As I finish lunch my pager beeps. Looking down I see we’ve been paged to transport a patient from the cardiovascular surgical ICU (CVSICU) to interventional radiology (IR). “Great,” I mumble and start walking toward our central communication center.
As I round the corner I meet my two teammates: a seasoned paramedic who has worked in critical care for 15 years and an EMT with about five years of experience. The looks on their faces offer me little reassurance. I push open the comms center door, pick up our report sheet, and get a short briefing from the dispatcher handling the transport request. “Level 4,” he says. “Sounds like a pretty sick kid.” “Great,” I repeat and turn my eyes to the faded copy of the faxed transport request.
From what I can put together, we are being asked to transport a 19-year-old male with severe sepsis and suspected endocarditis. He is running a fever, and they would like IR to pull his left subclavian central line and replace it on the right side. So far not too bad, I think, then continue to read—clinging to some remote hope that I’ve seen the worst and anything additional won’t complicate things.
It does. I notice he has a left ventricular assist device (LVAD) as well as a CentriMag right ventricular assist device (RVAD). Those two devices alone triple, if not quadruple, the complexity and acuity of this patient. Along with being intubated and mechanically ventilated, he also has two chest tubes, a mediastinal tube, a radial arterial line, a Foley catheter, a partially closed chest wall, an abdominal incision with packing, and a G-tube with enteral feedings, as well as five various infusions—Levophed, epinephrine, heparin, and two antibiotics—as well as sedation and analgesia. To say this patient is a level 4—in our world the highest acuity possible—is an understatement.
With a dramatic eye roll, the three of us grab our equipment (a portable ventilator, a monitor/defibrillator, and a backpack of ACLS medications) and walk to CVSICU. We are greeted with a near-perfect reflection of the faxed transport request: semicontrolled chaos. We get reports from the bedside nurses (mandatory two for this one patient) and physicians (plural) and begin to package the patient for transport.
Nonessential fluids are typically the first things we dispose of, but unfortunately there is nothing nonessential for this patient—it all needs to go. We discuss a plan and begin: We set the patient up on our ventilator and trial; chest tubes upright and in between the patient’s legs; coordinate the IV medications—one line for immediate access and use; secure the RVAD and assess the LVAD; and grab additional equipment for mechanical circulatory failure—a pair of clamps, a backup controller, batteries, and more. We transition the patient to our monitor, validate the ventilator settings, and with one last visual sweep are ready to move. The graduate nurse resident who is caring for the patient walks alongside us, pushing a cart with the RVAD—she wants to see how this whole “intrahospital transport” thing works.
A half-hour, several elevator rides, a dizzying trail of hallways, and 1,500 steps later, we arrive in one stable piece at interventional radiology. Before going into the room, we don “bunny suits”—white onesie-type coveralls that help maintain sterility. The circulating IR nurse is less than impressed with our arrival. To boot, she has never cared for a patient with an LVAD, much less an RVAD, and questions why this information was never relayed to her. With a professional smile poorly glued to my face, I calmly apologize and explain our current situation. With her own dramatic eye roll, she opens the doors and ushers us into a room.
The lights are bright, my face is red; I can feel my temperature rising as several radiology techs swarm the bed and prepare to help us transfer the patient from bed to table. An unrelenting question continuously scrolls through my head: What could go wrong here? The muffled chatter is barely audible over my cognition as I try to anticipate issues that might take this situation from bad to worse.
I hear my name—my paramedic partner is asking if I’m ready to sheet-lift the patient and transfer him. I nod and count, and it’s a fluid and smooth transition. Excellent, I think to myself, better than expected so far. I breathe a sigh of relief, but really I know better—cases like these rarely go as planned.
There are three commonly known venues of critical care transport—fixed wing, rotor wing, and ground—yet there is a fourth, growing both in popularity and recognition. It’s been around for years in a nonperfected capacity. Now increased patient volumes and acuities have demanded a better way to move critically ill and injured patients throughout healthcare facilities.
Intrahospital critical care transport uses evidence-based mechanisms to reduce adverse events during patient movement within hospitals. Medical centers both stateside and international are creating entire departments with dedicated teams to meet the growing demand of mobilizing critical patients safely and efficiently.
One of the first studies to demonstrate a need for in-hospital transport teams was conducted in 1999 by Dr. Christian Waydhas of Bergmannsheil University Hospitals in Germany. He reported that “adverse effects may occur in up to 70% of [intrahospital critical care] transports.”1 A 2014 article cast light on potential reasons, noting “the reduction or change of care, and the movement itself can [cause] serious complications.”2 Throw in the variable of inexperienced transport staff, and the results can be catastrophic. Hospitals all over the world have developed intrahospital transport policies, but many haven’t, due to lack of either resources or highly trained personnel.
Complications that occur during intrahospital transport of critically ill patients usually stem from circulatory and respiratory systems or transport equipment. Knowing this, a capable intrahospital transport provider should be able to prioritize safe and efficient critical care, maintain and support the cardiorespiratory systems (as well as others), and be an expert in patient transfer and transport. I believe with credentialing in critical care, such as the the CCP-C offered by the International Board of Specialty Certification, paramedics can be key parts of in-hospital transport teams.
Other areas of critical care transport have recognized the value of bringing hospital-based care to the prehospital environment; it is time we do the opposite as well. Bringing the prehospital mind-set into the hospital setting would allow providers to bring a fresh set of masteries to critically ill and injured patients. Proficiencies such safe and proper patient transport, expert work in resource-limited and high-stress environments, as well as innovation generation could be a welcome and refreshing skill set. Working in conjunction with a critical care RNs, providing safe and effective care in the in-hospital transport environment could reach new heights.
At a time when patient safety is central to hospital mission statements, the inclusion of critical care paramedics may be one of the answers we’ve been looking for.
For more on the case discussed in this article, visit FlightBridgeED.com, click the FlightBridgeED podcast, and search for RVAD vs. Air Embolus: A Lesson in CRM.
1. Waydhas C. Intrahospital transport of critically ill patients. Critical Care, 1999; 3(5), R83–R89.
2. Alamanou D, Brokalaki H. Intrahospital Transport Policies: The Contribution of the Nurse. Health Sci J, 2014 Jan; 8(2): 166–78.
Bruce Hoffman, MSN, BSN-RN, CFRN, FP-C, CCP-C, NR-P, C-NPT, is a critical care registered nurse and paramedic whose clinical background includes the ICU, ER, trauma, cardiology and critical care transport/flight. He holds a graduate degree in education and is currently enrolled in a nurse practitioner program. He is chief operating officer of FlightBridgeED Inc. Reach him at firstname.lastname@example.org.