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