Special Articles

Guidelines for the inter- and intrahospital transport of critically ill

patients*
Jonathan Warren, MD, FCCM, FCCP; Robert E. Fromm Jr, MD, MPH, MS; Richard A. Orr, MD;
Leo C. Rotello, MD, FCCM, FCCP, FACP; H. Mathilda Horst, MD, FCCM; American College of Critical Care
Medicine

Objective: The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient.
Data Source: Expert opinion and a search of Index Medicus
from January 1986 through October 2001 provided the basis for
these guidelines. A task force of experts in the field of patient
transport provided personal experience and expert opinion.
Study Selection and Data Extraction: Several prospective and
clinical outcome studies were found. However, much of the published data comes from retrospective reviews and anecdotal
reports. Experience and consensus opinion form the basis of
much of these guidelines.
Results of Data Synthesis: Each hospital should have a formalized plan for intra- and interhospital transport that addresses

he decision to transport a critically ill patient, either within

a hospital or to another facility, is based on an assessment
of the potential benefits of transport
weighed against the potential risks. Critically ill patients are transported to alternate locations to obtain additional care,
whether technical, cognitive, or procedural, that is not available at the existing
location. Provision of this additional care
may require patient transport to a diagnostic department, operating room, or
specialized care unit within a hospital, or

*See also p. 305.

From Northwest Community Hospital, Arlington
Heights, IL (JW); Baylor College of Medicine, Houston, TX
(REF); Childrens Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA (RAO); Suburban Hospital, Bethesda, MD (LCR); Henry Ford Hospital,
Detroit, MI (HMH).
These guidelines have been developed by the American College of Critical Care Medicine and the Society of
Critical Care Medicine. These guidelines reflect the official
opinion of the Society of Critical Care Medicine and do not
necessarily reflect, and should not be construed to reflect,
the views of certification bodies, regulatory agencies, or
other medical review organizations.
Copyright 2004 by Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0000104917.39204.0A

256

a) pretransport coordination and communication; b) transport

personnel; c) transport equipment; d) monitoring during transport;
and e) documentation. The transport plan should be developed by
a multidisciplinary team and should be evaluated and refined
regularly using a standard quality improvement process.
Conclusion: The transport of critically ill patients carries inherent risks. These guidelines promote measures to ensure safe
patient transport. Although both intra- and interhospital transport
must comply with regulations, we believe that patient safety is
enhanced during transport by establishing an organized, efficient
process supported by appropriate equipment and personnel. (Crit
Care Med 2004; 32:256 262)
KEY WORDS: intrahospital transport; interhospital transport; critical care; health planning; policy making; monitoring; standards

it may require transfer to another hospital. If a diagnostic test or procedural intervention under consideration is unlikely to alter the management or
outcome of that patient, then the need
for transport must be questioned. When
feasible and safe, diagnostic testing or
simple procedures in unstable or potentially unstable patients often can be performed at the bedside in the intensive
care unit (1, 2). Financial considerations
are not a factor when contemplating
moving a critically ill patient.
Critically ill patients are at increased
risk of morbidity and mortality during
transport (317). Risk can be minimized
and outcomes improved with careful
planning, the use of appropriately qualified personnel, and selection and availability of appropriate equipment (16 37).
During transport, there is no hiatus in
the monitoring or maintenance of a patients vital functions. Furthermore, the
accompanying personnel and equipment
are selected by training to provide for any
ongoing or anticipated acute care needs
of the patient.
Ideally, all critical care transports, both
inter- and intrahospital, are performed by

specially trained individuals. Since there

will almost certainly be situations when a
specialized team is not available for interhospital transport, each referring and tertiary institution must develop contingency
plans using locally available resources for
those instances when the referring facility
cannot perform the transport. A comprehensive and effective interhospital transfer
plan can be developed using a systematic
approach comprised of four critical elements: a) A multidisciplinary team of physicians, nurses, respiratory therapists, hospital administration, and the local
emergency medical service is formed to
plan and coordinate the process; b) the
team conducts a needs assessment of the
facility that focuses on patient demographics, transfer volume, transfer patterns, and
available resources (personnel, equipment,
emergency medical service, communication); c) with this data, a written standardized transfer plan is developed and implemented; and d) the transfer plan is
evaluated and refined regularly using a
standard quality improvement process.
This document outlines the minimum
recommendations for transport of the
critically ill patient. Detailed guidelines
Crit Care Med 2004 Vol. 32, No. 1

targeted to the transport of infants and

children have been published by the
American Academy of Pediatrics (23). Institutions performing commercial or organized interhospital transports are required to function at and meet a higher
standard, as the requirements for organized transport services are considerably
more rigorous than the recommendations in this guideline (24, 38 41).
The references for this guideline were
obtained from a review of Index Medicus
(see key words) from January 1986
through October 2001 and are categorized according to the degree of evidencebased data employed. The specific category assigned to each reference is noted
in the References at the end of this article. The letter a denotes a randomized,
prospective controlled investigation; b
denotes a nonrandomized, concurrent, or
historical cohort investigation; c denotes
a peer-reviewed state-of-the-art article,
review article, editorial, or substantial
case series; and d denotes a non-peerreviewed opinion such as a textbook
statement or official organizational publication. The asterisk symbol will follow a
statement of practice standards. This indicates a recommendation by the American College of Critical Care Medicine that
is based on expert opinion and is used in
circumstances where published supporting data are unavailable.

INTRAHOSPITAL TRANSPORT
Because the transport of critically ill
patients to procedures or tests outside
the intensive care unit is potentially hazardous, the transport process must be
organized and efficient. To provide for
this, at least four concerns need to be
addressed through written intensive care
unit policies and procedures: communication, personnel, equipment, and monitoring.
Pretransport Coordination and Communication. When an alternate team at a
receiving location will assume management responsibility for the patient after
arrival, continuity of patient care will be
ensured by physician-to-physician and/or
nurse-to-nurse communication to review
patient condition and the treatment plan
in operation. This communication occurs
each time patient care responsibility is
transferred. Before transport, the receiving location confirms that it is ready to
receive the patient for immediate procedure or testing. Other members of the
healthcare team (e.g., respiratory therCrit Care Med 2004 Vol. 32, No. 1

apy, hospital security) then are notified as

to the timing of the transport and the
equipment support that will be needed.
The responsible physician is made aware
of the transport. Documentation in the
medical record includes the indications
for transport and patient status throughout the time away from the unit of origin.
Accompanying Personnel. It is
strongly recommended that a minimum of
two people accompany a critically ill patient.* One of the accompanying personnel
is usually a nurse who has completed a
competency-based orientation and has met
previously described standards for critical
care nurses (42, 43). Additional personnel
may include a respiratory therapist, registered nurse, or critical care technician as
needed. It is strongly recommended that a
physician with training in airway management and advanced cardiac life support,
and critical care training or equivalent, accompany unstable patients.* When the procedure is anticipated to be lengthy and the
receiving location is staffed by appropriately trained personnel, patient care may be
transferred to those individuals if acceptable to both parties. This allows for maximum utilization of staff and resources. If
care is not transferred, the transport personnel will remain with the patient until
returned to the intensive care unit.
Accompanying Equipment. A blood
pressure monitor (or standard blood
pressure cuff), pulse oximeter, and cardiac monitor/defibrillator accompany every patient without exception.* When
available, a memory-capable monitor
with the capacity for storing and reproducing patient bedside data will allow review of data collected during the procedure and transport. Equipment for airway
management, sized appropriately for
each patient, is also transported with
each patient, as is an oxygen source of
ample supply to provide for projected
needs plus a 30-min reserve.
Basic resuscitation drugs, including
epinephrine and antiarrhythmic agents,
are transported with each patient in the
event of sudden cardiac arrest or arrhythmia. A more complete array of pharmacologic agents either accompanies the basic agents or is available from supplies
(crash carts) located along the transport route and at the receiving location.
Supplemental medications, such as sedatives and narcotic analgesics, are considered in each specific case. An ample supply of appropriate intravenous fluids and
continuous drip medications (regulated
by battery-operated infusion pumps) is

ensured. All battery-operated equipment

is fully charged and capable of functioning for the duration of the transport. If a
physician will not be accompanying the
patient during transport, protocols must
be in place to permit the administration
of these medications and fluids by appropriately trained personnel under emergency circumstances.
In many hospitals, pediatric patients
share diagnostic and procedural facilities
with adult patients. Under these circumstances, a complete set of pediatric resuscitation equipment and medications will
accompany infants and children during
transport and also will be available in the
diagnostic or procedure area.
For practical reasons, bag-valve ventilation is most commonly employed during intrahospital transports. Portable mechanical ventilators are gaining
increasing popularity in this arena, as
they more reliably administer prescribed
minute ventilation and desired oxygen
concentrations. In adults and children, a
default oxygen concentration of 100%
generally is used. However, oxygen concentration must be precisely regulated
for neonates and for those patients with
congenital heart disease who have single
ventricle physiology or are dependent on
a right-to-left shunt to maintain systemic
blood flow. For patients requiring mechanical ventilation, equipment is optimally available at the receiving location
capable of delivering ventilatory support
equivalent to that being delivered at the
patients origin. In mechanically ventilated patients, endotracheal tube position
is noted and secured before transport,
and the adequacy of oxygenation and ventilation is reconfirmed. Occasionally patients may require modes of ventilation
or ventilator settings not reproducible at
the receiving location or during transportation. Under these circumstances, the
origin location must trial alternate
modes of mechanical ventilation before
transport to ensure acceptability and patient stability with this therapy. If the
patient is incapable of being maintained
safely with alternate therapy, the risks
and benefits of transport are cautiously
reexamined. If a transport ventilator is to
be employed, it must have alarms to indicate disconnection and excessively high
airway pressures and must have a backup
battery power supply.*
Monitoring During Transport. All critically ill patients undergoing transport
receive the same level of basic physiologic
monitoring during transport as they had
257

in the intensive care unit. This includes,

at a minimum, continuous electrocardiographic monitoring, continuous pulse
oximetry (44), and periodic measurement
of blood pressure, pulse rate, and respiratory rate. In addition, selected patients
may benefit from capnography, continuous intra-arterial blood pressure, pulmonary artery pressure, or intracranial pressure monitoring. There may be special
circumstances that warrant intermittent
cardiac output or pulmonary artery occlusion pressure measurements.

INTERHOSPITAL TRANSPORT
Patient outcomes depend to a large
degree on the technology and expertise of
personnel available within each healthcare facility. When services are needed
that exceed available resources, a patient
ideally will be transferred to a facility that
has the required resources (45). Interhospital patient transfers occur when the
benefits to the patient exceed the risks of
the transfer. A decision to transfer a patient is the responsibility of the attending
physician at the referring institution.
Once this decision has been made, the
transfer is effected as soon as possible.
When needed, resuscitation and stabilization will begin before the transfer (46,
47), realizing that complete stabilization
may be possible only at the receiving facility.
In the United States, it is essential for
practitioners to be aware of federal and
state laws regarding interhospital patient
transfers. The Emergency Medical Treatment and Active Labor Act (EMTALA)
laws and regulations (updated at intervals
from the 1986 COBRA laws and the 1990
OBRA amendment) define in detail the
legal responsibilities of the transferring
and receiving facilities and practitioners.
The American College of Emergency Physicians has published a book (48) that
reviews the legal responsibilities of referring institutions as well as the ramifications of noncompliance with the COBRA/
EMTALA regulations, and it is an
excellent resource for any facility involved in patient transfers. In general,
under COBRA/EMTALA, financially motivated transfers are illegal and put both
the referring institution and the individual practitioner at risk for serious penalty
(49, 50).
Current regulations and good medical
practice require that a competent patient,
guardian, or the legally authorized representative of an incompetent patient give
258

Figure 1. Interfacility transfer algorithm.

informed consent before interhospital

transfer. The informed consent process
includes a discussion of the risks and
benefits of transfer. These discussions are
documented in the medical record before
transfer. A signed consent should be obtained, if possible. If circumstance do not
allow for the informed consent process
(e.g., life-threatening emergency), then
both the indications for transfer and the
reason for not obtaining consent are documented in the medical record. The re-

ferring physician always writes an order

for transfer in the medical record.
Several elements are included in the
process of interhospital transfer, and all
fall within minimum guidelines, as described subsequently. It is important to
recognize that these process elements
may frequently, and out of necessity, be
implemented simultaneously, especially when stabilization and treatment
are needed before transfer. An algorithm has been developed to guide pracCrit Care Med 2004 Vol. 32, No. 1

Table 1. Recommended minimum transport equipment

Airway management/oxygenationadult and pediatric
Adult and pediatric bag-valve systems with oxygen reservoir
Adult and pediatric masks for bag-valve system (multiple sizes as appropriate)
Flexible adaptors to connect bag-valve system to endotracheal/tracheostomy
tube
End-tidal carbon dioxide monitors (pediatric and adult)
Infant medium- and high-concentration masks with tubing
MacIntosh laryngoscope blades (#1, #2, #3, #4)
Miller laryngoscope blades (#0, #1, #2)
Endotracheal tube stylets (adult and pediatric)
Magil forceps (adult and pediatric)
Booted hemostat
Cuffed endotracheal tubes (5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0)
Uncuffed endotracheal tubes (2.5, 3.0, 3.5, 4.0, 4.5, 5.0)
Laryngoscope handles (adult and pediatric)
Extra laryngoscope batteries and light bulbs
Nasopharyngeal airways (#26, #30)
Oral airways (#0, #1, #2, #3, #4)
Scalpel with blade for cricothyroidotomy
Needle cricothyroidotomy kit
Water-soluble lubricant
Nasal cannulas (adult and pediatric)
Oxygen tubing
PEEP valve (adjustable)
Adhesive tape
Aerosol medication delivery system (nebulizer)
Alcohol swabs
Arm boards (adult and pediatric)
Arterial line tubing
Bone marrow needle (for pediatric infusion)
Blood pressure cuffs (neonatal, infant, child, adult large and small)
Butterfly needles (23-gauge, 25-gauge)
Communications backup (e.g., cellular telephone)
Defibrillator electrolyte pads or jelly
Dextrostix
ECG monitor/defibrillator (preferably with pressure transducer capabilities)
ECG electrodes (infant, pediatric, adult)
Flashlights with extra batteries
Heimlich valve
Infusion pumps
Intravenous fluid administration tubing (adult and pediatric)
Y-blood administration tubing
Extension tubing
Three-way stopcocks
Intravenous catheters, sizes 14- to 24-gauge
Intravenous solutions (plastic bags)
1000 mL, 500 mL of normal saline
1000 mL of Ringers lactate
250 mL of 5% dextrose
Irrigating syringe (60 mL), catheter tip
Kelley clamp
Hypodermic needles, assorted sizes
Hypodermic syringes, assorted sizes
Normal saline for irrigation
Pressure bags for fluid administration
Pulse oximeter with multiple site adhesive or reusable sensors
Salem sump nasogastric tubes, assorted sizes
Soft restraints for upper and lower extremities
Stethoscope
Suction apparatus
Suction catheters (#5, #8, #10, #14, tonsil)
Surgical dressings (sponges, Kling, Kerlix)
Tourniquets for venipuncture/IV access
Trauma scissors
The following are considered as needed
Transcutaneous pacemaker
Neonatal/pediatric isolette
Spinal immobilization device
Transport ventilator
PEEP, positive end-expiratory pressure; ECG, electrocardiogram; IV, intravenous.

Crit Care Med 2004 Vol. 32, No. 1

titioners through the transfer process

(Fig. 1).
Pretransport Coordination and Communication. The referring physician will
identify and contact an admitting physician at the receiving hospital to accept
the patient in transfer and confirm before
the transfer occurs that appropriate
higher level resources are available. The
receiving physician is given a full description of the patients condition. At that
time, advice can be requested concerning
treatment and stabilization before transport. The appropriateness of transferring
a patient from an inpatient setting (critical care unit) to an outpatient setting
(e.g., emergency department) at a receiving institution must be cautiously examined. If a physician will not be accompanying the patient during transport (34),
the referring and accepting physicians
will ensure there is a command physician
for the transport team who will assume
responsibility for medical treatment during the transport. It may be appropriate
for this individual to receive a medical
report before the team departs.
In some instances (e.g., when a receiving institution provides the transport
team), the receiving physician may determine the mode of transport. However,
the mode of transportation (ground or
air) usually is determined by the transferring physician, in consultation with
the receiving physician, based on the urgency of the medical condition (stability
of the patient), time savings anticipated
with air transport, weather conditions,
medical interventions necessary for ongoing life support during transfer, and
the availability of personnel and resources (51, 52). The transport service
then will be contacted to confirm its
availability, to prepare for anticipated patient needs during transport, and to coordinate the timing of the transport.
A nurse-to-nurse report is given by the
referring facility to the appropriate nursing unit at the receiving hospital. Alternatively, the report can be given by a
transport team member at the time of
arrival. A copy of the medical record, including a patient care summary and all
relevant laboratory and radiographic
studies, will accompany the patient. The
preparation of records should not delay
patient transport, however, as these
records can be forwarded separately (by
facsimile or courier) if and when the urgency of transfer precludes their assemblage beforehand. Under these circumstances, the most critical information is
259

Table 2. Recommended minimum transport medications

Adenosine, 6 mg/2 mL
Albuterol, 2.5 mg/2 mL
Amiodarone, 150 mg/3 mL
Atropine, 1 mg/10 mL
Calcium chloride, 1 g/10 mL
Cetacaine/Hurricaine spray
Dextrose 25%, 10 mL
Dextrose 50%, 50 mL
Digoxin, 0.5 mg/2 mL
Diltiazem, 25 mg/5 mL
Diphenhydramine, 50 mg/1 mL
Dopamine, 200 mg/5 mL
Epinephrine, 1 mg/10 mL (1:10,000)
Epinephrine, 1 mg/1 mL (1:1000) multiple-dose vial
Fosphenytoin, 750 mg/10 mL (500 PE mg/10 mL)
Furosemide, 100 mg/10 mL
Glucagon, 1 mg vial (powder)
Heparin, 1000 units/1 mL
Isoproterenol, 1 mg/5 mL
Labetalol, 40 mg/8 mL
Lidocaine, 100 mg/10 mL
Lidocaine, 2 g/10 mL
Mannitol, 50 g/50 mL
Magnesium sulfate, 1 g/2 mL
Methylprednisolone, 125 mg/2 mL
Metoprolol, 5 mg/5 mL
Naloxone, 2 mg/2 mL
Nitroglycerin injection, 50 mg/10 mL
Nitroglycerin tablets, 0.4 mg (bottle)
Nitroprusside, 50 mg/2 mL
Normal saline, 30 mL for injection
Phenobarbital, 65 mg/mL or 130 mg/mL
Potassium chloride, 20 mEq/10 mL
Procainamide, 1000 mg/10 mL
Sodium bicarbonate, 5 mEq/10 mL
Sodium bicarbonate, 50 mEq/50 mL
Sterile water, 30 mL for injection
Terbutaline, 1 mg/1 mL
Verapamil, 5 mg/2 mL
The following specialized/controlled medications are added immediately before transport as
indicated
Narcotic analgesics (e.g., morphine, fentanyl) (59)
Sedatives/hypnotics (e.g., lorazepam, midazolam, propofol, etomidate, ketamine) (59)
Neuromuscular blocking agents (e.g. succinylcholine, pancuronium, atracurium, rocuronium)
(60)
Prostaglandin E1
Pulmonary surfactant

communicated verbally. It is strongly

suggested that policies be established
within each institution regarding the
content of documentation and communication between personnel involved in the
transfer.
Accompanying Personnel. It is recommended that a minimum of two people,
in addition to the vehicle operators, accompany a critically ill patient during
interhospital transport.* When transporting unstable patients, the transport
team leader should be a physician or
nurse (41, 53, 54), preferably with additional training in transport medicine. For
critical but stable patients, the team
leader may be a paramedic (41). These
individuals provide the essential capabil260

ities of advanced airway management, intravenous therapy, dysrhythmia interpretation and treatment, and basic and
advanced cardiac life support. In the absence of a physician team member, there
will be a mechanism by which the transport team can communicate with a command physician. If communication of
this type becomes impossible, the team
will have preauthorization by standing
orders to perform acute lifesaving interventions. In the absence of a readily available external transport team, a transport
team and vehicle may need to be assembled locally. The development of policies
and procedures for such emergencies is
strongly recommended.
Minimum Equipment Required. Ta-

lthough both intra- and interhospital

transport

must comply with regulations, we believe patient

safety is enhanced during
transport by establishing an
organized efficient process
supported by appropriate
equipment and personnel.

bles 1 and 2 provide a detailed list of the

minimum recommended equipment and
pharmaceuticals needed for safe interhospital transport. Emphasis is placed on
airway and oxygenation, vital signs monitoring, and the pharmaceutical agents
necessary for emergency resuscitation
and stabilization as well as maintenance
of vital functions. Very short or very long
transports may necessitate deviations
from the listed items, depending on the
severity and nature of illness or injury.
Furthermore, advances in knowledge
over time will result in periodic review
and modification of these lists. All items
are checked regularly for expiration of
sterility and/or potency, especially when
transports are infrequent. Equipment
function is verified on a scheduled basis,
not at the time of transport when there
may be insufficient time to find replacements.
Monitoring During Transport. All critically ill patients undergoing interhospital transport must have, at a minimum,
continuous pulse oximetry, electrocardiographic monitoring, and regular measurement of blood pressure and respiratory rate.* Selected patients, based on
clinical status, may benefit from the
monitoring of intra-arterial blood pressure (55), central venous pressure, pulmonary artery pressure, intracranial
pressure, and/or capnography (56). With
mechanically ventilated patients, endotracheal tube position is noted and secured before transport, and the adequacy
of oxygenation and ventilation is reconfirmed.
Occasionally, patients may require
specialized modes of ventilation not reCrit Care Med 2004 Vol. 32, No. 1

producible in the transport setting. Under these circumstances, alternate modes

of mechanical ventilation are evaluated
before transport to ensure acceptability
and patient stability with this therapy. If
the patient is incapable of being maintained safely with alternate ventilator
therapy, the risks and benefits of transport are cautiously reexamined.
Patient status and management during transport are recorded and filed in the
patient medical record at the referring
facility. Copies are provided to the receiving institution.
Preparing a Patient for Interhospital
Transport There is no evidence to support a scoop and run approach to the
interhospital transport of critically ill patients. Therefore, referring facilities will,
before transport, begin appropriate evaluation and stabilization to the degree
possible to ensure patient safety during
transport. Unnecessary delays may be experienced if the transport team must perform lengthy or complex procedures to
stabilize the patient before the transfer
(57). Nonessential testing and procedures
will delay transfer and should be avoided.
Information and recommendations about
this aspect of patient care generally can
be requested from the accepting physician at the time of initial contact with the
receiving facility.
All critically ill patients need secure
intravenous access before transport. If
peripheral venous access is unavailable,
central venous access is established. If
needed, fluid resuscitation and inotropic
support are initiated, with all intravenous
fluids and medications maintained in
plastic (not glass) containers. A patient
should not be transported before airway
stabilization if it is judged likely that airway intervention will be needed en route
(a process made more difficult in a moving vehicle). The airway must be evaluated before transport and secured as indicated by endotracheal tube (or
tracheostomy).* Laryngeal mask airways
are not an acceptable method of airway
management for critically ill patients undergoing transport. For trauma victims,
spinal immobilization is maintained during transport unless the absence of significant spinal injury has been reliably
verified. A nasogastric tube is inserted in
patients with an ileus or intestinal obstruction and in those requiring mechanical ventilation. A Foley catheter is inserted in patients requiring strict fluid
management, for transports of extended
duration, and for patients receiving diCrit Care Med 2004 Vol. 32, No. 1

uretics. If indicated, chest decompression

with a chest tube is accomplished before
transport. A Heimlich valve or vacuum
chest drainage system is employed to
maintain decompression. Soft wrist
and/or leg restraints are applied when
agitation could compromise the safety of
the patient or transport crew, especially
with air transport. If the patient is combative or uncooperative, the use of sedative and/or neuromuscular blocking
agents may be indicated. A neuromuscular blocking agent should not be used
without sedation and analgesia.
Finally, the patient medical record and
relevant laboratory and radiographic
studies are copied for the receiving facility. In the United States, a COBRA/
EMTALA checklist is strongly suggested
to ensure compliance with all federal regulations regarding interhospital patient
transfers. Items on this checklist will include documentation of initial medical
evaluation and stabilization (to the degree possible), informed consent disclosing benefits and risks of transfer, medical
indications for the transfer, and physician-to-physician communication with
the names of the accepting physician and
the receiving hospital.

10.

11.

12.

13.

14.

15.

16.

17.

18.

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