Hospital-to-hospital transportation of patients in the COVID-19 era presents unique challenges to ensuring the safety of both patients and health care providers. Crucial factors to address include having adequate supplies of protective equipment and ensuring their appropriate use, defining patient care procedures during transport, and decontamination post-transport. Transport vehicles need to have adequate physical space, an isolated driver compartment, NS HEPA filtration of air. Having a standardized intake process can help identify patients who would benefit from transport to another facility.
Introduction
Transport of critically ill patients with COVID-19 presents a unique challenge given the risk of transmission for the disease. Most often, patients are transferred from one hospital to another for specialized services or a higher level of care.
Communication and preplanning are key elements to ensure safe transport of these patients and to minimize risk of disease transmission to the transport personnel. Items to consider at intake include necessity of transport, ideal destination facility and unit type, and duration of transport or out-of-hospital time. Subsequent planning includes appropriate use and type of protective equipment, patient care procedures during transport, and decontamination post-transport.
Cleveland Clinic Transport Plan
The Cleveland Clinic critical care transport team (CCT) partnered with the Cleveland Clinic Health System, our vehicle vendors, and the Ohio Department of Health to develop a comprehensive transport management plan for the transport of patients with confirmed or suspected COVID-19 infection. It was finished in about mid-March 2020.
Crucial factors in the plan for the safety of patients and transport personnel include maintaining adequate types and volumes of personal protective equipment (PPE) as well as ensuring that all staff have the appropriate training in regards to PPE management, including donning and doffing. Also needed are patient barriers and device adjuncts based on the patient’s clinical situation. Examples include face masks for nonintubated patients, adding HEPA filters at the ventilator exhalation valve or expiratory port of manual resuscitation devices (such as bag-valve-mask devices), and avoiding any disconnects of the ventilator circuit.
Policies and training modules were implemented to address PPE management and PPE recommendations based on risk in transport. For example, when transporting any patients with suspected or confirmed COVID-19, team members are required to wear a gown, gloves, goggles, and surgical mask. For patients at high risk for aerosolization of infectious material (eg, intubated patients), an N95 mask is required.
Patient transport factors to consider
The environment of the transport vehicle is also an important consideration. This includes having adequate physical space, isolating the driver (or pilot) compartment, providing HEPA filtration of recycled air, ensuring proper PPE, adequate cleaning of the space, and training of all transport personnel.4 Additionally, contingency plans should be in place for patient deterioration or medical emergencies during transport, including having additional PPE available for all transport personnel. Efforts should be made to ensure patient stability prior to transport, with particular emphasis on securing the airway. Having controlled intubation in a closed room will result in less aerosolization and, thus, less risk to caregivers versus intubation in a transport vehicle.
Collaboration between the Cleveland Clinic CCT and Cleveland Clinic Institutes and vehicle vendor partners has been crucial to ensuring seamless and safe transport of patients during the COVID-19 pandemic. The CCT provides care in a variety of environments ranging from the emergency department and intensive care unit transfers to prehospital requests with outside emergency management service (EMS) agencies.
Establishing a process for transfers
To standardize the intake process and ensure protection of all health care providers involved with a patient transfer, the CCT clinical coordinator routinely screens all transfer patients with a short COVID-19 screening questionnaire at the time of transfer request. As it is often not possible to obtain substantial patient-specific details for EMS or other out-of-hospital transfers prior to on-scene arrival, and due to the urgent and unpredictable environment while on scene, all of these patients are treated as potential COVID-19 cases and managed appropriately.
Additional modifications to the hospital transfer and CCT inter-facility transport request process have been implemented due to the risks of COVID-19 transmission. Cleveland Clinic has an external hospital transfer workflow protocol for patients with COVID-19 to help identify which patients may benefit from treatment or therapy otherwise unavailable at the referring facility (including referring capacity issues).