The future: CritiPORT

Context

Till date, NeoPORT has been used for 82 transports by the Amrita Institute of Medical Sciences (AIMS), Kochi. Supporting them has made us aware of some of its limitations, especially when the Receiver and the Transporter are housed in the same facility.

Therefore, we have conceptualized CritiPORT, an expanded version of NeoPORT. CritiPORT more thoroughly covers the administrative workflow of specialty-care hospitals (like AIMS) who receive complex cases from a broad network of Senders. These Senders themselves are well-equipped, and only use the system occasionally — when the medical needs of a patient exceed their capabilities. Thus, while the total volume of inbound transports is large, the source of these transports is spread out.

Further, CritiPORT proposes to expand the scope of the system from pediatric cardiac transports, to all emergency transports. Even when the type of transport changes, the core workflow — between Sender, Receiver and Transporter — does not change. Only the clinical data required changes.

We present CritiPORT in the form of a user story, set in and around AIMS.

Expandable blocks contain functional details. You do not have to open them.

Expandable blocks contain our interpretation of the user story, to arrive at functions that CritiPORT should provide. The full user story is accessible without having to open them.

The CritiPORT user story

Monday, 5:44 pm | Holy Family Hospital, Pediatric Ward

was worried. The most recent patient in his care — baby Reenu, all of two days old — had not gained weight in the past 24 hours. She had signs of cyanosis since her birth. In the past hour, her breathing has worsened.

As he completed his round of the pediatric unit, Dr. Thomas came to a decision. He needed help.

He reached for his phone.

Transports do not start with an app. They start with a clinical discussion, often enabled by personal connections. CritiPORT needs to start where the conversation ends.

“Dr. Thomas! How are you?” Simply hearing voice seemed to slow down Roy’s heart rate. They had met two months ago at a fetal cardiology workshop organized by Dr. Balu’s hospital, AIMS Kochi.

“No great, Dr. Balu”, Roy replied.

“What’s the matter?”

Dr. Thomas proceeded to summarize Reenu’s clinical history and present condition. “I think it is her heart,” he concluded.

“I agree with your assessment,” said Dr. Balu. “It seems like a congenital heart defect.”

“Do you have a bed free in the NICU?”

“Let me check. I’ll call you in five minutes.”

Dr. Thomas had just refilled his coffee — his third lukewarm cup of the day — when his phone beeped. A message has just come in:

“Please use the following link to create an emergency transport request to AIMS Kochi. This request has been pre-authorized by Dr. Balu Vaidyanathan. The link will expire in 30 minutes.”

Senders can be prompted to sign-up by the Receiver. The sign-in/ sign-up process shall use mobile phone numbers with an SMS OTP.

Once the phone number is validated, the Sender shall have to respond to two questions:

• Their full name

• Their institution: Select from a searchable dropdown list, or add as free-text

Because Senders can input free-text in the institution name, they can create duplicate hospitals. The Cluster administrator shall have the ability to merge duplicate institutions retroactively. This approach keeps the Sender workflow simple, and reduces sign-up effort.

The Cluster administrator is a clinical person based at the Receiving institution— ideally, someone in the ER department. They shall have complete control over who has access to the system, be it Senders, Receivers, or Transporters. They shall be able to delete records of past transports, and even initiate a transport request on behalf of a Sender — to support a Sender who does not have the time or means to access CritiPORT.

Also, to respond to a crisis where an ambulance has to be dispatched immediately, the Cluster administrator shall be able to override the need to get departmental approval.

By the time he finished scanning the message, Dr. Thomas’ phone rang. It was Dr. Balu. He was quick to get to the point. “I’ve asked the NICU to block a bed, and sent you a link to an electronic form. Once you fill it out, the ER folks will get on the job. They’ll inform you if an ambulance is available for dispatch.”

Dr. Thomas smiled to himself. “Is this another of your tech experiments, Dr. Balu?”

“Not me! You can lay the blame at door. It does seem to work, though.”

Dr. Thomas went back to his phone, and clicked on the link. It took him to a website, where he was prompted to fill in his name, institution, phone number and sign-in using an OTP.

The form itself was short — ten questions, most of which were multiple choice.

Only critical information — readily available to the Sender — shall be needed to initiate a transport. The Sender should have the option to add more clinical information — such as the frequency with which vitals must be monitored during transport — after the ambulance has been dispatched. This approach saves time.

To reduce optional fields, the Sender will select one of three types of forms at the outset:

1. Neonatal transport

2. Adult cardiac transport

3. Any other emergency transport

Finally, the Sender shall be able to request that the transport is accompanied by a nurse or physician. Honoring this request is at the Receiver’s discretion.

At the end, Dr. Thomas has the option to upload photos. He snapped a couple; covering the last 16 hours of vitals.

When he submitted the form, he received two text messages.

The first informed him that his request was in progress, and he could monitor the situation by logging in to the website.

The second gave him a link to download the completed form.

The Sender shall be able to download a print-friendly copy of their request. This helps them maintain a paper record and avoid duplicate data entry.

Dr. Thomas emailed the second message to himself, and walked over to his department chief’s office. It was time to bring Dr. Perumal into the loop.

Monday, 5:57 pm | AIMS, Emergency Room

Dr. Padma Nanammal glanced at her watch. “Another couple of hours to go”, she thought. “It will be nice to get home on time, for a change.” It had been a busy shift — she had finally been able to grab a chair after three straight hours on her feet, dealing with two victims of a road traffic accident. They were stable now, and being prepped for surgery.

She smiled. When hard work coincided with good work, even aching feet would not keep her spirits down.

She glanced at the desktop computer to her left. As if summoned by her attention, a notification popped up:

“Transfer request from Holy Family Hospital. Pre-authorized by Dr. Balu.”

CritiPORT needs to “know” the organizational structure of Receiver, so that incoming requests can be routed efficiently. Users who are Receivers shall be organized into departments. The Emergency department (ER) shall function as the Transporter.

Senders shall have three methods to initiate a request:

1. Contact a department

2. Contact the ER

3. Directly creates a request

Sender contacts department

As described in this narrative, if the Sender contacts the department, then CritiPORT shall enable the Receiver to send a pre-authorized link to the Sender. By doing so, the Sender indicates that they have verified that a bed is available.

To keep the information relevant, pre-authorized links shall expire after a short duration — say, 30 minutes.

Sender contacts ER

If the Sender calls the ER, then the ER shall verify that an ambulance is available, and send a pre-authorized link to the Sender. The ER shall also selects the department where bed availability has to be checked.

Direct request creation

If the Sender calls on a general helpline, then the respondent will share a link that asks the caller to create a Sender account, and then create a direct request.

Direct requests shall be sent to all users in the ER. If an ambulance is available, the ER shall authorize the request, select a department, and forward the request to it. All Receivers allocated to that department receive the notification.

Well, that saved her a trip to the fax machine, and a lot of shoe leather and phone tag. Previously, all requests for transports would come via a fax. Padma would then have to chase down individual departments to get an authorization that a ward bed was available.

Padma picked up the intercom and punched a few digits. A couple of rings later, a gravelly voice responded, “Ambulance dispatch, Kannan here.”

“K!” Padma knew that Kannan did not appreciate her habit of abbreviating names. “Need an ambulance. Neonatal transport, needs to go, let me see… yup, two-and-a-half hours away. Holy Family hospital. It’s pre-authorized, NICU is standing by.”

Kannan's voice dropped an octave. This was his all-business tone. “Princy is available. Will you go too?”

“I need to check. The baby is only two days old. She may need a physician on board to titrate her medicines.”

“Get here in five minutes.” Kannan hung up.

Dr. Nanammal stared at the beeping receiver for two heartbeats. Classic Kannan.

She shot up to her feet. “I need to call Dr. Balu,” she thought. “Now where can I find his num… oh, it’s in the app.”

Monday, 6:05 pm | Holy Family Hospital, Dr. Perumal’s office

“... and then he confirmed that a NICU bed was available,” said Dr. Thomas, as he finished updating Dr. Perumal. “Ma’am, I think we need to prep the patient for transport stat.”

“And talk to the parents,” said Dr. Rukmini Perumal. “I’ll ask Jaya to ring them up. They went back home barely an hour ago.” Somehow, Dr. Perumal knew the whereabouts of patients’ family members at all times. It was one of her many superpowers.

Roy’s phone beeped.

In addition to web app notifications, the Sender shall receive SMS notifications of all the critical events, such as ambulance departure, imminent arrival at Sending facility, and imminent arrival at Receiving facility.

Though transport is initiated by an individual, the Sending facility may need to make it accessible to many people. Therefore, like NeoPORT, all Senders connected to the same Sending facility will be able to view ongoing transports — but they will not receive notifications.

The initiator of the transport shall be able to nominate a colleague to have oversight of the transport. This is required to accommodate shift changes while the ambulance is still on the way to the Sending facility. If the nominee accepts, they will receive all further notifications.

To reduce notification volume, users shall have the option to snooze notifications when they are off duty. This feature shall be prominently displayed.

Ignoring Dr. Perumal’s pointed look, he checked it. “Ambulance is on its way. They have a doctor on board, too,” he said. “Dr. Padma Nanammal.”

“That’s good. Make sure we maintain the prostaglandin drip during transfer.”

“I already added that information to the digital form.”

“Yes, but double-check, please. And keep a few bottles of water handy for Ambulance personnel.”

Monday, 8:20 pm | Holy Family Hospital entrance

The AIMS ambulance was waved in quickly. Dr. Nanammal peered out of the window, and spotted a figure in a white coat waving… a bottle of water? She rolled down the window and stuck out her arm in acknowledgement.

12 minutes later, the transfer was complete. Dr. Nanammal switched from the shotgun seat to the back of the ambulance.

The ambulance’s phone already had the CritiPORT app open.

Handover will work just as it does in NeoPORT — Sender shall initiate it, and Transporter shall confirm it. Vitals tracking will also function as it does in NeoPORT.

She tapped on the app to confirm that the baby had been picked up. The screen changed, informing her that the next set of vitals had to be inputted in 30 minutes.

As the ambulance pulled out of the hospital, Dr. Nanammal looked back. The parents were getting into their car, preparing to follow.

Monday, 10:10 pm | AIMS ER entrance

Dr. Nanammal was startled when someone tapped on the rear window of the ambulance. She has just typed in the baby’s vitals, after a tense hour monitoring her respiratory rate and temperature, and titrating the prostaglandin dose. Thank goodness she has Dr. Balu and Dr. Thomas on

She looked up to see Kannan. “K…annan!”, she exclaimed, “Is the ER prepped?”

“Everything is ready. NICU team is here too.” Kannan replied.

The Receiver shall be notified when the Ambulance is five minutes away from the hospital. This feature is a carryover from NeoPORT.

Padma let out a sigh. Little Reenu would be in good hands. It felt good being a part of a team.

As the stretcher pulled away from the ambulance, she took a long, slow stretch. “Time to get home. Late again!” Padma’s growling stomach hastened her steps to the parking lot.

As she fished around for her keys, her phone beeped. A message awaited her:

“Please add clinical notes within 24 hours of the patient’s arrival.”

Clinical status of the infant on arrival enables us to calculate Ca-TRIPS score. As is the case in NeoPORT, Receivers will be prompted to fill this in within 24 hours. Any of the users in the ER or department shall be able to complete the form.

If the form is not filled within 24 hours, the transport will automatically be closed.