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CHAPTER 11: Transportation of the Critically Ill Patient 69

Transport of critically ill patients is a common element in their care,
• Lilly CM, Cody S, Zhao H, et al. Hospital mortality, length of stay,
and preventable complications among critically ill patients before encompassing journeys lasting from a few minutes to many hours.
These may include transfer from the scene of injury or illness to the
and after tele-ICU reengineering of critical care processes. JAMA.
2011;305(21):2175-2183. hospital, transport from the emergency department to the radiology
department and the operating room, and from there to the intensive
• Lilly CM, McLaughlin JM, Zhao H, et al. A multicenter study care unit. Transport across much greater distances may be necessary
of ICU telemedicine reengineering of adult critical care. Chest. in rural areas, for tertiary referrals, and in repatriation from overseas
2014;145(3):500-507. for both civilian and military patients. The main determinants of risk
• MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evalua- common to all patient movements are dependence on organ system sup-
tion of the effect of trauma-center care on mortality. N Engl J Med. port, physiological instability and limited reserve, and separation from
2006;354(4):366-378. sophisticated diagnostic and therapeutic interventions.
• Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, ■
Young TL. Physician staffing patterns and clinical outcomes in criti- PRIOR TO TRANSFER
cally ill patients: a systematic review. JAMA. 2002;288(17):2151-2162. Timing: Most transfers within the hospital occur at the convenience
• Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of the intensive care, imaging or operating room staff departments,
of telemedicine for remote monitoring of intensive care patients and are contingent on the urgency of the intervention. Critical care
with mortality, complications, and length of stay. JAMA. transfers between hospitals can be classified as either time critical
2009;302(24):2671-2678. or nontime critical. An example of a time critical transfer would be
• Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. that of an acute intracranial bleed requiring urgent neurosurgical
Impact of telemedicine intensive care unit coverage on patient intervention. Transfers outside working hours should be avoided
2
outcomes: a systematic review and meta-analysis. Arch Intern Med. if possible and, if aeromedical transfer is required, transfer during
2011;171(6):498-506. daylight hours is preferable. Duration of both intrahospital and inter-
• Ward NS, Afessa B, Kleinpell R, et al. Intensivist/patient ratios in hospital transfers varies widely; dedicated transfer teams may reduce
closed ICUs: a statement from the Society of Critical Care Medicine transfer times by reducing the time required for patient preparation. 3
Taskforce on ICU Staffing. Crit Care Med. 2013;41(2):638-645. Team Composition: To optimize efficiency and safety, a team leader
should assume responsibility for patient preparation, communication
between all relevant parties, and team coordination. The composition
of the transfer team will depend on the requirements of the patient,
REFERENCES specialist equipment in use, such as an intra-aortic balloon pump, and
the duration and mode of travel. Team composition will also depend
Complete references available online at www.mhprofessional.com/hall
on local protocols, regional systems, and team member experience
and training. A 2-year cohort study of 1169 patients transferred by
air demonstrated no difference in outcomes between nurse-lead and
physician-lead transfer teams. Indeed, nurse- or paramedic-lead
4
CHAPTER Transportation of the teams may be appropriate for less severely ill patients regardless of
the mode of transport. Longer distance transfers of patients requiring
5
11 Critically Ill Patient cardiovascular or respiratory support almost certainly benefit from
6,7
Charlotte Small the presence of an appropriately trained doctor as part of the team.
They should be experienced in anesthesia, intensive care, or an acute
Andrew McDonald Johnston care specialty and be proficient in airway management, resuscitation,
Julian Bion and organ support. Papson et al demonstrated that unexpected or
8,9
adverse events were common during intrahospital transfers between
the emergency department and the intensive care unit. The frequency
KEY POINTS of these events was negatively correlated with the experience level of
10
• The transport of critically ill patients should be undertaken by the escorting doctor. This effect may be ameliorated by training. 11
appropriately trained and supported staff. Some units and organizations will advocate the use of specialist
• All critically ill patients undergoing transport are at risk of retrieval teams trained to manage patients according to particular
This applies to pediatric hospitals and those providing
protocols.
12-18
complications. highly specialized services. It has been suggested that use of special-
• Preparation for transfer requires a systematic approach to assess- ized teams results in fewer adverse events, improved patient outcome,
ment, physiological stabilization before departure, and communi- improved staff satisfaction, and an increase in cost effectiveness. 3,18-19
cation between centers. A minimum of two escorts should accompany the patient. One of
9,20
• Adverse event recording and audit may improve the quality of those should be an experienced medical practitioner who is compe-
transport systems. tent at managing the airway as well as providing organ support and
resuscitation. All clinical members of the team should be familiar with
the patient’s condition and management to date. They should have
21
INTRODUCTION received training in patient transportation and be familiar with the
transport equipment and environment. 8,9
The transport of critically ill patients dates back to the Napoleonic wars, In some jurisdictions, some of the above provisions are mandated
with Baron Dominique Larrey’s invention of the “ambulance volante” by law. For example, in the United States among other requirements,
to transport injured soldiers rapidly to the surgeon. In the modern era transfer team members must be appropriately qualified and the
transport with ongoing intensive care support can be dated to Pantridge relevant documentation must accompany the patient. Medical staff
and Geddes’ 1967 description in The Lancet of the successful transport responsible for organizing or undertaking transfers should be famil-
of over 300 myocardial infarction patients to hospital by mobile inten- iar with local legal requirements and the recommendations of their
sive care unit with a high success rate for resuscitation. 1 national medical bodies.

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