Critical Care Retrieval in the Middle East: Descriptive Analysis of a Multidisciplinary Adult Critical Care Transfer and Retrieval Service in Qatar


 Introduction The regionalisation of critical care resources has led to an increase in the need to transfer patients between facilities. The advent and implementation of critical care transfer and retrieval services have been the bridge to this divide, lying at the confluence of prehospital emergency care, in-hospital emergency medicine, and intensive care. Within the State of Qatar, the concept of critical care transfer and retrieval is a relatively new. Consequently, we conducted a retrospective cross-sectional study of all transfer and retrieval activity of a dedicated multidisciplinary transfer and retrieval service to better understand the use of these services in the region. Methods Extracted patient care record data were analysed and described using univariate and multivariate descriptive statistics. A log-binomial regression model with robust variance estimator was used to calculate crude and adjusted prevalence ratios for intubation status and arteriovenous access; and intubation status and medication combination, adjusting for age and gender for each model. Results Amongst the completed cases, the majority were male (60.39%), and within the 40-59 (27.7%) age group. Amongst the cases transferred, those with a primary respiratory pathology were the most common (19.59%), followed by cardiovascular patients (18.5%). Half of all patients had a self-maintained airway (51.6%), followed by a third who had an endotracheal tube in situ (36.74%). Midazolam was the most common hypnotic administered (51.27%), as was Fentanyl (88.02%) amongst the analgesic medications, and Noradrenaline amongst the inotropes (72.77%). Intubated patients had the highest proportion of severe and critical patients; patients transported with a Doctor; patients with multiple routes of arterial and/or venous access; and patients receiving any hypnotic, analgesic or inotrope, or a combination thereof. Conclusion The transfer and retrieval of critical care patients across Qatar is a relatively common occurrence. Variations in patient type and severity and the expectations of the transfer team, are significant. Variation in airway type and ventilation modalities, types and combinations of hypnotic, analgesic and inotropes used, and the multitude of arteriovenous access points observed in this study directly contributed towards the complexity of moving these patients from one facility to another.


Introduction
Critical care is a clinically complex and resource-intensive discipline the world over. Consequently, the delivery of these services is compounded by the need to sustain a specialised workforce while maintaining consistent and high standards 1,2 . The regionalisation of critical care resources and the creation of referral networks has been one approach that has led to success in this area [2][3][4][5][6][7] . However, as steps have been made towards regionalisation, so too has the need to transfer patients between facilities to access these services.
An increase in the number of patients requiring the continuation of critical care in-transit has led to a need to expand the borders of traditional intensive care beyond the con nes of the hospital.
The advent and implementation of critical care transfer and retrieval services have been the bridge to this divide, lying at the con uence of prehospital emergency care, in-hospital emergency medicine, and intensive care. Undertaking the transfer of a patient requiring the initiation or continuation of critical care is no simple task. Variations in patient type and severity of their medical condition and the expectations of the transfer team, are signi cant. Reports regarding the transfer of patients ranging from critical neonates to the multi-comorbid geriatric; with complex underlying surgical and medical diagnoses; involving the concomitant administration of multiple vasoactive and sedative medications; with various oxygenation and ventilation requirements, are commonplace in the literature 6, 9−15 . Despite the relatively small size of the State of Qatar, critical care transfer and retrieval has nonetheless become a necessity within the country's healthcare system. Starting in 2014, a dedicated program was initiated to facilitate the transfer and retrieval of critical care patients across the country 16 . The Specialized High Acuity Adult Retrieval Program (SHAARP) is a joint initiative between the Hamad Medical Corporation Ambulance Service (HMCAS) and the Hamad Medical Corporation (HMC) Critical Care Network (CCN). It consists of a single dedicated purpose-built ambulance, manned and run 24 hours a day, seven days a week by various staff from both HMCAS and the CCN and deployed primarily for the transfer and retrieval of critical care patients across Qatar 17 . The program was further developed in 2016 and formalised under the Transfer and Retrieval division of the HMCAS, with dedicated HMCAS and CCN staff receiving bespoke training and continued education 18 ; the addition of specialised and dedicated communications staff for call taking, dispatch and monitoring; and focused governance and audit to maintain the highest quality of patient safety and quality of care. Since then, the program has seen considerable uptake within the country's health system. This study aimed to describe the activity of a dedicated high acuity adult retrieval program in the State of Qatar.

Methods
A retrospective cross-sectional study of all transfer and retrieval activity was conducted using patient care records of the Hamad Medical Corporation Ambulance Service's Specialised High Acuity Adult Retrieval Program.

Setting
The study was conducted within the Hamad Medical Corporation (HMC), the primary governmental provider of secondary and tertiary healthcare in Qatar, and the Hamad Medical Corporation Ambulance Service (HMCAS), the national ambulance service of Qatar. HMCAS is a two-tiered emergency medical service provider with Ambulance Paramedic (AP) staffed ambulances and advanced Critical Care Paramedic (CCP) staffed fast-response vehicles. Licensure and scope of practice within Qatar are governed by the Qatar Council for Healthcare Professionals (QCHP). Figure 1 highlights the locations of the tertiary health facilities across Qatar.

Data Collection
The study utilised routinely collected clinical data extracted from the HMCAS electronic patient care record (ePCR) database and the SHAARP case registry. The target population was identi ed by screening for all cases for which the SHAARP unit was dispatched.
Patients for whom the SHAARP unit was dispatched, and arrived at patient side, were included in the analysis. Primary cases (i.e., community-based patients); patient's being transferred home; patients transferred to and from the airport, and cases that were cancelled prior to the crew reaching the patient side were excluded. All cases meeting criteria for the period of January 2017 to February 2020 were included in the analysis.

Study Variables
The data collected was a combination of continuous and categorical variables. A data extraction template was developed to retrieve and sort call-time intervals; patient demographics;, departure, transport, and handover vital signs; interventions performed, and medications administered by the transferring crew. For descriptive purposes, each patient was categorised by broad category type and primary pathology, i.e. the primary diagnosis. Continuous data for age, call time intervals, Glasgow Coma Score (GCS) and Richmond Agitation-Sedation Scale (RASS) score were recategorized for analysis. Initial GCS was collected for non-ventilated patients and initial RASS score collected for all invasively ventilated patients. Methods of arterio-venous access were categorised as arterial, central venous and peripheral venous. Medications administered were categorised into primary hypnotic, primary analgesic and primary inotrope. Lastly, as part of the data extraction, the Risk Score for Transported Patients (RSTP) scale -a critical care inter-facility transfer risk score developed by Markakis et al. 18 was retrospectively applied for all cases ( Figure 2). Patient clinical data were collected starting from arrival at patient side by the transporting crew, throughout transport, until patient handover. All monitoring data was captured automatically and auto-populated into the unit's electronic health record following handover. All interventions and medications captured represent those continued or initiated primarily for the patient transfer.

Analysis
Extracted data were analysed and described using univariate and multivariate descriptive statistics. Chi-square analysis was used as the primary measure of association for all categorical data. A log-binomial regression model with robust variance estimator was used to calculate crude and adjusted prevalence ratios for intubation status and arteriovenous access; and intubation status and medication combination, adjusting for age and gender for each model. 95% con dence intervals were calculated where necessary and a p-value of 0.05 used as a cut-off for statistical signi cance. Missing data was reported where found and largely determined to be missing at random. All data was collected and sorted using Microsoft Excel

Results
A total of 1224 cases that met criteria were included in the analysis. Of these, 40 (3.27%) were cancelled following the transfer team's arrival at the patient side and/or attempted preparation for transfer (Table 1) 14), likely re ecting the relatively short distances of travel between facilities. In terms of crew composition, a Critical Care Paramedic was present on 99% (n=1166) of transfers and a doctor on 22.3% (n=264) of transfers.    Table 3). The most common combination amongst the three medication types was a hypnotic/analgesic combination [n=139 (11.74%)], followed by hypnotic/analgesic/inotrope combination [n=110 [9.29%)] (Table 4).

Discussion
This study represents the rst published data examining the activity of a dedicated multidisciplinary transfer and retrieval service, both in Qatar and the broader Middle East. Despite the relatively small size of the country, the frequency in which the service was utilised, and the nature and severity of the patients transferred by the unit has highlighted the potential niche of such a program in healthcare in Qatar.
Many of the patient and case demographics observed in this study align with that reported in the literature. Patients were generally found to be male, middle-aged and with a cardio-respiratory focus as the primary reason for their admission 6,8−10 . Similarly, there was a relatively high proportion of "out-of-hours" activity, as reported in the literature 8,10, demonstrating the importance of a 24-hour service in this setting. While patient preparation and handover times were similar to those reported in the literature, actual transport times were shorter, likely a consequence of Qatar's size and the location of its healthcare facilities 6,8−10 . The transfer team composition observed in this study was more heavily weighted towards EMS sta ng, which differs somewhat from conventional transfer team composition reported in the literature, where critical care transfer teams are primarily staffed by nurses and physicians 7,8,14,14 .
Few studies have reported comprehensively on the interventions performed before and/or during transfer. Variation in airway type and ventilation modalities, types and combinations of hypnotic, analgesic and inotropes used, and the multitude of arteriovenous access points observed in this study directly contributed towards the complexity of moving these patients from one facility to another. The occurrence of these transfer characteristics similarly highlighted the importance of the patient preparation phase prior to transfer, the time interval that contributed the most towards total mission time in this study. The development and implementation of transfer guidelines to limit variation and standardise practice are central towards maintaining quality the patient preparation phase's quality and safety and these services in general.

Conclusion
The transfer and retrieval of critical care patients across Qatar is a relatively common occurrence. Variations in patient type and severity and the expectations of the transfer team, are signi cant. Understanding the clinical needs of a patient is an essential step towards ensuring the safe and effective transfer of patients with complex needs across a challenging environment. Corporation, Qatar (MRC-01-19-154). All study procedures and processes were conducted in accordance with that described in the ethics application and the guidelines and regulations outlined by the local medical research council.
Consent to participate: Requirement for consent to participate was waivered by the approving ethics committee based on the nature and content of the study.
Consent for publication: Consent for publication was sought and approved as part of the ethics approval Author contributions: IH, WHA, IFH and LA conceptualised the study aim and objectives; IH, RS, SG and WT collected and analysed the data; all authors contributed equally towards the nal draft of the manuscript Figure 1 highlights the locations of the tertiary health facilities across Qatar Patient clinical data were collected starting from arrival at patient side by the transporting crew, throughout transport, until patient handover. All monitoring data was captured automatically and auto-populated into the unit's electronic health record following handover. All interventions and medications captured represent those continued or initiated primarily for the patient transfer.