Transporting critically Ill patients: Look before you leap!

Patient transport is an integral part of the management of critically ill patients. Transport of the critically ill patients may be within the hospital (intra-hospital) or to another hospital (inter-hospital). A wide variety of adverse events have been associated with the transport of critically ill patients, ranging from equipment failure, device removal to haemodynamic instability and death.[123]

A crucial first step is to determine whether transport is essential. Several diagnostic procedures (endoscopy, echocardiography, ultrasonography, etc) and therapeutic procedures (tracheostomy, feeding jejunostomy, etc.) can be performed at the bedside, thus avoiding the need for transport. However, an increasing array of investigations or treatment modalities such as computed tomography, digital subtraction angiography and magnetic resonance imaging (MRI) cannot be performed at the bedside. Despite the inherent risks, transport may be inevitable if the benefits exceed the risks involved. Hence, all personnel dealing with critically ill patients must acquire the technical as well as organisational skills to ensure the safe transport of a critically ill patient. The article by Kulshreshtha and Singh[4] in this issue of the journal provides an overview of the issues and solutions related to the transport of the critically ill patients.

The principal aims during the transport of a critically ill patient are to ensure patient safety and to provide the same intensity and quality of care en route, as that being provided in the Intensive Care Unit (ICU). It also involves providing the same intensity of care at a remote location that may not be designed to care for such patients, in a potentially unfavourable and resource-restricted environment (e.g., MRI suite). Fulfilling this aim requires adequately trained staff, pre-transport assessment and stabilisation of patients, planning and organisation. The procedure of transport has been divided into the pre-transport, transport and post-transport phases. Patients can be optimally prepared for transport by assessing and addressing the vulnerable issues in every phase.[5] Various guidelines[67] and checklists[58] have been formulated to enhance safe transport of patients. Incorporating transport checklists has been reported to decrease transport-related adverse events.[9]

In this issue of the journal, Dwivedi et al.[10] report an incident of a faulty setup of an oxygen cylinder during the pre-transfer phase. Serious complications were averted when the problem was detected during a pre-transport check. This highlights the need to have checklists that contain systematic checkpoints during all the three phases. Importantly, the authors analysed the reasons for the incorrect assembly and instituted a mechanism to eliminate such a problem. Thus, a safe system not only includes checklists, but also includes audit of performance, root-cause analysis of critical incidents, education and feedback. Barriers to the use of checklists include inadequate knowledge, emergency transport and lengthy, non-user-friendly checklists. While checklists can be found in literature, it is important to adapt checklists to individual institutions, as procedures, staffing and facilities may vary from one institution to another. ICU staff frequently transport and manage patients in the radiology department. Checklists should facilitate adherence to radiation safety precautions to ensure that ICU doctors are not exposed to hazardous radiation.[11]

Finally, as medical technology changes, checklists and protocols must be updated to keep pace with the new developments.