This content has been generated for SALG by Dr Scott Grier, Clinical Director, Retrieve Adult Critical Care Transfer Service and chair of the working party updating the ICS guidance on transfer of the critically ill adult.

A cardiac patient required transfer from one hospital to another. Upon arrival of the ambulance, there were delays both in locating the patient, and identifying which staff were to accompany the patient. The crew were waiting for over 30 mins while wider team decided. The doctor accompanying the patient did not have an assistant with them. It was unclear if the hospital staff were aware of the crew’s SOPs for the type of transfer.

The crew- assisted by nursing staff- transferred the patient onto the ambulance trolley. There was then a further 30-minute delay establishing IABP monitoring.

Multiple road closures near the destination caused a delay of approximately 5 minutes on normal journey time. The doctor accompanying the patient did not seem to be aware of the process for handover of the patient at the receiving hospital. Once inside the hospital, after handover to the appropriate hospital staff the patient suffered a cardiac arrest.

Commentary

Standards for inter-hospital transfer of critically ill patients have existed for over 25 years. An update of the Intensive Care Society’s guidance on transfer of the critically ill adult is due to be published before the end of 2025.¹

Existing guidelines describe the need for two clinical escorts from the referring hospital  to accompany the patient in order to continue to deliver critical care during transfer. Typically these individuals are doctors/ACCPs from anaesthesia/critical care backgrounds, accompanied by nurse or ODP colleagues.  The new guidelines emphasise the need for these individuals to be appropriately trained and experienced in the management of the condition the patient is suffering with as well as any anticipated deterioration/complication that may occur during transfer.

Paramedic colleagues have a defined scope of practice (JRCALC)² which is typically commensurate with ward levels of care plus administration of fluids, opiate analgesia and delivery of advanced life support. They should not be asked or expected to care for patients outside this scope who require inter-hospital transfer.

Inter-facility transfers are prioritised by ambulance services based on national criteria³ and Hospital Trusts/Departments should integrate the principles of these into their transfer guidelines.

In this case there are several areas for improvement:

• There was uncertainty regarding scope of practice and competence.
• The referring hospital was unable to rapidly provide two clinical escorts to accompany the patient.
• The doctor undertaking the transfer appears unfamiliar and inexperienced with the transfer environment, the exact destination and its access in the receiving hospital.
• Many areas of the United Kingdom have access to dedicated critical care transfer services and where this is the case, they should be considered for time-critical transfers such as this one.

Emergency driving is an inherently risky undertaking and is highly governed and controlled. Ambulance crews will ask the clinical escorts about the urgency of the transfer and use this to determine the use of emergency driving conditions. The responsibility for such decisions lies with the crew and should be justifiable in court and clearly documented in medical and ambulance service records.

References:

1. Faculty of Intensive Care Medicine and Intensive Care Society. Guidance on: Transfer of the critically ill adult, London, 2019
2. Joint Royal Colleges Ambulance Liaison Committee. JRCALC Guidelines. Available from https://jrcalc.org.uk/guidelines/ (accessed 25/9/2025)
3. NHS England. National framework for inter-facility transfers. Available from https://www.england.nhs.uk/long-read/national-framework-for-inter-facility-transfers/ (accessed 25/9/2025)