Plan & Conduct Evacuation

#### Evacuation Considerations

- May take more than 24 hours to execute an evacuation mission.
- Initiate evacuation coordination for PUI patients, regardless of symptoms, to next level of care as soon as possible due to limited oxygen supply, lack of advanced critical care capabilities, and limited number and availability of evacuation platforms.
- Patient Movement should be anticipated for COVID-19 PUIs when symptoms present concerning for progression of disease. There is no reason to delay request for evacuation.
- Ground and Air Medical Transport will depend on local CASEVAC/MEDEVAC notification plan and CASEVAC/MEDEVAC platforms available for transport.
- When clinically & operationally feasible, within the provider’s scope of practice, obtain central venous access in anticipation of need for multiple infusions, including vasopressors. Obtain at least two peripheral IV’s or one peripheral plus one central line access prior to transport, if possible.
- Early placement of arterial access secured by suture for invasive pressure monitoring is recommended, if available.
- Due to probability of myocardial injury, obtain ECG and troponin, if possible. Coordinate the medical management of acute coronary syndrome or myocarditis via teleconsultation prior to transport, if possible.
- Patients requiring >3 Lpm oxygen support to maintain oxygen saturations >92% may not tolerate the hypoxic environment of aeromedical evacuation and require pre-flight intubation.
- Consider consulting the Advanced Critical Care Evacuation Team (ACCET) DSN 312-429-BURN (2876) before transporting patients on moderate to high ventilator settings (PEEP > 14 and FiO2 > 70%). Refer to JTS Acute Respiratory Failure CPG. If prone ventilation is to be utilized in-flight, position patient pre-flight with adequate time to document patient stability and an arterial blood gas before transport. Review prone positioning procedures in the JTS Acute Respiratory Failure
- If intubated, place NG/OGT pre-flight and attached to intermittent suction. Post-pyloric enteric feeds may be continued in-flight using small bolus sizes (30 cc) and given twice hourly.
- Assemble and send pre-drawn and pre-mixed medications with primed tubing prior to transport.
- Prepare patient records for handoff including medical notes, ECGs, laboratory results, and imaging results (if available).
- Prepare patient belongings and ID/passport to accompany the patient.
- Place PPE for flight on patient including eye protection and ear protection, and DO NOT forget casualty face covering if not intubated.

#### Transition of Care for Evacuation

- Early patient report allows the evacuation team to prepare any medications and equipment that cannot be provided by the sending facility.
- Sending facility medical team should provide contact information when requesting patient movement.
- Evacuation team should contact the Role 1-2 medical team for initial report via approved means.

#### During Transport Team Handoff

- Provide up-to-date COVID-19 status (PUI vs confirmed)
- Current vital signs, exam findings, and recent trends or changes
- Current medication regimen if initiated (including antibiotics and anticoagulants)
- Critical care medication regimen (sedation, analgesia, paralysis, and vasopressors)
- Current PPE status, oxygen requirements and ventilator settings
- Any potential COVID-19 related complications identified during management (e.g. heavy respiratory secretions)

Note: Upon evacuation team arrival to receive the patient, handoff report should be repeated with key elements above, including any recent patient changes.

Warning: Transition to the evacuation team equipment presents risk of exposure to healthcare team. To reduce risk: Personnel should be limited to those directly involved in the care of the patient. Best available PPE should be worn by everyone involved in the care transition.

- ETT clamping technique should be instituted to limit aerosol creation during all ventilator circuit breaks including transfer to evacuation team ventilator
- Sufficient time should be allotted to confirm adequate oxygenation and ventilation prior to departure of the evacuation team.