Transfer of the

Critically Ill Adult

 ● Higher level of care for patient

● Centralisation of specialist
Transfer services

● Increasing demand
The Numbers

● 11,000 UK inter hospital transfers annually (1997)

○ No national report in GB or Ireland since
● 94,149 ICU admissions annually (UK 2009)
○ Based on audit of 73% of adult ICUS in GB and NI
○ More recent report not published
● 17% transfers in one year resulted in a critical incident
○ Audit of NHS North West London Trust 2007-08
The Reality

● Lack of specific training in transferring the critical patient

● An assumption that these skills must be present for the clinician to function
day to day

● Increasing data to show this assumption to be incorrect

● Noteworthy that “transport medicine” has become a specialty in itself

Overview

Types of
Types of Guidelines
Guidelines & Speciality
Specialty
Transfer
Risks
Risks Organisation
Organisation
and Training
Training considerations
Considerations
Transfer
Types of
Types of Guidelines
Guidelines & Speciality
Specialty
Transfer
Risks
Risks Organisation
Organisation
and Training
Training considerations
Considerations
Transfer
Types of Transfer

1. Primary
○ Land ambulance
○ Typically “Scene to Emergency Department”

2. Secondary
○ Intra/Inter-hospital transfer
○ Example: ICU admission from ward
○ Example: Transfer to CUH for Neurosurgical input
Categories of Interhospital Transfer

CATEGORY 1 CATEGORY 2
Specialist support or Organ support that is
investigation not available locally

CATEGORY 3 CATEGORY 4
Repatriation Local lack of critical
care beds
Types of
Types of Guidelines
Guidelines & Speciality
Specialty
Transfer
Risks
Risks Organisation
Organisation
and Training
Training considerations
Considerations
Transfer
 1. Physiological

a. Dynamic and Static

Risks 2. Transfer safety

3. Legal
1. Physiological - Dynamic
● Effect of Acceleration on the body
● Newton’s Third Law
○ EXTERNAL FORCE: The transfer vehicle’s
acceleration
○ INERTIAL FORCE: The body’s reaction
● Inertial force occurs in x-axis, y-axis and
z-axis
○ X-axis: Antero-posterior
○ Y-axis: Lateral
○ Z-axis: Cephalo-caudal
○ Or any combination of the above
● Effects
○ Cardiovascular
○ Gastrointestinal
1. Physiological - Static

● Noise

● Vibration

● Temperature

● Atmospheric Pressure
2. Transfer Safety
Patient
● Illness requiring transfer
● Transfer independently
associated with longer ICU stay
and increased mortality
● Specifically neuro patients
● Vehicle risks
Transfer Escort
● Vehicle risk
○ 300-400 crashes involving land
ambulance annually in UK.
○ 10 fatalities (Lutman 2008)
○ 84 air ambulance crashes over 10
years in US.
○ 72 fatalities, 64 injuries (Bledsoe ‘04)
3. Legal

● Four ethical assumptions of medicine

● Transfer probably challenges all of these assumptions

● Appropriate insurance necessary

● Clinical responsibility for appropriateness of transfer falls on senior decision

maker
Types of
Types of Guidelines
Guidelines & Speciality
Specialty
Transfer
Risks
Risks Organisation
Organisation
and Training
Training considerations
Considerations
Transfer
 A.C.C.E.P.T

● Assessment

● Control

Organisation ● Communication

● Evaluation

● Prepare and Package

● Transport
Assessment

● Initial assessment of patient

● Requirement for transfer

● Lines of responsibility
Control and Communication

● Who is managing the transfer?

● Assign team leader. Can be dynamic.

● Communication with all stakeholders (ISBAR)

○ Leader
○ Members (Referring team and Receiving team)
○ Family
Evaluation

1. Level of care needed

2. Necessity of transfer
3. Best location for further stabilisation
4. Degree of urgency for transfer
Urgency

● Priority 1
○ Immeadite, time critical life saving intervention
○ < 8 minutes
● Priority 2
○ Life- or limb-saving intervention
○ < 1 hour
● Priority 3
○ Clinical reason for transfer, but not Priority 1 or 2
○ < 4 hours
● Priority 4
○ Non clinical

UK National Ambulance Service Protocol

Evaluation

1. Level of care needed

2. Necessity of transfer
3. Best location for further stabilisation
4. Degree of urgency for transfer
5. Level of expertise required to stabilise and transfer patient
6. Transfer or retrieve?
Transfer or Retrieve?

● UCL compared two groups of similar demographics and severity of illness

○ Group A - transferred by specialist retrieval team
○ Group B - standard means: a transfer team from referring hospital
● Group A arrived at destination in better condition
○ Acidotic (pH < 7.1)
■ Group A: 3%, Group B: 11% (P < 0.008)
○ Hypotensive (MAP < 60)
■ Group A: 9%, Group B: 18% (P < 0.03)
○ Mortality (Death within 12 hours of arrival)
■ Group A: 3%, Group B: 7.7%
● Standard in Neonate tranfers
Prepare and Package

● Initial resuscitation
○ ABCD approach
● Acknowledge Murphy’s Law
● Checklist

● Package patient as if for surgery

● “PPP with care”
● “ETT secured”
● “Patient warmed with x,y,z”
● Standard monitoring
● Medical adjuncts
Transport

● Avoid clinical interventions during

transfer

● Transfer team to dictate speed of

transfer
○ Smooth and Steady vs. Fast and Rocky
Types of
Types of Guidelines
Guidelines & Speciality
Specialty
Transfer
Risks
Risks Organisation
Organisation
and Training
Training considerations
Considerations
Transfer
 ● Guidelines
○ AAGBI 2009

Guidelines & ○ ICS 2011

Training ● Training
○ STAR course
○ Dip Transfer and Retrieval
Medicine RCSEd
Types of
Types of Guidelines
Guidelines & Speciality
Specialty
Transfer
Risks
Risks Organisation
Organisation
and Training
Training considerations
Considerations
Transfer
 Speciality ● Neurosurgical Transfer

Considerations ● Vascular Emergencies

The Neurosurgical Transfer

● Most commonly an expanding haematoma

● NeuroT app provides excellent guidelines on
how to manage
● Focus on certain parameters will decrease
chances of secondary brain injury
○ Oxygenation (pO2 >13kPa)
○ Ventilation (pCO2 4.5-5 kPa)
○ BP
○ Temperature
The Vascular Transfer

● Most commonly a threatening AAA

● Key points:
○ Haemodynamic control to reduce wall stress
○ SBP 70-100 mmHg
○ HR <100 bpm
○ Pharmacological support
○ Judicious fluid resuscitation
In Summary

Types of
Types of Guidelines
Guidelines & Speciality
Specialty
Transfer
Risks
Risks Organisation
Organisation
and Training
Training considerations
Considerations
Transfer
Resources

● AAGBI Guidelines
○ Interhospital transfer 2009
○ Safe transfer of patients with brain injury 2006
● ICS Guidelines 2011
● Transfer of the critically ill adult
○ Hunt, D - Surgery 2015
○ Macartney and Nightingale - BJA 2001
● Secondary transfer of the critically ill adult
○ Handyman, J - Current anaesthesia and critical care 2007
Thank you