Transport Systems Moving our Children Across Systems: Challenges, Barriers & Enablers. Hilary Whyte MB Allan de Caen MD Andrew Macnab MB
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1 Transport Systems Moving our Children Across Systems: Challenges, Barriers & Enablers Hilary Whyte MB Allan de Caen MD Andrew Macnab MB
2 Outline Discuss interfacility transport of neonatal patients in Canada Benchmarking across country & beyond Discuss specific challenges for paediatric transport systems & potential solutions Discuss the model in British Columbia for maternal/newborn/paediatic transport
3 Historical Perspective - Neonatal 1970 s - Regionalized care for high risk mothers & newborns saved lives and reduced morbidity Swyer. Pediatr Clin North Am Segal S. Pediatr Clin North Am : Toronto SickKids opens helipad & RN/MD team demonstrates improved outcomes with specialized team Chance 1979 J Pediatr, Hood 1983 Crit Care Med A specialized transport system required to facilitate movement of patients to higher level of care Greene WT. Pediatrics; 1992 Lupton B, Pendray M. Seminars in Neonatology; 2004
4 Historical Perspective - Neonatal Survival outborn infants inversely proportional to infants age on arrival of transport team Hulsey, JSCMA; 1981 Team composition dictated by local infrastructure Paramedic/EMT vs. RN/RN vs. RN/RT teams No difference in patient outcomes Outcomes impacted by GA, pre-transport status of infant and prolonged transports Wirth,Clin Res:1979; Sumners, Pediatrics:1980; Kattwinkel,JOGN: 1983; Shoo Lee, Medical Care; 2002 Does a doctor make a difference? - not well studied but probably NOT
5 AAP Guidelines for Interfacility Transport Dedicated team proficient at neonatal and/or paediatric critical care during transport Adequate patient volumes to maintain skills and have optimal utilization On-line medical control by qualified physicians Ground and/or air ambulance capabilities Communications and dispatch capability
6 AAP guidelines Interfacility Transport Written clinical and operational guidelines Comprehensive database allowing for quality & performance improvement initiatives Medical & nursing direction Administrative resources Institutional endorsement and support
7 Transport Teams in Canada Today Population: 30 million. Births: 360,000 annually Transport Distances: up to 1000 kms. 3 teams transport children also 1 transport high risk maternal patients
8 Transport Team Models All hospital based vs. free standing Regional vs. Provincial (5) Dedicated vs NICU based ( runs) Neonatal only +/- attends delivery (2) Neonatal/paediatric (3)+/- high risk Moms (1) Lamont RF, Dunlop PD, Crowley P. J Perinat Med 1983 Hohlagschwandtner M, Arch Gynecol Obstet 2001 Training, certification & CME standards vary considerably
9 Transport Team Models RN/RT & RN/RN & RN/MD & Paramedic only Physician back up to team Dedicated fellows (3) vs NICU based trainees On-line medical control Staff physician (7) vs. trainee ->level of expertise for advice, transport triage & stabilization 5 teams have dedicated transport vehicles owned & operated vs. contracted vs. private ambulance vs. local EMS ambulances Caverni V, et al. J of Maternal- Fetal & Neonatal Medicine 2004
10 Training for Teams Safety training Certification Process None: 3 teams 6 weeks: 1 team 3-6 mths: 6 teams 6-12 mths: 2 teams mths: 2 teams CME none or ad hoc BC. & Toronto 70hrs
11 QA Programs: recorded calls, documentation standards, database, case reviews, safety reporting, critical incident reviews, physician feedback, satisfaction surveys, annual appraisal - rare
12 Location of Paediatric & Newborn Tertiary Centres Level III (Tertiary) Centres Modified Level III (Neonatal) Thunder Bay North Bay Sault Ste. Marie Sudbury Toronto Hamilton London Windsor Kingston Ottawa
13 Ornge provides air transport
14 Reliance on local EMS or private transfer vehicles to get to aircraft
15 Ornge: Ontario air ambulance Rotor & Fixed Wing Air Bases: Almonte Dryden Fort Frances Island Lake Kapuskasing Kenora London Moosonee Muskoka Ottawa Sioux Lookout Smith s Falls Sudbury Thunder Bay Timmins Toronto
16 Benchmarking USA & UK Larger population-> more volume, more NICUs Less Regionalized, more teams, shorter distances (400 teams in US; 53 teams in California) Most hospital based, own/contract ambulances Combi neo/paeds programs dedicated (30%), or single unit based (70%) Funding structure USA marketing teams USA - Most are RN/RT or RN/Paramedic UK crew RN/MD - lack of APN/NPs and RTs
17 Australia similar to Canada Geography & demography very similar Teams are MD/RN (no APNs/NPs, or RTs) Teams usually respond to neonates/paeds enhances patient volumes/critical mass & flexibility Facilitate maternal transfer best model Centrally coordinated- provide advice, triage, facilitate transport. Staffed by consultants & RN coordinator Most provide State wide service, may be based in a hospital. Central bed registry & availability consultants in tertiary care facility to provide on line medical control
18 NSW - NETS
19 How do we get to places
20 Fixed wing ambulances- power lifts
21 Dedicated ambulances power lifts
22 Transport Challenges in Canada #1. Staffing Availability & cost of health care professionals leadership, initiative, flexibility, independence, intelligence, problem solving, interpersonal & communication skills Requirements training/certification/evaluation/cme -no standards, none CAMTS certified Maintenance of competency problematic lack critical mass unless dedicated & neo/paeds
23 Staffing Challenges Hospital based access to clinical practice/skills and education BUT Resource to NICUs/hospital intramural transports, skills, many down time duties Constant stress: ambassadors, team schedules (8-12 hrs), overtime, fatigue, turnaround time, need for flexibility Teaching constantly referral staff, residents, fellows (NICU, PEM), observers Cumulative stress & self imposed ( DEATH )
24 Barriers to best practice #2. Funding Insufficient staff to operate dedicated team lack CME, safety training, uniforms Most hospitals try to make do with NICU personnel so inconsistent availability, training etc Variability in staff physician engagement Lack transport physicians Lack QA processes no feedback or review
25 Challenges of transport equipment #3. Equipment: Heavy & awkward with limited functionality & availability of commercial products Aging & not meeting safety standards Weight of equipment/supplies excessiveeverything carried by team No dedicated vehicles for transport of teams No power lifts or hoists in regular EMS vehicles/air ambulances for transport decks
26 Transport Equipment Total weight 250 lbs. Ht 48.5 Power required 115 VAC, 200Watts
27 Barriers to best practice #4. NO vehicles Reliance on other transport systems to move the team. Ontario ambulance act paramedic must be in back of ambulance A) EMS ambulances provide ride for team Competition with 911 calls, scene response 2 crews required for transport deck lift Increased mobilization & response times Increased transport times EMS refuses to wait with team who stay & play -> overtime/fatigue, cost Teams are stranded if patient stabilized, referred or deferred when no baby to bring back
28 Barriers to best practice B) EMS refusal to carry team with no patient Private transfer vehicles not ambulance Lack of regulation Availability variable Cost born by hospitals Increase in mobilization & response time Issues of weight & lack of power lifts
29 Challenges for Air Transport # 5. Air ambulance availability hospital based teams not part of the air system Issues of equipment & crew weight especially since paramedic required in every air ambulance Limits ability to carry parent & team never available for training/preceptoring Rotary cannot lift off helipads at certain times of the year with extra weight of neonatal equipment/team Special considerations- ECMO, ino add weight & team members
30 Barriers to Air Transport Cannot drop paramedic(s) off rotary - need to stay operational for trauma etc Aircraft configuration/electrics often incompatible with transport team deck left stranded on Tarmac especially with chartered aircraft
31 Challenges in Transport Process #6. Lack of integration of all hospital based transport teams Perinatal bed registry definitions closed/restricted vary not updated Problems when lack of team or bed locally - Delayed response baby first, bed second philosophy ideal Delays in finding beds or teams resulting in lengthy transport or wait times
32 Enabler one number to call for advice, triage, transport, & coordination in each Province Reliance accurate perinatal bed registry Integration with transport teams & land and air ambulance systems Integration with high risk obstetric service, NICUs, & Paediatric ICUs
33 #7.Challenge - In Utero Transports Outcomes similar to inborn tertiary care for infants with in-utero transfer where Moms transferred in labor Arad, E J of Obs, Gyn & Reprod. Biol Bennett, BJOG: 2002; Carlau, Clin. Paeds Aggressive approach to in-utero transfer can decrease outborn rates to < 10%
34 Enablers Treat every threatened pre-term labor as code 4 emergency Uniform approach to management Provide specialized transport team for high risk Mom dispatch Default matrix Tertiary facility Decouple maternal & NICU bed status Fetal fibronectin
35 Further challenges - capacity GTA Ontario, annual birth volumes 70,000 35% of all high risk Moms deliver outside high risk setting because No specialized system for high risk maternal transports Poor coordination, triage & timely advice Refusal of high risk moms usually based on availability of tertiary NICU beds FAILURE to provide in-utero transports ie. Best practice
36 Further challenges Paediatric transport system for acute, complex & critical care children may be lacking when neonatal transport team does not provide solution to both populations Dr Allan DeCaen
37 Thank you
38 Recommendations for Canada Fund Provincial Transport Systems for high risk maternal, newborn & paediatric transport Integration of advice line, transport dispatch, ambulance, bed finding system patient before bed Dedicated teams standardized training & certification, specialty examinations/evaluation, CME Dedicated ambulances appropriate equipment, less for team to carry & power lifts, safety standards Quality & accountability framework Documentation standards, database, QA indicators, Clinical practice guidelines, and outcome measures
39 NFL < 3m (50-100) RN/RT (11) Staff call taker > 50 % air Cert.< 6 weeks CME/skills NS Neo/Paed (50-100) RN/RT (10-20) Coordinato r PTV- ded >50% air 3-6 mths CME/Skills Quebec Neo ( ) RN/RT (<10) Staff call taker 30-40% air None None Montreal Neo ( ) RN/RT (10-20) TP/staff call taker Coordinato r 10-20% air * 3-6 mths CME/Skills *Toronto Neo/< 2 yrs. Del (700) RN/RT (24) TP Coordinato r 25% air * mth 70 hrs CME /skills * *Hamilto n Neo/Del (400) RN/RN (<10) Coordinato r PTV < 10% air 6-12 mths CME / skills * *London Neo/Paed (250) RN/RT (<10) Staff call taker PTV -< 10% air?? 40 hrs CME / skills * Ottawa Neo (250) RN/RT (16) Coordinato r < 10% air 6-12 mths 30 hrs CME /skills Mannitob a Neo ( ) RN/MD (10-20) TP > 50% air None < 10 hrs CME * *Sask Neo (150) RN/RT (11) Staff call taker Ded.land > 50% air 3 mths 2 days biannual * Edmonton Neo ( ) RN/RT (10-20) Ded. land 30% air * 3-6mths?? * Calgary Neo ( ) RN/RT ( <10) Staff call taker Ded.land 20% air 3-6 mths?? * *B.C. Mat/NB/Paeds Parame Staff call Coordinato Dedicate *24 mths 70 hrs
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