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Medical Reference
Manual
Adult Retrieval Victoria
January 2011
2
This document is intended as a reference manual and educational resource for ARV clinical
staff.
It is to be read in conjunction with all Ambulance Victoria Clinical Practice Guidelines.
The Clinical Practice Guidelines developed by AV for use in the field by MICA and Flight
MICA paramedics are appropriate in general scope to the range of practice of medical
Retrieval Physicians. These CPG’s are overseen by the Medical Advisory Committee and are
the initial reference point for ARV clinical practice.
The CPG’s are guidelines and do not strictly limit the scope of clinical practice of
practitioners, who in certain circumstances may reasonably work beyond or outside of the
guideline. The application of guidelines will be reviewed through the case review and audit
system, and appropriate feedback will be available.
Additions to, or alterations to guidelines will occur through the processes of the Medical
Advisory Committee (MAC)
This manual contains material and clinical recommendations that are specific to the retrieval
medical environment, which do not constitute formal guidelines.
All ARV practice occurs within the overarching policy framework of Ambulance Victoria.
This document is managed within standard AV document tracking systems as a departmental
manual. It is endorsed by the AV Medical Advisory Committee
3
Contents INTRODUCTION TO RETRIEVAL SYSTEMS ..........................................................10 What is Retrieval? ................................................................................................................................ 10 Time Critical (retrieval) ....................................................................................................................... 10 Retrieval: The Need .............................................................................................................................. 10 Retrieval Systems.................................................................................................................................. 11 Australian Retrieval Services .............................................................................................................. 11 Adult Retrieval Victoria (ARV) ......................................................................................................... 11 PETS (Victoria).................................................................................................................................. 11 NETS / PERS ..................................................................................................................................... 12 Tasmania ............................................................................................................................................ 12 South Australia –MedSTAR .............................................................................................................. 12 Queensland ......................................................................................................................................... 12 NSW - MRU ...................................................................................................................................... 12 Western Australia ............................................................................................................................... 12 Northern Territory .............................................................................................................................. 13 Operational Structure of Retrieval Systems ...................................................................................... 13 Patient Referral .................................................................................................................................. 13 Clinical Coordination ......................................................................................................................... 13 Response and Logistics ...................................................................................................................... 14 Clinical Intervention........................................................................................................................... 14 Destination ......................................................................................................................................... 15 Clinical Governance ........................................................................................................................... 15 Operational Management ................................................................................................................... 15 Retrieval System Relationships ........................................................................................................... 15 The Future of Retrieval........................................................................................................................ 16 Australian Innovation Trends in Retrieval Systems ........................................................................... 16 ADULT RETRIEVAL VICTORIA ...............................................................................17 Background ........................................................................................................................................... 17 What does ARV do? ............................................................................................................................. 17 When to call ARV ? .............................................................................................................................. 17 Patient Retrieval ................................................................................................................................... 17 Time Critical ......................................................................................................................................... 18 Activity .................................................................................................................................................. 18 ARV Case distribution ......................................................................................................................... 18 Supporting Critical Care Access ......................................................................................................... 19 Critical care access guidelines............................................................................................................ 19 4
Collocation of staff ................................................................................................................................ 20 Medical Workforce ............................................................................................................................... 20 Education and Research ...................................................................................................................... 20 ARV ‘system’ advantages .................................................................................................................... 20 ARV Website ..................................................................................................................................... 21 ARV corporate flyer - distributed in all referral hospitals.................................................................. 21 ARV Activation Promotion Flyer ...................................................................................................... 22 ARV Educational Poster – Preparation for Retrieval ......................................................................... 23 GOVERNANCE .........................................................................................................25 Clinical Governance ............................................................................................................................. 25 Structures ........................................................................................................................................... 25 Processes ............................................................................................................................................ 25 Corporate Governance ......................................................................................................................... 26 Responsibility ........................................................................................................................................ 26 Credentialing ........................................................................................................................................ 26 Credentialing Policy Framework ....................................................................................................... 27 Performance Management & Competency ........................................................................................ 27 Orientation ............................................................................................................................................ 36 Retrieval Consultant – Coordinator Daily Tasks / Activities ............................................................. 37 Retrieval Consultant – Retrieval Physician Daily Tasks / Activities ................................................. 38 Case Flow / Information Transfer....................................................................................................... 39 ARV Database....................................................................................................................................... 40 Case Review & Audit ........................................................................................................................... 43 Clinical Review .................................................................................................................................. 44 Tapes .................................................................................................................................................. 44 Case follow up ................................................................................................................................... 44 CLINICAL COORDINATION IN RETRIEVAL ...........................................................45 What makes a good Clinical Coordinator? ........................................................................................ 45 Different Models ................................................................................................................................... 45 Platforms ............................................................................................................................................... 45 Platform Decisions ............................................................................................................................. 45 Key Coordination Issues ...................................................................................................................... 46 What are the referrer’s needs? ............................................................................................................ 46 What are the coordination planning priorities? .................................................................................. 46 Barriers to good Clinical Coordination? ............................................................................................ 46 Turning barriers into enablers ............................................................................................................ 46 Key relationships................................................................................................................................ 46 Crew Mix ........................................................................................................................................... 46 Crew Mix Decisions........................................................................................................................... 46 Risk mitigation with crewing ............................................................................................................. 46 5
Time Criticality ..................................................................................................................................... 48 What factors impact on Task Time Criticality? ................................................................................. 48 Clinical Advice ...................................................................................................................................... 48 Destination Planning ............................................................................................................................ 48 Problem Solving in Retrieval Coordination ....................................................................................... 49 The nature of complex problems ........................................................................................................ 49 Competing “frames” or “reality models” ........................................................................................... 49 Problem Solving ................................................................................................................................. 50 Multiple Simultaneous Problems ....................................................................................................... 51 Prioritisation of problems ................................................................................................................... 51 Delegation .......................................................................................................................................... 52 Compromise ....................................................................................................................................... 52 Crisis Resource Management and Retrieval Coordination .............................................................. 53 Know your environment .................................................................................................................... 53 Leadership .......................................................................................................................................... 53 Anticipate and Plan ............................................................................................................................ 54 Effective Communication .................................................................................................................. 55 Call for help early............................................................................................................................... 55 Allocate attention wisely .................................................................................................................... 56 Distribute workload ............................................................................................................................ 56 High Performance Teams .................................................................................................................... 58 Effective Teams ................................................................................................................................. 58 Common Vocabulary ......................................................................................................................... 59 Diverse and complementary skillsets ................................................................................................. 59 Collaboration ...................................................................................................................................... 59 Task specific and flexible leadership ................................................................................................. 60 Common Specific Goals .................................................................................................................... 60 Team autonomy.................................................................................................................................. 60 Rapidly forming teams ....................................................................................................................... 60 ARV COORDINATOR GUIDELINES ........................................................................63 Activation of Retrieval ....................................................................................................................... 63 Aviation Resources ............................................................................................................................ 63 Blood and Blood Products ................................................................................................................. 63 Call Processes .................................................................................................................................... 63 Continuity and Handover ................................................................................................................... 64 Coordinator Contact and Availability ................................................................................................ 64 Crew Briefing ..................................................................................................................................... 64 Crew Mix ........................................................................................................................................... 67 Crewing Skill Mix Matrix .................................................................................................................. 68 Defined Patient Transfers ................................................................................................................... 69 Documentation of Coordination ......................................................................................................... 69 Drug Stocks : rare items ..................................................................................................................... 69 ECMO ................................................................................................................................................ 69 Hospitals Reference Database ............................................................................................................ 72 IABP .................................................................................................................................................. 72 Interstate Retrieval Procedures........................................................................................................... 72 Issues Incidents or Problems .............................................................................................................. 73 Morbid Obesity .................................................................................................................................. 73 Night Transfers .................................................................................................................................. 74 Palliation & Non-Transfer.................................................................................................................. 74 Paramedic Consultation ..................................................................................................................... 74 Peak Workload Strategy ..................................................................................................................... 74 Perinatal Emergency Retrievals ......................................................................................................... 75 6
Platform Options: ............................................................................................................................... 76 Prioritisation of Tasks ........................................................................................................................ 77 Receiving Hospital ............................................................................................................................. 77 Regional Retrieval Services ............................................................................................................... 78 Retrieval Physician Tasking ............................................................................................................... 78 Staff Welfare ...................................................................................................................................... 78 Tarmac Handovers ............................................................................................................................. 78 Trauma Calls ...................................................................................................................................... 78 Unable to respond .............................................................................................................................. 79 Uninsured Patients & Private Hospitals ............................................................................................. 80 Videoconferencing Capability............................................................................................................ 80 Coordination Maps ............................................................................................................................... 82 RETRIEVAL PHYSICIAN GUIDELINES ...................................................................85 Aviation resources.............................................................................................................................. 85 Blood Transfusion .............................................................................................................................. 85 Case review & Audit .......................................................................................................................... 85 Clinical Practice Guidelines ............................................................................................................... 85 Command & Control .......................................................................................................................... 85 Communication & Public relations .................................................................................................... 85 Contact and Availability .................................................................................................................... 86 Credentialing ...................................................................................................................................... 86 Death of Patient .................................................................................................................................. 86 Debriefing .......................................................................................................................................... 87 Documentation ................................................................................................................................... 87 Equipment .......................................................................................................................................... 87 Biomed Equipment............................................................................................................................. 87 Fatigue................................................................................................................................................ 88 Handover ............................................................................................................................................ 89 Incident reporting ............................................................................................................................... 89 Issues and Problems ........................................................................................................................... 89 Leave .................................................................................................................................................. 90 Morbid Obesity .................................................................................................................................. 90 Night transfers .................................................................................................................................... 90 Patient preparation and packaging ..................................................................................................... 90 Performance Management.................................................................................................................. 90 Retrieval Logistics ............................................................................................................................. 90 Road resources ................................................................................................................................... 91 Safety ................................................................................................................................................. 91 Staff Welfare ...................................................................................................................................... 92 Tarmac Handovers ............................................................................................................................. 92 Team Performance ............................................................................................................................. 92 Trauma System .................................................................................................................................. 92 AEROMEDICAL SAFETY .........................................................................................95 Aircraft ............................................................................................................................................... 95 Safety card.......................................................................................................................................... 95 Emergency Exits and doors ................................................................................................................ 95 Pre flight safety briefing..................................................................................................................... 95 Seat belts ............................................................................................................................................ 95 Emergency Oxygen during Cabin Depressurisation .......................................................................... 96 Fire extinguishers ............................................................................................................................... 96 Survival equipment ............................................................................................................................ 96 Emergency Locator Transmitter (ELT) .............................................................................................. 97 Emergency Landing ........................................................................................................................... 97 Life jackets ......................................................................................................................................... 98 Airside Safety ..................................................................................................................................... 98 Strategies for controlling risks/hazards .............................................................................................. 99 7
Fixed wing aircraft (FW) danger areas............................................................................................... 99 Approach to a fixed wing aircraft ...................................................................................................... 99 Approach to a ROTARY wing aircraft .............................................................................................. 99 Cabin safety........................................................................................................................................ 99 RETRIEVAL MEDICINE ..........................................................................................101 Airflight Medicine –the basics ........................................................................................................... 102 The Effects of Altitude on Gas Volume ........................................................................................... 102 The Effects Of Altitude On Oxygen Availability............................................................................. 102 The Effects Of Pressure Changes On Gas Bubble Formation .......................................................... 102 Stresses Of Flight ............................................................................................................................. 102 Pressurized Environments ................................................................................................................ 103 Confined Spaces ............................................................................................................................... 104 Addisonian Crisis................................................................................................................................ 105 Asthma - refractory ............................................................................................................................ 106 Beta Blocker Toxicity ....................................................................................................................... 108 Clonidine toxicity ................................................................................................................................ 110 Confirmation of Central Venous Catheter Placement ................................................................ 111 ECMO Retrieval ................................................................................................................................. 112 Retrieval Team ................................................................................................................................. 112 Equipment ........................................................................................................................................ 112 Cannulation ...................................................................................................................................... 112 ECMO Circuit .................................................................................................................................. 113 Clinical Considerations .................................................................................................................... 113 ECMO Transfers : ............................................................................................................................ 114 ECMO CPAV setup ......................................................................................................................... 116 ECMO Fixed Wing Setup ................................................................................................................ 118 Clinical Staff Checklist for ECMO transfers.................................................................................... 119 Equipment: ARV Standard Kit......................................................................................................... 120 Gastrointestinal Haemorrhage .......................................................................................................... 122 Hyperosmolar non-ketotic coma (Hyperosmolar Hyperglycaemic crisis) ..................................... 124 Intra-aortic Balloon Pump................................................................................................................. 126 Intracranial Haemorrhage................................................................................................................. 131 Morbidly Obese Critical Care Patient Retrieval ............................................................................. 133 Definitions........................................................................................................................................ 133 Specialised Clinical Units ................................................................................................................ 133 Physiologic consequences ................................................................................................................ 133 Assessment ....................................................................................................................................... 134 Mechanical ventilation ..................................................................................................................... 134 Pharmacology/Weight-Based Dosing .............................................................................................. 135 Transport Platform Options.............................................................................................................. 136 Bariatric Imaging Options ................................................................................................................ 137 Non ST Elevation AMI (NSTEMI) ................................................................................................... 139 8
AMBULANCE VICTORIA TRANSPORT PLATFORM SPECIFICATIONS ............141 AV Platform Capability and Fitout .................................................................................................. 142 Outline of MICA and Flight Paramedic Skillsets ............................................................................ 145 9
Inttroductio
on to Retrrieval Systems Wh
hat is Retrrieval? •
•
•
•
•
•
Interhosspital transferr using speciialised clinical staff, transsport platform
ms and
equipmeent.
ARV doo not undertaake primary response
r
but some other retrieval
r
servvices combin
ne
primary and secondaary response within the saame framew
work.
m
nursiing, paramed
dic/MICA.
Staff maay include medical,
Specialised assessmeent and manaagement, priior to and durring transfer of critically ill
patients..
From facilities wherre resources or
o services arre inadequate, to definitivve care.
Aim to provide
p
the same
s
or highher level of cllinical care thhan that avaiilable at the point
p
of referrral.
R
Receiveer
R
Retriev
val
Referrral
Tim
me Critica
al (retriev
val) In reespect of Rettrieval Transsfer – A patieent is consideered time criitical if the paatient has a
cliniical conditionn which pressents an imm
mediate threatt to life, limbb, cognition oor future quaality
of liife, and
• Delay inn definitive trreatment willl significantlly increase thhat outcome risk, and
• Definitivve managem
ment of that coondition or threat
t
is likelly to be achieeved by urgeent
transfer to another hospital, or
• Management of that condition deefinitively, or
o for a prolonnged interim
m period, is
beyond the
t resource capacity or clinical skill capacity of the current pprovider (or
would reesult in unaccceptable resoource drain and
a exposuree of other pattients to risk)).
Rettrieval: Th
he Need The need for retrrieval system
ms arises duee to a range of
o systems isssues. The reaal world
urbaan/rural dividde in regard to
t health infrrastructure reesults in patient isolationn and the need
d for
retriieval transferr in many criitical scenarios. The majo
ority of casess are transferrred because the
10
required level of clinical care or the necessary range of specialized clinical services are
unavailable at the referral point. This applies to both rural and metropolitan retrieval. To
optimize the quality of clinical care during transfer, specialized retrieval systems and services
are necessary.1
Retrieval services also usually provide outreach and support via clinical advisory systems
using a range of technologies.
Retrieval Systems Systems vary by State and Internationally, and there are no uniform system design standards.
Services vary in their use of platforms and crewmix (nurse, paramedic,Dr).
Drs may be employed by health dept, ambulance, by contract with private provider
(RFDS/Careflight) or services may utilise hospital personnel. A state service may incorporate
several retrieval service providers with central coordination e.g NSW (Air Ambulance NSW,
Careflight NSW, RFDS). Non government owned helicopters may be part of a state system.
Often started by passionate volunteers they are funded by community donations, corporate
sponsorship and government grants.
Australia has moved towards centralised state systems for retrieval. Central coordination
centres may incorporate nurses, paramedics and Drs, working together utilising their unique
skills and experience. Neonatal, paediatric, perinatal and adult retrieval services may be
collocated or separate. Some services have evolved due to their unique environment:
• Rugged mountainous terrain (Norway)
• Urban trauma service (HEMS London)
• European systems dealing with high density populations and high speed roadways
• Military systems
Australian systems are characterized by their need to deal with the “The tyranny of distance”
Large areas, sparsely populated, major hospitals separated by vast distances, mountain ranges
and extremes of weather and environment. In addition many advances in medicine &
technology are concentrated in major centres, increasing the need for transport. Examples
include interventional management of acute coronary syndromes and interventional radiology
e.g angio-embolisation.
Australian Retrieval Services Adult Retrieval Victoria (ARV) Managed by Ambulance Victoria
Responsible for the coordination of adult emergency retrieval services within Victoria.
ARV provides coordination of retrieval services within Victoria and provides clinical advice
relating to the management of time critical patients requiring retrieval.
The service also facilitates access to intensive care and coronary care beds across Victoria.
ARV transfers critically ill adults throughout Victoria, Tasmania and southern NSW.
Approx 3000 cases, 1500 retrievals pa
PETS (Victoria) Transfers critically ill children from hospitals throughout Victoria, Tasmania, and southern
New South Wales to the Royal Children’s Hospital and Monash Medical Centre in
Melbourne.
PETS makes the resources of paediatric intensive care available to severely ill children
throughout Victoria and offers them safe, expert inter-hospital transfer to a specialist
paediatric intensive care.
PETS also provides telephone advice to doctors, nurses, and ambulance staff on the
resuscitation of critically ill children.
1
Zalstein S, Danne P, et al, The Victorian major trauma transfer study. Injury 2010
Jan;41(1):102-9.
11
Approx 350 emerg cases per year
NETS / PERS NETS
• auspiced by the Royal Women’s Hospital
• provides safe transportation of sick newborn infants,
• continuing education in perinatal care and clinical advice regarding care of sick newborn
infants.
• 1000 approx emerg cases pa
PERS
• provide maternity care providers in Victoria with a coordinated, timely and safe approach
to
• Facilitating perinatal emergency transfers to appropriate facilities when required,
• Providing access to obstetric and neonatal resource information and
• Providing access to optimal expert clinical advice about perinatal emergencies.
• PERS and NETS share a common co-ordination service
Tasmania The Tasmanian Medical Retrieval Service (TMRS) operates out of Launceston & services the
whole state including the Bass Straight islands, TMRS only conducts adult retrievals.
TMRS is run in conjunction with the Tasmanian Ambulance Air Wing, the majority of work
is secondary response and interhospital transfers of critically ill patients who require specialist
care; occasionally the retrieval service will utilise the Police Air Wing where necessary.
The NETS/PETS service operates from the Royal Hobart Hospital.
South Australia –MedSTAR Medical retrieval service that commenced in 2009.
Health Department linked
Currently MedSTAR only coordinates adult retrieval services.
Paediatric and neonatal coordination will occur from MedSTAR’s base from February 2010
Multidisciplinary staffing and crew models
Queensland Retrieval Services Queensland: paediatric, neonatal & adult retrieval services were combined
under a new retrieval service 2009.
All calls for any of the specialties and the early notification of trauma are directed to ring the
one number.
The RCQ directs callers to their area of required specialty and liaises with Queensland
Ambulance Service (QAS), Royal Flying Doctor Service, Community Helicopter Providers
and contracted services
Retrieval Medical staff all contracted from Careflight
NSW ­ MRU The Aeromedical and Retrieval Services Division (of Ambulance) comprises of the
Aeromedical Operations Centre (AOC), the Aeromedical Retrieval Unit (AMRU), fixed wing
services and rotary wing services.
Staffed by Ambulance uniformed personnel and critical care clinicians.
Provides clinical care and statewide air transport of patients from pre-hospital locations and
IHT
Most patients are transported by fixed wing aircraft staffed by flight nurses.
Urgent responses to major accidents, emergencies and neo-natal cases are usually provided by
helicopters staffed with paramedics, doctors and/or nurses.
Western Australia RFDS based system (RFDS governance)
Mixed RFDS, Careflight aircraft
12
Paramedic Primary response
Clinical coordination recently developed medical staff
Funding increases indicate development
Major distance considerations
Northern Territory Centralised clinical coordination
RFDS governance largely
Medical Staff from Alice Springs and Darwin principally
Part State, part Careflight resources
Operational Structure of Retrieval Systems Retrieval systems generally have a number of common structures:
• Patient referral
• Clinical Coordination
• Response and Logistics
• Clinical Intervention
• Destination
• Clinical Governance
• Operational Management
Patient Referral Referral reason
Specialised service availability
Bed (Crit Care) availability
Staff / skills
Timing
Early vs Late
Service expectation
Communication
Need / coping / pressure
“too sick for here”
Junior staff
Understanding the capability of the referrer
Local escalation and help-seeking
Clinical Coordination Information gathering
Documentation
Planning
Immediate care
Response
Destination
Logistics
Crew
Transport Platforms
Balancing demand and capacity
o Right patient for right destination
o System monitoring and action (escalation)
Leadership
Guidance
Control
13
Arbitration
Problem solving
Flexibility
Holistic view
Negotiation
Patient perspective
Knowledge
Expert
Response and Logistics Crew mix decisions
Patient stability
Patient complexity
Available crew
Fatigue
Shift times and capability (esp pilots)
Specialised crews (ECMO etc)
Platform decisions
Time criticality
Distance
Destination features
Referral
Reception
Weather
Fuel
Equipment logistics
Standard kit management
Specialised equipment
Multi platform and multi-agency coordination
Compatibility of equipment
Communications
Ongoing communications
Referrer
Response team and crews
Receiving hospital
Quality and performance
Timeliness
Adverse events & near misses
Clinical review
Clinical Intervention Maximise patient preparation by referrer through excellent clinical coordination and advice
Involvement of receiving hospitals (continuity of care and planning)
Assessment
Conscious planning
Communicated
Risk assessment
o Communicated
Appropriateness of intervention
o What is necessary not what is possible
Transport awareness
Consultation
Coordinator
14
Receiving unit
Destination Appropriate for patient need
Neurosurgery, interventional cardiology, major trauma
Appropriate for system
Avoidance of over-service
o Tertiary problems for tertiary hospitals where possible
Platform and logistic considerations
Load sharing at peak demand times
o Managing systems with limited / no capacity
o Monitoring
o Escalation
o Pre-planning vs reactivity
Clinical Governance Guidelines for Coordinators
Guidelines for Retrieval Clinicians
Clinical Practice Guidelines
Support Staff Guidelines
Equipment Management Systems
Orientation and Training
CME
Clinical Documentation
Case follow up and feedback
Case Review and Audit
Incident Management
Indicator Measurement
Credentialing
Performance Management
Operational Management Program Guidelines
Quality Reporting
Reporting to Medical Advisory Committee
Management Guidelines
Data Management
Organisational Structure
Contracts and Memoranda of Understanding
Budget and Financial System
Annual and Strategic Planning
Management and Data Reports
Retrieval System Relationships In many respects, retrieval services operate at the interface of many health systems and
jurisdictions. This results in a need for special awareness and communication. Work in the
retrieval coordination and clinical response setting is often highly visible, emotive, politically
‘relevant’ and sensitive. Staff need to acquire skills in ambassadorial behavior, as well as the
important skills involved in managing pressured health workers, patients and families.
Stakeholders include:
• Staff groups (part-time staff)
15
•
•
•
•
•
•
•
•
Transport platform providers
Ambulance services
Aeromedical organisations
Commercial organisations
Other retrieval services
o Specialised (NETS, PETS, etc)
o Commercial / international
o Interstate
Referral base
Critical Care Community
Health departments and government
The Future of Retrieval Increasing demand (through unmet rural health needs)
o Ageing rural populations
o “tree-changes”
o Dwindling medical and nursing workforce in rural settings
o Urban concentration of wealth and political influence
Process Increased centralization
o Building economy and efficiency from commonality
o Commonality is not always seen / recognised in systems
o Process not detail defines systems
Building on relevant interfaces
Clinical advice, outreach and support
Improved communication
o Technology
o Telehealth
o Information technology (e.g. CIS, Digital Imaging)
o Web-based real-time comms
Platform management
o Availability
o Coordination
o Funding
Specialised staffing
o Tertiary qualifications
o Specialist medical college
Australian Innovation Trends in Retrieval Systems Replacement of many fixed wing aircraft
Increased reliability & reduced maintenance costs
o $250 million to RFDS federally
o Little consideration of larger airframes
Replacement of rotary wing aircraft
o Australian fleet almost exclusively twin engine IFR
Centralised clinical coordination
o Strengthened in almost all jurisdictions
o High level specialist advice in some & planned in most
Governance
o Increasing integration into a single accountable service
o Enthusiastic volunteers to professionalism
o Improved training, data collection & audit
Disaster
o Integration of retrieval / prehospital / disaster capability
16
Adult Retrieval Victoria Background Review of Retrieval services 2006-7
June 2007, at DHS’ request, Ambulance agreed to assume responsibility for managing the
Victorian adult retrieval service
Transition of VAERCS (Hospital Based) to ARV occurred November 2007
Priorities
Improve Governance
Integrate within Ambulance Victoria
Develop service improvement plan (SIP) for next 3-5 years
What does ARV do? •
•
•
•
•
Adult Retrieval Victoria (ARV) provides an integrated, quality and timely state-wide
adult retrieval and critical care coordination service 24 x 7.
Providing telephone advice and assistance relating to the clinical care of critically ill
patients (and related administrative concerns);
Providing adult emergency retrieval services for time critical and critically ill patients
across Victoria when necessary; and
Coordinating access for critically ill adult patients to the required level of care (eg.
intensive care or coronary care beds etc).
Trauma Advice and Referral Line: ARV manages this service, connecting referral
hospitals to appropriate receiving trauma services.
When to call ARV ? Referrers are advised to contact ARV for:
o Telephone advice and assistance relating to the clinical care of critically ill
patients (and related administrative concerns);
o Adult emergency retrieval services for time critical and critically ill patients
across Victoria
o Coordination of bed access and inter-hospital transfer for critically ill adult
patients
ƒ That is, into an intensive care, high dependency or coronary care unit,
or to a destination that will provide a critical intervention or
procedure
ARV provides educational material and support to referral centres to continuously improve
referral timeliness and quality.
Patient Retrieval Retrieval is the transfer of a patient from one hospital to another in which specialised clinical
teams and transport platforms and equipment are used.
o These teams may include medical, nursing, paramedic or MICA paramedic
personnel.
o Patient retrieval provides specialised assessment and management, prior to
and during transfer of time critical or critically ill patients.
o Retrieval occurs from facilities where resources or services are inappropriate
for ongoing care to facilities that are able to provide definitive care for the
patient.
17
o
During transsfer, a retrievval team prov
vides the sam
me or higher standard of care
c
than that avaailable at thee point of refe
ferral.
ƒ Thiss refers to thee skill set and care standaards offered by the retrieval
team
m – both direect clinical caare and transport care (thhis is not crafft
grouup, professioon or ‘rank’ specific).
s
Tim
me Critica
al In reespect of Rettrieval Transsfer – A patieent is consideered time criitical if the paatient has a
cliniical conditionn which pressents an imm
mediate threatt to life, limbb, cognition oor future quaality
of liife, and
o Delay in deffinitive treatm
ment will sig
gnificantly inncrease that ooutcome risk
k, and
o Definitive management
m
o that condiition or threaat is likely to be achieved
of
d by
urgent transffer to anotheer hospital, orr
o Managemennt of that conndition definiitively, or forr a prolongedd interim perriod,
is beyond thhe resource caapacity or clinical skill capacity of thhe current
provider (or would resullt in unaccepttable resourcce drain and exposure of
other patientts to risk).
Acttivity Re
etrievals
Casee volume: 30038
Retrrieval : 1515
Dr & Paramedicc (MICA or ALS)
A
30%
Paraamedic 70%
Casee referral basse: 65% non--metro
Retrrievals: 80% rural and reggional originn
Platfforms 65% air,
a 35% roadd
Critiical care destination: ~ 95%
Desttination hosppital: 15% reegional, 50% tertiary
Highhly resourcedd: Mission tiimes averagee ~6 hours
3038
3030
0
Case
es
246
61
2
2014
1585
1515
2008-09
9
2009-10
720
520
2006--07
2007-0
08
ARV
V Case disstribution
n Gippsland
15.09%
Grampians
7.39%
Hume
71%
6.7
Barwon Soutth West
7.88%
Loddon Mallee
18.57%
Sou
uth Australia
0.04%
Tasmania
0.14%
NSW
2.66%
M
Metro
41.51%
4
18
Supporting Critical Care Access Supporting Critical Care Access
The Victorian Critical Care Access webpage provides a close to real time picture of the
occupancy of Victorian Critical Care Units (ICU/HDU/CCU). It contains advanced
technology aids to facilitate monitoring of the critical care occupancy status and automated
alerts and messaging to notify key personnel within the acute health system of high levels of
occupancy and demand.
ARV hosts the website and manages website security, access, passwords and problems. ARV
uses the website to assist in the management of critical care transfers, ensuring timely and
appropriate access to critical care beds across the state.
Health services are responsible for ensuring timely data entry and for responding to high
demand alerts.
ARV recommends that the responsibility for data entry is allocated to a bed access manager
or similar role.
A hospital Executive must be nominated to receive and respond to SMS high occupancy
alerts.
Accessing the website is restricted to health services with an IP address registered in the
system.
Hospital Incident Response Data (HIRD) Management
This feature is activated during major emergencies, disasters and multi victim incidents to
allow monitoring of acute hospital and/or surge capacity and impacts. (Eg. in the event of
an epidemic or natural disaster where there is a need for monitoring of hospital status.)
Critical care access guidelines This guideline relates to the DHS Interim Critical Care Capacity Guideline.
(http://www.health.vic.gov.au/criticalcare/ccguide08.pdf)
Critical Care Access Restriction: occurs when ARV consultation mechanisms and/or the
critical care bed website indicates that a critical care patient cannot be placed in an
appropriate public or private bed within the next 6 hours.
Procedure to be followed at the time, and includes notification of Director or delegate,
and a number of external stakeholders including ICU directors.
19
Should there be need for a patient to access a bed in this setting (and no bed is available) a
defined transfer may be authorised by the Director of ARV or delegate. This process applies
for patients needing retrieval to a site where definitive care can be provided, and assumes that
such care is not available at the point of referral. The process assumes that the patient will
gain a higher level of care through this transfer. A patient should not be transferred under this
policy if all that is achieved is the same standard of care in another setting e.g. transfer of an
intubated overdose patient from ED in a metro centre with ICU consultation to the ED of a
tertiary centre.
Collocation of staff All staff based at Essendon Airport
• With AAV, June 2009
• Office, Admin, Support
• Equipment
• Coordination
• RASO
• Crit Care Coordinator
• Flight coordination
Medical Workforce On site coordination (12 hrs per day)
Covers > 75% of calls
• RP on site
• Registrars 24hrs
• Consultants 9hrs
• On call over night
Education and Research Grad Cert in Aeromedical and Retrieval Studies
Monash, DCEHPP
Registrar Training accreditation ACEM
Registrar appointments
Medical Student elective
ACEM 2009 conference
Research projects under consideration
o RAPS and REMS scores
o Death in ICU post retrieval
o ViTCCU
ARV ‘system’ advantages Whole System
Efficient Resource Use: decrease secondary transports
Patient Centred
Operational & Coordination
Standardisation
Quality
20
ARV Website www.arv.vic.gov.au
ARV corporate flyer ­ distributed in all referral hospitals 21
ARV Activation Promotion Flyer 22
ARV Educational Poster – Preparation for Retrieval 23
24
Gov
vernance
e The Bristol Inquuiry and the Douglas
D
Inquuiry into
Obstetrics and Gynaecologic
G
cal Services at
a King
Edw
ward Memoriial Hospital clearly
c
demoonstrate the
Regulatio
on impoortance of thhe Board’s acctive involveement in
(Law)
and governance of clinical saafety and quaality.
In thhese cases, thhe Boards annd senior mannagement
faileed to respondd to importannt safety and quality
Corporate Clinical issuees and patiennts and famillies experiennced
Goveernance
G
Governance
serioous and avoidable adversse events.
Bothh cases reveaaled evidencee of:
o a closed cultture unsuppoortive of
openly discllosing errors and adverse events;
m
t respond efffectively to known
to
k
cliniccal problemss;
o failure by management
o monitor, reeport and respond to
o non-existentt or ineffectivve systems to
performancee problems, errors
e
and ad
dverse eventss;
nd families, particularly
p
w
when things
o poor commuunication witth patients an
went wrong;;
mplaints and potential meedical negliggence cases;
o poor manageement of com
t
and credentialing
c
g to ensure cllinicians werre sufficientlly
o inadequate training
skilled;
m
and mortality monitoring
m
a review syystems;
and
o inadequate morbidity
o poor clinicall and emotional outcomees for patientss and familiees.
Clin
nical Gove
ernance The system by which
w
the govverning bodyy, managers and clinicianns share responsibility an
nd
are held
h accounttable for patient care, minnimising risk
ks to consum
mer, and for continuously
monnitoring and improving
i
thhe quality of clinical caree.
(ACHS)
o build a cultuure of trust annd honesty;
o foster organisational com
mmitment to continuous improvemen
i
nt;
o establish riggorous monitooring, reportting and respponse system
ms;
o evaluate andd respond to key aspects of
o organisatiional perform
mance.
Stru
uctures:
o
o
o
o
o
o
o
Processes:
o
o
o
o
o
o
o
Policy
Clinical Guiidelines and Standards
Clinical Pracctice Guideliines
Support Stafff Guideliness
Orientation and Trainingg
CME
Indicator Meeasurement
Clinical Doccumentation
Case follow up and feeddback
Case Review
w and Audit
Incident Maanagement
Credentialinng
Performancee Managemeent
Equipment Management
M
t Systems
25
Corporate Governance Framework of rules and practices by which a board of directors ensures accountability,
fairness, and transparency in the organisation’s relationship with its all stakeholders
(financiers, customers, management, employees, government, and the community).
This framework consists of:
explicit and implicit contracts between the firm and the stakeholders for distribution of
responsibilities, rights, and rewards,
procedures for reconciling organisational goals and outcomes with the duties, privileges,
roles, and performance of its components
procedures for proper supervision, control, and information-flows to serve as a system of
checks-and-balances.
Corporate Governance functions
o Strategic Planning
o Program Guidelines
o Quality Reporting
o Reporting to Medical Advisory Committee
o Management Guidelines
o Data Management
o Organisational Structure
o Contracts and Memoranda of Understanding
o Budget and Financial System
o Annual and Strategic Planning
o Management and Data Reports
Responsibility Responsibility is the state characterised by capability of fulfilling an obligation or trust, being
answerable or accountable, and having authority or control
Key clinical responsibilities:
Safety
Minimise risk
Action not reaction
Effectiveness
Knowledge and Ability
Clinical Outcomes
Efficiency
Add value at every step
Eliminate waste
Communication
Effective & professional
Humanistic
Credentialing A process to ensure:
services are provided within the capability and needs of the health service and its respective
campuses
medical practitioners appointed to the health services are competent and able to fulfill the
tasks and responsibilities of their appointment
a positive environment for medical practitioners, with a clear recognition of the resources
required to support high-quality services
appropriate and effective clinical governance.
26
Credentialing Policy Framework The credentialing policy framework for health practitioners is set by Federal Legislation and
administered by the Australian Health Practitioner Regulation Agency (AHPRA), and in the
local jurisdiction by the Department of Health
Credentialing within an organization is an annual process to ensure:
• services are provided within the capability and needs of the health service and its
respective campuses
• medical practitioners appointed to the health services are competent and able to fulfill
the tasks and responsibilities of their appointment
• a positive environment for medical practitioners, with a clear recognition of the
resources required to support high-quality services
• appropriate and effective clinical governance.
Performance Management & Competency ARV has a performance management system that includes continuous feedback, and an
annual review of performance and credentials. This is consistent with standard government
and DH policy and systems.
Registrar supervision and performance management follows standard training college systems
and requirements.
The structured document supporting ARV performance management is included below:
Performance Management is a process for establishing a shared workforce understanding
about what is to be achieved at an organisation level. It is about aligning the organisational
objectives with the employees’ agreed measures, skills, competency requirements,
development plans and the delivery of results.
Objectives
• Ensure that employees understand their role in working towards the goals and
objectives of ARV and Ambulance Victoria
• Ensure employees have the skills and resources they need in order to do what is
expected of them
• Promote regular feedback and discussion about contribution and professional
development.
• Recognise and encourage continued optimal performance
• Ensure effective people management processes and supportive working environments
27
Name: Current Clinical Appointments (if changed): What retrieval‐relevant CME have you participated in, in the last 6 months?
Have you published material in the last year of interest to retrieval services? Do you have any conditions or restrictions placed on your medical registration (either in Victoria or elsewhere), imposed in the last year? … Yes … No Have you been the subject of disciplinary action in the course of your work as a medical practitioner in the last year? … Yes … No Notes Certification required to demonstrate the following: 1.
Medical registration & Medical indemnity cover 2.
Familiarity with ARV Manual (including access, contents & updates) 3.
CME currency (College MOPS certification or similar) 4.
Aircraft and Vehicle Safety completed 5.
CRM training completed 6.
Completed Procedures Competency Checklist 7.
Completed Grad Cert Aeromed & Retrieval Studs or equivalent 8.
Performance review and credentialing interview (ARV Director or CA) Checked † † † † † † † ..…/.…./….. I authorise access to the above information by representatives of AV credentialing committees. I agree to notify the Medical Director, Adult Retrieval Victoria of any event/situation which may impact on my ability to exercise my scope of clinical practice, whether it be due to medical registration matters or otherwise. This includes matters about which I consider that the Medical Director, Adult Retrieval Victoria would wish to be informed and, as a minimum, includes the kinds of information covered in this document (such as any criminal charges or convictions, reductions in registration or insurance). Medical Officer Signature……………………………………… Certified by _________________________________________ (print name/signature & date) ARV Clin Advisor / Director 28
Critical Care Coordinator Reflection & Performance Management Interview Notes
Reflection on personal practice: • Identify areas for improvement in aeromedical and clinical knowledge relevant to the ARV environment • Problem Solving • Escalation & help‐seeking Reflect on their case/phone manner, particularly in relation to: • Difficult patients • Multiple difficult patients at the same time • Significant resource constraints, eg aviation resources, bed state. • “Stressed” referrers Incident Review • Issues identified in the incident review process will have been presented previously. Any outstanding issues identified for discussion. Improvement / Development plan or activities Certified by _________________________________________ (print name/signature & date) ARV Clin Advisor / Director 29
Retrieval Physician Reflection & Performance Management Interview Notes
You will be provided with a list of cases performed in the last year. It is suggested that you review these cases, and flag areas for discussion. Note: case volume, complexity, challenges, learnings… Reflection on personal practice: • Identify areas for improvement in aeromedical and clinical knowledge relevant to the ARV environment Identify a process to address these areas for improvement. • Provide a written summary of this plan to the Medical Director. Incident Review • Issues identified in the incident review process will have been presented previously. Any outstanding issues identified for discussion. Improvement / Development plan or activities
Certified by _________________________________________ (print name/signature & date) ARV Clin Advisor / Director 30
ARV Retrieval Physician Procedure Competency Checklist Demonstrate skills and knowledge to competently perform or explain the following: Note non compliance and educational plan Basic Life Support Expired Air Resuscitation External Cardiac compression Advanced Cardiac Life Support ACLS algorithm and drug doses Defibrillation in aircraft Transvenous pacing – use of & trouble shooting
Transcutaneous pacing
Airway Procedures Nasopharyngeal airway ‐ selection and insertion
Oropharyngeal airway ‐ selection and insertion
Bag‐valve‐mask ventilation Endotracheal intubation Laryngeal mask airway insertion/Intubating LMA
Failed airway drill & equipment Needle cricothroidotomy Minitracheostomy Breathing Needle Thoracentesis Chest Drain Insertion & connection to drainage system
Circulatory CVC insertion Intraosseus insertion
Central line connection & management
Arterial line connection & management
Connection, pressure bag, flushing Connection to Propaq
Transducer zeroing Prime and commence a blood pump set
Splinting & Packaging
Sizing & application of cervical collar 31
Application of Ferno Head Immobilizer
Application of Donway Traction Splint Log rolling Ancillary Equipment Syringe pump Alteration of syringe type Adjustment of rates Alarm functions Ventilator Demonstrate connection to patient and use of the following:
PEEP valve Use of test lung & testing disposable circuit Adjust of FiO2, frequency, minute volume and pressures
Use of non invasive settings Alarm functions Propaq Monitor Demonstrate use of the following: Pulse oximetry 3‐lead ECG NIBP Temperature Capnometry Invasive pressure Temperature Alarm settings Volume settings Display options In service demonstration mode Zoll Setup and commence operation. Demonstrate: Lead selection Charging of defibrillator and selection of settings
Setup & management of transcutaneous pacing
Alarm settings 32
i‐Stat analyzer Demonstrate analysis of specimen Indications for use Fault finding Glucometer Analyze specimen 33
Oxygen system Road Car Heli FW Aircraft and Vehicle Equipment & Safety Volume available and duration of supply Operation of supply, connection of additional supplies
Suction System Operation of electrical system
Operation of Venturi system
Aircraft power Power sources available ‐ voltages and current
Radio & intercom system Use of intercom and radio Stretchers Locking and unlocking in position in vehicle
Operation of back rest Operation of drop down legs (if fitted)
Loading patient Safety Fire extinguisher PPE Tyvec coveralls Masks Glasses Disposable gloves Equipment stowage and securing
Safety briefing Defibrillation in vehicles Workspace tidiness / order Operation of main hatch & steps
Loading processes Chain of Command and responsibility
34
Completion of CRM learning task (one of): … ARV CRM workshop (annual) … Accredited CRM workshop ie EMAC, ACME …../…../….. or ARV simulation day (once every 3 years) – date last completed: Certified by _________________________________________ (print name/signature & date) ARV Clin Advisor / CSO / AV Team manager OR Competency demonstrated by certified compliance with equivalent CME or training process. Evidence reviewed and approved by ARV Director or Clinical Advisor. _________________________________________ (print name/signature & date) ARV Director or Clinical Advisor 35
Orientation A comprehensive orientation process reviews all operational and structural elements of a
retrieval service:
o Base orientation and map
o Staff introductions
o Coordinator Guidelines
o Retrieval physician guidelines
o Process flow chart for coordination
o Documentation (coordinator record)
o Coordinator reference pack
o Outline of case review systems
o Incident review system
o Daily activities sheet
o Induction Checklist
o Site policies re access and security
o AV website
o ARV website
o AV intranet – policies, bulletins etc
o Photo ID
o Swipe / Access card
o HR processes complete
o Payroll processes complete
o Salary packaging
o Superannuation
o Mobile phone if applicable
o Pager if applicable
o Telephone use and recording
o ARV database
Orientation and induction of new staff also involves developing explicit understandings of
daily “routine” activities. This ensures smooth running of a service, and relaiable performance
of important checking and preparation routines. (see below).
36
Retrieval Consultant – Coordinator Daily Tasks / Activities Receive Handover
Familiarise self with in-progress jobs and critical care bed state.
Coordinate Cases
The process for telephony and case documentation is attached (flowcharts)
Follow up
Public to Private transfers (each morning) – check patient clinical status, liaise with ARV
business manager, determine need or appropriateness for transfer (and coordinate). Only
patients for whom ARV has financial responsibility need be followed up.
The coordinator will review in the ARV database, cases they performed on their previous
shift.
Data entry
After each mission, it is the responsibility of each coordinator to enter required coordination
information into the ARV database (see attached guide to the ARV database – areas with blue
background are coordinator data fields). For missions coordinated off-site, the coordination
record is returned to the ARV office by fax or mail for data entry. All data entry will be
checked / verified by an ARV admin officer.
Hospitals Database
Coordinators are required to check the hospitals database regularly for updates and
information. Where new information is obtained about a hospital (of relevance to the
database) please notify the ARV Admin Officer.
CME:
Coordinators are encouraged to take part in valid CME and research activity during waiting
periods on routine shifts.
Meetings
If available, coordinators on base will attend quality and operational issue meetings as
appropriate – including Incident Review Meetings, Case Coordination Review meetings
(monthly)
Provide Handover to next coordinator
37
Retrieval Consultant – Retrieval Physician Daily Tasks / Activities Equipment Check
Drug Check
Follow up:
All retrieval cases with medical crew will have a follow-up form attached by the ARV office
Case sheets will be stored in the ARV office.
The RP will obtain records from the previous 24 hour period and perform a 2 level follow up.
1. The receiving hospital will be contacted to ascertain patient status (with particular
reference to retrieval processes and care)
2. The referring hospital will be contacted (subsequently) to provide feedback regarding
pre-transfer patient care and preparation (where relevant), in-retrieval progress, and
information available from the destination hospital.
This information and persons contacted will be recorded on the follow-up form.
Data entry
After each mission, it is the responsibility of each Retrieval Physician to enter required
clinical information into the ARV database. For missions concluding after 2200 hrs, the PCR
may be left in the ARV office for entry the following morning by the retrieval physician on
the next shift. Each morning, the 0800-1800 shift RP will check for outstanding PCR’s from
the previous day (or provided by offsite RP’s) and enter them into the database.
Case reviews
The retrieval physician will review case records for missions where they have received a
formal case review document from the Clinical Advisor
The retrieval physician will review follow up forms filed for cases performed on their
previous shift (these may be obtained from the ARV admin officer).
CME
Retrieval physicians are encouraged to take part in valid CME and research activity during
waiting periods on routine shifts.
Meetings
If available, retrieval physicians on base will attend quality and operational issue meetings as
appropriate – including Incident Review Meetings, Case Coordination Review meetings
(monthly)
After each mission the retrieval physician will:
• Return their PCR to the ARV office
• Restock the drugs and equipment used, and sign off the register for this.
• Provide a verbal debrief on the mission to the coordinator if still on-site
Complete clinical data entry into the ARV Case database (unless the case finishes >2200 hrs)
38
Case Flow / Information Transfer 39
ARV Database 41
The ARV is a web based prototype database that supports clinical recording and management
reporting for ARV. The database is capable of real time data entry and has limited in-built
decision support features.
42
Casse Review
w & Audit 43
Clinical Review All medical retrieval cases are reviewed (ARV clinical advisor or director or CSO – randomly
allocated)
All cases are feedback to staff involved
25% ARV tasked paramedic (aeromedical cases) reviewed
Variations are recorded and coded (see form)
Significant variations are rare and are referred for formal clinical review (via QES)
Tapes All calls via ARV 1300 number are recorded
o Quality improvement
o Risk management
o Clinical record
Case follow up All ARV medical retrievals followed up within 24 hrs (by duty retrieval physician or
registrar)
Feedback to retrieval crew
Feedbaack to referring hospital (re patient progress and any retrieval issues)
Opportunity for referring hospital to provide feedback to ARV also
o Database linkages to VSTORM allow long term follow up of trauma patients
o VEMD linkages & ? ANZICS database linkages are being explored also
44
Clinical Coordination in Retrieval What makes a good Clinical Coordinator? o
o
o
o
o
o
o
o
o
o
o
o
o
o
Listening Skills
Critical Analysis
Multitasking
Ability to prioritise tasks on limited info
Risk assessment & management
Think outside of the square
Avoiding tunnel vision
Leadership
Guidance
Control
Arbitration
Diplomacy
Empathy
Self-reflection
Different Models Organisations
o Health Dept, Ambulance, Benevolent, RFDS, Hospital (specialised paediatric
and neonates)
o Hospital based (on or off “floor”)
o Off site
o Stand alone organisations
o Centralised / dispersed
Comms centre
o State wide
o Colocated with ambulance comms/aircraft
o Consultant, Nurse, Paramedic models
Consultation processes
Platforms Ambulance Victoria responsibility
AAV
Road
Ambulance Clinician
HATS
o Response
o Return
Platform Decisions AAV responsibility
Interdependence of crew & platform
Crew may be:
o Platform specific
o Patient specific
o Logistically specific
Multiple factors
o Availability
o Task Time
o Criticality
o Distance
o Terrain
o Patient Complexity
o Impact on Competing
tasks
o Alternatives
o Pros, Cons, C/I
45
Key Coordination Issues What are the referrer’s needs? Advice?
Patient Transport?
Critical care bed?
“Too sick for here”
What are the coordination planning priorities? Immediate care
Response
Destination
Logistics
Crew
Transport Platforms
Barriers to good Clinical Coordination? Referrer stress/ reluctance to engage
Referrer “demands”
Referrer perspective limited to the ‘here &
now’ – unaware of other patients, system
demands and priorities
Finite transport resources
Retrieval is resource hungry
Critical care bed access/availability
Emergency vs Elective demands
Difficulty in contacting hospital personnel
“Maybe” / “Call back this afternoon”
Too many players & variable hospital
processes (bed Mx, access Mx, AO, reg,
consultant)
Key relationships The getting of wisdom
Acquiring local knowledge in a centralised
system?
Establish referrer’s experience &
knowledge
Establish referrer and site capabilities and
limitations
Establish other staff involved/available
Advice already given & by whom
Telemedicine & other aids
Information systems
Crew Mix Skill mix required for each patient is the
dominant consideration in tasking
Not the only consideration
Compromise may be required
Crew Mix Decisions Medical Coordinator responsibility
Risk mitigation with crewing Anticipation
Beware:
o Sepsis
o Multisystem disease
o Pregnancy
o Morbid Obesity
o Complex toxicology
Turning barriers into enablers Interaction with referrer
Referrer understanding of process
Common understanding of patient
condition/needs (mental image)
Understanding of patient environment
Anticipate logistical difficulties/delays
Understand local culture
46
47
Time Criticality Condition which presents immediate threat to life, limb, cognition or future quality of life,
and
o Delay in definitive treatment will significantly increase that outcome risk, and
o Definitive management likely to be achieved by urgent transfer to another
hospital, or
o Management definitively, or for prolonged period, beyond the resource or
clinical skill capacity of provider (or would result in unacceptable resource
drain and exposure of other patients to risk).
What factors impact on Task Time Criticality? Patient stability
o Physiology
o Diagnosis/Pathology/Natural History of Condition (Known vs Unknown)
Capability of referral site
Benefit from: retrieval team care vs intervention at receiving site
o Time to respond to intervene (outbound leg)
o Time to destination (return leg)
o Total out-of-hospital time
Dynamic: may have to reorder priorities
Is a complex equation “who has most to gain by going first?”
Clinical Advice Assessment
Diagnosis
Management
o Immediate care (resuscitation)
o Ongoing care
Preparation & Packaging for transfer
Risk assessment
o Communicated
Appropriateness of intervention
o What is necessary not what is possible
Transport awareness
Destination Planning What factors are important when deciding the destination hospital for a patient?
Does patient need to move regardless? e.g small rural location:
o Early activation
o Special Needs? (neuro/CTR/trauma/PCI)
o Chronic illness? (continuity of care)
o Regional/Historical Network/Links
o Geographical zoning
o Access (airport/helipad)
o Hospital bed/ED capacity
o Insurance
o Balancing demand and capacity
o Right patient for right destination
o System monitoring and action (escalation)
For ICU/CCU patients a general principle (all other things being equal) is to move patients
with less complex issues not requiring tertiary care to non tertiary units.
48
Problem Solving in Retrieval Coordination Mark Putland
Superficially, the task of the CCC is a simple one. A referral site refers a critical care patient,
seeking assistance with any or all of bed finding, transport and clinical advice. The CCC has
access to up to date information about availability of different types of beds, transport
platform resources and retrieval staff resources as well as being able to provide clinical advice
from their personal critical care expertise and to source advice from appropriate experts
outside of the organisation when required. The scope for problems however is enormous.
Multiple referrals may come at once. Beds, transport platforms and retrieval staff may be in
short supply. Clinical problems can outstrip the skills of the CCC and outside experts can be
time consuming to contact or may have little grasp of the realities of the retrieval
environment. Moreover, the multiple people involved in the case can have vastly different
understandings of the problem and the best way to deal with it. These differing
understandings have been referred to as reality models(1) or frames(2). They are further
complicated by interpersonal and interagency tensions and loyalties.
The nature of complex problems The nature of complex problems has been examined in detail in the psychology literature.(1,
3) Complex problems are differentiated from simple ones by features including complexity
(multiplicity and interrelatedness of variables), dynamics (the time dependency and criticality
of the system due to ongoing actions by other agents and natural progression of the problem)
and "intransperance" (the inability of an agent to know everything about the problem before
needing to act on it or to see the immediate effect of the agent’s actions).(1) Consideration of
the retrieval-coordination environment illuminates these.
The complex system of variables at work in a single retrieval case includes the availability,
ability, fatigue and distractions of referral staff and equipment; availability of a transport
platform appropriate to the distance and accessibility of the particular referral site and the
likely receiving site, urgency of the case and size and shape of the patient; availability of a
receiving site bed and associated services and availability of retrieval staff (impacted on by
rosters, training, tasking for other cases). The case does not occur in isolation. Many cases
need to be coordinated each day so each one affects bed, platform and staff availability for the
others.
Retrieval and Coordination activities take time. In that time weather changes, patients
deteriorate, staff become fatigued, run out of rostered hours or are tasked to other activities,
and transport platforms and receiving hospital resources are lost to other cases. This
dynamism means that plans need to be made for “worst case scenarios” and must be revised
frequently.
The problem of intransperance is well known to all clinicians (although perhaps not by that
name) and is magnified for the CCC by the need to act at a distance, through the eyes and
hands of others. Discursive problems (verbal communication problems like accent and pace
of speech), fragmentation of the clinical process due to loss of visual cues and incomplete
information, uncertainty around sharing of responsibility for the patient and differing
expectations of the role of the service were all examined in a study of tensions between users
and providers of a paediatric infectious disease telemedicine service(4) and are familiar to the
CCC.
Competing “frames” or “reality models” The issue of competing “frames” or “reality models” is outlined in a review article on the
topic(2). Although from the environmental science literature there are lessons for health care
49
in it. Each agent with an interest in a problem brings with them a set of priorities, assumptions
and structural knowledge which comprise their frame which underpins the individual’s
understanding of the system in which they act and by which they predict the likely
progression of the problem and the likely effects of their efforts. The referring doctor, the
CCC, the flight coordinator, the retrieval physician and paramedic, the receiving intensivist
and others are all likely to have different frames and consultation between them, ostensibly in
the interests of clarification of the problem, can frequently in fact contribute to the ambiguity
about what the problem actually is. For example, in the case of a patient with a probable
intracranial haemorrhage in Omeo the referring nurse is concerned that the patient should
leave his care before deteriorating, the flight coordinator is concerned that the patient should
be moved in time for aircraft to be reused for the seven other tasks they had allocated it for
the day, the pilot is concerned with getting into and out of Omeo airstrip before the weather
closes in, the retrievalist is concerned with securing the airway safely and defending an
adequate blood pressure, the receiving neurosurgical registrar wants the patient to get to the
receiving hospital soon so they can be out of theatre and get some sleep before morning and is
reluctant to accept the patient directly to their overloaded tertiary centre in case the CT is
negative or the bleed is inoperable. All these frames are potentially in conflict.
Problem Solving A Google search on problem solving methodologies returns approximately 276000 results
rich with links to proprietary approaches. A common set of elements are reconfigured in a
variety of ways in most of these. The problem needs to be defined and goals established,
information needs to be collected to create a framework for predicting the progression of the
problem, and the likely effects of intervention. Actions need to be planned, decisions made
and actions executed. The effects of the actions and the strategy as a whole, need to be
reviewed, looping back if necessary to the beginning of the process again. This superficial
description of the problem solving process seems to offer little to the CCC however a there
are lessons on a closer look. Dorner(1) highlights some risks to the problem solver at the
earliest stage of goal definition.
Goals may be explicit (openly stated and obvious to the agents involved e.g. move patient X
from Stawell hospital to an urban ICU) or implicit (assumed by the problem solver e.g. ensure
patient X is no worse for being transported). Difficulties occur when one agent’s implicit
goals are not obvious to the other agents involved. The GP in Stawell may have a full clinic
waiting for her once she is finished supporting patient X; she has an implicit goal, that to her
is too obvious to need stating, of getting back to the clinic in order to attend to her other
patients. This will affect her whole approach to the case but the CCC may be entirely unaware
of the importance of it to her. Implicit goals of the CCC might include maintaining safety and
satisfaction of staff, maintenance of goodwill in receiving units, nurturing the development of
experience and expertise in referral units and conservation of relations with platform
providers. By working to make implicit goals explicit the problem solver becomes more
aware of the factors affecting their own thinking in difficult situations and is able to better
engage others in achieving these goals. Different sets of implicit goals can be seen as different
frames. In the discussion of competing frames cited above(2) the following techniques for
dealing with this problem are outlined. One can attempt to convert others to one’s own frame
by recourse to scientific reasoning (which works well as long as one is dealing with people
who have a fundamentally scientific frame to start with), by persuasive communication
(which is very personality dependant) or by an oppositional mode of action where a power
differential is used to impose one’s frame on others (which depends upon such a power
differential existing in one’s favour and which may have ongoing costs in terms of good will).
Alternatively a process of negotiation and compromise can be used to try to get the most
satisfactory outcome possible accepting the differences in frames or a dialogical approach can
be used where open discussion between the agents leads to frame enlargement: each agent
adapts their frame to incorporate some elements of the other’s frames also such that all the
agent’s goals start to become synchronous. This last technique is at the centre of Crisis
50
Resource Management where the importance of all “being on the same page” is stressed. A
team briefing in which all team members voce their understandings of the mission brings all
the different conceptions into synchrony with one another. Conference calls and video
conferencing are powerful tools for this. (5)
Goals may be clear or unclear. An example of an unclear goal is to “help hospital Y with a
multi-casualty traffic accident. Such an unclear goal does not allow for prioritised and
effective action. Breaking such a goal into specific elements produces clear goals (e.g.
establish the magnitude of the problem and the local capacity to manage it, engage the major
trauma services, provide case-by-case clinical advice and arrange evacuation of specific
patients).
Dorner also refers to “goal degeneration” where the problem solver becomes distracted by
achievable but largely irrelevant goals, losing sight of the big picture. In difficult situations
this can become self-perpetuating resulting in a “flow situation” where challenging but
achievable short-term goals are generated and accomplished again and again to the detriment
of the overall aims. The retrievalist is perhaps more at risk of this than the CCC, for example
treating an unstable and complex patient who is not responding to treatment in a small rural
setting the retrieval physician first inserts an extra intravenous line, then spends an hour trying
to insert an arterial line, then places a central line but for want of a chest X ray arranges for a
portable ultrasound machine to be brought from the maternity unit and attempts to use
ultrasound to confirm the placement of the line. Next, having sourced the ultrasound machine
with some difficulty, the retrievalist decides to do a bedside Echocardiogram and examine the
liver for signs of congestion. Meanwhile the more important issues of the patient’s labile
blood pressure, galloping sepsis and distance from definitive care are being avoided. The
retrievalist has been drawn into a flow situation and has lost situational awareness.
Multiple Simultaneous Problems Attention needs to be given to the issue of dealing with multiple simultaneous problems. The
CCC workload is highly variable and during busy periods 12-20 new cases a day might be
referred, often clustered together in the late afternoon (Dr Marcus Kennedy, Unpublished
Data on ARV Case Volume Loads 2010, 2010 November 23). Strategies for dealing with
multiple simultaneous problems include finding a central problem, the solution of which will
solve multiple problems, prioritisation (triage), delegation, compromise and attempts to
reshape the system such that negatively linked goals become positively linked.
Finding a central problem depends on identifying interdependencies between problems. The
CCC is uses an intimate knowledge of the intricacies of the state critical care system to take a
systems view of retrieval problems. When multiple patients need to be moved around the state
into and out of beds of varying acuity and specialisation via multiple different transport
platforms using multiple crew configurations getting the right patient to the right bed the right
way can avoid many subsequent problems.
Prioritisation of problems Prioritisation of problems is familiar to critical care physicians and is formalised in
emergency medicine in the Australasian Triage Scale.(6) When prioritising problems it is
important to recognise that importance and urgency are independent of one another. A
problem is urgent if the outcome will be altered adversely by a short delay to solution
however if the adverse outcome is trivial, or at least acceptable, then the problem might be
prioritised below a more important but less urgent one. A third factor to consider in
prioritisation is achievability. On occasion it may be appropriate to solve several easy but
fairly unimportant or non-urgent problems while leaving more important or time critical ones
unmanaged. This counter-intuitive approach has the advantage of de-cluttering the thinking
space of the problem solver but there is a danger of being seduced by the attraction of dealing
51
with easily soluble problems at the expense of important but difficult ones (the “flow
situation” referred to above).
Delegation Delegation is at the centre of effective crisis resource management. The CCC has a number of
other people to use when multiple problems need to be addressed simultaneously including
the retrieval administration support officer (RASO), the administrator, the retrieval physician
and registrar and ambulance logistic staff such as the flight coordinator. While delegation
makes the most of the available resources the delegator must maintain oversight of, and
responsibility for, tasks thus distributed.
Compromise Compromise is almost universally required in the retrieval coordination environment. A
referral hospital invariably wants the patient removed immediately, the receiving site
frequently needs time to prepare for reception of the patient and transport is frequently
delayed for logistical and distance reasons. Moreover, some patients require some immediate
stabilisation before transport.
The CCC has little opportunity in day to day work to reshape the system however providing
feedback to management relating to issues arising from cases may allow for this to occur.
In conclusion the CCC needs to assess and prioritise multiple complex problems at any given
time, the solutions to which will be interdependent on each other. They are a central point for
the interaction of people from all over the health care system all of whom will bring different
skills, assumptions, priorities and pressures and who must be made to work in a common
direction for the sake of the patient. The skills required include use of specific critical care,
aeromedical and health care system knowledge, time management, triage and delegation skills
and interpersonal communication and negotiation skills.
1. Dorner D. The Logic of Failure: Recognizing and Avoiding Error in Complex Situations.
New York: Basic Books; 1996.
2. Brugnach M, Dewulf A, Henriksen HJ, van der Keur P. More is not always better: Coping
with ambiguity in natural resources management. Journal of Environmental Management.
[Review]. 2010 January 2011;92(1):78-84.
3. Funke J, Frensch PA. Complex Problem Solving: The European Perspective - 10 Years
After In: Jonassen DH, editor. Learning to Solve Complex Scientific Problems. New York:
Laurence Erlbaum Associates; 2007. p. 25-47.
4. Wadhwa A, Lingard L. A Qualitative Study Examining Tensions in Interdoctor
Telephone Consultations. Medical Education. [Original Research]. 2006;40:759-67.
5. Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. The Potential for
Improved Teamwork to Reduce Medical Errors in the Emergency Department. Annals of
Emergency Medicine. 1999 Sept 1999;34(3):373-82.
6. Australasian College for Emergency Medicine. Guidelines for the Implementation of the
Australasian Triage Scale in Emergency Departments. Melbourne: Australasian College for
Emergency Medicine; 2005. p. 1-7.
52
Crisis Resource Management and Retrieval Coordination Belinda Carne
Crisis Resource Management is the term given to that area of human behaviour that concerns
itself with the management of medical crises. (1;2) It is a term adapted from the aviation
industry, which uses Crew Resource Management training as one of its tools to improve flight
safety. Research, particularly in the aviation industry, has identified certain behaviours that
contribute to poor outcomes in crises (3) and it is from here that a list of key points of Crisis
Resource Management has been developed. (4;5) It is thought that the practice of these
behaviours is likely to improve the management of crises with a resultant increase in patient
safety. These behaviours are particularly relevant in the setting of Retrieval Coordination,
which involves work of high complexity often performed under pressure, and requires liaison
between multiple stakeholders to achieve the best possible outcome for time critical and
critically ill patients (6).
The key points of Crisis Resource Management are:
1. Know your environment
2. Anticipate and plan
3. Take a leadership role
4. Communicate effectively
5. Call for help early
6. Allocate attention wisely and use all available information
7. Distribute the workload and utilize all available resources
Know your environment The first point, that of ‘know your environment,’ has applicability in both the physical and
cultural domains. The most obvious environment for the Retrieval Coordinator is that of the
office in which they work. A working knowledge of the location and function of
telecommunications equipment is needed to facilitate call taking, conferencing, and
documentation. Coordinators need to know where to access information relating to location
and clinical resources of referring hospitals, as well as platform options for those locations
(6). Similarly, information regarding the capabilities of receiving hospitals is needed to
streamline the process of finding a suitable destination for the patient. There would be no
point in successfully finding an ICU bed in a hospital without neurosurgical capability for a
previously well patient with a significant extradural haemorrhage. The smooth performance of
this often time pressured job relies upon a working knowledge of where things are, and how
they work. Knowledge of the environment also includes knowledge of the human resources
therein. People such as the Flight Coordinator, RASO (Retrieval Administration Support
Officer), Doctors and Paramedics form part of the environment, and knowledge of who is
working and what their capabilities are can also smooth the path of retrieval.
Leadership The cultural environment has the capacity to impact on the shape a retrieval takes. Studies
have shown that a direct link exists between team culture and performance (7). The retrieval
environment is one that brings together professionals from different disciplines and cultures.
This has the potential to create conflict and role confusion. Prominence, sociability and task
orientation are three dimensions in which interpersonal behaviour can vary. In general, ‘the
more education the team members have, the more prominent and task-oriented they are.’ (8)
A concomitant relatively lower level of sociability can impact upon the ability of individuals
to form effective teams. One of the roles of a Retrieval Coordinator is to be aware of the
cultural environment in which they work, and to be aware of the impact of this environment
53
on team performance. An awareness that leadership style can influence team dynamics is also
of value (9). Participative decision making processes can increase the degree of team
identification experienced by staff, whilst a collaborative approach to dealing with conflict
can create an increase in team members‘ sense of interdependence, and can reduce social
distance. These outcomes can all contribute towards creating a more cohesive, professional
and highly functioning team (11).
Anticipate and Plan ‘Anticipate and plan,’ is relevant at all stages of the co-ordination process. Thinking ahead to
what might happen, and developing a plan for that contingency can contribute to the success
or otherwise of a mission. Anticipation and planning begins with the start of the co-ordination
shift, when a handover and familiarisation with the critical care bed status occurs. It can be
anticipated that this knowledge will be needed during the day. Planning ahead to acquire this
knowledge at the start of a shift contributes to smoother management of retrievals later on.
Anticipation and planning is also relevant when the time comes for crew mix selection. Tools
such as the Crew Mix Grid can assist with this task (6), but a clinical appreciation of the
potential for deterioration is also necessary. An example of this includes the patient with a
significant ingestion of tricyclics antidepressants. A request for retrieval may be made due to
an impaired conscious state. Although the clinical situation at the time of the call may fit the
requirements for paramedic tasking, the potential for delayed onset of arrhythmias and
seizures (11) would suggest that the crew include a Retrieval Physician. Failure to anticipate
clinical deterioration can result in the necessity to task a second crew, which can delay the
patient’s access to definitive care. Similarly, a failure to anticipate the effect of weight on
transport options can result in the wasted deployment of aircraft at significant cost in both
financial and clinical terms.
It is recognised that the performance of complex tasks is impaired by factors to do with the
self (fatigue, inexperience, ill health, lack of knowledge), and environmental factors
(interruptions, handovers, production pressure, equipment failure) (14;15). These issues,
together with the HALTS factors - being hungry, angry, late, tired or stressed, can be partly
avoided by forward planning. The use of checklists has been shown in a variety of settings to
make a significant improvement in a person’s ability to successfully complete a series of
necessary tasks (16;17), and this is reflected in Adult Retrieval Victoria’s use of the
Coordinator Record (6). Another area in which checklists are useful is in the area of skills
competency. Having a skills checklist completed for each crew member allows the retrieval
coordinator to have confidence that a certain skill set is present prior to tasking.
Taking a Leadership Role is necessary in the retrieval coordination setting. There are often a
large number of stakeholders involved in any given retrieval, and there are often conflicting
agendas. The coordinator acts as the leader of the retrieval process, balancing the needs of the
individual patient, with the needs and requirements of the other stakeholders – referring
hospital, receiving hospital, retrieval team and platform coordinators. This leadership role is
best performed in a participative manner (11), but at times will need a more authoritarian
approach in settings such as that of Defined Patient Transfer (16). Even then, the leadership
style should employ the least confrontational approach consistent with the goal, anticipating
that maintaining good relationships will contribute to optimal outcomes in future interactions.
A hands-on leadership style which encourages a shared sense of purpose, a focus on results
and a collaborative environment can result in improvements in outcomes for patients (17).
Involving the team in the discussion on how to achieve a particular goal, can be more
effective than issuing a set of directives (18). Part of the leadership role can also include the
provision of debriefing, or directing those in need to peer support or counselling services
provided by Ambulance Victoria. Coordinators also need to recognise when they themselves
are affected by stress, and need to develop appropriate self care behaviours. Leadership in the
area of Clinical Governance – formalising lines of responsibility and accountability and
creating systems for quality improvement, can also impact on patient safety (19). Activities
such as routine peer coordination case review with feedback, review of retrievalist case
54
sheets, and incident review are examples of quality improvement activities within the retrieval
environment. The importance of continually examining systems and outcomes was
highlighted in the 1999 United States Institute of Medicine report ‘To Err is Human,’ and in
the 2001 report ‘Crossing the Quality Chasm’ which expanded on the original theme of
preventable error management (20).
Effective Communication Effective Communication is one of the most important factors in Crisis Resource
Management. Effective communication in the retrieval environment is crucial to the success
of a mission, and relies upon a reliable infrastructure (21) as well as excellent communication
skills. Skills likely to increase the chance of effective communication, particularly in times of
conflict, include the acknowledging of different perspectives (22), concentrating on the issue
at hand without recourse to personal attack (23), aiming for assertiveness rather than
aggression or submission (24), and taking the advice found in Desiderata – to ‘speak your
truth quietly and clearly and listen to others’ (25). These approaches to communication are
likely to result in an enhanced resolution of conflict, improved relationships between the
various stakeholders, and in the formation of teams who focus on the shared goal of the best
possible outcome for the patient. Listening and advising in a non judgemental manner is
likely to increase the likelihood of referring hospital staff and retrieval team members asking
questions in relation to optimal patient care. This may well result in a reduction in clinical risk
(26). The retrieval coordination role poses extra communication challenges not faced in the
standard workplace. A large proportion of the communication work is performed on the
telephone. In the normal setting, a substantial amount of communication is achieved by non
verbal means such as eye contact and body posture (27). Factors such as tone of voice, speed
and content of speech and listening become more important when visual cues do not form part
of the interaction. Cultural factors also play a part in effective communication. Issues such as
power distance, the effect of gender, individualism-collectivism and uncertainty avoidance
can vary greatly amongst cultures (28). An awareness of cultural variation can assist the
coordinator when interacting with colleagues and giving advice. A colleague from a culture
with a large power distance may be more reticent to question authority than a colleague from
a low power distance culture. Those from cultures with high uncertainty avoidance may
benefit from more directive advice than those from low uncertainty avoidance cultures. In
general, an assertive communication style which incorporates respect for others and a desire
to help will assist with the communication goals of the retrieval coordination role – those of
obtaining clinical information, giving clinical advice and arranging retrieval where necessary.
Call for help early Calling for help early is of relevance to every member of the retrieval team, including the
retrieval coordinator. There is sometimes resistance to asking for help – at the junior level for
fear of being criticised and at the senior level for fear of being seen to lack knowledge or
capability. The timely involvement of appropriate expertise can impact upon the success of a
retrieval. This may be from the clinical perspective, when the advice needed by a referrer or
retrieval team member lies outside the expertise of the coordinator, or it may be from a
logistical perspective when difficulties arise with arranging a destination hospital. Criteria that
mandate the calling for help have been validated as being useful in the clinical setting in the
form of the MET (medical emergency team) call (31;32). These criteria remove the barriers to
calling for help outlined above. Similarly, Adult Retrieval Victoria Coordinator Guidelines
describe situations that mandate the calling for help, stating that ‘failure to resolve platform or
crew response decisions within a reasonable time period (60 minutes) requires escalation of
the issue to ARV admin-on-call’ or equivalent, and ‘issues that cannot be simply resolved
must be escalated to the Director ARV or the Clinical Advisor ARV urgently’ (6). Delaying
the call for help in this situation can result in a potentially life threatening delay to definitive
care for the patient.
55
Allocate attention wisely There is a recognised tendency when stressed to focus on one particular issue that may lie
within the control of the stressed individual (31). The term given to this is fixation error. The
coordinator who finds themselves responsible for the retrieval of a critically ill individual
weighing 140mg at a distance of 250km from a suitable destination may find themselves
focussing on the difficulties of moving the patient given the weight limitations of fixed wing
(6). A wise allocation of attention may result in the focus changing to providing skilled
personnel to the referring site by the fastest means available, without allowing difficulties
around platform issues to delay provision of the skill set required to the patient. Using all
available information is also relevant to platform and crew selection. The synthesis of
variables such as availability of airports, distance from receiving hospital, availability of
alternate road options eg. HATS (high acuity transport service), CPAV (complex patient
ambulance vehicle) and Emergency car as well as the skill set of the crew (6)– represents a
complex decision making exercise where the best outcome may result from a broad outlook.
Distribute workload Distributing the workload and using all available resources is important to allow the
coordinator to maintain an awareness of the big picture. The appropriate delegation of tasks
and involvement of other team members is a necessary step to maximising situational
awareness. The necessity of distributing the workload has been recognised at an
organisational level, whereby various checklists for different team members have been
developed. This includes the Call Taker Script which defines that information to be gathered
by the RASO. Flow charts detail the process of call taking, and define the point at which the
coordinator begins to gather information from the referring clinician. ‘Anticipation’ provides
the impetus for the creation of checklists, remembering to ‘use all available resources’
provides the prompt to use the checklists. ‘Available resources’ in the retrieval context also
refers to the destination hospitals available to take patients. This includes the option of
transferring patients to the private sector. When using this option, it is important for the
coordinator to be aware of the financial implications for the organisation, and to facilitate
transfer back into the public system at the earliest opportunity for those without adequate
private insurance or DVA (Department of Veterans Affairs) cover. On occasion, an interstate
hospital will also constitute an available resource, and may be used for geographical reasons.
The use of this resource requires communication with all relevant parties by means of a
teleconference to avoid misunderstandings.
Crisis Resource Management principles are integral to the smooth and efficient running of a
retrieval service. Being mindful of the key points, particularly in the areas of communication,
leadership and forward planning can result in improved conflict management, enhanced job
satisfaction and most importantly, patient safety. The job of the Retrieval Coordinator is a
complex one, where application of the key components of Crisis Resource Management can
result in better performance and outcomes in the management of patients with critical and
time critical illness.
Reference List
(1) Gaba DM FKHS. Crisis Management in Anesthesiology. New York: Churchill Livingston, 1994.
(2) St Pierre M HGBC. Basic principles: error, complexity and human behaviour. In: St Pierre M
HGBC, editor. Crisis Management in Acute Care Settings: Human factors and team psychology in a
high stakes environment. New York: Springer, 2008: 1-16.
(3) Helmreich RL MAWJ. The Evolution of Crew Resource Management in Commercial Aviation.
International Journal of Aviation Psychology 1999.
(4) Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management
training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992;
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(5) Sundar E Sundar E,Sundar S,Pawlowski J,Blum R,Pratt S. Crew Resource Management and Team
Training. J Anesthesiology Clin 2007.
(6) Ambulance Victoria. Adult Retrieval Victoria: Coordinator Guidelines. 2010. URL:
http://www.ambulance.vic.gov.au/Media/docs/2ARV_Coordinator_Guidelines_25052010-68bb110a19f7-4c8e-95c8-a0bd20c19c28-3.PDF
(7) Davies HT, Mannion R, Jacobs R, Powell AE, Marshall MN. Exploring the relationship between
senior management team culture and hospital performance. Med Care Res Rev 2007; 64(1):46-65.
(8) Farrell MP, Schmitt MH, Heinemann GD. Informal roles and the stages of interdisciplinary team
development. J Interprof Care 2001; 15(3):281-295.
(9) Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the
literature. Acta Anaesthesiol Scand 2009; 53(2):143-151.
(11) Chilcutt AS. Exploring leadership and team communication within the organizational environment
of a dental practice. J Am Dent Assoc 2009; 140(8):1252-1258.
(11) Cameron P, Jelinek G, Kelly A-M, Murray L, Brown A. Textbook of Adult Emergency Medicine.
3rd ed. Sydney: Churchill Livingstone, 2009.
(12) Reason J. Understanding adverse events: human factors. Qual Health Care 1995; 4(2):80-89.
(13) Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual
Saf Health Care 2004; 13 Suppl 2:ii28-ii33.
(14) Reason J. Combating omission errors through task analysis and good reminders. Qual Saf Health
Care 2002; 11(1):40-44.
(15) Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP et al. A surgical safety
checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5):491499.
(16) Department of Human Services.Victorian State Government. Interim Critical Care Capacity
Guidelines. 2008.
(17) Keroack MA, Youngberg BJ, Cerese JL, Krsek C, Prellwitz LW, Trevelyan EW. Organizational
factors associated with high performance in quality and safety in academic medical centers. Acad Med
2007; 82(11):1178-1186.
(18) Spreier SW, Fontaine MH, Malloy RL. Leadership run amok. The destructive potential of
overachievers. Harv Bus Rev 2006; 84(6):72-82, 144.
(19) Balding C. From quality assurance to clinical governance. Aust Health Rev 2008; 32(3):383-391.
(20) Kohn LT CJDM. To err is human: building a safer health care system. 2000. Washington,
National Academy Press.
(21) Martin T. Aeromedical Transportation. A Clinical Guide. 2nd edition ed. Hampshire: Ashgate,
2006.
(22) O'Mara K. Communication and conflict resolution in emergency medicine. Emerg Med Clin North
Am 1999; 17(2):451-9, xii.
(23) Roger Fisher and William L.Ury. Getting to YES: Negoitiating Agreement Without Giving In .
Penguin, 1981.
(24) Jordan PJ, Troth AC. Emotional intelligence and conflict resolution in nursing. Contemp Nurse
2002; 13(1):94-100.
(25) Ehrmann M. Desiderata. 1927. Available from URL: http://mwkworks.com/desiderata.html
(26) Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective
teamwork and communication in providing safe care. Qual Saf Health Care 2004; 13 Suppl 1:i85-i90.
(27) Argyle M. Bodily Communication. New York: International Universities Press, 1988.
(28) Merritt A. Culture in the cockpit: do Hofstede's dimensions replicate? J Cross Cult Psychol 2000;
31(3):283-301.
(29) Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of paediatric in-patient cardiac
arrest and death with a medical emergency team: preliminary results. Arch Dis Child 2005; 90(9):11481152.
(30) Jones D, Bellomo R, Bates S, Warrillow S, Goldsmith D, Hart G et al. Patient monitoring and the
timing of cardiac arrests and medical emergency team calls in a teaching hospital. Intensive Care Med
2006; 32(7):1352-1356.
(31) Brindley PG. Patient safety and acute care medicine: lessons for the future, insights from the past.
Crit Care 2010; 14(2):217.
57
High Performance Teams Dawn Chan
High performance teams refer to teams, organisations or groups that are highly focused on
their goals.1
A team can be defined as “a small number of people with complementary skills who are
committed to a common purpose, set of performance goals, and approach for which they hold
themselves mutually accountable.” This definition is the difference between a work group and
a team.2 An effective team should be small enough to be efficient and productive, yet large
enough for collective strength from the diverse skill sets of team members.3 Teams thrive
when given an appropriate amount of autonomy, communication and trust levels are high and
a common goal is shared.4
These high performance teams are also employed in the corporate, military and aviation
industries.
In healthcare, we are no strangers to interdisciplinary co-operation. However, this interaction
is not always efficient. With the continued evolvement of specialised healthcare and a
growing number of patients, the need to develop successful interdisciplinary teams becomes
more apparent as we need to work quicker and more efficiently together. In the retrieval
setting, this is particularly relevant, especially via high performance teams.
Many personnel involved in the retrieval setting possess certain traits. In general, they are
highly skilled and credentialed individuals who possess technical competence, hardiness,
flexibility, commitment and well developed skills in clinical decision-making and critical
thinking. These characteristics aid in the formation of a high performance team environment.5
There are many factors contributing to the success and performance of high performance
teams. In general, the formation of a high performance team requires time for the building of
trust between members and for each member to have a shared understanding of his/her role
and the roles of other members, as well as the overall goal of the team. This allows team
structure to be defined within the team.3 Clinical teams that are temporary and formed rapidly
require an expedited team formation stage and progress rapidly to the performing stage.3 This
reflects the retrieval setting, whereby teams are often put together at the last minute with any
available personnel.
Effective Teams An effective team needs certain members. In our work setting at ARV, the tasked retrieval
team generally comprises of a skilled clinician, an environmental expert and a driver or pilot.
Complex cases can require staffing with two skilled clinicians.6 Clinicians can include a
doctor or MICA paramedic. The environmental expert is a paramedic, either an ALS
paramedic or MICA paramedic. On the HATS platform, this environmental expert is a
specifically trained critical care nurse. The driver on road platforms is generally another
paramedic, thereby providing an extra level of expertise to the team. On rotary wing
platforms, the crewman is trained to assist the MICA paramedic despite not having a medical
background. This team structure is generally replicated for our cases, which facilitates
expedited team formation. Although individuals may not have worked together prior to the
case, the skill sets are reasonably well defined in the above structure, thus allowing a certain
level of trust within the ad hoc team. Individual roles and team goals are already pre-defined
by our skill sets in this setting. As long as members are willing to cooperate on a personal and
professional level, this temporary team can still function as a high performance team. The
bigger team here includes the clinical co-ordinator, flight co-ordinator and
referring/destination hospitals.
58
Common Vocabulary Common vocabulary is a crucial factor for high performance teams. A standard set of generic
knowledge, skills and attitudes allows for effective and concise communication.4 It can reduce
errors due to miscommunication especially when using specialised lingo. This common
vocabulary can also help bind the team and promote trust when working together. In the
retrieval setting, it allows personnel from different backgrounds to work together as we can
all understand the clinical impetus and implications of the case. Team efficacy is improved
when individuals can work independently but yet together to achieve a common goal, thus
making the team larger than the sum of its parts.2 In particular, in the ARV setting, our work
involves transportation of critically ill patients. Doctors trained in critical care specialties and
trained paramedics are required. Referrals made by non-critical care trained staff often do not
convey the true picture, due to this lack of specialised common vocabulary. The common
knowledge of drugs, equipment and procedures allows for overlap and flexibility of roles,
thus improving safety and efficiency of the mission; especially when individuals are able to
pre-empt each other’s actions.
Diverse and complementary skillsets A high performance team comprises of members with diverse yet complementary skills.2 This
allows the team function under a much broader scope, but yet possess enough core strength
with overlapping skill sets to cope with most emergencies. Our team structure of doctor and
paramedics (MICA/ALS) is a good example. Extra skills doctors possess include an overall
assessment of the clinical situation and treatment needs (the big picture), interpretation of test
results, technical skills like invasive line insertions, airway management and invasive pacing,
familiarity with complex patients and most importantly familiarity with the hospital system.
This complements the MICA skill set, which includes familiarity with the transport
environment, expediently transporting and packaging unstable injured patients, airway skills
and familiarity with general advanced life support drugs. The ALS paramedics possess the
same environmental awareness and skill in transportation of sick/injured patients. The pilot
obviously possesses a very different and crucial skill set, but yet has the same environmental
awareness as the paramedics. The clinical co-ordinator is a highly skilled and experienced
critical care doctor, thus providing clinical leadership for the case. The flight co-ordinator
similarly is a highly skilled and experienced paramedic, thus providing situational leadership
for the case.
Collaboration Collaboration is another essential component of high performance team interaction.5 Having
members with the abovementioned complementary skills has limited use if they do not
collaborate whilst on a mission. Team members collectively performing patient assessments,
doing procedures and developing plans allows a clear understanding of the plan, fast and safe
execution of procedures and complete assessment within a shorter time.
To facilitate collaboration, mutual trust and respect is vital.2,3,5 The differing backgrounds of
teammates can generate differing opinions of boundaries and hierarchies, which can be
detrimental to the health of the team. It is very important to respect the skills and competence
of our colleagues. Doctors are often used to being the clinical team leader in the hospital
environment. MICA paramedics have similar experiences to us of being the clinical team
leader in their environment. An experienced MICA paramedic and doctor can often have very
similar competencies. In our retrieval setting, it is important to be mindful of this fact. Either
party depending on the clinical situation of the case can undertake the role of team leader.
This mutual respect and trust will allow collaboration i.e. parallel assessments and treatment
of the patient, thus improving efficacy and performance. For example, I am comfortable
leaving the paramedic to assess the patient whilst I get handover from the referring team.
These separate arms of action put together will generate a complete picture of the patient’s
status in a much shorter timeframe.
59
Task specific and flexible leadership High performance teams function best when leadership is task specific and flexible.5 The
profession with the needed expertise will lead the team at the time, allowing shared and
transient leadership. This rings true whilst transporting a patient. Medical staff can have
clinical leadership when dealing with the patient’s assessment and treatment. However, we
should defer to the paramedics who are the environmental experts in matters of packaging and
moving the patient. They have far more experience than we do with regards to the
performance of equipment whilst on different platforms, the likelihood of particular
complications whilst enroute and adapting to the platform environment when treating the
patient. This model ensures that the leader is always the most experienced person for the role,
which undoubtedly will improve performance of the team. To still allow for accountability
and administrative control5, the clinical co-ordinator and flight co-ordinator will still be the
overall team leaders in the respective areas mentioned above.
Common Specific Goals To function efficiently as a unit, the team needs to have a common goal.2-4 Having a bunch of
highly skilled personnel going off on their own tangents is likely to be counterproductive. It is
crucial to the success of a task that the plan is clearly understood by all team members, as the
actions and efforts of the individuals need to be towards achieving this common goal. For the
retrieval team, all staff need to understand the clinical condition and treatment plan for the
patient prior to any movement of the patient. In the event of deterioration or emergency
enroute, there is generally no time for discussion of the plan and or objections of the plan if
any. These issues need to be sorted out prior to patient movement.
Team autonomy Team autonomy4 is yet another factor that can boost performance. Giving an appropriate
amount of autonomy to the team can improve team morale and work satisfaction. This is
actually unavoidable in the retrieval setting. The retrieval team is often responsible for
making the clinical decisions for the mission. This is due partly to the expertise of the team
and partly to the nature of the work. Information received pre-mission is often sketchy and
possibly inaccurate. There is often also ongoing deterioration of the patient whilst awaiting
arrival of the retrieval team. Thus we are unable to formulate a definitive plan pre-mission.
Options for potential scenarios can be discussed in a pre-mission briefing. The complex
nature of many of our referrals also make it difficult for the clinical co-ordinator, who is
receiving information over the phone, to make definitive decisions and plans for the retrieval
team as subtle insinuations might be missed. In addition, the retrieval team is designed and
tasked as a highly skilled team of clinicians, who are trained to assess and treat this category
of patients. It would be logical to use this resource as it was designed, by allowing them to
assess and treat the patient based on their clinical judgement. This also touches on mutual
respect and trust accorded by the team leader (co-ordinator) to his or her retrieval team.
However, there still needs to be an overlying authority, who would be the co-ordinator in this
situation. This is to ensure that when various teams intersect, their interaction is not hampered
by each team’s autonomy.
Rapidly forming teams All the abovementioned factors are important in building a high performance team. However,
they are especially true for temporary teams, which have to be formed rapidly. The ad hoc
nature of our retrieval teams and work requires a higher level of commitment, trust and
respect of each other’s abilities and collaboration. The unpredictability of the work calls for a
certain amount of team autonomy. It is impossible to have a fixed plan until the team has
assessed the patient for themselves and considered the transport and clinical risks. It is a
valued trait for the team to be flexible and adaptable to the varied environment. There are
often unpredictable factors like weather, equipment failure and patient complications that can
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turn a routine case into a very complicated and difficult one. The challenges need to be
overcome promptly as they arise. High performance teams are generally static and moulded
over time to allow members to work together, assess each other, establish roles and learn to
trust each member of the team. It is a credit to all individual personnel involved that a
successful dynamic high performance team can be achieved in our retrieval setting. I believe
this is possible due to experience gained from our respective work and training, in the areas of
adaptability, interpersonal skills and teamwork.
References
1. Wikipedia: High Performance Teams.
http://en.wikipedia.org/wiki/High_Performace_Teams
2. Katzenbach JR, Smith DK. The Discipline of Teams. Harvard Business Review. 1993
71(2): 111
3. Anshu KJ et al. High-Performance Teams for Current and Future Physician Leaders:
An Introduction. Journal of Surgical Education. 2008. 65(2): 145-150
4. Sangvai D, Lyn M, Michener L. Defining High-Performance teams and Physician
Leadership. The Physician Executive. March/April 2008: 44-51
5. Stohler SA. High Performance Team Interaction in an Air Medical Program. Air
Medical Journal. July-Sept 1998. 17(3): 116-120
6. Adult Retrieval Victoria Medical Reference July 2010
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ARV Coordinator Guidelines Activation of Retrieval Early activation is imperative to optimize system efficiency and responsiveness. Activation
may occur prior to the known availability of a destination (receiving) hospital.
Activation includes early communication with all resources / platforms: AAV, AV, Regional
AV.
Aviation Resources The allocation of aviation resources is not the responsibility of the ARV Coordinator, but
rests with AAV. Input can be provided, but it should be recognized that AAV may have
multiple competing requirements, including primary response.
Aviation resources may not be available due to: weather conditions, pilot duty restrictions,
aircraft maintenance or performance issues, or other tasking.
AAV, regional AV and the coordinator need to be involved in discussion related to the
transfer of patients where the use of air resources is of marginal benefit or not available in a
timely manner.
Where aviation platforms are not available, the ARV coordinator must facilitate alternate
retrieval arrangements for the patient in consultation with the AV Clinician. This may include
consideration of road platforms (such as HATS, CPAV, Emerg car – local or metro), and
various options of retrieval team depending on availability and required skill mix. Failure to
resolve response decisions within a reasonable time period (60 minutes) requires escalation of
the issue to ARV admin-on-call, AAV manager, AV DTM, regional duty manager or others
as appropriate.
For fixed wing transfers, a patient weight limit of 120kg exists due to engineering limitations
around patient loading and aircraft floor load capacity.
For rotary transfers, patient weight limits are generally those of the stretcher (approximately
160-200kg) however the practical limitations of size and manual handling are usually reached
by patients at much lower weights than this. Any patient >120kg must specifically be
discussed with the flight coordinator to determine appropriateness for RW transfer.
Blood and Blood Products Urgent supplies of blood and blood products may be sourced from the Red Cross Blood Bank
(Contact: 03 9694 0200). Items will be delivered by RCBB by courier or taxi, or may be
collected by emergency vehicles (dispatched via the duty manager or clinician). Cold storage
bags are available on site for transporting products. Blood dispensed in this way should
remain with the patient, as should all completed records of administration.
It is preferable to source blood and blood products from the referring site laboratory where
possible.
A current project is expected to see availability of limited blood stocks on-site at Essendon in
early 2011.
Call Processes The coordinator will at all times communicate in a professional manner, respectful of the
circumstance of the referrer, the stressful nature of critical incidents, and the role of ARV and
AV in the State Health System.
The coordinator must remain mindful of the need for optimal communication styles, and of
communication strategies that may be applied to ensure complete and clear communication of
relevant clinical and risk related matters with the referrer.
• Always allow the referrer to complete statements – do not complete for them or “put
words in their mouths”
63
•
Reflective checking is valuable: “Thank you Dr X, I understand from your statement that
the patient is ….. – is that correct?”
• Ask direct risk related questions: “Dr, Do you perceive any major risks or hazards in the
transfer of this patient?”
• Leave the door open for further communication: “If you think of anything else that may
be important or that arises after this call, please phone me back”
Consideration will be given to early inclusion of other parties in the conference call (e.g.
AAV Flight Coordinator, Regional AV ops centre, receiving unit or Trauma Service, Duty
Retrieval Physician, Flight MICA/Paramedic)
The coordinator will determine whether the request is for one or more of:
• Request for assistance with accessing a critical care bed or time critical intervention
• Request for assistance with inter hospital transfer
• Clinical Advice
The coordinator will assess the clinical and situational information provided, and formulate a
plan in consultation with the referring party. Decision making in such circumstances is often
complex.
The coordinator will provide clinical and logistic advice as required to the referrer. This
advice may be to the requesting hospital, Retrieval Physician or paramedic escort. The
coordinator may need to seek assistance in some areas of clinical medicine. Specialists in the
receiving hospital should also be considered as sources of advice.
Where a Critical Care bed is required, the ARV Call Taker will confirm availability and
notify the coordinator immediately (and facilitate telephone connection with that unit).
Continuity and Handover At the end of the shift, the Coordinator will handover to the Coordinator rostered for the next
shift.
All cases which are incomplete or in progress must be communicated to the incoming staff.
This ensures that the active coordinator is aware of the location of all ARV retrieval staff and
teams. This is relevant from the perspective of potential mission diversion or re-prioritisation,
delays and risk management; in addition an active retrieval team may seek assistance from the
current coordinator who must be aware of the mission, its complexities, plan, destination etc.
Any cases which are believed to be completed but where significant potential exists for rereferral on the subsequent shift should be communicated.
All cases where significant outcome risk, organizational risk, media attention or major public
interest exist should be handed over to the next coordinator so they are aware of cases they
may receive enquiry about (such cases should also be communicated to the ARV office).
Coordinator Contact and Availability The Coordinator will be contacted by the ARV RASO, by either phone or pager.
The Coordinator will carry both mobile phone and pager while rostered.
The Coordinator will be available to discuss the case with the requesting party within 15
minutes.
All phone contact will occur via 1300 368 661 to enable voice logging for quality assurance
processes.
Calls will be received from across the entire State – regional retrieval services defer to ARV
metro as the central coordination office.
The ARV RASO will facilitate conference calls with ARV, Coordinator, Referrer or others as
required.
Crew Briefing For all retrieval missions, the coordinator will discuss the case and clinical details with the
responding crew (doctor or paramedic).
MICA road crew transfers within the metropolitan area should be considered as a retrieval
option only when the clinical situation requires an emergency level of response (re time
criticality), or the setting is analogous to a primary response. In other circumstances, it is
64
more appropriate to task ARV staff (according to hospital type) or to negotiate transfer by the
referring hospital.
65
66
Crew Mix The coordinator will determine the Crew-mix that has the most appropriate skill set for a
specific clinical scenario. Principle factors involved in this decision will be clinical
complexity and patient instability (actual and potential).
High Risk Patients
• A significant group of high risk patients are those who have a potential need for
airway intervention and ventilator support during a mission. This includes for
example patients with significant intracranial pathology. Such patients may be stable
at the time of presentation but have a significant risk of rapid deterioration (e.g.
conscious patients with subarachnoid haemorrhage). Retrieval of such patients should
be performed by crews that have capacity to provide airway support (MICA or
Doctor). If the patient is unstable or has existing significant neurological signs, a two
person crew must always be used, to ensure risk minimization in airway intervention
procedures and ongoing management of the patient in flight / transit.
• Current crew options include ARV retrieval physician, source hospital medical or
nursing staff, MICA Flight Paramedic, MICA Paramedic, Ambulance or Flight
Paramedic and combinations of these.
Critical Care Patients
• Normal crew recommendation for such patients (consistent with national guidelines
and industry governance norms) is two clinical staff. At least one must be critical care
trained (e.g. MICA, FMP, RetrDr) in all cases, and in some cases two critical care
trained staff are appropriate (e.g. very long jobs or very unstable/complex jobs).
• Whilst this is a guide and a recommendation (and in many senses ideal), it is also
something that needs to be considered on a per case basis – considering alternates,
most efficient response options, concurrent workload etc. There will be times that
expediting a single-clinical-crewed critical care retrieval is a better option (or the only
option) depending on resource availability and logistics.
Crew Mix Flexibility
• Desired crew mix is dependent on case complexity and actual or potential instability,
and on matching crew skill set with known or anticipated clinical need:
• In some circumstances, the preferred crew option may not be available, eg no
retrieval physician available, no MFP available, time criticality may preclude waiting
for RP to arrive at airport if response time is prolonged.
• In some circumstances, the initially tasked crew officer may have reservations about
their ability to comprehensively manage the patient. In these circumstances, the crew
mix should be strengthened by addition or replacement with another crew member.
Cardiac Pacing
A retrieval physician is required for (interhospital) retrieval of the following patient types:
patients requiring Cardiac Pacing (Transvenous or Transcutaneous)
patients with a high likelihood of requiring pacing - principally this will be patients receiving
Chronotropic Infusions (Isoprenaline / Adrenaline) for bradycardia.
These are circumstances where TCP may be a life-saving intervention. Currently MICA flight
paramedics are not credentialed to use the Zoll TCP.
The Zoll defib/pacer, and the external pacing box need to be included in the kit for these
missions. Transvenous wires are not currently part of the ARV standard equipment, will most
often be inserted at the referring hospital if required, and their insertion would require
individual physician credentialing. In a situation where a small hospital does not have the
resource or capability to initially stabilise a patient in this clinical scenario, coordinators
should consider expedited emergency MICA transfer (road or air as appropriate) to a centre
with capacity to provide resuscitation at least - rather than a delay for retrieval response. [This
is analogous to the patient with uncontrollable haemorrhage in a small hospital, unable to
provide intervention].
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Crewing Skill Mix Matrix Extreme
Highest Crew
configuration,
may be multiple.
Standard crewing
Mod
Low
Complexity
Intermediate
crewing
High
High level
crewing
Stable
Low
Risk
High
risk
Unstable
Instability 68
Defined Patient Transfers This guideline relates to the DHS Interim Critical Care Capacity Guideline.
(http://www.health.vic.gov.au/criticalcare/ccguide08.pdf)
Should there be need for a patient to access an ICU bed in the setting of no appropriate ICU
bed being declared available on the Victorian Critical Care Access Website, a defined transfer
may be authorised by the Director of ARV or delegate.
This process applies for patients needing retrieval to a site where definitive care can be
provided, and assumes that such care is not available at the point of referral. The process
assumes that the patient will gain a higher level of care through this transfer. A patient should
not be transferred under this policy if all that is achieved is the same standard of care in
another setting e.g. transfer of an intubated overdose patient from ED in a metro centre with
ICU consultation to the ED of a tertiary centre.
In this circumstance, the ARV admin on call (Director or delegate) will contact an appropriate
destination hospital, speak with the Executive Officer on duty, and authorize transfer of the
patient. The ARV coordinator will subsequently liaise with referring and receiving clinical
staff.
An analogous process is in place for patients with time urgent neurosurgical emergencies for
whom no bed is currently available.
Decisions about which hospital is to receive the patient will be made after consideration of:
• Capability and capacity of the referring health service.
• Nature of the surgical/other intervention required by the patient.
• Capability and capacity of the potential receiving health service.
• Nature of the clinical condition.
• Degree of clinical urgency.
• Known or anticipated critical care system demands.
• Normal referral and historical clinical relationship patterns.
• Geographical proximity.
• Needs and consideration of the patient’s family.
Documentation of Coordination All requests for assistance will be documented and included in the ARV database.
The standard Coordinator Data Form will form the base level of data and information capture
required.
Completed Coordinator Data Forms will be faxed or e-mailed to the ARV office within the
next working day.
Drug Stocks : rare items Where urgent need occurs for drugs that are not normally carried by ARV, a process has been
established to source items from the Alfred Hospital. The ARV coordinator should discuss the
request with the duty pharmacist at the Alfred, and make arrangements for collection of the
item.
Payment is managed via the ARV office on the next business day; the coordinator is required
to advise the ARV Business Manager of such cases.
ECMO Patients with ECMO. Alfred Hospital and RCH provide transport ECMO services
collaboratively with AV. ARV are responsible for logistics and platform coordination, and the
receiving hospital for staff and equipment. An MOU exists between AV and these hospitals
outlining these responsibilities and obligations. ARV contact for adult ECMO is the Alfred
ICU.
Key concepts include:
Optimal communication between all parties involved in retrieval work is essential. To this
end, ARV uses teleconferencing and videoconferencing technologies extensively. (All calls
to and from ARV are recorded for quality purposes)
69
Where patients are referred to ARV regarding potential ECMO transfer/commencement, or
where they meet general ECMO inclusion criteria, the ARV coordinator will initiate a
teleconference involving the Alfred Hospital ICU consultant.
Where the Alfred hospital receives direct referral of patients for ?ECMO transfer, the ICU
consultant will contact ARV to ensure commencement of a teleconference involving the ARV
coordinator from the outset.
All ECMO retrieval staff will be fully credentialed.
Decisions will be made jointly and collaboratively. Issues that cannot be resolved will be
escalated to the ARV and Alfred ICU directors (or delegate)
Prior to any ECMO mission, the ARV coordinator will discuss the case with the ARV director
or delegate, and subsequently convene a “Summary Teleconference”. This will be attended by
all involved clinical and logistics parties or the case must not proceed. In this
teleconference, the plan including contingencies will be discussed and agreed.
During ECMO transfers:
The ARV coordinator is the clinical ‘control point’ for all retrievals. They are responsible for
defining time criticality of a retrieval case, and for overall coordination of crewing, logistics
and resource.
All case communication will occur through the ARV RASO / coordination office.
All transport coordination will be provided by ARV utilising AV transport platforms.
Urgency of outbound legs will be discussed with the ARV coordinator who will coordinate
platform responses via AAV, ERTCOM or NETCOM.
Standard crewing will be: Paramedic, ARV retrieval physician, Alfred Team (Intensivist(s),
+/-ICU RN)
Clinical leadership will be provided by the senior intensivist
Operational leadership and environmental guidance will be provided by the ARV retrieval
physician
Patient movements and transfers will be minimized, and will occur in well-lit, protected
environments (e.g. a hangar rather than open tarmac).
During air missions, the pilot is responsible for the overall safety and management of
logistics. In flight the pilot is in control of all resources, and is responsible for all decisions in
relation to the aircraft, flight path, safe altitude etc.
Transfers of up to 4 hours travel time are normally performed by road platform although air
transport to the referring hospital (for response rapidity) may be appropriate. All ECMO
transfers must be discussed with ARV Director or delegate.
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71
Hospitals Reference Database The hospitals reference database provides an up to date profile of the referring and receiving
hospitals in Victoria, including their classifications, facilities, investigative lab capability etc,
and general recommendations regarding transport options.
It is available at: G:\Emergency Operations\ARV\ARV DataBase\Hospital Reference.
IABP For IABP, some referring hospitals have historically provided IABP equipment and staff,
ARV organizing logistics and additional staff if required. In general the preferred
arrangement is for ARV to coordinate IABP transfer with pump and technical support from
Perfusion Services Ltd, with whom ARV has an MOU and clearly developed systems and
standards designed for the transport environment. Contact Perfusion Services via: 95856011,
pager 96253184 or 1800641581 (James McMillan).
Transfers of up to 4 hours travel time are normally performed by road platform although air
transport to the referring hospital (for response rapidity) may be appropriate. Interstate or air
IABP transfers must be discussed with ARV Director or delegate.
Interstate Retrieval Procedures Adult Retrieval Victoria (ARV) is responsible for retrieval services in Victoria. From time to
time situations occur where a patient in Victoria requires retrieval to an interstate destination,
or where ARV is required to retrieve a patient from interstate to a Victorian hospital.
Principles
In these circumstances there are several principles that must be followed:
The clinical care of the patient is the primary consideration, and decisions made must not
compromise patient care or outcomes. NB: The clinical care of the patient may be influenced
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by numerous factors, including (time) availability of in-state retrieval services, weather,
platform availability, platform logistics e.g. weight limits.
The usual domicile of the patient and relevant relationships they have with clinical services
are significant. The patient’s wishes must be considered, for example a patient request to be
close to supportive family may mean a cross border transfer for someone living close to a
State border.
Coordination responsibility
Responsibility for coordination of a retrieval case fundamentally rests with the State in which
the referral hospital is located.
Exceptions to this are:
Patients located in southern NSW including Albury, Finley, Deneliquin and Barham, where
long standing referral and secondary care links exist into Victoria.
Some patients of Mildura Base Hospital - whose primary social support links or relevant
immediate past clinical care links are in Adelaide (assumes Adelaide destination hospital).
Interstate communication
Where ARV is coordinating a proposed patient retrieval from a Victorian referral hospital to
an interstate destination hospital, a teleconference must occur between the ARV Critical Care
Coordinator (CCC), the interstate Retrieval Services Coordinator (Adult), and any additional
stakeholder (receiving and referring clinicians, retrieval team members, aviation service
providers etc).
Retrieval to an interstate destination
Patients will normally be retrieved by the receiving State retrieval service, however situations
may occur where the referring State transports a patient interstate due to clinical platform
logistics or availability e.g. ARV retrieves a patient from Mildura to Adelaide. ARV cases,
with a planned interstate destination utilising ARV staff and AV assets, must be escalated to
the ARV Director or delegate prior to commencement of missions.
Contact numbers
SA Coordinator (RAH Retrieval Service Air Medical Consultant) (08) 8222 4222
NSW Medical Retrieval Unit (02) 1800 650 004
Tasmania (03) 6336 5799
Issues Incidents or Problems Issues or problems which may arise must be handled in a collegiate and professional manner,
with the patient well-being and clinical outcome the over-riding consideration. Issues that
cannot be simply resolved must be escalated to the Director ARV or the Clinical Advisor
ARV urgently.
Regional AV logistics or other issues may be escalated via the Regional Clinician to the
Regional Manager as required.
Any issue or event which exposes the service or a patient to risk or which results in harm to
staff, public or patient must be reported to the ARV Director and via the ARV Incident
Reporting framework.
At present these would be (by default):
• patient death in our care
• staff injury
• near miss / event with potential for patient harm (level 2 variation)
• actual patient harm due to error (level 1 variation)
• other critical risk (logistic or clinical)
Morbid Obesity Patients with morbid obesity (arbitrarily defined as: weight over 140kg, or BMI over 45) who
require mechanical ventilation for management of pulmonary pathology, or who require
mechanical ventilation and have other significant co morbidity, should routinely be crewed by
ARV doctor and MICA. These patients must be considered clinically very complex and at
significant risk for transfer.
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It is not possible to lift patients over 120kg into the current fixed wing aircraft due to
loading equipment limitations. This does not relate to rotary wing aircraft where patients over
120kg may be considered for transport on a case by case basis.
Night Transfers Transfer must never be delayed in a time critical patient. (This includes patients with
significant risk of deterioration during the time delay).
Non Time Critical aviation transfers should not occur after midnight (air crew fatigue and
human factors issues)
It is imperative that the skill set and capacity to provide ongoing care at the referral site is
factored in any decision to delay a transfer.
All cases where transfer at night is delayed will be specifically audited.
Time Critical: In respect of Retrieval Transfer – A patient is considered time critical if the
patient has a clinical condition which presents an immediate threat to life, limb, cognition or
future quality of life, and
• Delay in definitive treatment will significantly increase that outcome risk, and
• Definitive management of that condition or threat is likely to be achieved by urgent
transfer to another hospital, or
• Management of that condition definitively, or for a prolonged interim period, is beyond
the resource capacity or clinical skill capacity of the current provider (or would result in
unacceptable resource drain and exposure of other patients to risk).
Palliation & Non­Transfer Some patients referred for transfer are critically unwell with illness which is inevitably
terminal. The coordinator will consider such requests from the perspective of clinical
appropriateness, and psychosocial impacts. After considering the clinical scenario, including
where the patient currently is and what level of care can be provided, in some cases, it may be
better practice for the patient to remain where they are, and to die in their own community in
the presence of family and friends. This may be preferable to retrieval to a distant hospital for
futile care.
Situations arise where a retrieval physician may also make such a conclusion after assessment
of the patient – these situations must be discussed with the coordinator.
Paramedic Consultation Several of the AV Clinical Practice Guidelines require consultation between Flight MICA
Paramedics prior to specific interventions, and authorization by the ARV coordinator. These
include:
• Administration of ONeg blood,
• Use of NorAdrenaline in doses exceeding 25 mic/min
In such cases the coordinator must make an assessment of the case and provide authorization
and / or other clinical advice as is appropriate.
Familiarity with AV paramedic CPG’s and the skill set of paramedics is essential to this role
(and the provision of advice to the AV Clinician or crews). See: “paramedic skillsets” in this
manual or the AV CPGs at: CPG Link
(http://portal.mas.vic.gov.au/portal/page/portal/PAGEGRP_MAS_PROCS/Operations%20Sta
ndards%20%20Improvement/Clinical%20Practice%20Guidelines%20%28CPG%29
Peak Workload Strategy ARV workload by its nature is variable in intensity and volume. Under normal circumstances,
the current systems cope with standard loads however there are peaks of activity which can at
times be sustained (e.g. in winter). In such situations it is important that Coordinators and
RASO’s identify critical workload volumes and identify strategies to manage this load. The
advised process is as illustrated in the table below.
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In all cases of peaking workload, the above strategies should be implemented at the earliest
opportunity and continued informed communication with the ARV Admin on call should be
maintained, either by phone or email.
Strategy
In Hours
Time Out
Coordinator to request that the Contact ARV Admin on Call and
Admin on Call meet in the EOC teleconference to discuss the current
with the Coordinator and RASO situation and assistance required.
to review the current cases in
progress and to,
(When workload
is peaking,
multiple cases,
limited resource)
After Hours
1.Rate the risks,
2.Assign ‘urgency’ of cases and
to,
3. Determine the resource needs
of each job and prioritise
actions to be taken.
Additional call
taking resource
(The ARV office
will provide
additional RASO
function / call
taking)
Additional
coordination
resource
Contact the ARV Business
Manager who will organise
additional support from within
the ARV office staff group.
Contact the ARV Admin on Call
who will-
The ARV Admin on Call will
provide direct assistance (if
appropriate) or mobilise inhouse or on-call clinical
advisor, retrieval physician or
registrar staff to assist.
During extreme workload periods, a
second on call coordinator may be
rostered.
1. Authorise / organise to recall
additional clerical staff depending
on availability.
2. Authorise the use of on site RP
staff, depending on
tasking/availability.
Perinatal Emergency Retrievals The Perinatal Emergency Referral Service (PERS) is a state-wide service providing maternity
care providers in Victoria with a coordinated and timely safe approach for;
• Providing access to optimal expert clinical advice about perinatal emergencies.
• Providing access to obstetric and neonatal resource information.
• Facilitating perinatal emergency transfers to appropriate facilities when required.
In cases where there is likely rapid deterioration in maternal condition without specialist
intervention, such as occurs with major post-partum haemorrhage, uterine
rupture, or acute respiratory failure, or where the mother is or is likely to become critical,
PERS will refer case coordination responsibility and management of the mother to ARV.
In such cases:
The PERS consultant will contact the ARV critical care coordinator and provide a handover
of the clinical status.
Both consultants will discuss the priorities and clinical needs of the case (including but not
limited to):
o Pregnancy specific care needs for the mother
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o General care requirements of the mother
o The type of preferred destination unit for the mother
o Neonatal care considerations (involve NETS if required)
ARV will coordinate an appropriate crew response for the case
ARV will coordinate appropriate transport for the patient via relevant AV Operations Centres
and AAV where appropriate
ARV will access an appropriate critical care bed for the patient (at a centre which provides
obstetric care normally)
The PERS consultant will remain aware of the case and provide consultation and input via
intermittent briefings from the ARV coordinator, or through involvement in teleconferences
The outcome of the case and / or transfer will be communicated to PERS by ARV.
Platform Options: General Recommendations re range of service / retrieval response
Platform
Range
< 100km
50km < 175km
> 175km
Semi
Urgent
Not
Urgent
Urgency
Urgent
Time
Critical
Road
Rotary Wing
Fixed Wing
<50km
50-100km
100175km
>175km
Distance
Fixed Wing
Rotary Wing
Road
There are several modifying factors in platform selection:
1. Platform activation time
2. Return destination
3. Crew activation time
4. Secondary ground/air transfer times
5. Clinical Issues e.g. equipment and space needs
Failure to resolve platform or crew response decisions within a reasonable time period (60
minutes) requires escalation of the issue to ARV admin-on-call, AAV manager, AV DTM,
regional duty manager or others as appropriate.
Road Platforms
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The current options for road transport platforms include – emergency ambulance, CPAV,
HATS, non-emerg vehicle. Due to current staffing and crewing structures the standard
approach to road vehicle choice is as follows:
HATS (with driver + Crit Care Nurse crew) is preferred option during periods of availability,
and if response time is appropriate, unless
ARV Coordinator contacts HATS in the first instance as this is the preferred resource for
ARV retrievals
If HATS is not available the ARV Coordinator contacts the Clinician
In consultation with the ARV Coordinator the Clinician will provide the most appropriate
resource to accomplish the retrieval. In most cases this will be an AGP with at least one ALS
qualified paramedic aboard
If the ARV Coordinator determines that the retrieval requires MICA skill sets to assist the
retrieval physician (uncommon), the Clinician will organize a CSO/SRU to accompany or a
MICA vehicle to do the transfer
The Clinician may consider the use of a CPAV or Netcomm vehicle if they are able to
resource either unit with an ALS qualified or MICA paramedic
If required, the ARV Coordinator can liaise with the Clinician to determine clinical
requirements prior to contacting the Clinician to organize the retrieval
Activation of HATS is performed via Coordinator contacting NPT (private ambulance
service) on 1300 628728 (The RASO will fax a booking form to Netcom also).
Prioritisation of Tasks In some cases, requests for assistance finding a bed or transferring a patient come before all
relevant investigations are available. This information may be necessary to determine
appropriate bed, or of need for transfer, eg CT head, troponin levels. If clinically appropriate,
some decisions and actions can be deferred until that information is available. In other
circumstances, decisions need to be made with incomplete information. Some health services
are unable to provide what some would consider basic investigations (eg blood gases)
The coordinator will determine what are the highest priority patient factors in facilitating
bed access.
• Does the patient require a time critical intervention (eg hot angiogram, neurosurgery,
ruptured AA)? This may be a more important consideration than whether an ICU bed is
immediately available for the patient.
• For Cardiology patients: Do they (or are likely to) require access to (hot) angiography or
monitoring?
• For ICU: Do they require tertiary level care? Do they (or are they likely to) require access
to specialized services (eg dialysis, thoracic surgery)
• For drug overdose patients: There is likely to be a need for psychiatry services after ICU
discharge.
For patients primarily requiring an urgent intervention, this should not be delayed while
finding and ICU / CCU bed. If the intervention can be done in a hospital with a suitable bed,
this will reduce the need for secondary transfer.
Receiving Hospital The coordinator will contact appropriate units based on the above. Initial requests should go
to the lowest level hospitals able to deal with the current (and likely) clinical situation. This
will ensure beds may be available for future more complex patients who may not be clinically
suitable for the less complex hospital. For example, admitting an elderly, haemodynamically
stable NSTEMI to a tertiary hospital rather than an urban ICU, may impact on ability to
manage a (potential) young patient with STEMI and ongoing pain despite thrombolysis.
Geographic factors should be considered, because of impact on family and ambulance
resources. This should involve consideration of regional base hospitals as appropriate.
If the requesting hospital has easy helipad access, and the patient is suitable, consideration
may be given to metro hospitals with better helipad access – this increases efficiency of the
transfer process and resource use and is of particular relevance in trauma patients.
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Regional Retrieval Services Regional Retrieval Services should be considered for patients within their areas. Availability
and Range is as detailed below:
Days
Hours
Registrar
Consultant
As required
Out bound
retrievals
and
transfers
Yes
Available
for out of
area
retrievals
Consult
Geelong
M-F
1200-2400
Yes
Bendigo
M-F
1200-2400
No
Yes
Yes
No
Contact Point
ED duty cons.
ICU duty
cons.
Outside the above hours, each regional retrieval centre will, on request, provide advice and
input into retrieval activity, and each region has a designated contact person for discussion of
specific issues or requests that are outside of the usual agreed operating framework. (ARV
office will facilitate contact).
Retrieval Physician Tasking Retrieval missions will be allocated to the most appropriate RP responder according to
required skillset, physician location and mission activation urgency i.e. particular staff with
specialised skills may be selected for individual missions with known special clinical
challenges.
Where clinical acuity indicates a need for medical crew, and there is no specific need for
consultant level skillset, responding an (on site) consultant may remain an option for the
coordinator. It is important that consultant grade staff remain familiar with routine mission
activities, and be tasked to a range of mission types – both ‘routine’ and highest acuity. This
applies to both air and road missions.
Tasking decisions towards the ‘end of shift’ need to consider both rostered time of shift end
and clinician fatigue. It may be appropriate to delay some missions pending commencement
of a subsequent shift.
Registrars will be assessed early in their rotation to ARV and a decision made re solo
missions, and the level of mission acuity that may be appropriate for them at particular times.
Staff Welfare The nature of retrieval and coordination work can be stressful and difficult. Ambulance
Victoria offers all staff access to peer support and counselling services. These may be
accessed by individuals or via ARV management
Peer Support: contact via Corporate Paging (for duty peer support officer) 9483 8009;
Phone: 0419 002 956 Email: [email protected]
Counselling Service: Ms Heather Bancroft, VACCU
Phone: 9654 4144 Email: [email protected]
Tarmac Handovers Are generally inappropriate, and patients should be retrieved from a hospital setting. This
allows for controlled handover, assessment of the patient, checking of all equipment,
connections, placements etc. All tarmac handovers will be considered a variation and audited.
(Exceptions may exist e.g. an uncomplicated AMI being transferred urgently for PCI – in
such a case the risks associated with tarmac handover are low, and the time benefit may be
great)
Trauma Calls ARV facilitates the Statewide Trauma Advice and Referral System. Previously a dedicated
line (1800 700 001) was used to activate the Trauma System. Now all trauma calls utilize the
ARV 1300 368661 number. ARV RASO staff will answer the call.
Paediatric calls will be immediately transferred to the RCH
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Adult calls will be transferred to the requested trauma service
The Critical Care Coordinator will be conferenced into this call and may offer advice in
regard to patient transfer or retrieval.
All calls will be recorded as per standard ARV processes
The Coordinator may depart calls at their discretion if content is not of relevance to transfer or
retrieval (after informing other parties of this departure).
State Trauma System
(see also: http://www.health.vic.gov.au/trauma/guidelines/index.htm)
Adult Patients
Ambulance services should triage adult major trauma patients and suspected adult major
trauma patients directly to an adult Major Trauma Service (The Alfred and the Royal
Melbourne Hospital), when the travel time is less than 30 minutes.
If a Major Trauma Service is not within 30 minutes travel time, then the patient should be
triaged to the next highest-level trauma service within 30-minute travel time, from the
accident site.
Specialist Trauma Triage and Transfer
Hospitals with neurosurgical specialities should manage neurotrauma patients requiring
critical care support.
Major trauma including spinal trauma should initially be triaged to a Major Trauma Service.
Early consultation by each treating hospital with the Victorian Spinal Cord Unit at the Austin
Hospital is essential to optimise patient outcomes.
Discrete spinal cord injured patients over 16yrs of age, in the absence of other indicators of
major trauma, should be triaged to Austin Health’s, Victorian Spinal Cord Service by
telephoning (03) 9496 5000 and asking for Spinal Unit Acute Registrar.
Multiple trauma, incorporating the need for microsurgery, should be referred and transferred
to a Major Trauma Service. St Vincent’s Hospital also have capacity as leaders to manage
injuries requiring microsurgery.
Neurosurgical triage and transfer guidelines for major trauma still apply in rural areas, even
where a neurosurgical specialist practises locally, as the management of these patients
requires all the appropriate and agreed service supports of a Major Trauma Service.
Elderly patients with isolated neurotrauma may be transferred to a general neurosurgical unit.
Pregnant Trauma patients are transferred to the RMH where protocols are in place for shared
care with the RWH.
Major Trauma Triage Guidelines Require:
Pre-hospital major trauma to be identified according to specified physiological and
anatomical criteria.
Triage to a Major Trauma Service where a major trauma patient is less than 30 minutes
transport time from a Major Trauma Service.
Triage to the highest designated trauma service accessible in 30 minutes where a major
trauma patient is more than 30 minutes transport time from a Major Trauma Service.
Triage to a designated trauma service accessible in the least amount of time in isolated rural
areas that are more than 30 minutes from any trauma service.
Where a major trauma patient appears to be in an immediately life-threatening situation
during transport, the patient be diverted to the nearest designated trauma service for
stabilisation, with subsequent transport to a Major Trauma Service at the earliest appropriate
time.
Where a patient is triaged initially to a non-Major Trauma Service for stabilisation, early
liaison with the Major Trauma Service should occur via the Trauma Advice and Referral
telephone line 1800 700 001, which is answered by ARV calltakers. Consideration of
appropriate medical retrieval or interhospital transfer to a Major Trauma Service can then
occur from the initial call.
Unable to respond In any situation where timely retrieval response is not able to be provided (due to crewing or
weather, or other factors, this decision must be discussed with the referral agency, and every
79
effort made to assist in resolving the problem or resource gap. Review of the status of weather
or logistics within an agreed timeframe should occur, and further communication be
undertaken if necessary.
There are circumstances where such delays or impediments indicate that a preferred option
(only viable option) for a patient may be a ‘mercy dash’ with any available AV crew and
referring doctor to move the patient to the nearest site capable of necessary resuscitation.
AV provides a work instruction to facilitate this which essentially requires close collaboration
and planning between referrer, AV Clinician, AV crews, and ARV coordinator.
Uninsured Patients & Private Hospitals In general, uninsured patients should be preferentially placed in the public system, and
insured (including DVA) into the private system. Exceptions include trauma (either TAC or
Workcover) who should be transferred into the trauma system, and those requiring time
critical interventions which may be difficult to facilitate in the private system (eg urgent
craniotomy)
ARV is responsible for all costs incurred when moving a public patient from a regional/rural
hospital which has no ICU Unit (or patients from Werribee Mercy, RWH and RVEEH) into a
private bed. This does not apply to any metro/regional/rural hospital which has any ICU
capability. All other factors being equal, preference should be given to placing rural patients
into the public system.
In all such circumstances, it remains the responsibility of ARV to monitor the status of
patients on a daily basis, and to assist in transfer of the patient to a public hospital at the
earliest clinically appropriate time. It is the responsibility of the referring health service to
make available an appropriate bed for the patient to be returned to as soon as possible.
Regarding uninsured patients who self‐present to a private hospital ED and require
critical care admission (ICU, CCU, HDU): If the patient elects to be a public patient (as
opposed to agreeing to self-fund private care), then the hospital is responsible for all charges
for the first 24 hours of care, after contacting ARV to request patient transfer. This 24-hour
period allows ARV to find an appropriate public hospital, where it is clinically appropriate to
transfer the patient. ARV is responsible for payments after the first 24 hours if the patient
remains in the private hospital.
Videoconferencing Capability Guidelines for Virtual Trauma and Critical Care Unit (ViTCCU) and GRAHnet calls
Background
ViTCCU and GRAHnet provide broadband-based clinical support for hospitals in the
Loddon-Mallee and Grampians Healthcare Networks. Regional hospitals (attached list) are
able to link to ARV as well as some metro hospitals (Alfred, Austin, St.Vincents and The
Royal Children’s) from mobile video-conferencing units. The system has been operational
since 2009 but has been relatively underutilised due to lack of clinician engagement at both
sending and receiving sites.
ARV’s role is basically as a hub for clinical advice as well as the opportunity to link with
tertiary hospitals for referral / clinical advice as needed. Having real-time vision of the patient
as well as the ability to view x-rays, CT scans live makes patient assessment and retrieval
planning significantly easier. If this pilot project is successful, then there is the potential for
this technology to be rolled out statewide.
First and most importantly, Clinician engagement – there is a natural reluctance for clinicians
to engage with new technology. Encouraging their use of this technology – and making it a
‘user friendly’ experience will help reinforce its use in the future.
ARV also have a ‘forcing’ opportunity – that is by mandating its use when receiving calls for
advice / retrieval, we can ‘embed’ it as part of clinicians’ practice.
Guidelines for using ViTCCU
ViTCCU should always be used for clinical advice / retrieval calls from appropriately
equipped hospitals – please document ViTCCU use on the call sheet. If a clinician calls from
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one of the hospital on the list, they may need to be prompted to turn the system on and
position it – the unit may not always be in the calling unit and may need to the moved to the
patient. Simple instructions to facilitate this are available on the CC desk (Grampians yellow
folder, Loddon-Mallee white folder).
We have encouraged regional hospitals to ‘overuse’ the system initially to improve
familiarity.
Please be positive and welcome calls for advice, even if you don’t think they are core ARV
business – positive reinforcement of clinician engagement, will significantly improve longer
term uptake
Ultimately CT scans and other radiology will be available via a CERNA application – this is
still in development – for the time being, the resolution of the system is good enough to view
films on a light box or computer screen.
It is possible to have a three way teleconference involving receiving hospitals – the logistics
of this are currently being sorted out and further info will be provided once this is done.
List of VC equipped hospitals
Metro Sites
Alfred Hospital - ED fixed unit
Austin Hospital - ED fixed unit
St Vincent's Hospital - ICU fixed unit
Royal Children's Hospital - ED fixed unit (they may have another unit)
Loddon-Mallee Region
Grampians Region
Bendigo
ED – mobile unit
ED – fixed unit
CCU – fixed unit
Mildura
ED – mobile unit
ICU – mobile unit
Swan Hill
ED – mobile unit
HDU – mobile unit
Echuca
ED – mobile unit
HDU – mobile unit
Bendigo
ED – mobile unit
ED – fixed unit
CCU – fixed unit
Mildura
ED – mobile unit
ICU – mobile unit
Swan Hill
ED – mobile unit
HDU – mobile unit
Echuca
ED – mobile unit
HDU – mobile unit
Ballarat
Ararat
Stawell
Horsham
Baccus Marsh
Daylesford
Hopetoun
Nhill
Rapanyup
Edenhope
Beaufort
St Arnaud
Birchip
Warracknabeal
Donald
81
Coordination Maps The maps below indicates 100km ranges from each regional centre, and 50 and 150 km radius
from metro, plus 150km radius from Bendigo and Latrobe Valley
100 Km radius from regional Centres
M
82
150 Km Radius from Helicopter Airfields
Bendigo
Essendon
Latrobe Valley
Warrnambool
83
84
Retrieval Physician Guidelines Aviation resources The allocation of aviation resources is the responsibility of the AAV Flight Coordinator.
Aviation resources may not be available due to: weather conditions, pilot duty restrictions,
aircraft maintenance or performance issues, or other tasking.
Blood Transfusion Blood transfusion (or infusion of other blood products) is occasionally required for patients
being retrieved. In such cases blood must be stored in an appropriate approved blood shipping
container, and clear records must be kept of all agents used (including pack numbers). Where
available, standard transfusion documentation should be completed and handed over to the
receiving hospital clinical staff.
Case review & Audit • The Clinical Advisor or Director performs a document-based review of all ARV cases.
Data will be extracted from the records at this point to contribute to the ARV patient
record database quality indicators.
• The record is reviewed from the perspectives of compliance with documentary standards,
and clinical practice standards, and screened for the documentation of adverse events or
incidents that may have resulted in risk or harm.
• All cases are also screened from the perspective of logistics – assessing the smoothness of
a mission, its planning and execution, and the avoidance of unnecessary delays. Cases
include both patient-transfer cases, clinical-advice-only cases.
Clinical Practice Guidelines The Clinical Practice Guidelines developed by AV for use in the field by MICA and Flight
MICA paramedics are appropriate in general scope to the range of practice of medical
Retrieval Physicians. These CPG’s are overseen by the Medical Advisory Committee and will
be the initial reference point for ARV clinical practice.
The CPG’s are guidelines and do not strictly limit the scope of clinical practice of
practitioners, who in certain circumstances may reasonably work beyond or outside of the
guideline. The application of guidelines will be reviewed through the case review and audit
system, and appropriate feedback will be available.
• Additions to, or alterations to guidelines will occur through the processes of the Medical
Advisory Committee (MAC)
Command & Control During air missions, the pilot is responsible for the overall safety and management of
logistics. In flight the pilot is in control of all resources, and is responsible for all decisions in
relation to the aircraft, flight path, safe altitude etc.
The ARV coordinator is responsible for defining time criticality of a retrieval case.
The ARV coordinator will determine the crew-mix that has the most appropriate skill set for a
specific clinical scenario. Principle factors involved in this decision will be clinical
complexity and patient instability (actual and potential).
Communication & Public relations The coordinator and retrieval physician must remain mindful of the need for optimal
communication styles, and of communication strategies that may be applied to ensure
85
complete and clear communication of relevant clinical and risk related matters with the
referrer.
o Always allow the referrer to complete statements – do not complete for them / put
words in their mouths
o Reflective checking is valuable: “Thank you Dr X, I understand from your
statement that the patient is ….. – is that correct?”
o Ask direct risk related questions: “Dr, Do you perceive any major risks or hazards
in the transfer of this patient?”
o Leave the door open for further communication: “If you think of anything else
that may be important or that arises after this call, please phone me back”
• The retrieval physician must be aware of the high visibility nature of their work, and the
fact that they are often interacting with systems and individuals under pressure.
• A proportion of the work of ARV is considered ‘newsworthy’, and the involvement in
cases that may be considered such should be raised with the ARV office in the first
instance. The office may then liaise with press agencies via the corporate communications
area of AV.
• Individual staff members must be aware of and compliant with standard AV and public
service policies in regard to confidentiality and release of material to the media.
Contact and Availability The Retrieval Physician will be contacted by the ARV Call Taker, by phone.
The Retrieval Physician will be available to discuss the case with the ARV Coordinator
within 5 minutes.
All phone contact will occur via 1300 368 661 to enable voice logging for quality assurance
processes.
Calls to the referring hospital should be minimised. Requests by the retrieval physician for
additional information, insertion of lines or preparation of drug infusions should be made
through the ARV Coordinator, or by teleconferencing all involved parties. If the ARV
Coordinator is coordinating multiple concurrent tasks he/she may ask the retrieval physician
to communicate directly with the referrer.
The Retrieval Physician will at all times communicate in a professional manner, respectful of
the circumstance of the referrer, the stressful nature of critical incidents, and the role of ARV
and AV in the State Health System.
The Retrieval Physician, in conjunction with the RASO and ARV Coordinator should ensure
that both the referring and receiving hospitals are informed of the estimated time of arrival
(ETA) of the retrieval team. The retrieval physician should inform the RASO of ETAs on
departing and arriving back at Essendon. (Or on departing the referring hospital for road
missions.)
Credentialing Credentialing of retrieval staff occurs on an annual basis as a component of the performance
management interview.
Credentialing will be performed by the Clinical Advisor or Director and recorded in the staff
HR file.
Death of Patient All patient deaths during the care of an ARV physician must be notified to the Coordinator at
the earliest possible opportunity.
The ARV coordinator will report the death to the ARV Admin on Call at the earliest
appropriate opportunity. The case will then be flagged for early clinical review.
Deaths occurring in a metropolitan based vehicle (including Air, HATS and CPAV) must be
notified to the Duty Team Manager at Tally Ho. (RASO will arrange). Deaths occurring in a
regionally based vehicle must be notified to the appropriate control room. This will facilitate
an appropriate destination for the body.
The coroner should be notified in appropriate circumstances.
Peer support is available to all staff involved in the care of a patient who dies during transfer.
86
The deceased’s family will need to be notified of the death.
Debriefing • Retrieval physicians should take the opportunity to formally or informally discuss and
debrief each mission with other team members after each case. This presents a
mechanism to acknowledge good practice, highlight communication and to look for
improvement opportunities.
Documentation All cases will be documented utilizing the AV clinical information system (VACiS)
Guidelines for completion of the record are available.
Equipment • Daily checking of drugs and equipment (responsibility of the 0800-1800 retrieval
consultant)
• Manuals for all equipment are available in the ARV office.
• Equipment and drug checking Occurs daily at 0800hrs & after the completion of each
retrieval
o There are 4 kits in total to check
o The day shift Retrieval Physician– will check ALL Biomedical equipment
and the RED and BLUE bags and the YELLOW drug bag.
o An equipment checklist must be completed for each kit and anything found
missing can be sourced from the medical / equipment storeroom. The
completed checklist should be left with the kit. Anything used during
retrieval should be annotated on the list to facilitate restocking.
o Restocking - when restocking items, if there is found to be 2 or less of a
particular stock item remaining in the storeroom, you must flag that item for
ordering.
o IN HOURS - contact the ARV Business Manager. The BM will attempt to
source the required item – however if it is ‘out of stock’, there will be a time
lag between ordering and delivery. If the BM is not available, a message left
with the ARV Admin Assistant will be passed on.
o AFTER HOURS – write the item description on the whiteboard in the
storeroom and it will be ordered on the next business day.
o Drug Bag
o All expiry dates for drugs in the packs must be checked on the first of every
month.
o For drugs which are normally refrigerated, the date when they should be
discarded should be recorded on the ampoule.
o This would normally be 1 month for suxamethonium, 3 months for
rocuronium and pancuronium.
o Replacement Drugs can be obtained from the drug cupboard. Restricted items
are held in the drug safe – and must be checked in & out by two people. This
can be done by a FP &/or a MFP, and / or the FC.
Biomed Equipment Ventilators should be checked using a circuit & test lung with O2 cylinder located in
storeroom.
Monitors should be turned on and attachments checked.
Syringe driver battery level must be checked.
ZOLL monitor with external pacing should be tested.
iSTAT analysers – calibrated weekly
All ventilators, monitors and syringe drivers must be on charge while in the storeroom.
Faulty Biomed Equipment
87
Any equipment malfunction must be recorded in the Maintenance
Request/Defect Report book located in the storeroom. The faulty equipment
and the completed paperwork is to be given to the ARV Business Manager
(BM) in hours, and after hours the equipment and paperwork should be
placed in the ARV main office and an email sent to the BM. This will be
followed up on the next business day.
o Under no circumstances should faulty equipment be left in the packs or put
back on the shelf.
On Return From A Retrieval
o On completion of a mission the kit must be returned to base and restocked by
the retrieval physician so that it is immediately task ready.
o
Fatigue • ARV aims to minimise and manage the risk of medical staff fatigue in accordance with
duty of care obligations for crew and patients.
• The Civil Aviation Safety Authority (CASA) has prescriptive requirements for fatigue
minimisation for licensed aircrew engaged in emergency medical operations.
• These instructions have influenced the construction of this guideline.
• ARV will ensure that:
o A safety culture is established and maintained within the organisation
o All medical staff are educated in the identification and symptoms of fatigue
o Adequate rest and sleeping facilities are provided when necessary
o The principles of this guideline are understood by operational and
management staff.
•
ARV Medical staff will ensure that:
o The fatigue management guideline and system are understood and upheld
o Fatigue reduction methods are employed whenever it is practical to do so
during duty periods (see below.)
o Any infringement or safety issue that impacts on the fatigue management
guideline is reported to management as soon as possible.
Duty Periods
A duty period commences when the member performs any duty associated with the activation
of a medical task. This applies to on base and on call staff.
A duty period shall not exceed 12 hours except as provided for below:
o A duty period already commenced may be extended when medically essential
to recover the patient to appropriate medical facilities and the medical staff
consider themselves physically and mentally fit to do so. Where possible and
appropriate, arrangements can be made to replace fatigued staff for the final
leg of the mission (e.g. airport to hospital.)
o A duty period which contains a clear rest period of 4 consecutive hours or
more at suitable resting accommodation may be extended by up to 2 hours
(from 12 to 14 hours.) This extension may be applied once only during a duty
period.
o A duty period which contains a clear rest period with sleeping
accommodation can be extended by up to 4 hours (from 12 to 16 hours.) This
extension may be applied once only during a duty period.
o The ARV Coordinator must give approval to extend duty periods after
consideration of the medical aspects of the case and consultation with the
retrieval team.
Time Free of Duty
o When a duty period exceeds 12 hours, time free of duty shall be a minimum
of 10 hours.
o Staff should be aware of this when performing rostered on-call shifts vis a vis
their other clinical duties
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On Call Periods
Prior to undertaking rostered on call shifts with ARV, medical staff should have appropriate
rest. The nature of this rest / preparation is influenced by the type and nature of work
previously performed, and the length of prior shift. Staff are required to apply a sensible ‘safe
hours’ approach, as would be their responsibility in normal medical workplace rostering.
Safety and Extended Duty Periods
Extended duty for Medical staff may be limited by aviation safety requirements of the
aircrew.
Medical staff must be mindful of fatigue implications for the pilots.
Extended pilot hours have implications for subsequent rostering.
Complex mission planning involving fatigue concerns should be escalated to ARV admin on
call.
Sleeping areas are provided or alternative transport arrangements (other than driving home in
private car) can be made for Medical staff to return home after working extended duty periods
>12 hours.
Handover A clinical handover includes the presentation of relevant history, examination and
investigations. It should also include current clinical progress, including patient response to
any interventions performed.
The number of handovers should be minimised to reduce the risk of important information
being ‘lost’.
All members of the ‘receiving’ team should have access to the handover. At the referring
hospital, this includes the retrieval physician and the paramedic. At the destination hospital
this includes medical and nursing staff. The ‘destination’ handover should be documented on
the patient care record.
The handover should occur in a manner that is safest for the patient and most efficient for
staff. In general, this is whilst the patient is on a hospital bed, as opposed to an ambulance
stretcher. The patient is attached to a ventilator with by piped oxygen; syringe pumps and
monitors can be connected to mains power. In an unstable patient, sufficient information to
facilitate resuscitation may be given initially, followed by a more complete handover as the
situation evolves.
At these handover interactions, retrieval physicians are the visible face of Ambulance Victoria
and Adult Retrieval Victoria. Professional behaviours are expected.
Incident reporting The purpose of the ARV Incident Report is to record any issues, unusual situations or
variations to normal practice relating to adult retrieval activities across the state.
• A multidisciplinary group will review the information captured on this form. This will
ensure that circumstances around an identified case are explored, any suggested actions
are considered and improvements to the system are introduced if required.
• Feedback regarding outcome of a report will be provided to the reporter in all cases.
• At present default (mandatory) reports would include:
o patient death in ARV care
o staff injury
o near miss / event with potential for patient harm (level 2 variation)
o actual patient harm due to error (level 1 variation)
o other critical risk (logistic or clinical)
Issues and Problems Issues or problems which may arise must be handled in a collegiate and professional
manner, with the patient well-being and clinical outcome the over-riding consideration. Issues
that cannot be simply resolved must be escalated to the Coordinator in the first place, and if
necessary to the Director ARV or the Clinical Advisor ARV.
Any issue or event which exposes the service or a patient to risk or which results in harm to
staff, public or patient must be reported via the ARV Incident Reporting framework
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Leave Applications for leave should be submitted in advance to the Admin Officer ARV. Please
note that ARV will aim to accommodate all leave requests in line with other (external)
employment arrangements that RP’s may have, however this is not able to be guaranteed, and
there may be times when restrictions are placed on the availability of leave.
Provision of 6-8 weeks notice for leave requests is required.
Morbid Obesity Patients with morbid obesity (arbitrarily defined as: weight over 140kg, or BMI over 45) who
require mechanical ventilation for management of pulmonary pathology, or who require
mechanical ventilation and have other significant co morbidity, should routinely be crewed by
ARV doctor and Paramedic MICA if available. These patients must be considered clinically
very complex and at significant risk for transfer.
It is not possible to lift patients over 120kg into the current fixed wing aircraft due to
loading equipment limitations. This does not relate to rotary wing aircraft where patients over
120kg may be considered for transport on a case by case basis.
Night transfers Transfer must never be delayed in a time critical patient. (This includes patients with
significant risk of deterioration during the time delay).
Non Time Critical aviation transfers should not occur after midnight (air crew fatigue and
human factors issues).
It is imperative that the skill set and capacity to provide ongoing care at the referral site is
factored in any decision to delay a transfer.
All cases where transfer at night is delayed will be specifically audited.
Patient preparation and packaging Depending on sending hospital resources and expertise, patients may require little or
extensive interventions by the retrieval team before they are suitable to be transferred.
Requests to the sending hospital e.g. drugs pre-prepared in 50ml syringes should be made
through the coordinator.
It is not possible to lift patients over 120kg into the current fixed wing aircraft due to loading
equipment limitations.
Patients with IABP or ECMO require retrieval by a RP by road (transfer by fixed wing is
possible). A private perfusion service is available to assist. Retrieval Physicians should not
attempt these missions without the aid of staff familiar with the operation and troubleshooting
of this specialist equipment.
Performance Management Retrieval physicians will participate in yearly performance reviews which will be performed
in accordance with AV policy, and which are modified to ensure relevance and
appropriateness to medical staff.
The performance management system also defines the general scope of practice of the
retrieval physician.
Retrieval physicians will be expected to maintain a general level of health and physical fitness
appropriate for the physical requirements of their work and the retrieval environment.
Retrieval Logistics Both Road and Air departure points will normally be from Essendon Airport (AAV), where
all ARV equipment is stored and maintained. Equipment is not to be sent unescorted by taxi
due to safety issues surrounding the transport of drugs.
Early activation is imperative to optimise system efficiency and responsiveness. Activation
may occur prior to the known availability of a destination (receiving) hospital. Retrieval
physicians may be despatched before the coordinator is able to give full details of the task.
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Activation includes early communication with all resources / platforms: AAV, Regional
Ambulance Control rooms, Metropolitan Ambulance Clinicians, DTM (for CPAV) and NPT
(for HATS.)
ARV departure response times of less than 30 minutes will be aimed for where necessary, and
all activation delays greater than 60 minutes will be audited.
It will therefore normally be impractical for retrieval physicians to be on call from a site that
is more than 15(-20)km from the metro centre or Essendon airport.
Recall times commence at the active commencement of a mission (leaving a site of recall),
and do not include advanced warning of (planned delayed onset) missions.
The retrieval physician is part of a retrieval team. They bring a certain skill mix, which is
supplemented by the skill mix of the (MICA) paramedic.
AV has a zero blood alcohol policy for all active staff.
Road resources The current options for road transport platforms include – emergency ambulance, CPAV,
HATS, non-emerg vehicle. Due to current staffing and crewing structures the standard
approach to road vehicle choice is as follows:
Ö HATS (with driver + Crit Care Nurse crew) is preferred option during periods of
availability, and if response time is appropriate, unless
Ö ARV Coordinator contacts HATS in the first instance as this is the preferred resource for
ARV retrievals
Ö If HATS is not available the ARV Coordinator contacts the Clinician
Ö In consultation with the ARV Coordinator the Clinician will provide the most appropriate
resource to accomplish the retrieval. In most cases this will be an AGP with at least one
ALS qualified paramedic aboard
Ö If the ARV Coordinator determines that the retrieval requires MICA skill sets to assist the
retrieval physician (uncommon), the Clinician will organize a CSO/SRU to accompany or
a MICA vehicle to do the transfer
Ö The Clinician may consider the use of a CPAV or Netcomm vehicle if they are able to
resource either unit with an ALS qualified or MICA paramedic
Ö If required, the ARV Coordinator can liaise with the Clinician to determine clinical
requirements prior to contacting the Clinician to organize the retrieval
Activation of HATS is performed via Coordinator contacting NPT (private ambulance
service) on 1300 628728 (The RASO will fax a booking form to Netcom also).
Duty Team Manager AV - 1300 551 624
Safety Recurrent aircraft safety training will have a positive impact on flight crew emergency
preparedness. Aircraft loading and unloading competency is vital to safe operations on scene,
at helipads, and at airports. Mission profile, patient acuity, and aircraft performance all impact
the decision to perform hot or cold loads and unloads.
In addition to aircraft safety, crew and patient safety must be considered. Once the patient and
equipment have been secured on-board the aircraft, the air medical crew must ensure access
to the patient for any interventions that may be required at altitude.
Safety considerations and aircraft operations are essential components in the initial training
and continuing education of all personnel working in and around rotary-wing and fixed-wing
aircraft. The perspective and knowledge of an experienced pilot is a critical factor in the
training of air medical crew members
The flight crew members must work collaboratively with other services, including ground
ambulances to assure that all actions in and around the aircraft are safely carried out.
In general, ARV is not involved in “hot” loading or unloading .The pilot is responsible for
providing security of the main and tail rotors during all load/unload operations.
A helmet should be available for the Retrieval physician when flying in a helicopter.
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Staff Welfare The nature of retrieval and coordination work can be stressful and difficult. Ambulance
Victoria offers all staff access to peer support and counselling services. These may be
accessed by individuals or via ARV management
Peer Support: contact via Corporate Paging (for duty peer support officer) 9483 8009;
Phone: 0419 002 956 Email: [email protected]
Counselling Service: Ms Heather Bancroft, VACCU
Phone: 9654 4144 Email: [email protected]
Tarmac Handovers Are generally inappropriate, and patients should be retrieved from a hospital setting. This
allows for controlled handover, assessment of the patient, checking of all equipment,
connections, placements etc. All tarmac handovers will be considered a variation and audited.
(Exceptions may exist e.g. an uncomplicated AMI being transferred urgently for PCI – in
such a case the risks associated with tarmac handover are low, and the time benefit may be
great)
Team Performance Successful retrieval missions are dependent upon the performance of the team.
Cooperation, communication, diplomacy, respect and empathy are vital.
Team Performance = Skills x Behaviour
Trauma System Adult Patients
Ambulance services should triage adult major trauma patients and suspected adult major
trauma patients directly to an adult Major Trauma Service (The Alfred and the Royal
Melbourne Hospital), when the travel time is less than 30 minutes.
If a Major Trauma Service is not within 30 minutes travel time, then the patient should be
triaged to the next highest-level trauma service within 30-minute travel time, from the
accident site.
Specialist Trauma Triage and Transfer
Hospitals with neurosurgical specialities should manage neurotrauma patients requiring
critical care support.
Major trauma including spinal trauma should initially be triaged to a Major Trauma Service.
Early consultation by each treating hospital with the Victorian Spinal Cord Unit at the Austin
Hospital is essential to optimise patient outcomes.
Discrete spinal cord injured patients over 16yrs of age, in the absence of other indicators of
major trauma, should be triaged to Austin Health’s, Victorian Spinal Cord Service by
telephoning (03) 9496 5000 and asking for Spinal Unit Acute Registrar.
Multiple trauma, incorporating the need for microsurgery, should be referred and transferred
to a Major Trauma Service. St Vincent’s Hospital also have capacity as leaders to manage
injuries requiring microsurgery.
Neurosurgical triage and transfer guidelines for major trauma still apply in rural areas, even
where a neurosurgical specialist practises locally, as the management of these patients
requires all the appropriate and agreed service supports of a Major Trauma Service.
Major Trauma Triage Guidelines Require:
Pre-hospital major trauma to be identified according to specified physiological and
anatomical criteria.
Triage to a Major Trauma Service where a major trauma patient is less than 30 minutes
transport time from a Major Trauma Service.
Triage to the highest designated trauma service accessible in 30 minutes where a major
trauma patient is more than 30 minutes transport time from a Major Trauma Service.
Triage to a designated trauma service accessible in the least amount of time in isolated rural
areas that are more than 30 minutes from any trauma service.
Where a major trauma patient appears to be in an immediately life-threatening situation
during transport, the patient be diverted to the nearest designated trauma service for
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stabilisation, with subsequent transport to a Major Trauma Service at the earliest appropriate
time.
Where a patient is triaged initially to a non-Major Trauma Service for stabilisation, early
liaison with the Major Trauma Service should occur via the Trauma Advice and Referral
telephone line 1800 700 001, which is answered by ARV calltakers. Consideration of
appropriate medical retrieval or interhospital transfer to a Major Trauma Service can then
occur from the initial call.
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94
Aeromedical Safety Aircraft Beechcraft Super King Air 200
Twin engine turbo prop aircraft
Maximum range: 1800 nautical
miles
Pressurised cabin
Max Altitude: 35000ft
Engines: Pratt & Whitney 850 HP
each
Cruising speed: 289 knots
Safety card On walls in aircraft, one loose copy
available on request
See Appendix 2 for safety card.
Emergency Exits and doors Two doors for regular use, both located on left rear of aircraft. Cargo door for
loading/unloading of stretcher. Passenger stair door is located within cargo door. The
passenger stair is also one of the emergency exits.
The second emergency exit is at the front right side of the cabin over the wing.
In case of a water landing, ONLY use the emergency exit on the right side over the wing. DO
NOT use the rear exit in case of a water landing, as the cabin will quickly fill with water.
Pre flight safety briefing Before every flight the flight paramedics will do a safety briefing
Seat belts Must be worn during the following times:
During takeoff.
During landing.
Flights below 1000ft.
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Turbulent conditions.
As directed by the pilot.
By patients at all times.
Flight paramedics will give instruction in the correct
fitment of seatbelt.
Prior to take off and landing an audible tone will sound
to remind passengers to fasten seat belts.
Emergency Oxygen during Cabin Depressurisation All pressurised aircraft are required to have an
emergency oxygen system.
The King Air has a system that automatically deploys if
there is a cabin depressurisation. This occurs above
12500ft.
Yellow cup like oxygen masks (similar to commercial
airlines) will drop from the midline of the roof. Should
they deploy, fit your own mask immediately. Pull on the
mask to activate oxygen.
Put your own mask on first, and then assist others.
Fogging and wind rush might occur in the cabin.
The pilot will dive steeply and rapidly.
Seat belts must be worn.
Fire extinguishers Two 1kg fire extinguishers:
One under co-pilots seat in the cock pit (right hand seat).
One in rear of cabin on the left of the cargo door adjacent to the rear left hand seat.
Each contains approximately 25-30 seconds of
extinguishing agent.
Instructions:
Remove locking clips.
Pull the safety pin.
Hold unit upright, aim at the base of the fire.
Squeeze the trigger while doing a side to side
swinging motion.
Survival equipment Located under rearward facing seat at the front of the
cabin
Content:
Four litres of water
Emergency rations
Cordage
Hatchet and Leatherman tool
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Water proof matches
Water proof torch
Insect repellent
Mirror
Sun hats (3)
Thermal blankets
Illuminating light stick
Sea dye
Compass
First aid booklet
Emergency Locator Transmitter (ELT) In the event of a forced landing in an emergency situation the ELT automatically activate.
This activation is via a 7G force impact.
Should it not activate automatically, there is a manual switch located on the right side of the
cockpit console between the pilot seats. A plastic cover protects a red switch and light.
(Pictures above)
In the event of an impact a red light will be flashing. If not the ELT should be manually
activated.
Emergency Landing Wait for paramedic to call BRACE BRACE BRACE.
There will probably be more than one impact.
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Wait for the aircraft to come to a complete stop.
Be prepared to evacuate the aircraft to a safe distance.
The paramedic is responsible for the evacuation; however he may not be capable.
Life jackets Stowed under your seat.
Life jackets must be worn:
In an emergency situation on over water flights
In a low level flight over water (under 2000ft)
At the pilot’s discretion.
Spare life jackets are kept in the rear cabin cabinets.
A portable life raft will be loaded onto the aircraft if a flight over a great distance of water is
planned (e.g. to Tasmania).
The life raft contains a portable ELT that requires manual activation.
After activation of the life raft ELT, attach it to the raft with its own tether line and allow it to
freely float in the water.
The life raft carries basic survival equipment and water. It is advisable to retrieve the aircraft
survival kit.
Airside Safety The airside is the movement area of an aerodrome, adjacent terrain and buildings or portions
thereof, to which access is restricted. Commonsense and vigilance are required at all times
when airside.
Airside rules
High visibility vest are required to be worn at all times when airside (Pilots and passengers
are exempt if they are moving directly to or from the aircraft for operation purposes).
Aircraft always have right of way over vehicles, equipment or pedestrians.
Never park or stand within 3 metres of any aircraft unless you are directly involved with that
aircraft.
No person is permitted within 30 metres of a helicopter or a helicopter landing site unless
essential to the helicopter operation.
No smoking, alcohol or any banned substances are permitted to be consumed airside.
Never stand within 15 metres of a refueling aircraft.
Mobile phones are not permitted within 15 metres of a fuel hydrant point or aircraft that is
being refueled.
Never approach a jet or propeller driven aircraft with its engine/s running.
Never approach a helicopter with its engine/s running (unless escorted or entering or
departing the aircraft following specific procedures discussed in safety around helicopters).
Beware of the direct effects of jet blast and propeller wash and their effects on debris.
Foreign Object Debris (FOD) causes Foreign Object Damage – If you see debris – pick it up.
Beware of what you put down and where (light weight bags/equipment) – it may blow into
the path of an aircraft.
Be aware of vehicles moving around the airside – fuel trucks, maintenance and emergency
vehicles.
Only authorised vehicles with an operating anti collision light or vehicles being escorted by
an authorised escort are permitted airside.
Airside emergencies – depending upon the nature of the emergency, emergency services
should be notified if necessary and the airport duty operations manager must be notified in all
instances. In the event of a ‘full’ emergency the airport will be closed and all unnecessary
persons are to clear airside.
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Strategies for controlling risks/hazards Wearing appropriate clothing and footwear e.g. flame retardant flight suits and undergarments
and sturdy flat soled footwear. (No high heals – they are likely to get caught in the Douglas
tracking in the floor)
Using ear plugs on the tarmac and good quality headsets within the aircraft.
Securing all items within the aircraft.
Wearing seatbelts/harnesses at all times.
Listening to in-flight briefings and following directions of the flight crew.
Be well rested prior to duty and keep hydrated during flights.
Most importantly: maintain an awareness of your surroundings, use ‘common sense’ and if in
doubt – ask somebody who knows!
Fixed wing aircraft (FW) danger areas Propeller driven:
Propellers: large and spin at high speeds which make them difficult to see.
Exhausts: Piping hot emissions and exhaust remain hot for a period of time after shut down.
Jet driven:
Engine intakes – sucks in an enormous amount of air when engine is running.
Engine outlet: jet efflux is extremely hot gas.
Approach to a fixed wing aircraft It is normal practice to be in the cabin of the
FW with the doors closed prior to engine start.
The pilot will advise when clear to open doors
following engine shut down and when
propellers have stopped turning.
Approach and depart FW from the side
remaining well clear of the engines.
Remember: a propeller might still turn with the
engine shut down.
Approach to a ROTARY wing aircraft Approach to the helicopter should be limited to
pilot authorised movement.
All approaches should be within direct vision of
the pilot and acknowledged by them
Areas to the rear of the helicopter are ‘no go’
zones.
Cabin safety Command:
The Pilot in Command (PIC) is in sole command of the aircraft and its operation. No one may
load, equip or enter the aircraft without the knowledge and permission from the PIC.
The PIC will give commands regarding procedures to be undertaken when in the aircraft.
Seatbelts: must be securely fastened prior to take off and remained fastened until after landing
(unless restrained by an approved harness).
Exits: Identify your primary and secondary exits, their operation and reference point to locate
them. Remember this will be different for each seating position in the aircraft.
Communication: there should be no communication over the intercom during times the pilot
is communicating with air traffic control such as when receiving clearances or instructions
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and during take off and landing unless essential to aircraft safety. If necessary to
communicate with other medical crew during these times – request to be isolated from the
cockpit.
Controls: No person shall operate or interfere with any aircraft control, instrument or aviation
radio unless specifically requested to by the PIC.
Equipment stowage: No item should be loaded into the aircraft without the knowledge and
permission of the PIC.
Safety equipment: Safety equipment such as life vests/jackets should be worn when provided
by the crew. Even though the flight may not be anticipated to go over water, an unexpected
diversion may occur necessitating.
Observation:
It is important that all persons onboard the aircraft keep a good look out during all phases of
flight for anything that may pose a hazard to the aircraft and report the hazard to the PIC e.g.
other aircraft, power lines, people, animals.
When reporting a hazard give an indication of its position using the clock method, i.e. 12
o’clock is the nose of the aircraft, 6 o’clock the tail, 3 o’clock directly right, etc.; an
estimation of the distance and if relevant the level.
Briefings: prior to take off a briefing shall be given in accordance with Civil Aviation order
(CAO 20:11):
Use of flotation devices where applicable
Smoking, including the prohibition of
Stowage of hand luggage
smoking in toilets
Presence of on board special equipment
Use and adjustment of seatbelts
where applicable
Location of emergency exits
Use of oxygen where applicable
Emergency Procedures
In the event of an in-flight emergency:
Ensure you are secure
Ensure the cabin is secure
Familiarise yourself with your emergency
exits
Follow the instructions of the PIC.
Post landing:
Exit the aircraft following safe departure
procedures
Assist other WHERE SAFE TO DO SO,
and provide first aid
If in a remote area: Establish shelter, gather all emergency/survival equipment, ration
water/food, have signalling equipment prepared, ensure you know how to use it and use it at
an appropriate time.
If in the water: ONCE OUT OF THE AIRCRAFT inflate your life jacket, deploy the life raft
if carried on board, turn on ELT, prepare signalling equipment, dry out raft and prepare
rations.
Bottom line
The key to aviation safety is COMMON SENSE. Follow the directions of those whose
primary business is aviation and remain aware of your surroundings.
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Retrieval Medicine This section of the ARV manual is dedicated to specific clinical issues and in particular to
relevant aspects of their management in the retrieval setting.
It is not intended that this section be a ‘cloned textbook’, rather that it investigate common
retrieval clinical scenarios, define the particular challenges and risks of the most complex
transfer challenges, and present methods of awareness, risk mitigation and clinical
optimization.
This section assumes clinical knowledge at or close to specialist / consultant level and aims to
take the advanced clinician to the next level in retrieval medicine.
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Airflight Medicine –the basics The Effects of Altitude on Gas Volume Boyles Law
"When the temperature remains unchanged, the volume of a given mass of gas varies
inversely to its pressure."
In flight terms, as your aircraft ascends, increasing in altitude, the barometric pressure
diminishes. Any gas within an enclosed space will expand. Alternatively, as the aircraft
descends and barometric pressure increases, the gas will contract.
The Effects Of Altitude On Oxygen Availability Dalton’s Law: Pt = P1 + P2 + P3 + … Pn
Dalton's law states "the overall pressure of a gas mixture is the sum of the individual or partial
pressures of all the gases in the mixture."
In flight terms, oxygen is "thinner" in the upper atmosphere. Why? At sea level the barometric
pressure is 760 mm Hg, and the atmosphere is composed of 20.95% O2. As altitude increases,
the barometric pressure decreases, and the molecules in the atmosphere move farther apart.
While oxygen still comprises 20.95% of the atmosphere, there are less oxygen particles per
cubic millimeter to be utilized.
Clinically, an increase in altitude diminishes the oxygen available to the body and can result
in hypoxia. For instance, at 12,000 feet the barometric pressure decreases to 483 mm Hg. The
composition of the atmosphere remains the same, and so the percentage of oxygen remains at
20.95 percent. However, the partial pressure of oxygen will decrease to 101.19 mm Hg.
The Effects Of Pressure Changes On Gas Bubble Formation Henry's Law
Henry’s law states "...the quantity of gas dissolved in 1 cm3 of a liquid is proportional to the
partial pressure of the gas in contact with the liquid".
In clinical terms, an example of gas solubility in a liquid is decompression sickness (a.k.a.
"the bends"). As a diver ascends, the pressure is decreased on the nitrogen gas dissolved in the
blood. Ascending too quickly or flying within 24 hours of a dive can result in nitrogen bubble
formation in the blood, which can cause dire clinical consequences. Treatment includes 100
percent oxygen and rapid descent treatment in a hyperbaric chamber and may be necessary if
the symptoms do not resolve.
Altitude restriction in air transport is a consideration in only a few rare cases. When
transporting a patient with decompression sickness, altitude should be restricted to less than
1000 feet above ground level. An untreated pneumothorax is an absolute contraindication to
air transport. Prior to take-off, treatment with a chest tube or temporizing one-way valve
system is required. Decreased flying altitude results in increased turbulence, longer flying
times, and increased fuel consumption over a decreased aircraft range, consequences which
must be considered when a patient requires low altitude flight.
Stresses Of Flight In addition to hypoxia, barometric pressure changes, and thermal variations, the stresses of
flight include noise, vibration, humidity/dehydration, gravitational forces, third spacing, and
fatigue.
Noise
Permanent or temporary hearing loss may occur for patient or provider. The longer the
exposure, and the more intense the noise, the greater the potential damage. Consequences
include headaches, fatigue, nausea, vertigo, stress, and reduction in task performance
effectiveness. Noise may interfere in provider communications with the patient and other
crew members, and impedes the ability to auscultate the lungs, heart or blood pressure.
Hearing protection should be worn by patient and crew, and includes earplugs, headsets, and
helmets.
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Vibration
Vibration results from the aircraft motor/rotors and can be due to turbulent weather. Vibration
may result in an increase in metabolic rate, fatigue, shortness of breath, motion sickness, and
an inability to properly thermo-regulate. Low frequency vibration of the eye may cause visual
decrements. Vibration in general is less well tolerated in the supine position due to x-axis
vibrations. Neonates are most susceptible to direct injury from vibration and noise. Care must
be taken with fractures, as the vibration may increase discomfort at the fracture site or from
an inadequately padded and secured splint. Special consideration must be given to patients
with electronic monitoring as in-flight vibration may interfere with invasive and non-invasive
monitoring, and may cause dysfunction of activity-sensing pacemakers. Protection from
vibration is essentially limited to isolating the individual and equipment from the aircraft by
use of adequate padding.
Humidity/dehydration
Patients and crew flying at high altitude for prolonged flights will be exposed to very low
humidity and may develop dehydration. Patients in a hot environment or with pre-existing
dehydration may have an exacerbation of their condition, and attention should be paid to oral
and IV fluid intake and urine output when appropriate. Additionally, respiratory secretions
may become thick, resulting in less efficient gas exchange and contributing to hypoxia.
Dehydration may be prevented through humidified oxygen and adequate fluid intake.
Gravitational Forces
Gravitational forces are most evident on ascent and descent, or when the aircraft changes
speed or direction. Patient positioning during maneuvers may affect blood pooling and
intracranial pressure. For example, in a cardiac patient it may be advantageous to position
them with their head toward the rear of the aircraft during ascent, so that the G-forces help to
pool blood in the upper part of the body. Conversely, in patients with intracranial injury or
volume overload, a position with the feet toward the rear of the aircraft during ascent may
pool fluids in the lower extremities and avoid a transient and potentially detrimental increase
in intracranial pressure.
Third Spacing
Third Spacing is the loss of fluid from the intravascular space to the extravascular space in the
tissues. This phenomenon is due to the effect of pressure changes and cellular increases in
permeability resulting in fluid transitions. The effects of third spacing include edema,
dehydration, tachycardia and hypotension. These affects may be complicated by other stresses
of flight, including thermal variations, vibration, and gravitational force effects.
Fatigue
Fatigue is generally felt to be a culmination of all of the stresses of flight. Tactics should be
taken by the aircrew to minimize the effects of flight and personal stresses to maximize
effective performance, alertness and safety.
Pressurized Environments In order to minimize the effects of barometric pressure changes and subsequent hypoxia, a
controlled flow of compressed air can maintain a constant pressure in a fixed-wing aircraft.
Typically the cabin pressure can simulate an 8,000–10,000 foot altitude while flying at an
actual altitude of greater than 40,000 feet. Malfunction of the aircraft’s pressurization system
or structural damage sustained by the aircraft may result in rapid decompression. The crew
must understand this emergency, and be ready to respond. A loss of pressure through a large
defect results in a rush of air towards the defect. Any person or equipment not adequately
restrained may be blown about the cabin or through the defect due to the development of
cyclonic winds. Decompression sickness, hypothermia, hypoxia and expansion of GI tract
gases resulting in decreased respiratory movements and vaso-vagal syncope can result from
this loss in cabin pressure. Hypoxia is the most important immediate consequence of rapid
decompression. Supplemental oxygen must first be supplied to the pilot, the crew, and then
the patient or passengers. Recall that gas in medical systems will rapidly expand, and any
catheters, chest tubes, NG tubes, or drains should be unclamped. Losing cabin pressure may
also result in decompression sickness. This, however, is rarely a problem under 25,000 feet
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unless the patient has been exposed to compressed gas (i.e. scuba diving) within 24 hours of
the event. The nitrogen gas bubbles can result in a decrease or blockage of blood flow to any
organ system, and causes a wide variety of symptoms depending on the system affected.
Treatment includes application of 100 percent oxygen and rapid descent in altitude.
Unresolved symptoms will require treatment in a hyperbaric chamber.
Confined Spaces A final mention should be made of the challenges of the confined space in which the crew
must work. The tight quarters necessitates efficient use of space, compact equipment and
conservative storage of supplies. Equipment inventory should be replaced after each transport.
Advanced planning regarding patient access is also required.
Guidelines for Air Medical Crew Education, AAMS, Kendall/Hunt, Iowa USA,2004.
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Addisonian Crisis Key Clinical information
Consider in patients with lethargy, abdominal
pain / symptoms and cardiovascular collapse.
Consider in patients with hypotension
unresponsive to fluid and pressors especially
those who may have been on long-term
steroid treatment..
“Red Flags”
Cardiovascular Collapse
Often there has been a precipitant of
Addisonian crisis., particularly sepsis.
Key to treatment is to replace cortisol. It may
take 4-6 hours to see benefits of cortisol.
Hyponatraemia (Hyperkalaemia)
Hypoglycaemia
Investigations
It is important to begin treatment with intravenous steroid as soon as possible in critically ill
patients. However if time allows collecting the following blood tests will help in conformation
of a diagnosis
Cortisol
ACTH
Acid Base Status
Glucose
UEC
Synacthen with cortisol readings at
0 and 30min.
Interventions
The primary treatment of an Addisonian crisis is fluid resuscitation with N saline and
administration of IV steroid.
May require correction of hypoglycaemia with 50% dextrose.
Other treatments will be supportive. Supportive therapy will be required as hydrocortisone
may take 4-6 hours to become effective. Treatment may include vasopressor support, careful
monitoring of electrolytes and fluid balance. To facilitate this central venous access may well
be required.
Suggested medications
Hydrocortisone (Addisonian Crisis)
Fludrocortisone
IV
PO
200mg then 100mg at 6 hrs
0.1 – 0.3 mg daily
Specific Advice
In patients with known Addison’s disease who have infectious disease, are involved in trauma
or surgery, steroid replacement is crucial.
Normal daily steroid intake in these patients would be 30mg of hydrocortisone daily, 20mg on
awakening then 10mg at 1800.
For elective surgery 50-100mg of hydrocortisone should be given as a pre-med, followed by
150mg / day in divided doses in the recovery period.
Hydrocortisone is a better choice than dexamethasone which has limited mineralocorticoid
activity.
Retrieval issues
Retrieval may be of a primary Addisonian patient, or a known Addisonian patient who has
been involved in a physiologically stressful event which triggers a crisis.
It may take hours for intravenous steroid to have a noticeable effect.
The retrieval physician will need to support circulatory collapse and to monitor and treat fluid
depletion and electrolyte imbalance, taking an iStat may help with this.
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Asthma ­ refractory Key Clinical information
Require supplemental O2 to maintan sats >
90%
PEFR <200 L/min
“Red Flags”
Failure to improve despite maximal treatment
Heart rate > 120
Resp rate > 25
Diaphoresis / restlessness
INVESTIGATIONS
CXR
Clinical features, PEFR and oximetry are
reliable guides to the severity of the attack
Confusion
PEFR
Standard therapy
Salbutamol
Nebs / MDI
Hydrocortisone
Ipratropium Bromide
i/v
Neb
Oxygen
15L/min
Maximum Pre-intubation therapy
Salbutamol
nebs
Intravenous
5-10 mg or 8 puffs 10 – 15
minutely
250mg stat
500μg 2 hrly
Hudson or Non- Rebreather
mask
Continuous nebs
Bolus – 250-500μg
Infusion – 5-10μg/kg/hr
Recipe for infusion
2g over 20 mins
Magnesium
Intravenous
Consider
BiPAP (if tiring)
Adrenaline infusion
IPAP 10-20/ EPAP 2-5
May be of benefit in acute refractory asthma
Indications for intubation
Clinical assessment / monitoring probably better than serial ABG’s for monitoring and
guiding intubation
Decreasing level of consciousness / fatigue / exhaustion
Significant hypoxia (SpO2 < 90 despite aggressive therapy)
Rising PCO2 despite NIV
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Post intubation
Ventilator settings
TV 5-7 ml/kg
Rate 6-8 / min
Prolonged I:E ratio
Monitor flow loops – avoid breath stacking
Adequate sedation
Paralysis may help
If refractory consider
Ketamine infusion – bolus 1mg/kg followed by 1mg/kg/hr
Volatile anaesthetic agents
Ensure adequate fluid therapy
Reduced cardiac output
Fluid filling
Reduce rate (permissive hypercapnoea)
Bimanual compressions
Disconnect from ventilator
Retrieval issues
Transfer with CPAP / BiPAP generally contraindicated
Hypoxia / gas trapping will get worse with altitude
Possible considerations for ECMO
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Beta Blocker Toxicity Key Clinical information
Risk Assesment – Major toxicity expected
with Propranolol (non selective, lipophilic so
penetrates CNS) and Sotalol – (risks of
arrhythmia)
Readily absorbed, onset of effect may be
within ½ hr but usually 2-4 hours, however
Sotalol effects may occur up to two days
later.
If not Propranolol or Sotalol then course
likely to be more benign. If well at six hours
then no significant toxicity.
“Red Flags”
Caution in elderly, esp with Heart Failure
Co-existing airways disease (risk of
bronchospasm)
Co-ingestion of other cardiac meds especially
Ca channel blockers / digoxin
INVESTIGATIONS
ECG – 1st degree HB an early sign of toxicity
May have 1st-3rd degree block, junctional
bradycardia, ventricular bradycardia or even
asytole.
QRS >100ms predictive of seizures,
Clinical Features –
CVS –Hypotension + Bradycardias > may be
life threatening
CNS – Delirium, Coma, Seizures
Other – Bronchospasm (rare)
Hypoglycaemia
QRS widening in Propranolol toxicity is
predictive for ventricular arrhythmia +
seizures.
Sotalol causes QT prolongation, can lead to
Torsades de Pointes
BSL – given potential to cause
UEC hypoglycaemia
QRS >160ms predictive of ventricular
arrhythmia
Interventions
Supportive Care – Attend to airway if required, coma + seizures are likely if
significant Propranolol toxicity.
Treat Seizures conventially with benzodiazepines
Treat propranolol toxicity with wide QRS as if TCA toxicity, i.e Hyperventilate and
use Sodium Bicarb titrating to pH >7.50
Treat Torsades with : DC shock.
If refractory, then give :Isoprenaline bolus 20mcg, repeat as required, then infusion, may need high doses.
Overdrive pacing (rate 120-140bpm)
Suggested medications
Fluid bolus
20ml/kg for hypotension
Atropine for symptomatic bradycardia
0.5 to 1.0mg, rpt after 15 minutes
Inotropes
Conventional treatment may fail, expect
to need large doses.
Consider high dose isoprenaline infusion
for symptomatic bradycardia.
108
Glucagon.
5-10mg bolus followed by 5-10mg/hr
infusion if good response. NB This will
rapidly exhaust most hospitals supplies.
Activated Charcoal
if within 1st hour or once airway secure.
Specific Advice
Obtain toxicological advice
Seek and treat hypoglycaemia
Severe bradycardia may require
transvenous pacing
Retrieval issues
Should anticipate potential need for pacing.
Controversies / novel therapies
No evidence that glucagon is of benefit, despite being traditional drug of choice.
Potential role for High Dose Insulin Euglycaemic Therapy – discuss with
Toxicologist
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Clonidine toxicity Key Clinical information
Expect significant CNS depression with
Poor correlation between ingested dose and observed
ingestions > 20ug/kg
clinical effects.
Miosis, ataxia, hypertension initially;
Onset of toxicity is rapid, usually within 2 hrs and
followed by hypotension, bradycardia
always within 6hrs.
and coma in severe intoxication.
“Red Flags”
Conscious state may deteriorate rapidly.
Investigations
Screen: BSL, ECG, Paracetamol
Hypotension, Bradycardia
Serial ECGs.
Interventions
Basic resuscitative measures and supportive care ensures survival of the vast majority of
patients.
Bradycardia is common but treatment is only required in the presence of hypotension or
evidence of decreased end organ perfusion.
Occasional paradoxical hypertension should be treated very cautiously as it is transient and
likely to be followed by hypotension.
Suggested interventions
Bradycardia
Hypotension
Naloxone inconsistently reverses
CNS and respiratory depression.
Atropine, cathecholamine infusion, pacing
Fluid bolus 10-20ml/kg
Treat bradycardia
0.1mg IV q30-60 seconds, or
0.4mg SC/IM.
Specific Advice
Activated charcoal only after intubation as GCS can deteriorate rapidly.
Retrieval issues
Consider intubation prior to retrieval as rapid deterioration of GCS and BP may occur.
110
Confirmation of Central Venous Catheter Placement Key Clinical information
Inadvertent administration of vasoactive infusions through arterial lines can cause serious
complications.
Adverse events have occurred when retrieval teams have continued infusions through femoral
lines placed at referral hospitals.
Confirming that the line is venous (and not arterial) before commencing or continuing
infusions will prevent such complications.
“Red Flags”
Insertion during cardiac arrest or severe low cardiac output state
Insertion by inexperienced personnel
Femoral or brachial placment
Investigations
To confirm central venous placement of a line
Aspirate blood from distal lumen (confirms intravascular placement)
Connect to pressure transducer and assess pressure & waveform
Consider performing blood gas analysis
The value of obtaining a CXR after subclavian or internal jugular line placement must be
weighed up against the increase in scene time incurred.
Pneumothorax may not be detected on initial CXR (especially if supine.)
Interventions
If there is concern about the position of any intravascular line it should not be used
Arterial lines should be clearly labelled.
Retrieval issues
It should be routine practice to (at least temporarily) transduce any central venous line.
Continous monitoring of CVP during retrieval may be useful in some cases
Tension pneumothorax may develop from an occult pneumothorax at altitude.
111
ECMO Retrieval Retrieval Team The standard ECMO Retrieval Team consists of 5 members:
-
-
2 Alfred Team members (Usually 2 intensivists but may be Dr(s)+/-RN) - Clinical
leadership of the team will be provided by the senior intensivist. The Alfred
intensivist is responsible for perfusion management of the ECMO circuit.
ARV Retrieval Physican - The general role of the retrieval physician is to provide an
expert clinical interface with equipment and the practicalities of the retrieval process.
Paramedic – The paramedic is the clinican who is the expert interface between AV
environment, equipment and processes.
Pilot or single CPAV attendant - During air missions, the pilot is responsible for the
overall safety and management of logistics. In flight the pilot is in control of all
resources, and is responsible for all decisions in relation to the aircraft, flight path,
safe altitude etc. The CPAV attendant is responsible for operation of the stretcher,
lifting devices, and stabilisation of stretcher and equipment within the vehicle
(including power and gas supplies)
Equipment Other than the ECMO specific equipment, all retrieval equipment is provided by ARV. This
means the RP is the clinician familiar with infusion devices, drug pack, monitor and
ventilator. The RP is the hands on clinician who is relied upon to operate this equipment.
The RP is responsible for ensuring that there is good communication about settings and drug
dosing. The RP should ensure and communicate that there are adequate supplies of infusions,
oxygen and drugs for the entire, often lengthy retrieval. At a minimum, sufficicient sedation,
muscle relaxants and vasoactive infusions for the expected mission duration must be made-up
for rural ECMO missions. Ensure enough (at least three and perhaps more) infusion pumps
are taken for the job.
Generally there is time and space for the retrieval physician to sort out equipment, drugs, and
rationalise infusions during the ECMO cannulation process to reduce scene time.
Cannulation Most ECMO retrievals will be percutaneous, bilateral, peripheral, Seldinger technique
femoral cannulations although central (in theatre) or internal jugular options exist. The
cannula positions are often checked by ultrasound if available. A heparin bolus may be
requested towards the end of the cannulation process.
Veno-venous (VV) ECMO (for respiratory failure)
- One cannula tip is situated in the IVC – this is the access cannula, which draws dark
venous blood to the ECMO oxygenator.
- The other cannula tip is inserted to situate in or near the right atrium - this is the
return cannula for bright oxygenated blood.
If these cannula tips are too close together, already oxygenated blood can be drawn
back into the circuit.
Veno-arterial (VA) ECMO (usually for cardiac failure)
- The venous access cannula is usually at the right atrium.
- The arterial cannula is situated in a large (often femoral) artery for returning
oxygenated blood and also to supplement cardiac output. This cannula maybe in
another large artery if placed during cardiac surgery.
112
ECMO Circuit The ECMO circuit has 3 main components:
- The ECMO console, which provides the drive cable to the pump head and indicates
circuit flow rate. This is usually placed between the patient’s legs when pushing the
patient stretcher and tied down on the CPAV shelf or on the floor of fixed wing
aircraft.
- Has a centrifugal pump in the circuit which is driven by the ECMO console (or
manually in an emergency by a pump handle). This pump is clamped onto the patient
stectcher.
- An oxygenator in the circuit. This is also clamped onto the patient stretcher.
Clinical Considerations Sedation
All patients should be adequately sedated and paralysed with muscle relaxant prior to
cannulation and for the remainder of the retrieval.
Ventilation
Once the ECMO circuit is operating and oxygenation has improved, the aim of ventilation is
to prevent further ventilator related lung injury. The Alfred intensivists will help guide
settings. One common approach for retrievals is to select a safe pressure control setting eg:
inspiratory pressure of 30 and a safe PEEP of 15. Tidal Volumes may be very small in
patients with stiff lungs eg 150mls.
CO2
ECMO is more effective at removing CO2 than oxygenating blood. The oxygenator is
connected to an oxygen source with normal oxygen tubing such as the green tubing used with
a Hudson mask. This oxygen supply rate determines the amount of CO2 removed by the
oxygenator, analogous to minute ventilation to the lungs. Lung minute ventilation will also
contribute to the arterial CO2 but to a lesser extent. The end tidal CO2 becomes a poor
predictor of arterial pCO2, making it mandatory to carry I-Stat cartridges.
Oxygenation
FiO2 may still need to be 1.0 to aid oxygenation during the retrieval. To avoid oxygen
toxicity, the medium term aim is to be below a FiO2 0.7. Low FiO2 may result in reverse O2
diffusion from the ECMO blood to alveolar gas.
It is worth noting that increasing O2 supply flow to the ECMO oxygenator does not increase
ECMO oxygenation of the blood. It is by increasing ECMO circuit blood flow, particularly in
VV ECMO, that patient oxygenation is increased.
Many patients have permissive hypercapnia prior to ECMO institution. The rapid fall of CO2
when the circuit is switched on (as well as decreased right atrium pressures with VA ECMO)
can cause hypotension.
Intravascular Volume State
During VV ECMO there is a trade off between
1) Keeping vessels full – particularly the IVC – so that the ECMO cannulas can draw
blood at an appropriate rate, and,
2) Worsening oedema of the lungs with high filling pressures.
In the acute/retrieval setting the effective operation of the ECMO cannula usually takes
precedence and there may be a request for vascular filling, often with4% Albumin (if
available). The forces of acceleration/deceleration/ turbulence/rough roads on the IVC around
113
the venous cannula in VV ECMO and can drastically reduce flow rates, decreasing
oxygenation. Adequate filling above usual CVP parameters may help reduce these effects.
Patient Movement
Patient movements and transfers should be minimized and will occur in well-lit, protected
environments. All transfers(e.g. from bed to trolley etc) require a team of at least 5 people.
The RP should direct this team and be responsible for managing the ETT, standing at the
patient’s head. The Alfred intensivist will be responsible for managing the circuit and lines.
Effective communication between all team members if extremely important to minimise the
risk of catastrophic accidental line removal.
To bring a Victorian AAV aeroplane into a hangar usually requires an accredited engineer and
needs to be pre-planned.
ECMO Transfers : ECMO retrieval in Victoria is an advanced collaborative system involving ARV (AV) and
The Alfred Hospital, working within a formal memorandum of understanding.
ARV is the principal organisation in regard to retrieval in Victoria and is responsible for
coordination and delivery of critical care advice, outreach support and retrieval.
ARV provides support for many patients with severe (critical) cardiorespiratory failure, a
small proportion of whom may be considered for ECMO. The processes for ECMO retrieval
are broadly described in the attached flowchart.
Key concepts include:
Optimal communication between all parties involved in retrieval work is essential. To this
end, ARV uses teleconferencing and videoconferencing technologies extensively. (All calls
to and from ARV are recorded for quality purposes)
Where patients are referred to ARV regarding potential ECMO transfer/commencement, or
where they meet general ECMO inclusion criteria, the ARV coordinator will initiate a
teleconference involving the Alfred Hospital ICU consultant.
Where the Alfred hospital receives direct referral of patients for ?ECMO transfer, the ICU
consultant will contact ARV to ensure commencement of a teleconference involving the ARV
coordinator from the outset.
All ECMO retrieval staff will be fully credentialed.
Decisions will be made jointly and collaboratively. Issues that cannot be resolved will be
escalated to the ARV and Alfred ICU directors (or delegate)
Prior to any ECMO mission, the ARV coordinator will convene a “Summary
Teleconference”. This will be attended by all involved clinical and logistics parties or the
case must not proceed. In this teleconference, the plan including contingencies will be
discussed and agreed.
During ECMO transfers:
The ARV coordinator is the clinical ‘control point’ for all retrievals. They are responsible for
defining time criticality of a retrieval case, and for overall coordination of crewing, logistics
and resource.
All case communication will occur through the ARV RASO / coordination office.
All transport coordination will be provided by ARV utilising AV transport platforms.
Urgency of outbound legs will be discussed with the ARV coordinator who will coordinate
platform responses via AAV, ERTCOM or NETCOM.
Standard crewing will be: Paramedic, ARV retrieval physician, Alfred Team (Intensivist(s),
+/-ICU RN)
Clinical leadership will be provided by the senior intensivist
Operational leadership and environmental guidance will be provided by the ARV retrieval
physician
114
Patient movements and transfers will be minimized, and will occur in well-lit, protected
environments (e.g. a hangar rather than open tarmac).
During air missions, the pilot is responsible for the overall safety and management of
logistics. In flight the pilot is in control of all resources, and is responsible for all decisions in
relation to the aircraft, flight path, safe altitude etc.
115
ECMO CPAV setup Complex Patient
Ambulance Vehicle
(CPAV):
Mercedes Sprinter,
longer, wider and higher
than normal road car.
Hydraulic platform at the
rear: can lift 500kg.
Equipment carried
Patient trolley loaded and
secured.
ECMO Console mounts
on right (off) side shelf.
Oxygenator and Pump
secure to patient trolley
rear poles
Console is secured using
tie down straps.
Outlets to rear
Power adjacent.
116
Oxylog 300 and syringe
drivers mount on specific
fitted mounts forward of
ECMO console
Propaq Monitor mounts
on console in front of
principal attendan’ts seat.
Cases and equipment not
required for immediate
patient care are stowed in
the secure space (rear
near side)
117
ECMO Fixed Wing Setup Patient and equipment
loaded using lifting
mechanism
ECMO console is floor
mounted and secured by
mesh tie-downs
Oxygenator and pump
attach to patient
stretcher.
118
Clinical Staff Checklist for ECMO transfers 3 POINTS OF FORMAL CHECK EXIST IN THE ECMO MISSION
FOR THE RESPONDING CREW
1. Pre mission departure (ARV Essendon facility or other crew rendezvous point)
…
…
…
…
…
…
…
Case documentation is complete and all crew have full briefing
Full standard ARV Kit
i-STAT + cartridges
Additional syringe drivers
Full Alfred ECMO Kit
Check with all clinical crew re special needs
Staff comfort / food / clothing / bathroom
2. Pre loading (pre departure from referring hospital)
… Monitoring in place and secured
… art line,
… ECG,
… SaO2,
… ETCO2,
… Temp.
… Battery charged
… Ventilator circuit secured.
… Ventilator functioning,
… ECMO circuit secured to patient with adhesive fixings,
… trolley for ECMO equipment at patients feet.
… Ample infusions for duration of transfer pre prepared.
… Adequate portable oxygen for transfer to platform – 1 cylinder for Oxylog, additional
cylinder for ECMO oxygenator.
… Patient is paralysed
… Verbalise (walkthrough) loading and transfer processes
… Adequate staff for safe transfer of patient and equipment.
… Confirm with platform crew adequate O2 for duration of transfer. (ECMO
consumption is relatively low, usually 6-8litres / min, but cannot be interrupted.
3. During platform loading / return transfer preparation
…
…
…
…
…
…
…
Place Ventilator / ECMO on platform O2 supply
ECMO pump placed on inverter power (90mins battery power)
Place any other equipment on charge if possible
All equipment safely secured
All staff seated securely
Communications reviewed – radio, cell-phone
Transfer urgency agreed (steady/secure – avoid emergency driving / speed)
119
Equipment: ARV Standard Kit Left Side
DRUG
Sodium Bicarbonate
Glucose 50%
Glucagon
Hydrocortisone or
Dexamethasone
Suxamethonium
Propofol
Pancuronium
Rocuronium
Calcium Gluconate
Magnesium
Ceftriaxone
Aspirin
Right Side
DOSE
4.2g / 50ml
25g / 50ml
1mg
AMOUNT
2
1
1
DRUG
Stemetil
Maxalon
Ondansetron IV
DOSE
12.5mg
10mg
8mg
AMOUNT
2
2
2
250mg or 8mg
1
Ondansetron Wafer
4mg
4
100mg
200mg / 20ml
4mg
50mg
2.2mmol / 10ml
10mmol / 5ml
(2.5g)
1g
300mg
2
3
4
3
2
Phenytoin
Nifedipine Oral
Ventolin Obstetric
Lignocaine 1%
Adrenaline 1:1000
250mg
20mg
5mg / ml
50mg / 5ml
1mg / ml
4
4
1
2
10
2
Ventolin
50mcg / ml
3
1
4
Metoprolol
Naloxone
Amiodarone
Noradrenaline 1:1000
Aramine
Verapamil
Atropine
5mg / 5ml
400mcg / ml
150mg / 3ml
2mg / 2ml
10mg / 1ml
5mg / 2ml
600mcg / 1ml
1200mcg /
1ml
40mg / 4ml
3
4
3
6
2
2
1
Atropine
Lasix
3
4
In IV Kit section
GTN Patch 50mg
Panadol/Panadeine
120
BLUE BAG
Main compartment
Bag Valve Mask with PEEP valve
Braun Syringe pumps
ET CO2 cable in black box
1
3
1
Test lung
1
Equipment checklist
Power leads for syringe pumps
Top outer pocket
Bougie
Emergency pneumothorax kit
Chest drainage kit bag
Disposable ventilation circuit
Invasive pressure Monitoring MULTI
cable adaptor (NB. Handle with care)
End pocket 1
Oximax O2 sensor
Liquorice stick
Drager 90 degree angle connector
Penlite torch
End pocket 2
AA batteries for syringe pumps
Bacterial ETT filters
1
3
1
1
2
2
1
2
1
1
1
1 packet
2
*** Add 3 syringe drivers from the lockers to the main
compartment before bag is taken by the RP *** +/Oxylog& Propaq Charger
PROPAQ MONITOR
Temperature probe
Temperature cable
Monitor cables
ECG dots
O2 sat probe
O2 sat cable
1
1
1
1 bag
1
1
OPTIONAL EQUIPMENT
Zoll Defibrillator
ECG, NIB, Sats, RR
Invasive temperature
End tidal CO2
Invasive pressure line
2
Biphasic defibrillator
External pacing
iSTAT
Measure: Na, K, iCa, Glucose, Hct, pH, pCO2, pO2
Calculate: Hb, TCO2, HCO3, BE, sO2
Vacuum Mattress
Immobilisation of spinal patients
Can be used to facilitate transport of
intubated non spinal patients
Transvenous pacing module
RED BAG
Main compartment
Femoral arterial line
Long arrow radial arterial line
Pressure transducers
Invasive monitoring cables (square &
oval)
CVC kit
Rapid infusor
NaCL 500ml
5% dextrose 100ml
IV Pump set
Basic airway kit
Magills forceps – small
2
1
2
1 each
2
2
1
1
1
1
Magills forceps – large
1
Suction catheters 10F
Suction catheters 12F
ETT 6
ETT 7
ETT 7.5
ETT 8
Laryngoscope handle
Long blade
Short blade
C size batteries
10ml syringe
Liquorice stick connector
Wee device
50ml Syringe – catheter tip
Transpore tape
Sleek tape
Trauma shears
Hand sanitising gel
Tube ties
Guedel size 3 (green)
Guedel size 4 (yellow)
Guedel size 5 (red)
Nasopharyngeal airway 6.5 & 7.5
Nasogastric tube 16g
Lubricant
Easy Cap II – CO2 detector
Difficult Airway Kit
Fast Trach intubating LMA size 4
Fast Trach intubating LMA size 5
Fast Trach ETT 6, 7 & 8
Cuffed emerg cricothyroidotomy kit
Portex minitracheotomy kit
Lubricant
Pocket 1
50ml syringes
Min volume extension tubing
Short arrow radial lines
Pocket 2
Trauma shears
Waste bag for dirty equip
Intra osseous needle
Molnar retention disc
BSL monitor
Pocket 3
Pressure bags
Space blankets
Pocket 4
BP cuff – thigh, regular, small
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
2
1
1
1
1 each
1
5
1
1
1
1 each
1
1
5
3
3
2
1
2
1
1
1
2
2
1 each
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Gastrointestinal Haemorrhage Key Clinical information
Haematemesis / Melena - Haemorrhage not
responding to conservative measures (PPI,
reversal of anticoagulation)
Peptic – NSAIDs, Steroids
“Red Flags”
Shock - Hypotension / Tachycardia
Altered conscious state
Need for airway protection
Anticoagulation
INVESTIGATIONS
FBE, Coags, LFTs & U&Es
Mallory-Weiss tear / Gastritis
ETOH - Variceal bleeding
Stress (Burns, Cushing, ARDS, ICU)
Rare – Malignancy, Aorto-enteric fistula,
Trauma, AVM
Chronic liver dis. – coagulopathy,
encephalopathy
Previous variceal bleed.
Oesophageal Rupture
Unavailability of Endoscopist / Surgeon.
Cross-match PRBC / FFP
Erect CXR ?add ECG (risk
of MI in hypotension /
anaemia)
Interventions & Medications
2 large-bore peripheral IVs
PPI s
Reversal of Coagulopathy /
Warfarin
Octeotride
Antibiotics - Hepatic
Encephalopathy
Consider H2 Antagonists
? Vasopressin
Crystalloid, followed by
blood products
8mg/hr infusion
80mg bolus
(Pantoprazole /
Esomeprazole)
Prothrombinex 25-50
Vit. K 5-10mg IV
units/Kg,
FFP
Infusion – 25-50 mcg/hr (see
50-100mcg bolus
ARV inf. Table)
Ceftriaxone 1gr IV +/- Metronidazole 500mg IV, Cipro
400mg IV bd prophylaxis for bleeding cirrhotics
Ranitidine 50mg IV TDS
Risks may outweigh benefits.
May need combined GTN infusion.
Fluid resuscitation.
Interventions & Medications – cont’
URGENT ENDOSCOPY
on-site
Sengstaken-Blackmore tube
(requires expertise, see
instructions in packet)
Indications:
Uncontrolled variceal
bleeding despite above
management.
Mallory-Weiss tear with ongoing bleeding
Consider surgical
intervention on-site.
4 lumens – gastric, gastric
balloon, oesophageal
balloon, drainage above
oesophageal balloon.
Airway protection
Estimated distance to
stomach = distance from
nose to ear+ distance from
nose to xiphoid process.
X-ray conformation of intragastric position followed by
122
further inflation with 250ml
air.
TIPS / Embolisation
Traction – helmet, pulley
with a 500ml fluid bag
Further bleeding – inflate
oesophageal balloon to 2540mmHg (capillary
perfusion pressure) – approx.
150ml air.
Suction and irrigate lumens
1-2 hourly with 30mls NS.
Tertiary centre with angiographic capabilities
Specific Advice
Poor prognosis:
Active bleeding on gastroscopy.
Transfusion requirement > 2L
Encephalopathy
Abnormal LFT’s
Retrieval issues
Retrieval of unstable patient vs. available local treatment
options.
Retrieval of patient with Minnesota tube in-situ
Needs to be secured to mask
(not pulley).
Potential for dislodgment –
catastrophic.
Balloon pressure monitoring in
flight.
Potential for multiple infusions – Check ahead, rationalise,
and bring enough syringe drivers.
Transfusion during a retrieval may be hazardous, try to
ensure all units are checked prior to leaving referring
hospital.
123
Hyperosmolar non­ketotic coma (Hyperosmolar Hyperglycaemic crisis) Key Clinical information
Glucose typically higher than in DKA
(always >33 mmol/L; often up to 60
mmol/L)
pH typically >= 7.30
HCO3 > 18mmol/L
Anion gap variable
Often occurs in patients not previously
known to be diabetic
Typically no ketosis / acidosis, but may coexist with DKA in 20-40% of cases
“Red Flags”
Look for signs / history of precipitants:
pneumonia, UTI, gastroenteritis, cardiac
disease, medications (esp. thiazides, betablockers, Ca antagonists)
INVESTIGATIONS
Monitor BSL every hour and
A or VBG with electrolytes at
least every 2 hours until
stable.
Expect a high WCC due to
haemoconcentration, not
necessarily because of
infection
More dehydrated than DKA (usually 8-10L)
Serum osmolarity > 3230 mOsm/kg
Alteration in mental state
Occasionally seizures
Has a much higher mortality than DKA (up to
60%) due to the ages / comorbidities of the
different patient profiles.
A high anion gap metabolic acidosis may be
due to co-existing ketoacidosis, but may also
be a lactic acidosis related to the underlying
cause. Check lactate if possible.
UA with ketones
Mg2+ and K+ often fall
dramatically with insulin
therapy
ECG for signs of
hyperkalaemia
CXR
Cultures – urine, blood, +/sputum
Whole body K+ is typically
depleted despite high initial
K+;
Whole body Na+ is typically
reduced, despite high initial
Na+. Note corrected Na+ =
measured Na+ + 0.4 x (glc –
5.5)
Interventions
Treatment of dehydration is the first priority
Historically, endocrinologists recommended initial fluid resuscitation with 0.9% NaCl. More
recently, intensivists / ED physicians, observing the hyperchloraemic acidosis this causes, have
recommended Plasmalyte or Hartmann’s solution.
Typical regimen in an adult :
1L over 1st hour
1 L over 2 hours
& then titrate to clinical indices (urine output, cardioresp. signs).
Consider use of vasopressors if fluid therapy is insufficient to quickly restore MAP>65-75.
124
Treatment of hyperglycaemia is the second priority.
Hyperglycemia will often resond to fluid resuscitation
Commence insulin infusion 5-10 units/hr IV, aiming for a fall in glucose of approx.. 5
mmol/L/hr but keeping the glc>12 mmol/L for the first 24 hours.
When BSL falls to 12mmol/L, add 5% D at approx. 100ml/hr in addition to whatever volume
resuscitation is indictaed at that time.
Do not start insulin if K+<3.0mmol/L; correct K+ first (with eg. 30mmol IV over 1 hour
repeated as required
Electrolyte replacement
Expect to need to give KCl 10-30 mmol /hr IV when K+ falls to <5.5 mmol/L
Expect to need to give 1-2 x Mg2+ 20mmol slow boluses
Fluid and electrolyte therapy should now ideally be guided by frequent monitoring, not
theoretical calculations / protocols.
Other therapy
Give 5000U SC heparin bd unless contraindicated as the risk of DVT/PE is very high
Consider antibiotics if infectious cause suspected.
Sodium bicarbonate is not indicted to reverse the acidosis, with the possible exception of when
the pH remains <6.90 despite therapy.
Consider 50-100ml of 8.4% NaHCO3 if the initial K+>6.5, along with 10ml 10% Ca
gluconate, noting that K+ is still likely to require replacement once insulin is effective.
.
Suggested medications
Actrapid infusion
MgCl2
Na/K H2PO4
Heparin
Consider antibiotics.
eg. ceftriaxone
5-10 U / hr – aim to reduce glucose by
10-20mmol
10-20mmol
5000U SC
1g IV daily/bd
Specific Advice
Normalisation of BSL is not an indication to stop
the insulin/dextrose infusion, as insulin/dextrose is
required to clear the ketoacidosis, which does not
parallel improvement in the BSL. Continue
insulin/dextrose until ketones clear – which will
usually be at least the day after presentation.
A CVC or arterial line is likely to be
needed for frequent blood monitoring. If
peripheral IV access difficult, pt. has
contraindication to an arterial line,
volume status is particularly difficult to
assess or MAP < 65 – start with CVC.
Otherwise start with an arterial line.
Retrieval issues
Use the iStat for monitoring during prolonged
transfers
Ensure there is a CVC or arterial line in
place prior to a prolonged transfer to
allow access to blood samples
125
Intra­aortic Balloon Pump This document outlines the basics of IABP technology and its use in the retrieval
environment.
All IABP retrievals will be done with a perfusionist (technician) and retrievalist. The
Perfusionist brings the machine and manages the pump and circuit leaving the retrievalist to
manage the patient. A good working relationship between retrievalist and perfusionist should
be established early in the mission. Many of the perfusionists are used to travelling with fairly
junior cardiology registrars who have little familiarity with the transport environment.
What is an IABP?
The IABP is a long balloon over a catheter which is placed in the aorta, ideally just distal to
the left subclavian artery and proximal to the renal arteries. It is usually inserted femorally
although can be inserted from a brachial approach. A percutaneous Seldinger technique is
used, generally with fluoroscopic guidance in an angio suite although blind insertion with X
ray for confirmation of position is possible. The catheter has two lumens, one to measure
aortic pressure and one to inflate and deflate the balloon. The balloon is filled with helium gas
from a small tank on the pump and inflation-deflation is timed with the cardiac cycle. Helium
is used because of its flow characteristics allowing very rapid and precise inflation and
deflation.
How is it timed?
The balloon inflates in diastole, just prior to the dichrotic notch. The second peak after the
dichrotic notch, is the result of closure of the aortic valve and muscular and elastic recoil of
the aorta against the closed. The balloon deflates at the onset of systole. As it happens the
point “just prior to the dichrotic notch” corresponds to the mid-T wave and the beginning of
systole to the peak of the R wave.
Timing, therefore, can be achieved by computer recognition of ECG features (ECG peaks,
ECG shapes or patterns, atrial pacing spikes or ventricular pacing spikes), by fluctuations in
aortic pressure measured at the catheter tip or by an intrinsic, machine-generated rhythm in
case of cardiac arrest).
The machines used by Perfusion Services Australia have an Autopilot mode that
automatically selects the best timing mode for the conditions.
How does it help?
By inflating in diastole with a competent aortic valve the balloon displaces blood from the
aorta increasing forward flow during diastole when it would normally diminish and increasing
coronary perfusion by increasing diastolic pressure without any increase in intra-cardiac
pressure (although empirical evidence of the latter effect is less convincing). By deflating just
before the aortic valve opens again it decreases left ventricular afterload by presenting the left
ventricle with a relatively empty aorta to pump into. This means the left ventriclular wall
tension is lower as are left ventricular and left atrial end diastolic pressures which means a
reduction in preload. Stroke volume and cardiac output increase and myocardial oxygen
consumption decreases.
The pump can be used on every cardiac cycle or on a fraction of them. It must inflate on at
least 1 in 8 cycles to prevent thrombosis. Increasing the frequency of cycling will increase the
126
degree of help provided to the cardiac output. During weaning the cycling ratio is decreased
gradually
What will the blood pressure do?
So, you thought blood pressure was two numbers with a oblique line in between them (and
another in brackets if you are an intensivist)? Not once you have two pulsation pumps (heart
and IABP) working in series.
Figure 1. IABP cycling 1:2
In figure 1 the IABP is set to cycle 1:2, that is to say, the balloon inflates on every second
cardiac cycle. The first wave is a normal heartbeat without the IABP activating. There is a
systolic pressure (now called unassisted systole), a dichrotic notch and diastolic pressure (now
called an unassisted aortic end diastolic pressure). The IABP inflates after the next systole so
the next systolic pressure is another unassisted one. Diastole, however, is very different this
time. Note that the Augmented diastolic pressure is quite high, higher than systolic pressure
and that it is followed by a Assisted aortic end diastolic pressure which is lower than the
unassisted one (because of the effect of sudden evacuation of the aortic contents). Following
that there is another “normal” beat only this one is not normal because the ventricle is
benefiting from the decreased afterload that results from the lower assisted aortic end diastolic
pressure. This is, therefore an assisted systolic pressure.
So, with the IABP cycling 1:2 we have an unassisted systolic pressure, an augmented diastolic
pressure, an assisted end diastolic pressure, an assisted systolic pressure, an unassisted
diastolic pressure and then an unassisted systolic pressure again.
Thankfully the machine will report the mean arterial pressure making the task of keeping a
sensible obs chart somewhat easier.
Note though that the assisted pressures should be lower than the unassisted ones or will be in
patients who were relatively normotensive at the outset. In patients with hypotension an
increase in MAP will result as the increase in pressure during diastolic augmentation is
greater than the decrease in pressure during assisted systole and diastole.
When is it used?
• Cardiogenic shock
127
Ischaemic contractile failure- majority of cases, obvious benefits from
decreased preload and afterload and augmented pumping.
o Acute MR or ventricular septal rupture- leads to significant decrease in
backflow (MR) or left to right shunt (VSR).
Intractable angina
o Weaker indication, probably helps
High risk CABG peri-procedure
o Decreases time on bypass and post-op IABP time
High risk cardiac cath
o Weakest indication but may be beneficial should procedure related ischaemia
occur (e.g. in tight left main stenoses)
o
•
•
•
Contraindications
• Aortic regurgitation
o IABP relies on a competent aortic valve. In AR the IABP will cause
increased regurgitation and increased intracardiac pressures and wall tension,
the reverse of what it aims to do.
• Aortic dissection
o Risk of placement in a false lumen and aortic rupture
• Aortic aneurysm (large)
o Risk of rupture
• Severe peripheral vascular disease preventing insertion
• Uncontrolled septicaemia
• Uncontrolled bleeding diathesis
What could possibly go wrong?
• Vascular
o Bleeding
o Thrombosis
o Embolisation
o Limb ischaemia
o Infection
o Aortic branch vessel occlusion (particularly spinal arteries)
• Mechanical
o Balloon rupture
o Inadequate inflation
o Inadequate augmentation
o Catheter displacement or damage due to patient movement
• Haematological
o Thrombocytopenia and anaemia are common due to mechanical destruction
o Complications of heparinisation may occur
• Underlying disease may progress in spite of IABP.
Deaths from IABP are rare and mainly related to aortic dissection or rupture.
What do you need to check?
• Ensure you are clear about:
o The indication for insertion of the pump
o The response to treatment
o The rate of cycling, why this rate has been chosen and whether it has changed
since insertion.
ƒ Minimum rate to avoid thrombosis is 1:8
ƒ If cardiac output is inadequate rate can be increased as far as 1:1.
• Check with the perfusionist that the technology used at the referral site, their
technology to be used in transit and that which is likely to be used at the destination
128
•
•
•
•
•
site are going to be compatible. In general the machines used by PSA for transport are
able to be adapted to lines made for other machines.
Insertion site for haematoma, bleeding, adequacy of dressings and inflammation
Position
o Ensure you have seen radiological confirmation of the position. A CXR
should demonstrate a radio-opaque catheter tip at the top of the ascending
aorta.
o If it has been inserted fluoroscopically ask for a copy of the still images to
take with the patient or get a CXR taken before departure as evidence of
correct position
Heparin infusion rate and APTT if done already.
Patient comfort
o Patients need to lie flat and not move the affected limb for the duration of the
time the IABP is in. This necessitates good analgesia and often sedation,
especially when the patient is on a transport stretcher. In the aeromedical
transport environment this may require intubation in some cases. This should
be born in mind when coordinating IABP transfers from CCU to CCU.
Timing (see Figure 2 below)
o This is primarily the realm of the perfusionist however these are the things
that are considered. The key to assessing timing is assessment of the aortic
pressure waveform which is displayed on the machine monitor.
o Basically, the balloon can inflate too early (B) or too late (C) and can deflate
too early (D) or too late (E) ((A) is normal).
Figure 2. Timing issues with IABP
ƒ
ƒ
ƒ
ƒ
Early inflation (B) (before aortic valve closure) causes increased afterload and myocardial
oxygen consumption with the ventricle contracting against an inflated balloon.
Late inflation (C) occurs when the aorta pressure has already dropped off so there is less
potential for diastolic augmentation.
Early deflation (D) shortens the period of diastolic augmentation and may result in
backflow from coronaries and carotids.
Late deflation (E) has the same consequences as early inflation.
129
What about the hardware?
PSA use Arrow machines distributed in Australia by Mayo Healthcare. The two machines are
Autocat 2 Wave and ACAT 1.
The Autocat Wave 2 is pictured above. The display and control unit on top comes off the unit
and can sit on the lap of the perfusionist with a wired connection to the pump unit which
needs to be stowed securely. In Victoria CPAV should be used for IABP retrievals. NSW
ambulance services have a vehicle in each region that is purpose built to carry an IABP
patient with a lifter and docking area for the pump at the rear of the vehicle.
130
Intracranial Haemorrhage Aetiology: Chronic hypertension. Rupture of
aneurysm or AV malformation.
Haemorrhage into tumour or infarct.
Presents with sudden onset of headache or
neurologic deficit +/- associated headache,
vomiting and hypertension.
CTB required to distinguish from ischemic
stroke and between types of intracerebral
haemorrhage (subarachnoid,
intraparenchymal) and to assess prognosis,
likely response to treatment, and
complications (hydrocephalus, herniation)
“Red Flags”
Deteriorating conscious state and raised ICP due to expanding haematoma
Rising arterial blood pressure and falling pulse (Cushing reflex) in response to raised ICP.
Seizures
Warfarin therapy (see below)
INVESTIGATIONS
CTB
Coagulation profile
ABG, BSL
Interventions
Ventilation targets :
PaO2 > 100, PaCO2 approx. 35, avoid excessive PEEP (but PEEP is a secondary consideration
to adequate oxygenation)
Blood pressure control :
Manage hypertension on an individual basis with advice from receiving neurologist/surgeon
There is no definitive evidence however current ASA/AHA guidelines suggest that if SBP is >
180 or MAP is >130 then lowering of BP to a MAP of 110 or target BP of 160/90 using
intravenous medications is probably safe.
Anticonvulsant therapy :
Clinical seizures should be managed agressively using benzodiazepines.
Patients who have seized or who are showing evidence of seizure activity on EEG should be
propylactically loaded with :
Dilantin – 20mg/kg (if not already taking)
Other measures :
Elevate head 30 degrees
Control hyperglycaemia with insulin infusion
Suggested medications
Morphine
2mg IV boluses to effect
Ondansetron
4-8mg IV
15-20mg/kg SLOW IV
Phenytoin
(eg. Over 1 hour)
Propofol
Suxamethonium
Pancuronium
Vecuronium
1-2 mg/kg
100 -150mg
8mg IV
8mg IV
Titrate to pain
Antiemetic (if not intubated)
Seizure prophylaxis. Rapid infusion will
precipitate cardiac arrhythmia.
As required to facilitate intubation &
subsequent ventilation
Modify dose according to pts condition.
Follow with depolarizing relaxant
Avoid high rates of long acting sedatives
(i.e. morphine / midazolam) in order to
facilitate examination at receiving centre.
131
Actrapid infusion
Mannitol
IV 1-10 units / hr
1g/kg IV (noting 20%
solution has 0.2 g/ml),
then 0.25-0.5 g/kg q6hr
20% saline
10ml slow bolus
Paracetamol
1g IV or PO
Antihypertensives:
Metoprolol
Clonidine
Propofol for BP effect
GTN
Hydralazine
Labetalol
2-5mg IV
75-150mcg IV
0.5-5mcg/kg/min
5mg IV
10-20mg IV
Aim for BSL in normal range (6-10)
For signs of raised ICP ( Usually in
consultation with receiving unit)
An alternative to mannitol for signs of
raised ICP
To keep temp. 36-38 degrees. Also
consider active cooling.
Repeat as required, ideally with invasive
arterial pressure monitoring
Avoid nitroprusside (causes cerebral
vasodilation and raised ICP)
Specific Advice
Prothrombinex
Vit K
Reverse Warfarin
FFP
Reverse Heparin
Protamine
25-50IU/kg IV
10mg IV
300ml if Prothrombinex is also given;
10-15ml/kg (ie. 3-4 units in 80kg pt) if
Prothrombinex is not available.
Note Prothrombinex has low levels of
Factor VII, necessitating the additional
use of FFP.
1mg/100IU UFH given and according to
APTT. Give as a slow IV bolus to avoid
hypotension.
Retrieval issues
Protect against secondary brain injury from hypoxia, hypotension and hyperglycaemia
Arrange to take Prothrombinex to patient if not available in referral hospital
Discuss use of Mannitol with receiving neurologist or surgeon before departing referral
hospital.
Steroids are not indicated in ICH
Consider inserting CVC and arterial line to monitor / control BP. Mandatory if patient is
intubated.
Avoid hypotonic IV fluids (ie. 5% Dextrose, Hartmann’s solution) ; use plasmalyte or 0.9%
saline.
iStat useful to monitor ventilation and BSL on long transfers. ETCO2 may not be an accurate
guide to PaCO2, and at the very least the relationship betwen the two should be defined once
prior to transfer.
Even if prognosis is thought hopeless and transfer for surgery is not indicated, retrieval may
still be warranted to facilitate organ donation if the NOK agree.
132
Morbidly Obese Critical Care Patient Retrieval Definitions Body mass index, BMI = weight/height² in kg/m²
Overweight: BMI > 30
“Morbid obesity": BMI > 40
Specialised Clinical Units Specialised clinical units for managing critical morbidly obese patients are limited. Lifting
equipment and beds are available at:
• RMH
• Box Hill Hospital
• Maroondah Hospital
• Ballarat
• Bendigo
• ? other
Physiologic consequences Metabolic rate is proportional to body weight
• increased O2 demand
• increased CO2 production and alveolar ventilation
Restrictive lung disease
ƒ decreased chest wall compliance
ƒ diaphragm forced cephaladly
ƒ decreased lung volumes
o accentuated by supine position
ƒ functional residual capacity (FRC) may fall below closing capacity leading to
o alveolar collapse with ventilation/perfusion mismatch
o often relatively hypoxemic
o occasionally hypercapnic (obesity-hypoventilation or Pickwickian syndrome)
ƒ obesity usually extreme
ƒ hypercapnia
ƒ cyanotic
ƒ polycythemia
ƒ right-sided heart failure (cor pulmonale)
ƒ somnolence
ƒ often have obstructive sleep apnea syndrome (OSAS)
Obstructive sleep apnoea syndrome (OSAS)
ƒ snoring, apnea pauses during sleep
ƒ associated with
o hypertension
o hypoxia
o dysrhythmias
o myocardial infarction
o pulmonary oedema
o stroke
o difficult airway management
ƒ more vulnerable to airway obstruction after opioids or sedatives
Cardiovascular
o increased workload
o hypertension
o left ventricular hypertrophy (LVH)
o increased pulmonary blood flow and hypoxic pulmonary vasoconstriction leads to
ƒ pulmonary hypertension and
133
ƒ cor pulmonaale
Gasttrointestinal
o gastroessophageal refflux
o poor gasstric emptyin
ng
o hyperaciidic gastrc flluid
o fatty inffiltration of th
he liver
o elevated
d liver functioon tests
Assessment • cardiopu
ulmonary funnction
o chest X-ray
o ECG
o arterial blood gases
f
testss
o pulmonary function
s cuff (at least 75% off arm circum
mference)
• blood prressure with appropriate size
• assess need for centrral venous orr arterial acceess
• airway
o limited TM joint
j
mobilitty
nto-occipital mobility
o limited atlan
o narrow uppeer airway
ndible and stternal fat padds
o small space between man
•
In 100 morbidly
m
obeese patients, neither
n
obesiity nor body mass index ppredicted
problem
ms with tracheeal intubationn. However, a high Mallaampati scoree ( 3) and larrge
neck circumference may
m increasee the potentiaal for difficuult laryngoscoopy and
intubatioon (Brodskyy, et al, Anessth Analg 200
02;94:732-7336)
ƒ awaake fiberopticc intubation good
g
choice if difficult ddirect
laryngoscopy exxpected
ƒ relattively high FIO2
F
may be needed
Mecchanical ventilation Presssure-controllled ventilatioon (PCV) maay be a betteer alternative to Volume C
Controlled
Venntilation (VCV
V) in ICU paatients with morbid
m
obesity. The two differences between VC
CV
and PCV are thee flow patternn and the choosen target: PCV
P
uses a decelerating
d
flow, which
reacches the highhest possible value at the beginning
b
off inspiration,, while havinng a preset
presssure limitation but no miinimum Vt. Flow
F
diminisshes throughhout inspiratiion according
g to
the pressure
p
targget, and the reesulting Vt depends
d
on th
he pressure limitation
l
and on the chest
com
mpliance. Theese characterristics of PCV
V (faster tidaal volume delivery, differrent gas
distrribution, andd high and deecelerating innspiratory flo
ow) tend to compensate
c
ffor any poten
ntial
reduuction in venntilation caused by pressuure limitation
n. Furthermorre, the limitaation of presssure
leveels has a posiitive effect onn the patient's haemodyn
namics and might
m
even reeduce the risk
k of
barootrauma. (Caadi et al, Britiish Journal of
o Anaesthesiia 2008 100((5):709-716)
Morrbidly obese patients som
metimes requiire higher than normal raange of airwaay pressures (40–
50 cm
c H2O) to achieve
a
and maintain
m
adeqquate oxygen
nation. Thesee pressures, w
which can bee
geneerated by reggular ventilattors, are requuired to oppose the excesss weight, whhich is centraally
locaalized in the abdominal
a
arrea. Pressuree-controlled ventilation
v
w vigilant m
with
monitoring of
o
tidall volumes maay help prevvent barotraum
ma. Pressurees of up to 500 cm H2O haave been used
d
withhout adverse pulmonary sequelae.
s
The Oxylog 3000 can delivver up to 2l tiidal volumes,
withh peak pressuures to 55 cm
mH2O.
The adult 3-L Am
mbu bag is adequate
a
for obese patientts because thheir lung voluumes are nott
largeer than that of
o nonobese patients.
p
Moorbidly obesee patients cann be adequateely handventtilated with thhe standard (3-L)
(
ventilaation bag. On
ne can adjust the pressuree relief ("pop
off") valve so that larger thann usual inflattion pressurees (up to 50 cm
c H2O) cann be used to
134
inflate the lungs. The danger of barotrauma is minimized by the fact that most of the excess
pressure is directed towards opposing the additional abdominal girth during lung inflation.
The maximum 400 joules of energy in regular defibrillators is sufficient for the morbidly
obese. Although higher transthoracic impedance from chest wall fat may occasionally make
defibrillation difficult, the chest wall is usually not much thicker in most obese patients.
Pharmacology/Weight‐Based Dosing Highly lipophilic substances such as barbiturates and benzodiazepines, show significant
increases in volume of distribution (VD) for obese individuals relative to normal-weight
individuals Less-lipophilic compounds have little or no change in VD with obesity. Certain
exceptions to this rule include digoxin, procainamide , and remifentanil, which are highly
lipophilic drugs but which have no systematic relationship between their degree of
lipophilicity and their distribution in obese individuals. Consequently, their absolute VD
remains relatively consistent between obese and normal-weight individuals, and their doses
should be calculated on the basis of ideal body weight.
Drugs with weak or moderate lipophilicity can be dosed on the basis of ideal body weight
(IBW) or, more accurately, lean body mass (LBM). These values are not identical, because
20%–40% of an obese patient’s increase in total body weight can be attributed to an increase
in LBM. Adding 20% to the estimated IBW dose of hydrophilic medications is sufficient to
include the extra lean mass. Nondepolarizing muscle relaxants can be dosed in this manner.
The majority of anesthetic drugs are strongly lipophilic. Increased VD is expected for
lipophilic substances, but this is not consistently demonstrated in pharmacological studies
because of factors such as end-organ clearance or protein binding.
Weight-Based Dosing of Common IV Anaesthetics
Drug Propofol Dosing IBW
Maintenance:
TBW
Comments Systemic clearance and Vd at steady-state correlates well
with TBW (92). High affinity for excess fat and other well
perfused organs. High hepatic extraction and conjugation
relates to TBW.
TBW
Increased Vd. Increased blood volume, cardiac output, and
Thiopentone muscle mass (91). Increased absolute dose. Prolonged
duration of action (93).
TBW
Central Vd increases in line with body weight. Increased
Midazolam absolute dose. Prolonged sedation because larger initial
doses are needed to achieve adequate serum
concentrations (93, 94).
Plasma cholinesterase activity increases in proportion to
Succinylcholine TBW
body weight. Increased absolute dose (93).
IBW
Recovery may be delayed if given according to TBW
Vecuronium because of increased Vd and impaired hepatic clearance
(93, 95).
IBW
Faster onset and longer duration of action.
Rocuronium Pharmacokinetics and pharmacodynamics are not altered
in obese subjects (96, 97).
TBW
Absolute clearance, Vd, and elimination half-life do not
Atracurium change. Unchanged dose per unit body weight without
Cisatracurium prolongation of recovery because of organ- independent
elimination (98, 99).
TBW
Increased Vd and elimination half-time, which correlates
Fentanyl positively with
IBW = Ideal body weight; TBW = Total body weight; Vd = volume of distribution. 135
The morbidly obese are vulnerable to both pressure areas and thromboembolic complications.
Appropriate precautions should be taken.
Transport Platform Options General considerations
Morbidly obese patients need to be considered both in terms of their weight as well as their
physical dimensions, particularly width. A patient who is oversized for a stretcher may fall
off, develop pressure wounds, or make ongoing management impossible. If there is too much
“overhang” from the patient’s arms over the side rails, then this can also be a problem when
stretchers fit tightly against a wall such as in all AAV helicopters and HATS vehicles.
In general, a patient approaching 160kg will not fit on a standard ambulance stretcher because
of width rather than weight and should be considered for CPAV. A patient between 120 and
160kg should be carefully considered regarding platform selection. AAV fixed wing is
limited to 120kg.
Example: A 70year old 130kg, 160cm (5 ft 3 in) tall female only just fits on a standard
ambulance stretcher in HEMS 4 (with difficulty and after some equipment rearrangement).
This is due to both stretcher handling difficulty/pressure care/won’t fall off, but more because
the patient’s arms and body overhanging the stretcher edge won’t fit against the engine wall
and therefore the stretcher can’t be rolled in. A 180cm (6 ft) person of the same weight is
likely to fit with relative ease.
Road
“Emerg Cars”
All AV emergency ambulance vehicles have had stretchers upgraded to a 230kg capacity.
These stretchers are FERNO 50E brand and have green/yellow fluorescent legs.
The distance between the two side rails is 49cm. It is not uncommon to transport obese
patients with the torso/abdomen within the side rails but the arms (and some adipose tissue)
overhanging them and strapped in.
CPAV (Complex Patient Ambulance Vehicle)
There are 5 of these vehicles in Victoria:
Metropolitan Melbourne x2 (although usually one per shift)
Geelong x 1
Sale x 1
Bendigo x 1
They have specialised equipment for moving very large patients on a wide stretcher. They
have the ability to weigh their patients and have a stretcher capacity of 450kg.
Their largest clients in Victoria are around 330kg and these patients overhang their wide
stretcher.
HATS
Use the same FERNO 50E stretchers as the rest of AV – 230kg capacity,
Fixed Wing
Victoria
The capacity of the RFDS Super King Air in use at AAV is limited to 120kg by the lifting
mechanism on the aircraft. This means a 120kg patient plus equipment can be safely lifted.
NSW
RFDS standard planes have a capacity to lift 140kg without equipment or a bridge. There is a
plane based in Dubbo that has a capacity of 180kg (without equipment).
136
South Australia
MedSTAR’s RFDS planes can transport up to 180kg on their stretchers if the side rails can be
locked in the upright position.
Rotary Wing
AAV HEMS 4 & 5
These two aircraft are identical and employ a roll on roll off mechanism using standard
ambulance stretchers. This is limited to the 230kg limit of the stretcher. The size of the
patient on a standard stretcher is likely to limit this option rather than weight restrictions as
above.
AAV HEMS 1,2 & 3
These aircraft involve the litter (top part of the standard trolley) being manually lifted off the
stretcher legs and into the aircraft. The litter used by AV is a FERNO 155-E which has a
carrying capacity of 159kg when not on stretcher legs.
All patients greater than 120kg must be discussed with the flight coordinator to determine
appropriateness for RW transfer.
Bariatric Imaging Options CT
In general CT is logistically possible for many morbidly obese patients. Most patients will
have a CT scanner within their local area with a table capacity around 220kg.
The myth that there is an enormous elephant sized scanner at Werribee Zoo (or any other zoo)
is just that – a myth. Veterinarians do use CT (and sometimes put a horse leg or smaller
animals into it) but these are the same as the CT scanners made for the rest of the medical
industry.
MRI
The width of the patient is the rate limiting step for MRI in morbidly obese patients rather
than table capacity. The hardest part of the patient to get into the scanner is usually the
shoulder/arms where the patient often has to get them above the head to enter the scanner.
There are several “wide bore” 70cm MRI in metropolitan Melbourne which may be able to
accommodate larger patients.
There is an “open” scanner at Radar Medical Imaging in Bundoora which is mainly for
claustrophobic patients where patients do not get the medicare rebate. It has two plates above
and below the patient 33cm apart that the patient has to fit though. The table has a weight
limit of 170kg. Most morbidly obese patients have an AP thickness of greater than 33cm but
this scanner may be useful if only required to get a head or a neck into the scanner but would
be logistically challenging and require further clarification.
137
Hospital
Austin
Alfred
Box Hill
Dandenong
Epworth Richmond
Frankston
Geelong
Maroondah
Monash
Northern
Royal Melbourne
St Vincents
Sunshine
Western Footscray
There are regional
scanners:
Albury
Ballarat
Bendigo
Gippsland mobile unit
Shepparton
MRI Bore Diameter (cm)
60
55 & 60
60
60
70
70
60
No MRI
70
60
70 & 60
60
60
70
Table Limit (kg)
200
156
200
150
250
250
200
n/a
245
150
200
200
159
159
60
200
60
200
55
180
References:
Ogunnaike et al., Anesth Analg 2003;97:603-604
138
Non ST Elevation AMI (NSTEMI) Key Clinical information
Emergency re-perfusion not indicated, focus is on identification and early referral of high risk
patients
“Red Flags”
Elevated Troponin or CK-MB
Dynamic ST changes
new ST depression > 0.5mm or T inversion
Haemodynamic compromise – SBP <90,
diaphoresis
Acute LVF
Syncope
Prior PCI / CABP within 6 months
Diabetes or Chronic renal failure
INVESTIGATIONS
12 lead ECG
Repeat 10-15 minutely if non-diagnostic with ongoing pain
Consider RV and posterior leads
Cardiac biomarkers
Baseline FBE, U&E’s , Coagulation screen
CXR
General Management
Monitoring - Frequent ECG’s or Continuous ST-segment monitoring
Hudson or Non- Rebreather
Oxygen
15L/min
mask
Asprin
oral
300mg
Sublingual
600μg prn
GTN
Intravenous
20-200μg titrated to pain
Morphine
intravenous
2.5 mg boluses titrated to pain
Potassium
intravenous
Aim for K+ > 4.0
Additional therapy – consider for high risk patients
oral
B-blockers - unless contraindicated
LVF
SBP <110, HR <50
Intravenous
Asthma
20 or 30 Heart block
LMW Heparin
S/cut
Clopidogrel (in consultation with receiving
Oral
unit)
Gllb/llla inhibitors
Oral / I/V
Metoprolol - 25mg
Metoprolol - 5mg over 5mins
(up to 15mg) to control
tachycardia / hypertension
Img/kg
300mg loading dose
75mg daily
in consultation with receiving
unit
Indications for Early Angiography (within 48 hrs)
‘Red flag’ features
Pain or iscaemia refractory to medical therapy
High risk features on early stress testing
139
Risk Stratification (AHF guidelines)
High Risk features
Elevated biomarker – Troponin or CK-MB
Persistent ST depression > 0.5mm or new T inversion > 2mm
Dynamic ST elevation or depression > 0.5mm
Haemodynamic compromise – SBP <90, diaphoresis, new onset mitral regurgitation
Sustained VT
Syncope
Left ventricular failure
PCI within 6 months or previous CAPB
Diabetes or Chronic renal impairment
Intermediate Risk Features
Chest pain at rest
Age > 65
Known coronary heart disease
Two or more of :
140
Ambulance Victoria Transport Platform Specifications 141
AV Platform Capability and Fitout PLATFORM
HEMS 1
HEMS 2
HEMS 3
APPROX
RANGE
150 km out
150 km out
150 km out
CREW
Pilot,
Crewman,
MICA Officer
Pilot,
Crewman,
MICA Officer
Pilot,
Crewman,
MICA Officer
CAPACITY
(stretchers)
1
1 optimal,
2 possible
1 optimal,
2 possible
WEIGHT
MAX
Approx.
140kg
Approx.
140kg
Approx.
140kg
OXYGEN
CAPACITY
3270L Fixed
600L Portable
3270L Fixed
600L Portable
3270L Fixed
600L Portable
ELECTRICS
240 AC
12/24 DC
240 AC
12/24 DC
240 AC
12/24 DC
EQUIPMENT
Invasive Propaq
Monitor
NIBP, ECG, SpO2
Invasive Pressure,
ETCO2
Zoll Defibrillator
3 Infusion pumps
ACLS
Equipment/Drugs
LTV1200 Ventilator
Invasive Propaq
Monitor
NIBP, ECG, SpO2
Zoll Defibrillator
4 Infusion pumps
ACLS
Equipment/Drugs
LTV1200 Ventilator
Invasive Propaq
Monitor
NIBP, ECG, SpO2
Zoll Defibrillator
4 Infusion pumps
ACLS
Equipment/Drugs
LTV1200 Ventilator
RESTRICTIONS
At times dependant on
load or weather
conditions eg. cross
winds, storms, lightning,
fog and heat, may be
unable to land at certain
destinations eg.RMH,
RCH (new) Helipad
Landing restrictions
placed on certain rotary
platforms, may be
unable to land at certain
destinations eg.RMH,
RCH (new) Helipad.
These include most
replacement platforms
for servicing of HEMS.
Whilst distances may be
prohibitive, don't totally
dismiss Rotary as an
option as they still may
be the available best
option.
OXYGEN USAGE
VENTILATORS
LTV
MV x FIO2 / Min
Can run on ambient
air
Oxylog 2000
1L + 50% MV on
Airmix / Min
1L + 100%MV on
100% / Min
Oxylog 3000
0.5L + MV x %FIO2 /
Min
MV = Minute
Ventilation
PLATFORM
HEMS 4
APPROX
RANGE
150 km out
HEMS 5
150 km out
CREW
Pilot,
Crewman,
MICA Officer
Pilot,
Crewman,
MICA Officer
CAPACITY
(stretchers)
1 optimal,
2 possible
WEIGHT
MAX
230kg
(theoretical,
generally limit
at ~160kg
depending on
width etc)
OXYGEN
CAPACITY
3280L Fixed
(2xD's)
600L Portable
ELECTRICS
EQUIPMENT
240 AC
12/24 DC
Invasive Propaq
Monitor
NIBP, ECG, SpO2
Zoll Defibrillator
4 Infusion pumps
ACLS
Equipment/Drugs
LTV1200 Ventilator
1 optimal,
2 possible
230kg
(theoretical,
generally limit
at ~160kg
depending on
width etc)
3280L Fixed
(2xD's)
600L Portable
240 AC
12/24 DC
Invasive Propaq
Monitor
NIBP, ECG, SpO2
Zoll Defibrillator
4 Infusion pumps
ACLS
Equipment/Drugs
LTV1200 Ventilator
Invasive Propaq
Monitor
NIBP, ECG, SpO2
Zoll Defibrillator
2 Infusion pumps
ACLS
Equipment/Drugs
FIXED WING
2hrs out
1 Pilot 1
Paramedic or
MICA
1 optimal,
2 possible
120kg lift
capacity
3280L Fixed
(2xD's)
600L Portable
240 AC
12/24 DC
STANDARD
ROAD
N/A
2 Paramedics
1
160kg 'Old"
trolleys
230kg 'New'
50E trolleys
240 AC
12 DC only
on some
Non Invasive Phillips
MRX
NIBP, ECG, SpO2,
Defib.
Basic Airway, LMA's
MICA ROAD
N/A
As above
As above
3280L Fixed
(2xD's)
980L Backup
(2xC's)
980L Portable
(2xC's)
As above
As above
Non Invasive Phillips
4 seat
capacity total
As above.
RESTRICTIONS
OXYGEN USAGE
VENTILATORS
platform of choice eg
refuel options, helipad
to helipad.
Discuss with Flight
Coordinator.
At times dependant on
weather conditions eg.
cross winds, storms,
lightening, fog and heat,
may be unable to land
at certain destinations.
Patient weight may be
limiting factor.
143
PLATFORM
APPROX
RANGE
CREW
CAPACITY
(stretchers)
WEIGHT
MAX
OXYGEN
CAPACITY
ELECTRICS
4 seat
capacity total
CPAV
N/A
Non
Emergency
Crew x2
1
4 seat
capacity total
HATS
N/A
Non
Emergency
Crew x1
Critical Care
Nurse x1
4 seat
capacity total
1
318kg
stretcher full
height
450kg
stretcher
trundle
500kg tailgate
loader
230kg 'New'
50E trolleys
6560L Fixed
(2xD's)
980L Portable
(2xC's)
240 AC
12 DC
3280L Fixed
(2xD's)
1640L
Backup (1xD)
980L Backup
(2xC)
490L Portable
(1xC's)
240 AC x 6
EQUIPMENT
MRX
NIBP, ECG, SpO2,
Defib.
ETCO2, 12 lead ECG
ACLS
Equipment/Drugs
2 Infusion pumps
Non Invasive Phillips
MRX
NIBP, ECG, SpO2,
Defib.
Basic Airway, LMA's
Non Invasive Zoll M
Series
NIBP, ECG, SpO2,
Defib.
External Pacing
ACLS Airway
Equipment
RESTRICTIONS
OXYGEN USAGE
VENTILATORS
Light and sirens only in
special clinical settings.
Authorised by AV
Clinician.
Light and sirens only in
special clinicalsettings.
Authorised by AV
Clinician.
07-2400 Weekdays.
10-2200 Weekends. No
Public Holidays.
144
FlightPM
X
Road MICA
X
X
X
Flight MICA
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Infusions and Drugs: See CPGs for detailed information
Cardiac Pacing
Blood Transfusion on authorisation
Management of ICC / USWD
12G chest drain
Invasive pressure monitoring, iStat,
Radial Art line insertion
Intraosseous infusion
ETCO2
12 lead ECG
IV access, ECG, SpO2, Temp, non invasive BP monitoring
Mechanical Ventilation (incl NIV)
Rocuronium (Vecuronium, Atracurium)
NMB: Suxamethonium, Pancuronium
Propofol, Ketamine
Post ETT, Sedation / Analgesia (Fentanyl, Morhine, Midaz)
Cricothyroidotomy
Oro & Nasopharyngeal, LMA, BVM, Suction
Outline of MICA and Flight Paramedic Skillsets X
X
X
X
X
X
X
X
X
X
145