A 56-year-old woman with a spontaneous subarachnoid haemorrhage, presenting with a Glasgow Coma Scale of 12, requires transfer to a neurosurgical centre from a regional hospital.
Outline the clinical and organisational issues involved pre-transfer.
Mode of transfer – road or air (fixed or rotary wing) – should be determined by resources, distance to be covered and weather conditions. The mode of transfer should provide the shortest time from the referring hospital to the receiving centre and the standard of care should be maintained throughout the transfer. Staff safety during transfer is an essential consideration. College guidelines for minimum standards for transport of critically ill patients should be followed.
Co-ordination and communication
Ensure bed available at receiving centre
Establish key individual(s) at receiving centre for liaison to receive updates on transfer status and to provide expert advice re patient management
Ensure all necessary documentation prepared to accompany patient including clinical records and radiology
Ensure transport team know destination (town, hospital, ICU location)
Ensure patient’s next of kin are aware of need for transfer
Preparation of patient
Consider intubation and mechanical ventilation (with ongoing sedation and paralysis) depending on stability of patient and distance/mode of transport
Stabilise on transport ventilator
Vascular access including arterial line
Urinary catheterization and passage of NG tube TEDs
All lines and tubes secured and correct position confirmed Resuscitation and physiological stabilization of patient as indicated Final repeat clinical assessment immediately prior to departure
Full monitoring of patient including intra-arterial pressure, end-tidal CO2, oxygen saturation and ECG and TO4 if paralysing agents used
Ensure optimum MAP to maintain cerebral perfusion but target SBP < 150 mmHg to avoid re-bleed
Equipment and drugs
Ensure adequately trained personnel for retrieval team, including appropriately experienced medical practitioner
Ensure adequate staffing remains on site at base hospital
These retrieval questions should be approached with some sort of a system. ANZCA also have a policy document- Guidelines for Transport of Critically Ill Patients- which has been endorsed by CICM.
CICM have a policy document - Minimum Standards for Transport of Critically Ill Patients (IC-10, 2010) which is referred to in the college answer. This document provides a reasonable systematic framework. It is, however, a 12-page document.
In an abridged form, the recommendations are as follows:
ANZCA "Guidelines for Transport of Critically Ill Patients
CICM "Minimum Standards for Transport of Critically Ill Patients" (IC-10, 2010)