TRANSFER OF AN ILL OBSTETRIC’S PATIENT

GOALS..

1. To learn proper ways to transfer an ill patient2. To ensure patient safely arrive in tertiary centre

INTRODUCTION

Sarawak is the largest state in Malaysia with a land mass almost equal to Peninsular Malaysia

CHALLENGES..1. TOPOGRAPHY 3. TRANSPORTATION

2. DISTANCES 4. LOGISTIC

INTER-HOSPITAL TRANSFER OF AN ILL OBSTETRIC PATIENTS POSES AN ADDITIONAL RISK TO THE PATIENT

DISTRICT HOSPITALS SARAWAK GENERAL HOSPITAL

1.DECISION TO TRANSFER

EARLY AND APPROPRIATE REFERRAL Early referral O&G specialist

DISTRICT MO BUDDY SPECIALIST HEALTH CENTRES without MO --> SPECIALIST

Occasionally simultaneous referral to other specialties may be necessary (eg:anaesthetist/ physician/ surgeon)

RISK OF TRANSFERRING? The decission to transfer patient in remote parts may

be decided on the risk involved in transferring (eg:night transfer)

O&G specialist may decide against transferring the patient or delay the transfer till the next day if the risk of transfer is higher than managing the case in the referring centre

2. STABILIZATION BEFORE TRANSFER

Ensure the patient is stabilised as best as possible prior to transfer IV lines/ branula IV infussion / bloods

Medications- anti HPT, MgSO4, Inotropes Oxygen support/ intubation In PPH- may need Bakri baloon

THE SPECIALIST SHOULD PROVIDE THE APPROPRIATE INSTRUCTIONS OR GUIDANCE

TO THE REFERRING DOCTOR/ NURSE

HASTY TRANSFER OF AN UNSTABLE PATIENT MAY CAUSE MORE HARM !!!

3. MODE OF TRANSPORTATION

The following needs to be considered when deciding on the best mode of transportation

a) Urgency of transferb) Condition of the patientc) Availability of ambulance/ other mode of transportd) Distance and estimated transit timee) Time of day & weatherf) MEDEVAC is an option but enquire first if it can respond

quickly enough

CHALLENGES IN DISTRICT !!!

LAND TRANSPORTATION Distance from the referring centre to tertiary

hospital

Condition of road

Availability of transport- ambulance or 4WD

Weather

AIR TRANSPORTATION MEDEVAC- Decision should be discussed with O&G specialist JKNS- Considerations include:1. Severity of the cases2. Availability of the helicopter3. Weather

LOCAL KNOWLEDGE IS ESSENTIAL!!

MO/ MEDICAL STAFFS POSTED TO REMOTE CLINICS OR

HOSPITALS SHOULD LEARN ABOUT THE AREA WHERE THEY ARE SERVING AND FIND WAYS

OF QUICKLY AND SAFELY TRANSPORTING THEIR PATIENTS

!!

LUNDU

BAU

SERIAN

SIMUNJAN

SRI AMAN

BETONG

KUCHING DIVISSION

1. BAU (45MINS)2. LUNDU (1 1/2H)3. SERIAN (45

MINS)4. SIMUNJAN (3H)5. SRI AMAN (3H)6. BETONG (5H)

SARATOK

SARIKEI

MUKAH

KAPIT

DARODALAT

SIBU DIVISSION

1. SARATOK (45 MINS)2. SARIKEI (1H)3. DALAT (1 1/2H0)4. DARO (1 1/2H5. MUKAH (3H)6. KANOWIT (1H)7. KAPIT (3H)

KANOWIT

BELAGA

BINTULU DIVISSION

1. BELAGA (3H)

LIMBANG

LAWAS

MARUDI

MIRI DIVISSION

1. MARUDI (3H)2. LIMBANG (4H)3. LAWAS (5H)

4. DRUGS & EQUIPMENT

Ensure the ambulance or transport have the required resuscitative equipments that is in good working order (availability of oxygen tank)

Ensure the staff escorting the patient knows how to operate the resuscitative equipments

Ensure the appropriate medications (eg:MgSO4, parenteral anti-HPT, sedatives, muscle relaxants) which are needed should be prepared in prefilled syringes

Crossmatch blood products to bring along if indicated

If the patient is intubated ensure the Oxylog is functioning or adequate oxygen tanks to ensure the oxygen supply is adequate

NG tube is inserted to avoid aspiration during transfer

5. PERSONNEL

Ensure that the relevant personnel are alerted early (eg:ambulance driver, escorting MO/SN, blood bank staffs)

In fact, obstetric drills may include scenario involving patient transfer

All escorting staff should have at least accreditation in BLS and ideally passed SALSO

They must be able to recognise and address any deterioration They must be familiar with drugs and equipment involved

during transfer

6. HANDING OVER

This should be done systematically throughout all levels

- Escorting MO Referral centre MO/ Specialist- Escorting SN/ MA Referral centre SN Proper communication & documentation is vital

CHECKLIST BEFORE DEPARTURES

1. INTUBATED PATIENT- Oxylog functioning- Adequate O2 supply- ETT anchored- Suction machine- Nasogastric tube- Oropharyngeal airways - High flow mask/ ambubag- Drugs-Muscle relaxant and

sedation

2. EQUIPMENT/ MONITORING

- SpO2/BP monitor battery charged

- Infusion pumps charged- Resuscitation bag complete

3.MEDICATIONS- IV MgS04- Anti- HPT- Inotropes- Crystalloids or

Colloids- Anti-emetic

4. BLOOD PRODUCTS- Packed cell- Whole blood

5. OTHERS-Case notes/ films/ charts-Emergency contact/ Relative

informed

Obstetric Emergency Retrieval Team - To retrieve ill cases from clinics, district or private

hospitals and bring them back to the specialist hospital

AIM- To provide assistance in the management of obstetric emergencies in other

health centre & improve management of very ill patient during transfer to tertiary hospital

BENEFITS- O&G team can perform surgery in district hospitals before taking patient’s back

to the specialist hospital- Team can optimize patient during transfer- Team can manage complications better during transfer- Additional blood products- Anaesthetic doctor could come along in the relevant cases

DISADVANTAGES- Longer time taken to transfer patient

CLINICAL INDICATIONS

- Dire obstetric emergencies which requires close monitoring & stabilisation during transfer

- Complications during surgery in district hospitals or private centre that unable to be manage effectively

ACTIVATION

- The specialist/ consultant would make the decission if the retrieval team should be activated and depends on case to case basis

- Team members1. O&G specialist2. O&G registra3. Labour ward staff nurse4. Anaesthetist/ anaesthetic medical officer5. Paediatrician/ paediatric MO

THANK YOU……..