Intensive Care Transport second edition

Editors:Huf/Munich,P.Sefrin/WĂźrzburg and M.Weinlich/Filderstadt Š Journal Verlag GmbH,TauerntalstraĂ&#x;e 6,A-9971 Matrei in Osttirol,Austria,Printer:Carinthian Bogendruck GmbH/Klagenfurt No copyright owner can be named for photos that were left to the publisher without naming the author.

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Cover pictures:PIX,R.Huf,Braun Melsungen Medicine is an ever-changing science driven by new research and clinical experience.

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R.Huf/P.Sefrin/M.Weinlich (editors)

Intensive CareTransport Second edition

Journal Verlag

INTENSIVE CARE TR ANSPORT

Preface The world of hospitals has changed beyond recognition due to the changes in hospital financing and ongoing development in high performance medicine. A reduction in the number of beds due to the closure of small hospitals,the development of centres of excellence at all levels of care and the resulting centralisation of technical equipment and human resources all lead to increased interconnectedness and co-operation with regard to hospital units and integrated care.

Alongside many other prerequisites, optimised information technology and, most importantly, the best possible transport systems are the basic requirements to achieve the best possible care for the maximum number of patients in this situation.

This book by authors Huf, Sefrin and Weinlich and now in its second edition, considers all aspects relating to the transporting of intensive-care patients. Since the transporting of intensive-care patients has a long history in Germany,today’s methods of transporting intensive-care patients are not really emergency solutions, instead they provide the most versatile intensive-care supervision and treatment. This enables patients to be transferred with the utmost safety to a more specialised unit or back to a more general unit. Each chapter clearly emphasises the need for a wide range of requirements and preparatory work in high performance medicine,from administration,organisation and legal matters to staff and equipment. This leads naturally into the medical area where, depending on the clinical picture, highly specialised aspects of intensive-care treatment and transporting conditions must be taken into account. However,the book also reveals that it has only been possible to further develop this area because of the many emergency doctors and intensivecare medical staff and even more because of doctors going beyond the call of duty in the specialised field of transporting intensive-care patients.

With this outstanding group of authors,the publishers have succeeded in incorporating theory and personal experience to produce a book that offers practical help in everyday applications. I therefore hope that this book will gain respect and a wide circulation both in the field of medicine and health policy!

Prof.Dr. K.-W. Jauch

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Preface The transfer of severely ill and intensive-care patients has taken on an increasingly important role in recent years.The different classification of hospitals into sites providing primary and standard care to clinics providing the maximum range of treatments and care requires very different equipment and personnel resources.Consequently serious illnesses can no longer be treated in every hospital. However, in order to provide patients with the best possible diagnostic and treatment facilities individual hospitals offering different levels of care must be interlinked so that, if necessary, the required facilities can be made available to every patient.The possibilities of information technology have been increasingly used in recent years in order to support these links.Nevertheless a considerable percentage of patients still have to be transferred to hospitals which are the most suitable for them. In the case of the most seriously ill patients such a transfer must of course only take place take in a risk-adjusted manner,i.e.under intensive-care conditions if necessary.

Germany has a long history of transferring severely ill patients,which is inseparable from the development of the emergency services. If the previous, rather sporadic, operations are compared with today’s very differentiated and subtle intensive-care transfer possibilities, one cannot fail to be impressed by the rapid developments that have taken place in this sector.Transfers that once seemed inconceivable, nowadays take place routinely with great precision and success.

Modern means of transport have equipment which is equal to that of a fully-equipped intensive care ward in almost every way.

In order to arrive at the situation as it is today, considerable development work was necessary, both in terms of equipping the means of transport and the scientific evaluation of the transfers. Thanks to years of intensive work it has been possible to define the necessary requirements in respect of apparatus, personnel and contents. In doing so it has been shown that the extent of the problem is very broad and that in addition to organisational considerations a great deal of importance is attached to administrative,legal and medical aspects. However,it has also been shown that the success of such transfers is dependent on thoroughly thought through logistics.Ultimately the same phrase that was once formulated for flying also applies to intensive-care transfer: „Proper preflight planning prevents poor performance.“ Everyone involved in intensive-care transfers should take these “6 Ps”to heart.

In this book it will be attempted for the first time to fully summarise the possibilities and limits of the secondary transfers, i.e.with regard to the aforementioned differing aspects.The publishers have succeeded in presenting an extremely interesting subject through authors who not only have the theoretical knowledge but also extensive personal experience.The result is a book which through practice-related portrayal of the individual topics provides both a valuable aid for everyday use as well as a important document for planning and development In this respect it is hoped that this book will achieve a wide circulation.

Prof.Dr.Dr.h.c.F.W.Schildberg

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INTENSIVE CARE TR ANSPORT

Table of contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Organisation and tactical employment of intensive care transports . . . . . . . . . . . . . . . . . . . . . . . .11 Legal principles of inter-hospital transfers/ intensive-care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . .12 P.Hennes,Mainz Organisational principles and aspects relating to the practical implementation of intensive care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 R.Huf,E.Weninger,Munich Requirements for means of intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Standards for the ground- and air-assisted transport of intensive care patients . . . . . . . . . . . . . . . . 34 P.Knuth,Wiesbaden Details on the suitability and use of stationary equipment in intensive-care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 R.Huf,E.Weninger,Munich The specific challenges of transport trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 H.Reichle,Munich Personnel requirements for intensive-care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 R.Huf,E.Weninger,Munich Equipment for intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 Mechanical ventilation devices for intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 C.Metz,Regensburg Monitoring on intensive care transports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 J.Beneker,C.Brodel,Berlin

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Presentation of different means of intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Inter-hospital transfer in an intensive-care vehicle (ICV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 F.W.Spelsberg,Munich Bell 412 HP as ITH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 R.Huf,E.Weninger,Munich Eurocopter BK 117 as ITH (intensive-care transfer helicopter) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94 R.Jaki,Gerlingen Eurocopter EC 145 (BK 117 C 2) as Intensive-Care Transport Helicopter . . . . . . . . . . . . . . . . . . . . . . . .96 R.Huf,Munich Means of transport for intensive-care transfers – MD 900 / MD 902 . . . . . . . . . . . . . . . . . . . . . . . . . .98 T.Reinhardt,H.-J.Hennes,Mainz Airbus A310-300 MRT as intensive-care transport aircraft for the Bundeswehr (Fed.Armed Forces) . .100 B.Hossfeld,L.Lampl,Ulm Sikorsky CH53G as Medical Transport Helicopter for Special Assignments . . . . . . . . . . . . . . . . . . . . .106 B.Hossfeld,L.Lampl,Ulm Secondary Transports in Austria:EC 135 as Intensive Care Transport Helicopter (ITH) . . . . . . . . . . . .108 H.Trimmel,Wiener Neustadt The Challenger (CL) 604 as an intensive-care transfer aircraft (ICA) . . . . . . . . . . . . . . . . . . . . . . . . . .113 T.Burren,Zurich The Learjet 35 A as an intensive-care transfer aircraft (ICA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117 M.Mühlmeyer,J.Braun,Filderstadt Means of intensive-care transport - DO 328 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 M.Pedevilla,D.Egger-Büssing,Innsbruck Transporting intensive care patients on board Deutsche Lufthansa’s long-haul fleet . . . . . . . . . . . .124 D.Ehring,L.Bergau,Frankfurt Special features of intensive care transports with aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127 The Physics of the Atmosphere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128 R.Huf,E.Weninger,Munich Pressure related problems – procedures and avoidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132 H.Reichle,Munich

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Heliports at hospitals – legal principles and their implementation in practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137 G.Carloff,Sankt Augustin Landing sites for helicopters – selection and preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146 R.Maier,Munich Selected clinical pictures at intensive care transports and special features of transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149 Intensive-care transfer of critical patients – special factors in the case of cardiovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150 P.Rupp,J.Hesse,Ch.Peters,R.Stiller,Bern,Munich Intensive care transport and special features of the transport of thoracic patients . . . . . . . . . . . . . .163 H.-G.Koebe,Kassel Intensive-care transfer and special aspects of transportation in the case of conditions involving vascular surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168 R.Huf,E.Weninger,Munich Selected clinical pictures in intensive care transport and special features of transport, e.g.of patients with acute and chronic pulmonary diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173 R.Löb,Hamm Intensive care transport of patients with special neurosurgical and neurological disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184 E.Weninger,R.Huf,Munich Intensive care transport for polytraumatised patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197 R.Huf,E.Weninger,Munich Intensive care transport of burns patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203 R.Huf,E.Weninger,Munich The transportation of patients with hypothermia and frostbite . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206 S.Poloczek,T.W.Felbinger,Munich,Berlin Selected medical conditions involved in the transport of intensive care patients and transport challenges,e.g. in cases of infection and sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212 W.H.Hartl,D.Inthorn,Munich Hygiene aspects during intensive-care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225 B.Grabein,Munich

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Selected disorders associated with intensive care transports and special transport challenges in paediatric and neonatal patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232 L.Schrod,Frankfurt Selected clinical pictures in intensive-care transportation and special circumstances relating to transportation,e.g.in the case of poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .244 N.Felgenhauer,T.Zilker,Munich Intensive-care transportation of dialysis patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253 W.Samtleben,Munich Medicaments for intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257 Drug therapy during transportation of intensive-care patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .258 E.Weninger,R.Huf,Munich Intra-hospital intensive care transports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277 Intra-hospital intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .278 J.Koppenberg,Scuol Requirements of infusion pump systems with respect to transport within clinics . . . . . . . . . . . . . . .291 R.Huf,Munich Special features of the performance of intensive care transports with special equipment . . . .293 Transporting patients following diving and hyperbaric accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . .294 T.S.Mutzbauer,L.Lampl,Ulm Interhospital transfer with supplementary medical equipment using the example of extracorporeal membrane oxygenation (ECMO) . . . . . . . . . . . . . . . . . . . . . . . .311 R.Finkl,Hausham Intensive-care transportation of patients undergoing supporting treatment with intra-aortal balloon counterpulsation (IABP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .315 P.MÜhnle,F.Weis,Munich Quality management and documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .319 Quality management and documentation in interhospital transfer . . . . . . . . . . . . . . . . . . . . . . . . . .320 M.Weinlich,Filderstadt Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .339 List of author’s addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .355

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INTENSIVE CARE TR ANSPORT

Foreword to the second edition Emergency medicine has changed considerably since the publication of the first edition as a result of political and financial constraints.The transportation of intensive-care patients has been a major factor in this.The committee of health service experts predicted this development three years ago, anticipating a rise in secondary transport, including the transfer of intensive-care patients,given the current political climate.This change has indeed come about in the past few years, highlighting the importance of the issue of intensive-care transport and thereby also the significance of this book.

The hospital landscape has altered as a result of the modernisation of healthcare legislation.Local hospitals providing basic care have been cut back and had their functions revised on cost grounds.Specialisation and concentration have also contributed to the dilution of the in-patient care network.The consequence of this is that many patients need to be transferred to maximum-facility units after receiving primary care,and need to continue receiving intensive-care support during the journey.Increased demand for intensive-care medical transport services combined with the guidelines issued by experts in the Deutsche Interdisziplin채re Notfallmedizin [DIVI;German Interdisciplinary Association of Critical Care Medicine] have set higher standards for the skills which crews operating land-based and airborne intensive-care transport services have to master.This book has been written to support the required training but also as a reference work.

In the light of practical experience we found it necessary to expand both the scope and the content and topics covered.

So as to maintain the same physical size we have had to change the layout, as can be seen from the new font and the smaller gaps between lines.Almost all chapters have been revised,and some have been entirely rewritten.Particular attention has been paid to reflecting changes to the legal and administrative position,while the visual presentation of themes has also been revised.We have had to present new types of air rescue vehicles to reflect changes in the vehicles.A new chapter dealing with hygiene issues relating to intensive-care transport in the light of past experience (MRSA).The increased incidence of resistant germs in intensive-care therapy will affect the way patients are handled during intensive-care journeys.

It has unfortunately not been possible to create a DIN standard for intensive-care vehicles,which would have simplified matters.As a result,different types of vehicles are still in use and are built and fitted out in accordance with their operators' experience.This is why some components are also presented separately.In the absence of a standard, the DIVI and the BAND [Bundesvereinigung der Arbeitsgemeinschaften der Not채rzte Deutschlands,Federal Association of German Emergency Doctors' Consortiums],as expert bodies and opinion-formers,have therefore agreed recommendations for the design and fitting of intensive-care vehicles.

We have also been fortunate to secure the services of expert authors to write the chapters, all of whom have practical experience in the field.

The editors have made every effort to ensure that the content of this second edition reflects the new practical demands of intensive-care transportation.They would be happy to receive any comments and suggestions for improvement.

We thank the publishers for their cooperation and understanding.

Prof.Dr.P.Sefrin / Dr.R.Huf / Dr.M.Weinlich

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ORGANISATION AND TACTICAL EMPLOYMENT OF INTENSIVE CARE TRANSPORTS

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INTENSIVE CARE TR ANSPORT

P. Hennes

Legal principles of inter-hospital transfers/ intensive-care transfers Increasing importance of intensive-care transfers/inter-hospital transfers Few sectors in our present-day society are subject to such extensive specialisation as developments in medicine.We are experiencing advances which even a few years ago were scarcely imaginable, from laser technology in ophthalmology to modern methods of reproductive and transplant medicine, as well as in emergency and intensive-care medicine itself.We are exploring the beginning, the birth, and the end, the death, of our existence with ever more refined methods.Whether these results always lead to success, as a humane objective, is debatable. However, they contain developments which in turn concentrate on the provision of particular diagnostic and treatment possibilities for narrowly confined clinical pictures at a small number of locations, and sometimes even on clinics covering individual countries and continents.

However,this process,which is also just becoming recognisable in Germany,sets in train consequences which must also be dealt with. These include the necessary transportation of the patients involved to a hospital providing a specialised or maximum range of care.Although this also covers the return of the patients to the “home“-hospital ,which will play an increasingly important role in the future in view of the waiting lists which are usually existing and the fact that the “specialist”bed in question has to be filled again as quickly as possible.

In addition to this a choice can and must be made between land-based emergency services for such missions and a possible reversion to airborne emergency services. A further aspect must be taken into account in the current situation - the introduction of the new hospital reimbursement system DRG (Diagnosis Related Group). It is debatable whether there will be more than insignificant changes in the overall number of hospitals and beds.The hard facts of regional or even simply local policy considerations and strategies may often stand in the way of these expectations. What is certain however is increasing competition, a further reduction in admission periods, the fact that hospitals will act as focal points even more than before, and also work together with other clinics and other institutions, such as those for rehabilitation, and also form associations.And last but not least:smaller hospitals will no longer be able to accept all emergencies,or at least not serious emergencies. In certain circumstances this will also lead to changes in the use of emergency doctors and to new concepts of emergency medical care with a centralisation and regionalisation of emergency medical care.The extent to which these developments will involve additional tasks for the emergency services in general, and the field of transfers in particular, can currently only be presumed. However, all those involved must now prepare themselves for this .The possible system changes indicated for emergency doctors will have to take into account that the patient being treated by the emergency doctor will be transported over greater distances, in addition to the logistic problems of rapidly calling out an emergency doctor to the (more distant) deployment location. The significance of intensive-care transport will continue to increase in any case.

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Distinguishing from ambulance service – application of the emergency services laws Assuming that such transportation does not simply represent ”transporation by ambulance”,but forms part of the ”emergency services”sector, the individual state emergency services laws must be taken into account when considering the “legal principles“. Emergency services are not directly included in statutory medical treatment, are also not contained in the relevant “catalogue”of § 27 SGB V and are only “indirectly“ included as a partial aspect through the calculation of the travel costs (which,incidentally,is an anachronism which ought to be dealt with in the long overdue health reform).

Rather,the emergency services are subject to the legislative authority of the federal states as part of “risk aversion”. As a result of this 16 different variants have to be mentioned (which in itself rules out claims of completeness).

Intensive-care transfer and return service When considering this aspect,the (sometimes world-wide) return transportation following an accident or illness abroad should and must be ignored even though these transfers are generally carried out under intensive-care conditions with fixed-wing aircraft and therefore most definitely constitute an “intensive-care transfer”in the sense set out here.However these flights are not covered by the emergency services legislation of the federal states and are also subject to special insurance terms which do not form part of the social insurance system.They must therefore be kept distinct from the “emergency services”forming the basis of this article.

Distinguishing “intensive-care transfer” from “inter-hospital transfer” When discussing this topic further a distinction has to be made between the “mere”transfer of a patient from one hospital to another, which is known as an “inter-hospital transfer”(e.g.as part of normal consultation examinations) and the actual “intensive-care transfer”. Intensive-care transportation involves the conveyance of (emergency) patients whose life is at risk and who require intensive care transfer from a primary care hospital to a clinic providing a specialist or full range of care for further diagnostic and therapeutic measures. However,it does not involve the aforementioned “return” if following these measures further treatment can be carried out at the “home hospital”. In both cases it is predominantly a matter of having to continue the already initiated intensive-care treatment without interruption,i.e.to “take it over”and continue it during the transfer, possibly over greater distances, without negative effects for the patient.

In contrast, an “inter-hospital transfer”can simply be a matter of transporting the patient depending on the initial situation,as the patient “only”has to be looked after during this operation.In more serious cases,however,the patient may have to be accompanied by a doctor and appropriate medical care may be necessary,but not intensive care in the actual sense.Accordingly, to this extent it can also be referred to as an “emergency transfer“.

Absence of demarcation between the various types of operation It must however be expressly pointed out that the necessary demarcation between all the stated possible types of operation is often missing both in theory and in practice in the legislation of the federal states. Further discussion in the article will concentrate on “intensive-care transportation”in the sense of DIN 13050 (Emergency services/terms, September 2002) no.3.51 “Secondary operation”(“Operations to convey patients with appropriate care,including the maintenance and monitoring of vital physical functions from a medical institution or hospital,to or back from medical institutions providing further care).

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Initially two basic hypotheses must be taken into account: Distinguishing from ambulance transfer As part of the so-called “organisational unit”, ambulance transfer forms part of the “emergency services” according to the current and still predominant view.At this point is should be noted that this uniform implementation of both tasks was recently confirmed by the decision of the Court of the European Communities (CUE) in C-475/99 of 25th October 2001 on § 18 clause 3 of the Rhineland-Palatinate emergency services law,i.e.the introduction of a “separation model” is not absolutely necessary,at least in accordance with European competition regulations. However,as has already been mentioned, it is assumed in the following discussion that the field of “transfer” to and from the specialist clinic to be dealt with here does not generally cover “mere”, i.e.purely “attendant”ambulance transfers.Instead it must come under “emergency rescue”in the narrower sense.The difficulties involved in making this distinction will have to be examined.

In its report of September 1996,the structural questions working group of the “Emergency services”committee expressly distinguished between the transfer of emergency patients and ambulance transfers.“Emergency care also includes the transportation between treatment institutions of emergency patients already receiving clinical treatment“.

In its concluding report “Principles for the further development of airborne rescue in Germany“ of March 2000,the airborne rescue consensus group of the “Emergency services” committee reached the conclusion that in the field of airborne rescue the transfer of emergency patients must be strictly distinguished from ambulance transfers.It is even of the opinion that there are no proper instructions and indications for “ambulance transport”within airborne rescue.

Ruling on intensive-care transfers as emergency transfers already available?

Assuming the clear involvement in actual emergency rescue,the second hypothesis could state that these transfers are already regulated and that carrying out “intensive-care transfers”should basically not be problematic.

Despite the range of variants relating to the implementation of emergency transfers,the federal state laws all contain a comparable basic position: • Measures to be taken in the case of emergency patients • Ensuring transportability and • Transfer by emergency vehicle to a suitable hospital or other institution for further treatment This definition of “emergency transfer”should really include intensive-care transport because only the specialist patient group “emergency patient”is inferred within the term intensive-care transfer and not “normal“ patients.Cited number 3.51 of DIN 13050 also clearly assumes the term “emergency patients”by expressly referring to the “maintenance and monitoring of vital physical functions”. Furthermore,nothing is set out with regard to any “conditions”for the patient in question, e.g. reference to his or her age. Incubator intensive care transfers of a newborn baby whose life is at risk are therefore just as much part of this system as the transfer of a child, young person or adult.

The federal state laws do not make any distinctions with regard to the specific time of carrying out the measures either.

Their definition therefore also permits primary as well as secondary operation.

Transportation to a “suitable hospital (or other “institution”) for further treatment”includes transfers to a specialist clinic following initial treatment in a local hospital as well as the transportation of an emergency patient from the accident site directly to a institution providing a full range of care.

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The Hessen state emergency services plan can be used here as an example of this entirely feasible starting point.“Primary care”and the “transportation and treatment of patients whose life is at risk from one treatment centre to another” are expressly given equally ranking in the “core duties” in no. 1.1.1. (Nevertheless,“transfer for consultative care” is also included,i.e.the criticised “mixing”of intensive-care transports and inter-hospital transfers). According to the task description and demarcation set out in the Hessen emergency services law,the emergency services care does not therefore end with the handing-over of the patient to a treatment centre (primary care),but also includes the further transfer of already medically treated patients (secondary transfers).

Seen overall,many federal states assume this basic position and dispense with explicit special regulations for secondary operations/intensive-care transfers.Although certain other federal states explicitly set out that such emergency rescue operations come under emergency transfers, they leave it at that when deciding on this principle.

In the third “variant” the regulations only relate to airborne rescue, whereby it should be emphasized that the corresponding regulations are either to be found in the state emergency service law itself, or, as in most cases, in the state emergency services plan.

Only a few federal states, including Bavaria, Brandenburg, Hessen and Saxony-Anhalt have detailed and comprehensive regulations.

Distinctions with regard to patient transfer disputed in practice The problems lie in the fact that the clear starting positions indicated are not seen so clearly in theory and practice in relation to ambulance transfers. Private providers of “transfer movements”, whether by land-based vehicle or by air,often see their work from the much more cost-effective point of view of “patient transfers“.

The term “secondary operation”is also taken to mean “patient transfers”(Hessen emergency services plan under no.1.1.10) or “qualified”patient transfers (Saxony-Anhalt emergency services plan) in the various federal state regulations,in addition to the actual emergency care.Otherwise,the terms “interhospital transfer”and “intensive-care transfer”are treated as being equivalent (“Interhospital transfer guideline“, Bavaria,Thuringia state emergency services plan).

It is therefore not surprising that these “misunderstandings” result in supreme court rulings which assign the field of “secondary operations“ which are disputed here (transportation of patients from the intensive-care ward of one hospital to the intensive-care ward of another hospital or for special diagnosis or treatment, transportation of patients in the case of whom it is expected that transfer by land-based transport would bring about a risk to the vital functions or a medically unjustifiable deterioration of the overall condition) to patient transfer,thereby not declaring the regulations concerning the “(emergency) rescue services”as applicable.

Why private companies,even with the support or court decision,claim that such transfers are “only”patient transfers is obvious, because the approval conditions set different requirement levels.

The decision of CEU of 25th October 2001 should be seen as having definitively concluded any further discussion on whether emergency rescue in the narrowest sense should be seen as “worthy of protection” with regard to European regulations and should be exempted from free competition, e.g. in the form of the so-called “administration monop-

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oly“, while ordinary patient transfers have to be deregulated and opened to private “competition“.The European Court has consented to the use of “approval restrictions”(here in accordance with § 18 clause 3 RettDG RLP,which corresponds to the majority of other federal state regulations) on several grounds (which will not be set out in further detail here).

However this is subject to the express conditions that the institution responsible for carrying out the “emergency service”(emergency or patient transfer) and therefore to be “protected”, carries out its tasks at the highest quality level in the interests of the patients.In the case of intensive-care transfers this ensures that those responsible will make every effort to do so if they wish to be protected from private competition.(This also applies the other way round - whoever believes it can be done better must prove this first).

Special regulations of the federal states relating to intensive-care transfers Several federal states have decided to clarify the situation and issue their own regulations in order to underpin the actual clear allocation of intensive-care transfers to emergency rescue,and also because emergency medical care at a high level comparable with that of intensive-care treatment in hospital is required. Not infrequently the circumstances of intensive-care transfers go far beyond those of “normal”emergency situations.

• However,it is noticeable that a majority of these federal states have not directly included these (additional) regulations in the relevant emergency services legislations,but in the state emergency service plan or in other decrees.

• Also, such “extended”regulations are often expressly restricted to the field of airborne rescue, supporting the above hypothesis that “intensive-care transfers“ should basically be assigned to “normal“ emergency transfers,i.e.are already covered by the definition of (at least ground-based) transfers of this type.

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Legal principles in the individual federal states – tabular overview

BadenWürttemberg

In the BW emergency services law there are no special regulations for ground-based transfers. However, it is generally assumed that intensive-care transfers form part of the emergency services/emergency rescue (see below).

Also, no special locations for special vehicles are stipulated. The sector committees must endeavour to reach an overall agreement.

For airborne rescue the Emergency services plan 2000 BW of 22.5.01 contains the following information: 4.2 Airborne rescue service According to no. 4.2.2. a “secondary transfer“ by rescue helicopter takes places “if emergency patients have to be transferred from one hospital to another hospital with more suitable treatment possibilities and transportation by ground-based vehicles is ruled out on medical grounds.”

According to no.4.2.4 these are distinguished from “intensive-care helicopters“ (also known as ambulance helicopters), which “as part of emergency rescue are mainly used to transfer patients who have to receive intensive medical care during the flight”.

For such transfer flights there is a framework agreement directly between the German Air Rescue Service (DRF) and Baden-Württemberg health insurance associations “on carrying out transfers by helicopter (VHS)” at three locations.

Bavaria

Art. 26 para. 1 (ground-based emergency vehicles) and art. 25 para 1 clause 1 (Air rescue) BayRDG of 28.1.98, amended 25.7.02.

“The State Ministry of the Interior after hearing ...... determines the location of emergency vehicles for the transfer of emergency patients in intensive-care conditions (intensive-care transfers)“.

This applies accordingly to air rescue services.

See also the “Sample service instructions for emergency services according to § 13 para. BayRDG“ section three, I. Air rescue service: § 42 Types of operation 1. ...

2. ...

3. Transfer of emergency patients already being medically treated from one hospital to a hospital which is more suitable for further treatment.

4. ...

Further details are set out in a “Interhospital transfer guideline“ by the relevant ministry (e.g. qualifications of the deployed personnel, questionnaire forms for the relevant control centre etc). The specialist ministry has also determined four locations for intensive-care helicopters and six locations for intensive-care vehicles (including one replacement vehicle).

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Berlin

No special regulations for ground-based operations. An emergency doctor vehicle is retained for the Berlin fire brigade which has additional equipment for these special operations.

Use of an intensive-care helicopter for air rescue with equipment regulated by conditions in the approval notices. Otherwise reference is only made to “transfer flights“.

Brandenburg

State emergency services plan of 24.2.97 Air rescue § 11 Duties .....

(2) Patients to be treated in intensive-care conditions and patients who have received primary medical treatment can be transferred from a hospital to a suitable hospital for further treatment or for overall treatment (secondary transfer). § 13 Air ambulance Patients who for medical reasons cannot be transferred in accordance with § 9 clause 1 (i.e with landbased emergency vehicles) are transported by appropriately equipped and manned helicopters (transfer or intensive-care helicopters).

Further regulations relating to this are set out in the “Service instructions for the use of emergency helicopters and transfer helicopters in the state of Brandenburg“. These distinguish between four different types (emergency, transfer, intensive-care and ambulance helicopters) and several types of deployment (primary treatment, primary and secondary transfers).

Bremen

No special regulations.

Insofar as “emergency transfers” are also mentioned in § 24 para. 2, no. 2 BremHilfeG of 18.6.02 separately from “emergency rescue” in number 1, this does not expressly imply “intensive-care“ conditions. This simply refers to “specially equipped emergency vehicles”.

The Bremen fire service has a special vehicle for intensive-care transfers which may be used if required.

Hamburg

§ 3 para. 1 clause 2 HmbRDG of 9.6.92 ”Emergency rescue also includes the transfer, without delay, of injured or ill patients from one medical institution, more particularly a hospital, under specialist care, which includes the maintenance and monitoring of vital functions for further treatment in specialist medical institution, also the return transfer if necessary”.

The term “intensive-care transfer” is not expressly used.

No special additional regulations.

For the intensive-care transfer of premature and newly born babies a so-called “Baby emergency vehicle” is available. Otherwise there are no special vehicles.

For air rescue, helicopters stationed in Hamburg and its environs are used.

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Hessen

The HRDG of 24.11.98 contains no special regulations.

(Intermim) State emergency services plan of 31.5.99/30.4.01 1.1.2 Emergency care ”Emergency care is also the transfer of emergency patients between treatment facilities with the personnel qualified for this in suitable means of transport”.

1.1.10 Secondary deployment ”The emergency service providing the population with emergency treatment and patient transfer does not only cover the handing over of the patients to a treatment facility, but also the transfer of patients already being clinically treated if they are medically classified as requiring emergency care or patient transportation”.

According to no. 1.1.11 under the heading “Special secondary transfers” there is the regulation concerning additional capacities for special secondary transfers outside regular emergency service provision.

There are separate regulations relating to air rescue in no.5, whereby rescue helicopters can also be used for secondary deployments. In addition to these rescue helicopters, special secondary transfers are also carried out with transfer helicopters. Other details are set out in an additional “Specialist airborne emergency services plan for the state of Hessen” of 4.2.02., which, for example in no. 4, also mentions “intensive-care transfer helicopters”.

There is also a declaration of principles concerning the “Deployment of special secondary transports”, which sets out: • Criteria relating to choosing between land-based and airborne means of emergency transport • The availability of emergency doctor vehicles for transferring patients (transfer emergency doctor vehicles) at three locations, • The allocation and control of call-outs by the “Coordination centre for special emergency services secondary transports” set up at the BF Frankfurt.

Lower Saxony

No special regulations.

It has merely been that the “responsibility for airborne rescue in the context of the emergency services law” is assigned to the Ministry of Social Affairs. However, the Ministry of the Interior is now responsible for the emergency services in Lower Saxony.

NorthRhine Westphalia

§ 2 para. 1 clause 3 RettG NRW of 24.11.92 (with amendments) ”This also includes the transportation of initially treated emergency patients to diagnostic and treatment institutions“.

There is a directive by the relevant specialist ministry of 17.8.93„”Use of helicopters in emergency services“ for airborne emergency services . In no. 21 it assumes “secondary transfer flights“ in the case of emergency service helicopters. In addition to this according to no. 3 there are also “air ambulance helicopters“ for these tasks.

No special additional regulations. If necessary the locally responsible emergency services providers must themselves decide on any required measures in this area of deployment.

MecklenburgVorpommern

There are no special regulations relating to intensive care transports in the RDG M-V of 1.7.93 (with amendment).

Emergency services plan of 16.2.99/22.2.00 4.2 Airborne rescue 4.2.1.1 Tasks of the emergency services helicopter 1. ....

2. ....

3. Secondary deployment: “In the context of emergency rescue medically treated patients must be transported on the basis of medical indications from one treatment institution to the nearest treatment institution suitable for diagnosis and treatment“.

4. Secondary transfer: “In the context of (qualified) patient transfer, persons who are ill, injured or require help must be transferred with appropriate care if this is medically required and economically justified“.

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RhinelandPalatinate

At the time of the next revision of the emergency services law it is intended to add a new clause 2 for clarification: “Emergency transfer also includes the transfer of emergency patients under intensive-care conditions (Intensive-care transport)”.

An intensive-care helicopter for airborne rescue is based in Mainz (Christoph 77) for state-wide secondary transfers (transfer flights). Other regulations are set out in decrees by the specialist ministry (e.g. responsibility of the emergency services control centre in Mainz for assigning the deployment of this ICH in transfer flights).

Saarland

In the SRettG of 9.2.94 (amended on 27.11.96) there are no special regulations for land-based transfers. An intensive –care transporter is based in Saarbrücken.

There are “Instructions for carrying out airborne emergency services duties in Saarland” of 2.2.01. for the air rescue service According to no. 6 the tasks of the emergency services helicopter include: - ....

- ....

- in the case of a necessary transfer of patients having received primary care from one hospital to another hospital suitable for further treatment (secondary transfer flights)“.

Saxony

The SächsRettDG of 7.1.93 contains no special regulations.

State emergency services plan of 30.11.94 5.1.2 Patient transfers can be carried with land-based as well airborne emergency means.

8. Airborne emergency services 8.1.3 Urgent transportation of initially treated patients in life-threatening situations from one hospital to a hospital suitable for further treatment, as well as urgent transfer of patients under intensive care from a hospital to a hospital suitable for overall treatment (urgent secondary transfer).

SaxonyAnhalt

§ 11 para. 2 clause 2 RettDG-LSA of 11.11.93 talks of “qualified patient transfer)“ (secondary transportation) in airborne rescue.

The directive issued by the responsible specialist ministry of 13.2.02 on “Interhospital transfer emergency vehicles manned with a doctor“ assigns the area of deployment to “qualified patient transport” in accordance with § 2 clause. 3 RettDG-LSA. The decree determines the type of emergency vehicle used, its equipment, crew, procedures, call-out coordination etc.

SchleswigHolstein

No special regulations.

Thuringia

The ThürRettG of 22.12.92 contains no special regulations.

If necessary, an intensive-care helicopter is used for airborne rescue.

State emergency services plan of 15.6.95/29.8.00 2.3 Guarantee transfer/urgent secondary deployment The services of the emergency service also include the transportation of vital important medication, .... as well as special medical personnel.

2.4 Qualified intensive-care secondary transfer (interhospital transfer). .Qualified intensive-care secondary transfer (interhospital transfer) is a special type of patient transfer for which special equipment such as intensive care vehicles or intensive-care helicopter are considered.

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Even without claiming to be complete,the situation described in Germany shows an almost incalculable variety of statespecific regulations.As a “comment”it can be said that within the emergency services sector there are few areas which are split into so many different positions. In the author’s opinion the picture has become considerably more differentiated since the first edition of the book.It would be praiseworthy for the “Emergency services”to be committed to the aim of harmonising the various state regulation in the interests of all those involved.

Conclusion Nevertheless a central theme is still evident.

In the case of land-based transfers the majority of the federal states assume that this forms part of emergency services directly (through appropriate clarification,) or at least indirectly. In so far as the term “patient transfer” is used in exceptional cases “qualified patient transfer“ is clearly involved here in this context, at least. If there are special regulations going beyond this, they are essentially limited to transfers by air. Although the primary assignment of “transfer flights” to the emergency services is clearly seen here too. Thus, when seen overall, the varying regulations in the federal states appear to be comparable as the “legal basis“ for the implementation of intensive-care transfers despite the individual differences. This partly relates to the use of the term “Interhospital transfer“ as well. It is either characterised as “just” a transfer between hospitals, e.g. as a consultation transfer, or it is carried out in connection with “intensive-care” points of view, basically in accordance with the term “intensive-care transfer” used here.

Collaboration required On the other hand it must be assumed that the required transfers will extend beyond the territory of one or even more federal states as a rule, particularly in the case of transfers by air.Comprehensive organisation of these deployments is then particularly urgent.Agreement on the basing of additional ICHs is urgently necessary.Whilst recognising the indisputable commitment of the institutions and persons involved in air transfers,this is the only possible way to avoid putting the network of primary locations under strain,which could be described as almost too luxurious, by a further and just as expensive (in financial terms too) network of “transfer locations”. In this case,all those involved should agree on a common approach in the interests of keeping the financing of transfers by air under control. In each case a minimum requirement would be that a decision would only be made on further “own”intensive-care,transfer,ambulance or other helicopters after any additional use of the existing primarly locations (which cannot be changed,more for political than material reasons) through the increased assumption of transfer flights has already been thoroughly examined.

Agreement about the type of deployment and the locations of such vehicles is urgently required in the case of landbased transfers too, particularly assuming the use of special “large”intensive care vehicles.

However, it must be emphasised that the first “faint-hearted”attempts at cooperation are coming up against unanticipated difficulties.The administrative agreement between the states of Hessen and Rhineland-Palatinate of 9/21 April 1997 on cooperation in air rescue with the aim of operating a joint station in Mainz (Christoph 77) was declared invalid by the Hessen Adminstrative Court in rulings of 21st and 28th November 1997 as the conclusion of a state agreement

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is necessary for this type of cooperation.The Rhineland-Palatinate Ministry of Justice agreed with this view in a statement on the draft amendment to the emergency service law.This federal state now also shares the view that a state agreement is necessary.Could such a project ever be implemented in these circumstances?

Air rescue – landing sites for emergency/intensive-care helicopters As has been shown,discussion of the legal basis of intensive-care transport has primarily been aimed at the airborne emergency services.In connection with this the question of the “legal”prerequisites for landing sites for emergency helicopters at hospitals must be mentioned, because transfers by air could not take place without landing facilities.

In several federal states specific regulations relating to “helicopter landing sites”at hospitals have been issued (such as the Saxony state emergency services plan).

On this subject a distinction has to be made between landing sites at “permanent“ helicopter bases and landing facilities at the destination hospital (the third category, involving the direct deployment of the emergency helicopter at the site of the emergency,known as the “operating site“,will not be dealt with here).However,it must be taken into account that many of the regulations primarily relate to the aviation company as the operator of the helicopter, and not the hospital authorities as the owner of the landing sites (e.g. problem of changing to new types of helicopter). Furthermore,a distinction must be made between the actual helicopter emergency medical service deployments – HEMS, and ordinary ambulance flights. The conditions under discussion only apply to the HEMS sector.

The regulations of the Federal Ministry of Transport dating from 1969 have been used for such landing facilities to date, – if regulations have been used at all.The much derided JAR-OPS 3 (“Regulations of the Joint Aviation Authorities concerning the professional transportation of persons and materials by helicopter“) only implement already existing ICAO regulations (i.e.a large part of the discussion is evidently based on not taking into account already existing, but not yet applied regulations). As “technical regulations” JAR-OPS 3 have already been implemented in German law, which took place in October 1998 with a “reference” in the Luftfahrt BO. One of the main problems seems to be a “tightening-up”of the permitted angle of inclination which if implemented precisely makes larger free areas necessary in the event of incidents during the take-off and/or landing phase. This angle of incidence must also be achievable in emergency situations, such as during failure of one of the two engines, which makes corresponding demands on the helicopters used.

It must also be decided whether the landing should continue to be approved without formal procedures, as was the usual practice in the past, with reference to the “special right”of § 25 para.2 no.2 LuftVG as an “aid in the event of risk to life or limb”(see the corresponding information in the Brandenburg air emergency services directions),or whether approval as an “airfield/landing site” in the context of § 6 LuftVG is required.

However, what is urgently required in all cases is for all landing facilities, and their “registration” to be checked in an appropriate landing site directory, at least those to which flights are made regularly (see the Rhineland-Palatinate model,information via the internet can and will be considered). Providing this information to the airborne emergency service, and in particular to the flight crew, can contribute to achieving the objectives of JAR-OPS 3 by reducing the risk of deployments in the sector and increasing awareness of possible hazardous situations.

However, overall it can be stated that even with the possible introduction of transitional deadlines, the “problem of helicopter landing sites at hospitals“ does appear to be solvable,i.e.a “ban“ on transfers by air is hardly realistic and is not anticipated.

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Emergency vehicles for intensive-care transfers – standardisation The “Legal principles of intensive-care transfers”also include a look at any regulations relating to the vehicles used for this purpose and the personnel used in these vehicles and aircraft.

Despite the different ways of looking at this sector,there is broad agreement that the emergency vehicles used must meet a certain technical standard.It does not matter whether the regulations are based on specific standards such as DIN or EN, or they “only” refer in general to the “state of the art”, as long as such requirements are met.

In this case too it can be asserted in theory that such standardisation already exists, as with the question in the introduction. If the federal state laws refer to the use of emergency and/or emergency doctor vehicles for transporting patients to hospital, then this also applies to intensive-care transfers.EN1789 (which “replaces”the current DIN 75080) must therefore always be applied to these transfers. In regard to the definition in no..3.3.3 of the EN, the type C category is the main one involved here (“an emergency vehicle which has been designed and equipped for the transportation, further treatment and monitoring of patients”), whereby additional equipment for the specific purpose can certainly be considered.

However, in several federal states special vehicles are used for carrying out intensive-care transfers in the form of “intensive-care vehicles (ICV)“ (see “Guidelines for interhospital transfers“ Bavaria - where even the possibility of “carrying a bed“ is mentioned, see the Saarbrücken ICV and/or the ASB intensive-care bus - or the Thuringian state emergency services plan, the decree on deployment assignment in Hessen talks of emergency doctor vehicles for transfers“). For this reason an ad-hoc group of the AA 1.2 “Emergency vehicles and their medical and technical equipment“ committee of NARK at DIN has discussed the question of “own“ standardisation for such types of vehicle and has put forward an appropriate draft proposal.

The question has been positively resolved of whether after the inclusion of the type C in EN 1789 a standard can be drawn up for an additional vehicle. If, under type C in the EN an “emergency vehicle” is defined as:“an emergency vehicle which has been designed and equipped for the transportation, further treatment and monitoring of patients”, then what was initially set out with regard to the legal regulations applies.In actual fact transfers are included as the text is so broadly-based that,for example,a further transfer from a primary care hospital to a special clinic can, or maybe even has to be carried out in a type C.There seems therefore to be very little room for manoeuvre for separate standards.

If at all,then a vehicle would have to be developed which would be totally independent and also fulfill “other”tasks.

The responsible European committees have approved a separate German standardisation project under these conditions, so that this problem has become clarified.

However, the predominant view of the federal states remains unaffected by these developments. A commercially available vehicle should suffice for a “normal”intensive-care transfer, i.e.an existing emergency/emergency doctor vehicle or now a type C with additional equipment and specially trained personnel. Instead of the usual stretcher, the intensive-care transport system by Starmed (Ulm), which is now in use in several locations, or a comparable solution can be carried if necessary.

National basing and procurement should be arrived at for the remaining few individual cases of a “large” vehicle (carrying a complete intensive-care bed) so that the implementation of a planned standard for relatively few vehicles in the whole of Germany is rationally and economically possible. However, the corresponding DIN standardisation project is no longer being pursued.

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Standardisation of emergency helicopter and ITH DIN 13230 (still) applies to emergency and intensive-care helicopters.The introduction of a corresponding EN is currently under discussion, whereby it must be taken into account that the terminology used in the various regulations should he harmonised. JAR-OPS 3 describes “patient transfers with helicopters“, the draft EN “patient transfers with aircraft“ even though the same term „air ambulance“ is used in the English text (the intended “description” in the draft of the “aircraft for patient transfers“ matches our conception of an intensive-care transfer helicopter). The other proposed terms and definitions,such as “primary”and “secondary”deployment should be checked for correspondence with the terminology used in this country.Finally, special attention must be paid to the use of qualified personnel.

It is however noticeable, and it should be pointed out here, that the same emergency doctors make concessions in the ergonomic room for manoeuvre of the ITH which would be absolutely inconceivable in a land-based ICV,and they therefore consider the EN 1789 type C as unsuitable.

Intensive-care transfer personnel The legal regulations relating to the medical and non-medical personnel when carrying out intensive-care transfers are essentially based on the prevailing inclusion of these transfers in the field of emergency rescue and transfers.The use of qualified emergency doctors and similarly skilled emergency ancillary personnel is therefore stipulated. However,to some extent special requirements relating to experience in the intensive care of those involved are set out (e.g.“Guidelines for interhospital transfers”Bavaria).

Additional requirements relating to the HEMS crew members in accordance with JAR-OPS 3 (appendix 1 to JAR-OPS 3.005 (d)) may also have to be taken into consideration (e.g.training course components and examinations as well an annual repetitions).

Consideration of other regulations The“semi-official”regulations also form part of the discussion of this topic.Thus,the“provisions”of the DIVI recommendations relating to medical qualifications in intensive-care transfers (such as the required participation in special preparatory courses) are certainly binding to the extent that in the event of unsuccessful missions questions may be asked as to why the emergency vehicle personnel deviated from these provisions.“Organisational blame”can therefore certainly play a role.

In this connection reference must also be made to the “Recommendations of the Southwest German Emergency Doctor’s Working Group relating to Intensive-care transfers” (e.g. notes for nocturnal call-outs of the ICH which are linked to special criteria. See also examples from the Brandenburg working directive and the Hessen deployment decree).

The high requirements of an intensive care transfer,which are comparable with those of treatment in hospital,appear to make it necessary to apply the principles forming the basis of medical standards of hospital treatment to the quality of such a transfer and the qualifications of the persons involved in it.

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Necessary organisational principles A discussion of the legal principles should also take into consideration the necessary organisational preconditions of such a system,with a distinction being made between the organisational preconditions in the strict sense and the prerequisites to be applied to the medical sector.

Distinguishing between transfer by land and air on the basis of medical criteria only The effective organisation of intensive-care transfers assumes a clear distinction between land-based transfers and the deployment of emergency and/or intensive-care helicopters. It is not the motto “Flying is better“ that is the decisive factor,but strict medical indications.This presupposes an appropriate assessment and decision-making body in case of doubt.Furthermore, in several federal states (Bavaria, Hessen) economic points of view, i.e.the financial burden on the cost-carrier, must also be expressly taken into account.

Introduction of regional operations centres necessary This required “body“ can in turn only work rationally on a regional basis, i.e.a regional operations centre is required at the very least,to which an appropriate medical advisor is linked (see as examples the solutions in Hessen and RhinelandPalatinate.

Base coordination The “possibility of choosing“ between land-based transfers and aircraft also presupposes an appropriate structure, i.e. the bases for emergency aircraft and the bases for land-based emergency vehicles must be coordinated (see Bavaria and Hessen, planned in Rhineland-Palatinate). In regard to the difficulties involved in the economically viable implementation of interstate agreements,see the aforementioned example of a common base Christoph 77 in Mainz for Hessen and Rhineland-Palatinate.

Use of questionnaires There are corresponding “questionnaires”in several states (Bavaria,Hessen, Rhineland-Palatinate) for the selection criteria at the relevant (emergency) control centre.

Regulations in neighbouring countries Finally we cast a brief look at our German-speaking neighbours (who obviously approach this subject much more pragmatically).

Austria In Austria there are no special regulations relating to the transfer of intensive-care patients – interhospital transfers.

Therefore there is no express standardisation of IVC, as this is not considered necessary.

As in Germany individual solutions have developed at local level.Thus Vienna General Hospital has a larger vehicle (oneoff product manufactured by Dlouhy OHG,Vienna),into which a complete bed can be pushed. However, this vehicle is only used in the city of Vienna and close environs. In the rural regions it is assumed that transfers can and should be carried out by the vehicles available.This is comparable with the basic tendency in the German federal states.The tests with the Starmed stretcher are known and were also evaluated positively.

As in Germany the rescue helicopter bases are also used for intensive-care transfers/interhospital transfers as often as possible.Wiener Neustadt also has its own intensive-care helicopter “Christoph 9”(which is essentially financed by the ÖAMTC)

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Switzerland This country does not (yet) have special regulations relating to the implemntation of land-based intensive-care transfers either. Again,is it assumed that the available potential is utilised for such missions. There are special local solutions in individual cases , e.g.“RTW-Großraumsprinter“ with special additional equipment for transfers.

The Swiss Emergency Flight Watch (REGA) bases are used for emergency transfer flights.

Literature: 1. DIN 13050 – Emergency services terms -, DIN Deutsches Institut für Normung e.V., Berlin 2. Emergency services committee, Report by the working group on structural questions (March 1996), Emergency Services Handbook (B III.0.5.1) 3. Emergency services committee, Principles of the further development of aerial rescue (Concluding report of the aerial rescue consensus group,March 2000), Mendel Verlag,Witten (2nd edition April 2003) 4. Emergency services handbook, Mendel Verlag,Witten (Part B III.Regulations of the 16 federal states) 5. Interhospital transfer guidelines Bavaria, Bayerisches Ärzteblatt 1/99 6. Proclamation of the German implementation of the provision of the Joint Aviation Authorities concerning the professional conveyance of persons and materials in helicopters (JAR-OPS 3 German) of 4th August 1998, Federal Ministry of Transport, Bundesanzeiger 1998, Nr.182a 7. DIN EN 1789 – Emergency services vehicles and their equipment – patient ambulance – German version EN 1789:1999, 8. DIN Deutsches Institut für Normung e.V., Berlin 9. DIN 13230-Parts 1-5, Aircraft for transporting patients, DIN Deutsches Institut für Normung e.V., Berlin 10. DIN/EN 13718- Parts 1 and 2/draft, Means of transporting patients in the air, on water and in difficult terrain, DIN Deutsches Institut für Normung e.V., Berlin, September 1999 11. DIVI-recommendations relating to medical qualifications in intensive care transfers, Der Notarzt 16 (2000) 12. Recommendations relating to intensive-care transfers, Southwest German emergency doctors’ working group /AGSWN (published on the homepage of the AGSWN)

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Intensive-care transfer

ICV

Ambulance / ambulance with hospital doctor/ emergency doctor transfer emergency doctor vehicle TVerlegungsNAW

Land-based

Transport helicopter/ICH

Air rescue Rescue helicopter

Available transports (‘normal’ intensive-care patient) (Transfer transports)

Outside normal emergency services care (special secondary transfers)

emergency vehicles

Urgent transports (high risk patient) (urgent secondary transfers)

Emergency transport to transfer emergency patients under intensive care within the emergency service sector

Sedondary transfer/secondary deployment/transfer flights (general further transfer after initial treatment)

Transfer of patients

Patient transport (qualified patient transport)

Patient transfer vehicle Air rescue (ambulance flights, in part also secondary transfers) only in genuine medically justifiable exceptional cases, e.g. medically unacceptably long transport duration

Ambulance/ EMV

Emergency vehicle

Generally not urgent transfers

(Emergency) transport accompanied by doctor

e.g. consultation transfers

Interhospital transfer

INTENSIVE CARE TR ANSPORT

R.Huf, E.Weninger

Organisational principles and aspects relating to the practical implementation of intensive care transfers Procedural principles during intensive care transportation The safety of intensive-care transfers depends to a great extent on precise planning and defined procedures.The procedures described below for intensive-care transportation can be applied to all transfers in principle. However, the exchange of information between the referring institutions and the doctor involved in the transportation,the preparatory planning, the operational reliability of the equipment being used and the monitoring of all initiated measures are of great importance in this area.

Essential preparations for intensive care transfers Preliminary information Ideally all of the medical institutions,from which patients may have to be transferred,should be familiar with the capabilities of the intensive-care transportation system.However,this cannot be taken for granted. Experience shows that even today the possibilities of these systems tend to be underestimated rather than overestimated.One of the objectives with the highest priority is to inform all the institutions that may be involved from the moment that such a system is introduced. Providing the deployment control centres with this information is also not enough.The alarm procedure, timing and last but not least the question of who bears the costs must also be set out in addition to the medical possibilities that exist during a transfer.

Technical preparations The safety of the patients is highly dependent on the functional reliability of the equipment being used, particularly in the case of intensive-care transportation.The completeness and reliability of this equipment as well as that of the additionally carried equipment must be checked at appropriate intervals.In the case of intensive-care transportation there is no equivalent replacement equipment available for certain devices (e.g.intensive-care respirator) in contrast to the situation on an intensive-care ward. The replacement equipment (back-up) is generally much simpler and less powerful.

Critical equipment,which in the event of failure could endanger the patient,should be checked at the start of every shift, but at least once daily. Here,checklists can not only contribute to daily checking,but to overall quality assurance.In order to be able to eliminate faults,but also for regular servicing,close links with a suitable workshop (e.g.at the hospital location) are urgently recommended for more complex equipment, such as intensive-care ventilators. In this way the very complex requirements of the Medicinal Products Law can be implemented more easily.The same applies to the provision of medicines,which should also be the responsibility of a pharmacy (e.g.the hospital pharmacy).In this way existing legal regulations can also be observed without problems. However,experience shows that a spatial proximity is not absolutely necessary.

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Abb 1: Selektivpiepser modernster Bauart BOS-Pager Swissphone DE900 Entscheidende Merkmale sind lange Standbyzeit, Robustheit, kontrastreiches Display und einfache Bedienung.Beim abgebildeten Gerät erfolgt die Alarmierung wahlweise laut oder mittels Vibrationsalarm. Prioritätsrufe werden unabhängig davon immer laut ausgelöst.Dank dem neu entwickelten ECO-Mode sind Betriebszeiten von über 4 Monaten problemlos möglich.Der Pager wird im Ruhezustand in einen Schlafmodus gesetzt, während dem das Display ausgeschaltet wird.Der Empfänger bleibt weiterhin aktiv und empfangsbereit.

The primary prerequisite is the rapid and guaranteed availability of these means of transport for all the involved institutions.In order to guarantee this with maximum reliability, a secure and even superfluous alarm procedure is imperative. Ideally the means of transport (ICH, ICV or ambulance), the medical and non-medical personnel are all present at the same location and can be notified there immediately.Since this cannot always be the case, for example if a doctor and medical personnel cannot be accommodated at the airfield,secure radio communication alarm procedures are required. In addition to these radio alarms, e.g. BOS-Pager (fig.1), mobile phones are particularly helpfull if transfers do not have to be carried out immediately but at a set time. Public mobile signal receivers can also be used for this. However,it should be taken into account that there may be a significant time delay between the telephone alarm and signal transmission, i.e.the effective alarm.This system is therefore out of the question for time-critical call-outs, but can certainly be used for call-outs for which advance notice of up to 30 minutes is not a problem (e.g. return transfers).

Implementation and course of an intensive-care transfer In spite of the fact that every transfer has its own dynamics as a result of the clinical picture involved,the distance to be travelled,the time of day,the weather and changing conditions at the referring and receiving hospital,the procedures to be observed during every transfer should have a uniform structure.Accordingly every transfer can be divided into various phases.

Planning phase There is very frequently little information available about emergency patients in primary rescue operations.On the other hand an abundance of information will generally have been amassed in the case of a previously treated patient.Therefore direct contact between the transporting and treating doctor plays an important part in this phase.In a doctor-todoctor discussion all the relevant information about the patient should be passed and/or requested. Advance knowledge of as many of these details as possible is a prerequisite for rapidly and safely carrying out an intensive-care transfer.It is best if this information is exchanged in a routinely conducted doctor-to-doctor discussion.Structured questioning ensures that the relevant information is fully recorded.The necessary equipment and level of urgency as well as all other circumstances of relevance to the transfer and further care must be clarified.Dispensing with this direct doctor-to-doctor discussion is only acceptable if the necessary information is available from other sources (e.g.the presence of all the patient documents) or if in the face of evident urgency the doctor-to-doctor discussion would delay the transfer disproportionately.

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Preparatory phase The actual transfer preparations can begin as early as during the approach to the referring institution by air or road.

The crew should agree on the necessary measures and the equipment required for this.This largely prevents necessary equipment being forgotten or the logistic procedures being unclear and therefore uncoordinated. This phase of the transfer should also be used for final functional tests.

The referring institution should ensure that the transport crew can reach the patient without further delay. A “guide” should be available if the transport crew is not familiar with the site, especially in large and confusing hospitals. It must be ensured that access to the hospital is possible and not hermitically sealed off by the guard duty especially at night .

Take-over phase In principle, the take-over should be as detailed as possible and in keeping with the patient’s condition each time a patient is handed over by the referring treating doctor to the transporting doctor.The duration and detail of this take-over are not dependent on the transfer duration or distance, but on the complexity of the medical condition involved and any associated circumstances.

The actual take-over of the patient by the system carried on the means of transport must take place in such a way that the patient cannot be put at additional risk.This means that critical system changes must take place so that after the equipment change-over,checks must be performed to ensure that the change-over has taken place without deterioration in the patient’s condition. Pulsoximetry must constantly be available throughout the actual changeover when changing the ventilator for example, and after the change-over the respiratory situation must be monitored by way of blood gas analysis (BGA). Although this prolongs the time required for the handover, it largely prevents “nasty surprises”through sudden collapses in the respiratory or cardiocirculatory situation for instance. The transfer cannot begin until all critical system change-overs have been carried out in this way and it can be guaranteed that no negative effects have occurred.During this phase and during transfers,monitoring or treatment restrictions are almost never justified. On the contrary, it will often be necessary to extend monitoring of critical parameters during the transfer. Only when the patient has been securely connected to all the transport systems without setbacks can the next phase be commenced.

It must be checked once more that all the necessary information and paperwork is present immediately before leaving the referring ward. The receiving clinic should also be informed by telephone of the estimated time of arrival.

Transport phase Ideally this phase should only involve monitoring of the patient’s condition.Improvements which could not be brought about during the period of admission or at the time of handover cannot be accomplished during this phase.There is no place for such improvement attempts during this phase.Only changes in the current condition of the patient should be reacted to.

In order to do this it must be ensured that all the necessary parameters can also be monitored inside the means of transport.This requirement relates to helicopter transports in particular.The normal acoustic alarms in all medical appliances can only be heard with difficulty or not at all due to the noise in the cabin.Optical monitoring must therefore be possible and indeed take place.

In addition to the appropriate reactions to any medical problem which occurs,e.g.a deterioration in the primary illness, appropriate procedures to be followed in the event of the failure of critical systems must be planned in advance.Thus, there must be suitable replacement equipment available within easy reach so that the nearest hospital can be reached with a maximum degree of certainty. Appropriate equipment for the critical systems must also be available on intensive-care wards. A failed intensive ventilation system can be replaced with another equivalent device.This is often not possible in some means of intensive-care transport and in these cases simpler equipment must be used. The failure of a

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critical system during an intensive-care transfer constitutes a risk to the patient which must be taken seriously.In the event of the failure of the intensive-care ventilator with the patient in a critical condition,the patient must continue to be ventilated with the “back-up”ventilator available for emergencies.The respiratory situation can quickly deteriorate because of this, and therefore the nearest suitable hospital to be aimed for, must be agreed with the pilot or driver immediately, so that the patient can continue to be appropriately treated there (see case example).

In conclusion the tactics can be summarised with the “6 Ps” of safe intensive-care (airborne) transportation: Proper Preflight Planning Prevents Poor Performance In this way the frequency of relevant complications during a transfer can be reduced to an absolute minimum.However, in every case, clear procedures should be planned for problematic situations which could nevertheless occur. During the flight the decision to continue flying, to turn back or to fly to an alternative destination must be taken as quickly as possible at any time during the flight.This decision depends on the nature and urgency of the complication as well as the geographical and flying conditions.

Handover phase Here the patient is disconnected from the transport system and connected to the systems at the receiving hospital in the same order as at the take-over. Here too the critical parameters before and after the system change-over should be monitored.Sufficient time should be available for this phase as with the take-over.Time pressure due to other pending jobs or simply returning to the “home emergency services area”must be avoided.Handing over to unsuitable systems at the receiving clinic must also be avoided (e.g. to an emergency ventilator for the further transfer of patients with complex respiratory condition within the hospital).

A clearly structured and complete verbal handover of all patient information to the receiving doctor ends the transfer.

It is assumed that the means of transport isimmediately returned to a condition for carrying out transfers if at all possible.

Case report Incident management An approximately 20-year old patient with multiple injuries experienced increasing deterioration of the respiratory situation following a road traffic accident.In spite of an FiO2 of 1.0 and a PEEP of 8 mbars the deterioration in the situation could no longer be stopped at the treating hospital.For this reason,after consultation with a centre providing the maximum range of care it was planned to transfer the patient by intensive-care helicopter. When the transport team arrived the patient’s circulation was stable on 24 mg dopamine per hour.The paO2 was 76 mm Hg,pCO2 49 mm Hg.Maintaining the ventilation regime the patient was moved onto the intensive-care stretcher with an integrated intensive ventilator (Servo 300).The ventilator had previously been properly checked and no faults had been found. After moving the patient onto the transport unit all the parameters,including BGA,were checked again and no tendency towards deterioration was detected.The patient was taken to and loaded onto the intensive-care helicopter.Approximately 5 minutes after take-off a total failure of the ventilator occurred.The cause of this was subsequently found to have been a problem in the supply lines to the ventilator.Due to the failure of the ventilator the patient’s respiratory situation deteriorated dramatically (SaO2< 70%).Troubleshooting could not be carried out initially as appropriate measures had to be taken imme-

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Fig. 2: Respirator system with special pressure reducing demand valve and hand-operated respirator bag for ventilation with 100% oxygen (Company Dräger Medical, Lübeck, Germany) diately to stabilise the respiratory situation of the patient in order to at least ensure his survival. In order to do this the patient was ventilated with an FiO2 of 1.0 using a manual ventilation bag with a connected demand valve (fig.1).After consultation with the pilot it was established that a return to the referring hospital was the fastest way to reconnect the patient to a suitable ventilator. The relevant emergency services deployment centre was informed by radio and requested to forward the information about the dramatic deterioration of the patient.Although the patient’s circulation continued to be stable during the last minutes of the flight,an SaO2 of only 76 was measured as an indication of the dramatic deterioration of the respiratory situation. An auxiliary team from the referring hospital was standing by ready for the landing which sped up the unloading procedure and return to the referring ward considerably.At the referring ward the patient was reconnected to his ventilator. A second ITH from a more distant centre was notified because the situation which had occurred seemed to rule out safe transportation under conventional conditions. The existing situation was explained in detail and it was decided that the transfer should take place with the provision of a mobile ECLA. The respiratory situation of the patient had deteriorated further by the time the second team arrived. A paO2 of only 43 mm Hg was recorded under constant ventilation parameters and the paCO2 increased to 59 mm Hg. When the second team arrived it was decided to connect the patient to the mobile ECLA while still in the referring hospital.The patient could then be transported with the ITH while connected to the mobile ECLA.After several days of treatment with the ECLA the patient’s respiratory situation had improved considerably and he could be ventilated conventionally and eventually extubated.He was returned to the initially treating hospital within less than 3 weeks.

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