Transferring the Critically Ill

OVERVIEW

  • key principle is that the standard of care should not decrease during or after retrieval of a critically ill patient
  • College guidelines for minimum standards for transport of critically ill patients should be followed

MODE OF TRANSFER

  • Mode of transfer can be road or air (fixed or rotary wing)
  • should be determined by resources, distance to be covered and environmental / weather conditions
  • The mode of transfer should provide the shortest time from the referring hospital to the receiving centre and the standard of care should be maintained throughout the transfer
  • Staff safety during transfer is an essential consideration

CO-ORDINATION AND COMMUNICATION

  • Ensure bed available at receiving centre
  • Establish key individual(s) at receiving centre for liaison to receive updates on transfer status and to provide expert advice re: patient management
  • Ensure all necessary documentation prepared to accompany patient including clinical records and radiology
  • Ensure transport team know destination (town, hospital, ICU location) and have arrangements for accommodation / return
  • Ensure patient’s next of kin are aware of need for transfer

PRE-TRANSFER ASSESSMENT

Preparation of patient

  • Provide explanation, obtain consent
  • Consider intubation and mechanical ventilation (with ongoing sedation and paralysis) depending on stability of patient and distance/mode of transport
  • Replace air in ETT with saline if flying
  • Stabilise on transport ventilator and check settings
  • Vascular access including arterial line
  • Urinary catheterization and passage of NG tube
  • TEDs
  • All lines and tubes secured and correct position confirmed
  • Resuscitation and physiological stabilization of patient as indicated
  • Position patient appropriately (e.g. head up 30 degrees)
  • Final repeat clinical assessment immediately prior to departure

Monitoring

  • Full monitoring of patient including intra-arterial pressure, end-tidal CO2, oxygen saturation and ECG and TOF if paralysing agents used
  • If intracerebral haemorrhage: Ensure optimum MAP to maintain cerebral perfusion but target SBP < 150 mmHg to avoid re-bleed

Equipment and drugs

  • Transport ventilator
  • Monitor
  • Bag-valve-mask and re-intubation equipment
  • Oxygen cylinders
  • Defibrillator
  • Infusion pumps as needed
  • Needles and syringes etc
  • Sedative drugs and muscle relaxants
  • Resuscitation drugs
  • IV fluids
  • Prescribed drugs as indicated eg antibiotics

Personnel

  • Ensure adequately trained personnel for retrieval team, including appropriately experienced medical practitioner
  • Ensure adequate staffing remains on site at base hospital

TRANSPORT

  • invasive monitoring
  • hypothermia cares
  • remember decreased PaO2 with altitude (@ 1500m PaO2 = 75mmHg)
  • acceleration/deceleration can cause haemodynamic instability
  • ensure adequate supplies of O2 and batteries
  • stethoscope is largely useless in flight, use ultrasound if available

POST-TRANSPORT CARE

  • hand over to ICU staff
  • document how transfer proceeded and any interventions
  • Debrief and follow up

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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