Road biocontainment transport classification decision algorithm used during COVID-19 outbreak with isolator

The experience of the Red Cross in Sicily reported by the coordinator of operations Federico D’Urso, who has been responsible for organizing patients transfer during COVID-19 Outbreak 

During the COVID-19 pandemic, in order to ease the pressure on hospital structures, it was necessary to transfer several patients to biocontainment at the same time over short, medium and long distances. Civil literature relating to biocontainment transport by road, through ambulances with isolator or special bio-insulated vehicles, finds little evidence nowadays; this report aims at sharing best practices and encourage discussion.

An algorithm is hereby proposed to provide assistance personnel with an indication on which equipment to use, or which isolator to use, according to severity of infection, to protect staff and the environment while guaranteeing the highest level of patient care.

The lack of a decision-making algorithm means that the decision, both team and isolator, is at the discretion of those who have to manage the transport, instead the adoption of the algorithm for structuring the team to deal with the transfer of patients is useful for the organization of biocontainment transport.

The finding is the result of operations conducted on a sample of 1.407 transports carried out between December 2020 and March 2022 in Sicily. In this period of time, a total of 1.994 positive COVID-19 patients, or those suspected of being positive, were transferred by road of which no. 590 patients using two Isoark N36-4 isolators (Manufacturer Beth-El Industries, Zikhron Yaaqov, Israel, local Italian supplier INMM), no. 1.403 patients by means of a biocontainment van (Isoark Isolation Chamber equipped on IVECO to achieve a BioAmbulance, local Italian supplier INMM). 

Additionally, some transports concerned the extra-hospital areas conducted on a rotary wing using an Augusta Westland AW139/AW169 with a modified version of N 36 AVIO, under the direct supervision of the local Italian supplier INMM. A collaborative approach involving industries and operators in the ground helped with availability of equipment to face multiple differing needs.

Considering the number of transfers and the different severity of the patients to transport, with the priority in mind to ease burn out and fear for the unknown threat, the adoption of a common methodology to guide operators (mainly responsible for patients’ transfer) to orient them on the type of isolator to use according to the complexity of the transfer of patients to biocontainment, led to the construction of an algorithm based on the following parameters:

• Pathogen class: classification of pathogens based on the group they belong to; this change was introduced later to allow the use of the algorithm for pathogens other than SARS-COV-2. The class of the pathogen, or its suspicion, is determined by the facility requesting patients’ transport.
• Autonomy in patient walking (Walk): “autonomous patient” is someone who is able to walk independently, without any support, identified with W1 and “non-ambulatory” patient who is unable to move independently, identified with W2;
• Distance of transfer: “short range” transfers within the hospital itself, “medium range” transfers between hospitals, or facilities in general, with travel times of less than an hour and “long range” transfers lasting more than an hour. 
• Life support and/or monitoring: presence of patient monitoring systems such as multi-parametric monitors or vital support systems such as oxygen therapy, ventilators or infusion pumps, identified with W3;
• Type of transfer: route defined as starting point and arrival point, on this basis we distinguish three types of intra-hospital (between hospitals), extra-hospital (outside hospitals or between hospital and other type of structure) and air transport.

As described below, through the analysis of the parameters listed above, a level of complexity is reached, which classifies transports in the following way:

• Low complexity (C1 Transport), transport of W1 patients, without the need for life support;
• Intermediate complexity (C2 Transport), transport of patients undergoing monitoring and life support such as high flow oxygen;
• High complexity (C3 Transport), transports of critically ill patients with multiple life supports and monitored. Preparing the patient for the transfer is of fundamental importance, ensuring that all supports and monitors to which the patient is connected are correctly secured.

The algorithm (Figure 1) uses the arguments introduced, indicating to the operator the degree of complexity of the transport and recommending the correct isolation method to use and the team needed for the evacuation.

Figure 1 Biocontainment algorithm

The algorithm is made accessible to the operator through a flowchart whose resulting complexity determines the isolator and the team needed for the transport. 

Given the limited spaces inside the vehicles used for bio-transport, it is necessary to balance the size of the team considering the patient’s need for healthcare and the presence of appropriately trained technicians for the management of the isolator. (Table 1).

Depending on the complexity of the transfer, the team (only trained personnel) must be tailored to respond to the patient’s health needs. The team is made up of by the following figures:

• Biocontainment Technician: a purely technical figure who can be a rescuer or a healthcare worker trained in the use of isolators and who takes care of the logistics of the transfer;
• Team leader: the person who logistically manages the transport usually coincides with the most competent and technically expert person on the isolator.
• Coordinator: person external to the operation who verifies and manages the transport externally, is responsible for managing the team and planning any sequential or external activities to the transfer itself.
• Doctor: medical manager of the transfer, deals with the health management of the patient, carries out the health assessment prior to the transport of the patient, preparing the adequate resources for the purposes of the safe transfer, coordinates with the team leader to combine health needs with logistical ones.
• Nurse: in the absence of the doctor is responsible for the management of the patient, in the presence of the doctor they support them in their health management activities.

Table 1 Team composition

The tasks and consequent responsibilities are identified by the responsibility matrix, which applies only to the figures involved in each individual transport.

Below is the responsibilities matrix (Table 2) relating to transfers. (R responsible, V checks, C coordinates, CC collaborates).

Table 2 Responsibility matrix

Road transport in biocontainment poses important logistical and health challenges in a multidisciplinary team, a team that interacts during telephone contacts and in the preliminary stages of transport. The algorithm proposes to combine the logistical needs, given by the need for bio-isolation, and the healthcare needs given by the patient’s health conditions, all immersed in a context in which human healthcare/logistic resources were very limited.

Experience data: The application of the algorithm allowed the safe transfer of all 1.994 patients without complications for them or for the logistics team involved. Subsequent studies are necessary to confirm the safety and effectiveness of the same by extending this algorithm also to pathogens other than SARS-CoV-2 in order to find an optimal determination of the logistical and health assets of biocontainment transport.

By Federico D’Urso acted as volunteer within the Italian Red Cross