Contributors

Paul Allsop Anaesthetics, Burton-upon-Trent

Paul Baines Paediatric ICU, Liverpool

Danielle Bryden Anaesthesia, Manchester

Ruth Buckley Emergency Nursing, Stoke on Trent

John Burnside Ambulance Service, Manchester

Jim Davies ICU, Merthyr Tydfil

Peter Driscoll Emergency Medicine, Manchester

Mark Forrest ICU, Liverpool

Peter-Marc Fortune Paediatric ICU, Manchester

Sarah Gill Emergency Nursing, Kilmarnock

Tim Graham Cardiothoracic Surgery, Birmingham

Colin Green Paediatrics, Folkestone

Carl Gwinnutt Anaesthesia, Manchester

Ann Hanson ICBIS, Manchester

Pauline Holt Paediatric ICU Nursing, Liverpool

Jonathan Hyde Cardiothoracic Surgery, West Midlands

Peter Johnson ICU, Truro

Ian Macartney ICU, Manchester

Kevin Mackway-Jones Emergency Medicine, Manchester

Elaine Metcalfe ALSG, Manchester

Giles Morgan ICU, Portsmouth

Peter Oakley Anaesthesia/Trauma, Stoke on Trent

Claire O’Connor Formerly ICBIS Study, Manchester

Vincent O’Keeffe ICU, Glan Clwyd

Kate Olney ICBIS Study, Manchester

Gillian Park Emergency Medicine, Harrow

Shirley Remington ICU, Manchester

Stephen Shaw ICU, Liverpool

Gail Thomson Infectious Diseases, Manchester

Terence Wardle Medicine, Chester

Sarah Wheatly Anaesthesia, Manchester

Susan Wieteska ALSG, Manchester

Steve Wimbush ICU, Bristol

Preface to the second edition

When we first published this book in 2002 our aim was to bring a structured approach and simple guidelines to the management of transfers. The development of the Safe Transfer and Retrieval: The Practical Approach (STaR) course has gone some way to achieving this and our sincere hope is that the concept of ACCEPT, and its application to all forms of patient transfer, will become as well accepted as the ABCDE approach to resuscitation.

The second edition of this book has been substantially reworked, and is now divided into six parts. Part I introduces the subject by discussing the principles of the STaR structured approachto transfers. Part II deals with the management of the transfer, or retrieval, according to these principles. Part III describes some practical procedures relevant to transfer medicine, while Part IVprovides an overview of the clinical care required during the assessment and stabilisation phases of the transfer. Situations requiring specific changes in the core approach are also discussed here. Part V considers the legal and safety aspects of transfers, as well as the specific differences in helicopter transfers and transfers involving children.

Major changes can be seen in the section on clinical care, which has been rewritten and expanded, to remind those who are already experienced practitioners about some of the physiology behind the primary survey and some common conditions which may be encountered. It is hoped that this section will be a useful learning tool for those who are less experienced in these conditions and may also provide a useful reference source for all, when dealing with specific transfers. This section will not be tested on the course, and candidates should not be overwhelmed by the detail available here. The pages of essential reading for the course are differentiated by shading on their outside edge.

The STaR course is about teaching a structure, not medicine. During the course it is not possible to undertake a detailed assessment of the clinical knowledge of each of the participants. The course, therefore, has to assume that the participants have some clinical knowledge and experience appropriate to their position.

The 2006 edition of Safe Transfer and Retrieval: The Practical Approach has tried to take into account a wider audience including those involved in the intra-hospital transfer of patients who are less demanding than the classic level 3 intensive care patients. To fully understand this concept, readers should be aware of the new classifications of Levels of Care initiated by the Intensive Care Society and adopted by the Department of Health (DH). A summary of these can be seen in Appendix A (Levels of clinical care for hospitalised adults). Work is underway to develop courses aimed at those who deal with ‘ward level’ patients levels 0 to 2. This book and the associated course hope to be as relevant to those staff as the first edition was to those involved in level 3 transfers.

It is now accepted that the early recognition of potential and actual deterioration in a ward patient's condition is essential. This should be accompanied by an appropriate response for early intervention, which may include the possibility of transfer to a level 2 or 3 unit. Early Warning Scoring systems (EWS) have been introduced to improve the identification of physical deterioration. These tools are based upon the allocation of ‘points’ to physiological observations, the calculation of a total ‘score’ and the designation of an agreed calling ‘trigger’ level. A detailed description of the several variations of Early Warning Scoring systems is beyond the scope of this book.

Due to the heightened awareness of the risks of the transmission of infection, both to staff and to other patients, a new chapter “The infectious or contaminated patient” has been added. This is supported by additional advice on personal protective equipment in Chapter 15. In order to keep up to date with the latest guidance we would suggest that you also reference the WHO and HPA Web sites.

In this edition we have acknowledged the move towards Competences. In Ap-pendixIyou willfind some competences developedby ALSG which willbe mapped to the Skills for Health competences. More details of this can be found on the ALSG Web site.

Safe Transfer and Retrieval: The Practical Approach is aimed at those involved in adult medicine. However, the management structure and much of the physiology are applicable to paediatrics, Chapter 13 gives an introduction to the complexities of paediatric transfer medicine. A sister group of clinicians has developed the Paediatric & Neonatal Safe Transfer and Retrieval (PNeoSTaR) course and accompanying book aimed at those who need to know more about paediatric and neonatal transfers.

A major presentational change is the adoption of a loose-leaf format; this is to ensure that the reader is able to update this book with any evidence-based changes to practice. When this occurs new pages will be available to download from the ALSG Web site and inserted in the current text.

As transfer medicine continues to develop, we have developed a ‘Transfer Scenario Bank’, which is available for your information on the ALSG Website.

The official non-proprietary names of some medicines changed during 2005 and international non-proprietary names are usedin this text. Readers should note that as adrenaline and noradrenaline are the terms established in the European Pharmacopoeia, these continue to be the recommended names within the European states and are therefore used in this text. The international name will appear in parentheses.

Since its inception, a large number of experts have contributed to the development of STaR and we extend our thanks both to them and to our instructors who always provide helpful feedback.

Ian Macartney
Elaine Metcalfe
Peter Driscoll
Kevin Mackway-Jones
Manchester 2006

Chapter 1
Introduction

This book and its associated course are aimed at a multi-disciplinary audience and have been developed in an attempt to overcome the difficulties faced by all healthcare professionals when organising and carrying out the transfer of patients who may be critically ill or injured. There are essentially two components:

Organisational and management strategy
Practical problems that may be encountered during preparation, packaging and transportation of patients

Although the Safe Transfer and Retrieval (STaR) course focuses on transportation of patients between hospitals, the same approach should be applied to the transportation of any ill patients within hospitals.

In recent years, following concerns about the standard of head injury transfers, there has been a great deal of interest in improving the standards for the care of the critically ill who are transferred between hospitals.

In 1996, a multi-professional group from across the UK first met to devise a training system aimed at promoting a structured approach to the transfer of the critically ill. The vision was, and still is, that, in the same way that everybody now accepts the systematic ABCDE approach to resuscitation, healthcare professionals would adopt ACCEPT as the basis for a structured approach to transfer medicine.

In 1997 the Intensive Care Society (ICS) published its Guidelines for the Transport of the Critically Ill Adult; these were revised in 2002.

Safe Transfer and Retrieval: The Practical Approach was first published in 2002 as the core text for the STaR course.

The number of inter-hospital transfers continues to rise. This increasing demand for intensive care beds is fuelled by patients’ and relatives’ expectations and improved resuscitation and surgical techniques.

In most cases, an Intensive Care transfer results from the lack of a functioning ICU bed in the primary hospital. This could be due to lack of either an available bed or the nursing staff to look after the patient. The second most common cause is the requirement for specialist management in a tertiary centre. Box 1.1 demonstrates the wide spectrum of clinical pathologies which may be encountered.

The source of these patients also varies widely (Box 1.2). Emergency Departments and ICUs are the most frequent starting places for the movementof intensive care patients.

Though it is to be expected that patients moving from ICU will be fully stabilised and packaged, the same assumption cannot be made when patients are moved from other departments. These patients, and those coming from wards and theatres, may require considerable time before they are adequately prepared and packaged for transfer.

Inter-hospital transfers are not infrequently associated with adverse events which may be recorded on transfer forms or spotted by independent auditors. Those reported most commonly are shown in Box 1.3.

Although the ICS guidelines and the STaR course were initially aimed at improving the care delivered to critically ill patients, it seems that there are an increasingly large number of ‘high dependency’ patients whose transfers are less than ideal. It therefore seems logical to extend the concepts of Safe Transfer and Retrieval to encompass a wider spectrum of patients.

Furthermore, recent published work has highlighted that transfers within hospitals (intra-hospital transfer) are a cause for concern. Although this Australian study looked at reported incidents around the intra-hospital transfer of critically ill patients, there are lessons to be learned by all who transfer less seriously ill patients within hospitals. Of the reported incidents, 39% identified equipment problems, relating predominantly to battery/power supply, transport ventilator or monitor function. Also in this group, access to lifts was a significant problem. More than half (61%) of the reported incidents related to staff issues in which communication and liaison problems were highlighted.

The 2006 edition of Safe Transfer and Retrieval: The Practical Approach, the core text for the STaR course, has been redesigned in order to make the concept of a structured approach to transfers more widely available to healthcare professionals of all disciplines throughout hospitals.

The move towards competency-based medical education and the development of clinical levels of care for adults has enabled the authors to attempt to match the degree of illness with the competencies which will be required in order to successfully undertake transportation (Appendix A).

The “levels of critical care for adults’” allocates levels of care according to a patients’ clinical needs alone and ranges from level 0, which is general ward care in an acute hospital, through to level 3, which encompasses what was traditionally known as Intensive Care. Although not specifically designed for the purpose of informing the clinical needs of transfer medicine, these guidelines may be broadly appropriate for such work.

Furthermore, these levels of care can broadly be mapped across to the STaR Transfer Category Table (Chapter 5) which describes a structure for allocating vehicle and staffing resources based on clinical need, or levels of care, for ambulance transportation.

Level of care	Triage category
Level 3	Time Critical
Level 3	Intensive
Level 2	Ill-unstable
Level 1	Ill-stable/Unwell
Level 0	Well

Competency-based training and education is increasingly accepted as the measure of the clinical competence of an individual. In the 1997 ICS guidelines the advice about the required skills recommended that the doctor should be ‘experienced in transfer medicine and have at least two years experience in anaesthetics and intensive care’. The recommendations for the accompanying nurse, or technician, specified ‘experience in transfers, at least 2 years in intensive care and hold the ENB 100 qualification’. By 2002, the new ICS guidelines now prescribed competencies for the accompanying medical attendant, which included resuscitation, airway care, ventilation and other organ support. This medical practitioner should have ‘demonstrated competencies in transport medicine, and be familiar with the transport equipment’. The assistant ‘should be suitably experienced nurse, paramedic or technician, familiar with intensive care procedures and with the transport equipment’.

Therefore, it seems logical that all staff who are involved in the transfer of patients should be able to demonstrate that their general clinical skills are appropriate to the level of care required by their patients. They should also be able to demonstrate that they have the specific clinical competencies required to deliver appropriate care to the patient during transportation. The necessary competencies should be assessed, either as part of continuing professional development, or specific training, and this achievement recorded.

The achievement of general clinical competence in a particular field or level of care is gained by experience and in-house training. Training in the use of appropriate medical equipment is best undertaken in-house, but is often not formally assessed and is rarely recorded. The addition of a Safe Transfer and Retrieval course, designed to encourage a structured approach to areas specific to transfer medicine, can build on these existing competencies, resulting in a team whose documented competencies are matched to the individual patients’ needs.

The book is designed to accompany transfer courses appropriate to differing levels of care and seeks to form the basis of pre-course work, before undertaking specific training appropriate to the level of expertise required.

During a 2-day transfer course it is not possible to undertake a detailed assessment of the clinical knowledge of the participants; the course is about teaching a structure and not medicine. The Safe Transfer and Retrieval course has to assume that the participants have some clinical knowledge, and experience, appropriate to their position. However, the section on clinical care (Part IV) has been rewritten and expanded in order to include some of the physiology behind the primary survey, and the common conditions which may be encountered. It is hoped that this section will be a useful learning tool for those who are less experienced in these conditions. This section may also provide a useful reference source when dealing with specific transfers.

The book is divided into six sections.

Part I – Introduction: introduces the subject by discussing the principles of the STaR approach and also introduces the concept of the use of the ACCEPT acronymtodescribeastructured approachtothe organisation and executionofany transfer.

Part II – Managing the transfer: follows the development of the detail of the component parts of ACCEPT in Chapters 3 to 7; the whole process is demonstrated in a worked example in Chapter 8.

Part III – Practical aspects of transfer medicine: describes some of the equipment which may be required during a transfer, and some practical procedures.

Part IV – Assessment and clinical aspects of transfer medicine: describes some of the physiology behind the components of the primary and secondary surveys. Selected medical and surgical conditions are covered in Chapter 12.

Part V – Special considerations: considers an introduction to paediatric and air transfers and the infectious patient. It also includes some of the legal and insurance issues of transfers and health and safety issues in keeping staff safe.

Part VI – Appendices: contains the appendices.

Safe Transfer and Retrieval: The Practical Approach (second edition 2006) has been developed as the core text for the STaR course, but it will be useful to medical and allied personnel, whether they attend the course or not. The aim is to encourage a systematic approach to the transfer or retrieval of any patient.

Chapter 2
The structured approach to transfers

INTRODUCTION

The aim of a safe transfer policy is to ensure that patient care is streamlined and of the highest standard. To achieve this, the right patient has to be taken at the right time, by the right people, to the right place by the right form of transport and receive the right care throughout. This requires a systematic approach which incorporates a high level of planning and preparation prior to the patient being moved. One such approach is the ACCEPT method (Box 2.1).

Following ACCEPT ensures that assessments and procedures are carried out in the right order. This method also correctly emphasises the preparation that is required before the patient is transported. The component parts of ACCEPT are outlined below. Subsequent chapters deal with each part in detail.

ASSESSMENT

The first thing to do is assess the situation. Sometimes the clinician involved in the transportation has also been involved in the care given up to that point. Commonly, however, the transporter will have been brought in specifically for that purpose and will have no prior knowledge of the patient's clinical history.

CONTROL

Once assessment is complete, the transport organiser needs to take control of the situation. This requires:

Identification of the clinical team leader
Identification of the tasks to be carried out
Allocation of tasks to individuals or teams

The lines of responsibility must be established urgently. In theory ultimate responsibility is held jointly by the referring consultant clinician, the receiving consultant clinician and the transfer personnel at different stages of the transfer process. There should always be a named person with overall responsibility for organising the transfer.

COMMUNICATION

Moving ill or injured patients from one place to another obviously requires cooperation and the involvement of several people. Therefore key personnel need to be informed when transportation is being considered (Box 2.2).

Communication may take a long time to complete if one person does it all. It is therefore advisable to share the tasks between appropriate people, taking into account expertise and the local policies. In all cases it is important that information is passed on clearly and unambiguously. This is particularly the case when talking to people over the telephone. It is useful to plan what to say before telephoning and to use the systematic summary shown in Box 2.3.

The second question should be repeated at the end, to help summarise the situation. The response to all these questions should be documented in the patient's notes. The person in overall charge can then assimilate this information so that a proper evaluation of the patient's requirements for transportation can be made.

EVALUATION

The dual aims of evaluation are to assess whether transfer is appropriate for the patient and, if so, what clinical urgency the patient has. While evaluation is a dynamic process which starts fromfirst contact with the patient, it is only when the first phase of ACCEPT (that is, ACC) has been completed that enough information will have been gathered.

Is transfer appropriate for this patient?

Critically ill or injured patients require transfer because of the need for:

Specialist treatment
Specialist investigations unavailable in the referring hospital
Specialist facilities unavailable in the referring hospital

The risks involved in transfer must be balanced against the risks of staying and the benefits of care that can only be given by the receiving unit.

What clinical urgency does this patient have?

Once it has been established that transfer is needed, the urgency must be evaluated. The degree of urgency for transfer and the severity of illness may be used to rank the patient's transfer needs (see Box 2.4). This hierarchy also helps determine both the personnel required and the mode of transport.

PREPARATION AND PACKAGING

Preparation and packaging both have the aim of ensuring that patient transport proceeds with the minimum change in level of care provided and with no deterioration in the patient's condition. The first stage (preparation) involves completion of patient stabilisation and preparation of transfer team personnel and equipment. The second stage (packaging) involves the final measures that need to be taken to ensure the security and safety of the patient during the transportation itself.

Patient preparation

To reduce complications during any journey, meticulous resuscitation and stabilisation should be carried out prior to transfer. This may involve carrying out procedures requested by the receiving hospital or unit. The standard airway, breathing, and circulation (ABC) approach is useful. The airway must be cleared and secured. Appropriate respiratory support must be established.

Venous access is essential and preferably should include a minimum of two large bore cannulae. The patient must have received adequate fluid resuscitation to ensure optimal tissue oxygenation. Hypovolaemic patients tolerate the inertial forces of transportation very poorly.

Equipment preparation

All equipment must be functioning and supplies of drugs and fluids should be more than adequate for the whole of the intended journey. Particular care should be taken with supplies of oxygen, inotropes, sedative drugs and batteries for portable electronic equipment. Specialist equipment may also be required for particular patients – for example, children and patients with spinal injuries. A member of the team should be allocated the task of ensuring that all the patient's documents, including case notes, investigations, reports and a transfer form, accompany the patient.

The team requires a phone and contact names and numbers to enable direct communication with both the receiving and base units. In addition, all personnel need appropriate clothing, food if the journey is long and enough money to enable them to get home if needed.

Personnel preparation

The number and nature of staff accompanying patients during transport will reflect their transfer category (Chapters 1 and 6).

Whatever the category of the patient, all personnel should be competent in the transfer procedure and familiar with the equipment which is to be used as well as the details of the patient's clinical condition. The team should carry accident insurance with adequate provision for personal injury or death sustained during the transfer.

Packaging

All lines and drains should be secured to the patient, the patient should be secured to the trolley and the trolley must be secured to the ambulance.

Chest drains should be secured and unclamped with any underwater seal device replaced by an appropriate commercial drainage valve and bag system. If the patient has a simple pneumothorax or is at risk of developing one, a chest drain needs to be inserted prophylactically.

Mummy wrapping the patient provides additional security and reduces heat loss.

TRANSPORTATION

Mode of transport

The choice of transport needs to take into account several factors (Box 2.5).

Road ambulances are by far the most common means used in the United Kingdom. They have a low overall cost, rapid mobilisation time and are less affected by weather conditions. They also give rise to less physiological disturbance.

Air transfer may be used for journeys of more than 50 miles or 2 hours in duration or if road access is difficult. The speed of the journey itself has to be balanced against organisational delays and also the need for inter-vehicle transfer at the beginning and end of the journey.

Care during transport

Physiological problems which occur during transportation may arise from the effects of the transport environment on the deranged physiology of the patient. Careful preparation can minimise the deleterious effects of inertial forces, such as tipping, acceleration and deceleration, as well as changes in temperature and barometric pressure changes.

The standard of care and the level of monitoring carried out prior to transfer need to be continued, as far as possible, during the transfer. Monitoring will include oxygen saturation, ECG and direct arterial pressure monitoring in most patients. End-tidal carbon dioxide (ET/CO₂) monitoring should be used in all intubated patients.

The patient should be well covered and kept warm during the transfer. Road speed decisions depend both on clinical urgency and the availability of limited resources such as oxygen.

With adequate preparation, the transportation phase is usually incident free. However, untoward events do occur. Should this be the case, the patient needs to be reassessed using the ABC approach (Chapters 7 and 11). Appropriate corrective measures should then be instituted. This may require a stop at the first available place of safety: the benefits of intervention should always be weighed against the risks of delaying arrival at the receiving hospital with its better facilities. Following any untoward events, communications with the receiving unit are important. This should follow the systematic summary described previously.

Handover

At the end of the transfer direct contact with the receiving team must be established, so that a succinct, systematic summary can then be provided. This needs to be accompanied by a written record of the patient's history, vital signs, therapy and significant clinical events during transfer. All the other documents which have been taken with the patient should also be handed over. Whilst this is going on, the rest of the transferring team can help in moving the patient from the ambulance trolley to the receiving unit's bed. The team can then retrieve all their equipment and personnel and make their way back to their home unit.

SUMMARY

The safe transfer and retrieval of a patient requires a systematic approach. The ACCEPT method ensures that important activities will be carried out at the appropriate time.

Chapter 3
Assessment and control

INTRODUCTION

A clinician involved in a potential transfer situation may have had no contact with that particular patient before receiving a phone call from a member of the treating clinical team. It is important to learn how to assess such a situation quickly and effectively. This must be done before patient management continues.

Proper assessment requires consideration of both the patient's condition and the actions and capabilities of the transferring team. The answers to several key questions will help this process (Box 3.1).

ASSESSING THE SITUATION

Following a careful enquiry into the history of the current illness or injury, an ABCDE approach should be adopted to identify the immediate and predictable clinical needs of the patient. The question ‘what is being done’ provides the opportunity to check that appropriate treatment, if not already being undertaken on arrival, is started, and so this question also reflects ‘what should be done’. The effect of clinical interventions should be the subject of continuous evaluation; is what is being done working? If not, what is needed to improve the resuscitation? With effective resuscitative measures the patient can be stabilised for transfer. What is then needed is a safe transfer to a ward or department for definitive care.

It is almost certain that some form of handover or communication will be required during the transfer process. Such communication will start with a summary of the problem; in some cases this may be easy to describe succinctly. Often however, patients have a complex medical history, and it is difficult to rationalise all the available data into a presentable and reproducible format. During the transfer process the ‘problem’ may have to be communicated to a number of people in a short space of time, and health service professionals are not usually tolerant of long-winded explanations. As we live in a world of ‘sound bites’, a useful technique is to learn to reduce a complicated story into a sound bite of less than 10 words; an easily repeatable description of the most relevant aspects of the case. Following this sound bite introduction, a quick ABCDE description of what has been done, and its effect, will lead on to the request for transfer to a ward or department.

CONTROLLING THE SITUATION

Following the initial assessment, someone needs to take control of the situation. This involves:

Identifying the team leader
Identifying the tasks to be carried out
Allocation of tasks to individuals or teams

Identifying the team leader

A transfer team leader will be in overall control of the transfer; that is, the person will have responsibility for ensuring that the patient's clinical care continues, whilst others deal with communications, organise resources and timings, carry out the evaluation, oversee packaging and initiate the transfer itself.

The team leader may be in charge of the clinical care of the patient. If they are not then close liaison with the clinical team leader is essential.

Task identification

Once control is established, clinical care of the patient must continue; communication with those who need to know then becomes a priority. Resources including staffing, equipment and drugs will need to be identified and brought to the patient. This can be summarised in a general task list. This list will obviously have to be expanded and developed for individual clinical situations (Box 3.2).

Task allocation

Tasks should be allocated by the transfer team leader. Competence is the key attribute and tasks should only be given to staff who have the appropriate training and expertise. The team leader will need to consider the relative priority of each task and the scope for concurrent activity.

SUMMARY

The first step for the team leader is to assess the situation and determine what else the patient requires. To carry this out the team leader needs to take control of the situation by allocating key roles to staff.

WORKING GROUP AT SECOND EDITION

WORKING GROUP AT FIRST EDITION

Acknowledgements

Contact details and website information

UPDATES

TRANSFER SCENARIO BANK

ON-LINE FEEDBACK

PART I Introduction

INTRODUCTION

ASSESSMENT

CONTROL

COMMUNICATION

EVALUATION

Is transfer appropriate for this patient?

What clinical urgency does this patient have?

PREPARATION AND PACKAGING

Patient preparation

Equipment preparation

Personnel preparation

Packaging

TRANSPORTATION

Mode of transport

Care during transport

Handover

SUMMARY

PART II Managing the transfer

INTRODUCTION

ASSESSING THE SITUATION

CONTROLLING THE SITUATION

Identifying the team leader

Task identification

Task allocation

SUMMARY

PART I
Introduction

PART II
Managing the transfer