Cost, Quality of Care, and Staff Education and How They Interact

Transport teams are expensive. The cost to provide the service includes vehicle maintenance and repairs (these are significant costs even if the need is met by a vendor contract), the cost of durable equipment (eg, monitors, infusion pumps), the cost of disposable supplies (eg, syringes, tubing), medication costs, the expense to maintain a communications center (possibly its own cost center with component costs), marketing costs, insurance, staff continuing education, and personnel salaries and benefits.

Transport equipment may have the same capital outlay of standard hos­pital equipment, such as monitors, infant incubators, and stretchers; how­ever, the expected life span of most transport equipment is only about 75% the life expectancy of other hospital equipment. This is because of the man­ner in which it is used, getting it in and out of the ambulance or helicopter, tracking it over rough terrain, the vibration of sensitive electronic equipment during transport, and having it fall to the ground when not appropriately secured. In-house equipment that is permanently mounted to the wall for use has a much greater chance of reaching expected usefulness.

Transport team staff may require additional education to provide the level of care required in the field. Recent work published in the nursing lit­erature suggests that the increased cost to educate transport staff members is a worthy investment. Prowse and Lyne⁵ suggest that knowledge gained from literature and lectures becomes effective and clinically useful when placed into context by practice. Regardless of their personal knowledge base, the participants in that study were noted to improve effective (practical) knowledge through exposure to new information (study of the literature or participation in discussions regarding a topic of interest) and practical appli­cation.

Gaining and maintaining emergency skills that are high risk/low vol­ume, such as endotracheal intubation, needle thoracotomy, intraosseous needle insertion, and umbilical artery (UA)/umbilical vein (UV) catheter insertion, is standard for most programs that conduct neonatal transports. Acquiring and maintaining these competencies can be challenging. The implementation of medical simulation centers is rapidly gaining popularity for the training of physicians, nurses, and emergency medical services (EMS) workers. When staff members do not have opportunities to perform these skills on a regular basis, using patient simulators can fill in the gap. The cost of this technology is expensive—a basic infant mannequin for intubation may run as low as $200; however, an infant simulator may start at $60 000. Research, however, demonstrates that simulation improves learning.⁶ For teams that perform neonatal, pediatric, and young adult transports, an initial investment for simulators and the time investment to write and program scenarios with feedback mechanisms can easily run $500 000. And with such sophisticated equipment that is more labor intensive to set up, it is most beneficial to develop an entire simulation education center where the trainers are set up and ready to go for all clinical areas. Using such a center for the training of all critical care staff will help to spread the cost over many critical care units so that transport does not carry the increased financial bur­den. Using the simulator environment also helps improve team cohesiveness and communication.

Other work suggests that, in addition to improving personal and effec­tive knowledge, elevating the level of staff education and the calibers of educational programs are associated with improved clinical outcomes. Aiken et al⁷ noted that the risk of mortality was lower and patient outcomes were improved in surgical units staffed by bachelor-prepared nurses.

Medical transport leadership should have a systematic process that allows them to design and implement effective interventions to improve the quality of the services they provide. Transport team administrations have a significant level of readiness and action for quality improvement, but often, this action is carried out without the infrastructure of appropri­ate policies, procedures, and the development of a strategic initiative and environment. Managers and decision makers should decide the scope of the quality program they need to implement, which will depend on the structure and outcomes experienced by the transport program. Transport programs should develop robust quality improvement programs with the goal of pro­viding the best possible clinical care while demonstrating fiscally respon­sibility and resulting in desirable outcomes for patients, their families, and transport personnel.

In today's health care environment, just as in the hospital or provider setting, the transport program must enhance its internal quality improve­ment and monitoring efforts to better plan and deliver care rendered to patients, thereby improving outcomes, yet be flexible enough to adjust accordingly in a constantly changing health care environment.

Time and money invested in transport team equipment, quality pro­grams, and staff education is well spent. Orientation programs must develop a basic level of knowledge required to allow staff to care independently for patients in the field. Quality-improvement strategies must be embedded in each of the processes the transport team executes. Continuing educa­tion is clearly important to increase referential knowledge with the hope that it will become effective knowledge with increased experience. In the final analysis, hard evidence of quality improvement with measured out­comes and improved education of transport staff translates into improved patient outcomes.