Transport of Transport of critically ill patientcritically ill patient

Dr.Masthanamma.CDr.Masthanamma.CDr.Raju.P.S.NDr.Raju.P.S.N

The safest place for The safest place for the critically ill the critically ill patient is stationary patient is stationary in the ICU, connected in the ICU, connected to a ventilator with to a ventilator with all infusion pumps all infusion pumps running smoothly, running smoothly, intensive monitoring intensive monitoring installed, and with a installed, and with a nurse present to care nurse present to care for the patient. for the patient.

There may be situations when the There may be situations when the patient has to leave these secure patient has to leave these secure surroundings to be transported surroundings to be transported to the radiology department, OT to the radiology department, OT or to some other department or to some other department within the hospital. within the hospital.

This transport may create an increased This transport may create an increased risk for mishaps and adverse events byrisk for mishaps and adverse events by

1.1. Disconnecting such critically ill individuals from the Disconnecting such critically ill individuals from the

equipment in the ICU to some kind of transport equipment in the ICU to some kind of transport gear, gear,

2.2. Shifting them to another stretcher, and Shifting them to another stretcher, and

3.3. Reducing the personal and the equipment around.Reducing the personal and the equipment around.

At some point in At some point in everyevery physician’s career, he/she will physician’s career, he/she will be involved in the medical be involved in the medical transport of a sick or injured transport of a sick or injured patient.patient.

Types of TransportTypes of Transport

IntrahospitalIntrahospital--transport of a patient --transport of a patient from one location to another within from one location to another within the hospitalthe hospital

InterhospitalInterhospital--transport of a patient --transport of a patient between hospitalsbetween hospitals

Scene runScene run--transport of a patient from --transport of a patient from a non-medical site to the nearest a non-medical site to the nearest available or designated hospital available or designated hospital

Critically ill patients are at increased risk of morbidity and mortality during transport .

Risk can be minimized and outcomes improved with

1. Careful planning 2. Appropriately qualified personnel 3. Selection / availability of appropriate equipment

Because the transport of critically ill patients to procedures or tests outside the ICU is potentially hazardous, the transport process must be organized and efficient.

To provide for this, at least four concerns need to be addressed through written ICU policies and procedures:

1. Communication 2. Personnel 3. Equipment 4. Monitoring

Pretransport Communication

When an alternate team at a receiving location will assume responsibility for the patient after arrival, continuity of patient care will be ensured by physician-to-physician and nurse-to-nurse communication to review patient condition and the treatment plan.

Accompanying Personnel

It is strongly recommended that a minimum of two people accompany a critically ill patient.

Additional personnel may include a respiratory therapist, registered nurse, or critical care technician as needed.

It is strongly recommended that a physician with training in airway management and ACLS, and critical care training or equivalent, accompany unstable patients.

Accompanying Equipment

A BP monitor, pulse oximeter, and cardiac monitor/defibrillator accompany every patient without exception.

When available, a memory-capable monitor with the capacity for storing and reproducing patient data will allow review of data collected during the procedure, and transport.

Equipment for airway management, sized appropriately for each patient, is also transported with each patient, as is an oxygen source of ample supply to provide for projected needs plus a 30-min reserve.

Basic resuscitation drugs, includingepinephrine and antiarrhythmic agents,are transported with each patient in theevent of sudden cardiac arrest or

arrhythmia.

A more complete array of pharmacologicagents either accompanies the basicagents or is available from supplies(“crash carts”) located along the transportroute and at the receiving location.

Supplemental medications, such as sedatives and narcotic analgesics, are considered in each specific case.

An ample supply of appropriate intravenous fluids and continuous drip medications (regulated by battery-operated infusion pumps) is ensured.

All battery-operated equipmentis fully charged and capable of

functioningfor the duration of the transport.

If a physician will not be accompanying the

patient during transport, protocols mustbe in place to permit the administrationof these medications / fluids by

appropriatelytrained personnel under emergencycircumstances.

For practical reasons, bag-valve ventilation is most commonly employed during intrahospital transports.

Portable mechanical ventilators are gaining increasing popularity in this arena, as they more reliably administer prescribed minute ventilation and desired FiO2.

Monitoring During Transport.

All critically ill patients undergoing transportreceive the same level of basic physiologicmonitoring during transport as they had in the ICU.

This includes, at a minimum, continuous ECG monitoring, continuous pulse oximetry and periodic measurement of blood pressure, pulse rate, and respiratory rate.

In addition, selected patientsmay benefit from capnography,

continuousintra-arterial blood pressure,

pulmonaryartery pressure, or intracranial

pressuremonitoring.

Adverse effectsAdverse effects

Adverse events during transport of Adverse events during transport of critically ill patients fall into two critically ill patients fall into two general categories: general categories:

1.1. Mishaps related to intensive Mishaps related to intensive care (e.g., lead care (e.g., lead disconnections, loss of disconnections, loss of battery power, loss of battery power, loss of intravenous access, intravenous access, accidental extubation, accidental extubation, occlusion of the occlusion of the endotracheal tube, or endotracheal tube, or exhaustion of Oexhaustion of O22 supply), supply),

1.1. Physiologic deteriorations Physiologic deteriorations related to critical illness related to critical illness (e.g., worsening hypotension (e.g., worsening hypotension or hypoxemia).or hypoxemia).

The first indications that transport within The first indications that transport within hospital is a potentially dangerous hospital is a potentially dangerous undertaking were provided in the early undertaking were provided in the early 1970s, when arrhythmias were encountered 1970s, when arrhythmias were encountered in up to 84% of transports of patients with in up to 84% of transports of patients with high-risk cardiac disease, which required high-risk cardiac disease, which required emergency therapy in 44% of cases . emergency therapy in 44% of cases .

Significant complications such as bleeding Significant complications such as bleeding and hypotension were observed in seven and hypotension were observed in seven out of 33 transports of patients from the OR out of 33 transports of patients from the OR to the ICU. to the ICU.

In more recent reports the overall incidence of In more recent reports the overall incidence of adverse effects during intrahospital transport adverse effects during intrahospital transport was found to range from 6 - 71.1%. was found to range from 6 - 71.1%.

An exact description of the severity of these An exact description of the severity of these complications is lacking in many studies and complications is lacking in many studies and definitions differ in the others. definitions differ in the others.

However, major adverse effects with life-However, major adverse effects with life-threatening disturbances that require threatening disturbances that require interventions such as administration of interventions such as administration of vasoactive drugs, fluids or even CPR, as well as vasoactive drugs, fluids or even CPR, as well as those related to the disconnection of ventilatory, those related to the disconnection of ventilatory, intravenous or intra-arterial lines, may be intravenous or intra-arterial lines, may be as as high as 8% high as 8%

Teams for TransportTeams for Transport

“ “Team members should be chosen for Team members should be chosen for both their medical skills and their both their medical skills and their ability to behave responsibly when ability to behave responsibly when interacting with personnel at the interacting with personnel at the referring and receiving hospital, referring and receiving hospital, parent/patient and one another.”parent/patient and one another.”

Team members should be trained and Team members should be trained and competent in critical care and transport competent in critical care and transport medicine, recognizing limitations of and medicine, recognizing limitations of and managing supplies/equipment & managing supplies/equipment & physiologic effects of transport on the physiologic effects of transport on the patient.patient.

Transport Team Responsibilities Transport Team Responsibilities Stabilization PhaseStabilization Phase

Quick assessment of patient statusQuick assessment of patient status Stabilization of patient for transportStabilization of patient for transport Anticipation of problems likely Anticipation of problems likely

encountered on transportencountered on transport Secure all lines and tubesSecure all lines and tubes Communication with receiving Communication with receiving

physician/nursephysician/nurse

Intubating a patient in transit is difficult. If Intubating a patient in transit is difficult. If the patient is likely to develop a the patient is likely to develop a compromised airway or respiratory failure, he compromised airway or respiratory failure, he or she should be intubated before departure. or she should be intubated before departure.

Intubated patients should be mechanically Intubated patients should be mechanically ventilated. ventilated.

Inspired oxygen should be guided by arterial Inspired oxygen should be guided by arterial oxygen saturation and blood gas oxygen saturation and blood gas concentrations.concentrations.

Appropriate drugs should be used for Appropriate drugs should be used for sedation, analgesia, and muscle relaxation. sedation, analgesia, and muscle relaxation.

Intravenous volume loading will Intravenous volume loading will usually be required to restore and usually be required to restore and maintain satisfactory blood pressure, maintain satisfactory blood pressure, perfusion, and urine output. perfusion, and urine output.

Inotropic infusions may be needed. Inotropic infusions may be needed.

Unstable patients may need to have Unstable patients may need to have central venous pressure or pulmonary central venous pressure or pulmonary artery pressure monitored to optimise artery pressure monitored to optimise filling pressures and cardiac output. filling pressures and cardiac output.

Hypovolaemic patients tolerate Hypovolaemic patients tolerate transfer poorly, and circulating transfer poorly, and circulating volume should be normal or volume should be normal or supranormal before transfer. supranormal before transfer.

A patient persistently hypotensive A patient persistently hypotensive despite resuscitation must not be despite resuscitation must not be moved until all possible sources moved until all possible sources of continued blood loss have been of continued blood loss have been identified and controlled. identified and controlled.

Transport Team ResponsibilitiesTransport Team Responsibilities Transport PhaseTransport Phase

Safe movement of patient in and out of Safe movement of patient in and out of vehiclevehicle

Ongoing monitoring of major organ systems Ongoing monitoring of major organ systems during transportduring transport

Prompt recognition and Rx of problems en Prompt recognition and Rx of problems en routeroute

Provision of detailed report to admitting Provision of detailed report to admitting personnelpersonnel

Detailed documentation of events during Detailed documentation of events during transporttransport

Many of the complications reported Many of the complications reported during transport were caused by during transport were caused by equipment not functioning correctly, equipment not functioning correctly, however.however.

The use of more equipment could The use of more equipment could result in a higher probability of result in a higher probability of equipment-related problems that equipment-related problems that might divert the attention of the might divert the attention of the personnel from the patient to the personnel from the patient to the device. device.

In some cases the hazards of In some cases the hazards of transporting a patient could be transporting a patient could be prevented by performing prevented by performing diagnostic or therapeutic diagnostic or therapeutic procedures within the ICU or procedures within the ICU or choosing alternative (albeit choosing alternative (albeit equivalently effective) procedures equivalently effective) procedures that may render a transport of the that may render a transport of the patient unnecessary. patient unnecessary.

Such interventions may comprise the Such interventions may comprise the following: following: use of chest ultrasound in detecting use of chest ultrasound in detecting

intrathoracic pathologies intrathoracic pathologies the introduction of new mobile CT the introduction of new mobile CT

scanners that can be used in the ICU ; scanners that can be used in the ICU ; the application of dilatational the application of dilatational

percutaneous tracheostomy percutaneous tracheostomy in the placement of percutaneous in the placement of percutaneous

endoscopic gastrostomy and of inferior endoscopic gastrostomy and of inferior vena cava filters vena cava filters

Transfer Transfer

Care should be maintained at the same Care should be maintained at the same level as in the intensive care unit, accepting level as in the intensive care unit, accepting that in transit it is almost impossible to that in transit it is almost impossible to intervene. intervene.

Monitoring of arterial oxygen saturation, Monitoring of arterial oxygen saturation, expired carbon dioxide tensions, heart expired carbon dioxide tensions, heart rhythm, temperature, and arterial pressure rhythm, temperature, and arterial pressure should be continuous. should be continuous.

As non-invasive measurement of blood As non-invasive measurement of blood pressure is affected by movement, intra-pressure is affected by movement, intra-arterial monitoring is recommended. arterial monitoring is recommended.

ConclusionConclusion

Adverse effects during and after Adverse effects during and after transport of critically ill patients are transport of critically ill patients are frequent. frequent.

Although a few patient-related risk Although a few patient-related risk factors can be identified, the rate of factors can be identified, the rate of equipment-related adverse events may equipment-related adverse events may be as high as one-third of all transports. be as high as one-third of all transports.

Thus, particular attention has to be Thus, particular attention has to be focussed on the personnel, equipment focussed on the personnel, equipment and monitoring in use. and monitoring in use.

To further reduce the rate of To further reduce the rate of inadvertent mishaps from inadvertent mishaps from transports, alternative diagnostic transports, alternative diagnostic modalities or techniques, and modalities or techniques, and performing surgical procedures in performing surgical procedures in the ICU should be considered the ICU should be considered whenever possible. whenever possible.

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