CRITICAL ILLNESS AND INTENSIVE CARE - I
Transfer of the critically ill
adult patient
David Hunt
Abstract
Patient transfer has both resource ramifications and is an important
public health issue. With increasing centralization of specialist services
and the advent of regional trauma networks, the requirement for pa-
tient transfer is ever present. Every year in the UK over 11,000 inten-
sive care patients are transferred and the majority of these transfers
are facilitated by a team from the transferring hospital. Transferring a
critically ill patient is a process involving inherent risk. It follows that
prior preparation around planning for a safe transfer is essential,
both in terms of anticipating potential problems, mitigating against
them and ensuring clear and timely communication with the accepting
hospital and respective specialties responsible for the patient. In the
longer term, training of staff is essential in order to reduce instances
of harm to patients. Medical transfers must be the subject of further
research in order to consolidate best practice and improve our under-
standing of patient safety during transfer. This article provides an over-
view of the different types of patient transfer, the associated hazards,
human factors around decision making, communication, equipment
and organization.
Keywords Communication; equipment; governance; interhospital
transfer; risks; transfer
Introduction
The requirement for patient transfer is an inevitable consequence
of the centralization of acute services and increased utilization of
highly specialized services such as extracorporeal membrane
oxygenation (ECMO). Rarely, transfers can occur for logistic rea-
sons if locally available resources are exhausted or temporarily
unavailable, but this should of course be avoided unless abso-
lutely necessary as it is clearly not in the best interests of a patient
to undergo a potentially avoidable transfer. The over arching aim
of the vast majority of transfers should be to achieve a higher level
of care for the patient. The benefit of transfer for specialized
treatment is well established for trauma and cardiology patients
but it has taken a long time to achieve widespread acceptance of
this in the UK, particularly with regards to the former patient
group. It has also been demonstrated that the benefits of transfer
to a specialist center are not always related to receiving the
intervention for which the transfer was initiated.1 The transfer
team strives to ensure that the care a patient receives in transit is
equal to that they receive in intensive care. Taking into consid-
eration the objective risks of transporting a critically unwell pa-
tient, this is often difficult to achieve and requires an experienced
David Hunt MBBS FRCA FFICM MRCEM Dip IMC RCSEd PGCert (Mtn Med) FRGS
is a Consultant in Anaesthetics and Intensive Care Medicine at
Frimley Park Hospital and Defence Medical Services, Lt Col RAMC,
UK. Conflicts of interest: none declared.
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Please cite this article in press as: Hunt D, Transfer of the critically ill adult patient, Surgery (2018), https://doi.org/10.1016/j.mpsur.2018.01.005
and well- trained transfer team as a starting point. In the UK a
significant number of transfers are carried out by junior anaes-
thetists who will typically have received limited transfer training
and will often have little in the way of transfer experience. This
has both patient safety and resource implications.
Types of transfer
There are three main subcategories of patient transfer:
1. Primary transfer to hospital is normally undertaken by land
ambulance crews. For trauma patients who warrant a
response from a helicopter emergency medical crew (HEMs).
this phase may involve critical care interventions and trans-
port by helicopter with an advanced medical practitioner.
2. Following initial resuscitation and stabilization, secondary
transfer occurs when specialist care is required and not
available locally. This would normally occur by land
ambulance. A helicopter or fixed wing aircraft could be uti-
lized depending on the distance involved, weather, urgency,
traffic and the location of suitable landing sites among other
factors. There are long-standing guidelines available for the
transfer of patients via aeromedical means.2,3 A secondary
transfer may also have to occur if locally available resources
become overwhelmed or are temporarily unavailable.
3. Tertiary transfers occur for non-clinical reasons and should
be avoided unless absolutely necessary. This group generally
comprises patients wishing to be repatriated for social rea-
sons, such as being closer to friends and family but also
includes those who are injured abroad and need to be
repatriated to the UK.
Transfers can be further subdivided into two categories,
intrahospital and interhospital. This article will focus only on
interhospital transfer, although the same guiding principles will
apply to intrahospital transfers.
Decision making and human factors
Clear communication is required early on in the process of
transfer; disjointed planning and communication is sadly a
common occurrence during patient transfers leading to adverse
incidents. To help avoid this, it is essential that consultants are
involved in interhospital ITU transfers. It has already been said
that a transfer should only occur if it is likely to result in an
improvement in the patient’s overall condition. It is vital that the
risks and the benefits are balanced by an experienced clinician
with advice from the receiving specialists. The reason for the
transfer should be established and if it is for anything other than
an improvement in patient care, then this becomes at least in part
an ethical decision that should be clearly communicated to the
patient, if they have capacity, and their family.
After the decision to transfer has been made, delays and
complex organizational issues can occur. One study from
Australia has demonstrated on average 4.7 phone calls are
required to be made per patient, which when one considers the
requirement for concurrent patient resuscitation is a significant
burden of responsibility.4
Where is the patient going? This point is critical and must be
clearly articulated between the transfer team and the receiving
hospital. The resuscitation room of the emergency department
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 CRITICAL ILLNESS AND INTENSIVE CARE - I
should ideally be avoided, but it does provide possibilities for
stabilization should the patient have deteriorated prior to onward
movement. There should be no delay in transfer to an area for
definitive treatment such as a specialist intensive care unit or
operating theatre. All parties must be clear about the exact
destination, requiring an accurate description of the location to
be communicated to all parties including the patient’s family.
The receiving hospital should be made aware when the patient
leaves, updated with regards to any issues that occur in transit
and informed prior to the patient arrival with an estimated time
of arrival to allow for such tasks as a trauma call to be put out or
specialists to be summoned to theatre.
Organization of the transfer
It is useful to refer to a checklist or mnemonic in order to mitigate
against pivotal steps in the process being missed. It has repeat-
edly been demonstrated that human factors, particularly around
communication and other organizational issues, result in safety
incidents and adopting this type of protocolized management
helps to reduce avoidable incidents. The ACCEPT mnemonic
provides a useful handrail: AdAssessment, CdControl,
CdCommunication, EdEvaluation, PdPreparation, packaging,
and pre-departure checks, TdTransport.
The Association of Anaesthetists of Great Britain and Ireland
and the Intensive Care Society have produced useful pre-
departure checklists which can be viewed online.5,6 The
following list is adapted from both sources.
 Is the transfer agreed by ITU consultants at both the
receiving and transferring hospitals?
 Is the transfer agreed by both the receiving and trans-
ferring surgical/medical consultant?
 Is the receiving nurse in charge of ITU aware of the patient
being transferred?
 Are the patient (if possible) and their family aware?
 Is the patient resuscitated and stable for transfer and is
intubation indicated as part of an expectant management
strategy?
 What is the urgency and the most suitable type of transport
to request?
 Is the level of experience and composition of the transfer
team appropriate?
 Have the patient’s eyes and pressure points been
protected?
 Has the ventilator and transfer bag been checked?
 Is there a sufficient supply of oxygen and batteries for the
journey?
 Are AAGBI minimum monitoring standards being adhered
to including capnography?
 Transfer bagged checked?
 Appropriate drugs?
 Documentation: letter/notes/X-rays (image linked if
possible)/blood results and drug chart.
 Cross matched blood and blood products, if indicated
 Do the transfer team have appropriate personnel protective
equipment?
 Do the transfer team have money/bank cards/mobile
phone?
 Call to inform the receiving hospital prior to departure.
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 Perform an arterial blood gas 15 minutes before departure
and check the patient is adequately resuscitated before
departure.
To transfer or retrieve?
Retrieval teams are advocated by the Department of Health. A
team from University College London compared outcomes of
patients transferred by a specialist retrieval team (group A) and
those transferred by standard means, a team from the referring
hospital (group B). There were no difference in demographic
characteristics or severity of illness between the two groups;
however, significantly more patients in group B than in group A
were severely acidotic (pH < 7.1: 11% vs 3%, p < 0.008) and
hypotensive (MAP < 60: 18 % vs 9%, p < 0.03) on arrival. There
were more deaths within the first 12 hours after admission with
7.7 % deaths (7/91) in group B transfers versus 3% (5/168) in
group A.7 A university hospital in the Netherlands conducted a
prospective study comparing patient physiology in those patients
transferred by their newly established mobile critical care unit
(MICU) with prospectively collected data on patients transferred
by ambulance in 2005 in the same region. Distribution of dif-
ferences in arterial blood gases during transfer in 2009 versus
2005 showed significantly better values for the variables pH,
paO2 and paCO2 in the patient group transferred by MICU, using
the independent-samples t-test (a < 0.05). There was also a
significant increase in the number of patients who were trans-
ferred conventionally that required emergent advanced respira-
tory support immediately on arrival in the receiving ITU.8 The
retrieval model has a much stronger body of evidence for the
transport of paediatric patients and is much more widely prac-
ticed and it would seem intuitive that at least some of this
experience should be transferable to adult patients.
What is the urgency?
The national ambulance services clinical conveyance group inter-
hospital transfer protocol 2011 sets out guidance for patient prior-
itization. Those patients that are deemed to require an immediate
time critical life saving intervention are classed as priority 1 and
transport should arrive within 8 minutes. Those that require a life-
or limb-saving treatment are priority 2 and should be transferred in
less than 1 hour. Priority 3 patients have a clinical reason for
transfer but do not fall into either of the previous two categories and
transport should arrive in less than 4 hours. For those patients being
transferred for non-clinical reasons <8 hours is the set target.
Close attention to detail during the preparation phase is
paramount. A study from Canada found that a longer time spent
preparing the patient for transfer was associated with a shorter
ITU admission. It is important to re-emphasize that some trans-
fers are ‘time critical’ as patients still arrive at the ‘wrong’ hos-
pital and need to be transferred rapidly to receive life or limb
saving treatment.
Personnel and patient dependency
The use of patient categorization can be a useful communication
tool but is open to variable interpretation. In the UK critical care
patients are categorized as level 1, 2 or 3. The characteristics of
each respective group can be seen in Table 1.
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 CRITICAL ILLNESS AND INTENSIVE CARE - I
In adherence with the Intensive Care Society guidelines, all
critically ill patients should be accompanied by two experienced
and suitably trained staff. The exact team composition depends
on the clinical condition of the patient, the mode of transport
used and the likely duration of the transfer. Generally speaking,
most level 1 patients and a select group of stable level 2 patients
can be transferred with a nurse and paramedic or ambulance
technician escort. Some level 2 patients will require a nurse and a
medical escort from the sending team. The remaining patients
are those deemed most at risk and consist predominantly of level
3 patients but some level 2 patients. The latter group is poten-
tially very vulnerable and require a thorough risk assessment to
be made prior to leaving hospital as the potential for deteriora-
tion requiring an advanced critical care intervention to be per-
formed en route such as intubation exists, which is obviously
highly undesirable! A risk assessment of the patient utilizing an
early warning score system is recommended by the Intensive
Care Society and is used by some trusts in the UK.
Risks of transfer
The National Confidential Enquiry into Patient Outcome and
Death (NCEPOD) 2007 outlined the risks associated with patient
transport. By definition, all patients who are being transferred
are at risk from the pathology driving their critical illness. Pre-
vious studies have suggested that patient transfer is indepen-
dently associated with both a longer ITU stay and an increase in
mortality. There is a large body of evidence that also confirms
that interhospital transfer is associated with other measures of
patient harm and this is probably illustrated most clearly in the
head- injured population in whom adverse events during transfer
have long been known to worsen outcome and result in an
increased incidence and severity of secondary brain injury.
Hazards affecting staff are mainly related to the risk of road
traffic collisions and movement of unsecured equipment within
the vehicle. Data from the UK suggests a total of 300e400 crashes
involving a land ambulance per year, with up to 10 fatalities
annually.9 All staff should wear the correct personnel protective
UK critical care dependency levels
Level 0 Patients whose needs can be met by normal
ward care
Level 1 Patients recently stepped down from a higher
level of care, or those at risk of deteriorating
whose needs can be met on an acute ward
with support if required from a critical care
outreach service
Level 2 Patients requiring closer observation and or
intervention including support for a single
failing organ system. Those stepped down
from level three care
Level 3 Patients who are intubated or who require
basic respiratory support with two other organ
systems requiring support
Table 1
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equipment and ensure they have an adequate supply of food and
water. They should also ensure they have money or a bank card
to avoid the risk of being stranded as the ambulance may receive
another tasking.
Specific dangers to patients include the following:
Airway
Airway compromise due to:
 deteriorating conscious level
 progression of facial swelling caused by burns, angioe-
dema or haematoma
 obstruction of an endotracheal tube due to kinking or
secretions
 displacement of the endotracheal tube into the right main
bronchus (most commonly) or out of the trachea.
Breathing
 Equipment failure (either faulty or electrical supply failure)
 Failure of the oxygen supply.
 Worsening of chest pathology, ARDS, blossoming contu-
sions and accumulating haemothorax/expanding
pneumothorax.
 Fat embolization in patients with multiple long bone
fractures due to movement.
 Unidentified pulmonary embolus.
 Chest drain blockage commonly due to kinking and chest
drain removal.
Transferring staff should ensure that end tidal CO2 monitoring
is in place and that the discrepancy between the end tidal CO2
and the arterial CO2 is known prior to transfer to aid with deci-
sion making around alterations to ventilation.
Circulation
 Removal or blockage of lines.
 Difficulty in accessing intravenous lines due to limbs being
tightly packaged.
 Loss of invasive blood pressure measurement.
 Unidentified bleeding due to tight packaging of the patient.
 Hypotension due to fluid shifts as a result of acceleration
and deceleration forces.
Disability
 Pain due to poorly protected pressure areas resulting nerve
injuries.
 Inadequate sedation levels or running out of sedation.
 Reduction in cerebral perfusion pressure due to hypoten-
sion of any cause or raised intracranial pressure due to
impaired venous drainage, hypercapnia, hypoxia, cough-
ing or gagging caused by inadequate sedation.
 Venous drainage adversely affected by poor positioning.
 Damage to hearing due to lack of ear protection.
Environment and metabolism
 Hypothermia leading to coagulation issues and further
bleeding and increased cerebral metabolic rate due to
shivering if not adequately paralysed.
 Poor glucose control.
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 CRITICAL ILLNESS AND INTENSIVE CARE - I
 Trauma caused by road traffic collisions, movement of
improperly secured equipment or by the patient or transfer
team not being appropriately restrained in the vehicle.
 Movement artifact affecting non-invasive and invasive
monitoring.
 Difficulty clinically assessing a patient due to background
noise, movement and restricted assess to the patient.
Should the requirement to perform an intervention arise
the ambulance should be stopped, under no circumstances
should seat belts be removed in a moving vehicle.
Aeromedical transfer risks
Aeromedical transfers should be undertaken only by those with
advanced knowledge and skills in this field. However, an un-
derstanding of the risks presented is vital for those preparing
patients for transfer by air. A total of 13 accidents or serious
incidents involving HEMS aircraft have been reported to the Civil
Aviation Authority since the start of air ambulance operations in
the UK in 1987.10 As such, aeromedical transfer should only take
place if it is absolutely necessary.
 Motion sickness: Patients and staff may need pre-medica-
tion with an antiemetic.
 Engine noise and vibration leads to the risk of hearing
damage to patients and staff.
 Reduction in atmospheric pressure leading to a reduction
of the partial pressure of oxygen necessitating an increase
in Fio2 to prevent hypoxia. Expansion of air-filled spaces
such as pneumothorax, pneumoperitoneum and pneumo-
cranium. Civilian and military transport aircraft are nor-
mally pressurized to between 6000 and 8000 feet, which
can result in a 20% increase in the volume of a given gas.
 Tissue swelling can occur which requires the splitting of
plaster casts.
 Reduction in temperature and humidity.
The risks of transfer are not confined to those concerning
patient morbidity and mortality there is also the very real risk of
emotional stress caused to both the patient and their family
particularly if the transfer results in greater travel distances or
loss of continuity of care
Equipment
Equipment must be familiar and checked regularly, including
before departure. The ideal qualities of any item of transfer
equipment include:
 long battery Life
 lightweight
 robust and easy to operate
 clear display with visible and audible alarms
 safe and easy to secure.
The ventilator should have alarms for high and low pressures,
it should be possible to generate positive end expiratory pressure
and monitor FiO2.
Available monitoring should include:
 end tidal CO2 in ventilated patients
 temperature
 pulse oximetry
 non-invasive blood pressure
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 continuous ECG monitoring
 airway pressures.
All patients with brain injuries and level 3 patients should
have an indwelling arterial cannula to allow for beat-to-beat
blood pressure measurement and the titration of ionotropic
agents to a target blood pressure. Inotropes should be adminis-
tered through a central venous line, which may also be used to
guide optimization of filling status prior to departure.
Governance
In 2005 the department of health report ‘Quality critical care
beyond comprehensive critical care’ was published, defining the
remit of regional critical care networks (CCNs). Part of their re-
sponsibility is to ensure that there is uniformity of standards
across the network and that the standards for the transport of
critically ill adult patients as set out by the Intensive Care Society
are adhered too. Critical care networks and individual trusts are
responsible for their own governance, including training, audit
and recording of transfer data. There is currently no unifying
national database detailing all critical care transfers; clearly this
should be rectified. Sound clinical governance forms the
cornerstone of any organization undertaking patient transfers. As
such regular audit and continuing professional development of
staff should be encouraged.
Guidelines and training
Comprehensive guidelines on transporting critically unwell
adult patients have been published by the Intensive Care So-
ciety and the Association of Anaesthetists of Great Britain and
Ireland. Individual trusts have developed their own guidance
under the auspices of their respective CCNs. Training consists
of locally arranged courses and national courses such as the
‘Safe Transfer and Retrieval: the Practical Approach’ course run
by the Advanced Life Support Group that aims to teach when,
where and how to transfer patients and the procedures for both
before and after the transfer.11 As of September 2012 the Royal
College of Surgeons of Edinburgh has run an examination to
gain the diploma in transfer and retrieval medicine. The ex-
amination focuses on the secondary and tertiary retrieval of
patients from one healthcare facility to another. According to
the colleges guidelines, candidates should be competent in the
assessment, management, triage and transfer of adult patients
with a range of undifferentiated illnesses and injury patterns.
Previous experience of secondary or tertiary retrieval is
advised.
Military lessons
Historically, many of the major advancements in medicine and
specifically trauma care have been driven forward by the mili-
tary. During enduring operations in Iraq and Afghanistan the
DMS (Defence Medical Services) gained a unique perspective
and acquired a high level of proficiency and significant body of
experience in the time-critical transfer and repatriation of
trauma patients by dedicated retrieval teams. There are many
facets that have contributed to the excellent survival rates
experienced by victims of military trauma in Iraq and
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 CRITICAL ILLNESS AND INTENSIVE CARE - I
Afghanistan. Examples include the shift in care to a C ABC
paradigm and excellent frontline care, leading onto a timely
transfer followed by damage control resuscitation and surgery
and finally repatriation to the UK. Both the MERT (Medical
Emergency Response Team) and CCAST (Critical Care Air
Support Team) have without doubt played a significant role in
this chain of survival.
Military personnel chosen to work on these teams have had
the invaluable opportunity to work and train together prior to
deployment on operations and have the benefit of well-defined,
rehearsed and proven resuscitation protocols to aid them in their
decision making. The rigorous governance structure around this
critical link in the chain of survival of military personnel also
ensures that only suitably qualified and highly experienced
personnel are volunteered to serve as part of these teams and
compulsory predeployment training specific to the job in hand
must be completed before an individual can deploy as part of
either team.
Conclusions
Interhospital transfers represent a logistical challenge for critical
care networks and individual NHS trusts. With the inexorable
pressure on critical care services we must ensure that our
response to the challenge of patient transfer is robust and effec-
tive. This should occur through striving for national homogeneity
of critical care transfer services particularly with regards to data
collection which would help to encourage better quality research
in this field and subsequently drive improvement. At the present
time the retrieval model would seem to be most desirable on the
basis of the available evidence but involves overcoming signifi-
cant financial, geographical and political restraints. Until such a
time as dedicated retrieval teams become the standard of care, all
those involved in patient transfer should ensure they remain
current with their trust’s guidelines and equipment and the
importance of clinical governance should be emphasized at all
levels. A Care 2004; 8: 69.
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