David Watson, BA, PGDip Critical Care, SPQ, is resuscitation officer, advanced clinical skills, Lanarkshire NHS Trust.
Transfer of critically ill patients within a hospital is often necessary but can be associated with an increased risk of morbidity and mortality. Due to changing roles, nursing staff are commonly finding themselves responsible for transferring patients. This article outlines the issues involved in ensuring patient transfer is undertaken both safely and effectively.
The intra-hospital transfer of patients is recognised as a procedure that is fraught with complications and therefore requires careful planning and organisation. Although patients may derive significant benefit from such a transfer, there are also potential risks involved. The decision to initiate the transfer of any patient must therefore be taken with full consideration of the risks and benefits.
The Resuscitation Council (2004) gives clear instructions for transferring patients. The potential problem areas are:
- The equipment used for transferring the patient;
- The organisation of the transfer;
- The level of experience of the nurse transferring the patient;
- The level of training of the staff within the department receiving the critically ill patient.
Waydas (1999) identifies critically ill patients as being at risk during intra-hospital transfer. However, careful planning, appropriately qualified personnel and use of the correct equipment can reduce this risk. Inadequately organised transfers can ultimately go wrong, leaving the nurse feeling both angry and disappointed - but also partly responsible. Good practice to minimise this would be the provision of guidance from the trust or employer in relation to the patient transfer.
Most patients who are being considered for transfer will be having their vital functions closely monitored with regular blood pressure, pulse and oxygen saturations being recorded. During transfer these are not always continuously monitored. However, most guidelines suggest a minimum level of monitoring is essential for the safe transfer of patients. The Intensive Care Society (2002) recommends that the minimum number of checks should include:
- Blood pressure (acknowledging the limitation of non-invasive monitoring);
- Pulse oximetry;
- End-tidal CO2 (in patients who are intubated).
There are a variety of devices available commercially to allow accurate monitoring and observation of patients during transfer. To ensure that the appropriate device is selected, trials should be carried out.
Regardless of the device selected, training sessions will need to be organised to facilitate safe and appropriate use of the equipment.
Shirley (2004) recommends that the equipment should be durable, lightweight and have sufficient battery life.
The ideal would be to have appropriate equipment available at all times for transferring patients, as identified by the Department of Health’s clinical practice benchmarks (DoH, 1998).
Warren et al (2004) suggest that to minimise the risks of patient transfer, transport must be well organised and efficient.
A patient who is physiologically stable before transfer is more likely to remain so for the duration of the transfer (Association of Anaesthesia, 1996). It should be remembered, however, that this does not remove the need for constant vigilance and prompt action to deal with complications.
The patient should be reviewed prior to transfer to identify any deterioration in their clinical condition that may influence the care delivered or even postpone the transfer. There are key issues to address before transferring patients (Box 1) and ensuring these have been attended to will minimise the potential hazards that can occur during a transfer.
Transfer should only be undertaken if it is essential to the care of that patient. Experienced staff should accompany the patient during the transfer and appropriate documentation and equipment should be available. The transfer should be delayed if this is not the case. The receiving ward should also be prepared for the patient and portering staff organised to facilitate the transfer.
Experience and training
The level of skill and experience required for accompanying patients during transfer has been much debated. However, the Intensive Care Society (ICS, 2002) recommends that critically ill patients should be accompanied by a minimum of two attendants. The precise requirement for these will depend on the clinical circumstances of the individual patient.
In 2002 the Yorkshire Critical Care Transport Project undertook a local study into the secondary transfer of patients. They found that most anaesthetists who were involved in patient transfer were at senior house officer level but in 76 per cent of cases junior staff nurses accompanied them. Discussions with the nurses who transferred the patients revealed that their level of experience was minimal and that they had not undertaken resuscitation training during the previous year.
The ICS guidelines (2002) identify that in most cases the second attendant will be a nurse and that she or he will have an independent professional responsibility to the patient. Nursing staff undertaking patient transfer should be appropriately qualified and experienced. Ideally they should hold a postregistration qualification in critical care that should have included the transfer of critically ill patients and an advanced cardiac life support (ACLS) certification is also beneficial (ICS, 2002).
Nurses transferring sick patients should also be familiar with the equipment accompanying the patient (ICS, 2002). For example, a nurse transferring a patient whose clinical condition requires a defibrillator to a coronary care ward should have had training on how to use the defibrillator equipment.
Some hospital trusts are fortunate to have a hospital emergency care team nurse to help facilitate the transfer of patients. These nurses are trained to advanced life support level and highly skilled in patient assessment and intervention to enable them to manage transfers safely.
Implications for practice
The process of transporting patients to other departments has great potential for the level of care to deteriorate. The environment into which the patient is placed is often unpredictable and not well controlled (Royal College of Surgeons, 1997).
Careful planning can minimise the potential impact that these unintentional events may produce. The main aim prior to transfer and during transfer is to ensure satisfactory and stable perfusion and delivery of oxygen to tissues. The provision of appropriate equipment to facilitate monitoring during transfer and careful organisation will ensure improvement in the delivery of care.
These issues are also relevant to the transfer of patients to the scanning department, and any patient post-arrest transferring to a critical care area. Training specifically for the transferral of hospital patients is available and can be undertaken as a one-day course (Mark, 2004). The benefits of such training should be considered.
This article has been double-blind peer-reviewed.
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