Transport of critically ill patients

Critically ill patients are transported within and between hospitals on a regular basis; thus, transport of the critically ill is a component of most intensivists-practice. The motivation for these transports lies in obtaining diagnostic or therapeutic services not available at the bedside (intrahospital transport) or not available in the sending institution (interhospital transport). Deterioration in respiratory, cardiovascular, and other physiological systems is a potential complication of any patient transport. Using appropriate equipment and personnel and planning for each transport can minimize these complications and ensure optimal benefit to the patient.     

Emergency department organisation of critical care transfers in the UK

Objectives: Transport of the critically ill patient to or from the emergency department (ED) is a frequent occurrence. This study was designed to determine whether UK EDs currently have appropriate equipment, monitoring, staff training systems, and processes of care for transportation of the critically ill patient. Methods: A postal questionnaire regarding ED transfer patients was sent to 247 UK EDs, followed by repeat mailing and telephone follow up of non-responders. Results: In total, 139 EDs (56%) responded. An estimated 20–30 critically ill patients are transferred from and <20 are received by each ED annually. Processes of care are poorly developed; only 79 EDs (56%) have transfer guidelines available. Audit of transfers is ongoing in 59 EDs (42%), and critical incident reporting is ongoing in 122 (88%). There is a lack of immediately available transport equipment; for example, 17 EDs (12%) have no transport ventilator, 9 (6%) have no transport monitor, and 9 (6%) have no syringe pump. Transport equipment is invariably not standardised. Anaesthetic staff of specialist registrar (74 doctors; 53%) or senior house officer (36 doctors; 26%) grades carry out the majority of ED transfers accompanied by a D or E grade nurse. Both invariably have no formal transfer training. Conclusions: This study highlights inadequacies in provision of equipment and monitoring during interhospital transfer from the ED. Training and processes of care for transport of the critically ill are also suboptimum. Many departments are currently reviewing these processes to formalise and improve transfer training procedures and protocols.     

接收83例院际转运危重症传染病患儿的护理

总结接收83例院际转运危重症传染病患儿的护理。做好充分的转运设备准备和合适人员的配备;到达当地医院后护士先与家属沟通,签订转运知情同意书,详细评估患儿的病情,配合医生维持患儿病情的稳定,采取合理的隔离措施,做好患儿家属的健康宣教,对途中可能出现的病情变化做好充分的评估和准备;转运途中妥善安置患儿,加强病情的观察和处理,做好家属和患儿的安抚。患儿均安全入住儿童重症监护室进行隔离治疗,83例患儿中治愈78例,好转签字出院2例,死亡3例;转运人员、接触的工作人员及病房其他患儿未出现1例相关疾病的传染。     

Decision making in interhospital transport of critically ill patients: national questionnaire survey among critical care physicians

OBJECTIVE: This study assessed the relative importance of clinical and transport-related factors in physicians' decision-making regarding the interhospital transport of critically ill patients. METHODS: The medical heads of all 95 ICUs in The Netherlands were surveyed with a questionnaire using 16 case vignettes to evaluate preferences for transportability; 78 physicians (82%) participated. The vignettes varied in eight factors with regard to severity of illness and transport conditions. Their relative weights were calculated for each level of the factors by conjoint analysis and expressed in beta. The reference value (beta = 0) was defined as the optimal conditions for critical care transport; a negative beta indicated preference against transportability. RESULTS: The type of escorting personnel (paramedic only: beta = -3.1) and transport facilities (standard ambulance beta = -1.21) had the greatest negative effect on preference for transportability. Determinants reflecting severity of illness were of relative minor importance (dose of noradrenaline beta = -0.6, arterial oxygenation beta = -0.8, level of peep beta = -0.6). Age, cardiac arrhythmia, and the indication for transport had no significant effect. CONCLUSIONS: Escorting personnel and transport facilities in interhospital transport were considered as most important by intensive care physicians in determining transportability. When these factors are optimal, even severely critically ill patients are considered able to undergo transport. Further clinical research should tailor transport conditions to optimize the use of expensive resources in those inevitable road trips.     

危重患者院内转运的最佳证据总结

目的 遴选并获取国内外危重患者院内转运的相关证据, 并对最佳证据进行总结。方法 使用计算机检索英国医学杂志（the British Journal of Medicine,BMJ）、 美国指南网（National Guideline Clearinghouse, NGC）、英国国家医疗保健优化研究所（National Institute for Health and Care Excellence,NICE）、JBI循证卫生保健中心数据库、Cochrane Library、循证医学指南、欧洲医学会（European Society of Intensive Care Medicine,ESICM）、苏格兰学院间指南网（National Integrated Cancer Network Scottish Intercollegiate Guideline,SIGN）、中国生物医学文献数据库、PubMed、中国知网和万方数据库内关于危重患者院内转运的相关证据,证据类型包括临床决策支持、指南、系统评价、证据总结、专家共识。检索时限为建库至2019年7月25日。由2~4名研究员对文献进行独立评价,结合专业人士的判断,对符合标准的文献资料进行提取。结果 共纳入15篇文献,其中指南5篇、系统评价5篇、证据总结2篇、专家共识及建议2篇、临床决策支持1篇。最佳证据分别从危重患者院内转运的转运人员资质及培训、转运设备、转运计划、转运沟通、交接记录、转运管理、转运不良事件7个方面进行总结,共59条。结论 本研究总结了危重患者院内转运的最佳证据,为危重患者转运提供了循证依据,医务人员应用证据时应结合自身医院及科室的具体情况,有针对性地采用证据。但随着时间的推移,最佳证据会不断更新,应用人员需要对证据进行持续的更新,将证据更好的应用于临床,降低危重患者转运的不良事件发生率。     

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: A critical incidents study

IntroductionThe number of interhospital transports with intubated patients or where intubation readiness is required is increasing in Sweden and globally. Specialist nurses are often responsible for these transports, which involve numerous risks for critically ill patients.AimThe aim of this study was to describe nurse anaesthetists’ and intensive care nurses’ strategies for safe interhospital transports with intubated patients or where intubation readiness is required.MethodA qualitative study was conducted using the critical incident technique. During March and April 2020, 12 semi-structured interviews were conducted with nurse anaesthetists and intensive care nurses. Data were analysed according to the critical incident technique, and a total of 197 critical incidents were identified. The analysis revealed five final strategies for safe interhospital transport.ResultsParticipants described the importance of ensuring clear and adequate information transfers between caregivers to obtain vital patient information that enables the nurse in charge to identify risks and problems in advance and create an action plan. Stabilising and optimising the patient’s condition before departure and preparing drugs and equipment were other strategies described by the participants, as well as requesting assistance or support if questions or complications arose during transport.ConclusionTransports with intubated patients or where intubation readiness is required are complex and require systematic patient-safety work to ensure that strategies for increasing patient safety and decreasing risks are visible to the nurses in charge, that they are applied, and that they are, indeed, effective.     

Patient care during interfacility transport: a narrative review of managing diverse disease states

BACKGROUND: When critically ill patients require specialized treatment that exceeds the capability of the index hospitals, patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care. Therefore, appropriate and efficient care for patients during the process of transport between two hospitals(interfacility transfer) is an essential part of patient care. While medical adverse events may occur during the interfacility transfer process, there have not been evi...     

Safe long-distance interhospital ground transfer of critically ill patients with acute severe unstable respiratory and circulatory failure

OBJECTIVE: To assess the safety of long-distance ground interhospital transport of critically ill patients with the most severe unstable respiratory failure after establishment of a dedicated transport system. DESIGN AND SETTING: Cohort study, retrospective chart review in 13 hospitals and intensive care units (ICU) in Finland, and a tertiary referral center and ICU of a university hospital. PATIENTS: 66 consecutive critically ill patients who were transferred to our ICU from 13 different ICUs in Finland because of severe, progressive respiratory failure, 52 (79%) with acute respiratory distress syndrome. MEASUREMENTS AND RESULTS: Major complications during transfer and patients' oxygenation. The median transfer distance was 161 km (range 120-460 km). Drugs for cardiovascular support were infused in 59 patients (89%) during transfer. Fourteen patients (21%) were transferred in prone position because of life-threatening hypoxemia. The ratio of arterial blood PaO(2) and the fraction of oxygen in the ventilator was 8.5+/-2.7 kPa (64+/-20 mmHg) before transfer and 9.7+/-3.6 kPa (73+/-27 mmHg) after transfer. There were no major complications during the transfer. ICU mortality was 30%. CONCLUSIONS: Long-distance interhospital ground transfer of even critically ill patients with severe unstable respiratory and circulatory failure is safe if a dedicated transport team and a specially equipped transport vehicle are used.     

Interhospital transport. A pediatric perspective.

Interhospital transport of children must not be undertaken in a vacuum. Basic medical ethics and federal laws demand that there be some responsibility in providing adequate care during the transport process, and that this care meets or exceeds the level provided by the referring hospital. The care provided must also be appropriate to the severity of illness of the transported children. National guidelines and standards are needed to establish and coordinate a uniform interhospital transport process for critically ill children.     

Factors that contribute to complications during intrahospital transport of the critically ill.

Transporting patients from the protective environment of the intensive care (ICU) unit to other areas of the hospital has become increasingly common since high technologic testing has become an integral part of health care assessment. The hazards of moving critically ill patients by ambulance or air transport are well recognized and standards of care have been developed based on delineation of these risks. Despite the existing evidence of hazards of interhospital hospital transport, less attention has been given to the potential hazards associated with the intrahospital transport of critically ill patients. A high incidence of serious hemodynamic or respiratory alteration is associated with the intrahospital transport of critically ill patients. In one third of critically ill intrahospital transports, technical mishaps (eg, i.v. disconnects, which could potentially lead to deleterious physiologic outcomes) may occur. As patient acuity increases, there is a greater risk of hemodynamic instability. The purpose of this study was to further investigate the patient complications during transportation to and from the ICU to a diagnostic or treatment site. The sample consisted of thirty-five critically ill patients from the Neuro/Trauma ICU who required continuous physiological monitoring and had an arterial catheter in place. The systemic blood pressure, heart rate and peripheral oxygen saturation were monitored at nine time points throughout the transport process. The incidence of defined technical mishaps that occurred when the patient was off the unit were also recorded. Transport factors examined included the length of time spent off the unit and the number and level of personnel accompanying the patient. A within-subject repeat measure design was used to examine the physiologic changes and mishaps that occurred. Results indicate that while the majority of patients experienced some physiologic responses as a result of transport, the responses were not of sufficient magnitude to be classified as a deleterious. Twenty-three technical mishaps, which included inadvertent ventilator and electrocardiogram disconnects, power failures, interruption of medication administration and disconnection of drainage devices were observed. Factors related to these occurrences of technical mishaps were the number of intravenous solutions and infusion pumps and the time spent outside of the ICU environment.     

Evaluation of a portable blood gas analyzer for pediatric interhospital transport

We evaluated a portable blood gas analyzer for its speed, reliability, and usefulness during interhospital transportation of critically ill children in a prospective study. The accuracy of a portable blood gas analyzer (PBGA) was first established by comparing its results with values obtained from a standard blood gas analyzer. The speed, accuracy, and usefulness of the PBGA were then compared with those of standard analyzers at 10 referring hospitals during interhospital transportation of critically ill children. A highly significant linear correlation was demonstrated between values obtained using the PBGA and those derived from standard analyzers. The time required to obtain blood gas results was 2 min with the portable device, significantly less than the mean of 8.4 min ± 6.4 min (range 1–24 min) required to get results from the laboratory facilities of the referring hospitals. Modification of treatment or adjustment to mechanical ventilation was required in 30% of transported patients based on blood gas results obtained immediately before departure from the referring hospital. We conclude that a portable blood gas analyzer provides rapid, reliable, and useful data that help to determine therapy for critically ill children awaiting interhospital transport.     

Evaluation of a portable blood gas analyzer for pediatric interhospital transport

We evaluated a portable blood gas analyzer for its speed, reliability, and usefulness during interhospital transportation of critically ill children in a prospective study. The accuracy of a portable blood gas analyzer (PBGA) was first established by comparing its results with values obtained from a standard blood gas analyzer. The speed, accuracy, and usefulness of the PBGA were then compared with those of standard analyzers at 10 referring hospitals during interhospital transportation of critically ill children. A highly significant linear correlation was demonstrated between values obtained using the PBGA and those derived from standard analyzers. The time required to obtain blood gas results was 2 min with the portable device, significantly less than the mean of 8.4 min ± 6.4 min (range 1–24 min) required to get results from the laboratory facilities of the referring hospitals. Modification of treatment or adjustment to mechanical ventilation was required in 30% of transported patients based on blood gas results obtained immediately before departure from the referring hospital. We conclude that a portable blood gas analyzer provides rapid, reliable, and useful data that help to determine therapy for critically ill children awaiting interhospital transport.     

Equipment review: Intrahospital transport of critically ill patients

Background

This review on the current literature of the intrahospitaltransport of critically ill patients addresses type and incidence of adverseeffects, risk factors and risk assessment, and the available information onefficiency and cost-effectiveness of transferring such patients for diagnosticor therapeutic interventions within hospital. Methods and guidelines to preventor reduce potential hazards and complications are provided.

Methods

A Medline search was performed using the terms 'criticalillness', 'transport of patients', 'patienttransfer', 'critical care', 'monitoring' and'intrahospital transport', and all information concerning theintrahospital transport of patients was considered.

Results

Adverse effects may occur in up to 70% of transports. They includea change in heart rate, arterial hypotension and hypertension, increasedintracranial pressure, arrhythmias, cardiac arrest and a change in respiratoryrate, hypocapnia and hypercapnia, and significant hypoxaemia. Notransport-related deaths have been reported. In up to one-third of casesmishaps during transport were equipment related. A long-term deterioration ofrespiratory function was observed in 12% of cases. Patient-related riskindicators were found to be a high Therapeutic Intervention Severity Score,mechanical ventilation, ventilation with positive end-expiratory pressure andhigh injury severity score. Patients' age, duration of transport,destination of transport, Acute Physiology and Chronic Health Evaluation IIscore, personnel accompanying the patient and other factors were not found tocorrelate with an increased rate of complications. Transports for diagnosticprocedures resulted in a change in patient management in 40-50% of cases,indicating a good risk:benefit ratio.

Conclusions

To prevent adverse effects of intrahospital transports, guidelinesconcerning the organization of transports, the personnel, equipment andmonitoring should be followed. In particular, the presence of a critical carephysician during transport, proper equipment to monitor vital functions and totreat such disturbances immediately, and close control of the patient'sventilation appear to be of major importance. It appears useful to usespecifically constructed carts including standard intensive care unitventilators in a selected group of patients. To further reduce the rate ofinadvertent mishaps resulting from transports, alternative diagnosticmodalities or techniques and performing surgical procedures in the intensivecare unit should be considered.     

Quality of interhospital transport of the critically ill: impact of a Mobile Intensive Care Unit with a specialized retrieval team

Introduction  

In order to minimize the additional risk of interhospital transport of critically ill patients, we started a mobile intensive care unit (MICU) with a specialized retrieval team, reaching out from our university hospital-based intensive care unit to our adherence region in March 2009. To evaluate the effects of this implementation, we performed a prospective audit comparing adverse events and patient stability during MICU transfers with our previous data on transfers performed by standard ambulance.     

Intensive insulin therapy for critically ill patients

OBJECTIVE: To evaluate the clinical outcomes of glycemic control of intensive insulin therapy and recommend its place in the management of critically ill patients. DATA SOURCES: Searches of MEDLINE (1966-March 2004) and Cochrane Library, as well as an extensive manual review of abstracts were performed using the key search terms hyperglycemia, insulin, intensive care unit, critically ill, outcomes, and guidelines and algorithms. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and deemed relevant if they included and assessed clinical outcomes. DATA SYNTHESIS: Mortality among patients with prolonged critical illness exceeds 20%, and most deaths are attributable to sepsis and multisystem organ failure. Hyperglycemia is common in critically ill patients, even in those with no history of diabetes mellitus. Maintaining normoglycemia with insulin in critically ill patients has been shown to improve neurologic, cardiovascular, and infectious outcomes. Most importantly, morbidity and mortality are reduced with aggressive insulin therapy. This information can be implemented into protocols to maintain strict control of glucose. CONCLUSIONS: Use of insulin protocols in critically ill patients improves blood glucose control and reduces morbidity and mortality in critically ill populations. Glucose levels in critically ill patients should be controlled through implementation of insulin protocols with the goal to achieve normoglycemia, regardless of a history of diabetes. Frequent monitoring is imperative to avoid hypoglycemia.     

Position paper on critical care pharmacy services. Society of Critical Care Medicine and American College of Clinical Pharmacy Task Force on Critical Care Pharmacy Services

OBJECTIVE: The goal of the Task Force on Critical Care Pharmacy Services was to identify and describe the scope of practice that characterizes the critical care pharmacist and critical care pharmacy services. Specifically, the aims were to define the level of clinical practice and specialized skills characterizing the critical care pharmacist as clinician, educator, researcher, and manager; and to recommend fundamental, desirable, and optimal pharmacy services and personnel requirements for the provision of pharmaceutical care to critically ill patients. Hospitals having comprehensive resources as well as those with more limited resources were considered. DATA SOURCES: Consensus opinion of critical care pharmacists from institutions of various sizes providing critical care services within several types of pharmacy practice models was obtained, including community-based and academic practice settings. Existing guidelines and literature describing pharmacy practice and medication use processes were reviewed and adapted for the critical care setting. CONCLUSIONS: By combining the strengths and expertise of critical care pharmacy specialists with existing supporting literature, these recommendations define the level of clinical practice and specialized skills that characterize the critical care pharmacist as clinician, educator, researcher, and manager. This Position Paper recommends fundamental, desirable, and optimal pharmacy services as well as personnel requirements for the provision of pharmaceutical care to critically ill patients.     

Comparison of interhospital pediatric intensive care transport accompanied by a referring specialist or a specialist retrieval team

Objective Interhospital transfers of critically ill pediatric patients in The Netherlands are accompanied by referring specialists or by specialist retrieval teams. We compared the interventions before and directly after transports and the complications and the equipment available during transports in the two groups.Design and setting Prospective observational clinical study in pediatric intensive care units of Dutch university hospitals.Patients 249 pediatric patients requiring interhospital intensive care transport.Methods Data were collected on interhospital pediatric intensive care transports. We compared patient characteristics, interventions before and directly after transport, complications and equipment available during transport (137 accompanied by referring specialists, 112 by specialist retrieval teams).Results Interhospital transports accompanied by referring specialists had a longer average transport time (74.6 vs. 60.2 min), higher incidence of respiratory insufficiency (56.9% vs. 41.1%), and lower incidence of circulatory insufficiency (27.0% vs. 41.1%) than primary admission diagnoses. These transports had a lower percentage of ventilatory support (47.4% vs. 72.3%), higher need for acute interventions directly upon arrival on the pediatric ICU, and higher incidence of critical and serious complications. In 75% of the transfers accompanied by retrieval teams interventions before the transport were deemed to be necessary. During the transports accompanied by referring specialists the equipment and materials available proved rather limited.Conclusions During pediatric intensive care transports accompanied by nontrained referring specialists there appears to be a higher incidence of complications, specialized equipment is more often not available, and more acute interventions are required upon arrival in the pediatric ICU.     

Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care

OBJECTIVES: To describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level. PARTICIPANTS: A multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM). DATA SOURCES AND SYNTHESIS: Relevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts. Consensus for the final written document was reached through collaboration in meetings and through electronic communication modalities. Literature cited included previously written guidelines from the ACCM, published expert opinion and statements from official organizations, published review articles, and nonrandomized, historical cohort investigations. With this background, the ACCM writing panel described a three-tiered system of intensive care units determined by service-based criteria. CONCLUSIONS: Guidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.     

Managing bioterrorism mass casualties in an emergency department: lessons learned from a rural community hospital disaster drill.

Bioterrorism represents a threat for which most emergency departments (EDs) are ill prepared. In order to develop an evidence-based plan for ED and hospital management of contaminated patients, a review was conducted of the most effective strategies developed during the severe acute respiratory syndrome (SARS) epidemic, as well as Centers for Disease Control and Prevention and military guidelines on biowarfare. Six basic steps were identified: 1) lock down the hospital and control access to the ED; 2) protect emergency care personnel with appropriate personal protective equipment; 3) decontaminate and triage patients; 4) isolate patients; 5) treat patients with appropriate medications or measures, including decontamination of wounds; and 6) use restrictive admission and transfer guidelines. By emphasizing these six basic concepts, a rural ED passed an annual state-run bioterrorism mass-casualty drill. The drill provided health care personnel with the knowledge and skills necessary to prepare for future bioterrorism casualties. These same concepts could also be used to manage highly virulent viral or bacterial outbreaks.     

Physical stresses related to the transport of the critically ill: optimal nursing management.

The critically ill patient's physical well being is constantly at risk. This fragile physical state means the patient is vulnerable to a host of hazards within the critical care setting, none of which are more relevant to patient outcome than the hazards awaiting them should the patient require transportation. The stresses exerted on the human body and the vulnerability of the critically ill to various means of movement, transport and subsequent environmental changes are explored through this review. The review includes a brief history of the evolution of patient transportation, which has provided a basis for the inception of formal strategies in patient management related to transportation. Within this framework current optimal nursing management minimising the detrimental effects of transport on the critically ill is reasoned to its scientific base. The basic laws of physics are an important consideration in all modes of patient movement or transport and play an integral role in the critical care nurses' practice. A clear understanding of pathophysiological and technological processes involved in caring for the critically ill and applying the principles of physics to effective contextual practice enhances the capability of the critical care nurse.