Liverpool Hospital ICU Guideline: Clinical Guidelines Intensive Care Unit

Intra-hospital transfer of ICU Patient

Guideline: Intra-hospital transfer of ICU patient

Summary: Critically ill patients requiring transfer will be assessed by a senior medical
staff member. Equipment and monitoring will be checked and appropriate medications
prepared. Continuous monitoring will occur and be documented prior, during and at arrival
and prior to handover of the patient. If a transfer is well planned and involves appropriately
trained personnel with adequate equipment, risks can be minimised.[1]

Approved by: ICU Director,

ICU - NM
Publication (Issue) Date: May 2015

Next Review Date: May 2018

Related Standards or Legislation

NSQHS Standard 1 Governance

Related Policies:
All care provided within Liverpool Hospital will be in accordance with infection control,
manual handling and minimisation and management of aggression guidelines.

2. Guidelines:

The decision to transfer a critically ill patient for any reason must be:

 Made at Consultant level only

 Clinically justified Think: Do the benefits outweigh the risk?

Will this change patient management?
Is there a portable option?

 Optimally timed Think: Does this have to be done now?

Would waiting reduce the risk?
Do I have all the resources available now?

 Made in liaison with the bedside nurse and Clinical NUM

Planning
Non Intubated patients - Assess their ability to protect their airway, and whether they can
lie flat if required. If sedation for a procedure is anticipated, it must be discussed with the
ICU consultant, consultation with and referral to the anaesthetic department may be
required.
Agitated or confused patients should not be transferred without adequately addressing
sedation, which may include intubation.

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 Liverpool Hospital ICU Guideline: Clinical Guidelines Intensive Care Unit
Intra-hospital transfer of ICU Patient

Communication with the destination speciality is essential in terms of timing, positioning

and equipment requirements. The admitting team should be aware of planned transfers
e.g. for scans.
Ensure adequate time for preparation and transfer
Ensure a cannula is in place if IV contrast is to be administered. In bleeding patients large
bore access should be in place and blood available.

Requirements
The following table is a guide only. The need for an ICU medical escort during transfer is
determined by the ICU Consultant. All patients on invasive and non-invasive ventilation
require a medical escort. Medical and nursing staff should be relieved of all other duties
whilst preparing and transferring the patient (e.g. MET team, and looking after another
patient).
Personal protective equipment must be worn by all staff throughout the transfer procedure.

Clinical Requirements Transfer Personnel Requirements

High ventilatory requirements Advanced trainee/Consultant +/-
(PEEP >10, Fi02 >60%, plateau pressure >30 registrar, or Anaesthetic team.
recurrent recruitment requirements, Senior ICU Nurse
P insp >30) Ward Orderly x2
High/unstable ICP
> 2 chest tubes
Unstable cardiac rhythm, temporary pacemaker
dependent
Haemodynamic instability
Ongoing bleeding
Abdominal hypertension
Unstable spinal injury
Invasive or Non Invasive Ventilation Advanced trainee/Consultant, trainee
Inotropes/Vasopressors with anaesthetic/airway skills, or
Anaesthetic Team
Active bleeding/current transfusion Senior ICU Nurse
Neurosurgical/Traumatic Head Injury Ward Orderly
GCS<15
No ventilatory/renal/CVS support Senior ICU nurse
GCS 15 Ward Orderly

Monitoring
The following table is a guide only. A monitor does not replace clinical assessment and
observation. Observations are documented every 5 minutes on the Intra-Hospital Transfer
Observation Chart. If concerned, additional monitoring is to be documented.

Monitors should be visible at all times with alarms set appropriately.

Clinical Requirements Minimum Monitoring Necessary

Intubated ECG, SaO2, NIBP or arterial pressure
Waveform End Tidal CO2 (Mandatory)
Inotropes/Vasopressors ECG, SaO2, NIBP or arterial pressure if
present
ICP monitoring ICP monitor to remain active
Paralysis Train of Four monitor
No ventilatory/renal/CVS support ECG, SpO2, NIBP, respiratory rate
GCS 15
If > 30 minutes is anticipated or the patient is at risk of hypothermia temperature should be
monitored. GCS is monitored if required or if any change in level of consciousness.

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 Liverpool Hospital ICU Guideline: Clinical Guidelines Intensive Care Unit
Intra-hospital transfer of ICU Patient

Equipment

No equipment is to be placed on the patient

Ventilator Requirements
 All endotracheal tubes should be checked for position and adequately secured prior
to transfer.
 Two Oxylog 3000 transport ventilators are available for internal transfers. Their
functionality is limited, so if a patient requires advanced ventilator settings, or
PEEP>10, or Fi02>60% there is a Drager EVITA XL with attached oxygen cylinders
and batteries available for internal transfers.
 Non-invasive ventilation is possible using the Oxylog 3000 or the EVITA XL
ventilators if absolutely necessary. When in doubt, intubation should be considered.

Oxygen
 The Oxylog 3000 estimates oxygen consumption in litres/min. Requirements for
patients on facemask oxygen can be estimated from flow rates. Calculate your
oxygen requirements based on:
 Likely time away from ICU x oxygen consumption x 2[2]
 As a guide: CT- 1 hour MRI- 2 hours Operating Theatre- 30mins
 Any transfer involving an elevator should take at least 2 hours oxygen supply with
them.
 Standard Liverpool ICU portable oxygen cylinder capacity = 570 litres
 Portable suction should be available for all intubated patient transfers.

The CT and MRI scanners have wall oxygen supplies but this should not be relied upon.
Ensure sufficient portable oxygen is available for the procedure.

Drugs
Current infusions: Must be clearly labelled.
Infusion pumps must have alarms set, be fully charged and have spare batteries.

Adequate supplies of all current infused drugs should be taken with the transfer.
Calculations should be based on double the estimated transfer time. At least 2 hours of
drug infusions should be available for transfers involving lifts.

Inotropes and Vasopressors should be ‘double pumped’ which refers to a back up infusion
and infusion pump is immediately available as per policy.

All non essential infusions should be removed. Infusions of electrolytes, antibiotics and
other ‘intermittent’ IV drugs should be minimised to facilitate transfer. Where possible
infusion ceased and recommence when reassessed by the Senior Medical Officer.

NG feed and TPN should be interrupted and capped off to facilitate transfer.

Consider lengthening infusion lines for ease of patient transfer from bed to scan/operating
table. Ensure all lines are appropriately labelled.

Remember to take power cords for infusion pumps as battery life is limited.

Emergency Drugs
Emergency drug supplies are available in the transfer boxes in each unit (See Appendix 1
for contents). Ensure that these are complete and any other potential drug requirements
are available (e.g. antiepileptics).

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 Liverpool Hospital ICU Guideline: Clinical Guidelines Intensive Care Unit
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Patients under sedation should have an immediately available alternative delivery method
available if the infusion fails. (e.g. 20ml syringe of propofol).

Patients with labile blood pressures or who are on inotrope or vasopressor infusions
should have a 20ml syringe of 0.5mg/ml metaraminol drawn up prior to departure for use if
the infusion fails. All must be adequately labelled with the appropriate Injectable
medication label.

Intubation Equipment
Basic intubation equipment is available in the transfer boxes. Ensure laryngoscope bulbs
and batteries are working including a spare.

Other Equipment
All patients should be transferred with the following functioning equipment:
 Transfer kit (box in each unit, contents listed in Appendix 1)
 Self inflating bag, valve and mask
 Defibrillator
 Portable suction
 Transfer monitor

Chest Drains
Underwater sealed chest drains should be treated with extreme caution during transfer.
Displacement, siphoning or tipping are possible and may lead to tension pneumothorax.
Water chambers should remain below the level of the chest at all times. Chest drains
MUST NOT be clamped for transfers.

Balloon pumps
Whilst the equipment for intra-aortic balloon pumps is portable, extreme caution should be
used and will require extra personnel to transfer the patient. A senior registrar should
accompany the transfer.

External Ventricular Drain (EVD)

EVD should be clamped when the patient is moved to prevent inappropriate positioning. All
patients with EVDs must have the position of the EVD checked prior to transfer and arrival
to the destination

IN EVENT OF EMERGENCY
Take the patient to the nearest safe place if in transit. (i.e. back to ICU, Radiology room). If
in clinical area, stay there unless it is unsafe.

Call 666 Medical Emergency Team.

3. After the transfer

On returning to the ICU, ensure all equipment is functioning with adequate ventilation and
perfusion before the transfer team stands down. Document on the Liverpool ICU Intra-
hospital Transfer Checklist Form.

Events during transfer including personnel, infusions, ventilation settings and incidents
should be documented in the medical notes.

Any clinical incidents should be recorded in the Incident Information Management System
(IIMS).

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 Liverpool Hospital ICU Guideline: Clinical Guidelines Intensive Care Unit
Intra-hospital transfer of ICU Patient

4. Performance Measures

All incidents are documented using the IIMS and managed appropriately by the Head of
Department/ NUM and staff as required.

5. References / Links

1. Waydhas C. Intrahospital transport of critically ill patients Critical Care 1999;3:R83-

9
2. Mid-Trent Critical Care Transfer Protocol 2009
3. ANZCA Minimum Standards for the intrahospital transfer of critically ill patients
2010.
4. Winter MW. Intrahospital transfer of critically ill patients; a prospective audit within
Flinders Medical Centre Anaesthesia and Intensive Care May 1, 2010

Author: ICU NPc; ICU Staff Specialist

Reviewers: ICU Medical Director, ICU Staff specialists, NM, NUM, CNC, CNEs, CNSs.

Endorsed by: Prof Michael Parr, ICU Director

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 Liverpool Hospital ICU Guideline: Clinical Guidelines Intensive Care Unit
Intra-hospital transfer of ICU Patient
Intensive Care Transport Box Contents List
Appendix 1 Transfer kit

DRUGS
Adrenaline 1:1000 amp 4
Salbutamol 5mg neb 4
Metaraminol 3mg/6ml premix syringe 2
Hydrocortisone 100mg vial 2
Adenosine 6mg vial 3
Naloxone 400mcg amp 2
Hydralazine 20mg amp 3
Metoclopramide 10mg amp 2
Salbutamol 5mg amp 2
Frusemide 20mg amp 5
Vecuronium 10mg vial 3
Calcium chloride 10% (1gm/10ml) vial 2
Metoprolol 5mg amp 2
Noradrenaline 2mg amp 2
Suxamethonium 100mg amp 1
Propofol 200mg vial 1
Lignocaine 2% amp 2
Amiodarone 150mg amp 3
Atropine 1mg amp 2
Adrenaline 1:10000 amp 5
Glucose 50% (25g/50ml) vial 1
Sodium bicarbonate 4.2g vial 1
Magnesium sulphate 10mmol (2.5g/5ml) 1
EQUIPMENT
ETT sizes 7 &8 1 each Blood tubes 1 each
LMA sizes 3,4,5 1 each Interlink vial access device 5 each
Flexitube 1 Needles (18,21,23,25) 5 each
Swivel elbow suction port 1 Cannula cap 5
Guedel airway 9,10 1 each IV 300 and Cannula dressing 5 each
Laryngoscope handle 2 Gauze squares 5
Laryngoscope blade Mac 3,4 1 each Disposable tourniquet 2
ETCO2 filter line 1 0.9% NaCl 10ml amp 10
Magill forceps 1 Alcohol swabs 5
Bougie 1 Scissor 1
ETT white cotton tapes 2 sep lengths ECG electrodes 5
Lubricating jelly 3 sachets Transpore tape 2
Yankauer Suction 2 Sterile gloves 7,8 1 each
Suction catheters 10-14 2 each Clamp 1
Resuscitation Mask M,L 1 each IV pump set 2
Syringe 5ml 5 IVC (14,16,18,20) 2 each
Syringe 10ml 5 3 way tap 2
Syringe 20ml 2 Scalpel 1
Syringe 50ml 1 NRB oxygen face mask 1
Syringe ABG 2

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 Liverpool Hospital ICU Guideline: Clinical Guidelines Intensive Care Unit
Intra-hospital transfer of ICU Patient

Liverpool ICU Intra-hospital Transfer Checklist

Doctor ………………... Patient: ………………...

Nurse ………………… MRN …………………
A/B (Non-intubated) Drugs
⃞ Airway safe with no stridor ⃞ Oxygen (1x full cylinder+spare)
⃞ RR<25, Sp02>92% and GCS>14 ⃞ Emergency sedation
⃞ Cooperative and not agitated (e.g. 20ml Propofol 1%)
If fails to meet these requirements, seek senior assistance
and consider intubation
⃞ Emergency Muscle relaxant
(e.g. Cisatracurium 5mg)
⃞ Emergency vasopressor
A/B (Intubated)
(e.g. Metaraminol 10mg/20ml)
⃞ Airway safe and secure
⃞ Emergency intubation drugs
ETT at…..cm at lips
(e.g. Suxamethonium 100mg x2)
⃞ ET CO2 monitoring in place
⃞ Emergency IV Fluids
⃞ Sp02 Monitoring in place (e.g. 0.9% NaCl 500ml)
⃞ Pa02> mmHg or Sats>92%
⃞ Vt 6-8ml/kg
⃞ Stable on Transport Ventilator Equipment
Consider using portable Evita XL ventilator if patient requires
high level of support (e.g. PEEP>10, Fi02 >60%, Paw>30) ⃞ Bag, Valve, Mask (Tested ⃞)
⃞ Portable Suction (Tested ⃞)
C ⃞ Transfer Pack (Checked ⃞)
⃞ 2x IV access routes ⃞ Tracheostomy dilator/spares
⃞ Arterial/NIBP monitoring ⃞ Defibrillator (Checked ⃞)
⃞ adequate vasopressor supply for T/F ⃞ Transport Monitor
⃞ Alarms set
D
⃞ Spare batteries
⃞ GCS and pupils recorded
⃞ adequate sedation supply for T/F
Special Circumstances
Organisation ⃞ EVD turned off
⃞ ICP monitoring
⃞ ICU Consultant aware
⃞ Chest drain NOT clamped
⃞ Destination team aware
⃞ C-Spine immobilised
⃞ Patient notes available
⃞ Doctor, Nurse and Porter ready

In Event of Emergency during Transit:

Take patient to nearest safe area (ED Resus, Radiology, Recovery
or ICU) and call 666 for the MET

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 Liverpool Hospital ICU Guideline: Clinical Guidelines Intensive Care Unit
Intra-hospital transfer of ICU Patient

Date of transfer __/__/____ Patient: ………………...

Destination: MRN …………………

Time

Drugs During Transfer

SpO2

ETCO2

Pulse
Blood Pressure
Pupil Size and Reaction

Fluids during transfer

Ventilator Used……………….. Mode………. VT…….. FiO2…… Paw…… PEEP…….

Transfer Comments:

Critical Incidents:

Return to ICU: Date: Time:

⃞ ICU Ventilator reconnected ⃞ ABCD Stable

Signed:
Doctor…Print: Sign Date…/…/….
Nurse…Print Sign Date…/…/….

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