Designing a framework for long-range critical care transfer away from the epicentre of a crisis

ABSTRACT

Introduction: The North East London Critical Care Transfer And Retrieval (NECCTAR) Service provides a complete adult critical transfer capability. During the second wave of the COVID-19 pandemic, London was the epicentre of critical care activity1. Resource pressures escalated rapidly to unprecedented levels of demand.1 Beds for regional decompression became increasingly rare within London, necessitating long-range transfer. These were considered to be journeys over two hours in duration and to hospitals outside of the M25. NECCTAR was the first critical care transport service during this peak to decompress a London-based COVID-19 patient to a bed sourced nationally. Although longer-range ground transfers are associated with inherent risks, these can be mitigated through a dedicated transfer team and equipment.2,3 NECCTAR was required to rapidly and iteratively design a framework for long-range transfers. The service leadership drew on experience from aeromedical pre-hospital resources. Detailed case review was undertaken to refine the standard operating procedure. As pandemic pressures have reduced, the guidance has now become translatable to longer-distance repatriation and specialist transfers. Objective: To develop and refine a novel framework for maintaining patient safety during long-range critical care unit transfer. Methods: Risks associated with long-range critical care ground transfers were broadly identified as patient, staff, and equipment/technical risks. Ethical considerations were prominent in planning. Risks were categorised for standard operating procedure design purposes. Data were contemporaneously recorded for all taskings from point of referral to completion. The risks and their mitigations are summarised in Table 1. Results: An iteratively designed standard operating procedure was developed. NECCTAR has been referred 29 long-range missions and has completed 20 (68.9%) of these. Long-range taskings are significantly less likely to result in a completed transfer (68.9% v 88.3%, Fisher's p=0.029), predominately due to unanticipated changes in clinical status prior to departure. The longest duration of time and distance travelled under NECCTAR care was 5 hours, 32 minutes and 278 kilometres, respectively. All completed long-range transfers were followed up to discharge from intensive care;there were no significant adverse events in this group. Conclusion: NECCTAR has developed a framework that ensures stringent patient selection and transfers by a dedicated, senior-led crew with multiple risk mitigations. A strong governance process has informed updates to maintain patient safety. This framework has now been adapted for repatriation and specialist transfers and would also be generalisable to major incidents, including biohazard events and natural disasters.