Transferring a critically ill patient between hospitals in Lagos

Moving a critically ill patient from one hospital to another is among the higher risk things that happens in Nigerian healthcare, and it happens constantly because intensive care and dialysis capacity is concentrated in relatively few places.

The risk is not the destination. It is the journey, and the decisions made before it starts.

Confirm the bed before the patient moves

This is the failure that causes the most harm. A patient is loaded into an ambulance on the assumption that a bed exists, arrives, and is turned away. In Lagos traffic that can mean two hours of a critically ill patient in the back of a vehicle with limited monitoring, twice over.

Never move without explicit confirmation from a named person at the receiving unit that a bed or dialysis chair is available now, and that they have accepted this specific patient. Get the name.

Stabilise first

The instinct to move quickly is understandable and often wrong. A patient who is unstable in a hospital will be considerably more unstable in a vehicle, where the equipment, the lighting, the space and the number of hands available are all worse.

Before departure the airway should be secured if it is at risk, breathing and oxygenation should be adequate, obvious circulatory problems should be addressed with fluid or vasopressors, and dangerous electrolyte disturbances such as a critically high potassium should be treated to the extent possible. The transfer team should be confident the patient can tolerate the journey.

What travels with the patient

• A written referral letter with the working diagnosis, the treatment given so far and the reason for transfer
• All investigation results, including the most recent bloods with times taken
• Imaging, on disc or as photographs of films if that is what is available
• The electrocardiogram if there is any cardiac or electrolyte concern
• A current medication list including infusions and their rates
• Allergy information
• Hepatitis and HIV screening results where known, which matter for dialysis machine allocation
• Identification and HMO details
• A relative who can give history and consent

The ambulance itself

Ambulance provision varies enormously in Lagos, from fully equipped intensive care transport to a vehicle with a stretcher and an oxygen cylinder. Establish which you are getting before you commit.

For a critically ill patient the vehicle should carry oxygen with sufficient reserve for the journey and delays, suction, monitoring for rhythm, blood pressure and oxygen saturation, infusion pumps for any running drugs, resuscitation drugs and airway equipment, and staff competent to manage deterioration en route. A doctor or trained nurse should accompany a ventilated or unstable patient.

Plan the route with traffic in mind, and confirm which entrance to use on arrival. Time lost finding a gate is time lost.

Questions to ask the receiving hospital

• Do you have a bed or dialysis chair available now, and are you accepting this patient?
• Who is the named consultant taking the patient?
• Can you ventilate, and can you dialyse, if this patient deteriorates?
• Which entrance should the ambulance use, and who will meet us?
• What deposit or payment is required on arrival, and do you work with our HMO?
• What information do you want sent ahead?

For the family

You are entitled to ask why the transfer is being recommended and what the alternative is. A transfer to a facility that can provide something the current hospital cannot is a good reason. A transfer because a bill is unpaid is not.

Ask for copies of everything before you leave. Records that stay behind are records that get lost, and reconstructing them costs time the patient may not have.

How our unit handles referrals

The SkyHigh Medical Dialysis and ICU Centre at Mainland Hospital, Yaba, accepts referrals from hospitals across Lagos at any hour. Referring clinicians should call before transfer so that availability can be confirmed, the nephrologist or intensivist briefed, and the team ready on arrival rather than assessing from scratch.

If we are full we will say so on the phone. That is a far better outcome than a critically ill patient arriving to a unit that cannot take them.