ORGANISATIONAL ASPECTS

Provision of critical care transport services needs to be a part of regional ICU services. The staffing of critical care transport teams will depend on the workload, with around 300 per year being the threshold for a specific transport roster, depending on transport duration and regulations affecting duty times. Other factors include regional demographics, resources and geography. A team from within that unit, or from another ICU, or an emergency department, or a stand-alone transport service may provide transport of patients to a particular ICU. The merits of each system have been summarised.¹⁷ Whatever arrangement is chosen, staff should not be conscripts but selected from those interested in critical care transport, and should be appropriately trained. Use of junior inexperienced staff is associated with increases in preventable mortality and morbidity.^18,19 Rostering of teams needs to be appropriate for the workload and take into account the potential for significant overtime hours when urgent requests occur near shift changeovers. If personnel are also allocated to other clinical duties, they need to be readily relieved when required. Equipment should be prechecked and the team should have a practised routine to enable prompt departure.

A coordination centre should be used in systems involving multiple requests and transport teams.

PERSONNEL

The aim of the transport team is at least to maintain but preferably to enhance the level of care. This requires transport teams to have diagnostic and procedural skills to provide the full complement of care for the full range of patients transported. Ideally, the personnel caring for the patient in transit should be equivalent to the ‘front-line’ clinical team at the destination, implying a physician-based team, although transport of well-stabilised patients by non-physician teams has been reported.²⁰

The transport team should be a minimum of two people. For multiple patients a formula of n + 1 personnel for n critical patients has been suggested.²¹ Multidisciplinary teams of physicians, nurse and/or ambulance officers offer advantages of a wider range of skills and training than a team from any single profession. In certain circumstances, other specialised staff may need to be taken, for example a surgeon or obstetrician.⁶ It is preferable and safer to add a specialist to the standard team because of the latter’s familiarity with the practicalities of the transport environment. Other desirable attributes in staff include: good teamwork and communication skills; adaptability; reasonable body habitus and physical condition; and no significant visual or auditory impairment or susceptibility to motion sickness. Travel sickness medications such as hyoscine (scopolamine) are of limited value, needing to be taken up to 4 hours pretransport and possibly causing significant side-effects.²²

Training should encompass:

Staff should have:

PATIENT SELECTION

The best utilisation of a critical care transport system is when it is activated for appropriate patients, which will depend on the levels of care available within the ambulance services. The need for critical care transport may be identified by:

Both receiving hospitals and ambulance services need to be alert to possible cases where critical care transport is indicated, but not identified by the referring team. A mechanism that is highly sensitive and specific at identifying patients unsuitable for standard ambulance transport is required. Triage mechanisms and tables to aid in patient selection have been described.^23,24

COMMUNICATIONS

A systematic approach is necessary to ensure a smooth response when the need for transport of a critically ill patient is identified. A single toll-free telephone number with conference call capability is the ideal. Facsimile and teleradiology capabilities may also be of value. The one call for assistance should result in the provision of clinical advice if required, the dispatch of a transport team, and finding a bed in an appropriate hospital. Concise, simple clinical advice appropriate for the capabilities of the referring hospital by either the receiving hospital or the transport service is paramount. No matter how fast the transport team’s response, without some interim care the patient with major airway, breathing or circulatory compromise will not survive.^6,7 Ongoing advice, including stabilisation and preparation of the patient for transport, may be required prior to the arrival of the transport team. The provision to referring hospitals of a checklist for patient management and preparation for transport may assist.

The transport team should communicate with the receiving hospital, especially where changes in the patient’s condition change the time of arrival, posttransport management or destination within the hospital or to another centre. Cellular telephones have revolutionised communication in transit, but their use may not be possible in all circumstances. Radio communication between ground and air ambulances and relevant hospitals is a preferred back-up.

EQUIPMENT