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 11 from the first paper of 2022, 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
- Factors that dictate the choice of transport:
- Determined by nature of illness, urgency of retrieval, and the distance to the receiving centre
- 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
- Advantages and disadvantages of different modes of transport:
| Advantages |
Disadvantages |
| Road transport by ambulance |
- Quickest to arrange
- Cheaper
- Less danger to crew
- No complications of altitude
- Not affected by inclement weather
- Able to pull over to perform a lifesaving procedure, if needed
|
- Range is limited
- Speed is limited
- Road access is required
- A lot more vibration, depending on the road surface
|
| Air transport by helicopter |
- Faster to organise than fixed wing
- Rapid transit time
- VTOL: does not need an airport (flexible with landing sites, eg. corn field)
- Less turbulence, smoother ride
|
- Range is limited
- Highly weather-dependent
- Expensive
- Noisy for crew and patient; communication possible only via headset
- Small cabin, limited room
- Complications of altitude (albeit mild); cabin not pressurised
|
| Air transport by fixed wing aircraft |
- Highest range
- Fastest speed
- Less weather dependent than helicopter
- Large cabin, more equipment is available
- Better temperature and noise control than helicopter
- Can be pressurised at altitude
|
- Slowest to organise
- Most expensive
- Need to load into an ambulance, then load onto aircraft at the airport, then disembark at an other airport and load into another ambulance (i.e. in effect three separate transfers)
|
This table was derived in whole from this excellent summary by shakEM.co.nz. Theoretically, methods of retrieval may be as diverse as are the vehicles available, but CICM trainees would not be expected to discuss them.
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.