Michael A Frakes

Hartford Hospital, Hartford, Connecticut, United States

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Publications (44)37.53 Total impact

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    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.
    No preview · Article · Dec 2015 · Journal of Intensive Care Medicine
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    ABSTRACT: Objective The purpose of this study is to measure the rate and magnitude of changes in oxygenation that occur in patients with hypoxemic respiratory failure after transport by a critical care transport team. Methods We performed a retrospective review of 239 transports of patients with hypoxemic respiratory failure requiring a fraction of inspired oxygen (Fio2) > 50% transported from October 2009 to December 2012 from referring hospitals to 3 tertiary care hospitals. We analyzed the change the ratio of the partial pressure of oxygen in the blood to FiO2 from the sending to the receiving hospital as well as the percentage saturation of oxygen (Spo2) before, after, and en route. Results The mean change in the Pao2/Fio2 ratio from the sending to the receiving hospital was an increase of 27.62 (95% confidence interval [CI], 15.84-39.40; P =.0003). The mean change in Pao2 was an increase of 27.85 mm Hg (CI, 17.49-38.22; P <.0001). The mean Spo2 was not significantly changed at -0.12 (CI, - 1.69 to 1.45, P =.9). Despite improvement in the Pao2/Fio2 ratio and a stable Spo2 on arrival, 28.1% of patients desaturated to Spo2 < 90% in transport. Conclusion In patients with hypoxemic respiratory failure, Pao2/Fio2 and Pao2 increased after transport by a critical care transport team despite 28.1% of patients desaturating with hypoxemia in transit.
    No preview · Article · Nov 2015 · Journal of Air Medical Transport
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    ABSTRACT: Introduction Critical care transport (CCT) teams must manage a wide array of medications before and during transport. Appreciating the medications required for transport impacts formulary development as well as staff education and training. Problem As there are few data describing the patterns of medication administration, this study quantifies medication administrations and patterns in a series of adult CCTs. This was a retrospective review of medication administration during CCTs of patients with severe hypoxemic respiratory failure from October 2009 through December 2012 from referring hospitals to three tertiary care hospitals. Two hundred thirty-nine charts were identified for review. Medications were administered by the CCT team to 98.7% of these patients, with only three patients not receiving any medications from the team. Fifty-nine medications were administered in total with 996 instances of administration. Fifteen drugs were each administered to only one patient. The mean number of medications per patient was 4.2 (SD=1.8) with a mean of 1.9 (SD=1.1) drug infusions per patient. These results demonstrate that, even within a relatively homogeneous population of patients transferred with hypoxemic respiratory failure, a wide range of medications were administered. The CCT teams frequently initiated, titrated, and discontinued continuous infusions, in addition to providing numerous doses of bolused medications. Wilcox SR , Saia MS , Waden H , McGahn SJ , Frakes M , Wedel SK , Richards JB . Medication administration in critical care transport of adult patients with hypoxemic respiratory failure. Prehosp Disaster Med. 2015;30(4):1-5.
    No preview · Article · Jul 2015 · Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation
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    Full-text · Article · Sep 2013 · The American surgeon
  • Suzanne K Wedel · Richard A Orr · Michael A Frakes · Alasdair K T Conn

    No preview · Article · Feb 2013 · Critical care medicine
  • Michael A. Frakes · Heather A. Waden · Suzanne K. Wedel
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    ABSTRACT: It is clear that trauma outcomes improve when patients are cared for in an organized trauma system. As the trauma care system does not end with resuscitation or injury repair, neither does it begin there: Trauma care begins with the emergency medical services (EMS) system and includes all out of-hospital care components. EMS management of penetrating trauma outside the hospital is focused on accessing the patient safely, addressing immediately life-threatening injuries, and promptly transporting the patient to an appropriate trauma center. EMS may also have a beneficial role in determining resource utilization and in-hospital point of entry, as well. Important elements of clinical care include the following: 1) cervical spinal cord injury is rare in patients with penetrating trauma and can usually be predicted by mechanism, 2) prehospital endotracheal intubation for trauma patients is controversial and if done should be performed in systems with high procedure volume and with quality improvement processes, and 3) there is minimal benefit to prehospital volume resuscitation in penetrating trauma. Finally, there is a suggestion that reduced times to definitive care are beneficial. When patients are taken to non-trauma centers or to non-tertiary centers, transfer to a higher level center improves outcomes, and as patients increase in acuity and complexity, patient safety during movement requires providers with greater clinical and transport expertise. Each trauma system must construct an appropriate model for both transport to the hospital and, as needed, transport between hospitals.
    No preview · Chapter · Dec 2011
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    ABSTRACT: Myocarditis and malignant dysrhythmias are unusual presentations in pediatric patients. We report a series of 4 patients with myocarditis and arrhythmia who presented to community emergency departments and were transported to a pediatric tertiary-care center. Three of the patients required extracorporeal life support. We discuss considerations for stabilization and transport: airway and ventilation, hemodynamic support, induction and sedation medication choices, transport decisions, and the traits of an ideal receiving center.
    No preview · Article · Jul 2010 · Pediatric emergency care
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    ABSTRACT: Prolonged endotracheal tube cuff pressures (ETTCPs) greater than 30 cm H2O can cause complications. With increasing utilization of cuffed endotracheal tubes (ETTs) in pediatric patients comes the risk of overinflation. We evaluated the incidence of elevated ETTCP in pediatric patients intubated with cuffed ETTs, transported by a critical-care transport service and attempted to identify whether elevated ETTCP was associated with factors such as patient demographics, diagnostic category, and intubator credentials. In this prospective study, assessment of ETTCP was made upon transport crew arrival at the bedside. The study focused on a consecutive sample of pediatric patients undergoing transport with cuffed ETTs placed before transport team arrival. All patients had cuff pressures assessed by the same cuff manometry device. Pressures found to be greater than 30 cm H2O were corrected immediately. Forty-one percent of cases met the a priori defined cutoff for elevated ETTCP of 30 cm H2O; 30% of those elevated cuff pressures were twice that cutoff (>60 cm H2O). There were no associations between high ETTCP and any of the following independent variables: demographics, physician versus nonphysician intubator, and intubation location (ie, scene vs emergency department vs intensive care unit). A significant number of pediatric patients transported by a critical-care transport service had elevated ETTCP. Furthermore, there was no clear risk factor for elevated cuff pressures. This is further evidence that cuff pressures should be measured in all patients. Further research should focus on the effect of educational intervention and on the possible clinical results of elevated ETTCPs.
    No preview · Article · May 2010 · Pediatric emergency care
  • Michael A. Frakes · Laura Connelly · John Pliakas · Suzanne Wedel
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    ABSTRACT: Purpose: Early goal directed sepsis therapies are associated with improved outcomes. Critical care transport (CCT) teams often provide early care for septic pediatric patients. We report on the population seen by a generalist CCT team and their interventions. Methods: A retrospective review of pediatric (age < 16) patients with ICD-9 codes for infection transported by a single CCT team from 2002 - 2007. Septic shock was defined a priori as hypotension or vasopressor need, and hypoxia as SpO2 < 93%. Results: There were 315 patients: 205 (65.1%) male, and a mean age of 3.1 +/-3.9 years. Slightly more patients (n = 158, 51.1%) were sent from an Emergency Department, and most went to an inpatient unit (n = 237, 75.2%). Transport time was 30.1 +/- 18.1 minutes (range 6 – 150). There were 75 (23.8%) patients in septic shock, with no demographic differences between the shock and non-shock groups. Of the shock group, 46 (61.3%) were hypotensive at transport team arrival. During transport, 21 (45.7%) reached target MAP and none became hypotensive. In the non-shock group, 25 (9.3%) patients became hypotensive in transport. The unadjusted odds ratio of hypotension at the end of transport was 0.09 (95% CI 0.04 - 0.18). On initial presentation, 37 (49.3%) shock patients had not received 20 cc/kg of IV fluid (IQR 2.0 -16.5 cc/kg). At the end of transport, 13 (35.1%) had finished their first bolus, leaving 24 (32%) shock patients who did not receive a full fluid bolus prior to arrival at tertiary care (IQR 5.8 – 15.3). Of the 50 patients with hypotension at the end of transport, 40 (80%) had received at least 20 cc/kg of IV fluid and three were on a vasopressor (6%). There were 30 patients (9.5%) who were hypoxic at transport team arrival. Saturation improved in transport for 19 hypoxic patients (63.3%) but three normoxic patients (1.1%) became hypoxic. The unadjusted odds ratio of hypoxia at the end of transport was 0.02 (95% CI 0.00 – 0.07). In the shock group, 8 patients (10.7%) were hypoxic. During transport, saturation improved for 3 (37.5%) and one shock patient became hypoxic (1.5%). The unadjusted odds ratio of hypoxia at the end of transport for shock patients was 0.01 (95% CI 0.00 - 0.10). Conclusion: This generalist specialty care transport team frequently found infected pediatric patients in septic shock or hypoxic, and the team achieved significant improvements in MAP, SpO2, and volume resuscitation during transport. Opportunities for performance improvement exist in the early administration of IV fluid and in the addition of vasopressors to the management of hypotensive pediatric septic shock patients by the transport team.
    No preview · Conference Paper · Oct 2009

  • No preview · Article · Sep 2009 · Annals of Emergency Medicine
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    ABSTRACT: Pain relief is a key out-of-hospital patient care outcome measure, yet many trauma patients do not receive prompt analgesia. Although specialty critical care transport (CCT) teams provide analgesia frequently, successfully, and safely, there is still a population of CCT patients to whom analgesia is not offered. We report the factors associated with non-administration of analgesia and with analgesic effect in trauma patients cared for by CCT teams. This is a retrospective review of consecutive transport records for nonintubated trauma patients with self-reported pain during specialty CCT care. Patient demographics, CCT interventions, clinical traits, and pain self-reports are measured. Means comparisons are made with a univariate analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) are reported for between-group comparisons. Of the 209 enrolled patients, 169 (80.9%; 95% CI, 75.6%-86.2%) were treated (147 received analgesia and 22 offered analgesia but refused). In patients with pain scale documentation (n=145), self-reported pain on a scale from 0 to 10 decreased from 6.8+/-2.8 to 3.3+/-2.4 (P<or=.001). Three factors were associated with absence of analgesic administration: initial pain level (OR for administration, 0.13; 95% CI, 0.04-0.40), pain scale documentation (OR, 0.31; 95% CI, 0.15-0.60), and transport program (OR, 0.36; 95% CI, 0.17-0.74). No clinical factor was associated with analgesia effectiveness in treated patients. The identified factors may represent opportunities for CCT teams to optimize analgesic treatment.
    No preview · Article · Feb 2009 · The American journal of emergency medicine
  • Michael Sahjian · Michael A. Frakes
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    ABSTRACT: Structure fires are a common occurrence; however most deaths from them are not the result of burns, but inhalation of toxic substances. The process of combustion frequently results in the production of hydrogen cyanide and carbon monoxide along with other gases. The result can be wide ranging and understanding the effects and suspecting toxic exposure can aid with treatment decisions.
    No preview · Article · Mar 2008 · Advanced emergency nursing journal
  • Michael A Frakes · Lisa Duquette

    No preview · Article · Jan 2008 · AirMed
  • Michael Sahjian · Michael Frakes
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    ABSTRACT: Crush syndrome, or traumatic rhabdomyolysis, is an uncommon traumatic injury that can lead to mismanagement or delayed treatment. Although rhabdomyolysis can result from many causes, this article reviews the risk factors, symptoms, and best practice treatments to optimize patient outcomes, as they relate to crush injuries.
    No preview · Article · Oct 2007 · The Nurse Practitioner
  • Michael A Frakes · Samantha Van Voorhis
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    ABSTRACT: Checklists are a frequently recommended strategy for minimizing human error in both the aviation and medical industries, yet checklist noncompliance is sometimes cited as a factor in untoward incidents. We evaluate the use of a challenge-and-respond checklist designed to ensure compliance with basic pre-departure safety preparations by medical personnel at a helicopter air medical program. The studied helicopter air medical transport program uses an interactive, challenge-and-respond checklist prior to departure to verify completion of four operational safety items. This is a prospective, convenience sample evaluation of 33 observations in which a checklist violation was created artificially and detection of that violation by the transport team was measured by direct observation. Characteristics of the transport by time, site of origin, and patient acuity were also recorded. Undetected violations were corrected by the investigator prior to departure, ensuring operational safety. Seven of the violations (21.2%) were detected by the transport team during routine completion of the checklist. Team members with less than 3 years of experience in the program had a 10% detection rate (95% confidence interval [CI], 1.5-23.1), whereas those with greater than 3 years experience in the program had a 38.5% detection rate (95% CI, 12.0-65.0). In this sample, no other observed variable suggested an association with detection rates. Routine completion of an interactive challenge-and-respond checklist by medical personnel had a low rate of detecting operational safety omissions in the studied helicopter critical care transport program. There was some difference in results by crew tenure.
    No preview · Article · Sep 2007 · AirMed
  • Michael A Frakes · Steve W Neher
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    ABSTRACT: Defibrillation is a time-critical and life-saving intervention for patients in ventricular fibrillation or ventricular tachycardia. The preparation of rotor-wing critical care transport teams to manage such arrhythmias out of the transport vehicle is unclear. A mail and telephone survey of 230 rotor-wing critical care transport programs. Transport teams take a defibrillator to the patient's side on scene flights at 23.9% of programs, on interfacility flights at 48.3%, and after off-load at the receiving hospital at 43.1% of programs. Monitor style and utilization are associated with defibrillator deployment on scene flights, interfacility flights, and at offload. The site of patient origin does not affect transport team defibrillator availability on offload. It is not completely clear that defibrillators are immediately available during all phases of rotor-wing critical care transport. There are many opportunities for additional investigation.
    No preview · Article · May 2007 · AirMed
  • Michael Sahjian · Michael Frakes
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    ABSTRACT: Crush syndrome, or traumatic rhabdomyolysis, is an uncommon traumatic injury that can lead to mismanagement or delayed treatment. Although rhabdomyolysis can result from many causes, this article reviews the risk factors, symptoms, and best practice treatments to optimize patient outcomes, as they relate to crush injuries.
    No preview · Article · Apr 2007 · Advanced emergency nursing journal
  • Michael A Frakes · John G Kelly
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    ABSTRACT: Operational safety, both crash prevention and improved crash survival, is a central concern in the air medical community. Professional organizations have published operational safety guidelines, but the extent to which those guidelines are followed is unclear. We report the results of a survey of adherence with selected safe practice recommendations. An anonymous survey of adherence with 8 individual and 11 program safety guidelines was distributed to flight team members at 10 Association of Air Medical Services-member rotor-wing air medical programs selected by stratified random sample to ensure geographic diversity. Descriptive statistics are reported and relationships are evaluated with the chi-square test. The sample size provided 80% power at a .05 significance level for the comparisons. Data were analyzed from 126 of the 200 surveys distributed. Adherence with program-wide safety behaviors ranged from 41.3% (complete a pre-departure checklist) to 99.2% (program has an annual safety review). Adherence to individual behaviors ranged from 15.1% (wear fire-resistant gloves) to 99.2% (wear seatbelts and shoulder harnesses on approach and departure). There was 100% adherence to wearing helmets by the respondents whose program provided a helmet at no cost to the staff member. There were no associations between job description and any individual behavior. Hospital-operated programs were less likely to have a daily briefing (P < .05), less likely to have a written policy allowing flight refusal for fatigue (P < .01), and tended toward lower rates of having a written policy allowing flight refusal for fatigue (P = .07). Non-hospital-operated programs were less likely to provide helmets (P < .001), to operate in an airframe with a clear headstrike area (P < .001), and to wear long-sleeved fire-resistant flight suits (P = .01). Both organizational and individual adherence to community safety recommendations are variable and not universal. There is variability by operational models.
    No preview · Article · Mar 2007 · AirMed
  • Michael A Frakes · John G Kelly
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    ABSTRACT: Twenty-four hour availability creates physiological and psychological challenges for air medical teams. The 24-hour shift (24H) is a common staffing pattern in the air medical community. We report sleep dept and pre-duty activity patterns for 24H medical staff members at helicopter air medical transport programs. An anonymous survey collecting self-reported sleep quantities for off-duty, immediate pre-duty, and on-duty periods, along with self-reported outside employment patterns, was distributed to medical team members at cluster sample of 10 rotor wing air medical programs selected by stratified random sample to ensure geographic and operational diversity. Both matched-sample comparisons of sleep quantities in different phases of the duty-cycle and independent-sample comparisons between staff with and without outside employment had 80% power to detect a difference in means of 60 minutes at a 0.05 two-sided significance level using the appropriate t-test. Descriptive statistics are also reported; means are reported with the standard deviation. A total of 138 surveys were returned (69.0%) and the 133 (66.5%) that were fully completed were utilized for analysis. 24H crewmembers average nearly the same amount of sleep in 24 hour periods on both duty and non-duty days (6.9 +/- 1.3 v. 6.4 +/- 1.8 hours, p = NS, range 3 - 10 for duty days and 4 - 10 for non-duty days). On duty, they average 1.1 +/- 1.3 hours of sleep in the first half of their shifts (range 0 to 5) and 5.3 +/- 1.4 hours in the overnight portion (range 2 - 9). The lowest amount of on-duty sleep reported in the past 30 days ranged from 0 to 6 hours, averaging 1.9 +/- 1.7 hours. The minimum pre-duty sleep reported by 24H crewmembers prior to any shift in the past month averaged 4.6 +/- 1.6 hours (range 0-8), with 3.8% having reported in the past month with no sleep before their 24-hour shift. Outside employment (OE) in addition to the flight position was common for 24H crewmembers (81.1% of respondents). Pre-duty sleep did not differ significantly between 24H crewmembers with and without OE, but 16.3% of surveyed 24H crewmembers with OE had reported for flight duty within eight hours of leaving OE within the past 30 days. In the programs surveyed, 24H crewmembers completed an average duty cycle with little sleep debt and were unlikely to be sleepless prior to reporting for a shift. OE is common for 24H medical staff and some personnel report for flight duty within eight hours of leaving an OE position. As the industry considers the impact of fatigue on operational safety, shift length, on-duty rest, and outside employment will be important considerations.
    No preview · Article · Feb 2007 · AirMed
  • Michael A Frakes · Tracylain Evans
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    ABSTRACT: The federal government spends nearly 15% of the budget on Medicare services annually, and advanced practice nurses are eligible for reimbursement from that pool. The regulations governing reimbursement are complex because of the social, political, and financial pressures involved in their development. Although economic viability and due diligence considerations make it incumbent on advanced practice nurses to understand the rules, the profession, as a whole, has knowledge deficits in this area. The essentials of regulatory development and structure are reviewed and considerations for optimizing reimbursement are described.
    No preview · Article · Jan 2007 · Dermatology nursing / Dermatology Nurses' Association