GUIDELINES FOR THE TRANSPORT CRITICALLY ILL PATIENTS

PORTUGUESE SOCIETY OF INTENSIVE CARE

APPENDIX 1 - Medicines available to a transport team at the hospital of origin

APPENDIX 3 - Form for Inter-Hospital Transport of the Critically Ill Patients

INTRODUCTION

These guidelines constitute a pack of rules and practical procedures written by the members of a working group who share in common experience in the transport of patients in serious condition. The rules for a perfect performance in medicine and nursing are considered as essential principles so that the risks of instability, which characterize the transport activity, can be reduced or abolished.

The legal instruments were also considered, such as: Edict 293/93 - Rule for Transport of Patients, Law 38/2 - Legal Procedure for the Transport of Patients, Law 48/90 - Health Act, Law 12/97 which rules the activity of transport of patients by firemen and the Portuguese Red Cross.

The group decided to restrict this document to the secondary transport of patients in serious condition.

Regarding the research in terms of transport of newborns, we accept the possibility of extending the concept of newborn (28 days of life) to a higher age/weight, in accordance with the available space in the incubator/ambulance.

We realize that each institution should prepare and keeps operational transport teams, mostly between hospitals.

The rules should be evaluated on a regular basis in accordance with the principles of continuous quality improvement.

GUIDE FOR THE TRANSPORT OF CRITICALLY ILL PATIENTS

General Principles

We define as critically ill patients those that by dysfunction or deep failure of one or more organs or systems, depends his/her survival from advanced instruments of monitoring and therapy.

The transport of these patients takes some risks but it is acceptable between hospitals or services in the same hospital in order to give a better assistance or to make laboratory or image exams, which are not available in the service, or institution where the patient is admitted.
The transport of critically ill patients takes the following steps:

Decision
Planning
Implementing

1 . Decision

The decision of transporting a patient in serious condition is a medical action. Therefore, the responsibility is ascribed to the doctor who is attending the patient but also from the chief of the team and the service direction.

2 . Planning

The planning of the action is effected by the medical and nurse team of the service or unit and should consider the following problems:

The choice and the contact with the receptor service, evaluating the distance and the time delay;
2he choice of the mode of transport;
The selection of accurate monitoring methods and devices;
Individualized prediction of possible complications;
The selection of general and specific therapy instruments
The choice of the transport team (according to the availability and the characteristics of the patient).

3 . Implementing

The implementing of the transport is in charge of the selected transport team, and its technical and legal responsibility finishes only when the patient is delivered to the medical team of the destination service or on the arrival to the original service (when the transport is done for the fulfilling of diagnostic and / or therapeutical procedures) similar responsibilities for the doctors when they decide a transport.

The quality of surveillance and therapy procedure during the transport should not be lower than those verified at the referring service.

Purpose: Production of practical rules for the transport (between hospitals or in the same hospital) of patients in serious condition.
Sources: Revision of data with key words (Medline), systematic presentation of self-experiences.
Team work: Doctors and nurses members of the Sociedade Portuguesa de Cuidados Intensivos - SPCI -, with experience in the transport of patients in serious condition.
Key words: Transport (between hospitals or in the same hospital) serious condition, air transport, polytrauma, ambulance, medical-legal responsibility, protocols.

Intra-Hospital Transport of Critically Ill Patients

Introduction

When admitted in the ER (Emergency Room), after being resuscitated, the critically ill patients are often transferred from the emergency rooms to the intensive care unit (ICU) or operating room and then to recovering rooms or ICU's.

The patients with these characteristics sometimes still need to be removed in the hospital to therapeutical and diagnostic procedures.

The technological improvement makes the transport of patients from ICU's to other places in the hospital, where the possibilities of emergency action are very often inappropriate, mostly the radiology services (cat scan, nuclear magnetic resonance, invasive and non invasive angiography) and nuclear medicine.

The period of transport is characterized by a great instability to the patient, as its medical condition can eventually get worse with further complications, which should be expected.

In accordance with the diagnostic test, if the team realizes that the transport represents a serious risk, a new evaluation of the situation should be done.

This guidelines introduce the minimum requirements, which should be available during the transport of any patient in serious condition.

The transport in the hospital of the patient in serious condition should follow these rules:

Coordination before the transport
- Previous information that the area where the patient is meant to be moved is ready to receive him/her and to make the exam or planned therapy;
- The doctor in charge should go with the patient or whenever the transport of the patient is in charge of a different team, communication doctor to doctor and/or nurse to nurse should be established regarding the medical situation of the patient and the therapies, before and after the removal;
- Write in the medical record the events occurred during the transport and the evaluation of the condition of the patient.
Professionals with the patient
Two professionals (doctors/nurses) should accompany the patient in serious condition at least.
- One of the professionals should be the nurse in charge of the patient, with experience in CPR or specially trained in transport of patients in serious conditions;
- In accordance with the serious condition and the instability of the patient, the second professional can be a nurse or a doctor;
- A doctor should attend the patients who present physiological instability and eventually will need an emergent or urgent action.
Equipment to support the patient
- Transport monitor;
- Blood pressure reader;
- Endotracheal intubation kit, and manual resuscitator" (with PEEP valve);
- Oxygen source with a predictable capacity for the whole period of transport, with additional reserve for 30 minutes;
- Portable ventilator, with availability to offer volume/minute, pressure FiO2 of 100% and PEEP which the patient is doing previously, with disconnection alarm and high airway pressure alarm; during a pediatric transport the FiO2 should be accurately controlled;
- Drugs for resuscitation, namely adrenaline, lignocaine, atropine and sodium bicarbonate;
- Intravenous fluids and continuous infusion of drugs ruled by syringes or infusing pumps with battery to prevent any interruption;
- Additional medications to be administered according to the medical prescription.
Note: Somewhere on the road there should be available an aspirator and an emergency car in an average time of four minutes.
Monitoring during the transport
Note: The levels of monitoring were divided regarding the following classification:
Level 1 - compulsory;
Level 2 - highly recommended;
Level 3 - ideal.
- Continuous monitoring with periodical record:
  - ECG (level 1);
  - Pulse oximetry (level 1);
- Intermittent monitoring and record:
  - Blood pressure (level 1);
  - Heart rate (level 1);
  - Respiratory rates (level 1 in pediatrics and level 2 in other patients).
- In selected patients (regarding his/her medical condition):
  - Capnography (level 2);
  - Continuous measure of the blood pressure (level 3);
  - Measure of the pulmonary artery pressure (PAP) (level 3);
  - Measure of intracranial pressure (ICP) (level 3);
  - Intermittent measure of Central Venous Pressure (CVP) (level 3);
  - In patients intubated and mechanically ventilated the airway pressure (Paw) should be monitorized (level 1 in these situations)

Inter-Hospital Transport of Critically Ill Patients

Introduction

The main reason for the transfer of a patient in serious condition from a hospital to another one is the lack of diagnostic and therapy resources (human and technical) at the hospital of origin.
The decision of transferring a patient with these characteristics is just taken after the evaluation of benefits and risks subject to the transport.
The risk of transport takes two parts: medical risk (the medical situation of the patient; vibrations effects, acceleration - disacceleration and changes of temperature - factors that affect the heart-breathing physiology and the monitoring fiability) and the travel risk (vibration, acceleration-disacceleration, collision risk, which get highly worse with the speed).
In order to minimize the risks of transport, the patient should be previously stabilized at the hospital of origin, and the required diagnosis and therapies should be done to prepare a safe trip (venous access, thorax drains, intubation and others).

Before the initiation of a transport, the patient or his/her legal representative should be informed of the fact, and an explanation of the situation, the reason for the transport, the name of the referral hospital should be given, and when necessary, his/her agreement.

The transport should be considered as an extension of the hospital that is referring the patient, on its responsibility during the two first phases of the treatment (Decision and Planning). At the phase of Implementing, the transport team is responsible for the patient.

Coordination before the transport
- Once the decision of transfer is taken, it should be done as soon as possible;
- The doctor responsible for the transfer should contact the unit or service where he/she intends to send the patient and make sure that all the required resources for the treatment are available, and whether there are vacancies. The service expected to accept the patient should be fully informed of the medical situation and the predictable therapy procedures.
- The initial contact is done before the transport (and never during or after) and it should be individualized; in the process of transfer the names and contacts of the participants should be recorded;
- The medical and nursing records (transferring notes or photocopies) and the complementary diagnostic exams will be sent with the patient,
There should be a common record of the transport among the several hospitals (enclosed 3).
- The choice of the modes of transport (ambulance or helicopter) should consider:
  - The medical situation of the patient ("emergent", "urgent" or "elective" transport)
  - The distance/timing of transport;
  - The necessary medical procedures during the transport;
  - The staff availability and resources;
  - The weather forecast.
  Note: In case it's an air transport it is also important to be aware of possible physiological changing regarding the altitude and its influences on the clinical features.
Professionals to escort the patient
- The team escorting the patient in serious condition should be the current crew of the ambulance and at least two other elements (a doctor and a nurse) both with experience in Cardio Pulmonary Resuscitation (CPR), with the equipment, its use and maintenance.
Equipment
1. Equipment to serve the patient
  - Manual Resuscitator and appropriate masks;
  - Mayo tubes, laryngoscopes; endotracheal tubes and guide strings;
  - Oxygen source with appropriate capacity:
    Required O2 = [(20 + Vmin) x FiO2 x transport timing*] + 50%
    * in minutes;
  - Aspirator and probes;
  - Thoracic drains, introduction kit and accessories;
  - Transport monitor and defibrillator;
  - Automatic Blood Pressure reader and appropriate armbands;
  - Material for puncture and maintenance of venous lines (catheters, syringes, infusion systems, etc);
  - IV Fluids (crystalloid and colloid)
  - Drugs for advanced life support and others considered as necessary or specific (continued therapies or previously planned as intermittent);
  - Transport ventilator with volume/minute, pressure, PEEP and FiO2 with reliable regulation systems, capacity of monitoring of airway pressure , apnea, disconnection alarm and high pressure alarm; during the pediatric transport the FiO2 and the volume or pressure should be strictly controlled;
  - Communication equipment (to allow contracts between the hospitals of origin and referral).
2. Drugs available for the transport
  - Drugs (Appendix 1)
Monitoring
Note: The levels of monitoring were divided regarding the following classification:
Level 1 - compulsory
Level 2 - highly recommended
Level 3 - ideal
- Continuous monitoring with periodical record:
  - EEG (level 1)
  - Pulse oximetry (level 1)
- Intermittent monitoring and record:
  - Non invasive blood pressure (level 1);
  - Heart rate (level 1);
  - Respiratory rate (level 1 in pediatrics and level 2 with the other patients).
- In selected patients (according to his medical condition)
  - Capnography (level 2)
  - Continuous measure of the blood pressure (level 3)
  - Pulmonary Artery Pressure (PAP)(level 3);
  - Intracranial Pressure (ICP) (level 3);
  - Intermittent measure of Central Venous pressure (CVP) (level 3)
  - Whenever the patients are with tubes and mechanically ventilated the air pressure (Paw) should be monitored (level 1, under these circumstances).
Decision for the transport inter-hospital of critically ill patients

Proceed according to the algorithm (Appendix 2).

APPENDIX 1 - Medicines available to a transport team at the hospital of origin

Adenosine;
Adrenaline;
Alfentanil;
Aminofiline;
Amiodarone;
Atropine;
Sodium Bicarbonate;
Captopril;
Cefotaxime;
Dexametasone;
Diazepam;
Digoxine;
Isossorbide Dinitrate
Dobutamine;
Dopamine;
Etomidate;
Phenobarbital;
Flumazenil;
Furosemide;
Calcium Gluconate
Hypertonic Glucosis (30%)
Heparin;
Hidralazine;
Hydrate Chloral
Actrapid Insulin
Isoprenaline;
Labetalol Hydrochloride
2 % ev Lignocaine (+gel and spray)
Manitol;
Metilprednisolone;
Midazolam;
Morfine;
Naloxone;
Nifedipine;
Nitroglycerine or Glyceril Trinitrate
Noradrenaline;
Paracetamol;
Propofol;
Salbutamol ;
Succinilcoline;
Magnesium Sulphate
Thiopental Sodium
Vecuronium Bromide
Verapamil.

Enf^o António José Sousa Matos
Dr^a. Cristina Maria Simões Veríssimo
Dr. João Estrada
Dr. João Paulo Almeida e Sousa
Dr. Humberto Silva Machado
Dr. João Vitor de Gouveia Miranda Sá
Dr. Luís Artur Fonseca Reis
Dr. Ramiro Carvalho Figueira
Dr^a. Rita Perez Fernandes da Silva

Creation Date: 19 December 1997
Last Update: 19 December 1997

PORTUGUESE SOCIETY OF INTENSIVE CARE