1. Anders Aneman
2. Senior Staff Specialist, Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District
3. Conjoint Associate Professor, University of New South Wales, NSW, Australia

1. Oliver Bartells
2. Lieutenant Colonel Royal Army Medical Corps, Consultant Anaesthetist, Ministry of Defence Hospital Unit Northallerton, UK

1. Hannah Bawdon
2. Anaesthetic registrar, West Midlands Deanery
3. West Midlands Central Accident Resuscitation & Emergency (CARE) Team
4. West Midlands Ambulance Service NHS Foundation Trust Medical Emergency Response Incident Team (MERIT), UK

1. Jon Bingham
2. Consultant in Trauma, Resuscitation and Anaesthesia, Department of Anaesthesia, University Hospital of North Staffordshire, Stoke-on-Trent
3. Midlands Air Ambulance, Cosford
4. West Midlands Ambulance Service Medical Emergency Response Incident Team (MERIT)
5. North Staffordshire BASICs
6. West Midlands Central Accident Resuscitation & Emergency (CARE) Team, UK

1. Clare Bosanko
2. Specialty Doctor, Emergency Medicine, University Hospital North Staffordshire, Stoke-On-Trent; West Midlands Ambulance Service NHS Foundation Trust Medical Emergency Response Incident Team (MERIT), UK

1. Michael Büeschges
2. Resident, Universitätsklinikum Schleswig Holstein Campus Lübeck, Abteilung für Plastische Chirurgie, Intensiveinheit für Schwerbrandverletzte, Lübeck, Germany

1. Andrew Cadamy
2. Consultant in Intensive Care Medicine and Anaesthetics, NHS Greater Glasgow and Clyde, Glasgow, UK

1. Felicity Clarke
2. Specialist Registrar Intensive Care & Anaesthetics, University Hospital of North Staffordshire, NHS Trust, Stoke on Trent
3. PHEM Doctor, West Midlands Ambulance Service NHS Foundation Trust Medical Emergency Response Incident Team (MERIT), UK

1. Alasdair Corfield
2. Consultant, Emergency Medicine & Emergency Medical Retrieval Service
3. Honorary Clinical Associate Professor, University of Glasgow, Glasgow, UK

1. Stuart J Cox,
2. Senior Nurse, Critical Care and Aeromedical Transfer CEGA Air Ambulance, Dorset
3. Senior Charge Nurse, General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK

1. James Cuell
2. Anaesthetic Registrar, West Midlands Deanery, Birmingham School of Anaesthesia, Birmingham, UK

1. Zoey Dempsey
2. Consultant Anaesthetist, Department of Anaesthesia and Pain Medicine, Royal Infirmary of Edinburgh, UK

1. Joep M. Droogh
2. Consultant in Intensive Care Medicine
3. Medical Coordinator Mobile Intensive Care Unit, Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

1. Catriona Duncan
2. Consultant in Anaesthesia, Timaru District Hospital, Timaru, New Zealand

1. Daniel Ellis
2. Director, MedSTAR Emergency Medical Retrieval Service, South Australian Ambulance Service, Australia
3. Deputy Director of Trauma and Senior Consultant in Emergency Medicine, Royal Adelaide Hospital, Australia
4. Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Queensland, Australia

1. George Evetts
2. Specialist Registrar Intensive Care & Anaesthesia, Royal Air Force, Imperial College School of Anaesthesia, UK

1. Rob Fenwick
2. Charge Nurse, Emergency Department, Shrewsbury and Telford Hospitals NHS Trust, UK.

1. Anna Fergusson
2. Anaesthetic Registrar, Peninsula Deanery, South West School of Anaesthesia, Plymouth, UK

1. Karel Habig
2. Position
3. Greater Sydney Area Helicopter, Emergency Medical Service, Ambulance Service NSW Rescue, Helicopter Base, Bankstown Airport, NSW, Australia

1. Tim Harris
2. Professor Emergency Medicine, QMUL and Barts Health NHS Trust London, UK

1. Chris Harvey
2. Adult and Paediatric ECMO Consultant, ECMO Department, University Hospitals of Leicester, Leicester, UK

1. Stephen Hearns
2. Consultant in Emergency Medicine, Royal Alexandra Hospital, Paisley
3. Lead consultant Emergency Medical Retrieval Service, Scotland, UK

1. Jo Hegarty
2. Consultant Neonatologist, Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand

1. Matthias Helm
2. Assistant Professor, Head Section Emergency Medicine, Department of Anaesthesiology and Intensive Care Medicine, Federal Armed Forces Medical Centre, Ulm, Germany

1. Scott Hepburn
2. Consultant in Emergency Medicine and EMRS
3. EMRS Lead for Risk Management, Department of Emergency Medicine, Western Infirmary, Glasgow, UK

1. Craig Hore
2. ICU Staff Specialist, Liverpool Hospital ICU/ Retrieval Staff Specialist, Ambulance Service of New South Wales, Sydney, Australia

1. Martin Horton
2. Immediate Care Practitioner-nurse, Royal Air Force Emergency and pre hospital specialist MERT practitioner, Emergency Department, Heartlands Hospital, Birmingham, UK

1. Amy Hughes
2. Clinical Academic Lecturer in Emergency Response, Humanitarian and Conflict Response Institute, University of Manchester
3. Emergency Medicine Registrar, Derriford Hospital
4. Honorary Physician in Pre Hospital Care, London's Air Ambulance, Barts and The Royal London NHS Trust, UK

1. Jonathan Hulme
2. Consultant in Intensive Care Medicine and Anaesthesia, Sandwell and West Birmingham Hospitals NHS Trust
3. Honorary Senior Clinical Lecturer, University of Birmingham, Birmingham
4. West Midlands Ambulance Service NHS Foundation Trust Medical Emergency Response Incident Team (MERIT), UK
5. Medical Director, West Midlands Central Accident Resuscitation & Emergency (CARE) Team, UK
6. Mercia Accident Rescue Service (MARS) BASICS, UK
7. Midlands Air Ambulance, UK

1. Lesley Jackson
2. Consultant Neonatal Medicine and Regional Director, West of Scotland Neonatal Transport Service, Yorkhill Hospital, Glasgow, UK

1. Emma L. Joynes
2. Retrieval registrar, Careflight Darwin, NT, Australia

1. Damian D. Keene
2. Major, Specialist trainee Anaesthesia and Pre-Hospital Emergency Medicine, Department of Military Anaesthesia and Critical Care

1. Minh Le Cong
2. Assistant Professor in Retrieval Medicine, Royal Flying Doctor Service Queensland Section, Australia

1. Fiona Lecky
2. Clinical Professor and Honorary Consultant in Emergency Medicine, University of Sheffield and Salford Royal NHS Foundation Trust, Greater Manchester, UK

1. Ian Locke
2. Critical Care Paramedic, West Midland Ambulance Service, NHS Trust, Midlands Air Ambulance, UK

1. David Lockey
2. Consultant, North Bristol NHS Trust, Bristol, & London's Air Ambulance, UK
3. Hon. Professor University of Bristol, Bristol, UK

1. Adam Low
2. Specialist Registrar in Anaesthetics, West Midlands Deanery
3. West Midlands Central Accident Resuscitation & Emergency (CARE) Team, UK
4. West Midlands Ambulance Service NHS Foundation Trust Medical Emergency Response Incident Team (MERIT), UK
5. AMREF Flying Doctors, Kenya

1. Stefan Mazur
2. Chief Medical Officer, South Australian Ambulance Service
3. Senior Consultant, PreHospital and Retrieval Medicine, MedSTAR Emergency Medical Retrieval Service
4. Senior Consultant in Emergency Medicine, Royal Adelaide Hospital
5. Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Australia

1. Russell D. MacDonald
2. Attending Staff, Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
3. Associate Professor and Co-Director, Emergency Medicine Fellowship Program, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
4. Medical Director and Chair, Quality Care Committee, Ornge Transport Medicine, Mississauga, Ontario, Canada

1. Terry Martin
2. Consultant in Anaesthesia and Intensive Care Medicine, Royal Hampshire County Hospital, Winchester
3. Medical Director, Capital Air Ambulance, Exeter, UK, Director, CCAT Aeromedical Training, UK
4. Board Director, AMREF Flying Doctors, Nairobi, Kenya
5. Board Director, European Aeromedical Institute (EURAMI), Tuebingen, Germany

1. Heather Mcneilly
2. Paediatric Registrar, West Midlands Deanery, Birmingham, UK

1. Michael McCabe
2. Consultant in Anaesthesia, Anaesthetic Department, Worcester Royal Infirmary, Worcester, UK

1. Carl McQueen
2. PHEM Doctor, Midlands Air Ambulance; West Midlands Ambulance Service, Medical Emergency Response Incident Team (MERIT), UK &NIHR Doctoral Research Fellow, University of Warwick, UK

1. Mary Montgomery
2. Consultant, Kids Intensive Care & Decision Support, Birmingham Children's Hospital, West Midlands, Birmingham, UK

1. Patrick Morgan
2. Specialist Registrar, North Bristol NHS Trust, Bristol

1. Thomas Muehlberger
2. Associate Professor, Department of Plastic & Reconstructive Surgery, DRK-Kliniken, Berlin, Germany

1. Blair Munford
2. Senior Specialist Anaesthetist, Liverpool Hospital
3. Senior Retrieval Physician, CareFlight
4. Conjoint Lecturer in Anaesthetics, UNSW, and Senior Lecturer in Physiology, UWS Medical School
5. Sydney, Australia

1. Tim Nutbeam
2. Consultant in Emergency Medicine, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth
3. West Midlands Ambulance Service NHS Foundation Trust Medical Emergency Response Incident Team (MERIT), UK

1. William O'Regan
2. Senior Staff Specialist, Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District
3. Consultant for Careflight International Retrieval Service, Sydney, Australia

1. Christian Ottomann
2. Associate Professor, Universitätsklinikum Schleswig, Holstein Campus Lübeck, Sektion für Plastische Chirurgie und Handchirurgie, Intensiveinheit für, Schwerbrandverletzte, Lübeck, Germany

1. Peter Paal
2. Associate Professor, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
3. Helicopter Emergency Medical Service Christophorus 1, Innsbruck, Austria

1. Eithne Polke
2. Retrieval coordinator, Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK

1. Richard Protheroe
2. Consultant in Critical Care Medicine and Neuro-Anaesthesia, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK

1. David Quayle
2. Chief Flight Nurse, Air Medical Ltd, London Oxford Airport, UK

1. Samiran Ray
2. Consultant, Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK

1. Cliff Reid
2. Senior Staff Specialist and Director of Training, Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance, Australia
3. Clinical Associate Professor in Emergency Medicine, University of Sydney, Australia

1. Sanjay Revenna
2. Consultant, Kids Intensive Care & Decision Support, Birmingham Children's Hospital, West Midlands, Birmingham, UK

1. Gareth Roberts
2. Department of Anaesthesia, University Hospital of Wales, UK

1. Mark Ross
2. Specialist Trainee Registrar in Anaesthesia, Department of Anaesthesia and Pain Medicine, Royal Infirmary Edinburgh, UK

1. Mark Sheils
2. Flight Doctor, Careflight NT, Nightcliff, Darwin, Australia

1. Charlotte Small
2. Research Fellow, Anaesthesia and Critical Care, University Hospitals Birmingham NHS Foundation Trust (Queen Elizabeth Hospital) Birmingham, UK

1. Helen Simpson
2. Consultant Obstetrician, James Cook University Hospital, South Tees Foundation Trust, Middlesbrough, UK

1. Stephen J. M. Sollid
2. Dean, Norwegian Air Ambulance Academy, Norwegian Air Ambulance Foundation, Drøbak, Norway;
3. Consultant Anaesthetist, Air Ambulance Department, Oslo
4. University Hospital, Oslo, Norway
5. Associate professor, University of Stavanger, Stavanger, Norway

1. Karl Thies
2. Consultant Anaesthetist Birmingham Children's Hospital, Birmingham
3. West Midlands Ambulance Service NHS Foundation Trust Medical Emergency Response Incident Team (MERIT)
4. Mercia Accident Rescue Service (MARS) BASICS, UK

1. Robert Tipping
2. Consultant Anaesthetist, Queen Elizabeth Hospital, Birmingham, UK,
3. West Midlands Ambulance Service NHS Foundation Trust Medical Emergency Response Incident Team (MERIT), UK
4. University Hospitals Birmingham NHS Foundation Trust (Queen Elizabeth Hospital), Birmingham, UK

1. Oddvar Uleberg
2. Consultant anaesthetist, Norwegian Air Ambulance Foundation, Drøbak, Norway
3. Department of aeromedical and clinical emergency services, St Olavs University Hospital, Trondheim, Norway

1. Bettina Vadera
2. Chief Executive and Medical Director of AMREF Flying Doctors, Kenya
3. Vice-President of EURAMI (European Aeromedical Institute)
4. Member of AMPA (Air Medical Physician Association), USA

1. Mathew Ward
2. Head of clinical practice, West Midlands Ambulance Service; Immediate Care Practitioner, West Midlands CARE Team, UK

1. Jon Warwick
2. Consultant Anaesthetist, Oxford University Hospitals NHS Trust, UK
3. Medical Director, Air Medical Ltd, London Oxford Airport, UK

1. Anne Weaver
2. Consultant in Emergency Medicine & Pre-Hospital Care, London's Air Ambulance, Royal London Hospital, UK

1. Claire Westrope
2. Consultant PICU/ECMO, University Hospital Leicester NHS Trust, Leicester, UK

1. Yashvi Wimalasena
2. Consultant in Emergency Medicine, Retrieval/HEMS Fellow, Greater Sydney Area HEMS, Ambulance Service of NSW Rescue Helicopter Base Bankstown, NSW, Australia

1. Jan G. Zijlstra
2. Professor in Intensive Care, Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

Intensive care beds are a limited and often pressurised resource within any healthcare setting. As the complexity and breadth of surgical interventions increases, alongside longevity and associated co-morbidities, the requirement for critical care is expanding worldwide. In the developed world many healthcare systems are moving towards networked care: with tertiary centres for specialist care, meaning patients presenting to their local hospital may subsequently need to be transferred for definitive intervention (e.g. neuro/cardiothoracic/transplant surgery or an intervention such as hyperbaric oxygen therapy). Neonatal and paediatric intensive care facilities are becoming centralised, increasing the need for ‘Retrieval Teams’ who will travel to the patient, assist local health care professionals in resuscitation and stabilisation before transporting the patient back to base facility. The development of trauma networks may mean patients are transported longer distances from point of injury to Major Trauma Centres (MTCs), or stabilised at Trauma Units before onward transfer to a MTC for definitive multidisciplinary care. Regional Enhanced Care Teams (ECTs) are becoming increasingly common to assist in the primary management and transfer of these polytrauma patients. Figure 1.1 illustrates an example of a critically ill patient undergoing numerous transfers.

The increase in worldwide travel and business networks means people risk ill health while abroad. They may want or require repatriation for healthcare, family support or financial reasons. This request may be instigated by their medical insurance company, resulting in international transportation.

It is inevitable that critically ill patients will need to be moved at some point in their illness. This may be from point of injury or small healthcare facility to specialist care, or from one area of a healthcare facility to another. Pressures on critical care beds may necessitate movement of patients in order to manage local resources. In the UK, the NHS has created Critical Care Networks on a regional basis to facilitate this aspect of resource management. The principles and risks associated with moving any critically ill patient are discussed in depth in this book.

The following definitions and concepts are important to understand:

• Retrieval: deployment of a specialist team of appropriately trained health care professionals to the patient's location to resuscitate and stabilise prior to transfer to definitive care.
• Transfer: the movement of a patient (not necessarily critically ill), from one location (or healthcare facility) to another.
• Primary retrieval: from a pre-hospital location to hospital.
• Secondary retrieval: movement from a healthcare facility with limited resources/expertise to a specialist care facility.
• Tertiary retrieval: movement from one specialist care facility to another, or for bed availability.
• Repatriation: retrieval from distant or international health care facility to patient's local hospital or specialist care unit.
• Inter-hospital transfer: movement of a patient from one hospital facility to another.
• Intra-hospital transfer: movement of a patient from one department to another within the same hospital buildings.

Movement of critically ill patients can be achieved via a variety of transport modalities, selection of which requires clinical, financial and logistical consideration.

The movement of critically ill patients is not without risks to patient and team (summarised in Box 1.1). Historical data have suggested that retrievals and transfers may be associated with increased mortality and length of hospital stay, with increased incidence of hypoxaemia and hypotension, persisting upon arrival at the receiving facility (see Further reading).

Acknowledgement of these factors has resulted in the development of dedicated transfer and retrieval teams with associated clinical governance/training schemes, standardised equipment and standardised operating procedures to optimise patient safety (Box 1.2). All these factors will help to ensure ‘the rule of RIGHT’:

The RIGHT patient is taken at the RIGHT time, by the RIGHT people to the RIGHT place, using the RIGHT transport modality and receiving the RIGHT clinical care throughout.

This book aims to introduce the reader to all these different aspects of transfer and retrieval medicine. It is no substitute for hands-on clinical experience, but we hope it will provide a useful reference for any practitioner (paramedic, nurse or doctor) involved in the transfer and retrieval of critically ill patients.

Physiology of Transfer Medicine