Transfer of the ICU Patient Case File

Transfer of the ICU Patient Case File

Eugene C. Toy, MD, Manuel Suarez, MD, FACCP, Terrence H. Liu, MD, MPH

Case 2

A 55-year-old black man presents to the intensive care unit  (ICU) with an acute anterior ST segment elevation myocardial infarction (STEMI). Consultation with a  cardiologist indicates that the best treatment is percutaneous coronary angi­ography (PTCA). An alternative is the possible insertion of coronary artery stents with backup open cardiac bypass surgery, which is available at a transfer facility 30 minutes away. At the current facility, tissue plasminogen activator (T PA) is the only treatment option available. On arrival the patient was given 325 mg of aspirin, started on a heparin infusion, and nitroglycerin intravenous infusion, supplemented with a loading dose of clopidogrel. This occurred within 1 hour of symptoms.

⯈ What are the key conditions that must be  stabilized and secured when transfer­ring a critically ill patient between facilities?

⯈ What is involved  in intra-hospital  (within the same facility)  transportation (IHT) of the critically ill patient?

⯈ What other arrangements should be performed prior to interhospital transfer?

ANSWER TO CASE 2:

Transfer of the ICU  Patient

Summary: This 55-year-old man presents with a STEM! of acute onset and needs trans­fer for  a PTCA with possible stenting, which is not  available at the present facility. Transfer under acceptable transportation guidelines to a facility,  which has  PTCA, should be the best choice for his medical treatment and offers the best possible outcome.

• Key conditions needing stabilization: Stabilize the patient's vital signs, begin indicated emergency therapy, and arrange transfer to a new facility with the same treatments and personnel available in the ICU. Personnel experienced in transferring critically ill patients should be incorporated into the transfer. 
• IHT of the critically ill: (1) Transport the patient safely with documented appropriate reason for leaving the ICU. (2) The same monitoring that the patient was receiving in the ICU must continue during the patient's transporta­tion and his stay outside the ICU. 
• Other arrangements prior to arrival at the new facility: (1) Prearrange accep­tance prior to arrival at the accepting facility. (2) Activation of key personnel is important to avoid an interruption in patient care. (3) An agreement regard­ing optimal transfer methods should be reached. The fastest and safest route of transfer is the best choice. (4) The transport method chosen should have all equipment needed to enable a safe transfer. 

ANALYSIS

Objectives

1. Describe how to assess the benefits and risks of transferring the critically ill patient. 
2. Discuss the modalities of inter-hospital transfer the their advantages and dis­advantages. 
3. Describe the key requirements for transfer of the critically ill patient. 
4. List the adverse effects of intra and inter-hospital transfer of ICU patients. 

Considerations

Before transfer is attempted, it must be demonstrated that there is a clear benefit in the treatment available at the receiving facility compared to the current facility. The patient in this scenario is a 55-year-old with an ST elevation myocardial infarc­tion, and he would be best served by a PTCA, which is unavailable at   his current hospital. After assuring stabilization and the absence of life-threatening conditions or arrhythmias, he can be transferred with appropriate monitoring and personnel. The accepting institution is 30 minutes away which is a reasonable distance for transport. Communication and coordination are key to a  successful transfer.

Approach To:

Transferring the Critically Ill Patient 

Providing appropriate care during transport to and from the ICU presents a major challenge. Critical care transport has become a common occurrence. The centraliza­tion of therapeutic specialties and an expanding number of diagnostic and therapeu­tic options outside of the  ICU are major causes of this necessity. Bringing improved diagnostic testing and medical-surgical services to the patient reduces the adverse effects that accompany transportation outside the  ICU. Infection rates are also lower in patients who are transported less often in the ICU setting. Most instances of critical care transport occur within the hospital itself. Nevertheless, critical care transport is a high-risk undertaking, regardless of the setting. Adequate planning, proper equipment, and appropriate staffing can minimize the transportation risks. Inter-hospital transport of the critically ill patient presents more problems than in­house transport because of the distance, different hospital settings, and inability for prior planning. Guidelines of personnel needs such as physicians, nurses, and para­medics have come from these experiences. Alternative advantages and disadvan­tages in transport by air or ground are also necessarily weighed. Specific treatments such as pre-transfer tracheal intubation and other advanced life support conditions may be required (Table 2-1). 

Significant physiologic disturbances occur frequently in patients during their IHT including variations in heart rate, BP, or 02 saturation. However, physiologic vari­ability is also common in critically ill patients in  stationary circumstances, occurring in 60% of such patients compared with 66% in transported patients. An appropriately 

trained transport team can safely manage these physiologic changes, but even so, serious adverse events do occur. Cardiac arrest rates of 1.6% have been noted during IHT. Reduction in the PAO2/F102 ratio occurred in patients when transported while using a transport ventilator and severe changes (ie, >20% reduction from baseline) were common. These changes persisted for > 24 hours in 20% of transportees. Out­of-unit transport was an independent risk factor for ventilator-associated pneumo­nia (YAP). IHT is also one of the   factors associated with unplanned extubation in the mechanically ventilated patient. Compared to matched controls of patients not requiring transport, IHT individuals had a higher mortality rate (28.6% vs 11.4%) and a longer length of stay in the ICU. The increase in mortality was not directly attributable to complications of the   transport, and reflected a higher severity of ill­ness in patients who required transportation. Serious adverse events did, however, occur in 6% of all transports. See Table 2-2 which follows. 

Transport problems were the cause of complications. Rechecking the patient and equipment and assurance of skilled assistance prior to transfer were important pre­ventative measures. 

Transport from the operating room to the ICU. Hemodynamic variability is more common in patients being transferred from the operating room to the ICU than those transported for diagnostic procedures outside the ICU. This is probably related to the patient's emergence from anesthesia. Accurate and complete informa­tion is important in these transfers. Ideally, both the medical team (surgeon and anesthesiologist) and nursing team should communicate important information to the ICU team. A directed form to ensure that proper information is transmitted can be useful. Likewise, a clear understanding of which physician will be responsible for what aspect of the patient's care is vital.

Risk and benefit of IHT. Studies suggest that IHT is important in many circum­stances. Diagnostic testing made available through IHT has been found to result in treatment changes in up to 39% of patients. Radiologic studies in ICU patients can help in directing important changes in the therapy. 

Management of transport. Studies have shown that ventilators used in trans­port are known to reduce variability in blood gas parameters when compared with manual bagging. Nevertheless, manual bagging with a  tidal volume moni­tor was shown to be superior to mechanical ventilation (MV). No significant variations in blood gas parameters were noted in transport patients who received 

manual ventilation when under supervision by a respiratory therapist. Changes in blood gas parameters correlate with hemodynamic disturbances like arrhyth­mias and hypotension. Capnometry (Etco)  monitoring clearly reduces PAC02 variability in  adults.  In  children, less than one-third of   patients undergoing manual ventilation without Etco2 monitoring had ventilator parameters within the intended range. 

Hypothermia. Active warming during transport prevents hypothermia, which is common in trauma patients undergoing IHT. The use of   specially trained transport teams was associated with much lower complications than historical controls. The presence of physicians during transport was not clearly correlated with a  reduced risk for mishap.

lnterhospital transfer. The benefits to the patient of the higher care at another facility should be weighed against the considerable risks of the transport process. 

Adverse effects. The interhospital transport of critically ill patients is associated with an increased morbidity and mortality during and after the journey. Even with specialist mobile intensive care teams, the mortality before and during transport is substantial (2.5%) despite a low incidence of preventable deaths during trans­port (0.02%-0.04%). Others have reported an even higher intertransport mortality rate and have found that 24% to 70% of such incidents are avoidable. Physiologic derangements occur during 25% to 34% of adult and 10% to 20% of neonatal and pediatric transports. In adults, these disturbances are most often respiratory or car­diovascular, the  most  common  being arterial desaturation, a reduced P A02/Fro2 ratio (hypoxemia), arterial hypotension and tachycardia, respectively. The long­term outlook for critically ill patients who require interhospital transport is poorer than for those who do not require transport. Transported patients have a higher ICU mortality and longer ICU stays than do controls. Studies have found a 4% increase in mortality in the transferred group despite adjustments for diagnosis. It is unclear whether this resulted from the loss of time or unaccounted confounding variables, which resulted in an increased mortality as a result of an increase in the severity of the  patient's illness

Prediction of  adverse events. The prediction of patient deterioration during interhospital transport has proven difficult. The APACHE II, TISS, and rapid acute physiology score (RAPS) systems do not correlate with events in adults, and the pediatric risk of mortality (PRISM) score has proven similarly unreliable in chil­dren. The variables that predict deterioration in adults include older age, high F102 requirements, multiple injury, and inadequate stabilization. 

Planning of the transport. The importance of planning and preparing for IHT cannot be overstated. Poor plans lead to an increased incidence of adverse events and mortality. In an audit of transfers to a neurosurgical center, 43% of patients were found to have inadequate injury assessment and 24% of individuals received inad­equate resuscitation. Deficiencies in assessment and resuscitation before transfer were identified in all patients who died. Guidelines have been developed to address this issue in many jurisdictions, but inadequate assessment and resuscitation remain a problem. Some found that the application of national guidelines led to only modest improvements in patient care, with an incidence of hypoxia and hypotension that remains unacceptably high. 

Selection of personnel. A minimum of 2 people in addition to the vehicle oper­ators should accompany a critically ill patient during transport. The team leader can be a nurse or physician depending on clinical and local circumstances. It is imperative that the team leader has adequate training in transport medicine and advanced cardiac life support (ACLS). Adequately trained nurses and physicians are acceptable in transporting critically ill children. Appropriately staffed and equipped specialist retrieval teams are superior to impromptu teams in transferring critically ill adults and children, and have recorded up to an 80% reduction in critical incidents during pediatric interhospital transport.

Mode of  transport. The choice among the 3  options of ground,  helicopter, and fixed wing transport is affected by 3 main factors: distance, patient status, and weather conditions. A  retrospective review of adult transfers demonstrated no dif­ference in mortality or morbidity between patients transferred by air versus ground transportation. A prospective cohort study revealed that air transport is faster than ground transport, and for transfers of <225 km, helicopter transport is faster than by fixed wing. Severely injured patients undergoing interhospital transport had a reduced mortality when carried by air compared to surface transport. 

Equipment and monitoring. Comprehensive lists of equipment and medications needed for the transport of critically ill patients should be identical to that in an ICU environment. The transport ventilators used in intra-hospital transfers cre­ate less ventilatory fluctuation than hand ventilation (Ambu bagging). However, when compared to standard ICU ventilators, transport ventilators were inferior in delivering set tidal volume (Vt) and  had a tendency to trap gas. Extra care in ventila­tory monitoring is warranted when changing from an ICU to a transport ventilator. Arterial blood gas (ABO) analysis during interhospital transfer allows for an early identification and treatment of changes in gas exchange and metabolic parameters.

Pre-hospital  personnel, pre-hospital time, and  receiving care  facility. When compared with EMT pre-hospital care, physician pre-hospital management of trauma patients have shown to  reduce trauma related deaths.  Physicians tend to treat patients more aggressively than EMTs. When pre-hospital care is delayed more than 60 minutes, severely injured patients are at higher risk for death, increased length of hospital stay, and complications. There is a reduction in mortality for severely injured trauma patients when they  are transferred directly to a Level I trauma center. Patients treated primarily in Level I trauma centers had lower 1-year mortality rates than patients treated elsewhere. Subgroup analysis suggested that the mortality benefit was primarily confined to the more severely injured patients. 

CLINICAL CASE CORRELATION

• See also Case 1 (Early Awareness of Critical Illness), Case 3 (Scoring Systems and Patient Prognosis), and Case 4 (Monitoring). 

COMPREHENSION QUESTIONS

2.1 Following a night of   heavy alcohol consumption, a 29-year-old man ran down a hallway and collided with a  double-paned window, crashing through it and falling 7 stories to the ground, landing feet first. He was initially unconscious at the scene. Upon arrival at the ICU, the patient's vital signs were: blood pressure 118/68 mm Hg, pulse 94 beats/minute, respirations 21 breaths/minute, and oxy­gen saturation 100% on 10 L of O2 via face mask. On regaining consciousness, he became extremely combative, complaining of severe pain from the fractures in his lower extremities. He was intubated using rapid-sequence intubation. Despite the successful placement of an endotracheal tube, the patient was noted to have intermittently poor oxygen saturation observed on pulse oximetry. His breath sounds were decreased bilaterally and a large amount of crepitus was appreciated throughout the neck and anterior chest wall. A portable chest radiograph was significant for bilateral pneumothoraxes, managed with the insertion of chest tubes. What is the next best step? 

A.  Stabilize the patient at the bedside. 

B. Get a CT scan of the thorax. 

C. Get a CT scan of the abdomen. 

D. Transport the patient to a nearby facility with more capability of services. 

E. Complete all diagnostic imaging to help prioritize treatment. 

2.2 A 16-year-old boy presents to the ED of a small rural hospital after being extri­cated from a house fire with approximately 40% total body surface area bums. The patient is breathing spontaneously and maintaining 100% saturation on 10 L/min by nasal cannula. His sputum is noted to be black (carbonaceous). The current facility does not have MV capacity or a bum center with a   barometric pressure chamber. The patient's blood carbon monoxide level is 40%. He is awake and easily arousable. Vital signs, CBC, electrolytes are normal. ECG and chest x-ray are normal. The family requests transfer to a better -equipped facility. The next most appropriate step in the management of this patient is: 

A. Check a carboxyhemoglobin level. 

B. Give 100% F102 and transfer to nearest facility with bum center care capabilities. 

C. Monitor the patient closely for respiratory distress. 

D. Take the patient to the operating room for immediate debridement and grafting. 

E. Transfer the patient to a bum center via ambulance or helicopter. 

ANSWERS TO QUESTIONS

2.1 A. Stabilization in the ED and ICU is necessary to prepare the patient for safe transport for subsequent testing. No transfer of the patient is advised except when needed for an operative procedure or until the patient is stabilized. Bilat­eral pulmonary contusions and a large amount of air in the mediastinum and anterior chest wall extending into the neck have been controlled with the bilat­eral chest tubes. There is no need for interhospital transfer. Later, the patient improved quickly and was transferred out of the surgical ICU. The patient con­tinued to do well on the floor and was discharged home on hospital day 7. 

2.2 B. Stabilization in the ED and ICU is key to a safe transport to a hospital that can treat burn victims and carbon monoxide poisoning where MV is available. While this patient will most likely require transfer to a hospital equipped to handle burn victims, the first step is to stabilize the patient. Despite his 100% oxygen saturation, the presence of carbonaceous sputum is an ominous sign and should be considered an indication that the patient may require intubation and MV. Other signs and symptoms that indicate a burn victim will require intuba­tion include hoarseness, wheezing, stridor, burns inside the nose or the mouth or face, or a carboxyhemoglobin level > 10% and carbon monoxide level > 20%. The good neurological status suggests that the carboxyhemoglobin and carbon monoxide levels are much decreased with 2  hours on high flow O2. Decompen­sation may need intubation for upper airway obstruction secondary to edema. Once intubated and stable, patient should be transferred via fastest route avail­able to a hospital with a burn center, accompanied by skilled personnel and all the necessary equipment for a safe transfer. 

CLINICAL PEARLS

• Transport of the critically ill patients has become a necessary and impor­tant part  of clinical practice. 
• Physiologic derangements during  transport  are  seen slightly more  fre­quently than in the stationary ICU patient.
• Transport risk can be reduced by appropriate planning, including arrang­ing for trained transport  personnel, and achieving pre-transport  patient stabilization. 
• Trained, experienced teams are essential in interhospital transport of the critically ill patient. 
• The pre-hospital interventions associated with improved outcome are (1) helicopter transport of severely injured patients; (2)  presence of a  phy­sician on the pre-hospital  transport team; (3)  a  short injury-to-hospital time of less than 60 minutes; and (4) transfer directly to a Level l  trauma center. 
• Correct  transfer of the most severely injured  critically  ill patients has shown long-term benefit, evaluated at 1 year post transfer.

References

Deutschman CC, Neligan PJ. Evidence Based Practice of Critical Care, Expert Consult. Philadelphia: Saunders Publishers; 2011. 

Hurst JM, Davis K, Johnson DJ, et al. Cost and complications during in-hospital transport of critically ill patients: A prospective cohort study.] Trauma. 1992;33:582-585 . 

Koppenberg J, Taeger K. Inter-hospital transport: transport of critically ill patients. Curr Opin Anaesthe­siology. 2002;15:211-215.

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