Nurses versus physician-led interhospital critical care transport: a randomized non-inferiority trial

Abstract

Purpose Regionalization and concentration of critical care increases the need for interhospital transport. However, optimal staffing of ground critical care transport has not been evaluated.MethodsIn this prospective, randomized, open-label, blinded-endpoint non-inferiority trial, critically ill patients on mechanical ventilation transported by interhospital ground critical care transport were randomized between transport staffed by a dedicated team comprising a critical care nurse and paramedic (nurses group) or a dedicated team including a critical care physician (nurses + physician group). The primary outcome was the number of patients with critical events, both clinical and technical, during transport. Clinical events included decrease in blood pressure, oxygen saturation, or temperature, blood loss, new cardiac arrhythmias, or death. Non-inferiority was assumed if the upper limit of the two-sided 90 % confidence interval (CI) for the between-group difference lies below the non-inferiority margin of 3 %.ResultsOf 618 eligible transported critically ill patients, 298 could be analyzed after randomization and allocation to the nurses group (n = 147) or nurses + physician group (n = 151). The percentages of patients with critical events were 16.3 % (24 incidents in 147 transports) in the nurses group and 15.2 % (23 incidents in 151 transports) in the nurses + physician group (difference 1.1 %, two-sided 90 % CI [−5.9 to 8.1]). Critical events occurred in both groups at a higher than the expected (0–1 %) rate. In the nurses group consultations for physician assistance were requested in 8.2 % (12 in 147 transports), all of which were performed prior to transport.ConclusionsThe number of patients with critical events did not markedly differ between critical care transports staffed by a critical care nurse and paramedic compared to a team including a critical care physician. However, as a result of an unexpected higher rate of critical events in both groups recorded by an electronic health record, non-inferiority of nurse-led interhospital critical transport could not be established (http://www.controlled-trials.com/ISRCTN39701540).

Interhospital critical care transports: have a safe trip!

“…This means that in theory about half of the interhospital transports could be performed in the absence of a critical care physician. However, in the study of van Lieshout et al adverse events occurred in 15-16 % of transports in both groups [1]. In another study we found that the percentage of adverse events during transports performed with a dedicated MICU team was 12.5 % [2], and in a successive study most adverse events appeared to be caused by failure of technical equipment [3].…”

“…Dear Editor, We compliment Van Lieshout et al on their study comparing the quality of interhospital critical care transports with a mobile intensive care unit (MICU) performed by a team comprising a critical care nurse and a paramedic or by team comprising a critical care nurse and a critical care physician [1]. The frequency of critical events did not differ between the groups.…”

“…The question therefore arises of whether this study has implications for the current organization of interhospital critical care in the Netherlands and other European countries where-to date-all interhospital transports of critically ill patients are performed in the presence of a critical care nurse and a critical care physician. Based on the results reported by Van Lieshout et al [1] on their study population of relatively stable patients (307 randomized, 197 excluded because of positive end-expiratory pressure of >15 cm or excess vasopressor dose, triaged by an intensivist), it would appear to be possible to guarantee a safe road trip to a patient accompanied only by a critical care nurse-without a critical care physician-provided that before the start of the transfer the patient is stable in terms of hemodynamics and respiratory function. This means that in theory about half of the interhospital transports could be performed in the absence of a critical care physician.…”

Interhospital critical care transports: a safe trip indeed!

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Dear Editor, We thank Dr. Ligtenberg and colleges for their interest in our paper [1] and their subsequent correspondence [2], in which they comment on whether results of our study indicate that transports of critically ill patients in stable hemodynamic and respiratory condition with a mobile intensive care unit (MICU) can be safely performed by a team with a critical care nurse and a paramedic.We agree that a MICU represents a setting with limited personnel resources in the case the occurence of a critical event. Thereby, the authors' concern on the safety issue is well taken and indeed reflects the rationale of this trial.

We would like to stress that the objective of our study was not to detect a difference between the outcomes of two transport options using a classical superiority trial design, but to establish whether the omission of a critical care physician during MICU transports does not worsen the current transport protocol, which includes a physician.

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“…Dear Editor, We thank Dr. Ligtenberg and colleges for their interest in our paper [1] and their subsequent correspondence [2], in which they comment on whether results of our study indicate that transports of critically ill patients in stable hemodynamic and respiratory condition with a mobile intensive care unit (MICU) can be safely performed by a team with a critical care nurse and a paramedic.…”