Critical Transfer

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An example is in Figure 1 , and the formal recursive calculation is described in the Technical Appendix. At left is a sample network, with all hospitals transferring the same number of patients. This measure of network centrality is analogous to the measure of web-page prominence PageRank used by the search engine Google. A webpage to which many other webpages link is rated as more prominent. Likewise, a link coming from a webpage that is itself more prominent e.

However, F is more central then C, despite the fact that they both receive transfers from two other hospitals.

Principles of critical care transfers

In order to summarize the extent to which hospital characteristics are associated with variation in network centrality, we used a non-parametric Kruskal-Wallis test to avoid unnecessary assumptions about the distribution of variables. Table 1 We used a chi-squared test to evaluate the equivalence of the rates of characteristics across four hospital categories Table 2.

In order to test the relationship between the variation in network centrality and hospital characteristics, we used the R 2 , functioning as a multiple correlation coefficient. Details on calculations, and reports of sensitivity analyses are reported in the Technical Appendix. That is, nearly all hospitals participated in at least one transfer, and 4. The characteristics of the hospitals involved in the transfer networks are described in Table 1. Transfers tended to occur relatively early during the stay in the first hospitalization. Median length of stay at the sending hospital was 2 days mean 4.

Median length of stay at the receiving hospital was 8 days mean Selected characteristics of the hospitals are shown in Table 2. Hospitals that only send were smaller, less likely to have a residency program or medical school affiliation, and less likely to possess advanced surgical capacity. Hospitals that only receive were larger and had more of these capacities. Hospitals that both sent and received tend to be in the middle of these two extremes. The substantial interconnections between metropolitan areas — indeed between regions — is evident both in the national map and in the area of detail, chosen to give greater perspective on the variety of transfer relationships between hospitals.

The median patient was transferred The mean transfer distance was Hospitals are shown at their latitude and longitude in a simple Cartesian projection. Node size is proportional to centrality. Line darkness is proportional to the number of transfers passing between the two hospitals. Hospitals varied significantly in the number of other hospitals to which they sent and from which they received critically ill patients, as shown in Figure 3. As shown in Part A, hospitals received transfers from only 1 other hospital; 5 hospitals received transfers from more than 75 other hospitals during As shown in Part B, 30 hospitals transferred no patients out, hospitals transferred to only 1 other hospital, and, at the other extreme, hospitals transferred to 10 or more other hospitals.

The median hospital sent 11 total Medicare patients out to 4 other hospitals mean 4. Equivalent data is presented in tabular form to the right. Both horizontal and vertical axis are logarithmic due to wide variation. Hospital characteristics and capabilities were strongly associated with centrality in the transfer network. As shown in Table 1 , network centrality was associated with nearly all pre-specified organizational, medical, surgical and radiologic services.

More central hospitals were more capable in each of these bivariate associations. The presence of a skilled nursing facility at the hospital — which was hypothesized not to be associated with centrality e. The 26 hospital variables accounted for This study has several main findings. First, interhospital transfers of critically ill patients are common in fee-for-service Medicare, involving approximately 1 in 20 Medicare critical care stays of any length.

Second, hospitals transfer critically ill patients to several other hospitals, in contrast to the hub-and-spoke model often invoked to conceptually explain secondary and tertiary care. Third, the network appears to systematically move patients towards better resourced hospitals.

Question 1

These findings reveal the existence of an organic network of critical care transfers. Our main interpretation is that network analysis of the type reported in this paper can help define the criteria for a successful system of critical care transfers as well as suggest efficient ways to get there. For example, we observe that more central hospitals have more technologic capability, suggesting that the general flow of critically ill patients is toward better resourced hospitals.

However, not all patients flow in this direction.

Transfer course | Critical Care Network in North West London

Some move in the opposite direction and many patients do not move at all. We might ask which patients should remain where they are, which should be transferred to better performing hospitals and which, perhaps, should be sent to less resourced hospitals to improve efficiency or free capacity for sicker patients who need it more. Approximately 1 in 1, of possible interhospital connections actually occurred during In a low density network such as this, careful analysis may reveal quality-improving transfer relationships that are not currently established. Some hospitals may not be transferring patients to nearby facilities able to provide better care; some highly resourced hospitals may not be accepting patients from nearby less capable hospitals.

Some hospitals may not currently have optimal capabilities to support the load of incoming critically ill patients, and WE COULD target those hospitals for improvement or redirection of patients. No current incentive arrangement suggests that the existing network will optimize itself, but network analyses can help policy makers see and shape an aggregate structure that is invisible to the individual hospitals and patients. Network analyses are widely used in other areas, including sociology, 22 physics, 33 molecular biology, 33 management, 34 and military operations, 35 , 36 but only rarely in the study of health care systems.

The existing transfer system is not a simple hierarchy. Small community hospitals do not exist as satellites of single local centers, which then refer to dominant regional centers. This is true even within fee-for-service Medicare, so the heterogeneity of referrals is not the result of differing insurance plans within a hospital. Instead, hospitals appear to maintain diverse portfolios of other facilities to which they transfer patients. There are several potential reasons for this.

There may be significant congestion at referral centers, with more central hospitals not able to accept all patients in a timely manner. Families may have important roles in choosing closer, more prestigious, or better advertised hospitals. Differentiating among these hypotheses is essential to evaluating the extent to which the system is working to meet diverse, legitimate values, or is simply operating inefficiently.

The present work has a number of limitations. First, our data are derived from Medicare for a single year, and thus we cannot evaluate whether transfer patterns are different for non-Medicare patients or how they might change over time. However, over half of ICU patients are elderly, 41 and Medicare is a domain of public policy interest in its own right. Second, our data reflect transfers between critical care hospitalizations; limitations in the data prevent us from examining only direct ICU-to-ICU transfers.

It is possible that some of the transfers we have identified include patients who were discharge from the ICU to the floor at the first hospital, then transferred to a second hospital floor bed where they decompensated, requiring a distinct episode of ICU care. Our data cannot estimate the frequency with which this occurs.

  • Critical Care Patient Transfer Bag?
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This will allow organisation of transfer services to ensure adequate standards of care, quality assurance, critical incident reporting and auditing. Replacement equipment and new services may be required to fulfil recommended standards.

Dedicated transfer or retrieval teams may offer patient benefits and should be used when available. Local knowledge of both regional transport teams and hospital transport teams should be available and well publicised to maximise usage. New retrieval teams should integrate into existing systems to enhance rather than compete and thus improve the level of care for patients.


These can be complemented by courses in the transport of the critically ill to ensure that the highest possible standards are met. Local and regional coordinators should be appointed to oversee, advise and give feedbacks at a national level on the continuing state of critical care transfers. The quality of all transfers should be audited and critical incidents recorded.

It is only through such processes that standards are maintained and improved.

  1. Critical care in the emergency department: patient transfer.
  2. Critical care in the emergency department: patient transfer.
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  8. Emergency departments will always be involved in the transfer of critically ill patients. Local, regional and national organisation of care for the critically ill patient can help ensure that training, equipment and personnel are of the highest recommended standards. National Center for Biotechnology Information , U. Journal List Emerg Med J v. Accepted Sep This article has been cited by other articles in PMC.

    Question 1 What should be done before transferring the patient to the radiology department? Open in a separate window. Case progression A computed tomographic scanner is available immediately, and is a few minutes' walk from the resuscitation room of the emergency department. Question 2 Who should accompany the patient to the computed tomographic scanner? Transfer personnel Ideally, the transfer of critically ill patients would be carried out by specially trained individuals.

    Case progression Owing to the workload in theatre, an anaesthetist is not immediately available, and therefore an emergency department consultant, an emergency department nurse trained in critical care and a porter accompany the patient to the computed tomographic scanner and back to the emergency department. Question 3 What changes to this patient's transfer process should now be made?

    Transport preparation and equipment Decision making for patient transfer is a dynamic process. Communication Good communication between all parties is essential. Case progression The neurosurgeons accept the referral and wish the patient to be transferred direct to theatre. Question 4 What risks are incurred during interhospital transfer?

    Critical Care Network in North West London

    Hazards during transport There are many hazards during the transport of critically ill patients. Transport organisation In England and Wales, the Department of Health report, Comprehensive Critical Care, recommended methods of critical care delivery including the formation of regional systems called critical care networks. Summary Emergency departments will always be involved in the transfer of critically ill patients.

    Secondary transport of the critically ill and injured adult. Emerg Med J 21 — Emerg Med J 20 — Anaesthesia 49 — Intensive Care Society Guidelines for the transport of the critically ill adult. Clin Intensive Care 2 — Causes and effects of systemic complications among severely head injured patients transferred to a neurosurgical unit. Int Surg 77 — Injury 25 — Barry P W, Ralston C. Adverse events occurring during interhospital transfer of the critically ill. Arch Dis Child 71 8— Macartney I, Nightingale P.

    Transfer of the critically ill. Aust NZ J Surg 62 — Gentleman D, Jennet B. Lancet — Injury 28 — Ann Emerg Med 20 — Ann Emerg Med 25 — BMJ 1 — N Engl J Med — Pediatr Emerg Care 12 — Crit Care Med 32 — American College of Emergency Physicians Principles of appropriate patient transfer. Ann Emerg Med 19 — Australian and New Zealand College of Anaesthetists, Minimum standards for transport of the critically ill. Paediatric Intensive Care Society Standards for paediatric intensive care, including standards of practice for the transport of the critically ill child.

    Ann Intern Med — Mishaps during transport from the intensive care unit. Crit Care Med 18 — Intensive Care Med 26 — Transport of critically ill patients. Crit Care Med 14 — Department of Health Comprehensive critical care. A review of adult critical care services. Crit Care Med 22 — BMJ — The Association of Anaesthetists of Great Britain and Ireland Recommendations for the safe transfer of patients with brain injury.

    Kanter R, Tompkins J. Each module has been designed to hold the standardised transfer content for the individual category e. In order to reduce the volume of equipment carried on a transfer we have added a clear patient pocket, specifically designed to carry items relating to the individual patient being transferred. A widespread and comprehensive consensus published used the expertise and Hi experience of many clinicians to safely reduce the volume of transfer equipment carried.

    Why is the bag large? The bag is designed to hang from the bed so that the user has both hands free and is not carrying any weight during the transfer. Yes, the three 50mm straps allow you to attach the bag horizontally to any bed or trolley.

    Clinical scenario

    The inbuilt shoulder can also be used to secure the bag in vertical position. Does it have wheels? No, the bag is designed to hang from the bed so that the user has both hands free during the transfer. Who has recommended the contents list? The recommended contents list has been developed with the consultation of over Clinicians and was compiled by the North West London Critical Care Network.

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    For details of how the contents and the design of the bag came about please watch the video below. Backpack Straps , Grab Handles. Advanced , Drugs , Observation Kit. Your email address will not be published. Required fields are marked. This site uses Akismet to reduce spam.

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