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People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

The aim of this study was to develop a bundle to increase safety of intra-hospital transport in critically ill patients. A qualitative design with Delphi approach was conducted for creation of an intra-hospital transport bundle in 3 steps. First, doctors and nurses were questioned about their encounters with intra-hospital transport incidents. Second, several databases were looked through to find published checklists and recommendations for intra-hospital transport. Third, using this strategy, a bundle was created and reviewed with subject matter experts. The content validity index (CVI), which assesses the degree of expert agreement, was utilized to evaluate each item in the generated bundle. Two evaluation cycles were required before a minimal index could be reached. We looked at the content validity and important weighting of the items. The scale-CVI was calculated using the average of all the elements, and it was 1. The created bundle serves as a framework for directing doctors and nurses during intra-hospital transportation and offers continuity of care to improve patient safety. The techniques suggested in this study can be used to adapt this bundle to the needs of other hospitals., Competing Interests: The authors report no conflict of interest during the performance of this study., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Facilitating primary triage and care at pediatric trauma centers (PTCs) can improve outcomes for children after trauma. However, scene location and regional emergency medical services regulations may result in initial evaluation occurring at nonpediatric facilities with later transportation to PTCs for definitive care. In this study, we assessed the results of a change in transport time cutoff from 30 to 45 minutes on pediatric patient outcomes., Methods: After institutional review board approval, the Pediatric Trauma Database at a level 1 PTC was queried for patients seen before (January 1, 2015, to December 31, 2017) and after (January 1, 2018, to December 31, 2020) the implementation of a policy increasing transport cutoff time from 30 to 45 minutes. Patient outcomes were compared by transport status and Injury Severity Score (ISS) using generalized linear regression analysis., Results: A total of 505 patients were seen before policy changes, and 413 patients, after policy changes. Both groups had similar numbers of severely injured patients (ISS, ≥15; pre, 64 [13%]; post, 61 [15%]). Average transport time increased after change (pre, 20 minutes [95% confidence interval, 18-22 minutes]; post, 29 minutes [95% confidence interval, 26-33 minutes]; p = 0.0252), consistent with policy compliance. The proportion of transferred patients did not change after policy implementation ( p = 0.5856), and the complications among all patients with an ISS of ≥15 did not significantly decrease (pre, 75%; post, 65.6%). However, those patients with an ISS of ≥15 admitted directly from the scene had a lower frequency of complications after the policy changes (pre, 76%; post, 59%; p = 0.0319), and in the postperiod, transferred patients with an ISS of ≥15 had a higher complication rate than those admitted directly from the scene ( p < 0.0001)., Conclusion: Direct scene admission to a PTC is associated with a lower complication profile for patients with higher ISS. Methods to ensure adherence to cutoff thresholds for emergency medical services transport may have a positive benefit on patient outcomes., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: Swedish guidelines for therapeutic hypothermia (TH) after perinatal asphyxia were established in 2007, following several randomised studies that demonstrated improved outcomes. We assessed the implementation of hypothermia treatment in a mid-Swedish region with a sizeable proportion of outborn infants., Method: A population-based TH cohort from 2007 to 2015 was scrutinised for adherence to national guidelines, interhospital transport, including the use of a cooling mattress made of phase change material for thermal management, and outcomes., Results: Of 136 admitted infants, 99 (73 %) were born outside the hospital. Ninety-eight percent fulfilled the criteria for postnatal depression/acidosis, and all patients had moderate-to-severe encephalopathy. Treatment was initiated within 6 h in 85 % of patients; amplitude-integrated electroencephalography/electroencephalography was recorded in 98 %, cranial ultrasound in 78 %, brain magnetic resonance imaging in 79 %, hearing tests in all, and follow-up was performed in 93 %. Although target body temperature was attained later (p < 0.01) in outborn than in inborn infants, at a mean (standard deviations) age of 6.2 (3.2) h vs 4.4 (2.6) h, 40 % of those transported using the cooling mattress were already within the therapeutic temperature range on arrival, and few were excessively cooled. The mortality rate was 23 %, and 38 % of the survivors had neurodevelopmental impairment at a median of 2.5 years., Conclusion: The regionalisation of TH, including interhospital transport, was feasible and resulted in outcomes comparable to those of randomised controlled studies., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Aeromedical transport (AMT) is an integral part of healthcare systems worldwide. In this article, the personnel and equipment required, associated safety considerations, and evidence supporting the use of AMT is reviewed, with an emphasis on helicopter emergency medical services (HEMS). Indications for HEMS as guideded by the Air Medical Prehospital Triage Score are presented. Lastly, physiologic considerations, which are important to both AMT crews and receiving clinicians, are reviewed., Competing Interests: Disclosure The authors have nothing to disclose., (Published by Elsevier Inc.)

Background: Emergency medical services (EMS) transporting patients to the emergency department (ED) typically call ahead to provide an estimated time to arrival (ETA). Accurate ETA facilitates ED preparation and resource allotment in anticipation of patient arrival., Objective: The study purposed to determine the accuracy of ETA provided by EMS ground units., Methods: We performed a single-center, prospective, observational study of ED patients arriving via EMS ground transport. The primary outcome was the time difference between EMS-reported ETA and actual time of arrival (ATA). The difference between ATA and ETA was compared using the two-sided Wilcoxon Signed-Rank Test. Subgroup analysis was performed to evaluate ETA accuracy for specific types of transports and assess variability by month and time of day., Results: We included 1176 patient transports in the final analysis. The overall median difference ATA-ETA was 3 min (interquartile range 1-5 min) with a range of -26-48 minutes (Z = -25.139, p < 0.001). EMS underestimated ETA in 961 cases (81.7%), and 94 ETAs (8.0%) were accurate to within 1 min. The largest difference between ATA and ETA occurred between 07:00-07:59 and 16:00-16:59 (5 min, interquartile range 2-7)., Conclusion: Our data demonstrate that prehospital providers underestimate time to ED arrival in most ground transports; however, the median difference between estimated and actual time to arrival is small., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Prehospital spinal immobilization using a cervical collar and a backboard has been standard practice for suspected spinal cord injuries (SCIs) since the 1960s. Multiple studies have shown that the disadvantages of the spinal backboard outweigh its advantages. This report aims to present a review of the current literature along with the revised IDF protocol regarding patients with suspected SCI., Methods: In 2019, the IDF Medical Corps (IDFMC) convened a multidisciplinary expert committee to revise the IDFMC protocols regarding the use of spinal backboards. Prior to convening the committee, a review of the pertinent literature was done by conducting a thorough clinical evaluation in "PubMed" and "Google Scholar" databases to identify recent studies investigating traumatic SCI and the prehospital military use of spinal backboards., Results: There were no documented studies that have managed to prove the efficacy of spinal backboards to prevent exacerbation of spinal injuries during mobilization. Despite being a good tool for extraction from vehicles and combat arenas, more than 11 studies have shown that backboards may even result in adverse outcomes such as pain due to the contact between board and skin, the formation of decubitus ulcers, hypothermia, and inadequate ventilation., Conclusion: In light of the evidence showing the potential harmful effects of the routine use of spinal backboards, the IDF guidelines have been revised and now recommends avoiding the routine use of spinal backboards and using a standard stretcher for transporting potential SCI patients. Current IDF guidelines recommend using a backboard for the extraction of an entrapped patient and for obtunded or unconscious patients with obvious deformity or mechanism for spinal trauma., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: Competing interests: Eric Sy is a STARS Air Ambulance Transport Physician. Terrance Ross is a STARS Air Ambulance Transport Physician and medical director of the STARS Regina base.

Background Timely emergency medical services (EMS) response, management, and transport of patients with suspected acute coronary syndrome (ACS) significantly reduce delays to emergency treatment and improve outcomes. We evaluated EMS response, scene, and transport times and adherence to proposed time benchmarks for patients with suspected ACS in North Carolina from 2011 to 2017. Methods and Results We conducted a population-based, retrospective study with the North Carolina Prehospital Medical Information System, a statewide electronic database of all EMS patient care reports. We analyzed 2011 to 2017 data on patient demographics, incident characteristics, EMS care, and county population density for EMS-suspected patients with ACS, defined as a complaint of chest pain or suspected cardiac event and documentation of myocardial ischemia on prehospital ECG or prehospital activation of the cardiac care team. Descriptive statistics for each EMS time interval were computed. Multivariable logistic regression was used to quantify relationships between meeting response and scene time benchmarks (11 and 15 minutes, respectively) and prespecified covariates. Among 4667 patients meeting eligibility criteria, median response time (8 minutes) was shorter than median scene (16 minutes) and transport (17 minutes) time. While scene times were comparable by population density, patients in rural (versus urban) counties experienced longer response and transport times. Overall, 62% of EMS encounters met the 11-minute response time benchmark and 49% met the 15-minute scene time benchmark. In adjusted regression analyses, EMS encounters of older and female patients and obtaining a 12-lead ECG and venous access were independently associated with lower adherence to the scene time benchmark. Conclusions Our statewide study identified urban-rural differences in response and transport times for suspected ACS as well as patient demographic and EMS care characteristics related to lower adherence to scene time benchmark. Strategies to reduce EMS scene times among patients with ACS need to be developed and evaluated.

Objective: There are limited data regarding the typical characteristics of coronavirus disease 2019 (COVID-19) patients requiring interfacility transport or the clinical capabilities of the out-of-hospital transport clinicians required to provide safe transport. The objective of this study is to provide epidemiologic data and highlight the clinical skill set and decision making needed to transport critically ill COVID-19 patients., Methods: A retrospective chart review of persons under investigation for COVID-19 transported during the first 6 months of the pandemic by Johns Hopkins Lifeline was performed. Patients who required interfacility transport and tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction assay were included in the analysis., Results: Sixty-eight patients (25.4%) required vasopressor support, 35 patients (13.1%) were pharmacologically paralyzed, 15 (5.60%) were prone, and 1 (0.75%) received an inhaled pulmonary vasodilator. At least 1 ventilator setting change occurred for 59 patients (22.0%), and ventilation mode was changed for 11 patients (4.10%) during transport., Conclusion: The safe transport of critically ill patients with COVID-19 requires experience with vasopressors, paralytic medications, inhaled vasodilators, prone positioning, and ventilator management. The frequency of initiated critical interventions and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment, critical thinking, and decision making., (Copyright © 2021 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Background: The 2020 novel coronavirus (SARS-Cov-2) pandemic necessitates tailored recommendations addressing specific procedures for neonatal and paediatric transport of suspected or positive COVID-19 patients. The aim of this consensus statement is to define guidelines for safe clinical care for children needing inter-facility transport while making sure that the clinical teams involved are sufficiently protected from SARS-CoV-2., Methods: A taskforce, composed of members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Transport section and the European Society for Paediatric Research (ESPR), reviewed the published literature and used a rapid, two-step modified Delphi process to formulate recommendations regarding safety and clinical management during transport of COVID-19 patients., Results: The joint taskforce consisted of a panel of 12 experts who reached an agreement on a set of 17 recommendations specifying pertinent aspects on neonatal and paediatric COVID-19 patient transport. These included: case definition, personal protective equipment, airway management, equipment and strategies for invasive and non-invasive ventilation, special considerations for incubator and open stretcher transports, parents on transport and decontamination of transport vehicles., Conclusions: Our consensus recommendations aim to define current best-practice and should help guide transport teams dealing with infants and children with COVID-19 to work safely and effectively., Impact: We present European consensus recommendations on pertinent measures for transporting infants and children in times of the coronavirus (SARS-Cov-2 /COVID-19) pandemic. A panel of experts reviewed the evidence around transporting infants and children with proven or suspected COVID-19. Specific guidance on aspects of personal protective equipment, airway management and considerations for incubator and open stretcher transports is presented. Based on scant evidence, best-practice recommendations for neonatal and paediatric transport teams are presented, aiming for the protection of teams and patients. We highlight gaps in knowledge and areas of future research.

Objectives: The COVID-19 pandemic has brought new challenges to pediatric transport programs. The aims of this study were to describe the transport of pediatric patients with confirmed COVID-19 and to review the operational challenges that our transport system encountered., Methods: A retrospective descriptive study was performed to review all COVID-19 pediatric transport performed over a 6-month period during the initial pandemic surge in 2020. Pediatric patients with a known positive SARS-CoV-2 polymerase chain reaction test at the time of transport were included. Patients' hospital records, including their transport record, were reviewed for demographics, diagnoses, transport interventions and complications, and admission disposition. Descriptive statistics were used to describe the patient cohort., Results: Of the 883 transports performed between April and October 2020, 146 (16%) tested positive for COVID-19 during the initial surge in our geographical area. Patient acuity was diverse with 40% of children having a chronic complex medical condition. More than 25% of children required aerosol-generating procedures during transport. The most common medical diagnosis was respiratory compromise, and the most common surgical diagnosis was appendicitis. No adverse events occurred during transports, and no transport team members contracted COVID-19 because of workplace exposure. Transport program operational challenges ranged from rapidly changing system logistics/policies to educational and utilization of proper personal protective equipment., Conclusions: Children with COVID-19 can be transported safely with adaption of transport program procedures. Change management and team stress should be anticipated and can be addressed with repeated education and messaging., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To reflect on the safe care exercised by the pre-hospital care team by emergency ambulance in times of coronavirus infection., Method: A reflection and description of how to provide safe care to the patient and the professional during pre-hospital care in times of coronavirus infection., Results: To ensure the health of all those involved in the care, health professionals who work in pre-hospital care by emergency ambulance should use the recommended Personal Protective Equipment (PPE), such as the use of surgical masks and N95, N99, N100, PFF2 or PFF3, the use of an apron or overall, goggles and face shield, gloves and a hat. The entire team must receive training and demonstrate the ability to use PPE correctly and safely., Final Considerations: The professional working in the pre-hospital care by ambulance is exposed to a series of occupational risks that need to be discussed and minimized through professional training.

Objective: There are nearly 1000 annual ambulance crashes within the United States involving pediatric patients. In 2012 National Highway Traffic Safety Administration/US Department of Transportation released Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances. The aim of our study was to measure emergency medical services (EMS) providers' knowledge and opinions of how to safely transport pediatric patients. In addition, we aimed to gather information on barriers to safe pediatric transport., Methods: Members of 1 urban and 2 suburban EMS agencies completed an anonymous survey that assessed level of training, years of experience, exposure to pediatric patients, knowledge of best practices, and opinions about barriers to safe transport of pediatric patients., Results: A total of 114 EMS providers answered the survey. Sixty-three percent were basic life support providers who had more than 10 years of experience in EMS. Ninety-six percent reported that they transported 0 to 5 pediatric patients per week. Twenty percent reported being trained on pediatric safe transport practices. Thirty-two percent of providers reported that personnel did not drive faster when transporting a sick pediatric patient. Eighty-six percent reported that it was unsafe to transport a child on a parent's lap, but 27% reported that it was appropriate to transport a newborn on the stretcher with mom. Thirty-eight percent were comfortable identifying proper restraint system/seat for pediatric patients, and only 35% were comfortable installing/using these devices. Provider-reported barriers to safe transport were identified., Discussion: Our survey demonstrates that despite published best practices for the safe transport of children, many providers are unfamiliar with the safest way to transport these patients. In addition, we identified several existing barriers that may contribute to unsafe practices.

According to in-hospital guidelines, the biomarker, S100 calcium-binding protein B (S100B), is used to rule out intracranial lesions in mild-moderate traumatic brain injury (TBI). It is currently investigated whether S100B is applicable in a pre-hospital setting. The aim was to compare S100B values and hemolysis index in blood samples drawn and stored under simulated pre-hospital conditions to standardized blood samples. Thirty patients undergoing craniotomy at Department of Neurosurgery, Aarhus University Hospital (Aarhus, Denmark) each had six blood samples drawn. Two samples, drawn in in-hospital standardized Beckton Dickinson tubes and pre-hospital Monovette tubes, respectively, were stored as references at 21°C for 30 min. Two samples were stored at 15°C and 29°C, respectively, one sample was stored at prolonged time (60 min), and one sample was transported for 30 min before centrifugation. S100B values were compared by equivalence test with a pre-defined equivalence margin of ±8.5%. There was no clinically relevant difference between samples stored in different tubes, at various temperatures, or time to analysis compared to reference samples. Transported samples had an 11.5% (90% confidence interval [CI], 6.55; 16.61) higher median S100B value and a 430% (95% CI, 279.6; 661.4) higher median hemolysis index compared to reference samples. Three of 30 (10%) patients had an S100B value above guideline cutoff in the transported sample, which was not found in reference samples (false positive). There were no false negatives. In conclusion, S100B values were not influenced by different tubes, temperatures, and time to analysis. Transported samples had higher median S100B values and hemolysis, icterus, and lipemia index compared to reference samples.

Transporting patients with communicable diseases is common in critical care transport operations. At Ornge, Ontario's critical care transport provider, 13.7% of patients required contact, droplet, or airborne precautions during transport in 2019-2020. Ensuring that staff are protected while transporting patients with communicable diseases must remain a prime directive for medical transport administrators and operators. Success in safety requires a robust system of hazard identification and adherence to generally accepted methods of hazard control. This commentary will discuss some of the administrative and engineering controls, as well as the personal protective equipment (PPE) strategies deployed at Ornge.

Sport-related spine injury can be devastating and have long-lasting effects on athletes and their families. Providing evidence-based care for patients with spine injury is essential for optimizing postinjury outcomes. When caring for an injured athlete in American tackle football, clinicians must make decisions that involve unique challenges related to protective equipment (eg, helmet and shoulder pads). The Spine Injury in Sport Group (SISG) met in Atlanta, Georgia, March 2-3, 2019, and involved 25 health care professionals with expertise in emergency medicine, sports medicine, neurologic surgery, orthopaedic surgery, neurology, physiatry, athletic training, and research to review the current literature and discuss evidence-based medicine, best practices, and care options available for the prehospital treatment of athletes with suspected cervical spine injuries.1,2 That meeting and the subsequent Mills et al publication delineate the quality and quantity of published evidence regarding many aspects of prehospital care for the athlete with a suspected cervical spine injury. This paper offers a practical treatment guide based on the experience of those who attended the Atlanta meeting as well as the evidence presented in the Mills et al article. Ongoing research will help to further advance clinical treatment recommendations., (© by the National Athletic Trainers' Association, Inc.)

Objective: Despite the guidelines, significant variations can be encountered in initial therapy for pediatric diabetic ketoacidosis (DKA) in the prehospital setting. These variations occur mostly in fluid administration, insulin dosing, route of administration, and other aspects of the initial resuscitation and stabilization. The aim was to identify the effect of transport care on outcomes in children with DKA admitted to the emergency department (ED)., Methods: Patients admitted to a tertiary-care pediatric ED between 2015-2019 with a diagnosis of DKA were retrospectively identified. Details of pre-pediatric ED care, including transport modality, patient demographics, clinical features, laboratory evaluation, fluid therapy, insulin dosing, and short-term outcome were recorded., Results: The study cohort included 147 episodes of DKA in 136 patients aged 9 months-21 years. Emergency Medical Service (EMS) transported only 37.4% of cases. EMS utilization rate was significantly higher (p=0.003) in severe cases, most of whom were >10 years (p=0.04). During transport 85% received intravenous fluid bolus. Use of fluids other than normal saline was significantly higher when transport time was >30 minutes (p=0.001). Acute kidney injury and cerebral edema developed in 21.7% and 7.4% of episodes, respectively. These complications were more common in the EMS transport group. Pediatric intensive care admission rate was also higher in the EMS compared to the non-EMS group (p=0.01)., Conclusion: Parents did not call the ambulance for most cases although a higher complication rate occurred in EMS patients. EMS providers and referral facilities should improve their knowledge of pediatric DKA.

Transport of critically ill patients within and between hospitals is a common undertaking in an effort to improve patient outcomes. Intrahospital transports are frequently conducted to aid in diagnosis through advanced imaging techniques or to allow image-guided procedures. Interhospital transport is most frequently conducted to bring patients to specialized care, including centers of excellence for cardiac, trauma, transplant, and respiratory failure. Transport outside the hospital can be accomplished by ground or air, the latter including fixed-wing and rotor-wing aircraft. Often overlooked, transport of patients from the scene of an accident or illness to the hospital by emergency medical services is less sophisticated but more common than the other methods combined. Patients are also routinely transported to and from the operating room, a form of transport not commonly studied. Risks are inherent to transport, and an analysis of risks and benefits must be part of any risk-mitigation strategy. Monitoring the patient during transport by attendants and equipment is a key component of risk mitigation. Quicker transport times and specialized transport teams are associated with improved outcomes, whereas severity of illness is a harbinger of untoward complications. The type of monitoring during transport varies widely with the environment, the skill of the attendants, and the severity of patient illness. Standards for patient monitoring during transport are available, but they are predominantly based on expert opinion. This paper reviews guidelines and the risks of transport as a template for required monitoring, and it discusses common mishaps associated with transport and how these can be avoided with appropriate monitoring., (Copyright © 2020 by Daedalus Enterprises.)

There is a lack of consensus on quality indicators suitable for neonatal transport. The aim of this study is to make a proposal for specific quality indicators for newborn transport. A retrospective descriptive study was performed (2009 to 2015) where twenty-four indicators were selected, evaluated and classified according to the 6 dimensions of quality of the Institute of Medicine. Among the 24 evaluated quality metrics, there were 3 of them which needed a correction when evaluating neonatal transport performance, because they were significantly correlated with gestational age. They were (a) stabilisation time, (b) prevalence of newborn arterial hypotension (defined by gestational age) and (c) unnoticed hypothermia at referral hospital.Conclusion: Quality evaluation through the definition of specific metrics in newborn transport is feasible. These indicators should be defined or adjusted for newborn population to measure the actual performance of the transport service.What is Known:• Quality indicators may help in defining metrics for clinical practice, promoting benchmarking and defining areas of improvement.• Newborn characteristics call for a specialised care, and quality measure during newborn transport require specific metrics. Quality metrics for paediatric transport have been defined using Delphi method. Some of these measures need to be specific for newborn, due to their intrinsic characteristics.What is New:• Using evidence-based literature and our newborn transport experience, specific quality indicators for newborn transport are suggested.• Data analysis shows how some indicators need to be adjusted for gestational age.

Background: The current COVID-19 pandemic highlights the challenges air ambulance services are facing when transporting highly infectious patients for several hours in enclosed spaces. This overview provides an example of a standard operating procedure (SOP) for infection prevention measures in HEMS missions during the COVID-19 pandemic. Furthermore, we describe different methods used by several organizations in Europe and the experience of the Swiss air rescue organization Rega in transporting these patients. Possible benefits of the use of small patient isolation units (PIU) are discussed, including the fact that accompanying medical personnel do not need to wear personal protective equipment (PPE) during the transport but can still maintain full access to the patient. Rega has developed and patented its own PIU. This device allows spontaneously breathing or mechanically ventilated patients to be transported in pressurized jet cabins, small helicopters and ambulance vehicles, without the need to change between transport units. This PIU is unique, as it remains air-tight even when there is a sudden loss of cabin pressure., Conclusion: A wide variety of means are being used for the aeromedical transport of infectious patients. These involve isolating either the patient or the medical crew. One benefit of PIUs is that the means of transport can be easily changed without contaminating the surroundings and while still allowing access to the patient.

Objective: The aim of this study was to assess national pediatric/neonatal specialty transport teams' composition and training requirements to determine if any current standardization exists., Methods: This was a survey of the transport teams listed with the American Academy of Pediatrics via SurveyMonkey., Results: While most of the teams maintain internal criteria for team competency and training, there is large variation across team compositions. The vast majority of the teams have a nurse-led team with the addition of another nurse, medic, and/or respiratory therapist regardless of mode of transport. Many of the teams report adjusting team composition based on acuity. Fewer than 15% of teams have a physician as a standard team member. More than 80% required a minimum number of supervised intubations prior to independent practice; however, the number varied largely from as little as 3 to as many as 30. Eighty-eight percent of the teams report using simulation as part of their education program, but again there were marked differences between teams as to how it was used., Conclusions: There is tremendous variability nationally among pediatric/neonatal transport teams regarding training requirements, certifications, and team composition. The lack of standardization regarding team member qualifications or maintenance of competency among specialized transport teams should be looked at more closely, and evidence-based guidelines may help lead to further improved outcomes in the care of critically ill pediatric patients in the prehospital setting.

Objectives: We developed a Pediatric Transport Triage Tool (PT3) to objectively guide selection of team composition and transport mode, thereby standardizing transport planning. Previously, modified Pediatric Early Warning Score for transport has been used to assess illness severity but not to guide transport decision making., Methods: The PT3 was created for pediatric transport by combining objective evaluations of neurologic, cardiovascular, and respiratory systems with a systems-based medical condition list to identify diagnoses requiring expedited transport and/or advanced team composition not captured by neurologic, cardiovascular, and respiratory systems alone. A scoring algorithm was developed to guide transport planning. Transport data (mode, team composition, time to dispatch, patient disposition, and complications) were collected before and after PT3 implementation at a single tertiary care center over an 18-month period., Results: We reviewed 2237 inbound pediatric transports. Transport mode, patient disposition, and dispatch time were unchanged over the study period. Fewer calls using a transport nurse were noted after PT3 implementation (33.9% vs 30%, P = 0.05), with a trend toward fewer rotor-wing transports and transports requiring physicians. The majority of users, regardless of experience level, reported improved transport standardization with the tool. Need to upgrade team composition or mode during transport was not different during the study period. No adverse patient safety events occurred with PT3 use., Conclusions: The PT3 represents an objective triage tool to reduce variability in transport planning. The PT3 decreased resource utilization and was not associated with adverse outcomes. Teams with dynamic staffing models, various experience levels, and multiple transport modes may benefit from this standardized assessment tool.

Aim: Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation., Design and Implementation: We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including 'VITAL' (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, 'STOP' (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and 'STOP' (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme., Results: The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001)., Conclusion: The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Randomized controlled trials in the 1990s confirmed the safety and efficacy of inhaled nitric oxide (iNO) in near-term and term newborns with hypoxemic respiratory failure and pulmonary hypertension, demonstrating improved oxygenation and reduced need for extracorporeal membrane oxygenation (ECMO) therapy. However, in about 30% to 40% of sick newborns, these improvements in oxygenation and hemodynamics are not sustained and affected infants often require rapid transfer to an ECMO center despite the initiation of iNO. Abrupt discontinuation of iNO therapy before transport in patients who have had little apparent clinical benefit can be harmful because of acute deterioration with severe hypoxemia. Thus, continued use of iNO therapy during hospital transfer of infants with pulmonary hypertension is important. In this review, we describe: 1) the history of iNO use during transport; 2) a practical approach to iNO during transport; and 3) guidelines for the initiation of iNO before or during transport., (Copyright © 2020 by the American Academy of Pediatrics.)

Introduction: Increased out-of-hospital time is associated with worse outcomes in trauma. Sparse literature exists comparing prehospital scene and transport time management intervals between adult and pediatric trauma patients. National Emergency Medical Services guidelines recommend that trauma scene time be less than 10 minutes. The objective of this study was to examine prehospital time intervals in adult and pediatric trauma patients., Methods: We performed a retrospective cohort study of blunt and penetrating trauma patients in a five-county region in North Carolina using prehospital records. We included patients who were transported emergency traffic directly from the scene by ground ambulance to a Level I or Level II trauma center between 2013-2018. We defined pediatric patients as those less than 16 years old. Urbanicity was controlled for using the Centers for Medicare and Medicaid's Ambulance Fee Schedule. We performed descriptive statistics and linear mixed-effects regression modeling., Results: A total of 2179 records met the study criteria, of which 2077 were used in the analysis. Mean scene time was 14.2 minutes (95% confidence interval [CI], 13.9-14.5) and 35.3% (n = 733) of encounters had a scene time of 10 minutes or less. Mean transport time was 17.5 minutes (95% CI, 17.0-17.9). Linear mixed-effects regression revealed that scene times were shorter for pediatric patients (p<0.0001), males (p=0.0016), penetrating injury (p<0.0001), and patients with blunt trauma in rural settings (p=0.005), and that transport times were shorter for males (p = 0.02), non-White patients (p<0.0001), and patients in urban areas (p<0.0001)., Conclusion: This study population largely missed the 10-minute scene time goal. Demographic and patient factors were associated with scene and transport times. Shorter scene times occurred with pediatric patients, males, and among those with penetrating trauma. Additionally, suffering blunt trauma while in a rural environment was associated with shorter scene time. Males, non-White patients, and patients in urban environments tended to have shorter transport times. Future studies with outcomes data are needed to identify factors that prolong out-of-hospital time and to assess the impact of out-of-hospital time on patient outcomes.

Extracorporeal membrane oxygenation (ECMO), a term used to describe oxygenation that occurs outside of the body, is an increasingly common means of supporting the most critically ill patients. Because of the invasiveness and high probability of serious complications during ECMO, ECMO is typically indicated only when there is a high likelihood of death with conventional treatment. With continued improvements in technology and increasing clinical experience, transport clinicians are increasingly likely to be called on to transport patients on ECMO. ECMO can be initiated in 2 distinct forms, venovenous or venoarterial, and can primarily support the respiratory system or the cardiac and respiratory systems concurrently. This review will cover the basic physiology and components of ECMO as well as the preparation for ECMO transport for adults., (Copyright © 2019. Published by Elsevier Inc.)

Hypothermic cardiac arrest is rare and poses a challenge to prehospital responders. Standard cardiac arrest protocols advise treating reversible causes of arrest; however, rewarming the cold casualty is not easily achieved in the field. This article aimed to review the literature on hypothermia in order to produce evidence-based recommendations on rewarming that could realistically be applied to hypothermic cardiac arrest patients., (Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective: A checklist was developed to improve the ventilator management of pediatric patients for air medical transport with the aim of reducing the percentage of patients outside recommended parameters (no bag valve mask use, peripheral capillary oxygen saturation level > 90%, and end-tidal carbon dioxide level > 35 and < 50 mm Hg) from 41.3% to 20% within 7 months., Methods: The checklist was developed based on recommended guidelines. After checklist orientation, its effectiveness was analyzed via chart review for inclusion criteria (> 5 kg and < 18 years) from July 2018 to January 2019. Parameters identified in the aim statement were used to evaluate effectiveness. After transport, a Likert survey concerning the value of the checklist was distributed., Results: Significant improvements in pediatric ventilator management were noted when teams used the checklist. The rate outside of aim parameters was reduced significantly from 41.3% (n = 92, June 2012-May 2018 preintervention) to 10% (n = 20, July 2018-January 2019 postintervention) after the improvement action was implemented (χ 2  = 7.01, P = .008). The 5-point Likert survey results (n = 38, 4.68 ± .57) supported teams' improved comfort after checklist implementation., Conclusion: The checklist improved ventilator management proficiency of pediatric patients and the comfort level of air medical teams providing care., (Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective: The R Adams Cowley Shock Trauma Center (STC) is Maryland's primary adult resource center for trauma care. The Shock Trauma "Go-Team" is a specialized component of Maryland's emergency medical system and is composed of a physician and certified registered nurse anesthetist. They are dispatched when advanced prehospital resuscitation is required. The purpose of this study is to describe the capabilities and historic epidemiology outcomes of the Go-Team., Methods: A retrospective case series review of recoverable Go-Team records was performed from 2011 to 2018. Go-Team call logs/records were identified from multiple sources. Medical records were reviewed for patient demographics, mechanisms of injury, and treatments in the field. There was a total of 61 activations, with 22 deployments to the scene of injury., Results: The majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required., Conclusion: The STC Go-Team is a unique multidisciplinary specialized component of a statewide emergency medical system., (Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Background: Shock index, the ratio of heart rate to systolic blood pressure that changes with age, is associated with mortality in adults after trauma and in children with sepsis. We assessed the utility of shock index to predict sepsis diagnosis and survival in children requiring interfacility transport to a tertiary care center., Methods: We studied children aged 1 month to 21 years who had at least 2 sets of vital signs recorded during interfacility transport to the Children's Hospital of Pittsburgh by our critical care transport team. Subjects were divided into 4 age groups: group 1 (<1 year), group 2 (1-3 years), group 3 (4-11 years), and group 4 (≥12 years). Children were also grouped into sepsis or nonsepsis group based on the International Classification of Diseases, Ninth Revision categories. Primary outcome was survival to hospital discharge., Results: Of 3519 children studied, 493 (14%) had sepsis. Initial shock index decreased with increasing age: group 1, 1.45 ± 0.42 (mean ± SD); group 2, 1.35 ± 0.32; group 3, 1.20 ± 0.34; and group 4, 1.00 ± 0.32 (P < 0.001). Initial shock index was increased in children with sepsis versus those with no sepsis overall and in all age groups (all P < 0.05). Initial shock index showed a trend for association with survival in univariate analysis (P = 0.05) but was not associated with survival in a multivariable logistic regression. Highest quartile of shock index was associated with need for intensive care unit admission posttransport., Conclusions: Increased shock index in children requiring intrafacility transport was associated with hospital discharge diagnosis of sepsis but not hospital survival.

Background: We implemented a new policy at our institution where the responsibility for intensive care unit (ICU) patient transports to the operating room (OR) was changed from the anesthesia to the ICU service. We hypothesized that this approach would be associated with increased on-time starts and decreased turnover times., Methods: In the historical model, intubated patients or those on mechanical circulatory assistance (MCA) were transported by the anesthesia service to the OR ("pre-ICU Pickup"). In our new model, these patients are transported by the ICU service to the preoperative holding area (Pre-op) where care is transferred to the anesthesia service ("post-ICU Transfer"). If judged necessary by the ICU or anesthesia attending, the patient was transported by the anesthesia service ("post-ICU Pickup"). We retrospectively reviewed case tracking data for patients undergoing surgery before (January 2014 to May 2015) and after implementation (July 2016 to June 2017) of the new policy. The primary outcome was the proportion of elective, weekday first-case, on-time starts. To adjust for confounders including comorbidities and time trends, we performed a segmented logistic regression analysis assessing the effect of our intervention on the primary outcome. Secondary outcomes were turnover times and compliance with preoperative checklist documentation., Results: We identified 95 first-start and 86 turnover cases in the pre-ICU Pickup, 70 first-start and 88 turnover cases in the post-ICU Transfer, and 6 turnover cases in the post-ICU Pickup group. Ignoring time trends, the crude proportion of on-time starts increased from 32.6% in the pre-ICU Pickup to 77.1% in the post-ICU Transfer group. After segmented logistic regression adjusting for age, sex, American Society of Anesthesiologists (ASA) physical status, Sequential Organ Failure Assessment (SOFA) score, respiratory failure, endotracheal intubation, MCA, congestive heart failure (CHF), valvular heart disease, and cardiogenic and hemorrhagic shock, the post-ICU Transfer group was more likely to have an on-time start at the start of the intervention than the pre-ICU Pickup group at the end of the preintervention period (odds ratio, 11.1; 95% confidence interval [CI], 1.3-125.7; P = .043). After segmented linear regression adjusting for the above confounders, the estimated difference in mean turnover times between the post-ICU Pickup and pre-ICU Transfer group was not significant (-6.9 minutes; 95% CI, -17.09 to 3.27; P = .17). In post-ICU Transfer patients, consent, history and physical examination (H&P), and site marking were verified before leaving the ICU in 92.9%, 93.2%, and 89.2% of the cases, respectively. No adverse events were reported during the study period., Conclusions: A transition from the anesthesia to the ICU service for transporting ICU patients to the OR did not change turnover times but resulted in more on-time starts and high compliance with preoperative checklist documentation.

Objective: During transport, the time spent in stabilizing sick infants before repatriation is crucial in optimizing the outcome and effective use of resources. The study aim was to assess individual components of neonatal transport time to identify opportunities to minimize delay, optimize care, and improve the overall efficiency of transport., Methods: A single-center prospective observational study conducted at McMaster Children's Hospital, Hamilton, Ontario, Canada, with a dedicated transport team for over 12 months. The stabilization time was defined as the time interval between arrival and departure from the referring hospital., Results: Of 223 neonatal transfers, 67 required no procedural or therapeutic intervention before mobilization to the receiving unit, with a mean stabilization time of 113 ± 52 minutes. In 156 transport events, 1 or more interventions were required, with a significantly higher mean stabilization time of 165 ± 89 minutes (P < .0001)., Conclusion: This study found that the local stabilization time was more than 1.5 times that of the comparable published data. The reasons identified for this delay were mostly because of waiting times for vehicle mobilization, waiting for blood and radiology results, and bed availability. Modifying these factors could save up to 28% of the stabilization time., (Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

There is a dearth of evidence on safely transporting frail older adults in the community. Therefore, the purpose of the current study was to gain a better understanding of behavioral expression exhibited by older adults during van transportation and to learn what actions van assistants and van drivers take to prevent or address behavioral expressions, which can create potential challenges to safe transportation. A qualitative descriptive approach was used and included four focus groups of van assistants and van drivers (N = 32) at one urban Program of All-Inclusive Care for the Elderly (PACE), which routinely transports approximately 90% of enrollees to and from the PACE center. Conventional content analysis was used to analyze the data. Four themes emerged. The first two themes were common behaviors: Removing Seat Belts and Verbal Behaviors. The remaining two themes addressed unusual behaviors that left lasting impressions: Physical Aggression and Conflict Between Passengers. Van assistants and van drivers used redirection and reassurance as preventive interventions to keep everyone safe. Transportation of PACE enrollees requires well-trained and astute van assistants and van drivers skilled with preventing and diffusing potentially unsafe behaviors. [Res Gerontol Nurs. 2019; 12(4):184-192.]., (Copyright 2019, SLACK Incorporated.)

Background: The decision to utilize HEMS is a complex process that involves many considerations. Professional associations and agencies have published guidelines to assist providers with decision making for the utilization of helicopter transport., Study Objective: Determine if requests for HEMS align with recently published utilization guidelines., Study Design: A retrospective chart review was performed during a six-month period. Reviewers versed in Wisconsin HEMS Utilization, NAEMSP, and CAMTS guidelines determined if transport criteria were met. Charts were categorized according to whether or not criteria for each set of recommendations were followed., Results: 514 charts were reviewed; 439 consisted of completed patient transports. CAMTS, NAEMSP, and WI HEMS guidelines satisfied 85.4%, 83.4%, and 53.1% of requests, respectively. Statistically significant differences existed when comparing rates meeting criteria between WI HEMS and CAMTS and between WI HEMS and NAEMSP guidelines (p-value <0.0001). This was true in all subgroups except STEMI, which did not show significant difference. No difference existed between rates for CAMTS and NAEMSP guidelines in any group., Conclusion: Significant difference between Wisconsin HEMS utilization versus NAEMSP guidelines, and between Wisconsin HEMS utilization and CAMTS guidelines in all subgroups except STEMI patients exist. No statistically significant difference existed between NAEMSP and CAMTS guidelines., (Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective was to identify factors associated with transport of injured older adults meeting statewide geriatric trauma triage criteria to a trauma center., Methods: An observational retrospective cohort study using the 2009 to 2011 Ohio Trauma Registry. Subjects were adults ≥ 70 years old who met Ohio's geriatric triage criteria for trauma center transport by emergency medical services. We created multivariable logistic regression models to identify predictors of initial and ultimate (e.g., interfacility transfer) transport to a Level I or II trauma center and to a Level I, II, or III center., Results: Of 10,411 subjects, 47% were initially and 59% were ultimately transported to a Level I or II trauma center with rates of 66 and 74%, respectively, for transport to a Level I, II, or III center. For initial transport to a Level I or II center, age 80 to 89 (odds ratio [OR] = 0.89), age ≥ 90 (OR = 0.76), and either only a Level 3 (OR = 0.3) or no trauma center (OR = 0.11) in county of residence had decreased odds of transport, while male sex (OR = 1.38), black race (OR = 2.07), Injury Severity Score (ISS) 10-15 (OR = 1.99), ISS > 15 (OR = 2.85), and Glasgow Coma Scale score < 9 (OR = 2.11) had increased odds. Results were similar for ultimate transport to a Level I or II center. Analyzing transport to a Level I, II, or III center demonstrated similar results except a Level III trauma center in county of residence was associated with increased odds (OR = 2.00 for initial and 2.21 for ultimate) of transport to a Level I, II, or III center., Conclusions: We identified factors independently associated with failure to transport injured older adults to trauma centers in statewide data collected after adoption of geriatric triage criteria. Lack of a trauma center in the county of residence remained a factor even in analyses that included ultimate transport., (© 2019 by the Society for Academic Emergency Medicine.)

Background: In France, when someone presents with chest pain, it is recommended to call a health emergency number. The patient talks with an emergency doctor at a medical dispatch centre, who decides whether (or not) to send a Mobile Intensive Care Unit (MICU). Patients with an ST-segment elevation myocardial infarction (STEMI) should have an MICU as their first medical contact, to speed up confirmation of diagnosis and enable them to benefit from reperfusion therapy as quickly as possible., Aim: To evaluate the proportion of patients with STEMI benefiting from an optimal care pathway, and to identify the key factors leading to this pathway., Methods: RESCAMIP was a multicentre registry conducted between May 2015 and May 2017 in Midi-Pyrénées. All patients treated for STEMI within 12hours of symptoms onset, without initially going into cardiac arrest, were included., Results: Data from 1371 patients with STEMI were analysed; 60% had an MICU as their first medical contact. In-hospital mortality was 4%. Factors associated with calling the medical dispatch centre when presenting chest pain were: age>65 years (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.02-1.83), personal history of cardiovascular disease (OR 1.9, 95% CI 1.22-2.96) and having cardiovascular risk factors (OR 1.84, 95% CI 1.35-2.5). Factors associated with sending an MICU as first medical contact were: male sex (OR 2.11, 955 CI 1.49-2.99) and personal history of cardiovascular disease (OR 1.69, 95% CI 1.07-2.65)., Conclusions: The proportion of patients with STEMI going through non-optimal pathways was 40% in our area. We note that there are sex-based inequalities in accessing MICUs., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Aim: To examine associations between uptake of free primary eye care, service availability (density of optometric practices) and service accessibility (household car access and drive time to nearest provider) after accounting for socioeconomic status and other individual, household and area factors., Methods: We constructed a cohort of 294 870 community-dwelling adults aged 60 years, drawing contextual information from the 2011 Northern Ireland Census. Minimum drive times to the nearest optometry practice (1-19 min) and number of practices were derived for 890 geographical areas. The primary outcome was attendance at one or more publicly funded eye examinations to which all cohort members were entitled between 2009 and 2014. We used multiple log-binomial regression to estimate associations between eye care uptake, car ownership and drive time., Results: Eye examination uptake was 60.0%. 23.7% of the cohort had no car access, and these individuals had lower uptake than car owners (unadjusted risk ratio (RR) of uptake=0.86 (0.86, 0.87)). Among non-car owners, uptake decreased with drive time (longest vs shortest: RR=0.92 (0.88, 0.97)) with the largest decrease at 4 min drive time (approximately 1.5 miles). This pattern was weaker among car owners. These associations were independent of service availability, which was not associated with uptake., Conclusion: Both drive time and household car access were associated with eye care use, adjusting for individual, household and area factors. Policies to improve uptake should target those with no car access, especially those beyond walking distance from the nearest eye care provider., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)