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Transfer of the critical care patient 

Transfer of the critical care patient
Chapter:
Transfer of the critical care patient
Author(s):

Heather Baid

, Fiona Creed

, and Jessica Hargreaves

DOI:
10.1093/med/9780198701071.003.0020
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date: 18 May 2021

Transfer principles

The transfer of critical care patients can occur at various times throughout the admission period (e.g. following the initial stabilization of the patient, for diagnostic or interventional procedures, or for specialist treatment or repatriation). Other indications for patient transfer may be due to bed and staffing availability.

Critically ill patients are extremely vulnerable during transfer, and a high level of expertise is required in order to safeguard the patent from adverse events or near misses. Only experienced and well-trained critical care teams that are able to work together to manage the patient’s condition and the potential deterioration of the patient should undertake transfers.

Recommendations from the Intensive Care Society1 include competency- based training for all staff involved in patient transfers (i.e. ambulance crew, air medical crew, medical staff, operating department practitioner, nursing staff, and portering staff). The decision to transfer a patient must be made by the responsible consultant in consultation with colleagues from both the referring and receiving hospitals. All inter- and intra-hospital transfers should be audited, and any adverse event or near miss should be reported.

Although there are obvious differences between intra- and inter-hospital transfer (e.g. indication, duration, environment of transfer, availability of personnel, and equipment required), the main considerations when undertaking the preparation and execution of the transfer are similar. They mainly involve mitigating the associated risks (see Table 20.1).

Table 20.1 Risks involved in transferring the critical care patient

Potential risk

Examples

Technical complications

  • Displacement of airway

  • Displacement of intravascular lines or drains

  • Mechanical failure of equipment

  • Power failure of equipment

Inadequate monitoring or therapy

  • Simplified monitoring/ventilators

  • Interference due to motion

  • Pathophysiological

  • deterioration

  • Increased ICP with supine positioning

  • Hypotension or oxygen desaturation

  • Rupture of fibrin clots

  • Dislocation of unstable fractures

Inadequate personnel

  • Lack of competence

  • Lack of additional support

Reference

1 Intensive Care Society. Guidelines for the Transport of the Critically Ill Adult, 3rd edn. Intensive Care Society: London, 2011.Find this resource:

Intra-hospital transfer

This refers to transfers that take place within the hospital setting either as part of the admission or discharge process, or to enable surgery, specialist procedures, or diagnostic tests. Although the patient remains within the hospital, they are still exposed to high-risk and unfamiliar environments, and staff need to be mindful of this when undertaking the transfer (see Table 20.2).

Table 20.2 Preparing the critically ill patient for safe intra-hospital transfer

Preparation

Prior to transfer

Respiratory support

  • ABG and/or chest X-ray if necessary

  • Intubate if there is potential for the patient to deteriorate. Insert nasogastric tube (aspirate and free drainage)

  • Secure airway; check that the patient tolerates portable ventilator

  • Chest physiotherapy, suction, nebulizers

Cardiovascular support

  • Establish access (triple-lumen central venous catheter) and arterial line

  • Correct electrolyte or pH abnormalities

  • Set up drug infusions with back-up syringe and pumps, and ensure that colloid and crystalloid infusions are available

  • Insert urinary catheter

  • If the patient is bleeding, carry cross-matched/O-negative/group-specific blood

Gastrointestinal support

  • Pause enteral feeding

  • Pause unnecessary infusions (e.g. TPN, insulin)

Patient anxiety

Introduce self and team, and briefly discuss reasons for transfer, destination, journey time, and location of critical care unit

Pain control and sedation

Assess level of pain and need for increased analgesia or sedation during journey. Ensure that infusions and bolus drugs are available for journey

Pressure damage, wounds, or fractures

  • Assess pressure areas and avoid further pressure damage to vulnerable areas using pillows and/or pressure-relieving devices

  • Ensure that fractures are stabilized prior to movement of patient Check that wound dressings are patent and unlikely to leak

  • Protect cervical spine

Equipment or battery failure

Ensure that batteries are charged and check function of all equipment prior to moving

Relocation stress

Patients have reported experiencing negative physical and psychological responses to transfer. This is termed ‘relocation stress’, which occurs as a result of transfer from one environment to another. The key points to consider with regard to care of the patient include the process of transferring the patient, the information given, and the management of the patient post-transfer. Although the majority of patients report that relocation is a stressful experience, patients also regard transfer to a ward as a sign of improvement in their condition and relief from the stress of the critical care environment.

A significant factor in the patient experience is the abruptness of the transfer and the time of day at which it takes place. Preparation of the patient for transfer or discharge should begin early in the patient’s admission. Both the patient and their significant others need to be informed of the process and timing of the transfer and the management of the patient’s care post-transfer. Inadequate and poorly coordinated transfers must be avoided, so the following strategies should be considered.

  • Patient diaries that are commenced on admission and maintained during critical care and post transfer can help to reorientate the patient and provide them with the opportunity to reflect on their care in terms of their progress and ongoing care needs.

  • Information that is prepared using either local or national initiatives. For example, the Intensive Care Unit Support Teams for Ex-Patients (ICUsteps) was founded in 2005 by former patients, their relatives, and ICU staff to support patients and their families in their recovery from critical illness. ICUsteps have produced a range of literature, including Intensive Care: a guide for patients and relatives and Guide to Setting up a Patients and Relatives Intensive Care Support Group. The literature and further information are available from their website (Transfer of the critical care patienthttp://icusteps.org). Information based on local or national initiatives may be available in a written or Internet-based format. Managing the expectations of patients and their significant others will help to reduce anxiety, especially with regard to the change in staff to patient ratio. Where possible the information should be individualized to the specific patient.

  • Timing of transfers is important. They should avoid out-of-hours periods and not overburden the workloads of the receiving staff.

  • Acknowledgement by critical care staff of the anxiety that transfer can generate for the patient is important, as is recognition of the signs of stress, and helping patients to learn methods of managing their anxiety.

  • Communication between staff who are transferring and receiving the patient and communication with the patient and their significant other must be considered an essential component of every transfer. Debriefing following a transfer may help to identify points of good and poor practice.

Inter-hospital transfer

This refers to transfers that take place between critical care units for tertiary specialist care, or when a lack of critical care beds requires the patient to be transferred elsewhere.

Additional requirements for inter-hospital transfer

  • Staff should be specifically trained and experienced.

  • They should wear suitable clothing (for warmth and visibility).

  • They should take with them a charged mobile phone containing the contact details of the referring and receiving hospitals.

  • They should establish roles and responsibilities for the transfer and the level of experience within the transfer team.

  • They should establish the route to the receiving hospital, the entry site, and the route from the entry site to the critical care unit.

  • The trolley that is used to transport the patient and the equipment should be designed to withstand acceleration/deceleration forces and facilitate the mounting of equipment below the patient in order to maintain a lower centre of gravity and provide full access to the patient.

  • The equipment should be designed for transport, so should be light, reliable, and with a battery life of more than 4 h.

  • The equipment should be checked and calibrated prior to use, and fully charged.

  • Monitoring should include ECG, blood pressure (intra-arterial blood pressure or non-invasive), temperature, SpO2, and ETCO2 if the patient is intubated.

  • Adequate supplies of oxygen and medications should be prepared for the expected journey time, plus an extra 2 h (see Box 20.1).

  • A transfer bag with additional equipment for emergency use may be available. Emergency equipment should include a full range of resuscitation drugs and apparatus for administration, a defibrillator, intubation equipment, and suction (see Box 20.2).

  • The patient should be stable prior to commencement of the journey:

    • ventilation—ensure adequate ventilation or spontaneous breaths and gas exchange confirmed with ABG

    • cardiovascular—optimize blood pressure and heart rate

    • neurological—manage raised intracranial pressure.

Prior to commencement, the patient’s family should be informed of the destination details, the approximate length of the journey, and the reasons for the transfer. It is not usual for the patient’s family to be allowed to travel with the patient, due to vehicle insurance restrictions.

The receiving hospital should be informed of the patient’s departure and estimated time of arrival.

Physiological effects of transfer

In addition to the physiological effects of speed, acceleration, and deceleration on the patient during and in the hours subsequent to the transfer, there are other environmental effects, including temperature, noise, light, vibration, and atmospheric pressure.

Acceleration and deceleration will primarily affect the cardiopulmonary system. Acceleration will cause a drop in venous pressure and a corresponding drop in cardiac output. This reduction will also lead to a potential sympathetic response. In contrast, deceleration will increase venous pressure and cardiac output. This increase in filling pressure may not be accommodated, as the heart is unable to respond by increasing output, resulting in heart failure. Changes in heart rate occur when changes are maintained sufficiently for baroreceptor stimulus. A decrease in preload will lead to tachycardia, and bradycardia is associated with an increase in preload.

Acceleration for a patient in the upright position leads to less perfusion of the apices and more in the bases, resulting in a ventilation–perfusion mismatch. Therefore an increase in acceleration increases alveolar apical volume, which is unperfused, and causes an increase in basal shunt. In the supine position, acceleration towards the head means that the apical alveoli are stretched, whereas those at the bases are compressed. The key is to optimize filling pressures.

Indemnity information

The NHS Litigation Authority currently provides insurance for nurses for emergency transfers only (see NHS Risk Pooling Scheme). For planned transfers there is no formal cover. In order to increase or improve the cover currently available, nurses can obtain cover through a professional organization, arrange their own and seek reimbursement from their employing NHS trust, or set up a voluntary group personal accident scheme sponsored by the trust. Some NHS trusts have arranged commercial insurance cover for their employees.

Handover

Documentation should be maintained at all stages of the transfer. This should include details of the patient’s condition, the reason for transfer, the names of the referring and accepting consultants, the patient’s clinical status prior to transfer, and details of vital signs, clinical events, and therapy given before and during transfer. The patient’s clinical notes and investigation results should accompany them, and copies should be retained by the receiving hospital.

A formal handover must be undertaken between the transfer team and the medical and nursing staff who will have responsibility for the patient. The handover should include a verbal and written account of the transfer and the patient’s condition. The Intensive Care Society recommends the use of standardized transfer documentation.3

References

2 BOC Healthcare. Medical Oxygen: integral valve cylinders (CD, ZD, HX, ZX). Transfer of the critical care patient www.bochealthcare.co.uk/internet.lh.lh.gbr/en/images/504370-Healthcare%20Medical%20Oxygen%20Integral%20Valve%20Cylinders%20leaflet%2006409_54069.pdf

3 Intensive Care Society. Guidelines for the Transport of the Critically Ill Adult, 3rd edn. Intensive Care Society: London, 2011.Find this resource:

Further reading

Association of Anaesthetists of Great Britain and Ireland (AAGBI). AAGBI Safety Guideline: inter-hospital transfer. AAGBI: London, 2009.Find this resource:

Bench S et al. Effectiveness of critical care discharge information in supporting early recovery from critical illness. Critical Care Nurse 2013; 33: 41–52.Find this resource:

Cullinane J and Plowright C. Patients’ and relatives’ experiences of transfer from intensive care unit to wards. Nursing in Critical Care 2013; 18: 289–96.Find this resource:

Day D. Keeping patients safe during intrahospital transport. Critical Care Nurse 2010; 30: 18–32.Find this resource:

Fanara B et al. Recommendations for the intra-hospital transport of critically ill patients. Critical Care 2010; 14: R87.Find this resource:

Fludger S and Klein A. Portable ventilators. Continuing Education in Anaesthesia, Critical Care & Pain 2008; 8: 199–203.Find this resource:

National Institute for Health and Care Excellence (NICE). Rehabilitation after Critical Illness. CG83. NICE: London, 2009. Transfer of the critical care patientwww.nice.org.uk/guidance/cg83

van Lieshout EJ and Stricker K. Patient Transportation: skills and techniques. European Society of Intensive Care Medicine: Brussels, 2011.Find this resource: