Risks of transport of critically ill patients Technical complications: e.g. displacement of the tracheal tube,intravascular lines, drains etc. Pathophysiological deterioration: e.g. increased intracranial pressureas may occur from the lowering of a head-injured patient from semirecumbentto recumbent position for a CT scan), arterialhypotension, decrease in oxygen saturation. Inadequate monitoring of cardiovascular and pulmonary functiondue to less sophisticated monitors or equipment/interference due tomotion, etc. Inadequate therapy due to lack of appropriate equipment manytransportation ventilators cannot deliver the modes or levels ofventilation as a high-end ICU ventilator. (Note newer ICU ventilatorsmay be used for transport and are even becoming MRI compatible). Additional movements during transport (acceleration forces duringaeromedical or ambulance transport, tilting/lifting of patients frombed to trolley), may cause dislocation of fractures, fibrin clots,sutures, vascular emboli, etc.). Lack of immediate access to additional investigations or therapy ifneeded e.g. no chest X-ray in an ambulance to diagnose/exclude apneumothorax or extra unit of packed cells/clotting factors in case ofacute haemorrhage. Limited number of people involved in the transport, lack of moresenior people immediately to handWhich patients and situations face an increased risk of adverseevents during transport, and why?A. Paediatric patients: even small movements of the patient or associatedequipment (e.g. endotracheal tube) may lead to disconnection or dislocation ofthe tubes and lines. Transfer at night: this may mean fewer staff or staff with less experienceresulting in sub-optimal planning, preparation of conduct of transfer. Poorlighting may impair tasks and make correct dosage of medications or therecognition of complications more difficult. Patients with increased intracranial pressure: often it is not possible to elevatethe upper body for transport and positioning of the patient e.g. in the CT orMRI suite. Patients with increased positive airway pressure (> 4050 cmH20) duringventilation: many transport ventilators will not generate enough drivingpressure or PEEP to sufficiently oxygenate very obese patients or those withsevere ARDS. Abrupt change of clinical team: information may be lost if the transfer team hasno connection with the team previously providing care and has not hadsufficient time to get a proper clinical picture of the patient. Every handover ofinformation poses the risk of information being lost

What to monitor Three-lead (or more) ECG with heart rhythm and assessment of theST segment Invasive pressures (or if too time-consuming or not available, noninvasiveblood pressure may be acceptable) Haemoglobin oxygen saturation End-tidal capnography Temperature.During transfer of mechanically ventilated patients with serious headinjury, monitoring end-tidal capnography is crucial to prevent hyper- orhypocapnia with possible cerebral vasodilation or constriction and consequentchanges in intracranial pressure or ischaemia.Before any transport, the staff check: If enough spare syringes are available to cover the patients needs duringtransport For special and adequate tubing, depending on the type of pump For battery power and number of wall sockets available in the ambulanceor at the receiving site Which medications are indispensable and which may be interruptedtemporarily.syringe pumps, e.g. mcg/kg/min, mcg/min, mg/hour, ml/hour,or even number of drops/minute in infusion pumpspressure bags oradditional infusion pumps may be needed for every infusione.g. suction of tracheal ororal secretionsHow useful to patient care during the transport is the device? What are the risks for the patient if the device is displaced unintentionally (e.g.blood loss)? What is the battery capacity and what are the risks to the patient if the deviceshuts down? Is it safer to uncouple the device during transport because the risks outweighthe benefits? Do weight, size, possibility of firm attachment to ambulance or legal restrictionspreclude the use of a device, especially in aeromedical transport?Set appropriate alarm limits and ensure the alarm volume is loud enough to beheard.e.g. which model of a hip prosthesis. Based onclinical experience most implanted devices (such as stents, prostheses) withoutelectronic control are suitable for MRI. Electronically controlled devices, such asTask 3. Conduct of the transfer[24]pacemakers or infusion pumps, may not function properly during and after MRI and aneed for their presence precludes MRI scanning. Standard medical devices such asventilators or infusion pumps are not compatible with MRI and specialarrangements/equipment must be used.What may happenAdverse events (e.g. desaturation, persistent hypotension) or specific transportrelatedevents (e.g. unintended extubation, loss of intravascular access) shouldbe handled according to standard critical care practice.Even a simple medical interventionsuch as placement of an intravenous lineBefore transporting a patient after resuscitation for haemorrhagicshock, check that red blood cells and clotting products (platelets, fresh frozenplasma or concentrated factors) are availableDifficulty keeping the airway open, e.g. obesity and increased sleepinessfollowing morphine. Airway protection deserves special consideration in case ofincreased nausea or vomiting. Difficulty ventilating, e.g. heavy snoring, worsened sleep apnoea with obesityand morphine. Difficulty oxygenating, e.g. pulmonary oedema in left ventricular failure.Duration of the transfer? Role assignment of the team. Space for all the equipment.Connections to tubes and lines. Is the CT suite ready for the procedure and are thecorridors clear?Changing ventilators (with possible loss of PEEP), syringes on pumps or othertherapeutic equipment pose hazards. Frequent pitfalls include three-way stopcocksleft in the wrong position and errors with syringe pumps containing vasopressorsIndications for transportation.All equipment should be robust, durable and lightweight. Electrical equipmentmust be designed to function on battery when not plugged into the mains.Additional batteries should be carried in case of power failure. Battery life shouldbe maximised by exercising batteries in compliance with the manufacturers recommendations.8.6 Portable monitors should have a clear illuminated display and be capable of displayingECG, arterial oxygen saturation (SaO2), non-invasive blood pressure, threeinvasive pressures, capnography (EtCO2) and temperature. Alarms should be visibleas well as audible in view of extraneous noise levels.8.7 Portable mechanical ventilators should have as a minimum disconnection and highpressure alarms, the ability to supply positive end expiratory pressure (PEEP) andvariable inspired oxygen concentration (FiO2), inspiratory/expiratory (I/E) ratio,respiratory rate and tidal volume. In addition the ability to provide pressure controlledventilation, pressure support and continuous positive airway pressure(CPAP) is desirable.8.8 Gravity feed drips are unreliable in moving vehicles. Sufficient syringe or infusionpumps are required to enable essential fluids and drugs to be delivered. Pumpsshould preferably be mounted below the level of the patient and infusion sets fittedwith anti-siphon devices.8.9 Portable warm air devices for maintaining patient temperature can be useful and canalso be mounted on the patient trolley.8.10 Additional equipment for maintaining and securing the airway, intravenous access,etc should also be available (Appendix 1).8.11 High visibility clothing, a mobile telephone, contact telephone numbers, money/credit cards should be available for use in emergencies.Intubated patients should normally be paralysed, sedated and mechanically ventilated.Inspired oxygen may be guided by arterial oxygen saturation (SaO2) and ventilationby end tidal carbon dioxide (EtCO2). Following stabilisation on the transportventilator, at least one arterial blood gas analysis should be performed prior to departureto ensure adequate gas exchange. Inspired gases should be humidified using adisposable heat and moisture exchanging filter (HME).13.6 If a pneumothorax is present or likely, chest drains should be inserted prior to departure.Underwater seals should normally be replaced by leaflet valve (Heimlich type)drainage systems. Chest drains should not be clamped.13.7 Secure venous access is mandatory and at least two wide bore intravenous cannulae(central or peripheral) are required. A suitably secured indwelling arterial cannula isideal for blood pressure monitoring.13.8 Hypovolaemic patients tolerate moving poorly and circulating volume should be nearnormal prior to transportF2 . This may require volume loading with crystalloid, colloidor blood, guided by central venous or pulmonary artery occlusion pressure monitoringand cardiac output measurement. If inotropes or other vasoactive agents arerequired to optimise haemodynamic status, patients should be stabilised on thesebefore leaving the referring unit.13.9 Patients who are persistently hypotensive despite resuscitation efforts should not bemoved until stable. Continuing sources of blood loss or sepsis should be identifiedand controlled. Long bone fractures should be splinted to provide pain relief, cardiovascularstability and neurovascular protection.13.10 A naso- or orogastric tube and urinary catheter should be passed and free drainageallowed into collection bags.13.11 Conscious patients should be kept informed of the transfer and all other relevantinformation. Relatives should similarly be kept informed of travel arrangements butshould not normally travel with the patient.13.12 Before departure, named medical and nursing personnel at the receiving unit shouldbe contacted to confirm the availability of the bed, update them on the patientscondition and provide an estimated time of arrival.13.13 The means of return to base hospital for the medical and nursing staff accompanyingthe patient should be established.MONITORING DURING TRANSPORT14.1 The standard of care and monitoring during transport should be at least as good asthat at the referring hospital or base unit20. The minimum standards required for allpatients are:_ Continuous presence of appropriately trained staff_ ECG_ Non-invasive blood pressure_ Arterial oxygen saturation (SaO2)_ End tidal carbon dioxide (EtCO2) in ventilated patients_ Temperature (preferably core and peripheral).In mechanically ventilated patients the oxygen supply, inspired oxygen concentration(FIO2) ventilator settings and airway pressure should be monitored.14.7 A written record of patient status, monitored values, treatment given and any otherclinically relevant information should be completed during the transfer.SUPPLEMENTARY EQUIPMENT FOR USE DURINGTRANSPORTAirway Guedel airways (assorted sizes) Laryngeal masks (assorted sizes) Tracheal tubes (assorted sizes) Laryngoscopes (spare bulbs andbattery) Intubating stylet Lubricating gel Magills forceps Tape for securing tracheal tube Sterile scissors StethoscopeVentilation Self inflating bag and mask withoxygen reservoir and tubing High flow breathing circuit Spare valves for portable ventilator Chest drains (assorted sizes) Heimlich flutter valvesSuction Yankauer sucker Suction catheters (assorted sizes) Nasogastric tubes (assorted sizes) anddrainage bagCirculation Syringes (assorted sizes) Needles (assorted sizes) Alcohol wipes IV cannulae (assorted sizes) Arterial cannulae (assorted sizes) Central venous cannulae Intravenous fluids Infusion sets/extensions 3 way taps Dressings Tape Minor instrument/cut down set

CHECK LIST 1.IS THE PATIENT STABLE FOR TRANSPORT?Airway Airway safe or secured by intubation Tracheal tube position confirmed onchest X-rayVentilation Paralysed, sedated and ventilated Ventilation established on transportventilator Adequate gas exchange confirmed byarterial blood gasCirculation Heart rate, BP stable Tissue and organ perfusion adequate Any obvious blood loss controlled Circulating blood volume restored Haemoglobin adequate Minimum of two routes of venousaccess Arterial line and central venous accessif appropriateNeurology Seizures controlled, metabolic causesexcluded Raised intracranial pressureappropriately managedTrauma Cervical spine protected Pneumothoraces drained Intra-thoracic and intra-abdominalbleeding controlled Intra-abdominal injuries adequatelyinvestigated and appropriatelymanaged Long bone/pelvic fractures stabilisedMetabolic Blood glucose >4 mmol/L Potassium 1 mmol/L Acidbase balance acceptable Temperature maintainedMonitoring ECG Blood pressure Oxygen saturation End tidal carbon dioxide Temperature

ARE YOU READY FOR DEPARTURE?Patient Stable on transport trolley Appropriately monitored All infusions running and linesadequately secured Adequately sedated and paralysed Adequately secured to trolley Adequately wrapped to prevent heatlossStaff Adequately trained and experienced Received appropriate handover Adequately clothed and insuredEquipment Appropriately equipped ambulance Appropriate equipment and drugs Batteries checked (spare batteriesavailable) Sufficient oxygen supplies Portable phone charged and available Money/credit cards for emergenciesOrganisation Case notes, X-rays, results, bloodcollected Transfer documentation prepared Location of bed and receiving doctorknown Receiving unit advised of departuretime and estimated time of arrival Telephone numbers of referring andreceiving units available Relatives informed Return travel arrangements in place Ambulance crew briefed Police escort arranged if appropriateDeparture Patient trolley secured Electrical equipment plugged intoambulance power supply whereavailable Ventilator transferred to ambulanceoxygen supply All equipment safely mounted orstowed Staff seated and wearing seat beltsTRANSPORT DOCUMENTATIONThe following information should be recorded on transport documentation.Transfer details Patients name, address, date of birth Next of kin, what information they have been given and by whom Referring hospital, ward/unit, and contact telephone number Name of referring doctor and contact telephone number Receiving hospital, ward/unit and contact telephone number Name of receiving doctor and contact telephone number Names and status of the escorting personnelA medical summary Primary reason for admission to the referring unit History and past history Dates of operations and procedures Number of days on intensive care Intubation history, ventilatory support and blood gases Cardiovascular status including inotrope and vasopressor requirements Other medication and fluids Type of lines inserted and dates of insertion Recent results and MRSA statusA nursing summary Nursing care required with reference to the following Respiration, cardiovascular parameters, communication methods, nutrition, pain andsedation, sleep patterns, elimination, skin condition, hygiene and social needsPatient status during transfer Vital signs including ECG, blood pressure SaO2, EtCO2, temperature, respiratory rate,peak inspiratory pressure, PEEP Drugs given during transfer including infusions Fluids given during transfer Summary of patients condition during transfer signed by escorting doctorAudit data including: Reason for the transfer Whether the transfer was within or outside the local network The urgency of the transfer Time taken for transfer from time of ambulance request to completion Adverse events/critical incidents

(Name of the Hospital)DEVICES / ACCESSORIES MONITORING CHARTName: Bed No: Ward: Unit Dr.:Age: Sex: Body Wt.: Diagnosis:SL. ITEM1stAPPLIEDONCHANGEDONCHANGEDONCHANGEDONCHANGEDONCHANGEDONCHANGEDONCHANGEDONCHANGEDONCHANGEDONCHANGEDON1. Ryles Tube2.Central Line(CVC)3.Femoral CentralLine (PICC)4.Peripheral Line(PVC)5. I. V. Drip Set6. E. T. Tube7.TracheostomyTube8. Ventilator Circuit9. Foleys Catheter10.Chest Tube(if any

ICU Daily Quality Checklist Place Patient Sticker here 1) Sedation: Protocol Ordered? Yes No Midazolam Dexmetetomidine Propofol Study drug none Sedation Interrupted this AM MAAS score @ 0400: _____ RASS score @ 0400: _____

2) Analgesia: Protocol Ordered? Yes No Fentanyl Morphine None

3) Neuromuscular Blockade: Protocol Ordered? Yes No Vecuronium Cisatracurium None Train of 4: _____

4) Delirium: Protocol Ordered? Yes No None noted prn haloperidol/risperidol Current CAM ICU: _____

5) DVT prophylaxis: Standard ICU orders? Yes No SQ unfractionated heparin SQ enoxaparin SCDs Foot pumps Full anticoagulation with: Heparin: PTT _____ Enoxaparin Warfarin INR _____ Major bleeding Minor bleeding Location: ____________

6) Stress ulcer prophylaxis Lansoprazole: enteral parenteral: b.i.d. gtt Esomeprazole enteral parenteral: b.i.d gtt Famotidine: enteral parenteral: b.i.d. gtt TPN drug: _____________________

7) Head of Bed Mechanically ventilated? Yes No 30o? Yes No Recorded on bedside chart? Yes No

8) Skin condition Braden score recorded Yes No Score:________ Specialty bed ordered Yes No Lesion present on transfer to ICU Yes No Wound team consulted Yes No Additional wound(s): location ________________________

9) Nutrition None Enteral: OG tube NG tube Salem sump soft feeding tube G/J tube goal rate: _______ current rate: _______ ml/hr interrupted > 4 hours in past 24o Parenteral: TPN PPN at goal rate Oral diet: clear liquids mechanical soft regular (including specific diets) Nutrition team assessment updated in record Yes No

Your Name: _________________

10) Disposition/Code Status DNR DNI Full code Advanced Directive in chart DPOA in chart Palliative care consulted SW consulted

11) Glucose control Insulin protocol ordered? Yes No conventional (100 150) tight (80 110) Hours in parameters (0400 to 0400): _____

12) Severe Sepsis: Present? Yes No Protocol Ordered? Yes No Central line placed? Yes No SvO2 monitored? Yes No Value? _____ Lactate documented? Yes No Value? _____ Drotrecogin protocol active? Yes No

13) Therapies PT OT Speech ordered ordered ordered active active active

14) Central line None #1 Subclavian Internal jugular Femoral PICC Non subclavian Left Right Tunneled Date placed: _____ If non-SC, reason documented? Yes No #2 Subclavian Internal jugular Femoral PICC Non subclavian Left Right Tunneled Date placed: _____ If non-SC, reason documented? Yes No #3 Subclavian Internal jugular Femoral PICC Non subclavian Left Right Tunneled Date placed: _____ If non-SC, reason documented? Yes No Patient location when line placed? #1 MICU ED Ward OR Other ICU Outside hospital #2 MICU ED Ward OR Other ICU Outside hospital #3 MICU ED Ward OR Other ICU Outside hospital 15) Mechanical ventilation? Yes No NPPV ET tube size: _____ Trach size: _____ ALI/ARDS protocol Lung protective strategy Peak pressure: ____ Plateau pressure: _____ Weaning protocol active? Yes No