Patient transport and retrieval

Published on 14/03/2015 by admin

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Chapter 21 Patient transport and retrieval

Neil Ballard

Transferring critically ill or injured patients between hospitals is a potentially dangerous business. Although these transfers occur commonly, care needs to be taken to ensure that they are performed appropriately and safely. The Australasian critical care specialty colleges have issued joint policy documents specifying minimum standards of care required in these circumstances, and these are essential reading for staff involved.1,2

Although intrahospital transport is often thought to be routine, or not thought about at all, the issues raised below with regard to interhospital transport must be considered.

INDICATIONS FOR RETRIEVAL

Patients need retrieval or transport to another facility when their needs are beyond the scope of the facility that they are in. They may require a higher level of critical care, specialist surgical or medical services (e.g. neurosurgery or interventional cardiology) or investigations such as an MRI.

It is not unusual for critically ill patients to need transfer because no intensive care unit (ICU) beds are available. Time should be taken to ensure that this is the most appropriate course of action for a particular patient; if the patient is unstable or has a condition requiring urgent treatment and can be managed at the referring hospital, consideration should be given to moving another, more stable patient.

What the patient is being transferred for always needs to be borne in mind, for this will guide the urgency of the transfer. As soon as it becomes apparent that the condition of the patient is beyond the scope of care of the referring hospital, initiation of the transfer process should commence. In some circumstances this will mean activating a retrieval team even before the patient arrives at hospital, for example in the case of a multitrauma patient and a small country hospital.

If the patient is being transferred for life-saving care (e.g. urgent neurosurgical decompression of an acute extradural haematoma), the patient needs to be packaged safely but quickly, taking time only to do procedures necessary for transfer. However, in other cases, such as a patient in septic shock being transferred for tertiary ICU care, time can be taken to optimise the patient’s condition prior to moving them.

It is important to develop referral systems so that time is not wasted searching for a receiving hospital. These may be statewide or regional systems, or simply agreements between small hospitals and larger centres. An essential component of such systems is the ability of a practitioner in a small facility to be able to find a receiving hospital and get clinical advice with little difficulty, preferably via a single phone call.

THE RETRIEVAL TEAM

Interhospital patient transport should be performed by staff with the skills, experience and training to deal with potential problems that may arise during the course of the mission. Within Australasia, there are a number of specialised medical retrieval services which generally follow the staffing model of an experienced critical care doctor (emergency medicine, anaesthetics or ICU) plus either a paramedic or a flight nurse. As well as interhospital transfer of critically ill and injured patients, these services may also be involved in prehospital care.

If existing hospital staff are utilised in an interhospital transport, they need to be sufficiently experienced and skilled to make decisions and perform resuscitative measures in a potentially difficult environment, and they should be trained and familiar with the equipment that they use. The practice of sending an untrained junior doctor in the back of an ambulance with a critically ill patient can result in an adverse outcome for the patient, and a traumatic experience for the doctor involved.

EQUIPMENT

Monitors, syringe pumps and ventilators used in retrieval need to be light, robust and easy to use, with good battery life. Screens should be assessed for ability to be seen in variable light conditions (bright sunlight is particularly problematic) and at angles.

Airway, breathing and circulation equipment, plus appropriate medications and other necessary gear, should be kept in packs. These need to be checked regularly and staff involved in retrieval need to be familiar with the content and layout of these packs.

THE RETRIEVAL ENVIRONMENT

The hospital environment tends to be a familiar one: comfortable climate, controlled lighting, limited personal protection issues. However, interhospital transport of patients exposes both patient and staff to a number of different environments with various challenges.

Hot weather can result in dehydration and difficulty viewing monitors in bright sunlight. It can be difficult to assess a patient rugged up against the cold, or in the dark. Increasing altitude may result in hypoxia and cold. Interaction with unfamiliar staff of varying skills and experience at referring or receiving hospitals can present challenges, as can dealing with ambulance and other emergency services that one may come in contact with during interhospital patient transport. In such environments, the usual cues which alert one to deterioration in the patient’s condition may be missed.

All of these elements impact on the patient, but also on the retrieval team. Without awareness of these hazards and precautions (e.g. food, fluids, good light sources) against them, they will result in fatigue and impaired decision making.

RETRIEVAL VEHICLES

The vehicles generally used for interhospital patient transport are road ambulances, helicopters and fixed-wing aircraft. They have some similarities in that they all offer cramped and noisy workplaces and are thus difficult places to perform assessments and procedures. Lighting will be worse than in hospital, power for equipment may or may not be available and motion sickness may affect the patient or attendants.

Road ambulances are commonly used for short distance interhospital transfers, but care must be taken to secure equipment properly.

Helicopters tend to be used for medium distance transfers, and often have the advantage of flying direct from referring to receiving hospital, but are more susceptible to bad weather than other modes of transport and are a particularly difficult environment in which to perform clinical assessment or procedures.

Fixed-wing aircraft tend to have a greater range and fewer weight constraints than helicopters, but transfers involve road ambulance legs and more patient movements to and from stretchers, all with potential for mishap. Gravitational forces on take-off and landing may result in marked haemodynamic instability (including cardiac arrest), particularly with hypovolaemic patients.

Fixed-wing aircraft used as air ambulances tend to be pressurised, but helicopters are not and so issues with hypoxia and gas expansion at altitude come into play. Gases expand by approximately 40% at an altitude of 8000 feet, and this may result in deleterious clinical effects if in a confined space. Pneumothoraces should be drained before transport.

An arterial partial pressure of oxygen of 100 mmHg at sea level will fall to approximately 60 mmHg at 8000 feet if on the same fraction of inspired oxygen (FiO2). This may make the difference between a patient being stable on high flow oxygen via a non-rebreathing mask and requiring intubation and ventilation. It may also result in medical attendants becoming hypoxic on minimal exertion during the mission, which may result in headaches, fatigue and impaired judgement.

The choice of retrieval vehicle should be made by a central tasking authority. This should take into account vehicle availability, weather, distance and clinical considerations.

PREPARING A PATIENT FOR RETRIEVAL

The patient needs to be well packaged prior to interhospital transfer, always bearing in mind the clinical urgency of the case.

It is difficult to do any procedures en route, so necessary procedures should be performed prior to departure, taking into account the likely or potential clinical course.

If there is a concern about the airway, this should usually be secured by intubation prior to departure. The threshold for intubating a patient is lower than if they remain in a hospital environment.

A minimum of two peripheral intravenous cannulae should be in place. Infusions should be rationalised to those necessary for transfer, and fluids should go through a pump (blood-giving) to ensure that they can run.

Invasive blood pressure monitoring is more reliable than non-invasive readings, so an arterial line is preferable.

Indwelling urinary catheters and gastric tubes are generally required. Awake patients should have an anti-emetic.

Extreme care should be taken if moving an agitated or intoxicated patient. The risks of putting such patients in an aircraft are considerable, so transfer should either be deferred or involve sedation or even general anaesthesia.

Sufficient medications and infusions for the mission should be immediately available.

Copies of notes and imaging should go with the patient.

Accurate determination of the patient’s weight is essential, as the movement of obese patients can be logistically challenging and beyond the capacity of usual means.

Be sure to keep the patient’s family aware of what is going on and where the patient is going. Give them an honest idea of the likely clinical course.

IN TRANSIT

With a well-prepared patient, the time in transit is generally spent keeping a close eye on the patient and dealing with problems should they arise. Occasionally, however, significant resuscitation will be necessary which makes for an interesting journey.

Particular care should be taken any time the patient is transferred between stretchers, and during loading into and unloading from vehicles. These are danger times for inadvertent disconnections and even extubation, plus haemodynamically unstable patients can crash with even minor stimuli.

A clear and detailed record of the transfer should be kept.

HANDOVER

Handover at the receiving hospital should be to the most senior medical officer, but must also include the nursing staff who will be looking after the patient. Clinical course and immediate needs should be addressed, and also be sure to pass on contact details of the patient’s family.

EDITOR’S COMMENT

Each emergency department, especially those in smaller hospitals, must have an easily accessible document (e.g. on emergency department computer) that lists key phone numbers, checklists for doctors and nurses and how to organise transfers—the ‘one phone call’—as well as who to call to have the matter escalated if the emergency department is overwhelmed or finding a ‘brick wall’ at any receiving hospital.

Note: Murphy’s Law—it will be at night, on the weekend and/or at holiday time etc!

REFERENCES

1 Minimum standards for transport of critically ill patients. Joint Faculty of Intensive Care Medicine, Australian and New Zealand College of Anaesthetists and Royal Australasian College of Physicians, and Australian and New Zealand College of Anaesthetists, and Australasian College for Emergency Medicine.

2 Minimum standards for intrahospital transport of critically ill patients. Joint Faculty of Intensive Care Medicine, Australian and New Zealand College of Anaesthetists and Royal Australasian College of Physicians, and Australian and New Zealand College of Anaesthetists, and Australasian College for Emergency Medicine.

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