Who ya gonna call? Critical Care and Interfacility Transport in Canada. CAEP 2015 Edmonton, Alberta

Transcription

1 Who ya gonna call? Critical Care and Interfacility Transport in Canada CAEP 2015 Edmonton, Alberta

2 Faculty/Presenter Disclosure Presenter: Mark MacKenzie Emergency Physician, Royal Alexandra Hospital Medical Director, Air Ambulance, AHSEMS / STARS and Interfacility Transport Strategy Associate Professor, University of Alberta Relationships with commercial interests: Not Applicable

3 Agenda 4 Things 1. Research categories influencing critical interfacility transport HEMS studies EMS intubation studies Critical Care IFT studies Transport interval studies 2. Critical care transport teams (CCTs) 3. Factors affecting transport decisions 4. Insight into IFT operations 3

4 4 more things

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6 Interfacility Transport Connecting the right resources to the patient at the right time 6

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8 Helicopter EMS References Baxt WG, Moody P. The impact of a rotocraft aeromedical emergency care service on trauma mortality. JAMA. 1983;249: Galvagno SM, Thomas S, et al. Helicopter emergency medical services for adults with major trauma. Cochrane Database Syst Rev 2013 Andruszkow H, Lefering R, et al. Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients. Crit Care. 2013;17 Hannay R, Wryzykowski A, et al. Retrospective review of injury severity, interventions and outcomes among helicopter and non helicopter transport patients at a level 1 urban trauma centre. Can J Surg. 2014;5 Bekelis K, Missios S, MacKenzie TA. Prehospital helicopter transport and survival of patients with traumatic brain injury. Ann Surg. 2015;261

9 Helicopter EMS Positive trauma outcomes Benefit likely attributed to care provided Myth: Helicopters are faster

10 EMS Intubation References (all demonstrating worse outcomes) Stiell: CMAJ 2008;178: Davis: J Trauma 2003;54: Davis: J Trauma 2005;58:933 9 Davis: J Trauma 2005;59: Denninghoff: West J Emerg Med 2008;9:184 9 Murray: J Trauma 2000;49: Wang: Ann Emerg Med 2004;44: Wang: Prehosp Emerg Care 2006;10: Eckstein: Ann Emerg Med 2005;45:504 9 Bochicchio: JTrauma 2003;54: Arbabi: J Trauma 2004;56:

11 EMS Intubation in TBI Ground EMS = worse outcome HEMS Critical Care = improved outcome (Davis DP. The impact of aeromedical response to patients with moderate to severe traumatic brain injury. Ann Emerg Med 2005;46)

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13 Critical Care Teams Different from ACP / ALS Small numbers Often RN-led team Mission Profile Training Experience Physician driven Not tied to transport modality

14 Critical IFT References Singh JM, MacDonald RD. Incidence and predictors of critical events during urgent air medical transport. CMAJ 2009 Singh JM, MacDonald RD. Pro/con debate: do the benefits of regionalized critical care delivery outweigh the risks of interfacility patient transport? Crit Care 2009 Singh JM, MacDonald RD. Critical events during land based interfacility transport. Ann Emerg Med Singh JM, MacDonald RD. Post medication hypotension after administration of sedatives and opioids during critical care transport. Prehospital Emergency Care 2015

15 Critical Interfacility Transport Critical events (hemodynamic / respiratory) in 6.5 % or 1 in 15 of all emergent transports ACP crew level associated with increased odds of hypotension and other critical events High level of care essential for safe interfacility transport of critical patients

16 Challenges to Critical Care Team Implementation Lack of national or international standards for critical care inter hospital transport A consensus definition on what constitutes critical care transport remains elusive

17 Challenges to Critical Care Team Implementation Inter hospital transport is a black hole lacking in consistent standards, quality, outcome metrics, documentation and reporting * *

18 Transport Interval References Belway D, Dodek PM et al. The role of transport intervals in outcomes for critically ill patients who are transferred to referral centers. J Crit Care Newgard CD, Schmicker RH et al. Resuscitation Outcomes Consortium Investigators. Emergency medical services intervals and survival in trauma: assessment of the golden hour in a North American prospective cohort. Ann Emerg Med 2010

19 Transport Interval No appreciable association between transport intervals and in hospital mortality Longer packaging time associated with decreased length of stay in ICU/CCU

20 Transport Interval While it is intuitively appreciated that time must play some role in patient outcomes that require a higher level of care, the definition of that optimal time interval in the context of many clinical conditions is unknown

21 Interfacility Transport Operations Time Interval Total patient journey Patient arrives at initial facility call for medevac Call for medevac AMC arrives at patient side AMC arrives at patient AMC departs with patient Hours:Minutes 6:03 2:18 1:12 0: unscheduled (Emergent/Urgent) fixed wing patient transports into Edmonton Health Quality Council of Alberta (HQCA) Air Ambulance Report,

22 Air Ambulance IFT Multiple Bases Alberta = 8000 IFT missions/year Broad mission profile 24/7 CCT RW AW /7 ALS FW 24/7 CCT RW BK 117 Call intake Triage Dispatch Coordination of resources Weather checks Crew mobilization Ground support Circles represent 60 min flight time for Critical Care

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25 Mission References Davis DP. Early ventilation in traumatic brain injury. Resuscitation 2008;76 Warner KJ. The utility of early end tidal capnography in monitoring ventilation after severe injury. J Trauma 2009;66 Di Sero F et al. Laboratory testing during critical care transport: point of care testing in air ambulances. Clin Chem Lab Med 2010 Holcomb J. PROPPR: Transfusion of plasma, platelets and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma. JAMA 2015;313 Shehabi et al. SPICE Study: Early Intensive Care Sedation Predicts Mortality in Ventilated Critically Ill Patients. Am J Respir Crit Care Med 2012;186 ARDSnet.org Rudolph SS. Effect of prehospital ultrasound on clinical outcomes of nontrauma patients A systemic review. Resuscitation 2014;85

26 Head injury, polytrauma Goals of care: Precise ventilation, blood CO2 monitoring, avoidance of hypoxia, precise goals for blood pressure, optimal resuscitation using blood products and avoiding acidosis, coagulopathy, hypothermia

27 Mission possible Transport decisions cannot be made solely on time Crew capabilities and experience impact outcome and must be considered in all transport decisions Critical care transport services should be well defined and integrated into the broader EMS and IFT system 27

28 Thank you! Questions? Comments? ealthservices.ca