Decisions made by transport teams may not always appear sensible to referring and accepting hospitals. Many factors impact those decisions, including safety concerns, available resources, geography, traffic and weather.
While the rationale of transport team decisions may not be transparent, these decisions are made based on the best data available at the time of transport.
Safety concerns
Safety during transport is paramount and includes not only the patient and family but also the team and public at large.
Questions concerning mode of transport often are raised. Many factors are considered when deciding whether a patient should be transported by air or ground. If ground transport is selected, the use of emergency warning devices is an option. The efficacy of these devices must be balanced with the risk of their use. Public safety should be considered in all cases.
Availability of resources
If there are multiple transport requests concurrently, available modes may be limited. Multiple requests also can affect estimated time of arrival, but this may not be transparent to referring physicians.
The level of care being provided and resources available in the referring center also are crucial. In addition, each team may identify “significant diagnoses” or “anticipated emergencies” that require a standardized approach.
The anticipated trajectory of illness from the perspective of the critical care physician is important as well. For instance, a patient with limited intravenous access who has early signs of sepsis but the potential to progress rapidly to septic shock may receive accelerated attention. Meanwhile, a child with diabetic ketoacidosis with no signs of neurological deficit in a center with imaging resources may not receive the attention anticipated by the referring staff.
Environmental issues
The amount of time the patient will require management in a less-than-ideal environment also is a consideration. Factors include weather, geography, distance and traffic.
In some urban areas, traffic patterns and time of day necessitate air transport. In some rural areas, terrain and distance are more pressing concerns. Ground transport may be selected to expand the team or provide better assessment of the patient or specific interventions during transport.
The transport environment is unique. The stress of movement and its potential impact on patients cannot be overstated. No one will dispute the necessity of a secure airway, but the need for additional securing devices and a follow-up radiograph may seem excessive. In a premature infant, the distance between the vocal cords and the carina may be 2-3 centimeters. There is enough vibration inherent in transport that if the endotracheal tube is against the carina, an airway perforation may result.
In the case of a potential difficult airway, the transport team may wait until arriving at the accepting center before intervening so it has access to a difficult airway team including otolaryngology.
The transport carrier and vehicle also may have limited capability for temperature control, partially exposing the infant/child to the elements. Furthermore, simple tasks such as assessment and placement of intravenous lines are not as easily accomplished in a transport vehicle because once the infant/child is secured, mobility and access are limited.
Another consideration is that patients must be NPO for transport. While this usually is not a factor for critically ill patients, transport of a convalescent neonatal patient may be planned between feedings to avoid the need for intravenous therapy.
Communication
The transport of patients is not a benign event for the patient, family, team or public. Most transport professionals are eager to share the nuances of transport with colleagues. Each team may have standardized approaches based on its patient population and transport resources.
Ongoing communication about transport decision-making practices strengthens the relationship among referring centers, transport teams and accepting centers. Good lines of communication ultimately result in improved patient outcomes.
Dr. Stroud and Dr. Price-Douglas are members of the AAP Section on Transport Medicine Executive Committee.
