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CE Article: Interfacility Transport of the Burn-Injured Patient, Part 2
Objectives
Upon conclusion of this course, students will be able to:
- Recite criteria outlined by the American College of Surgeons Committee on Trauma and the American Burn Association (ABA) that dictate the types of burn injuries that should be referred to verified burn centers;
- Explain the community need for specialized resources and systems to safely transfer patients with critical burn injuries to the proper level of care;
- Develop a protocol to address transport of critical burn patients from a local hospital to a regional burn center;
- Detail the list of necessary and recommended supplies for ground and air transfer of the critical burn-injured patient.
Where burn care is immediately available, a local protocol should be developed to address transport from emergency scenes directly to the burn center. However, due to geography or overall distance, that is not the case for many communities. This article was created as a guide for agencies that must transport patients from a local hospital to a regional burn center. Each EMS agency that responds to 9-1-1 calls should consider a direct transport protocol from the scene to a verified burn center for serious burn injuries to avoid delays in definitive care.
The first part of this review covered the referral process and equipment; find it here. This second and concluding part addresses patient contact, assessment/evaluation, legal considerations, transport options, and destinations.
Assessment and Evaluation
Upon arrival at the referring (transferring) hospital, obtain all pertinent information related to the cause of injury and care provided to this point. Meet with the nurse or physician who called for the transfer and verify the destination hospital on the paperwork matches their verbal instructions. This will include a risk/benefit statement that must be completed by the transferring physician in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA).1 The referring physician must conduct an analysis to ensure the benefit of the transfer outweighs its risks.
The EMTALA requirement also includes that the level of care at the destination facility reasonably match that being provided prior to the transfer. Other paperwork includes any x-rays, laboratory results, other scans (e.g., MRI, CT), and progress notes. While many of these can be transmitted electronically, it is essential to ensure that information either accompany you or is forwarded to the receiving facility.
EMTALA is the main federal law that applies to emergency screening and interfacility transfer.2 With some exceptions, it generally provides that once a patient has arrived at a participating hospital, they must be screened for a life-threatening emergency condition, and appropriate treatment provided. For most burn patients this occurs at a community hospital, the first stop before transfer to a burn center.
EMTALA requires the initial receiving hospital to provide necessary stabilizing treatment for emergency medical conditions within its capacity and an appropriate transfer of an unstabilized individual to another medical facility if the individual or their representative, after being informed of the risks and the hospital’s obligations, requests it and a physician has certified the benefits outweigh the risks. Another qualified medical person may sign this certification after consulting with a physician if the physician is not physically present in the ED when the individual is transferred.
The sending hospital must provide treatment to minimize the risks of transfer, send all pertinent records to the receiving hospital, obtain the consent of the receiving hospital to accept the transfer, and ensure the transfer is effected through qualified personnel and equipment. Medical screening and/or stabilizing treatment cannot be delayed by inquiries about payment status.
Receiving hospitals must accept the appropriate transfer of individuals with an emergency medical condition if they have specialized capabilities and the capacity to treat them.2
All information in this article regarding EMTALA is current at the time of writing. Nevertheless, your policies and practices related to it should be reviewed by legal representation and reflect the most recent guidance from CMS.
Patient Assessment
The bedside patient assessment begins with determining a baseline level of consciousness and verifying the airway is patent and can be maintained throughout the transfer. If the patient is not intubated but the airway could be compromised during transfer secondary to an inhalation injury, the patient should be intubated. If the current airway is a blind-insertion airway device, replace it with an endotracheal tube. If an endotracheal tube is used to secure the airway, also place a nasogastric tube.
If the patient is being ventilated, check the ventilator settings. If the ventilator to be used during transfer does not include the capabilities of the ventilator being used, discuss it with the transferring physician. These capabilities may include settings such as assist control, synchronized intermittent mandatory ventilation, airway pressure-release ventilation (APRV), and continuous positive airway pressure. Continue the use of oxygen and adjust accordingly based on the targeted arterial blood gas (PaO2 90–130) or SpO2 (97–100).
Use dry oxygen only to move the patient from the hospital to the ambulance; otherwise the patient should continue to receive humidified oxygen. If an APRV mode of ventilation is used, it is imperative to discuss with the transferring physician, as removal of the patient from the ventilator even temporarily may result in a sudden cyclic recruitment/decruitment of alveoli and immediate instability of respiratory status.3
If a paralytic has been used, determine when it was administered and how much is needed to keep the patient sedated during transport. Once a paralytic has been initiated, this medication (or a suitable substitute) should accompany the patient throughout the transport with sufficient orders to keep them paralyzed. As a reminder, paralysis does not mean the patient is pain-free. Even worse, the patient may be unable to fully communicate pain because of the paralytic. Rely on indicators such as agitation, tearing, and tachycardia as indicators of pain and manage it accordingly.
Convert IV fluids to lactated Ringer’s (LR) and use it throughout the transfer. Check the infusion settings based on the consensus formula for fluid resuscitation (see table) or, if a urinary catheter has been in place for more than 30 minutes, use the urine output as a guide for adjusting the IV fluid infusion. Across the burn care profession, there are several fluid formulas in use, including the Parkland formula, consensus formula, and Brooke formula. Any of these can serve as a good starting point, but all should be abandoned once a urinary catheter is in place. If a urinary catheter has not been inserted, do so before transferring the patient and base ongoing fluid resuscitation on a urine output of 35–50 mL per hour (unless the patient has an electrical burn injury).4
The typical IV fluid infusion used is LR or 0.9% NaCl solution (with LR preferred). These fluids are also known as crystalloid solutions. There is evidence to suggest the use of colloid solutions may have some advantage, but it is recommended to defer that decision until the patient reaches a verified burn center.
Assess distal neurocirculatory function for all extremities, including an assessment to determine if a circumferential burn has occurred. If so, discuss potential escharotomy (typically performed by a surgeon) prior to transfer. An escharotomy is a longitudinal incision through the burned skin to decompress underlying tissues and facilitate perfusion. In the minutes following an escharotomy, reperfusion of the tissue can result in bleeding, which should be addressed at the time of the procedure. Wounds are typically dressed in a temporary dressing such as rolled gauze during transport.
Reassess the total body surface area assessment (TBSA) for a burn injury. For the TBSA assessment, do not include superficial (first-degree) burn injuries. An accurate TBSA includes only partial-thickness (second-degree) and full-thickness (third-degree) burns. TBSA is an important component of IV fluid resuscitation formulas. Two of the more common mistakes in burn care include excessive fluid resuscitation and overtriage due to including superficial burns in the TBSA assessment and including the total number for the entire extremity when only a portion is burned.5
Vital sign assessment should include the patient’s core body temperature. Hypothermia is a clear and present danger for serious burn injuries when the body has lost its ability to maintain normal temperature. Take steps to ensure the patient remains normothermic. Continue to monitor the blood pressure; use of a NIBPM is ideal given the amount of pain management that may be indicated during the transfer. Other vital signs include heart rate, respiratory rate, skin color, and skin turgor.
Wound care should include covering the burn injury with clean, dry dressings. While clean water can be used to cool the site, stop this process once the burning process has been stopped.6 Assess the temperature of the burn injury by palpating the uninjured area contiguous to it. If the burn size is 15% TBSA or more, pain management should include pharmacological agents such as morphine sulfate rather than cool water, which when used in excess can lead to hypothermia.
Other care includes the administration of a tetanus immune globulin (if applicable). Tetanus is a risk for burn-related wounds. There are a variety of tetanus-related vaccines based on the patient’s age; however, there is no unique formula for a burn injury. The tetanus vaccine that should be used is based on normal indicators, which include age and prior vaccine history.
With extremities, assess for circumferential burns and pay close attention to distal circulation and neurological function. Elevate any extremity that has a burn injury—gravity will promote pooling and further compromise circulation if the extremity is below the level of the heart during transfer.
Stabilization and Transfer
If the patient is intubated, place a nasogastric tube where possible, as well as a urinary catheter. Record the input and output prior to transport, and the patient should receive nothing by mouth during care at the community hospital or during the transfer.
Copies of labs and imaging should also be secured or electronically transmitted to the burn center. Typical labs may include electrolytes, glucose, creatinine, blood urea nitrogen (BUN), complete blood count (CBC), and urinalysis.
Regardless of how elaborate the capabilities of the mobile intensive care unit, medical helicopter, or fixed-wing aircraft, clinical resources in any vehicle are limited compared to those of a verified burn center. For critical injuries, initiate the transport immediately with the aim of providing high-level care.1 The team and vehicle should reflect the needs of the patient as well as the resources reasonably available.
Burn injury is time-sensitive. Aeromedical transport may be indicated, but much depends on weather conditions, proximity to the receiving hospital, and the ground transport resources available. For some communities the regional burn center may be located in a neighboring community and patients can safely be transferred by ground. Make the air/ground decision based on the distance to be covered, care available during the transfer, severity of the injury, and EMTALA requirements.
Ground and air ambulances have wide varieties of team configurations, layouts, and available equipment. A community hospital will typically know what is available to it for a transfer. For some areas, the best solution is to contact the receiving hospital, which has a team with specialized equipment, vehicles, and trained personnel. EMS systems that provide critical care transport services will also be able to provide the specialized knowledge and equipment to facilitate these transports and can often more quickly assemble a team and transport them to the sending hospital. For other areas, the best (or only) resource may be a local ambulance with additional supplies or personnel.
Patients with burn injuries are best managed at verified burn centers where specialized care is available.7,8 This includes a coordinated focus on resuscitation and injury management; recovery rehabilitation such as occupational therapy and physical therapy; and aesthetic restoration to minimize scars. Most burn centers are colocated with trauma centers, an important consideration for patients with concomitant injuries.
Conclusion
Please review the first part of this article series for a more complete picture of managing the patient with a burn injury in the interfacility setting.
The geography to be covered and resources available, including transport vehicles, vary significantly from community to community. This guide was developed to help ensure the needs of the burn-injured patient are met based on current science. Nevertheless, EMS clinicians should always rely on local protocols and local medical control should there be uncertainty or variance in treatment practices.
References
1. Emergency Medical Treatment and Active Labor Act, www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA.
2. Centers for Medicare and Medicaid Services. Certification and Compliance for the Emergency Medical Treatment and Labor Act (EMTALA), www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/EMTALA.pdf.
3. Grune J, Tabuchi A, Kuebler WM. Alveolar dynamics during mechanical ventilation in the healthy and injured lung. Intensive Care Med Exp, 2019; 7(Suppl 1): 34.
4. Belba M, Aleksi A, Nezha I, et al. Net fluid accumulation and outcome. A randomized clinical trial. Ann Burns Fire Disasters, 2009; 22(1): 16–21.
5. Armstrong JR, Willand L, Gonzalez B, Sandhu J, Mosier MJ. Quantitative Analysis of Estimated Burn Size Accuracy for Transfer Patients. J Burn Care Res, 2017; 38(1): e30–e35.
6. Cancio LC, Barillo DJ, Kearns RD, et al. Guidelines for Burn Care Under Austere Conditions: Surgical and Nonsurgical Wound Management. J Burn Care Res, 2017; 38(4): 203–14.
7. Holmes JH 4th, Carter JE, Neff LP, et al. The effectiveness of regionalized burn care: an analysis of 6,873 burn admissions in North Carolina from 2000 to 2007. J Amer Coll Surg, 2011; 212(4): 487–93, 493.e1–6, discussion 493–5.
8. Klein MB, Kramer CB, Nelson J, et al. Geographic access to burn center hospitals. JAMA, 2009; 302(16): 1,774–81.
Randy D. Kearns, DHA, MSA, FACHE, FRSPH, CEM, is an assistant professor in the College of Business Administration at the University of New Orleans and a retired clinical assistant professor from the School of Medicine at the University of North Carolina.
Christopher K. Craig, DMSc, MMS, PA-C, is assistant professor of surgery and senior physician assistant for trauma/burn services and disaster and prehospital services at Wake Forest University.
Eugene Elliott, MPH, MPA, MS, NRP, is a program analyst for the Department of Health and Human Services, program director for public safety and emergency management at Pamlico Community College, a staff paramedic for the CarolinaEast Health System, and adjunct EMS faculty at Anna Maria College in Paxton, Mass.
Charles Burnell, MD, FACEP, is chief medical officer for the Acadian Companies.
Jeffrey E. Carter, MD, FACS, is associate professor of surgery at the Louisiana State University Health Science Center New Orleans and medical director of the University Medical Center Burn Center, New Orleans.
