SCCM Resource Library-Prehospital Controversies: How Prehospital Treatment Affects Critical Care

Video Transcription

Welcome. Thank you for joining us. Today we're going to be talking about pre-hospital controversy,  how pre-hospital treatment affects critical care. So I am Susan Wilcox and I will be serving as your moderator today. First, we're going to cover protocols and regionalized delivery  of care. And then lastly, frontiers in critical care transport, from pharmacy to devices.  We want everyone to engage as the lecturers will be available to answer any of your questions. Please use the chat feature in Zoom to ask any questions that you may have. Thank you  for joining us. Hello. I hope this virtual presentation finds you well. My name is Jim Hauser. In preparation for our upcoming panel discussion, I am going  to spend the next 15 minutes providing a brief overview of protocols and regionalized delivery of critical care. But first, a little about me. I am entering my third decade in  critical care transport. I have a clinical background, starting my career as a volunteer firefighter EMT, then becoming a paramedic. I began in the communication center at Statt  Medivac and progressed through several business and operations roles. In parallel, I returned to nursing school and again to be trained as a nurse practitioner. I have the honor  of serving as the president and CEO of UPMC's Center for Emergency Medicine of Western Pennsylvania.  Within the center is our critical care ground and air transport program, Statt Medivac, which operates one critical care ground and 18 helicopter bases across five states. I  have no disclosures to share. All right. So let's start with the boring stuff first. The development of a protocolized delivery system requires careful evaluation of all  relevant licensure and regulatory requirements. First, one needs to be familiar with the state  and regional requirements. Whether your transport organization is small or large, because of  the reach of air medical transport services particularly, you may face requirements beyond your local jurisdiction, even if you're a small organization. In our organization, we  not only hold agency licensure in the five states we have physical operations, but also  maintain licensure in another three neighboring states. This means eight licensure application  and renewal processes, eight different required equipment and medication lists, and eight different inspection processes. And of course, eight different renewal fee structures. In  addition to the administrative requirements and equipment, each also has rules as to minimum  crew configurations, personnel licensure and certification, scope of practice, and protocol  parameters. Beyond state and regional licensure requirements, your capabilities may dictate  additional regulatory process. As example, if you want to provide point-of-care testing beyond  wave testing, it will require CLIA license. We currently assess blood gases and lactate using  point-of-care testing. As a result, we maintain all of the required laboratory quality monitoring  for 22 testing devices and hold a certificate for a moderately complex lab. In fact, we oversee more devices than our health system's largest facility. We also carry blood products,  which requires adherence to blood lab regulations. The same goes for pharmaceuticals and of course  controlled substances. Once you get past government and agency requirements, you then have to  navigate regional approaches to care. There is nuance between how critical care populations  are managed. You all realize this coming together for SCCM. When you think about regional care  delivery, you have to expect there will be discussions either with your referring colleagues  or even your partner facilities on how patients are managed. As an example, our organization  provides critical care transport not only for UPMC, but we also have a base of operations that supports Johns Hopkins Lifeline. Our medical direction teams have a great partnership  and are constantly discussing the best ways to align practice and protocols, sometimes with differing approaches. In addition to these requirements, there are also voluntary  accreditation programs that assess the performance of critical care transport systems. These  programs have standards that may overlap or they may be in addition to regulatory requirements  discussed previously. So how do we manage all these requirements at Stapp Medivac? Since we are headquartered and a majority of our operations are located in the state, we use  Pennsylvania as our foundation. From there, we layer our local, regional, state, and miscellaneous  requirements on top of each other. This compiles a master list of required minimums and shows  us where fallouts exist. We then operationalize between our lowest and our highest requirements  in each area. Once you have a good understanding of your licensure and regulatory requirements,  you then have to consider your plan for staffing. Are there certain staffing minimums? Some states require or are more prescriptive than others. Beyond minimums, your expected scope  of practice may impact crew selection. Most critical care level transport programs use a nurse combined with another provider, either a second nurse, a paramedic, a respiratory  therapist, et cetera. That said, there are helicopter programs that also staff to paramedic  level and function as ALS providers. Of course, advanced practice providers and physicians  are used as well. This combination falls somewhere between your expected level of care, delivery,  and regulatory requirements. Beyond configuration, years of experience are also a factor to consider.  How experienced do you expect candidates to be coming into your organization? Most would agree a new nurse or paramedic would not be the right fit for the type of skillset and  knowledge base needed to be a transport provider. Additionally, accrediting agencies put minimum years of experience thresholds in place as a requirement of the job description. Our  organization functions as a true critical care level, routinely transporting patients requiring positive pressure or complex ventilation strategies, balloon pumps, impellas, ECMOs.  Our team's minimum is the nurse-paramedic model, each requiring three years of experience  prior to hire. From there, we feel this combination of nurse and paramedic creates a complementary  dynamic, one providing pre-hospital experience and the other providing emergency and or critical  care nursing experience. We also have a team of flight physicians who fly second person, many of them subbing out either the nurse or paramedic role. In addition to those groups,  we have second and third year residents who fly dedicated third person regularly. Lastly, we've also began to introduce APPs to our team in the recent past. It's important to  emphasize staffing licensure and certification only permits the legal level of care. Their true level of function should be based upon the organization's ability and commitment  to train and maintain the personnel to the expected level. Once the crews are determined, trained and equipped, the teams need oversight and more importantly, clinical leadership.  Engaged medical direction is paramount for highly functioning transport teams. The medical director should develop care expectations and protocols based on current standards of  care, ideally reviewing each standard for relevance to academic literature, etc. The  development of treatment algorithms and protocols should be done in consultation with a multidisciplinary  group to ensure specialty and subspecialties can provide insight and review. Our medical direction team coordinates a committee of physicians who review and approve the protocols  annually. Speaking of annually, the protocol should be reviewed on a regular interval to maintain clinical relevance. Once protocols are developed, the medical director should be as  familiar with the protocols as the clinical teams who are expected to follow them. This includes routine training of protocols and procedures for the physicians providing medical  command. So now you have this team in place, trained and ready for the call. It's three  o'clock in the morning and the team is alone in a community ICU resuscitating a patient in attempt  to stabilize for transport. It is at this point your teams are following your set of finely  crafted protocols. There is significant trust by the medical director whose license they are  functioning under that they will follow the protocols as developed and written. This trust is obtained through constant training and competence assessment. You must develop programs  that assess clinical skills and critical thinking competence on regular interval. This is done  through didactic simulation, live patient interventions. Our teams are put through high  fidelity simulation and competence assessments twice per year in addition to lengthy quarterly  educational requirements and 12 live intubations. There is also a level of art to what our transport  teams do. The teams have robust protocols and training. The art lies in their critical thinking  skills. This is where previously mentioned experience requirements crosses over training.  Most protocols have an upper limit where any orders or procedures beyond this point require consult with expert medical direction. Art is knowing when to engage expert help  even when the protocol doesn't dictate. All of these processes should be routinely reviewed. A solid QA-QI program should be in place to verify care is being delivered  to the expected level. All clinical metrics are being met and there is a process to tie all of these things together with education. Finally,  collaboration with community colleagues is an essential component of regional models.  As mentioned previously, practice variability must be assumed. Thus, community providers should be  engaged in either the development or at a minimum the explanation of how protocols and procedures  were derived. In regions served by more than one type of transport team, community providers must  understand practice variability between transport services. Depending on markets and organizations,  there could be a mix of capability models. The typical delta in a market lies somewhere between  critical care and advanced life support helicopter programs. The partnership between referring  provider, transport team, medical direction, and receiving provider should include a process to  discuss appropriate utilization. Admittedly, this one's a bit delicate as the referring provider is  often also considered a customer. Proactive education and providing expert resources  is key to the patient receiving the right transport team and avoiding awkward UR conversations later.  As part of the PA Emergency Health Services Council, we developed a tool to help providers  less familiar with utilization considerations. Critical care transport is often thought to bring  two key benefits, a level of care higher than local emergency medical services, and speed.  Here, we place the two primary benefits of transport considerations on each axis, clinical capabilities on the Y and surface, which is transport terminology for ambulance,  and air, which represents helicopter on the X axis. As you can see, there are instances where lower acuity may necessitate the need for speed and other times when the higher acuity  may require a higher level of care but is not time sensitive. Through a statewide task force representing Pennsylvania critical care transport teams, we're using this tool to  help educate community providers on the appropriate use of transport team and mode.  So, in summary, regionalized transport systems require knowing regulatory boundaries exist,  your expected scope versus crew composition and capabilities, having engaged medical leadership, protocols to guide care, and processes in place to assure  competence, skill, and art. And of course, finally, you have to partner with your colleagues  in the community. So, with that, thank you. I'm really looking forward to the opportunity  to discuss these things in more length and answer your questions in our upcoming panel. Thank you.  Hi, so I'm Susan Wilcox, and I'm going to be discussing frontiers and critical care transport from pharmacy to devices. First, I have a disclosure. I'm the associate chief medical  officer of Boston MedPlay, and this means that I believe that critical care transport saves lives,  and so I want to be clear that I have this bias as I'm going through the rest of my talk.  The first thing I'm going to talk about today is inhaled bupropanol. So, the majority of people  who work in the intensive care unit realize that inhaled bupropanol is a useful instrument in our ICUs. We can use it for patients who have severe hypoxemic respiratory failure,  and patients who have RV failure or pulmonary hypertension. Now, inhaled bupropanol, of course,  does not improve outcomes. It does not improve patient-centered outcomes. It doesn't change mortality, and it doesn't change ICU days, ventilator days, anything like that. But what  it does do is increase oxygenation, and it decreases pulmonary artery pressure. This can  make it a very useful bridge, and I argue that this is an opportune time to use it in transport.  So, in transport, we often have patients who are at community hospitals who need to get to tertiary  care centers for advanced care, and sometimes people think that these patients are too sick  to transport. Inhaled bupropanol is an excellent instrument to get these patients stabilized so  that they can make the transport safely, and so here I have the example of using it in the intensive care unit, as well as using it in the back of an ambulance. At Boston MedFlight,  our use of inhaled bupropanol has been increasing ever since we introduced it in 2017.  You can see the data here through the fall of 2019, month by month, as we are continuing to use  more and more inhaled bupropanol. Our protocol is that we started at 50 nanograms per kilo  per minute of ideal body weight, and the patient has to be intubated or non-invasive ventilation to make sure that they have enough flow to be able to get the medication reliably.  We use the Aroneb system to deliver it as a nebulized solution, and the important point  is that once it's started, it cannot be stopped. The patient can only have it stopped if they have  a clear clinical deterioration with the initiation, which of course is extremely rare. Because we  cannot stop it, we want to make sure that we have a conversation between the sending physician,  the receiving physician, and the medical control physician to acknowledge that everyone is on board  with starting this medication, as well as to ensure that the receiving clinicians will have  it ready and available, so when the transport team arrives, there's no delay in the patient  having the medication ready to be started. The only contraindications we have to using it are  thrombocytopenia and active hemorrhage. They're extremely rare in this patient population.  So here's our data. This is what happens when we use inhaled bupropanol in our patients with  severe hypoxemic respiratory failure. Now you can see that the change in the SpO2 is not that great.  From about 88% to a little greater than 90%. However, our prior research has shown that about  28% of patients normally desaturate when they're transported with severe hypoxemic respiratory  failure. So in my mind, even keeping a patient relatively stable with an SpO2 is a win in this  patient population. There are concerns about the patients getting hypotensive when we start this,  but that has not been our experience. You know, there are some wide margins here on either side,  but you can see that the map for these patients is relatively flat. The patients are able to maintain a blood pressure while we start the inhaled bupropanol. This makes it a great  medication for us to use in transport to transport these very sick patients safely and get them to  the tertiary care center. The next thing I want to talk about isn't really a device or pharmacology,  but it's transporting the patients prone, and this is definitely at the frontier of transport. So historically, transporting patients prone has really been relatively taboo,  and the reason why is that there are some high risks associated with this. So if you think about  how we normally assess critically ill patients, we look at their faces, we look at them anteriorly,  and if you have a patient prone, especially in a vehicle, you're not going to be able to assess  that patient in the same way that you normally would. Heaven forbid you lose an airway in that  patient, not only are you at risk of the airway coming out because of the way they're positioned,  but then you're not going to be able to manage their airways easily. And then certainly if a  patient decompensates, as we run resuscitations, we're used to having patients supine. So having  a patient prone would totally throw off the ways that we normally resuscitate a patient.  But the benefits are substantial, and in the setting of the COVID pandemic, we have rethought  how we approach prone transports. So we're using proning now in patients who are awake or what we  call self-proning, and sometimes we can avoid intubation in these patients. I have an asterisk  here because much like the inhaled epiprostanol, it can improve oxygenation, but it doesn't  necessarily always improve outcomes. However, in a given patient, if we can avoid intubation,  that's a win. You can avoid deterioration because if you think about these patients who are sick  enough to need to be proned at the sending hospital, transporting them, like I said, 28%  desaturated en route, they're going to be high risk. And if we can keep them relatively stable,  that's also a win. And this all can help get these patients to an ECMO center or a tertiary  care center where they can get advanced therapies. So we wrote new protocols in the setting of COVID  to transport patients who are either not intubated or intubated in the prone position. For patients who are not intubated, we are concerned because we don't want to delay intubation  for that patient who's clearly going to need it, because all that does is increase the risk to the  patient. And so along those lines, patients are not prone specifically for transport. What we want is for the patient to have been proned at the sending hospital,  have been monitored there for a while, demonstrate stability, and then if they're appropriate,  then we will transport them in the prone position. The patients who are appropriate are those who  have minimal dyspnea, patients who do not have hypercapnic respiratory failure. They have a  normal mental status. They're able to interact with the transport team, and they don't have  any markers of being a difficult intubation. Patients who are intubated are obviously a very  high-risk cohort, and we are very concerned about making sure that everyone knows that we're talking  about high-risk transport when we're taking people prone. So again, we have a phone call between the  sending, the receiving, and a medical control physician to say on a recorded line that everyone  acknowledges this is a high-risk transport and there is a risk of death in the transport, but we believe the benefit outweighs the risk. We have to have a large group to move these  patients safely, usually a minimum of five people. We have one person who's dedicated to holding the  endotracheal tube. We make sure all lines are sutured and the endotracheal tube has a commercial  device holding it in place in addition to a person. We suction out the mouth and the stomach to reduce  the risk of aspiration, get all of the lines, tubes, and drains aligned to make sure that they're  not going to be pulled or be taut at any point. We give the patient sedation, analgesia, and  neuromuscular blockade, move the patient to the edge of the bed, and then stop. We look at all  the lines again to make sure that everything is where it should be and nothing is being pulled, and only then do we move the patient over onto the transport stretcher.  Positioning these patients is key, and so this is a picture that I took from a wonderful publication  from a doctor at Pittsburgh where they highlighted their experience transporting patients prone.  Here they've used a mannequin to show what it would look like to transport one of these patients.  We take great care to make sure we're protecting the patient's face, their breasts, their genitals,  knees, and toes, any pressure points. We don't want patients to get pressure sores in the transport,  and so we also have to make sure that we have a contingency plan. So if a patient does have a  deterioration in route, we have to know how we're going to be able to move that patient, and the way we do this is by wrapping a sheet partway around the patient so that we can flip  them if they need to be turned back to the supine position, and here's what this looks like. So the  sheet starts out around the patient, and then the clinicians are able to flip them to turn them back  so they can manage the airway or do whatever needs to be done to take good care of the patient.  We've published on this. We now have the largest series in the literature with 25 patients  transported in the prone position in the setting of COVID, and what we've found is, again,  the oxygen saturations and mass are at least stable if not slightly improved over the course  of the transport, and this is remarkable because these are extremely sick patients. Only one of  these patients had severe hypoxemia en route, which again, thinking about the cohort is really  a positive. The overall mortality rate for the 21 patients that we had follow-up on was 43%,  which is very high, but again, thinking about how sick these patients are, to have 57% of them  survive is definitely a positive, and so we strongly support the idea of transporting patients prone with training and being conscientious about being safe as we do it. I'm going to  end with talking about ECMO transports, the ultimate in the device transport world.  So in the old days, when we thought about ECMO cannulations, if a patient needed to be cannulated,  they needed to be at an ECMO center. However, over the last 10 years, we've really changed our  thinking about who can be cannulated and where it can occur. So if a patient is not currently at an  ECMO center but they have an indication for ECMO, there are a few options. The first one is that  they can be transported to an ECMO center on some other support, like a balloon pump, an  impella, or inhaled bupropanol. Another option is that you could send an ECMO team to the community  hospital to go get the patient. You could have them cannulate in the community hospital and then  bring the patient back on ECMO. This is a great option, but it requires a lot of investment from  an ECMO center. What we're seeing happen in New England is that there's this cannulating goes  strategy. People are learning how to cannulate in their training programs, going to surrounding  hospitals in the community, and then when they have a patient who deteriorates, they cannulate  there and then call us for transport. So we're seeing this happen more and more. These are our  numbers year after year from 2011 through 2019. And very, very few of these are primary ECMO  transports, meaning that an ECMO team went out, cannulated, and then brought the patient back.  The vast majority are secondary ECMO transports, or that cannulate and go strategy, where a patient  gets cannulated and then we're called to come transport the patient. So here are just some  illustrations of what the changes have been like over the last few years. So from 2011 to 2012, there were 11 cannulations at four centers in the New England area.  2013 to 2014, 14 cannulations at eight centers.  Then 29 cannulations at 14 centers.  39 cannulations at 11 centers.  30 cannulations at 11 centers in 2019. So this right there shows you how diverse geographically  the cannulations are and how they're occurring over a very large area. And then we're responsible for transporting these patients safely. So it's a unique situation. So we're  responsible for transporting these patients safely. So it's an incredible investment from  our transport organization. And I've highlighted New England here simply because this is where I  live and work. However, this is occurring across the country. And if it's not happening in your  area right now, I anticipate that it will be soon. This is a picture that I have from one of my ECMO  talks where I talk about the importance of LV venting. I have it included here because I think  VA ECMO transports, 35 of these patients were also supported with an impella as an LV vent, and 13 also had an enteritic balloon pump. So these are incredibly complicated,  complex transports that require a lot of specialization from a transport team.  I love this picture because it shows how much is going on in one of these transports.  So that's one of our excellent nurses sitting there at the bedside of a patient in the transport  vehicle. And you can see that the patient has an ECMO circuit down there in the bottom corner.  They have an impella at the foot of the stretcher. There are three chest tube canisters there,  and the patient had an open chest. I believe this patient was also being transvenously paced. I  can't see the pacing wire in this particular picture, but it just illustrates how much is  going on and how complicated these transports are. Here's another example showing what it's actually  like to be in a helicopter with one of these patients. And you can see there that our crew members are working in an entire, in a very confined little space, taking care of these  patients who have a ton of equipment. And so there's not a lot of room to maneuver in here.  And so if you're going to do ECMO transports, you really have to have a system. Who is on your team? Who is doing these cannulations? If you are at a center that  can do a primary ECMO transport, sending a team to go cannulate, that's fantastic. That's outstanding. But not every center has the resources to be able to not only take care  of their ECMO patients in their center, but also send a team out to go get patients. And if you do do that, then the question is, do you have the availability to do that 24-7, 365?  If not, how do you justify giving patients differential care depending upon when they deteriorate? No matter what your system is, it's really important that you have excellence in  training and education. That's really what it comes down to because these patients are extremely complicated and whoever's taking them has to be an expert at managing them.  If you invest those resources though, you can do things like this. I'm very proud of this slide.  It shows that in a period of about four hours, our organization did three ECMO transports,  not quite simultaneously, but almost. Two of them were over very long areas, large areas as well.  So you can see that there's a lot of investment that's required to be able to do this.  Also says that you have to have a physician on board for all of your ECMO transports.  We respectfully disagree with that. So here's our experience in transporting patients without  a physician on board. And we have accompanied transports that were accompanied with a  physician or an APP with critical care expertise, as well as those who are unaccompanied. And what  you can see in the middle of this here is that the major complications were about 22%  in both groups. Hypertension, which was a minor complication, was more common than the unaccompanied  and an unstable rhythm was the only major complication or adverse event that was more common in the unaccompanied as well. And it's hard for me to imagine that a physician on board  would stop the patient from having an unstable rhythm. This is our rate of major and minor complications over the years. There's no difference across the years with the rate of  our major adverse events. And so in conclusion, I would say that inhaled bupropanol doesn't improve  mortality, but it's a great bridge. And this makes it very appropriate for use in critical  care transport. Prone transports can be completed safely and effectively, but it requires a lot of  training, education, and caution on the part of the transport team. Everyone has to be on board  and recognize that this is a high risk transport, but the benefits can outweigh the risks.  And then lastly, ECMO cannulations are occurring throughout the community and critical care  transport teams, not just in our area, but across the country need to be ready and willing to  support these patients being transported either through primary transport when they send a team  to go cannulate or through secondary transports to get a patient who has been cannulated and bring  them back to an ECMO center. This requires a lot of training, education, and investment, but again, it can be done safely. And I believe these things can improve patient outcomes.  Thank you for your time. And we're happy to take any questions in the chat.

Video Summary

In this video, Susan Wilcox discusses pre-hospital controversy and its impact on critical care transport. She first talks about protocols and regionalized delivery of care, highlighting the importance of understanding state and regional requirements, as well as additional regulatory processes. She also mentions the need for staffing considerations and how crew composition and experience play a role. Wilcox emphasizes the importance of engaged medical leadership and the development of protocols based on current standards of care. She then moves on to discuss frontiers in critical care transport, specifically focusing on two topics: the use of inhaled epiprostanol and prone transports. She explains how inhaled epiprostanol can be a useful bridge in stabilizing patients for transport, especially in severe hypoxemic respiratory failure cases. She also discusses the benefits and challenges of transporting patients in the prone position, highlighting the need for caution and proper training. Finally, she touches on the transport of patients requiring extracorporeal membrane oxygenation (ECMO) and the importance of specialized training and education for transport teams in this area.

Asset Subtitle

Administration, Quality and Patient Safety, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives
Review clinical protocols related to ground and air critical care transport that may have system implications for regionalized critical care
Discuss frontiers of critical care transport controversies
Review hot topics in prehospital critical care research

Protocols and Regionalized Delivery of Critical Care
James Houser

Frontiers in Critical Care Transport: From Pharmacy to Devices
Susan Wilcox

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Transfers

Tag Communication

Tag Education

Year 2021

Keywords

critical care transport

protocols

regionalized delivery of care

staffing considerations

inhaled epiprostanol

prone transports

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