576 A BATCHELOR
Transfer of the critically ill patient
Primary transfer is from the scene of an incident.
Secondary transfer is between medical facilities or within
the same facility for surgery or investigation. This chapter
deals only with secondary transfer. Transfer either intra- or
interhospital requires the same preparations. Patient trans-
fers can and should be safe.
Components of a transfer
Patient
Reason to move
There must be a good reason to move, e.g. upgrade care,
surgery, investigation, repatriation or because of lack of
ICU beds. The reason should be documented. Moving one
patient to make way for another when that move is not in
the patient’s best interests requires careful consideration at
consultant level and consent from both patient and family.
Physiology of transportation
Acceleration and deceleration in an ambulance can cause
profound shifts of fluid in the circulation, particularly in
patients who are vasodilated, hypovolaemic or dysauto-
nomic, with adverse effect on cardiac output and blood
pressure. This affects both systemic and pulmonary circula-
tions, worsening ventilation–perfusion matching and neces-
sitating increased minute ventilation and inspired oxygen
to maintain the same ABGs. Ideally patients would be
placed across the direction of travel; however, this is rarely
possible as the position of the trolley is determined by the
ambulance layout.
Pre-transfer stabilization
The patient must be stable and well resuscitated.
• Endotracheal intubation is indicated if blood gases are
poor, GCS <9, or a higher but declining score, or if there
is airway compromise, e.g. burns or facial trauma.
Intubation in a moving vehicle or in a lay-by at the side of
the road may not be easy and should be avoided. The
tube should be well secured.
• The patient should be attached and stabilized on the
transport ventilator for a period prior to departure to
allow blood gases to be checked and adequacy of venti-
lation established. Consider paralysis to facilitate ventila-
tion and prevent unplanned self-extubation. Hand
ventilation is unacceptable.
• Volume: full patients travel better than empty ones.
Resuscitate using sequential fluid challenges accompa-
nied by appropriate use of vasoconstrictors. Insert at
least two large bore peripheral lines; central venous
access may also be required for infusions. All lines should
be well secured.
• Identify and drain pneumothoraces prior to transfer
• If patient has received thrombolysis for MI, remember
reperfusion arrhythmias and consider delaying transfer.
• Electrolytes, if potassium <3 or >6.5mmol/l correct
before transfer. Correct magnesium if low in the pres-
ence of rhythm disturbance.
• Fractures: splint to avoid pain and further injury. Pelvic
fractures have significant blood loss—consider external
fixation if possible.
• Urinary catheter and NG tube on free drainage.
• Ensure normothermia prior to transportl it’s very easy
to get cold in an ambulance.
Some patients should be transported without stabilization,
e.g. those requiring urgent definitive surgical treatment for
whom attempts at stabilization will compromise survival,
such as leaking abdominal aortic aneurysm.
Surgical including burns
Leaking oesophageal varices—take appropriate advice on
placement of a Sengstaken–Blackmore tube if patient must
be transferred to another site for haemorrhage control.
Burns—if in doubt protect the airway; swelling can be
severe and delayed intubation may be difficult. Use a high
concentration of oxygen if carbon monoxide or inhalation
injury is suspected until levels are established. For respira-
tory or limb circulatory problems, perform escharotomies
prior to transfer; diagrams can be faxed from a burn centre
to guide these. Fluid requirements can be large, and formu-
lae especially in the presence of inhalation injury are only
a guide; aim for urine output >0.5ml/kg/h. Maintain body
temperature or re-warm; cold water immersion/irrigation
and exposure can result in hypothermia. Cover burn with
clean dry dressings or cling film.
Neurosurgical
Avoid secondary injury; maintain oxygenation and blood
pressure. Treat other causes of haemorrhage, e.g. splenic
rupture, prior to transfer to avoid hypotension. If patient
is otherwise stable, aim for a prompt departure; early
evacuation of blood clots leads to optimal outcome.
Equipment
Ensure competence with all devices before transfer.
All equipment used in an ambulance must be securely
attached to the transport trolley and able to withstand
a 10g force. The patient should be secured to the trolley
with a 5-point restraint.
Monitoring
It is important to know your equipment and how and
where it is stored. Monitors should be robust, intuitive and
have an easily viewed screen, battery powered and kept
charged. Need to know type of battery and whether it is
susceptible to memory problems and poor charging.
Batteries must be interchangeable in use without loss of
monitoring.
• 5-lead ECG
• Preferably invasive blood pressure; non-invasive is more
susceptible to movement interference and is expensive
on battery power.
• Pulse oximetry
• Exhaled carbon dioxide
• If a pulmonary artery cather is used, the pressure must
be continually monitored to avoid spontaneous wedging
or it must be withdrawn into the SVC for transfer.
• Core temperature
• Airway pressure
 CHAPTER 33.14
Ventilator
Ventilators must be robust, have a wide range of settings
for tidal volume, I:E ratio, rate and PEEP to accommodate
most patients. Preferably battery powered and economical
with oxygen—any gas used for the ventilator must be
known and taken into account along with respiratory gas.
It should have a disconnect alarm.
Oxygen
Calculate the amount of oxygen required for the projected
transfer duration and include any driving gas for the venti-
lator. Take double this amount and at least an hour’s supply
in case of unexpected delays. If using the ambulance supply,
check these cylinders contain enough for your projected
journey time. Check connections are compatible. Take an
ambu bag with reservoir and face mask in case of ventilator
failure or unplanned extubation.
Volume of oxygen in standard UK cylinders in litres.
D size 340
E size 680
F size 1360
Infusion
All fluids must be administered via electronically controlled
devices, avoid hanging bags of fluid; movement and transfer
may result in air in the infusion tubing.
Drugs
Stop all unnecessary infusions before transport. Essential
infusions should be made in a concentration such that
syringe changes will not be required en route. If infusion
concentrations are changed, allow a period of stabilization
on the new concentrations prior to departure. Take spare
pre-prepared syringes in case of problems. All syringes
should be clearly labelled. Emergency drugs should prefer-
ably be in pre-loaded syringes.
Transfer team
Ideally all patients would be transferred by a specialized
transfer team; in most cases this is not feasible for many
reasons including cost, availability and the requirement for
rapid treatment in, for example, head injury. All anaesthesia
and critical care staff should undergo transfer training in
the necessary skills and be competent in the use of all the
equipment. It is not essential that all transfers are under-
taken by doctors, but it is essential that the accompanying
personnel are competent and have indemnity.
Whilst it is not acceptable to send the most junior inexpe-
rienced member of the hospital team on a transfer because
they will be least missed, it is important to consider both
the patient being transferred and those left behind, and
distribute skills accordingly.
The team members have the ultimate veto on the transfer
if they are unhappy that the patient, the equipment or they
are not fit for the transfer.
The transfer team members should be involved in patient
stabilization and the decision about fitness for and timing
of transfer. It is inappropriate for someone who does not
know the patient and their problems to be involved in a
transfer.
Team members must be adequately insured and have
suitable protective kit; they must have prior arranged
transport back to base.
Transfer of the critically ill patient 577
Communication
The referring hospital must ensure the recipient hospital is
able to provide the care and treatment the patient requires
before agreeing to transfer the patient. The recipient
hospital must have spare capacity before accepting the
patient. Whilst negotiating the transfer, the most senior
clinician involved should provide a full and detailed verbal
case summary including MRSA and C. difficile status. The
clinician caring for the patient must give a detailed hand-
over to the transferring team including all investigations
and results. The transfer team should then give a full
handover to the recipient team.
The team must have a means of communicating with their
base whilst en route; mobile phones may be used.
The receiving hospital should be given an estimated time of
arrival and informed when the patient is en route.
It is not appropriate for relatives to travel in an ambulance
with the patient unless the patient is a child.
Documentation
The reason for transfer along with conversations with
other teams, patient and family should all be documented.
Physiological observations should be charted during trans-
fer. Many networks have multicopy transfer forms so that
copies can be kept by the referring team and the network
for audit, as well as a copy placed in the patient notes. Take
all notes and X-rays on CD. Any critical incidents should be
fully documented
Mode of transport
Aeromedical transport is covered in Chapter 33.15.
Ambulances are not standard and vary considerably, so
check you are happy with all the equipment before loading
the patient. Many ambulances only have room for 2 rear
passengers, in addition to the patient; negotiate in advance
who will travel with the patient.
Patient and team safety
It is important to consider the safety not only of the patient
but also that of the team. All members should wear seat
belts. Protective reflective clothing should be available.
Each team member should be aware of his insurance
status. Hospital Trusts may not arrange appropriate cover,
and professional bodies may take out cover for their
members.
Ethics of transfer
Transfer a patient because they will benefit from it, e.g.
transfer to burns centre.
Protect and stabilize the patient so they do not come to
harm.
If possible, discuss move with patient and seek their view.
In exceptional circumstances, a patient may be moved to
free up resources for another patient, i.e. for the benefit of
another.
Medicolegal aspects
Prior to transport it may be appropriate to take advice
from the receiving centre on patient treatment; however, it
remains the responsibility of the referring clinicians to
decide if it is the correct advice.
Handover of responsibility follows formal handover; the
transfer team accepts responsibility from the referring unit
and then hands over to the receiving unit. Hospitals should
578 A BATCHELOR
agree lines of legal responsibility if a transfer team is used
and they wish to stabilize a patient at the referring hospital
where they are not employed.
Checklist system
Each unit or preferably network should establish a check-
list which includes all of the above points; this should be
with the patient documentation and should be formally
worked through prior to every transfer and signed by the
team members.
Further reading
Guidelines for the transport of the critically ill adult. Intensive
Care Society 2002 http://www.ics.ac.uk/icmprof/
standards.asp?menuid=7
Recommendations for the safe transfer of patients with brain injury.
Association of Anaesthetists 2006
http://www.aagbi.org/publications/guidelines.
htm#t