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 Since the transport team transports a wide variety of patients we must be prepared to handle them. The staff is well trained in how to handle all types of injuries and illnesses. Medical Control is available to the team 24/7 to provide medical direction if needed.

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 APLS- Advanced Pediatric Life Support-3 days with an animal lab NRP-Neonatal Resuscitation Program-8 hours AHA PALS-Pediatric Advanced Life Support-16 hours AHA PEPP-Pediatric Emergencies for Pre-hospital Providers 16 hours ALS 8 hours BLS Pediatric BTLS-Pediatric Basic Trauma Life Support should be included in the curriculum because the other courses do not address packaging of the pediatric trauma victim in detail. STABLE- Course designed to teach hospital staff the procedures to stabilize and prepare to transfer a neonate. ACLS- Advanced Cardiac Life Support (ACLS) should be standard training for all personnel assigned to a transport team which does both adults and children. AHA. ATLS- Advanced Trauma Life Support-ACS has scenarios with pediatric patients; however it is primarily an adult course.

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 A time comparison of a typical mission to Ellijay or any facility 40 miles outside of the metro Atlanta area.

Concern about Safety of Flight

HEMS Industry Statistics This is the data that the media presents to show how many people die in HEMS accidents each year. The patients have been removed from the empirical information because their numbers are limited, and only count for a portion of the total flight. The data above represents the entire crews (pilots, nurses, paramedics, and doctors) killed in the line of duty as related to a HEMS flight over a 20 year period. The average is 7.5 fatalities per year over the duration. = 7.5

HEMS Industry Growth Number of Personnel in HEMS 1980-2001 The blue bars shows the growth in the industry, and with exception of Desert Shield & Desert Storm in 1991 which temporarily took a lot of the HEMS personnel out of the United States in support of that cause, the industry has shown continual growth. The green bars at the bottom show the number of dedicated aircraft as seen in the next slide. Number of Personnel in HEMS 1980-2001

HEMS Industry Growth Number of HEMS Helicopters 1980-2001 The green bars depict the progressive growth of the industry in the number of dedicated HEMS aircraft (DS&DS considerations) starting with 39 in 1980 and growing to 400 by the year 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?????