Professional Documents
Culture Documents
Inter IntrahospitalTransport
Inter IntrahospitalTransport
Objective: The development of practice guidelines for the con- a) pretransport coordination and communication; b) transport
duct of intra- and interhospital transport of the critically ill pa- personnel; c) transport equipment; d) monitoring during transport;
tient. and e) documentation. The transport plan should be developed by
Data Source: Expert opinion and a search of Index Medicus a multidisciplinary team and should be evaluated and refined
from January 1986 through October 2001 provided the basis for regularly using a standard quality improvement process.
these guidelines. A task force of experts in the field of patient Conclusion: The transport of critically ill patients carries in-
transport provided personal experience and expert opinion. herent risks. These guidelines promote measures to ensure safe
Study Selection and Data Extraction: Several prospective and patient transport. Although both intra- and interhospital transport
clinical outcome studies were found. However, much of the pub- must comply with regulations, we believe that patient safety is
lished data comes from retrospective reviews and anecdotal enhanced during transport by establishing an organized, efficient
reports. Experience and consensus opinion form the basis of process supported by appropriate equipment and personnel. (Crit
much of these guidelines. Care Med 2004; 32:256 –262)
Results of Data Synthesis: Each hospital should have a for- KEY WORDS: intrahospital transport; interhospital transport; crit-
malized plan for intra- and interhospital transport that addresses ical care; health planning; policy making; monitoring; standards
T he decision to transport a crit- it may require transfer to another hospi- specially trained individuals. Since there
ically ill patient, either within tal. If a diagnostic test or procedural in- will almost certainly be situations when a
a hospital or to another facil- tervention under consideration is un- specialized team is not available for inter-
ity, is based on an assessment likely to alter the management or hospital transport, each referring and ter-
of the potential benefits of transport outcome of that patient, then the need tiary institution must develop contingency
weighed against the potential risks. Crit- for transport must be questioned. When plans using locally available resources for
ically ill patients are transported to alter- feasible and safe, diagnostic testing or those instances when the referring facility
nate locations to obtain additional care, simple procedures in unstable or poten- cannot perform the transport. A compre-
whether technical, cognitive, or proce- tially unstable patients often can be per- hensive and effective interhospital transfer
dural, that is not available at the existing formed at the bedside in the intensive plan can be developed using a systematic
location. Provision of this additional care care unit (1, 2). Financial considerations approach comprised of four critical ele-
may require patient transport to a diag- are not a factor when contemplating ments: a) A multidisciplinary team of phy-
nostic department, operating room, or moving a critically ill patient. sicians, nurses, respiratory therapists, hos-
specialized care unit within a hospital, or
Critically ill patients are at increased pital administration, and the local
risk of morbidity and mortality during emergency medical service is formed to
transport (3–17). Risk can be minimized plan and coordinate the process; b) the
*See also p. 305. and outcomes improved with careful team conducts a needs assessment of the
From Northwest Community Hospital, Arlington
Heights, IL (JW); Baylor College of Medicine, Houston, TX
planning, the use of appropriately quali- facility that focuses on patient demograph-
(REF); Children’s Hospital of Pittsburgh, University of Pitts- fied personnel, and selection and avail- ics, transfer volume, transfer patterns, and
burgh School of Medicine, Pittsburgh, PA (RAO); Subur- ability of appropriate equipment (16 –37). available resources (personnel, equipment,
ban Hospital, Bethesda, MD (LCR); Henry Ford Hospital, During transport, there is no hiatus in emergency medical service, communica-
Detroit, MI (HMH).
These guidelines have been developed by the Amer- the monitoring or maintenance of a pa- tion); c) with this data, a written standard-
ican College of Critical Care Medicine and the Society of tient’s vital functions. Furthermore, the ized transfer plan is developed and imple-
Critical Care Medicine. These guidelines reflect the official accompanying personnel and equipment mented; and d) the transfer plan is
opinion of the Society of Critical Care Medicine and do not are selected by training to provide for any evaluated and refined regularly using a
necessarily reflect, and should not be construed to reflect,
the views of certification bodies, regulatory agencies, or ongoing or anticipated acute care needs standard quality improvement process.
other medical review organizations. of the patient. This document outlines the minimum
Copyright © 2004 by Lippincott Williams & Wilkins Ideally, all critical care transports, both recommendations for transport of the
DOI: 10.1097/01.CCM.0000104917.39204.0A inter- and intrahospital, are performed by critically ill patient. Detailed guidelines
INTERHOSPITAL TRANSPORT
Patient outcomes depend to a large
degree on the technology and expertise of
personnel available within each health-
care facility. When services are needed
that exceed available resources, a patient
ideally will be transferred to a facility that
has the required resources (45). Interho-
spital patient transfers occur when the
benefits to the patient exceed the risks of
the transfer. A decision to transfer a pa-
tient is the responsibility of the attending
physician at the referring institution.
Once this decision has been made, the
transfer is effected as soon as possible.
When needed, resuscitation and stabiliza-
tion will begin before the transfer (46,
47), realizing that complete stabilization
may be possible only at the receiving fa-
cility.
In the United States, it is essential for
practitioners to be aware of federal and
state laws regarding interhospital patient
transfers. The Emergency Medical Treat-
ment and Active Labor Act (EMTALA)
laws and regulations (updated at intervals
from the 1986 COBRA laws and the 1990
OBRA amendment) define in detail the
legal responsibilities of the transferring
and receiving facilities and practitioners.
The American College of Emergency Phy-
sicians has published a book (48) that
reviews the legal responsibilities of refer-
Figure 1. Interfacility transfer algorithm.
ring institutions as well as the ramifica-
tions of noncompliance with the COBRA/
EMTALA regulations, and it is an informed consent before interhospital ferring physician always writes an order
excellent resource for any facility in- transfer. The informed consent process for transfer in the medical record.
volved in patient transfers. In general, includes a discussion of the risks and Several elements are included in the
under COBRA/EMTALA, financially moti- benefits of transfer. These discussions are process of interhospital transfer, and all
vated transfers are illegal and put both documented in the medical record before fall within minimum guidelines, as de-
the referring institution and the individ- transfer. A signed consent should be ob- scribed subsequently. It is important to
ual practitioner at risk for serious penalty tained, if possible. If circumstance do not recognize that these process elements
(49, 50). allow for the informed consent process may frequently, and out of necessity, be
Current regulations and good medical (e.g., life-threatening emergency), then implemented simultaneously, espe-
practice require that a competent patient, both the indications for transfer and the cially when stabilization and treatment
guardian, or the legally authorized repre- reason for not obtaining consent are doc- are needed before transfer. An algo-
sentative of an incompetent patient give umented in the medical record. The re- rithm has been developed to guide prac-
A
Adenosine, 6 mg/2 mL lthough both in-
Albuterol, 2.5 mg/2 mL
Amiodarone, 150 mg/3 mL tra- and interhos-
Atropine, 1 mg/10 mL
Calcium chloride, 1 g/10 mL pital transport
Cetacaine/Hurricaine spray
Dextrose 25%, 10 mL
Dextrose 50%, 50 mL
must comply with regula-
Digoxin, 0.5 mg/2 mL
Diltiazem, 25 mg/5 mL tions, we believe patient
Diphenhydramine, 50 mg/1 mL
Dopamine, 200 mg/5 mL safety is enhanced during
Epinephrine, 1 mg/10 mL (1:10,000)
Epinephrine, 1 mg/1 mL (1:1000) multiple-dose vial transport by establishing an
Fosphenytoin, 750 mg/10 mL (500 PE mg/10 mL)
Furosemide, 100 mg/10 mL organized efficient process
Glucagon, 1 mg vial (powder)
Heparin, 1000 units/1 mL supported by appropriate
Isoproterenol, 1 mg/5 mL
Labetalol, 40 mg/8 mL equipment and personnel.
Lidocaine, 100 mg/10 mL
Lidocaine, 2 g/10 mL
Mannitol, 50 g/50 mL
Magnesium sulfate, 1 g/2 mL
Methylprednisolone, 125 mg/2 mL bles 1 and 2 provide a detailed list of the
Metoprolol, 5 mg/5 mL minimum recommended equipment and
Naloxone, 2 mg/2 mL pharmaceuticals needed for safe interho-
Nitroglycerin injection, 50 mg/10 mL spital transport. Emphasis is placed on
Nitroglycerin tablets, 0.4 mg (bottle)
Nitroprusside, 50 mg/2 mL airway and oxygenation, vital signs mon-
Normal saline, 30 mL for injection itoring, and the pharmaceutical agents
Phenobarbital, 65 mg/mL or 130 mg/mL necessary for emergency resuscitation
Potassium chloride, 20 mEq/10 mL and stabilization as well as maintenance
Procainamide, 1000 mg/10 mL
of vital functions. Very short or very long
Sodium bicarbonate, 5 mEq/10 mL
Sodium bicarbonate, 50 mEq/50 mL transports may necessitate deviations
Sterile water, 30 mL for injection from the listed items, depending on the
Terbutaline, 1 mg/1 mL severity and nature of illness or injury.
Verapamil, 5 mg/2 mL Furthermore, advances in knowledge
over time will result in periodic review
The following specialized/controlled medications are added immediately before transport as
indicated and modification of these lists. All items
Narcotic analgesics (e.g., morphine, fentanyl) (59) are checked regularly for expiration of
Sedatives/hypnotics (e.g., lorazepam, midazolam, propofol, etomidate, ketamine) (59) sterility and/or potency, especially when
Neuromuscular blocking agents (e.g. succinylcholine, pancuronium, atracurium, rocuronium) transports are infrequent. Equipment
(60) function is verified on a scheduled basis,
Prostaglandin E1
Pulmonary surfactant not at the time of transport when there
may be insufficient time to find replace-
ments.
Monitoring During Transport. All crit-
communicated verbally. It is strongly ities of advanced airway management, in- ically ill patients undergoing interhospi-
suggested that policies be established travenous therapy, dysrhythmia interpre- tal transport must have, at a minimum,
within each institution regarding the tation and treatment, and basic and continuous pulse oximetry, electrocar-
content of documentation and communi- advanced cardiac life support. In the ab- diographic monitoring, and regular mea-
cation between personnel involved in the sence of a physician team member, there surement of blood pressure and respira-
transfer. will be a mechanism by which the trans- tory rate.* Selected patients, based on
Accompanying Personnel. It is recom- port team can communicate with a com- clinical status, may benefit from the
mended that a minimum of two people, mand physician. If communication of monitoring of intra-arterial blood pres-
in addition to the vehicle operators, ac- this type becomes impossible, the team sure (55), central venous pressure, pul-
company a critically ill patient during will have preauthorization by standing monary artery pressure, intracranial
interhospital transport.* When trans- orders to perform acute lifesaving inter- pressure, and/or capnography (56). With
porting unstable patients, the transport ventions. In the absence of a readily avail- mechanically ventilated patients, endo-
team leader should be a physician or able external transport team, a transport tracheal tube position is noted and se-
nurse (41, 53, 54), preferably with addi- team and vehicle may need to be assem- cured before transport, and the adequacy
tional training in transport medicine. For bled locally. The development of policies of oxygenation and ventilation is recon-
critical but stable patients, the team and procedures for such emergencies is firmed.
leader may be a paramedic (41). These strongly recommended. Occasionally, patients may require
individuals provide the essential capabil- Minimum Equipment Required. Ta- specialized modes of ventilation not re-