Transporting the Critically Ill Patient

I. INTRODUCTION. Critically ill patients often require transfer between or within hospitals when advanced levels of care, diagnostics, and/or procedures are required. The anticipated benefits of relocating a critically ill patient must be weighed against the potential risks involved during a transfer.

A. Interhospital Transport refers to the relocation of a patient from one health care institution to another in order to provide more timely or additional specialized care. Issues associated with air transport and specialized teams are covered later in this chapter. Many of the principles learned from interhospital transfer may be applied to intrahospital transport.

B. Intrahospital Transport is the movement of a patient to various sites within a health care facility for diagnostic or therapeutic procedures that cannot be performed at the primary location. For example, patients may be transported between locations of specialized resources such as the interventional radiology suite, operating room, or the intensive care unit.

II. RISKS ASSOCIATED WITH TRANSPORT. Whether the destination is near or far, the perceived benefit of transporting a patient must be balanced with the associated risks. These risks range from minor complications to major mishaps resulting in severe hypoxia, hypercarbia, or death. Hemodynamic and respiratory problems are most common. Patients who require transport out of the intensive care unit (ICU) have an increased rate of mortality, likely related to their severity of illness as opposed to transport alone.

A. Risks of patient transport can be categorized as either systems or patient based (Tables 14.1 and 14.2). System errors may arise from equipment problems or human factors, such as poor provider communication or lack of sufficient training. These errors and circumstances may result in delay of problem recognition and amelioration. Any deterioration of a patient’s condition may increase the risk of adverse events during transport. Sicker patients have low physiologic reserve and are exposed to more frequent intrahospital transfers. Compared with elective transport, emergent transport is associated with an increase in adverse events.

B. Schwebel et al. reviewed 3,000 intrahospital transports in 1,700 ventilated ICU patients (18 years or older from April 2000 to November 2010). They matched transported patients with controls who had similar likelihoods of being transported but were not. Intrahospital transport was associated with an increased risk of several complications (Table 14.3).

III. MINIMIZING RISKS OF TRANSPORT. Various critical care and emergency medicine societies throughout the world have established criteria for managing patients during intrahospital transport (Table 14.4). Institutions should have written protocols for transporting patients within and between health care facilities.

Each organ system must be assessed and specific plans made for transport and potential complications that may be encountered. A checklist is recommended (Appendices 1 and 2, supplemental material).

TABLE		Systems-Based Complications
14.1

Equipment

Battery failure of portable equipment

Monitor malfunction

Depletion of portable oxygen supplies

Ventilator failure/disconnect

Disruption in portable medication infusions/pumps

Disconnection or loss of intravenous access

Chest tube failure/disconnect

Inaccurate calibration of hemodynamic monitors

Human

Inadequate training or experience

Poor planning and anticipation

Failure in hand-off and communication

Lack of vigilance and monitoring

Unintended/unrecognized extubation or loss of airway

Under-/Overventilation

Under-/Overresuscitation

Failure to secure or protect patient extremities

TABLE		Patient-Based Complications
14.2

Neurological—change in need for sedation or pain management, increased ICP, seizure

Respiratory—secretions, aspiration, de-recruitment, increased oxygen consumption

Cardiac—hypertension, hypotension, arrhythmia, ischemia

Increased bleeding

Hypothermia leading to shivering, hypercarbia, and inadequate ventilation

TABLE		Schwebel et al. 2013 Crit Care Med
14.3

Deep venous thrombosis

Pneumothorax

Ventilator-associated pneumonia

Atelectasis

Hypoglycemia

Hyperglycemia

Hypernatremia

Increased hospital length of stay

TABLE		Essential Components of Safe Patient Transport
14.4

Stabilization of patient prior to transport

Risk assessment prior to patient transfer

Coordination and detailed communication between clinicians

Training and experience for managing patient condition and support mechanisms

Equipment adapted for transport and monitoring

Documentation—indication for transport and status pre-, during, and posttransport

Continuous patient and equipment checks

Establishing protocols and regular evaluation of transport processes

Minimize transport time

Close proximity of diagnostic and therapeutic units to ICU and emergency room

Adequate number of personnel

A. Airway. The stability of the patient’s airway must be assessed prior to any movement. The position, function, and stability of an endotracheal tube (ETT) must be confirmed and, if necessary, resecured. Studies show that intubation can be safely accomplished during transport, yet certain patients may benefit from elective intubation prior to transport (Table 14.5). For both intubated and nonintubated patients, backup airway materials such as a bag valve mask, oral airway, intubation kit, and full oxygen tank are essential.

B. Breathing and Ventilation. Adequate oxygenation and ventilation must be substantiated prior to transport. An arterial blood gas should reflect a reasonable partial pressure of arterial oxygen (PaO2), alveolar-to-arterial gradient (A-a) and partial pressure of arterial carbon dioxide (PaCO2). Patients with a low PaO2 or high A-a gradient may benefit from increased positive end-expiratory pressure (PEEP), increased fraction of inspired oxygen (FIO2), suctioning, diuresis, or bronchoscopic evaluation. Elevated PaCO2 can be addressed by optimizing minute ventilation, inspiratory-to-expiratory time or other ventilator mechanics. Paralysis may improve ventilator synchrony and prevent auto-PEEPing. Compared with manual ventilation, mechanical ventilation may be more appropriate in patients with complex medical issues, long transport distances, or specialized modes of ventilation. A chest tube for pneumothorax may be warranted, especially for air transport in which a small pneumothorax could expand into a tension pneumothorax.

TABLE		Indications for Pretransport Tracheal Intubation
14.5

Glasgow Coma Score less than 9

Respiratory acidosis and impending failure

Status asthmaticus

Shock (septic, hemorrhagic, cardiogenic, neurogenic)

Multitrauma

Recurrent seizures or status epilepticus

Facial or extensive burns

Acute epiglottitis

Angioedema

Anaphylaxis

Laryngeal-tracheal trauma

Combative patients

C. Circulation and Cardiovascular Support. Adequate and functioning intravenous access must be established. Actively infusing medications for hemodynamic support must be noted and include a discussion of prior and anticipated trends in hemodynamics. Additional medications should accompany transport to ensure continual supportive care in anticipation of patient deterioration. All infusion pumps and monitors should be accurately calibrated, reliably functioning, and have sufficient battery life.

D. Neurologic Status, Sedation, and Pain Management. Neurologic status and preexisting deficits should be evaluated and documented before and after transport. Providers must anticipate the potential for decline in mental status and loss of airway. Adequate sedation and pain management should be provided to ensure patient comfort and to prevent patient from self-extubation or self-injury; restraints may be warranted. Often critically ill patients lack the muscle strength to generate sufficient respiratory effort due to myopathy of critical illness, steroid myopathy, or injury. If neuromuscular blocking drugs have been administered, sedation is usually required to prevent awareness.

E. Temperature Regulation. Patient transport from a temperature-controlled operating room (OR) or ICU through cooler hospital corridors or diagnostic suites may lead to hypothermia and significant patient consequences such as coagulopathy or increased PaCO2 due to shivering. Warm blankets can be used during transport to minimize heat loss.

F. Patient Position. Repositioning patients, such as from the OR table to transport bed, may lead to hemodynamic instability (particularly in hypovolemic patients). Ensure all patient extremities are within the confines of the transport vehicle to avoid incidental injury when moving through narrow walkways. Advance the patient bed in a “feet-first direction.” The anesthesia provider should be positioned at head of bed, directing the movement and speed of transport, and maintain a clear and constant vision of monitors. There must be sufficient personnel to assist transport to allow for division of duties (pushing versus airway management or medication administration). The ability to call for help must be immediately available, such as with a mobile telephone.

G. Consent and Legal Issues. Disclosure of risks and consent to transport is usually implied, but should be delineated as separate from the risks associated with a planned procedure. Current guidelines require the patient or authorized health care proxy provide consent to interfacility transport.

1. Under the Emergency Medical Treatment and Active Labor Law (EMTALA, 1986), transfer of patients to other care facilities must not be prejudiced by race or gender and must not be financially motivated. According to a landmark case in Maryland, Sterling v. Johns Hopkins Hospital in 2002, and consistent with the American College of Emergency Physicians regarding interfacility transfers, the treating physician at the sending hospital is responsible for assessing the patient condition, ascertaining need for transfer and determining a safe mode of relocation to the receiving care center. The receiving physician is mainly responsible for ensuring his or her institution’s ability to provide the level of care requested. It is important to emphasize that the legal framework governing physician and hospital liability during interfacility transfer varies between states and the particular circumstances related to the transfer. This emphasizes the importance of formal interfacility transfer agreements that delineate assignment of duty between the sending and receiving facilities.