Travel trends

With the onset of travel, especially aviation, more people travel year on year. Since the middle of the last century there has been a significant increase in travel:

The United Nations World Tourism Organization (UNWTO) stated that of the 922 million international tourist arrivals in 2008, air transport accounted for about 52 % of arrivals and marine transport 6 %.

Travel, and specifically tourism, is a significant economic factor for both the UK and the world global economy at large. According to the Office of National Statistics (ONS 2010), spending by overseas residents within the UK has increased from £4.6 billion in 1984 to £16.6bn in 2009.

With mass movement of people there is also the corresponding movement of organisms and disease, which presents many health challenges. Firstly, as the human body can be a host for a number of organisms, mobilization of diseases across countries and continents is far easier when compared to 50 or 60 years ago. Secondly, as some parts of the world become more affluent, travelling is no longer seen as a luxury, and ease of travel means that more people have access to and the means to travel to different destinations.

Thirdly, as people live longer and many long-term conditions become the norm, the potential for illness, relapse, injury or deterioration requires the need for transportation of chronic and acutely ill patients often across long distances using modes of transport not originally intended for the care of the ill person. As such, this creates challenges in the environment of care and the associated assessment and operational factors required to provide this care. This chapter will discuss these in more detail.

Trends in admissions to critical care settings

Critical care admissions data collected by the NHS in England provide some insight into the patterns and reasons for admission to critical care units. Data from the first publication from Hospital Episodes Statistics (HES) in England show that 82 % of critical care records in the period April 2008–March 2009 were available, with 50 % of admissions showing detailed sources (Health and Social Care Information Centre 2009). While 45 % of data does not identify the reason for admission, of the remaining data just over 1 in 4 or 28 % are unplanned admissions with the majority being local admissions resulting in over 36 000 critical care transfers. While tertiary transfers are just fewer than 2900 cases, repatriations from neighbouring hospitals or overseas are recorded in over 3000 transfers. The dataset goes on to show that approximately 1 in 6 patients being admitted into a critical care bed will require a transfer and transportation.

• primary transportation refers to the initial response of the acutely ill or injured from the scene of accident or incident to a care facility

• secondary transportation is any onward movements following the primary transportation; also sometimes called tertiary transportation to specialist care or repatriation when it refers to moving someone back to their country of domicile after they become ill or injured abroad

• patient transport refers to general movement; patient transport service (PTS) is used for routine transportation of patients to and from hospital care, such as outpatients appointments or discharge to their place of residence.

Primary transfers

This is the transfer of the acutely ill or injured person to a care setting that offers care for the injuries or illness. This is following the immediate stabilization of the casualty or person, which allows for transportation. The primary purpose is to get the victim to a place of care as quickly and as safely as possibly without exacerbating the situation, injury or presenting complaint. This may be to a trauma centre for immediate life-saving intervention, or to a general accident and emergency service for on-going care after stabilization, assessment of other conditions, or other potential factors that may require intervention. This will only happen following stabilization prior to transport.

Because of the need for rapid intervention, transportation and support, time is a critical factor in insuring a fast transfer to the appropriate care setting. This will often mean only one or two modes which may be considered: road or air. In the majority of cases, because of limited aircraft availability the transport will usually be a road transfer. This is discussed further in the chapter.

The mode of transport will influence what care is needed pre-transportation. For example, it may be necessary to intubate in advance rather than attempt to intubate in transit because of space, movement and other external factors. The steps required for the pre-hospital care environment are discussed in Chapter 1.

Secondary transfers

As the name suggests, this is the transfer of the acutely ill or injured person needing transfer to another care setting for further or specialist care. This occurs after the initial primary transfer to a care setting for stabilization or management of injuries, and is sometimes referred to as ‘inter-hospital transfers’ if between local hospitals. If the clinical condition of the ill or injured person warrants it and there is a need to transfer to a speciality unit for on-going care, this is referred to as tertiary transfers.

Transfers back to the care setting responsible for the person’s on-going condition (including back to their country of domicile), or where rehabilitation is appropriate, are classed as repatriation transfers. Because of the distances involved, the patient’s clinical condition and resources will influence the appropriate mode of transportation. The Association of Anaesthetists of Great Britain and Ireland has developed recommendations that are summarized in Box 4.1.

Patient transport services

A third type of transportation is patient transport services, which are provided for patients requiring routine transportation to and from hospital for appointments and to transport them from hospital to home when clinically appropriate. This type of transportation is planned in advance, sometimes requires clinical warrants to be provided and is by road in most, if not all, cases. As this service is aimed at non-acutely ill patients, this chapter will not discuss the issues of patient transport services.

Factors affecting transfers

Several factors need to be balanced and risk assessed to ensure a successful transfer. The decision to make the transfer needs to be a multi-professional decision as each profession will bring their unique and valid perspectives ensures adequate preparation to such care. While the responsibility rests with the lead clinician, it is good practice to have a multi-professional input into secondary transfer to ensure appropriate risk assessment and planning takes place.

In some cases it is worth considering what, if any, alternatives to secondary transfers may be available, especially if the patient’s clinical condition is of concern. One such option is a visiting clinical team or service, especially for some surgical procedures. For example, cardiothoracic teams operate over a regional or geographic area rather than transferring acutely ill patients.

A key operational issue that is often overlooked is that unless a local policy dictates otherwise, secondary transfers, i.e., tertiary and repatriations transfers, should not route via the Emergency Department (ED) unless there has been deterioration in the patient’s condition or a new event requiring immediate intervention. Being sent to the ED for registration purposes is poor practice (Box 4.2).

Considerations on appropriate transportation

The mode of transport may have already been determined in some situations. In most cases the primary response will be a ground response due to resource availability. Not all ambulance response services will have air support, which is either provided at a regional or country level and then against strict criteria. Ground response will be appropriate in most cases, however there are some options and variances that should be considered. The mode of transport is a key factor in the management of the acutely ill person.

Where any of these factors are compromised then alternatives need to be considered, assuming such supportive resources exist or can be accessed. Holleran & Rhoades (2005) discuss these and similar factors in their work. In some parts of the UK air support may be provided by special request from neighbouring authorities, especially when road transportation in isolated areas or the victim’s condition is serious, rapid transportation to a facility may warrant the use of a primary helicopter. The Intensive Care Society (2002) suggests that for long journeys where road access is difficult, air transport may be quicker; however the perceived speed of air transport must be balanced against organizational delays and inter-vehicle transfers.

Ground transportation

Ground response is the most common. It is used for both primary and secondary transportation widely across the UK as well as internationally. The accepted form is the dedicated road ambulance vehicle.

Internationally, ambulance vehicles are specially adapted to provide a primary response as well as supportive care in transportation of the acutely ill adult. In the UK specialist retrieval teams and ambulances are developed, such as the CATS – the Children’s Acute Ambulance Service – specialist retrieval teams that support the acutely ill child by sending, stabilizing, and preparing a child for transfer to a tertiary service.

Modern vehicles all have life-saving equipment with automatic external defibrillators, suction, and a wide range of medication to support critical care to obstetric care. These will have 240 volt AC power, a secure critical care trolley and carry a ventilator and syringe drivers. It is more usual to request an ambulance from the local ambulance service to perform the transfer (Box 4.3).