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Pinto-Villalba RS, Leon-Rojas JE. Reported adverse events during out-of-hospital mechanical ventilation and ventilatory support in emergency medical services and critical care transport crews: a systematic review. Front Med (Lausanne) 2023; 10:1229053. [PMID: 37877027 PMCID: PMC10590890 DOI: 10.3389/fmed.2023.1229053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/20/2023] [Indexed: 10/26/2023] Open
Abstract
Background Emergency medical services (EMS) and critical care transport crews constantly face critically-ill patients who need ventilatory support in scenarios where correct interventions can be the difference between life and death; furthermore, challenges like limited staff working on the patient and restricted spaces are often present. Due to these, mechanical ventilation (MV) can be a support by liberating staff from managing the airway and allowing them to focus on other areas; however, these patients face many complications that personnel must be aware of. Aims To establish the main complications related to out-of-hospital MV and ventilatory support through a systematic review. Methodology PubMed, BVS and Scopus were searched from inception to July 2021, following the PRISMA guidelines; search strategy and protocol were registered in PROSPERO. Two authors carried out an independent analysis of the articles; any disagreement was solved by mutual consensus, and data was extracted on a pre-determined spreadsheet. Only original articles were included, and risk of bias was assessed with quality assessment tools from the National Institutes of Health. Results The literature search yielded a total of 2,260 articles, of which 26 were included in the systematic review, with a total of 9,418 patients with out-of-hospital MV; 56.1% were male, and the age ranged from 18 to 82 years. In general terms of aetiology, 12.2% of ventilatory problems were traumatic in origin, and 64.8% were non-traumatic, with slight changes between out-of-hospital settings. Mechanical ventilation was performed 49.2% of the time in prehospital settings and 50.8% of the time in interfacility transport settings (IFTS). Invasive mechanical ventilation was used 98.8% of the time in IFTS while non-invasive ventilation was used 96.7% of the time in prehospital settings. Reporting of adverse events occurred in 9.1% of cases, of which 94.4% were critical events, mainly pneumothorax in 33.1% of cases and hypotension in 27.6% of cases, with important considerations between type of out-of-hospital setting and ventilatory mode; total mortality was 8.4%. Conclusion Reported adverse events of out-of-hospital mechanical ventilation vary between settings and ventilatory modes; this knowledge could aid EMS providers in promptly recognizing and resolving such clinical situations, depending on the type of scenario being faced.
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Affiliation(s)
- Ricardo Sabastian Pinto-Villalba
- Carrera de Atención Prehospitalaria y en Emergencias, Universidad Central del Ecuador, Quito, Ecuador
- Facultad de Medicina, Carrera de Atención Prehospitalaria y en Emergencias, Universidad UTE, Quito, Ecuador
- Medignosis, Medical Research Department, Quito, Ecuador
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Cavanagh N, Blanchard IE, Weiss D, Tavares W. Looking back to inform the future: a review of published paramedicine research. BMC Health Serv Res 2023; 23:108. [PMID: 36732779 PMCID: PMC9893690 DOI: 10.1186/s12913-022-08893-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/28/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community. METHODS We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample. RESULTS The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice. CONCLUSIONS Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.
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Affiliation(s)
- N. Cavanagh
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - I. E. Blanchard
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - D. Weiss
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada
| | - W. Tavares
- grid.512795.dThe Wilson Centre, Department of Medicine, University of Toronto/University Health Network, Toronto, Ontario Canada ,grid.17063.330000 0001 2157 2938Department of Health and Society, University of Toronto, Toronto, Ontario Canada ,York Region Paramedic and Senior Services, Community Health Services Department, Regional Municipality of York, Newmarket, Ontario Canada
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Abstract
OBJECTIVES To assess recent advances in interfacility critical care transport. DATA SOURCES PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.
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Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport. Prehosp Disaster Med 2020; 35:495-500. [PMID: 32698933 DOI: 10.1017/s1049023x20000886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency. METHODS This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record. RESULTS Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals. CONCLUSION These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.
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Nawrocki PS, Poremba M, Lawner BJ. Push Dose Epinephrine Use in the Management of Hypotension During Critical Care Transport. PREHOSP EMERG CARE 2019; 24:188-195. [PMID: 30808241 DOI: 10.1080/10903127.2019.1588443] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Introduction: Hypotension is a critical event during the transport of critically ill patients. Push dose vasopressor use, though widely adopted by anesthesiologists, has only recently found use in the field of emergency medicine and may have utility in the management of out-of-hospital hypotension. This study aimed to characterize the hemodynamic effects and adverse events that occur following push dose epinephrine (PDE) administration by critical care transport (CCT) providers to correct documented hypotension. Methods: We performed a retrospective observational study of patients transported by a regional critical care transport service and who received PDE during transport to correct documented hypotension. Per protocol, 10-20 µg of 1:100,000 epinephrine was given intravenously every 2 min until: (1) the systolic blood pressure (SBP) was at least 90 mmHg, or (2) the mean arterial pressure (MAP) was 65 mmHg or greater. All patients were over 18 years of age and were transported between January 1, 2015 and December 31, 2016. Primary outcomes of interest were the primary diagnoses associated with PDE use, hemodynamic outcomes of the intervention, and adverse events. Results: During the study period 100 doses of push dose epinephrine were given during the transport of 58 patients. Of these, 94 (94.0%) were found to be appropriately dosed and indicated per protocol. The most common diagnoses associated with PDE use were: post-cardiac arrest (n = 24), sepsis (n = 9), altered mental status (n = 7), and cardiogenic shock (n = 3). The median increase in MAP across all doses was 13.0 (5.0-34.0) mmHg, and the heart rate increase was 2.0 (-1.0-9.3) beats per minute. Hypotension was resolved in 55 of 94 instances (58.5%). A single episode of transient extreme hypertension occurred after one PDE dose and did not result in patient harm. Conclusions: Push dose epinephrine may be an effective method of temporarily resolving hypotension during the CCT of critically ill patients. In the cases where PDE was administered, there was close adherence to the established protocol and adverse events were found to be rare directly following PDE administration. Further research is needed to validate these findings, establish optimal dosing, and evaluate use in non-CCT prehospital settings.
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El Sayed MJ, Tamim H, Mailhac A, Mann NC. Impact of prehospital mechanical ventilation: A retrospective matched cohort study of 911 calls in the United States. Medicine (Baltimore) 2019; 98:e13990. [PMID: 30681557 PMCID: PMC6358412 DOI: 10.1097/md.0000000000013990] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/23/2018] [Accepted: 12/12/2018] [Indexed: 11/26/2022] Open
Abstract
Prehospital use of ventilators by emergency medical services (EMS) during 911 calls is increasing. This study described the impact of prehospital mechanical ventilation on prehospital time intervals and on mortality.This retrospective matched-cohort study used 4 consecutive public releases of the US National Emergency Medical Services Information System dataset (2011-2014). EMS activations with recorded ventilator use were randomly matched with activations without ventilator use (1 to 1) on age (range ± 2 years), gender, provider's primary impression, urbanicity, and level of service.A total of 5740 EMS activations were included (2870 patients per group). Patients in the ventilator group had a mean age of 69.1 (±17.3) years with 49.4% males, similar to the non-ventilator group. Activations were mostly in urban settings (83.8%) with an advanced life support level of care (94.5%). Respiratory distress (77.8%) and cardiac arrest (6.8%) were the most common provider's primary impressions. Continuous positive airway pressure was the most common mode of ventilation used (79.2%).Mortality was higher at hospital discharge (29.0% vs 21.1%, P = .01) but not at emergency department (ED) discharge (8.4% vs 7.4%, P = .19) with prehospital ventilator use. Both total on-scene time and total prehospital time intervals increased with reported ventilator use (4.10 minutes (95% confidence interval [CI]: 2.71-5.49) and 3.59 minutes (95% CI: 3.04-4.14), respectively).Ventilator use by EMS agencies in 911 calls in the US is associated with higher prehospital time intervals without observed impact on survival to ED discharge. More EMS outcome research is needed to provide evidence-based prehospital care guidelines and targeted resource utilization.
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Affiliation(s)
- Mazen J. El Sayed
- Department of Emergency Medicine
- Emergency Medical Services and Prehospital Care Program
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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Nawrocki PS, Levy M, Tang N, Trautman S, Margolis A. Interfacility Transport of the Pregnant Patient: A 5-year Retrospective Review of a Single Critical Care Transport Program. PREHOSP EMERG CARE 2018; 23:377-384. [PMID: 30188241 DOI: 10.1080/10903127.2018.1519005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Interfacility transport of the pregnant patient poses a challenge for prehospital providers as it is an infrequent but potentially high acuity encounter. Knowledge of clinically significant events (CSEs) that occur during these transports is important both to optimize patient safety and also to help enhance crew training and preparedness. This study evaluated a critical care transport program's 5-year longitudinal experience transporting pregnant patients by ground and air, and described CSEs that occurred during the out-of-hospital phase of care. METHODS This study was a retrospective review of pregnant patients transported by a single critical care transport system into and within a large academic healthcare system. Patients who were pregnant, and were transported from a referring facility to one of the 2 receiving centers within Johns Hopkins Health System between January 1, 2012 and December 31, 2016 were included in this study. The primary outcome of interest was the occurrence of a predefined clinically significant event (CSE) during transport, while a secondary outcome of interest was the indication for transfer. RESULTS During the study period 1,223 pregnant patients were transported by our critical care transport service. There were 1,101 patients who met inclusion criteria; 693 (62.9%) of whom were transported by ground and 408 (37.1%) who were transported by rotor wing aircraft. The top 3 indications for transfer comprised 71.4% of all patients and included; preterm labor, hypertensive disorder of pregnancy, and other maternal life threatening disorder. The most common events that occurred across all transports were: exacerbation of hypertensive disease requiring intervention (4.5%), hypotension (1.3%), and altered mental status (0.2%). CONCLUSIONS Incidence of CSEs during the interfacility transport of pregnant patients within our critical care transport system is low (6.0%). Knowledge of the clinically significant events that occur during EMS transport is a vital component of ensuring system quality and optimizing patient safety. This data can be used to augment and focus provider education and training to mitigate and optimize response to future events.
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Colyer E, Sorensen M, Wiggins S, Struwe L. The Effect of Team Configuration on the Incidence of Adverse Events in Pediatric Critical Care Transport. Air Med J 2018; 37:186-198. [PMID: 29735232 DOI: 10.1016/j.amj.2018.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/20/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Specialty pediatric transport teams are widely used for pediatric interfacility transport in the United States, with little industry consensus on optimal team configuration. The aim of this study is to assess the quality of the nurse/paramedic specialty team configuration as indirectly measured by the rate of adverse events in these transports. METHODS Retrospective analysis of pediatric transport data from a hospital-based dedicated pediatric/neonatal transport team was conducted for patients transported in 2016. Data were categorized by general characteristics of transport and analyzed for the occurrence of adverse events. RESULTS Five hundred sixty-four cases were analyzed. Cases were described by team configuration and then by transport mode, duration, time, patient age and acuity, and disposition. The overall rate of adverse event incidence was 8.3%, chiefly centered in device and process domains. There was no significant difference in the rate of adverse events between team configurations. CONCLUSION There was no significant difference in the rate of adverse event occurrence in nurse/paramedic team configurations versus nurse/nurse configuration. Using critical care paramedics on pediatric transport teams enables a larger volume of patients to be transported to definitive care without concerns for decrease in quality or safety.
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Affiliation(s)
- Emily Colyer
- Pediatric/Neonatal Critical Care Transport Team, Children's Hospital & Medical Center, Omaha, NE.
| | - Megan Sorensen
- Pediatric/Neonatal Critical Care Transport Team, Children's Hospital & Medical Center, Omaha, NE
| | - Shirley Wiggins
- College of Nursing, University of Nebraska Medical Center, Lincoln, NE
| | - Leeza Struwe
- College of Nursing, University of Nebraska Medical Center, Lincoln, NE; Niedfelt Nursing Research Center, University of Nebraska Medical Center, Lincoln, NE
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Ventilator use by emergency medical services during 911 calls in the United States. Am J Emerg Med 2017; 36:763-768. [PMID: 29032875 DOI: 10.1016/j.ajem.2017.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/26/2017] [Accepted: 10/05/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Emergency and transport ventilators use in the prehospital field is not well described. This study examines trends of ventilator use by EMS agencies during 911 calls in the United States and identifies factors associated with this use. METHODS This retrospective study used four consecutive releases of the US National Emergency Medical Services Information System (NEMSIS) public research dataset (2011-2014) to describe scene EMS activations (911 calls) with and without reported ventilator use. RESULTS Ventilator use was reported in 260,663 out of 28,221,321 EMS 911 scene activations (0.9%). Patients with ventilator use were older (mean age 67±18years), nearly half were males (49.2%), mostly in urban areas (80.2%) and cared for by advanced life support (ALS) EMS services (89.5%). CPAP mode of ventilation was most common (71.6%). "Breathing problem" was the most common dispatch complaint for EMS activations with ventilator use (63.9%). Common provider impression categories included "respiratory distress" (72.5%), "cardiac rhythm disturbance" (4.6%), "altered level of consciousness" (4.3%) and "cardiac arrest"(4.0%). Ventilator use was consistently higher at the Specialty Care Transport (SCT) and Air Medical Transport (AMT) service levels and increased over the study period for both suburban and rural EMS activations. Significant factors for ventilator use included demographic characteristics, EMS agency type, specific complaints, provider's primary impressions and condition codes. CONCLUSIONS Providers at different EMS levels use ventilators during 911 scene calls in the US. Training of prehospital providers on ventilation technology is needed. The benefit and effectiveness of this intervention remain to be assessed.
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Alabdali A, Fisher JD, Trivedy C, Lilford RJ. A Systematic Review of the Prevalence and Types of Adverse Events in Interfacility Critical Care Transfers by Paramedics. Air Med J 2017; 36:116-121. [PMID: 28499680 DOI: 10.1016/j.amj.2017.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/31/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate if paramedics can safely transfer interfacility critically ill adult patients and to determine the prevalence and types of adverse events when paramedics lead interfacility critical care transfers. METHODS MEDLINE, Web of Science, Embase, and CINAHL databases were searched from 1990 up to February 2016. Eligibility criteria were adult patients (16 years and over), interfacility transfer (between two health care facilities), quantitative or qualitative description of adverse events, and a paramedic as the primary care provider or the sole health care provider. RESULTS Seven publications had paramedics as the sole health care provider conducting interfacility critical care transfers. All seven studies were observational studies published in the English language. The study duration ranged from 14 months to 10 years. The frequency of adverse events seen by paramedics in interfacility transfers ranges from 5.1% to 18%. CONCLUSION There is a gap in literature on the safety and adverse events in interfacility transfers by paramedics. The prevalence of in-transit adverse events is well established; however, because the published literature is lacking longitudinal monitoring of patients and only reporting in-transit events, we believe that further research in this area might provide the basis of paramedics safety in interfacility transfers.
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Affiliation(s)
| | - Joanne D Fisher
- Senior Research Fellow, Health sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chetan Trivedy
- Honorary Associate Clinical Professor, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard J Lilford
- Pro-Dean (Research), Professor of Public Health, Warwick Medical School, University of Warwick, Coventry, UK
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Wilcox SR, Ries M, Bouthiller TA, Berry ED, Dowdy TL, DeGrace S. The Importance of Ground Critical Care Transport. J Intensive Care Med 2016; 32:163-169. [PMID: 27625421 DOI: 10.1177/0885066616668484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Critical care transport (CCT) teams are specialized transport services, comprised of highly trained paramedics, nurses, and occasionally respiratory therapists, offering an expanded scope of practice beyond advanced life support (ALS) emergency medical service teams. We report 4 cases of patients with severe acute respiratory distress syndrome from influenza in need of extracorporeal membrane oxygenation evaluation at a tertiary care center, transported by ground. Our medical center did not previously have a ground CCT service, and therefore, in these cases, a physician and/or a respiratory therapist was sent with the paramedic team. In all 4 cases, the ground transport team enhanced the intensive care provided to these patients prior to arrival at the tertiary care center. In 2 of the cases, although limited by the profound hypoxemia, the team decreased the pressures and tidal volumes in an effort to approach evidence-based ventilator goals. In 3 cases, they stopped bicarbonate drips being used to treat mixed metabolic and respiratory acidosis, and in 1 case, they administered furosemide. In 1 case, they started cisatracurium, and in 3 others, they initiated inhaled epoprostenol. Existing literature supports the use of CCT teams over ALS teams for transport of the most critically ill patients, and helicopter CCT is not always available or practical. Therefore, offering comparable air and ground options, with similar staffing and resources, is a hallmark of a mature medical system with an integrated approach to CCT.
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Affiliation(s)
- Susan R Wilcox
- 1 Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Division of Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Michael Ries
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
| | - Ted A Bouthiller
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
| | - E Dean Berry
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
| | - Travis L Dowdy
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
| | - Sharon DeGrace
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
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Medication Administration in Critical Care Transport of Adult Patients with Hypoxemic Respiratory Failure. Prehosp Disaster Med 2015; 30:431-5. [PMID: 26178583 DOI: 10.1017/s1049023x1500494x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Critical care transport (CCT) teams must manage a wide array of medications before and during transport. Appreciating the medications required for transport impacts formulary development as well as staff education and training. Problem As there are few data describing the patterns of medication administration, this study quantifies medication administrations and patterns in a series of adult CCTs. METHODS This was a retrospective review of medication administration during CCTs of patients with severe hypoxemic respiratory failure from October 2009 through December 2012 from referring hospitals to three tertiary care hospitals. RESULTS Two hundred thirty-nine charts were identified for review. Medications were administered by the CCT team to 98.7% of these patients, with only three patients not receiving any medications from the team. Fifty-nine medications were administered in total with 996 instances of administration. Fifteen drugs were each administered to only one patient. The mean number of medications per patient was 4.2 (SD=1.8) with a mean of 1.9 (SD=1.1) drug infusions per patient. CONCLUSIONS These results demonstrate that, even within a relatively homogeneous population of patients transferred with hypoxemic respiratory failure, a wide range of medications were administered. The CCT teams frequently initiated, titrated, and discontinued continuous infusions, in addition to providing numerous doses of bolused medications.
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Stoltze AJ, Wong TS, Harland KK, Ahmed A, Fuller BM, Mohr NM. Prehospital tidal volume influences hospital tidal volume: A cohort study. J Crit Care 2015; 30:495-501. [PMID: 25813548 DOI: 10.1016/j.jcrc.2015.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/05/2015] [Accepted: 02/12/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE The purposes of the study are to describe current practice of ventilation in a modern air medical system and to measure the association of ventilation strategy with subsequent ventilator care and acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS Retrospective observational cohort study of intubated adult patients (n = 235) transported by a university-affiliated air medical transport service to a 711-bed tertiary academic center between July 2011 and May 2013. Low tidal volume ventilation was defined as tidal volumes less than or equal to 8 mL/kg predicted body weight. Multivariable regression was used to measure the association between prehospital tidal volume, hospital ventilation strategy, and ARDS. RESULTS Most patients (57%) were ventilated solely with bag valve ventilation during transport. Mean tidal volume of mechanically ventilated patients was 8.6 mL/kg predicted body weight (SD, 0.2 mL/kg). Low tidal volume ventilation was used in 13% of patients. Patients receiving low tidal volume ventilation during air medical transport were more likely to receive low tidal volume ventilation in the emergency department (P < .001) and intensive care unit (P = .015). Acute respiratory distress syndrome was not associated with prehospital tidal volume (P = .840). CONCLUSIONS Low tidal volume ventilation was rare during air medical transport. Air transport ventilation strategy influenced subsequent ventilation but was not associated with ARDS.
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Affiliation(s)
- Andrew J Stoltze
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Terrence S Wong
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Brian M Fuller
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO 63110; Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA 52242.
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Singh JM, MacDonald RD, Ahghari M. Post-medication Hypotension after Administration of Sedatives and Opioids during Critical Care Transport. PREHOSP EMERG CARE 2015; 19:464-74. [PMID: 25658022 DOI: 10.3109/10903127.2014.995848] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Identification of modifiable risk factors for hypotension during critical care transport is important to optimize patient preparation, crew training, and patient safety. We set out to determine the incidence of hemodynamic deterioration after administration of opioids or sedatives during critical care transport, and identify patient- and transport-level predictors. METHODS We assembled a retrospective cohort of adults undergoing urgent critical care transport between January 1, 2005, and December 31, 2010. The primary outcome was post-medication hypotension, defined by new hypotension or new vasopressor within 10 minutes of medication administration. RESULTS Opioids or sedatives were administered 28,592 times in 8,328 patient transports, with 159 episodes of post-medication hypotension (0.6% of all medication administrations). Mechanical ventilation (adjusted odds ratio [OR] 4.9; 95% confidence interval [95%CI] 2.7-8.9), baseline vasopressor requirement (adjusted OR 2.1; 95%CI 1.3-3.4), transport duration (adjusted OR 1.5; 95%CI 1.1-2.2) per log unit increment of duration), surgical diagnosis (adjusted OR 4.1; 95%CI 1.6-10.7 compared to trauma), and ACP crew level (adjusted OR 2.4 compared to baseline of CCP; 95%CI 1.5-3.8) were all associated with an increased odds of post-medication hypotension. ACP crew level remained associated with increased post-medication hypotension in a sensitivity analysis of 1,242 propensity-matched pairs (crude OR for ACP vs. CCP 3.0; 95%CI 1.4-6.5). CONCLUSIONS Post-medication hypotension occurred once in every 160 drug administrations and was associated with mechanical ventilation, baseline hemodynamic instability, transport duration, surgical diagnosis, and ACP crew. These findings provide targets for improvements in patient preparation, crew training, and clinical practices.
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Singh JM, MacDonald RD, Ahghari M. Critical events during land-based interfacility transport. Ann Emerg Med 2014; 64:9-15.e2. [PMID: 24412668 DOI: 10.1016/j.annemergmed.2013.12.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 11/24/2013] [Accepted: 12/05/2013] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE The risks associated with urgent land-based transport of critically ill patients are not well known and have important implications for patient safety, care delivery, and policy development. We seek to determine the incidence of in-transit critical events and associated patient- and transport-level factors. METHODS We conducted a retrospective cohort study using clinical and administrative data. We included adults undergoing urgent land-based critical care transport by a dedicated transport provider between January 1, 2005, and December 31, 2010. The primary outcome was in-transit critical event, defined by adverse events or resuscitative procedures. RESULTS In-transit critical events were observed in 333 (6.5%) of 5,144 urgent land transports. New hypotension (4.4%) or new vasopressors (1.6%) were the most common critical events, with fewer respiratory events (1.3%). Advanced care paramedics had a higher rate compared with critical care paramedics (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1 to 2.2), especially for patients with baseline hemodynamic instability. In multivariate analysis, mechanical ventilation (adjusted OR 1.7; 95% CI 1.3 to 2.2), baseline hemodynamic instability (adjusted OR 3.7; 95% CI 2.8 to 4.9), out-of-hospital duration (adjusted OR 3.6; 95% CI 2.9 to 4.5 per log-fold increase in time), and neurologic diagnosis (adjusted OR 0.5; 95% CI 0.3 to 0.7 compared with that of medical patients) were associated with critical events. CONCLUSION Critical events occurred in approximately 1 in 15 transports and were associated with mechanical ventilation, hemodynamic instability, and transport duration, and were less frequent in neurologic patients. The finding that hypotension is common and predicted by pretransport hemodynamic instability has implications for the preparation and management of this patient group.
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Affiliation(s)
- Jeffrey M Singh
- Division of Critical Care Medicine, University Health Network, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Russell D MacDonald
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Ornge Transport Medicine, Mississauga, Ontario, Canada
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Bledsoe BE, Anderson E, Hodnick R, Johnson L, Johnson S, Dievendorf E. Low-fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting. PREHOSP EMERG CARE 2011; 16:217-21. [PMID: 22191942 DOI: 10.3109/10903127.2011.640765] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of this study was to determine the effects of low-fractional concentration of inspired oxygen (FiO(2)) continuous positive airway pressure (CPAP) in prehospital noninvasive ventilation (NIV). With increasing concerns about the detrimental effects of hyperoxia, we sought to determine whether CPAP using a low FiO(2) (28%-30%) was effective in the prehospital setting. METHODS The study was a six-month prospective, nonblinded observational study conducted in a large, busy urban emergency medical services (EMS) system (Las Vegas, NV). RESULTS A total of 340 patients participated in the study. Most patients presented with symptoms consistent with a diagnosis of congestive heart failure/acute pulmonary edema (47.4%), followed by chronic obstructive pulmonary disease (COPD) (40.9%), asthma (22.7%), and pneumonia (15.9%). Improvements were seen in respiratory rate (p = 0.00) and oxygen saturation (p = 0.00). The overall CPAP discontinuation rate was 16.5%. The most common reason for CPAP discontinuation was anxiety/claustrophobia. The total number of patients requiring prehospital intubation was 5.6%. Subjective paramedic assessment of patient status at hospital delivery found that 71.5% of patients' conditions were improved, 15.1% remained unchanged, and 13.4% were worse. CONCLUSIONS CPAP using a low FiO(2) (28%-30%) was highly effective in the treatment of commonly encountered prehospital respiratory emergencies.
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Affiliation(s)
- Bryan E Bledsoe
- Department of Emergency Medicine, University of Nevada School of Medicine, Las Vegas, NV 89106, USA.
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Thomas J. The Circle of Caring Model for Neonatal Transport. Neonatal Netw 2011; 30:14-20. [PMID: 21317093 DOI: 10.1891/0730-0832.30.1.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Circle of Caring Model serves as a guide that superimposes nursing and medical practice models. This transformative template was formulated for advanced practice nursing in all health care settings, including neonatal care. This article proposes an extension of this model specific to neonatal transport. It also shows how the Circle of Caring Model for Neonatal Transport functions within the framework of a hypothetical patient case.
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Singh JM, MacDonald RD. Pro/con debate: do the benefits of regionalized critical care delivery outweigh the risks of interfacility patient transport? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:219. [PMID: 19678918 PMCID: PMC2750128 DOI: 10.1186/cc7883] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
You are providing input in planning for critical care services to a large regional health authority. You are considering concentrating some critical care services into high-volume regional centres of excellence, as has been done in other fields of medicine. In your region, this would require several centres with differing levels of expertise that are geographically separated. Given there are inherent risks and time delays associated with interfacility patient transport, you debate whether these potential risks outweigh the benefits of regional centres of excellence.
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Affiliation(s)
- Jeffrey M Singh
- Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, 2 McLaughlin - 411K, Toronto, Ontario M5T 2S8, Canada.
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