Infrastructure and System Design for Optimal Inter-facility Transports Maternal, Newborn & Paediatric

Infrastructure and System Design for Optimal Inter-facility Transports Maternal, Newborn & Paediatric Hilary E.A. Whyte, MB. MSc. FRCPI. FRCPC Professor of Paediatrics, U of Toronto, Medical Director, Acute Care Transport Services, SickKids Medical Director SickKids International

Disclosure I have no relevant financial relationships with the manufacturer of any commercial product and/or provider of commercial services discussed in this CME activity 2

Canada and China Canada China HKong Ontario Size sq miles 3,800,000 3,700,000 421 415,600 Pop. 35,703,000 1,337,000,000 7,264,000 13,600,000 Pop./sq ml 9 365 17,051 33 Birth rate 11.4/1000 14/1000 11.3/1000 10.5/1000 Perinatal Mortality 4.6 10.9 2.7 5.9 Infant Mortality 5 11 1.6 4.6 Tert. NICUs 30 55 6 8

Regionalization of Health Care Method of providing high-quality, cost-efficient health care to the largest number of patients. Aim is to improve patient outcomes by directing patients to facilities with optimal capabilities for a given type of illness or injury. Right patient, in right time, to right place, transported and treated by right personnel S.Lorch, S. Myers, B. Carr. The Regionalization of Pediatric Health Care. Pediatrics Vol. 126 No. 6 December 1, 2010

4 Neo-paediatric transport teams Great variations in practice exist: Karlsen et al. Paediatrics 2011;128(4) Outcomes differ widely: S.Eliason, H.Whyte, K.Dow et al. A.J.Perinatology, 2013 6

A Regionalized Ontario

Interfacility Transport System Bolte R. and Woodward G. in Textbook of Paeds Transport Medicine 1995, 33-40 and 41-49 Mosher S. Nursing for Women s Health 2013;17(3) Bigham M, Schwartz H. Clin Ped Emerg. Med 2013;14(3) 8

Ideal System Level 3 Level 2 Level 1 Patient flow based upon clinical need and service efficiency 9

Guidelines for Air and Ground Transport of Neonatal & Pediatric Patients American Academy of Pediatrics Section on Transport Medicine Edited by George A. Woodward, MD, MBA, FAA 3 rd edition.

The Accreditation Canada Qmentum Program for EMS Systems and the CAMTS Accreditation Standards for Air Medical Transport can inform efforts by CAPHC to propose standards for inter-facility neonatal pediatric and obstetric air transport systems in Canada.

Responsibility of the Transport system Ensure safe transport: Qualified Personnel Appropriate Mode Necessary Equipment Appropriate Mode: Acuity of patient Special needs of pt Team availability Mode availability Weather Distance Traffic Practicality

Interfacility Transport System: Transport Mode Woodward G, Insoft R, Kleinman M. Guidelines for air and ground transport of neonatal and paediatric patients, 3 rd ed. American Academy of Paediatrics, 2007 13

Crew Base Locations 9 dedicated bases staffed 24/7 Kenora London Moosonee Ottawa Sioux Lookout Sudbury Thunder Bay Timmins Toronto page 14

Rotor Wing Bases Circles are 60 minute response radius Helicopters most suited for on scene or where Helipads exist Kenora London Moosonee Muskoka Ottawa Sudbury Thunder Bay Toronto

Fixed Wing Bases Province wide coverage >250 Kms 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

EMS- On scene response Land Transportation Interfacility Critical Care Land Interfacility Stretcher Services Provide routine or booked transfers hospital funded Unregulated private service No lights and sirens

Challenges for Air Transport Air ambulance availability Issues of equipment & crew weight paramedic required in every air ambulance Limits ability to carry parent & team Never available for training Rotary cannot lift off helipads at certain times with extra weight of neonatal equipment/team Restrictions due to weather or night flight Special considerations ECMO, added & team members

Safety Considerations Transport regulations Size of helipad footprint Densely populated areas urban Additional transfer points if not going Helipad to Helipad Potential for accidents Helicopter declining rate 2 pilots Land Ambulance lights and sirens? indicated Safety design all equipment must be crash and pull tested and certified for air and land Patient, personnel properly secured Taylor C, Stevenson M, Jan S et al. International J. Care of Injured 2010; 41 (1) Hankins D. AMJ 2010;29(3) Rolnitsky A, Tomlinson, Whyte et al. PAS 2013. 19

Barriers to Air Transport Rotary aircraft reluctant to transport specialized teams will not drop paramedic(s) need to stay operational for trauma etc Fixed wing aircraft often incompatible with transport team equipment configuration & electrics team left stranded on Tarmac

Consider Aeromedical physiology Boyle s Law, Dalton s Law, Henry s Law. Some patients can best be transported by land ambulance e.g. those with air leak syndromes, or Oxygenation failure, or requiring multiple transport personel i.e. ECMO, interventions enroute

Interfacility Transport System: Equipment & Vehicles Droogh J, Smit M, Hu J et al. Crit.Ccare 2012; 16(1) Health & Safety executive. London: HMSO,1992 Bleak T, Trautman M. Air Med. Journal 1995;4(1) www. Accreditation.ca/emergency-medical-services,2013 23

Bowman E, Doyle L, Murton L.etal. BMJ 1998;297(6) Singh A, Duckett J, Newton T et al. J of Perinatal. 2010;30(1) Karlsen B, Lindkvist M, et al. Foundation Acta Paed. 2012;101(2)

Inhaled Nitric Oxide

Cooling Blanket Device Therapeutic Hypothermia

ECMO Transport Equipment

28

29

Supplies must be accessible

Barriers to best practice No Dedicated vehicles EMS ambulances provide transfer for team Paramedics must be in ambulance inefficient Competition with 911 calls, on scene response 2 crews required for transport deck lift specialized equipment Increased mobilization & response times Increased transport times EMS refuses to wait with team overtime/fatigue, costs Teams are stranded if patient stabilized, referred or deferred to another hospital as no patient to base hospital Equipment also stranded at referral or destination sites

Equipment unstable Not certified for safety

Dedicated Vehicles Fenton A, Leslie A, Skeoch C. ADC, F&N ed. 2004;89(3) Leslie A, Stephenson T. ADC 1994;71(1) 33

Interfacility Transport System: System and Process Bolte R. and Woodward G. in Textbook of Paeds Transport Medicine 1995, 33-40 and 41-49 Mosher S. Nursing for Women s Health 2013;17(3) Bigham M, Schwartz H. Clin Ped Emerg. Med 2013;14(3) 34

Canadian specialized transport teams Location: Hospital based Off site e.g ambulance base Transport certified: Dedicated Semi-dedicated 1 person only Pulled from bedside Ad Hoc: Limited training/ expertise Dedicated team Ad hoc team no team mixed NICU/ PICU team

The Provincial one number to call Emergency service for physicians for emergent, urgent and critically ill patients Consultation and effecting decisions on referral Providing "status of" acute care beds Secures the bed Conference in appropriate ambulance service and team Track all data on referrals & deferrals 36

Communications Sending and receiving physicians Transport team coordinator Ambulance dispatcher & Transport medicine physician Medical on line control for transport team

Integrated system Access via one number to call Single Point of Contact For initiation, consultation and issue escalation / resolution By telephone, fax, online Integrated Dispatch One Number to Call System-Wide Oversight Accountability for resources and performance Central Dispatch for all Patient Transport Emergent, urgent and nonambulance System-wide view of all patient transportation resources for health care facilities EXTERNAL TRANSPORT SYSTEM Dedicated Interfacility transport Local EMS Critical care patients Maternal, newborn, paediatric As appropriate As appropriate Air Ambulance Case Management / Coordination Develop and oversee transfer plan Coordinate communication Arrange transportation Access to Dedicated Team of Experts Inform transfer plan Clinical / medical consultation Transport experts Stretcher Transportation Services Stable non emergency patients

Recommendations Teams providing critical care transport for newborns and children should be specialized, the scope of practice and whether dedicated or not, to be dictated by the volumes, as a critical mass is required to maintain competency Collaborative practice model of care with 2 team members e.g. RN/MD or RN/RT provides optimal configuration 39

Recommendations Specific equipment and supplies to take ICU environment to patient which meet air and land specifications for safety Dedicated vehicles permit storage and allow for hydraulic lifts, increasing flexibility and occupational health and safety as well as decreasing response times 40

Recommendations One number to call as single access point must ensure timely medical advice, triage, rapid dispatch and identification of receiving physician and hospital Transport medicine physician to provide on line medical control and ensure quality and accountability framework with metrics 41

Save the date: 6 th OCTOBER, 2015 SickKids The inaugural INTERPROFESSIONAL Neonatology Conference T4 Health Triage, Transport, Treatment & Transition with Guest Speakers Joan Brennan-Donnan, PhD candidate Dr Andrew Berry, MB. FRACP Dr Lianne Woodward, PhD