CHAPTER 3
Planning the move

Learning outcomes

After reading this chapter, you will be able to:

• Define the complexity of transfer planning
• Name the factors that should be considered when planning a transfer
• Prepare for the likely events during transfer
• Recognise the need to appropriately plan for the worst case scenario

3.1 Introduction

The decision to move a patient pivots on a number of factors. The requirement for transfer may be to an internal location, such as the computed tomography (CT) scanner or theatres, or external, to another centre with staffing of facilities not available on the current site. The decision to proceed and the timing of the transfer must be based on balancing the benefits of the transfer against the clinical risk posed to the patient and team by the transfer. Whilst on most occasions this can be quite straightforward, there are a significant number of occasions where the risk of deterioration or even death en route will need to be weighed up in this analysis.

The first stage of this process is to gather all the key information required. This will usually be achieved during the assessment stage of the process but further information may also be needed.

The following information should be considered as a minimum dataset.

Patient

• Clinical assessment of the patient’s status:
  • How stable is the patient? (ABCDEF approach)
  • If unstable, is it possible to stabilise and how long might that be expected to take?
• An assessment of the likelihood of deterioration during transfer based on:
  • Diagnosis (if known)
  • Current status and physiological trends
  • Need to transfer before optimal stabilisation
  • Specific condition/transport factors, e.g.
    • Severe pulmonary dysfunction and air travel
    • Mobile extracorporeal membrane oxygenation
• Rationale for transfer, e.g. access to specialist care

Staff and logistics

• Staff:
  • Availability of staff with suitable competencies
  • Risk of removing expert staff from local unit (if local transfer team)
• Expected time taken for transfer (impacts on above)
• Safety of the transfer – weather/mode of transfer

ABCDEF approach

A	Airway assessment and control

B

Breathing

C	Circulation

D	Disability

E	Exposure (including temperature in neonates and children) and everything else

F

Family

3.2 Patient risk assessment

Increasingly, patient track and trigger systems (or early warning systems (EWS)) are embedded in hospital practice and are a tool for identifying patient deterioration by analysing physiological parameters. The monitored physiological parameters are scored, and when a threshold abnormal score is reached a clinical review is triggered.

The EWS may be employed in conjunction with a structured ABCDEF assessment to help highlight specific clinical risks associated with transport. The likelihood of deterioration during transfer may be assessed through serial EWS and reassessments of ABCDEF. An understanding of the progression of the disease process together with the likelihood of requiring additional interventions during transportation and an understanding of the clinical benefit of transfer will inform when to move a patient.

It is important to recognise both the advantages and limitations of EWS. They are designed to provide an alert, usually on the general wards, when a patient is likely to be unwell or deteriorating. It is critical to understand that a low score should never be used to provide reassurance when there are other worrying factors in the clinical assessment. It is also true that EWS are relatively insensitive to ongoing deterioration once a patient is decompensating and has already generated a high score. In summary, EWS are a useful adjunct to structured clinical assessment, which should always be the primary assessment tool. The patient’s lead consultant should always be contacted if at any time there is any doubt about this assessment. They in turn may choose to discuss the patient’s status with other colleagues or experts at the receiving centre where appropriate.

3.3 Staff and logistics risk assessment

Patient assessment for transfer should always be viewed in the context of the duration and mode of transport. The longer a transfer the more time there is for deterioration to occur. Even short transfers, within a hospital, may not be without challenges. For example, when going outside, between buildings, or when utilising a lift, never go without supplies for at least 30 minutes!

When travelling between centres the mode of transport may also present specific risks. In all cases there will be some limitation of access to the patient and equipment, and the team may not be 100% familiar with the environment and may have to cope with complex logistics. The latter is especially true for air transfers where there are also the effects of altitude physiology to consider.

The staff accompanying a patient must have suitable competencies to deliver clinical care not only at the current level of dependency of the patient, but also at an increased dependency level in the event of deterioration. In an ideal world, staff should neither be fatigued nor stressed and they should always be familiar with all the transport equipment, policies and procedures (see Chapter 4).

Adverse weather conditions such as snow, ice or poor visibility should always be factored into the assessment of the need for transfer. Risks of this type can be reduced by using familiar vehicles and modes of transport, by altering routes or delaying the transfer; an alternative destination may need to be considered for very long transfers. The use of sirens and blue lights to facilitate anything more than progression at safe, standard road speeds should be avoided wherever possible. High speed transfers have no impact on clinical outcome, but expose the patient, the team and the public to considerably enhanced risk. Safety of the team and patient is the absolute priority.

3.4 Use of physiological measurements in identifying transfer risk

The clinical risk of the transfer and the level of competence required by escorting staff will be informed by the patient’s condition. As discussed previously, a physiological track and trigger system (EWS) may, under certain circumstances, be used in combination with other parameters (SpO2, Glasgow Coma Scale (GCS), base excess) to risk assess patients prior to transfer. For the purposes of discussion, the risk may be divided into categories of low, medium and high. The EWS score may be used to inform this classification but will be dependent on the score used and therefore must be calibrated locally.

Low risk group

This group includes all patients with near normal physiology. In this group there are no additional concerns and these patients should have a low risk of clinical deterioration during transfer, although some clinical competences may be required during transfer, e.g. oxygen therapy or infusion therapy.

Medium risk group

These patients will have clear evidence of systemic illness or instability. They are likely to have an EWS score in the middle of the range. The group may include patients who would fit the criteria for high dependency care.

This group are potentially the highest risk transfers. They may be transported with the minimum of technological support but could be of risk of major deterioration during transfer. They require a detailed pre‐transfer assessment that should be based on an ABCDEF approach. The following should be considered:

• Is the general condition of the patient improving, stable or deteriorating?
• Review the rationale for the transfer:
  • Does the need/benefit for investigation or enhanced support outweigh the transfer risks?
  • Is this the right time to transfer?
• How long will the transfer take?
• What physiological deterioration may occur during the transfer?
• What competences are required during the transfer?

If after making the assessment, there are concerns for the patient’s safety during transfer, these must be discussed with senior medical staff. If it is judged appropriate to proceed, it is vital that the transfer team have the competencies to cope with the very worst case scenario. It is neither safe nor fair to the patient or staff to compromise on this.

High risk group

Patients in this group will have significant physiological derangement or have a condition that would be expected to rapidly deteriorate during transfer. They will usually have already have triggered an emergency response from the critical care team. A formal risk assessment and consideration of the cause, as described for the medium risk patient, must be undertaken.

Patients in this group must only be transferred by a team with critical care...