INTRODUCTION
The transfer of critically ill patients between hospitals (interfacility transfer) involves getting patients to the appropriate level of care in the most efficient amount of time. Interfacility transfers often occur when the patient’s care requires specialized treatment or resources that exceed the capability of the hospital to which the patient first presents. Interfacility transports of critical patients often demand rigorous resources and intensive driving mileage,[1] and ensure the safe transport of patients from one facility to another.[2]
Recent studies have focused on the safety and necessity of critical interfacility transfers, essential equipment needed, and the possibility of adverse events, including the causes and frequency of their occurrence.[3⇓-5] However, these studies did not provide specific recommendations for the best practices for potential issues during the interfacility transfer process. Common technical difficulties included restricted space, low-light conditions, loud noise, and equipment malfunctions.[6,7] Medical adverse events during interfacility transport include procedural errors, drug errors, and loss of intravenous (IV) access. Furthermore, patients experienced life-threatening events from bradycardia, hypotension, and cardiac arrest.[6,7] Difficulties with cardiac monitoring and electrocardiograms were also observed, indicating that cardiac events may go unnoticed during transport due to monitoring methods as well as the mechanics of transport.[8] Consequently, proposed solutions to decrease the risk of complications included improving monitoring capabilities and using specialized transport teams.[6]
With evolving advancements in stabilizing and treating critically ill patients and increased use of interfacility transport services, there is a need for evidence-based guidelines for transporting patients to ensure the best possible treatment enroute.[9] The purpose of this paper is to review available evidence-based practices for the safest and most efficient interfacility transfer of critically ill patients.
METHODS
For this literature review, we searched the PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and Scopus databases to assess literature on “interfacility transport” as it relates to patients with emergent/critical medical conditions. The terms “transport”, “transfer”, “interfacility”, and “emergency” were used. Boolean operators and medical subject headings (MeSH) terms were used to combine search terms. Search results were further limited to English language, human, and adult. The result revealed 75 matches. Database searches were supplemented by screening the reference lists of relevant studies and reviews, but we did not contact any corresponding authors for more information. This resulted in more eligible articles for inclusion. In total, 48 studies were included in the analysis.
Two reviewers independently screened titles and abstracts using the following criteria: Adult patients who had emergency department (ED)-to-ED transfer in critical condition were included. Articles were not included if they were not primarily in English or did not have an English translation, were focused on pediatric patients or were preliminary/unpublished results. Any discrepancies were resolved by discussion among the investigators. Additionally, we excluded articles not involving critically ill adult patients or articles not relating to urgent and/or emergent medical conditions.
RESULTS
Respiratory failure and prone positioning
Acute respiratory distress syndrome (ARDS) is a common condition associated with critical illnesses, which causes substantial mortalities.[10] Placing patients in the prone position improves oxygenation and reduces mortality in ARDS patients.[11] As the prone position becomes a more common practice for patients with hypoxic respiratory failure, new challenges are arising as traditional transportation systems are designed for supine patients. The challenges for transporting teams include preparing and situating the patient for transport, loss of established airway for patients receiving invasive ventilation, and performing cardiopulmonary resuscitation (CPR) on prone-positioned patients.
Transporting patients in the prone position can be a time-consuming affair, with on-scene time reported to be 1-3 h.[12] Patients requiring invasive mechanical ventilation need to be adequately sedated and secured to the stretcher to prevent them from shifting during transport, which can dislodge lines/tubes.[13] Patients may also require vasopressor agents such as norepinephrine during transport.[13]
Since prone positioning interferes with being able to access patients’ airways and endotracheal tubes, care must be taken to prevent dislodgement of any airway devices by supporting the head. Transport clinicians need to ensure that the intubated patient’s airway or mechanical ventilator has not been compromised, such as dislodgment or blocking of the endotracheal tube.[14] Preventive methods include the use of an anesthesia pillow or turning of the head slightly to one side and supporting it with towel rolls.[13] Although earlier reports indicated an increased risk of airway compromise in prone-positioned patients, recent literature suggests that there is no increase in accidental extubation, accidental catheter removal, endotracheal tube obstruction, barotrauma, or ventilator-associated pneumonia.[10]
In the event of a proned patient’s cardiac arrest, chest compressions can be performed with patients in the prone position. It is likely beneficial to a patient’s outcome to begin CPR immediately, rather than to supinate the patient before starting CPR. There is, however, conflicting evidence as to the method of performing chest compressions for proned patients. Compressions performed between the level of the T7-T10 vertebrae, below the inferior angle of the scapula,[14⇓⇓-17] were reported to be effective. However, the European Resuscitation Council (ERC) suggests performing compressions between the scapulae at the usual depth and rate.[18] Defibrillator pads can be placed either anterior-posterior or bi-axillary.[16,18] Support under the sternum may be needed to allow for proper chest compression. After initiating CPR, there may be a need to supinate the patient. The American Heart Association (AHA) recommendation for prone-positioned patients without an advanced airway is to supinate the patient and resume CPR; in the case of a prone-positioned patient with an advanced airway, it is recommended to continue CPR in the prone position to prevent dislodging the airway.[17] Another recommendation by the ERC is to continue prone CPR until supination is needed for an intervention, e.g., airway complications, or when chest compressions are ineffective and spontaneous circulation is not restored rapidly within minutes (supplementary Figure 1).[18]
Recommendation for personnel: transport clinicians with advanced cardiac life support (ACLS) experienced with difficult airways.
Recommendation for equipment: cardiac monitoring, advanced airway equipment, advanced sedative, paralytic medications, and portable ventilator.
Aortic dissection and blood pressure management
Acute aortic dissection (AAD) is an emergent life-threatening condition with a high mortality rate. As urgent surgical care is often the definitive treatment for patients with type A AAD, patients receiving care at hospitals with a high volume of aortic surgeries are associated with improved outcomes and should be strongly considered.[19] Interfacility transfer is not associated with a change in operative mortality, although patients transferred from low-volume facilities to high-volume centers experienced delays in receiving surgery. Transferring patients from a low-volume facility to a high-volume hospital is associated with a 7.2% absolute risk reduction in operative mortality.[19] Nonetheless, transport by air is not associated with faster time to surgical intervention[20] or better outcome.[21] Therefore, the type of transfer that provides the most effective transport for patients with AAD should be considered.
The 2010 AHA guidelines call for a desired systolic blood pressure (SBP) range 100-120 mmHg (1 mmHg=0.133 kPa) and a heart rate less than 60 beats/min for patients with acute dissection.[22] Patients undergoing interfacility transfer for suspected acute aortic dissection (SAAD) have heart rates exceeding 80 beats/min in 41.9% of cases and an SBP exceeding 120 mmHg in 67.7% of cases by the time the medical transport team arrived at the referral facility.[23] Poor blood pressure management prior to transfer can lead to delays in medical transport of SAAD and AAD and may lead to worsening outcomes. Patients with SAAD and invasive arterial blood pressure (IABP) monitoring undergo more aggressive hemodynamic management with a higher frequency of meeting hemodynamic goals upon arrival at the accepting facility.[24] The same study reports that invasive arterial cannulation by transport clinicians increases bedside care by 6 min,[24] thus supporting the placement of IABP catheters at the referring facility prior to transport.
Recommendation for personnel: clinicians with knowledge about AHA’s guidelines, experience with pharmacokinetics of common anti-hypertensive agents such as esmolol, nicardipine, clevidipine. Transport personnel may be trained on how to insert arterial line catheters and how to set up arterial blood pressure monitoring.
Recommendation for equipment and drugs: cardiac monitoring, arterial blood pressure monitoring; desired choice of antihypertensive agents based on the destination facility protocol.
Extracorporeal membrane oxygenation (ECMO)
ECMO is a treatment typically reserved for patients with severe respiratory or circulatory compromise. While transport of patients on ECMO has been studied for some time, challenges exist in the interfacility transfer of ECMO patients. One of the biggest hurdles is the preparation of an ECMO patient for transport. Transport teams need to be experienced in critical care transport in addition to having ECMO-specific training. Teams consisting of a critical care transport nurse, a paramedic, and an ECMO specialist (perfusionist, specially trained nurse, or respiratory therapist) are sufficient and are associated with similar patient outcomes when compared to teams without a physician, nurse practitioner, or physician assistant.[25]
Complications during transport of ECMO patients occur between 28% and 40% of transports. The majority (62%-65%) of patient-related complications include loss of tidal volume, hypovolemia, and circulatory instability, which can be associated with failures or limitations of medical equipment or issues associated with air transport. Transport via aircraft can cause complications due to forces associated with aircraft acceleration and deceleration and the changes in atmospheric pressure at altitude, which can create vibrations and dislodgement of tubes and lines.[26] Additional large-bore venous access should be established for immediate fluid resuscitation before transport, and infusions of vasoactive drugs must be immediately available if hypovolemia occurs.[27]
Recommendation for personnel: a perfusionist, a critical care transport nurse who is familiar with ECMO clinical scenarios and ventilator management, and a respiratory therapist recommended but not mandatory.
Recommendation for equipment: a backup ECMO circuit, ventilator, cardiac equipment. A point-of-care system for arterial blood gas analysis is also recommended.
Intracranial hemorrhage
Acute intracranial hemorrhages (either spontaneous or traumatic) require transfer to a facility with neurosurgical and neurocritical care for both diagnostic and therapeutic reasons.[28] Advanced monitoring, clinical experience, 24-hour magnetic resonance imaging (MRI) availability, and neurosurgical backup are necessary resources in managing patients with intracranial hemorrhages. Transporting patients with moderate to severe traumatic brain injury (TBI) (Glasgow Come Scale [GCS] <12) to a trauma center is well supported.[29⇓-31] Admission of spontaneous intracranial hemorrhage (sICH) patients to a neurologic ICU is associated with reduced mortality rates.[32] Referring medical centers should thoroughly evaluate the patient prior to transfer as the ideal service at the accepting facility (neurology, neurosurgery, etc.) is determined prior to the transfer of the patient to ensure a quick and smooth transfer of care.[29]
sICH accounts for 20% of strokes and is typically associated with an aneurysmal rupture.[33] A third of patients with sICH demonstrate acute neurological deteriorations (ND) with factors such as blood pressure variability (BPV) contributing to outcomes. Transfer of patients with TBI with CT findings of hemorrhage to a Level I (the highest level) or II trauma center is associated with survival benefits.[34] Transferring facilities need to monitor the maximum systolic blood pressure (SBPmax), as 75% of patients with an SBPmax > 240 mmHg develop ND.[32] Prolonged and severe hypertension can contribute to growing intracranial pressure (ICP), increase the risk of sICH, and worsen existing sICH. For this reason, the current guidelines from the American Stroke Association (ASA)[35] state that the SBP of patients with sICH should be reduced to 160 mmHg or less. Another important variable includes the difference between the highest and the lowest SBP (SBPmax-min) and patient age. An external ventricular drain, if neurosurgical resources are available, may be placed at the first facility to continuously monitor ICP or divert cerebrospinal fluid (CSF).
The main interventions initiated by the transport team for patients with ICH are pharmacotherapy and ventilator management. The most common medication administration includes sedative management (27%), followed by anti-hypertensive medication management (26%).[36] Patients received antiepileptics (P=0.030) and hyperosmolar therapy (P=0.031), with a significantly greater number of ND patients receiving interventions.[32] For the transport crew, the medical control (MC) physician determines the number and type of monitoring devices, such as ICP monitors, and the need for additional staff (i.e., second paramedic, nurse, or physician). ICP monitors need to be observed during the whole transport time to avoid dislodgement of the catheter. If dislodgement occurs, sterile dressing must be applied as CSF may leak from the site. A large-bore IV catheter should be established for fluids to maintain a minimum blood pressure or medications such as mannitol to reduce cerebral edema with increased ICP. Steps such as pre-transport checklists should be taken to avoid mistakes such as mannitol dosing errors.[37]
Recommendation for personnel: transport critical care nurses who are familiar with AHA/ASA guidelines for target blood pressure, pharmacokinetics of commonly used antihypertensive agents for these patients (nicardipine, clevidipine), ICP management, ventilator management in cases of increased ICP.
Recommendation for equipment: cardiac monitoring with the capability to measure cuff pressure every 2-3 min. Arterial blood pressure monitoring is optional but not mandatory.
Uncontrolled vaginal/uterine hemorrhage
While most ED visits for vaginal bleeding are managed at their respective facilities, there are situations where vaginal bleeding requires transfer. As an example, there are instances where menorrhagia can result in symptomatic anemia.[38] Serious bleeding can occur as a result of anatomical disruptions (polyps, fibroids), systemic hematological/oncological or endocrine etiologies, or trauma.[39] Severe uterine or vaginal bleeding may also occur post-partum in circumstances of multiple gestations, multiparity, prior history of post-partum bleeding, prolonged labor, and medications that can cause bleeding.[38]
The primary steps in managing vaginal hemorrhage are to identify the etiology, achieve source control and effect stabilization, and in cases where that cannot be done effectively at the local ED, initiate transport. This generally includes an external and internal (speculum) exam to better identify and address the source of bleeding. Symptomatic patients should also receive a transfusion of red blood cells or other necessary blood products.[38] With menorrhagia, if there is heavy bleeding and the cause is unknown, the focus of the treatment should look to reduce the amount of blood loss. This can be achieved through the use of non-steroidal anti-inflammatory drugs, oral tranexamic acid, combined or progesterone oral contraceptive pills, or a progesterone-eluting intrauterine device.[39] Transport teams should be ready to manage simultaneous administration of blood products and medications, and the receiving facility should have an interprofessional team ready for the patient’s arrival.
Recommendation for personnel: transport critical care nurses or paramedics with knowledge of blood products, blood transfusion, allergic reaction to blood products. Transport clinicians familiar with managing shock is strongly recommended. Knowledge about tamponade devices is optional but not mandatory.
Obstetric emergencies
Interfacility transport of obstetric emergencies presents significant challenges due to the numerous changes, both anatomically and physically, of pregnant patients. Other complications may include trauma, with 6% to 7% of all pregnancies having trauma complications.[40] Transporting a pregnant patient is often more beneficial than transporting the postpartum mother and neonate from the referring facility. Neonates who are transferred post-delivery are associated with higher rates of complications and greater morbidities when compared with those who were transferred antenatally.[41] As a result of the difficulties in the management of pregnant patients, transport to a higher level of care should be considered in a willing, stable patient where impending delivery is not expected during transport, and the benefits of transport outweigh the risks.[41⇓-43]
High-risk obstetric patients had a lower risk of maternal morbidity when treated at high-acuity centers compared to low-acuity centers.[44] Hospitals with the number of high-risk deliveries comprising >7.1% of their total number of deliveries were considered high-acuity centers. Using an established comorbidity index, high-risk conditions had a weight ≥3. High-risk conditions included severe preeclampsia/eclampsia (weight 5), chronic congestive heart failure (weight 5), congenital heart disease (weight 4), pulmonary hypertension (weight 4), and age >44 (weight 3).[44] Another study reported that transfer to a higher level of care may improve the outcome or change the course for 11% of all pregnancy-related deaths recorded in the study, with recommendations that maternal transport protocols should include earlier transfer to a higher level of care.[45]
Ground transport is the preferred method for obstetric transport due to more direct hospital-to-hospital transfer, a larger area to work in an ambulance, greater availability in number and utility in all weather conditions, and incidentally, lower cost.[43] Air transport is preferred over ground transport when long distances increase transport time. Transport personnel should be advanced life support (ALS) capable, including ACLS, IV cannulation, endotracheal intubation, neonatal evaluation and resuscitation skills.[43] They should be trained in obstetric and neonatal emergencies and be able to perform skills including interpretation of fetal monitors, performance of vaginal delivery, and administration of obstetric drugs such as tocolytics, anti-hypertensive agents, hemostatic agents, and magnesium sulfate.[41,46]
The frequency of adverse events in pregnant patients during both air (8.1%) and ground (4.8%) transport is relatively low. Exacerbation of hypertensive conditions is the most common adverse event, occurring in 4.5% of all transports.[47] Other adverse events included hypotension (1.3% of transports), altered mental status (0.2%), and dysrhythmia (0.1%); no other adverse events were reported for either air or ground transfers (n=1,101).[47] All hypotensive episodes were resolved with an IV fluid bolus. One study found that the rate of deliveries during the transport of obstetric patients, even those in advanced labor and fully dilated, was zero.[41] Another study found that the likelihood of delivery during interfacility transport is low, although screening patients for a high probability of delivery during transport is an important factor.[47] It is possible to transport obstetric patients in advanced labor if all factors, such as transport time and transport personnel skill, are considered and deemed acceptable by the care teams.[41] However, it is still recommended to delay transport if delivery is anticipated to occur during transport.[43]
Maternal and fetal monitoring and intervention are crucial in effecting an optimal transport. Fetal heart rate monitoring is recommended for the transport of critical obstetric patients, including trauma patients ≥23 weeks’ gestation, preterm labor, hemorrhage, sepsis, preeclampsia and eclampsia.[41,43,46,48] Continuous fetal heart rate monitoring is the preferred method; if continuous fetal monitoring is unavailable, fetal heart rate auscultation at least every 15 min can be sufficient.[41,43] Placing the patient in the left lateral position will avoid episodes of reduced cardiac output, hypotension and episodes of hypoperfusion.[41,43,46,48,49] In the case of obstetric trauma, the severity of maternal injuries and gestational age should be considered; interventions for maternal health should take priority over interventions for the fetus.[41,49] When major injuries are present, the patient should be transferred to a trauma center or ED regardless of the gestational age of the fetus. Ideally, the trauma obstetric patients should be transferred to a Level I trauma center combined with obstetrics capabilities. If there are no life- or limb-threatening injuries and the fetus is viable (>23 weeks’ gestation), the mother should be transported to a maternity facility; if the fetus is considered non-viable (and/or <23 weeks’ gestation), then the mother can be transferred to an ED instead.[49]
Although delivery should be delayed for transport, if delivery becomes imminent during transport, then preparation for necessary equipment such as an obstetric delivery kit is necessary. Providers should prepare for neonatal resuscitation and administration of oxytocin to reduce postpartum bleeding.[43] In the case of cardiac arrest during transport, transport teams should focus on maternal resuscitation. High-quality CPR should be initiated with left lateral uterine displacement, prioritization of airway management and oxygenation, and termination of fetal monitoring.[50] Transport should be to a facility with the capability to immediately perform perimortem cesarean delivery while continuing resuscitation.[50]
Recommendation for personnel: Transport clinicians are required to perform vaginal delivery, be familiar with the pharmacokinetics and adverse events of magnesium sulfate, tocolytics, and anti-hypertensive agents (labetalol and nicardipine), and be skilled in adult and neonatal airway management. The ability to interpret fetal monitoring tracing is strongly recommended.
Recommendations for equipment: Cardiac monitoring, neonatal airway equipment, obstetric delivery kit, and fetal monitoring are strongly recommended.
DISCUSSION
Interfacility transfer is an essential part of the spectrum of patient care. Although numerous studies evaluated the safety and necessity of these transfers, they did not provide specific guidelines for the best practices during the interfacility process. With technological advancements and the increased use of interfacility transport services, it is vital to establish evidence-based transport guidelines.[9] The transfer process can be lifesaving tools that connect the patient to services and treatments not available at their current facility. The higher risk transfers include respiratory failure requiring prone positioning, aortic dissection, ECMO, intracranial hemorrhage, uncontrolled uterine/vaginal hemorrhage, and obstetrics (Table 1). Interfacility transport does not come without complications. These complications can be divided into four categories: pulmonary/airway, cardiovascular, infectious, and endocrine.[51] Airway complications may include desaturation, pneumothorax, lung collapse, or accidental extubation leading to airway loss.[52] Important transport precautions to target these issues should include a full oxygen tank, appropriate sedation of the patient, confirmation of proper endotracheal tube placement, and a working pulse oximeter. Cardiovascular complications include tachycardia, hypotension or hypertension, arrythmias, and cardiac arrests. It is vital to have appropriate cardiac monitoring as well as hemodynamic monitoring tools and the equipment required to perform resuscitation in cases of cardiac arrest.[53] Infectious complications may arise both to a transported patient with improper use of sterile equipment and to the providers taking care of a patient who may have a transferable disease.[51] This is best avoided with attention to equipment and supplies used in the patient’s care and good communication between the transport team and the receiving team on the patient’s medical condition. Last, endocrine complications such as hypoglycemia and hyperglycemia and acid-base changes may occur during transfer due to discontinuation or altering of insulin or fluid therapy or the interruption of other vital infusions such as vasopressor or sedation medications.[51] This may be prevented by attending to infusion alterations as well as stat checks of blood glucose, blood gases, and electrolytes. By selecting appropriate transport care teams, equipment, and tools for patients in transfer, the referring facility can ensure the safest transfer of patients.
Table 1. Special consideration in critically ill patients prior to and during transportation
| Disease states | Special considerations |
|---|---|
| Respiratory failure | ● Placing patient in prone position ● Secure airway and prevent dislodgment of any airway devices while patient is in prone position, through the use of anesthesia pillow and supporting head with towel rolls ● Initiating CPR with patient in prone position |
| Aortic dissection | ● Control SBP between 100 mmHg and 120 mmHg ● Control HR <60 beats/min ● Arterial blood pressure monitor may improve guideline adherence |
| Intracranial hemorrhage | ● Control BP <160 mmHg ● ICP monitors ● Sedative management and anti-hypertensive medication ● Securing large-pore IV access |
| Vaginal hemorrhage | ● Consider blood product transfusion ● Provide anti-inflammatory medication |
| Obstetric emergencies | ● Continuous fetal monitoring ● Identify cause of bleeding ● Consider transfer to high level facilities |
CPR: cardiopulmonary resuscitation; SBP: systolic blood pressure; HR: heart rate; BP: blood pressure; ICP: intracranial pressure; IV: intravenous.
Funding: None.
Ethical approval: Not needed.
Conflicts of interest: The authors do not have a financial interest or relationship to disclose regarding this research project.
Contributors: QKT wrote the first draft of this paper. All authors approved the final version.
The supplementary file in this paper is available at http://wjem.com.cn.
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This observational study determined frequency and describes all-cause adverse event epidemiology in a large air medical transport system.Records of a mandatory reporting system were reviewed and a data set containing all of the patient care records was searched to identify aviation- and non-aviation-related adverse events. Two reviewers independently identified adverse events and categorized them using an established taxonomy. Descriptive statistics were used to report adverse events, with frequency calculated per 1,000 flights and 1,000 hours flown.Between January 1, 2002, and June 30, 2005, there were 1,447 reports, of which 598 included an adverse event. Case-finding identified an additional 125. A complete report was available in 680 of 723 (94.1%) events. There were 58,956 flights and 103,632 hours flown during the study period, for a rate of 11.53 adverse events per 1,000 flights (95% CI = 10.7 to 12.4 adverse events) or 6.56 per 1,000 hours flown (95% CI = 6.1 to 7.1 adverse events). The frequencies of events by category were as follows: communication (229; 33.7%), transport vehicle (143; 21.0%), medical equipment (88; 12.9%), patient management (77; 11.4%), clinical performance (68; 10.0%), weather (30; 4.4%), unclassified (24; 3.5%), and patient factors causing death (21; 3.1%). There was possible patient harm in 117 events.Air medical transport is associated with a low incidence of adverse events and possible patient harm. Communication problems were the most common cause of an event. Determining event epidemiology is necessary to identify modifiable factors, propose solutions to decrease the adverse events, and direct future efforts to improve safety.
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Intra- and inter-hospital transport is common due to the need for advanced diagnostics and procedures, and to provide access to specialized care. Risks are inherent during transport, so the anticipated benefits of transport must be weighed against the possible negative outcome during the transport. Adverse events are common in both in and out of hospital transports, the most common being equipment malfunctions. During inter-hospital transport, increased transfer time is associated with worse patient outcomes. The use of specialized teams with the transport of children has been shown to decrease adverse events. Intra-hospital transports often involve critically ill patients, which increases the likelihood of adverse events. Radiographic diagnostics are the most common in-hospital transport destination and the results often change the course of care. It is recommended that portable ventilators be used for transport, because studies show that use of a manual resuscitator alters blood gas values due to inconsistent ventilation. The performance of new generation transport ventilators has improved greatly and now allows for seamless transition from ICU ventilators. Diligent planning for and monitoring during transport may decrease adverse events and reduce risk.
Intrahospital transport of critically ill patients
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This review on the current literature of the intrahospital transport of critically ill patients addresses type and incidence of adverse effects, risk factors and risk assessment, and the available information on efficiency and cost-effectiveness of transferring such patients for diagnostic or therapeutic interventions within hospital. Methods and guidelines to prevent or reduce potential hazards and complications are provided.A Medline search was performed using the terms 'critical illness', 'transport of patients', 'patient transfer', 'critical care', 'monitoring' and 'intrahospital transport', and all information concerning the intrahospital transport of patients was considered.Adverse effects may occur in up to 70% of transports. They include a change in heart rate, arterial hypotension and hypertension, increased intracranial pressure, arrhythmias, cardiac arrest and a change in respiratory rate, hypocapnia and hypercapnia, and significant hypoxaemia. No transport-related deaths have been reported. In up to one-third of cases mishaps during transport were equipment related. A long-term deterioration of respiratory function was observed in 12% of cases. Patient-related risk indicators were found to be a high Therapeutic Intervention Severity Score, mechanical ventilation, ventilation with positive end-expiratory pressure and high injury severity score. Patients' age, duration of transport, destination of transport, Acute Physiology and Chronic Health Evaluation II score, personnel accompanying the patient and other factors were not found to correlate with an increased rate of complications. Transports for diagnostic procedures resulted in a change in patient management in 40-50% of cases, indicating a good risk:benefit ratio.To prevent adverse effects of intrahospital transports, guidelines concerning the organization of transports, the personnel, equipment and monitoring should be followed. In particular, the presence of a critical care physician during transport, proper equipment to monitor vital functions and to treat such disturbances immediately, and close control of the patient's ventilation appear to be of major importance. It appears useful to use specifically constructed carts including standard intensive care unit ventilators in a selected group of patients. To further reduce the rate of inadvertent mishaps resulting from transports, alternative diagnostic modalities or techniques and performing surgical procedures in the intensive care unit should be considered.
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The ongoing pandemic of COVID-19 brought to the fore prone positioning as treatment for patients with acute respiratory failure. With the increasing number of patients in prone position, both spontaneously breathing and mechanically ventilated, cardiac arrest in this position is more likely to occur. This scoping review aimed to summarize the available evidence on cardiopulmonary resuscitation in prone position ('reverse CPR') and knowledge or research gaps to be further evaluated. The protocol of this scoping review was prospectively registered on 10th May 2020 in Open Science Framework (https://osf.io/nfuh9).We searched PubMed, EMBASE, MEDLINE and pre-print repositories (bioRxiv and medRxiv) for simulation, pre-clinical and clinical studies on reverse CPR until 31st May 2020.We included 1 study on manikins, 31 case reports (29 during surgery requiring prone position) and 2 nonrandomized studies describing reverse CPR. No studies were found regarding reverse CPR in patients with COVID-19.Even if the algorithms provided by the guidelines on basic and advanced life support remain valid in cardiac arrest in prone position, differences exist in the methods of performing CPR. There is no clear evidence of superiority in terms of effectiveness of reverse compared to supine CPR in patients with cardiac arrest occurring in prone position. The quality of evidence is low and knowledge gaps (e.g. protocols, training of healthcare personnel, devices for skill acquisition) should be fulfilled by further research. Meanwhile, a case-by-case evaluation of patient and setting characteristics should guide the decision on how to start CPR in such cases.Copyright © 2020 Elsevier Inc. All rights reserved.
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PMID:32707142
[Cited within: 1]
To identify and summarize the available science on prone resuscitation. To determine the value of undertaking a systematic review on this topic; and to identify knowledge gaps to aid future research, education and guidelines.This review was guided by specific methodological framework and reporting items (PRISMA-ScR). We included studies, cases and grey literature regarding prone position and CPR/cardiac arrest. The databases searched were MEDLINE, Embase, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Scopus and Google Scholar. Expanded grey literature searching included internet search engine, targeted websites and social media.Of 453 identified studies, 24 (5%) studies met our inclusion criteria. There were four prone resuscitation-relevant studies examining: blood and tidal volumes generated by prone compressions; prone compression quality metrics on a manikin; and chest computed tomography scans for compression landmarking. Twenty case reports/series described the resuscitation of 25 prone patients. Prone compression quality was assessed by invasive blood pressure monitoring, exhaled carbon dioxide and pulse palpation. Recommended compression location was zero-to-two vertebral segments below the scapulae. Twenty of 25 cases (80%) survived prone resuscitation, although few cases reported long term outcome (neurological status at hospital discharge). Seven cases described full neurological recovery.This scoping review did not identify sufficient evidence to justify a systematic review or modified resuscitation guidelines. It remains reasonable to initiate resuscitation in the prone position if turning the patient supine would lead to delays or risk to providers or patients. Prone resuscitation quality can be judged using end-tidal CO, and arterial pressure tracing, with patients turned supine if insufficient.Copyright © 2020 Elsevier B.V. All rights reserved.
Cardiopulmonary resuscitation in the prone position in the operating room or in the intensive care unit: a systematic review
Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the emergency cardiovascular care committee and get with the guidelines-resuscitation adult and pediatric task forces of the American Heart Association
European Resuscitation Council COVID-19 guidelines executive summary
Interfacility transfer of medicare beneficiaries with acute type A aortic dissection and regionalization of care in the United States
DOI:10.1161/CIRCULATIONAHA.118.038867
PMID:31589488
[Cited within: 2]
The feasibility and effectiveness of delaying surgery to transfer patients with acute type A aortic dissection-a catastrophic disease that requires prompt intervention-to higher-volume aortic surgery hospitals is unknown. We investigated the hypothesis that regionalizing care at high-volume hospitals for acute type A aortic dissections will lower mortality. We further decomposed this hypothesis into subparts, investigating the isolated effect of transfer and the isolated effect of receiving care at a high-volume versus a low-volume facility.We compared the operative mortality and long-term survival between 16 886 Medicare beneficiaries diagnosed with an acute type A aortic dissection between 1999 and 2014 who (1) were transferred versus not transferred, (2) underwent surgery at high-volume versus low-volume hospitals, and (3) were rerouted versus not rerouted to a high-volume hospital for treatment. We used a preference-based instrumental variable design to address unmeasured confounding and matching to separate the effect of transfer from volume.Between 1999 and 2014, 40.5% of patients with an acute type A aortic dissection were transferred, and 51.9% received surgery at a high-volume hospital. Interfacility transfer was not associated with a change in operative mortality (risk difference, -0.69%; 95% CI, -2.7% to 1.35%) or long-term mortality. Despite delaying surgery, a regionalization policy that transfers patients to high-volume hospitals was associated with a 7.2% (95% CI, 4.1%-10.3%) absolute risk reduction in operative mortality; this association persisted in the long term (hazard ratio, 0.81; 95% CI, 0.75-0.87). The median distance needed to reroute each patient to a high-volume hospital was 50.1 miles (interquartile range, 12.4-105.4 miles).Operative and long-term mortality were substantially reduced in patients with acute type A aortic dissection who were rerouted to high-volume hospitals. Policy makers should evaluate the feasibility and benefits of regionalizing the surgical treatment of acute type A aortic dissection in the United States.
Ground same intratransport efficacy as air for acute aortic diseases
DOI:S1067-991X(18)30270-0
PMID:31122585
[Cited within: 1]
Patients with acute aortic diseases (AAoD) usually require transfer to tertiary centers for possible surgical care, for which intratransport management represents important continuing spectrum of care. There is little information comparing intratransport efficacy of air (ART) vs ground transport (GRT), nor how effectively they manage these patients' pain. Our study aims to compare how effective ART and GRT manage patients' intratransport HR, pressure.Charts were reviewed of adult patients interhospital transferred to a quaternary academic center (UMMC) between 01/01/2011 and 09/30/2015. Outcomes were percentages of patients achieving target hemodynamic parameters, mortality.We analyzed 226 patients, 58 (26%) transported by Air and 102 (45%) type A dissection. Ground transport was associated with higher percentage of patients with target HR 60-80 bpm comparing to ART (58% vs 43%, 95% CI 0.3-0.99). Both ART and GRT were associated with similar frequencies of patients achieving target SBP and adequate pain control. Time intervals from transfer request to surgery, and mortality were similar for both types of transport.Ground transport teams were more successful at achieving predefined target heart rate than Air transport. Intra-transport management of other vital signs and pain were equally effectively between both Air and Ground transport.Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
HEMS vs. EMS transfer for acute aortic dissection type A
DOI:10.1016/j.amj.2008.11.004
PMID:19414108
[Cited within: 1]
We thought to evaluate the impact of the mode of physician-based transportation (helicopter emergency medical service [HEMS] vs. ground-based emergency medical service [EMS]) on short- and long-term survival among patients suffering acute aortic dissection type A (AADA) as a primary end-point.One-hundred-seventy-seven AADA patients (59 +/- 13 years) were included who were admitted to a cardiothoracic surgery department with comprehensive transfer documentation. Cox proportional hazard models and log-rank tests were performed as well as Kaplan-Meier survival curves. Follow-up was 93% over 5 +/- 2(3/4) years.Cox proportional hazard model found no mortality difference for HEMS versus EMS on primary transport (P =.5), as well as log-rank (Mantel Cox) on interhospital transport (P = 0.5). HEMS interhospital transfer was eightfold more expensive than EMS (HEMS, 3,871; EMS, 497; P =.01). Ninety-nine patients (56%) were alive at follow-up (mean survival, 1,153 days +/- 1,124). Mortality after surgery was 2% (3/177) within the first hour, 5% (8/177) within 6 hours, 6% (10/177) within 12 hours, 11% (20/177) within 24 hours, 13% (23/177) within 48 hours, 14% (25/177) within 72 hours, and 26% (46/177) within 30 days after surgery.We found no advantage of survival rates among patients suffering from AADA who were transferred by either HEMS or EMS in primary or secondary transport. Although HEMS traveled a distance more than twofold longer than ground-based EMS at the same mission time, HEMS was eightfold more expensive than ground-based EMS in AADA.
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine
Inadequate hemodynamic management in patients undergoing interfacility transfer for suspected aortic dissection
PMID:15672333
[Cited within: 1]
The study goal was the analysis of effectiveness of hemodynamic management of patients undergoing interfacility transport for suspected acute aortic dissection (SAAD). Our retrospective, consecutive-case review examined 62 nonhypotensive patients transported by an air emergency medical services (EMS) service during 1998 to 2002, with referral hospital diagnosis of SAAD. Of patients with systolic blood pressure (SBP) less than 120 upon air EMS arrival, antihypertensives had been given in only 23/42 (54.8%). In 19 cases where pretransport SBP is less than 120, with no referral hospital antihypertensive therapy given, median pretransport SBP was 158 (range, 122-212). In 20/62 cases (32.3%), the air EMS agency instituted antihypertensive therapy, which was successful; of 42 cases with pretransport SBP less than 120, mean intratransport SBP decrement was 24 (95% confidence interval, 16-32). In patients undergoing transport for SAAD, pretransport hemodynamic therapy was frequently omitted and often inadequate, generating an opportunity for air EMS intervention. Education to improve SAAD care should focus upon both referral hospitals and transport services.
Use of arterial catheters in the management of acute aortic dissection
DOI:10.1016/j.amj.2014.06.001
PMID:25441531
[Cited within: 2]
The aim of this study was to investigate the relationship between the use of invasive arterial blood pressure (IBP) monitoring and reaching established aggressive medical management goals in acute aortic dissection.Data were collected through a retrospective chart review of patients diagnosed with acute aortic syndromes of the thoracic cavity who required transport to tertiary care over a 28-month period. The 2010 American Heart Association medical management goals of thoracic aortic disease were used as hemodynamic end points.A total of 208 patients were included, with 113 (54%) diagnosed at least in part with acute Stanford Type A aortic dissections and the remaining 95 (46%) having isolated Stanford Type B dissections. Emergency departments made up 158 (76%) of transfer departments; 129 (62%) patients had IBP catheters placed. The highest mean systolic blood pressures (SBPs) recorded were 165 mm Hg in the IBP group versus 151 mm Hg when noninvasive blood pressure (NIBP) cuffs were used (P <.01). The mean decrease in SBP during transport was 51 mm Hg in the IBP group versus 34 mm Hg in the NIBP group (P <.001). The difference between the last reported NIBP and the first IBP was noted as 19 mm Hg higher. The IBP group met the SBP goal more frequently than the NIBP group (P <.05) when the SBP was noted as greater than 140 mm Hg during transport. Bedside time increased only 6 minutes with IBP placement (P <.007).Patients with IBP catheters were noted to be more aggressively managed with antihypertensive medications, met hemodynamic goals more frequently, and had only 6 minutes longer bedside times. These findings support the placement of IBP catheters by emergency departments and critical care transport (CCT) teams in patients with acute aortic syndromes requiring interfacility transport to definitive care.Copyright © 2014 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
ECMO transport without physicians or additional clinicians
DOI:10.1017/S1049023X20001272
PMID:33121550
[Cited within: 1]
Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a "hub and spoke" model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport. However, as ECMO centers and networks grow, the increasing number of transports will be limited by this mandate.The aim of this study was to compare rates of adverse events occurring during transport of ECMO patients with and without an additional clinician, defined as a physician, nurse practitioner (NP), or physician assistant (PA).This is a retrospective cohort study of all adults transported while cannulated on ECMO from 2011-2018 via ground and air between 21 hospitals in the northeastern United States, comparing transports with and without additional clinicians. The primary outcome was the rate of major adverse events, and the secondary outcome was minor adverse events.Over the seven-year study period, 93 patients on ECMO were transported. Twenty-three transports (24.7%) were accompanied by a physician or other additional clinician. Major adverse events occurred in 21.5% of all transports. There was no difference in the total rate of major adverse events between accompanied and unaccompanied transports (P =.91). Multivariate analysis did not demonstrate any parameter as being predictive of major adverse events.In a retrospective cohort study of transports of ECMO patients, there was no association between the overall rate of major adverse events in transport and the accompaniment of an additional clinician. No variables were associated with major adverse events in either cohort.
Extracorporeal circulatory systems in the interhospital transfer of critically ill patients: experience of a single institution
DOI:10.4103/0256-4947.51792
PMID:19318758
[Cited within: 1]
Critically ill patients with acute circulatory failure cannot be moved to other institutions unless stabilized by mechanical support systems. Extracorporeal heart and lung assist systems are increasingly used as a bridge to end-organ recovery or transplantation, and as an ultimate rescue tool in cardiopulmonary resuscitation.From July 2001 to April 2008, we had 38 requests for extracorporeal support for interhospital transfer carried out by the air medical service. Respiratory failure was present in 29 patients, who were provided with pumpless extracorporeal lung assist (PECLA) or veno-venous extracorporeal membrane oxygenation (ECMO). Cardiac failure dominated in 9 patients, who underwent implantation of extracorporeal life support (ECLS). Underlying diseases were acute respiratory distress syndrome in 15 patients, pneumonia in 7, prior lung transplant status in 4, cardiogenic shock in 7, and septic shock in 4.All assist systems were connected via peripheral vessels by the Seldinger technique. Transport was uneventful in all cases with no technical failures. On arrival at the specialized care hospital, two patients had leg ischemia and underwent relocation of the arterial cannula. After a mean (SD) support of 5.1 (3.0) days for PECLA, 3.5 (2.9) days for ECLS, and 7.3 (5.8) days for ECMO, 60%, 66%, and 66% of patients, respectively, could be successfully weaned from the systems. Discharge rates were 45% for PECLA, 44% for ECLS, and 56% for ECMO.Our experience proves that minimized extracorporeal assist devices allow safe assistance of patients with isolated or combined heart and lung failure in need of interhospital transfer. Critically ill patients get a chance to reach a center of maximum medical care.
Interhospital transport of ARDS patients on extracorporeal membrane oxygenation
DOI:10.1007/s10047-018-1065-y
PMID:30121790
[Cited within: 1]
Veno-venous extracorporeal membrane oxygenation (ECMO) can be a lifesaving therapy for patients with severe acute respiratory distress syndrome (ARDS). ECMO is a technically complex and challenging procedure and should therefore only be performed in specialized centers. Transporting ARDS patients to ECMO centers for treatment can be dangerous because of the risk of hypoxemia during transport. This raises the question if ECMO should not be already initiated in the transferring hospital before transport. Over a 5-year period, we studied ARDS patients who had been transported to our department by our mobile ECMO team for further treatment after ECMO had already been initiated at the referring hospital. Data for analysis were obtained from our patient data management system (PDMS), the referral documents, and from the referring hospitals. Seventy-five patients meeting the selection criteria were studied. All had been successfully cannulated in the transferring hospitals. They were transported to our ECMO center by helicopter (n = 34) or mobile intensive care units (n = 41). No patient died during transport. Forty four of the patients were transported at night. Twenty-six patients (35%) died in our intensive care unit due to a therapy refractory course, comorbidities or limitation of therapy. Patients on ECMO therapy can be safely transferred to a specialist center. Setting up ECMO in an unfamiliar location and the subsequent patient transport can be very challenging and should only be performed by a highly trained, experienced team.
Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care
DOI:10.3171/2018.3.JNS173224
PMID:30074453
[Cited within: 1]
Interfacility neurosurgical transfers to tertiary care centers are driven by a number of variables, including lack of on-site coverage, limited available technology, insurance factors, and patient preference. The authors sought to assess the timing and necessity of surgery and compared transfers to their institution from emergency departments (ED) and inpatient units at other hospitals.Adult neurosurgical patients who were transferred to a single tertiary care center were analyzed over 12 months. Patients with traumatic injuries or those referred from skilled nursing facilities or rehabilitation centers were excluded.A total of 504 transferred patients were included, with mean age 55 years (range 19-92 years); 53% of patients were women. Points of origin were ED in 54% cases and inpatient hospital unit in 46%, with a mean distance traveled for most patients of 119 miles. Broad diagnosis categories included brain tumors (n = 142, 28%), vascular lesions, including spontaneous and hypertensive intracerebral hemorrhage (n = 143, 28%), spinal lesions (n = 126, 25%), hydrocephalus (n = 45, 9%), wound complications (n = 29, 6%), and others (n = 19, 4%). Patients transferred from inpatient units had higher rates of surgical intervention (75% vs 57%, p < 0.001), whereas patients transferred from the ED had higher rates of urgent surgery (20% vs 8%, p < 0.001) and shorter mean time to surgery (3 vs 5 days, p < 0.001). Misdiagnosis rates were higher among ED referrals (11% vs 4%, p = 0.008). Across the same timeframe, patients undergoing elective admission (n = 1986) or admission from the authors' own ED (n = 248) had significantly shorter lengths of stay (p < 0.001) and ICU days (p < 0.001) than transferred patients, as well as a significantly lower total cost ($44,412, $46,163, and $72,175, respectively; p < 0.001).The authors present their 12-month experience from a single tertiary care center without Level I trauma designation. In this cohort, 65% of patients required surgery, but the rates were higher among inpatient referrals, and misdiagnosis rates were higher among ED transfers. These data suggest that admitting nonemergency patients to local hospitals may improve diagnostic accuracy of patients requiring urgent care, more precisely identify patients in need of transfer, and reduce costs. Referring facilities may lack necessary resources or expertise, and the Emergency Medical Treatment and Active Labor Act (EMTALA) obligates tertiary care centers to accept these patients under those circumstances. Telemedicine and integration of electronic medical records may help guide referring hospitals to pursue additional workup, which may eliminate the need for unnecessary transfer and provide additional cost savings.
Rapid discharge after interfacility transfer for mild traumatic intracranial hemorrhage: frequency and associated factors
DOI:10.5811/westjem.2018.12.39337
PMID:30881551
[Cited within: 2]
Traumatic intracranial hemorrhage (TIH), brain injury with radiographic hemorrhage, is a common emergency department (ED) presentation, and encompasses a wide range of clinical syndromes. Patients with moderate and severe neurotrauma (Glasgow Coma Scale [GCS] < 13) with intracranial hemorrhage require care at a trauma center with neurosurgical capabilities. However, many patients with mild traumatic intracranial hemorrhage (mTIH), defined as radiographic bleeding and GCS ≥ 13, do not require operative intervention or intensive care unit monitoring, but are still routinely transferred to tertiary care centers. We hypothesized that a significant proportion of patients are managed non-operatively and are discharged within 24 hours of admission.This was a retrospective, observational study of consecutive patients age ≥ 16 years, GCS ≥ 13 who were transferred to an urban, medical school-affiliated, 100,000 annual visit ED over a seven-year period with blunt isolated mTIH. The primary outcome was discharge within 24 hours of admission. We measured rates of neurosurgical intervention, computed tomography hemorrhage progression, and neurologic deterioration as well as other demographic and clinical variables.There were 1079 transferred patients with isolated mTIH. Of these, 92.4% were treated non-operatively and 35.8% were discharged within 24 hours of presentation to the tertiary ED. Patient characteristics associated with rapid discharge after transfer include a GCS of 15 (odds ratio [OR] 2.9, 95% confidence interval [CI], 1.9 - 4.4), subdural hematoma ≤ 6mm (OR 3.1, 95% CI, 2.2 - 4.5) or the presence of an isolated subarachnoid hemorrhage (OR 1.7, 95% CI, 1.3 - 2.4). Of patients with length of stay < 24 hours, 79.8% were discharged directly from the ED or ED observation unit.Patients transferred to tertiary care centers are frequently discharged after brief observation without intervention. Risk can be predicted by clinical and radiographic data. Further prospective research is required to determine a safe cohort of patients who could be managed at community sites.
The mortality benefit of direct trauma center transport in a regional trauma system
DOI:10.1097/TA.0b013e318252510a URL [Cited within: 1]
Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury
DOI:10.1097/01.ta.0000203717.57821.8d URL [Cited within: 1]
Emergency department and transport predictors of neurological deterioration in patients with spontaneous intracranial hemorrhage
DOI:10.1016/j.ajem.2022.01.002
PMID:35063886
[Cited within: 3]
Patients with spontaneous intracranial hemorrhage (sICH) and intracranial hypertension are associated with poor outcomes. Blood pressure variability (BPV) and neurological deterioration (ND) are known factors associated with sICH outcomes, but the relationship between BPV and ND in the hyperacute phase remains poorly described. We hypothesized that BPV is associated with ND during patients' initial emergency department (ED) stay and during interhospital transport (IHT) to a tertiary care center.A retrospective study of adult patients with sICH was performed. Patients who were transferred from an ED to a tertiary care center between 01/01/2011 and 09/30/2015 and underwent external ventricular drainage were eligible. The outcome was ND at any time before arrival at a tertiary care center. Classification and Regression Tree (CART) analysis, a machine learning algorithm, was used to assign "relative variable importance" (RVI) for important predictive clinical factors.153 eligible patients were analyzed. Sixty-five (42%) patients developed ND. Maximum ED systolic blood pressure (ED SBP) was most predictive of sICH patients developing ND (RVI = 100%). Other important factors for ND included standard deviation in SBP (SBP) during ED stay and IHT, with RVI of 43% and 20%, respectively.ED SBP was the strongest predictive factor of ND, while other BPV components were also significant. Our study found evidence that BPV should be prioritized as it may also increase the risk of ND among patients with sICH who required external ventricular drain placement. Future studies should examine whether fluctuations in BP in an ED or IHT setting are associated with increased risk of worsening outcomes.Copyright © 2022 Elsevier Inc. All rights reserved.
Protocol adherence during inter-facility transfer of acute ischemic stroke patients treated with IV rtPA
Available at: https://digitalcommons.gardner-webb.edu/nursing_etd/160
Should they stay or should they go? Who benefits from interfacility transfer to a higher-level trauma center following initial presentation at a lower-level trauma center
DOI:10.1097/TA.0000000000002248
PMID:31124892
[Cited within: 1]
Interfacility transfer of patients from Level III/IV to Level I/II (tertiary) trauma centers has been associated with improved outcomes. However, little data are available classifying the specific subsets of patients that derive maximal benefit from transfer to a tertiary trauma center. Drawbacks to transfer include increased secondary overtriage. Here, we ask which injury patterns are associated with improved survival following interfacility transfer.Data from the National Trauma Data Bank was utilized. Inclusion criteria were adults (≥16 years). Patients with Injury Severity Score of 10 or less or those who arrived with no signs of life were excluded. Patients were divided into two cohorts: those admitted to a Level III/IV trauma center versus those transferred into a tertiary trauma center. Multiple imputation was performed for missing values, and propensity scores were generated based on demographics, injury patterns, and disease severity. Using propensity score-stratified Cox proportional hazards regression, the hazard ratio for time to death was estimated.Twelve thousand five hundred thirty-four (5.2%) were admitted to Level III/IV trauma centers, and 227,315 (94.8%) were transferred to a tertiary trauma center. Patients transferred to a tertiary trauma center had reduced mortality (hazard ratio, 0.69; p < 0.001). We identified that patients with traumatic brain injury with Glasgow Coma Scale score less than 13, pelvic fracture, penetrating mechanism, solid organ injury, great vessel injury, respiratory distress, and tachycardia benefited from interfacility transfer to a tertiary trauma center. In this sample, 56.8% of the patients benefitted from transfer. Among those not transferred, 49.5% would have benefited from being transferred.Interfacility transfer is associated with a survival benefit for specific patients. These data support implementation of minimum evidence-based criteria for interfacility transfer.Therapeutic/Care Management, Level IV.
2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association
Transportation management affecting outcomes of patients with spontaneous intracranial hemorrhage
DOI:S1067-991X(19)30248-2
PMID:32540110
[Cited within: 1]
Patients with spontaneous intracranial hemorrhage (sICH) have poor outcomes, in part because of blood pressure variability (BPV). Patients with sICH causing elevated intracranial pressure (ICP) are frequently transferred to tertiary centers for neurosurgical interventions. We hypothesized that BPV and care intensity during transport would correlate with outcomes in patients with sICH and elevated ICP.We analyzed charts from adult sICH patients who were transferred from emergency departments to a quaternary academic center from January 1, 2011, to September 30, 2015, and received external ventricular drainage. Outcomes were in-hospital mortality and the Glasgow Coma Scale on day 5 (HD5GCS). Multivariable and ordinal logistic regressions were used for associations between clinical factors and outcomes.We analyzed 154 patients, 103 (67%) had subarachnoid hemorrhage and 51 (33%) intraparenchymal hemorrhage; 38 (25%) died. BPV components were similar between survivors and nonsurvivors and not associated with mortality. Each additional intervention during transport was associated with a 5-fold increase in likelihood to achieve a higher HD5GCS (odds ratio = 5.4; 95% confidence interval, 1.7-16; P = .004).BPV during transport was not associated with mortality. However, high standard deviation in systolic blood pressure during transport was associated with lower HD5GCS in patients with intraparenchymal hemorrhage. Further studies are needed to confirm our observations.Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Mannitol dosing error during interfacility transfer for intracranial emergencies
DOI:10.3171/2014.11.JNS141596
PMID:26077141
[Cited within: 1]
Mannitol is commonly used to treat elevated intracranial pressure (ICP). The authors analyzed mannitol dosing errors at peripheral hospitals prior to or during transport to tertiary care facilities for intracranial emergencies. They also investigated the appropriateness of mannitol use based on the 2007 Brain Trauma Foundation guidelines for severe traumatic brain injury.The authors conducted a retrospective review of the Shock Trauma Air Rescue Society (STARS) electronic patient database of helicopter medical evacuations in Alberta, Canada, between 2004 and 2012, limited to patients receiving mannitol before transfer. They extracted data on mannitol administration and patient characteristics, including diagnosis, mechanism, Glasgow Coma Scale score, weight, age, and pupil status.A total of 120 patients with an intracranial emergency received a mannitol infusion initiated at a peripheral hospital (median Glasgow Coma Scale score 6; range 3-13). Overall, there was a 22% dosing error rate, which comprised an underdosing rate (<0.25 g/kg) of 8.3% (10 of 120 patients), an overdosing rate (>1.5 g/kg) of 7.5% (9 of 120), and a nonbolus administration rate (>1 hour) of 6.7% (8 of 120). Overall, 72% of patients had a clear indication to receive mannitol as defined by meeting at least one of the following criteria based on Brain Trauma Foundation guidelines: neurological deterioration (11%), severe traumatic brain injury (69%), or pupillary abnormality (25%).Mannitol administration at peripheral hospitals is prone to dosing error. Strategies such as a pretransport checklist may mitigate this risk.
Vaginal bleeding
Tranexamic acid for prevention and treatment of postpartum hemorrhage: an update on management and clinical outcomes
DOI:10.1097/OGX.0000000000000597
PMID:30379320
[Cited within: 2]
Postpartum hemorrhage (PPH) remains a major cause of maternal mortality worldwide, occurring in both vaginal and cesarean deliveries. We have witnessed improvements in both prevention and treatment of PPH. Tranexamic acid (TXA) has been investigated as a potential adjunct therapy to uterotonics within this setting.The aim of this article is to summarize existing recommendations on the use of TXA in obstetrics and review current data on clinical outcomes after TXA use.We reviewed guidelines from a number of professional societies and performed an extensive literature search reviewing relevant and current data in this area.In the prevention of PPH, TXA use before both vaginal and cesarean deliveries reduces the amount of postpartum blood loss and should be considered in patients at higher risk for hemorrhage. In the treatment of PPH, TXA should be initiated early for maximal survival benefit from hemorrhage, and it provides no additional benefit if administered more than 3 hours from delivery. Overall, current evidence assessing the risks of TXA use in an obstetric population is reassuring.
Trauma and surgical emergencies in the obstetric patient
DOI:10.1016/j.suc.2007.12.006
PMID:18381121
[Cited within: 1]
Pregnancy always must be considered when evaluating a female trauma victim of reproductive age. When managing the pregnant trauma victim, one must optimize the well-being of two patients, but the health of the mother is of paramount importance. Rapid assessment, treatment, and transport are critical to optimizing maternal and fetal outcome. Evaluation must be performed with an understanding of the physiologic changes that occur in pregnancy. These changes alter maternal response to trauma and require adaptations to care.
Handbook of obstetric and gynecologic emergencies. Fifth edition
Trauma in pregnancy
DOI:S0146-0005(17)30128-3
PMID:29463389
[Cited within: 1]
Trauma is the leading non-obstetric cause of death during pregnancy and approximately 6-8% of all pregnancies are complicated by injury, both accidental and intentional. The initial evaluation and management of the injured pregnant patient often requires a multidisciplinary, collaborative team to provide the optimal outcome for both mother and fetus. It is important to recognize that even minor mechanisms of injury may result in poor outcomes for both fetus and mother. Injured pregnant patients meeting admission criteria experience a progressive increase in the number of complications as well as the number of patients that require delivery. There exists opportunity to identify patients who require admission and provide supportive measures that may reduce the complications of prematurity. Patients that are admitted may benefit from a multidisciplinary approach including on-going care from obstetricians or maternal-fetal medicine physicians. Placental abruption is the most common pregnancy complication, and may occur with even minor mechanisms of injury. Increasing severity of trauma increases the frequency of abruption, admission, delivery, and fetal demise.Copyright © 2018. Published by Elsevier Inc.
Maternal-fetal transport in the high-risk pregnancy
In:
The effect of hospital acuity on severe maternal morbidity in high-risk patients
Maternal transport: an opportunity to improve the system of risk-appropriate care
DOI:10.1038/s41372-021-00935-9 URL [Cited within: 1]
Transport of the critically ill obstetric patient
Interfacility transport of the pregnant patient: a 5-year retrospective review of a single critical care transport program
Resuscitating the crashing pregnant patient
Guidelines for the management of a pregnant trauma patient
Part 1: executive summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care
Inter-hospital and intra-hospital patient transfer: recent concepts
Safety in intrahospital transportation: evaluation of respiratory and hemodynamic parameters
Monitoring high-risk cardiac patients during transportation in hospital
