• Nursing
• Pulmonary Clinical Trials

Qualified nurses can safely accompany selected critical care patients during ground transport, minimizing the need for physician assistance, suggest the results of a randomized controlled (IQ transport) trial, presented by Erik van Lieshout, MD, University of Amsterdam, Amsterdam, The Netherlands. Transport time and the incidence of clinical events were similar whether critical nurses or physicians accompanied patients during transport. Additionally, the frequency and magnitude of adjustments in inotropic or vasoactive medication did not differ between groups.

Regionalization of health care delivery has increased the need for interhospital transport of critically ill patients. The level of clinical expertise that is required to ensure safe ground transport of intensive care patients remains unclear, and the Society of Critical Care Medicine has provided no guidance on the issue [Crit Care Med 2004]. In an effort to resolve some of the uncertainty, participants in the Mobile Intensive Care Unit in the Amsterdam region designed a randomized trial to compare the safety of interhospital transport of critically ill patients who were escorted by critical care nurses versus physicians. The trial tested the hypothesis that ground transport of selected patients who are escorted by critical care nurses is not inferior to physician-based ground transport.

The trial design excluded patients with a low oxygenation index (P/F ratio <100 mm Hg) that was associated with a positive expiratory pressure >15 cm H₂O; mean arterial pressure <60 mm Hg despite adequate fluid therapy; increased inotrope requirements (noradrenaline >0.35 μg/kg/min or dopamine >15 μg/kg/min); or the need for cardiac resuscitation or defibrillation within the previous 24 hours.

The primary outcome was the number of critical events, comprising:

• Technical events (loss of battery power, device malfunction)

• Increase or decrease in arterial pressure >20 mm Hg for more than 10 minutes

• Decline in O₂ saturation >10% for more than 10 minutes

• Temperature <36°C (96.8° F)

Monitoring equipment was linked to an electronic medical record system to ensure that every critical event was documented automatically.

Investigators randomized 307 patients to nurse or physician escort during interhospital ground transport. The patients were 60 to 65 years of age, women accounted for about 40% of the study population, APACHE II scores were 18 to 19, and the length of intensive care unit (ICU) stay before transport averaged 3 days. Transport distance averaged 17 miles, and transport time averaged 65 minutes.

Overall, 51 critical events occurred during the study—28 in the physician group and 23 in the nurse group. There were no significant differences in the percentages of technical or critical events between the two groups.

Analysis of secondary outcomes showed no significant differences in the average number of events by transport time, adjustments to ventilator settings, or adjustments in inotropic/vasoactive medications. Physicians were more likely to make adjustments to O₂ settings (16% of patients vs 12%; p=0.03) and to administer >1000 ml of fluid (11% vs 5%; p=0.002).

“Ground critical care transport by nurses seems safe,” said Prof. van Lieshout. “The level of vasopressor, inotropic, and ventilator support could be tailored to the staffing of transport.”

Prof. van Lieshout acknowledged several limitations of the study, including the lack of evaluation of air transport, enrollment of a selected patient population, and no standardization of ICU stabilization. He suggested that future studies should compare physician and nurse performance in the transport of sicker patients and should examine the potential role that telemedicine might play in the transport of critically ill patients.

• © 2011 MD Conference Express