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Pearls Of Packaging Wisdom

Dr Arndt Melzer describes one sequence for packaging for critically-ill patients in an inter-hospital transfer.
An intubated patient being prepared for a transfer while still in the safety of the hospital bed
© Dr Arndt Melzer, North Central London Adult Critical Transfer Service (NCL-ACTS), Dr Simon Versteeg, Auckland City Hospital ,New Zealand

In this article, Dr Arndt Melzer, anaesthetic consultant and lead of the North Central London Adult Critical Transfer Service (NCL-ACTS) shares his tips for packaging critical care patients for transfer.

The process of packaging describes the way in which a patient is prepared for transfer. This is a crucial step as it sets the tone for the rest of the move and can help identify potential problems before they occur. Especially with awake patients, a systematic packaging sequence helps to build rapport and improve patient experience.

Principles Of The Packaging Sequence

  • Start with a “hands-off” handover of information.
  • Ensure physiological stability (may not be possible in time-critical transfers or evacuations).
  • Ensure both patient and equipment are secured to transfer stretcher.
  • Minimise the risk of disconnections of infusion lines or ventilator hoses.

Receiving Handover

Watch this video of our transfer team receiving a handover.

You may have noticed the team take a “hands-off” handover from the referring team. This means they are fully-focused and do not miss any crucial information.

Sometimes the referring team is not available immediately to hand over. Try to resist the temptation to start assessing and packaging the patient while you are waiting, as information from the handover may guide your approach.

Different professionals will have different information to hand over. For example, the nurse may be more familiar with the concentration of infusions, while the doctor may provide more guidance on the ongoing medical plan.

Now is your chance to clarify anything you are unsure about. Think about what details will be important for the team at the destination facility as they will undoubtedly have questions.
For another example of receiving a handover, watch this video from CATS (Children’s Acute Transport Service).

Systems Review & Physical Examination

We advocate assessment of the patient before beginning packaging to identify whether the patient is stable enough for transfer. It is also more convenient to perform any required procedures (e.g. further IV access, chest drain) on a hospital bed as opposed to a transfer stretcher, which is often cramped with poorer access to the patient.
Performing interventions while under the care of the referring hospital has legal implications and you may not be covered by the hospital’s indemnity.
This video shows an example of a structured assessment of a critical care patient prior to transfer.
  • Airway (and cervical spine stability): depth of endotracheal tube, cuff pressure, security of tube and cervical spine.
  • Breathing: FiO2 requirement, ventilator settings, chest drains, review of chest imaging.
  • Circulation: venous and arterial access, vasopressor support, signs of shock, heart rate and rhythm.
  • Disability: analgesia, sedation, requirement for neuromuscular blockade, neurological assessment, pupils and blood glucose.
  • Exposure: temperature, pressure areas, limb injuries and splints.
  • Monitoring and invasive devices.
  • Review of investigations, images and labs.

Switching Ventilators

After you have assessed the patient, it makes sense to start by connecting the patient to the transfer ventilator. This enables a trial of the patient on your own ventilator to see how the patient adapts to this.
  • The patient is pre-oxygenated to help prevent desaturation.
  • Clamping the tube prevents loss of positive end-expiratory pressure (PEEP) and reduces the risk of transmission of infection to staff and patient. This should be avoided in the spontaneously-ventilating patient as it may lead to negative pressure pulmonary oedema.
It is vital to confirm end-tidal CO2 after changing ventilators. An arterial blood gas 10-20 minutes after connection of the ventilator is good practice and should be documented.

Final Steps

The next steps in the packaging can be done simultaneously to save some time. One team member can change the pumps while the other one is connecting the monitoring. You can allocate the various roles in your brief or while on the way to the referring hospital.
Have a look at the minimum monitoring standards for critical care transfers in the UK.

Finally, you should transfer the patient to your stretcher, secure them and complete your pre-departure checklist and documentation.

© Dr Arndt Melzer, North Central London Adult Critical Transfer Service (NCL-ACTS), Dr Simon Versteeg, Auckland City Hospital ,New Zealand
This article is from the free online

A Journey Through Transfer Medicine

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