Case report:

"Neurosurgeons informed us [at a time in the early morning] of a patient coming from [DGH] intubated with isolated head and a blown pupil. We were informed [at a time 55 minutes later] that they were just leaving and that he had blown a second pupil. He arrived at [tertiary centre] at [a time 40 minutes after the second call (1hr and 35 minutes after the original notification)]. On arrival the pupils were unreactive and it was decided that it was too late for interventions.  Looking at the transfer document ambulance was ready [at a time 8 minutes after the original notification] so there was an hour in [DGH] ED which may have changed the outcome. The patient was transferred by the SpR who starts [15 minutes after the original notification]. Handing over takes time and I have concerns that this may be the reason for the hour delay"

Commentary

This incident demonstrates the logistical challenges of managing urgent cases that arise around the time of handover from one shift to another, particularly when allocating transfer-trained anaesthetist to out of hospital transfers. Local guidelines should recognise and address this issue, including clear communication structure and, for instance, contingencies around re-contacting the referring centre if updates on progress are not received.  The Association has published a guideline document on transfer of the brain injured patient [1].

Reference

[1] Safe transfer of the brain-injured patient: trauma and stroke. Association of Anaesthetists, 2019.