SUMMER TRAINING PROJECTS

Student: Mohit Agarwal

Organization: ImpactGuru
Secondary research: Maternal health in sikkim,
India – comparative study between NFHS - 4 & NFHS – 5.
Objectives:
- to describe the maternal health in Sikkim.
- to compare the various factors contributing to promote and
increase maternal health between NFHS - 4 & NFHS – 5
Insights:

YEAR Maternal Deaths Per 1,00,000 live births

2016-17 17

2017-18 09

2018-19 10

2019-20 08
Student : Akashi Gola
Organization : Rajiv Gandhi Cancer Institute
And Research Centre, New Delhi.
Project topic :
Estimation of waiting time and associated
factors at outpatient department and at
various investigation department
• Student: Dr Pravie

• Organization: Avoraus Consultancy

Services Pvt Ltd., Jaipur, Rajasthan.

• Project Topic: Sample planning and

preparation for a research study on
global magnetic beads market
awareness.

• Insights: Out of the total 1600 leads

generated, 40 respondents for the
region of India and 5 respondents for
the region of EMEA were successfully
identified as the Key Opinion Leaders
that will act as the sample size for the
study of global magnetic beads market
awareness which was to be conducted
by the client.
Student: Rima Datta
Organization: Aster Prime Hospital,
Hyderabad.

Project Topic-
◦ Satisfaction Survey of Dialysis
patients regarding service delivery
process in the Dialysis department of
Aster Prime Hospital

◦ Study on Turn Around Time of

Diagnostic Imaging
 Student: Dr Akriti Dua
Organization: Medtel Healthcare Pvt. Ltd.
Topic: Performance Evaluation Of The Existing Vendors Of A
Health-tech Company Based On Linear Average Method

Insights:
• Established the performance indicators
• To chose the best vendor within a vendor group
• Classifying the vendors into the following categories
on the basis of results
o Strategic vendors
o Preferred vendors
o Transactional vendors

Observational Learnings:
• Observed and participated in the various operational
activities going on in the Company.
• Drafted SOPs for Procurement , Vendor
Management , Sales Delivery, Inventory
Management , Client Support , Customer Success
Student: Dr Ishita Sawhney

Organisation: Healthark Insights

(Ahmedabad, Gujrat)

Study Topic: Comparative Evaluation

of Mental Health Disease Burden and
Digital Mental Health Market In India
and South Korea
Student: Dr Aastha Maingi
Organization: Max Superspeciality Hospital, Mohali.
Project: Hazard Identification And Risk Assessment (HIRA)
in the hospital premises.
Objective: The study's objective is to identify the hospital's
health and safety concerns, then address the medium and
high-risk hazards first, inform employees about their working
hazards, and recommend the necessary controls to the
concerned authorities.
Insights: a total of 114 various possible risks have been
identified from the different kinds of hazards in the sample
size of 16 departments. Most risks identified were moderate
in severity and probability. Recommendations were made for
all kinds of possible risks spotted.
Student: Stuti Kumari

Organization: Manipal Hospital, Jaipur

Project Topic:

TAT analysis of the radiology

department of the hospital.

Student: Dr Nidhi Sharma

Organization: Shalby Hospitals Jaipur

Project Topic:

To study the compliance of active IPD files and

billing process accuracy at Shalby hospitals.

Student: Shradha Govindrajan

Organization: Stanplus Pvt Ltd, Hyderabad.

Project Topic:

A study on the impact of unavailability of

resources on the company’s efficiency in

resolving the customer’s requirements

 Student: Shabya Singh
Organization: Narayana Super speciality Hospital ,
Gurugram.
Project Topic: Analysis of Turn Around Time in
discharge process of IPD .
Objectives :
• To calculate the average TAT of TPA, cash and
PSU patients .
• To identify the Gaps in the discharge process.

REASONS FOR DELAY OF DISCHARGE

PROCESS

Average Discharge TAT in month 10% 15%

7%
of May 38% 20%
1%9%
PSU
TYPE OF PATIENTS

TPA

CASH

0 5000 10000 15000 20000 25000 Bill preparation pharmacy clearance

AVERAGE TIME( SEC) nursing side summary by MT
TPA APPROVAL PATIENT'S SIDE
AVERAGE TAT(sec) STANDARD TIME (sec) IT
 Student: Devanshi Gupta
Organization: American Institute of Oncology, Jammu.
Objectives:
Turnaround time of chemotherapy from the arrival of the
patient till the initiation of the first drug.

These are the total 8 steps that are performed

after the arrival of the patient in the unit.

Time T1 T2 T3 T4 T5 T6 T7 T8

Standard time 0 2 10 2 2 8 2 4

Process Receiving Approval in Dispense in Physical Mixing Drug mixing The infusion The infusion
the patient Aria from Medibus dispense of nurse time nurse nurse
to daycare the medicine receiving receive initiates the
pharmacy the medicine mixed drug chemo
from
Admixture
room
FINDINGS
RECOMMENDATIONS:

Inform patients about

• Confusion between billing their journey- front • Patient overload
& registration desk Schedule patients • Arrival at same
• Arrival before consultation/ timings
billing

Follow Proper patient

protocols Avoid communication gaps/
pt. counselling in
• Confusion in same
name unavoidable delays
• No priority to early • Unheard order
arrivals • Miscoordination

Check the ‘daily tracker’

of Chemo TAT weekly Reduce data fudging by control
checks
HOSPITAL TRANSPORT SERVICES
Presented by:
Group 1
TABLE OF CONTENTS

S.No. TOPIC SLIDE NO.

1. Introduction 18

2. Intra Hospital Transport Services 19-27

3. Guidelines for Intra Hospital Transport for critically ill patients 28-35

4. Inter Hospital Transport Services 36-47

5. Current Scenario of Hospital transport services 48-59

6. Communication in Transport 60-63

7. NABH requirement of Ambulance 64-67

8 SOPs for transport during COVID-19 68-72

9. News articles on ambulance demand during COVID-19 73-76

10. References 77
 INTRODUCTION

• Patient transport is a service that transfers Different modes of Medical Transportation:

patients to and from medical facilities in non-
emergency situations. In emergency situations,
patients are transported by the Emergency
Medical Services.

• Severity of the situation, mileage, and the patient’s

medical condition determine the type of
transportation needed.

• In large hospitals, moving patients between

healthcare units and service areas fall under the
responsibility of the transportation department.

Benefits of Medical Transportation:

• It enables the patients to reach their destination

quickly and efficiently. While in transit, highly
trained drivers, emergency medical technicians
(EMTs), and paramedics provide medical services
that may be needed to ensure a safe arrival.
INTRA-HOSPITAL TRANSPORT SYSTEM
INTRODUCTION

• Intrahospital transport is called the transfer of patients in the

hospital for diagnostic or therapeutic purposes or their transfer to
specialized units of the hospital.

• Such transfers may be temporary (e.g., to obtain diagnostic

imaging) or for a longer term (e.g., transfer from inpatient ward to
an intensive care unit) and are critical transitions in which
complications and death may occur.

• The reduction or change of care and the movement itself can

become, for the critically ill patients, the cause for serious
complications and put their health at risk.

• Intra-hospital patient transfer usually required for:

1) Investigations or advanced diagnostic procedures
2) High intensity care to high intensity unit
3) Patient who continue their care for recovery but no longer need
close observation.
RISK FACTORS FOR COMPLICATIONS DURING INTRA - HOSPITAL
TRANSPORTS:

• Malfunction of the devices

• Inadequate monitoring of patient during transport
• Insufficient documentation of intrahospital transport procedure.
• Specifically, changes in the condition of the patient may occur due to pre-existing health conditions, changes of
environmental conditions, or may follow the course of the severe illness from which the patient suffers

• Various external factors when moving from the bed. The changes in patient's position can cause alterations in
flow of liquids and medicines, disconnection of intravenous catheters, extubating or deregulation of the
portable ventilator, causing respiratory distress. In addition, changes in location can result in pain and
movement or removal of drainage tubes.

• Inappropriate handling of the vehicle with which the patient is transported

• Equipment used during transport
• Lack of communication between staff of the sending and receiving departments of transport
Patient factors System factors

Incubated Length of travel FISH BONE ANALYSIS

PEEP> 6cmH20 No checklists

Post surgical status Equipment's failure

High quality/illness severity Manual ventilation only

Comorbidities (CAD, DM, CHF) Complex environment

Complications
from
Intrahospital
Transport for unnecessary studies
Transport
Unaccompanied
Unaccompanied byby physician
physician

Insufficient education

Inadequate monitoring

Unsecured device

Therapy disruption

Inadequate resuscitation
BEFORE/DURING/AFTER TRANSPORT PROCEDURES
Before
• All staff involved in transport is
relieved of other obligations.
• Stabilization of patient's condition.
• Collection and control of equipment
used in transport Collect patient’s
data (medical record).
• Connecting patient to monitoring
equipment and control of recording
parameters.
• Reassessment of patient's stability,
vital signs, intravenous and other
catheters and drainage.
• Communication of the sending
department with destination
department to inform those
responsible and to define the arrival
time.
During
• Follow the easy and short
route, planned. Elevators
should be available and
secured to avoid delays and
crowds.
• Means of communication with
the destination department
should be available.
• Continuously checking and
recording patient’s health
condition and the parameters
of the devices at regular
intervals, especially if the
duration of the transport is
long, to address any
complications.
After
• Admission of patient at
destination department and
reassessment of patient's health
condition and control of
equipment’s operation.
• Connect patient with the new
recording equipment, if
transfers from the stretcher.
• Detailed update to the
monitoring team. The transport
team does not leave the area, if
the other team is not fully
prepared to take over.
NURSE’S ROLE IN INTRAHOSPITAL TRANSPORT

Decision Making Intrahospital Transport Personnel

Policy

❑ In cases, where there are no

❑ The risk – benefit consideration ❑ It is important, even for non-ICU
transport plans available, highly
of its outcome and the search patients, to be transported by
trained nurses contribute by
for alternative solutions to avoid well-trained personnel, who
building a basic policy for
transport should be the first would know how to move
intrahospital transport
thought of health care without delays, protect patients
performance
professionals. from harm and inconvenience
that could lead to complications
❑ Nurses have the necessary
❑ Nurses participate in making and maintain patients’ dignity
clinical skills to create a
the decision to transport, along and respect through the
detailed protocol (plan),
with medical and paramedical crowded areas during transport.
consistent with the conditions of
personnel.
the hospital, and based on the
❑ Trained nurses not only
guidelines, regarding the
❑ They evaluate the health participate in intrahospital
personnel involved in
condition of the patient and transport team, but also
transports, the appropriate
suggest possible alternative educate unqualified personnel
equipment, the preparation
ways for patient to have the in managing emergent
procedures and the evaluation
diagnostic test. situations and crises during
of the outcome.
intrahospital transports.
NURSE’S ROLE IN INTRAHOSPITAL TRANSPORT (Contd.)
Equipment
❑ The devices, which are used in
intrahospital transports, should
have specific characteristics. It
is important the equipment to
meet the criteria for a safe
transport.
❑ Nurses, experienced in
intensive care, suggest the use
of specific equipment in
intrahospital transports of
critically ill patients.
❑ They train the new staff or the
intrahospital transport team in
their proper use and ensure the
equipment’s services and
replacement when needed
Preparation & Procedures Evaluation
❑ The completion of the
❑ Preparation for intrahospital
intrahospital transport, when
transport includes specific
performed according to an
necessary procedures that
existing protocol, should be
should be completed before,
evaluated
during and after transport.
❑ After the evaluation,
❑ Nurses have an active
improvement recommendations
involvement in every part of this
and further implementation of
process
them to the protocol are
expected so that the level of the
provided care will be
continuously upgraded for
critically ill patients in
intrahospital transports.
CHARACTERISTICS OF INSTRUMENTS USED IN INTRA-HOSPITAL
TRANSPORT

• Suitable designed •Equipped with alarm systems (visual and

• Portable acoustic)
• Simple in use
•Placed on special shelf, not on stretcher
• Resistant to hardship
•Able to work in special areas such as MRI
• Small in size
• Function with (ac)power and batteries(dc) chamber

• Broad base and low center of gravity •Easy to control and watch from distance

•Ability to record, store and playback data

COMPLICATIONS OF INTRA-HOSPITAL TRANSPORT

Cause Complications Cause Complication

Cardiovascular • Changes in blood pressure Other systems • Increase in intracranial pressure

System (usually hypotension) • Pain
• Tachycardia • Vomiting
• Arrhythmia • Hypothermia
• Cardiac arrest • Bleeding
• Pulmonary edema
Equipment • Disconnection/dysfunction of portable
Respiratory • Changes in respiratory frequency malfunction ventilator
System • Pneumonia, aspiration • Removal/Disconnection of
• Airway obstruction intravenous catheters or others
• Accidental • Removal of feeding tubes
displacement/Movement of • Shutdown devices (mechanical
endotracheal tube failure, drop in power, battery)
• Respiratory arrest • Interruption of oxygen supply
• SaO2 reduction • Removal of intracranial pressure
• Blood gas alterations measuring devices
• Alterations of acid-base balance • Patients’ injury
GUIDELINES FROM INDIAN SOCIETY OF CRITICAL CARE
MEDICINE FOR INTRA- HOSPITAL TRANSPORT
OF CRITICALLY ILL PATIENTS
INTRAHOSPITAL TRANSPORT
Intrahospital transport involves following areas of concern:

Protocol Development
Preparation of the Equipment, Drugs,
and Written
Patient and Monitoring
Procedures

Pre-transport
The Decision for
Coordination & Care During Transport
Transport
Communication

Identifying High Risk Accompanying

Care at Destination
Patients Personnel
❑ Protocol Development and Written Procedures
• In hospitals, the infrastructure will vary from place to place, therefore each ICU needs to develop its own solutions
to substitute for lack of sophisticated equipment, develop a protocol and implement it.

• These protocols should be widely known to all departments of the hospital.

• Proper documentation should occur at each stage during transport. This will help in audit, quality assessment and
then modification for improvement in the local protocols.

❑ The Decision for Transport

• The intensivist and primary physician will take the decision to transport the patient. The involvement of the primary
physician should be documented in all such instances.

• Documentation in the medical record includes the indications for transport and patient status throughout the time
away from the unit of origin.

• The risk of transporting the patient must be outweighed by the benefit that may accrue from the transport. The aim
or purpose and the justification to transport should be noted in the case records.

• The patient’s family should be informed of the risks involved and possible benefits should be explained to them.

• Patient’s or the responsible person’s consent should be taken in the standard format. Similarly, the primary
physician’s concurrence may be documented in the same form.
• Transport of the patient should not be undertaken in the following circumstances:
- Inability to provide adequate oxygenation and ventilation during transport either by manual ventilation, portable
ventilator, or standard intensive care unit ventilator,

- Inability to maintain acceptable hemodynamic performance during transport

- Inability to adequately monitor patient cardiopulmonary status during transport

- Inability to maintain airway control during transport

- Transport should not be undertaken unless all the

necessary members of the transport team are present.

❑ Identification of high-risk patients:

• helps in formulation of plan for transport

• Patients in following categories are at particularly high risk of physiological deterioration during or after transport
- The mechanically ventilated patients, particularly those with requirement of positive end expiratory pressure and
FIO2 > 0.5.
- Patients with high Therapeutic Injury Severity Score
- Head injured patients
- Hemodynamically unstable patients requiring continuous infusion of dobutamine, or a continuous infusion of
norepinephrine or other potent vasoactive agents.
❑ Preparing the patient for transport
• all attempts should be made to optimize haemodynamics and ventilatory parameters.

• The patient’s physiological variables and drug and ventilatory requirements before transport must be
documented.

• Special pharmacological requirements, if any, should be anticipated and these drugs should be available apart
from the standard drugs required during transport.

• The patient should be safely secured to the transport trolley.

• The patients’ medical records, previous films if any and necessary forms (especially the informed consent form
particularly if the transport is for intervention) are available.

• If the patient is being transported to the operating rooms, arrangement for blood and blood components should
be done by the ICU personnel. Informed consent for operative procedures should accompany the patient.

❑ Pre-transport coordination and communication

• the department where patient is going to be transported should be informed, to avoid a wait at the
receiving location.

• The receiving location must be ready to perform the diagnostic and / or intervention procedure
immediately on the arrival of the patient.
❑ Accompanying Personnel
• The patient should be ideally accompanied by a physician,
along with the nurse looking after the patient.

• If the patient is unstable, then the nurse, apart from the ICU
physician, should also accompany the patient.

• He / She should be competent to handle airway problems;

including the ability to intubate, cardiopulmonary
resuscitation, initiate and titrate vasoactive drugs, manage
mechanical ventilation.

• When the patients are accompanied by specially trained

transport teams, there are reduced number of complications.
Therefore, it is suggested that at least all Level III ICUs
should train personnel in transport of critically ill patients.

• Documentation of vitals and adverse events if any, during

transport should be carried out. Similarly patient status
during handing over care and back in the ICU should be
recorded if the care is transferred.
❑ Accompanying Equipment, Drugs & monitors:
• Equipment must be robust, lightweight, and battery powered

• All equipment should be dedicated for the purpose of

transport and should not be used elsewhere

• The equipment requiring charging should be kept

continuously charged with spare fully charged batteries
available

• A designated person should be responsible to look after,

check over the equipment periodically

• Drugs should be checked periodically for expiry and replaced

immediately when expired or used for a patient.

• Respiratory Support Equipment, Circulatory Support

Equipment and other equipments must be always available.

• Transport ventilators
❑ Care during transport:
• Ideally the patient should receive the same level of care as the pre-transport area

• Vitals should be monitored and recorded at fixed intervals. Use of memory-capable monitor should be used. This
will allow documentation of data during transport.

• Any adverse events should be noted and emergently acted upon.

• There should be a designated intensivist available for consult in case of an adverse or critical event during
transport.

• The transport team should be able to communicate with designated person during transit as well as upon arrival at
the destination in case of an emergency.

❑ Care at destination:
• If the patient is to be moved from the transport bed or trolley at the destination, care must be taken not dislodge
indwelling airway and vascular devices.

• If another team assumes responsibility of care, a complete hand over is given to the team leader. Patient status
should be documented at the time of hand over.

• The transport staff must remain with the patient until the receiving team is fully ready to take over care.

• When taking the patient back, a handover takes place and again patient status should be documented.
INTER-HOSPITAL TRANSPORT SYSTEM
 INTER-
HOSPITAL
TRANSPORT

STAFF AND
PATIENT
MATERIAL
TRANSPORT
TRANSPORT

STAFF CARS STORE VANS HEARSE VANS AMBULANCE

BASIC LIFE ACUTE LIFE PATIENT

SUPPORT SUPPORT SUPPORT
 PATIENT TRANSPORT SERVICES

INTRODUCTION:
• The transport ambulances are the vehicles that are used for treating and transporting the patients who need
emergency medical care to a hospital.
• The first motor powered ambulance was introduced in 1906.
• A Hearse’s Van is used for carrying the dead bodies from the hospitals to the

DESIGN:
The modern ambulances contain-
• Drivers Compartment
• Patient compartment big enough for two
EMTs and two supine patients
• Equipment and supplies
• Two-way radio communication
• Design for maximum safety and comfort

Dr Akriti Dua
BASIC LIFE SUPPORT AMBULANCE

A basic life support ambulance is equipped with the life support equipment like an oxygen cylinder, BP
Monitor and stethoscope. This type of ambulance can be used for emergencies when the patient can
be transported to the hospital quickly.

CLASSIFICATION: STAFFING:

Type I: Conventional, truck cab-chassis with Each ambulance is manned with-

a modular ambulance body that can be Two interchangeable Assistant Junior Ambulance Officer.
AJAOs are graduates who are:
transferred to a newer chassis as needed.
• Trained in multidisciplinary skills of first-aid emergency
Type II: Standard van, forward-control
management
integral cab-body ambulance
• Wireless communication and driving
TYPE III: Specialty van, forward control
• On receiving, a call of accident, proceeds to the sight
integral cab body ambulance.
ADVANCE LIFE SUPPORT (ALS)

• ALS ambulances are used to transport patients who require a higher level of care until they
reach the hospital.
• This ambulance is used during life-threatening situations when a patient is suffering from a
severe accident, heart attack or medical emergencies like respiratory distress, stroke, seizure,
or chest pains,
• It includes use of adjunctive equipment and techniques for :-
1. Assisting ventilation and circulation
2. ECG monitoring with dysrhythmia recognition and defibrillation
3. Establishment of I.V. access and pharmacologic therapy in addition to BLS skills.
EQUIPMENT :

▪ Defibrillators
▪ Cardiac patient monitor
▪ Ventilators
▪ Oxygen cylinders
▪ Pulse oximeter
▪ Resuscitation kit
▪ Suction machine
▪ Nebulizer and
▪ BP apparatus.
STAFFING :

The staff working on ambulances include :-

• Paramedics

• Emergency medical technicians

• Emergency ambulance crew

• Doctors: need depends upon the type of emergency,

accident or disaster.
CONTRIBUTION OF AMBULATORY SERVICE IN PATIENT
TRANSPORTATION

• The rationale

• The service

• The profession

• The community

• The health continuum

KEY ELEMENTS OF TRANSFER

• Decision to transfer and communication

• Pre-transfer stabilisation and preparation- A,B,C,D

• Mode of transfer- Ground and Air transport

• Accompanying the patient – Level 0,1,2 and 3.

• Equipment drugs and monitoring

• Documentation
PHYSIOLOGICAL ALTERATIONS DURING TRANSPORT

Noise

Vibration

Acceleration and gravitational forces

Temperature and humidity

Altitude- Hypobaric hypoxia, Expansion of gas in body spaces and in medical equipment, third
space fluid loss and motion sickness
COMPLICATIONS DURING TRANSPORT AND PREVENTION
STRATEGIES

Infectious complications Pulmonary and airway complications

• Atelectasis
• Risk of infection to both the patient
and to others who are exposed to • Pulmonary embolism
that patient • Bronchospasm
• Pneumothorax
Endocrine complications
Cardiovascular complications-
• Hyperglycemia
• Hypertension
• Hypoglycemia • Hypotension
• Acis-base derangement • Arrhythmia
• Equipment dislodgement • Tachycardia
RISK FACTORS FOR THE DEVELOPMENT OF COMPLICATIONS
DURING TRANSPORT
Staff related
• Inexperienced staff
• Unfamiliarity with monitoring
equipment
• Insufficient preparation of the
patient
• Poor communication with the
receiving facility
• Inadequate resuscitation
Patient related
• High positive end-expiratory
pressure (>6 cmH2O)
• History of coronary artery disease
• Postoperative patients
• Severe trauma patients
• Patients on complex medications
and infusion regimens
CURRENT SCENARIO FOR HOSPITAL
TRANSPORT
• Interhospital transport of the patients in Indian scenario
presents a challenge because of lack of specialized transport
teams such Medical Retrieval Units or Regional Transport
teams.
• Presence of written policy documents or guidelines, dedicated
equipment and trained personnel will be useful to units
undertaking interhospital transports
INTENSIVE CARE UNITS

• In Indian ICUs patients may need to be transferred to another hospital for:

• Further care when deterioration in patients’ clinical condition is expected and facilities for the same
are not available at the admitting hospital.

• For diagnostic or interventional purposes (such as CT scan or Angiography) when these facilities
are not available at the admitting or primary hospital. This scenario obtains quiet often in Indian
ICUs and the patient will be transported back to the same ICU at the end of the procedure.

• Patient initiated transfer where patient or family does not desire further care.
Interhospital transfer can also be of :
• Emergent type for acute life-threatening illnesses emergency interhospital
transport may be needed due to either lack of diagnostic facilities, lack of
staff and/or facilities for safe and effective therapy in the referring hospital
• Semi-emergent type for higher level of care or specialty service.
THE PROCESS

Initiating transport & preparing patient for transport

Communication & coordination

Selecting the mode of transport

Care during transport

Equipment, Drugs and monitoring.

Accompanying Personnel

Care at receiving ICU

INITIATING TRANSPORT & PREPARING PATIENT FOR
TRANSPORT

• The treating intensivist in consultation with primary physician (in open ICUs) will take
the decision to transport the patient. The family is informed of the necessity and
possible adverse effects of transport.

• The referring physician should always write an order to transfer the patient in the
medical records.

• In a life-threatening emergency, when informed consent is not possible, the reasons

for not obtaining informed consent and indication for transfer are documented in the
medical record.
COMMUNICATION & COORDINATION

▪ The destination hospital or referral centre must be informed of the time when the
patient sets off from the ICU, the expected time of arrival of the patient at the
destination.

▪ The receiving hospital must ensure that on arrival, the patient is immediately taken up
for intended investigation or intervention without delay to avoid wait at the destination.
If being transferred for further care, the receiving hospital must ensure that the patient
is directly taken up to the ICU without delay

▪ The transport team must be aware whom to contact in an emergency in case of

deterioration in the patients condition.
SELECTING THE MODE OF TRANSPORT

• Mode of transport used will depend partly on clinical requirements, on vehicle

availability, road conditions and on conditions at the referring and receiving sites.

• Choice of transport vehicle will be influenced by :

Nature of illness , possible clinical impact of the transport environment , urgency of
intervention ,location of patient distances involved ,number of retrieval personnel and
volume of accompanying , equipment road transport times and , road conditions range
and speed of vehicle , For air transport: weather conditions and aviation restrictions for
airborne transport aircraft landing facilities
CARE DURING TRANSPORT

▪ Management during transport should be at least equal to the level of management at the referring ICU and
must prepare the patient for admission to the receiving service.

▪ If the transport team does not belong to the referring hospital, ensure complete hand over of relevant
clinical details. This hand over and patients clinical status should be documented in the patients medical
records.

▪ In ventilated patients, check that the ventilator is connected properly and is working. Confirm bilateral air
entry and rule out hypoxia.
EQUIPMENT, DRUGS AND MONITORING

• Equipment must be robust, lightweight, and battery powered. All equipment

should be dedicated for the purpose of transport and should not be used
elsewhere.
• A designated person should be responsible to look after, check over the
equipment periodically.
• Drugs should be checked periodically for expiry and replaced immediately
when expired or used for a patient.
ACCOMPANYING PERSONNEL

• The patient should be ideally accompanied by a physician, along with a

nurse and a ward boy.
• All unstable patients and ventilated patients should be accompanied by a
trained person, ideally a physician competent to handle airway problems
including the ability to intubate, cardiopulmonary resuscitation, initiate and
titrate vasoactive drugs, manage mechanical ventilation.
CARE AT RECEIVING ICU

• The receiving ICU should ensure that the

patient is received immediately in the
ICU on arrival.
• The patients’ clinical status is assessed
immediately and thoroughly, a relevant
history & other details are obtained from
the transport team and the hand over is
documented.
• The personnel at the receiving ICU will
exchange the equipment's of the
referring hospital or ambulance with that
of the receiving hospital.
TRANSPORT SERVICES COMMUNICATION
 COMMUNICATION IN AMBULATORY SERVICES

Two types of communication:

1) external dialogue- in relations with patients
2) internal information exchange- in relations with coworkers in other professions.

• Ambulance workers must communicate with several different groups of emergency personnel. Since, communicators
cannot see each other leading to less reliability of the information exchange.
• Significant communication takes place before help arrives, and even when working together on site they must maintain
interactive communication with the emergency communications centers and other off-site resources.

NEED OF COMMUNICATION IN AMBULATORY SERVICES

1) The significance of securing communicative attention- to bridge the interdisciplinary gaps.

2) The importance of having a shared language- improper communication information to the

other emergency services on the digital network, because ‘it takes too much time to explain
things.

3) The need to avoid misinterpretation- senders only say what they think is necessary to
convey everything they want to convey k/the economical principle of communication.

4) The importance of understanding attitudes- “Incongruent communication”

COMMUNICATION PROCESS MODEL

SENSE - The 1-0-8 call is received by the Communication Officer who collects and records all facts regarding the emergency.
The information is then transferred to the Dispatch Officer who identifies the nearest ambulance to the scene of emergency
and gives instructions for dispatch of the ambulance. Technology plays an important role in providing state of the art CTI
(Computer Telephony Integration) solutions for receiving 1-0-8 emergency calls and maintaining records of the caller data.

REACH - Ambulances are strategically placed to reach the victim at the earliest possible time. In case of Police or Fire
emergencies local State Police Station or Fire department is immediately notified with full details.

CARE - the EMT can be in conference (via cell phone) with the in house ERCP (Emergency Response Care Physician) who is
a qualified medical practitioner, available 24/7 to support the EMT as and when required.

• VIDEO-PHONE/COMPUTER IN AN AMBULANCE the doctor can direct the paramedic to perform medical procedures.
Especially in the event of the patient being terminally ill, such devices can help make the most of the time at
hand.
INTER HOSPITAL TRANSFER COMMUNICATION
PRE-TRANSPORT COMMUNICATION AND COORDINATION

• A telephone or videoconference referral, gathering of history, examination, vital signs and initial investigations

• Discussion between referring and receiving senior medical staff

• Stabilization advice and additional management

• Agreement regarding the required medical and/or nursing attendants during transport

• A decision as to the appropriate mode and timing of transportation that considers

▪ the patient’s condition, age and size
▪ the urgency of transfer
▪ medical interventions anticipated
▪ personnel and other resource availability
▪ the time of day
▪ the weather and/or traffic conditions
▪ geographical considerations
▪ a decision regarding the required monitoring, equipment and medication.
NABH REQUIREMENTS OF
HOSPITAL AMBULANCE
AMBULANCE - NABH REQUIREMENT

▪ Ambulance of the hospital has a significant role in emergency medical

treatment . To provide excellent quality ambulance services to
emergency patients, NABH has precise requirements to be met. As
ambulance is related to emergency care, it is vital that this list should be
used in combination with checklist of emergency department standards
as per NABH.
IMPORTANT THINGS THAT NEEDS TO BE TAKEN CARE OF FOR AMBULANCE
ARE:

• The registration of the vehicle should be done as an ambulance (for each vehicle being used as ambulance).

• All legal documents should be available and within validity period. This includes vehicle registration, driver’s
license, PUC and Vehicle Insurance.

• The vehicle should be in compliance with ‘Minimum standards and guidelines for ambulances, National
Ambulance code issued by Ministry of Road and transport and Highways’.

• An identified parking spot near to emergency department should be used for parking ambulances , ER gate
should be clear..

• Ambulance should be identified as ALS equipped or BLS equipped. ALS equipped ambulance should be used for
transferring critically ill or unstable patients. For other patients BLS equipped ambulance can be used.

CONTD.
• ALS ambulance van must be equipped with necessary resources such as transport ventilator,
portable suction apparatus, portable oxygen equipment, AMBU resuscitation kit (for adult and
paediatric), multi-para monitors, intubation equipment, AED, syringe pumps, IV lines, immobilization
devices, emergency medicines etc.

• BLS equipment should be available, for instance- basic things like stretchers, emergency
medicines, portable oxygen, suction devices, first aid kit and AMBU bags.

• The staff in ambulance (driver and technician) should be trained in BLS skills.

• At-least one staff in ALS ambulance van should be trained in emergency medicines and ALS skills.

• Basic functioning of ambulance should be checked daily for things like lights, siren, tyre pressure,
fuel etc. These checks must be documented.

• A list of all equipment in ambulance must be maintained. All equipment must be checked daily to
ensure its functionality. The checks must be documented properly.
SOP FOR TRANSPORT SERVICES DURING COVID-19 BY
MOHFW
 ABOUT THE SOPs:
This SOP is applicable to current phase of COVID-19 pandemic in India (local transmission and limited community
transmission), wherein as per plan of action, all suspect cases are admitted to isolation facilities. These procedures are
meant to guide and be used for training ambulance drivers and technicians in transporting COVID19 patients. These
also aim to support programme officers in monitoring functionality and infection prevention protocols of the
ambulances.

TRANSPORTATION OF PATIENTS
Ideally, there should be ambulances identified specifically for transporting COVID suspect patients or those who have
developed complications, to the health facilities. Currently, there are two types of ambulances – ALS (with ventilators)
and BLS (without ventilators). States may empanel other ambulances having basic equipment like that of BLS and use
it for COVID patient. The fleet in - charge or person designated by CMO/CS, will supervise its adherence. Call centres
after receiving the call will try to triage the condition of the patient and accordingly dispatch either ALS, BLS or other
registered ambulances. Ambulance staff (technicians as well as drivers) should be trained and oriented about common
signs and symptoms of COVID-19 (fever, cough and difficulty in breathing).

They should also be aware about common infection, prevention and control practices including use of Personal
Protective Equipment (PPE). Both the EMT and driver of ambulance will wear PPE while handling, managing and
transporting the COVID identified/ suspect patients. Similar use of PPE is to be ensured by the health personnel at
receiving health facility. Patient and attendant should be provided with triple layer mask and gloves. Simple public
health measures like hand hygiene, respiratory etiquettes, etc. need to be adhered by all.
DISINFECTION OF AMBULANCE

All surfaces that may have come in contact with the patient or materials contaminated during patient care (e.g.,
stretcher, rails, control panels, floors, walls and work surfaces) should be thoroughly cleaned and disinfected using 1%
Sodium Hypochlorite solution. Clean and disinfect reusable patient-care equipment before use on another patient with
alcohol-based rub. Cleaning of all surfaces and equipment should be done morning, evening and after every use with
soap/detergent and water.

CAPACITY BUILDING

District Authorities to ensure capacity building of EMT and driver on following areas:

• Donning and doffing of PPE

• Infection prevention protocols given in this guideline .
• Triaging and identifying COVID-19 suspects based on their signs and symptoms.
• Similarly, emergency staff of health facility should also be trained in segregation, isolation and management of
COVID-19 patients. They should not be mixed with other patients.
INFECTION PREVENTION FOR PRE-HOSPITAL CARE

General Ambulance or emergency health care workers are exposed to many infectious agents during their work. Transmission of
infectious disease can occur while providing emergency care, rescue and body recovery/removal. Effective infection prevention and
control is central to providing high quality health care for patients and a safe working environment for those that work in healthcare
settings. Implementation of good infection control practices help to minimize the risk of spread of infection to patients and staff. Pre-
hospital care need to have an infection prevention program to monitor for HAIs (Healthcare Associated Infections) and prevent the
spread of diseases/infection.

Equipment disinfection:
Equipment and surfaces are contaminated if they have come in contact with patient’s skin, blood or body fluids. These can spread
infection. Therefore, it is mandatory that these are cleaned and disinfected using 1% sodium hypochlorite or alcohol-based
disinfectants at least once daily and after every patient contact. Patient care items and surfaces that can contribute to the spread of
infection include:
Stethoscopes
Blood pressure cuffs
Monitors
Stretchers, backboards, and immobilization devices
Laryngoscope blades
Radios/mobiles
Shelves
Door handles
Other items and surfaces in ambulance or transport vehicle
DECONTAMINATION OF AMBULANCE:
• Decontamination of ambulance needs to be performed every time a
suspect/confirmed case is transported in the ambulance. The following
procedure must be followed while decontaminating the ambulance:
• Gloves and N-95 masks are recommended for sanitation staff cleaning the
ambulance.
• Disinfect (damp wipe) all horizontal, vertical and contact surfaces with a cotton
cloth saturated (or microfiber) with a 1% sodium hypochlorite solution. These
surfaces include, but are not limited to: stretcher, Bed rails, Infusion pumps, IV
poles/Hanging IV poles, Monitor cables, telephone, Countertops, sharps
container. Spot clean walls (when visually soiled) with disinfectant-detergent
and windows with glass cleaner. Allow contact time of 30 minutes and allow air
dry.
• Damp mop floor with 1% sodium hypochlorite disinfectant.
• Discard disposable items and Infectious waste in a Bio/Hazard bag. The
interior is sprayed with 1% sodium hypochlorite. The bag is tied, and exterior
is also decontaminated with 1% sodium hypochlorite and should be given to
the hospitals to dispose of according to their policy.
• Change cotton mop water containing disinfectant after each cleaning cycle.
• Do not place cleaning cloth back into the disinfectant solution after using it to
wipe a surface.
• Remove gloves and wash hands.
NEWS ARTICLES ON AMBULANCE DEMAND DURING
COVID-19
DUE TO COVID-19 INCREASE IN AMBULANCE DEMAND
The rise in Covid-19 cases in the country has also led to a sharp rise in demand for ambulances. For example, Delhi-based
healthcare startup Medulance says it has witnessed a 3x surge in demand for its ambulance service amid the ongoing pandemic.
The end-to-end emergency response service provider, which was founded in 2017, recorded a jump of 350,000 new subscribers on
its platform after the Covid-19 outbreak in India. The company attributed the uptick in demand to the ease of booking, tracking,
timely diagnosis by its emergency services, and a dedicated helpline number.

DEMAND FOR AIR AMBULANCE

According to an article published in THE HINDU, patients started demanding for air ambulance.
Transporting critically ill patients is a difficult operation at the best of situations but transporting COVID positive patients needing
urgent care raises additional challenges, the most important being isolating the patients and the crew.
Shifting of a COVID-19 patient from Delhi to Chennai would cost not less than rupee 20 lakh, according to an operator.
Despite the costs, however, aggregators and charter plane operators said the demand for increased air transportation of patients
are being turned away as only a limited number of these air ambulances are equipped with isolation pods- mandated by the Health
Ministry for ferrying COVID-19 patients.

Stree Safe

Among the many ambulances carrying Covid patients to hospitals in Pune, one announces in bold pink letters that it is “by women,
for women”.
Known as Stree Safe, the ambulance service was started by the Ninebee Foundation around three weeks ago after there were
reports of abuse of unaccompanied women while they took a relative to a hospital in ambulances.
The Stree Safe ambulance is driven by women and can be availed for free.
KERALA: COVID AMBULANCE MANAGEMENT
The ambulance management module of Covid-19 Jagratha portal offers the facility for ambulance owners and service
providers to register their vehicles for Covid-duty. Also it enables public to request an ambulance by downloading Covid-19
Jagratha mobile app. It also allows tracking the vehicle and provides information about drivers and about how many
ambulances are engaged and which are all available for service.

CHALLENGES WE HAVE FACED:

'SO MANY BODIES,' SAYS AMBULANCE DRIVER
The beginning of the pandemic in India, ambulance drivers has seen and done it all: from rushing patients to hospitals
across Delhi to being the sole witness to last rites being performed. But this particular trip to the cremation ground brought
him a sense of complete helplessness.

CHALLENGES FOR RURAL HEALTH CARE IN INDIA

The rural health care system in India is not adequate or prepared to contain COVID-19 transmission, especially in many
densely populated northern Indian States because of the shortage of doctors, hospital beds, and equipment. The COVID-19
pandemic creates a special challenge due to the paucity of testing services, weak surveillance system and above all poor
medical care. The impacts of this pandemic, and especially the lockdown strategy, are multi-dimensional. The authors argue
for the need to take immediate steps to control the spread and its aftereffects and to use this opportunity to strengthen and
improve its primary health care system in rural India.
REFERENCES:
News articles:
▪ https://www.thehindu.com/news/national/coronavirus-demand-for-air-ambulances-soars-as-virus-exposes-crumbling-
healthcare/article34536057.ece
▪ https://indianexpress.com/article/cities/pune/pune-women-ambulance-stree-safe-covid-7341116/
▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199699/
SOPs:
▪ https://www.fortuneindia.com/venture/surge-in-covid-19-cases-pushes-ambulance-demand/104725
▪ https://abcnews.go.com/International/coronavirus-cases-explode-india-struggles-flatten-curve/story?id=73080777
▪ https://timesofindia.indiatimes.com/city/kozhikode/covid-ambulance-mgmt-handy-for-other-exigencies/articleshow/77621022.cms
Communication:
• https://trauma.reach.vic.gov.au/guidelines/inter-hospital-transfer/contact-retrieval-service
• https://www.oatext.com/Interdisciplinary-communication-on-digital-emergency-networks-in-ambulance-services-An-exploratory-study.php
• https://www.ijcrt.org/papers/IJCRT1705359.pdf
• Gnanasekar, I. and Arockia Raj, P., 2021. THE CADUCEUS OR THE STAFF OF HERMES: A FOCUS ON 108 AMBULANCE SERVICES IN
INDIA. International Journal of Creative Research Thoughts (IJCRT), [online] 6(ISSN: 2320-2882), pp.770-778. Available at:
<http://IJCRT1705359.pdf> [Accessed 7 August 2021].
Transport Services:
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966347/
• https://cpd.org.au/2007/07/how-an-ambulance-service-can-contribute-to-the-health-care-continuum/
▪ Schwebel C, Clec’h C, Magne S, Minet C, Garrouste-Orgeas M, Bonadona A, et al. OUTCOMEREA Study Group. Safety of intrahospital
transport in ventilated critically ill patients: A multicenter cohort study*. Crit Care Med. 2013;41:1919–28. [PubMed] [Google Scholar]
▪ Szem JW, Hydo LJ, Fischer E, Kapur S, Klemperer J, Barie PS. High-risk intrahospital transport of critically ill patients: Safety and outcome of the
necessary “road trip” Crit Care Med. 1995;23:1660–6. [PubMed] [Google Scholar]
▪ Waddell G. Movement of criticall ill patients within hospital. Br Med J. 1975;2:417–9. [PMC free article] [PubMed] [Google Scholar]
• Inter-hospital and intra-hospital patient transfer: Recent concepts (nih.gov)
• https://isccm.org/pdf/Section4.pdf
▪ https://isccm.org
▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966347/