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Appropriate Utilization of
Critical Care Ground Transport Services
Position Statement of the Association of Air Medical Services (AAMS)
BACKGROUND
Today, the growing demand for highly sophisticated critical care services
has been the result of a rapidly growing technological complexity of
medical care for critically ill and injured patients.1 Since critical care
ground transport has been integrated into AAMS, the association
identified the need for minimum guidelines for the use of critical care
ground ambulances and specialty care transports that augments the
position paper previously published by AAMS entitled Appropriate
Utilization of Air Medical Transport Services.2
The growing number of critical care transports across the country
establishes a significant need to develop a position statement for
Appropriate Utilization of Critical Care Ground Transport Services This
position paper will outline minimum standards and guidelines for triaging
the appropriate ground transport, qualifications of medical personnel, and
will provide guidelines of appropriate critical care to the consumers of
these services. It is critical to recognize that the skill and training of
personnel must commensurate with the rapidly advancing technologies
and sophisticated equipment needed for providing critical care in the
complex environment of transport.2
The basic reason for moving critically ill patients by any form of medical
transportation is the need for additional care, either technology and/or
specialists, not available at the patient’s current location. As a result of
health care changes and advancements, services providing critical care
ground transport have become a necessary extension of hospital emergency
and critical care services. In the hospital setting, physicians and nurses are
the primary care providers for patients requiring the most advanced
medical technology and care. Therefore, transport crew members must, at a
minimum, have strong assessment and critical thinking skills, ability to
manage patients, and a strong knowledge of communications and safety in
the out-of-hospital setting. They must also have the ability to function
autonomously in a variety of settings with treatment protocols if immediate
communication with a physician is not possible or if immediate life-saving
actions are required.
Interfacility patient transfers should be made when the benefit to the
patient exceeds the risks involved in the transfer. Positive patient
1
Emergency Nurses Association & Air & Surface Transport Nurses Association. (2001, December). Emergency
Nurses Association, Air & Surface Transport Nurses Association joint position statement: Staffing of critical care air
medical transport services. Available: http://www.astna.org/position-papers/staffing_CCT_services.html
2
ENA & ASTNA, 1
Association of Air Medical Services
1
Appropriate Use of Ground Critical Care Transport Services
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Section VII
outcomes depend on the expertise of nursing, medical personnel, and the
technology available in the healthcare system. A patient who needs
services that exceed the available resources of a facility should be
transferred to another facility with the required technologies and with
appropriately trained personnel and equipment.3
Consumers utilizing critical care ground transport services have the right
to receive a nationally consistent standard of care.
To assure the provision of appropriate critical care to the consumers of
these services, the skill and training of the personnel must commensurate
with the complex environment of transport.4
Although several professional organizations have developed or are
developing standards, at present none of these standards have been
nationally accepted and implemented throughout the United States.
PURPOSE
The medical transport community supports the safe and proper use of
critical care transport services. The standards of AAMS strive to promote
excellence in patient care. The purpose is as follows:
1. To establish minimum standard guidelines for the appropriate team
utilization of critical care ground transport services.
2. To enhance the quality of patient care by advocating the proper use
of critical care ground transport services.
3. To promote the concept that matching the high risk critical patient
with the proper medical personnel can reduce morbidity and
mortality.
4. To establish appropriate equipment for critical care ground
transport.
5. To publish definitions for critical care ground transport.
6. To publish descriptors of specific illnesses, injuries and conditions
that identifies high-risk and critical patients. These descriptors can
be used to identify appropriate inter-facility critical care ground
transports.
3
4
2
Moy, M. (2000). The EMTALA answer book (2nd Ed.). Gaithersburg, Maryland: Aspen Publications
ENA &ASTNA, 1
Association of Air Medical Services, 2004
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POSITION STATEMENT
For patients transported by ground medical transport, critical care ground
transport should be used when its inherent advantages over an advanced
life support (ALS) ambulance transport enhances patient care.
AAMS believes that the transportation of patients by a critical care ground
unit should include the following considerations:
.
1.
The level of care should not decrease during transport. The skill
level of the accompanying personnel must be equal to the interventions
required or anticipated for the patient during transport.
2.
Critical care transports should be performed by a specially trained
transport team as outlined in state guidelines and CAMTS standards.
3.
A minimum of two medical personnel, in addition to the driver,
shall accompany the patient to deliver direct patient care.
4.
The Medical Director of the transport program ensures competency
and currency of all medical personnel working with the service.
STAFFING
Currently there are no supported national standards regarding the staffing
of critical care ground transport services.

The American College of Emergency Physicians (1990) endorses
the following principle regarding patient transfers: “The health and
well-being of the patient must be the overriding concern when any
patient transfer is considered. The patient should be transferred in a
vehicle that is staffed by qualified personnel and contains
appropriate equipment.”5

The Commission on Accreditation of Medical Transport
Systems (CAMTS) in their Fifth Edition of Accreditation
Standards (2002) published the following: “A critical care
mission is defined as the transport of a patient, from a scene
or a clinical setting, whose condition warrants care
commensurate with the scope of practice of a physician or
registered nurse. The medical team must, at a minimum,
consist of a specially trained physician or registered nurse, as
the primary care provider”.6 Most recently, CAMTS will
allow for an alternative team composition (for example
5
American College of Emergency Physicians. (1990). Principles of appropriate patient transfer position statement.
Annals of Emergency Medicine, 19, 337.
6
Commission on Accreditation of Medical Transport Systems (CAMTS). (2002). Accreditation standards of
CAMTS (5thEd.). Anderson, SC: Author.
Association of Air Medical Services
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Section VII
paramedic-led teams) if they can demonstrate compliance
with the accreditation standards as a critical care team.

The Centers for Medicare Services (CMS) final rule dated
February 27, 2002 defines Specialty Care Transport (SCT) as:
“When medically necessary, for a critically injured or ill
beneficiary, a level of interhospital service furnished beyond the
scope of the paramedic as defined in the National EMS Education
and Practice Blueprint. This is necessary when a beneficiary’s
condition requires ongoing care that must be furnished by one or
more health professionals in an appropriate specialty area (for
example, nursing, emergency medicine, respiratory care,
cardiovascular care, or a paramedic with additional training).
Lastly, it is important to note that staffing should meet all state
requirements, as numerous states have developed standards or regulations
regarding the staffing of medical transport services in operation within
their jurisdiction. These staffing standards/regulations vary widely from
state to state. Likewise, the registered nurse’s role in an out-of-hospital
environment must be consistent with the scope of practice as defined by
that state’s Nurse Practice Act.7
Ambulance Equipment and Calibration
The ambulance designated for critical care must be designed to provide for
the medical care and transportation of a patient consistent with the mission
statement and scope of care of the service.8
1.
The ambulance must meet the federal Star of Life Ambulance
Specifications (KKK-A-1822E) and all state licensor requirements.
2.
Preventive maintenance program for each ambulance and its
equipment shall be developed and implemented to ensure optimal working
performance.
3.
Documentation shall be maintained by the provider to support
evidence of :
a.
Inspection
b.
Calibration
c.
Maintenance
Operation of the ambulance and its equipment shall be in accordance with
the requirements and maintenance schedule of the manufacturer or other
regulatory agencies.
Equipment specific to a critical patient
77
Ohio Nurses Association. (1996). The role of the registered nurse in the out-of-hospital emergency setting. Nurse
Practice Statement NP69.
8
AAMS. (2000). Standards and Safety Guidelines; CCG Standard I Ambulance equipment/Configuration, 31
4
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Include but not limited to:
1. Invasive monitors – Swan Ganz, arterial lines, CVP, ICP needle
2. Cardiac Assist Devices – pacemakers, intra-aortic balloon pump,
ventricular assist device, extra- corporeal support (ECMO), 12 lead
monitoring, interpretation and intervention
3. Specialty Drug Delivery – epidural catheters, intra-osseous lines
4. Respiratory equipment – ventilators, artificial airways, chest tubes,
capnography
5. Appropriate redundancies to ensure continued continuity in patient
care.
Criteria for use of Critical Care Transport
Critical transport should be utilized for interfacility transport of patients in
critical condition or with conditions with potential for deterioration during
transport.
In general, the following patients should be transported by a specially
trained critical care ground team with the following conditions:

Patients in critical condition

Potential for deterioration into critical condition during
transport

Unstable vital signs

Patients intubated and ventilated for an acute medical
condition
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Continuous infusion pharmacologic blood pressure support
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Any patient that the responsible sending physician certifies
that a higher than advanced life support level of care is
required to safely transport the patient
The following vascular events and surgical conditions that require timesensitive treatment should be safely transported by the most appropriate
mode of transport available.

Acute ischemic stroke

Expanding epidural hematoma

Acute myocardial infarction

Acute aortic dissection

Acute gastrointestinal hemorrhage

Rupturing aneurysm

Acute intra-abdominal hemorrhage from trauma

Amputation with planned reattachment

Ischemia of arm or leg

Necrotizing fasciitis
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Section VII
1. Neurologic
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Acute ischemic stroke
Malignant hypertension (Hypertensive emergency)
Intracranial hemorrhage
Epidural hematoma
Subarachnoid hemorrhage (SAH)
Subdural hematoma
Status epilepticus
2. Cardiac
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Acute myocardial infarction
Coronary artery disease on intra-aortic balloon pump
(IABP) or ventricular assist device (VAD)
Intermediate coronary syndrome (unstable angina)
Cardiogenic shock on continuous infusion
pharmacotherapy
Dysrhythmia on continuous infusion antidysrhythmic
therapy
Cardiac tamponade
Valvular insufficiency
Post-cardiac arrest
3. Trauma

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Intra-abdominal hemorrhage
Amputation with planned reattachment
Head injury with deteriorating mental status
Spinal cord injury with hypotension and/or neurological
deficits
Flail chest
Cardiac injury
Pelvic fracture with hypotension
Multiple long bone fractures with hypotension
Open fractures
4. Burns

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6
Major burn criteria
Inhalational injury
Burns with associated trauma
Electrical burns
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5. Critically-Ill Medical
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Gastrointestinal hemorrhage
Near-drowning
Emergency hemodialysis
Hyperbaric oxygen therapy (HBO)
Severe poisoning or overdose
Airway with potential for obstruction
Angioedema
Epiglottitis
Retropharyngeal abscess
Specialized ventilation
Acute respiratory distress syndrome (ARDS)
Inverse ratio ventilation
Jet ventilation
6. Critically-Ill Surgical
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Aortic dissection
Rupturing aneurysm
Necrotizing fasciitis
7. Pediatric
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ICU admission
Status asthmaticus
Status epilepticus
8. Obstetric
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Premature labor with neonatal weight < 2000g
Hydrops fetalis
Neonatal cardiac disease
Medical emergency
Pre-eclampsia or eclampsia
DKA
Poisoning or overdose
Surgical emergency
Abruption with hemorrhage
9. Neonatal
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Association of Air Medical Services
Intubated and ventilated
Bronchopulmonary dysplasia
Congenital heart defect
CHF
Persistent hypoglycemia
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Appropriate Use of Ground Critical Care Transport Services
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Section VII
Temperature instability
Sepsis or meningitis
Seizures
DIC
Necrotizing enterocolitis
Abdominal wall defect
Diaphragm hernia
10. Transplant

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Donor
Recipient
DEFINITIONS
Critical Care Transport – As defined by the Commission on Accreditation
of Medical Transport Systems (CAMTS): “the transport of a patient from
an emergency department or critical care unit who receives care
commensurate with the scope of practice of a physician or registered
nurse.”
Mobile Intensive Care Unit – As defined by the Ohio Revised Code:
“Mobile Intensive Care Unit means an ambulance used only for
maintaining specialized or intensive care treatment and used primarily for
inter-hospital transports.”
Critical Care Patient – Any patient who experiences an actual or potential
life or limb threatening illness/injury that requires continual monitoring
and care by specialized trained registered nurses.
Specialty Care Transport – As defined by CMS (HCFA): “Interfacility
transportation of a critically injured or ill beneficiary by a ground ambulance
vehicle, including medically necessary supplies and services, at a level of service
beyond the scope of the EMT-paramedic as defined in the National EMS
Education and Practice Blueprint. Patient’s condition requires ongoing care
provided by one or more health professionals in an appropriate specialty area
(nursing, medicine, respiratory care, cardiovascular care or a paramedic with
additional training).”9
9
8
Department of Health & Human Services. (2002). Program memorandum intermediaries/carriers (CMS
Publication No. 60AB). Washington: Author.
Association of Air Medical Services, 2004