Hrev_master [page 12] [Emergency Care Journal 2015; 11:4781] Complications in critically ill adult patients’ transportations reported in the recent litera- ture Stefano Bambi,1 Alberto Lucchini,2 Diego Innocenti,3 Elisa Mattiussi4 1Emergency Intensive Care Unit, Careggi University Hospital, Florence; 2General Intensive Care Unit, Emergency Department, San Gerardo Hospital, Monza 3Careggi University Hospital, Florence; 4Anesthesia and Intensive Care, Santa Maria della Misericordia University Hospital, Udine, Italy Abstract The transport of critically ill patients is a complex process, made up by several phases involving the healthcare professionals. It requires a careful planning for the prevention of potential complications undermining the patients’ safety outside critical care environ- ment. Literature review about complications and adverse events reported during intra and inter-hospital transport of critically ill adult patients. Intra-hospital transfers are affected by adverse events rates ranging from 22.2 to 75.7% in the published literature. Major adverse events, defined as life threatening conditions that require urgent therapeutic intervention, vary from 4.2 to 31%. Death is a rare occurrence. Adverse events during inter- hospital have a maximum rate of 34%. Technical incidents represent a typical feature of these transports. Authors reported problems to gas supply, ambulance electric system, equipment. There is a lack of studies about the complications related to rotary wing inter-hos- pital transports. While extracorporeal mem- brane oxygenation/extracorporeal life support patients seem to be the most complex category of critically ill to be transported outside the hospital, 11 papers revealed only 29 adverse events ranging from 0 to 17%. No deaths were recorded. Currently, research must explore more accurately how much transports affect the outcome of patients, and what are the most appropriate time-frames to assess the conse- quences of transfers on patients’ clinical con- ditions. Introduction The transport of critically ill patients is a complex process, made up by several phases involving the healthcare professionals, mainly doctors and nurses. It requires a careful plan- ning for the prevention of potential complica- tions undermining patients’ safety outside critical care environment. Healthcare trans- port of critically ill patients can be performed from the pre-hospital setting towards emer- gency department, inside different areas of the hospital for diagnostic and therapeutic inter- ventions, or from an hospital to another. In this case the aim is usually the centralization, or the need of a more appropriate level of care (inter-hospital transfer).1 Currently, the process of critically ill patient transfer is strictly related to risk management. Over the years we have observed a change in the use of words to describe the transport related events, getting closer to the typical terms used in clinical risk management . More than 20 years ago, Smith and coll., with the term mishaps, referred to the equip- ment related problems.2 Over the years we read in papers’ titles words like complications (worsening of general health conditions, for iatrogenic or other causes),3 and, afterwards incidents,4 unexpected events,5 audit,6 and adverse clinical events.7 To date, performing inter and intra-hospital transfer contemplates an accurate planning, through the analysis of diagnostic and therapeutic needs of the patient, the control of logistical, organizational and clinical variables to prevent complications and adverse events (outcome indicators). Guidelines and clinical/logistical check lists are the tools to achieve these goal. A lot of sci- entific associations have published guidelines on intra and inter-hospital transfer of critically ill patients.8-14 Most of these guidelines are similar. In fact the studies at the basis of rec- ommendations are mainly performed through descriptive and observational designs. It deter- mines a low level of available evidences. Hence the recommendations contained within the guidelines are essentially based on experts’ opinions, and so on the common sense. Anyhow, the phases of a transfer planning are summarized in Table 1. Effective standards of safety during patients’ transportation can be only achieved through an update knowledge of potential complications and adverse events reported by international scientific literature. We performed a literature review about complications and adverse events reported during intra and inter-hospital transport of critically ill adult patients, analyzing original research papers and significant reviews pub- lished in the last decade (from 01-01-1995 to 03-01-2013). We deliberately focused only intra and inter-hospital, excluding the issues related to pre-hospital transport because features are very different from the other settings. We searched articles in English and Italian on Medline and Google using keywords as: inter- hopital, in hospital, critically ill, extacorporeal membrane oxygenation, ECMO, extracorporeal life support, ECLS, transport, transportation, transfer. We found 831 records. Thirty three papers were included in this review. Some older papers were retrieved to integrate and discuss the results of this review. Intra-hospital transport com- plications Fanara et al.16 and Day17 have published, at the same time, in 2010, two extensive litera- ture reviews about intra-hospital transport of critically ill patients. These two papers, even if using slightly different terms and classifica- tions, show all the range of adverse events reported in international literature of last ten years (Table 2; adverse events related to intra- hospital transport). The differences of terms used by the authors in literature make often difficult to discern between an incident and an adverse event that can be caused by. Moreover they limit the opportunity to compare and standard- ize the results in a definitively way. Finally, the endeavor to differentiate major and minor events is carried on only by few researchers that provided arbitrary definition.16 Minor events seem to be featured by a physiologic decline higher than 20% of the baseline values before the transport, or equipment related problems. A major event is defined as a life treating condition that requires urgent thera- peutic intervention.16 In this view, the transport planning gains a relevant meaning, because it allows to identify a series of mandatory safety check points, Emergency Care Journal 2015; volume 11:4781 Correspondence: Alberto Lucchini, General Intensive Care Unit, Emergency Department, San Gerardo Hospital, via Pergolesi 33, Monza (MB), Italy. Tel: +39.039.2339824 - Fax: +39.039.2333287. E-mail: a.lucchini@hsgerardo.org; alberto.lucchi- ni@unimib.it Key words: Severe acute respiratory syndrome; Extracorporeal membrane oxygenation; Transportation of patients; Mobile emergency unit. Received for publication: 16 October 2014. Revision received: 11 December 2014. Accepted for publication: 15 December 2014. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright S. Bambi et al., 2015 Licensee PAGEPress, Italy Emergency Care Journal 2015; 11:4781 doi:10.4081/ecj.2015.4781 Non co mmerc ial us e o nly [Emergency Care Journal 2015; 11:4781] [page 13] starting when a minor event occurs before it turns into a major adverse one. These check points can be, for example, the decision moment to transfer the patient, the phase of preparation and organization.16,17 The main risk factors for adverse events during intra- hospital transport are summarized in Table 3, though not all are confirmed by statistical sig- nificance data. Moreover some authors state that the causal links between patients’ clinical conditions, equipment, environment, transfer management and the occurrence of adverse events have to be clearly investigated.16 In 1999 Waydhas published a literature review on complications related to intra-hospi- tal transport. Adverse events varied between 10 and 69%. Only one study reported a rate of 1.5% of cardiac arrests but without adding data on mortality.18 Equipment related incidents ranged from absence up to 34% of all transports across studies. 4 out of 10 studies in adult patients reported the performance of manual ventilation rather than mechanical ventilation during intra-hospital transportation.18 Eleven years after, the review of Fanara and colleagues carried out on studies of the later period, shows overall adverse events rates ranging from 22.2 to 67.9%.16 Indeed, the major adverse events amount to values ranging from 4.2 to 31%.16 The equipment was involved by incidents from a 10.4 to 45.9% of transports, while organizational problems often emerge as a matrix of adversity (up to 61%).16 In this review, the author revealed an important improvement in ventilation modes during transports, since among 8 studies, seven reported the use of a mechanical ventilator.16 Cardiac arrests were recorded between 0.34 and 1.5%,16 while, regarding mortality, the Australian incident reporting published by Beckmann et al.,4 included in the review of Fanara et al.,16 showed 4 reports related to patients’ death (2%), on 176 incident reports during intra-hospital transport.4 In this case we cannot really know the real number of death occurred during transports. In fact the report, being anonymous, could be drawn up by more than a person in staff who performed the same transfer. Apart from the studies included by Fanara et al. in their review, few other Review Table 1. Phases of critically ill patients transfer’s process. Based on Bambi.15 Phase Variable Logistical planning Architectural features Timing Destination service/hospital Equipment Vehicle Organizational planning Personnel performing the transport Destination service/hospital staff Communication/coordination Documents Clinical planning Potential complications Monitoring level Patient’s preparation/stabilization Table 2. Adverse events related to intra-hospital transport. Based on Fanara et al.16 and Day.17 Typology Incident Vital function Adverse event Equipment related Monitor shutdown A Airways loss Ventilator Disconnection/ventilator failure Extubation O2 supplies exhaustion Airways obstruction due to breathing circuit kinking or mucus plugs SpO2 sensor failure Inhalation Tangled or kinked tubes ECG wires disconnection Personnel related Gaps in monitoring B Respiratory arrest Medication administration failure Desaturation Accidental extubation Hypoxemia, lowering of PaO2/FiO2 ratio Hypoventilation Ventilator associated pneumonia Hyperventilation Hypertensive pneumothorax Chest drain loss Bronchospasm Venous or arterial catheter loss Patient-ventilator asynchrony Intracranial monitoring or ventriculostomy drain loss Selective intubation Derecruitment C Cardiac arrest Hemodynamic instability Increasing of O2 consumption Bleeding Gas embolism Tachycardia Bradycardia Arrhythmias Hypotension Hypertension Death D Spine destabilization Intracranial pressure elevation Agitation Pain E Hypothermia ECG, electrocardiography. Non co mmerc ial us e o nly [page 14] [Emergency Care Journal 2015; 11:4781] papers have been published,16 and they do not add much information compared to the frame- work just outlined, except for some types of accidents related to the unavailability of equip- ment ad hoc. This was the case of 2 episodes of airways obstruction from secretions developed by patients in 32 intra-hospital transfers in absence of portable suction devices.6 Actually, data from Brazil, reported a rate of adverse events of 75.7% on 48 intra-hospital transports of patients on mechanical ventilation, which exceed the maximum percentages reported in the previously published studies.19 Conversely, in Italy, Lucchini et al. have tested a transport system based on the use of a radio transparent spinal board coupled to a device for the hous- ing of electrical equipment. They performed 68 intra-hospital transports (8% with extra corpo- real membrane oxygenation) without any com- plication related to dislocation of medical equipment (infusion lines, chest drains, artifi- cial airway), as well as low percentages of hemodynamic instability (9.4%) and respirato- ry problems (4%).20 However, educational pro- grams and check lists for the transport prepa- ration seem to lower incisively the rates of severe unexpected events, as in the research of Choi et al., where the percentage decreased from 9.1 to 5.2%.21 Furthermore, Kue et al. have demonstrated that a specialized team for the transport management, produce very few adverse events (1.7% out of 3383 transfers).7 Finally, there are no consistent data about the intra-hospital transport influence on pri- mary outcomes as incidence of ventilator asso- ciated pneumoniae, hospital lenght of stay, and mortality rate (as previously outlined), that need a more accurate monitoring system.16 Inter-hospital transport com- plications As previously highlighted by the review of Fan et al., researches about adverse events related to inter-hospital transportations are numerically scarce.22 In Table 4 we summa- rized the results of perspective and retrospec- tive studies on inter-hospital transfer compli- cations published from 1996 till nowadays. As in the studies on intra-hospital transport, we cannot properly compare the results of various researches in the literature on inter-hospital transfer complications. This problem is due not only to the differences of definitions about problems and adverse events, but also to the mode of transports (e.g. mobile intensive care units), while noting a prevalence of ground transportations. We recorded rates of adverse events till 34% of studied transfers,27 and technical problems up to 15.5%.31 Mortality, where reported, reached always low rates. McGinn et al. found Review Table 3. Risk factors for development of adverse events during intra-hospital transfer. Based on Fanara et al.16 Category Risk factor Equipment Infusion line number Mechanical ventilation (ventilator change or ventilator setting) Sedation (starting, maintenance, variation) Transport team Lack of training Lack of expertise Equipment not adjusted for the aims of transport Coordination/organization Communication/coordination between services or wards Transport length Emergency or elective transports Patient Patient’s severity of clinical conditions Respiratory or circulatory supports Emergency or elective transports Table 4. Summary of studies about inter-hospital transfer complications. Authors Design Period Sample Transport mode Adverse events McGinn et al.23 Descriptive, perspective 4 and a half years 1305 Ground; air; dedicated team One death Gebremichael et al.24 Descriptive, perspective 2 years 39 Ground; MICU 2 major complications (5%), among which one death, and 2 deaths within 6 hours from the arrival time (leukemia/sepsis) Uusaro et al.25 Cohort, retrospective 6 years 66 Ground; dedicated team No technical or clinical major complications Gray et al.26 Descriptive, perspective 1 year 257 Ground; 29 ED 47 critical incidents in 38 patients (15%) Ligtenberg et al.27 Audit, perspective 14 months 100 Ground Adverse events in 34% of transports (about 30% due to technical problems) Markakis et al.28 Observational, perspective 1 year 128 Ground 14 patients (10.9%) encountered Major complications (no deaths) Lee et al.29 Descriptive, perspective 28 months 79 Ground; ED; dedicated team Adverse events in 16 transports (20.3%) Wiegersma et al.30 Descriptive, perspective 10 months 74 Ground; MICU 9 incidents (all due to technical problems), with minor changing of vital signs Droogh et al.31 Audit, 30 months 353 Ground; MICU 55 technical problems retrospective MICU, mobile intensive care unit; ED, emergency department. Non co mmerc ial us e o nly [Emergency Care Journal 2015; 11:4781] [page 15] one lonely death in a series of 1305 transport- ed patients23 and two patients (among 39 criti- cally ill transportations) died within 6 h from the arrival to the referral hospital reported by Gebremichael et al.24 Basically, major compli- cations occurring during inter-hospital trans- ports, especially those related to clinical condi- tion,28 are nearly superposed to the events reported in papers about intra-hospital trans- fers (Table 2). Conversely, technical incidents represent a typical feature of inter-hospital transport. Authors reported problems to gas supply, ambulance electric system, equipment, and electric supplied trolley.31 The most fre- quent problems recorded were leakages from gas supply,30,31 dysfunctional gas tube connec- tors, blown fuses, minor defects on doors and electrical or mechanical damages to the trolley.31 Among the most important adverse event related to technical problems there was a case of body temperature lowering from 37.8 to 34.8°C, due to the breakage of an electrical warmer during a transport.30 A critical feature emerged from the perspective audit performed by Ligtenberg et al. on 100 ground transporta- tions.27 The 70% of adverse events could have been prevented with a better preparation phase.27 Moreover in 50% of cases the clinical indications given by the intensivist physicians at the moment of departure, were disregarded by the transfer personnel.27 In the literature there is a lack of studies about complications related to inter-hospital transports performed through rotary wing. Seymour et al. published a retrospective cohort study of 191 patients on mechanical ventila- tion, transferred by helicopter during 36 months.32 They recorded only minor events Review Table 5. Summary of studies on inter-hospital transport complications of extracorporeal membrane oxygenation/extracorporeal life support patients. Authors Design Sample Team Transport mode Adverse events Rossaint et al.36 Cohort, 8 2 intensivist physicians MICU All transfers performed successfully; perspective and a trained nurse only one event: breakdown of a port in the higher zone of ECMO oxygenator Lindén et al.37 Observational 29 Dedicated team: one physician, Ambulance, No death related to transport; one nurse, and one coordinator helicopter, airplane 2 technical problems in 30 transports: a breakdown to ambulance’s suspensions, and a failure to helicopter’s electrical supply system Foley et al.38 Observational, 100 2 physicians, 2 ECLS specialists, Ambulance, All transfers performed successfully; retrospective 2 paramedics, and one nurse helicopter, airplane 17 technical problems: ambulance electrical for ground transports; supply (10 cases), ECLS battery circuit One pilot and 2 nurses for (4 cases), loss from ECLS circuit port or air-transport tube (3 cases) Huang et al.39 Observational, 31 One Cardiovascular surgeon, Ambulance All transfers performed successfully; retrospective one ECMO specialist 2 technical problems: 1 failure of ambulance electric system, and 1 tyre breakdown. Zimmermann et al.40 Observational, 8 One intensivist physician, Ambulance, helicopter, All transfers performed successfully; one retrospective one paramedic, one perfusionist transient ischemia of the lower limb, immediately after transportation Coppola et al.41 Descriptive, 68 One director/mission commander, Ambulance o military No deaths during transports; retrospective one pediatrician, one ECMO , ground vehicles, 6 technical problems: oxygenator clogging (2 coordinator one pediatric cardiologist, airplane cases), electric supply problems (2 cases), one surgeon, 2 ECMO specialists, loss from heat-exchanger (1 case), circuit 2 pediatric nurses, 1-2 respiratory breakdown due to a roller pump problem (1 therapist, other technicians or trainees case); all failures were repaired without severe interruption of ECMO Wagner et al.42 Observational, 23 One intensivist physician, Ambulance, airplane, No deaths or major complications due to retrospective one heart surgeon, one ICU nurse, militar airplane transports (not dedicated team) Haneya et al.43 Observational, 38 One intensivist physician, Ambulance, helicopter During transports for distances greater than retrospective one perfusionist, one nurse, 350 km a stop was needed because the one heart surgeon, oxygen supply was insufficient; a case of replacement of an oxygenator due to partial clogging of the membrane Clement et al.44 Descriptive, 112 One ECMO coordinator, one Helicopter, No deaths during transports; retrospective pediatric heart surgeon, airplane, ambulance one assistant surgeon, one intensivist physician no detailed information about adverse events during transfers Ciapetti et al.45 Descriptive 12 ARDS cases, One intensivist physician, Ambulance, airplane, All transfers performed successfully; observational, among which one heart surgeon, one helicopter absence of noteworthy incidents 4 transported cardiologist, one perfusionist, with ECMO one nurse Lucchini et al.46 Observational, 42 ARDS cases, Two intensivist physician, Ambulance, airplane All transfers performed successfully; retrospective which 29 one perfusionist, one nurse absence of noteworthy incidents with ECMO MICU, mobile intensive care unit; ECMO, extracorporeal membrane oxygenation; ECLS, extracorporeal life support; ICU, intensive care unit; ARDS, acute respiratory distress syndrome Non co mmerc ial us e o nly [page 16] [Emergency Care Journal 2015; 11:4781] (22% of cases), showing that this mode of transport can be performed safely.32 Also the secondary transfers of 173 patients with intra- aortic balloon pump by plane, helicopter or mobile intensive care unit were substantially free from relevant clinical and mechanical complications. Adverse events were defined as rupture of the intra-aortic balloon, pump mal- function, low level battery, catheter displace- ment, bleeding, loss of trigger signal, or car- diac arrest.33 Sometimes complications related to transfers may arise from inappropriate prac- tices of the transport team. The survey of Hauswald et al., published in 2000, was con- ducted on 37 inter-hospital air transport serv- ices, to explore the use of spinal board during transport. Twenty nine out of 30 respondent services, used spinal board also in long-dis- tance transfers.34 Eighteen services routinely re-immobilized the patient even if the case of radiological exclusion of spinal injuries. Two services reported cases of pressure ulcers due prolonged immobilization.34 Finally, while remaining on the theoretical plane, Karkada et al.35 have proposed a sugges- tive hypothesis for an unrecognized complica- tion of inter-hospital transfers. They use a mathematical model to describe the possibility of spreading throughout the United States highly resistant microorganisms carried by critically ill patients transferred from a state to another.35 Inter-hospital transport com- plications of extracorporeal membrane oxygenation-extra- corporeal life support patients The transports of patients undergoing car- diopulmonary bypass [extracorporeal mem- brane oxygenation (ECMO) and extracorporeal life support (ECLS)] are probably the most complex to be carried out for the intensive care staff. In fact the support offered by ECMO/ECLS determine organizational and logistical criticalities, and, above all, it is char- acterized by a high instability of respiratory and circulatory functions that requires the management of specialist referral centers. The transfer of patients in ECMO/ECLS can be car- ried out by ground or air. The results of studies on the safety of these kind of transfers are summarized in Table 5. Outside the aim of this review, Table 5 reports also research papers on neonatal and pediatric population, when being part of the case mix (with adults) studied by the authors. The 11 studies published from the late 90’s till now, collect a series of 451 transports of neonatal, pediatric and adult patients treated with extracorporeal cardiopulmonary support for respiratory failure (328 patients), and car- diac failure (123 patients). The transports were performed by ambulance (63%), airplane (17%), helicopter (20%). The whole of these papers revealed only 29 adverse events in a range that varies, according to the authors, from the absence to a maximum of 17%. No fatal accidents to the patients were recorded. Problems encountered were related to power supply (15 cases), components of the extracor- poreal circuit (13 cases), and vehicles (2 cases). Technical problems that occurred to ECMO/ECLS during transport were: blood loss, problems with batteries, clotted oxygenator, ECMO pump failure, broken ports, and losses from the heat exchanger. Conclusions This literature review shows that, at present as in the past, the risk of occurrence of adverse events relating to the transport of critically ill patients is concrete and depend on the setting, the teams and the kinds of patients and trans- ports carried out. In that regard some key mes- sages are summarized in Table 6. This con- cepts, arising from old and new papers, are useful for the planning of intra ad inter-hospi- tal transfers. The will to understand whether inter-hospital transport is potentially safer than intra-hospital is inappropriate. In fact there are important methodological limits to the studies published, mainly carried out with retrospective observational and descriptive designs. Furthermore we cannot exclude a general underreporting of incidents and adverse events related to transports, with con- sequent publication biases.55 However, inter-hospital transports of ECMO patients seem to be substantially the safest, due to lack of major events and outcomes. Conversely, intra-hospital transports are more burdened by the risk of complications and acci- dents. One possible explanation may lie in the composition of the team carrying out the transport. In fact, during ECMO/ECLS trans- fers, there are more healthcare workers and a higher skill mix. Indeed the best results in terms of prevention of complications are reached also in intra-hospital transfer when performed by dedicated teams.7,21 Currently, research must explore more accurately how much transports affect the outcome of patients, and what are the most appropriate time-frames to assess the direct consequences of transfers on patients’ clinical conditions. References 1. Italian Board of Health. Morte o grave danno conseguenti ad un malfunziona- mento del sistema di trasporto (intraospe- daliero, extraospedaliero). Available (in Italian) from: http://www.salute.gov.it/imgs/C_17_pub- blicazioni_1162_allegato.pdf 2. Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Crit Care Med 1990;18:278-81. 3. Doring BL, Kerr ME, Lovasik DA, Thayer T. Factors that contribute to complications during intrahospital transport of the criti- cally ill. J Neurosci Nurs 1999;31:80-6. 4. Beckmann U, Gillies DM, Berenholtz SM, et al. Incidents relating to the intra-hospi- tal transfer of critically ill patients. An ana- lysis of the reports submitted to the Australian incident monitoring study in intensive care. Intens Care Med 2004;30: 1579-85. 5. Papson JP, Russell KL, Taylor DM. Unexpected events during the intrahospi- tal transport of critically ill patients. Acad Emerg Med 2007;14:574-7. 6. Winter MW. Intrahospital transfer of criti- Review Table 6. Key information for planning transports of critically ill patients. 1. There is no evidence that the occurrence of accidents related to transport is directly proportional to the time spent outside critical care environment2,47 2. The emergency transports involve a higher risk of critical incidents compared to those that are pre-planned47 3. There are no differences in the occurrence of adverse events related to equipment between transport organized in emergency or elective conditions48 4. 75% of mishaps occur during radiological investigations and three-quarters of these during CT scanning2 5. The appearance of alterations of vital signs during preparation phase of transport could have predictive power for complications during the transfer29,49 6. It is possible that some alterations of monitored vital signs may occur independently by the transport performance50,51 7. Transport ventilators provide greater stability with respect to pH and PaCO2 of patients than manual ventilation52-54 CT, computed tomography. Non co mmerc ial us e o nly [Emergency Care Journal 2015; 11:4781] [page 17] cally ill patients; a prospective audit within Flinders Medical Centre. Anaesth Intens Care 2010;38:545-9. 7. Kue R, Brown P, Ness C, Scheulen J. Adverse clinical events during intrahospi- tal transport by a specialized team: a preli- minary report. Am J Crit Care 2011;20:153- 61. 8. Warren J, Fromm RE Jr, Orr RA, et al. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004;32:256-62. 9. Association of Anesthetists of Great Britain and Ireland. recommendations for the safe transfer of patients with brain injury. Available from: http://www.aagbi.org/sites/default/files/bra ininjury.pdf 10. Association of Anesthetists of Great Britain and Ireland. Interhospital transfer. Available from: http://www.aagbi.org/sites/default/files/int erhospital09.pdf 11. Intensive Care Society. Guidelines for the transport of critically ill adult. Intensive Care Society Standards 2011. London: Intensive Care Society; 2011. 12. Australasian and New Zealand College of Anaesthetists. Minimum standard for transport of critically ill patients. Melbourne: Australasian and New Zealand College of Anaesthetist; 2010. 13. Australasian College for Emergency Medicine. Minimum standards for intra- hospital transport of critically ill patients. Emerg Med Australas 2003;15:202-4. 14. Quenot JP, Milési C, Cravoisy A, et al. Intrahospital transport of critically ill patients (excluding newborns) recom- mendations of the Société de Réanimation de Langue Française (SRLF), the Société Française d'Anesthésie et de Réanimation (SFAR), and the Société Française de Médecine d'Urgence (SFMU). Ann Intensive Care 2012;2:1-10. 15. Bambi S. Il processo di trasferimento del politraumatizzato dalla sala emergenze ai servizi di diagnostica. Scenario 2002;3:4- 11. 16. Fanara B, Manzon C, Barbot O, et al. Recommendations for the intra-hospital transport of critically ill patients. Crit Care 2010;14:R87. 17. Day D. Keeping patients safe during intra- hospital transport. Crit Care Nurse 2010;30:18-32. 18. Waydhas C. Intrahospital transport of criti- cally ill patients. Crit Care 1999;3:R83-9. 19. Zuchelo LT, Chiavone PA. Intrahospital transport of patients on invasive ventila- tion: cardiorespiratory repercussions and adverse events. J Bras Pneumol 2009;35:367-74. 20. Lucchini A, Elli S, Gariboldi R, et al. Standardizzazione delle procedure di tra- sporto del paziente critico ricoverato in terapia intensiva: studio osservazionale su 68 trasporti intraospedalieri. Scenario 2012;29:15-20. 21. Choi HK, Shin SD, Ro YS, et al. A before- and after-intervention trial for reducing unexpected events during the intrahospi- tal transport of emergency patients. Am J Emerg Med 2012;30:1433-40. 22. Fan E, MacDonald RD, Adhikari NK, et al. Outcomes of interfacility critical care adult patient transport: a systematic review. Crit Care 2006;10:R6. 23. McGinn GH, MacKenzie RE, Donnelly JA, et al. Interhospital transfer of the critically ill trauma patient: the potential role of a specialist transport team in a trauma system. J Accid Emerg Med 1996;13:90-2. 24. Gebremichael M, Borg U, Habashi NM, et al. Interhospital transport of the extremely ill patient: the mobile intensive care unit. Crit Care Med 2000;28:79-85. 25. Uusaro A, Parviainen I, Takala J, Ruokonen E. Safe long-distance interho- spital ground transfer of critically ill patients with acute severe unstable respi- ratory and circulatory failure. Intens Care Med 2002;28:1122-5. 26. Gray A, Gill S, Airey M, Williams R. Descriptive epidemiology of adult critical care transfers from the emergency depar- tment. Emerg Med J 2003;20:242-6. 27. Ligtenberg JJ, Arnold LG, Stienstra Y, et al. Quality of interhospital transport of criti- cally ill patients: a prospective audit. Crit Care 2005;9:R446-51. 28. Markakis C, Dalezios M, Chatzicostas C, et al. Evaluation of a risk score for interho- spital transport of critically ill patients. Emerg Med J 2006;23:313-7. 29. Lee LLY, Lo WYL, Yeung KL, et al. Risk stra- tification in providing inter-facility tran- sport: experience from a specialized tran- sport team. World J Emerg Med 2010;1:49- 52. 30. Wiegersma JS, Droogh JM, Zijlstra JG, et al. Quality of interhospital transport of the critically ill: impact of a mobile intensive care unit with a specialized retrieval team. Crit Care 2011;15:R75. 31. Droogh JM, Smit M, Hut J, et al. Inter- hospital transport of critically ill patients; expect surprises. Crit Care 2012;16:R26. 32. Seymour CW, Kahn JM, Schwab CW, Fuchs BD. Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study. Crit Care 2008;12:R71. 33. Sinclair TD, Werman HA. Transfer of patients dependent on an intra-aortic bal- loon pump using critical care services. Air Med J 2009;28:40-6. 34. Hauswald M, McNally T. Confusing extri- cation with immobilization: the inappro- priate use of hard spine boards for inter- hospital transfers. Air Med J 2000;19:126- 7. 35. Karkada UH, Adamic LA, Kahn JM, Iwashyna TJ. Limiting the spread of highly resistant hospital-acquired microorga- nisms via critical care transfers: a simula- tion study. Intens Care Med 2011;37:1633- 40. 36. Rossaint R, Pappert D, Gerlach H, et al. Extracorporeal membrane oxygenation for transport of hypoxemic patients with seve- re ARDS. Brit J Anaesth 1997;78:241-6. 37. Lindén V, Palmér K, Reinhard J, et al. Inter-hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation – national and international experience. Intens Care Med 2001;27:1643-8. 38. Foley DS, Pranikoff T, Younger JG, et al. A review of 100 patients transported on extracorporeal life support. ASAIO J 2002;48:612-9. 39. Huang SC, Chen YS, Chi NS, et al. Out-of- center extracorporeal membrane oxygena- tion for adult cardiogenic shock patients. Artif Organs 2006;30:24-8. 40. Zimmermann M, Bein T, Philipp A, et al. Interhospital transportation of patients with severe lung failure on pumpless extracorporeal lung assist. Brit J Anaesth 2006;96:63-6. 41. Coppola CP, Tyree M, Larry K, DiGeronimo R. A 22-year experience in global transport extracorporeal membrane oxygenation. J Pediatr Surg 2008;43:46-52. 42. Wagner K, Sagnolt GK, Risnes I, et al. Transportation of critically ill patients on extracorporeal membrane oxigenation. Perfusion 2008;23:101-6. 43. Haneya H, Philipp A, Foltam M, et al. Extracorporeal circulatory sistems in the interhospital transfer of critically ill patients: experience of a single institu- tion. Ann Saudi Med 2009;29:110-4. 44. Clement KC, Fiser RT, Fiser WP, et al. Single-institution experience with inter- hospital extracorporeal membrane oxyge- nation transport: a descriptive study. Pediatr Crit Care Me 2010;11:509-13. 45. Ciapetti M, Cianchi G, Zagli G, et al. Feasibility of inter-hospital transportation using extra-corporeal membrane oxygena- tion (ECMO) support of patients affected by severe swine-flu (H1N1) related ARDS. Scand J Trauma Resusc Emerg Med 2011;19:32. 46. Lucchini A, De Felippis C, Elli S, et al. Mobile ECMO team for inter-hospital tran- sportation of patients with ARDS: a retro- spective case series. Heart Lung Vessel 2014;6:262-73. 47. Lahner D, Nikolic A, Marhofer P, et al. Review Non co mmerc ial us e o nly [page 18] [Emergency Care Journal 2015; 11:4781] Incidence of complications in intrahospi- tal transport of critically ill patients: expe- rience in an Austrian university hospital. Wien Klin Wochenschr 2007;119:412-6. 48. Lovell MA, Mudaliar MY, Klineberg PL. Intrahospital transport of critically ill patients: complications and difficulties. Anaesth Intens Care 2001;29:400-5. 49. Andrews PJ, Piper IR, Dearden NM, Miller JD. Secondary insults during intrahospital transport of head-injured patients. Lancet 1990;335:327-30. 50. Insel J, Weissman C, Kemper M, et al. Cardiovascular changes during transport of critically ill and postoperative patients. Crit Care Med 1986;14:539-42. 51. Szem JW, Hydo LJ, Fischer E, et al. High- risk intrahospital transport of critically ill patients: safety and outcome of the neces- sary "road trip". Crit Care Med 1995;23: 1660-6. 52. Braman SS, Dunn SM, Amico CA, Millman RP. Complication of intrahospital transport in critically ill patients. Ann Intern Med 1987;107:469-73. 53. Hurst JM, Davis K, Branson RD, Johannigman JA. Comparison of blood gases during transport using two methods of ventilatory support. J Trauma 1989;29: 1637-40. 54. Romano M, Raabe OG, Walby W, Albertson TE. The stability of arterial blood gases during transportation of patients using RespirTech PRO. Am J Emerg Med 2000; 18:273-7. 55. Bambi S. The risk of intrahospital tran- sport to patients. Crit Care Nurse 2010;30:14-6. Review Non co mmerc ial us e o nly