Intensive Care Unit

There is one critical care consultant on for the unit per week.  Out of hours the anaesthetic consultant on call covers the unit.  Half of the critical care consultants work cross-site, the others do on-call in SJH.

Day Time: 08:00 -1700hrs I.T.U. Consultant for the week

Night Time: 1700-0830hrs Different Consultant each night. Check the rota.

Weekend: Sat 0830-Mon 0830hrs One or two consultants – check rota as some consultants split the weekend

Critical Care Consultants who regularly do weeks in ICU are:

Dr Rowena Clark (cross site work at WGH)

Dr Richard Burnett

Dr Murray Geddes

Dr Thalia Monro-Somerville (cross site work at RIE)

Dr Sam Moultrie

Dr Grant Price (cross site work at RIE)

Dr Craig Walker

Dr Jen Service (cross site work at RIE)

If you ever have difficulty contacting a Consultant in an emergency then get switchboard, nurses or Yvonne to find someone else – in hospital hours this is usually no problem. Out of hours you may decide first to try the Consultant on ICU for that week, but use common sense and no one will mind helping out in a true emergency if they are able to.

Day Time Hours: 08:00 – 17:15 if short day and 20:30 if long day

Night Time Hours: 20:00 – 08:30 Check rota to see if you are doing long day (i.e. covering 17:15 - 20:00 in ICU)

ICU trainee carries the 3561 bleep at all times – this is an arrest page and obstetric emergency page as well. At night just this page goes for arrests, if you can’t attend find if an anaesthetist is required and if so get the 3948 bleep paged.

During the day until the hospital-at-night team come on then both pages go for arrests.

Eileen Miller and Elsa Jardine are the Band 7 senior charge nurses for our unit. We have a large number of critical care nurses and you might not get to know them all. Many have been with us for a long time and are very experienced in the care of critically ill patients and often initiate decision making.

The senior nurses in particular will make suggestions and recommendations regarding patient care and management. Please respect and listen to their advice and if unsure of anything clarify the course of action with a more senior member of medical staff.

Anne Neally is our unit pharmacist.  She tries to attend the weekday ward rounds. Many of the drugs we use in critical care may be unfamiliar to you and please approach Anne or the critical care consultant if you unsure of anything.  There is also a very handy guide on the critical care intranet site for those most commonly prescribed medications.

Elspeth Ewing and Lesley Cameron are the SJH pain nurses.  They will routinely review elective postop patients and can be contacted on page 3934 for patient review or advice.

Susan Nicol is the ward clerk. She is very knowledgeable and is a great point of contact for administrative queries.

Yvonne Mallon is the anaesthetic secretary and co-ordinates the running of the anaesthetic department.  Any rota queries should go to her and Dr Claire Caesar.

Critical care is a multi-disciplinary speciality.  There are a number of other very experienced healthcare professionals who are actively involved in patient care at a senior level. These include dietitians, physiotherapists and infection control nurses.

This occurs in the anaesthetic seminar room on the theatre offices corridor.  The consultant may or may not be present. 

Any potential admissions to ICU should be communicated at this time as well as any patients of concern in the hospital. 

Any patients recently discharged from ICU should also be handed over.

Following handover please ensure the emergency drugs bag is checked, if clinical activity allows.

Every patient on the unit requires a daily review. This should involve a systems-based approach, as in other areas of medicine, and include assessment of ventilatory and haemodynamic parameters, nutritional requirements, organ support, lines and any microbiology results/concerns. A basic plan should also be formulated. Use Trak short codes to document your assessment (seethe list at the end of this document).

You will be expected to present your patient in a concise and systematic manner together with your proposed plan on the morning consultant ward round. If there is a pressing clinical issue which needs to be promptly addressed please discuss this with the critical care consultant before the ward round. Please do not order any specialist investigations (e.g. CT scans) without discussion with the critical care consultant.

As part of your daily assessment please also ensure that:

• Blood results are signed off on TRAK
• Fluids are prescribed
• The drug kardex is reviewed and up to date
• There is an ECS printout in the notes and an Adults with Incapacity form completed (if appropriate)
• CVVHD is prescribed (if you are competent at doing this)
• Key aspects of care must be reviewed every day e.g. venous thromboembolism prophylaxis, need for sedation hold etc. These aspects are listed at the end of the structured daily review.

The I.T.U. Ward Round, comprising the Pharmacist, nursing and medical staff, usually takes place about 11:00hrs.

It is important that the haematological and biochemical results are ready for this time – get from the computer and sign that you have read them on TRAK.

Use the Trak shortcode to document the ward round and please make sure the daily goals section is completed.

In the afternoon please go back and review your patients to ensure their daily goals have been achieved.

Elective referrals

Planned elective cases will be identified pre-op via the waiting list system.  Any additional cases should be discussed with the critical care consultant.

Emergency referrals

Some sicker medical patients are looked after on medical level 1– depending on their requirements.Please be aware that sometimes the medical “registrar” at night is extremely junior, and that they are often very busy.  Medical Level 1 does not run vasopressors or have arterial lines so if a patient is ill, requiring organ support, then transfer them to ICU.

There is a non-invasive ventilation service in the hospital – you may be involved in assessing these patients (especially in regards to their Treatment Escalation Plan). NIV is done in medical Level 1 – it’s a good idea to familiarise yourself with the guidelines and ventilator.

On the whole if you are aware of a critically ill patient in the hospital then it is part of your professional duty to ensure they are in an appropriate place getting an appropriate level of care.  We have an excellent working relationship with the other specialists in the hospital and please continue this by providing appropriate support for colleagues if requested.

A few tips and ground rules regarding referrals

All patients admitted to critical care should be clerked/re-clerked using specific Critical Care short-codes for History / Physical Exam and Management Plan sections. All other sections should be reviewed and updated if there are any changes since the original hospital admission. The "Management Plan" is a standard Critical Care management plan and should be updated for each individual patient.

For all new patients please ensure the following:

• The names of the referring and accepting consultants are recorded in the admission note
• An admission checklist (see at the end of this document) is completed within 4 hours of admission and filed in the case notes.
• A critical care drug kardex is started and relevant drugs prescribed (please see admission checklist and intranet protocols for DVT and ventilator-associated pneumonia prophylaxis etc.).
• An ECS summary is printed out and filed in the notes. The drugs on this list should be reviewed and prescribed on the critical care kardex in accordance with the patient’s clinical status.
• Appropriate fluids are prescribed and relevant investigations are ordered.
• There is a clear plan documented on Trak.
• Relevant investigations are requested (please ensure you are logged into Trak as an SJH user).
• In certain patients, e.g. post op patients, you have referred to the relevant protocol.
• An Adults with Incapacity form is completed and signed if appropriate.
• Discussion with family members is on Trak.
• An APACHE score is completed at 24hrs (or at the time of discharge/death if within 24hrs) for all patients on Ward Watcher.

“Ward Watcher” is a national audit programme collecting data from all of the Scottish critical care units.   We gain important information, not only for our own use but also for regional and national audit purposes.   Please complete the APACHE Score at the end of the first 24hrs or when the patient is discharged, if sooner.   The Consultant should ensure that their week or weekend’s computer activity is up to date.

The microbiologist for St John’s is Dr Karen McSween, but she works across Lothian. Either she or a colleague will liaise with the doctors on ICU at some stage during the day – either by telephone or in person.

During the day, if Dr McSween is off site, then the covering microbiologist is the on call team at RIE – the Lab at St John’s will know who to contact. 

If there is any new information then please document this using the Trak shortcode.  Please also ensure that all microbiology results are signed off on Trak.

MRSA is a problem in all units and we routinely screen for it – (this sample will NOT show up other infections – you need to send further samples, on different forms for anything other than MRSA). We screen everyone on admission who is anticipated to be in for >48 hrs for MRSA. We do not “routinely” sample tracheal secretions, wounds or urine for other microbes as the value of such screening is not proven and can be confusing.

“Infection control staff” and Dr Moultrie collate data on MRSA acquisition – please help to avoid MRSA acquisition by adhering to infection control measures – hand washing on coming into the ward, hand washing or using gel for each patient contact, (hand wash if C Diff + as gel doesn’t get rid of it), pinny for each patient contact, “bare below elbows” – no watch or rings other than wedding ring.

Patients who have been in other hospitals – especially abroad recently need isolating until CPE (carbipenimase producing enterobacter) screening swabs are negative.

If there is suspicion of infection then appropriate samples should be sent – if chest is suspected then seriously consider a deep sample (e.g. bronchoscopic). For a significant pyrexia (>38ºC), blood cultures should be taken peripherally – take cultures in as aseptic manner as possible using clinell wipes and sterile gloves.

If the patient is on broad spectrum antibiotics and develops a pyrexia or is immunocompromised or has had an upper G.I. perforation, fungal infection should be considered.

Critical Care antimicrobial prescribing guidelines are available on the Antimicrobial Companion app.The app is available for download and the links are available here.

Or on the NHS Lothian intranet here: http://intranet.lothian.scot.nhs.uk/Directory/AMT/Pages/Antimicrobial%20Management%20Home%20Page.aspx

Once you have downloaded the app, download the NHS Lothian toolkit.  The critical care guidelines are found under “Specialty guidelines” and then “Other”.

In addition, think about the likely organisms in view of recent infections and antibiotics. Ask for advice if you are unsure - from your senior in the first instance but there is an on call microbiology consultant available for advice in difficult problems.  Remember that not all positive cultures need treatment – especially in long-term patients with altered commensals caused by antibiotics.

Please note Vancomycin if used is given as an infusion in critical care – the continuous infusion guidelines are on the critical care website and have to be followed quite carefully. 

Gentamicin has to be prescribed using the on line calculator – there is a pro-learn tutorial on this that you may find useful.

When prescribing antibiotics please write indication and review / stop date on kardex.

Insert central lines in an aseptic fashion with the use of gloves, gown and hat and mask please, use the USS machine, and fill in the CVP ‘bundle’ on the lines chart which is kept at the patient’s bed space.

Please ensure you are competent suturing in lines before doing so on patients. We advise that arterial lines should be secured by instrument ties rather than hand-tied knots. Seek assistance from senior medical staff if you are in any way unsure how to do this safely.

Change lines as clinically indicated, no set time limit.  Do not routinely send line tips just because the line is coming out – but if patient is septic and it is query line infection, send the tip with the following information on the form – “? Line associated infection”.  Do blood cultures at the same time.  To have a line associated blood stream infection by commonly accepted definition; one must have bacteraemia and evidence of line infection.

NB Burns patients get a lot of blood stream infections – thus we have decided that if any burns patients arrive with lines put in elsewhere, then seriously consider changing them soon.  Also, in burns patients we have agreed not keep lines in for “a long time” (>7 days).

There are a number of very detailed and comprehensive protocols for patient management in critical care available on the intranet (Directory>Critical care). 

They are also available on the critcare.net website (Username – crit Password – care) and this can be accessed on the internet and on your phone. Please familiarise yourself with the guidelines and refer to them on a regular basis. These include drug prescription and electrolyte replacement guidelines together with a number of admission guidelines and protocols for certain clinical scenarios.

There are several checklists in use which are also available on the intranet including: Emergency intubation, Extubation, Intra-Hospital Transfer and Percutaneous Tracheostomy.

Trak has a number of order sets for certain conditions and investigations including: community acquired pneumonia (CAP), bronchoalveolar lavage (BAL) and Covid-19.

Guidance on many aspects of the Covid-19 pandemic changes on a regular basis.  Any changes will be emailed to you on your nhslothian.scot.nhs.uk email address so please make sure you can access this.  The intranet has a Covid-19 site on it which is kept up to date with the latest guidance.

This is usually a planned procedure and should be prioritised as early as possible in the day. Acceptance from the parent team and a named consultant is required before discharge. It is essential that continuity of care is achieved for all patients through effective communication with accepting medical/surgical teams.  When contacting the parent team, convey pertinent information concerning:

• the patient’s condition
• progress and continuing problems
• medication and doses to be given in the near future
• any serious allergies
• the day’s results
• nutritional support
• information which has been given to the patient’s relatives and which of the relatives has been in regular contact

Medical patients admitted from ED should be discharged to the receiving medical Consultant for that day, as a default to medical Level 1.  However, they go back to parent consultant if admitted to ICU from the ward, and ALL respiratory discharges/pneumonias should be discharged under the care of a respiratory consultant (if unexpected discharge out of hours then discharge to on call medical registrar who will refer to respiratory on the next working day).

For any patient being discharged from the unit please complete a TRAK immediate discharge letter (IDL) in the correspondence section of TRAK using the appropriate shortcode.

All emergency patients should be discharged using the emergency IDL short-code.

All uncomplicated elective patients can be discharged using the elective short-code.

Other members of the MDT (Physio, Nutrition team) may add more detail to their sections of the IDL. Please record the note as an Inpatient Discharge Summary.

When completing an ICU IDL please ensure all fields including treatment escalation plan are completed prior to discharge.

Please note, patients do not get consultant discharge letter unless they have died or discharged straight home so this will be the only letter that is sent, and won’t go to the GP unless you ”authorise” it on TRAK.

Please ensure that any elevation in a patient’s NEWS score is addressed prior to discharge to the ward and “reset” the NEWS on the NEWS 2 chart if appropriate.

This is rarely unpredicted, so appropriate discussions with the relatives may have already taken place. Such situations need to be handled with sympathy and compassion. End of life care can be challenging on Critical Care so a clear plan for withdrawal of therapy and prescriptions of palliative medication should be outlined by the critical care consultant. There is a specific Critical Care End of Life Care Guideline on the intranet and a confirmation of death form that should be completed at the time of death, including a Trak shortcode. There are also bereavement packs which should be offered to all bereaved relatives.

The causes of death are usually apparent.  Some cases will need to be discussed with the Procurator Fiscal’s Office by the consultant – the reasons for this are included on the “death in hospitals” form but are usually related to the death being unexplained, secondary to violence, recent surgery, hospital acquired infections, neglect or deprivation; or any concerns regarding patient management.  If not a fiscal case then post mortem should be considered in all patients.   Obtaining consent for this should be left to the consultant. A Death Certificate can and should be issued whether or not a hospital PM is to be done (hospital now will not do a PM unless the certificate has been issued).

NEVER issue a death certificate without discussing what to put on it with the consultant.  This information should also be recorded on Trak in the correspondence section using the appropriate shortcode.  Please double check the information you have written on the death certificate with another member of the medical staff – you will be surprised at the number of unconscious errors that are made!All the relevant medical teams need to be informed – referring teams (including those at other hospitals) and General Practitioners. There is a checklist to complete to ensure all the correct documentation has been completed.

If you are involved in an incident or a distressing case try to speak to the Consultant before the end of the shift or as soon as possible after. Speak to your supervisors too. They can advise you how to proceed and organise more formal debriefing if it is helpful. Online Datix forms should also be completed for harmful/adverse incidents, following discussion with a consultant.

Dr Craig Walker is the ICU Lead for “M & M” (Morbidity & Mortality) meetings so please inform him of relevant issues by email at craig.a.walker@nhslothians.scot.nhs.uk.  Craig also runs an “A&A” (Awesome & Amazing) section in these meetings so let him know of any excellent/exceptional behaviours/events related to the care of critically-unwell patients so that we can highlight great performance as well as recognising where we can improve.  You can submit via this link http://tinyurl.com/SJH-ITU-Greatix (also accessible via Smartphones/internet) or email as above. Nominees receive recognition for their awesomeness as well as funky certificates for appraisals/end-of-year reviews. Consider nominating your colleagues!

Training and teaching should be an active process on your part.  Dr Ed Mellanby co-ordinates the SJH anaesthetic weekly teaching schedule.  There is an ICU meeting one lunchtime every week about 12:30 to about 13:30 in the Seminar room and on Teams – usually discussion of cases on the unit but can be anything with ICU relevance.  There are other meetings or teaching sessions at lunchtime and you are actively encouraged to volunteer for a slot and teach us all on a topic of your choice!There are monthly South East Scotland ICU tutorials and the SES critical care journal club occurs every Wednesday afternoon.  We join both virtually from the seminar room.

The workload varies in ICU and your aims should be to gain as much experience as possible – in particular try and accompany the consultant when they review patients who are referred to ICU.

This hospital is a tertiary referral centre for burns. If there is a patient with burns on the unit then endeavour to follow their treatment including grafting – you will not get exposure to this elsewhere in the region.

For those new to ICM – please go to the SICS (Scottish Intensive Care) website www.scottishintensivecare.org.uk and to the education page where there are induction tutorials. If you complete these modules, you will receive a certificate. There is also an annual educational meeting led by the ICM trainees, advertised on the SICS website, and held each November. This is very good and often oversubscribed.  Apply Early!There is a simulation-based fundamentals of intensive care course,‘PICT - Principles of Intensive Care Training’, aimed at FY2 and ST1 doctors at the Scottish Centre for Simulation and Clinical Human Factors in Forth Valley Royal Hospital, Larbert.Check SCSC^HF website for details: http://scschf.org/

If you are interested in a career in ICU then discuss with any of us, it is worth registering with the College and I would refer you to the Regional Advisor for ICU training – Dr Monika Beatty at the RIE.

There is a database of interesting articles on the shared drive, please add any interesting articles yourselves to the added articles folder – if it’s a major article consider presenting at the weekly lunchtime meeting.

Dr David Falzon is the anaesthetic lead for QI in SJH and Nicola McCabe is the critical care QI nurse. If you have or need any ideas for a project please speak to them.

Summary

Critically ill patients may require transfer to another hospital for specialist treatment or investigation; lack of critical care beds; or repatriation. Transferring such patients has risks; a clear pathway for referral, risk assessment and clinical protocols mitigate this risk.  Although relatively few transfers are carried out from SJH, the relative inexperience of anaesthetic trainees and potential for sudden deterioration in transit make this a particularly challenging area of critical care service.

This document aims to outline an operational framework to facilitate these transfers.  It is based on guidelines including the Faculty of Intensive Care Medicine (FICM) Guidance On: The Transfer Of The Critically Ill Adult (2021), the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guideline on Interhospital Transfer (2009) and the Royal College of Anaesthetists (RCoA) Stage 1 Curriculum (2021). 

Aim

The aim of this document is to provide those involved in transferring critically ill patients a clear understanding of their roles and responsibilities. It also outlines processes to be followed and the standards to be achieved.

Training staff in the safe transfer of critically ill patients is essential to minimise risk. This involves understanding of the physiological effects of road transfers, knowledge of the common problems and their solutions, and familiarity with equipment and modes of transport.

Scope

This document pertains to the inter-hospital transfer from SJH of: Adult level 3 patients and adult level 2 patients at risk of deterioration.

Most non-time critical paediatric transfers are undertaken by the SCOTSTAR paediatric retrieval service and will not be discussed in this document.

Definitions

Critically ill – Level 2 or 3 patients as per Intensive Care society definition (Appendix 1)

Unstable patient – a patient with an immediate life threatening condition/injuries who cannot be stabilised in the referring hospital and, at the discretion of the senior clinician, should be transferred without delay for extensive resuscitation and stabilisation.

Clinical transfer – a transfer for specialist treatment or investigation

Time critical transfer – the expedient transfer of a potentially unstable patient, in whom an emergency intervention, not available in SJH, is required.

Capacity transfer – a transfer carried out as there is a lack of staffed critical care beds

Repatriation – the transfer of a patient back to a hospital nearer to their home.

Roles and responsibilities

Directorate

• Nominate a lead consultant for critical care transfers with responsibility for guidelines, training and equipment provision (FICM, 2021)
• Develop and review local transfer policies
• Ensure systems and resources are in place to resuscitate, stabilise and transfer the critically ill.
• Undertake a detailed assessment of risk at organisational level
• Ensure transfers for capacity occur as a last resort and regard such as critical incidents.
• Have a dedicated policy for the management of paediatric admission and paediatric transfers.
• Ensure appropriate training for all staff involved in the transfer of the critically ill (FICM, 2021).

Referring Consultant Anaesthetist/Intensivist

• Responsible for the patient and the decision to transfer
• Responsible for referral to and communication with the receiving hospital.
• Responsible for ensuring that the patient is accepted by the appropriate parent team.
• Responsible for undertaking an assessment to determine the anticipated risk during transfer.
• Responsible for selection and assessment of competence of accompanying medical personnel.

Referring Lead Nurse/ODP

• Responsible for ensuring the patient is accompanied by appropriately trained nursing staff/ODP/technician

Escorting personnel

• Responsible for the patient during transfer until formal handover to receiving personnel
• Responsible for personal clinical competence appropriate to the role
• Responsible for checking that all necessary equipment and drugs are taken
• Responsible for completion of transfer care record

Organisation and Planning

Appropriate receiving location

• Clinical transfer: a specialist bed in the appropriate tertiary centre
• Repatriation: the appropriate critical care facility closest to the patient’s home
• Capacity transfer: the closest appropriate critical care facility.

Training

All staff involved in the transfer of critically ill patients should receive appropriate training and experience in a supernumerary capacity when possible. Anaesthetic trainees are required to demonstrate stage 1 key capabilities (RCoA, 2021) outlined in Appendix 2, if they are to transfer critically ill patients. CT1 anaesthetic trainees therefore, should not be asked to transfer critically ill patients. CT2 trainees may do so if appropriate training has been completed. Ideally, they should receive supernumerary intrahospital and interhospital transfer exposure. Standardisation of process and exposure to intra-hospital transfers will increase experience and familiarity with equipment.

 Equipment

Equipment must be suitable for use in transport environments, be capable of being secured to withstand acceleration and deceleration forces and be mounted on the transfer trolley in such a way as to be CEN compliant. Infusion devices, ventilators and monitors must be maintained and of a standard compatible with delivery of intensive care medicine during transfer. Alarms should be visible as well as audible.

Additional equipment must be available to deal with anticipated problems during transfer. This must be stowed safely in appropriate transfer bags. All transfer equipment should be maintained fully charged wherever possible.

Governance

All incidents occurring during transfer should be reported through datix at the referring unit after completion of the transfer. The specific incident form in the transfer folder should also be completed.

All transfers should be subject to a debrief process to facilitate service improvement. A carbon copy of the transfer record should be retained and filed in the transfer folder on return to the base unit.

Data should be collected as an ongoing audit of practise and cases presented with incidents reviewed on a quarterly basis at the departmental audit afternoons. 

Process

Decision and timing of transfers

The decision to transfer and accept a patient must be made by appropriately senior and experienced clinicians (AABGI, 2009) e.g. responsible consultant anaesthetist/intensivist and consultant colleagues from relevant specialty teams in both the referring and receiving hospitals. Transfer for immediate lifesaving interventions must not be delayed by lack of availability of a critical care bed (FICM, 2021).  

Most transfers should be carried out within normal working hours. If there is a time critical clinical intervention e.g. evacuation of an intracranial haematoma, then it would be appropriate to transfer out-with working hours.

Capacity transfers should be avoided whenever possible. They should take place during normal working hours. Standard practise is for the new patient to be transferred after stabilisation if possible.  If the newest patient cannot be stabilised then an alternative transfer candidate should be determined by clinical stability and clinical specialty.  It is not considered safe or acceptable to transfer critically ill patients between hospital sites in order to maintain operational function at the transferring site.

Communication with patients and relatives

Patients and relatives should be informed of the decision to transfer, the travel arrangements and any other pertinent information at the earliest opportunity.

Selection of transport mode

In most cases transfer by road is appropriate. It is rapidly available, relatively familiar and has less potential to cause physiological disturbance. Most transfers do not need high speed travel, which may endanger patients and personnel. Blue lights and sirens may be used to aid passage through traffic. 

Accompanying personnel

Critically ill patients should normally be accompanied by one or two suitably trained and experienced clinical staff during transfer (Medical/ACCP/Nursing/Other practitioner). In the transfer of any level 3 patient there should usually be two trained escorts including an ODP, ICU or ED nurse with appropriate training and expertise and a doctor with critical care competencies including transfer training and advanced airway skills. If a doctor is the sole escort from the base unit, a trained paramedic must also be part of the transfer team.

Risk assessment

A detailed risk assessment should be carried out by an experienced clinician to determine the potential risk during transfer. This should include:

• Patient’s presenting clinical condition, specific risks and level of dependency
• Risks related to the transfer/movement of the patient
• Likelihood of deterioration and need for additional intervention
• Mode of transport and likely duration of transfer

Preparation for transfer

Patients should be appropriately resuscitated and stabilised before transfer to reduce the risk of physiological disturbance and deterioration during transfer. The time taken to stabilise the patient must be balanced against the need for emergency intervention in time critical transfers.

Escort personnel should familiarise themselves with the patient’s history, clinical condition and treatment. A full clinical assessment including physical examination should be performed. The airway should be assessed, secured and protected if necessary. Secure venous access is mandatory, a minimum of two intravenous cannulae (central or peripheral) are recommended. 

Named medical and nursing staff at the receiving unit should be contacted before departure to update them on the patient’s condition and provide an estimated arrival time. A checklist should be used to ensure that all necessary preparations have been completed.

Monitoring

Minimum standards of monitoring must be applied in every case and should be continuous throughout transfer. All monitors, including ventilator displays and syringe drivers should be visible to accompanying staff. A documented record of observations and events must be maintained.

Minimum standards of monitoring are: Continuous observation, ECG monitoring, non-invasive blood pressure, oxygen saturation, temperature and end tidal carbon dioxide in intubated/ventilated patients.

Trauma

Major trauma cases are not frequent in SJH secondary to the local organisation of the SAS and emergency departments; transfers for major trauma are therefore unusual. Occasionally, patients with trauma-related injuries will self-present to SJH ED. If a specific surgical intervention is required which is not offered at SJH, this may be considered time critical and transfer could be done out with normal working hours. If transfer is considered time critical, with the need for ongoing resuscitation, a senior clinician should escort the patient.

Request for ambulance

Requests are determined by the nature of the transfer i.e. time critical, clinical transfer; capacity transfer; repatriation (See flow chart Appendix 2).

Safety during transport

Patients should be secured to the transfer trolley using the restraining harness. Reassurance, sedation, analgesia and antiemetics should be provided as required to reduce discomfort and distress. Unless contraindicated they should be kept warm and pressure areas protected. Lines and drains should be safely secured, visible and easily accessible. Portable equipment must be securely stowed for transport.

Staff should have access to personal protective equipment, warm clothing, high visibility jackets and a means of contacting the base and/or receiving unit. Staff should remain seated wearing the seat belts provided at all times. If the patient requires intervention, the ambulance must be stopped in a safe place before treatment is administered.

In the event that an ambulance cannot return the transfer team to their base hospital, arrangements must be made to ensure personnel and equipment be returned safely and promptly. The responsible consultant should contact the duty hospital manager to facilitate arrangements for a taxi.

Documentation and handover

Clear records should be kept including: decision to transfer, risk assessment, patient assessment, monitoring during transfer, clinical events during transfer and therapy given before, during and after transport. A referral letter, completed by the base speciality or the ED team, should also be available. 

There should be a formal structured handover between the transport team and the receiving team who will assume responsibility for the patient’s care. Details of advanced directives, treatment limitation decisions, resuscitation status and discussions with the patient and relatives should also be handed over.