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Creation of a Guide for the Transfer of Care of the Malignant Hyperthermia Patient from Ambulatory Surgery Centers to Receiving Hospital Facilities

Larach, Marilyn Green, MD, FAAP*; Dirksen, Sharon J. Hirshey, PhD; Belani, Kumar G., MBBS, MS; Brandom, Barbara W., MD*,§; Metz, Keith M., MD, JD, MSA; Policastro, Michael A., MD, FACEP; Rosenberg, Henry, MD†,#,**; Valedon, Arnaldo, MD††,‡‡; Watson, Charles B., MD, FCCM§§

doi: 10.1213/ANE.0b013e3182373b4a
Ambulatory Anesthesiology: Special Article
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CLINICAL PROBLEM: Volatile anesthetics and/or succinylcholine may trigger a potentially lethal malignant hyperthermia (MH) event requiring critical care crisis management. If the MH triggering anesthetic is given in an ambulatory surgical center (ASC), then the patient will need to be transferred to a receiving hospital. Before May 2010, there was no clinical guide regarding the development of a specific transfer plan for MH patients in an ASC.

MECHANISM BY WHICH THE STATEMENT WAS GENERATED: A consensual process lasting 18 months among 13 representatives of the Malignant Hyperthermia Association of the United States, the Ambulatory Surgery Foundation, the Society for Ambulatory Anesthesia, the Society for Academic Emergency Medicine, and the National Association of Emergency Medical Technicians led to the creation of this guide.

EVIDENCE FOR THE STATEMENT: Most of the guide is based on the clinical experience and scientific expertise of the 13 representatives. The list of representatives appears in Appendix 1. The recommendation that IV dantrolene should be initiated pending transfer is also supported by clinical research demonstrating that the likelihood of significant MH complications doubles for every 30-minute delay in dantrolene administration (Anesth Analg 2010;110:498–507).

STATEMENT: This guide includes a list of potential clinical problems and therapeutic interventions to assist each ASC in the development of its own unique MH transfer plan. Points to consider include receiving health care facility capabilities, indicators of patient stability and necessary report data, transport team considerations and capabilities, implementation of transfer decisions, and coordination of communication among the ASC, the receiving hospital, and the transport team. See Appendix 2 for the guide.

Published ahead of print November 3, 2011

Authors' affiliations are listed at the end of the article.

Funding: No financial support was required to develop this manuscript. Development of the guide being discussed was jointly supported by The Malignant Hyperthermia Association of the United States and the Ambulatory Surgery Foundation.

See Disclosures at end of the article for author Conflicts of Interest.

Reprints will not be available from the authors.

Address correspondence to Marilyn Green Larach, MD, FAAP, MHAUS, P.O. Box 1069, 1 N. Main Street, Sherburne, NY 13460-1069. Address e-mail to mlarach@gmail.com.

Accepted August 30, 2011

Published ahead of print November 3, 2011

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WHY WAS THIS GUIDE DEVELOPED?

Ambulatory surgical centers (ASCs) provide surgical care to many patients. By design, these units have more limited resources and capabilities than large hospitals. This necessitates planning for unexpected but possibly dangerous or life-threatening events that require transfer of ambulatory patients to a hospital for advanced treatment. Acute malignant hyperthermia (MH) is one such event.

An MH (MIM No. 145600)a event is a life-threatening hypermetabolic condition resulting from a genetic sensitivity of skeletal muscles to volatile anesthetics and depolarizing neuromuscular blocking drugs, which may occur during or after anesthesia. Because of incomplete reporting and variable presentation,1 the North American MH mortality rate is uncertain but not zero.2 The observed MH morbidity rate is 35% and includes coma, cardiac dysfunction, pulmonary edema, renal dysfunction, disseminated intravascular coagulation, and hepatic dysfunction. The importance of rapid therapeutic intervention is emphasized by the finding that the likelihood of MH complications triples for every 2°C increase in maximal temperature and doubles for every 30-minute delay in dantrolene administration.3

The prevalence of MH has been estimated at approximately 1 per 100,000 New York surgical inpatients4 and 0.3 per 100,000 New York and New Jersey ambulatory surgery patients.b Although patients of all ages may be susceptible to MH, results of a recent study of 269 individuals experiencing an MH event revealed a median age of 22 years (first quartile 10 years, third quartile 41 years, range 116 days to 78 years).3

In 2006, there were an estimated 35 million surgical visits for ambulatory procedures in the United States with 15 million of them occurring in freestanding ASCs. Compared with a decade earlier, freestanding ambulatory surgery center (ASC) visit rates tripled whereas hospital-based surgery center visit rates remained largely unchanged. If we extrapolate the MH prevalence figures for New York and New Jersey ambulatory surgery patients to all freestanding United States ambulatory surgery patients, then 47 MH events may be expected to occur in stand-alone ASCs annually. Although the 2006 National Survey of Ambulatory Surgery specifically asked about MH symptoms during or after an anesthetic, an estimate of their frequency based on the data collected was considered unreliable because of record-keeping constraints regarding patient privacy.5,c

The diagnosis and treatment of MH have been well described.6,7 However, because MH is not a frequent occurrence, it is strongly recommended that all staff members at all health care facilities using MH triggering agents periodically review the key elements of the diagnosis and treatment of this potentially life-threatening disorder. Furthermore, ASCs are required by a voluntary accrediting agency, the Accreditation Association for Ambulatory Health Care, Inc., to conduct drills on the recognition and treatment of MH and to have appropriate drugs and equipment to treat MH available.8 It is expected that patients experiencing MH in ASCs will be critically ill and will require transfer to a receiving hospital facility for on-going clinical management after initial diagnosis and immediate treatment in the ASC.

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WHAT OTHER STATEMENTS ARE AVAILABLE ON THIS TOPIC?

The American Academy of Pediatrics has long recognized the need for guidelines for the transport of critically ill infants and children.9 Their 2007 Guidelines Manual addresses the need for “optimal initial medical evaluation and stabilization, timely and appropriate transport care, and specialized referral center management …” to “… improve outcomes in critically ill or injured neonates, infants and older children.”10 They advocate that “transition of care from referring hospital to transport team to receiving center should be seamless, without compromise in the level of care or monitoring. This approach differs from the ‘swoop and scoop' … practice that may be appropriately applied during prehospital transport of a patient from an accident scene to an emergency department ….”11

Recognizing that critically ill patients are at increased risk for morbidity and mortality during transport, the American College of Critical Care Medicine and the Society of Critical Care Medicine published guidelines in 2004 for the inter- and intrahospital transport of critically ill patients. These state that “there is no evidence to support a ‘scoop and run' approach to the interhospital transport of critically ill patients.” They urge referring facilities to “… begin appropriate evaluation and stabilization to the degree possible to ensure patient safety during transport.” Their guidelines mandate “… careful planning, the use of appropriately qualified personnel, and selection and availability of appropriate equipment.” They advocate that during transport there be “… no hiatus in the monitoring or maintenance of a patient's vital functions” and that personnel and equipment be selected to provide for “any ongoing or anticipated acute care needs of the patient.”12

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HOW AND WHY DOES THIS STATEMENT DIFFER FROM EXISTING GUIDELINES?

Neither the American Academy of Pediatrics nor the American College of Critical Care Medicine specifically addresses the critically ill MH patient. Furthermore, the existing protocol for the treatment of MH patients, Emergency Therapy for MH,d developed by the Malignant Hyperthermia Association of the United States (MHAUS) expert anesthesiologists, does not address the unique challenges faced by ASC personnel as they plan for the immediate care and ensuing transfer of an MH patient. Therefore, in 2008, MHAUS and the Ambulatory Surgery Foundation (ASF), which is affiliated with the Ambulatory Surgery Center Association, decided to jointly develop this guide for the transfer of MH patients from ASCs to receiving hospitals.

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HOW WAS THIS GUIDE DEVELOPED?

MHAUS and ASF nominated individuals to participate in an expert panel, with members representing different areas of medical expertise along the transfer pathway, from the ASC to the transport vehicle to the arrival at the receiving facility (usually the emergency department). Along with MHAUS and ASF, 3 additional organizations were asked to nominate an individual to participate on this panel: the Society for Ambulatory Anesthesia, the Society for Academic Emergency Medicine, and the National Association of Emergency Medical Technicians. Ultimately, a panel of 13 members developed this guide for a transfer plan specific for MH that allowed for care continuation in these critically ill patients.

Panel members included 8 anesthesiologists with expertise in MH (MH Hotline consultants and MHAUS professional advisory committee members), pediatric and adult anesthesia, inpatient and ASC anesthesia (nominated by the Society for Ambulatory Anesthesia); a certified registered nurse anesthetist; an emergency medicine physician (nominated by the Society for Academic Emergency Medicine); an emergency medical technician (nominated by the National Association of Emergency Medical Technicians); an ASC nurse/administrator; and a nurse/ASC consultant (nominated by ASF) (Appendix 1).

The initial assessment used a modified Delphi process13,14 with questionnaires depicting various transfer scenarios pertaining to the care and transfer of an MH patient from an ASC to a local/regional hospital. A literature search produced no evidence-based documents that specifically addressed MH transfer issues. After a review of existing clinical practice guidelines, opinions were sought about various factors affecting transfer decisions such as the clinical condition of the patient, ability of the ASC staff to travel with the patient during transfer, distance from the ASC to the nearest receiving hospital, and the transport team's level of expertise. Four anonymous iterations over a 5-month period failed to produce agreement among panel members on a single transfer protocol to govern all ASCs because of the substantial variability among ASCs, transport services, receiving health care facilities, and the clinical presentation of MH itself.

After a conference call among panel members and representatives from MHAUS and ASF, an alternative process was proposed with one panel member (MAP) agreeing to provide an initial draft of a template document. The template focused on key considerations at all phases of patient care, from the primary ASC response to the triggered event with treatment initiation to transport team logistics and equipment considerations, and finally, to the receiving health care facility transfer procedures. The goal was to develop a document to help each ASC achieve optimal streamlined care with particular attention to the unique medical requirements of the surgical/medical patient with an MH crisis. Ultimately, the intent of the final guide document was to assist each ASC in the development of its own personalized MH transfer plan.

During the development of this guide, each category of care was reviewed and revised by the expert panel. Later in the process, a list of patient stability indicators was created. The panel also agreed that IV dantrolene therapy should be initiated before patient transfer. Refinement of the initial template required several months of conference calls with follow-up e-mails among panel members. Furthermore, a 30-day public comment period produced additional suggestions and recommendations for the panel members to consider, resulting in a final set of revisions. The final version of the guide was approved by all panel members and the ASF and MHAUS boards. In the Spring of 2010, 18 months after this project was initiated, the MH transfer of care guide was jointly released by MHAUS and ASF (Appendix 2, the Guide).

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WHAT ARE THE IMPLICATIONS OF THIS GUIDE?

The best way to increase the chances for a successful patient outcome in any transfer situation is to be prepared. For MH transfers, ASCs should review their own capabilities and resources, as well as those of the transport team and receiving facility. Prior planning regarding who will make decisions during an MH emergency, and staff awareness of their respective roles, will go a long way in assuring preparedness and providing the patient with the best chance for prompt diagnosis, appropriate treatment, and appropriate monitoring during the transfer. Additionally, individual ASCs may wish to review and follow up all MH transfer events through their quality outcomes monitoring program with the aim of improving or changing their MH transfer plan. Some ASCs may wish to incorporate their MH transfer plan into their more general transfer plan that is required already by many states, certifying bodies such as the Centers for Medicare and Medicaid Services, and by voluntary accrediting bodies.

The transfer guide developed for ASCs may also facilitate the management of MH crises in freestanding non-ASC facilities such as surgical or dental offices. MH deaths from events originating in non-ASC ambulatory facilitiese highlight the danger of the “scoop and run” approach to patient transfer.

Aspects of this guide (e.g., patient stability indicators, transport team and receiving hospital capabilities) may also be relevant to both intrahospital transport of the critically ill MH patient and choice of care unit after an MH event that starts in a hospital-based anesthetizing location. Many researchers have noted the inherent risks involved with intrahospital transport of critically ill patients.1517 Many advocate for the use of adapted equipment, checklists, and proper training programs.18

Although many guidelines are prepared and released by professional societies, their impact is not always clear and may depend on dissemination strategies including monitoring and evaluation of milestones and goals.1921 Thus far, a preliminary MHAUS survey of 29 ASCs that requested the MH transfer of care guide reveals that most have reviewed and/or revised their existing MH transfer plans and report forms and have checked on supplies in their MH treatment cart, including dantrolene. Only some of those ASCs have found it necessary to revise their agreements with a hospital receiving facility or to contact transport services. Of note, one ASC has reported that their procedures now include emergency medical service responders in their MH drills.f A formal survey study is under discussion to evaluate the impact of this guide once ample time is allowed for ASCs to incorporate the guide into their own transfer plans. Development of a checklist for use by ASCs during transport of the suspected MH patient is under discussion as well.

In summary, a 13-member expert panel collaborated to create a guide for the transport of MH patients from ASCs to receiving health care facilities to improve patient outcomes. This guide may also help improve the safety of transferring MH patients from anesthetizing locations in physicians' offices, hospitals, and other facilities to facilities that can institute the care required for successful management.

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AUTHOR AFFILIATIONS

From *The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States, Pittsburgh, Pennsylvania; †The Malignant Hyperthermia Association of the United States, Sherburne, New York; ‡School of Medicine, University of Minnesota, Minneapolis, Minnesota; §Children's Hospital and the University of Pittsburgh, Pittsburgh, Pennsylvania; ∥Great Lakes Surgical Center, LLC, Southfield, Michigan; ¶Qualified Emergency Medicine Specialists, Inc., Cincinnati, Ohio; #Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, New Jersey; **Columbia University, New York, New York; ††Ambulatory Surgery Division, First Colonies Anesthesia Associates, LLC, Reisterstown, Maryland; ‡‡Ambulatory Surgery Center Association and Ambulatory Surgery Foundation, Alexandria, Virginia; and §§Bridgeport Hospital, Yale-New Haven Health System, Bridgeport, Connecticut.

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DISCLOSURES

Name: Marilyn Green Larach, MD, FAAP.

Contribution: This author helped write the manuscript.

Attestation: Marilyn Green Larach approved the final manuscript.

Conflicts of Interest: Marilyn Green Larach received honoraria from the Malignant Hyperthermia Association of the United States, a 501(c)(3). This honorarium was given for helping to develop a Transfer of Care Guide for MH Patients in Ambulatory Surgery Centers. Its award was not contingent on any publications.

Name: Sharon J. Hirshey Dirksen, PhD.

Contribution: This author helped write the manuscript.

Attestation: Sharon J. Hirshey Dirksen approved the final manuscript.

Conflicts of Interest: Sharon J. Hirshey Dirksen works for the Malignant Hyperthermia Association of the United States, a 501(c)(3). MHAUS jointly (with the Ambulatory Surgery Foundation) sells the Transfer of Care Guide in poster format. This publication could affect sales of the guide in poster format.

Name: Kumar G. Belani, MBBS, MS.

Contribution: This author helped write the manuscript.

Attestation: Kumar G. Belani approved the final manuscript.

Conflicts of Interest: Kumar G. Belani received honoraria from Cadence Pharmaceuticals, received honoraria from Nonin Medical, Inc., and received honoraria from Oakstone Publishing. He is a speaker for Cadence Pharmaceuticals and Nonin Medical, Inc. He is a coordinating editor for Practical Reviews in Anesthesiology (Oakstone Publishing). He has received research funding from Augustine Biomedical + Design, LLC. His authorship in this article will add to his academic productivity and may have an indirect influence on his compensation from the University of Minnesota.

Name: Barbara W. Brandom, MD.

Contribution: This author helped write the manuscript.

Attestation: Barbara W. Brandom approved the final manuscript.

Conflicts of Interest: Barbara W. Brandom received research funding from the Malignant Hyperthermia Association of the United States, a 501(c)(3) and reported a conflict of interest with MHAUS. She has received research funds and travel fees from MHAUS and she is director of the North American Malignant Hyperthermia Registry which is a subsidiary of MHAUS. She does receive a small compensation from her employer (University of Pittsburgh Physicians) for every peer-reviewed publication in which she is a coauthor.

Name: Keith M. Metz, MD, JD, MSA.

Contribution: This author helped write the manuscript.

Attestation: Keith M. Metz approved the final manuscript.

Conflicts of Interest: Keith M. Metz reports a conflict of interest with the Ambulatory Surgery Center Association, a 501(c)(6), and the Ambulatory Surgery Foundation, a 501(c)(3). He is a board member of both organizations.

Name: Michael A. Policastro, MD, FACEP.

Contribution: This author helped write the manuscript.

Attestation: Michael A. Policastro approved the final manuscript.

Conflicts of Interest: Michael A. Policastro consulted for the Drug Enforcement Agency, consulted for DYAX, and received honoraria from the Neuroleptic Malignant Syndrome Information Service, a unit of the Malignant Hyperthermia Association of the United States, a 501(c)(3). He is a consultant for the Drug Enforcement Agency and a member of the drug safety monitoring board for the Ecallantide study of DYAX.

Name: Henry Rosenberg, MD.

Contribution: This author helped write the manuscript.

Attestation: Henry Rosenberg approved the final manuscript.

Conflict of Interest: Henry Rosenberg reported no conflicts of interest.

Name: Arnaldo Valedon, MD.

Contribution: This author helped write the manuscript.

Attestation: Arnaldo Valedon approved the final manuscript.

Conflicts of Interest: ArnaldoValedon reported a conflict of interest with the Ambulatory Surgery Center Association, a 501(c)(6) and the Ambulatory Surgery Foundation, a 501(c)(3). He is a board member.

Name: Charles B. Watson, MD, FCCM.

Contribution: This author helped write the manuscript.

Attestation: Charles B. Watson approved the final manuscript.

Conflict of Interest: Charles B. Watson reported no conflicts of interest.

This manuscript was handled by: Peter S. A. Glass, MB, ChB, and Steven L. Shafer, MD.

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ACKNOWLEDGMENTS

The authors thank Debra Stinchcomb, RN, BNS, CASC, Vice Chair of the Ambulatory Surgery Foundation Board (Alexandria, VA), for her helpful review of the manuscript. The authors thank Dianne M. Daugherty, Executive Director of the Malignant Hyperthermia Association of the United States (Sherburne, NY), for her assistance in the development of the manuscript.

a Online Mendelian Inheritance in Man. Available at: http://www.ncbi.nim.nih.gov/omim/145600. Accessed January 8, 2011.
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b Brady JE, Sun LS, Rosenberg H, Li G. Prevalence of malignant hyperthermia due to anesthesia in ambulatory surgery patients. American Society of Anesthesiologists Annual Meeting, 2009:A1521. Available at: http://www.asaabstracts.com/strands/asaabstracts/searchArticle.htm. Accessed March 29, 2011.
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c Karen A. Cullen, PhD, MPH, Health Scientist, Centers for Disease Control and Prevention, Atlanta, GA, written communication, January 10, 2011.
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d Available at: www.mhaus.org (for medical professionals; MH crisis management; MH protocol poster sample). Accessed May 6, 2011.
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e Personal phone communications from Henry Rosenberg, MD, President of MHAUS, Sherburne, NY, and Barbara W. Brandom, MD, Director, The North American Malignant Hyperthermia Registry of MHAUS, Pittsburgh, PA, March 10, 2011.
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f Survey results speak to value of “transfer of care guidelines.” The Communicator 2011;29:(2),4.
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g Affiliations listed are those pertaining to the period of the Transfer of Care Guideline Development Process.

h This material is adapted and reproduced from the document, Transfer Plans for Suspected MH Patients: Guidance for Ambulatory Surgical Centers with Regard to the Development of Emergent Malignant Hyperthermia Transfer Plans for Suspected MH Patients, with the written permission of the Ambulatory Surgery Foundation and the Malignant Hyperthermia Association of the United States.
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i MHAUS and the Foundation have developed these guidelines utilizing general consensus methods and recognized experts in the field. These guidelines are for reference, guidance, and informational purposes only, are implemented on a voluntary basis, and do not represent mandatory standards or requirements. ASCs should conduct their activities based on independent medical judgment. Neither MHAUS, the Foundation, nor the Ambulatory Surgery Center Association make any recommendations or exhortations regarding the conduct of ASCs, and they hereby disclaim all liability for any claims, losses, or damages in connection with use or application of these guidelines. The guidelines are the joint property of MHAUS and the Foundation. Reproduction or redistribution in whole or in part without the express written consent of MHAUS or the Foundation is prohibited. Copyright 2010 MHAUS and Ambulatory Surgery Foundation.
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APPENDIX 1: TRANSFER OF CARE PANEL MEMBER NAMES, AFFILIATIONS,g AND ROLE Kumar G. Belani, MBBS, MS

  • Professor of Anesthesiology, Medicine and Pediatrics, School of Medicine, Professor of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, MN
  • MHAUS MH Hotline Consultant
  • Physician Representative, Society for Ambulatory Anesthesia
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Barbara W. Brandom, MD

  • Professor of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
  • Director, The North American Malignant Hyperthermia Registry of MHAUS
  • Physician Representative, MHAUS Professional Advisory Council
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Cheryl Fielder, RN

  • Administrator, Peachtree Orthopaedic Surgery Center, Atlanta, GA
  • Administrative Representative, Ambulatory Surgery Center Association
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Marilyn Green Larach, MD, FAAP

  • Professor of Anesthesiology, Penn State College of Medicine, Hershey, PA
  • Senior Research Associate, The North American Malignant Hyperthermia Registry of MHAUS, Member, Professional Advisory Council of MHAUS
  • Principal Investigator
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E. Jane McCarthy, CRNA, PhD, FAAN

  • Director of the District of Columbia Association of Nurse Anesthetists' Annual Anesthesia Safety Conference
  • CRNA Representative, Member, Professional Advisory Council of MHAUS
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Keith M. Metz, MD, JD, MSA

  • Medical Director, Great Lakes Surgical Center, LLC, Southfield, MI
  • Physician Representative, Ambulatory Surgery Center Association
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Anthony Piccone, MD

  • Medical Director, Dry Creek Surgical Center, Englewood, CO
  • Board of Directors, Metro Denver Anesthesia, PC
  • Quality Council Representative, Symbion Ambulatory Resource Group
  • Physician Representative, Ambulatory Surgery Center Association
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Michael A. Policastro, MD, FACEP

  • Assistant Professor, Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
  • Medical Consultant, Cincinnati Drug and Poison Information Center
  • Physician Representative, Society for Academic Emergency Medicine
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Henry Rosenberg, MD

  • Director, Department of Medical Education and Clinical Research, St. Barnabas Medical Center, Livingston, NJ
  • President of MHAUS, Sherburne, NY
  • Physician Representative, MHAUS MH Hotline Consultant
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Debra Saxton Stinchcomb, RN, BSN, CASC

  • Consultant, Progressive Surgical Solutions, Farmington, AR
  • Administrative Representative, Ambulatory Surgery Foundation
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Arnaldo Valedon, MD

  • Chief and Managing Partner, Ambulatory Surgery Division, First Colonies Anesthesia Associates, LLC, Reisterstown, MD
  • Board Member, Foundation for Ambulatory Surgery in America
  • Surveyor, Accreditation Association for Ambulatory Health Care
  • Physician Representative, Ambulatory Surgery Center Association
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Charles B. Watson, MD, FCCM

  • Associate Clinical Professor, Department of Anesthesiology, University of Connecticut Health Center School of Medicine
  • Chairman, Department of Anesthesiology, The Bridgeport Hospital, Bridgeport, CT
  • Physician Representative, MHAUS MH Hotline Consultant
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Mark Weber, NREMT-P

  • Department Director, Emergency Medical Services Coordinator, Golden Heart Services, Heart of America Medical Center, Rugby, ND
  • Member of Board of Governors, National Association of Emergency Medical Technicians
  • President, North Dakota Emergency Medical Services Association
  • EMT Representative, National Association of Emergency Medical Technicians
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APPENDIX 2H: GUIDANCE FOR AMBULATORY SURGICAL CENTERS WITH REGARD TO THE DEVELOPMENT OF EMERGENT MALIGNANT HYPERTHERMIA TRANSFER PLANS FOR SUSPECTED MH PATIENTS

The following diagram and accompanying text represent guidelines issued by the Ambulatory Surgery Foundation, affiliated with the Ambulatory Surgical Center Association (ASC Association), and the Malignant Hyperthermia Association of the United States (MHAUS) to be utilized in the development of an Emergent MH Transfer Plan for suspected MH patients at ambulatory surgery centers (ASCs).i These guidelines are intended to assist each ASC through the development of its own individualized Emergent MH Transfer Plan, taking into account the resources and capabilities available to each ASC. It is advisable for each ASC to enter into a transfer agreement with a receiving facility that meets state, federal and accreditation requirements.

Due to the variety of state laws and the composition of emergency transport teams, it is not possible to recommend a specific protocol that will serve the transport needs of all ASCs across the country. Therefore, a listing of potential clinical associated problems and therapeutic intervention capabilities for consideration will be noted versus dictation of a specific transport protocol. The specific characteristics of each patient encounter and accompanying patient care needs may dictate alternative care, transport, or choice of healthcare receiving facility, as determined by the treating clinician.

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REFERENCES

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2. Larach MG, Brandom BW, Allen GC, Gronert GA, Lehman EB. Cardiac arrests and deaths associated with malignant hyperthermia in North America from 1987 to 2006: a report from The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States. Anesthesiology 2008;108:603–11
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4. Brady JE, Sun LS, Rosenberg H, Li G. Prevalence of malignant hyperthermia due to anesthesia in New York State, 2001–2005. Anesth Analg 2009;109:1162–6
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