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Transfer of patients - from the spoke to the hub   Back Bookmark and Share
Conor Deasy,I O’Sullivan

Ir Med J. 2007 Jul-Aug;100(7):538-9




Abstract
We describe the nature, frequency, and characteristics of transfers to a regional centre. This was a three month prospective descriptive study of all transfers into the hospital through the ED and a further sample survey of 100 patients received into the resuscitation room over a 2 year period. 105 patient transfers were surveyed over the three month period. A significant number (43 patients) arrived at the ED without prior notification being received by ED staff, a proportion (7 patients) warranting resuscitation room assessment. The rate of Doctor Transfer was 22%. Of the 23 patients that warranted assessment in the resuscitation room 10 were unaccompanied by a Doctor and 5 were unaccompanied by either a Doctor or a Nurse. 11% of transfers had no transfer letter or radiographs. Only 51% of transferred patients had an IV line in situ. 4 out of the 8 transfers into the resuscitation room performed by interns were associated with adverse events. There continues to be problems with the quality of care that these patients receive. Clinicians must be actively involved in the development of regional transfer protocols and interfacility agreements to ensure the safe transfer of patients to definitive care.



Introduction
Central to the development of the ‘hub and spoke’ regionalisation program in Ireland will be the provision of safe transfer and retrieval systems for ill patients. These revolve around getting the right patient to the right place at the right time by the right people with the right transport receiving the right care throughout. Secondary transport should only occur if it is likely to improve the patient’s clinical outcome 1,2 and should be undertaken in a manner that does not jeopardise the level and quality of care being given 3,4.

Cork University Hospital (CUH) is a regional trauma centre with all (except ENT) surgical specialties on site. It forms part of a city wide on take rota for acute neurological emergencies. CUH offers acute radiological facilities to district hospitals in the region.

We sought to ascertain the degree to which transfer standards were being espoused to in transfers into the Cork University Hospital Emergency Department (ED).

Methods
We performed a 3 month survey of all transfers into the ED between Oct - Dec 2004. 105 consecutive inward transfers were surveyed. A further survey was performed on all patients who were transferred into the resuscitation room over a 2 year period using the resuscitation room computerized log. A random sample of 100 patients was chosen.

Results
105 transfer patients were enrolled in the three months from October to December 2004. We were informed in advance that the transfer was occurring in 59% of cases. 23 of the 105 cases needed resuscitation room assessment and monitoring on arrival to the ED. ED was informed of the transfer in advance in this group of patients in 70% of cases.

23 (22%) cases transferred were accompanied by a Doctor, 2 by an intern, 13 by Senior House Officers and 8 by Registrars. Of the 23 patients that needed resuscitation room assessment 10 were not accompanied by a Doctor (4 of which were head injuries) and 5 had neither a Doctor nor a Nurse accompanying the transfer.

52% of patients being transferred had an intravenous (IV) line in situ.

A minority of patients 12/105 (11%) were transferred without notes or radiographs, this was compounded by the fact that 5 of these patients were not accompanied by either a Doctor nor a Nurse. 5% of cases transferred into the resuscitation room had inadequate cervical spine precautions in place. 8% had inadequate notes or x rays.

8 patients were accompanied to the resuscitation room by interns. Of these 8 patients one patient was considered to be in respiratory distress on arrival, another was transferred with a GCS of 9 and without airway or cervical spine precautions in situ, a third suffered a cardiac arrest 5 minutes before arrival, a fourth was an intubated patient.

Discussion
The standards of care provided during transfer have been widely reported as frequently being suboptimal with a lack of monitoring and appropriately trained staff 5,6,7 leading to a significant number of adverse events in both adults and children 8,9. The findings in this study echo these. Published guidelines on how the transfer of the critically ill should be conducted 10,11,12 are readily available. There is some evidence 9 that the quality of care is improved if a specialist retrieval or transfer team is used.

When transfer of patients is part of a regional plan to provide optimal care at a specialized medical facility, written transfer protocols and interfacility agreements should be in place. Many of the problems encountered in our survey may have been ameliorated by protocolised agreements.

The low rates (22%) of Doctor transfers reflects the severity of illness in most cases however in some cases it is clear that the severity of the illness was under appreciated as 10 out of the 23 patients that needed assessment in the resuscitation room on arrival were unaccompanied by a Doctor, 5 patients were unaccompanied by either Doctor or Nurse.

Patients being transferred to orthopaedic services with a diagnosis of fracture neck of femur or patients being transferred to plastic surgery for burns assessment warrant an IV line both for analgesia and IV fluids yet these were the common diagnosis where an IV line was not in situ.

The second part of this study looked purely at the patients transferred to the resuscitation room from other hospitals. It highlights problems with the use of interns for the transfer of critically ill patients. The use of interns to transfer intubated patients must in particular be addressed and discouraged.

In conclusion, clinicians must be actively involved in the development of regional transfer protocols and interfacility agreements to ensure the safe transfer of patients to definitive care.

References

  1. Whiteley S, Gray A, McHugh P, et al. On behalf of the Council of the Intensive Care Society. Guidelines for the transport of the critically ill adult. London: Intensive Care Society, 2002.
  2. The Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring. London: The Association of Anaesthetists of Great Britain and Ireland, 2000.
  3. Oakley PA. The needs for standards for inter-hospital transfer. Anaesthesia 1994;49:565–6.
  4. Wallace PGM, Ridley SA. ABC of intensive care. Transport of critically ill patients. BMJ 1999;319:368–71.
  5. Atkins ML, Pinder AJ, Murphy PG. Quality of care during the transfer of the critically ill neurosurgical patients in West Yorkshire: a comparison with national guidelines. J Neurosurg Anaesthesiol 1998;10:293.
  6. Wallace PGM, Ridley SA. ABC of intensive care. Transport of critically ill patients. BMJ 1999;319:368–71.
  7. Atkins ML, Pinder AJ, Murphy PG. Quality of care during the transfer of the critically ill neurosurgical patients in West Yorkshire: a comparison with national guidelines. J Neurosurg Anaesthesiol 1998;10:293.
  8. Barry PW, Ralston C. Adverse events occurring during interhospital transfer of the critically ill. Arch Dis Child 1994;71:8–11.
  9. Macartney I, Nightingale P. Transfer of the critically ill. Br J Anaesth CEPD reviews 2001;1:12–15.
  10. Faculty of Intensive Care of the Australasian and New ZealandCollege of Anaesthetists, and Australian College of Emergency Medicine. Minimum standards for transport of the critically ill. Melbourne: Faculty of Intensive Care of the Australasian and New Zealand College of Anaesthetists, and Australian College of Emergency Medicine, 1996.
  11. Whiteley S, Gray A, McHugh P, et al. On behalf of the Council of the Intensive Care Society. Guidelines for the transport of the critically ill adult. London: Intensive Care Society, 2002.
  12. Wallace PGM, Ridley SA. ABC of intensive care. Transport of critically ill patients. BMJ 1999;319:368–71.
Author's Correspondence
C Deasy  Lisfehill, Ballinhassig, Co. Cork E-mail: conordeasy@hotmail.com
Acknowledgement
No Acknowledgement
Other References
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