Safety of Nurse-Managed Inhaled Nitric Oxide During Critical Care Interfacility Transport.

Inhaled nitric oxide (iNO) is an advanced therapy typically managed by physicians and respiratory therapists in order to increase arterial oxygenation and decrease pulmonary arterial pressure. The Johns Hopkins Lifeline Critical Care Transportation Program (Lifeline) initiated a novel nurse-managed iNO protocol in order to optimize the oxygenation of critically ill patients during interfacility transport. This study was a retrospective chart review of adverse events associated with iNO initiation or continuation by Lifeline on patients transported from March 1, 2020, to August 1, 2022. Basic demographic data and adverse events were recorded. Recorded adverse events included hypotension defined as a mean arterial pressure (MAP) < 65 mm Hg, hypoxemia defined as a decrease of ≥ 10% arterial oxygenation saturation measured by pulse oximetry, new bradycardia or tachyarrhythmia, nitrogen dioxide (NO2) levels greater than 1.0 ppm, methemoglobinemia, and cardiac arrest. Fifteen patients were diagnosed with SARS-CoV-2 infection, of which one also had pulmonary emboli, 2 had bacterial pneumonia, 1 suffered cardiogenic shock from occlusive myocardial infarction and were on VA-ECMO, and 2 had significant thoracic trauma resulting in pulmonary contusions and hemopneumothorax. iNO was continued on 10 patients and initiated on 8 patients, 2 of whom were transitioned from inhaled epoprostenol. Hypotension occurred in 3 (16.7%) patients and one (5.56%) of the hypotensive patients subsequently went on to experience new atrial fibrillation with vasopressor titration. No patients developed worsening hypoxemia, elevated NO2 levels, methemoglobinemia, or suffered cardiac arrest. All 3 patients who experienced hypotension were already on vasopressor support and the hypotension resolved with medication titration. This study shows that iNO administration can be safely managed by appropriately trained nurses.

Decision Making and Interventions During Interfacility Transport of High-Acuity Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

OBJECTIVE: There are limited data regarding the typical characteristics of coronavirus disease 2019 (COVID-19) patients requiring interfacility transport or the clinical capabilities of the out-of-hospital transport clinicians required to provide safe transport. The objective of this study is to provide epidemiologic data and highlight the clinical skill set and decision making needed to transport critically ill COVID-19 patients. METHODS: A retrospective chart review of persons under investigation for COVID-19 transported during the first 6 months of the pandemic by Johns Hopkins Lifeline was performed. Patients who required interfacility transport and tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction assay were included in the analysis. RESULTS: Sixty-eight patients (25.4%) required vasopressor support, 35 patients (13.1%) were pharmacologically paralyzed, 15 (5.60%) were prone, and 1 (0.75%) received an inhaled pulmonary vasodilator. At least 1 ventilator setting change occurred for 59 patients (22.0%), and ventilation mode was changed for 11 patients (4.10%) during transport. CONCLUSION: The safe transport of critically ill patients with COVID-19 requires experience with vasopressors, paralytic medications, inhaled vasodilators, prone positioning, and ventilator management. The frequency of initiated critical interventions and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment, critical thinking, and decision making.

Interfacility Transport of the Pregnant Patient: A 5-year Retrospective Review of a Single Critical Care Transport Program.

INTRODUCTION: Interfacility transport of the pregnant patient poses a challenge for prehospital providers as it is an infrequent but potentially high acuity encounter. Knowledge of clinically significant events (CSEs) that occur during these transports is important both to optimize patient safety and also to help enhance crew training and preparedness. This study evaluated a critical care transport program's 5-year longitudinal experience transporting pregnant patients by ground and air, and described CSEs that occurred during the out-of-hospital phase of care. METHODS: This study was a retrospective review of pregnant patients transported by a single critical care transport system into and within a large academic healthcare system. Patients who were pregnant, and were transported from a referring facility to one of the 2 receiving centers within Johns Hopkins Health System between January 1, 2012 and December 31, 2016 were included in this study. The primary outcome of interest was the occurrence of a predefined clinically significant event (CSE) during transport, while a secondary outcome of interest was the indication for transfer. RESULTS: During the study period 1,223 pregnant patients were transported by our critical care transport service. There were 1,101 patients who met inclusion criteria; 693 (62.9%) of whom were transported by ground and 408 (37.1%) who were transported by rotor wing aircraft. The top 3 indications for transfer comprised 71.4% of all patients and included; preterm labor, hypertensive disorder of pregnancy, and other maternal life threatening disorder. The most common events that occurred across all transports were: exacerbation of hypertensive disease requiring intervention (4.5%), hypotension (1.3%), and altered mental status (0.2%). CONCLUSIONS: Incidence of CSEs during the interfacility transport of pregnant patients within our critical care transport system is low (6.0%). Knowledge of the clinically significant events that occur during EMS transport is a vital component of ensuring system quality and optimizing patient safety. This data can be used to augment and focus provider education and training to mitigate and optimize response to future events.