Author: Cliff D.; Loh N.H.W.
Abstract: High quality transfer of patients with brain injury improves outcome but is potentially hazardous if poorly executed [1]. Transfer to a specialised neurosurgical centre is urgent but priority should be given to thorough resuscitation before setting off. Patients with brain injury should be accompanied by a doctor of appropriate training and experience [1, 2]. Audit is crucial to improving standards of transfer [1]. This audit assessed the grade of doctor performing transfers, factors contributing to delays in arrival and any adverse
events occurring during transit to an ITU in a tertiary neurosurgical centre. Additionally, the quality of record keeping regarding transfer was examined. Methods A retrospective review of records completed by both transferring and receiving teams for every patient transferred into this tertiary neurosurgical intensive care unit between January 2009 and September 2011 was conducted. Results The total number of transfers performed was 519. Where the grade of doctor performing a transfer had been recorded, the distribution was: SHO 131 (42%), SpR 104 (34%), other 75 (24%). Of those transfers performed at night, 32 (52%) were performed by a junior trainee (SHO equivalent). The mean time taken to be ready to start a transfer at the admitting hospital was two hours 27 minutes. Mean time to commence the transfer once the ambulance had arrived was 30 minutes and mean journey time was 39 minutes. If the transfer was listed as 'time critical' and aimed to be completed within one hour, the mean transfer time was two hours 55 minutes. Adverse
events recorded during transfer were; cardiovascular instability (nine incidences), equipment failure (eight), development of new focal neurology (eight), an intubated patient arriving without or with inadequate sedation (eight) and intubated patients being transferred with no end tidal CO2 monitoring (three). Data relating to the identity of the transferring or receiving team was found to be missing frequently (29 incidences). Other
important omissions in record keeping included documentation of drugs given during transfer (12 incidences), vital signs (three), diagnosis (eight) and transfer timings (11). Discussion Substantial numbers of patient transfers are being performed by junior, potentially inexperienced trainees. This includes transfers undertaken at night when less senior assistance is available at both sending and receiving hospitals. Delays in arrival are
largely due to patient treatment in their presenting hospital which is deemed to take priority over an expedient transfer [1,2]. Adverse events are relatively common during transit and include both expected events relating to physiological instability in an acutely unwell patient but also the potentially avoidable issues of equipment failure and poor transfer technique. Logging of data by those transferring patients is often inadequate.
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