Retrieval

Retrieval coordination

Case coordination is at the heart of all retrieval systems. As a process, it commences with the initiation of contact from a referral site. Ideally, first contact with a retrieval service should be made prior to arrival at the first hospital—by the primary transport clinicians. It is important for referrers to understand the indications for retrieval and to have clear guidelines (both system and local) to encourage early referral and good decision making. Statewide trauma systems and neonatal paediatric care systems often have well established transfer criteria; however, processes for other clinical groups are often less developed and may be ad hoc . Mature retrieval systems act as a single point of entry for the referrer, preferably providing services by initiation of a single call to a system-wide phone number. Coordination staff are appropriately qualified senior clinicians, with specialized training and knowledge. Case coordination fundamentally answers: What are the needs of the referrer and their patient? Are the needs for clinical advice, for organization of transport and crew or for assistance in obtaining an appropriate destination for a critical patient? The coordinator must determine quickly and efficiently the planning and intervention priorities for each case. These may be for immediate care or advice, immediate response, destination planning or consideration of complex decisions involving logistics, crew or transport platforms. Coordinators need to display leadership while at all times taking a systems perspective and avoiding tunnel vision or task fixation.

Coordination must be provided through high-performance organizations and, typically, utilizes sophisticated communication technologies, such as multi-party conference calls, telehealth videoconferencing, case recording and comprehensive data management systems.

Coordination of retrieval also implies an ongoing process of communication and feedback with the referrer of case progress, estimated response times and knowledge of patient status changes. During the response and transfer phase, the coordination centre maintains communication with response teams, providing logistic support and mission oversight.

Transport platforms

Retrieval services generally use road, rotary wing (helicopter), or fixed wing aircraft response and transport platforms. For international retrieval missions, commercial larger jet transport is used, and in uncommon settings, aquatic transport platforms may be used. In consideration of platform selection for a mission, clinical factors must be factored first; these will include need for pressurization, need for space for specialized crew or equipment, and patient size. Further factors include urgency (of response or return leg or both outbound and return components), distance to referral hospital, availability of helipads at referral and destination hospitals, and need to minimize the out-of-hospital time for the patient. Heightened risk for patients in transit is experienced during platform transfers (from bed to trolley to ambulance to aircraft stretcher and so on) and, in general terms, in the out-of-hospital setting. Minimization of number of patient transfers and the out-of-hospital time for the critical care retrieval patient are important principles.

Road transport platforms should be specifically designed and fitted out for retrieval purposes to minimize variation (improving crew performance and safety) and the risk of ad hoc unsecured equipment placement. Use of helicopters (with crews of appropriate skill mix) in retrieval response has been demonstrated to improve patient outcomes, particularly patients with severe trauma and others with a need for time-critical interventions. In general, helicopter transfer is considered for retrieval of patients approximately 75 to 175 km from base, with road response used for shorter transfers and fixed wing for longer. These broad recommendations vary depending on road, geography and climatic conditions, and on the performance characteristics and landing options for individual aircraft. Fixed wing transfers have the advantage of providing a (usually) pressurized aircraft, greater speed and comfort, more space and a controlled temperature. Rotary wing aircraft have advantages of door-to-door transfer where helipads exist at referral and destination sites, the primary response capability and the potential to avoid road transport legs, and multiple patient transfers. Road transfer offers spatial flexibility, door-to-door transfer and cost efficiency ( Fig. 29.2.1 ).

Crew

Staff selected for roles in retrieval must meet required professional and personal standards. Critical-care capability is essential and medical staff specialist training in a critical-care specialty is desirable. Similarly, nursing and paramedic staff must be trained to intensive care practitioner level. In addition, all staff must have specific training in management of the retrieval environment, clinical care in transport settings and personal and crew behaviours.

The retrieval environment poses particular risk and technical training regarding platforms, procedures, relevant legislation, communication methods, rescue and escape procedures and equipment performance characteristics is needed. Training in clinical care during retrieval needs to ensure capability in management of the complete range of critical care, trauma and intensive care scenarios, and an ability to apply depth of clinical knowledge to the relatively compact window of patient care that the retrieval mission represents. Practitioners need to understand in a retrieval setting that an intervention may be possible and ideal while also being inappropriate and inefficient, or that an intervention may be desirable but not be possible or practical. Compromise and pragmatism have a role in pre- and interhospital transfer particularly, where priority exists for reaching a definitive care destination. Training in personal and crew behaviours is necessary to optimize the cohesiveness and functionality of the retrieval team—formal exposure to crisis resource management tools is a standard component of aeromedical and road-based retrieval education. In interaction with referring practitioners and primary responders, the retrieval team needs to exhibit empathy, listening skills and professional behaviours—avoiding arrogance, premature conclusions or judgmental behaviour. The training and knowledge base required is significant, therefore training processes must be formalized and must be supported by ongoing professional development and regular credentialing in addition to compliance with relevant regulations.

Crew safety is paramount, so personal protective equipment and clothing which meets aviation and ambulance service standards is mandatory. Safety risk arises also in long and overnight missions, and crewing must be adequate to allow sharing of clinical vigilance duties and patient interventions at times of fatigue and to allow for adequate breaks and rest.

Retrieval services play a major role in disaster response and management and generally provide a significant component of the early response to such incidents. Retrieval services and, in particular, their coordination processes are also key to the distribution and reception phase of the disaster response—providing system overview of capability and capacity of health services to receive victims. Retrieval staff must therefore be trained to expert status in this discipline.

Skill sets

Retrieval medicine and primary response aeromedical settings provide the most challenging of all clinical environments, and therefore, choice of staff skill sets and professional team makeup is fundamental to optimizing clinical outcomes. The central tenets of this clinical environment are that a critical-care retrieval team must consist of (at least) two professionals. They must be trained to critical-care standard and work within their core scope of practice. The skill set they provide must meet the clinical needs of the patient. In most national and international jurisdictions, blended medical practitioner and paramedic or nursing crews satisfy these tenets. Significant literature supports the role of medical practitioners in this environment due to the additional diagnostic capability, procedural range, extent of knowledge and depth of clinical understanding they contribute. Such skills are complemented by the skill set of critical-care-trained nursing staff. Paramedic staff contribute substantial critical-care capability (depending on individual jurisdictional training levels) together with expertise in the transport and pre-hospital scene environments. Crews composed of paramedic or nursing staff paired in various combinations and without a medical crew member are inappropriate for high-risk critical-care transfers, intubated critical care transfers or patients requiring significant cardiovascular and/or respiratory support. This level of crewing creates unacceptable safety, quality, governance and risk exposure; retrieval systems must be designed to ensure continuity of standards or to increase the quality of care provided during transfer. Such system and governance design principles are not lost in hospital governance and quality frameworks and are equally applicable in the pre-hospital and retrieval setting. The skill set needs to match the requirements of the patient in the basic dimensions of clinical complexity and physiological stability, with the more unstable and complex patient clearly requiring a higher skill mix in the retrieval team. In rare situations, and where life-saving intervention may be possible, the transport of highly specialized clinical staff to the patient may be appropriate and should be considered—for example, transporting a surgeon to perform an infield amputation on an entrapped patient ( Fig. 26.2.2 ).