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Quality of Inter-Hospital Transportation in 431 Transport Survivor Patients

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Quality of Inter-Hospital Transportation in 431 Transport Survivor Patients Blecha et al. Ann. Intensive Care (2018) 8:5 https://doi.org/10.1186/s13613-018-0357-y RESEARCH Open Access Quality of inter‑hospital transportation in 431 transport survivor patients sufering from acute respiratory distress syndrome referred to specialist centers Sebastian Blecha1* , Frank Dodoo‑Schittko2, Susanne Brandstetter2, Magdalena Brandl2, Michael Dittmar1, Bernhard M. Graf1, Christian Karagiannidis3, Christian Apfelbacher2, Thomas Bein1 and For the DACAPO Study Group Abstract Background: The acute respiratory distress syndrome (ARDS) is a life-threatening condition. In special situations, these critically ill patients must be transferred to specialized centers for escalating treatment. The aim of this study was to evaluate the quality of inter-hospital transport (IHT) of ARDS patients. Methods: We evaluated medical and organizational aspects of structural and procedural quality relating to IHT of patients with ARDS in a prospective nationwide ARDS study. The qualifcation of emergency staf, the organizational aspects and the occurrence of critical events during transport were analyzed. Results: Out of 1234 ARDS patients, 431 (34.9%) were transported, and 52 of these (12.1%) treated with extracorpor‑ eal membrane oxygenation. 63.1% of transferred patients were male, median age was 54 years, and 26.8% of patients were obese. All patients were mechanically ventilated during IHT. Pressure-controlled ventilation was the preferred mode (92.1%). Median duration to organize the IHT was 165 min. Median distance for IHT was 58 km, and median duration of IHT 60 min. Forty-two patient-related and 8 technology-related critical events (11.6%, 50 of 431 patients) were observed. When a critical event occurred, the ­PaO2/FiO2 ratio before transport was signifcant lower (68 vs. 80 mmHg, p 0.017). 69.8% of physicians and 86.7% of paramedics confrmed all transfer qualifcations according to requirements= of the German faculty guidelines (DIVI). Conclusions: The transport of critically ill patients is associated with potential risks. In our study the rate of patient- and technology-related critical events was relatively low. A severe ARDS with a PaO­ 2/FiO2 ratio < 70 mmHg seems to be a risk factor for the appearance of critical events during IHT. The majority of transport staf was well qualifed. Time span for organization of IHT was relatively short. ECMO is an option to transport patients with a severe ARDS safely to specialized centers. Trial registration NCT02637011 (ClinicalTrials.gov, Registered 15 December 2015, retrospectively registered) Keywords: Inter-hospital transfer, ARDS, Quality of care *Correspondence: [email protected] 1 Department of Anaesthesiology, University Medical Centre Regensburg, Franz‑Josef‑Strauss‑Allee 11, 93053 Regensburg, Germany Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Blecha et al. Ann. Intensive Care (2018) 8:5 Page 2 of 9 Background transport duration, the qualifcation of transportation Te acute respiratory distress syndrome (ARDS) is a life- personnel, technical equipment, ventilation parameters threatening condition characterized by either direct or and the incidence of critical events were recorded. indirect damage to the lung parenchyma often causing critical hypoxemia and/or hypercapnia [1]. Te mortal- Methods ity for ARDS remains high between 30 and 60% despite Study design and sample all the progress made in intensive care during the last We observed the quality of IHT in patients with an ARDS decades [2, 3]. Te management of this severe disease at in the context of a large Germany-wide prospective specialized intensive care units (ICU) is a resource-con- cohort study (DACOPO study [11], ClinicalTrials.gov suming process that requires a specially qualifed team, Identifer: NCT02637011). Briefy, the DACAPO study a high-technology standard and sophisticated treat- investigates the infuence of quality of care and indi- ment strategies to provide life-sustaining therapy [4]. vidual patient characteristics on HRQoL and return to Healthcare research in the feld of critical care medicine work in survivors of ARDS. Te study has been approved is relatively new, and data on the infuence of organiza- by the Ethics Committee of the University of Regens- tional structures or processes of care on mortality or burg (original approval: December 2013, approval of an health-related quality of life (HRQoL) in ICU survivors amendment: June 2014; fle number 13-101-0262) and are of growing interest [5, 6]. Not all of these critically ill (if necessary) by Ethics Committees of the participating patients with an ARDS are treated primarily in a special- study centers. Te inclusion criteria for enrollment of ized center and, thus, eventually experience inter-hospi- patients were the presence of an ARDS according to the tal transfer (IHT). Berlin defnition [12] and being 18 years of age or older. In Germany, the frequency of IHT has grown consider- Written informed consent was obtained from caregivers/ ably in recent years and will steadily increase as a result legal guardians and additionally from those patients who of the expansion of specialized centers. For example, in survived ICU. ARDS patients were included in the study the southwestern part of Germany the number of IHTs after admittance to one of the participating hospitals, and rose by 9.4% from 2014 to 2015 [7]. As a consequence, data on transport were collected retrospectively. Mor- the health expenditures for patient transports were tality during transportation could thus not be analyzed. increased each year and for Germany overall costs rose to Eligible patients were enrolled in 34 receiving hospitals 5.94 million Euros in 2013 [8]. all over Germany in the period from September 2014 to Te IHT is a secondary transport from one institution April 2016 (N = 1234). Te health status of all transferred of initial or standard care for further therapy to an insti- patients who had been treated before in a referring hos- tution of advanced and/or maximum care, while main- pital was retrospectively assessed for the period of their taining the intensive medical therapy already in progress stay in this hospital and for the period during inter-hos- [9, 10]. In this context, the IHT is synonymous with the pital transport. In the following, the examined aspects term intensive care transport. Te decision to trans- of the structural-, process- and outcome-related quality port an ARDS patient is based on an assessment of the with regard to IHT are explained. potential benefts of transport weighed against the poten- tial risks. Te transport must be as safe as possible and Measures should not pose additional risks. Sociodemographic and clinical parameters In Germany, IHT is conducted regularly by the author- Te following sociodemographic and clinical parameters ized organizations of the Emergency Medical Services were assessed: age, body mass index (BMI), distribution (EMS) coordinated by the local Emergency Medical Dis- of severity of ARDS, cause of ARDS, applied oxygen frac- patch Center (EMDC). Standard EMS vehicles do not tion (FiO2), positive end-expiratory pressure (PEEP), provide special intensive care equipment. ARDS patients concentration of applied continuous infusion of norepi- require continuous monitoring and expanded intensive nephrine (noradrenalin), sequential organ failure assess- medical equipment (e.g., for lung-protective mechanical ment (SOFA), use and duration for implementation of ventilation) and accordingly staf trained in intensive care extracorporeal membrane oxygenation (ECMO) and type medicine. Tese critically ill patients should be trans- of used respirator. Te clinical parameters of patients ferred with special vehicles such as intensive care ambu- before transport were stated in the morning of the trans- lances (ICA) or intensive care helicopters (ICH). portation day. In this study, we assessed the quality of IHT in trans- port survivor patients sufering from ARDS referred Structural quality of IHT to specialized centers in a Germany-wide multicenter Te structural quality of IHT can be determined on the study. In addition to the means of transport used and the basis of technical and human resources. In Germany, Blecha et al. Ann. Intensive Care (2018) 8:5 Page 3 of 9 technical equipment of rescue vehicles is standardized Due to the specifc requirements of intensive care trans- by Germany’s national standards body (DIN norms) and ports, the responsible paramedic also must have an addi- European Committee for Standardization (CEN norms), tional qualifcation [13]. We assessed the following items respectively. Te qualifcation of the EMS staf for IHT (yes/no): is recommended by the provisions of the German Inter- disciplinary Association of Critical and Emergency Care 1. Professional qualifcation: paramedic Medicine (DIVI: Deutsche Interdisziplinäre Vereinigung 2. At least 3 years in an emergency service in a full-time für Intensiv- und Notfallmedizin) and German Confed- or a time comparable to professional experience eration of Associations of Emergency Physicians (BAND 3. Attending a 20-h course “intensive
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