2009 Air Medical Transport Conference Abstracts

▪ An air medical company's review of crew duty time and the effects on endotracheal intubation success rates 

Dwayne Howerton, Brenda Watson

Introduction: With the recent surge of emphasis on safety, we elected to look at the impact that crew duty time may have on the success of endotracheal intubation at one air medical transport company. The skill of endotracheal intubation contains great risk no matter how experienced the provider may be and requires the up most alertness. There are many factors, both patient and provider, that can affect the outcome. One of these factors is crew duty time. Each encounter is unpredictable and presents its own set of challenges. The unsuccessful outcome can have deleterious effects on the patient.

Methods: A retrospective review was conducted of electronic records from 2005 through 2008. Due to variances in definition and opinion of an intubation attempt, we elected to look at the crew duty hour success rate of each encounter. An encounter is described as an engagement to establish an endotracheal tube for purposes of airway management. The crew member performing the intubation, the time of intubation encounter, and the intubation outcome were obtained. Crew member and time of intubation were then compared with schedule records to determine crew duty time. 934 intubation encounters were captured. We were unable to determine the crew duty time in 21 encounters (2%). Each year's number of encounters and success rates were graphically plotted for individual review analysis along with the cumulative results.

Results: The resulting graphs of the data collected showed an overall trend of increasing success rate of endotracheal intubation over the crew duty time. The resulting graphs of the data collected showed an overall trend of increasing success rate of endotracheal intubation over the crew duty time. A consistent decline in success rate occurred within the 10th duty hour, otherwise there were few similarities from year to year.

Conclusion: The data revealed has only scratched the surface of crew duty time and the effects on air medical crews to not only perform clinical skills, but to function safely within the hazardous environment of air medical transport. The data trends are not predictors of actual time of day. The consistent decline in success rate occurring at the 10th duty hour would fall, based on our assigned work shifts, at 1700 and 0500. Further break down of the data needs to occur to provide answers regarding questions of other factors that affect the alertness of air medical crews to function safely.

http://www.softconference.com/submissions/Receive/AAMS/291026/Abstract/D_94_160138_149559.xls

▪ Assessing Alaska's infrastructure readiness for supporting expedited EMS response to CAR crashes in age of crash vehicle telemetry 

M. Flanigan, K. Majka, A. Blatt, M. Miller, R. Perkins

Introduction: Recent activity by American College of Surgeons, GM and the CDC suggests that vehicle telemetry data from Advanced Automatic Crash Notification (AACN) systems (OnStar) may soon support post-crash triage and transport decision-making. Besides immediate notification, AACN crash messages provide crash location, severity and direction of impact. As part of the Alaska Emergency Medical Services Optimization (AKEMSO) Project, Alaska's physical and emergency medical infrastructure was examined to assess Alaska's readiness to fully exploit AACN. Physical infrastructure required for successful transmission of AACN data includes adequate cell tower coverage and sufficient GPS satellites (in field-of-view). Medical infrastructure requires that EMS responders and hospitals be geographically catalogued and networked so that closest medical responders can receive/access crash information electronically. (The ADAMS database was developed to geographically catalogue all air medical bases for this anticipated application.) Here we report measurements of cellular signal strength and GPS satellite visibility along Alaska roadways. We also map the emergency medical infrastructure and examine where crashes occurred within this context.

Methods: Cellular signal strength and GPS satellite coverage/geometry were measured along the Alaska Highway System using ZKCellTest equipment. Locations of ground and air ambulance bases, hospitals and trauma centers were mapped. Recent OnStar crash locations were acquired from AKDOTs CARS system. 481 geocoded fatal crashes (2001-2007) were obtained from NTHSAs FARS. Ambulance travel times by air and ground were computed in a Geographic Information System (GIS).

Results: Over 85% of measured 1800 mile route had cellular signal. GPS satellites-in-view ranged from 3 to 8. Over 38 weeks, 33 OnStar crashes were posted in AKCARS, demonstrating successful real-time AACN message transmission. 50% of Alaskas fatal crashes occur in isolated/highway villages or isolated subregional communities with no hospital. GIS calculations show total ground ambulance travel (base-scene-nearest hospital) could be accomplished in 35 minutes for 65% of FARS crashes. Ground travel to a Level-2 Trauma Center in 35 minutes was possible for 31%. With inclusion of helicopter transport, travel to the Trauma Center was possible within 45 minutes for 57% of FARS crashes. For 7% of crash sites, air transport is the only option.

Conclusion: Cellular and GPS measurements show physical infrastructure is fairly robust along much of the Alaska Highway System. This bodes well for AACN. Sharing AACN alert with nearest air medical service enables preflight preparations and tiered response planning to begin in parallel with first responder activities. Time trade-offs for ground/air transport to different hospitals are demonstrated.

http://www.softconference.com/submissions/Receive/AAMS/291026/Abstract/D_94_160180_174844.ppt#256,1,Slide 1

▪ Does the pilot operational risk assessment score used during adverse weather reliably predicit ‘Go vs. No Go’? 

S. Groke, F. Thomas, D. Handrahan

Introduction: From 2002-2005, 41 HEMS accidents resulted in 39 fatalities and 13 serious injuries. Of these accidents, 36% were due to adverse weather. To improve HEMS safety, the FAA issued a 2005 mandate (Notice 8000.301) requiring HEMS to develop and implement a preflight operational risk assessment score (ORAS) to enable pilots to objectively measure factors that may adversely or favorably affect the flight safety of the mission. Presumably, the higher the score is the greater the risk to fly. To date, the effectiveness of this score to predict mission-related flight risk has not been studied. This study's purpose was to determine the effectiveness of our ORAS to predict ‘Go vs. No Go’ for adverse weather-related HEMS missions.

Methods: Intermountain Life Flight uses several factors and a point system in its ORAS; PILOT EXPERIENCE: <2yrs = +7, 2-3yrs = +5, 4yrs = +3, >5yrs = +0, WEATHER: <3000AGL or 5sm = +5, Unknown/Unsure = +4, NIGHT FLIGHT: Unaided = +6, Aided = +4, NON-LOCAL FLIGHT: Familiar = +3, Unfamiliar = +5, LATE NIGHT FLIGHT (2-5AM): = +2, NO FORCE TRIM: = +2, PRIOR TURN DOWN: = +2. We retrospectively examined all ORAS for HEMS missions during the period between Aug '05-Apr '08. Missions turned down or aborted for reasons other than weather (i.e. patient expired) were excluded from the analysis. Mean±standard deviations and graphic analysis were used to evaluate the data.

Results: 139 ORASs were filled out by 14 Life Flight HEMS pilots (AGE: 55±8yrs; TOTAL RW PILOT EXPERIENCE: 40±16yrs & 9336±4658hrs [Military: 17±12yrs & 4157±3221hrs, Forestry: 3±6yrs & 571±1174hrs, Life Flight: 8±6yrs & 1471±1126hrs, Other HEMS: 2±4yrs & 432±823hrs, Other: 10±10yrs & 2704±2967hrs]. PILOT CERTIFICATES: 8-Commercial, 8-ATP, 10-Instrument, 7-Instructor). Outcomes of weather-related missions were 53(38%) successful, 20(14%) aborted, and 66(48%) turned down. The following figure ‘ORAS vs. Outcome’ depicts our results.

Conclusions: Intermountain Life Flight's ORAS does not reliably predict ‘Go vs. No Go’ for weather-related HEMS missions. Until future research validates an ORAS, HEMS pilots using an ORAS should be guarded as to its ability to reliably predict weather-related flight risks.

▪ Evaluation of a modified sign-out on emergency department documentation of medications administered by critical care transport teams 

Michael A. Frakes, Kenneth J. Robinson, Jacqueline McQuay

Introduction: Poor communication at care transition points causes up to 50% of medication errors and 20% of adverse drug events. With both clinical and financial implications, optimized medication reconciliation is a Joint Commission Patient Safety Goal. CCT teams frequently medicate trauma patients, but the paper CCT record is often not provided until hours or days later, leaving the ED record as the only source of that information. In a previous study of 144 consecutive CCT and matched ED records, we found that only 21.4 % (95% CI 13.829.0%) of ED records contained accurate medication name and dose information. The purpose of this study was to evaluate an intervention to improve communication between a critical care transport (CCT) team and the Emergency Department Trauma Team (EDTT) regarding medications administered during transport. The sign out was modified to include a second verbal report from the CCT to the EDTT recorder after the usual report to the team leader.

Methods: Six months after CCT team members began offering the second report, a prospective review of 79 consecutive records from patients transported to a single tertiary care center was conducted, comparing medications documented on the EDTT record as having been given during transport with those recorded on the CCT record.

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Results: Forty-two patients received a targeted medication from the CCT team (53.2%). All medication names and doses were correct on the ED record for 27 patients (64.3%, 95% CI 49.878.8%). Documentation accuracy improved (p < 0.05) for long-acting neuromuscular blockers, analgesics, benzodiazepines, and etomidate, but not for succinylcholine or ACLS medications.

Conclusion: Significant problems persist in the most basic information transfer: one provider reporting directly to another. However, in this study, accurate transition-point documentation of certain in-transport medications on the EDTT record was significantly improved by the simple intervention of a second verbal report to the EDTT recorder.

▪ Evaluation of a quality improvement initiative: Introduction of the less invasive seldinger method of chest tube insertion in neonates for use during transport 

Kyong-Soon Lee, Jodi Wingfield, Annette Martens, Joanna Gallacher

Introduction: The transport team (TT) at the Hospital for Sick Children (HSC) is comprised of registered nurses, registered respiratory therapists and physicians with advanced training who are responsible for the stabilization and transport of critically ill neonates and young infants. Among the advanced skills, a major barrier to the insertion of conventional chest tubes (CCTs) using Argyle tubes was the traumatic and invasive nature of the technique. A newer, less traumatic method of chest tube insertion using the Seldinger technique (Fuhrman) was already in routine practice in the United Kingdom and some Canadian NICUs. As a quality improvement initiative to introduce a potentially better practice, a training program was developed for insertion of the Seldinger chest tube (SCT). Although SCTs were adopted to minimize patient trauma and pain, it was noted that there is a paucity of literature comparing the efficacy and safety of CCTs vs SCTs. Objective: To compare the efficacy, safety and user satisfaction of conventional chest tubes (CCTs) with Seldinger chest tubes (SCTs) for drainage of air or fluid in neonates.

Methods: Retrospective review of chest tube insertions 12 months before and 13 months after the implementation of the SCT; and measurement of user satisfaction with the SCT using a questionnaire.

Results: Among 38 insertions, median GA was 37 weeks (range 25-41), and birthweight was 2842g (range 620-4390). Patient diagnoses were: RDS (n=17), TTN (n=7), MAS (n=7), HIE/PPHN (n=6), hypoplastic lungs (n=1). Thirty-seven were inserted for drainage of air and 1 for fluid. CCTs were inserted in 25(66%) and SCTs in 13 neonates. Drainage was unsuccessful on first attempt in 3(12%) CCTs vs 1(8%) SCTs (p=1.0). Complications were encountered in 7(28%) CCTs vs 4(31%) SCTs (p=1.0). CCT complications were: re-accumulation due to malposition (n=4); dislodgement (n=3). SCT complications were: dislodgement (n=2); blockage (n=1); kinking (n=1). Reinsertion was required in 5(20%) CCTs vs 3(23%) SCTs (p=1.0). User satisfaction with SCTs was high with all reporting that the technique was easier and less traumatic than CCTs.

Conclusion: In our sample, we found no differences in efficacy or safety between CCTs and SCTs; and higher user satisfaction with SCTs. Following our evaluation, SCTs have been adopted into routine practice and education has been implemented to minimize the complications noted during our evaluation. With increasing use of SCTs, surveillance is ongoing to monitor for any changes in efficacy and safety with this new technique.

▪ Investigation of time to reperfusion in rural patients with st elevation MI treated by PCI: The impact of transfer strategy 

Susan Toberman, Stuart J. Bresee, Jujhar S. Bains

Introduction: Optimal treatment of patients with ST elevation MI (STEMI) in rural areas without immediate access to a PCI-capable facility is controversial. A strategy of immediate transfer from the field to a PCI-capable facility instead of initial evaluation at a rural hospital ER is an option to decrease treatment delays.

Methods: We retrospectively evaluated 47 consecutive STEMI patients originating in rural counties without a PCI-capable facility. The patients were divided into two groups: Direct Transfer (Field) and Inter-Hospital Transfer. We assessed the two groups for baseline differences in age, gender, and TIMI score. We then evaluated the time to treatment, which was defined as time from entry into the health care system to documentation of infarct artery patency. This was subdivided into transport arrival time, defined as helicopter arrival in the field or referring hospital until arrival at receiving hospital; and PCI time, defined as receiving hospital arrival until documentation of patent infarct artery or first balloon inflation.

Results: Field transferred patients had a mean age of 64.5 while interhospital patients had a mean age of 57.8. Field-transferred patients had a mean TIMI score of 4.2. The transport arrival time from entry into the health care system to helicopter arrival on scene in the field transfers (mean 16.6 minutes) was significantly lower then for inter-hospital transfers (mean 98.9 minutes), a difference of 82 minutes with a p < .001. The transport time from the helicopter's arrival at the field to arrival at the PCI-capable facility (32 minutes) was not statistically significant versus inter-hospital transfers (39.7 minutes), with a difference of 6 minutes. The PCI time from arrival at the PCI-capable facility to first balloon inflation or patent infarct artery for field transfers (53.6 minutes) versus inter-hospital transfers (51.0 minutes) was not statistically significant. Total transfer time is defined as time from entry into the healthcare system to documentation of infarct artery patency. The time for field patients (102.4 minutes) was significantly lower than for inter-hospital transfer patients (189.6 minutes), with a difference of 87 minutes and p < .02.

Conclusion: This investigation demonstrates that direct transport of STEMI patients to a PCI-capable facility is associated with a significant reduction in time to vessel reperfusion.

▪ Presentation and progression of pediatric septic shock patients in critical care transport 

Michael A. Frakes, John Pliakas, Laura Connelly, Suzanne Wedel

Introduction: Timely compliance with early goal directed sepsis therapy guidelines available since 2002 is associated with improved outcomes. Specialty care transport teams are often involved in the early care of septic pediatric patients. We report on the population seen by a generalist transport team and the interventions provided by the team.

Methods: This is a retrospective review of pediatric (age < 16) patients with ICD-9 codes for infection transported by a single generalist critical care transport team between 2002 and 2007. Septic shock was defined a priori as hypotension or the need for vasopressor support and hypoxia as oxygen saturation < 93%. Comparisons are made using unadjusted odds ratios with 95% confidence intervals and the independent sample t-test.

Results: There were 315 patients: 205 (65.1%) male, and a mean age of 3.1 ±3.9 years. Slightly more patients (n = 158, 51.1%) were sent from an Emergency Department, and most went to an inpatient unit (n = 237, 75.2%). Transport time was 30.1 ± 18.1 minutes (range 6 150). There were 75 (23.8%) patients in septic shock, with no demographic differences between the shock and non-shock groups. Of the shock group, 46 (61.3%) were hypotensive at transport team arrival. During transport, 21 (45.7%) reached target MAP and none became hypotensive. In the non-shock group, 25 (9.3%) patients became hypotensive in transport. The unadjusted odds ratio of hypotension at the end of transport was 0.09 (95% CI 0.04 – 0.18). On initial presentation, 37 (49.3%) shock patients had not received 20 cc/kg of IV fluid (IQR 2.0 – 16.5 cc/kg). At the end of transport, 13 (35.1%) had finished their first bolus, leaving 24 (32%) shock patients who did not receive a full fluid bolus prior to arrival at tertiary care (IQR 5.8 15.3). Of the 50 patients with hypotension at the end of transport, 40 (80%) had received at least 20 cc/kg of IV fluid and three were on a vasopressor (6%). There were 30 patients (9.5%) who were hypoxic at transport team arrival. Saturation improved in transport for 19 hypoxic patients (63.3%) but three normoxic patients (1.1%) became hypoxic. The unadjusted odds ratio of hypoxia at the end of transport was 0.02 (95% CI 0.00 0.07). In the shock group, 8 patients (10.7%) were hypoxic. During transport, saturation improved for 3 (37.5%) and one shock patient became hypoxic (1.5%). The unadjusted odds ratio of hypoxia at the end of transport for shock patients was 0.01 (95% CI 0.00 – 0.10).

Conclusion: This generalist specialty care transport team frequently found infected pediatric patients in septic shock or hypoxic, and the team achieved significant improvements in MAP, SpO2, and volume resuscitation during transport. Opportunities for performance improvement exist in the early administration of IV fluid and in the addition of vasopressors to the management of hypotensive pediatric septic shock patients by the transport team.

▪ Comparison of rates for successful placement and volume resuscitation between the EZ-IO R and an 8 FR central venous catheter 

M. Sahjian, L. Bolton, J. Heath, K. Robinson

Introduction: Vascular access is of paramount importance in critically ill patients for administration of medications, IV fluids or blood products. In the air medical setting, vascular access is commonly obtained with a peripheral or central venous IV catheter. The intraosseous (IO) route, previously reserved for pediatric patients, is gaining popularity in adult patients with both EMS providers and air medical transport teams. The objective of this study was to compare successful placement and the adequacy of volume resuscitation between two devices, the EZ-IOR and an 8 Fr central venous line (CVL), by an air medical service. These devices are placed by an air medical crew consisting of an RN/EMT-P and an RT/EMT when peripheral IV access cannot be obtained.

Methods: A retrospective chart review was conducted for a one year period. All patents who received placement of either device were entered into a database along with age, insertion site, volume, infusion time, and adequacy of resuscitation. Successful placement was defined as a patent line on transfer of care. Adequacy of resuscitation was defined as a 20ml/kg bolus in 10 minutes in a pediatric, a 1000ml IV fluid bolus in an adult, or normalization of vital signs.

Results: During the study period 29 patients were identified; and two were excluded for use of both devices. One or more IOs were placed in 16 patients, and a CVL was placed in 11 patients. There was successful placement in 87.5% of the IO group and in 63.6% of the CVL group (p=0.187). Adequacy of resuscitation for the IO was 14.3% and 85.6% for the CVL, (p= 0.003). Mean total volume was 653.6 ml for the IO and 1342.9 ml for the CVL (p=0.047) and mean infusion rate was 30.0 ml/min for the IO group and 71.3 ml/min for the CVL group (p=0.037).

Conclusion: The EZ-IOR had a trend toward more successful placement, however successful CVL placement had a statistically significant higher volume administered, higher mean infusion rate, and higher proportion of adequate resuscitation. This makes CVL placement a preferred method of volume resuscitation.

▪ Comparision of the Airtraq to direct laryngoscopy by flight nurses and respiratory therapists in the simulated airway 

James C. Suozzi, Lauri Bolton, Thomas A. Nowicki, Richard Ventriglia, Kenneth J. Robinson

Introduction: Emergent in-flight endotracheal intubation is an infrequent event that carries additional challenges due to a confined space environment and limited patient/practitioner positioning. The purpose of this study was to compare intubation utilizing the Airtraq with direct laryngoscopy in the manikin model given both normal and difficult airway scenarios in the helicopter setting. We evaluated the number of attempts, time to successful ventilation, Cormack-Lehane view and the Airtraq's learning curve.

Methods: This was a randomized crossover study involving flight nurses and respiratory therapists. Each subject was given a standardized lecture and a demonstration of the Airtraq device including a set of instructions regarding its use. Participants were then allowed a 5 minute practice session on a Laerdal Airway Management Trainer with the Airtraq and direct laryngoscopy using a Macintosh #3 blade. Subjects then managed the following scenarios in the aircraft on a Laerdal SimMan manikin: (1) normal airway; (2) tongue edema; (3) c-spine immobilization; (4) normal airway. Results were analyzed utilizing Wilcoxon Signed Ranks Test.

Results: 21 flight personnel participated in this study. For scenario #1 (Normal airway) there were no significant differences in either the number of attempts or time to ventilation between the devices. A significantly lower grade view with use of the Airtraq was reported (p=.009). For scenario #2 (tongue edema) the median time to ventilation using direct laryngoscopy was 47.41s and using the Airtraq was 27.25s with a difference of 20.16s (p=.001). There were also significantly fewer intubation attempts (p=.05) and a lower grade view (p=.

Conclusion: The Airtraq was shown to be equal or faster than direct laryngoscopy with the Macintosh #3 blade for easy and difficult airway scenarios in this manikin model. The Airtraq also required fewer intubation attempts than direct laryngoscopy in the tongue edema scenario. Use of the Airtraq resulted in significantly lower Cormack-Lehane airway views compared with direct laryngoscopy for all scenarios.

▪ Web-based media for landing zone safety instruction 

M.A. Bellazzini, M.D. Repplinger, R.E. Gangnon

Introduction: Firefighters and EMS personnel are responsible for coordinating a safe landing zone for air medical transport crews at scene responses. Their knowledge of landing zone safety is critical to prevent disaster. This study assesses the use of on-line video to teach landing zone safety to firefighters and EMS personnel. Knowledge decay over 6 months is also assessed.

Methods: This is a randomized, prospective study using a on-line video to teach landing zone safety to firefighters and EMS personnel. Two hundred and fifty seven participants registered for the study and were asked to take an on-line safety exam before and after watching the video. Participants were randomized by agency to one of four post test groups to assess for knowledge decay. Group A took the exam after watching the video, Group B at 2 months, C at 4 months and D completed the exam at 6 months. Information on when participants last received landing zone safety training was also collected. Mixed effects linear regression models were used to determine the impact of timing of the post test on change in test performance. Analyses were conducted using Proc Mixed in SAS (SAS Institute, Cary NC). A nominal p-value of 0.05 was regarded as statistically significant.

Results: One hundred eighty four (71.6%) completed the study, Mean pre-test and post-test scores were 82.7% and 94.9% for group A, 81.9% and 91.2% group B, 86.3% and 88% group C, and 82.6% and 92.2% for group D. Statistically significant post-test score increases were seen in groups A (11.1%, 95% CI 6.0%, 16.1%), B (9.0%, 95% CI 3.1%, 14.9%), and D (9.9%, 95% CI 5.3%, 14.5%) P < 0.0001. Group C had a mean increase of 2.3%, but this was not statistically significant (p = 0.41). Over 40% of participants had not received landing zone training in over 2 years.

Conclusion: Firefighters and EMS personnel participating in our study had a moderate degree of baseline knowledge of landing zone safety. Knowledge of landing zone safety significantly increased after watching the safety video. Web-based media is an effective and easily accessible method of teaching landing zone safety to firefighters and EMS personnel. Knowledge of landing zone safety did not decline significantly over 6 months.