Pediatric Transport Overview

Toni Petrillo-Albarano, MDChildren’s Healthcare of

Atlanta

Goal and Objectives

Understand goals of Pediatric Transport

Identify make up and skills of a competent team

Recognize factors involved in choosing various modes

Understand rules of governance

Background

In the United States, hospital-based neonatal transport programs were first created in the 1960s and 1970s

Similar programs for older infants and children emerged in the 1980s

Background

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

Background

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

Neurologic15%

Respiratory32%

Cardiac7%

Trauma22%

Other9%

Neonatal15%

Diagnostic Categories Of Children Transported

Goal

Early direction and initiation of advanced care

Improve safety of the transport and patient outcome.

Goal

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

Essential components

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

Essential components

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

Essential components On-line medical control by qualified

physicians Ground and/or air ambulance

capabilities Communications/dispatch capabilities Prospectively written clinical and

operational guidelines

Essential components

Quality and performance improvement activities

Administrative resources Institutional endorsement and

financial support.

Team Composition

Depends on the patient’s needs determined in consultation with the

team and medical control Dedicated pool of qualified

physicians, nurses, paramedics and/or respiratory therapists

Team Composition

A team member’s degree is less important than his or her ability to provide the level of care required

Critical care during transport conditions is significantly different from an ICU or ED

Team Composition

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

Team Composition

Many dedicated teams include a physician Little published evidence that this

configuration results in improved outcome compared with non-physician teams

Team Composition

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

relations

Team Training Pediatric courses

Required PNCCT PALS, APLS

Optional PEPP Pediatric BTLS ATLS

Neonatal courses Required

NRP or NALS Optional

S.T.A.B.L.E

Team Training

Procedures Advanced airway

management Specialized

Medication Administration (PGE’s, surfactant, vasopressors)

Chest decompression

Chest tube insertion Hemodynamic

monitoring Vascular access ICP monitoring Ventilator

management Isolette

Consent

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

Consent

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

How to choose

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

conditions.

Determining mode Four critical steps necessary for

selection of the optimal mode Evaluation of the current patient status Evaluation of care the required before and

during transport Urgency of the transport Logistics of a patient transport (e.g., local

resources available for transport, weather considerations, and ground traffic accessibility)

Ground Vs Air Distance to the closest appropriate

facility is too great for safe and timely transport by ground ambulance

Ground Vs Air

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

Ground Vs Air

Beyond 100 miles, a ground may become inefficient, costly to operate, and time consuming

Helicopter is used for up to 150 mile radius

Fixed wing greater than 150

Performance Comparison Ground vs. Air

Ground Ambulance 70 MPH 100 minutes to

Ellijay 2 hours for peds

specialty care = 3.7 hours trip

time

Helicopter 155 MPH 23 minutes to Ellijay 30 Minutes for peds

specialty care = 53 min trip time

Concern about Safety of Flight

HEMS Industry Statistics

= 7.5

HEMS Industry Growth

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

1980 1983 1986 1989 1992 1995 1998 2001

Number of Personnel in HEMS 1980-2001

HEMS Industry Growth

0

50

100

150

200

250

300

350

400

1980 1983 1986 1989 1992 1995 1998 2001

Number of HEMS Helicopters 1980-2001

Who Chooses?

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

EMTALA

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

EMTALA One of the major responsibilities

under EMTALA is that the hospital must provide a medical screening examination and stabilizing care to any patient that “comes to the hospital” and requests care

EMTALA Law applies to

Patients on / in hospital premises (including parking areas, streets, alleys and sidewalks)

Within 250 yards of the main hospital buildings

Patients presenting at off-site urgent cares or walk-in clinics

Any patient in a hospital owned and operated ambulance no matter where it is located

EMTALA The critical elements of documentation

required by EMTALA are: Patient consent to transfer Physician certification of risks and benefits Hospital acceptance for transfer Physician order for mode, level of attendant care,

and special equipment Copy of medical records, tests, and radiology

films Physician signature at departure from sending ED

EMTALA

Hospitals do not have a “right” to divert, however A more accurate description would be

that diversion is a request by the hospital to EMS to assist in managing an overflow situation or other emergency

EMTALA

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

EMTALA

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

EMTALA

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

Liability/Responsibility

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

Liability/Responsibility

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

Liability/Responsibility

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

Liability/Responsibility

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

Liability/Responsibility

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

Liability/Responsibility

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

Cost

The approximate cost of a medically configured ground ambulance is approximately $150 000 to $350 000, depending on the manufacturer and model selected

The annual maintenance and fuel costs might range from $10 000 to $25 000 per vehicle

Cost Single-engine helicopter A‑Star or

Bell 407 averages $2 million. A light twin‑engine helicopter

EC145 and Bell 430, both medium‑sized twin engine helicopters, cost between $4 and $6 million

While a large twin‑engine helicopter about $1-2 million more

Cost Pilot salaries range from $60,000 to

$85,000 annually; a staff of four is required to cover 24/7

Financial concerns include fixed and variable costs Fixed costs include insurance, taxes, crew

costs, overheads, interest, hanger fees and capital equipment

Variable (hourly) costs vary directly with the number of hours flown. These costs include fuel and oil, scheduled maintenance labor, etc

Cost

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

Questions?????