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Purpose: Critical care transport is associated with a high rate of adverse events, and the risks and outcomes of transporting critically ill patients during the COVID-19 pandemic have not been previously described., Materials and Methods: We performed a retrospective review of transports of subjects with suspected or confirmed COVID-19 from sending hospitals to tertiary care hospitals in Boston. Follow-up data were obtained for patients transported between March 1st and April 20th, 2020., Results: Of 254 charts identified, 250 patients were transported. Nine patients (3.5%) had cardiac arrest prior to transport. Twenty-nine (11.6%) had hypotension, 22 (8.8%) had a critical desaturation, and 4 (1.6%) had both en route. Hospital follow-up data were available for 189 patients. Of those intubated during their hospitalization, 44 (25.0%) had died, 59 (33.5%) had been extubated, and 13 (17.6%) had been discharged alive. For the subgroup with prior cardiac arrest, follow-up data available for 6. Of these 6, 2 died and 4 (66.7%) have been discharged alive., Conclusions: Few patients with COVID-19 had an adverse event in transport. The in-hospital mortality rate was 25%, with a 33.5% extubation rate. Patients resuscitated from cardiac arrest prior to transport had a 66.7% discharge rate among those transported to consortium hospitals.

Background: In the prehospital setting, the use of ambulance lights and sirens (L&S) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation., Objective: The objective of this study was to evaluate the indications for L&S and the impact of L&S on transport times in interfacility critical care transport., Methods: We performed a retrospective analysis using administrative data from a large, urban critical care transportation organization. The indications for L&S were assessed and the transport times with and without L&S were compared using distance matching for common transport routes. Median times were compared for temporal subgroups., Results: L&S were used in 7.3% of transports and were most strongly associated with transport directly to the operating room (odds ratio 15.8; 95% confidence interval 6.32-39.50; p < 0.001). The timing of the transport was not associated with L&S use. For all transports, there was a significant decrease in the transport time using L&S, with a median of 8 min saved, corresponding to 19.5% of the overall transportation time without L&S (33 vs. 41 min; p < 0.001). The reduction in transport times was consistent across all temporal subgroups, with a greater time reduction during rush hour transports., Conclusions: The use of L&S during interfacility critical care transport was associated with a statistically significant time reduction in this urban, single-system retrospective analysis. Although the use of L&S was not associated with rush-hour transports, the greatest time reduction was associated with L&S transport during these hours., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Extracorporeal membrane oxygenation (ECMO), a term used to describe oxygenation that occurs outside of the body, is an increasingly common means of supporting the most critically ill patients. Because of the invasiveness and high probability of serious complications during ECMO, ECMO is typically indicated only when there is a high likelihood of death with conventional treatment. With continued improvements in technology and increasing clinical experience, transport clinicians are increasingly likely to be called on to transport patients on ECMO. ECMO can be initiated in 2 distinct forms, venovenous or venoarterial, and can primarily support the respiratory system or the cardiac and respiratory systems concurrently. This review will cover the basic physiology and components of ECMO as well as the preparation for ECMO transport for adults., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: We performed this study to quantify resources required by mechanically ventilated patients with hypoxemia after critical care transport (CCT) and to assess short-term clinical outcomes., Methods: We performed a retrospective review of transports of patients with severe hypoxemic respiratory failure from referring hospitals to 3 tertiary care hospitals to assess the outcomes including in-hospital mortality, ventilator days, intensive care unit length of stay (LOS), hospital LOS, disposition, and reported neurologic status on hospital discharge as well as medical interventions specific to acute respiratory failure and critical care., Results: Of 230 patients transported with hypoxemic respiratory failure, 152 survived to hospital discharge, for a mortality rate of 34.5%, despite a predicted mortality of 64% by Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Twenty-five percent of patients were treated with neuromuscular blockade, 10.1% received inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation was initiated in 2.6%., Conclusions: In this cohort with hypoxemic respiratory failure transported to tertiary care facilities, patients had a mortality rate comparable to patients with acute respiratory distress syndrome treated with best practices and a mortality rate lower than predicted based on APACHE-II score. The risks of CCT are outweighed by the benefits of transfer to a tertiary care facility, and pretransport hypoxemia should not be used as an absolute contraindication to transport.

Background: Fever is common among intensive care unit (ICU) patients. Clinicians may use microbiological cultures to differentiate infectious and aseptic fever. However, their utility depends on the prevalence of infection; and false-positive results might adversely affect patient care. We sought to quantify the cost and utility of microbiological cultures in a cohort of ICU patients with spontaneous intracerebral hemorrhage (ICH)., Methods: We performed a secondary analysis of a cohort with spontaneous ICH requiring mechanical ventilation. We collected baseline data, measures of systemic inflammation, microbiological culture results for the first 48 h, and daily antibiotic usage. Two physicians adjudicated true-positive and false-positive culture results using standard criteria. We calculated the cost per true-positive result and used logistic regression to test the association between false-positive results with subsequent antibiotic exposure., Results: Overall, 697 subjects were included. A total of 233 subjects had 432 blood cultures obtained, with one true-positive (diagnostic yield 0.1 %, $22,200 per true-positive) and 11 false-positives. True-positive urine cultures (5 %) and sputum cultures (13 %) were more common but so were false-positives (6 and 17 %, respectively). In adjusted analysis, false-positive blood and sputum results were associated with increased antibiotic exposure., Conclusions: The yield of blood cultures early after spontaneous ICH was very low. False-positive results significantly increased the odds of antibiotic exposure. Our results support limiting the use of blood cultures in the first two days after ICU admission for spontaneous ICH.

Objective: Although the benefit of transferring patients with hypoxemic respiratory failure to tertiary care centers has been shown, transporting hypoxemic patients remains controversial, given the risk of desaturation in transit., Methods: We performed a retrospective analysis of a database of critical care transports (CCTs) of patients with hypoxemic respiratory failure to quantify the number, types, and effects of ventilator changes performed by the CCT teams. We evaluated the changes in fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), tidal volume, both FiO2 and PEEP, and the administration of a neuromuscular blocking medication to assess for an association with an improvement in the arterial partial pressure of oxygen (PaO2) from the sending to the receiving hospitals., Results: Ventilator changes were made in 211 (89%) of the 237 identified transports, with significant changes in the tidal volume, PEEP, and FiO2. Analysis of variance revealed a significant relationship between changes in FiO2, PEEP, tidal volume, FiO2 and PEEP, and the administration of neuromuscular blocking agents and change in PaO2 (F5,1037 = 119.6, P < .001). Multivariable regression analyses showed a significant association between an increase in PaO2 and increasing FiO2, increasing FiO2 and PEEP, and the administration of a neuromuscular blocking medication., Conclusion: The CCT team performed multiple changes to ventilators. Complex ventilator management was associated with a higher PaO2 on arrival., (Copyright © 2016 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study is to measure the rate and magnitude of changes in oxygenation that occur in patients with hypoxemic respiratory failure after transport by a critical care transport team., Methods: We performed a retrospective review of 239 transports of patients with hypoxemic respiratory failure requiring a fraction of inspired oxygen (Fio2) > 50% transported from October 2009 to December 2012 from referring hospitals to 3 tertiary care hospitals. We analyzed the change the ratio of the partial pressure of oxygen in the blood to FiO2 from the sending to the receiving hospital as well as the percentage saturation of oxygen (Spo2) before, after, and en route., Results: The mean change in the Pao2/Fio2 ratio from the sending to the receiving hospital was an increase of 27.62 (95% confidence interval [CI], 15.84-39.40; P = .0003). The mean change in Pao2 was an increase of 27.85 mm Hg (CI, 17.49-38.22; P < .0001). The mean Spo2 was not significantly changed at -0.12 (CI, - 1.69 to 1.45, P = .9). Despite improvement in the Pao2/Fio2 ratio and a stable Spo2 on arrival, 28.1% of patients desaturated to Spo2 < 90% in transport., Conclusion: In patients with hypoxemic respiratory failure, Pao2/Fio2 and Pao2 increased after transport by a critical care transport team despite 28.1% of patients desaturating with hypoxemia in transit., (Copyright © 2015 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Introduction: Critical care transport (CCT) teams must manage a wide array of medications before and during transport. Appreciating the medications required for transport impacts formulary development as well as staff education and training. Problem As there are few data describing the patterns of medication administration, this study quantifies medication administrations and patterns in a series of adult CCTs., Methods: This was a retrospective review of medication administration during CCTs of patients with severe hypoxemic respiratory failure from October 2009 through December 2012 from referring hospitals to three tertiary care hospitals., Results: Two hundred thirty-nine charts were identified for review. Medications were administered by the CCT team to 98.7% of these patients, with only three patients not receiving any medications from the team. Fifty-nine medications were administered in total with 996 instances of administration. Fifteen drugs were each administered to only one patient. The mean number of medications per patient was 4.2 (SD=1.8) with a mean of 1.9 (SD=1.1) drug infusions per patient., Conclusions: These results demonstrate that, even within a relatively homogeneous population of patients transferred with hypoxemic respiratory failure, a wide range of medications were administered. The CCT teams frequently initiated, titrated, and discontinued continuous infusions, in addition to providing numerous doses of bolused medications.

ObjectivesTo assess recent advances in interfacility critical care transport.Data sourcesPubMed English language publications plus chapters and professional organization publications.Study selectionManuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients.Data extractionReview of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport.Data synthesisThe Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis.ConclusionsSince 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Introduction: Due to hospital crowding, mechanically ventilated patients are increasinglyspending hours boarding in emergency departments (ED) before intensive care unit (ICU)admission. This study aims to evaluate the association between time ventilated in the ED and inhospitalmortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS).Methods: This was a multi-center, prospective, observational study of patients ventilated in theED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. Allconsecutive adult patients on invasive mechanical ventilation were eligible for enrollment. Weperformed a Cox regression to assess for a mortality effect for mechanically ventilated patientswith each hour of increasing LOS in the ED and multivariable regression analyses to assessfor independently significant contributors to in-hospital mortal ity. Our primary outcome was inhospitalmortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. Wefurther commented on use of lung protective ventilation and frequency of ventilator changesmade in this cohort.Results: We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental statuswithout respiratory pathology was the most common reason for intubation, followed by traumaand respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time ofmechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer totalduration of intubation. However, adjusted multivariable regression analysis demonstrated onlyolder age and admission to the neurosciences ICU as independently associated with increasedmortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours hadchanges made to their ventilator.Conclusion: In a prospective observational study of patients mechanically ventilated in the ED,there was a significant mortality benefit to expedited transfer o f patients into an appropriate ICUsetting. [West J Emerg Med. 2017;18(5)972-979.]

Introduction: Although emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings’ education, experience, and knowledge regarding mechanical ventilation in the emergency department.Methods: We developed a survey of academic EM attendings’ educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings’ scores on the assessment instrument and their training, education, and comfort with ventilation. Results: Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0-1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one’s own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education.Conclusion: EM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0-1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation.

Critical care transport (CCT) teams are specialized transport services, comprised of highly trained paramedics, nurses, and occasionally respiratory therapists, offering an expanded scope of practice beyond advanced life support (ALS) emergency medical service teams. We report 4 cases of patients with severe acute respiratory distress syndrome from influenza in need of extracorporeal membrane oxygenation evaluation at a tertiary care center, transported by ground. Our medical center did not previously have a ground CCT service, and therefore, in these cases, a physician and/or a respiratory therapist was sent with the paramedic team. In all 4 cases, the ground transport team enhanced the intensive care provided to these patients prior to arrival at the tertiary care center. In 2 of the cases, although limited by the profound hypoxemia, the team decreased the pressures and tidal volumes in an effort to approach evidence-based ventilator goals. In 3 cases, they stopped bicarbonate drips being used to treat mixed metabolic and respiratory acidosis, and in 1 case, they administered furosemide. In 1 case, they started cisatracurium, and in 3 others, they initiated inhaled epoprostenol. Existing literature supports the use of CCT teams over ALS teams for transport of the most critically ill patients, and helicopter CCT is not always available or practical. Therefore, offering comparable air and ground options, with similar staffing and resources, is a hallmark of a mature medical system with an integrated approach to CCT. [ABSTRACT FROM AUTHOR]

Background Although Emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) residency curricula. Objectives The objective of this study was to quantify EM residents' education, experience, and knowledge regarding mechanical ventilation. Methods We developed a survey of residents' educational experiences with ventilators and an assessment tool with nine clinical questions. Correlation and regression analyses were performed to evaluate the relationship between residents' scores on the assessment instrument and their training, education, and comfort with ventilation. Results Of 312 EM residents, 218 responded (69.9%). The overall correct response rate for the assessment tool was 73.3%, standard deviation (SD) ± 22.3. Seventy-seven percent (n = 167) of respondents reported ≤ 3 h of mechanical ventilation education in their residency curricula over the past year. Residents reported frequently caring for ventilated patients in the ED, as 64% (n = 139) recalled caring for ≥ 4 ventilated patients per month. Fifty-three percent (n = 116) of residents endorsed feeling comfortable caring for mechanically ventilated ED patients. In multiregression analysis, the only significant predictor of total test score was residents' comfort with caring for mechanically ventilated patients (F = 10.963, p = 0.001). Conclusions EM residents report caring for mechanically ventilated patients frequently, but receive little education on mechanical ventilation. Furthermore, as residents' performance on the assessment tool is only correlated with their self-reported comfort with caring for ventilated patients, these results demonstrate an opportunity for increased educational focus on mechanical ventilation management in EM residency training. [ABSTRACT FROM AUTHOR]