COVID-19 Transport Best Practices

Topic Progress:

“Haphazard transport of infected cases leading to nosocomial spread can stymie efforts to break the chains of transmission1.”

Step 1: Take Your Time2-5

DO NOT RUSH THIS PROCESS.  Moving the patient is a prime time for tube/ line dislodgement.  Covid-19 patients can be difficult intubations initially.  Re-intubation can be even more challenging and tube dislodgement and vent circuit disconnects risk exposing everyone participating in the transport.  DO NOT LET IT HAPPEN.

Step 2: Have a Plan2-5

Manpower-assign a team lead.  Large patient?  Recruit more personnel.  It is key to have the right amount of manpower to safely transport and transfer the patient balanced with the minimal amount of staff to risk exposure. 

Transport in a bed if possible.

Bring medications and equipment for reintubation, an appropriately sized bag-valve-mask with the face mask and consider bringing a supraglottic airway.

Step 3: Identify roles2-5

Moving the patient to another surface will be the trickiest part. 

  1. Primary nurse – team lead
  2. Respiratory therapist – responsible for ventilator
  3. What help do you need for transfer. You will need more staff if the patient is obese. Additional staff for moving help and to assist with guiding the bed.
  4. Is the patient so unstable that a physician needs to attend?
  5. Make sure everybody knows who the team lead is – Primary nurse. We need to assign roles to each person who is accompanying the patient for transport. This way everybody knows what they are supposed to be doing and who they’re supposed to be listening to.
  6. Make sure there is a phone/walkie-talkie so that you can communicate with others during the transport if necessary.
  7. One team member will need to be assigned to clearing the way, opening doors. Ensuring that doors are closed and that anyone they encounter during transport remains at least six feet away.

Step 4: Equipment Check2-5

  1. Two full oxygen tanks.
  2. Wipe down all surfaces on the bed and other devices (vent, monitor, IV pump/ pole) prior to transport.
  3. Put a mask on the patient if not intubated
  4. Ensure all IV drips have sufficient amounts. If not bring additional medications as necessary.
  5. Check the battery on the pump to make sure you have enough time for the transport.
  6. Monitor for transport. Defib monitor with pads? Place on the bed for transport.  What is the power level on the monitor? Do you have enough for the transport?
  7. Checked all connections – IV, ETT, NG/OG, Make sure they are secure.
  8. Do you need suction for transport?
  9. Preparing the ventilator.
  10. Emergency airway supplies.
  11. PPE for the team, which includes airborne precautions to prepare for an accidental exposure to aerosol.

Step 5: Transport2-5

Go slow and deliberate.  When moving patient through the halls to the next department, ensure that you are using the route that exposes the fewest staff/patients in the hospital.  Also agree on who will guide the hospital bed/stretcher so that there is no concern for someone pulling or pushing in opposite directions.  Move slowly and deliberately, especially when taking turns.  If a member of the team says to stop, stop immediately until the issue is resolved (tangled line, IV getting pulled, patient waking from sedation, pump alarming, etc.)  Also ensure before you leave the ICU that you have enough pressors/sedation/fluids in your bags to accommodate the trip, including any delays. (don’t take nearly empty bags!)

Step 6: Arrival at the Destination2-5

Once the patient has arrived at their destination, ensure that there is enough length on the ventilator tubing, the IV tubing, monitoring cables, or anything else attached to the patient. This step is vital to prevent disconnection of the tube or the ventilator circuit. Talk with the receiving staff regarding how much patient movement there will be during the exam. Make sure that the nurse can see the monitor and the ventilator screen while the exam is going on.

HELP! The ETT Came Out!

PAUSE. Reframe your thoughts. Think airway, breathing, circulation etc.

  1. PAUSE.
  2. Control your emotion.
  3. YOU MUST BE IN FULL AIRBORNE PRECAUTIONS TO HELP THE PATIENT. IF YOU ARE NOT WEARING APPROPRIATE PPE, YOU MUST LEAVE, DON PPE, AND RETURN. NO EXCEPTIONS.
  4. Organize your team into responsibilities.
  5. Insert oral/nasal airway.
  6. Bag the patient as per your local guidelines.
  7. Activate emergency process (eg. Code blue)
  8. Anticipate re-intubation by the attending team

It is paramount to understand should the ETT or vent circuit be disconnected that all staff have airborne PPE before treating the patient.

References

1. Liew, M.F., Siow, W.T., Yau, Y.W. et al. Safe patient transport for COVID-19. Crit Care 24, 94 (2020). https://doi.org/10.1186/s13054-020-2828-4

2. O’Leary, R., Marsh, B., & O’Connor, P. (2018). Transfer of critically ill adults—assessing the need for training. Irish Journal of Medical Science, 187(3), 585–591.

3. Williams, P., Karuppiah, S., Greentree, K., & Darvall, J. (2020). A checklist for intrahospital transport of critically ill patients improves compliance with transportation safety guidelines. Australian Critical Care, 33(1), 20–24.

4. Gustafsson, M., Wennerholm, S., & Fridlum, B. (2010]. Worries and concerns experienced by nurse specialist during inter-hospital transports of critically ill patients: A critical incident study. Intensive and Critical Care Nursing, 26, 138-145.

5. Choi, H. K., Shin, S. D., Ro, Y. S., Kim, D. K., Shin, S. H., & Kwak, Y. H. (2012). A before- and after-intervention trial for reducing unexpected events during the intrahospital transport of emergency patients. The American Journal of Emergency Medicine, 30(8), 1433–1440.

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