When place and time matter: How to conduct safe inter-hospital transfer of patients

It is (not) always on Friday: inter-hospital patient transfers in orthopedic and trauma surgery

BACKGROUND

While inter-hospital transfers for patients who have suffered major trauma have been well investigated, patient flows for other injured patients, or cases with orthopedic complications, are rarely described. This study aims to analyze the affected collective and to show possible reasons, patterns, and pitfalls to optimize the process in future.

MATERIALS AND METHODS

In a prospective cohort study, all consecutive transfers to a Level I trauma center in Germany were documented and assessed. Patients suffering a major trauma were excluded. Data on the primary treating hospital, patient characteristics, and differences between emergency and elective surgery were analyzed.

RESULTS

A total of 227 patients were included; 162 were injured, while 65 had suffered a complication after elective orthopedic surgery or had a complex orthopedic pathology. The most common diagnoses leading to transfer were pathologies of the extremities (n = 62), pathologies of the spine (n = 50), and infections (n = 18). The main reasons stated by the transferring hospitals were a lack of expertise (137 cases) and a lack of capacity (43 cases). There was a significantly higher rate of transfers due to trauma (n = 162) than for orthopedic patients (n = 65), p < 0.0001.

CONCLUSION

There is currently no structured procedure or algorithm for transferring patients in orthopedics and trauma surgery.

Nonurgent Pediatric Interhospital Transfers: A Narrative Enquiry of Nurses' Experiences in Australia

INTRODUCTION

This study aimed to explore nonurgent pediatric interhospital transfers through the lens of nurses' experiences and perceptions when undertaking these transfers.

METHODS

Using a narrative inquiry approach, data were collected via semistructured interviews with registered nurses (N = 7) who had experience undertaking patient transfers between nonurgent low-acuity and urgent high-acuity hospital settings.

RESULTS

Findings established the following 8 themes: ensuring transfer preparation for risk mitigation, practicing confident advocacy, being accountable for risk mitigation of the deteriorating patient during transfer, maintaining standardized procedure, using training and mentorship to support confidence, maintaining interhospital and intrahospital relationships, recognizing the significance of transfer on families, and acknowledging the burden of transfer and delay.

DISCUSSION

By exploring the stories and experiences of emergency nurses who undertake pediatric interhospital transfers, a deep investigation of the risks and challenges has been described, an area often underrepresented in the literature. Findings from this study highlight important learnings for pediatric interhospital transfer that add value to the wider body of evidence.

Predictors of Urgent Dialysis Following Ambulance Transport to the Emergency Department in Patients Treated With Maintenance Hemodialysis

Background

Patients receiving maintenance hemodialysis frequently require ambulance transport to the emergency department (ambulance-ED transport). Identifying predictors of outcomes after ambulance-ED transport, especially the need for timely dialysis, is important to health care providers.

Objective

The purpose of this study was to derive a risk-prediction model for urgent dialysis after ambulance-ED transport.

Design

Observational cohort study.

Setting and Patients

All ambulance-ED transports among incident and prevalent patients receiving maintenance hemodialysis affiliated with a regional dialysis program (catchment area of approximately 750 000 individuals) from 2014 to 2018.

Measurements

Patients' vital signs (systolic blood pressure, oxygen saturation, respiratory rate, and heart rate) at the time of paramedic transport and time since last dialysis were utilized as predictors for the outcome of interest. The primary outcome was urgent dialysis (defined as dialysis in a monitored setting within 24 hours of ED arrival or dialysis within 24 hours with the first ED patient blood potassium level >6.5 mmol/L) for an unscheduled indication. Secondary outcomes included, hospitalization, hospital length of stay, and in-hospital mortality.

Methods

A logistic regression model to predict outcomes of urgent dialysis. Discrimination and calibration were assessed using the C-statistic and Hosmer-Lemeshow test.

Results

Among 878 ED visits, 63 (7.2%) required urgent dialysis. Hypoxemia (odds ratio [OR]: 4.04, 95% confidence interval [CI]: 1.75-9.33) and time from last dialysis of 24 to 48 hours (OR: 3.43, 95% CI: 1.05-11.9) and >48 hours (OR: 9.22, 95% CI: 3.37-25.23) were strongly associated with urgent dialysis. A risk-prediction model incorporating patients' vital signs and time from last dialysis had good discrimination (C-statistic 0.8217) and calibration (Hosmer-Lemeshow goodness of fit P value .8899). Urgent dialysis patients were more likely to be hospitalized (63% vs 34%), but there were no differences in inpatient mortality or length of stay.

Limitations

Missing data, requires external validation.

Conclusion

We derived a risk-prediction model for urgent dialysis that may better guide appropriate transport and care for patients requiring ambulance-ED transport.

Eating Disorders in Hospitalized School-Aged Children and Adolescents during the COVID-19 Pandemic: A Cross-Sectional Study of Discharge Records in Developmental Ages in Italy

Eating disorders (EDs) are characterized by behavioral and cognitive aspects that result in a significant impairment of an individual's well-being. COVID-19 pandemic consequences negatively impacted healthcare services and people's mental health. Particularly, in developmental ages, difficulties in coping with the situation could have had an impact on eating behaviors. Therefore, the aim of this study was to assess EDs' hospitalization trend before, during and after the pandemic peak to evaluate whether it has been influenced. A retrospective cross-sectional study was conducted on the hospital discharge forms of patients from 5 to 19 years old in Piedmont, which is a region in northern Italy. Overall, hospitalization, age, and gender-specific rates due to EDs that occurred in 2020 and 2021 were compared to those that occurred in 2018-2019. Since 2020, there has been a 55% reduction in overall hospitalizations, while the total proportion of EDs admissions has doubled from 2020 to 2021 (from 13.9‱ to 22.2‱). Significant hospitalization rate increases were observed both in 15-19 and in 10-14 females' age groups in 2021. Non-significant increases were observed in all males' age groups. The increase in hospitalizations for EDs should be further investigated, as it might be the tip of an iceberg not yet acknowledged.

Response Time in the Transport of Pediatric Patients to a Tertiary Critical Care Unit

Introduction:

Various barriers delay the process of patient transfer to critical care units. We implemented quality improvement methods to decrease the time required for interhospital transfer of critical care patients. As a result, we aimed to decrease the time from initial transfer call to specialized transport team arrival at the referring hospital from 150 minutes to <40 minutes over 2 years.

Methods:

Quality improvement initiative monitoring the length of transport time of 245 patients transferred from referral hospitals to a tertiary pediatric intensive care unit for 31 months from March 2013 to October 2015. We reviewed preexisting transport protocols and identified barriers to the timely arrival to the pediatric intensive care unit. We implemented 3 interventions: a transport information line serving as a central communication center to coordinate the transport process between all stakeholders, the formation of a specialized pediatric transport team, and a training program. We collected transport response time data and monitored the impact of interventions via statistical process control charts.

Results:

There was a significant decrease in the length of the time course pre- and postintervention. We noted a special cause to decrease in time from referral hospital call to arrival of our transport team by 76% from 150 minutes to 36 minutes. In addition, the statistical process chart revealed a stable and effective process without significant shifts above the process mean as early as 3 months postintervention.

Conclusions:

By improving our transport services with additional resources and people, we have improved the efficiency of patient transport between institutions.

Healthcare Supply Chain Reliability: The Case of Medical Air Transport

The principal task of national healthcare systems is to provide health services that are safe, accessible, high-quality and people-oriented. To ensure the continuity of healthcare, support activities related to patient transfer and logistics are necessary. Effective implementation of transport processes is a factor affecting the possibility of medical intervention, in terms of both planned and life-saving care. The reliability of the healthcare supply chain is a key factor in patient health. In our research, we have used the method of a single case study of a public regional hospital in Poland providing comprehensive medical services. The aim of the research is to identify the factors that affect the reliability of the healthcare supply chain in relation to the interhospital air transport of patients. Our qualitative research using process mapping reveals what factors affect the reliability of interhospital medical air transport. The analysis of 100 interhospital medical air transport cases has allowed us to create a general procedure related to the movement of patients between the facilities of the healthcare system in Poland. Our research shows that the key factor of reliability is the coherent and integrated cooperation of institutions involved in transport processes.

An exploratory study of the experiences and challenges faced by advanced life support paramedics in the milieu of neonatal transfers

Background

The safe transfer of critically ill neonates is important for their survival. This calls for greater preparedness on the part of paramedics to effect these transfers safely.

Aim

To understand the experiences and the challenges faced by advanced life support (ALS) paramedics during neonatal transfers.

Setting

The study setting consisted of advanced life support paramedics from urban and rural areas in KwaZulu-Natal. It comprised of a network of district hospitals as well air and ground transfer facilities, both public and private.

Method

Using a qualitative research approach, the study sought the views of ALS paramedics who were involved in neonatal transfers in KwaZulu-Natal. A purposive sample of n = 8 ALS paramedics was selected. Data were collected using in-depth semi-structured interviews. The data were analysed through the process of thematic analysis.

Results

The study found that paramedics faced multiple complex challenges related to neonatal transfers. Poor pre-transfer preparation of the neonate, equipment related challenges, lack of clinical support available during transfers and pressure to effect inappropriate transfers were some of the challenges they faced. These challenges coupled with insufficient education and the lack of sub-speciality programmes to capacitate, rendered them unprepared to deal with neonatal transfers effectively.

Conclusion

Emergency medicine needs to provide greater attention towards preparing all stakeholders for successful neonatal transfers.

Contribution

The findings provide recommendations for a programme that will limit risks involved with, and support the inter-healthcare facility transfer of critically ill neonates in South Africa.

Safety Matters: A Meta-analysis of Interhospital Transport Adverse Events in Critically Ill Patients

OBJECTIVE

Interhospital transport (IHT) is common among critically ill patients. Our meta-analysis investigated the prevalence and possible factors associated with adverse events (AEs) during IHT.

METHODS

Searching PubMed, Embase, and Scopus databases until February 12, 2021, we included studies that a priori defined AEs for adult medical patients. We excluded case reports, non-full-text, and non-English language studies. We performed a random effects meta-analysis and moderator analyses.

RESULTS

We identified 554 studies and included 19 studies (14,969 patients) in our final analysis. The mean patients' (standard deviation) age was 60 (13.7). The pooled medical AEs for IHT was 1,059 (11%, 95% confidence interval, 7.5%-16%). The most common AE (n, %) was hypotension (424, 2.8%). Moderator analyses and meta-regressions suggested that conditions (P < .001) such as respiratory failure from coronavirus infection (88%), stroke (19%), and the need for extracorporeal membrane oxygenation (40%) were associated with higher AE prevalence. Transport by nurses (31%) and physicians (11%) was associated with a higher AE prevalence, whereas transport type did not influence AE prevalence.

CONCLUSION

Our study suggests the prevalence of AEs of critically ill patients during IHT is low and likely due to patients' disease severity. Further studies should focus on interventions to mitigate AEs to improve patients' outcomes.

Factors Affecting Interprofessional Teamwork in Emergency Department Care of Polytrauma Patients: Results of an Exploratory Study

Considering that traumatic injuries are the leading cause of death among young adults across the globe, emergency department care of polytrauma patients is a crucial aspect of optimized care and premature death prevention. Unfortunately, many studies have highlighted important gaps in collaboration among different trauma team professionals, posing a major quality-of-care challenge. Using the conceptual framework for interprofessional teamwork (IPT) of , the aim of this qualitative descriptive exploratory study was to better understand IPT from the perspective of health professionals in emergency department care of polytrauma patients, specifically by identifying factors that facilitate and impede IPT. Data were collected from a sample of 7 health professionals involved in the care of polytrauma patients through individual interviews and a focus group. In the second phase, 2 structured observations of polytrauma patient care were conducted. Following a thematic analysis, results revealed multiple factors affecting IPT, which can be divided into 5 broad categories: individual, relational, processual, organizational, and contextual. Individual factors, a category that is not part of the conceptual framework of , also emerged as playing a major part in IPT.

Air ambulance outcome measures using Institutes of Medicine and Donabedian quality frameworks: protocol for a systematic scoping review

BACKGROUND

Dedicated air ambulance services provide a vital link for critically ill and injured patients to higher levels of care. The recent developments of pre-hospital and retrieval medicine create an opportunity for air ambulance providers and policy-makers to utilize a dashboard of quality performance measures to assess service performance. The objective of this scoping systematic review will be to identify and evaluate the range of air ambulance outcome measures reported in the literature and help to construct a quality dashboard based on a healthcare quality framework.

METHODS

We will search PubMed, MEDLINE, CINAHL, Scopus, and Cochrane Database of Systematic Reviews (from January 2001 onwards). Complementary searches will be conducted in selected relevant journals. We will include systematic reviews and observational studies (cohort, cross-sectional, interrupted time series) in critically ill or injured patients published in English and focusing on air ambulance delivery and quality measures. Two reviewers will independently screen all citations, full-text articles, and abstract data. The study methodological quality (or bias) will be appraised using appropriate tools. Analysis of the characteristics associated with outcome measure will be mapped and described according to the proposed healthcare quality framework.

DISCUSSION

This review will contribute to the development of an air ambulance quality dashboard designed to combine multiple quality frameworks. Our findings will provide a basis for helping decision-making in health planning and policy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019144652.

Machine Learning-Based Patient Load Prediction and IoT Integrated Intelligent Patient Transfer Systems

A mismatch between staffing ratios and service demand leads to overcrowding of patients in waiting rooms of health centers. Overcrowding consequently leads to excessive patient waiting times, incomplete preventive service delivery and disgruntled medical staff. Worse, due to the limited patient load that a health center can handle, patients may leave the clinic before the medical examination is complete. It is true that as one health center may be struggling with an excessive patient load, another facility in the vicinity may have a low patient turn out. A centralized hospital management system, where hospitals are able to timely exchange patient load information would allow excess patient load from an overcrowded health center to be re-assigned in a timely way to the nearest health centers. In this paper, a machine learning-based patient load prediction model for forecasting future patient loads is proposed. Given current and historical patient load data as inputs, the model outputs future predicted patient loads. Furthermore, we propose re-assigning excess patient loads to nearby facilities that have minimal load as a way to control overcrowding and reduce the number of patients that leave health facilities without receiving medical care as a result of overcrowding. The re-assigning of patients will imply a need for transportation for the patient to move from one facility to another. To avoid putting a further strain on the already fragmented ambulatory services, we assume the existence of a scheduled bus system and propose an Internet of Things (IoT) integrated smart bus system. The developed IoT system can be tagged on buses and can be queried by patients through representation state transfer application program interfaces (APIs) to provide them with the position of the buses through web app or SMS relative to their origin and destination stop. The back end of the proposed system is based on message queue telemetry transport, which is lightweight, data efficient and scalable, unlike the traditionally used hypertext transfer protocol.

Use of an Offsite Intraoperative MRI Operating Theater for Pediatric Brain Tumor Surgery: Experience from a Singapore Children's Hospital

BACKGROUND

Intraoperative magnetic resonance imaging (iMRI) has been recognized as a useful adjunct for brain tumor surgery in pediatric patients. There is minimal data on the use of an offsite intraoperative magnetic resonance imaging operating theater (iMRI OT), whereby vehicle transfer of patients is involved. The primary aim of this study is to validate the feasibility of perioperative patient transfer to use an offsite iMRI OT for patients with pediatric brain tumor. Secondary objectives include the assessment of tumor resection efficacy and perioperative outcomes in our patient cohort.

METHODS

This is a retrospective, single-institution clinical study of prospectively collected data from Singapore's largest children hospital. Variables of interest include issues encountered during interhospital transfer, achievement of surgical aims, length of stay in hospital, and postoperative complications. Our findings were compared with results of related studies published in the literature.

RESULTS

From January 1, 2009 to December 31, 2018, a total of 35 pediatric operative cases were performed in our offsite iMRI OT. Within this cohort, 24 of these were brain tumor surgery cases. For all the patients in this study, use of the iMRI OT influenced intraoperative decisions. Average ambulance transport time from parent hospital to the iMRI OT was 30.5 minutes, and from iMRI OT back to the parent hospital after surgery was 27.7 minutes. The average length of hospitalization stay was 7.9 days per patient. There were no ferromagnetic accidents during perioperative iMRI scanning and no airway/hemodynamic incidents in patients encountered during interhospital transfer.

CONCLUSIONS

In our local context, the use of interhospital transfers for access to iMRI OT is a safe and feasible option in ensuring good patient outcomes for a select group of patients with pediatric brain tumors.

The Patient's Situation During Interhospital Intensive Care Unit-to-Unit Transfers: A Hermeneutical Observational Study

Interhospital intensive care unit-to-unit transfers are an increasing phenomenon, earlier mainly studied from a patient safety perspective. Using data from video recordings and participant observations, the aim was to explore and interpret the observed nature of the patient's situation during interhospital intensive care unit-to-unit transfers. Data collection from eight transfers resulted in over 7 hours of video material and field notes. Using a hermeneutical approach, three themes emerged: being visible and invisible; being in a constantly changing space; and being a fettered body in constant motion. The patient's situation can be viewed as an involuntary journey, one where the patient exists in a constantly changing space drifting in and out of the health personnel's attention and where movements from the journey become part of the patient's body. Interhospital transfers of vulnerable patients emerge as a complex task, challenging the health personnel's ability to maintain a caring atmosphere around these patients.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time

BACKGROUND

The emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children.

OBJECTIVES

To describe the trends of emergency care for children in the United States from 2006-2014 in EDs across different pediatric volumes.

METHODS

We analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006-2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics.

RESULTS

From 2006-2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (-3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%).

CONCLUSIONS

Overall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.

Outcomes of Ventilated Patients With Sepsis Who Undergo Interhospital Transfer: A Nationwide Linked Analysis

OBJECTIVES

The outcomes of critically ill patients who undergo interhospital transfer are not well understood. Physicians assume that patients who undergo interhospital transfer will receive more advanced care that may translate into decreased morbidity or mortality relative to a similar patient who is not transferred. However, there is little empirical evidence to support this assumption. We examined country-level U.S. data from the Nationwide Readmissions Database to examine whether, in mechanically ventilated patients with sepsis, interhospital transfer is associated with a mortality benefit.

DESIGN

Retrospective data analysis using complex survey design regression methods with propensity score matching.

SETTING

The Nationwide Readmissions Database contains information about hospital admissions from 22 States, accounting for roughly half of U.S. hospitalizations; the database contains linkage numbers so that admissions and transfers for the same patient can be linked across 1 year of follow-up.

PATIENTS

From the 2013 Nationwide Readmission Database Sample, 14,325,172 hospital admissions were analyzed. There were 61,493 patients with sepsis and on mechanical ventilation. Of these, 1,630 patients (2.7%) were transferred during their hospitalization. A propensity-matched cohort of 1,630 patients who did not undergo interhospital transfer was identified.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The exposure of interest was interhospital transfer to an acute care facility. The primary outcome was hospital mortality; the secondary outcome was hospital length of stay. The propensity score included age, gender, insurance coverage, do not resuscitate status, use of renal replacement therapy, presence of shock, and Elixhauser comorbidities index. After propensity matching, interhospital transfer was not associated with a difference in in-hospital mortality (12.3% interhospital transfer vs 12.7% non-interhospital transfer; p = 0.74). However, interhospital transfer was associated with a longer total hospital length of stay (12.8 d interquartile range, 7.7-21.6 for interhospital transfer vs 9.1 d interquartile range, 5.1-17.0 for non-interhospital transfer; p < 0.01).

CONCLUSIONS

Patients with sepsis requiring mechanical ventilation who underwent interhospital transfer did not have improved outcomes compared with a cohort with matched characteristics who were not transferred. The study raises questions about the risk-benefit profile of interhospital transfer as an intervention.

Accuracy of inter-hospital transfer information in Australian hospital administrative databases

Inter-hospital transfers improve care delivery for which sending and receiving hospitals both accountable for patient outcomes. We aim to measure accuracy in recorded patient transfer information (indication of transfer and hospital identifier) over 2 years across 121 acute hospitals in New South Wales, Australia. Accuracy rate for 127,406 transfer-out separations was 87 per cent, with a low variability across hospitals (10% differences); it was 65 per cent for 151,978 transfer-in admissions with a greater inter-hospital variation (36% differences). Accuracy rate varied by departure and arrival pathways; at receiving hospitals, it was lower for transfer-in admission via emergency department (incidence rate ratio = 0.52, 95% confidence interval: 0.51-0.53) versus direct admission. Transfer-out data were more accurate for transfers to smaller hospitals (incidence rate ratio = 1.06, 95% confidence interval: 1.03-1.08) or re-transfers (incidence rate ratio > 1.08). Incorporation of transfer data from sending and receiving hospitals at patient level in administrative datasets and standardisation of documentation across hospitals would enhance accuracy and support improved attribution of hospital performance measures.

Investigating the Temporal Dynamics of Interorganizational Exchange: Patient Transfers among Italian Hospitals

Previous research on interaction behavior among organizations (resource exchange, collaboration, communication) has typically aggregated those behaviors over time as a network of organizational relationships. The authors instead study structural-temporal patterns in organizational exchange, focusing on the dynamics of reciprocation. Applying this lens to a community of Italian hospitals during 2003-7, the authors observe two mechanisms of interorganizational reciprocation: organizational embedding and resource dependence. The authors show how these two mechanisms operate on distinct time horizons: dependence applies to contemporaneous exchange structures, whereas embedding develops through longer-term historical patterns. They also show how these processes operate differently in competitive and non-competitive contexts, operationalized in terms of market differentiation and geographic space. In noncompetitive contexts, the authors observe both logics of reciprocation, dependence in the short term and embedding over the long term, developing into population-level generalized exchange. In competitive contexts, they find no reciprocation and instead observe the microfoundations of status hierarchies.

DIFICULDADES NO TRANSPORTE INTER-HOSPITALAR DE RECÉM-NASCIDO CRÍTICO REALIZADO PELAS EQUIPES DO SERVIÇO DE ATENDIMENTO MÓVEL DE URGÊNCIA

RESUMO Objetivo: investigar as dificuldades das equipes do Serviço de Atendimento Móvel Urgência para a realização do transporte inter-hospitalar de recém-nascido crítico em ambulância. Método: estudo qualitativo, realizado com 17 profissionais de saúde, dentre médicos, enfermeiros e condutores de veículos atuantes no Serviço de Atendimento Móvel de Urgência de um município do interior do Ceará, no período de novembro a dezembro de 2014. Os dados foram produzidos por meio de entrevista semiestruturada, sendo as entrevistas gravadas. Os dados foram analisados por meio da análise temática de conteúdo. Resultados: as categorias apreendidas foram: escassez de materiais, de equipamentos e de veículos exclusivos para o transporte inter-hospitalar do recém-nascido; conhecimento, prática e treinamento deficientes para assistência ao recém-nascido crítico; e falha na comunicação entre os profissionais e dificuldade para a mobilidade da ambulância em via pública. Conclusão: as dificuldades mencionadas estão atreladas a todos os níveis de gestão e necessitam de um olhar diferenciado para que se garanta assistência de elevado nível de excelência.

Characteristics of Fixed Wing Air Ambulance Transports in Victoria, Australia

OBJECTIVE

Air medical transport is important for the transfer of patients in the prehospital and interhospital environment. Few studies have described the services provided by fixed wing ambulances or the broader clinical profiles of patients they transport. Such information may be useful for the planning and allocation of resources, assistance with training, and refining clinical protocols. We sought to describe the characteristics of patients transported by fixed wing aircraft at Air Ambulance Victoria (AAV) and the service AAV provides in Victoria, Australia.

METHODS

A retrospective data review of patients transported by AAV fixed wing aircraft between January 1, 2011, and June 30, 2015, was performed. Data were sourced from the Ambulance Victoria data warehouse. Retrievals involving physicians were excluded.

RESULTS

A total of 16,579 patients were transported during the study period, with a median age of 66 years. Most patients were male (58.7%), and cardiovascular/hematologic conditions (27.2%) were most common. Overall, 51.7% of cases were prebooked routine transfers, 47.4% were interhospital routine transfers, and 0.9% were primary responses. Caseloads were largest in the regions furthest from the capital city.

CONCLUSION

The AAV fixed wing service in Victoria enables regional and remote patients to be transported to definitive care without major disruption to ground ambulances.

Sedation and Analgesia in Transportation of Acutely and Critically Ill Patients

Transportation of acutely or critically ill patients is a challenge for health care providers. Among the difficulties that providers face is the balance between adequate sedation and analgesia for the transportation event and maintaining acceptable respiratory and physiologic parameters of the patient. This article describes common challenges in providing sedation and analgesia during various phases of transport.

Endotracheal Cuff Pressure Changes During Helicopter Transport: A Systematic Review

OBJECTIVE

Cuff pressures are important in ventilated patients undergoing helicopter transport. An altitude-related increase in endotracheal tube (ETT) intracuff pressure has been shown in simulated hypobaric environments, model tracheas, and animal studies and may not accurately reflect in vivo pressures. The aim of this study was to determine if ETT intracuff pressure increases above the critical perfusion pressure of the trachea in ventilated patients during helicopter transport.

METHODS

Ovid Medline, CINAHL, Embase, Scopus, and the Cochrane Library were searched from their commencement to January 29, 2016. Google Scholar was searched, and reference lists of relevant articles were examined to identify additional studies. Articles were included if they reported on ETT intracuff pressure in ventilated patients during helicopter emergency medical service transport.

RESULTS

A total of 330 articles were identified; only 2 prospective observational studies met the inclusion criteria. The studies reported a mean cuff pressure increase of 23 cm H₂O and 33.9 cm H₂O. Both studies reported ETT intracuff pressure to frequently exceed the critical perfusion pressure of the tracheal mucosa during helicopter transport.

CONCLUSION

Further research with longitudinal follow-up is required to confirm these findings to determine if the effects of transient increased ETT intracuff pressure are clinically significant.

Comparison of four different intraosseous access devices during simulated pediatric resuscitation. A randomized crossover manikin trial

The aim of the study was to compare the success rate, procedure time, and user satisfaction of pediatric NIO™ compared to Pediatric BIG®, EZ-IO®, and Jamshidi intraosseous access devices. This was a randomized, crossover manikin trial with 87 paramedics. The correct location of intraosseous access when using NIO, BIG, EZ-IO, and Jamshidi was varied and was respectively 100, 90, 90, and 90%. The time required to obtain intravascular access (time T1) in the case of NIO, BIG, EZ-IO, and Jamshidi was varied and amounted to 9 s [IQR, 8-12] for NIO, 12 s [IQR, 9-16] for BIG, 13.5 s [IQR, 11-17] for the EZ-IO, and 15 s [IQR, 13-19] for Jamshidi. The paramedics evaluated each device on the subjective ease with which they performed the procedures. The intraosseous device, which proved the easiest to use was NIO, which in the case of CPR received a median rating of 1.5 (IQR, 0.5-1.5) points.

CONCLUSION

Our study found that NIO® is superior to BIG®, EZ-IO®, and Jamshidi. NIO® achieved the highest first attempt success rate. NIO® also required the least time to insert and easiest to operate even by novice users. Further study is needed to test our findings in cadavers or human subjects. Based on our findings, NIO® is a promising intraosseous device for use in pediatric resuscitation. What is Known: • Venous access in acutely ill pediatric patients, such as those undergoing cardiopulmonary resuscitation, is needed for prompt administration of drugs and fluids. • Intraosseous access is recommended by American Heart Association and European Resuscitation council if vascular access is not readily obtainable to prevent delay in treatment. What is New: • This simulated pediatric resuscitation compared performance of four commercially available pediatric intraosseous devices in a manikin model. • NIO® outperformed BIG®, EZ-IO®, and Jamshidi in first attempt success rates and time of procedure among novice users.

A Comparison of Bariatric Surgery in Hospitals With and Without ICU: a Linked Data Cohort Study

BACKGROUND

It is uncertain whether bariatric surgery can be safely performed in secondary hospitals without on-site intensive care unit (ICU) support. This study describes the outcomes of elective bariatric surgery patients who required inter-hospital transfers for unplanned ICU management, extrapolating this as a parameter for secondary hospital safety after bariatric surgery.

METHODS

This was a retrospective, statewide, population-based, linked data cohort study capturing all adult bariatric surgery patients for an entire Australian state between 2007 and 2011 (n = 12,062) with minimum 12-month follow-up.

RESULTS

In secondary hospitals, 2663 (22.1%) bariatric patients were operated on, with the majority (n = 2553) undergoing sleeve gastrectomies (SG) or adjustable gastric bands (LAGB). Forty-two patients (including 19 LAGB and 20 SG) required inter-hospital transfer to a tertiary hospital for unplanned ICU care (1.6%, 95% confidence interval 1.2-2.1), mainly due to surgical complications. Inter-hospital transfers incurred two deaths, both following sleeve gastrectomies. When compared to patients requiring unplanned ICU admissions after bariatric surgery in tertiary hospitals with an on-site ICU (n = 155), there was no difference in their demographic parameters, comorbid illnesses, or mortality (4.8 vs 3.9%, p = 0.68). The mortality following bariatric procedures both statewide (0.2%) and in secondary hospitals (0.2%) was both uncommon and comparable.

CONCLUSIONS

Statewide inter-hospital transfers for unplanned ICU care from secondary hospitals were low. Inter-hospital transfer mortality was comparable to a similar bariatric cohort requiring unplanned ICU care after surgery in a tertiary hospital. This suggests that certain bariatric procedures can be safely done in most secondary hospitals where elective ICU admission is deemed unnecessary.

Emergency Care Capabilities in North East Haiti: A Cross-sectional Observational Study

INTRODUCTION

The North East Department is a resource-limited region of Haiti. Health care is provided by hospitals and community clinics, with no formal Emergency Medical System and undefined emergency services. As a paucity of information exists on available emergency services in the North East Department of Haiti, the objective of this study was to assess systematically the existing emergency care resources in the region.

METHODS

This cross-sectional observational study was carried out at all Ministry of Public Health and Population (MSPP)-affiliated hospitals in the North East Department and all clinics within the Fort Liberté district. A modified version of the World Health Organization (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care and Generic Essential Emergency Equipment Lists were completed for each facility.

RESULTS

Three MSPP hospitals and five clinics were assessed. Among hospitals, all had a designated emergency ward with 24 hour staffing by a medical doctor. All hospitals had electricity with backup generators and access to running water; however, none had potable water. All hospitals had x-ray and ultrasound capabilities. No computed tomography scanners existed in the region. Invasive airway equipment and associated medications were not present consistently in the hospitals' emergency care areas, but they were available in the operating rooms. Pulse oximetry was unavailable uniformly. One hospital had intermittently functioning defibrillation equipment, and two hospitals had epinephrine. Basic supplies for managing obstetrical and traumatic emergencies were available at all hospitals. Surgical services were accessible at two hospitals. No critical care services were available in the region. Clinics varied widely in terms of equipment availability. They uniformly had limited emergency medical equipment. The clinics also had inconsistent access to basic assessment tools (sphygmomanometers 20% and stethoscopes 60%). A protocol for transferring patients requiring a higher level of care was present in most (80%) clinics and one of the hospitals. However, no facility had a written protocol for transferring patients to other facilities. One hospital reported intermittent access to an ambulance for transfers.

CONCLUSIONS

Deficits in the supply of emergency equipment and limited protocols for inter-facility transfers exist in North East Department of Haiti. These essential areas represent appropriate targets for interventions aimed at improving access to emergency care within the North East region of Haiti.