In the UK, the development of regional trauma centres and specialist centres, e.g., burn units, neurosurgical units (if not contained within trauma centres), specialist neonatal units (level 1), will mean secondary transfer will probably be necessary. The role of the nurse in the preparation, both pre-transfer and co-ordination of care by communicating with the receiving hospital/centre is key in the safe and effective transfer of the acutely ill or injured person.

(Data from Association of Anaesthetists of Great Britain and Ireland (2009) AAGBI Safety Guidelines: Inter-hospital Transfer. London: Association of Anaesthetists of Great Britain and Ireland.)

Modes of transportation

With the advent of emergency call centres, coupled with evidence-based decision-making algorithms, there is now a move away from dispatching two-person road ambulances, especially in cities and urban areas in parts of the UK. The initial response in some parts of England is now a single paramedic responder on a motorbike. Their role is to provide an initial response, provide care and call in for supportive back up based on that initial assessment or triage. While triage was historically developed for battlefield prioritization, it is now used routinely by emergency response services.

While progress in transportation over the last 100 years has increased the mode of transport options, the majority of both primary and secondary transfers have been by road transportation. Historically, ambulances provided a basic collection and removal of the ill or injured person. They now provide a mobile primary response service by providing the initial assessment, stabilization prior to transportation to on-going care at a hospital base. Aircraft and helicopters provide a means of rapid movement of people over long distances, offering significant advances to the survival of injured or ill patients. While each mode of transport has benefits they also have risks, and the choice of mode is as important as the response itself.

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).

Box 4.3 The European Committee for Standardization specifications for ambulances

Patient transport ambulances (Types A1, A2)

Generally only used for the non-emergency transportation of patients, either between facilities or between a facility and a residence. The emphasis is on transportation; such ambulances have limited treatment or equipment space. Smaller communities may also use such ambulances because of cost, particularly if there is no Advanced Life Support (ALS) service, or if another vehicle or pre-hospital response crew provides ALS.

Emergency ambulances (Type B)

This is the most commonly seen type of emergency ambulance. This vehicle type permits increased treatment space and also the ability to store significantly larger amounts of medical equipment. Such vehicles will typically respond independently to emergency calls, providing some level of treatment. For high-priority emergency calls, these will often be supplemented by the response of a pre-hospital response or British Association of Immediate Care (BASICS) support response crew.

Mobile intensive care unit (Type C)

This type of ambulance is commonly seen in the movement of high-acuity (ICU) patients between hospitals. It provides adequate space for not only the medical equipment commonly seen in ambulances, but also to accommodate hospital equipment such as ventilators, during transport. In some locations, vehicles of this design may be used to provide mobile resuscitation services, either supplemented by a pre-hospital response or Notarzt response, equivalent to the BASICS support response crew.

Air transportation

Used to move injured soldiers in World War I in Italy (Bellini 2008), and in common use by World War II, aircraft have advanced over time since then to be pressurized, comfortable and a common mode of general transportation. However, movement by air has limitations and the response will be determined by key factors. Response by air is influenced by whether it is a primary or secondary response. The major advantages of an air response are both speed by the reduction in journey time and the ability to get the acutely ill or injured person from point A to B with minimal changes or delays.

However, aircraft were never developed or intended as ambulances or designed for the acutely ill or injured. Aircraft are in effect long tubes flying at great speed at reduced internal air pressure. The higher the aircraft flies the greater the need for pressurization at an altitude that normal healthy people can breathe normally. Normal jet aircraft cruise between 11 000–12 200 metres (36 000–40 000 feet) and are pressurized to be between 1 800–2 400 metres (6000–8000 feet), which supports normal respiration in normally healthy people. Above 3 048 meters (10 000 feet) hypoxia becomes a major issue and consciousness is not sustainable without supplemental oxygen.

Effect of air pressure on acutely ill

Impact of available oxygen: In the last 100 years there has been a growing understanding of the impact of air travel and the changes in pressure to human physiology. Martin (2001), Rainford & Grandwell (2006) and Holleran (2009) outline in detail how changes in air pressure affect the human body.

Although the percentage of oxygen in inspired air is constant at different altitudes, the fall in atmospheric pressure at higher altitude decreases the partial pressure of inspired oxygen and hence the driving pressure for gas exchange in the lungs. An ocean of air is present up to 9 000–10 000m, where the troposphere ends and the stratosphere begins. The weight of air above us is responsible for the atmospheric pressure, which is normally about 100 kPa at sea level. This atmospheric pressure is the sum of the partial pressures of the constituent gases, oxygen and nitrogen, and also the partial pressure of water vapour (6.3 kPa at 37°C). As oxygen is 21 % of dry air, the inspired oxygen pressure at sea level (Peacock 1998) (Fig 4.1) is calculated as follows:

Because of the effect of falling barometric pressure, even while pressurized to 2 438 metres (8 000 feet), for the majority of people there are no adverse effects despite the partial pressure of oxygen being at 120 mmHg (16.0 kPa), which corresponds to 75 % of the sea-level value of oxygen at 160 mmHg (21.3 kPa). This means a reduction in arterial oxygen tension from 95 mmHg (12.7 kPa) to between 53–64 mmHg (7.0–8.5 kPa), so oxygen saturation reduces from 97 % saturation on the ground (at sea level) to between 80–92 % at cruising altitude 2 438 metres (8 000 feet) (British Medical Association 2004). This is known as the oxygen disassociation curve and is covered in more detail in Chapter 23.

Figure 4.1 Relationship between atmospheric pressure (mmHg) and altitude (ft) (British Thoracic Society (2004) Managing Passengers with Respiratory Disease Planning Air Travel Summary for Primary Care. London, British Thoracic Society. Adapted by permission from BMJ Publishing Group Limited.)

For healthy individuals there are usually no adverse effects; however, individuals with health problems that can affect the transportation, delivery or uptake of oxygen will need careful planning, management, monitoring and support during transport by air. These conditions include, but are not limited to, pulmonary disease, cardiac failure, anaemia, infection, or any organ susceptible to a reduction in oxygen, e.g., cerebral disease (trans-ischaemic attacks or cerebrovascular accidents).

Impact of pressure on main organs: Boyle’s gas law, where Pressure × Volume = Constant, means that as an aircraft ascends and pressure drops, gas expands. The expansion will be affected by the reduction in air pressure, and at 2 438 metres (8 000 feet) this means an increase in expanded gas of approximately 30 %. Where gas can pass freely there is no problem; however, there can be problems where there is trapped or limited free gas movement, including in any organ which has had surgery in the proceeding 14 days.

This means that any object which has air in an enclosed space will expand. For patients, this affects drains, intravenous giving sets and infusion bags, colostomy bags and even the surface they are lying on if it has enclosed air. It also affects the human body including the gastrointestinal tract, sinuses, teeth, and the ear canal. As such, any person who has had recent surgery where air will have entered the body should not fly without prior medical clearance, and this is usually not less than 10 days for the air to be naturally absorbed.

There are particular consequences for those who have circulatory problems or inability to carry oxygen, e.g., anaemia or hypovolaemia, with haemoglobin less than 7.5 gm/dL, as these travelers are at risk of hypoxia and require supplemental oxygen or transfusion to correct the anaemia. This would also include any patient where hypoxia could exacerbate an underlying problem, e.g., the cerebral or cardiac condition, those with trans-ischaemic attacks, or a cerebral vascular accident, because the reduced partial pressure of O₂ can increase the CO₂ in the cerebral tissue and potentially put them at risk of a further attack or worse an extension. Likewise, this includes any patient with myocardial blockages or a recent cardiac event.

Second are those patients with an underlying respiratory problem, chronic obstructive airways disease or left ventricular failure. Because of the oxygen disassociation curve principles, at sea level these patients are already compromised and a partial reduction due to the gas laws in an aircraft could mean a rapid de-saturation. It is imperative that ongoing monitoring of the patient oxygen saturation is maintained, and should their saturated O₂ rate fall below that on the ground, or below 85 %, that they are given supplemental oxygen. This includes those patients with COPD as the drop in O₂ is significant and will expose them to hypoxia. Supplemental oxygen is usually available in 2 and 4 litres flow rate per minute. It is essential to ensure an adequate amount of oxygen for the whole journey plus a reserve in case of a delay.

To ensure safe and uneventful transportation by air, the person travelling should be assessed for travel thoroughly by a suitably qualified aero-medical doctor. If it is deemed necessary that the person needs a clinical escort, it should be by a suitably qualified and trained aero-medical repatriation nurse or doctor.

At lower flying levels, aircraft cabins, including helicopters, are usually not pressurized. However, they are susceptible to the effects of turbulence, vibration, can be cold, and with helicopters noise. As a result, some equipment, e.g., stethoscopes, is unusable in the air. Sphygmomanometers containing mercury are restricted, so digital sphygmomanometers must be used. Furthermore, temperature affects the ability to record oxygen saturation and a low saturation due to cold peripheral extremities rather than hypoxia should be considered.

On commercial aircraft each airline is responsible for providing medical clearance for its patients prior to flight. The International Air Transport Association (2010) issued medical clearance guidance to airlines and their governing bodies to support suitability to fly. Box 4.4 summarizes the main impact of changes in air pressure on key organs.

Box 4.4 Effect of gas on main organs

• Ear (minimal impact) – gas is released from the Eustachian tubes by yawning; however where otitis media is present travel by air should not occur due to the significant risk of ruptured ear drum

• Sinuses – while normally not a problem, due to mucus build up there is a low risk of barosinusitis

• Lungs – normally no problem; however, where there has been history of pneumothorax the British Thoracic Society (2004) has issued guidance on a wide range of respiratory conditions and assessment, especially those with oxygen saturation levels below 95 %. When transferring a patient with a pneumothorax a one-way flutter valve (or Heimlich valve) should be connected to the draining tube to prevent the effect of gas expansion affect the thoracic tissue

• Abdomen – Normal gas releasing happens over time; however those with colostomies or urostomies need to be alerted to the effect of flying and the need to have a bag empty of air prior to flying otherwise risk of bursting will occur. It is possible for the abdomen to contain up to 1 000mL of gas at altitude

Contraindications to air travel

While for most patients in most situations travel by air is acceptable, there are a number of conditions where air travel is contraindicated (World Health Organization 2010). However, while some commercial airlines will accept a number of these conditions, a specialized air ambulance would be an alternative approach with appropriate medical and nursing support (Box 4.5).

Box 4.5 Contraindications to air travel

Travel by air is normally contraindicated in the following cases:

• Infants less than 48 hours old

• Women after the 36th week of pregnancy (32nd week for multiple pregnancies)

• Those suffering from:

• angina pectoris or chest pain at rest

• any active communicable disease

• decompression sickness after diving

• increased intracranial pressure due to haemorrhage, trauma or infection

• infections of the sinuses or of the ear and nose, particularly if the Eustachian tube is blocked

• recent myocardial infarction and stroke–elapsed time since the event depending on severity of illness and duration of travel

• recent surgery or injury where trapped air or gas may be present, especially abdominal trauma and gastrointestinal surgery, craniofacial and ocular injuries, brain operations, and eye operations involving penetration of the eyeball

• severe chronic respiratory disease, breathlessness at rest, or unresolved pneumothorax

• sickle-cell anaemia

• psychotic illness, except when fully controlled

The above list is not comprehensive, and fitness for travel should be decided on a case-by-case basis (World Health Organization 2010).

Primary response by air

A primary response by air usually uses helicopters because they can land and take off from places inaccessible by ground and other vehicles. Most trauma centres now have a helipad facilitating point-to-point transfers and rapid interventions; it is used primarily as air transfer as it may reduce transportation by a quarter of normal road response time. They also operate in lower altitudes, thus reducing any impact of changes of altitude on the body especially below 610 metres (2 000 feet). Specific primary response/transportation helicopters will be set up with key clinical equipment to support the retrieval and transportation of the acutely ill or injured person.

The adverse factors that can affect the patient’s physiological response as well as impact the ability of the medical personnel to perform certain functions and procedures are:

• noise

• vibration

• motion sickness

• and reduced or inability to maintain temperature management (Martin 2001).

The latter issue of temperature management is usually not an overarching factor as the transfer duration is relatively short time-wise. The majority of journeys are usually less than 30 minutes’ duration and rarely exceed one hour.

Unless these issues adversely affect the movement of the injured or acutely ill patient, air transportation may be the mode of choice, especially in ensuring rapid supportive care. Undoubtedly helicopter primary transfers have saved thousands of lives worldwide since their introduction, especially among the most critically ill (Nicholl et al. 1995, Chipp et al. 2010).

The initial preparation and nursing considerations for a primary transfer will be the same as for a road ambulance transfer. The patient will need to have had a primary survey, most if not all cases will require c-spine immobilization and have adequate airway with venous access should there be a need to rapidly infuse. The level of consciousness and mechanism of injury, or underlying condition may require further preparation of intubation to ensure a patent airway. It is possible to provide infusions in these types of transfers.

A key risk time is the loading and unloading of the patient, and vigilance in ensuring that the patient’s limbs do not get caught in stretchers. It is key that all members follow the lead of the clinical/medical lead especially with monitoring and clinical tubing. Only approved monitoring equipment authorized by the appropriate aviation authorities should be used (Box 4.6).

Box 4.6 The transfer process

As secondary transfers either relocate a primary injured patient from one hospital or facility to another, there is usually sufficient time to plan and prepare both the patient and agree a time with the accepting hospital or facility when they can expect or receive the patient. The steps in this process will vary slightly by region and hospital but principally are:

1. Before any transfer, the patient is accepted by a named consultant or clinician at the receiving hospital or faculty on a specified date.

2. The patient will be transported by the mode appropriate to their clinical condition taking into account accepted best practice, and any national or regional transfer guidance as well as economic and logistical factors. This will usually be decided by the dispatching hospital and where more than one mode is used, will have ensured the onward transfer by road ambulance and return of the transfer staff.

3. The transferred patient is clinically assessed immediately prior to transfer to ensure they are suitable for transfer, this assessment should include key nursing assessments including assessment for potential complications of pressure ulcers, and should this be a potential risk, action taken and interventions are duly documented.

4. The dispatching hospital or unit will ensure that the patient’s next-of-kin and any significant other(s) are informed of the transfer, the location, time and provide a contact name/number for them to liaise with.

5. The patient will be accompanied by appropriately trained clinical staff being trained to transfer in the mode, and able to work and respond to deterioration in that environment who will ensure that the patient’s dignity is maintained; monitoring the patient throughout the progress, documenting all monitoring and actions.

6. Clinical information will have been provided to the accepting clinical team in advance and should the accepting individual or team not be on duty when the patient arrives, that this information will have been passed to a named individual who will be able to accept and will be responsible for assessing the patient on arrival.

7. Because this is a secondary transfer, the patient will go straight to the clinical area, unless there has been deterioration in the patient’s condition or a new event warranting immediate assessment in an emergency unit. The transportation team, or named transfer nurse/doctor will remain with the patient until the assessing clinical staff have accepted the patient. If there is a likely delay this may be omitted subject to the nursing staff being comfortable with accepting the patient (and subject to local policy).

8. All clinical information will be provided, including radiological investigation, diagnostic investigations and clinical notes to reduce unnecessary duplication, delay in treatment and exposure to unnecessary procedures. The patient’s property should also accompany them unless there is good reason that this is not practical. The patient’s medication should be administered in line with recommended best practice (Royal College of Nursing 2006), especially in nurse-led transfers, and the medication are both prescribed and dispensed to the named patient.

9. Infection prevention is a key issue for all healthcare providers, as such the dispatching hospital will provide a report on the infectious status of the patient being admitted, and unless this is available or unclear, the receiving unit may choose to isolate the patient, unless clinically contraindicated, while maintaining their care.

10. The transferring clinical team will maintain confidentiality and apply universal precautions, follow infection prevention and control procedures including decontamination following the transfer.

Secondary repatriation by air

Pressurized twin or jet engine aircraft usually do air transfers, although for some secondary responses helicopters may be an option, especially for the acutely ill and medium-length transfers.

Aircraft in the UK are not usually dedicated to air responses unlike in other parts of Europe, the US and Australasia, although some companies that specialize in air repatriation have adapted and dedicated aircraft. In the UK, the majority of secondary air transfers will be from the Islands and from remote parts of the UK to tertiary services. The Intensive Care Society (2002) recommends that air transportation in a fixed wing aircraft should be considered for distances greater than 150 miles, and helicopter in place of long road journeys or where roads are inaccessible.

Search and rescue

A final service in transportation of people is ‘search and rescue’. In the UK, the Coast Guard manages this with Royal Air Force support for helicopter rescue. Its primary purpose is to retrieve the person from the situation, whether it is at sea, mountainous terrain, or on the side of a cliff, and then transport them to land or a place where care can take place. As well as possible trauma injuries, these people are prone to hypothermia.

Special considerations for transportation by air

Regardless of aircraft type, space is a major issue. In the majority of cases, where a patient is placed on a stretcher the patient will be positioned feet forward against the side of the aircraft, meaning access from either the left or right is not possible. This has major implications for access and also positioning, so care must be taken to note the skin integrity before, during and after the flight and secondary transport, with all corresponding actions to prevent pressure ulceration.

The patient is positioned in an aircraft on Joint Aviation Authorities (JAA)/Civil Aviation Authority (UK) CAA approved stretchers, with four-point (over shoulder and abdomen) safety belts. In commercial aircraft and smaller jets, the space above the person is usually restricted. Lastly, because of the gas laws of physics, any equipment that has air in it will expand.

Commercial airlines require any patient to be screened by their own staff, they require either an Incapacitated Passengers Handling Advice (INCAD) form and/or a Medical Information Form (MEDIF). If they are frequent travelers they are likely to have a Frequent Travelers medical card; however, these are only relevant to those individuals requiring mobility and clearance assistance rather than for transfer in an acute phase.

These forms help the airlines assess the level of risk of an interrupted journey, as the cost of a diversion is hugely expensive financially, operationally and adversely affects their reputation. They also ensure that all the appropriate support of supplemental oxygen, transfer arrangement and assistance on board and disembarking are in place.

More recently, many commercial airlines do not carry stretchers and require the patient to walk or to be wheeled to their seat, and should they need to lie down during the flight, airline now offer club seats or first class alternatives. Some airlines, e.g., Lufthansa, provide dedicated units for stretcher patients to support privacy and dignity. Where an airline cannot carry a person, such as risk to the person, infectious risk, or they are unsuitable candidates, the only alternative is a privately hired aircraft.

Venous Thromboembolisms: In the 1990s awareness of deep vein thrombosis (DVT), now considered part of venous thromboembolism (VTE), as part of long-haul flying came under scrutiny. The UK House of Lords Science and Technology Committee investigated and produced Air Travel and Health that identified those who are at low, medium and higher risk of developing DVT/VTEs in flight (UK Parliament 2000). A subsequent report (UK Parliament 2007) further looked at DVT/VTEs and other issues raised in the first report. The issues around DVT/VTEs were considered as part of a wider World Health Organization Research Into Global Hazards of Travel (WRIGHT) project that was developed to confirm that the risk of VTE is increased by air travel. The study also determined the magnitude of risk, the effect of other factors on the risk, and the effect of preventive measures on risk (Box 4.7).

Box 4.7 Venous thromboembolism and air travel

• Travelling for more than four hours in any form of transport approximately doubled the risk of VTE

• The absolute risk of VTE for a flight of more than four hours was 1 in 6 000 passengers, rising to about 1 in 1 000 passengers for longer journeys and multiple flights

• The longer the flight, including multiple trips, the greater the risk of developing VTE

• There is no difference in the relative risk of VTE if the cabin pressure was reduced

• Those who were very short, very tall or overweight were at slightly greater risk

• Travelling by air accentuated other pre-existing VTE risk factors, e.g., use of oral contraceptives and the presence of prothrombotic blood abnormalities

• ‘Hyper-responders’ seemed to react to unspecified flight-related factors. If an individual had a risk factor the likelihood of him developing VTE increased dramatically after an 8-hour flight

(UK Parliament (2007) House of Lords Science and Technology Committee Air Travel and Health: An Update. London, The Stationery Office.)

While there is still a lack of clarity on how to prevent air-related DVTs, the use of aspirin is yet to be clearly identified as a reputable source. However, the use of low-molecular-weight heparin in the prevention of DVT in higher-risk groups, including those who have previously had a DVT, is well established but it is not clear how it should be used in the prevention of travel-related DVT (British Medical Association 2004, Katsumata et al. 2012).

Special considerations

In all cases patient safety must be paramount in the transportation of patients or acutely ill persons. When dealing with specialist cases, e.g., intensive care patients, patients with traumatic brain or neurological injury, paediatric patients and neonates, specialist attention is required.

When preparing all transfers, it is paramount that specialist teams are considered, possibly using retrieval/collection teams if they exist. The suitably qualified (in the relevant specialty) and experienced clinical staff should follow the nationally agreed or professionally developed transfer guidelines (Middleton 2011). This should also include any specific documentation required as recommended.

Transfer of adult intensive care patients

In 1997 there were an estimated 11 000 tranfers (Association of Anaesthetists of Great Britain and Ireland 2009), however figures for the number of such transfers carried out currently are difficult to obtain as there is no national reporting (Intensive Care Society 2011). There are a number of international and national guidance documents (Association of Anaesthetists of Great Britain and Ireland 2009, Clinical Resource Efficiency and Resource Team 2006), which outline the key priorities. While these discuss the operational and skills level of the practitioner (Holleran 2002), there is also a need for nurses to have a suitable level of training to provide effective transfer and transportation support.

The Intensive Care Society (2002) issued guidance that covers an array of core service provision at EDs, consultant cover, transportation guidance on the number of staff and skills set, equipment and preparation, including competence of transport personnel, the role of nursing staff, the role of critical care networks, and the need for dedicated equipment.

While the rate of adverse events by clinically specialized teams is low (Kue et al. 2011), this requires adequate preparation of the team and the equipment. To support practitioners there is a need for adequate preparation (Bambi & Day 2010) and transportation checklists (Intensive Care Society 2002, Nocera 2002) have emerged that support practice around key areas. The Intensive Care Society guidelines include a number of checklists, for example: ‘Is the patient stable for transport’ covering airway, ventilation, circulation, metabolic, neurology, trauma, and monitoring and ‘Are you ready for departure’. These checklists are further supported by detailed guidance in the document.

Transfer of patients with neurological injuries

Patients who have developed brain or neurological injuries following trauma require special attention. The mechanism of injury will determine what care is required and the resulting injury may require treatment after initial resuscitation of other life-threatening injuries.

These types of injuries require rapid discussion, usually consultant-to-consultant prior to transfer. The Association of Anaesthetists of Great Britain and Ireland (2006) developed recommendations for the transfer of patients with brain injuries (Box 4.8).

Box 4.8 Safe transfer of patients with brain injury guidance

1. High-quality transfer of patients with brain injury improves outcome.

2. There should be designated consultants in the referring hospitals and the neuroscience units with overall responsibility for the transfer of patients with brain injuries.

3. Local guidelines on the transfer of patients with brain injuries should be drawn up between the referring hospital trusts, the neurosciences unit and the local ambulance service. These should be consistent with established national guidelines. Details of the transfer of responsibility for patient care should also be agreed.

4. While it is understood that transfer is often urgent, thorough resuscitation and stabilization of the patient must be completed before transfer to avoid complications during the journey.

5. All patients should be intubated and ventilated if they meet any of the following criteria:

• Glasgow coma score of 8 or less

• Significantly deteriorating conscious level, i.e., fall in motor score of two or more of the following factors: loss of protective laryngeal reflexes; hypoxaemia (PaO₂ <13 kPa on oxygen); hypercarbia (PaCO₂ >6 kPa); spontaneous hyperventilation causing PaCO₂ <4.0 kPa; bilateral fractured mandible; or copious bleeding into the mouth (e.g., from skull base fracture).

6. Patients with brain injuries should be accompanied by a doctor with appropriate training and experience in the transfer of patients with acute brain injury. They must have a dedicated and adequately trained assistant. Arrangements for medical indemnity and personal accident insurance should be in place.

7. The standard of monitoring during transport should adhere to previously published standards.

(Association of Anaesthetists of Great Britain and Ireland (2006) Recommendations for the Safe Transfer of Patients with Brain Injury. London: Association of Anaesthetists of Great Britain and Ireland.)

Transfer of children

Acutely ill paediatric transfers require the same attention to preparation and management as critical care transfers. The Royal College of Anaesthetists (2001) made the following recommendation on the transfer of paediatric patients; a transfer is normally undertaken by the paediatric emergency transfer team and where this is not feasible the following:

• there should be a designated consultant with the responsibility for transfers

• functional mobile equipment and relevant guidelines should be available

• all patient transfers should be accompanied by a trained doctor with a minimum of two years’ experience who has the ability to perform tracheal intubation and is accompanied by a trained assistant, either an ICU nurse or Operating Department Practitioner.

There will be times when a transfer to another care centre is appropriate, and guidelines for the transfer of ambulatory paediatric patients are recommended in these cases (Clinical Resource Efficiency and Resource Team 2001) (Box 4.9). While speedy intervention into paediatric care is important, Killion & Stein (2009) argue that air versus road ambulance transfers have no impact on patient outcome. Further studies in Australia suggest that different approaches can influence transfer time (Soundappan et al. 2007).

Box 4.9 Ambulatory paediatrics: guidelines for referrals and transfer

• An experienced paediatrician is needed when the unit is open, together with experienced nursing, clerical and other staff

• The service needs close association with, or inclusion of, a paediatric community nursing service

• Appropriate referrals are children considered by a general practitioner or ED staff to need further assessment, observation or investigation but likely to return home after a short period in the ambulatory unit

• The GP or ED must contact ambulatory unit staff to arrange the referral, especially if the child is acutely ill and needs paediatric expertise immediately

• Transfer arrangements must be carefully worked out with the local ambulance service

• Attendance will also be appropriate for some children who require follow up after discharge from hospital or initial attendance at the ambulatory unit, but this should not be used as a substitute for referral to a paediatric outpatient clinic

(Clinical Resource Efficiency and Resource Team (2001) Ambulatory Paediatrics Guidelines for referrals and transfer. Belfast, CREST.)

Consideration of infection

Infection prevention and control are as applicable within hospital care as well as external to hospital care. A significant amount of meticillin-resistant Staphylococcus aureus and other organisms are transferred into and between care settings from outside of hospital care. Transferring patients between hospitals poses significant risks to established infection control procedures, and each hospital will have localized policies in how patients are accepted and managed on arrival.

Some organizations will want confirmation of the status of a patient’s infectious status with regard to specific or a range of organisms. While it is unlikely that someone will be denied treatment because of their infectious status, operationally this can delay when someone is accepted, especially with regards isolation facilities.

The transferring crew must follow universal precautions. The Department of Health in England have issued some guidance on ‘Reducing infection through effective practice in the pre-hospital environment’ (Department of Health 2008a). The document covers a range of topics from hand hygiene, personal protective equipment, aseptic technique and environmental cleanliness, through to the decontamination of ambulance stretcher beds. The nurse and medical escorts must ensure appropriate disposal of infectious clinical equipment.

Conclusion

Health systems, commissioners and providers of health need to be aware of the emerging forces around the movement of people in general to both predict and manage increasing numbers who need care and will require transportation. Nurses, especially those in EDs, critical care areas and those involved in transportation of patients are well placed to assess, plan the pathway of transportation, implement that care and evaluate it. Evaluation needs to be against the three outcome domains for quality (Department of Health 2008b):

1. the anticipated and expected experience: was the experience for the patient as anticipated, was all done to improve that experience?

2. the effectiveness of the need to transport: was the outcome after the transfer anticipated and could only have resulted from the transfer? Was the mode of transport the appropriate one, both for outcome and cost?

3. the safety: was a risk assessment in place to identify potential problems or harms? Did any occur? And what did the nursing intervention in place do to reduce harm?

With a growing body of evidence on the trends, outcomes, experiences and not just data, nurses and healthcare practitioners will be increasingly better placed to influence and improve the effects of care.