3. How many times over the last 3 years have you needed 4 wheel drive capability? 8 times per year

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1 1. Can you share your ambulance transport data by number of transports by hour of day and day of the week on an annual basis? See attachment 2. What is the average loaded miles per transport? We are unable to get this information from the current provider. 3. How many times over the last 3 years have you needed 4 wheel drive capability? 8 times per year 4. Can we see your price/feature weighted decision grid? The scoring criteria can be revealed if requested after the bid. Past experience is one of the major criteria that will be evaluated. 5. Will the CTT be present for every request/transport? If not, can you confirm only BLS (EMT) transports will be requested? The Children s hospital neonatal or critical care transport team members will be present on 100% of the calls when EMT s are requested. A paramedic / UCD CCT RN configuration could be considered for a subset of calls. 6. Value of Billings - Payor Group - identified as Contracts 44.2% - Can you elaborate on what this exactly means? Are these contracts that UC Davis has with an assortment of different payors IE HMO, PPO s? What will be the transport company s estimated payor mix by % under this payor group (Contracts)? See attachment 7. Is there a separate RFP for the Adult population served? No Costs Proposal scenario option 1 and option 2, how would you like the itemized program cost broken down? Hourly/monthly/annually/ by transport? Monthly 8. Can we have a copy of the UC Davis Health Children s Hospital Critical Care Transport Program policies? See attachment, though please be advised they undergoing major revisions. 9. Could you confirm the requirement of 2 H oxygen tanks and 2 H medical air tanks for a total of 4 H tanks or is the requirement (1) each? 1 each 10. How many CTT teams can you staff at max capacity? Have you ever needed more than 2 ambulances at one time? 2 ambulances at one time 11. Are you willing to have the backup Ambulance have different modifications? Such as a Type 1 for 4x4 capability? Yes 12. On the inverters: Are these to be Perfect sine wave style, or is the standard electronically generated 60 cycle inverter OK? Are the two inverters to work in parallel on the complete system or do they operate separate outlets, or is one to be configured as a backup inverter? Two inverters, operate so that one is backup to the other 13. On the 24Volt outlets: Are these the Cigarette style outlets? Are the outlets to be constant hot or only operate when the unit is on? USB Style in lieu of cigarette style only when the unit is on

2 14. What are your cot and Isolette Hardware requirements? Stryker Cot manual load, so standard securement 15. Do you have any special agreements with EMS for ALS stocked/service on a BLS staffed ambulance? Follow Sacramento county requirements NICU/PICU Calls By Hour September 1, 2017 February 20, 2018 Hours Number of Calls 00:00-00: :00-01: :00-02: :00-03: :00-04: :00-05: :00-06: :00-07: :00-08: :00-09: :00-10: :00-11: :00-12: :00-13: :00-14: :00-15: :00-16: :00-17: :00-18: :00-19: :00-20: :00-21: :00-22: :00-23:59 8 Total Calls 311

3 Calls By Hour September 1, February 20, Neonatal and Pediatric ICU Inpatient Payor Mix Fiscal Years 2015/16 and 2016/17 Fiscal Year 2015/16 Fiscal Year 2016/17 % of Total Cases Cases ALOS % of Total Cases Cases ALOS Payor Group Medicare 0.3% % Medi-Cal 65.2% 1, % 1, Sacramento County 0.0% % Other County 0.0% % Private Ins 0.0% % Contracts 27.5% % Self-Pay 0.0% % Capitated-Full Risk 4.3% % Capitated-Partial Risk 2.8% % Grand Total 100.0% 2, % 2, Qualifications: All inpatient discharges from July June 2017 where patient account had at least one patient day billed under Revenue Centers D5 Neonatal Units or D10 Pediatric ICU/PICU.

4 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 1 UC Davis Children s Hospital Critical Care Transport Team Structure Standards Reviewed: Sept 2015 Debra Bamber, RNC, MSN, Manager PICU/PCICU and Critical Care Transport Team, Laura Kenny, CCRN, MSN, Assistant Program Manager Critical Care Transport Team and ECLS Coordinator I. LOCATION/PHYSICAL DESCRIPTION The University of California, (UC) Davis Children s Hospital Critical Care Transport Program offices are located in Room 3219 and 3217 in the Main Hospital building. The UC Davis Children s Hospital Critical Care Transport Team provides interfacility transport primarily within California but may provide interstate transports when requested. II. PURPOSE The Children s Transport Team is available for the interfacility transport of neonates, infants, and children up to the age of 18 from referring facilities to UC Davis Medical Center (UCDMC). Exceptions to the age limit may be made by the medical director based on the patient s diagnosis and developmental age. The team is also available to transport patients from UCDMC to other facilities when requested. The team is available to transport acute care patients when more appropriate means of transport, such as ALS ambulances, are not available or the patient would benefit from the services of a specialized pediatric transport team. The UC Davis Children s Hospital Transport Program endeavors to meet all recommendations of the American Academy of Pediatric committee on Pediatric Transport, the State Emergency Medical Services Authority recommendations on pediatric transport and other applicable organizations. III. GOALS A. The primary goal of the UC Davis Children s Hospital Critical Care Transport Team is the safe and expedient transport of critically ill and injured neonates, infants and children who would benefit from the services of a specialized neonatal/ pediatric transport team. B. The team supplements the care of healthcare providers in referring facilities, stabilizes patients for transport in referring facilities, prepares patients for transport and transports patients between facilities in ground ambulances, fixed wing aircraft and rotor wing aircraft. C. The Team provides care under the direction of medical control physicians (MCP) who are attending physicians at UC Davis Health System (UCDHS). The team has standing orders when they are unable to contact the MCP due to communication dead spaces or when it wouldn t be practical to contact the MCP prior to instituting standing orders such as a rapidly decompensating patient. D. The team ensures that the philosophy of family centered and culturally competent care is provided and is based on the three key elements of respect, collaboration, and support. Within this philosophy, the family is defined as the parent(s), children and significant others. E. The team is sensitive to religious or spiritual needs of the patient and the family. F. The team respects the right of the family members to participate in decision making and supports family centered care. G. The team supports the mission of the UCDHS and endeavors to contribute to the mission of the health system. IV. HOURS OF OPERATION

5 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 2 The Children s Transport Team functions on a twenty-four hours per day basis, 365 days a year. When available, the transport nurses will round every 2-3 hours as needed in the following units: PICU/PCICU, NICU, D7 Pediatric, & Peds Emergency Department (ED). The team will ensure the Charge RN has team pager numbers and Vocera contact information for the team. V. PHILOSOPHY Pediatric critical care transport is a highly specialized area of medicine in which the critically ill infant or child is stabilized and transported to a facility specializing in his or her care. The need for patient transport is indicated by the specific elements of care that cannot be provided by the referring institutions. The purpose of the Interfacility Transport Program is to facilitate communication between community physicians and the pediatric faculty regarding management of critically ill patients and/or possible transfer to the PICU/PCICU, NICU, D7 Pediatrics, and the Peds ED. The Children s Transport Team will: A. Provide an extension of the critical care unit (i.e., skills, equipment) to the referring facility B. Provide timely and safe transportation to a pediatric critical care center without an increase in morbidity or mortality C. Provide the highest quality of care for critically ill infants and children who require interfacility transport D. Increase the early transfer of critically ill pediatric patients who may benefit from care given in a regional Medical Center E. Improve early stabilization of critically ill pediatric patients in outlying institutions by an ongoing outreach educational program F. Provide optimal conditions for the safe transport of patients to and from UCDMC G. Meet California Children Services standards for PICU/PCICU VI. MEDICAL SERVICES ORGANIZATION/STRUCTURE OF UNIT A. MEDICAL 1. Medical Director for Pediatric Transports: The medical director of transport is appointed yearly by the Director, Hospital and Clinics, with the concurrence of the Department of Pediatrics Chairperson. The medical director for pediatric transports is a board certified Pediatric Critical Care Physician. He/she is CCS-paneled. The medical director, in conjunction with the program manager, approves and modifies all policies, procedures and standing orders for pediatric transport. The medical director monitors safety and quality assurance through monthly Continuous Quality Improvement (CQI) meetings. The medical director is the cochair of the CQI and Children s Transport Program Committee. The medical director provides input into capital equipment and supplies. 2. Medical Director of Neonatal Transports: The medical director of transport is appointed yearly by the Director, Hospital and Clinics, with the concurrence of the Department of Pediatrics Chairperson. The medical director for pediatric transports is a board certified neonatologist. He/she is CCS-paneled. The medical director, in conjunction with the program manager, approves and modifies all policies, procedures and standing orders for pediatric transport. The medical director monitors safety and quality assurance through monthly Continuous Quality Improvement meetings. The medical director provides input into capital

6 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 3 equipment and supplies. 3. Neonatology Fellows: The neonatology fellow may be assigned to participate in the transport of neonatal patients by the attending physician. They may direct the care of the neonate in the referring facility and during transport. They may perform procedures under the direction of the medical control physician and in consultation with the neonatal transport nurse. 4. House Staff: House staff may be assigned by the attending physicians to participate in transport for training purposes. House staff participating in transport will not be responsible in directing the care of the patient in the referring facility or during transport. These opportunities will only be available for ground transport. The lead Critical Care Transport Registered Nurse (CCTRN)/Neonatal Transport Nurse will take direction from the MCP or operate under Standing Orders. Procedures on transport will be the responsibility of the CCTRN under the direction of the MCP. B. PATIENT CARE SERVICES 1. Children s Hospital Critical Care Transport Program Manager: The Children s Hospital Critical Care Transport Program Manager has 24/7 responsibilities for the staffing, quality of care, instruction and supervision of the all hospital employees assigned to the program. The manager promotes an environment conducive to the practice of professional nursing. She/he participates in the formulation of the unit budget and is responsible for managing within the constraints of this budget. The Program Manager will be a RN licensed in California and be masters prepared. The Program Manager will also have experience in the care of critically ill children and preferably have critical care transport experience. The Program Manager shall meet all requirements of the Critical Care Transport Registered Nurse (CCTRN). The Program Manager is co-chair of the CQI and Transport Committee. The program manager reports directly to the Associate Director of Patient Care Services. 2. Children s Hospital Critical Care Transport Assistant Program Manager: The Assistant Program Manager will assist the Program Manager in the staffing, quality of care, instruction and supervision of the all hospital employees assigned to the program. The Assistant Program Manager promotes an environment conducive to the practice of professional nursing. The Assistant Program Manager will be a RN licensed in California and be bachelors prepared. The Assistant Program Manager will have experience in the care of critically ill children and preferably will have critical care transport experience.. The Assistant Program Manager is the chair of CQI and transport committees. The Assistant Program Manager reports to the Program Manager. 3. Children s Hospital Critical Care Transport Registered Nurse: The CCTRN is a RN responsible for the interfacility transport of neonates, infants and children. The CCTRN functions in an expanded role which includes x-ray interpretation for tube/line placement and pneumothoraces, oral tracheal intubation, needle chest decompression, intraosseous cannulation, external jugular vein cannulation, UAC/UVC insertions, and surfactant administration. They perform these procedures under Standardized Procedures approved by the Medical Executive Committee at UCDMC. The CCTRN functions under the direction of the medical control physician and, in instances when the MCP cannot be reached or when it is not practical, they function under standing orders approved by the Medical Executive Committee at UCDHS. The CCTRN will have critical care nursing or emergency nursing experience that includes care of infants and children. They will be licensed in California and will be bachelors prepared. The CCTRN reports to the Program and Assistant Program Manager.

7 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 4 4. Neonatal Transport Nurse: The Neonatal Transport Nurse is a RN responsible for the interfacility transport of neonates. The Neonatal Transport Nurse functions in an expanded role that includes x-ray interpretation for tube/line placement and pneumothoraces, Umbilical Arterial Catheter/Umbilical Venous Catheter (UAC/UVC) insertions, endotracheal intubations, needle chest decompression, PICC line placement, radial artery line placement, and surfactant administration. The neonatal transport nurse functions under the direction of the medical control physician, and in instances when the MCP cannot be reached or when it is not practical, they function under standing orders approved by the Medical Executive Committee at UCDHS. The neonatal transport nurse will have experience in the care of the neonate. They will be licensed in California and be bachelors prepared. The neonatal transport nurse shall report to the program/assistant program manager of transport for transport issues and to the manager of the NICU for other issues. 5. Respiratory Care Practitioners: Respiratory care practitioners (RCP) may participate in ground transports only of the neonate, infant or child when requested by the medical control physician, CCTRN or Neonatal Transport Nurse and directed by the supervisor of respiratory care. The RCP must be familiar with the equipment and supplies being utilized by the Children s Hospital Critical Care Transport Program and be provided an orientation to the transport environment prior to participating in transport. They will be licensed in the state of California as a RRT/Certified Registered Respiratory Therapists (CRRT). 6. Transport Partners: Other patient care staff not employed by UCDHS may participate in the transport of neonatal, infants and children. These staff may include EMT, EMT-P from the ground ambulance company or a RN or RT from the air ambulance company. In most instances, UCDHS Staff will provide direct patient care. In certain instances, assistance may be required in direct patient care when the patient condition warrants. In these instances, the employees of the ground or air ambulance may provide services consistent with their scope of practice and the policy and procedures of their employer. In all instances, the CCTRN or neonatal transport nurse operating under standing orders, patient care standardized procedures, or MCP direction will direct patient care. VII. NURSING PROFICIENCY/COMPENTENCY General requirement for Children s Hospital Critical Care Transport Registered Nurses: A. Qualifications: 1. Registered Nurse (RN) with three years experience in pediatric or neonatal critical care, emergency medicine or critical care transport. 2. Bachelor of Science in Nursing (BSN) required. B. Staff Selection Interviews will be conducted by the Nurse Manager and Assistant Program Manager. Other panel members may be included by invitation. C. Training: 1. Completion of critical care transport orientation program 2. Completion of 20 simulated oral intubations and six on patients in the operating room or appropriate unit. Four patients must be in the age range from newborn to 17 years of age.

8 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 5 4. Complete Crew Resource Management, Flight Physiology, Survival Training and Safety Training for helicopter, fixed-wing and ground safety. Once completed in the initial training period, these are completed on an annual basis as a mandatory requirement. D. Other Certification: 1. PALS Pediatric Advanced Life Support (American Heart Association and American Academy of Pediatrics). This is a mandatory requirement. 2. NRP Neonatal Resuscitation Program (American Academy of Pediatrics/AHA). This is a mandatory requirement. 3. ACLS strongly recommended 4. Certification in Pediatric or Neonatal Critical Care Nursing strongly recommended 5. Encouraged to complete a course in trauma, emergency or transport nursing with pediatric content within 12 months of employment E. Initial Evaluation: Certification of a Critical Care Transport Nurse to utilize listed standardized procedures will be granted according to the completion of experiences related to the specific function to be authorized. F. On-going Evaluation: 1. Chart review of all patients who receive therapy under the CCTT Standardized Procedures will be conducted by the transport program CQI Committee and the Medical Director 2. Each CCTTRN will maintain a list of standardized procedures performed and will be subject to review by the Program Manager or Medical Director. G. Circumstances under which a Critical Care Transport nurse may perform functions: 1. Setting In the referring facility, during transport or in the hospital under the direct/indirect supervision of a UCDMC attending physician or UCDMC NP competent in the procedure 2. Supervision indirectly by the Medical Control Physician H. Consultation with the Medical Control Physician is not required for emergent interventions as follows: 1. Oral Endotracheal Intubation 2. Laryngeal Mask Airway 3. Needle Thoracentesis 4. Intraosseous Cannulation 5. Umbilical Vessel Catheterization 7. Surfactant Administration I. Follow-up As soon as voice contact is established, the intervention will be reported to the Medical Control Physician. J. Development and approval of standardized procedures: 1. Developed by the Medical Director and the Program Manager for age appropriate procedures 2. Developed by the Pediatric and Neonatal Medical Directors and Program Manager for age appropriate procedures 3. Review period 3 years

9 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 6 VIII. General requirement for Neonatal Transport Expanded Role Nurses (ERNs): A. Experience Requirement for Transport ERN 1. Current RN License 2. Neonatal Experience: 24 months experience in neonatal intensive care with at least 1 year completed in the UCDMC NICU (exceptions can be made at the discretion of the Medical Director and Nurse Manager) 3. Skills consistent with a CNII in the UCD NICU 4. NRP Neonatal Resuscitation Program B. Training: 1. NRP and certification in Neonatal IV/ABG lines 2. Completion of Neonatal Transport Expanded Role orientation at UCDMC 3. Complete observation training requirements and demonstrated proficiency in transport 4. Maintain annual neonatal skills lab competencies and safety training 5. Complete a minimum of four (4) intubations annually, at least (1) intubation every quarter 6. Complete helicopter, fixed-wing and ground ambulance safety training C. Limitations to use Standardized Procedures will be as follows: Transport ERNs will utilize only those procedures authorized by the Neonatal Medial Director, NICU Manager, Transport Program Manager and Assistant Transport Program Manager, who serves as a liaison between NICU and CCTT, related to specific function and role required for neonatal transport. 1. Oral Endotracheal Intubation 2. Needle Thoracentesis 3. Closed Chest Thoracentesis 4. Umbilical Vessel Catheterization 6. Surfactant Administration D. On-going Evaluation: 1. Chart review of all patients who receive therapy under these procedures will be conducted by the Critical Care Transport CQI Committee. 2. All situations in which Transport ERN utilized an approved standardized procedure during transport will be reviewed by Medical Director for Neonatal Transport, and the Assistant Transport Program Manager. IX. COMMUNICATION PATHWAYS This section establishes guidelines that determine the transport pathway for UCD 4 Kids admission referrals to UCDMC. A. Admission requests made by a physician through the UCD 4 KIDs will be received by the Transfer Center.

10 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 7 The Transfer Center staff will direct these calls to either the PICU Attending Physician or the NICU Attending Neonatologist as indicated. The appropriate Attending will be paged to the UCD 4 KIDs bridge conference line. If the Attending does not call into the bridge within two minutes, the Transfer Center staff will repage the Attending and also call his personal home phone if the admission request is called in at night. Also, the Transfer Center staff will contact the specific unit related to admission request and confirm which Attending is covering the unit. B. If the patient is accepted for admission, and the Children s Hospital Critical Transport Team is designated to transport the patient, the Transport Center staff will activate the Transport Team along with the appropriate charge nurse from either the PICU or NICU. The Transport Team is comprised of the Critical Care Transport Team (CCTT) and/or the NICU transport member (T-ERN). Pediatric and neonatal transports will be transported by ground ambulance, fixed wing and/or rotor wing companies in contract with UCDMC for this purpose. The activation process will occur within one minute after the decision has been made to admit the patient. C. The Critical Care Transport Team will be ready to depart for transport within twenty minutes after activation. D. The ambulance crew will arrive at UCDMC to transport the team no later than twenty minutes after they have been contacted and agreed to do the transport. E. If fixed wing is part of the mode of transportation, the aircraft will be available at the designated airport no later than one hour after they have been contacted and agreed to transport. F. When the transport team arrives at the referring facility and makes patient contact, the Team Leader will contact the Attending Physician, within 10 minutes, to give patient report and receive transport orders. G. The transport team will leave the referring facility when the patient is stable enough to transport and within thirty minutes after initial patient contact. H. If any above target time is not met a CQI review will be activated. X. STAFFING A. Dress and Personal Appearance 1. All nurses of the Children s Hospital Critical Care Transport Team are representatives of UCDHS. As such, all staff shall dress in appropriate attire. 2. Transport personnel are to wear the uniform of the UC Davis Children s Hospital Critical Care Transport Team. 3. Employees shall dress in accordance with safety requirements in the workplace based on the nature of the work and proximity to possible safety hazards, such as machinery or hazardous substances. 4. The UCDHS photo identification badge is a required part of each employee s attire and must be visible while on duty. (Refer to UCDHS Policies and Procedures, Section 3306, Hospital Security) 5. Significant departures from conventional business dress or grooming standards shall not be permitted regardless of the nature of the employee s duties/responsibilities. 6. Exceptions to established standards may be granted for medical/religious/cultural reasons with the proper documentation and management approval. 7. Employees reporting to work improperly dressed or groomed will be subject to corrective action and may be sent home to make any required corrections.

11 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 8 8. Management reserves the right to determine appropriateness of dress. B. Pediatric Transport Team Configuration 1. All unstable critically ill pediatric patients will be transported to the PICU/PCICU by a minimum of two critical care transport team (CCTT) nurses. Additional team members may include: attending physician, respiratory therapists or emergency medical technicians (EMTs)/ paramedics from a ground ambulance, or fixed wing/rotor wing air ambulance service. 2. Stable, critically ill pediatric patients may be transported to the PICU/PCICU by one CCTT nurse and an EMT-Paramedic from a ground ambulance, or fixed wing/rotor wing air ambulance support service with approval of the Medical Control Physician (MCP) and in agreement with the CCTT RN. 3. Stable pediatric patient transports may be transported to the pediatric ward by one critical care transport nurse and an EMT-Paramedic from a ground ambulance, or fixed wing/rotor wing air ambulance support service with the approval of the medical control physician and in agreement with the CCTT RN. C. CCTTRN Role as T2 for NICU Transport 1. PRIOR TO TRANSPORT a. The CCTRN team (with the Davis 5 Neonatal Unit [D5NU]T-ERN, MCP and charge nurse) will be on conference call. b. After patient has been accepted, the CCTRN (if not out on transport) will utilize the most appropriate mode for transportation to arrange transport. Mode is collaboratively determined by the MCP and referring MD. c. When CCT team is not available to arrange transportation, the D5NU transport nurse in conjunction with the D5NU charge Nurse will arrange mode of transportation. Following arrangement of mode of transport, D5NU Charge Nurse will contact the Transfer Center staff to finalize the transport arrangements. Neonatal take back transport arrangements must involve the hospital discharge planner. A. Request chart and x-ray copies B. Accepting MD must be identified C. Confirm bed availability D. Obtain parent consent d. The CCTRN will notify the D5NU T-ERN with ETA of departure time. e. The CCTRN and D5NU T-ERN will determine and bring the appropriate module and supply bag(s) to the pre-arranged destination. f. The D5NU staff (T-ERN) will be responsible for diluted medications used during neonatal transport. D. CCTT RN Role During Independent NICU Transport. 1. SPECIAL TRANSPORT INSTRUCTIONS a. If CCTT staff transport a neonate patient (without a Neonatal RN in the T1 role) they will obtain the following specimens. This request will come from the UCDMC MCP to the referring facility physician in charge. The CCTT Transport RN will confirm receipt of these specimens prior to departing the referring facility. A special focus charting notation should

12 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 9 be placed in the transportation charting if one or both of these specimens is not able to be obtained. 1) A vial containing, at the minimum, four (4) milliliters of maternal blood (a purple EDTA tube is preferred, but a red clot tube would also be accepted) is required. The optimal amount of blood is eight (8) milliliters. The vial should be clearly labeled with the mother s information. Additional information on the tube should include: a) The date and time of the blood draw. b) The name or initials (depending on the referring facilities policy) of the person who drew the lab. c) Maternal blood should be placed in the biohazard bag with the large red sticker that says MATERNAL BLOOD on the outside, the infants name should be written below on the indicated line. On arrival to UC Davis, a label with the infants name and medical record should be placed on the red sticker. Maternal and cord blood will then be placed in the Davis 5 Specimen freezer until infant is discharged from the unit. 2) A vial containing, at the minimum, one (1) milliliter of cord blood (a purple EDTA tube is preferred, but a red clot tube would also be accepted) is required. If available, a higher volume is optimal. The vial should be clearly labeled with the mother s information. Additional information on the tube should include: a) The date and time of the blood draw. b) The name or initials (depending on the referring facilities policy) of the person who drew the lab. c) Cord blood should be placed in the biohazard bag with the large yellow sticker that says CORD BLOOD on the outside, the infants name should be written below on the indicated line. On arrival to UC Davis, a label with the infants name and medical record should be placed on the yellow sticker. Maternal and cord blood will then be placed in the Davis 5 Specimen freezer until infant is discharged from the unit. 2. DURING TRANSPORT Duties of the Critical Care Transport Nurse in conjunction with the NICU T1 is a shared responsibility as listed below: a. Confirm transport with Transfer Center staff and provide ETA for return to UCDMC b. Call referring hospital with an ETA c. Track and document arrival and departure times d. Charting and documentation e. Patient care: Prepare patient for transport by applying compatible transport module monitoring equipment. f. Discuss and coordinate plan of care g. Perform Standardized Procedure as discussed h. Confirm ventilator settings and function prior to moving patient to module ventilator i. Maintain line of communication between team members to coordinate patient transfer into transport module. 3. AFTER TRANSPORT Duties of the Critical Care Transport Nurse in conjunction with the NICU T1 is a shared responsibility as listed below:

13 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 10 D. Staff Development a. Assist the admitting nurse with patient transfer to NICU bed. b. Clean the module and restock the supply bags. If CCTT is not involved on a neonatal transport, the T-ERNs are responsible for cleaning the module used and restocking the supply bags. c. Post transport debriefing is required and all team members are expected to participate. (Examples of debriefing questions: How did the transport go?, Any issues or concerns?, Anything different that we could have done?, Are we in agreement with how everything went during the transport?, or Any equipment or staff interaction concerns? ) Contentious issues are to be respectfully confronted by team members and attempted to be resolved at this level. d. Unresolved behavioral issues are to be addressed with the respective Assistant Nurse Manager or Manager. e. Potential CQI issues are to be identified and documented on the CQI form by all team participants. f. Incident Reports (IR): To be filed jointly (by agreement). IRs must reflect items that place the nurse, MD or hospital at risk. 1. Purpose of staff development is to ensure the best possible outcome for the patient; increase staff s knowledge and skills; and familiarize staff with nursing research and current clinical practice. 2. Staff is encouraged to participate in certification programs and attend transport conferences. 3. Attend in-service training on new clinical equipment and practice. E. Staff Education 1. Quarterly skills training sessions are developed to provide the necessary didactic and clinical education to ensure the optimal care of the pediatric and neonatal patient during interfacility transport by expanded role registered nurses. During orientation and throughout the year, the CCTTRN will review the following topics: a. Pediatric Intubation- Indications and Procedures (This includes laryngeal mask airway (LMA), rapid sequence intubations (RSI), and intubations in the Children s Surgery Center operating room.) b. Neonatal Intubation- Indications and Procedures c. Pediatric and Neonatal Chest X-ray Interpretation d. Needle Chest Decompression in the Pediatric and Neonatal Patient e. Basics of Ventilation in the Neonatal and Pediatric Patient f. Pediatric and Neonatal Transport Ventilators g. Vascular Access in the Pediatric Patient- Utilizing intraosseous (IO) and external jugular (EJ) catheter placement

14 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 11 h. Vascular Access in the Neonatal Patient- Utilizing umbilical artery catheters (UAC) and/or umbilical venous catheters (UVC) to establish vascular access i. Thermoregulation in the Neonate in the Transport Environment j. Point of Care Testing In Transport- istat and glucose meter k. Legal Aspects of Transport and Expanded Role for Registered Nurses l. Referral Hospital Relations and Outreach Role of Transport Team m. Care of the Family and Family Participation on Transport n. Assessment and Interventions and the decision to transport o. Packaging the Pediatric and Neonatal Patient p. Standardized Procedures and Standing Orders q. Altitude Physiology and Stressors of Flight r. Transport Safety-Ambulance Familiarization and Safety s. Transport Safety-Fixed Wing Aircraft Familiarization and Safety; Rotor Wing Ride-A-Long, Aircraft Familiarization and Safety 2. Completed Competencies Required after Training and Re-Verification Annually of the following: a) Endotracheal Intubations, b) Needle Decompression of the Chest, c) Defibrillation/Cardioversion, d) Intraosseous Placement, e) External Jugular Vein Cannulation, f) UVC/UAC insertion and g) surfactant administration. XI. PATIENT FLOW This section addresses standards for determining appropriate mode of transport, as well as utilization of ground ambulance versus air ambulance by the UC Davis Children s Hospital Critical Care Transport Program. A. It is the responsibility of the receiving physician, in consultation with the referring physician, to determine the appropriateness of transfer, the appropriate mode of transportation and the appropriate personnel to provide care during transport. B. Medical personnel on transport will be trained to respond effectively to the needs of neonatal and pediatric patients during transport. C. Pre-hospital personnel involved in the interfacility transportation of patients shall adhere to the policies/procedures/protocols of the Local EMS Agency and the State Scope of Practice for prehospital personnel. 1. Basic Life Support (BLS) Ambulance a. The ambulance is staffed with at least two (2) Emergency Medical Technicians-Is (EMT-I). b. Patient care may not exceed the EMT-I Scope of practice. 2. Advance Life Support (ALS) Ambulance a. The ambulance is staffed with at least one (1) Emergency Medical Technician Paramedic (EMT-P). b. EMT-Ps involved in the interfacility transfer aspect of the EMS system shall follow Sacramento County EMS (SCEMS) Program Document #5101.

15 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 12 D. Patients requiring clinical skills (Scope of Practice) beyond those of an EMT-I or EMT-P shall be transported via Critical Care Transport and accompanied by appropriate clinical personnel. E. EMT-I Scope of Practice; During training or during interfacility transfer, a supervised EMT-I trainee or certified EMT-I is authorized to do any of the following: 1. Evaluate the ill and injured 2. Render basic life support, rescue and first aid to patients. 3. Obtain diagnostic signs including temperature, blood pressure, pulse, and respiration rates, level of consciousness, and pupil status. 4. Perform cardiopulmonary resuscitation, including the use of mechanical adjuncts to basic cardiopulmonary resuscitation and automated external defibrillators (AED) 5. Use the following adjunctive airway breathing aids: a. Oropharyngeal airway b. Nasal pharyngeal airway c. Suction devices d. Basic oxygen delivery devices 6. Use various types of stretchers and body immobilization devices. 7. Transport patients. 8. Administer oral glucose or sugar solutions. 9. Monitor peripheral lines delivering intravenous glucose solution without medication or isotonic balanced salt solutions without medication, including Ringers lactate for volume replacement. F. EMT-P Scope of Practice 1. Administer intravenous glucose solutions. 2. Administer isotonic balanced saline solutions. 3. Institute intravenous (IV) catheters and saline solutions. 4. Glucose meter 5. Perform pulmonary ventilation by use of endotracheal intubation. 6. Perform defibrillation. 7. Perform synchronized cardioversion. 8. Visualize the airway by use of the laryngoscope and remove foreign body (ies) with forceps. 9. Perform needle thoracostomy. 10. Perform Valsalva Maneuvers. 11. Medications: a. 25% and 50% Dextrose solutions b. Activated Charcoal

16 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 13 c. Albuterol d. Aspirin e. Atropine Sulfate f. Calcium Chloride g. Diphenhydramine HCl h. Dopamine HCl i. Epinephrine j. Furosemide k. Glucagon l. Lidocaine HCl m. Midazolam n. Morphine Sulfate o. Naloxone HCl p. Oxymetazoline HCl q. Phenylephrine HCl r. Sodium Bicarbonate s. 2-PAM HCL 12. Authorized Sacramento County EMS optional scope of practice a. Nasotracheal Intubation b. Rectal Diazepam c. Needle Cricothyrotomy with jet insufflation d. Pediatric Endotracheal Intubation e. Intraosseous Access/Infusion f. Transcutaneous Cardiac Pacing g. Monitor PIV with 20KCL in maintenance line (No other additives) G. The general policy will be that transport from a referring facility within a 75-mile radius of the UCDMC will be done by ground ambulance. If the referring facility is greater than 75 miles then fixed wing aircraft may be utilized. The ground ambulance provider should be contacted immediately after the patient is accepted to assist in a rapid response time. If the contracted ground ambulance provider is not able to provide an ambulance or crew other providers will be contacted regarding availability of ambulances. If two Critical Care Transport RNs are going on the transport, a BLS rig is requested. The ambulance provider may choose to send an ALS rig to respond to the call. We will provide a copy of the face sheet to the ambulance crew to assist them in billing. H. If the referring facility is greater than 75 miles then the contracted fixed wing or RW provider is contacted immediately after the patient is accepted. If the contracted fixed wing or RW provider is not able to be at the designated airport within 1 hour, please check the availability of aircraft from other providers. If the physician feels that response time is important and another provider is able to provide an aircraft sooner, then the fixed wing provider with the shortest response time to the designated airport shall be utilized. I. If weather does not permit flying, then ground transports outside the 75 mile radius will be performed. Extended periods of time waiting for weather to clear for flight (more than ½ hour) are highly discouraged. If the anticipated wait plus flight time are greater than the drive time, then ground transport is likely appropriate. The anticipated wait is often not accurate, so wait times greater than ½ hour are discouraged. J. If the referring MD and the accepting MD feel that ground transport within the 75 mile radius is not expedient enough for the patient s condition, then rotor wing transport may be offered utilizing the Rotor Wing Hybrid Transport Team for pediatric and neonatal admissions. K. If the referring MD and the accepting MD feel that fixed wing aircraft outside the 75 mile radius are not expedient enough for the patient s condition, then rotor wing transport may be offered utilizing the Rotor Wing Hybrid Transport Team for pediatric and neonatal admissions. L. Consideration of the anticipated medical/nursing needs of the infant or child during transport should be considered on each transport and the advantage of time weighed against the advantage of waiting for a highly

17 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 14 skilled team to transport the patient. It is often advantageous to wait for a specialized transport team even if the response time is significantly longer. The referring physician has the final decision on how to best transport the patient. XII. UNIT SPECIFIC NURSING RESPONSIBILITIES This section outlines the use of the Children s Critical Care Transport Registered Nurse (CCTRN) for support in patient care in the Pediatric ER, D7 Pediatrics, PICU/PCICU, NICU or other areas where children are provided nursing care. A. When available, the transport nurses will routinely round as needed in the following units: PICU/PCICU, NICU, D7Pediatrics, & PEDS ER. The team will ensure the Charge RN has team pager numbers and Vocera contact information for the team. B. The Team will keep track of the hours spent on the various units utilizing the Grasp system, but will not be recharged for the assistance by the CCTRN. C. The Team will be able to assist with the following, provided they can be relieved within five minutes should they receive a transport call: 1. Transports to CT and X-Ray 2. Lunch Relief 3. Patient admissions 4. IV starts 5. Trauma and pediatric codes 6. Other patient care D. The Team is NOT available for transports to MRI, due to inability to receive pages/calls for transport duties. E. The Team is NOT available to assist with conscious sedation due to the length of time to transfer care to someone else as the patient s welfare may suffer due to the lack of continuity of care. F. As time spent involved in direct patient care enhances the skills and proficiency of the CCTRN, the unit charge nurse should make every effort to offer experiences that help to maintain their proficiency. G. The Team may not be available to assist the units, even when not on transport, if they are performing other duties that ensure their immediate availability for transport such as stocking bags, checking equipment or completing documentation. H. The CCTRN will only be given a patient assignment when an emergency staffing condition exists and all pediatric areas, including the Peds ED, are closed to transports. Both CCTRNs may be given a patient assignment when all pediatric areas and the NICU are closed to transport. The transport Program Manager shall be notified prior to assigning patients to the CCTRN. XIII. UNIT BASED PERFORMANCE IMPROVEMENT Performance improvement activities in the UC Davis Children s Hospital Critical Care Transport Program are conducted for ongoing quality surveillance and documentation. A. The responsibility for Continuous Quality Improvement is the responsibility of the Program Manager/Assistant Program Manager and the Medical Director. A Critical Care Transport RN (CCTRN) may be assigned the additional duty of CQI coordinator for the transport program. B. Documentation of each transport will be reviewed by a CCTRN not participating in the transport as soon as practical after the transport but within 24 hours following the completion of the transport. The CQI Audit form will be utilized. The CCTRN completing the audit will review documentation to ensure it meets the

18 UC Davis Children s Hospital Critical Care Transport Team Structure Standards 15 documentation standards. The CCTRN completing the audit will review the documentation for appropriateness of care and adherence to standing orders. They will document their findings on the CQI form. Any issues regarding equipment or response time will be referred to the Assistant Program Manager/Program Manager for review. Any clinical issues will be referred to the medical director through the Assistant Program Manager/Program Manager for review. C. Any transport in which a standardized procedure is performed will be referred to either the Medical Director of the Transport Program for pediatric transports or the Medical Director of the Neonatal Intensive Care Unit for neonatal transports, through the assistant program manager/program manager for review. D. CCTRNs and the Neonatal T-ERNs are encourage to self identify any issues with equipment, supplies or clinical issues on the CQI audit form and take any steps necessary to resolve the issue. E. The Incident Report System (IR system) will be utilized for appropriate categories of incidents such as medical errors, falls, and arrests, etc. F. Data will be collected from the audit forms and summarized for the monthly CQI meeting. Any actions taken prior to the monthly CQI meeting to resolve issues should be added in the comments sections to add the CQI committee. G. The CQI committee will review CQI data for the previous month and make recommendations for improvements. Action items will be noted in the CQI meeting minutes. H. The CQI audits, data collection and minutes will be kept for a period of no less than 3 years. XIV. DOCUMENTATION STANDARDS: Below outlines the procedures for documentation of patient: A. Proper documentation will clearly explain what care was provided for the patient. B. When completing paperwork, please print the information clearly and concisely checking spelling carefully. C. Only used approved Abbreviations by UCDMC. D. Document facts only. E. All information contained in these records is strictly confidential. F. The completion of paperwork is the responsibility of all team members. G. All paperwork must be completed and turned in at the end of the transport or if a late transport, the next day.. H. The following are to be included on the run documentation: 1. Date 2. Name of patient 3. Date of Birth 4. Sex 5. Diagnosis/Mechanism of Injury 6. Referring MD Name/Referring Hospital 7. Accepting MD Name/Receiving Hospital 8. Vital Signs-Q15min, if Critical more frequent 9. Vital Signs-Q30min, if Stable or more at the discretion of the CCTT. 10. Additional Patient Assessment

19 UC Davis Children s Hospital Critical Care Transport Team Structure Standards Reason for Patient Transport 12. Medication Administration, pre, during, and post transport; and treatments administered. 13. Allergies 14. Past Medical History 15. Documentation of Procedures: a. Oral Endotracheal Intubation b. Laryngeal Mask Airway c. Needle Thoracentesis d. External Jugular Peripheral Vein Access e. Intraosseous Cannulation f. Umbilical Vessel Catheterization h. Surfactant Administration i. Defibrillation/Cardioversion j. Document transport times k. EKG strip interpreted and attached l. On arrival at UCDMC, place patient sticker with medical record number and name on transport document. m. Copies of imaging (if available) XV. EQUIPMENT This section outlines the equipment that is to be carried on all transport by the Children s Hospital Critical Care Transport Team. A. Pediatric Transport Equipment 1. Gurney or Aero sled with O2 tank 2. GO Bag (see Attachment A) 3. ICU Bag (See Attachment B) 4. Defibrillator 5. Propaq Monitor 6. IVAC Pump 7. Appropriate Transport Ventilator a) LTV1000 b) MVP10 c) 8. istat a) Cartridge EG7 - Gas+Lytes b) 9. Accu-Chek Glucose Meter 10. Linen 11. Documentation Packet 12. Pedimate 13. Chemical Mattress Warmer 14. Dr. Down 15. Portable ETCO2 Monitor B. Neonatal Transport Equipment 1. Transport Isolette with O2 tanks, Ventilator, Monitor, IVAC & Auto Syringes (The D5NU module will be available for NICU runs in the event the pediatric team s module is in use. This module will be used for in-house transport in case of emergency only). 2. GO Bag 3. ICU Bag 4. Defibrillator 5. Documentation Packet 6. Chemical Heat Mattress 7. Controlled Substances

20 UC Davis Children s Hospital Critical Care Transport Team Structure Standards Hand Held Pulse Oximeter 9. Critical Care Transport Pharmacy Bag XVI. MEDICATIONS/PHARMACY SUPPLIES This policy outlines the storage of medications taken during transport. Refer to P&P 3040 Maintenance and Inspection of Emergency Medications, Attachment 1, Section XVI for the list of medication in various kits that are used by CCTT A. The Pharmacy Bag will be kept in a yellow medication pack located inside the large blue ICU bag on the transport gurney. The Pharmacy Bag will be sealed with a pharmacy, red tamper evident lock, ensuring that a Pharmacist has verified its contents and expirations. If transport team utilizes the transport medication pack or the tamper evident lock is broken, the pack is to be returned to the Ground Floor Pharmacy where it will be exchanged for a sealed bag. B. Pediatric Transport Airway Medication and Pediatric Transport Code Medication kits are maintained in the ICU Go bag on the transport gurney. When medications are used from these kits, they will be taken to the Ground Floor Pharmacy and restocked. C. Controlled Substances are double-locked in the CCTT Office, Room Controlled substances shall be replaced by faxing the order to (916) or calling the Controlled Substance Technician pager (916) D. All controlled substances shall be inventoried by two RNs any time there is a change in personnel. The key to access them shall be in the custody of the individual who performed the inventory. E. All controlled substances taken out on transport must be documented on the narcotics accountability form and signed by the transport RN and left on the MAR. 1. If the narcotics are not used they will be returned to the locked narcotic box. Any narcotic used will be documented on the MAR per UCDMC policy and a CCTT Medication Log will be completed and faxed to pharmacy upon the return to UCDMC. 2. Any discrepancies in the controlled substances count shall be reported to management and pharmacy. The discrepancy report must be done utilizing the on-line incident reporting system. F. Uncontrolled medications such as PGE, Fosphenytoin, and Infrasurf will be kept in the refrigerator with the temperature monitored remotely by pharmacy. G. The Medical Control Physician (MCP) can recommend medications or infusions outside of standing orders with appropriate rational and supervision of use of those agents. The Transport Team will have the option to continue the medication infusion, stop the infusion, or contact the MCP for a more appropriate dosing. ATTACHMENTS Refer to UCDHS Policy and Procedure 3040, Attachment 1, Section XVI. XVII. SAFETY DURING GROUND AND AIR TRANSPORT This policy addresses the criteria to provide critical care transport in adverse weather conditions; safety guidelines during pediatric and neonatal ground and fixed wing and rotor wing transports; and the roles, duties and responsibilities of the UC Davis Children s Hospital Critical Care Transport RN on Rotor Wing Hybrid Transports. Adverse Weather: