key: cord-0940759-8w6u6l6k
authors: Troncoso, Ruben D.; Garfinkel, Eric M.; Leon, David; Lopez, Sandra M.; Lin, Andrew; Jones, Dennis; Trautman, Shawn; Levy, Matthew J.; Margolis, Asa M.
title: Decision-Making and Interventions During Interfacility Transport of High Acuity Patients with SARS-CoV-2 infection
date: 2021-04-05
journal: Air Med J
DOI: 10.1016/j.amj.2021.04.001
sha: dab77c7b0480f853acfec241427fa232b709f54b
doc_id: 940759
cord_uid: 8w6u6l6k

Introduction There is limited data regarding the typical characteristics of COVID-19 patients requiring interfacility transport or the clinical capabilities of the out-of-hospital transport clinicians required to provide safe transport. The objective of this study is to provide epidemiologic data and highlight the clinical skill set and decision-making needed to transport critically ill COVID-19 patients. Methods A retrospective chart review of Persons Under Investigation for COVID-19 transported during the first six months of the pandemic by Johns Hopkins Lifeline was performed. Patients who required interfacility transport and tested positive for SARS-CoV-2 RNA by PCR assay were included in the analysis. Results Sixty-eight patients (25.4%) required vasopressor support, 35 patients (13.1%) were pharmacologically paralyzed, 15 (5.60%) were prone, and one (0.75%) was receiving an inhaled pulmonary vasodilator. At least one ventilator setting change occurred for 59 patients (22.0%) and ventilation mode was changed for 11 patients (4.10%) during transport. Conclusions The safe transport of critically ill patients with COVID-19 requires experience with vasopressors, paralytic medications, inhaled vasodilators, prone positioning, and ventilator management. The frequency of initiated critical interventions and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment, critical thinking and decision-making.

The coronavirus pandemic has threatened to overwhelm hospitals and healthcare systems across the globe. 1 Interfacility transport programs have been tasked with the movement of these critically ill patients to tertiary and quaternary care centers to receive additional clinical expertise and resources. These transport programs also help facilitate regionalization of care to mitigate hospitals becoming disproportionally overwhelmed by number and/or acuity of patients. While data is emerging regarding the characteristics of COVID-19 patients transported by Emergency Medical Services (EMS) systems 2 , there is only limited information describing the typical illness severity of patients cared for during critical care transport. [3] [4] [5] Furthermore, there is a paucity of literature describing the interventions and decision-making by critical care transport clinicians during ground and air transport.

Johns Hopkins Lifeline (Lifeline) is a high-volume, high acuity critical care transport program responsible for movement and care of approximately 16,000 intrafacility transports, 5,500 interfacility ground transports, and 800 air transports per year predominantly throughout Maryland and Washington D.C. with occasional transports between Delaware, Pennsylvania, and Virginia. Created in response to the Ebola pandemic of 2014-2015, the Lifeline Special Operations Response Team (SORT) is a subset of Lifeline team members specially trained in movement of patients with high consequence infectious diseases. 6 Given the specific training and knowledge of the SORT members, this team was dedicated to the movement of Patients Under Investigation (PUI) for COVID-19 and patients with confirmed COVID-19 infections into and throughout the Johns Hopkins Health System. A SORT mission included the addition of a safety officer along with the patient care team. 7 Lifeline performed its first COVID-19 interfacility transport on February 29 th , 2020, approximately eleven days before the disease was declared a pandemic by the World Health Organization. 8 This paper is a novel observational study that describes the characteristics of COVID-19 patients and the clinical management by the Lifeline transport nurses and paramedics during the first six months of the pandemic.

This study was a retrospective chart review of patients with confirmed COVID-19 and PUI for COVID-19 transported by Lifeline from February 29 th , 2020 to August 31 st , 2020.

Patients who required interfacility transport and tested positive for SARS-CoV-2 RNA by PCR assay were included in the analysis. Patients were excluded if they required intrafacility transport or if they did not have a positive PCR assay for SARS-CoV-2 RNA. Patient characteristics prior to transport and clinical management during transport were captured via chart review (Zoll Data Systems, Broomfield, Colorado). All patients with confirmed COVID-19 and PUI were transported by Lifeline SORT.

Pre-transport data included patient demographics, vital signs, end-tidal carbon dioxide levels, and supplemental oxygen requirements. Patient temperature was inconsistently reported and was excluded. In addition, critical care interventions implemented prior to transport were 

Between February 29 th , 2020 and August 31 st , 2020 Lifeline completed 1,089 transports.

There were 381 (35.0%) interfacility transports and 708 (65.0%) intrahospital transports. Twohundred and eighty-two (74.0%) interfacility transport patients were COVID-19 positive and 11 (3.9%) were transported by air. There were 14 (5.0%) incomplete charts that were excluded from analysis. A total of 268 patients were included in the final analysis ( Figure 1 ). Figure 3 shows the cumulative percentage of patients requiring the studied clinical interventions.

The COVID-19 pandemic has resulted in the frequent transfer of patients due to capacity limitations and illness severity. This retrospective analysis is the largest study to date describing the acuity and management required for COVID-19 patients undergoing interfacility transport.

We have found these patients were frequently high acuity and required changes in management during transport to optimize care. Nearly 80% of patients received supplemental oxygen meeting the criteria for severe COVID-19 infection. Over half of these patients required invasive mechanical ventilation for respiratory failure meeting the definition for critical COVD-19 infection. 9 Invasive mechanical ventilation was the most common intervention that a Lifeline clinician was required to manage. Greater than 11% of the intubated patients were paralyzed to optimize respiratory support, which emphasizes the critical illness of the study population. This is also reflected by the ventilator changes required during transport, including adjusting settings for more than half of patients and changing the mode of ventilation for 10% of patients transported. Ventilator changes were guided by adhering to lung protective strategies and targeting tidal volumes of 6-8 ml/kg of ideal body weight as well as the most recent sending facility's arterial blood gas, oxygen saturation by pulse oximeter and end-tidal carbon dioxide level. Lifeline crews were encouraged to decrease supplemental FiO2 to maintain SpO2 between 92% and 96%.

In addition to ventilator management, critical care transport clinicians were required to provide hemodynamic support. One quarter of all transports received vasoactive infusions prior to transport to maintain adequate blood pressure, and another 7% had vasopressors initiated by the transport team.

Prior to the COVID-19 pandemic, transporting patients prone was rare as evidenced by the limited number of case reports. [10] [11] [12] As proning became important for management of COVID-19 patients [13] [14] [15] [16] [17] [18] , it became necessary to have this available during transport for the most critically ill with prolonged out of hospital time. To meet this need, Lifeline created a protocol for nurses and paramedics to transport patients in the prone position. Didactic and hands-on education was required for all clinicians to ensure proficiency placing patients in the prone position and rapidly supinating, if necessary. The successful transport of fifteen patients in the prone position without adverse effects suggests that this can be performed safely and effectively but further research is warranted.

Data from the first six months demonstrated a low number of patients had inhaled nitric oxide (iNO) or ECMO initiated prior to transport. Inhaled nitric oxide was the only pulmonary vasodilator used during the study period given the risk of aerosolization with other inhaled pulmonary vasodilators. The reason for the low ECMO transports was due to lack of ECMO capability at many of the referring hospitals and often patients were being transferred for consideration of ECMO. Inhaled nitric oxide remains controversial as a therapy for refractory hypoxemia due to cost and lack of clear mortality benefit. [19] [20] [21] Often ventilator optimization and pharmacologic paralysis achieved respiratory stability necessary for transport.

The COVID-19 pandemic has resulted in the need for hospitals and healthcare systems to continuously evaluate their capacity and ability to provide optimal care for COVID-19 patients.

The ability to regionalize care requires the use of highly trained critical care transport teams.

Given the current and anticipated surge of COVID-19, there will likely be a high demand for critical care transport services.

The safe transport of these patients is paramount and requires competency and comfort with titration and initiation of vasopressors, paralytic medications, and ventilator management.

While less common in the first six months, knowledge about how to transport patients requiring iNO is also necessary. The frequency of Lifeline initiated vasopressors, pharmacologic paralysis, and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment and critical thinking.

This report provides valuable insight to the skills needed by these out-of-hospital clinicians as well as the complexity of patients that require transport. Notable limitations include the use of data from a single system, absence of scene transports, and use of paramedic/nurse crew configuration. 

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Chad Bowman, Heidi Hubble, Ben Quintanilla and all of the SORT members were vital in developing and implementing the training, education, management protocols, and transport systems used by Lifeline SORT during the COVID-19 pandemic and offered invaluable insight towards the completion of this study. We would also like to acknowledge STAT MedEvac for their fantastic partnership, clinical expertise, and years of collaboration taking care of critically ill patients.The authors have no financial disclosures and no conflicts of interest to report.

All authors have contributed to the conception and design of the study, or acquisition of data, or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, and the final approval of the version submitted.