Chapter 78. Monitoring and Transport of the Critically Ill Patient

1. Intrahospital transport is performed within the same hospital to different sites for diagnostic and therapeutic interventions. Interhospital transport involves the movement of a critically ill patient from one treatment facility to another.

2. Subsequent clinical management will be altered in approximately 40% of patients after transport out of the intensive care unit for diagnostic procedures and facilitated interventions. Abdominal computed tomography and angiography results are most likely to result in a change of management; thus transport is often well-justified.

3. Hemodynamic changes commonly encountered in transport include systemic hypertension, hypotension, and tachycardia. No clear factors predict hemodynamic deterioration during transport have been identified, except the level of overall pretransport morbidity, instability, or the presence of a recent myocardial infarction.

4. Respiratory deterioration including hypercarbia, hypocarbia, and hypoxemia may occur in a significant fraction of transported patients. Factors that predict changes include the need for positive end-expiratory pressure, an FiO2 greater than 50%, and age older than 43 years.

5. Appropriate assessment and management of the patient's airway is paramount in safe movement. Intubation during transport can be highly successful when performed by trained personnel, although patients with potentially difficult-to-manage airways are best intubated before transport.

6. Mechanical ventilation may maintain respiratory stability better than manual ventilation. Individuals trained in optimum manual ventilation (eg, respiratory therapists and anesthesiologists) and those with excellent patient assessment skills tend to maintain satisfactory respiratory parameters in patients undergoing transport. However, transport ventilatory systems may lack optimum alarms and may require constant surveillance for malfunction.

7. The US Emergency Medical Treatment and Active Labor Act (EMTALA, 1986) was established to mitigate financially motivated transport and requires that hospitals with emergency medical departments provide appropriate medical screening examinations within the capability of that hospital's emergency department, including ancillary services, to any individual who enters the department. If an acute medical condition is found, the department must either provide care or stabilize the patient before transfer to another facility.

8. Current regulations and good medical practice require that the competent patient or a legally authorized representative give informed consent before transfer to another hospital.

9. Physiologic monitoring of patients during transport should be maintained at the current level of care in the interest of patient's safety.

10. The advantages of air transport include reduced transport time over long distances and the ability to transfer many patients at one time. The primary disadvantages include a need for dedicated landing space, vibration, and expense. Potential insults related to transport by air include hypoxemia, decreases in ambient pressure, and hypothermia. "Altitude restrictions" are commonly ordered for patients with eye trauma, pneumothorax, intracerebral air, and sinusitis.

11. Pediatric patients (newborns and older children) are transferred most commonly for pulmonary insufficiency, cardiovascular compromise and congenital heart disease, or neurologic injury. This population benefits from dedicated specialty transport teams with specialized equipment.

12. Transport system design must involve integration of space, monitors, and support equipment that is compatible among the various sites to which a patient will be moved. Equipment engineering teams must design systems that minimize discontinuation of monitoring and disconnection of infused medications and mechanical ventilation. They must also prevent loss of continuous hemodynamic measurements.

Transport is assuming a more important role in the medical and surgical management of critically ill adult and pediatric patients. Patients with severe injuries today are transported over long distances, between countries and continents, and across time zones for advanced care. Advances in medical technology and treatment options have resulted in the need to move critically ill patients within and between hospitals for specialty care.

Intrahospital transfer may be performed to the operating room urgently for surgery, the radiology suite for diagnostic and therapeutic procedures, and from the emergency department throughout the hospital for additional care. Interhospital transfer involves the movement of a critically ill patient from one treatment facility to another. Transport exposes the patient to multiple stresses that may result in alterations of blood pressure, hypoxemia, arrhythmias, and potential airway compromise. These and other adverse events of transport can occur far from the skilled personnel, equipment, and monitoring of the intensive care unit (ICU) or operating room. Effective and safe transport of a patient does not simply involve movement but also the creation of compatible systems to minimize transport time, eliminate monitoring and medication interruptions, and reduce distractions that take the focus away from the patient.1

Transfer of a patient to a referral center occurs when the perceived benefit exceeds the risks associated with moving the patient. The Society of Critical Care Medicine convened a task force to examine the benefits of regionalization of medical care based on benefits demonstrated in neonatal and perinatal medicine,2 trauma,3,4 and burn care. Such a transfer is commonly referred to as secondary transport.5 The reasons for transport vary among individual hospitals, within medical systems, and across countries. Indications vary over time as technologic advances result in better care.

Intrahospital transport involves the movement of a patient throughout the same hospital for additional care that cannot be performed safely or adequately at the patient's bedside. Certain technology has brought procedures that previously required transport (eg, right-heart catheterization, certain computed tomography [CT] studies, echocardiography, ultrasonography, closure of patent ductus arteriosus, tracheostomy, and inferior vena cava filter placement) to the patient. Other studies and treatment may require movement of the critically ill patient to distant and more isolated areas of the hospital (Table 78-1). The duration of the trip may be long because of complicated diagnostic and therapeutic procedures. Patients who are "too ill" for a procedure in the operating room are frequently taken to radiology or other sites by a single nurse and respiratory therapist.

The overall benefit of transporting a patient out of the safety of the ICU for studies or procedures has been studied. The necessary "travel" results a change in patient management in 24% to 39% of cases.6,7 Abdominal CT and angiography most commonly result in changes.

Knowledge of the risks of patient transfer within a hospital or between facilities is imperative for informed decision making. Relative contraindications to transport may include the inability to oxygenate or ventilate a patient, uncontrolled hemodynamic instability, inadequate monitoring, inability to maintain an airway, and inadequate personnel. Despite these complicating circumstances, the life-threatening condition may still necessitate transfer to other facilities or sites of treatment. Morbidity and mortality are primarily related to hemodynamic and respiratory deterioration but also include interruption of medication administration, disconnection of intravenous (IV) access, loss of airway support, and human error (Table 78-2).

Patients transported within a particular hospital commonly experience hemodynamic and respiratory changes that can be associated with adverse outcomes or unexpected morbidity. These "complications" may be defined as inconsequential such as minor hemodynamic perturbations or may include major events resulting in death. In previously reported studies, the incidence of hemodynamic and respiratory changes varies widely from 5% to 68%.6-10 Most mishaps occur at the destination (Table 78-3). Many complications occur in radiology where the physical isolation, need to move the patient from the stretcher to the imaging table and back, duration of the procedure, and delay at the site may contribute to the occurrence of a mishap.9 There appears to be no correlation of the mishap rate with severity of illness as defined by the Acute Physiology and Chronic Health Evaluation score, number of escorts, number of lines, monitoring, or time spent out of the ICU.9 Szem et al found an overall mortality rate of 28.6% for patients requiring transport out of the ICU that was significantly higher than the control group (11.4%).10 There were no deaths directly related to transport, although patients who required transport out of the ICU may have been sicker.

The Australian Incident Monitoring Study in Intensive Care evaluated all reports from 91 units submitted in relation to incidents occurring during transport within the hospital between 1993 and 1999. Of 7525 submitted reports, 176 described 191 incidents during intrahospital transport. Analysis revealed that 39% of the incidents were equipment related and 61% were patient/staff management issues. System-based and human-based problems occurred equally.11 Significant adverse outcomes to the patients occurred in nearly a third of the events. The high incidence of system-based problems may have arisen from a need to disconnect a patient from ventilation, interrupt the delivery of vital infusions while changing to pumps and monitors specific to the transport process, and the limited battery life of transport devices. Often another monitoring system was in place at the site of treatment or destination, requiring further interruptions.

Patient movement between hospitals may be associated with longer transport times, greater isolation from advanced care, and stresses related to vibration, noise, and gravitational forces if transport is accomplished by air. In addition these patients may be more ill and transfer undertaken with more limited monitoring than usual within a hospital. Adverse events occurred in at least a third of interhospital transports with 30% of these attributable to technical problems.12 An analysis of incidents during out-of hospital patient transportation demonstrated that most errors are due to equipment failure, patient problems, transport operations, and interpersonal communications (Table 78-4).13 Review indicated that more than 90% are considered preventable.13

Hemodynamic Changes

Adverse hemodynamic alterations are among the most common events during both intrahospital and interhospital transport. The cause of the instability may be interruption of vasopressor infusions, stress and anxiety, pain, inadequacy of sedation, or fluid redistribution with patient movement.

Hypotension or hypertension occurs in 25% to 50% of intrahospital transports.7,14,15 Factors demonstrated to contribute include emergence from the effects of anesthetic agents, manual ventilation, and spinal anesthesia in the obstetric patient.14,16,17 Arrhythmias requiring treatment may occur in up to half of patients transported for "high-risk" cardiovascular conditions.18 The care provider is often confronted with these changes while dealing with unfamiliar drug delivery systems, the need to disconnect and reconnect to a new monitor, and the need to search for therapeutic medications in an unfamiliar area or while maneuvering a stretcher through halls or elevators.

Hemodynamic changes are at least as common with secondary transport between hospitals. Unless blood pressure is monitored by invasive means, these changes may be missed with noninvasive means as a consequence of vibration and noise.

High-risk cardiac patients, including those with recent myocardial infarctions, may demonstrate instability when transferred to higher levels of care, often manifested as arrhythmias, pump failure, or cardiogenic shock.19 The intubated patient may be "safer" from an "airway management" point of view, but pretransport intubation in this group of patients tends to be a marker for precarious and unstable hemodynamics. The era of thrombolysis means that many patients will have had some degree of reperfusion before transport to a center capable of definitive management and actually a lower incidence of difficulties than in earlier years.20 Rubenstein's study of 755 acutely ill cardiac patients, most with class III or class IV New York Heart Association heart failure, transported from community hospitals to tertiary care centers showed no complications. However, half required urgent intervention (coronary artery bypass graft or percutaneous transluminal coronary angioplasty) upon arrival. Studies show, however, that even the most tenuous patients can be safely transported including those on extracorporeal life support.21

Respiratory Impairment

Respiratory compromises encountered in patient transport include hypoxemia, hypercarbia with respiratory acidosis, hypocarbia with respiratory alkalosis, drying of secretions, plugging or displacement of the endotracheal tube, unexpected extubation, and an increased risk of ventilator-associated pneumonia.22 The incidence of respiratory changes during transport varies widely in reported studies. Factors potentially responsible for these changes include changes in the pattern of ventilation, mode of ventilation (manual versus mechanical), loss or absence of positive end-expiratory pressure (PEEP) with disconnection, endotracheal tube displacement, and equipment failure.

Hypoxemia (defined as a decreased PaO2-to-FiO2 ratio) occurs in up to 86% of transports involving patients artificially ventilated.23 The need for PEEP and higher FiO2 before transport correlates with a higher risk of deterioration.23,24 Even brief interruptions of PEEP for connection and disconnection can be detrimental to systemic oxygenation. Decreases in measured PaO2 end points of oxygenation may be less frequent with manual ventilation as the FiO2 is more commonly increased to 100%, whereas transport ventilators may maintain the pretransport FiO2.25

Hypercarbia may have detrimental effects on patient populations including those with increased intracranial pressure, pulmonary hypertension, or an existing acidosis. Hypercarbia and a resulting acidosis do occur in a very high percentage of critically ill intubated patients transported within and between hospitals.16,26,27 The incidence of respiratory acidosis and alkalosis appears to be less with mechanical as compared with manual ventilation during transport. Hypocarbia may result from overly aggressive ventilation and may be detrimental in patients with neurologic injury. Hyperventilation may also result in air trapping or dynamic hyperinflation, which is especially dangerous in the setting of hypovolemia. Failure of a ventilator during transport may be catastrophic, and yet transport ventilator alarms may be less sophisticated and not well heard in a noisy transport environment, hence a need for heightened team vigilance.

Drying of secretions and damage to the tracheobronchial tree as a result of prolonged exposure to desaturated air has been demonstrated.28 Dried secretions may result in occlusion of the airways or endotracheal tube. Efforts should be made to humidify the air that intubated patients receive, especially those subject to the very dry dehumidified environment during flight at altitude (tank gas is always dry unless actively humidified).

Extubation can be a major catastrophe during transportation. Up to 15% of all extubations in the critically ill patient are accidental.29 Patient transport is among the factors responsible. Difficulty is encountered in 20% of reintubations.29 Moving the head or repositioning of the patient commonly results in accidental extubation even in the presence of sedation or restraints.30 Transport of a patient with a new tracheostomy needs to be considered an especially dangerous event if extubation occurs.

Either manual or mechanical ventilation can be effective and safe in transport. One disadvantage to manual ventilation is that a care provider must focus on management of ventilation and the airway while potentially neglecting hemodynamic monitoring and other support activities. Other disadvantages include the need for 2 hands, management of decreased lung compliance, and fatigue with long transport.

Temperature and Injury

Patient transport removes the individual from the controlled setting of the ICU or operating room with both inter-and intrahospital movement. Use of fluid warmers is generally interrupted, warming blankets are disconnected, transport oxygen is commonly inhaled dry, and patients may require exposure for procedures in settings where room temperature cannot be optimally adjusted to protect the patient from hypothermia. Higher death rates are reported among those individuals who develop hypothermia in transport between hospitals or from the scene of an accident to the hospital. The reduction of temperature does not necessarily correlate with gender, age, flight time, outside air temperature, or type of patient.31 Hypothermia precautions are especially important in patients who are prone to hypothermia, including children and the elderly, burn patients, and victims of spinal cord injury. Shivering in an attempt to maintain body temperature increases oxygen consumption, which may prove detrimental in patients with myocardial ischemia.

Other risks of transport include exacerbation of injury by displacement of fractures, movement of an unstable cervical spine, and dislodgement of tubes or drains. Finally, pressure injuries to limbs, eyes, and skin may result from contact with equipment or accidental trauma.

Appropriate assessment and preparation is imperative before transporting the patient within or between hospitals. Research has shown that even the sickest patients can be transported when appropriate interventions are established early. General assessment for transport between hospitals includes a review of the medical history, current condition, recent interventions, hemodynamic and respiratory status and stability, current monitors and therapeutic device settings and function, and any changes prompting transfer. Consent for transport from the family or guardian must be obtained for the critically ill, and communication with the receiving physician, nurse, or hospital must be established. Assessment also includes planning for possible deterioration and establishing a course of action to deal with physiologic compromise. Wallace and Ridley identified 9 principles of safe patient transfer, which are listed in Table 78-5.32

Much effort has been expended to predict the physiologic deterioration and mortality associated with patient transport. Some studies examined hemodynamics, respiratory status, monitoring, pharmacologic support, and laboratory analysis but failed to predict which patient will do poorly.33,34 Other studies looked at PEEP, Injury Severity Score, and Therapeutic Intervention Score before transport and demonstrated that the more ill a patient is, the more likely the patient is to demonstrate instability with transport.35,36 Generally speaking, there is no accurate and reproducible method to predict accurately which patients will experience difficulty with transport. Those patients who demonstrate hemodynamic and respiratory instability before transport are more likely to manifest these changes during movement. The difficulty in predicting instability may be a result of a bias that results in sicker patients being transported by specialized transport teams, whereas those thought to be more stable may be subject to less vigilant care and treated by more inexperienced personnel. Logically the more ill a patient and the more interventions required to maintain that patient, the more at risk the patient is for complications during transport.

The need for stabilization before transport within and between hospitals cannot be sufficiently stressed. There is no evidence that a "scoop-and-run" approach to interhospital transport of critically ill patients is beneficial. Stabilization before transport is similar to any resuscitation and follows the traditional ABCs (airway, breathing, and circulation). Checklists can prove invaluable in assuring that appropriate steps have been taken (Table 78-6).

Airway and Intubation

The benefits of appropriately securing a patient's airway prior to transport include avoiding the potentially difficult conditions for intubation found during ground transport, aeromedical evacuation, and in remote sites within the hospital. A patient whose airway is judged to be stable should receive supplemental oxygen in nearly all circumstances. Patients intubated before transport should be assessed for endotracheal tube (ETT) position and adequacy of tube function, along with making sure it is appropriately secured. Auscultation of lung fields, exhalation fogging of the ETT, rise and fall of the chest, nail bed or lip color, and pulse oximetry help to confirm effective intubation. Chest radiography confirms not only the ETT position but also may define underlying lung pathology. Colorimetric or infrared end-tidal carbon dioxide (CO2) detection serves as an additional confirmation of appropriate tube position.

Certain patients may be successfully managed without intubation but are at risk for airway compromise during movement. These patients may benefit from intubation before transfer. Common indications for "elective intubation" in anticipation of transport include a Glasgow Coma Score less than 9, respiratory acidosis or impending respiratory failure, status asthmaticus, severe hypoperfusion, or shock. Patients with anatomic airway compromise arising from burns, epiglottitis, angioedema, anaphylaxis, or tracheolaryngeal trauma can benefit from intubation because the course subsequent to injury may be downhill. Certain stable but combative patients may require airway intubation and paralysis or sedation to assure safety.

Emergency medical personnel are particularly skilled in management of the airway, and their advanced training includes intubation.37,38 The 97% success rate for intubation during transport by emergency medical services (EMS) personnel is the same as intubation before transport. Experienced and highly trained care providers are more likely to intubate those patients whose airway appeared to be difficult to manage before transport. This may account for the high rate of success and neglect the true difficulty that would be encountered if the same patients were transported without prior intubation.

The laryngeal mask airway (LMA) serves as a valuable alternative or "backup option" to the ETT in the setting of difficult intubation. The LMA is not a definitive airway and does not protect against aspiration nor does it allow prolonged positive pressure ventilation. Routine suctioning of the airway is not possible. Generally the LMA does not depend on facial and tracheal anatomy, and placement can be successful from almost any position.39 Emergency medical personnel have used the LMA successfully in managing the airway in 89% of failed intubations.40

The American College of Critical Care Medicine and the Society of Critical Care Medicine recommend certain airway supplies be transported with patients (Table 78-7).41 These supplies must be available even with a so-called secured airway because inadvertent dislodgement and loss of an airway can occur. Appropriate-size bag-valve systems with an oxygen reservoir are imperative for transport in addition to a variety of masks, laryngoscope blades, endotracheal tubes, oral and nasal airways, and a portable oxygen supply.

Breathing and Ventilation

Adequacy of breathing and ventilation should be assessed before transport. It is imperative that tidal volume, respiratory rate, inspired oxygen concentration, PEEP, and mode of ventilation be noted and recorded. The respiratory trend may actually be more important that the actual current status of the patient. Increases in PaCO2 may indicate pending ventilatory failure, whereas decreases in arterial oxygen saturation or PaO2 may herald further failure of oxygenation. Sedation or deepening of sedation should be considered to facilitate oxygenation and ventilation. Transfer at altitude by reducing alveolar oxygen concentration can contribute to hypoxemia.

The risks of positive pressure ventilation include barotrauma, hypercarbia and hypocarbia, and dynamic hyperinflation (auto-PEEP), resulting in a reduced venous return and hypotension. The benefits of manual ventilation versus mechanical ventilation during transport are commonly debated. Traditional volume-controlled ventilators used for transport cannot deliver the specialized modes, such as pressure support and inverse ratio ventilation that may be required for critically ill patients. Comparisons between mechanical and manual ventilation for pediatric transport found greater variation in parameters with manual ventilation.42 These changes may be more significant for longer than shorter duration transport and more important in patients who are subject to compromise of pulmonary or cerebral blood flow, such as newborns with persistent pulmonary hypertension or victims of traumatic brain injury. Weg and Haas compared manual and mechanical ventilation and concluded that manual ventilation can be both safe and effective if the inspired oxygen concentration and minute ventilation are known before transport and ventilation performed by skilled care providers.25 Most transport services use a combination of manual and mechanical ventilation. Some use mechanical ventilation exclusively. Only a small number of services use only manual support.43 Austin et al have identified the ideal characteristics of a transport ventilator (Table 78-8).44

Both manual and mechanical ventilation are satisfactory for most patients. Those requiring complicated modes of ventilation or high PEEP, or who are subject to long transport times, should be transported with mechanical ventilatory support.

Transport within the hospital is commonly done on a stretcher with the patient in a supine position. The benefits of a slightly head-up position in the ICU may be lost for several hours during transport, increasing the risk of aspiration and pneumonia.45 The supine position may need to be maintained for minutes to hours while a procedure is performed within the hospital. Patients transported between hospitals by ground or air may encounter turbulence that may exacerbate pain and interfere with the ability to cough. Precautions to protect the airway from aspiration must be taken, especially when sedatives are administered.

Continuous monitoring of saturation by pulse oximetry is imperative during transport for all patients. End-tidal CO2 monitors are recommended for all intubated patients. Capnography may serve 2 purposes: to confirm appropriate placement of an ETT and to monitor respiration in an environment in which direct auscultation is difficult. Quantitative capnography may especially benefit head trauma victims who are at risk from either hyper- or hypocarbia.46 Less physiologic variability occurs when end-tidal CO2 is continuously monitored during manual ventilation.47 Continuous capnography is associated with a lower incidence of false alerts and malfunction as compared with pulse oximetry and is not as subject to motion artifact or loss of signal due to vasoconstriction.48

The options for treatment of a respiratory/airway complication during transport must be considered. Elevation of FiO2 to 100% during brief periods of transport may avoid hypoxemia. Increasing PEEP levels to compensate for hypoxemia may be necessary, but decreased venous return and barotrauma must be avoided. Administration of skeletal muscle relaxation may increase chest wall compliance and facilitate ventilation.

Cardiovascular

The hemodynamic stability of a patient before transport is imperative. Many of the hemodynamic changes seen with patient transport are reflections of the course prior to movement. Monitors of hemodynamic function should include displays of the electrocardiogram and blood pressure by either invasive or noninvasive means. Monitors must have visible and audible alarms, a long battery life, and illuminated displays. Transport defibrillators are essential for transport between hospitals and for patients within the hospital who are at a high risk of an arrhythmia (myocardial infarction, cardiac surgery). If transcutaneous pacing is possible (and likely to be needed), adequate capture should be confirmed.

Oscillotonometric or noninvasive measurement of blood pressure facilitates monitoring in the operating theater, postanesthesia care unit, and treatment wards. This form of monitoring may be subject to error during the movement of patients. Although this might not be important in hemodynamically stable, nonventilated patients, it may be critical for others. If invasive arterial monitoring is expected, it should be secured before movement. Invasive monitors must be calibrated to a "zero" reference point. Zero points change with patient positioning. Reestablishing the appropriate "zero" reference upon patient transfer or at altitude during flight is imperative.

Adequate IV access for delivery of fluids, continuous medication delivery, and intermittent treatment must be established. The confines and motion of any transport vehicle or stretcher can make placement en route difficult (Fig. 78-1). Adequate function and placement of backup or secondary lines should be considered. If transfusion is anticipated during transport, blood should be brought with the patient.

Hemodynamic compromise may result from inadequate preload, afterload, impaired myocardial contractility, or disturbances of cardiac rate and rhythm. Assessment must include a strategy for addressing the hemodynamic instability by assessment, volume resuscitation, and infusion of inotropic or vasopressor support as needed. The resources needed to provide these therapies must be provided during transport.

Neurologic Status and Sedation

Secondary insults during transport of head-injured patients are common and may include hypoxemia, hypotension, and intracranial hypertension, each of which worsens neurologic outcome. Although physiologic instability during transport is correlated with instability before movement, anticipation of problems and preparation for the management of problems is imperative.49 Appropriate physiologic monitoring of oxygenation and ventilation is necessary. Transport patients may benefit from continuous end-tidal CO2 analysis to avoid detrimental periods of hyper- and hypocarbia. In the patients with significant head trauma and cerebral swelling, invasive arterial access is necessary because even brief episodes of hypotension are detrimental to the brain. If an intracranial bolt or catheter drain is placed, an appropriate "zero" level must be established. Protection of the device must be assured to avoid dislocation. Increases of intracranial pressure (ICP) are detrimental in head injury. ICP is a dynamic measurement, and the importance of a single measurement is unclear. A plan and resources for addressing an increase in ICP are necessary. Interventions include head elevation, hyperventilation, mannitol and/or Lasix infusions, and cerebrospinal fluid drainage. The effects of these interventions on other parameters (eg, cardiovascular) must be considered. The effects of sedation on the neurologic assessment must be taken into consideration.

Sedation and pain control are rarely addressed in the transport literature despite the fact that transport subjects a patient to significant stress. The levels of epinephrine and norepinephrine in healthy male volunteers subject to EMS protocols are increased without sedatives as compared with individuals receiving midazolam during the same protocol.50 Increased catecholamine levels can increase myocardial oxygen consumption, cardiac ischemia, and infarction. Planning for transport involves an assessment of pain before movement because ground or air vehicles often impair the ability to communicate effectively with the patient. Short-acting benzodiazepines are generally chosen as sedatives because of their ease of titration and historical success. Devellis et al studied the use of small doses of fentanyl (0.33-5.0 μg/kg) in pediatric trauma victims. There was a statistically significant decrease in systolic blood pressure but no other major complications.51 Small doses of fentanyl (25-200 μg per administration) with a total dose of 1.0 to 5.0 μg/kg were well tolerated in patients transported by air.52 Complications associated with prehospital sedation seemed to occur more often in patients receiving both sedation and analgesia and are more common in patients who received sedation for endotracheal intubation.53 Sedation during patient transport within the hospital has not been well-studied. Planning must take into account the side effects of the medication and the potential pain and anxiety that the patient will experience during a procedure.

Consent

Many care providers do not consider transport of the critically ill patient a high-risk procedure despite its high complication rate. Although consent is commonly implied when a patient must be moved, good medical care requires that the patient or a proxy be aware of the risks. Current guidelines suggest that a competent patient or legally authorized representative of a patient give informed consent before transfer to another hospital.41 Despite these recommendations a minority of patients actually give consent for a hospital transfer.54 Unfortunately, at the time of the study, transfer of patients from private to public hospitals of minorities, the unemployed, and those without insurance was a common practice. The Emergency Medical Treatment and Active Labor Law (EMTALA, 1986) required that hospitals appropriately screen patients and provide treatment. If transfer is necessary the hospital is liable to ensure that within medical probability, no worsening of the patient's condition occurs during transfer.55 Three principles result in compliance with EMTALA: avoidance of financially motivated transfer, transfer only in the best interest of the patient, and maintenance of standards of care during all transport.

Communication

Communication between those initiating patient transfer and those ultimately receiving the patient is imperative. The referring physician should identify and contact an admitting physician at the receiving hospital to accept the patient in transfer and confirm before the transfer occurs that appropriate higher level resources are available.41 The patient remains the responsibility of the transferring team until a formal nursing and medical handover has occurred in the receiving department.5 Continual communication to provide guidance for transport personnel must be established.

Communication not only refers to the verbal transfer of information but also that appropriate records, images, and consent accompany the patient. Duplication of records and studies is often needed and should be done early to avoid delaying transfer. The advent of regional health information systems may mitigate the problem of difficulty with transfer of information.

No specific national standards exist for monitoring or required equipment for the transport of patients. Guidelines for transport have been published by several organizations including the American College of Critical Care Medicine and the Society of Critical Care Medicine.41 In general, the equipment for transport must be similar to that used in the ICU, yet it must be portable, small, lightweight, and rugged.56 Additionally, equipment intended for aeromedical transport must be low in weight, compact, and should not interfere with navigation, communication, or control mechanisms. The electrical load must not overwhelm the aircraft's system. Incompatibility of monitors and medication infusion systems creates time delays and results in periods of inadequate monitoring in critical situations. Transport personnel are frequently required to disconnect and reconnect cables and reestablish zero references for invasive pressures. Medical infusion pumps may need to be discontinued briefly as a device capable of transport is prepared. Upon arrival at the receiving site another change in patient care technology may again be necessary.

Equipment used for transport within a hospital should be compatible in different locations ideally avoiding the need to change pressure transducers, electrocardiogram (ECG), and pulse oximeter probes. Care providers receiving a patient should also be comfortable with the equipment that arrives with the patient.

Infusion Technology

Critically ill patients are often transferred while receiving continual infusions of medications. Medications to control hemodynamics, total parenteral nutrition, anticoagulation, and antibiotics are the most common agents. These medications often have a very narrow therapeutic window separating benefit from potential adverse events. Infusion devices allow the uninterrupted delivery of medications to patients based on the specific drug, concentration, and desired rate of delivery.

Care providers involved in the transfer of patients must be familiar and proficient with the mode or modes of infusion technology used for the delivery of medications. A misprogrammed decimal point may result in the death of a patient.57 New "smart pumps" have many of the safety features of older devices including dose calculations, free-flow protection, and occlusion alerts. The "smart pumps" also have programmable drug libraries with standardized concentrations and both "soft" and "hard" delivery limits based on the ability to override the delivery rate or not. When "smart" pump technology was applied to patients in the cardiac surgery perioperative period, though, a reduction in the number of errors did not occur. Most adverse drug events occurred because care providers bypassed the drug library in programming or elected to override limits.

Hospital systems must be configured so drug infusion devices and drug concentrations are standardized between units. These devices have become increasingly sophisticated. The US Food and Drug Administration (FDA) has declared infusion pumps as a critical technology in response to a number of deaths, recalls, and other incidents.58 This decision changed the way that devices are designed, tested, and assessed by the FDA before approval.58 Modern drug infusion systems must possess certain characteristics to assure patient safety and clinical function (Table 78-9).

Personnel accompanying a patient in transport within the hospital and between hospitals must at a minimum possess all the skills of basic life support. Potential transport personnel include physicians, nurses, respiratory therapists, paramedics, and emergency medical technicians. Guidelines published by the Society of Critical Care Medicine for interhospital transport state that a minimum of 2 people in addition to the vehicle operator must accompany the patient, and at least one should be a registered nurse, physician, or advanced medical technician skilled in airway management, IV therapy, and dysrhythmia interpretation and management.41 Recently revised guidelines recommend that a physician with advanced skills in airway management and advanced cardiac life support accompany all unstable patients.45 The safety of transport of routine patients without a physician has been demonstrated.60 Of note, transport mandating that a physician be in attendance may remove an essential health care provider from the transporting facility, so backup coverage should be provided.19

The efficacy of specially trained teams responsible for transport has also been demonstrated for adult8 and pediatric patients.61 Use of specialty teams allows continual training, development of specialized skills, and the ability to cross-train in the skills of others.

Maintaining the safety of the health care provider responsible for patient transport is vital. Back injuries are frequently cited as a reason nurses transfer to less physically demanding jobs or leave nursing entirely.62 Tasks such as transferring, lifting, moving, and turning patients comprise a major part of the nurse's daily activities. In 2003, the Occupational Safety and Health Administration published guidelines regarding ergonomics for the prevention of musculoskeletal injuries in the medical workplace. This document called for the manual lifting of patients to be eliminated whenever possible. Texas was the first state to adopt safe patient handling legislation and requires that hospitals and nursing homes adopt a policy to identify, assess, and develop strategies to control the risk of injury to both patients and nurses associated with lifting, transferring, repositioning, or moving.63 Few other states have adopted such legislation.

The movement of a patient from the bed to a stretcher and then from the stretcher to the operating table or radiology scanner has traditionally been accomplished with a draw sheet placed under the patient. The draw-sheet method requires the greatest amount of physical force as compared with methods such as a plastic bag placed under the patient or a friction-reducing device.64 The least amount of force is required when a mattress inflated with a blower is used. Small holes release air on the underside of the mattress providing a smooth surface over which to move the patient. A study recently completed showed a substantial decrease in the number of claims related to back injury when a lateral transfer system was used in a hospital-wide initiative.65 An understanding of the appropriate ergonomics of lifting is important as well as ready availability of air mattresses, friction-reducing devices, lifts, and hoists.

The risks and benefits of ground versus air transport must be considered when transporting a patient between hospitals. Gray et al suggested 7 factors that should influence the choice of the mode of transport (Table 78-10).5 Staff responsible for initiating and performing evacuation should be familiar with the physiologic factors that may potentially affect the patient in transport, especially when considering air transport. The special needs of neonates and pediatric patients must be understood. The American College of Emergency Physicians endorsed the following principle regarding patient transfer: "The health and well-being of the patient must be the overriding concern when any patient transfer is considered. The patient should be transferred in a vehicle that is staffed by qualified personnel and contains appropriate equipment."66

Air Transport

Air transport can be divided into the fixed-wing type (aircraft) and the rotor-wing type (helicopter). Fixed-wing transport tends to cover distances greater than 250 miles, whereas rotor-wing transport covers distances less than 250 miles.67 Helicopter transport is primarily beneficial for distances greater than 45 miles when compared with ground transport.68 Specific advantages of transport by airplane include long-distance capabilities, larger areas for patient care, space for more care providers, the ability to transport and care for many patients, less vibration, and generally less noise than rotor-wing transport. Disadvantages include the need to transport the patient by ground to and from the aircraft and the need for dedicated landing facilities. Advantages of transport by helicopter include the capability for rapid mobilization, vertical takeoff and landing, ease of transport at lower altitudes, and the ability to transfer patients at speeds of up to 150 miles per hour.67 The disadvantages include limited space for patient care, vibration, and noise, as well as greater dependence on good weather for flying (Fig. 78-1). Awareness of altitude-sensitive conditions and specific preparation for transport by air decrease complications (Table 78-11; see also Table 78-14).

Hypoxemia is a risk to any patient in transport but especially those with coronary ischemia, pulmonary compromise (acute respiratory distress syndrome [ARDS]), or neurologic injury. Hypoxemia commonly results in tachycardia and hypertension that may increase myocardial oxygen consumption. The barometric pressure of ambient air declines as altitude increases, although oxygen concentration remains at a constant 21%.69 At sea level, barometric pressure is 760 mm Hg with a partial pressure of oxygen of 160 mm Hg. Most aircraft cabins are usually pressurized to a pressure equivalent to 5000 to 8000 feet, giving an atmospheric partial pressure of oxygen of 118 mm Hg.70 This accounts for the fact that the oxygen requirement (FiO2) of a patient on mechanical ventilation may increase at altitude. Lawless and colleagues demonstrated that animals with chemically induced ARDS were resistant to increases of FiO2 yet responded to increased PEEP during transport.71 Benumof suggests that hypoxemia, even at low altitudes (3281-9843 feet), may contribute to global hypoxic pulmonary vasoconstriction and pulmonary edema.72 Helicopter transport may allow a patient to be transported at lower altitudes so as to minimize this effect.

The decrease in ambient pressure at altitude contributes to the expansion of air within a cavity in accordance with Boyle law.67 This effect may result in hemodynamic compromise (tension pneumothorax), barotrauma (sinuses), equipment malfunction (blood pressure cuffs), and possible patient injury or compromised monitoring.67 Conditions such as pneumopericardium, subcutaneous emphysema, gas gangrene, systemic air emboli, decompression sickness, and gastric distension may be worsened at altitude. Equipment considered "altitude sensitive" includes endotracheal and tracheostomy cuffs, pneumatic antishock garments (eg, medical antishock trousers), air splints, colostomy bags, Foley catheters, orogastric and nasogastric tubes, ventilators, invasive monitors, and intra-aortic balloon pumps. Additionally patients with a closed head injury may experience increases in ICP. An experimental model showed an increase in intracranial air volume by 30% at the usual maximum cabin altitude of 8000 feet.73 "Altitude restrictions" are commonly ordered for patients with eye trauma, pneumothorax, intracerebral air, and sinusitis.74 These restrictions and flying at low levels may result in more turbulence and longer transport times.

Temperature decreases with altitude. Cold air holds far less moisture than warm air. This contributes to the drying of secretions, potential occlusion of endotracheal tubes, and dehydration during transport at altitude.

The flight environment subjects the patient to other unique physiologic challenges. Acceleration and deceleration may induce hemodynamic changes, stress, and injury. These may be exacerbated in patients suffering from hypovolemia and spinal cord injury. Aircraft vibrations contribute to fatigue and discomfort along with interference with the appropriate function of equipment.68

Ground Transport

The advantages of ground transfer are primarily related to lower cost, rapid mobilization of resources, less dependency on weather conditions, and easier patient monitoring. The disadvantages include limited space to perform interventions and procedures, potential for delays because of traffic, and vehicle accidents with further injury to the patient and care providers (Fig. 78-2).

Modes of ground transport are not equivalent, and optimization of ground transport depends in part on equipment availability and to a larger extent on care provider skill levels available. Skills range from simple basic life support to advanced cardiac life support, to specialized transport teams. The skills of the transport team must be known when transfer is arranged, and there must be optimum matching of patient acuity and type of illness with the transport team's skills and resources.75 The critically ill patient with conditions requiring care at the level of a physician or specially trained nurse should be transported by a specifically trained physician or Critical Care Transport Team. The Commission on Accreditation of Medical Transport Systems defines a critical care mission as "the transport of a patient, from a scene or a clinical setting, whose condition warrants care commensurate with the scope of practice of critical care professionals (ie, physician or registered nurse)."76 The Association of Air Medical Services defines 6 conditions appropriate for transport by a specially trained critical care ground team:

1. Patient in critical condition.

2. Potential for deterioration into critical condition during transport.

3. Unstable vital signs.

4. Patient is intubated and ventilated for an acute medical condition.

5. Patient is receiving continuous infusion pharmacologic blood pressure support.

6. Conditions require time-sensitive treatment.

Before ground transport it is imperative that the transferring physician be aware of the strengths and limitations of the team with respect to personnel, equipment, and training.

Certain patient disease categories deserve discussion including neurologic injury, obstetric patients, chemical injuries and toxic agent exposure, pediatric patients, and transport for mass casualty.

Neurologic Conditions

Three populations of neurologic patients are commonly transferred: traumatic brain injury, spinal injury, and stroke.

Patients transported with traumatic brain injury are commonly subject to secondary insults that can potentially worsen the injury, including systemic hypertension, hypotension, raised ICP, reduced cerebral perfusion pressure, hypoxemia, and hyperthermia. The most common of these are hypertension and raised intracranial pressure. In a study by Andrews et al, complications occurred in about half of transfers for neurologic injury.77 The number of insults during transport mimics the number of insults both before and after the move. The higher an individual's injury score (based on systemic and mean blood pressure, intracranial pressure and cerebral perfusion pressure, temperature, heart rate, oxygenation, and ventilation) before transport, the more likely the occurrence of a transport complication. The Working Group on Neurosurgical Intensive Care of the European Society of Intensive Care Medicine has recommended guidelines for pretransport stabilization of the head injury patient (Table 78-12).78

Benefits of transport for the patient with acute spinal cord injury to centers skilled in this type of specialized care have been reported.79 The earlier the transfer, the greater the benefit.80 Outcome is best for patients transported within 12 hours. Benefits are less certain for those transferred more than 48 hours after a cord injury. The Congress of Neurologic Surgeons recommends that patients with acute spinal cord injury be expeditiously and carefully transferred from the site of injury to the nearest capable definitive medical care facility. The mode of transport should be chosen based on the clinical characteristics of the patient, distance to the receiving facility, and geography.81 Despite the best efforts of health care providers, additional movement of the spine-injured patient is associated with risk of further cord injury. Del Rossi et al demonstrated that both a log roll and lift-and-slide technique of movement can cause additional injury at the site of cord damage.82

Patients with acute stroke are commonly transferred for specialized medical care to provide diagnostic angiography and intra-arterial thrombolysis after a hemorrhagic stroke has been ruled out.83 Studies demonstrate that thrombolysis delivered within 3 hours after the onset of an occlusive stroke significantly improves outcome. Benefit may be seen with treatment up to 6 hours after occlusion, but these are inconsistent. Delays in transport commonly occur because of geographic characteristics, delayed patient/physician awareness of stroke symptoms, slow referral pathways, and in-hospital factors. Nedeltchev et al note that patients with symptoms consistent with stroke may benefit from direct referral to a tertiary care center equipped to provide thrombolysis without delaying them at a community hospital for CT imaging.83

High-Risk Obstetrics

Obstetric patient transfers comprise only a small percentage of transports between hospitals, approximately 5% in one study.84 Common indications include premature labor, premature rupture of membranes, eclampsia, preeclampsia, and multiple gestations. The greatest concerns of those transferring these patients include in-flight delivery of the fetus, inadequate fetal monitoring, and inexperience with this type of transport. General crew configuration is frequently a nurse and paramedic. A physician is directly involved in only 5% of transfers. Complicating factors include systemic hypertension, hypotension, increased contractions, and decreased maternal respiratory drive.85 Nausea and vomiting occur often. The potential for a difficult airway to be managed must be recognized. Placenta previa and placenta accreta have the potential for sudden deterioration, and such patients should be transported rapidly with appropriate volume line access. Outcome is improved if the mother is transferred before delivery of the fetus.86

Chemical Injury and Disaster Transport

Exposure to toxic chemical substances occurs in a variety of ways including industrial accidents and the deliberate release of toxic substances by terrorists. The health service must assure that appropriate care is provided to the injured without endangering the lives of health care providers. The Department of Health Emergency Planning Coordination Unit of the United Kingdom released a series of consensus statements addressing transfer and transport of chemical casualties (Table 78-13).87 According to a study in Washington state, most victims of hazardous material events are transported to a hospital (70%) yet only a small percentage are admitted for further care (5%).88 Victims of trauma, thermal burns, dizziness, or central nervous system symptoms such as headache are most likely to require admission. It is imperative that physicians involved in the care of critically ill patients be familiar with the hospital's plan for evacuation and transport of such patients.

Pediatric Transport

The development of neonatal transport systems in the 1970s preceded the focus on pediatric transport programs in the 1980s and 1990s.89 The primary indications for pediatric transport to referral centers are respiratory failure and cardiovascular insufficiency followed by neurologic compromise.90 Today improved care at centers of excellence in the management of pediatric conditions such as congenital heart disease results in more transfers.91 Common complications encountered during transport in the pediatric population include hypotension, decreased arterial oxygen saturation, and hyperthermia.92 Adverse technical events such as loss of IV access, failure of monitors, and dislodgement or malposition of the ETT occur in nearly 36% of transfers. Clinically adverse events such as hypotension, hypoxia, or hypoglycemia occurred in 27% of transfers reported by Hatherill et al.93

Pediatric transport is highly specialized. Interviews with pediatricians reveal that nearly half report insufficient knowledge of sophisticated transport equipment.90 Transport complication frequencies are higher in children transported by a referring physician compared with children transported by a specialized pediatric transport team. The higher rate of complications is believed due to a lower rate of appropriate pretransport interventions, lack of expertise with equipment, insufficient specialized equipment, materials, and lack of medications usually available to specialized teams and indeed all transport teams. The complexity of neonatal and pediatric transport and improved outcomes at tertiary care centers has resulted in the creation of specialist retrieval teams composed of physicians and nurses. Bellingan et al compared transport by a pediatric specialist retrieval team to standard practice. Patients transported by standard support teams commonly led by a trainee physician were more acidotic and demonstrated more hypotension than those moved by specialist teams.94 Patients transported by standard teams also had a higher mortality within the first 12 hours. Transport of the complicated pediatric patient is an area where clear benefit is demonstrated by specialized teams.

The key to safe pediatric transport is adequate preparation. A high percentage of patients require some preparatory intervention prior to transport.92 Those who receive these interventions have a lower rate of decompensation during transport or upon arrival at the receiving center. Routine resuscitation priorities take precedence. Preparation requires appropriately securing the airway and assuring correct ventilation. More than a third of pediatric transport patients require a change of the mode of ventilation before departure, whereas intubation is required by the transport team in 16.1% of patients.92 Fluid resuscitation is initiated in nearly a third of transports, and approximately a quarter require the IV infusion of vasoactive drugs.92

Several factors increase a child's susceptibility to hypoxemia and respiratory compromise, including a more compliant lung cage, reduced diameter of the airways, increased pulmonary vascular reactivity to hypoxia (infancy), a predisposition to a decreased respiratory drive in the setting of hypoxia (up to 1-2 months of age), and reduced surfactant production (neonates).68

Transport of Patients with Acute Coronary Syndrome

Myocardial infarction continues to be a leading cause of morbidity and mortality in industrialized nations.95 The timely treatment of patients with an acute coronary syndrome (unstable angina, ST segment elevation myocardial infarction (STEMI), and non-ST segment elevation myocardial infarction) contributes significantly to improving outcome. Survival is directly related to the rapidity of reperfusion therapy.

Once a patient with a myocardial infarction arrives at a hospital, the role of timely transport for treatment is imperative. The American College of Cardiology has established an initiative that all patients with STEMI receive an acute coronary intervention within 90 minutes of arrival at the hospital.96 The 90-minute time frame is only a guideline. Work has shown that even greater reduction in mortality occurs when "door-to-balloon" time is reduced even further.97

Coordination, Integration, Data Collection, and Quality Assurance

Changes in the system of patient transport over the years have resulted in many improvements, including an ability to transport sicker patients over long distances for specialized care. This need for transport will continue and will likely expand as technology results in increasingly sophisticated treatment. Smaller hospitals and medical centers may not be able to support the financial burden of expensive technology and teams, resulting in the expanded regionalization of services. Improvements have been made, but an apparent threshold of morbidity has been reached that will not be reduced unless systemwide changes are implemented. These changes should include the integration of technology and transport system design, generalized use of critical care transport teams for certain categories of patients that can benefit from advanced care, establishment of key protocols and guidelines, establishment of Internet-based electronic medical records for efficient transfer of information, collection of data and analysis of the metrics that indicate a satisfactory or unsatisfactory transfer, and critical care reporting systems that track the outcome of inter- and intrahospital transfer.

Technology and Transport System Design

Safe movement of a critically ill patient requires the coordinated effort of numerous trained individuals. Often the patient, monitors, and infusion pumps must be changed several times during one movement. Poorly designed or antiquated systems may even require the disconnection of medications and monitors and reconnection to completely different infusion systems and monitoring systems even within the same hospital, increasing transport time as well as subjecting the patient to periods without observation of vital signs or infusion of vital drugs. Systems that are not efficient, compact, and uncluttered can harm patients. Current work is being done on mobile ICU models that have integrated monitoring and support systems including ventilators, defibrillators, suction, point-of-care blood chemistry analysis, invasive monitoring of blood pressures, pulse oximetry, temperature, oxygen flow, and ECG. The benefits of such compact, contained systems include the need for fewer transport personnel, shorter preparation time, reduced periods of manual ventilation, and the potential to provide continuity of care and monitoring from the site of injury, transport to the hospital, emergency department admission, studies and transport to the ICU.98,99 Not only must equipment be compact and standardized for transport, ideally it should be compatible among and between the emergency department, operating room, intensive care unit, and common sites of patient treatment (eg, cardiac catheterization, radiology). It is recognized that a system of universal compatibility among different hospitals may be too costly and difficult, but within a single transport system and hospital it is not only feasible but should be imperative.

The Cleveland Clinic Foundation and the Massachusetts General Hospital have established systems that allow the easy transfer of support equipment without interruptions in therapy or the flow of vital information.1 The same monitors and infusion pumps used in the operating room are used during transfer and upon arrival in the ICU. Transport monitoring merely becomes an extension of the familiar bedside monitor. The benefits seen include more rapid preparation of the patient for movement, fewer personnel needed for transfer, and improved patient care.100

A multidisciplinary approach to ICU, operating room, and transport is imperative when hospitals upgrade their systems. Representatives from critical care, anesthesiology, surgery, respiratory therapy, nursing, and administration have vested stakes in safe, efficient patient movement.

Critical Care Transport Teams

Teams specialized in the transport of distinct categories of patients have proven to be beneficial by decreasing morbidity and mortality while increasing provider satisfaction. Specialist retrieval teams were initially developed to transport critically ill pediatric patients. Such studies suggest that specialized transport teams are needed to provide consistent safe care with a low rate of transport-associated complications and morbidity. Other populations best served by specialized teams include patients with ARDS or who require extracorporeal oxygenation or left ventricular assist devices, and perhaps those with head injuries. Factors to consider in the creation of these teams include the quality and scope of patient care, costs, medical justification, medicolegal issues, and return on investment based on the analysis of patient volume, overhead, and logistics.101

Protocols and Guidelines

Multiple organizations have developed and published guidelines for the transfer of critically ill patients.41,59 These guidelines are general and have not been adopted as standards. Four critical elements are required for the development of transfer plans: a multidisciplinary planning team, a medical needs assessment, a written standardized transfer plan, and continual evaluation and refinement as needed.41

Emergency medical services have established protocols. Transfer protocols are detailed and address not only common populations (pediatric patients, traumatic brain injury, asthma, myocardial infarction) but also specialized conditions and devices (intra-aortic balloon pumps, ventricular assist devices, inhaled nitric oxide).

Boston MedFlight has developed complete protocols for both air and ground transport of patients. All protocols have 6 "organizing principles" (Table 78-14). Protocols may lead to improved outcomes when conditions are repeatedly encountered. Protocols also allow the stocking of standardized medications and acquisition of equipment based on these plans. Over time care providers develop comfort working within a common framework, and systematic "reiteration" of the protocols leads to improved quality and efficiency.

Transfer of Medical Information

Transfer involves not only the efficient movement of the patient but the exchange of vital information from the transferring physician to the care provider en route, and their final receiving care provider. A significant number of errors occur during a handoff when care is transferred from one individual or service to another. The Joint Commission National Patient Safety Goals now require that hospitals implement a standardized approach to "handoff" communications.102 Direct verbal communication between the transferring and receiving physicians along with nurse-to-nurse reporting before patient movement ensures that the receiving facility is appropriate for current patient needs or condition and is prepared for receipt of the patient (medications, ventilation, studies, surgery if necessary). Clinical course may dictate that transfer be delayed or changed to another facility. Other factors important to communicate include directions to the receiving station or unit within a facility.

Electronic medical records and teleradiology should allow easier exchange of complete vital information. Internet-based record systems facilitate the receiving physician's ability to fully assess whether a transfer is appropriate.

Reporting and Critical Incident Evaluation

Reporting of unsafe practices, complications during patient transport, and critical analysis of patient safety practices is imperative if the etiology of adverse events and errors are to be determined and rectified. The Australian Incident Monitoring Study in Intensive Care was developed in 1993 as an anonymous voluntary reporting system to identify critical incidents and determine their underlying causes and contributing factors.11 A review of events related to patient transfer was carried out in 2004. The study revealed a high rate of serious outcomes (nearly a third of the incidents had significant adverse outcomes) almost evenly divided between system-based and human-based factors. Most events occurred between the ICU and operating room or radiology. Failure of equipment was primarily related to either battery or drug infusion pump failure. Other significant events included insufficient oxygen reserve within canisters. The most common patient/staff management issues were problems related to communication between the ICU and site of destination or origin. The value of incident monitoring lies not only in the systematic gathering of information but in the detailed analysis of the root causes of the events.11 Several key recommendations arose from this important study (Table 78-15). These recommendations primarily emphasize careful consideration of the risks, careful preparation, dedicated transport teams, checklists, careful documentation of events in transport, and monitoring of compliance with established standards.

Incident reporting systems in health care arose from examinations of the benefits of safety reporting systems in the aviation industry. The aviation systems have been characterized by an organized process for collecting, analyzing, and dissemination of events, sentinel events, and near-miss events in a "no-fault" environment that focuses on fixing "systems" rather than identifying and blaming individual operators. The Institute of Medicine of the National Academy of Science has emphasized this strategy, reporting that system failures rather than individual incompetence are the primary cause of health care errors.101 A reporting system optimized for the area of patient transport should be voluntary, nonpunitive, easy to carry out, and capable of providing feedback to participants.103 Holzmueller et al developed an Internet-based reporting system to deal with common barriers to success in reporting systems including underreporting, fear of reprisal, patient confidentiality, time pressure, duplication, and a generalized opinion that efforts were wasted because of little feedback.101 Their work, although preliminary, has demonstrated that an Internet-based system that collects data from multiple different ICUs across the United States is possible. Internet-based reporting systems may allow collection of data easily at multiple centers and facilitate sharing the findings. Although a single event at a particular reporting center may not lead to prompt action, the discovery of several similar events at various locations may acquire significance and require action.

Critical incident reporting and review results in better training of staff, implementation of guidelines for the maintenance and readiness of equipment, and a reduction in the number of adverse events.104

• Beckmann U, Gillies DM, Berenholtz SM, et al. Incidents relating to the intra-hospital transfer of critically ill patients. Analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Med. 2004;30:1579-1585.
• Indeck M, Peterson S, Smith J, et al. Risk, cost, and benefit of transporting ICU patients for special studies. J Trauma. 1988;28:1020-1025.
• Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Crit Care Med. 1990;18:278-281.
• Szem JW, Hydo LJ, Fischer E, et al. High-risk intrahospital transport of critically ill patients: safety and outcome of the necessary "road trip." Crit Care Med. 1995;23:1660-1666.
• Warren J, Fromm RE, Orr RA, et al. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med. 2004;32:256-262.
• Waydhas C. Intrahospital transport of critically ill patients. Crit Care. 1999;3:R83-R89.
• Woodward GA, Insoft RM, Pearson-Shaver AL, et al. The state of pediatric interfacility transport: consensus of the Second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference. Pediatr Emerg Care. 2002;18:38-43.