Critical Transport Decisions

Before any transport, attention to the safety of the transport team and patient should always be the foremost consideration when determining the mode of transport. There are 4 subsequent critical decision steps necessary for each transport; consideration of these steps facilitates the selection of the optimal mode of transport.

The first step involves evaluation of the clinical status of the patient. It is important to know the patient's current medical condition and to anticipate the most serious complication reasonably possible during transport. This does not need to be based on a final diagnosis but on an accurate assessment of the patient's illnesses or injuries, present or potential. If a patient's medi­cal condition is unstable, even a minimal shortening of the response time to the referring facility achieved by selecting one mode of transportation over another may be lifesaving. The emphasis on reducing the out-of-hospital transport time may be especially beneficial to patient outcome in situations such as surgical emergencies.

The second step is an evaluation of the medical care the patient requires before and during transport, including an evaluation of the available medi­cal care at the referring facility or scene of an accident. Usually, the primary consideration is the level of care required during transport. However, there also may be a need for urgent provision of a higher level of care or additional personnel at the referring facility, such as for certain types of airway or surgi­cal emergencies.

The third step is to determine the urgency of the transport. For time­sensitive transports (eg, a need for urgent or locally unavailable interven­tions), the time required for a selected vehicle to reach the referring facility and to deliver the patient to the receiving facility should be considered. These considerations will take into account the distance between facili­ties, the mode of transportation, geographic characteristics of the area to be served, and the availability of vehicle options.

The fourth step involves some of the logistics of a patient transport (eg, local resources available for transport, weather considerations, and ground traffic accessibility). Depending on the type of vehicle selected, the number of staff may be affected. If a ground ambulance is used for a patient with a complex medical condition, staffing can potentially be increased as needed. Conversely, staffing additions may be limited in a small helicopter.

Most often, the decision on mode of transport is made between the transport logistics manager and the control physician. The decision to transport by ground or air involves expert judgment of the condition and potential complications that might be experienced by the patient and require high-complexity medical decision making. Once the team is dispatched, the control physician will remain in intermittent verbal contact with the transport team, assessing the patient's condition and supervising treat­ment options. These physician services are covered potentially by Current Procedural Terminology (CPT) codes 9948x1 and 9948x2.

General criteria addressing the appropriate use of air-medical services can be divided into categories, which correspond to the aforementioned third and fourth steps. These criteria are summarized in the following section.