The movement of critically ill patients around or between hospital sites is sometimes necessary for a variety of reasons. All transfers expose the patient and escorting clinicians to a degree of risk. When the decision to transfer is made the benefits of transfer must justify the risk.

Transfers may be categorised as interhospital (movement between hospital sites) or intrahospital (movement within the same hospital site). While the focus of much of this guideline is on interhospital transfer the risks of intrahospital transfers must not be underestimated and the same principles should be applied.

Interhospital transfers are often further classified as clinical, non-clinical or repatriation depending on the primary indication for the transfer.

• Clinical: transfer for care that is not available within the referring unit.
• Capacity: transfer due to insufficient capacity at the referring unit.
• Repatriation: transfer back to a referring unit when specialist care is no longer required or transfer for ongoing care at a unit closer to a patient’s home.

Clinicians who may be involved in transport of critically ill patients must be provided with opportunity for education and training and shouldonly be involved in transfers once they possess the appropriate competencies, skills and experience. This will include experience in a supernumerary capacity wherever possible.

Attendance at a transfer training course will help clinicians demonstrate they possess the required competence to participate in transfers but must not be relied upon alone. Completion of transfer training is; however, strongly recommended. In addition to face to face transfer training staff should complete relevant online training (‘LearnPro’).

Referring team

The consultant with overall responsibility for the patient is responsible for the decision to transfer a critically unwell patient and for ensuring transfer arrangements, including selection of escorting personnel, are appropriate to the anticipated level of risk. They must have discussed transfer with the consultant who will be assuming responsibility for the patient at the receiving hospital and any other relevant specialties. The referring consultant retains overall responsibility for the patient throughout the transfer and until handover is completed at the receiving unit.

The decision to transfer a critically ill adult between hospital sites must normally be discussed with a senior intensivist or anaesthetist at the referring hospital. The referring consultant remains responsible for the patient unless and until care is formally taken over at which point the relevant intensive care / anaesthetic consultant assumes responsibility. If, after a full review in person, the senior intensivist / anaesthetist decides the patient does not require their care to be taken over for transfer this must be discussed with the referring consultant and the reasons clearly documented.

Escorting clinicians

The clinicians escorting a patient on a transfer are responsible for clinical management of the patient from the time handover from the referring team is completed and until handover is completed at the receiving unit. The clinicians must be relieved of all other responsibilities for the duration of the transfer and return journey so arrangements must be made to ensure adequate cover for clinical areas they have left.

Only clinicians with the appropriate competencies, skills and experience should be involved in the transfer of a critically ill patient with the exception of those acting under direct supervision for the purposes of gaining experience. Patients who require (or are anticipated to require) level 3 care must be escorted by a minimum of two clinicians experienced in the management of critically ill patients including a doctor or advanced practitioner with critical care competencies and advanced airway skills.

If a competent senior clinician is not present throughout transfer, escorting clinicians are working in an unsupervised capacity and must be competent to complete the transfer (including any anticipated procedures) without direct supervision. This is particularly relevant (but not limited) to doctors and other clinicians in training roles.

Foundation Year 1 (FY1) doctors should not be expected or allowed to transfer patients without direct supervision from a competent senior clinician.

Scottish Ambulance Service

A paramedic should be involved in the transfer of critically ill patients who are being transferred between hospitals. The paramedic should be immediately available to assist the transfer team with equipment in the ambulance and clinical management, in their scope of practice, as necessary. The ambulance crew will not assume clinical responsibility for the patient.

The most senior escorting clinician is responsible for providing appropriate clinical information to the ambulance crew at the earliest opportunity after their arrival. This information should include demographics, the reason for hospital admission, current management, the reason for transfer and any anticipated problems. A plan should be agreed for safely stopping the ambulance in case escorting clinicians need to access the patient or equipment.

The ambulance crew are responsible for decisions around driving (including whether it is appropriate to use legal exemptions and emergency warning equipment).

Receiving team

The receiving team may be able to offer clinical advice around the time of transfer; however, the referring team retain overall responsibility for the patient until handover is complete at the receiving unit. If circumstances change the referring consultant may decide not to transfer the patient.

ScotSTAR is a division of the Scottish Ambulance Service that provides a service for the interhospital transport of neonates and children, retrieval of adult and paediatric patients from remote and rural environments, and the provision of pre-hospital critical care. The transfer of critically unwell children presenting to any hospital in NHS Ayrshire & Arran and the transfer of critically unwell adults presenting to community hospitals should be discussed with ScotSTAR.

Highly specialised tertiary services, such as those providing extracorporeal membrane oxygenation, will usually arrange for patients to be retrieved from referring hospitals by their own transport teams.

Decision to transfer

The decision to transfer a patient between hospitals must include careful consideration of potential risks to the patient, transfer team, public and other patients. Potential risks include deterioration of physiology or underlying pathology, critical incidents (including road traffic collision) and the impact on service provision. Environmental factors such as adverse weather must be taken into account. With the exception of transfers for time critical interventions most should occur in ‘normal working hours’.

A detailed risk assessment must be carried out prior to transfer. The risk assessment should consider the patient’s diagnosis, physiology, level of dependency, treatments and likelihood of deterioration. An example risk assessment is provided in the current Intensive Care Society / Faculty of Intensive Care Medicine (ICS/FICM) transfer guidelines.

Capacity transfers must be avoided wherever possible. If unavoidable, for example to deal with surge demand to provide emergency medical or surgical care, they should take place in normal working hours and be undertaken in such a way to minimise the risk of transfer. Further guidance on capacity transfers is available from ICS/FICM.

Mode of transport

The majority of interhospital transfers from acute sites in NHS Ayrshire & Arran are undertaken by road. Few hospital clinicians possess appropriate competencies or experience to safely conduct transfers using other platforms. It should be recognised that excess speed during road transport significantly increases the risk of transfer and is generally inappropriate. It may be appropriate to use emergency warning equipment to aid passage through traffic but this decision must be made by the ambulance crew and not the escorting clinicians.

An ambulance should be requested from the Scottish Ambulance Service according to the urgency of the transfer. An overview is provided here:

Time critical

Transfer for an immediate life, limb or sight saving intervention in another facility. The request will be prioritised in the same way as 999 calls from the public and should trigger a paramedic crew and blue light response.

Urgent

Transfer for care not available in the current facility but not meeting the criteria for a time critical response (for example, capacity transfer or transfer for planned procedure). An ambulance and escort appropriate to patient need will be provided; for critically ill patients this should normally include a paramedic.

Scheduled

Transfer for repatriation or step down / discharge to a non-hospital facility. An ambulance and escort appropriate to patient need will be provided; for critically ill patients this should normally include a paramedic.

In the event that a facility is unable to provide immediate life-saving clinical intervention (such as resuscitation or an obstetric emergency), and clinical assistance is required in addition to transport, the response should be categorised as time critical.

Treatment for immediate lifesaving interventions must not be delayed by lack of an available critical care bed at the receiving hospital (FICM). Should this situation arise there must be urgent discussion between referring and receiving consultants.

Communication

Communication between the referring and receiving team should be between a senior clinician at each site and between responsible consultants if at all possible. Relevant clinical records must be available for the receiving team (some information is available electronically but consideration should be given to taking hard copies as relevant). All communication must be clear with an accurate summary of any discussions recorded in the patient’s medical record.

The patient or relatives should be informed of the decision to transfer at the earliest opportunity. For interhospital transfers, the patient’s relatives should be provided with contact information for the receiving unit and given advice around travel arrangements. It is generally inappropriate for patients to be accompanied by relatives during transfer. All steps reasonable in the circumstances should be taken to facilitate discussion with the patient or their relatives such as professional interpreters and communication aids.

Medical and nursing staff at the receiving unit should be informed when the transfer team depart the referring unit including any relevant updates on the patient’s condition and an estimated arrival time.

Resuscitation status

It is appropriate to consider the resuscitation status of every critically ill patient who is being transferred. The patient’s resuscitation status should be clearly documented and handover over between teams as they assume responsibility for the patient. Clinicians should refer to the Scottish integrated DNACPR policy for adults (NHS Scotland)

Preparation for transfer

Escorting clinicians must receive a formal handover and have opportunity to familiarise themselves with the patient prior to assuming responsibility for clinical management.

Patients should be appropriately resuscitated and stabilised prior to transfer to reduce the risk of deterioration during the transfer. The urgency of time critical transfers must be balanced against the need for a period of stabilisation. On occasions where stability cannot be achieved without transfer for a definitive procedure it may be appropriate, after initial resuscitation, to undertake a time critical transfer rather than aiming to achieve absolute stability.

Patients must have secure venous access and a minimum of two points of access are recommended. In the absence of a contraindication patients should have circulating volume restored prior to transfer in order to reduce the adverse effects of movement on the circulation. Patients should be stabilised on any forms of organ support prior to departure. This includes cardiovascular support and the transfer ventilator.

The airway must be assessed by a competent clinician and should be secured if necessary (consideration must be given to the additional challenges of endotracheal intubation during transfer). Indications for endotracheal intubation prior to transfer exist in national guidelines for specific conditions including brain injury. A chest drain should be inserted if pneumothorax is present or suspected. A nasogastric / orogastric tube and urinary catheter should be inserted prior to transfer allowing the stomach and bladder to be emptied.

A pre-transfer checklist is incorporated into the NHS Ayrshire & Arran Critical Care Transfer Record; this acts as an aide memoir and must be completed prior to transfer.

Transfer equipment

All equipment used during a transfer must be suitable for use in transfer environments and must be stowed or secured in such a way that it would not pose a hazard in the event of a collision. Clinicians must be familiar with transfer equipment and its use.

Transfer equipment must be maintained in a state of readiness but a final check by escorting clinicians is recommended before departure. Device alarms (including limits and volumes) should be set appropriately.

The senior escorting clinician must ensure equipment or drugs which may be required during transfer are available for use. Medications anticipated to be needed should be prepared in advance. Spare syringes of medication being given should be carried; this is particularly important for vasoactive drugs and sedatives. Medication prepared for transfer must be recorded according to existing processes. Adequate infusion pumps must be available to administer medication throughout the transfer and consideration given to having a ‘spare’ pump available in case of equipment failure. Drugs should be administered by infusion pump as gravity-dependent administration is unreliable during transfer.

Oxygen

Prior to departure, the anticipated oxygen requirement for transfer must be calculated. To aid in the calculation of oxygen requirement for ventilated patients the Hamilton T1 ventilator used in NHS Ayrshire & Arran can display its current oxygen consumption. To account for delays or increases in oxygen consumption it is recommended that at least twice the anticipated volume of oxygen is available and that all oxygen cylinders are full on departure. A spare oxygen cylinder should be carried in case of failure.

Emergency ambulances should have two ‘F’ size oxygen cylinders available for use; these cylinders should be checked before departure as they are unlikely to be full.

Monitoring

At least the same level of monitoring provided in hospital should be continued during a transfer. Monitoring should include continuous observation by escorting clinicians, vital signs including cardiac rhythm, blood pressure, oxygen saturation, temperature and end-tidal carbon dioxide (in all intubated patients). An indwelling arterial cannula is suggested for blood pressure monitoring over intermittent non-invasive monitoring. The transducers for invasive pressures should be levelled appropriately then secured so that they do not move during transfer.

Patient packaging

Patients must be secured to the transfer trolley using the provided harness and straps throughout transfer. They should be carefully packaged with attention paid to pressure areas and temperature (usually patients need to be kept warm with blankets).

In the event that a paediatric patient needs to be transferred an appropriate restraint is available at UHC.

Documentation

Transfer details and observations should be recorded on the Ayrshire & Arran Critical Care Transfer Record. A copy of the transfer record should be given to the receiving team on handover, a copy should be filed in the patient’s medical record, and a final copy should be returned to the base hospital for audit.

Transfer documentation must include a record of any critical incident or adverse event related to the transfer. In addition to this documentation, critical incidents and adverse events should be reported as normal using the health board’s adverse event reporting system (DATIX).

Safety considerations

Escorting clinicians must be dressed appropriately in warm, safe clothes, and must be well equipped. A reliable means of communication must be available to the team, like a mobile phone pre-programmed with all appropriate telephone numbers, to allow direct communication with both the referring hospital and the receiving hospital.

Unless the ambulance is stopped in a safe place all escorting clinicians should remain seated and appropriately restrained for the duration of transfer. If it is necessary to access the patient during transfer this must be communicated to the ambulance crew and the vehicle stopped before clinicians leave their seats.

Equipment or medication that is likely to be needed during transfer should be securely stowed in such a way that it can be accessed without escorting clinicians needing to leave their seats. Monitors and other devices (such as pumps and ventilator) must be adjusted so that they can be seen by escorting clinicians throughout transfer. Ports for intravenous access should be positioned so they can be accessed without clinicians leaving their seats.

Immediately prior to departure, a visual “sweep” of the patient compartment should be performed to ensure equipment is appropriately secured, power and oxygen supplies are connected and that device batteries are charging as expected.

Handover

On arrival at the receiving unit the most senior transferring clinician is responsible for ensuring a handover is given to the most senior clinician available at the receiving unit.

Handover at the receiving unit should incorporate a clear transition of responsibility for the patient’s management. The transfer team should normally remain responsible for the patient until handover is complete. The name and designation of the most senior receiving clinician should be recorded along with the time of handover.

Following an interhospital transfer it may be possible, but is not mandatory, to arrange for the conveying ambulance to return transfer equipment and clinicians to the base hospital. If this is not possible a hospital taxi should be requested to return clinicians and equipment to the base hospital. As the transfer trolley cannot be safely transported by taxi it will be necessary to make separate arrangements to have this returned as soon as possible so that it is available for future transfers.

During the return journey the ambulance crew may still be asked to attend emergency calls. In this event the ambulance crew will be responsible for clinical management of any patients and it is generally inappropriate for hospital staff to be involved with their care. Staff asked to assist with the care of patients outside the hospital must consider the implications (including medicolegal) of operating outside their scope of practice.

On arrival back at the base hospital, the most senior escorting clinician should ensure equipment is ready for further use. Reusable items must be cleaned and appropriately stored, single use items including oxygen and drugs must be replenished. The transfer trolley must be plugged in and charging. The most senior clinician is also responsible for ensuring any relevant documentation and communication are complete.

On completion of a transfer consideration should be given to debriefing to allow for shared learning and to provision of a rest period as necessary.

While the duration and distance of interhospital transfers are relatively shorter than those between hospital sites the risks must not be underestimated and the principles applied to interhospital transfers in this guidance must be applied.

Intra-hospital transfer does not usually involve use of a dedicated transfer trolley; every effort should be made to ensure all equipment required is safely stowed or carried so as not to cause injury to patients or staff or damage to equipment.

Designated ‘theatre’ lifts may be less likely to malfunction and cause entrapment than other hospital lifts so wherever possible these lifts should be used to transfer critically ill patients in the hospital. Some ward areas have access to keys for operating theatre lifts and porters also have access.

NHS staff, carrying out transfers on behalf of their employing organisation and working within their scope of practice, are covered by the usual NHS indemnity arrangements.

Staff carrying out transfers under any other circumstance should ensure they have appropriate employer and/or personal indemnity cover in place.

Unfortunately, all transfers expose escorting clinicians to a risk of harm. It is advisable that staff involved in transfers ensure they have arranged adequate insurance cover for associated personal injury or death. Some societies (including the Intensive Care Society and AAGBI) have cover arrangements for members involved in the transport of critically ill patients. Details are available from the relevant societies.

Standard transfer equipment available at UHC and UHA includes critical care transfer trolleys and transfer bags containing standardised consumables. A transfer trolley is also available at Woodland View Hospital but some features are not standardised on this trolley.

Transfer trolley

Use of a critical care transfer trolley for interhospital transfer should be considered for all critically ill patients. The trolleys used in NHS Ayrshire & Arran are a mixture of Ferno CCT Six-P and CCT M models. As far as possible the trolleys are standardised to include a power supply, Hamilton T1 transport ventilator, vital signs monitor, syringe pumps, portable suction unit and two ‘E’ size oxygen cylinders.

Staff must be aware of different weight limits for the trolleys in Ayrshire & Arran; the CCT Six-P has a patient weight limit of 181kg while the CCT M has a limit of 250kg. If the CCT M is being used with side-extensions (for transfer of a bariatric patient) the ambulance service must be informed at the earliest opportunity as the trolley will be too wide on its offside to lock into most frontline ambulances. A bariatric ambulance will be required and this may delay transfer.

The transfer trolley does not incorporate a defibrillator. If use of a defibrillator may be necessary during transfer this should be discussed with the ambulance crew before departure. Most hospital clinicians will be unfamiliar with the device type used by the Scottish Ambulance Service so the ambulance crew should be prepared to operate the defibrillator if necessary.

Power supply

The transfer trolleys incorporate a charging system which charges onboard device batteries when plugged into a power supply. When fully charged, internal batteries for the ventilator, pumps and monitor should allow for several hours of normal use. The trolley must be kept plugged in wherever possible to maximise device battery life as this provides the backup in the event of power failure. The trolley can be plugged in using either a standard 240V power socket or an Anderson connector. Please note the CCT Six–P located at Woodland View Hospital does not have an Anderson connector to allow for charging during transfer.

Transfer bags

To assist with preparation for transfer, critical care transfer bags containing a range of consumables are available at UHC and UHA. Standardised drug packs are also available and contain a range of drugs which may be needed during transfer. A transfer bag and drug pack should be carried on any transfer of a critically ill patient.

SAS inter facility transfer guide - non-critical

SAS inter facility transfer guide - time critical