Editors: Huf/Munich, P. Sefrin/Würzburg and M.Weinlich/Filderstadt© Journal Verlag GmbH,Tauerntalstraße 6,A-9971 Matrei in Osttirol,Austria,Printer:Carinthian Bogendruck GmbH/KlagenfurtNo copyright owner can be named for photos that were left to the publisher without naming the author.Thus, the publisher cannot accept any possible claims.Cover pictures: PIX, R. Huf, Braun Melsungen

Medicine is an ever-changing science driven by new research and clinical experience.The authors and the publisher of this work have made every effort to ensure that the information provided in this workis correct and in accord with the standards of knowledge accepted at the time of publication. However, neither the au-thors nor the publisher warrant that the information contained herein is in every aspect accurate and complete.Readersare encouraged to confirm the information contained herein with other sources, and the responsibility for the treatmentof their patients is solely left to the readers.Registered trade names (trademarks) are not particularly marked.Thus, it cannot be concluded from the absence of suchmarkings that the trade name is unregistered.All rights reserved. This work is protected by copyright. Neither the book nor any part of it may be reproduced, distribu-ted or utilised in any form or by any means, including photocopying, microfilming, utilisation of electronic informationstorage and retrieval systems, and translations, without written permission from the copyright owner.

R. Huf/P. Sefrin/M.Weinlich (editors)

Journal Verlag

Intensive Care TransportSecond edition

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INTENSIVE CARET R A N S P O RT

The world of hospitals has changed beyond recognition due to the changes in hospital financing and ongoing develop-ment in high performance medicine. A reduction in the number of beds due to the closure of small hospitals, the devel-opment of centres of excellence at all levels of care and the resulting centralisation of technical equipment and humanresources all lead to increased interconnectedness and co-operation with regard to hospital units and integrated care.Alongside many other prerequisites, optimised information technology and, most importantly, the best possible trans-port systems are the basic requirements to achieve the best possible care for the maximum number of patients in thissituation.

This book by authors Huf, Sefrin and Weinlich and now in its second edition, considers all aspects relating to the trans-porting of intensive-care patients. Since the transporting of intensive-care patients has a long history in Germany,today’smethods of transporting intensive-care patients are not really emergency solutions, instead they provide the most ver-satile intensive-care supervision and treatment. This enables patients to be transferred with the utmost safety to a morespecialised unit or back to a more general unit. Each chapter clearly emphasises the need for a wide range of require-ments and preparatory work in high performance medicine, from administration, organisation and legal matters to staffand equipment. This leads naturally into the medical area where, depending on the clinical picture, highly specialisedaspects of intensive-care treatment and transporting conditions must be taken into account. However, the book also re-veals that it has only been possible to further develop this area because of the many emergency doctors and intensive-care medical staff and even more because of doctors going beyond the call of duty in the specialised field of transport-ing intensive-care patients.

With this outstanding group of authors, the publishers have succeeded in incorporating theory and personal experienceto produce a book that offers practical help in everyday applications. I therefore hope that this book will gain respect anda wide circulation both in the field of medicine and health policy!

Prof.Dr. K.-W. Jauch

Preface

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The transfer of severely ill and intensive-care patients has taken on an increasingly important role in recent years.Thedifferent classification of hospitals into sites providing primary and standard care to clinics providing the maximumrange of treatments and care requires very different equipment and personnel resources. Consequently serious illnessescan no longer be treated in every hospital. However, in order to provide patients with the best possible diagnostic andtreatment facilities individual hospitals offering different levels of care must be interlinked so that, if necessary, the re-quired facilities can be made available to every patient.The possibilities of information technology have been increas-ingly used in recent years in order to support these links.Nevertheless a considerable percentage of patients still have tobe transferred to hospitals which are the most suitable for them. In the case of the most seriously ill patients such atransfer must of course only take place take in a risk-adjusted manner, i.e.under intensive-care conditions if necessary.

Germany has a long history of transferring severely ill patients, which is inseparable from the development of the emer-gency services. If the previous, rather sporadic, operations are compared with today’s very differentiated and subtle in-tensive-care transfer possibilities, one cannot fail to be impressed by the rapid developments that have taken place inthis sector.Transfers that once seemed inconceivable, nowadays take place routinely with great precision and success.Modern means of transport have equipment which is equal to that of a fully-equipped intensive care ward in almostevery way.

In order to arrive at the situation as it is today, considerable development work was necessary, both in terms of equip-ping the means of transport and the scientific evaluation of the transfers. Thanks to years of intensive work it has beenpossible to define the necessary requirements in respect of apparatus, personnel and contents. In doing so it has beenshown that the extent of the problem is very broad and that in addition to organisational considerations a great deal ofimportance is attached to administrative, legal and medical aspects. However, it has also been shown that the success ofsuch transfers is dependent on thoroughly thought through logistics. Ultimately the same phrase that was once formu-lated for flying also applies to intensive-care transfer: „Proper preflight planning prevents poor performance.“ Everyoneinvolved in intensive-care transfers should take these “6 Ps”to heart.

In this book it will be attempted for the first time to fully summarise the possibilities and limits of the secondary trans-fers, i.e. with regard to the aforementioned differing aspects.The publishers have succeeded in presenting an extremelyinteresting subject through authors who not only have the theoretical knowledge but also extensive personal experi-ence.The result is a book which through practice-related portrayal of the individual topics provides both a valuable aidfor everyday use as well as a important document for planning and development In this respect it is hoped that thisbook will achieve a wide circulation.

Prof. Dr. Dr. h. c. F.W. Schildberg

Preface

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Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Organisation and tactical employment of intensive care transports . . . . . . . . . . . . . . . . . . . . . . . .11

Legal principles of inter-hospital transfers/ intensive-care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . .12P. Hennes, Mainz

Organisational principles and aspects relating to the practical implementationof intensive care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28R. Huf, E.Weninger, Munich

Requirements for means of intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Standards for the ground- and air-assisted transport of intensive care patients . . . . . . . . . . . . . . . . 34P. Knuth,Wiesbaden

Details on the suitability and use of stationary equipmentin intensive-care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43R. Huf, E.Weninger, Munich

The specific challenges of transport trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47H. Reichle, Munich

Personnel requirements for intensive-care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54R. Huf, E.Weninger, Munich

Equipment for intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Mechanical ventilation devices for intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58C. Metz, Regensburg

Monitoring on intensive care transports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75J. Beneker, C. Brodel, Berlin

Table of contentsINTENSIVE CARET R A N S P O RT

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Presentation of different means of intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Inter-hospital transfer in an intensive-care vehicle (ICV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88F.W. Spelsberg, Munich

Bell 412 HP as ITH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91R. Huf, E.Weninger, Munich

Eurocopter BK 117 as ITH (intensive-care transfer helicopter) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94R. Jaki, Gerlingen

Eurocopter EC 145 (BK 117 C 2) as Intensive-Care Transport Helicopter . . . . . . . . . . . . . . . . . . . . . . . .96R. Huf, Munich

Means of transport for intensive-care transfers – MD 900 / MD 902 . . . . . . . . . . . . . . . . . . . . . . . . . .98T. Reinhardt, H.-J. Hennes, Mainz

Airbus A310-300 MRT as intensive-care transport aircraft for the Bundeswehr (Fed.Armed Forces) . .100B. Hossfeld, L. Lampl, Ulm

Sikorsky CH53G as Medical Transport Helicopter for Special Assignments . . . . . . . . . . . . . . . . . . . . .106B. Hossfeld, L. Lampl, Ulm

Secondary Transports in Austria:EC 135 as Intensive Care Transport Helicopter (ITH) . . . . . . . . . . . .108H.Trimmel,Wiener Neustadt

The Challenger (CL) 604 as an intensive-care transfer aircraft (ICA) . . . . . . . . . . . . . . . . . . . . . . . . . .113T. Burren, Zurich

The Learjet 35 A as an intensive-care transfer aircraft (ICA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117M. Mühlmeyer, J. Braun, Filderstadt

Means of intensive-care transport - DO 328 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120M. Pedevilla, D. Egger-Büssing, Innsbruck

Transporting intensive care patients on board Deutsche Lufthansa’s long-haul fleet . . . . . . . . . . . .124D. Ehring, L. Bergau, Frankfurt

Special features of intensive care transports with aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127

The Physics of the Atmosphere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128R. Huf, E.Weninger, Munich

Pressure related problems – procedures and avoidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132H. Reichle, Munich

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Heliports at hospitals – legal principlesand their implementation in practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137G. Carloff, Sankt Augustin

Landing sites for helicopters – selection and preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146R. Maier, Munich

Selected clinical pictures at intensive care transports and special features of transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149

Intensive-care transfer of critical patients –special factors in the case of cardiovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150P. Rupp, J. Hesse, Ch. Peters, R. Stiller, Bern, Munich

Intensive care transport and special features of the transport of thoracic patients . . . . . . . . . . . . . .163H.-G. Koebe, Kassel

Intensive-care transfer and special aspects of transportationin the case of conditions involving vascular surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168R. Huf, E.Weninger, Munich

Selected clinical pictures in intensive care transport and special features of transport,e.g.of patients with acute and chronic pulmonary diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173R. Löb, Hamm

Intensive care transport of patients with special neurosurgical and neurological disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184E.Weninger, R. Huf, Munich

Intensive care transport for polytraumatised patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197R. Huf, E.Weninger, Munich

Intensive care transport of burns patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203R. Huf, E.Weninger, Munich

The transportation of patients with hypothermia and frostbite . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206S. Poloczek,T.W. Felbinger, Munich, Berlin

Selected medical conditions involved in the transport of intensive care patients and transport challenges, e.g. in cases of infection and sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212W. H. Hartl, D. Inthorn, Munich

Hygiene aspects during intensive-care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225B. Grabein, Munich

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Selected disorders associated with intensive care transports and special transport challenges in paediatric and neonatal patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232L. Schrod, Frankfurt

Selected clinical pictures in intensive-care transportation and special circumstances relating to transportation, e.g. in the case of poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .244N. Felgenhauer,T. Zilker, Munich

Intensive-care transportation of dialysis patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253W. Samtleben, Munich

Medicaments for intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257

Drug therapy during transportation of intensive-care patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .258E.Weninger, R. Huf, Munich

Intra-hospital intensive care transports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277

Intra-hospital intensive care transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .278J. Koppenberg, Scuol

Requirements of infusion pump systems with respect to transport within clinics . . . . . . . . . . . . . . .291R. Huf, Munich

Special features of the performance of intensive care transports with special equipment . . . .293

Transporting patients following diving and hyperbaric accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . .294T.S. Mutzbauer, L. Lampl, Ulm

Interhospital transfer with supplementary medical equipment using the example of extracorporeal membrane oxygenation (ECMO) . . . . . . . . . . . . . . . . . . . . . . . .311R. Finkl, Hausham

Intensive-care transportation of patients undergoing supportingtreatment with intra-aortal balloon counterpulsation (IABP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .315P. Möhnle, F.Weis, Munich

Quality management and documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .319

Quality management and documentation in interhospital transfer . . . . . . . . . . . . . . . . . . . . . . . . . .320M.Weinlich, Filderstadt

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .339

List of author’s addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .355

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INTENSIVE CARET R A N S P O RT

Emergency medicine has changed considerably since the publication of the first edition as a result of political and finan-cial constraints.The transportation of intensive-care patients has been a major factor in this.The committee of health ser-vice experts predicted this development three years ago, anticipating a rise in secondary transport, including the trans-fer of intensive-care patients,given the current political climate.This change has indeed come about in the past few years,highlighting the importance of the issue of intensive-care transport and thereby also the significance of this book.The hospital landscape has altered as a result of the modernisation of healthcare legislation.Local hospitals providing basiccare have been cut back and had their functions revised on cost grounds.Specialisation and concentration have also con-tributed to the dilution of the in-patient care network.The consequence of this is that many patients need to be trans-ferred to maximum-facility units after receiving primary care,and need to continue receiving intensive-care support dur-ing the journey. Increased demand for intensive-care medical transport services combined with the guidelines issued byexperts in the Deutsche Interdisziplinäre Notfallmedizin [DIVI;German Interdisciplinary Association of Critical Care Medi-cine] have set higher standards for the skills which crews operating land-based and airborne intensive-care transportservices have to master.This book has been written to support the required training but also as a reference work.

In the light of practical experience we found it necessary to expand both the scope and the content and topics covered.So as to maintain the same physical size we have had to change the layout, as can be seen from the new font and thesmaller gaps between lines.Almost all chapters have been revised,and some have been entirely rewritten.Particular atten-tion has been paid to reflecting changes to the legal and administrative position,while the visual presentation of themeshas also been revised.We have had to present new types of air rescue vehicles to reflect changes in the vehicles. A newchapter dealing with hygiene issues relating to intensive-care transport in the light of past experience (MRSA).The increasedincidence of resistant germs in intensive-care therapy will affect the way patients are handled during intensive-care jour-neys.It has unfortunately not been possible to create a DIN standard for intensive-care vehicles, which would have simplifiedmatters. As a result, different types of vehicles are still in use and are built and fitted out in accordance with their opera-tors' experience.This is why some components are also presented separately. In the absence of a standard, the DIVI andthe BAND [Bundesvereinigung der Arbeitsgemeinschaften der Notärzte Deutschlands,Federal Association of German Emer-gency Doctors' Consortiums],as expert bodies and opinion-formers,have therefore agreed recommendations for the designand fitting of intensive-care vehicles.We have also been fortunate to secure the services of expert authors to write the chapters, all of whom have practicalexperience in the field.

The editors have made every effort to ensure that the content of this second edition reflects the new practical demandsof intensive-care transportation.They would be happy to receive any comments and suggestions for improvement.We thank the publishers for their cooperation and understanding.

Prof. Dr. P. Sefrin / Dr. R. Huf / Dr. M.Weinlich

Foreword to the second edition

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ORGANISATION ANDTACTICAL EMPLOYMENT OF

INTENSIVE CARE TRANSPORTS

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INTENSIVE CARET R A N S P O RT

Increasing importance of intensive-care transfers/inter-hospital transfers

Few sectors in our present-day society are subject to such extensive specialisation as developments in medicine.Weare experiencing advances which even a few years ago were scarcely imaginable, from laser technology in ophthal-mology to modern methods of reproductive and transplant medicine, as well as in emergency and intensive-caremedicine itself. We are exploring the beginning, the birth, and the end, the death, of our existence with ever morerefined methods.Whether these results always lead to success, as a humane objective, is debatable. However, theycontain developments which in turn concentrate on the provision of particular diagnostic and treatment possibili-ties for narrowly confined clinical pictures at a small number of locations, and sometimes even on clinics coveringindividual countries and continents.

However, this process,which is also just becoming recognisable in Germany,sets in train consequences which must alsobe dealt with. These include the necessary transportation of the patients involved to a hospital providing a specialisedor maximum range of care.Although this also covers the return of the patients to the “home“-hospital , which will playan increasingly important role in the future in view of the waiting lists which are usually existing and the fact that the“specialist” bed in question has to be filled again as quickly as possible.

In addition to this a choice can and must be made between land-based emergency services for such missions anda possible reversion to airborne emergency services. A further aspect must be taken into account in the current sit-uation - the introduction of the new hospital reimbursement system DRG (Diagnosis Related Group). It is debat-able whether there will be more than insignificant changes in the overall number of hospitals and beds.The hardfacts of regional or even simply local policy considerations and strategies may often stand in the way of these expec-tations. What is certain however is increasing competition, a further reduction in admission periods, the fact thathospitals will act as focal points even more than before, and also work together with other clinics and other insti-tutions, such as those for rehabilitation, and also form associations. And last but not least: smaller hospitals will nolonger be able to accept all emergencies, or at least not serious emergencies. In certain circumstances this will alsolead to changes in the use of emergency doctors and to new concepts of emergency medical care with a centrali-sation and regionalisation of emergency medical care.The extent to which these developments will involve addi-tional tasks for the emergency services in general, and the field of transfers in particular, can currently only be pre-sumed. However, all those involved must now prepare themselves for this .The possible system changes indicatedfor emergency doctors will have to take into account that the patient being treated by the emergency doctor willbe transported over greater distances, in addition to the logistic problems of rapidly calling out an emergency doc-tor to the (more distant) deployment location. The significance of intensive-care transport will continue to increasein any case.

Legal principles of inter-hospital transfers/intensive-care transfers

P. Hennes

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Distinguishing from ambulance service – application of the emergency services laws

Assuming that such transportation does not simply represent ”transporation by ambulance”,but forms part of the ”emer-gency services” sector, the individual state emergency services laws must be taken into account when considering the“legal principles“. Emergency services are not directly included in statutory medical treatment, are also not containedin the relevant “catalogue” of § 27 SGB V and are only “indirectly“ included as a partial aspect through the calculationof the travel costs (which,incidentally, is an anachronism which ought to be dealt with in the long overdue health reform).Rather, the emergency services are subject to the legislative authority of the federal states as part of “risk aversion”. Asa result of this 16 different variants have to be mentioned (which in itself rules out claims of completeness).

Intensive-care transfer and return service

When considering this aspect,the (sometimes world-wide) return transportation following an accident or illness abroadshould and must be ignored even though these transfers are generally carried out under intensive-care conditions withfixed-wing aircraft and therefore most definitely constitute an “intensive-care transfer” in the sense set out here. How-ever these flights are not covered by the emergency services legislation of the federal states and are also subject to spe-cial insurance terms which do not form part of the social insurance system.They must therefore be kept distinct fromthe “emergency services” forming the basis of this article.

Distinguishing “intensive-care transfer” from “inter-hospital transfer”

When discussing this topic further a distinction has to be made between the “mere”transfer of a patient from one hos-pital to another, which is known as an “inter-hospital transfer” (e.g. as part of normal consultation examinations) andthe actual “intensive-care transfer”. Intensive-care transportation involves the conveyance of (emergency) patients whoselife is at risk and who require intensive care transfer from a primary care hospital to a clinic providing a specialist or fullrange of care for further diagnostic and therapeutic measures. However, it does not involve the aforementioned “return”if following these measures further treatment can be carried out at the “home hospital”. In both cases it is predomi-nantly a matter of having to continue the already initiated intensive-care treatment without interruption, i.e. to “take itover” and continue it during the transfer, possibly over greater distances, without negative effects for the patient.

In contrast, an “inter-hospital transfer” can simply be a matter of transporting the patient depending on the initial sit-uation,as the patient “only”has to be looked after during this operation.In more serious cases,however, the patient mayhave to be accompanied by a doctor and appropriate medical care may be necessary, but not intensive care in the actu-al sense. Accordingly, to this extent it can also be referred to as an “emergency transfer“.

Absence of demarcation between the various types of operation

It must however be expressly pointed out that the necessary demarcation between all the stated possible types of oper-ation is often missing both in theory and in practice in the legislation of the federal states. Further discussion in thearticle will concentrate on “intensive-care transportation” in the sense of DIN 13050 (Emergency services/terms, Sep-tember 2002) no.3.51 “Secondary operation”(“Operations to convey patients with appropriate care, including the main-tenance and monitoring of vital physical functions from a medical institution or hospital, to or back from medical insti-tutions providing further care).

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Initially two basic hypotheses must be taken into account:

Distinguishing from ambulance transferAs part of the so-called “organisational unit”, ambulance transfer forms part of the “emergency services” according tothe current and still predominant view.At this point is should be noted that this uniform implementation of both taskswas recently confirmed by the decision of the Court of the European Communities (CUE) in C-475/99 of 25th October2001 on § 18 clause 3 of the Rhineland-Palatinate emergency services law, i.e. the introduction of a “separation model”is not absolutely necessary,at least in accordance with European competition regulations. However,as has already beenmentioned, it is assumed in the following discussion that the field of “transfer” to and from the specialist clinic to bedealt with here does not generally cover “mere”, i.e.purely “attendant”ambulance transfers. Instead it must come under“emergency rescue” in the narrower sense.The difficulties involved in making this distinction will have to be examined.

In its report of September 1996,the structural questions working group of the “Emergency services”committee express-ly distinguished between the transfer of emergency patients and ambulance transfers.“Emergency care also includesthe transportation between treatment institutions of emergency patients already receiving clinical treatment“.

In its concluding report “Principles for the further development of airborne rescue in Germany“ of March 2000, the air-borne rescue consensus group of the “Emergency services” committee reached the conclusion that in the field of air-borne rescue the transfer of emergency patients must be strictly distinguished from ambulance transfers. It is even ofthe opinion that there are no proper instructions and indications for “ambulance transport” within airborne rescue.

Ruling on intensive-care transfers as emergency transfers already available? Assuming the clear involvement in actual emergency rescue, the second hypothesis could state that these transfers arealready regulated and that carrying out “intensive-care transfers” should basically not be problematic.

This definition of “emergency transfer”should really include intensive-care transport because only the specialist patientgroup “emergency patient” is inferred within the term intensive-care transfer and not “normal“ patients. Cited number3.51 of DIN 13050 also clearly assumes the term “emergency patients” by expressly referring to the “maintenance andmonitoring of vital physical functions”. Furthermore, nothing is set out with regard to any “conditions” for the patient inquestion, e.g. reference to his or her age. Incubator intensive care transfers of a newborn baby whose life is at risk aretherefore just as much part of this system as the transfer of a child, young person or adult.

The federal state laws do not make any distinctions with regard to the specific time of carrying out the measures either.Their definition therefore also permits primary as well as secondary operation.

Transportation to a “suitable hospital (or other “institution”) for further treatment”includes transfers to a specialist clin-ic following initial treatment in a local hospital as well as the transportation of an emergency patient from the accidentsite directly to a institution providing a full range of care.

Despite the range of variants relating to the implementation of emergency transfers, the federal state laws all con-tain a comparable basic position:• Measures to be taken in the case of emergency patients • Ensuring transportability and • Transfer by emergency vehicle to a suitable hospital or other institution for further treatment

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The Hessen state emergency services plan can be used here as an example of this entirely feasible starting point.“Pri-mary care” and the “transportation and treatment of patients whose life is at risk from one treatment centre to anoth-er” are expressly given equally ranking in the “core duties” in no. 1.1.1. (Nevertheless,“transfer for consultative care” isalso included, i.e. the criticised “mixing”of intensive-care transports and inter-hospital transfers). According to the taskdescription and demarcation set out in the Hessen emergency services law,the emergency services care does not there-fore end with the handing-over of the patient to a treatment centre (primary care), but also includes the further trans-fer of already medically treated patients (secondary transfers).

Distinctions with regard to patient transfer disputed in practice

The problems lie in the fact that the clear starting positions indicated are not seen so clearly in theory and practice inrelation to ambulance transfers. Private providers of “transfer movements”, whether by land-based vehicle or by air,oftensee their work from the much more cost-effective point of view of “patient transfers“.

The term “secondary operation”is also taken to mean “patient transfers”(Hessen emergency services plan under no.1.1.10)or “qualified”patient transfers (Saxony-Anhalt emergency services plan) in the various federal state regulations, in addi-tion to the actual emergency care.Otherwise, the terms “interhospital transfer”and “intensive-care transfer”are treatedas being equivalent (“Interhospital transfer guideline“, Bavaria,Thuringia state emergency services plan).

It is therefore not surprising that these “misunderstandings” result in supreme court rulings which assign the field of“secondary operations“ which are disputed here (transportation of patients from the intensive-care ward of one hospi-tal to the intensive-care ward of another hospital or for special diagnosis or treatment, transportation of patients in thecase of whom it is expected that transfer by land-based transport would bring about a risk to the vital functions or a med-ically unjustifiable deterioration of the overall condition) to patient transfer, thereby not declaring the regulations con-cerning the “(emergency) rescue services” as applicable.

Why private companies, even with the support or court decision, claim that such transfers are “only”patient transfers isobvious, because the approval conditions set different requirement levels.

The decision of CEU of 25th October 2001 should be seen as having definitively concluded any further discussion onwhether emergency rescue in the narrowest sense should be seen as “worthy of protection” with regard to Europeanregulations and should be exempted from free competition, e.g. in the form of the so-called “administration monop-

Seen overall,many federal states assume this basic position and dispense with explicit special regulations for secon-dary operations/intensive-care transfers. Although certain other federal states explicitly set out that such emer-gency rescue operations come under emergency transfers, they leave it at that when deciding on this principle.In the third “variant” the regulations only relate to airborne rescue, whereby it should be emphasized that thecorresponding regulations are either to be found in the state emergency service law itself, or, as in most cases,in the state emergency services plan.

Only a few federal states, including Bavaria, Brandenburg, Hessen and Saxony-Anhalt have detailed and com-prehensive regulations.

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oly“, while ordinary patient transfers have to be deregulated and opened to private “competition“.The European Courthas consented to the use of “approval restrictions”(here in accordance with § 18 clause 3 RettDG RLP,which correspondsto the majority of other federal state regulations) on several grounds (which will not be set out in further detail here).However this is subject to the express conditions that the institution responsible for carrying out the “emergency ser-vice” (emergency or patient transfer) and therefore to be “protected”, carries out its tasks at the highest quality level inthe interests of the patients. In the case of intensive-care transfers this ensures that those responsible will make everyeffort to do so if they wish to be protected from private competition.(This also applies the other way round - whoeverbelieves it can be done better must prove this first).

Special regulations of the federal states relating to intensive-care transfers

Several federal states have decided to clarify the situation and issue their own regulations in order to underpin the actualclear allocation of intensive-care transfers to emergency rescue,and also because emergency medical care at a high levelcomparable with that of intensive-care treatment in hospital is required. Not infrequently the circumstances of inten-sive-care transfers go far beyond those of “normal” emergency situations.

• However, it is noticeable that a majority of these federal states have not directly included these (additional) regulationsin the relevant emergency services legislations, but in the state emergency service plan or in other decrees.

• Also, such “extended” regulations are often expressly restricted to the field of airborne rescue, supporting the abovehypothesis that “intensive-care transfers“ should basically be assigned to “normal“ emergency transfers, i.e.are alreadycovered by the definition of (at least ground-based) transfers of this type.

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Legal principles in the individual federal states – tabular overview

In the BW emergency services law there are no special regulations for ground-based transfers. However, it isgenerally assumed that intensive-care transfers form part of the emergency services/emergency rescue (see below).Also, no special locations for special vehicles are stipulated. The sector committees must endeavour to reach anoverall agreement.

For airborne rescue the Emergency services plan 2000 BW of 22.5.01 contains the following information:

4.2 Airborne rescue serviceAccording to no. 4.2.2. a “secondary transfer“ by rescue helicopter takes places “if emergency patients haveto be transferred from one hospital to another hospital with more suitable treatment possibilities and trans-portation by ground-based vehicles is ruled out on medical grounds.”

According to no.4.2.4 these are distinguished from “intensive-care helicopters“ (also known as ambulancehelicopters), which “as part of emergency rescue are mainly used to transfer patients who have to receive inten-sive medical care during the flight”.

For such transfer flights there is a framework agreement directly between the German Air Rescue Service (DRF)and Baden-Württemberg health insurance associations “on carrying out transfers by helicopter (VHS)” at threelocations.

Art. 26 para. 1 (ground-based emergency vehicles) and art. 25 para 1 clause 1 (Air rescue) BayRDG of 28.1.98,amended 25.7.02.

“The State Ministry of the Interior after hearing ...... determines the location of emergency vehicles for the trans-fer of emergency patients in intensive-care conditions (intensive-care transfers)“.

This applies accordingly to air rescue services.

See also the “Sample service instructions for emergency services according to § 13 para. BayRDG“ section three,I. Air rescue service:

§ 42 Types of operation1. ...2. ...3. Transfer of emergency patients already being medically treated from one hospital to a hospital which is moresuitable for further treatment. 4. ...

Further details are set out in a “Interhospital transfer guideline“ by the relevant ministry (e.g. qualifications ofthe deployed personnel, questionnaire forms for the relevant control centre etc). The specialist ministry has alsodetermined four locations for intensive-care helicopters and six locations for intensive-care vehicles (includingone replacement vehicle).

Baden-Württem-berg

Bavaria

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No special regulations for ground-based operations. An emergency doctor vehicle is retained for the Berlin firebrigade which has additional equipment for these special operations.

Use of an intensive-care helicopter for air rescue with equipment regulated by conditions in the approval no-tices. Otherwise reference is only made to “transfer flights“.

State emergency services plan of 24.2.97Air rescue§ 11 Duties.....(2) Patients to be treated in intensive-care conditions and patients who have received primary medical treatmentcan be transferred from a hospital to a suitable hospital for further treatment or for overall treatment (secondarytransfer). § 13Air ambulancePatients who for medical reasons cannot be transferred in accordance with § 9 clause 1 (i.e with land-based emergency vehicles) are transported by appropriately equipped and manned helicopters (trans-fer or intensive-care helicopters). Further regulations relating to this are set out in the “Service instructions for the use of emergency helicoptersand transfer helicopters in the state of Brandenburg“. These distinguish between four different types (emer-gency, transfer, intensive-care and ambulance helicopters) and several types of deployment (primary treatment,primary and secondary transfers).

No special regulations.Insofar as “emergency transfers” are also mentioned in § 24 para. 2, no. 2 BremHilfeG of 18.6.02 separatelyfrom “emergency rescue” in number 1, this does not expressly imply “intensive-care“ conditions. This simplyrefers to “specially equipped emergency vehicles”.The Bremen fire service has a special vehicle for intensive-care transfers which may be used if required.

§ 3 para. 1 clause 2 HmbRDG of 9.6.92”Emergency rescue also includes the transfer, without delay, of injured or ill patients from one medical insti-tution, more particularly a hospital, under specialist care, which includes the maintenance and monitoring ofvital functions for further treatment in specialist medical institution, also the return transfer if necessary”. The term “intensive-care transfer” is not expressly used. No special additional regulations.For the intensive-care transfer of premature and newly born babies a so-called “Baby emergency vehicle” isavailable. Otherwise there are no special vehicles.

For air rescue, helicopters stationed in Hamburg and its environs are used.

Berlin

Branden-burg

Bremen

Hamburg

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The HRDG of 24.11.98 contains no special regulations.(Intermim) State emergency services plan of 31.5.99/30.4.01

1.1.2 Emergency care”Emergency care is also the transfer of emergency patients between treatment facilities with the personnel qual-ified for this in suitable means of transport”.

1.1.10 Secondary deployment”The emergency service providing the population with emergency treatment and patient transfer does not onlycover the handing over of the patients to a treatment facility, but also the transfer of patients already being clini-cally treated if they are medically classified as requiring emergency care or patient transportation”.According to no. 1.1.11 under the heading “Special secondary transfers” there is the regulation concerning addi-tional capacities for special secondary transfers outside regular emergency service provision. There are separate regulations relating to air rescue in no.5, whereby rescue helicopters can also be used for sec-ondary deployments. In addition to these rescue helicopters, special secondary transfers are also carried out withtransfer helicopters. Other details are set out in an additional “Specialist airborne emergency services plan for thestate of Hessen” of 4.2.02., which, for example in no. 4, also mentions “intensive-care transfer helicopters”. There is also a declaration of principles concerning the “Deployment of special secondary transports”, which setsout: • Criteria relating to choosing between land-based and airborne means of emergency transport • The availability of emergency doctor vehicles for transferring patients (transfer emergency doctor vehicles) at threelocations, • The allocation and control of call-outs by the “Coordination centre for special emergency services secondary trans-ports” set up at the BF Frankfurt.

No special regulations.It has merely been that the “responsibility for airborne rescue in the context of the emergency services law” isassigned to the Ministry of Social Affairs. However, the Ministry of the Interior is now responsible for the emer-gency services in Lower Saxony.

§ 2 para. 1 clause 3 RettG NRW of 24.11.92 (with amendments)”This also includes the transportation of initially treated emergency patients to diagnostic and treatment insti-tutions“. There is a directive by the relevant specialist ministry of 17.8.93„”Use of helicopters in emergency services“ for air-borne emergency services . In no. 21 it assumes “secondary transfer flights“ in the case of emergency service heli-copters. In addition to this according to no. 3 there are also “air ambulance helicopters“ for these tasks. No special additional regulations. If necessary the locally responsible emergency services providers must themselvesdecide on any required measures in this area of deployment.

There are no special regulations relating to intensive care transports in the RDG M-V of 1.7.93 (with amendment). Emergency services plan of 16.2.99/22.2.00 4.2 Airborne rescue4.2.1.1 Tasks of the emergency services helicopter1. ....2. ....3. Secondary deployment: “In the context of emergency rescue medically treated patients must be transported onthe basis of medical indications from one treatment institution to the nearest treatment institution suitable for diag-nosis and treatment“. 4. Secondary transfer: “In the context of (qualified) patient transfer, persons who are ill, injured or require help mustbe transferred with appropriate care if this is medically required and economically justified“.

Hessen

Lower Saxony

North-Rhine Westphalia

Mecklen-burg-Vorpommern

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At the time of the next revision of the emergency services law it is intended to add a new clause 2 for clarifi-cation: “Emergency transfer also includes the transfer of emergency patients under intensive-care conditions(Intensive-care transport)”.An intensive-care helicopter for airborne rescue is based in Mainz (Christoph 77) for state-wide secondary trans-fers (transfer flights). Other regulations are set out in decrees by the specialist ministry (e.g. responsibility ofthe emergency services control centre in Mainz for assigning the deployment of this ICH in transfer flights).

In the SRettG of 9.2.94 (amended on 27.11.96) there are no special regulations for land-based transfers. An inten-sive –care transporter is based in Saarbrücken.There are “Instructions for carrying out airborne emergency services duties in Saarland” of 2.2.01. for theair rescue service According to no. 6 the tasks of the emergency services helicopter include: - ....- ....- in the case of a necessary transfer of patients having received primary care from one hospital to another hos-pital suitable for further treatment (secondary transfer flights)“.

The SächsRettDG of 7.1.93 contains no special regulations.State emergency services plan of 30.11.94

5.1.2 Patient transfers can be carried with land-based as well airborne emergency means.

8. Airborne emergency services8.1.3 Urgent transportation of initially treated patients in life-threatening situations from one hospital to a hos-pital suitable for further treatment, as well as urgent transfer of patients under intensive care from a hospital to ahospital suitable for overall treatment (urgent secondary transfer).

§ 11 para. 2 clause 2 RettDG-LSA of 11.11.93 talks of “qualified patient transfer)“ (secondary transporta-tion) in airborne rescue.

The directive issued by the responsible specialist ministry of 13.2.02 on “Interhospital transfer emergencyvehicles manned with a doctor“ assigns the area of deployment to “qualified patient transport” in accor-dance with § 2 clause. 3 RettDG-LSA. The decree determines the type of emergency vehicle used, itsequipment, crew, procedures, call-out coordination etc.

No special regulations.

If necessary, an intensive-care helicopter is used for airborne rescue.

The ThürRettG of 22.12.92 contains no special regulations.

State emergency services plan of 15.6.95/29.8.00

2.3 Guarantee transfer/urgent secondary deploymentThe services of the emergency service also include the transportation of vital important medication, .... as wellas special medical personnel. 2.4 Qualified intensive-care secondary transfer (interhospital transfer). .Qualified intensive-care second-ary transfer (interhospital transfer) is a special type of patient transfer for which special equipment such as inten-sive care vehicles or intensive-care helicopter are considered.

Rhineland-Palatinate

Saarland

Saxony

Saxony-Anhalt

Schleswig-Holstein

Thuringia

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Even without claiming to be complete,the situation described in Germany shows an almost incalculable variety of state-specific regulations. As a “comment” it can be said that within the emergency services sector there are few areas whichare split into so many different positions. In the author’s opinion the picture has become considerably more differenti-ated since the first edition of the book.It would be praiseworthy for the “Emergency services”to be committed to the aimof harmonising the various state regulation in the interests of all those involved.

Conclusion

Collaboration required

On the other hand it must be assumed that the required transfers will extend beyond the territory of one or even morefederal states as a rule, particularly in the case of transfers by air. Comprehensive organisation of these deployments isthen particularly urgent.Agreement on the basing of additional ICHs is urgently necessary.Whilst recognising the indis-putable commitment of the institutions and persons involved in air transfers, this is the only possible way to avoid put-ting the network of primary locations under strain, which could be described as almost too luxurious, by a further andjust as expensive (in financial terms too) network of “transfer locations”. In this case, all those involved should agree ona common approach in the interests of keeping the financing of transfers by air under control. In each case a minimumrequirement would be that a decision would only be made on further “own”intensive-care, transfer,ambulance or otherhelicopters after any additional use of the existing primarly locations (which cannot be changed,more for political thanmaterial reasons) through the increased assumption of transfer flights has already been thoroughly examined.

Agreement about the type of deployment and the locations of such vehicles is urgently required in the case of land-based transfers too, particularly assuming the use of special “large” intensive care vehicles.

However, it must be emphasised that the first “faint-hearted” attempts at cooperation are coming up against unantic-ipated difficulties.The administrative agreement between the states of Hessen and Rhineland-Palatinate of 9/21 April1997 on cooperation in air rescue with the aim of operating a joint station in Mainz (Christoph 77) was declared invalidby the Hessen Adminstrative Court in rulings of 21st and 28th November 1997 as the conclusion of a state agreement

Nevertheless a central theme is still evident.In the case of land-based transfers the majority of the federal states assume that this forms part of emergencyservices directly (through appropriate clarification,) or at least indirectly. In so far as the term “patient transfer”is used in exceptional cases “qualified patient transfer“ is clearly involved here in this context, at least. If thereare special regulations going beyond this, they are essentially limited to transfers by air. Although the primaryassignment of “transfer flights” to the emergency services is clearly seen here too. Thus, when seen overall, thevarying regulations in the federal states appear to be comparable as the “legal basis“ for the implementation ofintensive-care transfers despite the individual differences. This partly relates to the use of the term “Interhospi-tal transfer“ as well. It is either characterised as “just” a transfer between hospitals, e.g. as a consultation trans-fer, or it is carried out in connection with “intensive-care” points of view, basically in accordance with the term“intensive-care transfer” used here.

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is necessary for this type of cooperation.The Rhineland-Palatinate Ministry of Justice agreed with this view in a state-ment on the draft amendment to the emergency service law.This federal state now also shares the view that a stateagreement is necessary. Could such a project ever be implemented in these circumstances?

Air rescue – landing sites for emergency/intensive-care helicopters

As has been shown, discussion of the legal basis of intensive-care transport has primarily been aimed at the airborneemergency services. In connection with this the question of the “legal” prerequisites for landing sites for emergencyhelicopters at hospitals must be mentioned, because transfers by air could not take place without landing facilities.In several federal states specific regulations relating to “helicopter landing sites” at hospitals have been issued (suchas the Saxony state emergency services plan).

On this subject a distinction has to be made between landing sites at “permanent“ helicopter bases and landingfacilities at the destination hospital (the third category, involving the direct deployment of the emergency helicop-ter at the site of the emergency, known as the “operating site“, will not be dealt with here).However, it must be takeninto account that many of the regulations primarily relate to the aviation company as the operator of the helicopter,and not the hospital authorities as the owner of the landing sites (e.g. problem of changing to new types of heli-copter). Furthermore, a distinction must be made between the actual helicopter emergency medical service deploy-ments – HEMS, and ordinary ambulance flights. The conditions under discussion only apply to the HEMS sector.

The regulations of the Federal Ministry of Transport dating from 1969 have been used for such landing facilities todate, – if regulations have been used at all.The much derided JAR-OPS 3 (“Regulations of the Joint Aviation Authori-ties concerning the professional transportation of persons and materials by helicopter“) only implement already exist-ing ICAO regulations (i.e. a large part of the discussion is evidently based on not taking into account already exist-ing, but not yet applied regulations). As “technical regulations” JAR-OPS 3 have already been implemented in Ger-man law, which took place in October 1998 with a “reference” in the Luftfahrt BO. One of the main problems seemsto be a “tightening-up” of the permitted angle of inclination which if implemented precisely makes larger free areasnecessary in the event of incidents during the take-off and/or landing phase. This angle of incidence must also beachievable in emergency situations, such as during failure of one of the two engines, which makes correspondingdemands on the helicopters used.

It must also be decided whether the landing should continue to be approved without formal procedures, as was theusual practice in the past, with reference to the “special right” of § 25 para. 2 no. 2 LuftVG as an “aid in the event ofrisk to life or limb”(see the corresponding information in the Brandenburg air emergency services directions),or whetherapproval as an “airfield/landing site” in the context of § 6 LuftVG is required.

However, what is urgently required in all cases is for all landing facilities, and their “registration” to be checked inan appropriate landing site directory, at least those to which flights are made regularly (see the Rhineland-Palati-nate model, information via the internet can and will be considered). Providing this information to the airborne emer-gency service, and in particular to the flight crew, can contribute to achieving the objectives of JAR-OPS 3 by reduc-ing the risk of deployments in the sector and increasing awareness of possible hazardous situations.

However, overall it can be stated that even with the possible introduction of transitional deadlines, the “problem ofhelicopter landing sites at hospitals“ does appear to be solvable, i.e. a “ban“ on transfers by air is hardly realistic andis not anticipated.

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Emergency vehicles for intensive-care transfers – standardisation

The “Legal principles of intensive-care transfers” also include a look at any regulations relating to the vehicles usedfor this purpose and the personnel used in these vehicles and aircraft.

Despite the different ways of looking at this sector, there is broad agreement that the emergency vehicles used mustmeet a certain technical standard. It does not matter whether the regulations are based on specific standards suchas DIN or EN, or they “only” refer in general to the “state of the art”, as long as such requirements are met.

In this case too it can be asserted in theory that such standardisation already exists, as with the question in theintroduction. If the federal state laws refer to the use of emergency and/or emergency doctor vehicles for trans-porting patients to hospital, then this also applies to intensive-care transfers. EN1789 (which “replaces” the currentDIN 75080) must therefore always be applied to these transfers. In regard to the definition in no..3.3.3 of the EN,the type C category is the main one involved here (“an emergency vehicle which has been designed and equippedfor the transportation, further treatment and monitoring of patients”), whereby additional equipment for the spe-cific purpose can certainly be considered.

However, in several federal states special vehicles are used for carrying out intensive-care transfers in the form of“intensive-care vehicles (ICV)“ (see “Guidelines for interhospital transfers“ Bavaria - where even the possibility of“carrying a bed“ is mentioned, see the Saarbrücken ICV and/or the ASB intensive-care bus - or the Thuringian stateemergency services plan, the decree on deployment assignment in Hessen talks of emergency doctor vehicles fortransfers“). For this reason an ad-hoc group of the AA 1.2 “Emergency vehicles and their medical and technicalequipment“ committee of NARK at DIN has discussed the question of “own“ standardisation for such types of vehi-cle and has put forward an appropriate draft proposal.The question has been positively resolved of whether after the inclusion of the type C in EN 1789 a standard canbe drawn up for an additional vehicle. If, under type C in the EN an “emergency vehicle” is defined as:“an emer-gency vehicle which has been designed and equipped for the transportation, further treatment and monitoring ofpatients”, then what was initially set out with regard to the legal regulations applies. In actual fact transfers are includ-ed as the text is so broadly-based that, for example, a further transfer from a primary care hospital to a special clin-ic can, or maybe even has to be carried out in a type C.There seems therefore to be very little room for manoeuvrefor separate standards.

If at all, then a vehicle would have to be developed which would be totally independent and also fulfill “other”tasks.The responsible European committees have approved a separate German standardisation project under these con-ditions, so that this problem has become clarified.

However, the predominant view of the federal states remains unaffected by these developments. A commerciallyavailable vehicle should suffice for a “normal” intensive-care transfer, i.e. an existing emergency/emergency doctorvehicle or now a type C with additional equipment and specially trained personnel. Instead of the usual stretcher,the intensive-care transport system by Starmed (Ulm), which is now in use in several locations, or a comparablesolution can be carried if necessary.

National basing and procurement should be arrived at for the remaining few individual cases of a “large” vehicle(carrying a complete intensive-care bed) so that the implementation of a planned standard for relatively few vehi-cles in the whole of Germany is rationally and economically possible. However, the corresponding DIN standardi-sation project is no longer being pursued.

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Standardisation of emergency helicopter and ITH

DIN 13230 (still) applies to emergency and intensive-care helicopters. The introduction of a corresponding EN iscurrently under discussion, whereby it must be taken into account that the terminology used in the various reg-ulations should he harmonised. JAR-OPS 3 describes “patient transfers with helicopters“, the draft EN “patienttransfers with aircraft“ even though the same term „air ambulance“ is used in the English text (the intended “descrip-tion” in the draft of the “aircraft for patient transfers“ matches our conception of an intensive-care transfer heli-copter). The other proposed terms and definitions, such as “primary”and “secondary”deployment should be checkedfor correspondence with the terminology used in this country. Finally, special attention must be paid to the use ofqualified personnel.

It is however noticeable, and it should be pointed out here, that the same emergency doctors make concessions in theergonomic room for manoeuvre of the ITH which would be absolutely inconceivable in a land-based ICV,and they there-fore consider the EN 1789 type C as unsuitable.

Intensive-care transfer personnel

The legal regulations relating to the medical and non-medical personnel when carrying out intensive-care transfers areessentially based on the prevailing inclusion of these transfers in the field of emergency rescue and transfers.The useof qualified emergency doctors and similarly skilled emergency ancillary personnel is therefore stipulated. However, tosome extent special requirements relating to experience in the intensive care of those involved are set out (e.g.“Guide-lines for interhospital transfers” Bavaria).

Additional requirements relating to the HEMS crew members in accordance with JAR-OPS 3 (appendix 1 to JAR-OPS3.005 (d)) may also have to be taken into consideration (e.g. training course components and examinations as well anannual repetitions).

Consideration of other regulations

The “semi-official”regulations also form part of the discussion of this topic.Thus,the “provisions”of the DIVI recommendationsrelating to medical qualifications in intensive-care transfers (such as the required participation in special preparatorycourses) are certainly binding to the extent that in the event of unsuccessful missions questions may be asked as towhy the emergency vehicle personnel deviated from these provisions.“Organisational blame”can therefore certainly playa role.

In this connection reference must also be made to the “Recommendations of the Southwest German EmergencyDoctor’s Working Group relating to Intensive-care transfers” (e.g. notes for nocturnal call-outs of the ICH which arelinked to special criteria. See also examples from the Brandenburg working directive and the Hessen deploymentdecree).

The high requirements of an intensive care transfer,which are comparable with those of treatment in hospital,appearto make it necessary to apply the principles forming the basis of medical standards of hospital treatment to the qual-ity of such a transfer and the qualifications of the persons involved in it.

_ 25 _

Necessary organisational principles

A discussion of the legal principles should also take into consideration the necessary organisational preconditions ofsuch a system, with a distinction being made between the organisational preconditions in the strict sense and the pre-requisites to be applied to the medical sector.

Distinguishing between transfer by land and air on the basis of medical criteria only The effective organisation of intensive-care transfers assumes a clear distinction between land-based transfers and thedeployment of emergency and/or intensive-care helicopters. It is not the motto “Flying is better“ that is the decisivefactor, but strict medical indications.This presupposes an appropriate assessment and decision-making body in case ofdoubt. Furthermore, in several federal states (Bavaria, Hessen) economic points of view, i.e. the financial burden on thecost-carrier, must also be expressly taken into account.

Introduction of regional operations centres necessaryThis required “body“ can in turn only work rationally on a regional basis, i.e. a regional operations centre is required atthe very least,to which an appropriate medical advisor is linked (see as examples the solutions in Hessen and Rhineland-Palatinate.

Base coordinationThe “possibility of choosing“ between land-based transfers and aircraft also presupposes an appropriate structure, i.e.the bases for emergency aircraft and the bases for land-based emergency vehicles must be coordinated (see Bavariaand Hessen, planned in Rhineland-Palatinate). In regard to the difficulties involved in the economically viable imple-mentation of interstate agreements,see the aforementioned example of a common base Christoph 77 in Mainz for Hes-sen and Rhineland-Palatinate.

Use of questionnairesThere are corresponding “questionnaires” in several states (Bavaria,Hessen, Rhineland-Palatinate) for the selection cri-teria at the relevant (emergency) control centre.

Regulations in neighbouring countries

Finally we cast a brief look at our German-speaking neighbours (who obviously approach this subject much more prag-matically).

AustriaIn Austria there are no special regulations relating to the transfer of intensive-care patients – interhospital transfers.Therefore there is no express standardisation of IVC, as this is not considered necessary.As in Germany individual solutions have developed at local level.Thus Vienna General Hospital has a larger vehicle (one-off product manufactured by Dlouhy OHG,Vienna),into which a complete bed can be pushed. However, this vehicle isonly used in the city of Vienna and close environs. In the rural regions it is assumed that transfers can and should becarried out by the vehicles available.This is comparable with the basic tendency in the German federal states.The testswith the Starmed stretcher are known and were also evaluated positively.As in Germany the rescue helicopter bases are also used for intensive-care transfers/interhospital transfers as often aspossible.Wiener Neustadt also has its own intensive-care helicopter “Christoph 9” (which is essentially financed by theÖAMTC)

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SwitzerlandThis country does not (yet) have special regulations relating to the implemntation of land-based intensive-care trans-fers either. Again, is it assumed that the available potential is utilised for such missions. There are special local solutionsin individual cases , e.g.“RTW-Großraumsprinter“ with special additional equipment for transfers.The Swiss Emergency Flight Watch (REGA) bases are used for emergency transfer flights.

Literature:1. DIN 13050 – Emergency services terms -, DIN Deutsches Institut für Normung e.V., Berlin2. Emergency services committee, Report by the working group on structural questions (March 1996),

Emergency Services Handbook (B III.0.5.1)3. Emergency services committee, Principles of the further development of aerial rescue (Concluding report of the aerial

rescue consensus group,March 2000), Mendel Verlag,Witten (2nd edition April 2003)4. Emergency services handbook, Mendel Verlag,Witten (Part B III. Regulations of the 16 federal states)5. Interhospital transfer guidelines Bavaria, Bayerisches Ärzteblatt 1/996. Proclamation of the German implementation of the provision of the Joint Aviation Authorities concerning the profes-

sional conveyance of persons and materials in helicopters (JAR-OPS 3 German) of 4th August 1998, Federal Ministryof Transport, Bundesanzeiger 1998, Nr. 182a

7. DIN EN 1789 – Emergency services vehicles and their equipment – patient ambulance – German version EN 1789:1999,8. DIN Deutsches Institut für Normung e.V., Berlin9. DIN 13230-Parts 1-5, Aircraft for transporting patients, DIN Deutsches Institut für Normung e.V., Berlin

10. DIN/EN 13718- Parts 1 and 2/draft, Means of transporting patients in the air, on water and in difficult terrain,DIN Deutsches Institut für Normung e.V., Berlin, September 1999

11. DIVI-recommendations relating to medical qualifications in intensive care transfers, Der Notarzt 16 (2000) 12. Recommendations relating to intensive-care transfers, Southwest German emergency doctors’ working group /AGSWN

(published on the homepage of the AGSWN)

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_ 28 _

INTENSIVE CARET R A N S P O RT

Procedural principles during intensive care transportation

The safety of intensive-care transfers depends to a great extent on precise planning and defined procedures.The proce-dures described below for intensive-care transportation can be applied to all transfers in principle. However, the exchangeof information between the referring institutions and the doctor involved in the transportation,the preparatory planning,the operational reliability of the equipment being used and the monitoring of all initiated measures are of great impor-tance in this area.

Essential preparations for intensive care transfers

Preliminary information Ideally all of the medical institutions, from which patients may have to be transferred, should be familiar with the capa-bilities of the intensive-care transportation system.However,this cannot be taken for granted. Experience shows that eventoday the possibilities of these systems tend to be underestimated rather than overestimated.One of the objectives withthe highest priority is to inform all the institutions that may be involved from the moment that such a system is intro-duced. Providing the deployment control centres with this information is also not enough.The alarm procedure, timingand last but not least the question of who bears the costs must also be set out in addition to the medical possibilitiesthat exist during a transfer.

Technical preparationsThe safety of the patients is highly dependent on the functional reliability of the equipment being used, particularly inthe case of intensive-care transportation.The completeness and reliability of this equipment as well as that of the addi-tionally carried equipment must be checked at appropriate intervals. In the case of intensive-care transportation there isno equivalent replacement equipment available for certain devices (e.g. intensive-care respirator) in contrast to the sit-uation on an intensive-care ward. The replacement equipment (back-up) is generally much simpler and less powerful.Critical equipment,which in the event of failure could endanger the patient, should be checked at the start of every shift,but at least once daily. Here, checklists can not only contribute to daily checking, but to overall quality assurance. In orderto be able to eliminate faults,but also for regular servicing,close links with a suitable workshop (e.g.at the hospital loca-tion) are urgently recommended for more complex equipment, such as intensive-care ventilators. In this way the verycomplex requirements of the Medicinal Products Law can be implemented more easily.The same applies to the provi-sion of medicines, which should also be the responsibility of a pharmacy (e.g. the hospital pharmacy). In this way exist-ing legal regulations can also be observed without problems. However, experience shows that a spatial proximity is notabsolutely necessary.

Organisational principles and aspects relating to the practical implementation of intensive care transfers

R.Huf, E.Weninger

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The primary prerequisite is the rapid and guaranteed availability of thesemeans of transport for all the involved institutions. In order to guaranteethis with maximum reliability, a secure and even superfluous alarm pro-

cedure is imperative. Ideally the means of transport (ICH, ICV or ambulance), the medical and non-medical person-nel are all present at the same location and can be notified there immediately. Since this cannot always be the case,for example if a doctor and medical personnel cannot be accommodated at the airfield, secure radio communicationalarm procedures are required. In addition to these radio alarms, e.g. BOS-Pager (fig.1), mobile phones are particu-larly helpfull if transfers do not have to be carried out immediately but at a set time. Public mobile signal receiverscan also be used for this. However, it should be taken into account that there may be a significant time delay betweenthe telephone alarm and signal transmission, i.e. the effective alarm.This system is therefore out of the question fortime-critical call-outs, but can certainly be used for call-outs for which advance notice of up to 30 minutes is not aproblem (e.g. return transfers).

Implementation and course of an intensive-care transfer

In spite of the fact that every transfer has its own dynamics as a result of the clinical picture involved, the distance to betravelled, the time of day, the weather and changing conditions at the referring and receiving hospital, the procedures tobe observed during every transfer should have a uniform structure. Accordingly every transfer can be divided into vari-ous phases.

Planning phaseThere is very frequently little information available about emergency patients in primary rescue operations.On the otherhand an abundance of information will generally have been amassed in the case of a previously treated patient.There-fore direct contact between the transporting and treating doctor plays an important part in this phase. In a doctor-to-doctor discussion all the relevant information about the patient should be passed and/or requested. Advance knowledgeof as many of these details as possible is a prerequisite for rapidly and safely carrying out an intensive-care transfer. It isbest if this information is exchanged in a routinely conducted doctor-to-doctor discussion.Structured questioning ensuresthat the relevant information is fully recorded.The necessary equipment and level of urgency as well as all other circum-stances of relevance to the transfer and further care must be clarified. Dispensing with this direct doctor-to-doctor dis-cussion is only acceptable if the necessary information is available from other sources (e.g.the presence of all the patientdocuments) or if in the face of evident urgency the doctor-to-doctor discussion would delay the transfer disproportion-ately.

Abb 1: Selektivpiepser modernster Bauart BOS-Pager Swissphone DE900

Entscheidende Merkmale sind lange Standbyzeit, Robustheit, kontrastreichesDisplay und einfache Bedienung. Beim abgebildeten Gerät erfolgt dieAlarmierung wahlweise laut oder mittels Vibrationsalarm. Prioritätsrufewerden unabhängig davon immer laut ausgelöst. Dank dem neuentwickelten ECO-Mode sind Betriebszeiten von über 4 Monaten problemlosmöglich. Der Pager wird im Ruhezustand in einen Schlafmodus gesetzt,während dem das Display ausgeschaltet wird. Der Empfänger bleibtweiterhin aktiv und empfangsbereit.

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Preparatory phaseThe actual transfer preparations can begin as early as during the approach to the referring institution by air or road.The crew should agree on the necessary measures and the equipment required for this.This largely prevents nec-essary equipment being forgotten or the logistic procedures being unclear and therefore uncoordinated. This phaseof the transfer should also be used for final functional tests.The referring institution should ensure that the transport crew can reach the patient without further delay. A “guide”should be available if the transport crew is not familiar with the site, especially in large and confusing hospitals. Itmust be ensured that access to the hospital is possible and not hermitically sealed off by the guard duty especial-ly at night .

Take-over phase In principle, the take-over should be as detailed as possible and in keeping with the patient’s condition each timea patient is handed over by the referring treating doctor to the transporting doctor.The duration and detail of thistake-over are not dependent on the transfer duration or distance, but on the complexity of the medical conditioninvolved and any associated circumstances.The actual take-over of the patient by the system carried on the means of transport must take place in such a waythat the patient cannot be put at additional risk. This means that critical system changes must take place so thatafter the equipment change-over, checks must be performed to ensure that the change-over has taken place with-out deterioration in the patient’s condition. Pulsoximetry must constantly be available throughout the actual change-over when changing the ventilator for example, and after the change-over the respiratory situation must be mon-itored by way of blood gas analysis (BGA). Although this prolongs the time required for the handover, it largelyprevents “nasty surprises”through sudden collapses in the respiratory or cardiocirculatory situation for instance. Thetransfer cannot begin until all critical system change-overs have been carried out in this way and it can be guar-anteed that no negative effects have occurred.During this phase and during transfers, monitoring or treatment restric-tions are almost never justified. On the contrary, it will often be necessary to extend monitoring of critical param-eters during the transfer. Only when the patient has been securely connected to all the transport systems withoutsetbacks can the next phase be commenced.It must be checked once more that all the necessary information and paperwork is present immediately beforeleaving the referring ward. The receiving clinic should also be informed by telephone of the estimated time ofarrival.

Transport phaseIdeally this phase should only involve monitoring of the patient’s condition. Improvements which could not be broughtabout during the period of admission or at the time of handover cannot be accomplished during this phase.There is noplace for such improvement attempts during this phase. Only changes in the current condition of the patient should bereacted to.In order to do this it must be ensured that all the necessary parameters can also be monitored inside the means of trans-port.This requirement relates to helicopter transports in particular.The normal acoustic alarms in all medical appliancescan only be heard with difficulty or not at all due to the noise in the cabin. Optical monitoring must therefore be possi-ble and indeed take place.

In addition to the appropriate reactions to any medical problem which occurs, e.g. a deterioration in the primary illness,appropriate procedures to be followed in the event of the failure of critical systems must be planned in advance.Thus,there must be suitable replacement equipment available within easy reach so that the nearest hospital can be reachedwith a maximum degree of certainty. Appropriate equipment for the critical systems must also be available on inten-sive-care wards. A failed intensive ventilation system can be replaced with another equivalent device.This is often notpossible in some means of intensive-care transport and in these cases simpler equipment must be used. The failure of a

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critical system during an intensive-care transfer constitutes a risk to the patient which must be taken seriously.In the eventof the failure of the intensive-care ventilator with the patient in a critical condition, the patient must continue to be ven-tilated with the “back-up” ventilator available for emergencies.The respiratory situation can quickly deteriorate becauseof this, and therefore the nearest suitable hospital to be aimed for, must be agreed with the pilot or driver immediately,so that the patient can continue to be appropriately treated there (see case example).

In conclusion the tactics can be summarised with the “6 Ps” of safe intensive-care (airborne) transportation:ProperPreflightPlanningPreventsPoorPerformance

In this way the frequency of relevant complications during a transfer can be reduced to an absolute minimum. Howev-er, in every case, clear procedures should be planned for problematic situations which could nevertheless occur. Duringthe flight the decision to continue flying, to turn back or to fly to an alternative destination must be taken as quickly aspossible at any time during the flight.This decision depends on the nature and urgency of the complication as well asthe geographical and flying conditions.

Handover phaseHere the patient is disconnected from the transport system and connected to the systems at the receiving hospital in thesame order as at the take-over. Here too the critical parameters before and after the system change-over should be mon-itored. Sufficient time should be available for this phase as with the take-over.Time pressure due to other pending jobsor simply returning to the “home emergency services area” must be avoided. Handing over to unsuitable systems at thereceiving clinic must also be avoided (e.g. to an emergency ventilator for the further transfer of patients with complexrespiratory condition within the hospital).A clearly structured and complete verbal handover of all patient information to the receiving doctor ends the transfer.It is assumed that the means of transport isimmediately returned to a condition for carrying out transfers if at all possi-ble.

Case report

Incident managementAn approximately 20-year old patient with multiple injuries experienced increasing deterioration of the respiratory situ-ation following a road traffic accident. In spite of an FiO2 of 1.0 and a PEEP of 8 mbars the deterioration in the situationcould no longer be stopped at the treating hospital. For this reason, after consultation with a centre providing the maxi-mum range of care it was planned to transfer the patient by intensive-care helicopter. When the transport team arrivedthe patient’s circulation was stable on 24 mg dopamine per hour.The paO2 was 76 mm Hg, pCO2 49 mm Hg. Maintain-ing the ventilation regime the patient was moved onto the intensive-care stretcher with an integrated intensive ventila-tor (Servo 300).The ventilator had previously been properly checked and no faults had been found. After moving thepatient onto the transport unit all the parameters, including BGA, were checked again and no tendency towards deteri-oration was detected.The patient was taken to and loaded onto the intensive-care helicopter. Approximately 5 minutesafter take-off a total failure of the ventilator occurred.The cause of this was subsequently found to have been a problemin the supply lines to the ventilator.Due to the failure of the ventilator the patient’s respiratory situation deteriorated dra-matically (SaO2< 70%).Troubleshooting could not be carried out initially as appropriate measures had to be taken imme-

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diately to stabilise the respiratory situation of the patient in order to at least ensure his survival. In order to do this thepatient was ventilated with an FiO2 of 1.0 using a manual ventilation bag with a connected demand valve (fig.1).Afterconsultation with the pilot it was established that a return to the referring hospital was the fastest way to reconnect thepatient to a suitable ventilator. The relevant emergency services deployment centre was informed by radio and request-ed to forward the information about the dramatic deterioration of the patient.Although the patient’s circulation contin-ued to be stable during the last minutes of the flight, an SaO2 of only 76 was measured as an indication of the dramaticdeterioration of the respiratory situation. An auxiliary team from the referring hospital was standing by ready for the land-ing which sped up the unloading procedure and return to the referring ward considerably.At the referring ward the patientwas reconnected to his ventilator. A second ITH from a more distant centre was notified because the situation whichhad occurred seemed to rule out safe transportation under conventional conditions. The existing situation was explainedin detail and it was decided that the transfer should take place with the provision of a mobile ECLA. The respiratory sit-uation of the patient had deteriorated further by the time the second team arrived. A paO2 of only 43 mm Hg was record-ed under constant ventilation parameters and the paCO2 increased to 59 mm Hg. When the second team arrived it wasdecided to connect the patient to the mobile ECLA while still in the referring hospital.The patient could then be trans-ported with the ITH while connected to the mobile ECLA.After several days of treatment with the ECLA the patient’s res-piratory situation had improved considerably and he could be ventilated conventionally and eventually extubated.He wasreturned to the initially treating hospital within less than 3 weeks.

Fig. 2: Respirator system with special pressurereducing demand valve and hand-operated respirator bag for ventilation with 100% oxygen(Company Dräger Medical, Lübeck, Germany)