Interhospital transportation

Here we go again!!!How to conduct a safe inter-hospital transfer of patients

dr. Thomas Tjahjono SpAnBack groundPict: courtesy of Mount Sinai Hospital

IHT Goal

Well organized system with appropriate equipment is crucial for safe IHTWHERE IS THE AMBULANCE..!?

Think before you start..Etxebatteria et al :

8Table 1. Risk Score for Transport Patients(adopted of Etxebarria MJ et al)MeasurementScore1. Haemodynamics Stable0 Moderately stable (requires volume < 15 ml/min in adults1 Unstable (requires volume > 15 ml/min in adults)22. Arrhythmias No0 Yes, not serious (AMI after 48 hours)1 Serious (AMI in the first 48 hours)23. ECG Monitoring No0 Yes (desirable)1MeasurementScore4. Intravenous line No0 Yes1 Pulmonary artery catheter25. Provisional pacemaker No0 Yes (not invasive ). Always AMI in the first 48 hours1 Yes (endocavity)26. Respiration Respiratory rate between 10 and 14 breaths/min in adults0 Respiratory rate between 15-35 breaths/min in adults1 Apnoea (36 irregular breathing2MeasurementScore7. Airway No0 Yes (Guedel tube)1 Yes (intubation or tracheostomy)28. Respiratory support No0 Yes (oxygen therapy)1 Yes (mechanical ventilation)29. Assessment GCS = 150 GCS 8-141 GCS 2000 g0 Newborn between 1200 and 2000 g1 Newborn < 1200 g211. Technopharmacological support (actual or en route) None0 Group I1 Group II2Table 2. Medication for risk groups(Etxebarria MJ et al)Group IGroup IIInotropicsInotropic + vasodilatorsVasodilatorsUterine relaxantsAntiarrhythmicsInfant incubatorBicarbonateGeneral anestheticsAnalgesicsAntiepilepticMASTSteroidsManitol 20 %TrombolyticsNaloxoneThoracic tubeSuctionTable 3. Management of at risk patientsPontsGroupVehicleStaff0-20Conventional ambulanceNone3-6IConventional ambulanceNurse/ParamedicOver 6IIGroup ICUDoctor + NurseDeciding the mode of transferPts physiological status

Pts ilness of injury

Accessibility by road and air

Weather or Traffic conditions

Total transfer time

PREPARING THE PATIENTChoosing the right modeLand or AirTable 4. Comparison of ground and air transportModeAdvantagesDisadvantagesGround / transportLow costRapid mobilizationLess weather dependentEasier patient monitoringLonger transport time for long distancesDependent on traffic condition Air transportShorter response time to patient and shorter transport timeCan access patients in topologically hard to reach areasSlow to mobilizeDependent on weather conditionsLanding site neededNeed for additional ground transport between landing site and hospitalLimited availability in comparison to ground transportMore expensiveGround transport

Air transportRotary

Fixed Wing

Speed and distance

Speed and distance Environmental factors

Environmental factors

HelicopterPrivate AircraftCommercial AircraftWhat Happens During the Trip..OXYGEN

OXYGENPRESSURES

PRESSUREAt sea level, barometric pressure is approximately 760 mmHg. At 8,000 feet, that pressure drops to 565 mmHg, a drop of 26%

Acceleration and gravitational forcesWhat it might be happened(Adverse Event)Cardiovascular : severe hypotension or hypertension, arrhytmia, cardiac arrest.Respiratory : hypoxia, aspiration, accidental extubation,, bronchospasm, patient ventilator dyssynchrony.Neurological: agitation, intracranial hypertensionHypothermia Technical failure : gas failure, oxygen or IV disconnection, monitoring equipment malfunctionHuman Error : drug error, patient mix upNon medical factorPatientDiseaseComplicationAgeSexScoreSurvival1CVAHypertension72F5Yes2PrematrAspiration0F4Yes3TraumaShock20M12Yes4TraumaShock19M16Yes5TraumaShock75F17No6TraumaShock35M12Yes7Head tr/Shock36F8Yes8Head tr/Coma18M12Yes9Head tr/Shock19M11Yes10TraumaShock56M7No11AMIShock65M9Yes12AMIAPO58M9No13CVAHypertension59M12Yes14CVAHypertension60M15YesSAFETYSAFETYMilitary Medical EvacuationCasualty Evacuation (CASEVAC)The difference between CASEVAC and a MEDEVAC :,MEDEVAC uses a standardized and dedicated vehicle providing en route careCASEVAC uses non standardized and non dedicated vehicles that may or may not provide en route care

CONCLUSIONInter-hospital transfer can be safe in the hands of expertsRSTP seems effective in differentiating critically ill patients prone to develop major en route complicationShock remains the most common problem encountered during transportationWell organized system with appropriate equipment is crucial for safe IHT