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Interhospital Transportation of Critically Ill
Interhospital Transportation of Critically Ill




             Dr. Rashidi...
Critical illnesses

•   Heart Attack                      •   Paralysis
•   Stroke                            •   Fulminan...
3 Categories of transport of
    critically ill patients

  • Prehospital transport
  • Intrahospital transport



 Interh...
Interhospital transportation

• Emergency interhospital transport
  - transporting patients with acute life-threatening il...
Transport of critically ill patients always
 involves some degree of risk to patient
   and   accompany personnel

    Pot...
Law/medico-legal




  SOP                            Ethic


        Transport critically
            ill patients




HO...
Safety culture
• "a work environment where a safety ethic
  permeates the organization and people's
  behavior focuses on ...
Ask yourself
• Am I well trained in transit medicine?
• Have I been told the safety measurement
  frequently?
• Am I insur...
An interface between
the hazard & vulnerability
Transport – related problem

• Patient-related complications:
 any difficulty or complication, related directly to the pat...
Jack JM et al. Quality of interhospital transport of
critically ill patients: a prospective audit. Critical Care
         ...
Transport Characteristics
Transfer diagnosis
The predicted mortality was 68-
 The predicted mortality was 68-
 100% and the subsequent hospital
100% and the subsequent...
• Substandard stabilization for 89% of 467
  patients transferred from ED to
  surrounding hospitals.

• 40% higher death ...
• Inadequate stabilization on trauma
  transports & on critically ill medical and
  surgical patients.
• A sizable number ...
• The Australian Incident Monitoring Study (AIMS)
  data suggest that 83% of reported critical incidents
  involved elemen...
“Transportation of critically ill patients to
EDHKL does not follow a standard guideline
(inadequate communication, ineffe...
How to overcome the risks &
                   complications?

• The necessity and safety for transport should be
  assess...
How to overcome the risks &
                 complications?

• Using appropriate equipment, personnel and planning
  for e...
Pretransport Coordination and
             Communication.
• The referring physician tasks:
  - contact an appropriate phys...
Is the transportation necessary?
A generic referral pattern
Good medical practice

• Informed consent and signed consent if possible
• A discussion of the risks and benefits of trans...
Accompany personnel

• Minimum of two excluding the driver
• Unstable patients: physician/nurse, preferably
  trained in t...
David Crippen: Inter Hospital Transport of Critically Ill Patients: Problems and
 Pitfalls. The Internet Journal of Anesth...
Minimum equipment requirement


• Emphasis is placed on airway and oxygenation, vital
  signs monitoring, and the pharmace...
Monitoring during transport


• Continuous pulse oximetry, ECG monitoring, regular
  measurement BP & RR
• Acceptable mech...
Preparing a patient for
       interhospital transport

•   Patient optimization
•   Avoid nonessential testing and proced...
• When a mobile intensive care unit is
  properly staffed and equipped and patient
  stabilization is performed before tra...
• A specialist transfer team vs standard
  ambulance with doctor provided by referring
  hospital. The specialist team sig...
Admission procedure at the
         referral hospital

• Direct admission into relevant discipline,
  by-passing ED dept. ...
Death while in transit

• Should go to the nearest hospital to certify death
  by a doctor, in the absence of an accompany...
Medicine is an imperfect art form:


Medical errors do occur and are an
inescapable part of medical practice


The problem...
.
Interfacility transfer algorithm
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
Interhospital Transportataion Dilemma
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Interhospital Transportataion Dilemma

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Interhospital Transportataion Dilemma

  1. 1. Interhospital Transportation of Critically Ill Interhospital Transportation of Critically Ill Dr. Rashidi Ahmad MD(USM), MMED(USM), FADUSM Emergentist Dept. of Emergency Medicine USM Health Campus
  2. 2. Critical illnesses • Heart Attack • Paralysis • Stroke • Fulminant Hepatitis • Kidney Failure • Motor Neurone Disease • Aplastic Anaemia • PPH • Blindness, deafness, speechless • HIV • End Stage Lung Disease • Benign Brain Tumour • End Stage Liver Failure • Meningoencephalitis • Coma • Major Head Trauma • Major Burns A disease which may lead to death.
  3. 3. 3 Categories of transport of critically ill patients • Prehospital transport • Intrahospital transport Interhospital transport
  4. 4. Interhospital transportation • Emergency interhospital transport - transporting patients with acute life-threatening illnesses to a referral centre due to lack of diagnostic facilities, staffs, other facilities & for safe and effective therapy • Semi-elective interhospital transport - transporting the critically ill patients with major organ failure, requiring organ support @ special investigations to a referral centre
  5. 5. Transport of critically ill patients always involves some degree of risk to patient and accompany personnel Potential Potential benefit risk
  6. 6. Law/medico-legal SOP Ethic Transport critically ill patients HOD Safety order Religious obligation
  7. 7. Safety culture • "a work environment where a safety ethic permeates the organization and people's behavior focuses on accident prevention through critical self-assessment, pro- active identification of management and technical problems, and appropriate, timely, and effective resolution of the problems before they become crises."
  8. 8. Ask yourself • Am I well trained in transit medicine? • Have I been told the safety measurement frequently? • Am I insured? • Is my job confirmed? • Is this ambulance in a good condition? • Are there protocols/guidelines related to interhospital transportation available at the institution?
  9. 9. An interface between the hazard & vulnerability
  10. 10. Transport – related problem • Patient-related complications: any difficulty or complication, related directly to the patient’s patho-physiology. • Equipment-related problems: equipment/technical mishaps & transport environmental factors that could result in patient instability
  11. 11. Jack JM et al. Quality of interhospital transport of critically ill patients: a prospective audit. Critical Care 2005, Vol 9 No 4; p 446 - 451 • 100 consecutive transfers of ICU patients were evaluated over a 14-month period. • University Medical Center Groningen,The Netherlands. • A prospective audit of the quality of transportation.
  12. 12. Transport Characteristics
  13. 13. Transfer diagnosis
  14. 14. The predicted mortality was 68- The predicted mortality was 68- 100% and the subsequent hospital 100% and the subsequent hospital mortality rate was 43% mortality rate was 43% Gembremichael : Crit Care Med 2000
  15. 15. • Substandard stabilization for 89% of 467 patients transferred from ED to surrounding hospitals. • 40% higher death rate in patients transferred with inadequate stabilization versus non-transferred patients. Schiff, RL, Ansell, DA, Schlosser, JE et al, Transfers to a public hospital. A prospective study of 467 patients. N Engl J Med 1986;314: 552-557
  16. 16. • Inadequate stabilization on trauma transports & on critically ill medical and surgical patients. • A sizable number of inadequacies in the study group were of an extremely basic nature. Olson, et al, Stabilization of patients prior to interhospital transfer. Am J Emerg Med 1987; 5:33-39 Mayer, in his review of the literature, found between 24 and 70% of transferred patients are inadequately stabilized prior to transport Interhospital transfer of emergency patients. Am J Em Med, Jan 1987 (5)1: 86-88
  17. 17. • The Australian Incident Monitoring Study (AIMS) data suggest that 83% of reported critical incidents involved elements of human error. • “Knowledge-based errors” contributed directly to about 1/4 of the reported incidents. • The outcome in 1/3 of incidents was also likely to have been minimized by prior experience or awareness of the potential problems Williamson JA, et al. Human failure: An analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:678-683.
  18. 18. “Transportation of critically ill patients to EDHKL does not follow a standard guideline (inadequate communication, ineffective liaison, untrained & inexperienced staff)” Ridzuan Isa, May 2003 A study on inter hospital ambulance transportation of critically ill patients to GHKL
  19. 19. How to overcome the risks & complications? • The necessity and safety for transport should be assessed by the multidisciplinary team of health care providers (e.g., respiratory therapist, physician, nurse). • The risks of transport should be weighed against the potential benefits from the diagnostic or therapeutic procedure to be performed Chang DW. AARC Clinical Practice Guideline: in-hospital transport of the mechanically ventilated patient--2002 revision & update. Respir Care 2002 Jun;47(6):721-3.
  20. 20. How to overcome the risks & complications? • Using appropriate equipment, personnel and planning for each transport can minimize these complications and ensure optimal benefit to the patient Fromm, R E Jr, Dellinger, R P, eng PT. Transport of critically ill patient J Intensive Care Med 1992;7:223-33 • Risks can be diminished if the patients are appropriately selected and carefully monitored during transportation Brokalaki HJ et al.Intrahospital transportation: monitoring and risks. Intensive Crit Care Nurs.1996 Jun;12(3):183-6
  21. 21. Pretransport Coordination and Communication. • The referring physician tasks: - contact an appropriate physician - discuss patient’s management - ensure the appropriate higher level resources are available - reconfirm before the transfer occurs - accompany patient if indicated, if not, ensure there is a command physician who responsible for medical treatment during the transport - determine mode of transportation - ensure a copy of the medical record (care summary, relevant laboratory & radiographic studies) & nurse report will accompany the patient.
  22. 22. Is the transportation necessary?
  23. 23. A generic referral pattern
  24. 24. Good medical practice • Informed consent and signed consent if possible • A discussion of the risks and benefits of transfer • Documented in the medical record before transfer. • If circumstance do not allow for the informed consent process: both the indications for transfer and the reason for not obtaining consent are documented. • The referring physician always writes an order for transfer in the medical record. The Emergency Medical Treatment and Active Labor Act (EMTALA) laws and regulations. (updated at intervals from the 1986 COBRA laws and the 1990 OBRA amendment)
  25. 25. Accompany personnel • Minimum of two excluding the driver • Unstable patients: physician/nurse, preferably trained in transit medicine • Critical but stable: trained paramedic in ACLS/ATLS • Without physician accompany: telemedicine/SOP • Communication failure: the team is authorized to perform acute lifesaving interventions.
  26. 26. David Crippen: Inter Hospital Transport of Critically Ill Patients: Problems and Pitfalls. The Internet Journal of Anesthesiology. 1997. Volume 1 Number 4. • No convincing data demonstrates the need or cost effectiveness of physician accompaniment of most inter-hospital patients. • Questions of appropriateness or cost effectiveness cannot be answered. • We need a randomized, prospective study of physician accompanied vs.unaccompanied transports.
  27. 27. Minimum equipment requirement • Emphasis is placed on airway and oxygenation, vital signs monitoring, and the pharmaceutical agents for emergency resuscitation, stabilization and maintenance of vital functions. • Regular item check for expiration & potency
  28. 28. Monitoring during transport • Continuous pulse oximetry, ECG monitoring, regular measurement BP & RR • Acceptable mechanical ventilator • Patient status and management during transport are recorded and filed in the patient medical record.
  29. 29. Preparing a patient for interhospital transport • Patient optimization • Avoid nonessential testing and procedures • Ensure patient comfort and safety, so do we • Intervene and anticipate complications • Documentation • Checklist
  30. 30. • When a mobile intensive care unit is properly staffed and equipped and patient stabilization is performed before transfer, severely ill pts with respiratory failure can be transferred safely. • The predicted mortality was 68-100% and the subsequent hospital mortality rate was 43% Gembremichael : Crit Care Med 2000
  31. 31. • A specialist transfer team vs standard ambulance with doctor provided by referring hospital. The specialist team significantly improve the acute outcomes ( acute physiology and early mortality) • acidotic (< 7.1) 3 vs 7 % hypotension (MAP) 9 vs 18 % mortality 3 vs 7.7 % G. Bellingan : Intensive Care Medicine 2000
  32. 32. Admission procedure at the referral hospital • Direct admission into relevant discipline, by-passing ED dept. is on the instruction of the receiving specialist and only if patient is accompanied by a doctor. MOH 1990
  33. 33. Death while in transit • Should go to the nearest hospital to certify death by a doctor, in the absence of an accompanying doctor in the ambulance. • Under such circumstances, the ambulance should return to its base and not proceed to its referral hospital but relevant staff involved should informed to the referring doctor, doctors of unit expecting the patient and ED MO at referral hospital.
  34. 34. Medicine is an imperfect art form: Medical errors do occur and are an inescapable part of medical practice The problem is not bad people, the problem is that the system of medical care needs to be made safer
  35. 35. . Interfacility transfer algorithm

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