Case reports

Case 1: A consultant on-call for ICU in a tertiary centre was contacted by a consultant cardiologist in the same centre to say they had been made aware that a ventilated patient was being transferred from a referring hospital after a cardiac arrest, possibly due to a STEMI: “Other clinical details unclear but reported to have had an approximately 1-hour downtime with Lucas Device chest compressions. Requesting urgent assistance. I confirmed that ICU or Anaesthesia teams had no prior knowledge of an incoming transfer but would make rapid enquiries with [referring unit] colleagues and organise a receiving team. Also confirmed we would make an available ICU bed to support. Cardiology consultant informed me that there was no available cath lab currently and they were not on-call but would stay to treat the patient given the cardiologist who was meant to be on-call was in another unit.    Contacted Anaesthesia Consultant On-Call to forewarn of likely need for urgent assistance. They immediately proceeded to organise a team including themself, ODPs and Anaesthesia registrars in cath labs.    Called [referring hospital] ICU Consultant … and requested patient details, status and ETA … they had no specific knowledge of a patient but that their registrar had been at a trauma call in ED for a prolonged time. Requested call back with any details… informed that transfer team have already left from ED with a different Consultant. No further clinical or patient information, nor destination.  On arrival in cath lab, the patient was found to be intubated/ventilated and in respiratory extremis with oxygen saturations in the low 80s on 100%. There were only 4 pieces of paper with the patient, none of which were formal medical records (e.g. A4 page with scribe details of ALS events) or labelled with accurate patient information. Multiple aspects of events being reported by Retrieve team (such as Anterior STEMI pattern on ECG, thrombolysis) were not evident in the notes with the patient.”             

Commentary

The ICS has published guidelines for standards of transfer of critically ill adults [1], which say “The poor quality of documentation and handover between providers is consistently identified as a factor in adverse events with multiple studies suggesting that improved communication is a key to reducing errors” and “Clear records should be kept at all stages. These should include details of the patient’s condition, reason for transfer, names of referring and accepting consultants, clinical status prior to transfer and details of vital signs, clinical events and therapy given before, during and after transport.”

It is hard to add to this advice, which clearly was not followed in this case.

Case report:

Case 2: “Patient admitted to ITU… with peri arrest secondary to hypovolemic shock…   [Next day] patient was put for CT head (urgent) r/t unequal pupil size. CT dept book the porter for the allocated time for the patient, only one porter arrived to accompany the patient, who is intubated and ventilated. Myself and Dr. asked him if he can push the bed alone, he said he can manage as he expressed they are short of staff. ITU Dr. was not happy as he has to push the door, check on the patient, look for airway patency and I am holding the transfer bag. After CT scan while getting the patient out from CT suite patient had brief period of loss of cardiac output. CPR commenced; arrest call raised team arrived within 5 mins patient gained ROSC in 5 cycles with 3 Adrenaline. Patient shifted back to ITU at this time porter with his supervisor accompanied the patient. ITU Dr did raised his concern to the porter supervisor to make sure ITU patients should always be accompanied by two porters especially when they are intubated and ventilated.”

Commentary:

Although this second case was an intra-hospital transfer, many of the principles of the ICS guidelines still hold true. Organisations should have written standards for these types of transfer, including minimum personnel need for each type of transfer. Medical and nursing staff should not accept a lesser standard.

Reference:

[1] Transfer of the Critically Ill Adult. Intensive Care Society, 2019