Critical Events During Land-Based Interfacility Transport Singh, Jeffrey M., MD, MSc, FRCPC; MacDonald, Russell D., MD, MPH, FRCPC; Ahghari, Mahvareh, BSc, MEng
Annals of emergency medicine,
07/2014, Volume:
64, Issue:
1
Journal Article
Peer reviewed
Study objective The risks associated with urgent land-based transport of critically ill patients are not well known and have important implications for patient safety, care delivery, and policy ...development. We seek to determine the incidence of in-transit critical events and associated patient- and transport-level factors. Methods We conducted a retrospective cohort study using clinical and administrative data. We included adults undergoing urgent land-based critical care transport by a dedicated transport provider between January 1, 2005, and December 31, 2010. The primary outcome was in-transit critical event, defined by adverse events or resuscitative procedures. Results In-transit critical events were observed in 333 (6.5%) of 5,144 urgent land transports. New hypotension (4.4%) or new vasopressors (1.6%) were the most common critical events, with fewer respiratory events (1.3%). Advanced care paramedics had a higher rate compared with critical care paramedics (odds ratio OR 1.6; 95% confidence interval CI 1.1 to 2.2), especially for patients with baseline hemodynamic instability. In multivariate analysis, mechanical ventilation (adjusted OR 1.7; 95% CI 1.3 to 2.2), baseline hemodynamic instability (adjusted OR 3.7; 95% CI 2.8 to 4.9), out-of-hospital duration (adjusted OR 3.6; 95% CI 2.9 to 4.5 per log-fold increase in time), and neurologic diagnosis (adjusted OR 0.5; 95% CI 0.3 to 0.7 compared with that of medical patients) were associated with critical events. Conclusion Critical events occurred in approximately 1 in 15 transports and were associated with mechanical ventilation, hemodynamic instability, and transport duration, and were less frequent in neurologic patients. The finding that hypotension is common and predicted by pretransport hemodynamic instability has implications for the preparation and management of this patient group.
Prone positioning during mechanical ventilation in patients with severe respiratory failure is an important intervention with both physiologic and empiric rationale for its use. This study describes ...a consecutive cohort of patients with severe hypoxemic respiratory failure due to COVID-19 who were transported in the prone position in order to determine the incidence of serious adverse events (SAEs) during transport.
This retrospective study used prospectively collected data from a provincial air and land critical care transport system where specially trained critical care paramedic crews transported intubated and mechanically ventilated patients with COVID-19 in the prone position. SAEs were determined a priori, and included markers of new hemodynamic or respiratory instability, new resuscitative measures, and equipment or vehicle malfunction. Two authors independently reviewed each patient care record to identify SAEs during transport, and the ability of the crews to successfully manage such events.
From April 2020 to June 2021, 127 intubated and mechanically ventilated patients were transported in the prone position. Of these, 117 were transported by land vehicle, 7 by rotor-wing, and 3 by fixed wing aircraft. 67 (52.8%) were vasopressor-dependent, 5 (3.9%) were receiving inhaled vasodilators, 9 (7.1%) were hypoxic (SpO
2
< 88%), and 3 (2.4%) were hypotensive (SBP < 90 or MAP < 65 mm Hg) when the transport crew made patient contact at the sending hospital. Of the 122 (96.1%) patients in which a pre-transport PaO
2
/FiO
2
ratio was available, the mean (median; range) was 86.7 (81; 47-144), with 27 patients greater having a ratio greater than 100. The mean (median; range) transport time was 49 (45; 14-176) minutes. There were 19 SAEs in 18 (14.2%) patients during transport, the most common of which was new hypoxia requiring ventilator adjustments (15 of 18 patients). All SAEs were successfully managed by the transport crews. No patient experienced tracheal tube obstruction, unintentional extubation, cardiac arrest, or died during transport.
Patients with severe hypoxemic respiratory failure due to COVID-19 can be safely transported in the prone position by specially trained critical care paramedic crews.
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