Authors: Lene Pedersen, Stig Arild Stenersen, Trond Elden
Presentation of case
Transfer of covid-19 positive respiratory patient from a local hospital to higher level of care.
The incubator team dispatched with the on-call helicopter and landed on the helipad by the local hospital. Before arrival the department where the patient was hospitalized was informed of the incubator transport routines, so that they were prepared.
On arrival, the equipment was prepared in the room next door to the patient. The rescue-paramedic was in charge of logistics and procedure monitoring and made sure that the doctors followed all routines.
The incubator was prepared with infusion ports for three syringe pumps with norepinephrine, dobutamine and sedation, in addition to Ringer Acetat. A separate O2 line was added to a ventilation bag. which was placed inside the incubator together with an iGel. In order to keep track of all lines and wires, a disposable diathermy bag was used as wrapping and taped onto the frame under the incubator. A HEPA filter was connected to the ventilator line and securely fastened with elastic bands and fed through the ventilation port (Fig. 1).
On the patient side, 2 x flexible connectors were connected in series within the incubator. To avoid accidental disconnection during transport, it may be beneficial to tape all the connections between the respirator line and the filter as well as connections between the filter and the flexible connectors.
All syringe pumps were prepared in advance and the ventilator was set and put on standby. The CorPuls™ monitor was packed in a yellow infectious clinical bag with all necessary cables outside the bag. The bag was then closed with strips. Draping in transparent plastic made operation of syringe pumps and respirators simple. When both doctors were dressed in PPE, they entered the patient room with the incubator.
First, the ventilator was connected (ETT blocked by a pean clamp, ward ventilator stopped, transport ventilator connected, pean clamp opened and transport ventilator started). Next, all infusions were transferred and labelled. All medications were freshly drawn, no infusions or medications were taken from the patient room. Only the pressure cuff for invasive BT was included and placed inside the incubator.
Monitoring with the CorPuls™ was initiated inside the incubator while the wireless monitor stayed outside the room, where the rescue-paramedic made sure that all parameters were received and registered properly.
After the checklists had been reviewed, the incubator lid was brought in from outside the patient room, the incubator sealed and disinfected on the outside. Finally, the incubator was rolled out of the patient room, over absorbent towels soaked in Perasafe™. The pilot in command was then informed that the team was ready for transport.
At the same time the department at the receiving hospital was informed of the patient status and expected arrival time.
From landing at the hospital until departure, it took exactly two hours to prepare for transport. During this time the on-call crew was on regular standby.
The transport played out after dark in partly turbulent flight conditions and the flight time was 1 hour and 20 minutes. The patient was sedated and muscle-relaxed during transport and there were no issues with the monitoring or treatment and care during transport. The hand over at the receiving hospital was uncomplicated.
Important learning points
It is important to have a good cooperation with the delivering hospital and to make sure that they are prepared for the procedures.
Being certified to use the transport incubator at EpiGuard and the CBRNE center at Oslo University Hospital, has been crucial to the 330 Squadron to become operational with its own infection-team with transport incubators in such a short time. During the establishment of the team, there has been a very good dialogue with the instructors and representatives from the supplier.
- Thorough preparation is essential, in addition to well-worked procedures and routines.
- It is important that the doctors have a broad experience in intensive care transports since these are generally complex patients that demand high vigilance in addition to the logistical challenges of the transport incubator itself.
- It is an advantage to have three people in the team, where the third person is not dressed in PPE, and can monitor and keep track of the two other team members and procedures.
- By transports of covid19 patients > 1-hour endotracheal intubation should be carefully considered as these patients can deteriorate quickly with respiratory distress and low paO2 and low pH.
- The SeaKing is a good transport platform for the EpiShuttle(R), providing good visual control of the entire incubator, good working space and enough room for all equipment.
- A dedicated team gives good flexibility in regard to readiness and offers the opportunity to change transport platform.
- Intubated patients should be transferred in an early phase. Severe respiratory distress and ARDS will only narrow the margins needed for transport and might make it impossible all together.