Interhospital transfer of Level 3 patients - St-marys-anaesthesia.co.uk

Interhospital transfer of Level 3 patients
Definitions
Clinical transfer – to facilitate intervention not available at this hospital (eg
neurosurgery)
Non clinical transfer – no ICU bed available
Level 3 – ventilated, high risk of needing ventilation, or two organ system support. For
the purposes of transfers a level 3 transfer is any one where anaesthetist is required as
an escort
Introduction
It is unfortunately sometimes necessary for critically ill patients to require transfer to
another hospital. Clearly this is undesirable under any circumstances, but is necessary
when this facilitates potentially life saving treatment, and occasionally unavoidable if
there is insufficient ICU capacity. In North West London as a whole, clinical transfers
make up roughly half of all Level 3 transfers; at St Mary’s the proportion is much higher.
About half of all transfers are associated with “critical incidents” of varying levels of
severity. It is unfortunately the case that many interhospital transfers in the UK are
poorly conducted.
Always
In all cases where a patient requires a level 3 (ICU/Ventilated) transfer the following must
always occur:
The ICU Consultant must be advised at an early stage to decide which patient should be
transferred, to authorise the transfer, and to advise on management.
o No level 3 patient should ever leave St Mary’s without discussion with an ICU
Consultant. Even if the transfer is a straightforward clinical transfer you MUST
inform the ICU Consultant.
o It is primarily the responsibility of Anaesthetic SpRs to undertake interhospital
transfers, however ICU staff will undertake most intrahospital transfers (eg CT scan),
unless the transfer if for the purpose of a procedure and the patient will require
anaesthesia.
• Within working hours the an ICU SpR or Anaesthetic SpR will undertake
interhospital transfers depending upon current workload and availability of
staff.
• Outside working hours the “General SpR” will usually undertake any
transfers. The Anaesthetic Locum Consultant will be required to come in to
anaesthetise any patients who require anaesthesia whilst the SpR is
unavailable.
The priority of the transfer depends upon the clinical situation.
o Where a life saving intervention is required (eg evacuation of an extradural
haematoma), the priority is to get the patient to the neurosurgical centre without
delay – in these circumstances prolonged optimisation is inappropriate.
o The goal is that all patients who require emergency neurosurgery should
undergo CT within 1hour of arrival in hospital and the haematoma should be
evacuated within 4 hours of injury. Clearly this is difficult to achieve. If this means
extra staff must come in then so be it.
o For nonclinical transfers (lack of a bed) the patient must be optimised before
transfer. Also it may be that an existing ICU patient is a better candidate for the
transfer. The ICU Consultant will decide who should be transferred.

The patient must be accompanied by a Specialist Registrar in Anaesthetics with experience
(and ideally training) in Interhospital Transfer. The experience of the escorting doctor must
match the severity of illness of the patient – more senior anaesthetists may be required if the
patient is very unstable.
Have a low threshold for the use of Noradrenaline in patients with suspected raised ICP or
hypotension. FULL PATIENTS TRAVEL BETTER.
Full monitoring should be applied, including in almost all cases (especially neuro)
invasive arterial monitoring.
A transfer form must be obtained from ICU to document the transfer. This must be
completed and then the top copy is left with the receiving hospital, and the remaining copies
returned to the ICU at St Mary’s. The transfer form also contains information about the safe
conduct of transfers and information such as contact phone numbers on the reverse.
The referring team must write a transfer letter, whether this is A&E, Medicine or Surgery –
the transfer form is not a substitute for this.
A Specialist Registrar of the referring speciality must always review the patient, unless this
will delay the receipt of life saving treatment.
The Transfer equipment is kept in ICU with the forms in ICU. This must be checked before
use by the transferring anaesthetist.
Take photocopies of relevant notes.
The bed manager (during day) or Site Practitioner during the night MUST be informed
of the transfer. They should help coordinate who is the most appropriate person to
accompany the doctor as an escort on the transfer. The site practitioner must also
make an entry on the hospital log to include:
o Date and time
o Patient name, hospital number and date of birth
o Reason for transfer
o Destination
o ICU Consultant on Call
o Referring Consultant
o Name of escorting doctor
o Name of escorting nurse
Phone the receiving ICU before leaving.
Take a mobile phone.
Return the transfer kit and bottom 2 sheets to the ICU
If the transfer occurred because of lack of ICU beds at St Mary’s a trust critical incident form
must always be completed, and returned to ICU.
If at any stage there are difficulties in arranging a transfer, especially where this is for definitive
treatment the referring Consultant and the ICU Consultant must be informed in order to prevent
anomalous delays in people receiving the right treatment. In particular the goal is that patients
who require emergent neurosurgical intervention to receive their treatment within 4
hours of the time of injury.
The safe conduct of any transfer is ultimately the responsibility of the referring hospital
and the escorting doctor. If you receive advice from the receiving hospital which you regard
as unsafe, you should discuss management with the Anaesthetic/ICU Consultant, but in no
case should a patient with significantly falling conscious level or coma (GCS

Checklist
Below are mnemonics for a pretransfer assessment
Allergies
Medications
Past Medical History
Last oral intake
Events leading upto transfer (ie what is the story)
Assessment of the patient
Airway & Cervical spine
Breathing
Circulation
Disability (Neuro)
Exposure and Fractures
Fluids electrolytes and renal
Gut
Haematology
Infection
Organisational
Just in case (Mobile etc)
Kit check
Lab Results
Monitoring
Notes & X rays
Oxygen
Paperwork and Phone
Quality control & Audit
Ready Steady Go
Process
Make the situation safe
Contact ICU Nurse in charge will send equipment and drugs – primary support
for ICU patients outside ICU and transfers
Establish basic facts
Contact ICU Consultant – Discuss case. Suitability for ICU Suitability for
transfer Decides on plan.
You contact receiving hospital ICUs (+/- ICU Consultant)
Refer back to ICU Consultant if problems finding a bed
You as the legal medical escort are responsible for patient safety, paper work
and equipment
You MUST please bring all equipment and the transfer forms back to ICU and give them
to the ICU Nurse in Charge.
Finally please, please let me know of any medical, political, or logistic problems you
experience- please fill out critical incident forms and email me. I can’t try and solve what
I do not know about.
Many thanks
Simon Ashworth (simon.ashworth@nhs.net)
ICU Consultant

Assess
Support transfer
Identify assistant
Enter transfer details
on Hospital Log
(Patient ID,
Destination, Escorts)
Bed Managr
or
Site
Practitioner
(Night)
ICU
Consultant
Control
Stabilise and establish
invasive monitoring
Communicate
Local Area
Nurse
in Charge
Decides on the plan
Establish priorities
Intervene if problems
Who goes
Where
Priority
Sorts out politics
Discusses with
receieving consultant
Get the facts!
Documentation
Fill in Transfer form
Transfer patient
YOU!
Return equipment and
ICU Nurse in
Charge
Referring
doctors
Support Anaesthetist
Transfer Letter
Phone receiving
medical team
Patient – needs
ICU or transfer
Assume
nothing and
trust no-one!
Support transfer with
- Equipment
- Documentation
Agree who will assist
on transfer with other
senior nurses
- Ward staff
- ODP
- ICU nurse

Airway
Pre transfer
Secure, Safe
GCS < 8 or fluctuating – intubate
pO2 < 8 Kpa - intubate
Pre & In transit
Suction
Spare equipment for potential loss of airway
Bag/valve/mask
Personnel
Cervical spine
Is the history compatible with injury
Clearance depends upon definitive CT
protocol
Scans reviewed by Consultant radiologist.
Examination must inform
If in doubt manage as if injured
Neutral position
Collar +/- Sandbags
Breathing
Adequate blood gases
Ventilated – stabilise 15 minutes prior to
transfer on transport ventilator
Breathing
Rib fractures
or
Pneumothorax
= CHEST DRAIN
Drains always unclamped (except post
pneumonectomy)
Circulation
‘Full patients travel better’
Give fluids and assess CVP & perfusion
prior to transfer
Ensure MAP > 75mmHg (>90 mmHg in
Neuro)
Ensure Systolic BP > 120mmHg
Pulse needs to be < 120 / minute
2 x IV cannula for travel
Fluids – (volumetric pumps are not
designed to travel)
Circulation
If in doubt start low dose pressors and/or
inotropes
Noradrenaline usually best if sedated
Augments benefit of “being full”
Make sure all infused drugs clear dead
space
3 way tap (¡Ö0.5ml) + lumen (0.3-0.5ml) ¡Ö
1ml
At 2 ml/h may take 1h
Run at 20ml/h for 2 mins then 10ml/h until
response seen
Disability (Neurological status)
History of suggesting neurological
impairment
Clinical Examination (symmetry)
Best GCS
Current GCS
Response to pain centrally (V) and
peripherally
Pupils (II, III)
Eye movements (II, III, IV, V, VI, VIII)
Reflexes and plantar reflexes
Corneal reflex
CT findings
Disability (Neurological status)
SEDATE ALWAYS if orally intubated
Relaxants USUALLY
Always consider seizures a possibility
Nonconvulsive status
Anticonvulsants
Raised ICP
KEEP MAP > 90
Deeper sedation
Exposure (and Fractures)
Check Temperature
Patients usually get cold
Vasoconstriction can precipitate pulmonary
oedema
Wrap well with blankets (even if just going
along corridors)
Pressure points must be well padded
Lines
Where How old Secure
Ensure secondary survey has
been completed (ATLS) or at least fully
documented to point it was stopped
Fractures must be stabilised (bones grate
against each other with the vibration of
travel)
Also imply blood loss/risk or bleeding
Fluids, Electrolytes and Renal
Sodium
Do NOT attempt complete or rapid
correction unless actively fitting
Potassium (aim 4.0 to 5.0)
Correct to safe range BEFORE moving
Mg >1.0 (give 20 mmol if necessary, esp MI
or PET)
Correct acidosis

Bicarbonate BY INFUSION if required
Urinary catheter
GLUCOSE
Gut
Nasogastric tube
Oral (head if base of skull fracture
suspected or coagulopathic)
Free drainage
CHECK POSITION ON CXR
History suggesting possible intra-abdominal
bleeding (AAA, Trauma)
NOT SUITABLE FOR TRANSFER unless
purpose is definitive surgical treatment
Haematology
Ensure Hb > 7.0
Aim > 10 if any risk of bleeding or recent MI
Coagulation satisfactory
Platelets > 50..100
What products have been given
Have you got and checked the crossmatched
blood
Known antibodies
Infection
Does your hospital have any current
problems with multiresistant or transmissible
organisms (eg MRSA, VRE, Acinetobacter)
Does this patient have any MR
Are they a contact
Any other transmissible infection (esp TB,
HIV, HBV, HCV)
Does the patient have active infection
Known bugs What antibiotics Doses up to
date
Have appropriate Cultures been taken
Infusions
Rationalise infusions
Sedation + Analgesia (Propofol + Opioid)
Relaxant (consider Pancuronium bolus)
Noradrenaline
Inotrope
Possibly Insulin
Possibly Bicarbonate
Syringe drivers ONLY
Put vasoactive drugs on smallest lumens
white or blue 18G
Keep larger CVP lumens (grey 14G) for
rapid infusion

Organisational
Just in case
Mobile phone + Phone numbers
Cash + Clothing
Food & drink
Cyclizine
Emergency drugs (ALWAYS LABELLED)
Kit Check
Batteries, Leads and Inverter
Defibrillator
Monitor
Suction unit
Transfer bag
Tracheostomy / Cricthyroidotomy kit
Ventilator
Air mix reduces usage by 50%
Allow DOUBLE expected requirement with a
buffer of at LEAST 1 hour (Lift stuck Traffic
jam)
Paperwork
Ensure details are filled out on transfer form
It is YOUR defence against litigation and
disciplinary action
It is a legal requirement
Bad forms usually correlate with poorly
conducted transfers
Complete checklist
Lab Results
If you have checked it … know the result
NEVER go without knowing at least
Glucose
Potassium
Hb
Blood gases
Monitoring
Minimum for Level 2
ECG
SpO2
NIBP
Minimum for Level 3
As above
Arterial Line
In most cases CVP (4+ lumens)
ETCO 2
Monitoring an equipment is secure
Notes and X Rays
Medical notes
Nursing notes
Transfer Letter for interhospital transfers
Transfer form
Complete checklist
Scans
X Rays
Oxygen
Minute volume = Tidal volume x Rate
Usually 5-15 L/min
Requirement = 60 x Minute volume L/h
Can usually assume a requirement of 600
L/h

Pretransfer checklist (see transfer form)
Airway:
Gag & Cough ok
GCS > 8
Intubated
ETT is ok on CXR
C Spine clear/immobile
Breathing:
OK on Transport vent
ABGs & CXR ok
Drains unclamped
Circulation:
Vital signs stable
Well filled
No bleeding
IVI through dead space
HR
BP
Disability:
Pupils ok
Alert
responds to Verbal
responds to Pain
Unresponsive
Sedation / relaxants ok
Exposure:
IV access x2 ok
Fractures stable (if any)
Pt secured on trolley
Fluids/Renal:
Catheterised
Gut:
NGT/OGT checked
Haematology:
Blood products
Infection:
Antibiotics given
Cultures taken
Just in Case:
Emergency Drugs
Kit Check:
Ventilator
Transfer bag
Batteries ok, Leads
Inverter & adaptor
Suction
Lab Results
Hb >7
Blood glucose > 4
K 3.5 to 5.5
pH >7.2 and BE +/-5
Monitoring
Notes and Scans
Oxygen - sufficient for journey x2
+1h
Phone
Mobile phone
Contact destination

Phone
YOU MUST notify
ICU Consultant
Destination to verify that they will be ready
Ambulance
Usually ask for Emergency ambulance will
arrive within 15min
Neurosurgical emergency – state this you
will get next ambulance
Do not delegate these tasks
Communication is Central
Quality Control
Critical incidents
You must fill out incident forms, otherwise it
will happen again, and again and again and
…. again
If equipment fails you must identify it
Make a note of the serial number and
hospital equipment number and record this
on critical incident form and transfer form
Ready to Go
Summary
THINK
Pink
Full
Stable
Warm
Simple
Finally, assume nothing and trust no one

Transfer documentation
Since 12/1/04 common transfer documentation has been used across West London. This is mandatory
for all Level 3 interhospital transfers. In case of doubt please fill out a form. The forms should be used for
all elective and emergency transfers, and certainly for any ventilated patient.
It is recognised that this represents yet another tedious bit of paper to fill out – however there are a
number of reasons it must be done.
1. Previously the process was undocumented – you and your trust and consultants are all vulnerable to
medicolegal challenge if a patient suffers a poor outcome, and the transfer cannot be shown to have
been well conducted. This is obviously impossible without any documentation! As the doctor
immediately present you are a most attractive target.
2. Many transfers are poorly conducted – the escorts know little about the patient. The patient is not
optimised prior to departure. The “plan” is of dubious quality – if there is one.
3. Too many transfers occur. It is hoped that with better data about transfers the number can be
reduced by better planning.
4. Transfers are a risky business. One study showed mishaps occurred in 67% of transfers. Why
What Any avoidable problems
5. Very few people get formal training in transfers. There is information on the back of the form, which
should be helpful.
6. The hospital site practitioner or bed manager must be informed as early as possible of the potential
need for transfer. They should be able to organise support and identify an assistant for you.
7. Failure to adequately fill in a transfer form or to inform the ICU Consultant before departure
will be taken seriously and will be reflected in your RITA reports.
Q. How do I get the form
A. The forms will be kept on ICU with the transfer kit. As soon as you identify a patient who needs a
transfer ask for the kit, and a form. The nurse in charge of ICU will ask for the destination and name of the
patient, and will send you a form with the kit.
Q. What do I do with it
A. Fill it out! By all means ask a nurse helping you with the patient to complete the demographics.
You then need to put in the medical details and do the observations. The form must be signed off at the
destination. The form is an A3 3 part carbon copy. Leave the top copy at the receiving hospital in the
notes, and bring back the remaining copies with the transfer kit to the ICU. Interestingly quality of transfer
does seem to correlate with the quality of the transfer – ie shambolic paperwork = shambolic transfer.
Q. What if there is an incident
A. Record this on the transfer form. You must also complete a trust critical incident form – by all
means do not put your name if you don’t want to.
Q. What if there are problems with transfers/politics, etc
A. “Acutely” the ICU or Anaesthetic consultants will sort these issues out. In due course please
contact me at St Mary’s and let me know about any problems, especially if you think an avoidable risk
exists.
Many thanks
Simon Ashworth
Consultant in Intensive Care and Anaesthesia, St Mary’s hospital
Lead clinician for Interhospital Transfers North West London Critical Care Network
Simon.ashworth@st-marys.nhs.uk

Little shop of Horrors
Transfer to Hammersmith 72 year old woman. Non clinical
Post laparotomy for ischaemic bowel
Septic shock
Kyphoscoliosis
Very poor exercise tolerance
Developmental delay
Transferred to permit admission of trauma patient
Trachy day 2
ICU Consultant rang HH to verify safe transfer…
Yes but…
Opening line from transferring doctor was “I don’t really know the patient…”
… no notes
No op note
Transfer note not really filled out
Didn’t realise she had had a trachy
Why did she have a trachy so early
Transfer to Royal Surrey County Hospital Non clinical
60y Aspiration pneumonia
Monitor Battery failed in South London
Pump batteries all failed during journey
…Never plugged in!
Transfer to Roehampton Non clinical
70y woman post laparotomy
Weaning. Moderate LV. Ischaemic heart disease
February -3˚C
Transferred unsedated on Waters bag.
Developed pulmonary oedema before even getting in ambulance
Hypoxic and distressed on arrival with gross pulmonary oedema
Transfer to Queen Square. Clinical transfer though not for definitive intervention
for EEG monitoring
25y Patient with refractory seizures due to anoxic encephalopathy
“Evolving sepsis” became septic shock
Arrived on >1mcg/kg/min Noradrenaline and Adrenaline
Died within hours
What are the lessons

Date
Surname
Hospital no
Destination
Escorting Dr
NHS
1 Who
NHS/Hospital/AE number
Name
Date of
Birth / /
Male
2 Where
Referring
Hospital
3 When
Female
Age
From Ward Theatre
ICU HDU A&E
Other
Consultant
Staff arranging transfer
Name
Speciality
Phone
Incident / / :
Arrival in
hospital
/ / :
Intubation / / :
/ / :
Decision to
Transfer
/ / :
Recipient
contacted
Transfer / / :
agreed
There is no need to enter an exact
time for any event which occured >48h
before transfer.
4 Why
Ext/Bleep
Grade
Type and Reason for transfer
One way
Return
Emergency
Very Urgent 4
K 3.5 to 5.5
pH >7.2 and BE +/-5
Monitoring
Notes and Scans
Oxygen - suffi cient for
journey x2 +1h
Phone
Mobile phone
Contact destination
/ /
Time :

This transfer form...
Q. Why do I have to fill out this form
A. It is now a requirement that the transfer of
critically ill patients is documented. Without it
neither trusts nor doctors have any defence in the
face of mishap. Good documentation protects the
people undertaking transfers. We also hope that
the form will help ensure that transport escorts
are aware of all relevant conditions before getting
into the intrinsically harsh environment of an
ambulance - not the place to discover an allergy
documented illegibly on a scrap of paper you
haven’t read. [ICS §14.7, §18, Appendix 5]
Q. What happens to the copy which goes to the
network
A. The form allows the network to know if their
are problems with the transfer process or for
example bed provision - this will help rational
commissioning of services, and ultimately we
hope, reduce the need for transfers.
Q. When should I fill out the form
It is worth starting the form once the need
for transfer has been identified. Apart from
documenting the transfer, the form should help
you to make effective referrals with all information
at your fingertips.
Q. Do I need a transfer letter as well
A. YES. This form is NOT a substitute for a
transfer letter, which is required to give a detailed
description of the events leading up to admission,
examination findings, past medical history,
investigations and treatment. The referring
medical or surgical must write this.
A copy of the notes, recent X-rays, CT scans and
current lab results must also go with the patient.
The transfer form boxes
Box 1. The post code helps determine if large numbers of out area
patients are being treated.
Box 2. Please fill this in as completely as possible. The destination
is the place where you relinquish care for the patient hand over
and detach your equipment - if the patient goes to theatres
then ICU, the destination is theatres. If you go via A&E to ICU,
the destination is ICU. The named consultants should be the
responsible ICU consultants, AND any other consultant under
whose care the patient falls (eg surgeon)
Box 3. Please put in all timings. The ambulance references should
be included for your reference, and will also help seniors to chase
up any delays or incidents.
Box 4. A non clinical transfer occurs when a patient is transferred
because there is no bed, nurse or equipment (please comment
what was lacking). Repatriation occurs when a patient is
transferred either back to a hospital from which they were
transferred out, or when they are transferred to a hospital nearer
home. If two categories apply (eg Repariation and lack of beds)
then tick both boxes.
Box 5. This obviously lists the basic ATLS dataset vital for patient
safety. Please remember to list antibiotics given, and their timing.
Box 6. Sumarises the interventions which have been made, the
support the patient requires, and essentially the neurological
status of the patient imediately prior to intubation - this may be of
vital prognostic importance.
Box 7. The observation chart. Please tick all the lines and
monitoring used, and enter the number of days the lines have
been in. If the lines were inserted in suboptimal condtions
(emergency, on normal ward, etc) then please draw attention
to this in the comments area. Before departure you should read
the checklist on this page and tick the “Checklist done” box.
You should start the observations before the transfer to verify
stability. Make sure that you check ABGs just before departure
and immediately after arrival - this will help identify rapidly any
sequelae of the transfer.
Box 8. Complete the checklist prior to departure.
Box 9. Verifies your identity and the level of training and experience
you have of transfers.
Box 10. Both the transferring and receiving doctors should sign
off the transfer. Make sure you indicate whether any incidents
occured - if there were problems you must fill out an incident
form at your home hospital. Transfer specific incidents are those
which could only occur during a transfer, such as hypotension on
acceleration, falling equipment, fall from trolley, vehicle crashes.
Transfer Politics
Q. Who decides
A. The decision to transfer a critically ill patient
is always a balance of the associated benefits
and risks, and must be made by a consultant
in intensive care medicine in discussion
with consultant colleagues from the referring
and receiving hospitals. The final decision to
accept a patient lies with the ICU consultant
in the receiving hospital. At the same time
the final decision as to which patient should
be transferred lies with the referring ICU
consultant. Recipient units should not attempt
to put undue pressure on the transferring unit
to transfer one patient rather than another.
[NWLCCN-A]
Q. Who goes A new unstable patient or an
existing stable patient [NWLCCN-A]
A. This is a very complex issue. In general
patients should not be subjected to any
intervention which is not in their best interests.
Within the Network established practice is to
avoid transferring patients from the safety of ICU
unless it is in their own best interests. In certain
circumstances it may be more pragmatic to
transfer a stable patient, particularly if they may
experience some gain from additional expertise
available at the receiving hospital (e.g. better
cover in some relevant subspeciality, nearer
home or relatives). If it is decided that the solution
which offers least risk to all patients involves the
transfer of a stable patient already in ICU, then
you must take the following steps:
1. The decision must be taken by the ICU
consultant at the referring hospital.
2. Document in the patient notes that the
decision has been taken, why, and who by.
3. Write a critical incident form, naming both
patients, and the reasons the decision has
been taken, and who took the decision.
4. Document in the patient’s notes that a
critical incident form has been generated.
5. Inform the relatives of the transfer, and the
reasons for it. You may refer them to network
policy in case of dissent, but if strong feelings
are expressed it may be wise to consider
other solutions.
6. At the earliest convenient opportunity,
inform the ICU director of the transfer and its
circumstances [NWLCCN-A §4.2]
Q. Who goes (with the patient)
A. Critically ill patients must be accompanied
by at least 2 “appropriately experienced
attendants, at least one of whom must be a
medical practitioner with training in Intensive
care medicine, Anaesthesia, or another acute
speciality”. [ICS §9]
Q. Scoop and run or stay and play
A. Patients should be meticulously resuscitated
prior to transfer, except where this may delay
life saving surgical treatment (e.g. emergency
aneurysm repair).
Q. Where should patients be transferred
A. Each hospital should have arrangements
in place to ensure that transfers for capacity
reasons alone occur only as a last resort. Where
necessary the transfer should be to the most
appropriate hospital for the needs of the patient,
taking account of bed availability and transfer
distance. Likely receiving hospitals should be
included in the referring hospitals designated
transfer group. Any transfer solely on the
basis of capacity beyond this is classified
as an adverse clinical event and must be
reported to through the ICU director to the
chief executive at the referring hospital. [ICS
§5-6]
Transfer Practicalities
Q. Who is responsible for the transfer
A. The transfer process is the joint responsibility of
the referring and receiving clinicians. The medical
staff at the receiving hospital may offer advice
on management, but patient management is
always ultimately the responsibility of the
doctor in attendance. [ICS §10.3]
Q. Who should be intubated
A. Intubation is mandatory if their are concerns
about the integrity of the airway or ventilation.
Intubated patients should be paralysed, sedated
and ventilated. [ICS §13.4]
Q. Who should have a chest drain
A. Anyone who has or is suspected of having
a pneumothorax. Ideally use Heimlich valve
systems in place of underwater seals. Do not
clamp drains. [ICS §13.6] If there is a very large
leak Heimlich valves have resistence and can
lead to tension so use caution, and seek senior
specialist advice before embarking.
Q. What monitoring is necessary
A. The minimum standards for monitoring
during transfer include the continuous
presence of appropriately trained staff, ECG,
noninvasive blood pressure, oxygen saturation,
end tidal carbon dioxide, and temperature. In
mechanically ventilated patients, inspired oxygen
tension and airway pressure should be monitored
continuously. Invasive arterial pressure should be
measured in almost all patients. [ICS §14]
Q. What else should I do
A. Insert an NG or OG tube. Control and carefully
correct any electrolyte or metabolic disturbances
such as hypoglycaemia, hypokalaemia, or
acidosis to normal if possible. [ICS §13]
Q. What mode of transport should be used
A. Road transport is preferable in most circumstances. Fixed
wing, pressurized air transfer should be considered for journeys
in excess of 150 miles. The organisation headaches should not be
underestimated. Helicopter transfer is less safe and helicopters
are very harsh working environment, however they are useful for
short to medium distance transfers or where access is difficult
(e.g. remote areas or traffic). [ICS §12]
Q. Are there any pitfalls I should consider
Unfortunately many, here is a selection:
1. Undertreatment - it is very difficult to institute
new treatment in the ambulance. If in doubt
resuscitate, paralyse, ventilate.
2. Redistribution of blood volume due to
acceleration or up slopes causes functional
hypovolaemia, with autotransfusion on braking.
It is a good idea to have inotropes/pressors
running even at very low dose and relative mild
hypervolaemia is usually helpful.
3. Monitoring is unreliable: notably NIBP and
SpO2.
4. The cold. Not only do patients become
hypothermic, but peripheral vasoconstriction can
precipitate pulmonary oedema, particularly in
combination with stress or anxiety.
5. Battery failure - many infusion pumps and
monitors last 70mmHg and certainly >50mmHg. This
implies a need to keep mean BP 90-100mmHg.
9. Pretty obvious really - haste, poor preparation,
lack of knowledge about the patient, a poor
transfer plan....
Equipment
Portable Ventilator
Must be capable of PEEP, and of delivering high
inspiratory pressures
Ambu bag with reservoir
Waters bag
Oxygen allow 10-20L/min depending on minute
volume, leaks, and FiO2
E 680L -> 30-60 minutes
F 1360L ->1-2h
G 3400L ->2-4h
As a minimum, you must take enough oxygen
for the expected duration of the trip, with a
reserve of 100% or 1 hour, whichever is greater.
Monitoring
Mains and Battery powered Monitor with ECG,
SpO2, NIBP, ETCO2, and at least 2 invasive
channels. Leads. Battery should be fully charged
Glucometer
Even for short transfers a 12V DC to AC
“invertor” (at least 400W) is a must, along with a
4-6 way adaptor
Syringe drivers for all infusions, with at least 1
spare
Airway management
2 working laryngoscopes with size 3 and 4
blades.
Gum elastic Bougie
ETT in a range of sizes (6-9)
Size 6-9 Tracheostomy tubes & with obturators
Size 3 and 4 LMA
Guedel airways Size 2, 3 and 4
Magill forceps
Nasal airways
Tracheostomy dilator
Emergencies
Scalpel
2 Silk sutures (0 or greater)
24, 28 and 32 Chest drains
Sterile scissors and Forceps
20ml Lignocaine 2% with Adrenaline
Cricothyroidotomy kit
Consumables
Syringes 1-50ml
Needles
Giving sets
2 Burrettes
22-14G Cannulae
Transducers and flush lines
Fluids
2-4L Colloid
2-4L Hartmans
2x 50ml 50% Glucose
200ml 8.4% Bicarbonate
250ml 20% Mannitol
References
[ICS] Guidlines for the transfer of the critically
ill adult. Intensive care society 2002
(http://www.ics.ac.uk/icstransport2002mem.pdf)
[NWLCCN-A] Network admissions policy
for adult critical care services. North West
London Critical Care Network 2002
Drugs
Take spare syringes of all infusions running
Other appropriate emergency drugs are:
Adrenaline 2-5 mg/50ml via CVP
Noradrenaline 4mg/50ml = 80 µg/ml CVP
GTN 50mg/50ml
Amiodarone 300mg/50ml Dextrose CVP
Labetolol 200mg/50ml
Phenytoin 1g/50ml N Saline CVP
Salbutamol 5mg/50ml
Aminophylline 500mg/50ml
Propofol 1% or 2%
Glucose 50%
Mannitol 20%
Midazolam
Suxamethonium
Atropine
Glycopyrrolate
Calcium
Metaraminol
Cisatracurium
Insulin
At 1mg in 50ml in a 70 kg person
1ml/h ≈ 0.005 µg/kg/min
20ml/h ≈ 0.1 µg/kg/min
Alternatively:
Place Weight (kg) x 0.3 mg of drug in 50ml
This means Infusion at 1ml/h=0.1 µg/kg/min
Etomidate is controversial. It may be better
avoided because of its adverse effects on
adrenal function which are harmful in critical
illness, and perhaps more of a worry when
aptients is to be transferred.
Etomidate should not be used in patients at
risk of seizures or with neurosurgical patients.
Other Tertiary referral centres
Individual hospitals may have other
hospitals within their own transfer groups,
but this must be checked locally. Other
specialist units include:
Atkinson Neuro 020 8946 7711
Morley
Broomfield, Burns 01245 440761
Chelmsford
Queen Burns 01342 410 210
Victoria, East
Grinstead
Kings Liver 020 7737 4000
College Neuro
Cardiac
National, Neuro 0207 837 3611
Queen
Square
Royal Free Neuro
Liver
020 7794 0500
Royal
National
Orthopaedic
Stoke
Mandeville
Ortho
Spinal
020 8954 2300
Spinal 01296 315 000
North West London
Critical Care Network
Consistent with the best interests of individual patients,
where possible transfers should be undertaken between
hospitals within the NWL Critical Care Network. Priority
should be given to patients originating within the
network.
The following hospitals are within the North West
London Critical Care Network:
Hospitals Tertiary Phone
Specialities
Central Middlesex 020 8965 5733
Charing Cross Vascular 020 8846 1234
Neuro SpR 07960 937 553
Chelsea and
020 8746 8000
Westminster
Burns 020 8746 8611-2
020 8237 2500
Ealing 020 8574 2444
Harefield
Cardiac and 01895 82 37 37
Thoracic
Hammersmith Cardiac, Liver, 020 8383 1000
Renal
Hillingdon (and
01895 238 282
Orthopaedics at
MVH)
Northwick Park & GI
020 8864 3232
St. Marks
Vascular
Royal Brompton Cardiac and 0207 352 8121
Thoracic
St. Mary’s Cardiology
Cardiothoracic,
Vascular
(Thoracic vascular)
020 7886 6666
West Middlesex 020 8560 2121
Clementine Independent 020 8872 3872
Churchill
Cromwell (L3) Independent 020 7460 2000
Harley street clinic HCA 020 7935 7700
(L3)
King Edward VII Independent 020 7486 4411
Lister hospital HCA 020 7730 3417
Portland HCA 020 7580 4400
Princess Grace HCA 020 7486 1234
Wellington (L3) HCA 020 7586 5959
Transfers beyond your hospital’s transfer group are defined
as adverse clinical events, and should be reported
to the ICU director who will report it both to the Chief
Executive and the critical care network.
Any comments on the design, usability or otherwise of this
form, please contact
Dr Simon Ashworth, AICU Consultant, St Marys
(simon.ashworth@nhs.net)
Queries regarding protocols should be addressed to:
Dr Ganesh Suntharalingam, Consultant ITU, Northwick Park
All other queries should be addressed to the Network manager
Angela Walsh (angela.walsh@ealingpct.nhs.uk),
c/o Ealing PCT, 1 Armstrong way, Southall, Middx, UB2
4SA. Tel 020 8893 0309
Any serious incident must be reported locally to the
Clinical director, and details copied to Dr Suntharalingam
and Angela Walsh.
Further information is available on the website:
www.nwlcritcarenetwork.nhs.uk