We have no ICU beds. These are the
words dreaded by us, on call anaesthetic registrars. It means local hospital has run out of ICU beds and now I need to find an ICU bed for this poor patient within my region or outside the region. Thus starts the chain of events- a formalized process in UK ‘Transfer of critically ill patient’ that will be described in this article.
Transfer of the critically ill patients is needed both in developed and developing countries due to lack of local resources. In the UK, recent Department of Health figures suggest total number of critical care beds as 3236, out of which ICU beds are 1793 and HDU are 1443. Despite this the transfer of critically ill patients has continued to rise as intensive care treatment is considered as necessity rather than luxury. Such transfers are predominantly done by road.
This has lead to the increased awareness of problems that could arise while doing such transfers. Courses have been developed to teach nurses and doctors alike, the principles of safe transfer. It is compulsory for Anaesthetic trainees to attend one of these courses before they can undertake transfers. UK intensive Care Society has formulated ‘Guidelines for the Transport of Critically Ill Adult’ to outline the minimum recommendations to ensure safe intra and inter hospital transport.
Common reported adverse events that one needs to be aware of while doing such transfers are:
- Cardiovascular instability- swings in blood pressure, arrhythmias
- Equipment problems- monitor
failure, unavailability of equipment
- Significant hypoxia due to variety of reasons
- Ambulance breakdown
- Death in transfer
These adverse events could be easily avoided if one approaches the situation in a systematic fashion. One such approach described in ‘Safe Transfer and Retrieval course’
(STaR) is according to following principles:
The systematic approach to patient transfer
A assessment
C control
C communication
E evaluation
P preparation and packaging
T transportation
Assessment : The relevant problems in a critically ill patient and actions being taken to address these problems constitute the assessment of the transfer situation. The ‘ABCDE” approach is usually used to assess the patient and this helps to formulate patient’s story in a nutshell.
Control : After initial assessment someone is designated to take control of the situation. This is usually a senior member of the anaesthetic team who will identify all the tasks related- to continue patient care, to mobilise equipments and resources and finally will communicate with the relevant hospital.
Communication: Clinicians and nurses at both end of the transfer need to communicate frequently so as to relay latest information about patient’s changing physiology. This is especially relevant in case of specialised transfer of such a patient with head injury that is being referred to neurosurgical centre.
Evaluation: Patient is constantly evaluated to determine the urgency of transfer and need for the transfer. A patient with ruptured aortic aneurysm needs to get to vascular centre immediately rather than a patient with exacerbation of Chronic Obstructive Airway Disease. Calls to the ambulance get prioritised according to this evaluation.
Preparation and packaging: This involves patient preparation, equipment preparation and preparation of medical staff undertaking transfers.
Patient preparation: ABCDE approach is once again used. Definitive airway in the form of endotracheal intubation is usually needed if there is any concern about patient’s airway and breathing. Chest drains if present need special care during transfer and must never be clamped. Circulation has to be optimised prior to transfer by securing at least 2 big bore intravenous access and at times by central venous access. Circulatory support may be needed for transfer in the form of ionotrope infusions. Disability in the form of suspected cervical spine injury needs neck support by use of hard collar and blocks. A naso/oro gastric tube and urinary catheter are other relevant considerations.
Equipment preparation: An adequately equipped vehicle consisting of adequate oxygen supply, suction, defibrillator and portable ventilator is used. Portable monitors giving information about oxygen saturation, end tidal CO2 and cardiovascular parameters are essential for safe transfer. The monitors need to have enough battery life to last the transfer. A transport rucksack containing all vital drugs, syringes, intubation devices etc is usually carried by the accompanying staff.
Staff preparation: In addition to paramedics on the ambulance, there are usually two accompanying staff for the transfer. An experienced doctor with skills in resuscitation and airway control and another doctor or experienced nurse with familiarity in transfer procedures constitute the transfer team. They need to be familiar with patient’s condition and the equipments.
Transportation: This final step involves actions to be taken to ensure safe transfer of the patient at various stages of transfer such as from referring hospital to the ambulance and from ambulance to the receiving hospital. The movement involved in this can lead to all possible disasters such as accidental extubation or IV access dislodgement. Such threats need to be considered pre-emptively so as to take actions without compromising patient safety.
All the above stepwise considerations are well rehearsed in courses on transfer of critically ill patients. It helps to minimise the adverse events that could occur in such transfers. The above short synopsis is to encourage readers to think carefully before undertaking transfer of critically ill and improve the local conditions to the best of available resources.
References
1. Warren J, Fromm RE Jr, Orr RA, Rotello LC, Horst HM. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004;32 (1) : 256-62.
2. Peter Driscoll, et al. (Advanced Life Support Group), Safe Transfer and Retrieval-The Practical Approach, Second edition 2006, Blackwell publishing, BMJ books. |
