Chapter 21 Patient transport and retrieval
Transferring critically ill or injured patients between hospitals is a potentially dangerous business. Although these transfers occur commonly, care needs to be taken to ensure that they are performed appropriately and safely. The Australasian critical care specialty colleges have issued joint policy documents specifying minimum standards of care required in these circumstances, and these are essential reading for staff involved.1,2
INDICATIONS FOR RETRIEVAL
Patients need retrieval or transport to another facility when their needs are beyond the scope of the facility that they are in. They may require a higher level of critical care, specialist surgical or medical services (e.g. neurosurgery or interventional cardiology) or investigations such as an MRI.
It is not unusual for critically ill patients to need transfer because no intensive care unit (ICU) beds are available. Time should be taken to ensure that this is the most appropriate course of action for a particular patient; if the patient is unstable or has a condition requiring urgent treatment and can be managed at the referring hospital, consideration should be given to moving another, more stable patient.
What the patient is being transferred for always needs to be borne in mind, for this will guide the urgency of the transfer. As soon as it becomes apparent that the condition of the patient is beyond the scope of care of the referring hospital, initiation of the transfer process should commence. In some circumstances this will mean activating a retrieval team even before the patient arrives at hospital, for example in the case of a multitrauma patient and a small country hospital.
If the patient is being transferred for life-saving care (e.g. urgent neurosurgical decompression of an acute extradural haematoma), the patient needs to be packaged safely but quickly, taking time only to do procedures necessary for transfer. However, in other cases, such as a patient in septic shock being transferred for tertiary ICU care, time can be taken to optimise the patient’s condition prior to moving them.
It is important to develop referral systems so that time is not wasted searching for a receiving hospital. These may be statewide or regional systems, or simply agreements between small hospitals and larger centres. An essential component of such systems is the ability of a practitioner in a small facility to be able to find a receiving hospital and get clinical advice with little difficulty, preferably via a single phone call.
THE RETRIEVAL TEAM
Interhospital patient transport should be performed by staff with the skills, experience and training to deal with potential problems that may arise during the course of the mission. Within Australasia, there are a number of specialised medical retrieval services which generally follow the staffing model of an experienced critical care doctor (emergency medicine, anaesthetics or ICU) plus either a paramedic or a flight nurse. As well as interhospital transfer of critically ill and injured patients, these services may also be involved in prehospital care.
If existing hospital staff are utilised in an interhospital transport, they need to be sufficiently experienced and skilled to make decisions and perform resuscitative measures in a potentially difficult environment, and they should be trained and familiar with the equipment that they use. The practice of sending an untrained junior doctor in the back of an ambulance with a critically ill patient can result in an adverse outcome for the patient, and a traumatic experience for the doctor involved.
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