Outline your principles of management in the transport of the critically ill patient.

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College Answer

Many candidates failed to mention guidelines, monitoring, handover or documentation.
Two inter-collegiate documents have been published (PS39 and IC-10) and cover the principles of management in detail. Intra-hospital transport requires justification of transport (review of risks vs benefits), availability of appropriate and functional equipment (monitoring and emergency intervention), adequately skilled staff, appropriate pre-departure procedures (including checking of equipment and drugs, and accompanying patient records/investigations), planning of appropriate timing and route, confirmation of appropriate clinical status before transport, appropriate monitoring during transport, assessment of monitoring and equipment at destination, appropriate handover if another team assumes responsibility for care, appropriate documentation of clinical status during transport and some process to facilitate quality assurance. Inter-hospital or pre- hospital transport also includes consideration of mode of transport (distance vs efficiency vs risks of road/fixed wing/helicopter), and potential preventative procedures before transport (e.g. chest tubes). For all transports, some forms of monitoring are considered mandatory (i.e. pulse oximetry, capnography [if mechanically ventilated], ECG, and blood pressure).

Discussion

This question closely resembles Question 7 from the second paper of 2010 and Question 9 from the second paper of 2012., though they deal primarily with aeromedical and interhospital transfer.

In brief:

Justification for transfer

  • All should agree that the benefit outweighs the risk

Interhospital transfer vehicle

  • Determined by nature of illness and urgency or retrieval
  • Need to be mindful of the effects of transport on the illness (eg. the effect of low cabin pressure on gas-filled obstructed bowel loops)
  • Number of staff and volume of equipment
  • Road conditions, weather conditions

Equipment

  • Airway equipment
  • Suction
  • Ventilator
  • Oxygen supply (in excess)
  • Defibrillator
  • Thermal insulation
  • Monitoring equipment
  • All drugs checked and labelled

Monitoring

  • Pulse oximeter
  • Capnometer
  • ECG
  • NIBP or arterial line
  • Airway equipment must have disconnection alarms

Patient preparation

  • Ideal patient is intubated, ventilated and paralysed
  • The patient should ideally be stabilised on a transport ventilator before departure
  • Vascular access should be secure; you should not be doing any elective procedures during transfer
  • One last pre-departure assessment

Communication:

  • Confirmation that the destination is aware of transfer, and is ready
  • Documentation travels with the patient

References