Case 2

A 55-year-old black man presents to the intensive care unit (ICU) with an acute anterior ST segment
elevation myoca rd ial i nfa rction (STEM I). Consu ltation with a cardiologist indicates that the best
treatment is percutaneous coronary a ngiography (PTCA) . An alternative is the possi ble insertion of
coronary artery stents with backup open cardiac bypass surgery, which is available at a transfer facility
30 minutes away. At the current facility, tissue plasminogen activator (TPA) is the only treatment option
available. On arrival the patient was given 325 mg of aspirin, started on a heparin Infusion, and
nitroglycerin intravenous i nfusion, supplemented with a loading dose of clopidogrel. Th is occurred with
in 1 hour of symptoms .

 What a re the key conditions that must be stabil ized and secu red when transferri ng a critically
ill patient between facilities?
 What is involved in intrahospital (with in the same facility) transportation (I HT) of the critically
ill patient?
 What other arrangements should be performed prior to i nterhospital transfer?

Summary : This 55-year-old man presents with a STEM! of acute onset and needs transfer for a PTCA
with possible stenting, which is not available at the present facility. Transfer under acceptable
transportation guidelines to a facility, which has PTCA, should be the best choice for his medical
treatment and offers the best possible outcome.

 Key conditions needing stabilization: Stabilize the patient's vital signs, begin indicated
emergency therapy, and arrange transfer to a new facility with the same treatments and
personnel available in the ICU. Personnel experienced in transferring critically ill patients should
be incorporated into the transfer.
 IHT of the critically ill: ( 1) Transport the patient safely with documented appropriate reason for
leaving the ICU. (2) The same monitoring that the patient was receiving in the ICU must continue
during the patient's transportation and his stay outside the ICU.
 Other arrangements prior to arrival at the new facility: ( 1) Prearrange acceptance prior to
arrival at the accepting facility. (2) Activation of key personnel is important to avoid an
interruption in patient care. (3) An agreement regarding optimal transfer methods should be
 reached. The fastest and safest route of transfer is the best choice. ( 4) The transport method
chosen should have all equipment needed to enable a safe transfer.

ANALYSIS

Objectives

1. Describe how to assess the benefits and risks of transferring the critically ill patient.
2. Discuss the modalities of inter-hospital transfer the their advantages and disadvantages.
3. Describe the key requirements for transfer of the critically ill patient.
4. List the adverse effects of intra and inter-hospital transfer of ICU patients.

Considerations

Before transfer is attempted, it must be demonstrated that there is a clear benefit in the treatment
available at the receiving facility compared to the current facility. The patient in this scenario is a 55-
year-old with an ST elevation myocardial infarction, and he would be best served by a PTCA, which is
unavailable at his current hospital. After assuring stabilization and the absence of life-threatening
conditions or arrhythmias, he can be transferred with appropriate monitoring and personnel. The
accepting institution is 30 minutes away which is a reasonable distance for transport.
Communication and coordination are key to a successful transfer.

Providing appropriate care during transport to and from the ICU presents a major challenge. Critical
care transport has become a common occurrence. The centralization of therapeutic specialties and
an expanding number of diagnostic and therapeutic options outside of the ICU are major causes of
this necessity. Bringing improved diagnostic testing and medical-surgical services to the patient
reduces the adverse effects that accompany transportation outside the ICU. Infection rates are also
lower in patients who are transported less often in the ICU setting. Most instances of critical care
transport occur within the hospital itself. Nevertheless, critical care transport is a high-risk
undertaking, regardless of the setting. Adequate planning, proper equipment, and appropriate
staffing can minimize the transportation risks. Interhospital transport of the critically ill patient
presents more problems than in house transport because of the distance, different hospital settings,
and inability for prior planning. Guidelines of personnel needs such as physicians, nurses, and
paramedics have come from these experiences. Alternative advantages and disadvan tages in
transport by air or ground are also necessarily weighed. Specific treatments such as pretransfer
tracheal intubation and other advanced life support conditions may be required (Table 2-1 ).

Significant physiologic disturbances occur frequently in patients during their IHT including variations
in heart rate, BP, or 02 saturation. However, physiologic variability is also common in critically ill
patients in stationary circumstances, occurring in 60% of such patients compared with 66% in
transported patients. An appropriately trained transport team can safely manage these physiologic
changes, but even so, serious adverse events do occur. Cardiac arrest rates of 1 .6% have been
noted during IHT. Reduction in the PAozfFro2 ratio occurred in patients when transported while
using a transport ventilator and severe changes (ie, >20% reduction from baseline) were common.
These changes persisted for > 24 hours in 20% of transportees. Out-of-unit transport was an
independent risk factor for ventilator-associated pneumonia (YAP) . IHT is also one of the factors
associated with unplanned extubation in the mechanically ventilated patient. Compared to matched
controls of patients not requiring transport, IHT individuals had a higher mortality rate (28.6% vs 1
1 .4%) and a longer length of stay in the ICU. The increase in mortality was not directly attributable
to complications of the transport, and reflected a higher severity of illness in patients who required
transportation. Serious adverse events did, however, occur in 6% of all transports. See Table 2-2
which follows.

Transport problems were the cause of complications. Rechecking the patient and equipment and
assurance of skilled assistance prior to transfer were important preventative measures.