This educational activity was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services. Its contents do not necessarily represent the policy of CDC or HHS and should not be considered an endorsement by the federal government. Hello and welcome to today's webcast, Patient Transport During Outbreaks and Disasters. My name is Charlotte Thomas. I am the Chief of Advanced Practice for Critical Care Medicine at Scripps Mercy Hospital in Chula Vista, California. I will be moderating today's webcast. A recording of this webcast will be available within five to seven business days. Log into mysccm.org and navigate to the My Learning tab to access the recording. A few housekeeping items before we get started. There will be a Q&A at the end of the presentation. To submit questions throughout the presentation, type into the questions box located on your control panel. Please note the disclaimer stating that the content to follow is for educational purposes only. And now I'd like to introduce your speakers for today. Dr. Honeyhocky is a pulmonary critical care physician at San Antonio Military Medical Center in San Antonio, Texas. And Jeffrey White is Director of Safety at HealthNet Aeromedical Services in Charleston, West Virginia. And now I'll turn things over to our first presenter. Thank you and welcome everyone for attending. Today, we would like to discuss several things that we've learned through COVID and how they can be applied in future pandemic or outbreak situations, conflicting standards that everyone had to face. We're going to review some personal protective equipment and how to use and how to verify that personal protective equipment is appropriate for use. Patient assessment challenges that we all faced. We will discuss severe adverse events and their risk to the patients and to us. Important decision points in the transport process of moving these patients. Key elements of transferring these patients. And then the use of a checklist to help make those decisions and move these patients appropriately. So my area of expertise is emergency medical services, emergency management services, bringing the patients from the field to the hospital. It offered a unique set of situations for everyone in the field. First, the thing that you have to understand is how this all fell under an OSHA controlled environment. The personal protective equipment we used in many states was dictated by OSHA. The thing you have to understand and how that all falls in is whether your state is an OSHA state or not and how your agency or organization falls into that as far as following the standards and how they have to follow those. The equipment that was recommended all needed to be NIOSH approved. All of the respirators have to be approved. They have to meet certain standards. The place to go for that is right on the NIOSH website. It outlines every bit of that information for you. So now we tie in the CDC and this is where the three together not necessarily were conflicting standards, but it was, you had to meet all three areas and it just offered a distinct challenge for, especially for emergency medical services. So when the CDC put out recommendations on how to manage patients and employees and protect themselves and keep exposure to a risk, you had to really figure out creative ways to work inside of those OSHA and NIOSH regulations and follow the CDC standards, which often was a challenge for many people. So again, the equipment, was it NIOSH approved? Did it have approval? Did it provide source control? And basically what we're trying to say there is we know that in any infectious disease scenario, there is a source patient and then exposed patients. So going into an environment where we potentially knew we had a source patient, there were days that leading up to where you could be asymptomatic, but still be a carrier. So if you didn't use appropriate PPE to control yourself, you were not considered source control. So that offered a challenge on also selecting the appropriate PPE. How did the OSHA standards fit in? Throughout COVID, the standards changed. They updated and added temporary standards that have since went away, but they did add those temporary standards. Sourcing of PPE when in the middle of a pandemic, you're trying to get appropriate PPE for every area of medical, in hospital, in nursing homes, in transport, in every single area, there was a limited supply and a very high demand. The other piece to that was the staffing issues, especially in EMS when you are low staffed. And then when you look in hospital and you have areas that are low staffed, or you have an employee that becomes exposed and has to take the mandatory quarantine at that time, now you're low staffed. So you're increasing not only the workload, but the fatigue, the PPE fatigue on the employees. So your burnout rate is a little higher. So it was all things that all played together that you had to manage and had to deal with. Patient assessment became difficult, especially in the EMS world, because you had accident scenes, you were at patient residence, and you had no idea what their exposure was and what your risk was. So you were having to full PPE to go into a situation and may not need it. So then that gets into burn rates of PPE, that gets into user fatigue, it gets into a whole lot of problems that leadership had to manage. When you're doing inter-facilities, which we'll talk more about later, you would walk into a patient room. Something beneficial in our world was what they call the view from the door. Stopping at the door of the patient's room before you get yourself into an exposed, potentially exposed environment, and talk to the family, talk to the patients, talk to the nursing staff, figure out and determine what level of PPE you needed before you entered that environment was hugely beneficial for those crews doing that. Probably the biggest challenge during COVID was with the masks themselves, in communicating with your patients and their family and any relatives that you may have to talk to, other healthcare professionals, just trying to give a report to someone. They may not be able to understand you through that mask. Someone with language barriers, if you would have someone that is hearing impaired that needs to read lips, they couldn't do that. The PPE that you needed to keep yourself and your patients safe offered a challenge in your ability to do that. All right. Let's move into the transport of critically ill patients during outbreaks and disasters once they are inside your facility. We are going to talk specifically about the most common serious adverse events and their underlying risk factors, the important decision points in the transfer process, and the use of checklists. I think this diagram from FNARA really helps to show the overview of what we are talking about. Now, this does say ICU to ICU, but it most likely will also be from ED to ICU or even OR to ICU. It's the same principle. The dashed green lines show where regular checks and corrective actions have to occur to prevent those adverse events we've been speaking of. We'll talk later about the use of checklists, which could be thought of as the dashed green lines in this diagram. There has been a lot of study and research on the types of serious adverse events which occur during transport of the critically ill, and that's during a normal situation, not even including what happens during disasters and outbreaks. So let's take a look at the ones most identified. Transporting complications is the name of the game for nearly everything with a critically ill patient, but even more so during a transport situation. It can be especially difficult in a high-intensity or high-volume situation where the staff transporting might not know each individual patient. The physical act of moving the patient from the bed to stretcher or CT table or even the movement down a hallway with door dividers in the floor can lead to the agitation and potential for increased intracranial pressure with head-of-bed angle changes. Development of hypotension or hypertension can occur from perhaps a vagal response to agitation or even medication issues with a pump or volume. Development of a drug box and medications to treat these issues as well as ACLS medications are needed and used for most patient transports. Having sedation and paralysis appropriate for the patient's condition is also of utmost importance. We often assume most critically ill patients are going to be mechanically ventilated, and most are, and this extra layer really relates to the pulmonary adverse events. Unfamiliarity with a transport ventilator could potentially cause abrupt changes in settings such as PEEP and FIO2, impacting things such as hypoxemia and pneumothoraces. Agitation could lead to an unplanned extubation or incorrect sedation levels could cause dyssynchrony with the ventilator. Obviously, these are going to be extremely problematic and life-threatening if they occur. Human errors and equipment malfunction are also key players in the development of SAEs, ensuring we never lose the basics of patient identifiers, not by room or bed number, but by verbal check if able with the patient or checking armbands even during the busiest of disasters will prevent misidentification and errors. Ensuring familiarity with all equipment, especially those used during high volume times of stress will prevent errors of programming or with power supplies and tank volumes. Even the risk factors for SAEs during transport have been studied. Now in the disaster outbreak setting, perhaps we are not going to know if someone who's had coronary artery disease, but we can look at the number of pumps on the pole and at the ventilator to see settings to know if this is likely going to be a high-risk transport. The staff-related risk factors are the most, the more likely ones we can impact. People are the resource, right, but only if we are using them appropriately. Using those out of their home departments during times of stress staffing has to be examined for appropriate roles and evaluated whether a transport one makes sense. Also ensuring stability of patients with adequate resuscitation from either the OR or ED prior to transport, making sure that the risk of that earlier transport when a patient is still somewhat unstable versus the benefit of the open bay or bed has to be evaluated first. The use of higher PEEP or having to use the bag valve mask for the entire transport also puts the patient at a much higher risk of an SAE. Do we need additional personnel or equipment for this transport? And here are dotted green lines from the first diagram. The moments when it's critical to ensure communication between staff and that both supplies and equipment are appropriate and ready to go. This is where you make sure you have that BVM, an extra bag of the vasopressor in case your supply runs low, pushes of sedation or paralysis if needed, and warming blankets or cooling supplies if they're indicated. Making sure all of these things are accounted for and that staff knows how to use them are considered key prior to transport. As we've talked about previously, who should be on the transports? If a patient has an unstable airway, do we actually need a physician to accompany that transport? Can we have the nurse who is staffing outside of their area remain back and watch another patient while a more experienced ED or ICU nurse transports? Having that drug box that we talked about previously ready to go, how many bags of infusions do we need to carry along? Could we change them all over to fresh bags prior to transport? Obviously keeping waste and drug shortages in mind. What sort of documentation is going to be done pre and post transfer? And what about complications? How are those going to be documented en route and ensure that this information is communicated across the lines? With a checklist, it goes without saying the single most important aspect is the effective communication between the professionals involved in the transport. If only one person is responsible for looking at it or checking to make sure the boxes are all marked, is it really going to be effective? The checklist can help identify who is appropriate for transfer from the patient stability perspective. It can also help identify who is going to be required to be accompanying based upon the status of the patient and their required therapies. Who is checking the stretcher or bed and who is responsible during transport to ensure tube and line safety? These should all be delineated clearly prior to transport and having a checklist will certainly help. During transport, who is watching what values for the patient monitor and who is checking that equipment is functioning appropriately and still has adequate levels? And then finally, checklists can also have areas which will help to create or complete records of the transport and document any complications or events that occur. Having that ready to be scanned in or placed to the chart at the end can save time and energy needed for the next event or transport. I appreciate your time looking at intra-facility transport. We will now be moving over to our final presenter, Dr. Honeyhocky. Hello, my name is John Honeyhocky. I'm a pulmonary critical care and ECMO physician out of San Antonio, Texas. I do have a disclaimer. I am an active duty member of the military and so these are my own views. They don't reflect those of the Department of Defense, but I am going to bring in some of my experience as a physician on the critical care air transport team. It's a CCAT team and it's part of the Air Force and I was able to have the privilege to transfer a number of patients between different facilities during COVID and so I'm hoping to share some of that experience with you all today. So what defines a successful transport between two facilities? You know, these facilities could be just across the street, or they could be across the country. I think we all are very much focused on patient outcomes, and so ultimately a safe transport is a successful transport. We also want the patient to be comfortable. We don't want them, hopefully if they're in a lot of distress, to remember it, or to be able to be comfortable and able to tolerate it as best as possible. It does require in a successful transport a lot of coordination across local, regional, state, and even national levels, sometimes international levels. And that has to have those appropriate channels of communication between different institutions that might be public, private, or even governmental. And ultimately, a successful transport is going to require the right amount of infrastructure and resources. So, then what happens when the system becomes overwhelmed? When that infrastructure is challenged, those resources become more limited. The ability to communicate, whether on a personal or individual level, as Jeffrey talked about in his section, you know, becomes challenged, or the ability to kind of coordinate breaks down because of different challenges during an outbreak or a pandemic. That kind of takes us to then going through this vicious cycle of being able to assess where we're at, make a decision about what to do next, and then reassess. So when we're talking about that decision to transfer a patient, it really comes down to three big factors. There are those patient factors about how sick they are, and really prioritizing which patients need to go to a higher level of care versus those that don't have really any limitations and can kind of wait until it's safer or there's more availability. There are definitely decision-maker factors about not only a person's professional background, but their experience with making decisions, and then ultimately, the environmental factors. And that's not only within a specific facility, but then also kind of not only the referring facility, but then the receiving facility, and ensuring that those resources are appropriate and that we are appropriately balancing them out. So these three big categories of factors all contribute towards that decision-making process, that framework. And I really like how they put that the next level was the moral distress that a lot of clinicians face during this most recent COVID pandemic and will likely be an issue in future outbreaks or pandemics, is not necessarily being burnt out immediately, but having that distress, the emotional effect of making these decisions, because ultimately, they become life and death decisions. So how do we prepare appropriately? Well, we have to process plan. There has to be a certain level of commitment between referring and receiving facilities to coordinate consistent processes. I think Jeffrey touched on it in terms of the different agencies that become involved in the decision-making process about the level of PPE, which is just one decision that had to be made. And then it has to be decided about what has to be followed, what's going to be followed. If someone says something different, who wins? And how do we make that decision so that there's not a discrepancy about me transporting a patient in a PAPR and showing up to someone who's receiving them in a simple face mask? There has to be a centralized method to bring all this data together, synthesize it, and help ensure that it's being tracked. And you have to have EMS being able to provide that care en route at the level that is expected. As Charlotte talked about in her section, you know, you really want to plan ahead to reduce the risk for adverse events, knowing that there are certain predictive factors, but then there are others. There are certain patients that it's hard to predict if they're going to do, if they're kind of worsening before they transport or if they look stable. The decision's made to transport, but they don't go for another 6 or 12 hours. And in that time frame, the clinical situation changes. So there has to kind of, EMS has to be prepared at the appropriate level and the resources have to be available. And then as I mentioned, tracking the patient so that they are either kind of repatriated or repopulated back to their originating facility, if it becomes an imbalanced situation between different facilities so that those larger tertiary care facilities don't become so overwhelmed that they can't provide that level of care that they're expected to as the as the tertiary care facility. So I mentioned here some pictures about the stressors of transport and then some specific examples. And really what I want to highlight is that it's not only stressful for a patient to be transported, but it's stressful for the team. And that's whether they're being transported even within the hospital or across the street to another hospital or across the country. It requires a lot of not only physical, but mental preparation to ensure that everything is planned out. And there are a certain number of things, though, for the longer range inter-facility transports that must be must be focused on. I want to highlight what Charlotte said about equipment. You really can't verify the equipment's functioning enough, ensuring that it has the right amount of power, the right cords associated with it, the right batteries, ensuring that your pumps are working, that you have those backup medications. But then also the things that you don't think about that are not necessarily clinically related, you know, as a transport team member, where you want to ensure that you're prepared mentally, that you're prepared physically, that you've eaten something, that you're staying hydrated, that you have ear protection, eye protection if it's needed, that you are drinking, that you're staying as sharp as possible and not distracted by your own kind of, you know, physical fatigue that you're going to inevitably feel. And then ultimately, if there is a flight that's involved, that brings on a whole another level of kind of stressors, which we've all experienced just flying commercial. But flying with a patient that you're transporting and you're staying focused, you know, you really need to kind of be prepared for those and understand what's out there so that you know what might occur so you can more appropriately deal with it. So in the next few slides, I have some picture examples from my own personal experience during COVID of transporting patients, and they're really meant to highlight some of these challenges that we talked about and how we're going to face these again in the future, the next outbreak, the next disaster, the next pandemic, because we have to have that mentality so that we're ready for it. Ultimately, you know, and I have appropriate permissions for these pictures. You know, we in the far left there, you know, we were all in our PPE, it demonstrates the challenges of talking and how we're all squeezed into an ambulance there. And in the other pictures, you see the number, the amount of equipment and transporting these critically ill patients that you have and how it's not as clean as you would expect. You know, you're trying to just pack all the equipment on there and trying to get the patient safely from point A to point B and ensuring that it's all secured down. But, you know, it's the era of kind of a really clean design equipment that's all kind of fits nicely into the stretchers and can kind of be used amongst different stretchers is not quite here yet across the different systems. I highlight here some, again, some of the very critically ill patients there on the right, the number of pumps, the equipment they had, the ventilator. These patients were on ECMO and how we had to do this within our transport container because of the requirements for our level of protection. And that container, you know, we were putting in the back of a cargo plane to where we had the cold zone outside where we could all kind of not have just wear a simple face mask, but going in there, how we had a process in place to get into the actual container and then being able to do clinical care for that patient, but not have to stay in that PPE the entire time. Albeit, I do know there are a lot of EMS services that would do long range transports and full PPE the entire time. And a few times we had to do that, too. It really just depends on the duration, the level of resources that are available to do that. So preparing for that next outbreak or disaster requires some very key concepts that I want to give some credit to. And then the state of California developed a plan that highlighted these concepts in 2018 before. So first off, you really want to assess and develop those capabilities within your organization or jurisdiction to support effective patient movement. In doing that capability assessment, you really should identify operational gaps. That is the goal, is to see where your weaknesses are at. Hopefully you will find a lot of strengths, but the weaknesses is what are what you're going to identify more readily when it's not as urgent or emergent. You want to conduct that planning within your organization to address these gaps, but within your capabilities and ultimately so that you can carry out successfully those actions as described in the plan. Then you have to develop training. It has to be conducted regularly that it really not only assures you, but increases the staff's competency and readiness to take these actions, to understand them and to do them. And then ultimately, you know, in identifying those operational gaps like I talk about, you really identify other potential hazards that, you know, could lead to the need to have to move patients and implement these strategies that really minimize the impact and ensure that you're mitigating that risk that could occur overall on a larger scale. So it's not only the plan within your facility, but the planning with other facilities and how that's going to look so that that risk is mitigated across the whole continuum of the transport spectrum. And so in summary, we really want to highlight a few key points. PPE should be approved and it's going to cause, it's going to provide that protection for the individuals, but it's also going to cause barriers with communications. Understand, too, that within the decision of which level PPE should be used, you might have multiple jurisdictional agencies that are going to counteract each other. And that confusion can kind of add to the cacophony of negativity in a stressful situation. So, you know, we would encourage you to kind of maintain heads about it and to try and get as much clarity as possible and then make the best decision that's safest for you and the patient. And ultimately, PPE as a resource is an important consideration for any duration of patient transport. That decision to transfer a patient really is a complex one that involves those three main factors that that framework really highlighted well. And to do it safely, it's going to require a lot of coordination across multiple levels of care, across multiple differences and across, you know, multiple kind of understandings of what a transport entails, because a lot of us clinicians focus on the clinical side. But then once you get into the EMS systems and the logistics of it, you understand how much more complex it can be. And so ultimately it comes down to preparation. That process planning is going to assist us to really be prepared for that next outbreak or disaster because we know it's going to happen and we know that there is going to be patient transports during it. So I really appreciate your time during my discussion. I look forward to your questions. All right, so now we are going to open things up to questions. I see that we have one here listed. Proning presented some serious issues with interfacility transport. Agreed. Being in a large aircraft made that easier than in the back of a helo. Any thoughts on the prone patient in interfacility transport? Dr. Hockey, I think that's for you. Yeah, that's a great question. We trained on being able to do it. Ultimately, we thought that the risk associated with it was greater than the potential benefit depending on the duration. You know, if we're talking across town, there's the there's the potential capability. But when we're talking about the cross country, we we were fortunate to have ECMO as an option. So we prefer to utilize ECMO when it was available as a resource. But I do know of some across town transports that occurred. And again, it just requires that planning for, you know, an accidental extubation. And the fact that a prone patient is a very sick one, they don't have a lot of reserves. So if something goes wrong, it goes very wrong quickly. That's right. I actually had a question for Jeff while I was listening to you, because I was interesting to me as we were working at this presentation, just how many different sources of information you all had to kind of work through. You know, I had the benefit of just walking over and saying, I need a size small. And someone handed me the mask that met all those criteria. So which was nice for me now looking at everything that you guys had to deal with. But, you know, if you if I'm just standing there in the moment by myself needing to understand what kind of PPE, you know, if you have a recommendation on where someone should go as a kind of a one source of truth, if I'm facing like a new situation or a new disaster outbreak situation, you know, is there like one place that you would recommend someone be able to go to to look? Absolutely, I would use the NIOSH website, they do all of the respirator testing and certification. So if you want in an OSHA standard when it says you have to use an approved respirator, if you go to the NIOSH website, it will give you a list of every approved respirator that you could find anywhere in the world. And and that would be your one stop shop to make sure you order the right personal protective equipment. Okay, excellent, excellent. And then I did have one other question for Dr. Hanenacki while I was listening to yours, because I agree with you, it's only kind of the matter of time before we end up with in our next scenario of disaster or outbreak. I mean, we hope that it doesn't happen, but I think we know that things are probably going to move that direction again. So what is your recommendation for like the individual at a facility, whether it's EMS or inpatient, to help determine or assist with the readiness for this next high stress situation with a disaster or an outbreak? Kind of what can an individual do for that? That's a great question, Charlotte. I think we all are a little bit over COVID. And so what's key is that we need to know if we have a plan. And it's not if it's a pandemic plan, it's if it's an outbreak, a disaster, a stressful situation that can occur that's going to overwhelm the system. Know if there is a plan and start to learn it. And if you're interested in being able to be a part of that, get involved in your facilities group or section that helps with that process planning and then start training on it. I think it's tough to say, well, we've been through this, we know what we're doing, but there are multiple levels of readiness. And I think we have to kind of focus on our individual readiness, but then also kind of our facilities readiness. And then if you have the ability or you're in the right position, being able to kind of start focusing on a more regional, not only the local, but the regional or even state or national level and getting the word out there to try and say, hey, we need to be ready to ensure that we're not as surprised next time because there are going to be new challenges that crop up next time. And we just need to be prepared mentally and physically with a process plan to address them. Great. Do we have any other questions for any of our presenters today? Okay. Well, we thank you all very much for being here and attending. And again, this webcast was recorded. The recording will be available to registered attendees within five to seven business days. You can log into mysccm.org and navigate to the My Learning tab to access the recording. And this concludes our presentation today. Thank you all so much for being here. Thank you all. Appreciate it.

Patient Transport

Outbreaks

Disasters

Webcast

Personal Protective Equipment

Coordination

Preparedness