The document discusses the risks associated with transporting critically ill patients between hospitals and provides guidelines to minimize these risks. It outlines categories of interhospital transport and notes that emergency transports involve acute life-threatening illnesses while semi-elective transports involve major organ failure. The document recommends pre-transport coordination, proper equipment and monitoring during transport, and protocols for admission at the receiving hospital to help reduce risks and complications during interhospital transportation of critically ill patients.

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. 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 Categories of transport of
critically ill patients
• Prehospital transport
• Intrahospital transport
Interhospital transport

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

6. Transport of critically ill patients always
involves some degree of risk to patient
and accompany personnel
Potential Potential
benefit risk

7. Law/medico-legal
SOP Ethic
Transport critically
ill patients
HOD Safety
order
Religious obligation

8. 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."

9. 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?

10. An interface between
the hazard & vulnerability

11. 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

12. 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.

13. Transport Characteristics

14. Transfer diagnosis

18. 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

20. • 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

21. • 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

22. • 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.

23. “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

33. 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.

34. 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

36. 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.

37. Is the transportation necessary?

38. A generic referral pattern

39. 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)

41. 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.

42. 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.

43. 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

44. 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.

45. 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

47. • 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

48. • 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

49. 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

50. 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.

51. 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

53. .
Interfacility transfer algorithm