Table 1.
Delphi consensus for interhospital transfer of patients with diagnosis of ruptured abdominal aortic aneurysm: rounds 2 and 3 compared
| Round 2 (n=38) | Round 3 (n=29) | Frequent comments | ||
| 1 | Level of requests for transfer | |||
| a | Must be assessed by local surgeon (SpR/consultant) | 23 (61%) | 16 (55%) | Do not delay |
| b | Consultant–consultant | 17 (45%) | 13 (45%) | |
| c | SpR–consultant | 19 (50%) | 25 (86%) | |
| d | SpR–SpR | 14 (37%) | 23 (79%) | Do not delay if no consultant available |
| e | Consultant–SpR | 6 (16%) | 17 (59%) | |
| f | No discussion, transfer to vascular unit | 2 (5%) | 3 (10%) | |
| g | Any grade of doctor | 8 (21%) | 6 (21%) | |
| h | Nurse/paramedic from ambulance | 11 (29%) | 12 (41%) | |
| 2 | Diagnostic criteria necessary | |||
| a | Abdominal/back pain and hypotension | 28 (74%) | 21 (72%) | |
| b | Known AAA with symptoms/collapse | 28 (74%) | 21 (72%) | |
| c | In-hospital diagnosis without imaging | 28 (74%) | 20 (68%) | |
| d | Ultrasound in A&E with symptoms/collapse | 21 (55%) | 20 (68%) | Use should increase to provide consensus |
| e | CT scan any | 18 (47%) | 11 (38%) | |
| f | CT scan read by SpR/consultant radiologist | 13 (34%) | 7 (24%) | |
| 3 | Patient age (years), suitable for transfer | |||
| a | <70 | 13 | 28 (97%) | |
| b | <80 | 15 | 28 (97%) | |
| c | <85 | 13 | 10 (34%) | |
| d | <90 | 10 (26%) | 6 (21%) | Consultant–consultant discussion |
| e | No limit | 28 (74%) | 22 (76%) | |
| 4 | Patient condition, suitable for transfer | |||
| a | Alert and talking | 38 (100%) | 29 (100%) | |
| b | Obeying commands | 38 (100%) | 29 (100%) | |
| c | Fluctuating consciousness | 31 (82%) | 22 (76%) | |
| d | Requiring inotropes | 23 (61%) | 22 (76%) | |
| e | Cardiac arrest in current episode | 9 (24%) | 6 (21%) | |
| f | Unconscious/intubated | 20 (53%) | 14 (48%) | |
| 5 | Patient health before admission if known, suitable for transfer | |||
| a | No or minimal systemic disease | 37 (97%) | 29 (100%) | |
| b | Moderate systemic disease | 37 (97%) | 29 (100%) | |
| c | Severe systemic disease | 18 (47%) | 19 (66%) | Consultant–consultant referral |
| d | Life-threatening systemic disease | 5 (13%) | 4 (14%) | |
| e | Not relevant | 5 (13%) | 5 (17%) | |
| 6 | Patient lifestyle before admission if known, suitable for transfer | |||
| a | Independent | 36 (95%) | 29 (100%) | |
| b | Needs some help with daily living | 36 (95%) | 26 (90%) | |
| c | Dependent on relatives/carers for daily living | 22 (58%) | 20 (68%) | |
| d | Dependent (eg, dialysis/heart failure/home oxygen) | 7 (18%) | 6 (21%) | |
| e | Institutional care for physical infirmities | 8 (21%) | 5 (17%) | |
| f | Institutional care for mental infirmities | 15 (40%) | 21 (72%) | |
| g | Irrelevant | 7 (18%) | 4 (14%) | |
| 7 | Tests essential before transfer | |||
| a | Ultrasound or CT scan (if diagnosis AAA not known) | 17 (45%) | 14 (48%) | Do not delay |
| b | Contrast/non-contrast CT | 4 (11%) | 3 (10%) | Do not delay |
| c | CT of whole aorta versus abdominal aorta | 4 (11%) | 2 (7%) | |
| d | FBC (and U+E/amylase): pancreatitis issue | 14 (37%) | 16 (55%) | Do not delay |
| e | Cross-match | 13 (34%) | 15 (52%) | |
| f | ECG to exclude acute MI | 21 (55%) | 13 (45%) | Do not delay |
| g | None of the above | 7 (18%) | 5 (17%) | |
| 8 | Maintain blood pressure with fluids | |||
| a | To systolic >90 mm Hg | 4 (11%) | 4 (14%) | |
| b | To systolic >70 mm Hg | 21 (55%) | 21 (72%) | |
| c | Travel with blood (O neg/group specific or full cross-match) | 16 (42%) | 12 (41%) | |
| d | No fluids unless patient deteriorates | 28 (74%) | 26 (90%) | |
| e | Travel with any available CT film/CD of CT | 27 (71%) | 25 (86%) | If time available, transfer electronically |
| 9 | Transfer conditions/ambulance and staff | |||
| a | Ambulance 999 | 27 (71%) | 28 (97%) | |
| b | Ambulance critical | 11 (29%) | 5 (17%) | |
| c | Ambulance next available | 5 (13%) | 1 (3%) | |
| d | With paramedics only | 16 (42%) | 21 (72%) | |
| e | With paramedics + nurse | 8 (21%) | 5 (17%) | |
| f | With paramedic + doctor | 8 (21%) | 2 (7%) | |
| g | With ATLS (airway control) accredited personnel | 5 (13%) | 5 (17%) | For intubated patients |
| h | No conditions | 5 (13%) | 5 (17%) | |
| 10 | Essential transfer conditions and staff at receiving hospital | |||
| a | Knowledge of ICU bed availability | 4 (11%) | 2 (7%) | |
| b | Knowledge of skilled anaesthetist availability | 16 (42%) | 18 (62%) | |
| c | CT scan and radiologist available | 16 (42%) | 18 (62%) | |
| d | Emergency endovascular repair available | 14 (37%) | 14 (48%) | |
| e | Transfer patient to A&E resuscitation bed | 24 (63%) | 25 (86%) | |
| f | Transfer patient to vascular unit bed | 7 (18%) | 0 | |
| g | Transfer patient to operating theatre/ICU | 22 (58%) | 22 (76%)* | |
Swings to consensus are underlined.
*For patients with CT scan and/or very unstable patients.
AAA, abdominal aortic aneurysm; FBC, full blood count; MI, myocardial infarction; U+E, urea and electrolytes.