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76 PART 1: An Overview of the Approach to and Organization of Critical Care

as to the most appropriate mode of spinal immobilization. Hard “spine TABLE 11-4 Outcomes of Interfacility Critical Care Adult Patient Transport:
boards” cause more rapid development of pressure sores than inflat- A Systematic Review 84
able devices or vacuum splints. Other complications of spine boards
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include raised intracerebral pressure, difficult airway management, Barriers to Transport Research and Recommendations for Future Studies
deep venous thrombosis, and impaired mouth care. 74 Barriers/Problems Potential Solutions/Approaches
Particular problems with transferring patients with severe, wide-
spread burns include difficulties in recognizing stridor and securing Lack of validated and feasible definitions for Develop a priori definitions for transport-
a compromised airway and difficulties with monitoring, temperature many transport-associated complications associated complications by expert consen-
regulation, and securing intravenous access. These factors should be sus; validate these prospectively (eg, pilot
taken into account prior to secondary transfer, with meticulous atten- study) or retrospectively (eg, chart review)
tion to securing endotracheal tubes and IV cannulas. There should be a Difficulties consistently documenting Standardization of pretransport data collec-
low threshold for intubating patients with airway burns, and establish- pretransport clinical status across multiple tion by centralized form/checklist admin-
ing invasive monitoring prior to transfer. Warming or cooling devices sending facilities istered by transport personnel at time of
should be provided for transfer where feasible. 23,75 patient retrieval and/or by telephone follow-
up following arrival at receiving facility
Obstetrics: Critically ill pregnant women may be transferred by road
or air to tertiary referral centers due to complications arising during Limited monitoring (eg, no blood tests or Standardization of data collection (eg,
pregnancy, such as preeclampsia or antepartum hemorrhage, or for x-rays) and documentation during transport physiological parameters) during transport
advanced neonatal care, in cases such as multiple pregnancy or pre- by centralized form/checklist administered
term labour. 76,77 Risk benefit to both the mother and the fetus should by transport personnel during transport
be considered carefully, as the outcome of a high-risk fetus is better Underreporting of adverse events/errors due Anonymous reporting and independent
when delivered in a specialist perinatal center when compared to a to a real or perceived culture of blame abstraction of documented adverse events/
local hospital. However, the transfer itself can be more hazardous for errors; achieve “buy-in” from frontline staff
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the mother prior to delivery. More commonly, critically ill patients are through education and involvement in proj-
transferred following delivery. In the United Kingdom, over a quarter ect development
of obstetric units do not have critical care facilities on-site, necessi- Inability to identify an adequately matched, Use of a multicenter, prospective obser-
tating an interhospital move. Standard monitoring and management nontransported comparison group due to het- vational cohort study including a broad
should be carried out as per generic critical care transportation guide- erogeneous patient population transported to spectrum of referral institutions; study risk
lines with the addition of avoidance of aortocaval compression using tertiary centers and inevitable selection bias of factors for transport-related adverse events
left lateral tilt and the presence of medical staff trained to manage those chosen for transport to these centers
obstetric emergencies and pediatric resuscitation in the unlikely event
of delivery. Road transfer should be undertaken at normal speed, Reproduced with permission from Fan E, MacDonald RD, Adhikari NK, et al. Outcomes of interfacility
regardless of the distance. 14 critical care adult patient transport: a systematic review. Crit Care. February 2006;10(1):R6.
Neonates/Pediatrics: In a large multicenter UK survey, Ramnarayan and Comprehensive documentation allows retrospective case review and
colleagues reported that critically ill children transferred to a pediatric identification of individual adverse events and trends.
intensive care unit have higher survival rates when transferred by a As noted above, there is a notable lack of rigorous scientific data sur-
specialist pediatric retrieval team compared to those transferred by rounding patient transfer. Research within the field of patient transport
nonspecialist teams. In common with adult patients, the most critically can be difficult due to the small numbers of heterogeneous patients
12
ill children are those at greatest risk of adverse events and deteriora- transferred by any one institution, difficulty in blinding in-house asses-
tion during transfer. Small diameter endotracheal tubes leave smaller sors, and ability of team members to collect research data while concen-
patients particularly vulnerable to tube obstruction by secretions and trating on patient care (see Table 11-4).
resultant hypoxia. Inspired oxygen concentration should be precisely
79
measured and controlled during the transfer of neonates. 9
The Infectious or Contaminated Patient: The receiving unit should be KEY REFERENCES
made aware of the infectious state of the patient, especially if they will • Fanara B, Manzon C, Barbot O, Desmettre T, Capellier G.
require isolation due to colonization or infection with a multidrug Recommendations for the intra-hospital transport of critically ill
resistant organism. Transfer of colonized patients increases the risk patients. Crit Care. 2010;14:R87.
of spread of infection to other patients; likewise patients are more • Iwashyna TJ, Christie JD, Moody J, Kahn JM, Asch DA. The struc-
likely to develop nosocomial infections following transfer. Patients ture of critical care transfer networks. Med Care. 2009;47:787-793.
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transferred from distant areas or countries may expose native patients
to previously unseen organisms, particularly those evacuated from • Jarden RJ, Quirke S. Improving safety and documentation in intra-
disaster areas or areas of conflict. 27 hospital transport: development of an intrahospital transport tool
for critically ill patients. Intensive Crit Care Nurs. 2010;26:101-107.
Training, Research, and Audit: Training for all types of transfer is often • Meisler R, Thomsen AB, Abildstrøm H, et al. Triage and mortality
inadequate. Training of medical staff can improve patient outcomes, in 2875 consecutive trauma patients. Acta Anaesthesiol Scand.
8
reduce incidence of adverse events, and increase speed of patient prepa- 2010;54:218-223.
ration prior to transfer. Staff involved in critical care transfers have a
8,11
responsibility to ensure that they receive adequate training appropriate • Newgard CD, McConnell KJ, Hedges JR, Mullins RJ. The benefit
to the types of transfers they undertake. This can occur locally or on of higher level of care transfer of injured patients from nontertiary
nationally recognized training schemes. Service provision can also hospital emergency departments. J Trauma. 2007;63:965-971.
2
be improved by the appropriate use of clinical audit. Feedback from • The Paediatric Intensive Care Society. Standards for the care of
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receiving units, whether formal or informal, can be of benefit to the critically ill children. 4th ed. 2010. http://www.rcoa.ac.uk/docs/
transfer team. Critical incidents, adverse events, and near misses sccic_2010.pdf.
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should be reported, recorded, and reviewed in a manner that is both • Ramnarayan P, Thiru K, Parslow RC, Harrison DA, Draper ES,
blame free and informs other medical personnel. It has been noted Rowan KM. Effect of specialist retrieval teams on outcomes in
that nurses are more likely than doctors to report adverse events.
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