From the Guidelines
For mechanical ventilation transfers between hospital and EMS devices, I recommend using a standardized checklist that covers pre-transfer, transfer, transport, and post-transport phases, prioritizing patient safety and minimizing complications like hypoxemia, barotrauma, or accidental extubation. This approach is supported by the most recent guidelines, such as those from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society 1.
Pre-Transfer Phase
Begin with patient assessment including:
- Vital signs
- Ventilator settings (FiO2, PEEP, respiratory rate, tidal volume, mode)
- Sedation status Document ETT/tracheostomy position and security. Before disconnecting, pre-oxygenate with 100% FiO2 for 2-3 minutes, as recommended by Fanara et al. 1.
Transfer Phase
During transfer, confirm identical settings on the transport ventilator, verify proper connections, and observe the first several breaths for chest rise and appropriate ventilation. Monitor oxygen saturation continuously during this critical period. The transfer team should be familiar with all of the equipment and drugs in the transfer kit and the transfer vehicle, as emphasized in the guidelines for safe transfer of the brain-injured patient 1.
Transport Phase
During transport, maintain regular assessments every 15 minutes including:
- Vital signs
- Ventilator parameters
- Sedation needs Use a sedation protocol with medications like propofol (5-80 mcg/kg/min), midazolam (1-5 mg/hr), or dexmedetomidine (0.2-0.7 mcg/kg/hr) as needed. Inspired oxygen should be guided by blood gas estimations before departure, and end-tidal carbon dioxide should be monitored continuously, as recommended in the guidelines for mechanical lung ventilation 1.
Post-Transport Phase
Post-transport, perform a comprehensive handoff including ventilation history, any adjustments made, and medication administration. This structured approach minimizes complications and ensures continuity of care, as ventilated patients are particularly vulnerable during transitions of care when equipment changes occur. The importance of a standardized checklist and careful monitoring during transport is highlighted by the potential for short periods of hypoxia to have significant consequences, and the need to maintain adequate PEEP to prevent atelectasis 1.
From the Research
Standardized Checklist for Mechanical Ventilation
There are several studies that provide guidance on the use of standardized checklists for mechanical ventilation in hospital transfers.
- The use of a standardized checklist can help prevent medical errors and ensure safe transfer of critically ill patients 2.
- A checklist can include items such as:
- Verification of patient identity and medical history
- Review of ventilator settings and parameters
- Assessment of patient's respiratory status and oxygenation needs
- Confirmation of adequate staffing and equipment for transport
- The American Association for Respiratory Care (AARC) recommends a patient-ventilator assessment that includes evaluation of plateau pressure, tidal volume, and positive end-expiratory pressure (PEEP) 3.
- A goal-directed mechanical ventilation order set can be implemented by respiratory therapists to improve compliance with best practices for mechanical ventilation 4.
- Initial ventilator settings for critically ill patients should include lung-protective ventilation strategies, such as tidal volume of 4-8 mL/kg predicted body weight and PEEP of at least 5 cmH2O 5.
Transfer and Transport Considerations
During transfer and transport, the following considerations should be taken into account:
- Continuous monitoring of patient's respiratory status and ventilator parameters
- Use of a standardized checklist to ensure that all necessary items are verified and confirmed
- Adequate staffing and equipment for transport, including a trained respiratory therapist or nurse
- Communication with the receiving team to ensure a smooth handover and continuity of care 2, 6.
Maintenance and Post-Service Care
After transfer and transport, the following considerations should be taken into account:
- Continued monitoring of patient's respiratory status and ventilator parameters
- Adjustment of ventilator settings as needed to ensure optimal oxygenation and ventilation
- Regular assessment of patient's skin and mucous membranes to prevent pressure ulcers and ventilator-associated pneumonia
- Documentation of patient's care and any changes to ventilator settings or treatment plan 3, 4.