Many of our columns have highlighted the radiology suite as a site where many patient safety issues occur (see our October 22, 2013 Patient Safety Tip of the Week for “How Safe Is Your Radiology Suite?” and the multiple columns listed below on safety issues in the radiology suite or MRI suite). Many of the same safety issues apply to transport of patients to other areas of the hospital as well (operating room, procedure suites, etc.). So it is critical that the various risks for transporting a patient be accurately addressed and conveyed to all staff when a patient is sent to radiology or other area. One way to facilitate such handoffs is to include information in a structured communication tool for transports like the “” we described in our April 8, 2008 column “Oxygen as a Medication”. Clinical researchers in the Netherlands recently developed a checklist for intrahospital transport of critically ill patients that improves upon some previous checklists (Brunsveld-Reinders 2015). We’ll get to the details of that checklist shortly but first we need to describe some of risks involved in such intrahospital transfers.
Most of the literature on the risks associated with intrahospital transport have dealt with critically-ill patients. While incidents do occur during intrahospital transport of non-ICU patients, those from ICU’s are the most vulnerable. The percentage of ICU patients needing such intrahospital transfer probably depends on a host of factors, such as nature of the patient population, imaging capabilities, etc. One study ((Van Velsen 2011) noted that about a third of ICU patients required intrahospital transports. The literature also suggests that the risk of incidents and adverse events during transports is also related to the time duration of the transport. Hence, events such as CT scanning tend to be associated with more incidents because they require more time (PPSA 2005a). We’ll also bet that the percentage of incidents related to transports to the MRI suite has been increasing in the past decade as more and more hospitals have their own MRI suites.
The overall rate of incidents during intrahospital transports is difficult to glean from the literature. In our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” we noted studies from the 1980’s and 1990’s that showed rates of transport incidents as high as 70%. A paper by Smith et al ( ) noted adverse events during 34% of all ICU transports but transport of ICU patients to the CT suite was associated with a 71% incidence of adverse events. Those high rates of transport incidents have probably diminished somewhat. Some of the authors from the current Netherlands study had previously noted an incidence of 3.7% (Van Velsen 2011). But when they prospectively monitored transports in the current study (Brunsveld-Reinders 2015) they found that in 26% of 503 transports to Radiology one or more incidents occurred.
Probably the most comprehensive review of incidents related to intrahospital transport came from the Australian Incident Monitoring Study in Critical Care, reported by researchers from Australia and Johns Hopkins (Beckmann 2004). They found 191 incidents related to intrahospital transport from 37 Australian ICU’s between 1993 and 1999. Roughly a third (31%) of the incidents had serious adverse outcomes, with major physiological derangement in 15%, physical/psychological injury in 4%, death in 2%, and prolonged hospital stay in 4%. In addition, patient/family dissatisfaction occurred in 7%. The site to which the transport occurred was evenly split between the Radiology suite and the OR, with some transports to the ward, ER, or other sites.
They were able to categorize the incidents as equipment-related in 39% and related to patient/staff management issues in 61%. Overall they identified 900 contributing factors, 46% of which were system factors and 54% human-based factors.
Equipment related issues included problems with oxygen, battery/power supply, ventilators, monitors, drug delivery systems, etc. But they also included things like problems with the hospital elevators. The patient/staff management issues mostly had to do with communication issues, airway management, vascular line management, monitoring, and positioning and set-up of equipment.
They did find a number of factors that seemed to prevent or limit harm to patients in the incidents. These included “rechecking equipment”, “rechecking the patient”, “prior experience”, “use of the correct protocol”, and “skilled assistance”. These mitigating factors led the researchers to recommend potential use of checklists, protocols/guidelines for transport, and specific training for transport or use of specialized transport teams. They also stress the importance of adequate monitoring of the patient throughout. Some of the potential checklist items to include relate to oxygen supply, battery life, lines and tubes, and capability of transferring patient between bed, stretcher and table. Preparation must include not only getting the patient and equipment ready but also liaising with the staff at the destination department.
The Beckmann study also demonstrates the value of having incident reporting that allows such drill-down and tracking of intrahospital transport incidents. That, in fact, is a metric we think should be part of an ICU quality and performance improvement program.
Problems maintaining adequate oxygenation are particularly a problem during transport of patients (within or outside of facilities). The Pennsylvania Patient Safety Authority highlighted this issue in a Patient Safety Advisory in 2005 “Continuity of Oxygen Therapy During Intrahospital Transport” (PPSA 2005b). They reviewed numerous reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) and looked at failure modes in the many steps involved in maintaining adequate oxygen therapy during transport. They noted that oxygen therapy has been reported to be interrupted in as many as 55% of transports. Failure modes identified included: failure to treat with oxygen when ordered, failure to initiate flow from the oxygen source, failure to connect the oxygen tubing to the source, failure to place the oxygen delivery device on the patient, and failure to anticipate the oxygen demand and provide an adequate supply throughout the transport.
Battery power failure (see our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”) is a potential risk. Not only do portable ventilators run on battery power but monitors and infusion pumps and possibly other equipment may also run on batteries.
In a commentary on the Beckmann study, Shirley and Bion (Shirley 2004) note the importance of making the decision about whether to transport a patient. They note that such decision “should be made by a senior, experienced and appropriately skilled clinician who remains responsible for the conduct of the transfer”. The potential benefits of a transport must be critically weighed against the potential risks. Beckmann et al. cite studies suggesting that care plans were changed for patients after such transports in only 24-39% of cases. So one really needs to consider how likely the imaging study (or other procedure the patient may be going for) is really going to change patient management. (See also the comments below by Day regarding questions to ask in making the decision to transport.)
Shirley and Bion also note that the transport team should be freed up from other responsibilities well in advance to allow adequate time for preparation for the transfer. They also stress that education and training are key and that part of the core curriculum for intensive care medicine should be devoted to transport medicine.
So back to the “Ticket to Ride” or intrahospital transport checklist. In the current Netherlands study (Brunsveld-Reinders 2015) the researchers first searched the literature and various databases for guidelines and checklists, then analyzed incidents that had taken place at their facility during intrahospital transport, and finally interviewed physicians and nurses about their experiences with the incidents. They then developed a checklist, discussed it with experts in the field and tested feasibility and usability.
Of the 5 checklists they found in the literature, only one (Jarden 2010) covered all three phases of transport (pre-transport, during-transport, and post-transport). So they modified that checklist to include other items they found relevant to their hospital.
They were able to identify 118 incidents related to intrahospital transfer at their hospital over the prior 36 months. Of these 38% occurred pre-transport, 47% during transport, and 15% post-transport. Equipment-related issues included, as expected, problems with oxygen supply and battery power to ventilators or infusion pumps, but also included things like equipment not suitable for use with MRI. Organization-related issues included things like inappropriate preparation of the patient leading to delays in transport or inadequate communication with the destination/receiving department. However, when they then prospectively monitored transports they found that in 26% of 503 transports to Radiology one or more incidents occurred.
Post-transport phase issues have been under the radar in the past but the Netherlands group identified many issues. Dislodgement of lines or tubes are often first noticed at this time and patients are often more hypoxic or more hypotensive after transport. They found an increased need for vasopressors or inotropes in many cases and many patients had increased agitation upon return from transports.
We refer you to the Netherlands study itself (Brunsveld-Reinders 2015) to actually see the checklist they created for intrahospital transports. The article also addresses transport team composition (which may vary depending upon whether the patient is ventilated or on pressors or inotropes) and education/training needs for members of the transport team. The equipment check prior to transport includes not only status of the oxygen supply and battery/power supplies but also considerations such as hydration before studies using radiographic contrast or whether equipment is MRI-compatible (eg. non-ferromagnetic materials, long enough IV lines, etc.) if the patient is going for an MRI. Medication and fluid status must be addressed prior to transport. And it is crucial that communication take place with the receiving department to ensure they are ready to accept the patient and whether any items such as informed consent are available. One often-overlooked item is ensuring that the transport route is clear and functional. We’ve seen unsafe transports take place because no one realized an elevator was out of service. They provide considerations for during transport, such as attention to equipment, monitoring, and medications/IV’s. And post-transport they focus on ensuring proper equipment and line/tubing connections, resumption of feeding if applicable, turning on the humidifier on the ventilator, etc. They also stress the importance of reporting any incidents or events that may have happened during the transport.
The Netherlands checklist took an average of 4.5 minutes per phase (range 3 to 10 minutes). It was generally well accepted and one of the key factors in that was its integration with their electronic medical record. A criticism was that documentation of the vital signs during the transport was paper-based rather than integrated with the EMR. Urgency of the transport was noted as an occasional barrier to its use. But we’ll point out that such urgency is a factor likely to contribute to adverse events. That was actually borne out in a German study that showed critical incidents occurred in 7.8% of emergent transfers compared to 2.4% in elective transfers (Lahner 2007). There are few truly emergent situations where the 4.5 minutes to do the checklist are likely to outweigh the benefits of planning for safe transport.
In an excellent review of issues related to intrahospital transport Day describes “the 5 W’s” (Day 2010). The first “W” is “Why” or “Why does the patient need to leave the ICU for the procedure?”. Important questions to ask here are “Are there bedside alternatives for the procedure? And “Is the patient’s condition stable?”. If the patient is considered unstable, the next questions are “Is the transport for a lifesaving intervention?” and “Is the transport to a diagnostic test pivotal to decision for emergent plan?”. Day’s second “W” is “Who”. This included both who is the patient and who will be caring for the patient and, importantly, will a handoff be required? The third “W” is “What” and refers to equipment, airway, ventilator support, circulatory support, and special considerations (eg. spine stability, intracranial pressure monitors, etc.). Under the fourth “W” for “When” Day discusses considerations about coordinating with the timing of the test or procedure (eg. fasting or withholding anticoagulants for procedures), renal protective protocols for contrast-using procedures, and collaborating with other healthcare providers. The last “W” is for “Where” which includes details about the route to be taken, issues regarding MRI safety if going for MRI, etc.
While the Netherlands checklist was developed for intrahospital transport of critically-ill patients, many of the core principles apply to transport of other inpatients as well. We have a few special considerations to comment on.
One issue that probably arises more often in non-ICU patient transports is maintenance of glucose in patients with diabetes. Many of the procedures necessitating intrahospital transport (eg. imaging or OR procedures) may require the patient to be NPO. Hence, in diabetic patients, it is common to hold insulin doses as well prior to the transport. But some patients on longer-acting insulin preparations may still be prone to hypoglycemia during a transport so you may need to ensure they have some glucose source in their IV fluids. Likewise, you have to remember to address oral or enteral intake and insulin dosing once the patient returns from the transport.
The same applies to other medications. If the patient was NPO for the transport they may miss a once daily dose of a medication unless a review of medications is performed when the patient returns.
And don’t neglect the importance of a “Ticket to Ride” type checklist for intrahospital transport of non-ventilated patients or non-ICU patients. There may be some special considerations in such cases. The “Ticket to Ride” concept (see our Patient Safety Tips of the Week for April 8, 2008 “ ”, November 18, 2008 “ ” and August 11, 2009 “ ”) is a tool ideally suited for the radiology suite. It was originally developed for patients on oxygen therapy needing transport to radiology since studies had shown over 50% of such transports resulted in patients running out of oxygen. However, this concept addressing handoffs has been expanded to include attention to medication management, suicide risk, wandering risk, etc. in patients transported to radiology or other sites within the hospital. A 2009 Pennsylvania Patient Safety Authority “Patient Safety Advisory” discussed development of a standardized handoff communication tool for intrahospital transports ( ). It has an excellent discussion on the development of questions you’ll want to use in your own transport communication tool.
Suicide risk should be considered when patients are transported to Radiology (or other sites) whether the patient is on a behavioral health unit or medical unit (see our prior columns January 6, 2009 “Preventing Inpatient Suicides”, February 9, 2010 “More on Preventing Inpatient Suicides” and December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”). We’ve inspected bathrooms in radiology departments in several hospitals and uniformly found that not only do those bathrooms have numerous “loopable” items that could be used for hanging but also that they can be locked from the inside and there is typically no one readily available with a key to get in. In fact, that is one of the items we added to our patient safety scavenger hunt list (see our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”). Bathrooms and other rooms in the radiology department also have many other tools and implements that could be used for suicide. So observation protocols for potentially suicidal patients on such units should ensure that doors are not locked (or, if they can be locked, that the “observer” has keys to access the bathroom). Having observers of the same gender as the patient also is recommended.
The “wandering” patient is also a risk when transported to other areas of the hospital. So if you have identified a patient as being at risk for wandering you need to ensure there will be appropriate supervision of that patient throughout the entire transport period.
Fall risk is something you clearly need to consider during intrahospital transports. Patients are likely to transfer from a bed to a wheelchair or gurney then to a table and then back again on many such trips. That provides ample opportunity for patients at risk for falls to actually fall and injure themselves. So the fall risk must be accurately communicated to transport staff as well as staff in the receiving department.
Hypothermia is a risk not often considered in intrahospital transfers. Particularly for some longer imaging studies or other procedures the risk for hypothermia may increase. While vital sign monitoring is mandatory in critically-ill patients on such transports, the focus is usually on blood pressure, pulse, and respiratory status. Measuring the patient’s temperature is often ignored.
One piece of equipment recommended by Day (Day 2010) for transports is a cellphone. While we’ve often discussed the potential distractions caused by cellphones in places like the OR, availability of a cellphone during a transport can be crucial. We recall as a medical student (in the days before cellphones!) being stuck in an elevator on the way to the OR with a patient needing emergent evacuation of a subdural hemaoma. Since delays and unanticipated events are common in intrahospital transports we think Day’s advice about carrying a cellphone on transports is valuable.
Wow! That’s a lot of stuff to consider in a checklist! We’ve discussed design considerations for checklists in several prior columns and it is most important to keep them as simple as possible. Remember: the goal of checklists is to help staff remember important steps or considerations that are easily missed. When checklists get too complicated or contain items that are seldom forgotten, they can become unwieldy and tend to be ignored. Checklist fatigue is real (see our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate”). In an upcoming column we’ll discuss some of the recent ideas in the literature to help improve the usability of checklists and reduce the risk of checklist fatigue.
Some of our prior columns on the “Ticket to Ride” concept:
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on patient safety issues related to MRI:
Brunsveld-Reinders AH, Arbous M, Kuiper SG, de Jonge E. A comprehensive method to develop a checklist to increase safety of intra-hospital transport of critically ill patients. Critical Care 2015; 19: 214 (7 May 2015)
Van Velzen C, Brunsveld-Reinders AH, Arbous MS. Incidents related to intrahospital transport of patients in the ICU. Critical Care 2011; 15(Suppl 1): P535
Pennsylvania Patient Safety Authority. Patient Safety Advisory. Is CT a High-Risk Area for Patient Transport? PA PSRS Patient Saf Advis 2005; 2(3): 11-12
Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3):278-281
Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P.
Incidents relating to the intra-hospital transfer of critically ill patients:
An analysis of the reports submitted to the Australian Incident Monitoring
Study in Intensive Care. Intensive Care Medicine 2004; 30(8): 1579-1585
Pennsylvania Patient Safety Authority. Patient Safety Advisory. Continuity of Oxygen Therapy During Intrahospital Transport. PA PSRS Patient Saf Advis 2005; 2(3): 9-10
Shirley PJ, Bion JF. Intra-hospital transport of critically
ill patients: minimising risk. Intensive Care Medicine 2004; 30(8): 1508-1510
Jarden RJ, Quirke S. Improving safety and documentation in intrahospital transport: development of an intrahospital transport tool for critically ill patients. Intensive Crit Care Nurs 2010; 26: 101-107
Lahner D, Nikolic A, Marhofer P, et al. Incidence of complications in intrahospital transport of critically ill patients: experience in an Austrian university hospital. Wein Klin Wochenschr 2007; 119: 412-416
Day D. Keeping Patients Safe During Intrahospital Transport. Crit Care Nurse 2010; 30: 18-32
Pennsylvania Patient Safety Authority. Patient Safety Advisory. Safe Intrahospital Transport of the non-ICU Patient Using Standardized Handoff Communication.
Pa Patient Saf Advis 2009; 6(1): 16-9
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