Risks of transport of critically ill patients

Technical complications: e.g. displacement of the tracheal tube,

intravascular lines, drains etc.
Pathophysiological deterioration: e.g. increased intracranial pressure
as may occur from the lowering of a head-injured patient from semirecumbent
to recumbent position for a CT scan), arterial
hypotension, decrease in oxygen saturation.
Inadequate monitoring of cardiovascular and pulmonary function
due to less sophisticated monitors or equipment/interference due to
motion, etc.
Inadequate therapy due to lack of appropriate equipment many
transportation ventilators cannot deliver the modes or levels of
ventilation as a high-end ICU ventilator. (Note newer ICU ventilators
may be used for transport and are even becoming MRI compatible).
Additional movements during transport (acceleration forces during
aeromedical or ambulance transport, tilting/lifting of patients from
bed to trolley), may cause dislocation of fractures, fibrin clots,
sutures, vascular emboli, etc.).
Lack of immediate access to additional investigations or therapy if
needed e.g. no chest X-ray in an ambulance to diagnose/exclude a
pneumothorax or extra unit of packed cells/clotting factors in case of
acute haemorrhage.
Limited number of people involved in the transport, lack of more
senior people immediately to hand
Which patients and situations face an increased risk of adverse
events during transport, and why?

A.
Paediatric patients: even small movements of the patient or associated
equipment (e.g. endotracheal tube) may lead to disconnection or dislocation of
the tubes and lines.
Transfer at night: this may mean fewer staff or staff with less experience
resulting in sub-optimal planning, preparation of conduct of transfer. Poor
lighting may impair tasks and make correct dosage of medications or the
recognition of complications more difficult.
Patients with increased intracranial pressure: often it is not possible to elevate
the upper body for transport and positioning of the patient e.g. in the CT or
MRI suite.
Patients with increased positive airway pressure (> 4050 cmH 20) during
ventilation: many transport ventilators will not generate enough driving
pressure or PEEP to sufficiently oxygenate very obese patients or those with
severe ARDS.
Abrupt change of clinical team: information may be lost if the transfer team has
no connection with the team previously providing care and has not had
sufficient time to get a proper clinical picture of the patient. Every handover of
information poses the risk of information being lost

What to monitor
Three-lead (or more) ECG with heart rhythm and assessment of the
ST segment
Invasive pressures (or if too time-consuming or not available, noninvasive
blood pressure may be acceptable)
Haemoglobin oxygen saturation
End-tidal capnography
Temperature.
During transfer of mechanically ventilated patients with serious head
injury, monitoring end-tidal capnography is crucial to prevent hyper- or
hypocapnia with possible cerebral vasodilation or constriction and consequent
changes in intracranial pressure or ischaemia.
Before any transport, the staff check:
If enough spare syringes are available to cover the patients needs during
transport
For special and adequate tubing, depending on the type of pump
For battery power and number of wall sockets available in the ambulance
or at the receiving site
Which medications are indispensable and which may be interrupted
temporarily.
syringe pumps, e.g. mcg/kg/min, mcg/min, mg/hour, ml/hour,
or even number of drops/minute in infusion pumps
pressure bags or
additional infusion pumps may be needed for every infusion
e.g. suction of tracheal or
oral secretions
How useful to patient care during the transport is the device?
What are the risks for the patient if the device is displaced unintentionally (e.g.
blood loss)?
What is the battery capacity and what are the risks to the patient if the device
shuts down?
Is it safer to uncouple the device during transport because the risks outweigh
the benefits?
Do weight, size, possibility of firm attachment to ambulance or legal restrictions
preclude the use of a device, especially in aeromedical transport?

Set appropriate alarm limits and ensure the alarm volume is loud enough to be
heard.
e.g. which model of a hip prosthesis. Based on
clinical experience most implanted devices (such as stents, prostheses) without
electronic control are suitable for MRI. Electronically controlled devices, such as
Task 3. Conduct of the transfer

[24]

pacemakers or infusion pumps, may not function properly during and after MRI and a
need for their presence precludes MRI scanning. Standard medical devices such as
ventilators or infusion pumps are not compatible with MRI and special
arrangements/equipment must be used.

What may happen

Adverse events (e.g. desaturation, persistent hypotension) or specific transportrelated
events (e.g. unintended extubation, loss of intravascular access) should
be handled according to standard critical care practice.
Even a simple medical intervention
such as placement of an intravenous line
Before transporting a patient after resuscitation for haemorrhagic
shock, check that red blood cells and clotting products (platelets, fresh frozen
plasma or concentrated factors) are available
Difficulty keeping the airway open, e.g. obesity and increased sleepiness
following morphine. Airway protection deserves special consideration in case of
increased nausea or vomiting.
Difficulty ventilating, e.g. heavy snoring, worsened sleep apnoea with obesity
and morphine.
Difficulty oxygenating, e.g. pulmonary oedema in left ventricular failure.

Duration of the transfer? Role assignment of the team. Space for all the equipment.
Connections to tubes and lines. Is the CT suite ready for the procedure and are the
corridors clear?
Changing ventilators (with possible loss of PEEP), syringes on pumps or other
therapeutic equipment pose hazards. Frequent pitfalls include three-way stopcocks
left in the wrong position and errors with syringe pumps containing vasopressors
Indications for transportation.
All equipment should be robust, durable and lightweight. Electrical equipment
must be designed to function on battery when not plugged into the mains.
Additional batteries should be carried in case of power failure. Battery life should
be maximised by exercising batteries in compliance with the manufacturers recommendations.
8.6 Portable monitors should have a clear illuminated display and be capable of displaying
ECG, arterial oxygen saturation (SaO2), non-invasive blood pressure, three
invasive pressures, capnography (EtCO2) and temperature. Alarms should be visible
as well as audible in view of extraneous noise levels.
8.7 Portable mechanical ventilators should have as a minimum disconnection and high
pressure alarms, the ability to supply positive end expiratory pressure (PEEP) and
variable inspired oxygen concentration (FiO 2), inspiratory/expiratory (I/E) ratio,
respiratory rate and tidal volume. In addition the ability to provide pressure controlled
ventilation, pressure support and continuous positive airway pressure
(CPAP) is desirable.
8.8 Gravity feed drips are unreliable in moving vehicles. Sufficient syringe or infusion
pumps are required to enable essential fluids and drugs to be delivered. Pumps

should preferably be mounted below the level of the patient and infusion sets fitted
with anti-siphon devices.
8.9 Portable warm air devices for maintaining patient temperature can be useful and can
also be mounted on the patient trolley.
8.10 Additional equipment for maintaining and securing the airway, intravenous access,
etc should also be available (Appendix 1).
8.11 High visibility clothing, a mobile telephone, contact telephone numbers, money/
credit cards should be available for use in emergencies.
Intubated patients should normally be paralysed, sedated and mechanically ventilated.
Inspired oxygen may be guided by arterial oxygen saturation (SaO 2) and ventilation
by end tidal carbon dioxide (EtCO2). Following stabilisation on the transport
ventilator, at least one arterial blood gas analysis should be performed prior to departure
to ensure adequate gas exchange. Inspired gases should be humidified using a
disposable heat and moisture exchanging filter (HME).
13.6 If a pneumothorax is present or likely, chest drains should be inserted prior to departure.
Underwater seals should normally be replaced by leaflet valve (Heimlich type)
drainage systems. Chest drains should not be clamped.
13.7 Secure venous access is mandatory and at least two wide bore intravenous cannulae
(central or peripheral) are required. A suitably secured indwelling arterial cannula is
ideal for blood pressure monitoring.
13.8 Hypovolaemic patients tolerate moving poorly and circulating volume should be near
normal prior to transportF2 . This may require volume loading with crystalloid, colloid
or blood, guided by central venous or pulmonary artery occlusion pressure monitoring
and cardiac output measurement. If inotropes or other vasoactive agents are
required to optimise haemodynamic status, patients should be stabilised on these
before leaving the referring unit.
13.9 Patients who are persistently hypotensive despite resuscitation efforts should not be
moved until stable. Continuing sources of blood loss or sepsis should be identified
and controlled. Long bone fractures should be splinted to provide pain relief, cardiovascular
stability and neurovascular protection.
13.10 A naso- or orogastric tube and urinary catheter should be passed and free drainage
allowed into collection bags.
13.11 Conscious patients should be kept informed of the transfer and all other relevant
information. Relatives should similarly be kept informed of travel arrangements but
should not normally travel with the patient.
13.12 Before departure, named medical and nursing personnel at the receiving unit should
be contacted to confirm the availability of the bed, update them on the patients
condition and provide an estimated time of arrival.
13.13 The means of return to base hospital for the medical and nursing staff accompanying
the patient should be established.

MONITORING DURING TRANSPORT

14.1 The standard of care and monitoring during transport should be at least as good as
that at the referring hospital or base unit20. The minimum standards required for all
patients are:
_ Continuous presence of appropriately trained staff
_ ECG
_ Non-invasive blood pressure
_ Arterial oxygen saturation (SaO2)
_ End tidal carbon dioxide (EtCO2) in ventilated patients

_ Temperature (preferably core and peripheral).

In mechanically ventilated patients the oxygen supply, inspired oxygen concentration

(FIO2) ventilator settings and airway pressure should be monitored.
14.7 A written record of patient status, monitored values, treatment given and any other
clinically relevant information should be completed during the transfer.

SUPPLEMENTARY EQUIPMENT FOR USE DURING

TRANSPORT
Airway
Guedel airways (assorted sizes)
Laryngeal masks (assorted sizes)
Tracheal tubes (assorted sizes)
Laryngoscopes (spare bulbs and
battery)
Intubating stylet
Lubricating gel
Magills forceps
Tape for securing tracheal tube
Sterile scissors
Stethoscope
Ventilation
Self inflating bag and mask with
oxygen reservoir and tubing
High flow breathing circuit
Spare valves for portable ventilator
Chest drains (assorted sizes)
Heimlich flutter valves
Suction
Yankauer sucker
Suction catheters (assorted sizes)
Nasogastric tubes (assorted sizes) and
drainage bag
Circulation
Syringes (assorted sizes)
Needles (assorted sizes)
Alcohol wipes
IV cannulae (assorted sizes)
Arterial cannulae (assorted sizes)
Central venous cannulae
Intravenous fluids
Infusion sets/extensions
3 way taps
Dressings
Tape
Minor instrument/cut down set

CHECK LIST 1.

IS THE PATIENT STABLE FOR TRANSPORT?

Airway
Airway safe or secured by intubation
Tracheal tube position confirmed on
chest X-ray
Ventilation
Paralysed, sedated and ventilated
Ventilation established on transport
ventilator
Adequate gas exchange confirmed by
arterial blood gas
Circulation
Heart rate, BP stable
Tissue and organ perfusion adequate
Any obvious blood loss controlled
Circulating blood volume restored
Haemoglobin adequate
Minimum of two routes of venous
access
Arterial line and central venous access
if appropriate
Neurology
Seizures controlled, metabolic causes
excluded
Raised intracranial pressure
appropriately managed
Trauma
Cervical spine protected
Pneumothoraces drained
Intra-thoracic and intra-abdominal
bleeding controlled
Intra-abdominal injuries adequately
investigated and appropriately
managed
Long bone/pelvic fractures stabilised
Metabolic
Blood glucose >4 mmol/L
Potassium <6 mmol/L
Ionised calcium >1 mmol/L
Acidbase balance acceptable
Temperature maintained
Monitoring
ECG
Blood pressure
Oxygen saturation
End tidal carbon dioxide
Temperature

ARE YOU READY FOR DEPARTURE?

Patient
Stable on transport trolley
Appropriately monitored
All infusions running and lines
adequately secured
Adequately sedated and paralysed
Adequately secured to trolley
Adequately wrapped to prevent heat
loss
Staff
Adequately trained and experienced
Received appropriate handover
Adequately clothed and insured
Equipment
Appropriately equipped ambulance
Appropriate equipment and drugs
Batteries checked (spare batteries
available)
Sufficient oxygen supplies
Portable phone charged and available
Money/credit cards for emergencies
Organisation
Case notes, X-rays, results, blood
collected
Transfer documentation prepared
Location of bed and receiving doctor
known
Receiving unit advised of departure
time and estimated time of arrival
Telephone numbers of referring and
receiving units available
Relatives informed
Return travel arrangements in place
Ambulance crew briefed
Police escort arranged if appropriate
Departure
Patient trolley secured
Electrical equipment plugged into
ambulance power supply where
available
Ventilator transferred to ambulance
oxygen supply
All equipment safely mounted or
stowed
Staff seated and wearing seat belts

TRANSPORT DOCUMENTATION

The following information should be recorded on transport documentation.

Transfer details
Patients name, address, date of birth
Next of kin, what information they have been given and by whom
Referring hospital, ward/unit, and contact telephone number
Name of referring doctor and contact telephone number
Receiving hospital, ward/unit and contact telephone number
Name of receiving doctor and contact telephone number
Names and status of the escorting personnel
A medical summary
Primary reason for admission to the referring unit
History and past history
Dates of operations and procedures
Number of days on intensive care
Intubation history, ventilatory support and blood gases
Cardiovascular status including inotrope and vasopressor requirements
Other medication and fluids
Type of lines inserted and dates of insertion
Recent results and MRSA status
A nursing summary
Nursing care required with reference to the following
Respiration, cardiovascular parameters, communication methods, nutrition, pain and
sedation, sleep patterns, elimination, skin condition, hygiene and social needs
Patient status during transfer
Vital signs including ECG, blood pressure SaO2, EtCO2, temperature, respiratory rate,
peak inspiratory pressure, PEEP
Drugs given during transfer including infusions
Fluids given during transfer
Summary of patients condition during transfer signed by escorting doctor
Audit data including:
Reason for the transfer
Whether the transfer was within or outside the local network
The urgency of the transfer
Time taken for transfer from time of ambulance request to completion
Adverse events/critical incidents

(Name of the Hospital)

DEVICES / ACCESSORIES MONITORING CHART
Name: Bed No: Ward: Unit Dr.:
Age: Sex: Body Wt.: Diagnosis:
SL. ITEM
1st
APPLIED
ON
CHANGED

ON
CHANGED
ON
CHANGED
ON
CHANGED
ON
CHANGED
ON
CHANGED
ON
CHANGED
ON
CHANGED
ON
CHANGED
ON
CHANGED
ON

1. Ryles Tube
2.
Central Line
(CVC)
3.
Femoral Central
Line (PICC)
4.
Peripheral Line
(PVC)
5. I. V. Drip Set
6. E. T. Tube
7.
Tracheostomy
Tube
8. Ventilator Circuit
9. Foleys Catheter
10.
Chest Tube
(if any

ICU Daily Quality Checklist Place Patient Sticker here

1) Sedation: Protocol Ordered? Yes No
Midazolam Dexmetetomidine
Propofol Study drug none
Sedation Interrupted this AM
MAAS score @ 0400: _____ RASS score @ 0400: _____

2) Analgesia: Protocol Ordered? Yes No

Fentanyl Morphine None
3) Neuromuscular Blockade:
Protocol Ordered? Yes No
Vecuronium Cisatracurium
None
Train of 4: _____
4) Delirium: Protocol Ordered? Yes No
None noted
prn haloperidol/risperidol
Current CAM ICU: _____
5) DVT prophylaxis: Standard ICU orders? Yes No
SQ unfractionated heparin SQ enoxaparin
SCDs Foot pumps
Full anticoagulation with:
Heparin: PTT _____ Enoxaparin
Warfarin INR _____
Major bleeding Minor bleeding Location: ____________
6) Stress ulcer prophylaxis
Lansoprazole: enteral parenteral: b.i.d. gtt
Esomeprazole enteral parenteral: b.i.d gtt
Famotidine: enteral parenteral: b.i.d. gtt
TPN drug: _____________________
7) Head of Bed
Mechanically ventilated? Yes No
30o? Yes No Recorded on bedside chart? Yes No
8) Skin condition
Braden score recorded Yes No Score:________
Specialty bed ordered Yes No
Lesion present on transfer to ICU Yes No
Wound team consulted Yes No
Additional wound(s):
location ________________________
9) Nutrition None
Enteral: OG tube NG tube Salem sump
soft feeding tube G/J tube
goal rate: _______ current rate: _______ ml/hr
interrupted > 4 hours in past 24o
Parenteral: TPN PPN at goal rate
Oral diet: clear liquids mechanical soft
regular (including specific diets)
Nutrition team assessment updated in record Yes No
Your Name: _________________
10) Disposition/Code Status
DNR DNI Full code
Advanced Directive in chart DPOA in chart
Palliative care consulted
SW consulted

11) Glucose control

Insulin protocol ordered? Yes No
conventional (100 150) tight (80 110)
Hours in parameters (0400 to 0400): _____
12) Severe Sepsis: Present? Yes No
Protocol Ordered? Yes No
Central line placed? Yes No
SvO2 monitored? Yes No Value? _____
Lactate documented? Yes No Value? _____
Drotrecogin protocol active? Yes No
13) Therapies
PT OT Speech
ordered ordered ordered
active active active
14) Central line None
#1 Subclavian Internal jugular Femoral
PICC Non subclavian
Left Right Tunneled Date placed: _____
If non-SC, reason documented? Yes No
#2 Subclavian Internal jugular Femoral
PICC Non subclavian
Left Right Tunneled Date placed: _____
If non-SC, reason documented? Yes No
#3 Subclavian Internal jugular Femoral
PICC Non subclavian
Left Right Tunneled Date placed: _____
If non-SC, reason documented? Yes No
Patient location when line placed?
#1 MICU ED Ward OR Other ICU
Outside hospital
#2 MICU ED Ward OR Other ICU
Outside hospital
#3 MICU ED Ward OR Other ICU
Outside hospital
15) Mechanical ventilation? Yes No
NPPV ET tube size: _____ Trach size: _____
ALI/ARDS protocol Lung protective strategy
Peak pressure: ____ Plateau pressure: _____

Weaning protocol active? Yes No