Interhospital Transportation of Critically IllInterhospital Transportation of Critically Ill

Dr. Rashidi AhmadMD(USM), MMED(USM), FADUSM

EmergentistDept. of Emergency Medicine

USM Health Campus

Critical illnesses

• Heart Attack • Stroke • Kidney Failure • Aplastic Anaemia• Blindness, deafness, speechless• End Stage Lung Disease• End Stage Liver Failure • Coma • Major Burns

• Paralysis • Fulminant Hepatitis • Motor Neurone Disease • PPH • HIV • Benign Brain Tumour• Meningoencephalitis• Major Head Trauma

A disease which may lead to death.

3 Categories of transport of critically ill patients

• Prehospital transport• Intrahospital transport

Interhospital transport

Interhospital transportation

• Emergency interhospital transport- transporting patients with acute life-threatening illnesses to a referral centre due to lack of diagnostic facilities, staffs, other facilities & for safe and effective therapy

• Semi-elective interhospital transport- transporting the critically ill patients with major organ failure, requiring organ support @ special investigations to a referral centre

Potential Potential benefit risk

Transport of critically ill patients always involves some degree of risk to patient

and accompany personnel

Transport criticallyTransport criticallyill patientsill patients

EthicEthicSOPSOP

HOD HOD orderorder

SafetySafety

Law/medicoLaw/medico--legallegal

Religious obligationReligious obligation

Safety culture

• "a work environment where a safety ethic permeates the organization and people's behavior focuses on accident prevention through critical self-assessment, pro-active identification of management and technical problems, and appropriate, timely, and effective resolution of the

problems before they become crises."

Ask yourself

• Am I well trained in transit medicine?• Have I been told the safety measurement

frequently?• Am I insured? • Is my job confirmed?• Is this ambulance in a good condition?• Are there protocols/guidelines related to

interhospital transportation available at the institution?

An interface between the hazard & vulnerability

Transport – related problem

• Patient-related complications:any difficulty or complication, related directly to the patientany difficulty or complication, related directly to the patient’’s s pathopatho--physiology. physiology.

• Equipment-related problems:equipment/technical mishaps & transport environmental equipment/technical mishaps & transport environmental factors that could result in patient instabilityfactors that could result in patient instability

Jack JM et al. Quality of interhospital transport of critically ill patients: a prospective audit. Critical Care

2005, Vol 9 No 4; p 446 - 451

• 100 consecutive transfers of ICU patients were evaluated over a 14-month period.

• University Medical Center Groningen,TheNetherlands.

• A prospective audit of the quality of transportation.

Transport Characteristics

Transfer diagnosis

Gembremichael : Crit Care Med 2000

The predicted mortality was 68-100% and the subsequent hospital

mortality rate was 43%

The predicted mortality was 68-100% and the subsequent hospital

mortality rate was 43%

Schiff, RL, Ansell, DA, Schlosser, JE et al, Transfers to a public hospital. A prospective study of 467 patients. N Engl J Med 1986;314: 552-557

• Substandard stabilization for 89% of 467 patients transferred from ED to surrounding hospitals.

• 40% higher death rate in patients transferred with inadequate stabilization versus non-transferred patients.

Olson, et al, Stabilization of patients prior to interhospital transfer. Am J Emerg Med 1987; 5:33-39

• Inadequate stabilization on trauma transports & on critically ill medical and surgical patients.

• A sizable number of inadequacies in the study group were of an extremely basic nature.

Mayer, in his review of the literature, found between 24 and 70% of transferred patients are inadequately stabilized prior to transport

Interhospital transfer of emergency patients. Am J Em Med, Jan 1987 (5)1: 86-88

• The Australian Incident Monitoring Study (AIMS) data suggest that 83% of reported critical incidents involved elements of human error.

• “Knowledge-based errors” contributed directly to about 1/4 of the reported incidents.

• The outcome in 1/3 of incidents was also likely to have been minimized by prior experience or awareness of the potential problems

Williamson JA, et al. Human failure: An analysis of 2000 incident reports.

Anaesth Intensive Care 1993; 21:678-683.

“Transportation of critically ill patients to EDHKL does not follow a standard guideline (inadequate communication, ineffective liaison, untrained &

inexperienced staff)”

RidzuanRidzuan IsaIsa, May 2003 A study on inter hospital ambulance transportation of, May 2003 A study on inter hospital ambulance transportation ofcritically ill patients to GHKLcritically ill patients to GHKL

• The necessity and safety for transport should be assessed by the multidisciplinary team of health care providers (e.g., respiratory therapist, physician, nurse).

• The risks of transport should be weighed against the potential benefits from the diagnostic or therapeutic procedure to be performed

Chang DW. AARC Clinical Practice Guideline: in-hospital transport of the mechanically

ventilated patient--2002 revision & update. Respir Care 2002 Jun;47(6):721-3.

How to overcome the risks & complications?

How to overcome the risks & complications?

• Using appropriate equipment, personnel and planning for each transport can minimize these complications and ensure optimal benefit to the patient

Fromm, R E Jr, Dellinger, R P, eng PT. Transport of critically ill patient J Intensive Care Med 1992;7:223-33

• Risks can be diminished if the patients are appropriately selected and carefully monitored during transportation

Brokalaki HJ et al.Intrahospital transportation: monitoring and risks. Intensive Crit Care Nurs.1996 Jun;12(3):183-6

Pretransport Coordination and Communication.

• The referring physician tasks:- contact an appropriate physician- discuss patient’s management- ensure the appropriate higher level resources are

available- reconfirm before the transfer occurs - accompany patient if indicated, if not, ensure

there is a command physician who responsible for medical treatment during the transport

- determine mode of transportation- ensure a copy of the medical record (care summary,

relevant laboratory & radiographic studies) & nurse report will accompany the patient.

Is the transportation necessary?

A generic referral pattern

Good medical practice

• Informed consent and signed consent if possible• A discussion of the risks and benefits of transfer• Documented in the medical record before transfer. • If circumstance do not allow for the informed

consent process: both the indications for transfer and the reason for not obtaining consent are documented.

• The referring physician always writes an order for transfer in the medical record.

The Emergency Medical Treatment and Active Labor Act (EMTALA)The Emergency Medical Treatment and Active Labor Act (EMTALA)

laws and regulations.laws and regulations.

(updated at intervals from the 1986 COBRA laws and the 1990 OBRA(updated at intervals from the 1986 COBRA laws and the 1990 OBRA amendment)amendment)

Accompany personnel

• Minimum of two excluding the driver• Unstable patients: physician/nurse, preferably

trained in transit medicine• Critical but stable: trained paramedic in

ACLS/ATLS• Without physician accompany: telemedicine/SOP• Communication failure: the team is authorized to

perform acute lifesaving interventions.

David Crippen: Inter Hospital Transport of Critically Ill Patients: Problems and Pitfalls. The Internet Journal of Anesthesiology. 1997. Volume 1 Number 4.

• No convincing data demonstrates the need or cost effectiveness of physician accompaniment of most inter-hospital patients.

• Questions of appropriateness or cost effectiveness cannot be answered.

• We need a randomized, prospective study of physician accompanied vs.unaccompanied transports.

Minimum equipment requirement

• Emphasis is placed on airway and oxygenation, vital signs monitoring, and the pharmaceutical agents for emergency resuscitation, stabilization and maintenance of vital functions.

• Regular item check for expiration & potency

Monitoring during transport

• Continuous pulse oximetry, ECG monitoring, regular measurement BP & RR

• Acceptable mechanical ventilator• Patient status and management during transport

are recorded and filed in the patient medical record.

Preparing a patient for interhospital transport

• Patient optimization• Avoid nonessential testing and procedures• Ensure patient comfort and safety, so do we• Intervene and anticipate complications• Documentation• Checklist

• When a mobile intensive care unit is properly staffed and equipped and patient stabilization is performed before transfer, severely ill pts with respiratory failure can be transferred safely.

• The predicted mortality was 68-100% and the subsequent hospital mortality rate was 43%

Gembremichael : Crit Care Med 2000

• A specialist transfer team vs standard ambulance with doctor provided by referring hospital. The specialist team significantly improve the acute outcomes ( acute physiology and early mortality)

• acidotic (< 7.1) 3 vs 7 %hypotension (MAP) 9 vs 18 %mortality 3 vs 7.7 %

G. Bellingan : Intensive Care Medicine 2000

Admission procedure at the referral hospital

• Direct admission into relevant discipline, by-passing ED dept. is on the instruction of the receiving specialist and only if patient is accompanied by a doctor.

MOH 1990

Death while in transit

• Should go to the nearest hospital to certify death by a doctor, in the absence of an accompanying doctor in the ambulance.

• Under such circumstances, the ambulance should return to its base and not proceed to its referral hospital but relevant staff involved should informed to the referring doctor, doctors of unit expecting the patient and ED MO at referral hospital.

Medical errors do occur and are an inescapable part of medical practice

The problem is not bad people, the problem is that the system of medical care needs to be made safer

Medicine is an imperfect art form:

InterfacilityInterfacility transfer algorithmtransfer algorithm..