Article

Journal of Intensive Care Medicine

1-7
Mortality and Resource Utilization ª The Author(s) 2015
Reprints and permission:
sagepub.com/journalsPermissions.nav
After Critical Care Transport of Patients DOI: 10.1177/0885066615623202
jic.sagepub.com
With Hypoxemic Respiratory Failure

Susan R. Wilcox, MD1,2, Jeremy B. Richards, MD1, Alissa Genthon, MD3,

Mark S. Saia, BS, RRT, NRP, FP-C4,
Heather Waden, RN, MSN, CCNS, CCRN, CFRN, CEN, EMT4,
Jonathan D. Gates, MD, MBA5,6, Michael N. Cocchi, MD7,8,
Susan J. McGahn, MSN, AGACNP-BC, CCRN, CEN, EMT4,
Michael Frakes, APRN, CCNS, CFRN, CCRN, EMTP4, and Suzanne K. Wedel, MD4

Abstract
Introduction: We performed this study to quantify resources required by mechanically ventilated patients with hypoxemia after
critical care transport (CCT) and to assess short-term clinical outcomes. Methods: We performed a retrospective review of
transports of patients with severe hypoxemic respiratory failure from referring hospitals to 3 tertiary care hospitals to assess the
outcomes including in-hospital mortality, ventilator days, intensive care unit length of stay (LOS), hospital LOS, disposition, and
reported neurologic status on hospital discharge as well as medical interventions specific to acute respiratory failure and critical care.
Results: Of 230 patients transported with hypoxemic respiratory failure, 152 survived to hospital discharge, for a mortality rate of
34.5%, despite a predicted mortality of 64% by Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Twenty-five
percent of patients were treated with neuromuscular blockade, 10.1% received inhaled pulmonary vasodilators, and extracorporeal
membrane oxygenation was initiated in 2.6%. Conclusions: In this cohort with hypoxemic respiratory failure transported to tertiary
care facilities, patients had a mortality rate comparable to patients with acute respiratory distress syndrome treated with best practices
and a mortality rate lower than predicted based on APACHE-II score. The risks of CCT are outweighed by the benefits of transfer to a
tertiary care facility, and pretransport hypoxemia should not be used as an absolute contraindication to transport.

Keywords
complications, critical care, respiratory failure, hospital mortality, length of stay, mechanical ventilation, outcomes, resource
utilization
1
Division of Pulmonary, Critical Care and Sleep Medicine, Medical University
of South Carolina, Charleston, SC, USA
Introduction 2
Division of Emergency Medicine, Medical University of South Carolina,
Charleston, SC, USA
Over the last decade, studies have shown that transferring 3
Department of Emergency Medicine, Brigham and Women’s Hospital, Bos-
patients with acute respiratory distress syndrome (ARDS) to ton, MA, USA
tertiary care centers, especially those with extracorporeal mem- 4
Boston MedFlight, Bedford, MA, USA
5
brane oxygenation (ECMO) capabilities, improved survival as Division of Trauma and Acute Care Surgery, Department of Surgery, Brigham
compared to remaining in community hospitals.1,2 This finding and Women’s Hospital, Boston, MA, USA
6
Division of Vascular and Endovascular Surgery, Department of Surgery,
has increased interest in the development of ARDS centers,
Brigham and Women’s Hospital, Boston, MA, USA
similar to trauma or burn centers.3,4 However, patients with 7
Department of Emergency Medicine, Beth Israel Deaconess Medical Center,
hypoxemia specifically have been considered one of the most Boston, MA, USA
8
precarious patient populations to transport between facili- Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel
ties,5-7 and mechanical ventilation has been shown to be an inde- Deaconess Medical Center, Boston, MA, USA
pendent risk factor for an adverse events during transport.8,9 Received August 2, 2015, and in revised form November 24, 2015.
Prior studies have demonstrated that patients on mechanical ven- Accepted for publication November 30, 2015.
tilation are more than twice as likely to have an adverse event in
transport as compared to those not on ventilation.9 Ventilation Corresponding Author:
Susan R. Wilcox, Division of Pulmonary, Critical Care and Sleep Medicine,
with an fraction of inhaled oxygen (FiO2) of greater than 50% has Division of Emergency Medicine, Medical University of South Carolina, 96
also been associated with the risk of respiratory deterioration Jonathan Lucas Street, Suite 812-CSB, Charleston, SC 29425-6300, USA.
after transfer.7 Clinical circumstances may warrant transport, Email: wilcoxsu@musc.edu

Downloaded from jic.sagepub.com at CMU Libraries - library.cmich.edu on January 4, 2016

2 Journal of Intensive Care Medicine
however, as the benefits of transferring to a tertiary care facility
may offset the risks of transporting a mechanically ventilated
patient with hypoxemia.5,10 In the United States, these high
acuity patients are often transported by critical care transport
(CCT) teams, generally composed of specially trained nurses
and paramedics11-13 who provide intensive care procedures
beyond advanced life support capabilities, such as airway man-
agement, advanced ventilator support, invasive monitoring, and
other high level interventions similar to the care a patient would
receive in an intensive care unit (ICU).
Although prior studies have assessed outcomes associated
with interfacility transport of critically ill patients,2,14-20 the
majority of prior studies involve heterogeneous populations
of critically ill patients.14-18 Only one prior study has evaluated
the outcomes of patients transported with severe acute respira-
tory failure.2 Furthermore, resource utilization allocated to
critically ill patients with hypoxemia after interfacility CCT
has not been well described in the literature.
To quantify the resources required by critically ill, mechani-
cally ventilated patients with hypoxemia after CCT and to assess
these patients’ short-term clinical outcomes, we performed a ret-
rospective analysis of patients transported from community hos-
pitals to tertiary care centers with hypoxemic respiratory failure.
We quantified clinical interventions performed in the ICU after
transport, including interventions specific to respiratory failure
as well as general intensive care procedures. Clinical outcomes
were determined, including ventilator days, ICU length of stay
(LOS), hospital LOS, disposition, and in-hospital mortality rate.
We performed subgroup analyses of patients categorized by pre-
transport oxygen saturation (SpO2) in order to determine the out-
comes and resources used for patients with different levels of
pretransport hypoxemia.
Methods
This study was approved by the internal review boards (IRBs)
of the 3 receiving hospitals, with all IRBs waiving the need for
informed consent. We performed a retrospective review of
transports of mechanically ventilated patients with severe
hypoxemic respiratory failure from October 2009 to December
of 2012 from referring hospitals to 3 tertiary care hospitals. All
decisions to transfer a patient were initiated by the physicians at
sending facilities. Transport records were queried for the terms
‘‘ARDS,’’ ‘‘hypoxia,’’ or ‘‘hypoxemia.’’ Charts of patients
receiving an FiO2 of at least 50% were selected for inclusion,
and discharge summaries from the tertiary care hospital were
reviewed for resource utilization and outcomes data. Full study
details have been described previously.21
Transport records were reviewed for demographic data and
pertinent comorbidities, including obesity, asthma, chronic
obstructive pulmonary disease, immunosuppression, and preg-
nancy as well as diagnosis. Outcomes data extracted from
receiving hospital records included in-hospital mortality, venti-
lator days, ICU LOS in days, and hospital LOS in days. Dis-
charge summaries were reviewed to determine if discharge
disposition was to home or to another health care facility such
Downloaded from jic.sagepub.com at CMU Libraries - library.cmich.edu on January 4, 2016
as a rehabilitation center or skilled nursing facility. The primary
outcome was in-hospital mortality. Secondary outcomes were
ventilator days, ICU LOS, hospital LOS, disposition, and
reported neurologic status on hospital discharge. As this was a
retrospective review, without dedicated neurologic testing
recorded on each patient, the physical examination the day of
discharge as well as the discharge summary narrative was
reviewed to determine patients’ neurologic status, noting
whether the patient’s mental status at discharge was at the pre-
morbid baseline or not, per the documentation of the discharging
provider. If the clinicians documented a ‘‘normal’’ or ‘‘baseline’’
neurologic examination, patients were documented as having
achieved their premorbid baseline neurologic status.
Data regarding resource utilization were extracted from dis-
charge summaries and hospital medical records. Medical inter-
ventions specific to acute respiratory failure and hypoxemia
were tabulated, including the use of neuromuscular blockade,
esophageal balloon placement, administration of pulmonary
vasodilators, and ECMO initiation. Other medical interven-
tions not necessarily specific to respiratory failure that were
performed in the ICU after transport were similarly extracted
and tabulated.
Outcomes and resource utilization for patients who survived
to discharge were compared to patients who did not survive the
posttransport hospitalization. In addition, subgroup analyses of
outcomes and resource utilization were performed for patients
categorized by pretransport oxygenation based on pulse
oximetry.
Data were analyzed in a descriptive manner with patient
demographics and clinical outcomes reported as means and
standard deviations. The number of interventions performed
for all patients in the cohort was determined and is summarized
as unadjusted event rates and percentages.
After tabulating results in Microsoft Excel (Microsoft, Red-
mond, Washington), data were exported to JMP Pro version
11.0 (SAS Institute Inc, Cary, North Carolina) for statistical
analyses. Comparisons between outcomes and resource utiliza-
tion for survivors versus nonsurvivors were performed using
unmatched two-tailed student t tests with unequal variances.
For the subgroup analysis of patients with different pretransport
SpO2, patients were categorized into one of the 3 subgroups based
on initial saturations of 100% to 90%, 89% to 80% for moderate
hypoxemia, or <80% for severe hypoxemia.22,23 One-way analy-
sis of variance was used to compare outcomes and resource utili-
zation between these 3 subgroups. Pearson correlations were
calculated to assess for associations between mortality and trans-
port time between hospitals. For all statistical analyses, an a of
<.05 was considered to be statistically significant.
Results
We identified 239 charts of patients transported with
hypoxemic respiratory failure from 51 community hospitals
to 3 tertiary care centers. Of these, 230 charts had follow-
up information available. Patients were high acuity, with
a mean Acute Physiology and Chronic Health Evaluation II
Wilcox et al 3

Table 1. Patient demographics.

Mean age, years 54.4 + 17.3

Male sex 50.4%
Comorbidities No. (%)
COPD 46 (20.0)
Asthma 21 (9.1)
Obesity 56 (24.3)
Pregnancy 3, 1 postpartum (1.3, 0.4)
Cardiac disease 36 (15.7)
Cancer 35 (15.2)
Diabetes 33 (14.3)
HTN 54 (23.5)
Other chronic disease 75 (32.6)
Diagnosis No. (%)
H1N1 influenza confirmed or suspected 38 (16.5)
Pneumonia 103 (44.8) Figure 1. Patient outcomes.
Abdominal sepsis or pancreatitis 37 (16.1)
Aspiration 16 (7.0)
Other respiratory failure 32 (14.0) Table 2. Outcomes for All Patients.
ARDS not otherwise specified 16 (7.0) P Value (Survivors
Sepsis not otherwise specified 9 (4.0) Clinical Parameter Outcome vs Nonsurvivors)
APACHE II score 28.2 + 6.8
PaO2/FiO2 ratio at sending 107.4 + 63.0 mm Hg Mortality 78 (34.4%) N/A
Number of sending hospitals 51 Hospital days (mean and SD) <.001
Mode of transport All patients 17.1 + 16.5
Ground 147 Surviving patients 21.8 + 17.2
Rotor wing 76 Nonsurviving patients 8.1 + 10.8
Fixed wing 7 Ventilator days .009
All patients 9.3 + 11.0
Abbreviations: COPD, chronic obstructive pulmonary disease; HTN, hyper-
Surviving patients 10.6 + 12.1
tension; ARDS, acute respiratory distress syndrome; APACHE II, Acute Phy-
siology and Chronic Health Evaluation II; PaO2/FiO2, partial pressure of Nonsurviving patients 6.8 + 8.4
oxygen to fraction of inhaled oxygen. ICU days <.001
All patients 10.9 + 11.4
Surviving patients 13.0 + 12.5
Nonsurviving patients 7.14 + 7.64
(APACHE II) score of 28.2 + 6.8 and a mean partial
Disposition to home N/A
pressure of oxygen to FiO2 (PaO2/FiO2) of 107.4 + 63.0 All patients 77 (50.7%)
mm Hg. Additional patient demographics are outlined in Neurologic dysfunction N/A
Table 1. The most common etiology for respiratory failure At premorbid baseline 108
was pneumonia. Altered mental status 40
One hundred and fifty two patients survived to hospital Unknown 4
discharge, for an in-hospital mortality rate of 34.5%. Four Abbreviations: SD, standard deviation; ICU, intensive care unit.
patients arrested in transfer, all with bradycardic arrests that
devolved into pulseless electrical activity. One lost pulses
being transferred to the stretcher prior to transport, with significant associations between time in route (r ¼ .0058,
rapid return of spontaneous circulation and hemodynamic P ¼ .09) or total transport time (r ¼ .063, P ¼ .94) and in
stability throughout the remainder of the transport. Two hospital mortality.
patients who arrested in route experienced prompt return For the entire cohort, the mean hospital LOS was 17.1 +
of circulation in response to cardiopulmonary resuscitation. 16.5 days, with a range of 0 to 105 days and a mean ICU LOS
The final patient who suffered an arrest during transport did of 10.9 +11.4 days, with a range of 0 to 58 days (Table 2).
not achieve return of spontaneous circulation; this patient’s About half (46.7%) of the patients who survived were dis-
APACHE II score was 38, consistent with a predicted mor- charged to home, and 71% were documented to have a cogni-
tality of over 85%. None of the patients who arrested during tive status at their premorbid baseline. Patients who survived to
transport survived to hospital discharge. Overall, 9 patients discharge had significantly longer ICU LOS, hospital LOS, and
died within 24 hours of transport, including the 3 patients days of mechanical ventilation as compared to patients who
with arrest and return of spontaneous circulation (ROSC) died (Table 2).
in transport (Figure 1). Of the 230 patients, 228 were included in subgroup analyses
We found no significant association between mode of trans- assessing resource utilization. Specifically, one patient who
port (rotor wing, fixed wing, or ground transportation) and in died en route and one who died in the receiving hospital ED
hospital mortality (F2,227 ¼ .93, P ¼ .40). There were also no prior to ICU admission were excluded from subgroup analyses.

Downloaded from jic.sagepub.com at CMU Libraries - library.cmich.edu on January 4, 2016

4 Journal of Intensive Care Medicine

Table 3. Respiratory Interventions for All Patients. Table 4. Additional Interventions and Resources.

P Value Intervention Patients (%)

(Survivors vs
Intervention Frequency (%) Nonsurvivors) Echocardiogram 83a (36.1)
TTE 78 (33.9)
Neuromuscular .08 TEE 9 (3.9)
blockade Bronchoscopy 48 (20.9)
All patients 57 (25.0) Dialysis 41 (17.8)
Surviving patients 32 (21.7) Chest tube placement 28 (12.2)
Nonsurviving 25 (32.1) Cardiac catheterization 10 (4.3)
patients Surgical intervention
Esophageal balloon .92 Exploratory laparotomy 5 (2.2)
placement Thoracic surgery 5 (2.2)
All patients 9 attempts, 8 successful (3.5) Neurosurgery 2 (0.9)
Surviving patients 6 attempts, 5 successful (3.3) Cardiac surgery 2 (0.9)
Nonsurviving 3 attempts, 3 successful (3.8) GI procedures
patients ERCP 3 (1.3)
Inhaled pulmonary .16 EGD 7 (3.0)
vasodilators Colonoscopy 1 (0.4)
All patients 23 (10.1) Tracheostomy 44 (19.1)
Surviving patients 12 (7.9) Gastric tube placement 24 (10.4)
Nonsurviving 11 (14.1)
patients Abbreviations: TEE, transesophageal echocardiogram; TTE, transthoracic
echocardiogram; GI, gastrointestinal; ERCP, endoscopic retrograde cholangio-
ECMO .88
pancreatogram; EGD, esophagogastroduodenoscopy.
All patients 10 consults, initiated in 6 (2.6) a
Five patients had TTE and TEE.
Surviving patients 7 consults, initiated in 4 (2.6)
Nonsurviving 3 consults, initiated in 2 (2.6)
patients more impaired neurologic status. As only 2 patients survived
to discharge in severe hypoxemia subgroup, the clinical sig-
Abbreviation: ECMO, extracorporeal membrane oxygenation.
nificance of this finding is unknown.

Overall, the patients in this cohort required high significant

resource allocation. Fifty-seven (25.0%) patients were treated
with neuromuscular blockade, and 23 (10.1%) received inhaled
pulmonary vasodilators (Table 3). Consultation for ECMO was
performed for 10 patients, and ECMO was initiated in 6 (2.6%).
The decision to initiate ECMO was made on a case by case
basis by the clinicians caring for the patient. There were no sig-
nificant differences in utilization of respiratory interventions
between survivors and nonsurvivors (Table 3). In addition to
interventions for respiratory failure, patients required other
critical care resources, with 83 (36.1%) patients undergoing
echocardiograms, and 48 (20.9%) patients undergoing
bronchoscopy (Table 4). Dialysis was required in 41 (17.8%)
of patients, and a tracheostomy tube was placed in 44 (19.1%).
In assessment of resource utilization for the subgroups
defined by pretransport SpO2, 41% of patients with moderate
hypoxemia received neuromuscular blockade as compared to
21.7% of those with mild hypoxemia, and the proportion of
patients requiring ECMO increased from 1.6% in mild hypox-
emia to 20% in severe hypoxemia (Table 5). In addition, 20%
of patients with moderate and severe hypoxemia received pul-
monary vasodilators, significantly more than patients with mild
hypoxemia (10%).
The subgroup analysis for outcomes revealed a mortality
rate for patients with moderate hypoxemia of 39% as com-
pared to 60% for severe hypoxemia (Table 6). However, only
neurologic status at discharge was significantly different
between groups, as patients with more severe hypoxemia had
Discussion
Historically, the risk of oxygenation desaturation in transport
and subsequent short-term and long-term consequences, such
as cardiac arrest or neurologic deterioration, has been the pri-
mary concern regarding transport of patients with hypoxemia.7
While these very sick patients are at risk of cardiac arrest, the
rate of cardiac arrest in our study was low, at 1.7%, comparable
to a previous report of arrest in transfer of patients with severe
ARDS when transported with sophisticated ECMO teams.2
During transport in the current study, 4 patients had cardiac
arrest, and 1 patient did not have return of spontaneous circula-
tion en route. In all cases, cardiac arrest was precipitous,
although none appeared to be due to hypoxemia as all 4 patients
had an SpO2 of greater than 90% prior to arresting. Although 3
of the cardiac arrests were brief, this finding reinforces that a
CCT team must be prepared for cardiac arrest, a time and
resource-intensive moment in clinical care, at any given time
when transporting such high acuity patients.
Receiving hospitals should anticipate a substantial morbid-
ity and mortality when accepting patients with mechanically
ventilated hypoxemia in referral. In this cohort, patients had
a 34.5% mortality rate, and 9 patients in the group died within
24 hours of arrival at the tertiary care center. Over half of the
patients who survived were discharged to a facility for further
care, and almost 30% of survivors were documented to have a
neurologic examination on discharge that differed from their
baseline. Understanding the risks after transport can provide

Downloaded from jic.sagepub.com at CMU Libraries - library.cmich.edu on January 4, 2016

Wilcox et al 5

Table 5. Subgroup Analysis for Interventions and Resources.

Interventions Number (%) SpO2  90% (n ¼ 184) SpO2 80%-89% (n ¼ 39) SpO2 <80% (n ¼ 5) F statistic P Value

Neuromuscular blockade 40 (21.7%) 16 (41.0%) 1 (20%) 3.28 .04

Pulmonary vasodilators 14 (7.6%) 8 (20.5%) 1 (20%) 3.29 .04
Esophageal balloon 8 (5.0%) 1 (2.6%) 0 (0%) 0.21 .81
ECMO 1 (0.005%) 4 (10.3%) 1 (20%) 9.56 <.001
Bronchoscopy 38 (21.0%) 10 (25.0%) 0 (0%) 0.86 .42
Chest tube placement 22 (12.0%) 6 (15%) 0 (0%) 0.49 .61
Dialysis 29 (15.8%) 11 (28.2%) 1 (20%) 1.70 .19
Tracheostomy tube 34 (18.4%) 8 (20.5%) 2 (40%) 0.74 .48
Abbreviations: ECMO, extracorporeal membrane oxygenation; SpO2, oxygen saturation.

Table 6. Subgroup Analysis for Outcomes.

Outcomes SpO2  90% SpO2 80%-89% SpO2 70%-79% F statistic P Value

Mortality, % 32.1 37.5 60.0 1.01 .37

Ventilator days 9.1 10.1 8.2 0.14 .87
ICU days 10.8 11.6 9.2 0.14 .87
Hospital days 17.5 16.3 11.8 0.36 .70
Disposition home, % 52.5 46.1 0a 1.21 .30
Premorbid neurologic status at hospital discharge, % 76.0 63.0 0% 3.7 .0

Abbreviations: ICU, intensive care unit; SpO2, oxygen saturation.

a
Three of the 5 patients in this group did not survive to hospital discharge.

information for clinicians at the sending facility and the CCT
team to better discuss the risks and benefits of transport, such
that families appreciate that even after transport to a tertiary
care facility, individual outcomes may still be poor in critically
ill, mechanically ventilated patients with hypoxemia.
Despite the outcomes observed in this study, it is unlikely that
transport directly contributed to poor outcomes. We found no sig-
nificant association between mode of transport, time en route, or
total transport time and outcomes. Previous work has shown that
transport by a dedicated CCT team is associated with an improve-
ment in both the partial pressure of oxygen (PaO2) and the ratio of
PaO2/FiO2.17,21 In assessing the oxygenation parameters of these
transports, we previously reported that in these patients the mean
change in PaO2/FiO2 ratio from the sending to the receiving hospi-
tal was an increase of 27.62 (confidence interval [CI] 15.84-
39.40, P ¼ .0003) and the mean change in PaO2 was an increase
of 27.85 torr (CI 17.49-38.22, P < .0001).21 Given improved oxy-
genation after CCT, transport itself is unlikely to directly result in
high mortality rates, and the severity of patients’ disease is a more
likely explanation for outcomes.
Furthermore, the only randomized controlled trial involving
transporting patients with hypoxemic respiratory failure, the
Conventional Ventilation or ECMO for Severe Adult Respira-
tory Failure (CESAR) Trial, published in 2009, found that
patients randomized to be transferred to an ECMO center had
a 36.7% 6 month mortality compared to 48.9% for those rando-
mized to care in their original institution.2 Notably, in this
study, 2 of the 90 patients randomized to transport for ECMO
died in transfer. However, the authors still recommend transfer-
ring adult patients with severe but potentially reversible
respiratory failure to an ECMO center to significantly improve
survival without severe disability, as this study demonstrates
that despite risks of transport, the benefits of tertiary care for
hypoxemic respiratory failure on mortality are substantial.
Despite the high acuity of this population, this cohort of
transferred patients overall had better than predicted out-
comes. APACHE II has been shown to be a good predictor
of outcomes in critically ill patients,24 especially patients with
respiratory failure.25 The mean APACHE II score in this
cohort was 28, with a predicted mortality of approximately
64%,26 compared to the rate of 34% in our study. Addition-
ally, patients with moderate ARDS, with a PaO2/FiO2 ratio
of 100 to 200 mm Hg, when treated with best practices
including low tidal volume ventilation, have a mortality rate
of 32% (95% CI: 29-34).27,28 Our mortality rate was similar,
despite the severity of disease in this group, reinforcing the
premise that transfer for optimal respiratory and tertiary care
can offer patients the lowest possible mortality rate.
The patients in this cohort required a substantial amount of
resources. This patient population had both long ICU and long
hospital LOS, and survivors had substantially longer LOS than
nonsurvivors, demonstrating a survivor bias. Although many
of the interventions performed during the hospitalization are not
unique to tertiary care centers, all require specialist expertise and
dedicated equipment, such as echocardiograms, bronchoscopies,
and dialysis. Additionally, many of these interventions, espe-
cially respiratory interventions such as neuromuscular blockade
and inhaled pulmonary vasodilators, require considerable staff
resources and require time and training from both nursing and
respiratory care providers. The patterns and frequency of respira-
tory rescue therapy utilization in this cohort of patients trans-
ferred between hospitals are similar to previous reports of

Downloaded from jic.sagepub.com at CMU Libraries - library.cmich.edu on January 4, 2016

6 Journal of Intensive Care Medicine
homogenous populations of patients who did not undergo inter-
facility transport, but rather, presented directly to the tertiary
care facility.29 That rescue therapy utilization is similar, indicat-
ing that interfacility transport does not appear to substantively
change clinical practice patterns and resource utilization in
mechanically ventilated patients with hypoxemia. These obser-
vations can assist tertiary care anticipate resource allocation
needs when accepting such patients from community hospitals.
To evaluate the effect of hypoxemia at the time of the CCT
team’s arrival at the sending facility, we compared outcomes
and resource utilization for patients with mild, moderate, and
severely hypoxemia. Unsurprisingly, patients with more severe
hypoxemia were more likely to be treated with many respira-
tory interventions. However, the outcomes were not statisti-
cally significantly different, with the sole exception of fewer
patients with normal or baseline neurologic status among
patients with severe hypoxemia, although there were only 2
patients in who survived in the severe hypoxemia group, mak-
ing drawing conclusions in this group difficult.
Therefore, although transport to a tertiary care hospital does
not exclude possible adverse outcomes such as death or morbid-
ity, the benefits of tertiary care outweigh risks of transport for
critically ill, mechanically ventilated patients with hypoxemia.
Transfer to a tertiary care center to receive evidence based,
resource-intensive care likely offers significant advantage over
remaining at a community hospital with limited resources.
Limitations
The limitations of this study are largely related to the nature of the
retrospective design. Discharge records were reviewed thor-
oughly, however, some details of the hospitalization or resources
used may have not been recorded. However, this would underes-
timate the resources used, and therefore, the observation that this
patient population requires substantial resources remains valid.
The ability to assess for neurologic outcome was limited by nature
of the retrospective review, as the patients did not necessarily
undergo dedicated neurologic assessment prior to discharge.
However, we used the physical examination documented at the
time of discharge, as noted by the discharging provider, to record
the neurologic assessment by the team providing care. As the
decision to initiate ECMO was made on a case by case basis, the
generalizability of the ECMO findings may be limited. The sub-
groups of moderate and severe hypoxemia may have been under-
powered to detect differences in interventions and outcomes.
Additionally, these patients were transported by a highly trained
CCT team, and whether similar results could be obtained with
other transport systems is unknown.
Conclusion
In this group of patients transported to tertiary care facilities,
patients had a mortality rate comparable to patients having
ARDS treated with best practices and a mortality rate lower than
predicted based on APACHE-II score. However, they had a sub-
stantial use of resources at the receiving hospital, although
Downloaded from jic.sagepub.com at CMU Libraries - library.cmich.edu on January 4, 2016
resource utilization is similar to undifferentiated cohorts of
patients with ARDS who did not undergo interfacility transfer.
Given the small numbers of patients with severely hypoxemia
in this study, conclusions regarding this subgroup of patients are
limited. While mortality rates and resource utilization are sub-
stantial in this population, the risks of CCT appear to be out-
weighed by the benefits of transfer from a community hospital
to a tertiary care facility, and pretransport hypoxemia should not
be used as an absolute contraindication to interfacility transport.
Author’s Note
The work contained herein was performed at Massachusetts General
Hospital, Brigham and Women’s Hospital, and Beth Israel Deaconess
Medical Center, Boston, MA, USA.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This study
was supported by institutional funds without external grant support.
References
1. Noah MA, Peek GJ, Finney SJ, et al. Referral to an extracorpor-
eal membrane oxygenation center and mortality among patients
with severe 2009 influenza A (H1N1). JAMA. 2011;306(15):
1659-1668.
2. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic
assessment of conventional ventilator support versus extracorpor-
eal membrane oxygenation for severe adult respiratory failure
(CESAR): a multicentre randomized controlled trial. Lancet.
2009;374(9698):1351-1363.
3. Adalja AA, Watson M, Waldhorn RE, Toner ES. A conceptual
approach to improving care in pandemics and beyond: Severe
lung injury centers. J Crit Care. 2013;28(3):318. e9-15.
4. Kahn JM, Linde-Zwirble WT, Wunsch H, et al. Potential value of
regionalized intensive care for mechanically ventilated medical
patients. Am J Respir Crit Care Med. 2008;177(3):285-291.
5. Warren J, Fromm RE Jr, Orr RA, Rotello LC, Horst HM.
American College of Critical Care Medicine. Guidelines for the
inter- and intrahospital transport of critically ill patients. Crit
Care Med. 2004;32(1):256-262.
6. Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P.
Incidents relating to the intra-hospital transfer of critically ill
patients. an analysis of the reports submitted to the australian inci-
dent monitoring study in intensive care. Intensive Care Med.
2004;30(8):1579-1585.
7. Marx G, Vangerow B, Hecker H, Leuwer M, Jankowski M,
Piepenbrock S, Rueckoldt H. Predictors of respiratory function
deterioration after transfer of critically ill patients. Intensive Care
Med. 1998;24(11):1157-1162.
8. Singh JM, MacDonald RD, Bronskill SE, Schull MJ. Incidence
and predictors of critical events during urgent air-medical trans-
port. CMAJ. 2009;181(9):579-584.
Wilcox et al
9. Singh JM, Macdonald RD, Ahghari M. Critical events during land-
based interfacility transport. Ann Emerg Med. 2014;64(1):9-15.e2.
10. Whiteley S, Macartney I, Mark J, Barratt H, Binks R. On behalf of
the Council of the Intensive Care Society. Guidelines for the
Transport of the Critically Ill Adult. 3rd edition. London: Inten-
sive Care Society; 2011.
11. Roeder JR. Flight team configuration of an air medical serivce.
Top Emerg Med. 1994;16(4):66-72.
12. Gebremichael M, Borg U, Habashi NM, Cottingham C, Cunsolo
L, McCunn M, . . . Reynolds HN. Interhospital transport of the
extremely ill patient: the mobile intensive care unit. Crit Care
Med. 2000;28(1):79-85.
13. Kashani KB, Farmer JC. The support of severe respiratory failure
beyond the hospital and during transportation. Curr Opin Crit
Care. 2006;12(1):43-49.
14. Fan E, MacDonald RD, Adhikari NK, Scales DC, Wax RS, Stewart
TE, . . . Ferguson ND. Outcomes of interfacility critical care adult
patient transport: a systemic review. Crit Care. 2006;10(1):R6.
15. Barillo DJ, Dickerson EE, Cioffi WG, Mozingo DW, Pruitt BA Jr.
Pressure-controlled ventilation for the long-range aeromedical
transport of patients with burns. J Burn Care Rehabil. 1997;
18(3):200-205.
16. Remond C, Jimeno MT, Dubouloz F. Mesures du CO2 expire
en transport extrahospitalier: Interets et limites. Jeur. 1998;4:
179-186.
17. Uusaro A, Parviainen I, Takula J, Ruokonen E. Safe long-distance
interhospital ground transfer of critically ill patients with acute
severe unstable respiratory and circulatory failure. Intensive Care
Med. 2002;28(8):1122-1125.
18. Veldman A, Diefenbach M, Fischer D, Benton A, Bloch R. Long-
distance transport of ventilated patients: advantages and limita-
tions of air medical repatriation on commercial airlines. Air Med
J. 2004;23(2):24-28.
19. Orf J, Thomas SH, Wedel SK. Ventilation rates in intubated head
injury patients undergoing helicopter EMS (HEMS) transport
[abstract] Crit Care Med. 2000;28:A208.
Downloaded from jic.sagepub.com at CMU Libraries - library.cmich.edu on January 4, 2016
7
20. Strauch U, Bergmans DCJJ, Winkens B, Roekaerts PMHJ. Short-
term outcomes and mortality after interhospital intensive care
transportation: an observational prospective cohort study of 368
consecutive transports with a mobile intensive care unit. BMJ
Open. 2015:5(4):3006801.
21. Wilcox SR, Saia MS, Waden H, et al. Improved oxygenation after
transport in patients with hypoxemic respiratory failure. Air Med
J. 2015;34(6):369-376.
22. Mort TC. Emergency tracheal intubation: complications associ-
ated with repeated laryngoscopic attempts. Anesth Analg. 2004;
99(2):607-613.
23. Mort TC, Waberski BH, Clive J. Extending the preoxygenation
period from 4 to 8 mins in critically ill patients undergoing emer-
gency intubation. Crit Care Med. 2009;37(1):68-71.
24. Beck DH, Taylor BL, Millar B, Smith GB. Prediction of outcome
from intensive care: a prospective cohort study comparing Acute
Physiology and Chronic Health Evaluation II and III prognostic
systems in a United Kingdom intensive care unit. Crit Care Med.
1997;25(1):9-15.
25. Del Bufalo C1, Morelli A, Bassein L, et al. Severity scores in
respiratory intensive care: APACHE II predicted mortality better
than SAPS II. Respir Care. 1995;40(10):1042-1047.
26. Kane SP. Acute Physiology and Chronic Health Evaluation
(APACHE II) Calculator. Web site. ClinCalc: //clincalc.com/
IcuMortality/APACHEII.aspx. Published October 26, 2011.
Updated November 20, 2014. Accessed July 25, 2015.
27. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al.
Acute respiratory distress syndrome: the Berlin Definition. JAMA.
2012;307(23):2526-2533.
28. Khandelwal N, Hough CL, Bansal A, Veenstra DL, Treggiari
MM. Long-term survival in patients with severe acute respiratory
distress syndrome and rescue therapies for refractory hypoxemia.
Crit Care Med. 2014;42(7):1610-1618.
29. Walkey AJ, Wiener RS. Utilization patterns and patient outcomes
associated with use of rescue therapies in acute lung injury. Crit
Care Med. 2011;39(6):1322-1328.