Critical Care Transport Standardstransported by any vehicle modality depending on the individual...
Transcript of Critical Care Transport Standardstransported by any vehicle modality depending on the individual...
Association of Critical Care Transport
www.ACCTforPatients.org
Critical Care Transport StandardsVersion 1.0
Dedication
Suzanne Wedel, MD
These Standards and the ongoing project are dedicated toDr. Suzanne
Wedel,agiftedphysician,scientist,leader,andhealer.Suzanne’spassion
for excellence and advocacy for patients inspired and led the work to
developtheseStandards.Suzannecontinuallytaughtandremindedusto
alwaysputpatientsfirstandatthecenterofthemedicalenterprise.Her
rigorous and continuing commitment to a safer, better, andmeasured
criticalcaremedicalsystemforeachpatientisatouchstoneforusallas
weundertakecareandthegiftofservice.
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ExecutiveSummaryWiththecontinuedregionalizationofhealthcare,changesinhealthcarereimbursement,andthe
advancementsinclinicaltherapies,theAssociationofCriticalCareTransport(ACCT)anticipatesthatthe
needforcriticalcaretransport(CCT)willcontinuetoincrease.Yet,therearecurrentlynoagreed-upon
consensusnationalstandardsoreveninternationalstandardsforcriticalcareinter-hospitaltransport.
Whatconstitutescriticalcaretransportstandards?Apatchworkofeffortshasattemptedtoaddressthe
differentsegmentsofpatienttransport.Regulatorshavepromulgatedlicensingandregulationatthe
jurisdictionallevel;theEuropeanCommitteeforStandardization(CEN)haspublishedambulancevehicle
standards;professionalsocietiessuchastheAmericanAcademyofPediatricshavepublishedbest
practicesandrecommendations,andaccreditingorganizationssuchastheCommissiononthe
AccreditationofMedicalTransportSystems(CAMTS)andtheEuropeanAirMedicalInstitute(EURAMI)
havedevelopedvoluntaryaccreditationstandards.
ThislackofaunifiedCCTstandardallowswidevariationinpractice,education,availablemedical
therapies,vehiclerequirements,andclinicaldocumentation.Mostimportantly,thelackof
standardizationpresentsriskstopatientsthatareoftennottransparenttoreferringandreceiving
clinicians,ortopatients,theirfamilies,northepublic(e.g.,failuretorecognizeorinterveneon
compromisedcriticalpatientsduetoinexperiencedand/orill-equippedclinicians).Astheneedforhigh
acuityCCTincreases,patientsandcliniciansalikewillbenefitfromstandardsofpractice.
Throughamulti-yearinteractiveprocess,ACCThasdevelopedasetofrecommendedclinicalstandards
forinter-hospitalCCT.Therecommendations,whicharepresentedintheAppendices,havebeen
conceivedandwrittentoapplytoallmodesoftransport
Indevelopingtheserecommendedstandards,ACCTfirstdistinguishesbetweenprimaryemergency
sceneresponseandinter-hospitaltransport.Secondly,ACCTrecognizesthewidespectrumofpatient
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acuityintransport.Noteverypatientrequiresthehighestlevelofcriticalcareduringtransport,nordoes
everyagencyneedtoprovide,withinitsmission,everypotentialtherapytoeverypatientregardlessof
ageandcomplexity.Transport,clinicalprovidersandagencies,however,mustbetransparentandclear
onthescopeofmissiontheyarepreparedtoundertakeforanyemergent,unscheduled,inter-hospital
transfer.
Toooften,inter-hospitaltransportisablackholebetweenreferringandreceivingcenterslackingin
consistentstandards,quality,outcomemetrics,documentation,andreportingtooversightagencies.
AppropriateandeffectiveCCTreducesmorbidityanddownstreamin-patientcost.Thefailureorinability
toinitiatecriticalacutemedicalinterventionsincreasestheriskofmortalityforpatients.Consistent,
transparent,andagreeduponstandardsprotectvulnerablepatientsandreduceliabilityriskfor
cliniciansresponsibleforinter-hospitaltransferdecisions.Ataminimum,CCTteamsshouldmaintain
continuityorimprovethelevelofpatientcareoneverytransportbetweenhospitals.
CCTisadistinctspecialtyintheprovisionofout-of-hospitalcare.CCTprovidesadditionalresources
necessaryforpatientswhoareclinicallyunstableorhavethepotentialforlifethreateningclinical
instabilityandwhorequiremoreadvancedandspecializedproviderknowledge,training,and
experience,aswellasdiagnosticandinterventionalcapabilities,equipmentandtherapeutics.Boththe
CCTagencyandCCTclinicalprovidersmusthavesufficientcapabilitiestomeetboththeexpectedand
potentialmedicalneedsofcriticalcarepatientsatreferralhospitalsandduringtransport.
Thechoiceoftransportmodality—ground,fixedwingorrotorwing—isbasedonmultiplefactors
includingpatientacuityandmedicalcondition,needfortimesensitive,definitivecare,out-of-hospital
time,(e.g.,aorticdissection,STelevationmyocardialinfarction,ortraumaticevent)andlogistical
considerations,includingdistanceandweather.Accordingly,criticalcaretransportpatientsmaybe
transportedbyanyvehiclemodalitydependingontheindividualcircumstancespresentatthetime.The
choiceofaparticularvehiclemodalitydoesnotinferthatatransportisorisnotacriticalcaretransport.
Thelevelofmedicalcarerequiredtotransportacriticalcarepatientincludesbutisnotlimitedto:
! anexpertlevelofcriticalcareproviderknowledge,experience,andskillsutilizingevidence-
basedcriticalcareguidelinesappropriatetothemedicalneedsofsuchpatients;
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! apatientcareenvironmentcommensuratewiththecriticalcareinterventionsprovided,
includingthenecessaryequipment,medicationsandsupplies;
! theabilitytoaddresstheaddedenvironmentalandlogisticalchallengesandstressorsof
transport;
! initiating,maintaining,andpotentiallyimprovingthecontinuityoftertiaryorquaternary
hospitalcareduringtransport;and,
! avehicle(ground,fixedwing,orrotorwing)equippedtosupportthedeliveryofmedicalcareto
criticalcarepatientsduringtransport(e.g.inverterpower,range,oxygenduration,andfull
patientaccess).
InMay2012,theAssociationofCriticalCareTransport(ACCT)StandardsCommitteeinitiatedawork
grouptoaddressthestandardsgapandcreateamodeldefinitionofcriticalcaretransport.Thework
groupcomprisedofcriticalcarephysicians,nurses,paramedics,respiratorytherapists,andhospital/
transportagencyadministratorsadoptedbyconsensusadefinitionofcriticalcaretransportandan
initialframeworkofstandards.
DefinitionofCriticalCareTransport:
Theprovisionofmedicalcarebyacriticalcare
transportteamtoapatientrequiringcriticalcare
transportbyacriticalcaretransportagencysuch
thatthefailuretoassess/recognizeresuscitation
needsandurgentlyinitiateandmaintainacute
medicaldiagnosticsand/orinterventions,
pharmacologicalinterventions,ortechnologies
wouldlikelyresultinsudden,clinicallysignificantor
lifethreateningdeteriorationinthepatient'scondition.ThesecapabilitiesexceedthoseofanAdvanced
LifeSupportEMSunit(subjecttothecorrespondingdefinitionsbelow).Ideally,CCTextendsamajority
ofthecriticalcarecapabilitiesofthetertiaryreceivingfacilitytothepatient,isinitiatedatpatient
contact,andisprovidedthroughoutthetransport.
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DefinitionofPatientRequiringCriticalCareTransport:
ApatientrequiringCCThasacriticalillnessorinjurythatacutelyimpairsoneormorevitalorgan
systemssuchthatthereisahighprobabilityofimminentorlifethreateningdeteriorationinthe
patient'sconditionduringtransport.Examplesofvitalorgansystemfailurethatmaycontributeto
morbidityormortalityinclude,butarenotlimitedto:centralnervoussystemfailure,circulatoryfailure,
shock,renal,hepatic,metabolic,and/orrespiratoryfailure.
DefinitionofCriticalCareTransportTeam:
CCTservicesaredeliveredbyaCCTteamconsistingofatleasttwoclinicalpersonnelwhopossessa
scopeofpractice,education,training,experience,andrequisitedecisionmakingskillstoassessand
supportahighlycomplexpatientactiveorpotentialvitalorgansystemfailureand/orto,atminimum,
preventfurtherlifethreateningdeteriorationofthepatient'sconditionduringtransport.
DefinitionofCriticalCareTransportAgency:
Thecriticalcaretransportagencymusthaveessentialsystemsandoversightinplacetomeetthe
medicalneedsofcriticalcarepatientsevidencedbylicensing,credentialing,andphysicianoversight.The
agencymustbelicensedand/orcredentialedtooperateinthestateinwhichitisbasedandatthe
highestclinicallevelestablishedinthestate.Theagencyhasphysicianmedicaloversightconsistentwith
theacuityandconditionsofthecriticalcarepatientstransported.Thismaybeacombinationofmedical
directorsoraphysicianteamsupplementedbytheadditionofconsultingspecialists.Suchappropriate
medicaloversightincludesanactivelypracticingphysicianwithcompetencyincriticalcaretransport
medicineandboardcertificationinaspecialtyrelevanttotheprovideragencymission,orexperiencein
criticalcaretransportmedicineconsistentwiththetypes,acuityandseverityofpatientstransported.
Theagencyalsohasstructuredphysician-directedclinicalqualitymanagementandclinicalperformance
improvementprogramsthatareconsistentwiththeconditionsofcriticalcarepatientstheorganization
cares.Theagencymustdemonstratecontinuousprocessimprovementforprovidingpatientcarethat
requiresactiveinvolvementbyaphysicianmedicaldirectortoensurequalityandadherenceto
appropriatestandards.Theprocessimprovementsystemalsomustincludereportingrequirements
relatedtoqualityassurance,utilizationreview,outcomes,proficiencymeasuresandpatientsafety.
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Withthesecoredefinitionsasstartingpoints,theACCTstandardsgrouphasworkedtodetailwhatis
neededwithintheentirescopeofCCT.ThefollowingappendicesworkthroughthelayersofCCTandare
thelatestiterationofrecommendedstandards,asadoptedbyACCT’sBoardofDirectorsinMarch,2016.
Althoughthesixstandardsarepresentedinseparateappendices,andeachonefocusesonaparticular
elementofCCT,theyshouldbeconsideredasawhole.Theinitialappendicesdetail:
Appendix1. ScopeofPracticeandclinicalcapabilityofproviders
Appendix2. Minimummedicalequipment,technology,andformulary
Appendix3. Minimumvehicleconfigurationandequipmentnecessarytosupportpatientcare
Appendix4. DocumentationStandards
Appendix5: “AlwaysandNeverEvent”qualitymeasuresincriticalcaretransport
Appendix6: Recommendedmetricsforcriticalcaretransport(inprocess)
Appendix7: StandardsReferences
Appendix8: Definitions
Mostimportantly,theserecommendationsshouldnotbeconsideredall-inclusive,asthecriticalcare
andemergencymedicaltransportindustryisamongthemostdynamicareasofmedicine.Theseinitial
recommendationsarepartofacontinuingevolutionaryprocessinadynamichealthcareenvironmentto
improvecareandtransportforpatientswithtimesensitiveandcriticalillnessorinjury.Additional
appendicesforMedicalOversightandadditionalQuality,processandoutcomemetricsarein
development.Further,ACCTexpectstocontinuallyreview,refine,andaddstandardsusingatri-annual
reviewschedule.
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ReferenceDocuments:
APPENDIX1:CRITICALCARETRANSPORTSCOPEOFPRACTICE_________________________________________7
APPENDIX2:CRITICALCARETRANSPORTMINIMUMEQUIPMENT/DEVICELIST _________________________17
APPENDIX3:CRITICALCARETRANSPORTVEHICLEATTRIBUTESTOSUPPORTCRITICALCARE________________25
APPENDIX4:CRITICALCARETRANSPORTDOCUMENTATIONSTANDARDS_______________________________32
APPENDIX5:CRITICALCARETRANSPORT–“ALWAYSEVENTS”AND“NEVEREVENTS”_____________________38
APPENDIX6:RECOMMENDEDMETRICSFORCRITICALCARETRANSPORT _______________________________53
APPENDIX7:REFERENCES _____________________________________________________________________59
APPENDIX8:DEFINITIONS&ACRONYMS_________________________________________________________62
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Appendix1:CriticalCareTransportScopeofPracticeBackgroundScopeofpracticecanbeidentifiedbythreecategories.Tobewithinascopeofpractice,therequirementsforpracticingaskillorprofessionmustsatisfyallthreecriteria:
! Educationandtraining—Hastheproviderbeeneducatedacademicallyoron-the-jobandhavedocumentationprovingeducationtodotheprocedureortreatmentinquestion?
! Governingbody—Doesthestate,district,provinceorfederalgovernmentalagencythatoverseestheskillorprofessionallow(ornotexplicitlydisallow)theiteminquestion?
! Institution—Doestheinstitutionallowaproviderortheprovider’sprofessiontoperformtheskillinquestion?
AprecursortothedevelopmentofthesestandardsincludedacompilationandreviewofstateRulesandprotocolsforairmedicaltransport.TheRulesvarywidelyinscope,breadth,andconstruct.Whileanumberofstateshavedefinedsomelevelofscopeofpracticeandreferencenationalaccreditationstandards,onlyonestate,Massachusetts,wasidentifiedtohaveacomprehensiverulesprocessdefiningcriticalcare.Uponevaluationofstate-definedscopeofpracticeformembersofCCTteams,mostwerefoundnottohavedefinedCCTspecificscopesofpractice,leadingtowidevariationsinstandardsofcare.Furthermore,scopesofpracticevaryinstatesthathaveworkingdefinitions.MedicaltransportprofessionalassociationssuchasAir&SurfaceTransportNursesAssociation(ASTNA)andInternationalAssociationofFlight&CriticalCareParamedics(IAFCCP)havedocumentedwhatthescopeofpracticeforaflightnurseorflightparamedicmaybe,butdonotprovideaunifiedCCTscopeofpractice.NeitherdotheseindividualAssociationsaddressphysicianlevelinterventionorcontinuityofcare,thoughthesearecommonlyaddressedoutsideofNorthAmerica.The“silos”thatseparatemanyprofessions,jobfunctionsanddisciplinescontributetoinconsistencyindefinitions.Thislackofconsistencyleadstodeliveryofsafeandeffectivepatientcare.Consequently,confusedandinaccurateexpectationsofscopeofpracticebyrequestinghospitalclinicianscanpotentiallyleadtoinappropriateteamselectionandpoorpatientoutcomes.ACCTbelievesCCTisaspecialtythatdrawsupontheskillsetstraditionallyheldbymultipledisciplines.CCTprovidersmayhaveformaltrainingasregisterednurses(RN),advancedpracticeregisterednurses(APRN),paramedics,physicians,physicianassistants(PA),orregisteredrespiratorytherapists(RRT);
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however,formalizedcivilianmedicaleducationdoesnotsufficientlyprepareanyonedisciplinetocareforthesepatientsinthetransportenvironment.Therefore,forthefutureofCCT,ACCTbelievesthatitisinthebestinterestofcriticallyillorinjuredpatientstobetransportedbypersonnelspeciallytrainedinCCT.ThescopeofpracticeforaCCTprovideriswellbeyondthescopeofafieldparamedic,asdefinedintheNationalHighwayTrafficSafetyAdministration(NHTSA)NationalEMSScopeofPracticeModelaswellasbeyondthetypicaltrainingreceivedbyatertiaryhospitalRN,asettingthathasthesupportofcountlessspecialtypersonnelonstaff.TheCriticalCareTransportAgency(CCTA)anditsmedicaldirectorhavetheresponsibilityofensuringalloftheirprovidersarewelltrained,wellequipped,andcompetentinthescopeofpracticetheyintendtoprovide.
ScopeofPractice1.
1.1. CriticalCareTransportAgency
1.1.1. TheCCTAmusthaveessentialsystemsandoversighttomeettheneedsofcriticalcarepatients.Thisshouldincludemedicaldirection,education,training,andqualityprocesses.
1.1.2. TheCCTAmustbelicensedand/orcredentialedtooperateinthestateinwhichit
isbasedandatthehighestapplicableclinicallevelofferedbythestate.1.1.3. TheCCTAhasphysicianmedicaloversightconsistentwiththeacuityandconditionsof
thecriticalcarepatientsbeingtransported.Thismaybeacombinationofmedicaldirectorsoraphysicianteamsupplementedbytheadditionofconsultingspecialists.Suchappropriatemedicaloversightincludesanactivelypracticingphysicianwhoparticipatesinthehiringprocess,orientationandtraining,qualityandsafetymeetings.ThemedicaldirectorwillhavecompetencyinCCTmedicineandboardcertificationinaspecialtyrelevanttotheprovideragencymission,orhaveexperienceinCCTmedicineconsistentwiththetypes,acuityandseverityofpatientstransported.CCTAphysiciansinvolvedwithmedicaloversightshouldattendongoingeducationandtrainingthatfocusesonmedicaldirectorresponsibilityinsupervising,evaluatingandensuringhighqualitymedicalcareisprovided.
1.1.4. TheCCTAhasstructuredphysician-directedclinicalqualitymanagementandclinical
performanceimprovementprogramsconsistentwiththeconditionofcriticalcarepatientsbeingtransported.Theseprogramsdemonstrateacontinuousprocessforimprovingcare,includingstandardsthatrequireactiveinvolvementbyphysicianmedicaldirectors.Medicaldirectorsensurequalityandadherencetoappropriate
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standardsandreportingrequirementsrelatedtoqualityassurance,utilizationreview,outcomes,proficiencymeasures,andpatientsafety.
1.2. CriticalCareTransportTeam
1.2.1. CCTteamsmustconsistofatleasttwoCCTproviders,withtheabilitytoprovide
acutemedicalinterventions,pharmacology,andtechnologicallifesupportsystemsconsistentwithtertiarylevelcare.Contemporaryteamsconsistofvariouscombinationsofprovidersthatinclude:RNs,APRNs,paramedics,physicians,PAs,andRRTs.CCTisrecognizedasmedicalcarethatisbeyondthetypicalpatientcaredeliveredwithintheUS911emergencysystem,whichreliesuponprovidersactingwithintheNHTSAEMSScopeofPracticeModel,DOTHS810657,February2007.
1.2.2. CCTproviderswillhavedocumentedcompetencyandexperienceinthecareand
transportofcriticalcarepatients.AllCCTteamprovidersshouldbeemployedbyoraffiliatedwiththeagencyprovidingtransport.
1.2.3. AtleastoneCCTprovidershallbelicensedasanRN,APRN,physician,orPAwith
documentedcompetencyandexperienceintheprovisionofcriticalcareinatertiarycriticalcareunitcommensuratewiththetypeandacuityofpatientstransportedandreceivestraininginthetransportenvironmentpursuanttotheCCTA’spolicy.Totheextentthatastate,province,orcountrymaydevelopcredentialingforaCCTproviderthatincludesotherlicensedcaregiverswhomeetthequalificationrequirementsin(1.1.2)aboveandthatrequiressuchcaregiverstohavethecompetencycomparabletothreefull-timeyearsinatertiarycriticalcareunitasaprimarycaregiver,suchcredentialingwillbeconsideredformeetingthisrequirement.Itisstronglyrecommendedthattransportprovidershaveaminimumof3700hoursofcriticalcarepatientcontactortheequivalentindynamichumanpatientsimulator(HPS)trainingoraminimumof5yearsofexperiencecaringforacutelyillorinjuredpatientsinacriticalcareenvironment.
1.2.4 AtleastoneCCTproviderhasspecialtycertificationinCriticalCareTransport(e.g.,
CertifiedFlightRegisteredNurse(CFRN),CertifiedTransportRegisteredNurse(CTRN),CertifiedNeonatalandPediatricTransport(CNPT),FlightParamedicCertified(FP-C),CriticalCareParamedicCertified(CCP-C),orrelevantphysicianspecialtypracticeachievedthroughavalidatedexamadministeredbyanindependententitynotassociatedwithaspecificcourseorprogramofeducation.TheagencyshouldhaveapolicyrequiringeventualtransportcertificationforeveryCCTprovider.
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1.2.5 Whentreatingspecialpatientpopulations(e.g.high-riskobstetric,pediatric,neonatal),additionalclinicalexperience,training,equipmentandtechnologymustbeincorporatedintotheteamanditsdeliveryofcriticalcareasappropriatetothemedicalconditionsofthepatient.
1.2.6 ACCTteammaybeaugmentedby
addingtertiaryteamsofspecialtyproviderstrainedtodelivercaretopatientswithhighlyspecializedcharacteristics,equipment,ormedicalconditions.SuchprovidersmaybeemployedbyanentityotherthantheCCTAbutshouldmeettheminimumrequirementsconsistentwiththeapplicabletertiarycarestandardforthepatientbeingtransported(e.g.,ExtracorporealMembraneOxygenation(ECMO),NeonatalIntensiveCareUnit(NICU)PediatricIntensiveCareUnit,(PICU),orHighRiskObstetrics(HROB).
1.3. CriticalCareTransportProviderQualificationsandTraining
1.3.1. CCTProviderQualifications
1.3.1.1. TheCCTprovidershallbelicensed,credentialed,orcertifiedasrequiredbythe
state,province,countryregulatorasaparamedic,RN,RRT,APRN,PAorphysician.TheCCTproviderfunctionsunderhisorherlicenseandassumesresponsibilityforthecareprovided.
1.3.1.2. Pre-hire,thenon-paramedicCCTproviderwillhaveaminimumofthree
yearsoffull-timeexperienceofcaringforcriticallyillorinjuredpatientsinacriticalcareenvironment.Thecandidate’sclinicaltimeisvalidatedbyaclinicalsupervisorpriortotheCCTteamorientationprocess.
1.3.1.3. Pre-hire,theparamedicCCTproviderwillhaveaminimumofthreeyearsoffull-timeexperienceofcaringforacutelyillorinjuredpatientsintheprehospitaland/orinter-hospitaltransportenvironmentinaprogressiveALSsystem.Thecandidate’sclinicaltimeisvalidatedbyaclinicalsupervisorpriortotheorientationprocess.
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1.3.1.4. PriortoemploymentbyaCCTA,theCCTproviderwillhaveaminimumofBasicCardiacLifeSupport(BCLS),AdvancedCardiacLifeSupport(ACLS)and/orPediatricAdvancedLifeSupport(PALS),orequivalentcertifications.TheymustalsoobtainNeonatalResuscitationProgram(NRP)certificationpriortoorientationcompletionifhigh-riskobstetrictransportisincludedinthescopeofpractice.
1.3.1.5. InordertobecredentialedasaCCTprovider,theorientationprocessshall
followguidelinesfortransportorientationthathavebeensetforthbyorganization-approvededucationalstandardssuchtheCommissiononAccreditationofMedicalTransportSystems(CAMTS),AirSurfaceTransportNurseAssociation(ASTNA),InternationalAssociationofFlight&CriticalCareParamedics(IAFCCP),UnitedStatedDepartmentofTransportation-NationalHighwayTrafficSafetyAdministration(USDOT-NHTSA).
1.3.1.6. Withinoneyearaftercompletionoforientation,theCCTprovidermustobtain
certificationinrespectivediscipline,(i.e.CertifiedFlightRegisteredNurse(CFRN),CertifiedTransportRegisteredNurse(CTRN),CertifiedNeonatalandPediatricTransport(CNPT),FlightParamedicCertified(FP-C)&/orCriticalCareParamedicCertified(CCP-C)).Duringthisfirstyear,theymustalsoobtainanadvancedtraumacertificationsuchasAdvancedTraumaLifeSupport(ATLS),Pre-hospitalTraumaLifeSupport(PHTLS),orTransportProviderAdvancedTraumaCertification(TPATC),iftraumaisincludedinthescopeofpractice.
1.4. CriticalCareTransportSpecialistQualifications
1.4.1. MeetsalltherequirementsofaCCTprovider.
1.4.2. Maintaincertificationinrespectivediscipline(e.g.CertifiedFlightRegisteredNurse
(CFRN),CertifiedTransportRegisteredNurse(CTRN),CertifiedNeonatalandPediatricTransport(CNPT),FlightParamedicCertified(FP-C)&CriticalCareParamedicCertified(CCP-C).
1.4.3. Completes150criticalcaretransports,ofwhich20maybedynamicHPS
transportsimulationsandaminimumof2yearsofexperienceasaCCTprovider.
1.5. Training
1.5.1. AlltrainingwillbedeterminedbytheCCTA’sscopeofpracticeandthepatient
populationserved
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1.5.2. Didactics:Criticalcarepatientmanagementinthetransportenvironment,advancedairwayandventilatormanagement,advancedcardiaccare,cardiaccriticalcare,medicalandsurgicaltrauma,advancedcareandtreatmentofthecriticallyillpatient
1.5.3. ClinicalLabTraining:Anatomyandphysiology,agespecificforscopeofpractice,advancedairwaylab,advancedmechanicalventilation,Intra-AorticBalloonPump(IABP),extracorporealmembraneoxygenation(ECMO),invasivehemodynamicmonitoring,CardiacAssistDevices(VADs),Intra-CranialPressure(ICP)monitoring.
1.5.4. ClinicalTime:Criticalcare,emergencydepartment/trauma,PICU,NICU,laborand
delivery.Clinicaltimemaybereplacedoraugmentedwithactualcriticalcarepatienttransportsandsimulatedcriticalcarepatientsandtransportsinahighfidelitysimulationlab.AllformsofclinicaltimeorreplacementswillhaveclearlydefinedobjectivesthatmeettheareaslistedaboveandareconsistentwiththeCCTA’sscopeofpracticeandpatientpopulation
1.5.5. AviationandGroundOperations:AirMedicalCrewResourceManagement,Aircraft
andGroundSafetyandAwarenessTraining,survivalskills,EMScommunications,hazardousmaterialstraining,NationalIncidentManagementSystem(NIMS)100,200,AltitudePhysiology&StressorsofFlight.
1.5.6. Certifications:Obtainremainingcertificationsaspertransportagenciesscopeof
practice(e.g.NeonatalResuscitationProgram(NRP),AdvancedTraumaLifeSupport(ATLS),Pre-hospitalTraumaLifeSupport(PHTLS),TransportProfessionalAdvancedTraumaCourse(TPATC)orequivalent).
1.5.7. TransportCertification:Withinoneyearaftercompletionoforientation,the
transportprovidermustobtaincertificationinrespectivediscipline(e.g.CFRN,CTRN,CNPT,FP-Cand CCP-C).
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1.6. CriticalCareTransportProviderSkills
CCTproviders’andspecialists’skillswillbebasedontheCCTA’sscopeofpracticeanddefinedpatientpopulation.Theyareabletopracticeundertheirdefineddiscipline’sscopeofpracticeinadditiontothefollowingprocedures.Thislistisnotintendedtobeall-inclusivenorisitexpectedthateveryCCTteamhastheabilitytoperformallofthelistedprocedures.Forexample,aCCTteamthatdoesnottransportneonatalpatientswouldnotneedtoperformumbilicalvein/arterycannulation.Theintentofthislistofadvancedskillsandproceduresistodemonstratethesignificantdifference,includingahigherlevelofknowledgeandtraining,betweenaCCTteamandanadvancedlifesupport(ALS)orCMS-definedspecialtycaretransport(SCT).
1.6.1. Airway/Respiratory
! AdvancedAirwayManagement:o Videoanddirectoral
laryngoscopyo RapidSequenceInduction
(RSI)
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o Supraglotticdeviceinsertion(e.g.LMAorKINGairway)o Needleandsurgicalcricothyroidotomy
! Chest/LungCompromiseo Needle,simple,andtubethoracostomyo Drainagesysteminitiationandmanagement
! Ventilation! Mechanicalventilationinitiationandmanagementofallmodesofventilation;to
includebutnotlimitedto:highfrequencyoscillating;volume,pressure,anddualmodeventilation;non-invasivepositivepressureventilation.CapabilitiesforallagegroupsintheCCTA’sscopeofpractice.
1.6.2. Cardiovascular
! ManagementofVentricularAssistDevice(VAD):includingbutnotlimitedto:percutaneousorcentralLVAD,RVAD,andBiVAD
! ManagementofExtracorporealMembraneOxygenation(ECMO)withorwithoutheater/coolercapability
! Intra-AorticBalloonPump(IABP)counterpulsation! Performandinterpret12LeadECGswithcatheterizationlabactivationcapabilities! Intraossesousaccess(e.g.EZ-IO,FAST1,etc.)! Indwellingportaccess(e.g.Hickman,Port-a-Cath,etc.)! Transcutaneous,transvenous,andepicardialwirepacemakercapabilities! Pericardiocentesis! Invasivehemodynamicmonitoring(e.g.CVP,PulmonaryArtery
Pressures,AbdominalPressures,arterialpressures,intracranialpressures)
! Blood/fluidwarmingdevices! Bloodproductadministration(e.g.PRBCs,plasma,platelets)! Operationofsingleandmulti-channelinfusionpump(s),includingbutnotlimited
toIntravascular,intraosseous,intrathecal,andintra-arterialroutes! CardiovascularDoppler/ultrasoundmonitoring! Arterialcannulation,radialand/orfemoral! Centralvenouscannulation,femoral,subclavian,andinternaljugular! Woundclosureincludingbutnotlimitedto:suturing,stapling,skinglue! Laboratorysampling,PointofCaretesting,resultinterpretation,andtreatment! Non-invasivetissueoxygenationmonitoring! Hemorrhagecontrolincludingbutnotlimitedto:tourniquetuse,chemical
clottingagents,Eshermanchestseal,tranexamicacid(TXA)andplasmaadministration
1.6.3. Gastro/Urinary
! Gastrictubeplacementandmanagement! Urinarycatheterinitiationandmanagement
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1.6.4. PHARMACOLOGY
! Abilitytocalculateandindependentlyadministermedicationsapplicabletothecriticalcareenvironmentandcoveredinprotocols,guidelines,orstandingorders.o Vasoactiveagentso Paralyticso Anxiolyticso Anti-inflammatoryo Anticonvulsanto Narcoticso Anesthetico Thrombolyticso Inhaledgases:Heliox,NitrousOxide,NitricOxide,Anesthesiagaseso Nebulizedmedications
o Antiemetico Antibioticso ACLSmedications:Epinephrine,Lidocaine,Atropine,Anti-arrhythmico Electrolytes:Potassium,Magnesium,Calciumo Prostaglandin,Surfactanto BloodandBloodProductso Tranexamicacid(TXA)
1.6.5. Other
! Radiographicinterpretation! Performandinterpretultrasoundimagingincludingutilizationforplacement
ofmedicaldevices! Abilitytomanageandtransportanyindwellingmedicaldevice! Invasiveandnon-invasivetemperaturemonitoring! Initiationandmanagementofnon-invasiveandinvasivethermoregulationdevices! Thoracicandextremityescharotomyandfasciotomy
1.6.6. Specialty
! Temperaturestabilization! Fetalheart/uterinemonitoring! Umbilicalvein/arterycannulation! Inhalednitricoxide! Surfactantadministration! Esophagealcompressiontubes! Peri-mortemcesareansection! Suprapubiccystostomy! Esophagealcoolingtubes
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TheCCTprovidermayberequiredtoperformskillsnototherwiselistedinthisdocumentviadirectorvideoremotemedicaloversight.BasedontheCCTA’spatientpopulation,theneedfortheseskillsshouldbeanticipatedandincludedintrainingandcompetencyassessment.SummaryACCTbelievesthatCriticalCareTransportandtheCCTprovidershouldberecognizedasahigherleveloftransportthantheCentersforMedicareServices(CMS)-definedreimbursementforSpecialtyCareTransport,whichprovidesreimbursementforcarebeyondthescopeofparamedicpractice.Itisessentialthatcriticallyillandinjuredpatientsreceivecarebyhighlytrainedandqualifiedclinicians.Duringinter-hospitalCCT,theCCTteamshould,ataminimum,providecriticalcarecommensuratewiththereferringfacility.Optimally,theCCTteamshouldadvancethelevelofcriticalcaretowardsthatofthereceiving,tertiaryhospital.Thegoalofstandardizedqualificationsandtrainingwouldallowforreferralprovidersandpatientstobeconfidentthattheirlevelofcareisnotcompromisedduringtransport.
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Appendix2:CriticalCareTransportMinimumEquipment/DeviceList
BackgroundCriticalCareTransport(CCT)MedicalEquipment:Maintainingtheinteroperabilityandcontinuityoftertiarylevelcarebetweenhospitalsandinitiatingtertiary-levelassessmentandinterventioncapabilitiesinreferralhospitalsettingsarecorerequirementsforthecriticalcaretransportagency(CCTA).WhileallmedicaltransportagenciesdonotprovideCCT,andallpatientsdonotrequirecriticalcaresupportduringtransport,theCCTAmustbeabletoprovideallcapabilitiesforanyunscheduledtransport.Essentialmedicalequipment,devices,andpharmaceuticalformulariesmustbeimmediatelyavailable,stockedonallvehiclesassigned,andaccessibletoclinicianstomanageanycriticallyillorinjuredadult,pediatricandneonatalpopulations,basedontheCCTA’sstatedmissionandscopeofpractice.TheCCTAmustmaintain,andhaveimmediatelyavailable,basicandadvancedlife-supportequipmentasrequiredbythejurisdictionalregulatorandlicensingauthority.SomeCCTAslimittheirscopeofpracticetotransportingspecificpatientpopulationssuchasneonatal,pediatric,andhigh-riskobstetrics(HROB)andtheminimumequipmentlistcanbemodifiedtoreflecttheneedsoftheirspecificpatientpopulation.CCTAsthatdonotexcludepatientpopulationsintheirscopeofpracticemustbecapableofemergentresponseandtransportforallpatientpopulationsandmustassuretheavailabilityofallrequiredtypesandsizesofmedicalequipment,devices,andpharmaceuticalformularyasnotedbelow.TheCCTAmusthavemedicalequipmentthatistestedandfunctionsinexpectedtemperature,atmosphericpressure,andhumidityconsistentwiththeCCTAservicearea.Ifthisisnotfeasibleforaregion(e.g.,wheretemperaturesmayroutinelydropbelow-18oCduringwintermonths),processes,guidelines,andstaffeducationmustaddresstheuseofthisequipmentasitpertainstostorageanduseinpatientcare.
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Electricallypoweredmedicalequipmentanddevicesshallfunctioncontinuouslyasintendedduringloading,transport,andtransferofcarewithbatteriessufficienttoprovidecontinuouslifesupportwithoutinterruptionduringallphasesoftransport.Fixation,storage,placementandprotectionofmedicalequipmentanddevicesmustmeetapplicableregulatorystandardsandbelocatedasnecessarytoprovideimmediateaccessasneededfor
resuscitationormanagementofmedicalemergenciesintransport.TheCCTAmusthavewrittenpolicyanddocumentationthatequipmentisfullymaintainedinaccordancewithmanufacturers,biomedicalandregulatoryrequirementsatprescribedintervals,consistentwithreferringandreceivinghospitalrequirementsforpatientsbeingtransportedbytheCCTA.
ThisminimummedicalequipmentandpharmaceuticalformularyshouldbebasedontheCCTA’sscopeofpracticeandpatientpopulation.Equipmentwillinclude,butnotbelimitedtothefollowing:
Equipment2.
2.1. PatientMonitoringEquipment
2.1.1. Patientmonitor(monitoringequipment)withthefollowingcapabilities:! Cardiacmonitoringtoinclude12Leadcapabilities! Pulseoximetry(neonatal/pediatricteamrequiresdualSpO2capabilityforpreand
postductalcontinuoussaturationmonitoring)! In-linecontinuouswaveformcapnographymonitoring! Non-invasiveandcoretemperaturemonitoring(e.g.esophageal/rectaland
skinprobes/tympanic)appropriateforpatientpopulationsmanagedortreatmentsadministered(i.e.targetedtemperaturemanagement)
! Aminimumoftwoinvasivelinemonitoringports(Arterial,PulmonaryArtery(PA),CentralVenousPressure(CVP),Intra-cranialPressure(ICP),etc.)andtransducers
! Non-InvasiveBloodPressure(NIBP)monitoring! Cardiacdefibrillation,cardioversion,andtranscutaneouspacingcapabilities
thatmeetILCORandAHA/ACLSguidelines! Abilitytotrendandprintpatientvitalsignsandpertinentclinical
managementevents(e.g.defibrillation)
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2.1.2. Doppler(certainmodelshavedifferentsensitivitybasedonpatientpopulations)! CardiacDopplerforteamsassessingextremitycirculation,VSassessmentfor
shockpatients,etc.! FetalDopplerforteamstransportingHROBpatients(unlessequippedwith2.1.3.)
2.1.3. ExternalfetalmonitoringisrequiredforHROBteams
2.1.4. Endotrachealcuffpressuremanometerrequiredinairtransportmodesand
stronglyencouragedingroundCCT,especiallyinmountainousregions.
2.1.5. Glucometerunlessincludedin2.1.6.
2.1.6. Pointofcarelabvalues’
testing/monitoring(i.e.hemoglobin/hematocrit,electrolytes,arterialbloodgas,INR,lactate,etc.)isstronglyrecommendedforCCTAswithextendedtransporttimes(greaterthan2hours),whorespondtoreferralhospitalsthatdonothavefullyavailablelaboratorycapabilities,orwhooffercriticalcareinterventionorcapabilitiesthatmaybeguidedbythelabresults(e.g.plasmainitiationtoreverseCoumadin).
2.1.7. Appropriatesize/agespecificstethoscope(s)forassessingheart,lung,andabdominalsounds.
2.2. RespiratorySupportEquipment:
2.2.1. Multi-modetransportventilatorthatisspecifictopatientageandidealweight
byheightspecificationsandscopeofpractice:! Volumeandpressurecontrolventilationwithstronglyrecommendedmode
ofPressureRegulatedVolumeControlled(PRVC)! Invasiveventilationcontrolmodesofcontrolled,AssistControlled(AC),
SynchronizedIntermittentMechanicalVentilation(SIMV)withPressureSupport(PS)available,PositiveEndExpiratoryPressure(PEEP),andtheabilitytoadjustinspiratorytime
! ContinuousPositiveAirwayPressure(CPAP)withtheabilitytoadjustpressureandFiO2from21%to100%
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! Non-invasivepositivepressureventilation(NPPV)(e.g.BiphasicPositiveAirwayPressure)withtheabilitytoadjustiPAP,ePAP,FiO2from21%to100%,RiseTime,iTime,flowandtimetermination
! Ventilatorshouldprovideclinicianstheabilitytoassesskeyrespiratorymonitoringoutputs(e.g.respiratoryrate,PIP,MAP,PlateauPressures,expiredVt,minutevolumes,etc.)
! Forneonatalteams,blendinggascapabilitydowntoroomairisrequiredandifinhaledNitricOxide(NO)isadministered,theproperadministrationdevicewhichintegratesintotransportventilatorisrequiredforallpatientpopulations
! Highfrequencyventilatorforneonataltransportteamsifwithinscopeofpractice! Humidification/artificialnoseforneonataltransportteams.! VentilatorcircuitsforallpatientpopulationstransportedbyCCTA’sscopeof
practice
2.2.2. TheabilitytoprovideelectiveEndotrachealTubeIntubation(ETI)remainsthegoldstandardforpatientsatriskforlossofairwayduringtransport.Acompleteselectionoflaryngoscopebladesandendotrachealtubesspecifictotheage/scopeofpracticearerequiredonalltransports.
2.2.3. Recentstudiesindicatethatvideo-assistedlaryngoscopy(VL)providessignificantrisk
reductionthroughimprovedfirstpasssuccessandsuccess-to-attemptratios.WhileVLshavebecomestandardequipmentforrescueoffailedETI,VLsareconsideredprimaryrequiredequipmentforCCTAsinwhichvehicle/patientconfigurationissuchthatstandardlaryngoscopyissuboptimalornotpossibleduetoinaccessibilitytotheheadofthestretcher.
2.2.4. Acompleteselectionofairwayadjunctsandperi/supraglotticalternateairway
devices(e.g.,LMAsandKingAirways)tomanagedifficultairwayoccurrencesofallpatientswithintheCCTA’sscopeofpracticearerequiredonalltransports.
2.2.5. Adultand/orpediatricsurgicalandneedlecricothyroidotomykitappropriateto
theCCTA’sscopeofpractice.
2.2.6. Tensionpneumothoraxneedledecompression,chesttubethoracostomy,andpericardiocentesiskitsthatareageappropriateforthepatientpopulationoftheCCTA’sscopeofpractice
2.2.7. HROBandneonatalteamsshouldhavemeconiumaspirators,suctioncathetersand
bulbsyringesincludedintheirdeliverykits.
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2.2.8. Fixed,oxygencylinderorliquidoxygensystemwithatleasttwoflowmetersandasourceat50psi,andcompressedairorotherrequiredinhaledagenttomeetspecificpatientneedsandtransportdurationfortheCCTA’scoveragearea.TheminimumgasvolumeavailablemustbeabletomeetanyventilatorandpatientspecificflowrequirementforthelongestpossibletransportbytheCCTA+a30-minutereserve.Forplannedlongtransportswhenitisimpossibletocarrytheamountofoxygenrequiredtocompletethetransportthereshouldbeaplaninplacetoreplenishthesupply.Afixedminimumcapacityof3000gaseouslitersforhelicoptersandfixedwingaircraftisrequired.CCTAsmustmaintainasystemforcalculationofflowratesandcapacityofoxygen.
2.2.9. Portablereserveoxygen/compressedairorotherrequiredinhaledagentwith30-
minuteminimumcapacityatpatientrequiredflowratefortransferofcareandemergencybackupiffixedsystemfailsoranunexpectedtransportdelayisincurred.Securestorageforportabletanksisnecessary.
2.2.10. Vehicle-poweredandportablesuctionsystemcapableofcontinuous300mmHg
suctionwithin4secondsofclosureofsuctionport.Vehicle-fixedsuctionsystemmustbecapableofoperationwithoutcompromisingvehicleenginepower,haveavisiblepressuregauge,rigidandsoftsuctioncathetersandendotrachealtubesuctioningcapability.
2.3. HemodynamicSupportEquipment:
2.3.1. Cardioversion/defibrillatorwithtranscutaneouspacingcapabilityincludingjoule
settingsandpadsforpediatricandadultpatients.NeonatalcapabilityconsistentwithpatientpopulationofCCTA.
2.3.2. Temporarytransvenous/epicardialpacemakercapabilities(Adult)
2.3.3. Consideranexternalchestcompressiondevice(e.g.LucasDevice)ifthe
CCTA’sprotocolsandpoliciesanticipatethepossibleprovisionofCPRduringtransport
2.3.4. Intra-AorticBalloonPump(IABP)forCCTAsthathaveIABPcounterpulsationaspart
oftheirscopeofpractice.IABPmustbeconfiguredforsecureplacementinvehiclewithacertifiedmanufacturedmountandhaveabatterypowercapabilitythatallowsforcontinuouscounterpulsationfromthehospitaltothevehicleandfromthevehiclebackintoatertiarycarecenter.
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2.3.5. ForCCTAsthatsupportortransportExtracorporealMembraneOxygenation(ECMO)andVentricularAssistDevices(VADs)aspartoftheirscopeofpractice,adequateadjuncts(i.e.,powerdelivery,invasivelinemonitoring,medicationformulary,infusionpumpsandcertifiedmanufacturedequipmentmounts)mustbeavailable.AppropriatelytrainedstafftomanagethepatientandequipmentmaybeaddedtoCCTcrewswhenappropriatelytrainedtothetransportenvironmentandsupervisedbyasafetyofficer.
2.3.6. TheabilitytoadministermultipleconcurrentmedicationsviaIVpumpwith
medicationformularyanddosagecalculatortomeetspecificpatientpopulationrequirementsincludingbackupandpatientspecificIVpumpssuchassyringepumpsfornewborns.ItisrecommendedthatIVpumpscontaincustomizablemedicationdosinglibrariesandthattheycanbesafelysecuredinthetransportvehicle.
2.3.7. IVplacementequipmentviaperipheral,intraosseousand/orcentralIVaccessor
othersuitablemeansformedicationandorfluidadministration.
2.3.8. Pressureinfusiondevice
2.3.9. UmbilicalarteryandumbilicalveininsertiondevicesandsetsforUA/UVCforneonatalandHROBteams
2.4. OtherEquipment:
2.4.1. Incubatorand/ortransportisolettesystemwithactivetemperature,ventilator,
andpharmaceuticalcontrolandsupportforneonatalandHROBteams
2.4.2. Warmingmattress(neonatalspecific)forneonatalandHROBteams(e.g.Transwarmer®)
2.4.3. Patientprotectiveequipmentincludingpediatrictransportequipment/systems
tomodifyadultstretcherasneeded
2.4.4. Pediatricrestraint/immobilizationdevice
2.4.5. Obstetricaldeliverykit
2.4.6. Appropriatesize/agegastricdecompressiondevices
2.4.7. Bleedingcontroldevices(e.g.clottingagents,glue,chestsealsandtourniquets)
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2.4.8. Bleedingcontrolinterventionssuchastheadministrationoftranexamicacid(TXA)
andthecontinuationorinitiationofthawedplasmaarestronglyencouragedforCCTAs.
2.4.9. Pelvicstabilizationdevices
2.4.10. Escharotomy/fasciotomysupplies
2.4.11. Thoraxdrainage/suctionequipment
2.4.12. Patientpackagingand/orthermoregulationdevice(i.e.IVFwarmer/cooler,Ready-Heat™,etc.)appropriateforgeographicserviceareameteorologicalconditionsandpatient-specificrequirementssuchashemodynamicshockstatesinpediatricpatients.
2.4.13. ProvisionsfortheinitiationandcontinuationofTargetedTemperature
Management(TTM)
2.4.14. Provisionsfortheisolationandmanagementofpatientswithhighlyinfectiousdiseasestates
2.4.15. System to protect and maintain vehicle cabin temperature (heat/cooling)
withinprescribedlimitsforpharmaceuticals,blood,andallothertemperaturesensitivesupplies
2.4.16. Communicationsequipmentconsistentwiththeabilitytoaccessmedicaloversightat
alltimes.Insomeregionsthismaynotbepossibleandmedicalguidelinesshouldspecificallyaddressprocessesforsuchinstances.
2.5. Formulary:
MinimumrequirementswillbebasedontheCCTA’sscopeofpracticeandneedsoftheagency’spatientpopulation.CCTAsmustmaintainsufficientmedicationforthemaximumdurationoftransport,plusa30-minutereserve.
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TheCCTAmustassuretemperaturestabilizationofallpharmaceuticalswithinlimitsprescribedbymanufacturerandincludingbloodproductsifcarriedbytheCCTA.Formularymayincludeallofthefollowing:
! Vasoactiveagents! Musclerelaxants/medicationsnecessaryforelectiveintubation! Anxiolytics/Sedatives! Anti-inflammatory/steroids! Anticonvulsants! Opioids/analgesiaagents! Inhaledgases:Oxygenandmedicalair! Otherinhaledgases,ifapplicabletotheCCTAscopeofmission/practice:Heliox,nitric
oxide! Nebulizedmedications(AlphaandBeta2-adrenergicagonist)! Antiemetics! Antibiotics! ACLSmedications:Epinephrine,Lidocaine,Atropine,anti-arrhythmic,etc.! Electrolytes:Potassium,Magnesium,Calcium! Tocolyticmedicationtomanagepretermlabor! VitaminK! Prostaglandins,surfactanttherapy(iftransportofneonatesiswithinCCTA’sstatedscope
ofpractice)! HypertonicNormalSaline! Osmoticdiuretics! Bloodglucosecontrolagents! BloodproductsifapplicabletotheCCTAscopeofmission/practice,geographicservice
areaandlimitationsofreferringhospitals
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Appendix3:CriticalCareTransportVehicleAttributestoSupportCriticalCareBackgroundCriticalCareTransport(CCT)MedicalEquipment:Maintainingtheinteroperabilityandcontinuityoftertiarylevelcarebetweenhospitalsandinitiatingtertiary-levelassessmentandinterventioncapabilitiesincriticalaccesshospitalsettingsarecorerequirementsforthecriticalcaretransportagency(CCTA).
Emergent,time-sensitiveCCTrequestsoftenmaynotallowforadhocreconfigurationofvehiclesandequipmentneededforsafeandeffectivecriticalcaretransport.NotallmedicaltransportagenciesneedtoprovideCCT,andnoteverypatientrequirescriticalcaresupportduringtransport.However,theCCTAmustassuretheimmediateavailabilityofconfiguredCriticalCare
TransportVehicles(CCTVs),includinggroundambulances,helicopterambulances,and/orfixedwingambulances,thatprovideallofthecapabilitieswithintheCCTA’sscopeofmission/practiceforanyunscheduledtransport.Thefollowingstandardsreflecttheconfigurationandsupportsystemsforessentialmedicalequipmentthatmustbeimmediatelyavailable,stockedandaccessibletomanagethecriticallyillandinjuredadult,pediatric,andneonatalpopulationsbasedontheCCTA’sstatedmissionandscopeofpractice.Itisrecognizedthatenvironmentalconditionsfortransportaremorevariablethanthoseofahospital;however,temperature,humidity,atmosphericpressure,vibrationandshockcausedbyCCTVmovementshouldbeminimizedtomaintainpatienthemodynamic,respiratory,neurologicalandmetabolicstatusduringtransport.Note:ThesestandardsdonotreflectalloftherequiredsafetyandoperationalattributesofaCCTV,suchasdesign,materials,engineperformance,exteriorlighting,communications,oronboardsafety
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equipment.Groundambulanceandairambulanceoperationalvehiclestandardsareregulatedbyapplicablegovernmentalagencies.ItisrecognizedthatsomeCCTAslimittransportstospecificpatientpopulationssuchasneonatal,pediatric,andhigh-riskobstetrics(HROB)andtheCCTVconfigurationmaybemodifiedtoreflecttheneedsofthespecificpopulationandscopeofpractice.TheseminimumCCTVconfigurationsandattributesshouldincludethefollowingbasedontheCCTA’sscopeofpracticeandmission.Climateandterrainoftheserviceareashouldalsobeconsidered.
VehicleAttributestoSupportCriticalCare3.
3.1. General:
3.1.1. TheCCTVmustmeetallstandardandregulatoryrequirementsfortherelevantjurisdictionalregulator.
3.1.2. TheCCTVshallbedesignedandof
sufficientsizetoaccommodateallpersonnelneededtoprovidetransportwithasafeworkingandoperationalenvironmentincludingapplicablecrew/passengerseatingandpatientstretcher;eachwithapplicableregulator(FAA,OSHA,DOT)approvedratedrestraintsystems.
3.1.3. TheCCTVwillbedesignedwiththepower,fuelendurance,andrangetomeetthe
95thpercentiletransportoftheCCTA’sserviceareaandenvironment.
3.1.4. TheCCTVisdesignedandequippedtoprovidecontinuouspatientcarewithinteroperabilityandinterchangeabilityofnecessarypatientsupportsystems.
3.1.5. The vehicle interior, equipment and all surfaces should be latex-free construction.
Whenlatex-freeequipmentisnotavailableorinpreexistingvehicles,latexshouldbeidentifiedtominimizepatientexposure.
3.1.6. TheCCTVdoorsmustbefullyoperationalfromtheinteriorandcapableofbeing
heldfullyopenbyamechanicaldevice.
3.1.7. TheCCTVmusthavesufficientandsecuredstorage tomaintainall criticalcareequipment,devices,andsupplies,aswellasallbasicandadvancedlife
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supportequipmentasrequiredbythejurisdictionalregulatorandlicensingauthority.
3.1.8. Intheaviationenvironment,theCCTAwillhaveasystemforregularly
documentingtheweightofallcarryonboardmedicalequipment,devicesandsupplies.
3.1.9. TheCCTVmustbedesignedandofsufficientsizetoallowloadingandunloadingofa
patientwithoutexcessivemaneuvering(nomorethan45degreesaboutthelateralaxisor30degreesaboutthelongitudinalaccess)thatcouldcompromiseanypatientmonitoringsystemsortherapeuticequipmentordevicessuchasventilationorinfusionsystems.
3.2. PatientTreatmentCompartment:
3.2.1. TheCCTVshallbeof
sufficientdimensionstoincorporateaminimumoftwoseatsformedicalpersonnelandonestretcherapprovedbytheapplicableregulatorycrashstandardsforcapacityandfixationtothevehicle.
3.2.2. Thepatientstretchershall
haveatminimumafive-pointrestraintsystemandabilitytoraisethepatient’shead30degreesduringtransport.
3.2.3. CCTprovidersmustbeabletomaintainfreeaccesstothepatient’shead,chest,abdomen,andpelvisatalltimesandunimpededaccessasnecessaryforexpectedcareandemergencyinterventions.IfHROBisincludedintheCCTA’sscopeofpracticeandthereisasignificantpotentialfordeliveryofaninfantduringtransport,adequatespaceandpatientaccessmustbeavailableforthedelivery,careofthemother,andcareoftheinfant(s).
3.2.4. CCTprovidersmustbeabletoaccessandmaintainapatient’sairwaywhileseated
to minimize the need to become unrestrained. CCTAs should evaluate thecapabilityofvideolaryngoscopestoimproveairwayplacementintheconfinesofamovingCCTV.
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3.2.5. ProvidingCardioPulmonaryResuscitation(CPR)inamovingvehicleissuboptimalclinically.ItcarrieshighriskforpatientsafetyastheabilitytocompressthechestwithadequatedepthandratepercurrentILCOR/AHAguidelinesforanextendedperiodrequiresmultipleproviderswhoarenotseatedorrestrained.Thesuccessfulapplicationofeithermanualormechanicalcompressionsinamovingvehicleisnotsupportedbyevidence.ResuscitationshouldbeavoidedifatallpossibleduringthetransportphaseandCCTAsshouldhaveclearpolicyonloadingapatientintoatransportvehiclewitheitherCPRinprogressorifthepatientisexpectedtoarrest.IftheCCTAcontemplatestheneedforCPRintheirclinicalguidelines(e.g.patientsexperiencingcardiacarrestduetoprofoundhypothermia<30oC),theCCTAshouldconsidertheuseofamechanicaldeviceratherthanmanualcompressionstomaintainsafety.
3.2.6. ThepatientcompartmentshallbedesignedsuchthatCCTprovidersareableto
access,view,andmanageallmedicalequipment,devices,andsuppliesnecessarytoresuscitateand/ormaintainacriticallyillpatient,ideallywithouttheneedtoremoveCCTproviderrestraints.
3.2.7. Medicalequipmentanddevicealarmsandcapacitygaugesforgasesshallbe
visibletotheCCTprovidersfrominsidethepatienttransportcompartmentwithoutobstruction.
3.2.8. Medicalgas/airsupplypointsorgaugeswillbecolorcodedandprotected/padded
topreventinjury.Oxygenandothergassupplytanksmustallowcompleteshutoffofflowfromtheinteriorofthevehicle
3.2.9. Thepatientcompartmentshallbedesignedtoprotectheadstrikesincluding
protectionfromallequipmentanddeviceconnections(oxygenregulators,IVhooks,andsuctionregulators)
3.2.10. Fixation(rail),storage,andplacementandprotectionofmedicalequipmentand
devicesmustmeetapplicableregulatorystandardsandbelocatedasnecessarytoprovideimmediateaccessasneededforresuscitationormanagementofmedicalemergenciesintransport.
3.2.11. Thepositioningofmedicalequipmentanddevicesshallallowforoperation
withoutobstructingemergencyegress.
3.2.12. TheCCTVwillbedesignedandconstructedforeaseofcleaning,decontamination,anddisinfectionofallsurfaces(e.g.ceiling,walls,floor).
3.2.13. Theconstructionofthemedicalinteriorwillbeflameresistant/retardantconsistentwithapplicableregulatorystandards.
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3.2.14. Helicopterfuelsystemsarerequiredtomeetthecrashworthinessrequirementsof
14CodeofFederalRegulations27.952or29.952.
3.3 EnvironmentalConditions
3.3.1 Tomaintainpatientthermalstability,theCCTVmusthaveanenvironmentalcontrolsystemcapableofraisingand/orloweringandthenmaintainingthetemperatureinthepatientcompartmentbetween60and80degreesF.Duringtimesofextremetemperatures,therewillbeadditionalmeans(i.e.equipment,processes,etc.)ofmaintainingthepatient’sbodytemperature.
3.3.2 Activeauxiliaryheatingandcoolingsystemsshouldbeavailablewhenthevehicleisstationary.
3.3.3 TheCCTVshouldprovidenormalambienthumidityconditionsforpatienttreatmentifpossible.
3.3.4 TheCCTVshouldhaveprovisionstomaintainapprovedthermalstabilityfor
medicationsandbloodproductsasstockedbytheCCTA.
3.3.5 FixedwingCCTVsthatoperateregularlyatflightaltitudeof15,000’shallhaveapressurizedcabincapableofmaintainingatmosphericpressureequivalentto3500’.
3.3.6 Interiorlightingshallbeprovidedwithaminimumof50lumensinpatientcompartmentareawith300lumensoverstretcherareaanda400-lumendirectionalspotlight.Allinteriorlightingwillbedimmable.
3.3.7 Abatterypoweredlightsourcewillbeavailableforemergencyoperationsandfilteredasnecessaryfornightvisiongoggles(NVG)operationsintherotorwing(RW)environment.Ifaportableflashlightisusedthepilotshouldbeshieldedfromthelight.
3.3.8 Thepilotand/ordriverofaCCTVwillbeshielded,withacurtainordoor,frompatientcompartmentlightingfornightoperationsoralightingsystemmustbeinplacetoprotectpilotordrivernightvision.
3.3.9 AlllightingintheRWenvironmentwillbeapprovedandcapableoffilteringforNVGoperationsasapplicable.
3.3.10 TheCCTVwillhaveapositiveorfreeflowventilationsystemdesignedtoprovidewashoutairflowandtoprotectpatientandclinicalpersonnelfromexcessiveairflow.
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3.3.11 IfnoiseexposureintheCCTVexceeds85dB(A)soundprotectionforbothallpersonnelandthepatient(s)willbeprovided.
3.3.12 AninternalcommunicationsystemwillbeavailableifthenoiseexposureintheCCTVexceeds85dB(A).
3.4 ElectricalSupply
3.4.1 Electricallypoweredmedicalequipmentanddevicesshallfunctioncontinuouslyasintendedduringloading,transport,andtransferofcarewithbatteriessufficienttoprovidecontinuouslifesupportwithoutinterruptionduringallphasesoftransport.
3.4.2 TheCCTVwillhaveaminimumoffour(4)12Vdcand120/240Vacoutletsseparatelyprotectedwithanominalvoltageof13.8V.
3.4.3 Alloutletswillbemarkedforvoltageandamperagecapacitywithavisualindicatorforpowertotheoutlet.
3.4.4 Electricalpowerthroughaninverterorappropriatepowersourcewillprovidesufficientamperagetocontinuouslysupportallrequiredmedicalequipmentanddeviceswithoutcompromisingtheoperationofthevehicleelectricalequipment.
3.4.5 TheCCTVwillhave“shoreline”powercapabilitytosupportoutletsinthepatientcompartmenttoprovideforcontinuouscurrentwhenthevehicleisnotoperating.
3.4.6 TheCCTVwillhavesufficientelectricalorenginevacuumpowertoprovidecontinuoussuctionof300mmHgwithoutcompromisingtheoperationalperformanceoftheCCTV.
3.4.7 ThedesignoftheRWandFWCCTVelectricalsystemsshallisolatemedical
equipmentanddevicesandcommunicationssystemstopreventinterferencebetweenthevehicleelectricaloravionicsystemsandpatientsupportsystems.
3.5 Other
3.5.1 TheCCTVmusthavefixedoxygencylindersorliquidoxygensystemswithcapacityforthelongesttransportpossiblefortheCCTAwithatleast15LPMflowcapacityandtoincludea30-minutereservecapacity.
3.5.2 Atleastoneoxygenoutletwillbea50-psisource.
3.5.3 Therewillbeaminimumoftwooxygenoutletsandtwosuction/vacuumpumps.
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3.5.4 TheCCTVmusthavefixedorportablemedicalair,compressedgas,orotherinhaledgaseswithcapacityforexpectedtransportsandreserves.Portablesystemsmustbeadequatelysecuredconsistentwithregulatoryrequirements.
3.5.5 Fixedandsecuredsharpscontainersshouldbeavailableinthepatientcompartment.
3.5.6 Afireextinguisherwillbeavailableinpatientcompartmentandaccessibletoclinicalpersonnelwithouttheneedtobecomeunrestrained.
3.5.7 Carryonspecializedmedicalequipmentsuchastransportisolettes,IABP,cardiacassistdevices,andECMOmusthaveindividualsecurefasteningsystemsandarenottobestrappedintoseatsorpatientstretcherwithseatbelts.
3.5.8 PediatricrestraintsystemsareavailablewithabilitytosecuretostretcherorairframeconsistentwithregulatoryrequirementsifpediatricsiswithintheCCTA’sscopeofpractice.
3.5.9 Communicationssystemstoallowmedicalcommunicationsthroughouttheentiretransportwithoutcompromisingvehiclerequiredcommunications.
3.5.10 Tominimizetheneedforrefuelingwithapatientonboard,theCCTVfuelcapacityshallmeetthe95thpercentiletransportprofileoftheCCTA’sservicearea.SelectionofahelicopterorfixedwingCCTVshouldincludethefollowingconsiderations:! Appropriatepowerforallenvironmentalconditionstoavoidtheneedto
decreasefuelcapacityorclinicalpersonnelinhightemperature,humidity,oraltitudeconditionsconsistentwiththeCCTAservicearea
! Minimizedtimefortransport! Limitednumberofgroundstops! Sufficientworkroomandenvironmentalconditionsnecessarytopositively
affectpatientcare! Sufficientworkroomandcapacityforadditionalmedicalpersonnelasneeded
byspecificpatientsandfortrainingpurposes! FixedwingCCTVsshouldhaveminimumthree-hourflighttimeendurancein
conditionsexpectedforservicearea.
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Appendix4:CriticalCareTransportDocumentationStandards
BackgroundCriticalCareTransport(CCT)Documentation:Itisthroughdocumentationthatpatientassessments,treatmentsandresponsesduringstabilizationandtransportarerecordedandmadeavailabletosubsequentcareproviderstoassurecontinuityofcareandthelongitudinalabilitytomeasureoutcomesandsystemeffectiveness.Accuratedocumentationisessentialtoimprovingprocessandperformancemeasures.Conversely,missingand/orinaccurateinformationexchangeduringatransitionofcarebetweenproviderscontinuestopresentsignificantrisktopatients.Accuratedocumentationandprompttransmittalofthepatientcarerecordtosubsequentcliniciansarticulatesthecriticalcarelevelofservice/interventionandmostimportantlyprotectsthepatientfromtheriskofiatrogenicadverseeventsinthetransitionofcare.TheCCTAmusthaveasystemizedandthoroughdocumentationprocesswithwrittenpolicyforclinicaldocumentationstandardsandappropriatehandlingofprotectedhealthinformation(PHI).Documentstandardsshouldinclude,butarenotlimitedtothefollowing:
DocumentationStandards4.
4.1 GeneralRequirements
4.1.1 Thepatientcarerecord(PCR)isspecifictoasinglepatientandispresentedinanorganizedrecordconsistentwiththechronologyofcare(preferablyanelectronicPCR).Thefinalreportwillcontainasingletreatmentsummarythathasvitalsignsandmedicalcrewinterventionsinchronologicalorder.
4.1.2 AllPCRsarehandledinamannerconsistentwithstateandnationalprivacystatues.AlltransportagencystaffwhocreateorhaveaccesstoPCRsreceivetrainingregardingconfidentiality.
4.1.3 PatientnameandauniqueidentifieraredocumentedoneachpageofthePCR.
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4.1.4 Contentisstandardized,legible,andifabbreviationsareallowed,anapprovedabbreviationlistisavailable.Nomedicationsshouldbeabbreviated.
4.1.5 UpontransferofcarefromtheCCTteamtothereceivingfacility’scareprovider(s),
theCCTproviderwillprovideawrittendocumentthatincludes:
! Patientname,ageandweight(ifknown)! Onsetofinjuryorsymptomsthatpromptedtransport! Fullnameofreferringindividual,agencyorproviderandphysical
locationoftransportinitiation! Significantphysicalassessmentfindings! Summaryofprocedures,treatments,medicationsandfluidsadministered
duringthetransportaswellaspatientresponseandperiodicvitalsigns
4.2 Fulldocumentationofcareshouldoccurwithin24hoursofthetransport.
4.2.1 AllentriesandupdatestothePCRmustbedatedandsigned.
4.2.2 AllcareprovidersontransportmustbenotedinthePCRbyfullnameandprofessionaldiscipline.
4.3 Documentationmustincludetimelineoftransportrelatedactivities:
! TimerequestreceivedbytheCCTA! Timeweather/roadconditions(is)arecheckedasapplicable! TimerequestisacceptedbyCCTteam! Timeenroute! Timeofarrivalatreferringlocationorscene! Timeassessmentandcareinitiated! Timedepartingreferringlocationorscene! Timearrivingatreceivingfacilityordestination! Timeofhandoffofcareatthereceivingfacility! Iffamilymembersaccompanypatientasaridealong,theirfullnameandpresencemustbe
documentedinthePCRordispatchrecord.! Fullnameoftherequestingindividual,agency,orproviderandthephysicallocationofthe
referringfacility/scenemustbedocumentedinthePCR.! Fullnameofthereceivingfacility,provider,andthedepartment/physicallocationof
patientcarehandoffistobedocumentedinthePCR.! Unexpecteddelaysintimeintervalsortheprovisionofcaremustbedocumentedinthe
PCR.
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4.4 ClinicalRequirements
4.4.1 HistoryofPresentIllness(HPI)mustdescribethechronologicalprocessofthepatient’sillnessorinjury,includingenoughdetailtopresentaclinicalpictureofthepatientpriortothetransitionofcaretotheCCTcrewsfortransport.
4.4.2 TheHPImustalsoincludethereasonforcriticalcaretransportandtheprovidersinvolvedinthedecision-makingprocessregardingbothdestinationandmodeoftransport.
4.4.3 Aclinicalimpression(working/fielddiagnosis)isdocumented.
4.4.4 Thepatient’spastmedical,surgical,andfamilyhistorysignificanttothecurrentclinicalimpressionaretobedocumentedinthePCR.Anobstetricalhistoryshouldbeincludedonallwomenwhoareorwererecentlypregnant.
4.4.5 CurrentpatientmedicationsandanyknownallergiesaretobedocumentedinthePCRwhenknown.
4.4.6 ChiefComplaint–Patientcomplaintandpertinentpositiveandnegativesignsandsymptomssupportingthecomplaintaretobedocumented.
4.4.7 Documentationoftreatmentanddiagnosticspriortoarrival(PTA)toinclude:! Summaryofclinicallypertinentprocedures,treatments,medications(doseand
timeifknown)andfluid/bloodproductinputandoutput(amount,typeandtimeifknown)PTAofthetransportteam.
! Descriptionofanyindwellingdevices(type,size,depth,location,placementverification,placementdate,securityandfunctionasappropriatetothedevice)
! Laboratory,radiologicandotherdiagnosticfindingssignificanttopatient’sclinicalcondition
4.4.8 Initialassessmentsandvitalsigns
topotentiallybedocumentedinclude(aprioritized,targetedassessmentandphysicalexamisanticipatedformostCCTpatients):! Ageappropriateassessments
ofheartrate,respiratoryrateandworkofbreathing,bloodpressure,temperature,pulse
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oximetryreading,endtidalCO2(ifindicated),capillaryrefilltime,painlevel,glucose(ifindicated),andGlasgowComaScale
! Forhigh-riskobstetricalpatients(HROB),additionalassessmentsincludecontractionfrequency,durationandintensity,uterinerestingtone,fundalheight,fetalheartrateandfetalmovement.IftheCCTA’sguidelinesallowforcervicaldilatationandeffacement,thesewouldalsobedocumented.
! PhysicalExamtoincludebothpertinentpositiveandnegativefindingsaretobedocumentedusingastandardformatistobeincludedinthePCR.Ifaspecificexamisdeferred,areasonfordeferralistobedocumented.
! GeneralAssessment-aninitialimpressionofpatient’sphysicalpresentationandthemostsignificantphysicalordiagnosticfindings.
! HEENT–visualandtactileassessmentofthecranium,eyes,ears,noseandthroat! Chest–visual,tactileandauscultoryassessmentofchesttoincludeheartand
breathsounds! Abdomen–visualandtactileassessmentofabdomen,dividedintofourquadrants
ifindicated! Back-visualandtactileassessmentofbackincludingcervical,thoracicandlumbar
portionsofthespine! Pelvis/GI/GU-visualandtactileassessmentofthepelvicandgenitalarea,as
necessaryandpertinenttoclinicalconditionorinjuries! Skin–generalassessmentofskin.Ifconditioninvolvesburns,documentationof
percentageofbodysurfaceareaanddegreeistobeincluded.! Extremities–visualandtactileassessmentoftheextremities,upperandlower,left
andright,includingcirculation,motorfunction,sensationandrangeofmotionwhenindicatedbyclinicalcondition
4.4.9 Continuingassessmentsandvitalsignsaretobedocumentedatleastevery15
minutesormorefrequentlyifindicatedbypatientcondition.
4.4.10 ChronologicalPCRentriesthatdescribetheprocessandtimingofassessments,treatments,stabilization,andtransportactivitiesaretobeincludedinthePCR.
4.4.11 Patientconditionathandoffofcaretoincludegeneralassessmentandvitalsigns.
4.5 DocumentationSpecifictoDiagnosticandTherapeuticProcedures
4.5.1 ForallproceduresperformedbymembersoftheCCTteam,documentationinthePCRmustincludeclinicalindications,time,specificprovider,outcome(successfulorunsuccessful),specificlocation,patienttoleranceandresponsetoprocedure,andanycomplications.
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4.5.2 Additionalspecific
documentationincludesbutisnotlimitedto:! Oxygenadministration–
methodanddevice,rateofflow,FiO2asappropriate
! Peripheralvenous/interosseousaccess-size,type,site,skinpreparation,securityandfunction
! Centralvenousandarterialaccess–size,type,location,skinpreparation,security,functionandifmonitored
! Fluidsadministeredincludinginputandoutputamounts! Bloodproductadministration–patientbloodtypeandRhfactor(ifknown),product
(e.g.,PRBCs,plasma,platelets,etc.),productunitABOtypeandRhfactor,expirationdate,andproductunitnumber,infusionrate,amountadministered(canbedocumentedintransportI&O),infusionsite,heartandrespiratoryrateandpatienttemperaturepriortoadministrationandat5,10and20minutesafterproductinitiation,timeinfusioncomplete,documentationofanytransfusionreactionandcrewresponse
! Medications–fullname,dose,route,time,rateofadministration,administrationsite,andeffectofmedicationincludinganyadversereaction
! Medicationdrips–fullname,concentration,basesolution,dose,rateofadministration,administrationsite,andeffectofmedicationincludinganyadversereactionandcrewresponsetoreaction
! Airwaymanagement–vitalsignsatonsetofprocedure,intendedmethod,documentationofpreparation,oralornasalplacement,blade(size/typeanddirectorvideolaryngoscope),useofstylet,useofendotrachealtubeintroducers(gumelasticbougie),tubesize,depthofinsertion,confirmationmethods,methodofsecuring,lowestoxygensaturationduringprocedure,vitalsignsat5,10and15minutesfollowingprocedure,endotrachealtubecuffpressure,verificationofplacementincludingfirstEtCO2andreverificationaftereachpatientmovement(i.e.,tostretcher,intotransportvehicle,outofvehicle,offstretcher)
! Invasivemechanicalventilation–mode,sensitivity,tidalvolume,inspiratorypressure,rate,FiO2,inspiratorytime,pressuresupport,PEEP,peakinspiratorypressure,exhaledtidalvolume,plateaupressure,meanairwaypressure,alarmsettingsasappropriatetomodedelivered
! Non-invasivepositivepressureventilation–inspiratorypressure,expiratorypressure,FiO2,rate(ifapplicable),ramp,flowtermination,spontaneousexpiratorytidalvolumes
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! Labs–POCversuslabtesting,typeofsample,site,specificlaboratorymarker(s)(e.g.glucose,sodium,pH,pCO2,lactate,etc.),result,laboratoryunit(e.g.,mg/dl,mmol,etc.),andthenormalrangeforspecificmarker(s)testedperCollegeofAmericanPathologists(CAP)standards
! Needleandsurgicalthoracostomy–site,size,typeofdevice,skinpreparation,initialair/fluidoutput,placementtoHeimlichvalveorsuction,responsetointervention,andcomplications
! Pericardiocentesis–puncturesite,needle/cathetersizeandtype,skinpreparation,initialoutput,responsetointervention,andcomplications
! Escharotomy/Fasciotomy–site,descriptionofincisions,skinpreparation,patientresponse(e.g.,respirationstatus,distalpulsestatus)
! Cricothyroidotomy–airwaysizeandtype,skinpreparation,proceduremethodtype,patientresponsetointervention,andcomplicationsOG/NGtube–tubesizeandtype,depthofinsertion,methodofverifyingplacement,securement,initialandongoingoutput(maybedocumentedinI&O),suction(e.g.,capped,openortolowintermittent/continuoussuction),patientresponsetointervention,andcomplications
! Urinarycatheter–tubesize,sitepreparation,initialandongoingoutput(maybedocumentedinI&O),patientresponsetointervention,andcomplications
! Cardioversion–presentingrateandrhythm,ifsynchronized,energysetting,padlocation,resultingrhythm,andcomplications
! Defibrillation-presentingrateandrhythm,energysetting,padlocation,resultingrhythm,andcomplications
! CardiacPacing–presentingrateandrhythm,pacermode,rate,setenergy,pad/catheter/wirelocation,patientresponsetointervention(e.g.,electricalandmechanicalcapture)andcomplications.Fortransvenouspacingorepicardialwires:pacingmode,mAforpacing,mVforsensing,thresholds,sitestatus,andsecurement
! Administrationofspecialgases(nitricoxide,Helioxornitrousoxide)–initiationtime,methodofadministration,patientresponsetointervention,andcomplications
! Useoftraumadevices(tourniquets,occlusivedressings,pelvicsplints,immobilizationdevices,tractionsplints)–indication,typeandlocation,timeofapplication(alsodocumenteddirectlyontoanytourniquetplaced),patientresponsetointervention,andcomplications
! Useofothercardiacandrespiratoryassistdevices(intra-aorticballoonpump,leftventricularassistdevice,bi-ventricularassistdeviceorextracorporealmembraneoxygenation)-cannulationsite,conditionofdressings,clinicallypertinentsettingsspecifictodeviceanddistalperfusion
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Appendix5:CriticalCareTransport–“AlwaysEvents”and“NeverEvents”BackgroundACCTiscommittedtoassuringanaccountableandsafeairandgroundCriticalCareTransport(CCT)systemthatrecognizestheinterestsofpatientsasthefirstpriority.Reducingandeliminatingpreventableinjuryandfatalitiesisanecessaryandever-continuingobjectivewithinmedicine.TheInstituteofMedicine’s1999reportToErrisHumanireporthighlightedtheenormouschallengeoferrorinmedicineandtheneedtorelentlesslysearchforstrategiestoimprovepatientsafety.Asmedicinebecomesevermorecomplex—withever-greaterbenefit,thechanceforerrorincreases.Theriskoferrorisintroducedateachlayerofassessment,decision,andinterventionandincreasesthepossibilitythattheexpectedoutcome,animprovementinhealthstatus,isnotachieved.TheToErrisHumanreportestimated44,000to98,000prematuredeathsoccurredeachyearinU.S.hospitalsduetoiatrogeniccauses.iiFifteenyearslater,thereremainsalongroadtoasafersystem.Recentstudies,withbetterreporting,estimate210,000to440,000prematuredeathsoccurannuallyinU.S.hospitalsduetomedicalerror.iiiThisstaggeringfigureranksiatrogenicmedicalerrorasthethirdleadingcauseofdeathinthecountry.CMS’findingspointtowidevariationintwomainareas:qualityofmedicalcareandhospitalsafetypractices.RecentestimatesbyMedicareProviderAnalysisandReview(MedPAR),examiningtheaverageriskofadjustedin-hospitalmortality,indicatethatifallhospitalsperformedatthehighestlevel,asrankedbythisCMSperformancereviewprogram,anestimated235,378deathsand183,534adverseeventsresultinginpatientharmwouldhavebeenavoidedbetween2009and2011.ivEmergencymedicalcareischaracterizedbydifficultattributes:eventsareunscheduled,unpredictable,andoften-unplannedwithcaredeliveredinuncontrolledsettings.Criticalcaremedicineiscomplex,urgent,andresourceintensive,withroutineapplicationofhighconsequenceinterventionsbyhighly
iKohnL,CorriganJ,DonaldsonM,eds.ToErrorisHuman:BuildingaSaferHealthSystem.CommitteeonQualityofHealthcareinAmerica,InstituteofMedicine,NationalAcademyPress,WashingtonD.C.2000iiKohnL,CorriganJ,DonaldsonM,eds.ToErrorisHuman:BuildingaSaferHealthSystem.CommitteeonQualityofHealthcareinAmerica,InstituteofMedicine,NationalAcademyPress,WashingtonD.C.2000iiiJames,JT,ANewEvidence-basedEstimateofPatientHarmsAssociatedwithHospitalCare,JournalofPatientSafety:Sept2013;Vol.9,Issue3ivAmericanHospitalQualityOutcomes2013:HealthgradesReporttotheNation,November2013
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trainedprofessionalsroutinelypracticingunderdemandingconditions.Thebenefitsofmoderncriticalcaremedicineareunparalleled,andyetthesebenefitscomewithpotentialrisksandcosts.Becausetime-emergentandcriticalcareinterventionsoccuratthehighestlevelsofconsequenceinmedicalpractice,extraordinaryattentiontodetailinmaintainingthehigheststandardsofqualityandpatientsafetyiscrucial.Criticalcareresponseandtransportmedicinecreatesauniquesynergybetweentransportationandmedicine.Therapiddeploymentofexpertclinicianswithskills,knowledge,experience,andequipmentcanliterallybringtertiarycaretoapatient’sside,allowingimmediatestabilizationofcriticalinjuryorillness–whetheronthesideofaroadorinacommunitycriticalaccesshospitalfollowedbydirecttransporttoaspecialtycarecenter.Whileevidencedemonstratesthebenefitofthisuniquetetheringoftwodistincttechnologies,aswithallbenefitsinmedicine,theinterfacebetweenthetwosystemsiscomplex.Thecomplexityitselfincreasesopportunityforerror.Similarly,themedicaltransportenvironment,whetheronthegroundorintheair,isamongtheuniqueandcomplexofmedicalarenas.ThisisespeciallytrueofhelicopterEMSoperationswherelimitedplanningtime,criticalclinicalneed,24-houroperationsandmarginalweatherconditionscombinedwithlimitedweatherreporting,andanoverallhazardous,unstructuredenvironmentconvergeinonesetting.Thisscenariorequiresextraordinaryattentiontodetailinmaintaininghighqualityandsafeoperations.TheNationalTransportationSafetyBoard(NTSB),theFederalAviationAdministration(FAA),andstateregulatoryoversightagenciesallhavehighlightedtheneedtoimprovesafetywithinthemedicaltransportenvironment.Assuringpatientsafetyisthefirstandforemosttaskofmedicalproviders.Leadingmedicalproviderorganizationsandphysicianshaveestablishedaframeworkforeventsthatshouldalwaysoccurandsimultaneously,aframeworkofeventsthatshouldneveroccurduringpatientcare.Togethertheseimprovetheoverallsafetyofpatientsduringmedicaltransportation.Thefollowingsuggestionsshouldbeconsideredaninitialstepinthedevelopmentof“alwaysevents”and“neverevents”frameworksforcriticalcaretransportagencies.Itmaybehelpfultoconceptualizethemastwosidesofacoinindevelopingsystemsandmeasurementtoolstoimprovepatientsafety.TheworkgrouphasusedtheNationalQualityForum(NQF)formattodescribetheseevents.ThePickerInstituteforPatientandFamilyCenteredCare,andmorerecentlytheInstituteforHealthcareImprovement(IHI),developedtheconceptof“AlwaysEvents”which“refertoaspectsofthepatientexperiencethataresoimportanttopatientsandfamiliesthathealthcareprovidersmustperformthemconsistentlyforeverypatient,everytime.”vAlwayseventswithinthecontextofcriticalcaretransportcanbethoughtofaspositivebehaviorsandsafetypracticesinthemanagementofcriticallyillandinjuredpatients.
vPickerInstitute.AlwaysEvents:CreatinganOptimalPatientExperience.Oct.2011AvailablethroughtheInstituteforHealthcareImprovement
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“NeverEvents”werefirstintroducedbyDr.KenKizer,theformerCEOoftheNQF,tobetterunderstandandhighlighttheneedtoaddressparticularlyegregiousmedicalerrors,suchasawrongsitesurgery.TheNQFhasexpandedthelistovertimetoidentifyunambiguousadversemedicaleventsthatareclearlyidentifiable,measureable,andpreventable.NevereventsarealsooftendefinedasSeriousReportableEvents(SRE)bystateregulators,theJointCommission,andtheAgencyforHealthCareResearchandQuality.TheNQFandtheCentersforMedicareandMedicaid(CMS)publishedalistof“neverevents”measures.Thetwolistsoverlaponsomemeasures,butwhiletheNQFisfocusedonthepreventionofunambiguouspreventableharm,CMSisfocusedonpreventableoccurrencesdeemednon-reimbursablebyMedicaresuchasserioushospitalacquiredinfections.ThispaperdoesnotspeaktoMedicarereimbursement.Nevereventswithinthecontextofcriticalcaretransportincludenotonlyactualdocumentedharm,death,ordisabilitytopatientsincurredwhileunderthecareatransportagencybutalsoincludepreventableadverseoccurrenceswheretheriskofharmoractualharmtoapatientwasgreaterthananypossibleclinicallybeneficialoutcomeforthepatient.CCTNeverEventsshouldbeevaluatedbystateregulatorsandtheCommissionfortheAccreditationofMedicalTransportSystems(CAMTS)forinclusioninsentinelorSREregistries.
ACCTencouragescriticalcaretransportagencies(CCTAs)toadoptthesemeasuresandcontinuethedialogueforadditionalevidencedbasedmeasures.CCTAsneedtodevelopinternalregistryreportingsystemsforbothnearmissandadverseeventsandareencouragedtodeveloporworkwithpatientsafetyorganizations,whichcanaggregateandsharede-identifieddataforwiderhealthcarecommunitylearning.
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ALWAYSEVENTS PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance1. CareCoordinationand
TransitionIncludes:a) CCTteamassuranceof
obtainingwrittenrecordsvs.verbalreportpriortointerfacilitytransport
b) DevelopingwrittenSBARtypecommunicationsforreceivingclinicians
Thiseventisintendedtocapture:! Processesassurethatallnecessary
documentationrelatedtothecareofapatientisobtainedpriortotransportandtransmittedtoreceivingclinicians
Caretransitionhasbeendemonstratedtobeoneoftheleadingrisksforpatientsduetolossormissedcrucialhealthinformation,recordofinterventions,diagnostics,andresultsinatimelymanner.CCTAsmustdevelopreliableprocessestoassurethatcarecoordinationandtransitionisseamlessandthorough.
2. Physicalcomfort,painrelief,emotionalsupport,andalleviationoffearandanxiety
Includes:a) Administrationof
adequateanalgesiaincludingbasicpainrelieftechniquessuchaspositioningandgentlehandling
b) Processestoimprovetheexperienceofcare
c) Assuranceofenvironment(visual,temperature,light,humidity,soundprotections,etc.)thatprotectspatientfromsecondaryexposurestophysiologicoremotionalstressors
Thiseventisintendedtocapture:! Proceduresforalleviatingpatient
painandfearbecausetheonsetofasuddencriticalillnessorinjuryisoftenbewilderingandfrightening.Uncontrolledpainandstressreactionsincreasemorbidity.
Inthefastpaceofhightechhealthcareitispossibletoinadvertentlylose“hightouch.”CCTAsmustdeveloppromptprocessestomanagepainanddiscomfortadequately,includingholdingapatient’shands,speakingsoftly,movingabitmoreslowly,andintroducingcalmtochaos.Developingacultureandmeasurablegoalsofsupportingpatientsisasimportantasthroughput.Sometimes“fastisslowandslowisfast.”
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ALWAYSEVENTS PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance3. Preventinvasivelineor
woundinfections.Includes:a) Placementofany
invasiveintravenouslineorinvasivedevicesuchasendotrachealtubesorurinarycatheters
b) Managementofindwellingcathetersordevicesduringtransport
Excludes:a) Documentedprevious
communityhospitalacquiredinfection
Thiseventisintendedtocapture:! Processesandprocedurestoassure
withintherealitiesoftheCCTenvironmentthemoststerileconditionsfortheplacementofanyindwellingcatheteranddevice.
Althoughtruesteriletechniqueisnearlyimpossibleinthetransportenvironment,CCTAsmustdeveloptightlymanagedprocessesandcarenormstominimizetheriskofiatrogenicinfectionManagementduringCCTmustprotectindwellingcathetersanddevices.Whileitisnearlyimpossibletodocumenttherelationshipbetweenpoortechniqueinresuscitativeandtransportcareofsubsequentdocumentedhospitalacquiredinfection,thetimecriticalityandlackofabilitytoassureasterilefieldforinvasivecarepresentsenormousrisktopatients.CCTAsmustdevelopprocessesanddemonstratecommitmenttoculturalnormstomakesureofhandcleaning,adequateskinpreparation,andpreventionofinfectionisattheleadingedgeofcare.Preventionofdownstreaminfectionisasormoreimportantthansuccessinplacementofanindwellingdevice.
4. PreventVentilatorAcquiredPneumonia(VAP)
Includes:a) Managementof
ventilatedpatientsduringtransporttomaintaincleanlinessofairwayandpositioningofpatienttopreventVAPthroughstandardhospitalpractice
Excludes:a) Transportofpreviously
documentedVAP
Thiseventisintendedtocapture:! Processestoassureinfection
controlstrategiesforthecareofintubatedventilatedpatients.
Wheneverpossible,ventilatedpatientsshouldbetransportedina30-degreeheadraisedpositiontominimizeriskofventilator-associatedpneumonia.
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ALWAYSEVENTS CAREMANAGEMENTEvent AdditionalSpecifications ImplementationGuidance1. Respectforpatients’
values,preferences,andexpressedneeds.
Includes:a) Respectforpatientand
familiesreligiousandculturevalues
b) Involvementoffamilyandfriends
Excludes:a) Patientandfamily
decisionsthatimpactsafety(e.g.parentaccompanyingchildduringtransport).Theparentmaynotbeabletorideinthepatientcarecompartmentormaynotbeabletoaccompanythetransportifpresenceincreasessafetyrisk.
Thiseventisintendedtocapture:! Processestoinvolvepatientsand
familiesinthecareofacriticallyillandinjuredpatient.Byandlargepatientsandfamiliesinthemidstofanemergencydonotgetmanychoicesinhowcareisgoingtobedelivered
Cliniciansarefacedwithmakingtimesensitivedecisionswiththefocusonimmediatepatientcareneedsratherthanthefullexperienceofcare.
Caregiversneedtodevelopprocessestoimprovecommunicationsandtrust;tomakesuretheyhaveclearunderstandingofpatients’religiousbeliefsandculturevalues.Thisisespeciallyimportantinthecareofpatientswhospeakadifferentprimarylanguagethanthecaregivers,orwho,throughimmigrationorrefugeestatus,comefromverydifferentculturalnormsorwhohaveacommunicationbarriersuchaslimitedvisualacuity,hearing,previouslossoffunctioninalimb.
Asanexample,manytransportagencieshavepoliciesthatprohibitaparent,child,orfamilymembertoaccompanyapatientduringtransport.CCTAsmustdeveloppoliciesandprocessestoallowriskmanagedexceptionsoraplantomakesurethefamilymemberissupportedtotraveltoadistantreceivinghospital.
2. Preventpressureulcers Includes:a) Patientacquiredpressure
ulcersfromtransportonbackboardsorprolongedtransportonhardstretchersinnon-moving,generallysupinepositions
Excludes:a) Patientswithknown
unstableorthopedic/neurologicinjury
b) Previouslyacquiredpressureulcers
Thiseventisintendedtocapture:! Processestoassurethatpatientsare
protectedfromprolongedsupineorsinglepositionimmobilizationonhardsurfaces
CCTAsshoulddeveloppoliciesandprotocolstominimizetransportofpatientsonbackboards.Currentevidencedemonstratesincreasedriskofharmforpatientsthatareimmobilizedforevenrelativelyshortperiodsoftime(30minutes)versusanybenefitfromtheimmobilizationforpendingclearanceofasuspectedspineinjury.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)CAREMANAGEMENTEvent AdditionalSpecifications ImplementationGuidance1. Patientdeathordisability
causedbylossofsupplyofoxygenoranyincidentinwhichalinedesignatedforoxygenorothergastobedeliveredtothepatientcontainsthewronggasoriscontaminatedbytoxicsubstances.
Includes:a) Depletionofvehicle
oxygensuppliesb) Mechanicalmalfunctionof
oxygensupplysystemc) Inability of transport
crews to operate theoxygensystem
d) Inabilitytodeliveroxygenduetooxygendeliverysystemincompatibilitywithvehicleports
Excludes:a) Unanticipatedaddition
ofapatientduetounforeseencircumstances(e.g.,familymemberaccompanyingpatientontransportbecomesill)
b) Oxygensupplyanddeliverywithinareferringorreceivingfacility
c) Unavoidableoxygendepletionviaportabletanksatanout-of-hospitalscenewhereextendedscenetimeisnecessaryduetoenvironment/safety/logisticalneeds
Thiseventisintendedtocapture:! Occurrencesofunintendeddepletion
ornon-deliveryofoxygenconcentrationsnecessarytomaintainadequatepatientoxygenationduringthepatienttransportphaseofamedicaltransportmission
Propertransportplanningshouldbecompletedpriortoanypatienttransport.Thisplanningshouldincludepotentialoxygenneedsforanypatienttransportorpatientconditionchangeduringtransport.Ifmultiplepatienttransportsarewithinthemissionprofile,adequatesystemsandsuppliesmustbetakenintoconsideration.Replenishmentofoxygenatdesignatedfacilitiesmaybeplannedandrequiredaspartofthemission.Dailyshiftchecksandpreventativemaintenanceonoxygendeliverysystemsshouldassurethatoxygendepletionornon-deliverydoesnotoccurduetodevicemalfunction.Educationalrequirementsshouldassurethatallcrewmembersarecompetenttocompleteshiftchecks,operate,andappropriatelytroubleshootequipment.ACCTAmusthaveassurancethatvendorsourcesofgassupplyhaveeffectivesafetycomplianceprograms.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)CAREMANAGEMENTEvent AdditionalSpecifications ImplementationGuidance2. Deliveryofababyduring
thetransportlegofapatientencounter.
Includes:a) Accuratepatient
assessmentandmanagementofHROBandpre-termlabortoassuredeliveryinmostcontrolledcircumstance
Excludes:a) Acceptedresidualriskof
deliveryduringtransportafterconsultationwithattendingorconsultingOB/Perinatologists
Thiseventisintendedtocapture:! Occurrencesofunplanneddeliveryof
aninfantinamovingvehicleCCTAsmusthaveriskmatrixandconsultingcapabilitytoassessandmanageHROBtopreventinadvertentdeliveryduringtransportunlessknownabsolutepost-deliveryrisktoinfantoutweighsriskofdeliveryinmovingvehicle,especiallyaircraft.Ingeneral,itispreferabletodeliverachildinthemoststableenvironmentorreferringcommunityhospitalwithtransportteampresentforsupportandsecondaryNICUretrievalteam/equipmentasneededforsubsequentnewborntransport.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance1. Patientorpassengerdeath
orseriousdisabilitycausedbytheCCTAvehiclefailureorcrash
Includes:a) Vehiclecrashesor
failuresduetomechanicalreasonsorhumanerror
Excludes:a) Actsofterrorismby
entitiesoutsideoftheCCTA,patient,orpassengersscreenedbytheCCTA
b) ActsofGod(e.g.birdstrikes)
Thiseventisintendedtocapture:! Occurrenceswhereavehiclefailureor
crashcausedpatientorpassengerdeathordisabilitythroughdirectinjuryorthroughthedelayindeliverytodefinitivecare
TheprimarygoalofaCCTAistoprovidetheappropriatelevelofmedicalcarewhiledeliveringthepatientsafelytotheintendeddestination.Ifthevehiclefailsorcrashesduetomechanicalreasonsorhumanerror,theCCTAwasunabletoprovidetheintendedserviceoritprovidedadisservicetothepatient.
TheCCTAmustassurequalitymaintenanceandcompletedocumentationofmaintenanceofallvehiclesutilizedbypatients,passengers,andcrewmembers.
TheCCTAmustassurequalitymaintenanceandcompletedocumentationofmaintenanceofallvehiclesutilizedbypatients,passengers,andcrewmembers.
TheCCTAmustassurequalityinitialandrecurrentvehicleoperationandsafetyeducationandcompletedocumentationofthiseducationforcrewmemberstransportingpatientsorpassengers.
TheCCTAmustcreate,educate,andutilizepostincident/accidentprocessestorespondtovehiclefailuresorcrashes.Thepoliciesprimarilyshouldaddresspatientandcrewsafetyneedsandprovideoptionsfortransportingthepatientandanyotherinjuredpassengerstoappropriatemedicalcarewithminimaldelay.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance2. Patientdeathorserious
disabilitycausedbytransporttoanunintendeddestination
Includes:a) Unintendedpatient
transporttodestinationsthroughhumanerror
Excludes:a) Specificdestinations
withinareceivingfacility(e.g.emergencydepartment,catheterizationlab,andcriticalcareunit)
b) Diversionsduetohospital/physicianorders,patientcondition,weather,oranyothersafetyissuenecessitatingadiversionfromtheplanneddestination
Thiseventisintendedtocapture:! Occurrenceswherethe
transportingprogramunintentionallytransportsapatienttoanunintendeddestinationthroughhumanerrorincommunication,navigation,orothermeans
TheprimarygoaltheCCTAistoprovidetheappropriatelevelofmedicalcarewhiledeliveringthepatientsafelytotheintendeddestination.Appropriateandexpedientmedicalcareatthedestinationfacilitycanhaveasignificanteffectonpatientoutcomes.Unintendedtransporttootherfacilitiesmaycausedelaystodefinitivecareandlesserordeficientmedicalcapabilitiesmaycreateanegativepatientoutcome.
3. Patientdeathorseriousdisabilitycausedbydroppingapatientorallowingapatienttofallduringthetransportprocess
Includes:a) Patientfallswhileunder
thecareoftransportcrews,droppingofpatientsbeingcarriedortransportbyadevice(stairchair,wheelchair,Stokesbasket,stretcher,backboard,loadingramps,harnesses,oranyotherapproved/unapproveddevice)
Thiseventisintendedtocapture:! Occurrenceswhereapatient
receivesunintendedtraumadirectlyresultingfromthetransportprocess
TheprimarygoaloftheCCTAistoprovidetheappropriatelevelofmedicalcarewhiledeliveringthepatientsafelytotheintendeddestination.ThoughCCTAprovidersofferpatientcareandtransportinavarietyofchallengingenvironments,itisexpectedCCTA’swillhavetheresources,equipment,andknowledgetooperateinthoseenvironmentsandbeabletotransportpatientswithoutfalls,drops,orotherunintendedinjury.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance4. Deathorseriousdisability
toEMSpersonnelorpatientcausedbyfailureoftheCCTAtocommunicateaninitialestimatedtimeofarrivaltothesceneorsubsequentdelaysofthetransportresponse
Includes:a) Communicationof
theinitialestimatedtimeofarrival(ETA)
b) Communicationofallexpectedorunexpecteddelaysinresponse
Excludes:a) Documented
communicationdelaysorerrorsbytherequestingEMSagencyorhealthcarefacility
Thiseventisintendedtocapture:! Occurrenceswheredelaysinpatient
transportorscenehazardsoccurduetothelackofcommunicatingresponsedelaysbytheCCTA
CCTAresourcesarerequestedtoprovidepatienttransporttodefinitivecareforinjuriesorillness.Responsedelaysmayimpactoperational/safetyissuesonsceneaswellaspatienttreatmentplans.ItisimperativethatCCTAproviderscommunicateanddocumenttheinitialestimatedtimeofarrivalofthemedicalresourceonthesceneoftherequest.Ifdelaysareexpectedoroccurunexpectedly,CCTAmustcommunicatethesedelaysassoonaspossibletotherequestingagencies.CCTAdelayssuchas“stackingcalls”shouldnotoccur.
Definition:Delayissubjecttoavarietyoffactorssuchasresponsemode,distance,andpatientcondition.Forthispurposedelayisdefinedasatimeframethatwillhaveanegativeimpactonscenesafetyoperationsorpatientcare.ItisessentialthattheCCTAconsiderthesefactorsandcommunicateanydelaythatmayimpactsafetyorcare.
5. Transportofapatientwithanundetectedesophagealintubation,patientdeathordisabilitycausedbylossofoxygen/hypoxia
Includes:a) Unrecognizedmissed
placementofanendotrachealtube
b) Unrecognizeddislodgementofanendotrachealtube
Thiseventisintendedtocapture:! Initialandrecurrentprocessesand
documentationsystemsforCCTAs;providerdirectobservation;physicalexam,andcontinuouswaveformend-tidalCO2monitoringtopreventundetectedmissedintubation
CCTAsmusthaveprocessesanddocumentationsystemstoverifycontinuedpropertubepositionduringtransportateveryphysicalmovementofpatientalongwithtimedobservations.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance6. Arrivalatthewrong
sendinglocationforeitherasceneresponseorinterfacilitytransport
Includes:a) Missedorfaulty
dispatchinformationgatheringresultingindelaysincareandtransport
Excludes:a) Documentedlocation
errorsbyrequestingagencies(e.g.,referringproviderprovidedwrongcoordinatesoraddress)
Thiseventisintendedtocapture:! Accuracyindispatchincluding
redundantsystemstocheckcoordinates;developknownlandingzones(LZ)/rendezvouspoints,andhospitalnames
CCTAsmusthaveprocessesandcrosscheckstoassureclearidentifiersandcoordinatesareprovidedtopilots/driverstoassurethattransportunitsarriveatthecorrectLZ/rendezvouspointorhospitalespeciallyincommunitieswithmultiplehospitalsorLZs.
7. Patientdeathorseriousdisabilitycausedorassociatedwithhypoglycemia,theonsetofwhichoccursduringtransport
Includes:a) Failuretotestor
documenthypoglycemiaimmediatelypriororduringtransport
b) Failuretocorrecthypoglycemiaduringtransport
Excludes:a) Continuedhypoglycemia
despiteintervention
Thiseventisintendedtocapture:Inadvertentandmissedrecognition,testing,anddocumentationofhypoglycemiaduringtransport
Neonatesandpediatricpatientsduetohighmetabolicdemandareparticularlyatriskforpooroutcomessecondarytomissedhypoglycemia.
8. Knowinglycausingpatientdeathordisabilityassociatedwithamedicationerror
Includeserrors:a) Wrongmedicationb) Wrongdosec) Wrongpatientd) Wrongtiminge) Wrongratef) Wrongpreparationg) Wrongrouteof
administrationh) Deliveryofpressorby
meansotherthaninfusionpump.
i) Administrationofknownorpotentiallyknownadulteratedorcontaminatedmedication
Excludes:a) Administrationof
medicationinwhichadulteration,mislabeledconcentration,orcontaminationwasunknowablebycaregiver.
Thiseventisintendedtocapture:! Occurrencesofpreventable
medicationerrorsCCTAsmusthavesystemsandculturalnormsinplacetopreventknownrecurrentcommonmedicationerrors.
CCTAsmusthavesystemstoaccuratelycalculatedosinganddeliverinfusionmedications.
CCTAsshouldhavesystemsandculturalnormstodocumentcrosscheckingbysecondcaregiverorothersystempriortoadministration.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance9. Knowinglycausingapatient
deathordisabilityassociatedwithhemolyticreactionduetotheadministrationofABO/HLA-incompatiblebloodorbloodproducts
Includes:a) Failuretoaccurately
identifypatientandbloodproductcompatibilitypriortoadministration
b) Failuretoquicklyrecognizeandinterveneinpatientwithsuspectedoridentifiedhemolyticreaction
c) Administrationofbloodthathasexceededsafestoragetemperatures
Thiseventisintendedtocapture:! Occurrencesinwhichprovidersdo
notfollowandordocumentstandardproceduresinadministrationofbloodproducts
CCTAsmusthaveprocessesanddocumentationsystemstomonitorsafetyofbloodproductstorage,compatibility,andknownpatientincompatibilitywithbloodproducts.
IncreasingnumbersofCCTAsarestockingbloodproductsfortransport.Carefulmonitoringofon-siteandtransportstoragesystemsisessentialforpatientsafety.
10. Knowinglycausedeathorseriousdisabilityassociatedwiththeuseofcontaminatedorinoperabledevices,useofdeviceforpurposeotherthanapproved,contaminateddrugs,orbiologics
Includes:a) Useofadevice,
instrument,ormedicationfornonFDAapprovedpurpose
b) Knownorpoorprocesscontrolleadingtouseofcontaminateddeviceormedication
Excludes:a) Adversepatient
occurrenceoroutcomeduetoinadvertentuseofunknowablecontaminatedorinoperabledevice.
b) Adversepatientoccurrenceoroutcomeduetoinadvertentuseofunknowablecontaminatedmedicationorbiologic
Thiseventisintendedtocapture:! Occurrencesofpatientharmdueto
misapplicationorfailuretohavesysteminplacetoassuresafetyofdevices,medications,andbiologics
CCTAsmusthaveprocessesandsystemsinplacetoassuresterilizationofequipmentifnon-singlepatientuse,andsystemstopreventinadvertentorknownuseofadeviceormedicationfornon-prescribedorapprovedusewithoutcarefulanddocumentedmedicaloversight.CCTAsmustprovideassuranceofpurchaseandstoragesystemstomaintainmedicationsanddevicesinaccordancewithmanufacturers'specificationsincludingtemperature,humidity,light,controlsandpackagingsterility,asapplicable.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)PATIENTPROTECTIONEvent AdditionalSpecifications ImplementationGuidance11. Patientdeathorserious
disabilitycausedbyimpairmentofmedicalprovider
Includes:a) Workingunderthe
influenceofintoxicatingmedications,drugs,oralcohol
b) Workingundertheinfluenceofaprescribedmedicationwithoutsupervisionbyagencymedicaldirectorandpersonalprimarycarephysician
c) Workingundertheinfluenceofanover-the-counter(OTC)medicationwithknownsideeffectsthatmightimpairprovider,i.e.,Benadrylcausingdrowsiness
d) Workinginafatiguestatethatimpairsjudgmentorcoordination
Thiseventisintendedtocapture:! Occurrencesinwhichanimpaired
providerisallowedorundertakespatientcare
CCTAsmusthavemeansforcrewtocheckthemselvesandeachotherforpotentialriskstopatientscausedbyknownorinadvertentimpairment.Asprovidersmayhavedutyconflicttocometoworkwithmildillness,fatigue,withorwithoutanOTC,CCTAsmusthaveajustculturesystemtoassistproviderswithalternativedutiesiftheyself-checkandidentifythattheymightbeunabletoperformtasksinsafemanner.
12. Patientdeathorpermanentdisabilitycausedbylackoftemperatureprotectionwithresultinghypoorhyperthermia
Includes:a) Knownexposureof
patienttoprolongedtemperatureextremeswithidentifiableriskofpatientharm,suchasposttraumahypothermia
b) Transportinvehiclewithoutadequateenvironmentalcontrolunitduringextremetemperatureconditions
Excludes:a) Rescueconditionsin
whichneedforextricationislessrisk/higherbenefitandoutweighsthermalprotectionofpatientduringrescue.
Thiseventisintendedtocapture:! Failuretoprovideathermally
controlledenvironmenttoapatientatriskofadverseoutcomeduetocombinationofinjury/illnessandambienttemperaturewhetherextremeofcoldorhot
FailureofCCTAtohaveenvironmentallycontrolledvehicleswithknownandexpectedextremeoftemperaturecondition,i.e.,failuretoprovideairconditioninginvehicleinclimatewithdocumentedtemperaturesinexcessof95Fforaverage>15daysperyearorfailuretoprovideadequateorfunctioningheatinginnorthernclimatewintermonths.
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NEVEREVENTS:SERIOUSREPORTABLEEVENTS(SRE)SYSTEMEVENT Event AdditionalSpecifications ImplementationGuidance1. Respondwithouta
formalrequestIncludes:a) Anyfreelance
responsestopotentialpatienttransports
Excludes:a) TheCCTAthat
participatesinauto-response/standbyresponsesaspartofacoordinated,integratedandpublishedpolicydevelopedincooperationwithlocal/regionalrequestingagencies
b) InstanceswhentheCCTAcrewhappensuponthesceneofanEMSneedandinitiallyactsasafirstresponder,notifyingthepublicserviceanswerpoint(PSAP)toactivatestandardresponseprotocolforthatlocation
Thiseventisintendedtocapture:! OccurrenceswhereaCCTAself-
dispatchesresourcestoscenesorhealthcarefacilitieswithoutaformalrequestfromorcoordinationwithpersonnelonscene.
TheutilizationofCCTAresourcesarecoordinatedeventsbetweentheCCTA,PSAPS,dispatchcenters,otherrespondingEMSresources,andhospitals.FreelanceresponsestopotentialpatienttransportsbyCCTAresourcescanjeopardizecoordinationeffortsaswellasimpactcrewandpatientsafety.TheremustbeaformalrequestofservicetorespondwithCCTAresources.
2. Knowinglymisrepresentinginformationinamedicalrecord,whetherbyfalsification,obfuscation,oromissionofinformation
Includes:a) Purposefulinaccurateor
misseddocumentationenteredinapatientrecord
b) Posttransporteditofpatientcarerecordtocoveruporchangepotentialerrorinpatientcare.
Thiseventisintendedtocapture:! Occurrencesinwhichproviders
purposefullyhideerrororadversepatientevent
! Occurrenceswhereproviderspurposefullyomitpertinentpatientinformationwithresultantadverseriskorharmtopatient.
CCTAsmusthaveareliableandthoroughpatientcaredocumentationsystemthathasthemeanstoidentifypostrecordcompletionedits.
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Appendix6:RecommendedSafetyMetricsforCriticalCareTransportBackgroundIn2006,theNationalAcademyofSciencesInstituteofMedicine’s(IOM)three-partlandmarkemergencycarereporthighlightedmultiplechallengesintheemergencycaresystem.TheEMSMedicalServices:attheCrossroadsreportnotingthataccountabilityhas“failedtotakehold”intheEMSsystem,callingforthedevelopmentofsystemperformanceindicatorsthat“includestructureandprocessmeasures,butevolvetowardoutcomemeasuresovertime.Theseperformancemeasuresshouldbenationallystandardizedsothatstatewideandnationalcomparisonscanbemade.Measuresshouldevaluatetheperformanceofindividualcomponentsofthesystem,aswellastheperformanceofthesystemasawhole.Measuresshouldalsobesensitivetotheinterdependenceofthesecomponents.”viWhilethereisearlyprogressandorganizationsuchastheAmericanAcademyofPediatrics(AAP)andtheAirMedicalPhysicianAssociation(AMPA)havedevelopedvoluntarymeasurementstandardsandshareddatabases,thereisalsocontinuinglackofagreementondefinitions,standards,andmetricsforcareleadingtowidevariabilityofpracticethroughouttheEMSsystem.Unfortunately,astheIOMpapernotesthisis“anurgentproblemofunknownscope”becausenonationallyagreedupondatasetorreportingcenterforadverseeventsexists.WhilethepublicandhealthcareprovidersperceivethatCriticalCareTransport(CCT)agencies,providers,andvehiclesareessentiallyallthesame,thereisasubstantialgapbetweenrealityandperception.Essentialtoimprovementistheattentionthatmustbepaidtounderlyingcontinuedproblemsinpatientsafety.Recognizingtheneedtoimproveout-of-hospitalcare,theFederalInteragencyCommitteeforEMSandtheNationalEMSAdvisoryCouncilthroughtheNationalHighwayTrafficSafetyAdministration(NHTSA)andtheEMSforChildren’sDivisionoftheU.S.HealthResourcesandServicesAdministrationengagedtheAmericanCollegeofEmergencyPhysicians(ACEP)todevelopanationalstrategytoimprovethecultureofsafetyinEMS.viiSignificantly,thewhitepaper,aNationalEMSCultureofSafetyusedrecentworkfromtheUniversityofPittsburghtodefineanadverseeventinEMSas“aharmfulorpotentiallyharmfuleventduringthecontinuumofEMScarethatpotentiallypreventableandthusindependentoftheprogressionofthepatient’scondition.”viii
viNationalAcademyofSciences/InstituteofMedicine:EmergencyMedicalServices:attheCrossroads.ISBN:0-309-66216-8,(2006)viiwww.emscultureofsafety.org/wp-content/uploads/2013/10/Strategy-for-a-National-EMS-Culture-of-Safety-10-03-13.pdfviiiPattersonPD,WeaverMD,AbebeK,Martin-GillC,etal.Identificationofadverseeventsingroundtransportemergencymedicalservices.AmJMedQual.2012Mar-Apr;27(2):139-46
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Achievingasaferandhigherqualitysystemisanenormouschallengethatwilltakeconcentratedeffortsbyeveryhealthcarestakeholder,policymaker,regulator,purchaser,aswellasthepublicandindividualpatientsandfamilies.Appropriatelyused,transportmedicinecanactasanintegratorofcareduetoitsmultiplejurisdictionalreach.ACCTmembersrecognizetheyhavebeenentrustedtoprovidehighqualitycriticalcaretotheirpatientsandthatiswhyACCTworkstoleadtheefforttocreateabettersystem.BuildingontheworkoftheNationalQualityForum(NQF)andtheInstituteforHealthcareImprovement(IHI),andconcurrentwithworkbytheAAPandAMPA,ACCThasdevelopedand/orconcurredwithaseriesofinitialcoremeasurestoimprovethequalityofcareandsafetyofpatientsinthecontinuumofcare.ThegoalsarealignedwithIHI“TripleAim”frameworktooptimizehealthsystemperformance:
! Improvingthepatientexperienceofcare(includingquality,safety,andsatisfaction);! Improvingthehealthofpopulations;and! Reducingthepercapitacostofhealthcare.
ACCT’sinitialcoremeasures,enumeratedinthissectionarepatientsafetyfocusedandareinspiredbytheJointCommissionontheAccreditationofHospitalOrganization(JCAHO)SentinelEventPolicyadoptedin1996.ixACCTbelievesthatitisimperativeforeveryCCTAtotrackthesebasicpatientsafetyeventmeasuresforthepurposeofinitiatingcontinuousqualityimprovementactivities.Developingameansofreportingthesemetricstoaprotected,nationwidedatabaseforthepurposeofmeasuringthequalityandsafetyoftheCCTindustryisafoundationalgoalofACCT.Inaddition,thisdatabasecouldallowparticipantstocomparetheirqualityandsafetymetricsagainsttheindustryforthepurposeoftargetingandprioritizingperformanceimprovementprojects.Movingforward,withtheinputofmembersandaffiliateassociations,ACCTaimstoreleaseadditionalclinicalperformancemeasuresbeyondthisinitialsetapplicabletoCCT.Theseshouldnotbeconsideredcriticalcareaccreditationstandardsormandatorydatareportingdatapointsfortheindustry.ACCT’sgoalistoaidstakeholdersinrecognizingthedistinctionbetweencriticalcaretransportperformancemeasuresversusevaluationsusedforothermodesofpatienttransport,alongwiththeassociatedhighstandardsandqualityofcareprovidedtoCCTpatients.
ixhttps://www.jointcommission.org/sentinel_event_policy_and_procedures/
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1 Domain:PatientSafety ClinicalArea:AllMeasureName:PatientSafetyIncidentsDescription:Anevent,incident,orconditionthatcouldhaveresultedordidresultinharmtoapatient.Apatientsafetyincidentcanbe,butisnotnecessarily,theresultofadefectivesystemorprocessdesign,asystembreakdown,equipmentfailure,orhumanerror.ASentinelEventisasubsetofpatientsafetyincidents.Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedPatientSafetyIncidentsDenominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingcondition,adversedrugreactionsorknowncomplicationsthatmayresultfromaprocedureortreatmentExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined2 Domain:PatientSafety ClinicalArea:AllMeasureName:PatientSafetySentinelEventsDescription:Apatientsafetyincidentthatreachesapatientandresultsinanyofthefollowing:death,permanentharm,severetemporaryharm.Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedPatientSafetySentinelEventsDenominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingcondition,adversedrugreactionsorknowncomplicationsthatmayresultfromaprocedureortreatmentExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined3 Domain:PatientSafety ClinicalArea: RespiratoryMeasureName:Transport-RelatedHypoxiaDescription:Patientsexperiencingadequateoxygenation(>90%SpO2)preandpostCCTbutexperiencehypoxia(<90%SpO2)duringCCTdocumentedpulseoximetryreadingbeginsat,orisresuscitatedto,90%orgreaterandsubsequentlydeclinestobelow90%.Multipleincidentswithonepatientareconsideredasoneincident.Measure:Incidentsper1,000patientcontactsNumerator:NumberofpatientcontactsduringwhichthehypoxiaoccurredDenominator:NumberofpatientcontactswhereSpO2was>90%priortoCCTassumingcareExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesencounterswheretheSpO2isneveratorabove90%,eitherbydesign,bychronichealthstate,orbycurrentphysiologyGoal:Tobedetermined4 Domain:PatientSafety ClinicalArea:Medical/TraumaBleedingMeasureName:BloodProduct/TransfusionErrorsandAdverseReactionsDescription:ThefollowingoccurredduringCCTteamadministrationofbloodproducts:
! Administeredincorrectly! Adversetransfusionreaction! Expired/deterioratedproduct! WrongABORhtype
! WrongIVfluidadministeredwithproduct! Wrongnumberofunits! Wrongpatient,rate,time,oruseofproduct! Failuretorecognizeorrespondappropriatelyto
transfusionreactionMeasure:Occurrencesper1000unitsofbloodproductsadministeredNumerator:NumberofCCT-relatedblood/transfusionincidentsoreventsDenominator:NumberofunitsofbloodproductsinitiatedbyCCTcrewExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined
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5 Domain:PatientSafety ClinicalArea: Environment/EquipmentMeasureName:Environmental/EquipmentConditionsDescription:Anypatientincidentoreventcausedbythefollowingequipmentconditions:
! Contaminated! Failure! Functionedorusedotherthanasintended! Unavailable/missing! Operatedincorrectly! Unintendedhypo/hyperthermia
Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedEnvironmental/Equipmentincidentsorevents(maybemorethanoneperpatientcontact)Denominator:NumberofpatientcontactsExclusions:Excludesoccasionswhereequipmentisassessedasfailed,contaminated,orunavailableunrelatedtoapatienttransport(i.e.duringadailyequipmentcheck)Goal:Tobedetermined6 Domain:PatientSafety ClinicalArea:Environmental-NeonateMeasureName:UnintendedNeonatalHypothermiaDescription:Infants(<29daysold)withoutsignificanthypothermiapriortoCCTwithadmissiontemperatureslessthan36.5oCaxillaryatdestination.Measure:Incidentsper1000patientcontactsNumerator:NumberofinfantsfoundhypothermicDenominator:NumberoftransportedneonatepatientsnotmeetingexclusioncriteriaExclusions:Excludesintentionalcooling(i.e.therapeutichypothermia)andpatientswithprofoundhypothermiapriortotransportGoal:Tobedetermined7 Domain:PatientSafety ClinicalArea:PatientMovementMeasureName:PatientFalls/DropsDescription:WhileinthecareoftheCCTteamthepatientexperiences:
! Allpatientfallsordroppingofpatients! Droppingequipmentontopatientcausingpain,skinintegrityimpairment,bruisingorfracture
Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedpatientfalls/drops(maybemorethanoneperpatientcontact)Denominator:NumberofpatientcontactsExclusions:ExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined8 Domain:PatientSafety ClinicalArea:VascularAccessMeasureName:Infiltration/VascularAccessRelatedDescription:Medicationinfiltrations(asinfusionsorIVpushmedications)viaperipheralinsertedcentralcatheter,centralvenouscatheter,peripheralintravenousline,intrathecal,orintraosseouslineMeasure:Occurrencesper1000medicationadministrationsviaincludedroutesNumerator:NumberofCCT-relatedinfiltration/vascularaccessrelatedincidentsoreventsDenominator:NumberofdruginfusionsviavascularaccessinitiatedbyCCTcrewsduringpatientcontactExclusions:ExcludesincidentsthatwereinitiatedreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined
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9 Domain:PatientSafety ClinicalArea:TherapeuticDevicesMeasureName:Unplannedremoval/dislodgementoftherapeuticdeviceDescription:UnplanneddislodgementsoftherapeuticdevicesthatwereinplacewhenCCTassumesprimarycareofthepatientthroughhandoffofcareatdestination.Therapeuticdevicesinclude,butarenotlimitedtothefollowing:peripheralIV,intraosseousline,UAC/UVC,centralvenouscatheters,arteriallines,advancedairway,tracheostomytubes,chesttubes,urinarycatheters,epicardialwires,surgicaldrains,G-tubes,J-tubes,etc.Measure:Occurrencesper1000patientcontactswhereapplicabledeviceswereinplacepriortotransferofcaretoCCTprovidersorwereinsertedbyCCTprovidersNumerator:Numberofunplannedremovals/dislodgementsoftherapeuticdevices(maybemorethan1perpatientcontact)Denominator:NumberofpatientcontactswheretherapeuticdeviceswereinplaceduringcareofCCTteamExclusions:Doesnotincludeintendedremovalofanydeviceduetomalfunctionormisplacementorduetoimprovingdevice(e.g.,removalofsupraglotticairwaywithsignificantairleaktoplaceanendotrachealtube)Goal:Tobedetermined10 Domain:PatientSafety ClinicalArea:CareManagementMeasureName:CareManagementDescription:ThroughmedicaldirectorreviewofCCTs,notificationfrominvolvedmedicalfacilities,orself-reportatleastoneofthefollowingincidentsarediscovered:
! Delayintreatment! Wrongtreatment! Omittedtreatment! Incorrectresponsetoresuscitationstatus! Infectionintroduction! Intravascularairembolism
Measure:Incidentsper1000patientcontactsNumerator:NumberofCCT-relatedmanagementofcareincidentsoreventsDenominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingcondition,adversedrugreactionsorknowncomplicationsthatmayresultfromaprocedureortreatmentExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined11 Domain:PatientSafety ClinicalArea:MedicationAdministrationMeasureName:MedicationAdministrationDescription:IncludesmedicationsadministeredbyCCTteamwhereatleastoneofthefollowincidentsoccurred:
! Wrongdose/quantity! Drug-druginteraction! Expiredmedicationadministered! MedicationincompatibilitywithIVfluids! Wrongconcentration! Wrongmedication:knownallergy! Wrongmedforclinicalcondition! Wrongpatient,rate,routeortime
Measure:Occurrencesper1000medicationsadministeredNumerator:NumberofCCT-relatedmedicationadministrationincidentsoreventsDenominator:NumberofmedicationadministrationsinitiatedbyCCTcrewsduringpatientcontactExclusions:Excludespreviouslyunknownorunavailablemedicationallergyinformation(e.g.,unknownandunresponsivepatientwithnofamilypresent)ExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined
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12 Domain:PatientSafety ClinicalArea:SkinIntegrityMeasureName:Pressureulcers/skinintegrityDescription:AnyofthefollowingskinintegrityimpairmentsresultingfromCCT:
! Pressureulcers! Tears! Abrasions! Lacerations! Burns
Measure:Occurrencesper1000patientcontactsNumerator:NumberofCCT-relatedskinintegrityincidentsorevents(maybemorethanoneperpatientcontact)Denominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined13 Domain:PatientSafety ClinicalArea:PatientSafety/SecurityMeasureName: Safety/SecurityDescription:AnyofthefollowingoccurringduringorrelatedtotheCCTprocess:
! Vehiclecrash! Improperornon-useofpatientrestraintsystems! Disappearance/elopement! Homicide! Improperbiohazarddisposal! Physicalassaultofpatientorstaff! Self-inflictedharm! Sexualmisconduct–abuseorassault! Suicide/attemptedsuicide
Measure:Occurrencesper1,000patientcontactsNumerator:NumberofCCT-relatedsafety/securityincidentsoreventsDenominator:NumberofpatientcontactsExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined14 Domain:PatientSafety ClinicalArea: ProceduresMeasureName:Surgical/InvasiveProceduresDescription:AnyofthefollowingincidentsresultingfromCCT:
! Anesthesia/induction-related! Wrongside/site! Sitecontamination! Unexpectedadversedeathduring/within24hours! Unexpectedinjury/complication/seriousdisability! Wrongpatient
Measure:Occurrencesper1000surgical/invasiveproceduresNumerator:NumberofCCT-relatedsurgical/invasiveprocedureincidentsorevents(maybemorethanoneperpatientcontact)Denominator:Numberofsurgical/invasiveproceduresinitiatedbyCCTcrewsduringpatientcontactExclusions:Excludesissuesrelatedtothenaturalcourseofthepatient’sillnessorunderlyingconditionExcludesincidentsthatwereinitiatedbyreferringorreceivingfacilitiesoutsidethecontroloftheCCTcrewsGoal:Tobedetermined
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Appendix7:ReferencesReferences
1. InitialCCRNCertification.AlisoViejo,CA:AmericanAssociationofCriticalCareNurses;2013.http://www.aacn.org/wd/certifications/content/initial-ccrn-certification.pcms?menu=certification#Initial_Eligibility_Requirements.AccessedSeptember9,2013.
2. Guideforinter-facilitypatienttransport.Washington,DC:NationalHighwayTrafficSafetyAdministration;April2006.http://www.nhtsa.gov/people/injury/ems/interfacility/images/interfacility.pdAccessedSeptember9,2013.
3. EmergencyMedicalServicesEligibilityCriteriaforCertification.EastLansing,MI:AmericanBoardofEmergencyMedicine;April2011.http://www.naemsp.org/Documents/EMSEligCriteriaFINALApril2011.pdfAccessedSeptember9,2013.
4. CertificationinformationforoperatingunderPart135.Washington,DC:FederalAviationAdministration.http://www.faa.gov/licenses_certificates/airline_certification/media/n135toc.pdfAccessedSeptember9,2013.
5. Nursing:ScopeandStandardsofPractice,secondedition.AmericanNursesAssociation;August2010.
6. Fairman,J.,Rowe,J.,Hassmiller,S.,&Shalala,D.BroadeningtheScopeofNursingPractice.NEnglJMed.2011;364:193-196.
7. ClinicalandPracticeManagement.Irving,TX:AmericanCollegeofEmergencyPhysicians;2013.http://www.acep.org/content.aspx?id=30466AccessedSeptember9,2013.
8. NationalEMSScopeofPracticeModel.Washington,DC:NationalHighwayTrafficSafetyAdministration;February2007.http://www.nhtsa.gov/people/injury/ems/EdAgenda/final/agenda6-00.htm.AccessedFebruary12,2013.
9. CriticalCare.Bethesda,MD:U.S.NationalLibraryofMedicine,U.S.DepartmentofHealthandHumanServices,NationalInstituteofHealth;April30,2013.http://www.nlm.nih.gov/medlineplus/criticalcare.htmlAccessedMay22,2013.
10. AlisoViejo,CA,AboutCriticalCareNursing;AmericanAssociationofCriticalCareNurses;2013.http://www.aacn.org/wd/pressroom/content/aboutcriticalcarenursing.pcms?menuAccessedFebruary21,2013.
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13. CriticalCareParamedicPositionStatement.Snellville,GA:InternationalAssociationofFlightParamedic;July2009http://c.ymcdn.com/sites/iafccp.site-ym.com/resource/resmgr/docs/critical_care_paramedic_posi.pdf?hhSearchTerms=%22critical+and+care+and+paramedic+and+position+and+statement%22AccessedFebruary21,2013.
14. Pub100-04MedicareClaimsProcessing,Transmittal1548.Washington,DC:CentersforMedicare&MedicaidServices;July9,2008https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1548CP.pdfAccessedFebruary21,2013.
15. Careofthepatientduringinterfacilitytransfer.DesPlaines,IL:EmergencyNursesAssociation;September2010http://tinyurl.com/zryzu3aAccessedSeptember27,2016.
16. AccreditationStandards,9thedition.SandySprings,SC:CommissiononAccreditationofMedicalTransportSystem;2012.
17. GuidelinesforAirandGroundTransportationofPediatricPatients.AmericanAcademyofPediatrics.Pediatrics1986;78;943
18. PediatricSpecializedTransportTeamsAreAssociatedwithImprovedOutcomes.AmericanAcademyofPediatrics.Pediatrics2009;124;40DOI:10.1542/peds.2008-0515
19. PediatricInterhospitalCriticalCareTransport:ConsensusofaNationalLeadershipConference.AmericanAcademyofPediatrics.Pediatrics1991;88;696
20. SpeedIsn'tEverythinginPediatricMedicalTransport.AmericanAcademyofPediatrics.Pediatrics2009;124;381DOI:10.1542/peds.2008-3596
21. ConsensusReportforRegionalizationofServicesforCriticallyIllorInjuredChildren.AmericanAcademyofPediatricsCommitteeonPediatricEmergencyMedicine;PediatricSectionAmericanCollegeofCriticalMedicineandSocietyofCriticalCareMedicine;PediatricSection,TaskForceRegionalizationofPediatricCriticalCare;2000;105;152
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10.1056/NEJMc101389527. MichiganSystemProtocolsInter-facilityPatientTransfersCriticalCarePatient
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39. PatientFirstAir-AmbulanceAlliance.PositionPaper:PayforPerformance:CoreMeasures/NeverEvents.June2009
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Appendix8:Definitions&AcronymsAAP:AmericanAcademyofPediatricsACLS:AdvancedCardiacLifeSupportAHA:AmericanHeartAssociationAMPA:AirMedicalPhysiciansAssociationAPRN:AdvancedPracticeRegisteredNurseBCLS:BasicCardiacLifeSupportCAMTS:CommissiononAccreditationofMedicalTransportSystemsCCP-C:CriticalCareParamedic-CertifiedCCT:CriticalCareTransportCCTA:CriticalCareTransportAgencyCCTV:CriticalCareTransportVehicleCFRN:CertifiedFlightRegisteredNurseCNPT:CertifiedNeonatalPediatricTransportCriticalCareTransport:Theprovisionofmedicalcarebyacriticalcareteamtoapatientrequiringcriticalcaretransportbyacriticalcaretransportagencysuchthatthefailuretoinitiateonanurgentbasis,ormaintainduringtransport,acutemedicalinterventions,pharmacologicalinterventions,ortechnologieswouldlikelyresultinsudden,clinicallysignificantorlifethreateningdeteriorationinthepatient’scondition.
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CriticalCareTransportAgency:Anorganizationlicensedestablishedtoprovidecriticalcaretransportbetweenhospitals.CriticalTransportProvider:Caregiverwhombyevidenceofeducation,training,licensure,applicableexperience,certification,andcredentialingisabletoprovideacutemedicalinterventions,pharmacology,andtechnicallifesupportsystemsexceedingthoseabletobeprovidedbythenationalscopeofpracticeofaparamedicascurrentlydefinedbyNationalHighwayTrafficSafetyAdministration’s(NHTSA)NationalEMSScopeofPracticeModel,DOTHS810657,February2007.CTRN:CertifiedTransportRegisteredNurseCriticalCareTransportSpecialist:Acriticalcaretransportproviderhasachievedmasteryoftheentry-leveltransportproviderrequirementsanddemonstratesstrongknowledge,applicationandcriticalthinkinginthecriticalcaretransportenvironment.CriticalCareTransportspecialistswillhaveobtainedaminimumnumberorcriticalcaretransporthoursandhavecertificationincriticalcaretransport.CriticalCareTransportTeam:Criticalcaretransportservicesaredeliveredbyacriticalcaretransportteamwiththerequisitedecisionmakingskillsofhighcomplexitytoassess,manipulate,andsupportvitalorgansystemfailureand/ortopreventfurtherlifethreateningdeteriorationofthepatient’sconditionduringtransport.ECMO:ExtracorporealMembraneOxygenationEURAMI:EuropeanAero-MedicalInstituteFP-C:FlightParamedicCertifiedHROB:HighRiskObstetricalILCOR:InternationalLiaisonCommitteeonResuscitationIntensiveCareUnit:Anintensivecareunitinwhichconcentratedspecialequipmentandskilledpersonnelareavailableforthecareofseriouslyillpatientsrequiringimmediateandcontinuousattention.Interchangeability:Thecapabilitytotransferpatientsbetweenscenesofemergencies,ambulancesandhospitalsaswellasbetweenhospitals,includingtransportbetweencountries,providingcontinuouspatientcare,treatmentandmonitoringInterface:Theplaceofinteractionbetweenoneormoreofthemedicaldevices,theambientconditions,theuser,thepatient,andwhenrelevant,thevariouskindsofambulancevehicles
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Interoperability:Theabilitytoconnectvariousmedicaldevicesthatareattachedtopatients,toconnectionsofassociatedmedicaldevicesincludingthepossibilityofconnectingpoweredmedicaldevicestovariouskindsofambulancevehiclesMedicaldevice:Instruments,apparatus,appliances,materialorotherarticle,whetherusedaloneorincombination,includingsoftwarenecessaryforitsproperapplicationintendedbythemanufacturertobeusedonpatientsforthepurposeofdiagnosis,prevention,monitoring,treatmentoralleviationofdiseaseandinjury.NRP:NeonatalResuscitationProgramNICU:NeonatalIntensiveCareUnitNeonatalIntensiveCareUnit:Anintensive-careunitspecializinginthecareofillorprematurenewborninfants.Thisunitistypicallydirectedbyoneormoreneonatologistsandstaffedbynurses,advancedpracticenursepractitioners,pharmacists,physicianassistants,residentphysicians,andrespiratorytherapiststrainedinnewborncriticalcare.PALS:PediatricAdvancedLifeSupportPatientCompartment:Adefinedspacewhichprovidesthepossibilitytoaccommodateandtransportoneormorepatient(s),medicalcrew,medicaldevices,systemsandinstallationswhicharerequiredduringtransporttoproperlytreatandcareforthepatient.Patienttreatmentarea:Thespacelocatedwithinthepatientcompartment,whichisrequiredtoaccommodateapatientonastretcheraswellastheminimumspaceinthevicinityofthestretcherenablingthemedicalcrewtoproperlycareandtreatapatientPatientRequiringCriticalCareTransport:Apatientrequiringcriticalcaretransporthasacriticalillnessorinjurythatacutelyimpairsoneormorevitalorgansystemssuchthatthereisahighprobabilityofimminentorlifethreateningdeteriorationinthepatient’sconditionduringtransport.PediatricIntensiveCareUnit:Aunitwithinahospitalspecializinginthecareofcriticallyillinfants,children,andteenagers.Theunitistypicallydirectedbyoneormorepediatricintensivistsandstaffedbyphysicians,nurses,andrespiratorytherapistswhoarespeciallytrainedandexperiencedinpediatriccriticalcare.Theratioofprofessionalstopatientsisgenerallyhigherthaninotherareasofthehospital,reflectingthehighacuityofpatientsandtheriskoflife-threateningcomplications.Complextechnologyandequipmentisofteninuse,particularlymechanicalventilatorsandpatientmonitoringsystems.PICU:PediatricIntensiveCareUnit
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PA:PhysicianAssistantQuaternaryCare:sometimesusedasanextensionoftertiarycareinreferencetoadvancedlevelsofmedicinewhicharehighlyspecializedandnotwidelyaccessed.Experimentalmedicineandsometypesofuncommondiagnosticorsurgicalproceduresareconsideredquaternarycare.RN:RegisteredNurseRT:RegisteredRespiratoryTherapistTertiaryIntensiveCare:Themostspecializedintensivecareadministeredtocriticallyillpatientswithsevereorcomplexdiseaseorinjuryrequiringhigh-riskpharmacologicregimens,surgicalprocedures,orhigh-techandadvancedresources.Oftenassociatedwithteachinginstitutionsandrequiressophisticatedtechnologyandmultiplespecialtyresources.TPATC:(formerlyTNATC)TransportProviderAdvancedProviderCourse.
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ACKNOWLEDGEMENTSTheAssociationofCriticalCareTransportwouldliketothankalloftheACCTMembersandBoardofDirectorswhohavesupportedthecreationofthesestandards.Aspecialrecognitiongoestothefollowingprogramsthathavededicatedextensivetime,resourcesandtalentintomakingthesestandardspossible:
AirliftNorthwest
AirSt.Luke’s
AnnandRobertHLurieChildren’sHospitalofChicagoTransportTeam
BostonMedFlight
CareFlite
Children’sMercyHospital,KansasCity,MO
ClevelandClinic
GeisingerLifeFlight
LeonardoHelicopters-AgustaWestland
LifeFlightEagle
LifeFlightofMaine
LifeLinkIII
LifeStarofKansas
MayoClinicMedicalTransport
SanfordAirMed
SuperiorAirGroundAmbulance,Inc.
STARS:ShockTraumaAirRescueSociety
UCHealth-AirCareandMobileCare
UniversityofMichiganHealthSystem,SurvivalFlight
UWMedFlight
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ABOUTACCTTheAssociationofCriticalCareTransport(ACCT)isanon-profitgrassrootspatientadvocacyorganization
committedtoensuringthatcriticallyillandinjuredpatientshaveaccesstothesafestandhighestquality
criticalcaretransportsystempossible.ACCTiscomprisedofairandgroundcriticalcaretransport
providers,businessorganizations,associations,andindividualsallstrivingtoprovideourcommunities,
hospitalsandEMSpartnersincare,regulators,andpolicymakerswithapathtowardasaferandfully
integratedcriticalcaretransportsystemthatrevolvesaroundtheneedsofthepatients.
ACCTExecutiveDirectorRoxanneShanksACCT2016/2017BoardofDirectorsMaryAhlers UCHealth-AirCareandMobileCare,OHKarenArndt OSFAviation,ILBetsyCasanave 7BarAviation,TXMikeChristianson SanfordMedicalCenterIntensiveAir,SDDr.JasonCohen BostonMedFlight,MAFrankErdman UniversityofWisconsin,WIEdwardEroe LifeLinkIII,MNSteveHaemmerle CarolinasMedicalCenter,NC KristaHaugen Survivor’sNetwork,WAGregHildenbrand LifeStar,KSTomJudge LifeFlightofMaine,MEDeniseLandis SurvivalFlight,MISherryMcCool Children’sMercyHospital,MOJamesPerry Patientrepresentative,MIDr.StevenRockoff SuperiorHenryFordAirMed1,MIJeffreyStearns MayoClinicMedicalTransport,MNRobbieTester Erlanger/LifeForce,TNLauraWestley Ann&RobertH.LurieChildren’sHospital,IL
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ACCTTRANSPORTPROGRAMMEMBERSAeromedTampaGeneralHospital LifeStarofKansas
AirSt.Luke's LifeFlightEagle
AirlifeDenver LifeFlightofMaine
AirliftNorthwest MayoClinicMedicalTransport
AngelOneTransport,ArkansasChildren'sHospital MedCenterAir
AnnandRobertHLurieChildren'sHospital MemorialHermannHospital
BostonMedFlight MeridianMobileHealth
Children'sMercyHospital,KansasCity,MO MissionHealthSystem
ClevelandClinicCriticalCareTransport OSFAviation/OSFLifeFlight
CookChildren'sTeddyBearTransport ParkviewSamaritan
Dartmouth-HitchcockAdvancedResponseTeam SanfordAirMed
Erlanger/LifeForce STARS
FlightforLife SuperiorAirGroundAmbulance
FlightForLifeColorado UCHealth-AirCareandMobileCare
GeisingerLifeFlight UniversityofMichiganSurvivalFlight
HumboldtGeneralHospitalEMSRescue UniversityofMississippi-Aircare
HuronValleyAmbulance UniversityofVermontMedicalCenter
LifeEMSAmbulance UWMedFlight
LifeLinkIII WestMichiganAirCare
Association of Critical Care Transport
www.ACCTforPatients.org
PO Box 170 • Platte City, MO 64079816-858-6175 • [email protected]