Guidelines For The Inter and Intrahospital.38 LT PDF

Special Articles
Guidelines for the inter- and intrahospital transport of critically ill

patients*
Jonathan Warren, MD, FCCM, FCCP; Robert E. Fromm Jr, MD, MPH, MS; Richard A. Orr, MD;
Leo C. Rotello, MD, FCCM, FCCP, FACP; H. Mathilda Horst, MD, FCCM; American College of Critical Care
Medicine
Objective: The development of practice guidelines for the con- a) pretransport coordination and communication; b) transport
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duct of intra- and interhospital transport of the critically ill pa- personnel; c) transport equipment; d) monitoring during transport;
tient. and e) documentation. The transport plan should be developed by
Data Source: Expert opinion and a search of Index Medicus a multidisciplinary team and should be evaluated and refined
from January 1986 through October 2001 provided the basis for regularly using a standard quality improvement process.
these guidelines. A task force of experts in the field of patient Conclusion: The transport of critically ill patients carries in-
transport provided personal experience and expert opinion. herent risks. These guidelines promote measures to ensure safe
Study Selection and Data Extraction: Several prospective and patient transport. Although both intra- and interhospital transport
clinical outcome studies were found. However, much of the pub- must comply with regulations, we believe that patient safety is
lished data comes from retrospective reviews and anecdotal enhanced during transport by establishing an organized, efficient
reports. Experience and consensus opinion form the basis of process supported by appropriate equipment and personnel. (Crit
much of these guidelines. Care Med 2004; 32:256 –262)
Results of Data Synthesis: Each hospital should have a for- KEY WORDS: intrahospital transport; interhospital transport; crit-
malized plan for intra- and interhospital transport that addresses ical care; health planning; policy making; monitoring; standards
T he decision to transport a crit- it may require transfer to another hospi- specially trained individuals. Since there
ically ill patient, either within tal. If a diagnostic test or procedural in- will almost certainly be situations when a
a hospital or to another facil- tervention under consideration is un- specialized team is not available for inter-
ity, is based on an assessment likely to alter the management or hospital transport, each referring and ter-
of the potential benefits of transport outcome of that patient, then the need tiary institution must develop contingency
weighed against the potential risks. Crit- for transport must be questioned. When plans using locally available resources for
ically ill patients are transported to alter- feasible and safe, diagnostic testing or those instances when the referring facility
nate locations to obtain additional care, simple procedures in unstable or poten- cannot perform the transport. A compre-
whether technical, cognitive, or proce- tially unstable patients often can be per- hensive and effective interhospital transfer
dural, that is not available at the existing formed at the bedside in the intensive plan can be developed using a systematic
location. Provision of this additional care care unit (1, 2). Financial considerations approach comprised of four critical ele-
may require patient transport to a diag- are not a factor when contemplating ments: a) A multidisciplinary team of phy-
nostic department, operating room, or moving a critically ill patient. sicians, nurses, respiratory therapists, hos-
specialized care unit within a hospital, or
Critically ill patients are at increased pital administration, and the local
risk of morbidity and mortality during emergency medical service is formed to
transport (3–17). Risk can be minimized plan and coordinate the process; b) the
*See also p. 305. and outcomes improved with careful team conducts a needs assessment of the
From Northwest Community Hospital, Arlington
Heights, IL (JW); Baylor College of Medicine, Houston, TX
planning, the use of appropriately quali- facility that focuses on patient demograph-
(REF); Children’s Hospital of Pittsburgh, University of Pitts- fied personnel, and selection and avail- ics, transfer volume, transfer patterns, and
burgh School of Medicine, Pittsburgh, PA (RAO); Subur- ability of appropriate equipment (16 –37). available resources (personnel, equipment,
ban Hospital, Bethesda, MD (LCR); Henry Ford Hospital, During transport, there is no hiatus in emergency medical service, communica-
Detroit, MI (HMH).
These guidelines have been developed by the Amer- the monitoring or maintenance of a pa- tion); c) with this data, a written standard-
ican College of Critical Care Medicine and the Society of tient’s vital functions. Furthermore, the ized transfer plan is developed and imple-
Critical Care Medicine. These guidelines reflect the official accompanying personnel and equipment mented; and d) the transfer plan is
opinion of the Society of Critical Care Medicine and do not are selected by training to provide for any evaluated and refined regularly using a
necessarily reflect, and should not be construed to reflect,
the views of certification bodies, regulatory agencies, or ongoing or anticipated acute care needs standard quality improvement process.
other medical review organizations. of the patient. This document outlines the minimum
Copyright © 2004 by Lippincott Williams & Wilkins Ideally, all critical care transports, both recommendations for transport of the
DOI: 10.1097/01.CCM.0000104917.39204.0A inter- and intrahospital, are performed by critically ill patient. Detailed guidelines
256 Crit Care Med 2004 Vol. 32, No. 1

targeted to the transport of infants and apy, hospital security) then are notified as ensured. All battery-operated equipment
children have been published by the to the timing of the transport and the is fully charged and capable of function-
American Academy of Pediatrics (23). In- equipment support that will be needed. ing for the duration of the transport. If a
stitutions performing commercial or or- The responsible physician is made aware physician will not be accompanying the
ganized interhospital transports are re- of the transport. Documentation in the patient during transport, protocols must
quired to function at and meet a higher medical record includes the indications be in place to permit the administration
standard, as the requirements for orga- for transport and patient status through- of these medications and fluids by appro-
nized transport services are considerably out the time away from the unit of origin. priately trained personnel under emer-
more rigorous than the recommenda- Accompanying Personnel. It is gency circumstances.
tions in this guideline (24, 38 – 41). strongly recommended that a minimum of In many hospitals, pediatric patients
The references for this guideline were two people accompany a critically ill pa- share diagnostic and procedural facilities
obtained from a review of Index Medicus tient.* One of the accompanying personnel with adult patients. Under these circum-
(see key words) from January 1986 is usually a nurse who has completed a stances, a complete set of pediatric resus-
through October 2001 and are catego- competency-based orientation and has met citation equipment and medications will
rized according to the degree of evidence- previously described standards for critical accompany infants and children during
based data employed. The specific cate- care nurses (42, 43). Additional personnel transport and also will be available in the
gory assigned to each reference is noted may include a respiratory therapist, regis- diagnostic or procedure area.
in the References at the end of this arti- tered nurse, or critical care technician as For practical reasons, bag-valve venti-
cle. The letter a denotes a randomized, needed. It is strongly recommended that a lation is most commonly employed dur-
prospective controlled investigation; b physician with training in airway manage- ing intrahospital transports. Portable me-
denotes a nonrandomized, concurrent, or ment and advanced cardiac life support, chanical ventilators are gaining
historical cohort investigation; c denotes and critical care training or equivalent, ac- increasing popularity in this arena, as
a peer-reviewed “state-of-the-art” article, company unstable patients.* When the pro- they more reliably administer prescribed
review article, editorial, or substantial cedure is anticipated to be lengthy and the minute ventilation and desired oxygen
case series; and d denotes a non-peer- receiving location is staffed by appropri- concentrations. In adults and children, a
reviewed opinion such as a textbook ately trained personnel, patient care may be default oxygen concentration of 100%
statement or official organizational pub- transferred to those individuals if accept- generally is used. However, oxygen con-
lication. The asterisk symbol will follow a able to both parties. This allows for maxi- centration must be precisely regulated
statement of practice standards. This in- mum utilization of staff and resources. If for neonates and for those patients with
dicates a recommendation by the Ameri- care is not transferred, the transport per- congenital heart disease who have single
can College of Critical Care Medicine that sonnel will remain with the patient until ventricle physiology or are dependent on
is based on expert opinion and is used in returned to the intensive care unit. a right-to-left shunt to maintain systemic
circumstances where published support- Accompanying Equipment. A blood blood flow. For patients requiring me-
ing data are unavailable. pressure monitor (or standard blood chanical ventilation, equipment is opti-
pressure cuff), pulse oximeter, and car- mally available at the receiving location
INTRAHOSPITAL TRANSPORT diac monitor/defibrillator accompany ev- capable of delivering ventilatory support
ery patient without exception.* When equivalent to that being delivered at the
Because the transport of critically ill available, a memory-capable monitor patient’s origin. In mechanically venti-
patients to procedures or tests outside with the capacity for storing and repro- lated patients, endotracheal tube position
the intensive care unit is potentially haz- ducing patient bedside data will allow re- is noted and secured before transport,
ardous, the transport process must be view of data collected during the proce- and the adequacy of oxygenation and ven-
organized and efficient. To provide for dure and transport. Equipment for airway tilation is reconfirmed. Occasionally pa-
this, at least four concerns need to be management, sized appropriately for tients may require modes of ventilation
addressed through written intensive care each patient, is also transported with or ventilator settings not reproducible at
unit policies and procedures: communi- each patient, as is an oxygen source of the receiving location or during transpor-
cation, personnel, equipment, and moni- ample supply to provide for projected tation. Under these circumstances, the
toring. needs plus a 30-min reserve. origin location must trial alternate
Pretransport Coordination and Com- Basic resuscitation drugs, including modes of mechanical ventilation before
munication. When an alternate team at a epinephrine and antiarrhythmic agents, transport to ensure acceptability and pa-
receiving location will assume manage- are transported with each patient in the tient stability with this therapy. If the
ment responsibility for the patient after event of sudden cardiac arrest or arrhyth- patient is incapable of being maintained
arrival, continuity of patient care will be mia. A more complete array of pharma- safely with alternate therapy, the risks
ensured by physician-to-physician and/or cologic agents either accompanies the ba- and benefits of transport are cautiously
nurse-to-nurse communication to review sic agents or is available from supplies reexamined. If a transport ventilator is to
patient condition and the treatment plan (“crash carts”) located along the trans- be employed, it must have alarms to in-
in operation. This communication occurs port route and at the receiving location. dicate disconnection and excessively high
each time patient care responsibility is Supplemental medications, such as seda- airway pressures and must have a backup
transferred. Before transport, the receiv- tives and narcotic analgesics, are consid- battery power supply.*
ing location confirms that it is ready to ered in each specific case. An ample sup- Monitoring During Transport. All crit-
receive the patient for immediate proce- ply of appropriate intravenous fluids and ically ill patients undergoing transport
dure or testing. Other members of the continuous drip medications (regulated receive the same level of basic physiologic
healthcare team (e.g., respiratory ther- by battery-operated infusion pumps) is monitoring during transport as they had
Crit Care Med 2004 Vol. 32, No. 1 257

in the intensive care unit. This includes,
at a minimum, continuous electrocardio-
graphic monitoring, continuous pulse
oximetry (44), and periodic measurement
of blood pressure, pulse rate, and respi-
ratory rate. In addition, selected patients
may benefit from capnography, continu-
ous intra-arterial blood pressure, pulmo-
nary artery pressure, or intracranial pres-
sure monitoring. There may be special
circumstances that warrant intermittent
cardiac output or pulmonary artery oc-
clusion pressure measurements.
INTERHOSPITAL TRANSPORT
Patient outcomes depend to a large
degree on the technology and expertise of
personnel available within each health-
care facility. When services are needed
that exceed available resources, a patient
ideally will be transferred to a facility that
has the required resources (45). Interho-
spital patient transfers occur when the
benefits to the patient exceed the risks of
the transfer. A decision to transfer a pa-
tient is the responsibility of the attending
physician at the referring institution.
Once this decision has been made, the
transfer is effected as soon as possible.
When needed, resuscitation and stabiliza-
tion will begin before the transfer (46,
47), realizing that complete stabilization
may be possible only at the receiving fa-
cility.
In the United States, it is essential for
practitioners to be aware of federal and
state laws regarding interhospital patient
transfers. The Emergency Medical Treat-
ment and Active Labor Act (EMTALA)
laws and regulations (updated at intervals
from the 1986 COBRA laws and the 1990
OBRA amendment) define in detail the
legal responsibilities of the transferring
and receiving facilities and practitioners.
The American College of Emergency Phy-
sicians has published a book (48) that
reviews the legal responsibilities of refer-
Figure 1. Interfacility transfer algorithm.
ring institutions as well as the ramifica-
tions of noncompliance with the COBRA/
EMTALA regulations, and it is an informed consent before interhospital ferring physician always writes an order
excellent resource for any facility in- transfer. The informed consent process for transfer in the medical record.
volved in patient transfers. In general, includes a discussion of the risks and Several elements are included in the
under COBRA/EMTALA, financially moti- benefits of transfer. These discussions are process of interhospital transfer, and all
vated transfers are illegal and put both documented in the medical record before fall within minimum guidelines, as de-
the referring institution and the individ- transfer. A signed consent should be ob- scribed subsequently. It is important to
ual practitioner at risk for serious penalty tained, if possible. If circumstance do not recognize that these process elements
(49, 50). allow for the informed consent process may frequently, and out of necessity, be
Current regulations and good medical (e.g., life-threatening emergency), then implemented simultaneously, espe-
practice require that a competent patient, both the indications for transfer and the cially when stabilization and treatment
guardian, or the legally authorized repre- reason for not obtaining consent are doc- are needed before transfer. An algo-
sentative of an incompetent patient give umented in the medical record. The re- rithm has been developed to guide prac-

Table 1. Recommended minimum transport equipment titioners through the transfer process
(Fig. 1).
Airway management/oxygenation—adult and pediatric
Pretransport Coordination and Com-
Adult and pediatric bag-valve systems with oxygen reservoir
Adult and pediatric masks for bag-valve system (multiple sizes as appropriate) munication. The referring physician will
Flexible adaptors to connect bag-valve system to endotracheal/tracheostomy identify and contact an admitting physi-
tube cian at the receiving hospital to accept
End-tidal carbon dioxide monitors (pediatric and adult) the patient in transfer and confirm before
Infant medium- and high-concentration masks with tubing
the transfer occurs that appropriate
MacIntosh laryngoscope blades (#1, #2, #3, #4)
Miller laryngoscope blades (#0, #1, #2) higher level resources are available. The
Endotracheal tube stylets (adult and pediatric) receiving physician is given a full descrip-
Magil forceps (adult and pediatric) tion of the patient’s condition. At that
Booted hemostat time, advice can be requested concerning
Cuffed endotracheal tubes (5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0)
Uncuffed endotracheal tubes (2.5, 3.0, 3.5, 4.0, 4.5, 5.0) treatment and stabilization before trans-
Laryngoscope handles (adult and pediatric) port. The appropriateness of transferring
Extra laryngoscope batteries and light bulbs a patient from an inpatient setting (crit-
Nasopharyngeal airways (#26, #30) ical care unit) to an outpatient setting
Oral airways (#0, #1, #2, #3, #4)
(e.g., emergency department) at a receiv-
Scalpel with blade for cricothyroidotomy
Needle cricothyroidotomy kit ing institution must be cautiously exam-
Water-soluble lubricant ined. If a physician will not be accompa-
Nasal cannulas (adult and pediatric) nying the patient during transport (34),
Oxygen tubing the referring and accepting physicians
PEEP valve (adjustable)
Adhesive tape will ensure there is a command physician
Aerosol medication delivery system (nebulizer) for the transport team who will assume
Alcohol swabs responsibility for medical treatment dur-
Arm boards (adult and pediatric) ing the transport. It may be appropriate
Arterial line tubing
for this individual to receive a medical
Bone marrow needle (for pediatric infusion)
Blood pressure cuffs (neonatal, infant, child, adult large and small) report before the team departs.
Butterfly needles (23-gauge, 25-gauge) In some instances (e.g., when a receiv-
Communications backup (e.g., cellular telephone) ing institution provides the transport
Defibrillator electrolyte pads or jelly team), the receiving physician may deter-
Dextrostix
ECG monitor/defibrillator (preferably with pressure transducer capabilities) mine the mode of transport. However,
ECG electrodes (infant, pediatric, adult) the mode of transportation (ground or
Flashlights with extra batteries air) usually is determined by the trans-
Heimlich valve ferring physician, in consultation with
Infusion pumps
the receiving physician, based on the ur-
Intravenous fluid administration tubing (adult and pediatric)
Y-blood administration tubing gency of the medical condition (stability
Extension tubing of the patient), time savings anticipated
Three-way stopcocks with air transport, weather conditions,
Intravenous catheters, sizes 14- to 24-gauge medical interventions necessary for on-
Intravenous solutions (plastic bags)
1000 mL, 500 mL of normal saline going life support during transfer, and
1000 mL of Ringers lactate the availability of personnel and re-
250 mL of 5% dextrose sources (51, 52). The transport service
Irrigating syringe (60 mL), catheter tip then will be contacted to confirm its
Kelley clamp
availability, to prepare for anticipated pa-
Hypodermic needles, assorted sizes
Hypodermic syringes, assorted sizes tient needs during transport, and to co-
Normal saline for irrigation ordinate the timing of the transport.
Pressure bags for fluid administration A nurse-to-nurse report is given by the
Pulse oximeter with multiple site adhesive or reusable sensors referring facility to the appropriate nurs-
Salem sump nasogastric tubes, assorted sizes
Soft restraints for upper and lower extremities ing unit at the receiving hospital. Alter-
Stethoscope natively, the report can be given by a
Suction apparatus transport team member at the time of
Suction catheters (#5, #8, #10, #14, tonsil) arrival. A copy of the medical record, in-
Surgical dressings (sponges, Kling, Kerlix)
cluding a patient care summary and all
Tourniquets for venipuncture/IV access
Trauma scissors relevant laboratory and radiographic
The following are considered as needed studies, will accompany the patient. The
Transcutaneous pacemaker preparation of records should not delay
Neonatal/pediatric isolette patient transport, however, as these
Spinal immobilization device
Transport ventilator records can be forwarded separately (by
facsimile or courier) if and when the ur-
PEEP, positive end-expiratory pressure; ECG, electrocardiogram; IV, intravenous. gency of transfer precludes their assem-
blage beforehand. Under these circum-
stances, the most critical information is

Table 2. Recommended minimum transport medications
A
Adenosine, 6 mg/2 mL lthough both in-
Albuterol, 2.5 mg/2 mL
Amiodarone, 150 mg/3 mL tra- and interhos-
Atropine, 1 mg/10 mL
Calcium chloride, 1 g/10 mL pital transport
Cetacaine/Hurricaine spray
Dextrose 25%, 10 mL
Dextrose 50%, 50 mL
must comply with regula-
Digoxin, 0.5 mg/2 mL
Diltiazem, 25 mg/5 mL tions, we believe patient
Diphenhydramine, 50 mg/1 mL
Dopamine, 200 mg/5 mL safety is enhanced during
Epinephrine, 1 mg/10 mL (1:10,000)
Epinephrine, 1 mg/1 mL (1:1000) multiple-dose vial transport by establishing an
Fosphenytoin, 750 mg/10 mL (500 PE mg/10 mL)
Furosemide, 100 mg/10 mL organized efficient process
Glucagon, 1 mg vial (powder)
Heparin, 1000 units/1 mL supported by appropriate
Isoproterenol, 1 mg/5 mL
Labetalol, 40 mg/8 mL equipment and personnel.
Lidocaine, 100 mg/10 mL
Lidocaine, 2 g/10 mL
Mannitol, 50 g/50 mL
Magnesium sulfate, 1 g/2 mL
Methylprednisolone, 125 mg/2 mL bles 1 and 2 provide a detailed list of the
Metoprolol, 5 mg/5 mL minimum recommended equipment and
Naloxone, 2 mg/2 mL pharmaceuticals needed for safe interho-
Nitroglycerin injection, 50 mg/10 mL spital transport. Emphasis is placed on
Nitroglycerin tablets, 0.4 mg (bottle)
Nitroprusside, 50 mg/2 mL airway and oxygenation, vital signs mon-
Normal saline, 30 mL for injection itoring, and the pharmaceutical agents
Phenobarbital, 65 mg/mL or 130 mg/mL necessary for emergency resuscitation
Potassium chloride, 20 mEq/10 mL and stabilization as well as maintenance
Procainamide, 1000 mg/10 mL
of vital functions. Very short or very long
Sodium bicarbonate, 5 mEq/10 mL
Sodium bicarbonate, 50 mEq/50 mL transports may necessitate deviations
Sterile water, 30 mL for injection from the listed items, depending on the
Terbutaline, 1 mg/1 mL severity and nature of illness or injury.
Verapamil, 5 mg/2 mL Furthermore, advances in knowledge
over time will result in periodic review
The following specialized/controlled medications are added immediately before transport as
indicated and modification of these lists. All items
Narcotic analgesics (e.g., morphine, fentanyl) (59) are checked regularly for expiration of
Sedatives/hypnotics (e.g., lorazepam, midazolam, propofol, etomidate, ketamine) (59) sterility and/or potency, especially when
Neuromuscular blocking agents (e.g. succinylcholine, pancuronium, atracurium, rocuronium) transports are infrequent. Equipment
(60) function is verified on a scheduled basis,
Prostaglandin E1
Pulmonary surfactant not at the time of transport when there
may be insufficient time to find replace-
ments.
Monitoring During Transport. All crit-
communicated verbally. It is strongly ities of advanced airway management, in- ically ill patients undergoing interhospi-
suggested that policies be established travenous therapy, dysrhythmia interpre- tal transport must have, at a minimum,
within each institution regarding the tation and treatment, and basic and continuous pulse oximetry, electrocar-
content of documentation and communi- advanced cardiac life support. In the ab- diographic monitoring, and regular mea-
cation between personnel involved in the sence of a physician team member, there surement of blood pressure and respira-
transfer. will be a mechanism by which the trans- tory rate.* Selected patients, based on
Accompanying Personnel. It is recom- port team can communicate with a com- clinical status, may benefit from the
mended that a minimum of two people, mand physician. If communication of monitoring of intra-arterial blood pres-
in addition to the vehicle operators, ac- this type becomes impossible, the team sure (55), central venous pressure, pul-
company a critically ill patient during will have preauthorization by standing monary artery pressure, intracranial
interhospital transport.* When trans- orders to perform acute lifesaving inter- pressure, and/or capnography (56). With
porting unstable patients, the transport ventions. In the absence of a readily avail- mechanically ventilated patients, endo-
team leader should be a physician or able external transport team, a transport tracheal tube position is noted and se-
nurse (41, 53, 54), preferably with addi- team and vehicle may need to be assem- cured before transport, and the adequacy
tional training in transport medicine. For bled locally. The development of policies of oxygenation and ventilation is recon-
critical but stable patients, the team and procedures for such emergencies is firmed.
leader may be a paramedic (41). These strongly recommended. Occasionally, patients may require
individuals provide the essential capabil- Minimum Equipment Required. Ta- specialized modes of ventilation not re-

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1987; 70:43– 45 (c) Transport Systems (CAMTS). Accreditation 52. Werman HA, Falcane RA, Shaner S, et al:
30. Blumen I, Gordon R: Taking to the skies. Standards. Fourth Edition. CAMTS, 1999 (d) Helicopter transport of patients to tertiary
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National Institute for Health and Care Excellence
1
Consultation
Chapter 34 Standardised
systems of care for intra- and
inter-hospital transfers
Emergency and acute medical care in over 16s: service
delivery and organisation
NICE guideline <number>
July 2017
Draft for consultation
Developed by the National Guideline Centre,

hosted by the Royal College of Physicians
Emergency and acute medical care
Contents
Disclaimer
Healthcare professionals are expected to take NICE clinical guidelines fully into account when
exercising their clinical judgement. However, the guidance does not override the responsibility of
healthcare professionals to make decisions appropriate to the circumstances of each patient, in
consultation with the patient and, where appropriate, their guardian or carer.
Copyright
© National Institute for Health and Care Excellence, 2017. All rights reserved.
Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

Contents
34 Hospital transfers ................................................................................................................. 5
34.1 Introduction .......................................................................................................................... 5
34.2 Review question: Do standardised systems of care for intra- and inter-hospital
transfers of critically ill patients improve outcomes?........................................................... 5
34.3 Clinical evidence.................................................................................................................... 5
34.4 Economic evidence ............................................................................................................. 13
34.5 Evidence statements ........................................................................................................... 15
34.6 Recommendations and link to evidence ............................................................................. 16
References..................................................................................................................................19
Appendices .................................................................................................................................24
Appendix A: Review protocol ........................................................................................................ 24
Appendix B: Clinical article selection ............................................................................................ 25
Appendix C: Forest plots ............................................................................................................... 26
Appendix D: Clinical evidence tables ............................................................................................. 29
Appendix E: Economic evidence tables ........................................................................................ 41
Appendix F: GRADE tables ............................................................................................................ 42
Appendix G: Excluded clinical studies ........................................................................................... 45
Appendix H: Excluded health economic studies ........................................................................... 48

4
1 34 Hospital transfers
2 34.1 Introduction
3 The transfer of critically ill patients is not at present standardised throughout the UK. There are some
4 guidelines that have been published however they do cause some degree of inconsistency.
5 Currently there are large numbers of critically ill patients who require transfer between critical care
6 units which does pose significant risks. It is also more than likely that these numbers will increase
7 over the coming years and, there is data that shows transfers are poorly performed, we needed to
8 look at all different ways this could be implemented and gather the evidence to make a strong
9 enough recommendation to improve the transfer of these patients.
10 There are also many transfers of critically ill patients for therapeutic or diagnostic purposes within
11 the same hospital which also needs to be looked at so that staff have some degree of instruction so
12 that we have the best possible outcome for these patients.
13 Carefully planned transfers improve outcomes such as mortality and avoidance of adverse effects
14 which the guideline group felt was of critical importance.
15 There is also some uncertainty as to how this should be standardised hence the reason the group
16 looked at different comparisons including the possible use of mobile ICU transfers. However, this has
17 to be cost effective and plausible. There can be significant differences throughout the country
18 however it is said that “transfers should be standardised whether the travel is 100yards or 100
19 miles”.
20
21 34.2 Review question: Do standardised systems of care for intra- and

22 inter-hospital transfers of critically ill patients improve outcomes?
23 For full details see review protocol in Appendix A.
24 Table 1: PICO characteristics of review question

Population Hospitalised adults and young people (16 years and over) with or at risk of critical
illness undergoing intra- or inter-hospital transfer.
Intervention Standardised system (including checklist of both staffing and equipment) for transfer.
Comparison No standardised system for transfers.
Outcomes Mortality (CRITICAL)
Avoidable adverse events (CRITICAL)
Quality of life (CRITICAL)
Length of stay (CRITICAL)
Patient and/or carer satisfaction (CRITICAL)
Staff satisfaction (IMPORTANT)
Study design Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no
relevant SRs or RCTs are identified.
25 34.3 Clinical evidence

26 Six studies for inter-hospital transfer systems were included in the review (7 papers); 3 were non-
27 randomised comparative studies and 3 were before-after studies16,35,51,52,65,74,77; these are
28 summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence

5
1 summary below (Table 3, Table 4, Table 5 and Table 6). See also the study selection flow chart in
2 Appendix B, forest plots in Appendix C, study evidence tables in Appendix D, GRADE tables in
3 Appendix F and excluded studies list in Appendix G.
4 No RCTs were identified by the search and following the review strategy, observational studies were
5 considered. The included observational studies pertain to standardised inter-hospital transfer
6 systems only, as no studies on standardised intra-hospital transfer systems were identified. All
7 included studies are non-randomised and the analyses un-adjusted.
8 Table 2: Summary of studies included in the review

Intervention and
Study comparison Population Outcomes Comments
Bellingan Transfer by: Retrospective ICU mortality, Specialist team
200016 standardised review of all inter- mortality within 6 consisted of an ICU-
system - UCLH hospital transfers and 12 hours of trained doctor (senior
Non- specialist team (n=259) into admission and SPR or consultant),
randomised using a mobile ICU University College hazard ratio of nurse, driver, and
comparative (n=168). London Hospital’s survival. medical physics
study (UCLH) intensive technician, all trained
Versus care unit, UK, over in the transfer of ICU
the course of 1 year patients. The specialist
Standard in 1996/1997. team spent between
emergency 30 and 300 mins
ambulance with a stabilising patients in
medical escort the referral hospital
provided by the before transfer.
referring hospital
(n=91). Unadjusted analysis.
Gallagher Standardised Before and after Narrative results Before most patients
2014B36 checklist - study involving only: with NSTE-ACS would
introduction of a patients (n=702) present to their district
Before and novel clinical treated at London Length of stay general hospital (DGH)
after study pathway Heart Chest Hospital, UK, (median, IQR), time and await transfer to
Attack Centre- over the course of to coronary regional cardiac centre
Extension (HAC-X) 1 year in angiography for angiography. The
for the 2009/2010. (median, IQR). novel pathway was
management of designed to rapidly
non-ST elevation identify patients with
acute coronary NSTE-ACS while in DGH
syndromes (NSTE- emergency
ACS). departments and
facilitate transfer to
Before (n=391). the regional
interventional centre
Versus for ‘early’ coronary
angiography.
After (n=311).
Patients in post-HAC-X
group were younger
and more likely to have
been smokers.
Unadjusted analysis.
Malpass Introduction of a Before and after 48-hour mortality, The novel patient
201552 novel patient study involving ICU mortality, transfer checklist
transfer patients (n=211) hospital mortality, covered: patient data,
Before and standardised admitted to the adverse events reason for transfer,

6
Intervention and
after study checklist. medical ICU team (antibiotics treatment
of a single changed on arrival, recommendations, and
Before (n=134). academic tertiary need for emergent condition on arrival.
referral centre in intubation and
Versus Virginia, US, who need for emergent Adjusted analysis but
were transferred central line). only for APACHE score.
After (n=77). from outside
hospitals over the
course of 1 year in
2009 (6 months)
and 2011 (6
months).
Reimer 201365 Transfer via: Retrospective Narrative results Non-randomised data;
standardised database review of only: not before-and-after
Non checklist - patients (n=133) study. Unadjusted
randomised streamlined inter- undergoing inter- Time in ED analysis.
comparative facility referral facility transport (median, IQR; total
study protocol (n=54) with a referring time patient spent Both cohorts were
diagnosis of acute in referring evaluated after a
Versus ST-segment department, streamlined inter-
elevation including time for facility referral
Traditional referral myocardial arrival of transport protocol to reduce
process (n=79). infarction (STEMI) team), door-to- door-to-balloon (D2B)
to a tertiary care balloon time times for patients
centre in Ohio, US, (median, IQR). experiencing acute
over the course of STEMI had been
1 year in implemented.
2009/2010.
The hospital operates a
hospital-based critical
care transport team
consisting of 2
helicopters and 1
ground ambulance; the
crews are staffed with
an acute care nurse
practitioner and critical
care registered nurse
and/or critical care
paramedic.
Waddell Inter-hospital Before and after Mortality within 24 Unclear if before-and-
197574 transfers via: study involving hours of transfer, after study
standardised critically ill patients final mortality. (‘retrospective’ versus
Non system - intensive (n=66) transferred ‘prospective’ data
randomised therapy unit ‘Flying to the intensive collection). Time
comparative squad’ team in an therapy unit of the period of data
study ambulance of Western Infirmary, collection for flying
standard design Glasgow, UK. squad not mentioned.
(n=20). Data of ambulance Six years for standard
transfers was ambulance.
Versus collected Unadjusted analysis
retrospectively and flying squad
Standard over 6 years. Data patients considerably
ambulance (n=46). for the intensive older.
therapy unit ‘flying
squad’ was Team composition of

7
Intervention and
collected standard ambulance
prospectively (time transfers not
period unknown). described.
‘Flying squad’
consisted of 1 or 2
members of a ‘shock
team’, who travelled to
transfer hospital set up
equipment, started
treatment and
accompanied the
patient in the
ambulance.
Wiegersma Inter-hospital Before and after Avoidable adverse Direct comparison of 2
201177 transfers via: study involving incidents (technical individual audits.
Ligtenberg standardised critically ill patients failure; staff Patients not
200551 system - mobile ICU (n=174) transferred management issues comparable at baseline
with a specialised to the University of and/or inadequate and no analysis and no
Before and retrieval system Groningen affiliated preparation), adjustments made; for
after study (n=74). ICU and the ICU of adverse events example, patients
Scheper Hospital in (delayed transferred via MICU
Versus Emmen, the hypotension). had higher disease
Netherlands. severity and were
Standard Standard older.
ambulance with ambulance transfer
staff provided by data was collected
the referring over 14 months51;
hospital (n=100). mobile ICU transfer
data was collected
over the course of
10 months in
200977.

8
1 Table 3: Clinical evidence summary: Standardised system of transfer versus standard ambulance transfer
No of Anticipated absolute effects
Participants Quality of the Relative
(studies) evidence effect Risk difference with Mobile ICU
Outcomes Follow up (GRADE) (95% CI) Risk with Control versus standard transfer (95% CI)
Adverse incidents (staff management issues or 174 ⊕⊝⊝⊝ Peto OR 0.13 Moderate
inadequate preparation) (1 study) VERY LOWa (0.06 to 0.32) 240 per 1000 201 fewer per 1000
due to risk of bias (from 148 fewer to 221 fewer)
Adverse incidents (technical failures) 174 ⊕⊝⊝⊝ RR 1.22 Moderate
(1 study) VERY LOWa, b (0.52 to 2.84) 100 per 1000 22 more per 1000
due to risk of bias, (from 48 fewer to 184 more)
imprecision
Adverse events (delayed hypotension) 66 ⊕⊝⊝⊝ RR 1.31 Moderate
imprecision
9
Mortality HR 259 ⊕⊝⊝⊝ HR 0.56 Moderate

(1 study) VERY LOWa, b (0.35 to 0.9) Control group risk Absolute effect cannot be calculated
due to risk of bias, not provided
imprecision
Mortality - Overall ICU mortality 259 ⊕⊝⊝⊝ RR 0.8 Moderate
(1 study) VERY LOWa, b (0.55 to 1.15) 352 per 1000 70 fewer per 1000
imprecision
Mortality - 6 hour mortality 259 ⊕⊝⊝⊝ RR 0.14 Moderate
imprecision
Mortality - 12 hour mortality 259 ⊕⊝⊝⊝ RR 0.39 Moderate
imprecision
Participants Quality of the Relative

(studies) evidence effect Risk difference with Mobile ICU
Outcomes Follow up (GRADE) (95% CI) Risk with Control versus standard transfer (95% CI)
Mortality - Final mortality 66 ⊕⊝⊝⊝ RR 1.15 Moderate
imprecision
Mortality - Mortality within 24 hours of transfer 66 ⊕⊝⊝⊝ RR 0.77 Moderate
imprecision
1 (a) All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2
2 increments if other factors suggest additional very high risk of bias.
3 (b) Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
4 Table 4: Clinical evidence summary: ICU transfer checklist versus no transfer checklist
10

Participants Quality of the Relative Risk difference with ICU transfer
(studies) evidence effect Risk with checklist versus no transfer checklist
Outcomes Follow up (GRADE) (95% CI) Control (95% CI)
Adverse events - adjusted OR - Need for emergent 211 ⊕⊝⊝⊝ OR 0.09 Moderate
central line (1 study) VERY LOW (0.02 to Control group Absolute effect cannot be calculated
due to risk of biasa 0.36) risk not
provided
Adverse events - adjusted OR - Need for emergent 211 ⊕⊝⊝⊝ OR 0.18 Moderate
intubation (1 study) VERY LOWa,b (0.02 to Control group Absolute effect cannot be calculated
due to risk of bias, 1.46) risk not
imprecision provided
Adverse events - adjusted OR - Antibiotics changed on 211 ⊕⊝⊝⊝ OR 0.48 Moderate

arrival (1 study) VERY LOWa, b (0.27 to Control group Absolute effect cannot be calculated
Anticipated absolute effects
No of
Participants Quality of the Relative Risk difference with ICU transfer
(studies) evidence effect Risk with checklist versus no transfer checklist
Outcomes Follow up (GRADE) (95% CI) Control (95% CI)
Mortality - adjusted OR - Hospital mortality 211 ⊕⊝⊝⊝ OR 0.85 Moderate
(1 study) VERY LOWa, b (0.46 to Control group Absolute effect cannot be calculated
Mortality - adjusted OR - ICU mortality 211 ⊕⊝⊝⊝ OR 0.77 Moderate
Mortality - adjusted OR - 48-hour mortality 211 ⊕⊝⊝⊝ OR 0.74 Moderate

11

1 (a) All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2
3 (b) Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
5 Narrative results
6 A retrospective database review65 compared the introduction of a streamlined transfer protocol with the traditional transfer protocol and found that it
7 reduced transfer times of patients experiencing ST-segment myocardial infarction (see Table 5 below). The authors also comment that door-to-balloon
8 times of 90 minutes or less were achieved in 13% of the traditional referral patients and in 30% of the streamlined protocol group (OR=2.9; 95% CI 1.2-7.0).
9 Table 5: Summary: Before and after introduction of a streamlined transfer

Traditional transfer (n=79) Streamlined transfer (n=54) P
Emergency department 60 (45-84) 55 (44-67) 0.07

Door-to-balloon time 122 (99-157) 101 (88-128) 0.001
1 Data reported in minutes as median (25-75% interquartile range). Emergency department time is total time patient spent in referring department, including time waiting for arrival of
2 transport team. Door-to-balloon time is total time from presentation at outside ED to percutaneous coronary intervention65.
3 A prospective observational study36 assessed a novel clinical pathway for the management of patients with non-ST elevation acute coronary syndromes
4 and found the direct transfer protocol reduced length of hospital stay and time to coronary angiography (see Table 6 below).
5 Table 6: Summary: Before and after introduction of a clinical pathway for patients with suspected acute coronary syndromes
Pre-HAC-X pathway (n=391) Post-HAC-X pathway (n=311) P
Time to coronary angiography 7.2 (5.1-10.2) 1.0 (0.7-2.0) <0.001
Length of hospital stay 9.0 (6.0-14.0) 3.0 (2.0-6.0) <0.001
6 Data reported in days as median (25-75% interquartile range).
7
12
8
1 34.4 Economic evidence

2 Published literature
3 No relevant health economic studies were identified.
4 The economic article selection protocol and flow chart for the whole guideline can found in the
5 guideline’s Appendix 41A and Appendix 41B.
6 Cost analysis
7 It is likely that the use of standardised systems for transfer will require more staff time for the
8 implementation of the relevant checklists or protocols.
9 Of the studies included in the clinical review, 3 were UK studies16,36,74. It was possible to attach unit
10 costs to resource use described in 1 of these studies, Bellingan 200016, which compared transferring
11 ICU patients using a UCLH specialist transfer team and a mobile ICU with transfer by standard
12 emergency ambulance with a medical escort (junior doctor with training in anaesthesia).
13 In Bellingan, the specialist transfer team consisted of an ICU-trained doctor (specialist registrar or
14 consultant), nurse, driver and medical physics technician all trained in transfer of ICU patients. The
15 mobile ICU is equipped to ICU standards with all-round stretcher access, piped oxygen and air, nitric
16 oxide, mechanical ventilation, suction 220-V power supply and multi-channel monitoring. The
17 specialist team spent between 30 and 300 minutes (mean 70 minutes) stabilising patients in the
18 referring hospital before transfer.
19 The mean cost per patient in the intervention and the control arms has been calculated using
20 information regarding the team composition and current unit costs. These costs are included in Table
21 7 for the intervention and in Table 8 for the comparator arms.
22 Table 7: Mean cost of staff time per patient in the intervention arm (mobile ICU)
Mean cost of Mean cost of
patient patient
stabilisation stabilisation
time at mean cost of time at
cost per referring actual receiving Weight Mean total
hour(a) hospital(b) transfer (c) hospital(d) (e) cost
Consultant ICU
£140 £163.33 £26.83 £70.00 0.5 £130
Specialist
registrar ICU £61 £71.17 £11.69 £30.50 0.5 £57
Nurse
£49 £57.17 £9.39 £24.50 1 £91
medical physics
technician £38 £44.33 £7.28 £19.00 1 £71
Mean cost per
patient £348
23 (a) Source: PSSRU 2014 costs for a medical consultant, registrar, Nurse, 24-hour ward (includes staff nurse, registered
24 nurse and registered practitioner) and science, technical and therapeutic staff: allied health professional (qualified),
25 respectively, including qualifications28.
26 (b) Based on a mean of 70 minutes as reported in the paper.
27 (c) Based on a mean travel distance of 12 miles, as reported in the paper, and 60 miles per hour.
28 (d) Assuming 30 minutes of stabilisation time in the receiving hospital.
29 (e) A weight of 0.5 assigned to both a consultant and a specialist registrar as the team could include either.

13
1 Table 8: Mean cost of staff time per patient in the control arm (standard ambulance)
Mean cost of
Mean cost of patient
patient stabilisation
stabilisation time mean cost of time at
cost per at referring actual receiving Weight Mean
hour(a) hospital(b) transfer (c) hospital(d) (e) total cost
Paramedic
(qualified) £33 £16.50 £6.33 £16.50 1 £39
Specialist
registrar £61 £30.50 £11.69 £30.50 1 £73
Mean cost
per patient £112
2 (a) Source: PSSRU 201428.
3 (b) Based on a mean of 30 minutes stabilisation time at referring hospital (assumed).
4 (c) Based on a mean travel distance of 12 miles, as reported in the paper, and 60 miles per hour.
5 (d) Based on a mean of 30 minutes stabilisation time at referring hospital (assumed).
6 (e) One paramedic (assumed) and 1 junior doctor (reported in the paper) are considered to be present in each journey.
7 Other costs not included here are the costs of the standard ambulance and the mobile ICU journey,
8 including the drivers’ time, as it was not possible to locate these costs. The transfer service is usually
9 provided by private providers with prices subject to locally negotiated contracts. Additionally,
10 training costs for members of the specialist transfer team were not included. Hence, costs of the
11 mobile ICU and specialist team intervention and its incremental cost compared to the standard
12 ambulance transfer are likely to be underestimated. Additionally, we have not included any time
13 required for the ambulance deployment and return to base.
14 Based on the study’s mortality data reported in the clinical review, the use of mobile ICU and
15 specialist transfer team was associated with lower overall ICU mortality (70 fewer per 1000, that is,
16 0.07 deaths averted per patient). Based on this, the incremental cost effective ratio could be
17 calculated as:
18 ICER= (£348-£112)/0.07=£3,377 per death averted.
19 For this intervention to be cost-effective at a cost-effectiveness threshold of £20,000 per QALY

20 gained, it has to generate a number of QALYs per patient equivalent to ΔQALYs where:
21 £20,000= ΔC/ΔQALYs = £3,377 /ΔQALYs.
22 Thus, ΔQALYs could be calculated to be 0.17 QALYs. This means the intervention will need to result in
23 at least 0.17 QALYs gained per patient to be cost-effective at a threshold of £20,000 per QALY gained.
24 As explained earlier, the calculated incremental cost is likely to be an underestimate due to the
25 possibly higher incremental cost when the cost of the transport vehicle is included. Additionally, if
26 the routine use of the mobile ICU for transfers would require extra staffing to provide cover in the
27 referring ICU, then the incremental cost of using the mobile ICU would be considerably higher. The
28 quality of the clinical evidence that informed this analysis should also be taken into account when
29 interpreting it. Furthermore, possible benefits from using a mobile ICU, other than mortality, have
30 not been included in this analysis.
31

14
1 34.5 Evidence statements

2 Clinical
3 Specialist transport systems versus standard ambulance transfer
4  Five studies compromising 1334 people evaluated the role of standardised systems of care for
5 intra- and inter-hospital transfers of critically ill patients for improving outcomes in secondary
6 care in adults and young people at risk of an AME, or with suspected or confirmed AME. The
7 evidence suggested that transfer via specialist transport systems may provide a benefit in
8 reduced adverse incidents expressed as staff management issues or inadequate preparation (1
9 study, very low quality) and mortality at 6 hours, 12 hours and ICU overall mortality (1 study,
10 very low quality) and mortality within 24 hours of transfer (1 study, very low quality).
11 However, there was a possible increase in adverse incidents technical failures (1 study, very
12 low quality) and adverse events delayed hypotension (1 study, very low quality) and final
13 mortality (1 study, very low quality).
14
15 ICU transfer checklists versus no transfer checklist
16  One study compromising 211 people evaluated the role of ICU transfer checklist versus no
17 transfer checklist for intra- and inter-hospital transfers of critically ill patients for improving
18 outcomes in secondary care in adults and young people at risk of an AME, or with suspected
19 or confirmed AME. The evidence suggested that transfer checklists and protocols may
20 provide a benefit in reduced adverse events and mortality. The evidence was graded very
21 low for all outcomes.
22 Economic
23  No relevant economic evaluations were identified.
24

15
1 34.6 Recommendations and link to evidence

Recommendations 20. Use standardised systems of care (including checklists, staffing and
equipment) when transferring critically ill patients within or between
hospitals.
Research
recommendations -
Relative values of The guideline committee considered mortality, avoidable adverse events as reported
different outcomes by study, quality of life, and carer/family satisfaction to be critical outcomes. Length
of stay, and staff satisfaction were considered important outcomes.
Trade-off between Six observational studies were identified for inter-hospital transfers. No evidence
benefits and harms from randomised trials was identified.
The evidence was presented across separate intervention types:
Standardised specialist transport systems versus standard ambulance transfer
Specialist transport systems include mobile intensive care units and standard
transport augmented by specialist retrieval. Mobile intensive care systems were
primarily focused on secondary transfers of critically ill patients from a referring
hospital to a major centre. Five studies were identified. The evidence suggested that
specialist transport systems may provide a benefit in reduced adverse incidents (staff
management issues or inadequate preparation) and mortality (overall ICU, 6 hour,
within 24 hours of transfer). However, in these observational and before-and-after
studies there was a possible increase in adverse incidents (technical failures and
episodes of delayed hypotension) and a higher final mortality. These trends,
associated with mobile intensive care unit transfers, are very likely to be a
consequence of unmeasured case mix differences and more effective monitoring:
specialist transport permits transfer of sicker patients. The committee noted that
other studies have shown physiological stability during specialist transfer 18,19. Whilst
the evidence was not conclusive, the committee felt that elements of standardised
specialist transport systems were likely to be effective in improving care including
the use of specialist staff and equipment.
ICU transfer checklist versus no transfer checklist
One study evaluated the role of ICU transfer checklist versus no transfer checklist for
critically ill patients. The evidence suggested that transfer checklists and protocols
may provide a benefit in reduced adverse events upon arrival at the receiving
hospital (that is, reduced need for emergent central venous cannulation, emergent
intubation, and changes to antibiotics at the time of arrival) and mortality (48-hour,
ICU and overall hospital mortality).
No evidence was found for length of stay, quality of life, carer/family satisfaction,
and staff satisfaction for either specialist transport systems or the transfer checklist
sections.
The committee felt that the benefits of a reduction in mortality and reduction of
adverse events was strong enough to make a recommendation to use standardised
systems of care for the transfer of critically ill patients, including standardised
protocols, skilled staff, specialised equipment and checklists for the secondary
transfer of critically ill patients.
The decision to make a strong recommendation based on weak evidence represents
the unanimous view of the committee based on extensive clinical experience, the
widespread adoption of standardised processes by industry and by the military, and
the promotion by the World Health Organisation of standardised care processes
such as the WHO checklist. Paediatric critical care has long provided specialist critical

16
hospitals.
Research
recommendations -
care regional retrieval services, demonstrated to be effective64 and now funded by
NHS England as part of specialised commissioning.
Trade-off between No economic evaluations were identified.

net effects and costs It was possible to attach UK-specific unit costs to resource use described in 1 of the
UK studies that compared transferring critically ill patients using mobile ICU with
transfer using standard ambulance. The analysis showed that transferring patients
using mobile ICU would be more costly, with an incremental cost of £236 per
patient. Combining this estimate of the incremental cost with the effectiveness
estimate from the systematic review of the clinical evidence, which estimated that
the use of mobile ICU would be associated with a reduced overall ICU mortality (70
fewer per 1000), it was possible to calculate an incremental cost ratio of £3,200 per
death averted for the mobile ICU intervention. A threshold analysis was also
presented where the minimum number of QALYs gained required in order to make
the use of mobile ICU cost effective at a threshold of £20,000 per QALY gained was
calculated and was found to be 0.17 QALYs gained per patient. The committee
highlighted that this could be considered a plausible QALY gain to achieve, however,
it has to be taken into account that these are critically ill patients. It was also
highlighted that the study on which this analysis is based was a small observational
study conducted in a single hospital in London and the generalisability of its findings
to the rest of the UK might be limited.
Additionally, the committee acknowledged that a mobile ICU might not always be
available, especially in rural areas, and it was important therefore to focus not on the
ambulance as the mobile ICU, but on the specialist staff and transport equipment
which constitute the basis of mobile intensive care. There are arguments for having
regional transport teams so that existing staff are not diverted away from delivering
care in the ICU. The cost-effectiveness of such a service is difficult to estimate and
will depend on local demand and travel times.
The results of the clinical review showed a benefit in terms of mortality and adverse
events for the use of standardised transfer systems using checklists, protocols and
skilled staff. Given the limited resources required for use, the committee believed
that these are likely to be cost-effective. Based on their collective experience, and
evidence from other clinical areas (for example, surgery), the committee believed
that there is clear evidence of benefit when using standardised systems.
The committee felt that there should not be a cost impact from the use of checklists
and protocols. For more high-risk transfers, for example transfer between ICUs,
specialist staff might be required, which could require investment in some parts of
the country.
Quality of evidence Six observational studies for inter-hospital transfer systems were included in the
review. No RCTs were identified by the search. The included observational studies
pertain to standardised inter-hospital transfer systems only, as no studies on
standardised intra-hospital transfer systems were identified.
All included studies are non-randomised and most of the analyses un-adjusted,
leading to very high risk of bias for most of the evidence. Also, before-and-after
studies do not control for an effect of time on the outcome. The evidence for
mortality and avoidable adverse events in both sections, mobile ICU transfers and
ICU transfer checklist, was of very low quality due to the study design, risk of bias

17
hospitals.
Research
recommendations -
and imprecision. In addition, data of 2 of the 6 studies (those that were in a cardiac
population) could only be presented in narrative form (medians and interquartile
range).
Three of the studies were from the UK. The committee considered the study
demonstrating reduced hazards of death through transport via a mobile ICU
particularly relevant to the current UK context. However, they also highlighted 1
other UK study on mobile ICU transfers as being old and at high risk of bias.
Other considerations The committee recognised that despite expansion of critical care services in England,
ICU transfers still occur in situations when 1 unit has reached capacity. The practice
may vary widely across the country depending on geography as well as local funding
of services (for example, urban versus rural locations). As transfer of critically ill
patients for non-clinical reasons is undesirable, if the practice persists because of
resource constraints, then standardising processes of care to assure patient safety
needs little justification. Paediatric retrieval teams were established precisely for this
reason.
Two of the studies focused on inter-hospital transfers to more specialist cardiology
units. The committee felt that hospital transfers involving highly specialist units are
important. They noted that there is already NICE guidance available about the use of
standardised systems of care for hospital transfer for specific indications. The NICE
service delivery guideline on Major Trauma published in 201657 recommends:
1.5 Transfer between emergency departments.
1.5.1 Provide a protocol for the safe and rapid transfer of patients who need
definitive specialist intervention.
1.5.2 Train clinical staff involved in the care of patients with major trauma in the
transfer protocol.
1.5.3 Review the transfer protocol regularly.
The committee noted that professional guidance exists for standardised transfers,
including equipment, personnel, training and communication34,45,48.
Adequate training in inter- and intra-hospital transfers is delivered uniformly in the
NHS. With the increasing move to integrated care, transfers between hospitals are
likely to be more common place. Training in the transfer of patients should be
embedded into the curricular of both medical and non-medical practitioners.
1
2

18
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37
38

23
1 Appendices
2 Appendix A: Review protocol
3 Table 9: Review protocol: standardised systems for intra- and inter-hospital transfers
Review question: Do standardised systems of care for intra- and inter-hospital transfers of critically ill
patients improve outcomes?
(Please note this is allocated as 2 questions as the criteria includes protocols, documentation and
equipment).
Rationale Systems for transferring critically ill patients within or between hospitals
vary widely. Standardised systems for planning and conducting transfers,
and for quality assurance through audit, may reduce risks in this highly
dependent patient population.
Topic code T6-12.
Population Hospitalised adults and young people (16 years and over) with or at risk of
critical illness undergoing intra- or inter-hospital transfer.
Intervention Standardised system (including checklist of both staffing and equipment) for
transfer.
Comparison No standardised system for transfers.
Outcomes Patient outcomes;
Mortality (CRITICAL)
Avoidable adverse events (CRITICAL)
Quality of life (CRITICAL)
Length of stay (CRITICAL)
Carer outcomes;
Carer/family satisfaction
Staff satisfaction
Exclusion Non-OECD countries.
Search criteria The databases to be searched are: Medline, Embase, the Cochrane Library.
Date limits for search: None.
Language: English.
The review strategy Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be
included if no relevant SRs or RCTs are identified.
Analysis Data synthesis of RCT data.
Meta-analysis where appropriate will be conducted.
Studies in the following subgroup populations will be included in subgroup
analysis:
 Inter versus intra-hospital.
In addition, if studies have pre-specified in their protocols that results for
any of these subgroup populations will be analysed separately, then they will
be included in the subgroup analysis. The methodological quality of each
study will be assessed using the Evibase checklist and GRADE.
5
6

24
1 Appendix B: Clinical article selection

Figure 1: Flow chart of clinical article selection for the review of inter- and intra-hospital
transfers
Records identified through database Additional records identified through

searching, n=2477 other sources, n=9
Records screened, n=2486
Records excluded, n=2416
Full-text articles assessed for

eligibility, n=70
Studies included in review, n=6 Studies excluded from review, n=63

(7papers)
Reasons for exclusion: see Appendix H
3
4

25
1 Appendix C: Forest plots

2 C.1 Standardised system versus standard ambulance transfer
Figure 2: Mortality (hazard ratio)
Hazard Ratio Hazard Ratio
Study or Subgroup log[Hazard Ratio] SE Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
1.5.1 Mortality HR
Bellingan 2000 -0.5798 0.2398 100.0% 0.56 [0.35, 0.90]

Subtotal (95% CI) 100.0% 0.56 [0.35, 0.90]
Heterogeneity: Not applicable

Test for overall effect: Z = 2.42 (P = 0.02)
0.1 0.2 0.5 1 2 5 10

Favours mobile ICU Favours stand. ambulance
Extracted from the Kapplan-Meier plot in the paper.
Figure 3: Mortality (at different time points)

Standardised systems Non-standardised systems Risk Ratio Risk Ratio
Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.4.1 Overall ICU mortality
Bellingan 2000 47 168 32 91 100.0% 0.80 [0.55, 1.15]
Subtotal (95% CI) 168 91 100.0% 0.80 [0.55, 1.15]
Total events 47 32
1.4.2 6 hour mortality

Bellingan 2000 1 168 4 91 100.0% 0.14 [0.02, 1.19]
Subtotal (95% CI) 168 91 100.0% 0.14 [0.02, 1.19]
Total events 1 4
1.4.3 12 hour mortality

Bellingan 2000 5 168 7 91 100.0% 0.39 [0.13, 1.18]
Subtotal (95% CI) 168 91 100.0% 0.39 [0.13, 1.18]
Total events 5 7
1.4.4 Final mortality

Waddell 1975 9 20 18 46 100.0% 1.15 [0.63, 2.10]
Subtotal (95% CI) 20 46 100.0% 1.15 [0.63, 2.10]
Total events 9 18
1.4.5 Mortality within 24 hours of transfer

Waddell 1975 1 20 3 46 100.0% 0.77 [0.08, 6.93]
Subtotal (95% CI) 20 46 100.0% 0.77 [0.08, 6.93]
Total events 1 3
0.1 0.2 0.5 1 2 5 10

Test for subgroup differences: Chi² = 5.57, df = 4 (P = 0.23), I² = 28.2%
4
Figure 4: Adverse incidents (due to staff management issues or inadequate preparation)

Standardised systems Non-standardised systems Peto Odds Ratio Peto Odds Ratio
Study or Subgroup Events Total Events Total Weight Peto, Fixed, 95% CI Peto, Fixed, 95% CI
1.1.1 Staff management issues or inadequate preparation
Wiegersma 2011 0 74 24 100 100.0% 0.13 [0.06, 0.32]
Subtotal (95% CI) 74 100 100.0% 0.13 [0.06, 0.32]
Total events 0 24
Test for overall effect: Z = 4.53 (P < 0.00001)
0.1 0.2 0.5 1 2 5 10


26
Figure 5: Adverse incidents (due to technical failures)

1.2.2 Technical failures
Wiegersma 2011 9 74 10 100 100.0% 1.22 [0.52, 2.84]
Subtotal (95% CI) 74 100 100.0% 1.22 [0.52, 2.84]
Total events 9 10
0.1 0.2 0.5 1 2 5 10

Figure 6: Adverse events (that is, delayed hypotension)

1.3.1 Adverse events (delayed hypotension)
Waddell 1975 4 20 7 46 100.0% 1.31 [0.43, 3.99]
Subtotal (95% CI) 20 46 100.0% 1.31 [0.43, 3.99]
Total events 4 7
0.1 0.2 0.5 1 2 5 10

3 C.2 ICU transfer checklist versus no transfer checklist

Figure 7: Mortality (at different time points)
Odds Ratio Odds Ratio
Study or Subgroup log[Odds Ratio] SE Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
2.3.1 Hospital mortality
Malpass 2015 -0.1567 0.3218 100.0% 0.85 [0.46, 1.61]
Subtotal (95% CI) 100.0% 0.85 [0.46, 1.61]
2.3.2 ICU mortality

Malpass 2015 -0.2601 0.3438 100.0% 0.77 [0.39, 1.51]
Subtotal (95% CI) 100.0% 0.77 [0.39, 1.51]
2.3.3 48-hour mortality

Malpass 2015 -0.3065 0.7045 100.0% 0.74 [0.19, 2.93]
Subtotal (95% CI) 100.0% 0.74 [0.19, 2.93]
0.1 0.2 0.5 1 2 5 10

Favours trans. instrument Favours no instrument
Test for subgroup differences: Chi² = 0.07, df = 2 (P = 0.97), I² = 0%
Analysis adjusted for APACHE score.

27
Figure 8: Adverse events upon arrival at receiving hospital

Odds Ratio Odds Ratio
Study or Subgroup log[Odds Ratio] SE Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
2.2.1 Need for emergent central line
Malpass 2015 -2.4651 0.7382 100.0% 0.09 [0.02, 0.36]
Subtotal (95% CI) 100.0% 0.09 [0.02, 0.36]
2.2.2 Need for emergent intubation

Malpass 2015 -1.6983 1.0582 100.0% 0.18 [0.02, 1.46]
Subtotal (95% CI) 100.0% 0.18 [0.02, 1.46]
2.2.3 Antibiotics changed on arrival

Malpass 2015 -0.734 0.2955 100.0% 0.48 [0.27, 0.86]
Subtotal (95% CI) 100.0% 0.48 [0.27, 0.86]
0.1 0.2 0.5 1 2 5 10

Favours trans. instrument Favours no instrument
Test for subgroup differences: Chi² = 5.18, df = 2 (P = 0.08), I² = 61.4%
Analysis adjusted for APACHE score.

28
1 Appendix D: Clinical evidence tables

Study Comparison of a specialist retrieval team with current UK practice trial: Bellingan 2000 16
Study type Non-randomised comparative study.
Number of studies (number of participants) 1 (n=259).
Countries and setting Conducted in United Kingdom; setting: University College London Hospitals (UCLH), UK.
Line of therapy 1st line.
Duration of study Other: retrospective review of all transfers over 1 year.
Method of assessment of guideline condition Adequate method of assessment/diagnosis.
Stratum Overall.
Subgroup analysis within study Not applicable.
Inclusion criteria All critically ill patients who were transferred into the UCLH intensive care unit (ICU) from 1st October 1996 to 30th
September 1997.
Exclusion criteria n/a.
29
Recruitment/selection of patients Patients were transferred either by the UCLH specialist team using a mobile ICU (n=168, 64.9%) or by standard
emergency ambulance with a medical escort provided by the referring hospital (n=91, 35.1%). Transfer by standard
ambulance occurred when the specialist team was busy or unavailable owing to training or maintenance. There was
no selection policy determining which mode of transfer was used.
Age, gender and ethnicity Age - Mean (SD): mobile ICU: 54 (19); standard ambulance: 56 (19). Gender (M:F): mobile ICU: 1/1; standard
ambulance: 3/2. Ethnicity: n/a.
Further population details 1. Inter versus Intra hospital: Inter hospital (transfer into ICU of UCLH from referring hospital).
Indirectness of population No indirectness.
Interventions (n=168) Intervention 1: Standardised system (including checklist of both staffing and equipment) for transfer - As
defined by the study. Inter-hospital transfer by specialist team using a mobile ICU. The team consisted of an ICU-
trained doctor (senior SPR or consultant), nurse, driver, and medical physics technician, all trained in the transfer of
ICU patients. The mobile ICU is an ambulance equipped to ICU standards (all round stretcher access, piped oxygen and
air, nitric oxide, mechanical ventilation, suction, 220V power supply and multi-channel monitoring). The specialist
team spent between 30 and 300 min (mean 70 min) stabilising patients in the referring hospital before transfer.
Duration: retrospective review of all transfers over the course of 1 year. Concurrent medication/care: n/a.
(n=91) Intervention 2: No standardised system for transfers - As defined by the study. Inter-hospital transfer by
standard ambulance with a medical escort provided by the referring hospital (when specialist team was busy or
unavailable). Duration: retrospective review of all transfers over the course of 1 year. Concurrent medication/care:
n/a.
Funding Funding not stated.
RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: INTER-HOSPITAL TRANSFER BY SPECIALIST TEAM USING A MOBILE ICU versus INTER-HOSPITAL
TRANSFER BY STANDARD AMBULANCE.
Protocol outcome 1: Mortality

- Actual outcome: Mortality within 6 hours of admission; Group 1: 1/168, Group 2: 4/91; Risk of bias: All domain - Very high, Selection - High, Blinding - High,
Incomplete outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ; Baseline details: no
difference in baseline characteristics; Group 1 Number missing: 0; Group 2 Number missing: 0
- Actual outcome: overall ICU mortality within ICU stay; Group 1: 47/168, Group 2: 32/91; Risk of bias: All domain - Very high, Selection - High, Blinding - High,
- Actual outcome: Mortality- HR at 1000 hours; HR 0.56 (95%CI 0.35 to 0.9) Reported; Risk of bias: All domain - Very high, Selection - High, Blinding - High, Incomplete
outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ; Baseline details: no difference in
baseline characteristics; Group 1 Number missing: 0; Group 2 Number missing: 0
30
- Actual outcome: Mortality within 12 hours of admission; Group 1: 5/168, Group 2: 7/91; Risk of bias: All domain - Very high, Selection - High, Blinding - High,
Protocol outcomes not reported by the study Avoidable adverse events; Quality of life; Length of stay; Carer/Family satisfaction; Staff satisfaction.
Study Direct transfer protocol for patients with non-ST-elevation acute coronary syndromes trial: Gallagher 201436
Study type Before and after study.

Countries and setting Conducted in United Kingdom; setting: London Chest Hospital, a 'stand-alone' regional interventional cardiac centre
serving a population of about 1.8 Million in North East London, UK. Prospective observational study of the
management of patients with non-ST elevation acute coronary syndrome (NSTE-ACS) treated at the institution
between October 2009 and October 2010. The study period represents the last 6 months of the previous NSTE-ACS
care model and the first 6 months of the new Heart Attack Centre Extension (HAC-X).
Duration of study Other: 6 months before + 6 months after introduction of transfer protocol.
Stratum Overall.
Inclusion criteria Inclusion criteria were an admission diagnosis of NSTE-ACS with chest pain within 24 h of presentation plus either an
elevated blood troponin T or troponin I concentration, or ECG changes compatible with ischaemia (defined asST-
31
segment depression ≥1 mm or T-wave inversion ≥2 mm in 2 contiguous leads, or biphasic ST/T wave segments
indicative of a critical stenosis in the left anterior descending artery).
Exclusion criteria Patients were excluded if they had contraindication to early interventional management including major medical
comorbidity, unexplained anaemia (haemoglobin concentration ≤10 g/dL), acute renal failure, recent traumatic injury
or loss of consciousness (except when secondary to cardiac arrhythmia), overt epsis or unexplained hypoxia.
Recruitment/selection of patients Patients were eligible for inclusion in the study if they presented to a district general hospital (DGH) ED participating
in the HAC-X project and were subsequently transferred to the Chest Hospital for further management.
Age, gender and ethnicity Age - Mean (SD): before: 65.2 (12.6); after: 57.0 (13.9). Gender (M:F): 7/3. Ethnicity: n/a.
Further population details 1. Inter versus Intra hospital: Inter hospital (transfer from district general hospital to this regional interventional
cardiac centre).
defined by the study. Direct transfer protocol through Heart Attack Centre-Extension. After initiation of the HAC-X
pathway patients diagnosed with NSTE-ACS in the DGH ED, and meeting the inclusion criteria received protocol driven
evidence-based medical therapy [Aspirin 200mg, Clopidogrel 600mg, Fondaparinux 2.5mg, and Eptifibatide bolus (180
mg/kg) as long as no contraindications] and were transferred to the Chest Hospital directly within 1 h of diagnosis.
There was no requirement for ECG review or prior notification of the patient's transfer to the centre but clinical
advice could be sought in cases of diagnostic uncertainty. If admission diagnosis of NSTE-ACS was confirmed at the
centre, coronary angiography was performed; unstable patients were taken directly for coronary angiography. Stable
patients had coronary angiography scheduled for later the same day, or on next available routine list. All subsequent
cardiac care was undertaken at the regional cardiac centre. Patients were aimed to be discharged within 48 hours of
their admission. Patients requiring surgical revascularisation remained at the centre until surgery was performed.
Duration: 6 months post-induction of the scheme. Concurrent medication/care: n/a.
(n=391) Intervention 2: No standardised system for transfers - As defined by the study. Previous NSTE-ACS care model
which involved admission of patients to their local DGH for 'medical stabilisation' pending availability of a bed at the
regional interventional cardiac centre for transfer for coronary angiography (and/or PCI). Clinical instability prompted
more urgent transfer and patients were usually transferred back to their local hospital for discharge following invasive
cardiac treatment. Duration: 6 months pre-induction of the scheme. Concurrent medication/care: n/a.
RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: DIRECT TRANSFER PROTOCOL THROUGH HEART ATTACK CENTRE-EXTENSION versus PREVIOUS
NSTE-ACS CARE MODEL.
Protocol outcome 1: Avoidable adverse events.

32
- Actual outcome: Time to coronary angiography (median) during study period; Indirectness of outcome: Serious indirectness, Comments: surrogate outcome for
avoidable adverse events
Protocol outcome 2: Length of stay.
- Actual outcome: Length of hospital stay at time from registration at the DGH ED to final hospital discharge (median); Indirectness of outcome: No indirectness.
Narrative data only -

Before and after introduction of a clinical pathway for patients with suspected acute coronary syndromes.
Pre-HAC-X pathway (n=391) Post-HAC-X pathway (n=311) P

Time to coronary angiography 7.2 (5.1-10.2) 1.0 (0.7-2.0) <0.001
Length of hospital stay 9.0 (6.0-14.0) 3.0 (2.0-6.0) <0.001
Data reported in days as median (25-75% interquartile range).
Protocol outcomes not reported by the study Mortality; Quality of life; Carer/Family satisfaction; Staff satisfaction.
Study Inter-hospital medical intensive care unit transfer instrument trial: Malpass 2015 52

Countries and setting Conducted in USA; setting: development of ICU transfer instrument development, pilot testing of the ICU transfer
instrument, and outcome ascertainment prior to and following the patient transfer instrument intervention by the
University of Virginia, USA. Pilot testing initiated and done by physicians accepting outside hospital transfers to a
closed medical ICU in a single academic tertiary referral centre. Pre-intervention data was collected over 6 months
starting January 2009; post-intervention data was collected over 6 months starting January 2011. In both cases
included all patients admitted to the medical ICU who were transferred from outside hospitals within the time period
specified.
Line of therapy 1st line
Duration of study Other: for 6 months before + for 6 months after induction 2 years later.
Stratum Overall.
33
Inclusion criteria The pre-intervention group included all patients admitted to the medical ICU team who were transferred from
outside hospitals for 6 months starting in January 2009; the post-intervention group included all patients admitted to
the medical ICU team transferred from outside hospitals for 6 months starting January 2011 (after implementation of
the transfer instrument).
Recruitment/selection of patients Pilot testing initiated and done by physicians accepting outside hospital transfers to a closed medical ICU in a single
academic tertiary referral centre. Pre-intervention data was collected over 6 months starting January 2009; post-
intervention data was collected over 6 months starting January 2011. In both cases included all patients admitted to
the medical ICU who were transferred from outside hospitals within the time period specified.
Age, gender and ethnicity Age - Mean (SD): 56.4 (16.4). Gender (M:F): 1/1. Ethnicity: n/a.
Further population details 1. Inter versus Intra hospital: Inter hospital (Inter-hospital transfer to a closed medical ICU at a tertiary referral
centre).
defined by the study. Inter-hospital ICU transfer instrument was developed which consisted of 4 main sections:
patient data, reason for transfer, treatment recommendations, and condition on arrival. It included physician and
hospital contact info, past medical history, a history of present illness narrative highlighting complicating problems,
the patient's current vital signs (e.g. airway, breathing, and circulation; notation of ventilator setting paired with the
ABG, blood pressure paired with vasopressor, and vascular access), and essential test results. The second section
prompted the user to notify key services that will be involved in the patient's care so that the full care team is ready
to act when the patient arrives. The third section prompted and documented recommendations made to referring
physician (including reasoning behind therapy choices to facilitate dialog and identify opportunities for intervention
delivery before or during transport). The final section provided feedback to the process by collecting data on the
patient's status on arrival to receiving hospital. The tool was to systematise communication between the units.
Duration: 6 month after intervention implementation. Concurrent medication/care: n/a.
(n=134) Intervention 2: No standardised system for transfers - As defined by the study. Pre-implementation of
transfer instrument. No information given as to how transfers were arranged before the tool had been developed and
implemented. Duration: 6 months before intervention implementation. Concurrent medication/care: n/a.
Funding No funding.
RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: INTER-HOSPITAL ICU TRANSFER INSTRUMENT versus PRE-IMPLEMENTATION OF TRANSFER
INSTRUMENT.
34
Protocol outcome 1: Mortality

- Actual outcome: ICU mortality; OR 0.77 (95%CI 0.39 to 1.51); Risk of bias: All domain - Very high, Selection - High, Blinding - High, Incomplete outcome data - Low,
Outcome reporting - Low, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ; Baseline details: post-implementation group had higher
predicted mortaity; Key confounders: unclear if adjusted for anything other than APACHE II score and predicted mortality; Group 1 Number missing: 0; Group 2 Number
missing: 0
- Actual outcome: 48-hour mortality at 48 hours; OR 0.74 (95%CI 0.19 to 2.93); Risk of bias: All domain - Very high, Selection - High, Blinding - High, Incomplete outcome
data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ; Baseline details: post-implementation group had
higher predicted mortaity; Key confounders: unclear if adjusted for anything other than APACHE II score and predicted mortality; Group 1 Number missing: 0; Group 2
Number missing: 0- Actual outcome: hospital mortality; OR 0.85 (95%CI 0.46 to 1.61); Risk of bias: All domain - Very high, Selection - High, Blinding - High, Incomplete
outcome data - Low, Outcome reporting - Low, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ; Baseline details: post-implementation
group had higher predicted mortaity; Key confounders: unclear if adjusted for anything other than APACHE II score and predicted mortality; Group 1 Number missing:
0; Group 2 Number missing: 0
- Actual outcome: Need for emergent central line; OR 0.09 (95%CI 0.02 to 0.36); Risk of bias: All domain - Very high, Selection - High, Blinding - High, Incomplete
- Actual outcome: Need for emergent intubation; OR 0.18 (95%CI 0.02 to 1.46); Risk of bias: All domain - Very high, Selection - High, Blinding - High, Incomplete
- Actual outcome: Antibiotics changed on arrival; OR 0.48 (95%CI 0.27 to 0.86); Risk of bias: All domain - Very high, Selection - High, Blinding - High, Incomplete
Protocol outcomes not reported by the study Quality of life; Length of stay; Carer/Family satisfaction; Staff satisfaction.
Study Decreasing door-to-balloon times through streamlined protocol trial: Reimer 2013 65
Countries and setting Conducted in USA; setting was a 1300-bed Midwest tertiary care centre that serves as a regional referral centre in
35
Northeast Ohio, USA. Two cohorts were analysed after implementation of a streamlined referral protocol to improve
door-to-balloon times for patients with acute STEMI (ST segment elevation myocardial infarction): patients
transferred using the streamlined protocol and patients referred through the traditional referral process. The cardiac
catheterisation laboratory is fully staffed weekdays, with on-call staffing for nights and weekends. The hospital
operates a hospital-based critical care transport (CCT) team consisting of 2 helicopters and 1 ground ambulance that
operate 24 hours a day 7 days a week. All CCT crews are staffed with an acute care nurse practitioner and critical care
registered nurse and/or critical care paramedic.
Duration of study Intervention time: 1 year.
Stratum Overall.
Inclusion criteria All patients undergoing transport by helicopter or ground for acute STEMI to the Cleveland Clinic for emergent PCI by
the hospital-based CCT team from July 2009 through to June of 2010 were eligible for the study.
Recruitment/selection of patients A hospital-based CCT log was used to track all streamlined cases for acute STEMI. The hospital also had an acute
myocardial infarction (AMI) database to identify door-to-balloon times which includes only patients with a referring
diagnosis of STEMI and a positive cardiac catheterisation defined as coronary artery occlusion deemed to be
associated with an acute coronary syndrome by the interventional cardiologist. Only cases that had complete data
entered into the CCT STEMI log and AMI database were included for analysis.
Age, gender and ethnicity Age - Median (IQR): streamlined: 55 (49-64); traditional: 61 (50-72). Gender (M:F): 1/2. Ethnicity: White: streamlined
(65%); traditional transfer (77%).
Further population details 1. Inter versus Intra hospital: Inter hospital (patients transferred for acute STEMI to the clinic for emergent PCI).
defined by the study. Streamlined referral protocol. The traditional protocol was reviewed to identify areas for
improvement by the transport team and cardiology management team. The abbreviated streamlined protocol was
then developed: Referring facilities were provided with a contact telephone number linked directly to a CCT
coordinator via a hotline dedicated to streamlined referrals. Upon receiving a hotline request, to coordinator obtained
patient information, location, and simultaneously dispatches the aircraft. The coordinator also instructs the referring
hospital to fax the patient’s electrocardiogram to the coronary care unit and a demographic sheet to the hospital
transfer centre. The aircraft is dispatched without regard for bed availability and without accepting physician
36
communication before dispatch. While the transport is taking place, the coordinator activates the catheterisation
laboratory to reserve a table or to activate the on-call team and then contacts the on-call cardiologist to inform them
of the referral and information regarding the referring facility. Duration: 1 year. Concurrent medication/care: n/a.
(n=79) Intervention 2: No standardised system for transfers - As defined by the study. The traditional protocol
processed time-sensitive patient transfer requests the same as all other transfer requests. It consisted of 21 steps
with an average time to complete of 42 minutes, ranging from 23 to 64 minutes. Duration: 1 year. Concurrent
medication/care: n/a.
RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: STREAMLINED REFERRAL PROTOCOL versus TRADITIONAL REFERRAL PROTOCOL.

- Actual outcome: door-to-balloon time (as surrogate for avoidable adverse events); Indirectness of outcome: Serious indirectness.
Protocol outcome 2: Length of stay

- Actual outcome: total time patient spent in referring ED, including time for arrival of transport team; Indirectness of outcome: No indirectness.
Narrative data only.
Before and after introduction of a streamlined transfer.

Emergency department 60 (45-84) 55 (44-67) 0.07
Door-to-balloon time 122 (99-157) 101 (88-128) 0.001
Data reported in minutes as median (25-75% interquartile range). Emergency department time is total time patient spent in referring department, including time
waiting for arrival of transport team. Door-to-balloon time is total time from presentation at outside ED to percutaneous coronary intervention.
Protocol outcomes not reported by the study Mortality; Quality of life; Carer/Family satisfaction; Staff satisfaction.
Study Effects of ambulance transport trial: Waddell 197574

Countries and setting Conducted in United Kingdom; setting: transfers of critically ill patients to the intensive therapy unit of the Western
37
Infirmary in Glasgow, UK, via ambulance from other hospitals over the course of 6 years. Time period of data
collection for intensive therapy unit 'flying squad' not reported.
Duration of study Not clear: no information given.
Stratum Overall.
Inclusion criteria Retrospective review of ambulance transfers to the Western Infirmary ICU; only ‘adequate’ records reported.
Prospective data collection of eligible patients for transfers via intensive therapy unit 'flying squad'.
Exclusion criteria Patients for whom no adequate records were available or who were deemed unsuitable for transfer.
Recruitment/selection of patients Retrospective review of ambulance transfers to the Western Infirmary ICU; only adequate records reported.
Prospective data collection of eligible patients for transfers via intensive therapy unit 'flying squad'.
Age, gender and ethnicity Age - Mean (SD): flying squad 57; standard ambulance 42 (SDs not provided). Gender (M:F): 3/2. Ethnicity: n/a.
Further population details 1. Inter versus Intra hospital: Inter hospital.
defined by the study. The intensive therapy unit ‘flying squad’ consisted of 1 or 2 members of a ‘shock team’. When
the intensive therapy unit received a request for a transfer the flying squad travelled to the referring hospital, set up
monitoring equipment, and began treatment. They accompanied the patient in an ambulance of standard design and
continued treatment on arrival at the unit. Average ambulance ride was 12 minutes and the total time from bed to
bed 33 minutes. Duration: unclear. Concurrent medication/care: n/a.
(n=46) Intervention 2: No standardised system for transfers - As defined by the study. Transfers by standard
ambulance from other hospitals to ICU of Glasgow Western Infirmary. Duration: 6 years. Concurrent medication/care:
n/a.
RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: TRANSFERS VIA INTENSIVE THERAPY UNIT 'FLYING SQUAD' versus TRANSFERS VIA STANDARD
AMBULANCE.
38
Protocol outcome 1: Mortality.

- Actual outcome: Mortality within 24 hours of transfer within 24 hours of transfer; Group 1: 1/20, Group 2: 3/46; Risk of bias: All domain - Very high, Selection - Very
high, Blinding - High, Incomplete outcome data - Low, Outcome reporting - High, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ;
Baseline details: flying squad patients much older and differences in clinical conditions; Key confounders: illness secerity, age etc.; Group 1 Number missing: 0; Group 2
Number missing: 0
- Actual outcome: Final mortality; Group 1: 9/20, Group 2: 18/46; Risk of bias: All domain - Very high, Selection - Very high, Blinding - High, Incomplete outcome data -
Low, Outcome reporting - High, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ; Baseline details: flying squad patients much older and
differences in clinical conditions; Key confounders: illness secerity, age etc.; Group 1 Number missing: 0; Group 2 Number missing: 0

- Actual outcome: Delayed hypotension; Group 1: 4/20, Group 2: 7/46; Risk of bias: All domain - Very high, Selection - Very high, Blinding - High, Incomplete outcome
data - Low, Outcome reporting - High, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ; Baseline details: flying squad patients much
older and differences in clinical conditions; Key confounders: illness secerity, age etc.; Group 1 Number missing: 0; Group 2 Number missing: 0
Protocol outcomes not reported by the study Quality of life; Length of stay; Carer/Family satisfaction; Staff satisfaction.
Study (subsidiary papers) Inter-hospital transport via a mobile intensive care unit trial: Wiegersma 201177 (Ligtenberg 200551)

Countries and setting Conducted in Netherlands; setting: consecutive transfers via mobile ICU to the University of Groningen affiliated ICU
and the ICU of the Scheper Hospital, Emmen, Netherlands, from 14 regional hospitals in the north-eastern region of
the Netherlands between March and December 2009. These data were compared to consecutive transfers of ICU
patients via standard ambulance to the same ICU from 18 regional hospitals in the north-eastern part of the
Netherlands over a 14 month period (not specified but must be pre-2005).
Line of therapy 1st line
Duration of study Other: 14 months standard transfer + 10 months mobile ICU.
Stratum Overall.
Inclusion criteria All consecutive transfers of ICU patients during the pre-defined study periods. Only patients admitted to the ICU are
transferred by MICU.
39

Recruitment/selection of patients Main indication for transfer was the need for higher intensity of care or advanced therapy; for example renal
replacement therapy. Main diagnoses at transfer were respiratory problems, sepsis, and multi-organ failure. Shortage
of ICU capacity was cited as the reason for transport on only a few occasions.
Age, gender and ethnicity Age - Mean (SD): mobile ICU 59.8 (15.6); standard ambulance 54.7 (1.7). Gender (M:F): 1/1. Ethnicity: n/a.
Further population details 1. Inter versus Intra hospital: Inter hospital.
defined by the study. Mobile ICU transfer. A specifically designed large-volume mobile ICU and a specialised retrieval
team were used to transfer critically ill patients. A stratified protocol clarification was sent to all referring ICUs in the
region, explaining the procedure of transfer. Before working in the mobile ICU team all ICU nurses and intensivists
completed a scenario-based training in skills-lab. Transfers between 8am and midnight 7 days a week. The referring
intensivist had to consult the MICU-coordinator, who completes a MICU transport form with patient characteristics
and study data. After authorisation of the transfer by the MICU-physician and the supervising staff member of the
accepting ICU, the MICU sets out to transfer the critically ill patient. Upon arrival at the referring ICU, the MICU-team
stabilises and prepares the patient for transfer. The APACHE II score (measure of severity of illness) was being
determined for the patient. Duration: 10 months. Concurrent medication/care: n/a.
(n=100) Intervention 2: No standardised system for transfers - as defined by the study. Standard ambulance transfer.
Patients were transferred after telephone consultation with the supervising staff member of the receiving ICU, who
authorised the admission. The referring hospital was advised to stabilise the patient as much as possible and to send a
skilled physician with the patient. The transfer was done by standard ambulance of the referring hospital. The patient
was accompanied by an ICU nurse in 23% and by a physician in 57% of transports. Duration: 14 months. Concurrent
medication/care: n/a.
Funding Funding not stated
RESULTS (NUMBERS ANALYSED) AND RISK OF BIAS FOR COMPARISON: MOBILE ICU TRANSFER versus STANDARD AMBULANCE TRANSFER.

- Actual outcome: Incidents during transfer (excluding technical failure - but including staff management or inadequate preparation) at 10 and 14 months; OR 0.13
(95%CI 0.06 to 0.32); Risk of bias: All domain - Very high, Selection - Very high, Blinding - High, Incomplete outcome data - Low, Outcome reporting - High,
Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ; Baseline details: not matched; separate audit data compared; Group 1 Number
missing: 0; Group 2 Number missing: 0
- Actual outcome: Incidents during transfer (technical failure) at 10 and 14 months; Group 1: 9/74, Group 2: 10/100; Risk of bias: All domain - Very high, Selection - Very
40
high, Blinding - High, Incomplete outcome data - Low, Outcome reporting - High, Measurement - Low, Crossover - Low; Indirectness of outcome: No indirectness ;
Baseline details: not matched; separate audit data compared; Group 1 Number missing: 0; Group 2 Number missing: 0
Protocol outcomes not reported by the study Mortality; Quality of life; Length of stay; Carer/Family satisfaction; Staff satisfaction.
1
2
Appendix E: Economic evidence tables
No studies were included.
2
3
4
41
Appendix F: GRADE tables
2 Table 10: Clinical evidence profile: Standardised system versus standard ambulance transfer
Quality assessment No of patients Effect
Importanc
Quality
e
Mobile ICU
No of Risk of Other versus Contro Relative
Design Inconsistency Indirectness Imprecision Absolute
studies bias considerations standard l (95% CI)
transfer
Adverse incidents (staff management issues or inadequate preparation) - Staff management issues or inadequate preparation
1 observational very no serious no serious no serious imprecision None 0/74 24% Peto OR 201 fewer per  CRITICAL
studies serious1 inconsistency indirectness (0%) 0.13 (0.06 to 1000 (from 148 VERY
0.32) fewer to 221 fewer) LOW
Adverse incidents (technical failures) - Technical failures

42
1 observational very no serious no serious very serious2 None 9/74 10% RR 1.22 22 more per 1000  CRITICAL
studies serious1 inconsistency indirectness (12.2%) (0.52 to (from 48 fewer to VERY
2.84) 184 more) LOW
Adverse events (delayed hypotension) - Adverse events (delayed hypotension)
1 observational very no serious no serious very serious2 None 4/20 15.2% RR 1.31 47 more per 1000  CRITICAL
studies serious1 inconsistency indirectness (20%) (0.43 to (from 87 fewer to VERY
3.99) 454 more) LOW
Mortality HR (over 1000 hours)
1 observational very no serious no serious serious2 None - 0% HR 0.56 -  CRITICAL

studies serious1 inconsistency indirectness (0.35 to 0.9) VERY
LOW
Mortality - Overall ICU mortality
1 observational very no serious no serious serious2 None 47/168 35.2% RR 0.8 (0.55 70 fewer per 1000  CRITICAL
studies serious1 inconsistency indirectness (28%) to 1.15) (from 158 fewer to VERY
53 more) LOW
Mortality - 6 hour mortality
1 observational very no serious no serious serious2 None 1/168 4.4% RR 0.14 38 fewer per 1000  CRITICAL
studies serious1 inconsistency indirectness (0.6%) (0.02 to (from 43 fewer to 8 VERY
1.19) more) LOW
Mortality - 12 hour mortality
1 observational very no serious no serious serious2 None 5/168 7.7% RR 0.39 47 fewer per 1000  CRITICAL
1.18) 14 more) LOW
Mortality - Final mortality
1 observational very no serious no serious very serious2 None 9/20 39.1% RR 1.15 59 more per 1000  CRITICAL
studies serious1 inconsistency indirectness (45%) (0.63 to 2.1) (from 145 fewer to VERY
430 more) LOW
Mortality - Mortality within 24 hours of transfer

43
1 observational very no serious no serious very serious2 None 1/20 6.5% RR 0.77 15 fewer per 1000  CRITICAL
6.93) 385 more) LOW
1 1
All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2
3 2
Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
4 Table 11: Clinical evidence profile: ICU transfer checklist versus no transfer checklist
Quality assessment No of patients Effect

Importanc
Quality
e
ICU transfer checklist
No of Risk of Other Contro Relative Absolut
Design Inconsistency Indirectness Imprecision versus no transfer
studies bias considerations l (95% CI) e
checklist
Adverse events - adjusted OR - Need for emergent central line
1 observational very no serious no serious no serious none - 0% OR 0.09 (0.02 -  CRITICAL
studies serious1 inconsistency indirectness imprecision to 0.36) VERY
LOW
Adverse events - adjusted OR - Need for emergent intubation
1 observational very no serious no serious very serious2 none - 0% OR 0.18 (0.02 -  CRITICAL
studies serious1 inconsistency indirectness to 1.46) VERY
LOW
Adverse events - adjusted OR - Antibiotics changed on arrival
1 observational very no serious no serious serious2 none - 0% OR 0.48 (0.27 -  CRITICAL
LOW
Mortality - adjusted OR - Hospital mortality
LOW
Mortality - adjusted OR - ICU mortality

44
LOW
Mortality - adjusted OR - 48-hour mortality
LOW
1 1
All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2
2 increments if other factors suggest additional very high risk of bias
3 2
Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
5
1 Appendix G: Excluded clinical studies

2 Table 12: Studies excluded from the clinical review
Study Exclusion reason
7
Aghababian 1991 No comparison, no data
Narrative review
Aguirre 20088 No relevant comparison
Ailsby 19879 No comparison, no data
Description of guidelines for the transport of critically ill patients
Anonymous 19891 No relevant comparison/intervention, no relevant outcomes
Description of 4 physical patient transfer systems
Anonymous 19933 No comparison, no data
Commentary
Anonymous 1993A2 No comparison, no data
Description of guidelines for the transfer of critically ill patients
Anonymous 2003F4 No comparison, no data
Description of minimum standards for transfer
Anonymous 20115 No comparison, no data
Commentary
Anonymous 2013F6 No comparison, no data
Narrative review
Ayers 201211 No comparison, no data
Commentary
Australasian College for No comparison, no data
Emergency Medicine 200310 Description of a standardised system/checklist for transfers
Bae 201012 No relevant outcomes
Effects of emergency medical service hospital notification on transfer
and processing times
Barry 200613 No comparison, no data
Description of a transfer mattress
Baruch 201014 Data not in analysable format
Pilot study with very low patient numbers (n=19)
Beckmann 200415 No comparison

Description of the type of incidents and factors contributing to the
incidents occurring during patient transfer
Belway 200617 Systematic review
20
Boyko 1994 No comparison, no data
Description of guidelines
Brown 2015 21 No relevant extractable outcomes
22
Brunsveld-Reinders 2015 No comparison, no data
Description of the development and piloting of a checklist for transport
Burney 199523 Not relevant comparison. Study compares aeromedical transport staffed
with physician/nurse with nurse/nurse
Burney 199224 Not relevant comparison. Study compares aeromedical transport staffed
with physician/nurse with nurse/nurse

45

25
Choi 2012 Data cannot be extracted in a meaningful way
Before and after study of implementation of transport checklist
Colardyn 199326 No comparison, no data
Narrative review
Comeau 2015 27 No relevant extractable outcomes
29
Dawkins 1983 No comparison, no data
Commentary
Dershin 199330 No comparison, no relevant outcomes
Case study only of a patient transportation system within a hospital
Etxebarria 199831 No relevant comparison
Study about the use of a scoring system rather than the standardisation
of the transfer process
Fan 200632 Systematic review
33
Fanara 2010 Narrative review
37
Gore 1983 No comparison
Evaluation of a cardiac transport system
Gray 200438 No comparison, no data
Narrative review
Gupta 200439 No comparison, no data
Description of guidelines
Hamilton 199440 No relevant comparison
Narrative review presenting some data from other studies
Havill 199541 No relevant comparison, incomplete data
42
Hendrich 2005 No relevant outcomes, no comparison
Study documents processes, labour, time and costs of transferring
patients between nursing units in the hospital
Henry 200543 No data
Pilot study with very low numbers (n<250)
Hindmarsh 201244 No comparison, no relevant data
Description of a checklist and initial small audit
Iwashyna 201246 No comparison, no data
Description of a conceptual framework for transfer
Jarden 201047 Narrative review and description of the development of a transfer tool
No data, no comparison
Koppenberg 200249 No data
Narrative review
Kue 201150 No relevant comparison/intervention
Before and after study comparing aborted versus completed intra-
hospital transfers by a specialised team
Manari 53 No relevant comparison

Retrospective study comparing directly admitted patients (i.e. no
transfer) with transferred patients
Manataki 2016 54 Incorrect study design – narrative study
55
Martin 2012 No comparison, no data
Narrative review

46

56
Mazza 2008 No comparison
Not from OECD country (Brazil)
Nerland 197858 No comparison, no data
Commentary
Newton 201559 No data
Description of an inter-hospital transfer centre model
Ohashi 200860 No comparison, no data
Description of an electronic vital sign-monitoring system for patient
transfers
Ong 201161 Review of failures in handoff communication during transfers
Petre 198962 No relevant intervention/comparison, no data
Description of a physical patient transport system
Pope 200363 No comparison, no relevant data
Narrative review including case study
Ridley 198966 No relevant comparison
Retrospective study comparing directly admitted patients (i.e. no
transfer) with transferred patients
Roland 201067 No comparison, no data
Description of a physical transport system for critically ill obese patients
Russell 2015 68 Incorrect intervention
69
Sethi 2014 No comparison, no data
Not from OECD country (India)
Sivaram 199670 No relevant outcomes, data cannot be extracted
Establishment of a communication system for transfers between 2
specific hospitals
Steenson 198971 No relevant comparison or data
Description of a quality assured structured transport system
Swickard 201472 No comparison, no data

Description of adopting a triage model for patient care to critical care
transport including 2 case studies
Uusaro 200273 No relevant comparison and no relevant outcomes (compares vital signs
before versus after the transport)
Watanabe 199176 No comparison, no data
Description of an intra-hospital transport service development
Warren 200475 No comparison, no data
Description of guidelines for safe transport
Wu 200778 No comparison, no data
Narrative review
Yamamoto 198879 No data
Description of an information system for patient transfer

47
1 Appendix H: Excluded health economic studies

2 No studies were excluded.

48
[Downloaded free from http://www.ijaweb.org on Sunday, October 13, 2019, IP: 103.78.96.137]
Review Article
Inter‑hospital and intra‑hospital patient transfer:

Recent concepts
Address for correspondence: Ashish Kulshrestha, Jasveer Singh1

Dr. Ashish Kulshrestha, Department of Anaesthesia and Intensive Care, Vardan Multispecialty Hospital, Garhi Sikrod, NH‑58, Meerut
Villa No. 83, Villa Anandam, Road, Ghaziabad, Uttar Pradesh, 1Department of Anaesthesia and Intensive Care, Government Medical
NH‑58, Meerut Road, College and Hospital, Chandigarh, India
Ghaziabad ‑ 201 002,
Uttar Pradesh, India.
E‑mail: kulshi_20@ ABSTRACT
rediffmail.com
The intra‑ and inter‑hospital patient transfer is an important aspect of patient care which is often
undertaken to improve upon the existing management of the patient. It may involve transfer of
patient within the same facility for any diagnostic procedure or transfer to another facility with
more advanced care. The main aim in all such transfers is maintaining the continuity of medical
care. As the transfer of sick patient may induce various physiological alterations which may
adversely affect the prognosis of the patient, it should be initiated systematically and according
to the evidence‑based guidelines. The key elements of safe transfer involve decision to transfer
and communication, pre‑transfer stabilisation and preparation, choosing the appropriate mode
of transfer, i.e., land transport or air transport, personnel accompanying the patient, equipment
Access this article online and monitoring required during the transfer, and finally, the documentation and handover of the
Website: www.ijaweb.org patient at the receiving facility. These key elements should be followed in each transfer to prevent
any adverse events which may severely affect the patient prognosis. The existing international
DOI: 10.4103/0019-5049.186012
guidelines are evidence based from various professional bodies in developed countries. However,
Quick response code
in developing countries like India, with limited infrastructure, these guidelines can be modified
accordingly. The most important aspect is implementation of these guidelines in Indian scenario
with periodical quality assessments to improve the standard of care.
Key words: Air transport, complications of patient transfer, intra‑hospital, inter‑hospital transfer,
intra‑hospital transfer guidelines, patient transfer
INTRODUCTION transferring the patient to the nearest facility providing

highest specialised care.[5] Both the transferring
The transfer of a patient to another facility or hospital and the receiving facility should aim at continuity
or to another department in the same hospital is least of medical care of the patient. A poorly organised
known but an equally important topic. The decision and hastily done patient transfer can significantly
to transfer the patient is based on the benefits of care contribute to morbidity and mortality.[6] This article
available at another facility against the potential risks reviews the various guidelines for an effective intra‑ or
involved. The need to transfer a patient should take inter‑hospital transfer and current scenario of patient
into account the benefit of providing extra care on transfer in developing countries like India.
the management or outcome. The risk of transferring
This is an open access article distributed under the terms of the Creative
a critically ill patient is manifold.[1] The various Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
contributors of need to transfer the patient include the others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
presence of few centres which provide super‑speciality
For reprints contact: [email protected]
care, non‑availability of speciality beds and funding
of medical treatment.[2‑4] Any intra‑ or inter‑hospital How to cite this article: Kulshrestha A, Singh J. Inter-hospital and
patient transfer should aim at maintaining optimal intra-hospital patient transfer: Recent concepts. Indian J Anaesth
health of the patient which is carried out by 2016;60:451-7.
© 2016 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow 451
Page no. 13
Kulshrestha and Singh: Patient transfer: Recent concepts
SEARCH OF LITERATURE clinical condition. The patient should be adequately

resuscitated and stabilised to the maximum extent
We conducted a systematic literature search using possible without wasting undue time. During the
search engines such as PubMed, Google and Google preparation, patient’s A, B, C and D, i.e., airway,
Scholar with the use of following single text words breathing, circulation and disability, should be
and combinations: Inter‑hospital transfer, inter‑facility checked, and any associated preventable problems
transfer, aeromedical transfer and guidelines for should be corrected. The use of pre‑transfer checklist
patient transfer. The search was performed from is useful in this context:[11,12]
the year 1970 till date. The references of relevant
articles were cross‑checked, and articles on inter‑ and Airway
intra‑hospital patient transfer were included. The patients with possibility of airway compromise
during transfer should be electively intubated with
EXISTING GUIDELINES endotracheal tube (ETT) with a cuff which should be
secured properly after confirming its correct position.
Different guidelines have been proposed to safely A properly placed nasogastric tube is required in
execute the patient transfer. The various professional some patients to prevent aspiration of gastric contents
bodies have formulated guidelines for safe patient during transfer. The cervical spine stabilisation may
transfer which includes American College of Critical be required in some trauma patients.
Care Medicine, Society of Critical Care Medicine,
Intensive Care Society, Association of Anaesthetist Breathing
of Great Britain and Ireland and Paediatric Intensive The ventilation should be adequately controlled
Care Society.[7,8] All guidelines have stressed upon with optimisation of the arterial blood gas values. In
some key elements of safe patient transfer which will the suspected pneumothorax, chest drain should be
be described in detail. These key elements are same inserted before transfer, especially before air transport.
for inter‑ or intra‑hospital transfer of patient.
Circulation
KEY ELEMENTS OF PATIENT TRANSFER The patient should have at least two wide bore
intravenous working cannulas in place before transfer.
Decision to transfer and communication External haemorrhage, if any, should be adequately
The decision to transfer the patient is important controlled, and any shock should be treated
because of exposure of the patient and the staff to with intravenous fluids and/or vasopressors. The
additional risk and additional expense for the relatives availability of crossed‑matched blood may be required
and the hospital. The decision to transfer the patient during the transport.
is taken by a senior consultant level doctor after
thorough discussion with patient’s relatives about the Disability or neurological status
benefits and risks involved. A written and informed Patients with head injury should have their Glasgow
consent of patient’s relatives along with the reason coma scale (GCS) adequately monitored and
to transfer is mandatory before the transfer. In some documented before and during transfer and before
countries, dedicated critical care transfer groups administration of any sedative or paralytic agent.
have been established to coordinate and facilitate the
patient transfer. These groups also arrange appropriate Apart from the above pre‑transfer checklist, the
facilities at the receiving hospital or facility.[9,10] A direct patient should be protected from cold by provision
communication between the transferring and receiving of suitable blankets. All the baseline investigations
facility should be undertaken with sharing of complete should be done on the day of transfer to reflect the
information on patient’s clinical condition, treatment present condition of the patient.
being given, reasons for transfer, mode of transfer and
timeline of transfer, in a written document. Mode of transfer
The two most commonly employed modes of transfer
Pre‑transfer stabilisation and preparation of patients are ground transport, with the inclusion
A proper and meticulous preparation and stabilisation of ambulances and Mobile Intensive Care Units
of patient should be done before transfer to prevent (MICUs), and air transport which includes helicopter
any adverse events or deterioration in patient’s or aeroplane ambulances.
452 Indian Journal of Anaesthesia | Vol. 60 | Issue 7 | Jul 2016

Page no. 14
Ground transport According to the guidelines of Air Medical Dispatch

This is accomplished by the use of different types of by American College of Emergency Physician, the air
ambulances: transport is indicated when the ground transport is
• Basic life‑support ambulance: These not feasible due to the factors such as time of transfer,
ambulances are equipped with appropriate staff distance to be travelled and the level of care needed
and monitoring devices to transport patients during the transfer.[19] The patients more likely to
with non‑life‑threatening conditions as these benefit from air transport are:
can only provide basic life‑support services • Severe trauma patients with penetrating chest
• Advanced life‑support ambulance: These injuries, multisystem injuries, crush injuries,
ambulances can provide advanced life‑support age less than 12 years or more than 55 years or
services such as endotracheal intubation, cardiac patients with unstable vital signs
monitoring, defibrillation, administration of • Patients with acute coronary syndrome in urgent
intravenous fluids or vasopressors. These are need of revascularisation procedure, cardiac
adequately staffed and equipped for transporting tamponade with haemodynamic compromise,
patients with life‑threatening conditions cardiogenic shock in need of intra‑aortic balloon
• MICU: These are specialised vehicles with all pump or other assist devices
the equipment and staff to transfer critically ill • Patients due to receive organ transplant
patients and are usually used in conjunction • Critically ill high‑risk medical or surgical
with specialist retrieval teams in few developed patients, for example, those on high
countries. The literature also supports the use vasopressors, special modes of ventilation,
of MICUs with reduced incidences of major requiring hyperbaric oxygen therapy or with
adverse events during transfer and improved surgical emergencies such as aortic dissection
survival rates with reduced mortality.[13‑15] with haemodynamic compromise.[20‑22]
Air transport Air transport may not be feasible in the presence

The use of air transport has been on the rise in of dangerous environmental conditions for flying,
developed countries because of advantages of rapid uncooperative patients, untreated pneumothorax or
transport with inclusion of specialised medical care. penetrating eye injury, patients with recent abdominal
There has been an improved prognosis of patients with surgery, potentially obstructed airway, respiratory
major trauma, acute myocardial infarction and acute distress, significant facial injury and reduced level of
stroke due to rapid provision of appropriate medical consciousness, as these patients can undergo sudden
care by use of air transport.[16‑18] The air transport is of decompensation during the air transfer.[23]
two types:
1. Fixed wing or aeroplane type air ambulance: It Accompanying the patient
is usually used for long distances inter‑hospital It is usually recommended to have at least two
patient transfer for approximately more than competent personnel accompanying the patient to be
240 km. It is more rapid mode of transport transferred. The care required by each patient during
with the provision of pressurised cabin and transfer depends on the level of patient’s critical care
less noise and vibration. It is used for travel dependency and accordingly are divided into:
across countries or continents. The main • Level 0: It includes the patients who can be
disadvantage is requirement of additional managed at the level of ward in a hospital and
ground transport between the hospital and the are usually not required to be accompanied by
air facility any specialised personnel
2. Rotor wing or helicopter ambulance: It can • Level 1: It includes those patients who are at
be used for shorter travel distances of about risk of deterioration in their condition during
80 km. It can be used to transfer the patient the transfer but can be managed in an acute
directly to the receiving hospital with the ward setting with support from critical care
facility of helipad. There is no requirement of team. These usually have to be accompanied by
additional ground transport. However, space is a paramedic or a trained nurse
more compact with interference of noise and • Level 2: It includes patients who require
vibration during patient transfer. observation or intervention for failure of single
Indian Journal of Anaesthesia | Vol. 60 | Issue 7 | Jul 2016 453
Page no. 15
organ system and must be accompanied by Documentation

trained and competent personnel The documentation of patient transfer is most
• Level 3: It includes patients with requirement of important but often missed as part of transfer. The
advanced respiratory care during the transport documentation should always be clear at all stages of
with support of at least two failing organ transfer. As it was the only legal document that the
systems. These patients have to be accompanied patient was transferred, so it must include the patient’s
by a competent doctor along with a nurse and a condition, reason to transfer, names and designation
paramedic. of referring and receiving clinicians, details and status
of vital signs before the transfer, clinical events during
The accompanying person should be suitably trained, the transfer and the treatment given. A standardised
competent and experienced and preferably should document should be used and maintained both for
have done training in patient transfer and should have intra‑ and inter‑hospital transfer. These documents
sufficient training in advanced cardiac life support, should be used for audit purposes for investigating
airway management and critical care. If the physician the flaws in the patient transfer. There should be a
is not available to transfer unstable patients, then the formal handing over at the receiving facility between
provision of contacting the concerned physician by the transferring team and the receiving team including
the transport team should definitely be available. the doctors and nurses. The various reports of clinical
investigations and diagnostic studies should be
Equipment, drugs, and monitoring handed over to the receiving team. In spite of existing
A proper monitoring with the provision of all lifesaving recommendations and guidelines for safe patient
drugs is mandatory for transfer of all patients with transfer, these are often not followed or are not met.
level 1, 2 and 3 critical care needs. The transfer
ambulance must be equipped with all the drugs PHYSIOLOGICAL ALTERATIONS DURING
and instruments required for airway management, TRANSPORT
oxygenation, ventilation, haemodynamic monitoring
and resuscitation. All the monitoring needs to be The transfer of patient, whether via ground or air,
established before the commencement of transfer imposes various physiological alterations in both the
along with the starting of infusion drugs. The drugs patient and the transport team, seriously affecting a
needed for patient transfer include muscle relaxants, safe patient transfer. These include:
sedatives, analgesics, inotropes and resuscitation
drugs. The person in charge of patient transfer should Noise
ensure proper supplies of these emergency drugs. The various sources of noise during the patient transfer
Some of these drugs may be required to be prepared in are external wind, rotors of helicopter, propellers of
pre‑filled syringes before the transfer. The minimum aircraft, engine and monitoring equipment. The noise
standard of monitoring recommended for patient created can hinder the auscultation of patient and also
transfer includes continuous electrocardiogram can interfere in conversation between the doctor and
monitoring, non‑invasive blood pressure, oxygen the transferring patient.
saturation, end‑tidal carbon dioxide (in ventilated
patients) and temperature. The non‑invasive blood Vibration
pressure may be significantly affected by the motion The various sources of vibration depend on the
artefacts, so it may be prudent to use invasive blood mode of transfer. The uneven roads and vehicular
pressure monitoring in selected subset of patients. All suspension create vibration in ground transport,
the monitoring equipment should be secured properly whereas engine, rotors, propellers and air turbulence
and should be placed at or below the level of the create vibration during air transport. The vibration
patient for uninterrupted monitoring. The electrical can cause nausea, discomfort, headache, impaired
equipment must be functional on battery power with visual performance, pain at fractured site, aggravation
the provision of extra batteries during the transfer. of spinal injuries and internal brain haemorrhage with
Patients on ventilator must be transferred on portable interference in intravenous cannulation, endotracheal
transport ventilators with the provision of display intubation, etc. There can be malfunction of motion
of alarms related to tidal volume, airway pressure, sensing pacemakers or gravity linked infusion pumps
inspiratory: expiratory ratio, inspired oxygen fraction and motion artefacts in the monitoring equipment.
and respiratory rate. These effects of vibration can be minimised by use

Page no. 16
of holding restraints for the accompanying persons, patients with trapped gas in body cavities such as
vibration absorbing mattresses and padding of contact untreated pneumothorax, pneumocephalus, recent
points between the vehicle and the patient. abdominal surgery and gas gangrene.
Acceleration and gravitational forces Third space fluid loss

The patients are subjected to both radial and linear The pressure changes associated with altitude changes
acceleration and deceleration forces during transfer cause increased vascular permeability thus causing
and the physiological effects produced may be fluid shifts from intravascular to extravascular
more profound in critically ill patients due to their compartment leading to oedema and hypovolaemia.
hypovolaemic and vasodilated nature. The patient can
have transient hypertension and dysrhythmias due to Motion sickness
sudden acceleration or deceleration. These effects can The difference between the visual and vestibular
be minimised by positioning the patient’s trolley at a inputs to brain produces nausea, vomiting or retching.
right angle to the long axis of aircraft and by keeping There should be provision of a mechanical or electrical
the legend of the patient towards the cockpit to avoid suction apparatus during the transfer to prevent from
venous pooling. any aspiration.
Temperature and humidity COMPLICATIONS DURING TRANSPORT AND

The environment inside the ambulance is kept at PREVENTION STRATEGIES
lower temperature by use of air conditioning which
can cause hypothermia in susceptible patients, Pulmonary and airway complications
especially neonates. These patients should be covered Literature shows that oxygen desaturation,
with warming blankets during transfer. The humidity atelectasis, bronchospasm, pneumothorax, accidental
decreases with altitude in air transport and thus can extubation and airway loss may occur during patient
lead to drying of secretions of respiratory tract and transport.[24‑26] These can be prevented by providing
mucous membranes. These patients will require the optimal sedation and analgesia with provision of
use of humidified oxygen and lubrication of eyes by suctioning of ETT, confirmation of correct position
use of artificial tears or drops. of ETT and provision of full oxygen cylinder before
transport. There should be provision of a properly
Altitude functioning pulse oximeter.
The effect of increasing the altitude is mainly related
to decrease in inspired oxygen levels. The rotor wing Cardiovascular complications
ambulances usually fly at 2000–5000 feet above Tachycardia, hypotension, hypertension, arrhythmia
sea levels, whereas fixed wing ambulances fly at and even cardiac arrest (0.34–1.6%) may occur during
15,000–40,000 feet above sea levels. It is recommended transport.[27‑29] These can be prevented by having
to have pressurised air cabins at an altitude of 10,000 adequate resuscitation before transport with provision
feet above sea level. The physiological effects of of invasive and non‑invasive haemodynamic
increasing the altitude are: monitoring can prevent these complications.
Hypobaric hypoxia Infectious complications

As mentioned earlier, the partial pressure of oxygen Risk of infection both to transported patient and
decreases with increase in altitude which can in turn others who might be exposed to that patient have
aggravate hypoxia in patients with cardiorespiratory been reported.[30] These can be prevented by good
problems. communication between transport team and receiving
team.
Expansion of gas in body spaces and in medical
equipment Endocrine complications
This is due to reduction in the atmospheric pressure Hyperglycaemia and hypoglycaemia may develop
and can lead to ear pain, gastric distension or ileus. during transport due to discontinuation of insulin
The cuff pressure in the ETT cuff or tracheostomy cuff pumps and altered fluid therapy. These can be
can increase considerably causing pressure necrosis. prevented by paying close attention to glucose
The high altitude flights are thus contraindicated in regulation during all phases of transport.
Page no. 17
Acid‑base derangement, equipment dislodgement and Table 1: Complications that may occur during patient
interruption in vital infusions such as vasopressor, transfer
inotrope, analgesia and sedation may occur.[31] These Complications during patient transfer
Pulmonary
complications may be prevented by provision of blood gas
Atelectasis
analysis before transport which can be repeated during Hypoxaemia
the transport if the facilities are available and ensuring Pulmonary embolism
the running and patent lines to continue infusions and Bronchospasm
transfer them to transport bed. Table 1 shows a complete Pneumothorax
list of complications during patient transfer. Cardiovascular
Hypertension
Hypotension
RISK FACTORS FOR COMPLICATIONS[32]
Arrhythmia
Cardiac arrest
Certain factors add to the risk for development of Endocrine
complications during transport [Table 2]. Attention to Hypoglycaemia
identification and possible optimisation may reduce Hyperglycaemia
morbidity and mortality during transport. Infectious
Ventilator‑associated pneumonia
INDIAN SCENARIO Infection risk for patient and for personnel
Acid‑base disorders
Metabolic acidosis
The International guidelines as described may not be
Metabolic alkalosis
possible in developing countries like India due to the Respiratory alkalosis
diversity of Intensive Care Units which may be state Respiratory acidosis
of the art or may be just basic units capable of giving Miscellaneous
initial resuscitative measures. In a study by Verma Dislodgement of monitoring equipment
et al. comparing the transfer characteristics of trauma Interruption of therapy
patients transferred to a tertiary trauma centre from

peripheral centres, they found a significant lower GCS, Table 2: Risk factors for the development of complications
higher injury severity score and a longer duration of during transport
Risk factors
hospital stay in the transferred patients. Only 3.66% of
Patient‑related
the patients were accompanied by a paramedic or trained
High positive end‑expiratory pressure (>6 cmH2O)
nurse, whereas only 2.9% of the patients had cervical History of coronary artery disease
spine stabilised.[33] The variation in the infrastructure Postoperative patients
of each hospital in India, thus, establishes the need to Severe trauma patients
modify the International guidelines according to the Patients on complex medications and/or infusion regimens
local needs. There is a need for proper documentation Staff related
Inexperienced staff
at all stages of patient transfer with continuous quality
Unfamiliarity with monitoring equipment
assessments to improve upon the existing protocols. Insufficient preparation of the patient
The existing guidelines from Indian Society of Critical Poor communication with the receiving facility
Care Medicine for intra‑ and inter‑hospital transport Inadequate resuscitation
of patient is an evidence‑based guideline developed Lack of checklists
for Indian scenario to help standardise the equipment, Failure to prepare monitors before transport
Interruption in therapy
the personnel and monitoring during these transfers.
These guidelines are similar to other international
guidelines with minor changes according to Indian additional care. Transfer should be initiated after
settings. These guidelines need to be implemented on carefully balancing the benefits obtained versus the
an urgent basis in India to improve the level of safe risks involved. The patient transfer should be based
transport of critically ill patients. on the concept of ‘stabilise and shift’ by initiating
stabilisation of patient at the transferring facility
SUMMARY and continuing such care till the receiving facility.
The transport personnel, an important factor in the
Transfer is an important but often neglected phase safe transport, should be well qualified to anticipate
of continuing care of a patient who may also need and manage any complications that may arise during

Page no. 18
the transport process. The guidelines should be 15. Wiegersma JS, Droogh JM, Zijlstra JG, Fokkema J, Ligtenberg JJ.
Quality of interhospital transport of the critically ill: Impact of
modified according to the infrastructure available in a Mobile Intensive Care Unit with a specialized retrieval team.
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assessments. 16. Essebag V, Halabi AR, Churchill‑Smith M, Lutchmedial S. Air
medical transport of cardiac patients. Chest 2003;124:1937‑45.
17. Imaizumi T, Hata N, Kobayashi N, Yokoyama S, Shinada T,
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Med Sch 2004;71:352‑6.
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and time. CMAJ 2009;181:569‑70.
There are no conflicts of interest. 19. Thomson DP, Thomas SH; Air Medical Services Committee of
the National Association of EMS Physicians. Guidelines for air
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2012;72:487‑90. 26. Mazza BF, Amaral JL, Rosseti H, Carvalho RB, Senna AP,
7. Warren J, Fromm RE Jr., Orr RA, Rotello LC, Horst HM; Guimarães HP, et al. Safety in intrahospital transportation:
American College of Critical Care Medicine. Guidelines for the Evaluation of respiratory and hemodynamic parameters. A
inter‑and intrahospital transport of critically ill patients. Crit prospective cohort study. Sao Paulo Med J 2008;126:319‑22.
Care Med 2004;32:256‑62. 27. Taylor JO, Chulay JD, Landers CF, Hood W Jr., Abelman WH.
8. American College of Emergency Physicians. Principles of Monitoring high‑risk cardiac patients during transportation in
appropriate patient transfer. Ann Emerg Med 1990;19:337‑8. hospital. Lancet 1970;2:1205‑8.
9. Duke GJ, Green JV. Outcome of critically ill patients undergoing 28. Damm C, Vandelet P, Petit J, Richard JC, Veber B, Bonmarchand
interhospital transfer. Med J Aust 2001;174:122‑5. G, et al. Complications during the intrahospital transport in
10. Vos GD, Nissen AC, Nieman FH, Meurs MM, critically ill patients. Ann Fr Anesth Reanim 2005;24:24‑30.
van Waardenburg DA, Ramsay G, et al. Comparison of 29. Schmidt JM. Stopping the chain of infection in the radiology
interhospital pediatric intensive care transport accompanied suite. Radiol Technol 2012;84:31‑48.
by a referring specialist or a specialist retrieval team. Intensive 30. Choi HK, Shin SD, Ro YS, Kim DK, Shin SH, Kwak YH. A
Care Med 2004;30:302‑8. before‑ and after‑intervention trial for reducing unexpected
11. Dunn MJ, Gwinnutt CL, Gray AJ. Critical care in the emergency events during the intrahospital transport of emergency
department: Patient transfer. Emerg Med J 2007;24:40‑4. patients. Am J Emerg Med 2012;30:1433‑40.
12. Martin TE, editor. Stabilization prior to transportation. In: 31. Conrad BP, Rossi GD, Horodyski MB, Prasarn ML, Alemi Y,
Handbook of Patient Transportation. 1st ed. London: Cambridge Rechtine GR. Eliminating log rolling as a spine trauma order.
University Press; 2001. p. 45‑54. Surg Neurol Int 2012;3 Suppl 3:S188‑97.
13. Uusaro A, Parviainen I, Takala J, Ruokonen E. Safe 32. Knight PH, Maheshwari N, Hussain J, Scholl M, Hughes
long‑distance interhospital ground transfer of critically ill M, Papadimos TJ, et al. Complications during intrahospital
patients with acute severe unstable respiratory and circulatory transport of critically ill patients: Focus on risk identification
failure. Intensive Care Med 2002;28:1122‑5. and prevention. Int J Crit Illn Inj Sci 2015;5:256‑64.
14. Gebremichael M, Borg U, Habashi NM, Cottingham C, Cunsolo 33. Verma V, Singh GK, Carvello EJ, Kumar S, Singh CM, Harjai
L, McCunn M, et al. Interhospital transport of the extremely M. Inter‑hospital transfer of trauma patients in a developing
ill patient: The Mobile Intensive Care Unit. Crit Care Med country: A prospective descriptive study. Indian J Community
2000;28:79‑85. Health 2013;25:309‑15.
Page no. 19
AARC GUIDELINE: IN-HOSPITAL TRANSPORT OF MECHANICALLY VENTILATED PATIENT
AARC Clinical Practice Guideline
In-Hospital Transport of the Mechanically

Ventilated Patient — 2002 Revision & Update
TMV 1.0 PROCEDURE: during transport.
Transportation of a mechanically ventilated patient 5.1.5 Transport should not be undertaken
for diagnostic or therapeutic procedures. unless all the necessary members of the
transport team are present.
TMV 2.0 DESCRIPTION/DEFINITION:
Transportation of mechanically ventilated patients TMV 6.0 HAZARDS & COMPLICATIONS:
for diagnostic or therapeutic procedures is always Hazards and complications of transport include the
associated with a degree of risk.1-9 Every attempt following:
should be made to assure that monitoring, ventila- 6.1 Hyperventilation during manual ventilation
tion, oxygenation, and patient care remain constant may cause respiratory alkalosis, cardiac dys-
during movement. Patient transport includes prepa- rhythmias, and hypotension.1,10,11
ration, movement to and from, and time spent at 6.2 Loss of PEEP/CPAP may result in hypox-
destination. emia or shock.16,17
6.3 Position changes may result in hypotension,
TMV 3.0 SETTINGS: hypercarbia, and hypoxemia.14
This guideline is intended for the critical care and 6.4 Tachycardia and other dysrhythmias have
acute care inpatient setting. been associated with transport.13-15
6.5 Equipment failure can result in inaccurate
TMV 4.0 INDICATIONS: data or loss of monitoring capabilities.8,9
Transportation of mechanically ventilated patients 6.6 Inadvertent disconnection of intravenous
should only be undertaken following a careful eval- access for pharmacologic agents may result in
uation of the risk-benefit ratio. hemodynamic instability.8,9,13
6.7 Movement may cause disconnection from
TMV 5.0 CONTRAINDICATIONS: ventilatory support and respiratory compro-
Transportation of the mechanically ventilated pa- mise.16,18
tient should not be undertaken until a complete 6.8 Movement may result in accidental extuba-
analysis of potential risks and benefits has been ac- tion.13,19
complished. 6.9 Movement may result in accidental removal
5.1 Contraindications include of vascular access.3-5,8,9
5.1.1 inability to provide adequate oxy- 6.10 Loss of oxygen supply may lead to hypox-
genation and ventilation during transport emia.
either by manual ventilation, portable 6.11 Ventilator-associated pneumonia has been
ventilator, or standard intensive care unit associated with transport.20
ventilator,1,10-12
5.1.2 inability to maintain acceptable TMV 7.0 LIMITATIONS OF METHOD:
hemodynamic performance during trans- The literature suggests that nearly two thirds of all
port,13-15 transports for diagnostic studies fail to yield results
5.1.3 inability to adequately monitor pa- that affect patient care.8,9
tient cardiopulmonary status during trans-
port,14 TMV 8.0 ASSESSMENT OF NEED:
5.1.4 inability to maintain airway control The necessity and safety for transport should be as-
RESPIRATORY CARE • JUNE 2002 VOL 47 NO 6 721

sessed by the multidisciplinary team of health care vide humidification during transport.
providers, eg, respiratory therapist, physician, 10.1.9 Stethoscope
nurse. The risks of transport should be weighed 10.1.10 Hand-held spirometer for tidal
against the potential benefits from the diagnostic or volume measurement
therapeutic procedure to be performed. 10.2 Personnel: All mechanically ventilated pa-
tients should be accompanied by a registered
TMV 9.0 ASSESSMENT OF OUTCOME: nurse and a respiratory therapist during the en-
The safe arrival of the mechanically ventilated pa- tire transport.
tient at his/ her destination is the indicator of a favor- 10.2.1 At least one team member must be
able outcome. proficient in managing the airway in the
event of accidental extubation.
TMV 10.0 RESOURCES: 10.2.2 At least one team member should
10.1 Equipment be proficient in operating and trou-
10.1.1 Emergency airway management bleshooting all of the equipment de-
supplies should be available and checked scribed in Section 10.1.
for operation before transport
10.1.2 Portable oxygen source of ade- TMV 11.0 MONITORING:
quate volume Monitoring provided during transport should be
10.1.3 A self-inflating bag and mask of similar to that during stationary care.
appropriate size 11.1 Electrocardiograph should be continuous-
10.1.4 Transport ventilators have been ly monitored for heart rate and dysrhythmias.
shown to provide more constant ventila- 11.2 Blood pressure should be monitored con-
tion than manual ventilation in some in- tinuously if invasive lines are present. In the ab-
stances. If a transport ventilator is used, it sence of invasive monitoring, blood pressure
should:1,10-12,21,22 should be measured intermittently via sphyg-
10.1.4.1 have sufficient portable power momanometer.
supply for the duration of transport;23 11.3 Respiratory rate should be monitored in-
10.1.4.2 have independent control of termittently.
tidal volume and respiratory frequen- 11.4 Airway pressures should be monitored if a
cy;16 transport ventilator is used.24
10.1.4.3 be able to provide full ventila- 11.5 Tidal volume should be monitored inter-
tory support as in assist-control or in- mittently to assure appropriate ventilation.25
termittent mechanical ventilation (not 11.6 Continuous pulse oximetry is appropriate
necessarily both); during transport of all mechanically ventilated
10.1.4.4 deliver a constant volume in patients.
the face of changing pulmonary 11.7 Breath sounds should be monitored inter-
impedance; mittently.
10.1.4.5 monitor airway pressure;
10.1.4.6 provide a disconnect alarm; TMV 12.0 FREQUENCY:
10.1.4.7 be capable of providing PEEP; Patients should be transported only when indica-
10.1.4.8 provide an FIO2 of 1.0. tions are present as described in Section 4.
10.1.5 A pulse oximeter is desirable.
10.1.6 Appropriate pharmacologic agents TMV 13.0 INFECTION CONTROL:
should be readily available. 13.1 Universal Precautions should be ob-
10.1.7 Portable monitor should display served.26
ECG and heart rate and provide at least 13.2 All equipment should be disinfected be-
one channel for vascular pressure mea- tween patients.
surement. 13.3 Centers for Disease Control and Preven-
10.1.8 An appropriate hygroscopic con- tion recommendations for control of exposure
denser humidifier should be used to pro- to tuberculosis and droplet nuclei are to be im-
722 RESPIRATORY CARE • JUNE 2002 VOL 47 NO 6

ill ventilator-dependent patients. Chest 1989;96(3):631-

plemented when patient is known or suspected 635.
to be immunosuppressed, is known to have tu- 13. Taylor JO, Chulay JD, Landers CF, Hood WB Jr, Abelman
berculosis, or has other risk factors for the dis- WH. Monitoring high-risk cardiac patients during trans-
ease.27 portation in hospital. Lancet 1970;2(7685):1205-1208.
14. Waddell G. Movement of critically ill patients within hos-
pital. Br Med J 1975;2(5968):417-419.
15. Rutherford WF, Fisher CJ. Risks associated with inhouse
Revised by David W Chang EdD RRT, Athens Tech- transportation of the critically ill (abstract). Clin Res
nical College, Athens GA, and approved by the 1986;34:414.
2002 CPG Steering Committee. 16. Branson RD. Intrahospital transport of critically ill, me-
chanically ventilated patients. Respir Care
Original publication: Respir Care 1993;38(11):1169-1172. 1992;37(7):775-795.
17. Komdeur R, van der Werf TS, Ligtenberg JJ, Tulleken JE,
Zijlstra JG. [Hemodynamic and ventilatory complications
of mechanical ventilation with high intrinsic positive end-
REFERENCES
expiratory pressure.] Ned Tijdschr Geneeskd
2000;144(30):1445-1450. article in Dutch
1. Braman SS, Dunn SM, Amico CA, Millman RP. Compli- 18. Johannigman JA, Branson RD, Campbell R, Hurst JM.
cations of intrahospital transport in critically ill patients. Laboratory and clinical evaluation of the MAX transport
Ann Intern Med 1987;107(4):469-473. ventilator. Respir Care 1990;35(10):952-959.
2. Edlin S. Physiological changes during transport of the crit- 19. Christie JM, Dethlefsen M, Cane RD. Unplanned endotra-
ically ill. Intensive Care World 1989;6:131. cheal extubation in the intensive care unit. J Clin Anesth
3. Smith I, Fleming S, Cernaianu A. Mishaps during trans- 1996;8(4):289-293.
port from the intensive care unit. Crit Care Med 20. Kollef MH, Von Harz B, Prentice D, Shapiro SD, Silver P,
1990;18(3):278-281. St John R, Trovillion E. Patient transport from intensive
4. Insel J, Weissman C, Kemper M, Askanazi J, Hyman AI. care increases the risk of developing ventilator-associated
Cardiovascular changes during transport of critically ill pneumonia. Chest 1997;112(3):765-773.
and postoperative patients. Crit Care Med 21. Dockery WK, Futterman C, Keller SR, Sheridan MJ, Akl BF.
1986;14(6):539-542. A comparison of manual and mechanical ventilation during
5. Ehrenwerth J, Sorbo S, Hackel A. Transport of critically pediatric transport. Crit Care Med 1999;27(4):802-806.
ill adults. Crit Care Med 1986;14(6):543-547. 22. Tobias JD, Lynch A, Garrett J. Alterations of end-tidal
6. Andrews PJ, Piper IR, Dearden NM, Miller JD. Secondary carbon dioxide during the intrahospital transport of chil-
insults during intrahospital transport of head-injured pa- dren. Pediatr Emerg Care 1996;12(4):249-251.
tients. Lancet 1990;335(8685):327-330. 23. Barton AC, Tuttle-Newhall JE, Szalados JE. Portable
7. Gentleman D, Jennett B. Audit of transfer of unconscious power supply for continuous mechanical ventilation dur-
head-injured patients to a neurosurgical unit. Lancet ing intrahospital transport of critically ill patients with
1990;335(8685):330-334. ARDS. Chest 1997;112(2):560-563.
8. Indeck M, Peterson S, Smith J, Brotman S. Risk, cost, and 24. Miyoshi E, Fujino Y, Mashimo T, Nishimura M. Perfor-
benefit of transporting ICU patients for special studies. J mance of transport ventilator with patient-triggered venti-
Trauma 1988;28(7):1020-1025. lation. Chest 2000;118(4):1109-1115.
9. Hurst JM, Davis K Jr, Johnson DJ, Branson RD, Campbell 25. McGough EK, Banner MJ, Melker RJ. Variations in tidal
RS, Branson PS. Cost and complications during in-hospi- volume with portable transport ventilators. Respir Care
tal transport of critically ill patients: a prospective cohort 1992;37(3):233-239.
study. J Trauma 1992;33(4):582-585. 26. Update: Universal precautions for prevention of transmis-
10. Hurst JM, Davis K Jr, Branson RD, Johannigman JA. sion of human immunodeficiency virus, hepatitis B virus,
Comparison of blood gases during transport using two and other blood-borne pathogens in health-care settings.
methods of ventilatory support. J Trauma MMWR 1988;37(24):377-382,387-388.
1989;29(12):1637-1640. 27. Dooley SW Jr, Castro KG, Hutton MD, Mullan RJ, Polder
11. Gervais HW, Eberle B, Konietzke D, Hennes HJ, Dick W. JA, Snider DE Jr. Guidelines for preventing the transmis-
Comparison of blood gases of ventilated patients during sion of tuberculosis in health-care settings, with special
transport. Crit Care Med 1987;15(8):761-763. focus on HIV-related issues. MMWR Recomm Rep
12. Weg JG, Haas CF. Safe intrahospital transport of critically 1990;39(RR-17):1-29.
Interested persons may photocopy these Guidelines for noncommercial purposes of scientific
or educational advancement. Please credit AARC and RESPIRATORY CARE Journal.
All of the AARC CPGs may be downloaded at no charge from
http://www.rcjournal.com/online_resources/cpgs/cpg_index.htm/
RESPIRATORY CARE • JUNE 2002 VOL 47 NO 6 723

Update in Anaesthesia
TRANSPORTATION OF THE CRITICALLY ILL AND INJURED PATIENT
Dr Peter J. Shirley, Intensive Care Fellow, Frimley Park Hospital, Surrey, UK. [email protected]
Terminology l Give oxygen preferably by face mask and at high flows

Primary transport: from the incident site to a medical facility. l Preserve blood volume; compression of bleeding sites and
limited fluid resuscitation
Secondary transport (Inter-hospital): patient moved between
two hospitals, usually for an increased level of medical care not l Splinting and packaging; unnecessary movement of
available locally. injured patients provokes bleeding. Basic splinting of fractures
will provide good analgesia and contribute to preserving blood
Intrahospital transport: movement of patients within the hospital
volume.
or its campus for investigations or treatment not available at the
ward or intensive care location. (eg CT scan) l Analgesia; this is humane and should be given when needed.
Morphine is cheap and effective. Non-steroidal analgesia should
History
be avoided initially in the trauma patient due to adverse effects
The primary and secondary transport of critically ill patients are on platelet aggregation and renal function.
complementary to one another. Primary transport from the site
l Expeditious transport; ultimately the patient needs to be in
of illness or incident to organised medical care has now moved
hospital and receiving a higher level of care than can be provided
on from the old ‘scoop and run’ philosophy. Developments often
‘in the street’. Unless treatment pre-hospital is beneficial it is
occurred following experiences in major conflict. The Knights of
often better to accept the limitations of what is achievable and
St John crusading in the 11th century received training from Arab
move them to hospital quickly but safely.
and Greek physicians. They acted as attendants to soldiers at the
point of injury and then transported them to treatment points. It has been argued in the past that the provision of more advanced
Baron Dominique Jean Larrey, Napoleon’s surgeon-in-chief, is pre-hospital care services in less affluent areas of the world is of
credited with the first organised vehicular ambulance service, little benefit unless sophisticated levels of care exist in receiving
taking medical attendants into the battlefield with the French hospitals. This has recently been refuted in a study looking at
army. Until recently, ambulances were still not designed with pre-hospital care services in Cambodia and Iraq, showing a 40%
the patient’s well being in mind. 1944 saw the first helicopter reduction in mortality from major trauma after the introduction
evacuation of combat casualties in Burma. In Vietnam 90% of of an ambulance service with trained attendants.1
hospitalised US battle casualties were evacuated by helicopter.
Secondary transport
Physician escorts for secondary transports are a relatively
Guidelines for the secondary transport of patients have been
recent phenomenon. Systems in North America were the first to
produced by the Australian and New Zealand College of
formalise these arrangements in the 1950’s. Since then transfer
Anaesthetists in 2003 and the UK Intensive Care Society in 2001.
teams and ‘retrieval’ services have been introduced in many
These attempt to bring together advice from different sources and
large hospitals and health systems world-wide including Africa
encourage an improvement in standards. The safe and successful
and SE Asia.
transport of the critically ill should follow these principles:
Primary transport
l Organisation. Planning of transfers should reflect local
Currently most injured patients are transported from an accident facilities and the availability of appropriately trained staff.
site to the nearest hospital emergency department by land- Clear guidelines and channels of communication must exist in
ambulance with ambulance paramedics providing care at the each hospital. In the absence of a recognised transfer team, each
incident. The presence of a doctor on board primary response units hospital must provide adequate staff and facilities for outgoing
continues to be a source of controversy. Some data have suggested patients, adhering as closely as possible to the standards of care
improved pre-hospital stabilisation and long term survival in provided in the hospital. Flexibility in staffing and rostering
victims of major trauma attended by a medical team containing arrangements must exist to allow this to happen, where possible
a doctor, as opposed to a paramedic only response unit. not organising transfers in the middle of the night when resources
and staffing are at their most stretched. The planning phase is vital
Most of the principles of trauma care covered in the primary
for a smooth transfer and a briefing format is worth considering.
trauma care course (PTC) are applicable in the pre-hospital
The military use these as a basis for most missions.
setting. This will obviously depend on the level of training of
the attendants and whether the facilities exist for more advanced l Transfer decisions. These must be made jointly by senior
levels of care. However, there are some simple cornerstones of medical staff in both the receiving and referring hospitals. The
treatment which form the basis of care and are available to the risk of transfer arising from the patient’s condition must be set
most basic of services: against the additional risk from the movement (tipping, vibration,
acceleration/ deceleration etc) as well as possible pressure
and temperature changes which may adversely affect cardio-

respiratory physiology. The risks to staff of injury or accident must
not be overlooked especially in adverse weather and in unsecured
areas at night. The decision to send a retrieval team or use staff
from the referring hospital will depend on the availability of such
resources and the clinical urgency of the case.
l Transfer mode. Keeping things simple has much to commend
it. The choice of transport will obviously be influenced by what
is available but other factors will come into play. The urgency of
the transfer and prevailing road and weather conditions, as well
as the range and speed of available vehicles. It may be necessary
for a receiving hospital to provide the vehicle (and sometimes the
personnel!) if this is considered appropriate. The use of aircraft
and in particularly helicopters can appear attractive, however they
usually do not reduce travel time unless the distances are large
and the terrain rough.
l Transfer vehicle requirements. Well-maintained and
adequately equipped vehicles should be used. Ease of access,
proper heating control, lighting and good communications are all
considerations. An oxygen supply and suction are also mandatory.
Safety provision for staff is important and noise and vibration
levels should be at acceptable levels.
l Accompanying personnel. In addition to the normal
complement of crew on a given vehicle there should be two
accompanying staff for the critically ill patient. An experienced
doctor with skills in resuscitation and airway control should
be responsible for the patient and preferably be experienced
in undertaking transfers. Another doctor or experienced nurse,
l Preparation for transfer. Stabilisation and meticulous
paramedic or technician with familiarity in transfer procedures,
preparation are the keys to a successful transfer. All personnel
the vehicle and equipment should be present and acts as an
should familiarise themselves with the patient and the current
assistant to the responsible doctor.
treatment. As with the planning phase, it is useful to have a
l Equipment must be suited to the environment i.e. be durable checklist to avoid omissions. This list is a useful starting point,
and lightweight and have sufficient battery life. A monitored when considering any treatment outside the hospital setting,
oxygen supply with a safety margin of two hours on the transfer whatever the circumstances. Full clinical examination with
time is essential. There should be storage space for equipment and reference to on-going monitoring should be carried out. Chest
staff should be appropriately clothed. A portable ventilator with drains should be fitted with flutter valves and be easily observed. A
disconnection and high-pressure alarms and the ability to provide review of recent investigations: CXR, other X-rays, haematology
PEEP and variable FiO2, I: E ratio, respiratory rate and tidal and biochemistry results.
volume. Portable monitors giving SaO2, ECG and non-invasive
Preparation for transfer checklist
BP. The facility to monitor invasive pressures (arterial and CVP)
are preferable depending on resources. A dedicated equipment l Respiration
bridge, containing ventilator, monitoring equipment and infusion l Circulation
devices is becoming the method of choice for providing theses l Head
requirements. (Figure 1) These can be manufactured locally but
l Other injuries
need to be robust and withstand the rigors of transport, especially
over rough terrain. Alarms should be visible as well as audible. l Monitoring
Suction and defibrillation should be immediately available. l Line placement and securing
A warming blanket is also a consideration in cold climates. A l Investigations
reasonable range and supply of drugs should be carried with
syringe pumps to administer them, ensuring that all such devices A patient should not be transported until all possible sources of
have charged and spare batteries (the Braun Perfusor FM compact continuing blood loss and sepsis have been located and controlled.
syringe driver will run off standard AA battery power). Non Satisfactory perfusion and optimum tissue oxygen delivery must
of these requirements should seriously affect the referring be achieved. Respiratory support is fundamental. Intubation
hospitals ability to deal with emergencies in terms of staff during transfer is difficult and hazardous; if any doubts exist about
or equipment whilst the transfer team is away. The vehicle respiratory function intubation and mechanical ventilation must
should have communications able to contact the base hospital be carried out pre-transport. For ventilated patients the pattern of
in emergencies and the receiving hospital to fore warn of any ventilation should be established and a base-line end tidal CO2
problems. achieved pre-transport.
Adequate venous access must be in place. A urinary catheter and Suggested briefing format for interhospital transfers
a naso/ orogastric tube should be passed. All lines and tubes need
S - Situation
to be securely fixed.
M - Mission
All documentation including referral letters should be gathered
E - Equipment
and the receiving hospital re-contacted prior to departure
to confirm availability of the bed and also to confirm their A - Administration
understanding of what they are accepting. C - Communnications
l Monitoring during transfer should approach that expected
at altitude; the risk of tracheal wall pressure leading to possible
within the hospital setting. Oxygen saturation and ECG and
airway oedema and necrosis. The pressure in air-filled cuffs
should be monitored continuously whenever possible. Invasive
should be checked regularly. Alternatively saline can be used to
BP is advisable as non-invasive measurements are subject to
inflate cuffs, which will not expand with changes in pressure.
movement artefact. Mechanically ventilated patients need
Temperature control, especially in helicopters, can be a problem.
end tidal CO2 monitoring and a disconnection alarm should be
Most rotary wing and small fixed wing aircraft have excessive
used with mechanical ventilators. For long journeys and in cold
levels of noise and vibration. Communication, monitoring, the
weather, temperature monitoring should be instituted. The use
function of equipment and the administration of fluids can all be
of a stretcher bridge, with all monitoring self-contained is to be
affected. The environment is unfamiliar to most. The available
recommended.
space, particularly in helicopters can be limited and they can be
Ideal basic ambulance equipment requirements cramped and noisy. Ideally, dedicated aircraft should be used
with adaptations making them suitable for aero medical use.
l Protective clothing and footwear
Both staff and patients can be affected by motion sickness. Staff
l Hard hats
who recurrently suffer with this problem should not be selected,
l Robust gloves similarly those who are unable to equalise their middle ear
l Safety glasses pressure are unsuitable as escorts. Long distance flights from
l Simple tools and cutting equipment
abroad have special considerations and specialist advice should
be sought.
l Communications
l Receiving hospital handover. On arrival the responsible
l Lighting and torches
doctor must liase with the medical officer taking over the care.
l Restraints for staff and equipment
A written summary of events in transfer should be added to
l Splints the clinical notes and ideally a copy kept for the records at the
l Oxygen referring centre. This will enable information to be supplied
l Suction unit for local audit and, if necessary, regional or national audit.
Without good documentation it is difficult to measure meaningful
l Secure stretcher
outcomes and improve care in the future. The Australian Patient
l Extrication (spinal) board Safety Foundation introduced an anonymous self-reporting
l Neck collars system for critical incidents during patient retrievals in July
l Defibrillators 1999. Any team member who felt that there had been a problem
endangering patient or staff safety can report this on a standard
l emperature control systems
form. These are collated centrally for the whole country in an
l Dressings attempt to identify recurring problems and improve the service.
l Oxygen masks It would be a positive step if such systems could be adopted
routinely everywhere. Whilst this is unrealistic for many, the
l Inter-hospital management. Despite good preparation utilisation of formal debriefing and mission analysis forms will
interventions may need to be carried out en-route; this may enable problems to be highlighted and lessons learned at a local
involve stopping the vehicle if transport is by road. A slow smooth level.
journey may be preferable to a fast bumpy one! Once patients l Training. Staff employed in such transfers should ideally
are secured on transfer stretchers and monitoring attached it is be specifically trained and have had the opportunity to act as
difficult to gain good access for continued treatment. observers in previous cases. This is often overlooked as it takes
l Aeromedical considerations. The use of aircraft is not time and often involves more staff than can be spared. Safety
without risk and this is especially true if the attendants are aspects of the vehicle employed, including safe approach and
not familiar with the flight environment. Increasing altitude escape routes, should be highlighted. All staff should have
potentates hypoxia and the reduction in alveolar partial pressure had basic orientation and safety training whatever the mode of
of oxygen necessitates supplemental oxygen in all patients. transport employed.
Pressurised commercial aircraft have cabin altitudes of 6000-8000 Intrahospital transport
feet; pneumothoraces will expand by 20% in these conditions,
hence chest drainage is mandatory if they are even remotely It must be remembered that transporting critically ill patients
suspected. The air in endotracheal cuffs will similarly expand within the hospital is in also potentially dangerous. These patients
have reduced physiological reserves and adverse changes can patient and make sure all his venous access is secure and he is
occur during the transport process. Careful planning is required cardiovascularly stable. They ensure he has been given sedative
when moving patients between facilities (eg theatres, wards, X- drugs and muscle relaxants and these are reviewed regularly. The
ray etc). Many of the points described above under interhospital position of the endotracheal tube is checked on chest X-ray and
transport are applicable. In addition the transport team should be a pelvic and C-spine films are performed. The pelvic and chest
freed from other duties and the departure and destination times x-rays are normal.
be agreed well in advance. All equipment to be used should be
His family arrive to find out what has happened to him and the
checked beforehand and in particular emergency equipment
doctor speaks to them about his current condition and need to go
such as resuscitators and suction units. The route used within
to the regional centre. The ambulance arrives and the escorting
the hospital should be identified and lifts and corridors secured
personnel check that it is suitable before moving the patient.
as necessary before the transfer begins. Any physiological
He is attached to a portable blood pressure, ECG and saturation
changes occurring during transport should be acted on where
probe. He is hand ventilated with a self-inflating respirator
appropriate and the patient transferred back to the Intensive Care
attached. All notes and X-rays are collected to be passed onto the
Unit if necessary. Documentation of the transport process and
receiving medical team. Ideally, this man would be transported
any adverse events should be made in the clinical record. The
on a mechanical ventilator such as an Oxylog 2000 (Draeger
overall process in any one hospital should be evaluated regularly,
Corporation), with end-tidal CO2 monitoring and with an arterial
so that recurrent problems can be identified and appropriate
line in-situ for continuous blood pressure measurement and an
changes made.
anaesthetist to escort. The reality is that many hospitals do not
Considerations in intra-hospital transport have the resources to provide these for the transported patients.
The balance of risks for this patient are that he is better cared
l Is it necessary ?
for in the regional hospital with its better imaging and intensive
l What is the best route ? care facilities despite the less than ideal transport conditions.
l Who should act as escort ? On arrival, the anaesthetic technical officer and nurse give a
l What equipment is required ?
verbal hand-over of the case and pass all notes and x-rays to the
medical team.
l Do they know we are coming ?
l Do the benefits outweight the risks ?
References / further reading
l When should it happen ? 1. Husum H, Gilbert M, Wisborg T, Van Heng Y, Murad M. Rural Prehospital
Trauma Systems in Low- Income Countries: a prospective study from North Iraq
l What preparations are necessary ? and Cambodia. J Trauma 2003;54:118-1196.
l Has the equipment been checked ? 2. Advanced Life Support Group. Safe Transfer and Retrieval: The Practical
Approach. BMJ Books, London, 2002. (ISBN 0 7279 1583 5)
l Have we got notes and request forms ?
3. Australian Patient Safety Foundation. (1999) Australian Incident Monitoring
Study (Retrieval Medicine). GPO Box 2050, Adelaide, SA 5001.
Case study: Closed head injury
4. Faculty of Intensive Care of the Australian and New Zealand College Of
A 25 year-old man is involved in a road traffic accident and is Anaesthetists and Australasian College for Emergency Medicine. (2003)
brought to the emergency room of a rural hospital. He is semi- Minimum standards for transport of the critically ill.
conscious with a Glasgow Coma Score of 6. Following an 5. Faculty of Intensive Care of the Australian and New Zealand College Of
‘ABCDE’ assessment in line with Primary trauma care guidelines Anaesthetists and Australasian College for Emergency Medicine. (2003)
he is intubated, with appropriate neck control and a hard cervical Minimum standards for intrahospital transport of the critically ill.
collar applied. The nearest hospital with imaging facilities and 6. Gilligan JE, Griggs WM, Jelly MT et al. 1999 Mobile intensive care services
an intensive care unit is 65 miles away. The doctor in charge of in rural South Australia. Medical Journal of Australia 1999 171:617-620.
care at the rural hospital makes contact with the doctor in charge 7. Martin TE. Handbook of Patient Transportation. (2001) Greenwich Medical
of the intensive care unit at the regional hospital. It is decided Media, 137 Euston Road, London, NW1 2AA. (ISBN 1 84110 071 4)
that the patient will be transferred by the rural hospital team 8. Intensive Care Society.(2001) Guidelines for the transport of the critically
in an ambulance sent by the regional hospital. They will send ill. UK.
an oxygen supply for the trip. The rural hospital can supply an 9. Wallace PGM, Ridley SA. ABC of intensive care. Transport of critically ill
anaesthetic technical officer and nurse to escort the patient. They patients. British Medical Journal 1999 319:368-371.
use the time whilst waiting for the ambulance to re-examine the
Clinical review
ABC of intensive care

Transport of critically ill patients
Peter G M Wallace, Saxon A Ridley
Intensive care patients are moved within hospital—for example,

Principles of safe transfer
to the imaging department—or between hospitals for upgraded
treatment or because of bed shortages. We will concentrate on x Experienced staff
transport of adults between hospitals, but the principles are x Appropriate equipment and vehicle
x Full assessment and investigation
similar for transfers within hospitals.
x Extensive monitoring
Although the Intensive Care Society and the Association of x Careful stabilisation of patient
Anaesthetists have recommended that retrieval teams are x Reassessment
established in the United Kingdom, 90% of patients are x Continuing care during transfer
accompanied by staff from the referring hospital. Over 10 000 x Direct handover
intensive care patients are transferred annually in the United x Documentation and audit
Kingdom, but most hospitals transfer fewer than 20 a year. Each
hospital thus has little expertise and few people gain knowledge
of transport medicine. Most patients are accompanied by on
call anaesthetic trainees. Not only does this leave the base
hospital with inadequate on call staff but accompanying doctors
often have little experience.
Dangers of transport
Intensive care patients have deranged physiology and require
invasive monitoring and organ support. Furthermore, they tend
to become unstable on movement. Transport vehicles are not
conducive to active intervention and no help is available. Staff
and patients are vulnerable to vehicular accidents and may be
exposed to temperature and pressure changes.
Audits in the United Kingdom suggest that up to 15% of
patients are delivered to the receiving hospital with avoidable
hypotension or hypoxia which adversely affects outcome. About
10% of patients have injuries that are undetected before
transfer. However, with experienced staff, appropriate
equipment, and careful preparation, patients can be moved Specially equipped ambulances are best for transferring patients
between hospitals without deterioration. The “scoop and run”
principle is not appropriate for moving critically ill patients.
Organisation
Each hospital should have a designated consultant responsible Organisational structure
for transfers who ensures that guidelines are prepared for
National and regional
referral and safe transfer, equipment and staff are available, and
Department of Health, purchasers, and specialist societies have
standards are audited. Proper routines for referral between responsibility for
hospitals and good communication should ensure appropriate x Guidelines
referral, coordination, and integration of services. An area or x Audit
regional approach may allow retrieval teams to be established. x Bed bureau
x Funding
x Regional retrieval teams
Transfer decisions Hospital or trust
Consultant with overall responsibility for transfers including
A decision to transfer should be made by consultants after full x Local guidelines, protocols, check lists
assessment and discussion between referring and receiving x Coordination with neighbouring hospitals
x Availability and maintenance of equipment
hospitals. Guidelines exist concerning timing of transfer for
x Nominated consultant for 24 hour decisions
certain groups of patients—for example, those with head injury. x Call out system for appropriate staff
For patients with multiple organ failure the balance of risk and x Indemnity and insurance cover
benefit needs to be carefully discussed by senior staff. x Liaison with ambulance service concerning specification of vehicle
The decision on whether and how to send or retrieve a and process of call out
patient will depend on the urgency of transfer, the availability x Communication systems between units and during transfer
and experience of staff, equipment, and any delay in mobilising x Education and training programmes
x Audit: critical incident, morbidity, and mortality
a retrieval team. Local policies should be prepared to reflect x Funding: negotiations with purchasers
referral patterns, available expertise, and clinical circumstances.
368 BMJ VOLUME 319 7 AUGUST 1999 www.bmj.com

Clinical review
Transfer vehicle
Vehicles should be designed to ensure good trolley access and
fixing systems, lighting, and temperature control. Sufficient
space for medical attendants, adequate gases and electricity,
storage space, and good communications are also important.
The method of transport should take into account urgency,
mobilisation time, geographical factors, weather, traffic
conditions, and cost.
Road transfer will be satisfactory for most patients. This also
has the advantages of low cost, rapid mobilisation, less weather
dependency, and easier patient monitoring. Air transfer should
be considered for longer journeys (over about 50 miles (80 km)
or 2 hours). The apparent speed must be balanced against
organisational delays and transfer between vehicles at the
beginning and end. Helicopters are recommended for journeys
of 50-150 miles (80-240 km) or if access is difficult, but they
provide a less comfortable environment than road ambulance
or fixed wing aircraft, are expensive, and have a poorer safety
record. Fixed wing aircraft, preferably pressurised, should be
used for transfer distances over 150 miles (240 km).
Close liaison with local ambulance services is required.
Contact numbers should be available in all intensive care units
Comfort and safety of patients and staff are
and accident and emergency departments to ensure rapid important
communication and advice.
Equipment
Equipment must be robust, lightweight, and battery powered.
The design of transport equipment has advanced greatly, and
most hospitals now have the essentials. Many ambulance
services also provide some items in standard ambulances.
Equipment for establishing and maintaining a safe airway is
essential. Another prerequisite is a portable mechanical
ventilator with disconnection alarms which can provide
variable inspired oxygen concentrations, tidal volumes,
respiratory rates, levels of positive end expiratory pressure, and
inspiratory:expiratory ratios. The vehicle should carry sufficient
oxygen to last the duration of the transfer plus a reserve of 1-2
hours.
A portable monitor with an illuminated display is required
to record heart rhythm, oxygen saturation, blood pressure by
non-invasive and invasive methods, end tidal carbon dioxide,
and temperature. Alarms should be visible as well as audible
Portable ventilator, battery powered syringe pumps, and monitor
because of extraneous noise during transfer. Suction equipment
and a defibrillator should be available. A warming blanket is
advantageous. The vehicle must also contain several syringe
pumps with long battery life and appropriate drugs. A mobile
phone for communication is advisable.
One person should be responsible for ensuring batteries are
charged and supplies fully stocked. All those assisting in the
transfer should know where the equipment is and be familiar
with using the equipment and drugs.
If patients are transferred on standard ambulance trolleys
equipment has to be carried by hand or laid on top of the
patient, which is unsatisfactory. Special trolleys should be used
that allow items to be secured to a pole or shelf above or below
the patient.
Accompanying staff
In addition to the vehicle’s crew, a critically ill patient should be
accompanied by a minimum of two attendants. One should be
an experienced doctor competent in resuscitation, airway care,
ventilation, and other organ support. The doctor, usually an
anaesthetist, should ideally have training in intensive care, have Trolley with shelf for equipment makes moving patients easier and safer
BMJ VOLUME 319 7 AUGUST 1999 www.bmj.com 369

Clinical review
carried out previous transfers, and preferably have at least two

years’ postgraduate experience. He or she should be assisted by
another doctor, nurse, paramedic, or technician familiar with
intensive care procedures and equipment. Current staffing
levels in many district general hospitals mean that this ideal is
not always achievable.
The presence of experienced attendants will not only ensure
that basics for ensuring safe transfer are undertaken but prevent
transfers being rushed without full preparation; this often
requires a senior voice. Hospitals should run regular training
programmes in safe transport techniques.
Provision must be made for adequate insurance to cover
death or disability of attendants in an accident during the
course of their duties. The hospital trust should provide medical
indemnity, and personal medical defence cover is also
recommended. Patients should be accompanied by an experienced doctor and another
trained member of staff
Preparation
Meticulous stabilisation of the patient before transfer is the key
to avoiding complications during the journey. In addition to full Is your patient ready for transfer?
clinical details and examination, monitoring before transfer Respiration Other injuries
should include electrocardiography, arterial oxygen saturation, x Airway safe? x Cervical spine, chest, ribs?
(plus periodic blood gas analyses), blood pressure preferably by x Intubation and ventilation x Pneumothorax?
direct intra-arterial monitoring, central venous pressure where required? x Bleeding—intrathoracic or
indicated, and urine output. Investigations should include chest x Sedation, analgesia, and abdominal?
paralysis adequate? x Long bone or pelvic fractures?
radiography, other appropriate radiography or computed x Arterial oxygen pressure x Adequate investigation?
tomography, haematology, and biochemistry. If intra-abdominal > 13 kPa? saturation > 95%? x Adequate treatment?
bleeding is suspected the patient should have peritoneal lavage. x Arterial carbon dioxide Monitoring
Intubating a patient in transit is difficult. If the patient is likely pressure 4-5 kPa? (fit young x Electrocardiography?
to develop a compromised airway or respiratory failure, he or she adult) x Pulse oximetry?
should be intubated before departure. Intubated patients should Circulation x Blood pressure?
be mechanically ventilated. Inspired oxygen should be guided by x Systolic blood pressure x End tidal carbon dioxide
arterial oxygen saturation and blood gas concentrations. > 120 mm Hg? pressure?
x Heart rate < 120 beats/min? x Temperature?
Appropriate drugs should be used for sedation, analgesia, and
x Perfusion OK? x Central venous pressure,
muscle relaxation. A chest drain should be inserted if a x Intravenous access adequate? pulmonary artery pressure,
pneumothorax is present or possible from fractured ribs. x Circulating volume replaced? or intracranial pressure
Intravenous volume loading will usually be required to x Blood needed? needed?
restore and maintain satisfactory blood pressure, perfusion, and x Urine volumes? Investigations
urine output. Inotropic infusions may be needed. Unstable x Continuing bleeding? Site? x Blood gases, biochemistry,
patients may need to have central venous pressure or Head and haematology sent?
pulmonary artery pressure monitored to optimise filling x Glasgow coma score? Trend? x Correct radiographs taken?
x Focal signs? x What else is needed?
pressures and cardiac output. Hypovolaemic patients tolerate
x Pupillary response? computed tomography,
transfer poorly, and circulating volume should be normal or x Skull fracture? peritoneal lavage, laparotomy?
supranormal before transfer. A patient persistently hypotensive
despite resuscitation must not be moved until all possible
sources of continued blood loss have been identified and
controlled. Unstable long bone fractures should be splinted to
provide neurovascular protection.
It is important that these measures are not omitted in an Departure checklist
attempt to speed transfer as resultant complications may be x Do attendants have adequate x Money or cards for
impossible to deal with once the journey has started. experience, knowledge of case, emergencies?
A gastric drainage tube should be passed and all lines and clothing, insurance? x Estimated time of arrival
x Appropriate equipment and notified?
tubes securely fixed. Equipment should be checked including
drugs? x Return arrangements
battery charge and oxygen supply. Case notes, x ray films, a x Batteries checked? checked?
referral letter, and investigation reports should be prepared and x Sufficient oxygen? x Relatives informed?
blood or blood products collected. The receiving unit should be x Trolley available? x Patient stable, fully
informed of the estimated time of arrival. x Ambulance service aware or investigated?
Travel arrangements should be discussed with relatives. ready? x Monitoring attached and
They should not normally travel with the patient. x Bed confirmed? Exact working?
location? x Drugs, pumps, lines
x Case notes, x ray films, results, rationalised and secured?
blood collected? x Adequate sedation?
Transfer x Transfer chart prepared? x Still stable after transfer to
x Portable phone charged? mobile equipment?
Care should be maintained at the same level as in the intensive x Contact numbers known? x Anything missed?
care unit, accepting that in transit it is almost impossible to
370 BMJ VOLUME 319 7 AUGUST 1999 www.bmj.com

Clinical review
intervene. Monitoring of arterial oxygen saturation, expired ICU TRANSFER FORM
Time
Time
carbon dioxide tensions, heart rhythm, temperature, and PATIENT DETAILS

INSTRUCTIONS FOR USE OF THIS FORM
To be used for all patients transferred to ICU - this is a legal record of transfer
TRANSFER DETAILS
Drugs
arterial pressure should be continuous. As non-invasive Name

Address
Transferring Unit Name
Recipient Unit Name
Postcode Date of Admission to Hospital
measurement of blood pressure is affected by movement, Age or DOB

Male/Female
Date of Transfer
Time
Monitoring
SaO2
ETCO2
intra-arterial monitoring is recommended. Transferred From: ICU WARD A&E
No staffed bed
THEATRE
Expert
OTHER
220
200
220
200
Is this a TRAUMA Yes Reason for space in ICU Management
Transfer should be undertaken smoothly and not at high Patient:

No
Transfer:
No bed space
in ICU Other (please state)
180
160
140
180
160
140
120 120
speed. A record must be maintained during transfer. Despite HISTORY & CLINICAL FINDINGS
Pre-Sedation GCS
100
80
60
100
80
60
careful preparation unforeseen clinical emergencies may occur; Fluids
STABILISATION TIME AMBULANCE DETAILS
the vehicle should then be stopped at the first safe opportunity Time Commenced: Incident No:
Time Arrived on Scene: Time leftScene: Arrived ICU:
Please list any precautions taken for fractured spine at any level.
to facilitate patient management. Time Ready to Transfer:
TRANSFER COMMENTS / PROBLEMS:

STAFF ARRANGING TRANSFER ESCORTING PERSONNEL
At Transferring Hospital Doctor:
Name:
Name:
Grade: Spec
Grade: Spec Transfer Training YES NO
Handover At Recipient Unit
Name:
Nurse/ODA:
Name:
Grade: Spec
Signature of Escorting Doctor
COMMENTS OF RECEIVING DOCTOR:
Grade: Spec Transfer Training YES NO
On arrival there must be direct communication between the VENTILATION DURING TRANSFER
Please tick
appropriateSpontaneous Mechanical Ambu Bag
MONITORING
Please tick
appropriate ECG Other (please state)
transfer team and the team who will assume responsibility for
boxes boxes
ET Tube Size NIBP
Ventilator Type No. and site IABP
Tidal Volume (VT) of lines SaO2 Signature of Receiving Doctor
Peak Inflation Pressure Temp
the patient. A record of the patient’s history, treatment, and Peep

F1O2
RR
ETCO2
PA Catheter
CVP
INSTRUCTIONS
When you have completed this form, please insert the White Copy in Patient Notes at Recipient Site. Post Yellow Copy to ICBIS
(pre-addressed envelopes are available in all ICU's), and the Green Copy should be fixed into the Transferring Hospital's Notes.
important events during transfer should be added to the notes.

Radiographs, scans, and results of other investigations should Form for recording patient transfer information
be described and handed over. The transfer team should retain
a record of the transfer on a prepared form for future audit.
The receiving hospital should provide refreshments and
arrange for staff to return to base. Money or credit cards should
be available for use in emergencies.
Audit, training, and funding

Regular audit of transfers is necessary to maintain and improve
standards. The responsible consultant should review all Peter G M Wallace is consultant anaesthetist, Western Infirmary,
transfers in and out of the hospital, and a similar process should Glasgow G11 6NT and Saxon A Ridley is director of intensive care,
be established at regional and national level. Norfolk and Norwich Hospital, Norwich NR1 3SR
Before taking responsibility for a transfer, staff should The ABC of intensive care is edited by Mervyn Singer, reader in
receive training and accompany patients as an observer. intensive care medicine, Bloomsbury Institute of Intensive Care
Resources are required to achieve this and to ensure safe Medicine, University College London and Ian Grant, director of
intensive care, Western General Hospital, Edinburgh. The series was
transfer systems throughout the United Kingdom. Purchasers conceived and planned by the Intensive Care Society’s council and
should reflect this in their budgetary priorities. research subcommittee.
The patient transfer form was provided by ICBIS. BMJ 1999;319:368-71
The ladder of truth

The story of a mother and her son
This story was told to me by Christopher’s mother and related to knowing nothing, nor right at the top knowing everything. They
a conversation they had when he was about 6. At the time he was will be somewhere in between.
attending a cystic fibrosis clinic where he came to know Rosie, Our job, as parents and professionals, is to try and discover
another patient about the same age. Sadly, Rosie died shortly where they are and to join them there. We can do this, when the
afterwards. occasion arises, by listening and by asking age appropriate,
One day, a little later, while perched on the draining board non-threatening questions. When we get some idea of where
watching his mother wash up, Christopher dropped his children are on the ladder, next comes the most vital part of all: it
bombshell by asking whether he had cystic fibrosis, whether he is their prerogative to choose whether they wish to stick there or
would always have it, and whether he, like Rosie, would die. She
to go up a rung or two. If they choose to go up, which they will
answered each question simply and truthfully.
indicate by asking questions, then we go with them but only one
To keep the ball in the air, she then asked Christopher if he was
step at a time. This means we are never required to give children
afraid of dying. He admitted that he was. Now, wisely assuming
nothing, she explored this statement by asking what exactly he information which they may neither want nor understand. It must
was afraid of. His answer was a bit unexpected, as children’s be a gentle ascent up the ladder with the children leading and
answers so often are. He said that he was afraid of being put with us holding their hand all the way.
under the ground. Now this presented no problem for Instinctively, Christopher’s wise and sensitive mother adopted
Christopher’s mother as she was able to explain in spiritual terms, the ladder concept. She found out where he was by attentive
consistent with their family beliefs, that a body was just like an listening and went up the ladder with him at his chosen pace,
overcoat which, when it became damaged or old and of no never jumping ahead or anticipating his thinking. Many of us
further use, was discarded. When Christopher died, she have learnt important lessons from her, and she was able to give
explained, his body would be like the overcoat. Christopher, being Christopher the comfort and confidence he sought. Christopher
in Heaven, would no longer need it, so burying it was fine. died in his late teens while awaiting a heart and lung transplant,
The way that Christopher’s mother handled this difficult but up until the end of his life he and his mother kept the open
conversation illustrated that truth is not just the opposite of a lie, and trusting relationship evident in this early conversation.
nor is truth necessarily the whole truth. It is, in fact, more like a
ladder. No child of questioning age is right at the bottom Olive McKendrick, retired paediatrician, Liverpool
BMJ VOLUME 319 7 AUGUST 1999 www.bmj.com 371

PS52
2015
Australasian College for Emergency Medicine (ACEM)
Australian and New Zealand College of Anaesthetists (ANZCA)
College of Intensive Care Medicine of Australia and New Zealand (CICM)
Guidelines for Transport of Critically Ill Patients
1. INTRODUCTION
Critically ill patients have life-threatening injuries or illnesses that are associated with
reduced or exhausted physiological reserves. Transporting such patients exposes them
to additional risks and requires the services of highly trained and skilled practitioners.
Safe transport of the critically ill patient requires accurate assessment and optimisation
of the patient before transport. There should be appropriate planning of transport and
maximised utilisation of communications. Safe transport requires the deployment of
appropriately trained staff with essential equipment, and effective liaison between
referring, transporting and receiving staff at a senior level.
As a guiding principle, the level of care provided during transport must aim to at least
equal that at the point of referral and must prepare the patient for admission to the
receiving service.
2. PURPOSE
To assist medical practitioners and hospitals develop and implement strategies and
protocols for the safe transport of critically ill patients. The goal of this document is to
minimise risks and maximise safety for patients during transport.
3. SCOPE
These guidelines are intended for medical practitioners and apply to all stages of critical
patient transport be that prehospital, interhospital or intrahospital.
4. BACKGROUND
With constantly evolving technology and knowledge, guidelines need to be reviewed

regularly to ensure that they are current and evidence-based. Earlier “minimum
standards” were divided into two separate documents, one for intrahospital transfers
and the other for interhospital transfers. Despite some specific differences, there are
sufficient similarities to combine them into the one set of guidelines.
Page 1 PS52 2015

5. ADMINISTRATIVE GUIDELINES
Administrative guidelines for organisations engaging medical practitioners in patient

transport should cover all aspects of transport of the critically ill. For interhospital
transfers these may include guidelines for such matters as insurance, budgeting and
personnel. Staff training, safety and protection are the responsibility of the employing
authority, which should carry appropriate insurance for all contingencies related to
patient transport activities and should also provide personnel with personal protective
equipment and instruction.
5.1 Initiation and response
Medical transport services using road ambulance, fixed and rotary wing aircraft
must be coordinated for prompt, rapid, efficient and safe transport of critically ill
patients on a 24 hour basis.
Initiation of patient transport should be simple, with clear guidelines and

communication channels. Ideally, the referring doctor should have to make only
one telephone call to initiate retrieval or patient transfer.
In all situations requiring transport of the critically ill, rapid response of the transport
system and minimal delays are paramount. In emergency interhospital transports,
dispatch of the prehospital and retrieval team to the referring hospital should not be
delayed pending the identification of a receiving hospital.
5.2 Coordination and communication
Coordination of transport services for the critically ill should be centralised to

ensure optimum utilisation of resources. Designated individuals need to be
available immediately for consultation and planning at a specialist level.
Coordinating clinicians need to have an understanding of referring hospital
capabilities and in-depth knowledge of receiving hospital capabilities. Coordinating
clinicians need to have an intimate knowledge of the benefits and limitations of the
transport frames at their disposal as well as the management capabilities of the
retrieval team. To best understand this, coordinating clinicians should be suitably
trained in prehospital and retrieval medicine and have ongoing operational
experience relevant to the type of transport undertaken.
Reliable communication must be available at all times between the prehospital and
retrieval team and the referring and receiving hospitals and ambulance services. At
the time of first contact, clinical advice can be provided to referral staff and sought
from senior specialty receiving staff as well as appropriate planning and advice
provided to the retrieval team.
5.3 Responsibility
The chain of responsibility must be clear throughout the transfer. Responsibility for
patient care during transport must be vested in an appropriately qualified medical
practitioner. Formal handover from referring doctor to retrieval doctor and from the
latter to the receiving hospital doctor is essential (see ACEM document Guideline
on Clinical Handover in the Emergency Department and ANZCA professional
document PS53 Statement on the Handover Responsibilities of the Anaesthetist).
This is equally as important for intrahospital transport.
5.4 Documentation
The clinical record should document the patient’s clinical status before, during and
after transport, relevant medical conditions, environmental factors, therapy given,
adverse logistic events, and procedures undertaken.
Page 2 PS52 2015

5.5 Governance
Organisations involved in prehospital transfers and retrieval should have an

effective quality management system that can monitor and audit performance and
safety, and make recommendations for appropriate improvements as part of their
reporting structure.
5.5.1 Clinical effectiveness and research
Operational and clinical performance indicators should be established

using an evidence-based approach. These performance indicators should
be monitored, benchmarked and regularly reported.
Research should be encouraged to develop evidence and enhance patient

care.
A means of patient follow-up after transport should be available to clinical

staff involved to assist in evaluating of individual, organisational and
system performance.
5.5.2 Audit
There should be a system for regular case review to assess level of care
provided, transport processes and logistics. These reviews should include
all aspects of the retrieval and transport process and be inclusive of
coordination, transport factors, crew issues, crew resource management as
well as the medical management component.
Provision should be made for feedback to and from the referring and
receiving centre.
5.5.3 Risk management
A system for reporting and reviewing sentinel events in a timely and non-
accusatory framework needs to be in place. Sentinel events should include
patient death and any other major adverse events relating to the patient,
crew or equipment.
5.5.4 Education and training
There should be opportunities for peer review within the organisation. The
system should also provide an educational function for all components for
the transport service.
5.5.5 Credentialing and scope of clinical practice
Prehospital and retrieval clinicians should undergo a formal credentialing

process to ensure their competence, performance and professional
suitability to provide safe, high quality medical care within the prehospital
and retrieval environment. Credentialing should take into account formal
qualifications, professional training and clinical experience as well as their
continuing professional development directly relevant to prehospital and
retrieval medicine. The credentialing process should help to define the
prehospital and retrieval clinicians’ scope of clinical practice within an
organisation.
6. CATEGORIES OF TRANSPORT
Transport of critically ill patients may be required in three sets of circumstances,

namely, prehospital transport, interhospital transport, and intrahospital transport.
Page 3 PS52 2015

6.1 Prehospital transport refers to:
Transport of a critically ill patient from the scene of trauma or illness to hospital.
Standards for prehospital transport, not involving medical practitioners, are
determined by ambulance and emergency services and are not covered by this
policy document. Where prehospital transport is carried out by medical personnel,
the same standards apply as for interhospital transport.
6.2 Interhospital transport may be:
6.2.1 Emergency interhospital transport
For acute life-threatening illnesses emergency interhospital transport may

be needed due to either lack of diagnostic facilities, staff, clinical expertise
and/or facilities for safe and effective therapy in the referring hospital.
6.2.2 Semi-urgent interhospital transport
For transport of the critically ill patient, either to a higher level of care or for
a specialty service.
6.3 Intrahospital transport refers to:
Transport of critically ill patients from one area of a hospital to another area within
the hospital.
7. STAFFING
Medical staff engaged in the role of prehospital transfers and retrieval of critically ill
patients will be required to work in a range of challenging environments. Patients are
entitled to the best standard of care available, regardless of location. Consequently,
prehospital and retrieval medical staff need to have the requisite skills and knowledge to
provide the highest level of care in these environments and for the patients they are
likely to encounter. Prehospital and retrieval personnel must be trained in all aspects of
patient transport relevant to their practice and participate in the organisational quality
and teaching activities (section 5.5 above), as well as relevant continuing professional
development.
Consultant staff with relevant current experience in prehospital and retrieval

need to be available to instruct and supervise junior staff and to provide real-time
clinical support as required.
The ability of prehospital and retrieval personnel to communicate effectively and to

function as part of a team is essential.
Staff must be briefed on, and be familiar with, emergency and evacuation procedures
for the transport frames in which they work. Medical staff undergoing helicopter retrieval
and transport where flights occur over water should complete a helicopter underwater
escape training course and maintain competency. All staff undertaking critically ill
patient transport must be aware of the capabilities and limitations of available
equipment and the working transport environment.
For intrahospital transport the team must be freed from other duties. For prehospital and
interhospital retrievals a team dedicated solely for such transports should be available.
7.1 Prehospital transport
Physicians who are deployed to provide prehospital treatment and transport as part
of a prehospital retrieval team can provide care that approaches that available in a
Page 4 PS52 2015

hospital resuscitation room. Prehospital and retrieval physicians require training in
their expected prehospital roles including scene organisation and safety, patient
assessment, treatment and extrication, mass casualty and chemical, biological and
radiological incidents, and the prehospital and retrieval environment. As part of
their training they must demonstrate the required skills and knowledge to operate
safely and effectively as part of a team in the prehospital and transport
environment.
Prehospital and retrieval staff should be provided with adequate personal

protective equipment so that their safety is not compromised and that they are
highly visible and easily identifiable at any prehospital scene.
Prehospital and retrieval physicians need to be familiar with local ambulance and
emergency service protocols, roles, responsibilities and equipment.
Prehospital retrieval physicians must be familiar with local, regional and state
disaster plans. They must have appropriate logistical skills, understand the roles
they may be required to perform, and be adequately trained and equipped to
perform these roles. Medical personnel involved in disaster response planning and
coordinating should be fully aware of the skills and expertise the prehospital
retrieval team is capable of bringing to the scene of a mass casualty disaster
response.
Prehospital and retrieval teams should be familiar with local radio protocols and the
range of communication devices used.
Medical staff involved in prehospital rescue work must be in a state of health and of
adequate fitness to perform these tasks safely. Medical staff involved in helicopter
winch rescue work must have undergone suitable training and competency
assessment. This competency must be maintained whilst they remain clinically
active.
7.2 Interhospital transport
Interhospital transport of critically ill patients must be performed by an appropriately

qualified retrieval team including an experienced medical practitioner. This team
must be familiar with their transport equipment particularly power and oxygen
supply limitations. The retrieval team needs to have adequate clinical
understanding of the patient’s medical condition and potential transport
complications (that is, altitude, temperature, movement, etc). The team must also
be aware of the treatment options available to them prior to and during transport of
the patient.
On extended journeys, sufficient staff should be carried to allow maintenance of

high standards of patient care, and to allow for staff rest periods.
Where it would be immediately lifesaving, the transport of expert medical

assistance, for example, a neurosurgeon, to the referring hospital should be
considered. At all times the risk of placing untrained personnel in an unfamiliar
transport environment must be balanced with the likely benefit to the patient.
Specifically trained personnel are required for the transport of neonates, infants,
and patients requiring extracorporeal life support or an intra-aortic balloon pump.
Bariatric patient retrievals pose particular clinical and logistic challenges. Services
undertaking transport of bariatric patients should have policies addressing manual
handling and safe transport issues around this patient group.
Special considerations are also required for long-haul/international patient

retrievals – not detailed in this document.
Page 5 PS52 2015

7.3 Intrahospital transport
Key personnel for each transport event should be identified. The transport team
should consist at least of an appropriately qualified nurse, an orderly, and a
medical practitioner with the specific skills and training required for such transport.
Whilst most intrahospital transports are not done by dedicated teams, the principles
of transport are similar to prehospital and interhospital retrieval.
Each team must be familiar with the equipment used on the transport and be
sufficiently experienced with securing airways, ventilation of the lungs,
resuscitation, and other anticipated emergency procedures.
8. TRANSPORT
Mode of transport used will depend partly on clinical requirements, on vehicle

availability and on conditions at the referring and receiving sites.
8.1 Choice of transport vehicle will be influenced by:
8.1.1 Nature of illness.
8.1.2 Possible clinical impact of the transport environment.
8.1.3 Urgency of intervention.
8.1.4 Location of patient.
8.1.5 Distances involved.
8.1.6 Number of retrieval personnel and volume of accompanying

equipment.
8.1.7 Road transport times and road conditions.
8.1.8 Weather conditions and aviation restrictions for airborne transport.
8.1.9 Aircraft landing facilities.
8.1.10 Range and speed of vehicle.
8.1.11 Availability of resources at the referring site.
8.1.12 Familiarity and training of retrieval staff on transport frame(s) available.
8.1.13 Medical and transport team fatigue limitations.
8.2 Transport vehicle requirements
Vehicles should be appropriate to the task in terms of design (including cabin

environment) and equipment in accordance with local regulations. Regular
inspection and servicing of vehicles and on-board equipment is required. Particular
requirements relate to:
8.2.1 Safety of both patient and staff.
8.2.2 Adequate space for patient access and to perform acute medical
interventions. As a minimum, ready access is needed to the head and
one complete side of the patient.
8.2.3 Adequate power and gases for life support systems.
Page 6 PS52 2015

8.2.4 Adequate suction.
8.2.5 Easy access for safe embarkation and disembarkation.
8.2.6 Adequate lighting and internal climate control.
8.2.7 Restraints for stretcher, equipment and passengers.
8.2.8 Acceptable noise and vibration levels and noise protection for all
passengers.
8.2.9 Adequate speed and response times.
8.2.10 Good communication systems, both internal and external.
8.2.11 Both auditory and visual patient monitoring alarms.
8.2.12 Impaired gravity drip of fluids.
In general, medical fittings to aircraft, and bulky items carried need to be approved
by aviation authorities.
8.3 Air transport exposes patients and crew to particular risks including:
8.3.1 Reduced oxygen partial pressure.
8.3.2 The need for pressurisation to sea level when clinically indicated.
8.3.3 Risk of rapid depressurisation.
8.3.4 Expansion of air filled cavities both within the patient and the equipment,
such as endotracheal tube cuff, middle ear, air-filled spaces under
airtight dressings etc.
8.3.5 Limb swelling beneath plaster casts.
8.3.6 Worsening of air embolism or decompression sickness.
8.3.7 Danger from agitated patients.
8.3.8 Limited space, lighting and facilities for interventions.
8.3.9 Noise.
8.3.10 Extremes of temperature.
8.3.11 Extremes of humidity.
8.3.12 Acceleration, deceleration and turbulence.
8.3.13 Vibration.
8.3.14 Electromagnetic interference between avionics and monitoring devices.
8.3.15 Danger from loose, mobile equipment.
8.3.16 Motion induced illness.
8.4 With all modes of transport, provision of a secure airway and intravenous access,
securing of all catheters and provision of appropriate monitoring before departure is
Page 7 PS52 2015

fundamental to safe transport. Stabilisation of vital signs should occur prior to
transport. The only exception to this is if stabilisation can only occur with treatment
available only at the receiving hospital (for example, ongoing internal haemorrhage
secondary to trauma).
8.5 Final preparation of the patient should be made prior to transport, with anticipation
of clinical needs. Examples include giving appropriate doses of muscle relaxants or
sedatives, replacing near-empty inotropic and other intravenous solutions with
fresh bags, and emptying drainage bags.
8.6 The patient must be reassessed before transport begins, especially after being
placed on monitoring equipment and the transport ventilator (if used). Transport
preparations must not overshadow or neglect the patient's fundamental care.
9. EQUIPMENT
Equipment carried should be appropriate for each transport. The duration of transport,
the patient’s diagnosis and severity of illness and the level of therapeutic intervention
required should be taken into account. In choosing equipment, attention must be given
to size, weight, volume, battery life, oxygen consumption and durability, as well as to
suitability for operation under conditions of transport.
Supplies, including oxygen and pharmacological agents, should be in excess of that

estimated for the maximum transport time.
Patient stretchers and all equipment must be restrained, in compliance with regulatory
guidelines. Electrical and gas supply fittings of all equipment must be compatible with
those of the transport vehicle. All equipment to be used in aircraft must be assessed for
compliance with regulatory requirements. All equipment must be maintained
appropriately, stored securely and items that may be required during transportation
must be readily available.
Specialised equipment is required, for example, for neonatal and paediatric transport,
as well as for patients requiring extra-corporeal life support.
Equipment that should be considered includes:
9.1 Respiratory support equipment
9.1.1 Airways (range of oral and nasopharyngeal airways and a range of

laryngeal mask airways).
9.1.2 Oxygen, masks, nebuliser.
9.1.3 Self-inflating bag for hand ventilation.
9.1.4 Positive end-expiratory pressure valve.
9.1.5 Suction equipment of appropriate standard.
9.1.6 Portable ventilator with disconnect and high pressure alarms.
9.1.7 Intubation equipment and endotracheal tubes.
9.1.8 Emergency surgical airway set.
9.1.9 Difficult airway equipment.
9.1.10 Pleural drainage equipment.
Page 8 PS52 2015

9.2 Circulatory support equipment
9.2.1 Monitor/defibrillator/external pacer combined unit.
9.2.2 Pulse oximeter.
9.2.3 Aneroid sphygmomanometer (not mercury-containing) with a range of

cuff sizes.
9.2.4 Vascular cannulae, peripheral and central.
9.2.5 Intravenous fluids and pressure infusion set.
9.2.6 Infusion pumps.
9.2.7 Arterial cannulae and pressure transducer kit.
9.2.8 Syringes and needles.
9.2.9 Pericardiocentesis and thoracotomy equipment.
9.2.10 A sharps disposal container and a bag for biological waste.
9.3 Other equipment
9.3.1 Nasogastric tube and bag.
9.3.2 Urinary catheter and bag.
9.3.3 Nasal decongestant spray.
9.3.4 Instruments, sutures, dressing, antiseptic lotions, gloves.
9.3.5 Thermal insulation and temperature monitor.
9.3.6 Splints and equipment for spinal and limb immobilisation.
9.3.7 Neonatal/paediatric/obstetric transport equipment when applicable.
9.3.8 Dressings, bandages, slings, splints and tape.
9.3.9 Cutting shears and portable torch.
9.3.10 Gloves and glasses for staff protection.
9.3.11 Consideration should be given to:
9.3.11.1 Alternative vascular access such as intraosseous devices for

adults and children.
9.3.11.2 Blood for transfusion when indicated.
9.4 Pharmacological agents
All drugs should be checked and clearly labelled prior to administration. The range
of drugs available should include all drugs necessary to manage acute life-
threatening medical emergencies and those specific to the patient’s clinical
condition. Close attention must be paid to drugs that require refrigeration to
maintain effectiveness.
Page 9 PS52 2015

9.5 Documentation
Prehospital and retrieval teams should document the handover history and clinical
examination findings of their patients. Documentation should include an ongoing
record of physiological status, clinical procedures, and any subsequent
interventions. A copy of this patient record should be provided to the receiving
hospital along with the clinical record and investigations from the referring facility,
where available. For intrahospital transport, this documentation may form part of
the inpatient notes.
10. MONITORING
Monitoring of certain physiological variables should be carried out during transport.

Some or all of these basic recommendations will need to be exceeded routinely
depending on the physical status of the patient.
Clearly any monitoring method may fail to detect unfavourable clinical developments
and monitoring does not guarantee any specific patient outcome.
10.1 Clinical patient monitoring
10.1.1 Circulation
The circulation must be monitored and recorded at frequent and clinically

appropriate intervals by detection of the arterial pulse, measurement of the
arterial blood pressure and assessment of peripheral perfusion.
10.1.2 Respiration
Respiratory rate should be assessed and recorded at frequent and

clinically appropriate intervals.
10.1.3 Oxygenation
The patient’s oxygenation should be assessed at frequent and clinically

appropriate intervals by observation and use of pulse oximetry.
10.1.4 Level of consciousness by Glasgow Coma Scale and pupil reaction.
10.1.5 Pain score
Patients’ pain should be monitored including regular assessment of pain

scores, and managed appropriately.
10.1.6 Patient comfort
Even deeply-sedated patients should be provided with appropriate noise,

eye and environmental protection.
Pressure care, including invasive devices, is essential for all patients who
are unconscious, immobilised or have impaired movement, sensation
and/or perfusion.
Ventilated patients in particular require continuous attention to eye care

and effects of the ETT and other invasive devices.
Page 10 PS52 2015

10.2 Equipment monitoring
10.2.1 Pulse oximeter and capnography
A pulse oximeter must be used for every critically ill patient during
transport. All patients undergoing artificial ventilation (for example, via a
tracheal tube or supraglottic airway) must have a form of capnography,
ideally waveform. Waveform capnography should also be considered for
sedated patients.
10.2.2 Alarms for breathing system disconnection or high pressure and

ventilator failure
When an automatic ventilator is in use, a device capable of warning

promptly of low and high pressure in the breathing system should be in
continuous operation.
10.2.3 Electrocardiograph
Equipment to monitor and continually display the electrocardiograph must

be used for every critically ill patient during transport.
10.2.4 Physiological pressures
Equipment for the invasive or non-invasive recording of blood pressure

must be used. Where clinically indicated, other physiological pressures
should be available for all critically ill transported patients.
10.2.5 Other equipment
When clinically indicated, equipment to measure other physiological

variables, such as temperature and point of care blood analysis should be
available.
Portable ultrasound is recommended where appropriately trained and

credentialed personnel are available.
10.2.6 Equipment alarms
Equipment should incorporate audible and visual alarms.
11. TRAINING
All new staff involved in patient transport should undergo appropriate training in all
aspects of patient transport outlined in this document and undertake supervised patient
transports prior to independent transport duties. In particular, training should include
instruction in local retrieval systems, organisational and transport vehicle related
matters and the defined team role and functions of both medical and non-medical
retrieval team personnel.
Training for safety and other operational issues should occur on a regular and recurrent
basis, with due consideration for occupational health and safety and infection control
issues.
All medical staff participating in patient transport activities must remain current and
compliant with continuing education standards of their specialty and/or other governing
body in addition to those of the retrieval organisation.
Page 11 PS52 2015

RELATED COLLEGE DOCUMENTS
ACEM Guideline on Clinical Handover in the Emergency Department
ANZCA professional document PS53 Statement on the Handover Responsibilities of the

Anaesthetist
This policy document has been prepared having regard to general circumstances, and it is
the responsibility of the practitioner to have regard to the particular circumstances of each
case, and the application of this policy document in each case.
Policy documents are reviewed from time to time, and it is the responsibility of the
practitioner to ensure that the practitioner has obtained the current version. Policy
documents have been prepared having regard to the information available at the time of their
preparation, and the practitioner should therefore have regard to any information, research
or material which may have been published or become available subsequently.
Whilst the colleges endeavour to ensure that policy documents are as current as possible at
the time of their preparation, they take no responsibility for matters arising from changed
circumstances or information or material which may have become available subsequently.
Promulgated (as PS23*): 1992

Reviewed: 1996 (rebadged as IC-10), 2003, 2013, 2015
Date of current document: August 2015
*Rebadged as PS52 in 2010.
Please note: this document is referred to as P03 by ACEM and IC-10 by CICM.
© Copyright 2015 – Australasian College for Emergency Medicine, Australian and New
Zealand College of Anaesthetists, and College of Intensive Care Medicine of Australia and
New Zealand. All rights reserved.
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no
part may be reproduced by any process without prior written permission from ANZCA.
Requests and inquiries concerning reproduction and rights should be addressed to the Chief
Executive Officer, Australian and New Zealand College of Anaesthetists, 630 St Kilda Road,
Melbourne, Victoria 3004, Australia. Website: www.anzca.edu.au email:
[email protected]
ACEM website: www.acem.org.au

ANZCA website: www.anzca.edu.au
CICM website: www.cicm.org.au
Page 12 PS52 2015

PS52 BP
2015
Australian and New Zealand College of Anaesthetists (ANZCA)
Guidelines for Transport of Critically Ill Patients
Background Paper
PURPOSE OF REVIEW
The transport of critically ill patients had previously been divided into two separate
documents, one for intrahospital transfers and one for interhospital transfers (P04/PS39
Minimum Standards for Intrahospital Transport of Critically Ill Patients and P03/PS52/IC-10
Minimum Standards for Transport of Critically Ill Patients). Both documents were last
reviewed in 2003. Following the establishment of the College of Intensive Care Medicine
(CICM), formerly the Joint Faculty of Intensive Care Medicine, as an independent entity in
2010, the documents were republished. The 2013 review is part of the usual review cycle to
ensure that the guidelines reflect contemporary knowledge and are based on current
evidence.
Although there are some significant differences between intrahospital and interhospital
transfers there is sufficient overlap to warrant combining the previously separate documents
into a single document.
BACKGROUND
Critically ill patients are at particular risk associated with reduced or exhausted physiological
reserves. Transporting such patients requires the services of highly trained and skilled
practitioners to manage these patients as they are exposed to additional risks during
transport.
As part of the process of continuing improvement in college professional documents each

document is considered from the perspective of the intended end-users and stakeholders,
with a view to simplification and usability, as well as the intention of the document. In that
context this document has been classified as a “guideline”.
The guidelines associated with this background paper are intended for medical practitioners
and apply to all stages of critical patient transport be that prehospital, interhospital or
intrahospital.
The goal of this document is to assist medical practitioners and hospitals develop and
implement strategies and protocols that reduce risks of transporting critically ill patients and
maximise their safety.
DISCUSSION OF ISSUES
In view of the spectrum of practitioners involved in transporting critically ill patients the
document development group (DDG) was formed with representation from each of the
Page 1 PS52 BP 2015

colleges of emergency medicine, intensive care medicine, and anaesthesia. This ensured
that the expertise and experience of each specialty contributing to the management of
critically ill patients was incorporated.
The principal issues considered include staffing, training, equipment, monitoring, transport,
and governance.
While the guidelines strive for excellence it is recognised that transport services provided by
non-medical practitioners, such as the ambulance services, have their own standards and
protocols. However, these guidelines apply whenever medical practitioners are involved.
Where differences exist between intrahospital and interhospital transport, they have been
identified and separately addressed.
1-4
There is evidence that in specific cases involving blunt trauma and those requiring
procedures such as thoracostomy or hysterotomy physician involvement had a significant
impact on improving outcomes and decreasing mortality (see item 7.1).
SUMMARY
Transport of critically ill patients exposes them to additional risks, which require the expertise
of highly trained and skilled medical practitioners to mitigate these transport risks. The goal
of this document is to assist medical practitioners and hospitals develop and implement
strategies and protocols that reduce risks of transporting critically ill patients and maximise
their safety.
REFERENCES
1. Bloomer R, Reid C, Wheatley R. Prehospital resuscitative hysterotomy. Eur J Emerg

Med. 2011 Aug;18(4):241-242.
2. Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating
trauma: A prehospital physician-performed resuscitation procedure that can yield
good results. J Trauma. 2011 May;70(5):E75-78.
3. Garner A, Rashford S, Lee A, Bartolacci R. Addition of physicians to paramedic

helicopter services decreases blunt trauma mortality. Aust N Z J Surg. 1999
Oct;69(10):697-701.
4. Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: Who are the survivors?
Ann Emerg Med. 2006 Sep;48(3):240-244.
PROCESS OF DOCUMENT REVIEW
In accordance with a memorandum of understanding agreed to in 2010, a document

development group (DDG) was established with representation from the three colleges, as
follows:
Dr Peter Roessler (chair), FANZCA, ANZCA Director of Professional Affairs (Professional

Documents)
Associate Professor Paul Forrest, FANZCA, ANZCA
Dr Stefan Mazur, FACEM, Australasian College for Emergency Medicine
Associate Professor Peter Morley, FCICM, College of Intensive Care Medicine
Page 2 PS52 BP 2015

Dr Roessler chaired proceedings, ensuring the process of review aligned with that detailed in
ANZCA professional document A01 Policy for the Development and Review of Professional
Documents.
The DDG amalgamated P04/PS39 Minimum Standards for Intrahospital Transport of

Critically Ill Patients and P03/PS52/IC-10 Minimum Standards for Transport of Critically Ill
Patients. The following stakeholders were invited to provide feedback on a preliminary draft,
prior to endorsement of the final draft by each college’s governance body:
ACEM Pre-Hospital and Retrieval Medicine Committee

ANZCA Council
ANZCA national/regional committees
Faculty of Pain Medicine Board and regional committees
ANZCA Trainee Committee
Anaesthesia and Critical Care in Unusual and Transport Environments Special Interest
Group (SIG)
Cardiothoracic, Vascular and Perfusion SIG
Diving and Hyperbaric Medicine SIG
Neuroanaesthesia SIG
Obstetric Anaesthesia SIG
Rural SIG
Trauma SIG
CICM Board
Professional documents of the Australian and New Zealand College of Anaesthetists (ANZCA) are
intended to apply wherever anaesthesia is administered and perioperative medicine practised within
Australia and New Zealand. It is the responsibility of each practitioner to have express regard to the
particular circumstances of each case, and the application of these ANZCA documents in each case. It
is recognised that there may be exceptional situations (for example, some emergencies) in which the
interests of patients override the requirement for compliance with some or all of these ANZCA
documents. Each document is prepared in the context of the entire body of the College's professional
documents, and should be interpreted in this way.
ANZCA professional documents are reviewed from time to time, and it is the responsibility of each
practitioner to ensure that he or she has obtained the current version which is available from the
College website (www.anzca.edu.au). The professional documents have been prepared having regard
to the information available at the time of their preparation, and practitioners should therefore take into
account any information that may have been published or has become available subsequently.
Whilst ANZCA endeavours to ensure that its professional documents are as current as possible at the
time of their preparation, it takes no responsibility for matters arising from changed circumstances or
information or material which may have become available subsequently.
Promulgated (as PS52 BP): 2013

Date of current document: June 2015
© Copyright 2015 – Australian and New Zealand College of Anaesthetists. All rights reserved.
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be
reproduced by any process without prior written permission from ANZCA. Requests and inquiries
concerning reproduction and rights should be addressed to the Chief Executive Officer, Australian and
New Zealand College of Anaesthetists, 630 St Kilda Road, Melbourne, Victoria 3004, Australia.
Website: www.anzca.edu.au email: [email protected]
ANZCA website: www.anzca.edu.au
Page 3 PS52 BP 2015

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Guidelines for the inter- and intrahospital transport of critically ill

256 Crit Care Med 2004 Vol. 32, No. 1

Crit Care Med 2004 Vol. 32, No. 1 257

258 Crit Care Med 2004 Vol. 32, No. 1

Crit Care Med 2004 Vol. 32, No. 1 259

260 Crit Care Med 2004 Vol. 32, No. 1

Crit Care Med 2004 Vol. 32, No. 1 261

262 Crit Care Med 2004 Vol. 32, No. 1

Draft for consultation

Developed by the National Guideline Centre,

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

21 34.2 Review question: Do standardised systems of care for intra- and

24 Table 1: PICO characteristics of review question

25 34.3 Clinical evidence

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

8 Table 2: Summary of studies included in the review

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

Mortality HR 259 ⊕⊝⊝⊝ HR 0.56 Moderate

Participants Quality of the Relative

No of Anticipated absolute effects

Adverse events - adjusted OR - Antibiotics changed on 211 ⊕⊝⊝⊝ OR 0.48 Moderate

Mortality - adjusted OR - 48-hour mortality 211 ⊕⊝⊝⊝ OR 0.74 Moderate

due to risk of bias, 2.93) risk not

9 Table 5: Summary: Before and after introduction of a streamlined transfer

Emergency department 60 (45-84) 55 (44-67) 0.07

1 34.4 Economic evidence

3 No relevant health economic studies were identified.

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

18 ICER= (£348-£112)/0.07=£3,377 per death averted.

19 For this intervention to be cost-effective at a cost-effectiveness threshold of £20,000 per QALY

21 £20,000= ΔC/ΔQALYs = £3,377 /ΔQALYs.

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

1 34.5 Evidence statements

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

1 34.6 Recommendations and link to evidence

ICU transfer checklist versus no transfer checklist

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

Trade-off between No economic evaluations were identified.

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

1.5 Transfer between emergency departments.

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

3 1 Patient transfer systems. Health Devices. 1989; 18(5):143-152

16 7 Aghababian R, Restuccia MC. Post resuscitation care in the emergency department, is a

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

3 33 Fanara B, Manzon C, Barbot O, Desmettre T, Capellier G. Recommendations for the intra-hospital

7 35 Gallagher J, McCarthy S, Byrne S. Economic evaluations of clinical pharmacist interventions on

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

1 49 Koppenberg J, Taeger K. Interhospital transport: transport of critically ill patients. Current

16 54 Manataki A, Fleuriot J, Papapanagiotou P. A workflow-driven, formal methods approach to the

Chapter 35 Standardised systems of care for intra- and inter-hospital transfers

15 71 Steenson M, Erdman TS. A comprehensive QA structured transport system: a qualitative and

18 72 Swickard S, Swickard W, Reimer A, Lindell D, Winkelman C. Adaptation of the AACN Synergy

20 73 Uusaro A, Parviainen I, Takala J, Ruokonen E. Safe long-distance interhospital ground transfer of