Critical Care Medicine
- Emergency assessment of a patient for transfer:
General principles with moving patients
Specific transport problems by organ system
Determining how the patient should be transferred
Preparing to transfer
Cost effectiveness of medical transports
What to expect en route?
Aggressive organ system support soon after the onset of acute life-threatening emergencies such as trauma, myocardial infarction and stroke improves outcome. The interests of critically ill patients should be best served by medical care delivery in a facility possessing a full range of necessary resources: monitoring technology, round-the-clock skilled personnel, invasive diagnostic capability and comprehensive surgical care.
A facility offering all these attributes defines a tertiary medical care center. There is evidence that critical care services provided by tertiary centers improve outcome for selected patient populations. Regionalization of health care for trauma, premature neonates, and burned patients has become common and the value of a rapid transportation system has been demonstrated in the initial care of traumatically injured patients. Critically ill medical-surgical patients may also benefit from regionalization of critical care services.
Emergency assessment of a patient for transfer:
From outside of healthcare facility
Stabilization entails assurance that the patient is likely to survive a trip where decompensations probably may not be completely corrected but only ameliorated to buy time. The classic "ABC" must be absolutely assured (Airway, Breathing and Circulation). If there is significant question about these hemodynamic and ventilatory parameters, transfer should be delayed until they can be effectively stablized. If they cannot be stabilized at the scene, the reality is that the patient probably won't survive.
If definitive care is delayed, irreversible organ system damage may occur, increasing morbidity and mortality as well as hospital length of stay. Traditional medical evacuation teams consisting of nurses or emergency medical technicians may not have sufficient experience in advanced hemodynamic monitoring and life support. As a result, they may be ill equipped to deal with critical care transports expertly. A sizable number of basic inter-hospital transport inadequacies were of an extremely basic nature. Therefore, "scoop and run" transport protocols used in trauma are evolving to "stabilize and transport" protocols for critical care medicine.
The issue of physician-accompanied "critical care" transport
Some reports suggest the need for initial evaluation and stabilization of critically ill medical-surgical patients by a critical care physician during the transport process. Physician-staffed transport system are useful specifically for the stabilization and transport of unstable patients with cardiac disease, where unpredicted decompensations can be quickly lethal if not countered at the physician level of expertise.
Much of the debate regarding the advisability of physician-accompanied inter-hospital transport teams takes the form of subjective, retrospective assessments as to whether or not physician presence might have been needed or useful. It is difficult to predict on the basis of preflight screening and consultation which patients would require cost-intensive physician attendance during transport.
Experienced critical care physicians are rarely available for immediate transport “after hours,” dramatically increasing response times. A more compelling question is: Would a critical care transport improve outcome and be much more cost-effective than transports without physician physical presence but with physician input (i.e., by portable cellular phone after assessment by an experienced ICU nurse)?
General principles with moving patients
A concerted evaluation should be made as to whether the patient will survive the trip as loaded. Many factors must be taken into account: recent history of unstable vital signs, recent cardiac arrhythmias, potential for acute respiratory failure, inability to maintain an airway, potential for vomiting en route, potential for bleeding or hypotension, and many more.
As a practical matter, if the potential for sudden instability en route passes the "better than not" test, the patient should not be transported until that potential is addressed and fixed. Trying to fix hemodynamic and ventilatory instabilities in a moving vehicle is notoriously difficult. The patient has a better chance of survival if those potential difficulties are addressed before movement.
If in doubt as to airway, it's usually better to intubate for the trip. This also allows more effective sedation as needed. For patients with some degree of obtundation, it is frequently better to place an NG tube and drain the stomach to avoid vomiting. Pressure dressings over bleeders are usually sufficient if bleeding has obviously stopped. it is good to hang bags of vasopressors and have them in-line if not actually infusing in case blood pressure becomes an issue en route. Emergency IV short-term sedation should be ready if the patient suddenly becomes agitated. It isn't out of the question that short-term neuromuscular blockade may be occasionally needed to control an agitated patient.
Specific transport problems by organ system
Transferring patients with severe trauma
It has been shown that speed of transfer to definitive care for trauma patients generates better outcomes. Some authors suggest that the shortest time possible from trauma to operating room is the key to outcome. Therefore, many aeromedical transport groups spend as little time in preparation for flight as possible, only maintaining the ABCs. Obvious fractures are splinted. Analgesia is given if there is no other contraindication.
Transferring patients with acute lung injury
Those transferring patients with acute lung injury should err on the side of intubating the patient if that expertise is available. Acute respiratory failure is difficult to deal with in a moving vehicle and the patient cannot be adequately sedated if the airway is not protected. If the patient has multiple chest trauma, chest tubes should be considered prophylactically.
Transferring patients with renal failure
Patients transferred for dialysis should have their electrolytes stabilized and potassium lowered with Kayexalate if necessary. Acidosis is treated with a temporary infusion of bicarbonate to decrease hyperventilation, which might exacerbate respiratory failure. Aggressive diuresis is given if there is urine output or pre-emptive intubation if there is fluid overload and respiratory insufficiency.
Patients with cardiogenic shock
Patients exhibiting unstable hemodynamics need rapid transfer to a full-service tertiary care center for cardiac catheterization, angioplasty or a definitive surgical procedure. Cardiac perfusion pressure should be maintained with adequate blood pressure, utilizing inotropes if necessary. Morphine should be given to decrease preload if needed. Beta blockade is given for decompensated tachycardia. If a portable intra-aortic balloon counterpulsation device is available, it should be considered before transport if a balloon tech is available for the trip.
Patients with myocardial infarction and acute coronary syndrome
Angina should be treated with beta blockers, nitrates and analgesia. Transport should be accomplished as soon as practicable, with full cardiac monitoring and a full range of defibrillation, countershock capability and a full range of cardiac medications.
Patients with neurologic and neurosurgical issues
Patients with any neurologic issue should have a CAT scan of the brain before transfer, and t-PA should be considered if in contact with a stroke center physician. Patients with stroke should have their blood pressure untreated if high to maintain maximum brain perfusion. Patients with intracranial bleeds should have their blood pressure limited to a systolic pressure of 140 or below with an appropriate antihypertensive.
Both should be transported with their upper body in 30% elevation and their airway under constant observation, with the option of emergency intubation if necessary. Normally sedatives or sedative analgesia is not given to patients with acute head injuries so an adequate mental status assessment can be done on arrival at the tertiary center.
Patients with fulminant hepatic failure
These patients should be intubated before transport and sedated with short-acting drugs such as fentanyl if they are agitated. Most benzodiazepines become long-acting drugs in patients with liver failure. Electrolytes should be checked and corrected if possible. Lactulose should usually be administered unless there is some contraindication. Patients may need dialysis as well on arrival at the tertiary center.
Determining how the patient should be transferred
Aero-medical transports offer a significant survival advantage over ground transportation for patients with trauma scores between 10 and 5. More therapeutic interventions by the helicopter team contributed to better outcomes for the air-transported group. These included endotracheal intubations, stopping hemorrhage, blood transfusions and more aggressive electrolyte resuscitation. The interval between the trauma and arrival of helicopter medical personnel, not the speed with which the patient is delivered to the tertiary care facility, is the key factor in improving survival.
When helicopter service is available, it makes sense to combine the “golden hour” of trauma with the ability to stabilize and maintain on portable life-support systems for a trip back to the tertiary center for definitive treatment. Aero-medical transport is, however, not without risk. There were 55 crashes of air ambulances between 2002 and 2007, resulting in 54 fatalities. Between 2007 and 2008 there were nine crashes resulting in 35 deaths. These sobering statistics have promoted much more stringent flight rules, resulting in more ground transports, which change the time-efficiency dynamics considerably.
Preparing to transfer
What should be done prior to transport? Once a patient arrives who is likely to require transport, call the transport service immediately to get started. They can offer valuable advice and begin gearing up for the transport logistics early, rather than late. Minutes sometimes count. In one group transferred by air, the time from injury to arrival at the hospital was an average of 23 minutes longer than the ground-transferred group due to time spent at the scene stabilizing the patient.
The argument has been made that a patient is inherently more unsafe reposing in an outlying emergency department than on a transport to a major center with inadequate expertise. The person in charge in an outlying area doesn’t know what to do for the patient, or is afraid to do anything; that’s why he or she wants the transport to occur. If the patient is in an emergency department, the attending physician probably has other patients to see and the ED nurses are busy with other patients as well.
It is unclear whether this is true. In a transport vehicle with an experienced paramedic or critical care nurse accompaniment, the patient at least gets most of the supportive care he or she could access in an ED and is the principal focus of attention. Paramedics and critical care nurses are specifically trained to recognize decompensations and do whatever is possible within their area of expertise to reverse them. It could be argued that most decompensations respond to relatively simple treatment and those that don’t have a high probability of progressing to death no matter what is done.
What documentation is required? The Consolidated Omnibus Budget Reduction Act of August 1986 (COBRA) requires a transferring hospital to assume liability for the adequacy of stabilization before any transport takes place. This also places the transferring hospital in the position of guaranteeing the adequacy of the receiving facility, with defined legal sanctions awaiting those found inadequate. The hospital will be held accountable for using the most suitable type of transfer for the patient’s needs, a fact not lost on insurance carriers, who will be looking very carefully at the qualifications of transport teams.
The Federal Emergency Medical Treatment and Labor Act (EMTALA) requires most hospitals to provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition. This does not necessarily mean that facility must admit and offer definitive treatment to that same patient.
If the facility does not have the appropriate provisions or expertise to treat the patient after stabilization, it may transfer him or her to a facility that does. Their only obligation is to ensure stabilization pre-transport. Once a facility having the ability to treat the patient is officially notified, it may not turn down the patient for transfer. The patient becomes its responsibility from the time it is notified. Accordingly, once notified, it becomes the tertiary facility's responsibility to prepare for receiving the patient.
Cost effectiveness of medical transports
Some data suggest that timely transport of patients to accomplish regionalization may be cost-effective as it may conserve complications and decrease hospital length of stay. As yet there are few convincing data that demonstrate the need or cost-effectiveness of physician accompaniment of most inter-hospital patients, especially when deployment and access times are delayed and extended.
To maintain expensive physician-assisted critical care transport teams for the relatively few runs where physicians might make a critical difference is arguable. In addition, there have been no objective measures of types of interventions a physician might be required to do, stratified by severity of illness scores. Until there is a randomized, prospective study of physician-accompanied vs. -unaccompanied transports, questions of appropriateness or cost-effectiveness cannot be effectively answered.
What should the transfer vehicle have in terms of equipment and personnel? The vehicle, be it an aircraft or a ground mobile unit, must have a full range of monitoring, resuscitative and life-maintaining equipment, appropriately miniaturized or downsized for most effective mobilization.
This includes but is not limited to IV solutions, plasma expanders, short- and long-acting IV medications, vasopressors, inotropes, sedatives, analgesics, portable mechanical ventilator with a full range of endotracheal tubes and other airway devices; full heart rate, blood pressure and ventilation monitoring with pulse oximetry; defibrillator and countershock device; warming and cooling blankets.
What to expect en route?
What kinds of medical problems should be watched for en route? Performing therapeutic manipulations in a moving vehicle can be challenging, especially in the cramped quarters of a helicopter. An agreement with the pilot of a helicopter before a transfer begins should be in force that an emergency landing might be necessary to create more space for emergency treatment, and he or she should be aware of this potential exigency during the flight. The same is true for mobile ground trips: the ambulance may need to pull into a secluded area as needed.
Should a referring hospital authorize "panic" transfers if there is a long wait for the referral facility's vehicle?
Example: At 0300 on a Friday night, a panicky call is received from a small hospital approximately 70 miles from the tertiary referral center requesting an immediate CCM team deployment. The patient is a 66-year-old female with a history of hypertension who came to their ED complaining of severe interscapular back pain and shortness of breath. A CAT scan shows what their radiologist considers to be a leaking thoracic aneurysm. The hospital does not have the ability to deal with this and needs the patient transferred for definitive care as soon as possible
The area of the tertiary care facility is socked in with storms. Obviously, there is no helicopter service. When informed that the helicopter is not available, they say they will put the patient in a local ambulance and send her with one of their nurses. They say they can have an ambulance there and the patient loaded in 15 minutes. It is normally an hour drive (with lights and sirens). Total estimated time for their ambulance to reach you from the time the decision is made is about 1 hour and 15 minutes.
The benefit: Fastest possible transport time.
The risk: If serious complications occur en route, the patient is at high risk that the low-tech equipment and low-experience accompanying personnel will not be able to handle it.
An alternative possibility is to call out the Critical Care Transport Team, have them gather their personnel and equipment, proceed to the scene by ground ambulance, stabilize the situation, then transport the patient back under the care of an experienced critical care physician and modularized monitoring equipment offering a full range of treatment options.
However, the furthest CCM team member lives about 30 minutes from the hospital. Once there, anticipate another 15 minutes to get equipment organized, mobilized and moved to the ambulance. It is about the same time-in-transit to the community hospital. So 45-minute mobilization time plus 1 hour and 15 minutes transit time through the storm gives you a time to arrival of about 2 hours.
The benefit: More effective stabilization of the patient once the team arrives and during the trip back to definitive care.
The risk: It will take at least 45 minutes or more longer to get a high-tech and high-experience team to the scene than if they simply put the patient in a local ambulance and transfer with lights and sirens. Most patients will survive the trip if basic life support is available.
It remains unclear whether the additional time required to mobilize a specialty team and the increased cost thereof is justified for the inter-hospital transport of critically ill patients.
The patient population reached by such mobilization must have a reasonable chance of salvageability as a direct result of access to the service provided. Toward this end, it must be held as ethically acceptable to utilize some form of "scoring system" to determine if a prospective patient is likely to benefit from transportation to a more expensive and sophisticated health care delivery service. Patients not likely to benefit from transfer must be transported by other means.
For a population of patients who would be moved from one locale to another, it must be demonstrated that such a change will result in an ultimate savings to the reimburser. This means a good chance of a shorter hospital course. Otherwise, there is no benefit in expending resources to move a patient from one place to another.
If it can be found economically and logistically acceptable to reach new patient populations by a critical care inter-hospital transportation system, the converse is not necessarily true. The utilization of a specialized transport system to remove “ resource depleters” from one hospital to a more vulnerable one cannot be condoned.
If it can be shown that reimbursement of facilities unable to adequately treat critically ill patients is self-defeating, it must follow that the best interest of reimbursers is best served by selective allocation of health care resources at the tertiary level. If it can be shown that transporting critically ill patients to tertiary care centers is cost-effective in the long run and that a reasonable number of the patient population served by it can be returned to productivity, then adequate reimbursement to maintain the service's viability is mandated.
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