Translating critical incidents to service development in urban critical care transfer

ABSTRACT

Introduction: Clinicians in retrieval and transfer medicine face increased diagnostic uncertainty by virtue of their operational environment.1 Integral to our quality improvement and clinical governance framework is individual case analysis, clinical incident interrogation and follow up of every single patient to the point of discharge from critical care. We describe a case where an adverse clinical incident several hours post patient handover was a driver for implementing process and diagnostic change within our own service. Objectives: Describe the translation of after-action review of a critical incident into service improvement. Methods: A 61-year-old patient with severe acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) developed an ischaemic lower limb. A diagnosis of femoral artery thrombosis was confirmed by computed tomography angiography, necessitating transfer to the regional vascular centre. The transfer was undertaken following emergent intubation of the patient by the referring unit and patient followup proceeded as per our standard operating procedures. Results: The transition to invasive ventilation demonstrated low lung compliance and a poor alveolar-arterial (Aa) gradient in keeping with established ARDS secondary to COVID-19.2 Deterioration in oxygenation and respiratory mechanics was partially (falsely) attributed to switching from semi-recumbent to supine positioning. Within 3 hours of handover to the receiving team, a rapid deterioration in oxygenation and ventilation occurred with subsequent diagnosis of tension pneumothorax. This was managed with an intercostal drain which resulted in a significant drop in peak airway pressure (24cm H2O). Close collaboration between our service and the involved hospitals enabled a detailed multi-service review. A number of missed opportunities were identified for prevention of deterioration due to a tension pneumothorax 1. Immediate post-intubation x-ray imaging regardless of time-critical nature of transfer 2. Lung POCUS post-intubation or at any point whilst transitioning care 3. Highlighting post-intubation imaging as an immediate post-arrival need at handover Pre-departure, post-intubation x-ray was added to our checklist as a cognitive aid. We further identified lung point of care ultrasound (POCUS), an established adjunct to clinical examination,3,4 as a potentially missing diagnostic safety-net. Consequently, we set out to introduce a lung POCUS operating policy. This includes a device optimised for the pre-hospital environment (VScan Air, GE Healthcare, USA), training package, decision-aid algorithm, and overarching governance. We will monitor the diagnostic impact of this tool and benchmark against previously published literature.3,4 Conclusion: Robust followup, governance, and stakeholder engagement allowed us to identify an adverse event detected several hours post patient disposition at the receiving site. With an increasing volume and complexity of transfers, diagnostic adjuncts formerly considered the exclusively the domain of in-hospital practice may well become core techniques in retrieval medicine.