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Table of Contents
COMMENTARY
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 139-141

Need of guidelines for safe transport of patients with COVID-19


Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Submission20-Jul-2020
Date of Acceptance20-Jul-2019
Date of Web Publication17-Aug-2020

Correspondence Address:
Dr. Rakesh Garg
Room No 139, First Floor, Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_447_20

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How to cite this article:
Dattari R, Garg R. Need of guidelines for safe transport of patients with COVID-19. J Anaesthesiol Clin Pharmacol 2020;36, Suppl S1:139-41

How to cite this URL:
Dattari R, Garg R. Need of guidelines for safe transport of patients with COVID-19. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2020 Sep 27];36, Suppl S1:139-41. Available from: http://www.joacp.org/text.asp?2020/36/5/139/292333



The European Network for Infectious Diseases (EUNID) has defined “highly infectious diseases as those which are transmitted from person-to-person causing life-threatening illness presenting a serious health hazard requiring specific control measures to contain it”.[1] Arial transfer of the patient is at time required for shifting the patient from a remote area or a health-care facility with limited resources to a better equipment health-care facility. The aeromedical evacuation refers to transport of patients across long distance after initial stabilization that allows a successful relocation.[2] Among the various concerns for such transfer, one of the concerns remains the risk of contamination. Additional concerns for transport of patient with contagious disease such as coronavirus disease-2019 (COVID-19) include safety of the involved personnel. The longer duration of secondary missions can be physically stressful and exhausting for the medical team.[3] Highly trained teams with well-planned protocol are involved in such evacuation due to significant risks to the involved crew and receiving community with potential for rapid deterioration of the patient. Various measures have been adopted for safe transport of patient with infectious diseases including the use of portable isolation facility. However, no guidelines are available for safe transport for aeromedical evacuation of patients with COVID-19.

The spread of infection to health-care worker during aeromedical evacuation is a possibility and related to duration of exposure, infectivity of the disease, susceptibility to the exposed person, load of infective material, and the airflow system in an enclosed cabin.[4] The additional compressed cabin air has low relative humidity (10%–14%) that increases the infectivity and survival of few airborne viruses.[5] Limited resources and space in the prehospital settings together with the airway procedures and mechanical ventilation that generate aerosols increases the risk of transmission of the infectious diseases to the aeromedical crew as compared to the in-hospital staff. Transport of such patients can be done via open or closed transport system.[5],[6],[7] The open transport system such as an multipatient transport unit facilitates patient management directly and the medical crew managing these patients don with appropriate protective gears including personnel protective equipment (PPE), N-95 face mask, face shield/goggles, protective gown.[6],[7] The closed transport system such as air transport isolator system allows separation of the patient from the attending medical crew.[6],[7] Commercially available closed isolation systems include stretcher isolators and Trexler air transport isolators. Stretcher isolators are used to transport patients exposed to infectious agents but asymptomatic and Trexler air transport isolators that are larger, closed systems are used in the transport of infected patients as it provides good patient comfort while facilitating medical care and helping to maintain containment during the transfer duration. Open transport systems have no additional benefit when used in transport of patients with COVID-19.[7] The use of patient isolator units is beneficial in the secondary transport of patients with COVID-19 despite high costs and logistical difficulties.[8]

This issue publishes a manuscript that describes the need of patient isolation pods for evacuation of patients with COVID-19.[9] The authors commented that isolation pods serve as bioisolation transport and temporary holding solution alleviating the need for isolation corridors and elevators. When connected to high-efficiency particulate air (HEPA) filtration system, these pods create a negative air pressure environment and protect the medical personnel. It is made up of white polyvinyl vhloride (PVC or vinyl) material which is puncture resistant with multiple access points that are wide gloved. It has nylon belt system with four hand grips on each side allowing maneuvering and transporting the patient. There are 21 air exchanges per hour and service ports that allow oxygen and intravenous lines to exit the pod. It also has waste transfer bag, clear view windows, rechargeable battery, and charger and it can be decontaminated. The various monitoring devices and other medical gadgets required for patient monitoring and management are placed within the isolator before sealing it.[4] The limitations of such patient isolation units are communication difficulty due to poor sound transmission, noise generated by air exchange system, and background noise of aircraft. Handheld two-way radios can be used to improve communication. It is difficult to conduct physical examination of the patient, suctioning is tough with nonfeasibility of mechanical ventilation. Phlebotomy is to be minimized and needleless intravenous system may be used to reduce the risk of puncturing the isolator.

Fusco et al. have reported the use of a modified system for manual ventilation of patient with COVID-19 during intra- and extra-hospital transfers to minimize the aerosolization of droplets. They used a DAR reservoir bag and used a high-efficiency particulate air filter “DAR ADULT electrostatic filter” placed on the expiratory limb of the bag. They also placed a surgical mask on the filter which reduced the possible spread of droplets and minimized the contact of the health-care worker with the airflow leaving the reservoir bag increasing the psychological satisfaction of the health-care worker.[10]

To conclude, the use of standard infection control practices, standard operating procedures, judicious patient placement, and simulation-based training of the involved crew in these practices and further experience with the use of patient isolators would help in the successful evacuation of the patients.



 
  References Top

1.
Bannister B, Puro V, Fusco FM, Heptonstall J, Ippolito G and the EUNID Writing Committee. Framework for the design and operational management of high-level isolation units in Europe: Consensus of the European Network for Infectious Diseases. Lancet Infect Dis 2009;9:45-56.  Back to cited text no. 1
    
2.
Hurd WW, Beninati W, editors. Aeromedical Evacuation: Management of Acute and Stabilized Patient. New York: Springer-Verlag; 2019. ISBN 978-3-030-15903-0.  Back to cited text no. 2
    
3.
Radonovich LJ Jr, Cheng J, Shenal BV, Hodgson M, Bender BS. Respirator tolerance in health care workers. JAMA 2009;301:36–8.  Back to cited text no. 3
    
4.
Garibaldi BT, Conger NG, Withers MR, Hatfill SJ, Gutierrez-Nunez JJ, Christopher GW. Aeromedical evacuation of patients with contagious infections. Aeromedical Evacuation 2019;27:317–35.  Back to cited text no. 4
    
5.
Buckland FE, Tyrrell DAJ. Loss of infectivity on drying various viruses. Nature 1962;195:1063-4.  Back to cited text no. 5
    
6.
European Centre for Disease Prevention and Control. Assessment and planning for medical evacuation by air to the EU of patients with Ebola virus disease and people exposed to Ebola virus. 2014 [cited 2018 Nov 01]. Available from: https://ecdc.europa.eu/en/publications-data/assessment-and-planning medical-evacuation-air-eu-patients-ebolavirus-disease. [Last accessed on 2020 Jul 11].  Back to cited text no. 6
    
7.
Albrecht R, Knapp J, Theiler L, Eder M, Pietsch U. Transport of COVID-19 and other highly contagious patients by helicopter and fixed-wing air ambulance: A narrative review and experience of the Swiss air rescue Rega. Scand J Trauma Resusc Emerg Med 2020;28:40.  Back to cited text no. 7
    
8.
Bannister B, Puro V, Fusco FM, Heptonstall J, Ippolito G. Framework for the design and operation of high-level isolation units: Consensus of the European network of infectious diseases. Lancet Infect Dis 2009;9:45-56.  Back to cited text no. 8
    
9.
Sasidharan S, Singh V, Dhillon HS, Babitha M. Patient isolation pods for the evacuation of COVID-19 infected patients – Is this the answer? J Anaesthesiol Clin Pharmacol 2020;36:152-4.  Back to cited text no. 9
  [Full text]  
10.
Fusco P, Petroni GM, Di Carlo S, Tullj S, Arcangeli V, Marinangeli F. Use of a modified system for manual ventilation of the patient for in-hospital and extra hospital transport to avoid aerosolizing spread of droplets during covid-19 outbreak. Anesth Analg 2020. doi: 10.1213/ANE.0000000000004922. Epub ahead of print.  Back to cited text no. 10
    




 

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