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