Critical care transfers: using audit to make a difference

Abstract

We read Dr Handy’s recent editorial [1] on critical care transfers with great interest. In many hospitals, trainees perform these transfers and they can become a neglected area of clinical care, as consultants who set the standards and control budgets are rarely involved. They often happen outside office hours, originate from the emergency department and involve critically ill patients who may be unstable, requiring transfer for definitive care. The patient may be transferred from an environment unfamiliar to the anaesthetist and with a nurse with whom the latter has never previously worked. It is therefore essential that all necessary equipment is available to induce and maintain anaesthesia to transfer the patient safely and swiftly to the destination hospital. At our hospital, we recognised a recurring problem of missing capnography equipment that led to both delays and transfers without continuous capnography. It has been repeatedly stated that capnography saves lives, most recently in the 4th National Audit Project [2], and it is included in guidelines by both the Association of Anaesthetists [3] and the Intensive Care Society [4] for critical care transfers. Indeed, in a recent editorial, Whitaker [5] reaffirmed the need for capnography everywhere, specifically mentioning the transfer of critically ill patients. We started auditing the transfer of our patients from the Emergency Department after intubation, looking at both the indications for transfer and the monitoring used. At the end of each shift, the on-call anaesthetic registrar was contacted and asked to provide details of any transfers that had occurred. During the first 3 months, two of 18 (11%) transfers were performed with continuous capnography. We then made several interventions aimed at improving the use of capnography, including ensuring the availability of capnography leads and monitors, educating anaesthetic trainees on how to conduct transfers, placing reminder posters in the resuscitation bays and feeding back the results of audit. Our audit ran continuously and after 18 months, 20 out of 23 (87%) transfers were conducted with continuous capnography. This demonstrates that by identifying the challenges faced by trainees, collecting high quality data and feeding back effectively to the consultant and trainee bodies, both groups were made aware of the problems and the situation improved.