One of the critical task that hospitals have to frequently undertake is to transfer a critically ill or unstable patient from one hospital to another. Transfer of such patient are likely to induce various physiological changes, which may adversely affect the health of patient even leading up-to death. Hence, such transfers shall be undertaken with great care and as per evidenced-based guidelines. Following are the key elements and guidelines for safely executing transfer for an unstable patient.
Criteria for identifying unstable patients
A patient whose physiological status is in fluctuation and for whom emergent treatment and/or surgical intervention are anticipated, is considered as an unstable patient. Hospital should use clinical criteria to identify an unstable patient. Following criteria can be used as reference for developing hospital’s own criteria
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Patients with one or more of below condition shall be considered as unstable patient
Glasgow coma scale <= 14
Pulse < 60 or > 120 beats per minute
Systolic blood pressure > 190 mmhg
Respiratory rate < 12 or > 24 breaths per minute
Poor gas exchange, with oxygen saturation < 90%
Temperature < 92°f (< 33°c)
Paralysis
Hoarseness or inability to talk
Laboured respirations
Severe pain
External haemorrhage
Combative
Severe deformity involving spine, neck, chest or extremities
Penetrating wound from head to popliteal fossa
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Following comorbid condition if present increases the risk of unstability
Age > 55 years
History of coronary artery disease
History of COPD
History of liver disease
History of coagulation disorder
History of mental illness
Current insulin-dependent diabetes mellitus
Current anticoagulation therapy
Current pregnancy
Neonates
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Decision to transfer:
The decision to transfer the patient shall be taken by a senior consultant level doctor after discussing with patient's relatives about the benefits and risks involved. The decision of transfer shall only be taken if benefits of transferring the patient outweigh the risks involved in transferring. A written informed consent shall be taken from patient/family before the transfer
Communication with receiving facility:
The facility where the patient is being transferred shall be informed prior to shifting. It is always preferable that the consultant doctor of the transferring facility speaks to the consultant doctor of the receiving facility. Complete information on patient's clinical condition, treatment being given, reasons for transfer, mode of transfer and timeline of transfer, shall be shared with the receiving facility in a written document.
Pre-transfer stabilisation and preparation:
Patients should be properly stabilized and prepared before transferring to prevent any adverse event or deterioration in patient’s clinical condition during transfer. The patient should be adequately resuscitated and stabilised to the maximum extent possible. Following points can be used as a checklist for pre-transfer stabilization
1. Airway – If compromise in airway is suspected during transfer of patient, endotracheal tube intubation shall be done. 2. Breathing – Arterial blood gas values should be optimized and breathing should be adequately controlled. In patients suspected of pneumothorax, chest drain shall be inserted.
3. Circulation – Control for external haemorrhage. Ensure that cross matched blood is available during transport, if required. Haemorrhagic shock shall be adequately treated
4. Neurological status – In case of patients with head injury their Glasgow coma scale should be adequately monitored and documented.
Patient shall also be protected from cold by provision of blankets during transfer.
Mode of transfer
Mode of transferring the patient shall be selected as per the clinical condition of the patient. Following guidelines shall be taken into consideration.
1. Patients with non-life threatening condition can be transported in a Basic Life-Support Ambulance.2. Patients with life-threatening conditions or patients who may endotracheal intubation, cardiac monitoring, defibrillation, administration of intravenous fluids or vasopressors, during transfer, shall be transported using Advances Life-Support Ambulance
3. Patients on life support system, i.e. ventilator can be transported in a mobile ICU ambulance, if available
4. In some extreme cases, where patients clinical condition is critical and time is a big factor, use of air ambulance shall be considered, if available. However, feasibility of air transfer shall be ascertained with respect to environment, and patient’s condition. If the patient, due to his/her condition can undergo sudden decompensation during air transfer, the same shall be avoided
Accompanying the patient
It is recommended that two competent personnel accompany the unstable patient during transfer. The accompanying person shall be suitably trained in patient transfer, advanced cardiac life support, airway management and critical care. It is also recommended that a physician shall accompany the patient, however, if this is not possible then provision for contacting the concerned physician shall be there. For deciding who should accompany, the patient can be categorized into 4 levels
· Level 0 – Patients who can be managed at the level of ward, usually do not require any specially trained person to accompany· Level 1 – These are patients who are at risk of deterioration during transfer, but can be managed in acute care setting. Such patient shall be accompanied by a paramedic or a nurse
· Level 2 – These patients require observation or intervention for failure of single organ system and must be accompanied by trained and competent personnel
· Level 3 – These are patients with advanced respiratory care requirement during transfer with support of at-least two failing organs. These patients shall be accompanied by a competent doctor along-with nurse or paramedic
Equipment and Drug
The ambulance transporting the patient shall be equipped with necessary equipment, monitoring devices, medicines and consumables. All the monitoring needs to be established before the commencement of transfer along with the starting of infusion drugs. There should be one person responsible for patient transfer, who shall ensure availability of all these.
Documentation and record
In all stages of transfer, documentation shall be clearly done. Patient's condition, reason to transfer, names and designation of referring and receiving clinicians, details and status of vital signs before the transfer, clinical events during the transfer and the treatment given, shall be recorded in patients’ medical files.
Handing over shall also be documented and things handed over along with the patient, such as medical files, clinical reports, films etc. shall also be recorded.
Quality improvement
Any untoward incident happening during transfer shall be recorded and reported to appropriate authority. Each such incident shall be investigated and proper corrective and preventive actions shall be taken. Periodic audit of transfer process shall be done and the transfer records shall be reviewed.
Reference: Kulshrestha A, Singh J. Inter-hospital and intra-hospital patient transfer: Recent concepts. Indian journal of anaesthesia. 2016 Jul;60(7):451.
