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Inter hospital transfer of the critically ill patients
Dr. Mesaros Daniel
AAGBI 2009European Society Of Intensive Care Medicine
Introduction
• appropriate clinical reasons
• difficult and potentially dangerous
• appropriate personal, equipment, training and support
BACKGROUND
• Recommendations• Indications• Risks• Planning the transfer• Conduct of the transfer
Recommendations
• Transfer can be safely even in extremely ill patients• Decision must involve a senior and experienced clinician• Protocols, documentations and equipment should be
standardized within networks• Appropriate competencies, qualifications and experience• Hospital must ensure: - suitable transfer equipment - adequate insurance cover - personal & equipment can safely return to base • Recorded and review
Indications
• Technical and professional expertise: - neurosurgery - interventional radiology - percutaneous transluminal coronary angioplasty - continuous renal replacement therapy - organ transplantation - specific critical care interventions ( mechanical ventilation in prone postion)
• Organizational aspects: - lack of available beds - massive influx of patients
Risks of transport• Technical complications – displacement of tubes,
Intravascular lines
• Pathophysiological deteriorations: - increased intracranial pressure - systemic hypotension/hypertension crisis - cardiac arrhytmias/arrest - drop in oxygenation saturation/airway obstruction
• Additional movements: - acceleration/deceleration - tilting/lifting
• Inadequate monitoring of cardiopulmonary function due to less advanced equipment/interference due to motion, etc…
Deciding/planning the transfer• Made by senior/consultant • Influenced by multiple factors: - course of disease (improvement/deterioration? - communication - staffing: medical, paramedical - logistics: equipment, resources - transport condition: distance, weather - modes of transportation: ambulance, helicopter, aircraft - handing over: documents, information - medico legal and ethical aspects
Transfer team
• Specialized transport teams provide better care with decreased morbidity during and after transport
• Two qualified personnel• Vehicle operator• Respiratory therapist
Transfer equipment
• Airway management equipment• Medication• Electric devices• Trolley• Oxygen cylinder
Airway equipment
Airway management equipment
• Resuscitation kit• Bag & mask• Oral airway• Laryngoscope & blade different sizes• ET tubes different sizes• Suction devices• Nebulizer• Adhesive tape
Oxygen cylinder
Electronic devices
Pule oxymeter
Infusion pumpsECGInvasive/noninvasive BPEnd-tidal capnographyTemperature
Monitors
Standard resuscitations drugs
• Sedatives• Analgesics• Muscles relaxants• Inotropes
Trolley
Conduct the transfer
• Check trolley and all equipment before and after each transfer
• Preparing patient for transport: - secure intra venous access - airway stabilization - trauma victims – spinal mobilization - nasogastric tube - Foley’s catheterization - chest tube insertion - all drains - infusion pump & IV drips functioning properly - soft wrist and leg restraints - vital signs displayed on monitors - patient is safely secured on a trolley
• Documentation
In transit procedure
• Best route
• Status of patient checked of intervals
• Continuous monitoring
Arrival procedure
• Assessment
• Shifted
• Complete handover
• Documentation – patient status with time
Conclusions• Systematic approach• Careful planning• Benefits and risks should be weighed in every
individual critically ill patient before transport • Anticipate the worst, think about possible
complications and have a plan for how to react• With sufficient preparation and good equipment
transfer is possible without an adverse event• Early communication will give you enough time to
organize additional personnel & transfer itself• Proper use of personnel• Selection and availability of appropriate equipment
Thank you