Cause of Device-Related Incident
*Not stated

Clinical Specialty or Hospital Department
Cardiology / Cardiac Catheterization; CCU / ICU / NICU; Emergency Medicine; Nursing

Device Factors
*Not stated

Document Type
Guidance Articles

External Factors
*Not stated

Mechanism of Injury or Death
*Not stated

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

Transporting Critically Ill Patients

Guidance [Health Devices Dec 1993;22(12):590-1]

Guidelines for transporting critically ill patients were published simultaneously in the June 1993 issue of Critical Care Medicine (21[6]:931-7) and the May 1993 issue of the American Journal of Critical Care (2[3]:189-95). Developed by a task force composed of members from the American College of Critical Care Medicine, the Society of Critical Care Medicine, and the American Association of Critical-Care Nurses (AACN), these guidelines, summarized below, outline the reasons and requirements for transporting patients, including the personnel who should be involved and the equipment (including monitors) that should accompany the patient. The task force's recommendations are consistent with ECRI's previous recommendations, also summarized below, but are more comprehensive and stringent in some respects and provide additional details.

Task Force Recommendations

In-Hospital Transport

Transporting a critically ill patient always presents an increased level of risk; thus, each decision to transport must be considered carefully. For example, if it is unlikely that the diagnostic test or procedural intervention under consideration will alter the management or outcome of the patient, then the need for transport must be questioned. If transport is considered necessary, then, because of the increased risk, the monitoring or maintenance of the patient's vital functions should continue during the transport. In addition, all critical care transports should ideally be performed by a dedicated, specially trained transport team; however, it is typically recognized that this goal is not always feasible.

While hospitals with organized in-hospital transport services/teams would already have rigorous standards in place, the new guidelines are intended to provide a minimum standard for hospitals to follow if they do not have such a service or team. However, even without an in-hospital transport service/team, each patient care unit should have a written transport policy. The policy should contain information on the following:

  1. Pretransport coordination and communication. The transferring unit must verify that the receiving unit is ready for the patient before initiating the transport. Ancillary services (e.g., security, respiratory therapy, escort) have to be notified of any needed support and the timing and routing of the transport. The responsible physician has to be notified when the transport takes place and the reasons for it, and the patient's condition has to be documented.
  2. Personnel accompanying the patient. At least two people should accompany the patient, at least one of whom should be a critical care nurse trained as a transport nurse or, alternatively, the nurse assigned to that patient. The nurse should have completed a competency-based orientation and meet standards for critical care nurses. A physician should accompany all physiologically unstable patients, who might need acute interventions that are outside the realm of nursing practice.
  3. Equipment accompanying the patient. A defibrillator/monitor should accompany the patient, as well as equipment necessary for airway management, an oxygen supply, standard resuscitation drugs, and a blood pressure cuff. A resuscitation cart and suction equipment should be readily available (obtainable within four minutes), but do not have to accompany the patient. An ample supply of IV fluids should accompany patients who require continuous infusion medications. Mechanically ventilated patients should be accompanied by transport equipment that can supply the same airway pressure, minute ventilation, fraction of inspired oxygen (FiO2), and positive end-expiratory pressure (PEEP) that patients were getting before the transport.
  4. Monitoring during transport. Patients should receive the same physiologic monitoring during transport that they were receiving in the unit initiating care (if technologically possible). At minimum, ECG and blood oxygen saturation (SpO2) must be continuously monitored and periodically documented; blood pressure, pulse rate, and respiratory rate must be monitored and documented intermittently. In addition, depending on clinical status, the patient may benefit from end-tidal carbon dioxide (ETCO2), invasive arterial blood pressure, intracranial pressure, intermittent central venous pressure, pulmonary artery wedge pressure, and cardiac output monitoring. Intubated patients on mechanical ventilation should have an airway pressure monitor. Also, transport ventilators should have alarms to indicate disconnections and high airway pressure.

Interhospital Transport

The task force's guidelines also provide information on transporting patients between facilities, stressing that patients be so transported only when the referring facility does not have the resources to support its patients adequately and when the transport will not further compromise the patient's outcome. The guidelines also stress the need to comply with federal and local laws with regard to interhospital transfers. For example, transporting patients between hospitals for financial reasons is illegal. The task force provides a flowchart that outlines a decision tree algorithm on whether to transfer a patient. It also provides the details of the minimum requirements of an interhospital transport plan, divided into the same categories as those for in-hospital transports, as discussed above. Interhospital transports require more equipment and higher levels of training for transport staff because the patient will not have ready access to the resources of either hospital facility during the transport.

ECRI Recommendations

Previous Recommendations

  1. In our Evaluation of physiologic patient monitors (Health Devices 20[3-4], March-April 1991), we stated that ECG monitoring should be required for all in-hospital transports of critically ill patients and that pulse oximetry should be used on all ventilator-dependent patients. The need to monitor additional parameters depends on the patient's condition. We also stated that, if the transport were to go through a nonclinical area, a defibrillator should accompany the patient.
  2. In our Evaluation of defibrillator/monitor/pacemakers (Health Devices 22[5-6], May-June 1993), we also discussed the need for a physician trained in advanced cardiac life support to accompany the patient during transport and restated the need for monitoring other parameters in addition to ECG when transporting critically ill patients.

Additional Recommendations

  1. Hospitals should review and modify, if necessary, their documented transport procedures. These procedures should, at minimum, follow the recommendations in the task force's guidelines.
  2. Hospitals should purchase or reallocate transport monitors that can match the parameters being monitored within the patient's care area.
  3. Refer to the March-April 1991 and May-June 1993 issues of Health Devices for information on selecting appropriate physiologic monitoring and defibrillation equipment, respectively.
  4. Those who desire the complete guidelines (Publication No. 4644-820) can contact AACN directly. This publication also includes a section evaluating the transfer plan, as well as many appendixes that provide samples of different forms, reports, and procedures.

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