Interfacility transport choreography for critical care paramedics

The only people looking for heroes on transfer calls of critically ill patients are attorneys


Updated January 26, 2016

EMS providers excel in creating organization out of chaos in the prehospital world. Most of us develop and practice a systematic approach for rapidly sizing up a scene, stabilizing, packaging and transporting a patient.

Interfacility transports require a very similar “dance” in order to efficiently and safely transfer a patient. Whether transporting a patient from a cath lab back to a sending hospital, from a freestanding ED to a hospital, from one ICU to another ICU across town, or from a cardiology office to a local ED, choreography matters.

Scene versus interfacility runs
Unlike most scene calls, patients in need of interfacility transport are often attached to multiple monitors and medical devices. The goals and safety concerns differ vastly between prehospital and interfacility moves. There should never be an urgency to transport that compels providers to risk their safety or take chances with patient life or limb in order to transport.

Response times and “scene” times differ considerably from prehospital benchmarks. Liability reaches limits we would never have imagined previously, as patients are already at a source of definitive care. If we approach interfacility transport with the same tactics we use successfully on 911 calls day in and day out, we’re eventually very likely going to get burned.

Response times tend not to be as demanding as 911 responses, and even when patients are critically ill, more instead of less time is often needed to properly package a patient for transport. Acceptable response time standards vary, often negotiated in contracts between the transport service and medical facility, and different levels of urgency are typically noted by dispatch when a transfer request is received.

The only people looking for heroes on interfacility transfer calls are attorneys. Choreographing interfacility transports requires you to slow down, think carefully and thoroughly, collaborate with other health care providers, and prepare for a far bigger range of complications than any scene call could ever deliver.

Preplanning is key to success
Preparation is essential for safe interfacility work and should begin at the time of call receipt. The communications center should obtain as much information as possible about the patient problems, current condition, medications infusing, and the medical equipment in use or required for transport.

Ventilators, intra-aortic balloon pumps (IABPs), infusion pumps, and medical equipment all have specific power, space and storage requirements. Knowing before you arrive at a patient’s bedside what devices, equipment and medications you’ll encounter can help you plan for a smooth transport.

Steps to a successful transfer
Your first priority on arrival at the medical facility is to carefully survey your route of ingress so that you can ensure egress. Unlike scene calls, interfacility transports not only load up your stretcher with a patient and multiple medical devices, but often add additional pieces of rolling equipment such as cardiac assist devices, ventilators and infusion pumps. The combined dimensions of your stretcher and these tethered devices could prevent you from exiting by the same route you entered.

Packaging and moving a patient should take no more than 20 minutes, unless additional procedures or resuscitation are needed to assure the patient is stable for transport. Good teamwork is essential to meeting this goal.

One provider should assess the patient and equipment, noting the programmed settings of each medical device (infusion pumps, ventilators, cardiac assist devices, etc.). Each line, tube and catheter is traced back to its source; assure every infusion tubing set is labeled with the medication it contains, and note the current vital signs and overall state of the patient.

The second provider should obtain reports from the provider caring for the patient, review labs and diagnostic images/reports, prepare the transport stretcher, and fire up all the transport monitors and medical devices.

Prior to physically moving the patient, the team connects each piece of equipment to the patient and assures correct settings and operation. Reassure and reassess the patient to be certain that their condition has not changed adversely after transfer to the transport equipment and, when satisfied, physically move the patient onto the transport stretcher. This provides a good opportunity to find and meet the family, assure them that their loved one is safe, confirm the name and location of the destination facility and review travel plans.

While this is being done, perform a “pull away test,” slowly moving the transport stretcher (with the patient) away from the bedside to assure that no cables, tubes, wires, or equipment remain attached. Once complete, movement towards the transport vehicle can begin.

High-risk concerns
Safety in the interfacility transport environment is paramount and requires providers to anticipate problems. Having backup equipment, power supplies, and medications available to address issues that might arise during transport are key to good outcomes.

Adverse patient outcomes, destroyed careers and costly litigation ensue when providers knowingly (or unknowingly) accept a transfer that is beyond their skills, knowledge and abilities. Any time you have the slightest doubt about whether a transfer is within your scope of practice or skill set, you should immediately have a cell phone discussion with your medical director.

Having a nurse come along from the transferring facility, someone who you are unfamiliar with, may help to share liability should things go sour during transport, but in no way absolves you of direct responsibility and liability for adverse patient outcomes! If you are not certain what potential complications the patient and equipment you are transporting might encounter, or you don’t believe you have the knowledge and supplies to manage any potential complication, then you have no business transporting that patient.

Never risk your license, certification, job, career, bank account and everything else you own in order to do a transport that is beyond your skill set. Surgeons, physicians, nurses, and a whole cadre of other health care professionals refuse patients who are outside their skills and abilities every day, day in and day out. Don’t ever feel pressured to accept a transfer.

Ensuring safety of an interfacility transfer
Remember, no matter the level of skill and equipment the sending facility may have, it is considered definitive care. While the usual reason for interfacility transfer is to obtain a “higher level of care,” getting to that higher level of care should never include additional insult or injury to the patient.

Bottom line: if you don’t think the vascular access is adequate, the airway is stable, the blood pressure sufficient to perfuse target organs, then speak up and get those problems resolved before you leave. Never accept a patient who, in your opinion, is not stable enough to make it to the receiving facility.

Sure, problems can and will arise during interfacility moves. However, predictable catastrophes will invariably make you look like the fool. You are, after all, the expert on what you need to do your job, and everyone expects you to advocate for whatever is required to safely move your patients.

Two of the most common interfacility transport catastrophes are stretcher tips or drops, and patient injury related to agitation. These are preventable incidents, and they need to be in the forefront of your mind.

Finally, make sure you have a list of the possible and the most likely problems that might arise during transport. Start transport with the right tools in your toolbox to safely manage each of these. Questions to ask yourself can include:

  • Do you have additional sedatives if the patient becomes agitated?
  • What’s in your bag if you max out on Levophed and the blood pressure is still dropping?
  • Do you have a backup battery or on-board power for that IV pump, IABP or transvenous pacer?
  • How will you manage if you suddenly lose all venous access?
  • Do you have the right supplies and personnel in case a high-risk OB patient delivers her neonate during transport?

These are real-life concerns and worries that require preplanning and swift action should they happen en route.

Summary
Like field EMS, interfacility transport work needs a well-choreographed “dance.” Safely moving a patient from one facility to another poses unique and different challenges to a street-wise medic. Never allow yourself to be rushed, and don’t ever accept a patient for transport that exceeds your skills or abilities. Plan ahead, and plan thoroughly.

Always remember: every interfacility transport originates at a source of definitive care. Moving an unstable patient is just plain foolishness and could not only cost the patient their life, but also you your career.

References

Pollak AN, Murphy M, Strathers CL, Pecora D, McEvoy M, Rabrich JS (eds). Critical Care Transport. Burlington, MA: Jones and Bartlett Publishers. 2011.

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