Transporting the critically ill 543

BENEFITS OF PRE-HOSPITAL
EMERGENCY TREATMENT
The provision of pre-hospital emergency medical services is
of proven value for victims of a cardiac arrest provided that
cardiopulmonary resuscitation is initiated by a bystander,
the paramedics arrive at the scene within a few minutes and
the patient is rapidly transferred to hospital for definitive
care. The benefits for trauma victims are less clear, except
when a coordinated approach from primary transport to
specialized trauma centres is established (see below; Biewener
et al., 2004).
SECONDARY TRANSPORT
Considerably fewer seriously ill patients require secondary
transport, although in the UK it is thought that at least
10 000 critically ill patients require interhospital transfer
each year (Mackenzie et al., 1997). The increasing tendency
to concentrate specialist services such as trauma, neurosur-
gery, plastic surgery, cardiothoracic surgery, nephrology and
intensive care in regional centres is likely to increase the
demand for secondary transfer of the most seriously ill
patients (Wallace and Lawler, 1997).
PRINCIPLES OF SAFE SECONDARY TRANSPORT
(Tables 21.1 and 21.2) (Australian and
New Zealand College of Anaesthetists, Joint
Faculty of Intensive Care Medicine, Australasian
College for Emergency Medicine, 2003; Intensive Care
Society, 2002; Wallace and Ridley, 1999;
Warren et al., 2004)
Optimize patient’s condition before transfer
Prior stabilization is fundamental to the safe transfer of
critically ill patients – the ‘scoop and run’ approach descri-
bed above for primary transport is not appropriate in this

Table 21.1 Transporting critically ill patients: a checklist

Administration Equipment
Establish effective communication between transferring and Provision of respiratory support and monitoring
receiving hospitals and ambulance authority Equipment for airway management
Gas supply: oxygen ± air
Notify and explain reasons for transfer to relatives
Cylinders
For the conscious patient, explain the reasons for the transfer Portable liquid oxygen containers
Air compressor
Collect together patient records to accompany patient
Portable ventilator
Ensure appropriately experienced and qualified staff accompany Heat and moisture exchanger
patient Suction apparatus
(Extracorporeal membrane oxygenation)
Select most appropriate mode of transport: surface ambulance,
Airway pressure gauge
air transport (fixed-wing, helicopter), sea
Pulse oximeter
Before transfer, receiving location confirms that they are ready Capnography
to receive the patient
Provision of cardiovascular monitoring and support
Document reasons for transfer in medical record Fluid administration: infusion pumps
Vasoactive agents and inotropes: syringe pumps
Preparation of patient
Portable defibrillator
Optimize patient’s condition Continuous electrocardiogram monitoring
Circulating volume Continuous direct intra-arterial pressure monitoring
Haemodynamic support (Pulmonary artery pressures)
Respiratory support (Intracranial pressure)
Appropriate monitoring (Cardiac output)
Evaluate need for sedation, analgesia and muscle (Intra-aortic balloon pump)
relaxants (Continuous haemofiltration)
Rarely need surgery before transfer
Drugs
Underwater seal drains: do not clamp or lift above patient Resuscitation drugs
Antiarrhythmics
Nutritional support: if this is discontinued, beware of
Sedatives/analgesics
hypoglycaemia
Muscle relaxants
Maintain body temperature (warming blanket) Crystalloids/colloids
Investigations Mobile phones
Radiographs to confirm position of endotracheal tube,
intravascular cannulae and chest drains
544 INTENSIVE CARE
Table 21.2 Principles of safe transfer
Experienced staff
Appropriate equipment and vehicle
Full assessment and investigation
Comprehensive monitoring
Stabilize patient before transfer
Reassessment before transport
Continuing care during transfer
Direct handover
Documentation and audit
situation (Gebremichael et al., 2000; Uusaro et al., 2002). A
detailed systems-based assessment of the patient’s condition
should be performed before instituting measures to prepare
the patient for transfer. Most will require optimization of
their circulating volume (hypovolaemic patients are intoler-
ant of transfer), as well as institution of mechanical ventila-
tion and appropriate monitoring if these are not already in
progress. Needless to say, reliable venous access must be
established. Because endotracheal intubation in transit can
be extremely difficult it is advisable to intubate those at risk
of developing a compromised airway or respiratory failure
before departure. Intubated patients should be mechanically
ventilated.
It is important to ensure adequate sedation, analgesia
and, when indicated, muscle relaxation before moving the
patient. A few may need surgery before transfer (e.g. to
evacuate an acute intracranial haematoma). Investigations
may include radiographs to confirm the positions of the
endotracheal tube, intravascular cannulae and chest drains.
These must be securely tied or sutured in place before
moving the patient. Underwater seal drains should not be
clamped or lifted above the patient during transfer. It is
important to appreciate that abrupt cessation of glucose
administration (e.g. if parenteral nutrition is discontinued)
may precipitate dangerous hypoglycaemia. A nasogastric
tube should be inserted in those with an ileus or intestinal
obstruction and in patients requiring mechanical ventila-
tion. Measures should be taken to maintain body tempera-
ture. If the patient is conscious the proposed transfer and all
that is entailed should be explained to him or her.
Maintain a high standard of care during transfer
In general there should be no reduction in the level of care
during transport; it is strongly recommended that a
minimum of two people accompany all critically ill patients.
Medically qualified personnel are nearly always involved in
secondary transport, although occasionally it may be accept-
able for a stable patient to be transferred by an experienced
critical care nurse with another non-physician member of
the critical care team (e.g. technician, paramedic). All unsta-
ble patients must, however, be accompanied by an appropri-
ately trained doctor. In some countries (e.g. North America,
Australia and France) comprehensive transport systems have
been developed, but in the UK the provision of specialist
services for secondary transfer remains poor and around
90% of patients are accompanied by staff from the referring
hospital. Not only does this deprive the base hospital of on-
call staff but the accompanying clinical team will usually
have only limited experience of transferring critically ill
patients.
This may partly account for the observation that medical
care during transfer is often deficient. In a series of 50 mainly
postoperative patients, for example, 7 developed life-threat-
ening complications, including obstruction of an endotra-
cheal tube, respiratory arrest, unrecognized disconnection of
arterial and central venous cannulae and severe hypotension
(Bion et al., 1988). This study also suggested that patients
under the care of experienced anaesthetists deteriorated less
during transport than those supervised by other medical
specialties (Bion et al., 1988). It is therefore recommended
that the patient should be accompanied by an experienced
doctor competent in resuscitation, airway care, ventilation
and other organ support. This doctor, usually an anaesthe-
tist, should preferably have received training in intensive care
and should ideally be trained and have experience in trans-
port medicine (Koppenberg and Taeger, 2002). The doctor
should be assisted by another doctor or a nurse, paramedic
or technician familiar with intensive care procedures and
equipment, although in many countries staff shortages mean
that this ideal is not always achieved (Wallace and Ridley,
1999). A service for transporting extremely ill patients has
been described in which the team consists of an attending
physician with critical care training, a critical care nurse
and a respiratory therapist. Even the driver has expertise and
training in respiratory therapy, critical care medicine and
transport physiology (Gebremichael et al., 2000).
Personnel involved in patient transfer should not be
prone to motion sickness, should not have ear or sinus dis-
orders and should have no difficulty with working in a con-
fined space. Although in general the patient’s condition
improves after initial resuscitation and, with careful medical
care, does not usually deteriorate further during transport
(Bion et al., 1985), invasive monitoring, including pulmo-
nary artery catheterization, has clearly demonstrated that
transport can sometimes adversely affect even patients who
have been adequately resuscitated.
The use of a specialist transfer team has been associated
with significantly improved acute physiology of critically ill
patients on arrival in the receiving unit and may reduce early
mortality (Bellingan et al., 2000). Certainly critically ill
patients can be safely transferred provided that those
involved are appropriately trained and equipped, with fewer
than 1% dying during transfer and only 3% dying within 12
hours of arrival in the receiving unit (Bellingan et al., 2000;
Markakis et al., 2006). Even the most seriously ill patients
with severe, unstable respiratory and circulatory failure can

be safely transferred over long distances by a dedicated
transfer team using a customized, fully equipped ground
transport vehicle (Gebremichael et al., 2000; Uusaro et al.,
2002). It is even possible to transfer patients safely with
severe acute respiratory distress syndrome (ARDS) without
major complications (Gebremichael et al., 2000; Uusaro
et al., 2002) and extracorporeal membrane oxygenation
has been used during the transfer of hypoxaemic patients
with severe ARDS (Rossaint et al., 1997).
Communication and cooperation
Communication and cooperation between the transferring
and receiving hospitals, as well as close liaison with the
ambulance authority, are fundamental to the success of sec-
ondary transport. A decision to transfer should be made by
senior clinicians only after a full assessment and discussion
between referring and receiving hospitals, taking into
account the balance of risk and benefit. The receiving unit
should be informed of the estimated time of arrival. Conti-
nuity of patient care must be ensured by effective commu-
nication between medical and nursing staff at the referring
and receiving institutions. Changes in the patient’s condition
and response to treatment during transfer should be recorded
and this, together with a written summary of the patient’s
history (including the results of relevant laboratory investi-
gations and imaging), and initial treatment and the indica-
tion for transfer, must be handed over to the receiving staff.
When transfer is urgent, however, the preparation of written
records should not delay departure – necessary documenta-
tion can be delivered later.
MODES OF TRANSPORT
Selection of the most appropriate mode of transport should
be individualized and requires consideration of the
following:
■ the patient’s diagnosis and the possible effects of trans-
port on his or her condition;
■ the degree of any instability;
■ the urgency of the transfer;
■ the level of medical care the patient is receiving;
■ the level of medical care the patient requires;
■ the availability and experience of staff,
■ the distance and duration of the journey;
■ the methods of transport available;
■ the weather and traffic conditions;
■ cost.
As a general principle transport should be performed
smoothly, rather than at high speed.
SURFACE AMBULANCES
Surface ambulances are probably the most practical and effi-
cient means of transport within urban areas and for jour-
neys not exceeding 40–80 km (25–50 miles) or 2 hours’
Transporting the critically ill 545
duration, and are satisfactory for the majority of patients.
Despite recent improvements in the design of standard
ambulances, however, unmodified multipurpose vehicles are
not ideal for transferring critically ill patients. On the other
hand, purpose-built mobile ICUs (MICUs) or critical care
ambulances are expensive and inflexible.
The advantages of surface ambulances include:
■ rapid mobilization,
■ door-to-door service;
■ no requirement for landing zone or runway;
■ little or no restrictions due to weather;
■ in an emergency the vehicle can be stopped at the road-
side to facilitate performance of procedures;
■ can divert to the nearest hospital if the patient deterio-
rates or supplies are exhausted;
■ relative ease of personnel training,
■ low cost.
The main disadvantages of surface transport include:
■ long journey times, especially when there is traffic con-
gestion, poor road conditions, inclement weather or
roadworks;
■ the uncomfortable rough ride, ‘sway and bounce’, vibra-
tion, repetitive acceleration/deceleration;
■ motion sickness;
■ limited accessibility, poor lighting and limited power;
■ difficulty gaining access to remote or restricted areas.
AIR TRANSPORT
The main advantage of air transport is the shorter journey
time; it is therefore used more frequently in North America
and Australia where patients often have to be transported
over long distances. Air transport may also be used to achieve
rapid delivery of paramedics and doctors to the scene of the
incident (see above). Elective movement of patients between
hospitals by air may also be preferred because of the reduc-
tion in journey times. Generally air transport should be
considered for journeys longer than about 80 km (50 miles),
although the apparent speed often has to be balanced against
organizational delays and the need for transfer between
vehicles at the beginning and/or end of the journey.
Secondary transportation of trauma victims by air fol-
lowing stabilization at the receiving hospital can be per-
formed safely and many consider this to be an important
aspect of regionalized trauma care. Some authors (Moylan
et al., 1988) have demonstrated improved survival of trauma
victims transported by air rather than surface ambulance,
although the efficacy of air transport may depend on local
geography, since in an urban setting the use of a helicopter
appeared to offer no advantage compared to a sophisticated
paramedic-based system of pre-hospital care (Schiller et al.,
1988). Certainly in the immediate vicinity of a trauma centre
there appears to be no advantage of a helicopter emergency
medical service (HEMS) as compared to ground ambulance.
Further, even when the accident is a long distance from the
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