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Transporting the critically ill

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BENEFITS OF PRE-HOSPITAL EMERGENCY TREATMENT

The provision of pre-hospital emergency medical services is of proven value for victims of a cardiac arrest provided that cardiopulmonary resuscitation is initiated by a bystander, the paramedics arrive at the scene within a few minutes and the patient is rapidly transferred to hospital for definitive care. The benefits for trauma victims are less clear, except when a coordinated approach from primary transport to specialized trauma centres is established (see below; Biewener et al., 2004).

SECONDARY TRANSPORT

SECONDARY TRANSPORT

Considerably fewer seriously ill patients require secondary transport, although in the UK it is thought that at least 10 000 critically ill patients require interhospital transfer

each year (Mackenzie et al., 1997). The increasing tendency to concentrate specialist services such as trauma, neurosur- gery, plastic surgery, cardiothoracic surgery, nephrology and intensive care in regional centres is likely to increase the demand for secondary transfer of the most seriously ill patients (Wallace and Lawler, 1997).

PRINCIPLES OF SAFE SECONDARY TRANSPORT (Tables 21.1 and 21.2) (Australian and New Zealand College of Anaesthetists, Joint Faculty of Intensive Care Medicine, Australasian College for Emergency Medicine, 2003; Intensive Care Society, 2002; Wallace and Ridley, 1999; Warren et al., 2004) Optimize patient’s condition before transfer

Prior stabilization is fundamental to the safe transfer of critically ill patients – the ‘scoop and run’ approach descri- bed above for primary transport is not appropriate in this

Table 21.1 Transporting critically ill patients: a checklist

Administration

Equipment

Establish effective communication between transferring and receiving hospitals and ambulance authority

Provision of respiratory support and monitoring Equipment for airway management Gas supply: oxygen ± air Cylinders Portable liquid oxygen containers Air compressor Portable ventilator Heat and moisture exchanger Suction apparatus (Extracorporeal membrane oxygenation) Airway pressure gauge Pulse oximeter Capnography

Notify and explain reasons for transfer to relatives

For the conscious patient, explain the reasons for the transfer

Collect together patient records to accompany patient

Ensure appropriately experienced and qualified staff accompany patient

Select most appropriate mode of transport: surface ambulance, air transport (fixed-wing, helicopter), sea

Before transfer, receiving location confirms that they are ready to receive the patient

Provision of cardiovascular monitoring and support Fluid administration: infusion pumps Vasoactive agents and inotropes: syringe pumps Portable defibrillator Continuous electrocardiogram monitoring Continuous direct intra-arterial pressure monitoring (Pulmonary artery pressures) (Intracranial pressure) (Cardiac output) (Intra-aortic balloon pump) (Continuous haemofiltration)

Document reasons for transfer in medical record

Preparation of patient

Optimize patient’s condition Circulating volume Haemodynamic support Respiratory support Appropriate monitoring Evaluate need for sedation, analgesia and muscle relaxants Rarely need surgery before transfer

Drugs

Underwater seal drains: do not clamp or lift above patient

Resuscitation drugs

Nutritional support: if this is discontinued, beware of hypoglycaemia

Antiarrhythmics

Sedatives/analgesics

Muscle relaxants

Maintain body temperature (warming blanket)

Crystalloids/colloids

Investigations Radiographs to confirm position of endotracheal tube, intravascular cannulae and chest drains

Mobile phones

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INTENSIVE CARE

Table 21.2 Principles of safe transfer

Experienced staff

Appropriate equipment and vehicle

Full assessment and investigation

Comprehensive monitoring

Stabilize patient before transfer

Reassessment before transport

Continuing care during transfer

Direct handover

Documentation and audit

situation (Gebremichael et al., 2000; Uusaro et al., 2002). A detailed systems-based assessment of the patient’s condition should be performed before instituting measures to prepare the patient for transfer. Most will require optimization of their circulating volume (hypovolaemic patients are intoler- ant of transfer), as well as institution of mechanical ventila- tion and appropriate monitoring if these are not already in progress. Needless to say, reliable venous access must be established. Because endotracheal intubation in transit can be extremely difficult it is advisable to intubate those at risk of developing a compromised airway or respiratory failure before departure. Intubated patients should be mechanically ventilated. It is important to ensure adequate sedation, analgesia and, when indicated, muscle relaxation before moving the patient. A few may need surgery before transfer (e.g. to evacuate an acute intracranial haematoma). Investigations may include radiographs to confirm the positions of the endotracheal tube, intravascular cannulae and chest drains. These must be securely tied or sutured in place before moving the patient. Underwater seal drains should not be clamped or lifted above the patient during transfer. It is important to appreciate that abrupt cessation of glucose administration (e.g. if parenteral nutrition is discontinued) may precipitate dangerous hypoglycaemia. A nasogastric tube should be inserted in those with an ileus or intestinal obstruction and in patients requiring mechanical ventila- tion. Measures should be taken to maintain body tempera- ture. If the patient is conscious the proposed transfer and all that is entailed should be explained to him or her.

Maintain a high standard of care during transfer

In general there should be no reduction in the level of care during transport; it is strongly recommended that a minimum of two people accompany all critically ill patients. Medically qualified personnel are nearly always involved in secondary transport, although occasionally it may be accept- able for a stable patient to be transferred by an experienced critical care nurse with another non-physician member of the critical care team (e.g. technician, paramedic). All unsta-

ble patients must, however, be accompanied by an appropri- ately trained doctor. In some countries (e.g. North America, Australia and France) comprehensive transport systems have been developed, but in the UK the provision of specialist services for secondary transfer remains poor and around 90% of patients are accompanied by staff from the referring hospital. Not only does this deprive the base hospital of on- call staff but the accompanying clinical team will usually have only limited experience of transferring critically ill patients. This may partly account for the observation that medical care during transfer is often deficient. In a series of 50 mainly postoperative patients, for example, 7 developed life-threat- ening complications, including obstruction of an endotra- cheal tube, respiratory arrest, unrecognized disconnection of arterial and central venous cannulae and severe hypotension (Bion et al., 1988). This study also suggested that patients under the care of experienced anaesthetists deteriorated less during transport than those supervised by other medical specialties (Bion et al., 1988). It is therefore recommended that the patient should be accompanied by an experienced doctor competent in resuscitation, airway care, ventilation and other organ support. This doctor, usually an anaesthe- tist, should preferably have received training in intensive care and should ideally be trained and have experience in trans- port medicine (Koppenberg and Taeger, 2002). The doctor should be assisted by another doctor or a nurse, paramedic or technician familiar with intensive care procedures and equipment, although in many countries staff shortages mean that this ideal is not always achieved (Wallace and Ridley, 1999). A service for transporting extremely ill patients has been described in which the team consists of an attending physician with critical care training, a critical care nurse and a respiratory therapist. Even the driver has expertise and training in respiratory therapy, critical care medicine and transport physiology (Gebremichael et al., 2000). Personnel involved in patient transfer should not be prone to motion sickness, should not have ear or sinus dis- orders and should have no difficulty with working in a con- fined space. Although in general the patient’s condition improves after initial resuscitation and, with careful medical care, does not usually deteriorate further during transport (Bion et al., 1985), invasive monitoring, including pulmo- nary artery catheterization, has clearly demonstrated that transport can sometimes adversely affect even patients who have been adequately resuscitated. The use of a specialist transfer team has been associated with significantly improved acute physiology of critically ill patients on arrival in the receiving unit and may reduce early mortality (Bellingan et al., 2000). Certainly critically ill patients can be safely transferred provided that those involved are appropriately trained and equipped, with fewer than 1% dying during transfer and only 3% dying within 12 hours of arrival in the receiving unit (Bellingan et al., 2000; Markakis et al., 2006). Even the most seriously ill patients with severe, unstable respiratory and circulatory failure can

Transporting the critically ill

545

be safely transferred over long distances by a dedicated transfer team using a customized, fully equipped ground transport vehicle (Gebremichael et al., 2000; Uusaro et al., 2002). It is even possible to transfer patients safely with severe acute respiratory distress syndrome (ARDS) without major complications (Gebremichael et al., 2000; Uusaro et al., 2002) and extracorporeal membrane oxygenation has been used during the transfer of hypoxaemic patients with severe ARDS (Rossaint et al., 1997).

Communication and cooperation

Communication and cooperation between the transferring and receiving hospitals, as well as close liaison with the ambulance authority, are fundamental to the success of sec- ondary transport. A decision to transfer should be made by senior clinicians only after a full assessment and discussion between referring and receiving hospitals, taking into account the balance of risk and benefit. The receiving unit should be informed of the estimated time of arrival. Conti- nuity of patient care must be ensured by effective commu- nication between medical and nursing staff at the referring and receiving institutions. Changes in the patient’s condition and response to treatment during transfer should be recorded and this, together with a written summary of the patient’s history (including the results of relevant laboratory investi- gations and imaging), and initial treatment and the indica- tion for transfer, must be handed over to the receiving staff. When transfer is urgent, however, the preparation of written records should not delay departure – necessary documenta- tion can be delivered later.

MODES OF TRANSPORT

MODES OF TRANSPORT

Selection of the most appropriate mode of transport should be individualized and requires consideration of the following:

the patient’s diagnosis and the possible effects of trans- port on his or her condition;

the degree of any instability;

the urgency of the transfer;

the level of medical care the patient is receiving;

the level of medical care the patient requires;

the availability and experience of staff,

the distance and duration of the journey;

the methods of transport available;

the weather and traffic conditions;

cost.

As a general principle transport should be performed smoothly, rather than at high speed.

SURFACE AMBULANCES

Surface ambulances are probably the most practical and effi- cient means of transport within urban areas and for jour- neys not exceeding 40–80 km (25–50 miles) or 2 hours’

duration, and are satisfactory for the majority of patients. Despite recent improvements in the design of standard ambulances, however, unmodified multipurpose vehicles are not ideal for transferring critically ill patients. On the other hand, purpose-built mobile ICUs (MICUs) or critical care ambulances are expensive and inflexible. The advantages of surface ambulances include:

rapid mobilization,

door-to-door service;

no requirement for landing zone or runway;

little or no restrictions due to weather;

in an emergency the vehicle can be stopped at the road- side to facilitate performance of procedures;

can divert to the nearest hospital if the patient deterio- rates or supplies are exhausted;

relative ease of personnel training,

low cost.

The main disadvantages of surface transport include:

long journey times, especially when there is traffic con- gestion, poor road conditions, inclement weather or roadworks;

the uncomfortable rough ride, ‘sway and bounce’, vibra- tion, repetitive acceleration/deceleration;

motion sickness;

limited accessibility, poor lighting and limited power;

difficulty gaining access to remote or restricted areas.

AIR TRANSPORT

The main advantage of air transport is the shorter journey time; it is therefore used more frequently in North America and Australia where patients often have to be transported over long distances. Air transport may also be used to achieve rapid delivery of paramedics and doctors to the scene of the incident (see above). Elective movement of patients between hospitals by air may also be preferred because of the reduc- tion in journey times. Generally air transport should be considered for journeys longer than about 80 km (50 miles), although the apparent speed often has to be balanced against organizational delays and the need for transfer between vehicles at the beginning and/or end of the journey. Secondary transportation of trauma victims by air fol- lowing stabilization at the receiving hospital can be per- formed safely and many consider this to be an important aspect of regionalized trauma care. Some authors (Moylan et al., 1988) have demonstrated improved survival of trauma victims transported by air rather than surface ambulance, although the efficacy of air transport may depend on local geography, since in an urban setting the use of a helicopter appeared to offer no advantage compared to a sophisticated paramedic-based system of pre-hospital care (Schiller et al., 1988). Certainly in the immediate vicinity of a trauma centre there appears to be no advantage of a helicopter emergency medical service (HEMS) as compared to ground ambulance. Further, even when the accident is a long distance from the

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Extracts © 2008 Elsevier Limited. All rights reserved.

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