) Managementofindwellingcathetersordevicesduringtransport
Excludes:a) Documentedprevious
communityhospitalacquiredinfection
Thiseventisintendedtocapture:! Processesandprocedurestoassure
withintherealitiesoftheCCTenvironmentthemoststerileconditionsfortheplacementofanyindwellingcatheteranddevice.
Althoughtruesteriletechniqueisnearlyimpossibleinthetransportenvironment,CCTAsmustdeveloptightlymanagedprocessesandcarenormstominimizetheriskofiatrogenicinfectionManagementduringCCTmustprotectindwellingcathetersanddevices.Whileitisnearlyimpossibletodocumenttherelationshipbetweenpoortechniqueinresuscitativeandtransportcareofsubsequentdocumentedhospitalacquiredinfection,thetimecriticalityandlackofabilitytoassureasterilefieldforinvasivecarepresentsenormousrisktopatients.CCTAsmustdevelopprocessesanddemonstratecommitmenttoculturalnormstomakesureofhandcleaning,adequateskinpreparation,andpreventionofinfectionisattheleadingedgeofcare.Preventionofdownstreaminfectionisasormoreimportantthansuccessinplacementofanindwellingdevice.
4. PreventVentilatorAcquiredPneumonia(VAP)
Includes:a) Managementof
ventilatedpatientsduringtransporttomaintaincleanlinessofairwayandpositioningofpatienttopreventVAPthroughstandardhospitalpractice
Excludes:a) Transportofpreviously
documentedVAP
Thiseventisintendedtocapture:! Processestoassureinfection
controlstrategiesforthecareofintubatedventilatedpatients.
Wheneverpossible,ventilatedpatientsshouldbetransportedina30-degreeheadraisedpositiontominimizeriskofventilator-associatedpneumonia.
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ALWAYSEVENTS CAREMANAGEMENTEvent AdditionalSpecifications ImplementationGuidance1. Respectforpatients’
values,preferences,andexpressedneeds.
Includes:a) Respectforpatientand
familiesreligiousandculturevalues
b) Involvementoffamilyandfriends
Excludes:a) Patientandfamily
decisionsthatimpactsafety(e.g.parentaccompanyingchildduringtransport).Theparentmaynotbeabletorideinthepatientcarecompartmentormaynotbeabletoaccompanythetransportifpresenceincreasessafetyrisk.
Thiseventisintendedtocapture:! Processestoinvolvepatientsand
familiesinthecareofacriticallyillandinjuredpatient.Byandlargepatientsandfamiliesinthemidstofanemergencydonotgetmanychoicesinhowcareisgoingtobedelivered
Cliniciansarefacedwithmakingtimesensitivedecisionswiththefocusonimmediatepatientcareneedsratherthanthefullexperienceofcare.
Caregiversneedtodevelopprocessestoimprovecommunicationsandtrust;tomakesuretheyhaveclearunderstandingofpatients’religiousbeliefsandculturevalues.Thisisespeciallyimportantinthecareofpatientswhospeakadifferentprimarylanguagethanthecaregivers,orwho,throughimmigrationorrefugeestatus,comefromverydifferentculturalnormsorwhohaveacommunicationbarriersuchaslimitedvisualacuity,hearing,previouslossoffunctioninalimb.
Asanexample,manytransportagencieshavepoliciesthatprohibitaparent,child,orfamilymembertoaccompanyapatientduringtransport.CCTAsmustdeveloppoliciesandprocessestoallowriskmanagedexceptionsoraplantomakesurethefamilymemberissupportedtotraveltoadistantreceivinghospital.
2. Preventpressureulcers Includes:a) Patientacquiredpressure
ulcersfromtransportonbackboardsorprolongedtransportonhardstretchersinnon-moving,generallysupinepositions
Excludes:a) Patientswithknown
unstableorthopedic/neurologicinjury
b) Previouslyacquiredpressureulcers
Thiseventisintendedtocapture:! Processestoassurethatpatientsare
protectedfromprolongedsupineorsinglepositionimmobilizationonhardsurfaces
CCTAsshoulddeveloppoliciesandprotocolstominimizetransportofpatientsonbackboards.Currentevidencedemonstratesincreasedriskofharmforpatientsthatareimmobilizedforevenrelativelyshortperiodsoftime(30minutes)versusanybenefitfromtheimmobilizationforpendingclearanceofasuspectedspineinjury.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)CAREMANAGEMENTEvent AdditionalSpecifications ImplementationGuidance1. Patientdeathordisability
causedbylossofsupplyofoxygenoranyincidentinwhichalinedesignatedforoxygenorothergastobedeliveredtothepatientcontainsthewronggasoriscontaminatedbytoxicsubstances.
Includes:a) Depletionofvehicle
oxygensuppliesb) Mechanicalmalfunctionof
oxygensupplysystemc) Inability of transport
crews to operate theoxygensystem
d) Inabilitytodeliveroxygenduetooxygendeliverysystemincompatibilitywithvehicleports
Excludes:a) Unanticipatedaddition
ofapatientduetounforeseencircumstances(e.g.,familymemberaccompanyingpatientontransportbecomesill)
b) Oxygensupplyanddeliverywithinareferringorreceivingfacility
c) Unavoidableoxygendepletionviaportabletanksatanout-of-hospitalscenewhereextendedscenetimeisnecessaryduetoenvironment/safety/logisticalneeds
Thiseventisintendedtocapture:! Occurrencesofunintendeddepletion
ornon-deliveryofoxygenconcentrationsnecessarytomaintainadequatepatientoxygenationduringthepatienttransportphaseofamedicaltransportmission
Propertransportplanningshouldbecompletedpriortoanypatienttransport.Thisplanningshouldincludepotentialoxygenneedsforanypatienttransportorpatientconditionchangeduringtransport.Ifmultiplepatienttransportsarewithinthemissionprofile,adequatesystemsandsuppliesmustbetakenintoconsideration.Replenishmentofoxygenatdesignatedfacilitiesmaybeplannedandrequiredaspartofthemission.Dailyshiftchecksandpreventativemaintenanceonoxygendeliverysystemsshouldassurethatoxygendepletionornon-deliverydoesnotoccurduetodevicemalfunction.Educationalrequirementsshouldassurethatallcrewmembersarecompetenttocompleteshiftchecks,operate,andappropriatelytroubleshootequipment.ACCTAmusthaveassurancethatvendorsourcesofgassupplyhaveeffectivesafetycomplianceprograms.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)CAREMANAGEMENTEvent AdditionalSpecifications ImplementationGuidance2. Deliveryofababyduring
thetransportlegofapatientencounter.
Includes:a) Accuratepatient
assessmentandmanagementofHROBandpre-termlabortoassuredeliveryinmostcontrolledcircumstance
Excludes:a) Acceptedresidualriskof
deliveryduringtransportafterconsultationwithattendingorconsultingOB/Perinatologists
Thiseventisintendedtocapture:! Occurrencesofunplanneddeliveryof
aninfantinamovingvehicleCCTAsmusthaveriskmatrixandconsultingcapabilitytoassessandmanageHROBtopreventinadvertentdeliveryduringtransportunlessknownabsolutepost-deliveryrisktoinfantoutweighsriskofdeliveryinmovingvehicle,especiallyaircraft.Ingeneral,itispreferabletodeliverachildinthemoststableenvironmentorreferringcommunityhospitalwithtransportteampresentforsupportandsecondaryNICUretrievalteam/equipmentasneededforsubsequentnewborntransport.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance1. Patientorpassengerdeath
orseriousdisabilitycausedbytheCCTAvehiclefailureorcrash
Includes:a) Vehiclecrashesor
failuresduetomechanicalreasonsorhumanerror
Excludes:a) Actsofterrorismby
entitiesoutsideoftheCCTA,patient,orpassengersscreenedbytheCCTA
b) ActsofGod(e.g.birdstrikes)
Thiseventisintendedtocapture:! Occurrenceswhereavehiclefailureor
crashcausedpatientorpassengerdeathordisabilitythroughdirectinjuryorthroughthedelayindeliverytodefinitivecare
TheprimarygoalofaCCTAistoprovidetheappropriatelevelofmedicalcarewhiledeliveringthepatientsafelytotheintendeddestination.Ifthevehiclefailsorcrashesduetomechanicalreasonsorhumanerror,theCCTAwasunabletoprovidetheintendedserviceoritprovidedadisservicetothepatient.
TheCCTAmustassurequalitymaintenanceandcompletedocumentationofmaintenanceofallvehiclesutilizedbypatients,passengers,andcrewmembers.
TheCCTAmustassurequalitymaintenanceandcompletedocumentationofmaintenanceofallvehiclesutilizedbypatients,passengers,andcrewmembers.
TheCCTAmustassurequalityinitialandrecurrentvehicleoperationandsafetyeducationandcompletedocumentationofthiseducationforcrewmemberstransportingpatientsorpassengers.
TheCCTAmustcreate,educate,andutilizepostincident/accidentprocessestorespondtovehiclefailuresorcrashes.Thepoliciesprimarilyshouldaddresspatientandcrewsafetyneedsandprovideoptionsfortransportingthepatientandanyotherinjuredpassengerstoappropriatemedicalcarewithminimaldelay.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance2. Patientdeathorserious
disabilitycausedbytransporttoanunintendeddestination
Includes:a) Unintendedpatient
transporttodestinationsthroughhumanerror
Excludes:a) Specificdestinations
withinareceivingfacility(e.g.emergencydepartment,catheterizationlab,andcriticalcareunit)
b) Diversionsduetohospital/physicianorders,patientcondition,weather,oranyothersafetyissuenecessitatingadiversionfromtheplanneddestination
Thiseventisintendedtocapture:! Occurrenceswherethe
transportingprogramunintentionallytransportsapatienttoanunintendeddestinationthroughhumanerrorincommunication,navigation,orothermeans
TheprimarygoaltheCCTAistoprovidetheappropriatelevelofmedicalcarewhiledeliveringthepatientsafelytotheintendeddestination.Appropriateandexpedientmedicalcareatthedestinationfacilitycanhaveasignificanteffectonpatientoutcomes.Unintendedtransporttootherfacilitiesmaycausedelaystodefinitivecareandlesserordeficientmedicalcapabilitiesmaycreateanegativepatientoutcome.
3. Patientdeathorseriousdisabilitycausedbydroppingapatientorallowingapatienttofallduringthetransportprocess
Includes:a) Patientfallswhileunder
thecareoftransportcrews,droppingofpatientsbeingcarriedortransportbyadevice(stairchair,wheelchair,Stokesbasket,stretcher,backboard,loadingramps,harnesses,oranyotherapproved/unapproveddevice)
Thiseventisintendedtocapture:! Occurrenceswhereapatient
receivesunintendedtraumadirectlyresultingfromthetransportprocess
TheprimarygoaloftheCCTAistoprovidetheappropriatelevelofmedicalcarewhiledeliveringthepatientsafelytotheintendeddestination.ThoughCCTAprovidersofferpatientcareandtransportinavarietyofchallengingenvironments,itisexpectedCCTA’swillhavetheresources,equipment,andknowledgetooperateinthoseenvironmentsandbeabletotransportpatientswithoutfalls,drops,orotherunintendedinjury.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance4. Deathorseriousdisability
toEMSpersonnelorpatientcausedbyfailureoftheCCTAtocommunicateaninitialestimatedtimeofarrivaltothesceneorsubsequentdelaysofthetransportresponse
Includes:a) Communicationof
theinitialestimatedtimeofarrival(ETA)
b) Communicationofallexpectedorunexpecteddelaysinresponse
Excludes:a) Documented
communicationdelaysorerrorsbytherequestingEMSagencyorhealthcarefacility
Thiseventisintendedtocapture:! Occurrenceswheredelaysinpatient
transportorscenehazardsoccurduetothelackofcommunicatingresponsedelaysbytheCCTA
CCTAresourcesarerequestedtoprovidepatienttransporttodefinitivecareforinjuriesorillness.Responsedelaysmayimpactoperational/safetyissuesonsceneaswellaspatienttreatmentplans.ItisimperativethatCCTAproviderscommunicateanddocumenttheinitialestimatedtimeofarrivalofthemedicalresourceonthesceneoftherequest.Ifdelaysareexpectedoroccurunexpectedly,CCTAmustcommunicatethesedelaysassoonaspossibletotherequestingagencies.CCTAdelayssuchas“stackingcalls”shouldnotoccur.
Definition:Delayissubjecttoavarietyoffactorssuchasresponsemode,distance,andpatientcondition.Forthispurposedelayisdefinedasatimeframethatwillhaveanegativeimpactonscenesafetyoperationsorpatientcare.ItisessentialthattheCCTAconsiderthesefactorsandcommunicateanydelaythatmayimpactsafetyorcare.
5. Transportofapatientwithanundetectedesophagealintubation,patientdeathordisabilitycausedbylossofoxygen/hypoxia
Includes:a) Unrecognizedmissed
placementofanendotrachealtube
b) Unrecognizeddislodgementofanendotrachealtube
Thiseventisintendedtocapture:! Initialandrecurrentprocessesand
documentationsystemsforCCTAs;providerdirectobservation;physicalexam,andcontinuouswaveformend-tidalCO2monitoringtopreventundetectedmissedintubation
CCTAsmusthaveprocessesanddocumentationsystemstoverifycontinuedpropertubepositionduringtransportateveryphysicalmovementofpatientalongwithtimedobservations.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance6. Arrivalatthewrong
sendinglocationforeitherasceneresponseorinterfacilitytransport
Includes:a) Missedorfaulty
dispatchinformationgatheringresultingindelaysincareandtransport
Excludes:a) Documentedlocation
errorsbyrequestingagencies(e.g.,referringproviderprovidedwrongcoordinatesoraddress)
Thiseventisintendedtocapture:! Accuracyindispatchincluding
redundantsystemstocheckcoordinates;developknownlandingzones(LZ)/rendezvouspoints,andhospitalnames
CCTAsmusthaveprocessesandcrosscheckstoassureclearidentifiersandcoordinatesareprovidedtopilots/driverstoassurethattransportunitsarriveatthecorrectLZ/rendezvouspointorhospitalespeciallyincommunitieswithmultiplehospitalsorLZs.
7. Patientdeathorseriousdisabilitycausedorassociatedwithhypoglycemia,theonsetofwhichoccursduringtransport
Includes:a) Failuretotestor
documenthypoglycemiaimmediatelypriororduringtransport
b) Failuretocorrecthypoglycemiaduringtransport
Excludes:a) Continuedhypoglycemia
despiteintervention
Thiseventisintendedtocapture:Inadvertentandmissedrecognition,testing,anddocumentationofhypoglycemiaduringtransport
Neonatesandpediatricpatientsduetohighmetabolicdemandareparticularlyatriskforpooroutcomessecondarytomissedhypoglycemia.
8. Knowinglycausingpatientdeathordisabilityassociatedwithamedicationerror
Includeserrors:a) Wrongmedicationb) Wrongdosec) Wrongpatientd) Wrongtiminge) Wrongratef) Wrongpreparationg) Wrongrouteof
administrationh) Deliveryofpressorby
meansotherthaninfusionpump.
i) Administrationofknownorpotentiallyknownadulteratedorcontaminatedmedication
Excludes:a) Administrationof
medicationinwhichadulteration,mislabeledconcentration,orcontaminationwasunknowablebycaregiver.
Thiseventisintendedtocapture:! Occurrencesofpreventable
medicationerrorsCCTAsmusthavesystemsandculturalnormsinplacetopreventknownrecurrentcommonmedicationerrors.
CCTAsmusthavesystemstoaccuratelycalculatedosinganddeliverinfusionmedications.
CCTAsshouldhavesystemsandculturalnormstodocumentcrosscheckingbysecondcaregiverorothersystempriortoadministration.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance9. Knowinglycausingapatient
deathordisabilityassociatedwithhemolyticreactionduetotheadministrationofABO/HLA-incompatiblebloodorbloodproducts
Includes:a) Failuretoaccurately
identifypatientandbloodproductcompatibilitypriortoadministration
b) Failuretoquicklyrecognizeandinterveneinpatientwithsuspectedoridentifiedhemolyticreaction
c) Administrationofbloodthathasexceededsafestoragetemperatures
Thiseventisintendedtocapture:! Occurrencesinwhichprovidersdo
notfollowandordocumentstandardproceduresinadministrationofbloodproducts
CCTAsmusthaveprocessesanddocumentationsystemstomonitorsafetyofbloodproductstorage,compatibility,andknownpatientincompatibilitywithbloodproducts.
IncreasingnumbersofCCTAsarestockingbloodproductsfortransport.Carefulmonitoringofon-siteandtransportstoragesystemsisessentialforpatientsafety.
10. Knowinglycausedeathorseriousdisabilityassociatedwiththeuseofcontaminatedorinoperabledevices,useofdeviceforpurposeotherthanapproved,contaminateddrugs,orbiologics
Includes:a) Useofadevice,
instrument,ormedicationfornonFDAapprovedpurpose
b) Knownorpoorprocesscontrolleadingtouseofcontaminateddeviceormedication
Excludes:a) Adversepatient
occurrenceoroutcomeduetoinadvertentuseofunknowablecontaminatedorinoperabledevice.
b) Adversepatientoccurrenceoroutcomeduetoinadvertentuseofunknowablecontaminatedmedicationorbiologic
Thiseventisintendedtocapture:! Occurrencesofpatientharmdueto
misapplicationorfailuretohavesysteminplacetoassuresafetyofdevices,medications,andbiologics
CCTAsmusthaveprocessesandsystemsinplacetoassuresterilizationofequipmentifnon-singlepatientuse,andsystemstopreventinadvertentorknownuseofadeviceormedicationfornon-prescribedorapprovedusewithoutcarefulanddocumentedmedicaloversight.CCTAsmustprovideassuranceofpurchaseandstoragesystemstomaintainmedicationsanddevicesinaccordancewithmanufacturers'specificationsincludingtemperature,humidity,light,controlsandpackagingsterility,asapplicable.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance11. Patientdeathorserious
disabilitycausedbyimpairmentofmedicalprovider
Includes:a) Workingunderthe
influenceofintoxicatingmedications,drugs,oralcohol
b) Workingundertheinfluenceofaprescribedmedicationwithoutsupervisionbyagencymedicaldirectorandpersonalprimarycarephysician
c) Workingundertheinfluenceofanover-the-counter(OTC)medicationwithknownsideeffectsthatmightimpairprovider,i.e.,Benadrylcausingdrowsiness
d) Workinginafatiguestatethatimpairsjudgmentorcoordination
Thiseventisintendedtocapture:! Occurrencesinwhichanimpaired
providerisallowedorundertakespatientcare
CCTAsmusthavemeansforcrewtocheckthemselvesandeachotherforpotentialriskstopatientscausedbyknownorinadvertentimpairment.Asprovidersmayhavedutyconflicttocometoworkwithmildillness,fatigue,withorwithoutanOTC,CCTAsmusthaveajustculturesystemtoassistproviderswithalternativedutiesiftheyself-checkandidentifythattheymightbeunabletoperformtasksinsafemanner.
12. Patientdeathorpermanentdisabilitycausedbylackoftemperatureprotectionwithresultinghypoorhyperthermia
Includes:a) Knownexposureof
patienttoprolongedtemperatureextremeswithidentifiableriskofpatientharm,suchasposttraumahypothermia
b) Transportinvehiclewithoutadequateenvironmentalcontrolunitduringextremetemperatureconditions
Excludes:a) Rescueconditionsin
whichneedforextricationislessrisk/higherbenefitandoutweighsthermalprotectionofpatientduringrescue.
Thiseventisintendedtocapture:! Failuretoprovideathermally
controlledenvironmenttoapatientatriskofadverseoutcomeduetocombinationofinjury/illnessandambienttemperaturewhetherextremeofcoldorhot
FailureofCCTAtohaveenvironmentallycontrolledvehicleswithknownandexpectedextremeoftemperaturecondition,i.e.,failuretoprovideairconditioninginvehicleinclimatewithdocumentedtemperaturesinexcessof95Fforaverage>15daysperyearorfailuretoprovideadequateorfunctioningheatinginnorthernclimatewintermonths.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)SYSTEMEVENT Event AdditionalSpecifications ImplementationGuidance1. Respondwithouta
formalrequestIncludes:a) Anyfreelance
responsestopotentialpatienttransports
Excludes:a) TheCCTAthat
participatesinauto-response/standbyresponsesaspartofacoordinated,integratedandpublishedpolicydevelopedincooperationwithlocal/regionalrequestingagencies
b) InstanceswhentheCCTAcrewhappensuponthesceneofanEMSneedandinitiallyactsasafirstresponder,notifyingthepublicserviceanswerpoint(PSAP)toactivatestandardresponseprotocolforthatlocation
Thiseventisintendedtocapture:! OccurrenceswhereaCCTAself-
dispatchesresourcestoscenesorhealthcarefacilitieswithoutaformalrequestfromorcoordinationwithpersonnelonscene.
TheutilizationofCCTAresourcesarecoordinatedeventsbetweentheCCTA,PSAPS,dispatchcenters,otherrespondingEMSresources,andhospitals.FreelanceresponsestopotentialpatienttransportsbyCCTAresourcescanjeopardizecoordinationeffortsaswellasimpactcrewandpatientsafety.TheremustbeaformalrequestofservicetorespondwithCCTAresources.
2. Knowinglymisrepresentinginformationinamedicalrecord,whetherbyfalsification,obfuscation,oromissionofinformation
Includes:a) Purposefulinaccurateor
misseddocumentationenteredinapatientrecord
b) Posttransporteditofpatientcarerecordtocoveruporchangepotentialerrorinpatientcare.
Thiseventisintendedtocapture:! Occurrencesinwhichproviders
purposefullyhideerrororadversepatientevent
! Occurrenceswhereproviderspurposefullyomitpertinentpatientinformationwithresultantadverseriskorharmtopatient.
CCTAsmusthaveareliableandthoroughpatientcaredocumentationsystemthathasthemeanstoidentifypostrecordcompletionedits.
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Appendix6:RecommendedSafetyMetricsforCriticalCareTransportBackgroundIn2006,theNationalAcademyofSciencesInstituteofMedicine’s(IOM)three-partlandmarkemergencycarereporthighlightedmultiplechallengesintheemergencycaresystem.TheEMSMedicalServices:attheCrossroadsreportnotingthataccountabilityhas“failedtotakehold”intheEMSsystem,callingforthedevelopmentofsystemperformanceindicatorsthat“includestructureandprocessmeasures,butevolvetowardoutcomemeasuresovertime.Theseperformancemeasuresshouldbenationallystandardizedsothatstatewideandnationalcomparisonscanbemade.Measuresshouldevaluatetheperformanceofindividualcomponentsofthesystem,aswellastheperformanceofthesystemasawhole.Measuresshouldalsobesensitivetotheinterdependenceofthesecomponents.”viWhilethereisearlyprogressandorganizationsuchastheAmericanAcademyofPediatrics(AAP)andtheAirMedicalPhysicianAssociation(AMPA)havedevelopedvoluntarymeasurementstandardsandshareddatabases,thereisalsocontinuinglackofagreementondefinitions,standards,andmetricsforcareleadingtowidevariabilityofpracticethroughouttheEMSsystem.Unfortunately,astheIOMpapernotesthisis“anurgentproblemofunknownscope”becausenonationallyagreedupondatasetorreportingcenterforadverseeventsexists.WhilethepublicandhealthcareprovidersperceivethatCriticalCareTransport(CCT)agencies,providers,andvehiclesareessentiallyallthesame,thereisasubstantialgapbetweenrealityandperception.Essentialtoimprovementistheattentionthatmustbepaidtounderlyingcontinuedproblemsinpatientsafety.Recognizingtheneedtoimproveout-of-hospitalcare,theFederalInteragencyCommitteeforEMSandtheNationalEMSAdvisoryCouncilthroughtheNationalHighwayTrafficSafetyAdministration(NHTSA)andtheEMSforChildren’sDivisionoftheU.S.HealthResourcesandServicesAdministrationengagedtheAmericanCollegeofEmergencyPhysicians(ACEP)todevelopanationalstrategytoimprovethecultureofsafetyinEMS.viiSignificantly,thewhitepaper,aNationalEMSCultureofSafetyusedrecentworkfromtheUniversityofPittsburghtodefineanadverseeventinEMSas“aharmfulorpotentiallyharmfuleventduringthecontinuumofEMScarethatpotentiallypreventableandthusindependentoftheprogressionofthepatient’scondition.”viii
viNationalAcademyofSciences/InstituteofMedicine:EmergencyMedicalServices:attheCrossroads.ISBN:0-309-66216-8,(2006)viiwww.emscultureofsafety.org/wp-content/uploads/2013/10/Strategy-for-a-National-EMS-Culture-of-Safety-10-03-13.pdfviiiPattersonPD,WeaverMD,AbebeK,Martin-GillC,etal.Identificationofadverseeventsingroundtransportemergencymedicalservices.AmJMedQual.2012Mar-Apr;27(2):139-46
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Achievingasaferandhigherqualitysystemisanenormouschallengethatwilltakeconcentratedeffortsbyeveryhealthcarestakeholder,policymaker,regulator,purchaser,aswellasthepublicandindividualpatientsandfamilies.Appropriatelyused,transportmedicinecanactasanintegratorofcareduetoitsmultiplejurisdictionalreach.ACCTmembersrecognizetheyhavebeenentrustedtoprovidehighqualitycriticalcaretotheirpatientsandthatiswhyACCTworkstoleadtheefforttocreateabettersystem.BuildingontheworkoftheNationalQualityForum(NQF)andtheInstituteforHealthcareImprovement(IHI),andconcurrentwithworkbytheAAPandAMPA,ACCThasdevelopedand/orconcurredwithaseriesofinitialcoremeasurestoimprovethequalityofcareandsafetyofpatientsinthecontinuumofcare.ThegoalsarealignedwithIHI“TripleAim”frameworktooptimizehealthsystemperformance:
! Improvingthepatientexperienceofcare(includingquality,safety,andsatisfaction);! Improvingthehealthofpopulations;and! Reducingthepercapitacostofhealthcare.
ACCT’sinitialcoremeasures,enumeratedinthissectionarepatientsafetyfocusedandareinspiredbytheJointCommissionontheAccreditationofHospitalOrganization(JCAHO)SentinelEventPolicyadoptedin1996.ixACCTbelievesthatitisimperativeforeveryCCTAtotrackthesebasicpatientsafetyeventmeasuresforthepurposeofinitiatingcontinuousqualityimprovementactivities.Developingameansofreportingthesemetricstoaprotected,nationwidedatabaseforthepurposeofmeasuringthequalityandsafetyoftheCCTindustryisafoundationalgoalofACCT.Inaddition,thisdatabasecouldallowparticipantstocomparetheirqualityandsafetymetricsagainsttheindustryforthepurposeoftargetingandprioritizingperformanceimprovementprojects.Movingforward,withtheinputofmembersandaffiliateassociations,ACCTaimstoreleaseadditionalclinicalperformancemeasuresbeyondthisinitialsetapplicabletoCCT.Theseshouldnotbeconsideredcriticalcareaccreditationstandardsormandatorydatareportingdatapointsfortheindustry.ACCT’sgoalistoaidstakeholdersinrecognizingthedistinctionbetweencriticalcaretransportperformancemeasuresversusevaluationsusedforothermodesofpatienttransport,alongwiththeassociatedhighstandardsandqualityofcareprovidedtoCCTpatients.
ixhttps://www.jointcommission.org/sentinel_event_policy_and_procedures/
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1 Domain:PatientSafety ClinicalArea:AllMeasureName:PatientSafetyIncidentsDescription:Anevent,incident,orconditionthatcouldhaveresultedordidresultinharmtoapatient.Apatientsafetyincidentcanbe,butisnotnecessarily,theresultofadefectivesystemorprocessdesign,asystembreakdown,equipmentfailure,orhumanerror.ASentinelEventisasubsetofpatientsafetyincidents.Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedPatientSafetyIncidentsDenominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingcondition,adversedrugreactionsorknowncomplicationsthatmayresultfromaprocedureortreatmentExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined2 Domain:PatientSafety ClinicalArea:AllMeasureName:PatientSafetySentinelEventsDescription:Apatientsafetyincidentthatreachesapatientandresultsinanyofthefollowing:death,permanentharm,severetemporaryharm.Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedPatientSafetySentinelEventsDenominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingcondition,adversedrugreactionsorknowncomplicationsthatmayresultfromaprocedureortreatmentExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined3 Domain:PatientSafety ClinicalArea: RespiratoryMeasureName:Transport-RelatedHypoxiaDescription:Patientsexperiencingadequateoxygenation(>90%SpO2)preandpostCCTbutexperiencehypoxia(<90%SpO2)duringCCTdocumentedpulseoximetryreadingbeginsat,orisresuscitatedto,90%orgreaterandsubsequentlydeclinestobelow90%.Multipleincidentswithonepatientareconsideredasoneincident.Measure:Incidentsper1,000patientcontactsNumerator:NumberofpatientcontactsduringwhichthehypoxiaoccurredDenominator:NumberofpatientcontactswhereSpO2was>90%priortoCCTassumingcareExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesencounterswheretheSpO2isneveratorabove90%,eitherbydesign,bychronichealthstate,orbycurrentphysiologyGoal:Tobedetermined4 Domain:PatientSafety ClinicalArea:Medical/TraumaBleedingMeasureName:BloodProduct/TransfusionErrorsandAdverseReactionsDescription:ThefollowingoccurredduringCCTteamadministrationofbloodproducts:
! Administeredincorrectly! Adversetransfusionreaction! Expired/deterioratedproduct! WrongABORhtype
! WrongIVfluidadministeredwithproduct! Wrongnumberofunits! Wrongpatient,rate,time,oruseofproduct! Failuretorecognizeorrespondappropriatelyto
transfusionreactionMeasure:Occurrencesper1000unitsofbloodproductsadministeredNumerator:NumberofCCT-relatedblood/transfusionincidentsoreventsDenominator:NumberofunitsofbloodproductsinitiatedbyCCTcrewExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined
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5 Domain:PatientSafety ClinicalArea: Environment/EquipmentMeasureName:Environmental/EquipmentConditionsDescription:Anypatientincidentoreventcausedbythefollowingequipmentconditions:
! Contaminated! Failure! Functionedorusedotherthanasintended! Unavailable/missing! Operatedincorrectly! Unintendedhypo/hyperthermia
Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedEnvironmental/Equipmentincidentsorevents(maybemorethanoneperpatientcontact)Denominator:NumberofpatientcontactsExclusions:Excludesoccasionswhereequipmentisassessedasfailed,contaminated,orunavailableunrelatedtoapatienttransport(i.e.duringadailyequipmentcheck)Goal:Tobedetermined6 Domain:PatientSafety ClinicalArea:Environmental-NeonateMeasureName:UnintendedNeonatalHypothermiaDescription:Infants(<29daysold)withoutsignificanthypothermiapriortoCCTwithadmissiontemperatureslessthan36.5oCaxillaryatdestination.Measure:Incidentsper1000patientcontactsNumerator:NumberofinfantsfoundhypothermicDenominator:NumberoftransportedneonatepatientsnotmeetingexclusioncriteriaExclusions:Excludesintentionalcooling(i.e.therapeutichypothermia)andpatientswithprofoundhypothermiapriortotransportGoal:Tobedetermined7 Domain:PatientSafety ClinicalArea:PatientMovementMeasureName:PatientFalls/DropsDescription:WhileinthecareoftheCCTteamthepatientexperiences:
! Allpatientfallsordroppingofpatients! Droppingequipmentontopatientcausingpain,skinintegrityimpairment,bruisingorfracture
Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedpatientfalls/drops(maybemorethanoneperpatientcontact)Denominator:NumberofpatientcontactsExclusions:ExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined8 Domain:PatientSafety ClinicalArea:VascularAccessMeasureName:Infiltration/VascularAccessRelatedDescription:Medicationinfiltrations(asinfusionsorIVpushmedications)viaperipheralinsertedcentralcatheter,centralvenouscatheter,peripheralintravenousline,intrathecal,orintraosseouslineMeasure:Occurrencesper1000medicationadministrationsviaincludedroutesNumerator:NumberofCCT-relatedinfiltration/vascularaccessrelatedincidentsoreventsDenominator:NumberofdruginfusionsviavascularaccessinitiatedbyCCTcrewsduringpatientcontactExclusions:ExcludesincidentsthatwereinitiatedreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined
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9 Domain:PatientSafety ClinicalArea:TherapeuticDevicesMeasureName:Unplannedremoval/dislodgementoftherapeuticdeviceDescription:UnplanneddislodgementsoftherapeuticdevicesthatwereinplacewhenCCTassumesprimarycareofthepatientthroughhandoffofcareatdestination.Therapeuticdevicesinclude,butarenotlimitedtothefollowing:peripheralIV,intraosseousline,UAC/UVC,centralvenouscatheters,arteriallines,advancedairway,tracheostomytubes,chesttubes,urinarycatheters,epicardialwires,surgicaldrains,G-tubes,J-tubes,etc.Measure:Occurrencesper1000patientcontactswhereapplicabledeviceswereinplacepriortotransferofcaretoCCTprovidersorwereinsertedbyCCTprovidersNumerator:Numberofunplannedremovals/dislodgementsoftherapeuticdevices(maybemorethan1perpatientcontact)Denominator:NumberofpatientcontactswheretherapeuticdeviceswereinplaceduringcareofCCTteamExclusions:Doesnotincludeintendedremovalofanydeviceduetomalfunctionormisplacementorduetoimprovingdevice(e.g.,removalofsupraglotticairwaywithsignificantairleaktoplaceanendotrachealtube)Goal:Tobedetermined10 Domain:PatientSafety ClinicalArea:CareManagementMeasureName:CareManagementDescription:ThroughmedicaldirectorreviewofCCTs,notificationfrominvolvedmedicalfacilities,orself-reportatleastoneofthefollowingincidentsarediscovered:
! Delayintreatment! Wrongtreatment! Omittedtreatment! Incorrectresponsetoresuscitationstatus! Infectionintroduction! Intravascularairembolism
Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedmanagementofcareincidentsoreventsDenominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingcondition,adversedrugreactionsorknowncomplicationsthatmayresultfromaprocedureortreatmentExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined11 Domain:PatientSafety ClinicalArea:MedicationAdministrationMeasureName:MedicationAdministrationDescription:IncludesmedicationsadministeredbyCCTteamwhereatleastoneofthefollowincidentsoccurred:
! Wrongdose/quantity! Drug-druginteraction! Expiredmedicationadministered! MedicationincompatibilitywithIVfluids! Wrongconcentration! Wrongmedication:knownallergy! Wrongmedforclinicalcondition! Wrongpatient,rate,routeortime
Measure:Occurrencesper1000medicationsadministeredNumerator:NumberofCCT-relatedmedicationadministrationincidentsoreventsDenominator:NumberofmedicationadministrationsinitiatedbyCCTcrewsduringpatientcontactExclusions:Excludespreviouslyunknownorunavailablemedicationallergyinformation(e.g.,unknownandunresponsivepatientwithnofamilypresent)ExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined
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12 Domain:PatientSafety ClinicalArea:SkinIntegrityMeasureName:Pressureulcers/skinintegrityDescription:AnyofthefollowingskinintegrityimpairmentsresultingfromCCT:
! Pressureulcers! Tears! Abrasions! Lacerations! Burns
Measure:Occurrencesper1000patientcontactsNumerator:NumberofCCT-relatedskinintegrityincidentsorevents(maybemorethanoneperpatientcontact)Denominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined13 Domain:PatientSafety ClinicalArea:PatientSafety/SecurityMeasureName: Safety/SecurityDescription:AnyofthefollowingoccurringduringorrelatedtotheCCTprocess:
! Vehiclecrash! Improperornon-useofpatientrestraintsystems! Disappearance/elopement! Homicide! Improperbiohazarddisposal! Physicalassaultofpatientorstaff! Self-inflictedharm! Sexualmisconduct–abuseorassault! Suicide/attemptedsuicide
Measure:Occurrencesper1,000patientcontactsNumerator:NumberofCCT-relatedsafety/securityincidentsoreventsDenominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined14 Domain:PatientSafety ClinicalArea: ProceduresMeasureName:Surgical/InvasiveProceduresDescription:AnyofthefollowingincidentsresultingfromCCT:
! Anesthesia/induction-related! Wrongside/site! Sitecontamination! Unexpectedadversedeathduring/within24hours! Unexpectedinjury/complication/seriousdisability! Wrongpatient
Measure:Occurrencesper1000surgical/invasiveproceduresNumerator:NumberofCCT-relatedsurgical/invasiveprocedureincidentsorevents(maybemorethanoneperpatientcontact)Denominator:Numberofsurgical/invasiveproceduresinitiatedbyCCTcrewsduringpatientcontactExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined
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Appendix7:ReferencesReferences
1. InitialCCRNCertification.AlisoViejo,CA:AmericanAssociationofCriticalCareNurses;2013.http://www.aacn.org/wd/certifications/content/initial-ccrn-certification.pcms?menu=certification#Initial_Eligibility_Requirements.AccessedSeptember9,2013.
2. Guideforinter-facilitypatienttransport.Washington,DC:NationalHighwayTrafficSafetyAdministration;April2006.http://www.nhtsa.gov/people/injury/ems/interfacility/images/interfacility.pdAccessedSeptember9,2013.
3. EmergencyMedicalServicesEligibilityCriteriaforCertification.EastLansing,MI:AmericanBoardofEmergencyMedicine;April2011.http://www.naemsp.org/Documents/EMSEligCriteriaFINALApril2011.pdfAccessedSeptember9,2013.
4. CertificationinformationforoperatingunderPart135.Washington,DC:FederalAviationAdministration.http://www.faa.gov/licenses_certificates/airline_certification/media/n135toc.pdfAccessedSeptember9,2013.
5. Nursing:ScopeandStandardsofPractice,secondedition.AmericanNursesAssociation;August2010.
6. Fairman,J.,Rowe,J.,Hassmiller,S.,&Shalala,D.BroadeningtheScopeofNursingPractice.NEnglJMed.2011;364:193-196.
7. ClinicalandPracticeManagement.Irving,TX:AmericanCollegeofEmergencyPhysicians;2013.http://www.acep.org/content.aspx?id=30466AccessedSeptember9,2013.
8. NationalEMSScopeofPracticeModel.Washington,DC:NationalHighwayTrafficSafetyAdministration;February2007.http://www.nhtsa.gov/people/injury/ems/EdAgenda/final/agenda6-00.htm.AccessedFebruary12,2013.
9. CriticalCare.Bethesda,MD:U.S.NationalLibraryofMedicine,U.S.DepartmentofHealthandHumanServices,NationalInstituteofHealth;April30,2013.http://www.nlm.nih.gov/medlineplus/criticalcare.htmlAccessedMay22,2013.
10. AlisoViejo,CA,AboutCriticalCareNursing;AmericanAssociationofCriticalCareNurses;2013.http://www.aacn.org/wd/pressroom/content/aboutcriticalcarenursing.pcms?menuAccessedFebruary21,2013.
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11. Warren,J.,Fromm,R.,Orr,R.,Rotello,L.,&Horst,H.Guidelinesfortheinter-andintrahospitaltransportofcriticallyillpatients.CritCareMed.2004Jan;32(1):255-262.
12. GuidelinesforICUAdmission,Discharge,andTriage.TaskForceoftheAmericanCollegeofCriticalCareMedicine,SocietyofCriticalCareMedicine.CritCareMed.1999Mar;27(3):633-638.
13. CriticalCareParamedicPositionStatement.Snellville,GA:InternationalAssociationofFlightParamedic;July2009http://c.ymcdn.com/sites/iafccp.site-ym.com/resource/resmgr/docs/critical_care_paramedic_posi.pdf?hhSearchTerms=%22critical+and+care+and+paramedic+and+position+and+statement%22AccessedFebruary21,2013.
14. Pub100-04MedicareClaimsProcessing,Transmittal1548.Washington,DC:CentersforMedicare&MedicaidServices;July9,2008https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1548CP.pdfAccessedFebruary21,2013.
15. Careofthepatientduringinterfacilitytransfer.DesPlaines,IL:EmergencyNursesAssociation;September2010http://tinyurl.com/zryzu3aAccessedSeptember27,2016.
16. AccreditationStandards,9thedition.SandySprings,SC:CommissiononAccreditationofMedicalTransportSystem;2012.
17. GuidelinesforAirandGroundTransportationofPediatricPatients.AmericanAcademyofPediatrics.Pediatrics1986;78;943
18. PediatricSpecializedTransportTeamsAreAssociatedwithImprovedOutcomes.AmericanAcademyofPediatrics.Pediatrics2009;124;40DOI:10.1542/peds.2008-0515
19. PediatricInterhospitalCriticalCareTransport:ConsensusofaNationalLeadershipConference.AmericanAcademyofPediatrics.Pediatrics1991;88;696
20. SpeedIsn'tEverythinginPediatricMedicalTransport.AmericanAcademyofPediatrics.Pediatrics2009;124;381DOI:10.1542/peds.2008-3596
21. ConsensusReportforRegionalizationofServicesforCriticallyIllorInjuredChildren.AmericanAcademyofPediatricsCommitteeonPediatricEmergencyMedicine;PediatricSectionAmericanCollegeofCriticalMedicineandSocietyofCriticalCareMedicine;PediatricSection,TaskForceRegionalizationofPediatricCriticalCare;2000;105;152
22. ClinicalandPracticeManagement,CriticalCareFAQ.AmericanCollegeofEmergencyMedicine.http://www.acep.org/content.aspx?id=30466.AccessedMarch2014
23. Guidelinesfortheinter-andintrahospitaltransportofcriticallyillpatients;SocietyofCriticalCareMedicine:CritCareMed2004Vol.32,No.1
24. CriticalCare:http://www.nlm.nih.gov/medlineplus/criticalcare.html25. ClinicalandPracticeManagement:ACEP:http://www.acep.org/content.aspx?id=3046626. NursesScopeofPractice.NEnglJMed2011:364:280-281January20,2011DOI:
10.1056/NEJMc101389527. MichiganSystemProtocolsInter-facilityPatientTransfersCriticalCarePatient
Transports(optional)Date:September2004
AssociationofCriticalCareTransport-CriticalCareTransportStandards-Version1.0©2016 Page61
28. Washtenaw/LivingstonMedicalControlAuthorityApril201:MICUProtocolsandMicutransportCapabilities
29. PediatricEmergencyMedicine;PediatricSectionAmericanCollegeofCriticalCareMedicineandSocietyofCriticalCareMedicine;PediatricSection,TaskForceonRegionalizationofPediatricCriticalCarePediatrics2000;105;152
30. MassachusettsGeneralLaws,PartI,Chapter111C,EmergencyMedicalServicesSystem;and105CMR170.000:EmergencyMedicalServicesSystem
31. AmericanCollegeofEmergencyMedicine,ClinicalandPracticeManagement,CriticalCareFAQ.http://www.acep.org/content.aspx?id=30466
32. EuropeanAeromedicalInstitute(EURAMI):StandardsV.4.0;AccessedJanuary2014.www.eurami.org
33. EuropeanCommitteeforStandardization(CEN)MedicalVehiclesandtheirEquipment–AirAmbulances—PartI:Requirementsformedicaldevicesusedinairambulances;prEN13718-1:2013MedicalVehiclesandtheirEquipment—AirAmbulances—PartII:Operationalandtechnicalrequirementsofairambulances;prEN13718-2:2013
34. DepartmentofPublicSafety--MaineEMS:Rules.May201335. Making Healthcare Safer II: An updated Critical Analysis of the Evidence for Patient
Safety Practices; Agency for Healthcare Research and Quality (AHRQ). Evidence ReportTechnologyAssessmentNumber211.March2013
36. SeriousReportableEventsinHealthcare—2011UpdateNationalQualityForum(NQF).www.qualityforum.org
37. LembitzA,ClarkTJ;Clarifying“neverevents”andintroducing“alwaysevents:Editorial.PatientSafetyinSurgery2009,3:26doi:10.1186/1754-9493-3-26December2009BioMedCentral
38. JamesJT:ANew,Evidence-basedEstimateofPatientHarmsAssociatedwithHospitalCare;JournalPatientSafety;Vol.9,Number3,September2013www.journalpatientsafety.com
39. PatientFirstAir-AmbulanceAlliance.PositionPaper:PayforPerformance:CoreMeasures/NeverEvents.June2009
40. PickerInstitute:AlwaysEvents:CreatinganOptimalPatientExperienceOctober201141. PickerInstitute:AlwaysEventsforCommunicationandCareTransitions:Anideaguide.
October201142. AHRQPatientSafetyNetwork—NeverEvents;AgencyforHealthcareResearchand
Quality(AHRQ):www.ahrq.govAccessed8February201443. MedicalDirectionandMedicalControlofAirMedicalServices.PositionStatementofthe
AirMedicalPhysicianAssociation.http://tinyurl.com/jjhe8ty.AccessedSeptember27,2016.
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Appendix8:Definitions&AcronymsAAP:AmericanAcademyofPediatricsACLS:AdvancedCardiacLifeSupportAHA:AmericanHeartAssociationAMPA:AirMedicalPhysiciansAssociationAPRN:AdvancedPracticeRegisteredNurseBCLS:BasicCardiacLifeSupportCAMTS:CommissiononAccreditationofMedicalTransportSystemsCCP-C:CriticalCareParamedic-CertifiedCCT:CriticalCareTransportCCTA:CriticalCareTransportAgencyCCTV:CriticalCareTransportVehicleCFRN:CertifiedFlightRegisteredNurseCNPT:CertifiedNeonatalPediatricTransportCriticalCareTransport:Theprovisionofmedicalcarebyacriticalcareteamtoapatientrequiringcriticalcaretransportbyacriticalcaretransportagencysuchthatthefailuretoinitiateonanurgentbasis,ormaintainduringtransport,acutemedicalinterventions,pharmacologicalinterventions,ortechnologieswouldlikelyresultinsudden,clinicallysignificantorlifethreateningdeteriorationinthepatient’scondition.
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CriticalCareTransportAgency:Anorganizationlicensedestablishedtoprovidecriticalcaretransportbetweenhospitals.CriticalTransportProvider:Caregiverwhombyevidenceofeducation,training,licensure,applicableexperience,certification,andcredentialingisabletoprovideacutemedicalinterventions,pharmacology,andtechnicallifesupportsystemsexceedingthoseabletobeprovidedbythenationalscopeofpracticeofaparamedicascurrentlydefinedbyNationalHighwayTrafficSafetyAdministration’s(NHTSA)NationalEMSScopeofPracticeModel,DOTHS810657,February2007.CTRN:CertifiedTransportRegisteredNurseCriticalCareTransportSpecialist:Acriticalcaretransportproviderhasachievedmasteryoftheentry-leveltransportproviderrequirementsanddemonstratesstrongknowledge,applicationandcriticalthinkinginthecriticalcaretransportenvironment.CriticalCareTransportspecialistswillhaveobtainedaminimumnumberorcriticalcaretransporthoursandhavecertificationincriticalcaretransport.CriticalCareTransportTeam:Criticalcaretransportservicesaredeliveredbyacriticalcaretransportteamwiththerequisitedecisionmakingskillsofhighcomplexitytoassess,manipulate,andsupportvitalorgansystemfailureand/ortopreventfurtherlifethreateningdeteriorationofthepatient’sconditionduringtransport.ECMO:ExtracorporealMembraneOxygenationEURAMI:EuropeanAero-MedicalInstituteFP-C:FlightParamedicCertifiedHROB:HighRiskObstetricalILCOR:InternationalLiaisonCommitteeonResuscitationIntensiveCareUnit:Anintensivecareunitinwhichconcentratedspecialequipmentandskilledpersonnelareavailableforthecareofseriouslyillpatientsrequiringimmediateandcontinuousattention.Interchangeability:Thecapabilitytotransferpatientsbetweenscenesofemergencies,ambulancesandhospitalsaswellasbetweenhospitals,includingtransportbetweencountries,providingcontinuouspatientcare,treatmentandmonitoringInterface:Theplaceofinteractionbetweenoneormoreofthemedicaldevices,theambientconditions,theuser,thepatient,andwhenrelevant,thevariouskindsofambulancevehicles
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Interoperability:Theabilitytoconnectvariousmedicaldevicesthatareattachedtopatients,toconnectionsofassociatedmedicaldevicesincludingthepossibilityofconnectingpoweredmedicaldevicestovariouskindsofambulancevehiclesMedicaldevice:Instruments,apparatus,appliances,materialorotherarticle,whetherusedaloneorincombination,includingsoftwarenecessaryforitsproperapplicationintendedbythemanufacturertobeusedonpatientsforthepurposeofdiagnosis,prevention,monitoring,treatmentoralleviationofdiseaseandinjury.NRP:NeonatalResuscitationProgramNICU:NeonatalIntensiveCareUnitNeonatalIntensiveCareUnit:Anintensive-careunitspecializinginthecareofillorprematurenewborninfants.Thisunitistypicallydirectedbyoneormoreneonatologistsandstaffedbynurses,advancedpracticenursepractitioners,pharmacists,physicianassistants,residentphysicians,andrespiratorytherapiststrainedinnewborncriticalcare.PALS:PediatricAdvancedLifeSupportPatientCompartment:Adefinedspacewhichprovidesthepossibilitytoaccommodateandtransportoneormorepatient(s),medicalcrew,medicaldevices,systemsandinstallationswhicharerequiredduringtransporttoproperlytreatandcareforthepatient.Patienttreatmentarea:Thespacelocatedwithinthepatientcompartment,whichisrequiredtoaccommodateapatientonastretcheraswellastheminimumspaceinthevicinityofthestretcherenablingthemedicalcrewtoproperlycareandtreatapatientPatientRequiringCriticalCareTransport:Apatientrequiringcriticalcaretransporthasacriticalillnessorinjurythatacutelyimpairsoneormorevitalorgansystemssuchthatthereisahighprobabilityofimminentorlifethreateningdeteriorationinthepatient’sconditionduringtransport.PediatricIntensiveCareUnit:Aunitwithinahospitalspecializinginthecareofcriticallyillinfants,children,andteenagers.Theunitistypicallydirectedbyoneormorepediatricintensivistsandstaffedbyphysicians,nurses,andrespiratorytherapistswhoarespeciallytrainedandexperiencedinpediatriccriticalcare.Theratioofprofessionalstopatientsisgenerallyhigherthaninotherareasofthehospital,reflectingthehighacuityofpatientsandtheriskoflife-threateningcomplications.Complextechnologyandequipmentisofteninuse,particularlymechanicalventilatorsandpatientmonitoringsystems.PICU:PediatricIntensiveCareUnit
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PA:PhysicianAssistantQuaternaryCare:sometimesusedasanextensionoftertiarycareinreferencetoadvancedlevelsofmedicinewhicharehighlyspecializedandnotwidelyaccessed.Experimentalmedicineandsometypesofuncommondiagnosticorsurgicalproceduresareconsideredquaternarycare.RN:RegisteredNurseRT:RegisteredRespiratoryTherapistTertiaryIntensiveCare:Themostspecializedintensivecareadministeredtocriticallyillpatientswithsevereorcomplexdiseaseorinjuryrequiringhigh-riskpharmacologicregimens,surgicalprocedures,orhigh-techandadvancedresources.Oftenassociatedwithteachinginstitutionsandrequiressophisticatedtechnologyandmultiplespecialtyresources.TPATC:(formerlyTNATC)TransportProviderAdvancedProviderCourse.
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ACKNOWLEDGEMENTSTheAssociationofCriticalCareTransportwouldliketothankalloftheACCTMembersandBoardofDirectorswhohavesupportedthecreationofthesestandards.Aspecialrecognitiongoestothefollowingprogramsthathavededicatedextensivetime,resourcesandtalentintomakingthesestandardspossible:
AirliftNorthwest
AirSt.Luke’s
AnnandRobertHLurieChildren’sHospitalofChicagoTransportTeam
BostonMedFlight
CareFlite
Children’sMercyHospital,KansasCity,MO
ClevelandClinic
GeisingerLifeFlight
LeonardoHelicopters-AgustaWestland
LifeFlightEagle
LifeFlightofMaine
LifeLinkIII
LifeStarofKansas
MayoClinicMedicalTransport
SanfordAirMed
SuperiorAirGroundAmbulance,Inc.
STARS:ShockTraumaAirRescueSociety
UCHealth-AirCareandMobileCare
UniversityofMichiganHealthSystem,SurvivalFlight
UWMedFlight
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ABOUTACCTTheAssociationofCriticalCareTransport(ACCT)isanon-profitgrassrootspatientadvocacyorganization
committedtoensuringthatcriticallyillandinjuredpatientshaveaccesstothesafestandhighestquality
criticalcaretransportsystempossible.ACCTiscomprisedofairandgroundcriticalcaretransport
providers,businessorganizations,associations,andindividualsallstrivingtoprovideourcommunities,
hospitalsandEMSpartnersincare,regulators,andpolicymakerswithapathtowardasaferandfully
integratedcriticalcaretransportsystemthatrevolvesaroundtheneedsofthepatients.
ACCTExecutiveDirectorRoxanneShanksACCT2016/2017BoardofDirectorsMaryAhlers UCHealth-AirCareandMobileCare,OHKarenArndt OSFAviation,ILBetsyCasanave 7BarAviation,TXMikeChristianson SanfordMedicalCenterIntensiveAir,SDDr.JasonCohen BostonMedFlight,MAFrankErdman UniversityofWisconsin,WIEdwardEroe LifeLinkIII,MNSteveHaemmerle CarolinasMedicalCenter,NC KristaHaugen Survivor’sNetwork,WAGregHildenbrand LifeStar,KSTomJudge LifeFlightofMaine,MEDeniseLandis SurvivalFlight,MISherryMcCool Children’sMercyHospital,MOJamesPerry Patientrepresentative,MIDr.StevenRockoff SuperiorHenryFordAirMed1,MIJeffreyStearns MayoClinicMedicalTransport,MNRobbieTester Erlanger/LifeForce,TNLauraWestley Ann&RobertH.LurieChildren’sHospital,IL
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ACCTTRANSPORTPROGRAMMEMBERSAeromedTampaGeneralHospital LifeStarofKansas
AirSt.Luke's LifeFlightEagle
AirlifeDenver LifeFlightofMaine
AirliftNorthwest MayoClinicMedicalTransport
AngelOneTransport,ArkansasChildren'sHospital MedCenterAir
AnnandRobertHLurieChildren'sHospital MemorialHermannHospital
BostonMedFlight MeridianMobileHealth
Children'sMercyHospital,KansasCity,MO MissionHealthSystem
ClevelandClinicCriticalCareTransport OSFAviation/OSFLifeFlight
CookChildren'sTeddyBearTransport ParkviewSamaritan
Dartmouth-HitchcockAdvancedResponseTeam SanfordAirMed
Erlanger/LifeForce STARS
FlightforLife SuperiorAirGroundAmbulance
FlightForLifeColorado UCHealth-AirCareandMobileCare
GeisingerLifeFlight UniversityofMichiganSurvivalFlight
HumboldtGeneralHospitalEMSRescue UniversityofMississippi-Aircare
HuronValleyAmbulance UniversityofVermontMedicalCenter
LifeEMSAmbulance UWMedFlight
LifeLinkIII WestMichiganAirCare
Association of Critical Care Transport
www.ACCTforPatients.org
PO Box 170 • Platte City, MO 64079816-858-6175 • info@acctforpatients.org