Land, sea, air or which way do we go?
Potpourri
Level of Service
See no evil, hear no evil, smell no evil (when or how to use telemedicine)
Floperations
Clinical Connundrums in Transport
100
This is the primary air ambulance vendor used by Kaiser Permanente in Northern California.
What is Reach Air Services?
100
Over the last 4 years, this Kaiser PICU has had an increasing volume of transported patients
What is Roseville? Based on VPS Transport Data
100
5 PART ANSWER....100 PTS PER ANSWER. ALL OR NONE!
These are the existing levels of service of transport for pediatric patients
What are BLS, ALS, Critical Care Transport, Private Air Services, Pediatric Hospital Based Critical Care Transport Team?
100
This was the first service in TPMG to make use of inpatient Telemedicine carts.
What is Pediatric Inpatient Services? This was initiated by Stevan Cavalier in 2012. The original pilot started at Oakland and Santa Clara with each facility responding to 3 ED's. The initial small pilot had 44 cases total and demonstrated 8 avoided intubations. Other clinical benefits and improved communication was found.
100
It is recommended to do this in the case of quality and safety issues involving ambulance transport.
What is send an eRRF? This helps with tracking of transport problems and allows identification of concerning trends. Data can be used to highlight issues and develop solutions.
100
A patient is being transported from Modesto by a critical care team for Diabetic Ketoacidosis. In route, patient starts to become somnolent, then slurs his words and becomes less responsive. What is your next step?
What is administer mannitol or Hypertonic Saline. Communicate with your receiving PICU and determine if you can safely make it to the facility, if you should pull over, divert to a closer ED, or go straight to CT.
200
You are called by the Modesto ED with a 8 month old with an epidural hemorrhage on a Friday night. The ED physician requests transport. What mode (air vs. ground) of transport should you use?
Air, based on distance and acuity. The goal is to get a patient into the OR within 4 hours, which may be difficult due to traffic conditions.
200
Your transport team is picking up a 5 day old infant with a ductal dependent lesion. Your team must bring this medication with them or confirm that the sending has it available.
What is PGE? One study noted that 30% of hospitals do not carry this medication.
200
If a patient needs cardiorespiratory monitoring, they should not go by this level of care.
What is BLS?
200
You are called by a pediatric clinic to help with urgent stabilization. You instruct the clinic to call 911 and the MA leaves to do this. The doctor is pleading for help and asks about video support. You do this next.
What is use you Kaiser iPhone to call the physician by clinician connect to do a video consult and help walk them through the clinical scenario until an ambulance arrives?
200
General late performance of ambulances in region has lead to 20-25% late ambulance, depending on service level. KP Regional EMS Services have chosen to focus first on the most severe issues. You should escalate to the hub immediately for transports that are this number of minutes late.
What is 60 minutes? This metric is measured from the time of first ETA.
200
This device is used for this clinical problem
What is respiratory distress? This is a portable high flow nasal cannula device that can be used to support patients with bronchiolitis, pneumonia, and asthma.
300
REACH air services uses Bubble CPAP in place of what respiratory modality
What is High Flow Nasal Cannula? RAM Cannula can also be used with a ventilator on a Non-Invasive mode.
300
DAILY DOUBLE
VPS stands for Virtual Pediatric Systems and is a National administrative database for PICU's.
According to VPS Data, Kaiser PICU's generally admit more patients from this referral source as compared to the National VPS reference group.
What is an outside ED?
300
An ED doctor calls about a 2 yo asthmatic with a severe level of distress. He says he has followed your joint asthma protocol and administered magnesium, epinephrine, a terbutaline drip. He is on 20 mg/hr of continuous albuterol. What is the appropriate level of care for this patient?
It depends,
Pediatric internal pediatric critical care team if available.
CCT is an option,
Consider speaking with the dispatch center to contact the CCT-RN about comfort level. Reach Air ambulance is competent but extremely costly.
300
Video Teleconsultation is used in this % of transport intake calls.
What is 10-15%. Data is collected from Electronic Pediatric Intake Transport Notes.
300
Delivery issues with this specific medication has lead to clinical quality and safety issues, especially in the north valley.
What is albuterol? Continuous albuterol has been the most problematic. EMS Vendors have been asked to deliver the medication from bedside to bedside. A Vacaville performance improvement project has lead to RT to transport team handoffs of a 4 hour supply of albuterol. Alternate transport teams have also been used instead of county EMS CCT-RN teams
300
DAILY QUADRUPLE- CHARADES! YOUR TEAM MUST ACT OUT THE ANSWER IN CHARADES IN A SIMULATED AMBULANCE. YOU NEED 2 EMT'S, AN RN, AN RT, AN MD AND A PATIENT TO ACT OUT THE ANSWER. USE YOUR CHAIRS AS PROPS.
A 6 yo male with pneumonia and respiratory distress and hypotension is being transported by your Kaiser Pediatric Critical Care Team. You are on the freeway traveling at a high rate of speed. The patient is currently on High Flow Nasal Cannula, but having desaturations. An I-stat gas shows a VBG of 7.13/65/45/-14. You do this next.
What is speak with your team and have the ambulance pull over to intubate the patient? Attempting to intubate the patient while the vehicle is moving is unsafe for the crew and patient and will decrease the chance of first pass success.
400
This external factor can dictate the safety of AIR transport?
What is the weather? Snow, thunderstorms, high winds, poor visibility all cause issues.
400
You are a hospitalist at a non-tertiary pediatric center and you are consulting on a bronchiolitis patient in the ED. It is winter and bed availability is sparse. When presenting a patient for potential transfer to a tertiary care site, the accepting physician doesn't feel the patient meets admission criteria. You are concerned that the child is sick enough to be hospitalized. You decide to do this next.
What is use telemedicine to look at the patient together to develop a shared mental model of the clinical scenario?
400
This level of transport is used in lieu of CCT-RN Transport Solano county.
What is ALS-RN in Solano County? It is designed to limit the use of CCT-RN and is probably somewhere between ALS and CCT-RN. The RN staffing the ambulance is typically an ED RN, but they may lack appropriate critical care experience.
400
DAILY TRIPLE-
Surprise! Have someone on your team share a patient story about telemedicine leading to improved quality, safety, or care experience.
What is your story?
400
You have accepted a 6 month old with bronchiolitis for admission to your ward. The patient has been stabilized on high flow nasal cannula. The ED Doctor said his department has been transporting kids on HFNC by CCT-RN. You respond by saying this.
What is "It is not a national standard for EMS ambulance services to provide HFNC." This has been confirmed by TPMG and KFH leadership in Northern California. Let's arrange a Pediatric Critical Care Team or Use REACH." ?
400
You have just pulled over to intubate a 6 yo male with pneumonia and septic shock. You administer this for RSI
What is ketamine? Consider premedication with atropine.
500
You have a 13 yo patient with known Marfan's who has an ascending aortic dissection in the Roseville ED. The patient has been accepted to Lucille Packard Children's Hospital. They suggest sending their air transport. This mode of transport is fastest and safest in this scenario.
What is use a Pediatric Critical Care Ground Team? Both Oakland and Roseville do not have helipads. Arranging for a landing zone is complex and requires a secondary ambulance transport from the landing site. This may affect the speed advantage that is perceived to come from air transport.
500
A patient is currently in a Kaiser ED and has burns that encircle the entire chest wall. The total body surface is estimated to be 20%. This is the most appropriate disposition for this patient.
Burn and Trauma are universally referred out. There is a regional burn specialist, Dr. Ikeda, a plastic surgeon out SSF, who will assist with recommendations for burn patients.
500
This mode of respiratory support is only available by Children's Hospital Based Pediatric Critical Care Teams
What is High Flow Nasal Cannula?
500
This facility has both a unit based telemedicine cart to request PICU support, and a receiving base station to take telemedicine calls from outside ED's
What is Walnut Creek? A pilot started earlier this year at Walnut Creek for a collaboration between Oakland and Santa Clara and so far has lead to some early successes. Walnut creek recently obtained a base receiving station for improved communication with Dublin Urgent Care.
500
Your transport team goes to an outside ED to pick up a 10 month old infant with periorbital cellulitis. When the team arrives, they find that the patient is in septic shock. They request an epinephrine drip from the ED. The ED physician disagreed and refused to give the drug. The sending facilitated justifies this action by saying this.
What is the sending facility is not required to supply the transport team with medications if they belief it is not medically indicated? The sending facility carries liability for the patient. In this real world example, the team did have a vasopressor in the team kit and administered the medication themselves prior to leaving the outside ED. Transport teams should consider this scenario and decide what types of medications they need available to them and in what scenarios this may be needed.
500
You are transporting a 6 yo male with pneumonia and septic shock. You have just pulled over to intubate the patient. After intubation the patient above has a drop in blood pressure to 70/30. Extremities are cool and cap refill is 2 seconds. There is equal aeration, chest rise, and no tracheal shift. The patient has received 3 20 ml/kg boluses prior to intubation. Your team does this next.
What is start a inotrope/vasopressor? The agent of choice in this situation is epinephrine due to the presence of cold shock.