OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• critical care (intensive care medicine)
• emergency medical retrieval services for transfer of the critically ill
• Dr Andrew Tagg's video tutorial on preparing for a safe transfer
• Victorian metropolitan critical care bed availability
• ACEM policy - Minimum standards for Transport of Critically Ill Patients (pdf)
• ACEM policy - Minimum standards for the Intrahospital Transport of Critically Ill Patients (pdf)
• Adult Retrieval Victoria (ARV) - ph: 1300 36 86 61 (24hrs)
  • ARV referral form (pdf)
  • ARV infusion guidelines (pdf)
  • ARV clinical care guidelines to assist retrieval doctors in the Mx of critically ill patients (pdf)

• appropriate selection of transport vehicle, destination and escort
• adequate communication with receiving hospital team including determining where in the hospital patient is to go - ED or ICU, etc, and if it is the ED, ensure the receiving ED team are made aware of the impending transfer.
• clinical stabilisation of the patient
• ensuring a secure airway and iv access
• if hypotension has been or is possibly an issue, then an arterial line placement should be considered as this will provide much more reliable and accurate BP monitoring en route.
• if patient has been intubated, then don't forget nasogastric tube (orogastric tube if head injury), check positions of tubes on CXR, check ABG's and ETCO₂ for evidence of adequate ventilation, and place urethral catheter.
• ensure all catheters and intercostal tubes are secured
• ensure adequate battery life on monitors, iMed pumps, and ventilators
• ensure adequate oxygen available for transport
• if patient has required large transfusions, check potassium level prior to transfer, and ensure adequate FFP and platelets have been given.
• check transfer box contains what is needed, in particular, a working laryngoscope, bag/mask/valve ventilator that is functioning, correct size ETT's, LMA's and oral/nasopharyngeal airways, RSI drugs, cardiac arrest drugs, etc.
• consider creating ready made syringes to manage en route emergencies - for example, morphine to address sedation issues, aramine if there has been hypotension, muscle relaxant such as vecuronium in case it has worn off.
• clinical notes are photocopied and pathology results printed and radiology images placed on CD for transfer (unless destination is another campus of the same network).
• ensure adequate protective clothing for yourself - gown, gloves
• taxi voucher to get you back home

• take great care not to dislodge any tubes
• minimise risk of hypothermia in Winter
• use ambulance AC inverter power ASAP to prolong battery life - usually ambulances have 2 AC points
• use ambulance oxygen ASAP to prolong oxygen cylinder

• wear seat belt
• ensure personnel and patient safety by avoiding excessive speed and unnecessary risks en route
• continuous close monitoring of the patient, with intermittent documentation of vital signs
• an adequately prepared, stabilised, intubated patient should result in an uneventful trip
• failure of sedation or muscle relaxation en route resulting in agitation, or poorly secured airway or iv access may result in life threatening loss of protective airway or iv access which can further compound the issues with lack of immediate ability to sedate, re-intubate or provide inotropic support.
• patients who were not intubated may also become agitated and disaster ensues - for example the patient with H&M who has a sudden large haematemesis, or the patient with APO who gets suddenly worse towards the end of transfer due to the cold and supine position in the ambulance.

• take great care not to dislodge any tubes
• place patient back on portable oxygen
• remove all your belongings from ambulance as you will not usually be going back to the ambulance
• inform destination triage nurse

• successful patient outcomes not only rely on all the above being addressed but that the receiving team adequately understands all the important issues regarding your patient.
• unfortunately ED staff tend to have a short attention span, even shorter when they are stressed, and thus ALL parties should be aware of this and take extra steps to ensure there is adequate and effective communication, after all, the escort doctor may have been the one who has managed to stabilise this patient over the past few hours and is aware of how sensitive the patient may be to certain interventions such as propofol, etc, and the receiving team can do well to LISTEN FIRST BEFORE JUMPING IN like cowboys no matter how arrogant or condescending their personalities may be.
• effective outcome here is much more dependent on human behaviour than on skill sets
• success relies upon cooperation, communication, diplomacy, respect and empathy
• successful communication techniques for the receiving team include:
  • allowing the referrer to complete their statements without cutting them short or putting words in their mouth
  • use reflective checking such as “thank you, I understand from your statement that …., is this correct?”
  • ask direct risk related questions such as “are you aware of any issues that have not been addressed or which are likely to put the patient at risk?”
  • leave the door open for further communication eg. “If you think of anything else that may be important, let me know”
• in general, after a very brief, preliminary handover, the patient should be transferred from the ambulance stretcher to the bed and all circuits and monitoring transferred to the receiving hospital's equipment BEFORE a detailed handover is provided.