A structured pre-transfer checklist should be completed before every transfer. The ICS Intra-hospital Transfer Checklist (https://ics.ac.uk/resource/transfer-critically-adult.html) is a widely adopted example, and its principles apply equally to inter-hospital transfers. The following domains should be systematically assessed:

Airway

Is the airway secured? For intubated patients: confirm ETT position clinically and on chest radiograph, check that the cuff is inflated to an appropriate pressure, ensure the tube is securely fixed, and document the depth of insertion at the teeth or lips. Is a transport ventilator set up and tested? Does the escort have the skills to manage a dislodged or obstructed airway during transfer?

Breathing

Transfer ventilator settings should be documented and should match (or be appropriately adjusted from) the ICU ventilator settings. ETCO2 monitoring must be available and connected. Oxygen supply should be calculated for the anticipated journey time plus a minimum of two hours extra — oxygen consumption during transfer is easy to underestimate, particularly if FiO2 requirements are high.

Circulation

All vasoactive drug infusions should be switched to transport syringe pumps before departure — never transfer with gravity infusions alone, as flow rate is uncontrolled during movement. Ensure IV access is adequate (at least two working venous access points), all lines are properly secured and labelled, and the arterial line is transduced and zeroed. Blood pressure should be stable and within acceptable limits before departure.

Drugs

Calculate the drug requirements for the transfer duration plus two hours and confirm adequate supplies are loaded onto the transfer trolley. This includes all infusions (sedation, vasopressors, analgesics, inotropes), emergency drugs (adrenaline, atropine, rocuronium, suxamethonium, thiopental), and any specific drugs the patient requires. Ensure spare syringe drivers and batteries are available.

Documentation

A comprehensive transfer letter or summary should accompany the patient, including the admitting diagnosis, relevant past medical history, current drug chart, investigation results, and imaging. For inter-hospital transfers, this documentation is the receiving team’s only source of information about decisions made before arrival. Any relevant CD-ROMs, printed imaging, or electronic transfer summaries should be prepared in advance.

Communication

The receiving unit must be contacted before departure and must confirm they are ready to accept the patient. If the patient’s condition changes materially during preparation, the receiving unit must be updated. Family members should be informed of the transfer and given the receiving hospital’s contact details.

Monitoring Parameter	Why Essential During Transfer
Continuous SpO2	First and most sensitive indicator of respiratory deterioration; any desaturation must be investigated immediately
Continuous ECG	Detects arrhythmias, rate changes, and ischaemic changes; particularly important in cardiac patients
ETCO2 (capnography)	Confirms ETT position continuously throughout transfer; detects hypo/hyperventilation; essential for any intubated patient
Non-invasive or invasive BP	Haemodynamic changes occur during transfer; NIBP every 5 minutes minimum; invasive arterial line preferred for haemodynamically unstable patients
Temperature	Hypothermia is common during transfer (exposed patient, cold ambulance); significant hypothermia worsens coagulopathy and cardiac arrhythmias