Assessment

The Decision to Transfer

The decision to transfer a patient is always the joint responsibility of the referring and receiving clinicians. The medical staff at the receiving unit may offer specialist advice on patient management however, responsibility for the patient always lies with the clinician in attendance who may, if circumstances change, decide not to transfer, (ICS 2019) or decide how the transfer is undertaken (such as deciding to intubate and ventilate the patient).

Indications for transfer

Decisions to transfer a patient may be made for the following reasons:

• Escalation of level of care

• Specialist surgical procedure/intervention or investigation

• De-escalation of critical care

• Repatriation

These decisions are usually straight forward, and the main consideration is likely to be the optimal timing of the transfer.

Another possible reason for transfer is a lack of critical care capacity, this presents more ethical considerations when making the decision to transfer

Risk / Benefit

The risks associated with transferring a patient must be balanced against the benefits of the transfer. If the patient is unstable and transfer is likely to cause further deterioration, consideration should be given to alternative courses of action available. It may be necessary to delay the transfer until the patient becomes more stable, consultation with the receiving unit may aid this assessment if transfer is for specialist treatment. Consideration should also be given to the advantages and disadvantages of different modes of transport available from physiological and time perspectives.

An assessment of the risk benefit of time over possible physiological compromise may be necessary. The ICS (2019) give an example of a risk assessment you could use.

Ethical issues

The main ethical consideration in relation to transfer is when transferring due to a lack of critical care beds. The contentious issue here is whether to transfer a new potentially unstable patient or an existing patient who is more stable and less likely to deteriorate during transfer.

The ICS (2019) state in general no patient should be subjected to an intervention that is not in their best interests and that it could therefore be considered unethical to transfer one patient out of a critical care unit for the sole purpose of making room for another. Other ethical considerations are the patient's ability to consent and the requirement of the Mental Capacity Act (2005). Where the patient is unable to consent to the transfer, it may be necessary to consult the patient’s relatives. In all cases, the decision to transfer and the reasons for the transfer must be clearly documented in the patient’s notes. Discussions with patients’ relatives must also be documented in the medical notes.

Patient Assessment

Key considerations should be:

• The condition of the patient – ABCDE approach

• The capabilities of the transfer team

• Who holds responsibility for the patient’s care – in some cases will be dual care i.e. involvement of an external specialised unit.

Key questions to assist with assessment:

• What would affect the decision to transfer the patient?

• What are the benefits of transferring the patient?

• Why is the transfer being considered?

• Who has made the decision transfer?

• Who has accepted the patient?

• Where is the patient going?

• Who else needs to know?

• What is the patient’s diagnosis?

• What treatment are they receiving?

• What effect is it having?

• What is needed now?

Transporting patients is potentially hazardous. By adopting a systematic approach and considering the physiological effects of the transfer on the patient and taking action to minimise these where possible, will reduced the chance of avoidable adverse incidents occurring.

Airway

• Assess the patient's ability to maintain their airway, including if their gag and cough reflexes are sufficient.

• Secure the airway with elective intubation if there is any doubt about its patency or the patient’s level of consciousness.

Guidelines for elective intubation pre-transfer:

• GCS <9 (or expected to fall to this level during transfer)

• Respiratory rate >30

• Patient tiring

• PaCO2 rising

• Control of ICP

• FiO2 >60%

• Risk of aspiration

• Risk of airway swelling e.g. facial burns.

• Unstable Patient or ‘just in doubt

If intubated, oral/nasal/tracheostomy check the position of the ETT on a chest x-ray and by clinical examination.

Breathing

• Assess the adequacy of the patients breathing, including respiratory rate, work of breathing, air entry breath sound, oxygen saturations and arterial blood gas.

• Review the chest x ray

• Treat any reversible causes for inadequate breathing/ventilation such as bronchospasm, pneumothorax, pleural effusion, or pulmonary oedema.

• If breathing remains inadequate consider elective intubation (see above guidelines for elective intubation pre-transfer)

• If chest drains are in situ, check they are functioning correctly

  • Do not clamp chest drains

  • Keep underwater seal drains below the level of the patient.

  • If they are on suction, consider if they need to be and if so, how you will maintain this during transfer?

  • Standard wall suction is not suitable for chest drains.

Circulation

• Assess the cardiovascular system including heart rate and rhythm, blood pressure and perfusion.

• If there is evidence of hypovolaemia, correct with fluids. (A full patient travels better, see Physiological effects of transfer)

• Control blood loss where possible; consider transfusion if Hb is less than 8g/dl.

• Commence inotropes or vasopressors if appropriate.

• Ensure you have adequate access.

  • A minimum of 2 large bore cannulas should be in situ and easily accessible.

At times it is necessary to transfer a patient with an intra-aortic balloon pump (IABP) in place. This requires careful consideration and liaison with the ambulance service (See Appendix C transferring the patient with an IABP).

Disability

• Assess GCS, pupil size and reaction, look for any abnormal movement and signs of seizure activity and evidence of pan or agitation.

• Consider the need for sedatives to control any agitation.

  • • Agitated patients pose an injury risk both to themselves and others during transfer.

• Control any seizures with anticonvulsants.

• Consider the need to electively intubate the patient if unable to control seizures or manage agitation or if there is evidence of brain injury, encephalopathy or coma (see above guidelines for elective intubation pre-transfer)

• Assess evidence of or potential for raised intracranial pressure.

  • If present transfer the patient with 10-15 degree head up tilt and maintain:

    • • MAP >80mmHg

      • PaO2 >=13KPa

      • PaCO2 4.5-5KPa.

(Appendix D: Transferring the Neuro Patient)

• The cervical spine should be immobilised in patients with a suspected or known neck injury.

(Appendix E: Transferring the Spinal Patient)

Environment

• Biochemistry

• Check blood glucose and treat if required (beware of administering treatment for hyperglycaemia if the patient will not be receiving any form of calories during transfer)

• Check U and E's, FBC and clotting

• Check ABG's

• Gastrointestinal

• Consider the need for anti-emetics in awake patients to prevent sickness induced by movement.

• Consider the need for a nasogastric tube in all patients: Intubated patients, unless contra indicated, should have a nasogastric/orogastric tube inserted pre-transfer.

• Renal

• Consider the need for a urinary catheter. Most critical care patients will require one for haemodynamic monitoring.

• Assess urine output and give fluid boluses or diuretics if required.

• More specific guidance can be found in the Wessex Kidney Centre Transfer Policy and Check List V2

• Temperature

• Check temperature and commence warming or cooling therapies if indicated.

• Keep patients warm and well covered.

• Attempt to complete all procedures prior to transfer to reduce risk of exposure.

• Skin/Pressure Areas

• Assess all pressure areas including potential equipment associated damage

• Assess any wounds and dress/redress if required

Control, Communication, Evaluation

Clear effective communication and record keeping are an essential part of the transfer process. Communication begins at the point of referral and needs to be continued throughout all stages of the transfer process. To ensure that communication is effective information needs to be concise and relevant and needs to be interpreted correctly.

Telephone communication

Many different methods of communication may be used throughout the transfer process but most communication that takes place will be via the telephone and so it is useful to use a systematic approach such as:

S - Situation B - Background A - Assessment R – Recommendations

S – Situation

• Introduce yourself to the patient and check that you are speaking with the correct person.

• Identify the patient you are calling about (who and where).

• Discuss anything you need advice on.

• 
  

B – Background

• Background information about the patient

• Reason for admission

• Relevant past medical history

A - Assessment

• Specific observations and vital sign values based on an ABCDE approach.

• Any specifics that are required to resolve any problems.

• Therapies that have already been instituted and the response made to such therapies.

• Any infection control issues that may need to be considered.

R – Recommendations

• State explicitly any actions that need to be carried out by the person you are calling/talking to. This is of relevance when transferring a patient to a specialist centre.

• One of the most important telephone calls during the transfer process is the one to the receiving unit prior to departure; however, this is often forgotten in the pressure to get going.

• It is also wise to take a mobile phone and telephone numbers of both the referring and receiving units as these may prove extremely valuable during any unexpected events.

• Check the numbers on the transfer form to ensure they are up to date; you may also be transferring to Theatre/Cath Lab so you may need to obtain these numbers.

Written communication

Aside from communication on the telephone, the next important method of communication is written records.

These are important from both a clinical and legal perspective, once a transfer has been completed; written notes are often the only record that will remain.

It is usually necessary to reproduce written notes for the receiving unit for inter hospital transfers as original copies are usually retained by the referring hospital.

Documentation of the transfer itself is something that is often neglected but is as important as all other documentation.

Forms for both inter and intra hospital transfers are available. Ensure that the patient (if able), along with relatives and significant others, is informed of the transfer, the destination, time and reason for transfer and this conversation is documented in the patient’s notes.

Patient confidentiality should be considered and maintained during all communication, be it verbal or written.

Documentation

Documentation is a legal and permanent record of the transfer process.

Clear records of all stages must be maintained. Standardised documentation in the way of transfer checklists have been created to ensure that core data is documented, and vital components are remembered prior, during and at the end of a transfer.

It needs to be photocopied so a record can be retained by the transferring hospital.

If any incident occurs the Incident form should be completed, a copy emailed to your transfer Lead and a Datix form completed with “Critical Care Transfer” as an identifier to allow reliable data collection.

For Inter hospital transfers copies of all the patient’s clinical records will be required by the receiving hospital.

Copies of x-rays and scans may need to be transferred to disk or may be sent electronically, this should be discussed with radiography and the receiving hospital.

Forms for both inter and intra hospital transfers are available

Remember the 6 P's: Prior Planning and Preparation Prevents Poor Performance!

Handover following transfer

There should be a clear handover on arrival to the receiving hospitals medical and nursing team, who will then assume responsibility for the patient’s care.

It is usual for the patient to be transferred onto the receiving unit’s bed and equipment prior to a detailed handover to the receiving unit. The transferring team should therefore maintain some control during this process and ensure no interruption to vital treatment.

Handover should include a verbal and written account of the patient’s history, vital signs, therapy, significant clinical events at previous hospital and during transport, using the TVWACC ODN form.

X-rays, notes, patient property, and medications should be handed to the nursing staff. Consider the safe handover of controlled medications

Modes of transport

There are different modes of transport for critical care transfer and there are several key factors that must be taken into consideration which are; nature of the illness, urgency of transfer, availability of transport and mobilisation times, geography, weather conditions and cost.

Road transport is relatively low cost, has rapid mobilisation time, is less limited by adverse weather, causes less physiological disturbance and allows for easier patient monitoring. Staff are also more familiar with this environment.

Air transport may be considered for longer journeys, where road access is difficult, or when for other reasons it may be quicker. Helicopters and fixed wing air frames differ, and each come with their own set of issues such as cramped environment, noise, vibration, altitude, need for road transfers to and from airheads, need for staff training and costs.

Acceleration and deceleration can cause adverse effects to patient and equipment often need to be made airworthy. It is also important that staff are competent to fly with patients. The ICS guidelines (2019) recommend staff without appropriate training should not undertake aeromedical transfers.

Minimum requirements include safety training, evacuation procedures for the aircraft and basic on-board communication skills. More advanced training in aeromedical transfer is however desirable.

Aeromedical considerations are detailed in Appendix G as a guide for those preparing a patient for air transfer.

Time

Those critical care patients that need to be transferred for more specialised treatment for example head injuries that require invasive surgery will need to be transferred with greater urgency and priority than the repatriation of a stable critically ill patient. The following response level definitions have been included to provide clear explanation and guidance to help you select the appropriate response to meet the clinical needs of the patient.

Safety Issues

Accidents causing injury to the occupants of road ambulances are relatively rare.

The prime concern during transport must be the safety of all those involved in the transfer together with that of the road users and pedestrians and careful judgement needs to be placed on the speed of travel.

• Patients should be secured with a 5-point harness/straps.

• Warming/insulating blankets should be used.

• All lines should be safely secured, visible / accessible.

• All equipment should be adequately stowed.

• All pumps must be secured to the trolley.

• Gas cylinders must always be held in secure housings.

Insurance and Indemnity

Although accidents causing severe injury or death when transferring patients are rare, it is advised that all staff who are involved in transporting patients ensure they have adequate financial arrangements in place for themselves and their dependents. It is important to check the policy of the hospital or organisation that you work for.

Sirens and Blue Lights

In most transfers high speed is not required.

Blue lights and sirens can be used to aid progress through areas of high traffic density such as junctions without requiring the ambulance to be driven at high speed.

This approach delivers a smooth journey with the minimum delay (ICS 2019).

Stop if a critical event occurs

Staff should always remain seated and wear seat belts.

Adequately resuscitated and stabilised patients should not normally require any significant changes to treatment during transfer. If, however, unforeseen clinical emergencies do arise, and the patient requires intervention this should not be attempted in a moving ambulance and the vehicle should be stopped appropriately in a safe place (ICS 2019).

You must ask the ambulance crew to stop the vehicle to enable you to stabilise the patient.

The driver can only stop when it is safe to do so; this may not be immediately.

Reflective jackets must be taken for all transfer personnel on out-of-hospital transfers. If the transfer vehicle breaks down and you are outside of the vehicle you must be clearly visible to all other traffic.

Specific Conditions