Malignant hyperthermia is a rare occurrence in ambulatory surgery centers, but when it occurs, the ASC must be prepared to respond properly and without hesitation. Time lost trying to determine how to respond to the crisis could lead to a lost life. One critical component for an adequately prepared ASC is an effective MH transfer plan.
Cynthia A. Wong, MD, professor and vice chair of the Department of Anesthesiology for the Northwestern University Feinberg School of Medicine in Chicago, is also an Malignant Hyperthermia Association of the United States (MHAUS) Hotline consultant. She has personally been involved as a consultant in at least one MH case in an ASC that resulted in a patient death because she believes there was an inadequate transfer plan in place.
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She identifies the following seven best practices for ASCs to help ensure an effective transfer plan.
1. Determine when you will initiate the transfer of the patient. If you have MH occurring in your ASC, do you have a protocol to follow to determine when and how you will get the patient to the backup organization? "It's better not to transfer a critically ill patient in the middle of an MH crisis," Dr. Wong says. "It would be better to actually treat the MH crisis before the patient was transferred but that's a hard thing to do in an ambulatory care center because most of them don't have the ability to measure blood gases or other labs and there are fewer number of people to help out in an emergency."
2. Ensure transfer vehicle is properly equipped to treat MH patients. "Patients are going to be transferred in some sort of vehicle — whether it's an ambulance or air transport — and my understanding is there are different levels of care capabilities in these ambulances," Dr. Wong says. "It seems appropriate that arrangements be made to transfer the patient in an ICU-type ambulance where the EMTs are capable of supporting ventilation and administering intravenous medications."
3. Identify a suitable backup facility. You need to not only know what institution is serving as your backup for transfer, but if you're going to transfer an MH patient or someone who possibly has MH, Dr. Wong says you need to ensure you are sending the patient to a backup institution with the capabilities of treating MH. This likely means an organization with ICU facilities.
4. Communicate directly with the people who should and will receive the MH patient. With MH, every moment is critical — time spent in your ASC, during the trip over to the backup organization and at the backup facility. It is the responsibility of the ASC to not only arrange for transfer of the patient but to make sure the patient ends up at the backup organization in the correct hands and as quickly as possible.
"You can't spend time when MH is happening calling the hospital operator and figuring out how to get a hold of these people," says Dr. Wong. "You have to know ahead of time — with the telephone number written down and readily available — that you can call this hospital and know the person you're talking to is going to have something to do with admitting the patient you're sending. This direct communication is particularly important."
She says you need to know who is going to be the receiving service and/or physician. In many hospitals, patients are transferred through the ED as opposed to directly to an ICU. If the patient goes directly to an ED, it is important to understand that the admitting physician — likely an ED physician — is not necessarily the physician in the hospital who has expertise in MH. "That would be the anesthesiologist," says Dr. Wong. "You need to know who at the ambulatory care center is going to communicate with whom at the other end. We recommend that there be direct physician-to-physician or at least direct anesthesia provider-to-physician communication."
5. Provide an MH report form. A valuable tool to provide the backup organization to help with a smooth transfer is a report form from the ASC that provides important details directly relating to the MH incident — such as anesthetic agents used and the amount of dantrolene given to the patient — in addition to standard information about the patient provided during transfers.
6. Develop a plan for patients you suspect might have MH. "Even if you don't think a patient has MH but there are indications it may be MH, there has to be some sort of plan for how you're going to watch these patients," says Dr. Wong. "At a hospital we would watch them in the recovery room for a few hours before we decided what the appropriate care is and that's not always a viable option for many ambulatory care units."
She says decisions for how to move forward in instances like these are usually made on a patient-to-patient basis. If there are any questions or concerns, she advises organizations to call and discuss the circumstances with an MH hotline consultant, which ASCs can reach any time at (800) MH-HYPER. "What to do next will depend on the patient, how sick they are from a baseline perspective, how suspicious we are that they actually had MH and how critical it is that we measure lab values as part of that diagnosis," Dr. Wong says. "That's not something most ambulatory care centers can do easily. If that is a critical part of the differential diagnosis or deciding how we are going to further manage this patient, in almost all likelihood they are going to be transferred.
7. Incorporate the transfer plan into your MH drills. If you're going to conduct an MH drill and want to simulate the entire experience, Dr. Wong says it would be worthwhile to include the transfer element in the training. "Calling all of those telephone numbers and making sure you're getting hold of the right people might be a good addition to your drill; it's going beyond just giving dantrolene in the OR," she says.
Editor's note: Visit MHAUS (www.mhaus.org) for many MH related tools and resources, including a poster developed by MHAUS and the Ambulatory Surgery Foundation on "Transfer Plans for Suspected MH Patients" for ASCs.
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