British Journal of Anaesthesia 115 (1): 33–7 (2015) doi: 10.1093/bja/aev159 Review Article
Transport of the trauma patient G. Davies1, * and A. Chesters2 1
London’s Air Ambulance, The Helipad, Royal London Hospital, London E1 1BB, UK, and 2East Anglian Air Ambulance, Cambridge Airport, UK
Abstract The transport of the seriously injured patient is associated with risk and requires particular expertise and attention. The aim of this review is to provide a historical overview of transport services available to trauma patients in the UK, describe the various transport platforms that are used, identify risks from a system and disease perspective and how they may be mitigated, and make international comparisons. The transfer of patients requiring medical attention has developed over the years and now includes complex undertakings that undoubtedly confer a degree of risk on the patient. A number of different transport platforms are in regular use in the UK, and a number of different health-care professions of varying training, experience, and seniority undertake these transfers. The general principles are to provide no worse care en route than has been provided at the departure destination and to transport patients to a destination capable of delivering whichever intervention the patient is deemed to require. When deciding to transport an injured patient, there are risks, and appropriate mitigation must be in place, particularly if primary transfer to a major trauma centre involves bypassing a nearer facility. It is clear that those clinicians who undertake medical transfers must be appropriately trained and must have access to local or national guidelines. Medical transfers must be the subject of ongoing research, both to ensure that best practice is in place and to continue to understand the safest way of achieving essential transfers effectively. Key words: transfer; trauma
Introduction The transport of the seriously injured patient is associated with risk and requires particular expertise and attention.1–3 The aim of this review is to provide a historical overview of transport services available to trauma patients in the UK, describe the various transport platforms that are used, identify risks from a system and disease perspective and how they may be mitigated, and make international comparisons.
Different transport platforms In the UK, it is the responsibility of the National Health Service (NHS) to transport patients who need urgent trauma care. There are 11 ambulance services in England operating as independent NHS Trusts. Scotland and Wales also operate national ambulance services. While the responsibility for the movement of patient lies with the NHS, the practical movement of patients may be subcontracted to private sector
ambulance services for both scene and interhospital work. With the exception of the Scottish Ambulance Service, which has a selection of helicopter and fixed-wing aircraft, the UK NHS ambulance services transport patients in ground ambulances. Police, military, or charity-run aircraft may undertake aeromedical transfers, working in association with the ambulance services. Working alongside the NHS response, there is a network of rotary-wing (helicopter) air ambulances throughout the UK, with 35 helicopter air ambulances, operated by 24 air ambulance organizations.4 The majority of helicopter air ambulances undertake only primary transfers from the scene of accidents to the referring hospital, although some, such as the Emergency Medical Retrieval Service in Scotland, are primarily focused on the interhospital movement of patients.5 There are also specialized land-based transport services that are focused on the transport of children, such as the Children’s Acute Transport Service in London.6
© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
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*Corresponding author. E-mail: [email protected]
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Editor’s key points • Primary transfer is the movement of the trauma patient from the scene of the accident to a hospital. • Trauma services in the UK aim to achieve primary transfer to a trauma centre within a transfer time of 45 min. • Secondary transfer is the movement of patients from one facility to another. • Transfer between centres is associated with increased mortality but is inevitable in some instances. • A number of guidelines regarding patient transfer are available, including those of the UK Intensive Care Society.
Modern-day history of the ambulance service and patient transfer Understanding of the history of UK ambulance helps to explain why the movement of patients is still considered a difficult and dangerous process, lacking in governance and dedicated resource. Ambulance services in the UK were the responsibility of the Home Office and county councils until the late 1960s. In 1966, the Millar report highlighted the minimal training of staff and basic equipment that was available during patient transfer.7 In 1974, responsibility for providing an ambulance service was shifted from local authority to central government control as part of the National Health Service Reorganisation Act (1973), and with it came a gradual standardization of training and recognition that additional skills were required. The 1980s saw development of medical interventions that could be delivered at the scene or en route to hospital, such as tracheal intubation and the use of certain i.v. fluids. In the 1990s, the registration of the term ‘paramedic’ was established, and in the 2000s, the opportunity for a higher education route into the ambulance profession arose with the development of the paramedic science degree.8 New recruits into the ambulance services in the UK are now likely to have this qualification. A few regions in the UK have seen the introduction of paramedics with advanced skills and autonomous practice, as either consultant paramedics or critical care paramedics. On the whole, these schemes are focused on the treatment and transport of injured patients from the scene to
Definition and types of transfers and crew configuration There are two basic phases of patient movement: from the scene of the accident to a hospital; or from one hospital to a more specialized hospital. The skills required at each phase of transport are different. For interhospital transfers, it is important to ensure that the level of medical care that the patient is receiving in hospital is the same during the transfer. Around the world, a wide range of professional groups are involved in the transfer of patients, including emergency medical technicians, paramedics, doctors, and nurses.
Primary transfer Primary transfer, sometimes called scene transfer, is the movement of the patient from the scene of the accident to a hospital. The level of care afforded to a patient at this stage of transport is much debated and varies around the world. In the UK, it is the responsibility of the ambulance service. This care may be provided by an emergency medical technician trained in basic life support without advanced airway skills. There is no national standard that each major trauma patient should be afforded care by a paramedic trained in advanced life support, although this is often aspirational at a local level. Recent commissioning standards have tried to improve the care provided to trauma patients by ensuring that an enhanced care team (be they physicians or critical care paramedics) are available to the trauma network. In the UK, the recently developed trauma networks are designed to move the patient directly to the right hospital. By definition, the aim is to reduce the number of interhospital transfers. Such trauma networks are a feature of many health-care systems and are thought to reduce mortality.11–13 A consequence of this is that trauma patients have longer transfer times from the scene of the accident to the major trauma centre. An arbitrary figure of 45 min has been used by the majority of regional major trauma networks in the UK as a cut-off transfer time to a major trauma centre. If travel times are estimated to be longer than this, land ambulance crews should divert to the local hospital (trauma unit). Whether this cut-off time is appropriate remains unclear. The figure was a consensus-derived number from a group of prehospital care experts designing the London trauma network, which went live some years before the rest of the UK, and was partly based on calculations that wherever someone lives in London, they will be less than 45 min from one of the four major trauma centres.14 It is likely, however, that some patients would benefit from longer travel times for definitive care (for example, those patients with head injuries) and others from minimal
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on June 22, 2015
International movement of trauma patients for repatriation purpose is not the responsibility of the NHS and is dependent on funding through either insurance or private donation. Such international repatriation of trauma patients occurs in large fixed-wing aircraft, some using seats or sections of seats on commercial flights, others using dedicated air ambulances. Since the war in Afghanistan, the UK has seen military patients repatriated to the UK in aircraft capable of moving up to 30 ventilated, injured patients. In addition to organized transport services, it should be recognized that a proportion of seriously injured patients arrive at hospital on private and public transport, and in extraordinary circumstances, such as multiple or mass casualty incidents, trauma patients with minor injuries can arrive by public transport buses commandeered for the purpose. What type of platform should be used for transporting a trauma patient is multifactorial and depends on availability, prevailing weather and daylight conditions, distance, and terrain. Whatever platform, the crew background and training of the transporting clinician must be appropriate to manage any ongoing or predicted clinical needs of the patient.
the hospital. They do not train paramedics to undertake independent transfer of critically injured, ventilated patients, for whom a suitably qualified doctor from the referring institution is required to escort the patient. In most European, Scandinavian, and Australasian trauma systems, seriously injured patients are transferred between hospitals by specialist physician/paramedic teams. In the UK, this still requires a suitably skilled doctor from the referring hospital to undertake the transfer. Several authors have suggested that in addition to various guidelines relating to standards for transfer, more focus should be placed on ensuring that doctors who undertake transfers should have specific training in the transport of patients.9 10 In some countries, most notably the USA, teams consisting of critical care paramedics and flight nurses undertake the both scene work and interhospital transfers of patients.
Transport of the trauma patient
Secondary transfer Secondary transfer, or interfacility transfer, is the movement of patients from one facility to another. Interfacility transfers have been shown to increase morbidity and mortality and formed one of the drivers to develop trauma networks and major trauma centres in the UK.15 While getting the right patient directly to the right hospital is an important tenet of all trauma networks, patients can still arrive at the ‘wrong’ hospital. Patients may self-refer without contacting the ambulance service, or the local trauma triage tool may suggest that the benefit to the patient of being transported to the nearest hospital outweighs the risk of a longer transfer. Transfer of some patients is therefore inevitable. This should usually occur only if it is likely to improve the clinical outcome for the patient, but it is recognized that non-clinical reasons, such as critical care bed capacity and repatriation to local hospitals, must sometimes occur.3 Some transfers may be deemed ‘time critical’, when a patient has arrived at a small local hospital that cannot deliver life- or limb-saving saving treatment, whereas others involve a more planned transfer of a less immediately unwell patient who has had a degree of stabilization. Examples of the latter scenario include transfer for planned definitive reconstructive surgery or for investigations that are not available at the referring hospital.
Transportation and risk The risks and problems of transporting trauma patients can be viewed at several levels: the disease; the interventions; and the choice of transport platform. Demetriades and colleagues16 compared arrival at hospital by ambulance with arrival by private transport (or with the Police). The crude relative risk of death when arriving by ambulance was 2.32, with a statistically
significant difference in mortality of 28.8% for the former group and 14.1% for the latter. This association remained, even when adjusting for injury severity score (relative risk of death 1.6 if arriving by ambulance). This trend was replicated more than 15 years later by Johnson and colleagues,17 who demonstrated that patients with blunt and penetrating trauma and those requiring advanced and basic life support were more likely to die if they were transported to hospital by the emergency medical service rather than arriving by private transport (odds ratio 1.9; 95% confidence interval 1.5–2.4). The outcomes differed from the earlier study in that the effect did not persist in severely injured patients. While such papers present compelling data, some form of ambulance response is important and inevitable, but they serve to emphasize that for certain diseases and for certain skill mixes of providers, speed is of the essence. Several authors have documented the risk associated with transfer in various patient groups. An audit of transfers of patients with head injuries who were transferred from local hospitals to a specialist neurosurgical centre showed a 6% incidence of hypoxia and a 15% incidence of hypotension during the transfer.18 A study from Australia reported incidents during outof-hospital patient transportation undertaken by a dedicated retrieval service. Incidents most commonly involved equipment or direct patient care, and 59% were judged to result in patient harm.19 Mortality in trauma patients transferred between hospitals has been shown to be high.20 The simple fact that patients who are transferred are often more unwell and who, by definition, require specialist care may be one reason for this, but other factors are also relevant. For patients moving from the scene or undergoing rapid secondary transfer, the quantum of injury or pathophysiology is not static. Pneumothoraces develop over time, and bleeding may vary over time. The simple physical movement of some injuries, such as major unstable pelvic fractures, can precipitate bleeding.21 Morbidity and mortality effects of transport may also be attributable to equipment failure, and the presence of enhanced interventions in the out-of-hospital setting, such as the movement of patients with multiple i.v. infusions, pumps, invasive monitoring devices, ventilators, and other advanced life support equipment, increase the complexity of the transfer. Simple problems, such as inadvertent loss of an i.v. line or kinking and blockage of tracheal or intercostal tubes, become a larger problem to recognize and ameliorate during a transfer than may be the case in a more controlled hospital setting. Vehicle noise and movement and restricted access to the patient all contribute to the problem. There are studies that refute that the transfer of patients is associated with increased risk. A systematic review of the impact of interhospital transfer on outcomes for trauma patients by Hill and colleagues22 concluded that there was no difference in mortality between transported and non-transported patients. Their review included heterogeneous studies, many of which excluded patients who had died at outlying hospitals, so the estimation of association of transport and mortality may be biased by selfselecting patients deemed stable for transfer. Data from the UK suggest a yearly total of 300–400 crashes involving a land ambulance, with up to 10 fatalities annually.23 A total of 13 accidents or serious incidents involving Helicopter Emergency Medical Service (HEMS) aircraft have been reported to the Civil Aviation Authority since the start of air ambulance operations in the UK in 1987.24 This compares with published rates from Germany, Australia, and the USA, which have fatal accident rates per 10 000 missions ranging between 0.04 and 0.23. In the USA between 2003 and 2008, there were 85 HEMS crashes with 77 fatalities, making employment by a HEMS organization
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travel times (for example, exsanguinating injury an from abdominal stab wound). Dynamic risk assessment on an individual patient basis, made with the support of senior expert clinicians, may deliver the best results. All the UK trauma networks have developed a trauma triage tool to assist ambulance crews in the transport decision. Such tools use combinations of any or all of the three factors mechanism of injury, patient physiology, and identified injuries to help the triage decision. Data on the efficacy of these tools will become available as these networks mature. Increasingly, helicopter air ambulances also attend the major trauma patient, although only a few operate at night either by response cars or helicopter. The care provided to the trauma patient by the air ambulance community also varies depending on the crew configuration, with some of the UK air ambulance services operating a doctor–paramedic model, some operating with two paramedics on board, and some operating with a less predictable variation of both models.4 For services that operate a physician–paramedic crew configuration, the additional clinical skills of the physician change the drugs, equipment, and procedures that can be provided for the patient. This difference in skill mix can change the triage of patients and the cut-off time for transport to a major trauma centre. For example, services that carry blood and prothrombin complex concentrates can deliver a significant proportion of the key interventions that a small trauma unit could provide. In some patients, this may extend to surgical interventions, such as thoracotomy. Where patients are seen by physician–paramedic-enhanced care teams, trauma triage tools have less applicability to the individual patient because bespoke decisions may be made around patient care.
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amongst the most high risk of occupations in the country and the subject of a National Transportation Safety Board public hearing.25 Further risks of medical transportation are highlighted by the fatal crash of the fixed-wing air ambulance service of the Isle of Man in 2000,26 and more recently, with the crash involving a land ambulance in Hampshire,27 which led to the deaths of an ambulance service staff member and the patient being transported.
Improving the safety of patient transport
Training and governance for transport systems Along with, and perhaps in recognition of, national guidelines, there are a number of nationally and internationally recognized courses, in addition to local training that relates specifically to patient transfer. ‘Safe Transfer and Retrieval: the Practical Approach’ is a course run by the Advanced Life Support Group that aims to teach when, where, and how to transfer patients safely and the procedures for before and after the transfer.34 In recognition of the suboptimal situation in which transfers are undertaken by relatively junior and inexperienced staff, the courses are aimed at advanced paramedics, consultants, and registrars. Locally run transfer and retrieval courses are in place in several regions across the UK and may be linked with regional systems, such as critical care or trauma networks. In addition, the Faculty of Pre-Hospital Care has developed a national qualification, the Diploma in Retrieval and Transfer Medicine, awarded by the Royal College of Surgeons of Edinburgh, for practitioners who want to develop expertise and formalize existing knowledge through a recognized qualification. It is important that any system undertaking the transport of patients operates within a sound clinical governance system. This should form the cornerstone of any organization and encompass formal training and qualifications as outlined above, and can also use standards set by national consensus bodies to benchmark performance and to set internal audit and key performance standards. Staff should have the opportunity for
Clinical considerations It is beyond the scope of this article to detail the management of each type of injury. It is, however, important to recognize key areas where care of the patient in hospital differs from care out of hospital. Resources such as oxygen, drugs, and i.v. fluids are not infinite in the prehospital environment, and resilience must be built into the transfer. For example, some services have produced nomograms that can be used to calculate oxygen requirements for transfers of various lengths based on predicted usage.35 Likewise, equipment and batteries can and often do fail; again, resilience (including low-tech, basic mechanical solutions) must be built into the transfer. Most importantly, the principle that the level of care should not deteriorate for the period of transfer must prevail.
Conclusion The transfer of patients requiring medical attention has developed over the years and now includes complex undertakings that undoubtedly confer a degree of risk on the patient. A number of different transport platforms are in regular use in the UK, and a number of different health-care professions of varying training, experience, and seniority undertake these transfers. The general principles are to provide no worse care en route than has been provided at the departure destination and to transport patients to a destination capable of delivering whichever intervention the patient is deemed to require. When deciding to transport an injured patient, there are risks, and appropriate mitigation must be in place, particularly if primary transfer to a major trauma centre involves bypassing a nearer facility. It is clear that those clinicians who undertake medical transfers must be appropriately trained and must have access to local or national guidelines. Medical transfers must be the subject of ongoing research, both to ensure that best practice is in place and to continue to understand the safest way of achieving essential transfers effectively.
Authors’ contributions G.D. was approached to write a manuscript on this subject. G.D. and A.C. subsequently wrote, reviewed, and revised the manuscript. Both G.D. and A.C. read and approved the final manuscript submission.
Declaration of interest None declared.
References 1. Parmentier-Decrucq E, Poissy J, Favory R, et al. Adverse events during intrahospital transport of critically ill patients: incidence and risk factors. Ann Intensive Care 2013; 3: 10 2. Arthur KR, Kelz RR, Mills AM, et al. Interhospital transfer: an independent risk factor for mortality in the surgical intensive care unit. Am Surg 2013; 79: 909–913 3. Gray A. Secondary transport of the critically ill and injured adult. Emerg Med J 2004; 21: 281–5 4. UK HEMS. www.ukhems.co.uk. Available from http://www. ukhems.co.uk/localairambulance.html (accessed 7 June 2014)
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A number of national reports, such as the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in 2007, have outlined the risk associated with patient transport.28 The Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the European Society of Intensive Care Medicine have issued recommendations for the safe transfer of patients with traumatic brain injury.29 30 The AAGBI also have a safety guideline relating to interhospital transfers in general.31 The Royal College of Surgeons of England recognized the dangers of inadequately organized or poorly supervised patient transfers and the importance of responsive and safe primary and secondary transfers of injured patients in their working group publication, ‘Better Care for the Severely Injured’.15 Similar guidelines are available internationally, such as the interfacility transfer of injured patients guidelines for rural communities, published by the American College of Surgeons Committee on Trauma.32 The presence of specific guidelines from such large professional bodies is indicative of both the complexity of patient transport and the recognition of the need for consensus standards to improve safety. These guidelines are not limited to trauma patients; the UK Intensive Care Society has produced guidelines and standards relating to transport of critically ill adults.33 Any organization that undertakes patient transport has a duty to be aware of these guidelines and to ensure that their own system and processes are compliant with agreed best practice.
continuing professional development and appraisal in recognition of this specialized activity.
Transport of the trauma patient
20. Nirula R, Maier R, Moore E, Sperry J, Gentilello L. Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 2010; 69: 595–9; discussion 599–601 21. Chesters A, Roberts I, Harris T. Minimising blood loss in early trauma resuscitation. Trauma 2013; 16: 27–36 22. Hill AD, Fowler RA, Nathens AB. Impact of interhospital transfer on outcomes for trauma patients: a systematic review. J Trauma 2011; 71: 1885–900; discussion 1901 23. Lutman D, Montgomery M, Ramnarayan P, Petros A. Ambulance and aeromedical accident rates during emergency retrieval in Great Britain. Emerg Med J 2008; 25: 301–2 24. Chesters A, Grieve PH, Hodgetts TJ. A 26-year comparative review of United Kingdom helicopter emergency medical services crashes and serious incidents. J Trauma Acute Care Surg 2014; 76: 1055–60 25. USA National Transportation Safety Board. Public Hearing: Helicopter Emergency Medical Services. Washington, DC, 2009 26. Aircraft Accident Investigation Branch. AAIB Bulletin No: 1/ 2001. 2001 27. BBC News. Two dead in New Forest ambulance crash. 2013. Available from http://www.bbc.co.uk/news/uk-englandhampshire-22309545 (accessed 7 May 2014) 28. National Confidential Enquiry Into Patient Outcome and Death. Trauma: Who Cares? London: National Confidential Enquiry into Patient Outcome and Death (NCEPOD), 2007 29. Association of Anaesthetists of Great Britain and Ireland. Recommendations for the Safe Transfer of Patients with Brain Injury. London: Association of Anaesthetists of Great Britain and Ireland, 2006 30. Ferdinande P. Recommendations for intra-hospital transport of the severely head injured patient. Intensive Care Med 1999; 25: 1441–3 31. Association of Anaesthetists of Great Britain and Ireland. AAGBI Safety Guideline: Interhospital Transfer. London: Association of Anaesthetists of Great Britain and Ireland, 2009 32. American College of Surgeons Committee on Trauma. Interfacility Transfer of Injured Patients: Guidelines for Rural Communities. Chicago, Illinois: American College of Surgeons, 2002 33. Intensive Care Society. Guidelines for the Transport of the Critically Ill Adult, 3rd Edn. London: Intensive Care Society, 2011 34. Moine P. Safe transfer and retrieval: the practical approach. Crit Care 2004; 8: 69 35. Lutman D, Petros A. How many oxygen cylinders do you need to take on transport? A nomogram for cylinder size and duration. Emerg Med J 2006; 23: 703–4 Handling editor: S.J. Howell
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5. Emergency Medical Retrieval Service. Available from http:// www.emrs.scot.nhs.uk/ (accessed 7 June 2014) 6. Children’s Acute Transport Service. Available from http:// www.site.cats.nhs.uk/ (accessed 7 May 2014) 7. Millar E. Report by the Working Party on Ambulance Training and Equipment. Part 1 – Training. London: Her Majesty’s Stationery Office, 1966: 14–16 8. College of Paramedics. Historical perspectives of paramedic development. In: Paramedic Curriculum Guidance, 3rd Edn. Bridgwater: College of Paramedics, 2014: 7–10 9. Spencer C, Watkinson P, McCluskey A. Training and assessment of competence of trainees in the transfer of critically ill patients. Anaesthesia 2004; 59: 1248–9 10. Cosgrove J, Kilner A, Batchelor A, Clarke F, Bonner S, Mensah J. Training and assessment of competency in the transfer of critically ill patients. Anaesthesia 2005; 60: 413–4 11. Celso B, Tepas J, Langland-Orban B, et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma 2006; 60: 371–8; discussion 378 12. Lansink KWW, Leenen LPH. Do designated trauma systems improve outcome? Curr Opin Crit Care 2007; 13: 686–90 13. Härtl R, Gerber LM, Iacono L, Ni Q, Lyons K, Ghajar J. Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury. J Trauma 2006; 60: 1250–6; discussion 1256 14. Healthcare for London. Travel Times and Ambulance Coverage for Proposed Hyper-Acute Stroke Units and Major Trauma Centres in London. London Health Programmes, 2009: 1–6. Available at www.londonhp.nhs.uk (accessed 27 May 2015) 15. The Royal College of Surgeons of England and the British Orthopaedic Association. Better Care for the Severely Injured. London: The Royal College of Surgeons of England, 2000 16. Demetriades D, Chan L, Cornwell E, et al. Paramedic vs private transportation of trauma patients: effect on outcome. Arch Surg 1996; 131: 133–8 17. Johnson NJ, Carr BG, Salhi R, Holena DN, Wolff C, Band RA. Characteristics and outcomes of injured patients presenting by private vehicle in a state trauma system. Am J Emerg Med 2013; 31: 275–81 18. Dunn LT. Secondary insults during the interhospital transfer of head-injured patients: an audit of transfers in the Mersey Region. Injury 1997; 28: 427–31 19. Flabouris A, Runciman WB, Levings B. Incidents during outof-hospital patient transportation. Anaesth Intensive Care 2006; 34: 228–36
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Transport of the trauma patient G. Davies1, * and A. Chesters2 1
London’s Air Ambulance, The Helipad, Royal London Hospital, London E1 1BB, UK, and 2East Anglian Air Ambulance, Cambridge Airport, UK
Abstract The transport of the seriously injured patient is associated with risk and requires particular expertise and attention. The aim of this review is to provide a historical overview of transport services available to trauma patients in the UK, describe the various transport platforms that are used, identify risks from a system and disease perspective and how they may be mitigated, and make international comparisons. The transfer of patients requiring medical attention has developed over the years and now includes complex undertakings that undoubtedly confer a degree of risk on the patient. A number of different transport platforms are in regular use in the UK, and a number of different health-care professions of varying training, experience, and seniority undertake these transfers. The general principles are to provide no worse care en route than has been provided at the departure destination and to transport patients to a destination capable of delivering whichever intervention the patient is deemed to require. When deciding to transport an injured patient, there are risks, and appropriate mitigation must be in place, particularly if primary transfer to a major trauma centre involves bypassing a nearer facility. It is clear that those clinicians who undertake medical transfers must be appropriately trained and must have access to local or national guidelines. Medical transfers must be the subject of ongoing research, both to ensure that best practice is in place and to continue to understand the safest way of achieving essential transfers effectively. Key words: transfer; trauma
Introduction The transport of the seriously injured patient is associated with risk and requires particular expertise and attention.1–3 The aim of this review is to provide a historical overview of transport services available to trauma patients in the UK, describe the various transport platforms that are used, identify risks from a system and disease perspective and how they may be mitigated, and make international comparisons.
Different transport platforms In the UK, it is the responsibility of the National Health Service (NHS) to transport patients who need urgent trauma care. There are 11 ambulance services in England operating as independent NHS Trusts. Scotland and Wales also operate national ambulance services. While the responsibility for the movement of patient lies with the NHS, the practical movement of patients may be subcontracted to private sector
ambulance services for both scene and interhospital work. With the exception of the Scottish Ambulance Service, which has a selection of helicopter and fixed-wing aircraft, the UK NHS ambulance services transport patients in ground ambulances. Police, military, or charity-run aircraft may undertake aeromedical transfers, working in association with the ambulance services. Working alongside the NHS response, there is a network of rotary-wing (helicopter) air ambulances throughout the UK, with 35 helicopter air ambulances, operated by 24 air ambulance organizations.4 The majority of helicopter air ambulances undertake only primary transfers from the scene of accidents to the referring hospital, although some, such as the Emergency Medical Retrieval Service in Scotland, are primarily focused on the interhospital movement of patients.5 There are also specialized land-based transport services that are focused on the transport of children, such as the Children’s Acute Transport Service in London.6
© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
33
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on June 22, 2015
*Corresponding author. E-mail: [email protected]
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Editor’s key points • Primary transfer is the movement of the trauma patient from the scene of the accident to a hospital. • Trauma services in the UK aim to achieve primary transfer to a trauma centre within a transfer time of 45 min. • Secondary transfer is the movement of patients from one facility to another. • Transfer between centres is associated with increased mortality but is inevitable in some instances. • A number of guidelines regarding patient transfer are available, including those of the UK Intensive Care Society.
Modern-day history of the ambulance service and patient transfer Understanding of the history of UK ambulance helps to explain why the movement of patients is still considered a difficult and dangerous process, lacking in governance and dedicated resource. Ambulance services in the UK were the responsibility of the Home Office and county councils until the late 1960s. In 1966, the Millar report highlighted the minimal training of staff and basic equipment that was available during patient transfer.7 In 1974, responsibility for providing an ambulance service was shifted from local authority to central government control as part of the National Health Service Reorganisation Act (1973), and with it came a gradual standardization of training and recognition that additional skills were required. The 1980s saw development of medical interventions that could be delivered at the scene or en route to hospital, such as tracheal intubation and the use of certain i.v. fluids. In the 1990s, the registration of the term ‘paramedic’ was established, and in the 2000s, the opportunity for a higher education route into the ambulance profession arose with the development of the paramedic science degree.8 New recruits into the ambulance services in the UK are now likely to have this qualification. A few regions in the UK have seen the introduction of paramedics with advanced skills and autonomous practice, as either consultant paramedics or critical care paramedics. On the whole, these schemes are focused on the treatment and transport of injured patients from the scene to
Definition and types of transfers and crew configuration There are two basic phases of patient movement: from the scene of the accident to a hospital; or from one hospital to a more specialized hospital. The skills required at each phase of transport are different. For interhospital transfers, it is important to ensure that the level of medical care that the patient is receiving in hospital is the same during the transfer. Around the world, a wide range of professional groups are involved in the transfer of patients, including emergency medical technicians, paramedics, doctors, and nurses.
Primary transfer Primary transfer, sometimes called scene transfer, is the movement of the patient from the scene of the accident to a hospital. The level of care afforded to a patient at this stage of transport is much debated and varies around the world. In the UK, it is the responsibility of the ambulance service. This care may be provided by an emergency medical technician trained in basic life support without advanced airway skills. There is no national standard that each major trauma patient should be afforded care by a paramedic trained in advanced life support, although this is often aspirational at a local level. Recent commissioning standards have tried to improve the care provided to trauma patients by ensuring that an enhanced care team (be they physicians or critical care paramedics) are available to the trauma network. In the UK, the recently developed trauma networks are designed to move the patient directly to the right hospital. By definition, the aim is to reduce the number of interhospital transfers. Such trauma networks are a feature of many health-care systems and are thought to reduce mortality.11–13 A consequence of this is that trauma patients have longer transfer times from the scene of the accident to the major trauma centre. An arbitrary figure of 45 min has been used by the majority of regional major trauma networks in the UK as a cut-off transfer time to a major trauma centre. If travel times are estimated to be longer than this, land ambulance crews should divert to the local hospital (trauma unit). Whether this cut-off time is appropriate remains unclear. The figure was a consensus-derived number from a group of prehospital care experts designing the London trauma network, which went live some years before the rest of the UK, and was partly based on calculations that wherever someone lives in London, they will be less than 45 min from one of the four major trauma centres.14 It is likely, however, that some patients would benefit from longer travel times for definitive care (for example, those patients with head injuries) and others from minimal
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International movement of trauma patients for repatriation purpose is not the responsibility of the NHS and is dependent on funding through either insurance or private donation. Such international repatriation of trauma patients occurs in large fixed-wing aircraft, some using seats or sections of seats on commercial flights, others using dedicated air ambulances. Since the war in Afghanistan, the UK has seen military patients repatriated to the UK in aircraft capable of moving up to 30 ventilated, injured patients. In addition to organized transport services, it should be recognized that a proportion of seriously injured patients arrive at hospital on private and public transport, and in extraordinary circumstances, such as multiple or mass casualty incidents, trauma patients with minor injuries can arrive by public transport buses commandeered for the purpose. What type of platform should be used for transporting a trauma patient is multifactorial and depends on availability, prevailing weather and daylight conditions, distance, and terrain. Whatever platform, the crew background and training of the transporting clinician must be appropriate to manage any ongoing or predicted clinical needs of the patient.
the hospital. They do not train paramedics to undertake independent transfer of critically injured, ventilated patients, for whom a suitably qualified doctor from the referring institution is required to escort the patient. In most European, Scandinavian, and Australasian trauma systems, seriously injured patients are transferred between hospitals by specialist physician/paramedic teams. In the UK, this still requires a suitably skilled doctor from the referring hospital to undertake the transfer. Several authors have suggested that in addition to various guidelines relating to standards for transfer, more focus should be placed on ensuring that doctors who undertake transfers should have specific training in the transport of patients.9 10 In some countries, most notably the USA, teams consisting of critical care paramedics and flight nurses undertake the both scene work and interhospital transfers of patients.
Transport of the trauma patient
Secondary transfer Secondary transfer, or interfacility transfer, is the movement of patients from one facility to another. Interfacility transfers have been shown to increase morbidity and mortality and formed one of the drivers to develop trauma networks and major trauma centres in the UK.15 While getting the right patient directly to the right hospital is an important tenet of all trauma networks, patients can still arrive at the ‘wrong’ hospital. Patients may self-refer without contacting the ambulance service, or the local trauma triage tool may suggest that the benefit to the patient of being transported to the nearest hospital outweighs the risk of a longer transfer. Transfer of some patients is therefore inevitable. This should usually occur only if it is likely to improve the clinical outcome for the patient, but it is recognized that non-clinical reasons, such as critical care bed capacity and repatriation to local hospitals, must sometimes occur.3 Some transfers may be deemed ‘time critical’, when a patient has arrived at a small local hospital that cannot deliver life- or limb-saving saving treatment, whereas others involve a more planned transfer of a less immediately unwell patient who has had a degree of stabilization. Examples of the latter scenario include transfer for planned definitive reconstructive surgery or for investigations that are not available at the referring hospital.
Transportation and risk The risks and problems of transporting trauma patients can be viewed at several levels: the disease; the interventions; and the choice of transport platform. Demetriades and colleagues16 compared arrival at hospital by ambulance with arrival by private transport (or with the Police). The crude relative risk of death when arriving by ambulance was 2.32, with a statistically
significant difference in mortality of 28.8% for the former group and 14.1% for the latter. This association remained, even when adjusting for injury severity score (relative risk of death 1.6 if arriving by ambulance). This trend was replicated more than 15 years later by Johnson and colleagues,17 who demonstrated that patients with blunt and penetrating trauma and those requiring advanced and basic life support were more likely to die if they were transported to hospital by the emergency medical service rather than arriving by private transport (odds ratio 1.9; 95% confidence interval 1.5–2.4). The outcomes differed from the earlier study in that the effect did not persist in severely injured patients. While such papers present compelling data, some form of ambulance response is important and inevitable, but they serve to emphasize that for certain diseases and for certain skill mixes of providers, speed is of the essence. Several authors have documented the risk associated with transfer in various patient groups. An audit of transfers of patients with head injuries who were transferred from local hospitals to a specialist neurosurgical centre showed a 6% incidence of hypoxia and a 15% incidence of hypotension during the transfer.18 A study from Australia reported incidents during outof-hospital patient transportation undertaken by a dedicated retrieval service. Incidents most commonly involved equipment or direct patient care, and 59% were judged to result in patient harm.19 Mortality in trauma patients transferred between hospitals has been shown to be high.20 The simple fact that patients who are transferred are often more unwell and who, by definition, require specialist care may be one reason for this, but other factors are also relevant. For patients moving from the scene or undergoing rapid secondary transfer, the quantum of injury or pathophysiology is not static. Pneumothoraces develop over time, and bleeding may vary over time. The simple physical movement of some injuries, such as major unstable pelvic fractures, can precipitate bleeding.21 Morbidity and mortality effects of transport may also be attributable to equipment failure, and the presence of enhanced interventions in the out-of-hospital setting, such as the movement of patients with multiple i.v. infusions, pumps, invasive monitoring devices, ventilators, and other advanced life support equipment, increase the complexity of the transfer. Simple problems, such as inadvertent loss of an i.v. line or kinking and blockage of tracheal or intercostal tubes, become a larger problem to recognize and ameliorate during a transfer than may be the case in a more controlled hospital setting. Vehicle noise and movement and restricted access to the patient all contribute to the problem. There are studies that refute that the transfer of patients is associated with increased risk. A systematic review of the impact of interhospital transfer on outcomes for trauma patients by Hill and colleagues22 concluded that there was no difference in mortality between transported and non-transported patients. Their review included heterogeneous studies, many of which excluded patients who had died at outlying hospitals, so the estimation of association of transport and mortality may be biased by selfselecting patients deemed stable for transfer. Data from the UK suggest a yearly total of 300–400 crashes involving a land ambulance, with up to 10 fatalities annually.23 A total of 13 accidents or serious incidents involving Helicopter Emergency Medical Service (HEMS) aircraft have been reported to the Civil Aviation Authority since the start of air ambulance operations in the UK in 1987.24 This compares with published rates from Germany, Australia, and the USA, which have fatal accident rates per 10 000 missions ranging between 0.04 and 0.23. In the USA between 2003 and 2008, there were 85 HEMS crashes with 77 fatalities, making employment by a HEMS organization
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travel times (for example, exsanguinating injury an from abdominal stab wound). Dynamic risk assessment on an individual patient basis, made with the support of senior expert clinicians, may deliver the best results. All the UK trauma networks have developed a trauma triage tool to assist ambulance crews in the transport decision. Such tools use combinations of any or all of the three factors mechanism of injury, patient physiology, and identified injuries to help the triage decision. Data on the efficacy of these tools will become available as these networks mature. Increasingly, helicopter air ambulances also attend the major trauma patient, although only a few operate at night either by response cars or helicopter. The care provided to the trauma patient by the air ambulance community also varies depending on the crew configuration, with some of the UK air ambulance services operating a doctor–paramedic model, some operating with two paramedics on board, and some operating with a less predictable variation of both models.4 For services that operate a physician–paramedic crew configuration, the additional clinical skills of the physician change the drugs, equipment, and procedures that can be provided for the patient. This difference in skill mix can change the triage of patients and the cut-off time for transport to a major trauma centre. For example, services that carry blood and prothrombin complex concentrates can deliver a significant proportion of the key interventions that a small trauma unit could provide. In some patients, this may extend to surgical interventions, such as thoracotomy. Where patients are seen by physician–paramedic-enhanced care teams, trauma triage tools have less applicability to the individual patient because bespoke decisions may be made around patient care.
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amongst the most high risk of occupations in the country and the subject of a National Transportation Safety Board public hearing.25 Further risks of medical transportation are highlighted by the fatal crash of the fixed-wing air ambulance service of the Isle of Man in 2000,26 and more recently, with the crash involving a land ambulance in Hampshire,27 which led to the deaths of an ambulance service staff member and the patient being transported.
Improving the safety of patient transport
Training and governance for transport systems Along with, and perhaps in recognition of, national guidelines, there are a number of nationally and internationally recognized courses, in addition to local training that relates specifically to patient transfer. ‘Safe Transfer and Retrieval: the Practical Approach’ is a course run by the Advanced Life Support Group that aims to teach when, where, and how to transfer patients safely and the procedures for before and after the transfer.34 In recognition of the suboptimal situation in which transfers are undertaken by relatively junior and inexperienced staff, the courses are aimed at advanced paramedics, consultants, and registrars. Locally run transfer and retrieval courses are in place in several regions across the UK and may be linked with regional systems, such as critical care or trauma networks. In addition, the Faculty of Pre-Hospital Care has developed a national qualification, the Diploma in Retrieval and Transfer Medicine, awarded by the Royal College of Surgeons of Edinburgh, for practitioners who want to develop expertise and formalize existing knowledge through a recognized qualification. It is important that any system undertaking the transport of patients operates within a sound clinical governance system. This should form the cornerstone of any organization and encompass formal training and qualifications as outlined above, and can also use standards set by national consensus bodies to benchmark performance and to set internal audit and key performance standards. Staff should have the opportunity for
Clinical considerations It is beyond the scope of this article to detail the management of each type of injury. It is, however, important to recognize key areas where care of the patient in hospital differs from care out of hospital. Resources such as oxygen, drugs, and i.v. fluids are not infinite in the prehospital environment, and resilience must be built into the transfer. For example, some services have produced nomograms that can be used to calculate oxygen requirements for transfers of various lengths based on predicted usage.35 Likewise, equipment and batteries can and often do fail; again, resilience (including low-tech, basic mechanical solutions) must be built into the transfer. Most importantly, the principle that the level of care should not deteriorate for the period of transfer must prevail.
Conclusion The transfer of patients requiring medical attention has developed over the years and now includes complex undertakings that undoubtedly confer a degree of risk on the patient. A number of different transport platforms are in regular use in the UK, and a number of different health-care professions of varying training, experience, and seniority undertake these transfers. The general principles are to provide no worse care en route than has been provided at the departure destination and to transport patients to a destination capable of delivering whichever intervention the patient is deemed to require. When deciding to transport an injured patient, there are risks, and appropriate mitigation must be in place, particularly if primary transfer to a major trauma centre involves bypassing a nearer facility. It is clear that those clinicians who undertake medical transfers must be appropriately trained and must have access to local or national guidelines. Medical transfers must be the subject of ongoing research, both to ensure that best practice is in place and to continue to understand the safest way of achieving essential transfers effectively.
Authors’ contributions G.D. was approached to write a manuscript on this subject. G.D. and A.C. subsequently wrote, reviewed, and revised the manuscript. Both G.D. and A.C. read and approved the final manuscript submission.
Declaration of interest None declared.
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A number of national reports, such as the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in 2007, have outlined the risk associated with patient transport.28 The Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the European Society of Intensive Care Medicine have issued recommendations for the safe transfer of patients with traumatic brain injury.29 30 The AAGBI also have a safety guideline relating to interhospital transfers in general.31 The Royal College of Surgeons of England recognized the dangers of inadequately organized or poorly supervised patient transfers and the importance of responsive and safe primary and secondary transfers of injured patients in their working group publication, ‘Better Care for the Severely Injured’.15 Similar guidelines are available internationally, such as the interfacility transfer of injured patients guidelines for rural communities, published by the American College of Surgeons Committee on Trauma.32 The presence of specific guidelines from such large professional bodies is indicative of both the complexity of patient transport and the recognition of the need for consensus standards to improve safety. These guidelines are not limited to trauma patients; the UK Intensive Care Society has produced guidelines and standards relating to transport of critically ill adults.33 Any organization that undertakes patient transport has a duty to be aware of these guidelines and to ensure that their own system and processes are compliant with agreed best practice.
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Transport of the trauma patient
20. Nirula R, Maier R, Moore E, Sperry J, Gentilello L. Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 2010; 69: 595–9; discussion 599–601 21. Chesters A, Roberts I, Harris T. Minimising blood loss in early trauma resuscitation. Trauma 2013; 16: 27–36 22. Hill AD, Fowler RA, Nathens AB. Impact of interhospital transfer on outcomes for trauma patients: a systematic review. J Trauma 2011; 71: 1885–900; discussion 1901 23. Lutman D, Montgomery M, Ramnarayan P, Petros A. Ambulance and aeromedical accident rates during emergency retrieval in Great Britain. Emerg Med J 2008; 25: 301–2 24. Chesters A, Grieve PH, Hodgetts TJ. A 26-year comparative review of United Kingdom helicopter emergency medical services crashes and serious incidents. J Trauma Acute Care Surg 2014; 76: 1055–60 25. USA National Transportation Safety Board. Public Hearing: Helicopter Emergency Medical Services. Washington, DC, 2009 26. Aircraft Accident Investigation Branch. AAIB Bulletin No: 1/ 2001. 2001 27. BBC News. Two dead in New Forest ambulance crash. 2013. Available from http://www.bbc.co.uk/news/uk-englandhampshire-22309545 (accessed 7 May 2014) 28. National Confidential Enquiry Into Patient Outcome and Death. Trauma: Who Cares? London: National Confidential Enquiry into Patient Outcome and Death (NCEPOD), 2007 29. Association of Anaesthetists of Great Britain and Ireland. Recommendations for the Safe Transfer of Patients with Brain Injury. London: Association of Anaesthetists of Great Britain and Ireland, 2006 30. Ferdinande P. Recommendations for intra-hospital transport of the severely head injured patient. Intensive Care Med 1999; 25: 1441–3 31. Association of Anaesthetists of Great Britain and Ireland. AAGBI Safety Guideline: Interhospital Transfer. London: Association of Anaesthetists of Great Britain and Ireland, 2009 32. American College of Surgeons Committee on Trauma. Interfacility Transfer of Injured Patients: Guidelines for Rural Communities. Chicago, Illinois: American College of Surgeons, 2002 33. Intensive Care Society. Guidelines for the Transport of the Critically Ill Adult, 3rd Edn. London: Intensive Care Society, 2011 34. Moine P. Safe transfer and retrieval: the practical approach. Crit Care 2004; 8: 69 35. Lutman D, Petros A. How many oxygen cylinders do you need to take on transport? A nomogram for cylinder size and duration. Emerg Med J 2006; 23: 703–4 Handling editor: S.J. Howell
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