Transfer of critically ill patients in the Northern region

Transfers between intensive care units are now so common that the Department of Health has issued guidance on which critically ill patients should be transferred [1]. In order to ensure the patient's safety, guidance has been issued by the Neuroanasthesia Society and the Association of Anasthetists of Great Britain & Ireland on transfer of acute head injuries [2] and by the Intensive Care Society, for general patients [3]. Despite this advice, audit has shown relatively poor compliance with guidance [4]. Documentation of transfers is also said to be generally of poor quality. In January 1999, we introduced a pilot transfer form to the southern part of the former Northern region. The form was aimed to improve documentation and to drive up quality transfer of patients in the region by using structured documentation. We audited forms returned to us from between 1 January and 31 July 1999, in order to assess compliance with published guidance. During this period 114 forms were returned. One-fifth [21%] of transfers occurred between midnight and 09.00, 39% between 09.00 and 17.00 and the rest between 17.00 and midnight. Transfers originated from an ICU on 75% of occasions and from A & E departments on 21% of occasions. On 47% of occasions, the reason for transfer was lack of beds or staff (bed space transfers). Patients were transferred for upgrade care on 33% of occasions, while 19% of transfers was for repatriation to the home hospital. Consultants were reported to have organised 49% of transfers, while 24% were organised by nurses, 11% by SHOs and 8% by SpRs or nontraining grades. Over half (58%) of the patients were accompanied by SHOs, 20% by SpRs, 12% by Staff Grades and only 9% by Consultants. As many as 51% of doctors stated they had received special training in transfers, where only 38% of nurses claimed to have done so. The majority of patients (80%) were mechanically ventilated, while 2% were ‘hand-bagged’. A fifth (18%) breathed spontaneously. Only 58% were sedated, 28% by bolus injection. One-third (36%) were paralysed. ECG, oxygen saturation and blood pressure were monitored in 96 patients (84%), with 72% receiving intra-arterial monitoring. End-tidal CO2 was monitored in 16% of patients. Intravenous access appeared to be available in only 51% of patients. Our audit indicated a clear problem with documentation in volume and legibility. As might be expected, consultants accompanied few transferred patients, with well over 50% of transfers being escorted by SHOs. Given the conflicting needs and roles of consultants, this level seems unlikely to improve without development of dedicated, independent transfer teams, as has occurred for critically ill children. However, most ICUs should have systems able to monitor patients during intrahospital transfer, for instance to X-ray: it is therefore particularly surprising that almost one-fifth of transfers are undertaken with no monitoring of ECG or oxygenation, and a quarter are transferred without intra-arterial monitoring. While personnel problems are likely to prove intractable, this audit demonstrates that there are some areas (e.g. monitoring) that should be remediable. Even the fittest patient receiving general anasthesia for elective simple surgery receives a higher standard of monitoring than 20% of critically ill patients transferred between hospitals in the hostile environment of the isolated ambulance. Failure to monitor anasthetised patients is considered negligent: failure to monitor patients during transfer seems cavalier.