Defining the Core Content for Transport Physician Training Programs.

In many parts of the world, emergency medical services (EMS) clinical care is traditionally delivered by different levels or types of EMS clinicians, such as emergency medical technicians and paramedics. In some areas, physicians are also included among the cadre of professionals administering EMS-based care. This is especially true in the interfacility transport (IFT) setting. Though there is significant overlap between the knowledge and skills necessary to safely and effectively provide care in the IFT and prehospital settings, the IFT care environment requires physicians to develop several additional competencies beyond those that are expected of traditional EMS clinicians. NAEMSP first published recommendations regarding what some of these competencies should be in 1983 and subsequently updated those recommendations in 2002. This document is an updated work, given the evolution of the field.

Interfacility Transport of Mechanically Ventilated Patients with Suspected COVID-19 in the Prone Position.

OBJECTIVE: Prone positioning during mechanical ventilation in patients with severe respiratory failure is an important intervention with both physiologic and empiric rationale for its use. This study describes a consecutive cohort of patients with severe hypoxemic respiratory failure due to COVID-19 who were transported in the prone position in order to determine the incidence of serious adverse events (SAEs) during transport. METHODS: This retrospective study used prospectively collected data from a provincial air and land critical care transport system where specially trained critical care paramedic crews transported intubated and mechanically ventilated patients with COVID-19 in the prone position. SAEs were determined a priori, and included markers of new hemodynamic or respiratory instability, new resuscitative measures, and equipment or vehicle malfunction. Two authors independently reviewed each patient care record to identify SAEs during transport, and the ability of the crews to successfully manage such events. RESULTS: From April 2020 to June 2021, 127 intubated and mechanically ventilated patients were transported in the prone position. Of these, 117 were transported by land vehicle, 7 by rotor-wing, and 3 by fixed wing aircraft. 67 (52.8%) were vasopressor-dependent, 5 (3.9%) were receiving inhaled vasodilators, 9 (7.1%) were hypoxic (SpO2 < 88%), and 3 (2.4%) were hypotensive (SBP < 90 or MAP < 65 mm Hg) when the transport crew made patient contact at the sending hospital. Of the 122 (96.1%) patients in which a pre-transport PaO2/FiO2 ratio was available, the mean (median; range) was 86.7 (81; 47-144), with 27 patients greater having a ratio greater than 100. The mean (median; range) transport time was 49 (45; 14-176) minutes. There were 19 SAEs in 18 (14.2%) patients during transport, the most common of which was new hypoxia requiring ventilator adjustments (15 of 18 patients). All SAEs were successfully managed by the transport crews. No patient experienced tracheal tube obstruction, unintentional extubation, cardiac arrest, or died during transport. CONCLUSION: Patients with severe hypoxemic respiratory failure due to COVID-19 can be safely transported in the prone position by specially trained critical care paramedic crews.

A Dedicated SARS-CoV-2 Testing Center for Public Service Agency Personnel: Implementation, Results, and Impact on Human Resources.

Objective: A global pandemic due to an emerging infectious disease requires efficient use of resources to ensure continued operation of essential services. To mitigate risk to these services and the population served, there needs to be a rapid identification of infected personnel via screening and testing.Methods: This retrospective study used prospectively collected data from a dedicated SARS-CoV-2 testing center for fire, police, and paramedic personnel in Toronto, Canada to determine the incidence of seropositive personnel and their immediate household, and estimate the days off work saved by timely access to testing and results.Results: In the consecutive 12-month study period, 10624 tests were carried out. Of 7951 personnel tested, 282 (3.55%) were positive, with positivity rates ranging from 2.52% for paramedics, 4.01% for police, and 4.25% for fire personnel. Household members tested positive in 173 of 2592 cases (6.67%), ranging from 5.22% for fire, 6.34% for paramedic, and 7.04% for police households. The median time to obtain test results was 1 day, with 90% available within 2 days. Implementation of the Center is estimated to have saved the Services 7669 person-days off work.Conclusion: A dedicated SARS-CoV-2 testing center for essential personnel can improve access to diagnostic testing and turnaround time for results, and provide a positive impact on human resource availability during a pandemic.

Pretransport Risk Assessment of Agitated Patients in Air Medical Transport.

OBJECTIVE: To determine the ability for a simple pretransport mental health risk assessment tool for patients who are agitated or experiencing an acute psychiatric illness to predict in-transit disruptive behavior necessitating additional intervention(s) while being transported via air ambulance. METHODS: We conducted this retrospective cohort study using existing data from the provincial air and land critical care transport system (Ornge) in Ontario, Canada, from April 2019 until March 2020. A total of 498 cases were included in this study. Transport medicine physicians fill in the modified mental health risk assessment tool as part of their pretransport assessment of each mental health patient undergoing transport. The transport medicine physician-derived risk score is categorized as low, moderate, and high. The primary outcomes were sensitivity, specificity, and predictive values of the modified tool for predicting pre- or in-transit disruptive behavior necessitating escalation in care. RESULTS: Of those patients meeting the study criteria, 207, 198, and 93 cases were assessed as low, moderate, and high risk, respectively, for potential agitation or disruptive behavior requiring escalation of care during transport. The sensitivity, specificity, positive predictive value, and negative predictive value were 70% (95% confidence interval [CI], 69.2%-70.8%), 87.1% (95% CI, 86.9%-87.2%), 37.6% (95% CI, 37.0%-38.2%), and 96.3% (95% CI, 96.2%-96.4%), respectively. CONCLUSION: A simple pretransport risk assessment tool can reliably rule out the need for escalation of care during air medical transport of the potentially agitated patient. This may help improve resource utilization and safety, without sacrificing quality of care.

Toward an all-inclusive trauma system in Central South Ontario: development of the Trauma-System Performance Improvement and Knowledge Exchange (T-SPIKE) project.

Background: There is currently no integrated data system to capture the true burden of injury and its management within Ontario's regional trauma networks (RTNs), largely owing to difficulties in identifying these patients across the multiple health care provider records. Our project represents an iterative effort to create the ability to chart the course of care for all injured patients within the Central South RTN. Methods: Through broad stakeholder engagement of major health care provider organizations within the Central South RTN, we obtained research ethics board approval and established data-sharing agreements with multiple agencies. We tested identification of trauma cases from Jan. 1 to Dec. 31, 2017, and methods to link patient records between the various echelons of care to identify barriers to linkage and opportunities for administrative solutions. Results: During 2017, potential trauma cases were identified within ground paramedic services (23 107 records), air medical transport services (196 records), referring hospitals (7194 records) and the lead trauma hospital trauma registry (1134 records). Linkage rates for medical records between services ranged from 49% to 92%. Conclusion: We successfully conceptualized and provided a preliminary demonstration of an initiative to collect, collate and accurately link primary data from acute trauma care providers for certain patients injured within the Central South RTN. Administration-level changes to the capture and management of trauma data represent the greatest opportunity for improvement.

Contexte: On ne dispose actuellement d'aucun système intégré de gestion des données pour évaluer le fardeau réel des traumatismes et de leur gestion dans les réseaux régionaux de traumatologie (RRT) en Ontario, en bonne partie en raison de la difficulté d'identifier les cas parmi la multiplicité des dossiers d'intervenants médicaux. Notre projet représente un effort itératif pour créer la capacité de cartographier le parcours de soin de tous les polytraumatisés du RRT de la région Centre-Sud. Méthodes: Grâce à l'engagement général des intervenants des grandes organisations de santé du RRT de la région Centre-Sud, nous avons obtenu l'approbation d'un comité d'éthique de la recherche et conclu des accords de partage des données avec plusieurs agences. Nous avons testé l'identification des cas de traumatologie du 1er janvier au 31 décembre 2017 et les méthodes de liaison des dossiers de patients entre les divers échelons de soin pour identifier les obstacles à la liaison et leurs solutions administratives possibles. Résultats: Au cours de 2017, les cas de traumatologie potentiels ont été identifiés auprès des services ambulanciers terrestres (23 107 dossiers), des services de transport médical aérien (196 dossiers), des hôpitaux référents (7194 dossiers) et du registre hospitalier principal de traumatologie (1134 dossiers). Les taux de liaison entre les différents services pour les dossiers médicaux variaient de 49 % à 92 %. Conclusion: Nous avons conceptualisé et présenté avec succès la démonstration préliminaire d'un projet visant à recueillir, colliger et relier avec justesse les données primaires des intervenants en traumatologie aiguë pour certains patients blessés du RRT du Centre-Sud. Des changements administratifs centrés sur la saisie et la gestion des données de traumatologie représentent la meilleure voie vers une amélioration.

Blood product transfusion during air medical transport: A needs assessment.

OBJECTIVES: Early administration of blood products to patients with hemorrhagic shock has a positive impact on morbidity and mortality. Smaller hospitals may have limited supply of blood, and air medical systems may not carry blood. The primary outcome is to quantify the number of patients meeting established physiologic criteria for blood product administration and to identify which patients receive and which ones do not receive it due to lack of availability locally. METHODS: Electronic patient care records were used to identify a retrospective cohort of patients undergoing emergent air medical transport in Ontario, Canada, who are likely to require blood. Presenting problems for blood product administration were identified. Physiologic data were extracted with criteria for transfusion used to identify patients where blood product administration is indicated. RESULTS: There were 11,520 emergent patient transports during the study period, with 842 (7.3%) where blood product administration was considered. Of these, 290 met established physiologic criteria for blood products, with 167 receiving blood, of which 57 received it at a hospital with a limited supply. The mean number of units administered per patient was 3.5. The remaining 123 patients meeting criteria did not receive product because none was unavailable. CONCLUSION: Indications for blood product administration are present in 2.5% of patients undergoing time-sensitive air medical transport. Air medical services can enhance access to potentially lifesaving therapy in patients with hemorrhagic shock by carrying blood products, as blood may be unavailable or in limited supply locally in the majority of patients where it is indicated.

Air medical transport myths.

The role of air medical and land-based critical care transport services is not always clear amongst traditional emergency medical service providers or hospital-based health care practitioners. Some of this is historical, when air medical services were in their infancy and their role within the broader health care system was limited. Despite their evolution within the regionalized health care system, some myths remain regarding air medical services in Canada. The goal is to clarify several commonly held but erroneous beliefs regarding the role, impact, and practices in air medical transport.

Paediatric health care access in community health centres is associated with survival for critically ill children who undergo inter-facility transport: A province-wide observational study.

BACKGROUND: Diverse settlement makes inter-facility transport of critically ill children a necessary part of regionalized health care. There are few studies of outcomes and health care services use of this growing population. METHODS: A retrospective study evaluated the frequency of transports, health care services use, and outcomes of all critically ill children who underwent inter-facility transport to a paediatric intensive care unit (PICU) in Ontario from 2004 to 2012. The primary outcome was PICU mortality. Secondary outcomes were 24-hour and 6-month mortality, PICU and hospital lengths of stay, and use of therapies in the PICU. RESULTS: The 4,074 inter-facility transports were for children aged median (IQR) 1.6 (0.1 to 8.3) years. The rate of transports increased from 15 to 23 per 100,000 children. There were 233 (5.7%) deaths in PICU and an additional 78 deaths (1.9%) by 6 months. Length of stay was median (IQR) 2 (1 to 5) days in PICU and 7 (3 to 14) days in the receiving hospital. Lower PICU mortality was independently associated with prior acute care contact (odds ratio [OR]=0.3, 95% confidence interval [CI]: 0.2 to 0.6) and availability of paediatric expertise at the referral hospital (OR=0.7, 95% CI: 0.5 to 1.0). CONCLUSIONS: We found that in Ontario, children undergoing inter-facility transport to PICUs are increasing in number, consume significant acute care resources, and have a high PICU mortality. Access to paediatric expertise is a potentially modifiable factor that can impact mortality and warrants further evaluation.

Assessment of Pain Management During Interfacility Air Medical Transport of Intubated Patients.

OBJECTIVE: The management of pain is an important component of care in the prehospital and transport setting. However, recent evidence suggests that pain control is infrequently achieved in these settings. The objective of the current study was to determine the proportion and frequency of opioid analgesia provided to intubated patients during interfacility transport by an air medical transport system. METHODS: This was a health records review examining electronic records of intubated patients transported by Ornge from July 2015 to November 2015. Cases were identified using Ornge database, and intubated patients were selected based on the inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was whether analgesia was provided. Secondary outcomes included the frequency of administration and dose adequacy of an opioid analgesia; the analgesic used; adverse events; and the impact of age, sex, past medical history of chronic pain, or reason for transfer on pain management. RESULTS: Of the 500 potential patient transports, 448 met our inclusion criteria. Among the 448 patients, 295 (65.8%) were men, 327 (73.0%) received analgesia, and 211 (64.3%) received more than 1 dose during transport (median frequency of 2 doses, interquartile range = 1 to 3). The average transport time was 135 minutes, and repeated dosing (> 1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.9%), and the most common dose was 50 µg (51.8%). Adverse events occurred in 8 patients (2.5%), most commonly new hypotension (mean arterial pressure < 65 mm Hg, n = 5). There was no significant difference in the administration of analgesia based on the patient's age or sex (68.0% of female patients and 75.6% of male patients received analgesia). Interestingly, only 30.8% of patients repatriated to their originating hospital received analgesia compared with 72.3% of patients undergoing their initial transfer to a higher level of care. CONCLUSION: Seventy-three percent of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex, past medical history of chronic pain, or reason for transfer other than repatriation to the originating hospital.

A regional massive hemorrhage protocol developed through a modified Delphi technique.

BACKGROUND: A massive hemorrhage protocol (MHP) enables rapid delivery of blood components in a patient who is exsanguinating pending definitive hemorrhage control, but there is variability in MHP implementation rates, content and compliance owing to challenges presented by infrequent activation, variable team performance and patient acuity. The goal of this project was to identify the key evidence-based principles and quality indicators required to develop a standardized regional MHP. METHODS: A modified Delphi consensus technique was performed in the spring and summer of 2018. Panellists used survey links to independently review and rate (on a 7-point Likert scale) 43 statements and 8 quality indicators drafted by a steering committee composed of transfusion medicine specialists and technologists, and trauma physicians. External stakeholder input from all hospitals in Ontario was sought. RESULTS: Three rounds were held with 36 experts from diverse clinical backgrounds. Consensus was reached for 42 statements and 8 quality indicators. Additional modifications from external stakeholders were incorporated to form the foundation for the proposed MHP. INTERPRETATION: This MHP template will provide the basis for the design of an MHP toolkit, including specific recommendations for pediatric and obstetrical patients, and for hospitals with limited availability of blood components or means to achieve definitive hemorrhage control. We believe that harmonization of MHPs in our region will simplify training, increase uptake of evidence-based interventions, enhance communication, improve patient comfort and safety, and, ultimately, improve patient outcomes.