How to transfer a sick patient.
Transferring a patient is a common daily activity. Xray, CT scan, some procedure or another, or even just between wards. Often it is no big deal. The patient can go on a bed or in a wheelchair pushed by a wardsperson.
But what if they are a bit sick….or you are just concerned for their safety?
Here are a few tips for the safe escort of an unwell, unstable or unsafe patient1.
Before Escort:
- Make the decision Do they need an escort? Some form of risk analysis should be made before all patient transfers. This should include:
Ability: does the patient have any special needs or are they likely to pose a risk to themselves during the transport? ( some examples might include confused or unsteady patients)
Stability:Are they haemodynamically and neurologically stable? What is the potential for them to deteriorate or crash during transport? Do not underestimate your gut feelings here.
Utility: Does the patient require any special equipment or interventions during transport. (some examples might include: Oxygen therapy, Spinal precautions, IV pumps, bariatric equipment etc) - Assemble the personnel: Once the decision has been made to escort your patient make sure you have the appropriate resources. This might just be yourself pushing a wheelchair, or include a wardsperson or even a doctor. If there is a significant risk of your patient crashing you should have a minimum of 3 people doing the escort all of whom have at least BLS capabilities. Those working in critical care areas doing similar transfers should have at least one staff member certified in adult/paeds advanced life support2.
Relatives. Sometimes it is appropriate for the relatives to accompany the patient on your escort (particularly with paediatric patients). When making the decision to allow relatives to come with you always consider how this would pan out if the patient were to deteriorate en route. Patients have this particular knack of crashing in elevators, which if crowded with people and relatives, can be a complicated scenario to manage. An alternative is to send relatives ahead with another staff member (or directions) to meet at the destination. - Assemble the equipment: Anticipate any equipment and/or drugs that may be needed during transport or at the destination (in the case of medical imaging for example). Items to check include IV fluids (are they going to run through?). IV pumps ( are the batteries about to run dry?)
Transport packs. Most areas now have some form of transport packs which should as a minimum contain Airway adjuncts ( naso/oro-pharangeyal) Bag-valve-mask (BVM), Suctioning equipment, Personal Protective Equipment (gloves, eye protection etc).
In the case of critical care escorts check the settings and power of monitoring and ventilation equipment.
Carry 2 full oxygen cylinders.
Carry extra paralising agents.
For intubated patients, don’t just take BVM, take a correct sized mask in case of accidental extubation.
Check that the patient has no multi-resistant organisms (MRO’s) that will require PPE for transporting staff (bonus points if you make sure the destination staff are aware of any MRO’s prior to departure). - Grab the patients notes. Take the patient notes and observation charts with you.
If the patient is off to theatre, check that consent and any pre-OT paperwork has been completed.
And make sure the patient has a correct ID bracelet. - Inform the patient & introduce the escort team: Make sure that the patient actually knows were he is about to be taken to…and why. You would be surprised how many times they have absolutely no idea.
During Escort:
- Keep an eye on. Don’t walk off in front. Walk behind the patient so you can see what is going on.
If the patient is intubated/ventilated, the patient should be pushed feet-first with the most senior person at the back of the bed watching over the airway and monitors (the wardsperson can pull from the front). - Keep a look out. If you are on an epic journey, say from one end of the hospital to another, keep track of where exactly you are so that if you have to call a code, you will know which floor and location you are at. Seriously, I have found myself with a crook patient on one occasion and completely blanked out as to which ward I was outside of (perhaps thats just me).
- Stay frosty. Often you deliver your patient to their destination and hand over to the staff in that area. But sometimes you will be required to stay and return with them after the procedure/investigation. I have talked before about the importance of not getting distracted one you have arrived at the destination. The CT staff will want to engage you in their animated discussion of Kim Kardashian’s plastic surgery history. Don’t fall for it. Your patient is just looking for a chink in your concentration to do something nasty.
And dont forget to continue with patient observations (at a frequency of your professional discretion) if you are staying with them. There is nothing worse than having a sick patient return from being away with absolutely no documentation as to what happened during that time.
After Escort:
You know they say that most mountaineering accidents happen within the last 200 meters of the descent.
It is no different for us.
- Remember the journey out and the journey back are the same journey.
Maintain points 1 and 2 from the previous section. - Once back, if they are on oxygen, make sure the tubing is reconnected to the wall. Quite a few times I have found patients breathing into masks with no flow ’cause this wasn’t done and their cylinder has tanked out.
- Plug everything back in that you unplugged.
- Document the time that the patient returned, and do a full set of welcome-home obs.
I did an essay on this exact topic in my post grad dip for emergency and it is not a well researched area of practise yet we all do this everyday…and when things go wrong adverse outcomes for our patients are common, the old boy scout motto “be prepared” is so important here as is taking the time to ensure safety all too often pt transfers are done in a rush and things can go very wrong very quickly. Great topic!!
This is a great article Ian. While working in the medical imaging department of my hospital, we were collecting statistics on how many patients arrived late, without armbands and without the staff being informed of the patients infectious status. It was appalling. I believe we should have been monitoring how often patients were sent with inappropriate escorts as well. The amount of times a patient arrived cardiac monitored with just a wardsman, a patient requiring a CTPA for ?pulmonary emboli, just parked up in the CT waiting room from ED and left, patients arriving for CVAD insertions with no armbands/pre-op checklist done, IV infusions stopped and left in the patients lap, and the orderly asked to hand over to the medical imaging nurses to start running it again when the patient gets there…no fluid order attached etc etc. At the hospital I work at, any patient requiring >2L O2 requires a nurse escort, >6L requires an RN escort. I once had a patient actually die in the waiting area after she was sent from the ward and her hudson mask had been taken off so the nurse didn’t have to go on the transfer.