Critical care transfers

Abstract

In his recent editorial, Handy raises interesting points regarding critical care transfers [1]. We endorse the view that only by collecting accurate data regarding transfer activity can we hope to ensure such transfers are undertaken to recognised standards. Only when armed with such data, including robust clinical governance and critical incident review, can we demonstrate the volume of work involved and the need for appropriate resources. We would suggest that the recent evaluation of the Emergency Medical Retrieval Service exemplifies this approach [2], and resulted in continuation of the service after an 18-month pilot, built on the strengths of an earlier voluntary model. A recent audit of inter-hospital transfers in Scotland again showed a reduced incidence of equipment failure when dedicated transfer teams were utilised, compared with ad hoc transfer arrangements (0.6% vs 9.2%) and a reduced incidence of unsecured medical equipment (1% vs 18%) [3]. One factor not discussed is that transfers are multi-agency tasks, involving both hospital and ambulance services. We suggest that an essential element when developing a critical care transfer network is to build closer working relationships. Greater understanding of the needs and priorities in a critical care transfer and the logistics and practical constraints on the ambulance service will improve the transfer process. As anaesthetists, we are familiar with paramedic airway skills training in the operating theatre, but to improve the critical care transfer process it is probably worth offering greater critical care exposure. We are concerned by the assertion that ‘retrieval teams will never be able to perform time-critical transfers as quickly as the referring hospital’ and the implication that neurosurgical emergencies are not time-critical. This assumes that the UK is wholly covered by district general hospitals and tertiary centres. Across much of remote and rural Scotland, initial emergency care is provided at general practioner-staffed community hospitals with no CT scanner and no staff able to institute advanced airway care. The Department of Health report ‘Comprehensive Critical Care’ stressed the importance of providing critical care beyond traditional unit boundaries [4]. Patients from these centres requiring critical care can be transferred more rapidly by an airborne critical care team to the most appropriate unit, rather than by local means. Local personnel have infrequent exposure to critical care and undertaking such a transfer stretches local services for a prolonged time, as the return journey is often protracted. It makes more sense to take critical care skills to the patient, then to resuscitate, stabilise and triage appropriately. We disagree with the suggestion that ‘if retrieval teams are to accommodate all transfers at all times of the year, they will need to incorporate significant built-in redundancy… a situation deemed intolerable in the current UK healthcare climate.’ Emergency care is an essential aspect of the NHS, and critical care transfers will often involve clinical emergencies at unsocial hours. A recent report from the Royal College of Surgeons highlights the issue of marginalisation of emergency surgery and similar considerations apply to critical care transfers [5]. This reinforces the need for accurate data and a clear appreciation of the urgency of cases and severity of illness involved. Audit will inform accurate deployment of resources, and a predictable seasonal variation in activity may allow a greater emphasis on teaching and training at times of reduced demand, with increased clinical availability at peak times. It is interesting to compare this editorial with one from 1994 [6]. Whilst progress has been made, increasing centralisation of the emergency specialities of trauma and interventional cardiology, and expansion of extracorporeal membrane oxygenation services, will place additional pressures on transfer services with an expectation that our specialty will be able to respond. A thorough appreciation of the current workload is essential.