2. TRANSPORT OF CRITICALLY ILL PATIENTS DR.T. GOPINATHAN MD.,IDCCM.,EDIC Consultant Intensivist Department of Critical Care Medicine,KMCH

3. HISTORY RESCARE 2015ICU UPDATE 2015 Dominique Jean Larrey ( 8 July 1766 – 25 July 1842 ) French surgeon in Napolean’s army and an important innovator in battlefield medicine

4. INTRODUCTION RESCARE 2015ICU UPDATE 2015 Need for additional care, either technology and/or specialists, not available at the patient's current location Involves some degree of risk to the patient and sometimes to the accompanying personnel. ( 6 -71%, life threatening 8% IHT) These risks can be minimized and outcomes improved with careful planning, the use of appropriately qualified personnel, and selection and availability of appropriate equipment.

5. TYPES OF TRANSFER RESCARE 2015ICU UPDATE 2015 Primary transfer – home/street to ER/ICU Secondary transfer – Intra / Inter hospital Emergency or elective

6. TYPES OF TRANSFER RESCARE 2015ICU UPDATE 2015 Basic requirements are similar for inter hospital and intra hospital transport. However, inter hospital transport requires more careful planning, a greater variety of drugs, a higher battery backup, well equipped vehicle, essential gases for life support and an experienced medical crew.

7. ADVERSE EVENTS RESCARE 2015ICU UPDATE 2015

8. RELATED TO EQUIPMENT RESCARE 2015ICU UPDATE 2015 Monitor Power Failure Ventilator disconnect/failure Depleted oxygen supply Oxygen Probe Failure Tubing tangles ECG lead disconnection

9. RELATED TO STAFF RESCARE 2015ICU UPDATE 2015 Gaps in monitoring Missed treatment/medications Unintended Airway Extubation Under ventilation Over ventilation Loss of chest tube Loss of invasive access Under/Over Resuscitation Loss of ICP monitor

10. RELATED TO PATIENT RESCARE 2015ICU UPDATE 2015 Airway - Aspiration Breathing - Derecruitment Desaturation Increased oxygen consumption Circulation - Arrhythmia Hypothermia Hyper/hypotension Neurological - Agitation/Pain

11. ADVERSE EVENTS RESCARE 2015ICU UPDATE 2015 Minor AEs- physiological decline of more than 20% problem due to equipment Major AEs- which put the patient's life at risk and require urgent therapeutic intervention.

12. CIRCUMSTANCES RESCARE 2015ICU UPDATE 2015

13. CONDUCT OF TRANSFER RESCARE 2015ICU UPDATE 2015 The ideal way to imagine transport of a critically ill patient is to imagine it as a “mobile, but seamless continuation of the ICU environment”.

14. CONDUCT OF TRANSFER RESCARE 2015ICU UPDATE 2015 Remember acronym….. Assessment Control Communication Evaluation Prepare and package Transport

15. ASSESSMENT RESCARE 2015ICU UPDATE 2015 Initial assessment of the patient and situation as a whole Indications - benefits must outweigh risks Stabilize before transport Anticipation of problem likely encountered en route Degree of urgency to transfer

16. ASSESSMENT RESCARE 2015ICU UPDATE 2015

17. CONTRAINDICATIONS RESCARE 2015ICU UPDATE 2015 Inability to provide adequate oxygenation and ventilation during transport either by manual ventilation, portable ventilator, or standard intensive care unit ventilator Inability to maintain acceptable hemodynamic performance during transport Inability to adequately monitor patient cardiopulmonary status during transport Inability to maintain airway control during transport Transport should not be undertaken unless all the necessary members of the transport team are present

18. CONTROL AND COMMUNICATE RESCARE 2015ICU UPDATE 2015 Communication - excellent communication within team and receiving end Continuous assessment of effectiveness of resuscitation and stabilization process When an alternate team at a receiving location will assume responsibility for the patient after arrival, continuity of patient care will be ensured by physician-to-physician and nurse-to-nurse communication to review patient condition and the treatment plan.

19. TRANSPORT RESCARE 2015ICU UPDATE 2015

20. PERSONNEL RESCARE 2015ICU UPDATE 2015 It is recommended that a minimum of two people, in addition to the vehicle operator, accompany a critically ill pt. It is strongly recommended that a physician with training in airway management and ACLS, and critical care training or equivalent, accompany unstable patients. The team must be proficient in operation and troubleshooting all of the equipment The transferring personnel should be familiar with the patient’s history, condition and special requirements to allow appropriate planning and anticipation of problems unique to the patient.

21. EQUIPEMENT GENERAL PRINCIPLES RESCARE 2015ICU UPDATE 2015 Choose equipment that you are familiar with and check every piece to make sure it works. Never place equipment on top the patient. Equipment often comes in different sizes - have an appropriate selection for your patient. Ensure adequate power (battery pack) backup and check that they are fully charged, but plug the equipment back in at destination Check that gas cylinders are full and function (estimate > 30 min more than needs). Check that you have enough spare IV fluids.

22. EQUIPEMENT GENERAL PRINCIPLES RESCARE 2015ICU UPDATE 2015 A cellular phone and a key to call the elevator are useful for emergencies. Antibiotics should be brought along to keep the patient on schedule with antibiotics Transport protocol should define who is responsible for checking and how often. All procedures for the proper setup, maintenance, and use of all equipment for transport must be strictly followed. Some patients may not tolerate movement and/or changes in ventilatory support. A trial of body movement, manual ventilation, or application of transport ventilator in the ICU is warranted to ensure patient tolerance

23. DRUGS RESCARE 2015ICU UPDATE 2015 Cardiac arrest Intubation Hypotension and hypertension Agitation and pain Cardiac dysrhythmia Anaphylaxis Bronchospasm Hypoglycaemia and hyperglycaemia Seizures

24. DRUGS RESCARE 2015ICU UPDATE 2015 In specific circumstances it may be necessary to be able to treat the following during transport: - Raised ICP Uterine atony Adrenal dysfunction Narcotic depression

25. PREPARE AND PACKAGE RESCARE 2015ICU UPDATE 2015 Verify physician's order. Gather and assemble all equipment. Maintain electrical power to all monitors prior to departure to ensure the maximum charge of the batteries. Label, level, and zero all pressure transducers. Secure all pressure monitoring lines to avoid inadvertent disconnection and decannulation. Set appropriate alarm limits for all monitored parameters. Stop nutrition

26. PREPARE AND PACKAGE RESCARE 2015ICU UPDATE 2015 All bags emptied before departure Lines, cables and drainage tubes (Heimlich chest tube valve, abdomen, bladder) unclamped, functional, secure, untangled and transportable Limit the number of infusion pumps as much as possible Aspirate the patient before departure and check the cuff pressure of endotracheal tube Consider appropriate physical restraints for the patient if indicated. Do not forget to take patient notes and images. If patient consent is required – do you have it?

27. PREPARE AND PACKAGE RESCARE 2015ICU UPDATE 2015 Head raised if possible (to prevent intracranial hypertension and ventilator- associated pneumonia) Prepare medication (emergency, sedation, analgesia, paralysing agents), fluid loading solutions Route for venous access isolated and secured (quick injection, administration of vasopressors) Always reassess the patient immediately prior to leaving, with all transport equipment attached and functioning – following an A – airway, B – breathing, C – circulation, D – drugs, and E – equipment algorithm will ensure you not missing anything.

28. CHECKLIST FOR PREPARATION RESCARE 2015ICU UPDATE 2015

29. MONITORING RESCARE 2015ICU UPDATE 2015 Same level of basic physiologic monitoring during transport as received in the ICU. Continuous ECG,pulse oximetry and periodic measurement of blood pressure, pulse rate, and respiratory rate. In addition, selected patients may benefit from capnography, continuous intra-arterial blood pressure, pulmonary artery pressure, or intracranial pressure monitoring. Alarms should be visible as well as audible in view of extraneous noise levels

30. POST PROCEDURE RESCARE 2015ICU UPDATE 2015 Upon returning to the unit, place the patient on the appropriate bedside monitoring and respiratory equipment. Re-level and re-zero all pressure transducers. Check and reset all necessary alarm parameters and ensure patient comfort. Remove all transport equipment from the patient's room, disinfect as appropriate, and store monitors with connection to AC power for recharging of the batteries.

31. DOCUMENTATION RESCARE 2015ICU UPDATE 2015 Document the ventilator or oxygen settings prior to departing and upon returning to the unit. Document any cardiopulmonary or hemodynamic changes that may have occurred during the transport Include the occurrence of adverse reactions and interventions that were made. Documentation serves to remind the team to systematically check monitoring and patient status, helps to identify trends in the patient’s condition earlier, and allows quality assurance activities. The medico- legal implications of documentation are obvious.

32. CHECK LIST RESCARE 2015ICU UPDATE 2015

33. RESCARE 2015ICU UPDATE 2015 CHECK LIST

34. RESCARE 2015ICU UPDATE 2015 CONCLUSION Adverse effects during and after transport of critically ill patients are frequent. Although a few patient-related risk factors can be identified, the rate of equipment-related adverse events may be as high as one-third of all transports. Thus, particular attention has to be focused on the personnel, equipment and monitoring in use.

35. RESCARE 2015ICU UPDATE 2015 CONCLUSION To further reduce the rate of inadvertent mishaps from transports, alternative diagnostic modalities or techniques, and performing surgical procedures in the ICU should be considered whenever possible.

36. RESCARE 2015ICU UPDATE 2015 …….. For your patience and opportunity

37. Thank you! RESCARE 2015ICU UPDATE 2015