ArticlePDF Available

Transporting critically ill patients by ambulance: audit by sickness scoring

Authors:
Julian Bion at University of Birmingham
Julian Bion
I H Wilson
I H Wilson
I H Wilson
  • This person is not on ResearchGate, or hasn't claimed this research yet.
P A Taylor
P A Taylor
P A Taylor
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Download full-text PDF
Read full-text
Download citation
Content uploaded by Julian Bion
Author content
All content in this area was uploaded by Julian Bion on Sep 07, 2015
Content may be subject to copyright.
170
BRITISH
MEDICAL
JOURNAL
VOLUME
296
16
JANUARY
1988
genetic
associations
may
be
masked
by
ethnic
heterogeneity
and,
with
age,
by
the
increasing
impact
of
hormonal
and
environmental
factors.
1
Tikkanen
MJ.
Immunogenetic
polymorphism
of
apolipoprotein
B
in
man.
Studies
with
a
monoclonal
anti-Ag(c)
antibody.
Am
HeartJ
1987;113:462-7.
2
Viikari
J,
Akerblom
HK,
Nikkari
T,
et
al.
Atherosclerosis
precursors
in
Finnish
children
and
adolescents.
IV.
Serum
lipids
in
newborns,
children
and
adolescents.
Acta
Paediatr
Scand
1985;318
(suppl):
103-9.
3
Berg
K.
DNA
polymorphism
at
the
apolipoprotein
B
locus
is
associated
with
lipoprotein
level.
Clin
Genet
1986;30:515-20.
4
Talmud
PJ,
Barni
N,
Kessling
AM,
et
al.
Apolipoprotein
B
gene
variants
are
involved
in
the
determination
of
serum
cholesterol
levels:
a
study
in
normo-
and
hyperlipidaemic
individuals.
Atherosclerosis
1987;67:81-9.
5
Young
SG,
Bertics
SJ,
Scott
TM,
et
al.
Apolipoprotein
B
allotypes
MB19t
and
MB192
in
subjects
with
coronary
artery
disease
and
hypercholesterolemia.
Arteriosclerosis
1987;7:61-5.
(Accepted
14
October
1987)
Third
Department
of
Medicine,
Meilahti
Hospital,
University
of
Helsinki,
00290
Helsinki
M
J
TIKKANEN,
MD,
acting
associate
professor
Department
of
Medicine,
University
of
Turku
J
VIIKARI,
MD,
associate
professor
Children's
Hospital,
University
of
Helsinki
H
K
AKERBLOM,
MD,
professor,
II
department
of
paediatrics
E
PESONEN,
MD,
paediatric
cardiologist,
I
department
of
paediatrics
Correspondence
to:
Dr
Tikkanen.
Transporting
critically
ill
patients
by
ambulance:
audit
by
sickness
scoring
Patients
who
are
critically
ill
may
be
safely
transported
by
specialist
teams'
but
no
prospective
studies
to
investigate
the
efficacy
of
transporting
such
patients
by
ordinary
ambulances
attended
by
junior
doctors
have
been
reported.
Such
studies
are
important
because
most
critically
ill
patients
are
probably
transported
in
this
way.
Financial
constraints
may
result
in
increasing
use
of
ordinary
ambulances
to
transfer
such
patients
to
centralised
units.
We
performed
an
audit
of
non-specialist
transport
within
a
district
general
hospital
group
in
which
a
sickness
score
was
used
to
control
for
severity
of
illness.
Patients,
methods,
and
results
Vascular
and
general
surgery,
coronary
care,
and most
medical
specialties
are
sited
within
a
five
mile
radius
of
this
intensive
care
unit;
patients
are
therefore
commonly
transferred
to
the
unit
by
ambulances,
the
journey
taking
a
maximum
of
30
minutes.
The
unit
accepts
all
patients
except
those
with
uncomplicated
head
injuries.
We
studied
50
consecutive
patients
transferred
to
the
unit.
Severity
of
illness
was
assessed
with
a
sickness
score,'
which
is
a
modification
of
the
acute
physiology
and
chronic
health
evaluation
(APACHE
II)
score.2
The
sickness
score
was
calculated
from
data
collected
immediately
before
and
after
transport.
Arterial
blood
samples
for
blood
gas
analysis
were
taken
before
transport,
packed
in
ice,
and
analysed
together
with
a
sample
drawn
on
arrival.
Patients
were
not
monitored
during
the
journey.
Controlled
ventilation
was
provided
with
an
Ambu
bag;
patients
who
had
not
been
intubated
received
a
controlled
supply
of
oxygen
from
MC
facemasks.
The
partial
pressure
of
inspired
oxygen
was
measured
with
an
oxygen
meter.
Complications
occurring
during
transfer
and
the
seniority
and
specialty
of
the
medical
attendant
were
noted.
Survival
was
taken
as
discharge
home.
Of
the
50
patients,
31
had
had
operations
and
19
had
medical
conditions
(repair
of
an
aortic
aneurysm
13;
acute
renal
failure,
12;
sepsis,
seven;
cardiac
arrest,
five;
and
respiratory
problems,
13).
Seven
patients,
three
of
whom
had
had
operations,
developed
eight
serious
complications
during
transfer:
obstruc-
tion
of
an
endotracheal
tube,
respiratory
arrest
on
arrival
at
the
hospital,
accidental
disconnection
of
arterial
and
central
venous
cannulas,
withdrawal
of
crucial
inotropic
and
bronchodilator
infusions
(two
cases),
and
unrecordable
blood
pressure
on
arrival
(three).
Six
of
the
seven
patients
were
attended
by
junior
staff
(registrar
grade
or
below)
who
were
not
anaesthetists
(x2=
10-79,
p<0005).
The
table
shows
the
numbers
of
patients
and
their
mean
sickness
scores
before
and
after
transfer.
The
difference
in
scores
between
the
survivors
and
non-
survivors
was
highly
significant
(p<00001).
The
mean
score
for
non-survivors
showed
a
small
increase
after
transport,
though
this
was
not
significant.
Patients
who
suffered
complications
and
those
accompanied
by
junior
staff
or
staff
other
than
anaesthetists
tended
to
have
higher
scores,
but
the
differences
were
not
significant.
Sickness
scores
(and
95%
confidence
intervals)
before
and
after
transport
categorised
by
outcome,
grade
and
specialty
of
attending
staff,
and
complications
Mean
sickness
score
No
of
patients
Before
transport
After
transport
Survivors
34
10-2
(8
9
to
12-0)
10-4
(9-1
to
12-2)
Non-survivors
16
19-0
(16-3
to
21-6)
20-6
(17-7
to
23-4)
Senior
staff
27
12-0
(9-7
to
14-3)
12-5
(10-3
to
14-7)
Junior
staff
23
14-1
(11-3
to
16-9)
15-0 (11-8
to
18-2)
Anaesthetists
34
12-4
(10-5
to
14-4)
13-0
(11-0
to
15-0)
Other
16
14-1
(10-4
to
17-9)
151
(10-8
to
19-3)
Complications
7
15-2(10-1
to20-4)
16-5(10-2
to22-9)
No
complications
43
12-6
(10-7
to
14-5)
13-2
(11-2
to
15-2)
Comment
This
study
showed
that
life
threatening
complications
may
occur
in
critically
ill
patients
when
conventional
ambulances
are
used
for
transport.
Complications
were
more
common
in
patients
attended
by
junior
doctors
and
doctors
other
than
anaesthetists
and
were
not
due
to
more
severe
illness
among
these
patients.
The
training
in
resuscitation
received
by
anaesthetists
may
be
an
advantage
in
caring
for
patients
when
monitoring
is
not
available.
The
complications
were
not
the
direct
cause
of
death
in
any
patient,
probably
because
of
the
short
journey;
longer
transport
times
might
have
resulted
in
a
significant
increase
in
sickness
scores.
Because
severity
of
illness
was
controlled
for,
these
results
suggest
that
inexperience
in
the
management
of
patients
who
are
critically
ill
is
the
dominant
factor
in
the
development
of
complications
during
transfer,
confirming
earlier
work.3
The
results
support
the
need
for
improved
training
in
resuscitation4
and
suggest
that
blood
pressure
should
be
monitored
during
transfer.
1
Bion
JF,
Edlin
SA,
Ramsay
G,
McCabe
S,
Ledingham
IMcA.
Validation
of
a
prognostic
score
in
critically
ill
patients
undergoing
transport.
BrMedJ
1985;291:432-4.
2
Knaus
WA,
Draper
EA,
Wagner
DP,
Zimmerman
JE.
APACHE
II:
a
severity
of
disease
classification
system.
Cn't
Care
Med
1985;13:818-29.
3
Waddell
G,
Scott
PDR,
Lees
NW,
Ledingham
IMcA.
Effects
of
ambulance
transport
in
critically
ill
patients.
BrMedJ7
1975;i:386-9.
4
Baskett
PJF.
Resuscitation
needed
for
the
curriculum?
Br
MedJ7
1985;290:1531-2.
(Accepted
30
September
1987)
Intensive
Care
Unit,
Plymouth
General
Hospital,
Plymouth
PL4
8QQ
J
F
BION,
MRCP,
FFARCS,
senior
registrar
I
H
WILSON,
FFARCS,
registrar
P
A
TAYLOR,
FFARcs,
consultant
Correspondence
to:
Dr
J
F
Bion,
Department
of
Anaesthetics,
Birmingham
University,
Birmingham
B15
2TH.
Is
altered
cardiac
sensation
responsible
for
chest
pain
in
patients
with
normal
coronary
arteries?
Clinical
observation
during
cardiac
catheterisation
Most
patients
with
chest
pain
characterised
as
angina
pectoris
have
obstructive
atheromatous
disease
of
the
coronary
arteries.
In
a
few
patients
with
angina
pectoris
exercise
testing
indicates
abnormalities
but
coronary
angiograms
are
normal.I
Various
theories
have
been
proposed
to
explain
these
findings,
termed
syndrome
X,
and
which
include
abnormalities
of
coronary
reserve
or
myocardial
metabolism
and
abnormal
histological
appearances.2-4
During
routine
cardiac
catheterisation
we
observed
that
patients
with
syndrome
X
were
unusually
sensitive
to
intracardiac
instru-
mentation.
We
report
the
findings
of
a
preliminary
study.
Patients,
methods,
and
results
We
studied
seven
patients
with
syndrome
X
(exertional
chest
pain
associated
with
ST
segment
depression
of
more
than
1
mm
during
exercise
and
normal
coronary
arteries);
four
patients
with
typical
angina
but
negative
results
on
exercise
testing
and
normal
coronary
arteries;
seven
patients
with
atherosclerotic
coronary
artery
disease;
and
nine
patients
with
mitral
valve
disease.
... Mitophagy is a selective form of autophagy, which controls mitochondrial quality by removing damaged mitochondria and is involved in the pathology of Parkinson's disease [13,27]. Te PINK1/Parkin pathway is reported to play an essential role in triggering mitophagy [28]. We thus investigated whether OB-induced improvement in mitochondria function is associated with PINK1/Parkin- Journal of Clinical Pharmacy and Terapeutics dependent mitophagy. ...
Preparation and Evaluation of Onjisaponin B-Loaded Liposomes for Drug Delivery to Enhance Mitochondrial Function and Rescue Parkinson’s Disease by Activating Mitophagy
Article
Full-text available
Onjisaponin B (OB) is the main active ingredient of Radix Polygalae with various bioactivities. However, the protective effect of OB in Parkinson’s disease (PD) has not been fully studied. Liposomes are ideal nanocarriers for drugs targeting the brain. In this study, we investigated the therapeutic effect of OB-loaded liposomes (lip OB) on a 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine- (MPTP-) induced mouse model of PD and 1-methyl-4-phenylpyridinium- (MPP+-) induced cell model of PD. Our results showed that lip OB significantly ameliorated MPTP-induced motor deficits and dopaminergic neuron loss in vivo and prevented MPP+-triggered cell viability reduction and apoptosis in vitro. Lip OB also improved mitochondrial dysfunction in PD models by driving PINK1/Parkin-mediated mitophagy. Furthermore, silencing PINK1 compromised the beneficial effects of lip OB on MPP+-treated PC12 cells. These findings suggested lip OB mitigates Parkinsonism in vivo and in vitro by enhancing mitochondrial dysfunction through the PINK1/Parkin pathway of mitophagy, which provides a new possibility for treating PD.
View
... 7 Multiple single-center studies reveal fewer adverse events when pediatric-trained teams are used. [8][9][10][11][12][13][14][15][16][17] Thus, pediatric-trained transport teams are the expected norm, although the specific pediatric training and optimal composition is unknown. ...
Effect of Transition From a Unit-Based Team to External Transport Team for a Pediatric Critical Care Unit
Article
Full-text available
Objective Pediatric hospitals must consider staff, training, and direct costs required to maintain a pediatric specialized transport team, balanced with indirect potential benefits of marketing and referral volume. The effect of transitioning a unit-based transport team to an external service on the pediatric intensive care unit (PICU) is unknown, but information is needed as hospital systems focus on population management. We examined the impact on PICU transports after transition to an external transport vendor. Methods Single-center retrospective review performed of PICU admissions, referrals, and transfers during baseline, post-, and maintenance period with a total of 9-year follow-up. Transfer volume was analyzed during pre-, post-, and maintenance phase with descriptive statistics and statistical process control charts from 1999 to 2012. Results Total PICU admissions increased with an annual growth rate of 3.7%, with mean annual 626 admissions prior to implementation to the mean of 890 admissions at the end of period, P < .001. The proportion of transport to total admissions decreased from 27% to 21%, but mean annual transports were unchanged, 175 to 183, P = .6, and mean referrals were similar, 186 to 203, P = .8. Seasonal changes in transport volume remained as a predominant source of variability. Annual transport refusals increased initially in the postimplementation phase, mean 11 versus 33, P < .03, but similar to baseline in the maintenance phase, mean 20/year, P = .07. Patient refusals were due to bed and staffing constraints, with 7% due to the lack of transport vendor availability. Conclusion In a transition to a regional transport service, PICU transport volume was maintained in the long-term follow-up and total PICU admissions increased. Further research on the direct and indirect impact of transport regionalization is needed to determine the optimal cost–benefit and quality of care as health-care systems focus on population management.
View
View
Use of intensive care unit priority model in directing intensive care unit admission in Sudan: A prospective cross-sectional study
Article
Full-text available
  • Mar 2021
Background: The shortage of specialized intensive care beds is one of the principal factors that limit intensive care unit (ICU) admissions. This study explores the utilization of priority criteria in directing ICU admission and predicting outcomes. Methods: This was a prospective cross-sectional study conducted in two ICUs in Sudan from April to December 2018. Patients were assessed for ICU admission and were ranked by priority into Groups 1, 2, 3, and 4 (1 highest priority and 4 lowest priority), and these groups were compared using independent t-test, Chi-square, and ANOVA. Results: A total of 180 ICU admitted patients were enrolled, 53% were male. The prioritization categories showed that 86 (47.8%), 50 (27.8%), 13 (7.2%), and 31 (17.2%) were categorized as priority 1, 2, 3, and 4, respectively. Patients in priority groups 3 and 4had significantly higher ICU mortality rates compared to those in groups 1 and 2 (P < 0.001), were likely to be older (P < 0.001), had significantly more comorbidities (P = 0.001), were more likely to be dependent (P < 0.001), and had longer ICU length of stay (P = 0.028). Conclusion: Patients classified as priority 3 and 4 were predominantly older and had many comorbidities. They were likely to be dependent, stay longer in ICU, and exhibit mortality. Keywords: Admission, appropriateness, categories, intensive care unit, priority
View
Rationing and Triage
Chapter
  • Jan 1995
In the last few years, most industrialized countries have been examining methods of controlling health care expenditure. The need for cost containment has come about as a consequence of the recession, rapidly rising health service costs, and a progressive increase in the proportion of the population who are of pensionable age [1]. Despite the great variation in national expenditures on health care, it seems unlikely that cost containment can be achieved without restricting in some way the quantity, quality or range of services provided. However, few governments (Oregon in the USA [2], and Holland [3]) have had the courage to examine openly various options for rationing. In general, politicians tend to find the term emotive and inconvenient, preferring euphemisms like ‘clinical prioritization’. Perhaps they forget that rationing is not a new phenomenon: in various forms it has always been an inevitable and integral feature of health care. This implicit rationing usually required the cooperation of doctors, but the medical profession is less willing to act as gatekeeper now that it is losing authority and power to managers who do not have the same direct responsibility for individual patient care. Other factors have also stimulated the debate about explicit rationing, these include a greater respect for patient autonomy; the lack of evidence for the comparative efficacy of different treatments; recognition of the power of medical interventions to do harm; realization that individual patient decisions affect the medical commons; and acceptance of public consultation and consensus on matters of health policy.
View
Audit in Intensive Care
Chapter
  • Jan 1990
The term “audit” is of Latin origin, and implied public examination of fact. In an industrial context it refers to verification of accounts and assessment of performance — cost effectiveness. Medical audit is more difficult to define because of the diversity of activities which represent health care, and audit therefore means different things to different people. There are however certain common elements of medical audit, which may be defined as “the systematic and public examination of factors which affect the delivery of good medical care”. This activity has always been a normal part of medical practice in the form of morbidity and mortality meetings, consensus conferences, and in the conduct of medical research. However, the definition raises questions which should themselves be the subject of research: what systems or standards are needed, and how can they be derived? Who should monitor results and have access to data? What factors should we measure and how? What do we mean by good medical care? Does the process of audit itself improve medical care? Simplistic phrases such as ‘value for money’ ignore the fact that health care systems are complex structures, even when the relationship between purchaser and provider is apparently clearly defined as in private practice.
View
Transporting the Critically Ill
Chapter
  • Jan 1992
Since biblical times there have been reports of man helping his stricken fellow to places of safety and comfort. However, it was not until the eighteenth century that, under the influence of army surgeons, the collection and transportation of the injured became organized. Modern warfare has been accompanied by the development of increasingly efficient and sophisticated evacuation chains. In the Korean and Vietnam conflicts, casualty evacuation was well organized so that ultimately wounded servicemen could expect to arrive at surgical complexes capable of definitive treatment within 30 min. Civilian transport systems similarly have become sophisticated and life-support techniques are now widely practised both in the field and in transit. In addition, as medical practice becomes more specialized, increasing numbers of critically ill patients will be moved between hospitals, often during an acute phase of their illness.
View
Preventing iatrogenic Complications
Chapter
  • Jan 2003
‘Human error should be seen as a consequence, not a cause, of failure’. An organisation with a memory. Department of Health, London 2001 when Ignac Semmelweis tried to convince the medical community that the contagion of puerperal sepsis was transmitted on the hands of attending medical staff, one of the arguments adduced against his evidence was that doctors, being well-intentioned almost by definition, could not therefore be maleficent agents. Such paternalistic attitudes have changed since the mid-nineteenth century, but only in recent years has there been a willingness to accept that iatrogenic disease is frequent, serious, and most importantly, often preventable. There is also a growing understanding that medical error as a subset of iatrogenic disease, represents a failure of the system, not just the individual, and the prevention of error therefore requires a systems approach.
View
Intensive care in the United Kingdom: Report from the King's Fund panel
Article
  • May 1989
Intensive care units (ICU) epitomise the challenge of high technology medicine. They make heavy demands in terms of staff, equipment and other resources yet they have the potential to save lives and increase the chances of survival where alternative therapies have nothing to offer. Furthermore, while they undoubtedly bring benefit to some patients, ICUs also result in loss of the patient's dignity, privacy and autonomy. Balancing benefits and costs is not easy, and it was this issue that a multi-disciplinary panel convened by the King's Fund sought to address at a number of meetings in 1988. The panel reviewed the published literature on ICUs, considered submissions from a small number of invited experts and drew on the experience of its members. It soon became apparent that lack of data in the United Kingdom would make it impossible to prepare a definitive statement on the role of ICUs in the National Health Service (NHS). Accordingly, the panel decided to produce a report summarising the current state of knowledge about intensive care, highlighting the absence of evidence and calling for a substantial programme of research.
View
Intra-hospital transport of critical patients
Article
Full-text available
  • Oct 2007
The medicine knowledge and development of new technologies for diagnoses and treatment of patients had permitted the longevity of healthy people and of those with acute or chronic illness. These technological advances are not well distributed, but there are clearly improvements on the management of patients in medical field leading to a lower mortality and a better quality of life. With these improvements, hospitals needed to increase the area of critical care settings. Patients have being beneficiated by these diagnose technologies, most of them including image, but to access them, they need to be transported out of a intensive care unit, needing to maintain the same level of monitorization. That is the great importance on transportation of a critical patient, and it has being neglected by most health professionals. The objective of this article is to make a reflection of the various moments, phases and care involving the intra-hospital transport, discussing its various aspects.
View
APACHE II
Article
Full-text available
  • Oct 1985
  • CRIT CARE MED
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases.When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
View
Validation Of A Prognostic Score In Critically Ill Patients Undergoing Transport
Article
Full-text available
  • Sep 1985
Fifty consecutive critically ill patients transported between hospitals by a mobile intensive care team were assessed prospectively using a modification of the acute physiology and chronic health evaluation (APACHE II) sickness scoring system. Assessments were made before and after resuscitation, on return to base, and after 24 hours of intensive care. No patient died during transport. Twenty two patients died subsequently in hospital and 28 survived to return home. The mean score for the non-survivors before resuscitation was 21.7 and for the survivors 12.2 (p less than 0.0005). Among the non-survivors there was a significant fall in score with resuscitation but this did not alter their subsequent outcome. Neither group deteriorated during transport. The sickness score is a powerful method for determining prognosis, and employed longitudinally it may be useful in the assessment of treatment. It has important implications for the administration and organisation of regional intensive care services.
View
APACHE II: a severity of disease classification system
Article
Full-text available
  • Nov 1985
  • CRIT CARE MED
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
View
Effects of ambulance transport in critically ill patients
Article
  • Mar 1975
Two groups of critically ill patients were transferred by ambulance from other hospitals to a central intensive therapy unit. The effect of transport was reviewed retrospectively in 46 patients and prospectively in 20 patients. Of the 46 patients reviewed retrospectively six became hypotensive, six became hypertensive, and seven developed delayed hypotension. One patient developed fits and six out of 13 patients had a rise in arterial PCO-2 of 1-6-4-1 kPa (12-31 mm Hg). Of the 20 patients reviewed prospectively, one patient became hypertensive due to overtransfusion, one had a fit, but none became hypotensive. Three out of four cases of delayed hypotension were related to starting intermittent positive pressure ventilation. Arterial PCO-2 fell in one patient and arterial PCO-2 rose in two, each change being related to changed oxygen therapy or narcotics. There were no changes in other cardiovascular or respiratory indices, body temperature, or urine production. Earlier transfer, resuscitation before transfer, continuing medical care during the journey, and hence a slower smoother journey seemed to be important factors in the management of these patients. Our findings, may have important implications in the future regional organization of the care of critically ill patients.
View
Resuscitation needed for the curriculum?
Article
  • Jun 1985
The calibre of resuscitation skills found among preregistration house officers at one of our premier teaching hospitals should provide some thought and some activity from the designers of the medical schools' curriculum. Investigators found that a mere 55% of their preregistration house officers could perform the techniques of basic life support: clearance and maintenance of the airway, artificial ventilation by the mouth to mouth method, and external compression of the chest. Theirs is not an isolated finding. Nor are our young doctors proficient at advanced life support skills, where one might suppose they would come into their own.
View