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Hi, good evening, everybody. Welcome back to this autumn term of SI CS evening education updates. Um We are delighted to have our first out of Scotland speaker this evening, which is really fantastic. The SI CS evening updates are expanding and we've gone to the south of England for our speaker this evening. Um I know that many of you are members of SI CS for, but for those of you who aren't aware of our society, the Scottish Intensive Care Society, it is a society which focuses on quality care in er for critically ill adults in Scotland and really does that through three main methods, research and audit education um and the provision of an annual scientific meeting which later this or for this year will be moving away from Saint Andrews, which has been at home for many years. Um and then to some a more central location which will be confirmed soon. Um Membership, there are many different uh types of multidisciplinary membership and membership comes with a number of different benefits including reduced uh rates at our meetings, access to education and travel bursaries and comprehensive travel insurance. For those of you who provide uh trans transfer insurance for those of you that provide transfers for critically ill patients. Um So, moving on to our speaker this evening, um I am delighted to welcome um Doctor Daniel Eden this evening. Um He is a consultant at Dare Ford Hospital in Plymouth and is the training education lead for retrieve, which is the dedicate he has interested in transfer medicine and for anesthesia for vascular and colorectal cases. He lives in Cornwall, which is far sunnier than here and, and spends his spare time doing anything that involves being in or er, on the sea, including swimming, rowing, paddle boarding and surfing. He has put him back as badly though. So, er, we're delighted to welcome here. Thank you for coming to speak to us this evening and I'll hand over um, to you. If anybody has any questions throughout, please just pop them in the chat box and we'll put them to doctor Eden at the end. But thank you for joining us. That's great. Thanks Julie. Uh, do you know how I get my slides up? They've disappeared. Oh, if you click um, present node down the bottom. Uh Yeah, I got you again. Good, perfect, great. Thank you. Um Yeah, thank you everybody for having me. Um, like Julie said, my name's Dan. I'm primarily an anesthetist down at uh dare Hospital in Cornwall um in Plymouth rather. And as part of my job plan, I'm also due to consultant for retrieve, which is the critical care transfer service for the Southwest covering Devon Cornwall, the Bristol area, Gloucestershire and Wiltshire. And I'm here to have a little chat about adult critical care transfer our service, how it's set up and also to go through a couple of interesting cases with you as well. Um I'm here primarily cos I'm also the training and education lead for retrieve or one of the two of us that are um and I happened to attend the trainee conference that was in Glasgow, hence how I got um in contact with you guys back in June. So uh my presentation will include kind of where transfer was traditionally and I believe kind of still is in Scotland to a large degree. Um how our service and other services across England and Wales are organized and set up what we believe the future of our service and other services should look like. And then like I said, I'll present a couple of interesting cases which kind of show some of the more challenging aspects of transfer medicine um other than just the clinical side. So what happened in the past? Well, uh intensive care as you know, as a specialty kind of was formed around the 19 sixties and 19 seventies and ad hoc transfers were very much um part of the parcel of that for for many decades. It was only really around the 19 nineties where due to the centralization of services across the country, neonatal and pediatric services specifically began to become organized into um a more coordinated transfer fashion. Um Various guidelines uh nationally dictated guidelines were published in the intervening couple of decades. But still the vast majority of the transfers that were done across England and Wales were still very much ad hoc and it was only really kind of around the late um 2000 and tens leading up to the pandemic where there became a real impetus to change that um based on the evidence that was available. Um and then as we all know, the pandemic came along in 2020 which really accelerated what needed to be done anyway, but kind of forced the issue for for many areas across England and Wales, excuse me. Um 2019 really was the year that this realization that something needed to change kind of came about um three of the kind of main publications really that help drive that um are kind of shown. One was a Health Services Safety Investigation Board publication based on the death of a 54 year old gentleman who has an a acute aortic dissection. There were delays in diagnosis, um attendance at hospital and the hospital that he did attend was not a hospital that could um offer definitive treatment. So he needed to be transferred to a tertiary center and actually died en route. Um The outcomes and the recommendations from that report suggested that actually we should be coordinating the development of national guidance and government should be established to oversee all of the transfers of critically ill patients. Um The intensive care society also updated for the third time, its guidance on the transfer of the critically ill adult of which there were 19 recommendations for the organization and planning of of those services. And 16 for the clinical care. The Association of AIS also published a um a guideline for the transfer of brain injured patients which kind of reinforced many of the guidance and um the best practice that had been published up until that point. Um My lead consultant, Scott Greer, who is also the um one of the co leads for critical care transfer with NHS England, um co wrote and published an analysis of over 1000 transfers delivered by our ad hoc system in the lead up to 2019. Um And that was quite interesting. Um It was probably the first published data on transfer activity um looking at the UK critical care network and it very much demonstrated that ad hoc provision really wasn't meeting the longstanding and well published guidance and data that we'd had up until that point. Um There was significant inequity across the country both in terms of the care that was provided and the delays that that, that sometimes led to there was no focused service provision, there was inequity and lack of investment as well in in what is deemed a, a very critical service for intensive care. Um, and as, as we kind of have experience of many of the sickest patients were being transferred for time critical transfers by some of the most junior members within the hospital because they were deemed some of the most. Um, I don't want to use the word expendable lightly but they were the ones that could be freed up the most easily. Um, you know, impacting the care within those hospitals, the least I'm guessing. Um And then the pandemic came and things really accelerated from 2020 through to 2021 based on necessity and the threat and in some cases, the critical care centers across the country becoming overwhelmed with COVID patients. Um and it's probably worth just pausing at the moment to just revisit what we mean by critical care transfer. That's very much what I'm talking about is the the the transfer of adults. So that's usually a age 16 and above who require specialist critical care inputs during their journey from a referring center to a receiving center. Now, these can be either for clinical or nonclinical reasons. The clinical reasons are fairly obvious. I hope in that the care that's provided at the usually a dis district general hospital can be provided there for their definitive treatment and they need transferring to a tertiary or quaternary center. Um These can be either time critical or non time critical, time critical usually means that when they arrive at the receiving center, they're going for an immediate life or limb saving treatment. Um Repatriations are also a fairly big chunk of our work that is for nonclinical reasons, but for well intended reasons in that the patient and or their family may be a long way from where they live and therefore for visiting, for motivation for rehabilitation. It makes a lot of sense to try and get them closer to where they live and then capac capacity as we know, sometimes some centers struggle and we need to try and offload those centers to ones that might might be able to more to cope with with those patients at that time. Um The adult critical care transfer service does have a service specification which is written and published by NHS England. Um The overriding principles are very obvious but very profound. I think we should be providing high quality critical care throughout the patient pathway. And that is regardless of whether they are in hospital or whether they are in the back of an ambulance, we should be striving to care for them to the same degree, regardless of where they currently are in that patient journey equity is also really important. Um not not only geographically and you know, there is a certain postcode lottery to where patients may end up getting cared for. We're also talking about the time of the day, the day of the week, the week of the year. Um patients should be getting the same care regardless of all of those factors. And also we should be striving for a national network of services which operate in a very similar fashion, learning from best practice, learning from each other and interchanging their um operational um capacities and, and their SA PS to some degree as well. Um And kind of underlying all of this is to ensure that recurrent funding is there, which it is now. Um And this ensures that whatever services are set up, they're here to stay because that makes a huge difference in the motivation and also the improvements that we can make that are gonna last. Um This is where we are across England and Wales. Um over the last three years now with retrieve, who I work for being in the Southwest, they, they launched in November 2021. So we are coming up to our third anniversary now. Um and slowly but surely over those intervening three years, we've had more and more come online. We don't have yet full coverage of England and Wales, but we're getting there slowly. Um And as I mentioned in the previous slide, what we are striving to achieve is operational similarity across services all looking at the same A CCT S specification and striving to achieve equity and high quality service. Um As I've mentioned already, retrieve is the service I work for covering the whole of the south West of Wales. Um If you wanna find about, find out more about a service and even our so ps please visit our website at retrieve.nhs.uk. This is the geography of the region that we cover. Um We have two bases simply because of the distances involved across the southwest. And they're denoted by the small green boxes with the white R in them. So we have one base covering Devon and Cornwall in Launceston, which is geographically very central to the hospitals that we we cover. And then the other one is by the M four M five junction in Bristol and that covers Gloucestershire, Somerset Wilshire and, and the hospitals surrounding it. So we're very lucky to, to have the luxury of those two bases. And there is some overlap in the areas we cover based on um the demand of services and otherwise how busy the other team might be at any one time. But we, we strive for identical operational similarity ac across both bases. And indeed, we actually have staff that interchangeably work at both which we try and encourage as well. Indeed, we have educational days where the whole team across the entire region come to as well. Um So Asco and that of the A CT A CCT S service, is that any critically ill or injured patient over the age of 16 who needs transfer falls with an Asco and very broadly, how do you, how we define any critically ill or in adult? Well, the obvious ones are those that are intubated and need to be looked after by someone with airway skills. Um more broadly, it would, it would be any patient as well at any significant risk of deterioration. And the way we kind of filter these ones out is to ask ourselves or the referring team, would they have otherwise sent a medical escort with this patient? If the answer is yes. Um then they probably fall within our scope. Um If the answer is no, then it doesn't necessarily mean they fall out of scope. We just need a bit more careful consideration as to why we might need to get involved. Um I've mentioned we cover the whole of the South West and these are for the time critical, urgent or planned repatriation or capacity transfers, as I've mentioned before. Um So how our pathway works? Well, we have an 0 300 number which is manned by the Bristol ambulance switchboard that any Referrer can ring. And we've from the very start, we've tried to be as open as possible to who that Referrer might be. And even though it's a consultant triage service from the retrieve perspective, we very much don't say that it needs to be a consultant that's making the referral because the reality of a lot of the the work from the referring side is that they are obviously busy, they've got an acutely unwell patients and sometimes it falls to whoever might be the most free at that point. And by a clinician, we don't even mean doctor, we mean nurse or any other healthcare professional as well. What we do expect is obviously the for the that professional to have seen the patient and to know the basic information that we might need as a minimum, the responsible consultant, both at the receiving and referring hospitals should be aware. And we say critical care should know as well given that we are a critical care transfer service. And actually the high risk point is probably between the two hospitals. Basic information that we might ask for is fairly obvious. And typically we we try to keep the the conversation brief if it's a fairly straightforward referral and that would normally be under five minutes. Um Like I've mentioned, we as well as during the day where it's mostly a consultant led service in person at night time, we also have an on call consultant triaging that calls from across the region. So for the vast majority of shifts, it is a consultant led triage process even though it might not necessarily always be a consultant led transfer that is occurring. Sometimes we're not available. In which case we're there for advice as to what the other options might be, whether that's to get the local ambulance service involved with a local team put together in an ad hoc fashion, or it might even be to get our um complementary team from either the peninsula or from Bristol to do that for them. Uh One thing that we, we do find works quite nicely is, um, particularly for the time critical ones where we're given a heads up before necessarily that patient is accepted. We're happy to mobilize to the referring hospital before that acceptance has been confirmed simply because of the geography and the time that we have to get from base to that referring hospital actually by saving 40 30 40 minutes by leaving before that happens, that can actually make quite a big difference, you know, and worst case scenario, we, you know, we get stood down, we turn around and go back to base and it's not, it's not a big deal. Um, what we do have er, promotionally up and around all the local centers in our region is the poster on the left. Um We've been around for a while now. So 99% of people have heard of us and people know to, to phone the number that you see on the posters. Um, on the right hand side is a checklist that we point to refer us to once we have accepted the referral, which can be found on our website. And essentially, it's just a little guide um for them to know what to get ready in anticipation of our arrival. And by doing this, um, it just saves a lot of time and a lot of wasted delay at, at the top, at the point we pick the patient up because things like the notes have been printed, any spare drugs have been drawn up and are ready to take with us any last minute, antibiotics have been given and it just smooths out the whole process very nicely. Um So our team, uh so during the day, we almost always have a duty consultant. I say almost always because we do have gaps in our rota room. We're not quite fully staffed just yet. Although the picture is improving what we do, 99.9% of the time have is a transfer practitioner. Now, these are critical care nurses and we've been very careful to ensure that all of our transfer practitioners have critical care experience. We've had discussions previously as to whether we should allow ODP or nurses who may have higher care experience but not necessarily critical care transfer experience. But actually, we've drawn the line and said that some of these patients can be really sick. And actually when the proverb proverbial does hit the fan, it's really good to have that experience to fall back on. Um We obviously have a driver to drive the ambulance and a lot, a lot of the our drivers have a lot of blue light experience and some are, are retired firemen. Some are retired policemen who are doing this. Um as a bit of a retirement gift really. Um The ones in gray are ones that we sometimes have along with us So we have a transfer doctor program which is usually senior anesthetic intensive care trainees who are coming to us for 3 to 12 months as part of an SI A or SS Y fellowship. Um They help to staff the out of hours rota and uh as well as receiving 1 to 1 training during the day shifts. Our attached doctors are our local trainees who come to get some transfer experience for a couple of days at each of their stages of training. Obviously, one of the disadvantages for the region, particularly for training of having these organized transfer services is our trainees get a lot less experience of transfer and the curriculum for from the RC RCO A and the F ICM is such that they do require in person transfer experience and our attached doctor program, which you can find out more about on our website as well is a way of um ensuring we meet that we also welcome observers from a whole array of backgrounds who can come with us for a day or two. sit in the ambulance and, and see what we do. A lot of these might be ECMO nurses, they might be er CCCU nurses. Um Just, just to think of a couple of examples off the top of my head. Um operationally we have very strong governance. Um Our last C QC rating was, was outstanding. And I think a, a large part of that comes down to how tightly organization and governance is, is is organized and run. Um part of that comes from um having stuff written down in guidance, easily digestible and easily available guidance that we as the clinicians on the ground can access at any one time. This includes clinical SA PS as well as operational. So PS um an example of an operational S AP which is very important is packaging because that's a really key component of the transfer and the safety and the patient care of of of during that transfer. And that just tells us in a fairly standardized way how our patients should be packaged. Those are all ones that are also available on our website for the public to view if you're interested and no talk on transfer. Medic medicine would be complete without the obligatory er helicopter photo. Um and I've not just put it in there for, for no reason, we do actually have a um an agreement with the search and rescue team um run by Bristow out of new airport to perform some of our longer distance transfers for patients that are particularly unwell. Now, we still need to transfer the patient from the hospital to the helipad at both ends. So it doesn't actually save us in terms of direct transfer time as much as you would think, but where it does really come in handy. Um for two main reasons. Firstly, Truro is a very remote hospital right down in the Southwest Peninsula and our local burns unit is Swansea. So to drive from Truro all the way round to Swansea is, is a long way round. So putting them in a helicopter and driving straight across the Sever Estuary is um a, a very efficient way of, of getting them to the burn center quickly. Mostly we use it for very sick liver patients from who need to go to one of our local liver units. I say local referring liver units are in London, which is a good five hour drive. And as, as you know, some of them can be very, very unwell, some of them can be filter dependent. So by putting them in a in a large s 92 helicopter which you know, is quite roomy in the back, it just means we can provide um good quality care but also get from A to B as quickly as possible, which is really important in this patient group. Um just a little slide on call handling, which is as a um a triage and consultant. I find actually the the hardest bit of the job um more so than the clinical work, which for the most part is relatively straightforward. Um simply because a lot of our patients are quite stable at the point that we pick them up and, and have to transfer them. Whereas the call handling is a lot more unpredictable because we are dealing with humans who are um in a stressful environment with a lot of other distractions going on. It's challenging because as, as you all know, as referrers and, and um the people accepting referrals, the information that you get um is, is usually second or third hand and sometimes you don't have all the information that you require. So this is even more challenging for us because we're often speaking to patients or sorry to referrers in hospitals we've never worked in before. So quite a lot of the time, you don't know these people, so you don't have the advantage of, of familiarity. Um As I've mentioned before, they are often junior members who might not be fully aware of the picture and the urgency of what's going on. Usually the referral is made from a noisy environment, both for the Referrer and for us, because quite often we might be taking these in the back of an ambulance um that can make communication very difficult. Um Both teams, both us and them may be multitasking at the same time, um which can be challenging, particularly I think more so for them actually, because, you know, if we're in the back of an ambulance, usually we're fairly settled, but the referrers usually have 100 and one things to be doing at the same time as well as making a referral and particularly for the time critical transfers, we need to be gathering information and making a decision quickly. Um So since we launched, sorry, I said November 2021 didn't I? What I meant is to say is, um we kind of launched November 2020. So we're actually coming to our fourth anniversary, not our third anniversary. Um We've had over 4000 referrals and performed over 2.5 1000 transfers in that time, which is quite a significant amount. Um in terms of how that breaks down into the triad of transfer types that I mentioned earlier or three quarters of those um were for escalation of care. Um Just under a quarter of them were repatriations which can be from the Southwest to virtually anywhere in the UK. And you know, we've been as, as far as I can't remember what our furthest from one north is. I think it was kind of leeds or maybe even as far as Newcastle with been some pretty hefty transfers. Um What we do say is whoever the referring or wherever the patient is, ie where the referring hospice is. It's the local transfer service to the hospital that does the repatriation. So for example, if we're going from Cornwall to London, the Cornish team would do it. If the patient was going from London to Cornwall, it would be the London team that would do it. Um And it's probably worth mentioning if I just go back a slide um of those 2500 transfers. Um What was I gonna say? Yeah, it, it's estimated um which I should have mentioned earlier that there's probably 20 to 25,000, critical care transfers that occur across England and Wales each year and down in the Southwest, we perform probably uh thousands to um, 1000.5 transfers a year. Um So, yeah, sorry, I've just realized as well that that number's probably slightly out of date because what we're finding is our transfer numbers are increasing and it's usually about um 20% year on year. So April to April, this is April 2023 to April 24. This year, we've performed almost 1500 referrals out of what is estimated to be 20 to 25,000. Um Sorry, transfers. No, this is referral. Sorry, I'm, I'm confusing myself. Yes. Um We've had 1500 referrals which is a 20% increase year on year. How this breaks down, er, mostly escalation of cares. Almost two thirds of which are, are non time critical and about a third are time critical. The rest being repatriations and er capacity transfers. Um And all of this information is available in our annual report again, available on our website. If you, if you fancy some light bedtime reading. Um If you look at the transfers by specialty, what you find is neurosurgery takes uh a large chunk of those. Um These are usually for acute intracranial events. Um going from AD GH to our tertiary center which is DD for either monitoring or for an immediate intervention in the neurosurgical theaters. This doesn't include necessarily the stroke patients, although there can be a bit of overlap. Um these are usually transferred for thrombectomy, which is a service we provide again at Dare Ford Hospital. The rest um are kind of fairly minor players, but we do get um splattering of those. Um Now and again and yes, this is, this is the number of transfers. We do say the 1500 was the number of referrals. This is the number of transfers which again is increasing 20% year on year from the previous year. Um Our acceptance rate is about 55%. Um This is slightly skewed from the previous year because a lot of, well, all of the stroke thrombectomy referrals were coming to us for a while regardless of whether they needed critical care input or not. This has now changed back to where we are. We're only getting the referrals for the ones that do require critical care input. Um And we found now that this acceptance rate should go up as a result of that. There are lots of reasons why we might take a referral but we can't do the transfer. Some of them are fair, fairly obvious like we were already committed to another one. Um Sometimes once the referring hospital find out how far away we are, they may elect just to call the local ambulance service and do the transfer themselves. Unjust, unjustifiable overrun is one that we try and avoid, but sometimes towards the end of a shift again, based on our geography, you know, minimum is 3 to 4 hours. Sometimes from leaving base to returning to base. That's on our shortest transfer quite often. We might be out for five or six hours. So if we're half an hour before the end of our shift, some of us might have clinical commitments the following day, we just can't do it unfortunately. So that's where we are at the moment. I think what's quite exciting is where we're heading. Um And for us, it's very much towards the 24 7 service and this is moving towards the equity of care that I mentioned earlier. At the moment, we do provide a consultant led and delivered service most of the vast majority of the time during the day and in an ideal world that would be at night as well. Although having a consultant delivered service out of hours has many, many problems and is realistically unachievable. But what we are striving to do is have it whereby we have a transfer doctor program filled with senior trainees that actually staff our out of hours rotor so that all of our shifts, hopefully, and we'll get to this point in a couple of years time, all of our shifts will be covered at least by an airway trained medic. Um The out of hours referrals will still be triaged by a consultant, but actually it will, it will be transferred, doctor led at night time. Um When we first launched, it was simply just a day service. A couple of years later, um almost out of necessity really rather than because it was planned. Um in the autumn and the winter of 2022 2023 our local ambulance service was, was under significant pressure, operational pressure and asked us for help. And part of this was providing our ambulance and driver to provide a bit of extra capacity for the network during the night time hours so that any transfers that needs to take place whilst the referring hospital would still need to provide a doctor, nurse and a trolley. At least we could provide an ambulance because some of the weights were getting quite scary. Um recently in the last 12 months. Um And over over the winter, we've launched our out of hours transfer practitioner led service where now as well as a driver and an ambulance, we also have a transfer practitioner and trolley. So all the referring hospital needs to do is provide a medic and in April and May we had our first official transfer doctor on our new out of hours rota. Um And that's kind of our first step towards getting a full 24 7 coverage because of the two bases that we have and the um staffing requirements of an out of hours rota, we actually have capacity for 12 trans excuse me 12 transfer doctors across the service, which is a lot of people to, to be coming through as trainees at any one time. Will we get there? Hopefully, I'm, I'm, I'm, I'm optimistic but it's gonna be a slow burn and it's, it's gonna be something, um, that we need to promote and work actively towards, to, to help fill those spots. But hopefully we'll get that, um, improvement and feedback. It is something that we're striving to, to achieve all of the time. We are massively helped by going by being all electronic in terms of our record keeping from the very start. And this is something that has been um inherent in, in how our services develop from the start. As we know, data is king and what an A minable um database allows us to do is to look at what we've done, how we, how well we're doing against our guidelines and our SA PS and what we can do to improve things moving forwards, audit quality improvement, the cornerstone of that um we have an audit and quality improvement lead now, as we do have a research lead um to look at key questions being set nationally and how we can um move critical care transfers forwards, go into the future. How well are we doing well quality? Um and audit is, is part of that. We wanna be reviewing all of the metrics and, and our outcomes as much as possible. Um And and part of this is feedback. So when we um pick up a patient and when we drop off a patient, we are very diligent at trying to get contact details for those people we've interacted with that, we can send feedback requests to in the in the following days. What we also do is follow up on our patients the following day, give the receiving centers a ring and find out what's happened to those patients and kind of combining that feedback that follow up with all of our quality metrics, you know, gives us a very strong data set to to hopefully improve the service. Um training is can be a cornerstone and and so so important to any um any service that's being developed and and exists. And we've invested heavily in, in training within retrieve um in in terms of personnel at each of our bases. We have a band seven educator who works full time for retrieve in both both a clinical and an educational capacity. Each base of which I am one has a lead consultant for training in education and we are lucky enough to get paid at one pa for for that role. So there is a lot of funding there for education because it seems so important. We are we are undergoing and kind of developing as we go along a transfer practitioner framework, which is kind of trying to more formally recognize the transfer practitioner role through a postgraduate qualification and that is being developed and run in combination with, er, Birmingham. We have lots of daily programmed activities, daily educational activities and the education team as a whole of, have worked really hard over the last couple of years to develop the, um, materials to deliver. That we have not, it says annual but actually it's about 22 times a year now. Um, training days somewhere. We get together as a, as a, as a, a team ie either Peninsula or Bristol, but one, at least one of the ones every year we try and get together as a whole service, which we had one only a couple of weeks ago and they're just great because a lot of the time we do a lot of our work either over the phone or team. So it's great to be able to meet people, face to face. Um, a large part of the training and education we do as well is induction and competency. And I think our programs are, are quite well developed now and well tested. Um, we're always open to change and feedback, but they seem to be quite good at getting people up to speed as quickly as possible. And on an ongoing basis, we have annual competency documents that we have to ensure that we are adhering to, um, attached doctors. I've mentioned already. Um, if you know anyone or there are any trainees out there that wanna come down to the South West. Um, we're open to doctors in training from all over the country. Um, we'd love to have you. Um, we're also developing within, within our local critical care network. A transfer course aimed at registrars again because they struggle to get the clinical experience. Hopefully this, the course with our endorsement will help tick some of those curriculum boxes. Um, we have had approved and have bought a couple of mannequins one for each base. So simulation um forms a large port part of our daily education and those er rubber guys are out or, or girls are out quite a lot um as part of our daily routine. Um and as I've already alluded to data and technology is something that we've tried to, to have at our heart and build upon as the service has developed for, for the reasons I've already mentioned. Um A ems is the main it electronic record keeping system that we use, but it's not just that it's not just the record of the, the referrals and the transfers. We also use Google Drive extensively for all of our documentation. Um And we also have something called the EOS app, which is where a repository for a lot of the information that we use on a day to day basis is kept. It's where our voters are, it's where the so PS are kept, et cetera, et cetera. And then looking to the future, there's a picture of space for a good reason a geography as, as I'm sure you have the same in Scotland is such that mobile phone signal can be quite patchy. So, a problem with relying on electronic systems for record keeping is quite often you are reliant on a, um, er, an internet connection as well. And one of the ideas with floating is to maybe have Starlink, um, dishes attached to the roof of our ambulance. So that regardless of where we are on the roads and how, how poor the mobile phone signal is. As long as there's clear sky above us, we might still be able to get internet connection. But it's just one of the, one of the examples of how we're looking um to the future and think about things slightly laterally. Um Another example of how we hope to move forward in the future is to work more closely with our pediatric and neonatal services. Um, as we obviously complement each other in many ways, they are more mature than us and that they've been around for for longer, but that doesn't mean that they can learn from us and we can learn from them and vice versa. This has been made a lot easier recently in that, we moved to a new base, a new shared base in Bristol so that the Sonar watch and retrieve at least the Bristol retrieve base teams are now under the same roof. And whilst operationally, we're fairly separate, still, hopefully over time, we can start to integrate our services and our learning from each other more and more as we go along. Um, we do have mutual aid agreements. So even though we're strictly an adult transfer service, if watch, for example, we're really under the cost, then we do have the ability via APD mate harness attached to our trolleys to transfer um, kids as long as they're above about 30 kg. And then, um, I'm gonna move on to a couple of interesting cases if that's ok. And these, these are a couple which I've personally been involved with. And I think they just demonstrate some of the difficulties with um transfer medicine, not necessarily the clinical side, but kind of more the organizational side and the logistical side. So hopefully, um you'll find these interesting. Um So the first one is called a long way from Liverpool. So this is a 29 year old lady with ABM I of 93. Um She wasn't quite as heavy as you might expect simply because she was quite short. So actually she was 225 kg, which as you'll come to see was quite fortuitous that she wasn't any heavier simply because af no trolleys with the monitoring and, and the ventilators, et cetera have a limit of 250. So with the weight of her and all the monitoring, if she was a couple of kilos lighter, we might not actually have been able to do her um apart from mild asthma, she was other way otherwise fit and well in inverted commas. And um she was recently treated for leg cellulitis and came down to um Cornwall on holiday while she was down in Cornwall. She went to bed one night feeling unspecifical unwell and woke the next day with a dense left hemiparesis. So she presented herself to the local hospital which is in Truro called the Royal Cornwall Hospital Trust and act scan showed basically clots everywhere. Um She wasn't that unwell initially but her O2 requirements became increasingly um high, there was a decision not to thromb um because it was deemed to be too high risk. Um and therefore she was referred to Dere Ford Hospital, which for those of you who aren't familiar to the region is about an hour and a quarter away. Um And she was referred for a mechanical thrombectomy for which she was accepted. Now, we're not entirely sure quite how she got from Truro to Dere and the documentation around it isn't entirely clear, but she did end up at Plymouth. Um We're assuming virus was transfer plus or minus a medical escort, although as she was on CPAP, I'm assuming she was on as she did have a medical escort. The reason we didn't get involved in that transfer initially is because we were committed on another equally urgent transfer at the time. Probably not surprising they failed the thrombectomy. Um not only was access to the groin, almost impossible. Um Whenever she lay flat, she showed signs of um S VC obstruction went blue and became incredibly hypoxic very quickly. So that was quickly abandoned and she was sent to the intensive care unit um and put on an in fractionated heparin infusion. Uh long discussions with the patient and family ensued. Um It was deemed she was pretty much on her ceiling of treatment at that point. So she wasn't for intubation. She wasn't for CPR if things went south. But actually over the next few days, she made good progress. Um Her CPAP was downgraded to high flow and high flow was downgraded to nasal specs. And her continuous heparin infusion was switched to er once daily trin Doane, um she would start on some antibiotics for an infection. And then on day six, she was deemed good enough for repatriation because as I mentioned, she was from Liverpool. So it's about a five hour drive for her family. And actually by this point, she wasn't really requiring any critical care input, but the referring the referring hospital um had arranged with Liverpool and I'm trying to remember the name of the actual hospital which we ended up going to. But anyway, the intensive care there accepted her even though she wasn't technically um receiving any intensive care input at that point, but she was obviously a very high risk patient. So luckily the referral happened quite early in the morning uh our shift starts at half eight. So it wasn't long after the shift had started and we, er, made our way to dare. So we arrived about quarter to 11, found the patient who was as sold. Um, and despite her weight, she was lying entirely supine on the bed but only requiring a couple of liters of um oxygen. She was G CS 15. Er, she wasn't otherwise supported, but obviously she had a very large body habitus. So packaging was a challenge um as was hoisting as well. So we were very fortunate that in DD, they have a double hoist system which has a very high weight um capacity. I'm not sure what the upper limit is, but they seem very happy with uh a weight of 225 kg. As I mentioned, I truly on paper, it can take up to 250 kg, although it's not necessarily designed for a large patient as we'll see in in the coming photos. Um and packaging is always gonna be um a challenge um if if not because of the body habitus, but also because of the length of journey. And therefore you really want to be careful about those pressure, pressure areas. Um whilst in transit, um usually we'd stop every two hours for patient comfort and patient positioning. But in her, it just it she was on the trolley just in about the only position she could be. So there wasn't really much scope for that. Unfortunately, our old Furno trolleys did have um, side extensions. Um, but what this did do was leave big gaps. So again, even though the tray can take 250 kg, it's not necessarily designed for a wide patient. So we had to be a bit inventive and roll some sheets up and fill those gaps. We also got some pink pads from theater and if any of you do regular lists where you need extreme positioning, pink pads are a really good way of preventing the patient from slipping on the operating table. And we thought it would be a good idea to have these on her, not only for the comfort for providing an extra layer of um protection for the skin, but also to stop her slipping down the trolley and that seemed to work really well. Uh The cage at the end of the bed had to come off because her legs were too wide and were getting pinched by the cage. So where our monitoring normally sits on top of the cage again, we just have to be a bit inventive and find a different position for that. What I do those, all those were all challenges. I was certainly anticipating. I think what I possibly wasn't anticipating and, and maybe I should have done was the logistics and the difficulty moving the trolley from ICU to ambulance and back again once we got to the um receiving hospital, it's obviously 250 kg weight and there's only two of us. So moving, it was quite a trick, um, particularly when it came to slopes and when we got to, er, Liverpool, there was one long corridor, we had to take the patient down to get to ICU downhill. And actually it was quite a struggle stopping the trolley running away from us. So we, all of our weight was being used to stop the trolley running away. Um Getting on the ambulance is also a challenge because the winches have a, a certain weight limit as do the tail lifts. If, if you use an ambulance of that design, another difficulty particularly at Riford is where we park our ambulance. There's a small ramp with the um little Nubbins on to help the sorry to help um people who might not have the best eyesight. Um They're quite bumpy, they're quite sharp and getting the patient over this little ramp again was a challenge which we didn't necessarily anticipate until we were faced with it. Um The transfer thankfully was uneventful. Um She was stable. She remained stable and she just slept for most of the um journey, like I mentioned before, we would normally try and stop every two hours for patient comfort, but she was practically wedged in the trolley as it was. And sh and she kind of was awake and able to move enough of her to kind of make small movements to improve wherever she could. Um We arrived just over five hours later at the receiving hospital and they were very accepting of her. Um and very lovely actually, um I think when we followed her up the next day, she only stayed in ICU for, for the for the night, had bed and breakfast and then then was actually discharged to the stroke ward um to continue her rehab habilitation. But again, hoisting at the receiving hospital wasn't an the issue that we thought it might be. They only had a single hoist, but again, they just seemed to take it in their stride. Um And, and, and got on and hoisted this lady as, as comfortable as they could. Um It was a long day. We didn't return to base until about one o'clock in the morning. Um and probably left, left the base about half an hour later after we'd done all of our checks and, and whatnot at the end of our shift. So, challenges packaging I've already mentioned was a particular challenge particularly um for a trolley that isn't, is designed for vertical weight but not necessarily um width of the patient themselves. The manual handling was a challenge and it's a good job. We had some spinach for breakfast that morning. Um deterioration plan. This, this is a key component of any long distance particularly transfer is what is, what is our plan if something goes wrong between A and B. Um luckily, we were traveling along a main motorway corridor. Um Both the M five and M six primarily and there are lots of um main conurbations with large hospitals along the way. So we always knew we wouldn't be too far from somewhere to, to divert to if, if we needed to, if this patient had gone off during the the journey, obviously, we were fairly limited as to what the options were. Fortunately, the sensible discussions with the family and the patient had already been done by the referring teams. So it's very clear we weren't gonna be trying to intubate this lady in the back of an ambulance um because it would have just been a disaster for all involved, maybe that's a conversation that the receiving hospital might have wanted to revisit at some point once the patient made a recovery, but certainly in the back of an ambulance, that's not something we were gonna entertain. Um as was cardiac arrest, which was gonna, you know, CPR would have been futile in this lady. What we would have done was to, you know, if we had time to divert to a hospital and, and get some help there and, and think about what our options might be at that point, depending on what the deterioration was gonna be more than likely a respiratory deterioration is, is what would have been anticipated. Um So lessons learned in, in a, in obesity and we're all very familiar with this uh everything is just more difficult, it needs more time. And the Furno seat, the Furno trolleys have their limitations when it comes to large patients. And we just need to be a bit flexible with how we package them. Um Certainly plan your exit route carefully, not just out of hospital but out of the um the ICU as well. And the trolley can be a very tight fit and you really are limited in even in a patient of a normal size as to what interventions you can do once you're underway on in the back of an ambulance. But even more so with a patient of this size. Um the next one is um this is a little nod to my my dislike of of acronyms er but T CT time critical transfer for thrombotic thrombocytopenic purpura. Um So just to a kind of overview how our TTP referral pathways work in the Southwest. Um for the whole of our region. The Bristol Royal Infirmary is our specialist center where they provide plasma plasma exchange ideally within four hours, but certainly no longer than eight hours from diagnosis, which due to ADR is gonna be a challenge particularly for patients that might be coming from Truro because that's a three hour drive from Truro to Bristol in itself. Um Treatment is usually directed by the on call excuse me hemostasis consultant based at the B RI and it usually involves um initial treatments with metal pred F FP um and early intubation and ventilation, particularly any of those patients that are showing er cerebral irritation. And this is very much a time critical transfer because we are getting them to the ri for immediate plasma exchange. This is what our referral pathway looks like. Um And I'd just like to focus on the high risk criteria of those patients that we as a critical care transfer service should be getting involved with. A lot of them are fairly obvious. Um hypoxia, the the agitated and confused patients, those with um significant risk of deterioration. Um and it is anticipated that at least 90% if not all TTP um patients needing to be transferred to Bristol, we would get involved in these, it would be very much a a small minority that would be suitable, excuse me for um the local ambulance service. So just to remind us of the geography, um Royal Cornwall Hospital particularly is a long way from the B ri um as is North Devon just because of the state of the roads to get from there to um the local motorway network. So four hours is almost gonna be impossible for a large proportion of our patients. Ee even eight hours is gonna be a challenge. So the case I'm gonna just gonna quickly cover um is one that kind of shows how we can be quite dynamic with our workforce planning really rather than the clinical side, which hopefully you're all fairly familiar with. This just shows how particularly with our 24 7 service and our night teams, we can now be a bit more flexible with how we arrange our workforce and our transfers themselves. So the case was a 58 year old man with learning difficulties, but no other significant past medical history. He uh had presented to true with his mum's best friend who at that time was his next of kin. Um It was back in January this year um where he presented with chest pain and a fairly dense right sided hemiparesis. Um Interestingly, it was suspected that this was due to aortic dissection. Um And indeed the CT scan that the emergency department at Truro did, it was, was reported as suspective of an aortic dissection because of aortic stranding. So we got the referral just as we were dropping a patient off at Plymouth. And if, if I just remind you Plymouth is about an hour and a quarter away from Truro, we were just dropping a patient off when we got the initial referral and it was more of a heads up really to say that we've got this suspected aortic dissection at Truro that may need to come to DD um to be accepted under the cardiothoracic surgeons. However, it, it transpired that the Riford radiology department weren't that convinced that this was a um aortic dissection and we were stood down at this point. We did get another phone call about another 20 minutes later, once we were in the ambulance on our way back to base saying that the full blood counts just come back. This patient's platelets are 12 and actually, rather than aortic dissection, we're suspecting TTP instead at this point because of the time critical nature um of it, we, we kind of had a discussion as to what, what we do cos it was approaching, you know, towards the end of our shift. Do we set off for true in anticipation that this is TTP that's gonna be confirmed and we need to go to Bristol. Do we go back to base, which we were kind of already halfway towards um to kind of refresh refuel and wait for the confirmation. We weren't quite sure. But what happened is at about half six TCP was confirmed by the local hematologist. Um And we set off for Truro at this point, Truro have an interesting set up that even though we don't provide medical cover out of hours as a transfer service cornwall because of their geography do have what's called a trauma consultant who performs most of the out of hours transfers, not necessarily just for trauma. So this provides flexibility in terms of getting a transfer done when we might not be able to do it. Um So we got them involved, um gave them a heads up um and they actually agreed to be part of the transfer so that we would start the transfer together from Royal Cornwall on our way past Launceston, which if I just go back to the map, um, is about an hour and a quarter away from Royal Cornwall, which would kind of be towards the end of our shift. They would drop us off and then they would continue the transfer from there with the new night that were starting at half eight. So rather than the day team, therefore doing the whole transfer and having a significant overrun what the geography of the transfer allowed us to do and the time of the day was to do a a quick stopover at Laton so that a new team could take over with the trauma consultant we picked up from true. Um And that's what we did. Uh We got to the bedside at about 20 to 8 in the evening, the patient did need to be intubated. Um Even though the referral was uh G CS was 14, um kind of just slightly confused by the time we arrived there, their G CS was about 12 or 13 and, and looking increasingly agitated. So it was a fairly easy decision to intubate um at in Ed before the transfer as as always, these things take a lot longer than you think they're going to. Um once you put an arterial line in, got all the drugs ready, et cetera, et cetera. So we actually had about an hour's turn around before we left at about a quarter to nine. We got to Laton about an hour later on, blue lights swapped the teams and then they continued to do the, the rest of the transfer up to Bristol where they arrived at half 11, which was just off the top of my head. That's about five hours, isn't it? After the, um, TTP was confirmed. Um, but many, many hours after the initial symptoms, they had, uh, just over an hour's turn around as well. And they, the whole team arrived back at base at three o'clock in the morning. So this, this was a good reinforcement and, and we did have an S AP about um TTP, which we referred to and this is where the S AP has really come in handy because we, as consultants, we only do two retrieve shifts a month. The vast majority of which um the transfers we do are neurosurgical or, or cardiothoracic. So for the rarer transfers such as TTP, it's really, really useful to have an S AP to refer to which has been written with National Guidance in mind and based on local evidence and in discussion with the local experts to know and to remind ourselves of exactly what we should be doing on these transfers. Um Preemptive deployments wasn't employed in this instance, but it's just a reminder that that is something that we try and do if, if it's all possible and is actively encouraged to dependence on the time of the day and other workload at the time. We're very lucky in tr that we've got this flexibility of an overnight trauma consultant. We now have the ability to batten our staffing um both between day and night teams, but also in between our two services, let's say, between the peninsula and Bristol teams, we've done it whereby, uh you know, we might swap halfway between Laton and Bristol because of the time of the day or the geography of where the, the patient needs to end up at. And that, that has a really great flexibility in what we do. One of the um not uncomfortable, but one of the points that did come up out of this was because we had two consultants, effectively both myself and the Royal Cornwall Trauma consultants. It wasn't quite clear necessarily who was leading the transfer. In retrospect, it probably made a lot more sense for them to lead it from the start simply because they were doing the whole distance. And I was only doing an hour's worth of the transfer, but that wasn't necessarily clear for that um overlap period. And we had an issue with drugs, drugs labeling as well. And it was a good reminder for all of us to, to remember to, to label any infusions that we do draw up properly because we hadn't necessarily handed over to the next team, exactly what concentration of a particular drug was in one of the syringes. So it's those extra human factors that whilst swapping teams is really beneficial in many ways, it does lead to other um possible sources of error, um or misjudgment and challenges of this one. The uncertainty around the initial diagnosis was certainly a challenge and, um, I don't want to say amusing, but it was, it kind of raised my eyebrow really. And, and that's, it's kind of presenting as a stroke or possibly aortic dissection isn't something I was aware of. TTP um, being able to present as. So that was certainly a, a good learning point for me being towards the end of your shift does affect your decision making even though, you know, it shouldn't do really and be, we should be providing a full service right up until the end of our shift. We are all human. We do have other clinical commitments as I did the next day in Plymouth, um, which, which do come into your decision making. Um, but actually our leadership team are very supportive. If we deem that an overrun is gonna be too significant, they, they will back us in and the decision that we make. Um, we were very lucky with the trauma consultants, er, that we had, um, that they were very happy to help with the transfer. Um, and another issue that we came across was, er, we, we picked up four bags of F FP from Truro to, to be given en route. Um, but the giving set we had and the height above the bed. Um and the, the, the the pressure bag that we had meant that the infusions weren't possibly given as rapidly as we would have hoped. That's kind of why that that challenge um is, is marked there as a learning point for us. Um So think flexibly in terms of staffing um early intubation and TTP and onward teams should probably be taking the lead in most cases. Uh We, we certainly learned that we should probably be using a volumetric pump or a pressure bag rather than what, what kit we did have available. And as I've already mentioned, er, drugs labeling when you're having handover and shift changes is really, really important and that is the end of my talk. Um Thank you very much. Um I think I'm gonna be taking some questions now from Julie. But if after this talk, anyone wants to contact me or ask any further questions, please email me on that email that you see on the screen. Great. Thank you so much doctor. And that was absolutely fascinating, especially uh I guess working within Scotland where all of our, almost all of our transfers, I think are done on an ad hoc kind of who's around who's in theater basis. It's amazing to hear about a service um that provides such robust um and equitable service to the patients that it cares for. And there are a few questions that have come uh, through on the chat. Um, there's one here from Ian Scott. I'm particularly interested to hear the responses because I was also thinking about this. Do you have? So how many drivers would you take on a long retriever? Do you have any sort of sop that governs how long you can work for before you have to take a break? Do you take any kind of no from aviation or is it all just a bit? Um, how people are feeling it? It's a very good question and we do have an S AP, but it very much depends on the driver. The only hard and fast rule that they're governed by is that they need 11 hours between their shifts. So a lot of our drivers will be working to consecutive days. So if they finish late, um, they'll either have to come in late the next day or we'll have to find another driver to do their shift in terms of a long distance transfer. Some are happy just to suck it up and do it all themselves. Some request a second driver. Now again, fortuitously, the way that our geography is such, particularly in Devon and Cornwall is that we drive past the Bristol ambulance base on the way up country to, to, to wherever the repatriation is going to be. So it's very easy for us to pick up a second driver. And what they will do then is do a couple of hours on a couple of hours off, kind of there and back and that and that does work really well, but some drivers are just quite happy to, to do it really. Um So it very much depends the, the only hard and fast rule, as I said is the 11 hours break. I think their governance is such that if they feel ok to drive, then they can drive. Um There's a question here from Claire, she's saying thank you, talk fantastic program and brilliant service you provide. Um And then it's a question really about um how did you gain support? Did you meet resistance for funding? It sounds like you cover a number of different geographic trusts as well. So how, how did you negotiate that process of trying of going from kind of idea to implementation of your service? I must admit that's not something I was personally involved with. Um, a lot of that work was done before I joined the service. I think I joined in April 2022. So it is already reasonably well established by then. It was um Scott Greer um alongside Dave Ashton Cleary and our lead nurses, um, Amy and Caroline that did a lot of that initial work. Um I think the pandemic felt massively, a lot of money was thrown at these services through necessity. Um And fortuitously, the move towards formalized critical care transfer services was already kind of s underway. Really by the time the pandemic came along. So I think a lot of stars aligned at just the right time that getting off the ground wasn't necessarily a fight. What it was was a hell of a lot of work for those that did get it off the ground because suddenly they had to create a service from nothing in a, in a very short period of time. Um I think probably what's been harder for them is to get that recurrent funding now that the pandemic is over and to get it, get a more kind of entrenched acceptance as to how important this is and to ensure that all of the services that are set up across the country do things in a similar fashion as possible. Cos as we know, standardizing standardization is a a key to patient quality and patient care. Uh There is a question here, but have you any idea at the moment, roughly what percentage of transfers are done by your transfer service versus being still done by ad hoc or local teams? Yeah, it's, it's a really good question and the answer, honest answer is we, we're not, we're not sure we're not sure as, as services become more established and there's more and more people know about us and, and pretty much everyone does know about us now. Um We're confident that we're getting the vast majority of them, certainly during the day, if not all of them during the day. Because even if we're not available to do a transfer. The calls will come to us for triage because people don't know, we're not available until we tell them out of hours is, is more unpredictable. Um, certainly since we've had the R OV, which is the retrieve overnight vehicles, certainly, since we've now added in a transfer practitioner and a trolley onto that, we're getting more than we used to of the out of hours referrals. But that doesn't mean people are just doing these referrals themselves. Um In which case, we wouldn't necessarily know about them because we, we, we're not, we're not told and that data isn't necessarily collected anywhere. So it's not gonna be 100% it's gonna be most of them. But where, where the truth lies in between those two, we, we honestly don't know. Um I maybe missed, you tell us about your, your transfer practitioners and they, where does their background lie? Because I have seen there's various transverse services that utilize um extended healthcare rules. We, you know, we have a large cohort in, in Scotland of advanced critical care practitioners who are really incredibly skilled healthcare practitioners. So weird. What's their background with, with your transfer practitioners? And do you ever see a service that is um that, that those pe people are doing independent transfers without uh an additional medic there. So just on, on, on that second question, they, they already do some transfer any practitioners. Yeah. So there are certain more straightforward ones which we are happy for a transfer practitioner to do by themselves usually well, or as a minimum, we say there has to be two people in the back of an ambulance. So whether that's two transfer practitioners, which our road sometimes allows for or whether it's a transfer practitioner and another critical care nurse that we've picked up from the referring hospital. You know, I, if there's any airway, you know, if, if the patient's got a track in, they've got a tube in. If there's any airway deterioration concerns, then that's not a suitable one. The suitable ones might be those on um, a low dose noradrenaline infusion, those that get down to a renal unit who have been on CVH, but otherwise reasonably stable, those ones that, you know, are, are, are pretty safe really. And, and our transfer practitioners going back to your first question, all have quite extensive critical care experience and it's one of the reasons we, we have specified and, and if we've had a lot of conversations about this and it always comes back to the same thing in that we, we want experienced critical care nurses while some other services we appreciate do use other healthcare professionals such as O DPS, um or, or nurses from higher care areas. It's, it's not a route we have decided to go down for good reason. Uh And then a final question here, um er, can paramedics contact you directly? Er, for medical interventions, if, er, I'm assuming that's prehospital services are not available. Oh, I've, I've never heard of that happening. Um, I don't know why they would necessarily know about us. Um, but yeah, I'm not sure cos it's, it's not a group that we advertise to or have any pathways through. Um, if they do need advice, I think most hem services have a, a, a contactable consultant, don't they? For, for medical advice? So I'm assuming they would go to that primarily rather than through us. We are, you know, a sec, we're, we're a secondary transfer service rather than a primary transfer service. Perfect. Thank you. II think um that is all the questions that I can see available at the minute. Um So, er, finally I just have to thank you for giving your Thursday evening up to um come and educate us all about um the transfer of critically ill patients. Thank you so, so much for all of you, for attending. I think there was a peak of around 100 and 20 people on the call, which is amazing. We're not a particularly large geographic, we're not a particularly large, er, a network of critical care healthcare providers in Scotland. So you've picked up a number of us here and, and converted us to the ways of the transfer network. Um The feedback link is in the chat there that will take you directly to your link to your CPD certificate. Um next year's, uh next month's um talk will be advertised shortly. That is a talk from Brendan mcgrath on Tracheostomy Safety speaking and weaning, which um uh should be very interesting. Thank you all for joining and have a lovely evening. Thank you for having me.