Transport of the critically ill patient

Question 9 from the second paper of 2012 asked vaguely about "clinical and organisational issues involved pre-transfer" in the context of trying to ship a subarachnoid haemorrhage survivor out of a backwater dungheap and into a neurosurgical unit. Other questions on this topic include Question 1 from the second paper of 2003 and Question 7 from the second paper of 2005.  The answer to all such questions can be found in college policy documents. ANZCA also have a policy document- Guidelines for Transport of Critically Ill Patients- which has been endorsed by CICM. Additionally, 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 for a good quality answer. It is, however, a 12-page document.

In an abridged form, the recommendations are listed below.

Basic rationale of interhospital transfer

• Critically ill patients are at increased risk of morbidity and mortality during transport
• Risk can be minimized:
  • Careful planning
  • Appropriately qualified personnel
  • Appropriate equipment
• There should be no hiatus in monitoring or therapy

Vehicle factors

• 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

Personnel

• At least two people to accompany
• Medical staff with training in airway management and advanced cardiac life support
•  

Equipment

• Airway equipment
• Pericardiocentesis equipment
• Pleural drainage eqipment
• 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:

• Bed availability
• Accepting primary consultant
• Accepting unit (ICU)
• Next of kin
• Documentation travels with the patient
• Receiving unit receives updates on transfer status

In addition to the college documents, the retrieval enthusiast would be entertained by the 2004 article by Warren et al, which offers a summary of the reasoning and evidence behind many of the abovelisted guidelines. Unsurprisingly, this is not an area rich in high quality RCT evidence, and much of the recommendations are based on expert opinion and personal experience.