Pediatric Transport Overview

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
Cardiac Trauma
7% 22%
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
 Sufficient volume of critically ill and
injured patients to enable team to
maintain expertise
 On-line medical control by qualified
physicians
 Ground and/or air ambulance capabilities
 Communications/dispatch capabilities
 Prospectively written clinical and operational
guidelines
 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  Neonatal courses
 Required  Required
 PNCCT  NRP or NALS
 PALS, APLS  Optional
 Optional  S.T.A.B.L.E
 PEPP
 Pediatric BTLS
 ATLS
Team Training
 Procedures  Chest tube insertion
 Advanced airway  Hemodynamic
management monitoring
 Specialized  Vascular access
Medication  ICP monitoring
Administration  Ventilator management
(PGE’s, surfactant,
vasopressors)  Isolette
 Chest
decompression
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  Helicopter
Ambulance  155 MPH
 70 MPH  23 minutes to Ellijay
 100 minutes to  30 Minutes for peds
Ellijay specialty care
 2 hours for peds  = 53 min trip time
specialty care
 = 3.7 hours trip
time
Concern about Safety of Flight
HEMS Industry Statistics
Absolute Number of Crew
Fatalities by Year, 1980-2001
25
20
15 Crew
Fatalities
10
= 7.5
5
0
1980 1986 1992 1998
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.”
 They are illusions that fail to properly
reflect the overlapping responsibility
issues this setting produces
 EMTALA specifically places medical
control of the patient in the hands of
the transferring physician until the
moment of departure
 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.
 Responsibility then diminishes from the
referring facility and increases to the
receiving facility as the distance
changes
 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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 PNCCT  NRP or NALS

 PALS, APLS  Optional

Number of Personnel in HEMS 1980-2001

Number of HEMS Helicopters 1980-2001

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