LEARNING OBJECTIVES
On completion of this chapter, the learner will be able to:
- Acquire knowledge to avoid unwanted incident and thus reducing the risk for any complication and confusion
- Practice transfering of patients safely.
INTRODUCTION
This chapter has been written for nurses working in ICU, who are dealing with shifting and transferring a critically sick patient from ICU to other departments or units of hospital regularly. Many a times, it has been observed that nurses do not follow any protocol for such events. It has also been noticed that transfer of a patient to and from the ICU is sometimes unplanned and in emergency (e.g. taking the patients to radiology department for investigation purposes). Critically ill patients are at high-risk of morbidity and mortality during transport.
The care of acutely ill patient routinely includes safe transportation, both within a given hospital to undergo tests and procedures, and between hospitals, as patients may require transfer to other facilities for specialized services. Critically ill patients in particular commonly require such transfers and are at high-risk for complications on the route. The intra-hospital and inter-hospital transfer of critically ill patients is an inevitable part of emergency department practice. Developing practices to reduce or minimize this risk represents a potentially important area of patient safety research. Stabilization before transport, in the field or in the transferring hospital, and the mode of transferring patients from the field to specialized centers also present important research and policy questions. Careful planning is required to move these patients as they may be hemodynamically unstable and have limited or no reserves. These patients may be on electronic gadgets, life support system, with lots of tubings that require constant and close monitoring.2
Transport of critically ill patient could be pre-hospital (transport from an accident or illness location to the hospital), inter-hospital (transportation of the patient between hospitals) and intra-hospital (transportation of the patient within a hospital for the purpose of undergoing diagnostic and therapeutic procedures or transfer to specialized units).
This chapter deals with intra hospital transport of the critically ill patients. Nurses play an important role in the transport of these patients. All the staff involved in the transport of the patient should work together to ensure positive patient outcome. The decision to transfer a patient to another area is made after an assessment of the potential risks and benefits to the patient.
The present chapter has adopted the guidelines given by the Australian and New Zealand College of Anaesthetists and Joint Faculty of Intensive Care Medicine on the Minimum Standards for Intra Hospital Transport of Critically Ill Patients (2003)1 and The Intensive Care Society Guidelines for transport of critically ill adult (2002).2 Certain modifications are made to suit the Indian settings.
Definition
Transferring generally involves movement of critically ill patients from intensive care areas of the hospital (including intensive care units, emergency departments, operating theaters and recovery rooms) to areas typically not involved in the delivery of such care (e.g. a radiodiagnostic department).
Purposes
Purposes of safely transferring a critical ill patient are:
- To mobilize a critically ill patient safely without any complication.
- To avoid any adverse event during transfer.
- To minimize life threatening risks to patient.
- To promote patient's benefits and safety.
- To avoid confusion among staff responsible for shifting and receiving patient.
- To save time and energy.
- ➢ Airway
- ➢ Guedel airway (assorted sizes)
- ➢ Laryngeal masks (assorted sizes)
- ➢ Tracheal tubes (assorted sizes)
- ➢ Laryngoscope (spare bulbs and blades)
- ➢ Intubating stylet
- ➢ Lubricating jelly
- ➢ Tape for securing tracheal tubes
- ➢ Scissors
- ➢ Stethoscope
- ➢ Oxygen cylinder (full)
- ➢ Ventilation
- Self inflating bag and mask with oxygen reservoir and tubing
- High flow breathing circuit
- Spare valves for portable ventilator
- Portable ventilator with alarm limits set
- ➢ Suction
- Suction catheters different sizes
- Portable suction machine
- NG tube and drainage bags
- ➢ Circulation
- Syringes
- Needles
- Alcohol swabs
- IV cannulae
- Central venous cannulae
- IV fluids
- Infusion sets/extensions
- 3 way connection
- Dressings
- Tape
- Cut down set
- ➢ Other equipments
- Portable monitor with alarm limits set
- Spare electrodes
- Defibrillator (Fig. 1.2)
- Infusion pumps (if the patient requires drugs needing accurate administration of infusions) (Fig. 1.3)
- Emergency drugs, analgesics, sedatives, muscle relaxants and any other drug needed for the patient if indicated
- Chest tube clamps (if water seal drainage present)
- Pulse oximeter
- Appropriate, fully charged spare battery packs should be ready
Successful and adverse event free completion of such complex task involves the requirement of a carefully formulated protocol in which all the relevant staff are involved. Such a protocol should be made widely known and available. Checklist and principles for transferring a critically ill patient is as follows:5
- Staffing and communicationThe following points are to be followed regarding staffing and communication while transferring patient
- Personnel for each transport event must be identified. The transport team should consist at least a nurse, a doctor and a hospital attendant.
- Each team member must be familiar with the equipment and be sufficiently experienced with securing airways, ventilation of lungs, resuscitation and other anticipated emergency procedures.
- Predeparture of the patient, the transport team must be freed from other duties.
- The receiving personnel or the staff at the destination must be notified in advance about patient's status for necessary arrangements.
- Supplementary equipment to be used during transportAll the equipments to be used in the transfer should be durable and fully functional. These trolley linked devises should be able to enter lifts and pass through doorways on the route. Moreover, different appliances in the trolley should be compatible with those being used in the destination (e.g. gas cylinders, suction, etc.)
- Patient stabilization assessment for transportThe patient must be reassessed before transport begins, especially after being placed on the monitoring equipment and transport ventilator. The following assessment should be carried out:➢ Airway
- Airway safe or secured by intubation
- Ventilation is adequate; respiratory variables are appropriate
- Tracheal tube position confirmed on chest X-ray.
➢ Ventilation- Paralysed, sedated and ventilated
- Ventilation established on transport ventilator
- PEEP/ CPAP, FiO2 are correct
- Adequate gas exchange confirmed by ABG analysis.
➢ Circulation- Heart rate, BP stable
- Tissue and organ perfusion adequate
- Any obvious blood loss controlled
- Circulating volume restored
- Hemoglobin adequate
- Minimum of two routes of venous access
- Arterial and central venous line secured (if present).
➢ Neurology- Seizures controlled
- Raised ICP adequately managed
➢ Trauma- Cervical spine protected
- Any internal bleed/injuries managed appropriately
- Long bone/pelvic fracture stabilized
➢ Metabolic- Blood glucose maintained within normal limits
- Calcium maintained within normal limits
- Acid base balance appropriate
- Temperature maintained.
➢ Others- All equipment alarms are switched on
- Vital signs and other parameters are displayed on the transport monitor
- All drains (urinary, wound, water seal drains are functioning and secured)
- Water seal drainage is not clamped.
- Pneumathoraces drained
- Readiness for departureThe following are to be checked one final time before patient is moved out of the ICU area➢ Patient:
- Stable on transport trolley
- Appropriately monitored
- All infusion running and lines adequately secured
- Adequately sedated and paralyzed
- Adequately secured to the trolley
- Adequately wrapped to prevent heat loss.
➢ Staff:- Adequately trained and experienced
- Received appropriate handover.
➢ Equipment- Appropriately equipped trolley
- Appropriate equipment and drugs
- Batteries checked, spare batteries available
- Sufficient oxygen supplies.
➢ Organization- Case notes, X-rays, results and blood collected
- Transfer/shift documentation prepared
- Location of bed and receiving doctor known
- Receiving unit advised of departure time
- Telephone numbers of transferring and receiving units available
- Relatives informed.
➢ Intransit procedures- A best route should be planned. Lifts should be reserved or secured beforehand.
- Adequate communication facilities during transit and at the destination should be available.
- Monitoring during transportContinuous monitoring of the patients should be carried during transport. The minimum standards required are:
- Continuous presence of appropriate trained staff
- ECG monitoring
- Oxygen saturation
- Temperature
- In mechanically ventilated patients, the oxygen supply, inspired oxygen concentration (FiO2) adeguacy of oxygenation (SpO2) ventilator setting and airway pressure should be monitored
- A written record of monitored values and treatment given, if any should be maintained.
- DocumentationThe clinical record should document the patient's clinical status during the transport until handover or return to the unit.
During transportation, patient with critical illness may face certain unwanted but avoidable conditions and complications. A critical care nurse must be careful while planning as well as during transfer for such patients. During transfer patient may encounter:
- Cardiac arrest
- Respiratory problems
- Dislodgement of endotracheal tube
- Dislodgement of any other tubing e.g. chest tube, IV cannulae, etc.
- Hypothermia
- Hypovolemic shock
- Inadequate arrangements at receiving end
- Incomplete records or information.
Certain types of trauma and critical care patients require special considerations during transfer. For example, if there is a potential or actual spinal cord injury, the patient should be maintained in spinal immobilization. The best method for this is by placing the patient on a hard, full length backboard with a stiff cervical collar, sandbags on either side of the neck and taping the head to the backboard by using adhesive tapes across the eyebrows. The patient should be completely restrained to the backboard with binders to prevent any movement of body.
Burn patients have the potential problem of going into hypothermia and therefore every effort should be taken to keep them as warm as possible.
Before concluding, let us come to the ground reality of our own health set ups. Asking to follow above guidelines may be just like asking for moon. Trying to achieve these guidelines may be possible today for corporate hospitals followed by to some extent by our state of art tertiary care national level institutes. But the reality in rest of the health care setups is well known to all of us. So what to do? Let us all be aware of these guidelines to begin with. We must try to do what all is available with us with a content endeavor to improve with each passing day till we achieve the desired levels of care at our own level. Where there is a will, there is a way.
CONCLUSION
Both intra- and inter-hospital transfer must comply with regulations as patient safety is enhanced during transport by establishing an organized efficient process supported by appropriate equipment and personnel8. Various transfer protocols have been developed for different categories of patient population and they have been shown to decrease morbidity and mortality from transport related incidents.8
REFERENCES
- Australian and New Zealand College of anaesthetists, joint faculty of intensive care medicine and Australian college for emergency medicine. Minimum standards for intra-hospital Transport of critically ill patients. 2003
- The intensive care society. Guideline for the Transport of Critically ill adult. 2002 London.
- Pollack MM, Alexander SR, Clarke N, et al. Improved outcomes from tertiary centre pediatric intensive care: a state wide comparison of tertiary and non tertiary care facilities. Crit Care Med. 1991; 19: 150–9.
- Martins SB, Shojania KG. Making health care safer: A critical analysis of patient safety practices. AHRQ Publication. Available online at URL http://www.ahrq.gov/clinic/ptsafety/chap47.htm. Accessed on 10th Sept, 2012.
- Kanter RK, Tompkins JM. Adverse events during inter-hospital transport: physiologic deterioration associated with pre-transport severity of illness. Pediatrics. 1989; 84: 43–8.
- Borker S, Rudolph C, Tsuruki T et al. Interhospital referral of high-risk newborns in a rural regional perinatal program. J Perinatol. 1990; 10: 156–63.
- McCloskey KA, Faries G, King WD, et al. Variables predicting the need for a pediatric critical care transport team. Pediatr Emerg Care. 1992; 8: 1–3.
- Young JS, Bassam D, Cephas GA, et al. Inter-hospital versus direct scene transfer of major trauma patients in a rural trauma system. Am Surg. 1998; 64: 88–92.