Principles Of HCID Transfers

As we’ve seen in the previous step, there is a long list of diseases that are defined as HCIDs. Each of these diseases may have specific implications for patient transfer. Specialist input is vital to help coordinate these transfers, which may be highly complex clinically and logistically. Here, we discuss some general considerations and potential solutions.

Transfer Challenges

• The diagnosis may be unclear. When asked to transfer a patient who has returned from a high-risk region with a fever, specialist advice should be sought. In the UK, the Imported Fever Service provides round-the-clock advice on such cases.
• Patients are often critically-ill and most clinicians in non-endemic countries will have limited experience of managing these diseases.

In Week 1 we learnt about the risk of spreading infection due to patient transfer. There is a high risk of provoking an outbreak and/or infecting transfer staff by transporting patients with HCID.

• During the transfer, access to the patient may be limited. The use of PPE may impede communication and make practical tasks more difficult.
• You may be required to use different equipment or vehicles, that can be safely decontaminated or disposed of. Training and familiarisation is vital.
• Diversion to a place of safety (e.g. the nearest emergency department) may not be possible.
• The patient may be arriving at a non-clinical setting (e.g. an airport), where specialist receiving units may need to be established.
• Precautions may differ depending on whether the patient has confirmed disease, probable disease or is a person under investigation (PUI). The nature of symptoms may also influence the precautions required.

General Considerations

• Personnel should be trained in the transfer of HCID patients.
• Use the minimum number of professionals possible to keep the patient safe and minimise contact time.
• Minimise high-risk procedures (e.g. aerosol-generating procedures, exposure to bodily fluids).
• Use designated equipment and vehicles and bring the minimum amount of equipment necessary for safety.

Escorting clinicians should not leave the vehicle after coming into contact with the patient, until arrival at the receiving unit

• In the transport vehicle, the driver compartment should be separate from the patient compartment.
• When travelling by road, support vehicles may be required to travel in convoy in case of emergency.

Personal Protective Equipment

• Personal protective equipment (PPE) should always be worn when conducting transfers of HCID patients. The exact PPE required will depend on factors including the mode of transmission, the nature of symptoms and the risk level of the patient.
• Staff should be fit-tested and trained in donning and doffing procedures.

In addition to PPE, the patient may need to be wrapped in an impermeable sheet to prevent leakage of bodily fluids. For certain HCIDs, systems that isolate the patient from their surroundings may be warranted.

Open Isolation Systems

• A mobile unit, such as a tent, is fixed within the aircraft or ambulance, allowing staff to access the patient, while reducing the risk of contamination of the vehicle.
• An anteroom allows staff to move in and out of the unit, which may be useful on a long flight. At the end of the transfer, the unit can be removed from the vehicle.

Closed Isolation Systems

• These consist of a single-patient unit with in-built filters and a ventilation system, which can create a negative or positive pressure environment.
• There are ports that allow clinicians to access the patient and to transmit monitoring cables and oxygen tubing.

These systems can be used to protect the environment from the patient (e.g. HCID patient) or to protect the patient from the environment (e.g. immunosuppressed patient or chemical attack).

• They may reduce contamination of the transport vehicle and hospital environment and reduce risk of transmission to staff and other patients.
• Access to the patient to perform treatment interventions is limited. PPE should still be used when using these systems, however it may be possible for clinicians to wear less intensive PPE.

There are several models available from different manufacturers. One such system is the EpiShuttle® from EpiGuard®.

The EpiShuttle® patient isolation system by EpiGuard®.

Decontamination

• Prior to transfer, a plan for decontamination of equipment, staff and vehicles should be made. The ability to disinfect equipment and vehicles safely with chemical disinfectants should be checked. Equipment will need to be disposed of safely if it cannot be decontaminated.
• For interest, take a look at this report from the European Centre for Disease Prevention and Control on the aeromedical evacuation of Ebola patients.

References