Fall 2015 Surface & Air Transport Bulletin

Fall 2015 Surface & Air Transport Bulletin

Chair
Billy L. Hutchison, BA, RRT-NPS
Carefusion
Houston, TX
billyhutchison@carefusion.com
Chair-Elect
Tabatha Dragonberry, MEd, RRT-NPS, RRT-ACCS, AE-C, CPFT, EMT
Children’s National Medical Center
Washington, DC
(571) 264-5451
dragonberry@icloud.com
Co-Editors
Steve Sittig, RRT-NPS, C-NPT, FAARC
Sanford Health
Sioux Falls, SD
Steven.Sittig@Sanfordhealth.org
abbeyroad1@hotmail.com
Bryan Byrd, RRT-NPS
Hamilton Medical Center
Dalton, GA
bryanrrt@gmail.com
CAMTS Representative
Steve Sittig, RRT-NPS, C-NPT, FAARC
Sanford Health
Sioux Falls, SD
Steven.Sittig@Sanfordhealth.org

Specialty Practitioner of the Year: Joe Hylton, BSRT, RRT-NPS, FAARC, FCCM

Our section is proud to bestow its 2015 Specialty Practitioner of the Year Award on Joe Hylton, BSRT, RRT-NPS, FAARC, FCCM. Joe will receive the award at AARC Congress 2015 in Tampa this November.

Joe has been a transport therapist at MedCenter Air Critical Care Transport in Charlotte, NC, since 2008. Prior to joining MedCenter Air, he worked in a variety of capacities at Carolinas Medical Center and Wake Forest University Baptist Medical Center and has a number of other awards to his credit. He received the F.H. “Sammy” Ross Trauma ICU and Hilda Hemby Medical ICU awards at Carolinas Medical Center in 2003 and was the recipient of the AARC Adult Acute Care Section Specialty Practitioner of the Year award in 2005. He became a Fellow of the AARC in 2010 and a Fellow of the Society for Critical Care Medicine (SCCM) in 2013.

On the state level, Joe is currently serving on the board of directors for the North Carolina Society for Respiratory Care and has served as the organization’s vice president and treasurer as well. On the national level, he is currently co-editor of the Adult Acute Care Section Bulletin. He has served the SCCM as a member of its Rapid Response Committee and is a Fundamentals of Critical Care Support and Fundamental Disaster Management instructor. Joe also serves as an adjunct faculty member at Stanly Community College, in Albemarle, NC, and at Carolinas Simulation Center in Charlotte, NC.

Joe received his BS in respiratory care from the University of Kansas in Lawrence in 2009 and his AS degree in the field from Forsyth Technical Community College in Winston-Salem, NC, in 1995.


How Important Is the AARC’s Involvement with the Commission on Accreditation of Medical Transport Services?

Steve Sittig, RRT-NPS, C-NPT, FAARC, Sanford Health, Sioux Falls, SD

The AARC has liaisons with many outside organizations, but for those of us in the transport world, one of the most important is the Commission on Accreditation of Medical Transport Services (CAMTS). For those of you who may not be familiar with CAMTS, it is an organization that strives to improve safety and patient care through vetted standards every 2-3 years. The board of directors is comprised of 21 transport-related representatives. A list of the organizations and representatives can be viewed on the CAMTS website.

This year marks the 25th anniversary of CAMTS and I am proud to say that the AARC has been a member since its inception. There have been four AARC RT representatives to the CAMTS board over this time: Kathy Peterson, Jerry Focht, Tom Cahill, and myself.

By the time this article is published, the 10th edition of the CAMTS standards will be out, and programs undergoing reaccreditation next year will be evaluated under these new updated standards.

Ideas for new standards come from the industry and from individual board members. All potential new standards are discussed by the board and then put out to the transport industry for comment. An incident that occurred just this year illustrates how important it is for the AARC to be represented on this board.

During our spring board meeting we had only minor changes to discuss. In July another revision was distributed to the board. I noted one big change that somehow occurred since our spring meeting version.

Under qualifications for transport team members from nursing, medics, and respiratory therapy, we stated they should have three years of ICU/ED experience . In the July draft, somehow the requirement for RT was changed to three years of hospital-wide experience, which I felt was not kosher for an RT wanting to be part of a critical care transport team. A background where the bulk of clinical experience was in general care areas, with very limited exposure to the ICU/ED, would not bode well for a transport team. As the bar on education and specialty credentialing has been raised for all who participate in medical transport, to lower the experience level of a new transport RT was not in the best interests of the candidate or the patient.

I contacted several other transport RTs from across the country to get their opinion. Everyone was in agreement that we, as a profession, need to be under the same prerequisites as other medical transport providers. I am happy to say that through our efforts the original language was reinstated. Had we not had a seat at the table, we, as a profession, may have lost ground when it comes to being accepted on or even considered for critical care transport teams.

If you have any ideas or concerns on the new standards or how the board operates, please feel free to contact me via email.


Neonatal Abstinence Syndrome: A Growing Clinical Entity in the Neonatal Transport Environment

Bradley A. Kuch, MHA, RRT-NPS, FAARC, and Melissa M. Riley, MD, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA

Neonatal abstinence syndrome (NAS) is a condition that occurs as a result of the sudden discontinuation of either a licit or illicit substance used by the mother during pregnancy. Infants diagnosed with NAS have longer and more complicated hospitalizations that may be characterized by feeding intolerance, respiratory distress, and seizures.

The syndrome has become a significant public health problem, with increasing incidence and associated health care costs.1 Patrick and colleagues reported the incidence of opioid specific NAS went from 3.4 per 1000 hospital births in 2009 to 5.8 per 1000 in 2012, reaching a total of 21,732 infants with the diagnosis.1 The group further described the increase in aggregate hospital charges from $732 million to $1.5 billion over the same time period.1 The financial burden fell primarily on public payers, as 81% of NAS related health care costs were attributed to state Medicaid programs.1

The etiology of NAS has changed over the decades. Prior to 1970, the primary causative substance of NAS was either morphine or heroin. Today the syndrome is more complex, being secondary to the intrauterine exposure to a wide array of substances, including morphine, heroin, methadone, buprenorphine, prescription opioid analgesics, antidepressants, anxiolytics, and/or other substances.2 Table 12,3 presents the timeline of events contributing to the progression of neonatal NAS as we experience it today. The wide range of causes, coupled with the potential of simultaneous use of multiple opioids, has complicated the diagnosis and treatment of the disorder.

Table 1. Distribution of Events Contributing to NAS by Years. Information Adapted from References 2 & 3.

transport_fall_2015_table1

Most recently, selective serotonin reuptake inhibitors (SSRIs) have been implicated as a source of NAS.3 It is estimated that depressive and anxiety disorders affect 13.5% and 4.7% of reproductive-aged women, respectively.3 Because SSRIs have been considered safer than alternative pharmacologic adjuncts, they are frequently used to treat depression prior to and during pregnancy.4 Levinson-Castiel and collogues reported an estimated 30% of neonates exposed to SSRIs may present with clinical signs during the first days of life.5

The increased incidence and severity of NAS have resulted in a significant upsurge in NICU admissions. Napolitano et al. reported a ten-fold increase in NAS-related NICU admissions from 2005 to 2011.6 Unfortunately, the increased incidence has been reported uniformly across community, teaching, and children’s hospitals throughout the nation, with all communities and ethnicities being affected. Given the growing epidemic and its increasing complexity of care, it is critical that transport systems responsible for the care of critically ill neonates are familiar with the etiology, signs/symptoms, and treatment of NAS.

Clinical presentation

Diagnosis of NAS begins with the clinical suspicion of the syndrome, identified by the constellation of multiple system symptomology. Early presentation includes tremors, irritability, excessive crying, and diarrhea. (See Table 2)2,7

Table 2. Clinical Findings of Neonatal Abstinence Syndrome. Information Adapted from References 2 & 7.

transport_fall_2015_table2

Seizures may be observed in 2-11% of neonates with the syndrome.2 Seizures are a significant manifestation of NAS and must be treated immediately. The hallmark of NAS is hyperirritability, which leads to agitation, difficulty sleeping, and inconsolable crying. The high-pitched uncontrollable excessive crying is striking, requiring immediate attention. Additional autonomic nervous system signs include temperature instability, sweating, sneezing, and mottling.2 These symptoms may last for weeks to months. Specific information regarding onset, duration of the syndrome, and incidence of NAS by causative agent can be found in Table 3.2,7

Table 3. Agent, Onset, Duration and Incidence of NAS. Information Adapted from References 2 & 3.

transport_fall_2015_table3

In addition to the previously mentioned neurologic symptoms, NAS may also present with cardiopulmonary manifestations. These symptoms include tachycardia, nasal flaring, and nasal stuffiness, which may be misinterpreted as respiratory distress.2 In some situations these signs may be accompanied by hyperthermia, which can result in a misdiagnosis of neonatal sepsis. Unfortunately, this can result in additional diagnostic tests, adding to health care cost, length of stay, and complexity of care.

Another significant component of neonatal NAS is feeding intolerance and increased insensible loses through moderate to severe diarrhea. Poor feeding, excessive motor activity, vomiting, and diarrhea can result in poor weight gain.2 These issues may result in dehydration and electrolyte imbalances, which are most commonly seen in infants suffering from heroin withdrawal.

Presentation time, duration, and severity of NAS depend on the type of drugs abused by the mother, amounts, duration of abuse, placental transferability, and pharmacological properties of the substance (Table 3).2 In addition, time of the last dose taken by the mother may affect the onset of the syndrome. Case in point: heroin exposure typically results in earlier and shorter withdrawal, while methadone and/or buprenorphine can result in later onset and longer withdrawal symptoms.2

Management in the transport environment

Management of NAS in the transport environment begins at the time of the initial transport call. The transport physician should identify the potential for the syndrome by first obtaining a maternal history focusing on the use of both opioid and non-opioid substances. These may include, but are not limited to, heroin, methadone, prescription opioid medications, SSRIs, tricyclic antidepressants, alcohol, methamphetamines, and inhalants. If there is a positive history for intrauterine exposure, the severity of NAS must be assessed using a validated scoring system. Most commonly used is the Finnegan score, which is useful for both opioid and non-opioid withdrawal assessment.2

The Finnegan Score includes 22 variables from three specific organ systems (i.e., central nervous system, metabolic/vasomotor/respiratory, and gastrointestinal disturbances). Figure 17 is an example of a Finnegan Score grading tool including each component for severity assessment of NAS.

Transport_fall_2015_figure

Quantifying severity of withdrawal will help determine if and/or when intervention is indicated, as well as assist in monitoring, titrating, and terminating therapy. Finnegan scoring should be performed after feeds, in three to four hour intervals, while the infant is awake.2

Management of NAS includes both pharmacological and non-pharmacologic care, with non-pharmacologic therapy being the first option.2 These therapies are easily acceptable, less expensive, and far less controversial than pharmacological adjuncts and include the following:2

  • Gentle handling
  • Demand feeding
  • Avoidance of waking the sleeping infant
  • Swaddling
  • Minimal stimulation
  • Dim lighting
  • Low noise environment
  • Frequent feeding with high calorie formula
  • Kangaroo care
  • Use of pacifiers
  • Music therapy
  • Massage therapy

In addition to these interventions, parents and volunteers can be a valuable resource, as they can help calm and soothe the infant before the cycle of irritability, excessive crying, poor feeding, and lack of sleep sets in.2 However, this resource is limited in the transport environment. If the abovementioned interventions are unsuccessful in treating the infant and/or the Finnegan score continues to increase, pharmacologic intervention is indicated.

Pharmacologic therapy should be considered in any infant who has either two consecutive scores ≥12 or three consecutive scores ≥8.2 If the infant meets this criteria, a thorough maternal history regarding past and recent drug use should be obtained. The infant may be started on morphine at 0.05 mg/kg/dose.2 If there is no evidence of opioid use and the infant displays elevated scores, alternative therapies such as phenobarbital may be consider to treat the withdrawal.2 Your institution’s approved treatment protocol should be followed. Dosage and frequency may be titrated for the best possible effect measured by the Finnegan score.

Transport considerations

NAS is a growing clinical entity in the transport environment. Those responsible for the inter-facility transfer of neonatal patients must be aware of its incidence, signs/symptoms, and treatment to ensure the best care for a fragile patient population.

As previously mentioned, the presentation of the disorder can be easily misdiagnosed as sepsis, transient tachypnea of the newborn, or seizures. For this reason, it is important for the transport therapist to understand the risk factors and to pay particular attention to the maternal history in neonates being referred for irritability and hypertonia, and/or to rule out sepsis.

It is also important for the clinician to understand all agents resulting in NAS, as the treatment regimens vary. Assuming all NAS is the result of opioid withdrawal may result in the infant being unnecessarily exposed to therapeutic doses of morphine. In the transport environment, treatment is supportive in nature and can include managing and assessing withdrawal symptoms, correcting electrolyte imbalances, reversing dehydration, and monitoring for seizures. Through increased awareness, transport teams can provide an increased quality of care for this patient population through a combination of early intervention and enhanced communication.

References

  1. Patrick SW, Davis MM, Lehman CU, Copper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatology 2015;35:650-655.
  2. Kocherlakota P. Neonatal abstinence syndrome. Pediatrics 2014;134(2):e547-e561.
  3. Moses-Kolko EL, Bogen D, Perel J, et al. Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: literature review and implications for clinical applications. JAMA 2005;293(19):2372-2383.
  4. Klinger G, Merlob P. Selective serotonin reuptake inhibitor induced neonatal abstinence syndrome. Isr J Psychiatry Relat Sci 2008;45(2):107-113.
  5. Levinso-Castiel R, Merlob P, Linder N, et al. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch Pediatr Adolesc Med 2006;160:173-176.
  6. Napolitano A, Theophilopoulos D, Seng SK, Calhoun DA. Pharmacologic management of neonatal abstinence syndrome in a community hospital. Clin Obstet Gynecol 2013;56(1):193-201.
  7. Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn; American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics 2012;129(2):e540-e560.

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