Inter-hospital transport of critically ill patients : the reality of a hospital in the Northeast region of Portugal

Background: The need to transfer patients between health institutions is an unquestionably current subject. Objective: To characterize the supervision of patients during inter-hospital transport. Methodology: Retrospective cross-sectional study. The study included 184 patients from an emergency department in the northeast region of Portugal who were transferred between hospitals under the supervision of the service’s team between November 2015 and October 2016. Results: Among the transferred patients, 58.7% were men; 33.2% were aged 71-80 years; the most common diagnosis was neurological disease (31.5%); 15.8% of them had a risk score 0-2; 45.7% a risk score 3-6; 18.5% had a risk score ≥7; and 20.1% had a risk score <7 and item scoring 2 points. They were supervised by a nurse (77.2%) or by a physician and a nurse (22.8%). Conclusion: The risk score influences the type of supervision during inter-hospital transport. Most patients with a higher risk score were supervised by a physician and a nurse.


Introduction
The recent changes in the structure of the Portuguese National Health Service (Serviço Nacional de Saúde, SNS) and the reorganization of some hospital treatment and diagnosis services have contributed to the need for transferring patients between different institutions in pursuit of the best approach to different situations.The decision to transport critically ill patients should always take into account the benefit-risk assessment since the transport of patients increases the risk of morbidity and mortality.For the first time in 1992, the American Society of Critical Care Medicine published guidelines for inter-hospital transport.In 1997, the Portuguese Society of Intensive Care (Sociedade Portuguesa de Cuidados Intensivos, SPCI) developed a guide on patient transfer that emphasized the need for correct transport planning in order to minimize risks.In 2001, the Working Group in Emergencies of the North Regional Health Administration (Administração Regional de Saúde do Norte, ARSN) published the regulation for secondary transfer.This document was later updated in 2006.In 2008, the SPCI and the Portuguese Medical Association (Ordem dos Médicos, OM) elaborated a document with recommendations for the transfer of critically ill patients with the purpose of minimizing potential risks and making it more efficient.This document complemented the already existing documentation on the topic.The inter-hospital transport of patients should be investigated in order to obtain valid information and implement corrective actions, if necessary, as well as to contribute to the development of other studies.The professionals who supervise the patient during transport are responsible for making decisions to anticipate and resolve any potential incident during transfer, thus contributing to a successful transport.The general objective of this study was to characterize the supervision of patients during inter-hospital transport.Its specific objectives were: to determine if the type of patient supervision depends on the transport risk score; to determine if the type of patient supervision is influenced by the reason for transfer; to associate the clinical diagnosis with the type of patient supervision; and to analyze if the type of patient supervision is influenced by the medical specialty unit from which the patient is being transferred.

Background
The emergency department has become patients' entry point into the SNS for several reasons, which requires an organized and hierarchical referral network.Referral networks aim to regulate institutional complementarity with the purpose of ensuring that all patients have access to all services of the SNS (Comissão de Reavaliação da Rede Nacional de Emergência/ Urgência, 2012).In Portugal, services in the emergency network are classified in ascending order, according to resource availability and response capacity (Despacho nº 10319/2014 de 11 de agosto): basic emergency service (serviço de urgência básica, SUB), medical-surgical emergency service (serviço de urgência medico-cirúrgica, SUMC), and polyvalent emergency service (serviço de urgência polivalente, SUP).In addition to responding to urgency and emergency situations in their area of influence, these services complement each other in order to achieve a differentiated network.

Critically ill patients
The SPCI and the OM define a critically ill patient "as a patient whose survival, due to severe dysfunction or failure of one or more organs or systems, depends on advanced means of monitoring and therapy" (Ordem dos Médicos [Comissão da Competência em Emergência Médica] e Sociedade Portuguesa de Cuidados Intensivos, 2008, p. 8).Patients' current or impending multiple organ failure syndrome means that they have virtually no physiologic reserve or ability to adapt to sudden changes.Thus, the smallest change can make them vulnerable to great instability and clinical deterioration.Changes have a multiplier effect in the worsening of patients' clinical condition.Therefore, inter-hospital transport is recommended in two situations: in case of lack of human or technical resources to treat and diagnose the patient, and in case of bed unavailability at the hospital of origin (Ordem dos Médicos [Comissão da Competência em Emergência Médica] e Sociedade Portuguesa de Cuidados Intensivos, 2008).According to the SPCI and the OM, inter-hospital transport involves risks.Therefore, it is essential to perform a benefit-risk assessment of the impact that the transfer may have on the patient's treatment, diagnosis, and final outcome.The less differentiated is an emergency department, the higher will be the likelihood of an inter-hospital transport.2008) by stating that the professionals who decide, plan, assist, and transport patients are responsible for identifying, understanding, and minimizing the risks involved in the transfer, as well as for making decisions aimed at improving the patient's prognosis.Furthermore, the level of supervision, surveillance, and care during transport should at least correspond to the level found in the unit of origin.The inadequate preparation -of the patient and/or the transport team -can lead to a suboptimal care delivery.

Inter-hospital transport
Inter-hospital patient transport consists in the transfer of patients between hospitals (Lacerda, Cruvinel, & Silva, 2011).Nowadays, since not every hospital has every option available, there is an increasing need to transfer patients to a hospital where they can receive adequate care based on their clinical situation.According to the same authors, and in line with the INEM (2012), patient transport involves the following phases: Decision -it is a medical act, it assumes that benefits and risks have been assessed.Transport risk has two components: the clinical risk, which depends on the factors that affect the cardiorespiratory physiology and the reliability of monitoring -effects of vibrations and possible temperature changes -and the travel risk (acceleration, deceleration, and risk of collision, which increase significantly with speed); Planning -it is carried out by the medical and nursing teams.Proper planning can help avoiding most patient transport incidents.It requires good coordination within the team that transfers the patient, communication between the units that refer and receive the patient, the stabilization of the patient, the selection of a team, the use of proper equipment and means of transport, and adequate patient documentation; Implementation -the selected team is responsible for the patient's transport up until the arrival at the unit of destination or, in the case of transport for complementary exams or therapeutic interventions, until the patient's return to the hospital of origin.It has equal responsibilities to those of the team who transports the patient.The level of care during transport should not be lower than the care provided at the unit of origin.Rua (1999) argues that, despite the difficulties inherent to inter-hospital transport, it can be performed safely when it is planned and carried out by an experienced team and using appropriate equipment.According to the Ordem dos Médicos (Comissão da Competência em Emergência Médica) e Sociedade Portuguesa de Cuidados Intensivos (2008), argue that the team's technical qualifications (i.e., level of training and clinical experience) is one of the most important aspects for patient safety during transport.However, the authors emphasize that experience in hospital settings is not enough.Even professionals experienced in caring for critically ill patients need specific training on care delivery to critically ill patients during the transport.The transport of patients poses risks that must be considered at the time of the decision.Patients should only be transferred when their clinical condition is not directly or indirectly worsened as a result of the transport.The adequate preparation of both the patient and the transport team is essential to an optimal care delivery between the units of origin and destination (INEM, 2012).

Transport risk score
According to the recommendations of the Ordem dos Médicos (Comissão da Competência em Emergência Médica) e Sociedade Portuguesa de Cuidados Intensivos ( 2008), the identification of the necessary level of care during transport involves the completion of an assessment grid to determine the risk score (Figure 1).This transport risk score was designed by Etxebarría et al. (1998) to identify the necessary human resources, equipment, and vehicle to supervise and monitor patients according to the severity of their condition.International studies (Etxebarría et al., 1998;Kulshrestha & Singh, 2016) have documented the risk inherent to patient transport.Sethi and Subramanian (2014) have concluded that patients with a risk score ≥ 7 are at high risk for critical events and subsequent mortality.In this case, continuity of care should be maintained during the inter-hospital transport, and the team must be trained and qualified to anticipate, manage, and resolve any technical and medical difficulties that may arise during transport.Kulshrestha and Singh (2016) reinforce this idea while also emphasizing that the decision to transport a patient based on the benefit-risk assessment and its planning based on team communication and risk score are essential to determine the risk of transport, both for the patient and the transport team.Droogh, Smit, Absalom, Ligtenberg, and Zijlstra (2015) argue that, despite the use of scores, the transport itself can also influence the severity score to the extent that inter-hospital transport is associated with the risk of physiological  This transport risk score was designed by Etxebarría et al. (1998) to identify the necessary human resources, equipment, and vehicle to supervise and monitor patients according to the severity of their condition.International studies (Etxebarría et al., 1998;Kulshrestha & Singh, 2016) have documented the risk inherent to patient transport.Sethi and Subramanian (2014) have concluded that patients with a risk score ≥ 7 are at high risk for critical events and subsequent mortality.In this case, continuity of care should be maintained during the inter-hospital transport, and the team must be trained and qualified to anticipate, manage, and resolve any technical and medical difficulties that may arise during transport.Kulshrestha and Singh (2016) reinforce this idea while also emphasizing that the decision to transport a patient based on the benefit-risk assessment and its planning based on team communication and risk score are essential to determine the risk of transport, both for the patient and the transport team.Droogh, Smit, Absalom, Ligtenberg, and Zijlstra (2015) argue that, despite the use of scores, the transport itself can also influence the severity score to the extent that inter-hospital transport is associated with the risk of physiological  This transport risk score was designed by Etxebarría et al. (1998) to identify the necessary human resources, equipment, and vehicle to supervise and monitor patients according to the severity of their condition.International studies (Etxebarría et al., 1998;Kulshrestha & Singh, 2016) have documented the risk inherent to patient transport.Sethi and Subramanian (2014) have concluded that patients with a risk score ≥7 are at high risk for critical events and subsequent mortality.In this case, continuity of care should be maintained during the inter-hospital transport, and the team must be trained and qualified to anticipate, manage, and resolve any technical and medical difficulties that may arise during transport.Kulshrestha and Singh (2016) reinforce this idea while also emphasizing that the decision to transport a patient based on the benefit-risk assessment and its planning based on team communication and risk score are essential to determine the risk of transport, both for the patient and the transport team.Droogh, Smit, Absalom, Ligtenberg, and Zijlstra (2015) argue that, despite the use of scores, the transport itself can also influence the severity score to the extent that inter-hospital transport is associated with the risk of physiological deterioration and adverse events.This risk is proportional to the patient's level of severity before the transport and the team's level of experience and knowledge.The authors also mention that a specialized team, that is adjusted to the transport risk score, will be better able to stabilize the patient before transfer and anticipate or respond to complications, which results in fewer and less severe adverse events.According to Nunes (2009), the transport must be carried out with the lowest possible risk and the highest possible safety to ensure the patient's right to quality care, of which safety is a critical component.The author also emphasizes that, in their decision-making process, nurses may refuse to accompany the patient if, after analyzing the factors involved, they conclude that the minimum and desirable conditions are not in place to transport the patient safely and with the least possible risk, both for the patient and the team.

Research question
What is the type of supervision of patients during inter-hospital transport?Data were collected in March 2017 from patients who were transferred from the SUMC of ULSNE -Hospital Unit of Bragança in a land ambulance.This information was provided to the researcher, anony-mously, by the head of the service.Data were collected using the inter-hospital transport form which was used at the SUMC of ULSNE -Hospital Unit of Bragança.This form has information on the patient (age, gender, and place of origin), the necessary transport (hospital of origin and destination), the reason for transfer, the transport team, the patient's hemodynamic and neurological status, clinical diagnosis, procedures already performed, and the patient's history and examinations.Based on these parameters, each patient is assigned with a risk score that is calculated using the patient transport risk stratification scale to determine the type of supervision.This scale ranges from 0 to 20 points, where 0-2 does not require qualified super-

Results
The  The most common reasons for transfer were specialist consultation, 38% (70), and therapeutic intervention, 37% (68).In addi-tion, the supervision of a physician and a nurse was more frequent (42.9%) in these cases (Table 3).In relation to the risk score, 15.8% (29) of patients who had a risk score 0-2, but no indication for qualified supervision, were supervised by a nurse.Of the patients with a score 3-6 points, 45.7% (84), 98.8% were supervised by a nurse and 1.2% were supervised by a physician and a nurse.Of the patients with a risk score ≥7 or <7 and item scoring 2 (38.6%), 42.3% were supervised by a nurse and 57.7% were supervised by a physician and a nurse.The chi-square test found a statistically significant difference (p = 0.000) in the distribution of proportions between the type of supervision and the risk score.Most patients with higher risk scores were supervised by a physician and a nurse (57.7%), and 42.3% of the patients with indication for supervision of a physician and a nurse based on the risk score were only supervised by a nurse (Table 4).

Discussion
This research work had some difficulties and limitations due to the small number of scientific articles published on this topic, which is why the discussion will focus on the interpretation of the collected data.There may have been some situations of underreporting, where the service team supervised patients during inter-hospital transport but did not complete the data collection tool.

Sociodemographic characterization
In this sample, 97.8% of patients lived in the district of Bragança, and 46.2% lived in the municipality of Bragança.Regarding the age group, 33.2% were aged 71-80 years, which may be associated with the population ageing in the region (200 older people per 100 young people in 2015; PORDATA, Base de Dados Portugal Contemporâneo, 2015).The majority of patients lived in the district and municipality of Bragança because this is the area of reference of the SUMC of ULSNE -Hospital Unit of Bragança.No study with a sociodemographic characterization of the target population was found, thus preventing any possible comparison.

Characterization of the clinical profile
Cardiovascular diseases (67.9%) and endocrine diseases (54.9%) were the most prevalent comorbidities, followed by respiratory, renal, immunological/infectious diseases, mental/behavioral, and hematological diseases.The most common diagnosis was neurological disease, followed by cardiovascular disease.In an observational study conducted by Wiegersma et al. (2011) in the northeast region of the Netherlands on patient transfers to more differentiated hospitals, the main diagnosis of transfer was respiratory failure (27%), followed by sep-sis (17.6%), and multi-organ failure (10.8%).These results are contrary to those found in this study, where respiratory diseases appear in fifth place.Septic shock was the most common diagnosis reported by Sethi and Subramanian (2014).This difference in results may be associated with the response capacity of the Intensive Care Unit of the Hospital Unit of Bragança to treat patients with immunological/infectious and respiratory diseases, not needing to transfer them.On the other hand, there is a need to transfer neurological and cardiac patients because the hospital does not have response capacity to treat these patients.Some patients who did not require qualified supervision based on the risk score were also transferred with the supervision of a nurse.In these cases, the physician responsible for the transfer may have decided to maintain the level of supervision of the unit of origin during transport.
Sethi and Subramanian (2014) have concluded that patients with a risk score ≥7 are at high risk for critical events and subsequent mortality.In this case, continuity of care should be maintained during the inter-hospital transport, and the team must be trained and qualified to anticipate, manage, and resolve any technical and medical difficulties that may arise during transport.Kulshrestha and Singh (2016) reinforce this conclusion while also emphasizing that the decision to transport a patient based on the benefit-risk assessment and its planning based on team communication and risk score are essential to determine the clinical safety of the transport, both for the patient and the transport team.Droogh et al. (2015) argue that, despite the use of scores, the transport itself can also influence the severity score to the extent that inter-hospital transport is associated with the risk of physiological deterioration and adverse events.This risk is proportional to the patient's level of severity before transport and team's lack of experience and knowledge.The authors also mention that a specialized team, that is adjusted to the transport risk score, will be better able to stabilize the patient before transfer and anticipate or respond to complications.
The comparison of the supervision found in this study sample to the findings of the above-mentioned studies showed gaps when choosing the transport team, particularly in patients with a risk score ≥7 or <7 and item scoring 2, who were transferred under the supervision of a nurse, thus exposing the patient and the team more to potential complications.In these cases, the patient should be transferred under the supervision of a physician and a nurse in order to ensure the quality of care and surveillance.According to Nunes (2009), the transport must be carried out with the lowest possible risk and the highest possible safety to ensure the patient's right to quality care, of which safety is a critical com-ponent.The author also emphasizes that, in their decision-making process and for the patient's benefit, nurses may analyze the factors involved and, for the patient's benefit, refuse to accompany the patient until the minimum and desirable conditions are in place to transport the patient safely and with the least possible risk, both for the patient and the team.However, our study revealed that patients were transferred under the supervision of a nurse, without implementing the the desirable safety conditions.

Conclusion
The results of this study allowed concluding that the risk score influences the type of supervision during inter-hospital transport.
Most patients with higher risk scores were supervised by a physician and a nurse; patients with a risk score 3-6 were supervised by a nurse; and patients with a risk score 0-2 were supervised by a nurse, even though they did not require qualified supervision.These situations revealed an excessive use of nursing resources.The type of patient supervision is associated with the clinical diagnosis and the care unit of origin.Patients diagnosed with cardiovascular diseases and patients transferred from the internal medicine unit were most often supervised by a physician and a nurse during transport.An association was found between the care unit of origin and the type of supervision.The supervision of a physician and a nurse prevailed in transfers from the internal medicine unit, which is in line with these patients' transport risk score.This study aimed to contribute towards the advancement of knowledge in the area of inter-hospital transport of critically ill patients.These results are expected to help improving the process of patient transfer by facilitating the management of human resources with the purpose of maximizing health gains.Future studies should be conducted to include variables related to the occurrence of complications during transport.An inter-hospital transport protocol should be developed to identify the human and material resources necessary for a safe transport and to avoid the excessive use of resources.
Inter-hospital transport of critically ill patients: the reality of a hospital in the Northeast region of Portugal *Low risk = without immediate life risk or need for immediate therapeutic intervention.*Highrisk = immediate life risk or need for immediate therapeutic intervention.

*
Low risk = without immediate life risk or need for immediate therapeutic intervention.*High risk = immediate life risk or need for immediate therapeutic intervention.

*
Low risk = without immediate life risk or need for immediate therapeutic intervention.*High risk = immediate life risk or need for immediate therapeutic intervention.

A
retrospective cross-sectional study was conducted between November 2015 and October 2016 at the SUMC of the Northeast Local Health Unit (Unidade Local de Saúde do Nordeste, ULSNE), Hospital Unit of Bragança.This service integrates the second level of care and, due to its characteristics and geographical location, is required to transfer a large number of patients.The target population of this study consisted of all patients who, under the responsibility of SUMC, were transferred between hospitals in an ambulance with supervision of the service's team during the study period.Patients who were transferred in an air ambulance and those who were supervised by external teams were excluded from the study.The final sample was composed of 184 patients (Figure2).

Figure 2 .
Figure 2. Organogram of the sampling process.

Figure 2 .
Figure 2. Organogram of the sampling process.

Table 1
Distribution of participants according to the type of supervision and clinical diagnosis ANDREIA CATARINA GONÇALVES DA GRAÇA et al.

Table 2
Distribution of participants according to the type of supervision and care unit of origin

Table 3
Distribution of participants according to the type of supervision and reason for transfer

Table 4
Distribution of participants according to the type of supervision and risk score