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June 28, 2016

ARTICLE REVIEW

The requirement for interhospital transport of critically ill patients is common due to the requirement for advanced diagnostics and procedures (1). It is likely to increase due to the continued development of tertiary care centres for major trauma and interventional procedures (1,2). 

Transport of a critically ill patient has inherent risks, both technical and clinical (1,2). These are thought to be reduced by the presence of a dedicated critical care transport system but the additional benefit of a critical care physician as part of the transfer team has not been demonstrated (3,4). The aim of this study (5) was to demonstrate the non-inferiority of an intensive care nurse and paramedic team in the inter hospital transfer of critically ill patients.

This was a prospective, randomised, open label study with a blinded endpoint based in a single-centre in the Netherlands. It was designed to show non-inferiority of critical care transport with patients randomised to a critical care nurse and paramedic group (nurse group), or a critical care physician and nurse group (nurse and physician group). 

All adult intensive care patients requiring an inter hospital transfer were eligible, however patients with severe hypoxia, significant haemodynamic instability, recent CPR or those requiring immediate transport (within 30 minutes) were excluded. 

The primary outcome was the number of patients who sustained critical events during transport, both clinical and technical. A sample size calculation of 307 patients was based on an expected adverse event rate of 1% in the nurse group. 147 patients were analysed on an intention to treat basis in the nurse group and 163 patients in the nurse and physician group. 

The percentage of patients with critical events were 16.3% (24 incidents in 147 patients) in the nurse group and 15.2% (23 incidents in 151 patients) in the nurse and physician group. These were mostly clinical rather than technical events. As a result of the greater than anticipated critical event rate, non-inferiority in the nurses group was not established. Reasons given by the authors for this high event rate were the use of electronic reporting of events. Previous studies with lower event rates had relied on manual, self-reporting (6,7). 

This study focused on an important area of critical care. Strengths of the study were the robust randomisation process, the use of blinded endpoints and the intention to treat analysis. The groups were well-matched at baseline and the authors used relevant surrogate endpoints as the primary outcome measure. 

Weaknesses were the single centre design and high critical event rate, limiting generalisability of the results. There was also no standardised checklist used prior to transfer. 

The numbers of patients recruited to this study was ultimately too small to give definitive evidence that a nurse-led transfer of critically ill patients is non-inferior to clinician-led transfer. 

Further studies are needed in order to answer this important clinical question and ensure appropriate use of staff resources in the future.

Article review submitted by Fraser Magee on behalf of the ESICM Journal Review Club.


References

1.    Thomas C Blakeman MSc RRT and Richard D Branson: Inter- and Intra hospital Transport of the Critically Ill; Respiratory Care; June 2013 Vol 58 No 6

2.    Jeffrey M Singh and Russell D MacDonald: Pro/con debate: Do the benefits of regionalised critical care delivery outweigh the risks of inter facility patient transport? Critical Care 2009, 13:219

3.    Belway D, Henderson W, Keenan SP, Levy AR, Dodek PM (2006) Do specialist transport personnel improve hospital outcome in critically ill patients transferred to higher centers? A systematic review. J Crit Care 21:8–17

4.    Wiegersma JS, Droogh JM, Zijlstra JG, Fokkema J, Ligtenberg JJ (2011) Quality of interhospital transport of the critically ill: impact of a mobile intensive care unit with a specialised retrieval team. Crit Care 15:R75

5.    van Lieshout EJ, Binnekade J, Reussien E, Dongelmans D, Juffermans NP, de Haan RJ, Schultz MJ, Vroom MB. Nurses versus physician-led interhospital critical care transport: a randomised non-inferiority trial. Intensive Care Med. 2016 Jul;42(7):1146-54. doi: 10.1007/s00134-016-4355-y. Epub 2016 May 11. (OPEN ACCESS)

6. Kue R, Brown P, Ness C, Scheulen J (2011) Adverse clinical events during intrahospital transport by a specialised team: a preliminary report. Am J Crit Care 20:153–162

7.    Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P (2004) Incidents relating to the intra-hospital transfer of critically ill patients. An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Med 30:1579–1585

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