Transport of critically ill patients
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7206.368 (Published 07 August 1999) Cite this as: BMJ 1999;319:368
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EDITOR- Having just returned from a dedicated medical retrieval post
in New South Wales (NSW), Australia I read with interest the excellent
review by Wallace and Ridley on the transport of critically ill
patients.[1] NSW is approximately 3.5 times as large as the UK and
transport of patients between intensive care units is performed by
land ambulance in the metropolitan areas, by helicopter for journeys of
less than 400km and by fixed-wing aircraft for journeys of more than
400km. Having experienced the transfer system here and overseas I have
three points to make.
Firstly, staff safety is emphasised continuously in the NSW system and a
pre-requisite for helicopter operations is that all crew (including the
doctor!) have to under take
helicopter under-water escape training (HUET) and pass a proficiency test
in safety procedures. This is laid down in civil aviation law in Australia
(Civil Aviation Order
20.11). Whilst it is obviously impractical to train all hospital ICU staff
in such procedures, who may only occasionally be involved in such
transfers it would not be
unreasonable to have a core number who are always up to date in aspects of
flight safety. Working parties in the UK suggested several years ago that
safety training of
staff should be a part of running services which involve helicopter or
fixed-wing transfers.[2][3] This may also contribute to decreasing
insurance costs.
Secondly, the development of light-weight transfer equipment and in
particular self-contained stretcher bridges has been undertaken in
Australia over the last 15 years and there is a programme of continuous
upgrading.[4][5] Sydney
Aeromedical Retrieval Service has recently switched to using carbon-fibre
stretchers for its road ambulance as well as aluminium frames for its
equipment bridges. All this
is workshop tested and crash-rated before use.
Thirdly, in July 1999 the Australian Incident Monitoring Study for
Retrieval Medicine (AIMS) was launched. This is a centrally funded and
anonymous, voluntary reporting
system for all those involved in medical retrieval (clinicians, flight
nurses, paramedics, pilots and aircrewmen). Any incident where a patient,
member of staff or aircraft is perceived to have been at risk can be
reported; this may be clinical, technical or organisational.
The transport of patients is still a developing service in the UK we have
the luxury of being able to draw on the experiences both here and
elsewhere to improve it still
further.
P J Shirley Specialist registrar
Department of Anaesthesia, Aberdeen Royal Infirmary,
Foresterhill, Aberdeen, AB25 2ZG
1 Wallace PG, Ridley SA. Transport of critically ill patients. ABC of
intensive care. BMJ 1999;319:368-71.
2 Working Party Report. Medical helicopter systems- recommended minimum
standards for patient management. J R Soc Med 1991;84:242-4.
3 Working Party Report. Recommended standards for UK fixed wing medical
air transport systems and for patient management during transfer by fixed-
wing aircraft. J R Soc Med 1992;85:767-71.
4 Wishaw KJ, Munford BJ, Roby HP. The Careflight stretcher bridge: a
compact mobile intensive care unit. Anaes Intensive Care 1990;18:234-8.
5 Evans JSM, Hotter A. A novel equipment bridge for helicopter transport
of critically ill patients. Anaes Intensive Care;22:284-7.
Competing interests: No competing interests
Transport of Critically Ill Patients
The excellent review by Wallace and Ridley (BMJ 7 Aug. 1999, p 368),
being exclusively technical, excludes the one really salient point about
transfers. Some transfers are, as they say, for "upgraded treatment" but
many in urban England are for bed shortages.
Unless my unit is atypical many transfers "out" for ITU care are only
needed because a neighbouring unit has already transferred "in" filling a
bed. This crazy merry-go-round seems unstoppable since the people who run
intensive care are not those inconvenienced by the transfers, notably
trainee anaesthetists, those non-intensivists who cover them and patients
relatives. Similar lunacy means that these foreign patients often risk
the hazards of transfer a second time to send them home when a bed is
available on their own ITU. What should be done is an absolute (and rapid)
moratorium on all transfers other than for upgraded care.
Each ITU would
then have to find cost effective ways of being able to stretch and
contract, moving equipment and staff around within its hospital or even
between hospitals.
Intensivists treat this suggestion, when made, with scorn or horror, but
only radical steps will prevent some of the sickest patients and most
valuable staff from passing their nights (it is always at night!) in
needless ambulance trips. This is particularly true since intensivists
seem to regard transfers to meet capacity as at worst a necessary evil
and at best a chance for research and publication. The flexibility needed
will not be that great because the need to keep one's own patients will be
offset by not having to accommodate anyone else's.
Andrew Skinner
Consultant Anaesthetist,
St. Helens and Knowsley Hospitals Trust
Competing interests: No competing interests