Interhospital transportation is a common event in a decentralized health network, and the ambulance transport of critical patients is associated with increased complications [13]. Safety transport needs basic non-human conditions such as appropriate equipment and vehicle and direct handover. However, the ambulance staff plays the most important role in patient support through intensive monitoring, early red flag recognition, and on-time stabilization [14].
Despite the conceptual importance of experienced staff, novice ED personnel are normally used in ground transport as well as other hospital doctors upon request [15]. The high cost of maintaining fixed high-quality professionals for transportation, mainly with idle periods and short trips, justify this organization [16]. These new professionals, usually tired and with interruptions in their activity and commute to help with transport, probably have field practice limitations. The temporary absence of these professionals during duty is also associated with crowding in the ED [17].17 In parallel, there is evidence to suggest that paramedics (which can be extrapolated to nursing in our country) have discernment in recognizing stable and critically ill patients and can abort transport if there is a high risk of instability. Presumably, these professionals screen for safer transportation situations, implying a low chance of medical intervention on the way [18, 19].
Some studies show that up to 15% of the patients transported in ambulances arrive at another hospital presented with hypotension or hypoxia, and a part of them have already experienced these changes at the beginning of the transport and not been diagnosed. In part, the reason can be attributed to the characteristics of the medical team that performs this type of transport, being mostly done by doctors with little experience [20].
It is noteworthy that the occupational risk is also greater in ambulance transport, especially when there is a need to provide care with vehicle movement [21]. Furthermore, approximately 40% of transport is unnecessary, suggesting the need for strict protocols before the patient can board the ambulance [22, 23]. Such evidence presumably supports the low probability of medical intervention during transport. The presence of more experienced physicians is an effective measure to ensure transport safety both in the initial assessment and in the handling of possible complications on the way [20]. In this study, the TM physician on duty had experience with critically ill patients, was working with low mental stress conditions, and the aid to transport had little impact on the care routine. This data initially supports the cost-effectiveness of the strategy, with a positive impact on the ED teams who keep their doctors in situ. Furthermore, no impairment was found in TM activity.
TM is already a reality in health services, being useful in reducing the time for medical intervention and with a high rate of accuracy in diagnosis and cost-effectiveness [24]. The broad public, professional caregivers, and patients reported a positive attitude toward TM for emergency treatment during ambulance transportation and chronic care at home. These results support further improvement of TM solutions in these domains [25]. Adjusting for health status, socioeconomic status, and provider availability reduced the quartile 1 versus quartile 4 difference in ambulance transport rates. Geographic variability in ambulance use is large and associated with the variation in patient health status and their socioeconomic status [16].
In this study, ambulance transport was considered safe, with low rates of complications, contrary to what is shown in the literature, and little need for medical intervention. There are two key points in this finding: 1) the checklist made by the nursing staff who removed extremely unstable patients from this transport modality and 2) the nursing’s ability to recognize a threatening situation, activate TM, and follow recommendations. It is noteworthy that in the study population, only 4.5% of the patients were eligible for the criteria to abort transfer without an onboard doctor. The extremely low rate of patients who became unstable on arrival at the main unit reinforces the effectiveness of the two key points. The vast majority of communications between the ambulance and remote physicians were effective, and there was no compromise in understanding any important recommendation. During transport, only 22 patients needed TM-support intervention, 12 being the only interpretation of data obtained in monitoring. The others had increased oxygen supply, administration of symptomatic drugs, IV hydration, or use of hypotensive agents. About one-third of the patients were found to be unstable when they arrived at the central unit, a situation recognized by changes in vital signs. There was no clear association of these changes with the lack of adequate support in transport; on the contrary, the patients maintained changes similar to the exit from the satellite unit: 3 cases of sepsis with borderline blood pressure, 2 cases of sustained hypertension, and 3 cases of non-critical hypoxemia. This emphasizes the very low number of patients in this situation and without a clear implication of the worst prognosis associated with transport. Although TM is already widespread, there are a few reports in the literature demonstrating the functioning of the interhospital transport system in partnership with TM.
This study demonstrated that telehealth offers a technology strategy to address the potentially unnecessary ambulance transports. Based on prior cost-effectiveness analyses, the reduction of unnecessary ambulance transports translates into an overall reduction in Emergency Medical System agency costs. Telehealth programs offer a viable solution to support alternate destinations and alternate transport programs [27].
The use of telehealth in transport allows qualified doctors to provide support to several ambulances, reducing the costs for the health-care system and optimizing team time management; however, it should be noted that there is a need for a well-prepared team (e.g., a qualified nurse). The interventions can be guided, when necessary, via TM without prejudice to the patient. There is already evidence of patients with low clinical severity and non-emergent conditions, and telehealth avoids inappropriate referrals in more than half of the cases. Presumably, these patients will not experience any complications during transportation [27].
The interhospital ambulance transportation is very common nowadays, and despite the assumed association of the need for hospitalization with greater severity, the vast majority of the patients stabilized in satellite units were transported uneventfully to the central unit. The very few cases that required any intervention during transport were properly guided by a TM-experienced doctor. A checklist before transportation can exclude the cases that need a doctor on board, such as patients with ST-elevation myocardial infarction, ongoing stroke, and intubates.
There are some limitations to this study. First, it is a retrospective cohort based on institutional care routine; second, some life-threatening situations have not been contemplated for, and finally, no comparison was drawn with similar groups transported with onboard doctors. With respect to the strength of this study, it reflects real-life practice with 2840 patients with prevalent conditions who were transported safely and with a better cost ratio.