Dr. Mike Smith (Host): This is Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Mike. And today, we'll discuss the Behavioral Health Vehicle Program at Children's Health. With us today is Frank Milano, Director of Transport Services at Children's Health. Frank, thanks for joining me today.

Frank Milano: Sure, absolutely.

Host: It's great have you on. Tell us a little bit about the Behavioral Health Vehicles Program that you direct. Like what teams are involved, the services you provide, and the patients that you're serving.

Frank Milano: The Behavioral Health Program, we started launching this program back in-- the inception was around 2022, mid '22, but we started preparing in 2021. So, we developed the program to help facilitate our behavioral health patients from Children's Emergency Departments to inpatient psychiatric facilities throughout the Dallas Fort Worth area. Children's currently does not offer any inpatient pediatric psychiatric care. So, we have several inpatient facilities throughout the DFW area that works with us very well.

The types of patients, we really focus on patients aged eight to 18, who meet specific criteria to be able to transport via these vehicles. The vehicles are staffed with our paramedic team. We staff two paramedics. They're specially trained by our mental health experts at the facility on how to address unique and special needs of this patient population. And we focus on that to ensure the safety and comfort during the transport of both our patients and our staff.

Host: So, how do these vehicles differ from more traditional emergency vehicles? And if you're a patient inside one of these vehicles, what is that like?

Frank Milano: So, the vehicles are Ford expeditions. And we modify those expeditions with, number one, safety and comfort in mind to offer the best experience as possible for these patients. They're unlike traditional ambulances. Ambulances are, you know, there's a big box, some are vans. There's bright lighting inside those. Patients are typically on a stretcher with five-point restraints. And it can be intimidating for these patients depending on what their trigger points are.

So, these vehicles have been modified, like I stated earlier. They lack emergency lighting, they don't have sirens, there's no stretchers, there's no harsh overhead lighting. We actually installed LED lighting to control the environment, the temperament of the vehicle itself. The patients are seatbelted regularly as with a normal family vehicle. There is a caretaker, one of our paramedics rides in that middle seat next to them. So, the way that we design the whole experience is more controlled and personalized, tailored to the needs of these patients.

Host: You know, if you go to an emergency room, whether it's Parkland or you move over to Children's Health, we already know that emergency room wait times, Frank, can be pretty long, but they can be longer for mental health patients, because the more medically sick patients get seen or prioritized first. So, how has your service helped decrease those wait times around mental health patients?

Frank Milano: Many of these patients have wait times up to eight hours and even longer, waiting for a transport agency, whether it's children's health transport or an outside agency to be available to come transport them to get their definitive care. The patients that do not require ambulances, as in many of these patients, when ambulances are used, it does take valuable resources from the community for 911 responses, and it does take our services out of service for these patients as well, for other patients that need ambulance transports.

So once the patients are accepted to an inpatient facility, and they do meet criteria for the use of this vehicle, it allows us to use the ambulances and our critical care teams and our paramedic teams to respond to other medically ill children in the community. Again, this frees up the EMS community resources. And talking about time, the average time from disposition, which means the patient has been accepted to an inpatient facility, and for us to transport a behavioral health patient during the launch of this program, we've timed all these. The time was about eight hours, approximately eight hours. And that's looking at all the behavioral health patients that were admitted in our ED.

When we implemented this program, we looked at these times again. And from the mean disposition to transport time, it went from eight hours to 37 minutes. So, we have saved hundred and hundreds of hours and roughly 109 patient days using this vehicle.

Host: Yeah. In clinical medicine, Frank, we call that a significant difference. That's really good. It seems to me though, this is not just about time. It's about cost as well because prior to this program, like you said, they were having to use ambulances, right? It's not just time, it's cost as well.

Frank Milano: Yes, it's a much more efficient means of transporting this delicate patient population.

Host: You mentioned there were two paramedics, I think, in each car or each truck, right?

Frank Milano: Yes, sir.

Host: And what about the drivers? Do they have to go through any extra training or anything like that?

Frank Milano: All of our paramedics, they do a driving course annually. We vet our paramedics through a pretty rigid process here at Children's itself. But there's no other special driving courses for this vehicle. All of our medics get vetted through the ambulance program, and they take driving courses annually. They have to take defensive driving, and they do normal background checks with driving and driving records, which are reported on an annual basis.

Host: Does this program operate 24/7?

Frank Milano: Yes. Sir, this program does operate 24/7. So, the way that we configure the vehicle with 24/7 is we have a paramedic that drives and we have a paramedic that sits in the back seat with the patient. So, all the patients have to be between eight years old and 18 or actually 17 years and 364 days. All patients must be medically cleared. So, they can't have an IV. They have to be big enough to be properly secured by a seat belt. And we've implemented what's called an aggression tool, and I'll get into that here in a second. But they have to have an approved score on that aggression tool. And they need to be able to sit upright by themselves to be considered to be transported by this vehicle.

We launched the program by starting with the emergency room as a pilot, so we can work our bugs out, make sure that we have a fluent process. And we have since expanded this to both campuses, Dallas and Plano, and then into the pediatric floors in Plano.

The aggression tool is a validated tool that we worked with our mental health experts in the hospital, and it gives us an idea of the possibility of a patient trigger in the back of the vehicle. And they have to have an accepted score to be able to be transported by this vehicle. Otherwise, we will go by ambulance. And that's a crew safety.

Host: So, there's a standard operating procedure that's in place that determines when this vehicle is going to be dispatched.

Frank Milano: Yes, sir.

Host: Is this the only behavioral health vehicle program that you know in Texas? Is this unique?

Frank Milano: This is very unique. We started this in late '21, and then launched in '22, there was only one program in the nation who offered a similar type of service, but not like Children's had launched. We launched this on a much bigger scale, and we are currently the only program that I'm aware of in the state of Texas offering this type of service.

Host: Wow, that's fantastic. Now, besides the significant difference in wait time in emergency rooms, what are some other positive results you've seen with this program?

Frank Milano: So, we get really good responses from our patients. And like you said, with the decreased wait times, the whole environment is non-threatening. It's a non-threatening atmosphere for them. It's more like a family style vehicle, which improves their experience. We started with a designated team for these patients to make sure that we can offer the best experience for our patients and the best safety for our patients. So, we have since cross trained our whole entire team to be able to perform these transports and be able to assist these patients 24/7.

Host: So, when you look at the program the way it is today, Frank, and it sounds like, you know, you're directing an amazing program for the North Texas area, what are your goals or hopes for innovation and maybe the future of this program?

Frank Milano: We would love to have this program expand to the entire organization. There's a little bit different processes that we have to look at when you're looking at inpatient at the Dallas campus. So, we currently serve both emergency rooms. We serve our pediatric floor in Plano. And for the future, we want to expand this to the Dallas campus on all of our pediatric floors where patients will meet criteria and allow us to transport them.

We started the program with two vehicles. We've expanded to four vehicles, so we've really increased the number of vehicles for our use with projecting the future that we're going to be much busier and be able to transport a lot more patients.

Host: Hey, thank you so much for your time, Frank, with us today. This has been fantastic. You know, before we wrap up, is there anything else that you would like to share about this program?

Frank Milano: Thank you, Mike. It's been my pleasure. It's been really good today. This is a very innovative idea that we were able to bring to fruition with the collaboration of many departments within Children's, and actually with the state of Texas. We collaborated with five or six different departments within the hospital. We've been talking to the state to ensure that we're following the guidelines as the state deems necessary. And actually the city of Dallas, we're very proud of this program, and that it meets the special population in a more friendly way and child-friendly way. You know, we're always looking for ways to improve our care for the children in the community.

And to end, I'd like to share is we received a grant from the state, and when I talked about expanding our fleet, that was how we were able to our fleet to four vehicles. We were able to hire more staff, do training, outfit the vehicles. So, in the future, we are hoping that we can expand to the rest of the hospital and take care of our community.

Host: Hey, Frank, excellent job. I'm so proud of what you're doing because I know this is such an amazing program. service. So, thanks for coming on. Hey, thanks for listening to Pediatric Insights: Advances, and Innovations with Children's Health, where we explore the latest in pediatric care and research. You can find more information at childrens.com/behavioralhealth. And if you found this podcast helpful, please rate and review or share the episode. And please follow Children's Health on your social channels.