Question 9

Created on Tue, 05/12/2015 - 23:54
Last updated on Sun, 04/30/2017 - 17:58
Pass rate: 56%
Highest mark: 8.9

Other SAQs in this paper

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A 56-year-old woman with a spontaneous subarachnoid haemorrhage, presenting with a Glasgow Coma Scale of 12, requires transfer to a neurosurgical centre from a regional hospital.

Outline the clinical and organisational issues involved pre-transfer.

 

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College Answer

Mode of transfer – road or air (fixed or rotary wing) – should be determined by resources, distance to be covered and weather conditions. The mode of transfer should provide the shortest time from the referring hospital to the receiving centre and the standard of care should be maintained throughout the transfer. Staff safety during transfer is an essential consideration. College guidelines for minimum standards for transport of critically ill patients should be followed.

Co-ordination and communication

Ensure bed available at receiving centre

Establish key individual(s) at receiving centre for liaison to receive updates on transfer status and to provide expert advice re patient management

Ensure all necessary documentation prepared to accompany patient including clinical records and radiology 
Ensure transport team know destination (town, hospital, ICU location)

Ensure patient’s next of kin are aware of need for transfer

Preparation of patient

Consider intubation and mechanical ventilation (with ongoing sedation and paralysis) depending on stability of patient and distance/mode of transport

Stabilise on transport ventilator

Vascular access including arterial line

Urinary catheterization and passage of NG tube TEDs

All lines and tubes secured and correct position confirmed Resuscitation and physiological stabilization of patient as indicated Final repeat clinical assessment immediately prior to departure

Monitoring 
Full monitoring of patient including intra-arterial pressure, end-tidal CO2, oxygen saturation and ECG and TO4 if paralysing agents used

Ensure optimum MAP to maintain cerebral perfusion but target SBP < 150 mmHg to avoid re-bleed

Equipment and drugs

  • Transport ventilator 
  • Monitor
  • Bag-valve-mask and re-intubation equipment 
  • Oxygen cylinders 
  • Defibrillator
  • Infusion pumps as needed 
  • Needles and syringes etc
  • Sedative drugs and muscle relaxants 
  • Resuscitation drugs
  • IV fluids 
  • Prescribed drugs as indicated eg antibiotics

Personnel

Ensure adequately trained personnel for retrieval team, including appropriately experienced medical practitioner

Ensure adequate staffing remains on site at base hospital

Discussion

These retrieval questions should be approached with some sort of a system. ANZCA also have a policy document- Guidelines for Transport of Critically Ill Patients- which has been endorsed by CICM.

CICM have a policy document - Minimum Standards for Transport of Critically Ill Patients (IC-10, 2010) which is referred to in the college answer. This document provides a reasonable systematic framework. It is, however, a 12-page document.

In an abridged form, the recommendations are as follows:

Vehicle

  • Determined by nature of illness and urgency or retrieval
  • Need to be mindful of the effects of transport on the illness (eg. the effect of low cabin pressure on gas-filled obstructed bowel loops)
  • Number of staff and volume of equipment
  • Road conditions, weather conditions

Equipment

  • Airway equipment
  • Pericardiocentesis equipment
  • Pleural drainage eqipment
  • Suction
  • Ventilator
  • Oxygen supply (in excess)
  • Defibrillator
  • Thermal insulation
  • Monitoring equipment
  • All drugs checked and labelled

Monitoring

  • Pulse oximeter
  • Capnometer
  • ECG
  • NIBP or arterial line
  • Airway equipment must have disconnection alarms

Patient preparation

  • Ideal patient is intubated, ventilated and paralysed
  • The patient should ideally be stabilised on a transport ventilator before departure
  • Vascular access should be secure; you should not be doing any elective procedures during transfer
  • One last pre-departure assessment

Communication:

  • Bed availability
  • Accepting primary consultant
  • Accepting unit (ICU)
  • Next of kin
  • Documentation travels with the patient