ICU Without Walls—Interprofessional High Acuity Response Teams (HARTs) Improve Access to Higher Level of Care in Rural and Remote Communities

  • Interior Health
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Interior Health (IH) covers a vast mountainous territory in British Columbia with limited acute care services at the rural and remote hospitals and health centers. Traditionally, this area has been serviced by British Columbia Ambulance Service (BCAS) basic life support (BLS) ground paramedics, and a provincial critical care paramedic (CCP) air ambulance system. However, transportation within IH is challenged by long distances and severe winter weather, which affect flight conditions. When the air ambulance is unable to perform transport, the registered nurse (RN) and/or physician (MD) on duty in these communities has been required to transport acutely/critically ill or injured patients to a higher level of care, leaving these communities without health personnel for hours. As an alternative, IH has established flexible deployment High Acuity Response Teams (HART) comprised of critical care RNs and registered respiratory therapists (RRTs) based out of four regional hospitals. These HARTs help diagnose and treat evolving critical illness/injury at an earlier stage, and, because they are dedicated to inter-facility transport, the HARTs enable rural clinicians to remain on duty. From its inception, HART has used a program of continuous quality improvement (CQI) as a foundation to monitor quality of patient care and performance benchmarks. CQI data and patient care audits are analyzed by the clinicians, medical directors, and program managers to identify opportunities to enhance service delivery, professional development, and operational efficiency. This paper describes the establishment, scope, operations, and utilization of HARTs within IH.

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... Lastly, increasing peer-to-peer and patient outcome feedback for certain staff groups may provide peer support and improve patient management skills for newly qualified 119 120 and specialist paramedics. [121][122][123][124][125][126] ...
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Background Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development. Methods A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses. Results The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ ² =0.32 (95% CI 0.22, 0.50), with an I ² value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity. Conclusion This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS. PROSPERO registration number CRD42020162600.
... 21 All patients were transferred to one of the five receiving facilities for higher level care than was available locally and were transported by one of the four methods: ground basic life support (BLS) ambulance crew, air and ground critical care paramedic (CCP) ambulance crew, ground BLS ambulance crew with a doctor and nurse escort from the sending facility or a dedicated transfer team made up of a Registered Nurse (RN) and Registered Respiratory Therapist working with a ground BLS ambulance crew, known as a High Acuity Response Team (HART). 22,23 Criteria for inclusion were being 16 years or older on admission, direct admission to the sending site emergency department, a Canadian Triage and Acuity Scale (CTAS) score of one or two at the receiving facility, transport between 20 th November 2010 and 6 th October 2014 and categorisation as neurological, cardiac, respiratory, sepsis or trauma. Eligible records were identified through an electronic patient database and selected randomly for data extraction, which was carried out at the five receiving facilities by a researcher and a clinician. ...
Introduction: While 12.4% of British Columbians live rurally, only 2.0% of specialists practise rurally, making interfacility transport of high-acuity patients vital. Decision-making aids have been identified as a way to improve the interfacility transfer process. We conducted a pilot study to explore the potential of the Standardised Early Warning Score (SEWS) as a decision-making aid for staff at sending facilities. Methods: SEWSs were calculated from a database of 418 transfers from sending facilities in rural, small and medium population centres to larger receiving facilities. The SEWSs were compared against one another over time using McNemar's and the Wilcoxon signed-ranks tests. The SEWSs were then tested for their association with six outcomes using Pearson's or Fisher's Chi-squared test and the Mann-Whitney U-test. Results: While at the sending facility, both the number of SEWSs that was four or greater and the average SEWS decreased over time (P < 0.001 for both). A first SEWS of four or greater was predictive of more intervention categories during transport (P = 0.047), an adverse event during transport (P = 0.004), an adverse event within 30 min of arrival at the receiving facility (P = 0.004) and death before discharge from the receiving facility (P = 0.043) but not deterioration during transport, or the length of stay at the receiving facility. Conclusion: Overall, the performance of the SEWS in the context of rural interfacility transport suggests that the tool will have utility in supporting decision-making.
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Introduction: The High Acuity Response Team (HART) was introduced in British Columbia (BC), Canada, to fill a gap in transport for rural patients that was previously being met by nurses and physicians leaving their communities to escort patients in need of critical care. The HART team consists of a critical care registered nurse (CCRN) and registered respiratory therapist (RRT) and attends acute care patients in rural sites by either stabilizing them in their community or transporting them. HART services are deployed in partnership with provincial ambulance services, which provide vehicles and coordination of all requests in the province for patient transport. This article presents the qualitative findings from a research evaluation of the efficacy of the HART model, including staffing and inter-organizational functioning. Method: Open-ended qualitative research interviewing was done with key stakeholders from 21 sites. Research participants included HART CCRNs, RRTs, administrative leads, as well as local emergency department (ED) physicians and nurses. Thematic analysis was done of the transcripts. Results: A total of 107 interviews in 21 study sites were completed. Participants described characteristics of the model, perceptions of efficacy and areas for improvement. Rural sites reported a decrease in physician- and nurse-accompanied transports for high-acuity patients due to the HART team, but also noted challenges in delayed deployment, sometimes leading to adverse patient outcomes. Conclusions: The salient issues for the HART model were grounded in a somewhat artificial distinction between pre-hospital and interfacility transport for rural patients, which leads to a lack of service coordination and potentially avoidable delays. A beneficial systems change would be to move towards dedicated integration of high-acuity transport services into hospital organizational structures and community health services in rural areas.
Critical illness is often preceded by physiological deterioration. Track and trigger systems are intended to facilitate the timely recognition of patients with potential or established critical illness outside critical care areas. The aim of this article is to review the evidence for the use of such systems. Existing track and trigger systems have low sensitivity, low positive predictive values, and high specificity. They often fail to identify patients who need additional care and have not been shown to improve outcomes. The development of such systems must be based on robust methodological and statistical principles. At present, few track and trigger systems meet these standards. Although track and trigger systems, combined with appropriate response algorithms, have the potential to improve the recognition and management of critical illness, further work is required to validate their utility.
Little is known about the risks of urgent air-medical transport used in regionalized health care systems. We sought to determine the incidence of in-transit critical events and identify factors associated with these events. We conducted a population-based, retrospective cohort study using clinical and administrative data. We included all adults undergoing urgent air-medical transport in the Canadian province of Ontario between Jan. 1, 2004, and May 31, 2006. The primary outcome was in-transit critical events, which we defined as death, major resuscitative procedure, hemodynamic deterioration, or inadvertent extubation or respiratory arrest. We identified 19 228 patients who underwent air-medical transport during the study period. In-transit critical events were observed in 5.1% of all transports, for a rate of 1 event per 12.6 hours of transit time. Events consisted primarily of new hypotension or airway management procedures. Independent predictors of critical events included female sex (adjusted odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1-1.5), assisted ventilation before transport (adjusted OR 3.0, 95% CI 2.3-3.7), hemodynamic instability before transport (adjusted OR 3.2, 95% CI 2.5-4.1), transport in a fixed-wing aircraft (adjusted OR 1.5, 95% CI 1.2-1.8), increased duration of transport (adjusted OR 1.02 per 10-minute increment, 95% CI 1.01-1.03), on-scene calls (adjusted OR 1.7, 95% CI 1.4-2.1) and type of crew (adjusted OR 0.6 for advanced care paramedics v. critical care paramedics, 95% CI 0.5-0.7). Critical events occurred in about 1 in every 20 air-medical transports and were associated with multiple risk factors at the patient, transport and system levels. These findings have implications for the refinement of training of paramedic transport crews and processes for triage and transport.
ASTNA standards for critical care & specialty ground transport
  • L L Demmons
  • S E James
Demmons LL, James SE. ASTNA standards for critical care & specialty ground transport. 2nd ed. Greenwood Village: Air & Surface Transport Nurses Association; 2010.