Friday 22 January 2021
Ethical considerations for inter-hospital patient transfer & unit capacity
This statement aims to give decision-makers guidance on the ethical considerations relevant for patient transfer. It was developed by the ICS Legal and Ethical Advisory Group and has been endorsed by the Critical Care Networks of England, Wales and Northern Ireland.
Intensive Care is under very significant strain as a result of the pandemic, with accelerating transmission and admission rates which are well documented elsewhere (1). Although demands are high nationwide the geographical pressures are variable in severity and chronology. Our expectation is of continuing extreme pressure for an extended period, as the vaccine is not likely to impact on at risk populations for a number of months.
Reflecting the complexity of ICU therapies and care, determining ICU capacity is complex and dependent on multiple factors, defined and explained in previously published guidance from the Intensive Care Society, partner professional organisations and NHS organisations:
- Clinical guide for the management of critical care for adults with COVID-19 during the Coronavirus pandemic (2).
- Guidelines for the provision of Intensive Care Services – Second edition (3).
- Advice on acute sector workforce models curing COVID-19, NHS England and NHS Improvement (4)
Additional relevant documents will be individual hospital / Trust surge plans, and regional and national equivalents.
As highlighted in our recent statements “Intensive Care 2020 & Beyond: Co-Developing the future "(5) and explanatory staffing briefing (6) specialist staff are the most essential element in providing a critical care service. During a pandemic staffing levels and patient demand at any given site may fluctuate significantly over short time frames.
In order maintain admission capacity at any given site, transfer of patients within and between hospital sites has been increasingly used (7,8). Such transfers have been termed “capacity transfers” to differentiate them from “clinical transfers” of patients to hospitals with specialist expertise which are a routine aspect of care. Specialist transfer teams have long been a feature of such specialist therapy networks (for example neonatal care, paediatric intensive care, severe acute respiratory failure (ECMO) networks) and have involved long distance transfers routinely. However, long distance inter-regional or intra-regional transfers for capacity have been rare, and when previously utilised during periods of ICU strain have been both ethically and operationally controversial (9).
Maintaining ICU capacity as an ethical outcome
We have previously described how critical care admissions and services should adapt during phases of the pandemic to maintain ethical decision-making during periods of increased demand:
- Assessing whether COVID 19 patients will benefit from critical care, and Clinical Guideline (10).
- An in-depth ethical analysis of the relevant ethical risks, and suggested strategies to avoid them, was published in the same issue of the Journal of the Intensive Care Society (11).
Maintaining critical care admission capacity within hospitals was recognised as a relevant outcome, predominately to ensure the ethical principle of justice is maintained which in turn:
- Ensures equality of access for COVID and non-COVID patients requiring intensive care, regardless of physical location or chronology of presentation during the pandemic waves.
- Ensures that reductions in access or standards of care which might be required during periods of extreme demand (CRITCON 3 & 4) are applied consistently across the NHS and at an appropriate point.
- Maintains individualised decision making during the pandemic, shared with patients and their relatives where appropriate to do so, as recommended and required by the GMC (12), relevant legislation, NICE guidance (13) and ethical statements from other professional organisations (14,15).
- Equalises the demands of the pandemic across staff, hospitals, services and sites in order that adverse outcomes for staff or patients are not felt disproportionately in any given group, and resultant discriminatory effects are reduced or mitigated.
- Improves the efficiency of the system as a whole; including system wide improvements in safety (risk reduction) which could be expected to reduce overall length of stay, and therefore increase total resource available. Efficient use of resource becomes even more crucial as demand increases.
These outcomes are of relevance and importance to all patients, their families, staff and society as a whole. However, there are other outcomes which are of particular relevance to patients and their families.
Risks / Harms of transfer
- A full analysis of the clinical risks of transfer is outside the scope of this statement. However, there is an attributable risk to transfer of critically ill patients, even where expertly performed with stable patients (16).
- Patients are very likely to be further from home and family, limiting visiting (less relevant under current COVID restrictions) and complicating subsequent decision making and discharge. A return “repatriation” transfer may be required.
- Multiple handovers and clinical teams dilute personal relationships, complicate and potentially undermine communication and introduce clinical risk.
- Where patients have expressed a wish not to be transferred, a capacity transfer may cause harm to their autonomy.
Benefits of transfer
- Therapies and care available for patients are inevitably reduced in quality and quantity in Intensive Care Units under significant strain, and this has been associated with poorer outcomes(17). Transfer to a unit capable of delivery of required therapy, but under less strain, should be associated with better quality care and outcomes.
- During a pandemic patients, families and staff may choose to accept small personal harms or risks in order to achieve the improvements to justice outcomes outlined above.
- The benefits of altruism to a patient are difficult to measure, are individual to a particular patient and circumstance, and may be overestimated when there is a risk to personal health.
There is therefore a balance between the relative risks of transfer, which accrue principally to a given patient and their family, and the benefits which also accrue to that patient, but in addition to all other current and future patients in the base ICU and hospital. Such individualised decision-making, taking account of the specific and changing context, is an important skill familiar to senior clinicians in intensive care medicine in the UK (18).
When should patients be transferred?
At lower CRITCON levels (1 & 2) units should be open to accepting patients from intensive care units under greater strain. However, there may be a need even at these lower CRITCON levels to transfer patients safely in advance of deteriorating local resources. Early transfers are an important component of regional and national mutual aid and will help to prevent local deterioration. Intensive care is highly complex, making it particularly vulnerable to shortages of staff and equipment, which will need to be anticipated. Early consideration of transfers will facilitate individualised decision-making, avoiding decisions being made under the immediate pressure of a service being overwhelmed.
Our previous guidance recommended that an explicit utilitarian ethical approach (prioritisation of the most goods to most people) does not replace individualised balanced decision making until and unless there is an NHSE declaration of CRITCON 4 and all regional and national mutual aid options have been exhausted. Transfer is an important element of that mutual aid, and as such it is appropriate to utilise it at lower CRITCON levels specifically to prevent deterioration to resource limited decision making. The overriding duty of the intensive care community is to provide safe and effective intensive care to everyone who can benefit from it, with the resources available.
Which patient should be transferred?
The above risks, harms and benefits of transfer are dependent on a patient’s clinical and personal situation and may be highly variable between individuals. They are important in making a balanced decision on which patient should be transferred, where, when and by whom. As with other important ethical decisions best practise would require a consensus amongst the multi-disciplinary team, including two consultants, although this may be practically difficult to achieve at high ICU strain and should not prevent urgent unit decompression.
The use of explicit ethical decision-making frameworks has been recommended to help clinical teams make consistent, justifiable and defensible decisions (14) . There will be a tendency for patients meeting similar criteria, potentially even the same patient, be repeatedly identified as the most suitable for transfer. This raises a risk of discrimination and guarding against this possibility is an important reason why collection of appropriate metrics of transfer is required for ethical as well as operational and clinical reasons. The ICS will work with partner organisations responsible for operational delivery and data collection and analysis to identify how this might be best achieved.
Clinical teams must also recognise the particular vulnerability of patients who cannot participate fully in decisions in relation to their care. Such patients may not be able to convey their interests and preferences to their clinical team. Furthermore, restricted contact with relatives may mean that these patients lack an advocate for their interests.
Communicating with patients and families during the pandemic has been challenging and there is existing resource and guidance to help clinical teams with this vital component of quality and compassionate care (19) . The ACCTS service in the Midlands have produced a leaflet for patients and families, and this provides a useful summary of important aspects that should form the basis of communicating the decision to transfer.
Operational guidance as to how to deliver transfer services is outside the remit of the ICS Legal and Ethical Advisory Group, but existing guidance from the ICS and FICM is available and has been recently updated (pre pandemic);
- Guidance on the Transfer of the Critically Ill Adult (20).
- UK Government. Coronavirus (COVID 19) in the UK – Daily Update. https://coronavirus.data.gov.uk/. Accessed January 2021.
- The Intensive Care Society and The Faculty of Intensive Care Medicine. Clinical guide for the management of critical care for adults with COVID-19 during the Coronavirus pandemic. October 2020. Clinical guide for the management of critical care for adults with COVID-19 — ICM Anaesthesia COVID-19 (icmanaesthesiacovid-19.org). Version 4. 1–21.
- The Intensive Care Society and Faculty of Intensive Care Medicine. Guidelines for the Provision of Intensive Care Services (GPICS). June 2019. GPICS 2nd Edition. Second Edition. 1–251.
- NHS England and NHS Improvement with Health Education England. Advice on acute sector workforce models during COVID-19. December 2020. 1–39.
- The Intensive Care Society. Intensive Care 2020 and Beyond. https://www.ics.ac.uk/ICS/ICS/News_Statements/Intensive_Care_2020_and_Beyond.a. January 2021.
- The Intensive Care Society. Understanding Intensive Care Staffing, Occupancy and Capacity. https://www.ics.ac.uk/ICS/ICS/News_Statements/Understanding_intensive_care_staffing_occupancy_and_capacity_03012021.aspx. January 2021.
- Pett E, Leung HL, Taylor E, et al. Critical care transfers and COVID-19: Managing capacity challenges through critical care networks. Journal of the Intensive Care Society. 2020. 175114372098027–7.
- Intensive Care National Audit & Research Centre. ICNARC report on COVID-19 in critical care. 2021. 1–75.
- Thomas, Rebecca. Health Service Journal. London critical care patients could be sent to Yorkshire as capital’s ICUs top 100pc occupancy. https://www.hsj.co.uk/coronavirus/london-critical-care-patients-could-be-sent-to- yorkshire-as-capitals-icus-top-100pc-occupancy/7029237.article. December 2020.
- Montgomery J, Stokes-Lampard HJ, Griffiths MD, Gardiner D, Harvey D, Suntharalingam G. Assessing whether COVID-19 patients will benefit from critical care, and an objective approach to capacity challenges during a pandemic: An Intensive Care Society clinical guideline. CS Guidance on decision-making under pandemic conditions. Journal of the Intensive Care Society. 2020. 175114372094853–7.
- Harvey D, Gardiner D, McGee A, DeBeer T, Shaw D. CRITCON-Pandemic levels: A stepwise ethical approach to clinician responsibility. Link. Journal of the Intensive Care Society. 2020. 36. 175114372095054–8.
- General Medical Council (GMC). Coronavirus: Your frequently asked questions. https://www.gmc-uk.org/ethical-guidance/ethical-hub/covid-19-questions-and- answers#Decision-making-and-consent. Accessed January 10, 2021.
- National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: critical care in adults. 2020. 1–14.
- Royal College of Physicians. Supporting Implementation of NICE Critical Care Guidelines (NG159). www.criticalcarenice.org.uk. Accessed 11 January 2021.
- British Medical Association (BMA). COVID-19: Ethical Issues.https://www.bma.org.uk/advice-and-support/covid-19/ethics/covid-19-ethical-Barratt H, Harrison DA, Rowan KM, Raine R. Effect of non-clinical inter-hospital critical care unit >to unit transfer of critically ill patients: a propensity-matched cohort analysis. Critical Care. October 2012. 16. 1–10.Gabler NB, Ratcliffe SJ, Wagner J, et al. Mortality among Patients Admitted to Strained Intensive Care Units. American Journal of Respiratory and Critical Care Medicine. 2013. 188. 800–6.
- Barratt H, Harrison DA, Rowan KM, Raine R. Effect of non-clinical inter-hospital critical care unit to unit transfer of critically ill patients: a propensity-matched cohort analysis. Critical Care. October 2012. 16. 1–10.
- Gabler NB, Ratcliffe SJ, Wagner J, et al. Mortality among Patients Admitted to Strained Intensive Care Units. American Journal of Respiratory and Critical Care Medicine. 2013. 188. 800–6.
- The Faculty of Intensive Care Medicine (FICM). Waeland D. Critical Capacity – A Short Research Survey on Critical Care Bed Capacity.https://www.ficm.ac.uk/sites/default/files/ficm_critical_capacity_- March 2018. 1-6
- The Intensive Care Society. Use of video communications for patients and relatives in intensive care. >https://www.ics.ac.uk/ICS/COVID-19/COVID-19_patient_and_relative/Patient_and_Relative_Resources.aspx. Accessed January 10, 2021.
- The Intensive Care Society and The Faculty of Intensive Care Medicine. Guidance on: The Transfer of the Critically Ill Adult. 2019. Transfer of the Critically Ill Adult (ics.ac.uk)