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Transfer of the critically ill adult patient
CRITICAL ILLNESS AND INTENSIVE CARE: I
Transfer of the critically ill adult patient
consideration the objective risks of transporting a critically unwell patient this is often difficult to achieve and requires an experienced and well-trained transfer team as a starting point. Generally speaking in the UK the vast majority of transfers are carried out by junior anaesthetists who will typically have received limited transfer training and will often have little in the way of transfer experience. This has both patient safety and resource implications.
David Hunt Kate Prior
Abstract
Types of transfer
Patient transfer has resource ramifications and is an important public health issue. With increasing centralization of specialist services and the advent of regional trauma networks the requirement for patient transfer is ever present. Every year in the UK over 11,000 intensive care patients are transferred and the majority of these transfers are facilitated by a team from the transferring hospital as opposed to being carried out by a dedicated retrieval team. Transferring a critically ill patient is a process involving inherent risk, so prior preparation around planning for a safe transfer is essential both in terms of anticipating potential problems, mitigating against them and ensuring clear and timely communication with the accepting hospital and respective specialties responsible for the patient. In the longer term, training of staff is essential in order to reduce instances of harm to patients. This article provides an overview of the different types of patient transfer, the associated hazards, human factors around decisionmaking, communication, equipment and organization.
There are three main categories of patient transfer, as follows. 1. Primary transfer to hospital is normally undertaken by land ambulance crews. For trauma patients who warrant a response from a helicopter emergency medical service (HEMS), this phase may involve critical care interventions and transport by helicopter with an advanced medical practitioner. 2. Following initial resuscitation and stabilization, secondary transfer occurs when specialist care is required and not available locally. This would normally occur by land ambulance, but could utilize a helicopter or fixed-wing aircraft depending on the distance involved, weather, urgency, traffic and the location of suitable landing sites among other factors. There are longstanding guidelines available for the transfer of patients via aeromedical means. A secondary transfer may also have to occur if locally available resources become overwhelmed or are temporarily unavailable. 3. Tertiary transfers occur for non-clinical reasons and should be avoided unless absolutely necessary. This type of transfer is usually for patients wishing to be repatriated for social reasons, such as being closer to friends and family and those who face funding issues and those who are injured abroad and need to be repatriated to the UK.2 Transfers can be further subdivided into two subcategories: intraand inter-hospital. This article will focus only on inter-hospital transfer although the same guiding principles will apply to intra-hospital transfers also.
Keywords Centralization; communication; decision-making; organization; preparation; risk; training
Introduction The requirement for patient transfer is an inevitable consequence of the centralization of acute services and increased utilization of highly specialized services such as extracorporeal membrane oxygenation (ECMO). Rarely, transfers can occur if locally available resources are exhausted or temporarily unavailable but this should, of course, be avoided unless absolutely necessary as it is clearly not in the best interests of a patient to undergo a potentially avoidable transfer. The over-arching aim of the vast majority of transfers should be to achieve a higher level of care for the patient. The benefit of transfer for specialized treatment is well established for trauma and cardiology patients but it has taken a long time to achieve widespread acceptance of this in the UK, particularly with regards to the former patient group. It has also been demonstrated that the benefits of transfer to a specialist centre are not always related to receiving the intervention for which the transfer was initiated.1 The transfer team strives to ensure that the care a patient receives in transit is equivalent to that they receive in an intensive care unit. Taking into
Decision-making and human factors Clear communication is required early on in the process of transfer. Sadly, disjointed planning and communication is a common occurrence during patient transfers leading to adverse incidents. To help avoid this it is essential that consultants are involved in inter-hospital critical care transfers. It has already been said that a transfer should only occur if it is likely to result in an improvement in the patient’s overall condition, so it is vital that the risks and the benefits are evaluated by an experienced clinician with advice from the receiving specialists. The reason for the transfer should be established and, if it is for anything other than an improvement in patient care, this becomes, in part, an ethical decision which should be clearly communicated to the patient, if they have capacity, and their family. After the decision to transfer has been made delays and complex organizational issues can occur. One study from Australia has demonstrated that, on average, 4.7 telephone calls are required to be made per patient, which when one considers the requirement for concurrent patient resuscitation is a significant burden of responsibility.3
Major David Hunt FRCA MCEM RAMC is an ST6 in Anaesthetics and Intensive Care Medicine at King’s College London, UK. Conflicts of interest: none declared. Surgeon Commander Kate Prior FRCA RN is a consultant in Anaesthetics and Major Trauma at King’s College London, UK. Conflicts of interest: none declared.
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CRITICAL ILLNESS AND INTENSIVE CARE: I
Perform an arterial blood gas 15 minutes before departure and check the patient is adequately resuscitated before departure.
Where is the patient going? This point is critical and must be clearly articulated between the transfer team and the receiving hospital. The resuscitation room of the emergency department should ideally be avoided, but does provide possibilities for stabilization should the patient have deteriorated prior to onward movement. There should be no delay in transfer to an area for definitive treatment such as a specialist intensive care unit or operating theatre. All parties must be clear about the exact destination requiring an accurate description of the location to be communicated to all parties including the patient’s family. The receiving hospital should be made aware of the patient’s departure, updated about any issues that occur in transit and informed prior to the patient arrival with an estimated time of arrival to allow for tasks such as a trauma call to be put out or specialists to be summoned to theatre.
To retrieve or transfer? Retrieval teams are advocated by the Department of Health.6 A team from University College London compared outcomes of patients transferred by a specialist retrieval team (group A) and those transferred by standard means, a team from the referring hospital, (group B). There were no differences in demographic characteristics or severity of illness between the two groups. However, significantly more patients in group B than in group A were severely acidaemic (pH <7.1: 11% vs. 3%, p <0.008) and hypotensive (mean arterial pressure (MAP) <60: 18 % vs. 9%, p <0.03) on arrival. There were more deaths within the first 12 hours after admission with 7.7 % deaths (7/91) in group B transfers vs. 3% (5/168) in group A.7 A university hospital in the Netherlands conducted a prospective study comparing patient physiology in those patients transferred by their newly established mobile intensive care unit (MICU) with prospectively collected data on patients transferred by ambulance in 2005 in the same region. Distribution of differences in arterial blood gases during transfer in 2009 versus 2005 showed significantly better values for the variables pH, paO2 and paCO2 in the patient group transferred by MICU, using the Independent-Samples t-test (a <0.05). There was also a significant increase in the number of patients who were transferred conventionally that required emergent advanced respiratory support immediately on arrival in the receiving ITU.8 The retrieval model has a much stronger body of evidence for the transport of paediatric patients and is much more widely practised and it would seem intuitive that at least some of this experience should be transferable to adult patients.
Organization of the transfer It is useful to refer to a checklist or mnemonic in order to mitigate the risk of pivotal steps in the process being missed. It has repeatedly been demonstrated that human factors, particularly around communication and other organizational issues, result in safety incidents and adopting this type of protocolized management helps to reduce avoidable incidents. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Intensive Care Society (ICS) have produced useful pre-departure checklists which can be viewed online.4,5 The authors find the following list useful: Is the transfer agreed by ITU consultants at both the receiving and transferring hospitals? Is the transfer agreed by both the receiving and transferring surgical/medical consultant? Is the receiving sister in charge of ITU aware of the patient being transferred? Are the patient (if possible) and their family aware? Is the patient resuscitated and stable for transfer and is intubation indicated as part of an expectant management strategy? What is the urgency and the most suitable type of transport to request? Is the level of experience and composition of the transfer team appropriate and are they properly equipped with suitable personal protective equipment? Have the patient’s eyes and pressure points been protected? Have the ventilator and transfer bag been checked? Is there a sufficient supply of oxygen and batteries for the journey? Are the AAGBI minimum monitoring standards being adhered to including capnography? Is there an adequate supply of appropriate drugs? Documentation: letter, notes, X-rays (image linked if possible), blood results and drug chart. Cross-matched blood and blood products if indicated. Does the transfer team have money/bank cards/mobile phone? Call to inform the receiving hospital prior to departure
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What is the urgency? The National Ambulance Services’ Clinical Conveyance Group inter-hospital transfer protocol 2011 sets out guidance for patient prioritization. Those patients that are deemed to require an immediate time-critical, life-saving intervention are classed as priority 1 and transport should arrive within 8 minutes. Those that require a life- or limb-saving treatment are priority 2 and should be transferred in less than 1 hour. Priority 3 patients have a clinical reason for transfer but do not fall into either of the previous two categories and transport should arrive in less than 4 hours. For those patients being transferred for non-clinical reasons less than 8 hours is the set target.9 Close attention to detail during the preparation phase is paramount. A study from Canada found that a longer time spent preparing the patient for transfer was associated with a shorter ITU admission (RR, 0.97; 95% CI, 0.95e0.99).10
Personnel and patient dependency The use of patient categorization can be a useful communication tool but is open to variable interpretation. In the UK critical care patients are categorized as level 1, 2 and 3 respectively, the characteristics of each respective group can be seen in Table 1. In adherence with the ICS guidelines all critically ill patients should be accompanied by two experienced and suitably trained
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Ó 2015 Elsevier Ltd. All rights reserved.
CRITICAL ILLNESS AND INTENSIVE CARE: I
Obstruction of an endotracheal tube due to kinking or secretions. Displacement of the endotracheal tube into the right main bronchus (most commonly) or out of the trachea.
Categorization of patients Level 0 Level 1
Level 2
Level 3
Patients whose needs can be met by normal ward care Patients recently stepped down from a higher level of care, or those at risk of deteriorating whose needs can be met on an acute ward with support if required from a critical care outreach service Patients requiring closer observation and/or intervention including support for a single failing organ system. Those stepped down from level 3 care Patients who are intubated or who require basic respiratory support with two other organ systems requiring support
Breathing Equipment failure (either faulty or electrical supply failure). Failure of the oxygen supply. Worsening of chest pathology, acute respiratory distress syndrome (ARDS), blossoming contusions and accumulating haemothorax/expanding pneumothorax. Fat embolization in patients with multiple long bone fractures due to movement. Unidentified pulmonary embolus. Chest drain blockage commonly due to kinking and chest drain removal. Transferring staff should ensure that end tidal CO2 monitoring is in place and that the discrepancy between the end tidal CO2 and the arterial CO2 is known prior to transfer to aid with decisionmaking around alterations to ventilation.
Table 1
staff. The exact team composition depends on the clinical condition of the patient, the mode of transport used and the likely duration of the transfer. Generally speaking, most level 1 patients and a select group of stable level 2 patients can be transferred with a nurse and paramedic or ambulance technician escort. Some level 2 patients will require a nurse and a medical escort from the sending team. The remaining patients are those deemed most at risk and consist predominantly of level 3 patients but some level 2 patients; the latter group is potentially very vulnerable and requires a thorough risk assessment to be made prior to leaving hospital as the potential for deterioration requiring an advanced critical care intervention to be performed en route such as intubation exists which is obviously highly undesirable! A risk assessment of the patient utilizing an early warning score system is recommended by the ICS and is used by some trusts in the UK.11
Circulation Inadvertent removal or blockage of lines. Difficulty in accessing intravenous lines due to limbs being tightly packaged. Loss of invasive blood pressure measurement. Unidentified bleeding due to tight packaging of the patient. Hypotension due to fluid shifts as a result of acceleration and deceleration forces.
Disability
Risks of transfer
Pain due to poorly protected pressure areas resulting in nerve injuries. Inadequate sedation levels or running out of sedation. Reduction in cerebral perfusion pressure due to hypotension of any cause or raised intracranial pressure due to impaired venous drainage, hypercapnia, hypoxia, coughing or gagging caused by inadequate sedation. Venous drainage adversely affected by poor positioning. Damage to hearing due to lack of ear protection.
By definition all patients who are being transferred are at risk from the pathology driving their critical illness. Previous studies have suggested that patient transfer is independently associated with both a longer ITU stay and an increase in mortality.11e13 There is a large body of evidence that also confirms that interhospital transfer is associated with other measures of patient harm and this is probably illustrated most clearly in the headinjured population in whom adverse events during transfer have long been known to worsen outcome and result in an increased incidence and severity of secondary brain injury.14 Hazards affecting staff are mainly related to the risk of road traffic collisions and movement of unsecured equipment within the vehicle. All staff should wear the correct personal protective equipment and ensure they have an adequate supply of food and water. They should also ensure they have money or a bank card to avoid the risk of being stranded as the ambulance may receive another tasking. Specific dangers to patients include the following.
Environment and metabolism Hypothermia leading to coagulation issues and further bleeding and increased cerebral metabolic rate due to shivering if not adequately paralysed. Poor glucose control. Trauma caused by road traffic collisions, movement of improperly secured equipment or by the patient or transfer team not being appropriately restrained in the vehicle. Movement artifact affecting non-invasive and invasive monitoring. Difficulty clinically assessing a patient due to background noise, movement and restricted assess to the patient. Should the requirement to perform an intervention arise, the ambulance should be stopped and, under no
Airway Airway compromise due to deteriorating consciousness level. Progression of facial swelling caused by burns, angioedema or haematoma.
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CRITICAL ILLNESS AND INTENSIVE CARE: I
Available monitoring should include: end tidal CO2 in ventilated patients temperature pulse oximetry non-invasive blood pressure continuous ECG monitoring airway pressures. All brain-injured patients and level 3 patients should have an indwelling arterial cannula to allow for beat-to-beat blood pressure measurement and the titration of inotropic agents to a target blood pressure. Inotropes should be administered through a central venous line which may also be used to guide optimization of filling status prior to departure.
circumstances, should seat belts be removed in a moving vehicle.3
Aeromedical transfer risks Aeromedical transfers (Figure 1) should be undertaken only by those with advanced knowledge and skills in this field; however an understanding of the risks presented is vital for those preparing patients for transfer by air. Motion sickness, patients and staff may need pre-medication with an antiemetic. Engine noise and vibration leads to the risk of hearing damage to patients and staff. Reduction in atmospheric pressure leading to a reduction of the partial pressure of oxygen necessitating an increase in FiO2 to prevent hypoxia. Expansion of air-filled spaces such as pneumothorax, pneumoperitoneum and pneumocranium. Military and civilian transport aircraft are normally pressurized to between 6000 and 8000 feet, which can result in a 20% increase in the volume of a given gas. Tissue swelling can occur which requires the splitting of plaster casts. Reduction in temperature and humidity. The risks of transfer are not confined to those concerning patient morbidity and mortality there is also the very real risk of emotional stress caused to both the patient and their family particularly if the transfer results in greater travel distances or loss of continuity of care.
Governance In 2005, the Department of Health report ‘Quality Critical Care Beyond Comprehensive Critical Care’ was published defining the remit of regional critical care networks (CCNs). Part of their responsibility is to ensure that there is uniformity of standards across the network and that the ICS standards for the transport of critically ill adult patients are adhered too. Critical care networks and individual trusts are responsible for their own governance including training, audit and recording of transfer data. There is currently no unifying national database detailing all critical care transfers and clearly this should be rectified.
Guidelines and training Comprehensive guidelines on transporting critically unwell adult patients have been published by the ICS and the AAGBI. Individual trusts have developed their own guidance under the auspices of the CCNs and training largely consists of locally arranged courses ideally delivered during induction periods. As of September 2012, the Royal College of Surgeons of Edinburgh has run an examination to gain the Diploma in Retrieval and Transfer Medicine. The examination focuses on the secondary and tertiary retrieval of patients from one healthcare facility to another. According to the college’s guidelines, candidates should be competent in the assessment, management, triage and transfer of adult patients with a range of undifferentiated illnesses and injury patterns. Previous experience of secondary or tertiary retrieval is advised.
Equipment Equipment must be familiar and checked regularly including before departure. The ideal qualities of any item of transfer equipment include: long battery life lightweight robust and easy to operate clear display with visible and audible alarms safe and easy to secure. The ventilator should have alarms for high and low pressures and it should be possible to generate positive end expiratory pressure and monitor FiO2.
Military lessons Historically, many of the major advancements in medicine and specifically trauma care have been driven forward by the military. During enduring operations in Iraq and Afghanistan the Defence Medical Services (DMS) have gained a unique prospective and acquired a high level of proficiency and significant body of experience in the time-critical transfer and repatriation of trauma patients by dedicated retrieval teams. There are many facets that have contributed to the excellent survival rates experienced by victims of military trauma in Iraq and Afghanistan. Examples include the shift in care to aABCDE paradigm ( is for control of catastrophic haemorrhage) and excellent front-line care, leading onto a timely transfer followed by damage control resuscitation and surgery and finally repatriation to the UK. Both the MERT (Medical Emergency Response
Figure 1: Typical critical care aeromedical transfer.
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2 Greaves I, Porter K, Garner J. Trauma care manual. 2nd edn. London: Hodder Arnold, 2009; 265. chp 23. 3 Craig SS. Challenges in arranging inter-hospital transfers from a small regional hospital: an observational study. Emerg Med Australas 2005; 17: 124e31. 4 Association of Anaesthetists of Great Britian and Ireland. Safety standards for the interhospital transfer of adults. London: AAGBI, 2009. 5 The Intensive Care Society. Guidelines for the transport of the critically ill adult. 3rd edn. London: Intensive Care Society, 2011. 6 Department of Health. Comprehensive critical care. A review of adult critical care services. London: Department of Health, 2000. 7 Belligan G, Oliver T, Bateson S, Webb A. Comparison of a specialist retrieval team with current UK practice for the transport of the critically ill patient. Intensive Care Med 2000; 26: 740e4. 8 Wiegersma JS, Droogh JM, Zijlstra JG, Fokkema J, Ligtehberg JJM. Quality of interhospital transport of the critically ill: impact of a Mobile Intensive Care Unit with a specialized retrieval team. Crit Care 2011; 15: R75. 9 National Ambulance Clinical Conveyance Group. Inter-hospital transfer policy. National Ambulances Service 2011. 10 Belway D, Dodek PM, Keenan SP, Norena M, Wong H. The role of transport intervals in outcomes for critically ill patients who are transferred to referral centers. J Crit Care 2008; 23: 287e94. 11 Flabouris A, Hart GK, George C. Outcomes of patients admitted to tertiary intensive care units after interhospital transfer: comparison with patients admitted from emergency departments. Crit Care Resusc 2008; 16: 97e105. 12 Flabouris A, Hart GK, George C. Observational study of patients admitted to intensive care units in Australia and New Zealand after interhospital transfer. Crit Care Resusc 2008; 16: 90e6. 13 Duke GGJ. Outcome of critically ill patients undergoing interhospital transfer. Med J Aust 2001; 16: 122e5. 14 Gentleman D, Jennett B. Hazards of inter-hospital transfer of comatose head-injured patients. Lancet 1981; 2: 853e4. 15 Mackenzie PA, Smith EA, Wallace PG. Transfer of adults between intensive care units in the United Kingdom: postal survey. Br Med J 1997; 314: 1455e6.
Team) and CCAST (Critical Care Air Support Team) have, without doubt, played a significant role in this chain of survival. Military personnel chosen to work on these teams have had the invaluable opportunity to work and train together prior to deployment on operations and have the benefit of well-defined, rehearsed and proven resuscitation protocols to aid them in their decision-making. The rigorous governance structure around this critical link in the chain of survival of military personnel also ensures that only suitably qualified and highly experienced personnel serve as part of these teams and compulsory predeployment training specific to the task in hand must be completed before an individual can deploy as part of either team.
Conclusions The task of safely navigating what has been estimated to be over 11,000 inter-hospital transfers a year represent a logistical challenge for critical care networks and individual NHS trusts.15 With the inexorable pressure on critical care services we must ensure that our response to the challenge of patient transfer is robust and effective. This should occur through striving for national homogeneity of critical care transfer services particularly with regards to data collection which would help to encourage better quality research in this field and subsequently drive improvement. At the present time the retrieval model would seem to be most desirable on the basis of the available evidence but involves overcoming significant financial, geographical and political restraints. Until such a time as dedicated retrieval becomes the standard of care, all those involved in patient transfer should ensure they remain current with their trust’s guidelines and equipment and the importance of clinical governance should be emphasized at all levels. A REFERENCES 1 Noah M, Peek GJ, Finney SJ, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). J Am Med Assoc 2011; 16: 1659e68. http://dx.doi.org/10.1001/jama.2011.1471.
SURGERY 33:4
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Ó 2015 Elsevier Ltd. All rights reserved.
Transfer of the critically ill adult patient
consideration the objective risks of transporting a critically unwell patient this is often difficult to achieve and requires an experienced and well-trained transfer team as a starting point. Generally speaking in the UK the vast majority of transfers are carried out by junior anaesthetists who will typically have received limited transfer training and will often have little in the way of transfer experience. This has both patient safety and resource implications.
David Hunt Kate Prior
Abstract
Types of transfer
Patient transfer has resource ramifications and is an important public health issue. With increasing centralization of specialist services and the advent of regional trauma networks the requirement for patient transfer is ever present. Every year in the UK over 11,000 intensive care patients are transferred and the majority of these transfers are facilitated by a team from the transferring hospital as opposed to being carried out by a dedicated retrieval team. Transferring a critically ill patient is a process involving inherent risk, so prior preparation around planning for a safe transfer is essential both in terms of anticipating potential problems, mitigating against them and ensuring clear and timely communication with the accepting hospital and respective specialties responsible for the patient. In the longer term, training of staff is essential in order to reduce instances of harm to patients. This article provides an overview of the different types of patient transfer, the associated hazards, human factors around decisionmaking, communication, equipment and organization.
There are three main categories of patient transfer, as follows. 1. Primary transfer to hospital is normally undertaken by land ambulance crews. For trauma patients who warrant a response from a helicopter emergency medical service (HEMS), this phase may involve critical care interventions and transport by helicopter with an advanced medical practitioner. 2. Following initial resuscitation and stabilization, secondary transfer occurs when specialist care is required and not available locally. This would normally occur by land ambulance, but could utilize a helicopter or fixed-wing aircraft depending on the distance involved, weather, urgency, traffic and the location of suitable landing sites among other factors. There are longstanding guidelines available for the transfer of patients via aeromedical means. A secondary transfer may also have to occur if locally available resources become overwhelmed or are temporarily unavailable. 3. Tertiary transfers occur for non-clinical reasons and should be avoided unless absolutely necessary. This type of transfer is usually for patients wishing to be repatriated for social reasons, such as being closer to friends and family and those who face funding issues and those who are injured abroad and need to be repatriated to the UK.2 Transfers can be further subdivided into two subcategories: intraand inter-hospital. This article will focus only on inter-hospital transfer although the same guiding principles will apply to intra-hospital transfers also.
Keywords Centralization; communication; decision-making; organization; preparation; risk; training
Introduction The requirement for patient transfer is an inevitable consequence of the centralization of acute services and increased utilization of highly specialized services such as extracorporeal membrane oxygenation (ECMO). Rarely, transfers can occur if locally available resources are exhausted or temporarily unavailable but this should, of course, be avoided unless absolutely necessary as it is clearly not in the best interests of a patient to undergo a potentially avoidable transfer. The over-arching aim of the vast majority of transfers should be to achieve a higher level of care for the patient. The benefit of transfer for specialized treatment is well established for trauma and cardiology patients but it has taken a long time to achieve widespread acceptance of this in the UK, particularly with regards to the former patient group. It has also been demonstrated that the benefits of transfer to a specialist centre are not always related to receiving the intervention for which the transfer was initiated.1 The transfer team strives to ensure that the care a patient receives in transit is equivalent to that they receive in an intensive care unit. Taking into
Decision-making and human factors Clear communication is required early on in the process of transfer. Sadly, disjointed planning and communication is a common occurrence during patient transfers leading to adverse incidents. To help avoid this it is essential that consultants are involved in inter-hospital critical care transfers. It has already been said that a transfer should only occur if it is likely to result in an improvement in the patient’s overall condition, so it is vital that the risks and the benefits are evaluated by an experienced clinician with advice from the receiving specialists. The reason for the transfer should be established and, if it is for anything other than an improvement in patient care, this becomes, in part, an ethical decision which should be clearly communicated to the patient, if they have capacity, and their family. After the decision to transfer has been made delays and complex organizational issues can occur. One study from Australia has demonstrated that, on average, 4.7 telephone calls are required to be made per patient, which when one considers the requirement for concurrent patient resuscitation is a significant burden of responsibility.3
Major David Hunt FRCA MCEM RAMC is an ST6 in Anaesthetics and Intensive Care Medicine at King’s College London, UK. Conflicts of interest: none declared. Surgeon Commander Kate Prior FRCA RN is a consultant in Anaesthetics and Major Trauma at King’s College London, UK. Conflicts of interest: none declared.
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Ó 2015 Elsevier Ltd. All rights reserved.
CRITICAL ILLNESS AND INTENSIVE CARE: I
Perform an arterial blood gas 15 minutes before departure and check the patient is adequately resuscitated before departure.
Where is the patient going? This point is critical and must be clearly articulated between the transfer team and the receiving hospital. The resuscitation room of the emergency department should ideally be avoided, but does provide possibilities for stabilization should the patient have deteriorated prior to onward movement. There should be no delay in transfer to an area for definitive treatment such as a specialist intensive care unit or operating theatre. All parties must be clear about the exact destination requiring an accurate description of the location to be communicated to all parties including the patient’s family. The receiving hospital should be made aware of the patient’s departure, updated about any issues that occur in transit and informed prior to the patient arrival with an estimated time of arrival to allow for tasks such as a trauma call to be put out or specialists to be summoned to theatre.
To retrieve or transfer? Retrieval teams are advocated by the Department of Health.6 A team from University College London compared outcomes of patients transferred by a specialist retrieval team (group A) and those transferred by standard means, a team from the referring hospital, (group B). There were no differences in demographic characteristics or severity of illness between the two groups. However, significantly more patients in group B than in group A were severely acidaemic (pH <7.1: 11% vs. 3%, p <0.008) and hypotensive (mean arterial pressure (MAP) <60: 18 % vs. 9%, p <0.03) on arrival. There were more deaths within the first 12 hours after admission with 7.7 % deaths (7/91) in group B transfers vs. 3% (5/168) in group A.7 A university hospital in the Netherlands conducted a prospective study comparing patient physiology in those patients transferred by their newly established mobile intensive care unit (MICU) with prospectively collected data on patients transferred by ambulance in 2005 in the same region. Distribution of differences in arterial blood gases during transfer in 2009 versus 2005 showed significantly better values for the variables pH, paO2 and paCO2 in the patient group transferred by MICU, using the Independent-Samples t-test (a <0.05). There was also a significant increase in the number of patients who were transferred conventionally that required emergent advanced respiratory support immediately on arrival in the receiving ITU.8 The retrieval model has a much stronger body of evidence for the transport of paediatric patients and is much more widely practised and it would seem intuitive that at least some of this experience should be transferable to adult patients.
Organization of the transfer It is useful to refer to a checklist or mnemonic in order to mitigate the risk of pivotal steps in the process being missed. It has repeatedly been demonstrated that human factors, particularly around communication and other organizational issues, result in safety incidents and adopting this type of protocolized management helps to reduce avoidable incidents. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Intensive Care Society (ICS) have produced useful pre-departure checklists which can be viewed online.4,5 The authors find the following list useful: Is the transfer agreed by ITU consultants at both the receiving and transferring hospitals? Is the transfer agreed by both the receiving and transferring surgical/medical consultant? Is the receiving sister in charge of ITU aware of the patient being transferred? Are the patient (if possible) and their family aware? Is the patient resuscitated and stable for transfer and is intubation indicated as part of an expectant management strategy? What is the urgency and the most suitable type of transport to request? Is the level of experience and composition of the transfer team appropriate and are they properly equipped with suitable personal protective equipment? Have the patient’s eyes and pressure points been protected? Have the ventilator and transfer bag been checked? Is there a sufficient supply of oxygen and batteries for the journey? Are the AAGBI minimum monitoring standards being adhered to including capnography? Is there an adequate supply of appropriate drugs? Documentation: letter, notes, X-rays (image linked if possible), blood results and drug chart. Cross-matched blood and blood products if indicated. Does the transfer team have money/bank cards/mobile phone? Call to inform the receiving hospital prior to departure
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What is the urgency? The National Ambulance Services’ Clinical Conveyance Group inter-hospital transfer protocol 2011 sets out guidance for patient prioritization. Those patients that are deemed to require an immediate time-critical, life-saving intervention are classed as priority 1 and transport should arrive within 8 minutes. Those that require a life- or limb-saving treatment are priority 2 and should be transferred in less than 1 hour. Priority 3 patients have a clinical reason for transfer but do not fall into either of the previous two categories and transport should arrive in less than 4 hours. For those patients being transferred for non-clinical reasons less than 8 hours is the set target.9 Close attention to detail during the preparation phase is paramount. A study from Canada found that a longer time spent preparing the patient for transfer was associated with a shorter ITU admission (RR, 0.97; 95% CI, 0.95e0.99).10
Personnel and patient dependency The use of patient categorization can be a useful communication tool but is open to variable interpretation. In the UK critical care patients are categorized as level 1, 2 and 3 respectively, the characteristics of each respective group can be seen in Table 1. In adherence with the ICS guidelines all critically ill patients should be accompanied by two experienced and suitably trained
154
Ó 2015 Elsevier Ltd. All rights reserved.
CRITICAL ILLNESS AND INTENSIVE CARE: I
Obstruction of an endotracheal tube due to kinking or secretions. Displacement of the endotracheal tube into the right main bronchus (most commonly) or out of the trachea.
Categorization of patients Level 0 Level 1
Level 2
Level 3
Patients whose needs can be met by normal ward care Patients recently stepped down from a higher level of care, or those at risk of deteriorating whose needs can be met on an acute ward with support if required from a critical care outreach service Patients requiring closer observation and/or intervention including support for a single failing organ system. Those stepped down from level 3 care Patients who are intubated or who require basic respiratory support with two other organ systems requiring support
Breathing Equipment failure (either faulty or electrical supply failure). Failure of the oxygen supply. Worsening of chest pathology, acute respiratory distress syndrome (ARDS), blossoming contusions and accumulating haemothorax/expanding pneumothorax. Fat embolization in patients with multiple long bone fractures due to movement. Unidentified pulmonary embolus. Chest drain blockage commonly due to kinking and chest drain removal. Transferring staff should ensure that end tidal CO2 monitoring is in place and that the discrepancy between the end tidal CO2 and the arterial CO2 is known prior to transfer to aid with decisionmaking around alterations to ventilation.
Table 1
staff. The exact team composition depends on the clinical condition of the patient, the mode of transport used and the likely duration of the transfer. Generally speaking, most level 1 patients and a select group of stable level 2 patients can be transferred with a nurse and paramedic or ambulance technician escort. Some level 2 patients will require a nurse and a medical escort from the sending team. The remaining patients are those deemed most at risk and consist predominantly of level 3 patients but some level 2 patients; the latter group is potentially very vulnerable and requires a thorough risk assessment to be made prior to leaving hospital as the potential for deterioration requiring an advanced critical care intervention to be performed en route such as intubation exists which is obviously highly undesirable! A risk assessment of the patient utilizing an early warning score system is recommended by the ICS and is used by some trusts in the UK.11
Circulation Inadvertent removal or blockage of lines. Difficulty in accessing intravenous lines due to limbs being tightly packaged. Loss of invasive blood pressure measurement. Unidentified bleeding due to tight packaging of the patient. Hypotension due to fluid shifts as a result of acceleration and deceleration forces.
Disability
Risks of transfer
Pain due to poorly protected pressure areas resulting in nerve injuries. Inadequate sedation levels or running out of sedation. Reduction in cerebral perfusion pressure due to hypotension of any cause or raised intracranial pressure due to impaired venous drainage, hypercapnia, hypoxia, coughing or gagging caused by inadequate sedation. Venous drainage adversely affected by poor positioning. Damage to hearing due to lack of ear protection.
By definition all patients who are being transferred are at risk from the pathology driving their critical illness. Previous studies have suggested that patient transfer is independently associated with both a longer ITU stay and an increase in mortality.11e13 There is a large body of evidence that also confirms that interhospital transfer is associated with other measures of patient harm and this is probably illustrated most clearly in the headinjured population in whom adverse events during transfer have long been known to worsen outcome and result in an increased incidence and severity of secondary brain injury.14 Hazards affecting staff are mainly related to the risk of road traffic collisions and movement of unsecured equipment within the vehicle. All staff should wear the correct personal protective equipment and ensure they have an adequate supply of food and water. They should also ensure they have money or a bank card to avoid the risk of being stranded as the ambulance may receive another tasking. Specific dangers to patients include the following.
Environment and metabolism Hypothermia leading to coagulation issues and further bleeding and increased cerebral metabolic rate due to shivering if not adequately paralysed. Poor glucose control. Trauma caused by road traffic collisions, movement of improperly secured equipment or by the patient or transfer team not being appropriately restrained in the vehicle. Movement artifact affecting non-invasive and invasive monitoring. Difficulty clinically assessing a patient due to background noise, movement and restricted assess to the patient. Should the requirement to perform an intervention arise, the ambulance should be stopped and, under no
Airway Airway compromise due to deteriorating consciousness level. Progression of facial swelling caused by burns, angioedema or haematoma.
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Available monitoring should include: end tidal CO2 in ventilated patients temperature pulse oximetry non-invasive blood pressure continuous ECG monitoring airway pressures. All brain-injured patients and level 3 patients should have an indwelling arterial cannula to allow for beat-to-beat blood pressure measurement and the titration of inotropic agents to a target blood pressure. Inotropes should be administered through a central venous line which may also be used to guide optimization of filling status prior to departure.
circumstances, should seat belts be removed in a moving vehicle.3
Aeromedical transfer risks Aeromedical transfers (Figure 1) should be undertaken only by those with advanced knowledge and skills in this field; however an understanding of the risks presented is vital for those preparing patients for transfer by air. Motion sickness, patients and staff may need pre-medication with an antiemetic. Engine noise and vibration leads to the risk of hearing damage to patients and staff. Reduction in atmospheric pressure leading to a reduction of the partial pressure of oxygen necessitating an increase in FiO2 to prevent hypoxia. Expansion of air-filled spaces such as pneumothorax, pneumoperitoneum and pneumocranium. Military and civilian transport aircraft are normally pressurized to between 6000 and 8000 feet, which can result in a 20% increase in the volume of a given gas. Tissue swelling can occur which requires the splitting of plaster casts. Reduction in temperature and humidity. The risks of transfer are not confined to those concerning patient morbidity and mortality there is also the very real risk of emotional stress caused to both the patient and their family particularly if the transfer results in greater travel distances or loss of continuity of care.
Governance In 2005, the Department of Health report ‘Quality Critical Care Beyond Comprehensive Critical Care’ was published defining the remit of regional critical care networks (CCNs). Part of their responsibility is to ensure that there is uniformity of standards across the network and that the ICS standards for the transport of critically ill adult patients are adhered too. Critical care networks and individual trusts are responsible for their own governance including training, audit and recording of transfer data. There is currently no unifying national database detailing all critical care transfers and clearly this should be rectified.
Guidelines and training Comprehensive guidelines on transporting critically unwell adult patients have been published by the ICS and the AAGBI. Individual trusts have developed their own guidance under the auspices of the CCNs and training largely consists of locally arranged courses ideally delivered during induction periods. As of September 2012, the Royal College of Surgeons of Edinburgh has run an examination to gain the Diploma in Retrieval and Transfer Medicine. The examination focuses on the secondary and tertiary retrieval of patients from one healthcare facility to another. According to the college’s guidelines, candidates should be competent in the assessment, management, triage and transfer of adult patients with a range of undifferentiated illnesses and injury patterns. Previous experience of secondary or tertiary retrieval is advised.
Equipment Equipment must be familiar and checked regularly including before departure. The ideal qualities of any item of transfer equipment include: long battery life lightweight robust and easy to operate clear display with visible and audible alarms safe and easy to secure. The ventilator should have alarms for high and low pressures and it should be possible to generate positive end expiratory pressure and monitor FiO2.
Military lessons Historically, many of the major advancements in medicine and specifically trauma care have been driven forward by the military. During enduring operations in Iraq and Afghanistan the Defence Medical Services (DMS) have gained a unique prospective and acquired a high level of proficiency and significant body of experience in the time-critical transfer and repatriation of trauma patients by dedicated retrieval teams. There are many facets that have contributed to the excellent survival rates experienced by victims of military trauma in Iraq and Afghanistan. Examples include the shift in care to a
Figure 1: Typical critical care aeromedical transfer.
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2 Greaves I, Porter K, Garner J. Trauma care manual. 2nd edn. London: Hodder Arnold, 2009; 265. chp 23. 3 Craig SS. Challenges in arranging inter-hospital transfers from a small regional hospital: an observational study. Emerg Med Australas 2005; 17: 124e31. 4 Association of Anaesthetists of Great Britian and Ireland. Safety standards for the interhospital transfer of adults. London: AAGBI, 2009. 5 The Intensive Care Society. Guidelines for the transport of the critically ill adult. 3rd edn. London: Intensive Care Society, 2011. 6 Department of Health. Comprehensive critical care. A review of adult critical care services. London: Department of Health, 2000. 7 Belligan G, Oliver T, Bateson S, Webb A. Comparison of a specialist retrieval team with current UK practice for the transport of the critically ill patient. Intensive Care Med 2000; 26: 740e4. 8 Wiegersma JS, Droogh JM, Zijlstra JG, Fokkema J, Ligtehberg JJM. Quality of interhospital transport of the critically ill: impact of a Mobile Intensive Care Unit with a specialized retrieval team. Crit Care 2011; 15: R75. 9 National Ambulance Clinical Conveyance Group. Inter-hospital transfer policy. National Ambulances Service 2011. 10 Belway D, Dodek PM, Keenan SP, Norena M, Wong H. The role of transport intervals in outcomes for critically ill patients who are transferred to referral centers. J Crit Care 2008; 23: 287e94. 11 Flabouris A, Hart GK, George C. Outcomes of patients admitted to tertiary intensive care units after interhospital transfer: comparison with patients admitted from emergency departments. Crit Care Resusc 2008; 16: 97e105. 12 Flabouris A, Hart GK, George C. Observational study of patients admitted to intensive care units in Australia and New Zealand after interhospital transfer. Crit Care Resusc 2008; 16: 90e6. 13 Duke GGJ. Outcome of critically ill patients undergoing interhospital transfer. Med J Aust 2001; 16: 122e5. 14 Gentleman D, Jennett B. Hazards of inter-hospital transfer of comatose head-injured patients. Lancet 1981; 2: 853e4. 15 Mackenzie PA, Smith EA, Wallace PG. Transfer of adults between intensive care units in the United Kingdom: postal survey. Br Med J 1997; 314: 1455e6.
Team) and CCAST (Critical Care Air Support Team) have, without doubt, played a significant role in this chain of survival. Military personnel chosen to work on these teams have had the invaluable opportunity to work and train together prior to deployment on operations and have the benefit of well-defined, rehearsed and proven resuscitation protocols to aid them in their decision-making. The rigorous governance structure around this critical link in the chain of survival of military personnel also ensures that only suitably qualified and highly experienced personnel serve as part of these teams and compulsory predeployment training specific to the task in hand must be completed before an individual can deploy as part of either team.
Conclusions The task of safely navigating what has been estimated to be over 11,000 inter-hospital transfers a year represent a logistical challenge for critical care networks and individual NHS trusts.15 With the inexorable pressure on critical care services we must ensure that our response to the challenge of patient transfer is robust and effective. This should occur through striving for national homogeneity of critical care transfer services particularly with regards to data collection which would help to encourage better quality research in this field and subsequently drive improvement. At the present time the retrieval model would seem to be most desirable on the basis of the available evidence but involves overcoming significant financial, geographical and political restraints. Until such a time as dedicated retrieval becomes the standard of care, all those involved in patient transfer should ensure they remain current with their trust’s guidelines and equipment and the importance of clinical governance should be emphasized at all levels. A REFERENCES 1 Noah M, Peek GJ, Finney SJ, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). J Am Med Assoc 2011; 16: 1659e68. http://dx.doi.org/10.1001/jama.2011.1471.
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