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Transportation of the Critically Ill: Moving
in the Right Direction
P.G. Brindley and T. O’Leary
J.-L. Vincent (ed.), Annual Update in Intensive Care and Emergency Medicine 2011
DOI 10.1007/978-3-642-18081-1, ˇ Springer Science+Business Media LLC 2011
Introduction
The goal of patient transportation is to enhance patient care by making investiga-
tions or treatments available that are not possible at the bedside or in the refer-
ring institution. Patient transport can be local, regional, national, and even inter-
national. Regardless, it requires the coordination of many teams, departments,
and institutions. This is complex and potentially dangerous. As a result, profi-
ciency should be taught not assumed. This manuscript offers a basic primer.
Transports can be divided into those within a single hospital site (intra-hospi-
tal transport) and those between different hospitals (inter-hospital transport).
Unless transport is performed safely, benefits can easily be outweighed by the
risks. In order to minimize patient risk during transport, regions should have
suitable guidelines or protocols. Fortunately, many national societies have pro-
duced guidelines [1–3]; unfortunately, these are not well known, widely taught,
or well practised.
In the same way that athletic relay races are often won or lost during handover
of a baton, patients are probably at their most perilous during handover from one
team to the next, or from one location to another. For over 30 years, the putative
risks of transporting critically ill patients have been assumed, but insufficiently
studied [4, 5]. It is widely assumed that critically ill patients are safer when static
in the intensive care unit (ICU). Patients presumably benefit from the ICU’s ready
access to cutting-edge equipment, close monitoring, and a high-ratio of well-
trained multidisciplinary staff. Critical care staff should make every effort to rep-
licate these ‘safety-nets’ during transport.
Risks during transportation are compounded for critically ill patients with
insufficient ‘physiological reserve’. This is because patients may be additionally
stressed when they are moved (even just between stretchers). They may also be
disconnected from monitors (meaning that vital signs are temporarily unknown),
and temporarily removed from positive pressure ventilation or placed on an infe-
rior transport ventilator (with the risk of lung-derecruitment or relative hypoven-
tilation). All these factors can result in increased morbidity and mortality for
transfer patients [6, 7]. It also means that a medical transport is more than just
a ‘medical taxi’. Safe transport means optimizing the patient beforehand and also
optimizing the team en route. As the saying goes, ‘failure to prepare’ is akin to
‘preparing to fail’.
Transfer of critically ill patients uses time and resources. In one British survey,
the average time from decision to arrival at the receiving hospital was approxi-
mately five hours, with an additional two hours for staff to return. Moreover,
741
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almost half (46 %) of these transfers occurred at night, or on weekends, when
hospitals are relatively short-staffed [8]. Therefore, we should not forget the
potential risk to patients who remain behind, especially in smaller centers. We
should also not ignore risks to the transport team, especially during inclement
weather. As such, part of safe patient-transfer is a judgment as to whether this is
the ‘right patient’, at the ‘right time’, and to the ‘right location’. This includes
deciding whether to get the patient to treatment, i.e., ‘scoop and run’ or whether
to get the treatment to the patient, i.e., ‘in situ resuscitation’. The demands of
medical transportation require that we make a “science of human performance”
and a “science of managing complexity” [9]. The goal is to make a “failure to res-
cue” unlikely, but also unacceptable. This starts by understanding the inherent
risks.
Risks
Risks can be subdivided into four major categories: Patient-related, equipment-
related; personnel-related (human factors); and process-related (organizational).
Many studies have confirmed adverse events associated with both inter-hospital
and intra-hospital transport of the critically ill patient [10–15]. Singh et al. [10]
studied urgent air transportation within Ontario, Canada. Over 19,000 patients
were transported over a two-and-a-half year period. These authors found that
approximately 5 % of urgent air transports involved a critical incident, 0.1 %
died, and the majority of adverse events involved cardiorespiratory deterioration.
They recognized many independent risk factors for adverse events including
mechanical ventilation, duration of transport, type of crew, and curiously female
compared to male sex. An Australian analysis [16] of adverse events studied 191
submitted incident reports that arose over seven years of transports. Fifteen per-
cent of patients showed major physiological derangement, 4 % had increased hos-
pital stay, and 2 % died. This study also attempted to determine causation. Of 900
potential contributors, they concluded that 54 % of preventable errors were asso-
ciated with human factors, and 46 % associated with process or organizational
factors.
More data exist for intra-hospital than for inter-hospital transport. In fact, in
a 2006 review, Fan et al. [17] found only five studies of inter-hospital transport.
They reported that ventilation problems occurred in 5–28 % of transports, intra-
venous line disconnections in 8–34 %, and monitor disconnections in 15–74 %.
If only serious adverse events were included (defined as ‘life threatening’ or where
changes in vital signs necessitated treatment), then the rate dropped to 4–8 %.
Predictably, the authors also found that the more equipment, the higher the risk
of equipment-related adverse events. Similarly, for intra-hospital transfer, Szem et
al. [18] found significantly higher all cause mortality when stationary patients
were compared with transported patients (28.6 % vs 11.4 %).
It is difficult to compare studies given the many confounding variables, and
the dearth of common definitions. This might also explain the wide variation in
the incidence of adverse events. In addition, without knowing the denominator
(i.e., the total number of transports rather than the total number of critical inci-
dences) it is tough to estimate the independent risk associated with each adverse
event. Error mitigation is also more complex than simply identifying one causa-
tive factor to fix...or one individual to blame. Transport errors are typically the
742 P.G. Brindley and T. O’Leary
XVII
sum of several smaller – seemingly trivial – factors. Each of these errors, mis-
takes, or oversights rarely results in disaster on its own. Adverse outcomes with
patient-transfer are better understood by the so-called ‘Swiss cheese model’,
where concurrent small issues line up, even if only momentarily; therefore, it is
typically the combination that results in an error [9].
While the data are imperfect, these studies do illustrate the potential perils of
both intra-hospital and inter-hospital transport. They may also suggest where to
channel our energy. For example, if the causes of error are multi-factorial then its
mitigation must be equally multipronged. We will use a construct familiar to all
critical care personnel, namely addressing the risks and strategies by organ sys-
tem: Airway, breathing, circulation and the central nervous system.
Airway
Transportation to and from the ICU involves ventilated and non-ventilated
patients. Each situation has its potential difficulties. For example, unplanned
extubation still occurs. Excessive head flexion can also force an endotracheal tube
(ETT) into the right main bronchus causing hypoxemia due to increased imbal-
ance between ventilation and perfusion. Excessive head extension can lift the tube
above the glottis, increasing the risk of unplanned extubation. Something as sim-
ple as assigning one personto be responsible for holding the tube during any
patient movement may mitigate this. Targeted sedation also helps with tube toler-
ance. In addition, during unpressurized air transport, the ETT pilot balloon
should be filled with fluid (i.e., saline), and not air. This is in order to prevent bal-
loon distension, and dislodgement, due to the lower barometric pressure associ-
ated with increased altitude. Concurrent continuous end-tidal carbon dioxide
monitoring (ETCO2) is mandatory in most transport guidelines. Loss of ETCO2
indicates that the patient may have self-extubated or the tube may have migrated
out of the airway.
For non-intubated patients, the risks center more on decision making. For
example, the sending and receiving doctor should decide in concert whether the
patient should be intubated for transfer. Transportation, especially over large dis-
tances, represents a potentially perilous journey between two centers of relative
control. As such, many accepting physicians have a very low threshold to request
intubation, even if the patient is still in control of their airway. The rationale for
pre-emptive intubation is that, once en-route, intubation is not easy in a cramped
ambulance environment or with limited equipment. Furthermore, the intubated
patient can be more readily sedated and fluid resuscitated en-route. Intubation
may also facilitate tests when the patient arrives (e.g., if the patient must lie flat
or be sedated in order to avoid respiratory motion). Mechanical ventilation may
also lend more stability until the worst of the disease has abated. Regardless, the
patient can be subsequently electively extubated by airway experts at the receiv-
ing hospital.
However, rather than automatic intubation for all patients (i.e., “intubate any-
one that can’t talk you out of it!”), physicians have to weigh factors such as the
experience of the intubator, and the associated time delay. In addition they must
be cognizant of the hypotension that often results with the change from negative
to positive pressure breathing. In addition, the sending team must now have rudi-
mentary experience with how to mechanically ventilate their patient. Inadequate
Transportation of the Critically Ill: Moving in the Right Direction 743
XVII
ventilation can exacerbate acidemia/acidosis, while overzealous ventilation can
further impair hemodynamics. If concurrent hemodynamic support is required,
then the sending team now also needs basic competence (and equipment) in
order to titrate inotropes and vasopressors. Physicians, and transport crews, in
rural areas may or may not have these tertiary care skills. If not, then the next
question becomes whether skilled staff can be mobilized to offer assistance. In
short, transportation medicine requires judgment and decision-making as much
as it requires factual knowledge and procedural dexterity. Clearly, resuscitation is
as much ‘cerebral’ as ‘procedural’.
Breathing
Hypoxemia or low oxygen saturation has been reported in up to 86 % of trans-
ports [19]. Causes are multi-factorial, and the same diagnosis and treatment prin-
ciples apply as for the static patient. However, there are specific transport consid-
erations. Firstly, transportation means using portable equipment. Despite impres-
sive advances, portable ventilators are often not able to deliver the advanced
modes of ventilation achieved by their ICU counterparts. As such, oxygenation
and ventilation may further worsen en-route. Therefore, it is incumbent to notify
the transport team of significant concerns with pre-transport oxygenation and
ventilation. It also means that the transport personnel must be vigilant during the
transport. At the receiving end, there must also be staff prepared to receive an
unstable patient.
For intra-hospital transfers from the ICU to operating room, the anesthesiolo-
gist should also receive advanced notice of any oxygenation or ventilation con-
cerns. After all, the anaesthesiolgy ventilator is designed for the routine operative
patient, not the ICU patient. It is not ideal in the setting of high oxygen require-
ments or with poorly compliant lungs. On occasion, the decision is made to keep
the patient on the ICU ventilator. This means confirming that the anesthesiologist
is comfortable with that machine or ensuring that personnel are available to
assist. Very rarely – with a patient in extremis – the decision is made to perform
the surgery in the ICU so that the patient is neither moved, nor temporarily dis-
connected. However, this requires a willing surgeon, extra equipment in the ICU,
and efforts to ensure sterility. Explicit preparation and open communication are
essential.
It is essential to insure that sufficient oxygen exists to last through the trans-
port. Helpful websites do exist (http://manuelsweb.com/O2remaining.htm), but
physicians should still know the rudiments. For example, we assume that a porta-
ble E-sized oxygen cylinder is full with a pressure of approximately 2000 pounds
per square inch (PSI) (approximately 14,000 kilo Pascals). This means it contains
(conservatively) 600 liters of oxygen. Therefore, the patient on 10 liters/minute
will have 60 minutes of oxygen. Accordingly, if 1000 PSI remains then the patient
has 30 minutes at 10 liters/minute, or 60 minutes at 5 liters/minute. It is prudent
never to use a tank with < 500 PSI (approximately 3500 kPA).
It is important to humidify gases during transport. This is in order to prevent
the drying of secretions, which can worsen gas exchange and airway patency,
especially with infrequent suctioning. This is of particular concern during air
transport due to the drier air associated with altitude and lower temperature. As
a result, a heat and moisture exchanger is recommended. At least one study has
744 P.G. Brindley and T. O’Leary
XVII
shown that intra-hospital transport of patients is an independent predictor for
developing ventilator-associated pneumonia (VAP) [20]. It is speculated that this
is due to aspiration resulting from suboptimal patient position and movement of
the ETT during transport.
The equations used to precisely determine tissue oxygen at altitude are com-
plex. Moreover, barometric pressure (Pb) fluctuates, and different patients have
different compensatory mechanisms and metabolic demands. However, again,
web-based guides do exist (http://www.altitude.org/oxygen_levels.php) and physi-
cians should know the basics. These calculations are gross simplifications, but do
facilitate decisions regarding how patients can be protected during flight (or if
elective patients are safe to be moved). For example, while the fraction of oxygen
is 0.21 regardless of altitude, Pb drops in a linear fashion with a rising altitude. If,
at sea level, we assume a Pb of 760 mmHg, then by 5,000 ft (1524 m), it drops to
approximately 639 mmHg. The partial pressure of oxygen in dry air (PO2) is now
approximately 134 (rather than 160 mmHg at sea level). However, water vapor
pressure at a normal body temperature is 47 mmHg, regardless of altitude. This
means a partial pressure of inspired oxygen (PiO2) of 87 mmHg. Expressed
another way, this means < 80 % of the oxygen available to the lungs compared to
at sea level. At 10,000 ft (3048 m), Pb drops to 534 mmHg, meaning a dry air PO2
of 112 mmHg, a PiO2 of 65 mmHg, and < 60 % of the oxygen available at sea
level. Calculations were shown for 5,000 and 10,000 feet because most planes,
whether medical or commercial, are pressurized to approximately 8,000 feet
(2438 m). In healthy individuals, this results in a small decrease in oxygen satura-
tion to approximately 90 %. However, if a patient already has a reduced terrestrial
PaO2, then the decrease with altitude will be more significant [21]. This supple-
mental oxygen should be initiated before take-off, and followed in-flight with a
saturation monitor.
Whichever mode of ventilation is used, it is again worth stressing that ETCO2
is highly recommended. ETCO2 is usually approximately 5 mmHg less thanpar-
tial pressure of arterial CO2 (PaCO2). Therefore, ETCO2 helps with targeted venti-
lation during transportation when arterial blood gas analysis is curtailed. While
second nature to many, it is worth reminding inexperienced personnel that while
a saturation monitor tracks oxygenation, only ETCO2 approximates ventilation.
Circulation
Changes in blood pressure and heart rate are seen in almost 1-in-2 patient trans-
ports [7]. Predictably, hemodynamic disturbances occur more in those trans-
ported with cardiac pathology, poor cardiac reserve, or insufficient blood volume.
The primary physiologic response to a lowered PaO2 is chemoreceptor-induced
hyperventilation, mediated by an increase in tidal volume. However, systemic
hypoxia is also compensated for by increased cardiac output, mediated primarily
through tachycardia. Therefore, it makes sense that altitude-related decreases in
PiO2 can decrease the ischemic-threshold in patients with exercise-induced
angina. Hypoxia can also stimulate atrial arrhythmias and premature ventricular
contractions [21]. Gravitational forces involved in vehicle transport (i.e., corne-
ring, stopping, rapid acceleration and deceleration) can also exacerbate hemody-
namic abnormalities either through increased sympathetic nervous system acti-
vation or vagal stimulation [4].
Transportation of the Critically Ill: Moving in the Right Direction 745
XVII
It is tougher to respond to hemodynamic changes in a cramped space or if the
patient is tightly wrapped. Visualizing the monitor is also more difficult due to
the shaking associated with either flight or road transport. It is also hard to com-
municate to other team members because of background noise. Patient tempera-
ture is also infrequently measured during transportation, despite evidence corre-
lating hypothermia and worse outcome [22, 23]. Movement also increases the
chance of intravenous access being lost, and reinsertion is more difficult. Moni-
tors and infusion pumps rely upon limited battery power. Insufficient transport
analgesia can also add to patient pain, anxiety and sympathetic stimulation.
It is essential to make sure that the patient has adequate venous access, and
inotropes and vasopressors should be pre-mixed. Fluids should also be hanging,
and blood products should have been checked. In short, a proactive plan is
required in case of deterioration. Again, ETCO2 is useful as it also offers a surro-
gate of cardiac output. For example, a large pneumothorax or a large pulmonary
embolus can increase dead-space ventilation, which subsequently decreases
ETCO2. As such the ETCO2 trend should be followed. The ultimate dead-space,
namely cardiac arrest, substantially lowers ETCO2. Recovery of ETCO2 can guide
resuscitative efforts and also prognosticate non-survival.
As outlined above, as altitude increases, Pb decreases. In accordance with
Boyle’s law, the volume of gas is inversely proportional to pressure. In an unpres-
surized plane at 30,000 ft (9144 m), gas trapped in the lung (or sinuses, or gastro-
intestinal tract) would expand to > 4 times its volume at sea level. Most air trans-
ports occur at lower altitude with cabins pressurized to 7,000–10,000 ft
(2134–3048 m). This means that small pneumothoraces, and even blebs and bul-
lae can expand from 30–40 %. Gas expansion can compress remaining lung and
cause circulatory collapse (i.e., tension-pneumothorax). Therefore, the threshold
to insert thoracostomy tubes prior to air transport must be low. Clinical suspicion
en-route following any deterioration must also remain high. Chest tubes should
never be clamped, and emergent needle decompression must be followed by tube
thoracostomy [21].
Central Nervous System
In a study of 100 intra-hospital transports of brain-injured patients, 54 showed a
> 5 % decrease in brain tissue partial pressure of oxygen, and longer episodes of
brain tissue hypoxemia post-transport versus pre-transport [24]. Moreover, con-
tinuous intracranial pressure (ICP) monitoring is rarely available during transfer.
This is all the more reason why pupillary reaction and, once again, ETCO2 moni-
toring, should be followed. The team can also simply assume that the ICP is
mildly elevated (i.e., 20 mmHg) and, therefore, aim for a mean arterial pressure
(MAP) of approximately 85 mmHg. Because cerebral perfusion pressure (CPP) is
MAP – ICP this approach targets a CPP of 65 mmHg. This is of course providing
there is no contraindication to slightly elevated blood pressure such as penetrat-
ing trauma or an unsecured aneurysm.
The gravitational forces associated with transit may also worsen ICP. There-
fore, in less time-critical transports it may be better to have slower transport with
less directional forces than fast transport with high-speed cornering. External
ventricular drains must be closed during any patient movement and then re-lev-
eled with the tragus of the ear. If ICP cannot be monitored then, once the patient
746 P.G. Brindley and T. O’Leary
XVII
is stationary, the external ventricular drain drip chamber can be placed 10 cm
above the tragus, and in the open position. This permits cerebrospinal fluid (CSF)
egress. If monitoring is available, then the external ventricular drain can be inter-
mittently opened and closed (just as it would be in the ICU). This allows CSF
drainage and ICP measurement, respectively.
Immobilization of the neck with a semi-rigid collar does not assure complete
stabilization of the cervical-spine during transport. As a result, a long spine board
is recommended along with a semi-firm collar, tapes, neck bolsters, and body
straps. A transport stretcher, let alone a spine board, is harder than a standard
bed. Both can cause discomfort and nerve damage. They can also cause pressure
sores, especially after several hours. Therefore, it is important to periodically
reassess the need for a spine board.
Transport Options
Definitive evidence regarding the most appropriate form of patient transport is
lacking. [25, 26]. This may because generalizations are difficult, and the best
transport is probably that which works for a particular patient, from a particular
location, and at a particular time (Table 1). Regardless, Gray et al. [27] summa-
Table 1. Summary of the pros and cons concerning options for inter-hospital transport (United King-
dom units)
Ground Rotary-wing Fixed-wing
Distance < 50 miles Up to 250 miles Almost unlimited
Speed Up to 60 mph 100–200 mph > 100 mph depending on air-
craft
Interior Limited space, least
noisy
Cramped space, noisy Space depends on aircraft
(small single engine up to
commercial jet)
Number of
patients
1 1–2 Multiple
Staff training Less specialized trans-
port training
Specialist air crew training Specialist air crew training
Cost Least expensive to pur-
chase, maintain and
operate (�£ 150–200
per transport)
Most expensive to pur-
chase, maintain and oper-
ate (£ 10,000–£ 20,000
per flight)
Most civilian transports are
cheaper than rotary wing to
maintain and operate
Limited by Road access, traffic
conditions
Weather conditions, spe-
cific landing requirements,
noise can impair commu-
nication
Some weather conditions,
need for a defined landing
area, noise can impair com-
munication
Effects on
patients
Acceleration and decel-
eration forces may
cause harm
Low flying so few altitude
effects
Altitude effects may be of con-
cern in unpressurized aircraft
mph: miles per hour
Transportation of the Critically Ill: Moving in the Right Direction 747
XVII
rized factors that influence the choice of transport; these were the apparent
urgency, transport availability, geographical factors, traffic conditions, weather
conditions, and cost.
Ground transportation is less expensive, offers door-to-door service, and there
may be less delay in help arriving at the sending hospital. However, overall travel
time may be increased due to traffic congestion. In remote areas or during
inclement weather, road access can be limited. Staff (and awake patients)may
also get travel-sickness. As mentioned above, there can also be adverse physiolog-
ical ramifications from the gravitational forces associated with rapid road travel.
As such, in non-time-critical transports, a slower smoother journey may be pref-
erable to arriving at definite care sooner.
Air ambulances, either rotary- or fixed-wing, are employed over longer dis-
tances. However, they are more costly due to the expense of hardware, landing
sites, and pilots. Personnel also require extra training because inexperience can
compromise safety. As a result, many air transportation organizations employ
specialist transport-teams. The advantage of fast air transport may be lost
because of unavailable aircraft and longer mobilization time, and the distance of
landing sites from institutions. Physicians should, therefore, know about local
factors that affect the choice of rotary-wing versus fixed-wing aircraft. There are
considerable variations depending upon the jurisdiction, but generally rotary-
wing aircraft are considered for approximately 50–250 miles (80–400 km), and
fixed wing aircraft for distances > 200 miles (> 300 km). For shorter distances,
the speed advantage of air travel can be lost by the need for ground transporta-
tion at each end [25, 26].
Transport Education
Evidence suggests that transports performed by trained personnel reduce adverse
events and improve patient outcome [28]. In contrast, in some jurisdictions,
unsupervised and undertrained junior personnel perform transports [29, 30].
There may be a specious assumption that if individuals manage patients in a hos-
pital then these skills will freely transfer elsewhere. However, transport is a spe-
cialized competency not well addressed by traditional curricula [9, 31].
Regular training – along with regular evaluation of transport equipment, rou-
tine audits, and efforts to learn from critical incidences – should be integral to a
medical transport program. Chief amongst the required competencies are team-
work, communication, and medical decision-making. These skills are collectively
known as crisis resource management (CRM). Curricula and validated evalua-
tion-tools already exist. These competencies can be taught and assessed, and
readers are encouraged to go beyond this manuscript [31–33]. Of note, CRM was
co-opted from the civilian transport industry, and is therefore ideally suited to
medical transportation [9].
Improving Teamwork and Communication
The impetus to improve teamwork outside of medicine coincided with the obser-
vation that the modern jet “is too much airplane for one man to fly” [31]. Simi-
larly, the complexity of transport medicine means that it must be a viewed as a
748 P.G. Brindley and T. O’Leary
XVII
team pursuit. Teams are more than just superiors and subordinates giving and
receiving orders. One difference is that true teams possess a shared understand-
ing of the situation, the task, and the available resources. This is also called a
“shared mental model” [31, 33]. If time permits, the leader is responsible for
sharing mental models. In time-critical situations leaders need to communicate a
model that the team can share. In short, leaders ensure everyone is “on the same
page”. Otherwise the cognitive resources of the entire team cannot be fully lever-
aged [33].
The word ‘communication’ means to “share, join, unite, or make understanding
common” [31]. Therefore, teamwork equates with good communication. Commu-
nication enables the team not only to establish a shared mental model, but also to
coordinate tasks, to control the flow of information, to establish a structure for
task-completion, and even to stabilize emotions [33]. As a result, safe critical care
transportation really cannot be achieved without good communication skills.
Research shows that during crises, physicians commonly fail to communicate
what they are doing, or why. For nurses, there are often lengthy delays between
when a problem is first identified, and when this is shared [31]. Many practical
strategies exist to close the ‘communication gap’. These include SBAR (Situation-
Background-Assessment-Recommendation), the read-back/hear-back technique,
graded-assertiveness, and five-step advocacy [31]. Regardless of the strategy,
acute care communication should include:
1. Who you are, and who you are communicating with
2. Relevant clinical details
3. How the problem is being currently addressed
4. What you require.
5. Confirmation that the request was understood
6. And confirmation that the action was completed.
The unique “verbal dexterity” [31] required during transportation should also be
addressed. For example, non-transport medical communication often occurs
face-to-face. This means that it includes non-verbal communication (e.g., facial
expression, hand gestures) and is facilitated by visual clues (e.g., the appearance
of the patient). In contrast, transport communication usually forces ‘blind’ com-
munication, i.e., telephone and written communication; it also frequently occurs
between relative strangers from unfamiliar locations. Therefore, the specific
choice of words (i.e., verbal communication) and the tone, pitch and timing of
speech (i.e., paraverbal communication) become even more important. Compe-
tence in transport communication should therefore be taught and practiced,
rather than assumed. [31]
The loss of cues means it is beneficial to provide a predictable structure (or
checklist) for communication. That way, both sender and receiver know what to
expect and should be more likely to identify omissions. The ‘sender’ must learn
to be unambiguous and concise. The ‘receiver’ must learn to demonstrate that the
information is understood, or demand clarification. It is worth remembering the
adage: “meant is not said; said is not heard; heard is not understood and under-
stood is not done” [31]. Communication can breakdown anywhere along this
chain, but, again, numerous strategies exist. While it is not possible to go into
detail in this manuscript, readers are encouraged to explore further [31].
The stress of transportation can impair decision-making, such that some
‘freeze’ with indecision and others make rash choices. Using a decision-making
Transportation of the Critically Ill: Moving in the Right Direction 749
XVII
guideline can increase consistency [34, 35]. This creates a goal-directed struc-
ture that is useful both to control stress and to provide familiarity for team
members unfamiliar with each other’s style. It is also intended to improve effi-
ciency as routine decisions can be made automatically (e.g., have we confirmed
that suction is available). Using a decision-making guideline also reduces cogni-
tive overload by freeing the brain to focus on more complex decisions (e.g.,
what advanced interventions will this patient require upon arrival). In short, all
of these strategies are intended to make the patient safer by making the trans-
port team work better.
Conclusion
Transportation of critically ill patients is time-consuming, resource-dependent,
and potentially dangerous. It is an integral part of modern critical care medicine,
and therefore needs to be ‘done right’. Many national critical care programs
require experience and proficiency in transportation medicine, but training is
often ad-hoc. Furthermore, knowledge of, and adherence to, guidelines is insuffi-
cient. For these reasons, transportation is a substantial patient-safety concern. It
is also a significant educational opportunity.
The goal of a transport curriculum is to encourage structured assessment and
preparation based upon the specifics of the patient, the location, and the
resources (Table 2). Education should also focus upon teamwork, communication,
and decision-making, or what has been called ‘Crisis Resource Management’. In
Table 2. Example of a standardized transport training algorithm
A Assessment Consideration of patient’s condition and needs
Rationale for transport
Capabilities of transport team
Who is involvedC Control Identify a team leader
Identify tasks
Allocate tasks
C Communication With own team
With receiving center (department)
With patient/relatives
With ambulance control
E Evaluation Risk: benefit of transport
Patient reassessment
Urgency of transport
Appropriate mode of transport
P Preparation and packaging Prepare patient
Prepare equipment
Prepare personnel
T Transportation Transport the patient
Based upon the ”Mid Trent Critical Care Network Transfer Training Course” used with the permission of
Dr A. Norton, Lead for Transfer Training
750 P.G. Brindley and T. O’Leary
XVII
these ways, critical care medicine can show that its commitment to safe patient
care goes beyond the walls of the ICU.
Acknowledgements: Thank you to Dr Pierre Cardinal for his review and sugges-
tions.
References
1. Intensive Care Society (2002) Guidelines for the transport of the critically ill adult. Avail-
able at: http://www.ics.ac.uk/intensive_care_professional/standards_and_guidelines/trans-
port_of_the_critically_ill_2002 Accessed Nov 24, 2010
2. Warren J, Fromm RE Jr, Orr RA, Rotello LC, Horst HM (2004) Guidelines for the inter-
and intrahospital transport of critically ill patients. Crit Care Med 32: 256–262
3. Australian and New Zealand College of Anaesthetists (2003) Minimum standards for
transport of critically ill patients. Emerg Med (Fremantle) 15: 202–204
4. Waddell G, Scott PD, Lees NW, Ledingham IM (1975) Effects of ambulance transport in
critically ill patients. Br Med J 1: 386–389
5. Waddell G (1975) Movement of critically ill patients within hospital. Br Med J 2: 417–419
6. Voigt LP, Pastores SM, Raoof ND, Thaler HT, Halpern NA (2009) Review of a large clinical
series: intrahospital transport of critically ill patients: outcomes, timing, and patterns. J
Intensive Care Med 24: 108–115
7. Waydhas C (1999) Intrahospital transport of critically ill patients. Crit Care 3: R83–89
8. NHS Modernisation Agency (2004) The Neurosurgical Care Report. Available at:
http://www.sehd.scot.nhs.uk/nationalframework/Documents/neuro/key%20docs/DOH-
NeuroscienceCriticialCareReport.pdf Accessed Nov 24, 2010
9. Brindley PG (2010) Patient safety and acute care medicine: Lessons for the future, insights
from the past. Crit Care 14: 217–222
10. Singh JM, MacDonald RD, Bronskill SE, Schull MJ (2009) Incidence and predictors of crit-
ical events during urgent air-medical transport. Can Med Assoc J 181: 579–584
11. Seymour CW, Kahn JM, Schwab CW, Fuchs BD (2008) Adverse events during rotary-wing
transport of mechanically ventilated patients: a retrospective cohort study. Crit Care 12:
R71
12. Doring BL, Kerr ME, Lovasik DA, Thayer T (1999) Factors that contribute to complica-
tions during intrahospital transport of the critically ill. J Neurosci Nurs 31: 80–86
13. Dryden CM, Morton NS (1995) A survey of interhospital transport of the critically ill
child in the United Kingdom. Paediatr Anaesth 5: 157–160
14. Barry PW, Ralston C (1994) Adverse events occurring during interhospital transfer of the
critically ill. Arch Dis Child 71: 8–11
15. Kanter RK, Boeing NM, Hannan WP, Kanter DL (1992) Excess morbidity associated with
interhospital transport. Pediatrics 90: 893–898
16. Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P (2004) Incidents relating
to the intra-hospital transfer of critically ill patients. An analysis of the reports submitted
to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Med 30:
1579–1585
17. Fan E, MacDonald RD, Adhikari NK, et al (2006) Outcomes of interfacility critical care
adult patient transport: a systematic review. Crit Care 10: R6
18. Szem JW, Hydo LJ, Fischer E, Kapur S, Klemperer J, Barie PS (1995) High-risk intrahospi-
tal transport of critically ill patients: safety and outcome of the necessary ”road trip”. Crit
Care Med 23: 1660–1666
19. Waydhas C, Schneck G, Duswald KH (1995) Deterioration of respiratory function after
intra-hospital transport of critically ill surgical patients. Intensive Care Med 21: 784–789
20. Bercault N, Wolf M, Runge I, Fleury JC, Boulain T (2005) Intrahospital transport of criti-
cally ill ventilated patients: a risk factor for ventilator-associated pneumonia-a matched
cohort study. Crit Care Med 33: 2471–2478
21. Essebag V, Halabi AR, Churchill-Smith M, Lutchmedial S (2003) Air medical transport of
cardiac patients. Chest 124: 1937–1945
Transportation of the Critically Ill: Moving in the Right Direction 751
XVII
22. Wang HE, Callaway CW, Peitzman AB, Tisherman SA (2005) Admission hypothermia and
outcome after major trauma, Crit Care Med 33: 1296–1301
23. Lenhardt R, Marker E, Goll V, et al (1997) Mild intraoperative hypothermia prolongs post-
anesthetic recovery, Anesthesiology 87: 1318–1323
24. Swanson EW, Mascitelli J, Stiefel M, et al (2010) Patient transport and brain oxygen in
comatose patients. Neurosurgery 66: 925–931
25. Svenson JE, O’Connor JE, Lindsay MB (2006) Is air transport faster? A comparison of air
versus ground transport times for interfacility transfers in a regional referral system Air
Med J 25: 170–172
26. Diaz MA, Hendey GW, Bivins HG (2005) When is the helicopter faster? A comparison of
helicopter and ground ambulance transport times. J Trauma 58: 148–153
27. Gray A, Bush S, Whiteley S (2004) Secondary transport of the critically ill and injured
adult. Emerg Med J 21: 281–285
28. Bellingan G, Olivier T, Batson S, Webb A (2000) Comparison of a specialist retrieval team
with current United Kingdom practice for the transport of critically ill patients, Intensive
Care Med 26: 740–744
29. Hallas P, Folkestad L, Brabrand M (2009) Level of training and experience in physicians
performing interhospital transfers of adult patients in the internal medicine department.
Emerg Med J 26: 743–744
30. Cook C, Allan C (2008) Are trainees equipped to transfer critically ill patients? Journal of
the Intensive Care Society 9: 145–147
31. Brindley PG, Reynolds SF (2010) Improving verbal communication in critical care medi-
cine. J Crit Care (in press)
32. Gaba DM, Fish KJ, Howard SK (1994) Crisis Management in Anesthesiology. Churchill
Livingstone, New York
33. St Pierre M, Hofinger G, Buerschaper C (2008) Crisis Management in Acute Care Settings:
Human Factors and Team Psychology in a High Stakes Environment. Springer, New York
34. van Lieshout EJ, de Vos R, Binnekade JM, de Haan R, Schultz MJ, Vroom MB (2008) Deci-
sion making in interhospital transport of critically ill patients: national questionnaire sur-
vey among critical care physicians. Intensive Care Med 34: 1269–1273
35. Esmail R, Banack D, Cummings C, et al (2006) Is your patient ready for transport? Devel-
oping an ICU patient transport decision scorecard. Healthc Q 9: 80–86
752 P.G. Brindley and T. O’Leary
XVII
	Transportation of the Critically Ill: Moving in the Right Direction
	Introduction
	Risks
	Airway
	Breathing
	Circulation
	Central Nervous System
	Transport Options
	Transport Education
	Improving Teamwork and Communication
	Conclusion
	References