Appropriate Utilization of

Critical Care Ground Transport Services

Position Statement of the Association of Air Medical Services (AAMS)

BACKGROUND

Today, the growing demand for highly sophisticated critical care services has been the result of a rapidly growing technological complexity of medical care for critically ill and injured patients.[1] Since critical care ground transport has been integrated into AAMS, the association identified the need for minimum guidelines for the use of critical care ground ambulances and specialty care transports that augments the position paper previously published by AAMS entitled Appropriate Utilization of Air Medical Transport Services.2

The growing number of critical care transports across the country establishes a significant need to develop a position statement for Appropriate Utilization of Critical Care Ground Transport Services This position paper will outline minimum standards and guidelines for triaging the appropriate ground transport, qualifications of medical personnel, and will provide guidelines of appropriate critical care to the consumers of these services. It is critical to recognize that the skill and training of personnel must commensurate with the rapidly advancing technologies and sophisticated equipment needed for providing critical care in the complex environment of transport.[2]

The basic reason for moving critically ill patients by any form of medical transportation is the need for additional care, either technology and/or specialists, not available at the patient’s current location. As a result of health care changes and advancements, services providing critical care ground transport have become a necessary extension of hospital emergency and critical care services. In the hospital setting, physicians and nurses are the primary care providers for patients requiring the most advanced medical technology and care. Therefore, transport crew members must, at a minimum, have strong assessment and critical thinking skills, ability to manage patients, and a strong knowledge of communications and safety in the out-of-hospital setting. They must also have the ability to function autonomously in a variety of settings with treatment protocols if immediate communication with a physician is not possible or if immediate life-saving actions are required.

Interfacility patient transfers should be made when the benefit to the patient exceeds the risks involved in the transfer. Positive patient outcomes depend on the expertise of nursing, medical personnel, and the technology available in the healthcare system. A patient who needs services that exceed the available resources of a facility should be transferred to another facility with the required technologies and with appropriately trained personnel and equipment.[3]

Consumers utilizing critical care ground transport services have the right to receive a nationally consistent standard of care.

To assure the provision of appropriate critical care to the consumers of these services, the skill and training of the personnel must commensurate with the complex environment of transport.[4]

Although several professional organizations have developed or are developing standards, at present none of these standards have been nationally accepted and implemented throughout the United States.

PURPOSE

The medical transport community supports the safe and proper use of critical care transport services. The standards of AAMS strive to promote excellence in patient care. The purpose is as follows:

  1. To establish minimum standard guidelines for the appropriate team utilization of critical care ground transport services.
  2. To enhance the quality of patient care by advocating the proper use of critical care ground transport services.
  3. To promote the concept that matching the high risk critical patient with the proper medical personnel can reduce morbidity and mortality.
  4. To establish appropriate equipment for critical care ground transport.
  5. To publish definitions for critical care ground transport.
  6. To publish descriptors of specific illnesses, injuries and conditions that identifies high-risk and critical patients. These descriptors can be used to identify appropriate inter-facility critical care ground transports.

POSITION STATEMENT

For patients transported by ground medical transport, critical care ground transport should be used when its inherent advantages over an advanced life support (ALS) ambulance transport enhances patient care.

AAMS believes that the transportation of patients by a critical care ground unit should include the following considerations:

.

  1. The level of care should not decrease during transport. The skill level of the accompanying personnel must be equal to the interventions required or anticipated for the patient during transport.
  1. Critical care transports should be performed by a specially trained transport team as outlined in state guidelines and CAMTS standards.
  1. A minimum of two medical personnel, in addition to the driver, shall accompany the patient to deliver direct patient care.
  1. The Medical Director of the transport program ensures competency and currency of all medical personnel working with the service.

STAFFING

Currently there are no supported national standards regarding the staffing of critical care ground transport services.

  • The AmericanCollege of Emergency Physicians (1990) endorses the following principle regarding patient transfers: “The health and well-being of the patient must be the overriding concern when any patient transfer is considered. The patient should be transferred in a vehicle that is staffed by qualified personnel and contains appropriate equipment.”[5]
  • The Commission on Accreditation of Medical Transport Systems (CAMTS) in their Fifth Edition of Accreditation Standards (2002) published the following: “A critical care mission is defined as the transport of a patient, from a scene or a clinical setting, whose condition warrants care commensurate with the scope of practice of a physician or registered nurse. The medical team must, at a minimum, consist of a specially trained physician or registered nurse, as the primary care provider”.[6] Most recently, CAMTS will allow for an alternative team composition (for example paramedic-led teams) if they can demonstrate compliance with the accreditation standards as a critical care team.
  • The Centers for Medicare Services (CMS) final rule dated February 27, 2002 defines Specialty Care Transport (SCT) as: “When medically necessary, for a critically injured or ill beneficiary, a level of interhospital service furnished beyond the scope of the paramedic as defined in the National EMS Education and Practice Blueprint. This is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area (for example, nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training).

Lastly, it is important to note that staffing should meet all state requirements, as numerous states have developed standards or regulations regarding the staffing of medical transport services in operation within their jurisdiction. These staffing standards/regulations vary widely from state to state. Likewise, the registered nurse’s role in an out-of-hospital environment must be consistent with the scope of practice as defined by that state’s Nurse Practice Act.[7]

Ambulance Equipment and Calibration

The ambulance designated for critical care must be designed to provide for the medical care and transportation of a patient consistent with the mission statement and scope of care of the service.[8]

  1. The ambulance must meet the federal Star of Life Ambulance Specifications (KKK-A-1822E) and all state licensor requirements.
  2. Preventive maintenance program for each ambulance and its equipment shall be developed and implemented to ensure optimal working performance.
  3. Documentation shall be maintained by the provider to support evidence of :
  4. Inspection
  5. Calibration
  6. Maintenance

Operation of the ambulance and its equipment shall be in accordance with the requirements and maintenance schedule of the manufacturer or other regulatory agencies.

Equipment specific to a critical patient

Include but not limited to:

1. Invasive monitors – Swan Ganz, arterial lines, CVP, ICP needle

2. Cardiac Assist Devices – pacemakers, intra-aortic balloon pump,

ventricular assist device, extra- corporeal support (ECMO), 12 lead

monitoring, interpretation and intervention

3. Specialty Drug Delivery – epidural catheters, intra-osseous lines

4. Respiratory equipment – ventilators, artificial airways, chest tubes,

capnography

5. Appropriate redundancies to ensure continued continuity in patient

care.

Criteria for use of Critical Care Transport

Critical transport should be utilized for interfacility transport of patients in critical condition or with conditions with potential for deterioration during transport.

In general, the following patients should be transported by a specially trained critical care ground team with the following conditions:

  • Patients in critical condition
  • Potential for deterioration into critical condition during transport
  • Unstable vital signs
  • Patients intubated and ventilated for an acute medical

condition

  • Continuous infusion pharmacologic blood pressure support
  • Any patient that the responsible sending physician certifies that a higher than advanced life support level of care is required to safely transport the patient

The following vascular events and surgical conditions that require time-sensitive treatment should be safely transported by the most appropriate mode of transport available.

  • Acute ischemic stroke
  • Expanding epidural hematoma
  • Acute myocardial infarction
  • Acute aortic dissection
  • Acute gastrointestinal hemorrhage
  • Rupturing aneurysm
  • Acute intra-abdominal hemorrhage from trauma
  • Amputation with planned reattachment
  • Ischemia of arm or leg
  • Necrotizing fasciitis
  1. Neurologic
  • Acute ischemic stroke
  • Malignant hypertension (Hypertensive emergency)
  • Intracranial hemorrhage
  • Epidural hematoma
  • Subarachnoid hemorrhage (SAH)
  • Subdural hematoma
  • Status epilepticus
  1. Cardiac
  • Acute myocardial infarction
  • Coronary artery disease on intra-aortic balloon pump (IABP) or ventricular assist device (VAD)
  • Intermediate coronary syndrome (unstable angina)
  • Cardiogenic shock on continuous infusion pharmacotherapy
  • Dysrhythmia on continuous infusion antidysrhythmic therapy
  • Cardiac tamponade
  • Valvular insufficiency
  • Post-cardiac arrest
  1. Trauma
  • Intra-abdominal hemorrhage
  • Amputation with planned reattachment
  • Head injury with deteriorating mental status
  • Spinal cord injury with hypotension and/or neurological

deficits

  • Flail chest
  • Cardiac injury
  • Pelvic fracture with hypotension
  • Multiple long bone fractures with hypotension
  • Open fractures
  1. Burns
  • Major burn criteria
  • Inhalational injury
  • Burns with associated trauma
  • Electrical burns
  1. Critically-Ill Medical
  • Gastrointestinal hemorrhage
  • Near-drowning
  • Emergency hemodialysis
  • Hyperbaric oxygen therapy (HBO)
  • Severe poisoning or overdose
  • Airway with potential for obstruction
  • Angioedema
  • Epiglottitis
  • Retropharyngeal abscess
  • Specialized ventilation
  • Acute respiratory distress syndrome (ARDS)
  • Inverse ratio ventilation
  • Jet ventilation
  1. Critically-Ill Surgical
  • Aortic dissection
  • Rupturing aneurysm
  • Necrotizing fasciitis
  1. Pediatric
  • ICU admission
  • Status asthmaticus
  • Status epilepticus
  1. Obstetric
  • Premature labor with neonatal weight < 2000g
  • Hydrops fetalis
  • Neonatal cardiac disease
  • Medical emergency
  • Pre-eclampsia or eclampsia
  • DKA
  • Poisoning or overdose
  • Surgical emergency
  • Abruption with hemorrhage
  1. Neonatal
  • Intubated and ventilated
  • Bronchopulmonary dysplasia
  • Congenital heart defect
  • CHF
  • Persistent hypoglycemia
  • Temperature instability
  • Sepsis or meningitis
  • Seizures
  • DIC
  • Necrotizing enterocolitis
  • Abdominal wall defect
  • Diaphragm hernia
  1. Transplant
  • Donor
  • Recipient

DEFINITIONS

Critical Care Transport – As defined by the Commission on Accreditation of Medical Transport Systems (CAMTS): “the transport of a patient from an emergency department or critical care unit who receives care commensurate with the scope of practice of a physician or registered nurse.”

Mobile Intensive Care Unit – As defined by the Ohio Revised Code: “Mobile Intensive Care Unit means an ambulance used only for maintaining specialized or intensive care treatment and used primarily for inter-hospital transports.”

Critical Care Patient – Any patient who experiences an actual or potential life or limb threatening illness/injury that requires continual monitoring and care by specialized trained registered nurses.

Specialty Care Transport – As defined by CMS (HCFA): “Interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including medically necessary supplies and services, at a level of service beyond the scope of the EMT-paramedic as defined in the National EMS Education and Practice Blueprint. Patient’s condition requires ongoing care provided by one or more health professionals in an appropriate specialty area (nursing, medicine, respiratory care, cardiovascular care or a paramedic with additional training).”[9]

Association of Air Medical Services1

[1]Emergency Nurses Association & Air & Surface Transport Nurses Association. (2001, December). Emergency Nurses Association, Air & Surface Transport Nurses Association joint position statement: Staffing of critical care air medical transport services. Available:

[2]ENA & ASTNA, 1

[3]Moy, M. (2000). The EMTALA answer book (2nd Ed.). Gaithersburg, Maryland: Aspen Publications

[4]ENA &ASTNA, 1

[5]AmericanCollege of Emergency Physicians. (1990). Principles of appropriate patient transfer position statement. Annals of Emergency Medicine, 19, 337.

[6]Commission on Accreditation of Medical Transport Systems (CAMTS). (2002). Accreditation standards of CAMTS (5thEd.). Anderson, SC: Author.

[7]7Ohio Nurses Association. (1996). The role of the registered nurse in the out-of-hospital emergency setting. Nurse Practice Statement NP69.

[8]AAMS. (2000). Standards and Safety Guidelines; CCG Standard I Ambulance equipment/Configuration, 31

[9]Department of Health & Human Services. (2002). Program memorandum intermediaries/carriers (CMS Publication No. 60AB). Washington: Author.