Military Critical Care Transfers

Objectives

These Critical Care (CC) patient transfer guidelines and checklist have been developed using national standards, with consideration of defence requirements and operational constraints for use in the deployed setting.

Scope

This guidance refers to secondary CC patient transfers (i.e. transfer of critically unwell patients from an MTF), though they can be applied and adapted for in hospital transfers, as the same level of care would be expected.

The aim is to provide a safe, succinct, standardised approach to critical care patient transfer, to improve patient outcomes and to reduce the cognitive load to the transfer team.

These checklists can be printed and can form part of a patient’s medical record.

Modules RAF 575 and Ground Tactical Evacuation 556: provides the equipment and EME required for CC transfers.

Audience

Critical Care Nurses, ACCPs, Doctors.

Initial Assessment & Management

Patient transfer risk: benefit must be considered and documented. In the deployed environment, transfer is often necessary for upscale of care, progression along the OPCP and to liberate the MTF to permit operational activity.
Risk assessment is used to determine transfer team composition
All team members should have prior critical care experience and transfer training. In Defence this can be demonstrated by completion of the Multidisciplinary Defence Competency Transfer Passport prior to deployment.
Assessment considers patient condition, likelihood of deterioration, potential interventions, mode of transport, transfer duration. Increased risk, which prompts an increment in ‘clinical risk’, is associated with the following:
- Prolonged +/- isolated transfers
- Air (requires specific training)
- Non-permissive environments

Low Clinical Risk	Suggested Team
Airway safe, spontaneous ventilation FiO2 < 0.4 No CV support GCS 14-15 Normothermic Biochemically stable	Practitioner competent in critical care transfer
Medium Clinical Risk
Airway safe, spontaneous ventilation FiO2 < 0.6 Low dose CV support GCS 9-13 Mild hypo- or hyperthermia Biochemical derangement (mild – mod)	Practitioner competent in critical care transfer + Doctor/ACCP with advanced airway skills.
High Clinical Risk
ETT or tracheostomy Invasive ventilation GCS < 8 High dose/unstable CV support Major trauma Ongoing DCR Uncontrolled pain Biochemical derangement (severe)	Practitioner competent in critical care transfer + Doctor/ACCP with advanced airway skills

* Subject to operational environment

Advanced Assessment & Management

PLATFORM SPECIFIC CONSIDERATIONS

Maritime	Land	Air
Waterproofing: Kit/Patient/Team	Convoy	Lithium ion batteries (DG cargo)
Lifejackets	Friendly forces location	AME clearances
Weather conditions	CRM (duration/fatigue)	Bluetooth off (rotary)
First Spear body armour (rotary over water)	Platform suitability: size/terrain	Boyles Law: - Increased FiO₂ - Drain gas spaces - ‘Ground’ cabin pressurisation? - CI to travel? - Cuff pressures - Ventilator (Vol mode) - Split casts

Transfer Checklists

Transfer Details
Patient Name
Service no./Identifier
DoB

Transfer Platform/s
Est. Transfer Time

Timings	DTG
Activation
Departing for Transfer
Arrival at MTF
Depart MTF
Arrival at destination

Team
Name
Role
Registration

ACTIVATION CHECKS

Equipment	Acknowledge	O₂ Checks
Transfer bag		Total volume (L)
Ventilator + circuit		Cylinders (no.)	CD
Infusion pumps			ZX
Monitor + defib		LPO connection
Suction
EME spare batteries		Blood Plan
Stretcher + harness +/- VACMat/mattress		Required (Where/what)
Pt warming
Blood/fluid warmer
Drug/fluid pack

Team Brief
Fit and ready to go
Passport + personal documentation
Personal kit
PPE	Medical Military
Route	A ↔ B
	Detour/RV
Comms plan (PACE)	Team
	Patient
	External

PRE-DEPARTURE (MTF) CHECKLIST

Review	Comments
A – E (variation from HOTO)
Investigations
CXR	ETT/CVC position ok? Y / N
US
Bloods
Other investigations

Final Checks
Ambu Bag (BVM) attached to cylinder
Lines aspirated/flushed (if required)
Lines and tubes secured
Rescue line (IV) available
Bags emptied e.g. urinary catheter
Monitoring attached +/- tactical mode
Sufficient medication
Stop non-essential medication
Patient pre-medication
Patient secured (harness +/- immobilisation)
Patient belongings
Patient PPE
Patient notes
X-Ray discs
Clinical requirements e.g. pt position, neuro parameters
EME connected to mains (if possible)

ARRIVAL AT DESTINATION

	Acknowledge
Patient handover complete	Name Registration
Infusions/monitoring/ventilator transferred
Patient safety incident?	ASER Y / N
Team Debrief	Y / N

PATIENT TRANSFER HO/TO

Referring Facility
Referring Clinician/contact
Receiving Facility
Receiving Clinician/contact

Patient Name
Service no./Identifier
DoB			Gender
Allergies
PMHx/ Drug Hx
Mechanism of injury/ Preceding events
Time of Injury/ Admission time
Infection risk	Y / N What?
Intervention
Current Medication
Blood	RBC	Lyo/FFP		Ca₊

Ongoing DCR required?	Yes No
Recommendations	Secondary survey required Y / N

Airway	Own NP OP ETT Tracheostomy
Breathing	SV NIV IPPV FiO₂ SpO₂ Mode Rate TV PEEP I:E
Circulation	BP HR Temp Lines Infusions Fluids
Disability	Pupils Lt Rt GCS E V M /15 RASS Paralysed? Y / N Time Pain Score Analgesia Glucose
‘Everything else’	Wounds ABx + timing Other lines/tubes:

MD/ACCP

AHP/Nurse

Registration

DTG

Transfer Kit List

This is a generic list, for a transfer bag + EME, based on national recommendations; it is an aide memoire, it does not override the judgement of the transfer team. The mission, clinical requirements and logistics will determine the final laydown.

Recommend = minimum recommended critical care transfer equipment. Team to consider sizes (where appropriate) and quantity, based on clinical state, no. patients, transfer distance/time, etc.

Consider = recommended by national guidelines, or transfer services, but necessity can be assessed by the transfer team.

Recommend

Consider

Airway

1. Laryngoscope & batteries + spare + blades (Mac 3, 4)

2. ETT (size 6, 7, 8) + Bougie + lubricating gel

3. ETT tie/tape + 10ml syringe

4. Magill forceps

5. *Suction device + Yankauer + catheters + tubing

6. Anaesthetic facemask (size 4, 5)

7. 2^nd Gen Supraglottic device (size 3, 4, 5)

8. Oropharyngeal (size 3, 4) + Nasopharyngeal (size 6, 7) airways

9. Non-rebreather mask + O2 tubing

10. eFONA equipment

1. *Videolaryngoscope

2. ETT size 9

3. Tracheostomy box

4. Tracheal dilators

5. Stylet

6. Inline Suction

Chest

1. Bag Valve Mask (BVM)

2. *Transfer ventilator + battery

3. Ventilator circuit + catheter mount + HMEF

4. Thoracostomy set (antiseptic, scalpel, Spencer Wells/clamp, gauze, gloves)

5. Stethoscope

1. Mapelson C circuit

2. Chain drain equipment

3. *Spare ventilator batteries & mains charger

Abdomen

1. Glucometer

2. Nasogastric tube +/- bile bag

1. Urinary catheter + drainage system

Limbs & Lines

1. IV access packs (cannula 14/16/18/20 + dressing + tourniquet + alcohol wipes)

2. EZ-IO device + IO needles + 3-way tap

3. Arterial tourniquet

4. Pressure bags

5. 3-way taps

1. Arterial lines + transducer

2. CVC line (+ insertion kit) + Transducer

3. Limb splintage

4. Trauma line

5. *Blood/fluid warmer

Drugs & Drivers

1. *Infusion pumps + clamps

2. Giving sets/extension lines (2 per pump)

3. Blood giving set

4. Syringes – (minimum 4 x 50/20/10ml)

5. Drug labels + Syringe caps

6. Drug/fluid pack

7. Drawing up needles

8. 0.9% saline + water ampules

1. *Mains chargers & spare batteries

2. Blood products & blood storage

3. A-clamps (Blue clamps)

Skin & Security

1. Transfer compatible stretcher (+ mattress) + harness

2. Heating Blanket

3. Generic dressings + gauze + tape

4. Scissors/tuff cuts

1. VACMat

2. Pressure relieving dressings

3. Patient immobilization e.g. head position

Monitoring

1. *Monitor – (Min. ECG, NIBP, SpO₂, EtCO₂, temperature, defibrillator)

2. EtCO₂ connection/sample lines

3. ECG dots and defibrillator pads

4. NIBP cuffs

5. Temperature probe + cable

1. IABP transducer

2. *TOF monitor

3. *Portable Ultrasound

4. *Blood gas analyzer and syringes

Oxygen

1. Transport onboard oxygen

2. Portable O₂ cylinder

1. Large O₂ cylinders

Documentation

1. Transfer paperwork

2. Patient notes/summary

Miscellaneous

1. PPE – gloves, eye protection, masks, aprons

2. Patient care pack

3. Clinical waste bags + ties

4. Sharps box

1. Patient belongings

2. Patient ear and eye protection

3. Extra clamps

4. Carabiners

5. Sterile gloves

*Electrical Medical Equipment (EME)

Oxygen

O₂ Device Conversions

Nasal cannula		Hudson facemask		Non-rebreathe mask
L/min	FiO₂	L/min	FiO₂	L/min	FiO₂
1	0.22	2	0.25	6	0.6
2	0.25	3	0.27	7	0.7
3	0.27	4	0.3	8	0.8
4	0.3	5	0.35	9	0.85
5	0.35	6	0.4	10+	0.9
		7	0.45

O₂ CYLINDERS

Cylinder sizes and volumes
ZX	3040L
E	680L
CD	460L

OXYGEN CALCULATIONS

Calculate patient oxygen requirements for all transfers. Good practice convention is to uplift twice the calculated volume.

Spontaneously breathing patient:

O₂ Requirement (L) = Flow (L/min) x transfer time (mins) x 2

NIV CPAP – with leak compensation:

O₂ Requirement (L) = Minute Volume (L) + [Leak x 2] (L/min) x FiO₂ x transfer time (mins) x 2

Minute volume = Resp rate (breaths per min) x tidal volume (L)

Mechanically ventilated patient (Eve-TR^TM ventilator):

O₂ Requirement =

[Minute Volume (L) + ventilator consumption (2L/min) ] x FiO₂ x transfer time (mins) x 2

Note. FiO₂ 1.0 should be used for unstable patients.

Medications

The following is a recommended minimum drug pack for carriage during patient transfer.

Availability, quantity and additional medications will vary depending on patient requirements, patient no., transfer time, operational constraints, etc., and so clinical consideration is required.

Note. Ensure compliance with medication destruction policy, especially post-transfer.

Drug	Presentation	Quantity Suggested
Cardiac
Adenosine	6mg/2ml	4
Adrenaline 1:1,000	5mg/5ml	4
Adrenaline 1:10,000	1mg/10ml	4
Amiodarone	150mg/3ml	8
Labetalol	100mg/20ml	2
Metaraminol	10mg/1ml	4
Noradrenaline	4mg/4ml	4
Vasopressin	20units/1ml	2
Sedation, paralysis and analgesia
Atracurium	50mg/5ml	4
Clonidine	150mcg/1ml	5
Fentanyl	500mcg/10ml	5
Ketamine	200mg/20ml	2
Midazolam	10mg/2ml	3
Morphine	10mg/1ml	3
Paracetamol	1g/100ml	1
Propofol 2%	1g/50ml	4
Remifentanil	2mg powder for dilution	1
Rocuronium	50mg/5ml	4
Electrolytes
Calcium chloride 10%	1g/10ml	2
Potassium Chloride 15%	1.5g/10ml (20mmol K⁺)	1
Magnesium sulphate 50%	5g/10ml	1
Others
Chlorphenamine	10mg/1ml	1
Glucagon	1mg powder or pre-filled syringe	2
Glucose 50%	25g/50ml	1-2
Hydrocortisone	100mg powder	2
Insulin human (Actrapid)	100units/1ml	1
Levetiracetam	500mg/5ml	6
Lidocaine 2%	400mg/20ml	1
Naloxone	400mcg/1ml	2
Ondansetron	4mg/2ml	2
Salbutamol IV	500mcg/ml	4
Tranexamic Acid	500mg/5ml	4
Antibiotics – uplift depending on patient requirements
Fluids
5% dextrose	250ml	1
0.9% sodium chloride	10ml	5
0.9% sodium chloride	500ml	1
3/5% sodium chloride	500ml	1
Plasmalyte or Hartmann’s	1000ml	2
8.4% sodium bicarbonate	100ml	1
Water for injection	10ml	5

Continuous Infusions

Standardised infusion concentrations².

Medication	Concentration	Example infusion composition	Central (C) or peripheral (P) delivery
Cardiac
Adrenaline	80mcg/ml	4mg in 50ml	C / P
	160mcg/ml	8mg in 50ml	C
	320mcg/ml	16mg in 50ml	C
Amiodarone (loading)	6mg/ml	300mg in 50ml	C
Amiodarone (continuous infusion)	18mg/ml	900mg in 50ml	C
Amiodarone (continuous infusion)	1.8mg/ml	900mg in 500ml	C / P*
Metaraminol	500mcg / ml	20mg in 40ml	C / P
Noradrenaline	16mcg/ml	4mg in 250ml	C / P
	80mcg/ml	4mg in 50ml	C
	160mcg/ml	8mg in 50ml	C
	320mcg/ml	16mg in 50ml	C
Sedation
Atracurium	10mg/ml	500mg in 50ml	C / P*
Clonidine	15mcg/ml	750mcg in 50ml	C / P
Fentanyl	50mcg/ml	2.5mg in 50ml	C / P
Midazolam	1mg/ml	50mg in 50ml	C / P
Midazolam	2mg/ml	100mg in 50ml	C / P
Morphine	1mg/ml	50mg in 50ml	C / P
Morphine	2mg/ml	100mg in 50ml	C / P
Propofol 2%	20mg/ml	1000mg in 50ml	C / P
Remifentanil	50mcg/ml	2mg in 40ml	C / P
Others
Magnesium Sulphate	0.4mmol/ml	20mmol in 50ml	C / P
Insulin	1unit/ml	50units in 50ml	C / P

*(P) - Short term use only, high risk of phlebitis.

MIXED MEDICATION INFUSIONS

Best practice advises against mixing medications in one syringe/bag. However, operational constraints and patient requirements may necessitate this practice.

All medicine mixtures should be checked for signs of incompatibility, for example cloudiness, haze, precipitate or a change in colour. In addition, infusion site reactions such as phlebitis should be monitored for as this could be a sign of incompatibility. It is also recommended that all combined solutions should be used within 24hours to minimise risk of microbial contamination ^4,5,6.

Sedative drugs are the most commonly combined medications. Below provides an accepted reference for these combinations.

Drug infusion	Drug dose	Solvent	Total Volume	Final concentration	Recommended dosing
Morphine + Midazolam	30mg Morphine 30mg Midazolam	0.9% saline	30ml	1mg/ml Morphine 1mg/ml Midazolam	0-15ml/hr
Fentanyl + Midazolam	300mcg Fentanyl 30mg Midazolam	0.9% saline	30ml	10mcg/ml Fentanyl 1mg/ml Midazolam	0-15ml/hr
Ketamine + Midazolam	400mg Ketamine 10mg Midazolam	0.9% saline	50ml	8mg/ml Ketamine 200mcg/ml Midazolam	ml/hr = weight (kg) /4 Note. above is anaesthesia dosing.
Ketamine + Midazolam	800mg Ketamine 20mg Midazolam	0.9% saline	100ml (bag)	8mg/ml Ketamine 200mcg/ml Midazolam	0-25 drops/ 3min (see below)
Ketamine + Fentanyl	400mg Ketamine 500mcg Fentanyl	0.9% saline	50ml	8mg/ml Ketamine 10mcg/ml Fentanyl	0-25ml/hr

DROP RATES

Drop dose on giving set is 20 drops/ml (regular giving set).

Infusion rate ml/hr	Drop Rate / 3min	Drop Interval (secs)
20	20	9
25	25	7

The app and website was publicly released on 2 Apr 2024

Military Critical Care Transfers

Objectives

Scope

Audience

Initial Assessment & Management

Advanced Assessment & Management

Transfer Checklists

Transfer Kit List

Oxygen

Medications