CRITICAL ILLNESS AND INTENSIVE CARE: I

Transporting the adultcritically ill patientTerry Martin

AbstractMore than 10,000 intensive care patients are transferred each year in the

UK, of whom the vast majority are accompanied by staff from the referring

hospital. The high frequency of transfer of critically ill patients is primarily

due to the escalating complexity of healthcare, the concentration of skills

into specialized regional centres, and the relative lack of availability of

intensive care unit (ICU) beds. The care practised during the constraints

of patient transfer (whether within or between hospitals) should attempt

to mirror the detailed attention provided in the hospital ICU, and it is the

responsibility of the transport team to ensure the efficacy of the process

and safety of the patient. This is achieved through careful preparation and

planning and preparation starts with adequate and appropriate training

of transfer personnel as well as selection of equipment which is fit for

purpose. Success is based on anticipation and prevention of potential

complications and hazards to the patient and transfer team. This article

gives an overview of the hazards, organization, and planning of patient

transfers, and highlights the importance of interdisciplinary teamwork,

good communications, and appropriate decision-making. It also

discusses special situations encountered in the transfer or retrieval of

patients with complex needs, such as those requiring intra-aortic balloon

counterpulsation or extracorporeal membrane oxygenation.

Keywords ICU transfer; inter-hospital transfer; patient transfer; patient

transport; retrieval

Introduction

The frequency of transfer of critically ill patients between

hospitals has been increasing ever since the development of

intensive care medicine. This is mostly due to the escalating

complexity of healthcare, the concentration of skills into

specialized regional centres, and the relative lack of intensive

care bed availability. In addition, the slow drift of hospital

mergers with subsequent decrease to lower levels of acuity in

some is likely to see a significant increase in transfer activity in

the coming years. Although the principles of safe transport

between intensive care units (ICUs) are no different to those of

any other patient transfer, critical care patients offer the most

difficult challenges and require detailed planning, preparation,

skill, knowledge and teamwork to achieve success. Even the

transport of patients between two departments in one hospital

can be challenging and risky. Success is based on anticipation

and prevention of potential complications and hazards to both

patient and the transfer team.

Terry Martin BSc FRCS(Ed) FRCA is a Consultant in Intensive Care and

Anaesthesia at Royal Hampshire County Hospital, Winchester, UK.

Conflicts of interest: none declared.

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Inter-ICU transfers in the UK

� There are approximately 300 critical care units in the UK.

� Most hospitals transfer fewer than 20 patients each year,

but some regional centres transfer many more.

� More than 10,000 intensive care patients are transferred

annually in the UK.

� Most patients are accompanied by staff from the referring

hospital.

The aim of most transfers is to achieve a higher level of care for

the patient. This may be because the patient needs specialist

referral for diagnostic services (such as cardiac catheterization,

neurophysiology or nuclear medicine), or because definitive

management requires the skills of specialist teams (such as

neurosurgery, cardiothoracic surgery or extracorporeal membrane

oxygenation (ECMO)). On the other hand, same-level transfers

may be necessary when patients have completed their specialist

diagnostics or therapy and need to be repatriated to the original

referring ICU. Similarly, same-level transfers may result from local

ICU bed shortages, or when patients are transferred to an ICU

nearer home for social, family or financial reasons.

The care carried out in the confined environment of an

ambulance should at least attempt to mirror the detailed atten-

tion provided in a hospital intensive care unit, and it is the

transport team’s responsibility to provide this standard of care.

This is achieved through careful preparation and planning.

Preparation starts with training of the personnel and selection of

optimal equipment. Planning needs to consider the patient’s

physiologic reserve, available supplies of oxygen and electrical

power, and the crew’s ability to sustain high performance for the

duration of the transfer. At the very least, the transfer should do

no harm, but studies show that even this aim is not always

possible.

Hazards of transportation

Critically ill patients have deranged physiology, and require

organ support and invasive monitoring. They tolerate movement,

changes in temperature and vibration poorly, and complications

are not uncommon. In transfers between hospitals, audits

suggest that between 4 and 15% of patients arrive at the desti-

nation hospital with detrimental hypoxia or hypotension,1 and

10% have injuries that were not detected before transfer.

Complications en route may be less frequent if senior anaesthe-

tists accompany the patients, or if fewer personnel in specialist

teams are allowed to gather experience. Once in the ambulance,

supervision and advice is difficult to obtain. This is obvious, but

there is no room for complacency even in transfers between

departments of the same hospital.

In a study of 191 incident reports from intra-hospital transfers

in Australia, Beckmann et al2 found that 39% of incidents iden-

tified problems with equipment, and 61% identified patient

management issues. Serious adverse outcomes occurred in 31%

of the reports. These included major physiological derangement

(15%), prolonged hospital stay (4%), physical/psychological

injury (3%) and death (2%). It is interesting to note that of 191

incidents, over 900 contributing factors were highlighted.

Communication problems, inadequate protocols, inadequate

servicing and poor training were prominent factors in equipment-

related incidents. Errors of problem recognition and judgement,

� 2012 Published by Elsevier Ltd.

CRITICAL ILLNESS AND INTENSIVE CARE: I

failure to follow protocols, inadequate patient preparation, haste

and inattention were common management-related incidents.

When the authors conclude that intra-hospital transport poses an

important risk to ICU patients, readers might, not surprisingly,

expect that inter-hospital transfers offer even more opportunities

for error and less-than-optimum performance of both people and

machinery.

The large number of contributing factors compared with the

number of incidents in the Beckmann study suggests that the

‘Swiss Cheese’ model of accidents is alive and well in patient

transport. In an ideal world each defensive layer which protects

a patient from error or incident (such as clinical management

guidelines, human judgement, checklists, monitor alarms, and so

on) would be intact. In reality, however, these layers are more

like slices of Swiss cheese, having many holes. Unlike the cheese,

though, these holes are continually opening, closing, and moving

their location. The presence of holes in any one slice does not

normally cause a bad outcome. Usually, this can happen only

when the holes in many layers momentarily line up to permit

a trajectory of opportunity, bringing hazards into damaging

contact with victims.

Organization

There are two models for the construction of transport teams.

The first is ‘retrieval’, in which the patient is stabilized, collected

and transported by a team from the accepting hospital. The

second is ‘transfer’ when a transport team is despatched by the

referring hospital or an independent ambulance provider. Bellin-

gan et al3 retrospectively compared the use of specialist retrieval

teams (group A e 168 transfers) with the use of a standard

ambulance with junior doctor escort (group B e 91 transfers).

They found that, although there were no significant differences in

demographic characteristics or severity of illness between the two

groups, significantly more patients in group B were severely

acidotic (pH <7.1: 11% vs. 3%, p <0.008) and hypotensive (MAP

<60: 18% vs. 9%, p <0.03) upon arrival at their destination

hospital. In addition, there were more deaths within the first

12 hours after admission with 7.7% deaths (7/91) in group B

transfers compared with 3% (5/168) in group A. Their conclusion

is that the use of specialist retrieval teams may significantly

reduce early mortality in ICU, and the UK Intensive Care Society

and the Association of Anaesthetists of Great Britain now

recommend that retrieval teams from the accepting hospital

should conduct the transfer. Despite this, predominant current UK

practice is group B (i.e. junior doctor from the referring hospital).

Apart from diluting staffing levels, another major disadvantage to

referral hospitals using their own staff to undertake inter-hospital

transfers is that there are too few transfers to allow individual

medical and nursing personnel to gain expertise.

Retrieval teams are most often used by regional centres which

accept specific subspeciality patients. The aim is to send the

retrieval team out to the referring hospital where the patient can

be stabilized before transfer back to the specialist centre for

expertise in definitive management. Currently, this is most often

seen when district ICUs need to transfer children to paediatric

ICU, but other examples include patients being referred for

neurosurgery, interventional radiology, cardiovascular proce-

dures or ECMO.

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Since the majority of patient transfers are still being under-

taken by staff from the referring hospital, at the very least, each

hospital should have the following key criteria.

Minimum requirements for hospitals for patient transfer

� Designated consultant responsible for transfers.

� Guidelines for referral and for the transfer itself.

� Equipment specifically prepared and packed.

� Personnel nominated to check, replenish, clean and

recharge equipment.

� Nominated medical and nursing transfer personnel.

� Training for transfer personnel.

� Good communication within and between hospitals.

� Proper routines for referral between hospitals.

� Regular audit.

In the UK Department of Health document ‘Comprehensive

Critical Care’, the expert group recognized that individual NHS

Trusts, no matter how well resourced, can not meet all peaks in

demand for critical care, nor have the expertise to meet every need

for specialist care. The report recommended the formation of

networks with the objective that the needs of all critically ill

patients in their geographical area are met. Specifically, one of

the objectives was to reduce the numbers of long-distance

transfers that take place for non-clinical reasons. The recom-

mendation contained the following conditions:

� if transfers for non-clinical reasons are essential, they

should be contained within the network and only take

place after consultant-to-consultant discussion and

agreement

� all transfers, including repatriations from overseas and

from other network regions, should be recorded

� each transfer sent outside the network should be regarded

as an adverse incident and appropriately investigated

� special agreements should be reached for transfers

between hospitals within the network and at the borders of

adjacent networks

� standards for safe transfer must be agreed with each

network drawing on guidance published by professional

groups

� the means of achieving these standards may vary

depending on geography and unit size, but dedicated

retrieval teams have been shown to be effective.

A year later, the Department of Health report ‘Quality Critical

Care Beyond Comprehensive Critical Care’, defined the remit of

regional critical care networks (CCNs) in the UK as integration of

critical care standards and provision of high-quality and equi-

table critical care services. One of the major functions of these

CCNs is to work together to ensure an integrated approach to the

planning and delivery of critical care services for a local pop-

ulation. This includes the safe transfer of patients between

hospitals for whatever reason, and CCNs have been fundamental

in ensuring that the key requirements (above) are met by all ICUs

and that there is convergence of procedures and equipment at

least within each region (although not nationally).

Transfer decisions

Poor initial communication is a frequent occurrence for which

there is no easy solution. The details of the patient to be

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CRITICAL ILLNESS AND INTENSIVE CARE: I

transferred must be discussed between the referring and

receiving medical teams at senior (preferably consultant) level.

Clear answers are needed to the following questions:

� Why is transfer occurring now?

� Is the medical risk acceptable?

But other questions can help inmaking decisions with regard to the

logistics of the transfer. These can be simply remembered by:

Why; What; When; Where; Who; How

Why is the transfer taking place?

Is the patient being moved for a higher level of care or for

a diagnostic procedure not available within the referring

hospital? If not, then the reasons should be justifiable, preferably

by demonstrating direct benefit to the patient. This may not

always be possible and agreement with the patient or next of kin

is essential if patients are transferred for non-clinical reasons.

What are the risks?

Risk analysis is essential so that identifiable risks are avoided or

otherwise managed appropriately. Risks may be clinical or

logistic, and there may also be risks to the transfer team to

consider. Clearly, if the risks outweigh the benefits then an

alternative solution must be found.

When should the transfer take place?

The timing of transfer for certain groups of patients is critical.

Guidelines have been published to help the decision-making

process, for example in head injury patients (Neuroanaesthesia

Society of Great Britain and Ireland), but for others it is more

difficult. For instance, in patients with multiple organ failure, the

balance of risk and benefit needs to be carefully considered

before the decision on whether and how to send or retrieve the

patient is made.

Where is the patient’s destination?

It is vital that the transfer team, ambulance crew and next of kin

are informed of the patient’s receiving facility. It is not sufficient

just to give the name of the hospital. Essential information

includes the department within the destination hospital, key

telephone numbers, and names of key people (e.g. the receiving

consultant and the charge nurse of the receiving ICU or other

facility). Family members should be instructed not to follow the

ambulance but to make their way independently and allow time

for the patient to arrive and be seen by the receiving team.

Who will escort the patient?

Successful inter-hospital transfers require a well-coordinated

team effort. A full-time hospital consultant in intensive care

medicine should be responsible for the service, training of

transfer personnel and audit of transfer activities. In addition to

the crew of the ambulance, a critically ill patient should be

accompanied by a minimum of two attendants who are familiar

with the patient and competent to undertake the transfer.

� Intensive care doctor, usually an anaesthetist, with:

� previous transfer experience

� at least 2 years’ postgraduate experience

� a qualification in the speciality.

� Intensive care nurse, anaesthetic, paramedic, or technician

familiar with intensive care procedures and equipment.

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Although it appears that junior doctors more often undertake

transfers from district general hospitals (DGHs), there has been

muchdiscussionabout thequality of training andpoorpreparedness

for these risk-prone patient moves.4 However, recent years has seen

a growth in training courses which aim to ensure that useful skills

are taught to thosewho are likely to be called at short notice to escort

a critically ill patient. The 2-day STaR (Safe Transfer and Retrieval)

course was established by the Advanced Life Support Group and

offers amanagement process to improve the efficiency and safety of

patient care. Many ‘me-too’ courses have followed, most of which

are taught at DGHs for local staff. CCAT (Clinical Considerations in

Aeromedical Transport) is a 6-day course for those interested in air

ambulance transfers and offers a more practical and hands-on

approach to all aspects of patient transfers and retrievals.5

How will the transfer be undertaken?

Time-critical transfersmay require careful thought about the choice

of transport mode. The recent establishment of CCNs in the UK has

led to the introduction of dedicated intensive care ambulances, and

other countries have now instituted so-called ‘MICUs’ (mobile

intensive care units) with seemingly improved outcomes for the

patients transported.6 In addition, helicopters are more available in

recent years, but decision-makers must be able to undertake

a risks/benefits evaluation of each transport mode. It is vital to be

aware of the limitations of helicopters, and also of the risks to both

patient and crew.7 The choice depends onmany factors, including:

� urgency of the patient’s condition

� mobilization time

� distance (or, preferably, time) to destination

� weather

� traffic conditions

� location of nearest helicopter landing sites (and hence,

need for secondary ground transfers)

� cost.

All vehicles, whether they are road or air ambulances, must

have:

� trolley access and fixing systems

� sufficient space for two or three medical attendants

� lighting and temperature control within the cabin

� adequate gases and electricity supply

� storage space for drugs and equipment

� good means of communications.

Intensive care patients can also be transferred by a vast array of

fixed-wing aircraft types. The majority of these are small air

ambulances which are tasked solely for the transfer of an indi-

vidual patient. However, some organizations (such as the

civilian companies Rega and Air Tyrolean, and military medevac

organizations) operate larger aircraft where several intensive

care teams can look after multiple patients. On occasions, civilian

transfers are undertaken by commercial passenger-carrying

aircraft simply because of the logistics of long-haul transport.8

Lufthansa now markets a complete intensive care module

(the ‘patient transport compartment’) which can be loaded onto

its larger aircraft and acts as a medium-sized and isolated

intensive care bay. It contains self-sufficient intensive care

equipment, seats for two medical crew, 13,000 litres of oxygen

and all necessary medical materials and consumables.

The advantages and disadvantages of different modes of

transport are summarized in Table 1.

� 2012 Published by Elsevier Ltd.

Advantages and disadvantages of different modes of transport

Mode Advantages Disadvantages

C Road ambulance C Low cost

C Rapid mobilization

C Less weather dependent

C Easier patient monitoring

C Slow over long distances

C Dependent on traffic conditions

C Helicopter air

ambulance

C Efficient for journeys of over 50 miles

C Fast and direct as long as both referring and receiving

hospitals have a collocated helicopter landing site

C Slow to mobilize

C Requires ground ambulances at either end if no

dedicated hospital landing sites

C Noise levels often high

C Vibration

C Small cabin

C Often only available during daylight hours

C Expensive

C Fixed-wing air

ambulance

C Efficient for journeys of over 150 miles

C Compared to a helicopter:

� faster

� more space

� less noise and vibration

� less weather dependent

� less costly

� 24-hour service

C Slow to mobilize

C Requires ground ambulances at either end

C Distance to nearest airport may be great

Table 1

CRITICAL ILLNESS AND INTENSIVE CARE: I

The transfer (Figures 1e3)

Stabilization of the patient should follow the principles outlined

by the advanced trauma life support (ATLS) and advanced

cardiac life support (ACLS) ‘ABC’ approach and, since hypo-

volaemic patients tolerate movement poorly, circulating volume

should be normal or supranormal before departure. Intravenous

loading will usually be required to maintain satisfactory blood

pressure, perfusion and urine output, but inotrope or vasopressor

therapy may also be needed. Particularly unstable patients may

need central venous pressure or cardiac output monitoring to

optimize haemodynamic indices. In addition, monitoring

Figure 1 Patient being readied for transfer.

SURGERY 30:5 222

immediately prior to transfer should include ECG and blood gas

analysis.

Documentation must include a referral letter, the hospital

notes, imaging hard copies or digital media (if available), and

results of all investigations. Any unused cross-matched blood or

blood products must accompany the patient if there is an

agreement between the hospitals for its use after departure from

the referring facility. Finally, the consultant and nurse in charge

from the receiving ICU must be informed of the estimated time of

arrival and travel arrangements should be discussed with

relatives.

Figure 2 Helicopter emergency medical services kit.

� 2012 Published by Elsevier Ltd.

Figure 3 Flight doctor with transfer kit.

CRITICAL ILLNESS AND INTENSIVE CARE: I

If possible, the patient should be positioned to provide

maximum access during the transfer. Space at the head end will

allow monitoring and management of the airway. All-round

access is ideal but not always achievable in road ambulances,

and almost always impossible in aircraft.

The transfer should be undertaken smoothly and rarely at

high speed. The staff/patient ratio during the journey is better

than normally expected in ICU and the aim is to provide the same

standard of monitoring, nursing care and medical intervention.

The caveat, of course, is that in transit it can be difficult or

impossible to undertake major procedures. In fact, an ‘ideal’

transport is when no intervention is needed once underway. This

may only be achieved after timely stabilization and attention to

detail before moving out of the ICU safe environment. However,

the unexpected can occasionally happen and thought must be

given as to how interventions and procedures can be safely

undertaken en route. Clearly, any significant incidents may be

best managed after the ambulance has pulled over to the side of

the road e a luxury not available in aircraft.

Specialized adult critical care transfers

Coronary care

Specialized coronary care transport teams have been operating in

the USA since the 1980s and, although it is recognized that

America has widely differing patient transport needs because of

vast distances between hospitals, it is likely that an increasing

number of schemes will operate in the UK in the future. Recent

advances in intra-aortic balloon counterpulsation (IABC) tech-

nology have made transport of selected patients safer. Accepted

indications for transfer of a patient on an IABC pump are:

� accelerating angina (transport to a cardiac facility for

bypass surgery)

� ischaemic or idiopathic cardiomyopathy when cardiac

transplantation is an option

� emergency repair of structural defects, such as mitral valve

defect

� haemodynamic instability during cardiac catheterization

� need for advanced pharmacological therapy necessitating

transfer to a tertiary care facility

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� IABC-dependent patient has exhausted the resources of the

referring facility.

Extracorporeal membrane oxygenators (ECMO): ECMOs have

been recently utilized during ground transfers and reports of their

use in aeromedical transfers are becoming more commonplace.

Dedicated retrieval teams fromECMOspecialist centres are used to

collect patients from peripheral units. Foley et al9 reviewed

100 patients transported on extracorporeal life support up to

January 1999. Patients were transported either by ground ambu-

lance (80), helicopter (15), or fixed-wing aircraft (5). Sixty-six

patients survived to discharge and complications that occurred

during transport included 10 cases of electrical power failure, three

cases of circuit tubing leakage, andone case each of circuit rupture,

membrane lung thrombosis and membrane lung leakage. None of

the complications had an adverse effect on outcome.

Prostacyclin and nitric oxide

Other advanced ventilatory adjuncts have been successfully used

during aeromedical transfers, these include nitric oxide10 and

prostacyclin. Reily et al11 described the technique of using

inhaled prostacyclin (iPGI(2)) to enable the safe inter-ICU heli-

copter transport of a patient with severe acute respiratory

distress syndrome (ARDS). The case describes a 32-year-old

woman with ARDS who failed multiple attempts on a transport

ventilator because of severe hypoxaemia. After the administra-

tion of iPGI(2), oxygen saturation improved significantly,

enabling her safe transport to a regional centre for higher level

intensive care.

Conclusions

The establishment of critical care networks has resulted in better

management of ICUs and improvements in standards which

include the transfer of patients to higher echelons of medical care.

In addition, the numbers of non-clinical transfers have fallen and

the enforced uniformity of transport equipment and procedures

has ensured that junior staff rotating between hospitals during

training have the comfort of familiarity when they are faced with

transfers in each hospital that they work. It seems that the ambi-

tious aim of every transfer being escorted by the most senior and

experienced intensivist is still a longway off, as is the stated aim of

having retrieval teams for every transfer. However,much progress

has been achieved in the past decade and training of staff continues

to improve. Since it is unlikely that the number of ICU beds in the

UK will increase significantly, the next decade is sure to witness

even greater numbers of patient transports. A

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FURTHER READING

Association of Anaesthetists of Great Britain and Ireland. Recommenda-

tions for standards of monitoring during anaesthesia and recovery.

London: AAGBI, 2000.

Fromm Jr RE, Varon J. Critical care transport. Critical Care Clin 2000; 16:

695e705.

Intensive Care Society. Guidelines for the transport of the critically ill

adult. London: Intensive Care Society, 1997.

� 2012 Published by Elsevier Ltd.