Risk benefit analysis of transferring the critically ill - Essay Example

? Risk benefit analysis of transferring the critically ill of the Health sciences and medicine of the October 12, Risk benefit analysis of transferring critically ill patients Introduction Transfer of critically ill patients is a procedure that is many a time unavoidable and yet, is fraught with reluctance and undertaken with reservations. Understandably so, as these patients are at the most unstable even in an environment where best possible medical and technical help is available. Transportation of these patients involves exposure to settings which may be suboptimal and in addition, access to resource personnel is limited and may not be immediately available. Authors have rightly commented that such transfers are akin to expeditions for which thorough preparation is required and surprises are to be expected (Droogh et al, 2012). Before undertaking such transfers, the necessity and indication for transportation of the patient is evaluated along with the patient’s risk factors which are usually a part of the critical illness like mechanical ventilation, haemodynamic instability etc. If it is determined that the transfer will help to achieve a better outcome in terms of diagnosis, management or for any other reason, patients are transported despite their critical status with all the precautions for minimising the risk of adverse events. Herein, it is valuable to understand the risk benefit analysis for the transfer of critically ill patients so that evidence based decisions can be made in the best interests of the patient. Another arena where critically ill patients undergo transportation is from the site of inciting injury or event to the hospital. In these cases, patients are even more critical and not optimised, yet need urgent medical care and life saving interventions. Prehospital care is administered at the site of injury and en route. For these cases, transfer to a medical facility is indicated irrespective of other factors and risk is more in case timely medical aid is not provided. Indications for transport As mentioned above, transfer of critically ill may be done from the site of injury to the hospital (primary transfer), or it may be that of an already admitted or hospitalised patient (secondary transfer) (Gray, Bush & Whiteley, 2004). A hospitalised critically ill patient may undergo interhospital or intrahospital transfer. Interhospital transfer is indicated for patients who need specialised care such as trauma patients, acute coronary syndrome patients, burns patients, spine injury patients, patients with head trauma or stroke, or patients who require advanced monitoring. Regionalisation or centralisation of medical care as well as development of dedicated specialised centres has led to an increase in the number of such transfers. However, there is no consensus among medical community about the criteria for patient transfer and it is still a subjective decision (Iwashyna, 2012). Gray, Bush and Whiteley (2004) in their review very clearly listed the reasons for which transport of critically ill patients is done. Briefly, they listed reasons like absence of critical care facilities at the transferring hospital, unavailability of diagnostic facilities and normal clinical expertise, repatriation and non-clinical transfer. Intrahospital or with-in hospital transfer of critically ill patients is done between facilities such as intensive care unit (ICU), emergency department (ED), radiology and imaging suites, and operation theatres. Benefits All these transfers are done with the aim of achieving better outcome for the patient. Benefits can be categorised in the context of mortality and non mortality (Iwashyna, 2012). So far as interhospital transport is concerned, patient may benefit from specialised care in terms of infrastructure, medical specialists and trained staff and personnel. A dedicated centre is more likely to have advanced treatment, medical and surgical options for a severely ill patient. There may even be a re-evaluation of the diagnosis and management plan. Also, there may possibly be financial factors for the patient such as when reimbursement or funding is available for a particular hospital. Personal reasons or family convenience may be another reason for interfacility transfer (Blackwell, 2002). Patients may be comforted by having receiving ‘good’ and specialised care (Iwashyna, 2012). Intrahospital transport is done to transfer sick patients from ED or operation theatre to ICU or for interventions that cannot be accomplished in the ICU or critical care unit (CCU) such as MRI or CT scans, haemodialysis or operating room surgical procedures. As has been specified by College of Intensive Care Medicine of Australia and New Zealand (2010), the transport of critically ill patients must be justified and benefits of the intervention must be more than the risks posed by moving the critically ill patient. Various studies support the benefits of transfer in select patient population such as trauma patients or patients with acute coronary syndromes (Iwashyna, 2012). However, the process of identifying transfer eligible patients is still not standardised (Iwashyna, 2012). Iwashyna and Courey (2011) in their review tried to answer the questions of selecting which patients to transfer, where to transfer, how to transfer and whether transfer improves outcome in a critically ill patient. More importantly, they argued the point that if benefits are to be truly realised, referrals should be made to centres consistently showing good outcomes in objective hospital data, a strategy termed as guided transfer. In every critically ill patient, a risk benefit analysis must be individually carried out prior to transfer (Fanara et al, 2010). Iwashyna and Courey (2011) analysed whether actual benefits occur by transferring patents to specialised centres and results are still equivocal. Risks involved A number of risks are associated with these transfers. No matter how much benefit patient will receive at the new facility, inadequate care and mismanagement during transport may irreversibly compromise the patient (Johnson, 2006). As such the patient is inherently critical and taking him out of the relatively safer, stable confines of hospital can prove to be a threat to his safety. Even in the hospital itself, intrahospital transfers are associated with adverse events. First of all, it is cumbersome to move a critically ill patient due to all the paraphernalia attached to the body. More critically ill the patient is, more would be the number of monitoring and other devices attached to him or her such as endotracheal tube and breathing circuits, arterial and non invasive blood pressure monitoring, ECG leads, orogastric or nasogastric tube, central venous catheters and intravenous accesses with high pressure tubings and infusions sets, saturation probe, Foley’s catheter and urobag, drains, casts, tractions etc. With so many devices in situ, there is always a risk of inadvertent pulling out of some devices or damage to the monitoring equipment. Usually portable monitoring equipments do allow continuous assessment of the patient’s condition. However, interference with signals and recording can occur due to motion, upward or downward movement or battery failure. This can lead to missed data and loss of monitoring which can be disastrous for the patient. Inadvertent extubation or dislodgement of the endotracheal or tracheostomy tube can occur despite taking every precaution in securing the tube which can be potentially lethal in an acute respiratory distress syndrome or head injury patient who is being mechanically ventilated. Reintubation in transit is done in hurry, in a compromised patient, with limited equipment options and often by a person infrequently exposed to the procedure. This can vastly increase the morbidity of the patient by causing oral and airway injury, raising intracranial pressure, causing sympathetic stimulation or haemodynamic instability, and hypoxia and end organ damage. Failure to secure the airway can lead to death. Peripheral and central venous catheters are in the danger of being pulled out leaving no route for administration of drugs and fluids. Chest drains are similarly vulnerable. That is why, it is mandatory that transferring team should be skilled in airway management and establishment of intravenous access. Technical competence in manual handling procedures and patient transfer is a must. Apart from the risk of pulling out of devices, another big risk is that of equipment malfunction. Common errors are with oxygen cylinders and ventilator batteries. Oxygen cylinder which becomes empty on the way can land the patient, and the retrieval team, in a soup. Patient may need to be hand ventilated in case portable ventilator batteries lose charge and this can deteriorate their respiratory parameters. There would be no way to judge the adequacy of treatment interventions if monitors are not charged. Even worse would be the case scenario where defibrillators don’t work when urgent defibrillation is required, or gel is not available to apply on paddles and patient sustains burns. Some other malfunctions which can greatly endanger patient’s life are unavailability of suction catheters, endotracheal tube stylets or cylinder key, malfunctioning AMBU device, endotracheal tube cuff or laryngoscope bulb, broken flow meters, expired or ineffective drugs not kept in the refrigerator or drug injection errors. Mere presence of equipment will not ensure security of the patient. An inexperienced and untrained transfer crew is itself a health hazard for the patient. Retrieval team members who take multiple attempts in securing intravenous line or establishing an airway can greatly increase patient’s risks. Also, the crew who has not been updated or is not trained in the current recommendations for cardiopulmonary resuscitation or does not know about the nuances of mechanical ventilation is likely to do more harm than good. Transfer of the critically ill and retrieval medicine is currently the focus of many researches. Also, many authors have studied the nature of adverse events that happen during these transfers in order to have a better understanding of the underlying mechanisms. Gillman et al (2006) identified several adverse events during intrahospital transport of patients from emergency department to the intensive care unit. Grossly, these events can be classified as being related to patient factors, equipment related factors or environment factors. Equipment related problems, cardio-respiratory problems, hypothermia and incorrect patient identification label were identified as some of the adverse events during intrahospital transfers in a study (Gillman et al, 2006). Singh et al (2009) ascertained that incidence of critical events is about 1 in every 20 such aeromedical transportations. Adverse events in their study included death, respiratory arrest, unplanned extubation, haemodynamic instability and major resuscitative procedures. The authors identified multiple patient related and transport related factors which are associated with occurrence of these adverse events. Ligtenberg et al (2005) recorded 34 adverse events in 100 transfers and authors estimated that 70% of these events could have been prevented by better pre-transfer preparation and communication. Main adverse events that were characterised comprised of hypoxia and respiratory insufficiency, unprotected airway, active bleeding, hypotension and haemodynamic instability, oxygen supply breakdown and ambulance breakdown on the road. Seymour et al (2008) reported adverse events during air transport of mechanically ventilated patients. There were no major adverse events like death, cardiovascular collapse, seizures or pneumothorax. Minor adverse events of respiratory compromise (desaturation, modification of ventilatory settings) and cardiovascular compromise (hypotension, bradycardia, arrhythmias) were reported at a low frequency. Mode of transfer Risks which are related to the mode of transfer should also be considered. For ground medical transport, delays in reaching the hospital due to traffic jams and vehicular accidents involving the transporting ambulance or mobile ICU are transport related hazards (Droogh et al, 2012). Aeromedical transport of critically ill patients has its own risks. There could be increased patient anxiety, confined space may make resuscitative efforts difficult and physiological altitude related derangements can occur (Seymour et al, 2008; Blackwell, 2002; Gray, Bush & Whiteley, 2004). Nevertheless, aeromedical transport is indicated for long distance transfer and accompanying staff should be trained in the aspects of aeromedical transportation (Gray, Bush & Whiteley, 2004). Risk reduction Key focus in any risk benefit analysis should be on minimising the risk. Risk reduction entails planning, qualified personnel and equipment selection. Numerous studies have already characterised the nature and incidence of adverse events that can occur during critical transfers and evaluated whether pretransfer stabilisation of patients, planning and post transfer care can reduce this incidence. All these measures are expected to help the health care personnel undertaking such transfers to anticipate these risks and adverse problems and take measures to prevent and reduce the incidence of such problems. For example, much equipment related problems such as empty oxygen cylinders, malfunctioning ventilators, monitors, breathing circuits and AMBU devices, and drained batteries can be prevented by routine and regular maintenance and pre-transfer checking of the equipment. Also, patient appropriate equipment should be on board, for example, in paediatric retrievals. Mobile intensive care units (MICU) transferring severely ill patients have been found to have better outcomes when compared to standard ambulances used for transfers (Wiegersma et al, 2011) which again emphasises the importance of having specialised and adapted equipment for special situations. Availability of equipment is not sufficient to reduce risks. Dependency on modern equipment demands familiarity, technical knowledge and ability to troubleshoot in case of malfunctioning of equipment. Another way to significantly minimise the risk is pre transfer stabilisation of the patient. Vasopressors infusions should be started prior to transport if situation warrants it. Airway should be suctioned clear of secretions and made patent. In a patient with acute respiratory distress, need for endotracheal intubation should be anticipated. Similarly, the need for defibrillation may be anticipated in patients with unstable heart rhythms. Patient related risks can be anticipated only if a proper hand-over of the patient has been taken by the transfer team from the unit treating the patient about patient’s current problems, past history and comorbid illnesses, vital parameters and current cardio-respiratory status. Jenkin et al (2007) assessed the current hand-over procedures and recommended that so far as hand-overs for critically ill patients are concerned, there is a lack of standardisation and consistency in the procedure. Also, their study revealed that more paramedics receive formal handover training than doctors or nurses. Exchange of essential information between ICU or ED staff and ambulance crew is important in maintaining the standard of ongoing care for the patients and anticipation of problems. Simulation and mock drills of adverse scenarios and critical events that can happen should be routinely performed for participants of the retrieval team (Droogh et al, 2012). These procedures are less elective and more emergent in nature. So, these drills are useful in assessing acute reflexes and responses, and management skills of the transfer team. Along with technical and medical skills, participants should be trained in team work as well as communication skills. Similarly, an audit and discussion of critical events that actually happened or were narrowly averted should be done to make the team members wiser. Guidelines and recommendations Every hospital should have a written protocol in place for transfer of the critically ill patients which should be evidence based to minimise patient’s health risks and should be followed by all the team members. This protocol can be based on the recommendations of the College of Intensive Care Medicine (2010). As per this protocol, equipments such as monitors, defibrillators, suctioning device, ventilators, infusion pumps, airway equipment and drugs should be in working order along with backup. Equipment and patient checklists along with in-transit and arrival procedures have been described. Also, guidelines have been advocated for the transfer of interhospital and intrahospital transport of critically ill patients by Warren et al (2004). They recommended that a hospital should have written policy for transport of such patients and it should focus on 4 key aspects of coordination and communication regarding handover and treatment plan, training and qualification of accompanying personnel, equipment and monitoring. More recently, Fanara et al (2010) also put forward recommendations for safe intra-hospital transport of critically ill patients. The authors reviewed various studies and came up with their own checklists and preventive measures to be followed before and during intrahospital transport. It is essential that all transports with critically ill patients are subjected to a retrospective review to ensure that protocols for patient transfer are followed, and to evaluate the effectiveness of such transfers as a part of quality improvement process (Blackwell, 2002). Role of paramedic One important aspect of the work profile of paramedics is the transfer of critically ill patients as a part of retrieval medicine. Specialised retrieval teams have greatly reduced the number of adverse events occurring during transportation and critical care paramedics are integral members of these teams. That the paramedics undertaking transfer and retrieval of critically ill patients should be trained in critical and advanced care seems an obvious observation. Still, confidence in the skills and training of paramedics for transferring such patients is found lacking amongst the physicians as was determined in a survey undertaken by van Lieshout and colleagues (2008). Their survey revealed that decision making in this transfer process is largely influenced by the level of escorting personnel rather than the condition of the patient. A team consisting of a physician, nurse and a paramedic was preferred to an advanced life support paramedic trained in protocols of advanced life support and capable of administering medication, cardiopulmonary resuscitation and intubation. This situation warrants more consideration in the context of availability of more qualified, trained and experienced paramedics in the field of critical care and retrieval medicine. It is of the essence that paramedics are aware of the issues surrounding the transport of critically ill patients. Pre-transfer patient assessment, stabilisation and knowledge of patient’s risk factors require full participation of paramedic as a health care provider rather than just acting as a transporter. Conclusion Transport of critically ill patients is an ‘essential risk’ and occurrence of adverse events during the transfer of critically ill patients for various reasons is a well acknowledged and recognised phenomenon. On the other hand, patients may really benefit from such transfers by getting better management and care at the new place. Decisions in this context are taken by weighing benefits against the risks involved in the transfer. If it is decided to undertake the transfer, it should be done according to the current and institutional protocols, so that patient safety is not compromised and adverse events can be minimised. To ensure this, specialised retrieval teams should be instituted who understand the concepts and issues underlying such transfers and institutional protocols should be in place to guide such transfers. Paramedics are crucial participants in such teams and it is imperative that they are trained to prevent and recognise any adverse event that can happen during these transfers and manage it efficiently. Training should focus on both medical and technical problems. Only then critically ill patients can gain from such transfers. References Blackwell, T. H. (2002). Interfacility transports. Seminars in Respiratory and Critical Care Medicine, 23(1), 11-18. College of Intensive Care Medicine of Australia and New Zealand. (2010). Minimum Standards for Intrahospital Transport of Critically Ill Patients. Retrieved from http://www.anzca.edu.au/resources/professional-documents/documents/professional standards/professional-standards-39.html Fanara, B., Manzon, C., Barbot, O., Desmettre, T. & Capellier, G. (2010). Recommendations for the intra-hospital transport of critically ill patients. Critical Care ,14, R87. doi: 10.1186/cc9018 Droogh, J. M., Smit, M., Hut, J., de Vos, R., Ligtenberg, J. J. 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Intensive Care Medicine, 34, 1269 -1273. doi: 10.1007/s00134-008-1023-x Wiegersma, J. S., Droogh, J. M., Zijlstra, J. G., Fokkema, J., & Ligtenberg, J. J. (2011). Quality of interhospital transport of the critically ill: impact of a Mobile Intensive Care Unit with a specialized retrieval team. Critical Care, 15, R75. doi:10.1186/cc10064 Warren, J., Fromm, R. E., Orr, R. A., Rotello, L. C., & Horst, M. (2004). Guidelines for the inter- and intrahospital transport of critically ill patients. Critical Care Medicine, 32(1), 256 –262. doi: 10.1097/01.CCM.0000104917.39204.0A Read More