Transport vitalno ugroženog bolesnika

Pratnja bolesnika  je jedna od najtežih zadaća u radu medicinskog osoblja. Svaka pratnja ima svoje specifičnosti i problematiku a značajno ovise o internim pravilima zdravstvene ustanove kao i lokalnim specifičnostima npr. dužini transporta. Unatoč mnogobrojnim razlikama te različitim pristupima problemu premještaja i pratnje bolesnika između bolnica jedna činjenica im je zajednička. Naime gotovo u svim bolnicama pratnju kritičnih i vitalno ugroženih bolesnika obavlja anesteziološki tim koji čine anesteziolog i anesteziološki tehničar. Činjenica je kako je anesteziološki tim najkompetentniji za osiguranje i održavanje vitalnih funkcija bolesnika. Transport vitalno ugroženih bolesnika je značajna procedura tijekom koje je bolesnik izložen nastanku i razvoju ozbiljnih i po život opasnih komplikacija. Vitalno ugroženim bolesnikom smatra se svaki bolesnik kod kojeg postoji sumnja da bi se mogli razviti ili su se već razvili kardiovaskularna i / ili respiratorna disfunkcija koja im ugrožava život i zahtjeva primjenu intenzivnih mjera potpore vitalnih funkcija. Transport može biti unutarbolnički  i  međubolnički.  Transportu vitalno ugroženih bolesnika pridaje se posebna pažnja jer je premještaj bolesnika dokazano prepoznat kao čimbenik dodatnog rizika koji doprinosi lošijem ishodu liječenja.

Glavni razlozi transporta vitalno ugroženih bolesnika su :

• transport zbog potrebe za dodatnim dijagnostičkim postupcima
• transport zbog potrebe za dodatnim terapijskim postupcima
• transport zbog potrebe da se bolesnika premjesti bliže svom domu

Kod unutarbolničkog transporta najčešće se radi o transportu sa odjela u jedinicu intenzivnog liječenja ili na drugi odjel zbog dodatnih dijagnostičkih postupaka. Unutarbolnički transport najčešće se obavlja na pokretnim bolesničkim krevetima uz pratnju anesteziološkog tima i uz odgovarajući monitoring vitalnih funkcija. Prosječno vrijeme unutarbolničkog transporta je do 60 minuta.

Glavna značajka unutarbolničkog transporta je da se odvija s odjela na odjel u kontroliranim bolničkim uvjetima sa brzim pristupom jedinici intenzivnog liječenja i mogućnošću brzog zbrinjavanja mogućih komplikacija nastalih tijekom transporta.

Za razliku od unutarbolničkog transporta međubolnički transport je umnogome složeniji s mnogobrojnom i različitom problematikom. Glavna značajka beđubolničkog transporta je da se odvija u nekontroliranim vanbolničkim uvjetima bez brzog pristupa bolnici i u konačnici obilježen je nizom specifičnosti kao što su dužina prijevoza, vremenski uvjeti itd. Tijekom transporta pristup bolesniku je otežan pa anesteziološki tim znatno više ovisi o opremi i informacijama s monitora. Stoga je bitno da se kod opremanja vozila za transport nabavlja oprema koja je testirana za rad u vanbolničkim uvjetima jer na rad opreme utječu vibracije, buka ,promjene temperature,ubrzanje i slično. Kod vitalno ugroženih bolesnika u transportu ovi utjecaji mogu pogodovati nastanku ozbiljnih komplikacija. Na žalost oprema u specijalnim vozilima za transport kod nas nije standardizirana, ali bi trebala zadovoljavati barem osnovni i viši oblik kardio-pulmonalne reanimacije. Minimalni nivo praćenja vitalnih funkcija tijekom transporta bi bio:

Podrazumijeva se da su svi monitori i oprema opremljeni sa alarmima za lakši nadzor nad bolesnikovim vitalnim funkcijama.

Danas su uglavnom u primjeni monitori i aparati specijalno prilagođeni za potrebe transporta kod kojih se snabdijevanje električnom energijom vrši putem izmjenjivih baterija koje imaju mogućnost da se pune. Većina tih monitora i aparata ima i mogućnost priključka na izvor istosmjerne ili naizmjenične struje kojima raspolažu vozila za transport.

Za medicinski dio transporta vitalno ugroženog bolesnika odgovoran je anesteziološki tim koji mora izvršiti određene zadatke  da bi transport bio uspješan. Anestetičar ima odgovornu ulogu u transportu i njegova zadaća je:

• priprema svih lijekova i materijala potrebnih za transport
• priprema i osiguravanje funkcionalnosti opreme potrebne za transport
• ispravno rukovanje i čuvanje monitora i aparata potrebnih za transport
• priprema pacijenta za transport

Anestetičar je dužan u dogovoru sa anesteziologom pravilno pripremiti opremu,lijekove i bolesnika za pratnju. Obim opreme i količina lijekova ovise od osnovne bolesti zbog koje se bolesnik upućuje u drugu medicinsku ustanovu kao i očekivano vrijeme transporta. Uvijek treba pripremiti zaliha materijala računajući na nemedicinske(promet na putu,vremenski uvjeti i sl.) i medicinske (hitna intubacija, reanimacija i sl.) uvjete koji mogu produžiti vrijeme transporta. Anestetičar osigurava sigurnost  i udobnost bolesniku u tijeku samog transporta smještajući ga u pravilan položaj. Također  daje propisanu terapiju, asistira anesteziologu u provođenju medicinskih intervencija te provodi zdravstvenu njegu i higijenu bolesnika tijekom cijelog transporta.

Komplikacije i poteškoće u međubolničkom transportu se najlakše mogu podijeliti na medicinske  i paramedicinske,a važno je da obje imaju veliki utjecaj na stanje bolesnika. Paramedicinske poteškoće najčešće su vezane uz vremenske uvjete,otežan cestovni promet i ispravnost vozila. Zajedničko im je to da mogu znatno produžiti vrijeme provedeno u transportu, a svaka minuta provedena u transportu duže od planiranog povećava rizik od razvoja komplikacija u bolesnika.

Medicinske komplikacije vezane za transport vitalno ugroženog pacijenta većinom su vezane za bolest zbog koje je potreban transport,neplanirano duži transport , ispravnost i funkcionalnost opreme te ograničena količina lijekova.

Najčešće komplikacije vezane za bolest je kliničko pogoršanje bolesti tijekom transporta koje kompromitiraju kardiopulmonalni sustav,a od anesteziološkog tima zahtijevaju pravovremeno prepoznavanje nastanka istih i promptnu i ispravnu reakciju.

Neplanirano duži transport donosi opasnosti u vidu nedovoljnih količina lijekova i plinova koji se bolesniku ordiniraju u transportu. Ovdje ponajprije mislimo na dovoljnu količinu kisika i ostalih lijekova koje bolesnik prima tijekom transporta. Ove opasnosti se najlakše izbjegavaju dobrim planiranjem samog transporta i pripremom malo većih količina lijekova i plinova ode onih koje očekujemo da će se potrošiti.

Za ispravnost i funkcionalnost medicinske opreme u anesteziološkom timu brine se anestetičar a odgovoran je anesteziolog. Bitno je da je sva medicinska oprema i aparati u vozilu za transport uredno atestirana i redovno servisirana , a odgovornost anestetičara je pravilno rukovanje i održavanje opreme.

OPĆI PRINCIPI MEDICINSKOG PRIJEVOZA

Siguran prijevoz bolesnika i pratećeg medicinskog osoblja uz odabir primjerenog prijevoznog sredstva koje će osigurati minimalno potrebno vrijeme trajanja prijevoza uz osiguranje optimalne medicinske skrbi kao  i primjerene opreme za tu skrb i tima koji je osposobljen da je provede, osnovni je preduvjet svakog medicinskog prijevoza unutar bolnice ili između bolnica. Prijevoz bolesnika iz jedne bolnice u drugu u visoko razvijenim zemljama svijeta propisan je nizom protokola koji u pojedinim zemljama imaju snagu zakona. Potrebe koje moraju ispunjavati bolnice i liječnici koji sudjeluju u medicinskim prijevozima odredio je zakon (Consolidated Omnibus Budget reconcilation Act COBRA) iz 1986 god. Njegov glavni cilj jeste jamčenje jednak pristup hitnom  liječenju za sve građane bez obzira na njihovo materijalno stanje, daje odgovornost za prijevoz bolesnika bolnici odnosno liječniku koji prima bolesnika i određuje kako bolesnik može  biti prevezen iz jedne bolnice u drugu. Prema tim protokolima bolnice ne smiju prevoziti bolesnika u bolnicu koja mu ne može pružiti specifično liječenje. Bolesnik rodbina ili skrbnik moraju pristati na prijevoz nakon što su  pismeno ili usmeno izviješteni o rizicima i dobrobiti prijevoza te dati pismenu suglasnost za prijevoz. Liječnik zadužen za prijem bolesnika mora izjaviti (pisanim dokumentom) da je korist od prijevoza veća od rizika. Bolnica koja organizira prijevoz odgovorna je za osiguravanje maksimalne zdravstvene skrbi tijekom prijevoza kao i za stabilizaciju zdravstvenog stanja bolesnika prije prijevoza. Bolnica koja prima bolesnika mora imati dovoljno mjesta, odgovarajuće osoblje, opremu za prijem i mora pristati na prijevoz i prijem.

Osnovne pretpostavke organiziranja medicinskog prijevoza:

• utvrđivanje osobe odgovorne za donošenje odluke
• utvrđivanja sastava tima za medicinski prijevoz prema stanju bolesnika
• izbor prijevoznog sredstva- utvrđivanje potrebne opreme i njenih svojstava koja će omogućiti primjereni prijevoz, nadzor životnih parametara bolesnika kao i provođenje potrebnih postupaka tokom prijevoza
• utvrđivanje lijekova nužnih tokom prijevoza
• utvrđivanje potrebne dokumentacije
• utvrđivanje i osiguravanje načina komunikacije

OSOBA ODGOVORNA ZA PRIJEVOZ

U donošenje odluke o potrebi prijevoza mora biti uključen stariji liječnik u službi jer prijevoz izlaže i bolesnika i osoblje dodatnom riziku. Odluka mora biti dokumentirana i potpisana od strane liječnika koji ju je donio te u njoj mora biti naveden razlog zbog kojeg se bolesnika prevozi te datum i vrijeme kad je odluka donesena. Taj dokument mora biti sastavni dio prateće dokumentacije.

Nakon što je donesena odluka o potrebi premještaja bolesnika, osoba odgovorna za to mora osigurati njegov prijem u drugoj ustanovi  izravnom komunikacijom s nadležnom osobom ili prema važećim lokalnim protokolima i s tim mora upoznati tim koji će biti u pratnji. Isto tako na toj je osobi i odgovornost  da osigura svu potrebnu dokumentaciju koja se odnosi na:

• na identifikaciju i povijest bolesti bolesnika
• postupke provedene za vrijeme stabilizacije stanja bolesnika te parametre koji su ključni za procjenu odgovora bolesnika na provedene postupke
• važne nalaze svih fizikalnih pregleda i dijagnostičkih postupaka

Većina priznatih protokola razvijenih zemalja svijeta naglašava potrebu uspostavljanja sustava on-line i off-line medicinskog nadzora za vrijeme  prijevoza bolesnika. On-line medicinski nadzor se provodi glasovnom komunikacijom u realnom vremenu između članova tima zaduženih za prijevoz bolesnika i liječnika koji je odgovoran za taj prijevoz. Off-line medicinski nadzor znači da će se skrb bolesnika za vrijeme prijevoza provoditi na temelju pisanih protokola ili naredbi.

SASTAV TIMA I ODGOVORNOST TIJEKOM TRANSPORTA

Tijekom prijevoza se mora osigurati pružanje optimalne medicinske skrbi uz primjerenu opremu te s liječnikom i medicinskom sestrom/medicinskim tehničarom koji imaju odgovarajuće znanje i vještine za izvođenje svih postupaka koji su potrebni ili mogu biti potrebni za zbrinjavanje bolesnika. Sastav tima medicinskog prijevoza ovisi o stanju bolesnika i razini potrebne skrbi. Bolesnika,prema tome mora pratiti dobro uvježbani tim službe hitne medicinske službe, anesteziološki tim ili tim iz jedinice intenzivnog liječenja. Kad se radi o  prijevozu neonatoloških i pedijatrijskih bolesnika u timu mora biti prisutan za to posebno osposobljen specijalist( neonatolog i/ili pedijatar). Tko  će pratiti pacijenta u određenom slučaju ovisi i o ustroju službe medicinskog prijevoza kao i o bolničkim protokolima.

Medicinski tim vodi liječnik. Članovi medicinskog tima odgovorni su za stanje pacijenta tijekom prijevoza. Član tima zadužen za provjeru opreme mora svu opremu osobno provjeriti prije prijevoza, održavati je tijekom prijevoza i provjeriti stanje opreme nakon prijevoza.

Terapijske intervencije( postavljanje intravenskih kanila, postavljanje središnjih venskih katetera, endotrahealna intubacija, dekompresija prsnog koša, kontrola krvarenja) tijekom unutar bolničkog ili među bolničkog prijevoza moraju se učiniti prije prijevoza prema medicinskim standardima i protokolima.

IZBOR PRIJEVOZNOG SREDSTVA

Prijevoz bolesnika iz jedne bolnice u drugu može biti učinjen raznim prijevoznim sredstvima: avionom, helikopterom, cestovnim medicinskim vozilom i brodom. Izbor prijevoznog sredstva ovisit će o kliničkim potrebama, o dostupnosti prijevoznog sredstva, te o uvjetima na mjestu odlaska i dolaska pacijenta. Prilikom izbora sredstava za prijevoz potrebno je poznavati i posebnosti prijevoza određenim sredstvom kako bi se za njih moglo pripremiti. Tijekom prijevoza zrakom ili vodom zbog buke nije moguća auskultacija tako da nadzor vitalnih funkcija ovisi isključivo o monitorima (RR, EKG, kapnometrija, pulsna oksimetrija). Bolesnik i posada izloženi su mnogobrojnim  rizicima tijekom prijevoza zrakom ili vodom.

OPREMA

Oprema za potporu i nadzor disanja i cirkulacije kao i ostala oprema koja će se rabiti  tijekom prijevoza, mora biti standardizirana i s njom se mora moći lako rukovati. Ona mora biti postavljena i pričvršćena tako da je lako dostupna te da je rukovanje sa njom sigurno za bolesnika i zdravstvene radnike. Pri odabiru opreme mora se paziti na njenu veličinu, težinu,  otpornost na mehanička i druga oštećenja, kapacitet baterija, potrošnju kisika, kao i prikladnost za rad u uvjetima prijevoza. Poželjno je da bolesnik neko vrijeme prije prijevoza bude priključen na prijenosni ventilator i ostalu opremu koja će se rabiti tijekom prijevoza.

Potrebno je osigurati dvostruku količinu kisika od one izračunate za svakog bolesnika koji se prevozi zbog mogućih kašnjenja, kvara opreme, ili prijevoznog sredstva. Prijenosni monitori moraju imati baterije koje će izdržati dulje nego je predviđeno trajanje prijevoza. Monitori moraju imati sustav protiv artefakata koji nastaju zbog kretanja, vibracija, mogućih mehaničkih udara, promjena tlaka zraka ili temperature. Oprema mora imati vizualne i zvučne alarme. Bolesnička nosila moraju imati mogućnost dobrog učvršćivanja unutar prijevoznog sredstva. Idealno bi se na njima trebala moći učvrstiti sva oprema, uključujući boce sa kisikom, ventilator, aspirator, uređaje za kontinuiranu primjenu infuzijskih otopina i lijekova, kao i rezervne baterije. Električni i plinski priključci moraju biti kompatibilni s onim u prijevoznom sredstvu. Za neonatološki i pedijatrijski prijevoz potrebna je posebna oprema

1. Oprema za potporu i nadzor disanja

• usni i nosni nastavci za osiguranje dišnog puta( raspon oralnih i nazofaringealnih usnih nastavaka, te laringealne maske)
• set za intubaciju (uključujući raspon usnih nastavaka laringoskopa i ET- tubusa)
• samonapuhavajući ručno-ventilirajući sklop, s mogućnošću PEEP valvule
• prijenosni ventilator s alarmom i monitorom
• kisik, maske, raspršivač (kisik u količini koja nadmašuje potrebe najduljeg prijevoznog vremena)
• set za hitno kiruško osiguranje dišnog puta (perkutana traheotomija)
• oprema za sukciju odgovarajućeg standarda
• oprema za pleuralnu drenažu

2. Oprema za potporu i nadzor cirkulacije

• kombinirati ili odvojeni sustav monitora s defibrilatorom i vanjskim elektrostimulatorom
• intravenske kanile, periferni i središnji venski kateteri, arterijske kanile
• intravenske tekućine i set za infuziju pod tlakom
• infuzijske crpke
• štrcaljke i igle
• oprema za perikardiocintezu

3. Ostala oprema tijekom prijevoza bolesnika

• nazogastrična sonda i vrećica
• urinarni kateter i vrećica
• sprej za nosnu dekongestiju
• instrumenti, konci, gaze, antiseptični losioni, rukavice
• toplinska izolacija i monitor za temperaturu
• udlage i oprema za imobilizaciju kralježnice i udova
• u određenim slučajevima oprema za neonatalni/pedijatrijski/opstetricijski prijevoz
• gaze, zavoji, remeni, udlage i samoljepljiva vrpca
• škare za rezanje
• rukavice i zaštitne naočale
• spremnik za otpad

4. Prijevozno sredstvo

Izbor prijevoznog sredstva ovisi od:

• naravi bolesti
• mogućem kliničkom utjecaju prijevoza
• hitnosti intervencije
• lokaciji bolesnika
• udaljenosti među bolnicama
• broju osoba koje preuzimaju bolesnika te količini opreme koja je uključena u prijevoz
• potrebnom vremenu cestovnog prijevoza i uvjetima na cesti
• vremenskim uvjetima i zračnim ograničenjima za zračni prijevoz

LIJEKOVI

Svi lijekovi moraju biti provjereni, jasno obilježeni prije davanja i pravilno uskladišteni. Članovi tima prijevoza moraju se opskrbiti sa svim potrebnim lijekovima u dovoljnoj količini, računajući na moguća kašnjenja i zastoje tijekom prijevoza. Nužno je opskrbiti se lijekovim koji  utječu na osnovne životne funkcije, lijekovima koji su specifični za stanje bolesnika koji se prevozite lijekovima koji su primjenjivani u jedinici intenzivnog liječenja. Tijekom prijevoza potrebni se lijekovi primjenjuju intravenskim putem.

DOKUMENTACIJA

Uz bolesnika moraju biti kopije sveukupne medicinske dokumentacije, uključujući radiološke snimke te ostalu dijagnostiku. Dokumentirati se mora kliničko stanje bolesnika prije, tijekom i nakon prijevoza (stanje svijesti, sedacija, bol, nemir, promjene drugih bitnih kliničkih nalaza) kao i sve važne parametre vitalnih funkcija koje prati monitor, čimbenike okoline i primijenjenu terapiju.

MEĐUBOLNIČKI PRIJEVOZ VITALNO UGROŽENOG BOLESNIKA

Međubolnički prijevoz vitalno ugroženog bolesnika može se u odnosu na mogućnost razine zbrinjavanja podijeliti na hitni i na prijevoz koji zahtjeva hitno zbrinjavanje stanja koja mogu ugroziti život ili kakvoću života zbog odgađanja pružanja skrbi u za to osposobljenim i dostupnim ustanovama.

Potreba za organizacijom hitnog međubolničkog prijevoza vitalno ugroženog bolesnika podrazumijeva da bolnica koja skrbi o takvom bolesniku nema ili potrebnu dijagnostiku ili dovoljan broj osposobljenog osoblja ili opremu za sigurnu i učinkovitu primjenu potrebnog liječenja.

Potreba za organizacijom prijevoza što zahtjeva hitno zbrinjavanje stanja koja mogu ugroziti život ili kakvoću života zbog odgađanja pružanja skrbi u za to osposobljenim i dostupnim ustanovama, podrazumijeva da bolnica koja skrbi o takvom bolesniku nema taj stupanj skrbi ili specijalističke usluge.

Uvođenje telemedicinskih usluga može uvelike poboljšati i olakšati prijenos relevantnih podataka prilikom dogovaranja međubolničkih prijevoza bolesnika. Bolesnik koji je u stanju da može prosuđivati i dati pristanak za prijevoz mora biti informiran o rizicima i dobrobiti prijevoza te on mora potpisati suglasnost za prijevoz što se mora dokumentirati. Ako bolesnik nije u stanju da može prosuđivati, tada odluku donosi najbliža rodbina, skrbnik ili staratelj, što se također mora dokumentirati

BOLNIČKI PRIJEVOZ

Sveukupna je učestalost incidenata tijekom bolničkog prijevoza u rasponu os 6 do 70%. Pod incidentima podrazumijevamo promjene funkcije različitih organa i organskih sustava: kardiovaskularnog, respiracijskog, živčanog i drugih. Do incidenata dolazi zbog pokretanja bolesnika, ponekad zbog lošeg nadzora vitalnih funkcija, neprimjerene opreme ili zbog problema sa opremom kao i zbog neosposobljenosti pratećeg osoblja.

Potencijalna opasnost prijevoza je dobro poznata kod srčanih bolesnika. Kod njih je visoka učestalost aritmija (više od 80%). Aritmije se uz hipotenziju ili hipertenziju zapažaju i kod operiranih bolesnika. Ovi incidenti iziskuju primjenu antiaritmika, vazoaktivnih lijekova, infuzija, respirator i slično. Kardiovaskularni incidenti pojavljuju se učestalo u različitim skupinama bolesnika bez obzira na osnovnu, nekardijalnu bolest.( do 47%).

Respiracijske se komplikacije zapažaju kod gotovo svakog trećeg bolesnika tijekom prijevoza: porast frekvence disanja, pad arterijskog parcijalnog tlaka kisika, pad inspiracijske frakcije kisika. Kasna je komplikacija prijevoza, povećana učestalost pneumonija u odnosu prema bolesnicima koji nisu bili podvrgnuti prijevozu. Najčešći incidenti kod bolesnika koji su vezani za respirator bi bili hipotenzija i aritmije.

Kod svakog drugog bolesnika s ozljedom glave i mozga zapažene su tijekom bolničkog prijevoza brojne komplikacije poput: hipotenzije, hipoksije, porasta intrakranijalnog tlaka, hipotermije i dr.

Oko trećina svih incidenata povezana je sa opremom. Tijekom prijevoza dešava se niz tehničkih problema:odvajanje elektroda i infuzijskih pripravaka, odvajanje ventilatora, prekid rada monitora, manjak kisika, ispadanje tubusa, intravenske ili intraarterijske kanile, nazogastrične sonde. Učestalost tehničkih incidenata iznosi do 10%.

Oporavak vitalnih funkcija poslije poremećaja tijekom prijevoza ponekad je vrlo spor. Zapaženo je da kod oko polovine bolesnika mora mijenjati terapija zbog pogoršanja vitalnih parametara uzrokovanih prijevozom te kod oko četvrtine bolesnika i 48 sati nakon završenog prijevoza.

PREVENCIJA KOMPLIKACIJA

Vrlo je teško identificirati sve one čimbenike rizika koji su povezani sa nastankom incidenata. Važno je dovoljno rano obaviti sve koordinacije i komunikacije između osoba koje sudjeluju u organizaciji prijevoza i osoba koje će sudjelovati u samom prijevozu. Pri tome je vrlo važno na vrijeme provjeriti svu potrebnu opremu, monitore i medicinske uređaje.

U prijevozu mora učestvovati najmanje dvoje zdravstvenih djelatnika od kojih je jedan medicinski tehničar iz JIL-a. Ako su životne funkcije bolesnika nestabilne ili postoji moguća potreba za intervencijama tada u prijevozu mora sudjelovati i liječnik. Ako je bolesnik priključen na stroj za ventilaciju u prijevozu mora sudjelovati i liječnik. U praksi, tijekom prijevoza najčešće su prisutni liječnik i medicinska sestra, a katkad i respiracijski fizioterapeut. Nije dokazan utjecaj broja pratećeg osoblja na učestalost pojavljivanja neželjenih događaja. Pokazano je međutim da je broj incidenata tijekom transporta znatno smanjen ako je prisutan liječnik. Prisustvo posebno educiranog tima za prijevoz smanjuje učestalost neželjenih događaja na 15%.

ZAKLJUČCI

Opći principi prijevoza unutar bolnice isti su kao i oni između bolnica te bi trebali osigurati sigurnost bolesnika i osoblja, minimalno vrijeme trajanja prijevoza, pružanje optimalne skrbi te odgovornost liječnika. Prijevoz vitalno ugroženog bolesnika mora se smatrati produžetkom intenzivne skrbi. Kvalitetan medicinski nadzor potrebno je provoditi za cijelo vrijeme prijevoza. Bolesnika za vrijeme prijevoza mora pratiti iskusna ekipa. Liječnik je najodgovorniji za sve što se događa tijekom prijevoza i mora biti spreman reagirati na sve neželjene događaje koji mogu životno ugroziti bolesnika. Liječnik-anesteziolog mora biti u pratnji svih intubiranih pacijenata koji iziskuju strojnu ventilaciju, kao i svih kod kojih je nestabilan respiracijski kardiovaskularni ili središnji živčani sustav. Oprema koja se rabi za vrijeme prijenosa unutar bolnice mora biti lako prenosiva te se mora sastojati od opreme za potporu i nadzor disanja i cirkulacije. Za prijevoz se moraju osigurati i svi lijekovi potrebni za održavanje osnovnih životnih funkcija i lijekovi specifični za stanje bolesnika.

Boce sa kisikom s visokotlačnim regulatorom, mjeračem protoka i dovoljno dugim cijevima za svaki prijevoz moraju biti sigurno pričvršćene za bolesnička nosila.

Medicinski uređaji i monitori moraju imati pouzdane baterije sa dovoljno kapaciteta u slučaju gubitka struje ili neočekivanih zastoja. Nužno je osigurati redovno provjeravanje opreme koja se rabi za prijevoz bolesnika.

Svi podaci koji se odnose na samog bolesnika, njegovo zdravstveno stanje prije, tijekom i nakon prijevoza moraju se dokumentirati.

Transport vitalno ugroženog bolesnika je vrlo kompleksan i zahtjevan zadatak koji ima svoju specifičnu problematiku ponajviše vezanu za rizike vanbolničkih uvjeta rada i ograničenost dostupne opreme i lijekova. Da bi se rizici od eventualnih komplikacija i poteškoća u transportu sveli na minimum oprema mora biti provjerena i funkcionalna a tim za transport dobro uvježban.

LITERATURA

1. Župan Ž, Juranić J., 2011(56-58, 60-63).Dostupno na stranici hrcak.srce.hr/file/105575 Pristup dana 20.07.2014
2. Filipović N,2004(311-314).Dostupno na stranici doiserbia.nb.rs/ft.aspx. Pristup dana 20.07.2014
3. Waren J,Fromm RE, Orr RA, Rotello LC, Horst HM. American College of Critical
4. Care Medicine. Guidelines for the inter-and intrahospital transport of critically ill patiens. Crit Care Med 2004;32:256262
5. Australian Cimmision on Safty and Quality in Health Care. OSSIE Guide to Clinical Handover Improvement. Sydney 2009
6. Waydas C. Equipment review: Intrahospital transport of critically ill patiens. Critical Care 1999; 3:R83-R89

 

TRANSPORT OF VITALLY ENDANGERED PATIENTS

Author:

Franjo Babić, medical tehnician

Department of Anesthesia, Resuscitation and Intensive Care

University Clinical Hospital Mostar

 

Accompanying patients is one of the most difficult tasks in the work of the medical staff. Each accompaniment has its own peculiarities and problems and significantly depend on the internal rules of the health institutions as well as local specificities for instance: length of transport. Despite the many differences and different approaches to the problem of transfer and escort of patients between hospitals,there is one fact that they have in common. Indeeedpractice has shown that almost all hospitals critical accompaniment of PICU patients is performed by anesthetic team composed of Anesthesiologists and anesthetic technician.

The fact is that the anesthetic teams most competent and best qualified to ensure the maintenance of vital functions of the patient. Transportation of PICU patients is an important procedure during which the patient is exposed to the emergence and development of serious and life-threatening complications. Critically ill patient is any patient who is suspected to be able to develop or have already developed cardiovascular and/or respiratory dysfunction of life-threatening and requires the application of intensive support measures of vital functions. Transportation can be intrahospital and among hospitals. To the transportation of PICU patients must be given particular attention, because the transfer of patients has been recognized as an important additional risk factor that contributes to poorer results of treatment.

The main reasons for the transport of PICU patients are:

• The need for additional diagnostic procedures
• The need for additional therapeutic procedures
• The need to move patients closer to home

Transportation of patients within the hospital is performed by Department of Transport in the intensive care unit or by another department for additional diagnostic procedures. Intrahospital transport is most often performed on movable hospital bed accompanied by anesthesiological team and with appropriate monitoring of vital functions. Average time for intrahospitaltransport takes up to 60 minutes.

The main feature of intrahospital transport is to take place with from department to department in a controlled hospital conditions with quick access to the intensive care unit and with the possibility of rapid disposal of possible complications arising during transportation.

In comparisonwith intrahospitaltransport, the transport among hospitals is much more complex with numerous and diverse issues. The main feature of transport among hospitals is to take place in uncontrolled outpatient conditions without quick access to the hospital and ultimately marked by a number of specifics such as length of transportation, weather conditions etc.

During the transport access to the patient is much more difficult, so anesthetic is much more dependent on the equipment and the information from the monitor. Therefore it is essential to fit vehicles for transport and equipment must been tested to work in outpatient conditions for the operation of equipment affected by the vibration, noise, temperature changes, acceleration etc. In transport of PICU, these effects may causethe occurrence of serious complications. Unfortunately, equipment in special vehicles for transportation in our country is not standardized, but should at least meet the basic and higher form of cardio-pulmonary resuscitation standards.

The minimum level of monitoring of vital functions during transport of the patientmust be understood and all monitors and equipment must be equipped with alarms for easier control over the patient’s vital functions.

In nowadays are mostly in use the monitors and apparatus specially adapted for the purpose of transport in which the supply of electricity is done via removable batteries that have the possibility to be supplemented. Most of these monitors and the appliances have the possibility of connection to a source of electricity on the vehicle.

Medical part of transport of vitally endangered patients is responsibility of anesthetic team which must perform certain tasks in order to accomplish successful transport. The anesthetist has a very responsible role in the transportwith following tasks:

• Preparation of all drugs and materials required for transport
• Preparation and assuranceof the needed functionality of the equipment for transport
• The correct handling and storage of the monitor and otherappliances required for transport
• Preparation of transport

The anesthetist is required to consult with the anesthesiologist in order to proper preparation of the equipment, medication and patient companion. The volume of the equipment and the quantity of basic drugs depends on the disease for which the patient is referred to another hospital and the expected transport time. Always must be prepared inventories of materials counting on non-medical (traffic on the road, weather conditions, etc.) and medical (emergency intubation, resuscitation, etc.) conditions can increase the time of transport. The anesthetist ensures the safety and comfort of the patient during the transport placing it in the correct position. It also gives the prescribed treatment, assists the anesthesiologist in the conduct of medical interventions and providing health care and hygiene of the patient during the entire transport.

Complications and difficulties in transporting could be divided into medical and paramedical, and it is important that both have a major impact on the patient’s condition. Paramedical problems are usually related to weather conditions, difficult road traffic and vehicle safety. Significantly increase of the transportation time is common for all hospitals, and every minute spent in transport longer than planned increases the risk of complications in patients.

Medical complications related to transport of vitally endangered patients are mostly related to the disease due of which patient needs transprtation, unplanned longer transportion time, safety and functionality of the equipment and a limited amount of medication.

The most common complications related to the disease’s clinical deterioration during transport diseases that compromise the cardiopulmonary system, and anesthesiological team require timely recognition of the occurrence thereof and prompt and correct response.

Unplanned longer transportion time brings hazards in the form of a shortages of drugs and gases that are administered to the patient during his/her transportation. This primarily relates to the insufficient oxygen and other medications that the patient receives during transport. These dangers are most easily avoided with good planning the transportation and preparation of slightly larger quantities of drugs and gases leave those who expect to spend.

For proper operation and normal functioning of medical equipment is responsible the anesthetic team, anesthetist and responsible anesthesiologist. It is essential that all medical equipment and appliances in the vehicle for transport duly attested and regularly serviced and it is responsibility of anesthetist for proper operating and maintainance of equipment.

GENERAL PRINCIPLES OF MEDICAL TRANSPORTATION

Safe transportation of patients and accompanying medical staff with the selection of appropriate means of transport that will ensure minimal required transportation time, ensuring optimal medical care as well as appropriate equipment for the care and the team that is qualified to realize its taskrepresents an essential precondition of a medical transport within the hospital or among hospitals. Transportation of patients from one hospital to another in highly developed countries of the world has been prescribed in a number of protocols in different countries have the force of law.

Needs that must be met by hospitals and doctors who participate in medical transportation is determined by the law (Consolidated Omnibus Budget Reconciliation Act COBRA) from 1986. Its main objective is to guarantee equal access to emergency treatment for all citizens regardless of their financial condition, with responsibility for transport of patients to the doctor or hospital that receives the patient and determines how the patient can be transported from one hospital to another. According to these protocols, hospitals are forbidden from transporting patients to the hospital which can not provide specific treatment. The sick relatives or legal guardian must agree to the transfer after writing or verbally informed of the risks and benefits of transport and give written consent to the transfer. The doctor in charge of the reception of patients are required to disclose (a written document) that the benefits of transportation outweigh the risks. The hospital which organizes transport is responsible for ensuring maximum health care during transport as well as to stabilize the health status of the patient during transport. The hospital that receives patients must have adequate space, adequate staff, equipment for reception and must agree to the transfer and reception.

Basic assumptions for organizing medical transport that must be met by hospital  are:

• Determination of the person who is responsible for making the decision
• Determination of the team for medical transport according to the patient’s condition
• Choice of means of transport – establishing the necessary equipment and its properties which will allow adequate transportation, control parameters of life of patients as well as the implementation of the necessary procedures during transport
• Determination of necessary medications during transport
• Determination of the required documentation
• Identifying and providing a means of communication.

A PERSON RESPONSIBLE FOR TRANSPORTATION OF THE PATIENTS

In making decisions fortransportion must be included seniordoctor(with long experience)due to the risk that patient is exposed. The decision must be documented and signed by the doctor who brought it, and it must specify the reason for which the patient is transported and the date and time when the decision was made. This document must be an integral part of the supporting documentation.

Once the decision was made on the need to transfer patients, the person responsible for it must ensure that its admission to another institution in direct communication with the competent person or under applicable local protocols with these must meet the team who will be accompanied. Also it is doctor’s responsibility to provide all necessary documentation relating to:

• The identification and medical history of patients
• Operations carried out during the stabilization of the patient’s condition and parameters that are critical for assessing the response of patients to the implemented procedures
• Important findings of physical examination and diagnostic procedures. Most recognized protocols in developed countries highlight the need to establish a system of on-line and off-line medical supervision during transport of patients. On-line medical supervision is carried out voice communication in real time between the team members responsible for transportation of the patient and the doctor who is responsible for the transportation. Off-line medical supervision means that the care of patients during transport carried out on the basis of written protocols or orders.

TEAM COMPOSITION AND ACCOUNTABILITY IN TRANSPORT

Optimal medical care must be ensured during transportation, with appropriate equipment, a doctor and nurse/medical technician who have the appropriate knowledge and skills to perform all the procedures that are required or may be required for care of patient. Members of team for medical transport are chosen depending on the patient’s condition and level of eeded care. Patients therefore must be accompanied by a well-trained team of emergency medical services, anaesthesiology team or a team from the intensive care unit. When it comes to moving neonatology and pediatric patients in a team must be included particular qualified specialist (neonatologist and/or pediatrician). Who will monitor the patient’s condition in a particular case depends on the organization of medical transport services as well as hospital protocols.

The medical team is led by a doctor. Members of the medical team responsible for the patient’s condition during transport. Team member responsible for checking the equipment must personally check all equipment prior to transport, maintain all during transport and check the condition of the equipment after transport.

Therapeutic interventions (inserting intravenous cannula, installation of central vein catheters, endotracheal intubation, decompression of the chest, bleeding control) during the hospital within or between hospital transport must be made prior to transportation to medical standards and protocols.

CHOICE OF TRANSPORTATION DEVICE

Transportation of patients from one hospital to another can be made ​​by various means of transport: airplane, helicopter, road ambulance and boat. The choice of means of transport will depend on the clinical needs, the availability of means of transport, and on the conditions at the place of departure and arrival of the patient. When selecting the means of transport is necessary to know the specific transport certain means to them to be prepared. During transport by air or water because of the noise is not possible auscultation so that monitoring of vital functions depend solely on the monitors (RR, ECG, capnometry, pulse oximetry). The patient and his crew are exposed to many risks during transportation by air or water.

EQUIPMENT

Equipment used during transport to support and monitor breathing and circulation as well as other equipment must be standardized and must be easy to handle. It must be set and fixed so that it is readily available and that the handling of it is safe for patients and health care workers. When choosing equipment, must be paid particular attention to its size, weight, resistance to mechanical and other damage, battery capacity, oxygen consumption and suitability to work in conditions of carriage. It is desirable some time before transport to connect patient to a ventilator and other equipment that will be used during transportion.

It is necessary to provide double the amount of oxygen than those calculated for each patient to be transported in caseof possible delays, equipment failure or means of transport. Portable monitors must have batteries that will endure longer than the planned duration of transport. Monitors must have anti artifacts that occur due to movement, vibration, mechanical shock potential, the change in air pressure or temperature. Equipment must have visual and audible alarms. Hospital stretchers should have a prospect of securing inside the means of transport.The ideal for them to be able to consolidate all the equipment, including oxygen bottles, fan, aspirator, devices for continuous infusion solutions and drugs, as well as spare batteries. Electric and gas connections must be compatible with that of the means of transport. For neonatal and pediatric transport requires special equipment.

1. Equipment for support and breathing control

• Oral and nasal extensions for securing the airway (range of oral and nasopharyngeal mouthparts extensions, and laryngeal mask)
• Set for intubation (including range extensions mouthparts laryngoscope and ET-tube)
• Self-inflating hand-ventilated assembly with the possibility of PEEP-valve
• Portable fan with alarm and monitor
• Oxygen, masks, nebulizer (oxygen in an amount that exceeds the needs of the longest transport time)
• Set for emergency surgical securing the airway (percutaneous tracheostomy)
• Supplies suction for appropriate standards
• Supplies for pleural drainage.

 

2. Equipment for support and monitoring the circulation

• Combined or separate system monitors with the defibrillator and external pacemaker
• Intravenouscannula, peripheral and central venous catheters, arterial cannula
• Intravenous and fluid infusion set pressure
• Infusion pumps
• Syringes and needles
• Supplies for perikardiocintezu

 

3. Otherrequired equipment during transportion of the patients

• Nasogastric probe and bags
• Urinary catheter and bag
• Spray for nasal decongestion
• The instruments, sutures, gauze, antiseptic lotions, gloves
• Thermal isolation and temperature monitor
• Splints and equipment to immobilize the spine and extremities
• In certain cases, equipment for neonatal/pediatric/obstetric transport
• Gauze, bandages, straps, splints and masking tape
• Scissorsfor cutting
• Gloves and goggles
• Container for trash

4. Transportation device

The choice of means of transport depends on:

• The nature of the disease
• The potential clinical impact of transportation
• Emergency intervention
• Location of patients
• Distances between hospitals
• The number of people who take the patient and the amount of equipment involved in the transport
• The time needed for road transport and road conditions
• Weather conditions and air traffic restrictions for air freight

MEDICAMENTS (Drugs)

All medications must be checked, clearly labeled prior to administration and properly stored. Team members of transport must prvided with all the necessary medication in sufficient quantity, taking into account possible delays and delays during transport. It is necessary to supply the drugs that affect the vital functions, drugs that are specific to the condition of patients who carry the drugs that are administered in the intensive care unit. During transport needed medications are administered intravenously.

DOCUMENTATION

Overall medical records must be with the patient, including radiological images and other diagnostics. Must be documented the clinical condition of the patients before, during and after transportion (state of consciousness, sedation, pain, discomfort, changes in other relevant clinical findings) as well as all the important parameters of vital functions monitored by the monitor, environmental factors and the therapy.

TRANSPORTATION OF VITALLY ENDANGERED PATIENTS AMONG HOSPITALS

Transportation of vitally endangered patients may be in respect of the level of care to share the emergency and transport, which requires emergency care conditions that may endanger the life or quality of life because of the delay in providing care by qualified and available facilities.

The need to organize emergency transport of vitally endangered patients among hospitals means that care for these patients required diagnosis or a sufficient number of qualified personnel or equipment for the safe and effective implementation of necessary treatment.

The need for a organizing transportation which requires emergency care conditions that may endanger the life or quality because of the delay in providing care by qualified and available facilities, it is understood that the hospital takes care of such a patient does not have this level of care or specialist services.

The introduction of telemedicine services can greatly improve and facilitate the transfer of relevant information during the negotiation among hospitals transport of patients. A patient who is in a position to be judged and give consent for the transfer must be informed about the risks and benefits of transportation, also he/she must sign a consent for transport which must be documented. If the patient is not able for conscious judge, then the decision is made by the nearest relative, guardian or custodian, which must be documented.

HOSPITAL TRANSPORTATION

The overall frequency of incidents during hospital transport axis in the range 6-70%. Incidents includes changes of functions of various organs and organ systems: cardiovascular, respiratory, nervous and others. Incidents occured because of moving the patients, sometimes because of poor monitoring of vital functions, improper equipment or due to problems with equipment as well as the incompetence of support staff.

The potential danger of transportation is well known by cardiac patients. They also have the high incidence of arrhythmias (over 80%). Arrhythmias and hypotension or hypertension are observed in the treated patients. These incidents require the application of anti-arrhythmic, vasoactive drugs, infusion, respirator, and the etc. Cardiovascular incidents occur frequently in different groups of patients, regardless of the underlying, non-cardiac disease (up to 47%).

Respiratory complications were detected in each third observed patient during his/her transportion: an increase in respiratory rate, decrease in arterial oxygen partial pressure, decrease inspiratory fraction of oxygen. The late complications of transportation, the increased incidence of pneumonia compared with patients who were not transported. The most frequent incidents to the patients who are attached to the respirator ae hypotension and arrhythmia.

To every second patient with a head or brain injury that was observed during hospital transportionwere detected many complications such as hypotension, hypoxia, increase in intracranial pressure, hypothermia and others.

About a third of all incidents connected with the equipment. During transport occurs a number of technical problems: the separation of the electrodes and infusion preparations, separation fan shutdown monitors, oxygen deficit, falling out of the tube, intravenous or intra-arterial cannula, a nasogastric tube. Frequency of technical incidents amounts to 10%.

The recovery of vital functions after disturbance during transport is sometimes very slow. It is noticed that about half of patients must change therapy due to worsening vital parameters caused by transport and in about a quarter of patients, and 48 hours after completion of transport.

PREVENTION OF COMPLICATIONS

It is very difficult to identify those risk factors that are associated with the occurrence of incidents. The important thing is early realize all the coordination and communication between the people involved in the organization of transport and persons who will participate in the transport of patients. It is very important to timely check all the necessary equipment, monitors and medical devices.

The transport must attend at least two health workers, of which one nurse from the intensive care unit. If the vital functions of patient are unstable or there is a possible need for interventions, then the transportion must attend a doctor. If the patient is connected to a ventilation machine, a doctor must be in the team when transporting. In practice, during transport are usually attending doctor and nurse, and sometimes respiratory therapist. There was no evidence the influence of the number of support staff in the incidence of adverse events. It has been shown, however, that the number of incidents during transport substantially reduced if present physician. The presence of specially trained team of transportation reduces the incidence of adverse events at 15%.

CONCLUSIONS

General principles of intrahospitaltransport are the same as those among the hospitals and should ensure the safety of patients and staff, the minimum duration of transport, providing optimal care and responsibility of the doctor. Transportation of vitally endangered patients should be considered as an extension of intensive care. High quality medical supervision is necessary to carry out the whole time of transport. Patients during transport must be accompanied by an experienced team. The doctor is most responsible for everything that happens during transportation and must be ready to react to any unwanted events that can endanger life of the patient. Doctor-anesthesiologist must be accompanied with all intubated patients who require mechanical ventilation, as well as those with respiratory unstable cardiovascular or central nervous system. The equipment is used during transmission within the hospital should be easily transferable and must consist of equipment to support and monitor breathing and circulation. Transportation must be provided with all medicines needed to maintain basic life functions and medications specific to the patient’s condition.

Bottles with oxygen with high pressure regulator, flow meter and sufficiently long hoses for each transport must be securely attached to the sickness wore.

Medical devices and monitors must have reliable batteries with enough capacity in the event of loss or unexpected power outages. It is necessary to ensure regular checking of equipment that is used to transport patients.

All information pertaining to the patient, his health before, during and after transport must be documented.

Transportation of vitally endangered patients is very complex and demanding task that has its own specific issues primarily related to the risks of outpatient operating conditions and limitations of available equipment and drugs. In order to reduce risks of any complications and difficulties in transport all equipment must be checked by functional and well trained  team for transportation.

REFERENCES

1. Župan Ž, Juranić J., 2011(56-58, 60-63).Available on the websitehrcak.srce.hr/file/105575. Accessed on20^th July 2014
2. Filipović N,2004(311-314).Available on the websitedoiserbia.nb.rs/ft.aspx. Accessed on20^th July 2014
3. WarenJ,Fromm RE, Orr RA, Rotello LC, Horst HM. American College of Critical
4. Care Medicine. Guidelines for the inter-and intrahospital transport of critically ill patiens. Crit Care Med 2004;32:256262
5. Australian Cimmision on Safty and Quality in Health Care. OSSIE Guide to Clinical Handover Improvement. Sydney 2009
6. Waydas C. Equipment review: Intrahospital transport of critically ill patiens. Critical Care 1999; 3:R83-R89