Pediatric Transport Overview Toni Petrillo-Albarano, MD Children’s Healthcare of Atlanta Goal and Objectives Understand goals of Pediatric Transport Identify make up and skills of.
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Transcript Pediatric Transport Overview Toni Petrillo-Albarano, MD Children’s Healthcare of Atlanta Goal and Objectives Understand goals of Pediatric Transport Identify make up and skills of.
Pediatric Transport Overview
Toni Petrillo-Albarano, MD
Children’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
Diagnostic Categories Of Children
Transported
Trauma
22%
Cardiac
7%
Other
9%
Respiratory
32%
Neonatal
15%
Neurologic
15%
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
Absolute Number of Crew
Fatalities by Year, 1980-2001
25
20
15
10
= 7.5
5
0
1980 1986 1992 1998
Crew
Fatalities
HEMS Industry Growth
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
1980 1983 1986 1989 1992 1995 1998 2001
Number of Personnel in HEMS 1980-2001
HEMS Industry Growth
400
350
300
250
200
150
100
50
0
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?????