MAINTAINING

CREW SAFETY
IN CRITICAL CARE
TRANSPORTS
The Johns Hopkins Lifeline team sets the
standard in reducing risk of disease transmission

A SPECIAL SUPPLEMENT
BROUGHT TO YOU BY
W
hile COVID-19 is the most recent and certainly
the most deadly global pandemic in recent
memory, EMS clinicians are well aware that it
wasn’t the first deadly pathogen to endanger
EMS transport crews. And it won’t be the last. In 2015, as a result
of the deadly Ebola outbreak, a team of forward-thinking clini-
cians at Johns Hopkins Lifeline Critical Care Transport Program
in Baltimore, MD, banded together to form the Lifeline Special
Operations Response Team (SORT), a dedicated group of staff
members who are committed to moving Lifeline patients with
high consequence infectious diseases safely.
Johns Hopkins Lifeline manages transport inside Johns
Hopkins Hospital and between all five Johns Hopkins member
hospitals in Maryland and Washington, explains Asa Margolis,
medical director of the Johns Hopkins Lifeline Critical Care
Transportation Program.
“The idea behind SORT was to be able to develop a process
to safely transport patients with high-consequence infectious
diseases,” Margolis says.
Johns Hopkins Lifeline teams with air medical transport partner STAT Medevac, a crit-
ical care transport system and the clinical arm of the Center for Emergency Medicine
of Western Pennsylvania (CEM). STAT MedEvac operates 18 helicopter base sites in
Pennsylvania and surrounding states, and supplies the paramedic and pilot during
Lifeline transports. (Photos: Johns Hopkins Lifeline)
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS

Johns Hopkins Lifeline LIFELINE SORT: COVID-19

Since its inception 28 years ago, Lifeline has provided care RELATED TRANSPORTS
for patients within the Johns Hopkins Hospital and Health Sys-
tem. The team has a multifaceted transport mission, including • COVID-19 related flights: 37
movement of critically ill patients within the Johns Hopkins • COVID-19 related ground transports: 554
Hospital, emergency response in the hospital and around the • COVID-19 related intrahospital transports: 778
medical campus, and the interfacility ground and air transport (Data represents February 29, 2020–December 31,
of patients referred into the health system. 2020)
The team is involved in approximately 22,000 air, ground,
and in-hospital patient transports each year. The Johns Hop-
kins Hospital is a 1,154-bed quaternary care hospital and 1 of
10 Regional Ebola and Special Pathogen Treatment Centers.
While each hospital is able to manage patients with COVID-19,
patients are transferred to The Johns Hopkins Hospital because
of their clinical complexity or as part of a systemwide plan to
achieve the best balance of patients across the health system.
Lifeline also teams with air medical transport partner STAT
Medevac, the clinical arm of the Center for Emergency Medicine
of Western Pennsylvania (CEM). STAT MedEvac operates 18
helicopter base sites in Pennsylvania and surrounding states,
and supplies the paramedic and pilot during Lifeline transports.
To prepare for the COVID-19 response, SORT team coordi-
nator Chad Bowman, MSN, worked with Hospital Epidemiology
and Infection Control (HEIC) to adapt the existing protocols
for high consequence pathogens specifically for COVID-19.
Among the changes were the addition of a safety officer to
monitor every transport, and modification of treatment plans
to mitigate aerosol generating therapies. SORT team members
then assisted with training Lifeline staff in donning and doffing
of the COVID-19 PPE ensemble.
In August 2020, the Johns Hopkins Lifeline SORT transport
team transported its 1,000th patient who was either known to
have COVID-19 or who was under investigation for the disease.
“Most remarkable is not simply the volume of transports in a
relatively short time frame, but also the fact that we have had
zero staff conversions—meaning no staff members have con-
tracted COVID-19 during their patient interactions,” says Heidi
Hubble, MHA, director of operations for Johns Hopkins Lifeline
critical care transportation. “This means that our infection con-
trol procedures and the model that we are using, which includes
a transport safety officer, is successful.” As of the time of this
publication, the team still reports zero transmission to staff.
How did they achieve it? The main components of the Life-
line SORT team are outlined here.

The Transportation Safety Officer (TSO)

The primary responsibility of the TSO is to ensure staff and
bystander safety during the transport of patients with suspect-
ed or confirmed COVID-19. There is no patient care responsi-
bility associated with this position, a purposeful decision to

EMSWORLD.com | 2021 3
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS

I am the Chief Administra-

tive Officer for Emergen-
cy Medicine and Capacity
Management at The Johns
Hopkins Hospital, which includes respon-
sibility for Hopkins Lifeline. I happen to be
one of the founders of Lifeline, which was
the first critical care transport system in
Maryland when we began some 27 years
ago. Lifeline has grown so much since
then—from a single critical care team
on a single ambulance to the point now,
where we provide care in every possible
care venue. Lifeline teams now provide the
inter-hospital patient transfers by ground
and by air, and we provide care during
intra-hospital critical care transports,
bringing an entirely new level of safety
to those challenging patient movements.
Lifeline has been a pioneer in the specialty
of transportation medicine and has always
operated under the premise that we bring
the Johns Hopkins level of care to our
patients, and that the patients’ recovery
begins the moment our team begins the
transport to Johns Hopkins.
—Jim Scheulen, PA, MBA,
Chief Administrative Officer,
Johns Hopkins Hospital

EMSWORLD.com | 2021 4
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS

ensure focus is maintained on the sole objective—safety.

Training to become a TSO is available to all Lifeline staff. A
half-day course consisting of didactic and hands-on training
is followed by an observed evaluation.
The TSO’s first objective is to ensure the proper donning of
PPE. The TSO observes vigilantly for best practice deviations
during the donning process, using a checklist to confirm all
PPE is being appropriately worn and that the teams’ respira-
tors have proper fit and function. The TSO remains outside the
patient room while maintaining full visibility of the treatment
team members. The TSO is empowered to pause patient
care and movement operations for actions that could lead
to a breach in infection control practices. Real-time feedback
and relevant education are provided to health care staff to
reduce future occurrences and improve safety.
Once the patient is ready for transport, a transport safety
checklist is again reviewed by the TSO that includes ensuring a
surgical mask is placed on the patient, PPE is being appropri-
ately worn, and high-efficiency particulate air filters are in the
proper location within the ventilator circuit should the patient
require noninvasive support or ventilator management.
Because hospital staff, bystanders, and other patients
are at risk of exposure once the patient leaves their isolation
room, the TSO also plays a crucial role in mitigating the risk
to these individuals. Tight corridors and small elevators do
not allow for physical distancing and represent a potential
opportunity for exposure.
Throughout the transport, the TSO walks ahead of the
stretcher and clears hallways of bystanders to reduce any SORT team members assist with training Lifeline staff in donning and doffing PPE.
risk. Doors are opened, and buttons
are pushed for the crew to avoid
potential contamination of the hos- There is always going to be
pital and transport environments. If a
crewmember accidentally touches a
another pandemic. Viruses
door handle or other surface, the TSO will keep evolving. That’s a
is equipped with cleaning wipes to dis-
infect the area.
guarantee. What we’re doing is
During ambulance transport, the creating systems and protocols
TSO travels in the passenger seat of
the cab, which has been partitioned off
that will keep our people safe not
from the patient care compartment to just now, but well into the future.”
minimize pathogen transmission. The
crew members providing direct patient
care are equipped with a 2-way radio
worn under their PPE, which allows for easy communica-
tion with the TSO. To limit the risk of breaching PPE and
to decrease contaminating surfaces in the ambulance, the
TSO relays messages from the crew to the communica-
tions center or the medical control physician when online
consultation is required.
Similarly, when patient transport occurs via air, the TSO
occupies the co-pilot seat of the helicopter. Upon hospital
arrival, the TSO is responsible for ensuring that hand hygiene

EMSWORLD.com | 2021 5
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS

I am one of the lead clinical

nurses at Lifeline. As this
pandemic response has con-
tinued, my role has evolved.
One of those roles has been co-coordinator
of our SORT team. During the initial phase of
the response, we were focused on developing
best-practice processes to ensure our staff
had the best PPE and logistical support to
stay safe. We worked collaboratively with our
Hospital Epidemiology and Infection Control
Department, as well as our Biocontainment
Unit, to provide the most up-to-date and
safest options. Since we provide both ground
and air transports as well as transports with-
in The Johns Hopkins Hospital, we needed to
come up with different strategies to safely
move these patients while maintaining a safe
work environment for our staff. This process
has been evolving as lessons are learned and
continues to be a challenge. My role has been
very much a collaborative effort across our
leadership and all our staff.
—Eric Leslie, BSN, RN,
Lead Clinical Nurse,
Lifeline Critical Care Transport

EMSWORLD.com | 2021 6
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS

is completed upon exiting the transport

vehicle and that the transport route is
clear. During flight operations, the TSO
assists the flight crew as they remove
their flight helmets and don their face
shield.
Once patient care has been trans-
ferred, the crew doffs their PPE under
the supervision of the TSO. Doffing is a
high-risk procedure; a previous study of
health care workers caring for potential
Ebola virus patients identified 103 ways
that the doffing process could fail and
result in exposure.
The TSO is responsible for mitigating
this risk by monitoring and assisting crews
in the removal and disposal of their PPE.
A best practice checklist is used to ensure
that all steps are followed. Finally, equip-
ment is decontaminated to be ready for
the next call.

The Receiving ‘Clean

Donning and doffing PPE can be a high-risk procedure.
Team’
Additional risk mitigation is achieved by
assigning a separate Lifeline clinical team
to receive interfacility transport patients
on hospital arrival. This team assumes
patient care on hospital arrival and trans-
ports the patient to the receiving unit.
The intent of the secondary “clean
team” is to decrease the risk of potential
contamination to the hospital environ-
ment from high-risk ground transports,
such as extended transports beyond
60 minutes or those that require aero-
sol-generating procedures. This handoff

Most remarkable is not of care limits the introduction of biobur-

den from PPE and relieves the transport
simply the volume of team who are often mentally and/or

transports in a relatively short time physically fatigued as a result of providing

ongoing resuscitation during long trans-
frame, but also the fact that we ports while in PPE.

have had ZERO staff conversions— The TSO remains with the new clean
team to ensure a consistent member of
meaning no staff members have the initial team is present upon handoff to

contracted COVID-19 during their hospital staff. There have been no reports
of errors in omission or commission of
patient interactions.” patient information during the handoff
to hospital staff.

EMSWORLD.com | 2021 7
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS

My role is director of operations for

the Lifeline Team. I am responsible
for oversight of the entire Lifeline
operation—ground, in-house, the
Communications Center, and other operations.
This includes assessing, planning, implementing,
evaluating and directing all operational compo-
nents of the program, ensuring that our priorities
and operations are aligned with the vision and
strategic goals of the health system, and manag-
ing relationships with our contracted vendors. It
also includes development and implementation of
policies, procedures and programs to improve or
enhance the quality of Lifeline
operations, in collaboration with the Lifeline
Leadership team and JHHS stakeholders.
—Heidi Hubble, MHA,
Director of Operations,
Lifeline Critical Care Transport

EMSWORLD.com | 2021 8
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS
Lifeline has a multifaceted transport mission, including moving critically ill patients throughout the health system.
PPE and Transport Modification
Standard isolation gowns were found to be impractical for both
ground and air transport. The constant movement that occurred
during transport resulted in ripping and tearing of the gowns. Given
these concerns, the use of surgical gowns was implemented because
of their increased durability and flexibility.
As an increased transport safety measure, the junction between
the surgical gown and gloves is secured with polyethylene-coated,
nonpermeable adhesive tape (duct tape).
Because of repetitive movement, the wrist cuffs of the surgical
gowns often migrated up the arm, creating a gap of exposed skin
between the cuff and the glove; taping the wrists prevents this gap
and potential exposure.
When team configuration permits, the emergency vehicle operator
is responsible for starting the transport vehicle and ensuring that the
air conditioner in the patient care compartment is activated. This
is done to reduce ambient air temperature for patient and team
comfort. A rechargeable cooling vest is available to staff as an addi-
tional comfort measure for extended ground and air transports.
Additional considerations and modifications were necessary to
ensure the same high-level compliance and safety of staff involved
in helicopter emergency medical services transport. As expected,
powered air-purifying respirators were not feasible because of flight
helmets. Instead, a fit-tested Draeger or N95 respirator was worn
underneath the helmet.
Once off the aircraft, the clinicians remove their helmet and
replace it with a face shield. Because of the modifications in the
doffing steps to accommodate the flight helmet, all flight team
members including TSOs were validated in PPE donning and doffing
specific to flight operations.
The pilot remains in the helicopter, removed from the patient
care team, to decrease the need to sanitize the front of the aircraft
and prevent exposure.
EMSWORLD.com | 2021 9
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS

RESPONSIBILITIES
OF THE TRANSPORT
SAFETY OFFICER (TSO)

GENERAL RESPONSIBILITIES
•  Ensure staff and bystander safety
•  Halt operations if there is a hazard risk
BEFORE TRANSPORT
•  Assist with proper donning
•  Ensure patient is properly prepared for transport,
including applying a surgical mask
•  Gross decontamination of high-touch surface areas
prior to exiting patient room
DURING TRANSPORT
•  Monitor for infection control breaches and quickly
remedy any that occur
•  Clear traffic from hallway
•  Open doors and press elevator buttons
•  Responsible for radio and cellular communications
AFTER TRANSPORT
•  Observe and assist with proper doffing
•  Gross decontamination of equipment

Lessons for EMS “The single most important thing that an EMS jurisdiction can
The Lifeline Team shares their lessons learned to help mitigate do is to designate a safety officer,” says Margolis. “And this doesn’t
and/or reduce staff transmission: have to be difficult. In many cases it doesn’t even have to be an EMS
• Train personnel to fulfill multiple roles as this will increase clinician.” Education on the core tenets of crew safety, mitigating
the number of team members available to function as a TSO. disease transmission, PPE and other basics can be enough.
• Ensure PPE is both practical and protective for the “There is always going to be another pandemic,” says Margolis.
out-of-hospital environment. “Viruses will keep evolving -that’s a guarantee. What we’re doing is
• The TSO is crucial to mitigating risks to the transport team creating systems and protocols that will keep our people safe not
and ensuring best practice standards are maintained. just now, but well into the future.”
• Constant communication with epidemiology and infection
control colleagues is critical to ensure ongoing collaboration and
consistency with best practices.
• Identifying a coordinator for special operation transport
is essential to ensuring the goals, objectives, and mission of the
team continue to align with the growing and changing demands.
• Maintaining team flexibility is equally important while
ensuring that fundamental safety objectives are always met.

EMSWORLD.com | 2021 10
ENSURING CREW SAFETY IN CRITICAL CARE TRANSPORTS

INTRODUCING THE X SERIES ® ADVANCED:

ADVANCE YOUR CARE FOR EVERY RESCUE

Manage your patients more effectively than ever with ZOLL’s new
X Series Advanced monitor/defibrillator. X Series Advanced offers
two groundbreaking new features:

Real BVM Help™ provides real-time clinical feedback on

manual ventilation, including delivered tidal volume and
rate, a ventilation quality indicator, and a countdown timer.

TBI Dashboard enables care providers to effectively

manage patients with traumatic brain injury. The
dashboard combines trending of critical vital signs with
real-time ventilation feedback in one comprehensive view.

Interested to learn more? https://bit.ly/3rdsQPo

© 2019 ZOLL Medical Corporation. All rights reserved. Real BVM Help, X Series Advanced and
ZOLL are trademarks or registered trademarks of ZOLL Medical Corporation in the United States
and/or other countries. All other trademarks are the property of their respective owners.
EMSWORLD.com | 2021 11
MCN IP 1910 0295-05