Inter hospital transfer of the critically ill patients

Dr. Mesaros Daniel

AAGBI 2009European Society Of Intensive Care Medicine

Introduction

• appropriate clinical reasons

• difficult and potentially dangerous

• appropriate personal, equipment, training and support

BACKGROUND

• Recommendations• Indications• Risks• Planning the transfer• Conduct of the transfer

Recommendations

• Transfer can be safely even in extremely ill patients• Decision must involve a senior and experienced clinician• Protocols, documentations and equipment should be

standardized within networks• Appropriate competencies, qualifications and experience• Hospital must ensure: - suitable transfer equipment - adequate insurance cover - personal & equipment can safely return to base • Recorded and review

Indications

• Technical and professional expertise: - neurosurgery - interventional radiology - percutaneous transluminal coronary angioplasty - continuous renal replacement therapy - organ transplantation - specific critical care interventions ( mechanical ventilation in prone postion)

• Organizational aspects: - lack of available beds - massive influx of patients

Risks of transport• Technical complications – displacement of tubes,

Intravascular lines

• Pathophysiological deteriorations: - increased intracranial pressure - systemic hypotension/hypertension crisis - cardiac arrhytmias/arrest - drop in oxygenation saturation/airway obstruction

• Additional movements: - acceleration/deceleration - tilting/lifting

• Inadequate monitoring of cardiopulmonary function due to less advanced equipment/interference due to motion, etc…

Deciding/planning the transfer• Made by senior/consultant • Influenced by multiple factors: - course of disease (improvement/deterioration? - communication - staffing: medical, paramedical - logistics: equipment, resources - transport condition: distance, weather - modes of transportation: ambulance, helicopter, aircraft - handing over: documents, information - medico legal and ethical aspects

Transfer team

• Specialized transport teams provide better care with decreased morbidity during and after transport

• Two qualified personnel• Vehicle operator• Respiratory therapist

Transfer equipment

• Airway management equipment• Medication• Electric devices• Trolley• Oxygen cylinder

Airway equipment

Airway management equipment

• Resuscitation kit• Bag & mask• Oral airway• Laryngoscope & blade different sizes• ET tubes different sizes• Suction devices• Nebulizer• Adhesive tape

Oxygen cylinder

Electronic devices

Pule oxymeter

Infusion pumpsECGInvasive/noninvasive BPEnd-tidal capnographyTemperature

Monitors

Standard resuscitations drugs

• Sedatives• Analgesics• Muscles relaxants• Inotropes

Trolley

Conduct the transfer

• Check trolley and all equipment before and after each transfer

• Preparing patient for transport: - secure intra venous access - airway stabilization - trauma victims – spinal mobilization - nasogastric tube - Foley’s catheterization - chest tube insertion - all drains - infusion pump & IV drips functioning properly - soft wrist and leg restraints - vital signs displayed on monitors - patient is safely secured on a trolley

• Documentation

In transit procedure

• Best route

• Status of patient checked of intervals

• Continuous monitoring

Arrival procedure

• Assessment

• Shifted

• Complete handover

• Documentation – patient status with time

Conclusions• Systematic approach• Careful planning• Benefits and risks should be weighed in every

individual critically ill patient before transport • Anticipate the worst, think about possible

complications and have a plan for how to react• With sufficient preparation and good equipment

transfer is possible without an adverse event• Early communication will give you enough time to

organize additional personnel & transfer itself• Proper use of personnel• Selection and availability of appropriate equipment

Thank you