Public Health Emergency Preparedness

Chapter 5. Patient Transport

As described previously, the use of the shuttered hospital would begin 3 to 7 days out from the catastrophic event when patient transport would begin. Transport would need to be completed within a period of hours or a few days under Scenario 1 (medically stable medical-surgical patients), and might continue over the course of weeks during an evolving epidemic under Scenario 2 (infectious disease/isolation). This section discusses transportation needs, including vehicles, drivers, and medical attendants, and regulatory issues related to patient transportation.

5.1 Surge Facility Location and Route

Both assessed shuttered hospitals are located outside the core metropolitan Boston area and thus would likely be outside the area of impact of a chemical release, focal biologic release, or a nonnuclear explosive device. Both hospitals, however, are within 10 miles of Boston's tertiary hospitals, making transportation of patients sufficiently expedient.

The tertiary care hospitals and shuttered hospitals in the Boston metro area are accessible by a number of different roadways. There are numerous surface road route alternatives between the tertiary hospitals and the shuttered facilities so that, even if some roadways were closed, sufficient alternative routes should be available to allow for patient transport.

As outlined in Chapter 2 of this report, both of the shuttered hospitals are readily accessible by public transportation (for staff and families), ambulance, and van. Minor modifications to designated helipad areas could be performed rapidly to permit helicopter landing at each facility, although this would probably not be necessary under either scenario, since medically unstable patients would not be relocated to the surge facility.

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5.2 Preparing Patients for Transport

Appropriately preparing patients and their records and medications for transport may present a greater challenge than the actual transport itself. The critical tasks will involve preplanning the processes for patient discharge from the tertiary facility, patient admission to the surge facility, transfer of medical records and orders, and communication among care providers.

Patient Medications and Supplies. Prior to transfer, there must be an assessment of which medications and supplies each patient will need in the short term at the surge facility and when or whether these materials will be available. These medications probably cannot be transported with the patient and must be sent to the surge facility in advance of each patient's transport.

Patient Records. Transfer of each patient's full medical record will probably not be feasible during the emergency, especially as many of Boston's tertiary hospitals use electronic health records that are not interoperable and there will be no comparable electronic record system at the surge facility. Patients cannot be transported safely to a surge facility without certain pieces of critical medical information, however, and our team of emergency medical experts has devised an abbreviated portable discharge summary that can be created easily and rapidly at the sending hospital prior to discharge. This record would ideally be physically transferred on the patient's person, such as in a necklace binder. The transfer record would include information such as diagnosis, recent care, further care needed, current and prior medications, physician and family contact information, etc. The Patient information chapter of this document explains this transfer record in detail.

Patient Discharge/Transfer. Patients being relocated to the surge facility must be formally discharged from the primary hospital. In addition to the critical actions of preplanning this process for large numbers of patients, there may be additional regulatory requirements for discharge (e.g., patient consent to transfer).

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5.3 Appropriate Transport Vehicles

For the patient populations slated for transport, transportation could be successfully conducted using a combination of buses, ambulances, and wheelchair vans. Our assumptions of how many patients would be transported via each vehicle type are outlined in Table 15. These assumptions vary for the two scenarios, with more patients under Scenario 1 probably requiring BLS ambulance transport.

Bus

The most appropriate patients to be transported by bus would be both medically stable and fully ambulatory. While it may be possible to transport non-ambulatory patients by bus, using backboards or litters, this is not desirable and would probably not be pursued. Buses used for patient transport would need to be staffed by medical personnel as well as drivers. Patients transported by bus who require frequent reassessment of vital signs, for example, would increase staffing requirements. It is not generally feasible to provide significant ongoing medical care or monitoring during transport by bus. Patients requiring this level of care would need to be transported by BLS ambulance.

Under the infectious disease outbreak scenario, careful consideration must be given to which patients are appropriate for bus transfer. Personal protective gear appropriate for the hazard, such as HEPA-filtered respirators, may be necessary for all transport staff.

Ambulance

Non-ambulatory or more seriously ill patients would be transported by ambulance. It is presumed that most of the patients designated for transfer to a surge facility could be transferred by BLS level of staffing during transport comprised of two emergency medical technicians (EMTs). Patients requiring ALS during transport would probably not be appropriate for relocation to the surge facility.

Wheelchair Van

Non-ambulatory patients (those using wheelchairs) who are able to sit in a chair and who do not require continuous monitoring, oxygen or IV lines, could be transported by wheelchair van.

Staffing for Transport of Infectious Patients

Under the infectious disease outbreak scenario, it was postulated that bus and van drivers may not wish to serve in transporting infected patients. While EMTs and paramedics may have a legal obligation to respond while on duty, private drivers cannot be forced to serve. EMS personnel serving with DMATs from other States (from areas not affected by the incident) were identified as one potential source of replacement staffing for transport of patients to the surge facility, although local drivers would be preferable because they know the local roadways.

Vehicle Decontamination

Medical experts on the project team indicated that cleaning and decontamination of vehicles following transport of infectious patients could be readily conducted and should not pose any significant obstacle or challenge.

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5.4 Regulatory Issues

Several important regulatory issues were identified during the patient transport assessment that need to be more fully explored. These issues included clinician communications, privacy of information, patient consent to transfer, exemptions from pre-hospital staffing requirements, and liability.

A thorough review of the relevant regulatory environment in each State should be completed prior to reaching the conclusion that rapid transport of large numbers of hospitalized patients can be successfully achieved.

Recommendation: Patient/family consent to transfer is an EMTALA-related issue that needs to be addressed to permit use of a surge facility.

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5.5 Preparing for Patient Transportation

As neither of the assessed facilities has vehicles or drivers at their disposal, and other shuttered facilities will probably not have these resources, arrangements must be made to procure medical transport vehicles and qualified drivers. It is also important to establish appropriate patient discharge and transfer procedures prior to transport. Details on feasibility, needed actions, and timing for conducting these activities are outlined below. For some of the issues surrounding patient transport, the two facilities we assessed present no barriers and no further action is needed for potential surge capacity use. Site location, roadways to the area, access roadways, vehicle access potential, and patient unloading and facility entry all appear to be satisfactory and no further discussion of these issues is offered below.

5.5.1 Patient Transport Vehicles

It will be necessary to arrange for vehicles, qualified drivers, and EMTs to transport patients from primary hospitals to a surge facility. In reviewing the patient populations slated for transport, emergency physicians determined that patient transportation to the surge facility could be successfully conducted using a combination of buses, ambulances, and wheelchair vans in the ratios presented in the table below. Assuming that 300 patients will be transported, the number of needed vehicles trips was projected and an average round trip time of 2 hours was assumed. This includes the 30 minutes of driving time to and from the facility, and 30 minutes each of loading and unloading time. This allows for completion of 4 trips per vehicle per 8-hour day.

Transit authority officials indicated that a typical transit bus can carry up to 45 passengers. Assuming that medical patients may require more room (i.e., most of a seating row each), this was divided in half to assume 22 bus passengers per trip. Ambulances were assumed to carry one patient per trip; ambulances could possibly transport two patients per trip, one on a stretcher and one on a backboard on the seat, but that was not presumed as necessary for patient transport to a surge facility. Wheelchair van service officials indicated that the average wheelchair van holds three wheelchairs and patients. Given these vehicle capacities, and assuming 8 completed trips conducted over 2 8-hour days, Table 16 lists the number of each of the vehicle types needed to transport 300 patients.

The existing private and public vehicle fleets in the greater metropolitan Boston area vastly exceed the number of needed vehicles. Even though demand for patient transport in the area may still be somewhat elevated 3 to 7 days following a mass casualty event of the size anticipated here, the vehicles needed for patient transport to the surge facility comprise such a small portion of the overall fleet that there should be no shortage of vehicles for this purpose.

For example, approximate fleet information for the greater metropolitan Boston area is as follows:

Buses. The public transit authority serving metropolitan Boston owns approximately 1,000 standard transit buses. This authority also contracts with some of the private bus companies and 250 additional private buses providing service for the transit authority. Private bus fleets, shuttle vans, and school buses are not included in these counts.

Ambulances. There are approximately 1,200 ambulances in service in Massachusetts, about 80% of these private and 20% public. The majority of these serve the more populous eastern portion of the State where Boston is located.

Wheelchair Vans. The City of Boston maintains a fleet of wheelchair vans through the Mayor's Office on Elder Services, and there are also three private nonprofit organizations providing wheelchair van service in the communities immediately surrounding Boston. This creates a wheelchair van fleet of approximately 200 vehicles, not including private wheelchair van services or transit authority vehicles with wheelchair capacity. The private nonprofits are primarily funded through State transportation and community development grants; and wheelchair van fleets may be somewhat lower (per capita) elsewhere in the United States.

As is the case in the metropolitan Boston area, public transit authorities typically have a working relationship with the Fire Department/Local Emergency Planning Committee to provide buses as part of the community's evacuation plans for chemical disaster planning as required under the Federal Emergency Planning and Community Right to Know Act. These coordinated efforts are well-established and predate September 11, 2001. In the Boston area, as would be expected in other U.S. cities, the local transportation authority indicated that they would be willing to provide their vehicles for patient transport to a surge facility. Similarly, the local wheelchair van services indicated that they have a prearranged agreement with the local Fire Departments and would also be willing to transport patients to a surge facility.

Major hospitals often have existing contractual relationships with some private ambulance services (preferred provider agreements), and patient transport to the surge facility could generally fall within the scope of these contracts. Other private ambulance services also indicated that they would be willing to serve in transporting patients to the surge facility, but they would prefer to establish emergency contractual arrangements in advance. Private ambulance services frequently have contracts with the city and if emergency contractual arrangements are to be established, it will be important to avoid competing contractual obligations.

The city public ambulance services will likely not be able to participate in transporting patients outside of the city limits to a surge facility. However, public ambulance services in municipalities or counties that do not have a major hospital, and routinely transport patients outside of their locale to a major hospital, may be able to serve as this is within their ordinary scope of service.

In the event that fleet owners are unwilling to provide vehicles for emergency transport of patients to a surge facility, vehicles could be commandeered under certain circumstances. For example, the Massachusetts public health authority has jurisdiction over ambulances and could commandeer these vehicles. City emergency officials also indicated that they have the authority to commandeer needed vehicles during a catastrophic emergency. Their authority in this regard is stronger if a formal "State of Emergency" has been declared by the Mayor, Governor or President.

5.5.2 Required Staffing Levels for Safe Patient Transport

Medical attendant staffing levels during transport are as follows:

Bus. General medical oversight will be needed, but BLS of two EMTs or ALS of two paramedics will not be required.

Wheelchair Van. At a maximum, the BLS level of two EMTs would be needed for patients transported in wheelchair vans.

Ambulance. Most patients transported by ambulance to a surge facility could be transported under BLS, because we specifically would not be transporting patients requiring intensive care; a very small proportion of those transported might require ALS.

Under emergency conditions in Massachusetts, the State department of public health can issue a waiver that drops the requirement for ALS from two paramedics to one paramedic and one EMT, and in many States there is no requirement for two paramedics for ALS.

5.5.3 Drivers and EMTs

While vehicles can be commandeered in the circumstances outlined above, private drivers cannot be compelled to serve. Public drivers can be instructed to serve as part of their job duties, but they can certainly refuse to perform duties or walk off the job. Essentially, there is no way to force drivers to serve if they are unwilling.

Driver Willingness to Serve. All of these transportation entities discussed in the previous section reported that they were fully staffed with qualified personnel. All of these fleet operators who could provide vehicles were also willing and able to provide their drivers and EMTs for these vehicles under Scenario 1 (noninfectious traumatic casualty event). However, under Scenario 2 (infectious patients), the majority of public and private transport services indicated that they would not ask their drivers to serve, or believed their drivers would not serve. Exceptions to this included a wheelchair van service that reported that all of their drivers were willing to transport AIDS patients during the era when fear of AIDS was at its peak, and the mechanism for infection with AIDS was not yet well understood. This wheelchair van service manager believed Scenario 2 would constitute a similar situation and that his drivers would continue to work

Protection for Ambulance Drivers and EMTs. Private ambulance services in particular indicated that EMTs may not serve in Scenario 2 under current conditions, but that they would serve if their drivers and EMTs were provided with respiratory protection from biological agents. City emergency planning officials and some private ambulance services indicated that they are confident that devices for respiratory protection from biological agents will be provided to all EMTs and paramedics through DHS grants as early as spring of 2005. Currently, public and private EMTs and paramedics are all outfitted with N95 respirators commonly referred to as TB (tuberculosis) masks. These particulate filter respirators are typically of the mask variety, though they can also be cartridge-type. They are protective against TB and also smallpox if they are properly fitted. Facial hair, for example, greatly interferes with the fit and therefore protective function of the mask. OSHA set a separate standard for TB respiratory protection that does not require medical screening (including pulmonary function tests) and annual fit testing procedures beyond the initial fit test. The separate TB standard is controversial, so this waiver on medical screening and fit testing may be overturned.

Respiratory protection devices to be issued under the Homeland Security grants are N100 respirators, commonly referred to as HEPA respirators. These are also particulate filters that protect against a wider array of biological agents as they provide greater removal efficiency than N95 respirators for particulates such as viruses and bacteria. These are cartridge-type air-purifying respirators (APRs) or powered air-purifying respirators (PAPRs). PAPRs provide an even higher level of protection than APRs as they create a positive pressure atmosphere that prevents entry of particulates into the breathing zone if there are any breaches in the respirator seal. Under the OSHA general respiratory protection standard 134, medical screening and formal fit testing are required for use of these respirators.

A key element of planning for the proposed surge facility is to check with local public and private ambulance services on their status in terms of respiratory protection for their EMTs. Under Scenario 2, ambulances may be the only transportation that can be procured, and even these drivers may be unwilling or unable to serve if they are not adequately protected. Fortunately, the necessary protective equipment is becoming available in urban areas throughout the country. It thus appears that drivers and EMTs who require respirators as a prerequisite for Scenario 2 will have this equipment, and will likely be willing to transport patients. Alternatively, such respirators could be added to the list of needed equipment and supplies, for use during the 2 days of patient transport to the surge facility. If drivers do have respiratory protection, the head of the Statewide private ambulance association indicated that he could readily muster 200 to 300 staffed ambulances for the mass transport to the surge facility within the needed time.

Protection for Bus Drivers. Public and private bus companies generally indicated that their drivers would not transport infectious patients. A local transit authority official suggested that Hazmat-trained firefighters outfitted with respiratory protection could drive the buses since they have training and protective gear and are qualified to drive a large vehicle such as a bus since they are qualified to drive a fire truck.

Transportation experts and emergency physicians both indicated that there was no feasible method to create a physical airspace barrier within a vehicle that would separate the driver from the infectious patients and prevent potential disease transmission to the driver, confirming that respiratory protection for the driver is the most feasible option.

5.5.4 Preparing Patients

Patients will need to be discharged rapidly from tertiary hospitals with adequate medical records and short-term orders for use at the surge facility. For this reason, an abbreviated Patient Information Form was developed. This form captures the critical medical information needed for transfer and continued care of the patient, as well as important medical and family contact information, in a standardized format. A detailed description of the form appears in the section on Patient Information, and a sample of the Patient Information Form appears in the Tool Kit accompanying this report.

Emergency transportation experts advise that it would be unwise to transport medications with the patient due to issues with controlled substances, cold storage, etc. Therefore, if a patient requires medications that will not be available at the surge facility pharmacy, these must be transported to the surge facility separately, and in advance of the patient's need for this medication.

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