TRANSPORT OF CRITICALLY ILL

WHO WHAT

WHEREWHEN

WHY

SAFETY..SAFETY..SAFETY..

LEARNING OBJECTIVES

• PHYSIOLOGICAL IMPACTS OF TRANSPORTATION

• TYPES OF TRANSFER

• ADVERSE EVENTS DURING TRANSPORTATION

• ORGANIZATION OF TRANSFER

• PREVENTION OF COMPLICATIONS

Dangers of transfers1) Physiological changes:

Resp:

-decrease oxygenation

-Increase incidence of VAP 24% in transported pt vs 4.4% in non transported pt

Haemodynamics : Changes in HR, BP esp in post op pt

Neuro : increase ICP

• 2)Hostile and unfamiliar environment

• 3)Limited resources

• 4)Equipment problems

• 5)Technical complications

• 6)Failure of continuity of care

• 7)Crisis - e.g : hypotension/ hypertension/ arrythmias/ desaturation

FREQUENCY AND NATURE OF UNEXPECTED EVENTS

types of transfer

• Pre hospital

• Inter-hospital

• Intra-hospital

intrahospital transfer

• From emergency to wards

• From emergency to OT/ ICU

• From ward to OT/ICU

• From ward/ ICU to Radiology

• From ward / ICU to ward/ ICU

ORGANIZATION OF

TRANSFER

Because the transport of critically ill patients to procedures or tests outside the ICU is potentially hazardous, the transport process must be organized and efficient.

Guidelines for the inter- and intra-hospital transport of critically ill patients

Critical Care MedicineVolume 32(1), January 2004, pp 256-262

AssessmentControlCommunicationEvaluationPrepare and packageTransport

Remember acronym…..

Assessment• Initial assessment of the patient and situation as a

whole

• Indications - benefits must outweigh risks

• Stabilize before transport

• Anticipation of problem likely encountered en route

• Degree of urgency to transfer

Stable to transfer??• Refractory / Severe shock - High vasopressor/

inotrope -

• Hypoxemia - High ventilator settings/ FiO2 1.0 ?

• Secure airway when in doubt, borderline indication -> intubation

control and communicate• Communication - excellent communication within

team and receiving end

• Continuous assessment of effectiveness of resuscitation and stabilisation process

• Experienced staff in intensive care or transfer

• Clear chain of responsibility

Prepare and package

• Preparation of patient, equipment, supplies, accompanying medical and nursing personnel

• Sufficient supplies of drugs, fluids and oxygen must be available to cope with extraordinary delays

• Secure tubes, lines

equipments* Equipment for airway management: * -sized appropriately for each patient* -oxygen source of ample supply to provide for

projected needs plus a 30-min reserve.

* Adequate battery back up

References

*Basic resuscitation drugs, including epinephrine and anti-arrhythmic agents, are transported with each patient in the event of sudden cardiac arrest or arrhythmia.

*Supplemental medications, such as sedatives and narcotic analgesics, are considered in each specific case.

TRANSPORT

accompanying personal

* It is strongly recommended that a minimum of two people accompany a critically ill patient.

* It is strongly recommended that a physician with training in airway management and ACLS, and critical care training or equivalent, accompany unstable patients.

* Continuous BP monitor, pulse oximeter, and cardiac monitor must accompany every patient without exception.

* Alarms should be visible as well as audible in view of extraneous noise levels

monitoring

documentation• Clinical status before, during and after transfer

• patient condition - trend

• medicolegal implications

• proper handover referring -> transfer -> receiving doctor

• in the end, evaluate process of transfer - for quality improvement

Prevention of complications

• the necessity and safety for transport should be assessed by multidisciplinary team

• risk of transport should be weighed against potential benefits

• Use appropriate equipment, personal and planning for each transport can minimise these complications and ensure optimal benefit to patients

• Risks can be diminished if patients are appropriately selected and carefully monitored during transportation

• In some cases, hazards of transporting a patient could be prevented by performing diagnostic or therapeutic procedures within ICU or choosing alternative procedures that may render a transport of the patient unnecessary.

• Avoid delay. Each 30 min delay can increase mortality 300 times in severe injured patient.

TERIMA KASIH

•TERIMA KASIH