Here we go again!!!

How to conduct a safe inter-hospital transfer of patients

dr. Thomas Tjahjono SpAn

Back ground
A large number of
inter-hospital transfers
already take place and
increasing
Anesthetists/
intensivists are
commonly involved in
transferring the sickest
of these patients
Pict: courtesy of Mount Sinai Hospital

IHT Goal

Optimal health and well being of the patient

Decision : risk and benefit
Choice of hospital : continuity treatment
Transfer process initiated and completed ASAP

Well organized system

with appropriate
equipment is crucial
for safe IHT

WHERE IS THE AMBULANCE..!?

Think before you start..

What's the level
of the patient?

Safety /
Comfort /
Explanation

Have we got
the right staff
and equipment?

Etxebatteria et al :

The Risk score for transport patients

(RSTP) :
based on patients physiological
parameters

Table 1. Risk Score for Transport Patients

(adopted of Etxebarria MJ et al)
Measurement

Score

1. Haemodynamics
Stable

Moderately stable (requires volume < 15 ml/min in

adults

Unstable (requires volume > 15 ml/min in adults)

2. Arrhythmias
No

Yes, not serious (AMI after 48 hours)

Serious (AMI in the first 48 hours)

3. ECG Monitoring
No

Yes (desirable)

Measurement

Score

4. Intravenous line
No

Yes

Pulmonary artery catheter

5. Provisional pacemaker
No

Yes (not invasive ). Always AMI in the first 48 hours

Yes (endocavity)

6. Respiration
Respiratory rate between 10 and 14 breaths/min in
adults

Respiratory rate between 15-35 breaths/min in adults

Apnoea (<10) or>36 irregular breathing

Measurement

Score

7. Airway
No

Yes (Guedel tube)

Yes (intubation or tracheostomy)

8. Respiratory support
No

Yes (oxygen therapy)

Yes (mechanical ventilation)

9. Assessment
GCS = 15

GCS 8-14

Measurement

Score

10. Prematurity
Newborn > 2000 g

Newborn between 1200 and 2000 g

Newborn < 1200 g

11. Technopharmacological support (actual or en route)

None

Group I

Group II

Table 2. Medication for risk groups

(Etxebarria MJ et al)
Group I

Group II

Inotropics

Inotropic + vasodilators

Vasodilators

Uterine relaxants

Antiarrhythmics

Infant incubator

Bicarbonate

General anesthetics

Analgesics
Antiepileptic

MAST

Steroids
Manitol 20 %
Trombolytics
Naloxone
Thoracic tube
Suction

The score serves as a triage tool

for assessing the risk of adverse
event during IHT
Score > 7 were at significant risk
and subsequent mortality
(Markaksi et al)

Table 3. Management of at risk patients

Ponts

Group

Vehicle

Staff

0-2

Conventional ambulance

None

3-6

Conventional ambulance

Nurse/Paramedic

Group ICU

Doctor + Nurse

Over 6 II

Drag picture to
placeholder or
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Deciding the
mode of transfer
Pts physiological status
Pts ilness of injury
Accessibility by road and air
Weather or Traffic conditions
Total transfer time

PREPARING THE PATIENT

As far as possible the patient must be stabilized prior to transfer.
Any necessary interventions and treatments need to be done prior to leaving the
referring hospital e.g. chest drains, x-rays, invasive pressure monitoring.
A formal handover of the patient by medical and nursing staff is essential, as are
written notes, results of investigations and copies of imaging procedures.
The referring medical staff should communicate directly with the receiving
institution medical staff.
The transfer team should speak directly with the receiving staff if further advice
is required, and confirm an approximate arrival time.

Recent blood results including biochemistry, glucose and

haemoglobin are essential
ABGs must be examined after the patient has been stabilized
on the transport ventilator.
The importance of rigorously securing the airway cannot be
overemphasized.
All IV access, infusion lines, monitoring equipment, drains, etc.
must be checked, rechecked and secured.
Spare IV access is essential.

Arrange infusion lines and monitoring equipment such that they

are free from tangling and lie in such a fashion that they will
be accessible according to the particular aircraft used.
Access to the patients limbs, chest and abdomen may be
restricted in flight, depending on the layout of the aircraft.
Always plan for the worst case scenario, and consider how
emergency re-intubation or CPR would be performed in the
cabin

Prior to moving the patient, all loose equipment around the

patient should be safely secured to guard against downdraft from
helicopter blades or wind when moving the patient around exposed
airport areas.
The patient must be secured onto the stretcher with a harness
approved for aviation use.
Before leaving the referring hospital, a final check of the patient,
equipment and team is performed and contact made with the
aircrew to ensure the aircraft is fully fuelled, ready to receive the
patient and there are no problems with the planned routing.

Choosing the right mode

Land or Air

Table 4. Comparison of ground and air

transport
Mode

Advantages

Disadvantages

Ground / transport

Low cost
Rapid mobilization
Less weather
dependent
Easier patient
monitoring

Longer transport time

for long distances
Dependent on traffic
condition

Air transport

Shorter response time

to patient and shorter
transport time
Can access patients in
topologically hard to
reach areas

Slow to mobilize
Dependent on weather
conditions
Landing site needed
Need for additional
ground transport
between landing site
and hospital
Limited availability in
comparison to ground
transport
More expensive

Ground transport

Air transport
Rotary

Fixed Wing

Speed and distance

Helicopters :
typically cruise at 120150 knots (220
280km/h) with a useful radius of 50300km.
Time taken to prepare and launch the
helicopter and also fuel endurance limit
their advantages for very short or long
distances
The advantage over fixed wing aircraft is
the ability to operate from a range of
surfaces, e.g. dedicated helipads, parking
areas, recreational parks and fields

Speed and distance

Fixed wing aircraft :

benefit from increased cruise speed
(from 300km/h for piston engine aircraft
to 850km/h for jet aircraft) and are best
suited for ranges of 2002000km.
They require prepared runways
necessitating road or helicopter
ambulance transfer between hospital
and airport at each end.

Environmental factors
Helicopter :
The internal noise levels are frequently >95dB(A) such that normal
conversation is impossible.
Auscultation is redundant, as is reliance on audible monitor alarms.
Intercom headsets are required for crew communication.
Earplugs are used for all patients regardless of conscious state to
reduce hearing damage.
Cabin lighting may be poor due to the dangers of distracting the
aircrew and adversely affecting pilot night vision.
Blue or red lighting may be used instead of white light, which may
make moni- tors, cyanosis, veins and patient movement difficult to
see.
Vibration is greatest at take-off and landing and may induce pain in
unstable fractures, and makes accurate adjustment of fluid infusion
rates difficult.

Environmental factors
Fixed wing flights :
Continuous noise, vibration, changes in temperature,
cramped space, ultraviolet radiation and time zone
changes contribute to high levels of fatigue.
Limited chance for rotation of medical personnel en
route may mean extended working hours; therefore,
appropriate rest periods prior to and after flights
should be scheduled in staff rosters.
Staff should ensure they are physically fit to fly, not
suffering from the effects of respiratory infections
and be under the residual effects of neither
medication nor alcohol.
Neither helicopters nor small fixed wing aircraft have
toilet facilities.

Fixed WIng
Axial tilt, acceleration and deceleration forces may be
significant during take-off, landing and extreme
turbulence in fixed wing aircraft.
Adverse effects on haemodynamics and ICP may result.
Altering patient orientation within the cabin during the
flight to attenuate these forces is impractical
Cabin heating may be poorly controlled or slow to
respond to changes in temperature. Staff must be
vigilant in moni- toring the patients temperature and
avoiding hypothermia, and ensure they also wear
suitable flight clothing.

Helicopter

Commercial Aircraft
Private Aircraft

What Happens During the

Trip..

OXYGEN

Daltons Law dictates that the partial pressure of oxygen

decreases with altitude.

OXYGEN
If necessary, the aircrew can be requested to provide sea level cabin
pressurization.
Typically this necessitates flying at altitudes of 20 000ft, which increases fuel
consumption.
Aside from COST implications, this may necessitate more frequent refuelling
stops, which will significantly increase journey time with roll-on implications for
patient safety, battery requirements, total oxygen requirements, fatigue, etc.
Adverse meteorological conditions may on occasion prevent flying at lower
altitude.

PRESSURES

PRESSURE

Consideration
should also be
given to splitting
orthopaedic casts.

Chest drains
should be inserted
where necessary
prior to departure
and left in situ for
the duration of
the flight.

All surgical drains

should be
unclamped and
patent.

ETT cuffs should

either be filled
with saline or
have their
pressure rigorously
checked and
adjusted in-flight.

Ensure pulmonary
artery catheter
balloons are fully
deflated.

At sea level, barometric pressure is approximately 760

mmHg. At 8,000 feet, that pressure drops to 565 mmHg, a
drop of 26%

Acceleration and gravitational

forces
The body is
exposed to
linear and
radial
acceleration
and
deceleration
forces

ng
uri r
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A ct ur rga en
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Tra
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This may lead to

venous pooling
in lower limbs
with fall cardiac
output with
tachycardia.
There may be
changes in
intracranial blood
volume and
pressure

The cardiovascular system of

critically ill patients is more
susceptible due to their
compromised physiological
reserves (hypovolemic, dilated
peripheral vasculature).

The effect of these

forces is greater
during take off and
landing

What it might be happened

(Adverse Event)

1. Cardiovascular : severe hypotension or

hypertension, arrhytmia, cardiac arrest.
2. Respiratory : hypoxia, aspiration,
accidental extubation,, bronchospasm,
patient ventilator dyssynchrony.
3. Neurological: agitation, intracranial
hypertension
4. Hypothermia

5.Technical failure : gas failure,

oxygen or IV disconnection, monitoring
equipment malfunction

6. Human Error : drug error, patient mix up

7. Non medical factor

Patient

Disease Complication

Age

Sex

Score

Survival

CVA

Hypertension

72

Yes

Prematr

Aspiration

Yes

Trauma

Shock

20

12

Yes

Trauma

Shock

19

16

Yes

Trauma

Shock

75

17

No

Trauma

Shock

35

12

Yes

Head tr/

Shock

36

Yes

Head tr/

Coma

18

12

Yes

Head tr/

Shock

19

11

Yes

10

Trauma

Shock

56

No

11

AMI

Shock

65

Yes

12

AMI

APO

58

No

13

CVA

Hypertension

59

12

Yes

14

CVA

Hypertension

60

15

Yes

SAFETY

The aircraft is an
unfamiliar environment
for most medical staff.

Safety of the patient

and aeromedical team
is paramount.

Staff must undergo

training in aeromedical
evacuation and an
orientation to the
equipment and aircraft,
with emphasis placed on
common aircraft
emergencies, emergency
evacuation procedures,
emergency depressurization,
communication procedures
and survival equipment.

The tail rotor and main

rotors of helicopters
can be lethal, and even
provide hazardous
obstacles when
motionless.

Underwater escape
training from a
helicopter simulator is
recommended where
flights may take place
over water.

SAFETY

Without proper training,

disorientation and
confusion are likely, and
the ability for staff to
provide the best patient
care will be adversely
affected.

A study examining the

ability of medical staff to
provide CPR to mannequins
during helicopter flight
showed significant
differences between those
who had undergone
training in aeromedical
evacuation and those who
had not.

No pressure must be put

on the aircrew to alter
their normal safety
procedures. The captain
has the final say on
whether the conditions are
suitable for flight, no
matter what the condition
of the patient.

Clinical governance
mechanisms should be in
place for reporting and
investigation of critical
incidents.

Military Medical Evacuation

Casualty Evacuation (CASEVAC)
The difference between CASEVAC and a MEDEVAC :,
MEDEVAC uses a standardized and dedicated vehicle
providing en route care
CASEVAC uses non standardized and non dedicated vehicles
that may or may not provide en route care

CONCLUSION
Inter-hospital transfer can be safe in the
hands of experts
RSTP seems effective in differentiating
critically ill patients prone to develop major
en route complication
Shock remains the most common problem
encountered during transportation
Well organized system with appropriate
equipment is crucial for safe IHT

THANK
YOU