Lessons learned from the first 50 COVID-19 critical care transfer missions conducted by a civilian UK Helicopter Emergency Medical Service team

Background The COVID-19 pandemic has placed exceptional demand on Intensive Care Units, necessitating the critical care transfer of patients on a regional and national scale. Performing these transfers required specialist expertise and involved moving patients over significant distances. Air Ambulance Kent Surrey Sussex created a designated critical care transfer team and was one of the first civilian air ambulances in the United Kingdom to move ventilated COVID-19 patients by air. We describe the practical set up of such a service and the key lessons learned from the first 50 transfers. Methods Retrospective review of air critical care transfer service set up and case review of first 50 transfers. Results We describe key elements of the critical care transfer service, including coordination and activation; case interrogation; workforce; training; equipment; aircraft modifications; human factors and clinical governance. A total of 50 missions are described between 18 December 2020 and 1 February 2021. 94% of the transfer missions were conducted by road. The mean age of these patients was 58 years (29–83). 30 (60%) were male and 20 (40%) were female. The mean total mission cycle (time of referral until the time team declared free at receiving hospital) was 264 min (range 149–440 min). The mean time spent at the referring hospital prior to leaving for the receiving unit was 72 min (31–158). The mean transfer transit time between referring and receiving units was 72 min (9–182). Conclusion Critically ill COVID-19 patients have highly complex medical needs during transport. Critical care transfer of COVID-19-positive patients by civilian HEMS services, including air transfer, can be achieved safely with specific planning, protocols and precautions. Regional planning of COVID-19 critical care transfers is required to optimise the time available of critical care transfer teams.

Cases in Paediatric Critical Care Transfer and Retrieval Medicine

Critically ill paediatric transfers have expanded rapidly over the past ten years and, as such, the need for transfer teams to recognise, understand and treat the various illnesses that they encounter is greater than ever. This highly illustrated book covers a multitude of clinical presentations in a case-based format to allow an authentic feel to the transfer process. Written by clinicians with experience in thousands of transfers, it brings together many years of experience from a world-renowned hospital. Following the case from initial presentation, to resuscitation and referral and finally with the transfer itself; the book explores the clinical stabilisation, human factors decisions and logistical challenges that are encountered every day by these teams. Following the entire journey, this is an ideal resource for all professionals who may be involved in critical care transfer and retrieval medicine, particularly those working in paediatrics, emergency medicine, anaesthesiology, intensive care, or pre-hospital settings.

Critical Care Retrieval in the Middle East: Descriptive Analysis of a Multidisciplinary Adult Critical Care Transfer and Retrieval Service in Qatar

Introduction The regionalisation of critical care resources has led to an increase in the need to transfer patients between facilities. The advent and implementation of critical care transfer and retrieval services have been the bridge to this divide, lying at the confluence of prehospital emergency care, in-hospital emergency medicine, and intensive care. Within the State of Qatar, the concept of critical care transfer and retrieval is a relatively new. Consequently, we conducted a retrospective cross-sectional study of all transfer and retrieval activity of a dedicated multidisciplinary transfer and retrieval service to better understand the use of these services in the region. Methods Extracted patient care record data were analysed and described using univariate and multivariate descriptive statistics. A log-binomial regression model with robust variance estimator was used to calculate crude and adjusted prevalence ratios for intubation status and arteriovenous access; and intubation status and medication combination, adjusting for age and gender for each model. Results Amongst the completed cases, the majority were male (60.39%), and within the 40-59 (27.7%) age group. Amongst the cases transferred, those with a primary respiratory pathology were the most common (19.59%), followed by cardiovascular patients (18.5%). Half of all patients had a self-maintained airway (51.6%), followed by a third who had an endotracheal tube in situ (36.74%). Midazolam was the most common hypnotic administered (51.27%), as was Fentanyl (88.02%) amongst the analgesic medications, and Noradrenaline amongst the inotropes (72.77%). Intubated patients had the highest proportion of severe and critical patients; patients transported with a Doctor; patients with multiple routes of arterial and/or venous access; and patients receiving any hypnotic, analgesic or inotrope, or a combination thereof. Conclusion The transfer and retrieval of critical care patients across Qatar is a relatively common occurrence. Variations in patient type and severity and the expectations of the transfer team, are significant. Variation in airway type and ventilation modalities, types and combinations of hypnotic, analgesic and inotropes used, and the multitude of arteriovenous access points observed in this study directly contributed towards the complexity of moving these patients from one facility to another.

Lessons learned from the first 50 COVID-19 critical care transfer missions conducted by a civilian UK Helicopter Emergency Medical Service

Background The COVID-19 pandemic has placed exceptional demand on Intensive Care Units, necessitating the critical care transfer of patients on a regional and national scale. Performing these transfers required specialist expertise and involved moving patients over significant distances. Air Ambulance Kent Surrey Sussex (AAKSS) created a designed critical care transfer team and was one of the first civilian air ambulances in the United Kingdom to move ventilated COVID-19 patients by air. We describe the practical set up of such a service and the key lessons learned from the first 50 transfers. Methods Retrospective review of air critical care transfer service set up and case review of first 50 transfers. Results We describe key elements of the critical care transfer service, including coordination and activation; case interrogation; workforce; training; equipment; aircraft modifications; human factors and clinical governance. A total of 50 missions are described between 18 December 2020 and 1 February 2021. The mean age of these patients was 58 years (29–83). 30 (60%) were male and 20 (40%) were female. The mean total mission cycle (time of referral until the time team declared free at receiving hospital) was 264 minutes (range 149–440 min). The mean time spent at the referring hospital prior to leaving for the receiving unit was 72 minutes (31–158). The mean transfer transit time between referring and receiving units was 72 minutes (9–182). Conclusion Critically ill COVID-19 patients have highly complex medical needs during transport. Critical care transfer of COVID-19-positive patients by civilian HEMS services, including air-transfer, can be achieved safely with specific planning, protocols and pre-cautions. Regional planning of COVID-19 critical care transfers is required to optimise the time available of critical care transfer teams.

Early warning scores and critical care transfer – patient heterogeneity, low sensitivity, high mortality

Background Emergency warning systems (EWS) are becoming a standard of care, but have unproven screening value in early critical illness. Similarly, emergency response team (ERT) care is of uncertain value. These questions are most controversial in mixed patient populations, where screening performance might vary, and intensivist-led ERT care might divert resources from existing patients. Aims To examine triggering events, disposition and outcome data for an intensivist-staffed EWS-ERT system. Methods We analysed process and outcome data over three years, classing EWS-triggered patients into three categories (non-escalated, escalated ward care and critical care transfer). The relationships between EWS data, pre-triggering clinical data, and patient disposition and outcome were examined. Results There were 1675 calls in 1190 patients. Most occurred later during admission, with critical care transfer in a minority; the rest were followed by escalated or non-escalated ward care. Patients transferred to critical care had high mortality (40.3%); less than half of patient transfers occurred following triggering EWS score predicted overall hospital mortality, but not mortality after critical care. Conclusions In a diverse hospital population, most triggering patients did not receive critical care and most critical care transfers occurred without triggering. Triggering was an insensitive screening measure for critical illness, followed by poor outcome. Higher scores predicted higher probability of transfer, but not later mortality, suggesting that EWS is being used as a decision aid but is not a true severity of illness score. Other, non-EWS data are needed for earlier detection and for prioritizing access to critical care.

Factors related to interrupted inpatient stroke rehabilitation due to acute care transfer or death

OBJECTIVES: To identify factors that are independently related to interrupted stroke rehabilitation due to acute care transfer or death. METHODS: Medical records of stroke inpatients admitted from 2012 to 2017 were reviewed. Stroke inpatients with interrupted stroke rehabilitation due to acute care transfer or death were enrolled into the case group. Those without interruption admitted in the same month were randomly selected into the control group (case to control ratio of 1 : 5). Ten clinical factors were studied. RESULTS: Among stroke inpatients, 3.2% were transferred to acute care facilities and 0.2% died. The most common causes of acute care transfer were respiratory tract infection, intracranial hemorrhage, recurrent ischemic stroke, ischemic heart disease, and seizure. Three factors were found to be significantly associated with interrupted stroke rehabilitation, i.e. presence of feeding tube, presence of anemia and age. Our results also revealed significant association between presence of feeding tube and respiratory tract infection (p = 0.005). CONCLUSION: Feeding tube, anemia and old age were identified as independent predictors of interrupted stroke rehabilitation due to acute care transfer or death. Interventions to reduce severe complications should be implemented in order to prevent interruption of rehabilitation process and to reduce the patient transfer rate.