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Guidelines for the inter- and intrahospital transport of critically ill patients

Guidelines for the inter- and intrahospital transport of critically ill patients

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Special Articles
Guidelines for the inter- and intrahospital transport of critically illpatients*
Jonathan Warren, MD, FCCM, FCCP; Robert E. Fromm Jr, MD, MPH, MS; Richard A. Orr, MD;Leo C. Rotello, MD, FCCM, FCCP, FACP; H. Mathilda Horst, MD, FCCM; American College of Critical CareMedicine
he decision to transport a crit-ically ill patient, either withina hospital or to another facil-ity, is based on an assessmentof the potential benefits of transport weighed against the potential risks. Crit-ically ill patients are transported to alter-nate locations to obtain additional care, whether technical, cognitive, or proce-dural, that is not available at the existinglocation. Provision of this additional caremay require patient transport to a diag-nostic department, operating room, orspecialized care unit within a hospital, orit may require transfer to another hospi-tal. If a diagnostic test or procedural in-tervention under consideration is un-likely to alter the management oroutcome of that patient, then the needfor transport must be questioned. Whenfeasible and safe, diagnostic testing orsimple procedures in unstable or poten-tially unstable patients often can be per-formed at the bedside in the intensivecare unit (1, 2). Financial considerationsare not a factor when contemplatingmoving a critically ill patient.Critically ill patients are at increasedrisk of morbidity and mortality duringtransport (3–17). Risk can be minimizedand outcomes improved with carefulplanning, the use of appropriately quali-fied personnel, and selection and avail-ability of appropriate equipment (16–37).During transport, there is no hiatus inthe monitoring or maintenance of a pa-tient’s vital functions. Furthermore, theaccompanying personnel and equipmentare selected by training to provide for anyongoing or anticipated acute care needsof the patient.Ideally, all critical care transports, bothinter- and intrahospital, are performed byspecially trained individuals. Since there will almost certainly be situations when aspecialized team is not available for inter-hospital transport, each referring and ter-tiary institution must develop contingencyplans using locally available resources forthose instances when the referring facilitycannot perform the transport. A compre-hensive and effective interhospital transferplan can be developed using a systematicapproach comprised of four critical ele-ments: a) A multidisciplinary team of phy-sicians, nurses, respiratory therapists, hos-pital administration, and the localemergency medical service is formed toplan and coordinate the process; b) theteam conducts a needs assessment of thefacility that focuses on patient demograph-ics, transfer volume, transfer patterns, andavailable resources (personnel, equipment,emergency medical service, communica-tion); c) with this data, a written standard-ized transfer plan is developed and imple-mented; and d) the transfer plan isevaluated and refined regularly using astandard quality improvement process.This document outlines the minimumrecommendations for transport of thecritically ill patient. Detailed guidelines
*See also p. 305.
From Northwest Community Hospital, ArlingtonHeights, IL (JW); Baylor College of Medicine, Houston, TX(REF); Children’s Hospital of Pittsburgh, University of Pitts-burgh School of Medicine, Pittsburgh, PA (RAO); Subur-ban Hospital, Bethesda, MD (LCR); Henry Ford Hospital,Detroit, MI (HMH).These guidelines have been developed by the Amer-ican College of Critical Care Medicine and the Society ofCritical Care Medicine. These guidelines reflect the officialopinion of the Society of Critical Care Medicine and do notnecessarily reflect, and should not be construed to reflect,the views of certification bodies, regulatory agencies, orother medical review organizations.Copyright © 2004 by Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0000104917.39204.0A
The development of practice guidelines for the con-duct of intra- and interhospital transport of the critically ill pa-tient.
Data Source: 
Expert opinion and a search of Index Medicusfrom January 1986 through October 2001 provided the basis forthese guidelines. A task force of experts in the field of patienttransport provided personal experience and expert opinion.
Study Selection and Data Extraction: 
Several prospective andclinical outcome studies were found. However, much of the pub-lished data comes from retrospective reviews and anecdotalreports. Experience and consensus opinion form the basis ofmuch of these guidelines.
Results of Data Synthesis: 
Each hospital should have a for-malized plan for intra- and interhospital transport that addressesa) pretransport coordination and communication; b) transportpersonnel; c) transport equipment; d) monitoring during transport;and e) documentation. The transport plan should be developed bya multidisciplinary team and should be evaluated and refinedregularly using a standard quality improvement process.
The transport of critically ill patients carries in-herent risks. These guidelines promote measures to ensure safepatient transport. Although both intra- and interhospital transportmust comply with regulations, we believe that patient safety isenhanced during transport by establishing an organized, efficientprocess supported by appropriate equipment and personnel. (CritCare Med 2004; 32:256–262)
: intrahospital transport; interhospital transport; crit-ical care; health planning; policy making; monitoring; standards
256 Crit Care Med 2004 Vol. 32, No. 1
targeted to the transport of infants andchildren have been published by the American Academy of Pediatrics (23). In-stitutions performing commercial or or-ganized interhospital transports are re-quired to function at and meet a higherstandard, as the requirements for orga-nized transport services are considerablymore rigorous than the recommenda-tions in this guideline (24, 38
41).The references for this guideline wereobtained from a review of Index Medicus(see key words) from January 1986through October 2001 and are catego-rized according to the degree of evidence-based data employed. The speci
c cate-gory assigned to each reference is notedin the References at the end of this arti-cle. The letter
denotes a randomized,prospective controlled investigation;
denotes a nonrandomized, concurrent, orhistorical cohort investigation;
denotesa peer-reviewed
article,review article, editorial, or substantialcase series; and
denotes a non-peer-reviewed opinion such as a textbookstatement or of 
cial organizational pub-lication. The asterisk symbol will follow astatement of practice standards. This in-dicates a recommendation by the Ameri-can College of Critical Care Medicine thatis based on expert opinion and is used incircumstances where published support-ing data are unavailable.
Because the transport of critically illpatients to procedures or tests outsidethe intensive care unit is potentially haz-ardous, the transport process must beorganized and ef 
cient. To provide forthis, at least four concerns need to beaddressed through written intensive careunit policies and procedures: communi-cation, personnel, equipment, and moni-toring.
 Pretransport Coordination and Com- munication.
When an alternate team at areceiving location will assume manage-ment responsibility for the patient afterarrival, continuity of patient care will beensured by physician-to-physician and/ornurse-to-nurse communication to reviewpatient condition and the treatment planin operation. This communication occurseach time patient care responsibility istransferred. Before transport, the receiv-ing location con
rms that it is ready toreceive the patient for immediate proce-dure or testing. Other members of thehealthcare team (e.g., respiratory ther-apy, hospital security) then are noti
ed asto the timing of the transport and theequipment support that will be needed.The responsible physician is made awareof the transport. Documentation in themedical record includes the indicationsfor transport and patient status through-out the time away from the unit of origin.
 Accompanying Personnel.
It isstrongly recommended that a minimum of two people accompany a critically ill pa-tient.* One of the accompanying personnelis usually a nurse who has completed acompetency-based orientation and has metpreviously described standards for criticalcare nurses (42, 43). Additional personnelmay include a respiratory therapist, regis-tered nurse, or critical care technician asneeded. It is strongly recommended that aphysician with training in airway manage-ment and advanced cardiac life support,and critical care training or equivalent, ac-companyunstablepatients.*Whenthepro-cedure is anticipated to be lengthy and thereceiving location is staffed by appropri-atelytrainedpersonnel, patientcaremaybetransferred to those individuals if accept-able to both parties. This allows for maxi-mum utilization of staff and resources. If care is not transferred, the transport per-sonnel will remain with the patient untilreturned to the intensive care unit.
 Accompanying Equipment.
A bloodpressure monitor (or standard bloodpressure cuff), pulse oximeter, and car-diac monitor/de
brillator accompany ev-ery patient without exception.* Whenavailable, a memory-capable monitor with the capacity for storing and repro-ducing patient bedside data will allow re- view of data collected during the proce-dure and transport. Equipment for airwaymanagement, sized appropriately foreach patient, is also transported witheach patient, as is an oxygen source of ample supply to provide for projectedneeds plus a 30-min reserve.Basic resuscitation drugs, includingepinephrine and antiarrhythmic agents,are transported with each patient in theevent of sudden cardiac arrest or arrhyth-mia. A more complete array of pharma-cologic agents either accompanies the ba-sic agents or is available from supplies(
crash carts
) located along the trans-port route and at the receiving location.Supplemental medications, such as seda-tives and narcotic analgesics, are consid-ered in each speci
c case. An ample sup-ply of appropriate intravenous
uids andcontinuous drip medications (regulatedby battery-operated infusion pumps) isensured. All battery-operated equipmentis fully charged and capable of function-ing for the duration of the transport. If aphysician will not be accompanying thepatient during transport, protocols mustbe in place to permit the administrationof these medications and
uids by appro-priately trained personnel under emer-gency circumstances.In many hospitals, pediatric patientsshare diagnostic and procedural facilities with adult patients. Under these circum-stances, a complete set of pediatric resus-citation equipment and medications willaccompany infants and children duringtransport and also will be available in thediagnostic or procedure area.For practical reasons, bag-valve venti-lation is most commonly employed dur-ing intrahospital transports. Portable me-chanical ventilators are gainingincreasing popularity in this arena, asthey more reliably administer prescribedminute ventilation and desired oxygenconcentrations. In adults and children, adefault oxygen concentration of 100%generally is used. However, oxygen con-centration must be precisely regulatedfor neonates and for those patients withcongenital heart disease who have single ventricle physiology or are dependent ona right-to-left shunt to maintain systemicblood
ow. For patients requiring me-chanical ventilation, equipment is opti-mally available at the receiving locationcapable of delivering ventilatory supportequivalent to that being delivered at thepatient
s origin. In mechanically venti-lated patients, endotracheal tube positionis noted and secured before transport,and the adequacy of oxygenation and ven-tilation is recon
rmed. Occasionally pa-tients may require modes of ventilationor ventilator settings not reproducible atthe receiving location or during transpor-tation. Under these circumstances, theorigin location must trial alternatemodes of mechanical ventilation beforetransport to ensure acceptability and pa-tient stability with this therapy. If thepatient is incapable of being maintainedsafely with alternate therapy, the risksand bene
ts of transport are cautiouslyreexamined. If a transport ventilator is tobe employed, it must have alarms to in-dicate disconnection and excessively highairway pressures and must have a backupbattery power supply.*
 Monitoring During Transport.
All crit-ically ill patients undergoing transportreceive the same level of basic physiologicmonitoring during transport as they had
257Crit Care Med 2004 Vol. 32, No. 1
in the intensive care unit. This includes,at a minimum, continuous electrocardio-graphic monitoring, continuous pulseoximetry (44), and periodic measurementof blood pressure, pulse rate, and respi-ratory rate. In addition, selected patientsmay bene
t from capnography, continu-ous intra-arterial blood pressure, pulmo-nary artery pressure, or intracranial pres-sure monitoring. There may be specialcircumstances that warrant intermittentcardiac output or pulmonary artery oc-clusion pressure measurements.
Patient outcomes depend to a largedegree on the technology and expertise of personnel available within each health-care facility. When services are neededthat exceed available resources, a patientideally will be transferred to a facility thathas the required resources (45). Interho-spital patient transfers occur when thebene
ts to the patient exceed the risks of the transfer. A decision to transfer a pa-tient is the responsibility of the attendingphysician at the referring institution.Once this decision has been made, thetransfer is effected as soon as possible. When needed, resuscitation and stabiliza-tion will begin before the transfer (46,47), realizing that complete stabilizationmay be possible only at the receiving fa-cility.In the United States, it is essential forpractitioners to be aware of federal andstate laws regarding interhospital patienttransfers. The Emergency Medical Treat-ment and Active Labor Act (EMTALA)laws and regulations (updated at intervalsfrom the 1986 COBRA laws and the 1990OBRA amendment) de
ne in detail thelegal responsibilities of the transferringand receiving facilities and practitioners.The American College of Emergency Phy-sicians has published a book (48) thatreviews the legal responsibilities of refer-ring institutions as well as the rami
ca-tions of noncompliance with the COBRA/ EMTALA regulations, and it is anexcellent resource for any facility in- volved in patient transfers. In general,under COBRA/EMTALA,
nancially moti- vated transfers are illegal and put boththe referring institution and the individ-ual practitioner at risk for serious penalty(49, 50).Current regulations and good medicalpractice require that a competent patient,guardian, or the legally authorized repre-sentative of an incompetent patient giveinformed consent before interhospitaltransfer. The informed consent processincludes a discussion of the risks andbene
ts of transfer. These discussions aredocumented in the medical record beforetransfer. A signed consent should be ob-tained, if possible. If circumstance do notallow for the informed consent process(e.g., life-threatening emergency), thenboth the indications for transfer and thereason for not obtaining consent are doc-umented in the medical record. The re-ferring physician always writes an orderfor transfer in the medical record.Several elements are included in theprocess of interhospital transfer, and allfall within minimum guidelines, as de-scribed subsequently. It is important torecognize that these process elementsmay frequently, and out of necessity, beimplemented simultaneously, espe-cially when stabilization and treatmentare needed before transfer. An algo-rithm has been developed to guide prac-
Figure 1.
Interfacility transfer algorithm.
258 Crit Care Med 2004 Vol. 32, No. 1

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