Critical Care Transport Standardstransported by any vehicle modality depending on the individual...

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.

AssociationofCriticalCareTransport-CriticalCareTransportStandards-Version1.0©2016 Page1

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

Page2 AssociationofCriticalCareTransport-CriticalCareTransportStandards-Version1.0©2016

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;


! 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.


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.


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.


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


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);


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


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.


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.


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


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).


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)


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


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


TheCCTprovidermayberequiredtoperformskillsnototherwiselistedinthisdocumentviadirectorvideoremotemedicaloversight.BasedontheCCTA’spatientpopulation,theneedfortheseskillsshouldbeanticipatedandincludedintrainingandcompetencyassessment.SummaryACCTbelievesthatCriticalCareTransportandtheCCTprovidershouldberecognizedasahigherleveloftransportthantheCentersforMedicareServices(CMS)-definedreimbursementforSpecialtyCareTransport,whichprovidesreimbursementforcarebeyondthescopeofparamedicpractice.Itisessentialthatcriticallyillandinjuredpatientsreceivecarebyhighlytrainedandqualifiedclinicians.Duringinter-hospitalCCT,theCCTteamshould,ataminimum,providecriticalcarecommensuratewiththereferringfacility.Optimally,theCCTteamshouldadvancethelevelofcriticalcaretowardsthatofthereceiving,tertiaryhospital.Thegoalofstandardizedqualificationsandtrainingwouldallowforreferralprovidersandpatientstobeconfidentthattheirlevelofcareisnotcompromisedduringtransport.


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.


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)


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%


! 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.


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.


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)


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.


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


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


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


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.


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.


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.


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.


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.


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.


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.


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


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.


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


! 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


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


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


“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.


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.”


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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/


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


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


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


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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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.


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


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


PA:PhysicianAssistantQuaternaryCare:sometimesusedasanextensionoftertiarycareinreferencetoadvancedlevelsofmedicinewhicharehighlyspecializedandnotwidelyaccessed.Experimentalmedicineandsometypesofuncommondiagnosticorsurgicalproceduresareconsideredquaternarycare.RN:RegisteredNurseRT:RegisteredRespiratoryTherapistTertiaryIntensiveCare:Themostspecializedintensivecareadministeredtocriticallyillpatientswithsevereorcomplexdiseaseorinjuryrequiringhigh-riskpharmacologicregimens,surgicalprocedures,orhigh-techandadvancedresources.Oftenassociatedwithteachinginstitutionsandrequiressophisticatedtechnologyandmultiplespecialtyresources.TPATC:(formerlyTNATC)TransportProviderAdvancedProviderCourse.


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


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


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 • [email protected]

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