TRANSPORTATION OF THE CRITICAL ILL PATIENT DEPARTEMENT OF ANESTHESIOLOGY AND INTENSIVE CARE FACULTY OF MEDICINE, UNIVERSITY OF INDONESIA

CRITICAL ILL PATIENT ? Usually have a comprised function of organs and/or systems Usually have a comprised function of organs and/or systems Under medical and/or apparatus life support Under medical and/or apparatus life support Have invasive or non invasive continuous monitoring Have invasive or non invasive continuous monitoring

i.V lines and life supporting devices

Transport of critical ill patient Divided into 2 categories : Divided into 2 categories : 1. intrahospital (within hospital) 1. intrahospital (within hospital) example: from ICU to radilogy depart example: from ICU to radilogy depart 2. interhospital (between hospital) 2. interhospital (between hospital)

Important ! Before transportation Condition of the patient (primary survey) Condition of the patient (primary survey) The need of comprehensive monitoring The need of comprehensive monitoring Skill medical personnel Skill medical personnel Benefits of transportation Benefits of transportation The level of care during transportation equals or exceed the level before transportation without any interruptions of care The level of care during transportation equals or exceed the level before transportation without any interruptions of care

Reasons for transportation Patient needs More sophisticated life support equipment and / or medicine More sophisticated life support equipment and / or medicine More skill expertise More skill expertise Needs diagnostic procedure Needs diagnostic procedure

RISK IN TRANSPORTATION Significant changes in Heart rate (bradycardia / tachycardia Heart rate (bradycardia / tachycardia Blood pressure (hypotension / hypertension) Blood pressure (hypotension / hypertension) Dysrthythmia Dysrthythmia Breathing (apnea / dyspnea ) Breathing (apnea / dyspnea ) Oxygenation (desaturation) Oxygenation (desaturation) CO2 changes (hypercarbia) CO2 changes (hypercarbia) Neurologic (paralyze) Neurologic (paralyze) Can cascade into life-threatening complication

GUIDELINES FOR SAFE PATIENT TRANSPORT Plan in advance for patient transfer & transport Plan in advance for patient transfer & transport Prevent delays through comprehensive coordination & detail communication Prevent delays through comprehensive coordination & detail communication Make appropriate selection & utilization of available resources Make appropriate selection & utilization of available resources Ensure patient stabilization prior to transport Ensure patient stabilization prior to transport Verify all tubes & lines functional & secure Verify all tubes & lines functional & secure Provide safe transport environment for patient & staff Provide safe transport environment for patient & staff Continuous monitoring Continuous monitoring Treat as indicated for any changes Treat as indicated for any changes Safely deliver the patient Safely deliver the patient

TRANSPORT DECISION MAKING The responsibility of the referring physician : The personnel staff The personnel staff The type of transportation The type of transportation The proper equipment that should be prepared The proper equipment that should be prepared The medication on hand The medication on hand

TRANSPORT PERSONNEL CONSIDERATION Special trained transport personnel (physician, critical care nurse, paramedic) Special trained transport personnel (physician, critical care nurse, paramedic) Experience Experience Have clinical abilities to evaluate & treat the patient Have clinical abilities to evaluate & treat the patient

TRANSPORT EQUIPMENT CONSIDERATION All equipment be appropriate for the patient & transportation environment, should compatible with power source, must consider weight & space restriction of the transport All equipment be appropriate for the patient & transportation environment, should compatible with power source, must consider weight & space restriction of the transport Can provide continuing intensive care throughout the trip Can provide continuing intensive care throughout the trip Portable monitor & infusion pumps with audible & visible alarms with adequate battery power reserve Portable monitor & infusion pumps with audible & visible alarms with adequate battery power reserve Monitoring may be compromised by vibration, motion artifacts, electromag interference, limited visibility, but the monitor should withstand stress Monitoring may be compromised by vibration, motion artifacts, electromag interference, limited visibility, but the monitor should withstand stress Oximetry, ECG, automatic BP are recommended Oximetry, ECG, automatic BP are recommended Oxygen supply should be adequate Oxygen supply should be adequate

INTERHOSPITAL TRANSPORT transport personnel transport personnel Referring Receiving Referring Receiving physcian/facilities physcian/facilities physcian/facilities physcian/facilities

REFERRING PHYSICIAN Informed consent to patient or family Informed consent to patient or family Coordinate the transfer Coordinate the transfer Consultation with receiving physician: available bed, provide appropriate treatment, agrees to accept the patient Consultation with receiving physician: available bed, provide appropriate treatment, agrees to accept the patient Responsible for qualified transport personnel & equipment Responsible for qualified transport personnel & equipment Provide copy medical record & discharge summary Provide copy medical record & discharge summary

RECEIVING PHYSICIAN 24-hr communication system 24-hr communication system Cannot refuse patient that have been transported Cannot refuse patient that have been transported The receiving physician may make recommendations : Ongoing patient management Ongoing patient management Mode of transportation Mode of transportation Composition of the transportation team Composition of the transportation team Patient’s preparation before transportation Patient’s preparation before transportation

SELECTION OF TRANSPORTATION Several considerations : Local resources Local resources Speed of the transportation Speed of the transportation Weather Weather Ground traffic Ground traffic Accessibility of roads & landing areas Accessibility of roads & landing areas Total distance to travel Total distance to travel One-way travel, or two-legged/ three-legged One-way travel, or two-legged/ three-legged

SELECTION OF TRANSPORTATION Ground ambulances Ground ambulances Rotor-wing air ambulances (helicopter) Rotor-wing air ambulances (helicopter) Fixed-wing air ambulances (airplane) Fixed-wing air ambulances (airplane) Boat ambulances Boat ambulances

GROUND AMBULANCE (1) ADVANTAGES Availability Availability No special facility No special facility Directly transport patient to hospital, less movement from one vehicle to another Directly transport patient to hospital, less movement from one vehicle to another Larger room space Larger room space Fewer restriction concerning equipment Fewer restriction concerning equipment Easier to stop ambul to do assessment & intervention Easier to stop ambul to do assessment & intervention Easier to divert to alternate destination Easier to divert to alternate destination Operate in weather condition not safe for air transport Operate in weather condition not safe for air transport

All-terrain off-road ambulance

GROUND AMBULANCE (2) Disadvantages More time required to transfer More time required to transfer Can be delay by road condition, traffic, weather Can be delay by road condition, traffic, weather Cannot access patient in remote areas Cannot access patient in remote areas Can be rough & turbulent ride Can be rough & turbulent ride

High roof Spacious interior to accommodate 3- 4 persons with equipments

G-force max speed 60 kph no sudden brakes or turning

Downhill, gravitation to the head, more circulation to the head, intracranial pressure increases

Uphill, gravitation to the legs, circulation to the head decreases

HELICOPTER ADVANTAGES Speed Speed Direct point-to-point transfer Direct point-to-point transfer Needs only small landing space Needs only small landing space Can fly to inaccessible location Can fly to inaccessible location Cover more area than ground ambulances Cover more area than ground ambulances

helicopter

HELICOPTER Disadvantages If no near landing site available, more time wasted If no near landing site available, more time wasted Small cabin space Small cabin space Size & weight limited for equipment Size & weight limited for equipment Depends on weather condition Depends on weather condition Unpressurized cabin Unpressurized cabin More vibration, noise & turbulence More vibration, noise & turbulence Personnel wear headsets or helmets Personnel wear headsets or helmets

AIRPLANE Advantages Speed Speed Sufficient space Sufficient space Size, weight less restriction Size, weight less restriction Weather, noise & turbulence less Weather, noise & turbulence less Pressurized cabin Pressurized cabin

AIRPLANE Disadvantages Ground delays Ground delays Possible dislodgement of vital equipment during transfer to & from ground ambulances Possible dislodgement of vital equipment during transfer to & from ground ambulances Hypoxia with high altitude Hypoxia with high altitude Malfunction of pressurized equipment Malfunction of pressurized equipment

Cabin not pressurized

INTRAHOSPITAL TRANSPORT Critical ill patients may require procedures that cannot be performed in the ICU Critical ill patients may require procedures that cannot be performed in the ICU May be transported to radiology, operating room or other location for diagnostic/therapeutics proc May be transported to radiology, operating room or other location for diagnostic/therapeutics proc Complications during transport: increase pCO2, decrease O2Sat, hypotension, hypertension, dysrhythmias, cardiac arrest, accidental extubation, disconnection of central lines Complications during transport: increase pCO2, decrease O2Sat, hypotension, hypertension, dysrhythmias, cardiac arrest, accidental extubation, disconnection of central lines

INTRAHOSPITAL TRANSPORT Risks & benefits : best weighed against the outcome of the test & the impact on patient care, if the test can change the therapy, transport may be justified Risks & benefits : best weighed against the outcome of the test & the impact on patient care, if the test can change the therapy, transport may be justified Informed consent to the patient & family Informed consent to the patient & family Communication & coordination to verify immediate acceptance of the patient upon arrival Communication & coordination to verify immediate acceptance of the patient upon arrival

TRANSPORT DECISION MAKING Evaluate the patient Evaluate the patient Evaluate the medical care required Evaluate the medical care required Assess for special requirements (equipment & medication) Assess for special requirements (equipment & medication) Consider the personnel (physician, resident, nurse) Consider the personnel (physician, resident, nurse)

MEDICAL PERSONNEL Minimum 2 people, one of whom critical care nurse Minimum 2 people, one of whom critical care nurse Accompanying physician necessary for unstable patient Accompanying physician necessary for unstable patient In teaching hospitals, primary nurse & resident phyiscian In teaching hospitals, primary nurse & resident phyiscian

KEY POINTS Provide equivalent or higher degree of monitoring & medical care than prior to transport Provide equivalent or higher degree of monitoring & medical care than prior to transport Evaluation of the risks & benefits of transportation & the selected transportation Evaluation of the risks & benefits of transportation & the selected transportation To minimized risks to patients, careful planning, use of qualified personnel, appropriate equipment, proper evaluation & stabilization of patient (primary survey) To minimized risks to patients, careful planning, use of qualified personnel, appropriate equipment, proper evaluation & stabilization of patient (primary survey) The referring physician is responsible for the transport-related decision The referring physician is responsible for the transport-related decision

References Stene JK, Grande CM. Anesthesia for trauma. In Anesthesia, editor Miller. 6 th ed 2005, 2487 Stene JK, Grande CM. Anesthesia for trauma. In Anesthesia, editor Miller. 6 th ed 2005, 2487 Orr RA, Han YY, Roth K. Pediatric Transport: shifting the paradigm to improve patient outcome. In Pediatric Critical Care, editor Fuhrman BP, Zimmerman JJ. 3 rd ed 2006, Orr RA, Han YY, Roth K. Pediatric Transport: shifting the paradigm to improve patient outcome. In Pediatric Critical Care, editor Fuhrman BP, Zimmerman JJ. 3 rd ed 2006, Moon RE, Camporesi EM. Respiratory monitoring. In Anesthesia,editor Miller. 6 th ed 2005, 1472 Moon RE, Camporesi EM. Respiratory monitoring. In Anesthesia,editor Miller. 6 th ed 2005, 1472 Blumen IJ, Thomas F, Williams D. Transportation of the critically ill patient. In Principles of critical care, ed Hall JB et al. 3 rd ed 2005, Blumen IJ, Thomas F, Williams D. Transportation of the critically ill patient. In Principles of critical care, ed Hall JB et al. 3 rd ed 2005,

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TRANSPORT DECISION MAKING(2) The referring physician also : Must accurately assess patient’s illness/injuries, should the patient be stabilized first or transport immediately, usually stabilization is more important than immediate transport Must accurately assess patient’s illness/injuries, should the patient be stabilized first or transport immediately, usually stabilization is more important than immediate transport Decision on airway & haemodynamics management prior to transportation Decision on airway & haemodynamics management prior to transportation Anticipate complications & the treatment Anticipate complications & the treatment Estimate the pace of illness, to judge whether “team or time” represents greater opportunity to improve outcome Estimate the pace of illness, to judge whether “team or time” represents greater opportunity to improve outcome