Continuing educationVaidya:

articleTransport of critically ill patient

Transport of the critically ill patient

Abhishek Vaidya*
Email: [email protected]

Abstract
Transportation of a critically ill patient is a challenging task necessitating development of safety guidelines
that can be universally followed to minimise problems during transit. This not only requires trained personnel
with good communication skills but also necessitates a well-equipped transportation facility such as ambulance
and modification of traffic rules to suit preferential allowance of such vehicles. It is also vital that the trained
personnel are experts in handling emergencies, trained in cardiopulmonary resuscitation and airway management.
The transport vehicle (ambulance) should be spacious enough to allow resuscitation that may require multiple
personnel to be around the patient. Furthermore, the vehicle should have advanced communication equipment so
as to be in constant communication with the hospital personnel to which the patient is getting shifted.
Keywords: Critically ill; Patient transport; Transportation of equipment; Check list; Risk factors.

Introduction transport require to be knowledgeable in use of

A critically ill person is one who has dysfunction equipment, cardiopulmonary resuscitation, have
of any organ system either alone or in combination good communication skills etc.1,2 There is a need
with other organ systems that contributes to for development of rationale guidelines that can be
disruption of normal physiology in such a way that applied in developing countries for monitoring and
it becomes an immediate threat to the patients life. transporting such patients. The transfer of critically
Mechanical ventilation of a critically ill patient is ill patients may be within the hospital or between
well established in the intensive care units. However, two different hospitals. Both these require clear and
when a need arises for transport of such patients decisive protocols to ensure patient safety.
to another location within the hospital or to
another hospital, this becomes a highly challenging A) Transfer of critically ill patients within the
task requiring multiple factors to be addressed.1 hospital
These include but are not limited to requirement A critically ill patient may be required to be
of trained personnel, effective communication transported within the hospital to various other
between the locations, additional equipment and places for either diagnostic purposes such as
gadgets such as portable monitors to be carried MRI suite, CT scan or for therapeutic purposes
along with the patient during transfer. The to operating locations. In such situations, it is
hospital personnel attending such a patient during essential to adhere to certain clear protocols in
order to safeguard the patient during transit period.
The most important step is to identify a high risk
Abhishek Vaidya, BSc RT, CRT
Assistant Professor of Respiratory Therapy, patient and have a clear, purposeful communication
Manipal College of Allied Health Sciences, between personnel involved in patient care at ICU,
Manipal at the location to which the patient is to be shifted

How to cite this article: Vaidya A. Transport of the critically ill patient. Ind J Resp Care 2012;1:28-31.

28 Indian Journal of Respiratory Care | January 2012 | Volume 1 | Issue 1

 Vaidya: Transport of critically ill patient

and those involved in patient transport. The next that is portable and easy to handle and if ventilator
step is to ensure adequate supply of medications, is not available then a PEEP valve and self-inflating
monitoring and resuscitation equipment and have bag can be used with reservoir bag to deliver 100%
personnel trained in cardiopulmonary resuscitation oxygen.1,2 Splints and backboards should be used
accompany the patient. Some of the essential in order to avoid spinal fractures that may occur
elements for intrahospital transport are discussed while shifting the patients. One must ensure that the
below. drainage bags are emptied and intercostal drainage
(ICD) tubes clamped at the time of shifting the
Protocol development and written procedure: patients. Also, it is essential to ensure working and
Due to the varied differences in the availability of adequate venous access. Patients medical records
infrastructure between hospitals in countries such as and consent forms should also be shifted along with
India, an universal protocol will not be possible to be the patient.
implemented at this stage. Hence, it is important that
each hospital develops its own protocol based on the Accompanying personnel: In our hospital, a
infrastructure. Furthermore, every department in patient is usually accompanied by a critical care
the hospital must be clearly aware of these protocols. physician looking after the patient along with a
Proper documentation of the events at each stage respiratory therapist and the admitting unit doctor.
will not only help provide best patient care but also This ensures that an appropriately trained person
will help in auditing and quality assessment. in cardiopulmonary resuscitation and airway
management is always available during transfer. It
Decision: Documentation has to be done in medical has been clearly established that the life threatening
records that includes indications for transport and complications during transport are minimised by the
patient status. The intensivist and primary physician presence of trained personnel during transfer.1,8
will take the decision to transport the patient. The
aim of transport should be noted in case records. Equipment, drugs and monitoring: Equipment
The patients family should be informed of risks should be portable and checked to be ready for use.
involved, possible benefits should be explained and The transport trolley ideally should have custom
consent should be taken in standard format. made shelves near the bed to keep the emergency
drugs. All equipment should be operable by battery
Identification of high risk patient: Mechanically and should be fully charged. One must have equipment
ventilated patients with high requirement of positive compatible with the working environment such as
end-expiratory pressure (PEEP) and inspired MRI compatible equipment.
oxygen concentration (FIO2 > 0.5), patients with
high therapeutic injury severity score, patients with Care during transport: The vitals signs should be
head injury and haemodynamically unstable patient monitored continuously during transport, airway
requiring continuous infusion of vasopressors or patency should be ensured and any adverse events
inotropes.1-7 should be noted and immediately acted upon.

Preparing the patient for transport: This involves B) Transport between the hospitals
optimisation of haemodynamics and ventilator Interhospital transport of the patients in Indian
parameters with optimal fluid resuscitation and scenario presents an even more challenging scenario
use of vasoactive agents as necessary; appropriate because of lack of specialised transport teams such
airway management and ensuring proper fixation as medical retrieval units or regional transport
of endotracheal tube or tracheostomy tube; sedation teams. Currently, there is an ever increasing need
and analgesia as needed to reduce anxiety and fear for interhospital transport due to the development
of the patient along with use of muscle relaxants as of speciality centres in the management of different
required; having a sophisticated transport ventilator problems such as respiratory failure, trauma,
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 Vaidya: Transport of critically ill patient

transplant, cardiac setups.2 In the developed world, intervention, the distance to be covered, facilities
interhospital transport may happen by road or available for transport and the patients economic
by air transfers. However, in India, most of the status.
transports are by road through ambulance services.
Interhospital transport may be necessary in India Care during transport: Equal care as given at the
for either therapeutic purpose to higher specialised referring ICU should be provided during transport
centres or for diagnostic purposes such as CT scan or also. The instances when mishaps are most likely to
MRI as many of these facilities are not available in happen during transport are while shifting the patient
large number of hospitals while it may also happen from hospital to ambulance trolley, shifting the
due to monitory constraints when the patients may patient trolley in ambulance and while shifting
need to be shifted to centres that offer care at lower the trolley from ambulance at receiving hospital.
prices. Therefore, during these intervals extra vigilance
is needed to prevent disconnections, equipment
Initiating transport and preparing patient for malfunctions and dislodgement of indwelling
transport: The treating critical care expert should catheter. All relevant information and imaging
decide the timing of transport ensuring that the films including copies of medical records and
patient is reasonably stable enough to tolerate the investigation reports should accompany the patient
stress associated with transport. The patients family during transport. Patient trolley must be secured
should be taken into confidence and informed about appropriately in ambulance. If the patient is intubated
necessity and possible adverse effects of transport and ventilated, head must be secured appropriately
while the indication for transport, risks and expected in the ambulance to prevent undue movements.1,8
benefits must be clearly written in medical records.
If the patient is transferred for further care, the Complications
receiving intensivist should be contacted directly Complications that may occur during transport of a
and patients clinical status should be communicated critically ill patient can be subdivided into individual
clearly to him/her as he/she might have some systems:2
suggestions to improve the patients stability which
may be undertaken before shifting the patient and Cardiovascular complications: Tachy or brady
this will also ensure that the intensivist receiving the arrhythmias, hypotension, hypertension, myocardial
patient is in a prepared position to tackle the patient ischaemia, worsening of the cardiac condition and
on arrival. If non urgent, the transport should be possibly cardiac arrest.
planned for morning to avoid peak traffic.
Respiratory complications: Problems in ventila-
Communication and coordination: The destination tion, hypoxaemia, aspiration, barotrauma, airway
hospital must be informed of the time when the obstruction, accidental extubation, endobronchial
patient sets off from the ICU, the expected time of migration of the tracheal tube etc.
arrival of the patient at destination. Transport team Neurologic complications: Anxiety, increase in
must be able to keep constant contact with referring intracranial pressure in susceptible patients.
as well as the receiving intensivist. The receiving
hospital must ensure that the patient is directly Other complications: such as increased risk for the
taken up to ICU without any delay on arrival. The development of ventilator associated pneumonia,
transport team must be aware of whom to contact haemorrhage, hypothermia etc. may also happen
in an emergency. during transport. Often equipment failure such as
loss of battery power, loss of oxygen supply, loss
Mode and choice of transport: This may be of venous access or damage to equipment may
influenced by the nature of the illness, clinical also contribute the significant problems during
impact of the transport environment, urgency of transport.

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 Vaidya: Transport of critically ill patient

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