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Essential Nursing Care of the Critically Ill Patient 123

antiseptic-coated catheters they can be used safely for up transport, or within a hospital from one department
to seven days. 156 Currently available evidence supports to another, this being intrahospital transport. 158,159 This
the use of maximal barriers (head cap, face mask, sterile section will focus on intrahospital transport, while inter-
body gown, sterile gloves and full-size body drape) during hospital transport is described in Chapter 22. A large
routine insertion of central venous catheters along with proportion of intrahospital transports occur from the
antiseptic solutions to prepare the skin, and catheter emergency department 160 to the critical care unit. Patients
119
insertion by appropriately trained personnel. Chapter within the ICU may require transport to imaging depart-
3 contains information on central line care bundles and ments for scans or operating theatres for procedures.
checklists. Although chlorhexidine solutions are recom-
mended their effectiveness depends upon the strength of Guidelines for the transport of critically ill patients are
the solution. In Australia decontamination of the inser- available in many countries including Australia and New
158,159,161
tion site is with 0.5% chlorhexidine gluconate in 70% Zealand with the principles applying equally to
162
119
isopropyl alcohol. The use of antimicrobial ointments intrahospital as other transport. Specific guidelines
to prevent local colonisation is recommended for long- may need to be observed for certain groups of patients,
term tunnelled catheters used for haemodialysis. 119 for example those with head injury. A careful assessment
of risk versus benefit should be undertaken before making
Nurses are responsible for the maintenance of central a decision to transport a patient. 161,163 To reduce the risk
venous catheters once inserted, including care of the of adverse events during transport, various diagnostic
insertion site dressing and infusion line management. tests or surgical procedures should be evaluated in terms
The types of dressing commonly used are transparent of their potential to be undertaken in the critical care
semi-permeable and more recently chlorhexidine gluco- unit. 161,164
nate gel dressings. 119,157 Transparent dressings are advan-
tageous because they allow direct observation of the entry ASSESSMENT
site of the catheters. Dressings should be replaced when- As adverse effects may occur in 40–70% of critically ill
119
ever their seal is broken or every seven days. Catheter patients transported within hospitals, 164,165 the primary
hubs are another site of colonisation for microorganisms, focus of assessment should be on patient safety and the
such as Staphylococcus epidermidis and effective hand prevention of adverse events. A transport ‘event’ can be
hygiene combined with non-touch aseptic techniques any event that has an adverse impact and can be patient-,
when accessing the catheter hub should be implemented. staff- or equipment-related. 166 The patient may be
Intravenous administration sets containing blood prod- adversely affected during transport, ranging from anxiety
ucts or lipids or parenteral nutrition infusions are changed or pain to respiratory or cardiovascular compromise. Staff
when the infusion completes or daily, while others may have difficulty with managing the equipment or
can be left for intervals of up to 4 days or changed patient’s needs during transport and equipment related
according to local protocols. Infusions such as propofol problems during transport of critically ill patients are a
or nitroglycerine may have additional manufacturer major consideration. 164-167 Risk–benefit assessment is
guidelines regarding admini stration set changes. 119
helpful to identify patients with a high risk of complica-
After removal of the catheter, and once homeostasis has tions. 163,166 For example, the potential risk of moving a
been established, the site should be covered with an severely head-injured patient with unstable intracranial
occlusive dressing, which should be left in place for 48 pressure may outweigh the potential benefit of a CT scan.
hours to minimise the risk of infection. The catheter Meticulous planning for all aspects of the transport,
should be examined after removal and any damage based on a thorough assessment of the patient’s anti-
reported. It may be hospital or unit policy to send the cipated needs is the key to safe intrahospital trans-
catheter tip for culture and sensitivity. port. 158,163,166 A comprehensive outline of information
addressing key components of intrahospital transport of
critically ill patients should be available to personnel at
every hospital. 158,159,161
Practice tip
Safe transport requires accurate assessment and stabilisa-
Unless contraindicated in a specific patient, a central venous tion of the patient before transport. 158 Key elements 162 are
catheter dressing should be changed whenever there is evi- identified in Box 6.6. All equipment should be checked
dence of fluid accumulation or loss of the dressing’s occlusive for functionality prior to transport and while it is vital to
seal. ensure that sufficient equipment is taken to maintain the
patient, unnecessary equipment complicates the logistics
of managing the transport smoothly. Specifically con-
structed transport beds, or attachments such as equip-
TRANSPORT OF CRITICALLY ILL ment tables, designed to support equipment safely during
PATIENTS: GENERAL PRINCIPLES transfer are useful. 158,163,166 The period of transport should
ideally be as short as possible, although safety should not
The transport of a critically ill patient may occur for be sacrificed for speed. Pre-planning the route of trans-
several reasons, such as from an accident site categorised port and good dialogue between department staff can
as pre-hospital transport, or to move a patient to another help to maximise the efficiency of transport and reduce
facility for treatment which is known as interhospital unnecessary delays. 161,166