Interhospital transport in critically

ill patients

Specialized patients

‘ABC’ approach

Physiology of patient movement

Transfer process

Equipment

Interhospital transport

Contents

• Reasons: Additional care (technical, cognitive, procedure)

• Assessment potential benefits > risks

• Critically ill patients are at increased risk of morbidity & mortality during transport

• Minimized risk

• Planning

• Qualified personnel

• Appropriated equipment

Overviews

• Vibration • Discomfort and fatigue

• Blurred vision, shortness of breath, motion sickness, chest or abdominal pain

• Increased requirement of sedation and analgesia

• Fracture sites may produce more discomfort

• Pulse may be difficult to palpate

• Sensors, electrodes, ET-tube, IV line may easily disconnected or dislodged

• NIBP may fail to read

• Difficult to do procedure

Physiology of patient movement

• Noise • Ear discomfort, deterioration performance of task

• Headache, fatigue, nausea, vertigo

• Communication is difficult

• Audible alarms may not be heard

• Motion sickness

• Acceleration

Physiology of patient movement

4 Elements

Multidisciplinary team

- Physicians - Nurses - Respiratory therapist - Hospital administration - Local EMS

Assessment - Patient demographic data

- Transfer volume - Transfer pattern - Availability resources

Evaluation and refinement transfer plan

Standard transfer plan

- Development - Implementation

Systemic approach

Attending physician at the referring institution

Decision

Transfer process

Assess patient condition. Is patient stable? Resuscitation and other measures as indicated and to

degree possible: a) Secure airway b) I.V. access c) Fluid resuscitation d) Lab/x-ray

Assess need for transfer. Are resource at current facility adequate to address patient needs?

Compare benefits and risks of transfer. Is patient a candidate for transfer?

Select receiving facility: a) Distance b) Resources c) Bed availability d) Patient preference

Identify and communicate with receiving physician. Has transfer been accepted?

Continue current management plan

NO

NO

NO

NO

YES

YES

YES

YES

Transfer process

Initiate transport Patient sedation as needed Restraints as needed Medical record keeping during transport Follow protocols Communications with medical command as needed

YES

Obtain informed consent/family notification Select mode of transfer (air or ground) a) Cost b) Patient acuity c) Distance d) Weather conditions Mobilize necessary personnel, transfer equipment,

and pharmaceuticals Nurse-to-nurse report to receiving facility Copy medical records for receiving facility

When completed, evaluate transfer for quality improvement.

YES

• Transport attendants • Assess patient’s condition

• Familiar with treatment

• Full clinical details & assessment (P.E. + lab)

• Check patient identity against blood products

• Resuscitation and stabilization before transport • Airway & breathing

• Circulation and hemodynamic

• Procedure equipment

Preparation for transport

• Interventions will benefit before transfer

• Investigations will benefit before transfer

• Procedures may be necessary during transfer

Preparation for transport

‘ABC’ approach

• Concern adequacy of airway and ventilation • Tracheal intubation before transfer

• NOT accept laryngeal mask airway

• Confirm position by chest X-ray

• Secured and protected • Displacement

• ET-tube bite block

• Confirm displacement by ETCO2

• Sedate paralyzed

Airway

Airway

Breathing

• SaO2 or SpO2 guide for FiO2

• EtCO2 guide for ventilation

• One ABG analysis before transfer

• Inspired gas via HME

• If present with pneumothorax • Inserted ICD prior transfer

• Use Heimlich chest valve

• Not use under water seal

• Don’t clamp ICD

Heimlich chest valve

Breathing

• Patients with oxygenation and ventilation problems should use transport ventilator.

Breathing

• If patient requires high PEEP and no transport ventilator.

• Use PEEP valve connect with ambu bag.

Circulation

• Running IV fluids via set may easily be performed whilst the ambulance is travelling

• Secure venous access

• At least two large bore I.V cannulae

• A-line is ideal for BP monitoring

• Treat hypovolemia

• Persistent hypotension should not be moved

Circulation

• Stop bleed and source control of sepsis

• Splint long bone fracture

• Intravenous fluid and medications in plastic (not glass) containers

Disability

• Spine should be immobilized if there is any suggestion of damage

• Pain in the neck or back

• Neurological symptoms or signs of cord injury

• Significant injury above clavicles

• Suggestive mechanism of injury in an unconscious pt.

Spine immobilization

Others

• NG or OG tube in patients with ileus, gut obstruction or mechanical ventilation

• Foley’s catheter is inserted in patients required restrict fluid, long transport or receiving diuretic

• Soft wrist and/or leg restraints for safety

Monitoring during transport

• Continuous presence of appropriately trained staff

• ECG

• NIBP

• SaO2

• EtCO2

• Temperature

Monitoring during transport

• NIBP is sensitive to motion artifact and unreliable in a moving vehicle

• PAC should be continuously displayed or withdrawn to RA or SVC

• The oxygen supply, FiO2, setting and Paw should be monitored

• Record of patient status

Aeromedical considerations

• Staffs have high level of expertise, specialist knowledge and practice training

• Fall in barometric pressure • PAO2 FiO2 is mandatory

• Increase in volume of gas filled cavity

• Pneumothorax must be drained

• NG tube should be inserted and free drainage

• Pneumoperitoneum and intracranial air are relative C/I

• Tissue may swell and plaster casts should be split

• Decrease in temperature keep warm

Aeromedical considerations

• Noise and vibration • Nausea and pain

• Anti-emetic drugs for patients and staff

• Ear protectors

• Intercom headphones use for communication

Handover to receiving hospital

• Formal handover • Transport team

• Receiving medical and nursing staff

• Verbal and written account of • Patient’s history and V/S

• Therapy and significant clinical events during transport

• All investigation results should be described and handover to receiving staff

Equipments

Electrical equipment

• Fully charged

• Shortened life • Age of battery

• Increased electrical demands

• Spare batteries are essential

Multi-function monitor

Ventilators

Defibrillator

• Manual or semi-automatic model

• External pacing

Syringe pumps

Doctor’s bag

Thai Ambulance

Stroke

• Time to rtPA = 4.5 hr.

• Stroke chain of survival • Detection

• Dispatch

• Delivery

• Door

• Data

• Decision

• Drug

• Disposition

Stroke detection

Stroke: prepare

• Goals • Rapid evaluation

• Early stabilization

• Neurological evaluation

• Rapid transport and triage

• Communicate with receiving hospital

• Important history • Time of symptom onset (last known normal)

• Seizure

• Trauma before onset

Stroke: prepare

• Airway • Most of patient do not require emergency airway

management

• Breathing • Keep SpO2 > 94%

• Oxygen therapy

• Circulation • Hypotension: BP < premorbid state or SBP < 120 mmHg

• Treatment of hypertension when SBP > 220 mmHg

Stroke: prepare

• Check blood sugar • Hypoglycemia mimic stroke

• BS < 60 mg/dL try glucose

• Rehydration by NSS > dextrose water

• I.V. access and blood sample

Acute coronary syndrome

Primary goals of therapy

1. Reduce amount of myocardial necrosis

2. Prevent major adverse cardiac events

3. Treat acute life-threatening complications • VF, VT

• Unstable tachycardia and bradycardia

• Pulmonary edema

• Cardiogenic shock

• Mechanical complications

STEMI patient who is a candidate for reperfusion

Initiate seen at a PCI-capable

hospital

Initiate seen at a non-PCI-capable

hospital

PCI-capable hospital: ศูนย์หัวใจสิริกิต์, รพ.ขอนแก่น, รพ.มหาราชนครราชสีมา, รพ.สรรพสิทธิประสงค์, รพ.อุดรธานี (อนาคต)

Primary PCI FMC-device time

90 min

Transfer for primary PCI

FMC-device time as soon as

possible and 120 min

Fibrinolytic agent within 30 min of

arrival when anticipated FMC-device > 120 min

Urgent transfer for PCI for

patients with failed reperfusion

or reocclusion

Transfer for angiography and revascularization within 3-24 h for other patients as

part of an invasive strategy

Diagnostic angiogram

PCI CABG Medical therapy only

Acute coronary syndrome

Urgent transfer

1. Cardiogenic shock

2. Acute severe HF

3. Failed fibrinolytic therapy

4. Re-occlusion

5. Ongoing ischemia

6. Intractable arrhythmia

7. Ineligible for fibrinolytic therapy

Acute coronary syndrome

• 50% of patients present with cardiac arrest • High quality CPR

• Consider therapeutic hypothermia

• Airway and breathing • Oxygen therapy, keep SpO2 > 94%

• Do not delay intubation and MV in patients with respiratory failure

• Consider PEEP for maintain oxygenation during transfer

• May give sedation and analgesia

Acute coronary syndrome

• Circulation • 12-lead ECG and E-transfer to receiving hospital

• Continuous ECG monitoring

• Prompt to ACLS and defibrillation

• Presence with cardiogenic shock

• Immediate transfer

• Use inotrope and vasopressors

• Use syringe pumps during transfer

• Continuous arterial pressure monitoring

Acute coronary syndrome

• Drugs • Aspirin 160-325 chew as soon as possible

• NTG tabs or spray every 3-5 min up to 3 doses

• Contraindication: shock, RV infarction, taking PDE-5 inhibitors

• Morphine for chest pain which unresponse to NTG

• Fibrinolytic therapy (FMC-device > 120 min)

• Checklist

• Failure or success

6 hour

MAP 65 mmHg

ScvO2 70% or SvO2 65%

CVP 8-12 mmHg

Urine output 0.5 mL/kg/hr

Severe sepsis/septic shock

Severe sepsis/septic shock

• Hemoculture 2 specimens before start ATB

• Antibiotics • Community or nosocomial setting?

• Broad spectrum antibiotics

• As soon as possible and < 1 hr.

• Fluids • Isotonic crystalloid at least 30 mL/kg

• CVP or IVC distensibility for monitor preload

• Large 2 bore I.V. catheter

Severe sepsis/septic shock

• MAP 65 mmHg • Use norepinephrine first

• Monitor A-line if possible

• Insert Foley’s catheter

• Check blood sugar and ABG or HCO3

• Stabilize airway and breathing before transfer

• Resuscitation hemodynamic before transfer

Summary

• Development transport team and network

• Training and feedback

• Appropriate transport equipment

• At least two experienced attendants

• Mode of transport: ground VS air transport

• Resuscitate and stabilize prior transport

• ‘ABC’ approach + spine immobilization in trauma patient

• Effective communication with receiving hospital

• Documentation and consent form

Thank you!

Contact Address:

Anupol Panitchote

Email:

apanitchote@yahoo.com