Patient Transfer and Shifting

Transfer and Shifting in Health Care

Principles of safe transfer  Experienced staff  Appropriate equipment and vehicle  Full assessment and investigation  Extensive monitoring  Careful stabilization of patient  Reassessment  Continuing care during transfer direct handover  Documentation and audit.

    Intensive care patients are moved within hospital for example, to the imaging department or between hospitals for upgraded treatment or because of bed shortages. We will concentrate on transport of adults between hospitals, but the principles are similar for transfers within hospitals.

• Principles of safe transfer
• Experienced staff
• Appropriate equipment and vehicle
• Full assessment and investigation
• Extensive monitoring
• Careful stabilization of patient
• Reassessment
• Continuing care during transfer direct handover
• Documentation and audit

    Although the Intensive Care Society and the Association of Anaesthetists have recommended that retrieval teams are established in the United Kingdom, 90% of patients are accompanied by staff from the referring hospital. Over 10,000 intensive care patients are transferred annually in the United Kingdom, but most hospitals transfer fewer than 20 a year. 

    Each hospital thus has little expertise and few people gain knowledge of transport medicine. Most patients are accompanied by on call anesthetic trainees. Not only does this leave the base hospital with inadequate on call staff but accompanying doctors often have little experience.

Dangers of transportation

    Intensive care patients have deranged physiology and require invasive monitoring and organ support. Furthermore, they tend to become unstable on movement. Transport vehicles are not conducive to active intervention and no help is available. Staff and patients are vulnerable to vehicular accidents and may be exposed to temperature and pressure changes.

• Organizational structure
• National and regional
• Department of Health, purchasers, and specialist societies have responsibility for
• Guidelines
• Audit
• Bed bureau funding
• Regional retrieval teams
• Hospital or trust
• Consultant with overall responsibility for transfers including
• Local guidelines, protocols, check lists
• Coordination with neighboring hospitals
• Availability and maintenance of equipment
• Nominated consultant for 24 hour decisions
• Call out system for appropriate staff
• Indemnity and insurance cover
• Liaison with ambulance service concerning specification of vehicle and process of call out
• Communication systems between units and during transfer
• Education and training programs
• Audit: critical incident, morbidity, and mortality
• Funding: negotiations with purchasers

    Audits in the United Kingdom suggest that up to 15% of patients are delivered to the receiving hospital with avoidable hypotension or hypoxia which adversely affects outcome. 

    About 10% of patients have injuries that are undetected before transfer. However, with experienced staff, appropriate equipment, and careful preparation, patients can be moved between hospitals without deterioration. The “scoop and run” principle is not appropriate for moving critically ill patients.

Organization

    Each hospital should have a designated consultant responsible for transfers who ensures that guidelines are prepared for referral and safe transfer, equipment and staff are available, and standards are audited. 

    Proper routines for referral between hospitals and good communication should ensure appropriate referral, coordination, and integration of services. An area or regional approach may allow retrieval teams to be established.

Transfer decisions

    A decision to transfer should be made by consultants after full assessment and discussion between referring and receiving hospitals. Guidelines exist concerning timing of transfer for certain groups of patients for example, those with head injury. For patients with multiple organ failure the balance of risk and benefit needs to be carefully discussed by senior staff.

    The decision on whether and how to send or retrieve a patient will depend on the urgency of transfer, the availability and experience of staff, equipment, and any delay in mobilizing a retrieval team. Local policies should be prepared to reflect referral patterns, available expertise, and clinical circumstances.

Transfer vehicle

    Vehicles should be designed to ensure good trolley access and fixing systems, lighting, and temperature control. Sufficient space for medical attendants, adequate gases and electricity, storage space, and good communications are also important. 

    The method of transport should take into account urgency, mobilization time, geographical factors, weather, traffic conditions, and cost.

    Road transfer will be satisfactory for most patients. This also has the advantages of low cost, rapid mobilization , less weather dependency, and easier patient monitoring. Air transfer should be considered for longer journeys (over about 50 miles (80 km) or 2 hours). 

    The apparent speed must be balanced against organizational delays and transfer between vehicles at the beginning and end. 

    Helicopters are recommended for journeys of 50-150 miles (80-240 km) or if access is difficult, but they provide a less comfortable environment than road ambulance or fixed wing aircraft, are expensive, and have a poorer safety record. Fixed wing aircraft, preferably pressurized , should be used for transfer distances over 150 miles (240 km).

    Close liaison with local ambulance services is required. Contact numbers should be available in all intensive care units and accident and emergency departments to ensure rapid communication and advice.

Equipment

    Equipment must be robust, lightweight, and battery powered. The design of transport equipment has advanced greatly, and most hospitals now have the essentials. Many ambulance services also provide some items in standard ambulances.

    Equipment for establishing and maintaining a safe airway is essential. Another prerequisite is a portable mechanical ventilator with disconnection alarms which can provide variable inspired oxygen concentrations, tidal volumes, respiratory rates, levels of positive end expiratory pressure, and inspiratory: expiratory ratios. 

    The vehicle should carry sufficient oxygen to last the duration of the transfer plus a reserve of 1-2 hours.A portable monitor with an illuminated display is required to record heart rhythm, oxygen saturation, blood pressure by non-invasive and invasive methods, end tidal carbon dioxide, and temperature. 

    Alarms should be visible as well as audible because of extraneous noise during transfer. Suction equipment and a defibrillator should be available. A warming blanket is advantageous. The vehicle must also contain several syringe pumps with long battery life and appropriate drugs. A mobile phone for communication is advisable.

    One person should be responsible for ensuring batteries are charged and supplies fully stocked. All those assisting in the transfer should know where the equipment is and be familiar with using the equipment and drugs.

    If patients are transferred on standard ambulance trolleys equipment has to be carried by hand or laid on top of the patient, which is unsatisfactory. Special trolleys should be used that allow items to be secured to a pole or shelf above or below the patient.

Accompanying staff

    In addition to the vehicle's crew, a critically ill patient should be accompanied by a minimum of two attendants. One should be an experienced doctor competent in resuscitation, airway care, ventilation, and other organ support. The doctor, usually an anesthetist , should ideally have training in intensive care, have carried out previous transfers, and preferably have at least two years' postgraduate experience. 

    He or she should be assisted by another doctor, nurse, paramedic, or technician familiar with intensive care procedures and equipment. Current staffing levels in many district general hospitals mean that this ideal is not always achievable.

    The presence of experienced attendants will not only ensure that basics for ensuring safe transfer are undertaken but prevent transfers being rushed without full preparation; This often requires a senior voice. Hospitals should run regular training programs in safe transport techniques.

    Provision must be made for adequate insurance to cover death or disability of attendants in an accident during the course of their duties. The hospital trust should provide medical indemnity, and personal medical defense cover is also recommended.

Preparation

    Meticulous stabilization of the patient before transfer is the key to avoiding complications during the journey. 

    In addition to full clinical details and examination, monitoring before transfer should include electrocardiography, arterial oxygen saturation, (plus periodic blood gas analyses), blood pressure preferably by direct intra-arterial monitoring, central venous pressure where indicated, and urine output. 

    Investigations should include chest radiography, other appropriate radiography or computed tomography, hematology , and biochemistry. If intra-abdominal bleeding is suspected the patient should have peritoneal lavage .

    Alternate Level of Care: A level of care that can safely be used in place of the current level and determined based on the acuity and complexity of the patient's condition and the type of needed services and resources.

Appropriateness of Setting: Used to determine if the level of care needed is being delivered in the most appropriate and cost-effective setting possible.

Continuum of Care: The continuum of care matches ongoing needs of the individuals being served by the case management process with the appropriate level and type of health, medical, financial, legal and psychosocial care for services within a setting or across multiple settings.

Custodial Care: Care provided primarily to assist a patient in meeting the activities of daily living but not requiring skilled nursing care.

Discharge Planning: The process of assessing the patient's needs of care after discharge from a healthcare facility and ensuring that the necessary services are in place before discharge. This process ensures a patient's timely, appropriate, and safe discharge to the next level of care or setting including appropriate use of resources necessary for ongoing care.

Hospice: A system of inpatient and outpatient care, which is supportive and palliative family-centered care, designed to assist the individual with terminal illness to be comfortable and maintain satisfactory lifestyle through the end of life.

Level of Care: The intensity of effort required to diagnose, treat, preserve or maintain an individual's physical or emotional status.

Levels of Service: Based on the patient's condition and the needed level of care, used to identify and verify that the patient is receiving care at the appropriate level.

Skilled Care: Patient care services that require delivery by a licensed professional such as a registered nurse or physical therapist, occupational therapist, speech pathologist, or social worker.

Subacute Care Facility: A healthcare facility that is a step down from an acute care hospital and a step up from a conventional skilled nursing facility intensity of services.

Transitional Planning: The process case managers apply to ensure that appropriate resources and services are provided to patients and that these services are provided in the most appropriate setting or level of care as outlined in the standards and guidelines of regulatory and accreditation agencies. It focuses on moving a patient from most complex to less complex care setting.