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What’s New in the
Patient Safety World
February 2021
Risk from
Intrahospital Transfer: Healthcare-Associated Infection
We’ve done many columns on the dangers of
intrahospital transports and the need to do careful planning to avoid those
dangers. But we’ve focused primarily on temporary
transports to areas such as radiology or the OR. But there is a different sort
of intrahospital transfer that is also problematic – the transfer of patients
from beds on one unit to beds on another unit.
A recent study from the UK (Boncea 2021) found that intrahospital transfers are associated with increased odds of developing a healthcare-associated infection (HAI). The authors suggest that strategies for minimizing intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment.
The frequency of
such intrahospital transfers should probably not surprise you. Only 27.8% of
patients did not undergo any intrahospital transfers. 44.2% of patients
underwent one intrahospital transfer, 17.1% underwent two transfers, and 11.0%
underwent three or more transfers. Overall, 11.9% of patients developed an HAI.
C. difficile infection accounted for almost a third of the HAI’s, but many
other pathogens were implicated as well.
The accompanying editorial (Escobar
2021) notes that cases and controls
were well matched, and the statistical modelling provided very compelling
results. But it notes the study
did not adjust for the indication for transfer (eg,
transfer to or from the intensive care unit based on patient acuity, transfer
for isolation precautions or transfer due to bed capacity
or staffing issues) to determine if the patient care needs, isolation status or
hospital strain modify the observed risk. It therefore recommends, as do Boncea et al., that prospective studies are needed to
better identify the clinical, administrative and systems factors that
contribute to more frequent intrahospital transfers.
Boncea et al. note several factors that could
underlie a possible association between HAIs and intrahospital transfers:
- Patients with frequent transfers are exposed to a greater number of environments and contacts in the hospital, increasing their risk of exposure to pathogens from contaminated surfaces, other patients or healthcare workers.
- Transferred patients may also experience delays in receiving care on admission to a new unit, thus extending their hospital stay, which is itself a risk factor for HAIs.
- Extended interactions with hospital staff are
known to promote infection spread. They cite that 1.7 nurses are required
for conducting a transfer, and 1.9 nurses for receiving one.
Especially in the COVID-19 era, where hospital bed shortages are rampant, we often move patients from one site to another, The Boncea study suggests we not simply act reflexly in such intrahospital transfers, but rather carefully consider the implications before carrying out such transfers. The 9% increased risk of an HAI associated with each transfer is a substantial consideration. There are, of course, other unwanted consequences of intrahospital transfers. For example, one study (Goldberg 2015) found that room transfers amongst hospitalized elderly medical patients substantially increased the risk of development of delirium (OR 9.69).
But one has to
weigh the benefits of transfer against the risks. There are risks of keeping a
patient on a unit not used to caring for such patients. We cohort patients on
floors with special expertise in care for patients with certain conditions. A
patient being followed by one service (eg. neurology)
who is temporarily housed on a non-neurology floor gets less attention from the
neurology staff than he would were he housed on the neurology floor. In
addition, the nursing care on the specialty unit is much more attuned to the
problems that neurology patient is likely to have. So, decisions about
transferring patients from one location in the hospital to another can’t simply be based on the risk of HAI. Nevertheless, the
substantial risk of HAI pointed out in the Boncea
study should make us recognize that decisions about transfer of patients should
not be made rashly.
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
- April 8, 2008 “Oxygen as a Medication”
- November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
- August 11, 2009 “The Radiology Suite…Again!”
- March 13, 2012 “Medical Emergency Team Calls to Radiology”
- August 25, 2015 “Checklist for Intrahospital Transport”
- September 1, 2015 “Smarter Checklists”
- November 2016 “Oxygen
Tank Monitoring”
- February 2018 “Oxygen
Cylinders Back in the News”
- May 22, 2018 “Hazardous
Intrahospital Transport”
- October 30, 2018 “Interhospital
Transfers”
- March 31, 2020 “Intrahospital Transport
Issues in Children”
- June 23, 2020 “Telemetry Incidents”
- July 14, 2020 “A Thesis on
Intrahospital Transports”
- August 4, 2020 “Intravenous Issues”
References:
Boncea E, Expert P, Honeyford K. Association between intrahospital transfer and hospital-acquired infection in the elderly: a retrospective case-control study in one urban UK Hospital network. BMJ Qual Saf 2021; Published Online First: 25 January 2021
https://qualitysafety.bmj.com/content/early/2021/01/24/bmjqs-2020-012124
Escobar D, Pegues D. Healthcare-associated infections: where we came from and where we are headed. BMJ Quality & Safety 2021; Published Online First: 08 January 2021
https://qualitysafety.bmj.com/content/early/2021/01/08/bmjqs-2020-012582
Goldberg A, Straus SE, Hamid JS, Wong CL. Room transfers and the risk of delirium incidence amongst hospitalized elderly medical patients: a case-control study. BMC Geriatr 2015; 15: 69. Published 2015 Jun 25
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478641/pdf/12877_2015_Article_70.pdf
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