1. Pediatric Transport Overview
Toni Petrillo-Albarano, MD
Children’s Healthcare of Atlanta

2. 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

3. 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

4. Background
Neonatal-pediatric transport programs part of the continuum of care in a system of emergency medical services for children

5. Background
They provide a safe, therapeutic environment for pediatric patients who must be transferred between health care institutions under urgent or emergent circumstances

6. 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.

7. Goal Early direction and initiation of advanced care
Improve safety of the transport and patient outcome.

8. Goal
Treatment and monitoring with the expected expertise and capabilities of the tertiary care center while the patient is still in the referring facility

9. Essential components
Dedicated team proficient at providing neonatal and/or pediatric critical care during transport

10. Essential components
Sufficient volume of critically ill and injured patients to enable team to maintain expertise

11. Essential components On-line medical control by qualified physicians
Ground and/or air ambulance capabilities
Communications/dispatch capabilities
Prospectively written clinical and operational guidelines

12. Essential components Quality and performance improvement activities
Administrative resources
Institutional endorsement and financial support.

13. 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

14. 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

15. 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

16. Team Composition Many dedicated teams include a physician
Little published evidence that this configuration results in improved outcome compared with non-physician teams

17. 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

18. 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

19. 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.

20. Consent
The basic concept is that “informed consent” must be obtained for the purposes of any treatment of a patient

21. 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

22. 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.

23. 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)

24. Ground Vs Air
Distance to the closest appropriate facility is too great for safe and timely transport by ground ambulance

25. 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

26. 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

27. 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.

28. Concern about Safety of Flight

29. 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

30. 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

31. 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

32. Who Chooses?
The mode of transport, as per EMTALA, is officially determined by the referring physician

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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.

41. 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.”

42. Liability/Responsibility
They are illusions that fail to properly reflect the overlapping responsibility issues this setting produces

43. Liability/Responsibility
EMTALA specifically places medical control of the patient in the hands of the transferring physician until the moment of departure

44. 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.

45. Liability/Responsibility
Responsibility then diminishes from the referring facility and increases to the receiving facility as the distance changes

46. Liability/Responsibility
The transport team retains medical responsibility until that proper hand-off has occurred, even though the receiving facility shares responsibility

47. Cost
The approximate cost of a medically configured ground ambulance is approximately $ to $ , depending on the manufacturer and model selected
The annual maintenance and fuel costs might range from $ to $ per vehicle

48. 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

49. 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

50. 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

51. Questions?????