For non-ICU rural communities, is there a flowchart/checklist for patients awaiting transport?

Posted on April 14, 2020 by Madalon Burnett

Summary

No flowcharts or checklists could be found but the Alberta Health Services and Universty of Toronto have useful guidelines about transporting patients with COVID-19. While waiting for transport the Government of Canada guidelines about managing severe cases of COVID-19 can be followed.

  • Unfortunately a checklist, flowchart, or set of guidelines about preparing a patient for transport to ICU from a rural community couldn’t be found. 
  • The following resources could be helpful in making decisions regarding transportation and patient care while awaiting transport:

I.   Related resources are available in the following REAKT responses:

Are there basic guidelines for rural/remote sites for airway management while awaiting transport of a COVID-19 patient?

Addresses airway management while awaiting transport of a COVID-19 patient

 

II.   TRANSPORTATION GUIDELINES FOR PATIENTS WITH COVID-19

  1. All health care providers involved in transport must use appropriate isolation precautions. For intubated patients and those with active AMGP underway (eg open suctioning), staff involved in the transport should don N95 respirators. In the absence of the above conditions, surgical masks should be worn.
  2. Staff providing direct care during the transport should also don protective eye wear, masks, gown and gloves. Note: personal eye wear is not sufficient.
  3. Hand hygiene should be performed before and after patient transport. 
  4. Wipe the handles of the bed before transport with disinfectant wipes. Designate one porter/assistant as ‘clean’ to open doors and touch elevator buttons. 
  5. Transport with minimum number of people necessary – registered nurse (RN), registered respiratory therapist (RRT), most responsible health practitioner (MRHP), and health care aide (HCA) as appropriate.
  6.  If patient intubated: 
    1. Transport using an in-line filter, in-line suction catheter and heat moisture exchange filter (HMEF). 
    2. Use of transport ventilators (with filtering systems) is preferred to minimize the need for hand bagging. If use of a transport ventilator is not possible, use a manual bagging unit (with PEEP valve). 
    3. RRT will manage airway and oxygen requirements. 
    4. Clean O2 cylinder(s) and transport stretcher with disinfectant wipes before returning to general circulation. Clean and disinfect transport ventilator after use and discard breathing circuit.
  7. If patient not intubated: 
    1. Transport with non-humidified (dry) oxygen supply – respiratory to identify the most appropriate oxygen delivery mask.
    2. Patients should wear a procedure mask if tolerated 
  8. Clean O2 cylinder(s) and transport stretcher with disinfectant wipes before returning to general circulation.
  • The University of Toronto Interdepartmental Division of Critical Care Medicine has the following recommendations about transport under COVID-19 Management Considerations (3):

III.   MANAGEMENT OF SEVERE AND CRITICAL COVID-19 WHILE WAITING FOR TRANSPORT

The Health Canada guidelines for managing severe and critical COVID-19 patients can be found here (4): https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html#7

IV.   INITIAL INVESTIGATIONS ORDERED WHEN A PATIENT ARRIVES IN ICU

  • While awaiting transport, doing these investigations could save time when the patient arrives at the ICU
  • Alberta Health guidelines on admission to ICU for laboratory work are as follows (2):
  1. Intubated patients with COVID-19 should always have both ETA and NPS performed as soon as possible on admission to ICU if not already collected.
  2. If there is a clinical possibility of other more unusual pathogens (as in an immunosuppressed patient), consideration should be given to performing bronchoalveolar lavage (BAL) recognizing that bronchoscopy is an aerosolizing procedure. Bronchoscopy solely for the purposes of microbial sampling in otherwise uncomplicated patients is not recommended.
  3. As viral pathogens are only one diagnostic possibility for most clinical presentations, additional testing should be obtained in the patient presenting with COVID-19 to look for other pathogens. At a minimum this would generally include blood cultures, endotracheal aspirate for bacterial culture (if intubated) or expectorated sputum for bacterial culture (if not intubated), urine Legionella antigen testing, liver function tests, urinalysis, and sampling of pleural fluid if present in significant quantities.
  • The University of Toronto Interdepartmental Division of Critical Care Medicine recommends these tests upon admission to the ICU (3): 
    • CBC
    • Electrolytes and Ca/albumin
    • Mg
    • Phos
    • Glucose
    • Creatinine
    • Bilirubin, ALT, AST, ALP
    • Troponin
    • Lactate
    • Arterial or venous blood gas (if on respiratory support)

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Liew, Mei Fong, et al. “Safe Patient Transport for COVID-19.” Critical Care, vol. 24, no. 1, 18 Mar. 2020, ccforum.biomedcentral.com/articles/10.1186/s13054-020-2828-4/tables/1, 10.1186/s13054-020-2828-4. Accessed 15 Apr. 2020.
  2. Care of the Adult Critically Ill COVID-19 Patient Annex D Provincial Critical Care Communicable Disease Working Group Critical Care Strategic Clinical Network Alberta Health Services.
  3. ‌“COVID 19 Resources | Interdepartmental Division of Critical Care.” Utoronto.Ca, 2020, www.criticalcare.utoronto.ca/covid-19-resources. Accessed 15 Apr. 2020.
  4. Public Health Agency of Canada. Clinical Management of Patients with Moderate to Severe COVID-19 – Interim Guidance – Canada.ca [Internet]. Canada.ca. 2020 [cited 2020 Apr 15]. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html#7

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.